Post-polio syndrome is not a dysimmune condition.

BACKGROUND: Poliomyelitis is a global disabling disease affecting 12-20 million of people. Post poliomyelitis syndrome (PPS) may affect up to 80% of polio survivors: increased muscle weakness, pain, fatigue, functional decline. It relies on aging of an impaired neuro-muscular system with ongoing denervation processes. A late involvement of humoral or cellular pro-inflammatory phenomena is also suspected. AIM: To assess the dysimmune hypothesis of PPS by comparing lymphocyte subpopulations and humoral immune factors between PPS patients and controls. DESIGN: Cross-sectional study. SETTING: Montpellier University Hospital. POPULATION: Forty-seven PPS and 27 healthy controls. METHODS: PPS patients and controls were compared on their lymphocyte subpopulations and humoral immune factors (IL-1ß, IL-6, IL-8, IL-17, IL-21, IL-22, IL-23, IFN-γ, TNF-α, GM-CSF, RANTES, MCP1, MIP-3a, IL-10, TGF-ß, IL4, IL13). Patients were further compared according to their dominant clinical symptoms. Sample size guaranteed a power >90% for all comparisons. RESULTS: PPS patients and controls were comparable in gender, age and corpulence. Most patients had lower limb motor sequelae (N.=45, 95.7%), a minority had upper limb motor impairment (N.=16, 34.0%). Forty-five were able to walk (94%), 35/45 with technical aids. The median of the two-minute walking test was 110 meters (interquartile range 55; 132). Eighteen (38%) required help in their daily life. Their quality of life was low (SF36). All described an increased muscular weakness, 40 (85%) a general fatigue, and 39 (83%) muscular or joint pain. Blood count, serum electrolytes, T and B lymphocyte subpopulations and cytokines were comparable between patients and controls, except for creatine phospho kinase that was significantly higher in PPS patients. None of these variables differed between the 20/47 patients whose late main symptoms were pain or fatigue, and other patients. CONCLUSIONS: Our results suggest that PPS is not a dysimmune disease. CLINICAL REHABILITATION IMPACT: Our results do not sustain immunotherapy for PPS. Our work suggest that PPS may be mostly linked to physiological age-related phenomena in a disabled neuromuscular condition. Thus, our results emphasize the role of prevention and elimination of aggravating factors to avoid late functional worsening, and the importance of rehabilitation programs that should be adapted to patients' specific conditions.

Early shoulder-girdle MRI findings in severe COVID-19-related intensive care unit-acquired weakness: a prospective cohort study.

OBJECTIVE: To describe clinical and early shoulder-girdle MR imaging findings in severe COVID-19-related intensive care unit-acquired weakness (ICU-AW) after ICU discharge. METHODS: A single-center prospective cohort study of all consecutive patients with COVID-19-related ICU-AW from November 2020 to June 2021. All patients underwent similar clinical evaluations and shoulder-girdle MRI within the first month and then 3 months (± 1 month) after ICU discharge. RESULTS: We included 25 patients (14 males; mean [SD] age 62.4 [12.5]). Within the first month after ICU discharge, all patients showed severe proximal predominant bilateral muscular weakness (mean Medical Research Council total score = 46.5/60 [10.1]) associated with bilateral, peripheral muscular edema-like MRI signals of the shoulder girdle in 23/25 (92%) patients. At 3 months, 21/25 (84%) patients showed complete or quasi-complete resolution of proximal muscular weakness (mean Medical Research Council total score > 48/60) and 23/25 (92%) complete resolution of MRI signals of the shoulder girdle, but 12/20 (60%) patients experienced shoulder pain and/or shoulder dysfunction. CONCLUSIONS: Early shoulder-girdle MRI findings in COVID-19-related ICU-AW included muscular edema-like peripheral signal intensities, without fatty muscle involution or muscle necrosis, with favorable evolution at 3 months. Precocious MRI can help clinicians distinguish critical illness myopathy from alternative, more severe diagnoses and can be useful in the care of patients discharged from intensive care with ICU-AW. KEY POINTS: • We describe the clinical and shoulder-girdle MRI findings of COVID-19-related severe intensive care unit-acquired weakness. • This information can be used by clinicians to achieve a nearly specific diagnosis, distinguish alternative diagnoses, assess functional prognosis, and select the more appropriate health care rehabilitation and shoulder impairment treatment.

Muscle weakness in critically ill patients: Effects of a systematized rehabilitation nursing program.

OBJECTIVE: Intensive care unit-acquired muscle weakness (ICUAW) in critically ill patients is frequent and associated with negative outcomes. Early rehabilitation is a strategy to improve outcomes. The aim was to assess the effects of a rehabilitation nursing programme at discharge from intensive care unit. METHODS: Quasi-experimental study with the comparison between two groups: one enrolled in a systematized nursing rehabilitation program and the other with usual nursing rehabilitation care. A non-probabilistic sample, sequential, of 42 critically ill ventilated patients, 21 patients in the control group and 21 patients the intervention group (June 2017 to June 2019), in three intensive care units of one large Portuguese teaching hospital. Mann-Whitney test was performed to compare Medical Research Council Sum Score (MRC-SS) values between groups. RESULTS: Patients undergoing the rehabilitation program had a decrease in ICUAW (at ICU discharge mean MRC-SS = 38 vs. mean MRC-SS = 42.7, p = 0.043, U = 152,5). There was a decrease in severe muscle weakness (9.5% vs. 28.6%) and significant muscle weakness (42.9% vs. 52.4%) and an increase without muscle weakness (47,6% vs. 19%). CONCLUSIONS: The systematic rehabilitation nursing program can improve muscle strength and reduce functional disability at the time of discharge from intensive care.

A wireless controlled intelligent healthcare system for diplegia patients.

Rehabilitation engineering is playing a more vital role in the field of healthcare for humanity. It is providing many assistive devices to diplegia patients (The patients whose conditions are weak in terms of muscle mobility on both sides of the body and their paralyzing effects are high either in the arms or in the legs). Therefore, in order to rehabilitate such types of patients, an intelligent healthcare system is proposed in this research. The electric sticks and chairs are also a type of this system which was used previously to facilitate the diplegia patients. It is worth noting that a voice recognition system along with wireless control feature has been integrated intelligently in the proposed healthcare system in order to replace the common and conventional assistive tools for diplegia patients. These features will make the proposed system more user friendly, convenient and comfortable. The voice recognition system has been used for movements of system in any desired direction along with the ultrasonic sensor and light detecting technology. These sensors detect the obstacles and low light environment intelligently during the movement of the wheelchair and then take the necessary actions accordingly.

Activity Levels in Survivors of the Intensive Care Unit.

OBJECTIVE: Limited data exist on the quantification of activity levels and functional status in critically ill patients as they transition from the intensive care unit (ICU) to the wards and, subsequently, back into the community. The physical activity of critically ill patients from their ICU stay until 7 days after hospital discharge was characterized, as well as correlate physical activity levels with an objective measure of physical function. METHODS: This prospective observational study of previously independent adults aged 55 or older, undergoing mechanical ventilation for up to 7 days, recruited participants at the time of spontaneous breathing trials or less than 24 hours after extubation. Participants received an accelerometer at enrollment to wear until 1 week after discharge. RESULTS: Twenty-two participants received accelerometers; 15 were suitable for analysis. Participants had a mean (SD) age of 68 (9.6) years; 47% were female. Mean step counts were 95 (95% CI = 15-173) in the 3 days before ICU discharge, 257 (95% CI = 114-400) before hospital discharge, 1223 (95% CI = 376-2070) in the first 3 days at home, and 1278 (95% CI = 349-2207) between day 4 and 6 post-hospital discharge. Physical activity was significantly higher post- compared with pre-hospital discharge. Short Physical Performance Battery scores were poor at ICU and hospital discharge; however, they correlated moderately with physical activity levels immediately upon return home. CONCLUSIONS: Physical activity remained low as survivors of critical illness transitioned from ICU to hospital wards, but significantly increased upon return to the community. Despite poor Short Physical Performance Battery scores at both ICU and hospital discharge, participants were significantly more active immediately after discharge than in their last 3 days of hospitalization. This may represent rapid functional improvement or, conversely, constrained physical activity in hospital. IMPACT: This study highlights the need for further evaluation of physical activity constraints in hospital and ways to augment physical activity and function upon discharge. LAY SUMMARY: Physical activity (step counts) increased modestly as survivors of critical illness transitioned from ICU to hospital wards, but significantly increased upon return to the community. This study highlights the need for further evaluation of physical activity constraints in the hospital setting and ways to augment physical activity and function postdischarge.

Functional electrical stimulation-assisted cycle ergometry-based progressive mobility programme for mechanically ventilated patients: randomised controlled trial with 6 months follow-up.

PURPOSE: Functional electrical stimulation-assisted cycle ergometry (FESCE) enables in-bed leg exercise independently of patients' volition. We hypothesised that early use of FESCE-based progressive mobility programme improves physical function in survivors of critical care after 6 months. METHODS: We enrolled mechanically ventilated adults estimated to need >7 days of intensive care unit (ICU) stay into an assessor-blinded single centre randomised controlled trial to receive either FESCE-based protocolised or standard rehabilitation that continued up to day 28 or ICU discharge. RESULTS: We randomised in 1:1 ratio 150 patients (age 61±15 years, Acute Physiology and Chronic Health Evaluation II 21±7) at a median of 21 (IQR 19-43) hours after admission to ICU. Mean rehabilitation duration of rehabilitation delivered to intervention versus control group was 82 (IQR 66-97) versus 53 (IQR 50-57) min per treatment day, p<0.001. At 6 months 42 (56%) and 46 (61%) patients in interventional and control groups, respectively, were alive and available to follow-up (81.5% of prespecified sample size). Their Physical Component Summary of SF-36 (primary outcome) was not different at 6 months (50 (IQR 21-69) vs 49 (IQR 26-77); p=0.26). At ICU discharge, there were no differences in the ICU length of stay, functional performance, rectus femoris cross-sectional diameter or muscle power despite the daily nitrogen balance was being 0.6 (95% CI 0.2 to 1.0; p=0.004) gN/m2 less negative in the intervention group. CONCLUSION: Early delivery of FESCE-based protocolised rehabilitation to ICU patients does not improve physical functioning at 6 months in survivors. TRIAL REGISTRATION NUMBER: NCT02864745.

Physical training and exercise in myasthenia gravis.

Myasthenia gravis is characterized by muscle weakness and fatigue. As sustained muscle use increases the weakness, the value of physical training programs has previously been questioned. This is a review to clarify the safety and usefulness of systematic training in myasthenia gravis, based on a systematic search in available databases using the relevant key words. Ten intervention studies including 159 patients with generalized disease have been published regarding the effect of systematic physical training, three of them on respiratory muscles. Muscle strength improved, and in the majority of the studies also daily function and quality of life. The feeling of fatigue not directly related to actual muscle weakness was less influenced by physical training. Continuous training was necessary to maintain the improved function. Physical training and exercise are safe in myasthenia gravis. This can improve both muscle strength and daily function. Type and intensity of systematic training should be adapted in the individual patient. A minimum of 150 min of exercise per week is recommended for myasthenia gravis patients with mild and moderate disease.

The Relevance of Dual Tasking for Improving Trunk Muscle Endurance After Back Surgery.

OBJECTIVE: To determine the effect of dual tasking on trunk muscle endurance in patients after lumbar diskectomy. DESIGN: Cross-sectional study. SETTING: Rehabilitation hospital setting. PARTICIPANTS: Individuals (N=14) undergoing primary lumbar diskectomy. INTERVENTION: Using a randomized design on 2 separate days, muscle endurance was evaluated during prone bridging and Biering-Sorensen tests. Each test was randomly performed under 2 cognitive conditions: single task without cognitive condition and self-regulated dual task (ie, mathematical task). MAIN OUTCOME MEASURES: The primary outcomes were time to failure and pain assessed by the visual analog scale from 0 to 100 mm. The secondary outcomes were kinesiophobia assessed by the Tampa Scale and disability assessed by the Oswestry Disability Index. Associations were tested using a repeated measures analysis of variance with relevant interaction test. RESULTS: A significant interaction between condition, endurance tests, and kinesiophobia (P=.005) was found. The post hoc comparison showed positive effects between cognitive conditions in both endurance tests (prone bridging test: mean difference, 15.7s; 95% confidence interval [CI], 7.5-24s; P=.001; Biering-Sorensen test: mean difference, 7.9s; 95% CI, 1.9-14s; P=.014). The linear regression analysis between the Tampa Scale for Kinesiophobia and the difference of time to failure between cognitive conditions showed a positive correlation only during the Biering-Sorensen test (r=0.80; P=.001). CONCLUSIONS: A self-regulated dual task increases trunk muscle endurance in patients after lumbar diskectomy. The results suggest that the difference observed in time to failure between the single task and dual task is associated with fear avoidance, especially during back extension. This strategy seems especially relevant for patients with high levels of fear avoidance and may be used to improve trunk muscle endurance.

Association of affected lower limb flexor muscle strength with swing phase duration and gait speed in elderly post-stroke patients.

BACKGROUND: Although several studies have shown an association of muscle weakness with gait speed (GS), no study has explored the relationship of muscle strength with swing phase duration and GS after stroke among the elderly in Saudi Arabia. OBJECTIVE: To examine the association of affected ankle dorsiflexor and hip flexor muscle strength with swing phase duration and GS in the elderly with different stroke chronicity. METHODS: In this cross-sectional study, we included a total of 60 post-stroke patients aged ≥55 years who were admitted in neurorehabilitation units between May 2017 and August 2018. Linear regression was employed to examine the association of muscle strength (measured using a handheld dynamometer) with swing phase duration and GS (both measured using the computerized Zebris-Mat). RESULTS: The chronicity of the stroke was negatively associated (p < 0.05) with swing phase duration. The ankle dorsiflexor muscle strength was significantly associated with GS (ß= 0.656, p = 0.041). In contrast, hip flexor muscle strength was significantly associated with GS (ß= 0.574, p < 0.0001) even after adjusting for stroke chronicity (ß= 0.561, p < 0.0001). CONCLUSIONS: Stroke chronicity was the predictor that reduced swing phase duration. The ankle dorsiflexor muscle strength was associated with GS. However, the hip flexor muscle strength was associated with GS even after adjusting for stroke chronicity.

Association of outcomes in acute flaccid myelitis with identification of enterovirus at presentation: a Canadian, nationwide, longitudinal study.

BACKGROUND: Acute flaccid myelitis (AFM) is characterised by rapid onset of limb weakness with spinal cord grey-matter abnormalities on MRI scan. We aimed to assess whether detection of enterovirus in respiratory or other specimens can help predict prognosis in children with AFM. METHODS: In this nationwide, longitudinal study, we evaluated the significance of detection of enterovirus in any sample in predicting outcomes in a cohort of Canadian children younger than 18 years presenting with AFM to tertiary paediatric hospitals in Canada in 2014 and 2018. All patients fulfilled the 2015 US Centers for Disease Control and Prevention case definition for definite AFM or probable AFM. Clinical data, laboratory findings, treatment, and neuroimaging results were collected (follow up period up to 5 years). We assessed neurological function and motor outcomes using Kurtzke's Expanded Disability Status Scale (EDSS) and a Weakest Limb Score. FINDINGS: 58 children with AFM (median age 5·1 years, IQR 3·8-8·3) were identified across five of Canada's ten provinces and three territories. 25 (43%) children had enterovirus detected in at least one specimen: 16 (64%) with EV-D68, two (8%) with EV-A71, two (8%) with coxsackievirus, 10 (40%) with untyped enterovirus. Children who were enterovirus positive were more likely than those that were negative to have had quadriparesis (12 [48%] of 25 vs four [13%] of 30; p=0·028), bulbar weakness (11 [44%] of 25 vs two [7%] of 30; p=0·028), bowel or bladder dysfunction (14 [56%] of 25 vs seven [23%] of 30; p=0·040), cardiovascular instability (nine [36%] of 25 vs one [3%] of 30; p=0·028), and were more likely to require intensive care unit admission (13 [52%] of 25 vs 5 [17%] of 30; p=0·028). On MRI, most children who were enterovirus positive showed brainstem pontine lesions (14 [61%] of 23), while other MRI parameters did not correlate with enterovirus status. Median EDSS of enterovirus positive (EV+) and enterovirus negative (EV-) groups was significantly different at all timepoints: baseline (EDSS 8·5, IQR 4·1-9·5 vs EDSS 4·0, IQR 3·0-6·0; p=0·0067), 3 months (EDSS 4·0, IQR 3·0-7·4 vs EDSS 3·0, IQR 1·5-4·3; p=0·0067), 6 months (EDSS 3·5, IQR 3·0-7·0 vs EDSS 3·0, IQR 1·0-4·0; p=0·029), and 12 months (EDSS 3·0, IQR 3·0-6·9 vs EDSS 2·5 IQR 0·3-3·0; p=0·0067). Kaplan-Meier survival analysis of a subgroup of patients showed significantly poorer motor recovery among children who tested positive for enterovirus than for those who tested negative (p=0·037). INTERPRETATION: Detection of enterovirus in specimens from non-sterile sites at presentation correlated with more severe acute motor weakness, worse overall outcomes and poorer trajectory for motor recovery. These results have implications for rehabilitation planning as well as counselling of families of children with these disorders. The findings of this study support the need for early testing for enterovirus in non-CNS sites in all cases of AFM. FUNDING: None.

Michigan Initiative for Anterior Cruciate Ligament Rehabilitation (MiACLR): A Protocol for a Randomized Clinical Trial.

OBJECTIVE: Restoring quadriceps muscle strength following anterior cruciate ligament reconstruction (ACLR) may prevent the posttraumatic osteoarthritis that affects over 50% of knees with ACLR. However, a fundamental gap exists in our understanding of how to maximize muscle strength through rehabilitation. Neurological deficits and muscle atrophy are 2 of the leading mechanisms of muscle weakness after ACLR. High-intensity neuromuscular electrical stimulation (NMES) and eccentric exercise (ECC) have been shown to independently target these mechanisms. If delivered in succession, NMES and then ECC may be able to significantly improve strength recovery. The objectives of this study were to evaluate the ability of NMES combined with ECC to restore quadriceps strength and biomechanical symmetry and maintain cartilage health at 9 and 18 months after ACLR. METHODS: This study is a randomized, double-blind, placebo-controlled, single-center clinical trial conducted at the University of Michigan. A total of 112 participants between the ages of 14 and 45 years and with an anterior cruciate ligament rupture will be included. Participants will be randomly assigned 1:1 to NMES combined with ECC or NMES placebo combined with ECC placebo. NMES or NMES placebo will be delivered 2 times per week for 8 weeks beginning 10 to 14 days postoperatively and will be directly followed by 8 weeks of ECC or ECC placebo delivered 2 times per week. The co-primary endpoints are change from baseline to 9 months and change from baseline to 18 months after ACLR in isokinetic quadriceps strength symmetry. Secondary outcome measures include isometric quadriceps strength, quadriceps activation, quadriceps muscle morphology (cross-sectional area), knee biomechanics (sagittal plane knee angles and moments), indexes of patient-reported function, and cartilage health (T1ρ and T2 relaxation time mapping on magnetic resonance imaging). IMPACT: The findings from this study might identify an intervention capable of targeting the lingering quadriceps weakness after ACLR and in turn prevent deterioration in cartilage health after ACLR, thereby potentially improving function in this patient population.

Cochrane Review Summaries-October 2020.

: With the current issue, the journal continues to bring new insights from Cochrane Systematic Reviews to the readers of Obstetrics & Gynecology. This month, we focus on potential interventions to improve pregnancy outcomes for women with recurrent pregnancy loss and antiphospholipid antibodies, the utility of pelvic floor muscle training in the perinatal period to prevent incontinence, and the use of adhesion barriers in gynecologic surgery. The summaries are published below, and the complete references with hyperlinks are listed in Box 1. BOX 1. ABSTRACTS DISCUSSED IN THIS SUMMARY.

The 6 Ps of post-ICU recovery: application of a shared conceptual model.

PURPOSE OF REVIEW: We aimed to explore, through a conceptual model, how we can maximize the post-ICU recovery of patients with ICU-acquired weakness (ICU-AW). The '6 Ps' were used to structure our research questions, what are the Predisposing (pre-ICU patient characteristics), Precipitating (ICU exposures) and Perpetuating (hinder recovery) risk factors for ICU-AW (Problem) and what Protective strategies and Proactive treatment can we adopt to improve muscle mass, strength and function of these patients? RECENT FINDINGS: Examination of the relationship between pre-ICU patient characteristics with ICU-AW and post-ICU factors that prolong recovery are limited. Our understanding of the pathophysiology of the condition is improving, however, much of the biological mechanisms of ICU-AW and persistent weakness remain unknown. Investigation into the ICU-AW phenotype and prediction tools would be of great clinical utility. Further research on ICU-AW muscle biology and recovery may permit the application of precision and personalized medicine to therapeutic interventions. SUMMARY: A structured approach to clinical practice and future research to better understand the mechanism (Problem), and identify Predisposing, Precipitating and Perpetuating risk factors will advance the field in better managing ICU-AW through implementation of Protective strategies and Proactive multimodal treatments.

Contralateral Strength Training as Preparation for Direct Strength Training in a Patient With Unilateral Foot-Drop Because of Multiple Sclerosis: A Case Report.

OBJECTIVE: Direct strength training (DST) is effective in managing unilateral weakness in people with multiple sclerosis (MS). Its feasibility, however, is considerably reduced if one limb is too compromised to train. In this case, contralateral strength training (CST) of the unaffected side to induce a strength transfer to the untrained homologous muscles can help to establish a strength baseline in the weaker limb, eventually allowing direct training. Limited effects for CST, however, have been reported on patient functioning. We tested the effects on dynamometric, electromyographic, and functional outcomes of a sequential combination of CST and DST of the ankle dorsiflexors in a case of MS-related foot-drop. METHODS: A 56-year-old man diagnosed with relapsing-remitting MS exhibited severe weakness of the right dorsiflexors impairing functional dorsiflexion. The intervention consisted of a 6-week CST of the unaffected dorsiflexors followed by 2 consecutive 6-week DST cycles targeting the weaker dorsiflexors. RESULTS: At baseline, the participant could not dorsiflex his right ankle but could do so after CST. Maximal strength of the affected dorsiflexors increased by 80% following CST, by 31.1% following DST-1, and by a further 44.6% after DST-2. Neuromuscular recruitment was found progressively increased, with the largest changes occurring after DST-1. Improvements in mobility and walking speed were also detected, although plantar flexors' spasticity on the Modified Ashworth Scale increased from 1+ to 2. CONCLUSION: In this case, the sequential combination of CST and DST proved a feasible approach to manage severe unilateral weakness in a patient who was not able, at least initially, to dorsiflex his weaker ankle. In this perspective, CST may prime a minimum gain in strength necessary to allow subsequent direct training.

Advances in the rehabilitation of intensive care unit acquired weakness: A case report on the promising use of robotics and virtual reality coupled to physiotherapy.

INTRODUCTION: Traditional physiotherapy is currently the best approach to manage patients with intensive care unit acquired weakness (ICUAW). We report on a patient with ICUAW, who was provided with an intensive, in-patient regimen, that is, conventional plus robot-assisted physiotherapy. Aim of this case study was to assess the efficacy of a combined approach (conventional plus robot-assisted physiotherapy), on muscle strength, overall mobility, and disability burden in a patient with ICUAW in post-ICU intensive rehabilitation setting. PATIENT CONCERNS: A 56-years-old male who was unable to stand and walk independently after hospitalization in an Intensive Care Unit. He initially was provided with daily sessions of conventional physiotherapy for 2 months, with mild results. DIAGNOSIS: The patient was affected by ICUAW. INTERVENTION: Given that the patient showed a relatively limited improvement after conventional physiotherapy, he was provided with daily sessions of robot-aided training for upper and lower limbs and virtual reality-aided rehabilitation for other 4 months, beyond conventional physiotherapy. OUTCOMES: At the discharge (6 months after the admission), the patient reached the standing station and was able to ambulate with double support. CONCLUSIONS: Our case suggests that patients with ICUAW should be intensively treated in in-patient regimen with robot-aided physiotherapy. Even though our approach deserves confirmation, the combined rehabilitation strategy may offer some advantage in maximizing functional recovery and containing disability.