Transcranial Color Coded Duplex Sonography Findings in Stroke Patients Undergoing Rehabilitation: An Observational Study

Background Transcranial color-coded duplex sonography (TCCD) provides information on intracranial blood flow status in stroke patients and can predict rehabilitation outcomes. Objective This study aimed to assess middle cerebral artery (MCA) parameters using TCCD in MCA territory stroke patients admitted for rehabilitation and correlate with clinical outcome measures. Material and Methods Patients aged 18 to 65 years with a first MCA territory stroke, within 6 months of onset were recruited. The clinical outcome scales and TCCD parameters were assessed at both admission and discharge. The scales used were the Scandinavian stroke scale (SSS), Barthel Index (BI), modified Rankin Scale (mRS), Fugl–Meyer upper extremity scale (FMA-UE), modified motor assessment scale (mMAS) scores. TCCD parameters measured were MCA peak systolic, end diastolic, mean flow velocities (MFV), and index of symmetry (SI) and were correlated with clinical scores. Results Fourteen patients were recruited with median age of 56.5 years, median duration of stroke was 42.5 days. Mean flow velocities of affected and unaffected MCA were 46.2 and 50.7 cm/s, respectively. Flow velocities and SI did not change between the two assessments. There was significant improvement in clinical outcome scores at discharge. Significant correlation was observed for patient group with SI > 0.9 at admission with FMA-UE, SSS, and BI scores at discharge (p < 0.05). Conclusion Flow velocity parameters did not change during in-patient rehabilitation. Patients with symmetric flow at admission had improved clinical outcomes measure scores at discharge. Thus SI can predict rehabilitation outcomes in stroke survivors.

A New Framework to Interpret Individual Inter-Hemispheric Compensatory Communication after Stroke

Stroke constitutes the main cause of adult disability worldwide. Even after application of standard rehabilitation protocols, the majority of patients still show relevant motor impairment. Outcomes of standard rehabilitation protocols have led to mixed results, suggesting that relevant factors for brain re-organization after stroke have not been considered in explanatory models. Therefore, finding a comprehensive model to optimally define patient-dependent rehabilitation protocols represents a crucial topic in clinical neuroscience. In this context, we first report on the rehabilitation models conceived thus far in the attempt of predicting stroke rehabilitation outcomes. Then, we propose a new framework to interpret results in stroke literature in the light of the latest evidence regarding: (1) the role of the callosum in inter-hemispheric communication, (2) the role of prefrontal cortices in exerting a control function, and (3) diaschisis mechanisms. These new pieces of evidence on the role of callosum can help to understand which compensatory mechanism may take place following a stroke. Moreover, depending on the individual impairment, the prefrontal control network will play different roles according to the need of high-level motor control. We believe that our new model, which includes crucial overlooked factors, will enable clinicians to better define individualized motor rehabilitation protocols.

Perspectives on Rehabilitation Using Non-invasive Brain Stimulation Based on Second-Person Neuroscience of Teaching-Learning Interactions

Recent advances in second-person neuroscience have allowed the underlying neural mechanisms involved in teaching-learning interactions to be better understood. Teaching is not merely a one-way transfer of information from teacher to student; it is a complex interaction that requires metacognitive and mentalizing skills to understand others’ intentions and integrate information regarding oneself and others. Physiotherapy involving therapists instructing patients on how to improve their motor skills is a clinical field in which teaching-learning interactions play a central role. Accumulating evidence suggests that non-invasive brain stimulation (NIBS) modulates cognitive functions; however, NIBS approaches to teaching-learning interactions are yet to be utilized in rehabilitation. In this review, I evaluate the present research into NIBS and its role in enhancing metacognitive and mentalizing abilities; I then review hyperscanning studies of teaching-learning interactions and explore the potential clinical applications of NIBS in rehabilitation. Dual-brain stimulation using NIBS has been developed based on findings of brain-to-brain synchrony in hyperscanning studies, and it is delivered simultaneously to two individuals to increase inter-brain synchronized oscillations at the stimulated frequency. Artificial induction of brain-to-brain synchrony has the potential to promote instruction-based learning. The brain-to-brain interface, which induces inter-brain synchronization by adjusting the patient’s brain activity, using NIBS, to the therapist’s brain activity, could have a positive effect on both therapist-patient interactions and rehabilitation outcomes. NIBS based on second-person neuroscience has the potential to serve as a useful addition to the current neuroscientific methods used in complementary interventions for rehabilitation.

Association of anemia with rehabilitation outcomes for subacute geriatric rehabilitation patients in a secondary hospital in malaysia

Background: To evaluate the effects of anemia on rehabilitation outcomes for geriatric subjects in the Taiping Hospital subacute geriatric rehabilitation ward. Methods: This was a retrospective study with 126 subjects that compared the change in the modified Barthel Index score of anemic and non-anemic subjects. Results: In the study, 43.7% of subjects were anemic. Among anemic subjects, 45.5% were Malay, 38.2% were Chinese, 14.5% were Indian, and 1% were others. The median (Interquartile (IQR)) modified Barthel Index (MBI) on admission for anemic and non-anemic subjects was insignificantly different, at 47 (29, 63) and 36 (21, 59), respectively (P = 0.059). The median (IQR) of MBI improvement for non-anemic subjects was found to be significantly higher than for anemic subjects, which were 14 (5, 26) and 8 (1, 18; P = 0.021). Subjects with hemoglobin (hb) ≥ 9 g/dL were significantly associated with MBI improvement of more than 20, P = 0.009. Simple linear regression found that the P-values were not significant for albumin, creatinine, the Charlson comorbidity index, or the clinical frailty scale; hence, they were not significantly associated with rehabilitation outcome. Conclusions: The study suggested that non-anemic subjects showed significant MBI improvement. Our study also suggested that judicious practices to target a hb threshold of 9 g/dL might be able to improve a subject’s functional outcome. These results should encourage further research with a larger elderly population to provide insights and awareness for the need to treat anemia in rehabilitation subjects. Keywords: Geriatric, anemia, rehabilitation, modified barthel index

Cerebellar Dysfunction in Multiple Sclerosis: Considerations for Research and Rehabilitation Therapy

Introduction. Cerebellar pathology is common among persons with multiple sclerosis (PwMS). The cerebellum is well recognized for its role in motor control and motor learning and cerebellar pathology in multiple sclerosis is associated with enhanced motor impairment and disability progression. The Problem. To mitigate motor disability progression, PwMS are commonly prescribed exercise and task-specific rehabilitation training. Yet, whether cerebellar dysfunction differentially affects rehabilitation outcomes in this population remains unknown. Furthermore, we lack rehabilitation interventions targeting cerebellar dysfunction. The Solution. Here, we summarize the current understanding of the impact of cerebellar dysfunction on motor control, motor training, and rehabilitation in persons with multiple sclerosis. Recommendations. Additionally, we highlight critical knowledge gaps and propose that these guide future research studying cerebellar dysfunction in persons with multiple sclerosis.

Norepinephrine in Goal-Directed Fluid Therapy during General Anesthesia in Elderly Patients Undergoing Spinal Operation: Determining Effective Infusion Rate to Enhance Postoperative Functions

Background and Objective: Intraoperative hypotension is a common complication in general anesthesia that could result in different serious complications particularly in elderly patients. This Randomized Clinical Trial (RCT) aims to determine effective continuous infusion rate of norepinephrine to prevent intraoperative hypotension during spinal surgery under general anesthesia in elderly patients. Methods: This RCT was conducted on elderly patients (n= 108) undergoing general anesthesia for posterior lumbar spinal fusion. The patients were randomly divided into 0.030, 0.060, and 0.090 μg.kg-1.min-1 groups of norepinephrine infusion rates. The outcomes were assessed at entrance to operation room (T0), 15 mins after anesthesia induction (T1), 60 mins following surgery (T2), and immediately after surgery (T3). The intraoperative and postoperative complications and rehabilitation outcomes were comparatively assessed. Results: All three groups significantly reduced the incidence of delayed wound healing (0.030 vs. 0.060 vs. 0.090 μg.kg-1.min-1; 33.3% vs. 10% vs. 10%, P=0.024) and wound infection (26.7% vs. 6.7% vs. 6.7%, P=0.031). Intraoperative total fluid volume and colloids volume in the 0.030 group were significantly higher than 0.060 and 0.090 groups (P=0.005, P=0.003, and P=0.01, respectively). The 0.060 and 0.090 groups significantly increased mean-arterial-pressure than the 0.030 group at T2 and T3. Both 0.060 and 0.090 infusion rates significantly reduced intraoperative hypotension than 0.030 dosage (P=0.01 and P=0.003, respectively). The bradycardia incidence in the 0.090 group was significantly higher than the 0.030 (P=0.026) and 0.060 groups (P=0.038). The 0.060 group decreased the first intake by 1.4 hours (P=0.008) and first flatus by 1.1 hours (P=0.004) and postoperative hospital stay by 1 day (P=0.066). Conclusion: The 0.060 µg·kg-1·min-1 norepinephrine infusion combined with goal-directed fluid therapy exhibited adequate intraoperative management and postoperative outcomes.