Changes in Quadriceps Muscle Thickness, Disease Severity, Nutritional Status, and C-Reactive Protein after Acute Stroke

No association between vascular aging and sarcopenia in healthy participants

BACKGROUND & AIMS

Several reports inform an association between vascular aging and sarcopenia. However, both conditions appear along with aging. Therefore, their association may be circumstantial and not casually linked. Our aim was to determine if individuals with higher-than-expected vascular aging have a higher frequency of sarcopenia.

METHODS

In 802 participants we calculated the association between pulse wave pressure and carotid intima media thickness and age and blood pressure, to derive predictive regression equations. In 161 of these participants we measured body composition by double beam X ray absorptiometry (DEXA), hand grip strength, rectus femoris thickness by ultrasound, activity energy expenditure by actigraphy and peak oxygen consumption and workload in an incremental exercise test. We calculated their expected values for pulse wave velocity and carotid intima media thickness and compared muscle mass and function between those with higher or lower than expected parameters. In 60 of these participants, we measured body composition sequentially to assess its change over time.

RESULTS

Age and blood pressure predicted the variance of pulse wave velocity and carotid intima media thickness with R2 values of 0.94-0.97 and 0.54 to 0.66, respectively. No differences in the frequency of sarcopenia and in muscle mass and strength were observed between participants with higher or lower than expected pulse wave velocity and carotid intima media thickness. In the group with sequential assessments, no differences in the change of muscle mass over time were observed in participants with and without accelerated vascular aging.

CONCLUSIONS

We were not able to find an association between vascular aging and sarcopenia.

Factors influencing the reduction in quadriceps muscle thickness in the paretic limbs of patients with acute stroke

BACKGROUND & AIMS

Muscle atrophy is an early event that occurs after stroke, but there are few reports on the changes in skeletal muscle thickness in acute stroke. This study investigated the factors contributing to reduced muscle thickness in patients with acute stroke.

METHODS

In total, 51 patients with stroke and the National Institute of the Health Stroke Scale (NIHSS) > 3 were included in our study. They were admitted to our hospital between July 2017 and May 2020. The quadriceps muscle thickness was measured with an ultrasound device within 2 days after admission and 14 days later. The collected data included age, sex, body mass index, stroke type, neuromuscular electrical stimulation, NIHSS, serum albumin at admission, start of enteral nutrition, Functional Oral Intake Scale (FOIS), start of mobilization and ambulation, number of physical and occupational therapy units, C-reactive protein at admission and whether surgery had been performed. These data were retrospectively retrieved from medical documents. A dietician calculated energy intake, protein intake, and energy adequacy. Multiple regression analysis was used to identify the factors associated with reduced quadriceps muscle thickness. The independent variables were NIHSS, date of start of enteral feeding, protein intake, FOIS, date of mobilization, and date of start of ambulation training.

RESULTS

The rate of change in quadriceps muscle thickness of the paretic limb was -15.3 % (interquartile range, -46.1-14.8 %). Multiple regression analysis showed that the factors responsible for the decrease in muscle thickness on the paretic side were FOIS (β: 0.376; 95 % Cl, 0.999 to 4.541) and the start date of ambulation (β: -0.378; 95 % Cl, -2.575 to -0.543), with a multiple correlation coefficient of 0.456.

CONCLUSION

The FOIS and the start date of ambulation after acute stroke were related to the rate of reduction in muscle thickness on the paretic side.

Mfat-1 ameliorates cachexia after hypoxic-ischemic brain damage in mice by protecting the hypothalamus-pituitary-adrenal axis

AIMS

Cachexia, a metabolic syndrome, affects 21 % of patients suffering from ischemic encephalopathy. However, the specific mechanism and prevention measures are still unclear. Omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been proven to reduce inflammatory cytokine levels during ischemic events, but whether they have a protective effect against cachexia after hypoxic-ischemic brain damage (HIBD) remains unclear.

MAIN METHODS

C57BL/6J wild-type and mfat-1 transgenic male mice were treated with and without HIBD. One day after HIBD, the epididymal white fat, gastrocnemius muscle and hypothalamus were weighed and analyzed the phenotypic changes. RNA sequencing was applied to gastrocnemius muscle to identify differential genes and pathways in HIBD groups. The effect of HPA axis on cachexia post-HIBD was examined via adrenalectomy, dexamethasone (0.1 mg/kg), and corticosterone injection (100 mg/kg).

KEY FINDINGS

The results showed that the incidence of cachexia in mfat-1 mice, which produce high proportion of n-3 PUFAs, was significantly lower than that in wild-type mice post-HIBD. Cachexia-related factors, such as inflammation, muscle atrophy and lipid metabolism were significantly improved in mfat-1 HIBD. RNA sequencing revealed that catabolic and proteasome pathways were significantly downregulated. In hypothalamus, inflammatory cytokines, lipid peroxidation levels were reduced. Corticosterone, glucocorticoid receptor, and dexamethasone suppression test all showed that mfat-1 improved the dysfunction of the HPA axis post-HIBD. The present study elucidated for the first time that mfat-1 reduced HIBD-induced hyperactivation of the HPA axis in mice by reducing inflammation and oxidative stress and contributed to the reduction of metabolic imbalance in peripheral tissues.

SIGNIFICANCE

Our study provides mechanistic information for the development of intervention strategies to prevent cachexia.

Relationship between physical activity levels and changes in skeletal muscle characteristics in patients with stroke

PURPOSE

This study aimed to investigate the relationship between physical activity (PA) levels and short-term changes in skeletal muscle characteristics in patients with subacute hemiparetic stroke.

MATERIALS AND METHODS

This prospective observational study included 76 patients with stroke who received inpatient care in a convalescent rehabilitation ward. The PA level was measured as the duration of daily total PA (≥ 1.5 metabolic equivalents) using a triaxial accelerometer for 7 days after admission. The outcomes were changes in the quadriceps muscle quality and quantity on the affected and unaffected sides, as assessed by ultrasonography at admission and 1 month after admission.

RESULTS

Multiple regression analysis indicated that the duration of total PA was significantly associated with a percentage change in quadriceps muscle quality (p = 0.011) and quantity (p = 0.012) on the affected side. However, no significant relationship was observed between the muscle quality and quantity on the unaffected side.

CONCLUSIONS

The results revealed that PA was associated with changes in the quadriceps muscle quality and quantity on the affected side in patients with subacute hemiparetic stroke. These findings highlight the importance of promoting PA in stroke rehabilitation to improve muscle properties and functional outcomes.

Surgery-Related Muscle Loss after Pancreatic Resection and Its Association with Postoperative Nutritional Intake

To study the occurrence of surgery-related muscle loss (SRML) and its association with in-hospital nutritional intake, we conducted a prospective observational cohort study including patients who underwent pancreatic surgery because of (suspected) malignant diseases. Muscle diameter was measured by using bedside ultrasound 1 day prior to surgery and 7 days postoperatively. Clinically relevant SRML was defined as ≥10% muscle diameter loss in minimally one arm and leg muscle within 1 week after surgery. Protein and caloric intake was measured by nutritional diaries. The primary endpoint included the number of patients with SRML. Secondary endpoints included the association between SRML and postoperative nutritional intake. Of the 63 included patients (60.3% men; age 67.1 ± 10.2 years), a total of 24 patients (38.1%) showed SRML. No differences were observed in severe complication rate or length of hospital stay between patients with and without SRML. During the first postoperative week, patients with clinically relevant SRML experienced more days without any nutritional intake compared with the non-SRML group (1 [0-4] versus 0 [0-1] days, p = 0.007). Significantly lower nutritional intake was found in the SRML group at postoperative days 2, 3 and 5 (p < 0.05). Since this study shows that SRML occurred in 38.1% of the patients and most of the patients failed to reach internationally set nutritional goals, it is suggested that more awareness concerning direct postoperative nutritional intake is needed in our surgical community.

The Assessment of the Risk of Malnutrition (Undernutrition) in Stroke Patients

Malnutrition is common in stroke patients, as it is associated with neurological and cognitive impairment as well as clinical outcomes. Nutritional screening is a process with which to categorize the risk of malnutrition (i.e., nutritional risk) based on validated tools/procedures, which need to be rapid, simple, cost-effective, and reliable in the clinical setting. This review focuses on the tools/procedures used in stroke patients to assess nutritional risk, with a particular focus on their relationships with patients' clinical characteristics and outcomes. Different screening tools/procedures have been used in stroke patients, which have shown varying prevalence in terms of nutritional risk (higher in rehabilitation units) and significant relationships with clinical outcomes in the short- and long term, such as infection, disability, and mortality. Indeed, there have been few attempts to compare the usefulness and reliability of the different tools/procedures. More evidence is needed to identify appropriate approaches to assessing nutritional risk among stroke patients in the acute and sub-acute phase of disease or during rehabilitation; to evaluate the impact of nutritional treatment on the risk of malnutrition during hospital stay or rehabilitation unit; and to include nutritional screening in well-defined nutritional care protocols.

Association of Physical Activity and Nutritional Intake with Muscle Quantity and Quality Changes in Acute Stroke Patients

OBJECTIVES

To evaluate longitudinally the muscle properties of acute stroke patients and examine the association between physical activity and nutritional intake.

MATERIALS AND METHODS

This study enrolled 21 stroke patients (72.7±10.4 years). Muscle quantity (fat-free mass, appendicular skeletal muscle mass) and quality (extracellular water/intracellular water ratio, phase angle) were assessed using a bioelectrical impedance device at baseline (within three days) and two weeks after stroke onset. Physical activity and sedentary were calculated from the accelerometer data. Total energy and protein intake were calculated from the dietary surveys as nutritional intake. The association of physical activity, sedentary, and nutritional intake with the rate of changes in muscle properties was examined.

RESULTS

The fat-free mass significantly decreased (from 43.4±8.0 to 42.2±7.6 kg), and the skeletal muscle was unchanged (from 17.8±4.2 to 17.7±4.0 kg) after two weeks. The extracellular water/intracellular water ratio significantly increased (from 0.63±0.02 to 0.65±0.03) and the phase angle significantly decreased (from 5.1±0.6 to 4.9±0.8°), suggesting that the muscle quality have declined. Correlation analysis showed that the extracellular water/intracellular water ratio was significantly associated with physical activity [metabolic equivalents (ρ=-0.61)] and sedentary (ρ=0.67) and that the phase angle was significantly associated with physical activity [metabolic equivalents (ρ=0.69)], sedentary (ρ=-0.68), and nutritional intake [total energy (r=0.45), protein (r=0.45)].

CONCLUSIONS

The fat-free mass and muscle quality (extracellular water/intracellular water ratio and phase angle) declined two weeks after stroke. Physical activity and nutritional intake were lower in patients with decreased muscle quality, suggesting the importance of exercise and nutrition in the acute phase.

Impaired Nutritional Condition After Stroke From the Hyperacute to the Chronic Phase: A Systematic Review and Meta-Analysis

Background

Malnutrition is common after stroke and can affect rehabilitation and healthcare costs. A comprehensive overview of stroke patients' nutritional condition from the hyperacute to the chronic phase is lacking. This systematic review aimed to investigate the prevalence of impaired nutritional condition (INC) across the continuum of care in specific phases after stroke.

Methods

CAB ABSTRACTS, Embase, MEDLINE, were used to collect studies published between 01-01-1999 and 26-08-2020. Primary and secondary outcomes were prevalence of INC and prevalence of malnutrition, respectively. Exploratory outcomes were prevalence of INC at follow-up, nutritional examination methods, prevalence of dysphagia, stroke severity, adverse events, and continent-specific prevalence of INC. A random-effects meta-analysis model was used to estimate the phase-specific pooled prevalence of INC and malnutrition.

Results

The dataset consisted of 78 study groups selected over a total of 1,244 identified records. The pooled prevalence of INC and malnutrition were 19% (95%CI:7–31) (N = 4) and 19% (95%CI:9–29) (N = 3), 34% (95%CI:25–43) (N = 34) and 26% (95%CI:18–35) (N = 29), 52% (95%CI:43–61) (N = 34) and 37% (95%CI:28–45) (N = 31), 21% (95%CI:12–31) (N = 3) and 11% (95%CI:0–24) (N = 3) and 72% (95%CI:41–100) (N = 3) and 30% (95%CI:0–76) (N = 2) in the hyperacute, acute, early subacute, late subacute, and chronic phase, respectively.

Conclusion

INC and malnutrition are highly prevalent in all stages of stroke care. Since malnutrition has been shown to negatively affect clinical outcomes, mortality, and overall healthcare expenditure in stroke survivors, it is essential to examine and monitor the nutritional status of stroke patients throughout their care journey to guide and plan, timely nutritional support and dietary modification.

Changes in muscle architecture on ultrasound in patients early after stroke

BACKGROUND

Early muscle changes are believed to occur in patients with stroke. However, there are insufficient data on the changes in muscle mass and architecture of these patients.

OBJECTIVES

This study investigates differences in ultrasound-derived muscle architecture parameters of the hemiplegic upper and lower limbs in patients with subacute stroke.

METHODS

This is a prospective observational study, which recruited 40 adult patients who had experienced a first ever unilateral stroke (ischemic or hemorrhagic), with a duration of < 1 month post stroke. The brachialis, vastus lateralis and medial gastrocnemius on both the hemiplegic and normal side were evaluated via ultrasound. We recorded clinical variables including Motricity Index, Modified Ashworth Scale (MAS) and Functional Independence Measure (FIM)-walk.

RESULTS

We found reduced mean muscle thickness (p < 0.001) and increased echo intensity (p < 0.001) in the brachialis muscle, increased echo intensity (p = 0.002) in the vastus lateralis muscle, and reduced muscle thickness (p < 0.001) with increased echo intensity (p < 0.001) in the medial gastrocnemius muscle compared to the normal side. There were no significant correlations between ultrasound findings and Motricity Index.

CONCLUSIONS

We report changes in ultrasound-derived muscle architecture in the hemiplegic limbs of patients with subacute stroke, with consistent findings of decreased muscle mass and increased echo intensity.

Relationship between longitudinal changes in skeletal muscle characteristics over time and functional recovery during intensive rehabilitation of patients with subacute stroke

BACKGROUND

Stroke is a disease that easily impairs skeletal muscle characteristics, resulting in low quantity, low quality, and poor strength. However, the recovery process of skeletal muscles in patients with stroke is not well established.

OBJECTIVES

We aimed to determine the longitudinal changes in skeletal muscle characteristics in patients with stroke during intensive rehabilitation and examine their relationship with functional recovery.

METHODS

Eighty-five patients with stroke were prospectively recruited. We defined muscle quantity and quality as ultrasonographic muscle thickness and echo intensity, respectively, and muscle strength as knee extension strength. These skeletal muscle characteristics were compared at four time points: on admission, after 2 weeks, after 4 weeks, and at discharge. We also explored the relationship between changes in skeletal muscle characteristics and functional recovery.

RESULTS

Non-paretic knee extension torque (F = 5.838, P = .001), paretic quadriceps thickness (F = 2.943, P = .039), and paretic tibialis anterior thickness (F = 4.654, P = .004) improved over time, and changes in the paretic side quadriceps thickness were significantly associated with recovery for balance ability (odds ratio, 1.05; 95% confidence interval, 1.00-1.09; P = .048).

CONCLUSIONS

The present study revealed that knee extension muscle strength on the non-paretic side and quadriceps and tibialis anterior thickness on the paretic side significantly improved over time and that changes in the paretic side quadriceps thickness were associated with the recovery of balance ability.

Relationship between Energy Intake and Changes in Thigh Echo Intensity during the Acute Phase of Stroke in Older Patients with Hemiplegia

OBJECTIVE

The aim of this study was to investigate the relationship between energy intake and changes in thigh echo intensity (TEI) during the acute phase of stroke in older patients with hemiplegia.

SUBJECTS AND METHODS

Older hemiplegic inpatients with stroke were enrolled in this post hoc analysis of a prospective observational study. Patients were divided into 2 groups according to energy intake during the 7 days after admission as follows: energy sufficient (ES) and energy insufficient (EIS) groups. The outcome was the rate of changes in TEI of the paralyzed and nonparalyzed sides between admission and after 4 weeks. A decrease in skeletal muscle quality is defined as an increase in intramuscular adipose tissues, which shows as an increase in echo intensity.

RESULTS

The study included 44 males and 39 females (median age 81 years). The rate of change of TEI in each group was as follows: +4.5% in the ES/paralyzed group, +6.7% in the EIS/paralyzed group, -0.9% in the ES/nonparalyzed group, and +4.4% in the EIS/nonparalyzed group. The univariate analyses showed no significant difference in the rate of change in TEI between ES and EIS groups in both paralyzed side (p = 0.190) and nonparalyzed side (p = 0.183). Multivariate analysis showed that higher energy intake was associated with a smaller increase in the rate of change in TEI on the nonparalyzed side (B = -4.115, 95% confidence interval, -7.127 to -1.103).

CONCLUSIONS

Higher energy intake during 7 days after admission was associated with a smaller increase in the rate of change in TEI on the nonparalyzed side upon admission and after 4 weeks.

Elevated Urinary Titin and its Associated Clinical Outcomes after Acute Stroke

INTRODUCTION

Urinary titin is a biomarker of muscle atrophy, which is a serious complication after stroke. However, there are currently no clinical data regarding urinary titin in stroke patients.

METHODS

Consecutive stroke patients admitted to the stroke care unit were included. Spot urine samples were collected immediately after admission, and on days 3, 5, and 7. The primary outcome was the trend of urinary titin in patients after acute stroke. The secondary outcomes included the association between the peak urinary titin level and the modified Rankin Scale (mRS) score, the National Institutes of Health Stroke Scale (NIHSS) score, and the Barthel index (BI) upon hospital discharge. Multivariate analysis was adjusted for age, sex, NIHSS at admission, and the peak urinary titin to predict poor outcome (mRS 3-6).

RESULTS

Forty-one patients were included (29 male; age, 68 ± 15 years), 29 had ischemic stroke, 8 had intracerebral hemorrhage, and 4 had subarachnoid hemorrhage. The levels of urinary titin on days 1, 3, 5, and 7 were 9.9 (4.7-21.1), 16.2 (8.6-22.0), 8.9 (4.8-15.2), and 8.7 (3.6-16.2) pmol/mg Cr, respectively. The peak urinary titin level was associated with the mRS score (r = 0.55, p < 0.01), the NIHSS score (r = 0.72, p < 0.01), and the BI (r = -0.59, p < 0.01) upon hospital discharge. In multivariate analysis, the peak urinary titin was associated with poor outcome (p = 0.03).

CONCLUSIONS

Urinary titin rapidly increased after stroke and was associated with impaired functional outcomes at hospital discharge.

Neuromuscular Electrical Stimulation and High-Protein Supplementation After Subarachnoid Hemorrhage: A Single-Center Phase 2 Randomized Clinical Trial

INTRODUCTION

Aneurysmal subarachnoid hemorrhage (SAH) survivors live with long-term residual physical and cognitive disability. We studied whether neuromuscular electrical stimulation (NMES) and high-protein supplementation (HPRO) in the first 2 weeks after SAH could preserve neuromotor and cognitive function as compared to standard of care (SOC) for nutrition and mobilization.

METHODS

SAH subjects with a Hunt Hess (HH) grade > 1,modified Fisher score > 1 and BMI < 40 kg/m² were randomly assigned to SOC or NMES + HPRO. NMES was delivered to bilateral quadricep muscles daily during two 30-min sessions along with HPRO (goal:1.8 g/kg/day) between post-bleed day (PBD) 0 and 14. Primary endpoint was atrophy in the quadricep muscle as measured by the percentage difference in the cross-sectional area from baseline to PBD14 on CT scan. All subjects underwent serial assessments of physical (short performance physical battery, SPPB) cognitive (Montreal Cognitive Assessment Scale, MoCA) and global functional recovery (modified Rankin Scale, mRS) at PBD 14, 42, and 90.

RESULTS

Twenty-five patients (SOC = 13, NMES + HPRO = 12) enrolled between December 2017 and January 2019 with no between-group differences in baseline characteristics (58 years old, 68% women, 50% HH > 3). Median duration of interventions was 12 days (range 9-14) with completion of 98% of NMES sessions and 83% of goal HPRO, and no reported serious adverse events. There was no difference in caloric intake between groups, but HPRO + NMES group received more protein (1.5 ± 0.5 g/kg/d v 0.9 ± 0.4 g/kg/d, P < 0.01). Muscle atrophy was less in NMES + HPRO than the SOC group (6.5 ± 4.1% vs 12.5 ± 6.4%, P 0.01). Higher atrophy was correlated with lower daily protein intake (ρ = - 0.45, P = 0.03) and lower nitrogen balance (ρ = 0.47, P  = 0.02); and worse 3 month SPPB (ρ = -  0.31, P = 0.1) and mRS (ρ = 0.4, P  = 0.04). NMES + HPRO patients had a better median [25%,75] SPPB (12[10, 12] v. 9 [4, 12], P = 0.01) and mRS (1[0,2] v.2[1, 3], P = 0.04) than SOC at PBD 90.

CONCLUSIONS

NMES + HPRO appears to be feasible and safe acutely after SAH and may reduce acute quadriceps muscle wasting with a lasting benefit on recovery after SAH.

Preventive Effects of Repetitive Peripheral Magnetic Stimulation on Muscle Atrophy in the Paretic Lower Limb of Acute Stroke Patients: A Pilot Study

Objective:

The aim of this study was to investigate the effect of repetitive peripheral magnetic stimulation (rPMS) on muscle atrophy prevention in the rectus femoris muscle (RF) of the paretic limb in acute stroke patients.

Methods:

Twelve acute stroke patients with a National Institute of Health Stroke Scale score >5 and a motor score of the paretic lower limb >2 at admission were divided into an intervention group (rPMS: mean age, 75±6.4 years) and a conventional care group (non-rPMS: mean age, 62±11.8 years). Baseline measurements were performed within 4 days of stroke onset. In the rPMS group, treatment was applied to the paretic thigh only for 2 weeks, 5 days a week, in addition to conventional care. The cross-sectional area (CSA) of the RF was assessed in both limbs using ultrasound at baseline and 2 weeks later. Data on patient characteristics were collected from the clinical records to assess correlations with the CSA rate of change.

Results:

Patients in the rPMS group were significantly older. Although the CSA of the RF did not change significantly on either side in the rPMS group, there was a significant decrease in the CSA on the paretic side in the non-rPMS group. However, no significant difference was observed in the CSA rate of change in the rPMS and non-rPMS groups. The CSA rate of change on the paretic side correlated negatively with age in the rPMS group.

Conclusions:

Our results suggest that rPMS prevents muscle atrophy more effectively in patients in their 60s than in patients more than 70 years old.

The evaluation of the tendon and muscle changes of lower extremity in patients with acromegaly

PURPOSE

Although it is well known that acromegaly causes enlargement in the extremities, studies investigating the effects of acromegaly on tendons, muscles and soft tissue are limited. The aims of our study were to investigate tendons, the presence of enthesitis, soft tissue, muscle groups in terms of thickness and pennation angle (PA) which is an indicator of microstructure and strength of the muscle, of the lower extremities.

METHODS

Thirty-nine patients with acromegaly and thirty-nine healthy control subjects similar for age, sex and body mass index were enrolled. Lower extremity tendons, skin, muscle groups were evaluated by ultrasound.

RESULTS

The thicknesses of heel skin, heel pad, plantar fascia and Achilles tendon were higher in acromegaly than the control group (p < 0.05). The incidence of Achilles enthesitis were increased in the acromegaly group (p < 0.05). The thicknesses of the gastrocnemius medial head, vastus medialis, lateralis muscles for both sides and the left rectus femoris muscle were found to be lower in the acromegaly patients than controls (p < 0.05). However, thicknesses of vastus intermedius, gastrocnemius lateral head and soleus were similar between the acromegaly and control groups (p > 0.05). PA values of the right and left vastus medialis and the right vastus lateralis were found to be decreased in the acromegaly group (p < 0.05). Myostatin levels were lower in acromegaly group (p < 0.05).

CONCLUSIONS

Acromegaly may cause to an increase in tendon and soft tissue thickness, enthesitis formation, decrease in the thickness of some muscles, and deterioration in microstructures in lower extremity.

Non-paretic lower limb muscle wasting during acute phase is associated with dependent ambulation in patients with stroke

BACKGROUND

Muscle wasting in patients with stroke is a factor for a poor functional outcome. However, there have been few studies on the relationships between lower limb muscle wasting during the acute phase and dependent ambulation. This study examined whether lower limb muscle wasting during the acute phase is associated with the dependent ambulation status at 3 months after stroke.

METHODS

In this observational cohort study, we measured the quadriceps muscle thickness in the paretic and non-paretic limbs within 1 and 3 weeks after admission using ultrasonography in non-ambulatory patients with acute stroke. Patients were categorized into two groups based on their ambulation ability: dependent, functional ambulation category (FAC) 0-3 and independent, FAC 4-5) at 3 months after stroke.

RESULTS

In total, 55 patients were included and completed follow-up, and 28 patients (51%) had an ambulation status of dependent at 3 months after stroke. Significant differences in muscle wasting were observed in the non-paretic limb (-5.5% [8.7%] : -16.8% [13.6%], independent group: dependent group, respectively, P < 0.001), but not in the paretic limb (-15.0% [14.3%] : -18.7% [15.1%], P = 0.36). Even after adjusting for covariates, muscle wasting in the non-paretic limb was a significant independent predictor of dependent ambulation (adjusted odds ratio, 0.87; 95% confidence interval, 0.76-0.99, P = 0.033).

CONCLUSION

Post-stroke muscle wasting in the non-paretic lower limb during the acute phase is independently associated with dependent ambulation after stroke.

Cross-sectional study of quadriceps properties and postural stability in patients with chronic stroke and limited vs. non-limited community ambulation

Background: Changes in the paretic-side metabolism post-stroke and quadriceps muscle mechanical properties favour muscle wasting, affecting postural instability and walking impairment. Further clarification is needed in subjects post-stroke who show limited or non-limited community ambulation. Objectives: To analyze between-limb differences in quadriceps muscle thickness, strength and thigh cutaneous temperature, as well as investigate postural stability in subjects with chronic stroke and limited vs. non-limited community ambulation and compared against healthy controls. Methods: In this controlled cross-sectional study, 26 participants with chronic hemiparesis post-stroke (divided in a slow gait group (SG<0.8 m/s) (n = 13) and a fast gait group with full community ambulation speed (FG≥0.8 m/s)) and 18 healthy people were recruited. Thigh surface temperature, rectus femoris (RF) and vastus intermedius (VI) muscles thickness, quadriceps' isometric maximal voluntary contraction and postural stability were measured. Results: The SG presented significantly lower RF (P = .019) and VI (P = .006) muscle thickness, less peak force (P < .001) and lower temperature (P = .002) in the paretic vs the non-paretic limb. The FG showed significantly lower VI thickness (P = .036) and peak force (P < .001) in the paretic vs the non-paretic limb. Regarding balance, all indices were worse in the SG versus the FG and CG. Conclusions: Subjects of the FG, despite showing full community ambulation speed, had less quadriceps strength and VI muscle thickness but not RF muscle wasting in the paretic limb. The paretic VI muscle wasting may be an important factor to reach normal walking. The SG showed between-limb differences in all the studied variables and the worst postural stability.

Body weight changes and incidence of cachexia after stroke

BACKGROUND

Body weight loss is a frequent complication after stroke, and its adverse effect on clinical outcome has been shown in several clinical trials. The purpose of this prospective longitudinal single-centre observational study was to investigate dynamical changes of body composition and body weight after ischemic stroke and an association with functional outcome.

METHODS

Sixty-seven consecutive patients (age 69 ± 11 years, body mass index 27.0 ± 4.1 kg/m² , 42% female patient, mean ± SD) with acute ischemic stroke with mild to moderate neurological deficit (National Institute of Health Stroke Scale median 4, ranged 0-12) were analysed in the acute phase (4 ± 2 days) and at 12 months (389 ± 26 days) follow-up. Body composition was examined by dual energy X-ray absorptiometry. Cachexia was defined according to the consensus definition by body weight loss ≥5% within 1 year and additional clinical signs. Lean tissue wasting was considered if a ratio of upper and lower limbs lean mass sum to squared height (kg/m² ) was ≤5.45 kg/m² for female patient and ≤7.25 kg/m² for male patient.

RESULTS

According to the body weight changes after 12 months, 42 (63%) patients had weight gain or stable weight, 11 (16%) patients had moderate weight loss, and 14 (21%) patients became cachectic. A relative decline of 19% of fat tissue and 6.5% of lean tissue was observed in cachectic patients, while no changes of lean tissue were observed in non-cachectic patients after 12 months. The modified Rankin Scale was 48% higher (2.1 ± 1.6, P < 0.05), Barthel Index was 22% lower (71 ± 39, P < 0.01), and handgrip strength was 34% lower (21.9 ± 13.0, P < 0.05) in cachectic compared to non-cachectic patients after 12 months. The low physical performance if defined by Barthel Index <60 points was linked to the lean tissue wasting (OR 44.8, P < 0.01), presence of cachexia (OR 20.8, P < 0.01), and low body mass index <25 kg/m² (OR 11.5, P < 0.05). After adjustment for cofounders, lean tissue wasting remained independently associated with the low physical performance at 12 months follow-up (OR 137.9, P < 0.05).

CONCLUSIONS

In this cohort study, every fifth patient with ischemic stroke fulfilled the criteria of cachexia within 12 months after index event. The incidence of cachexia was 21%. Cachectic patients showed the lowest functional and physical capacity.

The effects of early neurodevelopmental Bobath approach and mobilization on quadriceps muscle thickness in stroke patients

Background/aim

Following stroke, damage to the central nervous system and adaptive changes in muscle tissue are factors responsible for the loss of muscle strength. Even though it is suggested that early physiotherapy and mobilization prevent structural adaptive changes in muscle tissue, studies regarding this issue are insufficient. The aim of this study is to investigate the effects of early physiotherapy and mobilization on quadriceps muscle thickness (QMT) in stroke patients.

Materials and methods

Twelve stroke patients who were admitted to the neurology intensive care unit and 13 healthy controls were included in the study. QMT was examined at admission and discharge for each subject. Additionally, functional extremity movements, balance, and functional ambulation status were evaluated with the Stroke Rehabilitation Assessment of Movement Scale (STREAM). All of the patients were mobilized as early as possible by a physiotherapist and included in a treatment program consisting of the neurodevelopmental Bobath approach.

Results

The patients’ QMT values at admission and discharge were found to be similar to those of the healthy control group (P > 0.05). When the patients’ QMT at the time of admission and discharge were compared, it was seen that the affected side and the nonaffected side were similar (P > 0.05). Additionally, when the admission and discharge results were compared, improvements in functional extremity movements, balance, and functional ambulation levels were observed (P < 0.05).

Conclusion

It can be seen that QMT can be preserved and functional improvements can be provided through intense physiotherapy and mobilization initiated in the early period following stroke.

Systemic inflammatory markers in individuals with cerebral palsy

Individuals with cerebral palsy (CP) develop skeletal muscle contractures that impair muscle function. In turn, contractures affect the ability to ambulate and often promote a sedentary lifestyle. The aim of the present study was to investigate the systemic inflammatory markers transforming growth factor beta-1 (TGFβ1), C-reactive protein (CRP), and interleukin-6 (IL-6) in children and adults with CP. Blood samples of n = 34 participants (24 individuals with CP (n = 14 children with CP age 10.36 ± 1.1 and n = 10 adults with CP age 38.80 ± 3.6) and 10 healthy adults age 36.63 ± 3.8) were analyzed for circulating levels of TGFβ1, CRP, and IL-6 using Sandwich Enzyme linked immunosorbent assay (ELISA) analyses (R&D systems). TGFβ1 and CRP levels were significantly higher in children with CP compared to both adults with CP (TGFβ1: P < 0.0005 and P < 0.0002, respectively) and healthy adults (CRP: P < 0.0001 and P < 0.0001, respectively), while no differences were observed between the adults with CP and healthy adults in TGFβ1 ( P = 0.29) and CRP ( P = 0.59), respectively. Furthermore, IL-6 levels showed no significant differences between the groups. The present findings indicate that the level of systemic inflammation is increased in children with CP. We speculate that persisting inflammation in children with CP might influence the development of muscle contractures, resulting in reduced muscle mass and marked muscle weakness in adults with CP.

Neuromuscular electrical stimulation is ineffective for treating quadriceps muscle wasting with ruptured aneurysm: A case report

Introduction

Neuromuscular electrical stimulation (NMES) is a preventive intervention for muscle wasting in patients with aneurysms during the acute phase; however, its efficacy still remains unclear. In this case study, we report the effects of NMES on quadriceps muscle wasting for a patient with ruptured middle cerebral artery aneurysms during the acute phase.

Presentation of case

A 66-year-old woman was admitted because of a ruptured middle cerebral artery aneurysm resulting from intracerebral hematoma with subarachnoid hemorrhage. The following day, the patient started undergoing 60–120-min NMES treatment for both her quadriceps muscles, which was continued for 10 days in 2 weeks. Quadriceps muscle thickness as measured by ultrasonography was decreased in both sides (26% and 35% for the right and left sides, respectively). The compound muscle action potential (CMAP) amplitude in the peroneal nerve was also decreased in both sides (73% vs 76%).

Discussion

The lack of efficacy of NMES in preventing muscle wasting is the decreased CMAP amplitude in this patient, which showed the possibility of existence of critical illness polyneuropathy.

Conclusion

NMES had no effect on quadriceps muscle wasting in a patient with ruptured middle cerebral artery aneurysms who had decreased CMAP amplitude in the peroneal nerve during the acute phase. NMES is not effective for patients with peripheral nerve conduction abnormalities.

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NMES is not effective for preventing muscle wasting and disability.

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NMES is not effective for patients with peripheral nerve conduction abnormalities.

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The efficacy of NMES is dependent on whether conduction abnormalities exist.

Effects of l-Carnitine Supplementation, Botulinum Neurotoxin Injection, and Rehabilitation for a Chronic Stroke Patient

Botulinum neurotoxin injection therapy and rehabilitation have been conducted for stroke patients to reduce the spasticity of their affected limbs and improve their walking ability and daily living. Furthermore, their disability was reported to be related to muscle wasting. Supplementation of l-carnitine was reported to improve physical endurance and was used to treat sarcopenia in, for example, patients with cancer. Here, we report a case of chronic stroke with muscle wasting in a patient with improved walking endurance by l-carnitine supplementation, botulinum neurotoxin injection, and rehabilitation. A 58-year-old woman had a left putamen hemorrhage 9years before, and right spastic hemiplegia and walking disability. She could walk no more than 20m. Botulinum neurotoxin injection and rehabilitation were performed 6times every 3 months. The first time, walking speed and continuous walking distance increased as her spasticity decreased. However, the improvement declined after the second and third treatments. She had right leg pain during walking, accompanied by muscle wasting. The l-carnitine prescription contributed to the attenuation of her leg pain during walking and rapid improvement of her continuous walking distance. Walking speed and endurance further improved. In addition, the withdrawal of l-carnitine did not decrease her walking ability or induce a recurrence of her leg pain. Interestingly, creatine phosphokinase increased after l-carnitine was stopped, indicating that l-carnitine had helped to reduce muscle damage during rehabilitation. This case suggests that chronic stroke patients with muscle wasting have an abnormality in the mitochondrial energy metabolism of their muscles.

Efficacy of neuromuscular electrical stimulation for preventing quadriceps muscle wasting in patients with moderate or severe acute stroke: A pilot study

BACKGROUND

Stroke-related muscle wasting is one of the factors leading to long-term disability and functional dependency. No study has reported an effective therapeutic intervention for such muscle wasting.

OBJECTIVE

The purpose of this study was to investigate the effects of neuromuscular electrical stimulation (NMES) on quadriceps muscle mass preservation in patients with acute moderate or severe stroke by using ultrasonography (US).

METHODS

Twenty patients with acute, moderate, or severe stroke (age: 68±11 years) were divided into usual care group (control group) and intervention groups (NMES group), respectively. Patients in the NMES group underwent NMES treatment for bilateral quadriceps muscles for 2 weeks in addition to the usual care. Quadriceps muscle thickness was measured on admission and 2 weeks after the first measurement.

RESULTS

The quadriceps muscle thickness on the paretic and non-paretic sides in the NMES group (-12.4% ±12.7%, -5.5% ±15.3%, respectively) significantly decreased to a lesser degree than that in the control group (-29.5% ±12.1%, P = 0.004; and -22.0% ±16.8%, P = 0.04, respectively).

CONCLUSIONS

NEMS seemed to have preserved the quadriceps muscle mass in patients with moderate or severe acute stroke.

Quadriceps muscle thickness changes in patients with aneurysmal subarachnoid hemorrhage during the acute phase

Background Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition that often leads to severe disability in relatively young and healthy people. This disability is physical in many aSAH survivors, so muscle dysfunction may be an important factor in the functional level of these patients. Thus, measuring muscle thickness represents a suitable method for determining muscle function in patients with acute aSAH, because the disordered consciousness often experienced during the acute phase causes active movement to be difficult for these patients. Objectives We investigated changes in quadriceps muscle thickness in patients with aneurysmal subarachnoid hemorrhage to determine whether muscle dysfunction during the acute phase relates to (or predicts) the outcome of aSAH. Methods Seventeen patients with aSAH (mean age = 66 ± 11, men/women = 4/13) were enrolled, and their quadriceps muscle thickness measured ultrasonographically upon admission and again 2 weeks later. Results Quadriceps muscle thickness significantly decreased from admission (mean = 3.00 ± 0.72 cm) to the second measurement (2.67 ± 0.74 cm, p = 0.001). The relative differences in quadriceps muscle thickness were correlated with the Hunt and Hess grade (r = -0.72, p = 0.001) and the modified Rankin Scale score at 90 days (r = -0.78, p = 0.0002). Conclusions Our results indicate that quadriceps muscle thickness decreases in patients with acute aneurysmal subarachnoid hemorrhage, particularly in patients with poor Hunt and Hess grade or marked disability.