Quadriceps Thickness and Echo Intensity Predict Gait Independence in Individuals with Severe and Mild Hemiparetic Stroke

Relationship between progressive improvement in gait ability one year after discharge and skeletal muscle characteristics of stroke survivors

BACKGROUND

The clinical importance of skeletal muscle characteristics for improving gait ability of stroke survivors is increasing. We aimed to examine the association between muscle quantity and quality at discharge and changes in gait independence at the time of 1 year after discharge in patients with stroke.

METHODS

This prospective observational study included 100 patients with stroke who were admitted to a convalescent rehabilitation ward. We defined muscle quantity and quality operationally as muscle thickness and echo intensity observed in ultrasonography images, respectively, and measured quadriceps muscle on the paretic and non-paretic sides at the time of discharge. The outcome measured in our study was changes in gait independence 1 year after discharge, as assessed by the Functional Independence Measure gait assessment tool score.

RESULTS

Among the study participants, 23 (23.0 %) were assessed to have reduced gait independence, while 77 (77.0 %) were evaluated to have improved or maintained gait independence. Our multivariate logistic regression analysis revealed that only muscle quantity on the paretic side was significantly associated with an improvement or maintenance of gait independence (odds ratios 3.32; 95 % confidence interval 1.01-10.95; p = 0.049).

CONCLUSIONS

Our findings revealed that an improvement in gait independence 1 year after discharge was influenced by quadriceps muscle quantity on the paretic side at the time of discharge in patients with subacute stroke. This finding highlights the importance of lower limb muscle quantity on the paretic side as a clinically significant factor that influences the improvement in gait ability after hospital discharge.

The relationship between sarcopenic obesity and changes in quadriceps muscle thickness and echo intensity in patients with stroke

BACKGROUND

Research findings on skeletal muscle degeneration in post-stroke sarcopenic obesity are limited. Thus, this study aimed to investigate the association between post-stroke sarcopenic obesity and quantitative and qualitative changes in skeletal muscles.

METHODS

This was a cross-sectional study conducted on patients with stroke admitted to the convalescent rehabilitation ward. For skeletal muscle assessment, an ultrasound system was used to measure quadriceps muscle thickness and echo intensity (QMT and QEI) on the paretic and non-paretic sides. Sarcopenic obesity was defined as the presence of both sarcopenia and obesity. Multiple regression analysis was performed to determine the relationships between sarcopenic obesity and QMT and QEI.

RESULTS

A total of 130 patients with stroke were included in this study (mean age: 69.4 ± 12.7 years). The prevalence of sarcopenic obesity was 23.1%. The multiple regression analysis showed that sarcopenic obesity was significantly negatively associated with QMT on both the paretic and non-paretic sides (paretic side: β =  -0.28, p < 0.001; non-paretic side: β =  -0.37, p < 0.001) and significantly positively associated with QEI (paretic side β = 0.21, p = 0.034; non-paretic side: β = 0.20, p = 0.029).

CONCLUSIONS

Post-stroke sarcopenic obesity was independently associated with quantitative and qualitative changes in skeletal muscles on both the paretic and non-paretic sides.

The Validity of Quadriceps Muscle Thickness as a Nutritional Risk Indicator in Patients with Stroke

This study aimed to investigate whether quadriceps muscle thickness (QMT) is useful for nutritional assessment in patients with stroke. This was a retrospective cohort study. Nutritional risk was assessed using the Geriatric Nutritional Risk Index (GNRI), with GNRI < 92 indicating a risk of malnutrition and GNRI ≥ 92 indicating normal conditions. Muscle mass was assessed using QMT and calf circumference (CC). The outcome was Functional Independence Measure (FIM) effectiveness. The cutoff values of QMT and CC for discriminating between high and low GNRI were determined using the receiver operating characteristic curve. The accuracy of the nutritional risk discrimination model was evaluated using the Matthews correlation coefficient (MCC). Multiple regression analysis was performed to assess the relationship between nutritional risk, as defined by QMT and CC, and FIM effectiveness. A total of 113 patients were included in the analysis. The cutoff values of QMT and CC for determining nutritional risk were 49.630 mm and 32.0 cm for men (MCC: 0.576; 0.553) and 41.185 mm and 31.0 cm for women (MCC: 0.611; 0.530). Multiple regression analysis showed that only nutritional risk defined by QMT was associated with FIM effectiveness. These findings indicate that QMT is valid for assessing nutritional risk in patients with stroke.

Structural and pathophysiological muscle changes up to one year after post-stroke hemiplegia: a systematic review

INTRODUCTION

Muscle changes after stroke cannot be explained solely on the basis of corticospinal bundle damage. Muscle-specific changes contribute to limited functional recovery but have been poorly characterized.

EVIDENCE ACQUISITION

We conducted a systematic review of muscular changes occurring at the histological, neuromuscular and functional levels during the first year after the onset of post-stroke hemiplegia. A literature search was performed on PubMed, Embase and CINHAL databases up to November 2022 using a keyword combination comprising cerebral stroke, hemiplegic, atrophy, muscle structure, paresis, skeletal muscle fiber type, motor unit, oxidative stress, strength, motor control.

EVIDENCE SYNTHESIS

Twenty-seven trial reports were included in the review, out of 12,798 articles screened. Structural modifications described on the paretic side include atrophy, transformation of type II fibers into type I fibers, decrease in fiber diameter and apparent myofilament disorganization from the first week post-stroke up to the fourth month. Reported biochemical changes comprise the abnormal presence of lipid droplets and glycogen granules in the subsarcolemmal region during the first month post-stroke. At the neurophysiological level, studies indicate an early decrease in the number and activity of motor units, correlated with the degree of motor impairment. All these modifications were present to a lesser degree on the non-paretic side. Although only sparse data concerning the subacute stage are available, these changes seem to appear during the first two weeks post-stroke and continue up to the third or fourth month.

CONCLUSIONS

Considering these early pathophysiological changes on both the paretic and non-paretic sides, it seems crucial to promptly stimulate central and also peripheral muscular activation after stroke through specific rehabilitation programs focused on the maintenance of muscle capacities associated with neurological recovery or plasticity.

Utility of ultrasound as a promising diagnostic tool for stroke-related sarcopenia: A retrospective pilot study

Stroke patients undergo extensive changes in muscle mass which lead to stroke-related sarcopenia. Stroke-related sarcopenia has a significant impact on the functional outcome of stroke survivors. So, it is important to measure muscle mass in stroke patients. This study aimed to examine the correlation between ultrasonographic quadriceps muscle thickness (QMT) and dual-energy X-ray absorptiometry (DXA) derived appendicular lean mass (ALM) in patients with acute hemiplegic stroke. Twenty five participants were included (13 men and 12 women) in this study, who were diagnosed with stroke within 1 month. For both paretic and non-paretic legs, QMT was measured by an ultrasound and ALM was obtained by performing DXA scan. We analyzed the difference and the correlation between ultrasonographic QMT and DXA-derived lean body mass of both paretic and non-paretic legs. Stroke patients were divided into 2 groups according to the paretic knee extensor power. Ultrasonographic QMT, DXA scan findings, and functional parameters were compared. There was a significant correlation between QMT and ALM index, and between QMT and site-specific lean mass (SSLM) of both the legs for both the sexes (P < .05). In multivariate linear regression model, we made adjustments for the confounding factors of age, sex, body mass index (BMI) and paretic knee extensor power. We observed a positive relationship between QMT and ALM index (P < .05), and between QMT and SSLM of both the legs (P < .05). The % QMT showed higher difference than % SSLM between paretic and non-paretic legs (10.25% vs 4.58%). The QMT measurements of ultrasound show a great relationship with DXA scan findings. Ultrasound better reflects the change of muscle mass between paretic and non-paretic legs than DXA scan at an acute phase of stroke. Ultrasound could be a useful tool to evaluate stroke-related sarcopenia.

Greater Quadriceps Muscle Mass at Post-Acute Care Admission is Associated with Better Swallowing Ability at Discharge among Adults with Stroke

OBJECTIVES

This study aimed to examine the relationship between muscle mass and intramuscular adipose tissue of the quadriceps at post-acute care admission and recovery of swallowing ability in patients with stroke.

DESIGN

Prospective study.

SETTING AND PARTICIPANTS

This study was hospital-based and included 62 inpatients with stroke.

METHODS

The primary outcome was swallowing ability at discharge. The swallowing ability was assessed using the Food Intake Level Scale (FILS). The FILS change was calculated by subtracting FILS at admission from FILS at discharge. Ultrasound images were acquired at admission using B-mode ultrasound imaging. Muscle mass and intramuscular adipose tissue of the quadriceps were assessed based on muscle thickness and echo intensity, respectively. The mean muscle thickness and echo intensity of the right and left quadriceps were used in the analysis. A multiple regression analysis was performed to identify the factors independently associated with the FILS at discharge and FILS change. The independent variables were the muscle thickness and echo intensity of the quadriceps, FILS at admission, age, sex, body mass index, days from stroke onset, C-reactive protein, updated Charlson comorbidity index, number of medications, unit number of rehabilitation therapy, and Barthel Index score at admission.

RESULTS

Muscle thickness of the quadriceps was significantly and independently associated with FILS at discharge (β = 0.27) and FILS change (β = 0.40). Echo intensity of the quadriceps was not significantly and independently associated with FILS at discharge (β = 0.22) and FILS change (β = 0.31).

CONCLUSIONS AND IMPLICATIONS

Our results indicated that greater quadriceps muscle mass at post-acute care admission was associated with better swallowing ability at discharge in patients with stroke. Assessing muscle mass of the quadriceps at admission is important for predicting recovery of swallowing ability and interventions for quadriceps muscle mass may be effective for improving swallowing ability of patients with stroke.

Increased intramuscular adipose tissue of the quadriceps is related to decreased activities of daily living in patients who have had a stroke

OBJECTIVE

This study examined the relationships between intramuscular adipose tissue of the quadriceps on the paretic and non-paretic sides at admission and activities of daily living (ADL) at discharge in patients who had a stroke.

METHODS

This prospective cohort study included 44 stroke inpatients. ADL were assessed at discharge using the Barthel index (BI) score. Ultrasound images were acquired at admission using B-mode ultrasound imaging. Intramuscular adipose tissue and muscle mass of the quadriceps were assessed based on echo intensity and muscle thickness, respectively. Relationships between BI score at discharge and quadriceps echo intensity or thickness on the paretic and non-paretic sides were assessed using partial correlation coefficients. Age, sex, days from onset of stroke, Fugl-Meyer assessment lower extremity score, and subcutaneous fat thickness of the thigh were used as the control variables in the partial correlation analysis.

RESULTS

BI score at discharge was significantly related to quadriceps echo intensity on the paretic (partial correlation coefficient = -0.377, P = 0.018) and non-paretic (partial correlation coefficient = -0.364, P = 0.023) sides. By contrast, quadriceps thickness on the paretic (partial correlation coefficient = 0.284, P = 0.075) and non-paretic (partial correlation coefficient = 0.278, P = 0.083) sides were not significantly related to BI score at discharge.

CONCLUSIONS

The present study revealed the negative relationship between intramuscular adipose tissue of the quadriceps on the paretic and non-paretic sides at admission and ADL at discharge. Assessments and interventions of intramuscular adipose tissue in the quadriceps may be essential for predicting and improving ADL of patients who have had a stroke.

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.