Changes in Post-Stroke Skeletal Muscles: an Ultrasonographic Evaluation

Background: Stroke is the second leading cause of death worldwide, with chronic disability remaining in up to 50% of survivors. Ultrasonography studies to examine disruptions in the normative architecture of post-stroke muscles have documented changes in muscle thickness, fascicle length, pennation angle, and echo intensity (EI) in patients in chronic patients Purpose: Assessing early modification in paretic muscles could ameliorate the comprehension of the prognosis and address a better rehabilitation program. Methods: Adult patients admitted in Physical Medicine and Rehabilitation with acute ischemic stroke from January 2019 to January 2022 were identified as the study population. Muscle thickness (MT), ACSA (anatomical cross sectional area) in Biceps Brachii (BB), Rectus Femoris(RF), Gastrocnemius Medialis (GM) in the both sides were assessed with ultrasound at admission, after 60, 90 days and at 6 months. The influence of comorbidities and echo intensity was also assessed. Results: Twenty-two patients were finally enrolled. Most of patients were male (54,5%), the mean age was 71 (55-83). BB thickness decreased during the first 30 days and in the following time intervals. At 6 months, mean thickness decreased with a variation of 12.66% in the paretic side. RF thickness decreased from 15.95 to 14.75, with a difference of 7.52% from baseline to T3 [95% CI, .0272; 0.817], p < 0.001. GM thickness decreased from 15.86 to 14,39, with a difference of 9.27% from baseline to T3 [95% CI, . ,033; 0. ,058], p = 0.001. No significant different was found in T2-T3 and T0-T3. The age had a significant negative correlations with MT RF and ACSA RF. Charlson index had a negative correlation with MT GM. Conclusion: Early research at the patient's bedside for insights that can improve the outcome and prevent irreversible and useless muscle modification in paretic side in post-stroke patients

BoNT-A for post-stroke spasticity: guidance on unmet clinical needs from a Delphi panel approach

There is extensive literature supporting the efficacy of botulinum toxin (BoNT-A) for the treatment of post-stroke spasticity, however, there remain gaps in the routine management of patients with post-stroke spasticity. A panel of 21 Italian experts was selected to participate in this web-based survey Delphi process to provide guidance that can support clinicians in the decision-making process. There was a broad consensus among physicians that BoNT-A intervention should be administered as soon as the spasticity interferes with the patients' clinical condition. Patients monitoring is needed over time, a follow-up of 4-6 weeks is considered necessary. Furthermore, physicians agreed that treatment should be offered irrespective of the duration of the spasticity. The Delphi consensus also stressed the importance of patient-centered goals in order to satisfy the clinical needs of the patient regardless of time of onset or duration of spasticity. The findings arising from this Delphi process provide insights into the unmet needs in managing post-stroke spasticity from the clinician's perspective and provides guidance for physicians for the utilization of BoNT-A for the treatment of post-stroke spasticity in daily practice

Rehabilitation interventions for glioma patients: a mini-review

Glioma is a group of tumors that originate from glial cells within the central nervous system and comprise 27% of all tumors and 80% of malignant tumors. With remarkable progress in surgical practices, chemotherapy, and radiation therapy, patients with glioma are experiencing greater survival times, which means they need more rehabilitative care. In fact, people with this condition may experience a variety of symptoms that can affect their functions and drastically reduce their quality of life. In fact, patients suffering from glioma has a distinctive symptom complex highlighting the requirement for customized care. Growing evidence shows that rehabilitation therapy can improve the functional prognosis and quality of life of glioma patients. However, there is limited evidence of the success of rehabilitation protocols designed specifically for individuals with glioma. It is essential to determine the most comprehensive rehabilitation programs as well as the sufficient resources, dosage, and duration. The goal of this mini-review was to classify and map rehabilitation interventions used to treat multiple disabling sequalae in individuals affected by glioma. We aim to provide a comprehensive overview of the rehabilitation protocols used for this population, so that clinicians have a guide to support treatment and an inspiration for further research. This document is intended to be a reference point for professionals involved in the management of adult patients with gliomas. Further exploration is needed to form improved care models for recognizing and addressing functional restrictions in this population

Ischemic Stroke in a 29-Year-Old Patient with COVID-19: A Case Report

Increasing evidence reports a greater incidence of stroke among patients with Coronavirus disease 2019 (COVID-19) than the non-COVID-19 population and suggests that SARS-CoV-2 infection represents a risk factor for thromboembolic and acute ischemic stroke. Elderly people have higher risk factors associated with acute ischemic stroke or embolization vascular events, and advanced age is strongly associated with severe COVID-19 and death. We reported, instead, a case of an ischemic stroke in a young woman during her hospitalization for COVID-19-related pneumonia. A 29-year-old woman presented to the emergency department of our institution with progressive respiratory distress associated with a 2-day history of fever, nausea, and vomiting. The patient was transferred to the intensive care unit (ICU) where she underwent a tracheostomy for mechanical ventilation due to her severe clinical condition and her very low arterial partial pressure of oxygen. The nasopharyngeal swab test confirmed SARS-CoV-2 infection. Laboratory tests showed neutrophilic leucocytosis, a prolonged prothrombin time, and elevated D-dimer and fibrinogen levels. After 18 days, during her stay in the ICU after suspension of the medications used for sedation, left hemiplegia was reported. Central facial palsy on the left side, dysarthria, and facial drop were present, with complete paralysis of the ipsilateral upper and lower limbs. Computed tomography (CT) of the head and magnetic resonance imaging of the brain confirmed the presence of lesions in the right hemisphere affecting the territories of the anterior and middle cerebral arteries, consistent with ischemic stroke. Pulmonary and splenic infarcts were also found after CT of the chest. The age of the patient and the absence of serious concomitant cardiovascular diseases place the emphasis on the capacity of SARS-CoV-2 infection to be an independent cerebrovascular risk factor. Increased levels of D-dimer and positivity to β2-glycoprotein antibodies could confirm the theory of endothelial activation and hypercoagulability, but other mechanisms – still under discussion – should not be excluded

Clinical efficacy of botulinum toxin type A in patients with traumatic brain injury, spinal cord injury, or multiple sclerosis: An observational longitudinal study

Botulinum toxin type A (BoNT-A) is the treatment of choice for focal spasticity, with a concomitant effect on pain reduction and improvement of quality of life (QoL). Current evidence of its efficacy is based mainly on post stroke spasticity. This study aims to clarify the role of BoNT-A in the context of non-stroke spasticity (NSS). We enrolled 86 patients affected by multiple sclerosis, spinal cord injury, and traumatic brain injury with clinical indication to perform BoNT-A treatment. Subjects were evaluated before injection and after 1, 3, and 6 months. At every visit, spasticity severity using the modified Ashworth scale, pain using the numeric rating scale, QoL using the Euro Qol Group EQ-5D-5L, and the perceived treatment effect using the Global Assessment of Efficacy scale were recorded. In our population BoNT-A demonstrated to have a significant effect in improving all the outcome variables, with different effect persistence over time in relation to the diagnosis and the number of treated sites. Our results support BoNT-A as a modifier of the disability condition and suggest its implementation in the treatment of NSS, delivering a possible starting point to generate diagnosis-specific follow-up programs.Clinical trial identifierNCT04673240

The menstrual cycle of the Baboon (Papio hamadryas) evaluated by vaginal cytology and hormonal variations

Hamadryas baboons (Papio hamadryas) form part of a highly successful branch of the primate family (Cercopithecidae), commonly referred to as savannah baboons. They are broadly distributed over the African continent, and the Arabian Peninsula inhabiting the semiarid regions [1]. Baboons are menstruating primates, the average length of a normal reproductive cycles is 32 (24-38) days with close similarity to women's [2]; so that the baboon is considered a valuable model for increasing knowledge to overcome human reproductive disorders. This study aims s to acquire knowledge on the modifications of vaginal cytology and Fallopian tubes during the menstrual cycle of females living in captivity. The stage of the menstrual cycle of 14 healthy adult females of different ages (8.5 yrs) and weights (10.5 kg) on the day of laparoscopic salpingectomy has been evaluated. The baboons breed with high fertility rates in captivity so that laparoscopic salpingectomy was employed as irreversible contraceptive surgical therapy for an extensive control birth program in the Safari Zoo (Fasano - BR). The clinical activity was authorized with written informed consent by the Zoo’s property (Lion 3000 S.p.a.) and obtained the favorable opinion of the ethics committee of DETO (05/2020). The stage of the reproductive cycle was analyzed by 1) vaginal cytology (Harris-Shorr’s and Diff-Quik staining), 2) endocrine changes measuring 17β-estradiol (E2) and progesterone (P4) concentrations in peripheral plasma by ELISA, 3) histological uterine tubes morphology. The stage of the cycle can be also approximated by external observation of the perineum so that the perineal turgescence, characteristic of the follicular phase, was checked during the observation of external genitalia. Laparoscopic evaluations monitored the presence of corpora lutea and the Graafian follicle and when ovulation had occurred, the increased vascularized fimbriae too. Changes in the type of vaginal cells (basal and parabasal, small and large intermediate, anuclear keratinized, erythrocytes, neutrophils) found during the follicular and luteal phases (early and late) of the ovarian cycle were analyzed. Based on hormonal evaluations and cytological observations we found 9/14 subjects in the follicular phase (mean E2 concentration 150±73 pg/ml; mean P4 concentration 0.3±0.1 ng/ml; presence of small and large intermediate, anuclear keratinized cells) and 5/14 females in the luteal phase (mean E2 concentration 50±20 pg/ml; mean P4 concentration 4±0.5 ng/ml; presence of basal and parabasal cells, neutrophils) of their reproductive cycle. Histological investigations revealed morphological and morphometric changes in the uterine tube segments related to the stage of the menstrual cycle. In addition, a different degree of hyperemia was observed in the infundibulum between follicular and luteal stages. The acquired knowledge could be the starting point to propose a hormonal contraceptive strategy for baboons living in captivity with little effect on social interactions such as grooming relationships, aggression, affiliation and sexual behavior while reducing their reproductive success. [1] Newman TK, Jolly CJ, Rogers J. Mitochondrial phylogeny and systematics of baboons (Papio). American Journal of Physical Anthropology, 124: 17-27, 2004. [2] Stevens VC, Sparks SJ, and Powell JE. Levels of estrogens, progestogens, and luteinizing hormone during the menstrual cycle of the baboon. Endocrinology, 87: 658, 1970

Combined Effects of Isokinetic Training and Botulinum Toxin Type A on Spastic Equinus Foot in Patients with Chronic Stroke: A Pilot, Single-blind, Randomized Controlled Trial

Botulinum toxin A (BoNT-A) has been shown effective for poststroke lower limb spasticity. Following injections, a wide range of multidisciplinary approach has been previously provided. The purpose of this pilot, single-blind, randomized controlled trial was to determine whether BoNT-A combined with a regime of a four-week ankle isokinetic treatment has a positive effect on function and spasticity, compared with BoNT-A alone. Secondly, the validity of the use of an isokinetic dynamometer to measure the stretch reflex at the ankle joint and residual strength has been investigated. Twenty-five chronic stroke patients were randomized to receive combined treatment (n = 12; experimental group) or BoNT-A alone (n = 13; control group). Outcome measures were based on the International Classification of Functioning, Disability and Health. An isokinetic dynamometer was also used for stretch reflex and strength assessment. Patients were evaluated at baseline (t0), after five (t1) and eight weeks after the injection (t2). The experimental group reported significantly greater improvements on lower limb spasticity, especially after eight weeks from baseline. Gait speed (10-m walk test) and walking capacity (6-min walking test) revealed statistically significantly better improvement in the experimental than in control group. Peak resistive ankle torque during growing angular velocities showed a significant reduction at the higher velocities after BoNT-A injections in the experimental group. Peak dorsiflexor torque was significantly increased in the experimental group and peak plantarflexor torque was significantly decreased in control group. Alternative rehabilitation strategies that combine BoNT-A and an intense ankle isokinetic treatment are effective in reducing tone and improving residual strength and motor function in patients with chronic hemiparesis

Intra-articular injection of botulinum toxin type A for shoulder pain in glenohumeral osteoarthritis: A case series summary and review of the literature

Introduction: Shoulder pain is one of the most common musculoskeletal diseases, and can be due to glenohumeral osteoarthritis, rotator cuff tear, impingement, tendinitis, adhesive capsulitis, and subacromial bursitis. Several therapies have been proposed, including steroids, nonsteroidal anti-inflammatory drugs, intra-articular injections, and physical therapies. Many published studies have reported on the employment of botulinum toxin type A (BoNT-A) to reduce pain in subjects with neurological and musculoskeletal diseases by inhibiting substance P release and other inflammatory factors. Methods: In the present article, we briefly update current knowledge regarding intra-articular BoNT therapy, reviewing existing literature on intra-articular use of BoNT-A, including nonrandom-ized and randomized prospective and retrospective cohort studies and case series published from December 1989 to November 2017. We also describe a case series of six subjects treated with intra-articular injection of incobotulinumtoxin A for the treatment of pain deriving from osteoarthritis. Conclusion: Intra-articular BoNT-A is effective and minimally invasive. Pain reduction with an increase in shoulder articular range of motion in our experience confirms the effectiveness of BoNT-A injection for the management of this syndrome

Reasons and Determinants of BoNT-A Treatment Discontinuation in Patients Living with Spasticity: A 10-Year Retrospective Analysis

Background: The present study aimed to evaluate the reasons and determinants of BoNT-A discontinuation in patients with stroke, multiple sclerosis, spinal cord injury, and traumatic brain injury. Methods: It is a retrospective study of 56 discontinuer patients treated with botulinum toxin between January 2011 and December 2021. Discontinuation rates and their predictors were estimated using Kaplan–Meier, Log rank test, and Cox’s regression method of analyses. Results: The mean age was 56.54 years, 53.57% were affected by post-stroke spasticity, 17.86% by spinal cord injury, 12.5% and 16.07% by traumatic brain injury and multiple sclerosis, respectively. The median discontinuation time was 5 months. The main reason for discontinuation were logistic problems (37%) and orthopedic surgeries or intrathecal baclofen (27%). Discontinuers were more likely to have severe spasticity (R = 1.785), have no pain (HR = 1.320), no access to rehabilitation services (HR = 1.402), and have cognitive impairment (HR = 1.403). Conclusions: The main reasons for discontinuation are related to logistic issues (due to distance or the absence of an adequate caregiver) and surgical interventions for spasticity, including intrathecal baclofen. It is crucial to identify possible predictors of discontinuation to improve the effectiveness of a multidisciplinary management. The study confirms the crucial role of rehabilitation and caregivers in achieving better long-term outcomes

Adjuvant treatments associated with botulinum toxin injection for managing spasticity: An overview of the literature

A wide range of adjunct therapies after botulinum toxin administration have been proposed. The aim of the present paper is to provide an overview of major writings dealing with adjuvant (non-pharmacological) treatments associated with botulinum toxin for managing spasticity in order to provide some up-to-date information about the usefulness of the most commonly used procedures