Hideto Okazaki

Changes in Serum Growth Factors in Stroke Rehabilitation Patients and Their Relation to Hemiparesis Improvement

Predicting recovery from hemiparesis after stroke is important for rehabilitation. A few recent studies reported that the levels of some growth factors shortly after stroke were positively correlated with the clinical outcomes during the chronic phase. The aim of this study was to examine the relationships between the serum levels of growth factors (vascular endothelial growth factor [VEGF], insulin-like growth factor-I [IGF-I], and hepatocyte growth factor [HGF]) and improvement in hemiparesis in stroke patients who received rehabilitation in a postacute rehabilitation hospital. Subjects were 32 stroke patients (cerebral infarction: 21 and intracerebral hemorrhage [ICH]: 11). We measured serum levels of VEGF, IGF-I, and HGF and 5 items of the Stroke Impairment Assessment Set (SIAS) for hemiparesis on admission and at discharge. Age-matched healthy subjects (n=15) served as controls. Serum levels of VEGF and HGF in cerebral infarct patients on admission were higher than those in control subjects, and the serum levels of IGF-I in stroke patients were lower than those in controls. The level of HGF in ICH patients on admission was negatively correlated with gains in SIAS, and higher outliers in HGF concentration were correlated with lower gains in SIAS. Focusing on the extremely high levels of these factors may be a predictor of the low recovery from hemiparesis after stroke.

Line Bisection and Rebisection: The Crossover Effect of Space Location

Objective. To investigate the relationship between the bisection test and the severity of behavioral hemineglect and to verify if this test can predict the behavioral hemineglect. Methods. Thirty stroke patients with left hemiparesis were divided into 4 groups according to the Catherine Bergego Scale, which assessed the behavioral hemineglect: severe unilateral neglect (UN), moderate UN, mild UN, and lack of UN. Eleven healthy subjects served as age-matched control subjects. In the bisection test, 18 lines were presented on the left, middle, and right of an A4 paper, respectively. The subjects were asked to place a short cross mark in the exact middle point of each line on the paper using their right hand. The middle 6 lines in the above bisection test were extracted on another sheet of A4 paper for the rebisection test. The subjects were asked to divide a line into 4 segments by successive bisections. The proportion of the right part to the length of line for bisecting was calculated. Results. In the bisection test, the main effect of space was significant in every group except the mild neglect group. The crossover effect of space location was found in the severe UN group, the group without UN, and the controls. In the severe UN group, the patients bisected the left and middle lines with rightward bias (<50%) but bisected the right lines with leftward bias (>50%). In the group without UN and the controls, the subjects bisected the left lines with leftward bias (>50%) but bisected the middle and right lines with rightward bias (<50%). Almost the same results were seen in the rebisection test. Conclusions. This study showed that if the spatial crossover effect occurred in the right space condition, it was strongly supported that this patient had moderate to severe behavioral hemineglect. The crossover effect of the space location was explained by a new model.

Change in thigh muscle cross-sectional area through administration of an anabolic steroid during routine stroke rehabilitation in hemiplegic patients.

Objective:The aim of this study was to clarify the effect of administration of an anabolic steroid (AS) without the addition of specific training in stroke patients by measuring the cross-sectional area (CSA) of the thigh. Design:Twenty-six hemiplegic stroke patients during subacute rehabilitation were randomly assigned to a metenolone enanthate (ME) administration group or a control group (CT group). In the ME group, ME (100 mg) was injected intramuscularly weekly for 6 wks in the ME group. The CSA of the bilateral thigh muscles was measured using computed tomography. Motor subscore of the Functional Independence Measure (FIM-M) was assessed before the experimental period. Results:At the end of 6 wks, the CSA increase in the ME group (13.4%, affected side; 14.5%, unaffected side) was significantly larger than that in the CT group (3.3%, affected side; 5.2%, unaffected side). Correlation coefficients between the initial FIM-M score and the CSA increase at 6 wks were −0.754 for the affected side and −0.567 for the unaffected side in the ME group and 0.199 for the affected side and 0.431 for the unaffected side in the CT group. Conclusions:ME administration is effective for improving muscle CSA and, thus, muscle strengthening in stroke rehabilitation. The CSA increase in the ME group was most prominent in patients with a low initial FIM-M score.

Effects of exercise and bryostatin-1 on serotonin dynamics after cerebral infarction.

Although it has been suggested that the combination of exercise and bryostatin-1 administration may induce greater functional recovery than exercise alone, the detailed molecular mechanisms are not well known. Here, we examined the relationship between this combination treatment and monoamine dynamics in the cerebral cortex peri-infarction area to promote our understanding of these molecular mechanisms. Experimental cerebral cortex infarctions were produced by photothrombosis in rats. Voluntary exercise was initiated 2 days after surgery. Motor performance was then measured using the rotarod test. Monoamine concentrations in the perilesional cortex were analyzed by high-performance liquid chromatography. In behavioral evaluations, performance in the rotarod test was significantly increased by exercise. Moreover, performance in the rotarod test after the combination of exercise and bryostatin-1 administration was significantly greater than that after exercise alone. In the analysis of monoamines, serotonin (5-HT) concentrations were significantly higher in the groups treated with exercise and bryostatin-1. In addition, 5-HT turnover was significantly lower in the groups treated with exercise and bryostatin-1. Furthermore, the mean latency in the rotarod test showed a significant positive correlation with 5-HT levels. In immunohistochemical analysis, 5-HT immunoreactivity in the dorsal raphe nucleus was shown to be higher in the groups treated with exercise. In the present study, we detected changes in the levels of monoamines associated with the combined treatment of exercise and bryostatin-1 administration in the perilesional cortex. It has been suggested that this combination of therapies may affect 5-HT turnover and serve to increase local 5-HT concentrations in the perilesional area.

Evaluation of Use of the Medical Outcome Study 36-Item Short Form Health Survey and Cognition in Patients with Stroke

The Medical Outcome Study 36-Item Short Form Health Survey (SF-36) is a widely used method to evaluate health-related quality of life and has been applied for patients with stroke. However, because it is a self-assessment tool, there is a risk in using results of the survey because of lack of information on patients who cannot answer the questionnaire. For this report, 38 patients with stroke hospitalized in the rehabilitation department filled out the SF-36 and motor items of the Functional Independence Measure (FIM) and the Stroke Impairment Assessment Set. We then examined characteristics of patients who could not be evaluated by the SF-36. Of the 38 patients, 19 patients could and 19 patients could not be evaluated by the SF-36. There was no remarkable relationship among capacity or incapacity for evaluation by the SF-36, motor subscores on the FIM, and motor items on the Stroke Impairment Assessment Set. All 10 patients having a communication subscore on the FIM of 10 points or less and/or a social cognition subscore on the FIM of 13 points or less could not be evaluated by the SF-36. The remaining unevaluable patients were not cooperative. Studies in which the entry criteria include the ability to answer the SF-36 questionnaire neglect patients with poor cognition. Therefore, when administering the SF-36 for patients with stroke, we recommend using an interview setting.

Dysphagia Following Putaminal Hemorrhage at a Rehabilitation Hospital.

BACKGROUND Dysphagia occurs frequently during the acute phase of cerebral hemorrhage; however, there are few reports of dysphagia associated with cerebral hemorrhage in the subacute and chronic phase. We focused on putaminal hemorrhage at a rehabilitation hospital and evaluated the relationships between the frequencies of dysphagia, focus, and hematoma volume and type. METHODS A hundred patients with putaminal hemorrhage referred to our rehabilitation hospital were evaluated. Bedside swallowing assessments (BSAs) were conducted and results were evaluated relative to the information obtained on computed tomography imaging, including hematoma type and volume, and oral intake at the time of admission/discharge from the hospital. RESULTS A regular diet was provided to 48 patients, dysphagia diet to 44 patients, and enteral feeding to 8 patients. There were significant feeding group differences in age, hematoma volume and type, existence of ventricle rupture, neurological manifestation, cognitive function, existence of unilateral neglect and aphasia, initial BSA, activities of daily living (ADL) score using the Functional Independence Measure at the time of admission/discharge from the hospital, and length of stay. At discharge, we provided a regular diet to 81 patients and dysphagia diet to 19 patients. Age and ADL score had the greatest influence on oral intake at the time of discharge from the hospital. CONCLUSION The prognosis of dysphagia caused by putaminal hemorrhage is good, with no patient requiring enteral feeding, although putaminal hemorrhage often causes dysphagia. Patient age and ADL score on admission are used to predict the residual factors of dysphagia.

Aphasia Following Left Putaminal Hemorrhage at a Rehabilitation Hospital

Objective: We aimed to clarify the relationship between aphasia and hematoma type/volume in patients with left putaminal hemorrhage admitted to a rehabilitation facility. Methods: We evaluated the relationship between the presence, type, and severity of aphasia and hematoma type/volume in 92 patients with putaminal hemorrhage aged 29-83 years. Hematoma type and volume were evaluated on the basis of CT images obtained at stroke onset. The Standard Language Test for Aphasia was conducted as part of the initial assessment. Results: Aphasia was observed in 79 of 92 patients. A total of 31 patients had fluent aphasia, while 48 had non-fluent aphasia. Non-fluent aphasia often involved hematoma on the anterior limb of the internal capsule, while fluent aphasia often involved hematoma on the posterior limb of internal capsule. When the hematoma volume exceeded 20 mL, patients experienced difficulty in repeating spoken words. When hematoma volume exceeded 40 mL, non-fluent aphasia was observed in all patients. Conclusion: Our findings suggest that hematoma type and volume not only influence the development of aphasia following putaminal hemorrhage but also play a major role in determining the patients fluency and repetition ability.

Lower Limb Orthotic Therapy for Stroke Patients in a Rehabilitation Hospital and Walking Ability at Discharge

Background: The purpose of this study was to clarify the use of orthotic therapy and the ability to walk at discharge among stroke patients who were treated at our rehabilitation hospital. Methods: This retrospective, observational cohort study included 1040 patients with first-ever stroke who were referred to our rehabilitation hospital between January 2013 and December 2015. The patients were divided into knee-ankle-foot orthosis (KAFO), ankle-foot orthosis (AFO), and no orthosis groups. Neurological symptoms, cognitive function, daily activities, duration from hospitalization to orthosis creation, hospitalization duration, and walking ability at discharge were compared. Results: The age of the patients ranged from 12 to 94 years. The mean duration from onset to hospitalization was 34.1 ± 17.8 days, and the mean length of hospital stay was 64.3 ± 35.3 days. Of the 1040 patients, 414 received orthotic therapy (220 in the KAFO group and 194 in the AFO group). The AFO group had patients with lower age than those in the no orthosis group, and neurological symptoms and cognitive function were more severe in the KAFO group than in the other groups. Their own KAFO was prescribed in 156 patients and AFO was prescribed in 230 patients. The mean period from hospitalization to orthosiscompletion was 11.3 ± 5.8 days in the KAFOs and 33.9 ± 20.9 days in the AFOs. Orthosis was needed by 375 patients (47 KAFOs and 328 AFOs) at discharge from the rehabilitation hospital. Among the patients, 540 patients could walk independently and these included 43.2% patients from the KAFO group and 66.5% patients from the AFO group. Conclusion: An orthosis was required in a number of patients who have been transferred to a rehabilitation hospital. We believe that it is clear that orthosis therapy is indispensable for rehabilitation of stroke patients.

Factors necessary for independent walking in patients with thalamic hemorrhage

BackgroundThalamic hemorrhages cause motor paralysis, sensory impairment, and cognitive dysfunctions, all of which may significantly affect walking independence. We examined the factors related to independent walking in patients with thalamic hemorrhage who were admitted to a rehabilitation hospital.MethodsWe evaluated 128 patients with thalamic hemorrhage (75 men and 53 women; age range, 40–93 years) who were admitted to our rehabilitation hospital. The mean duration from symptom onset to rehabilitation hospital admission was 27.2 ± 10.3 days, and the mean rehabilitation hospital stay was 71.0 ± 31.4 days. Patients’ neurological and cognitive functions were examined with the National Institutes of Health Stroke Scale (NIHSS) and Mini-Mental State Examination (MMSE), respectively. The relationship between patients’ scores on these scales and their walking ability at discharge from the rehabilitation hospital was analyzed. Additionally, a decision-tree analysis was used to create a model for predicting independent walking upon referral to the rehabilitation hospital.ResultsAmong the patients, 65 could walk independently and 63 could not. The two patient groups were significantly different in terms of age, duration from symptom onset to rehabilitation hospital admission, hematoma type, hematoma volume, neurological symptoms, and cognitive function. The decision-tree analysis revealed that the patient’s age, NIHSS score, MMSE score, hematoma volume, and presence of ventricular bleeding were factors that could predict independent walking.ConclusionsIn patients with thalamic hemorrhage, the neurological symptoms, cognitive function, and neuroimaging factors at onset are useful for predicting independent walking.