The utility of ALS staging systems in a multi-ethnic patient cohort.

Objective: To compare two ALS staging systems, King's clinical staging and Milano-Torino (MiToS) functional staging, using prospective data from a multi-ethnic cohort of ALS patients. Methods: The stages of disease were determined prospectively based on existing definitions. The two systems were compared for timing of stages using box plots, correspondence using chi-square tests and association using Spearman's rank correlation. Results: The distribution of stages differed between the two systems. The proportions of disease stages of the King's staging system were more evenly distributed whereas in MiToS, there was greater weight seen at the later stages of disease. At the early stages, patients moved consecutively in the MiToS staging system but not in the King's staging system where patients tended to skip stages to reach later stages. Both systems had good correlation (Spearman's rho = 0.869) and the King's stage 4 most frequently corresponded to MiToS stage 2. Conclusion: We found the King's staging was helpful in determining the stages of disease burden, whereas both were helpful in determining the time to functional dependence with MiToS further refining the levels of dependence.

Natural history and clinical features of ALS in Malaysia.

OBJECTIVE: Studies from multiethnic populations are rarely reported but do indicate differences in phenotypic presentation and survival in amyotrophic lateral sclerosis (ALS). In this study, we aimed to investigate the natural history of a cohort of ALS patients from a multiethnic population. Methods: Data from ALS patients presenting to our multidisciplinary ALS clinic were prospectively collected from January 2015 to June 2020 as part of an ongoing hospital-based patient registry. Kaplan-Meier and Cox regression model were performed to identify potential prognostic factors. Results: A total of 144 ALS patients were recruited. We estimated the crude ALS incidence as 0.53 per 100,000 for 2019 but rises to 2 per 100,000 in patients aged 60-74 years. The majority of patients were of Chinese ethnicity (59.7%), followed by Malay (24.3%), Indian (11.1%), and others (4.9%). Malaysian Indians had a significantly steeper ALSFRS-R slope at diagnosis (p = 0.040). We found a worse prognosis in patients with bulbar-onset (HR = 1.915, p = 0.019), older age (HR = 1.052, p = 0.000), and who were fast-progressors (HR = 1.274, p = 0.000). In contrast, a higher body mass index (HR = 0.921, p = 0.007) and a longer time to diagnosis (HR = 0.967, p = 0.006), noninvasive ventilation (HR = 0.820, p = 0.000) and percutaneous endoscopic gastrostomy insertion (HR = 0.823, p = 0.000) were associated with better survival. On multivariate analysis, diagnostic delay and slow disease progression were associated with better survival. Conclusions: In our cohort, diagnostic delay and a slow disease progression were significantly associated with better survival in ALS. We also found ethnic variation with Chinese preponderance and more rapid disease progression in patients of Indian descent.

Social Participation Determines Quality of Life Among Urban-Dwelling Older Adults With Stroke in a Developing Country.

BACKGROUND AND PURPOSE: Poor quality of life (QoL) is a well-recognized consequence after stroke. Quality of life is influenced by a complex interaction between personal and environmental factors. Most previous investigations of the QoL after stroke have focused on personal factors, for example, physical deficits directly resulting from stroke. The influence of environmental factors, including social participation, is relatively understudied partly due to its high variation across different sociocultural contexts. The purpose of this study was to investigate the determinants of QoL among older adults with stroke living in an urban area of a developing country. METHODS: This cross-sectional observational study included 75 older adults who were at least 3 months poststroke and 50 age-matched healthy controls. Depressive symptoms were quantified using the World Health Organization Quality of Life Brief version (WHOQoL-BREF). Physical function was examined using Functional Ambulation Category, grip strength, 5 times Sit-to-Stand test, and Box and Block tests. The Montreal Cognitive Assessment and visual-manual reaction time were used to index cognitive function. Depressive symptom was quantified using the Patient Health Questionnaire-9. The Barthel Index and Fatigue Severity Scale were used to quantify activity limitation. Social participation and environmental participation were assessed using the Assessment of Life Habit and Craig Hospital Inventory of Environment Factors, respectively. Linear stepwise regression models were used to determine explanators for WHOQoL-BREF domain scores. RESULTS: Individuals with stroke demonstrated significantly worse QoL on all WHOQoL-BREF domains compared with healthy controls. Stroke was a strong determinant for QoL and explained 16% to 43% of variances. Adding other outcome measures significantly improved the robustness of the models (R change = 12%-32%). The physical, psychological, social, and environmental domains of WHOQoL-BREF were all explained by the LIFE-H scores (ß = -10.58, -3.37, 4.24, -5.35, respectively), while psychological, social, and environmental domains were explained by Montreal Cognitive Assessment scores (ß = .47, 0.78, 0.54, respectively). CONCLUSION: Social participation and cognition were strong determinants of QoL among urban-dwelling older adults with stroke. Social and recreational activities and cognitive rehabilitation should therefore be evaluated as potential strategies to improve the well-being of older adults affected by stroke.

Predicting return to work following a cardiac event in Malaysia.

BACKGROUND: Return to work is an important aspect for cardiac rehabilitation following a major cardiac event. OBJECTIVE: The aim was to understand the local prevalence and factors associated with returning to work in Malaysia after a cardiac event. METHODS: A cross sectional design was used. All patients attending the cardiac rehabilitation program after major cardiac event during an 11-months period (2011-2012) were included. Data relating to socio-demographic, work-related, risk factors and acute myocardial infarction were collected. The SF-36 questionnaire was used to assess quality of life. Regression analysis was used to determine the predicting factors to return to work. RESULTS: A total of 398 files were screened, 112 respondents agreed to participate giving a response rate of 47.3%. The prevalence of returned to work (RTW) was 66.1% [95% CI: 57.2-75.0]. Factors associated with work resumption were age (Adj. OR: 0.92 (95% CI: 0.84-0.99), diabetes mellitus (Adj. OR: 3.70, 95% CI: 1.35-10.12), Mental Component Summary (MCS) score (Adj. OR: 1.05 (95% CI: 1.01-1.09) and baseline angiography findings. Patients with single vessel and two vessel disease were 8.9 times and 3.78 times more likely to return to work compared to those with 3 vessels (Adj. OR: 8.90 (95% CI: 2.29-34.64) and Adj. OR: 3.78, (95% CI: 1.12, 12.74). CONCLUSIONS: We proposed a cardiac rehabilitation program to emphasize mental health as it may improve successful return to work after cardiac event.

The Effect of Repetitive Transcranial Magnetic Stimulation on Postural Stability After Acute Stroke: A Clinical Trial.

INTRODUCTION: Balance impairment is a common problem and a major cause of motor disability after stroke. Therefore, this study aimed to investigate whether low-frequency repetitive Transcranial Magnetic Stimulation (rTMS) improves the postural balance problems in stroke patients. METHODS: This randomized double blind clinical trial with 12 weeks follow-up was conducted on stroke patients. Treatment was carried with 1 Hz rTMS in contralateral brain hemisphere over the primary motor area for 20 minutes (1200 pulses) for 5 consecutive days. Static postural stability, Medical Research Council (MRC), Berg Balance Scale (BBS), and Fugl-Meyer assessments were evaluated immediately, 3 weeks and 12 weeks after intervention. RESULTS: A total of 26 patients were enrolled (age range=53 to 79 years; 61.5% were male) in this study. Administering rTMS produced a significant recovery based on BBS (df=86, 7; F=7.4; P=0.01), Fugl-Meyer Scale (df=86, 7; F=8.7; P<0.001), MRC score (df=87, 7; F=2.9; P=0.01), and static postural stability (df=87, 7; F=9.8; P<0.001) during the 12 weeks follow-up. CONCLUSION: According to the findings, rTMS as an adjuvant therapy may improve the static postural stability, falling risk, coordination, motor recovery, and muscle strength in patients with stroke.

Evaluation of the topic lists used in two world Congresses (2015 and 2016) in Physical and Rehabilitation Medicine.

BACKGROUND: Evaluation of the initial list of proposed abstract topics for Congresses of Physical and Rehabilitation Medicine (PRM) was needed in order to ensure its feasibility for use in future congress announcements and invitations for abstract submission. METHODS: The initial proposals were based on 5 main areas of PRM research: biosciences in rehabilitation, biomedical rehabilitation sciences and engineering, clinical PRM sciences, integrative rehabilitation sciences, and human functioning sciences. This list became a model for structuring the abstracts for the 9th and 10th World Congresses of PRM, held in Berlin, Germany (2015) and Kuala Lumpur, Malaysia (2016), respectively. The next step was to evaluate the implementation of this model in both congresses. RESULTS: It was found that the 5 main research areas were still used as the main principles (chapters) in which to organize the abstracts. However, some modifications have been made to cover topics that were not included in the initial proposal. CONCLUSION: A more comprehensive list of topics has been developed, not only for topic list announcements, but also for the structuring and classification of abstracts for future international, regional or national PRM congresses.

Test-retest reliability, internal consistency and concurrent validity of Fatigue Severity Scale in measuring post-stroke fatigue.

BACKGROUND: Post-stroke fatigue (PSF) is a common complaint among stroke survivors and has significant impacts on recovery and quality of life. Limited tools that measure fatigue have been validated in stroke. AIM: The purpose of this study was to determine the psychometric properties of Fatigue Severity Scale (FSS) in patients with stroke. DESIGN: Cross-sectional study. SETTING: Teaching hospital outpatient setting. POPULATION: Fifty healthy controls (mean age 61.1±7.4 years; 22 males) and 50 patients with stroke (mean age 63.6±10.3 years; 34 males). METHODS: FSS was administered twice approximately a week apart through face-to-face interview. In addition, we measured fatigue with Visual Analogue Scale - Fatigue (VAS-F) and Short-Form Health Survey 36 version 2 vitality scale. We used Cronbach alpha to determine internal consistency of FSS. Reliability and validity of FSS were determined by intraclass correlation coefficient (ICC) and Spearman correlation coefficient (r). RESULTS: FSS showed excellent internal consistency for both stroke and healthy groups (Cronbach's alpha >0.90). FSS had excellent test-retest reliability for stroke patients and healthy controls (ICC=0.93 and ICC=0.90, respectively). The scale demonstrated good concurrent validity with VAS-Fatigue (all r>.60) and a moderate validity with the SF36-vitality scale. Furthermore, FSS was sensitive to distinguish fatigue in stroke from the healthy controls (P<0.01). CONCLUSIONS: FSS has excellent internal consistency, test-retest reliability and good concurrent validity with VAS-F for both groups. CLINICAL REHABILITATION IMPACT: This study provides evidence that FSS is a reliable and valid tool to measure post-stroke fatigue and is readily to be used in clinical settings.

Aftereffects of 2 noninvasive brain stimulation techniques on corticospinal excitability in persons with chronic stroke: a pilot study.

BACKGROUND AND PURPOSE: Noninvasive brain stimulation, including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), have gained popularity in the stroke rehabilitation literature. Little is known about the time course and duration of effects of noninvasive brain stimulation on corticospinal excitability in individuals with stroke. We examined the aftereffects of a single session of high-frequency rTMS (5 Hz) and anodal tDCS on corticospinal excitability in the same sample of participants with chronic stroke. METHODS: Ten individuals with chronic stroke participated in this randomized cross-over study. Participants received 1 session of rTMS and 1 session of tDCS, with 1 week between sessions. During the rTMS session, 5-Hz rTMS (total of 1200 stimuli) was administered to the ipsilesional primary motor cortex (M1). For anodal tDCS, 1 mA of direct current was delivered to the ipsilesional M1 for 20 minutes. Motor evoked potentials were measured before and after (immediately, 15 minutes, 30 minutes, and 60 minutes) each stimulation session. RESULTS: Both 5-Hz rTMS and anodal tDCS significantly increased corticospinal excitability for 30 to 60 minutes after stimulation. There was no statistically significant difference between the 2 stimulation techniques in their effects on motor evoked potentials. No changes in measures of motor or cognitive performance were observed. DISCUSSION AND CONCLUSION: Both 5-Hz rTMS and anodal tDCS induced effects on corticospinal excitability in persons with chronic stroke lasting at least 1 hour after stimulation. In the absence of concurrent motor practice, neither form of stimulation applied in a single session was associated the changes in motor performance. These approaches to increased cortical excitability may be of value as adjuncts to training. VIDEO ABSTRACT AVAILABLE: See Video (Supplemental Digital Content 1, http://links.lww.com/JNPT/A83) for more insights from the authors.

Sample size calculation in physical medicine and rehabilitation: a systematic review of reporting, characteristics, and results in randomized controlled trials.

OBJECTIVE: To assess systematically the reporting of sample size calculation in randomized controlled trials (RCTs) in 5 leading journals in the field of physical medicine and rehabilitation (PM&R). DATA SOURCES: The data source was full reports of RCTs in 5 leading PM&R journals (Journal of Rehabilitation Medicine, Archives of Physical Medicine and Rehabilitation, American Journal of Physical Medicine and Rehabilitation, Clinical Rehabilitation, and Disability and Rehabilitation) between January and December of 1998 and 2008. Articles were identified in Medline. STUDY SELECTION: A total of 111 articles met our inclusion criteria, which include RCTs of human studies in the 5 selected journals. DATA EXTRACTION: Sample size calculation reporting and trial characteristics were collected for each trial by independent investigators. DATA SYNTHESIS: In 2008, 57.3% of articles reported sample size calculation as compared with only 3.4% in 1998. The parameters that were commonly used were a power of 80% and alpha of 5%. Articles often failed to report effect size or effect estimates for sample size calculation. Studies reporting sample size calculation were more likely to describe the main outcome and to have a sample size greater than 50 subjects. The study outcome (positive vs negative) was not associated with the likelihood of sample size reporting. Trial characteristics of the 2 periods (1998 vs 2008) were similar except that in 1998 there were more negative studies compared with 2008. CONCLUSIONS: Although sample size calculation reporting has improved dramatically in 10 years and is comparable with other fields in medicine, it is still not adequate given current publication guidelines.