Effectiveness of Intermittent Theta Burst Stimulation to Enhance Upper Extremity Recovery After Stroke: A Pilot Study.

OBJECTIVES: To first investigate the effectiveness of modified constraint-induced movement therapy (mCIMT) in low-functioning patients with stroke (PwS). Second, we aimed to investigate the efficiency of intermittent theta-burst stimulation (iTBS), applied on intermittent days, in addition to the mCIMT in PwS. DESIGN: A randomized, sham-controlled, single-blinded study. SETTING: Outpatient clinic. PARTICIPANTS: Fifteen PwS (age [mean±SD]: 66.3±9.2 years; 53% female) who were in the first 1 to 12 months after the incident were included in the study. INTERVENTIONS: PwS were divided into 3 groups: (1) mCIMT alone; (2) mCIMT + sham iTBS; (3) mCIMT + iTBS. Each group received 15 sessions of mCIMT (1 hour/session, 3 sessions/week). iTBS was applied with 600 pulses on impaired M1 before mCIMT. MAIN OUTCOME MEASURES: Upper extremity (UE) impairment was assessed with the Fugl-Meyer Test (FMT-UE), whereas the motor function was evaluated with the Wolf-Motor Function Test (WMFT). Motor Activity Log-28 (MAL-28) was used to evaluate the amount of use and how well (How Well Scale) the impaired UE movements. RESULTS: With-in-group analysis revealed that all groups had statistically significant improvements based on the FMT-UE and MAL-28 (p<.05). However, the performance time and arm strength variables of WMFT were only increased in the mCIMT + iTBS group (p<.05). The only between-group difference was observed in the intracortical facilitation in favor of the mCIMT + iTBS group (p<.05). The effect size of iTBS was f=0.18. CONCLUSIONS: Our findings suggest that mCIMT with and without the application of iTBS has increased the UE motor function in low-functioning PwS. iTBS applied on intermittent days may have additional benefits as an adjunct therapy for facilitating cortical excitability, increasing the speed and strength of the impaired UE as well as decreasing disability.

Priming constraint-induced movement therapy with intermittent theta burst stimulation to enhance upper extremity recovery in patients with stroke: protocol for a randomized controlled study.

BACKGROUND: The treatments based on motor control and motor learning principles have gained popularity in the last 20 years, as well as non-invasive brain stimulations that enhance neuroplastic changes after stroke. However, the effect of intermittent theta burst stimulation (iTBS) in addition to evidence-based, intensive neurorehabilitation approaches such as modified constraint-induced movement therapy (mCIMT) is yet to be investigated. AIM: We aim to establish a protocol for a randomized controlled study investigating the efficiency of mCIMT primed with iTBS after stroke. METHODS: In this randomized controlled, single-blind study, patients with stroke (N = 17) will be divided into 3 groups: (a) mCIMT + real iTBS, (b) mCIMT + sham iTBS, and (c) mCIMT alone. 600-pulse iTBS will be delivered to the primary motor cortex on the ipsilesional hemisphere, and then, patients will receive mCIMT for 1 h/session, 3 sessions/week for 5 weeks. Upper extremity recovery will be assessed with Fugl-Meyer Test-Upper Extremity and Wolf Motor Function Test. Electrophysiological assessments, such as Motor-Evoked Potentials, Resting Motor Threshold, Short-Intracortical Inhibition, and Intracortical Facilitation, will also be included. CONCLUSIONS: In this study, a protocol of an ongoing intervention study investigating the effectiveness of iTBS on ipsilesional M1 prior to the mCIMT in patients with stroke is proposed. This will be the first study to research priming mCIMT with iTBS and it may have the potential to reveal the true effect of the iTBS when it is added to the high-quality neurorehabilitation approaches. TRIAL REGISTRATION: Trial registration number: NCT05308667.

Sarcopenic obesity is not associated with sexual dysfunction in older adults: a cross-sectional study.

BACKGROUND: This study aimed to investigate the frequency of sexual dysfunction (SD) and the association between SD and body composition abnormalities, such as sarcopenia, obesity, and sarcopenic obesity. METHODS: Older adults (≥65 years) were included. Sarcopenic obesity was diagnosed by using newly defined ESPEN-EASO diagram. Sarcopenia was diagnosed according to the European Working Group on Sarcopenia in Older People criteria. Obesity was defined using the fat percentile cut-offs suggested by ESPEN-EASO. SD was determined by Arizona Sexual Experience Scale (ASEX). RESULTS: Two-hundred and sixty-seven volunteers (64.4% female, mean age 73.63 ± 6.22 years) participated in this study. One-hundred seventy-eight individuals (66.7%) had SD. It was present in 83.1% and 36.8% of the females and males, respectively (p < 0.0001). There was no association between SD and sarcopenia alone (OR: 1.359, 95% CI: 0.650-2.838, p = 0.415) or obesity alone (OR: 0.986, 95% CI: 0.543-1.791, p = 0.963). Sarcopenic obesity was significantly associated with SD (OR: 9.116, 95% CI: 1.173-70.851, p = 0.035). However, this significance was lost after the model was adjusted for gender, marital status, and comorbidities (OR: 4.676, 95% CI: 0.578-37.801, p = 0.148). CONCLUSIONS: SD was present in 66.7% of the older adults and was not associated with sarcopenia, obesity, or sarcopenic obesity. Further longitudinal studies are needed on this topic.

The frequency of sexual experience in community-dwelling older adults was only 33.7% and 53.2% in the last 1 year and 5 years, respectively.One-hundred seventy-eight individuals (66.7%) had sexual dysfunction (SD).The female gender and being a widow/widower were found to increase the odds of SD.Sarcopenia, obesity, or sarcopenic obesity were not associated with a higher risk of SD.

The Validity and Reliability of the Turkish Version of Self-Perceived Barriers for Physical Activity Questionnaire.

Identifying the barriers to physical activity (PA) is important for comprehensive management strategies to decrease physical inactivity. This study aimed to translate and cross-culturally adapt the Self-Perceived Barriers for Physical Activity Scale (SPBPA) into Turkish and investigate its psychometric properties. One-hundred fifty-two young and middle-aged adults (mean age of 33.3 ± 12.66 years) were included. Within a 5-to-15-day period after the first assessment, the participants completed the Turkish version of SPBPA (SPBPA-T) to evaluate test-retest reliability. Cronbach's alpha (α) was used to assess internal consistency. The correlation between the SPBPA-T and Physical Activity Barriers Questionnaire (PABQ) and Short Form-12 (SF-12) was determined to check the validity. The SPBPA-T had a strong internal consistency (α = .83) and test-retest reliability (ICC2,1 = .90). There was a strong correlation between PABQ and SPBPA-T (r = 0.709; p < .0001), indicating strong construct validity. The convergent validity of SPBPA-T was confirmed with the mental component of SF-12 (r = -.228; p < .0001). There was no floor or ceiling effect. The questionnaire had a 1.083 SEM value and its MDC was 3.00 points. The SPBPA-T is semantically and linguistically adequate and has strong internal validity and test-retest reliability to determine the self-perceived barriers to PA among Turkish-speaking young adults.

Enhancement of motor skill acquisition by intermittent theta burst stimulation: a pilot study.

OBJECTIVE: This study aims to analyze the effects of intermittent theta burst stimulation (iTBS) on motor skill acquisition of healthy subjects when applied on alternate days to ensure high adherence to treatment. MATERIALS AND METHODS: Ten healthy participants (40-54 years) were included in the study. The control group (CG) (60% female) only received motor training (i.e., finger tapping task-FTTa), whereas the experimental group (EG) (100% female) received iTBS in addition to the motor training (every other day for 5 sessions). Cortical excitability measurements were taken with TMS. The correct sequences of the finger tapping test (FTTe) were recorded for behavioral analysis. RESULTS: While SICI was increased by 0.03 in EG, ICF was increased by 0.18 between pre-and post-treatment. On the other hand, CG had a lower ICF difference (MD: 0.05) and a higher SICI difference (MD: 0.21). There was no difference between EG and CG in FTTe at the end of the intervention (p > 0.05 for all variables), except for the increased number of correct sequences within the EG (p = 0.018). There was a significant difference in FTTa between EG and CG, in favor of EG (p = 0.042). The effect size was 0.62. CONCLUSION: Although no difference was found in terms of cortical excitability and FTTe between the EG and CG at the end of the alternate-day treatment, it seemed like iTBS increased cortical facilitation further than CG. Furthermore, the number of correct sequences in FTTe and FTTa was significantly increased in EG, showing that intermittent iTBS might improve motor learning and performance.

Prevalence of Malnutrition According to the Global Leadership Initiative on Malnutrition Criteria in Community-dwelling Older Adults in Turkey.

Objective: This study aimed to investigate the prevalence of malnutrition according to the Global Leadership Initiative on Malnutrition (GLIM) criteria in community-dwelling older adults in Turkey. Methods: Malnutrition was assessed based on the GLIM criteria, and Mini-Nutritional Assessment-Short Form was used for screening. The severity of malnutrition was determined as severe or moderate based on the phenotypic criteria of GLIM. Results: Five hundred sixty-nine (69% female, mean age 74.42±6.58 years) community-dwelling older adults participated in this study. The educational statuses of the participants were as follows: 17.2%, illiterate; 13.3%, literate; 35.3%, primary school; 7.0%, secondary school; 11.1%, high school; and 16.2%, university graduates. Among the participants, 16.4% were living alone, whereas 43.9% of them were living with their spouses. The rest were living with their extended families. According to the GLIM criteria, 24.5% (n=139) of the participants had malnutrition, and 13.9% of the total population had severe malnutrition. Age was significantly associated with malnutrition [odds ratio 1.064, 95% confidence interval (CI) 1.034-1.096, p<0.0001]. No significant difference was found between genders (p=0.207), education groups (p=0.323), and living status (p=0.434) in terms of malnutrition. However, women had higher malnutrition rates than men (26.0% vs. 21.0%) (risk ratio 0.757, 95% CI 0.494-1.160, p=0.207). Conclusions: The prevalence of malnutrition was 24.5%, whereas the rate of severe malnutrition was 13.9% in community-dwelling older adults. Women had higher rates of malnutrition, and age was associated with malnutrition. We recommend for researchers and clinicians to integrate the GLIM criteria into their practices to create a common language in malnutrition assessment.

Effect of upper limb focal muscle vibration on cortical activity: A systematic review with a focus on primary motor cortex.

This systematic review aimed to investigate the effects of upper extremity focal muscle vibration (FMV) on cortical activity. A systematic literature search was conducted for articles published in English in the SCOPUS, PEDro, PUBMED, REHABDATA, MEDLINE, and Web of Science databases. Eighteen studies (6 controlled and 12 experimental studies) were included in the systematic review. A total of 264 individuals (20 to 68 years) participated in the studies. The outcome of this review showed that FMV might have contradictory effects on cortical areas: (a) Reduction of cortical activity in the primary motor cortex (M1) and somatosensory cortex (S1), (b) no changes in the cortical activity of M1, and (c) increased cortical activity of M1 and S1. These effects may depend on different factors such as frequency and amplitude of FMV, vibration exposure time, and muscle status. However, no single factor can definitely be accounted for the variance.

Nutritional status as a mediator between the age-related muscle loss and frailty in community-dwelling older adults.

PURPOSE: The purposes of the study were: a) to investigate the prevalence of sarcopenia, obesity and sarcopenic obesity (SO) in older adults, b) to explore the effect of nutrition as mediator of the association between these entities and frailty. MATERIALS AND METHODS: Older adults (≥65 years) were evaluated based on European Working Group on Sarcopenia in Older People criteria for the presence/absence of sarcopenia. Obesity was diagnosed by using Zoico methodology. FRAIL scale was used to evaluate frailty and nutritional status was assessed with Mini Nutritional Assessment (MNA). RESULTS: Five-hundred-seventy individuals (68,9% female, mean age 74,41±6,57 years) were included. The prevalence of sarcopenia, obesity and SO were 18,6%, 28,9% and 11,2%, respectively. FRAIL scores were directly affected by having sarcopenia (ß: 0.42, 95% CI: (0.21-0.67), p<0.001) and SO (ß: 0.31, 95% CI: (0.06-0.59), p:0.015), whereas obesity had no direct effect on FRAIL (ß: 0.1, 95% CI: (-0.08-0.3), p:0.26). MNA was a mediator (ß: -0.35, 95% CI: (-0.12-(-0.08)), p<0.0001) in both sarcopenic (ß: -0.69, 95% CI: (-3.34-(-1.69)), p<0.0001) and SO patients (ß: -0.34, 95% CI: (-2.21-(-0.26)), p:0.013), but not in obese group (ß: -0.01, 95% CI: (-0.08-0.04). After the Bonferroni corrections,only sarcopenia had an association with frailty with MNA being the mediator. CONCLUSION: The findings revealed that the frailty rate was higher in sarcopenia (20,8%) and SO (17,2%) groups than obese (5,5%) group. Frailty was associated with sarcopenia and SO, but not with obesity. Nutritional status was found to be a mediator of the association between age-related muscle loss and frailty To the best of our knowledge, this is the first study to report the mediator of the associations between age-related muscle loss and frailty.

Validity and reliability of the Turkish version of "the Dyspnea-ALS-Scale (DALS-15)".

AIM: The aim of this study was to investigate the validity and reliability of the Turkish version of The Dyspnea-ALS-Scale (DALS-15). METHODS: Forward translation, back translation, and cross-cultural adaptation were used to ensure the equivalency of translated version of the scale. Then, patients with amyotrophic lateral sclerosis (ALS) who have dyspnea or orthopnea that develops with effort or at rest were evaluated using DALS-15 via online surveys. The respiratory subscale of ALS Functional Rating Scale-Revised (ALSFRS-R) and Modified Borg Dyspnea Scale (MBDS) was used to investigate the construct validity of the Turkish DALS-15. Reliability was assessed with Cronbach's α and inter-item correlation matrix (internal consistency). RESULTS: We have included 52 ALS patients in the study. Findings showed that Turkish version of DALS-15 was highly correlated with respiratory subscale of ALSFRS-R (r = - 0.668; p = < 0.0001) and MBDS (for upright position: r = 0.728; p = < 0.0001 and for supine: r = 0.78; p = < 0.0001). The scale did not show any ceiling or floor effect. Also, DALS-15 had a high level of Cronbach's α (0.95) and internal consistency (ICC: 0.949; 95%CI: 0.92-0.96). Test-re-test reliability of the questionnaire was (ICC: 0.909; 95% CI: 0.81-0.95). The standard error of measurement value was 2.76, whereas the minimal detectable change score was 7.66 points for the translated version of the scale. CONCLUSIONS: The Turkish version of DALS-15 possesses strong psychometric properties with excellent validity and reliability. It is shown to be useful for online self-assessment, outside of the clinical settings, especially in hard times such as a pandemic.

Anthropometric and Body Composition Measurements Related to Osteoporosis in Geriatric Population.

Objective: This study aimed to evaluate different anthropometric and body composition measurements, including weight, body mass index (BMI), body fat percentage (fat%), skeletal muscle index (SMI), a body shape index (ABSI), waist circumference (WC), and hip circumference (HC), in relation to bone mineral density. Methods: This is a cross-sectional study of a total of 482 patients who consulted the geriatric outpatient clinic between 2018 and 2019. Patients were evaluated with dual-energy X-ray absorptiometry. Anthropometric measurements (HC, WC, weight, BMI, and ABSI), as well as body composition analysis (fat% and SMI) by bioimpedance analysis system, were performed. The patients were evaluated with the rapid Assessment of Physical Activity Index in terms of aerobic exercise habits. Results: There was a significant correlation between lumbar spine (LS) T-score and SMI (r=0.36, p=0.000) and between LS T-score and weight (r=0.21, p=0.000), BMI (r=0.10, p=0.045) and WC (r=0.15, p=0.001). There was a statistically significant correlation between femur neck (FN) T-score and fat% (r=0.15, p=0.001), SMI (r=0.15, p=0.010), weight (r=0.22, p=0.000), BMI (r=0.20, p=0.000), WC (r=0.14, p=0.003), and HC (r=0.17, p=0.001). There was no statistically significant correlation between physical activity and LS T-score (n=353, r=0.08, p=0.16) and FN T-score (n=360, r=0.03, p=0.53). In multiple regression analysis, SMI contributes most in predicting FN and LS T-scores. Conclusions: Anthropometric measurements should be carefully selected in the geriatric population. Among the measurements, the strongest relationship was found between LS T-score and SMI.

Prevalence of osteosarcopenic obesity in community-dwelling older adults: a cross-sectional retrospective study.

In our study investigating the prevalence of osteosarcopenic obesity (OSO) in community-dwelling older adults and possible factors responsible for falls, we have found that prevalence of OSO is 10.7%. OSO does not significantly increase the odds of falling, whereas lower handgrip strength, ALMi and gait speed were independent factors associated with falls. PURPOSES: The purposes of the study were (a) to determine the prevalence of osteosarcopenic obesity (OSO) in community-dwelling older adults and (b) to investigate the association between falls and possible factors in individuals with and without OSO. METHODS: Medical records of patients aged ≥ 65 years were retrospectively reviewed. Individuals were diagnosed with OSO based on their T-score assessed by dual x-ray absorptiometry, handgrip strength, appendicular lean mass index (ALMi), gait speed and body fat percentile. Comorbidities, history of falls, depressive state, medications and anthropometric measures were also noted. RESULTS: A sample of 460 individuals were assessed (337 females; 123 males) and 49 patients were diagnosed with OSO. There was no statistically significant difference in falls between the two groups (OR: 0.768, 95% CI: 0.409-1.440, p: 0.41) and the presence of OSO was not significantly associated with increased odds of falling (OR: 1.755, 95% CI: 0.547-5.628, p: 0.344). Handgrip strength (OR: 0.931, 95% CI: 0.893-0.971, p: 0.001), ALMi (OR: 0.799, 95% CI: 0.708-0.901, p < 0.0001) and gait speed (OR: 0.529, 95% CI: 0.283-0.988, p: 0.046) were independently associated with falls in overall group, whereas interaction analysis did not reveal any significant moderator effect of OSO vs. non-OSO in the associations between risk factors and falls. CONCLUSION: The prevalence of OSO was 10.7%. OSO was not associated with elevated odds of falling, whereas lower handgrip strength, ALMi and gait speed were independent factors associated with falls. Further prospective research is needed to clarify the effect of OSO on odds of falling, in consideration with possible risk factors. TRIAL REGISTRATION NUMBER AND DATE: NCT04288401 /26.02.2020.

Determinants of Bone Health in Older Adults.

OBJECTIVE: The objective of this study was to determine the predictors of bone health in older adults. METHODS: A total of 313 subjects older than 65 years (mean age 74.2±6.4 years, 70.6% female) were included in the study. Demographic characteristics of participants such as gait speed, handgrip strength, level of physical activity (using Rapid Assessment of Physical Activity-RAPA scale), vitamin D levels, T scores of femur neck (FN) and lumbar spine (LS) were recorded. RESULTS: Based on FN, 40.7% of participants had normal T scores whereas 46.2% and 13.1% of them were osteopenic and osteoporotic, respectively. FN was correlated with age (r:-0.184, p<0.001), BMI (r:0.269, p<0.001), and handgrip strength (r:0.149, p:0.009) in addition to the aerobic subscale of RAPA (RAPA-aerobic) (r:-0.133, p:0.02). Similarly, the LS was correlated with female gender (r:-0.207, p<0.001), age (r:0.136, p:0.016), body mass index (BMI) (r:0.246, p<0.001) and handgrip strength (r:0.217, p<0.001). The predictors of bone health were decided upon using multiple logistic regression analysis. The deterministic model consisted of age, gender, BMI, height, weight, handgrip strength, gait speed, RAPA-aerobic and vitamin D. For LS dependent variable, the overall model was significant (F:10.149, p<0.001). However, only two variables were significant predictors in the model ie. weight (ß:0.389, p<0.001) and handgrip strength (ß=0.186, p<0.001). Similarly for independent variable of FN, the overall model was significant (F:6.525, p<0.001) and only two variables were significant predictors: weight (ß:0.371, p<0.001) and RAPA-Aerobic (ß:0.148, p:0.009). CONCLUSION: Lower levels of body weight, participation in aerobic activity and handgrip strength might be risk factors for deterioration of bone health in older adults.

What are the determinants of explicit and implicit motor imagery ability in stroke patients?: a controlled study.

Purpose: The purposes of the study were to (a) investigate both explicit and implicit motor imagery ability (MIA) impairment after stroke, (b) examine predictive effects of clinical characteristics for MIA after stroke.Materials and Methods: Forty one patients with stroke (PwS) (mean age 59.41 ± 10.19 years; %41 female) and 36 healthy participants (mean age 62.47 ± 9.29 years; %47 female) completed Chaotic Motor Imagery Assessment-Hand Rotation for implicit MIA and Movement Imagery Questionnaire-3 (MIQ-3) and Box and Block Test (BBT) for explicit MIA. The severity of motor and sensory impairments were determined by the Fugl-Meyer Assessment-Upper Extremity (FMAUE) scores. The Turkish version of Motor Activity Log-28 was used to assess amount of use (AUS) and quality of movement in daily life.Results: Our results indicated that both implicit and explicit MIA (except kinaesthetic imagery of MIQ-3) in PwS were statistically impaired compared to controls (p < 0.05). The sensorimotor impairment level, amount of use and movement quality of the affected upper limb were found to be correlated with MIA in various degrees. Total motor scores in FMAUE and AUS were significant predictors of explicit MIA (p < 0.01). Additionally, explicit MIA scores of stroke subgroups were statistically different between severely and mildly impaired patients, in favour of mildly impaired group (p < 0.05).Conclusion: In conclusion, both motor impairment level and amount of daily use of upper extremity were found to be predictive factors for explicit MIA. Further investigation with brain imaging techniques is needed to explore the validity of these findings in establishing MIA.