Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023 (J-ReCIP 2023).

Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the "Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit" to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.

Rehabilitation effects in idiopathic normal pressure hydrocephalus: a randomized controlled trial.

BACKGROUND: Gait-balance disturbances are core symptoms of idiopathic normal pressure hydrocephalus (iNPH). However, the rehabilitation effects of cerebrospinal fluid (CSF) shunting along with other treatment or no further treatment (natural course [NC]) for iNPH are unknown. OBJECTIVES: This study evaluated whether dynamic equilibrium gait training (DEGT) can improve gait-balance functions after CSF shunting of patients with iNPH compared to standard exercise (SE) and NC. Furthermore, it investigated the incidence of falls. METHODS: A total of 70 patients with iNPH who underwent CSF shunting were randomly assigned to 6 weeks of DEGT (n = 23), 6 weeks of SE (n = 23), or NC (n = 24). Evaluation was performed at baseline (preoperatively) and at 1 week, 7 weeks (postintervention), and 6 months postoperatively (follow-up). Outcomes were measured using the functional gait assessment (FGA), 10-m walk test, timed up-and-go test, life-space assessment (LSA), and fall incidence. RESULTS: A total of 65 participants completed the study. During the intention-to-treat analysis, the DEGT group demonstrated significant recovery of gait-balance functions according to only the FGA at postintervention and follow-up compared to the SE and NC groups; however, recovery of the SE group did not differ from that of the NC group. The DEGT group had a significantly lower fall incidence than the other groups at follow-up. Significantly better LSA results were observed for all groups at follow-up compared to baseline; however, no difference in LSA results were observed between groups. CONCLUSIONS: DEGT in addtion to CSF shunting can facilitate the recovery of gait-balance function and reduce the fall incidence of iNPH patients.

Dynamic gait stability in patients with idiopathic normal pressure hydrocephalus with high and low fall-risk.

BACKGROUND: This study aimed to investigate whether dynamic gait stability differs between idiopathic normal-pressure hydrocephalus with high- and low-fall-risk. METHODS: Participants comprised 40 idiopathic normal-pressure hydrocephalus patients and 23 healthy-controls. Idiopathic normal-pressure hydrocephalus patients were divided into those with high-fall-risk (n = 20) and low-fall-risk (n = 20) groups using the cut-off score of ≤14/30 for fall-risk on the Functional Gait Assessment. Dynamic stability during gait was assessed by three-dimensional motion analysis. Dynamic stability was defined as the ability to maintain an extrapolated center of mass within the base of support at heel contact, with the distance between the two defined as the margin of stability. Conscious motor control was assessed by the Movement-Specific Reinvestment Scale. FINDINGS: Anteroposterior and mediolateral margin of stabilities were significantly larger in both idiopathic normal-pressure hydrocephalus groups than in healthy-controls. The mediolateral margin of stability was significantly higher in the high-fall-risk group than in the low-fall-risk group; whereas, the anteroposterior margin of stability did not differ between idiopathic normal-pressure hydrocephalus groups. The Movement-Specific Reinvestment Scale was significantly higher in the high-fall-risk group than in the low-fall-risk group. INTERPRETATION: Idiopathic normal-pressure hydrocephalus patients with have high forward and lateral dynamic stability during gait regardless of their fall-risk. In particular, idiopathic normal-pressure hydrocephalus patients with high-fall-risk may consciously maintain lateral dynamic stability to a greater extent than those with low-fall-risk. These findings highlight a conscious motor control component in the pathological gait of idiopathic normal-pressure hydrocephalus, and provide clues for rehabilitation and fall prevention strategies in idiopathic normal-pressure hydrocephalus patients.

Impact of Early Intervention for Idiopathic Normal Pressure Hydrocephalus on Long-Term Prognosis in Prodromal Phase.

Objectives: Because the progression of idiopathic normal pressure hydrocephalus (iNPH) is partially irreversible, we hypothesized that early intervention would markedly improve its prognosis. To test this hypothesis, we retrospectively investigated the long-term prognosis of patients with early intervention in the prodromal phase of iNPH. Methods: We defined the prodromal phase of iNPH as a 3m Timed Up and Go (TUG) of 13.5 s or less and a Mini-Mental State Examination (MMSE) of 24 or more. Of the 83 iNPH patients who underwent shunt surgery at Osaka Medical and Pharmaceutical University Hospital over 3 years from January 2015, 12 prodromal phase cases (73.3 ± 6.2 years, 10 males and 2 females) were included in the study. The iNPH grading scale (INPHGS), MMSE, Frontal Assessment Battery (FAB), intermittent gait disturbance (IGD), social participation status, and development of comorbidities were evaluated over 4 years. Results: Preoperative MMSE was 27.2 ± 1.5, FAB was 14.1 ± 1.8, TUG was 10.7 ± 1.4 s, and total iNPHGS was 2.8 ± 1.4. At 1, 2, 3, and 4 years postoperatively, total INPHGS improved to 0.8, 0.9, 1.5, and 1.7, respectively, and remained significantly better than preoperatively except at 4 years postoperatively. The MMSE improved slightly to 27.5 after 1 year and then declined by 0.35 per year. After 4 years, the mean MMSE was 26.1, and only one patient had an MMSE below 23. FAB improved to 15.2 after 1 year and then declined slowly at 0.85/year. Ten patients (83%) maintained a high capacity for social participation postoperatively. The preoperative tendency to fall and IGD in 9 (75%) and 8 (67%) patients, respectively, completely disappeared postoperatively, resulting in improved mobility. Shunt malfunction associated with four weight fluctuations and one catheter rupture caused temporary worsening of symptoms, which were recovered by valve re-setting and catheter revision, respectively. Conclusion: Early intervention in the prodromal phase of iNPH patients maintained good cognitive and mobility function and social participation ability in the long term. The maintenance of long-term cognitive function suggests its preventive effect on dementia. To realize early intervention for iNPH, it is desirable to establish an early diagnosis system for iNPH.

Dynamic stability during gait in idiopathic normal pressure hydrocephalus and Parkinson's disease.

OBJECTIVES: To clarify a characteristic of dynamic stability during gait in idiopathic normal pressure hydrocephalus (iNPH) and Parkinson's disease (PD), and to explore the association between dynamic stability and disease severity in each disease. MATERIALS AND METHODS: The 5-m gait of 36 iNPH (precerebrospinal fluid drainage), 20 PD (medicated state), and 25 healthy controls (HC) were evaluated using three-dimensional motion analysis. Ambulatory dynamic stability was defined as the ability to maintain the extrapolated center of mass within the base of support at heel contact, with the distance between the two referred to as the margin of stability (MOS). RESULTS: Anteroposterior direction (AP) MOS was significantly larger in the iNPH and PD groups than in the HC group; no significant difference was found between the iNPH and PD groups. Mediolateral direction (ML) MOS was significantly larger in the iNPH and PD groups than in the HC group and significantly larger in the iNPH group than in the PD group. In the iNPH group, the disease severity was positively correlated with only ML MOS. In the PD group, the disease severity was positively correlated with the AP MOS and ML MOS. CONCLUSIONS: Dynamic stability in iNPH increases in AP and ML, and it may be associated with not only iNPH-associated gait disturbance but also with a voluntarily cautious gait strategy. Dynamic stability in PD only increased in AP, and this may be associated with PD symptoms. These findings will help physicians understand the difference in pathological gait including dynamic stability between patients with iNPH and PD.

Forward gait instability in patients with Parkinson's disease with freezing of gait.

Freezing of gait (FOG) appears to be associated with increased risk of forward falls in patients with Parkinson's disease (PD). This study aimed to experimentally validate forward gait instability in PD patients with FOG (PD + FOG). Eleven PD + FOG patients, 9 PD patients without FOG (PD - FOG), and 13 healthy controls participated. Self-selected paced gait was analyzed by a three-dimensional motion-capture analysis system. We assessed the distance between the center of mass and the base of support (COM-BOS distance) and the margin of stability (MOS), considering the position and velocity of the COM as gait stability parameters, spatiotemporal gait parameters and kinematic parameters. The anteroposterior COM-BOS distance was smaller in PD + FOG patients than in PD-FOG patients and controls. Anteroposterior MOS was larger in PD + FOG and PD - FOG patients than controls (p < 0.05). PD + FOG patients showed smaller anteroposterior MOS than PD - FOG patients, when adjusting for disease severity (p < 0.05). Only in the PD + FOG group, when adjusting for disease severity, step length was positively correlated with the anteroposterior COM-BOS distance (p < 0.05), and cadence was negatively correlated with the anteroposterior MOS (p < 0.05). These results indicated that PD patients with FOG have forward gait instability and suggested that such instability may be associated with reduced step length and increased cadence.

Perceived and actual changes in gait balance after CSF shunting in idiopathic normal pressure hydrocephalus.

OBJECTIVES: We evaluated the perceived and actual changes in gait and balance function immediately after cerebrospinal fluid (CSF) shunting in patients with idiopathic normal pressure hydrocephalus (iNPH), including those with mild cases. MATERIALS AND METHODS: Ninety-nine iNPH patients were assessed using the timed Up and Go (TUG) and Functional Gait Assessment (FGA) before and 1-week after CSF shunting and their perceived changes were assessed on a Global Rate of Change (GRC) scale. Minimal clinically important differences (MCIDs) were calculated using a receiver operating characteristic (ROC) curve method using GRC scores. RESULTS: In all patients (n = 99), the TUG value postoperatively was significantly faster than the preoperative value (difference; 3.1 ± 4.6 s, p < 0.001), and the postoperative FGA score was significantly better than the preoperative score (difference; 3.8 ± 3.3 points, p < 0.001). In the TUG <15 s group (n = 51), the postoperative FGA score was significantly improved (difference; 3.3 ± 2.9 points, p < 0.001), whereas the TUG value was only slightly improved (difference; 0.6 ± 1.6 s, p = 0.008). The ROC curve MCIDs of GRC ≥2 points, which is the recommended level of improvement, were 1.7 s (16.5%) for the TUG and 4 points (20.0%) for the FGA in all patients (n = 99) and the TUG <15 s group (n = 51). CONCLUSIONS: FGA can be used to confirm treatment effects, including perceived and actual changes after CSF shunting, in patients with mild iNPH. Our results can help clinicians to determine the clinical significance of improvements in gait and balance function immediately after CSF shunting in individual patients with iNPH.

A text mining analysis of perceptions of the COVID-19 pandemic among final-year medical students.

AIM: The coronavirus disease 2019 (COVID-19) pandemic has presented various challenges to medical schools. We performed a text mining analysis via essay task to clarify perceptions among final-year medical students toward the COVID-19 pandemic. METHODS: We posed the following essay question to 124 final-year medical students: "What should medical staff do during the COVID-19 pandemic; what should you do?" Responses were subjected to quantitative analysis using a text mining approach. Frequently occurring key words were extracted, followed by multidimensional scaling and co-occurrence network calculations. RESULTS: Of the 124 students, 123 (99.2%) responded to the essay question. The following seven key words were identified as high-frequency words: medical, infection, patient, human, myself, doctor, and information. Co-occurrence network calculations revealed that the word "medical" had a high degree of correlation with most key words, except for "doctor." The word "myself" was correlated with not only "medical" but also "infection," "human," and "doctor." CONCLUSION: Our analysis of perceptions among final-year medical students toward the COVID-19 pandemic revealed that most medical students are strongly affected by the COVID-19 pandemic and are motivated to work as physicians among health care professionals.

Ultrasound-assisted near nerve method in nerve conduction study for the diagnosis of tarsal tunnel syndrome. A case report.

OBJECTIVES: The sensitivity of nerve conduction studies (NCSs) of the medial and lateral plantar nerves for the diagnosis of tarsal tunnel syndrome (TTS) is not high enough. The near nerve method (NNM) is a recording technique for NCSs that allows the recording of large, clear potentials. The NNM was reported to improve the sensitivity of diagnoses of TTS. However, the NNM requires special skill using electrical motor threshold in positioning a needle electrode correctly. Thus, we performed the NNM with the aid of ultrasound imaging (ultrasound-assisted). The aim of this case report is to show the utility of ultrasound-assisted NNM in the electrodiagnosis of TTS. CASE REPORT: A 69-year-old woman presented with paresthesia on the lateral sole of her right foot. Ultrasound imaging showed a space occupying lesion (SOL) posterior to the medial malleolus, caused by tenosynovitis, as discovered after surgery. We performed an NCS of the medial and lateral plantar nerves with ultrasound-assisted NNM. Ultrasound-assisted NNM allowed us to easily determine the needle insertion site just proximal to the SOL and to avoid penetrating the SOL and the vessels, and, furthermore, simplified moving the needle electrode toward the target nerve. The results of the NCS revealed that there was severe injury to the lateral plantar nerve and no injury to the medial plantar nerve. CONCLUSIONS: In the NCS of the medial and lateral plantar nerves with NNM to diagnose TTS, ultrasound-assisted NNM can be useful for simplicity and safety.

Comparison between quantitative and subjective assessments of chemotherapy-induced peripheral neuropathy in cancer patients: A prospective cohort study.

OBJECTIVE: Chemotherapy-induced peripheral neuropathy (CIPN) is a common adverse event experienced by cancer patients. In general, CIPN is evaluated subjectively based on patient self-assessment or clinician-reported scales; evidence supporting the utility and validity of quantitative sensory tests (QST) is lacking in this patient population. The aim of this study was to objectively assess CIPN of lower extremities by QSTs, and to evaluate the concordance between QSTs and subjective assessments. METHODS: In this prospective cohort study, outpatients with cancer receiving chemotherapy were recruited at a single university hospital. We assessed CIPN at the lower extremities at baseline and three months after baseline. The QSTs were performed by applying a monofilament and a tuning fork to determine touch and vibration thresholds, respectively, at the affected site. Subjective assessments were performed based on the visual analog scale (VAS) and the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) toxicity grade. Kappa coefficients were calculated to evaluate the concordance between QSTs and subjective assessments. RESULTS: After exclusion and drop-outs during follow-up, nineteen patients were included in the analysis. The prevalence of patients with abnormal sensation was 37% based on QSTs, 32% based on the VAS, and 14% based on CTCAE grading, respectively. Kappa coefficients were 0.32 between QSTs and VAS, and 0.28 between QSTs and CTCAE. CONCLUSIONS: The concordance rates between quantitative and subjective assessments were low. CIPN should be assessed using both quantitative and subjective assessments.

Long-Term Prognosis of Cognitive Function in Patients With Idiopathic Normal Pressure Hydrocephalus After Shunt Surgery.

The long-term prognosis of cognitive function in patients with idiopathic normal pressure hydrocephalus (iNPH) remains unclear. This study aimed to determine the long-term prognosis of cognitive function in patients with iNPH, as well as the factors related to it. It included 48 patients with iNPH who were treated with cerebrospinal fluid shunting between January 2015 and December 2017 at Osaka Medical College Hospital, with follow-up evaluation of their cognitive function for >2 years. Cognitive function was measured using the Mini-Mental State Examination (MMSE) preoperatively and at 3 months, 1 and 2 years post-operatively. The mean MMSE score (22.4 ± 5.4 preoperatively) improved at 3 months [23.8 ± 5.0 (p = 0.0002)] and 1 year [23.7 ± 4.8 (p = 0.004)] post-operatively. At 2 years post-operatively, they were able to maintain their preoperative level (22.6 ± 5.3). The patients were classified in to the cognitive decline group [11 (23%) patients; a decrease in the MMSE score by ≥ 2 points 2 years after surgery] and the maintenance/improvement group [37 (77%) patients]. Univariate and receiver operating characteristic analyses were performed for the two groups to identify factors associated with cognitive prognosis. In both groups, the patients who were younger (p = 0.009) or had milder symptoms (p = 0.035) had a better long-term prognosis of cognitive function. The cutoffs for age and disease severity (idiopathic normal-pressure hydrocephalus grading scale; INPHGS) were 78 years (area under the curve = 0.77) and 5 points (area under the curve = 0.71), respectively. In conclusion, most patients (77%) were able to improve and maintain cognitive function for at least 2 years after surgery. The fact that disease severity and age are associated with cognitive prognosis suggests that early iNPH intervention is desirable to improve cognitive prognosis.

Effects of strengthening the hip flexor muscles on walking ability and the locomotive syndrome rank test: An intervention study.

BACKGROUND: Locomotive syndrome is a state in which locomotive function is decreased due to musculoskeletal diseases. To extend a healthy lifespan, it is important to prevent falls and locomotive syndrome development accompanying aging by slowing the decline in walking ability. However, it is unclear whether hip flexor muscle strengthening improves walking ability and locomotive syndrome. This study aimed to examine the effect of hip flexor muscle strengthening on walking ability and the locomotive syndrome rank test. METHODS: Forty participants were enrolled. Before hip flexor muscle strengthening, maximum muscle strength on the exercised side was measured, and gait analysis and the two-step test were performed simultaneously. Participants were divided into a healthy group and a locomotive syndrome group based on the two-step test and were given hip flexor muscle training at least three days a week for six weeks. After completing the training, maximum muscle strength was measured and gait analysis was performed for all participants. The difference between the two-step test conducted pre- and post-training in the locomotive syndrome group was statistically analyzed. RESULTS: Twenty-two and 14 participants were included in the healthy and the locomotive syndrome groups, respectively. Hip flexion strength on the exercised side increased from 1.68 to 1.95 Nm/kg (p < 0.0001) and 1.04 to 1.21 Nm/kg (p = 0.0031) in the healthy and the locomotive syndrome groups, respectively. Step length, stride length and walking speed measured by gait analysis also increased in both groups. Consequently, the two-step test score improved from 1.17 to 1.30 (p = 0.0002) and the stage of locomotive syndrome improved in 9 participants (p = 0.041). CONCLUSIONS: Strengthening of the hip flexor muscles improved walking ability and the stage of locomotive syndrome. Therefore, strengthening of the hip flexor muscles is important for the prevention and improvement of locomotive syndrome.

Electroneurography value as an indicator of high risk for the development of moderate-to-severe synkinesis after Bell's palsy and Ramsay Hunt syndrome.

Background: The degree of distress caused by the sequelae of peripheral facial nerve palsy usually depends on the severity of synkinesis. Objective: To clarify whether electroneurography (ENoG) can predict the severity of synkinesis after peripheral facial nerve palsy. Materials and methods: One-hundred and fourteen patients treated for facial nerve palsy at our hospital from April 2014-September 2016 were retrospectively reviewed. ENoG was performed 10-16 days after symptom onset. Patients were classified into Groups A (ENoG value 10%-20%, n = 9) and B (ENoG value <10%, n = 21). Eight months after symptom onset, electrophysiological and symptomatic outcomes were evaluated as the aberrant regeneration ratio of the blink reflex and the total synkinesis score of the Sunnybrook facial grading system, respectively. The outcomes of the groups were compared. Results: Group B had a significantly higher median aberrant regeneration ratio (0% versus 87%, p=.015), median total synkinesis score (1 versus 3, p < .001), and incidence of moderate-to-severe synkinesis (0% versus 57.2%, p=.003) than did Group A. Conclusions and significance: Patients with an ENoG value of <10% have higher risks of aberrant regeneration and moderate-to-severe synkinesis than those with an ENoG value of 10%-20%. Patients with ENoG values of <10% may require rehabilitation to prevent synkinesis.

Associations among falls, gait variability, and balance function in idiopathic normal pressure hydrocephalus.

OBJECTIVES: The factors influencing falls in idiopathic normal pressure hydrocephalus (iNPH) remain unclear, although iNPH-associated gait and balance disturbances can lead to an increased risk of falls. This study aimed to investigate the associations among fall status, gait variability, balance function in iNPH, and to identify fall-related factors in iNPH. PATIENTS AND METHODS: Sixty-three patients with iNPH with a positive cerebrospinal fluid tap test result according to the iNPH diagnosis criteria participated in this prospective cross-sectional study. Patients were assessed using the 10-meter walk test (10MWT), the Functional Gait Assessment (FGA), the Berg Balance Scale (BBS), and the isometric quadriceps strength (QS). We also investigated each patient's history of falls in the past 6 months. Gait variability was measured using a triaxial accelerometer attached to the patient's torso at the L3 vertebra level during the 10MWT. RESULTS: Fall status correlated significantly with gait variability (measured as the coefficient of variation; CV) in step time and movement trajectory amplitude (i.e., center of mass movement) in the medial/lateral (ML) and vertical (VT) directions, with balance function as assessed by FGA and BBS scores. In contrast, QS was not correlated with fall status. The independent variables associated with the risk of falling were step time CV, FGA score, and age. CONCLUSION: The factors associated with the risk of falling in iNPH were aging and gait-balance instability, particularly temporal gait variability and dynamic balance dysfunction. Our results may enable physicians to identify the patients with iNPH who are at risk of falling and implement suitable prevention strategies.

Dynamic Balance Measurements Can Differentiate Patients Who Fall From Patients Who Do Not Fall in Patients With Idiopathic Normal Pressure Hydrocephalus.

OBJECTIVES: To investigate which clinical assessments are suitable for differentiating patients who fall from patients who do not fall in patients with idiopathic normal pressure hydrocephalus (iNPH). DESIGN: Prospective observational study. SETTING: Osaka Medical College Hospital. PARTICIPANTS: Patients with a cerebrospinal fluid tap test (TT) result meeting the diagnosis criteria for iNPH (N=68). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants were assessed before the TT based on the following: timed Up and Go (TUG), 10-meter walk test (10MWT), Functional Gait Assessment (FGA), Berg Balance Scale (BBS), isometric quadriceps strength (QS), and a history of falls within the past 6 months. RESULTS: The full area under the curve (AUC) of the receiver operating characteristic curves and 95% confidence interval were found to be 0.651 (95% confidence interval, 0.503-0.775) for the TUG, 0.692 (95% confidence interval, 0.540-0.812) for the 10MWT, 0.869 (95% confidence interval, 0.761-0.933) for the FGA, and 0.796 (95% confidence interval, 0.663-0.886) for the BBS; except for QS, they all were identified as statistically significant predictive variables. In the TUG<20 seconds group (n=47), the FGA (AUC 0.849 [95% confidence interval, 0.698-0.932]) and BBS (AUC 0.734 [95% confidence interval, 0.550-0.862]) were found to be statistically significant predictive variables; however, the other assessments were not. In the TUG<15 seconds group (n=34), the FGA was found to be the only statistically significant predictive variable (AUC 0.842 [95% confidence interval, 0.640-0.942]), whereas the other assessments were not. The AUC of the FGA was statistically significantly greater than those of the other assessments. CONCLUSIONS: Our findings indicate that patients with iNPH who fall experience falls due to dynamic balance dysfunction during gait rather than lower limb muscle strength. The FGA may be more suitable than other assessments for differentiating patients who fall from patients who do not fall in patients with mild iNPH.

Postural control before and after cerebrospinal fluid shunt surgery in idiopathic normal pressure hydrocephalus.

OBJECTIVES: This study aimed to confirm whether cerebrospinal fluid (CSF) shunting for idiopathic normal-pressure hydrocephalus (iNPH) improves postural instability, and to investigate the relationship between postural control and gait ability. PATIENTS AND METHODS: Twenty-three iNPH patients and 18 age-matched healthy controls (HC) were examined using the timed up and go (TUG) test and a force platform for calculating the center of pressure (COP) trajectory during voluntary multidirectional leaning and quiescent standing. We determined the patients' TUG values and COP trajectories before and after shunt surgery. RESULTS: Postural sway was greater in iNPH patients before shunt surgery and the TUG value was lower in iNPH patients before shunt surgery than in HC. Voluntary COP movements were significantly improved in iNPH patients at 1 week post-surgery, but no significant changes in quiescent standing were found between pre- and post-surgery. Significant correlations were found between the TUG value and voluntary COP movements in iNPH patients before and after surgery, but no significant correlations were observed between the TUG value and quiescent standing. CONCLUSION: Our results indicate that CSF shunting in iNPH patients may improve voluntary postural control and reduce the risk of falling. Impaired voluntary COP control in iNPH patients may reflect the underlying pathophysiological mechanisms of balance disturbance in iNPH.

The effect of CSF drainage on ambulatory center of mass movement in idiopathic normal pressure hydrocephalus.

BACKGROUND: Although gait and balance disturbances are core symptoms of idiopathic normal pressure hydrocephalus (iNPH), the ambulatory center of mass (COM) movements in patients with iNPH remain unclear. We aimed to clarify the ambulatory COM movements using an accelerometer on the patients' lower torsos and to investigate the changes in COM movement after cerebrospinal fluid tap tests (TT) and shunt surgeries (SS). METHODS: Twenty-three patients with iNPH and 18 age-matched healthy controls (HCs) were recruited. A triaxial accelerometer was fixed with a belt onto each participant's torso at the L3 vertebra level. We assessed each patient's 10-m gait before TT, 3 days after TT, and 1 week after SS. RESULTS: Compared to the HCs, the patients exhibited decreased gait velocities, increased step numbers, and increased step times. Their movement trajectory amplitudes (i.e., the COM movements) were increased in the medial/lateral direction and decreased in the vertical direction. They also exhibited greater variability (measured as coefficients of variation) in step time and movement trajectory amplitude in both the medial/lateral and vertical directions. The patients' gait parameters were significantly improved after TT and SS. SIGNIFICANCE: Our results suggest that iNPH-associated gait disturbances could cause abnormal ambulatory COM movements and that these disturbances are mitigated by TT and SS.

Postural instability differences between idiopathic normal pressure hydrocephalus and Parkinson's disease.

OBJECTIVES: We investigated the differences in postural control disability between idiopathic normal pressure hydrocephalus (iNPH) and Parkinson's disease (PD). PATIENTS AND METHODS: Twenty-seven iNPH patients, 20 PD patients, and 20 healthy controls (HCs) were examined using the Timed Up and Go test (TUG) and a force platform for recording the center of pressure (COP) trajectory during quiescent standing and voluntary multidirectional leaning (forward, backward, right, and left for 10 s each). RESULTS: In the leaning task, postural control in PD patients was impaired during forward and backward leaning, whereas postural control in iNPH patients was impaired in all directions. In particular, postural control during right and left leaning was significantly worse in iNPH patients than in PD patients. No significant difference was observed between iNPH and PD patients in TUG and postural sway during quiescent standing. CONCLUSION: Our results showed that the characteristics of impaired voluntary COP control in iNPH and PD patients might reflect pathophysiological differences in postural instability for each disease. In particular, postural instability during right and left leaning in iNPH patients may be responsible for wider steps and a higher risk of falling.

Immediate effects of unaffected arm exercise in poststroke patients with spastic upper limb hemiparesis.

BACKGROUND: Spasticity is a major disabling symptom in stroke patients. Clinically, one of the goals of management of stroke patients should be to reduce spasticity. Recent evidence suggests that motor recovery after stroke comprises a hierarchical, dynamic framework of interacting mechanisms in brain cortex. We hypothesized that unaffected arm exercise can stimulate the ipsilateral motor cortex and change the affected upper limb function and spasticity in stroke patients. To test the hypothesis, we evaluated the effects of unaffected arm exercise on spasticity of the affected upper limb and motor function in stroke patients. METHODS: The study was performed in 41 chronic stroke patients with upper limb hemiparesis. Affected upper limb spasticity and function were assessed at baseline and after each intervention by the modified Ashworth Scale and Fugl-Meyer Assessment, respectively. Patients were also evaluated clinically by the modified Rankin Scale, Functional Independence Measurement and National Institutes of Health Stroke Scale. Subjects stood for 10 min during the control period, and then cycled an arm crank ergometer at 50% of maximum work load for 10 min by the unaffected arm in standing position. RESULTS: The mean age at study entry was 64.6 ± 1.7 years. The latency between onset of stroke and the study was 109.0 ± 17.0 months (range, 6-495). The cause of hemiparesis was cerebral infarction (n = 21), intracerebral hemorrhage (n = 17) or subarachnoid hemorrhage (n = 3). Exercise significantly improved the modified Ashworth Scale compared with baseline (p < 0.0001). No such change was noted after the control intervention. The Fugl-Meyer Assessment score did not change after exercise compared with baseline (p = 0.95). CONCLUSIONS: We conclude that 10 min of unaffected arm exercise improves the affected upper limb spasticity in stroke patients. Further studies are needed to determine the exact mechanism of such improvement and the long-term effects of unaffected arm exercise on motor performance.