Vol 6, No 4 (2024)

BACKGROUND: To enhance post-stroke motor recovery, integrating proven noninvasive brain stimulation techniques into clinical practice is essential. An important translational limitation is that phenotypes of beneficial response to noninvasive brain stimulation remain underdetermined.

AIM: This study aims to evaluate the strength of regression of post-stroke hand paresis following adjuvant treatment with repetitive transcranial magnetic stimulation in a real-world clinical setting, based on patient phenotype.

MATERIALS AND METHODS: The retrospective observational study involved 1,295 subjects (age: 23–83; men: 52.4%) with post-stroke hand paresis. Patients were divided into four phenotypes based on the motor deficit grade (Medical Research Committee (MRC) Scale for Muscle Strength) and resting motor threshold of the cortical representation of m. Abductor pollicis brevis in the affected hemisphere. They are Phenotype 1 (MRC grade 4-3 w/o resting motor threshold increase); Phenotype 2 (MRC grade 4-3 with an increased resting motor threshold); Phenotype 3 (MRC grade 2-0 w/o resting motor threshold increase); Phenotype 4 (MRC grade 2-0 with an increased resting motor threshold). Phenotype 1 and 3 subjects received adjuvant treatment with high-frequency repetitive transcranial magnetic stimulation of the affected hemisphere; Phenotype 2 and 4 subjects received low-frequency repetitive transcranial magnetic stimulation of the unaffected hemisphere. In the comparator group of each phenotype, noninvasive brain stimulation was not performed. Clinical efficacy was assessed immediately after the treatment based on an increase in MRC score by ≥1.

RESULTS: Increased clinical efficacy in repetitive transcranial magnetic stimulation groups was detected for Phenotypes 2 (p <0.022) and 4 (p <0.0002). An additional beneficial outcome is expected, on average, in every seventh (Phenotype 4) and ninth (Phenotype 2) treated patient. Phenotype 1 showed lower (p <0.031) clinical efficacy in the repetitive transcranial magnetic stimulation group versus the comparator group. Repetitive transcranial magnetic stimulation in Phenotype 3 subjects showed no adjuvant efficacy.

CONCLUSION: The study showed an increased strength of muscle weakness regression after repetitive transcranial magnetic stimulation in Phenotype 2 and 4 patients. The study showed that rhythmic transcranial magnetic stimulation affected the sanogenetic process of motor recovery in Phenotype 1 subpopulation. The study outlined prerequisites to identifying phenotypes in patients with post-stroke, non-paretic motor deficit.

BACKGROUND: Functional status at the onset of stroke is an important component that determines treatment and rehabilitation tactics.

AIM: To study the relationship between gender and age characteristics, type of stroke, comorbid status, travel time to the hospital and the severity of the functional state at the time of hospitalization in patients with stroke living in the Arkhangelsk region.

MATERIALS AND METHODS: The study included 5221 people in the acute period of stroke. In a retrospective longitudinal two-center study, factors influencing the patient’s functional status at the time of hospitalization were studied: gender, age, type of stroke, concomitant diseases, travel time to the hospital. Multivariate analyzes were performed on models assessing outcome by mean National Institutes of Health Stroke Scale (NIHSS) score as relative risk (RR) using Poisson regression; using median regression for NIHSS score; median regression for the modified Rankin scale (mRs) score.

RESULTS: With increasing age, the number of NIHSS scores increased, significantly in patients in groups over 70. The median mRs score was higher by 1.2 (95% CI: 0.60–1.81) in patients over 90 years of age relative to younger ones. In women, the average NIHSS score was 1.11 times higher relative to men (95% CI: 1.08–1.13), but the median mRs score was 0.2 lower (95% CI: 0.08–0.33). The mean NIHSS value in patients with hemorrhagic stroke was 1.3 times (95% CI: 1.24–1.34) higher than this indicator in patients with cardioembolic stroke, the median mRs score in patients with hemorrhagic stroke was 0.7 higher (95% CI: 0.46–1.04). As travel time increased, the mean NIHSS and median mRs scores decreased. Arterial hypertension increased the average NIHSS score by 1.16 times (95% CI: 1.09–1.23), obesity by 1.16 times (95% CI: 1.10–1.21), chronic heart failure in 1.13 times (95% CI: 1.10–1.16), chronic kidney disease by 1.12 times (95% CI: 1.09–1.16), cancer by 6% (95% CI: 1.01–1.10) and coronary heart disease by 3% (95% CI: 1.00–1.05). In the presence of diabetes mellitus, the mean NIHSS value decreased by 4% (95% CI: 1.01–1.06). When assessed by mRS, only the presence of chronic heart failure increased the median score by 0.2 (95% CI: 0.05–0.35).

CONCLUSION: The main predictors of the severity of the functional status at the time of hospitalization, which appeared in all models, were female gender, elderly and senile age, hemorrhagic stroke and chronic heart failure. The studied predictors are not the same in significance and degree of influence when assessing the outcome on different scales.

Spasticity is one of the most common conditions in individuals with central nervous system damage and a significant contributor to the patient’s recovery. The processes indirectly contributing to this condition include the increased viscosity of hyaluronic acid due to paresis-associated changes in the circulation of extracellular matrix resulting in increased muscle rigidity. This is why spasticity may not be considered solely as a consequence of damage of the central nervous system.

The review aims to verify the phenomenon of spasticity and study the possibility of its objective diagnosis. PubMed and eLibrary databases were used to search for literature.

Analysis of available sources permits to abandon the widespread use of the term “spasticity” by replacing it with “deforming spastic paresis,” which will allow us to cover various pathophysiological attributes and variants of this condition, and, accordingly, reconsider both diagnostic and therapeutic approaches to it. Deforming spastic paresis may manifest with varying degrees of severity, in different movement phases, and different muscles.

Despite the rapid development of instrumental methods of diagnosis, there are currently no uniform, general-purpose algorithms used to evaluate deforming spastic paresis. This is also true for the Modified Ashworth Scale and Modified Tardieu Scale used to quantify spasticity in clinical setting as they are reproduced only when the patient does not move, and do not directly evaluate the contribution of this phenomenon to the motor act. Methods involving robot-based test movements for verification appear to be most adequate, since they allow to standardize the method and make it more convenient for specialist assessment.

Literature reports on the risk of SARS-CoV-2 in people with inflammatory rheumatisms are inconsistent. According to most studies, the risk of infection and development of severe COVID-19 is higher in rheumatism patients versus the general population, but largely depends on rheumatism type and activity. Thus, patients with severe rheumatism most often required artificial ventilation and died more often. It was associated with immune dysfunction caused by both the disease itself and antirheumatic therapy with immunomodulating agents.

Immunosuppression, additional chronic comorbidities, and incomplete vaccination are progression factors of COVID-19, hospital stay, intensive care, and risk factors of severe COVID-19 outcomes and reinfection with coronavirus in rheumatism patients. During the spread of SARS-CoV-2 Omicron variant, they were still significant. Although there is no full consensus in the literature regarding the association of rheumatism with the severity of COVID-19, rheumatism is usually not considered a factor of increased severity and mortality of COVID-19.

SARS-CoV-2 vaccines boost humoral response, and reduce the incidence and severity of COVID-19. Nevertheless, rheumatism patients show reduced or no antibody production in response to even completed vaccination, along with higher rates of post-vaccination breakthrough infection. Further research into specific rheumatic diseases and the use of antirheumatic drugs in the context of COVID-19 is required to reduce the severity of COVID-19 in this population.