Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
A Novel Approach to Stroke Rehabilitation: Constraint Therapy
More than three fourths of ischemic stroke survivors experience hemiparesis, with the majority of victims continuing to suffer long term limitations in functional use of their upper extremities. Recently, Constraint-Induced Movement Therapy (CIMT) has been studied as a method of late intervention (1 year or more post-stroke) for residual paresis.
The CIMT approach recognizes that in the face of functional deficit, it is a natural tendency to use the more agile arm to perform everyday tasks of living. Hence, the paretic limb undergoes further 'learned nonuse' dysfunction. CIMT involves placing the more functional limb in restraint for 2-3 weeks, with supervised practice in the use of the paretic limb.
The EXCITE Trial enrolled individuals who had sustained a stroke and were felt to have achieved a stable level of maximum recovery, but still suffered upper extremity functional deficits. Patients were assigned to a 2-week CIMT group or usual care group, and followed for 1 year afterwards (n = 222).
The Motor Activity Log measures capacity to perform 30 common daily activities. When measured at 12 months, the CIMT group was statistically significantly improved compared to usual care as measured both by the Motor Activity Log and the Wolf Motor Function Test (which measures improvements in rapidity of functional motion, strength, and quality of movement). Although this is the first large randomized trial of CIMT, the results support its use as a rehabilitative method, even late in the course of post-stroke dysfunction.
Wolf SL, et al. JAMA. 2006;296:2095-2104.
Is Carbohydrate Really a 'Bad-Guy'?
Despite bookshelves in modern bookstores brimming with advice about diet, ascertaining just what constitutes the 'best' dietary structure remains elusive. Proponents of low versus high carbohydrate, fat, or protein provide intellectually appealing rationale to support their particular 'fad' diet, but little science is available to confirm most assertions about an optimum diet.
The Nurses Health Study began in 1976 with an initial enrollment of over 121,000 nurses. Since 1980, dietary information has been included in survey questionnaires.
Based upon surveys returned by 82,000 women over a 20 year period of observation, stratification tables by percentage of energy derived from carbohydrate were developed. Incident coronary heart disease (CHD) was then correlated with dietary pattern.
Over 20 years of followup, persons on a low-carbohydrate diet did not show an effect on the incidence of CHD. Amongst women who followed a low-carbohydrate diet, those who preferentially consumed protein and fat from vegetable sources had lower risk for incident CHD than those in the same group whose source of fat and protein was primarily from animal sources. Although the dietary carbohydrate intake patterns in this population did not closely match the Spartan restriction seen in the Adkins diet, the lowest decile of carbohydrate intake did not demonstrate reduced CHD risk. This data would suggest that in women, the choice of fat and protein is more impactful than level of carbohydrate intake.
Halton TL, et al. N Engl J Med. 2006;355:1991-2002.
Can D-dimer Establish Best Duration of Anticoagulation?
The appropriate duration of anticoagulation after an episode of unprovoked thromboembolism is uncertain, although in general "longer is better." The most dramatic benefit of anticoagulation is seen early in treatment, ie, the first 3 months. Because the risk-benefit relationship between bleeding versus the reduction of future thromboembolic episodes becomes progressively less favorable over time, it would be valuable to have some way to discern which individuals merit longer anticoagulation. D-dimer may be useful in such a setting, the premise being that an elevated D-dimer reflects ongoing thrombotic tendency.
Patients (n = 608) who had experienced a first episode of idiopathic DVT (or pulmonary embolus) received "traditional" treatment with Coumadin for 3 months. At that point, D-dimer levels were measured, and those individuals with an elevated D-dimer (DIM+), comprising 37% of the total group, were then randomized to receive continued anticoagulation or placebo. Persons with a normal D-dimer received no further anticoagulation.
The rate of new thromboembolic vents over the next 16 months in DIM+ subjects was 15% in the untreated group, versus 2% in the treated group. In the DIM- group, new DVT occurred in 6.2%. Even though the risk for recurrent DVT was more than twice as great in DIM+ individuals than DIM- individuals over a 16-month period of observation, the event rate of the latter "low risk" group is still substantial (6.2%), corroborating the authors' comment: "The optimal course of anticoagulation in patients with a normal D-dimer level has not been clearly established."
Palareti G, et al. N Engl J Med. 2006;355:1780-1789.
More than three fourths of ischemic stroke survivors experience hemiparesis, with the majority of victims continuing to suffer long term limitations in functional use of their upper extremities.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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