Predictive Ability of Frontal Assessment Battery for Cognitive Improvement After Shunt Surgery in Individuals With Idiopathic Normal Pressure Hydrocephalus.

BACKGROUND: The predictive ability of the Frontal Assessment Battery (FAB) for postoperative cognitive improvement in idiopathic normal pressure hydrocephalus (iNPH) is unstudied. OBJECTIVE: To compare the predictive ability of the FAB and the Mini-Mental State Examination (MMSE) for postoperative cognitive improvement in individuals with iNPH after shunt surgery. METHOD: We retrospectively reviewed the medical records of individuals with iNPH who had shunt surgery between January 2016 and October 2018. Individuals had completed the tap test and clinical evaluations (FAB, MMSE, Timed Up and Go [TUG]) both before and 24-48 hours after CSF tapping and after surgery. We excluded individuals without complete clinical evaluations and those with shunt surgery performed >6 months after CSF tapping. Factors associated with postoperative FAB and MMSE improvement as per the 2011 iNPH guidelines were extracted using univariate and multivariate logistic regression analyses. Independent variables were baseline FAB and MMSE scores, FAB and MMSE score changes and TUG amelioration rate after CSF tapping, Evans index, age, and days from CSF tapping to surgery and from surgery to postoperative assessment. RESULTS: The mean number of days from CSF tapping to surgery and from surgery to postoperative assessment were 77.5 (SD = 36.0) and 42.0 (SD = 14.5), respectively. Logistic regression analyses showed significant associations in the univariate analyses of postoperative FAB improvement with baseline FAB scores ( P = 0.043) and with FAB score changes after CSF tapping ( P = 0.047). CONCLUSION: The FAB may help predict postoperative cognitive improvement after shunt surgery better than the MMSE.

Treatment outcome of local injection of botulinum toxin for claw toe: Differences between cerebral hemorrhage and infarction.

BACKGROUND: Some patients with post-stroke claw toe respond well to botulinum toxin (BoNT) treatment while others do not. This study was designed to assess the impact of stroke type (cerebral hemorrhage and cerebral infarction) on the outcome of BoNT treatment for claw toe. METHODS: We retrospectively examined the medical records of patients who received local BoNT (onabotulinumtoxin A) injections into the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles. All patients suffered stroke-related leg paralysis and spasticity. RESULTS: The study participants were 58 patients (mean age, 61.4 ± 10.3 years, ± SD) with time since stroke of 6.7 ± 4.4 years. The stroke type was cerebral hemorrhage (n = 38) and cerebral infarction (n = 20). After a total of 124 BoNT administrations with medical records entries on the subjective symptoms, the odds for symptomatic improvement was approximately 5.8 times higher in patients of the infarction group compared with the hemorrhage group (OR = 5.787, 95% CI = 2.369-14.134, p = 0. 000). Fifty-one patients (32 with cerebral hemorrhage, 19 with cerebral infarction) received the first local BoNT injection and had available medical records, analysis of which showed a significantly higher rate of symptomatic improvement in patients of the infarction group than those of the hemorrhage group (p = 0.006). After adjustment by factors known to influence treatment outcome (degree of spasticity and paralysis, BoNT dosage, and extent of FDL muscle control of toe movements), the treatment effect was predominantly higher in patients with cerebral infarction. CONCLUSION: The BoNT treatment response was better for claw toes in cerebral infarction patients than in hemorrhage patients, possibly suggesting that claw toe is associated with more severe spasticity in this group of patients.

Effects of Flexor Digitorum Longus Muscle Anatomical Structure on the Response to Botulinum Toxin Treatment in Patients with Post-Stroke Claw Foot Deformity.

(1) Background: The purpose of this retrospective case-control study was to determine the relationship between the control of toe movements by flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles and the response to treatment with botulinum toxin (BoNT) in post-stroke patients with claw toe. (2) Methods: Subjects with stroke-related leg paralysis/spasticity and claw toes received multiple injections of BoNT (onabotulinumtoxin A) into the FHL or FDL muscles. We investigated the relationship between the mode of transmission of FHL and FDL muscle tension to each toe (MCT) and treatment outcome using the data of 53 patients who received 124 injections with clinically recorded treatment outcome. We also dissected the potential variables that could determine the treatment outcome. (3) Results: The effectiveness of BoNT treatment was significantly altered by FDL-MCT (OR = 0.400, 95% CI = 0.162-0.987, p = 0.047). Analysis of the response to the first BoNT injection showed an odds ratio of FDL-MCT of approximately 6.0 times (OR = 0.168, 95% CI = 0.033-0.857, p = 0.032). The more tibial the influence of the FDL muscle on each toe, the better the treatment outcome on the claw toe. (4) Conclusions: The anatomic relation between FDL muscle and each toe seems to affect the response to treatment with BoNT in post-stroke patients with claw toes.

A new screening test for idiopathic normal pressure hydrocephalus using bimanual coordination: A preliminary study.

BACKGROUND: The clinical spectrum of idiopathic normal pressure hydrocephalus (iNPH) comprises the triad of gait disturbance, cognitive impairment, and urinary incontinence. However, motor abnormalities involving the upper extremities in iNPH patients have few quantitative studies. OBJECTIVE: The present study was designed to quantitatively assess bimanual tapping tasks in iNPH patients and to compare with the control groups. METHODS: The subjects were divided into three groups: iNPH patients, older healthy group, and younger healthy group. The tasks were three synchronization finger-to-thumb tapping tasks with the auditory stimuli specified at 1 Hz by metronome: unilateral, bimanual simultaneous, and bimanual alternate. Two-way ANOVA was used to compare the outcomes of the three errors (absolute error: AE, variable error: VE, and constant error: CE) for tapping cycles. RESULTS: In the iNPH group, the absolute and variable errors increased in bimanual alternate tapping task with statistical significance (AE: p < 0.05 and VE: p < 0.05). There were no significant differences in errors between the older and young healthy groups (AE: p = 0.62, CE: p = 1.00 and VE: p = 0.31). CONCLUSIONS: We could quantitatively evaluate the bimanual coordination on iNPH patients using the bimanual alternate tapping task, potentially useful for evaluating patients unable to walk.

Effects of botulinum toxin A therapy and multidisciplinary rehabilitation on lower limb spasticity classified by spastic muscle echo intensity in post-stroke patients.

OBJECTIVES: The purpose of the present study was to investigate retrospectively the relationship between botulinum toxin type A plus multidisciplinary rehabilitation and muscle echo intensity in post-stroke patients with spasticity. The primary aim was to investigate whether the effects of the intervention on the improvement of spasticity depend on muscle echo intensity, and the secondary aim was to investigate whether the motor function of the lower limbs depends on muscle echo intensity. METHODS: A 12-day inpatient protocol was designed for 102 post-stroke patients with spasticity due to lower limb paralysis. Muscle echo intensity of the triceps surae muscle was measured by ultrasonography, and the patients were categorized into four groups based on Heckmatt scale grades (Grades I-IV). RESULTS: All four groups classified by the Heckmatt scale showed significant pre-to-post-intervention differences in the knee and ankle modified Ashworth scale scores (p < 0.05). Grades I-III patient groups showed a significant improvement in lower limb motor function following intervention. Grade IV patients did not show a significant improvement in lower limb motor function. CONCLUSIONS: We observed significant improvements in the modified Ashworth scale scores after botulinum toxin type A and multidisciplinary rehabilitation therapy on post-stroke patients with spasticity. Although patients with lower muscle echo intensity demonstrated improvements in motor function, the improvement was poor in those with higher muscle echo intensity.

Effects of botulinum toxin A therapy and multidisciplinary rehabilitation on upper and lower limb spasticity in post-stroke patients.

OBJECTIVES: The purpose of this study was to examine the effects of combined botulinum toxin type A (BoNT-A) and inpatient multidisciplinary (MD) rehabilitation therapy on the improvement of upper and lower limb function in post-stroke patients. METHODS: In this retrospective study, a 12-day inpatient treatment protocol was implemented on 51 post-stroke patients with spasticity. Assessments were performed on the day of admission, at discharge, and at 3 months following discharge. RESULTS: At the time of discharge, all of the evaluated items showed a statistically significant improvement. Only the Functional Reach Test (FRT) showed a statistically significant improvement at 3 months. In subgroup analyses, the slowest walking speed group showed a significantly greater change ratio of the 10 Meter Walk Test relative to the other groups, from the time of admission to discharge. This group showed a greater FRT change ratio than the other groups from the time of admission to the 3-month follow-up. CONCLUSION: Inpatient combined therapy of simultaneous injections of BoNT-A to the upper and lower limbs and MD may improve motor function.

Applicability of the two-step thickened water test in patients with poststroke dysphagia: a novel assessment tool for paste food aspiration.

This study evaluated the clinical usefulness of the newly developed Two-Step Thickened Water Test (TTWT) in identifying patients with poststroke dysphagia at risk of aspiration of paste food. The study subjects were 110 poststroke patients (mean age, 73 ± 10 years). The TTWT comprises a bedside pretest (tongue protrusion, vocalization, voluntary cough, and dry swallow) and a direct swallowing test using 4 mL of thickened water. Fiberoptic endoscopic evaluation of swallowing determined the subject's ability to swallow the paste food. Based on the test results and endoscopic evaluation, we calculated the TTWT's sensitivity and specificity in identifying paste food aspiration. We also calculated these values when normal water was used instead of thickened water in a direct swallowing test. The prevalence of dysphagia for paste food was 41% in our study group. The sensitivity and specificity of the TTWT in identifying dysphagia for paste food was 93% and 88%, respectively. The specificity decreased to 78.5% when normal water was used, with no decrease in sensitivity. The test was completed in less than 10 minutes, with no adverse events in any subject. Our data suggest that the TTWT might be a useful assessment tool for evaluating the risk of paste food aspiration in patients with poststroke dysphagia.

Swallowing analysis for semisolid food texture in poststroke dysphagic patients.

BACKGROUND: Our objective was to determine the texture of semisolid foods that are appropriate for poststroke dysphagic patients. METHODS: Subjects included 52 poststroke dysphagic patients (72 ± 8 years of age) who were trained with semisolid foods and required the evaluation of swallowing function. Fifty-two homogeneous semisolid foods not requiring mastication were given. Texture were measured twice using a rheometer (TPU-2S; Yamaden Co. Ltd., Tokyo, Japan). Texture characteristics were as follows: hardness, 1873 to 19,510 N/m(2) (mean 9,129 N/m(2)); cohesiveness, 0.13 to 0.67 (mean 0.32); adhesiveness, 2 to 878 J/m(3) (mean 209 J/m(3)); and gumminess, 546 to 8781 N/m(2) (mean 2908 N/m(2)). Patients sat during fiberoptic endoscopic evaluation and ingested a single semisolid food. The patients were asked to swallow 4 g of food, and the texture, pharyngeal residue, penetration into the larynx, and aspiration were evaluated. We observed and noted the association between the texture of foods and swallowing movements by videoendoscopy. RESULTS: Evaluating food texture by endoscopy revealed significant differences in adhesiveness according to residue deposition and significant differences in gumminess according to aspiration. CONCLUSIONS: We identified the textures of different semisolid foods as being either appropriate or inappropriate for poststroke dysphagic patients.

Application of combined 6-Hz primed low-frequency rTMS and intensive occupational therapy for upper limb hemiparesis after stroke.

INTRODUCTION: The purpose of this study was to clarify the safety, feasibility and efficacy of 6-Hz primed low-frequency repetitive transcranial magnetic stimulation (rTMS) applied with intensive occupational therapy (OT) for upper limb hemiparesis after stroke. SUBJECTS AND METHODS: Eleven patients with history of stroke and upper limb hemiparesis (age at intervention: 61.0 ± 13.7 years, time after stroke onset: 70.2 ± 39.8 months) were studied. Each patient received 22 sessions of 6-Hz primed low-frequency rTMS (10-min 6-Hz priming stimulation followed by 20-min low-frequency rTMS of 1-Hz) applied to the non-lesional hemisphere plus intensive OT comprising 60-min one-to-one training and 60-min self-training during 15-day hospitalization. The motor function of the affected upper limb was evaluated by Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) on the days of admission and discharge. RESULTS: All patients completed the 15-day protocol without any adverse effects. The treatment increased the FMA score (from 42.2 ± 6.9 to 45.6 ± 7.2 points, p< 0.005) and shortened the log performance time of WMFT (from 3.26 ± 1.21 to 2.81 ± 1.26 sec, p< 0.05). CONCLUSIONS: The 15-day protocol of 6-Hz primed low-frequency rTMS combined with intensive OT seems safe and a potentially useful therapeutic modality for upper limb hemiparesis after stroke.

Baseline severity of upper limb hemiparesis influences the outcome of low-frequency rTMS combined with intensive occupational therapy in patients who have had a stroke.

OBJECTIVE: To clarify whether the efficacy of combined low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) depends on baseline severity of upper limb hemiparesis after stroke. DESIGN: Retrospective comparative study. SETTING: Department of Rehabilitation Medicine at a university hospital. SUBJECTS: Fifty-two patients who had sustained a stroke and had upper limb hemiparesis (age: 57 ± 13 years; time after onset: 50 ± 33 months). Based on the Brunnstrom stage for hand-fingers at admission, patients were divided into a Stage 3 group (n = 13), a Stage 4 group (n = 20), and a Stage 5 group (n = 19). INTERVENTIONS: During a 15-day hospitalization, each patient underwent 22 sessions of 20-minute low-frequency rTMS that was applied to the non-lesional hemisphere and 120 minutes of intensive OT (one-on-one training and self-training). MAIN OUTCOME MEASURES: Motor function of the affected upper limb was evaluated with the Fugl-Meyer Assessment and the Wolf Motor Function Test (WMFT) on the days of admission and discharge. WMFT performance time data were log-transformed. RESULTS: The Fugl-Meyer Assessment score increased significantly in all patients (from 40.2 ± 12.2 to 43.4 ± 11.8 points, P < .001), but the score increase was significantly larger in the Stage 4 group than in the other two groups (2.1 ± 2.3 points in the Stage 3 group, 5.1 ± 2.9 points in the Stage 4 group, and 2.3 ± 1.8 points in the Stage 5 group, all P < .05). Similarly, the WMFT performance time decreased significantly in all patients (from 3.27 ± 0.90 to 2.96 ± 1.10, P < .001), but the difference in the extent of the decrease was significant between Stage 3 and Stage 4 groups and between Stage 3 and Stage 5 groups (0.04 ± 0.07 in the Stage 3 group, 0.41 ± 0.29 in the Stage 4 group, and 0.35 ± 0.31 in the Stage 5 group, all P < .01). CONCLUSIONS: Our 15-day protocol of low-frequency rTMS and intensive OT is potentially promising in improving motor function of the affected upper limb. The extent of motor improvement by the intervention seemed to be influenced by the severity of upper limb hemiparesis at study entry.

Anti-spastic effect of low-frequency rTMS applied with occupational therapy in post-stroke patients with upper limb hemiparesis.

OBJECTIVE: To determine the effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with occupational therapy (OT) on the spasticity of the hemiparetic upper limb after stroke. SUBJECTS AND METHODS: The study subjects were 39 post-stroke patients with spastic upper limb hemiparesis (age: 56.5 ± 16.0 years, time after onset: 50.3 ± 37.8 months). At admission, the severity of hemiparesis was categorized as Brunnstrom stage 3-5 for hand-fingers. During 15-day hospitalization, each patient received 22 sessions of low-frequency rTMS applied to the non-lesional hemisphere and OT (one-to-one training and self-training). The spasticity of finger and wrist flexors of the affected upper limb was evaluated using the modified Ashworth scale (MAS) on the day of admission and discharge and 4 weeks after discharge. Each subject underwent Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT). RESULTS: The low-frequency rTMS/OT protocol significantly decreased the MAS scores for both finger and wrist flexors at discharge and at 4 weeks after discharge. In addition, the low-frequency rTMS/OT protocol significantly increased the FMA score and shortened the WMFT performance time. CONCLUSIONS: The 15-day in-patient protocol of low-frequency rTMS/OT is potentially suitable for reducing spasticity as well as improving motor function on the affected upper limb after stroke.

Combination treatment of low-frequency rTMS and occupational therapy with levodopa administration: an intensive neurorehabilitative approach for upper limb hemiparesis after stroke.

The combination treatment of low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy was applied with concomitant oral administration of levodopa in five post-stroke patients with upper limb hemiparesis (age at treatment: 56-66 years; interval between onset of stroke and treatment: 18-143 months) as a 15-day inpatient protocol. Daily levodopa administration of 100 mg was initiated 1 week before admission and continued until 4 weeks after discharge. Low-frequency rTMS of 1 Hz was applied to the contralesional hemisphere for 40 min daily (two 20-min sessions) combined with intensive occupational therapy consisting of 60-min one-on-one training and 60-min self-exercise. Motor function of the affected upper limb was serially evaluated with the Fugl-Meyer Assessment and the Wolf Motor Function Test. At the end of the treatment, all patients showed improved motor function in the affected upper limbs. In some patients, the improvement was maintained until 4 weeks after discharge. No patient showed any adverse effect from the intervention. Our proposed protocol featuring levodopa administration, low-frequency rTMS, and intensive occupational therapy could provide a safe and feasible intervention for upper limb hemiparesis after stroke.

Low-frequency rTMS combined with intensive occupational therapy for upper limb hemiparesis after brain tumour resection.

OBJECTIVE: To assess the safety, feasibility and efficacy of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with occupational therapy (OT) in a hemiparetic patient who had undergone brain tumour resection. PARTICIPANT: A 39-year-old right-handed woman underwent brain tumour resection and presented 5 years later with right upper limb hemiparesis. At admission, she was considered to have reached a probable plateau state of motor functional recovery of the affected upper limb in spite of conventional occupational therapy. INTERVENTION: Low-frequency rTMS with 1 Hz applied to the right primary motor cortex followed by intensive occupational therapy (one-on-one training and self-training) was provided daily during the 15-day hospitalization. MAIN OUTCOME MEASURES: Fugl-Meyer Assessment and Wolf Motor Function Test were conducted serially to evaluate motor function on the affected upper limb. RESULTS: Neither adverse effect nor deterioration of neurological symptoms was recognized during the treatment period. The 15-day combination protocol improved motor function of the right upper limb and further improvement was noted 4 weeks after discharge. CONCLUSION: The proposed protocol of low-frequency rTMS with intensive occupational therapy is a potentially useful rehabilitative programme for upper limb hemiparesis after brain tumour resection.

Low-frequency repetitive transcranial magnetic stimulation and intensive occupational therapy for poststroke patients with upper limb hemiparesis: preliminary study of a 15-day protocol.

The purpose of the study was to determine the safety and feasibility of a 15-day protocol of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with intensive occupational therapy (OT) on motor function and spasticity in hemiparetic upper limbs in poststroke patients.Fifteen poststroke patients (age at study entry 55 ± 17years, time after stroke 57± 55 months) with upper limb hemiparesis categorized as Brunnstrom stages 3­5 forhand­fingers were recruited. They were considered to have reached a plateau state at study entry, based on the lack of any increase in Fugl­Meyer Assessment (FMA) Score inthe last 3 months. During the 15-day hospitalization, each patient received 22 sessions of rTMS with 1 Hz applied to the contralesional cerebral hemisphere, followed by intensive OT (one-to-one training including shaping techniques and self training). Upper limb motor function was evaluated by FMA and Wolf Motor Function Test at admission and discharge. The spasticity of finger flexors,wrist flexors and elbow flexors in the affected upper limb was also evaluated with Modified Ashworth Scale. The15-day protocol was well tolerated by all patients. Atdischarge, the FMA Score was increased in all 15 patients(17­57 to 18­61 points). Shortening of performance time on Wolf Motor Function Test was noted in 12 patients(44­1584 to 39­1485 s). The Modified Ashworth ScaleScore for some flexor muscles decreased in 12 patients.In conclusion, our 15-day protocol of low-frequency rTMS combined with intensive OT seems feasible not only for improving motor function, but also for reducing spasticity in the affected upper limb in post stroke hemiparetic patients.

Language-related brain function during word repetition in post-stroke aphasics.

We compared fMRI findings (using SPM99) obtained with repetition task in normal subjects with those of two patients with Broca's and Wernicke's aphasia who received speech therapy and showed complete recovery. Both aphasic patients with left hemisphere damage who showed complete recovery exhibited activation of only the compensatory area in the right hemisphere during the repetition task. Recovery from Broca's aphasia involves reorganization and neuromodulation between the external temporopolar area and the anterior superior temporal area of the superior temporal gyrus, putamen and the inferior frontal gyrus, while that from Wernicke's aphasia involves reorganization and neuromodulation between the superior temporal gyrus of the temporal region, the posterior supramarginal gyrus and inferior parietal lobule of the parietal region.

Current status of rehabilitation medicine in Asia: a report from New Millennium Asian Symposium on Rehabilitation Medicine.

With the aim of promoting rehabilitation medicine in Asian countries, where the number of persons with disability occupies a significant proportion in the world, New Millennium Asian Symposium on Rehabilitation Medicine was held in February 2001 in Tokyo, under the sponsorship of the Japanese Association of Rehabilitation Medicine. Twenty-three guest speakers from 14 Asian countries and regions participated in the 2-day meeting. With a structured questionnaire that was sent to the participants beforehand, demographic data related to rehabilitation practice and information on training and certification in rehabilitation medicine in the participating countries were collected, and presented at the meeting. Based on these data, the current status of rehabilitation medicine in Asia was summarized. The symposium marked an important step forward for the promotion of rehabilitation medicine in Asia.