Ultrasound Assessment of Changes in Muscle Architecture of the Brachialis Muscle After Stroke-A Prospective Study.

Objective: To investigate changes in ultrasound-derived muscle architecture parameters of the brachialis and correlations in patients with subacute stroke. Design: Prospective longitudinal observational study. Setting: Tertiary inpatient rehabilitation center. Participants: Fifty adult patients (N=50) who were recruited within the first month poststroke. The patients had a mean age of 57.2±12.3 years and 68.0% were male. The majority of patients had significant upper limb weakness with a low mean Motricity Index of 18.5±24.7 and median elbow flexor strength of grade 0. Intervention: Not applicable. Main Outcome Measures: Ultrasound of the intact and hemiparetic brachialis was performed at 3-time intervals: within 1 month of stroke onset and at 1 and 6 months after first assessment. Clinical variables captured included upper limb motor power and elbow flexor spasticity. Results: Compared to the intact brachialis, there was reduced muscle thickness (1.93 cm vs 2.07 cm, 1.86 cm vs 2.08 cm, 1.85 cm vs 2.05 cm; P=.022) and increased echo intensity (63.3 arbitrary units [AU] vs 56.8 AU, 69.4 AU vs 56.6 AU, 77.4 AU vs 58.2 AU; P<.001) in the hemiparetic brachialis at all assessment intervals (baseline, 1 month, 6 months). Reduction in muscle mass was greater in older patients, with the correlation coefficient ranging from -0.30 (P=.03) at baseline to -0.50 (P<.001) at 6 months. Presence of elbow flexor spasticity at 1-month assessment interval was associated with lower muscle mass reduction (1.93 cm vs 1.74 cm; P=.017), lower echo intensity (65.1 AU vs 75.1 AU; P=.023), and longer fascicle lengths (12.92 cm vs 9.83 cm; P=.002). Conclusions: Changes including decreased muscle thickness and increased echo intensity of the hemiparetic brachialis were noted over time. Elbow flexor spasticity at 1-month assessment interval appears to mitigate against these changes.

Changes in muscle architecture on ultrasound in patients early after stroke.

BACKGROUND: Early muscle changes are believed to occur in patients with stroke. However, there are insufficient data on the changes in muscle mass and architecture of these patients. OBJECTIVES: This study investigates differences in ultrasound-derived muscle architecture parameters of the hemiplegic upper and lower limbs in patients with subacute stroke. METHODS: This is a prospective observational study, which recruited 40 adult patients who had experienced a first ever unilateral stroke (ischemic or hemorrhagic), with a duration of < 1 month post stroke. The brachialis, vastus lateralis and medial gastrocnemius on both the hemiplegic and normal side were evaluated via ultrasound. We recorded clinical variables including Motricity Index, Modified Ashworth Scale (MAS) and Functional Independence Measure (FIM)-walk. RESULTS: We found reduced mean muscle thickness (p < 0.001) and increased echo intensity (p < 0.001) in the brachialis muscle, increased echo intensity (p = 0.002) in the vastus lateralis muscle, and reduced muscle thickness (p < 0.001) with increased echo intensity (p < 0.001) in the medial gastrocnemius muscle compared to the normal side. There were no significant correlations between ultrasound findings and Motricity Index. CONCLUSIONS: We report changes in ultrasound-derived muscle architecture in the hemiplegic limbs of patients with subacute stroke, with consistent findings of decreased muscle mass and increased echo intensity.

Robotic Assisted Upper Limb Training Post Stroke: A Randomized Control Trial Using Combinatory Approach Toward Reducing Workforce Demands.

Post stroke upper limb rehabilitation is a challenging problem with poor outcomes as 40% of survivors have functionally useless upper limbs. Robot-aided therapy (RAT) is a potential method to alleviate the effort of intensive, task-specific, repetitive upper limb exercises for both patients and therapists. The present study aims to investigate how a time matched combinatory training scheme that incorporates conventional and RAT, using H-Man, compares with conventional training toward reducing workforce demands. In a randomized control trial (NCT02188628, www.clinicaltrials.gov), 44 subacute to chronic stroke survivors with first-ever clinical stroke and predominant arm motor function deficits were recruited and randomized into two groups of 22 subjects: Robotic Therapy (RT) and Conventional Therapy (CT). Both groups received 18 sessions of 90 min; three sessions per week over 6 weeks. In each session, participants of the CT group received 90 min of 1:1 therapist-supervised conventional therapy while participants of the RT group underwent combinatory training which consisted of 60 min of minimally-supervised H-Man therapy followed by 30 min of conventional therapy. The clinical outcomes [Fugl-Meyer (FMA), Action Research Arm Test and, Grip Strength] and the quantitative measures (smoothness, time efficiency, and task error, derived from two robotic assessment tasks) were independently evaluated prior to therapy intervention (week 0), at mid-training (week 3), at the end of training (week 6), and post therapy (week 12 and 24). Significant differences within group were observed at the end of training for all clinical scales compared with baseline [mean and standard deviation of FMA score changes between baseline and week 6; RT: Δ4.41 (3.46) and CT: Δ3.0 (4.0); p < 0.01]. FMA gains were retained 18 weeks post-training [week 24; RT: Δ5.38 (4.67) and week 24 CT: Δ4.50 (5.35); p < 0.01]. The RT group clinical scores improved similarly when compared to CT group with no significant inter-group at all time points although the conventional therapy time was reduced to one third in RT group. There were no training-related adverse side effects. In conclusion, time matched combinatory training incorporating H-Man RAT produced similar outcomes compared to conventional therapy alone. Hence, this study supports a combinatory approach to improve motor function in post-stroke arm paresis. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02188628.

Neurorehabilitation From a Distance: Can Intelligent Technology Support Decentralized Access to Quality Therapy?

Current neurorehabilitation models primarily rely on extended hospital stays and regular therapy sessions requiring close physical interactions between rehabilitation professionals and patients. The current COVID-19 pandemic has challenged this model, as strict physical distancing rules and a shift in the allocation of hospital resources resulted in many neurological patients not receiving essential therapy. Accordingly, a recent survey revealed that the majority of European healthcare professionals involved in stroke care are concerned that this lack of care will have a noticeable negative impact on functional outcomes. COVID-19 highlights an urgent need to rethink conventional neurorehabilitation and develop alternative approaches to provide high-quality therapy while minimizing hospital stays and visits. Technology-based solutions, such as, robotics bear high potential to enable such a paradigm shift. While robot-assisted therapy is already established in clinics, the future challenge is to enable physically assisted therapy and assessments in a minimally supervized and decentralized manner, ideally at the patient's home. Key enablers are new rehabilitation devices that are portable, scalable and equipped with clinical intelligence, remote monitoring and coaching capabilities. In this perspective article, we discuss clinical and technological requirements for the development and deployment of minimally supervized, robot-assisted neurorehabilitation technologies in patient's homes. We elaborate on key principles to ensure feasibility and acceptance, and on how artificial intelligence can be leveraged for embedding clinical knowledge for safe use and personalized therapy adaptation. Such new models are likely to impact neurorehabilitation beyond COVID-19, by providing broad access to sustained, high-quality and high-dose therapy maximizing long-term functional outcomes.

Assessment of the Efficacy of EEG-Based MI-BCI With Visual Feedback and EEG Correlates of Mental Fatigue for Upper-Limb Stroke Rehabilitation.

OBJECTIVE: This single-arm multisite trial investigates the efficacy of the neurostyle brain exercise therapy towards enhanced recovery (nBETTER) system, an electroencephalogram (EEG)-based motor imagery brain-computer interface (MI-BCI) employing visual feedback for upper-limb stroke rehabilitation, and the presence of EEG correlates of mental fatigue during BCI usage. METHODS: A total of 13 recruited stroke patients underwent thrice-weekly nBETTER therapy coupled with standard arm therapy over six weeks. Upper-extremity Fugl-Meyer motor assessment (FMA) scores were measured at baseline (week 0), post-intervention (week 6), and follow-ups (weeks 12 and 24). In total, 11/13 patients (mean age 55.2 years old, mean post-stroke duration 333.7 days, mean baseline FMA 35.5) completed the study. RESULTS: Significant FMA gains relative to baseline were observed at weeks 6 and 24. Retrospectively comparing to the standard arm therapy (SAT) control group and BCI with haptic knob (BCI-HK) intervention group from a previous similar study, the SAT group had no significant gains, whereas the BCI-HK group had significant gains at weeks 6, 12, and 24. EEG analysis revealed significant positive correlations between relative beta power and BCI performance in the frontal and central brain regions, suggesting that mental fatigue may contribute to poorer BCI performance. CONCLUSION: nBETTER, an EEG-based MI-BCI employing only visual feedback, helps stroke survivors sustain short-term FMA improvement. Analysis of EEG relative beta power indicates that mental fatigue may be present. SIGNIFICANCE: This study adds nBETTER to the growing literature of safe and effective stroke rehabilitation MI-BCI, and suggests an additional fatigue-monitoring role in future such BCI.

Treatment of severe, disabling spasticity with continuous intrathecal baclofen therapy following acquired brain injury: the experience of a tertiary institution in Singapore.

INTRODUCTION: Intrathecal baclofen (ITB) therapy is a proven, effective treatment for disabling cortical spasticity. We describe the first local series of five patients with acquired brain injury (ABI) who received ITB and were followed up for 63.8 months. METHODS: A retrospective review of medical and rehabilitation records of patients who received ITB therapy was carried out. Data studied included baseline demographic and injury variables, implantation data, spasticity and function, ITB dosage over time and complications. RESULTS: From 2006 to 2010, a total of five patients received ITB therapy via implanted pumps about 39.4 months after ABI. Four out of five patients experienced significant reductions in their lower limb spasticity scores and improvements in global function and dependency. One patient had minor adverse events associated with baclofen-related sedation. The mean ITB dose at one year was 182.7 ± 65.6 mcg/day. CONCLUSION: Our preliminary study showed encouraging long-term outcomes and safety for ITB therapy after ABI-related intractable spasticity. Individual ITB responses over time were variable, with gender differences. The outcomes experienced by our centre were comparable to those in the general ABI population, supporting the efficacy of ITB therapy for chronic disabling spasticity.