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OBJECTIVE: To examine a treatment for upper extremity impairment in stroke survivors that combines administration of cyproheptadine hydrochloride with repetitive practice focused on control of muscle activation patterns. DESIGN: Double-blind, randomized controlled trial. SETTINGS: Laboratory within a free-standing rehabilitation hospital. PARTICIPANTS: A total of 94 stroke survivors with severe, chronic hand impairment were randomly assigned to 1 of 4 treatment groups. INTERVENTIONS: Participants received either a placebo or cyproheptadine hydrochloride in identical pill form. The daily dosage of cyproheptadine/placebo was gradually increased from 8 to 24 mg/d over 3 weeks and then maintained over the next 6 weeks while participants completed 18 therapy sessions. Therapy consisted of either (1) active practice of muscle activation patterns to play "serious" computer games or control a custom hand exoskeleton or (2) passive, cyclical finger stretching imposed by the exoskeleton. MAIN OUTCOME MEASURES: Hand control was evaluated with the primary outcome measure of time to complete the Graded Wolf Motor Function Test (GWMFT) and secondary outcome measures including finger strength and spasticity. RESULTS: Across the 88 participants who completed the study, a repeated-measures analysis of variance revealed a significant effect of GroupxEvaluation interaction on GWMFT (F=1.996, P=.026). The 3 groups receiving cyproheptadine and/or actively practicing muscle activation pattern control exhibited significant reduction in mean time to complete the GWMFT tasks; roughly one-third of these participants experienced at least a 10% reduction in completion time. Gains were maintained at the 1-month follow-up evaluation. The group receiving placebo and passive stretching did not show improvement. No significant differences among groups were observed in terms of changes in strength or spasticity. CONCLUSIONS: Despite chronic, severe impairment, stroke survivors were able to complete the therapy focused on muscle activations and achieved statistically significant improvement in hand motor control. Cyproheptadine hydrochloride is a potential complementary treatment modality for stroke survivors with hand impairment.
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IMPORTANCE: Spinal cord stimulation (SCS) is a neuromodulation technique that can improve paresis in individuals with spinal cord injury. SCS is emerging as a technique that can address upper and lower limb hemiparesis. Little is understood about its effectiveness with the poststroke population. OBJECTIVE: To summarize the evidence for SCS after stroke and any changes in upper extremity and lower extremity motor function. DATA SOURCES: PubMed, Web of Science, Embase, and CINAHL. The reviewers used hand searches and reference searches of retrieved articles. There were no limitations regarding publication year. STUDY SELECTION AND DATA COLLECTION: This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. The inclusion and exclusion criteria included a broad range of study characteristics. Studies were excluded if the intervention did not meet the definition of SCS intervention, used only animals or healthy participants, did not address upper or lower limb motor function, or examined neurological conditions other than stroke. FINDINGS: Fourteen articles met the criteria for this review. Seven studies found a significant improvement in motor function in groups receiving SCS. CONCLUSIONS AND RELEVANCE: Results indicate that SCS may provide an alternative means to improve motor function in the poststroke population. Plain-Language Summary: The results of this study show that spinal cord stimulation may provide an alternative way to improve motor function after stroke. Previous neuromodulation methods have targeted the impaired supraspinal circuitry after stroke. Although downregulated, spinal cord circuitry is largely intact and offers new possibilities for motor recovery.
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Paresia , Estimulação da Medula Espinal , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral , Humanos , Paresia/reabilitação , Paresia/etiologia , Estimulação da Medula Espinal/métodos , Acidente Vascular Cerebral/complicações , Reabilitação do Acidente Vascular Cerebral/métodos , Extremidade Superior/fisiopatologia , Extremidade Inferior , Recuperação de Função FisiológicaRESUMO
BACKGROUND/PURPOSE: To determine the feasibility of training with electromyographically (EMG) controlled games to improve control of muscle activation patterns in stroke survivors. METHODS: Twenty chronic stroke survivors (>6 months) with moderate hand impairment were randomized to train either unilaterally (paretic only) or bilaterally over 9 one-hour training sessions. EMG signals from the unilateral or bilateral limbs controlled a cursor location on a computer screen for gameplay. The EMG muscle activation vector was projected onto the plane defined by the first 2 principal components of the activation workspace for the nonparetic hand. These principal components formed the x- and y-axes of the computer screen. RESULTS: The recruitment goal (n = 20) was met over 9 months, with no screen failure, no attrition, and 97.8% adherence rate. After training, both groups significantly decreased the time to move the cursor to a novel sequence of targets (P = 0.006) by reducing normalized path length of the cursor movement (P = 0.005), and improved the Wolf Motor Function Test (WMFT) quality score (P = 0.01). No significant group difference was observed. No significant change was seen in the WMFT time or Box and Block Test. DISCUSSION/CONCLUSIONS: Stroke survivors could successfully use the EMG-controlled games to train control of muscle activation patterns. While the nonparetic limb EMG was used in this study to create target EMG patterns, the system supports various means for creating target patterns per user desires. Future studies will employ training with the EMG-controlled games in conjunction with functional task practice for a longer intervention duration to improve overall hand function.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A379).
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Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral , Mãos , Humanos , Músculo Esquelético , Projetos Piloto , Acidente Vascular Cerebral/terapiaRESUMO
OBJECTIVES: The goal of this study was to examine how the administration and dosing of the anti-serotonergic medication cyproheptadine hydrochloride (HCl) affects involuntary muscle hypertonicity of the spastic and paretic hands of stroke survivors. MATERIALS AND METHODS: A randomized, double-blinded, placebo-controlled longitudinal intervention study was performed as a component of a larger clinical trial. 94 stroke survivors with chronic, severe hand impairment, rated as levels 2 or 3 on the Chedoke-McMaster Stroke Assessment Stage of Hand (CMSA-H), were block randomized to groups receiving doses of cyproheptadine HCl or matched doses of placebo. Doses were increased from 4 mg BID to 8 mg TID over 3 weeks. Outcomes were assessed at baseline and after each of the three weeks of intervention. Primary outcome measure was grip termination time; other measures included muscle strength, spasticity, coactivation of the long finger flexors, and recording of potential adverse effects such as sleepiness and depression. RESULTS: 89 participants (receiving cyproheptadine HCl: 44, receiving placebo: 45) completed the study. The Cyproheptadine group displayed significant reduction in grip termination time, in comparison with the Placebo group (p<0.05). Significant change in the Cyproheptadine group (45% time reduction) was observed after only one week at the 4mg BID dosage. The effect was pronounced for those participants in the Cyproheptadine group with more severe hand impairment (CMSA-H level 2) at baseline. Conversely, no significant effect of Group * Session interaction was observed for spasticity (p=0.6) or coactivation (p=0.53). There were no significant changes in strength (p=0.234) or depression (p=0.441) during the trial. CONCLUSIONS: Use of cyproheptadine HCl was associated with a significant reduction in relaxation time of finger flexor muscles, without adversely affecting voluntary strength, although spasticity and coactivation were unchanged. Decreasing the duration of involuntary flexor activity can facilitate object release and repeated prehensile task performance. REGISTRATION: Clinical Trial number: NCT02418949.
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Fármacos Neuromusculares , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral , Ciproeptadina/efeitos adversos , Humanos , Espasticidade Muscular/diagnóstico , Espasticidade Muscular/tratamento farmacológico , Espasticidade Muscular/etiologia , Fármacos Neuromusculares/uso terapêutico , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/tratamento farmacológico , Sobreviventes , Resultado do TratamentoRESUMO
OBJECTIVE: To investigate the performance of the less affected upper limb in people with stroke compared with normative values. To examine less affected upper limb function in those whose prestroke dominant limb became paretic and those whose prestroke nondominant limb became paretic. DESIGN: Cohort study of survivors of chronic stroke (7.2±6.7y post incident). SETTING: The study was performed at a freestanding academic rehabilitation hospital. PARTICIPANTS: Survivors of chronic stroke (N=40) with severe hand impairment (Chedoke-McMaster Stroke Assessment rating of 2-3 on Stage of Hand) participated in the study. In 20 participants the prestroke dominant hand (DH) was tested (nondominant hand [NH] affected by stroke), and in 20 participants the prestroke NH was tested (DH affected by stroke). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Jebsen-Taylor Hand Function Test. Data from survivors of stroke were compared with normative age- and sex-matched data from neurologically intact individuals. RESULTS: When combined, DH and NH groups performed significantly worse on fine motor tasks with their nonparetic hand relative to normative data (P<.007 for all measures). Even the participants who continued to use their prestroke DH as their primary hand after the stroke demonstrated reduced fine motor skills compared with normative data. In contrast, grip strength was not significantly affected in either group of survivors of stroke (P>.140). CONCLUSIONS: Survivors of stroke with severe impairment of the paretic limb continue to present significant upper extremity impairment in their nominally nonparetic limb even years after stroke. This phenomenon was observed regardless of whether the DH or NH hand was primarily affected. Because this group of survivors of stroke is especially dependent on the nonparetic limb for performing functional tasks, our results suggest that the nonparetic upper limb should be targeted for rehabilitation.
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Avaliação da Deficiência , Reabilitação do Acidente Vascular Cerebral/métodos , Acidente Vascular Cerebral/diagnóstico , Extremidade Superior/fisiopatologia , Centros Médicos Acadêmicos , Idoso , Doença Crônica , Estudos de Coortes , Estudos Transversais , Teste de Esforço/métodos , Feminino , Força da Mão/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Paresia/reabilitação , Prognóstico , Valores de Referência , Centros de Reabilitação , Medição de Risco , Acidente Vascular Cerebral/terapia , Sobreviventes , Resultado do TratamentoRESUMO
OBJECTIVE: To compare participation and subjective experience of participants in both home-based multiuser virtual reality (VR) therapy and home-based single-user (SU) VR therapy. DESIGN: Crossover, randomized trial. SETTING: Initial training and evaluations occurred in a rehabilitation hospital; the interventions took place in participants' homes. PARTICIPANTS: Survivors of stroke with chronic upper extremity impairment (N=20). INTERVENTIONS: Four weeks of in-home treatment using a custom, multiuser virtual reality system (VERGE): 2 weeks of both multiuser (MU) and SU versions of VERGE. The order of presentation of SU and MU versions was randomized such that participants were divided into 2 groups, First MU and First SU. MAIN OUTCOME MEASURES: We measured arm displacement during each session (m) as the primary outcome measure. Secondary outcome measures include time participants spent using each MU and SU VERGE and Intrinsic Motivation Inventory scores. Fugl-Meyer Assessment of Motor Recovery After Stroke Upper Extremity (FMA-UE) score and compliance with prescribed training were also evaluated. Measures were recorded before, midway, and after the treatment. Activity and movement were measured during each training session. RESULTS: Arm displacement during a session was significantly affected the mode of therapy (MU: 414.6m, SU: 327.0m, P=.019). Compliance was very high (99% compliance for MU mode and 89% for SU mode). Within a given session, participants spent significantly more time training in the MU mode than in the SU mode (P=.04). FMA-UE score improved significantly across all participants (Δ3.2, P=.001). CONCLUSIONS: Multiuser VR exercises may provide an effective means of extending clinical therapy into the home.
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Serviços de Assistência Domiciliar , Reabilitação do Acidente Vascular Cerebral/métodos , Telerreabilitação/métodos , Jogos de Vídeo , Realidade Virtual , Adulto , Idoso , Estudos Cross-Over , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Motivação , Recuperação de Função Fisiológica , Extremidade Superior/fisiologiaRESUMO
OBJECTIVE: Junior tenure-track faculty report high levels of stress and low satisfaction; the increasingly competitive funding environment compounds this discontent. We examined factors associated with junior investigators who were thinking about quitting research. METHOD: Data were collected as part of a program evaluation of an interdisciplinary research mentoring program in an academic medical center. RESULTS: Of the 62 mentees, 44 responded to the survey (71%). When asked "In the past year, have you considered quitting research?" 39 mentees answered the question; 17 (44%) answered in the affirmative. Those who had considered quitting had lower scores on the Clinical Research Appraisal Inventory-12 (CRAI-12) and job satisfaction and higher scores on burnout. In a regression model, we found that only CRAI-12 scores were significantly, inversely associated with thinking about quitting. CONCLUSION: Factors associated with thinking about quitting included lower confidence in research skills, reduced job satisfaction, and higher levels of burnout.
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Priming is a type of implicit learning wherein a stimulus prompts a change in behavior. Priming has been long studied in the field of psychology. More recently, rehabilitation researchers have studied motor priming as a possible way to facilitate motor learning. For example, priming of the motor cortex is associated with changes in neuroplasticity that are associated with improvements in motor performance. Of the numerous motor priming paradigms under investigation, only a few are practical for the current clinical environment, and the optimal priming modalities for specific clinical presentations are not known. Accordingly, developing an understanding of the various types of motor priming paradigms and their underlying neural mechanisms is an important step for therapists in neurorehabilitation. Most importantly, an understanding of the methods and their underlying mechanisms is essential for optimizing rehabilitation outcomes. The future of neurorehabilitation is likely to include these priming methods, which are delivered prior to or in conjunction with primary neurorehabilitation therapies. In this Special Interest article, we discuss those priming paradigms that are supported by the greatest amount of evidence, including (i) stimulation-based priming, (ii) motor imagery and action observation, (iii) sensory priming, (iv) movement-based priming, and (v) pharmacological priming.Video Abstract available. (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A86) for more insights from the authors.
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Córtex Motor/fisiopatologia , Plasticidade Neuronal/fisiologia , Estimulação Transcraniana por Corrente Contínua , Estimulação Magnética Transcraniana , Humanos , Imaginação/fisiologia , Movimento/fisiologiaRESUMO
BACKGROUND: Frequent and objective monitoring of motor recovery progression holds significant importance in stroke rehabilitation. Despite extensive studies on wearable solutions in this context, the focus has been predominantly on evaluating limb activity. This study aims to address this limitation by delving into a novel measure of wrist kinematics more intricately related to patients' motor capacity. OBJECTIVE: To explore a new wearable-based approach for objectively and reliably assessing upper-limb motor ability in stroke survivors using a single inertial sensor placed on the stroke-affected wrist. METHODS: Seventeen stroke survivors performed a series of daily activities within a simulated home setting while wearing a six-axis inertial measurement unit on the wrist affected by stroke. Inertial data during point-to-point upper-limb movements were decomposed into movement segments, from which various kinematic variables were derived. A data-driven approach was then employed to identify a kinematic variable demonstrating robust internal reliability, construct validity, and convergent validity. RESULTS: We have identified a key kinematic variable, namely the 90th percentile of movement segment distance during point-to-point movements. This variable exhibited robust reliability (intra-class correlation coefficient of .93) and strong correlations with established clinical measures of motor capacity (Pearson's correlation coefficients of .81 with the Fugl-Meyer Assessment for Upper-Extremity; .77 with the Functional Ability component of the Wolf Motor Function Test; and -.68 with the Performance Time component of the Wolf Motor Function Test). CONCLUSIONS: The findings underscore the potential for continuous, objective, and convenient monitoring of stroke survivors' motor progression throughout rehabilitation.
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Stroke is a leading cause of disability worldwide and upper limb hemiparesis is the most common post-stroke disability. Recent studies suggest that clinically significant motor recovery is possible in chronic stroke survivors with severe impairment of the upper limb. Three promising strategies that have been investigated are (1) high dose rehabilitation therapy (2) bilateral motor priming and (3) vagus nerve stimulation. We propose that the future of effective and efficient upper limb rehabilitation will likely require a combination of these approaches.
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BACKGROUND: Diminished sensorimotor control of the hand is one of the most common outcomes following stroke. This hand impairment substantially impacts overall function and quality of life; standard therapy often results in limited improvement. Mechanisms of dysfunction of the severely impaired post-stroke hand are still incompletely understood, thereby impeding the development of new targeted treatments. OBJECTIVE: To identify and determine potential relationships among the mechanisms responsible for hand impairment following stroke. METHODS: This cohort study observed stroke survivors (n = 95) with severe, chronic hand impairment (Chedoke-McMaster Hand score = 2-3). Custom instrumentation created precise perturbations and measured kinematic responses. Muscle activation was recorded through electromyography. Strength, spasticity, muscle relaxation time, and muscle coactivation were quantified. RESULTS: Maximum grip strength in the paretic hand was only 12% of that achieved by the nonparetic hand, and only 6 of 95 participants were able to produce any net extension force. Despite force deficits, spastic reflex response of the finger flexor evoked by imposed stretch averaged 90.1 ± 26.8% of maximum voluntary activation, relaxation time averaged 3.8 ± 0.8 seconds, and coactivation during voluntary extension exceeded 30% of maximum contraction, thereby resulting in substantial net flexion. Surprisingly, these hypertonicity measures were not significantly correlated with each other. CONCLUSIONS: Survivors of severe, chronic hemiparetic stroke experience profound weakness of both flexion and extension that arises from increased involuntary antagonist activation and decreased voluntary activation. The lack of correlation amongst hypertonicity measures suggests that these phenomena may arise from multiple, potentially independent mechanisms that could require different treatments.
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Qualidade de Vida , Acidente Vascular Cerebral , Estudos de Coortes , Eletromiografia , Força da Mão/fisiologia , Humanos , Músculo Esquelético , Acidente Vascular Cerebral/complicações , Sobreviventes , Extremidade SuperiorRESUMO
BACKGROUND: Various priming techniques to enhance neuroplasticity have been examined in stroke rehabilitation research. Most priming techniques are costly and approved only for research. Here, we describe a priming technique that is cost-effective and has potential to significantly change clinical practice. Bilateral motor priming uses the Exsurgo priming device (Exsurgo Rehabilitation, Auckland, NZ) so that the less affected limb drives the more affected limb in bilateral symmetrical wrist flexion and extension. The aim of this study is to determine the effects of a 5-week protocol of bilateral motor priming in combination with task-specific training on motor impairment of the affected limb, bimanual motor function, and interhemispheric inhibition in moderate to severely impaired people with stroke. METHODS: Seventy-six participants will be randomized to receive either 15, 2-h sessions, 3 times per week for 5 weeks (30 h of intervention) of bilateral motor priming and task-specific training (experimental group) or the same dose of control priming plus the task-specific training protocol. The experimental group performs bilateral symmetrical arm movements via the Exsurgo priming device which allows both wrists to move in rhythmic, symmetrical wrist flexion and extension for 15 min. The goal is one cycle (wrist flexion and wrist extension) per second. The control priming group receives transcutaneous electrical stimulation below sensory threshold for 15 min prior to the same 45 min of task-specific training. Outcome measures are collected at pre-intervention, post-intervention, and follow-up (8 weeks post-intervention). The primary outcome measure is the Fugl-Meyer Test of Upper Extremity Function. The secondary outcome is the Chedoke Arm and Hand Activity Index-Nine, an assessment of bimanual functional tasks. DISCUSSION: To date, there are only 6 studies documenting the efficacy of priming using bilateral movements, 4 of which are pilot or feasibility studies. This is the first large-scale clinical trial of bilateral priming plus task-specific training. We have previously completed a feasibility intervention study of bilateral motor priming plus task-specific training and have considerable experience using this protocol. TRIAL REGISTRATION: ClinicalTrials.gov NCT03517657 . Retrospectively registered on May 7, 2018.
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Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral , Humanos , Paresia/diagnóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica/fisiologia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Reabilitação do Acidente Vascular Cerebral/métodos , Resultado do Tratamento , Extremidade SuperiorRESUMO
BACKGROUND AND PURPOSE: The purpose of this study was to investigate the influence of prolonged and repetitive passive range of motion (PROM) stretching of the fingers on hand function in stroke survivors. PARTICIPANTS: Fifteen chronic stroke survivors with moderate to severe hand impairment took part in the study. METHOD: Participants underwent 3 experimental sessions consisting of 30 minutes of rest, prolonged, or repetitive stretching of the finger flexor muscles by a powered glove orthosis (X-Glove). Outcome measures, comprised of 3 selected tasks from the Graded Wolf Motor Function Test (GWMFT), grip strength, lateral pinch strength, and grip relaxation time, were recorded at the start and end of each session. Change in outcome score for each session was used for analysis. RESULTS: Data suggested a trend for improvement following stretching, especially for the repetitive PROM case. For one GWMFT task (lift washcloth), the effect of stretching condition on performance time approached a statistical significance (P = .015), with repetitive PROM stretching producing the greatest mean reduction. Similarly, repetitive stretching led to a 12% ± 16% increase in grip strength, although this change was not statistically different across groups (P = .356); and grip termination time was reduced, albeit non-significantly, by 66% ± 133%. CONCLUSION: Repetitive PROM stretching exhibited trends to be more effective than prolonged stretching for improving hand motor control. Although the results were highly variable and the effects are undoubtedly transient, an extended period of repetitive PROM stretching may prove advantageous prior to hand therapy sessions to maximize treatment.
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Terapia por Exercício/métodos , Mãos/fisiopatologia , Amplitude de Movimento Articular/fisiologia , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral/fisiopatologia , Adulto , Idoso , Análise de Variância , Doença Crônica , Feminino , Lateralidade Funcional , Força da Mão , Humanos , Masculino , Pessoa de Meia-Idade , Aparelhos Ortopédicos , Avaliação de Resultados em Cuidados de SaúdeRESUMO
BACKGROUND: There are limited effective and evidence-based interventions for upper extremity hemiparesis post-stroke. To prepare for an RCT and minimize misuse of resources, there is value in conducting a feasibility study. OBJECTIVE: To examine the feasibility of recruitment and other related outcomes for an intense upper limb intervention. METHODOLOGY: Feasibility outcomes included retention, adherence, accrual rate, sample characteristics, and identification of productive recruitment methods. Other outcomes included satisfaction with the study, fidelity, and equipoise of both staff and participants. RESULTS: Participants were enrolled at a rate of 1.33 per month. The recruitment timeline had to be extended by 4 months, to meet the target of 16 randomized participants. Staggered recruitment was the most successful strategy. We found that following up with individuals who missed initial appointments prior to study enrollment led to decreased adherence. CONCLUSION: It is feasible to recruit and retain post-stroke participants for an intense intervention study. TRIAL REGISTRATION: NCT02277028.
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BACKGROUND: Bilateral priming, device assisted bilateral symmetrical wrist flexion/extension, is a noninvasive neuromodulation technique that can be used in the clinic. OBJECTIVE: We examined the additive effect of bilateral motor priming and task specific training in individuals with severe upper limb hemiparesis. METHODS: This is a parallel assignment, single-masked, randomized exploratory pilot study with three timepoints (pre-/post-intervention and follow up). Participants received either bilateral motor priming or health care education followed by task specific training. Sixteen participants who were at least 6 months post-stroke and had a Fugl Meyer Upper Extremity (FMUE) score between 23 and 38 were randomized. Our primary and secondary measures were Chedoke Arm & Hand Activity Index 9 (CAHAI-9) and the FMUE respectively. We determined changes in interhemispheric inhibition using transcranial magnetic stimulation. We hypothesized that improvement in the priming group would persist at follow up. RESULTS: There was no between-group difference in the CAHAI. The improvement in the FMUE was significantly greater in the experimental group at follow up (tâ=â2.241, pâ=â0.045). CONCLUSIONS: Both groups improved in the CAHAI. There was a significant between-group difference in the secondary outcome measure (FMUE) where the bilateral priming group had an average increase of 10 points from pre-intervention to follow up.
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Atividade Motora/fisiologia , Paresia/terapia , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral/terapia , Extremidade Superior/fisiopatologia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Paresia/fisiopatologia , Projetos Piloto , Recuperação de Função Fisiológica/fisiologia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/fisiopatologia , Reabilitação do Acidente Vascular Cerebral/métodos , Estimulação Magnética Transcraniana/métodos , Resultado do Tratamento , Extremidade Superior/fisiologiaRESUMO
A majority of the seven million stroke survivors in the U.S. have hand impairments, adversely affecting performance of a variety of activities of daily living, because of the fundamental role of the hand in performing functional tasks. Disability in stroke survivors is largely attributable to damaged neuronal pathways, which result in inappropriate activation of muscles, a condition prevalent in distal upper extremity muscles following stroke. While conventional rehabilitation methods focus on the amplification of existing muscle activation, the effectiveness of therapy targeting the reorganization of pathological activation patterns is often unexplored. To encourage modulation of activation level and exploration of the activation workspace, we developed a novel platform for playing a serious game through electromyographic control. This system was evaluated by a group of neurologically intact subjects over multiple sessions held on different days. Subjects were assigned to one of two groups, training either with their non-dominant hand only (unilateral) or with both hands (bilateral). Both groups of subjects displayed improved performance in controlling the cursor with their non-dominant hand, with retention from one session to the next. The system holds promise for rehabilitation of control of muscle activation patterns.
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Eletromiografia/métodos , Jogos Experimentais , Reabilitação do Acidente Vascular Cerebral/instrumentação , Adulto , Fenômenos Biomecânicos , Calibragem , Feminino , Lateralidade Funcional , Mãos/fisiopatologia , Voluntários Saudáveis , Humanos , Masculino , Músculo Esquelético/fisiopatologia , Desempenho Psicomotor , Recuperação de Função Fisiológica , Adulto JovemRESUMO
OBJECTIVE: To evaluate the feasibility of a fully implanted cortical stimulator for improving hand and arm function in patients following ischemic stroke. METHOD: Twenty-four chronic stroke patients with hemiplegia were randomized to targeted implanted cortical electrical stimulation of the motor cortex with upper limb rehabilitation therapy or rehabilitation therapy alone. RESULTS: Using repeated measures regression models, we estimated and compared treatment effects between groups over the study follow-up period. The investigational group had significantly greater mean improvements in Upper Extremity Fugl-Meyer (UEFM) scores during the 6-month follow-up period (weeks 1-24 following therapy), as compared to the control group (difference in estimated means = 3.8, p = .042). Box and Block (B & B) test improvement from baseline scores were also significantly better in the investigational group across the 6-month follow-up assessments (difference in estimated means = 3.8, p = .046). There was one report of seizure after device implant but prior to cortical stimulation and rehabilitation therapy, but no reports of neurologic decline. There were no improvements seen in the other measures assessed. CONCLUSION: Evidence suggests that cortical stimulation with rehabilitation therapy produces a lasting treatment effect in upper extremity motor control and is not associated with serious neurological complications. A larger multicenter study is underway.
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Isquemia Encefálica/reabilitação , Terapia por Estimulação Elétrica , Córtex Motor/fisiologia , Próteses e Implantes , Reabilitação do Acidente Vascular Cerebral , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/fisiopatologia , Terapia por Estimulação Elétrica/efeitos adversos , Terapia por Estimulação Elétrica/métodos , Feminino , Hemiplegia/etiologia , Hemiplegia/fisiopatologia , Hemiplegia/reabilitação , Humanos , Masculino , Pessoa de Meia-Idade , Modalidades de Fisioterapia , Projetos Piloto , Estudos Prospectivos , Recuperação de Função Fisiológica/fisiologia , Convulsões/etiologia , Acidente Vascular Cerebral/complicações , Resultado do Tratamento , Extremidade SuperiorRESUMO
Chronic upper extremity hemiparesis following stroke is a significant impairment that can limit a person's independence in all aspects of ADL, IADL, and functional mobility. Although recovery of functional independence may be more efficient using traditional compensatory techniques, these therapeutic methods often do not encourage integration of the hemiparetic arm and hand. In contrast, the task-oriented approach to motor recovery of poststroke hemiparesis emphasizes integration of the impaired limb into all functional tasks via skill-based training. Cortical changes have been documented following skill-based training of the upper limb in the healthy animal model. Additionally, the combination of subthreshold cortical stimulation combined with skill-based forelimb training in the induced-stroke rat model has demonstrated better outcomes than training alone. Preliminary research with human stroke survivors using task-oriented training and subthreshold cortical stimulation has shown promising results. The purpose of this article is to introduce an upper limb training protocol that was used in a national multisite trial that compares cortical stimulation in conjunction with taskoriented training to training alone.
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Terapia por Estimulação Elétrica , Córtex Motor/fisiologia , Terapia Ocupacional/métodos , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral/terapia , Adulto , Animais , Humanos , Masculino , Paresia/reabilitação , Paresia/terapia , Extremidade SuperiorRESUMO
Priming can be described as behavior change generated by preceding stimuli. Although various types of priming have been long studied in the field of psychology, priming that targets motor cortex is a relatively new topic of research in the fields of motor control and rehabilitation. In reference to a rehabilitation intervention, priming is categorized as a restorative approach. There are a myriad of possible priming approaches including noninvasive brain stimulation, motor imagery, and sensory-based priming, to name a few. The authors report on movement-based priming which, compared to other priming types, is less frequently examined and under reported. Movement-based priming includes, but is not limited to, bilateral motor priming, unilateral priming, and aerobic exercise. Clinical and neural mechanistic aspects of movement-based priming techniques are explored.
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Movimento/fisiologia , Plasticidade Neuronal/fisiologia , Terapia Ocupacional/métodos , Priming de Repetição/fisiologia , Exercício Físico/fisiologia , Humanos , EnsinoRESUMO
Many mechatronic devices exist to facilitate hand rehabilitation, however few directly address deficits in muscle activation patterns while also enabling functional task practice. We developed an innovative voice and electromyography-driven actuated (VAEDA) glove, which is sufficiently flexible/portable for incorporation into hand-focused therapy post-stroke. The therapeutic benefits of this device were examined in a longitudinal intervention study. Twenty-two participants with chronic, moderate hand impairment [Chedoke-McMaster Stroke Assessment Stage of Hand (CMSA-H = 4)] enrolled > 8 months post-stroke for 18 1-h training sessions ( 3 × week) employing a novel hand-focused occupational therapy paradigm, either with (VAEDA) or without (No-VAEDA) actuated assistance. Outcome measures included CMSA-H, Wolf Motor Function Test (WMFT), Action Research Arm Test, Fugl-Meyer Upper Extremity Motor Assessment (FMUE), grip and pinch strength and hand kinematics. All outcomes were recorded at baseline and endpoint (immediately after and four weeks post-training). Significant improvement was observed following training for some measures for the VAEDA group (n = 11) but for none of the measures for the No-VAEDA group (n = 11). Specifically, statistically significant gains were observed for CMSA-H (p = 0.038) and WMFT (p = 0.012) as well as maximum digit aperture subset (p = 0.003, n = 7), but not for the FMUE or grip or pinch strengths. In conclusion, therapy effectiveness appeared to be increased by employment of the VAEDA glove, which directly targets deficits in muscle activation patterns.