Effects of Transcranial Direct Current Stimulation Combined With Neuromuscular Electrical Stimulation on Upper Extremity Motor Function in Patients With Stroke.

OBJECTIVE: The aim of the study was to investigate the treatment effects of transcranial direct current stimulation combined with neuromuscular electrical stimulation on the motor function of upper extremity in persons with stroke. DESIGN: This study was a pilot double-blind randomized controlled trial. Twenty-six patients due to stroke onset of more than 6 mos were randomly allocated to three groups: transcranial direct current stimulation combined with neuromuscular electrical stimulation group, transcranial direct current stimulation group, or control group. In addition to conventional rehabilitation, all subjects received one of the three protocols in a total of 15 sessions for 3 wks. RESULTS: A significant difference among the three groups was found for the change scores of the Fugl-Meyer Assessment upper extremity subscale from pretreatment to 1-mo follow-up (P = 0.02), in favor of the transcranial direct current stimulation combined with neuromuscular electrical stimulation group. Moreover, the transcranial direct current stimulation combined with neuromuscular electrical stimulation group showed significant within-group improvement on the Fugl-Meyer Assessment upper extremity (from preintervention to postintervention, P = 0.01) and the Action Research Arm Test (from preintervention to postintervention and to 1-mo postintervention, P = 0.03 and P = 0.04, respectively). CONCLUSIONS: This preliminary study reveals that combining transcranial direct current stimulation and neuromuscular electrical stimulation with regular rehabilitation programs may enhance better upper extremity functional improvement than regular rehabilitation programs alone in patients with chronic stroke.

Inspiratory muscle activation during inspiratory muscle training in patients with COPD.

BACKGROUND AND OBJECTIVES: The main target of inspiratory muscle training (IMT) is to improve diaphragm function in patients with COPD who have inspiratory muscle weakness. Ventilatory demand is already increased during quiet breathing in patients with COPD, and whether threshold load imposed by IMT would active more accessory muscle remained to be determined. The purpose of this study was to examine diaphragm and sternocleidomastoid (SCM) activation during IMT with intensities of 30% and 50% maximal inspiratory pressure (PImax). METHODS: Patients with COPD and a PImax lower than 60 cmH2O were recruited for the study. Surface electromyography (EMG) was used to measure diaphragm and SCM activation, and group-based trajectory modeling (GBTM) was used to identify activation patterns during IMT. The generalized estimating equation (GEE) was then used to detect differences of variables between various breathing tasks. Statistical significance was established at p < 0.05. RESULTS: A total of 30 patients with COPD participated in this study. All patients demonstrated significant increases in diaphragm and SCM activation during 30% and 50% PImax of IMT than during quiet breathing (all p < 0.001). Diaphragm demonstrated two distinct patterns in response to IMT: low activation (n = 8) and high activation (n = 22) group using GBTM analysis. CONCLUSION: Diaphragm and SCM were substantially activated during IMT in patients with COPD who had inspiratory muscle weakness. Regardless of whether diaphragm activation was high or low, SCM was activated to a greater extent in response to IMT.

Validity of the Polar V800 Monitor for Assessing Heart Rate Variability in Elderly Adults under Mental Stress and Dual Task Conditions.

Background: Aging may result in autonomic nervous dysfunction. Heart rate variability (HRV) is a non-invasive method to measure autonomic nervous activities. Many studies have shown that HRV contributes to the risk assessment of diseases. A Polar V800 heart rate monitor is a wearable device that measures R-R intervals, but has only been validated in younger adults under limited testing conditions. There is no validation of the V800 under mental stress or in dual task testing conditions. Therefore, this study investigated the validity of the Polar V800 heart rate monitor for assessing R-R intervals and evaluated if there were differences on HRV parameters under different situations in community-dwelling elderly adults. Methods: Forty community-dwelling elderly adults were recruited. Heart rates were recorded via electrocardiogram (ECG) and the V800 under sitting, during an arithmetic test, during a naming test, a self-selected walking velocity test (SSWV), and dual tasks (SSWV performing mental arithmetic test and SSWV performing naming test). Indices of time and frequency domains of HRV were calculated afterwards. The intra-class correlation coefficient (ICC) analysis and effect size were calculated to examine the concurrent validity between the V800 and the ECG. Results: All HRV indices from the V800 were highly correlated with the ECG under all tested conditions (ICC = 0.995-1.000, p < 0.001) and the effect size of bias was small (<0.1). Conclusion: Overall, the V800 has good validity on the assessment of HRV in community-dwelling elderly adults during sitting, mental arithmetic test, naming test, SSWV, and dual tasks.

Mechanism of Fatigue Induced by Different Cycling Paradigms With Equivalent Dosage.

Leg cycling is one of the most common modes of exercise used in athletics and rehabilitation. This study used a novel cycling setting to elucidate the mechanisms, central vs. peripheral fatigue induced by different resistance with equivalent works (watt∗min). Twelve male adults received low and relatively high resistance cycling fatigue tests until exhausted (RPE > 18) in 2 weeks. The maximal voluntary contraction, voluntary activation level, and twitch forces were measured immediately before and after cycling to calculate General (GFI), central (CFI), and peripheral (PFI) fatigue indices of knee extensors, respectively. The results showed that the CFI (high: 92.26 ± 8.67%, low: 78.32 ± 11.77%, p = 0.004) and PFI (high: 73.76 ± 17.32%, low: 89.63 ± 11.01%, p < 0.017) were specific to the resistance of fatigue protocol. The GFI is influenced by the resistance of cycling to support the equivalent dosage. This study concluded that the mechanism of fatigue would be influenced by the resistance of fatigue protocol although the total works had been controlled.

Low-Intensity Electrical Stimulation to Improve the Neurological Aspect of Weakness in Individuals with Chronic Anterior Cruciate Ligament Lesion.

PURPOSE: This study is aimed at investigating the effect of low-intensity electrical stimulation on the voluntary activation level (VA) and the cortical facilitation/inhibition of quadriceps in people with chronic anterior cruciate ligament lesion. METHODS: Twenty former athletes with unilateral ACL deficiencies (ACL group) and 20 healthy subjects (healthy control group) participated in the study. The quadriceps VA level, motor-evoked potential (MEP), short-interval intracortical inhibition (SICI), and intracortical facilitation (ICF) elicited by transcranial magnetic stimulation were tested before and after 30 minutes of low-intensity electrical stimulation (ES). RESULTS: Before ES, the quadriceps VA in the ACL lesion legs of the ACL group was lower compared to the legs of the healthy control group (P < 0.05). The MEP sizes in the ACL lesion legs and the healthy control were not significantly different. The ACL lesion legs showed lower SICI and higher ICF compared to the healthy control group (P < 0.05). After ES, the quadriceps VA level increased and the SICI-ICF was modulated only in the ACL lesion legs (P < 0.05) but not in the healthy controls. CONCLUSIONS: Low-intensity ES can normalize the modulation of intracortical inhibition and facilitation, thereby ameliorating the activation failure in individuals with ACL lesion.

Novel human models for elucidating mechanisms of rate-sensitive H-reflex depression.

BACKGROUND: This study used novel human neurophysiologic models to investigate whether the mechanism of rate-sensitive H-reflex depression lies in the pre-synaptic or post-synaptic locus in humans. We hypothesized that pre-synaptic inhibition would suppress Ia afferents and H-reflexes without suppressing alpha motor neurons or motor evoked potentials (MEPs). In contrast, post-synaptic inhibition would suppress alpha motor neurons, thereby reducing H-reflexes and MEPs. METHODS: We recruited 23 healthy adults with typical rate-sensitive H-reflex depression, 2 participants with acute sensory-impaired spinal cord injury (SCI) (to rule out influence of sensory stimulation on supra-spinal excitability), and an atypical cohort of 5 healthy adults without rate-sensitive depression. After a single electrical stimulation to the tibial nerve, we administered either a testing H-reflex or a testing MEP at 50-5000 ms intervals. RESULTS: Testing MEPs were not diminished in healthy subjects with or without typical rate-sensitive H-reflex depression, or in subjects with sensory-impaired SCI. MEP responses were similar in healthy subjects with versus without rate-sensitive H-reflex depression. CONCLUSIONS: Results from these novel in vivo human models support a pre-synaptic locus of rate-sensitive H-reflex depression for the first time in humans. Spinal reflex excitability can be modulated separately from descending corticospinal influence. Each represents a potential target for neuromodulatory intervention.

Immediate effects of noxious and innocuous thermal stimulation on brain activation in patients with stroke.

Case-control studies have shown that noxious thermal stimulation (TS) can improve arm function in patients with stroke. However, the neural mechanisms underlying this improvement are largely unknown. We explored functional neural activation due to noxious and innocuous TS intervention applied to the paretic arm of patients with stroke. Sixteen participants with unilateral cortical infarctions were allocated to one of two groups: noxious TS (8 patients; temperature combination: hot pain 46°C to 47°C, cold pain 7°C-8°C) or innocuous TS (n = 8; temperature combination: hot 40°C-41°C, cold 20°C-21°C). All subjects underwent fMRI scanning before and after 30 min TS intervention and performed a finger tapping task with the affected hand. Immediate brain activation effects were assessed according to thermal type (noxious vs. innocuous TS) and time (pre-TS vs post-TS). Regions activated by noxious TS relative to innocuous TS (P < .05, adjusted for multiple comparisons) were related to motor performance and sensory function in the bilateral primary somatosensory cortices, anterior cingulate cortex, insula, thalamus, hippocampus and unilateral primary motor cortex, secondary somatosensory cortex at the contralateral side of lesion, and unilateral supplementary motor area at the ipsilateral side of lesion. Greater activation responses were observed in the side contralateral to the lesion, suggesting a significant intervention effect. Our preliminary findings suggest that noxious TS may induce neuroplastic changes unconstrained to the local area.Trial registration: NCT01418404.

Influence of Alternate Hot and Cold Thermal Stimulation in Cortical Excitability in Healthy Adults: An fMRI Study.

Stroke rehabilitation using alternate hot and cold thermal stimulation (altTS) has been reported to improve motor function in hemiplegia; however, the influence of brain excitability induced by altTS remains unclear. This study examined cortical activation induced by altTS in healthy adults, focusing on motor-related areas. This involved a repeated crossover experimental design with two temperature settings (innocuous altTS with alternate heat-pain and cold-pain thermal and noxious altTS with alternate heat and cold thermal) testing both arms (left side and right side). Thirty-one healthy, right-handed participants received four episodes of altTS on four separate days. Functional magnetic resonance imaging scans were performed both before and after each intervention to determine whether altTS intervention affects cortical excitability, while participants performed a finger-tapping task during scanning. The findings revealed greater response intensity of cortical excitability in participants who received noxious altTS in the primary motor cortex, supplementary motor cortex, and somatosensory cortex than in those who received innocuous altTS. Moreover, there was more motor-related excitability in the contra-lateral brain when heat was applied to the dominant arm, and more sensory-associated excitability in the contra-lateral brain when heat was applied to the nondominant arm. The findings highlight the effect of heat on cortical excitability and provide insights into the application of altTS in stroke rehabilitation.

Age related changes of the motor excitabilities and central and peripheral muscle strength.

INTRODUCTION: The purpose was to investigate the age effects on central versus peripheral sources of strength, fatigue, and central neural excitabilities. METHODS: 42 healthy subjects were recruited as young group (23.73 ±â€¯2.15 years; n = 26) and middle-aged group (57.25 ±â€¯4.57 years; n = 16). Maximum voluntary contraction force (MVC), voluntary activation level (VA), and twitch force of quadriceps were evaluated to represent general, central, and peripheral strengths. Central and peripheral fatigue indexes were evaluated using femoral nerve electrical stimulation. Cortical excitabilities were evaluated using transcranial magnetic stimulation (TMS). RESULTS: The middle-aged group had lower MVC and twitch force of quadriceps, but not VA, than young group. No between group differences were found in fatigue indexes. The cortical excitability in middle-aged group was different from young group in paired TMS with inter-stimulus interval of 7 ms. CONCLUSION: The age-related strength loss at early stage was primarily caused by peripheral muscular strength. The deviation of central neural excitability can be detected but the activation level was not impaired in middle-age adults.

Effects of the hybrid of neuromuscular electrical stimulation and noxious thermal stimulation on upper extremity motor recovery in patients with stroke: a randomized controlled trial.

BACKGROUND: Neuromuscular electrical stimulation (NMES) and noxious thermal stimulation (NTS) have been developed and incorporated in stroke rehabilitation. OBJECTIVE: This study aimed to compare the effects of NMES, NTS, and the hybrid of NMES and NTS ("Hybrid") on motor recovery of upper extremity (UE) for patients with stroke. METHODS: We conducted a prospective, single-blind randomized controlled trial with concealed allocation. Forty-three patients with chronic stroke (onset >6 months) were randomly assigned to three groups (NMES, NTS, and "Hybrid"). In addition to conventional rehabilitation, participants received 30 min of NMES or 30 min of NTS or 15 min of NTS followed by 15 min of NMES. The treatment period was 8 weeks, 3 days/week, 30 min/time. The UE subscale of Fugl-Meyer assessment (UE-FMA, the primary outcome), Motricity index, modified Ashworth scale, and Barthel index were administered by a blinded assessor at baseline, posttreatment, and one-month follow-up. RESULTS: Most of the participants had mild-to-moderate disability in activity of daily living. No significant differences in the outcome measures at posttreatment and one-month follow-up were found among the NMES group (n = 13), NTS group (n = 13), and the hybrid of NMES and NTS group (n = 17). However, significant score changes in UE-FMA (p < 0.025) from baseline to posttreatment and one-month follow-up were found for the "Hybrid" group. CONCLUSIONS: This study reveals that the hybrid of NMES and NTS therapy appears to be beneficial to UE recovery after stroke but is not superior to NMES or NTS alone.

Validity and reliability of the Traditional Chinese version of the Multidimensional Fatigue Inventory in general population.

BACKGROUND: Fatigue is a common symptom in the general population and has a substantial effect on individuals' quality of life. The Multidimensional Fatigue Inventory (MFI) has been widely used to quantify the impact of fatigue, but no Traditional Chinese translation has yet been validated. The goal of this study was to translate the MFI from English into Traditional Chinese ('the MFI-TC') and subsequently to examine its validity and reliability. METHODS: The study recruited a convenience sample of 123 people from various age groups in Taiwan. The MFI was examined using a two-step process: (1) translation and back-translation of the instrument; and (2) examination of construct validity, convergent validity, internal consistency, test-retest reliability, and measurement error. The validity and reliability of the MFI-TC were assessed by factor analysis, Spearman rho correlation coefficient, Cronbach's alpha coefficient, intraclass correlation coefficient (ICC), minimal detectable change (MDC), and Bland-Altman analysis. All participants completed the Short-Form-36 Health Survey Taiwan Form (SF-36-T) and the Chinese version of the Pittsburgh Sleep Quality Index (PSQI) concurrently to test the convergent validity of the MFI-TC. Test-retest reliability was assessed by readministration of the MFI-TC after a 1-week interval. RESULTS: Factor analysis confirmed the four dimensions of fatigue: general/physical fatigue, reduced activity, reduced motivation, and mental fatigue. A four-factor model was extracted, combining general fatigue and physical fatigue as one factor. The results demonstrated moderate convergent validity when correlating fatigue (MFI-TC) with quality of life (SF-36-T) and sleep disturbances (PSQI) (Spearman's rho = 0.68 and 0.47, respectively). Cronbach's alpha for the MFI-TC total scale and subscales ranged from 0.73 (mental fatigue subscale) to 0.92 (MFI-TC total scale). ICCs ranged from 0.85 (reduced motivation) to 0.94 (MFI-TC total scale), and the MDC ranged from 2.33 points (mental fatigue) to 9.5 points (MFI-TC total scale). The Bland-Altman analyses showed no significant systematic bias between the repeated assessments. CONCLUSIONS: The results support the use of the Traditional Chinese version of the MFI as a comprehensive instrument for measuring specific aspects of fatigue. Clinicians and researchers should consider interpreting general fatigue and physical fatigue as one subscale when measuring fatigue in Traditional Chinese-speaking populations.

No Difference Between Noxious and Innocuous Thermal Stimulation on Motor Recovery of Upper Extremity in Patients With Acute Stroke: A Randomized Controlled Trial With 6-Month Follow-up.

BACKGROUND: Thermal stimulation (TS) has been developed and incorporated into stroke rehabilitation. However, whether noxious and innocuous TS induce the same effects on motor function recovery after stroke is still unknown. A comparative study of different temperature combination regimens is needed. OBJECTIVE: To compare the short- and long-term effectiveness between noxious and innocuous TS on motor recovery of upper extremity in patients with acute stroke. DESIGN: Randomized, controlled trial with concealed allocation, intention-to-treat analysis and blinded outcome assessors. SETTING: A university hospital rehabilitation department in Taiwan. PARTICIPANTS: A total of 79 patients with acute ischemic stroke were recruited. The majority had moderate to severe motor impairment of the upper extremity (UE). INTERVENTION: In addition to traditional rehabilitation, the experimental group (n = 39) underwent noxious TS (heat pain 46-47°C/cold pain 7-8°C), and the control group (n = 40) received innocuous TS (heat 40-41°C/cold 20-21°C). TS intervention was applied for 30 minutes once per day and for a total of 20-24 times during hospital stay. A custom-made TS instrument, comprising 2 thermal stimulators and their respective thermal pads constructed in a closed-loop system, was used. OUTCOMES: The Fugl-Meyer upper extremity score (the primary outcome), Action Research Arm Test, Motricity Index, Barthel Index, and modified Ashworth scale (the secondary outcomes) were administered by a blinded assessor at baseline, post-12th TS, post-intervention, 1-month, and 6-month follow-ups. RESULTS: No significant differences between groups were found on the primary outcome at postintervention and follow-up assessments. At 1-month follow-up, the innocuous group showed a small effect (partial η2 = 0.02) that was greater than that of the noxious group, but that effect was eliminated at 6 months. Both groups presented significant within-group improvements over time (both P < .001). CONCLUSIONS: Combining noxious TS with traditional rehabilitation did not yield better short-term or long-term results than combining innocuous TS with traditional rehabilitation on UE functional recovery for individuals with acute stroke. LEVEL OF EVIDENCE: II.

A psychometric evaluation of the Chinese version of the nursing home survey on patient safety culture.

AIMS AND OBJECTIVES: To test the psychometric properties of the Chinese version of the Nursing Home Survey on Patient Safety Culture scale among staff in long-term care facilities. BACKGROUND: The Nursing Home Survey on Patient Safety Culture scale is a standard tool for safety culture assessment in nursing homes. Extending its application to different types of long-term care facilities and varied ethnic populations is worth pursuing. DESIGN: A national random survey. METHODS: A total of 306 managers and staff completed the Chinese version of the Nursing Home Survey on Patient Safety Culture scale among 30 long-term care facilities in Taiwan. Content validity and construct validity were tested by content validity index (CVI) and principal axis factor analysis (PAF) with Promax rotation. Concurrent validity was tested through correlations between the scale and two overall rating items. Reliability was computed by intraclass correlation coefficient and Cronbach's α coefficients. Statistical analyses such as descriptive, Pearson's and Spearman's rho correlations and PAF were completed. RESULTS: Scale-level and item-level CVIs (0.91-0.98) of the Chinese version of the Nursing Home Survey on Patient Safety Culture scale were satisfactory. Four-factor construct and merged item composition differed from the Nursing Home Survey on Patient Safety Culture scale, and it accounted for 53% of variance. Concurrent validity was evident by existing positive correlations between the scale and two overall ratings of resident safety. Cronbach's α coefficients of the subscales and the Chinese version of the Nursing Home Survey on Patient Safety Culture scale ranged from .76-.94. CONCLUSIONS: The Chinese version of the Nursing Home Survey on Patient Safety Culture scale identified essential dimensions to reflect the important features of a patient safety culture in long-term care facilities. The researchers introduced the Chinese version of the Nursing Home Survey on Patient Safety Culture for safety culture assessment in long-term care facilities, but further testing of the reliability of the scale in a large Chinese sample and in different long-term care facilities was recommended. RELEVANCE TO CLINICAL PRACTICE: The Chinese version of the Nursing Home Survey on Patient Safety Culture scale was developed to increase the users' intention towards safety culture assessment. It can identify areas for improvement, understand safety culture changes over time and evaluate the effectiveness of interventions.

Accuracy of Wristband Activity Monitors during Ambulation and Activities.

PURPOSE: The main purpose of this study was to examine the accuracy of wristband activity monitors on measuring step counts at prescribed speeds on a treadmill and under short bouts of common daily activities. METHODS: Thirty healthy young adults wore three wristband activity monitors on both wrists while walking or jogging on a treadmill at different speeds (54, 80, 107, and 134 m·min) and performing six different common daily activities for 5 min each. The monitors included the Fitbit Flex, the Garmin Vivofit, and the Jawbone UP. The common daily activity conditions included two sitting activities (playing a tablet computer game and folding laundry), two walking activities (pushing a stroller, carrying a bag), and two stair climbing activities (down and up). Absolute percentage error (APE) scores were computed to examine the accuracy between actual observed steps and monitor-detected steps. RESULTS: Under the treadmill condition, the APE ranged between 1.5% and 9.6%. Accuracy was improved at faster speeds (134 m·min) for all the monitors (APE < 2.5%). In the common daily activity conditions, substantial step counts were registered when folding laundry. All monitors significantly underestimated actual steps (all APE >33%) when pushing a stroller. Higher APE was observed when worn on the dominant wrist under the common daily activity conditions. CONCLUSIONS: The wristband activity monitors examined were more accurate for measuring step counts between 80 and 134 m·min as compared with a slower speed. Accuracy under each common daily activity condition ranged widely between monitors and activity, with less error when worn on the nondominant wrist. These results will help to inform researchers on the use and accuracy of wristband activity monitors for future studies.

Cardiopulmonary Function, Exercise Capacity, and Echocardiography Finding of Pediatric Patients With Kawasaki Disease: An Observational Study.

Coronary artery (CA) abnormalities influence exercise capacity (EC) of patients with Kawasaki disease (KD), and Z-score of CA is a well established method for detecting CA aneurysm. We studied the influence of KD on cardiopulmonary function and EC; meanwhile we analyzed echocardiographic findings of KD patients. We also assessed the correlation between CA Z-score and EC of KD patients to see if CA Z-score of KD patients could reflect EC during exercise.Sixty-three KD patients were recruited as KD group 1 from children (aged 5-18 y) who received transthoracic echocardiographic examinations and symptom-limited treadmill exercise test for regular follow-up of KD from January 2010 to October 2014 in 1 medical center. We then divided KD group 1 into KD group 2 (<5 y, n = 12) and KD group 3 (≥5 y, n = 51) according to time interval between KD onset to when patients received test. Control groups were matched by age, sex, and body mass index. Max-Z of CA was defined as the maximal Z-score of the proximal LCA or RCA by Dalliarre equation or Fuse calculator.All routine parameters measured during standard exercise test were similar between KD and control groups, except that peak rate pressure products (PRPPs) in KD group 1 to 3 were all lower than corresponding control groups significantly (P = 0.010, 0.020, and 0.049, respectively). PRPPs correlated with Max-Z of CA by both equations modest inversely (by Dallaire, P = 0.017, Spearman rho = -0.301; by Fuse, P = 0.014, Spearman rho = -0.309).Our study recruited larger number of KD patients and provided a newer data of EC of KD patients. Our finding suggests that after acute stage of KD, patients could maintain normal cardiorespiratory fitness. Therefore, we believe that it is important to promote cardiovascular health to KD patients and KD patients should exercise as normal peers. However, since KD patients might still have compromised coronary perfusion during exercise, it remains crucial to assess and monitor cardiovascular risk of KD patients. Max-Z of CA correlates with PRPP modest inversely and might be used as a follow-up indicator of CA reserve during exercise after acute stage of KD.

Restoration of Central Programmed Movement Pattern by Temporal Electrical Stimulation-Assisted Training in Patients with Spinal Cerebellar Atrophy.

Disrupted triphasic electromyography (EMG) patterns of agonist and antagonist muscle pairs during fast goal-directed movements have been found in patients with hypermetria. Since peripheral electrical stimulation (ES) and motor training may modulate motor cortical excitability through plasticity mechanisms, we aimed to investigate whether temporal ES-assisted movement training could influence premovement cortical excitability and alleviate hypermetria in patients with spinal cerebellar ataxia (SCA). The EMG of the agonist extensor carpi radialis muscle and antagonist flexor carpi radialis muscle, premovement motor evoked potentials (MEPs) of the flexor carpi radialis muscle, and the constant and variable errors of movements were assessed before and after 4 weeks of ES-assisted fast goal-directed wrist extension training in the training group and of general health education in the control group. After training, the premovement MEPs of the antagonist muscle were facilitated at 50 ms before the onset of movement. In addition, the EMG onset latency of the antagonist muscle shifted earlier and the constant error decreased significantly. In summary, temporal ES-assisted training alleviated hypermetria by restoring antagonist premovement and temporal triphasic EMG patterns in SCA patients. This technique may be applied to treat hypermetria in cerebellar disorders. (This trial is registered with NCT01983670.).

Cycling regimen induces spinal circuitry plasticity and improves leg muscle coordination in individuals with spinocerebellar ataxia.

OBJECTIVES: To compare the reciprocal control of agonist and antagonist muscles in individuals with and without spinocerebellar ataxia (SCA) and to evaluate the effect of a 4-week leg cycling regimen on functional coordination and reciprocal control of agonist and antagonist muscles in patients with SCA. DESIGN: Randomized controlled trial with repeated measures. SETTING: Research laboratory in a general hospital. PARTICIPANTS: Individuals with SCA (n=20) and without SCA (n=20). INTERVENTIONS: A single 15-minute session of leg cycling and a 4-week cycling regimen. MAIN OUTCOME MEASURES: Individuals with SCA (n=20) and without SCA (n=20) underwent disynaptic reciprocal inhibition and D1 inhibition tests of the soleus muscles before and after a single 15-minute cycling session. Individuals with SCA were randomly assigned to either participate in 4 weeks of cycling training (n=10) or to receive no training (n=10). The disynaptic reciprocal inhibition and D1 inhibition and International Cooperative Ataxia Rating Scale (ICARS) scores were evaluated in both groups after 4 weeks. RESULTS: Individuals with SCA showed abnormally strong resting values of disynaptic reciprocal inhibition and D1 inhibition (P<.001) and impaired inhibition modulation capacity after a single 15-minute session of cycling (P<.001). The inhibition modulation capacity was restored (P<.001), and the ICARS scores improved significantly (pre: 13.5±9.81, post: 11.3±8.74; P=.046) after 4 weeks of cycling training. CONCLUSIONS: A 4-week cycling regimen can normalize the modulation of reciprocal inhibition and functional performance in individuals with SCA. These findings are applicable to the coordination training of patients.

Neuromuscular electrical stimulation of the median nerve facilitates low motor cortex excitability in patients with spinocerebellar ataxia.

The neuromodulation of motor excitability has been shown to improve functional movement in people with central nervous system damage. This study aimed to investigate the mechanism of peripheral neuromuscular electrical stimulation (NMES) in motor excitability and its effects in people with spinocerebellar ataxia (SCA). This single-blind case-control study was conducted on young control (n=9), age-matched control (n=9), and SCA participants (n=9; 7 SCAIII and 2 sporadic). All participants received an accumulated 30 min of NMES (25 Hz, 800 ms on/800 ms off) of the median nerve. The central motor excitability, measured by motor evoked potential (MEP) and silent period, and the peripheral motor excitability, measured by the H-reflex and M-wave, were recorded in flexor carpi radialis (FCR) muscle before, during, and after the NMES was applied. The results showed that NMES significantly enhanced the MEP in all 3 groups. The silent period, H-reflex and maximum M-wave were not changed by NMES. We conclude that NMES enhances low motor excitability in patients with SCA and that the mechanism of the neuromodulation was supra-segmental. These findings are potentially relevant to the utilization of NMES for preparation of motor excitability. The protocol was registered at Clinicaltrials.gov (NCT02103075).

Effect of thermal stimulation on corticomotor excitability in patients with stroke.

OBJECTIVE: This study examined the immediate effects of noxious and innocuous thermal stimulation intervention on corticomotor excitability for the paretic arm in patients with stroke. DESIGN: Sixteen patients with stroke for more than 3 mos were randomly assigned into the experimental and control groups. All participants received the thermal stimulation protocol on the affected arm for 30 mins. The experimental group received noxious heat (46°C-47°C) and cold (7°C-8°C) stimuli, and the control group received innocuous heat (40°C-41°C) and cold (20°C-21°C) stimuli. Corticomotor excitability was assessed to measure the motor threshold, size of cortical motor output map, and mean motor evoked potentials for the abductor pollicis brevis by focal transcranial magnetic stimulation before and after 30 mins of thermal stimulation intervention program. RESULTS: The findings of transcranial magnetic stimulation revealed a significant increase in map size of the affected hemisphere and mean motor evoked potentials in the experimental group. Moreover, significant differences in the change values of map size (7.0 [7.9] for the experimental group vs. -1.7 [2.9] for the control group, P = 0.03) and mean (SD) motor evoked potentials (0.4 [8.9] mV for the experimental group vs. -0.1 [0.1] mV for the control group, P = 0.03) were found. CONCLUSIONS: The preliminary results suggest that the noxious 30 mins of thermal stimulation intervention induced neurophysiologic changes in the motor cortex of the lesioned hemisphere.

Effect of biofeedback cycling training on functional recovery and walking ability of lower extremity in patients with stroke.

This study aimed to investigate the effectiveness of biofeedback cycling training on lower limb functional recovery, walking endurance, and walking speed for patients with chronic stroke. Thirty-one patients with stroke (stroke onset >3 months) were randomly assigned into two groups using a crossover design. One group (N = 16; mean: 53.6 ± 10.3 years) underwent conventional rehabilitation and cycling training (30 minutes/time, 5 times per week for 4 weeks), followed by only conventional rehabilitation for another 4 weeks. The other group (N = 15; mean: 54.5 ± 8.0 years) underwent the same training in reverse order. The bike used in this biofeedback cycling training was the MOTOmed viva2 Movement Trainer. Outcome measures included the lower extremity subscale of Fugl-Meyer assessment (LE-FMA), the 6-minute walk test (6MWT), the 10-meter walk test (10MWT), and the modified Ashworth scale (MAS). All participants were assessed at the beginning of the study, at the end of the 4(th) week, and at the end of the 8(th) week. Thirty participants completed the study, including the cycling training interventions and all assessments. The results showed that improvements in the period with cycling training were significantly better than the noncycling period in the LE-FMA (p < 0.05), 6MWT (p < 0.001), 10MWT (p < 0.001), and MAS (p < 0.001) scores. No significant carryover effects were observed. The improvements on outcome measures were significantly different between the cycling period and the noncycling period after adjusting for potential confounding factors in the multivariate analysis of variance (p < 0.001). The study result indicates that the additional 4-week biofeedback cycling training could lead to improved LE functional recovery, walking endurance, and speed for patients with chronic stroke.