Transcutaneous Auricular Vagus Nerve Stimulation (tAVNS) Delivered During Upper Limb Interactive Robotic Training Demonstrates Novel Antagonist Control for Reaching Movements Following Stroke.

Implanted vagus nerve stimulation (VNS) delivered concurrently with upper limb rehabilitation has been shown to improve arm function after stroke. Transcutaneous auricular VNS (taVNS) offers a non-invasive alternative to implanted VNS and may provide similar therapeutic benefit. There is much discussion about the optimal approach for combining VNS and physical therapy, as such we sought to determine whether taVNS administered during robotic training, specifically delivered during the premotor planning stage for arm extension movements, would confer additional motor improvement in patients with chronic stroke. Thirty-six patients with chronic, moderate-severe upper limb hemiparesis (>6 months; mean Upper Extremity Fugl-Meyer score = 25 ± 2, range 13-48), were randomized to receive 9 sessions (1 h in length, 3x/week for 3 weeks) of active (N = 18) or sham (N = 18) taVNS (500 ms bursts, frequency 30 Hz, pulse width 0.3 ms, max intensity 5 mA, ∼250 stimulated movements per session) delivered during robotic training. taVNS was triggered by the onset of a visual cue prior to center-out arm extension movements. Clinical assessments and surface electromyography (sEMG) measures of the biceps and triceps brachii were collected during separate test sessions. Significant motor improvements were measured for both the active and sham taVNS groups, and these improvements were robust at 3 month follow-up. Compared to the sham group, the active taVNS group showed a significant reduction in spasticity of the wrist and hand at discharge (Modified Tardieu Scale; taVNS = -8.94% vs. sham = + 2.97%, p < 0.05). The EMG results also demonstrated significantly increased variance for the bicep peak sEMG amplitude during extension for the active taVNS group compared to the sham group at discharge (active = 26.29% MVC ± 3.89, sham = 10.63% MVC ± 3.10, mean absolute change admission to discharge, p < 0.01), and at 3-month follow-up, the bicep peak sEMG amplitude was significantly reduced in the active taVNS group (P < 0.05). Thus, robot training improved the motor capacity of both groups, and taVNS, decreased spasticity. taVNS administered during premotor planning of movement may play a role in improving coordinated activation of the agonist-antagonist upper arm muscle groups by mitigating spasticity and increasing motor control following stroke. Clinical Trial Registration: www.ClinicalTrials.gov, identifier (NCT03592745).

Non-invasive treatment of patients with upper extremity spasticity following stroke using paired trans-spinal and peripheral direct current stimulation.

BACKGROUND: Muscle spasticity is a common impediment to motor recovery in patients with chronic stroke. Standard-of-care treatments such as botulinum toxin injections can temporarily relieve muscle stiffness and pain associated with spasticity, but often at the expense of increased muscle weakness. Recent preclinical investigations of a non-invasive treatment that pairs trans-spinal direct current stimulation and peripheral nerve direct current stimulation (tsDCS+pDCS) provided promising data for a novel approach based on bioelectronic medicine for the treatment of patients with post-stroke spasticity. METHODS: Twenty-six patients with upper limb hemiparesis and wrist spasticity at least 6 months after their initial stroke participated in this single-blind crossover design study to test whether tsDCS+pDCS reduces chronic upper-extremity spasticity. Subjects received five consecutive daily sessions (20 min of stimulation or sham) of anodal tsDCS+pDCS, separated by a one-week washout period. The sham condition always preceded the active condition. Clinical and objective measures of spasticity and motor function were collected before and after each condition, and for five weeks after the completion of the active intervention. RESULTS: Subjects treated with active tsDCS+pDCS demonstrated significant reductions in both Modified Tardieu Scale scores (summed across the upper limb, P < 0.05), and in objective torque measures (Nm) of the spastic catch response at the wrist flexor (P < 0.05), compared to the sham condition. Motor function also improved significantly (measured by the Fugl-Meyer and Wolf Motor Function Test; P < 0.05 for both tests) after active treatment. CONCLUSIONS: tsDCS+pDCS intervention alone significantly reduced upper limb spasticity in participants with stroke. Decreased spasticity was persistent for five weeks after treatment, and was accompanied by improved motor function even though patients were unsupervised and there was no prescribed activity or training during that interval. TRIAL REGISTRATION: NCT03080454, March 15, 2017.

Intensive seated robotic training of the ankle in patients with chronic stroke differentially improves gait.

BACKGROUND: Robotic driven treatment plans targeting isolated joints of the upper limb have improved the sensorimotor condition of patients with stroke. Similar intensive efforts to allay lower limb gait impairment have not been so successful. In patients with stroke, targeted robot assisted training of the ankle joint, in a seated position, has demonstrated significant alterations in ankle stiffness and foot-ankle orientation at foot strike which may provide a new treatment option for gait impairment. OBJECTIVE: To determine if isolated robot-assisted training of the ankle joint improves chronic hemiparetic gait in patients with stroke who are categorized according to baseline gait impairment. METHODS: Patients with chronic stroke (>6mo) and hemiparetic gait (N = 29) received 18 sessions of isolated robot-assisted motor training of the ankle (3×/week for 6 weeks). All participants had stable clinical baseline scores across three admission measures, and no participant was receiving simultaneous outpatient rehabilitation. Baseline gait speed determined three impairment groups: high, >0.8 m/s; medium, 0.4-0.8 m/s; low, <0.4 m/s. Outcome measures included the Berg Balance Scale, the 6 Minute Walk Test, and the 10 Meter Walk Test, and were recorded upon admission, discharge, and 3 months following intervention. RESULTS: Three distinct and significant between-group patterns of recovery emerged for gait speed. The within-group analysis showed that the medium and high group exhibited significant improvements in gait speed and endurance upon discharge, that were maintained at 3-months. Gait speed improvements were clinically significant (>0.16 m/s) for the high function group across all gait speed and endurance measures at discharge and at 3 months. The moderate group also exhibited clinically significant improvements at follow-up on the 10 Meter Walk Test, fast pace (0.16 m/sec), and approached clinical significance for the 10 Meter Walk comfortable pace (0.12 m/sec). The low group had small but significant improvements, at discharge on two of the three gait measures, and these improvements were maintained at 3 months. For balance measures, the low and moderate impairment groups had significant improvements at discharge that were robust on follow-up measure. The high function group demonstrated no significant change in balance. CONCLUSIONS: Joint-specific robotic training of the paretic ankle provided the most benefit to individuals with moderate or mild gait speed impairments after stroke. Baseline gait speed function (low, moderate, high) was associated with three distinct recovery profiles. This suggests that severity-specific intervention may be critical to improving efficiency of stroke recovery.

Evaluation of acupuncture for cancer symptoms in a cancer institute in Brazil.

INTRODUCTION: Acupuncture has been progressively included in the practice of mainstream medicine in recent decades. The State of Sao Paulo Cancer Institute is a public hospital established in 2008 and its acupuncture service follows the experience and model of several oncology centres in the USA, aiming to optimise the treatment of symptoms such as postoperative pain, oncological pain, neuropathic pain, nausea, vomiting, xerostomia and fatigue induced by chemotherapy. This paper describes the population given acupuncture treatment and the effects of the intervention on symptom management. METHODS: One hundred and eighty-three patients from our service were enrolled in the study. Baseline and final symptom intensity was recorded using a visual analogue score (VAS) ranging from 0 to 10 cm, with a higher score meaning higher symptom intensity. RESULTS: Fifty-four (29.50%) were receiving active treatment with chemotherapy and/or radiotherapy, 29 (15.85%) were receiving hormone therapy and 100 (54.65%) were considered to be in remission. The main symptoms were: oncological pain in 44 (24.04%), chemotoxicity in 34 (18.6%), lumbar pain in 53 (28.96%) and chronic postoperative pain in 54 (28.4%). The mean (SD) initial symptom score was 7.04 (1.8), which was reduced to 2.56 (2.75) after treatment (p<0.001), an improvement of 63.6% in control of the symptoms. Further analysis of the data showed that the effect was similar in different indications for acupuncture treatment. CONCLUSIONS: Use of acupuncture may have improved symptom control in patients enrolled in this study.