Clinical application of repetitive transcranial magnetic stimulation in improving functional impairments post-stroke: review of the current evidence and potential challenges.

In recent years, the stroke incidence has been increasing year by year, and the related sequelae after stroke, such as cognitive impairment, motor dysfunction, and post-stroke depression, seriously affect the patient's rehabilitation and daily activities. Repetitive transcranial magnetic stimulation (rTMS), as a safe, non-invasive, and effective new rehabilitation method, has been widely recognized in clinical practice. This article reviews the application and research progress of rTMS in treating different functional impairments (cognitive impairment, motor dysfunction, unilateral spatial neglect, depression) after stroke in recent years, and preliminary summarized the possible mechanisms. It has been found that the key parameters that determine the effectiveness of rTMS in improving post-stroke functional impairments include pulse number, stimulated brain areas, stimulation intensity and frequency, as well as duration. Generally, high-frequency stimulation is used to excite the ipsilateral cerebral cortex, while low-frequency stimulation is used to inhibit the contralateral cerebral cortex, thus achieving a balance of excitability between the two hemispheres. However, the specific mechanisms and the optimal stimulation mode for different functional impairments have not yet reached a consistent conclusion, and more research is needed to explore and clarify the best way to use rTMS. Furthermore, we will identify the issues and challenges in the current research, explore possible mechanisms to deepen understanding of rTMS, propose future research directions, and offer insightful insights for better clinical applications.

A systematic review of vestibular stimulation in post-stroke visual neglect.

Unilateral visual neglect is a condition that negatively impacts the lives of many stroke survivors. Studies have investigated different forms of vestibular stimulation as a potential therapy, but evidence is yet to be systematically reviewed. We therefore reviewed the effects of vestibular stimulation on outcomes of neglect and activities of daily living (ADL) for people with visual neglect. We searched relevant databases up until September 2022. Eligible articles included any form of vestibular stimulation, study design, or control condition. Included participants were 18 years or older, presenting with neglect following a haemorrhagic or ischaemic stroke. Relevant outcomes were clinically validated measures of neglect and ADL. Cochrane risk of bias tools were used to assess study quality. Meta-analyses and narrative methods were used to synthesize the data. Our search returned 17 relevant studies comprising 180 participants. Meta-analyses showed no difference between galvanic vestibular stimulation and sham conditions on outcomes, whereas caloric vestibular stimulation led to improvement compared to pre-stimulation scores. Narrative syntheses showed mixed results. Clinical and methodological heterogeneity was found both within and between studies. Overall, results were inconsistent regarding the effects of vestibular stimulation as a treatment for neglect. Further trials are warranted but require more careful methodological planning.

Study of the Possibility of Using Virtual Reality Application in Rehabilitation among Elderly Post-Stroke Patients.

Thanks to medical advances, life expectancy is increasing. With it comes an increased incidence of diseases, of which age is a risk factor. Stroke is among these diseases, and is one of the causes of long-term disability. The opportunity to treat these patients is via rehabilitation. A promising new technology that can enhance rehabilitation is virtual reality (VR). However, this technology is not widely used by elderly patients, and, moreover, the elderly often do not use modern technology at all. It therefore becomes a legitimate question whether elderly people will be able to use virtual reality in rehabilitation. This article presents a rehabilitation application dedicated to patients with upper limb paresis and unilateral spatial neglect (USN). The application was tested on a group of 60 individuals including 30 post-stroke patients with an average age of 72.83 years. The results of the conducted study include a self-assessment by the patients, the physiotherapist's evaluation, as well as the patients' performance of the exercise in VR. The study showed that elderly post-stroke patients are able to use virtual reality applications, but the ability to correctly and fully perform an exercise in VR depends on several factors. One of them is the ability to make logical contact (p = 0.0001 < 0.05). However, the study presented here shows that the ability to use VR applications does not depend on age but on mental and physical condition, which gives hope that virtual reality applications can be used in post-stroke rehabilitation among patients of all ages.

An immersive virtual reality tool for assessing left and right unilateral spatial neglect.

The reported rate of the occurrence of unilateral spatial neglect (USN) is highly variable likely due to the lack of validity and low sensitivity of classical tools used to assess it. Virtual reality (VR) assessments try to overcome these limitations by proposing immersive and complex environments. Nevertheless, existing VR-based tasks are mostly focused only on near space and lack analysis of psychometric properties and/or clinical validation. The present study evaluates the clinical validity and sensitivity of a new immersive VR-based task to assess USN in the extra-personal space and examines the neuronal correlates of deficits of far space exploration. The task was administrated to two groups of patients with right (N = 28) or left (N = 11) hemispheric brain lesions, also undergoing classical paper-and-pencil assessment, as well as a group of healthy participants. Our VR-based task detected 44% of neglect cases compared to 31% by paper-and-pencil tests in the total sample. Importantly, 30% of the patients (with right or left brain lesions) with no clear sign of USN on the paper-and-pencil tests performed outside the normal range in the VR-based task. Voxel lesion-symptom mapping revealed that deficits detected in VR were associated with lesions in insular and temporal cortex, part of the neural network involved in spatial processing. These results show that our immersive VR-based task is efficient and sensitive in detecting mild to strong manifestations of USN affecting the extra-personal space, which may be undetected using standard tools.

Computer-Assisted Rehabilitation Shows Greater Efficacy Than Traditional in Visuospatial Skills and Cognition in Neglect Patients.

This study is crucial for improving unilateral spatial neglect (USN) treatments, focusing on comparing the effectiveness of computer-assisted cognitive rehabilitation (CACR) against conventional rehabilitation (CR) methods. It aimed to address a significant research gap and improve patient outcomes by evaluating the impact of CACR versus CR on visuospatial perception, visual field and attention, and visual memory in patients with USN. This study was a randomized controlled trial. Forty-five consecutive patients with USN from a university rehabilitation center were divided into two groups: 22 patients received CACR with Rehacom software, focusing on saccadic eye movement, visual field, and visual-motor coordination, while 23 underwent CR that combined hemispheric activation approach, mental imagery training, and vibration therapy. Assessments included the Motor-Free Visual Perception Test (MVPT), Line Bisection Test (LBT), Visual Span Test (VST), and Visual Recognition Test (VRT). The study employed ANCOVA and effect size calculations to evaluate the effectiveness of CACR compared to CR in treating patients with USN. Results indicated that CACR significantly outperformed CR in improving visuospatial perception, visual field, attention, and memory, showcasing its effectiveness in treating USN. These findings demonstrate the superiority of CACR over CR, particularly in enhancing visual memory and attention, as evidenced by the large effect size in VRT and moderate effects in LBT and VST. This suggests CACR's potential as a more effective approach for rehabilitation in patients with USN due to brain injuries.

Advancements in brain-computer interfaces for the rehabilitation of unilateral spatial neglect: a concise review.

This short review examines recent advancements in neurotechnologies within the context of managing unilateral spatial neglect (USN), a common condition following stroke. Despite the success of brain-computer interfaces (BCIs) in restoring motor function, there is a notable absence of effective BCI devices for treating cerebral visual impairments, a prevalent consequence of brain lesions that significantly hinders rehabilitation. This review analyzes current non-invasive BCIs and technological solutions dedicated to cognitive rehabilitation, with a focus on visuo-attentional disorders. We emphasize the need for further research into the use of BCIs for managing cognitive impairments and propose a new potential solution for USN rehabilitation, by combining the clinical subtleties of this syndrome with the technological advancements made in the field of neurotechnologies.

Barriers to patient recruitment in a poststroke neurorehabilitation multicenter trial in Brazil

There is a high demand for stroke rehabilitation in the Brazilian public health system, but most studies that have addressed rehabilitation for unilateral spatial neglect (USN) after stroke have been performed in high-income countries. Therefore, the aim of this study was to analyze USN patient recruitment in a multicenter noninvasive brain stimulation clinical trial performed in Brazil and to provide study design recommendations for future studies. We evaluated the reasons for exclusion of patients from a multicenter, randomized, double-blinded clinical trial of rehabilitation of USN patients after stroke. Clinical and demographic variables were compared between the included and excluded patients. A descriptive statistical analysis was performed. Only 173 of the 1953 potential neglect patients (8.8%) passed the initial screening. After screening evaluation, 87/173 patients (50.3%) were excluded for clinical reasons. Cognitive impairment led to the exclusion of 21/87 patients (24.1%). Low socioeconomic status led to the exclusion of 37/173 patients (21.4%). Difficulty obtaining transportation to access treatment was the most common reason for their exclusion (16/37 patients, 43.3%). The analyzed Brazilian institutions have potential for conducting studies of USN. The recruitment of stroke survivors with USN was restricted by the study design and limited financial support. A history of cognitive impairment, intracranial stenting or craniectomy, and lack of transportation were the most common barriers to participating in a multicenter noninvasive brain stimulation trial among patients with USN after stroke.

Norm scores of cancelation and bisection tests for unilateral spatial neglect: data from a Brazilian population

OBJECTIVE: Unilateral spatial neglect (USN) results in a consistent and exaggerated spatial asymmetry in the processing of information about the body or space due to an acquired brain injury. There are several USN tests for clinical diagnosis, but none of them are validated in Brazil. The aim was to obtain normative values from a healthy sample in Brazil and to evaluate the effects of demographic variables on USN tests. METHODS: This was a cross-sectional study performed with 150 neurologically healthy individuals. USN was evaluated using the line cancelation (LC), star cancelation (SC), and line bisection (LB) tests in the A3 (29.7 x 42.0 cm) sheet format. RESULTS: In LC, 143 participants had 0 omissions, and the occurrence of failure was significantly associated with aging (OR=1.1[1.02-1.2]; p=0.012). In SC, 145 participants had fewer than 1 omission, and the occurrence of failure was significantly associated with aging (OR=1.07[1.03-1.11]; p<0.001). In LB, deviations were the lowest for those with the highest level of education (r=0.20; p=0.015), and the deviation was 9.5 mm. CONCLUSION: The cutoff points presented in this study may be indicative of USN, but due to performance differences based on age, we suggest using different norm scores for different age groups. These norm scores can be used in the clinic immediately for USN diagnosis.

Validation of the Catherine Bergego Scale in patients with unilateral spatial neglect after stroke / Validação da Escala Catherine Bergego em pacientes com negligência espacial unilateral após acidente vascular cerebral

ABSTRACT: The Catherine Bergego Scale (CBS) is a scale to evaluates the impact of unilateral spatial neglect (USN) on everyday life of patients after stroke. Objective: The aim of this study was to evaluate the reliability and comprehension of the Portuguese version of the CBS for patients with USN after stroke. Methods: This was a cross-sectional study in patients with stroke and USN. The CBS was translated, culturally adapted and applied by two independent investigators. The patients were also evaluated by the Behavioural Inattention Test (BIT), NIHSS, mRS and Barthel scale to assess USN severity, neurological function, disability and autonomy consecutively. Consistency and coherence were analysed using Cronbach's α, inter-observer reliability by Kappa, and the correlation between the CBS, BIT, NIHSS, mRS, and Barthel was determined using Pearson correlation. Results: Twenty-two patients were evaluated and the observed Cronbach's α=0.913. For intra-observer reproducibility, the 10 items showed a reasonable and high reliability between evaluators. The CBS showed a negative correlation with the BIT. There was a low correlation between the BIT and NIHSS, mRS and Barthel index. Conclusion: The CBS is an adequate and validated scale for assessing patients with USN after stroke in a Brazilian population.

RESUMO: A Escala de Catherine Bergego (CBS) é uma escala para avaliar o impacto da negligência espacial unilateral (USN) no cotidiano de pacientes após AVC. Objetivo: Não há validação da CBS para população brasileira e o objetivo deste estudo foi avaliar a confiabilidade e compreensão da versão em português da CBS para pacientes com USN após AVC. Métodos: Trata-se de um estudo transversal em pacientes com AVC e USN. A CBS foi traduzida, adaptada culturalmente e aplicada por dois investigadores independentes. Os pacientes também foram avaliados pelo Behaviour Innatention Test (BIT), NIHSS, mRS e Barthel para avaliar a gravidade da USN, função neurológica, incapacidade e autonomia consecutivamente. A consistência e a coerência foram analisadas pelo coeficiente α de Cronbach, a confiabilidade interobservador foi avaliada pelo coeficiente kappa e a correlação entre o CBS, BIT, NIHSS, mRS e Barthel foi avaliada pela correlação de Pearson. Resultados: Vinte e dois pacientes foram avaliados e observaram-se consistência e coerência pelo coeficiente α de Cronbach=0,913. Na análise da reprodutibilidade intraobservador, os 10 itens da escala apresentaram confiabilidade razoável e alta entre os avaliadores. O CBS mostrou correlação negativa com o BIT. Houve baixa correlação entre BIT e NIHSS, mRS e índice de Barthel. Conclusão: A CBS é uma escala adequada e validada para avaliar pacientes com USN após AVC em uma população brasileira e de língua portuguesa.

Unilateral spatial neglect in the acute phase of ischemic stroke can predict long-term disability and functional capacity

OBJECTIVE: The aim of this study was to assess the relationship between the degree of unilateral spatial neglect during the acute phase of stroke and long-term functional independence. METHODS: This was a prospective study of right ischemic stroke patients in which the independent variable was the degree of spatial neglect and the outcome that was measured was functional independence. The potential confounding factors included sex, age, stroke severity, topography of the lesion, risk factors, glycemia and the treatment received. Unilateral spatial neglect was measured using the line cancellation test, the star cancellation test and the line bisection test within 48 hours of the onset of symptoms. Functional independence was measured using the modified Rankin and Barthel scales at 90 days after discharge. The relationship between unilateral spatial neglect and functional independence was analyzed using multiple logistic regression that was corrected for confounding factors. RESULTS: We studied 60 patients with a median age of 68 (34-89) years, 52% of whom were male and 74% of whom were Caucasian. The risk for moderate to severe disability increased with increasing star cancellation test scores (OR=1.14 [1.03-1.26], p=0.01) corrected for the stroke severity, which was a confounding factor that had a statistically positive association with disability (OR=1.63 [1.13-2.65], p=0.01). The best chance of functional independence decreased with increasing star cancellation test scores (OR=0.86 [0.78-0.96], p=0.006) corrected for the stroke severity, which was a confounding factor that had a statistically negative association with independence (OR=0.66 [0.48-0.92], p=0.017). CONCLUSION: The severity of unilateral spatial neglect in acute stroke worsens the degree of long-term disability and functional independence.

Reabilitação cognitiva à pessoa com acidente vascular cerebral: intervenção do enfermeiro especialista em enfermagem de reabilitação / Cognitive rehabilitation for people with stroke: intervention by the rehabilitation nurse

A mortalidade por Acidente Vascular Cerebral (AVC) no mundo e em Portugal, encontra-se em decréscimo nas últimas décadas. Contudo, a taxa de incidência tem apresentado um comportamento contrário. Do AVC decorrem alterações neurológicas, constituindo-se como um acontecimento crítico que despoleta no indivíduo/família, um processo de transição. As alterações da função cognitiva, apresentam impacto na funcionalidade, autonomia e qualidade de vida: provocam uma redução na eficiência do funcionamento, diminuição da performance nas Atividades da Vida Diária (AVD) e dificuldade de adaptação. A reabilitação cognitiva baseia-se na neuroplasticidade, ou seja, promove processos de reestruturação, investindo na capacidade do Sistema Nervoso Central em modificar-se e reorganizar-se a nível estrutural e funcional. Os cuidados do Enfermeiro Especialista em Enfermagem de Reabilitação (EEER) à pessoa com AVC, iniciam-se com uma avaliação neurológica sistematizada e criteriosa, para mensuração dos défices e dos ganhos em saúde obtidos através da implementação de programas de reabilitação que incluam a dimensão cognitiva. Estes planos de cuidados contemplam a execução de tarefas terapêuticas exercitadas repetidamente, relacionadas com o autocuidado e/ou direcionadas para o treino da função lesada. As estratégias de intervenção do EEER podem ser de reestruturação ou compensatórias e é a sua mobilização conjugada que torna o programa de reabilitação mais efetivo. Sobre a reabilitação cognitiva, não existem estudos que comprovem inequivocamente as vantagens e os ganhos em saúde e da funcionalidade da pessoa. No entanto, por não existir impacto negativo, devem ser implementados estes programas de reabilitação, porque haverá maior probabilidade de trazer algum benefício comparativamente com a não atuação. O Relatório de Estágio constitui-se como um instrumento metodológico, que sintetiza as aprendizagens e demonstra o desenvolvimento de competências comuns e específicas do EEER, através da descrição, análise e reflexão das atividades realizadas durante o Ensino Clínico, que decorreu em contexto hospitalar e comunitário.

Mortality from Stroke in the world and in Portugal has been decreasing in recent decades. However, the incidence rate has shown an opposite behavior. A stroke results in neurological changes, constituting a critical event that triggers a transition process in the individual/family. Changes in cognitive function have an impact on functionality, autonomy, and quality of life: it causes a reduction in functioning efficiency, decreased performance in Activities of Daily Living (ADL) and difficulty in adapting. Cognitive rehabilitation is based on neuroplasticity, which promotes restructuring processes, investing in the ability of the Central Nervous System to modify and reorganize itself at a structural and functional level. The care provided by the Nurse Specialist in Rehabilitation Nursing (EEER) to the person with stroke begins with a systematic and careful neurological assessment, to measure the deficits and health gains obtained through the implementation of rehabilitation programs that include the cognitive dimension. These care plans contemplate the execution of therapeutic tasks exercised repeatedly, related to self-care and/or directed to the training of the injured function. The EEER intervention strategies can be restructuring or compensatory and it is their combined mobilization that makes the rehabilitation program more effective. About cognitive rehabilitation, there are no studies that unequivocally prove the advantages and gains in health and functionality of the person. However, as there is no negative impact, these rehabilitation programs should be implemented, as they will be more likely to bring some benefit compared to not acting. This report is a methodological instrument, which summarizes the learning and demonstrates the development of common and specific competences of the RNS, through the description, analysis and reflection of the activities carried out during the internships, which took place in a hospital and community context.

Standardization of the face-hand test in a Brazilian multicultural population: prevalence of sensory extinction and implications for neurological diagnosis

OBJECTIVE: The face-hand test is a simple, practical, and rapid test to detect neurological syndromes. However, it has not previously been assessed in a Brazilian sample; therefore, the objective of the present study was to standardize the face-hand test for use in the multi-cultural population of Brazil and identify the sociodemographic factors affecting the results. METHODS: This was a cross sectional study of 150 individuals. The sociodemographic variables that were collected included age, gender, race, body mass index and years of education. Standardization of the face-hand test occurred in 2 rounds of 10 sensory stimuli, with the participant seated to support the trunk and their vision obstructed in a sound-controlled environment. The face-hand test was conducted by applying 2 rounds of 10 sensory stimuli that were applied to the face and hand simultaneously. The associations between the face-hand test and sociodemographic variables were analyzed using Mann-Whitney tests and Spearman correlations. Binomial models were adjusted for the number of face-hand test variations, and ROC curves evaluated sensitivity and specificity of sensory extinction. RESULTS: There was no significant relationship between the sociodemographic variables and the number of stimuli perceived for the face-hand test. There was a high relative frequency of detection, 8 out of 10 stimuli, in this population. Sensory extinction was 25.3%, which increased with increasing age (OR=1.4[1:01–1:07]; p=0.006) and decreased significantly with increasing education (OR=0.82[0.71-0.94]; p=0.005). CONCLUSION: In the Brazilian population, a normal face-hand test score ranges between 8–10 stimuli, and the results indicate that sensory extinction is associated with increased age and lower levels of education.