Efficacy of Tape Feedback Therapy on Synkinesis Following Severe Peripheral Facial Nerve Palsy.

BACKGROUND: Mirror feedback rehabilitation is effective in preventing the development of oro-ocular synkinesis following severe facial palsy. However, we do not have effective maneuvers to prevent the deterioration of oculo-oral synkinesis. We developed a new method of biofeedback rehabilitation using tape for the prevention of oculo-oral synkinesis. OBJECTIVE: The aim of the present study was to investigate the efficacy of taping feedback rehabilitation. METHODS: Twelve consecutive patients with peripheral facial nerve palsy who developed synkinesis were divided into 2 groups. Six patients were treated with the new training method, and the remaining 6 patients were treated with conventional therapy as controls. In the experiment group, tape was placed around the mouth, and the patient was instructed to close the eyes so that no movements of the mouth would be perceived from sensations of the taped skin. After 4 weeks of training, facial movements were recorded and movie images were graded for mouth synkinesis using the revised Sunnybrook facial grading system by examiners blinded to patient grouping. RESULTS: Mouth corner contraction during eye closure was significantly weaker in the experimental group than in the control group. CONCLUSIONS: Our new feedback method could help prevent the deterioration of oculo-oral synkinesis.

A new therapeutic application of brain-machine interface (BMI) training followed by hybrid assistive neuromuscular dynamic stimulation (HANDS) therapy for patients with severe hemiparetic stroke: A proof of concept study.

BACKGROUND: Hybrid assistive neuromuscular dynamic stimulation (HANDS) therapy improved paretic upper extremity motor function in patients with severe to moderate hemiparesis. We hypothesized that brain machine interface (BMI) training would be able to increase paretic finger muscle activity enough to apply HANDS therapy in patients with severe hemiparesis, whose finger extensor was absent. OBJECTIVE: The aim of this study was to assess the efficacy of BMI training followed by HANDS therapy in patients with severe hemiparesis. METHODS: Twenty-nine patients with chronic stroke who could not extend their paretic fingers were participated this study. We applied BMI training for 10 days at 40 min per day. The BMI detected the patients' motor imagery of paretic finger extension with event-related desynchronization (ERD) over the affected primary sensorimotor cortex, recorded with electroencephalography. Patients wore a motor-driven orthosis, which extended their paretic fingers and was triggered with ERD. When muscle activity in their paretic fingers was detected with surface electrodes after 10 days of BMI training, we applied HANDS therapy for the following 3 weeks. In HANDS therapy, participants received closed-loop, electromyogram-controlled, neuromuscular electrical stimulation (NMES) combined with a wrist-hand splint for 3 weeks at 8 hours a day. Before BMI training, after BMI training, after HANDS therapy and 3month after HANDS therapy, we assessed Fugl-Meyer Assessment upper extremity motor score (FMA) and the Motor Activity Log14-Amount of Use (MAL-AOU) score. RESULTS: After 10 days of BMI training, finger extensor activity had appeared in 21 patients. Eighteen of 21 patients then participated in 3 weeks of HANDS therapy. We found a statistically significant improvement in the FMA and the MAL-AOU scores after the BMI training, and further improvement was seen after the HANDS therapy. CONCLUSION: Combining BMI training with HANDS therapy could be an effective therapeutic strategy for severe UE paralysis after stroke.

The effects of anodal transcranial direct current stimulation and patterned electrical stimulation on spinal inhibitory interneurons and motor function in patients with spinal cord injury.

Supraspinal excitability and sensory input may play an important role for the modulation of spinal inhibitory interneurons and functional recovery among patients with incomplete spinal cord injury (SCI). Here, we investigated the effects of anodal transcranial direct current stimulation (tDCS) combined with patterned electrical stimulation (PES) on spinal inhibitory interneurons in patients with chronic incomplete SCI and in healthy individuals. Eleven patients with incomplete SCI and ten healthy adults participated in a single-masked, sham-controlled crossover study. PES involved stimulating the common peroneal nerve with a train of ten 100 Hz pulses every 2 s for 20 min. Anodal tDCS (1 mA) was simultaneously applied to the primary motor cortex that controls the tibialis anterior muscle. We measured reciprocal inhibition and presynaptic inhibition of a soleus H-reflex by stimulating the common peroneal nerve prior to tibial nerve stimulation, which elicits the H-reflex. The inhibition was assessed before, immediately after, 10 min after and 20 min after the stimulation. Compared with baseline, simultaneous application of anodal tDCS with PES significantly increased changes in disynaptic reciprocal inhibition and long-latency presynaptic inhibition in both healthy and SCI groups for at least 20 min after the stimulation (all, p < 0.001). In patients with incomplete SCI, anodal tDCS with PES significantly increased the number of ankle movements in 10 s at 20 min after the stimulation (p = 0.004). In conclusion, anodal tDCS combined with PES could induce spinal plasticity and improve ankle movement in patients with incomplete SCI.

Modulation of cortical and spinal inhibition with functional recovery of upper extremity motor function among patients with chronic stroke.

PURPOSE: We hypothesized that recovery of upper extremity motor function is associated with reduction of intracortical inhibition and improved reciprocal inhibition. This study examines the relationships of functional recovery in chronic stroke with the intracortical inhibition and spinal reciprocal inhibition. METHODS: Participants were 61 patients with chronic hemiparetic stroke. The participants were applied hybrid assistive neuromuscular dynamic stimulation (HANDS) therapy for 3 weeks. The Fugl-Meyer test upper extremity motor score (FM) and modified Ashworth scale (MAS) were assessed before (T0), immediately after (T1) and 3 months after (T2) the end of HANDS therapy. A paired pulse TMS paradigm was applied to assess short intracortical inhibition (SICI). Reciprocal inhibition (RI) was assessed with H reflex conditioning-test paradigm. RESULTS: FM and MAS were improved until T2. The change of FM from T0 to T2 was positively correlated with the change in affected SICI from T0 toT1. The change of wrist MAS from T0 to T1 was positively correlated with the change of RI. CONCLUSIONS: In chronic stroke patients with moderate or severe hemiparesis, well-recovered patients showed disinhibition of ipsilesional hemisphere and increased resiprocal inhibition of forearm.

The correlation between motor impairments and event-related desynchronization during motor imagery in ALS patients.

BACKGROUND: The event-related desynchronization (ERD) in EEG is known to appear during motor imagery, and is thought to reflect cortical processing for motor preparation. The aim of this study is to examine the modulation of ERD with motor impairment in ALS patients. ERD during hand motor imagery was obtained from 8 ALS patients with a variety of motor impairments. ERD was also obtained from age-matched 11 healthy control subjects with the same motor task. The magnitude and frequency of ERD were compared between groups for characterization of ALS specific changes. RESULTS: The ERD of ALS patients were significantly smaller than those of control subjects. Bulbar function and ERD were negatively correlated in ALS patients. Motor function of the upper extremities did was uncorrelated with ERD. CONCLUSIONS: ALS patients with worsened bulbar scales may show smaller ERD. Motor function of the upper extremities did was uncorrelated with ERD.

Immediate effects of electrical stimulation combined with passive locomotion-like movement on gait velocity and spasticity in persons with hemiparetic stroke: a randomized controlled study.

OBJECTIVE: Research to examine the immediate effects of electrical stimulation combined with passive locomotion-like movement on gait velocity and spasticity. DESIGN: A single-masked, randomized controlled trial design. SUBJECTS: Twenty-seven stroke inpatients in subacute phase (ischemic n = 16, hemorrhagic n = 11). INTERVENTIONS: A novel approach using electrical stimulation combined with passive locomotion-like movement. MAIN MEASURES: We assessed the maximum gait speed and modified Ashworth scale before and 20 minutes after the interventions. RESULTS: The gait velocity of the electrical stimulation combined with passive locomotion-like movement group showed the increase form 0.68 ± 0.28 (mean ± SD, unit: m) to 0.76 ± 0.32 after the intervention. Both the electrical stimulation group and passive locomotion-like movement group also showed increases after the interventions (from 0.76 ± 0.37 to 0.79 ± 0.40, from 0.74 ± 0.35 to 0.77 ± 0.36, respectively). The gait velocity of the electrical stimulation combined with passive locomotion-like movement group differed significantly from those of the other groups (electrical stimulation combined with passive locomotion-like movement versus electrical stimulation: P = 0.049, electrical stimulation combined with passive locomotion-like movement versus passive locomotion-like movement: P = 0.025). Although there was no statistically significant difference in the modified Ashworth scale among the three groups, six of the nine subjects (66.6%) in the electrical stimulation combined with passive locomotion-like movement group showed improvement in the modified Ashworth scale score, while only three of the nine subjects (33.3%) in the electrical stimulation group and two of the nine subjects (22.2%) improved in the passive locomotion-like movement group. CONCLUSION: These findings suggest electrical stimulation combined with passive locomotion-like movement could improve gait velocity in stroke patients.

Effects of integrated volitional control electrical stimulation (IVES) on upper extremity function in chronic stroke.

We evaluated the efficacy of a novel electromyogram (EMG)-controlled electrical stimulation system, called the integrated volitional control electrical stimulator (IVES), on the recovery of upper extremity motor functions in patients with chronic hemiparetic stroke. Ten participants in the chronic stage (more than 12 months post-stroke with partial paralysis of their wrist and fingers) received treatment with IVES to the extensor carpi radialis and extensor digitorum communis 6 h/day for 5 days. Before and after the intervention, participants were assessed using upper-extremity Fugl-Meyer motor assessment (FMA), the active range of motion (A-ROM), the nine-hole peg test (NHPT), and surface EMG recordings. The upper extremity FMA showed a statistically significant increase from 50.8 ± 5.8 to 56.8 ± 6.2 after the intervention (P < 0.01). The A-ROM of wrist extension was also significantly improved from 36.0° ± 15.4° to 45.0° ± 15.5° (P < 0.01). The NHPT significantly decreased from 85.3 ± 52.0 to 63.3 ± 29.7 (P = 0.04). EMG measurements demonstrated statistically significant improvements in the coactivation ratios for the wrist flexor and extensor muscles after the intervention. This study suggested that 5 days of IVES treatment yields a noticeable improvement in upper extremity motor functions in patients with chronic hemiparetic stroke.

Motor improvement and corticospinal modulation induced by hybrid assistive neuromuscular dynamic stimulation (HANDS) therapy in patients with chronic stroke.

BACKGROUND AND OBJECTIVE: We devised a therapeutic approach to facilitate the use of the hemiparetic upper extremity (UE) in daily life by combining integrated volitional control electrical stimulation with a wrist splint, called hybrid assistive neuromuscular dynamic stimulation (HANDS). METHODS: Twenty patients with chronic hemiparetic stroke (median 17.5 months) had moderate to severe UE weakness. Before and immediately after completing 3 weeks of training in 40-minute sessions, 5 days per week over 3 weeks and wearing the system for 8 hours each day, clinical measures of motor impairment, spasticity, and UE functional scores, as well as neurophysiological measures including electromyography activity, reciprocal inhibition, and intracortical inhibition were assessed. A follow-up clinical assessment was performed 3 months later. RESULTS: UE motor function, spasticity, and functional scores improved after the intervention. Neurophysiologically, the intervention induced restoration of presynaptic and long loop inhibitory connections as well as disynaptic reciprocal inhibition. Paired pulse transcranial magnetic stimulation study indicated disinhibition of the short intracortical inhibition in the affected hemisphere. The follow-up assessment showed that improved UE functions were maintained at 3 months. CONCLUSION: The combination of hand splint and volitional and electrically induced muscle contraction can induce corticospinal plasticity and may offer a promising option for the management of the paretic UE in patients with stroke. A larger sample size with randomized controls is needed to demonstrate effectiveness.

Effects of transcutaneous electrical stimulation combined with locomotion-like movement in the treatment of post-stroke gait disorder: a single-case study. Short report.

PURPOSE: This study was designed to examine the effects of electrical stimulation combined with locomotion-like movement (ES/LM) for improving gait disorder in a stroke patient. METHOD: A four-phase ABAB single-subject design with five therapy sessions per phase was employed. In the intervention phases, transcutaneous electrical stimulation was applied to the tibialis anterior (at the end of the hip extension phase and in the initial hip flexion phase) and the soleus (in the initial hip extension phase) during passive hip flexion and extension. To assess improvement, the soleus H-reflex and the ambulatory function were measured (gait velocity and step length). RESULTS: Application of ES/LM resulted in a decrease of the soleus H-reflex and significant increase of gait velocity and step length. CONCLUSION: These findings suggest that ES/LM is a feasible treatment method for impaired ambulatory function in stroke patients at the subacute stage after the event.

Long-loop reflex from arm afferents to remote muscles in normal man.

The present study was designed to examine the effects of median nerve stimulation on motoneurones of remote muscles in healthy subjects using H-reflex, averaged EMG and PSTH methods. Stimulation of the median nerve induced facilitation of soleus H-reflex from about 50 ms and it reached a peak at about 100 ms of conditioning-test interval. Afferents that induced the facilitation consisted of at least two types of fibres, the high-threshold cutaneous fibres and the low-threshold fibres. When the effects were examined by the averaged surface EMG and PSTH, no facilitation but rather inhibition or inhibition-facilitation was induced in all tested muscles except for the upper limb muscles on the stimulated side. The inhibition latency was shortest in masseter muscle and longest in leg muscles, while values for the contralateral upper limb muscles were in the middle, indicating that the onset of inhibition was delayed from rostral to caudal muscles. Inputs from the median nerve converged to inhibitory interneurones, which mediate the masseter inhibitory reflex. Our findings suggested that inputs from the median nerve initially ascend to the brain, at least to the brainstem, and then descend to the spinal cord. Therefore, inhibition induced by median nerve stimulation was not considered as an interlimb reflex mediated by a propriospinal pathway, but long-loop reflex, at least via the pons. The discrepancy between the results of reflex and motor units suggests that facilitation of soleus H-reflex following median nerve stimulation was mainly due to reduced presynaptic inhibition.