Arterial spin labeling reveals relationships between resting cerebral perfusion and motor learning in Parkinson's disease.

Parkinson's disease (PD) is an age-related neurodegenerative disease that produces changes in movement, cognition, sleep, and autonomic function. Motor learning involves acquisition of new motor skills through practice, and is affected by PD. The purpose of the present study was to evaluate regional differences in resting cerebral blood flow (rCBF), measured using arterial spin labeling (ASL) MRI, during a finger-typing task of motor skill acquisition in PD patients compared to age- and gender-matched controls. Voxel-wise multiple linear regression models were used to examine the relationship between rCBF and several task variables, including initial speed, proficiency gain, and accuracy. In these models, a task-by-disease group interaction term was included to investigate where the relationship between rCBF and task performance was influenced by PD. At baseline, perfusion was lower in PD subjects than controls in the right occipital cortex. The task-by-disease group interaction for initial speed was significantly related to rCBF (p < 0.05, corrected) in several brain regions involved in motor learning, including the occipital, parietal, and temporal cortices, cerebellum, anterior cingulate, and the superior and middle frontal gyri. In these regions, PD patients showed higher rCBF, and controls lower rCBF, with improved performance. Within the control group, proficiency gain over 12 typing trials was related to greater rCBF in cerebellar, occipital, and temporal cortices. These results suggest that higher rCBF within networks involved in motor learning enable PD patients to compensate for disease-related deficits.

Cheiro-Oral Syndrome.

Cheiro-Oral Syndrome (COS) is a very rare neurological syndrome associated with varied etiology. We report a 53-year-old man presented with left sided perioral and ipsilateral hand/fingers burning sensation for a one-month duration. On examination, he had hypesthesia over left perioral and distal palmar aspect of all five fingers. MRI revealed subacute infarct in the posterior limb of right internal capsule adjacent to and minimally involving thalamus. He was diagnosed as CheiroOral Syndrome as a result of ischemic stroke and managed.

Effects of somatosensory electrical stimulation on motor function and cortical oscillations.

BACKGROUND: Few patients recover full hand dexterity after an acquired brain injury such as stroke. Repetitive somatosensory electrical stimulation (SES) is a promising method to promote recovery of hand function. However, studies using SES have largely focused on gross motor function; it remains unclear if it can modulate distal hand functions such as finger individuation. OBJECTIVE: The specific goal of this study was to monitor the effects of SES on individuation as well as on cortical oscillations measured using EEG, with the additional goal of identifying neurophysiological biomarkers. METHODS: Eight participants with a history of acquired brain injury and distal upper limb motor impairments received a single two-hour session of SES using transcutaneous electrical nerve stimulation. Pre- and post-intervention assessments consisted of the Action Research Arm Test (ARAT), finger fractionation, pinch force, and the modified Ashworth scale (MAS), along with resting-state EEG monitoring. RESULTS: SES was associated with significant improvements in ARAT, MAS and finger fractionation. Moreover, SES was associated with a decrease in low frequency (0.9-4 Hz delta) ipsilesional parietomotor EEG power. Interestingly, changes in ipsilesional motor theta (4.8-7.9 Hz) and alpha (8.8-11.7 Hz) power were significantly correlated with finger fractionation improvements when using a multivariate model. CONCLUSIONS: We show the positive effects of SES on finger individuation and identify cortical oscillations that may be important electrophysiological biomarkers of individual responsiveness to SES. These biomarkers can be potential targets when customizing SES parameters to individuals with hand dexterity deficits. TRIAL REGISTRATION: NCT03176550; retrospectively registered.

Delayed recovery of the affected finger extensors at chronic stage in a stroke patient: A case report.

RATIONALE: A 33-year-old male presented with complete weakness of the right extremities due to corona radiata infarct. PATIENT CONCERNS: The main concerns of the patient is recovery of hand function especially related to finger extension. DIAGNOSES: Right corona radiata infarct. INTERVENTIONS: He underwent physical therapy and occupational therapy at the outpatient clinic of the rehabilitation department of the same university hospital until 2 years after onset. In addition, he underwent neuromuscular electrical stimulation for the right finger extensors continuously until 4 years after onset. OUTCOMES: At 6 months after onset, the weakness of his right side recovered to subnormal state except for the right finger extensors which were completely weak. At 1.5 years after onset, the right finger extensors began to show slow and continuous recovery. At 4 years after onset, the patient showed motor recovery in the right finger extensors to the extent that he was able to move against gravity. Discontinuation of the left corticospinal tract was observed on 2-month diffusion tensor tractography (DTT); however, the integrity of this discontinuation had recovered to the primary motor cortex on 4-year DTT. On 2-month transcranial magnetic stimulation (TMS), no motor-evoked potential was evoked; in contrast, motor-evoked potentials were obtained at the right-hand muscle on 4-year TMS study. LESSONS: We demonstrated unusual delayed and long-term recovery of the affected finger extensors in a patient with corona radiata infarct using DTT and TMS.

Cerebral compensation during motor function in Friedreich ataxia: The IMAGE-FRDA study.

BACKGROUND: Friedreich ataxia is characterized by progressive motor incoordination that is linked to peripheral, spinal, and cerebellar neuropathology. Cerebral abnormalities are also reported in Friedreich ataxia, but their role in disease expression remains unclear. METHODS: In this cross-sectional functional magnetic resonance imaging study, 25 individuals with Friedreich ataxia and 33 healthy controls performed simple (self-paced single-finger) and complex (visually cued multifinger) tapping tasks to respectively gauge basic and attentionally demanding motor behavior. For each task, whole brain functional activations were compared between groups and correlated with disease severity and offline measures of motor dexterity. RESULTS: During simple finger tapping, cerebral hyperactivation in individuals with Friedreich ataxia at the lower end of clinical severity and cerebral hypoactivation in those more severely affected was observed in premotor/ventral attention brain regions, including the supplementary motor area and anterior insula. Greater activation in this network correlated with greater offline finger tapping precision. Complex, attentionally demanding finger tapping was also associated with cerebral hyperactivation, but in this case within dorsolateral prefrontal regions of the executive control network and superior parietal regions of the dorsal attention system. Greater offline motor precision was associated with less activation in the dorsal attention network. DISCUSSION: Compensatory activity is evident in the cerebral cortex in individuals with Friedreich ataxia. Early compensation followed by later decline in premotor/ventral attention systems demonstrates capacity-limited neural reserve, while the additional engagement of higher order brain networks is indicative of compensatory task strategies. Network-level changes in cerebral brain function thus potentially serve to mitigate the impact of motor impairments in Friedreich ataxia. © 2017 International Parkinson and Movement Disorder Society.

Crying spells triggered by thumb-index rubbing after thalamic stroke: a case report.

BACKGROUND: Pathologic crying, devoid of any emotional counterpart, is known to occur as a consequence of various brain stem, cortical hemispheric and cerebellar lesions or, quite exceptionally, of "dacrystic" epilepsy. The case reported here suggests that thalamic lesions may also cause crying spells, under the special circumstances described below. CASE PRESENTATION: After a mild left thalamic stroke a caucasian 77 years old man presented with crying spells with no emotional counterpart, triggered by thumb-index rubbing of his right hand. Only a modest sensation loss on right infra-orbital and nose-labial areas and the first three right fingers could be detected at clinical examination. The circumstances and processes leading to the crying spells were investigated, together with their neural substrate. Brain computerized tomography (CT), magnetic resonance imaging (MRI) and functional magnetic resonance imaging (fMRI) were conducted. Neurophysiologic studies included Video-Electroencephalography, Electromyography, motor and sensory Evoked potentials. Active thumb-index rubbing, passive fingertips stimulation and interaction of sensory-motor stimulation with cognitive/speech activities were tested under different paradigms. A treatment with pregabalin (75 mg twice a day) was attempted. CT and MRI showed a small ischemic infarct in the left ventral postero-lateral thalamus, while fMRI led to the expected findings, i.e. a bilateral activation of the hand motor representation during the crying-triggering right-hand finger rubbing activity. Sensory potentials evoked from stimulation of the right upper limb were the only abnormal neurophysiologic test. Crying spells could be invariably evoked by both real and imagined active finger rubbing, in either the left of right hemi-space. Rubbing by an examiner was ineffective. Immersion in water (18 °C) but not oiling of the fingertips prevented the symptom. Administration and discontinuation of pregabalin 75 mg daily could be associated with suppression and reappearance of the symptom, respectively. CONCLUSIONS: In this patient loss of sensation seemed to generate crying spells rather than the more common allodynia. As a matter of speculation, both symptoms might represent responses to a sensory loss, but in this case the pathway might have been selectively affected providing inhibition from the lateral to the medial segment of the VPLT, which is linked to the anterior cingulate (limbic) cortex engaged in emotional behaviour.

Developing Non-Somatotopic Phantom Finger Sensation to Comparable Levels of Somatotopic Sensation through User Training With Electrotactile Stimulation.

Cutaneous electrical stimulation can provide tactile feedback for upper-limb amputees through somatotopic feedback (SF) or non-somatotopic feedback (NF). The SF delivers electrotactile stimulus to projection finger maps (PFMs) on the stumps of amputees, which outperforms NF that transfers stimulus to other human intact skin areas in general. However, the SF areas on stumps are very limited and often occupied by electromyography (EMG) sensors in application of myoelectric prosthesis. This work aims at improving NF performance on human upper arms through user training with electrotactile stimulation. The experiments were conducted over seven consecutive days on nine able-bodied subjects and two forearm amputees. The performance measures of NF/SF included the correct identification rates (CIRs), the response time and the NASA-TLX questionnaire. The between-day CIR s on NF sites increased logarithmically with a mean course of 3-day rapid-improving phase and plateaued in the relative-steady phase. The response time and NASA-TLX scores could also rapidly reduce to the comparable levels of the SF areas during the same mean period of 3-day rapid-improving phase, respectively. These results indicated that the performance of NF could be highly improved to the equivalent level as that of SF through 3-day electrotactile training, which we named as "3-day effect". It provides important insights that intact skin areas without phantom sensations can effectively replace SF sites to transfer tactile feedback after continuous user training, which validates effectiveness of non-invasive interfaces of tactile feedback for upper-limb amputees in practice.

Spatiotemporal trajectories of reactivation of somatosensory cortex by direct and secondary pathways after dorsal column lesions in squirrel monkeys.

After lesions of the somatosensory dorsal column (DC) pathway, the cortical hand representation can become unresponsive to tactile stimuli, but considerable responsiveness returns over weeks of post-lesion recovery. The reactivation suggests that preserved subthreshold sensory inputs become potentiated and axon sprouting occurs over time to mediate recovery. Here, we studied the recovery process in 3 squirrel monkeys, using high-resolution cerebral blood volume-based functional magnetic resonance imaging (CBV-fMRI) mapping of contralateral somatosensory cortex responsiveness to stimulation of distal finger pads with low and high level electrocutaneous stimulation (ES) before and 2, 4, and 6weeks after a mid-cervical level contralateral DC lesion. Both low and high intensity ES of digits revealed the expected somatotopy of the area 3b hand representation in pre-lesion monkeys, while in areas 1 and 3a, high intensity stimulation was more effective in activating somatotopic patterns. Six weeks post-lesion, and irrespective of the severity of loss of direct DC inputs (98%, 79%, 40%), somatosensory cortical area 3b of all three animals showed near complete recovery in terms of somatotopy and responsiveness to low and high intensity ES. However there was significant variability in the patterns and amplitudes of reactivation of individual digit territories within and between animals, reflecting differences in the degree of permanent and/or transient silencing of primary DC and secondary inputs 2weeks post-lesion, and their spatio-temporal trajectories of recovery between 2 and 6weeks. Similar variations in the silencing and recovery of somatotopy and responsiveness to high intensity ES in areas 3a and 1 are consistent with individual differences in damage to and recovery of DC and spinocuneate pathways, and possibly the potentiation of spinothalamic pathways. Thus, cortical deactivation and subsequent reactivation depends not only on the degree of DC lesion, but also on the severity and duration of loss of secondary as well as primary inputs revealed by low and high intensity ES.

Acupuncture for the treatment of trigger finger in adults: a prospective case series.

OBJECTIVE: To determine the effect of acupuncture performed at the synovial and ligamentous tendon sheath (A1 pulley site) on pain during snapping and the severity of the snapping phenomenon in patients with trigger finger. METHODS: In this observational study, changes in the patients' condition were compared before and after acupuncture treatment. Acupuncture was performed on 19 fingers of 15 patients. Acupuncture needles were inserted into the radial and ulnar sides of the flexor tendon at the A1 pulley of the affected finger. Treatment was performed daily up to a maximum of five times. Before and after each treatment, pain during snapping and the severity of snapping were evaluated using a visual analogue scale (VAS). RESULTS: VAS scores for pain and snapping severity were significantly improved immediately after the first treatment (p<0.001). Pain during snapping, assessed before each treatment, improved over time, reaching statistical significance from the second treatment onwards (p<0.001); similarly, a significant improvement in the severity of snapping was observed, also from the second treatment (p<0.001). Patients with clinically significant improvements (≥50%) in pain and snapping severity had a significantly shorter duration of the disorder than those with <50% improvement (p<0.05). CONCLUSIONS: Acupuncture at the impaired A1 pulley site may be an effective treatment for trigger finger. We postulate that acupuncture may reduce inflammation/swelling of the synovial membrane of the tendon sheath, which predominates when the disorder is of short duration. Further research is required to confirm the efficacy/effectiveness of acupuncture for trigger finger and its mechanisms of action.

Myoelectric intuitive control and transcutaneous electrical stimulation of the forearm for vibrotactile sensation feedback applied to a 3D printed prosthetic hand.

This paper presents the development of a myoelectric prosthetic hand based on a 3D printed model. A myoelectric control strategy based on artificial neural networks is implemented on a microcontroller for online position estimation. Position estimation performance achieves a correlation index of 0.78. Also a study involving transcutaneous electrical stimulation was performed to provide tactile feedback. A series of stimulations with controlled parameters were tested on five able-body subjects. A single channel stimulator was used, positioning the electrodes 8 cm on the wrist over the ulnar and median nerve. Controlling stimulation parameters such as intensity, frequency and pulse width, the subjects were capable of distinguishing different sensations over the palm of the hand. Three main sensations where achieved: tickling, pressure and pain. Tickling and pressure were discretized into low, moderate and high according to the magnitude of the feeling. The parameters at which each sensation was obtained are further discussed in this paper.

Sensory electrical stimulation for suppression of postural tremor in patients with essential tremor.

Essential tremor is an involuntary trembling of body limbs in people without tremor-related disease. In previous study, suppression of tremor by sensory electrical stimulation was confirmed on the index finger. This study investigates the effect of sensory stimulation on multiple segments and joints of the upper limb. It denotes the observation regarding the effect's continuity after halting the stimulation. 18 patients with essential tremor (8 men and 10 women) participated in this study. The task, "arms stretched forward", was performed and sensory electrical stimulation was applied on four muscles of the upper limb (Flexor Carpi Radialis, Extensor Carpi Radialis, Biceps Brachii, and Triceps Brachii) for 15 seconds. Three 3-D gyro sensors were used to measure the angular velocities of segments (finger, hand, and forearm) and joints (metacarpophalangeal and wrist joints) for three phases of pre-stimulation (Pre), during-stimulation (On), and 5 minute post-stimulation (P5). Three characteristic variables of root-mean-squared angular velocity, peak power, and peak power frequency were derived from the vector sum of the sensor signals. At On phase, RMS velocity was reduced from Pre in all segments and joints while peak power was reduced from Pre in all segments and joints except for forearm segment. Sensory stimulation showed no effect on peak power frequency. All variables at P5 were similar to those at On at all segments and joints. The decrease of peak power of the index finger was noted by 90% during stimulation from that of On phase, which was maintained even after 5 min. The results indicate that sensory stimulation may be an effective clinical method to treat the essential tremor.

Referred pain patterns of the third and fourth dorsal interosseous muscles.

BACKGROUND: Myofascial pain (MP) is a common disorder that can involve any skeletal muscle in the human body. There are no published reports of the referred pain patterns of the third and fourth dorsal interosseous muscles. OBJECTIVE: To investigate the referred pain patterns of the third and fourth dorsal interosseous muscles. STUDY DESIGN: Prospective evaluation. SETTING: Academic medical center. METHODS: Twenty healthy adults participated in the study. Needle placement and injection of 0.2 mL 6% hypertonic saline solution into the midpoint of the interosseous muscles were performed under ultrasonographic (US) guidance. After the injections, the participants were instructed to wait until they felt the most pain and then draw a pain diagram. This drawing was transferred to the computer for analysis. RESULTS: The referred pain distributions for the third dorsal interosseous muscle were as follows: the interdigital space of the third and fourth fingers, 80%; the distal phalanx of the third and fourth fingers, 45%; and the ulnar side of the palm, 55%. Three and 6 participants reported pain on the volar side of the wrist and in the fifth finger, respectively. The referred pain distributions for the fourth dorsal interosseous muscle were as follows: the interdigital space of the fourth and fifth fingers, 80%; the hypothenar area, 65%; and the distal phalanx of the fourth and fifth fingers, 60%. Seven and 3 participants also reported pain on the ulnar side of the wrist and the ulnar side of the forearm, respectively. LIMITATION: This study is limited by its small sample size. CONCLUSION: Referred pain patterns of the third and fourth interosseous muscles resemble the pain experienced in C7 or C8 radiculopathies or the ulnar neuropathy. Thus, identification of the third and fourth interosseous muscle trigger point should be considered when patients experience pain on the ulnar aspect of the hand and wrist.

Effects of electromyography-driven robot-aided hand training with neuromuscular electrical stimulation on hand control performance after chronic stroke.

PURPOSE: An electromyography-driven robot system integrated with neuromuscular electrical stimulation (NMES) was developed to investigate its effectiveness on post-stroke rehabilitation. METHODS: The performance of this system in assisting finger flexion/extension with different assistance combinations was evaluated in five stroke subjects. Then, a pilot study with 20-sessions training was conducted to evaluate the training's effectiveness. RESULTS: The results showed that combined assistance from the NMES-robot could improve finger movement accuracy, encourage muscle activation of the finger muscles and suppress excessive muscular activities in the elbow joint. When assistances from both NMES and the robot were 50% of their maximum assistances, finger-tracking performance had the best results, with the lowest root mean square error, greater range of motion, higher voluntary muscle activations of the finger joints and lower muscle co-contraction in the finger and elbow joints. Upper limb function improved after the 20-session training, indicated by the increased clinical scores of Fugl-Meyer Assessment, Action Research Arm Test and Wolf Motor Function Test. Muscle co-contraction was reduced in the finger and elbow joints reflected by the Modified Ashworth Scale. CONCLUSIONS: The findings demonstrated that an electromyography-driven NMES-robot used for chronic stroke improved hand function and tracking performance. Further research is warranted to validate the method on a larger scale. Implications for Rehabilitation The hand robotics and neuromuscular electrical stimulation (NMES) techniques are still separate systems in current post-stroke hand rehabilitation. This is the first study to investigate the combined effects of the NMES and robot on hand rehabilitation. The finger tracking performance was improved with the combined assistance from the EMG-driven NMES-robot hand system. The assistance from the robot could improve the finger movement accuracy and the assistance from the NMES could reduce the muscle co-contraction on finger and elbow joints. The upper limb functions were improved on chronic stroke patients after the pilot study of 20-session hand training with the combined assistance from the EMG-driven NMES-robot. The muscle spasticity on finger and elbow joints was reduced after the training.

Effects of neuromuscular electrical stimulation on the wrist and finger flexor spasticity and hand functions in cerebral palsy.

PURPOSE: To evaluate the effects of neuromuscular electrical stimulation on wrist range of motion, wrist and finger flexor spasticity, and hand functions in patients with unilateral cerebral palsy. METHOD: Twenty-four children with unilateral spastic cerebral palsy (14 boys and 10 girls) between the ages of 5 and 14 years were randomized into neuromuscular electrical stimulation and control groups. Conventional exercises were applied, and static volar wrist-hand orthosis was administered to all patients 5 days a week for 6 weeks. Additionally, 30-minute neuromuscular electrical stimulation sessions were applied to the wrist extensor muscles in the neuromuscular electrical stimulation group. Patients were evaluated by Zancolli Classification System, Manual Ability Classification System, and Abilhand-Kids Test. RESULTS: Compared with baseline, a significant increase was evident in active wrist extension angle at the fourth and sixth weeks in both groups (all P < 0.001), more prominent in the neuromuscular electrical stimulation group at the fourth and sixth weeks (P = 0.015 and P = 0.006, respectively). A decrease was observed in the spasticity values in the neuromuscular electrical stimulation group at the fourth and sixth weeks (P = 0.002 and P = 0.001, respectively) and in the control group only at the sixth week (P = 0.008). Abilhand-Kids values improved only in the neuromuscular electrical stimulation group (P < 0.001). CONCLUSION: Neuromuscular electrical stimulation application in addition to conventional treatments is effective in improving active wrist range of motion, spasticity, and hand functions in cerebral palsy.

Assisted movement with proprioceptive stimulation reduces impairment and restores function in incomplete spinal cord injury.

OBJECTIVE: To test whether treatment with assisted movement with enhanced sensation (AMES) using vibration to the antagonist muscle would reduce impairments and restore upper limb function in people with incomplete tetraplegia. DESIGN: Prospective, pre-post study. SETTING: Laboratory and rehabilitation hospital. PARTICIPANTS: We recruited 15 arms from 10 individuals (8 men; mean age, 40.5 y; mean years postspinal cord injury [SCI], 3) with chronic, incomplete tetraplegia. INTERVENTION: Two or three 20-minute sessions per week over 9 to 13 weeks (25 sessions total) on the AMES device, which combines repeated movement with targeted vibration to the antagonist muscle. MAIN OUTCOME MEASURES: Strength and active motion tests on the AMES device; International Standards for the Neurological Classification of SCI (ISNCSCI) motor and sensory examinations; Modified Ashworth Scale (MAS); grasp and release test (GRT); Van Lieshout Test (VLT); and Capabilities of Upper Extremity questionnaire (CUE). RESULTS: The AMES strength test scores improved significantly in metacarpophalangeal flexion (P=.024) and extension (P=.007) and wrist flexion (P=.001) and extension (P<.000). The AMES active motion scores improved in the hand (P=.001) and wrist (P=.001). The MAS and ISNCSCI scores remained unchanged, whereas the GRT scores increased (P=.025). Post hoc analysis showed a trend from pre- to posttreatment (P=.068) and a significant change from pretreatment to 3-month follow-up (P=.046). There was no significant change in the VLT (P=.951) or the CUE (P=.164). Five of the 10 participants reported a return of sensation to the digits after the first, second, or third treatment session. CONCLUSIONS: People with chronic, incomplete tetraplegia may experience improvements in impairments and function after treatment on a device combining assisted movement and proprioceptive stimulation. Further investigation is warranted.

Hand rehabilitation using MIDI keyboard playing in adolescents with brain damage: a preliminary study.

BACKGROUND: As a sequential, programmed movement of fingers, keyboard playing is a promising technique for inducing execution and a high level of coordination during finger movements. Also, keyboard playing can be physically and emotionally rewarding for adolescents in rehabilitation settings and thereby motivate continued involvement in treatment. OBJECTIVE: The purpose of this study is to evaluate the effects of keyboard playing using Musical Instrument Digital Interface (MIDI) on finger movement for adolescents with brain damage. METHODS: Eight adolescents with brain damage, ages 9 to 18 years (M = 13 years, SD = 2.78), in physical rehabilitation settings participated in this study. Measurements included MIDI keyboard playing for pressing force of the fingers and hand function tests (Grip and Pinch Power Test, Box and Block Test of Manual Dexterity [BBT], and the Jebsen Taylor Hand Function Test). RESULTS: Results showed increased velocity of all fingers on the MIDI-based test, and statistical significance was found in the velocity of F2 (index finger), F3 (middle finger), and F5 (little finger) between pre- and post-training tests. Correlation analysis between the pressing force of the finger and hand function tests showed a strong positive correlation between the measure of grip power and the pressing force of F2 and F5 on the Grip and Pinch Strength Test. All fingers showed strong correlation between MIDI results and BBT. For the Jebsen Taylor Hand Function Test, only the moving light objects task at post-training yielded strong correlation with MIDI results of all fingers. CONCLUSIONS: The results support using keyboard playing for hand rehabilitation, especially in the pressing force of individual finger sequential movements. Further investigation is needed to define the feasibility of the MIDI program for valid hand rehabilitation for people with brain damage.

Myoelectrically driven functional electrical stimulation may increase motor recovery of upper limb in poststroke subjects: a randomized controlled pilot study.

The objective of this randomized controlled pilot study was to assess the feasibility and effectiveness of myoelectrically controlled functional electrical stimulation (MeCFES) for rehabilitation of the upper limb in poststroke subjects. Eleven poststroke hemiparetic subjects with residual proximal control of the arm, but impaired volitional opening of the paretic hand, were enrolled and randomized into a treated and a control group. Subjects received 3 to 5 treatment sessions per week until totaling 25 sessions. In the experimental group, myoelectric activity from wrist and finger extensors was used to control stimulation of the same muscles. Patients treated with MeCFES (n = 5) had a significant (p = 0.04) and clinically important improvement in Action Research Arm Test score (median change 9 points), confirmed by an Individually Prioritized Problem Assessment self-evaluation score. This improvement was maintained at follow-up. The control group did not show a significant improvement (p = 0.13). The reduced sample size of participants, together with confounding factors such as spontaneous recovery, calls for larger studies to draw definite conclusions. However, the large and persistent treatment effect seen in our results indicate that MeCFES could play an important role as a clinical tool for stroke rehabilitation.

Unilateral versus bilateral upper limb training after stroke: the Upper Limb Training After Stroke clinical trial.

BACKGROUND AND PURPOSE: Unilateral and bilateral training protocols for upper limb rehabilitation after stroke represent conceptually contrasting approaches with the same ultimate goal. In a randomized controlled trial, we compared the merits of modified constraint-induced movement therapy, modified bilateral arm training with rhythmic auditory cueing, and a dose-matched conventional treatment. Modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing targeted wrist and finger extensors, given their importance for functional recovery. We hypothesized that modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing are superior to dose-matched conventional treatment. METHODS: Sixty patients, between 1 to 6 months after stroke, were randomized over 3 intervention groups. The primary outcome measure was the Action Research Arm test, which was conducted before, directly after, and 6 weeks after intervention. RESULTS: Although all groups demonstrated significant improvement on the Action Research Arm test after intervention, which persisted at 6 weeks follow-up, no significant differences in change scores on the Action Research Arm test were found between groups postintervention and at follow-up. CONCLUSIONS: Modified constraint-induced movement therapy and modified bilateral arm training with rhythmic auditory cueing are not superior to dose-matched conventional treatment or each other in improving upper limb motor function 1 to 6 months after stroke. CLINICAL TRIAL REGISTRATION URL: http://www.trialregister.nl. Unique identifier: NTR1665.

A pilot study of sensory feedback by transcutaneous electrical nerve stimulation to improve manipulation deficit caused by severe sensory loss after stroke.

BACKGROUND: Sensory disturbance is common following stroke and can exacerbate functional deficits, even in patients with relatively good motor function. In particular, loss of appropriate sensory feedback in severe sensory loss impairs manipulation capability. We hypothesized that task-oriented training with sensory feedback assistance would improve manipulation capability even without sensory pathway recovery. METHODS: We developed a system that provides sensory feedback by transcutaneous electrical nerve stimulation (SENS) for patients with sensory loss, and investigated the feasibility of the system in a stroke patient with severe sensory impairment and mild motor deficit. The electrical current was modulated by the force exerted by the fingertips so as to allow the patient to identify the intensity. The patient had severe sensory loss due to a right thalamic hemorrhage suffered 27 months prior to participation in the study. The patient first practiced a cylindrical grasp task with SENS for 1 hour daily over 29 days. Pressure information from the affected thumb was fed back to the unaffected shoulder. The same patient practiced a tip pinch task with SENS for 1 hour daily over 4 days. Pressure information from the affected thumb and index finger was fed back to the unaffected and affected shoulders, respectively. We assessed the feasibility of SENS and examined the improvement of manipulation capability after training with SENS. RESULTS: The fluctuation in fingertip force during the cylindrical grasp task gradually decreased as the training progressed. The patient was able to maintain a stable grip force after training, even without SENS. Pressure exerted by the tip pinch of the affected hand was unstable before intervention with SENS compared with that of the unaffected hand. However, they were similar to each other immediately after SENS was initiated, suggesting that the somatosensory information improved tip pinch performance. The patient's manipulation capability assessed by the Box and Block Test score improved through SENS intervention and was partly maintained after SENS was removed, until at least 7 months after the intervention. The sensory test score, however, showed no recovery after intervention. CONCLUSIONS: We conclude that the proposed system would be useful in the rehabilitation of patients with sensory loss.