Kinesthetic illusion induced by visual stimulation influences sensorimotor event-related desynchronization in stroke patients with severe upper-limb paralysis: A pilot study.

BACKGROUND: Repetition of motor imagery improves the motor function of patients with stroke. However, patients who develop severe upper-limb paralysis after chronic stroke often have an impaired ability to induce motor imagery. We have developed a method to passively induce kinesthetic perception using visual stimulation (kinesthetic illusion induced by visual stimulation [KINVIS]). OBJECTIVE: This pilot study further investigated the effectiveness of KINVIS in improving the induction of kinesthetic motor imagery in patients with severe upper-limb paralysis after stroke. METHODS: Twenty participants (11 with right hemiplegia and 9 with left hemiplegia; mean time from onset [±standard deviation], 67.0±57.2 months) with severe upper-limb paralysis who could not extend their paretic fingers were included in this study. The ability to induce motor imagery was evaluated using the event-related desynchronization (ERD) recorded during motor imagery before and after the application of KINVIS for 20 min. The alpha- and beta-band ERDs around the premotor, primary sensorimotor, and posterior parietal cortices of the affected and unaffected hemispheres were evaluated during kinesthetic motor imagery of finger extension and before and after the intervention. RESULTS: Beta-band ERD recorded from the affected hemisphere around the sensorimotor area showed a significant increase after the intervention, while the other ERDs remained unchanged. CONCLUSIONS: In patients with chronic stroke who were unable to extend their paretic fingers for a prolonged period of time, the application of KINVIS, which evokes kinesthetic perception, improved their ability to induce motor imagery. Our findings suggest that although KINVIS is a passive intervention, its short-term application can induce changes related to the motor output system.

A novel neurocognitive rehabilitation tool in the recovery of hemiplegic hand grip after stroke: a case report.

Stroke has significant physical, psychological and social consequences. Recent rehabilitation approaches suggest that cognitive exercises with dual-task (sensory-motor) exercises positively influence the recovery and function of the hemiplegic hand grip. The purpose of this study was to describe a rehabilitation protocol involving the use of a new neurocognitive tool called "UOVO" for hand grip recovery after stroke. A 58-year-old right-handed male patient in the chronic stage of stroke, presenting with left-sided hemiparesis and marked motor deficits at the level of the left hand and forearm, was treated with the UOVO, a new rehabilitation instrument based on the neurocognitive rehabilitation theory of Perfetti. The patient was evaluated at T0 (before treatment), T1 (after treatment) and T2 (2 months of follow-up). At T2, the patient showed improvements of motor functions, shoulder, elbow and wrist spasticity, motility and performance. This case report explores the possibility of improving traditional rehabilitation through a neurocognitive approach with a dual-task paradigm (including motor and somato-sensory stimulation), specifically one involving the use of an original rehabilitation aid named UOVO, which lends itself very well to exercises proposed through the use of motor imagery. The results were encouraging and showed improvements in hemiplegic hand grip function and recovery. However, further studies, in the form of randomized controlled trials, will be needed to further explore and confirm our results.

Participation and community-based walking activity after neuroprosthesis use in children with hemiplegic cerebral palsy: A pilot study1.

PURPOSE: To explore the effects of neuroprosthesis use on participation, level of community-based walking activity, safety and satisfaction in children with hemiplegic CP. METHODS: Eleven children (mean 9 years 11 months) with hemiplegic CP Gross Motor Function Classification System (GMFCS) Level I and II participated in a 16-week intervention using the Ness L300 neuroprosthesis. Outcome measures included satisfaction and performance with self-selected participation goals (Canadian Occupational Performance Measure (COPM)), level of community-based walking activity (Step Watch Activity Monitor (SAM)), trip and fall frequency (caregiver report) and a satisfaction questionnaire. RESULTS: Significant (p< 0.001) improvements in performance and satisfaction with self-selected participation goals (COPM) were demonstrated. No significant changes were noted in SAM values. A significant (p= 0.01) decrease in trips was demonstrated from baseline to post. Satisfaction with the device was high. CONCLUSION: Results indicate that daily neuroprosthesis use may improve performance and satisfaction with participation goals and reduce trips. No changes in community-based walking activity were noted. Further study is needed to examine response based on GMFCS levels, across geographical regions and between FES neuroprosthesis and a control group.

Motor imagery for walking: a comparison between cerebral palsy adolescents with hemiplegia and diplegia.

The goal of the study was to investigate whether motor imagery (MI) could be observed in cerebral palsy (CP) participants presenting a bilateral affected body side (diplegia) as it has been previously revealed in participants presenting a unilateral body affected sided (hemiplegia). MI capacity for walking was investigated in CP adolescents diagnosed with hemiplegia (n=10) or diplegia (n=10) and in adolescents with typical motor development (n=10). Participants were explicitly asked to imagine walking before and after actually walking toward a target located at 4 m and 8 m. Movement durations for executed and imagined trials were recorded. ANOVA and Pearson's correlation analyses revealed the existence of time invariance between executed and imagined movement durations for the control group and both groups of CP participants. However, results revealed that MI capacity in CP participants was observed for the short distance (4 m) but not for the long distance (8 m). Moreover, even for short distance, CP participants performed worse than typical adolescents. These results are discussed inline of recent researches suggesting that MI in CP participants may not depend on the side of the lesion.

[Effect of "Jin three-needle therapy" on cognitive function and activity of daily living in patients of hemiplegia after stroke: a multi-central randomized controlled study].

OBJECTIVE: To provide reliable evidence of "J in three-needle therapy" for treatment of stroke. METHODS: Multi-central randomized controlled trials were adopted, 180 hemiplegia patients of ischemic stroke were randomly divided into a fin three-needle group (90 cases) and a routine acupuncture group (90 cases). Two groups were both treated with basic neurology therapies, and J in three-needle group was treated with J in three-needle therapy, three acupoints of tempora, hand and foot etc. were selected; the routine acupuncture group was treated with traditional acupuncture, Quchi (LI 11), Huantiao (GB 30), Futu (ST 32) etc. were selected. Both groups were treated with acupuncture for 5 weeks. The cognitive function score of functional comprehensive assessment scale (FCA), the scores of mini-mental state examination scale (MMSE) and modified Barthel index (BI) were compared before and after treatment between two groups. Results After treatment, the scores of FCA, MMSE and BI in both groups were significantly improved compared to those before treatment (P < 0.01, P < 0.05); the improvement of FCA score, MMSE score and BI score in the J in three-needle group were superior to those of the routine acupuncture group after treatment (P < 0.01, P < 0.05). The total effective rate of 85.4% in the J in three-needle group was superior to tohat of 70.0% in the routine acupuncture group (P < 0.05). CONCLUSION: J in three-needle acupuncture treatment can obviously improve the cognitive function and activity ability of daily life of hemiplegia patients after stroke, and the therapeutic effect of J in three-needle therapy is superior to that of traditional acupuncture treatment.

Use of information feedback and attentional focus of feedback in treating the person with a hemiplegic arm.

BACKGROUND AND PURPOSE: Feedback about motor performance can induce either an internal focus of attention (about body movement) or an external focus of attention (about the effects on the environment) in the learner. The main aim of this pilot study was to examine the attentional focus of feedback given by physiotherapists during treatment of the hemiplegic arm. A second aim was to examine the frequency of feedback about motor performance during treatment. METHOD: A multi-methods design was used (quantitative and qualitative). Eight physiotherapists and eight patients with stroke were recruited from two hospitals. Data were collected by video recordings of treatment, interviews (both therapists and patients) and questionnaire (therapists). Information feedback, instructions and motivational statements were identified from the video recordings. Feedback and instructions were further grouped into internal focus, external focus or mixed focus of attention. Themes were drawn from the interview transcripts. Triangulation was used to provide corroborating information from the different data sets. RESULTS: Two hundred and forty-six of the total 1914 statements identified in the videos were feedback, the rest comprising instructions and statements of motivation. Of the feedback statements, 236 of the total 247 identified had an internal focus. Therapist interviews and questionnaires revealed more external focus communication than actual treatment. CONCLUSIONS: Physiotherapists used instructions and statements of motivation more than feedback and directed the patient's attention more to body movement than movement effects. The outcome of this study may prompt clinicians' to examine the amount and the attentional focus of the feedback they use in their clinical practice, and to consider whether it is a most effective approach in light of current evidence.

The role of biofeedback in stroke rehabilitation: past and future directions.

Biofeedback has been applied to many aspects of stroke rehabilitation, with mixed results. This is largely due to the varying modalities, differences between study designs, and methods of measuring success and progress. How well biofeedback works appears to be inversely related to the direct observability of the function about which information is being provided. The more covert the function (e.g., swallowing muscle activity, attention, cortical functioning, etc.), the more helpful biofeedback is likely to be. However, biofeedback in general can have a very positive impact, even through indirect means. Improvements in self confidence, shifting of locus of control, and instantly being provided information regarding changes in one's physical functioning as a result of mental activity can be helpful in setting the tone for success in rehabilitation more generally.

Impaired motor imagery in right hemiparetic cerebral palsy.

It is generally assumed that movements of a part of the body (e.g., hands) are simulated in motor imagery (MI) tasks. This is evidenced by a linear increase in reaction time as a function of the angular rotation of the stimulus. Under the assumption that MI plays a critical role for anticipatory motor planning, which is known to be impaired in individuals with right hemiparetic cerebral palsy (right HCP; left congenital brain damage), but to a lesser extent in individuals with left HCP, we hypothesized that MI is impaired in the participants with right HCP. In the present study, 8 participants with right and 11 participants with left congenital brain damage and 9 neurologically healthy controls were presented with two MI tasks to study this supposed relation between hemispheric processes and behaviour. Participants were instructed to make a laterality judgment on the basis of displayed pictures of hands (either holding a hammer or not) presented in different orientations. For both the control group and the left HCP group, a linear increase in reaction time as a function of angle of rotation was found. Interestingly, no such relationship was observed for the right HCP group, suggesting a disorder in MI for these participants. Collectively, these findings provide new insights into the cause of the anticipatory planning deficits in right HCP individuals.

[Complications in the hemiplegic patient in the first year after the stroke]. / Complicaciones en el paciente hemipléjico durante el primer año tras el ictus.

INTRODUCTION: After a cerebrovascular accident (CVA) a hemiplegic patient is at risk from numerous complications after leaving hospital. OBJECTIVE: To analyze the frequency of occurrence of the commonest complications characteristic of the hemiplegic syndrome, during the first year after the stroke. PATIENTS AND METHODS: We evaluated 73 hemiplegic patients admitted to the rehabilitation department for treatment after a stroke. At each medical consultation, on admission and three, six and twelve months after the CVA, the complications 'belonging' to the hemiplegic syndrome were evaluated. These included contractures, painful shoulder, sympathetic-reflex dystrophy, fractures and thalamic pain. RESULTS: During the first year of the illness 81% of the patients had some type of complication. A painful shoulder was the commonest complication, seen in 40% of the patients, followed by contractures (23%). Sympathetic-reflex dystrophy of the paretic arm occurred in 11 patients (15%). CONCLUSION: The commonest complication in patients during the first year after their stroke are painful shoulder and contractures.

To see better to the left when looking more to the right: effects of gaze direction and frames of spatial coordinates in unilateral neglect.

Unilateral spatial neglect entails a failure to detect or respond to stimuli in the space opposite to a brain lesion. However, the contralesional hemispace can be determined by different frames of spatial coordinates, such as eyes-, head-, body-, or environment-centered coordinates. We observed 2 patients with a right hemisphere stroke whose left spatial neglect was modulated by distinct coordinates systems depending on the task. Four tasks were given in different conditions of central gaze and either the eyes or the head rotated 30 degrees to the right or 30 degrees to the left. While the 2 patients had a retinotopic defect in 1 visual field quadrant that remained the same irrespective of gaze direction (upper or lower quadrant in 1 case each), the other quadranopic field defect improved with eyes rotation to the right but not with head rotation, suggesting a head-centered spatiotopic deficit. Performance on line bisection was influenced both by eyes and head rotation, as well as by the position of the lines with respect to the trunk midline, suggesting the involvement of both head-centered and body-centered coordinates. Visual imagery and auditory extinction were not modified by changing the eyes or head position. These findings suggest that distinct spatial coordinates are brought into play depending on the tasks demands.

Possible mechanisms of anosognosia: a defect in self-awareness.

Anosognosia of hemiplegia is of interest for both pragmatic and theoretical reasons. We discuss several neuropsychological theories that have been proposed to explain this deficit. Although for psychological reasons people might deny deficits, the denial hypothesis cannot account for the hemispheric asymmetries associated with this disorder and cannot explain why some patients might deny one deficit and recognize another equally disabling deficit. There is some evidence that faulty feedback from sensory deficits, spatial neglect and asomatognosia might be responsible for anosognosia in some patients. However, these feedback hypotheses cannot account for anosognosia in all patients. Although the hemispheric disconnection hypothesis is appealing, disconnection is probably only a rare cause of this disorder. The feedforward intentional theory of anosognosia suggests that the discovery of weakness is dependent on attempted action and some patients might have anosognosia because they do not attempt to move. We present evidence that supports this theory. The presence of one mechanism of anosognosia, however, does not preclude the possibility that other mechanisms might also be working to produce this disorder. Although a large population study needs to be performed, we suspect that anosognosia might be caused by several of the mechanisms that we have discussed. On the basis of the studies of impaired corporeal self-awareness that we have reviewed, we can infer that normal self-awareness is dependent on several parallel processes. One must have sensory feedback and the ability to attend to both one's body and the space where parts of the body may be positioned or acting. One must develop a representation of the body, and this representation must be continuously modified by expectations (feedforward) and knowledge of results (feedback).

Motor function in young and aged hemiplegic rats: effects of a Ginkgo biloba extract.

We have previously shown beneficial effects of a Ginkgo biloba extract (EGb761-IPSEN) in accelerating functional recovery from hemiplegia induced by unilateral motor cortex ablation. Here, we report the behavioral and histological effects of various dose regimes of EGb761. In young rats (3 months), 10 mg/kg/day for 7 days produced an improvement in motor performance, relative to untreated controls, on the last day of treatment. Applying a priming (P)-maintenance (M) dose regime (P-7 = 7 days, M-21 = 21 days), a P-7 of 50 (all doses expressed in mg/kg/day) and a M-21 of 10 promoted recovery from the second day after surgery. However, in aged rats (26-28 months old) this treatment ameliorated motor performance only after the 10th day of treatment. A P-7 of 100 or 200 and a M-21 of 50 or 100 produced an acceleration of behavioral recovery in aged animals. Improvement was evident by the fifth day of treatment and was maintained after the treatment regimen. These two groups also demonstrated reduced glial fibrillary acid protein (GFAP) immunostaining and ex vacuo hydrocephalus. Thus, the confirmed efficacy of EGb in hemiplegic rats can be enhanced by an appropriate posology.

Memory for words and drawings in children with hemiplegic cerebral palsy.

A list-learning paradigm was used to study learning and memory of verbal and figurative material in children with right versus left-sided hemiplegic cerebral palsy. Thirty-one children with right (n = 18), or left (n = 13) congenital hemiplegia were compared with normal controls (n = 19). All children had normal intelligence (IQ > 80), and were attending standard schools. The inclusion criteria for the two hemiplegic groups were; no epilepsy, no hearing or visual impairments, and a mild to moderate hemiparesis. The aim of this study was to explore material-specific (words and drawings) differences in the acquisition, recall and serial position effects in children with an early unilateral brain lesion. The left-hemisphere impaired (i.e. right hemiplegia) group showed impaired acquisition for drawings, as compared with the normal controls. There was also a material-specific difference in the serial position effect for all three groups. Learning of words followed the primacy principle, whereas the learning of drawings followed the recency principle. There were no group-differences in delayed-recall (i.e. long-term memory) for either words or drawings. The results are discussed in terms of acquisition and retention of verbal and figurative materials in relation to lesion side and size.

Unconscious activation of motor responses in a hemiplegic patient with anosognosia and neglect.

Unconscious processing of environmental stimuli has been convincingly demonstrated for a large number of neuropsychological syndromes. However, only few studies have successfully recorded on-line the activation of the autonomous or the motoric nervous systems. The activation of the motor system by unconscious stimuli would be a strong argument that information processing in the brain is not organized into two serial steps (stimulus identification first, response selection second). This would argue for parallel processes of stimuli identification routines and response selection mechanisms on the basis of only provisionally worked out stimulus features. Investigating an anosognostic patient we found electrodermal activity (EDA) and electromyographic responses (EMG) to bimanual tasks, mental imagery, and to the request to execute specific actions. But overt behavior remained hemiplegic and the patient was unable to feel any kind of control of her paralyzed left arm and hand. Generally, the data can be interpreted along the lines of a theory of two different routes to action, leaving the unconscious selection of action patterns intact, whereas the intentional triggering of overt behavior with the left hand and arm was impossible for the patient.

Digit span performance and unilateral neglect.

This study tested the alternative hypotheses of Weinberg et al. (J. clin. Psychol. 28, 361, 1976) and Robertson (Neuropsychologia 28, 217-222, 1990) regarding the nature of dysfunctions underlying impaired backward digit span among patients with unilateral neglect. Results support the Weinberg et al. hypothesis that visual imagery plays a primary role in performance of Digits Backward. The findings also indicate a unilateral component to the Digits Backward task. Both neglecting and non-neglecting patients with high digit span discrepancy (DD) evidenced attentional bias to right space and a specific impairment in rotating objects in left space. Results were not consistent with Robertson's hypothesis that high DD arises from a general attentional deficit. In fact, patients with low DD evidence greatest impairment on tests of attention.

Bilateral neuropsychological deficits in unilateral paramedian thalamic infarction.

The neuropsychological deficits in 5 patients with chronic and MRI-proven unilateral infarctions in the perfusion territory of the paramedian thalamic arteries were studied. All patients showed deficits pointing to a dysfunction of frontotemporal hemispheric structures on the side of the thalamic lesion. However, 4 patients revealed additionally neuropsychological deficits pointing to a dysfunction of frontotemporal hemispheric structures overlying the nonaffected thalamus. The contralateral deficits showed (in 4 patients) signs of temporal and (in 3 patients) frontal lobe dysfunction. It is suggested that the bilaterality of the neuropsychological deficits results from additional contralateral thalamic lesions not detected by MRI and/or from bilateral cortical hypometabolism.

On the different roles of the cerebral hemispheres in mental imagery: the "o'Clock Test" in two clinical cases.

This paper develops the hypothesis of different roles of the two hemispheres in imaginal processes. A test designated the "o'Clock Test" is proposed, which contains closely confrontable perceptual and imaginal tasks. It enables examination of the abilities both to generate mental images and to explore them in their right and left halves (R + L Condition). This test was used to examine two patients, one severely affected by hemi-inattention resulting from a right posterior lesion, and the other with a selective deficit of imagery due to a left occipital lesion. The former demonstrated left neglect in both perceptive and imaginal capacities, while the latter was able to perform correctly only the perceptive tasks. These results suggest that the right hemisphere has functions of organization and spatial exploration at both perceptive and imaginal levels, and that the left hemisphere's role is to generate mental images.