Effects of photobiomodulation on pain, lactate and muscle performance (ROM, torque, and EMG parameters) of paretic upper limb in patients with post-stroke spastic hemiparesis-a randomized controlled clinical trial.

The objective of the study was to investigate the impact of photobiomodulation (PBM) on the paretic upper limb in post-stroke patients with spastic hemiparesis and to understand the potential of PBM as a long-term non-invasive therapy for reducing the side effects caused by spasticity in the hemiparetic upper limb after a stroke. This is a double-blind randomized clinical trial constituted of 27 participants, being Control group (CG = 12 healthy individuals) and PBM group (PBMG = 15 post-stroke individuals). In the CG, the baseline blood lactate (BL) was evaluated, followed by the evaluation of the IC torque of the biceps and triceps muscles, with the isokinetic dynamometer associated with surface electromyography (EMG) and, subsequently, a new measurement of BL. The PBMG received 10 sessions of treatment with PBM (780 nm, Power: 100 mV, Power Density: 3.18 W/cm2, Energy: 4 J, Fluency: 127.4 J/cm2, Time: 40 s per point and 1.280 s total, Spot: 0.0314 cm2, 32 Points: 16 points (brachial biceps) and 16 points (brachial triceps) applied with contact at 90°, Total Energy: 64 J), which in the pre-treatment evaluation measured BL, the visual analogue scale (VAS) of pain; torque and EMG of the same muscles in the IC, subsequently, a new measurement of VAS and BL, and measurement of range of motion (ROM) during the reaching movement. At the conclusion of the ten sessions, all participants underwent a reassessment, wherein all tests originally administered during the initial evaluation were repeated. Subsequently, the data were analyzed using the Shapiro-Wilk normality test. For related data, the paired t-test was used for normal distributions and the Wilcoxon test for non-normal data. For unrelated data, the t test was used for normal distributions and the Mann-Whitney test for non-normal data. Muscle torque was higher for the CG, with a significant difference (CGxPBMG = p < 0.0001). There was no significant difference between the EMG values of the CG in relation to the Pre-PBM phase and with the Post-PBM phase of the PBMG (p > 0.05). On the other hand, there was a 38% reduction in pain reported by hemiparetic patients (p = 0.0127) and a decrease in BL in the PBMG. Post-PBM ROM increased by 46.1% in the elbow extension of the paretic limb. In conclusion, Photobiomodulation (PBM) demonstrated significant improvements in muscle performance, reducing fatigue and pain levels, and enhancing range of motion in post-stroke patients with spastic hemiparesis. These findings support the potential integration of PBM into rehabilitation protocols, but further research and clinical trials are needed to validate and expand upon these promising outcomes.

Segmental zoster paresis of the lower extremity: Case report.

Herpes zoster (HZ) is a segmental vesicular eruption, pain, and sensorial symptoms. Segmental motor weakness can rarely be seen as a complication of HZ. Here, we present two cases of motor paresis associated with HZ, case 1 was L2 and L3 segmental motor paresis with femoral neuropathy and case 2 was L5 and S1 segmental motor paresis with sensorial ganglion involvement. In both cases after electrotherapy, exercise program, and medication for pain, there were no motor weakness and pain. Zoster motor paresis is a rare complication that responds to treatment and physicians should be careful about its presence in clinical follow-up.

Reaching exercise for chronic paretic upper extremity after stroke using a novel rehabilitation robot with arm-weight support and concomitant electrical stimulation and vibration: before-and-after feasibility trial.

BACKGROUND: Our group developed a rehabilitation robot to assist with repetitive, active reaching movement of a paretic upper extremity. The robot is equipped with a servo motor-controlled arm-weight support and works in conjunction with neuromuscular electrical stimulation and vibratory stimulation to facilitate agonist-muscle contraction. In this before-and-after pilot study, we assessed the feasibility of applying the robot to improve motor control and function of the hemiparetic upper extremity in patients who suffered chronic stroke. METHODS: We enrolled 6 patients with chronic stroke and hemiparesis who, while sitting and without assistance, could reach 10 cm both sagitally and vertically (from a starting position located 10 cm forward from the patient's navel level) with the affected upper extremity. The patients were assigned to receive reaching exercise intervention with the robot (Yaskawa Electric Co., Ltd. Fukuoka, Japan) for 2 weeks at 15 min/day in addition to regular occupational therapy for 40 min/day. Outcomes assessed before and after 2 weeks of intervention included the upper extremity component of the Fugl-Meyer Assessment (UE-FMA), the Action Research Arm Test (ARAT), and, during reaching movement, kinematic analysis. RESULTS: None of the patients experienced adverse events. The mean score of UE-FMA increased from 44.8 [SD 14.4] to 48.0 [SD 14.4] (p = 0.026, r = 0.91), and both the shoulder-elbow and wrist-hand scores increased after 2-week intervention. An increase was also observed in ARAT score, from mean 29.8 [SD 16.3] to 36.2 [SD 18.1] (p = 0.042, r = 0.83). Kinematic analysis during the reaching movement revealed a significant increase in active range of motion (AROM) at the elbow, and movement time tended to decrease. Furthermore, trajectory length for the wrist ("hand path") and the acromion ("trunk compensatory movement") showed a decreasing trend. CONCLUSIONS: This robot-assisted modality is feasible and our preliminary findings suggest it improved motor control and motor function of the hemiparetic upper extremity in patients with chronic stroke. Training with this robot might induce greater AROM for the elbow and decrease compensatory trunk movement, thus contributing to movement efficacy and efficiency. Trial registration UMIN Clinical Trial Registry, as UMIN000018132, on June 30, 2015. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000020398.

Changes in spectroscopic biomarkers after transcranial direct current stimulation in children with perinatal stroke.

BACKGROUND: Perinatal stroke causes lifelong motor disability, affecting independence and quality of life. Non-invasive neuromodulation interventions such as transcranial direct current stimulation (tDCS) combined with intensive therapy may improve motor function in adult stroke hemiparesis but is under-explored in children. Measuring cortical metabolites with proton magnetic resonance spectroscopy (MRS) can inform cortical neurobiology in perinatal stroke but how these change with neuromodulation is yet to be explored. METHODS: A double-blind, sham-controlled, randomized clinical trial tested whether tDCS could enhance intensive motor learning therapy in hemiparetic children. Ten days of customized, goal-directed therapy was paired with cathodal tDCS over contralesional primary motor cortex (M1, 20 min, 1.0 mA, 0.04 mA/cm2) or sham. Motor outcomes were assessed using validated measures. Neuronal metabolites in both M1s were measured before and after intervention using fMRI-guided short-echo 3T MRS. RESULTS: Fifteen children [age(range) = 12.1(6.6-18.3) years] were studied. Motor performance improved in both groups and tDCS was associated with greater goal achievement. After cathodal tDCS, the non-lesioned M1 showed decreases in glutamate/glutamine and creatine while no metabolite changes occurred with sham tDCS. Lesioned M1 metabolite concentrations did not change post-intervention. Baseline function was highly correlated with lesioned M1 metabolite concentrations (N-acetyl-aspartate, choline, creatine, glutamate/glutamine). These correlations consistently increased in strength following intervention. Metabolite changes were not correlated with motor function change. Baseline lesioned M1 creatine and choline levels were associated with clinical response. CONCLUSIONS: MRS metabolite levels and changes may reflect mechanisms of tDCS-related M1 plasticity and response biomarkers in hemiparetic children with perinatal stroke undergoing intensive neurorehabilitation.

Varón de 77 años con disfonía y disfagia / A 77-year-old man with dysphonia and dysphagia

No disponible

Ability of electrical stimulation therapy to improve the effectiveness of robotic training for paretic upper limbs in patients with stroke.

We investigated whether untriggered neuromuscular electrical stimulation (NMES) can increase the effectiveness of shoulder and elbow robotic training in patients with hemiparesis. Thirty subacute stroke patients were randomly equally allocated to robot only (RO) and robot and electrical stimulation (RE) groups. During training, shoulder and elbow movements were trained by operating the robotic arm with the paretic arm, and the robotic device helped to move the arm. In the RE group, the anterior deltoid and triceps brachii muscles were electrically stimulated at sub-motor threshold intensity. Training was performed (approximately 1h/day, 5 days/week for 2 weeks) in addition to regular rehabilitation. Active range of motion (ROM) values of shoulder flexion and abduction, and Fugl-Meyer assessment (FMA) scores were measured before and after training. Active shoulder ROM was significantly better after than before training in the RE group; however, no such improvement was noted in the RO group. FMA scores were significantly better in both groups, and there was no significant difference between the groups. Untriggered NMES might increase the effectiveness of shoulder and elbow robotic training in patients with hemiparesis. Additionally, NMES at a sub-motor threshold during robotic training might facilitate activation of paretic muscles, resulting in paralysis improvement.

The adaptive drop foot stimulator - Multivariable learning control of foot pitch and roll motion in paretic gait.

Many stroke patients suffer from the drop foot syndrome, which is characterized by a limited ability to lift (the lateral and/or medial edge of) the foot and leads to a pathological gait. In this contribution, we consider the treatment of this syndrome via functional electrical stimulation (FES) of the peroneal nerve during the swing phase of the paretic foot. A novel three-electrodes setup allows us to manipulate the recruitment of m. tibialis anterior and m. fibularis longus via two independent FES channels without violating the zero-net-current requirement of FES. We characterize the domain of admissible stimulation intensities that results from the nonlinearities in patients' stimulation intensity tolerance. To compensate most of the cross-couplings between the FES intensities and the foot motion, we apply a nonlinear controller output mapping. Gait phase transitions as well as foot pitch and roll angles are assessed in realtime by means of an Inertial Measurement Unit (IMU). A decentralized Iterative Learning Control (ILC) scheme is used to adjust the stimulation to the current needs of the individual patient. We evaluate the effectiveness of this approach in experimental trials with drop foot patients walking on a treadmill and on level ground. Starting from conventional stimulation parameters, the controller automatically determines individual stimulation parameters and thus achieves physiological foot pitch and roll angle trajectories within at most two strides.

Stimulation map for control of functional grasp based on multi-channel EMG recordings.

Transcutaneous activation of muscles with electrical stimulation has limited selectivity in recruiting paralyzed muscles in stroke patients. However, the selectivity could be increased by the application of smaller electrodes and their appropriate positioning on the skin. We developed a method for selecting the appropriate positions of the stimulating electrodes based on electromyography (EMG). The EMG activity maps were estimated from signals recorded with two electrode arrays and two 24-channel wearable amplifiers positioned on the nonparetic and paretic forearms. The areas where the difference between the EMG maps obtained from the nonparetic and paretic arms was significant were identified as the stimulation sites. The stimulation was applied through array electrodes with magnetic holders and two wearable stimulators with four output channels each. The measures of functionality included joint angles measured with goniometers (hand opening) and grasp force measured with a multi-contact dynamometer (grasping). The stimulation protocol comprised co-activation of flexors and extensors to stabilize the wrist joint and prevent pronation/supination.

ESCAPS study protocol: a feasibility randomised controlled trial of 'Early electrical stimulation to the wrist extensors and wrist flexors to prevent the post-stroke complications of pain and contractures in the paretic arm'.

INTRODUCTION: Approximately 70% of patients with stroke experience impaired arm function, which is persistent and disabling for an estimated 40%. Loss of function reduces independence in daily activities and impacts on quality of life. Muscles in those who do not recover functional movement in the stroke affected arm are at risk of atrophy and contractures, which can be established as early as 6 weeks following stroke. Pain is also common. This study aims to evaluate the feasibility of a randomised controlled trial to test the efficacy and cost-effectiveness of delivering early intensive electrical stimulation (ES) to prevent post-stroke complications in the paretic upper limb. METHODS AND ANALYSIS: This is a feasibility randomised controlled trial (n=40) with embedded qualitative studies (patient/carer interviews and therapist focus groups) and feasibility economic evaluation. Patients will be recruited from the Stroke Unit at the Nottingham University Hospitals National Health Service (NHS) Trust within 72 h after stroke. Participants will be randomised to receive usual care or usual care and early ES to the wrist flexors and extensors for 30 min twice a day, 5 days a week for 3 months. The initial treatment(s) will be delivered by an occupational therapist or physiotherapist who will then train the patient and/or their nominated carer to self-manage subsequent treatments. ETHICS AND DISSEMINATION: This study has been granted ethical approval by the National Research Ethics Service, East Midlands Nottingham1 Research Ethics Committee (ref: 15/EM/0006). To our knowledge, this is the first study of its kind of the early application (within 72 h post-stroke) of ES to both the wrist extensors and wrist flexors of stroke survivors with upper limb impairment. The results will inform the design of a definitive randomised controlled trial. Dissemination will include 2 peer-reviewed journal publications and presentations at national conferences. TRIAL REGISTRATION NUMBER: ISRCTN1648908; Pre-results. Clinicaltrials.gov ID: NCT02324634.

Surface peroneal nerve stimulation in lower limb hemiparesis: effect on quantitative gait parameters.

OBJECTIVE: The objective of this study was to evaluate possible mechanisms for functional improvement and compare ambulation training with surface peroneal nerve stimulation vs. usual care via quantitative gait analysis. DESIGN: This study is a randomized controlled clinical trial. SETTING: The setting of this study is a teaching hospital of an academic medical center. PARTICIPANTS: One hundred ten chronic stroke survivors (>12 wks poststroke) with unilateral hemiparesis participated in this study. INTERVENTIONS: The subjects were randomized to a surface peroneal nerve stimulation device or usual care intervention. The subjects were treated for 12 wks and followed up for 6-mo posttreatment. MAIN OUTCOME MEASURES: Spatiotemporal, kinematic, and kinetic parameters of gait were the main outcome measures. RESULTS: Cadence (F3,153 = 5.81, P = 0.012), stride length (F3,179 = 20.01, P < 0.001), walking speed (F3,167 = 18.2, P < 0.001), anterior-posterior ground reaction force (F3,164 = 6.61, P = 0.004), peak hip power in preswing (F3,156 = 8.76, P < 0.001), and peak ankle power at push-off (F3,149 = 6.38, P = 0.005) all improved with respect to time. However, peak ankle ankle dorsiflexion in swing (F3,184 = 4.99, P = 0.031) worsened. In general, the greatest change for all parameters occurred during the treatment period. There were no significant treatment group × time interaction effects for any of the spatiotemporal, kinematic, or kinetic parameters. CONCLUSIONS: Gait training with peroneal nerve stimulation and usual care was associated with improvements in peak hip power in preswing and peak ankle power at push-off, which may have resulted in improved cadence, stride length, and walking speed; however, there were no differences between treatment groups. Both treatment groups also experienced a decrease in peak ankle ankle dorsiflexion in swing, although the clinical implications of this finding are unclear.

Clinical efficacy and sEMG analysis of a new traditional Chinese medicine therapy in the treatment of spasticity following apoplectic hemiparalysis.

To investigate the clinical effect and surface electromyography (sEMG) of rehabilitation exercise therapy in combination with total glucosides form Shaoyao Gancao decoction in treating spasticity after apoplectic hemiparalysis. Composite spasticity scale (CSS), Fugl-Meyer assessment (FMA) and modified Barthel index were compared between the exercise only group and the combined therapy group before and 1 month after the treatment to scale muscular tension, function and activities of daily living. Meanwhile, integrate EMG and root mean square (RMS) were used to detect the tension of upper limbs (biceps brachii) and ankles (tibialis anterior muscle and gastrocnemius) after the 1-month treatment. In the combined therapy group, the Ashworth and CSS scales were significantly improved compared to before the treatment (P < 0.05) and compared to the patients in the control group (P < 0.05). After the 1-month treatment, the combined therapy group showed significantly higher FMA and BI scores (P < 0.05) compared to the control group. For the combined therapy group, the sEMG was significantly improved at 1 month after the treatment (P < 0.05), while the control group only showed relatively slight improvement in the RMS of the tibialis anterior muscle and the gastrocnemius. The total glucosides form Shaoyao Gancao decoction could significantly improve the efficacy of the rehabilitation exercise therapy in the treatment of spasticity after apoplectic hemiparalysis, and its mechanism might involve the decrease of muscular tension.

[Optimization of diagnosis and control of treatment of gastrointestinal paresis in the early postoperative period in extended peritonitis].

The results of treatment of patients, operated on for extended peritonitis in reactive and toxic phases, presenting with prominent gastrointestinal paresis, using the impulse stimulation of their peristalsis and early enteral nutrition under guidance of electrogastroenterography, are analyzed. The method is simple in application, it may be used in surgical and reanimation stationaries of any level, it has not the current restrictions and special contraindications.

The effects of electromyography-controlled functional electrical stimulation on upper extremity function and cortical perfusion in stroke patients.

OBJECTIVE: The relation was investigated between hemiparetic arm function improvement and brain cortical perfusion (BCP) change during voluntary muscle contraction (VOL), EMG-controlled FES (EMG-FES) and simple electrical muscle stimulation (ES) before and after EMG-FES therapy in chronic stroke patients. METHODS: Sixteen chronic stroke patients with moderate residual hemiparesis underwent 5 months of task-orientated EMG-FES therapy of the paretic arm once or twice a week. Before and after treatment, arm function was clinically evaluated and BCP during VOL, ES and EMG-FES were assessed using multi-channel near-infrared spectroscopy. RESULTS: BCP in the ipsilesional sensory-motor cortex (SMC) was greater during EMG-FES than during VOL or ES; therefore, EMG-FES caused a shift in the dominant BCP from the contralesional to ipsilesional SMC. After EMG-FES therapy, arm function improved in most patients, with some individual variability, and there was significant improvement in Fugl-Meyer (FM) score and maximal grip strength (GS). Clinical improvement was accompanied by an increase in ipsilesional SMC activation during VOL and EMG-FES condition. CONCLUSION: The EMG-FES may have more influence on ipsilesional BCP than VOL or ES alone. SIGNIFICANCE: The sensory motor integration during EMG-FES therapy might facilitate BCP of the ipsilesional SMC and result in functional improvement of hemiparetic upper extremity.

Tolerability and effectiveness of a neuroprosthesis for the treatment of footdrop in pediatric patients with hemiparetic cerebral palsy.

OBJECTIVE: To assess the tolerability and efficacy of a commercially available footdrop neuroprosthesis for treatment of footdrop in children with hemiparetic cerebral palsy. DESIGN: A prospective, observational pilot study. SETTING: Marshfield Clinic, Department of Physical Medicine. PARTICIPANTS: Ten children, ages 7-12 years, with hemiparetic cerebral palsy, who use an ankle foot orthosis (AFO) for correction of footdrop. METHODS: Children replaced their AFO with a transcutaneous peroneal (fibular) nerve stimulation neuroprosthesis for 3 months. MAIN OUTCOME MEASUREMENTS: The ability to tolerate fitting and programming of the device, device-recorded wear time, a daily-use diary, satisfaction survey, and secondary measures, including passive range of motion and gait laboratory measurement of gait velocity and ankle kinematics. RESULTS: All 10 participants (100%) tolerated fitting and programming of the neuroprosthesis and wore the device for 6 weeks. Seven of 10 (70%) wore the device for the entire 3-month study period; 6 of 10 (60%) continued to use the device after study completion. Wear time varied from 2 to 11 hours per day. Tolerability and satisfaction were high; although 6 participants complained of "size" and "bulkiness" of the device, and 2 reported skin irritation. Gait velocity increased in 5 subjects (50%). Seven participants (70%) preferred the neuroprosthesis to their AFO. CONCLUSION: Analysis of the preliminary evidence suggests that electrical stimulation by a footdrop neuroprosthesis is tolerated well by children and is effective for the treatment of footdrop in children with hemiparetic cerebral palsy. Commercially available neuroprostheses may offer a promising alternative treatment option for children with footdrop.

The effects of dual-channel functional electrical stimulation on stance phase sagittal kinematics in patients with hemiparesis.

Sixteen subjects (aged 54.2 ± 14.1 years) with hemiparesis (7.9 ± 7.1 years since diagnosis) demonstrating a foot-drop and hamstrings muscle weakness were fitted with a dual-channel functional electrical stimulation (FES) system activating the dorsiflexors and hamstrings muscles. Measurements of gait performance were collected after a conditioning period of 6 weeks, during which the subjects used the system throughout the day. Gait was assessed with and without the dual-channel FES system, as well as with peroneal stimulation alone. Outcomes included lower limb kinematics and the step length taken with the non-paretic leg. Results with the dual-channel FES indicate that in the subgroup of subjects who demonstrated reduced hip extension but no knee hyperextension (n = 9), hamstrings FES increased hip extension during terminal stance without affecting the knee. Similarly, in the subgroup of subjects who demonstrated knee hyperextension but no limitation in hip extension (n = 7), FES restrained knee hyperextension without having an impact on hip movement. Additionally, step length was increased in all subjects. The peroneal FES had a positive effect only on the ankle. The results suggest that dual-channel FES for the dorsiflexors and hamstrings muscles may affect lower limb control beyond that which can be attributed to peroneal stimulation alone.

Foot and Knee Behaviour During Gait in Response to the Use of Additional Means of Treatment in Cerebral Palsied Children

BACKGROUND: Physiological human gait is characterized by tree-dimensional pelvis movements, which make that gait is smooth and does not require excessive energy expenditure. In children with cerebral palsy determinants of the pelvis may be affected, mainly due to pathological afferent synergisms. Therefore many specialists is looking for ways to improve this situation. The aim of this study was to verify whether the use of botulinium toxin or inhibitive casts affects the kinematic parameters of the pelvis during the gait of children with hemiparetic form of cerebral palsy. MATERIAL AND METHODS: The study involved 34 hemiparetic children with cerebral palsy aged 7-14 years who reached the capacity of walking. All were improving by neurodevelop-mental treatment according to NDT-Bobath method. Two groups were created. In the first group inhibiting casting was used in 16 children. In the second group botulinium toxin was injected in 18 children. Gait analysis was performed before and after using those type of treatment. Ultrasonic CMS-HS system (Zebris) was used for three dimensional gait analysis. RESULTS: Despite of the characteristic for hemiplegic gait pattern asymmetry, various ab-normalities of pelvis kinematic parameters were observed. Gait symmetry was improved aafter the treatment. Using inhibiting casts also improved kinematic parameters of the pelvis, especially in those children who are found deficit of decreasing and rotation of the pelvis. CONCLUSIONS: 1) The use of Btx-A or inhibitive casts results in improving temporal- spatial parameters of gait of cerebral palsied children with hemiparesis. 2) The improvement of kinematic pelvis parameters are obtained through the use of inhibitive casts, while the use of Btx-A does not have a significant impact on them.

Effects of dual-channel functional electrical stimulation on gait performance in patients with hemiparesis.

The study objective was to assess the effect of functional electrical stimulation (FES) applied to the peroneal nerve and thigh muscles on gait performance in subjects with hemiparesis. Participants were 45 subjects (age 57.8 ± 14.8 years) with hemiparesis (5.37 ± 5.43 years since diagnosis) demonstrating a foot-drop and impaired knee control. Thigh stimulation was applied either to the quadriceps or hamstrings muscles, depending on the dysfunction most affecting gait. Gait was assessed during a two-minute walk test with/without stimulation and with peroneal stimulation alone. A second assessment was conducted after six weeks of daily use. The addition of thigh muscles stimulation to peroneal stimulation significantly enhanced gait velocity measures at the initial and second evaluation. Gait symmetry was enhanced by the dual-channel stimulation only at the initial evaluation, and single-limb stance percentage only at the second assessment. For example, after six weeks, the two-minute gait speed with peroneal stimulation and with the dual channel was 0.66 ± 0.30 m/sec and 0.70 ± 0.31 m/sec, respectively (P < 0.0001). In conclusion, dual-channel FES may enhance gait performance in subjects with hemiparesis more than peroneal FES alone.

Motor imagery in stroke patients, or plegic patients with spinal cord or peripheral diseases.

OBJECTIVES: When motor imagery (MI) is impaired in stroke patients, it is not clear, whether this is caused by the central lesion with a disruption of networks or this may be due to inactivity/lack of practice following hemiparesis. To answer this question, we investigated MI in two groups of patients: stroke patients and patients with no central lesion, who suffered high-grade tetraparesis caused by myopathy or spinal muscular atrophy. MATERIALS AND METHODS: The first study measured MI in 31 sub-acute and chronic stroke patients with hand paresis. We used self-assessment questionnaires [Kinaesthetic and Visual Imagery Questionnaire (KVIQ), the Vividness of Motor Imagery Questionnaire (VMIQ)] as well as a new chronometric test (mental version and normal/physical version of Box and Block Test). The second study assessed MI in 10 patients without a central lesion, but with severe tetraparesis of peripheral origin. They were incapable of performing the requested task physically. RESULTS: MI in patients was better (i) for the third-person (VMIQ(3.P) ) compared to the first-person perspective (VMIQ(1.P) ), (ii) in patients without sensory impairment compared to those with impaired proprioception, (iii) in patients with light paresis compared to severe paresis and (iv) for the non-affected than the affected hand (KVIQ-10). Patients with severe tetraparesis were able to imagine another person's knee bends, but were not capable of imagining themselves performing knee bends. CONCLUSIONS: MI may be hampered on the affected side in severely paretic patients, particularly in the presence of impaired proprioception. Remarkably, the second study illustrates that motor experiences shape MI. This confirms the close relationship between MI and movement execution. The study advocates the careful use of test batteries for assessment of MI when investigating mental training in clinical trials. Not all patients might benefit to the same extent from MI training. This is possibly contingent on intact proprioception and preserved MI.

The effect of operant-conditioning balance training on the down-regulation of spinal H-reflexes in a spastic patient.

Spasticity in chronic hemiparetic stroke patients has primarily been treated pharmacologically. However, there is increasing evidence that physical rehabilitation can help manage hyper-excitability of reflexes (hyperreflexia), which is a primary contributor to spasticity. In the present study, one chronic hemiparetic stroke patient operantly conditioned the soleus H-reflex while training on a balance board for two weeks. The results showed a minimal decrease in the Hmax-Mmax ratio for both the affected and unaffected limb, indicating that the H-reflex was not significantly altered with training. Alternatively, paired-reflex depression (PRD), a measure of history-dependent changes in reflex excitability, could be conditioned. This was evident by the rightward shift and decreased slope of reflex excitability in the affected limb. The non-affected limb decreased as well, although the non-affected limb was very sensitive to PRD initially, whereas the affected limb was not. Based on these results, it was concluded that PRD is a better index of hyperreflexia, and this measurement could be more informative of synapse function than simple H-reflexes. This study presents a novel and non-pharmacological means of managing spasticity that warrants further investigation with the potential of being translated to the clinic.