Shoulder complex and trunk coordination of individuals with severe hemiparesis following a constraint-induced movement therapy protocol: A case series.

INTRODUCTION: Constraint Induced Movement Therapy (CIMT) has been shown to be an effective rehabilitation technique in individuals with mild and moderate upper limb (UL) hemiparesis. The aim was to evaluate the effect the CIMT for improving paretic UL use and interjoint coordination with individuals in severe hemiparesis. METHODS: Six individuals with severe chronic hemiparesis (mean age = 55 ± 16 years) received a UL CIMT intervention for 2 weeks. UL clinical assessments were conducted five times: two assessments at pre-intervention and then, one assessment at post-intervention and 1- and 3-month follow-up using the Graded Motor Activity Log GMAL) and the Graded Wolf Motor Function Test (GWMFT). Scapula, humerus and trunk coordination variability were assessed using the 3-D kinematics during arm elevation, combing hair, turning on the switch and grasp a washcloth. A paired t-test was used to check differences between coordination variability and a one-way ANOVA repeated measures was used to check differences between GMAL and GWMFT scores. RESULTS: There were no differences in GMAL and GWMFT between the patient screening and the baseline data collection (p > 0.05). GMAL scores increased at post-intervention and at follow-ups (p < 0.02). GWMFT performance time score decreased at post-intervention and at 1-month follow-up (p < 0.04). Improvements in kinematic variability of the paretic UL at pre and post-intervention were observed in all tasks, except in the activity of turn on the light switch. CONCLUSION: Following the CIMT protocol, improvements in GMAL and GWMFT scores may reflect improvements in paretic UL performance, in real-life environment. Improvements in kinematic variability may reflect an improving of UL interjoint coordination for individuals with chronic severe hemiparesis.

Repetitive peripheral magnetic stimulation combined with intensive physical therapy for gait disturbance after hemorrhagic stroke: an open-label case series.

In this pilot study, we aimed to determine the safety and feasibility of a 15-day protocol consisting of in-hospital repetitive peripheral magnetic stimulation (rPMS) combined with intensive physical therapy for the recovery of the gait disturbance in chronic stroke patients with lower limb hemiparesis. Seven hemorrhagic stroke patients with lower limb hemiparesis and gait disturbance (age: 50-78; time from onset of stroke: 7-107 months) were enrolled. rPMS was applied to the muscles of the paretic lower limb with a parabolic coil. A train of stimuli at a frequency of 20 Hz was applied for 3 s followed by a 27-s rest interval. Therapy with rPMS was performed with eighty such trains of stimuli (total 4800 pulses). Following rPMS therapy, 120 min of physical therapy was administrated daily. Each patient received this combination treatment over fifteen consecutive days, with the walking function of all participants assessed before and after the intervention. The proposed treatment protocol resulted in significant improvements in the walking speed, ambulation ability, and balance ability, but showed no significant effects on the endurance capacity, step length, and spasticity. No rPMS-related side effects were noted. Our protocol consisting of rPMS and intensive physical therapy appears well tolerated and feasible for therapy in hemorrhagic stroke patients with gait disturbance. Further large-scale studies are required to confirm its efficacy.

Dose-response of rPMS for upper Limb hemiparesis after stroke.

INTRODUCTION: Repetitive peripheral magnetic stimulation (rPMS) therapy is an innovative and minimally invasive neurorehabilitative technique and has been shown to facilitate neural plasticity. However, there is at present no research that clarifies the dose-response of rPMS therapy on the recovery of upper limb hemiparesis after stroke. This trial aims to clarify the dose-response of rPMS therapy combined with intensive occupational therapy (OT) for chronic stroke patients with moderate to severe upper limb hemiparesis. METHODS AND ANALYSIS: This multicenter, prospective, assessor-blinded, randomized controlled study with 3 parallel groups will be conducted from January 20, 2020 to September 30, 2022. Fifty patients will be randomly assigned in a ratio of 1:2:2 to the control group, the group receiving daily 2400 pulses of rPMS, or the group receiving daily 4800 pulses of rPMS, respectively. From the day after admission (Day 1), rPMS therapy and intensive OT will be initiated. The primary outcome is the change in the motor function of the affected upper extremity (Fugl-Meyer Assessment) between the time of admission (Day 0) and the day after 2 weeks of treatment (Day 14). Secondary outcomes will include the changes in spasticity, active range of motion, motor evoked potential, and activity of daily living. ETHICS AND DISSEMINATION: The study was approved by the Jikei University Certified Review Board for all institutions (reference number: JKI19-020). Results of the primary and secondary outcomes will be published in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients. TRIAL REGISTRATION NUMBER: jRCTs032190191.

Evaluation of a Magic Camp for Children with Hemiparesis: A Pilot Study.

This single-group open trial was designed to evaluate the effectiveness of a two-week magic camp as a means of hand-arm motor skills training to improve upper limb motor function (unilateral and bilateral) in children with hemiparesis. Seven children with hemiparesis participated in a magic camp program which met 3 days a week, 4 hours each day, for two consecutive weeks for a total of 24 hours. Participants completed three assessments at the beginning of the camp, post-camp, and at a three-month follow-up: the Jebsen Hand Function Test (JHFT), Children's Hand Experience Questionnaire (CHEQ), and a box opening task that required coordination of both upper limbs. A Wilcoxon signed-rank test revealed significant improvement in JHFT composite scores of the affected limb at post-camp (p = .04) and three-month follow-up (p = .04). In addition, a significant improvement in the number of activities performed using two hands from baseline to three-month follow-up was observed (p = .03). This pattern of improvement was also observed in the speed of completion for the box opening task. The improvement in motor function seems related to the participants' continuing performing daily activities with the affected hand and two hands after the magic camp.

Upper limb robot-assisted rehabilitation versus physical therapy on subacute stroke patients: A follow-up study.

This study aims to analyse the long-term effects (6 months follow-up) of upper limb Robot-assisted Therapy (RT) compared to Traditional physical Therapy (TT), in subacute stroke patients. Although the literature on upper-limb rehabilitation with robots shows increasing evidence of its effectiveness in stroke survivors, the length of time for which the re-learned motor abilities could be maintained is still understudied. A randomized controlled follow-up study was conducted on 48 subacute stroke patients who performed the upper-limb therapy using a planar end-effector robotic system (Experimental Group-EG) or TT (Control Group-CG). The clinical assessments were collected at T0 (baseline), T1 (end of treatment) and T2 (6 months follow-up): Upper Limb part of Fugl-Meyer assessment (FM-UL), total passive Range Of Motion (pROM), Modified Ashworth Scale Shoulder (MAS-S) and Elbow (MAS-E). At T1, the intra-group analysis showed significant gain of FM-UL in both EG and CG, while significant improvement in MAS-S, MAS-E, and pROM were found in the EG only. At T2, significant increase in MAS-S were revealed only in the CG. In FM-UL, pROM and MAS-E the improvements obtained at the end of treatment seem to be maintained at 6 months follow-up in both groups. The inter-groups analysis of FM-UL values at T1 and T2 demonstrated significant differences in favour of EG. In conclusion, upper limb Robot-assisted Therapy may lead a greater reduction of motor impairment in subacute stroke patients compared to Traditional Therapy. The gains observed at the end of treatment persisted over time. No serious adverse events related to the study occurred.

Central Drive to the Paretic Ankle Plantarflexors Affects the Relationship Between Propulsion and Walking Speed After Stroke.

BACKGROUND AND PURPOSE: The ankle plantarflexor muscles are the primary generators of propulsion during walking. Impaired paretic plantarflexion is a key contributor to interlimb propulsion asymmetry after stroke. Poststroke muscle weakness may be the result of a reduced force-generating capacity, reduced central drive, or a combination of these impairments. This study sought to elucidate the relationship between the neuromuscular function of the paretic plantarflexor muscles and propulsion deficits across individuals with different walking speeds. METHODS: For 40 individuals poststroke, we used instrumented gait analysis and dynamometry coupled with supramaximal electrostimulation to study the interplay between limb kinematics, the neuromuscular function of the paretic plantarflexors (ie, strength capacity and central drive), propulsion, and walking speed. RESULTS: The strength capacity of the paretic plantarflexors was not independently related to paretic propulsion. Reduced central drive to the paretic plantarflexors independently contributed to paretic propulsion deficits. An interaction between walking speed and plantarflexor central drive was observed. Individuals with slower speeds and lower paretic plantarflexor central drive presented with the largest propulsion impairments. Some study participants with low paretic plantarflexor central drive presented with similarly fast speeds as those with near-normal central drive by leveraging a compensatory reliance on nonparetic propulsion. The final model accounted for 86% of the variance in paretic propulsion (R = 0.86, F = 33.10, P < 0.001). DISCUSSION AND CONCLUSIONS: Individuals poststroke have latent paretic plantarflexion strength that they are not able to voluntarily access. The magnitude of central drive deficit is a strong indicator of propulsion impairment in both slow and fast walkers.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A298).

Analysis of the association between selected factors and outcomes of treadmill gait training with biofeedback in patients with chronic stroke.

OBJECTIVE: To examine the effects of age, time from stroke onset, gender and side of paresis in gait re-education with the use of treadmill with biofeedback, in patients with chronic stroke. METHODS: The study was performed with a group of 50 patients. 10-metre walk test, 2-minute walk test, "Up and Go" test, the number of steps performed with the paretic lower limb at a distance of 10 metres, Barthel index and FIM scale were used to assess the effects of rehabilitation. RESULTS: The study shows that the subjects' abilities and fitness prior to the rehabilitation were not related to age, sex or side of paresis. Analysis of the impact of age, time from stroke and sex on rehabilitation outcomes showed no statistically significant correlations. On the other hand, analysis of rehabilitation results relative to the side of paresis showed that the latter factor significantly differentiates rehabilitation outcomes measured with gait velocity test - p= 0.045. CONCLUSION: Age, duration of time from stroke onset, and sex do not affect outcomes of gait re-education based on treadmill training in patients at a chronic stage post-stroke and Brunnstrom recovery stage 3-4. Side of paresis significantly differentiates rehabilitation outcomes measured with speed test. The best scores in all the performance measures before rehabilitation were identified in the group 3-6 years after stroke.

Effects of in home high dose accelerometer-based feedback on perceived and actual use in participants chronic post-stroke.

Purpose To explore the effects of home-based high dose accelerometer-based feedback on (1) perception of paretic upper extremity (UE) use; (2) actual amount of use (AOU); and (3) capability. The secondary purpose was to characterize paretic UE use in the home setting. Materials and Methods : Prospective experimental pre/post design (trial reg: NCT02995213). Eight participants chronic post-stroke (57.03 ± 6.64 y.o.) wore bilateral wrist accelerometers for 3 weeks during which seven sessions of accelerometer-based feedback were administered in the home. Accelerometer data (overall use, unimanual use, bimanual use, paretic/nonparetic use ratio, different intensities of use) were collected at all follow-up visits; clinical outcomes/questionnaires were collected at baseline, mid-study, and post-intervention. Results : After receiving high dose accelerometer-based feedback, participants had significant perceived gains in how much (p = 0.017) and how well (p = 0.050) they used the paretic UE. However, there were no significant group changes in actual paretic UE AOU or capability. Conclusions : In home high dose accelerometer-based feedback increased perceived paretic UE use and overall awareness of paretic UE use. Perception of use may serve as a first step to promote the behavioral change necessary to encourage actual paretic UE use, potentially decreasing the maladaptive effects of learned nonuse on participation.

Effects of concomitant neuromuscular electrical stimulation during repetitive transcranial magnetic stimulation before repetitive facilitation exercise on the hemiparetic hand.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) and Repetitive facilitative exercise (RFE) improves motor impairment after stroke. OBJECTIVE: To investigate whether neuromuscular electrical stimulation (NMES) can facilitate the effects of rTMS and RFE on the function of the hemiparetic hand in stroke patients. METHODS: This randomized double-blinded crossover study divided 20 patients with hemiparesis into two groups and provided treatment for 4 weeks at 5 days/week. NMES-before-sham group and NMES-following-sham group performed NMES sessions and sham NMES sessions for each 2 weeks. Patients received NMES or sham NMES for the affected extensor muscle concurrently with 1 Hz rTMS for the unaffected motor cortex for 10 min and performed RFE for 60 min. The Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), Box and Block Test (BBT) and Modified Ashworth Scale (MAS) were used for evaluation. RESULTS: FMA and ARAT improved significantly during both sessions. The gains in the BBT during an NMES session were significantly greater than those during a sham NMES session. MAS for the wrist and finger significantly decreased only during an NMES session. CONCLUSIONS: NMES combined with rTMS might facilitate, at least in part, the beneficial effects of RFE on motor function and spasticity of the affected upper limb.

Studying the correlation between balance assessment by Biodex Stability System and Berg Scale in stroke individuals.

INTRODUCTION: Balance disorders are considered to be a serious clinical manifestation after stroke. Therefore, to assess stroke patients' balance performance, use of a quantitative method appears essential. A fundamental step would be the approval of the efficiency of the measurement instruments. The current study aimed to investigate correlations between balance assessment as examined by Biodex Stability System (BSS) and the clinical Berg Balance Scale (BBS) in post-stroke hemiparesis. METHODS: Twenty-five stroke survivors and 25 healthy age-sex matched subjects were recruited. The subjects were assessed using BSS during 3 days, with a 24-h interval. The high interclass correlation coefficient (ICC) values showed that the system was reliable enough to continue the study. The clinical evaluation was performed by the standard BBS. RESULTS: There was a significant moderate negative correlation between the Biodex overall indices and BBS scores in the stroke groups (ravg = -0.68) and in the healthy cohort (ravg = -0.55). Also, a significant moderate negative correlation was found between the Biodex antero-posterior stability indices and BBS scores in the stroke groups (ravg = -0.67) and in healthy cohort (ravg = -0.55). The correlation between the Biodex mediolateral stability indices and BBS scores was moderate to low in the stroke and healthy groups (ravg = -0.67 and -0.39 respectively). DISCUSSION AND CONCLUSION: Moderate negative correlation between the stability indices of the Biodex Stability System and BBS scores indicates that dynamic balance status of the participants partially reflects their functional balance status.

Dance-based exergaming for upper extremity rehabilitation and reducing fall-risk in community-dwelling individuals with chronic stroke. A preliminary study.

Background: Post-stroke, individuals demonstrate persistent upper extremity (UE) motor impairments that impact functional movements and change-in-support strategies essential for recovery from postural instability. OBJECTIVES: This study primarily aims to quantify the effect of dance-based exergaming (DBExG) intervention on improving paretic UE movement control. The secondary aim is to assess if these improvements in UE movement control if observed, could partially account for improved fall-risk.Methods: Thirteen adults with chronic stroke received DBExG training using the commercially available Kinect dance gaming "Just Dance 3". Surface electromyography of shoulder muscle activity during the stand-reaching task and UE shoulder kinematics for a dance trial were recorded. Changes in balance control were determined using the Activities-specific Balance Confidence scale [ABC] and Timed-Up-and-Go test [TUG].Results: Post-training, participants demonstrated improvements in shoulder muscle activity in the form of performance (reaction time, burst duration, and movement time) and production outcomes (peak acceleration) (p < .05). There was also a post-training increase in shoulder joint excursion (Ex) and peak joint angles (∠) during dance trials (p < .05). Participants exhibited positive post-intervention correlations between ABC and shoulder joint Ex [R2 of 0.43 (p < .05)] and between TUG and peak joint ∠ [R2 of 0.51 (p < .05)]. CONCLUSION: Findings demonstrated the beneficial effect of DBExG for improving UE movement and the training-induced gains were also positively correlated with improvements in fall-risk measures in people with chronic stroke. Thus, DBEx training could be used as a meaningful clinical application for this population group.

[Efficacy of Music Therapy in Functional Recovery of the Upper Limb After a Stroke: a Systematic Review and Meta-Analysis]. / Eficacia de la terapia musical en la recuperación funcional del miembro superior después de un ictus: una revisión sistemática y meta-análisis.

INTRODUCTION: Formal therapeutic interventions based on music have been used in rehabilitation to stimulate the brain functions involved in movement. OBJECTIVE: The objective of this study was to conduct a systematic review and meta-analysis following the PRISMA recommendations on the effectiveness of music therapy in improving the functionality of the upper limb in patients with hemiparesis secondary to stroke. METHODS: A search of the Pubmed, clinicaltrials.gov and Cochrane databases was performed in September 2018. The articles included in this review had to meet the following criteria: randomised controlled trials with therapeutic interventions that evaluated improvement in manual dexterity, measured with the box and block test in patients older than 18 years with a residual deficit secondary to an ischaemic or haemorrhagic stroke in the previous months. RESULTS: Of 371 studies analysed, six were included in the study and subsequent meta-analysis with a total of 149 patients. The musical interventions improved the functionality of the parietal limb in patients with stroke compared with that in controls who received conventional treatment. This effect was statistically significant in the meta-analysis, with a difference in the standardised mean in the box and block test of 0.40 (95% CI 0.09 - 0.72). CONCLUSIONS: Musical interventions could be beneficial for the functional recovery of the upper extremity. These results are encouraging but a greater number of clinical trials are required to confirm these findings before their subsequent implementation in clinical practice.

The ESCAPS study: a feasibility randomized controlled trial of early electrical stimulation to the wrist extensors and flexors to prevent post-stroke complications of pain and contractures in the paretic arm.

OBJECTIVE: To establish feasibility of initiating electrical stimulation treatment of wrist extensors and flexors in patients early after stroke to prevent muscle contractures and pain. DESIGN: Feasibility randomized controlled trial with economic evaluation. SETTING: A specialist stroke unit in Nottinghamshire. SUBJECTS: A total of 40 patients recruited within 72 hours post-stroke with arm hemiparesis. INTERVENTIONS: Participants were randomized to receive usual care or usual care and electrical stimulation to wrist flexors and extensors for 30 minutes, twice a day, five days a week for three months. Initial treatment was delivered by an occupational therapist or physiotherapist who trained participants to self-manage subsequent treatments. MEASURES: Measures of feasibility included recruitment and attrition rates, completion of treatment, and successful data collection. Outcome data on wrist range of motion, pain, arm function, independence, quality of life, and resource use were measured at 3-, 6-, and 12-months post-randomization. RESULTS: A total of 40 participants (of 215 potentially eligible) were recruited in 15 months (20 men; mean age: 72 (SD: 13.0)). Half the participants lacked mental capacity and were recruited by consultee consent. Attrition at three-month follow-up was 12.5% (death (n = 2), end-of-life care (n = 2), and unable to contact (n = 1)). Compliance varied (mean: 65 (SD: 53)) and ranged from 10 to 166 treatments per patient (target dosage was 120). Data for a valid economic analysis can be adequately collected. CONCLUSION: Early initiation of electrical stimulation was acceptable and feasible. Data collection methods used were feasible and acceptable to participants. A large definitive study is needed to determine if electrical stimulation is efficacious and cost effective.

Bilateral Contralaterally Controlled Functional Electrical Stimulation Reveals New Insights Into the Interhemispheric Competition Model in Chronic Stroke.

Background. Upper-limb chronic stroke hemiplegia was once thought to persist because of disproportionate amounts of inhibition imposed from the contralesional on the ipsilesional hemisphere. Thus, one rehabilitation strategy involves discouraging engagement of the contralesional hemisphere by only engaging the impaired upper limb with intensive unilateral activities. However, this premise has recently been debated and has been shown to be task specific and/or apply only to a subset of the stroke population. Bilateral rehabilitation, conversely, engages both hemispheres and has been shown to benefit motor recovery. To determine what neurophysiological strategies bilateral therapies may engage, we compared the effects of a bilateral and unilateral based therapy using transcranial magnetic stimulation. Methods. We adopted a peripheral electrical stimulation paradigm where participants received 1 session of bilateral contralaterally controlled functional electrical stimulation (CCFES) and 1 session of unilateral cyclic neuromuscular electrical stimulation (cNMES) in a repeated-measures design. In all, 15 chronic stroke participants with a wide range of motor impairments (upper extremity Fugl-Meyer score: 15 [severe] to 63 [mild]) underwent single 1-hour sessions of CCFES and cNMES. We measured whether CCFES and cNMES produced different effects on interhemispheric inhibition (IHI) to the ipsilesional hemisphere, ipsilesional corticospinal output, and ipsilateral corticospinal output originating from the contralesional hemisphere. Results. CCFES reduced IHI and maintained ipsilesional output when compared with cNMES. We found no effect on ipsilateral output for either condition. Finally, the less-impaired participants demonstrated a greater increase in ipsilesional output following CCFES. Conclusions. Our results suggest that bilateral therapies are capable of alleviating inhibition on the ipsilesional hemisphere and enhancing output to the paretic limb.

Functional electrical stimulation improves reaching movement in the shoulder and elbow muscles of stroke patients: A three-dimensional motion analysis.

BACKGROUND: Recovery of motor function following stroke is essential to restore adequate functionality. The use of functional electrical stimulation (FES) technology as a neuroprosthesis to enhance the motor function of the UL, and thus facilitate the performance of ADL, could lead to a stroke patient's greater activity and participation in daily life. OBJECTIVE: The aim of the present study was to establish whether the application of FES in patients who have suffered a stroke with UL motor impairment is able to modify and facilitate their reaching patterns, measured by a three-dimensional motion capture system. METHODS: 20 patients with chronic stroke participated in this study. For muscle stimulation, the electrical stimulator Compex® was used. Motion analysis was performed using the VICON Motion System®. Joint movements of the thorax, shoulder and elbow were analyzed in the sagittal plane, during the reaching movement under two different conditions of stimulation: FES condition and placebo condition. RESULTS: Differences between FES condition and placebo condition were observed. In the FES condition it was recorded: an increased shoulder flexion and elbow extension in the reaching movement. CONCLUSIONS: Functional electrical stimulation improved reaching movement in stroke patients with upper limb impairment.

Effects of Vibrotactile Biofeedback Coding Schemes on Gait Symmetry Training of Individuals With Stroke.

Variations in biofeedback coding schemes for postural control, in recent research, have shown significant differences in performance outcomes due to variations in coding schemes. However, the application of vibrotactile biofeedback coding schemes to gait symmetry training is not well explored. In this paper, we devised various vibrotactile biofeedback modes and identified their efficacy during gait symmetry training of individuals suffering from hemiparesis due to stroke. These modes are composed of variations in vibration type (on-time or intensity), and relation type (proportional or inversely-proportional) with the error in symmetry ratio. Eight individuals with stroke participated in walking trials. From dependent t-tests on the collected data, we found improved achievement of temporal gait symmetry while utilizing all the provided biofeedback modes compared to no biofeedback (P < 0.001). Furthermore, two-way repeated measures ANOVA revealed statistically significant difference in symmetry ratio for main effect of vibration type (P-value = 0.016, partial eta squared = 0.585). The participants performed better with modes of biofeedback with varying vibration on-times. Furthermore, participants showed better performance when the biofeedback varied proportionally with the error. These findings suggest that biofeedback coding schemes may have a significant effect on the performance of gait training.

Sound design for auditory biofeedback and motor performance in participants with stroke: a pilot study.

Background: Although auditory biofeedback (ABF) has proved to be effective in stroke rehabilitation, there are a variety of means by which to present information through sound. Objectives: To examine if ABF sound design influences the motor performance of patients with stroke. Methods: A total of four people with chronic stroke participated . They were asked to track target signals by their paretic ankle dorsiflexion. Half of the participants were assigned to one of the two groups. Those in the Error ABF group heard ABF that alerted them to the error between the target and the joint angle. Those in the Full ABF group heard ABF that presented both the target and the angle separately by modulating the frequencies of two sounds. Therefore, when there was no error, no sound or two sounds with the identical frequency were heard in the Error and Full ABF sessions, respectively. The same visual BF (VBF) was always present regardless of the group. The accuracy of the task was quantified via an accuracy index (AI, ranging from -100 to 100). All participants were trained by repeating tracking, and the pre- and post-training AIs were obtained. Results: The AIs of all participants increased after training, but the increase was greater for the Error ABF group (mean increase = 8.9 and 14.9 for the Full and Error groups, respectively). Conclusions: The Full ABF was less effective than the Error ABF, probably because the VBF was present, and the information provided by the Full ABF was therefore redundant.

Fu's subcutaneous needling and constraint-induced movement therapy for a patient with chronic stroke: One-year follow-up case report.

RATIONALE: Spasticity is a common issue in chronic stroke. To date, no study has reported the long-term (up to 1 year) outcomes of Fu's subcutaneous needling in combination with constraint-induced movement therapy in chronic stroke. This report describes the successful addition of acupuncture on spasticity and arm function in a patient with chronic stroke and arm paresis. PATIENT CONCERNS: The patient suffered an infarction in the right posterior limb of the internal capsule 1 year ago, which resulted in hemiparesis in his left (nondominant) hand and arm. The only limitation for constraint-induced movement therapy was insufficient finger extension. The patient was unable to voluntarily extend his interphalangeal or metacarpophalangeal joints beyond the 10 degrees required for constraint-induced movement therapy. However, his muscle tension did not change after the BTX type A injection. DIAGNOSES: A 35-year-old male experienced arm paresis after an infarction in the right posterior limb of the internal capsule 1 year before the intervention. INTERVENTIONS: The BTX type A injection did not work, so the patient received Fu's subcutaneous needling as an alternative therapy before 5 h of constraint-induced movement therapy for 12 weekdays. OUTCOMES: All outcome measures (Modified Ashworth Scale, Fugl-Meyer Assessment, Action Research Arm Test, and Motor Activity Log) substantially improved over the 1-year period. Moreover, during the observation period, the patient's muscle tone and arm function did not worsen. LESSONS: As a result of a reduction in spasticity, a reduction of learned nonuse behaviors, or use-dependent plasticity after the combined therapy, the arm functions include volitional movements, and coordination or speed of movements in the paretic arm have been improved. However, we cannot rule out the possibility of an influence of the passage of time or the Hawthorne effect. The costs of the treatment of stroke may be reduced, if this combined therapy proved useful in future controlled studies.

Synergy-Based FES for Post-Stroke Rehabilitation of Upper-Limb Motor Functions.

Functional electrical stimulation (FES) is capable of activating muscles that are under-recruited in neurological diseases, such as stroke. Therefore, FES provides a promising technology for assisting upper-limb motor functions in rehabilitation following stroke. However, the full benefits of FES may be limited due to lack of a systematic approach to formulate the pattern of stimulation. Our preliminary work demonstrated that it is feasible to use muscle synergy to guide the generation of FES patterns.In this paper, we present a methodology of formulating FES patterns based on muscle synergies of a normal subject using a programmable multi-channel FES device. The effectiveness of the synergy-based FES was tested in two sets of experiments. In experiment one, the instantaneous effects of FES to improve movement kinematics were tested in three patients post ischemic stroke. Patients performed frontal reaching and lateral reaching tasks, which involved coordinated movements in the elbow and shoulder joints. The FES pattern was adjusted in amplitude and time profile for each subject in each task. In experiment two, a 5-day session of intervention using synergy-based FES was delivered to another three patients, in which patients performed task-oriented training in the same reaching movements in one-hour-per-day dose. The outcome of the short-term intervention was measured by changes in Fugl-Meyer scores and movement kinematics. Results on instantaneous effects showed that FES assistance was effective to increase the peak hand velocity in both or one of the tasks. In short-term intervention, evaluations prior to and post intervention showed improvements in both Fugl-Meyer scores and movement kinematics. The muscle synergy of patients also tended to evolve towards that of the normal subject. These results provide promising evidence of benefits using synergy-based FES for upper-limb rehabilitation following stroke. This is the first step towards a clinical protocol of applying FES as therapeutic intervention in stroke rehabilitation.

The comparative efficacy of theta burst stimulation or functional electrical stimulation when combined with physical therapy after stroke: a randomized controlled trial.

OBJECTIVE:: To study the long-term effectiveness of Theta Burst Stimulation (TBS) or Functional Electrical Stimulation (FES) combined with Physical therapy (PT) as compared to PT alone for improving arm functions in patients with acute stroke. DESIGN:: Single blind randomized controlled trial. SETTING:: Outpatient clinics and inpatient wards at tertiary care neurology center. SUBJECTS:: Adult patients with acute middle cerebral artery territory ischemic stroke. INTERVENTIONS:: 60 patients were randomized into three groups of 20 each: TBS+PT; FES+PT; and PT alone. TBS group received intermittent TBS of ipsilesional hemisphere and continuous TBS of contralesional hemisphere while FES group received FES of paretic limb, both for four weeks. All groups received supervised physical therapy for four weeks followed by home physiotherapy for one year. OUTCOME MEASURES:: Fugl Meyer Assessment upper limb score (FMA-UL) was primary outcome measure. Patients were evaluated at baseline and subsequently at one, three and six months and one year. RESULTS:: Compared to PT group, mean FMA-UL scores were higher in TBS and FES groups at all follow-ups ( P < 0.001). From baseline to one year, mean (SD) FMA-UL scores increased from 14.9(2.1) to 55.55(2.46) in TBS group, 15.5(1.99) to 55.85(2.46) in FES group, and 14.3(2.2) to 43.3(4.22) in PT group indicating an increase of 273%, 260%, and 203% respectively. There was no difference between FES and TBS groups. CONCLUSION:: A four-week intervention with TBS or FES combined with PT produces better long-term arm functions as compared to PT alone in patients with acute stroke.