Wrist Rehabilitation Assisted by an Electromyography-Driven Neuromuscular Electrical Stimulation Robot After Stroke.

BACKGROUND: Augmented physical training with assistance from robot and neuromuscular electrical stimulation (NMES) may introduce intensive motor improvement in chronic stroke. OBJECTIVE: To compare the rehabilitation effectiveness achieved by NMES robot-assisted wrist training and that by robot-assisted training. METHODS: This study was a single-blinded randomized controlled trial with a 3-month follow-up. Twenty-six hemiplegic subjects with chronic stroke were randomly assigned to receive 20-session wrist training with an electromyography (EMG)-driven NMES robot (NMES robot group, n = 11) and with an EMG-driven robot (robot group, n = 15), completed within 7 consecutive weeks. Clinical scores, Fugl-Meyer Assessment (FMA), Modified Ashworth Score (MAS), and Action Research Arm Test (ARAT) were used to evaluate the training effects before and after the training, as well as 3 months later. An EMG parameter, muscle co-contraction index, was also applied to investigate the session-by-session variation in muscular coordination patterns during the training. RESULTS: The improvement in FMA (shoulder/elbow, wrist/hand) obtained in the NMES robot group was more significant than the robot group (P < .05). Significant improvement in ARAT was achieved in the NMES robot group (P < .05) but absent in the robot group. NMES robot-assisted training showed better performance in releasing muscle co-contraction than the robot-assisted across the training sessions (P < .05). CONCLUSIONS: The NMES robot-assisted wrist training was more effective than the pure robot. The additional NMES application in the treatment could bring more improvements in the distal motor functions and faster rehabilitation progress.

A pilot controlled trial of a combination of dense cranial electroacupuncture stimulation and body acupuncture for post-stroke depression.

BACKGROUND: Our previous studies have demonstrated the treatment benefits of dense cranial electroacupuncture stimulation (DCEAS), a novel brain stimulation therapy in patients with major depression, postpartum depression and obsessive-compulsive disorder. The purpose of the present study was to further evaluate the effectiveness of DCEAS combined with body acupuncture and selective serotonin reuptake inhibitors (SSRIs) in patients with post-stroke depression (PSD). METHODS: In a single-blind, randomized controlled trial, 43 patients with PSD were randomly assigned to 12 sessions of DCEAS plus SSRI plus body electroacupuncture (n = 23), or sham (non-invasive cranial electroacupuncture, n-CEA) plus SSRI plus body electroacupuncture (n = 20) for 3 sessions per week over 4 weeks. Treatment outcomes were measured using the 17-item Hamilton Depression Rating Scale (HAMD-17), the Clinical Global Impression - Severity scale (CGI-S) and Barthel Index (BI), a measure used to evaluate movement ability associated with daily self-caring activity. RESULTS: DCEAS produced a significantly greater reduction of both HAMD-17 and CGI-S as early as week 1 and CGI-S at endpoint compared to n-CEA, but subjects of n-CEA group exhibited a significantly greater improvement on BI at week 4 than DCEAS. Incidence of adverse events was not different in the two groups. CONCLUSIONS: These results indicate that DCEAS could be effective in reducing stroke patients' depressive symptoms. Superficial electrical stimulation in n-CEA group may be beneficial in improving movement disability of stroke patients. A combination of DCEAS and body acupuncture can be considered a treatment option for neuropsychiatric sequelae of stroke. TRIAL REGISTRATION: http://www.clinicaltrials.gov, NCT01174394.

Oral health promotion interventions on oral yeast in hospitalised and medically compromised patients: a systematic review.

Yeast are major aetiological agents of localised oral mucosal lesions, and are also leading causes of nosocomial bloodstream infections. The purpose of this systematic review was to examine the effectiveness of oral health promotion interventions on the prevalence and incidence of these opportunistic oral pathogens in hospitalised and medically compromised patients. The PubMed, ISI Web of Science and Cochrane Library databases were searched for clinical trials assessing the effect of oral health promotion interventions on oral yeast. Chlorhexidine delivered in a variety of oral hygiene products appeared to have some effect on oral yeast, although some studies found equivocal effects. Although a wide array of other compounds have also been investigated, their clinical effectiveness remains to be substantiated. Likewise, the utility of mechanical oral hygiene interventions and other oral health promotion measures such as topical application of salivary substitute, remains unsettled. Although many chemical agents contained in oral hygiene products have proven in vitro activity against oral yeast, their clinical effectiveness and potential role as adjuncts or alternative therapies to conventional treatment remains to be confirmed by further high-quality randomised controlled trials. This is pertinent, given the recent emergence of yeast resistance to conventional antifungal agents.

An fMRI study showing the effect of acupuncture in chronic stage stroke patients with aphasia.

Acupuncture is used as a treatment in stroke patients with aphasia, yet the underlying neural mechanisms are unknown. This study aims to examine the relationship between changes in language function and brain activation using functional magnetic resonance imaging in chronic stroke patients with aphasia who underwent an 8-week acupuncture protocol. Seven chronic stroke patients were identified from a stroke database of a regional acute hospital in Hong Kong between January and July 2007. Patients were treated three times a week over a period of 8 weeks. Four acupoints were stimulated on the weak side of the patient's body. No other rehabilitation was given during the study period. Changes in language function were measured by aphasia quotient (AQ) of Cantonese Aphasia Battery (CAB). Functional magnetic resonance imaging blood oxygen level dependent signals were used to demonstrate the correlation between changes in AQ and brain activation after treatment. The patients were divided into well-recovered and poorly- recovered groups based on their CAB scores at entry. The well-recovered group showed significant improvement in CAB scores after receiving acupuncture treatment. A significant correlation between changes in AQ and blood oxygen level dependent activation in the lesioned Wernicke's speech area was found. These preliminary results suggest that acupuncture may be beneficial to language recovery in chronic stroke patients.

A randomized controlled trial of mental imagery augment generalization of learning in acute poststroke patients.

BACKGROUND AND PURPOSE: Our previous studies demonstrated that mental imagery intervention enhanced poststroke patients relearning daily task performance. This study aimed to test the efficacy of mental imagery for promoting generalization of the task skills learned in a training environment to trained and untrained tasks carried out in a novel environment. METHODS: Thirty-five acute poststroke patients were randomly assigned to the mental imagery (MI; n=18) or conventional functional rehabilitation (FR; n=17) group. The MI intervention was 3-week standardized practices and daily tasks using the chunking-regulation-rehearsal strategies. Outcome measurements were the performances on trained and untrained tasks in the training and novel environments. RESULTS: The MI patients showed significantly better performances on 4 of 5 trained tasks (P=0.001 to 0.026) versus only 1 task in the FR patients (P=0.021). The MI patients also outperformed their FR counterpart on the 3 (of 5) (P=0.025 to 0.049) trained and 2 (of 3) untrained tasks (P=0.042 to 0.045) carried out in the novel environment. CONCLUSIONS: The mental imagery intervention was useful for improving patients' ability on performing the tasks which they did not previously trained on and in places different from the training environments. These involved generalization of the skills learned at the task performance level. Our findings are limited to poststoke patients who share similar characteristics with those in this study.

A pilot study of randomized clinical controlled trial of gait training in subacute stroke patients with partial body-weight support electromechanical gait trainer and functional electrical stimulation: six-month follow-up.

BACKGROUND AND PURPOSE: This study aimed to assess the effectiveness of gait training using an electromechanical gait trainer with or without functional electrical stimulation for people with subacute stroke. METHODS: This was a nonblinded randomized controlled trial with a 6-month follow-up. Fifty-four subjects were recruited within 6 weeks after stroke onset and were randomly assigned to 1 of 3 gait intervention groups: conventional overground gait training treatment (CT, n=21), electromechanical gait trainer (GT, n=17) and, electromechanical gait trainer with functional electrical stimulation (GT-FES, n=16). All subjects were to undergo an assigned intervention program comprising a 20-minute session every weekday for 4 weeks. The outcome measures were Functional Independence Measure, Barthel Index, Motricity Index leg subscale, Elderly Mobility Scale (EMS), Berg Balance Scale, Functional Ambulatory Category (FAC), and 5-meter walking speed test. Assessments were made at baseline, at the end of the 4-week intervention program, and 6 months after the program ended. RESULTS: By intention-to-treat and multivariate analysis, statistically significant differences showed up in EMS (Wilks' lambda=0.743, P=0.005), FAC (Wilks' lambda=0.744, P=0.005) and gait speed (Wilks' lambda=0.658, P<0.0001). Post hoc analysis (univariate 2-way ANCOVA) revealed that the GT and GT-FES groups showed significantly better improvement in comparison with the CT group at the end of the 4 weeks of training and in the 6-month follow-up. CONCLUSIONS: For the early stage after stroke, this study indicated a higher effectiveness in poststroke gait training that used an electromechanical gait trainer compared with conventional overground gait training. The training effect was sustained through to the 6-month follow-up after the intervention.

Cortical reorganization for response regulation with unilateral thalamic stroke detected by functional MRI.

To understand neural reorganization of response regulation after stroke, a 54-year-old woman with a chronic left thalamic stroke performed a task requiring decisions about the directionality of an arrow during cerebral functional magnetic resonance imaging. Her performance was compared to 13 matched healthy control subjects. Her behavioral responses were slower but as accurate. Bilateral frontal activations were observed in the right medial frontal gyrus (BA 9), left superior frontal gyrus (BA 45), and left frontal rectus gyrus (BA 11). Activation in the right medial frontal gyrus, along with activity in close proximity to the anterior cingulate cortex, was observed, which may reflect reorganization of activity after the loss of function of the anterior cingulate cortex.

Gait training of patients after stroke using an electromechanical gait trainer combined with simultaneous functional electrical stimulation.

BACKGROUND AND PURPOSE: This case report describes the implementation of gait training intervention that used an electromechanical gait trainer with simultaneous functional electrical stimulation (FES) for 2 patients with acute ischemic stroke. CASE DESCRIPTION: Two individuals with post-stroke hemiplegia of less than 6 weeks' duration participated in a 4-week gait training program as an adjunct to physical therapy received at a hospital. After the 4-week intervention, both patients were discharged from the hospital, and they returned after 6 months for a follow-up evaluation. OUTCOMES: By the end of the 4-week intervention, both patients had shown improvements in scores on the Barthel Index, Berg Balance Scale, Functional Ambulation Categories Scale, 5-m timed walking test, and Motricity Index. In the 6-month follow-up evaluation, both patients continued to have improvements in all outcome measures. DISCUSSION: This case report shows that, following the use of an electromechanical gait trainer simultaneously with FES, patients after acute stroke had improvements in gait performance, functional activities, balance, and motor control in the long term.

The differential effects of thalamus and basal ganglia on facial emotion recognition.

This study examined if subcortical stroke was associated with impaired facial emotion recognition. Furthermore, the lateralization of the impairment and the differential profiles of facial emotion recognition deficits with localized thalamic or basal ganglia damage were also studied. Thirty-eight patients with subcortical strokes and 19 matched normal controls volunteered to participate. The participants were individually presented with morphed photographs of facial emotion expressions over multiple trials. They were requested to classify each of these morphed photographs according to Ekman's six basic emotion categories. The findings indicated that the clinical participants had impaired facial emotion recognition, though no clear lateralization pattern of impairment was observed. The patients with localized thalamic damage performed significantly worse in recognizing sadness than the controls. Longitudinal studies on patients with subcortical brain damage should be conducted to examine how cognitive reorganization post-stroke would affect emotion recognition.

Functional electrical stimulation improves motor recovery of the lower extremity and walking ability of subjects with first acute stroke: a randomized placebo-controlled trial.

BACKGROUND AND PURPOSE: The effectiveness of functional electrical stimulation (FES) has been investigated in chronic hemiplegia. The present study examines whether FES, given during acute stroke, was more effective in promoting motor recovery of the lower extremity and walking ability than standard rehabilitation alone. METHODS: Forty-six subjects, 70.9+/-8.0 years old and 9.2+/-4.1 days after stroke, were assigned randomly to 1 of 3 groups receiving standard rehabilitation with FES or placebo stimulation or alone (control). FES was applied 30 minutes and placebo stimulation 60 minutes, 5 days per week for 3 weeks. Outcome measurements included composite spasticity score, maximum isometric voluntary contraction of ankle dorsi-flexors and planter-flexors, and walking ability. They were recorded before treatment, weekly during the 3-week treatment, and at week 8 after stroke. RESULTS: No significant differences were found in the baseline measurements. After 3 weeks of treatment, there was a significant reduction in the percentage of composite spasticity score, and a significant improvement in the ankle dorsiflexion torque, accompanied by an increase in agonist electromyogram and a reduction in electromyogram cocontraction ratio in the FES group, when compared with the other 2 groups (P<0.05). All subjects in the FES group were able to walk after treatment, and 84.6% of them returned home, in comparison with the placebo (53.3%) and control (46.2%, P<0.05) groups. CONCLUSIONS: Fifteen sessions of FES, applied to subjects with acute stroke plus standard rehabilitation, improved their motor and walking ability to the degree that more subjects were able to return to home.