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.

Efficacy of individualized homeopathic medicines in treatment of post-stroke hemiparesis: A randomized trial.

BACKGROUND: Hemiparesis is a serious motor impairment following stroke and affecting around 65% of stroke patients. This trial attempts to study the efficacy of individualized homeopathic medicines (IHMs) in comparison with identical-looking placebos in treatment of post-stroke hemiparesis (PSH) in the mutual context of standard physiotherapy (SP). METHODS: A 3-months, open-label, randomized, placebo-controlled trial (n = 60) was conducted at the Organon of Medicine outpatient departments of National Institute of Homoeopathy, West Bengal, India. Patients were randomized to receive IHMs plus SP (n = 30) or identical-looking placebos plus SP (n = 30). Primary outcome measure was Medical Research Council (MRC) muscle strength grading scale; secondary outcomes were Stroke Impact Scale (SIS) version 2.0, Modified Ashworth Scale (MAS), and stroke recovery 0-100 visual analogue scale (VAS) scores; all measured at baseline and 3 months after intervention. Group differences and effect sizes (Cohen's d) were calculated on intention-to-treat sample. RESULTS: Although overall improvements were higher in the IHMs group than placebos with small to medium effect sizes, the group differences were statistically non-significant (all P>0.05, unpaired t-tests). Improvement in SIS physical problems was significantly higher in IHMs than placebos (mean difference 2.0, 95% confidence interval 0.3 to 3.8, P = 0.025, unpaired t-test). Causticum, Lachesis mutus, and Nux vomica were the most frequently prescribed medicines. No harms, unintended effects, homeopathic aggravations or any serious adverse events were reported from either group. CONCLUSION: There was a small, but non-significant direction of effect favoring homeopathy against placebos in treatment of post-stroke hemiparesis. TRIAL REGISTRATION: CTRI/2018/10/016196; UTN: U1111-1221-7664.

[Restoration of hand function in patients with hemiparesis using mirror therapy in combination with myofascial stretching and postisometric relaxation]. / Vosstanovlenie funktsii kisti u patsientov s gemiparezom s primeneniem metoda zerkal'noi terapii v sochetanii s miofastsial'nym rastyazheniem i postizometricheskoi relaksatsiei.

The increase in the number of cerebral strokes is accompanied by the accumulation of patients with hemiparesis. It is especially difficult to restore the function of the upper limb, in particular the hand, which significantly limits the social, domestic and labor adaptation of patients. This makes it relevant to search for new methods for restoring the functions of the hand. Today, mirror therapy is becoming increasingly popular, which, however, does not eliminate myogenic contractures in the joints of a paralyzed limb. PURPOSE OF THE STUDY: Rationale for the use of mirror therapy in combination with myofascial stretching and postisometric relaxation in patients with hemiparesis. MATERIAL AND METHODS: 277 patients with hemiparesis were examined, of which 68 patients were included in the main group; 209 - to the comparison group. All patients underwent a course of rehabilitation treatment for 10 days. Patients of the main group additionally received mirror therapy in combination with myofascial stretching and post-isometric relaxation: course - 10 individual sessions, session duration - 30 minutes. Upon admission and before discharge, patients were evaluated for neurological status, severity of spastic and pain syndromes; the strength of the muscles of the paralyzed upper limb according to the Lovett scale; tested self-service skills in accordance with the International Classification of Functioning, Disabilities and Health. RESULTS: In patients of both groups, the severity of spastic and pain syndromes decreased, muscle strength increased. In the main group, these changes were more pronounced; 35 patients of the main group mastered new types of grip, which statistically significantly improved their social adaptability. CONCLUSION: Mirror therapy in combination with soft manual therapy techniques is able to restore precise targeted movements in the joints of the hand and fingers, form different grip options, which expands the possibilities of self-care for patients.

Effectiveness of Repetitive Facilitative Exercise Combined with Electrical Stimulation Therapy to Improve Very Severe Paretic Upper Limbs in with Stroke Patients: A Randomized Controlled Trial.

Background: The difference in the effects of combined therapy with repetitive facilitative exercise (RFE) and neuromuscular electrical stimulation (NMES) on stroke upper limb paralysis was only reported by a pilot study; it has not been investigated in many patients. Objective: We investigated the effect of combined therapy with RFE and NMES on stroke patients with severe upper paresis. Methods: This study included 99 of the very severe paresis stroke patients with scores of zero or 1a in the Finger-Function test of the Stroke Impairment Assessment Set (SIAS). We randomly divided the patients into four groups, namely, NMES, RFE, RFE under NMES, and conventional training (CT) groups. A total of 20 min of group-specific training in addition to 40 min of conventional exercise per day, seven times a week for 4 weeks after admission, was performed. The upper extremity items of the Fugl-Meyer Assessment (FMA) were evaluated before and after the training period. Results: The total score gains of the FMA, FMA wrist item, and FMA finger item were significantly larger in the RFE under NMES group than those in the CT group (p < 0.05). Conclusion: The combination of voluntary movement and electrical stimulation may promote the activation of paralyzed muscles and improve distal function for very severe paralyzed upper limbs.

A scoping review of the contralateral effects of unilateral peripheral stimulation on neuromuscular function.

It is known that resistance exercise using one limb can affect motor function of both the exercised limb and the unexercised contralateral limb, a phenomenon termed cross-education. It has been suggested that cross-education has clinical implications, e.g. in rehabilitation for orthopaedic conditions or post-stroke paresis. Much of the research on the contralateral effect of unilateral intervention on motor output is based on voluntary exercise. This scoping review aimed to map the characteristics of current literature on the cross-education caused by three most frequently utilised peripheral neuromuscular stimulation modalities in this context: electrical stimulation, mechanical vibration and percutaneous needling, that may direct future research and translate to clinical practice. A systematic search of relevant databases (Ebsco, ProQuest, PubMed, Scopus, Web of Science) through to the end of 2020 was conducted following the PRISMA Extension for Scoping Review. Empirical studies on human participants that applied a unilateral peripheral neuromuscular stimulation and assessed neuromuscular function of the stimulated and/or the unstimulated side were selected. By reading the full text, the demographic characteristics, context, design, methods and major findings of the studies were synthesised. The results found that 83 studies were eligible for the review, with the majority (53) utilised electrical stimulation whilst those applied vibration (18) or needling (12) were emerging. Although the contralateral effects appeared to be robust, only 31 studies claimed to be in the context of cross-education, and 25 investigated on clinical patients. The underlying mechanism for the contralateral effects induced by unilateral peripheral stimulation remains unclear. The findings suggest a need to enhance the awareness of cross-education caused by peripheral stimulation, to help improve the translation of theoretical concepts to clinical practice, and aid in developing well-designed clinical trials to determine the efficacy of cross-education therapies.

Neuromuscular Electric Stimulation in Addition to Exercise Therapy in Patients with Lower Extremity Paresis Due to Acute Ischemic Stroke. A proof-of-concept randomised controlled trial.

INTRODUCTION: Exercise therapy and neuromuscular electrical stimulation (NMES) during the initial 14 days after stroke may benefit recovery of gait. We aimed to determine whether poststroke NMES of vastus medial and tibial muscles during exercise therapy is more effective than exercise therapy alone. MATERIALS AND METHODS: In this proof-of-concept randomised trial patients with first-ever acute ischemic stroke and a leg paresis (40-85 years of age) were randomised (1:1) to 10 min of daily NMES + exercise therapy or exercise therapy alone. Primary outcome was the between-group difference in change in 6 min Walk Test (6MWT) at 90 days post stroke estimated with a mixed regression model. Secondary outcomes included 10 m Walk Test, Fugl-Meyer Motor Assessment, Guralnik Timed Standing Balance, Sit to Stand, Timed Up and Go, EQ-5D-5L, Montreal Cognitive Assessment and Becks Depression Inventory. RESULTS: 50 stroke survivors (25 in each group) with a mean age of 67 years (range 43-83) were included. An insignificant between-group difference in change of 28.3 m (95%CI -16.0 to 72.6, p = 0.23, adjusted for baseline) in 6MWT at 90-days follow-up was found, in favour of the NMES group. All secondary outcomes showed no statistically significant between-group difference. The conclusion was that adding NMES to exercise therapy had no effect on poststroke walking distance measured by the 6 MWT or any of the secondary outcomes. CONCLUSIONS: In this proof-of-concept RCT, we demonstrated that NMES in addition to exercise therapy during the first 14 days after onset of ischemic stroke did not improve walking distance or any of the secondary outcomes. Future studies with a longer trial period, stratifying patients into subgroups with comparable patterns of expected spontaneous recovery - if possible within 48 h post stroke, and greater sample size, than in this study are suggestions of how rehabilitation research could go on exploring the potential for NMES as an amplifier in stroke recovery.

Effects of hybrid assistive neuromuscular dynamic stimulation therapy for hemiparesis after pediatric stroke: a feasibility trial.

BACKGROUND: Hybrid assistive neuromuscular dynamic stimulation (HANDS) therapy, consisting of a wrist-hand splint and an integrated volitional control electrical stimulator to stimulate the extensor digitorum communis, is effective for chronic hemiparesis after stroke in adults. We investigated the feasibility and effects of HANDS therapy for patients with pediatric stroke by performing a longitudinal study. METHODS: Twelve patients with chronic hemiparetic pediatric stroke (aged 14-38 years) wore the herapeutic device for 3 weeks. The device was active for 8 h during the daytime, and patients were instructed to use their paretic hand as much as possible. Upper extremity items of the Fugl-Meyer Motor Assessment Scale and the Stroke Impairment Assessment Set motor test were used to measure motor function and were compared before and after the intervention with the Wilcoxon signed rank test. RESULTS: All patients were fully compliant with the therapy with no adverse events. After the intervention, both treatment endpoints improved significantly (p < .05). The effect size for upper extremity items of the Fugl-Meyer Motor Assessment Scale was medium (d = 0.59). CONCLUSION: This preliminary study demonstrated the feasibility and effectiveness of HANDS therapy in patients with pediatric stroke.Implications for rehabilitationPediatric stroke is a very rare disease and patients are forced to live with sequelae in most of the rest of their lives.Hybrid assistive neuromuscular dynamic stimulation therapy is effective for upper limb paralysis of adult stroke.Hybrid assistive neuromuscular dynamic stimulation therapy was adaptable even for children, and improvement of upper limb paralysis was observed even in a relatively short period of intervention.

Effects of kinesiotaping combined with the motor relearning method on upper limb motor function in adults with hemiparesis after stroke.

INTRODUCTION: Kinesio Taping (KT) is being widely used in neurorehabilitation as an adjuvant technique due to its therapeutic effects. The objective of this study was to determine the effects of Kinesio Taping combined with the motor relearning method on upper limb motor function in adult patients with post-stroke hemiparesis. METHODS: A quasi-experimental study with pre-test and post-test in a sample of 10 adult patients with post-stroke hemiparesis, randomly assigned in two groups: experimental (n: 5) who received 12 sessions of Kinesio Taping combined with the motor relearning method and a control group (n: 5) who only received 12 sessions of the motor relearning method. Motor function was assessed through the selective movement pattern scale for adult patients with upper motor neuron injury before and after each intervention. RESULTS: statistically significant differences (p < 0.05) were found when comparing the means of upper limb movement patterns of the experimental group. CONCLUSIONS: the use of Kinesio Taping combined with the motor relearning method was encouraging for upper limb motor function in patients with spastic hemiparesis.

Effects of home-based mirror therapy and cognitive therapeutic exercise on the improvement of the upper extremity functions in patients with severe hemiparesis after a stroke: a protocol for a pilot randomised clinical trial.

INTRODUCTION: Neuroplasticity is defined as the capacity of the brain to reorganise new neuronal pathways. Mirror therapy (MT) and cognitive therapeutic exercise (CTE) are two neurorehabilitation techniques based on neuroplasticity and designed to improve the motor functions of the affected upper extremity in patients with severe hemiparesis after a stroke. Home-based interventions are an appropriate alternative to promote independence and autonomy. The objective of this study is to evaluate which of these techniques, MT and CTE, combined with task-oriented training, is more effective in functional recovery and movement patterns of the upper extremities in patients with severe hemiparesis after a stroke. METHODS AND ANALYSIS: This is a home-based, single-blind, controlled, randomised clinical trial with three parallel arms, including 154 patients who had a stroke aged above 18 years. The primary outcome will be the functionality of the affected upper extremity measured using the Fugl-Meyer Assessment. Secondary variables will include cognitive performance, emotional state, quality of life and activities of daily living. During 6 weeks, one of the intervention groups will receive a treatment based on MT and the other one on CTE, both combined with task-oriented training. No additional interventions will be provided to the control group. To assess the progress of patients who had a stroke in the subacute phase, all variables will be evaluated at different visits: initial (just before starting treatment and 4 weeks post-stroke), post-intervention (6 weeks after initial) and follow-up (6 months). ETHICS AND DISSEMINATION: This protocol has been approved by the Institutional Review Board (CEIm-2.134/2.019) and registered at ClinicalTrials.gov (NCT04163666). The results will be disseminated through open-access peer-reviewed journals, conference presentation, broadcast media and a presentation to stakeholders. These study results will provide relevant and novel information on effective neurorehabilitation strategies and improve the quality of intervention programmes aimed at patients after a stroke. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT04163666).

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.

Test-retest reliability and responsiveness of isokinetic dynamometry to assess wrist flexor muscle spasticity in subacute post-stroke hemiparesis.

INTRODUCTION: To overcome the limitations of clinical scales, objective measurement methods are becoming prominent in spasticity assessment. The aim of this study was to assess the test-retest reliability and responsiveness of isokinetic dynamometry to evaluate wrist flexor spasticity in patients with subacute stroke. METHODS: Twenty six patients with hemiparetic stroke (13 men, 13 women, mean age 51.38 ± 12.64 years) volunteered to take part in this study. Resistive torque in the wrist flexor muscles was measured twice, 1 day apart, with an isokinetic dynamometer. Wrist extension was tested at four speeds (5, 60, 120 and 180°/s). Torque response at the lowest speed (5°/s) was attributed to the non-neural component of the wrist flexor muscles, and was subtracted from the torque response at the higher speeds to calculate reflex torque (spasticity). The reliability of reflex torque measurements at 60, 120 and 180°/s was evaluated with the intraclass correlation coefficient (ICC2,1) and standard error of measurement (SEM and SEM%), which reflect reproducibility and measurement error, respectively. Responsiveness was calculated as the smallest real difference (SRD and SRD%). RESULTS: Reproducibility was excellent at different movement speeds (ICC2, 1 0.76-0.85). SEM% ranged from 11% to 21%, and SRD% ranged from 30% to 58%. ICC values increased, and SEM% and SRD% decreased, as test speed increased. CONCLUSION: Our results support the reliability and responsiveness of isokinetic dynamometry to quantify spasticity in wrist flexor muscles in patients with subacute stroke. Reliability and responsiveness increased as the speed of wrist movement increased.

Repetitive peripheral magnetic stimulation improves severe upper limb paresis in early acute phase stroke survivors.

BACKGROUND: It is very difficult for patients with severe upper extremity (UE) paresis after stroke to achieve full recovery because of the lack of a definitive approach for improving severe UE paresis immediately after onset. OBJECTIVE: to investigate the effects of repetitive peripheral magnetic stimulation (rPMS) on severe UE paresis during early acute phase of stroke. METHODS: Nineteen participants with severe UE disability met the criteria. 10 subjects received 15-20 minutes of rPMS prior to standard care per session, while 9 age- and severity-matched subjects received two times 20 minutes of standard care. Outcome measures included UE motor section of the Fugl-Meyer Motor Assessment Scale (FMA-UE), Wolf motor function test (WMFT), and box and block test (BBT). RESULTS: The rPMS group received treatment (average sessions: 7.8) after a median 9.2 days from stroke (16.5 sessions after 5 days for control). To adjust the different treatment durations, we defined "progress rate" as the gains of UE function scores divided by treatment duration. The progress rate was significantly different in FMA-UE and WMFT, but not in BBT. CONCLUSIONS: The present study suggested beneficial effects of rPMS on severe UE paresis during early acute phase of stroke.

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.

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).

Refined Sphenopalatine Ganglion Stimulator Placement and Intensity Setting to Augment Blood Flow and Neurologic Function.

Background and Purpose- Two large, randomized trials indicated that sphenopalatine ganglion (SPG) stimulation improves final disability outcome in acute anterior circulation patients with ischemic stroke with confirmed cortical involvement. This study evaluated 2 refinements in SPG stimulation treatment technique: (1) SPG electrode placement with real-time optical tracking guidance; and (2) stimulation intensity comfortable tolerance level selection using non-noxious facial physiological markers. Methods- This study was a single, active arm trial at 4 centers, enrolling patients with anterior circulation ischemic stroke, National Institutes of Health Stroke Scale 1 to 6 including arm weakness subitem score ≥1, not receiving recanalization therapies, and within 24 hours of onset. Stimulation level was set based on ipsilateral facial tingling sensation or lacrimation. SPG stimulation effects were assessed by measuring volumetric blood flow in the ipsilateral common carotid artery by ultrasound and grasp and pinch strength in the affected hand before and during stimulation, and by change in National Institutes of Health Stroke Scale from day 1 to 7. Results- Among 50 enrolled patients, age was median 66 years (interquartile range, 60-74), 44% were female, National Institutes of Health Stroke Scale median was 5 (interquartile range, 4-5), and median onset-to-screening time was 18 hours (interquartile range, 9-20). Median implantation skin-to-skin time was 4 minutes (interquartile range, 3-7), and all 50 implants were placed correctly. Comfortable tolerance level was found based on physiological biomarkers in 96% of patients, including 86% in the optimal, low-medium intensity range. SPG stimulation significantly increased common carotid artery peak systolic and end-diastolic blood flow (44%, P<0.0001; and 52%, P<0.0001) and improved pinch strength (42%, P<0.0001) and grasp strength (26%, P<0.0001). Degree of National Institutes of Health Stroke Scale recovery by day 7 was greater than in matched historic controls, median 75% versus 50%, P=0.0003. Conclusions- SPG stimulator placement with real-time optical tracking guidance was fast and accurate, and selection of stimulation intensity levels based on non-noxious facial tingling and lacrimation was feasible in nearly all patients. SPG stimulation led to cervico-cranial blood flow augmentation and improved hand motor function. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03551093.

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.

Motor learning with the PNF-concept, an alternative to constrained induced movement therapy in a patient after a stroke; a case report.

INTRODUCTION: Over sixteen million people suffer a stroke each year. Stroke is characterized by a one-sided paresis. Upper extremity and hand function are most limited. The current view on "neuro rehabilitation" advocates a constrained induced movement therapy (CIMT) setting. This case report seeks to illustrate the clinical reasoning and the feasibility of applying an alternative approach in patients who are not accepted or not suitable for the constrained induced movement therapy. CASE DESCRIPTION: A male patient, 68 years of age, developed impairments in his right arm and hand, such as loss of range of motion and strength besides spasticity after a stroke. This resulted in a loss of dexterity in his affected right side and in "disuse" of that arm and hand. PATIENT MANAGEMENT: A therapy was designed based upon the Proprioceptive Neuromuscular Facilitation-concept (PNF-concept) and consisting of PNF pattern exercises in a functional task setting with specified PNF-principles of facilitations and PNF-techniques for motor re-learning activities, over a period of six weeks. This resulted in clinical important improvements of wrist extension, grip strength, spasticity, dexterity and patient satisfaction with specific tasks. DISCUSSION AND CONCLUSION: The provided comprehensive therapy mimics CIMT and robotics. The approach addresses possibly motor learning effects, cortical reorganization and structural impairments. Proprioceptive Neuromuscular Facilitation (PNF) - diagonal movement patterns have been described as: "having beneficial effects in cortical adaptations and cortical organization resulting in motor learning effects". In cases where CIMT is difficult to apply, a specified PNF-based therapy has shown to be a feasible alternative.

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.