Effect of functional electrical stimulation on the proprioception, motor function of the paretic upper limb, and patient quality of life: A case report.

Functional electrical stimulation (FES) has shown to improve motor function of the affected side in stroke patients; however, the effects of FES on proprioception, the functional recovery of the paretic upper limb, and the patient quality of life (QoL) are not clear. The aim of the current case report was to determine whether FES can improve joint position sense and the scores on measurements of upper limb function and a QoL survey. The participant was assessed before and after 10 consecutive intervention sessions; in addition, the patient performed the training tasks in the workstation assisted by the FES device. Improvements in angles and time only in the affected wrist and enhancement in the Action Research Arm Test scores for both upper limbs were found after FES intervention. In addition, the patient's health-related QoL measurements improved. FES could ameliorate the proprioceptive deficit and the activity limitations of a stroke survivor. OXFORD LEVEL OF EVIDENCE: 3b; individual case control study.

Recovery of motor imagery ability in the first year after stroke.

The aim of this study was to examine the level and recovery of motor imagery ability (MIA) in the first year after stroke and whether the recovery of MIA is related to that of arm/hand function. Twenty-three patients with diminished arm/hand function were included. The accuracy score on the hand laterality judgment task was used to assess MIA and the Fugl-Meyer Assessment was used to evaluate the recovery of arm/hand function. The patients were assessed 3, 6, 16, 26, and 52 weeks after stroke. In the first year after stroke, the percentage of patients with moderate to good MIA improved from 78% after 3 weeks to 94% after 1 year. The recovery of MIA took place in the first 6 weeks after stroke. No correlation was found between the recovery of MIA and arm/hand function, despite the fact that the greatest improvement in both occurred in the first 6 weeks.

Utilization of motor imagery in upper limb rehabilitation: a systematic scoping review.

OBJECTIVE: To determine how motor imagery is being delivered in upper limb rehabilitation to guide practice and research. DATA SOURCE: MEDLINE, PubMed, CINAHL, EMBASE, PsychINFO databases were searched from 1987 to November 2014 STUDY SELECTION: English, adults, any clinical population or diagnosis, intervention for upper limb with an outcome measure used. All types of studies were included. Two authors independently selected studies for review using consensus. DATA EXTRACTION: Seven motor imagery elements were extracted using a model implemented in sport research: PETTLEP model (Physical, Environment, Task, Timing, Learning, Emotion, and Perspective). RESULTS: The search yielded 1107 articles with 1059 excluded leaving 48 articles for full review. A total of 38 articles involved individuals with stroke, five articles involved individuals with complex regional pain syndrome, and five articles for other conditions. Motor imagery elements most commonly described were physical, environment, task, and perspective. Elements less commonly described were timing, learning, and emotional aspects. There were significant differences between study populations (e.g. stroke and complex regional pain syndrome) and within populations on how motor imagery was delivered. CONCLUSION: Many of the imagery elements reviewed are not being considered or reported on in the selected studies. How motor imagery is being delivered within and between populations is inconsistent, which may lead to difficulties in determining key elements of effectiveness.

Randomized controlled trial of yoga for chronic poststroke hemiparesis: motor function, mental health, and quality of life outcomes.

PURPOSE: To assess the efficacy of yoga for motor function, mental health, and quality of life outcomes in persons with chronic poststroke hemiparesis. METHOD: Twenty-two individuals participated in a randomized controlled trial involving assessment of task-orientated function, balance, mobility, depression, anxiety, and quality of life domains before and after either a 10-week yoga intervention (n = 11) or no treatment (n = 11). RESULTS: The yoga intervention did not result in any significant improvements in objective motor function measures, however there was a significant improvement in quality of life associated with perceived motor function (P = .0001) and improvements in perceived recovery approached significance (P = .072). Memory-related quality of life scores significantly improved after yoga intervention (P = .022), and those participating in the intervention exhibited clinically relevant decreases in state and trait anxiety. CONCLUSIONS: Preliminary results offer promise for yoga as an intervention to address mental health and quality of life in persons with stroke-related activity limitations. There is a need to more rigorously evaluate these yoga benefits with a larger randomized controlled trial, which, based on this preliminary trial, is feasible.

Effects of horseback riding therapy on quality of life in patients post stroke.

BACKGROUND: Persons with stroke commonly have serious sequelae requiring long-term medical treatment. They often experience distress, and thus improving quality of life (QOL) has been considered a therapeutic objective in addition to prolonging the patient's life. OBJECTIVE: The aim of this study was to analyze the impact of horseback riding therapy (HBRT) on the QOL of individuals with hemiparesis after stroke. METHODS: In this single-blind, randomized, controlled trial, 24 poststroke patients were assigned to the experimental (n = 12) and control (n = 12) groups. The control group participated in a conventional physiotherapy program, whereas the experimental group participated in physiotherapy plus HBRT sessions for 16 weeks. The patients were evaluated by means of the Medical Outcomes Study 36-item Short-Form health survey (SF-36). Data analysis was applied through the use of descriptive and inferential statistics, with a 5% level of significance. RESULTS: Significant improvement was observed in the total score of the SF-36 in the experimental group when compared with the control group. The combination of conventional physiotherapy and HBRT was associated with improvements in functional capacity (P = .02), physical aspects (P = .001), and mental health (P = .04) of the stroke patients. CONCLUSIONS: Supplementation of conventional physiotherapy with HBRT, applied in different contexts, may yield positive QOL outcomes for people with stroke. We recommend that further studies be carried out to clarify the benefits of HBRT applied singly.

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.

Modulation of event-related desynchronization during motor imagery with transcranial direct current stimulation in a patient with severe hemiparetic stroke: a case report.

Recently, surface electroencephalogram (EEG)-based brain-machine interfaces (BMI) have been used for people with disabilities. As a BMI signal source, event-related desynchronization of alpha-band EEG (8-13 Hz) during motor imagery (mu ERD), which is interpreted as desynchronized activities of the activated neurons, is commonly used. However, it is often difficult for patients with severe hemiparesis to produce mu ERD of sufficient strength to activate BMI. Therefore, whether it is possible to modulate mu ERD during motor imagery with anodal transcranial direct-current stimulation (tDCS) was assessed in a severe left hemiparetic stroke patient. EEG was recorded over the primary motor cortex (M1), and mu ERD during finger flexion imagery was measured before and after a 5-day course of tDCS applied to M1. The ERD recorded over the affected M1 increased significantly after tDCS intervention. Anodal tDCS may increase motor cortex excitability and potentiate ERD during motor imagery in patients with severe hemiparetic stroke.

Determining specificity of motor imagery training for upper limb improvement in chronic stroke patients: a training protocol and pilot results.

Motor imagery (MI) refers to the mental rehearsal of a movement without actual motor output. MI training has positive effects on upper limb recovery after stroke.However, until now it is unclear whether this effect is specific to the trained task or a more general motors kill improvement. This study was set up to advance our insights into the efficacy of MI training and the specificity of its effects. We investigated whether MI training affected the trained hand exclusively, or both hands. Four stroke participants received a 15-min MI training four times a week for 3 weeks. Hand function was measured before and after the training using three measurement of increasing complexity. Hand function improved after MI training, thus confirming the earlier studies. Second, we found specific effects of the MI training for two of the three measurements. These results suggest that MI specificity is dependent on the complexity of the hand function task.

Abnormal motor excitability in patients with psychogenic paresis. A TMS study.

BACKGROUND: Patients with motor conversion disorders present an inability to execute movements voluntarily, although central and peripheral motor pathways are normal. We speculated that this phenomenon could be due to an abnormal loss of excitatory drive on central motor areas. METHODS: The effect of motor imagery on motor excitability was tested in a group of eight patients with a functional (psychogenic) hemiparesis and in an age-matched control group (n=8) by using transcranial magnetic stimulation (TMS). TMS pulses were applied at rest and while subjects imagined a tonic index finger adduction. Amplitudes of motor evoked potentials (MEP) recorded from the first dorsal interosseous muscle were used as an indicator of motor excitability. RESULTS: Motor thresholds and MEP amplitudes at rest were almost identical in the patient group and the control group. During motor imagery, MEP amplitudes increased by 200% in healthy subjects. In the patient group, motor imagery of the "paretic" index finger was associated with a mean MEP amplitude decrease of 37% compared with the MEP size at rest. Motor imagery of the unaffected index finger increased MEPs by 63% which was significantly different both from results in the control group and the "paretic" side. CONCLUSIONS: We suggest that the paradoxical decrease of motor excitability during motor imagery is the electrophysiological correlate of a disturbed voluntary control in motor conversion disorder. The results further indicate that this abnormality is not restricted to the clinically affected body part.

Efficacy of motor imagery in post-stroke rehabilitation: a systematic review.

BACKGROUND: Evaluation of how Motor Imagery and conventional therapy (physiotherapy or occupational therapy) compare to conventional therapy only in their effects on clinically relevant outcomes during rehabilitation of persons with stroke. DESIGN: Systematic review of the literature METHODS: We conducted an electronic database search in seven databases in August 2005 and also hand-searched the bibliographies of studies that we selected for the review. Two reviewers independently screened and selected all randomized controlled trials that compare the effects of conventional therapy plus Motor Imagery to those of only conventional therapy on stroke patients. The outcome measurements were: Fugl-Meyer Stroke Assessment upper extremity score (66 points) and Action Research Arm Test upper extremity score (57 points). Due to the high variability in the outcomes, we could not pool the data statistically. RESULTS: We identified four randomized controlled trials from Asia and North America. The quality of the included studies was poor to moderate. Two different Motor imagery techniques were used (three studies used audiotapes and one study had occupational therapists apply the intervention). Two studies found significant effects of Motor Imagery in the Fugl-Meyer Stroke Assessment: Differences between groups amounted to 11.0 (1.0 to 21.0) and 3.2 (-4 to 10.3) respectively and in the Action Research Arm Test 6.1 (-6.2 to 18.4) and 15.8 (0.5 to 31.0) respectively. One study did not find a significant effect in the Fugl-Meyer Stroke Assessment and Color trail Test (p = 0.28) but in the task-related outcomes (p > 0.001). CONCLUSION: Current evidence suggests that Motor imagery provides additional benefits to conventional physiotherapy or occupational therapy. However, larger and methodologically sounder studies should be conducted to assess the benefits of Motor imagery.

A high performance sensorimotor beta rhythm-based brain-computer interface associated with human natural motor behavior.

UNLABELLED: To explore the reliability of a high performance brain-computer interface (BCI) using non-invasive EEG signals associated with human natural motor behavior does not require extensive training. We propose a new BCI method, where users perform either sustaining or stopping a motor task with time locking to a predefined time window. Nine healthy volunteers, one stroke survivor with right-sided hemiparesis and one patient with amyotrophic lateral sclerosis (ALS) participated in this study. Subjects did not receive BCI training before participating in this study. We investigated tasks of both physical movement and motor imagery. The surface Laplacian derivation was used for enhancing EEG spatial resolution. A model-free threshold setting method was used for the classification of motor intentions. The performance of the proposed BCI was validated by an online sequential binary-cursor-control game for two-dimensional cursor movement. Event-related desynchronization and synchronization were observed when subjects sustained or stopped either motor execution or motor imagery. Feature analysis showed that EEG beta band activity over sensorimotor area provided the largest discrimination. With simple model-free classification of beta band EEG activity from a single electrode (with surface Laplacian derivation), the online classifications of the EEG activity with motor execution/motor imagery were: >90%/ approximately 80% for six healthy volunteers, >80%/ approximately 80% for the stroke patient and approximately 90%/ approximately 80% for the ALS patient. The EEG activities of the other three healthy volunteers were not classifiable. The sensorimotor beta rhythm of EEG associated with human natural motor behavior can be used for a reliable and high performance BCI for both healthy subjects and patients with neurological disorders. SIGNIFICANCE: The proposed new non-invasive BCI method highlights a practical BCI for clinical applications, where the user does not require extensive training.

Influence of combined afferent stimulation and task-specific training following stroke: a pilot randomized controlled trial.

BACKGROUND: Reorganization of the human motor cortex can be induced by specific patterns of peripheral afferent stimulation. The potential for afferent stimulation to facilitate the functional recovery associated with conventional rehabilitative techniques has not previously been investigated. OBJECTIVE: The authors sought to determine whether combining appropriate afferent stimulation with task-specific training resulted in greater improvements than training alone in patients with impaired upper limb function in the subacute phase following stroke. METHOD: Twenty patients with hemiparesis due to stroke were allocated randomly to either a stimulation or control group. All received 9 sessions of task-specific physiotherapy training over 3 weeks. Prior to each training session, associative electrical stimulation of the motor point of 2 hand muscles was given in the stimulation group, whereas the control group received sham stimulation. Changes in dexterity were assessed using a grip-lift task, and standard measures of upper-limb function were made before and following the intervention. Corticospinal excitability was examined using transcranial magnetic stimulation. RESULTS: Both groups showed comparable improvements in functional measures of upper-limb function. Of the 20 patients, only 14 could perform the grip-lift task, which is an objective measure of dexterity. Patients in the stimulation group exhibited significantly greater improvements in this task than the control group. There was no significant change in corticospinal excitability in either group. CONCLUSION: This pilot study provides preliminary data suggesting that targeted afferent stimulation may facilitate the response to conventional rehabilitation in patients with hemiparesis due to stroke, but these results need to be confirmed in a larger scale study.

Mental practice in chronic stroke: results of a randomized, placebo-controlled trial.

BACKGROUND AND PURPOSE: Mental practice (MP) of a particular motor skill has repeatedly been shown to activate the same musculature and neural areas as physical practice of the skill. Pilot study results suggest that a rehabilitation program incorporating MP of valued motor skills in chronic stroke patients provides sufficient repetitive practice to increase affected arm use and function. This Phase 2 study compared efficacy of a rehabilitation program incorporating MP of specific arm movements to a placebo condition using randomized controlled methods and an appropriate sample size. Method- Thirty-two chronic stroke patients (mean=3.6 years) with moderate motor deficits received 30-minute therapy sessions occurring 2 days/week for 6 weeks, and emphasizing activities of daily living. Subjects randomly assigned to the experimental condition also received 30-minute MP sessions provided directly after therapy requiring daily MP of the activities of daily living; subjects assigned to the control group received the same amount of therapist interaction as the experimental group, and a sham intervention directly after therapy, consisting of relaxation. Outcomes were evaluated by a blinded rater using the Action Research Arm test and the upper extremity section of the Fugl-Meyer Assessment. RESULTS: No pre-existing group differences were found on any demographic variable or movement scale. Subjects receiving MP showed significant reductions in affected arm impairment and significant increases in daily arm function (both at the P<0.0001 level). Only patients in the group receiving MP exhibited new ability to perform valued activities. CONCLUSIONS: The results support the efficacy of programs incorporating mental practice for rehabilitating affected arm motor function in patients with chronic stroke. These changes are clinically significant.

Delayed neuropsychiatric syndrome in a child following carbon monoxide poisoning.

Here, we report the case of a five-year-old boy with carbonic monoxide (CO) poisoning. The patient initially recovered after the initiation of hyperbaric oxygen (HBO) therapy, but lethargy as well as visual and gait disturbances appeared two days later. Left hemiparesis and mood lability also subsequently appeared. Slow frontal activity was noted on electroencephalography, while fluid-attenuation inversion recovery and diffusion-weighted magnetic resonance imaging (MRI) revealed high signal-intensity lesions in the hippocampus and deeper layers of the occipital and frontal cerebral cortex. The neurological symptoms subsided gradually during the 10-day course of HBO therapy, but the left-hand paresis and quadrantic hemianopsia persisted, in association with impaired attention, slow mental processing, and incontinence. Lesions in the globus pallidum were noted on follow-up MRI at 14 days, and cortical lesions became evident as linear, low signal-intensity areas on T1-weighted imaging 4 months after presentation. Delayed neuropsychiatric syndrome in CO poisoning is rare in childhood, although children should be carefully monitored after CO exposure. The finding of cortical laminar necrosis in this patient is quite atypical in CO poisoning, and suggests a broader and previously nonpredicted pathomechanism in this condition.

A strategy for computer-assisted mental practice in stroke rehabilitation.

OBJECTIVE: To investigate the technical and clinical viability of using computer-facilitated mental practice in the rehabilitation of upper-limb hemiparesis following stroke. DESIGN: A single-case study. SETTING: Academic-affiliated rehabilitation center. PARTICIPANT: A 46-year-old man with stable motor deficit of the upper right limb following subcortical ischemic stroke. INTERVENTION: Three computer-enhanced mental practice sessions per week at the rehabilitation center, in addition to usual physical therapy. A custom-made virtual reality system equipped with arm-tracking sensors was used to guide mental practice. The system was designed to superimpose over the (unseen) paretic arm a virtual reconstruction of the movement registered from the nonparetic arm. The laboratory intervention was followed by a 1-month home-rehabilitation program, making use of a portable display device. MAIN OUTCOME MEASURES: Pretreatment and posttreatment clinical assessment measures were the upper-extremity scale of the Fugl-Meyer Assessment of Sensorimotor Impairment and the Action Research Arm Test. Performance of the affected arm was evaluated using the healthy arm as the control condition. RESULTS: The patient's paretic limb improved after the first phase of intervention, with modest increases after home rehabilitation, as indicated by functional assessment scores and sensors data. CONCLUSION: Results suggest that technology-supported mental training is a feasible and potentially effective approach for improving motor skills after stroke.

Neural substrates for motor imagery in severe hemiparesis.

BACKGROUND: The beneficial effects of imagined movements on motor learning and performance suggest that motor imagery is functionally close to preparatory and executive motor processes. OBJECTIVE: The purpose of this study was to examine the cortical processes associated with imagery of movement of the wrist in subjects with severe hemiparesis. METHODS: During fMRI, subjects with stroke performed alternating blocks of imagining wrist-tracking movements with the hemiparetic hand, active wrist-tracking movements with the unaffected hand, and resting. Control subjects performed the same tasks using an assigned hand. Cortical activation in the primary motor (M1), primary sensory (S1), supplementary motor area (SMA), and pre-SMA regions was determined through a laterality index of active voxels and signal intensity. Ability to imagine was assessed with an Imagery Rating Scale. RESULTS: All subjects displayed primarily contralateral control during the track condition. Healthy subjects demonstrated contralateral control in all areas during the imagine condition, whereas subjects with stroke displayed primarily contralateral activation in S1 but ipsilateral in M1 and SMA. The percentage change in signal intensity was greater in the ipsilateral hemisphere in subjects with stroke than in the ipsilateral hemisphere in healthy subjects during the imagine condition. Additionally, subjects with self-reported low ability to imagine displayed no difference in activation compared to those with high imagery ability. CONCLUSIONS: These findings are consistent with other works demonstrating primarily ipsilateral control of the hemiparetic hand in subjects with functional movement and lay the groundwork for further investigation into the ability of mental imagery to affect functionally relevant cortical control in subjects recovering from stroke.

[Features of learning voluntary control of posture after pyramidal and nigrostriatal lesions]. / Osobennosti obucheniia proizvol'nomu kontroliu pozy pri porazheniiakh piramidnoi i nigro-striarnoi sistem.

The study was aimed at investigation of a deficit of learning the center-of-pressure voluntary control in patients with lesions of corticospinal and nigrostriatal systems. Thirty three patients with Parkinson's disease and 20 patients with hemiparesis after cerebrovascular accidents in the MCA participated in the investigation. The subjects stood on a force platform and in the form of a computer game were trained to match the projection of the center of pressure (a cursor) with a target on the screen under the visual feedback control. Two different postural tasks were presented. In the first task the direction of the center-of-pressure shift was not known before, so the subject learned the general strategy of the center-pressure control. In the other task a precise postural coordination should be formed. The voluntary control of the center-of-pressure position was found to be impaired in both groups of patients. In the task of moving the center of pressure in various directions (general strategy), no differences in the initial deficit of the task performance were found between the groups, but the learning was more efficient in the group of hemiparetic patients. However, in the task with precise postural coordination, despite the greater initial deficit in the parkinsonian patients, the learning in this group of patients was substantially more efficient than in hemiparetic patients. The results suggest both common and different features of the involvement of the corticospinal and nigrostriatal systems in learning voluntary control of posture.

[Deficit of learning of posture voluntary control in patients with cortical lesions of various locations: cortical mechanisms of posture regulation]. / Narusheniie obucheniia proizvol'nomu kontroliu pozy pri korkovykh porazheniiakh razlichnoi lokalizatsii: k voprosu o korkovykh mekhanizmakh reguliatsii pozy.

Forty two hemiparetic patients after cerebrovascular accidents were trained to change the position of the center of pressure according to a target on the screen with the visual feedback control. The learning was substantially impaired in comparison with the group of healthy subjects. Patients with the right-hemispheric lesions showed somewhat greater learning deficit than patients with lesions in the left hemisphere. Lesion localization also affected the process of learning. The learning was disturbed to a greater extent in patients with lesions involving not only motor but also premotor and parietal cortical areas. In patients with parieto-temporal lesions the learning reached a very low level after three initial days of training, possibly, because of the deficit of sensory integration and of body scheme in the extra-personal space. Patients with combined lesions of the motor, premotor, and parietal areas showed the lowest results. The learning was shown to depend on the deficit of proprioception and extent of postural disturbances (asymmetry of body weight distribution and amplitude of the center of pressure oscillations) rather than on the extent of motor deficit (paresis and spasticity). However, the learning itself improved some motor disturbances.