Robotized Knee-Ankle-Foot Orthosis-Assisted Gait Training on Genu Recurvatum during Gait in Patients with Chronic Stroke: A Feasibility Study and Case Report.

Genu recurvatum (knee hyperextension) is a common problem after stroke. It is important to promote the coordination between knee and ankle movements during gait; however, no study has investigated how multi-joint assistance affects genu recurvatum. We are developing a gait training technique that uses robotized knee-ankle-foot orthosis (KAFO) to assists the knee and ankle joints simultaneously. This report aimed to investigate the safety of robotized KAFO-assisted gait training (Experiment 1) and a clinical trial to treat genu recurvatum in a patient with stroke (Experiment 2). Six healthy participants and eight patients with chronic stroke participated in Experiment 1. They received robotized KAFO-assisted gait training for one or 10 sessions. One patient with chronic stroke participated in Experiment 2 to investigate the effect of robotized KAFO-assisted gait training on genu recurvatum. The patient received the training for 30 min/day for nine days. The robot consisted of KAFO and an attached actuator of four pneumatic artificial muscles. The assistance parameters were adjusted by therapists to prevent genu recurvatum during gait. In Experiment 2, we evaluated the knee joint angle during overground gait, Fugl-Meyer Assessment of lower extremity (FMA-LE), modified Ashworth scale (MAS), Gait Assessment and Intervention Tool (G.A.I.T.), 10-m gait speed test, and 6-min walk test (6MWT) before and after the intervention without the robot. All participants completed the training in both experiments safely. In Experiment 2, genu recurvatum, FMA-LE, MAS, G.A.I.T., and 6MWT improved after robotized KAFO-assisted gait training. The results indicated that the multi-joint assistance robot may be effective for genu recurvatum after stroke.

Impact of Repetitive Transcranial Magnetic Stimulation to the Cerebellum on Performance of a Ballistic Targeting Movement.

This study aimed to investigate the effects of repetitive transcranial magnetic stimulation (rTMS) of the cerebellum on changes in motor performance during a series of repetitive ballistic-targeting tasks. Twenty-two healthy young adults (n = 12 in the active-rTMS group and n = 10 in the sham rTMS group) participated in this study. The participants sat on a chair in front of a monitor and fixed their right forearms to a manipulandum. They manipulated the handle with the flexion/extension of the wrist to move the bar on the monitor. Immediately after a beep sound was played, the participant moved the bar as quickly as possible to the target line. After the first 10 repetitions of the ballistic-targeting task, active or sham rTMS (1 Hz, 900 pulses) was applied to the right cerebellum. Subsequently, five sets of 100 repetitions of this task were conducted. Participants in the sham rTMS group showed improved reaction time, movement time, maximum velocity of movement, and targeting error after repetition. However, improvements were inhibited in the active-rTMS group. Low-frequency cerebellar rTMS may disrupt motor learning during repetitive ballistic-targeting tasks. This supports the hypothesis that the cerebellum contributes to motor learning and motor-error correction in ballistic-targeting movements.

Neural correlates of spatial attention bias: Changes in functional connectivity in attention networks associated with tDCS.

The prevailing theory concerning the pathophysiology of unilateral spatial neglect is that it is caused by an interhemispheric imbalance in attention networks. Previous studies have demonstrated that repetitive transcranial magnetic stimulation or transcranial direct current stimulation (tDCS) delivered over the right posterior parietal cortex can induce transitory neglect-like deficits in healthy individuals. We examined whether right cathodal and left anodal tDCS delivered over the posterior parietal cortex could produce neglect-like deficits and change the resting-state functional connectivity (rsFC) of attention networks. We found that the reaction time for targets in the left hemifield was significantly prolonged during two different types of visual search tasks, and rsFC of the attention networks was altered by tDCS. Furthermore, the change in the reaction times for the left visual target in the two different tasks significantly correlated with the change in the rsFC of either the right dorsal attention network (DAN) or right ventral attention network (VAN) based on the tasks. These results suggest that tDCS delivered to the posterior parietal cortex bilaterally induced neglect-like deficits by altering the connectivity of the attentional networks through excitability changes in the cortical area under the electrode. The results of this study are consistent with the hypothesis that the cause of neglect is the interhemispheric imbalance of attention networks. This is the first study to demonstrate that local cortical stimulation can induce changes not only in the local brain function but also in the cortical networks in healthy individuals.

Effect of Prism Adaptation Therapy on the Activities of Daily Living and Awareness for Spatial Neglect: A Secondary Analysis of the Randomized, Controlled Trial.

BACKGROUND: Rehabilitation for unilateral spatial neglect (USN) using prism adaptation (PA) is one of the most widely used methods, and the effectiveness of PA is well-evidenced. Although the effect of PA generalized various neglect symptoms, the effectiveness for some aspects of neglect is not fully proven. The Catherine Bergego Scale (CBS) was developed to identify problems with the activities of daily living (ADL) caused by USN. The CBS is composed of 10 observation assessments and a self-assessment questionnaire. To assess the self-awareness of USN, the anosognosia score is calculated as the difference between the observational scores and the self-assessment scores. To investigate how PA affects ADL and self-awareness in subacute USN patients during rehabilitation, we analyzed each item of the CBS and self-awareness from a randomized, controlled trial (RCT) that we previously conducted (Mizuno et al., 2011). METHODS: A double-masked randomized, controlled trial was conducted to evaluate the effects of a 2-week PA therapy on USN in 8 hospitals in Japan. We compared each item of the CBS, anosognosia score, and absolute value of the anosognosia score between the prism group and the control group. RESULTS: Two of ten items (gaze orientation and exploration of personal belongings) were significantly improved in the prism group compared with those in the control group. The absolute value of the anosognosia score was significantly improved by PA. CONCLUSIONS: Improvement of oculomotor exploration by PA may generalize the behavioral level in a daily living environment. This study suggested that PA could accelerate the self-awareness of neglect during subacute rehabilitation.

Right as well as left unilateral spatial neglect influences rehabilitation outcomes and its recovery is important for determining discharge destination in subacute stroke patients.

BACKGROUND: Unilateral spatial neglect (USN) can interfere with rehabilitation processes and lead to poor functional outcome. AIM: To investigate the influence of left and right USN on rehabilitation outcomes using Catherine Bergego Scale (CBS) in stroke patients and the relationships among improvement of USN, improvement of motor autonomy (measured by functional independence measure [FIM] gain), length of stay and discharge destination. DESIGN: Observational study. SETTING: Rehabilitation hospital in Japan. POPULATION: We investigated 60 first-ever stroke patients who were admitted to a rehabilitation hospital within 3 months after stroke onset (27 patients with neglect and 33 without neglect). METHODS: Multiple regression analyses were used to explain FIM gain, FIM effectiveness and length of stay. Independent variables were motor and cognitive FIM, CBS, Stroke Impairment Assessment Set Motor Score (SIAS-M) and time after stroke onset at admission. RESULTS: The incidences of USN in patients with right and left hemisphere damage were 55.6% and 37.1%, respectively. CBS predicted motor FIM, motor FIM gain, motor FIM effectiveness and length of stay. On the other hand, SIAS-M did not predict either FIM nor length of stay. CBS Score decreased significantly in patients with USN who retuned their home, while it did not change in patients who did not. Cognitive FIM Score at admission was significantly lower in patients who did not return home than in patients who returned home. CONCLUSIONS: CBS is more useful than SIAS-M for prediction of functional outcomes in patients with both left and right hemisphere damages. Improvement of USN is important for returning home. Cognitive impairment may interfere with recovery of USN. CLINICAL REHABILITATION IMPACT: Improvements of USN are important for planning the rehabilitation goal and determination of discharge destination.

Correlation between changes in functional connectivity in the dorsal attention network and the after-effects induced by prism adaptation in healthy humans: A dataset of resting-state fMRI and pointing after prism adaptation.

It has been reported that it is possible to observe transient changes in resting-state functional connectivity (FC) in the attention networks of healthy adults during treatment with prism adaptation. by using functional magnetic resonance imaging (fMRI) (see "Prism adaptation changes resting-state functional connectivity in the dorsal stream of visual attention networks in healthy adults: A fMRI study" (Tsujimoto et al., 2018) [1]. Recent neuroimaging and neurophysiological studies support the idea that prism adaptation (PA) affects the visual attention and sensorimotor networks, which include the parietal cortex and cerebellum. These data demonstrate the effect of PA on resting-state functional connectivity between the primary motor cortex and cerebellum. Additionally, it evaluates changes of resting-state FC before and after PA in healthy individuals using fMRI. Analyses focus on FC between the primary motor cortex and cerebellum, and the correlation between changes in FC and its after-effects following a single PA session. Here, we show data that demonstrate the change in resting-state FC between the primary motor cortex and cerebellum, as well as a correlation between the change ratio of FC and the amplitude of the after-effect.

Prism adaptation changes resting-state functional connectivity in the dorsal stream of visual attention networks in healthy adults: A fMRI study.

Unilateral spatial neglect (USN) can be defined as a failure to orient to contra-lesional stimuli in the absence of either sensory or motor defects. Although the behavioral and clinical effects of prism adaptation (PA) are widely accepted, its underlying mechanisms are still controversial. However, recent neuroimaging and neurophysiological studies support the idea that PA affects the visual attention and sensorimotor networks including in the parietal cortex and cerebellum. We investigate the effect of PA on functional connectivity (FC) in attention and sensorimotor networks, evaluating changes of resting-state FC before and after PA in healthy individuals using functional magnetic resonance imaging (fMRI). MR sessions were conducted before PA, after PA (Post1), and 1 h after PA (Post2). The FC between the right frontal eye (FEF) field and the right intraparietal sulcus was significantly decreased at Post1 and that between the right FEF and the right anterior cingulate cortex was significantly increased after PA and recovered within 1 h. This is the first study to demonstrate transient changes of resting-state FC in the right dorsal attention network (DAN) by PA in healthy adults using fMRI. These results will contribute to the elucidation of the underling mechanism of PA therapy and to devising new therapies for USN and/or other higher cortical dysfunctions.

Effect of the combination of motor imagery and electrical stimulation on upper extremity motor function in patients with chronic stroke: preliminary results.

BACKGROUND: The combination of motor imagery (MI) and afferent input with electrical stimulation (ES) enhances the excitability of the corticospinal tract compared with motor imagery alone or electrical stimulation alone. However, its therapeutic effect is unknown in patients with hemiparetic stroke. We performed a preliminary examination of the therapeutic effects of MI + ES on upper extremity (UE) motor function in patients with chronic stroke. METHODS: A total of 10 patients with chronic stroke demonstrating severe hemiparesis participated. The imagined task was extension of the affected finger. Peripheral nerve electrical stimulation was applied to the radial nerve at the spiral groove. MI + ES intervention was conducted for 10 days. UE motor function as assessed with the Fugl-Meyer assessment UE motor score (FMA-UE), the amount of the affected UE use in daily life as assessed with a Motor Activity Log (MAL-AOU), and the degree of hypertonia in flexor muscles as assessed with the Modified Ashworth Scale (MAS) were evaluated before and after intervention. To assess the change in spinal neural circuits, reciprocal inhibition between forearm extensor and flexor muscles with the H reflex conditioning-test paradigm at interstimulus intervals (ISIs) of 0, 20, and 100 ms were measured before and after intervention. RESULTS: UE motor function, the amount of the affected UE use, and muscle hypertonia in flexor muscles were significantly improved after MI + ES intervention (FMA-UE: p < 0.01, MAL-AOU: p < 0.01, MAS: p = 0.02). Neurophysiologically, the intervention induced restoration of reciprocal inhibition from the forearm extensor to the flexor muscles (ISI at 0 ms: p = 0.03, ISI at 20 ms: p = 0.03, ISI at 100 ms: p = 0.01). CONCLUSION: MI + ES intervention was effective for improving UE motor function in patients with severe paralysis.

Effect of anticipation triggered by a prior dyspnea experience on brain activity.

[Purpose] Oxygenated hemoglobin (oxy-Hb) concentrations in the prefrontal cortex are closely associated with dyspnea. Dyspnea is influenced not only by physical activity, but also by visual stimuli, and several studies suggest that oxy-Hb concentrations change in response to certain external stimuli. However, the effects of internal psychological states on dyspnea have not been reported. This study explored the influence of anticipation triggered by previous episodes of dyspnea on brain activity. [Subjects] The subjects were 15 healthy volunteers with a mean age of 25.0 ± 3.0 years. [Methods] The subjects were shown a variety of photographs and instructed to expect breathing resistance matched to the affective nature of the particular photograph. After viewing the images, varying intensities of breathing resistance that were identical to, easier than, or harder than those shown in the images were randomly administered to the subjects; in fact, the image and resistance were identical 33% of the time and discordant 66% of the time. [Results] The concentrations of oxy-Hb in the right medial prefrontal cortex (rMPFC) increased significantly with an inspiratory pressure that was 30% of the maximum intensity in the subjects shown a pleasant image compared to the concentrations in subjects shown an unpleasant image. Moreover, rMPFC activity was significantly correlated with the magnitude of the dyspnea experienced. [Conclusion] These results suggest that a correlation exists between increased oxy-Hb in the rMPFC and the effects of expectations on dyspnea.