The C-Brace® microprocessor controlled stance and swing orthosis improves safety, mobility, and quality of life at one year: Interim results from a prospective registry.

Introduction: The C-Brace microprocessor-controlled stance and swing control orthosis has been shown to improve function, mobility, and quality of life. A systematic registry to gather long-term, real-world safety and effectiveness data in patients fit with a C-Brace has not been performed. Methods: International multicenter registry. Patients undergoing routine C-Brace fittings were assessed at baseline and 1 year after fitting. Primary outcomes were fast walking speed (FWS) measured by 25-foot or 10-meter walk test, Timed Up and Go (TUG) and the Activity-specific Balance Confidence (ABC) Scale. Secondary and exploratory outcomes included the Patient-specific Functional Scale (PSFS), falls, pain, PROMIS Pain Interference (PI), and quality of life. Results: 48 subjects with 1-year baseline and follow up data were analyzed. With the C-Brace, FWS improved by + 0.26 ± 0.33 m/s (p < .0001), TUG by -8.1 ± 14.6 sec (p < .0001), and ABC by + 24.9 ± 25.8% (p < .0001). Mean falls reduced from 33 ± 77 to 3.0 ± 5.6 (p = .0005). PSFS increased by 3.60 ± 2.34 points (p < .0001). Outcomes for pain, PI and quality of life showed significant improvements with the C-Brace. Conclusion: The C-Brace is an effective option to improve safety, mobility, and quality of life for patients needing a KAFO for ambulation.

The efficacy of contralaterally controlled functional electrical stimulation compared to conventional neuromuscular electrical stimulation for recovery of limb function following a stroke: a systematic review and meta-analysis.

Introduction: Limb paresis following a stroke is a common sequela that can impact patients' quality of life. Many rehabilitation strategies targeting the restoration of motor function exist. This systematic review and meta-analysis aim to evaluate the effects of contralaterally controlled functional electrical stimulation (CCFES) as a modality for limb rehabilitation. Unlike conventional neuromuscular electrical simulation (NMES), the contra-laterality in CCFES is achieved by two methods a bend angle sensor or an electromyographic bridge (EMGB) method, both of which targets signals from the unaffected limb. Method: This review study was performed following the preferred reporting item for systematic review and meta-analysis (PRISMA) guidelines. Records that met the inclusion criteria were extracted from the following databases: Medline, Embase, and Cochrane Register of Controlled Trials (CENTRAL). Additional articles were also retrieved from clinicaltrials.gov and China/Asia on Demand (CAOD). Only randomized controlled studies (RCTs) were included. Results: Sixteen RCTs met the inclusion criteria, and 14 of which were included in the quantitative analysis (meta-analysis). The results of the analysis show that when compared to conventional NMES, CCFES displayed a better improvement in the upper extremity Fugl-Meyer assessment (UEFMA) (SMD = 0.41, 95% CI: 0.21, 0.62, p-value <0.0001, I2 = 15%, GRADE: moderate), box and blocks test (BBT) (SMD = 0.48, 95% CI: 0.10, 0.86, p-value = 0.01, I2 = 0%, GRADE: very low), modified Barthel index (mBI) (SMD = 0.44, 95% CI: 0.16, 0.71, p-value = 0.002, I2 = 0%, GRADE: moderate), active range of motion (AROM) (SMD = 0.61, 95% CI: 0.29, 0.94, p-value = 0.0002, I2 = 23%, GRADE: moderate), and surface electromyography (sEMG) scores (SMD = 0.52, 95% CI: 0.14, 0.90, p-value = 0.008, I2 = 0%, GRADE: low). The results of the subgroup analysis for the type of sensor used in CCFES shows that an EMGB (SMD = 0.58, 95% CI: 0.33, 0.84, p-value <0.00001, I2 = 7%) is more effective than a bend angle sensor (SMD = 0.17, 95% CI: -0.12, 0.45, p-value = 0.25, I2 = 0%). Conclusion: The results of this study provide strong evidence that shows CCFES being a better electrical stimulation modality compared to conventional NMES. This could be explained by the fact that CCFES is bilateral in nature which offers a platform for better neuroplasticity following a stroke. There is still a need for high-quality studies with a standardized approach comparing CCFES to other treatment modalities. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=342670, identifier CRD42022342670.

Movement Component Analysis of Reaching Strategies in Individuals With Stroke: Preliminary Study.

BACKGROUND: Upper limb motor paresis is a major symptom of stroke, which limits activities of daily living and compromises the quality of life. Kinematic analysis offers an in-depth and objective means to evaluate poststroke upper limb paresis, with anticipation for its effective application in clinical settings. OBJECTIVE: This study aims to compare the movement strategies of patients with hemiparesis due to stroke and healthy individuals in forward reach and hand-to-mouth reach, using a simple methodology designed to quantify the contribution of various movement components to the reaching action. METHODS: A 3D motion analysis was conducted, using a simplified marker set (placed at the mandible, the seventh cervical vertebra, acromion, lateral epicondyle of the humerus, metacarpophalangeal [MP] joint of the index finger, and greater trochanter of the femur). For the forward reach task, we measured the distance the index finger's MP joint traveled from its starting position to the forward target location on the anterior-posterior axis. For the hand-to-mouth reach task, the shortening of the vertical distance between the index finger MP joint and the position of the chin at the start of the measurement was measured. For both measurements, the contributions of relevant upper limb and trunk movements were calculated. RESULTS: A total of 20 healthy individuals and 10 patients with stroke participated in this study. In the forward reach task, the contribution of shoulder or elbow flexion was significantly smaller in participants with stroke than in healthy participants (mean 52.5%, SD 24.5% vs mean 85.2%, SD 4.5%; P<.001), whereas the contribution of trunk flexion was significantly larger in stroke participants than in healthy participants (mean 34.0%, SD 28.5% vs mean 3.0%, SD 2.8%; P<.001). In the hand-to-mouth reach task, the contribution of shoulder or elbow flexion was significantly smaller in participants with stroke than in healthy participants (mean 71.8%, SD 23.7% vs mean 90.7%, SD 11.8%; P=.009), whereas shoulder girdle elevation and shoulder abduction were significantly larger in participants with stroke than in healthy participants (mean 10.5%, SD 5.7% vs mean 6.5%, SD 3.0%; P=.02 and mean 16.5%, SD 18.7% vs mean 3.0%, SD 10.4%; P=.02, respectively). CONCLUSIONS: Compared with healthy participants, participants with stroke achieved a significantly greater distance via trunk flexion in the forward reach task and shoulder abduction and shoulder girdle elevation in the hand-to-mouth reach task, both of these differences are regarded as compensatory movements. Understanding the characteristics of individual motor strategies, such as dependence on compensatory movements, may contribute to tailored goal setting in stroke rehabilitation.

A microprocessor stance and swing control orthosis improves balance, risk of falling, mobility, function, and quality of life of individuals dependent on a knee-ankle-foot orthosis for ambulation.

INTRODUCTION: The C-Brace microprocessor stance and swing control orthosis was designed to overcome safety and functional limitations of traditional knee-ankle-foot orthoses (KAFOs) for individuals with lower limb paresis. However, a systematic comparison to established KAFO types has not been performed in a bigger sample. METHODS: International multicenter, randomized, controlled, cross-over clinical trial. Legacy KAFO users at risk of falling were randomized to KAFO/C-Brace or C-Brace/KAFO use for three months with each orthosis. Primary outcome was balance assessed with the Berg Balance Scale (BBS). Secondary outcomes were falls, mobility, function, and quality of life. RESULTS: Intention-to-treat analysis with 102 participants. With the C-Brace, the BBS improved by 3.3 ± 6.3 points (p < 0.0001). Significantly fewer participants presented BBS scores <40 indicative of increased fall risk (16 vs. 36, p = 0.018). Mean falls reduced from 4.0 ± 16.8 to 1.1 ± 3.3 (p = 0.002). Outcomes for function, mobility, and quality of life showed significant improvements with the C-Brace. DISCUSSION: The improvements in fall risk and mobility can be attributed to the stumble recovery and controlled knee flexion during weight bearing of the C-Brace and have a positive impact on the quality of life of users. CONCLUSION: The C-Brace represents an option for KAFO users with increased fall risk and reduced mobility.

When prescribing traditional knee-ankle-foot orthoses (KAFOs), their known limitations, such as limited function and mobility, and the requirement to walk with compensatory mechanisms, especially on non-level terrains, should be considered.For patients with compromised balance and increased risk of falling when using a traditional KAFO, a microprocessor stance and swing control orthosis (MP-SSCO) may be considered as an orthotic option to reduce their fall risk.For patients with mobility restrictions using a traditional KAFO, a MP-SSCO may be considered to improve function, mobility, reintegration into normal living, and quality of life.

Concomitant sensory stimulation during therapy to enhance hand functional recovery post stroke.

BACKGROUND: Post-stroke hand impairment is prevalent and persistent even after a full course of rehabilitation. Hand diminishes stroke survivors' abilities for activities of daily living and independence. One way to improve treatment efficacy is to augment therapy with peripheral sensory stimulation. Recently, a novel sensory stimulation, TheraBracelet, has been developed in which imperceptible vibration is applied during task practice through a wrist-worn device. The objective of this trial is to determine if combining TheraBracelet with hand task practice is superior to hand task practice alone. METHODS: A double-blind randomized controlled trial will be used. Chronic stroke survivors will undergo a standardized hand task practice therapy program (3 days/week for 6 weeks) while wearing a device on the paretic wrist. The device will deliver TheraBracelet vibration for the treatment group and no vibration for the control group. The primary outcome is hand function measured by the Wolf Motor Function Test. Other outcomes include the Box and Block Test, Action Research Arm Test, upper extremity use in daily living, biomechanical measure of the sensorimotor grip control, and EEG-based neural communication. DISCUSSION: This research will determine clinical utility of TheraBracelet to guide future translation. The TheraBracelet stimulation is delivered via a wrist-worn device, does not interfere with hand motion, and can be easily integrated into clinical practice. Enhancing hand function should substantially increase stroke survivors' independence and quality of life and reduce caregiver burden. TRIAL REGISTRATION: NCT04569123 . Registered on September 29, 2020.

Post-stroke Rehabilitation of Severe Upper Limb Paresis in Germany - Toward Long-Term Treatment With Brain-Computer Interfaces.

Severe upper limb paresis can represent an immense burden for stroke survivors. Given the rising prevalence of stroke, restoration of severe upper limb motor impairment remains a major challenge for rehabilitation medicine because effective treatment strategies are lacking. Commonly applied interventions in Germany, such as mirror therapy and impairment-oriented training, are limited in efficacy, demanding for new strategies to be found. By translating brain signals into control commands of external devices, brain-computer interfaces (BCIs) and brain-machine interfaces (BMIs) represent promising, neurotechnology-based alternatives for stroke patients with highly restricted arm and hand function. In this mini-review, we outline perspectives on how BCI-based therapy can be integrated into the different stages of neurorehabilitation in Germany to meet a long-term treatment approach: We found that it is most appropriate to start therapy with BCI-based neurofeedback immediately after early rehabilitation. BCI-driven functional electrical stimulation (FES) and BMI robotic therapy are well suited for subsequent post hospital curative treatment in the subacute stage. BCI-based hand exoskeleton training can be continued within outpatient occupational therapy to further improve hand function and address motivational issues in chronic stroke patients. Once the rehabilitation potential is exhausted, BCI technology can be used to drive assistive devices to compensate for impaired function. However, there are several challenges yet to overcome before such long-term treatment strategies can be implemented within broad clinical application: 1. developing reliable BCI systems with better usability; 2. conducting more research to improve BCI training paradigms and 3. establishing reliable methods to identify suitable patients.

Treatment of upper limb spasticity with inhibitory repetitive transcranial magnetic stimulation: A randomized placebo-controlled trial.

BACKGROUND: Upper limb dysfunction is a frequent complication after stroke impairing outcome. Inhibitory repetitive transcranial magnetic stimulation (rTMS) applied over the contralesional hemisphere is supposed to enhance the positive effects of conventional rehabilitative treatment. OBJECTIVE: This double-blind randomized placebo-controlled trial investigated whether inhibitory rTMS as add-on to standard therapy improves upper limb spasticity. METHODS: Twenty-eight patients (aged 44 to 80 years) with unilateral stroke in the middle cerebral artery territory were analyzed. Participants were randomly assigned to inhibitory, low-frequency (LF-) rTMS (n = 14) or sham-rTMS (n = 14). The primary outcome measure was the spasticity grade, which was assessed with the Modified Ashworth Scale (MAS). In addition, the Fugl-Meyer-Assessment (FMA) for the upper extremity (UE) and a resting-state fMRI were performed to measure motor functions and the sensorimotor network, respectively. RESULTS: The MAS score was reduced in the LF-rTMS group only, whereas the FMA score improved in both groups over time. Regarding the fMRI data, both groups activated typical regions of the sensorimotor network. In the LF-rTMS group, however, connectivity to the left angular gyrus increased after treatment. CONCLUSION: Changes in functional connectivity in patients receiving inhibitory rTMS over the contralesional motor cortex suggest that processes of neuronal plasticity are stimulated.

Multimodal Assessment of the Motor System in Patients With Chronic Ischemic Stroke.

BACKGROUND AND PURPOSE: Despite continuing efforts in the multimodal assessment of the motor system after stroke, conclusive findings on the complementarity of functional and structural metrics of the ipsilesional corticospinal tract integrity and the role of the contralesional hemisphere are still lacking. This research aimed to find the best combination of motor system metrics, allowing the classification of patients into 3 predefined groups of upper limb motor recovery. METHODS: We enrolled 35 chronic ischemic stroke patients (mean 47 [26-66] years old, 29 [6-58] months poststroke) with a single supratentorial lesion and unilateral upper extremity weakness. Patients were divided into 3 groups, depending on upper limb motor recovery: good, moderate, and bad. Nonparametric statistical tests and regression analysis were used to investigate the relationships among microstructural (fractional anisotropy (FA) ratio of the corticospinal tracts at the internal capsule (IC) level (classic method) and along the length of the tracts (Fréchet distance), and of the corpus callosum) and functional (motor evoked potentials [MEPs] for 2 hand muscles) motor system metrics. Stratification rules were also tested using a decision tree classifier. RESULTS: IC FA ratio in the IC and MEP absence were both equally discriminative of the bad motor outcome (96% accuracy). For the 3 recovery groups' classification, the best parameter combination was IC FA ratio and the Fréchet distance between the contralesional and ipsilesional corticospinal tract FA profiles (91% accuracy). No other metrics had any additional value for patients' classification. MEP presence differed for 2 investigated muscles. CONCLUSIONS: This study demonstrates that better separation between 3 motor recovery groups may be achieved when considering the similarity between corticospinal tract FA profiles along its length in addition to region of interest-based assessment and lesion load calculation. Additionally, IC FA ratio and MEP absence are equally important markers for poor recovery, while for MEP probing it may be important to investigate more than one hand muscle.

A Case of Herpes Zoster Presented with Lower Limb Paresis.

Herpes zoster is a common viral disorder that typically shows characteristic painful skin lesion. Motor neuropathy rarely complicates herpes zoster infection, and it may be overlooked without suspicion. Here, we report a case of a herpes zoster patient who presented with sciatica and paresis, but without the typical skin lesion. The patient was initially misdiagnosed as having other disorders including trauma or spine lesion. Electrodiagnostic study and magnetic resonance imaging (MRI) helped to make an accurate diagnosis and localize the motor nerve involvement of herpes zoster.

Combined Transcranial Direct Current Stimulation and Virtual Reality-Based Paradigm for Upper Limb Rehabilitation in Individuals with Restricted Movements. A Feasibility Study with a Chronic Stroke Survivor with Severe Hemiparesis.

Impairments of the upper limb function are a major cause of disability and rehabilitation. Most of the available therapeutic options are based on active exercises and on motor and attentional inclusion of the affected arm in task oriented movements. However, active movements may not be possible after severe impairment of the upper limbs. Different techniques, such as mirror therapy, motor imagery, and non-invasive brain stimulation have been shown to elicit cortical activity in absence of movements, which could be used to preserve the available neural circuits and promote motor learning. We present a virtual reality-based paradigm for upper limb rehabilitation that allows for interaction of individuals with restricted movements from active responses triggered when they attempt to perform a movement. The experimental system also provides multisensory stimulation in the visual, auditory, and tactile channels, and transcranial direct current stimulation coherent to the observed movements. A feasibility study with a chronic stroke survivor with severe hemiparesis who seemed to reach a rehabilitation plateau after two years of its inclusion in a physical therapy program showed clinically meaningful improvement of the upper limb function after the experimental intervention and maintenance of gains in both the body function and activity. The experimental intervention also was reported to be usable and motivating. Although very preliminary, these results could highlight the potential of this intervention to promote functional recovery in severe impairments of the upper limb.

Clinical, electrophysiologic, and imaging features of zoster-associated limb paresis.

INTRODUCTION: Paresis is a long-recognized complication of herpes zoster, but there has been comparatively little study of zoster-associated limb paresis (ZALP). METHODS: In this study we reviewed 49 Mayo Clinic patients with ZALP. RESULTS: The mean age of onset was 71 years, 67% were men, and the lower limb was affected in 55%. The mean weakness score was 2.0 (0 = normal strength, 4 = plegia). Most patients developed postherpetic neuralgia (PHN, 92% at 1 month and 65% at 3 months), and the average minimum duration of weakness was 193 days. ZALP was caused by radiculopathy (37%), plexopathy (41%), mononeuropathy (14%), and radiculoplexus neuropathy (8%). MRI demonstrated nerve enlargement, T2 signal prolongation, or enhancement in a majority (64%) of affected plexi and peripheral nerves. CONCLUSIONS: ZALP is associated with considerable weakness. It typically lasts at least several months, localizes to plexus or peripheral nerve in 63%, and is associated with high rates of PHN.