Mapeo del lenguaje utilizando estimulación magnética transcraneal repetitiva por navegación: un estudio comparativo con la estimulación cortical directa intraoperatoria / Language mapping using repetitive transcranial magnetic stimulation by navigation: a comparative study with direct intraoperative cortical stimulation

Introducción: la estimulación cortical directa (DCS) es una metodología corrientemente usada para localizar áreas del lenguaje en intervenciones quirúrgicas que incluyan resecciones.La estimulación magnética transcraneana repetitiva (rTMS) a demostrado también su capacidad para inducir alteraciones transitorias. Recientemente el desarrollo del Sistema de Navegación de TMS asegura precisa localización del sitio estimulado. El objetivo del trabajo es estudiar la confiabilidad de la estimulación magnética transcraneal repetitiva navegada (nrTMS) en la localización de los sitios del lenguaje. Métodos: Once pacientes seleccionados para mapeo del lenguaje por DCS fueron evaluados pre-cirugía con nrTMS. Los mapeos de lenguaje prequirúrgicos mediante nrTMS fueron comparados con DCS. Resultados: Un total de 25 nrTMS sitios del lenguaje y 38 DCS fueron localizados. La sensibilidad y la especificidad obtenida fue de 88.4 y 95.6, respectivamente. La distancia media fue evaluada en 4,5mm. Conclusiones: Los dispositivos de nrTMS permiten la identificación de las áreas corticales del lenguaje. Con un alto grado de concordancia con el mapeo TMS. La nrTMS se muestra como una herramienta de interés en la investigación y aplicación práctica en la función del lenguaje.

Introduction: direct cortical stimulation (DCS) is currently used to localise language areas in surgical resections. Repetitive transcranial magnetic stimulation (rTMS) has also shown its capacity to induce transient language alterations. Newly developed Navigated Brain Systems of TMS ensure precise topographical localisation of the stimulated site. The objective was to study the reliability of navigated repetitive transcranial magnetic stimulation (nrTMS) in language sites localisation.Methods: Eleven patients selected for DCS language mapping were presurgically evaluated with nrTMS. These presurgicalnrTMS language maps were then compared with DCS.Results: A total number of 25 nrTMS and 38 DCS language sites were localised. Sensitivity and specificity were calculated as 88.4 and 95.6 respectively. Mean distance was assessed as 4.5 millimetres. Conclusions: nrTMS devices allow identification of cortical language areas, with a high degree of concordance to TMS mapping. NrTMS shows up as an interesting tool for research and practical application in language function.

Is botulinum toxin type A effective in the treatment of spastic shoulder pain in patients after stroke? A double-blind randomized clinical trial.

OBJECTIVE: To determine the efficacy of botulinum toxin type A for the treatment of spastic shoulder pain in patients after stroke. DESIGN: Double-blind randomized clinical trial. PATIENTS: Of 31 patients enrolled from an acute-care hospital in Spain, 2 cases dropped out (drop-out rate 6.5%). Fourteen subjects were treated with infiltration of 500 units of botulinum toxin type A in the pectoralis major muscle of the paretic side, and 15 with a placebo. METHODS: After infiltration, both groups received transcutaneous electrical nerve stimulation for 6 weeks. Patients were assessed by the use of the Visual Analogue Scale for pain. A good result concerning pain was considered when the Visual Analogue Scale score was below 33.3 mm or less than half the initial score. The patients were followed-up for 6 months. RESULTS: The patients treated with botulinum toxin type A showed a significantly greater pain improvement from the first week post-infiltration. Persistent shoulder pain was observed more frequently in the placebo group, with relative risks in the range 0.32-0.41 during the follow-up period. CONCLUSION: Patients with spastic shoulder pain treated with a botulinum toxin type A infiltration in the pectoralis major muscle of the paretic side have a higher likelihood of pain relief (between 2.43- and 3.11-fold).

[Determination of maximal diaphragm strength in chronic obstructive pulmonary disease: cervical magnetic stimulation versus traditional sniff maneuver]. / Fuerza máxima del diafragma en la EPOC: estimulación magnética cervical frente a la clásica maniobra de inhalación forzada.

OBJECTIVE: Magnetic stimulation of the diaphragm allows its strength to be assessed. The clinical applications of this technique are becoming more widespread given that the patient's cooperation is not required. The aim of the present study was to compare this inhalation technique with traditional voluntary forced inspiration (sniff test) in a group of patients with chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS: Sixteen men with moderate-to-severe COPD were studied (mean [SD] forced expiratory volume in 1 second, 35% [15%] of the reference value). For all patients, the maximal transdiaphragmatic pressure (a measure of the contractility of the muscle) was determined at peak inspiration and during cervical magnetic stimulation. RESULTS: A moderate correlation between measurements with the 2 techniques was observed. The value obtained with stimulation was approximately 20% of that obtained with the sniff maneuver (22 [7] cm H2O vs 97 [27] cm H2O, respectively). The stimulation technique yielded an intraindividual coefficient of variability of 12% (7%) and an interindividual one of 33% (6%). Very similar values for these coefficients were obtained with the sniff maneuver. Qualitative analysis of the stimulation technique showed it to have a high sensitivity (89%) for diagnosing muscle weakness, with few false negatives. In contrast, specificity was very low (43%), and false positives for muscle weakness were relatively common. The overall effectiveness of the prediction was acceptable (69%). CONCLUSIONS: Cervical magnetic stimulation appears to be a good clinical option for ruling out diaphragm weakness. It is particularly indicated in patients with limited capacity for understanding instructions or those unable to cooperate.

Fuerza máxima del diafragma en la EPOC: estimulación magnética cervical frente a la clásica maniobra de inhalación forzada / Determination of maximal diaphragm strength in Chronic Obstructive Pulmonary Disease: cervical magnetic stimulation ersus traditional sniff maneuver

Objetivo: La estimulación magnética del diafragma es una técnica que permite evaluar la fuerza de este músculo. Dado que obvia la necesidad de colaboración del paciente, va extendiendo progresivamente su aplicación clínica. El objetivo del presente estudio ha sido comparar esta técnica de estimulación con la clásica de inhalación voluntaria forzada (sniff) en un grupo de pacientes con enfermedad pulmonar obstructiva crónica (EPOC). Pacientes y métodos: Se estudió a 16 pacientes varones con EPOC de moderada a grave (valor medio ± desviación estándar del volumen espiratorio forzado en el primer segundo del 35 ± 15% del valor de referencia). En todos ellos se obtuvo la presión máxima del diafragma (expresión de la fuerza contráctil del músculo) por maniobras de inhalación voluntaria máxima y de estimulación cervical magnética. Resultados: Se observó una relación moderada entre ambas técnicas, siendo los valores obtenidos con estimulación de aproximadamente un 20% de los obtenidos con la maniobra voluntaria (97 ± 27 y 22 ± 7 cmH2O, respectivamente). La técnica de estimulación mostró unos coeficientes de variabilidad intraindividual del 12 ± 7%, e interindividual del 33 ± 6%, muy similares a los del método de inhalación. El análisis cualitativo de la técnica de estimulación para el diagnóstico de debilidad muscular mostró una elevada sensibilidad (89%), con escasos falsos negativos. Por el contrario, su especificidad fue muy baja (43%), con una tasa relativamente elevada de sobrediagnósticos. La eficacia de la predicción resultó globalmente aceptable (69%). Conclusiones: La técnica de estimulación magnética cervical se muestra como una buena opción clínica para descartar debilidad del diafragma, con indicación sobre todo en pacientes con poca capacidad de comprensión o incapacidad de colaboración

Objective: Magnetic stimulation of the diaphragm allows its strength to be assessed. The clinical applications of this technique are becoming more widespread given that the patient's cooperation is not required. The aim of the present study was to compare this inhalation technique with traditional voluntary forced inspiration (sniff test) in a group of patients with chronic obstructive pulmonary disease (COPD). Patients and methods: Sixteen men with moderate-to-severe COPD were studied (mean [SD] forced expiratory volume in 1 second, 35% [15%] of the reference value). For all patients, the maximal transdiaphragmatic pressure (a measure of the contractility of the muscle) was determined at peak inspiration and during cervical magnetic stimulation. Results: A moderate correlation between measurements with the 2 techniques was observed. The value obtained with stimulation was approximately 20% of that obtained with the sniff maneuver (22 [7] cm H2O vs 97 [27] cm H2O, respectively). The stimulation technique yielded an intraindividual coefficient of variability of 12% (7%) and an interindividual one of 33% (6%). Very similar values for these coefficients were obtained with the sniff maneuver. Qualitative analysis of the stimulation technique showed it to have a high sensitivity (89%) for diagnosing muscle weakness, with few false negatives. In contrast, specificity was very low (43%), and false positives for muscle weakness were relatively common. The overall effectiveness of the prediction was acceptable (69%). Conclusions: Cervical magnetic stimulation appears to be a good clinical option for ruling out diaphragm weakness. It is particularly indicated in patients with limited capacity for understanding instructions or those unable to cooperate