Hebbian plasticity induced by temporally coincident BCI enhances post-stroke motor recovery.

Functional electrical stimulation (FES) can support functional restoration of a paretic limb post-stroke. Hebbian plasticity depends on temporally coinciding pre- and post-synaptic activity. A tight temporal relationship between motor cortical (MC) activity associated with attempted movement and FES-generated visuo-proprioceptive feedback is hypothesized to enhance motor recovery. Using a brain-computer interface (BCI) to classify MC spectral power in electroencephalographic (EEG) signals to trigger FES-delivery with detection of movement attempts improved motor outcomes in chronic stroke patients. We hypothesized that heightened neural plasticity earlier post-stroke would further enhance corticomuscular functional connectivity and motor recovery. We compared subcortical non-dominant hemisphere stroke patients in BCI-FES and Random-FES (FES temporally independent of MC movement attempt detection) groups. The primary outcome measure was the Fugl-Meyer Assessment, Upper Extremity (FMA-UE). We recorded high-density EEG and transcranial magnetic stimulation-induced motor evoked potentials before and after treatment. The BCI group showed greater: FMA-UE improvement; motor evoked potential amplitude; beta oscillatory power and long-range temporal correlation reduction over contralateral MC; and corticomuscular coherence with contralateral MC. These changes are consistent with enhanced post-stroke motor improvement when movement is synchronized with MC activity reflecting attempted movement.

Integrating Machine Learning with Robotic Rehabilitation May Support Prediction of Recovery of the Upper Limb Motor Function in Stroke Survivors.

Motor impairment is a common issue in stroke patients, often affecting the upper limbs. To this standpoint, robotic neurorehabilitation has shown to be highly effective for motor function recovery. Notably, Machine learning (ML) may be a powerful technique able to identify the optimal kind and intensity of rehabilitation treatments to maximize the outcomes. This retrospective observational research aims to assess the efficacy of robotic devices in facilitating the functional rehabilitation of upper limbs in stroke patients through ML models. Specifically, clinical scales, such as the Fugl-Meyer Assessment (A-D) (FMA), the Frenchay Arm Test (FAT), and the Barthel Index (BI), were used to assess the patients' condition before and after robotic therapy. The values of these scales were predicted based on the patients' clinical and demographic data obtained before the treatment. The findings showed that ML models have high accuracy in predicting the FMA, FAT, and BI, with R-squared (R2) values of 0.79, 0.57, and 0.74, respectively. The findings of this study suggest that integrating ML into robotic therapy may have the capacity to establish a personalized and streamlined clinical practice, leading to significant improvements in patients' quality of life and the long-term sustainability of the healthcare system.

Motor imagery-based brain-computer interface rehabilitation programs enhance upper extremity performance and cortical activation in stroke patients.

BACKGROUND: The most challenging aspect of rehabilitation is the repurposing of residual functional plasticity in stroke patients. To achieve this, numerous plasticity-based clinical rehabilitation programs have been developed. This study aimed to investigate the effects of motor imagery (MI)-based brain-computer interface (BCI) rehabilitation programs on upper extremity hand function in patients with chronic hemiplegia. DESIGN: A 2010 Consolidated Standards for Test Reports (CONSORT)-compliant randomized controlled trial. METHODS: Forty-six eligible stroke patients with upper limb motor dysfunction participated in the study, six of whom dropped out. The patients were randomly divided into a BCI group and a control group. The BCI group received BCI therapy and conventional rehabilitation therapy, while the control group received conventional rehabilitation only. The Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) score was used as the primary outcome to evaluate upper extremity motor function. Additionally, functional magnetic resonance imaging (fMRI) scans were performed on all patients before and after treatment, in both the resting and task states. We measured the amplitude of low-frequency fluctuation (ALFF), regional homogeneity (ReHo), z conversion of ALFF (zALFF), and z conversion of ReHo (ReHo) in the resting state. The task state was divided into four tasks: left-hand grasping, right-hand grasping, imagining left-hand grasping, and imagining right-hand grasping. Finally, meaningful differences were assessed using correlation analysis of the clinical assessments and functional measures. RESULTS: A total of 40 patients completed the study, 20 in the BCI group and 20 in the control group. Task-related blood-oxygen-level-dependent (BOLD) analysis showed that when performing the motor grasping task with the affected hand, the BCI group exhibited significant activation in the ipsilateral middle cingulate gyrus, precuneus, inferior parietal gyrus, postcentral gyrus, middle frontal gyrus, superior temporal gyrus, and contralateral middle cingulate gyrus. When imagining a grasping task with the affected hand, the BCI group exhibited greater activation in the ipsilateral superior frontal gyrus (medial) and middle frontal gyrus after treatment. However, the activation of the contralateral superior frontal gyrus decreased in the BCI group relative to the control group. Resting-state fMRI revealed increased zALFF in multiple cerebral regions, including the contralateral precentral gyrus and calcarine and the ipsilateral middle occipital gyrus and cuneus, and decreased zALFF in the ipsilateral superior temporal gyrus in the BCI group relative to the control group. Increased zReHo in the ipsilateral cuneus and contralateral calcarine and decreased zReHo in the contralateral middle temporal gyrus, temporal pole, and superior temporal gyrus were observed post-intervention. According to the subsequent correlation analysis, the increase in the FMA-UE score showed a positive correlation with the mean zALFF of the contralateral precentral gyrus (r = 0.425, P < 0.05), the mean zReHo of the right cuneus (r = 0.399, P < 0.05). CONCLUSION: In conclusion, BCI therapy is effective and safe for arm rehabilitation after severe poststroke hemiparesis. The correlation of the zALFF of the contralateral precentral gyrus and the zReHo of the ipsilateral cuneus with motor improvements suggested that these values can be used as prognostic measures for BCI-based stroke rehabilitation. We found that motor function was related to visual and spatial processing, suggesting potential avenues for refining treatment strategies for stroke patients. TRIAL REGISTRATION: The trial is registered in the Chinese Clinical Trial Registry (number ChiCTR2000034848, registered July 21, 2020).

A Comparative Study on the Organ Representation Characteristics of Three Mainstream Anatomical Ontologies / 医学信息学杂志

Purpose/Significance To analyze the characteristics of organ representation of anatomical ontologies,and to provide ref-erences for the research and construction of ontology in other fields.Method/Process The similarities and differences of three mainstream anatomical ontologies of SNOMED CT(SCT),Uberon and the foundational model of anatomy ontology(FMA)in terms of organ classifi-cation methods and term mapping are compared.Result/Conclusion Among the three main types of anatomical ontologies,SCT and Uberon are mainly classified according to the function of organs,while FMA is mainly classified according to the anatomical morphology of organs.The concept of organs in FMA and Uberon is the same as the concept of entire organs in SCT,and the representation forms of paired organs in SCT,Uberon and FMA are similar.

Comparative Evaluation of Cranial Base Length and Flexure on Facial Parameters in Hypodivergent, Normodivergent and Hyperdivergent Patients: A Retrospective Cephalometric Study.

AIM: The aim of the study was to assess the influence of cranial base length (CBL) and Flexure on facial parameters in Hypodivergent, Normodivergent, and Hyperdivergent patients. MATERIALS AND METHODS: Around 60 standardized cephalograms were divided into Hypodivergent, Normodivergent, and Hyperdivergent groups (20 each) based on the FMA angle. The CBL, cranial flexure (CF), and various facial parameters were measured for each case. The results were analyzed for the correlation between Cranial and facial parameters in each of the three study groups. RESULTS: Comparison and Pairwise Comparison of variables between study groups were done using ANOVA and Tukey's post hoc Test. Cranial base length, mandibular body length, LAFH, N-Me-Go angle (p-value <0.001), and Jarabak's ratio were found to be significantly different between the groups. Pearson's Correlation showed that most of the facial parameters had a significant correlation with CBL in Hypodivergent groups. CONCLUSION: The CBL is more closely related to facial parameters in vertical dysplasia individuals than CF. The CBL is positively correlated to facial variables, especially in Hypodivergent individuals. The N-Me-Go Angle introduced in the study was significantly different in all three vertical facial types studied; hence, it cannot be used as a valuable diagnostic tool. CLINICAL SIGNIFICANCE: Changes in the length and flexure of the cranial base influence the anteroposterior position of jaw bases. The influence of the cranial base on the development of vertical dysplasias is not studied much, hence the present study aims at resolving this lacuna in literature.

Effects of fixed functional orthodontic treatment in hypodivergent and hyperdivergent class II patients-a retrospective cephalometric investigation.

OBJECTIVE: To compare skeletal and dentoalveolar changes after orthodontic treatment of class II malocclusion in patients with hypodivergent and hyperdivergent growth patterns through cast splint fixed functional appliances (FFA). MATERIALS AND METHODS: N = 42 out of n = 47 patients with mandibular plane angles < 34° or ≥ 34° were divided into a hypodivergent (n = 24) and a hyperdivergent (n = 18) group. All patients received a single-step mandibular advancement protocol through an FFA. Lateral cephalograms were analyzed after initial leveling and alignment (T1) and immediately after FFA removal (T2). The therapeutic effect was calculated through comparison with age-matched controls from a growth survey. Statistical significance was set at p < 0.05. RESULTS: Hypodivergent and hyperdivergent patients showed different treatment outcomes, but significant differences existed only for overbite and interincisal angle. Nearly all measurements suggested similar treatment-related changes for both groups with exception for dentoalveolar parameters. CONCLUSION: Treatment with FFA causes similar skeletal and dentoalveolar effects in hypodivergent and in hyperdivergent patients. The correction of overjet and molar relationship is mainly caused by dentoalveolar changes. CLINICAL RELEVANCE: Hyperdivergent patients do not respond unfavorably to FFA treatment compared to hypodivergent patients. Lower incisor protrusion occurs more pronounced in hypodivergent patients. The growth pattern ought to be considered when choosing FFA for class II treatment.

Corrigendum: Prediction of motor function in patients with traumatic brain injury using genetic algorithms modified back propagation neural network: a data-based study.

[This corrects the article DOI: 10.3389/fnins.2022.1031712.].

Custom TKA enables adequate realignment with minimal ligament release and grants satisfactory outcomes in knees that had prior osteotomies or extra-articular fracture sequelae.

PURPOSE: To report the early clinical and radiographic outcomes of custom total knee arthroplasty (TKA) in knees that had prior osteotomies and/or extra-articular fracture sequelae. METHODS: The authors retrospectively analysed a consecutive series of 444 knees that received custom TKA between 2016 and 2019 and identified 41 knees that had prior extra-articular events (osteotomies or fracture sequelae). Patients responded to pre- and post-operative (> 12 months) questionnaires, including Knee Society Score (KSS), Oxford Knee Score (OKS), Forgotten Joint Score (FJS) and Knee injury and Osteoarthritis Outcome Score (KOOS). Net improvements were calculated by subtracting pre- from post-operative scores. In addition to a preoperative CT scan, pre- and post-operative long-leg weight-bearing radiographs were obtained, on which the hip-knee-ankle (HKA) angle, femoral mechanical angle (FMA, between femoral mechanical axis and joint line) and tibial mechanical angle (TMA, between tibial mechanical axis and joint line) angles were measured, and alignment was planned within a 'target zone' of FMA and TMA within 85°-95° and HKA angle within 175°-183°. Agreements between preoperative, planned and post-operative angles were calculated using intra-class correlation coefficients (ICC). RESULTS: From the initial 41 knees, 3 had incomplete post-operative data and 1 was revised for painful stiffness due to uncorrected rotational malunion, leaving 37 knees for analysis. Twenty had prior osteotomies (tibia, n = 18, femur, n = 2), 8 had isolated fractures (tibial, n = 3; femoral, n = 5), and 9 had both osteotomies and fractures. Postoperative coronal alignments were 90.4° ± 2.4° for FMA, 89.3° ± 2.6° for TMA and 179.9° ± 3.0° for HKA angle. Agreements between planned and achieved alignments were fair to excellent, and 29 (78%) knees were within the 'target zone'. At a mean follow-up of 15 ± 5 months, all clinical scores had improved significantly (p < 0.001). CONCLUSIONS: Custom TKA granted satisfactory clinical outcomes and a low complication rate in knees that had prior osteotomies and/or extra-articular fracture sequelae. Using custom implants and strategies for coronal alignment, 29 (78%) of the 37 knees were successfully aligned within the 'target zone', and 35 (95%) of the 41 knees did not require ligament release. LEVEL OF EVIDENCE: IV.

Effects of Rehabilitation Training Combined with Acupuncture on Upper Limb Function of Stroke Patients Based on Kinect / 医用生物力学

Objective To investigate the effect of rehabilitation training combined with acupuncture ( RTA) on upper limb function of stroke patients by Kinect. Methods Stroke patients with upper limb dysfunction werrandomly divided into control group (rehabilitation training) and treatment group ( RTA), with 15 cases in each group. The modified Barthel Index ( MBI), Fugl Meyer assessment ( FMA), and Wolf motor function test (WMFT) were compared between two groups before and after treatment. The changes in motor time ( MT), motor unit number (MUN), index of curvature (IC), elbow flexion angle (EFA), shoulder flexion angle (SFA),and shoulder adduction angle ( SAA) during three actions, namely, placing forearm on the table, extending elbow and drinking water, were evaluated by Kinect and then compared between two groups before and after treatment. Results After 6 weeks of intervention, the scores of MBI, FMA, WMFT and elbow extension in treatment group were higher than those in control group (P<0. 05). The scores of MBI, FMA, WMFT and three actions after treatment were higher than those before treatment (P<0. 05). For three actions, the improvement of MT, MUN, IC, EFA, SFA, and SAA in treatment group were better than those in control group ( P< 0. 05). Compared with pre-treatment, for the action of forearm placement on the table and elbow extension, both treatment group and control group showed an increase in EFA (P<0. 05), and a decrease in MT, MUN, IC, SFA and SA (P<0. 05). For the action of drinking water, both treatment group and control group showed an increase in EFA and SAA (P< 0. 05), and a decrease in MT, MUN, IC and SAA ( P< 0. 05). Conclusions RTA can improve the upper limb function of stroke patients. Kinect can accurately reflect the changes in upper limb function of stroke patients, and it is suitable for clinical work.

Investigation of the change in the degree of Frankfort mandibular plane angle after levelling the curve of spee in different malocclusion groups.

BACKGROUND AND OBJECTIVES: The curve of Spee is a naturally occurring phenomenon in the human dentition. Leveling the curve of Spee can affect the Frankfort-mandibular plane (FMP) Angle and thus the lower anterior facial height. This study examined the degree of change in FMP angle after leveling the curve of Spee in different malocclusion groups. METHODS: In this study, 75 patients who were aged >14 years and had undergone fixed appliance therapy using a 0.022-slot MBT bracket system were included. The pre- and post-treatment casts and lateral cephalograms of the patients were divided into three groups, namely Class I, II, and III malocclusions, with 25 patients in each group. The curve of Spee and FMP angle were measured before and after orthodontic treatment, and their correlation was evaluated. RESULTS: After leveling the curve of Spee, the FMP angle decreased in Class I and II groups and increased in Class III group. These results were statistically significant except in Class I malocclusion group. A mild positive correlation was observed between the curve of Spee and FMP angle in Class I and III malocclusion groups and a negative correlation in Class II malocclusion group. CONCLUSION: The change in FMP angle, following the leveling of the curve of Spee, in Class II and III malocclusion group, is attributed to alterations in lower anterior facial height. The study observed a mild positive correlation between the curve of Spee and FMP angle in Class I and III malocclusion groups and a negative correlation in Class II malocclusion group.

Intermittent theta-burst stimulation with physical exercise improves poststroke motor function: A systemic review and meta-analysis.

Background: Intermittent theta-burst stimulation (iTBS) is an optimized rTMS modality that could modulate the excitability of neural structures. Several studies have been conducted to investigate the efficacy of iTBS in improving the motor function of stroke patients. However, the specific role of iTBS in motor function recovery after stroke is unclear. Hence, in our study, we performed a meta-analysis to investigate the efficacy of iTBS for the motor function improvement of stroke patients. Methods: MEDLINE, Embase, and Cochrane Library were searched until May 2022 for randomized controlled trials (RCTs). Results: Thirteen RCTs with 334 patients were finally included in our study. The primary endpoints were the Fugl-Meyer assessment scale (FMA) and Motor Assessment Scale (MAS) change from baseline. We found that iTBS led to a significant reduction in FMA score (P = 0.002) but not in MAS score (P = 0.24) compared with the sham group. Moreover, standard 600-pulse stimulation showed a better effect on motor function improvement than the sham group (P = 0.004), however, 1200-pulse iTBS showed no effect on motor function improvement after stroke (P = 0.23). The effect of iTBS for improving motor function only exists in chronic stroke patients (P = 0.02) but not in subacute patients (P = 0.27). Conclusion: This study supports that iTBS has good efficacy for improving motor function in stroke patients. Therefore, standard 600-pulse stimulation iTBS therapy is proper management and treatment for chronic stroke.

Diagnostic value of cardiac magnetic resonance imaging for myocardial fibrosis in patients with heart failure and its predictive value for prognosis.

OBJECTIVE: To determine the diagnostic value of cardiac magnetic resonance imaging (CMRI) for myocardial fibrosis (MF) in patients with heart failure (HF) and its predictive value for prognosis. METHODS: A total of 180 patients with heart failure who were hospitalized in the Cardiology Department of The First People's Hospital of Shangqiu City from September 2019 to May 2021 were selected and assigned to Group B (n=80) given levosimendan and Group A (n=100) given levosimendan combined with ivabradine hydrochloride. The cardiac function indicators (left ventricular end-systolic volume (LVESV), left ventricular ejection fraction (LVEF), and left ventricular end-systolic diameter (LVESD) were measured by nuclear magnetic resonance (MRI). Myocardial fibrosis (MF)-related indicators (pyridinoline cross-linked carboxy-terminal telopeptide of type I collagen (ICTP), N-terminal propeptide of procollagen type III (PIIINP), connective tissue growth factor (CTGF), and hyaluronic acid (HA), inflammatory factors (Hs-CRP and IL-8) were measured using ELISA. Quality of life (QoL) and physical recovery (6-min walking test (6MWT), Fugl-Meyer Assessment (FMA), and Barthel index) of the two groups were compared. The late gadolinium enhancement (LGE) was used to analyze the occurrence of MF in patients. The patients were further divided into the LGE (+) group (cases) and LGE (-) group (cases). The changes of cardiac function indicators before treatment were analyzed, and their predictive value was analyzed. RESULTS: Compared with Group B, Group A showed a lower incidence of complications, and presented a higher LVEF level and lower levels of LVESV, LVESD, ICTP, PIIINP, CTGF, HA, LN, and inflammatory factors. The area under the curves of LVESV, LVESD, and LVEF in predicting MF were all >0.7. CONCLUSION: Levosimendan combined with ivabradine hydrochloride can effectively alleviate MF in patients with MF, and CMRI has a good predictive value for MF in such patients, which is worthy of clinical promotion.

Identification of critical operational hazards in a biogas upgrading pilot plant through a multi-criteria decision-making and FTOPSIS-HAZOP approach.

The hazard and operability analysis (HAZOP) is one of the most popular approaches for risk management, although weaknesses such as the limited number of risk factors considered, the inaccuracy of experts' opinions or the limited process knowledge might compromise the quality of the results. In this context, conventional HAZOP analysis can be improved via a Fuzzy Multi-Attribute HAZOP technique. Under a fuzzy logic, Analytic Hierarchy Process and the Technique for Order of Preference by Similarity to Ideal Solution can be combined with Fuzzy Multi-Attribute HAZOP to determine the weight of risk factors and to rank critical hazards. The inherent risks biogas upgrading, such as explosiveness, overpressure, or premature deterioration of equipment, should be identified for planning of critical control points and for enabling a proper maintenance plan. Previous models were applied to a photosynthetic biogas upgrading and a biogas-to-polyhydroxyalkanoates production pilot plant in order to identify and get more information about associated risks of the operation of these valorization biotechnologies, sometimes not fully provided by HAZOP analysis. Biotrickling filter and the polyhydroxyalkanoates production tank were identified as the most critical subsystems, with contributions of 33.3% and 17.8% to the overall risk, respectively (within quartile 1, Q1). Additionally, biogas and recycling/feeding streams clustered a large number of operational risks (up to 83.4% of total risk within Q1). The sensibility analysis demonstrated the reliability and robustness of the final ranking. The results of this analysis will support preventive maintenance by identifying critical monitored points when scaling-up biological biogas upgrading processes.

Fermented Mentha arvensis administration provides neuroprotection against transient global cerebral ischemia in gerbils and SH-SY5Y cells via downregulation of the MAPK signaling pathway.

BACKGROUND: Globally, ischemic stroke is a major health threat to humans that causes lifelong disability and death. Mentha arvensis (MA) has been used in traditional medicine to alleviate oxidative stress and inflammation-related disorders. In the present study, the neuroprotective properties of fermented MA (FMA) extract were investigated in the gerbil and SH-SY5Y cells. model of transient global cerebral ischemia. METHODS: Bilateral common carotid artery occlusion-induced transient global cerebral ischemia in gerbil and hydrogen peroxide (H2O2)-mediated neurotoxic effects in human neuroblastoma cells (SH-SY5Y) were investigated. FMA (400 mg/kg) was orally administered for 7 days before induction of ischemic stroke. To evaluate the neuroprotective activity of FMA, we implemented various assays such as cell viability assay (MTT), lactate dehydrogenase (LDH) assay, histopathology, immunohistochemistry (IHC), histofluorescence, and western blot. RESULTS: FMA pretreatment effectively decreased transient ischemia (TI) induced neuronal cell death as well as activation of microglia and astrocytes in the hippocampal region. The protective effects of FMA extract against H2O2-induced cytotoxicity of SH-SY5Y cells were observed by MTT and LDH assay. However, FMA pretreatment significantly increased the expression of the antioxidant marker proteins such as superoxide dismutase-1 (SOD-1) and superoxide dismutase-2 (SOD-2) in the hippocampus and SH-SY5Y cells. Furthermore, the activation of mitogen-activated protein kinase (MAPK) further activated a cascade of outcomes such as neuroinflammation and apoptosis. FMA pretreatment notably decreased TI and H2O2 induced activation of MAPK (c-Jun N-terminal kinase (JNK), extracellular signal-regulated protein kinase (ERK), and p38) proteins in hippocampus and SH-SY5Y cells respectively. Besides, pretreatment with FMA markedly reduced H2O2 mediated Bax/Bcl2 expression in SH-SY5Y cells. CONCLUSION: Thus, these results demonstrated that neuroprotective activities of FMA might contribute to regulating the MAPK signaling pathway.

Association Between Temporal Asymmetry and Muscle Synergy During Walking With Rhythmic Auditory Cueing in Survivors of Stroke Living With Impairments.

Objective: To examine the relationship between temporal asymmetry and complexity of muscle synergy during walking using rhythmic auditory cueing (RAC) and the factors related to changes in muscle synergy during walking with RAC in survivors of stroke. Design: Cross-sectional study. Setting: Wards at 2 medical corporation hospitals. Participants: Forty survivors of stroke (N=40; mean age, 70.4±10.3 years; time since stroke, 72.2±32.3 days) who could walk without physical assistance. Interventions: Not applicable. Main Outcome Measures: The participants were assessed in a random block design under 2 conditions: comfortable walking speed (CWS) and walking with RAC. Single-leg support time, kinematics, and electromyograms were measured. Factors related to the complexity of muscle synergy (variance accounted for by 1 synergy [VAF1]) between the walking conditions were examined using hierarchical multiple regression analysis. Results: In the RAC condition, lower limb flexion and knee flexion angles, single-leg support time on the paretic side, and the symmetry index of single-leg support time were increased compared with those in the CWS condition. VAF1 was decreased in the RAC condition (73.9±0.15) compared with that in the CWS condition (76.9±0.13, P=.002). Hierarchical multiple regression analysis revealed that the change in VAF1 was explained by change in single-leg support time (R 2=0.43, P=.002). Conclusions: The RAC condition demonstrated a more complex representation of muscle synergy than the CWS condition; the change in single-leg support time on the paretic side related to the changes in muscle synergy more than changes in lower limb angle. These findings can help in the walking-training concept to improve muscle synergy deficits in survivors of stroke.

Effects of dry needling and exercise therapy on post-stroke spasticity and motor function- protocol of randomized clinical trial.

Background: Spasticity is one of the most common problems after the first stroke. Dry needling (DN) has been presented as a new therapeutic approach used by physiotherapists for the management of post-stroke spasticity. This study aimed to determine whether the addition of exercise therapy to the DN results in better outcomes in wrist flexors spasticity, motor neuron excitability, motor function and range of motion (ROM) in patients with chronic stroke. Methods: We will use a single-blind randomized controlled trial (RCT) in accordance with the CONSORT guidelines. A total of 24 patients with stroke will be included from the University Rehabilitation Clinics. The outcome measures will include Modified Modified Ashworth Scale, Hmax/Mmax ratio, H-reflex latency, Action Research Arm Test, Fugl-Meyer Assessment, and wrist extension active and passive range of motion. Patients in the DN and exercise therapy group will undergo 4 sessions of deep DN in flexor carpi radialis and flexor carpi ulnaris muscles on the affected upper limb and exercise therapy. Participants in the DN group will only receive DN for target muscles. Clinical and neurophysiological tests will be performed at baseline, after four therapy sessions, and at three weeks' follow-up. Discussion: This study will provide evidence for additional effects of exercise therapy to DN in comparison to DN alone on wrist flexors spasticity, motor neuron excitability, upper-limb motor function, and ROM in patients with chronic stroke.

[Clinical observation on cluster acupuncture at scalp points combined with exercise therapy in treatment of limb spasm after stroke].

OBJECTIVE: To observe the clinical effect of cluster acupuncture at scalp points in treating limb spasm after stroke on the basis of conventional exercise therapy. METHODS: A total of 72 patients with limb spasm after stroke were randomly divided into an observation group (36 cases, 5 cases dropped off) and a control group (36 cases, 6 cases dropped off). The control group was treated with exercise therapy. In the observation group, on the basis of the control group, penetrating technique of acupuncture was exerted at Qianding (GV 21) to Baihui (GV 20), Xinhui (GV 22) to Qianding (GV 21), etc. once a day, 5 days a week for 4 weeks. Before and after treatment, the changes of the modified Ashworth scale (MAS), simplified Fugl-Meyer motor assessment (FMA), and modified Barthel index (MBI) scores of the two groups were compared. RESULTS: After treatment, the MAS scores of upper and lower limbs in the two groups were lower than before treatment (P<0.05), and those in the observation group were lower than the control group (P<0.05). After treatment, the scores of FMA and BMI in the two groups were higher than before treatment (P<0.05), and the score of MBI in the observation group was higher than the control group (P<0.05). CONCLUSION: On the basis of conventional exercise therapy, cluster acupuncture at scalp points can reduce the spasm, improve motor function and activities of daily living in patients with limb spasm after stroke.

Effects of combining two techniques of non-invasive brain stimulation in subacute stroke patients: a pilot study.

BACKGROUND: Strokes have recently become a leading cause of disability among Thai people. Non-invasive brain stimulation (NIBS) seems to give promising results in stroke recovery when combined with standard rehabilitation programs. OBJECTIVE: To evaluate the combined effect of low-frequency repetitive transcranial magnetic stimulation (rTMS) and cathodal transcranial direct current stimulation (tDCS) over the non-lesional primary motor cortex on upper limb motor recovery in patients with subacute stroke. No reports of a combination of these two techniques of NIBS were found in the relevant literature. METHODS: This pilot study was a double-blinded, randomized controlled trial of ten patients with subacute stroke admitted to the Rehabilitation Medicine Inpatient Unit, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. They were randomized into two groups: five in an active and five in a sham intervention group. Fugl-Meyer's upper extremity motor score (FMA-UE) and Wolf Motor Function Test (WMFT) were used to assess motor recovery at baseline, immediately, and 1 week after stimulation. RESULTS: A two-way repeated ANOVA (mixed design) showed a significant improvement in FMA-UE scores in the active intervention group both immediately and 1 week after stimulation in comparison to the baseline, [time, F (2, 16) = 27.44, p < 0.001, time x group interaction, F (2, 16) = 13.29, p < 0.001]. Despite no statistical significance, a trend toward higher WMFT scores was shown in the active intervention group. CONCLUSIONS: A single session of low-frequency rTMS and cathodal tDCS over the non-lesional primary motor cortex may enhance upper limb motor recovery in patients with subacute stroke.

Custom TKA combined with personalised coronal alignment yield improvements that exceed KSS substantial clinical benefits.

PURPOSE: The purpose of this study was to report Knee Society Scores (KSS) at 12-month follow-up in a series of 266 knees that received custom TKA. The hypothesis was that custom TKA combined with personalised alignment would yield improvements greater than substantial clinical benefits (SCB) of KSS Knee and Function. METHODS: From a consecutive series of 905 patients (918 knees) that received primary TKAs, 261 (29%) patients (266 knees) received computed tomography (CT)-based posterior-stabilised cemented custom TKA. Knees were aligned aiming to preserve or restore constitutional alignment within predetermined limits of 85°-95° for femoral mechanical angle (FMA) and tibial mechanical angle (TMA), and 175°-183° for hip knee ankle (HKA) angle. The KSS Knee and Function were collected preoperatively and 12 months postoperatively, to determine if patients achieved SCB. Uni- and multivariable analyses were performed to determine associations between KSS scores (Knee and Function) and patient demographics as well as pre- and postoperative radiographic alignments. RESULTS: Of the initial cohort of 261 patients, 4 (1.8%) were reoperated for patellar resurfacing, 1 (0.4%) for lavage to treat infection, and 1 (0.4%) had arthroscopy to treat a stiff knee with < 90° range of motion. Complete clinical records were available for 227 patients (232 knees, 87%) that comprised 102 men (5 bilateral) and 125 women. At 12-month follow-up, mean improvements in KSS Knee and Function scores were, respectively, 61.0 ± 13.0 and 42.7 ± 16.7, which exceeded the SCB of KSS. Comparison of knees inside versus outside the target zone revealed no differences in KSS Knee (94.1 ± 9.1 versus 94.3 ± 9.0, n.s.) and Function (96.1 ± 9.2 versus 96.3 ± 8.9, n.s.). Multivariable analysis revealed worse KSS Knee in knees with preoperative FMA > 95° (ß = - 6.21; p = 0.023), but no association between KSS Function and patient demographics or pre- and postoperative radiographic alignments. CONCLUSIONS: Custom TKA combined with personalised alignment yielded improvements that exceeded substantial clinical benefits of KSS Knee and Function scores. These findings demonstrate the feasibility of custom TKA with 'personalised alignment' and encourage further investigations using comparative studies at longer follow-up. LEVEL OF EVIDENCE: IV, case series.