Combined Brain and Peripheral Nerve Stimulation in Chronic Stroke Patients With Moderate to Severe Motor Impairment.

OBJECTIVES: To evaluate effects of somatosensory stimulation in the form of repetitive peripheral nerve sensory stimulation (RPSS) in combination with transcranial direct current stimulation (tDCS), tDCS alone, RPSS alone, or sham RPSS + tDCS as add-on interventions to training of wrist extension with functional electrical stimulation (FES), in chronic stroke patients with moderate to severe upper limb impairments in a crossover design. We hypothesized that the combination of RPSS and tDCS would enhance the effects of FES on active range of movement (ROM) of the paretic wrist to a greater extent than RPSS alone, tDCS alone or sham RPSS + tDCS. MATERIALS AND METHODS: The primary outcome was the active ROM of extension of the paretic wrist. Secondary outcomes were ROM of wrist flexion, grasp, and pinch strength of the paretic and nonparetic upper limbs, and ROM of wrist extension of the nonparetic wrist. Outcomes were blindly evaluated before and after each intervention. Analysis of variance with repeated measures with factors "session" and "time" was performed. RESULTS: After screening 2499 subjects, 22 were included. Data from 20 subjects were analyzed. There were significant effects of "time" for grasp force of the paretic limb and for ROM of wrist extension of the nonparetic limb, but no effects of "session" or interaction "session x time." There were no significant effects of "session," "time," or interaction "session x time" regarding other outcomes. CONCLUSIONS: Single sessions of PSS + tDCS, tDCS alone, or RPSS alone did not improve training effects in chronic stroke patients with moderate to severe impairment.

Increase in Short-Interval Intracortical Facilitation of the Motor Cortex after Low-Frequency Repetitive Magnetic Stimulation of the Unaffected Hemisphere in the Subacute Phase after Stroke.

Low-frequency repetitive transcranial magnetic stimulation of the unaffected hemisphere (UH-LF-rTMS) in patients with stroke can decrease interhemispheric inhibition from the unaffected to the affected hemisphere and improve hand dexterity and strength of the paretic hand. The objective of this proof-of-principle study was to explore, for the first time, effects of UH-LF-rTMS as add-on therapy to motor rehabilitation on short-term intracortical inhibition (SICI) and intracortical facilitation (ICF) of the motor cortex of the unaffected hemisphere (M1UH) in patients with ischemic stroke. Eighteen patients were randomized to receive, immediately before rehabilitation treatment, either active or sham UH-LF-rTMS, during two weeks. Resting motor threshold (rMT), SICI, and ICF were measured in M1UH before the first session and after the last session of treatment. There was a significant increase in ICF in the active group compared to the sham group after treatment, and there was no significant differences in changes in rMT or SICI. ICF is a measure of intracortical synaptic excitability, with a relative contribution of spinal mechanisms. ICF is typically upregulated by glutamatergic agonists and downregulated by gabaergic antagonists. The observed increase in ICF in the active group, in this hypothesis-generating study, may be related to M1UH reorganization induced by UH-LF-rTMS.

Non-invasive brain stimulation and kinesiotherapy for treatment of focal dystonia: Instrumental analysis of three cases.

Dystonia is a disabling movement disorder characterized by co-contraction of antagonist and agonist muscles, leading to abnormal sustained postures and impaired motor control. Cervical Dystonia (CD) and Hand Focal Dystonia (HFD) have been the most common forms of focal dystonia (FD). Do Non-Invasive Brain Neuromodulation (NIBS) such as Transcranial Direct Current Stimulation (tDCS) and repetitive Transcranial Magnetic Stimulation (rTMS) modulate the excitability of the connections between the motor cortical areas and may represent a therapeutic alternative for focal dystonia? Herein, we reported three cases of focal dystonia, two of them with cervical dystonia (CD) and one with hand focal dystonia (HFD), treated with NIBS combined to kinesiotherapy. The patients were daily submitted to 15 sessions of NIBS combined simultaneously with kinesiotherapy. CD patients were treated with tDCS (2 mA, 20 min, over the primary motor cortex), and HFD patient with rTMS (1 Hz, 1200 pulses, 80% of resting motor threshold, over the premotor cortex). For the CD patient's assessment, the Modified Toronto Scale for Cervical Dystonia Assessment (MTS), quiet balance test, and visual postural assessment were applied to observe the therapeutic effects. Quality handwriting analysis, tremor acceleration amplitudes, and the Wrinter's Cramp Rating Scale (WCRS) were used to assess the NIBS effect on HFD symptoms. Patients were evaluated before (pretest), immediately after (posttest), and three months after treatment (retention). NIBS associated with kinesiotherapy produced a long-term improvement of dystonia symptoms in all three patients. rTMS and tDCS associated with kinesiotherapy showed to be useful and safe to relief the dystonia symptoms in individuals with different types of focal dystonia with distinct functional disorders. SIGNIFICANCE: The combined use of these intervention strategies seems to optimize and anticipate satisfactory clinical results in these neurological conditions, characterized by its difficult clinical management.

Executive Function Performance Test: transcultural adaptation, evaluation of psychometric properties in Brazil.

OBJECTIVES: Executive dysfunction occurs in 18.5% to 39% of patients who present with cognitive impairment. Occupational therapy aims to facilitate independence and autonomy, hence improving quality of life. The Executive Function Performance Test - Brazilian version (EFPT-BR) has been developed to assess the need for assistance in performing four basic daily tasks. The aims of this research were: (1) to offer cross-cultural adaptation in patients with stroke; (2) to assess the psychometric properties of the Brazilian version of the EFPT-BR in patients with stroke; (3) to assess the relationship between scores on the EFPT-BR in patients with stroke, and demographic variables, stroke location, symptoms of anxiety and depression. METHODS: The transcultural adaptation and validation were performed based on standard procedures, and psychometric properties were assessed in 86 Brazilian patients who suffered a stroke. RESULTS: The test has shown a good internal consistency (Cronbach's alpha: 0.819). The ICC for intra-rater reliability was 0.435 and for the inter-rater was 0.732. Significant correlations between scores in the EFPT-BR and executive measures (verbal fluency test, clock drawing test, digit span - forwards and backwards, zoo map test and Six Elements Test) were observed. CONCLUSION: The EFPT-BR is a valid and reliable tool for occupational therapists to assess executive dysfunction in daily routine tasks in patients with stroke in Brazil.

Repetitive Peripheral Sensory Stimulation and Upper Limb Performance in Stroke: A Systematic Review and Meta-analysis.

BACKGROUND: Enhancement of sensory input in the form of repetitive peripheral sensory stimulation (RPSS) can enhance excitability of the motor cortex and upper limb performance. OBJECTIVE: To perform a systematic review and meta-analysis of effects of RPSS compared with control stimulation on improvement of motor outcomes in the upper limb of subjects with stroke. METHODS: We searched studies published between 1948 and December 2017 and selected 5 studies that provided individual data and applied a specific paradigm of stimulation (trains of 1-ms pulses at 10 Hz, delivered at 1 Hz). Continuous data were analyzed with means and standard deviations of differences in performance before and after active or control interventions. Adverse events were also assessed. RESULTS: There was a statistically significant beneficial effect of RPSS on motor performance (standard mean difference between active and control RPSS, 0.67; 95% CI, 0.09-1.24; I2 = 65%). Only 1 study included subjects in the subacute phase after stroke. Subgroup analysis of studies that only included subjects in the chronic phase showed a significant effect (1.04; 95% CI, 0.66-1.42) with no heterogeneity. Significant results were obtained for outcomes of body structure and function as well as for outcomes of activity limitation according to the International Classification of Function, Disability and Health, when only studies that included subjects in the chronic phase were analyzed. No serious adverse events were reported. CONCLUSIONS: RPSS is a safe intervention with potential to become an adjuvant tool for upper extremity paresis rehabilitation in subjects with stroke in the chronic phase.

Cognitive assessment: A challenge for occupational therapists in Brazil.

Cognitive impairment is a common dysfunction after neurological injury. Cognitive assessment tools can help the therapist understand how impairments are affecting functional status and quality of life. OBJECTIVE: The aim of the study was to identify instruments for cognitive assessment that Occupational Therapists (OT) can use in clinical practice. METHODS: The instruments published in English and Portuguese between 1999 and 2016 were systematically reviewed. RESULTS: The search identified 17 specific instruments for OT not validated in Brazilian Portuguese, 10 non-specific instruments for OT not validated in Brazilian Portuguese, and 25 instruments validated for Portuguese, only one of which was specific for OT (Lowenstein Occupational Therapy Cognitive Assessment). CONCLUSION: There are few assessment cognitive tools validated for use in the Brazilian culture and language. The majority of the instruments appear not to be validated for use by OT in clinical practice.

Déficits cognitivos são comuns após uma lesão neurológica. Avaliação cognitiva pode auxiliar o terapeuta a compreender melhor as dificuldades do sujeito e como afetam as habilidades funcionais e qualidade de vida. OBJETIVO: O objetivo desta pesquisa foi de identificar avaliações cognitivas que o Terapeuta Ocupacional (TO) pode utilizar na prática clínica. MÉTODOS: Uma revisão sistemática da literatura foi realizada sobre os instrumentos publicados em inglês e português nas bases de dados de 1999 a 2016. RESULTADOS: Foram identificados 17 instrumentos de avaliação específicos para Terapia Ocupacional, mas que não estão validados em português, 10 instrumentos que não são específicos, mas que podem ser utilizados por TO que também não foram validados para a população brasileira e por fim 24 instrumentos validados, porém apenas um é específico para TO (Lowenstein Occupational Therapy Cognitive Assessment). CONCLUSÃO: Existem poucas avaliações cognitivas validadas para a cultura e língua brasileira. Possivelmente a maioria destes instrumentos não tenha sido validado para a TO utilizar na pratica clínica.

Diversity of approaches in assessment of executive functions in stroke: limited evidence?

Stroke is a leading cause of disability worldwide. Cognitive functions and, in particular, executive function, are commonly affected after stroke, leading to impairments in performance of daily activities, decrease in social participation and in quality of life. Appropriate assessment and understanding of executive dysfunction are important, firstly to develop better rehabilitation strategies for executive functions per se and secondly to consider executive function abilities on rehabilitation strategies in general. The purpose of this review was to identify the most widely used assessment tools of executive dysfunction for patients with stroke, and their psychometric properties. We systematically reviewed manuscripts published in English in databases from 1999 to 2015. We identified 35 publications. The most frequently used instruments were the Stroop, Digit Span and Trail making tests. Psychometric properties were described for the Executive Function Performance Test, Executive Clock Drawing Task, Chinese Frontal Assessment Battery and Virtual Action Planning - Supermarket, and two subtests of the Cambridge Cognitive Examination - Revised. There is a paucity of tools to reliably measure executive dysfunction after stroke, despite the fact that executive dysfunction is frequent. Identification of the best tools for executive dysfunction assessment is necessary to address important gaps in research and in clinical practice.

Executive Function Performance Test: transcultural adaptation, evaluation of psychometric properties in Brazil / Teste de Desempenho da Função Executiva: adaptação transcultural, avaliação das propriedades psicométricas no Brasil

ABSTRACT Executive dysfunction occurs in 18.5% to 39% of patients who present with cognitive impairment. Occupational therapy aims to facilitate independence and autonomy, hence improving quality of life. The Executive Function Performance Test - Brazilian version (EFPT-BR) has been developed to assess the need for assistance in performing four basic daily tasks. Objectives: The aims of this research were: (1) to offer cross-cultural adaptation in patients with stroke; (2) to assess the psychometric properties of the Brazilian version of the EFPT-BR in patients with stroke; (3) to assess the relationship between scores on the EFPT-BR in patients with stroke, and demographic variables, stroke location, symptoms of anxiety and depression. Methods: The transcultural adaptation and validation were performed based on standard procedures, and psychometric properties were assessed in 86 Brazilian patients who suffered a stroke. Results: The test has shown a good internal consistency (Cronbach's alpha: 0.819). The ICC for intra-rater reliability was 0.435 and for the inter-rater was 0.732. Significant correlations between scores in the EFPT-BR and executive measures (verbal fluency test, clock drawing test, digit span - forwards and backwards, zoo map test and Six Elements Test) were observed. Conclusion: The EFPT-BR is a valid and reliable tool for occupational therapists to assess executive dysfunction in daily routine tasks in patients with stroke in Brazil.

RESUMO Disfunção executiva ocorre em 18,5% a 39% dos pacientes que apresentam comprometimento cognitivo. A terapia ocupacional visa proporcionar independência e autonomia, de modo a melhorar a qualidade de vida. O Teste Desempenho da Função Executiva (TDFE) foi desenvolvido para avaliar a necessidade de assistência para realizar quatro tarefas diárias básicas. Objetivos: Os objetivos desta pesquisa são: (1) realizar a adaptação transcultural em pacientes com AVC; (2) avaliar as propriedades psicométricas da TDFE em pacientes com AVC; (3) avaliar a relação entre TDFE em pacientes com AVC e variáveis demográficas, região afetada pelo acidente vascular cerebral, sintomas de ansiedade e depressão. Métodos: A adaptação e validação transcultural foram realizadas com base em procedimentos padrão e as propriedades psicométricas foram avaliadas em 86 pacientes brasileiros que sofreram acidente vascular cerebral. Resultados: O teste apresentou boa consistência interna (alfa de Cronbach: 0,819). A confiabilidade intra examinador foi de 0,435 e para o inter examinador foi de 0,855. Foram observadas correlações significativas entre a pontuação final do TDFE e os seguintes testes de função executiva: teste de fluência verbal, teste do desenho do relógio, Teste de Extensão dos Dígitos (diretos e inversos), subteste do mapa zoológico e subteste modificado dos seis elementos. Conclusão: A TDFE é uma ferramenta válida e confiável para os terapeutas ocupacionais para avaliar a disfunção executiva nas tarefas de rotina diária em pacientes com AVC no Brasil.

Cognitive assessment: A challenge for occupational therapists in Brazil / Avaliação cognitiva: um desafio para os terapeutas ocupacionais no brasil

ABSTRACT Cognitive impairment is a common dysfunction after neurological injury. Cognitive assessment tools can help the therapist understand how impairments are affecting functional status and quality of life. Objective: The aim of the study was to identify instruments for cognitive assessment that Occupational Therapists (OT) can use in clinical practice. Methods: The instruments published in English and Portuguese between 1999 and 2016 were systematically reviewed. Results: The search identified 17 specific instruments for OT not validated in Brazilian Portuguese, 10 non-specific instruments for OT not validated in Brazilian Portuguese, and 25 instruments validated for Portuguese, only one of which was specific for OT (Lowenstein Occupational Therapy Cognitive Assessment). Conclusion: There are few assessment cognitive tools validated for use in the Brazilian culture and language. The majority of the instruments appear not to be validated for use by OT in clinical practice.

RESUMO Déficits cognitivos são comuns após uma lesão neurológica. Avaliação cognitiva pode auxiliar o terapeuta a compreender melhor as dificuldades do sujeito e como afetam as habilidades funcionais e qualidade de vida. Objetivo: O objetivo desta pesquisa foi de identificar avaliações cognitivas que o Terapeuta Ocupacional (TO) pode utilizar na prática clínica. Métodos: Uma revisão sistemática da literatura foi realizada sobre os instrumentos publicados em inglês e português nas bases de dados de 1999 a 2016. Resultados: Foram identificados 17 instrumentos de avaliação específicos para Terapia Ocupacional, mas que não estão validados em português, 10 instrumentos que não são específicos, mas que podem ser utilizados por TO que também não foram validados para a população brasileira e por fim 24 instrumentos validados, porém apenas um é específico para TO (Lowenstein Occupational Therapy Cognitive Assessment). Conclusão: Existem poucas avaliações cognitivas validadas para a cultura e língua brasileira. Possivelmente a maioria destes instrumentos não tenha sido validado para a TO utilizar na pratica clínica.

A interferência dos aspecos percepto-cognitivos nas atividades de vida diária e nas atividades instrumentais de vida diária, em clientes com seqüelas por lesão neurológica / The influence of the Cognitive-Perceptual Difficulties on the Activities of Daily Living and Instrumental Activities of Daily Living in Patients with Neurological Damages

Este artigo é um levantamento bibliográfico sobre a interferência dos aspectos percepto-cognitivos durante a realização das Atividades de Vida Diária (AVDs) e Atividades Instrumentais de Vida Diária (AIVDs) em clientes com seqüelas por lesão neurológica. Com o objetivo de indicar o quanto esses déficits interferem na reabilitação do cliente e no retorno às atividades cotidianas, o artigo mostra que essas atividades ? que aparentemente são simples e já conhecidas por eles ? têm de ser aprendidas outra vez. Por outro lado, o artigo revela que não apenas esses aspectos interferem nessas tarefas durante o tratamento e no final dele (no qual o cliente apresentará uma maior ou menor independência), mas também há fatores ? como os motores, emocionais, culturais, sociais, econômicos e principalmente a família ? que influenciarão de maneira positiva ou negativa o cliente e seu processo de reabilitação. Para ilustrar esta pesquisa, foram apresentados três casos clínicos atendidos no serviço de Terapia Ocupacional.

This is a literature review on the influence of perceptual-cognitive aspects in the performance of activities of daily living (ADL) and instrumental activities of daily living (IADL) in patients with neurological injury sequelae. In order to show how much these deficits impair the clients’ rehabilitation and their return to routine activities, the review shows that such activities - which seem apparently simple and are previously known by them - have to be learned again. On the other hand, the review shows that these aspects not only interfere with these tasks (for which the client can be more or less independent), but also that there are factors – motor, emotional, cultural, social, economic, and, mainly, familial – that can positively or negatively influence the patient and his rehabilitation. Three clinical cases seen at the Occupational Therapy Service will be presented in order to illustrate this review.