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Li R, Liu S, Li T, Yang K, Wang X, Wang W. The stratified effects of repetitive transcranial magnetic stimulation in upper limb motor impairment recovery after stroke: a meta-analysis. Front Neurol 2024; 15:1369836. [PMID: 38628695 PMCID: PMC11020108 DOI: 10.3389/fneur.2024.1369836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 03/11/2024] [Indexed: 04/19/2024] Open
Abstract
Background The recovery of upper extremity motor impairment after stroke remains a challenging task. The clinical effectiveness of repetitive transcranial magnetic stimulation (rTMS), which is believed to aid in the recovery process, is still uncertain. Methods A systematic search was conducted in Medline (Ovid), Cochrane and Embase electronic databases from March 28, 2014, to March 28, 2023. The inclusion criteria consisted of randomized controlled trials that assessed the effects of rTMS on the recovery of upper limb motor impairment among stroke patients. Various measurements, including the Fugl Meyer Assessment Upper Extremity Scale (FMA-UE), Brunnstrom recovery stage, Action Research Arm Test (ARAT), and Barthel index, were evaluated both before and after the intervention. Results Nineteen articles with 865 patients were included. When considering only the rTMS parameters, both inhibitory and excitatory rTMS improved FMA-UE (MD = 1.87, 95% CI = [0.88]-[2.86], p < 0.001) and Barthel index (MD = 9.73, 95% CI = [4.57]-[14.89], p < 0.001). When considering only the severity of upper limb hemiplegia, both less severe (MD = 1.56, 95% CI = [0.64]-[2.49], p < 0.001) and severe (MD = 2.05, 95% CI = [1.09]-[3.00], p < 0.001) hemiplegia benefited from rTMS based on FMA-UE. However, when considering the rTMS parameters, severity of hemiplegia and stroke stages simultaneously, inhibitory rTMS was found to be significantly effective for less severe hemiplegia in the acute and subacute phases (MD = 4.55, 95% CI = [2.49]-[6.60], p < 0.001), but not in the chronic phase based on FMA-UE. For severe hemiplegia, inhibitory rTMS was not significantly effective in the acute and subacute phases, but significantly effective in the chronic phase (MD = 2.10, 95% CI = [0.75]-[3.45], p = 0.002) based on FMA-UE. Excitatory rTMS was found to be significantly effective for less severe hemiplegia in the acute and subacute phases (MD = 1.93, 95% CI = [0.58]-[3.28], p = 0.005) based on FMA-UE. The improvements in Brunnstrom recovery stage and ARAT need further research. Conclusion The effectiveness of rTMS depends on its parameters, severity of hemiplegia, and stroke stages. It is important to consider all these factors together, as any single grouping method is incomplete.
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Affiliation(s)
- Ran Li
- Department of Rehabilitation Center, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Sihan Liu
- Capital Medical University Eighth Clinical School, Beijing, China
| | - Tianyuan Li
- Capital Medical University Eighth Clinical School, Beijing, China
| | - Kun Yang
- Department of Evidence-based Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Xue Wang
- Department of Medical Library, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Wenjiao Wang
- Department of Medical Library, Xuan Wu Hospital, Capital Medical University, Beijing, China
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Lakshminarayanan K, Shah R, Daulat SR, Moodley V, Yao Y, Ezhil SL, Ramu V, Sengupta P, Madathil D. Feasibility and usability of a virtual-reality-based sensorimotor activation apparatus for carpal tunnel syndrome patients. PLoS One 2023; 18:e0292494. [PMID: 37819927 PMCID: PMC10566719 DOI: 10.1371/journal.pone.0292494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/15/2023] [Indexed: 10/13/2023] Open
Abstract
PURPOSE This study aimed to assess the usability of a virtual reality-assisted sensorimotor activation (VRSMA) apparatus for individual digit rehabilitation. The study had two main objectives: Firstly, to collect preliminary data on the expectations and preferences of patients with carpal tunnel syndrome (CTS) regarding virtual reality (VR) and an apparatus-assisted therapy for their affected digits. Secondly, to evaluate the usability of the VRSMA apparatus that was developed. METHODS The VRSMA system consists of an apparatus that provides sensory and motor stimulation via a vibratory motor and pressure sensor attached to a button, and a virtual reality-based visual cue provided by texts overlaid on top of a 3D model of a hand. The study involved 10 CTS patients who completed five blocks of VRSMA with their affected hand, with each block corresponding to the five digits. The patients were asked to complete a user expectations questionnaire before experiencing the VRSMA, and a user evaluation questionnaire after completing the VRSMA. Expectations for VRSMA were obtained from the questionnaire results using a House of Quality (HoQ) analysis. RESULTS In the survey for expectations, participants rated certain attributes as important for a rehabilitation device for CTS, with mean ratings above 4 for attributes such as ease of use, ease of understanding, motivation, and improvement of hand function based on clinical evidence. The level of immersion and an interesting rehabilitation regime received lower ratings, with mean ratings above 3.5. The survey evaluating VRSMA showed that the current prototype was overall satisfactory with a mean rating of 3.9 out of 5. Based on the HoQ matrix, the highest priority for development of the VRSMA was to enhance device comfort and usage time. This was followed by the need to perform more clinical studies to provide evidence of the efficacy of the VRSMA. Other technical characteristics, such as VRSMA content and device reliability, had lower priority scores. CONCLUSION The current study presents a potential for an individual digit sensorimotor rehabilitation device that is well-liked by CTS patients.
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Affiliation(s)
- Kishor Lakshminarayanan
- Neuro-rehabilitation Lab, Department of Sensors and Biomedical Engineering, School of Electronics Engineering, Vellore Institute of Technology, Vellore, Tamil Nadu, India
| | - Rakshit Shah
- Department of Chemical and Biomedical Engineering, Cleveland State University, Cleveland, OH, United States of America
| | - Sohail R. Daulat
- University of Arizona College of Medicine–Tucson, Tucson, AZ, United States of America
| | - Viashen Moodley
- Arizona Center for Hand to Shoulder Surgery, Phoenix, AZ, United States of America
| | - Yifei Yao
- Soft Tissue Biomechanics Laboratory, Med-X Research Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Srignana Lokesh Ezhil
- Neuro-rehabilitation Lab, Department of Sensors and Biomedical Engineering, School of Electronics Engineering, Vellore Institute of Technology, Vellore, Tamil Nadu, India
| | - Vadivelan Ramu
- Neuro-rehabilitation Lab, Department of Sensors and Biomedical Engineering, School of Electronics Engineering, Vellore Institute of Technology, Vellore, Tamil Nadu, India
| | - Puja Sengupta
- Neuro-rehabilitation Lab, Department of Sensors and Biomedical Engineering, School of Electronics Engineering, Vellore Institute of Technology, Vellore, Tamil Nadu, India
| | - Deepa Madathil
- Jindal Institute of Behavioural Sciences, O. P. Jindal Global University, Sonipat, Haryana, India
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Alashram AR, Padua E, Annino G. Effects of Brain-Computer Interface Controlled Functional Electrical Stimulation on Motor Recovery in Stroke Survivors: a Systematic Review. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2022. [DOI: 10.1007/s40141-022-00369-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Wang H, Ghazi M, Chandrashekhar R, Rippetoe J, Duginski GA, Lepak LV, Milhan LR, James SA. User Participatory Design of a Wearable Focal Vibration Device for Home-Based Stroke Rehabilitation. SENSORS (BASEL, SWITZERLAND) 2022; 22:3308. [PMID: 35590997 PMCID: PMC9105527 DOI: 10.3390/s22093308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 06/15/2023]
Abstract
Stroke often leads to the significant impairment of upper limb function and is associated with a decreased quality of life. Despite study results from several interventions for muscle activation and motor coordination, wide-scale adoption remains largely elusive due to under-doses and low user compliance and participation. Recent studies have shown that focal vibration has a greater potential to increase and coordinate muscle recruitment and build muscle strength and endurance. This form of treatment could widely benefit stroke survivors and therapists. Thus, this study aimed to design and develop a novel wearable focal vibration device for upper limb rehabilitation in stroke survivors. A user participatory design approach was used for the design and development. Five stroke survivors, three physical therapists, and two occupational therapists were recruited and participated. This pilot study may help to develop a novel sustainable wearable system providing vibration-based muscle activation for upper limb function rehabilitation. It may allow users to apply the prescribed vibratory stimuli in-home and/or in community settings. It may also allow therapists to monitor treatment usage and user performance and adjust the treatment doses based on progression.
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Affiliation(s)
- Hongwu Wang
- Department of Occupational Therapy, University of Florida, Gainesville, FL 32603, USA
| | - Mustafa Ghazi
- Department of Rehabilitation Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73117, USA
| | | | - Josiah Rippetoe
- Department of Rehabilitation Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73117, USA
| | - Grace A Duginski
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK 73019, USA
| | - Louis V Lepak
- Department of Rehabilitation Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73117, USA
| | - Lisa R Milhan
- Department of Rehabilitation Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73117, USA
| | - Shirley A James
- Department of Rehabilitation Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73117, USA
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Hokazono A, Etoh S, Jonoshita Y, Kawahira K, Shimodozono M. Combination therapy with repetitive facilitative exercise program and botulinum toxin type A to improve motor function for the upper-limb spastic paresis in chronic stroke: A randomized controlled trial. J Hand Ther 2021; 35:507-515. [PMID: 33820711 DOI: 10.1016/j.jht.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 01/15/2021] [Accepted: 01/21/2021] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN An open-label, randomized, controlled, observer-blinded trial. INTRODUCTION Repetitive facilitative exercise (RFE) is a movement therapy to recover from hemiparesis after stroke. However, improvement is inhibited by spasticity. Recently, botulinum toxin type A (BoNT-A) injection has been shown to reduce spasticity. PURPOSE To examine the combined effect of an RFE program and BoNT-A treatment on upper-limb spastic paresis in chronic stroke. METHODS Forty chronic stroke inpatients with upper-limb spastic paresis (Brunnstrom stage ≥III and Modified Ashworth Scale [MAS] score ≥1) were enrolled. Subjects were randomized into 2 groups of 20 each and received 4 weeks of treatment. The intervention group received RFE and BoNT-A injection; the control group underwent RFE only. Assessments were performed at baseline and at study conclusion. The primary outcome was change in Fugl-Meyer Assessment score for the upper extremity (FMA). The Action Research Arm Test (ARAT), active range of motion, Box and Block Test, and MAS were also evaluated. RESULTS All participants completed this study. After 4 weeks, the intervention group evidenced a significantly greater increase in FMA score (median 11.0 [range 4-20]) than the control group (median 3.0 [range 0-9]) (P < .01, r = 0.79); as well as improvements in the other measures such as ARAT (median 12.5 [range 4-22] vs 7 [0-13]) (P < .01, r = 0.6), and MAS in the elbow flexors (median -1.5 [range -2 to 0] vs -1 [-2 to 0]) (P < .01, r = 0.45). DISCUSSION A high degree of repetitive volitional movement induced by the facilitative technique with concomitant control of spasticity by BoNT-A injection might increase efficiency of motor learning with continuous movement of the affected upper-limb. CONCLUSIONS The combination of RFE and BoNT-A for spastic paresis might be more effective than RFE alone to improve upper-limb motor function and to lessen impairment in chronic stroke.
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Affiliation(s)
- Akihiko Hokazono
- Department of Rehabilitation and Physical Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Seiji Etoh
- Department of Rehabilitation and Physical Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yuiko Jonoshita
- Department of Rehabilitation, Kirishima Rehabilitation Center of Kagoshima University Hospital, Kagoshima, Japan
| | - Kazumi Kawahira
- Department of Rehabilitation and Physical Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Megumi Shimodozono
- Department of Rehabilitation and Physical Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan.
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Musculoskeletal Ultrasonography Assessment of Functional Magnetic Stimulation on the Effect of Glenohumeral Subluxation in Acute Poststroke Hemiplegic Patients. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6085961. [PMID: 30065941 PMCID: PMC6051292 DOI: 10.1155/2018/6085961] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/19/2018] [Accepted: 03/19/2018] [Indexed: 12/18/2022]
Abstract
Background Glenohumeral subluxation (GHS) is common in patients with acute hemiplegia caused by stroke. GHS and upper limb function are closely related. Objective Using musculoskeletal ultrasonography (MSUS) to objectively evaluate the efficacy of functional magnetic stimulation (FMS) in the treatment of GHS in acute hemiplegic patients after stroke. Methods The study used prospective case control study. Stroke patients with GHS were recruited and assigned to control group and FMS group. Control group received electrode stimulation at the supraspinatus and deltoid muscles of the hemiplegic side, while FMS group was stimulated at the same locations. Before and after treatment, the distances of the acromion-greater tuberosity (AGT), acromion-lesser tuberosity (ALT), acromiohumeral distance (AHD), supraspinatus thickness (SST), and deltoid muscle thickness (DMT) in patients' bilateral shoulder joint were measured by MSUS, respectively. Meanwhile, Fugl-Meyer Assessment (FMA) was used to evaluate the improvement of upper limb function. Results 30 patients were recruited. After FMS treatment, there was a significant decrease in the difference value between ipsilateral side and contralateral side of AGT [t = 8.595, P < 0.01], ALT [t = 11.435, P < 0.01], AHD [t = 8.375, P < 0.01], SST [t = 15.394, P < 0.01], and DMT [t = 24.935, P < 0.01], and FMA score increased [t = −13.315, P < 0.01]. Compared with control group, FMS group decreased more significantly in the difference value between ipsilateral side and contralateral side of AGT [t = 2.161, P < 0.05], ALT [t = 3.332, P < 0.01], AHD [t = 8.768, P < 0.01], SST [t = 6.244, P < 0.01], and the DMT [t = 3.238, P < 0.01], and FMA score increased more significantly in FMS group [t = 7.194, P < 0.01]. Conclusion The study preliminarily shows that the MSUS can objectively and dynamically evaluate the treatment effect of GHS in hemiplegic patients. Meanwhile, compared with control group, the FMS is more effective and has fewer side effects, and the long-term effect of FMS is worth further study. This trial is registered with ChiCTR1800015352.
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Guan YZ, Li J, Zhang XW, Wu S, Du H, Cui LY, Zhang WH. Effectiveness of repetitive transcranial magnetic stimulation (rTMS) after acute stroke: A one-year longitudinal randomized trial. CNS Neurosci Ther 2017; 23:940-946. [PMID: 28971620 DOI: 10.1111/cns.12762] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/04/2017] [Accepted: 09/07/2017] [Indexed: 01/13/2023] Open
Abstract
AIMS To evaluate the effectiveness of repetitive transcranial magnetic stimulation (rTMS) on motor recovery after stroke using a prospective, double-blind, randomized, sham-controlled study. METHODS Patients with unilateral subcortical infarction in the middle cerebral artery territory within 1 week after onset were enrolled. The patients were randomly divided into an rTMS treatment group and a sham group. We performed high-frequency rTMS or sham rTMS on the two groups. Motor functional scores were assessed pre- and post-rTMS/sham rTMS and at 1 month, 3 months, 6 months, and 1 year after stroke onset. The scores included the National Institutes of Health Stroke Scale (NIHSS), Barthel Index (BI), Fugl-Meyer Assessment Upper Limb/Lower Limb (FMA-UL/LL), modified Rank Score (mRS), and the resting motor threshold (RMT) of the hemiplegic limb. RESULTS At baseline, no significant differences were found between the two groups for motor functional scores. On the second day after rTMS treatment, score improvements of the NIHSS, BI, FMA-UL in the real treatment group were more significant than those in the sham group. In addition, similar results were obtained at 1 month. However, at 3 months, 6 months, and 1 year after onset, no significant differences in improvement were observed between the two groups, except for the FMA-UL score improvement. CONCLUSION rTMS facilitates motor recovery of acute stroke patients, and the effect can last to 1 month, except the function improvement on upper extremities could last for 1 year. A single course of rTMS in the acute stage may induce the improvement of upper extremities function lasted for 1 year.
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Affiliation(s)
- Yu-Zhou Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Li
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xue-Wei Zhang
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.,Department of Interventional Radiology, China Meitan General Hospital, Beijing, China
| | - Shuang Wu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Hua Du
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Li-Ying Cui
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.,Neuroscience Center, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei-Hong Zhang
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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Aşkın A, Tosun A, Demirdal ÜS. Effects of low-frequency repetitive transcranial magnetic stimulation on upper extremity motor recovery and functional outcomes in chronic stroke patients: A randomized controlled trial. Somatosens Mot Res 2017; 34:102-107. [PMID: 28427299 DOI: 10.1080/08990220.2017.1316254] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) was suggested as a preconditioning method that would increase brain plasticity and that it would be optimal to combine rTMS with intensive rehabilitation. OBJECTIVE To assess the efficacy of inhibitory rTMS on upper extremity motor recovery and functional outcomes in chronic ischemic stroke patients. METHODS In this randomized controlled trial, experimental group received low-frequency (LF) rTMS to the primary motor cortex of the unaffected side + physical therapy (PT), and control group received PT. RESULTS No statistically significant difference was found in baseline demographical and clinical characteristics of the subjects including stroke severity or severity of paralysis prior to intervention. There were statistically significant improvements in all clinical outcome measures except for the Brunnstrom Recovery Stages. Fugl-Meyer Assessment, Box and Block test, motor and total scores of Functional Independence Measurement (FIM), and Functional Ambulation Scale (FAS) scores were significantly increased in both groups, however, these changes were significantly greater in the rTMS group except for FAS score. FIM cognitive scores and standardized mini-mental test scores were significantly increased and distal and hand Modified Ashworth Scale scores were significantly decreased only in the rTMS group (p < .05). CONCLUSIONS LF-rTMS can safely facilitate upper extremity motor recovery in patients with chronic ischemic stroke. TMS seems to be a promising treatment for motor, functional, and cognitive deficits in chronic stroke. Further studies with a larger number of patients with longer follow-up periods are needed to establish its effectiveness in stroke rehabilitation.
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Affiliation(s)
- Ayhan Aşkın
- a Department of Physical Medicine and Rehabilitation , Katip Celebi University , Izmir , Turkey
| | - Aliye Tosun
- a Department of Physical Medicine and Rehabilitation , Katip Celebi University , Izmir , Turkey
| | - Ümit Seçil Demirdal
- a Department of Physical Medicine and Rehabilitation , Katip Celebi University , Izmir , Turkey
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Tomioka K, Matsumoto S, Ikeda K, Uema T, Sameshima JI, Sakashita Y, Kaji T, Shimodozono M. Short-term effects of physiotherapy combining repetitive facilitation exercises and orthotic treatment in chronic post-stroke patients. J Phys Ther Sci 2017; 29:212-215. [PMID: 28265141 PMCID: PMC5332972 DOI: 10.1589/jpts.29.212] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 10/27/2016] [Indexed: 11/24/2022] Open
Abstract
[Purpose] This study investigated the short-term effects of a combination therapy
consisting of repetitive facilitative exercises and orthotic treatment. [Subjects and
Methods] The subjects were chronic post-stroke patients (n=27; 24 males and 3 females;
59.3 ± 12.4 years old; duration after onset: 35.7 ± 28.9 months) with limited mobility and
motor function. Each subject received combination therapy consisting of repetitive
facilitative exercises for the hemiplegic lower limb and gait training with an ankle-foot
orthosis for 4 weeks. The Fugl-Meyer assessment of the lower extremity, the Stroke
Impairment Assessment Set as a measure of motor performance, the Timed Up & Go test,
and the 10-m walk test as a measure of functional ambulation were evaluated before and
after the combination therapy intervention. [Results] The findings of the Fugl-Meyer
assessment, Stroke Impairment Assessment Set, Timed Up & Go test, and 10-m walk test
significantly improved after the intervention. Moreover, the results of the 10-m walk test
at a fast speed reached the minimal detectible change threshold (0.13 m/s). [Conclusion]
Short-term physiotherapy combining repetitive facilitative exercises and orthotic
treatment may be more effective than the conventional neurofacilitation therapy, to
improve the lower-limb motor performance and functional ambulation of chronic post-stroke
patients.
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Affiliation(s)
- Kazutoshi Tomioka
- Department of Rehabilitation, Tarumizu Municipal Medical Center Tarumizu Chuo Hospital, Japan
| | - Shuji Matsumoto
- Department of Rehabilitation and Physical Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Japan
| | - Keiko Ikeda
- Department of Rehabilitation, Kirishima Rehabilitation Center of Kagoshima University Hospital, Japan
| | - Tomohiro Uema
- Department of Rehabilitation, Kirishima Rehabilitation Center of Kagoshima University Hospital, Japan
| | - Jun-Ichi Sameshima
- Department of Rehabilitation, Tarumizu Municipal Medical Center Tarumizu Chuo Hospital, Japan
| | - Yuji Sakashita
- Department of Rehabilitation, Tarumizu Municipal Medical Center Tarumizu Chuo Hospital, Japan
| | - Tomokazu Kaji
- Department of Rehabilitation, Tarumizu Municipal Medical Center Tarumizu Chuo Hospital, Japan
| | - Megumi Shimodozono
- Department of Rehabilitation and Physical Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Japan
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