Spasticity, Motor Recovery, and Neural Plasticity after Stroke

Stroke Survivors' Interaction With Hand Rehabilitation Devices: Observational Study

BACKGROUND

The hand is crucial for carrying out activities of daily living as well as social interaction. Functional use of the upper limb is affected in up to 55% to 75% of stroke survivors 3 to 6 months after stroke. Rehabilitation can help restore function, and several rehabilitation devices have been designed to improve hand function. However, access to these devices is compromised in people with more severe loss of function.

OBJECTIVE

In this study, we aimed to observe stroke survivors with poor hand function interacting with a range of commonly used hand rehabilitation devices.

METHODS

Participants were engaged in an 8-week rehabilitation intervention at a technology-enriched rehabilitation gym. The participants spent 50-60 minutes of the 2-hour session in the upper limb section at least twice a week. Each participant communicated their rehabilitation goals, and an Action Research Arm Test (ARAT) was used to measure and categorize hand function as poor (scores of 0-9), moderate (scores of 10-56), or good (score of 57). Participants were observed during their interactions with 3 hand-based rehabilitation devices that focused on hand rehabilitation: the GripAble, NeuroBall, and Semi-Circular Peg Board. Observations of device interactions were recorded for each session.

RESULTS

A total of 29 participants were included in this study, of whom 10 (34%) had poor hand function, 17 (59%) had moderate hand function, and 2 (7%) had good hand function. There were no differences in the age and years after stroke among participants with poor hand function and those with moderate (P=.06 and P=.09, respectively) and good (P=.37 and P=.99, respectively) hand function. Regarding the ability of the 10 participants with poor hand function to interact with the 3 hand-based rehabilitation devices, 2 (20%) participants with an ARAT score greater than 0 were able to interact with the devices, whereas the other 8 (80%) who had an ARAT score of 0 could not. Their inability to interact with these devices was clinically examined, and the reason was determined to be a result of either the presence of (1) muscle tone or stiffness or (2) muscle weakness.

CONCLUSIONS

Not all stroke survivors with impairments in their hands can make use of currently available rehabilitation technologies. Those with an ARAT score of 0 cannot actively interact with hand rehabilitation devices, as they cannot carry out the hand movement necessary for such interaction. The design of devices for hand rehabilitation should consider the accessibility needs of those with poor hand function.

Influence of nitrate supplementation on motor unit activity during recovery following a sustained ischemic contraction in recreationally active young males

PURPOSE

Dietary nitrate (NO3-) supplementation enhances muscle blood flow and metabolic efficiency in hypoxia, however, its efficacy on neuromuscular function and specifically, the effect on motor unit (MU) activity is less clear. We investigated whether NO3- supplementation affected MU activity following a 3 min sustained ischemic contraction and whether this is influenced by blood flow restriction (BFR) during the recovery period.

METHOD

In a randomized, double-blinded, cross-over design, 14 males (mean ± SD, 25 ± 6 years) completed two trials following 5 days of supplementation with NO3--rich (NIT) or NO3--depleted (PLA) beetroot juice to modify plasma nitrite (NO2-) concentration (482 ± 92 vs. 198 ± 48 nmol·L-1, p < 0.001). Intramuscular electromyography was used to assess MU potential (MUP) size (duration and area) and mean firing rates (MUFR) during a 3 min submaximal (25% MVC) isometric contraction with BFR. These variables were also assessed during a 90 s recovery period with the first half completed with, and the second half completed without, BFR.

RESULTS

The change in MUP area and MUFR, did not differ between conditions (all p > 0.05), but NIT elicited a reduction in MUP recovery time during brief isometric contractions (p < 0.001), and during recoveries with (p = 0.002) and without (p = 0.012) BFR.

CONCLUSION

These novel observations improve understanding of the effects of NO3- on the recovery of neuromuscular function post-exercise and might have implications for recovery of muscle contractile function.

TRIAL REGISTRATION

The study was registered on clinicaltrials.gov with ID of NCT05993715 on August 08, 2023.

Exploring the experiences of adults with stroke in virtual community-based stroke programs: a qualitative descriptive study

BACKGROUND

Stroke is among the top contributors to disability and can impact an individual's cognition, physical functioning, and mental health. Since the COVID-19 pandemic, several community-based organizations have started delivering stroke programs virtually. However, participants' experiences in these programs remain understudied, and evidence-based guidelines to inform and optimize virtual stroke program development and delivery are lacking. Thus, this study aimed to describe the perspectives and experiences of individuals with stroke who participated in virtual community-based organization stroke programs, including perceived access and participation facilitators and barriers and suggestions for improving these programs.

METHODS

A qualitative descriptive design was used to gather participant experiences through semi-structured interviews. Audio-recorded interviews were conducted on Zoom and transcribed verbatim. Adult participants who had experienced a stroke and attended at least one Canadian virtual community-based organization stroke program were recruited. Data were analyzed using inductive thematic analysis.

RESULTS

Twelve participants (32-69 years, 2-23 years post-stroke, eight women and four men) participated in this study. Five themes were identified: (1) motives to join virtual community-based organization stroke programs, including gaining peer connections, knowledge and information; (2) perceived barriers to accessing and participating in virtual community-based organization stroke programs, including technology inequities, difficulties navigating technology, and inadequate facilitation; (3) perceived facilitators to accessing and participating in virtual community-based organization stroke programs, including remote access, virtual platform features and program leader characteristics/skills; (4) unmet needs during virtual community-based organization stroke programs, including in-person connection and individualized support; and (5) suggestions and preferences for improving virtual community-based organization stroke programs, including program facilitation, content and format.

CONCLUSIONS

Study findings highlight opportunities to improve virtual community-based organization stroke programs to optimize participant experiences and outcomes. Addressing the barriers and suggestions identified in this study may improve virtual community-based organization stroke programs' access and quality.

Patterns and assessment of spastic hemiplegic gait

Hemiparetic gait disorders are common in stroke survivors. A circumductory gait is often considered the typical hemiparetic gait. In clinical practice, a wide spectrum of abnormal gait patterns is observed, depending on the severity of weakness and spasticity, and the anatomical distribution of spasticity. Muscle strength is the key determinant of gait disorders in hemiparetic stroke survivors. Spasticity and its associated involuntary activation of synergistic spastic muscles often alter posture of involved joint(s) and subsequently the alignment of hip, knee, and ankle joints, resulting in abnormal gait patterns. Due to combinations of various levels of muscle weakness and spasticity and their interactions with ground reaction force, presentations of gait disorders are variable. From a neuromechanical perspective, a stepwise visual gait analysis approach is proposed to identify primary underlying causes. In this approach, the pelvic and hip joint movement is examined first. The pelvic girdle constitutes three kinematic determinants. Its abnormality determines the body vector and compensatory kinetic chain reactions in the knee and ankle joints. The second step is to assess the ankle and foot complex abnormality. The last step is to examine abnormality of the knee joint. Assessment of muscle strength and spasticity of hip, knee, and ankle/foot joints needs to be performed before these steps. Lidocaine nerve blocks can be a useful diagnostic tool. Recognizing different patterns and identifying the primary causes are critical to developing clinical interventions to improve gait functions.

The Role of Botulinum Toxin Type-A in Spasticity: Research Trends from a Bibliometric Analysis

Botulinum toxin type-A (BoNT-A) has emerged as a key therapeutic agent for the management of spasticity. This paper presents a comprehensive bibliometric and visual analysis of research concerning BoNT-A treatment of spasticity to elucidate current trends and future directions in this research area. A search was conducted in the Web of Science database for articles focused on the use of BoNT-A in spasticity published between 2000 and 2022. We extracted various metrics, including counts of publications and contributions from different countries, institutions, authors, and journals. Analytical methods in CiteSpace were employed for the examination of co-citations, collaborations, and the co-occurrence of keywords. Our search yielded 1489 publications. Analysis revealed a consistent annual increase in research output. The United States, United Kingdom, and Italy were the leading contributors. The top institution in this research was Assistance Publique Hopitaux, Paris. The journal containing the highest number of relevant publications was Toxins. Key frequently occurring keywords were 'stroke', 'cerebral palsy', 'adult spasticity', and 'upper extremity'. This study identified 12 clusters of keywords and 15 clusters of co-cited references, indicating the main focus areas and emerging themes in this field. This study comprehensively analyzed and summarized trends in BoNT-A research in the field of spasticity over the past 22 years.

Effects of Real-Time Feedback Methods on Static Balance Training in Stroke Patients: A Randomized Controlled Trial

BACKGROUND

The purpose of this study was to investigate the effects of real-time feedback methods on static balance training in stroke patients. There are two types of real-time feedback methods, as follows: one is Knowledge of Result (KR), and the other is Knowledge of Performance (KP).

METHOD

Thirty stroke patients participated in this study and were randomly assigned to the KR group (n = 15) or the KP group (n = 15). All of the groups underwent real-time feedback training for four weeks (30 min per session, five sessions per week). The primary outcomes were sway length, sway velocity, and area 95%, which were assessed before and after the intervention. The secondary outcomes included the Berg Balance Scale, the Fugl Meyer Assessment for Lower Extremity, the Postural Assessment Scale for Stroke Trunk Impairment Scale, and the Fall Efficacy Scale. A group × time interaction was assessed using two-way ANOVA with repeated measures.

RESULT

There was a significant increase over time in all outcomes (p < 0.05). Significant differences were observed for a group × time interaction in sway length and area 95% (p < 0.05).

CONCLUSIONS

Real-time feedback training for static balance enhanced stroke patients' static balance abilities, clinical outcome assessments, and promoted self-efficacy against falls.

Exploring the Prospects of Transcranial Electrical Stimulation (tES) as a Therapeutic Intervention for Post-Stroke Motor Recovery: A Narrative Review

INTRODUCTION

Stroke survivors often have motor impairments and related functional deficits. Transcranial Electrical Stimulation (tES) is a rapidly evolving field that offers a wide range of capabilities for modulating brain function, and it is safe and inexpensive. It has the potential for widespread use for post-stroke motor recovery. Transcranial Direct Current Stimulation (tDCS), Transcranial Alternating Current Stimulation (tACS), and Transcranial Random Noise Stimulation (tRNS) are three recognized tES techniques that have gained substantial attention in recent years but have different mechanisms of action. tDCS has been widely used in stroke motor rehabilitation, while applications of tACS and tRNS are very limited. The tDCS protocols could vary significantly, and outcomes are heterogeneous.

PURPOSE

the current review attempted to explore the mechanisms underlying commonly employed tES techniques and evaluate their prospective advantages and challenges for their applications in motor recovery after stroke.

CONCLUSION

tDCS could depolarize and hyperpolarize the potentials of cortical motor neurons, while tACS and tRNS could target specific brain rhythms and entrain neural networks. Despite the extensive use of tDCS, the complexity of neural networks calls for more sophisticated modifications like tACS and tRNS.

The beneficial effects of transitional care for patients with stroke: A meta-analysis

INTRODUCTION

Transitional care interventions have emerged as a promising method of ensuring treatment continuity and health care coordination when patients are discharged from hospital to home. However, few studies have investigated the frequency and duration of interventions and the effects of interventions on physical function. Therefore, this study aimed to determine the efficacy of transitional care for patients with stroke.

METHODS

Six databases and the grey literature were searched to obtain relevant articles from October 1, 2022 to March 10, 2023. The primary outcomes studied were motor performance, walking speed, activities of daily living (ADLs) and caregiver burden following hospital-to-home transitional care. The quality of the studies was assessed with Cochrane risk of bias version 2. The quality and sensitivity of the evidence were assessed to ensure rigour of the findings. Meta-analyses were performed using stata 17.0.

RESULTS

A total of 2966 patients were identified from 23 studies. Transitional care improved post-stroke motor performance, walking speed and ADLs, and reduced caregiver burden.

CONCLUSION

The findings suggest that provision of transitional care model implementation in patients with stroke is important because it reduces disability in stroke patients and helps to decrease caregivers' burden.

IMPACT

The findings of the study emphasize the importance of transitional care programmes for stroke patients after they are discharged from the hospital and returned to their homes. To meet the needs of patients, all levels of health professionals including nurses should be aware of the discharge process and care plan.

Therapeutic robots for post-stroke rehabilitation

Stroke is a prevalent, severe, and disabling health-care issue on a global scale, inevitably leading to motor and cognitive deficits. It has become one of the most significant challenges in China, resulting in substantial social and economic burdens. In addition to the medication and surgical interventions during the acute phase, rehabilitation treatment plays a crucial role in stroke care. Robotic technology takes distinct advantages over traditional physical therapy, occupational therapy, and speech therapy, and is increasingly gaining popularity in post-stroke rehabilitation. The use of rehabilitation robots not only alleviates the workload of healthcare professionals but also enhances the prognosis for specific stroke patients. This review presents a concise overview of the application of therapeutic robots in post-stroke rehabilitation, with particular emphasis on the recovery of motor and cognitive function.

Corticospinal tract: a new hope for the treatment of post-stroke spasticity

Stroke is the third leading cause of death and disability worldwide. Post-stroke spasticity (PSS) is the most common complication of stroke but represents only one of the many manifestations of upper motor neuron syndrome. As an upper motor neuron, the corticospinal tract (CST) is the only direct descending motor pathway that innervates the spinal motor neurons and is closely related to the recovery of limb function in patients with PSS. Therefore, promoting axonal remodeling in the CST may help identify new therapeutic strategies for PSS. In this review, we outline the pathological mechanisms of PSS, specifically their relationship with CST, and therapeutic strategies for axonal regeneration of the CST after stroke. We found it to be closely associated with astroglial scarring produced by astrocyte activation and its secretion of neurotrophic factors, mainly after the onset of cerebral ischemia. We hope that this review offers insight into the relationship between CST and PSS and provides a basis for further studies.

Spiral strapping for improving upper extremity motor functions in individuals with stroke: A randomized controlled trial

BACKGROUND

The rehabilitation process for the upper extremities of individuals with stroke requires therapists to use splints for supportive and corrective purposes. The aim of this study was to assess the effectiveness of spiral strapping in inhibiting spasticity and improving the upper extremity motor functions of individuals with chronic stroke.

METHODS

Forty Saudi individuals aged 50-60 years with chronic stroke participated in this study. Their degrees of spasticity according to the Modified Ashworth Scale ranged across grades 1, 1+, and 2. Participants were randomly assigned to experimental and control groups. Participants in both groups received 1 h of conventional physical therapy for 3 d/wk to improve the motor functions of their upper extremities. In addition, participants in the experimental group wore an upper-limb spiral strapping with a hand splint 10 h/d for 6 d/wk. The treatment program for both groups was delivered for 4 weeks. Changes in the scores of Action Research Arm Test for elbow joint spasticity, active range of motion of the shoulder, elbow, and forearm joints, and hand grip strength were evaluated before and after treatment in both groups.

RESULTS

Significant improvements in all measured variables after treatment were reported in both groups, except for elbow joint spasticity in the control group. The experimental group showed significant post-treatment improvement in the scores for all measured variables compared with the control group.

CONCLUSIONS

Spiral strapping was beneficial in inhibiting mild degrees of spasticity and improving the motor functions of the upper extremities of stroke patients.

Effect of tDCS on corticomuscular coupling and the brain functional network of stroke patients

Transcranial direct current stimulation (tDCS) is an emerging brain intervention technique that has gained growing attention in recent years in the rehabilitation area. In this paper, we investigated the efficacy of tDCS in the rehabilitation process of stroke patients, utilizing corticomuscular coupling (CMC) and brain functional network analysis. Specifically, we examined changes in CMC relationships between the treatment and control groups before and after rehabilitation by transfer entropy (TE), and constructed brain functional networks by TE. We further calculated features of the functional networks, including node degree, global efficiency, clustering coefficient, characteristic path length, and small world index. Our results demonstrate that CMC in patients increased significantly after treatment, with greater improvements in the tDCS group, particularly within the beta and gamma bands. In addition, the functional brain network analysis revealed enhanced connectivity between brain regions, improved information processing capacity, and increased transmission efficiency in patients as their condition improved. Notably, treatment with tDCS resulted in more significant improvements than the sham group, with a statistically significant difference observed after rehabilitation treatment (p < 0.05). These findings provide compelling evidence regarding the role of tDCS in the treatment of stroke and highlight the potential of this approach in stroke rehabilitation. The use of tDCS for therapeutic interventions in stroke rehabilitation can significantly improve the coupling of patients' functional brain networks. Also, using Transfer Entropy (TE) as a characteristic of CMC, tDCS was found to significantly enhance patients' TE, i.e. enhanced CMC.

Testing spasticity mechanisms in chronic stroke before and after intervention with contralesional motor cortex 1 Hz rTMS and physiotherapy

BACKGROUND

Previous studies showed that repetitive transcranial magnetic stimulation (rTMS) reduces spasticity after stroke. However, clinical assessments like the modified Ashworth scale, cannot discriminate stretch reflex-mediated stiffness (spasticity) from passive stiffness components of resistance to muscle stretch. The mechanisms through which rTMS might influence spasticity are also not understood.

METHODS

We measured the effects of contralesional motor cortex 1 Hz rTMS (1200 pulses + 50 min physiotherapy: 3×/week, for 4-6 weeks) on spasticity of the wrist flexor muscles in 54 chronic stroke patients using a hand-held dynamometer for objective quantification of the stretch reflex response. In addition, we measured the excitability of three spinal mechanisms thought to be related to post-stroke spasticity: post-activation depression, presynaptic inhibition and reciprocal inhibition before and after the intervention. Effects on motor impairment and function were also assessed using standardized stroke-specific clinical scales.

RESULTS

The stretch reflex-mediated torque in the wrist flexors was significantly reduced after the intervention, while no change was detected in the passive stiffness. Additionally, there was a significant improvement in the clinical tests of motor impairment and function. There were no significant changes in the excitability of any of the measured spinal mechanisms.

CONCLUSIONS

We demonstrated that contralesional motor cortex 1 Hz rTMS and physiotherapy can reduce the stretch reflex-mediated component of resistance to muscle stretch without affecting passive stiffness in chronic stroke. The specific physiological mechanisms driving this spasticity reduction remain unresolved, as no changes were observed in the excitability of the investigated spinal mechanisms.

Radial extracorporeal shock wave therapy as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients. A randomized controlled study

PURPOSE

To evaluate the effectiveness of radial extracorporeal shock wave therapy (r ESWT) as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients.

METHODS

100 eligible stroke patients with calf muscles spasticity were randomized into 2 groups. Group I: 50 patients exposed to rESWT 1.500 pulses, 0.10 mJ to 0.3mJ/mm2, with a frequency 4 Hz once weekly for one month. Group II: 50 patients exposed to Sham rESWT once weekly for one month. Clinical, electrophysiological & musculoskeletal ultrasound assessments were done for all patients.

RESULTS

After controlling baseline as covariate, the trend for modified Ashworth scale (MAS), Passive ankle dorsiflexion motion (PADFM), 10 meters walk test (10-MWT), and Ratio of maximum H reflex to maximum M response (H/M ratio) after one & two months was significantly different between the two groups, with improvement of all clinical and electrophysiological parameters in group I.

CONCLUSION

ESWT represents a useful non-invasive, additional modality for the reduction of foot spasticity and equinus deformity in stroke patients.

Immediate Effects of TECAR Therapy on Gastrocnemius and Quadriceps Muscles with Spastic Hypertonia in Chronic Stroke Survivors: A Randomized Controlled Trial

BACKGROUND

The aim of this study was to assess changes in muscle properties after a single session of capacitive and resistive energetic transfer (TECAR) therapy on spastic gastrocnemius and quadriceps muscles in chronic post-stroke.

METHODS

A total of 36 chronic stroke survivors with lower limb hypertonia were enrolled in a double-blind randomized controlled trial. The experimental group (n = 18) received a single 30 min session of TECAR therapy in combination with functional massage (FM) on the gastrocnemius and quadriceps muscles. The control group (n = 18) received a sham treatment of TECAR therapy (without electrical stimulation) in combination with real FM. The primary outcome was muscle tone of the lower limb muscles assessed with the Modified Ashworth Scale (MAS). The secondary outcomes were goniometric degrees of the MAS (goniometer), neuromuscular properties of the gastrocnemius/quadriceps (myotonometer), and passive range of motion (inclinometer). All measurements were performed at baseline (T0), immediately after treatment (T1), and at 30 min post-treatment (T2) by a blinded assessor.

RESULTS

The MAS score ankle dorsiflexion significantly decreased at T0-T1 (p = 0.046), and the change was maintained at T0-T2 (p = 0.019) in the experimental group. Significant improvements were noted in the passive range of motion for knee flexion (p = 0.012) and ankle dorsiflexion (p = 0.034) at T2. In addition, knee flexion improved at T1 (p = 0.019).

CONCLUSION

A single session of Tecar therapy at the same time with FM on the gastrocnemius and rectus femoris immediately reduces muscle tone and increases the passive range of motion of both ankle and knee in chronic stroke survivors. There were no significant changes in the neuromuscular properties measured with myotonometer.

Individual Muscle Force Estimation in the Human Forearm Using Multi-Muscle MR Elastography (MM-MRE)

OBJECTIVE

To establish the sensitivity of magnetic resonance elastography (MRE) to active muscle contraction in multiple muscles of the forearm.

METHODS

We combined MRE of forearm muscles with an MRI-compatible device, the MREbot, to simultaneously measure the mechanical properties of tissues in the forearm and the torque applied by the wrist joint during isometric tasks. We measured shear wave speed of thirteen forearm muscles via MRE in a series of contractile states and wrist postures and fit these outputs to a force estimation algorithm based on a musculoskeletal model.

RESULTS

Shear wave speed changed significantly upon several factors, including whether the muscle was recruited as an agonist or antagonist (p = 0.0019), torque amplitude (p = <0.0001), and wrist posture (p = 0.0002). Shear wave speed increased significantly during both agonist (p = <0.0001) and antagonist (p = 0.0448) contraction. Additionally, there was a greater increase in shear wave speed at greater levels of loading. The variations due to these factors indicate the sensitivity to functional loading of muscle. Under the assumption of a quadratic relationship between shear wave speed and muscle force, MRE measurements accounted for an average of 70% of the variance in the measured joint torque.

CONCLUSION

This study shows the ability of MM-MRE to capture variations in individual muscle shear wave speed due to muscle activation and presents a method to estimate individual muscle force through MM-MRE derived measurements of shear wave speed.

SIGNIFICANCE

MM-MRE could be used to establish normal and abnormal muscle co-contraction patterns in muscles of the forearm controlling hand and wrist function.

High-definition transcranial direct current stimulation for upper extremity rehabilitation in moderate-to-severe ischemic stroke: a pilot study

Introduction

Previous studies found that post-stroke motor impairments are associated with damage to the lesioned corticospinal tract (CST) and hyperexcitability of the contralesional cortico-reticulospinal tract (CRST). This proof-of-concept study aims to develop a non-invasive brain stimulation protocol that facilitates the lesioned CST and inhibits the contralesional CRST to improve upper extremity rehabilitation in individuals with moderate-to-severe motor impairments post-stroke.

Methods

Fourteen individuals (minimum 3 months post ischemic stroke) consented. Physician decision of the participants baseline assessment qualified eight to continue in a randomized, double-blind cross-over pilot trial (ClinicalTrials.gov Identifier: NCT05174949) with: (1) anodal high-definition transcranial direct stimulation (HD-tDCS) over the ipsilesional primary motor cortex (M1), (2) cathodal HD-tDCS over contralesional dorsal premotor cortex (PMd), (3) sham stimulation, with a two-week washout period in-between. Subject-specific MR images and computer simulation were used to guide HD-tDCS and verified by Transcranial Magnetic Stimulation (TMS) induced Motor Evoked Potential (MEP). The motor behavior outcome was evaluated by an Fugl-Meyer Upper Extremity score (primary outcome measure) and the excitability of the ipslesoinal CST and contralesional CRST was determined by the change of MEP latencies and amplitude (secondary outcome measures).

Results

The baseline ipsilesional M1 MEP latency and amplitude were correlated with FM-UE. FM-UE scores were improved post HD-tDCS, in comparison to sham stimulation. Both anodal and cathodal HD-tDCS reduced the latency of the ipsilesional M1 MEP. The contralesional PMd MEP disappeared/delayed after HD-tDCS.

Discussion

These results suggest that HD-tDCS could improve the function of the lesioned corticospinal tract and reduce the excitability of the contralesional cortico-reticulospinal tract, thus, improving motor function of the upper extremity in more severely impaired individuals.

Post-Stroke Spastic Movement Disorder and Botulinum Toxin A Therapy: Early Detection And Early Injection

Post-stroke spastic movement disorder (PS-SMD) develops in up to 40% of stroke survivors after a first ever stroke within the first year. Chronic PS-SMD is often associated with severe disabilities and complications, emphasizing the importance of its early recognition and early adequate management. Extensive research has aimed to accurately predict and sensitively detect a PS-SMD. Symptomatic therapies include conventional rehabilitation and local intramuscular injections of botulinum toxin A (BoNT-A). The latter is widely used, but primarily in the chronic phase of stroke. However, recent studies have shown the safety and efficacy of BoNT-A therapy even in the acute phase and early sub-acute phase after stroke, i.e., within three months post-stroke, leading to an improved long-term outcome in stroke rehabilitation. Local BoNT-A injections evolve as the primary approach in focal, multifocal, and segmental chronic or acute/subacute PS-SMD. Patients at high risk for or manifest PS-SMD should be identified by an early spasticity risk assessment. By doing so, PS-SMD can be integral part of the patient-centered goal-setting process of a multiprofessional spasticity-experienced team. The benefit of an early PS-SMD treatment by BoNT-A should predominate putative degenerative muscle changes due to long-term BoNT-A therapy by far. This, as early treatment effectively avoids complications typically associated with a PS-SMD, i.e., contractures, pain, skin lesions. The management of PS-SMD requires a comprehensive and multidisciplinary approach. Early assessment, patient-centered goal setting, early intervention, and early use of BoNT-A therapy prevents from PS-SMD complications and may improve rehabilitation outcome after stroke.

Functional electrical stimulation therapy controlled by a P300-based brain-computer interface, as a therapeutic alternative for upper limb motor function recovery in chronic post-stroke patients. A non-randomized pilot study

Introduction

Up to 80% of post-stroke patients present upper-limb motor impairment (ULMI), causing functional limitations in daily activities and loss of independence. UMLI is seldom fully recovered after stroke when using conventional therapeutic approaches. Functional Electrical Stimulation Therapy (FEST) controlled by Brain-Computer Interface (BCI) is an alternative that may induce neuroplastic changes, even in chronic post-stroke patients. The purpose of this work was to evaluate the effects of a P300-based BCI-controlled FEST intervention, for ULMI recovery of chronic post-stroke patients.

Methods

A non-randomized pilot study was conducted, including 14 patients divided into 2 groups: BCI-FEST, and Conventional Therapy. Assessments of Upper limb functionality with Action Research Arm Test (ARAT), performance impairment with Fugl-Meyer assessment (FMA), Functional Independence Measure (FIM) and spasticity through Modified Ashworth Scale (MAS) were performed at baseline and after carrying out 20 therapy sessions, and the obtained scores compared using Chi square and Mann-Whitney U statistical tests (𝛼 = 0.05).

Results

After training, we found statistically significant differences between groups for FMA (p = 0.012), ARAT (p < 0.001), and FIM (p = 0.025) scales.

Discussion

It has been shown that FEST controlled by a P300-based BCI, may be more effective than conventional therapy to improve ULMI after stroke, regardless of chronicity.

Conclusion

The results of the proposed BCI-FEST intervention are promising, even for the most chronic post-stroke patients often relegated from novel interventions, whose expected recovery with conventional therapy is very low. It is necessary to carry out a randomized controlled trial in the future with a larger sample of patients.

Immediate Effects of Anti-Spastic Epidural Cervical Spinal Cord Stimulation on Functional Connectivity of the Central Motor System in Patients with Stroke- and Traumatic Brain Injury-Induced Spasticity: A Pilot Resting-State Functional Magnetic Resonance Imaging Study

OBJECTIVE

Spinal cord stimulation (SCS) is one approach to the potential improvement of patients with post-stroke or post-traumatic spasticity. However, little is known about whether and how such interventions alter supraspinal neural systems involved in the pathogenesis of spasticity. This pilot study investigated whether epidural spinal cord stimulation at the level of the C3-C5 cervical segments, aimed at reducing spasticity, alters the patterns of functional connectivity of the brain.

METHODS

Eight patients with spasticity in the right limbs as a result of left cerebral hemisphere damage (due to hemorrhagic and ischemic stroke or traumatic and anoxic brain injury) were assessed with fMRI immediately before and immediately after short-term (1 to 6 days) test cervical epidural SCS therapy. Eight demographically and clinically comparable patients with spasticity in the right extremities due to a left hemisphere ischemic stroke and brain injury who received conventional therapy were examined as a control group. All patients also had paresis of one or two limbs and hyperreflexia.

RESULTS

After the SCS therapy, there were three main findings: (1) higher functional connectivity of the brainstem to the right premotor cortex and changes in functional connectivity between cortical motor areas, (2) increased functional connectivity between the right and left lateral nodes of the sensorimotor network, and (3) a positive correlation between decreased spasticity in the right leg and increased functional connectivity within the right hemisphere sensorimotor cortex. All these changes in functional connectivity occurred with a statistically significant decrease in spasticity, as assessed using the modified Ashworth scale. The control group showed no decrease in spasticity or increase in functional connectivity in any of the seeds of interest. On the contrary, a decrease in functional connectivity of the brainstem and right postcentral gyrus was observed in this group during the observation period.

CONCLUSIONS

We were thus able to detect intrinsic brain connectivity rearrangements that occurred during spasticity mitigation following short epidural SCS therapy.

SIGNIFICANCE

The clinical results obtained confirmed the efficacy of short-term anti-spastic SCS therapy. The obtained data on functional rearrangements of the central motor system may shed light on the mechanism of antispastic action of this procedure.

Treatment effects of low-frequency repetitive transcranial magnetic stimulation combined with motor relearning procedure on spasticity and limb motor function in stroke patients

Objective

Limb paralysis, which is a sequela of stroke, limits patients' activities of daily living and lowers their quality of life. The purpose of this study was to investigate the effects of repetitive transcranial magnetic stimulation (rTMS) combined with a motor relearning procedure (MRP) on motor function and limb spasticity in stroke patients.

Methods

Stroke patients were randomly divided into a combined treatment group (rTMS + MRP) and a control group (MRP) (n = 30 per group). The control group was given MRP in addition to conventional rehabilitation, and the combined treatment group was given 1 Hz rTMS combined with MRP. The treatment efficacy was assessed by the modified Ashworth scale (MAS), Fugl-Meyer motor function scale, and motor evoked potential (MEP) testing.

Results

After 4 weeks of treatment, the Brunnstrom score, Fugl-Meyer lower extremity motor function, and Fugl-Meyer balance function were significantly higher in the combination treatment group compared to the control group, while the MAS score was lower in the combination treatment group compared to the control group. The MEP extraction rate was higher in the combined treatment group compared to the control group, while the threshold and central motor conduction time (CMCT) were lower in the combined treatment group compared to the control group.

Conclusion

Low-frequency rTMS combined with MRP had better efficacy on spasticity and motor function in stroke patients with hemiparesis than MRP alone.

Spasticity evaluation with the Amadeo Tyromotion device in patients with hemispheric stroke

Objective

The objective of this study is to verify the reliability and the concurrent and discriminant validity of the measurements of spasticity offered by the robotic device, quantifying the (1) test-retest reliability, (2) correlation with the clinical evaluation using the Modified Ashworth Scale (MAS), (3) inter-rater reliability between the two physiotherapists, and (4) ability to discriminate between healthy and stroke patients.

Methods

A total of 20 stroke patients and 20 healthy volunteers participated in the study. Two physical therapists (PT1 and PT2) independently evaluated the hand spasticity of stroke subjects using the MAS. Spasticity was assessed, both in healthy and stroke patients, with the Amadeo device at three increasing velocities of passive movement for three consecutive repeated assessments, while raw data of force and position were collected through an external program.

Data analysis

The intraclass correlation coefficient (ICC) and the weighted kappa were computed to estimate the reliability of the Amadeo device measurements, the inter-rater reliability of MAS, and the correlation between the MAS and Amadeo device measurements. The discriminant ability of the Amadeo device was assessed by comparing the stroke and healthy subjects' spasticity measurements with the percentage of agreements with 0 in MAS for healthy subjects.

Results

The test-retest reliability of the Amadeo device was high with ICC at all three velocities (ICC = 0.908, 0.958, and 0.964, respectively) but lower if analyzed with weighted kappa correlation (0.584, 0.748, and 0.749, respectively) as mean values for each velocity. The correlation between Amadeo and the clinical scale for stroke patients with weighted kappa correlation was poor (0.280 ± 0.212 for PT1 and 0.290 ± 0.155 for PT2). The inter-rater reliability of the clinical MAS was high (ICC = 0.911).

Conclusion

Both MAS and Amadeo spasticity scores showed good reliability. The Amadeo scores did not show a strong clinical correlation with the MAS in stroke patients. Hitherto, Amadeo evaluation shows trends that are consistent with the characteristics of spasticity, such as an increase in spasticity as the speed of muscle stretching increases. The ability of the device to discriminate between stroke patients and healthy controls is low. Future studies adopting an instrumental gold standard for spasticity may provide further insight into the validity of these measurements.

Progressive Rehabilitation Based on EMG Gesture Classification and an MPC-Driven Exoskeleton

Stroke is a leading cause of disability and death worldwide, with a prevalence of 200 millions of cases worldwide. Motor disability is presented in 80% of patients. In this context, physical rehabilitation plays a fundamental role for gradually recovery of mobility. In this work, we designed a robotic hand exoskeleton to support rehabilitation of patients after a stroke episode. The system acquires electromyographic (EMG) signals in the forearm, and automatically estimates the movement intention for five gestures. Subsequently, we developed a predictive adaptive control of the exoskeleton to compensate for three different levels of muscle fatigue during the rehabilitation therapy exercises. The proposed system could be used to assist the rehabilitation therapy of the patients by providing a repetitive, intense, and adaptive assistance.

Correlation between spasticity and corticospinal/corticoreticular tract status in stroke patients after early stage

We investigated the correlation between spasticity and the states of the corticospinal tract (CST) and corticoreticular tract (CRT) in stroke patients after early stage. Thirty-eight stroke patients and 26 healthy control subjects were recruited. The modified Ashworth scale (MAS) scale after the early stage (more than 1 month after onset) was used to determine the spasticity state of the stroke patients. Fractional anisotropy (FA), apparent diffusion coefficient (ADC), fiber number (FN), and ipsilesional/contra-lesional ratios for diffusion tensor tractography (DTT) parameters of the CST and CRT after the early stage were measured in both ipsi- and contra-lesional hemispheres. This study was conducted retrospectively. The FA and FN CST-ratios in the patient group were significantly lower than those of the control group (P < .05), except for the ADC CST-ratio (P > .05). Regarding the DTT parameters of the CRT-ratio, the patient group FN value was significantly lower than that of the control group (P < .05), whereas the FA and ADC CRT-ratios did not show significant differences between the patient and control groups (P > .05). MAS scores showed a strong positive correlation with the ADC CRT-ratio (P < .05) and a moderate negative correlation with the FN CRT-ratio (P < .05). We observed that the injury severities of the CST and CRT were related to spasticity severity in chronic stroke patients; moreover, compared to the CST, CRT status was more closely related to spasticity severity.

Effects of transcranial combined with peripheral repetitive magnetic stimulation on limb spasticity and resting-state brain activity in stroke patients

Background and objective

Transcranial magnetic stimulation and peripheral repetitive magnetic stimulation (rPMS), as non-invasive neuromodulation techniques, can promote functional recovery in patients with post-stroke spasticity (PSS), but the effects of transcranial magnetic stimulation combined with peripheral magnetic stimulation on PSS remain largely unknown. Therefore, we examined the effects of low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) combined with rPMS on PSS patients and its potential neural correlates to behavioral improvements.

Methods

Forty-nine PSS patients were divided randomly into three groups: a combined group (n = 20), a LF-rTMS group (n = 15), and a control group (n = 14). The combined group received LF-rTMS and rPMS treatment, the rTMS group received LF-rTMS treatment, and the control group received only routine rehabilitation. All patients underwent Ashworth Spasm Scale (MAS), upper extremity Fugl-Meyer (FMA-UE), and modified Barthel Index (MBI) assessments before and after intervention. In addition, resting-state functional magnetic resonance imaging data were collected pre- and post-treatment to observe changes in the amplitude of low-frequency fluctuation (ALFF).

Results

The MAS score was decreased, FMA-UE score and MBI scores were increased in the three groups after therapy than before therapy (all P &lt; 0.05). In particular, the combined group showed significant effect on improved motor function and relieved spasticity in PSS (P &lt; 0.01). Moreover, the combined treatment increased ALFF values mainly in the right supplementary motor area, right middle frontal gyrus, and right cerebellum, while reduced ALFF values mainly in the right post-central gyrus compared with pre-treatment. Compared with the LF-rTMS and control groups, the combined treatment increased ALFF values in the right cerebellum and reduced ALFF values mainly in the frontoparietal cortex. Improvements in the MAS score were positively correlated with the change in ALFF values in the right cerebellum (r = 0.698, P = 0.001) and the right supplementary motor area (r = 0.700, P = 0.001) after combined treatment.

Conclusion

Transcranial combined with peripheral repetitive magnetic stimulation could improve spastic state and motor function in PSS patients, and this effect may be associated with altered cerebellar and frontoparietal cortical activity.

Clinical trial registration

http://www.chictr.org.cn/index.aspx, identifier ChiCTR1800019452.

Low-frequency repetitive transcranial magnetic stimulation can alleviate spasticity and induce functional recovery in patients with severe chronic stroke: A prospective, non-controlled, pilot study

Objective

Developing new therapies to improve motor function in patients with severe chronic stroke remains a major focus of neurorehabilitation. In this prospective, non-controlled, pilot study, we aimed to investigate the effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with occupational therapy (OT) on the motor function recovery of the affected upper limb in chronic stroke patients with severe upper limb hemiparesis.

Methods

Consecutive patients (n = 40) diagnosed with chronic stroke (time since stroke, ≥1 year) and upper limb hemiparesis were enrolled in this study. Patients were classified according to the Brunnstrom recovery stage (BRS) for fingers. The severity of upper limb hemiparesis was categorized as mild (BRS IV-VI) or severe (BRS I-III). Patients received low-frequency rTMS to the contralesional primary motor area (M1) followed by OT for 12 consecutive days. The primary outcome was upper limb motor recovery, as measured with the Fugl-Meyer assessment (FMA). Secondary outcomes included manual dexterity, upper limb use, spasticity of the fingers and wrist, and motor evoked potential (MEP).

Results

Patients with severe hemiparesis showed a significant increase in upper limb use, significantly improved quality of movement, and significantly reduced spasticity. Those with mild hemiparesis showed significant improvements in the FMA scores and manual dexterity, a significant increase in upper limb use and MEP, and significantly reduced spasticity.

Conclusions

Low-frequency rTMS applied to the contralesional M1 combined with OT was effective in the rehabilitation of chronic stroke patients with severe upper limb hemiparesis by reducing the spasticity of the fingers.

MCP extensors respond faster than flexors in individuals with severe-to-moderate stroke-caused impairment: Evidence of uncoupled neural pathways

Damage in the corticospinal system following stroke produces imbalance between flexors and extensors in the upper extremity, eventually leading to flexion-favored postures. The substitution of alternative tracts for the damaged corticospinal tract is known to excessively activate flexors of the fingers while the fingers are voluntarily being extended. Here, we questioned whether the cortical source or/and neural pathways of the flexors and extensors of the fingers are coupled and what factor of impairment influences finger movement. In this study, a total of seven male participants with severe-to-moderate impairment by a hemiplegic stroke conducted flexion and extension at the metacarpophalangeal (MCP) joints in response to auditory tones. We measured activation and de-activation delays of the flexor and extensor of the MCP joints on the paretic side, and force generation. All participants generated greater torque in the direction of flexion (p = 0.017). Regarding co-contraction, coupled activation of the extensor is also made during flexion in the similar way to coupled activation of the flexor made during extension. As opposite to our expectation, we observed that during extension, the extensor showed marginally significantly faster activation (p = 0.66) while it showed faster de-activation (p = 0.038), in comparison to activation and de-activation of the flexor during flexion. But movement smoothness was not affected by those factors. Our results imply that the cortical source and neural pathway for the extensors of the MCP joints are not coupled with those for the flexors of the MCP joints.

Physiotherapy Efficiency in Post-stroke Upper Extremity Spasticity: TENS vs. Ultrasound vs. Paraffin

BACKGROUND/AIM

Post-stroke spasticity is a significant debilitating condition with negative consequences on individual functional independence and quality of life. This study aimed to identify the differences between transcutaneous electrical stimulation (TENS), ultrasound therapy and paraffin procedures on post-stroke upper extremity spasticity and dexterity.

PATIENTS AND METHODS

Twenty-six patients were enrolled in the study, divided into three therapy groups: TENS (n=9), paraffin (n=10) and ultrasound therapy (n=7). For 10 days, the patients received specific group therapy and conventional physical therapy exercises for upper extremities. Modified Ashworth Scale, Functional Independence Measure, Functional Coefficient, Stroke Specific Quality of Life Scale, Activities of Daily Living score and ABILHAND questionnaire were used to assess the participants before and after therapy.

RESULTS

The results of the group comparisons by analysis of variance showed no significant difference between outcomes by the applied treatments. In contrast, one-way analysis of variance suggested significant improvements in patients in all three groups after therapy. Step-wise regression results on functional independence measure and quality-of-life scales suggested that functional range of motion values for elbow and wrist influence individual independence and quality of life.

CONCLUSION

TENS, ultrasound, and paraffin therapy bring equal benefits in the management of post-stroke spasticity.

Prevalence and clinical predictors of spasticity after intracerebral hemorrhage

BACKGROUND

Spasticity is a common complication of intracerebral hemorrhage (ICH). However, no consensus exists on the relation between spasticity and initial clinical findings after ICH.

METHODS

This retrospective study enrolled adult patients with a history of ICH between January 2012 and October 2020. The modified Ashworth scale was used to assess spasticity. A trained image analyst traced all ICH lesions. Multivariable logistic regression was used to examine the association between ICH lesion sites and spasticity.

RESULTS

We finally analyzed 304 patients (mean age 54.86 ± 12.93 years; 72.04% men). The incidence of spasticity in patients with ICH was 30.92%. Higher National Institutes of Health stroke scale (NIHSS) scores were associated with an increased predicted probability for spasticity (odds ratio, OR = 1.153 [95% confidence interval, CI 1.093-1.216], p < .001). Logistic regression analysis revealed that lower age, higher NIHSS scores, and drinking were associated with an increased risk of moderate-to-severe spasticity (OR = 0.965 [95% CI 0.939-0.992], p = .013; OR = 1.068 [95% CI 1.008-1.130], p = .025; OR = 4.809 [95% CI 1.671-13.840], p = .004, respectively). However, smoking and ICH in the thalamus were associated with a reduced risk of moderate-to-severe spasticity (OR = 0.200 [95% CI 0.071-0.563], p = .002; OR = 0.405 [95% CI 0.140-1.174], p = .046, respectively) compared with ICH in the basal ganglia.

CONCLUSIONS

Our results suggest that ICH lesion locations are at least partly associated with post-stroke spasticity rather than the latter simply being a physiological reaction to ICH itself. The predictors for spasticity after ICH were age, NIHSS scores, past medical history, and ICH lesion sites.

Knowledge, attitude, and practice regarding stroke potential complications among stroke survivors' family members in Shiraz, Iran

Objectives

This study aimed to evaluate stroke survivors' family members' knowledge, attitude, and practice about these sequelae.

Patients and methods

In this cross-sectional survey, 105 family members (57 males, 48 females; mean age: 48.3±9.7 years; range 18 to 60 years) of stroke survivors were examined via a self-structured questionnaire between September 2019 and January 2020. Patients' medical characteristics, as well as participants' sociodemographic and opinions regarding studying variables, were surveyed.

Results

The participants were mostly married and had relatively high scores in knowledge, attitude, and practice questionnaires. We found a significant correlation between participants' knowledge and practice. Moreover, data analysis revealed significantly higher knowledge scores in the employed participants and higher practice scores in the urban population. Furthermore, the relationship of patients with their family members can affect their attitude toward stroke complications.

Conclusion

This study has revealed that caregivers in rural areas with lower education levels are less knowledgeable about potential stroke complications, and subsequently, the patients are more vulnerable to those sequelae. Stakeholders should consider these groups their priorities in education and empowerment processes for stroke survivors' caregivers.

Isoform selectivities of novel 4-hydroxycoumarin imines as inhibitors of myosin II

Muscle myosin inhibition could be used to treat many medical conditions involving hypercontractile states, including muscle spasticity, chronic musculoskeletal pain, and hypertrophic cardiomyopathy. A series of 13 advanced analogs of 3-(N-butylethanimidoyl)ethyl)-4-hydroxy-2H-chromen-2-one (BHC) were synthesized to explore extended imine nitrogen side chains and compare aldimines vs. ketimines. None of the new analogs inhibit nonmuscle myosin in a cytokinesis assay. ATPase structure-activity relationships reveal that selectivity for cardiac vs. skeletal myosin can be tuned with subtle structural changes. None of the compounds inhibited smooth muscle myosin II. Docking the compounds to homology models of cardiac and skeletal myosin II gave rationales for the effects of side arm length on inhibition selectivity and for cardiac vs. skeletal myosin. Properties including solubility, stability and toxicity, suggest that certain BHC analogs may be useful as candidates for preclinical studies or as lead compounds for advanced candidates for drugs with cardiac or skeletal muscle myosin selectivity.

Fine-grained brain tissue segmentation for brain modeling of stroke patient

Brain segmentation of stroke patients can facilitate brain modeling for electrical non-invasive brain stimulation, a therapy for stimulating brain function using an electric current. However, it remains challenging owing to its time-consuming, labor-dependent, and complicated pipeline. In addition, conventional tools that define lesions into one region rather than distinguishing between the stroke-affected regions and cerebrospinal fluid can lead to inaccurate treatment results. In this study, we first define a novel stroke-affected region as a detailed sub-region of the conventionally defined lesion. Subsequently, a novel comprehensive framework is proposed to segment head-brain and fine-level stroke-affected regions for normal controls and chronic stroke patients. The proposed framework consists of a time-efficient and precise deep learning-based segmentation model. The experiment results indicate that the proposed method perform better than the conventional deep learning-based segmentation model in terms of the evaluation metrics. The proposed method would be a valuable addition to brain modeling for non-invasive neuromodulation.

Synergic Effect of Robot-Assisted Rehabilitation and Antispasticity Therapy: A Narrative Review

BACKGROUND

Stroke and spinal cord injury are neurological disorders that cause disability and exert tremendous social and economic effects. Robot-assisted training (RAT), which may reduce spasticity, is widely applied in neurorehabilitation. The combined effects of RAT and antispasticity therapies, such as botulinum toxin A injection therapy, on functional recovery remain unclear. This review evaluated the effects of combined therapy on functional recovery and spasticity reduction.

MATERIALS AND METHODS

Studies evaluating the efficacy of RAT and antispasticity therapy in promoting functional recovery and reducing spasticity were systemically reviewed. Five randomized controlled trials (RCTs) were included. The modified Jadad scale was applied for quality assessment. Functional assessments, such as the Berg Balance Scale, were used to measure the primary outcome. Spasticity assessments, such as the modified Ashworth Scale, were used to measure the secondary outcome.

RESULTS

Combined therapy improves functional recovery in the lower limbs but does not reduce spasticity in the upper or lower limbs.

CONCLUSIONS

The evidence supports that combined therapy improves lower limb function but does not reduce spasticity. The considerable risk of bias among the included studies and the enrolled patients who did not receive interventions within the golden period of intervention are two major factors that should be considered when interpreting these results. Additional high-quality RCTs are required.

Malnutrition on admission is associated with trunk function recovery but not with lower limb muscle strength recovery in patients with acute stroke: an observational cohort study

OBJECTIVES

The aim of this study was to determine the effects of malnutrition on trunk function and lower leg muscle strength in patients with acute stroke upon hospitalization.

METHODS

This prospective cohort study included hospitalized patients with acute stroke. Nutritional status was assessed using the Global Leadership Initiative on Malnutrition criteria. Trunk function and lower leg muscle strength were assessed using the trunk control test (TCT) and Motricity Index (MI), respectively, on admission and at discharge. Logistic regression analysis was performed to examine the relationship between malnutrition and poor improvement in TCT and MI scores at discharge.

RESULTS

Patients (N = 241) with acute stroke (median age 79 y) were included in this study. In adjusted logistic regression analysis, malnutrition was independently associated with poor TCT score improvement (adjusted odds ratio, 3.82; 95% confidence interval, 1.11-13.20; P = 0.03). In contrast, malnutrition was not independently associated with poor MI score improvement (adjusted odds ratio, 0.86; 95% confidence interval, 0.30-2.52; P = 0.79).

CONCLUSION

Malnutrition on admission leads to poor trunk function, but not lower leg muscle strength, in patients with acute stroke.

Translation of the Fugl-Meyer assessment into Romanian: Transcultural and semantic-linguistic adaptations and clinical validation

Purpose

The Fugl-Meyer Assessment (FMA) scale, which is widely used and highly recommended, is an appropriate tool for evaluating poststroke sensorimotor and other possible somatic deficits. It is also well-suited for capturing a dynamic rehabilitation process. The aim of this study was to first translate the entire sensorimotor FMA scale into Romanian using the transcultural and semantic-linguistic adaptations of its official afferent protocols and to then validate it using the preliminary clinical evaluation of inter- and intra-rater reliability and relevant concurrent validity.

Methods

Through three main steps, we completed a standardized procedure for translating FMA's official afferent evaluation protocols into Romanian and their transcultural and semantic-linguistic adaptation for both the upper and lower extremities. For relevant clinical validation, we evaluated 10 patients after a stroke two times: on days 1 and 2. All patients were evaluated simultaneously by two kinesi-physiotherapists (generically referred to as KFT1 and KFT2) over the course of 2 consecutive days, taking turns in the roles of an examiner and observer, and vice versa (inter-rater). Two scores were therefore obtained and compared for the same patient, i.e., being afferent to an inter-rater assay by comparing the assessment outcomes obtained by the two kinesi-physiotherapists, in between, and respectively, to the intra-rater assay: based on the evaluations of the same kinesi-physiotherapist, in two consecutive days, using a rank-based method (Svensson) for statistical analysis. We also compared our final Romanian version of FMA's official protocols for concurrent validity (Spearman's rank correlation statistical method) to both of the widely available assessment instruments: the Barthel Index (BI) and the modified Rankin scale (mRS).

Results

Svensson's method confirmed overall good inter- and intra-rater results for the main parts of the final Romanian version of FMA's evaluation protocols, regarding the percentage of agreement (≥80% on average) and for disagreement: relative position [RP; values outside the interval of (-0.1, 0.1) in only two measurements out of the 56 comparisons we did], relative concentration [RC; values outside the interval of (-0.1, 0.1) in only nine measurements out of the same 56 comparisons done], and relative rank variation [RV; all values within an interval of (0, 0.1) in only five measurements out of the 56 comparisons done]. High correlation values were obtained between the final Romanian version of FMA's evaluation protocols and the BI (ρ = 0.9167; p = 0.0002) for FMA-upper extremity (FMA-UE) total A-D (motor function) with ρ = 0.6319 and for FMA-lower extremity (FMA-LE) total E-F (motor function) with p = 0.0499, and close to the limit, with the mRS (ρ = -0.5937; p = 0.0704) for FMA-UE total A-D (motor function) and (ρ = -0.6615; p = 0.0372) for FMA-LE total E-F (motor function).

Conclusions

The final Romanian version of FMA's official evaluation protocols showed good preliminary reliability and validity, which could be thus recommended for use and expected to help improve the standardization of this assessment scale for patients after a stroke in Romania. Furthermore, this endeavor could be added to similar international translation and cross-cultural adaptations, thereby facilitating a more appropriate comparison of the evaluation and outcomes in the management of stroke worldwide.

New insights into acupuncture techniques for poststroke spasticity

With the trend of aging population getting more obvious, stroke has already been a major public health problem worldwide. As a main disabling motor impairment after stroke, spasticity has unexpected negative impacts on the quality of life and social participation in patients. Moreover, it brings heavy economic burden to the family and society. Previous researches indicated that abnormality of neural modulation and muscle property corelates with the pathogenesis of poststroke spasticity (PSS). So far, there still lacks golden standardized treatment regimen for PSS; furthermore, certain potential adverse-events of the mainstream therapy, for example, drug-induced generalized muscle weakness or high risk related surgery somehow decrease patient preference and compliance, which brings challenges to disease treatment and follow-up care. As an essential non-pharmacological therapy, acupuncture has long been used for PSS in China and shows favorable effects on improvements of spastic hypertonia and motor function. Notably, previous studies focused mainly on the research of antispastic acupoints. In comparison, few studies lay special stress on the other significant factor impacting on acupuncture efficacy, that is acupuncture technique. Based on current evidences from the clinic and laboratory, we will discuss certain new insights into acupuncture technique, in particular the antispastic needling technique, for PSS management in light of its potential effects on central modulations as well as peripheral adjustments, and attempt to provide some suggestions for future studies with respect to the intervention timing and course, application of acupuncture techniques, acupoint selection, predictive and aggravating factors of PSS, aiming at optimization of antispastic acupuncture regimen and improvement of quality of life in stroke patients. More innovations including rigorous study design, valid objective assessments for spasticity, and related experimental studies are worthy to be expected in the years ahead.

[Experience of using rhythmic transcranial magnetic stimulation, extracorporeal shock wave therapy and botulinotherapy in individual motor recovery programs in patients with spastic paresis of the lower limb]

Walking disorder is one of the most frequent consequences of stroke and traumatic brain injury, occurring in 80% of cases. Spastic paresis of the muscles of the lower extremity is the cause formed in 20-40% of patients within a few weeks after brain damage. In this case, a complex of symptoms occurs: motor deficiency (muscle paresis), increased muscle tone (spasticity), biomechanical changes in muscles, joints and surrounding tissues, contractures. Recovery of walking is a difficult task due to the peculiarities of its organization in the norm. At the same time, changes occurring in the muscles of the lower limb after a stroke, their modular reorganization, the formation of various pathological patterns, violation of the regulation of movements by the central nervous system, rapidly occurring changes in muscles, ligaments, complicate this process. Improving walking is one of the most important priorities of rehabilitation. Already at the second (stationary) stage of rehabilitation, patients have a lack of proper support on the lower limb, which inevitably leads to excessive load on the second limb, a change in the body scheme, incorrect foot placement, violation of the mechanics of walking (moving from heel to toe) due to plantar flexion / turn of the foot, etc. All this makes patients dependent on outside help, and walking unsafe, increases the risk of falls and complications (arthropathy, contracture, etc.). In this regard, it is important to timely diagnose the totality of changes in the lower limb and create optimal comprehensive rehabilitation programs using highly effective treatment methods aimed at reducing the severity of the motor defect, reducing spasticity and preventing complications. The article discusses the place of rhythmic transcranial magnetic stimulation, extracorporeal shock wave therapy and botulinum therapy during rehabilitation in patients with spastic paresis of the lower limb after a stroke. The results of the protocol of clinical approbation «Complex rehabilitation of patients with lower limb spasticity after focal brain damage at the second stage of medical rehabilitation» are presented.

A functional near-infrared spectroscopy study of the effects of video game-based bilateral upper limb training on brain cortical activation and functional connectivity

Video game-based therapies are widely used in rehabilitation. Compared with conventional bilateral upper limb training (CBULT), the effects of video game-based bilateral upper limb training (VGBULT) on brain cortical activation and functional connectivity, still not fully clear. We have developed a VGBULT system, and measured the brain activity of 20 elderly subjects (10 male, mean age = 62.4 ± 5.8) while performing CBULT and VGBULT tasks by using functional near infrared spectroscopy (fNIRS). The results showed that the cerebral cortex of the two groups both showed significant activation (p < 0.05), compared with the baseline; In the VGBLUT group, the activation of motor cortex (MC) and prefrontal cortex (PFC) was stronger, and the functional connectivity between PFC and MC was also enhanced. This study showed that VGBULT is potentially more beneficial for the elderly neural activities and cognitive control, and provides a theoretical basis for future research and development of such rehabilitation products. Moreover, fNIRS is a reliable tool for tracking brain activation in the evaluation of retraining regimens.

Aberrant interhemispheric functional reciprocities of the default mode network and motor network in subcortical ischemic stroke patients with motor impairment: A longitudinal study

Purpose

The purpose of the present study was to explore the longitudinal changes in functional homotopy in the default mode network (DMN) and motor network and its relationships with clinical characteristics in patients with stroke.

Methods

Resting-state functional magnetic resonance imaging was performed in stroke patients with subcortical ischemic lesions and healthy controls. The voxel-mirrored homotopic connectivity (VMHC) method was used to examine the differences in functional homotopy in patients with stroke between the two time points. Support vector machine (SVM) and correlation analyses were also applied to investigate whether the detected significant changes in VMHC were the specific feature in patients with stroke.

Results

The patients with stroke had significantly lower VMHC in the DMN and motor-related regions than the controls, including in the precuneus, parahippocampus, precentral gyrus, supplementary motor area, and middle frontal gyrus. Longitudinal analysis revealed that the impaired VMHC of the superior precuneus showed a significant increase at the second time point, which was no longer significantly different from the controls. Between the two time points, the changes in VMHC in the superior precuneus were significantly correlated with the changes in clinical scores. SVM analysis revealed that the VMHC of the superior precuneus could be used to correctly identify the patients with stroke from the controls with a statistically significant accuracy of 81.25% (P ≤ 0.003).

Conclusions

Our findings indicated that the increased VMHC in the superior precuneus could be regarded as the neuroimaging manifestation of functional recovery. The significant correlation and the discriminative power in classification results might provide novel evidence to understand the neural mechanisms responsible for brain reorganization after stroke.

Immediate and short-term effects of continuous theta burst transcranial magnetic stimulation over contralesional premotor area on post-stroke spasticity in patients with severe hemiplegia: Study protocol for a randomized controlled trial

Background

Post-stroke spasticity is an important complication that greatly affects survivors' functional prognosis and daily activities. Increasing evidence points to aberrant contralesional neuromodulation compensation after brain injury as a possible culprit for increased spasticity in patients with severe stroke. Hyperactivity of the contralesional premotor area (cPMA) was supposed to be highly correlated with this progression. This study aims to demonstrate the immediate and short-term efficacy of continuous theta-burst stimulation (cTBS) targeting cPMA on upper limb spasticity in severe subacute stroke patients.

Methods

This trial is a single-center, prospective, three-group randomized controlled trial. Forty-five eligible patients will be recruited and randomized into three groups: the sham-cTBS group (sham cTBS targeting contralesional PMA), the cTBS-cM1 group (cTBS targeting contralesional M1), and the cTBS-cPMA group (cTBS targeting contralesional PMA). All subjects will undergo comprehensive rehabilitation and the corresponding cTBS interventions once a day, five times a week for 4 weeks. Clinical scales, neurophysiological examinations, and neuroimaging will be used as evaluation tools in this study. As the primary outcome, clinical performance on muscle spasticity of elbow/wrist flexor/extensors and upper-limb motor function will be evaluated with the modified Ashworth scale and the Fugl-Meyer Assessment of Upper Extremity Scale, respectively. These scale scores will be collected at baseline, after 4 weeks of treatment, and at follow-up. The secondary outcomes were neurophysiological examinations and Neuroimaging. In neurophysiological examinations, motor evoked potentials, startle reflex, and H reflexes will be used to assess the excitability of the subject's motor cortex, reticulospinal pathway, and spinal motor neurons, respectively. Results of them will be recorded before and after the first cTBS treatment, at post-intervention (at 4 weeks), and at follow-up (at 8 weeks). Neuroimaging tests with diffusion tensor imaging for all participants will be evaluated at baseline and after the 4-week treatment.

Discussion

Based on the latest research progress on post-stroke spasticity, we innovatively propose a new neuromodulation target for improving post-stroke spasticity via cTBS. We expected that cTBS targeting cPMA would have significant immediate and short-term effects on spasticity and related neural pathways. The effect of cTBS-cPMA may be better than that of cTBS via conventional cM1. The results of our study will provide robust support for the application of cTBS neuromodulation in post-stroke spasticity after a severe stroke.

Clinical trial registration

This trial was registered with chictr.org.cn on June 13, 2022 (protocol version). http://www.chictr.org.cn/showproj.aspx?proj=171759.

Application of Network Analysis to Uncover Variables Contributing to Functional Recovery after Stroke

To estimate network structures to discover the interrelationships among variables and distinguish the difference between networks. Three hundred and forty-eight stroke patients were enrolled in this retrospective study. A network analysis was used to investigate the association between those variables. A Network Comparison Test was performed to compare the correlation of variables between networks. Three hundred and twenty-five connections were identified, and 22 of these differed significantly between the high- and low-Functional Independence Measurement (FIM) groups. In the high-FIM network structure, brain-derived neurotrophic factor (BDNF) and length of stay (LOS) had associations with other nodes. However, there was no association with BDNF and LOS in the low-FIM network. In addition, the use of amantadine was associated with shorter LOS and lower FIM motor subscores in the high-FIM network, but there was no such connection in the low-FIM network. Centrality indices revealed that amantadine use had high centrality with others in the high-FIM network but not the low-FIM network. Coronary artery disease (CAD) had high centrality in the low-FIM network structure but not the high-FIM network. Network analysis revealed a new correlation of variables associated with stroke recovery. This approach might be a promising method to facilitate the discovery of novel factors important for stroke recovery.

[Clinical practice guideline for the treatment of spasticity: Consensus and algorithms]

Spasticity is a complex phenomenon of extremely variable clinical expression, a dynamic and evolutionary process that can condition the activity and treatment of the patient. The current recommendation for early treatment aims to avoid progression and complications, and involves an individualized approach based on a wide range of pharmacological and non-pharmacological measures. This guide results from a forum of expert specialists who faced some frequent uncertainties in the assessment process and therapeutic approach of the spastic patient such as the suitability of initiating treatment, considerations for initiating, continuing and ceasing treatment with botulinum toxin, adjuvant treatments, pain or follow-up. The result is one algorithm of decision for the therapeutic approach of spasticity. Both scientific progress and the exchange of clinical experience on which this guide is based, can support decision-making on some areas of gloom that we find in daily practice.

Hand Rehabilitation Devices: A Comprehensive Systematic Review

A cerebrovascular accident, or a stroke, can cause significant neurological damage, inflicting the patient with loss of motor function in their hands. Standard rehabilitation therapy for the hand increases demands on clinics, creating an avenue for powered hand rehabilitation devices. Hand rehabilitation devices (HRDs) are devices designed to provide the hand with passive, active, and active-assisted rehabilitation therapy; however, HRDs do not have any standards in terms of development or design. Although the categorization of an injury’s severity can guide a patient into seeking proper assistance, rehabilitation devices do not have a set standard to provide a solution from the beginning to the end stages of recovery. In this paper, HRDs are defined and compared by their mechanical designs, actuation mechanisms, control systems, and therapeutic strategies. Furthermore, devices with conducted clinical trials are used to determine the future development of HRDs. After evaluating the abilities of 35 devices, it is inferred that standard characteristics for HRDs should include an exoskeleton design, the incorporation of challenge-based and coaching therapeutic strategies, and the implementation of surface electromyogram signals (sEMG) based control.

Effects of Non-Invasive Brain Stimulation on Post-Stroke Spasticity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

In recent years, the potential of non-invasive brain stimulation (NIBS) for the therapeutic effect of post-stroke spasticity has been explored. There are various NIBS methods depending on the stimulation modality, site and parameters. The purpose of this study is to evaluate the efficacy of NIBS on spasticity in patients after stroke. This systematic review and meta-analysis was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. PUBMED (MEDLINE), Web of Science, Cochrane Library and Excerpta Medica Database (EMBASE) were searched for all randomized controlled trials (RCTs) published before December 2021. Two independent researchers screened relevant articles and extracted data. This meta-analysis included 14 articles, and all included articles included 18 RCT datasets. The results showed that repetitive transcranial magnetic stimulation (rTMS) (MD = −0.40, [95% CI]: −0.56 to −0.25, p < 0.01) had a significant effect on improving spasticity, in which low-frequency rTMS (LF-rTMS) (MD = −0.51, [95% CI]: −0.78 to −0.24, p < 0.01) and stimulation of the unaffected hemisphere (MD = −0.58, [95% CI]: −0.80 to −0.36, p < 0.01) were beneficial on Modified Ashworth Scale (MAS) in patients with post-stroke spasticity. Transcranial direct current stimulation (tDCS) (MD = −0.65, [95% CI]: −1.07 to −0.22, p < 0.01) also had a significant impact on post-stroke rehabilitation, with anodal stimulation (MD = −0.74, [95% CI]: −1.35 to −0.13, p < 0.05) being more effective in improving spasticity in patients. This meta-analysis revealed moderate evidence that NIBS reduces spasticity after stroke and may promote recovery in stroke survivors. Future studies investigating the mechanisms of NIBS in addressing spasticity are warranted to further support the clinical application of NIBS in post-stroke spasticity.

Shared and distinct voxel-based lesion-symptom mappings for spasticity and impaired movement in the hemiparetic upper limb

Hemiparesis and spasticity are common co-occurring manifestations of hemispheric stroke. The relationship between impaired precision and force in voluntary movement (hemiparesis) and the increment in muscle tone that stems from dysregulated activity of the stretch reflex (spasticity) is far from clear. Here we aimed to elucidate whether variation in lesion topography affects hemiparesis and spasticity in a similar or dis-similar manner. Voxel-based lesion-symptom mapping (VLSM) was used to assess the impact of lesion topography on (a) upper limb paresis, as reflected by the Fugl-Meyer Assessment scale for the upper limb and (b) elbow flexor spasticity, as reflected by the Tonic Stretch Reflex Threshold, in 41 patients with first-ever stroke. Hemiparesis and spasticity were affected by damage to peri-Sylvian cortical and subcortical regions and the putamen. Hemiparesis (but not spasticity) was affected by damage to the corticospinal tract at corona-radiata and capsular levels, and by damage to white-matter association tracts and additional regions in the temporal cortex and pallidum. VLSM conjunction analysis showed only a minor overlap of brain voxels where the existence of damage affected both hemiparesis and spasticity, suggesting that control of voluntary movement and regulation of muscle tone at rest involve largely separate parts of the motor network.

Anomalies of motor unit amplitude and territory after botulinum toxin injection

OBJECTIVE

Botulinum toxin (BT) induced cholinergic denervation of hyperactive motor units is a clinically accepted and extensively practiced way of managing focal spasticity after stroke. The denervation potentially initiates a temporary reorganization of the motor unit (MU) structure by inducing the emergence of a large number of newly innervated muscle fibers. In this study, we quantify the effect of the BT on motor unit action potential (MUAP) amplitudes and on the motor unit territory areas (MUTA) as seen on the surface of the skin over the biceps brachii (BB) muscle.

APPROACH

We have used a 128 channel high-density electromyography (HDsEMG) grid on the spastic and contralateral BB muscle and recorded the myoelectric activity along with the contraction force during isometric contraction of elbow muscles. We have decomposed the recorded EMG signal into individual MU potentials and estimated the MUAP amplitudes and territory areas before and two weeks after a BT injection.

MAIN RESULT

We found that there were significantly larger median (47±9%) MUAP amplitudes as well as reduction of MUTA (20±2%) two weeks after the injection compared to the respective pre-injection recording.

SIGNIFICANCE

The observed covariation of the amplitude and the territory area indicates that the large amplitude MUs that appeared after the BT injection have a relatively smaller territory area. We discuss the potential contributing factors to these changes subsequent to the injection in the context of the investigated subject cohort.

Role of the Contra-Lesional Corticoreticular Tract in Motor Recovery of the Paretic Leg in Stroke: A Mini-Narrative Review

This review discusses the role of the contra-lesional corticoreticular tract (CRT) in motor recovery of the paretic leg in stroke patients by reviewing related diffusion tensor tractography studies. These studies suggest that the contra-lesional CRT can contribute to the motor recovery of the paretic leg in stroke patients, particularly in patients with complete injuries of the ipsilesional corticospinal tract and CRT. Furthermore, a review study reported that the motor recovery of the paretic ankle dorsiflexor, which is mandatory for achieving a good gait pattern without braces in hemiparetic stroke patients, was closely related to the contra-lesional CRT. These results could be clinically important in neuro-rehabilitation. For example, the contra-lesional CRT could be a target for neuromodulation therapies in patients with complete injuries of the ipsilesional corticospinal tract and CRT. On the other hand, only three studies were reviewed in this review and one was a case report. Although the CRT has been suggested to be one of the ipsilateral motor pathways from the contra-lesional cerebral cortex to the paretic limbs in stroke, the role of the CRT has not been elucidated clearly. Therefore, further prospective follow-up studies combining functional neuroimaging and transcranial magnetic stimulation for the paretic leg with diffusion tensor tractography will be useful for elucidating the role of the contra-lesional CRT in stroke patients.

Pre- and post-conditioning with poly I:C exerts neuroprotective effect against cerebral ischemia injury in animal models: A systematic review and meta-analysis

BACKGROUND

Toll-like receptor (TLR) agonist polyinosinic-polycytidylic acid (poly I:C) exerts neuroprotective effects against cerebral ischemia (CI), but concrete evidence supporting its exact mechanism of action is unclear.

METHODS

We evaluated the neuroprotective role of poly I:C by assessing CI indicators such as brain infarct volume (BIV), neurological deficit score (N.S.), and signaling pathway proteins. Moreover, we performed a narrative review to illustrate the mechanism of action of TLRs and their role in CI. Our search identified 164 articles and 10 met the inclusion criterion.

RESULTS

Poly I:C reduces BIV and N.S. (p = 0.00 and p = 0.03). Interestingly, both pre- and post-conditioning decrease BIV (preC p = 0.04 and postC p = 0.00) and N.S. (preC p = 0.03 and postC p = 0.00). Furthermore, poly I:C upregulates TLR3 [SMD = 0.64; CIs (0.56, 0.72); p = 0.00], downregulates nuclear factor-κB (NF-κB) [SMD = -1.78; CIs (-2.67, -0.88); p = 0.0)], and tumor necrosis factor alpha (TNF-α) [SMD = -16.83; CIs (-22.63, -11.02); p = 0.00].

CONCLUSION

We showed that poly I:C is neuroprotective and acts via the TLR3/NF-κB/TNF-α pathway. Our review indicated that suppressing TLR 2/4 may illicit neuroprotection against CI. Further research on simultaneous activation of TLR3 with poly I:C and suppression of TLR 2/4 might open new vistas for the development of therapeutics against CI.

Relation Between Sensorimotor Rhythm During Motor Attempt/Imagery and Upper-Limb Motor Impairment in Stroke

Motor attempt (MA)/motor imagery (MI)-based brain-computer interface (BCI) is a newly developing rehabilitation technology for motor impairment. This study aims to explore the relationship between electroencephalography sensorimotor rhythm and motor impairment to provide reference for a BCI design. Twenty-eight stroke survivors with varying levels of motor dysfunction and spasticity status in the subacute or chronic stage were enrolled in the study to perform MA and MI tasks. Event-related desynchronization (ERD)/event-related synchronization (ERS) during and immediately after motor tasks were calculated. The Fugl-Meyer assessment scale (FMA) and the modified Ashworth scale (MAS) were applied to characterize upper-limb motor dysfunction and spasticity. There was a positive correlation between FMA total scores and ERS in the contralesional hemisphere in the MI task (P < .05) and negative correlations between FMA total scores and ERD in both hemispheres in the MA task (P < .05). Negative correlations were found between MAS scores of wrist flexors and ERD in the ipsilesional hemisphere (P < .05) in the MA task. It suggests that motor dysfunction may be more correlated to ERS in the MI task and to ERD in the MA task while spasticity may be more correlated to ERD in the MA task.