Canadian Platform for Trials in Noninvasive Brain Stimulation (CanStim) Consensus Recommendations for Repetitive Transcranial Magnetic Stimulation in Upper Extremity Motor Stroke Rehabilitation Trials

Objective. To develop consensus recommendations for the use of repetitive transcranial magnetic stimulation (rTMS) as an adjunct intervention for upper extremity motor recovery in stroke rehabilitation clinical trials. Participants. The Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim) convened a multidisciplinary team of clinicians and researchers from institutions across Canada to form the CanStim Consensus Expert Working Group. Consensus Process. Four consensus themes were identified: (1) patient population, (2) rehabilitation interventions, (3) outcome measures, and (4) stimulation parameters. Theme leaders conducted comprehensive evidence reviews for each theme, and during a 2-day Consensus Meeting, the Expert Working Group used a weighted dot-voting consensus procedure to achieve consensus on recommendations for the use of rTMS as an adjunct intervention in motor stroke recovery rehabilitation clinical trials. Results. Based on best available evidence, consensus was achieved for recommendations identifying the target poststroke population, rehabilitation intervention, objective and subjective outcomes, and specific rTMS parameters for rehabilitation trials evaluating the efficacy of rTMS as an adjunct therapy for upper extremity motor stroke recovery. Conclusions. The establishment of the CanStim platform and development of these consensus recommendations is a first step toward the translation of noninvasive brain stimulation technologies from the laboratory to clinic to enhance stroke recovery.

Specific Brain Lesions Impair Explicit Motor Imagery Ability: A Systematic Review of the Evidence

OBJECTIVE

To determine which neurologic disorders/lesions impair or restrict motor imagery (MI) ability.

DATA SOURCES

CINAHL, Cochrane, Embase, MEDLINE, Web of Science, PsychINFO, Physiotherapy Evidence Database, and Grey Literature were searched between May 8 and May 14, 2014. Keywords and Medical Subject Headings from 2 concepts (MI and lesion) were exploded to include related search terms (eg, mental practice/mental imagery, neurologic damage/lesion).

STUDY SELECTION

Two independent reviewers assessed the 3861 studies that resulted from the database search. The studies were assessed for relevancy using the following inclusion criteria: use of explicit kinesthetic MI; neurologic lesion location identified; and use of an MI ability assessment tool.

DATA EXTRACTION

Twenty-three studies encompassing 196 participants were included. The 23 studies used 8 different methods for assessing MI ability. MI assessment scores were then normalized to facilitate comparison across studies.

DATA SYNTHESIS

Lesion locations comprised many brain areas, including cortical (eg, parietal and frontal lobes), subcortical (eg, basal ganglia, thalamus), and cerebellum. Lesion etiology primarily was comprised of stroke and Parkinson disease. Several participants presented with lesions resulting from other pathologies. Subjects with parietal lobe damage were most impaired on their ability to perform MI. Subjects with frontal lobe and basal ganglia damage also consistently showed impairment in MI ability.

CONCLUSIONS

Subjects with damage to specific brain structures, including the parietal and frontal lobes, showed impaired MI ability. As such, MI-based neurorehabilitation may not be efficacious in all patient populations. Therefore, decisions related to the use of MI in neurorehabilitation should, in part, be based on the patient's underlying pathophysiology.

Head movement compensation in real-time magnetoencephalographic recordings

Neurofeedback- and brain-computer interface (BCI)-based interventions can be implemented using real-time analysis of magnetoencephalographic (MEG) recordings. Head movement during MEG recordings, however, can lead to inaccurate estimates of brain activity, reducing the efficacy of the intervention. Most real-time applications in MEG have utilized analyses that do not correct for head movement. Effective means of correcting for head movement are needed to optimize the use of MEG in such applications. Here we provide preliminary validation of a novel analysis technique, real-time source estimation (rtSE), that measures head movement and generates corrected current source time course estimates in real-time. rtSE was applied while recording a calibrated phantom to determine phantom position localization accuracy and source amplitude estimation accuracy under stationary and moving conditions. Results were compared to off-line analysis methods to assess validity of the rtSE technique. The rtSE method allowed for accurate estimation of current source activity at the source-level in real-time, and accounted for movement of the source due to changes in phantom position. The rtSE technique requires modifications and specialized analysis of the following MEG work flow steps.•Data acquisition•Head position estimation•Source localization•Real-time source estimation This work explains the technical details and validates each of these steps.

Laterality of brain activity during motor imagery is modulated by the provision of source level neurofeedback

Motor imagery (MI) may be effective as an adjunct to physical practice for motor skill acquisition. For example, MI is emerging as an effective treatment in stroke neurorehabilitation. As in physical practice, the repetitive activation of neural pathways during MI can drive short- and long-term brain changes that underlie functional recovery. However, the lack of feedback about MI performance may be a factor limiting its effectiveness. The provision of feedback about MI-related brain activity may overcome this limitation by providing the opportunity for individuals to monitor their own performance of this endogenous process. We completed a controlled study to isolate neurofeedback as the factor driving changes in MI-related brain activity across repeated sessions. Eighteen healthy participants took part in 3 sessions comprised of both actual and imagined performance of a button press task. During MI, participants in the neurofeedback group received source level feedback based on activity from the left and right sensorimotor cortex obtained using magnetoencephalography. Participants in the control group received no neurofeedback. MI-related brain activity increased in the sensorimotor cortex contralateral to the imagined movement across sessions in the neurofeedback group, but not in controls. Task performance improved across sessions but did not differ between groups. Our results indicate that the provision of neurofeedback during MI allows healthy individuals to modulate regional brain activity. This finding has the potential to improve the effectiveness of MI as a tool in neurorehabilitation.

Examining the use of constraint-induced movement therapy in canadian neurological occupational and physical therapy

PURPOSE

To investigate the use of constraint-induced movement therapy (CIMT) in Canadian neurological occupational and physical therapy.

METHOD

An online survey was completed by occupational and physical therapists practising in Canadian adult neurological rehabilitation. We measured participants' practices, perceptions, and opinions in relation to their use of CIMT in clinical practice.

RESULTS

A total of 338 surveys were returned for a 13% response rate; 92% of respondents knew of CIMT, and 43% reported using it. The majority (88%) of respondents using CIMT employed a non-traditional protocol. Self-rating of level of CIMT knowledge was found to be a significant predictor of CIMT use (p≤0.001). Commonly identified barriers to use included "patients having cognitive challenges that prohibit use of this treatment" and "lack of knowledge regarding treatment."

CONCLUSIONS

Although the majority of respondents knew about CIMT, less than half reported using it. Barriers to CIMT use include lack of knowledge about the treatment and institutional resources to support its use. Identifying and addressing barriers to CIMT use-for example, by using continuing professional education to remediate knowledge gaps or developing new protocols that require fewer institutional resources-can help improve the feasibility of CIMT, and thus promote its clinical application.

What are the "ingredients" of modified constraint-induced therapy? An evidence-based review, recipe, and recommendations

Modified constraint induced movement therapy (mCIT) increases paretic upper extremity use and movement in all phases of stroke. Although fundamental to its appropriate implementation, specific details on day to day implementation on this promising family of therapies have not heretofore been published. Consequently, some integral behavioral facets of mCIT may be overlooked, while other approaches may be easily mistaken to constitute mCIT, during attempts to implement the therapy. The purpose of this paper is to review mCIT, and to provide the clinician-reader with a detailed description of the "ingredients" of mCIT and their rationale, including clinical examples of these components. It is expected that a more complete understanding of the components comprising this promising approach will overcome knowledge barriers associated with its appropriate use, and encourage better patient management in clinical practice.

State-related changes in MEG functional connectivity reveal the task-positive sensorimotor network

Functional connectivity measures applied to magnetoencephalography (MEG) data have the capacity to elucidate neuronal networks. However, the task-related modulation of these measures is essential to identifying the functional relevance of the identified network. In this study, we provide evidence for the efficacy of measuring "state-related" (i.e., task vs. rest) changes in MEG functional connectivity for revealing a sensorimotor network. We investigate changes in functional connectivity, measured as cortico-cortical coherence (CCC), between rest blocks and the performance of a visually directed motor task in a healthy cohort. Task-positive changes in CCC were interpreted in the context of any concomitant modulations in spectral power. Task-related increases in whole-head CCC relative to the resting state were identified between areas established as part of the sensorimotor network as well as frontal eye fields and prefrontal cortices, predominantly in the beta and gamma frequency bands. This study provides evidence for the use of MEG to identify task-specific functionally connected sensorimotor networks in a non-invasive, patient friendly manner.

Ultrasound for diagnosis of scaphoid fractures

We investigated the diagnostic value of two different ultrasound scanning methods for the early diagnosis of acute scaphoid fractures. Fifty-seven patients with ten scaphoid fractures were assessed within a week of injury. The accuracy of the ultrasound assessment was 84% and its specificity was 91%. However, its sensitivity was only 50%. We conclude that ultrasound examination is unreliable for the diagnosis of acute scaphoid fractures.

Idiopathic avascular necrosis of the scaphoid. Case report

A 30 year old woman presented with pain in her right wrist a year after operation for de Quervain's tenosynovitis. Magnetic resonance imaging showed avascular necrosis of the scaphoid without loss of volume. She was instructed to wear a brace on her wrist while working. A year later she was free of symptoms but the scan was unchanged. Avascular necrosis of the scaphoid not associated with injury is extremely rare.

Combination of rupture of the ulnar collateral ligament and spiroid fracture of the thumb. Case report

A combination of rupture of the ulnar collateral ligament in the first metacarpophalangeal joint and a concomitant spiroid fracture of the proximal phalanx in the thumb is described. Suture of the ligament was performed ten weeks posttraumatically, and a good result was achieved.

The pathological plica in the knee. Results after arthroscopic resection

Fifty-three consecutive patients were treated for a symptomatic plica mediopatellaris of the knee joint with arthroscopic resection of the plica. Forty-six patients were followed up 43 months after the operation. Preoperatively, 40% of the patients had anterior knee pain on exertion, and 60% had mechanical symptoms. The symptoms were preceded by a knee trauma in 50% of the patients. The overall results after arthroscopic resection were satisfying, with 80% excellent or good results according to the Lysholm score, and 59% of the patients were completely free of symptoms. The presence of chondromalacia of the patella or femoral condyles or malalignment of the patella did not worsen the results. It is concluded that arthroscopic resection of a pathological plica mediopatellaris generally gives good results, even if other pathology of the knee joint is present.

Subungual keratoacanthoma. Case report

A case of subungual keratoacanthoma in a 64-year-old man with psoriasis is described. Important differential diagnoses are squamous cell carcinoma and epidermoid cyst. The treatment recommended is local removal. Follow up should be prolonged, as recurrence has been reported more than two years after primary operation.

Arthroscopic determination of patellofemoral malalignment

Patellofemoral alignment was determinant by arthroscopy according to the degree of knee flexion at which the lateral facet, the patellar ridge, and the medial facet of the patella gained contact with the femur. The intraarticular pressure was 75 mm Hg. In 17 patients with a normal patellofemoral joint, the lateral facet aligned at a mean knee flexion of 20 degrees, the patellar ridge at 35 degrees, and the medial facet at 50 degrees. Twelve patients with patellar subluxation showed no difference in the alignment of the lateral facet, but differed significantly with regard to alignment of both the ridge and the medial facet with contact at a mean flexion of 55 degrees and 85 degrees, respectively. The median measurements in 20 patients with idiopathic anterior knee pain did not deviate significantly from the normal material. However, the dispersion was increased significantly, with eight patients having increased measurements consistent with malalignment and three having decreased measurements below the lower limit of normal alignment. Patients with idiopathic anterior knee pain apparently can be reclassified according to the arthroscopically determined alignment, which may prove important in the treatment of these patients.

Synovial hemangioma of the knee joint--a case report

At arthroscopy, a 22-year-old woman with repeated spontaneous hemarthrosis of the knee was found to have a synovial hemangioma, which was removed by arthrotomy. In cases of spontaneous hemarthrosis without abnormal bleeding tendency, arthroscopy is recommended to identify and, if possible, treat the cause of bleeding, as repeated bleedings may damage the joint.

Arthroscopy of the ankle joint

The technique and results of 11 arthroscopies of the ankle joint are presented. The main indications were post-traumatic pain and osteochondritis dissecans of the talus. As a result of arthroscopy, a radionegative loose body was found, exploratory arthrotomy was avoided in one case, incisions and operative procedures were changed, and loose bodies were removed by arthroscopic operation in one case.

Arthroscopy in children, with special emphasis on meniscal lesions

Seventy-six children under 16 years of age (mean age 14.5) underwent diagnostic arthroscopy of the knee. Seventeen were examined under local anaesthesia as outpatients. The referring doctors suspected a meniscal lesion in 25 cases, but in only 6 of these was the diagnosis confirmed. The surgeon's diagnosis was verified in 9 out of 31 cases; unsuspected lesions of both menisci in one knee make a total of 10 patients with meniscal lesions (10 knees, 11 menisci). The most frequent lesion found was rupture of the anterior cruciate ligament (12). Because of the arthroscopy, three minor meniscal lesions could be observed without treatment, and no menisci were totally removed. In two cases an arthrotomy would have been done on the wrong side of the knee if the operation had not been preceded by arthroscopy. Fifteen arthroscopic operations were done but only three for meniscal lesions.

Arthroscopy of the elbow. Diagnosis and extraction of loose bodies

Arthroscopy of the elbow was performed in 35 cases of suspected loose bodies. Loose bodies were found in 13 cases. Preoperative radiographs were falsely negative in two cases and falsely positive in 12. In ten cases arthroscopic removal was attempted; it succeeded in six cases. When no loose bodies were found, the most common diagnosis was degenerative joint disease. Arthroscopy is recommended for diagnosis and treatment of loose bodies in the elbow joint.

Glued periosteal grafts in the knee

Periosteal grafting was performed in 4 patients with osteochondritis dissecans of the medial femoral condyle and 1 patient with osteonecrosis of the lateral femoral condyle following prednisone therapy. The lesions were drilled out deep into the cancellous bone. The periosteal graft was taken from the medial facet of the tibia and fixed to the excavated bony defect by the tissue glue Fibrinkleber Human Immuno (Tisseel). The patients were followed clinically, by arthroscopic examination and by radiography at 3, 6, and 12 months. After 1 year the borderline between the new and surrounding cartilage was hardly visible.

Nifedipine cardioplegia experience: results of a 3-year cooperative clinical study

Previous animal studies and a preliminary clinical trial of the addition of nifedipine to cardioplegic solution demonstrated salutary effects in terms of postischemic performance. This report examines the combined results of extended clinical trials conducted in two centers: Barnes Hospital, St. Louis, and Allegheny General Hospital, Pittsburgh. From an open-heart population of 4,777 patients, 205 highest-risk persons were selected for study. One hundred seventy of them were given nifedipine in cardioplegic solution. The remaining 35 served as controls to compare with 39 treated patients in the randomized subset of 74. Thirty-eight percent were women; the average age was 61 +/- 1 year; and most were in New York Heart Association Class IV. One-third had valve replacement, one-quarter had coronary artery bypass grafting (CABG), and 37% had valve, CABG, and other procedures in combination. Characteristically, these patients had a 50% increase in end-diastolic volumes, low cardiac indexes (1.7 +/- 1 L/min/m2), and low left ventricular stroke work indexes (22 +/- 2 gm-m/m2). Average cross-clamp time was 77 minutes. At Allegheny, an extracellular hyperkalemic solution was used to deliver an average dose of 407 +/- 22 micrograms per patient. At Barnes, a low-sodium hyperkalemic solution was used; the average dose was 476 +/- 22 micrograms. The results of hemodynamic studies in the randomized subset demonstrated approximately a twofold greater improvement in the treated group in cardiac index, stroke volume, left ventricular stroke work index, and pulmonary vascular resistance immediately after bypass. The incidence of acute low cardiac output death was 4% versus 11% in the nontreated group. The hospital survivorship for all treated patients was 84%. It is concluded that the addition of a calcium antagonist, nifedipine, reduced the incidence of acute global cardiac failure in the immediate postoperative interval.

Total condylar prosthesis placement in knee arthroplasty. Biomechanic analysis of human knee preparations

Knee replacement using the Total Condylar Prosthesis was carried out on six large cadaveric knees. Tibiofemoral articulation was studied radiographically with the tibial component placed anteriorly as well as posteriorly on the tibial plateau. It is concluded that, in this model, when using the Total Condylar Prosthesis for big-sized knees, a tall, posteriorly placed tibial component gave the best placement of the femoral component and the most central tibio-femoral articulation, entailing optimal distribution of the load on the trabecular bone beneath the tibial component.

Deltoid ligament. Functional analysis of the medial collateral ligamentous apparatus of the ankle joint

On 34 osteoligamentous ankle preparations the function of the various components of the deltoid ligament has been elucidated by tracing mobility patterns after successive transection of the components in varying sequence. The anterior and posterior talofibular ligaments were included in the study to investigate the interaction between these structures and the deltoid ligament. The tibiocalcaneal and the intermediate tibiotalar ligaments control abduction of the talus. The anterior tibiotalar and talofibular ligaments control plantar flexion, while dorsiflexion is inhibited by the posterior tibiotalar and talofibular ligaments, and partly by the anterior talofibular ligament as well. In combination, the anterior and intermediate tibiotalar ligaments control external rotation, while the intermediate and posterior tibiotalar ligaments control both external and, together with the anterior talofibular ligament, internal rotation of the talus. Isolated, neither the anterior nor the posterior tibiotalar ligament appears to play any major role in ankle stability.

Distal tibiofibular ligaments. Analysis of function

The function of the anterior tibiofibular ligament, of the syndesmosis between the distal parts of the tibia and fibula, and of the posterior tibiofibular ligament was elucidated by tracing mobility patterns before and after successive ligament transection in varying sequence. Eighteen osteoligamentous preparations were studied. Mobility was only minimally influenced by isolated cutting of the anterior tibiofibular ligament, and even complete cutting of the distal tibiofibular ligaments involved only minor abnormality in motion. However, external rotation was greatly increased by further cutting of the anterior part of the deltoid ligament or of the posterior talofibular ligament. This indicates that isolated injury of the anterior tibiofibular ligament must be rare, and total rupture of the distal tibiofibular structures is presumably as a rule combined with lesions of the anterior part of the deltoid ligament and/or of the posterior talofibular ligament.

Burkitt's lymphoma mimicking prostatitis

We report on a 24-year-old man who had symptoms suggestive of acute pancreatitis but the diagnosis was Burkitt's lymphoma infiltrating the prostate. He was treated with cytotoxic drugs with a good initial response. Voiding improved and the tumor had disappeared completely on rectal palpation. However, the patient suffered a relapse and, despite intensive chemotherapy, he died a few months later with disseminated tumor infiltration.

Brachymesophalangy and loose bodies in the metacarpophalangeal joints

A family with autosomal inherited brachymesophalangy is presented. Some of the family members also had loose bodies in the metacarpophalangeal joints. This condition is similar to osteochondritis in other joints. New loose bodies may be formed after operative removal and arthrotic changes may occur. The patients were not able to perform hard physical work with their hands.

The neurovascular island pedicle flap

Nine patients with irreparable damage to the nerves of the thumb, treated with a neurovascular island pedicle flap from the third or fourth finger to the defect thumb, have been re-examined 9 months to 8 years after the operation. Eight patients had a 2-point discrimination of less than 15 mm corresponding to the flap and all had a positive Ninhydrin test. Two had complete cortical reorientation and three partial reorientation. Six found the function of the thumb to be good or fair. Three described the result as poor and three had to be reoperated because of contractures of the donor finger and/or thumb. The method can be recommended for use in young, well motivated patients.

Dislocation of the trapezium (multangulum majus). A case report

A case of complete, closed dislocation of the trapezium is reported. The treatment was open reposition and fixation with two Kirschner wires. No avascular necrosis occurred. Two and a half years after the injury there were no subjective complaints, the mobility and strength of the thumb were normal and there were no radiological signs of arthrosis.