Feasibility of single and combined with other treatments using transcranial direct current stimulation for chronic stroke: A pilot study

Objectives

This pilot study aimed to investigate the safety and efficacy of transcranial direct current stimulation (tDCS) for chronic stroke in adult and pediatric patients. We also aimed to verify the efficacy of botulinum toxin A and peripheral neuromuscular electrical stimulation combined therapy involving bilateral tDCS in adult patients with chronic stroke.

Methods

We conducted a pilot study applying an unblinded, non-randomized design. Eleven patients were recruited, and classified into three groups. Group I-a involved bilateral transcranial direct current stimulation and intensive occupational therapy for chronic stroke in adult patients. Group I-b involved bilateral tDCS and intensive occupational therapy for chronic stroke in pediatric patients. Group II involved bilateral tDCS, peripheral neuromuscular electrical stimulation, and intensive occupational therapy after botulinum toxin A injection for chronic stroke in adult patients. Clinical evaluations to assess motor function and spasticity were performed at baseline as well as in 2-week and 4-month follow-up visits. The questionnaire included questions regarding the presence of tDCS side effects, such as headache, redness, pain, itching, and fever.

Results

There were clinically meaningful changes in total Fugl-Meyer Assessment Upper Extremity (FMA-UE) scores at the 2-week follow-up and in the Action Research Arm Test (ARAT) scores at 4-month follow-up in Group I-b. In addition, Group II showed significant improvement in total FMA-UE scores in the 2-week follow-up (p < 0.05) but not on the ARAT scores (p > 0.05). However, Group II showed improvements in total Motor Activity Log scores at both follow-up visits (p < 0.05). No serious adverse events were reported.

Conclusion

The results of this study indicate that tDCS therapy is a potential treatment in pediatric patients with chronic stroke. Furthermore, our data indicate that botulinum toxin A and peripheral neuromuscular electrical stimulation combined therapy may enhance the efficacy of tDCS on motor function.

Feasibility of Robot-assisted Rehabilitation in Poststroke Recovery of Upper Limb Function Depending on the Severity

The single-joint Hybrid Assistive Limb (HAL-SJ) robot is an exoskeleton-type suit developed for the neurorehabilitation of upper limb function. Several studies have addressed the usefulness of the robot; however, the appropriate patient selection remains unclear. In this study, we evaluated the effectiveness of the HAL-SJ exoskeleton in improving upper limb function in the subacute phase after a stroke, as a function of the severity of arm paralysis. Our analysis was based on a retrospective review of 35 patients, treated using the HAL-SJ exoskeleton in the subacute phase after their stroke, between October 2014 and December 2018. The severity of upper limb impairment was quantified using the Brunnstrom recovery stage (BRS) as follows: severe, BRS score 1–2, n = 10; moderate, BRS 3–4, n = 12; and mild, BRS 5–6, n = 13. The primary endpoint was the improvement in upper limb function, from baseline to post-intervention, measured using the Fugl-Meyer assessment upper limb motor score (ΔFMA-UE; range 0–66). The ΔFMA-UE score was significant for all three severity groups (P <0.05). The magnitude of improvement was greater in the moderate group than in the mild group (P <0.05). The greatest improvement was attained for patients with a moderate level of upper limb impairment at baseline. Our findings support the feasibility of the HAL-SJ to improve upper limb function in the subacute phase after a stroke with appropriate patient selection. This study is the first report showing the effect of robot-assisted rehabilitation using the HAL-SJ, according to the severity of paralysis in acute stroke patients with upper extremity motor deficits.

Biofeedback effect of hybrid assistive limb in stroke rehabilitation: A proof of concept study using functional near infrared spectroscopy

Introduction

Robot-assisted rehabilitation has been increasingly drawing attention in the field of neurorehabilitation. The hybrid assistive limb (HAL) is an exoskeleton robot developed based on the “interactive biofeedback” theory, and several studies have shown its efficacy for patients with stroke. We aimed to investigate the mechanisms of the facilitative effect of neurorehabilitation using a single-joint HAL (HAL-SJ) and functional near-infrared spectroscopy (fNIRS).

Materials and methods

Subacute stroke patients admitted to our hospital were assessed in this study for HAL eligibility. We evaluated motor-related cortical activity using an fNIRS system at baseline and immediately after HAL-SJ treatment on the same day. Cortical activity was determined through the relative changes in the hemoglobin concentrations. For statistical analysis, we compared the number of flexion/extension movements before and immediately after HAL-SJ treatment using paired t-test. fNIRS used both the methods of statistical parametric mapping and random effect analysis.

Results

We finally included 10 patients (eight men, two women; mean age: 66.8 ± 12.0 years). The mean number of flexion/extension movements within 15 s increased significantly from 4.2 ± 3.1 to 5.3 ± 4.1 immediately after training. fNIRS showed increased cortical activation in the primary motor cortex of the ipsilesional hemisphere immediately after HAL-SJ treatment compared to the baseline condition.

Conclusions

This study is the first to support the concept of the biofeedback effect from the perspective of changes in cortical activity measured with an fNIRS system. The biofeedback effect of HAL immediately increased the task-related cortical activity, and this may address the functional recovery. Further studies are warranted to support our findings.

Tailor-made rehabilitation approach using multiple types of hybrid assistive limb robots for acute stroke patients: A pilot study

This article investigated the feasibility of a tailor-made neurorehabilitation approach using multiple types of hybrid assistive limb (HAL) robots for acute stroke patients. We investigated the clinical outcomes of patients who underwent rehabilitation using the HAL robots. The Brunnstrom stage, Barthel index (BI), and functional independence measure (FIM) were evaluated at baseline and when patients were transferred to a rehabilitation facility. Scores were compared between the multiple-robot rehabilitation and single-robot rehabilitation groups. Nine hemiplegic acute stroke patients (five men and four women; mean age 59.4 ± 12.5 years; four hemorrhagic stroke and five ischemic stroke) underwent rehabilitation using multiple types of HAL robots for 19.4 ± 12.5 days, and 14 patients (six men and eight women; mean age 63.2 ± 13.9 years; nine hemorrhagic stroke and five ischemic stroke) underwent rehabilitation using a single type of HAL robot for 14.9 ± 8.9 days. The multiple-robot rehabilitation group showed significantly better outcomes in the Brunnstrom stage of the upper extremity, BI, and FIM scores. To the best of the authors' knowledge, this is the first pilot study demonstrating the feasibility of rehabilitation using multiple exoskeleton robots. The tailor-made rehabilitation approach may be useful for the treatment of acute stroke.

Combined therapy using botulinum toxin A and single-joint hybrid assistive limb for upper-limb disability due to spastic hemiplegia

We investigated the combination of robot-assisted rehabilitation (RT) using a single-joint hybrid assistive limb (HAL-SJ) and botulinum toxin A (BTX-A) as therapy for paretic arm with spasticity in post-stroke patients. Participants were seven patients (4 females, 3 males; mean (±SD) age: 60.6±8.4years) who had spastic hemiplegia following chronic stroke. On the day following BTX-A injection, we started RT, which was performed for 20 sessions of 60min each over a two-week period. Clinical outcome measures, including Fugl-Meyer Assessment (FMA), Motor Activity Log (MAL), and Disability Assessment Scale (DAS), and cortical activity were evaluated at baseline, and two weeks, and four months following BTX-A injection. Cortical activity associated with elbow joint movement of the affected arm was assessed via functional near infrared spectroscopy (fNIRS). FMA, MAL, and DAS scores significantly improved at two weeks and four months (p<0.05), except DAS scores at four months (p=0.068). The fNIRS study showed that cortical activation increased in the ipsilesional primary sensorimotor area at two weeks and at the four months follow-up. Our pilot study showed that the combination of RT and BTX-A therapy was an effective approach for treating spastic hemiplegia due to stroke, and functional imaging study showed neuroplasticity induced by the treatment.

External coaptation of rostral mandibular fractures in calves

Six cases of rostral mandibular fracture with considerable displacement were treated successfully by external coaptation. Four cases were simple and two were compound fractures. After xylazine sedation and manual reduction of the fractures, the casting tape was laminated to make a rigid splint below the mandibles and then the splint was secured using the casting tape passing the nasal bridge and cranial and/or caudal to the ears as it encircled the head. During application of the tape, a PVC pipe 25 mm in diameter was held in its jaws to keep the mouth open so that the calf could suckle. Simple rostral mandibular fractures were cured after two weeks of cast immobilisation and compound fractures after about three weeks. This method is easy and non-stressful and provided a good prognosis in the present cases.

Milk-flow, ultrasonographic, theloscopic, and histopathological characteristics of the teat in cows with toxic mastitis

The milk-flow, imaging, and histopathological characteristics of the teat in five cows with toxic mastitis were investigated. Teats were grouped into type I (without gross and histopathological abnormality), type II (no abnormal gross findings, but with histopathological abnormality), and type III (with gross and histopathological abnormality). Normal teats from six cows served as controls. Type II and III teats had lower milk-flow, compared with the controls. Ultrasonography revealed no abnormal findings, except for irregular mucosal surface in type II teats and absence of hyperechoic line along the teat canal in type III teats. The theloscopic findings varied from normal to mucosal abnormalities in type II and III teats. Histopathology demonstrated epithelial changes, congestion, hemorrhage, edema, cellular infiltration, and elastic fiber degradation in type II and III teats, with the type III teats showing severe changes. Toxic mastitis was characterized by impaired milk-flow and various degrees of imaging and histopathological abnormality.

Fracture of the extensor process of the distal phalanx in a bull and a cow

Two cases of extensor process fracture of the distal phalanx in the forelimb in a Holstein bull and a lactating Holstein cow are described. Each animal showed acute onset of severe lameness with a gait characterised by lengthening of the cranial phase of the step in order to place more weight on the heel. Mild swelling and a localised pain response upon application of deep pressure above the coronet were also observed. A definitive diagnosis was made by radiography with complementary ultrasonography, which provided the best definition of the fracture fragment over the dorsal aspect of the distal interphalangeal joint. Applying a wooden block to a sound claw for three weeks was curative and provided a good prognosis in both cases.

[Comparative clinical study on 5-FU concentrations for oral HCFU and i.v. 5-FU]

Using the cross-over method, the same patients were administered continuous intravenous injections of 5-FU and HCFU, an oral derivative of 5-FU widely used for breast and colon cancer in Japan. The pharmacokinetics of 5-FU in blood of both drugs were then compared. The AUC of the 5-FU concentration in blood of the HCFU 100 mg group tended to be higher than that in the 5-FU 250 mg group and lower than that in the 5-FU 500 mg group. There was, however, no statistically significant difference between the HCFU and 5-FU 250 mg groups (p = 0.3274), or between the HCFU and 5-FU 500 mg groups (p = 0.1921).

Use of an enrichment broth cultivation-PCR combination assay for rapid diagnosis of swine erysipelas

We have previously described the creation by Tn916 mutagenesis of avirulent transposition mutants from a highly virulent strain of Erysipelothrix rhusiopathiae, the causative agent of swine erysipelas. In this study, we cloned a 2.2-kb DNA fragment which flanked the Tn916 insertion in an avirulent mutant (strain 33H6) and evaluated the possibility that this region could be used for the specific detection of E. rhusiopathiae. According to the sequences of this region, oligonucleotide primers were designed to amplify a 937-bp fragment of the E. rhusiopathiae chromosome by PCR. The specificity of the PCR was investigated by analyzing 64 strains of Erysipelothrix species and 27 strains of other genera different from Erysipelothrix. A 937-bp DNA fragment could be amplified from all E. rhusiopathiae strains tested, and no amplification was observed by using DNAs from the other species tested. To make a rapid and definite diagnosis of swine erysipelas in slaughterhouses, we developed an enrichment broth cultivation-PCR combination assay, which used a commercially available DNA extraction kit, to identify E. rhusiopathiae in the specimens from swine with arthritis. After samples were enriched in selective broth culture, detection of E. rhusiopathiae was tested by either conventional methods or the PCR. Of 102 samples tested, 15 samples were positive by conventional methods and 12 of the 15 samples were positive by the PCR. The detection limit of the PCR was 10(3) CFU per reaction mixture for the PCR-positive samples. These results indicate that this PCR technique could be used as a first-line screening technique for the specific detection of E. rhusiopathiae in specimens.

Isolation, identification, and plaque titration of parvovirus from Muscovy ducks in Japan

Muscovy ducks (Cairina moschata) showed abnormal feathering, leg weakness, and high mortality. A virus was isolated from these ducks after several blind passages in embryonating Muscovy duck eggs. The isolate was resistant to chloroform, to pH 3.2, and to 65 C for 30 min. Electron microscopy showed that the isolate was an icosahedral and nonenveloped virus 20-22 nm in diameter. The isolate reacted with an antiserum against a goose parvovirus in agar gel precipitation tests. After 15 passages of the isolate in embryonating eggs, the isolate was adapted to Muscovy duck embryo fibroblasts. The adapted virus developed cytopathic effects and made clear plaques on sheets of the fibroblasts. When 5-iodo-2-deoxyuridine was added to the culture medium, virus growth was inhibited. From the data shown above, the isolate was identified as a goose parvovirus.

[Proximal displacement of the femoral head after Chiari pelvic osteotomy for coxarthrosis with dysplastic acetabulum]

Proximal displacement of the femoral head can been seen sometimes after Chiari pelvic osteotomy. In order to clarify the causes of the displacement, a quantification analysis was performed to evaluate the factors of this osteotomy. The statistical analysis showed that 54% of the causes could be explained as being due to the angle of osteotomy, obesity ratio, the variation of the acetabular trochanteric distance, and other three factors. Paying attention to get good results: 1) making the angle of osteotomy from 11 degrees to 20 degrees, 2) keeping the variation of the acetabular trochanteric distance within 20mm, 3) the improvement of the lever arm ratio within 15%, and 4) the approximate acetabular index above 30%. In a case with the greater trochanter pulled down, a computer simulation showed that the centripetal force of the femoral head was decreased, and the displacement was increased.