Regulatory Considerations for the Clinical and Research Use of Transcranial Direct Current Stimulation (tDCS): review and recommendations from an expert panel

The field of transcranial electrical stimulation (tES) has experienced significant growth in the past 15 years. One of the tES techniques leading this increased interest is transcranial direct current stimulation (tDCS). Significant research efforts have been devoted to determining the clinical potential of tDCS in humans. Despite the promising results obtained with tDCS in basic and clinical neuroscience, further progress has been impeded by a lack of clarity on international regulatory pathways. We therefore convened a group of research and clinician experts on tDCS to review the research and clinical use of tDCS. In this report, we review the regulatory status of tDCS, and we summarize the results according to research, off-label and compassionate use of tDCS in the following countries: Australia, Brazil, France, Germany, India, Iran, Italy, Portugal, South Korea, Taiwan and United States. Research use, off label treatment and compassionate use of tDCS are employed in most of the countries reviewed in this study. It is critical that a global or local effort is organized to pursue definite evidence to either approve and regulate or restrict the use of tDCS in clinical practice on the basis of adequate randomized controlled treatment trials.

Quantifying swallowing function after stroke: A functional dysphagia scale based on videofluoroscopic studies

OBJECTIVE

To develop a sensitive, specific scale for quantifying functional dysphagia in stroke patients, using results obtained from videofluoroscopic swallowing studies.

DESIGN

Data collected from a serial oral and pharyngeal videofluoroscopic swallowing study.

SETTING

A dysphagia clinic in a department of rehabilitation medicine at a tertiary care university hospital.

PARTICIPANTS

One hundred three consecutively admitted stroke patients.

INTERVENTIONS

Videoflurorscopy to measure a scale of 11 variables: lip closure score, bolus formation, residue in oral cavity, oral transit time, triggering of pharyngeal swallow, laryngeal elevation and epiglottic closure, nasal penetration, residue in valleculae, coating of pharyngeal wall after swallow, and pharyngeal transit time.

MAIN OUTCOME MEASURES

Polychotomous linear logistic regression analysis of videofluoroscopic and aspiration results. Scale sensitivity and specificity, and the correlation between the total score of the scale and aspiration grade were analyzed.

RESULTS

The scale's sensitivity and specificity for detecting supraglottic penetration and subglottic aspiration were 81%, 70.7%, and 78.1%, 77.9%, respectively. A significant positive correlation was found between the scale's total score and the severity of aspiration (Spearman's r =.58943, p =.00001).

CONCLUSION

This functional dysphagia scale, which was based on a videofluoroscopic swallowing study in stroke patients, is a sensitive and specific method for quantifying the severity of dysphagia.

Effects of combined peripheral nerve stimulation and brain polarization on performance of a motor sequence task after chronic stroke

BACKGROUND AND PURPOSE

Recent work demonstrated that application of peripheral nerve and cortical stimulation independently can induce modest improvements in motor performance in patients with stroke. The purpose of this study was to test the hypothesis that combining peripheral nerve stimulation (PNS) to the paretic hand with anodal direct current stimulation (tDCS) to the ipsilesional primary motor cortex (M1) would facilitate beneficial effects of motor training more than each intervention alone or sham (tDCS(Sham) and PNS(Sham)).

METHODS

Nine chronic stroke patients completed a blinded crossover designed study. In separate sessions, we investigated the effects of single applications of PNS+tDCS, PNS+tDCS(Sham), tDCS+PNS(Sham), and PNS(Sham)+tDCS(Sham) before motor training on the ability to perform finger motor sequences with the paretic hand.

RESULTS

PNS+tDCS resulted in a 41.3% improvement in the number of correct key presses relative to PNS(Sham)+tDCS(Sham), 15.4% relative to PNS+tDCS(Sham), and 22.7% relative to tDCS+PNS(Sham). These performance differences were maintained 1 and 6 days after the end of the training.

CONCLUSIONS

These results indicate that combining PNS with tDCS can facilitate the beneficial effects of training on motor performance beyond levels reached with each intervention alone, a finding of relevance for the neurorehabilitation of motor impairments after stroke.

The Prediction of Persistent Dysphagia Beyond Six Months After Stroke

The purpose of this study was to identify the videofluoroscopic prognostic factors that affect the recovery of swallowing function at an early stage after stroke and to make a tool for predicting the long-term prognosis. Eighty-three poststroke patients were selected prospectively. These patients had all undergone videofluoroscopic swallowing studies at an average of 40 days after stroke onset and were followed up for over six months. Prognostic factors were determined by logistic regression analysis between the baseline videofluoroscopic findings and aspiration over six months (p < 0.05). A videofluoroscopic dysphagia scale (VDS) with a sum of 100 was made according to the odds ratios of prognostic factors. The validity of the scale was evaluated by using a receiver operating characteristic curve. The VDS was compiled using the following 14 items: lip closure, bolus formation, mastication, apraxia, tongue-to-palate contact, premature bolus loss, oral transit time, triggering of pharyngeal swallow, vallecular residue, laryngeal elevation, pyriform sinus residue, coating of pharyngeal wall, pharyngeal transit time, and aspiration. At a scale cutoff value of 47, the sensitivity was 0.91 and the specificity was 0.92. The VDS was developed to be used as an objective and quantifiable predictor of long-term persistent dysphagia after stroke.

Movement of the hyoid bone and the epiglottis during swallowing in patients with dysphagia from different etiologies

PURPOSE

(1) To compare the kinematic motion of the hyoid bone and the epiglottis in healthy controls and a sample of patients with dysphagia of different etiologies, and (2) to evaluate the potential value of kinematic swallowing analysis to differentiate the mechanism of dysphagia.

METHODS

We performed two-dimensional video motion analysis of the hyoid bone using videofluoroscopic images in nine controls without any swallowing difficulty, and seven patients with supratentorial stroke, three patients with inflammatory myopathy who showed dysphagia. Main outcome measures were: (1) horizontal and vertical excursion of the hyoid bone, and rotation of the epiglottis, and (2) trajectory of the hyoid bone and epiglottis during swallowing.

RESULTS

Horizontal excursion of the hyoid bone and rotation of the epiglottis were reduced in patients with myopathy as compared to control and patients with stroke (P<0.05). Patients with dysphagia showed different patterns as compared to control in trajectory analysis according to their etiology.

CONCLUSION

We conclude that extent and pattern of movement of the hyoid bone and the epiglottis during swallowing were different according to etiology of dysphagia, and swallowing motion analysis could be applied to differentiate the mechanism of dysphagia.

Intramuscular botulinum toxin-A reduces hemiplegic shoulder pain: a randomized, double-blind, comparative study versus intraarticular triamcinolone acetonide

BACKGROUND AND PURPOSE

Shoulder pain is frequent after stroke and interferes with the rehabilitative process and outcome. However, treatments used for hemiplegic shoulder pain are limited and largely ineffective. This prospective, randomized, double-blind controlled study was conducted to compare the efficacies of botulinum toxin type A (BoNT-A) and triamcinolone acetonide (TA) on hemiplegic shoulder pain and their effects on arm function in patients with stroke.

METHODS

Twenty-nine hemiplegic stroke patients with shoulder pain (duration <or=24 months, pain on numeric rating scale >or=6/10) were randomized into 2 groups. One group received intramuscular injections of BoNT-A (BOTOX 100 U total) during one session to the infraspinatus, pectoralis and subscapularis muscles in conjunction with an intraarticular injection of normal saline to painful shoulder joint, whereas the other group received an intraarticular injection of TA (40 mg) and an intramuscular injection of normal saline to the same muscles. Outcome measures were pain (measured using a numeric rating scale), physician's global rating scale, shoulder range of motion (ROM) in 4 directions, arm function measured using Fugl-Meyer score, and spasticity measured using the modified Ashworth scale. Measurements were made at baseline and 2, 6, and 12 weeks after injection.

RESULTS

At 12 weeks after treatment mean decrease in pain was 4.2 in the BoNT-A-treated group versus 2.5 in the TA-treated group (P=0.051), and improvements in overall ROM were 82.9 degrees versus 51.8 degrees in these groups (P=0.059), showing a strong trend toward there being less pain and better ROM among those treated with BoNT-A than with TA. However, no significant differences were observed between the 2 groups in terms of improvement in physician global rating, Fugl-Meyer score or modified Ashworth scales. No adverse effect was observed in either group.

CONCLUSIONS

Results from this study suggest that injection of BoNT-A into selected muscles of the shoulder girdle might provide more pain relief and ROM improvement than intraarticular steroid in patients with hemiplegic shoulder pain. A larger clinical trial needs to be undertaken to confirm the benefits of this approach.

The effect of aquatic therapy on postural balance and muscle strength in stroke survivors — a randomized controlled pilot trial

Objective: To evaluate the effect of an aquatic therapy programme designed to increase balance in stroke survivors.

Design: A randomized, controlled pilot trial.

Setting: Rehabilitation department of a university hospital.

Subjects: Ambulatory chronic stroke patients (n = 25):13 in an aquatic therapy group and 12 in a conventional therapy group.

Interventions: The aquatic therapy group participated in a programme consisting of Ai Chi and Halliwick methods, which focused on balance and weight-bearing exercises. The conventional therapy group performed gym exercises. In both groups, the interventions occurred for 1 hour, three times per week, for eight weeks.

Main measures: The primary outcome measures were Berg Balance Scale score and weight-bearing ability, as measured by vertical ground reaction force during four standing tasks (rising from a chair and weight-shifting forward, backward and laterally). Secondary measures were muscle strength and gait.

Results: Compared with the conventional therapy group, the aquatic therapy group attained significant improvements in Berg Balance Scale scores, forward and backward weight-bearing abilities of the affected limbs, and knee flexor strength (P<0.05), with effect sizes of 1.03, 1.14, 0.72 and 1.13 standard deviation units and powers of 75, 81, 70 and 26%, respectively. There were no significant changes in the other measures between the two groups.

Conclusions: Postural balance and knee flexor strength were improved after aquatic therapy based on the Halliwick and Ai Chi methods in stroke survivors. Because of limited power and a small population base, further studies with larger sample sizes are required.

Quantification of the path of center of pressure (COP) using an F-scan in-shoe transducer

By tracking the path of the center of pressure (COP) during the stance phase, the balance and pattern of progression can be determined. The path of COP is frequently used in clinical practice, although it is not quantified. In this study, an F-scan pressure sensitive insole system was used to quantify the path of COP. The COP of initial contact and the average during the stance phase corresponded to the center of the heel and to the center of the total plantar surface, respectively. The COP displacement corresponded to 83% of foot contact length and 18% of forefoot contact width. When the longitudinal axis of the insole was plotted as the Y-axis and the transverse axis of the insole as X-axis, the slopes of the COP coordinates during stance phase was 6 degrees inward. Velocities of the COP during each functional rocker action were even and 22-27 cm/s. The changes of quantified COP parameters according to the biomechanical alteration of the foot were confirmed by high-heeled gait.

Improved picture naming in aphasia patients treated with cathodal tDCS to inhibit the right Broca's homologue area

PURPOSE

Previous reports have suggested that noninvasive cortical stimulation could influence speech production in patients with chronic stroke. Here, we evaluated the hypothesis that cathodal transcranial DC stimulation (ctDCS), a technique that decreases excitability of stimulated cortical sites, applied over a healthy right Broca's homologue area could improve picture naming in patients with post-stroke aphasia.

METHODS

Ten right-handed patients with post-stroke aphasia were enrolled in this double blind, counterbalanced sham-controlled, crossover study. Each patient received an intervention of ctDCS (2 mA for 20 min) and of sham tDCS (2 mA for 1 min) daily for 5 consecutive days in a randomized crossover manner with a minimum interval of one week between interventions, over a healthy right Broca's homologue area using a left supraorbital anode and simultaneous daily sessions of conventional word-retrieval training. The primary endpoint measure of this study was a standardized, validated Korean version of the Boston Naming Test, which is a measure of picture naming skills.

RESULTS

ctDCS was not found to have any adverse effects. Furthermore, significantly improved picture naming (p = 0.02) was observed at 1 hour following the last (5th) ctDCS treatment session, but no changes were observed after sham tDCS.

CONCLUSION

These results demonstrate that cathodal tDCS over the right healthy Broca's homologue area with a left supraorbital anodal location can improve picture naming task performance in post-stroke aphasia.

Upper Extremity Functional Evaluation by Fugl-Meyer Assessment Scoring Using Depth-Sensing Camera in Hemiplegic Stroke Patients

Virtual home-based rehabilitation is an emerging area in stroke rehabilitation. Functional assessment tools are essential to monitor recovery and provide current function-based rehabilitation. We developed the Fugl-Meyer Assessment (FMA) tool using Kinect (Microsoft, USA) and validated it for hemiplegic stroke patients. Forty-one patients with hemiplegic stroke were enrolled. Thirteen of 33 items were selected for upper extremity motor FMA. One occupational therapist assessed the motor FMA while recording upper extremity motion with Kinect. FMA score was calculated using principal component analysis and artificial neural network learning from the saved motion data. The degree of jerky motion was also transformed to jerky scores. Prediction accuracy for each of the 13 items and correlations between real FMA scores and scores using Kinect were analyzed. Prediction accuracies ranged from 65% to 87% in each item and exceeded 70% for 9 items. Correlations were high for the summed score for the 13 items between real FMA scores and scores obtained using Kinect (Pearson’s correlation coefficient = 0.873, P<0.0001) and those between total upper extremity scores (66 in full score) and scores using Kinect (26 in full score) (Pearson’s correlation coefficient = 0.799, P<0.0001). Log transformed jerky scores were significantly higher in the hemiplegic side (1.81 ± 0.76) compared to non-hemiplegic side (1.21 ± 0.43) and showed significant negative correlations with Brunnstrom stage (3 to 6; Spearman correlation coefficient = -0.387, P = 0.046). FMA using Kinect is a valid way to assess upper extremity function and can provide additional results for movement quality in stroke patients. This may be useful in the setting of unsupervised home-based rehabilitation.

Effect of a tDCS electrode montage on implicit motor sequence learning in healthy subjects

BACKGROUND

This study was undertaken to test the hypothesis that a combination of excitatory anodal transcranial direct current stimulation (tDCS) to the contralateral motor cortex and inhibitory cathodal tDCS to the ipsilateral motor cortex of the motor performing hand (Bi-tDCS) would elicit more implicit motor sequence learning than anodal tDCS applied to the contralateral motor cortex alone (Uni-tDCS).

METHODS

Eleven healthy right-handed adults underwent a randomized crossover experiment of Uni-tDCS, Bi-tDCS, or sham stimulation. Subjects performed a 12-digit finger sequence serial reaction time task with the right hand at baseline (Pre), at immediately (Post 1), and 24 hours after stimulation (Post 2). The ratios of reaction times of predetermined repeating sequence versus random sequence were subjected to statistical analysis.

RESULTS

The paired t test showed that reaction time ratios were significant decreased by all stimulation types at Post 1 versus Pre (P < 0.01). However, mean reaction time ratios showed a significant decrease after Uni-tDCS (P < 0.01) and Bi-tDCS (P < 0.01), but only a marginal decreased after Sham (P = 0.05) at Post 2, which suggests that motor sequence learning is consolidated by Uni-tDCS and Bi-tDCS, but only partially consolidated by sham stimulation. No significant differences were observed between Uni-tDCS and Bi-tDCS in terms of in reaction time ratios at Post 1 or 2.

CONCLUSIONS

No significant difference was found between Uni-tDCS and Bi-tDCS in terms of induced implicit motor sequence learning, but tDCS led to greater consolidation of the learned motor sequence than sham stimulation. These findings need to be tested in the context of stroke hand motor rehabilitation.

Oropharyngeal Dysphagia in a community-based elderly cohort: the korean longitudinal study on health and aging

This study was conducted to investigate the prevalence of dysphagia and evaluated the association of dysphagia and activities of daily living in a geriatric population residing in an independent-living facility in Korea. Korean men and women 65-yr and older living in a single, typical South Korean city (n=415) were enrolled in the Korean Longitudinal Study on Health and Aging study. Dysphagia was assessed using the Standardized Swallowing Assessment. Data were collected on activities of daily living (ADL), instrumental ADL (IADL), and medical history and laboratory. The overall prevalence of dysphagia in the random sample was 33.7% (95% CI, 29.1-38.4), including 39.5% in men and 28.4% in women. The identified risk factors for dysphagia were men (OR, 3.6, P=0.023), history of stroke (OR, 2.7, P=0.042) and presence of major depressive disorder (OR, 3.0, P=0.022). Dysphagia was associated with impairment in IADL domains of preparing meals and taking medicine (P=0.013 and P=0.007, respectively). This is the first published report of the prevalence of dysphagia in older community-dwelling Koreans. Dysphagia is a common problem among elderly people that limits some IADL domains.

The Factors Associated with Good Responses to Speech Therapy Combined with Transcranial Direct Current Stimulation in Post-stroke Aphasic Patients

Objective

To determine factors associated with good responses to speech therapy combined with transcranial direct current stimulation (tDCS) in aphasic patients after stroke.

Method

The language function was evaluated using Korean version of Western aphasia battery (K-WAB) before and after speech therapy with tDCS in 37 stroke patients. Patients received speech therapy for 30 minutes over 2 to 3 weeks (10 sessions) while the cathodal tDCS was performed to the Brodmann area 45 with 1 mA for 20 minutes. We compared the improvement of aphasia quotient % (AQ%) between two evaluation times according to age, sex, days after onset, stroke type, aphasia type, brain lesion confirmed by magnetic resonance image and initial severity of aphasia. The factors related with good responses were also checked.

Results

AQ% improved from pre- to post-therapy (14.94±6.73%, p<0.001). AQ% improvement was greater in patients with less severe, fluent type of aphasia who received treatment before 30 days since stroke was developed (p<0.05). The adjusted logistic regression model revealed that patients with hemorrhagic stroke were more likely to achieve good responses (odds ratio=4.897, p<0.05) relative to infarction. Initial severity over 10% in AQ% was also found to be significantly associated with good improvement (odds ratio=8.618, p<0.05).

Conclusion

Speech therapy with tDCS was established as a treatment tool for aphasic patients after stroke. Lower initial severity was associated with good responses.

Health-related quality of life of patients using clean intermittent catheterization for neurogenic bladder secondary to spinal cord injury

OBJECTIVES

To determine the psychological and social status of patients using clean intermittent catheterization for neurogenic bladder according to health-related quality of life (HRQOL).

METHODS

We conducted a prospective trial involving 132 patients (81 men and 51 women, mean age 41.8 years, range 18 to 80 years) using clean intermittent catheterization because of neurogenic bladder secondary to spinal cord injury. The 150 controls (90 men and 60 women) lived in the same region as the patients and were frequency matched to ensure equal age and sex distributions. HRQOL was measured using the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36).

RESULTS

The SF-36 scores did not reveal any significant differences between the men and women in the patient group. The SF-36 scores of the patients were significantly lower than those of the general population. When patients and controls were divided into two groups according to sex and age, the SF-36 scores of the patients were significantly lower than the controls across both sex and all age groups, other than the energy and vitality scale, the differences for which were not statistically significant in women and those younger than 50 years.

CONCLUSIONS

Our findings suggest that patients using clean intermittent catheterization because of neurogenic bladder secondary to spinal cord injury generally exhibit a reduced quality of life in all health domains as assessed by the SF-36.

Functional Recovery After Ischemic Stroke Is Associated With Reduced GABAergic Inhibition in the Cerebral Cortex: A GABA PET Study

BACKGROUND

γ-Aminobutyric acid (GABA) plasticity plays an important role in stroke motor recovery in a mouse model. However, little is known about changes over time in neuronal excitability mediated by GABA receptors in human stroke patients.

OBJECTIVES

To establish the mechanism of neuroplasticity during the recovery phase following ischemic stroke by assessing the changes in cerebral GABA activity using [(18)F]flumazenil ([(18)F]FMZ) positron emission tomography (PET).

METHODS

A total of 10 patients with unilateral ischemic stroke were studied at 1 month (T0) and 3 months (T1) postonset using [(18)F]FMZ PET. Changes in regional GABAergic activity were assessed longitudinally, and values were also compared with those in 15 age-matched controls. Upper-extremity motor function was evaluated using the Fugl-Meyer score (FMS).

RESULTS

During the follow-up period, statistical parametric mapping analysis demonstrated a decrease in GABAA receptor availability throughout the cerebral cortex and cerebellum, especially the contralateral hemisphere. GABAA availability in the bilateral primary motor cortex, contralateral supplemental motor cortex, and globus pallidus at T0 was positively correlated with the FMS score at T1 CONCLUSIONS: This is the first prospective, controlled longitudinal study showing that the change in GABA receptor availability over time is significantly related to motor recovery after stroke in humans. This work supports the rationale for a novel strategy to promote motor recovery after stroke.

Health-related quality of life and related factors in stroke survivors: Data from Korea National Health and Nutrition Examination Survey (KNHANES) 2008 to 2014

As persons with stroke are surviving longer, monitoring and managing their quality of life is becoming important. We reviewed the Korea National Health and Nutrition Examination Survey (KNHANES) in order to evaluate the health-related quality of life (HRQoL) in stroke survivors as measured by the Euro Quality of Life-5D (EQ-5D), and to find out influencing factors. A total of 42,500 subjects were enrolled in the KNHANES, and 575 of them were persons with stroke. The EQ-5D index was lower in persons with stroke than those without stroke, when adjusted for age and sex (with stroke: 0.757±0.012, without stroke: 0.948±0.001, p < .0001). Dimension-specific influencing factors of HRQoL were observed in persons with stroke; mobility problems increased with old age; self-care problems increased with old age and depression; usual activity problems increased with old age, low income, absence of economic activity, and depression; pain/discomfort problems increased with low income. The EQ-5D index was lower in stroke survivors with older age, hypertension, diabetes mellitus, and lack of regular exercise. This is the first study to utilize nationally representative data of the Korean population to investigate the effect of stroke on HRQoL and explore the dimension-specific influencing factors. Further development of rehabilitative interventions for post-stroke depression, vocational rehabilitation, and tailored programs for encouraging physical activity may be needed to improve the HRQoL in Korean stroke survivors.

Association between muscle strength and metabolic syndrome in older Korean men and women: the Korean Longitudinal Study on Health and Aging

The objective of the study was to investigate the association between metabolic syndrome (MS) and muscle strength in community-dwelling older men and women in Korea. Korean men and women 65 years and older living in a single, typical South Korean city (n = 647) were enrolled in the Korean Longitudinal Study on Health and Aging study. The diagnosis of MS was evaluated according to the definition of the National Cholesterol Education Program Adult Treatment Panel III. Isokinetic muscle strength of the knee extensors, as determined by peak torque per body weight (newton meter per kilogram) and hand-grip strength per body weight (newton per kilogram), was measured. Participants without MS had greater leg muscle strength and grip strength per weight. The effect of MS on muscle strength was more prominent in men than in women in our study population. Only men showed a significant interaction between MS and age for muscle strength (P = .014), and the effect was greater in men aged 65 to 74 years compared with those older than 75 years (119.2 ± 31.2 vs 134.5 ± 24.3 N m/kg). Participants with MS had weaker knee extensor strength after controlling the covariates (β = -90.80, P = .003), and the interaction term (age × MS × male sex) was significant (β = 1.00, P = .017). Metabolic syndrome is associated with muscle weakness, and this relationship is particularly pronounced in men. Age can modify the impact of MS on muscle strength. Men aged 65 to 74 years with MS need a thorough assessment of muscle strength to prevent disability.

Non-invasive cortical stimulation improves post-stroke attention decline

PURPOSE

Attention decline after stroke is common and hampers the rehabilitation process, and non-invasive transcranial direct current stimulation (tDCS) has the potential to elicit behavioral changes by modulating cortical excitability. The authors tested the hypothesis that a single session of non-invasive cortical stimulation with excitatory anodal tDCS applied to the left dorsolateral prefrontal cortex (DLPFC) can improve attention in stroke patients.

METHODS

Ten patients with post-stroke cognitive decline (MMSE 25) and 10 age-matched healthy controls participated in this double blind, sham-controlled, crossover study involving the administration of real (2 mA for 20 min) or sham stimulation (2 mA for 1 min) to the left DLPFC. Attention was measured using a computerized Go/No-Go test before and after intervention. Improvements in accuracy and speed after stimulation relative to baseline were compared for real and sham stimulations.

RESULTS

In healthy controls, no significant improvement in Go/No-Go test was observed after either real or sham stimulation. However, in stroke patients, tDCS led to a significant improvement in response accuracy at 1 hour post-stimulation relative to baseline, and this improvement was maintained until 3 hours post-stimulation (P< 0.05), whereas sham stimulation did not lead to a significant improvement in response accuracy (P> 0.05). Changes in reaction times were comparable for the two stimulations (P> 0.05).

CONCLUSION

Non invasive anodal tDCS applied to the left DLPFC was found to improve attention versus sham stimulation in stroke patients, which suggests that non-invasive cortical intervention could potentially be used during rehabilitative training to improve attention.

Relationship between muscle mass and physical performance: is it the same in older adults with weak muscle strength?

BACKGROUND

the relationship between muscle mass and physical performance has not been consistent among studies.

OBJECTIVE

to clarify the relationship between muscle mass and physical performance in older adults with weak muscle strength.

DESIGN

cross-sectional analysis using the baseline data of 542 older men and women from the Korean Longitudinal Study on Health and Aging.

METHODS

dual X-ray absorptiometry, isokinetic dynamometer and the Short Physical Performance Battery (SPPB) were performed. Two muscle mass parameters, appendicular skeletal mass divided by weight (ASM/Wt) and by height squared (ASM/Ht(2)), were measured. We divided the participants into a lower-quartile (L25) group and an upper-three-quartiles (H75) group based on the knee-extensor peak torque. Correlation analysis and logistic regression models were used to assess the association between muscle mass and low physical performance, defined as SPPB scores <9, after controlling for confounders.

RESULTS

in the L25 group, no correlation between mass and SPPB was detected, whereas the correlation between peak torque and SPPB was significant and higher than that in the H75 group. Results from the logistic models also showed no association between muscle mass and SPPB in the L25 group, whereas muscle mass was associated with SPPB in the H75 group.

CONCLUSION

muscle mass was not associated with physical performance in weak older adults. Measures of muscle strength may be of greater clinical importance in weak older adults than is muscle mass per se.

Mobile game-based virtual reality rehabilitation program for upper limb dysfunction after ischemic stroke

BACKGROUND

Virtual reality (VR) has the potential to provide intensive, repetitive, and task-oriented training, and game-based therapy can enhance patients' motivation and enjoyment.

OBJECTIVE

The objective of the present study was to develop a mobile game-based upper extremity VR program for patients who have experienced stroke, and to evaluate the feasibility and effectiveness of the program.

METHODS

This randomized, double-blind, controlled trial included 24 patients with ischemic stroke. The intervention group (n = 12) received 30 min of conventional occupational therapy (OT) and 30 min of the mobile upper extremity rehabilitation program using a smartphone and a tablet PC (MoU-Rehab). The controls (n = 12) received conventional OT alone for 1 h per day. Rehabilitation consisted of 10 sessions of therapy, 5 days per week, for 2 weeks. The outcome measures (Fugl-Meyer Assessment of the upper extremity [FMA-UE], Brunnström stage [B-stage] for the arm and the hand, manual muscle testing [MMT], modified Barthel index [MBI], EuroQol-5 Dimension [EQ-5D], and Beck Depression Inventory [BDI]) were assessed at the beginning and end of treatment, and at 1 month. User satisfaction was evaluated by a questionnaire.

RESULTS

A greater improvement in the FMA-UE, B-stage, and MMT was found after treatment with the MoU-Rehab than with conventional therapy. The extent of improvements in the MBI, EQ-5D, and BDI was not significantly different between the two groups. Patients in the experimental group completed the 2-weeks treatment without adverse effects, and they were generally satisfied with MoU-Rehab.

CONCLUSION

This mobile game-based VR rehabilitation program appears to be feasible and effective for promoting upper limb recovery after ischemic stroke.

Categorization of dysphagia diets with the line spread test11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated

OBJECTIVE

To categorize dysphagic diets according to the food's viscosity, as determined by an objective method.

DESIGN

Description of dysphagic diet in terms of viscosity.

SETTING

Food science laboratory at a university hospital.

SPECIMENS

Twenty kinds of foods: 10 commercially available and 10 formulated for a dysphagic diet in a tertiary university hospital, representing a wide range of food viscosities.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Viscosity, measured with a viscometer, and a line spread test (LST).

RESULTS

Logarithmic viscosity (centiPoise [cP]) values measured using a viscometer were inversely correlated with the extent of spread (centimeters) on an LST. (Pearson r=-.95, P=.0001). Viscosities and the LST results were 0.9+/-0.1cP and 5.5+/-0.5cm for water, 63.1+/-4.8cP and 3.4+/-0.1cm for the barium solution, 671.0+/-76.9cP and 2.4+/-0.1cm for yogurt, and 10,031+/-728cP and 1cm for pudding.

CONCLUSIONS

Dysphagic diets can be categorized according to their viscosities by objective measurements. The LST correlated well with viscometer measurement and is a practical method with which to measure viscosity.