Adding transcutaneous electrical nerve stimulation to visual scanning training does not enhance treatment effect on hemispatial neglect: a randomized,controlled, double-blind study

Background: Left-sided transcutaneous electrical nerve stimulation (TENS) increases right hemispheric activity, which may improve the rehabilitative outcome of hemispatial neglect.

Objective: To examine the behavioral effect of electrical stimulation of the nerve afferents of the left hand during early neuropsychological rehabilitation of post-stroke patients with hemispatial neglect.

Methods: This randomized, controlled, double-blind study included 29 patients (enrolled in the experimental or control group) with left hemispatial neglect after right hemispheric stroke. For 3 weeks, patients received 15 therapeutic sessions involving TENS (active or sham) with a mesh glove applied on the entire left hand during the first 30 minutes of a 45-minute conventional visual scanning training (VST). Signs of hemispatial neglect were assessed using a psychometric test before and after treatment.

Results: Univariate analysis of covariance revealed that differences between the control and experimental groups were not significant after treatment (F(1, 22)?=?0.294, P?=?0.593) when adjusted for pre-treatment scores and time since stroke onset. This suggested that electrical stimulation failed to mitigate the severity of hemispatial neglect symptoms.

Conclusion: Our study did not provide evidence of the effectiveness of TENS when added to VST during early rehabilitation for patients with post-stroke hemispatial neglect. Other techniques (applied alone or together) should be sought to improve recovery in this population.     

Kinematic optimization of spatiotemporal patterns in paretic arm training with stroke patients

The effect of rhythmic cueing on spatiotemporal control of sequential reaching movements of the paretic arm was studied in 21 hemispheric stroke patients. Reaching movements were studied with and without rhythmic metronome cuing in a counterbalanced design. Metronome frequencies were entrained to the naturally selected frequency of the patient. Results indicate statistically significant (P<0.05) improvements of spatiotemporal arm control during rhythmic entrainment. Variability of timing and reaching trajectories were reduced significantly. Time series analysis of sequential movement repetitions showed an immediate reduction in variability of arm kinematics during rhythmic entrainment within the first two to three repetitions of each trial. Rhythm also produced significant increases in angle ranges of elbow motion (P<0.05). Analysis of acceleration and velocity profiles of the wrist joint showed significant kinematic smoothing during rhythmic cuing. The link between rhythmic sensory timing and spatiotemporal motor control was investigated using a mathematical optimization model with minimization of peak acceleration as criterion. Rhythmically cued acceleration profiles fit the predicted model data significantly closer (P<0.01) than the self-paced profiles. Since velocity and acceleration are mathematical derivatives of position-time trajectories, the model data suggest that enhanced timing precision via temporal phase and period coupling of the motor pattern to the rhythmic time timekeeper enhances the brain's computational ability to optimally scale movement parameters across time.     

Electromyogram-triggered neuromuscular stimulation and stroke motor recovery of arm/hand functions: a meta-analysis

Debate persists about the effectiveness of poststroke behavioral interventions for progress toward motor recovery. The current meta-analysis assessed the effect of electromyogram (EMG)-triggered neuromuscular stimulation on arm and hand functions. Computer searches of PubMed and Cochran databases, as well as hand searches of reference lists identified seven EMG-triggered neuromuscular stimulation studies. Outcome measures focused on arm and hand motor capability functions. In addition, the quality of each study was rated on three guidelines: randomization, double blind, and dropouts. After adjusting data for consistency in the arm/hand outcome measures and to avoid bias, five active stimulation studies were included in the analysis. Rehabilitation treatment in each study focused on wrist extension. The total number of individuals in the treatment groups was 47 whereas the control groups had 39 subjects. The meta-analysis revealed a significant overall mean effect size (delta=0.82, S.D.=0.59). A homogeneity test indicated that the pooled standardized effect sizes estimated the same treatment effect. A fail-safe test for null effect findings revealed that 15 studies were required to reduce the large effect (0.82) to a small effect (0.20). These improved wrist extension motor capabilities findings support EMG-triggered neuromuscular stimulation as an effective poststroke protocol.     

经皮电刺激联合功能训练治疗卒中后吞咽功能障碍的疗效比较

目的本研究旨在探讨经皮神经电刺激（TENS）联合吞咽功能训练治疗急性期、恢复期脑卒中后吞咽功能障碍的疗效评价,对比急、慢性期患者治疗的效果差异;以及对比急性期患者TENS联合治疗与单纯吞咽功能训练的疗效差异。方法118例脑卒中后吞咽功能障碍的患者分为急性期治疗组和恢复期TENS联合功能训练治疗组（简称：恢复期联合治疗组）;其中急性期治疗组随机分为急性期TENS联合吞咽功能训练治疗组（简称：急性期联合治疗组）和急性期吞咽功能训练组（急性期功能训练组）两个亚组。三组均使用常规药物治疗和吞咽功能训练,除急性期吞咽功能训练组外其他两组在此基础上加用TENS治疗,疗程两周。在治疗前、治疗1周、治疗2周后采用吞咽x线电视透视检查吞咽功能进行评价。急性期联合治疗组、急性期吞咽功能训练组分别与恢复期联合治疗组比较;以及急性期两亚组间进行比较。结果治疗后2周急性期联合治疗组有效35例,有效率87．5％;急性期功能训练组有效32例,有效率82％;恢复期联合治疗组有效24例,有效率61．5％。急性期联合治疗组和急性期功能训练组均与恢复期联合治疗组比较,差异有统计学意义（P〈0．05）;但急性期两亚组间差异无统计学意义（P〉0．05）。结论脑卒中后吞咽功能障碍患者采用吞咽功能训练联合TENS治疗和单纯吞咽功能训练均有效改善脑卒中后的吞咽功能,急性期明显高于慢性期患者的疗效。但是急性期采用吞咽功能训练联合TENS与单纯吞咽功能训练的效果相当。     

Home-based hand rehabilitation with a robotic glove in hemiplegic patients after stroke: a pilot feasibility study

Objective: To evaluate the feasibility and safety of home rehabilitation of the hand using a robotic glove, and, in addition, its effectiveness, in hemiplegic patients after stroke.

Methods: In this non-randomized pilot study, 21 hemiplegic stroke patients (Ashworth spasticity index ≤ 3) were prescribed, after in-hospital rehabilitation, a 2-month home-program of intensive hand training using the Gloreha Lite glove that provides computer-controlled passive mobilization of the fingers. Feasibility was measured by: number of patients who completed the home-program, minutes of exercise and number of sessions/patient performed. Safety was assessed by: hand pain with a visual analog scale (VAS), Ashworth spasticity index for finger flexors, opponents of the thumb and wrist flexors, and hand edema (circumference of forearm, wrist and fingers), measured at start (T0) and end (T1) of rehabilitation. Hand motor function (Motricity Index, MI), fine manual dexterity (Nine Hole Peg Test, NHPT) and strength (Grip test) were also measured at T0 and T1.

Results: Patients performed, over a mean period 56 (49–63) days, a total of 1699 (1353–2045) min/patient of exercise with Gloreha Lite, 5.1 (4.3–5.8) days/week. Seventeen patients (81%) completed the full program. The mean VAS score of hand pain, Ashworth spasticity index and hand edema did not change significantly at T1 compared to T0. The MI, NHPT and Grip test improved significantly (p = 0.0020, 0.0156 and 0.0024, respectively) compared to baseline.

Conclusion: Gloreha Lite is feasible and safe for use in home rehabilitation. The efficacy data show a therapeutic effect which need to be confirmed by a randomized controlled study.     

The effect of locomotor training combined with functional electrical stimulation in chronic spinal cord injured subjects: walking and reflex studies

With the new developments in traumatology medicine, the majority of spinal cord injuries sustained are clinically incomplete and the proportion is likely to continue to rise. Thus, it is necessary to continue to develop new treatment and rehabilitation strategies and understand the factors that can enhance recovery of walking following spinal cord injury (SCI). One new development is the use of functional electrical stimulation (FES) device to assist locomotion. The objective of this review is to present findings from some recent studies on the effect of long-term locomotor training with FES in subjects with SCI. Promising results are shown in all outcome measures of walking, such as functional mobility, speed, spatio–temporal parameters, and the physiological cost of walking. Furthermore, the change in the walking behavior could be associated with plasticity in the CNS organization, as seen by the modification of the stretch reflex and changes in the corticospinal projection to muscles of the lower leg. In conclusion, recovery of walking is an increasing possibility for a large number of people with SCI. New modalities of treatment have become available for this population but most still need to be evaluated for their efficacy. This review has focused on FES assisted walking as a therapeutic modality in subjects with chronic SCI, but it is envisaged that the care and recovery of SCI in the early phase of recovery could also be improved.     

Sleep cycles in cats during chronic electrical stimulation of the area postrema and the anterior raphe

Sleep-waking profiles were obtained from 130 7 hr stimulation-EEG recording sessions in a series of cats bearing chronically implanted stimulating electrodes in the regions of the area postrema and anterior raphe nuclei. The results indicated that: (a) during electrical stimulation of the region of the area postrema with 0.5 or 10 Hz at 1 and 2 mA there were significant increases in the occurrence of the deeper aspects of slow-wave sleep and in REM sleep. These elevations were significant in comparison to nonstimulation baselines and to sleep profiles obtained during stimulation of points located dorsal and anterior to the area postrema. (b) Stimulation of the medial reticular formation including the anterior raphe using the same parameters employed for the area postrema did not alter the occurrence of any stage of sleep. These findings indicate that the region of the area postrema may be more involved in the generation of sleep than the anterior raphe nuclei.     

神经肌肉电刺激治疗脑卒中后吞咽障碍疗效观察

目的观察神经肌肉电刺激（Neuromuscular electrical stimulation,NMES）治疗脑卒中后吞咽障碍（Dysphagia after stroke,DAS）的疗效。方法将经电视透视吞咽检查（Videofluoroscophic swallowing study,VFSS）确诊的60倒DAS患者随机分为两组,治疗组30例,对照组30倒。两组均给予常规内科治疗及传统康复治疗,治疗组同时给予NMES治疗,疗程为10d。比较两组治疗前、治疗10d的VFSS评分及治疗10d、治疗后1个月、治疗后6个月的疗效。结果治疗前两组VFSS评分比较无统计学意义（P〉0．05）;治疗10d,治疗组VFSS评分明显高于对照组,有效率、显效率高于对照组,差异有统计学意义（P〈0．05）,治疗后1个月,两组有效率无统计学意义（P〉0．05）,但治疗组显效率明显高于对照组（P〈0．05）;治疗后6个月,两组吞咽障碍预后良好率无差异（P〉0．05）。结论NMES治疗DAS的近期疗效肯定,疗效可持续1个月。     

电刺激对大鼠缺血性脑卒中的保护作用

目的探讨皮层电刺激对大鼠永久性缺血性脑卒中的保护作用。方法雄性sD大鼠随机分成对照组和实验组。实验组根据刺激频率不同分成2Hz组,20Hz组,100Hz组,100／2Hz组。建立永久性梗塞模型。梗塞3h后,电极植入右侧大脑缺血区皮层进行刺激。分别在梗塞5h和24h进行行为学评分。在梗塞24h行2％氯化三苯基四氮唑溶液染色测量脑梗死比。于刺激结束1h后取脑组织Westernblot分析脑源性神经营养因子（BDNF）和血管内皮生长因子（VEGF）表达量的变化。结果2Hz电刺激组在梗死比的减少及行为学评分的改善方面最显著（均P〈0．05）。VEGF的表达量下降,而BDNF表达水平较其他各组无显著性差异。结论对于脑缺血溶栓未通患者,皮层电刺激对脑缺血可能有保护作用。     

功能性电刺激结合重复经颅磁刺激用于缺血性脑卒中偏瘫患者步行障碍恢复的临床观察

目的 观察功能性电刺激结合重复经颅磁刺激用于缺血性脑卒中偏瘫患者步行障碍恢复的临床疗效。方法 将53例缺血性脑卒中偏瘫患者随机分为对照组、治疗组、假治疗组3组,在均接受常规康复训练的基础上对照组接受功能性电刺激治疗,治疗组接受功能性电刺激及重复经颅磁刺激治疗,假治疗组接受功能性电刺激及假重复经颅磁刺激治疗; 治疗前及治疗8周后采用步态运动学参数、时间参数、距离参数及Amer-Lindholm分级对3组患者的下肢综合运动功能进行评定。结果 治疗前3组患者步态运动学参数、时间参数、距离参数及Amer-Lindholm分级评分均无显著差异(P>0.05),治疗8周后3组患者上述指标明显改善且治疗组改善幅度明显优于其余2组(P<0.05)。结论 功能性电刺激联合重复经颅磁刺激治疗有利于改善缺血性脑卒中偏瘫患者的步行运动功能。     

Neuromuscular electrical stimulation improves severe hand dysfunction for individuals with chronic stroke: a pilot study

Restoring hand function is difficult post-stroke. We sought to determine if applying neuromuscular electrical stimulation (NMES) was beneficial for reducing severe hand impairments. Subjects with chronic stroke (N=8; 3 Fe, 5 M; 58.3 +/- 6.9 y/o) received 10 sessions of NMES using two different methods applied in a counterbalanced order. In one intervention, we applied NMES (active) in a novel fashion using multiple stimulators on the forearm flexors and extensors to assist subjects with grasping and releasing a tennis ball. In the other intervention, the NMES ('passive') stimulated repeated wrist extension and flexion. Motor performance was assessed prior to and immediately following the interventions and at retention. Upper extremity (UE) Fugl-Myer scores significantly improved (p < 0.002) immediately following either intervention. Significant improvement was also observed in the Modified Ashworth Spasticity Scale (MASS) (p < 0.03), immediately following intervention, primarily due to the NMESpassive treatment (p < 0.034). Subjects performed grasping tasks significantly faster (p < 0.0433) following interventions, with performance speeds on dexterous manipulation increasing approximately 10% for NMESactive immediately following intervention, compared to only 0.1% improvement following NMESpassive. Generally, improvements in motor speed remained 10 days following NMESactive intervention, although slightly diminished. In conclusion, severe hand impairment was reduced after a short duration of NMES therapy in this pilot data set for individuals with chronic stroke. NMES-assisted grasping trended towards greater functional benefit than traditional NMES-activation of wrist flexors/extensors.     

Motor recovery following stroke: a transcranial magnetic stimulation study.

OBJECTIVES: To verify the usefulness of early recording of motor evoked potentials (MEPs) in predicting motor outcome after stroke and to investigate the neural mechanisms underlying functional recovery following stroke. METHODS: We performed a comparative analysis of the behaviour of motor responses evoked by transcranial magnetic stimulation (TMS) of the ipsilateral and contralateral motor cortex in the affected and unaffected thenar muscles of 21 consecutive patients with acute stroke. RESULTS: According to the behaviour of MEPs in the affected muscles, patients could be divided into 3 groups: (a) 10 subjects with absent responses to TMS of both the damaged and undamaged hemisphere, whose motor recovery was poor and related to the size of MEPs on the normal side; (b) 5 subjects with larger MEPs upon TMS of the ipsilateral (undamaged) than of the contralateral (damaged) cortex, whose good recovery possibly resulted from the emergence of ipsilateral pathways; (c) 6 subjects with larger MEPs in the affected than in the unaffected muscles, whose good recovery was possibly subserved by alternative circuits taking over cortical deafferentation. CONCLUSIONS: Early MEP recording in acute stroke provides useful information on the clinical prognosis and the different mechanisms of motor recovery.     

Effects of the hybrid of neuromuscular electrical stimulation and noxious thermal stimulation on upper extremity motor recovery in patients with stroke: a randomized controlled trial

Background: Neuromuscular electrical stimulation (NMES) and noxious thermal stimulation (NTS) have been developed and incorporated in stroke rehabilitation.

Objective: This study aimed to compare the effects of NMES, NTS, and the hybrid of NMES and NTS (“Hybrid”) on motor recovery of upper extremity (UE) for patients with stroke.

Methods: We conducted a prospective, single-blind randomized controlled trial with concealed allocation. Forty-three patients with chronic stroke (onset >6 months) were randomly assigned to three groups (NMES, NTS, and “Hybrid”). In addition to conventional rehabilitation, participants received 30 min of NMES or 30 min of NTS or 15 min of NTS followed by 15 min of NMES. The treatment period was 8 weeks, 3 days/week, 30 min/time. The UE subscale of Fugl-Meyer assessment (UE-FMA, the primary outcome), Motricity index, modified Ashworth scale, and Barthel index were administered by a blinded assessor at baseline, posttreatment, and one-month follow-up.

Results: Most of the participants had mild-to-moderate disability in activity of daily living. No significant differences in the outcome measures at posttreatment and one-month follow-up were found among the NMES group (n = 13), NTS group (n = 13), and the hybrid of NMES and NTS group (n = 17). However, significant score changes in UE-FMA (p < 0.025) from baseline to posttreatment and one-month follow-up were found for the “Hybrid” group.

Conclusions: This study reveals that the hybrid of NMES and NTS therapy appears to be beneficial to UE recovery after stroke but is not superior to NMES or NTS alone.     

Anatomofunctional organization of the insular cortex: a study using intracerebral electrical stimulation in epileptic patients

Purpose: Different lines of evidence suggest that the insular cortex has many important functional roles. Direct electrical stimulation (ES) of the human insular cortex during surgical procedures for epilepsy, functional imaging techniques, and lesion studies also occasionally induces clinical responses. Methods: In this study, we evaluated 25 patients with drug‐refractory focal epilepsy by stereotactically implanting at least one electrode into the insular cortex using an oblique approach (transfrontal or transparietal). One hundred twenty‐eight insular sites (each situated between two contiguous contacts within the same electrode) were examined within the gyral substructures. We located each stimulation site by fusing preimplantation three‐dimensional (3D) magnetic resonance imaging (MRI) images with the postimplantation 3D computed tomography (CT) scans that revealed the electrode contacts. Results: Sixty‐seven stimulations induced at least one clinical response. Stimulation from within the insular cortex evoked 83 responses, without evidence of afterdischarge in the insular or extrainsular regions. We classified the principal responses as sensory (paresthesias and localized warm sensations), motor, pain, auditory, oropharyngeal, speech disturbances (including speech arrest and reduced voice intensity) and neurovegetative phenomena, such as facial reddening, generalized sensations of warmth or cold, hypogastric sensations, anxiety attacks, respiratory accelerations, sensations of rotation, and nausea. Conclusions: These findings may indicate a functional specificity for the insular gyri and show the need for exploring this structure during invasive presurgical evaluation of epileptic patients according to seizure manifestations.     

A miniaturized cuff electrode for electrical stimulation of peripheral nerves in the freely moving rat

A bipolar cuff electrode for electrical stimulation of small diameter peripheral nerves is described. The cuff is made of a highly flexible rubber-impression material, and the electrode assembly is suited for chronic implantation. Its manual construction is easy and reliable, utilizing only simple tools. The cuff completely envelopes nerves of varying diameter and requires a minimal amount of manipulations of the nerve, thereby reducing the chance of surgical trauma. The snug envelope prevents the nerve from drying, and minimizes shunting between the two leads by extracelfular fluids. Small outer dimensions were achieved: 1.4 × 1.1 × 2.3 mm (width × height × length) when used with nerves of 1 mm diameter, which minimizes pressure and damage to surrounding tissues. Morphometric analysis of nerves enclosed in cuffs for 28–30 h revealed a small decrease in the number of large-diameter fibers. Stimulation thresholds remained, however, constant throughout the experiments.     

低频重复经颅磁刺激联合以任务为导向作业疗法对脑卒中患者上肢运动功能的康复作用

目的探讨低频重复经颅磁刺激联合以任务为导向作业疗法对脑卒中患者上肢运动功能的康复作用。方法共42例脑卒中后偏瘫患者随机接受常规康复训练和以任务为导向作业疗法(对照组,20例)以及在此基础上联合健侧运动皮质低频(1 Hz)重复经颅磁刺激(治疗组,22例),分别于治疗前、治疗4周时和治疗后3个月采用Fugl-Meyer上肢评价量表(FMA-UE)和Wolf运动功能测验(WMFT)评价上肢运动功能,记录并分析健侧运动皮质运动诱发电位潜伏期和中枢运动传导时间。结果与对照组相比,治疗组FMA-UE评分(P=0.006)和WMFT评分(P=0.024)均增加;两组不同时间点FMA-UE评分(P=0.000)和WMFT评分(P=0.000)差异有统计学意义,其中治疗4周时和治疗后3个月FMA-UE评分(均P=0.000)和WMFT评分(均P=0.000)均高于治疗前,治疗后3个月FMA-UE评分(均P=0.000)和WMFT评分(均P=0.000)亦高于治疗4周时。两组患者治疗前后健侧运动皮质运动诱发电位潜伏期(P=0.979)和中枢运动传导时间(P=0.807)差异无统计学意义,不同时间点(治疗前、治疗4周时和治疗后3个月)健侧运动皮质运动诱发电位潜伏期(P=0.085)和中枢运动传导时间(P=0.507)差异亦无统计学意义。结论脑卒中患者健侧运动皮质低频重复经颅磁刺激联合以任务为导向作业疗法可以有效改善脑卒中患者上肢运动功能,值得临床推广应用。