Effects of home-based sensory and motor amplitude electrical stimulation on arm dysfunction in chronic stroke

OBJECTIVE: To examine the effects of a home-based arm exercise programme of sensory and motor amplitude electrical stimulation. DESIGN: Non-concurrent, multiple-baseline, single-subject design. SUBJECTS: Ten adults with chronic arm hemiparesis following stroke. Subjects ranged in age from 38 to 74 years and were 2-16 years post stroke. Three subjects had right-sided involvement; seven had left. INTERVENTION: Subjects completed an eight-week, individualized, home programme of neuromuscular and sensory amplitude electrical stimulation. All subjects engaged in stimulation-assisted task-specific exercises for 15 minutes 2 -3 times daily. Participants with sensory deficits received an additional 15 minutes of sensory amplitude stimulation twice daily. The Action Research Arm Test was used to examine arm function; the Stroke Rehabilitation Assessment of Movement was used to examine movement quality; and the Modified Ashworth Assessment of Spasticity was used to examine muscle tone. RESULTS: A statistically significant improvement was demonstrated by six of the 10 subjects on the Action Research Arm Test, and five subjects on the Stroke Rehabilitation Assessment of Movement. Four subjects had > or = 10% improvement on the Modified Ashworth Assessment of Spasticity. Two subjects demonstrated significant improvement on all three outcome measures; six subjects improved on two or more measures; and seven subjects improved on one or more measure. Subjects who improved on two or more measures tended to have had more recent onset of stroke, were older and had higher baseline motor and functional capacity. CONCLUSION: Subjects with chronic stroke can experience impairment and functional improvements following a home-based programme of motor and sensory amplitude electrical stimulation.     

Short-term ankle motor performance with ankle robotics training in chronic hemiparetic stroke

Cerebrovascular accident (stroke) often results in impaired motor control and persistent weakness that may lead to chronic disability, including deficits in gait and balance function. Finding ways to restore motor control may help reduce these deficits; however, little is known regarding the capacity or temporal profile of short-term motor adaptations and learning at the hemiparetic ankle. Our objective was to determine the short-term effects of a single session of impedance-controlled ankle robot ("anklebot") training on paretic ankle motor control in chronic stroke. This was a double-arm pilot study on a convenience sample of participants with chronic stroke (n = 7) who had residual hemiparetic deficits and an equal number of age- and sex-matched nondisabled control subjects. Training consisted of participants in each group playing a target-based video game with the anklebot for an hour, for a total of 560 movement repetitions in dorsiflexion/plantar flexion ranges followed by retest 48 hours later. Task difficulty was adjusted to ankle range of motion, with robotic assistance decreased incrementally across training. Assessments included robotic measures of ankle motor control on unassisted trials before and after training and at 48 hours after training. Following exposure to the task, subjects with stroke improved paretic ankle motor control across a single training session as indexed by increased targeting accuracy (21.6 +/- 8.0 to 31.4 +/- 4.8, p = 0.05), higher angular speeds (mean: 4.7 +/- 1.5 degrees/s to 6.5 +/- 2.6 degrees/s, p < 0.01, peak: 42.8 +/- 9.0 degrees/s to 45.6 +/- 9.4 degrees/s, p = 0.03), and smoother movements (normalized jerk: 654.1 +/- 103.3 s(-2) to 537.6 +/- 86.7 s(-2), p < 0.005, number of speed peaks: 27.1 +/- 5.8 to 23.7 +/- 4.1, p < 0.01). In contrast, nondisabled subjects did not make statistically significant gains in any metric after training except in the number of successful passages (32.3 +/- 7.5 to 36.5 +/- 6.4, p = 0.006). Gains in all five motor control metrics were retained (p > 0.05) at 48 hours in both groups. Robust maintenance of motor adaptation in the robot-trained paretic ankle over 48 hours may be indicative of short-term motor learning. Our initial results suggest that the anklebot may be a flexible motor learning platform with the potential to detect rapid changes in ankle motor performance poststroke.     

Levodopa improves procedural motor learning in chronic stroke patients

Rösser N, Heuschmann P, Wersching H, Breitenstein C, Knecht S, Flöel A. Levodopa improves procedural motor learning in chronic stroke patients.

Objective

To test the hypothesis that administration of dopamine precursor levodopa improves procedural motor learning (defined as the ability to acquire novel movement patterns gradually through practice) in patients with residual motor deficits in the chronic phase after stroke (≥1y after stroke).

Design

A double-blind, placebo-controlled, randomized crossover design.

Setting

Neurology department in a German university.

Participants

Eighteen patients with chronic motor dysfunction because of stroke (13 men, 5 women; age range, 53-78y; mean time poststroke ± SD, 3.3±2.1y).

Intervention

Patients received 3 doses of levodopa (100mg of levodopa plus 25mg of carbidopa) or placebo before 1 session of procedural motor learning.

Main Outcome Measures

Procedural motor learning performed by using the paretic hand assessed by using a modified version of the serial reaction time task with a probabilistic sequence. The primary outcome measure was the difference in reaction times between random and sequential elements.

Results

Levodopa significantly improved our primary outcome measure, procedural motor learning, compared with placebo (P<.05). Reaction times to random elements, analysis of error rates, psychophysical assessments, and performance in a simple motor task were comparable between conditions, indicating that better learning under levodopa was not caused by differences in response styles, arousal, mood, or motor reaction times but that levodopa modulated learning.

Conclusions

Our results show that levodopa may improve procedural motor learning in patients with chronic stroke, in line with our hypothesis. These findings suggest that this interventional strategy in combination with customary rehabilitative treatments could significantly improve the outcome of neurorehabilitation in the chronic stage after stroke. (Clinicaltrials.gov identifier NCT00126087.)     

Restoration of gait and motor recovery by functional electrical stimulation therapy in persons with stroke

Purpose.?To evaluate the clinical efficacy of functional electrical stimulation (FES) therapy of the tibialis anterior (TA) muscle on gait restoration and enhancing motor recovery with stroke patients.

Method.?Thirty hemiparetic participants with spastic foot-drop impairments who were at least 3 months post-stroke were recruited from a rehabilitation institute and were assigned either to a control group or a FES group. Both the groups participated in a conventional stroke rehabilitation program for 60?min per day, 5 days a week, for 12-weeks. The FES group received the electrical stimulation to the TA muscle for correction of foot-drop.

Results.?Functional electric stimulation (FES) resulted in a 26.3% (p?<?0.001) improvement of walking speed measured with 10-m walkway, whereas the improvement in the control group was only 11.5% (p?<?0.01). The FES group also showed significantly greater improvements compared to control group in other gait parameters (e.g. cadence, step length), physiological cost index (PCI), ankle range of motion, spasticity of calf muscle, Fugl–Meyer scores, and the maximum value of the root mean square (RMS_max), which reflects the capacity of the muscle output.

Conclusions.?These findings suggest that, the FES therapy combined with conventional therapy treatment more effectively improves the walking ability and enhances the motor recovery when compared with conventional therapy alone in stroke survivors.     

Effects of robotic therapy on motor impairment and recovery in chronic stroke

OBJECTIVE: To examine whether robotic therapy can reduce motor impairment and enhance recovery of the hemiparetic arm in persons with chronic stroke. DESIGN: Pre-posttest design. SETTING: Rehabilitation hospital, outpatient care. PARTICIPANTS: Volunteer sample of 20 persons diagnosed with a single, unilateral stroke within the past 1 to 5 years, with persistent hemiparesis. INTERVENTIONS: Robotic therapy was provided 3 times weekly for 6 weeks. Subjects able to reach robot targets were randomly assigned to sensorimotor or progressive-resistive robotic therapy groups. Robotic therapy consisted of goal-directed, planar reaching tasks to exercise the hemiparetic shoulder and elbow. MAIN OUTCOME MEASURES: The Modified Ashworth Scale, Fugl-Meyer test of upper-extremity function, Motor Status Scale (MSS) score, and Medical Research Council motor power score. RESULTS: Evaluations by a single blinded therapist revealed statistically significant gains from admission to discharge (P<.05) on the Fugl-Meyer test, MSS score, and motor power score. Secondary analyses revealed group differences: the progressive-resistive therapy group experienced nonspecific improvements on wrist and hand MSS scores that were not observed in the sensorimotor group. CONCLUSIONS: Robotic therapy may complement other treatment approaches by reducing motor impairment in persons with moderate to severe chronic impairments.     

Relation between stimulation characteristics and clinical outcome in studies using electrical stimulation to improve motor control of the upper extremity in stroke.

OBJECTIVE: Electrical stimulation can be applied in a variety of ways to the hemiparetic upper extremity following stroke. The aim of this review is to explore the relationship between characteristics of stimulation and the effect of electrical stimulation on the recovery of upper limb motor control following stroke. METHODS: A systematic literature search was performed to identify clinical trials evaluating the effect of electrical stimulation on motor control. The reported outcomes were examined to identify a possible relationship between the reported effect and the following characteristics: duration of stimulation, method of stimulation, setting of stimulation parameters, target muscles and stage after stroke. RESULTS: Nineteen clinical trials were included, and the results of 22 patient groups were evaluated. A positive effect of electrical stimulation was reported for 13 patient groups. Positive results were more common when electrical stimulation was triggered by voluntary movement rather than when non-triggered electrical stimulation was used. There was no relation between the effect of electrical stimulation and the other characteristics examined. CONCLUSION: Triggered electrical stimulation may be more effective than non-triggered electrical stimulation in facilitating upper extremity motor recovery following stroke. It appears that the specific stimulus parameters may not be crucial in determining the effect of electrical stimulation.     

Transcutaneous electrical nerve stimulation (TENS) reduces chronic hyperalgesia induced by muscle inflammation

Transcutaneous electrical nerve stimulation (TENS) reduces pain through central mechanisms involving spinal cord and brainstem sites. Since TENS acts through central mechanisms, we hypothesized that TENS will reduce chronic bilateral hyperalgesia produced by unilateral inflammation when applied either ipsilateral or contralateral to the site of muscle inflammation. Sprague-Dawley rats were injected with carrageenan in the left gastrocnemius muscle belly. Mechanical withdrawal threshold was tested bilaterally before and 2 weeks after carrageenan injection. After testing withdrawal thresholds at 2 weeks, rats received TENS treatment either ipsilateral or contralateral to the site of inflammation. In each of these groups, rats were randomized to control (no TENS), low frequency (4 Hz), or high frequency (100 Hz) TENS treatment. TENS was applied for 20 min at sensory intensity under light halothane anesthesia. Mechanical withdrawal thresholds were re-assessed after TENS or 'no TENS' treatment. Unilateral injection of carrageenan to the gastrocnemius muscle significantly reduced the mechanical withdrawal threshold (mechanical hyperalgesia) bilaterally 2 weeks later. Either low or high frequency TENS applied to the gastrocnemius muscle ipsilateral to the site of inflammation significantly reversed mechanical hyperalgesia, both ipsilateral and contralateral to the site of inflammation. Low or high frequency TENS applied to the gastrocnemius muscle contralateral to the site of inflammation also significantly reduced mechanical hyperalgesia, both ipsilateral and contralateral to the site of inflammation. Since ipsilateral or contralateral TENS treatments were effective in reducing chronic bilateral hyperalgesia in this animal model, we suggest that TENS act through modulating descending influences from supraspinal sites such as rostral ventromedial medulla (RVM).     

P型迭代学习控制法在上肢FNS反馈控制中的应用

目的；探讨闭环控制在功能性电刺激中的应用，根据反馈信号来实时调节控制刺激的输出强度、方法：利用Ｐ型迭代学习控制方法，对正常人和偏瘫患者上肢肘关节运动角度分别进行了运动反馈控制研究。结果及结论：迭代学习控制，算法简单，参数易调整，控制量变化平缓，轨迹跟踪精度高，在对正常人和瘫痪患者上肢肘关节的运动控制中，基本能达到预期效果。     

变频相位干涉电场刺激对运动皮层兴奋性及运动学习表现的影响

摘要 目的：探究变频相位干涉电场刺激（temporal interference electrical fields stimulation, TI）对健康成年人运动皮层兴奋性及运动学习能力的影响,为TI刺激的应用提供依据。 方法：采用随机交叉双盲设计,研究对象为健康成年人。试验1：20例受试者完成经颅磁刺激（transcranial magnetic stimulation,TMS）测试,评估刺激前后皮层兴奋性指标的改变,包括运动诱发电位（motor evoked potential, MEP）、静息运动阈值（resting motor threshold, RMT）、短时距皮层内抑制（short-interval intracortical inhibition, SICI）、皮质内促通（intracortical facilitation, ICF）。试验2：16例受试者完成随机反应时任务（random reaction time task, RRTT）和序列反应时任务（serial reaction time task, SRTT）,测试指标包括平均反应时（reaction time, RT）、第一内隐学习（first implicit learning, FIL）、第二内隐学习（second implicit learning, SIL）。通过双因素重复测量方差分析评价TI刺激对受试者运动皮层兴奋性及运动学习能力的影响。 结果：试验1：刺激条件和时间对MEP（F=28.787,P<0.001,ηP2=0.602）和RMT（F=23.524,P<0.001,ηP2=0.580）具有显著交互作用,而SICI和ICF无显著交互效应。试验2：与假刺激相比,TI刺激后SRTT中的FIL有显著提升（F=4.601,P=0.049,ηP2=0.235）,而RRTT任务则无显著交互效应。 结论：变频TI刺激可以显著增加初级运动皮层的兴奋性,这种调控效应可能有助于促进健康成年人运动学习表现。     

Effects of electromyography-driven robot-aided hand training with neuromuscular electrical stimulation on hand control performance after chronic stroke

Purpose: An electromyography-driven robot system integrated with neuromuscular electrical stimulation (NMES) was developed to investigate its effectiveness on post-stroke rehabilitation. Methods: The performance of this system in assisting finger flexion/extension with different assistance combinations was evaluated in five stroke subjects. Then, a pilot study with 20-sessions training was conducted to evaluate the training’s effectiveness. Results: The results showed that combined assistance from the NMES–robot could improve finger movement accuracy, encourage muscle activation of the finger muscles and suppress excessive muscular activities in the elbow joint. When assistances from both NMES and the robot were 50% of their maximum assistances, finger-tracking performance had the best results, with the lowest root mean square error, greater range of motion, higher voluntary muscle activations of the finger joints and lower muscle co-contraction in the finger and elbow joints. Upper limb function improved after the 20-session training, indicated by the increased clinical scores of Fugl-Meyer Assessment, Action Research Arm Test and Wolf Motor Function Test. Muscle co-contraction was reduced in the finger and elbow joints reflected by the Modified Ashworth Scale. Conclusions: The findings demonstrated that an electromyography-driven NMES–robot used for chronic stroke improved hand function and tracking performance. Further research is warranted to validate the method on a larger scale.

• Implications for Rehabilitation

• The hand robotics and neuromuscular electrical stimulation (NMES) techniques are still separate systems in current post-stroke hand rehabilitation. This is the first study to investigate the combined effects of the NMES and robot on hand rehabilitation.

• The finger tracking performance was improved with the combined assistance from the EMG-driven NMES–robot hand system. The assistance from the robot could improve the finger movement accuracy and the assistance from the NMES could reduce the muscle co-contraction on finger and elbow joints.

• The upper limb functions were improved on chronic stroke patients after the pilot study of 20-session hand training with the combined assistance from the EMG-driven NMES–robot. The muscle spasticity on finger and elbow joints was reduced after the training.

     

经皮穴位电刺激对脑卒中患者上肢功能及运动诱发电位的影响

摘要 目的：探讨经皮穴位电刺激（TAES）对脑卒中恢复期患者偏瘫上肢功能及运动诱发电位（MEP）的影响。 方法：41例脑卒中恢复期患者随机分为TAES组（n=21）和安慰刺激组（n=20）。TAES组采用TAES治疗仪治疗于患侧上肢的肩髃、曲池、外关和合谷4个穴位行频率100Hz、脉宽0.2ms和患者可耐受最大强度的电刺激治疗,1次/d,1h/次,5次/周,连续3周;安慰刺激组接受TAES安慰刺激（即仅连接TAES治疗仪,不开机）。治疗前、治疗第2周、治疗第3周时行患侧上肢Fugl-Meyer评分和改良Barthel指数评分（MBI）评定及患侧皮质MEP的检测。 结果：治疗前两组患者基线资料类似（P>0.05）。治疗第2周和第3周两组患者的FMA-UE、MBI评分及MEP与治疗前比较均改善（P<0.05）;TAES组FMA-UE、MBI评分及MEP的改善较安慰刺激组明显（P<0.01）。 结论：TAES治疗能改善脑卒中恢复期患者上肢功能,提高生活自理能力,推测其机制可能与增强脑卒中患者患侧大脑皮质兴奋性有关。     

踏车训练中应用循环性功能性电刺激对脑卒中患者下肢运动功能恢复的影响

目的:观察踏车训练中联合应用循环性功能性电刺激对脑卒中患者下肢运动功能恢复的影响。方法:40例脑卒中患者随机数字表法分为观察组和对照组各20例。2组均采用常规康复训练,其中对照组增加下肢踏车训练(RT300踏车训练系统),观察组在踏车训练的基础上增加循环性功能性电刺激(FES)训练。治疗前后分别采用简式Fugl-Meyer评定法(FMA),Berg评定法(BBS),功能性步行分级量表(FAC)进行下肢运动功能评定。结果:治疗8周后,2组FMA、BBS评分及FAC分级均较治疗前明显提高(均P0.05),且观察组高于对照组(P0.05)。结论:在踏车训练中联合应用循环性功能性电刺激能够更好地改善脑卒中患者的下肢运动功能。     

感觉电刺激对慢性期脑卒中患者上肢运动及感觉功能的影响

目的:探讨感觉电刺激对慢性期脑卒中患者上肢运动及感觉功能的影响。方法:招募病程超过6个月的脑卒中患者78例,随机分为两组:试验组为感觉电刺激加常规运动治疗组39例,对照组为神经肌肉电刺激加常规运动治疗组39例。两组患者分别在治疗前后进行感觉阈值、两点辨别觉、捏力、握力的评定及功能独立性评定(FIM)Fugl-Meyer运动功能评定。结果:两组患者的治疗前后的FIM评分及Fugl-Meyer评分比较均有显著差异(P0.05);治疗后两组间对比,试验组捏力和两点辨别觉较对照有显著性差异(P0.05)。结论:感觉电刺激可改善慢性期脑卒中患者的手部肌力无感觉,其疗效优于常规康复治疗。     

Transcutaneous electrical nerve stimulation: its role in the control of chronic pain

An assessment was made of the effectiveness of long-term transcutaneous electrical nerve stimulation (TENS) in the treatment of chronic posttraumatic pain. Compensation Board files showed that 846 patients received TENS from 1975 to 1979, with more than 70% having intractable back pain. Of this group using TENS, 44.6% were free of disability, and an additional 36.2% were capable of modified work. Questionnaire responses were obtained from 563 of 637 patients receiving TENS in 1978 or 1979. At the six-month follow-up, most respondents (472, 83.8%) reported continuing benefit from TENS, including a reduction of pain (418, 74.2%), less need for medication (322, 57.2%), and improved sleep patterns (331, 58.8%). Only 13.6% of those who had returned to work reported no benefit from TENS, while 18.4% of those still unemployed reported no benefit. Among those who had returned to work (264 cases, 46.9% of respondents), benefit was reported equally by those with back injuries and by those with other injuries. The responses observed in this trial seem larger and more long-lasting than could be obtained by a placebo effect, and further attempts at a controlled trial may be warranted. However, there are major practical difficulties to such an investigation, and the resulting controversy could reduce the therapeutic effectiveness of TENS in conditions where alternative treatments are either ineffective or undesirable.     

电视腹腔镜胆囊切除128例无胆道损伤并发症

1993年10月至1997年1月，应用电视腹腔镜进行胆囊切除术128例，无一例胆道损伤并发症。128例中有12例因Calot三角区严重粘连或胆囊完全萎缩或因既往手术史而致腹腔内广泛粘连而中转开腹，1例放置腹腔引流管，但24小时仅引出不足10ml淡血性液体，全组病例无一例胆道损伤，术中术后均未发生其他并发症，术后住院3天～7天，约10天可恢复正常工作，这一高新科技手术适应于腹腔和胆囊周围无广泛粘连的病例，其最大的优点是创伤小，疼痛轻微，胃肠道功能恢复快，康复时间短。     

多通道功能性电刺激对脑卒中患者下肢运动功能的影响

目的：探讨多通道功能性电刺激（FES）对脑卒中偏瘫患者早期下肢运动及平衡功能的影响及其脑可塑性机制。方法：将早期脑卒中患者18例随机分为FES组10例和对照组8例。2组均采用常规治疗,FES组加用基于人体正常行走模式设计的FES治疗仪治疗,对照组给予无电流输出的安慰电刺激。治疗前后采用Fugl—Meyer运动评定量表（FMA）中下肢部分评定下肢运动功能和Berg平衡量表（BBS）评定平衡功能,并给予核磁共振弥散张力成像（DTI）检查。结果：治疗3周后,2组FMA及BBS评分均较治疗前明显提高（P〈0．05）,且FES组更高于对照组（均P〈0．05）;DTI检查结果显示：治疗后,FES组病灶局部水肿较治疗前明显减少,双侧纤维束较治疗前明显增多增粗;对照组病灶局部水肿较治疗前减少,患侧纤维束较治疗前增加不明显。结论：FES治疗能提高脑卒中早期患者下肢运动功能,改善平衡功能,同时促进脑功能重组。