The orthotic effect of functional electrical stimulation on the improvement of walking in stroke patients with a dropped foot: a systematic review

OBJECTIVE: Analysis of the available evidence on the improvement of walking in stroke patients with a dropped foot when using peroneus stimulation. METHODS: A systematic review was performed to identify trials that investigated the orthotic effect of functional electrical stimulation (FES) on walking in stroke patients with a dropped foot. Two independent raters scored the methodological quality of the included articles. Walking speed and physiological cost index (PCI) were selected as the primary outcome measures. Studies that measured walking speed were pooled and a pooled difference including confidence interval was calculated. RESULTS: Eight studies were included in the review, of which one was a randomized controlled trial. Methodological score ranged from 8 to 18 out of 19. Six studies measured walking speed. The pooled improvement in walking speed was 0.13 m/s (0.07-0.2) or 38% (22.18-53.8). CONCLUSIONS: The present review suggests a positive orthotic effect of functional electrical stimulation on walking speed.     

Can forced-use therapy be clinically applied after stroke? An exploratory randomized controlled trial

OBJECTIVE: To determine the efficacy, safety, and compliance with forced-use therapy (FUT) applied without additional "shaping" therapy during the rehabilitation phase of stroke. DESIGN: Prospective, randomized controlled trial. SETTING: Tertiary mixed rehabilitation center. PARTICIPANTS: Consecutive sample of 30 inpatients or outpatients with first stroke showing minimal movement of the arm and hand. Subjects who scored below 26 on the Mini-Mental State Examination were excluded. Seven subjects either did not provide consent or withdrew from the study. The remaining subjects were randomized into the control group (n=13) and the FUT group (n=10). INTERVENTION: FUT involved wearing a thick constraint mitten on the sound arm for as many as 6 hours a day. MAIN OUTCOME MEASURES: The Chedoke McMaster Impairment Inventory for arm, hand, postural control, and shoulder pain; Action Research Arm Test; grip strength; and FIM instrument. RESULTS: FUT subjects experienced 20% more recovery of the arm than did control subjects and more recovery of postural control (P=.04). Men benefited most from the program, and there was a tendency for FUT subjects to have more shoulder pain. Compliance was related to cognitive status. CONCLUSIONS: FUT, without shaping therapy, appears to augment arm recovery, but a larger sample is required to confirm these findings. The FUT mitten was safe and well tolerated; however, more research is needed to determine the relation between FUT and hemiplegic shoulder pain.     

Belief and awareness: reflections on a case of persistent anosognosia

Persisting anosognosia after acute lesions is relatively rare, and no case studies to date have reported functional scanning investigation of this disorder. This is a case report of an 85-year-old right-handed Scottish woman, EN, who showed persistent anosognosia for hemiplegia following a haemorrhagic stroke. Extensive damage in the right hemisphere caused left upper and lower limb flaccid hemiplegia and severe left-sided neglect. Lack of awareness for her deficits was still present 2 years after the stroke, when neurological, neuropsychological, and SPECT examinations were performed. Testing revealed severe left unilateral neglect and poor performance on verbal fluency tasks. EN had age normal memory performance, and her object recognition and praxic abilities were preserved. She showed no global reasoning or language problems apart from her abnormal beliefs. EN believed that she was able to walk and carry out several activities, in a context of other disorders of belief. SPECT scan showed marked hypoperfusion in the right parietotemporal cortex and this extended to the associative cortex in the right frontal regions. The persistence of anosognosia in this patient cannot be explained by memory impairments or global cognitive decline. A possible account might be that alteration in awareness was maintained by contingent right frontal and/or parietal dysfunction causing a suspension or change in the ability to monitor and check the 'real' and especially to assess the veracity of mental contents.     

13例儿童交替性偏瘫的临床特征

目的 总结儿童交替性偏瘫(AHC)的临床特征。方法 对13例AHC患儿的临床与实验室资料进行分析。13例均做头颅MRI、脑电图(EEG)检查,血氨基酸、尿有机酸分析,血乳酸、丙酮酸测定。部分患儿做头颅磁共振血管成像(MRA)、数字减影动脉造影(DSA)及录像脑电图(VEEG)监测。结果 13例中男12例,女1例。发病年龄2d～55个月,平均13．1个月。起病症状表现为眼的运动异常(包括斜视、双眼向上或向一侧凝视、眼震)2例,眼的运动异常伴肌张力不全姿势9例,偏瘫2例。本组均有反复的偏瘫发作,每次发作持续时间数分钟～10d。发作频率从每天8次到每两月1次。10例在偏瘫发作时反复出现眼的运动异常或肌张力不全姿势,伴舞蹈手足徐动2例,共济失调1例。7例曾有四肢瘫的病史,在四肢瘫发作时伴构音障碍或失语4例,伴呼吸急促和吞咽困难各2例。无力和上述发作性症状在睡眠时减轻。有智力障碍者9例,惊厥3例。除3例有EEG或VEEG异常外,其余实验室检查均正常。12例用氟桂利嗪治疗的患儿中,有8例偏瘫发作严重程度、持续时间和发作频率有降低。结论 AHC是一种以频繁发作的交替性偏瘫伴锥体外系症状和智力低下为临床特征的疾病,氟桂利嗪治疗对部分病例有效。     

Computed tomographic studies of the basis pedunculi in chronic hemiplegic patients: Topographic correlation between cerebral lesion and midbrain shrinkage

Summary A computed tomographic method for analyzing the shrinkage of the basis pedunculi (BP) due to the secondary degeneration of the descending fibers was applied in correlation to the site of cerebral lesions in 89 chronic hemiplegic patients. Cerebral lesions in the anterior coronar radiata or the anterior limb of the capsula interna caused shrinkage of the medial BP. Lesions in the central corona radiata or the genu and posterior limb of the capsula interna caused shrinkage of the central BP, while lesions of the posterior corona radiata or the posterior limb of the capsula interna caused shrinkage of the lateral BP. These results suggested that CT images are able to reveal the principle sites of atrophy of the descending fiber tracts in chronic hemiplegia.     

临床护理路径在脑外科偏瘫高危患者肢体早期活动中的应用研究

目的 为脑外科偏瘫高危患者肢体早期活动寻找最佳的临床护理路径,以减少肢体瘫痪,提高生活质量.方法 将2007年1-12月收治的112例脑外科偏瘫高危患者作为实验组,于入院第1天进行肢体早期活动,并应用临床护理路径进行肢体早期活动;选取2006年1-12月89例手术后病情稳定时进行肢体活动患者作为对照组.分别于2组出入院时运用布郎斯壮运动功能评价法(Brunnstrom)进行等级评估,并对结果进行比较.结果 实验组上肢、手、下肢肢体活动功能等级显著高于对照组(P＜0.05),特别是手的分离运动增强,协调能力提高,差异有统计学意义(P＜0.01).结论 对脑外科偏瘫高危患者应用临床护理路径进行肢体早期活动,能达到有效地恢复肢体功能运动的目的 .     

Kinematic effects on gait of a newly designed ankle-foot orthosis with oil damper resistance: a case series of 2 patients with hemiplegia

The ankle joint of ankle-foot orthoses (AFOs) should restrict plantarflexion to prevent foot drop during the swing phase. However, excessive plantarflexion resistance causes excessive knee flexion during the stance phase. Plantarflexion resistive moment should be easily adjustable according to the gait ability of patients with hemiplegia. Because it is difficult to adjust plantarflexion resistive moment exactly, we developed an AFO with an oil damper. It is a small shock absorber that utilizes hydraulic resistance. The oil damper generates a resistive moment to the plantarflexion rotation of the ankle joint at the initial stance phase. The magnitude of the plantarflexion resistive moment at the heel strike can be easily adjusted to accommodate each patient's condition by simply turning an adjustment screw. We used a gait analysis system to compare the gait of 2 hemiplegic patients while they were wearing either the AFO with the oil damper or the AFO with the plantarflexion stop. The AFO with the oil damper achieved sufficient plantarflexion of the ankle and mild flexion of the knee by adjusting a proper plantarflexion resistive moment during initial stance phase, and provided a more comfortable gait than did the AFOs with a plantarflexion stop.     

Ipsilateral motor pathway confirmed by combined brain mapping of a patient with hemiparetic stroke: a case report

This study investigated the motor control pathway using both functional magnetic resonance imaging (fMRI) and transcranial magnetic stimulation (TMS) in a patient with left hemiparesis with an infarction on the posterior limb of the right internal capsule. fMRI was performed using the blood oxygen level-dependent technique at 1.5 T with a standard head coil. The motor activation task consisted of hand grasp-release movements in 1-Hz cycles. TMS was performed using a butterfly coil; the intersection of the wings (center of the coil) was applied tangentially to the scalp 1.0 cm apart. Stimulation was performed at 100% of maximal output. Motor evoked potentials (MEPs) from both abductor pollicis brevis (APB) muscles were obtained simultaneously. fMRI showed that the unaffected (left) primary sensorimotor cortex (SM1) was activated by movements of the unaffected (right) hand. Conversely, the bilateral SM1 were activated by movements of the affected (left) hand. Brain mapping using TMS showed that ipsilateral MEPs were obtained at the affected (left) APB muscle when the unaffected (left) motor cortex was stimulated. We concluded that the ipsilateral motor pathway from the unaffected motor cortex to the affected hand was present in this patient.