Motor dysfunction of the hand and upper limb is a major cause of physical disability for patients with chronic stroke. Our aim was to investigate the effectiveness of a peripheral plus central ...repetitive transcranial magnetic stimulation (rTMS) treatment for upper limb motor rehabilitation in chronic stroke patients.
We reported the case of a patient WLX, who had one ischemic stroke more than 3 years ago, and had underwent intermittent rehabilitation since then. He still had profound right upper limb paralysis and moderate spasm, accompanied with non-fluent aphasia when came to our department; and complained that his recovery had been rather slow for about two years. In addition to the custom rehabilitation, we applied a peripheral plus central rTMS paradigm to him, which included 3 sessions of peripheral magnetic stimulation to his paralyzed right forearm, followed by a session of high frequency rTMS to the bilateral sensorimotor cortex region. The total magnetic stimulation therapy lasted about 30min a day, and was applied 5 days/week for 4 weeks.
After 4 weeks’ treatment, the patient's Fulg–Meyer upper limb assessment (FMA) score was obviously improved (from 27 to 37 points), and the spasm was largely relieved in his right hand and arm.
Peripheral plus central rTMS might be an effective treatment for motor dysfunction of chronic stroke patients.
Mirror therapy (MT) (affected limb is masked inside the mirror box) and modified constraint induced movement therapy (mCIMT) (unaffected limb is constrained during therapy hours) are well established ...and effective therapies in the upper extremity functioning of children with Cerebral Palsy (CP). But comparing the effectiveness of MT and mCIMT is an understudied area, especially in CP. The aim of this study was to compare the effectiveness MT with mCIMT in the rehabilitation of persons with hemiplegic CP post orthopaedic selective spasticity surgery (OSSCS).
A prospective clinical trial was conducted among 80 persons with CP, who were selected and randomly assigned into two groups. All the persons underwent OSSCS of forearm flexors and pronators of affected upper limb and were undergoing rehabilitation with a sequenced protocol based physical and occupational therapy. Group A (n=40) received MT (6 weeks-1hour/day), Group B (n=40) received mCIMT (6 weeks-1hour/day) and both the groups received regular intensive physical and occupational therapy apart from the above interventions. The primary outcome measures included were the Besta scale and Melbourne assessment of upper extremity function (MAUULF). Outcomes were measured at baseline, 6 weeks after the treatment and follow-ups at 1 month and 3 months later.
After six weeks of treatment, the mCIMT group showed significant improvements compared to the MT group in both Besta (P<0.01) and MAUULF (P<0.01) scores for hemiplegic upper extremity who underwent OSSCS. The obtained outcomes were maintained at 1 month and 3 months follow up also.
Modified CIMT showed greater improvement than MT in the upper extremity function of persons with hemiplegic CP. However, both the groups improved in their outcomes compared to baseline.
Upper extremity of persons with spastic cerebral palsy (CP) typically presents with various problems including an impaired range of motion that affects the positioning of the upper extremity. This ...impaired range of motion often develops into contractures that further limit functioning of the spastic hand and arm. Orthopaedic Selective Spasticity Surgery (OSSCS) involves 2 procedures of intramuscular lengthening and sliding lengthening for reduction of spasticity. To evaluate effectiveness of upper extremity OSSCS on muscle tone and functional outcome in persons with cerebral palsy (CP).
A retrospective analysis was done among 120 persons with spastic quadriplegia and hemiplegia, aged 5 to 20 years, who underwent OSSCS of elbow flexors, forearm flexors, pronators and hand intrinsic muscles. The rehabilitation after the removal of plaster after 2 weeks, involved occupational therapy, physiotherapy and aquatic therapy. The rehabilitation was for 6 days per week for 5 months. The outcome measures were modified Ashworth Scale (mAS), Manual Ability Classification System (MACS) and Melbourne Assessment of Unilateral Upper Limb Function (MAUULF). Data were collected at baseline and at 5 months’ post-surgery. Follow-up data was collected 1-year post-surgery.
Among the study group, females (62%) were predominant and 45% of the participants were aged 10 to 15 years. The commonest muscles released were the forearm flexors and pronators (78%). Persons who underwent OSSCS followed by rehabilitation showed a significant improvement of mAS (P<0.001), MACS (P<0.001), MAUULF (P<0.001) compared to the baseline. The follow-up data were obtained for around 55% of the participants, in which the progress was maintained in more than 80% of the participants.
Upper extremity OSSCS followed by intensive rehabilitation is effective in reduction of upper extremity muscle tone and improvement of function among persons with cerebral palsy.
Rehabilitation of the upper limb post-stroke represents a significant challenge with only 5% of severely affected individuals fully recovering function of their arm and hand. This study used a newly ...designed instrumented bimanual exerciser to assess the effects of an error augmentation (EA) protocol on upper limb bilateral coordination post-stroke.
Twenty participants, 10 individuals post-stroke (median age; time post-stroke 60.5 years; 4 months) able to hold a handle (median Chedoke hand 4/7) and 10 healthy controls, volunteered to participate. They were assessed on the bimanual exerciser using an EA protocol (baseline with symmetrical resisted movement at 30% (1min) and 15% (1min); adaptation with asymmetrical resistance (15% and 30%: 6min) and post-adaptation at 15% resistance (3min). The effects of the EA protocol on bilateral synchronisation when initiating pushing movements were determined.
Stroke and healthy participants took the same time to execute the baseline 15% pushing task (median 0.8–1s). The movement amplitude for the non-paretic arm was greater than for the paretic one (34cm vs. 30cm). Stroke participants produced a maximal symmetrical pushing force 25% lower on the paretic side while healthy participants had symmetrical values (7% difference). For both groups, the asymmetric resistance (adaptation) modified the bilateral coordination with increasing onset delays between arms (median values: healthy: 6.4% (55ms); Stroke: 9.4% (89ms)). The delays were reversed and differed from baseline at the beginning of the post-adaptation period (post-effects). The large between-subject variability prevented the detection of a difference between groups although the delays were greater overall in post-stroke participants during the adaptation period.
Preliminary findings suggest that the EA protocol could modify the timing between movements of the two arms during a bimanual task. Additional data is currently analysed to further understand the potential benefits of training patients with the bimanual exerciser on inter-limb coordination.
Shoulder spasticity post-stroke or -traumatic brain injury (TBI) may cause pain and restrict joint range of motion (ROM). Few studies have investigated botulinum toxin injections into shoulder ...muscles for spasticity treatment. Here we present data for sub-populations of patients receiving shoulder injections of abobotulinumtoxinA (aboBoNT-A) in two international, multicentre clinical studies: phase-4 Upper Limb International Spasticity Study-II (ULIS-II; post-stroke spasticity; NCT01020500), and phase-3 AUL open-label study (Adult Upper Limb; post-stroke or -TBI spasticity; NCT01313299).
ULIS-II: selection and achievement of patient-centred primary goals. AUL study: Tardieu scale for passive ROM (XV1), angle of catch (XV3) and spasticity angle (X) for shoulder muscles; and Modified Frenchay Scale (MFS) for active function.
In ULIS-II, 82 patients receiving aboBoNT-A in shoulder muscles selected pain treatment goal three times more often than those without (Fig. 1), with high goal achievement (85.7 and 85.0%, respectively). In AUL study, 96 patients received ≥1 injection cycle in shoulder muscles, of which 84 received ≥ 2 shoulder injections. In patients with 1 shoulder injection, improved shoulder muscle spasticity (Tardieu) at last injection cycle: mean change from baseline at Week 4 was +12.3° and −8.2° for XV3, and X, respectively (Fig. 2). Patients with ≥ 2 shoulder injections had an improvements of +17.9° in XV3. Concomitant improvements were also observed in active function (Week 4 Cycle 4, ≥ 2 shoulder injections: MFS: +0.71 0.48) (Fig. 3). A trend towards lower injection doses in proximal compared with distal muscles was seen.
Post-stroke or -TBI patients receiving abobotulinumtoxinA in shoulders, in addition to other proximal muscle groups, reached high levels of goal achievement, particularly relating to pain and showed improvement in active function (MFS).
Upper limb (UL) robotic assisted therapy (RAT) is a powerful promising tool for stroke rehabilitation, particularly in the early stage. Associated to conventional therapy (CT), studies agreed that ...RAT decrease UL impairment. When it is provided as substitution, RAT is at least as effective as CT, but it remains uncertain if it is more effective than CT. In addition, studies often confine themselves to a single domains of the International Classification of Functioning framework (ICF).
This study aims to perform a single-blind randomized controlled trial to evaluate effectiveness of UL RAT in the acute phase of stroke rehabilitation following ICF, with RAT as partial substitution to CT.
Forty-five acute stroke patients were randomized into two groups (CT group, n=22 and RAT group, n=23). Both interventions were dose-matched about the duration of treatment and lasted nine weeks. The CT followed a standard rehabilitation. In the RAT group, four sessions of CT (25%) were substituted by RAT each week. RAT consisted of moving the paretic UL along a reference trajectory while the robot provided an assistance-as-needed. A blinded assessor evaluated the patients before and after the intervention and at 6-month post-stroke according to all domains of ICF.
Seventeen patients dropped out during the study. The UL motor control (Fugl Meyer +16%; P=0.05) and gross manual dexterity (Box and Block test +10 blocks/min; P=0.02) improved significantly more in the RAT group than in the CT group at 6-months post-stroke. The ability to perform activities of daily living and their social participation tend also to improve more in the RAT group than in CT group.
RAT is effective for the UL motor rehabilitation in the acute phase of stroke rehabilitation. Thus, a RAT protocol can be included in practice increasing patient intensity of rehabilitation and decreasing patient's impairments.
Upper limb pain after breast cancer treatment is a common and difficult to treat problem. The aim of the present study was to investigate the effect of a single botulinum toxin A infiltration in the ...pectoralis major muscle in addition to a standard physical therapy program for treatment of persistent upper limb pain in breast cancer survivors.
Fifty breast cancer patients with pain participated in a double-blinded randomized controlled trial. The intervention group received a single botulinum toxin A (BTX-A) infiltration. The control group received a placebo (saline) infiltration. Within one week after the infiltration, all patients attended an individual physical therapy program (12 sessions) during the first 3 months and a home exercise program up to 6 months after infiltration. The primary outcome was change in pain intensity at the upper limb (Visual Analogue Scale VAS 0–100) after 3 months. Secondary outcomes were prevalence rate of pain, pressure hypersensitivity, pain quality, shoulder function and quality of life. Measures were taken before the intervention and at 1, 3 and 6 months follow-up.
No significant difference in change in pain intensity after 3 months was found (mean difference in change of 3/100; 95% CI: −13 to 19). From baseline up to 6 months, a significantly different change in upper limb pain intensity was found between groups in favor of the intervention group (mean difference in change of 16/100; 95% CI: 1 to 31).
A single botulinum toxin A infiltration in combination with an individual physical therapy program has been found to significantly decrease pain intensity at the upper limb in breast cancer survivors up to 6 months. However, the effect size was not clinically relevant and no other beneficial effects were found.
Initial muscle tone increase may be apparent within 6 weeks, and even days, post-stroke. Botulinum toxin-A (BoNT-A), an effective and well-tolerated treatment for upper limb spasticity (ULS), ...improves muscle tone and function, however most studies were conducted>6 months post-stroke. The ONTIME and ABCDE-S studies assessed efficacy and safety of early use (2–12 weeks post-stroke) of abobotulinumtoxinA (aboBoNT-A) in ULS.
ABCDE-S (NCT00234546; 2008): 24-week, randomised (1:1 aboBoNT-A n=80: placebo n=83), study assessing muscle tone changes in patients treated within 2–12 weeks of first stroke, with a Modified Ashworth Scale (MAS) score≥1+. ONTIME (NCT02321436; 2016): 28-week, randomised study (2:1 aboBoNT-A n=28: placebo n=14), assessing time to appearance or reappearance of reinjection criteria in patients with MAS score≥2 treated 2–12 weeks post-stroke. All observed or volunteered adverse events (AEs) were recorded.
MAS score improvements at Week 4 were greater in aboBoNT-A-treated patients than placebo in both studies (ABCDE-S −1.5 vs. −0.5; ONTIME −1.25 vs. −0.25). At 12-weeks post-injection, fewer aboBoNT-A-treated patients versus placebo had MAS scores≥2 in ONTIME (29.6 vs. 69.2%) and ABCDE (21.3 vs. 60.2%) (Table 1). In ONTIME, 11 (39.3%) aboBoNT-A-treated patients did not require reinjection for≥28 weeks versus 2 (14.3%) for placebo. AboBoNT-A was well-tolerated; most AEs were mild–moderate in intensity, with no clinically significant differences in AEs between groups (Table 2). Six patients had treatment-related AEs: two in placebo groups (dysuria and complex regional pain syndrome), and four in aboBoNT-A groups (fatigue n=2, pyrexia, muscular weakness). No serious AEs or deaths were considered treatment-related.
Early treatment with aboBoNT-A (2–12 weeks) was well-tolerated and had a longer time to reinjection versus placebo.
Background and purpose
Parkinson’s disease (PD) reduces independence and quality of life through deterioration of upper limb motor function. Transcranial direct current stimulation (tDCS) may offer ...an alternative, adjunctive therapy for PD. However, the efficacy of tDCS for upper limb motor rehabilitation in PD is unknown. In this systematic review, evidence is compiled regarding the effects of tDCS on upper limb motor function in PD.
Methods
Studies of tDCS applied to PD patients that assessed upper limb motor function, conducted between January 2000 and November 2018, were screened for inclusion via a systematic search of Medline, Cochrane, PsycINFO, EMBASE, CINAHL, and Web of Science.
Results
Ten out of 606 studies were included and their findings synthesized into five categories regarding the effects of tDCS on: (1) Unified Parkinson’s Disease Rating Scale motor section (UPDRS III), (2) upper limb motor tasks, (3) manual dexterity, (4) reaction time, and (5) neurophysiology.
Conclusions
When applied to the primary motor cortex, tDCS may improve UPDRS III and the speed and force of movement. Considerable variation was found in tDCS parameters and further study is needed to clarify the long-term effects of tDCS on both simple and complex motor tasks and to compile relevant neurophysiological evidence.
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