Posts Tagged Neurorehabilitation

[REVIEW] CONTROL OF FUNCTIONAL ELECTRICAL STIMULATION FOR RESTORATION OF MOTOR FUNCTION – Full Text PDF

Abstract

An injury or disease of the central nervous system (CNS) results in significant limitations in the communication with the environment (e.g., mobility, reaching and grasping). Functional electrical stimulation (FES) externally activates the muscles; thus, can restore several motor functions and reduce other health related problems.

This review discusses the major bottleneck in current FES which prevents the wider use and better outcome of the treatment. We present a control method that we continually enhance during more than 30 years in the research and development of assistive systems. The presented control has a multi-level structure where upper levels use finite state control and the lower level implements model based control. We also discuss possible communication channels between the user and the controller of the FES. The artificial controller can be seen as the replica of the biological control. The principle of replication is used to minimize the problems which come from the interplay of biological and artificial control in FES. The biological control relies on an extensive network of neurons sending the output signals to the muscles. The network is being trained though many the trial and error processes in the early childhood, but staying open to changes throughout the life to satisfy the particular needs. The network considers the nonlinear and time variable properties of the motor system and provides adaptation in time and space.

The presented artificial control method implements the same strategy but relies on machine classification, heuristics, and simulation of model-based control. The motivation for writing this review comes from the fact that many control algorithms have been presented in the literature by the authors who do not have much experience in rehabilitation engineering and had never tested the operations with patients.

Almost all of the FES devices available implement only open-loop, sensory triggered preprogrammed sequences of stimulation. The suggestion is that the improvements in the FES devices need better controllers which consider the overall status of the potential user, various effects that stimulation has on afferent and efferent systems, reflexive responses to the FES and direct responses to the FES by non-stimulated sensory-motor systems, and the greater integration of the biological control.

Full Text: PDF

References

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Source: CONTROL OF FUNCTIONAL ELECTRICAL STIMULATION FOR RESTORATION OF MOTOR FUNCTION | Popović | Facta Universitatis, Series: Electronics and Energetics

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[Abstract] Bilateral sequential motor cortex stimulation and skilled task performance with non-dominant hand

Highlights

  • Both, contralateral M1 iTBS and ipsilateral M1 cTBS improved non-dominant skilled-task performance.
  • Bilateral sequential M1 TBS (contralateral cTBS followed by ipsilateral iTBS) improved skilled-task performance more than unilateral or sham TBS.
  • Bilateral sequential M1 TBS may be particularly effective in improving motor learning, also in the neurorehabilitation setting.

Abstract

Objective

To check whether bilateral sequential stimulation (BSS) of M1 with theta burst stimulation (TBS), using facilitatory protocol over non-dominant M1 followed by inhibitory one over dominant M1, can improve skilled task performance with non-dominant hand more than either of the unilateral stimulations do. Both, direct motor cortex (M1) facilitatory non-invasive brain stimulation (NIBS) and contralateral M1 inhibitory NIBS were shown to improve motor learning.

Methods

Forty right-handed healthy subjects were divided into 4 matched groups which received either ipsilateral facilitatory (intermittent TBS [iTBS] over non-dominant M1), contralateral inhibitory (continuous TBS [cTBS] over dominant M1), bilateral sequential (contralateral cTBS followed by ipsilateral iTBS), or placebo stimulation. Performance was evaluated by Purdue peg-board test (PPT), before (T0), immediately after (T1), and 30 min after (T2) an intervention.

Results

In all groups and for both hands, the PPT scores increased at T1 and T2 in comparison to T0, showing clear learning effect. However, for the target non-dominant hand only, immediately after BSS (at T1) the PPT scores improved significantly more than after either of unilateral interventions or placebo.

Conclusion

M1 BSS TBS is an effective intervention for improving motor performance.

Significance

M1 BSS TBS seems as a promising tool for motor learning improvement with potential uses in neurorehabilitation.

Source: Bilateral sequential motor cortex stimulation and skilled task performance with non-dominant hand – Clinical Neurophysiology

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[ARTICLE] Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis – Full Text

Abstract

Background

Stroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.

Methods

Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

Results

Twenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [−0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD −0.10; CI [−0.59, 0.38], n = 35).

Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.

Conclusions

FES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.

Background

Stroke is defined as a clinical syndrome characterised by rapidly developing focal or global disturbance in cerebral function lasting more than 24 h or leading to death due to a presumed vascular cause [1]. Globally, approximately 16 million people have a stroke each year [2] and in the UK, first-ever stroke affects about 230 people per 100,000 population each year [3]. Stroke represents a cost to the UK economy of approximately £9 billion annually, of which £1.33 billion results from productivity losses [4].

Stroke often leads to significant impairment of upper limb function and is associated with decreased quality of life in all domains except for mobility [5]. Few patients attain complete functional recovery [6]; this deficit impairs performance of activities of daily living (ADL), including self-care and social activities [7, 8]. ADL reflect the level of functional impairment in daily life and are therefore the most clinically relevant outcome measures in assessing recovery after stroke [9].

Functional electrical stimulation (FES) was well established as an intervention for motor rehabilitation. FES is the electrical stimulation of motor neurons such that muscle groups are stimulated to contract and create/augment a moment about a joint [2]. Transcutaneous electrodes offer the most immediate and clinically viable treatment option as they are non-invasive and may permit home-based treatment.

There are various terms used in the literature to describe different forms of electrical stimulation, often inconsistently. Some authors define FES as electrical stimulation applied to a subject which causes muscle contraction. This passive modality is also referred to as neuromuscular electrical stimulation [10]. Others define FES as electrical stimulation applied during a voluntary movement [4]. This definition acknowledges the volitional component of physical rehabilitation and was used in this systematic review. The distinction is important because neuroimaging studies have identified different cortical mechanisms according to stimulation type [11, 12, 13]. Indeed, perfusion to the ipsilesional sensory-motor cortex and cortical excitability were increased with FES when compared to passive modalities of electrical stimulation [12, 13, 14]. These findings could indicate greater potential for volitional FES to induce neuroplasticity. This is believed to play an important role in neurorehabilitation [15] and is a key objective of post-stroke functional recovery [16].

FES has been widely researched for post-stroke lower limb rehabilitation; several systematic reviews [17, 18, 19] and national guidelines [20, 21] exist. Improvement in upper limb function is central to post-stroke rehabilitation as it positively affects ADL and quality of life [22]. Yet, there is still a lack of clarity on the effectiveness of FES in post-stroke upper limb rehabilitation [23] despite systematic reviews having been undertaken [24, 25, 26, 27, 28]. In part, this is due to methodological limitations [27, 28] or the outdated nature of some existing reviews [24, 25, 26]. The latter was highlighted by a recent Cochrane overview of reviews calling for an up-to-date review and meta-analysis of randomised controlled trials (RCTs) related to electrical stimulation [29]. A more recent systematic review found a significant improvement in motor outcomes with upper limb FES [27]. However, this was based on a single meta-analysis that combined ADLs with upper limb-specific measures of functional motor ability, including studies where results were at risk of performance bias (intervention groups receiving greater duration of treatment than control groups) [27]. Another found no improvement in motor function when FES was applied within 6 months of stroke [28]. However, this predominantly included studies that applied electrical stimulation in the absence of volitional muscle contraction, confounding interpretation of the results. This inconsistency is reflected in the 2016 guidelines set by the Royal College of Physicians which recommends FES only in the context of clinical trials as an adjunct to conventional therapy [21].

This systematic review aims to elucidate the effectiveness of upper limb FES compared to standard therapy in improving ADL, in addition to motor outcomes, post-stroke. It represents an important addition to the literature that focuses on the use of volitional FES and, for the first time, distinguishes its effect on clinically relevant patient outcomes from surrogate markers of patient rehabilitation. This includes analyses based on patient sub-groups defined by the time after stroke at which FES was initiated.

Fig. 1 Flow diagram for included studies

Continue —> Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis | Systematic Reviews | Full Text

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[Systematic Review] Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis – Full Text

Abstract

Background

Stroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.

Methods

Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

Results

Twenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [−0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD −0.10; CI [−0.59, 0.38], n = 35).

Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.

Conclusions

FES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.

Background

Stroke is defined as a clinical syndrome characterised by rapidly developing focal or global disturbance in cerebral function lasting more than 24 h or leading to death due to a presumed vascular cause [1]. Globally, approximately 16 million people have a stroke each year [2] and in the UK, first-ever stroke affects about 230 people per 100,000 population each year [3]. Stroke represents a cost to the UK economy of approximately £9 billion annually, of which £1.33 billion results from productivity losses [4].

Stroke often leads to significant impairment of upper limb function and is associated with decreased quality of life in all domains except for mobility [5]. Few patients attain complete functional recovery [6]; this deficit impairs performance of activities of daily living (ADL), including self-care and social activities [7, 8]. ADL reflect the level of functional impairment in daily life and are therefore the most clinically relevant outcome measures in assessing recovery after stroke [9].

Functional electrical stimulation (FES) was well established as an intervention for motor rehabilitation. FES is the electrical stimulation of motor neurons such that muscle groups are stimulated to contract and create/augment a moment about a joint [2]. Transcutaneous electrodes offer the most immediate and clinically viable treatment option as they are non-invasive and may permit home-based treatment.

There are various terms used in the literature to describe different forms of electrical stimulation, often inconsistently. Some authors define FES as electrical stimulation applied to a subject which causes muscle contraction. This passive modality is also referred to as neuromuscular electrical stimulation [10]. Others define FES as electrical stimulation applied during a voluntary movement [4]. This definition acknowledges the volitional component of physical rehabilitation and was used in this systematic review. The distinction is important because neuroimaging studies have identified different cortical mechanisms according to stimulation type [11, 12, 13]. Indeed, perfusion to the ipsilesional sensory-motor cortex and cortical excitability were increased with FES when compared to passive modalities of electrical stimulation [12, 13, 14]. These findings could indicate greater potential for volitional FES to induce neuroplasticity. This is believed to play an important role in neurorehabilitation [15] and is a key objective of post-stroke functional recovery [16].

FES has been widely researched for post-stroke lower limb rehabilitation; several systematic reviews [17, 18, 19] and national guidelines [20, 21] exist. Improvement in upper limb function is central to post-stroke rehabilitation as it positively affects ADL and quality of life [22]. Yet, there is still a lack of clarity on the effectiveness of FES in post-stroke upper limb rehabilitation [23] despite systematic reviews having been undertaken [24, 25, 26, 27, 28]. In part, this is due to methodological limitations [27, 28] or the outdated nature of some existing reviews [24, 25, 26]. The latter was highlighted by a recent Cochrane overview of reviews calling for an up-to-date review and meta-analysis of randomised controlled trials (RCTs) related to electrical stimulation [29]. A more recent systematic review found a significant improvement in motor outcomes with upper limb FES [27]. However, this was based on a single meta-analysis that combined ADLs with upper limb-specific measures of functional motor ability, including studies where results were at risk of performance bias (intervention groups receiving greater duration of treatment than control groups) [27]. Another found no improvement in motor function when FES was applied within 6 months of stroke [28]. However, this predominantly included studies that applied electrical stimulation in the absence of volitional muscle contraction, confounding interpretation of the results. This inconsistency is reflected in the 2016 guidelines set by the Royal College of Physicians which recommends FES only in the context of clinical trials as an adjunct to conventional therapy [21].

This systematic review aims to elucidate the effectiveness of upper limb FES compared to standard therapy in improving ADL, in addition to motor outcomes, post-stroke. It represents an important addition to the literature that focuses on the use of volitional FES and, for the first time, distinguishes its effect on clinically relevant patient outcomes from surrogate markers of patient rehabilitation. This includes analyses based on patient sub-groups defined by the time after stroke at which FES was initiated.

Continue —> Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis | Systematic Reviews | Full Text

Fig. 1 Flow diagram for included studies

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[ARTICLE] Weight compensation characteristics of Armeo®Spring exoskeleton: implications for clinical practice and research – Full Text

Abstract

Background

Armeo®Spring exoskeleton is widely used for upper extremity rehabilitation; however, weight compensation provided by the device appears insufficiently characterized to fully utilize it in clinical and research settings.

Methods

Weight compensation was quantified by measuring static force in the sagittal plane with a load cell attached to the elbow joint of Armeo®Spring. All upper spring settings were examined in 5° increments at the minimum, maximum, and two intermediate upper and lower module length settings, while keeping the lower spring at minimum. The same measurements were made for minimum upper spring setting and maximum lower spring setting at minimum and maximum module lengths. Weight compensation was plotted against upper module angles, and slope was analyzed for each condition.

Results

The Armeo®Spring design prompted defining the slack angle and exoskeleton balance angle, which, depending on spring and length settings, divide the operating range into different unloading and loading regions. Higher spring tensions and shorter module lengths provided greater unloading (≤6.32 kg of support). Weight compensation slope decreased faster with shorter length settings (minimum length = −0.082 ± 0.002 kg/°; maximum length = −0.046 ± 0.001 kg/°) independent of spring settings.

Conclusions

Understanding the impact of different settings on the Armeo®Spring weight compensation should help define best clinical practice and improve fidelity of research.

Continue —> Weight compensation characteristics of Armeo®Spring exoskeleton: implications for clinical practice and research | Journal of NeuroEngineering and Rehabilitation | Full Text

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[ARTICLE] Using Biophysical Models to Understand the Effect of tDCS on Neurorehabilitation: Searching for Optimal Covariates to Enhance Poststroke Recovery – Full Text

Stroke is a leading cause of worldwide disability, and up to 75% of survivors suffer from some degree of arm paresis. Recently, rehabilitation of stroke patients has focused on recovering motor skills by taking advantage of use-dependent neuroplasticity, where high-repetition of goal-oriented movement is at times combined with non-invasive brain stimulation, such as transcranial direct current stimulation (tDCS). Merging the two approaches is thought to provide outlasting clinical gains, by enhancing synaptic plasticity and motor relearning in the motor cortex primary area. However, this general approach has shown mixed results across the stroke population. In particular, stroke location has been found to correlate with the likelihood of success, which suggests that different patients might require different protocols. Understanding how motor rehabilitation and stimulation interact with ongoing neural dynamics is crucial to optimize rehabilitation strategies, but it requires theoretical and computational models to consider the multiple levels at which this complex phenomenon operate. In this work, we argue that biophysical models of cortical dynamics are uniquely suited to address this problem. Specifically, biophysical models can predict treatment efficacy by introducing explicit variables and dynamics for damaged connections, changes in neural excitability, neurotransmitters, neuromodulators, plasticity mechanisms and repetitive movement, which together can represent brain state, effect of incoming stimulus and movement-induced activity. In this work, we hypothesize that effects of tDCS depend on ongoing neural activity, and that tDCS effects on plasticity may be also related to enhancing inhibitory processes. We propose a model design for each step of this complex system, and highlight strengths and limitations of the different modeling choices within our approach. Our theoretical framework proposes a change in paradigm, where biophysical models can contribute to the future design of novel protocols, in which combined tDCS and motor rehabilitation strategies are tailored to the ongoing dynamics that they interact with, by considering the known biophysical factors recruited by such protocols and their interaction.

Source: Frontiers | Using Biophysical Models to Understand the Effect of tDCS on Neurorehabilitation: Searching for Optimal Covariates to Enhance Poststroke Recovery | Stroke

Figure 1. Diagram of top-down and bottom-up stroke neurorehabilitation strategies. Sensory–motor training and brain stimulation contribute to rehabilitation protocols that exploit neural plasticity. The bottom-up approach includes sensory–motor training, which can be aided by robots, electrical stimulation of the periphery, and constrains. The top-down approaches include methods to stimulate the brain non-invasively.

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[Abstract] Contracture of Finger and Hand and Disturbance in Speech After Stroke were Improved in a Short Duration by Grasping a High Repulsion Cushion Grip

Abstract

Stroke is a common disease especially for elders and it is often followed by unpleasant aftereffects: muscle rigidity, contracture, stiff joint and speech disturbance. Extensive neurorehabilitation is useful for these aftereffects but it sometimes doesn’t work enough. Thus there are many persons who are obligated to spend a low quality of life after the attack. Here we made a cushion grip that has a strong repulsion power against the outer pressure. Once the grip was held continuously for 24 h, the aftereffects lasted for years were ameliorated in about one month. However, voluntary movements of digits have not recovered yet. Continuous, normal, pleasant sensorimotor stimuli due to the strong repulsion power would be the base of the amelioration. We believe the grip is a useful item producing a prompt amelioration of aftereffects of stroke. Data suggest that extensive neurorehabilitation in association with sensorimotor stimuli to hand is a key procedure for treatment of aftereffects of stroke.

We recommend

Vibration Selectively Modulates Corticomotor Excitability in Hand Muscles Following StrokeYang, Bing-Shiang et al., Journal of Neuroscience and Neuroengineering, 2013

Assessment to Aesthetic Shape Using the Stability of GrippingWidiyati, Khusnun et al., Advanced Science Letters,2013

Force Closure Analysis for the Forging Gripping Mechanisms,Li, Qunming et al., Advanced Science Letters, 2011

Low-Cost Design and Fabrication of an Anthropomorphic Robotic Hand,Ali Bin Junaid et al., Journal of Nanoscience and Nanotechnology, 2014

Analysis of Human Hand Kinematics: Forearm Pronation and Supination,Rahman, Hisyam Abdul et al., Journal of Medical Imaging and Health Informatics, 2014

Source: Contracture of Finger and Hand and Disturbance in Speech After St…: Ingenta Connect

 

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[ARTICLE] How Can We Improve Current Practice in Spastic Paresis? – Full Text

Abstract:

Spastic paresis can arise from a variety of conditions, including stroke, spinal cord injury, multiple sclerosis, cerebral palsy, traumatic brain injury and hereditary spastic paraplegia. It is associated with muscle contracture, stiffness and pain, and can lead to segmental deformity. The positive, negative and biomechanical symptoms associated with spastic paresis can significantly affect patients’ quality of life, by affecting their ability to perform normal activities. This paper – based on the content of a global spasticity interdisciplinary masterclass presented by the authors for healthcare practitioners working in the field of spastic paresis – proposes a multidisciplinary approach to care involving not only healthcare practitioners, but also the patient and their family members/carers, and improvement of the transition between specialist care and community services. The suggested treatment pathway comprises assessment of the severity of spastic paresis, early access to neurorehabilitation and physiotherapy and treatment with botulinum toxin and new technologies, where appropriate. To address the challenge of maintaining patients’ motivation over the long term, tailored guided self-rehabilitation contracts can be used to set and monitor therapeutic goals. Current global consensus guidelines may have to be updated, to include a clinical care pathway related to the encompassing management of spastic paresis.

Spastic paresis may be caused by a variety of conditions, including stroke, spinal cord injury, multiple sclerosis, retroviral and other infectious spinal cord disorders, cerebral palsy, traumatic brain injury and hereditary spastic paraplegia.1 The exact prevalence of spastic paresis (in which spasticity is the most commonly recognised manifestation) is not known. However, it is estimated that around 30% of stroke survivors are affected by significant spasticity2 and 50% who present to hospital with stroke develop at least one severe contracture.3

Spastic paresis is a complex condition that may be associated with soft tissue contracture, pain and limitations of day-to-day activities, which have a substantial impact on patients’ and caregivers’ quality of life.4 Although treatment guidelines have been developed for (focal) spasticity,5 there remains a lack of consensus on key aspects of diagnosis, approaches to care and the care pathway that would help healthcare practitioners to more fully understand and manage this condition.

To address some of these limitations, a group of physicians and a physiotherapist with expertise in the management of spastic paresis developed a global spasticity masterclass for healthcare practitioners working in this field in order to share best practices and to discuss issues and current trends in the management of patients with spasticity. The outputs of this masterclass are presented here.

Continue —> How Can We Improve Current Practice in Spastic Paresis? | Touch Neurology | Independent Insight for Medical Specialists

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[ARTICLE] How Can We Improve Current Practice in Spastic Paresis? – Full Text HTML

Abstract:

Spastic paresis can arise from a variety of conditions, including stroke, spinal cord injury, multiple sclerosis, cerebral palsy, traumatic brain injury and hereditary spastic paraplegia. It is associated with muscle contracture, stiffness and pain, and can lead to segmental deformity. The positive, negative and biomechanical symptoms associated with spastic paresis can significantly affect patients’ quality of life, by affecting their ability to perform normal activities. This paper – based on the content of a global spasticity interdisciplinary masterclass presented by the authors for healthcare practitioners working in the field of spastic paresis – proposes a multidisciplinary approach to care involving not only healthcare practitioners, but also the patient and their family members/carers, and improvement of the transition between specialist care and community services. The suggested treatment pathway comprises assessment of the severity of spastic paresis, early access to neurorehabilitation and physiotherapy and treatment with botulinum toxin and new technologies, where appropriate. To address the challenge of maintaining patients’ motivation over the long term, tailored guided self-rehabilitation contracts can be used to set and monitor therapeutic goals. Current global consensus guidelines may have to be updated, to include a clinical care pathway related to the encompassing management of spastic paresis.

Spastic paresis may be caused by a variety of conditions, including stroke, spinal cord injury, multiple sclerosis, retroviral and other infectious spinal cord disorders, cerebral palsy, traumatic brain injury and hereditary spastic paraplegia.1 The exact prevalence of spastic paresis (in which spasticity is the most commonly recognised manifestation) is not known. However, it is estimated that around 30% of stroke survivors are affected by significant spasticity2 and 50% who present to hospital with stroke develop at least one severe contracture.3

Spastic paresis is a complex condition that may be associated with soft tissue contracture, pain and limitations of day-to-day activities, which have a substantial impact on patients’ and caregivers’ quality of life.4 Although treatment guidelines have been developed for (focal) spasticity,5 there remains a lack of consensus on key aspects of diagnosis, approaches to care and the care pathway that would help healthcare practitioners to more fully understand and manage this condition.

To address some of these limitations, a group of physicians and a physiotherapist with expertise in the management of spastic paresis developed a global spasticity masterclass for healthcare practitioners working in this field in order to share best practices and to discuss issues and current trends in the management of patients with spasticity. The outputs of this masterclass are presented here.

Pathophysiology and definitions
Spastic paresis
Spasticity is one of several components of spastic paresis, also known as the upper motor neuron (UMN) syndrome. Spastic paresis is primarily characterised by a quantitative lack of command directed to agonist muscles involved in performing movements.1,6,7 In addition, hyperactive spinal reflexes mediate some of the positive phenomena seen in spastic paresis, while other positive symptoms are related to disordered control of voluntary movement in terms of an abnormal efferent drive or are caused

Continue —> How Can We Improve Current Practice in Spastic Paresis? | Touch Neurology | Independent Insight for Medical Specialists

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[Abstract] Increased functional connectivity one week after motor learning and tDCS in stroke patients

Abstract

Recent studies using resting-state functional magnetic resonance imaging (rs-fMRI) demonstrated that changes in functional connectivity (FC) after stroke correlate with recovery. The aim of this study was to explore whether combining motor learning to dual transcranial direct current stimulation (dual-tDCS, applied over both primary motor cortices (M1)) modulated FC in stroke patients.

Twenty-two chronic hemiparetic stroke patients participated in a baseline rs-fMRI session. One week later, dual-tDCS/sham was applied during motor skill learning (intervention session); one week later, the retention session started with the acquisition of a run of rs-fMRI imaging. The intervention + retention sessions were performed once with dual-tDCS and once with sham in a randomized, cross-over, placebo-controlled, double-blind design. A whole-brain independent component analysis based analysis of variance (ANOVA) demonstrated no changes between baseline and sham sessions in the somatomotor network, whereas a FC increase was observed one week after dual-tDCS compared to baseline (qFDR <0.05, t63 = 4.15). A seed-based analysis confirmed specific stimulation-driven changes within a network of motor and premotor regions in both hemispheres.

At baseline and one week after sham, the strongest FC was observed between the M1 and dorsal premotor cortex (PMd) of the undamaged hemisphere. In contrast, one week after dual-tDCS, the strongest FC was found between the M1 and PMd of the damaged hemisphere.

Thus, a single session of dual-tDCS combined with motor skill learning increases FC in the somatomotor network of chronic stroke patients for one week.

Abbreviations

  • ANOVA, analysis of variance;
  • damH, damaged hemisphere;
  • DAN, dorsal attentional network;
  • FC, functional connectivity;
  • ICA, Independent Component Analysis;
  • LI, Learning Index;
  • M1, primary motor cortex;
  • NIBS, non-invasive brain stimulation;
  • PI, performance index;
  • PMd, dorsal premotor cortex;
  • qFDR, q False Discovery Rate;
  • ROI, region of interest;
  • rs-fMRI, resting-state functional magnetic resonance imaging;
  • SAT, speed/accuracy trade-off;
  • SMA, supplementary motor area;
  • SMN, somatomotor network;
  • tDCS, transcranial direct stimulation;
  • TMS, transcranial magnetic stimulation;
  • undamH, undamaged hemisphere;
  • VN, visual network

Source: Increased functional connectivity one week after motor learning and tDCS in stroke patients

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