Brunnstrom Stage Research Articles

Effect of botulinum toxin type-A in patients with focal spasticity.

OBJECTIVE:To investigate the effect of botulinum toxin type-A (BTX-A) on spasticity and function in patients with focal spasticity.METHODS:Patients attended to the outpatient clinic of physical medicine and rehabilitation department with a diagnosis of focal spasticity and had BTX-A injections because of spasticty were evaluated for the study. Demographic data, exercise status, orthoses, drugs used for spasticity, functional status, stages of spasticity of muscles before and after 1st and 3rd months of BTX-A injection according to Modified Ashworth Scale (MAS) were evaluated retrospectively. MedCalc 11.6 statistical program was used for statistical analyses. Statistical significance was defined as p<0.05.RESULTS:Forty-nine patients with focal spasticity were recruited for the study (35 men, 14 women). Mean age of the patients was 21.59±20.09 years. The patients had cerebral palsy (CP, n=28), 19 had hemiplegia (n=19) and paraplegia (n=2). Forty-three patients were using orthoses and exercising regularly. Mean Pediatric Functional Independence Measurement (WeeFIM) scores of the patients with CP was 54.82±28.91 and according to the Gross Motor Function Classification System (GMFCS) the patients were in stages 2 (14%), 3 (46%), 4 (11%) and 5 (29%). Mean Functional Independence Measure (FIM) of hemiplegic and paraplegic patients was 80.80±20.88. Brunnstrom staging scores for upper extremity (3.52±0.96), hands (2.68±0.82), lower extremity (4.57±1.01) were calculated. MAS muscles demonstrated statistically significant decrease in spasticity at the end of first and third months (p<0.05).CONCLUSION:We saw a significant decrease in the spasticity of upper and lower extremities in patients with focal spasiticity who received BTX-A injections. We suggest that if BTX-A injections are supported with orthoses and exercise programs, then functional status of the patients would be better.

Effect of heel pressure pad attached to ankle-foot orthosis on the energy conversion efficiency in post-stroke hemiplegic gait.

[Purpose] This study aimed to analyze the effect of heel pads in ankle-foot orthoses on dynamic motion aspects of gait in stroke patients from the viewpoint of energy conversion efficiency. [Subjects] Fourteen chronic stroke patients who were ambulatory and had lower extremity motor function categorized as Brunnstrom stage IV participated in the study. [Methods] A three-dimensional motion analysis system was used to assess the effect of heel pad intervention on dynamic motion gait parameters using a single-system A-B-A design. [Results] The results showed that a heel pad attached to the ankle-foot orthosis caused significant retention of the center-of-pressure at the heel during the heel rocker function and significant increase in the dorsiflexion moment and the height of the center of gravity. [Conclusion] The present study showed that a heel pad attached to the calcaneal region of an ankle-foot orthosis caused slight retention of the center-of-pressure at the heel during the heel rocker function along with center of gravity elevation in the stance phase and improved the energy conversion efficiency, especially on the non-paretic side.

Investigation of the H reflexes, F waves and sympathetic skin response with electromyography (EMG) in patients with stroke and the determination of the relationship with functional capacity.

The purpose of the study was to evaluate the relationship between sympathetic skin responses (SSR), electrodiagnostic reflex activities (F wave, H reflex), and functional capacity in post-stroke patients. The study comprised 40 hemiplegia patients (mean age 57.8 ± 10.9 years) and 40 healthy volunteers (mean age 557 ± 85 years). In electrophysiological studies, SSR, F wave and H reflex were evaluated and for the functional capacities of patients, FIM scores and Brunnstrom stages were calculated. There was no statistical significant difference between SSR latency and amplitude in the hemiplegic and non-hemiplegic extremities of patients (p > 0.05). SSR latency values of patients were higher than those of controls (p < 0.05). Amplitude values of paretic arms were significantly lower than the control group extremities (p < 0.05). There was a significant correlation between SSR amplitude values and FIM scores. A significant increase in H max/M max amplitude rate was detected in the affected side (p < 0.05) and F-wave mean latency values of the affected side were found to be significantly lower in the control group (p < 0.05).

Hand Bone Mineral Density in Hemiplegia and Their Clinical Corelation

Objective: The aim of this study was to evaluate the hand bone mineral density (BMD) measurements and to assess the relationship between demographic and clinical parameters. Material and Methods: The study included 119 (46 women, 63 men) hemiplegic patients. Brunnstrom stage of the upper extremity and Modified Ashworth scale was used, for the evaluation of motor function and spasticity. The level of functional independence in patients were evaluated with the functional independence measure (FIM). Hand dual energy x-ray absorptiometry (DEXA; Lunar Prodigy Advance, Lunar Corp., USA) for the assessment of bone mineral density of both hands were used. Results: In the entire group (p<0.01) and women (p<0.01) and in males (p<0.05) the paretic hand BMD values were significantly lower than the non-paretic side. Non-paretic hand BMD in women, were significantly lower than men (p<0.05). BMD on the hemiplegic hand was correlated with the hand and upper extremity spasticity severity (p<0.05), Brunnstrom stage (p<0.01), age in women (p<0.05) and FIM score (p<0.01). There were no statistically significant correlation between hand BMD and disease duration. Regression analysis revealed that the strongest predictors of BMD of the hemiplegic side were Brunnstrom stage (OR=4.701, p=0.001), FIM (OR=4.022, p=0.001) and women age (OR=1.220, p=0.050), respectively. Conclusion: To avoid an increase in fractures and associated morbidity due to a decrease in BMD of the upper extremity; the improvement in motor paresis and spasticity and functional independence, should take place in neurological rehabilitation program.

Functional electrical stimulation based on a working pattern influences function of lower extremity in subjects with early stroke and effects on diffusion tensor imaging: a randomized controlled trial

To explore the possible mechanisms for improving lower extremity motor function in patients with early stroke through combining magnetic resonance diffusion tensor imaging (DTI) technology and functional electrical stimulation (FES) based on human walking patterns. From August 2012 to September 2013, a total of 48 eligible patients were stratified according to age, gender, disease course, Brunnstrom staging and types of stroke. And the Minimize software was used to divided them randomly into four-channel FES group (n = 18), dual-channel FES group (n = 15) and comfort stimulation group (n = 15). For all three groups, general medication and standard rehabilitation were provided. Based on normal walking pattern design of FES treatment, four-channel FES groups received the stimulations of quadriceps, hamstring, anterior tibialis and medial gastrocnemius. For the dual-channel FES group, the stimulations of tibialis anterior, peroneus longus and peroneus brevis muscles were applied. In comfort electrical stimulation group, the electrode positions were identical to the stimulation group, but there was no current output during stimulation. Before and after 3-week treatment, three groups received weekly rehabilitation evaluations of Fugl-Meyer assessment (FMA), posture assessment of stroke scale (PASS), Brunel balance assessment (BBA), Berg balance scale (BBS) and modified Barthel index (MBI). Before and after treatment, DTI examination was performed for some patients. Among three groups, general patient profiles and pre-treatment evaluations showed no significant difference. For intra-group comparisons versus pre-treatment, at week 1, 2 and 3, the scores of PASS, BBA, BBS, FMA and MBI had statistically significant differences (P < 0.05); At week 3 post-treatment, when four-channel and double-channel FES groups were compared versus pre-treatment, the scores of ipsilateral FA had statistically significant differences (P < 0.05). At week 1 post-treatment, MBI had statistically significant difference among 3 groups (P = 0.037). As compared with placebo, four-channel group had statistically significant difference [(52 ± 12) vs (38 ± 18), P < 0.05]; At week 2 post-treatment, the scores of PASS and MBI were (29 ± 3, 73 ± 13) in four-channel FES group versus (24 ± 8, 60 ± 17) in dual-channel FES group. And the scores of PASS, BBA, BBS, FMA and MBI were (9 ± 3, 8.3 ± 2.4, 37 ± 7, 22 ± 5, 73 ± 13) in four-channel FES group versus (21 ± 7, 6.2 ± 3.1, 24 ± 16, 15 ± 8, 47 ± 20) in comfort electrical stimulation group. When dual-channel FES and comfort stimulation groups were compared, MBI had significant statistical difference [(60 ± 17) vs (47 ± 20), P < 0.05]. At week 3 post-treatment, four-channel and dual-channel FES groups were compared, there was also statistical significance in FMA [(25 ± 5) vs (20 ± 7), P = 0.055]. The scores of PASS, BBS, FMA and MBI were (31 ± 3, 43 ± 8, 25 ± 5, 81 ± 13) in four-channel FES group versus (25 ± 8, 29 ± 17, 17 ± 9, 54 ± 25) in comfort stimulation group respectively. When dual-channel FES and comfort stimulation groups were compared, the scores of MBI were (71 ± 15) and (54 ± 25) respectively. And the difference was statistically significant (P < 0.05). At week 3 post-treatment, the scores of FA significantly increased [four-channel FES group (0.321 ± 0.172) vs comfort stimulation group (0.217 ± 0.135) (P = 0.020)]. When dual-channel FES group (0.333 ± 0.164) and comfort stimulation group (0.217 ± 0.135) (P = 0.049) were compared, the differences were statistically significant. DTI showed that four-channel FES group increased significantly, but contralateral fiber bundle was not obvious. And the improvements of dual-channel FES and comfort stimulation groups were insignificant. Compared with traditional dual-channel FES, functional electrical stimulation based on human walking patterns is more efficacious. And it helps to restore brain structure and function and promote motor function recovery in patients with early stroke.

Relationship between postural alignment in sitting by photogrammetry and seated postural control in post-stroke subjects.

This study was executed to find out correlation between postural alignment in sitting measured through photogrammetry and postural control in sitting following stroke. A cross-sectional study with convenient sampling consisting of 45 subjects with acute and sub-acute stroke. Postural alignment in sitting was measured through photogrammetry and relevant angles were obtained through software MB Ruler (version 5.0). Seated postural control was measured through Function in Sitting Test (FIST). Correlation was obtained using Spearman's Rank Correlation co-efficient in SPSS software (version 17.0). Moderate positive correlation (r = 0.385; p < 0.01) was found between angle of lordosis and angle between acromion, lateral epicondyle and point between radius and ulna. Strong negative correlation (r = -0.435; p < 0.01) was found between cranio-vertebral angle and kyphosis. FIST showed moderate positive correlation (r = 0.3446; p < 0.05) with cranio-vertebral angle and strong positive correlation (r = 0.4336; p < 0.01) with Brunnstrom's stage of recovery in upper extremity. Degree of forward head posture in sitting correlates directly with seated postural control and inversely with degree of kyphosis in sitting post-stroke. Postural control in sitting post-stroke is directly related with Brunnstrom's stage of recovery in affected upper extremity in sitting.

Relationship between Diffusion Tensor Fractional Anisotropy and Long-term Motor Outcome in Patients with Hemiparesis after Middle Cerebral Artery Infarction

Magnetic resonance diffusion tensor fractional anisotropy (DTI-FA) is often used to characterize neural damage after stroke. Here we assessed the relationship between DTI-FA and long-term motor outcome in patients after middle cerebral artery (MCA) infarction. Fractional anisotropy (FA) maps were generated from diffusion tensor brain images obtained from 16 patients 14-18 days postinfarction, and tract-based spatial statistics (TBSS) analysis was applied. Regions of interest were set within the right and left corticospinal tracts, and mean FA values were extracted from individual TBSS data. Hemiparesis motor outcome was evaluated according to Brunnstrom stage (BRS: 1-6, severe-normal) for separate shoulder/elbow/forearm, hand, and lower extremity functions, as well as the motor component score of the Functional Independence Measure (FIM-motor: 13-91, null-full) 5-7 months after onset. Ratios between FA values in the affected and unaffected hemispheres (rFA) were assessed by BRS and FIM-motor scores. rFA values were .636-.984 (median, .883) and BRS scores were 1-6 (median, 3) for shoulder/elbow/forearm, 2-6 (median, 3) for hand, and 3-6 (median, 5) for the lower extremities. FIM-motor scores were 51-90 (median, 75). Analysis revealed significant relationships between rFA and BRS data (correlation coefficient: .687 for shoulder/elbow/forearm, .579 for hand, and .623 for lower extremities) but no significance relationship between rFA and FIM-motor scores. The results suggest that DTI-FA is applicable for predicting the long-term outcome of extremity functions after MCA infarction.

Effect of infrared-C radiation on skin temperature, electrodermal conductance and pain in hemiparetic stroke patients

Purpose: A novel application of infrared-C (IR-C) radiation (3–1000 μm) on hemiparetic stroke patients was evaluated. Hot compresses (HC) were used on the paretic shoulders of patients in this placebo-controlled trial to investigate the effects of IR-C on skin temperature, electrodermal conductance (EC) and pain relief.Materials and methods: Skin temperature at the center of the middle deltoid (CMD), Quchi (LI11), and the center of the third metacarpal bone on dorsum of hand (COT) of the subjects at Brunnstrom stage 3–5 before and after IR-C HC, were examined. Meanwhile, EC was measured on Hegu (LI4), Quchi and Juanyu (LI15). Pain intensity was evaluated before and after treatment.Results: Skin temperature increased significantly at the CMD and COT on the paretic side in males. In females after treatment, similar skin temperatures were found in each measured region on both the paretic and non-paretic sides. The EC on the paretic side tended to be higher than the non-paretic side before treatment. After treatment, the EC on paretic side declined in both sexes and became even lower than the non-paretic side in females. Pain intensity was lessened after treatment especially in males, which appeared to correspond with an increase in skin temperature and a decrease in EC.Conclusion: IR-C hot compress is a promising method for stroke patients in rehabilitation. Physiological mechanisms of this treatment were proposed and summarized from this research.

The balance effect of acupuncture therapy among stroke patients.

To analyze how acupuncture therapy affects balance in patients experiencing their first stroke and to identify the stroke group with greatest improvement in balance after acupuncture intervention. Retrospective case-control study. Ward of a medical university hospital. A total of 629 stroke patients were enrolled initially; 345 patients met the study criteria and 132 were analyzed (66 each in the study and control groups). The study group received physiotherapy combined with acupuncture and the control group received only physiotherapy. The Postural Assessment Scale for Stroke patients (PASS) was used to evaluate balance. This balance scale system can be subdivided into static balance (PASS-MP, maintain posture) and dynamic balance (PASS-CP, change posture). This study revealed no statistically significant improvement of balance in the study group (t test). When patients with high Brunnstrom stage (Br stage) and low Br stage were analyzed separately, once again no statistical difference was detected between the study and control groups of those with high Br stage. However, among low-Br stage patients, the study group showed significant improvement in static balance (mean PASS-MP score±standard deviation: 4.7±3.7) compared with the control group (PASS-MP score: 2.8±2.7) (p<0.05). In first-ever stroke patients with a low Br stage, acupuncture therapy can improve static balance during rehabilitation. However, the effect on balance was limited among high-Br stage patients. This study provides information valuable to patients with hemiplegic stroke because it suggests that acupuncture can be used to improve balance. A prospective double-blind, randomized, controlled study design is recommended for future studies in patients with hemiplegic stroke.

Mirror Therapy Enhances Motor Performance in the Paretic Upper Limb After Stroke: A Pilot Randomized Controlled Trial

ObjectiveTo investigate the effectiveness of mirror therapy (MT) combined with bilateral arm training and graded activities to improve motor performance in the paretic upper limb after stroke. DesignRandomized, controlled, assessor-blinded study. SettingInpatient stroke rehabilitation center of a tertiary care teaching hospital. ParticipantsPatients with first-time ischemic or hemorrhagic stroke (N=20), confined to the territory of the middle cerebral artery, occurring <6 months before the commencement of the study. InterventionThe MT and control group participants underwent a patient-specific multidisciplinary rehabilitation program including conventional occupational therapy, physical therapy, and speech therapy for 5 d/wk, 6 h/d, over 3 weeks. The participants in the MT group received 1 hour of MT in addition to the conventional stroke rehabilitation. Main Outcome MeasuresThe Upper Extremity Fugl-Meyer Assessment for motor recovery, Brunnstrom stages of motor recovery for the arm and hand, Box and Block Test for gross manual hand dexterity, and modified Ashworth scale to assess the spasticity. ResultsAfter 3 weeks of MT, mean change scores were significantly greater in the MT group than in the control group for the Fugl-Meyer Assessment (P=.008), Brunnstrom stages of motor recovery for the arm (P=.003) and hand (P=.003), and the Box and Block Test (P=.022). No significant difference was found between the groups for modified Ashworth scale (P=.647). ConclusionsMT when combined with bilateral arm training and graded activities was effective in improving motor performance of the paretic upper limb after stroke compared with conventional therapy without MT.

Comparative study of the therapeutic effect of functional electrical stimulation and ankle-foot orthosis in improving walking function in stroke patients

Objective To compare the clinical therapeutic effect of functional electrical stimulation (FES) and ankle-foot orthosis (AFO) in improving walking function in stroke patients.Methods Thirty-six stroke patients satisfying the enrolling criterion of the research were randomly divided into two groups:FES group and AFO group (n =18 in each).Both groups received the same routine rehabilitation therapy and medical treatment.Patients of FES group received FES of common peroneal nerve and tibialis anterior muscle of the affected limb,30 min per day,5 days per week,4 weeks in total,while the patients of AFO group received walking training with AFO wearing on,30 min per day,5 days per week,4 weeks in total.Walking function was assessed by 10-meter maximum walking speed,timed-up and go test (TUGT),functional ambulation category(FAC),the muscle tension of ankle flexor and Brunnstrom stage,which were carried out before treatment and four weeks after treatment.Results Before treatment,there was no significant difference between the two groups for the baseline of measurement(P ＞ 0.05).After 4 weeks of treatment,10MWT,TUGT,FAC scores and Brunnstrom stages in the two groups significantly increased (P ＜ 0.05).The 10MWT,FAC scores and Brunnstrom stage increased more significantly in FES group than those in AFO group (P ＜ 0.05).There was no significant differences with regard to TUGT and the muscle tension of ankle flexor between the two groups (P ＞ 0.05).Conclusions Both FES and AFO can accelerate the recovery of walking function in hemiplegia patients.FES can improve the walking ability in patients with stroke more significantly. Key words: Functional electrical stimulation; Ankle-foot orthosis; Stroke

Abstract T P30: Novel Algorithm for the Prediction of Motor Recovery of Upper Limb and Finger Using Diffusion Tensor Imaging after Stroke

Introduction: Prediction of the outcome of upper limb and finger disability is critical for the rehabilitation in the acute stage of stroke. Here, we show a novel algorithm for the prediction of the recovery patterns by using diffusion tensor imaging (DTI). Methods: 42 supratentorial stroke patients, including both ischemic and hemorrhagic types, with upper limb and finger paralysis were prospectively recruited from May 2012. DTI was performed with a 1.5-T MRI during 14-16 days after onset. Fractional anisotropy (FA) within the cerebral peduncle were measured and the ratios between FA values in the affected and unaffected side (rFA) were calculated. Fiber-tracking was also constructed by the one ROI method using same ROI as the FA measurement in the affected side. DTI findings were categorized into 3 types according to rFA and fiber-tracking (Fig. 1). Brunnstrom stage (BRS, upper limb + finger) was assessed at 2 weeks, 1 month, and 3 months after onset. Recovery patterns were also categorized into 3 groups according to the phase of recovery and final BRS (early recovery: BRS achieved 9-12pt. within 1 month, late recovery: BRS achieved 9-12pt. during 1-3 months, poor recovery: BRS had never achieved 9pt. within 3 months). We statically analyzed the correlation between DTI types and recovery patterns. Results: Positive correlation was found between rFA and final BRS.(p&lt;0.01, Spearman r=0.52) Furthermore, extremely strong correlation was also found between recovery patterns and DTI types.(p&lt;0.0001, Spearman r=0.91) Based on these results, we created a simple algorithm, which can predict the patterns of upper limb and finger recovery during 3 months after stroke with high accuracy. (Fig. 1, early recovery; 73%, late recovery; 85% and poor recovery; 95%) Conclusions: Our algorithm is novel in terms of taking advantages of both FA and fiber-tracking. This method allows us to predict not only final outcome, but also the phase of recovery, which are critical for the rehabilitation.

Doppler ultrasonographic evaluation of the radial and ulnar arteries in hemiparetic patients after stroke

To evaluate blood flow of hand arteries (using Doppler ultrasonography) and sympathetic skin response (SSR) in patients with hemiparesis. Fifty-six stroke patients (30 M, 26 F) with unilateral hemiparesis (age 53.5 ± 10.8 years, mean disease duration 12.0 ± 19.1 months) were included. The patients' arm and hand motor functions were assessed according to Brunnstrom's stages. SSR was evaluated bilaterally from median nerves at the wrist level. Radial and ulnar artery blood flow was measured at the wrist in the neutral position. Both radial and ulnar artery volume flow and end diastolic velocity, and radial artery diameter were smaller on the paretic side (all p < 0.0125). Radial artery resistance and pulsatility index were greater on the paretic side (both p < 0.0125). SSR amplitude was lower on the paretic side of patients with right-sided hemiparesis patients (p = 0.009). Hand Brunnstrom's stage was negatively correlated with nonparetic-paretic difference in radial artery volume flow and SSR amplitudes (all p < 0.025). Hand blood flow was lower on the paretic side and was accompanied by a similar decrease in SSR amplitudes in patients with right-sided hemiparesis.

Retrospective assessment of the implementation of critical pathway in stroke patients in a single university hospital.

ObjectiveTo evaluate the effects of the implementation of critical pathway (CP) in stroke patients treated at a single university hospital.MethodsA retrospective medical review collected data from 497 patients who had suffered acute stroke in the rehabilitation center. Stroke outcomes were compared between before and after the implementation of CP based on factors including demographic factors, stroke characteristics, pre-existing medical conditions, medical complications, functional states, and length of stay (LOS).ResultsAfter the implementation of CP, the patients showed significantly higher stage for upper proximal (p=0.008) and lower extremity (p=0.001) on Brunnstrom stage and significantly lower scores for modified Rankin Scale (p=0.003) at transfer. For those with pre-existing medical conditions, there were significantly increased osteoarthritis (p=0.002) and valvular heart disease (p=0.011). Regarding medical complications during acute inpatient rehabilitation, there were significantly decreased shoulder pain (p=0.001) and dysphagia (p=0.017), and significantly increased gastrointestinal symptoms (p=0.001). Functional gain and efficiency of stroke patients during rehabilitation center hospitalization did not significantly change after implementation of CP. But, shorter LOS of total hospitalization, pre-rehabilitation center hospitalization, and rehabilitation center hospitalization were evident.ConclusionAfter the implementation of CP, patients less often developed complications and displayed no changes in functional gain and efficiency. They had shorter LOS of total hospitalization, pre-rehabilitation center hospitalization and rehabilitation center hospitalization.

Effect of constraint-induced movement therapy and mirror therapy for patients with subacute stroke.

ObjectiveTo evaluate the effectiveness of constraint-induced movement therapy (CIMT) and combined mirror therapy for inpatient rehabilitation of the patients with subacute stroke.MethodsTwenty-six patients with subacute stroke were enrolled and randomly divided into three groups: CIMT combined with mirror therapy group, CIMT only group, and control group. Two weeks of CIMT for 6 hours a day with or without mirror therapy for 30 minutes a day were performed under supervision. All groups received conventional occupational therapy for 40 minutes a day for the same period. The CIMT only group and control group also received additional self-exercise to substitute for mirror therapy. The box and block test, 9-hole Pegboard test, grip strength, Brunnstrom stage, Wolf motor function test, Fugl-Meyer assessment, and the Korean version of Modified Barthel Index were performed prior to and two weeks after the treatment.ResultsAfter two weeks of treatment, the CIMT groups with and without mirror therapy showed higher improvement (p<0.05) than the control group, in most of functional assessments for hemiplegic upper extremity. The CIMT combined with mirror therapy group showed higher improvement than CIMT only group in box and block test, 9-hole Pegboard test, and grip strength, which represent fine motor functions of the upper extremity.ConclusionThe short-term CIMT combined with mirror therapy group showed more improvement compared to CIMT only group and control group, in the fine motor functions of hemiplegic upper extremity for the patients with subacute stroke.

Suprascapular Nerve Block versus Intra-articular Hyaluronic Acid Injection in Hemiplegic Shoulder Pain

Results: Both groups showed significant improvements in pain assessed by VAS, but the changes between the two groups were not significantly different. There were no significant improvements and did not show any significant differences between the two groups in FMS, WMFT, Brunnstrom stage, MAS and ROM of shoulder joint. On several items of the BPI concerning the interference of patient’s function (activity, mood, work, and enjoy), only SSNB group showed significant improvement, even though the differences between the two groups were not significant. Conclusion: Both SSNB and intra-articular HA injection were safe and effective in pain and functional ability in hemiplegic shoulder pain. But comparing the interference of patient’s function caused by pain, only SSNB showed significant improvement. (Brain & NeuroRehabilitation 2014; 7: 118-125)

Comparison of the Effects of 1 Hz and 20 Hz rTMS on Motor Recovery in Subacute Stroke Patients.

ObjectiveTo compare the low frequency (1 Hz) repetitive transcranial magnetic stimulation (rTMS) with high frequency (20 Hz) rTMS on motor functional improvement of the affected upper extremity in subacute stroke patients.MethodsForty patients with subacute ischemic stroke participated in this study. The first group received 10 sessions of 20 Hz rTMS at ipsilesional M1 area and the other group received 10 sessions of 1 Hz rTMS at contralesional M1 area. Motor training of the hemiparetic hand was conducted after each rTMS train. All the patients received conventional occupational therapy immediately after each rTMS session. Manual function test (MFT), Fugl-Meyer Assessment scale (FMS), Modified Barthel Index (MBI), Brunnstrom recovery stage, and grip strength were used to assess motor function before, at the end of, and one month after the last session of rTMS.ResultsNo adverse side effects were reported during the course of the experiment using rTMS. No significant difference in motor function of the affected upper extremity was observed between the two groups before rTMS. Significant improvements in MFT, FMS, MBI, and Brunnstrom stage were observed in the both groups at the end of the last rTMS session and one month later (p<0.05). No significant difference was found between the two groups (p>0.05).ConclusionThere was no significant difference in motor function of the affected upper extremity between 1 Hz and 20 Hz rTMS during the subacute period of ischemic stroke. Thus, we cannot conclude which has a greater effect.

Factors Affecting the Motor Evoked Potential Responsiveness and Parameters in Patients With Supratentorial Stroke

ObjectiveTo investigate the factors which affect the motor evoked potential (MEP) responsiveness and parameters and to find the correlation between the function of the upper extremities and the combined study of MEP with a diffusion tensor tractography (DTT) in patients with stroke.MethodsA retrospective study design was used by analyzing medical records and neuroimaging data of 70 stroke patients who underwent a MEP test between June 2011 and March 2013. MEP parameters which were recorded from the abductor pollicis brevis muscle were the resting motor threshold, latency, amplitude, and their ratios. Functional variables, Brunnstrom stage of hand, upper extremity subscore of Fugl-Meyer assessment, Manual Function Test, and the Korean version of Modified Barthel Index (K-MBI) were collected together with the biographical and neurological data. The DTT parameters were fiber number, fractional anisotropy value and their ratios of affected corticospinal tract. The data were compared between two groups, built up according to the presence (MEP-P) or absence (MEP-N) of MEP on the affected hand.ResultsFunctional and DTT variables were significantly different between MEP-P and MEP-N groups (p<0.001). Among the MEP-P group, the amplitude ratio (unaffected/affected) was significantly correlated with the Brunnstrom stage of hand (r=-0.427, p=0.013), K-MBI (r=-0.380, p=0.029) and the time post-onset (r=-0.401, p=0.021). The functional scores were significantly better when both MEP response and DTT were present and decreased if one or both of the two studies were absent.ConclusionThis study indicates MEP responsiveness and amplitude ratio are significantly associated with the upper extremity function and the activities of daily living performance, and the combined study of MEP and DTT provides useful information.

Low-Cost Tele-assessment System for Home-Based Evaluation of Reaching Ability Following Stroke

Tele-assessment techniques can provide healthcare professionals with easily accessible information regarding patients' clinical progress. Recently, kinematic analysis systems have been used to assess rehabilitative outcomes in stroke patients. Kinematic systems, however, are not compatible with tele-assessment. The objective of our study was to develop a tele-assessment system for acquiring kinematic data of forward reaching movements in stroke patients, with an emphasis on cost-effectiveness, portability, and ease of use. We selected four healthy control participants and eight hemiplegic stroke patients for our study. The stroke patients were classified as Brunnstrom stage III, stage IV, or stage V. Our tele-assessment system used two three-axes accelerometers, a potentiometer, a multifunctional data acquisition card, and two computers. A standardized kinematic system was applied simultaneously to validate the measurements recorded by our tele-assessment system during five repetitions of forward reaching movements. The correlation coefficients of the reaching displacement, velocity, and acceleration measurements obtained using our tele-assessment system and the standardized kinematic system were 0.956, 0.896, and 0.727, respectively. Differences in the maximum reaching distance and the maximum reaching velocity of forward reaching movements were observed among the study groups. There were no significant differences in the time required to complete the testing session among the study groups. Our tele-assessment system is valid for the evaluation of upper-extremity reaching ability in stroke patients. Further research is needed to investigate the feasibility of the use of the tele-assessment system in patients' homes.

Fuzzy inference system based automatic Brunnstrom stage classification for upper-extremity rehabilitation

Post-stroke rehabilitation has been considered vitally important for improving the life quality of stroke patients. In order to perform rehabilitation effectively, it is crucial to have a standardized system to examine patients’ impairment severity in prior to any treatments and to track their training results. Brunnstrom stages classification is one of the most common measures of stroke patients’ rehabilitation progress and usually can only be performed by experienced physicians. A fuzzy inference system based upper-extremity motion evaluation system is presented in this paper to provide a reliable computerized solution for objective motion quality assessment and automatic Brunnstrom stage classification. An Adaptive Neuro-Fuzzy Inference System (ANFIS) is implemented for system modeling with Principle Component Analysis (PCA) as a feature extraction measure in order to reduce the complexity and improve the performance of the system. Experiments have been conducted and the results have demonstrated that the system is able to produce quantified outcomes reflecting patient’s motion performance according to the Brunnstrom approach. An 87.5% of cross-validation correct rate was achieved for Brunnstrom stages classification.