Chronic Post-stroke Individuals Research Articles

Bi-cephalic transcranial direct current stimulation combined with functional electrical stimulation for upper-limb stroke rehabilitation: A double-blind randomized controlled trial.

Stroke survivors often present poor upper-limb (UL) motor performance and reduced movement quality during reaching tasks. Transcranial direct current stimulation (tDCS) and functional electrical stimulation (FES) are widely used strategies for stroke rehabilitation. However, the effects of combining these two therapies to rehabilitate individuals with moderate and severe impairment after stroke are still unknown. Our primary aim was to evaluate the effects of concurrent bi-cephalic tDCS and FES on UL kinematic motor performance and movement quality of chronic post-stroke subjects with moderate and severe compromise. Our secondary aim was to verify the effects of combining these therapies on handgrip force and UL motor impairment. We randomized 30 individuals with moderate and severe chronic hemiparesis after stroke into tDCS plus FES (n=15) and sham tDCS plus FES (n=15) groups. Participants were treated 5 times a week for 2 weeks. Kinematic motor performance (movement cycle time, velocity profile) and movement quality (smoothness, trunk contribution, joint angles) were assessed during an UL reach-to-target task.Handgrip force and motor impairment were also recorded before and after the intervention. Participants allocated to the tDCS plus FES group improved movement cycle time (P=0.039), mean reaching velocity (P=0.022) and handgrip force (P=0.034). Both groups improved the mean returning phase velocity (P=0.018), trunk contribution (P=0.022), movement smoothness (P=0.001) and UL motor impairment (P=0.002). Concurrent bi-cephalic tDCS and FES slightly improved reaching motor performance and handgrip force of chronic post-stroke individuals with moderate and severe UL impairment. ClinicalTrials.gov (NCT02818608).

Contralesional Cathodal versus Dual Transcranial Direct Current Stimulation for Decreasing Upper Limb Spasticity in Chronic Stroke Individuals: A Clinical and Neurophysiological Study

Different transcranial direct current stimulation (tDCS) paradigms have been implemented to treat poststroke spasticity, but discordant results have been reported. This study aimed to determine the efficacy and persistence of dual tDCS (anode over affected motor cortex [M1] and cathode over contralateral M1) compared with cathodal tDCS (cathode over contralateral M1) on upper limb (UL) functional, behavioral, and neurophysiological measures in chronic poststroke individuals. Ten subjects with UL spasticity (7 men; mean 62 years; 8 ischemic stroke; years from event: 2.3 years) were enrolled in a cross-over, double-blinded study. Cathodal and dual tDCS, both preceded by 1 week of sham stimulation 1 month before real stimulation, were applied with 3 months interval. Stimulating paradigm was 20 minutes for five consecutive days in each block. Evaluations were performed before (T1), after real or sham treatment (T2), and after 1 (T3), 4 (T4), and 8 weeks (T5). Functional, behavioral, and neurophysiological tests were performed at each time. Both tDCS paradigms decreased spasticity, increased strength, and ameliorated behavioral scales. Cathodal tDCS was superior to dual tDCS in reducing UL distal spasticity immediately after treatment (T2: cathodal > dual: P = .023) and provided a higher and longer lasting reduction at proximal districts (T3: cathodal > dual: P = .042; T4: cathodal > dual: P = .028; T5: cathodal > dual: P = .05). These findings are supported by an H-reflex modulation (overall time effect P > .002). Cathodal tDCS is slightly more effective than dual tDCS in reducing distal UL spasticity in chronic poststroke subjects. A modulation of spinal inhibitory mechanisms, demonstrated by H-reflex modifications, supports this finding.

EP 20. Contralesional Cathodal tDCS versus dual-tDCS for decreasing upper limb spasticity in chronic stroke individuals: A clinical and neurophysiological study

Background Different transcranial direct current stimulation (tDCS) paradigms have been implemented to treat post-stroke spasticity, but discordant results have been reported. Objective To determine the efficacy and persistence of dual-tDCS (anode over the affected motor cortex (M1) and cathode over the contralateral) compared to cathodal tDCS (cathode over contralateral M1) on upper limb (UL) functional, behavioral and neurophysiological measures in chronic post-stroke individuals. Methods 10 subjects with UL spasticity (7 men; mean age 62 y; 8 ischaemic stroke; years from event: 2.3 y) were enrolled in a cross-over, double-blinded study. Cathodal tDCS and dual-tDCS, both preceded by one week of sham stimulation 1 month before real, were applied with a 3 months interval. Stimulating paradigm was 20 min for five consecutive days in each block. Evaluations were performed before treatment (T1), after real or sham treatment (T2), and after one (T3), four (T4) and eight weeks (T5). Functional, behavioral and neurophysiological tests were performed at each time. Results Both tDCS paradigms decreased spasticity, increased strength and ameliorated behavioral scales. Cathodal tDCS was indeed superior to dual-tDCS in reducing UL distal spasticity immediately after treatment (T2: cathodal > dual: p = 0.023), and providing a higher and longer lasting reduction at proximal districts (T3: cathodal > dual: 0.042; T4: cathodal > dual: 0.028; T5: cathodal > dual: 0.05). These findings are supported by a slight major effect of cathodal tDCS on H reflex modulation (overall time effect p > 0.002). Conclusions Cathodal tDCS is slightly more effective than dual-tDCS in reducing distal UL spasticity in chronic post-stroke subjects. A modulation of spinal inhibitory mechanisms, as demonstrated by H reflex modifications, supports this finding.

Medo de cair e sua relação com a medida da independência funcional e a qualidade de vida em indivíduos após Acidente Vascular Encefálico

The aim of this cross-sectional study was to evaluate the fear of falling of 52 chronic post-stroke individuals and to assess its relationship with measures of functional independence and quality of life (QOL). Fear of falling was assessed by the Brazilian version of Falls Efficacy Scale International (FES-I-BRAZIL) and functional independence by the Functional Independence Measure (FIM) and QOL by the Stroke Specific Quality of Life (SSQOL) scale. Spearman's correlation coefficients were calculated to verify the associations between FES-I-BRAZIL and the other instruments, and the Mann-Whitney U test to compare groups with low and high fall concerns. There was a predominance of individuals with high concerns regarding falling, higher QOL, and independence. FES-I-BRAZIL was statistically associated with FIM and SSQOL. Significant relationships were also found between FES-I-Brazil with FIM transfer and locomotion sub-scales, as well as with the following SSQOL energy, family role, language, mobility, mood, self-care, and upper extremity function domains. Thus, fear of falling may contribute to reduced functional independence and QOL in post-stroke individuals and should be included in the evaluation process of these patients to ensure greater benefits during rehabilitation.

Insights into upper limb kinematics and trunk control one year after task-related training in chronic post-stroke individuals

Study designRandomized clinical trial. IntroductionLong-term follow-up of training investigations involving post-stroke individuals can lead to advancing clinical decisions. Extended task-related training (TRT) effects on reaching with the impaired upper limb were evaluated, using a pre-test/posttest/follow-up design. PurposeOne-year follow-up examinations analyzed whether improved shoulder and elbow motion were maintained following prolonged practice of the upper limb. MethodsLong-term kinematic analysis on 21 moderately impaired post-stroke participants (upper extremity Fugl-Meyer between 19 and 40/66), as well as results from standardized outcome measures performed on these patients and another 16 post-stroke participants. ResultsSignificant initial changes were maintained for kinematic shoulder and elbow motion, as well as functional measures. Compensatory reaching involving the trunk has been shown to be maintainable, but ultimately less efficient. ConclusionsTraining that involves a conscious decision to control the trunk led to the most improved functional performance, and may lead to ideal restorative strategies. Level of evidence2B.

REHABILITATION OF REACHING AFTER STROKE

Purpose/Hypothesis: For post-stroke individuals, effects of Task-Related Training (TRT) and Resistive Exercise (RE) on reaching with the paretic limb were evaluated using a pre-/posttest/follow-up design. Forward trunk motion was curtailed during training by a stabilization device. Previously, posttest kinematic analysis indicated that reaching improved more with TRT than with RE, evidenced by: straighter hand paths, decreased proportion of time after first velocity peak and increased shoulder flexion at the difficult ipsilateral target. At follow-up, individuals performing both types of training were expected to show improved use of the arm during reaching. However, it was hypothesized that the TRT group would produce greater gains since prior work showed this group learned to use the trunk motion extensively to complete the task. Number of Subjects: Eleven individuals with moderate arm impairment (19 to 39 on the Fugl-Meyer upper arm subsection scale (FMA)), 7 months to 3 years post unilateral-stroke onset were randomly assigned to TRT or RE and tested at pre/post and follow-up. Materials/Methods: Subjects received 4 weeks of training while having the trunk restrained. In TRT, specific activities using the paretic upper-limb at varied locations across the workspace were performed. In RE, repetitive whole arm resistance exercises in planes and distances similar to those of the TRT movements were performed. During pre-/posttests and follow-up, conducted with trunk unrestrained, individual subjects reached to targets ipsilateral, midline and contralateral to the paretic upper limb. Additionally, individuals were administered the Wolf Motor Function test, the Fugl-Meyer scale (FMA) and AROM measures. Kinematic analysis (3-D) of individual's wrist and trunk motion during reaching was carried out. A 2 (training group) × 3 (pretest/ posttest/follow-up) × 3 (target position) analysis of variance (ANOVA), with repeated measures on the last two factors, was used. Results: At one-year follow-up, shoulder angle flexion and FMA was maintained for both groups overall (p<.03 eta sqr =.32 and p<.00 eta sqr =.66, respectively), while elbow angle extension increased for the TRT group over the three testing sessions (p<.00 eta sqr = .54). Conclusions: Initial kinematic analysis indicated that reaching improved more for TRT than for RE, evidenced by: straighter hand paths, decreased proportion of time after first velocity peak and increased shoulder flexion at the difficult ipsilateral target. One year after completing formal TRT and RE training with trunk restraint, these measures of reaching ability were maintained, with increases of elbow angle for the TRT group; indicating long-term effects from the original training for these chronic post-stroke individuals. Clinical Relevance: Although both training protocols demonstrated that reaching was maintained one year after training was completed, training under more realistic conditions associated with TRT (with trunk restrained) resulted in functional reaching improvements and should be encouraged for chronic post-stroke individuals.

IMPROVED GAIT AND ELEVATION SPEED OF INDIVIDUALS POST-STROKE AFTER LOWER EXTREMITY TRAINING IN VIRTUAL ENVIRONMENTS.

PURPOSE/HYPOTHESIS: The purpose of this study was to determine if lower extremity training in virtual reality (VR) transferred to improved gait and elevations speeds. We hypothesized that selected individuals post-stroke would improve their walking and elevations speeds after VR training. NUMBER OF SUBJECTS: Six individuals 9 months to 8 years post-stroke (1 female and 5 males) ages 41-81 participated in the study. All individuals ambulated independently. Three used either an assistive device or a brace. Their walking speeds ranged from .14 ft/sec to .88 ft/sec. MATERIALS/METHODS: Study design was a double baseline pre-post-test. A robotic device (the Rutgers Ankle) was the input to the virtual environment (VE). Participants, who were seated, used the movements of their affected foot to control a plane or a boat in the VE, which was displayed on a desktop computer. Their task was to navigate in the VE through a series of targets without contacting them. Parameters such as range of motion, platform resistance and speed of targets were adjusted to create warm up, endurance, speed, strengthening and coordination exercises. Perturbations were created using haptic (sensation) effects and changing visibility in the VE. Subjects trained three times a week for four weeks. Primary outcome measures included gait and elevation speed. Primary clinical outcome variables were gait speed (measured as the average of three walking trials collected on the Gait Rite), endurance (six minute walk test) and elevation speed (time to ascend and descend two flights of steps). Training effects were assessed using paired t-tests with the two baselines averaged. RESULTS: Gait speed increased 11% from .64 ft/sec. to .71 ft/sec (p=.08) and elevation time decreased 14% from 27 to 23 seconds (p=.05). Gait endurance increased 11% from 800 to 891 feet/6 minutes (NS). Gait speed improvements ranged from 0 to 44%. Elevation speed improvements ranged from 3-33%. CONCLUSIONS: Improved gait and elevation speed as well as gait endurance were made by a group of chronic post-stroke individuals. Variability in the amount of improvement observed indicates that the training was more effective for some of the participants. Frequency and duration of treatments were similar however, training intensity varied based on participant's ability. CLINICAL RELEVANCE: Individuals post-stroke from a broad age range were able to train lower extremity movements in a virtual environment with a transfer to the real world. The training intensity achieved in VR may be related to the transfer of improvements. This is preliminary evidence that VR may be a viable adjunct for gait training of selected individuals post-stroke.

The effects of the functional tone management (FTM) arm training program on upper extremity motor control on chronic post-stroke individuals

Background: The purpose of this study is to investigate the effect of functional arm training with a FTM dynamic orthosis on upper extremity movment of chronic post-CVA survivors. The FTM was designed to allow stroke patients to quickly incorporate grasp and release function. Methods: Each subject was fitted for a FTM dynamic orthosis and received 5 days of therapeutic treatment and training, 6 hours per day. Treatment intervention consisted of repetitive, task oriented arm movements using the FTM dynamic orthosis, movement specific exercises using the Hemi-Glide™ exercise device, and neuromuscular electrical stimulation targeted to the wrist and finger extensors. Results: Data analysis using paired t-tests showed significant improvements in shoulder flexion, shoulder abduction, elbow flexion, elbow extension,and wrist extension. Additionally, all 3 qualitative assessment tools—the Fugl Meyer, the Motor Status Assessment, and the modified Ashworth—showed statistically significant improvements. Conclusion: The FTM dynamic orthosis used in combination with the prescribed UE exercise protocol increased mean values for shoulder flexion, shoulder abduction, elbow flexion, elbow extension, and wrist extension in a group of 13 adult post CVA participants.