Degree Of Motor Recovery Research Articles

Cortical reorganization correlates with motor recovery after low-frequency repetitive transcranial magnetic stimulation combined with occupational therapy in chronic subcortical stroke patients

The combination of low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) and intensive occupational therapy (iOT) has been shown to ameliorate upper limb hemiparesis in patients with chronic subcortical stroke. However, the neural mechanisms underlying its efficacy are poorly understood. Our aim was to examine the cortical reorganization after LF-rTMS and iOT, as well as to explore its association with the degree of motor recovery using functional magnetic resonance imaging (fMRI). Thirty chronic subcortical stroke patients with mild-to-moderate upper limb hemiparesis underwent 18 treatment sessions. Each session included LF-rTMS to the unaffected hemisphere for 20 min as well as iOT for 120 min. The patients were evaluated before and after therapy using behavioral assessments, including the Fugl-Meyer Assessment (FMA), Wolf Motor Function Test (WMFT), and task-based fMRI. The fMRI data obtained during hand movement were used to calculate the laterality index (LI). After the treatment, the motor function test scores of FMA and WMFT improved significantly. The LI during movements of the affected hand increased significantly, suggesting changes in the activation balance within the primary motor, primary sensory, and premotor cortexes toward the lesioned hemisphere. Moreover, the LI changes in the aforementioned areas significantly correlated with gains in the WMFT. These results suggest that the motor improvements produced by the combination of LF-rTMS and iOT in chronic subcortical stroke patients are closely linked to cortical reorganization, in which a more physiological activation pattern is reinstated in the ipsilesional hemisphere by suppression of the aberrant activation of the contralesional hemisphere.

Sex differences in recovery of motor function in a rhesus monkey model of cortical injury

BackgroundStroke disproportionately affects men and women, with women over 65 years experiencing increased severity of impairment and higher mortality rates than men. Human studies have explored risk factors that contribute to these differences, but additional research is needed to investigate how sex differences affect functional recovery and hence the severity of impairment. In the present study, we used our rhesus monkey model of cortical injury and fine motor impairment to compare sex differences in the rate and degree of motor recovery following this injury.MethodsAged male and female rhesus monkeys were trained on a task of fine motor function of the hand before undergoing surgery to produce a cortical lesion limited to the hand area representation of the primary motor cortex. Post-operative testing began two weeks after the surgery and continued for 12 weeks. All trials were video recorded and latency to retrieve a reward was quantitatively measured to assess the trajectory of post-operative response latency and grasp pattern compared to pre-operative levels.ResultsPostmortem analysis showed no differences in lesion volume between male and female monkeys. However, female monkeys returned to their pre-operative latency and grasp patterns significantly faster than males.ConclusionsThese findings demonstrate the need for additional studies to further investigate the role of estrogens and other sex hormones that may differentially affect recovery outcomes in the primate brain.

Incidence and degrees of neurologic decline following thoracic costotransversectomy

Background ContextThoracic costotransversectomies (TCT) are amongst the most invasive spine procedures performed. Of greatest concern to the patient and surgeon is the risk of iatrogenic neurologic injury associated with these procedures. Most available studies limit their assessment of neurologic function to nonspecific scales such as the broader ASIA scoring system of A to E and have not comprehensively described the rates of iatrogenic injury following these procedures by looking more precisely with ASIA motor scoring (0–100) which allows for more in-depth analysis. PurposeThe purpose of this study is to investigate the rates and degree of iatrogenic neurologic decline following TCT and subsequent rates and degree of motor recovery. Study Design/SettingRetrospective medical record review at a single institution. Patient SampleAround 116 consecutive patients undergoing TCT operations. Outcome MeasuresNeurological changes from preprocedure to final follow-up assessed by lower extremity motor score. MethodsA retrospective chart review of patients undergoing TCT between May 2008 and April 2018 was carried out. Clinical, surgical, and intraoperative neuromonitoring data were collected. Patients who demonstrated an initial postoperative decline in lower extremity motor scores (LEMS) were followed through their final follow up to assess recovery. ResultsAround 116 patients underwent TCT between T2 and T12 between May 2008 and April 2018. Seven (6.0%) patients demonstrated an immediate postoperative decline as defined by a drop of more than 4 points (mean 15.1; range 5–50) in motor score. All patients who demonstrated an initial postoperative motor score decline returned to within 4 LEMS points of their preoperative LEMS by final follow up. IOMN changes were noted only in half of all monitored patients who were noted to have a decline. ConclusionsIn our series, 6.0% of patients undergoing TCT experienced an initial decline in motor score with 94.0% demonstrating an unchanged or improved examination compared to preoperative exam. In our series, all patients who exhibited a decline recovered to within 4 points of the preoperative motor score within the first year postoperatively.

Gait analysis of hemiplegic patients by measurement of ground reaction force

Ground reaction force during walking was measured and analyzed in 58 patients who had been hemiplegic for more than 6 months. Utilizing the impulse (area between a component curve and the baseline) as an assessment value, several parameters were selected to represent the characteristics of each component curve (vertical, fore-aft and lateral) of the ground reaction force, and correlated with the degree of motor recovery in the patients. As a result, a high correlation was found between these parameters and the degree of motor recovery, indicating that ground reaction force well reflects the degree of motor recovery, which is highly correlated with the gait ability of hemiplegic patients. This evaluation method would also be very helpful for objective and quantitative estimation of the gait of hemiplegic patients

Electrophysiological evidence for pre-attention information processing improvement in patients with central hemiplegic after peripheral nerve rewiring: a pilot study

Central neurologic injury (CNI) causes dysfunctions not only in limbs but also in cognitive ability. We applied a novel peripheral nerve rewiring (PNR) surgical procedure to restore limb function. Here, we conducted a prospective study to develop estimates for the extent of preattentive processes to cognitive function changes in CNI patients after PNR. Auditory mismatch negativity (MMN) was measured in CNI patients who received the PNR surgery plus conventional rehabilitation treatment. During the 2-year follow-up, the MMN was enhanced with increased amplitude in the PNR plus rehabilitation group compared to the rehabilitation-only group as the experiment progressed, and progressive improvement in behavioural examination tests was also observed. Furthermore, we found a significant correlation between the changes in Fugl-Meyer assessment scale scores and in MMN amplitudes. These results suggested that PNR could affect the efficiency of pre-attention information processing synchronously with the recovery of motor function in the paralyzed arm of the in chronic CNI patients. Such electroencephalographic measures might provide a biological approach with which to distinguish patient subgroups after surgery, and the change in MMN may serve as an objective auxiliary index, indicating the degree of motor recovery and brain cognitive function.

Gray matter volume changes in chronic subcortical stroke: A cross-sectional study.

This study aimed to investigate the effects of lesion side and degree of motor recovery on gray matter volume (GMV) difference relative to healthy controls in right-handed subcortical stroke. Structural MRI data were collected in 97 patients with chronic subcortical ischemic stroke and 79 healthy controls. Voxel-wise GMV analysis was used to investigate the effects of lesion side and degree of motor recovery on GMV difference in right-handed chronic subcortical stroke patients. Compared with healthy controls, right-lesion patients demonstrated GMV increase (P < 0.05, voxel-wise false discovery rate correction) in the bilateral paracentral lobule (PCL) and supplementary motor area (SMA) and the right middle occipital gyrus (MOG); while left-lesion patients did not exhibit GMV difference under the same threshold. Patients with complete and partial motor recovery showed similar degree of GMV increase in right-lesion patients. However, the motor recovery was correlated with the GMV increase in the bilateral SMA in right-lesion patients. These findings suggest that there exists a lesion-side effect on GMV difference relative to healthy controls in right-handed patients with chronic subcortical stroke. The GMV increase in the SMA may facilitate motor recovery in subcortical stroke patients.

Measurement properties of the lower extremity motor coordination test in individuals with stroke

To evaluate the construct validity, inter- and intra-rater reliabilities, best scoring method and testing methods (direct vs video observations), and to determine the smallest real difference (SRD) and standard error of the measurement (SEM) of the lower Extremity Motor Coordination Test (LEMOCOT). Methodological study. Thirty-six stroke subjects. Outcomes include measures of motor recovery, muscular tone, strength, motor coordination, foot tactile sensation, and gait speed. The LEMOCOT scores were able to discriminate between stroke individuals from those predicted for healthy subjects, between the paretic and non-paretic limbs for both the sub-acute and chronic groups and differentiated between individuals with different functional levels and degrees of motor recovery. For the intra- and inter-rater reliabilities, very high and significant coefficients were found for both the paretic and non-paretic lower limbs for both groups (intra-class correlation coefficients (ICC) > 0.97, p < 0.0001). Significant differences were found regarding all scoring methods (18.91 < F < 27.49, p < 0.0001), but they were not clinically important and all showed adequate test-retest reliability and acceptable SRD and SEM (< 15%) values. There was also agreement between the scores from the direct and video observations. The LEMOCOT demonstrated adequate measurement properties in stroke subjects and, therefore, could be an appropriate measure for research and clinical purposes.

Diffusion Tensor Imaging Predicts Motor Functional Outcome after Acute Hypertensive Intracerebral Hemorrhage

Early evaluation of the corticospinal tract (CST) is critical for patients with acute hypertensive intracerebral hemorrhage (ICH) to predict long-term motor functional outcome. Therefore, we investigated motor functional outcome of an ICH using diffusion tensor imaging (DTI) in patients with hypertensive ICH. Thirty six patients with hemiparesis due to hypertensive ICH underwent DTI within 3 days after onset. Fractional anisotropy (FA) was measured within the CST at levels of the posterior limbs of the internal capsules, and motor impairment was assessed on admission and 8 weeks after ICH by manual muscle test. The correlation between FA ratio and improvement of motor function was analyzed by Pearson’s correlation analysis. The FA ratio from the initial DTI showed a correlation with motor function improvement. The amount of hematoma correlated with motor function on admission, but did not show correlation with the degree of motor recovery. Therefore, FA ratio analysis calculated from FA values of DTI could be a prognostic factor of motor function improvement in patients with hypertensive ICH.

The promotion of recovery through rehabilitation after acquired brain injury in children.

A degree of motor recovery is typically seen after acquired brain injury in children. The extent to which rehabilitation efforts can claim credit for this is disputed. Strong correlations between late impairment outcomes and early severity and impairment indices are seen both in adults and children. These correlations have been interpreted by some as evidence that recovery is largely intrinsic and that any additional rehabilitation effects are small. Such views are belied by published animal studies demonstrating the possibility of large rehabilitation effects. Animal models suggest that to achieve similar rehabilitation treatment effect sizes in clinical practice, rehabilitation 'doses' should be greater, rehabilitation efforts should start sooner, and premature accommodation of impairment should be avoided.

Restoration of hand function in a rat model of repair of brachial plexus injury

The incurability of spinal cord injury and subcortical strokes is due to the inability of nerve fibres to regenerate. One of the clearest clinical situations where failure of regeneration leads to a permanent functional deficit is avulsion of the brachial plexus. In current practice, surgical re-implantation of avulsed spinal roots provides a degree of motor recovery, but the patients neither recover sensation nor the use of the hand. In the present rat study, we show that transplantation of cultured adult olfactory ensheathing cells restores the sensory input needed for a complex, goal-directed fore-paw function and re-establishes synaptic transmission to the spinal grey matter and cuneate nucleus by providing a bridge for regeneration of severed dorsal root fibres into the spinal cord. Success in a first application of human olfactory ensheathing cells in clinical brachial plexus injury would open the way to the wider field of brain and spinal cord injuries.

Gait performance with compensatory adaptations in stroke patients with different degrees of motor recovery.

Gait patterns vary among stroke patients. This study attempted to discover gait performance with compensatory adaptations in stroke patients with different degrees of motor recovery. Data were gathered from 35 stroke patients and 15 healthy subjects. Gait performance and motor recovery were assessed 6 mos after stroke. Stroke patients further were divided into poor and good groups. The walking velocity was correlated with Brunnström's stages, and the temporal stride and motion variables of the two groups were compared. Walking velocity was positively correlated with the Brunnström's stages of the proximal lower limb. The poor group displayed slower walking velocity and shorter single-support time compared with the good group. Both groups displayed low maximum excursion of hip extension and ankle plantarflexion during the stance phase and low maximum excursion of hip and knee flexion and ankle dorsiflexion during the swing phase. Moreover, both groups displayed excessive pelvic tilts during the stance and swing phases. However, the poor group displayed different pelvic motion and timing sequences to each peak joint angle from normal subjects and the good group. Peak hip and knee angles of the affected limb during the stance phase occurred almost simultaneously in this group. Selective control of the proximal lower limb may be the main determinant of walking velocity. The compensatory adaptations were similar, except for pelvic motion, in stroke patients with different levels of motor recovery, whereas the poor group walked with synergistic mass patterns and reduced stability.

Longitudinal Study of Motor Recovery After Stroke

The goal of this study was to characterize cortical reorganization after stroke and its relation with the site of the stroke-induced lesion and degree of motor recovery using functional MRI (fMRI). Fourteen stroke patients with an affected upper limb were studied longitudinally. Three fMRI sessions were performed over a period of 1 to 6 months after stroke. Upper limb recovery, Wallerian degeneration of the pyramidal tract, and responses to transcranial magnetic stimulation were assessed. Two main patterns of cortical reorganization were found. Pattern 1 was focusing, in which, after initial recruitment of additional ipsilateral and contralateral areas, activation gradually developed toward a pattern of activation restricted to the contralateral sensorimotor cortex in 9 patients. Five patients were found to have pattern 2, persistent recruitment, in which there was an initial and sustained recruitment of ipsilateral activity. Occurrence of recruitment or focusing seemed to depend mainly on whether the primary motor cortex (M1) was lesioned; persistent recruitment was observed in 3 of 4 patients with M1 injury, and focusing was seen in 8 of 10 patients with spared M1. These patterns had no relation to the degree of recovery; in particular, focusing did not imply recovery. However, there was a clear relation between the degree of recovery and the degree of Wallerian degeneration. These results suggest that ipsilateral recruitment after stroke corresponds to a compensatory corticocortical process related to the lesion of the contralateral M1 and that the process of compensatory recruitment will persist if M1 is lesioned; otherwise, it will be transient.

Characteristics and course of urinary tract dysfunction after acute transverse myelitis in childhood

Bladder involvement is common in transverse myelitis but its characteristics and natural history, particularly in relation to neurological outcome, have not been described in a paediatric population previously. Ten children, with ages ranging from 8 months to 16 years, who had a diagnosis of acute transverse myelitis were studied with video urodynamics and followed up in a tertiary paediatric neurourology clinic. Nine often children had obstructive urinary tract symptoms at presentation and all went on to develop' irritative’urinary tract symptoms (frequency and urgency) about 1 month after initial presentation. Video urodynamics showed a combination of irritative (detrusor hyperreflexia) and obstructive (detrusor‐sphincter dyssynergia) abnormalities in most patients and enabled management to be specifically directed towards these. The patients progress was followed up for a median duration of 36 months. All had residual bladder dysfunction, only four were asymptomatic on treatment. The degree of recovery of bladder function was not related to the degree of motor recovery.

Gait analysis of hemiplegic patients by measurement of ground reaction force

Ground reaction force during walking was measured and analyzed in 58 patients who had been hemiplegic for more than 6 months. Utilizing the impulse (area between a component curve and the baseline) as an assessment value, several parameters were selected to represent the characteristics of each component curve (vertical, fore-aft and lateral) of the ground reaction force, and correlated with the degree of motor recovery in the patients. As a result, a high correlation was found between these parameters and the degree of motor recovery, indicating that ground reaction force well reflects the degree of motor recovery, which is highly correlated with the gait ability of hemiplegic patients. This evaluation method would also be very helpful for objective and quantitative estimation of the gait of hemiplegic patients.

Micturition Patterns After Spinal Trauma As A Measure Of Autonomic Functional Recovery

The purpose of these experiments was to determine whether experimental spinal trauma would result in urological dysfunction similar to that seen clinically and whether recovery of normal micturition can be correlated with motor functional recovery. A standard rat model of spinal impact trauma was employed. Neurologic evaluation included a modified 7 point hindlimb Tarlov scale applied weekly for 4 weeks after injury. Micturition measurement was accomplished by placing the animal in a metabolic cage for 24-hour periods and collecting urine on an electronic scale connected to Lotus Measure data acquisition software. All assessments were performed in a blinded fashion. Animals were categorized as normal control (N = 10), sham injured (N = 11), spinal cord injury (SCI) without (N = 11) and with locomotor recovery (N = 11).There were no differences in total micturition volume among the 4 groups, while the number of micturitions per 24 hours was significantly less for SCI without locomotor recovery (10.4 ± 5.9) than for control (21.3 ± 4.5). The volume per micturition was significantly greater for SCI (2.0 ± 0.7 ml.) than for control (0.8 ± 0.2 ml.). There were no differences among groups in the ratio of number of micturitions night/day. The SCI group had significantly greater largest and smallest micturitional volumes.Results clearly show alterations in micturition patterns induced by SCI. These were proportional to, but did not correlate fully with, the severity of injury and degree of motor recovery. Thus, recovery of a normal micturition pattern did not occur to the same extent as did motor functional recovery. This difference underscores the potential value of autonomic measures of SCI for distinguishing outcome categories after experimental SCI.

Reanalysis of central cervical cord injury management.

Early investigators indicated that conservative management was superior to operative intervention in the treatment of central cord injuries. Their clinical data suggested that operative treatment, in fact, worsened the condition. Recent experience with this clinical entity, however, indicates that in selected patients operative intervention may be of value in improving the rate and degree of motor recovery. A retrospective study of all individuals admitted to our hospital (Delaware Valley Spinal Cord Injury Center) with central cervical spinal cord injury was done (28 patients). One-half had been treated with medical therapy alone (Group I); the others were treated both medically and surgically (Group II). Medical therapy consisted of intravenous mannitol, dexamethasone, and sodium bicarbonate given during the acute phase of the injury. Both groups were immobilized using either a halo or a Philadelphia collar. Criteria for entry into the surgical group were one or both of the following: (a) failure to improve progressively after an initial period of improvement, with persistent compression of neural tissue visualized on myelography and (b) unacceptable instability of the spinal bony elements. The patients were given neurological scores based on the motor power of the major muscle groups. The stability of the spine was scored using the Panjabi-White scale. The two groups were compared using Student's t-test and the two-factor analysis of variance. There was no significant difference in initial neurological scores between the groups. The surgical groups had a higher incidence of instability of the bony elements of the cervical spine, as judged by the Panjabi-White scale.(ABSTRACT TRUNCATED AT 250 WORDS)

A study of the effects of hyperbaric oxygen on the experimental spinal cord injury.

The degree of motor recovery in sheep with a controlled contusion to the thoracic spinal cord is compared with the recovery in sheep treated with hyperbaric oxygen and confirms the results of a preliminary series previously reported. The degree of central cord cystic necrosis and degeneration in the surrounding white matter is compared in the control and treated animals. The improvement in motor recovery and in the degree of cord degeneration after treatment with hyperbaric oxygen suggests that ischaemia plays a significant role in the experimental animal with a contusion injury to the spinal cord.