Atsuko Ogata

Addition of intensive repetition of facilitation exercise to multidisciplinary rehabilitation promotes motor functional recovery of the hemiplegic lower limb.

OBJECTIVE To evaluate the effects of the intensive repetition of movements elicited by the facilitation technique to improve voluntary movement of a hemiplegic lower limb in patients with brain damage. DESIGN A multiple-baseline design (A-B-A-B: A without specific therapy, B with specific therapy) across individuals. PATIENTS The sample comprised 22 subjects with stroke and 2 brain tumour-operated subjects (age: 50.7 +/- 9.6 years, time after onset: 7.1 +/- 2.6 weeks). They were selected from among 165 patients with stroke who were admitted to our rehabilitation centre from September 1, 1995 to March 31, 1997. METHODS Two 2-week facilitation technique sessions (more than 100 repetitions a day for each of 5 kinds of movement) were applied at 2-week intervals in patients with hemiplegia, who were being treated with continuous conventional rehabilitation exercise without the facilitation technique for hemiplegia. Motor function of the affected lower limb (Brunnstrom Recovery Stage of hemiplegia, the foot-tap test and the strength of knee extension/flexion) and walking velocity were evaluated at 2-week intervals. RESULTS Significant improvements in Brunnstrom Stage, foot-tapping and the strength of knee extension/flexion of the affected lower limb were seen after the first conventional rehabilitation exercise session and after the first and second facilitation technique and conventional rehabilitation exercise sessions. The improvements after facilitation technique and conventional rehabilitation exercise sessions were significantly greater than those after the preceding conventional rehabilitation exercise sessions. CONCLUSION Intensive repetition of movement elicited by the facilitation technique (chiefly proprioceptive neuromuscural facilitation pattern, stretch reflex and skin-muscle reflex) improved voluntary movement of a hemiplegic lower limb in patients with brain damage.

Benefits of a Repetitive Facilitative Exercise Program for the Upper Paretic Extremity After Subacute Stroke A Randomized Controlled Trial

Background. Repetitive facilitative exercise (RFE), a combination of high repetition rate and neurofacilitation, is a recently developed approach to the rehabilitation of stroke-related limb impairment. Preliminary investigations have been encouraging, but a randomized controlled evaluation has yet to be performed. Objectives. To compare the efficacy of RFE with that of conventional rehabilitation in adults with subacute stroke. Methods. A total of 52 adults with stroke-related upper-limb impairment (Brunnstrom stage ≥III) of 3 to 13 weeks’ duration participated in this randomized, controlled, observer-blinded trial. Participants were randomized into 2 groups and received treatment on a 4-week, 40 min/d, 5 d/wk schedule. Those assigned to RFE received 100 standardized movements of at least 5 joints of their affected upper extremity, whereas those in the control group participated in a conventional upper-extremity rehabilitation program. Primary and secondary outcomes (improvement in group Action Research Arm Test [ARAT] and Fugl-Meyer Arm [FMA] scores, respectively) were assessed at the end of training. Results. In all, 49 participants (26 receiving RFE) completed the trial. ARAT and FMA scores at baseline were 19 ± 21 and 39 ± 21 (mean ± standard deviation). Evaluation at the trial’s completion revealed significantly larger improvements in the RFE group than in the control group in both ARAT (F = 7.52; P = .009) and FMA (F = 5.98; P = .019) scores. Conclusions. These findings suggest that RFE may be more effective than conventional rehabilitation in lessening impairment and improving upper-limb motor function during the subacute phase of stroke.

Improvements in limb kinetic apraxia by repetition of a newly designed facilitation exercise in a patient with corticobasal degeneration.

Corticobasal degeneration is a progressive neurological disorder characterized by a combination of parkinsonism and cortical dysfunction such as limb kinetic apraxia, alien limb phenomenon, and dementia. To study the effect of repetitive facilitation exercise (RFE) in a patient with corticobasal degeneration, we used a newly designed facilitation exercise designed to elicit movements isolated from the synergy in hemiplegia. This exercise included movements of each isolated finger using stretch reflex and skin-muscle reflex and repetitive movements demanded in activities of daily living (ADL) and manipulating objects. To evaluate improvements in hand functions by RFE, 1-week RFE sessions for the hand were administered alternatively to the left or right hand. The number of finger taps by the hand increased during each 1-week RFE session for the hand, but did not increase during 1-week sessions without RFE. After 1 month of treatment, the patients difficulties in ADL, including wearing clothes, manipulating objects and cooking, decreased. Our results suggest the importance of the repetition of facilitation exercises and movements in ADL for recovery in patients with degenerative neurogenic diseases.

Brief Clinical Report REDUCTION OF CENTRAL POSTSTROKE PAIN WITH THE SELECTIVE SEROTONIN REUPTAKE INHIBITOR FLUVOXAMINE

To investigate the effect of the selective serotonin reuptake inhibitor (SSRI) fluvoxamine on central poststroke pain (CPSP), fluvoxamine (25 to 125 mg daily) was given to 31 patients. Although 3 patients dropped out within 1 week, 28 patients who received fluvoxamine for 2 to 4 weeks showed a significant reduction in the visual analog scale (VAS) for pain from 7.7 - 2.2 to 6.0 - 3.4 (p <. 01). This improvement in VAS was significant in patients within less than 1 year after stroke, but not in those with a duration of more than 1 year. Zung s Self-rating Depression Scale (SDS) was also significantly improved after treatment, but there was no significant correlation between the changes in VAS and SDS. Although this is not a double-blind, placebo-controlled trial, these results suggest that fluvoxarnine is useful for the control of CPSP regardless of depression when used relatively early after stroke.

Effects of repetitive trascranial magnetic stimulation on repetitive facilitation exercises of the hemiplegic hand in chronic stroke patients.

OBJECTIVE To investigate whether multiple sessions of 1-Hz repetitive transcranial magnetic stimulation (rTMS) facilitates the effect of repetitive facilitation exercises on hemiplegic upper-limb function in chronic stroke patients. DESIGN Randomized double-blinded crossover study. PATIENTS Eighteen patients with hemiplegia of the upper limb. METHODS Patients were assigned to 2 groups: a motor-before-sham rTMS group, which performed motor rTMS sessions for 2 weeks followed by sham rTMS sessions for 2 weeks; or a motor-following-sham rTMS group, which performed sham rTMS sessions for 2 weeks followed by motor rTMS sessions for 2 weeks. Patients received 1-Hz rTMS to the unaffected motor cortex for 4 min and performed repetitive facilitation exercises for 40 min during motor rTMS sessions. The Fugl-Meyer Assessment, Action Research Arm Test (ARAT) and Simple Test for Evaluating Hand Function were used to evaluate upper-limb function. The Modified Ashworth Scale and F-wave were measured to evaluate spasticity. RESULTS Motor function improved significantly during the motor, but not sham, rTMS sessions. ARAT score gains were 1.5 (0-4.0) (median, interquartile range) during the motor rTMS session, and 0 (-0.8-1.8) during the sham rTMS session (p = 0.04). Spasticity did not significantly change during either session. CONCLUSION Multiple sessions of 1-Hz rTMS facilitated the effects of repetitive facilitation exercises in improving motor function of the affected upper limb, but did not change spasticity.

Salivary Secretion and Occlusal Force in Patients with Unilateral Cerebral Stroke

ABSTRACT The purpose of this study was to investigate salivary secretion in unilateral cerebral stroke patients, including the effects of masticatory forces. We compared the volumes of unstimulated and acid-stimulated saliva between 30 patients with unilateral cerebral stroke and 30 age-matched healthy subjects. The volume of whole-mouth salivary secretion was measured by the modified cotton swab method. Occlusal forces were measured with an occlusal force meter in patients/subjects, in groups with normal teeth and dentures, respectively. The volume of unstimulated saliva in stroke patients was significantly lower than that in controls. For subjects with normal teeth, the volume of acid-stimulated saliva and the occlusal force on the hemiplegic side in stroke patients were significantly lower than those in control subjects. For those with dentures, while the volume of unstimulated saliva in stroke patients was significantly lower than that in controls, there were no significant differences in occlusal forces between the two groups. These results suggest that salivary secretion might be reduced in cerebral stroke patients, which might be caused partly by an inability to generate sufficient masticatory force, and which, in turn, might lead to a reduced masticatory-parotid reflex and consequent disuse atrophy of the salivary glands.

RELATIONSHIP BETWEEN DYSGEUSIA AND DYSESTHESIA IN STROKE PATIENTS

This study investigated the relationship between dysgeusia and dysesthesia in stroke patients and evaluated the effect of carbamazepine therapy. Twenty-four patients with dysesthesia of the face, oral cavity, or tongue were divided into two groups: with and without subjective dysgeusia. Taste thresholds were objectively evaluated using the filter-paper taste test and electrogustometry. There was no significant difference in taste thresholds between the two groups. Carbamazepine had an effect on subjective dysgeusia in four of the eight treated patients. Dysgeusia with dysesthesia in stroke patients might be caused by disorders of the somatosensory pathway rather than disorders of the gustatory pathway.

Impaired visuo-motor skills in the unaffected lower limb of patients with stroke.

To study the motor skills of the unaffected lower limb of patients with stroke, the visuo-motor skills of the unaffected lower limb in patients with stroke was compared with those in healthy control subjects using a computerized motor skill analyzer that calculated the accuracy in the tracking task in terms of lap time and trajectory error. Trajectory errors in the task by the unaffected lower limb in the patients with stroke were significantly greater than those in the lower limb of healthy control subjects. These results suggest that patients with stroke have impaired visuo-motor skills of the unaffected lower limb.

Evaluation of skilled leg movements in patients with stroke using a computerized motor-skill analyzer for the lower limb.

The utility of a new computerized motor-skill analyzer for the lower limb was studied in healthy subjects and patients with stroke. The computerized motor-skill analyzer for the lower limb evaluated accuracy in a figure-tracking task with the foot. The intraclass correlation coefficients of measurements in subjects were .61 to .89 (p < .01). The trajectory errors of the unaffected lower limb in stroke patients were negatively correlated with physical ability. Trajectory errors of the patients were significantly larger than those of the healthy subjects. These results suggest that the computerized motor-skill analyzer is useful for quantitatively evaluating motor-skills of the lower limb.

Stroke Patient with Mirror Movement of the Affected Hand Due to an Ipsilateral Motor Pathway Confirmed by Transcranial Magnetic Stimulation: A Case Report

ABSTRACT A stroke patient with right hemiplegia and mirror movement underwent transcranial magnetic stimulation (TMS) and somatosensory-evoked potential (SEP) testing. The motor-evoked potentials (MEPs) of both abductor pollicis brevis muscles after stimulating the unaffected right hemisphere showed similar latencies, and were potentially produced by corticospinal tracts from the same motor cortex. N20 responses of SEPs were recorded at C4′ after contralateral stimulation of the unaffected left median nerve, but not stimulation of the affected right median nerve. The mirror movements and motor recovery might have utilized an ipsilateral motor pathway between the unaffected hemisphere and the affected hand.