Cordula Werner

Robot-assisted arm trainer for the passive and active practice of bilateral forearm and wrist movements in hemiparetic subjects.

OBJECTIVEnTo determine whether use of a robotic arm trainer for bilateral exercise in daily repetitive training for a 3-week period reduced spasticity and improved motor control in the arm of severely affected, chronic hemiparetic subjects.nnnDESIGNnBefore-after trial.nnnSETTINGnCommunity rehabilitation center in Germany.nnnPARTICIPANTSnConsecutive sample of 12 chronic hemiparetic patients; minimum stroke interval 6 months; patients could maximally protract the affected shoulder, hold the extended arm, or slightly flex and extend the elbow.nnnINTERVENTIONSnAdditional daily therapy of 15 minutes with the arm trainer for 3 weeks; the 1 degree of freedom trainer enabled the bilateral passive and active practice of a forearm pronation and supination and wrist dorsiflexion and volarflexion; impedance control guaranteed a smooth movement.nnnMAIN OUTCOME MEASURESnPatients impressions, the Modified Ashworth Scale (MAS) score (range, 0-5) to assess spasticity, and the arm section of the Rivermead Motor Assessment (RMA) score (range, 0-15) to assess motor control were rated before therapy, after each 3-week interval, and at follow-up 3 months later.nnnRESULTSnAll patients had favorable impressions: the extremity felt more vivid, and 8 subjects noticed a reduction in spasticity, an ease of hand hygiene, and pain relief. The MAS score of the wrist and fingers joints decreased significantly (P<.0125) from a median of 3 (2-3) and 3 (3-4) to 2 (1-2) and 2.5 (2-3). The RMA score minimally increased in 5 cases without improvement in functional tasks. The median RMA score before therapy was 2.0 (1-2) and 2.0 (1-3.75) after therapy. There were no side effects. At follow-up, the effects had waned.nnnCONCLUSIONSnThe arm trainer made possible intensive bilateral elbow and wrist training of severely affected stroke patients. Future studies should address the treatment effect in subacute stroke patients and determine the optimum treatment intensity.

Treadmill training with partial body weight support and physiotherapy in stroke patients: a preliminary comparison

Treadmill training with partial body weight support can restore the gait ability of chronic non‐ambulatory hemiparetic subjects. A combination of physiotherapy and treadmill training may accelerate the rate of recovery. Therefore a randomized study was planned. Twenty‐eight non‐ambulatory hemiparetic patients were randomly assigned to group A or B. A 3‐week baseline of conventional therapy was followed by 15 sessions of physiotherapy and treadmill training in patients of group A and by 15 sessions of treadmill training in patients of group B over a period of 3u2003weeks. Follow‐up was 4u2003months later. The major outcome variables were gait ability and ground level walking velocity. Gait ability and velocity did not change during the baseline. In group B, five patients became independent walkers after the specific intervention, whereas 10 patients of group A regained independent walking ability in the same period (Pu2003<u20030.05). Four months later group differences had waned. Three weeks of treadmill training plus physiotherapy accelerated the restoration of gait ability in hemiparetic subjects, however, the double amount of therapy in group A does not exclude a simple dose–response phenomenon.

Poststroke motor dysfunction and spasticity: Novel pharmacological and physical treatment strategies

Following stroke, approximately 90% of patients experience persistent neurological motor deficits that lead to disability and handicap. Both pharmacological and physical treatment strategies for motor rehabilitation may be considered. In terms of pharmacological treatment, drugs that may potentially promote motor recovery when added to a regimen of physical therapy include the stimulants amphetamine and methylphenidate, as well as levodopa and fluoxetine. Botulinum toxin A has proven effective and well tolerated in several placebo-controlled trials for the treatment of focal upper and lower limb spasticity, although it has not been shown to improve motor function. The focal injection of botulinum toxin A inhibits the release of acetylcholine into the synaptic cleft, resulting in a reversible paresis of the muscles relevant for the spastic deformity. Other drugs, such as benzodiazepines, antiepileptic drugs and antipsychotics, may have detrimental effects on motor function and should be avoided, if possible.With respect to physical strategies, modern concepts of motor learning favour a task-specific repetitive approach that induces skill-acquisition relevant to the patient’s daily life. Constrained-induced movement therapy based on the concept of learned non-use, electromyography-triggered electrical stimulation of the wrist muscles, robot-assisted motor rehabilitation to increase therapy intensity and bilateral practice to facilitate the movement of the paretic extremity are examples in upper limb rehabilitation. Lower limb rehabilitation has been enriched by treadmill training with partial bodyweight support, enabling the practice of up to 1000 steps per session; automated gait rehabilitation to relieve the strenuous effort required of the therapist; and rhythmic auditory stimulation, applying individually adjusted music to improve walking speed and symmetry.

No benefit from D-amphetamine when added to physiotherapy after stroke: a randomized, placebo-controlled study

Objective: To assess the effect of D-amphetamine on the recovery of activities of daily living and motor functions after stroke, Design: Randomized, placebo-controlled study, Setting: Inpatient rehabilitation centre, Subjects: Twenty-four stroke survivors after a first ischaemic supratentorial stroke within six weeks before study onset, severely to moderately affected, with a Barthel Index (0–100) ranging from 25 to 50, no severe concomitant internal, neurological or psychiatric diseases, and participating in a comprehensive rehabilitation programme of 10–12 weeks, Interventions: Ten sessions with 10 mg D-amphetamine (or placebo) every fourth day totalling 100 mg in a time period of 36 days combined with physical therapy according to the neurodevelopmental concept within 60 minutes after drug intake. Main outcome measures: Barthel Index (0–100) served as the primary outcome measure and the Rivermead Motor Assessment Score with its three sections (gross function, leg and trunk, and arm) as the secondary outcome measure, assessed at days 0, 20, 36, 90, 180 and 360. Results: The two groups did not differ with respect to clinical data and outcome measures at study onset. All patients improved significantly except for arm function over the intervention period and up to day 90 after study onset. The comparison between groups did not reveal any difference at any time; amphetamine-treated patients did not show any increase in motor function or ADL compared with the control group. Conclusions: The placebo-controlled study failed to show any effect of D-amphetamine on stroke recovery compared with control. The small number of patients, the timing and content of physical therapy were limiting factors of the present study. Further trials are warranted.

Arm studio to intensify the upper limb rehabilitation after stroke: concept, acceptance, utilization and preliminary clinical results.

OBJECTIVESnTo assess the acceptance, utilization and clinical results of an arm studio designed to intensify treatment of the severely to moderately affected arm after stroke. In line with a distal bilateral approach, the equipment comprised 4 workstations, 1 finger trainer, and 3 machines for bilateral training of selected distal and proximal movements.nnnDESIGNnOpen study.nnnSUBJECTSnOf 119 treated patients after subacute stroke, 30 completed a questionnaire and 24 were assessed.nnnMETHODSnAll patients completed 15 sessions, each of 30-45 min duration, on each of 2 workstations. Based on the patients impairment level they were divided into 3 groups, as follows: group A, plegic; group B, proximal and distal movements but hand non-functional; and group C, able to grasp and release an object. Motor functions were assessed with the Fugl-Meyer Score (FM, 0-66) for groups A (n = 6) and B (n = 6), and the Action Arm Research Test (ARAT, 0-57) for group C (n = 12).nnnRESULTSnNo side-effects occurred. The patients regarded the training positively. The initial FM was 8.5 (standard deviation (SD) 3.3) and final FM 21.2 (SD 4.4) for group A, initial FM 25.3 (SD 6.9) and final FM 44.3 (SD 9.1) for group B, and initial ARAT 33.3 (SD 11.2) and final ARAT 43.5 (SD 10.7) for group C.nnnCONCLUSIONnThe use of the arm studio to intensify upper limb rehabilitation after stroke is promising, and a controlled study is warranted.

Botulinum Toxin A Treatment of Adult Upper and Lower Limb Spasticity

This article discusses the treatment of spasticity with botulinum toxin A as a new approach in the neurological rehabilitation of patients after stroke. Clinical studies have been reviewed to provide information about target groups, technical aspects and the advantages and disadvantages of treating spasticity with botulinum toxin A. Open and controlled studies showed that the intramuscular injection of Dysport® 500 to 1500U or Botox® 100 to 300U could reversibly relieve upper limb flexor and lower limb extensor spasticity. A reduced muscle tone, pain relief, better hand hygiene and improved walking function were the main benefits. Patients tolerated the treatment well. Activity or, if not possible, electrical stimulation of the injected muscles may enhance the effectiveness of the costly toxin. Serial casting is another option. With respect to the action of botulinum toxin A, it is suggested that the effect of the toxin could be mediated by paresis of both the extrafusal and intrafusal muscle fibres, thereby altering the afferent discharge in the muscle.

Muscle activation patterns of healthy subjects during floor walking and stair climbing on an end-effector-based gait rehabilitation robot

A major criterion for the application of rehabilitation robots in gait therapy is the question to what extent the machine is able to facilitate physiologically correct muscle activation patters in the patients leg muscles in order to achieve an optimal gait training effect. The EMG data presented in this paper is based on intermediate results of a study with 8 healthy subjects (5 male, 3 female) to evaluate the end-effector based gait rehabilitation robot HapticWalker in position controlled mode. The study investigated two different walking trajectories (floor, upstairs) at three different cadences (45, 60, 90 steps/min) in three different modes (free walking, HapticWalker with vertical CoM motion, HapticWalker without vertical CoM motion). Results show that muscle EMGs measured from all relevant leg muscles have the same phasic and rhythmic muscle activation patterns on the HapticWalker as with free walking. Even though there are differences in patterns of dedicated muscles, we observed reduced amplitudes and slightly delayed activation on the HapticWalker compared to free walking. No differences in EMGs were observed between the two different HapticWalker modes (with vertical CoM motion, cancelled CoM motion), which might eliminate the need for an active trunk suspension system in the latter case. A passive patient lifter would significantly reduce the complexity of the machine construction, all advanced training modes (e.g. dynamic body weight reduction) could then be accomplished via compliant behavior of the freely programmable footplates. Numerous EMG measurements with healthy subjects and non-ambulatory stroke patients were performed on the predecessing electromechanical Gait Trainer GT I and showed that physiologically relevant findings from healthy subjects (e.g. correct phasic muscle activation) can be transferred to a certain extent to stroke patients, but nevertheless studies with stroke patients on the robotic gait trainer HapticWalker are needed to confirm the results presented in this paper.

Ambulante Krankengymnastik von Schlaganfallpatienten zu Hause Vorläufige Ergebnisse über Umfang, Inhalt und Effektivität

ZusammenfassungZielsetzung. Umfang, Inhalt und Effektivität der ambulanten Krankengymnastik von Schlaganfallpatienten zu Hause sollten in dieser Studie überprüft werden.nn Methodik. 74 erstmalige Schlaganfallpatienten, die zum Entlassungszeitpunkt nach Hause einen mittleren Barthel-Index (BI) von 55,6 aufwiesen, wurden in die Studie aufgenommen. Ein Fragebogen erfasste Umfang, Umstände, Inhalt und Zufriedenheit mit der ambulanten Physiotherapie während der letzten 6 Monate sowie die Items des BI und des Rivermead-Motor-Scores (RMS).nn Ergebnis. Von 54 erhielten 50 Patienten durchgehend Krankengymnastik, mit einer Intensität von 90,2 min/Woche (SD 60,9), verteilt auf im Mittel 2,9 Sitzungen/Woche. Die Therapiezufriedenheit war hoch (84%) und der Therapeut war wesentlicher außerfamiliärer Bezugspunkt. Der BI und der RMS hatten sich im Vergleich zur Entlassung nicht geändert, die Therapieintensität korrelierte nicht mit deren individuellen Veränderungen.nn Schlussfolgerung. Im internationalen Vergleich erhielten die noch funktionell beeinträchtigten Schlaganfallpatienten umfangreiche Physiotherapie. Die Patienten waren sehr zufrieden und konnten ihr Entlassungsniveau halten. Einschränkend gilt, dass keine Korrelation zwischen der interindividuell unterschiedlichen Therapieintensität und Veränderungen der Fähigkeiten vorlag. Weitere Studien, auch unter Berücksichtigung moderner Therapiekonzepte, sind angezeigt.SummaryAim. This study was intended to examine extent, content, and effectiveness of outpatient physiotherapy in stroke patients.nn Methods. Seventy-four first-time stroke survivors were included who had a mean Barthel index (BI) of 55.6 when discharged home. A questionnaire asked about the extent, content, and satisfaction with their outpatient physiotherapy over the previous 6 months and scored the items of the BI and the gross functions of the Rivermead Motor Assessment Score (RMS).nn Results. Fifty of 54 patients had received ongoing physiotherapy, mean intensity was 90.2 min/week (SD 60.9) with a mean of 2.9 (range 1 to 5) sessions/week. Eighty-four per cent of the patients were content and rated the therapist as their most important social contact out of family. The BI and RMS remained stable. Therapy intensity did not correlate with their individual course.nn Conclusions. The moderately affected stroke patients received a great amount of therapy. They were content and had maintained their activity level. However, the individually varying therapy intensity did not correlate with any individual activity changes. Further studies are needed that take modern therapy concepts into account.

Management of Upper and Lower Limb Spasticity in Neuro-Rehabilitation

This article reviews the treatment of upper and lower limb spasticity in neurological rehabilitation. Botulinum toxin A proved effective in several placebo-controlled studies reducing muscle tone, easing hand hygiene and nursing, improving upper limb motor functions and gait ability. The effects are reversible and the toxin is well tolerated. Electrical stimulation, tonic stretch post injection and the active use of the treated extremity are means to increase the effectiveness of the costly therapy. Phenol 5% is an alternative in case of budget constraints, but the technique is demanding and side effects are more frequent. Further, task-specific repetitive therapy should follow the successful treatment of focal spasticity in eligible patients to get the maximum profit with regard to disability.