Kazushige Kobayashi

Language-related brain function during word repetition in post-stroke aphasics

We compared fMRI findings (using SPM99) obtained with repetition task in normal subjects with those of two patients with Brocas and Wernickes aphasia who received speech therapy and showed complete recovery. Both aphasic patients with left hemisphere damage who showed complete recovery exhibited activation of only the compensatory area in the right hemisphere during the repetition task. Recovery from Brocas aphasia involves reorganization and neuromodulation between the external temporopolar area and the anterior superior temporal area of the superior temporal gyrus, putamen and the inferior frontal gyrus, while that from Wernickes aphasia involves reorganization and neuromodulation between the superior temporal gyrus of the temporal region, the posterior supramarginal gyrus and inferior parietal lobule of the parietal region.

Anti-spastic effect of low-frequency rTMS applied with occupational therapy in post-stroke patients with upper limb hemiparesis

Objective: To determine the effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with occupational therapy (OT) on the spasticity of the hemiparetic upper limb after stroke. Subjects and methods: The study subjects were 39 post-stroke patients with spastic upper limb hemiparesis (age: 56.5 ± 16.0 years, time after onset: 50.3 ± 37.8 months). At admission, the severity of hemiparesis was categorized as Brunnstrom stage 3–5 for hand–fingers. During 15-day hospitalization, each patient received 22 sessions of low-frequency rTMS applied to the non-lesional hemisphere and OT (one-to-one training and self-training). The spasticity of finger and wrist flexors of the affected upper limb was evaluated using the modified Ashworth scale (MAS) on the day of admission and discharge and 4 weeks after discharge. Each subject underwent Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT). Results: The low-frequency rTMS/OT protocol significantly decreased the MAS scores for both finger and wrist flexors at discharge and at 4 weeks after discharge. In addition, the low-frequency rTMS/OT protocol significantly increased the FMA score and shortened the WMFT performance time. Conclusions: The 15-day in-patient protocol of low-frequency rTMS/OT is potentially suitable for reducing spasticity as well as improving motor function on the affected upper limb after stroke.

Combination Treatment of Low-Frequency rTMS and Occupational Therapy with Levodopa Administration: An Intensive Neurorehabilitative Approach for Upper Limb Hemiparesis After Stroke

ABSTRACT The combination treatment of low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy was applied with concomitant oral administration of levodopa in five post-stroke patients with upper limb hemiparesis (age at treatment: 56–66 years; interval between onset of stroke and treatment: 18–143 months) as a 15-day inpatient protocol. Daily levodopa administration of 100 mg was initiated 1 week before admission and continued until 4 weeks after discharge. Low-frequency rTMS of 1 Hz was applied to the contralesional hemisphere for 40 min daily (two 20-min sessions) combined with intensive occupational therapy consisting of 60-min one-on-one training and 60-min self-exercise. Motor function of the affected upper limb was serially evaluated with the Fugl–Meyer Assessment and the Wolf Motor Function Test. At the end of the treatment, all patients showed improved motor function in the affected upper limbs. In some patients, the improvement was maintained until 4 weeks after discharge. No patient showed any adverse effect from the intervention. Our proposed protocol featuring levodopa administration, low-frequency rTMS, and intensive occupational therapy could provide a safe and feasible intervention for upper limb hemiparesis after stroke.

Application of combined 6-Hz primed low-frequency rTMS and intensive occupational therapy for upper limb hemiparesis after stroke.

INTRODUCTION The purpose of this study was to clarify the safety, feasibility and efficacy of 6-Hz primed low-frequency repetitive transcranial magnetic stimulation (rTMS) applied with intensive occupational therapy (OT) for upper limb hemiparesis after stroke. SUBJECTS AND METHODS Eleven patients with history of stroke and upper limb hemiparesis (age at intervention: 61.0 ± 13.7 years, time after stroke onset: 70.2 ± 39.8 months) were studied. Each patient received 22 sessions of 6-Hz primed low-frequency rTMS (10-min 6-Hz priming stimulation followed by 20-min low-frequency rTMS of 1-Hz) applied to the non-lesional hemisphere plus intensive OT comprising 60-min one-to-one training and 60-min self-training during 15-day hospitalization. The motor function of the affected upper limb was evaluated by Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) on the days of admission and discharge. RESULTS All patients completed the 15-day protocol without any adverse effects. The treatment increased the FMA score (from 42.2 ± 6.9 to 45.6 ± 7.2 points, p< 0.005) and shortened the log performance time of WMFT (from 3.26 ± 1.21 to 2.81 ± 1.26 sec, p< 0.05). CONCLUSIONS The 15-day protocol of 6-Hz primed low-frequency rTMS combined with intensive OT seems safe and a potentially useful therapeutic modality for upper limb hemiparesis after stroke.

Baseline Severity of Upper Limb Hemiparesis Influences the Outcome of Low-Frequency rTMS Combined With Intensive Occupational Therapy in Patients Who Have Had a Stroke

To clarify whether the efficacy of combined low‐frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) depends on baseline severity of upper limb hemiparesis after stroke.

Swallowing analysis for semisolid food texture in poststroke dysphagic patients.

BACKGROUND Our objective was to determine the texture of semisolid foods that are appropriate for poststroke dysphagic patients. METHODS Subjects included 52 poststroke dysphagic patients (72 ± 8 years of age) who were trained with semisolid foods and required the evaluation of swallowing function. Fifty-two homogeneous semisolid foods not requiring mastication were given. Texture were measured twice using a rheometer (TPU-2S; Yamaden Co. Ltd., Tokyo, Japan). Texture characteristics were as follows: hardness, 1873 to 19,510 N/m(2) (mean 9,129 N/m(2)); cohesiveness, 0.13 to 0.67 (mean 0.32); adhesiveness, 2 to 878 J/m(3) (mean 209 J/m(3)); and gumminess, 546 to 8781 N/m(2) (mean 2908 N/m(2)). Patients sat during fiberoptic endoscopic evaluation and ingested a single semisolid food. The patients were asked to swallow 4 g of food, and the texture, pharyngeal residue, penetration into the larynx, and aspiration were evaluated. We observed and noted the association between the texture of foods and swallowing movements by videoendoscopy. RESULTS Evaluating food texture by endoscopy revealed significant differences in adhesiveness according to residue deposition and significant differences in gumminess according to aspiration. CONCLUSIONS We identified the textures of different semisolid foods as being either appropriate or inappropriate for poststroke dysphagic patients.

Low-frequency rTMS combined with intensive occupational therapy for upper limb hemiparesis after brain tumour resection

Objective: To assess the safety, feasibility and efficacy of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with occupational therapy (OT) in a hemiparetic patient who had undergone brain tumour resection. Participant: A 39-year-old right-handed woman underwent brain tumour resection and presented 5 years later with right upper limb hemiparesis. At admission, she was considered to have reached a probable plateau state of motor functional recovery of the affected upper limb in spite of conventional occupational therapy. Intervention: Low-frequency rTMS with 1 Hz applied to the right primary motor cortex followed by intensive occupational therapy (one-on-one training and self-training) was provided daily during the 15-day hospitalization. Main outcome measures: Fugl-Meyer Assessment and Wolf Motor Function Test were conducted serially to evaluate motor function on the affected upper limb. Results: Neither adverse effect nor deterioration of neurological symptoms was recognized during the treatment period. The 15-day combination protocol improved motor function of the right upper limb and further improvement was noted 4 weeks after discharge. Conclusion: The proposed protocol of low-frequency rTMS with intensive occupational therapy is a potentially useful rehabilitative programme for upper limb hemiparesis after brain tumour resection.

Effects of botulinum toxin A therapy and multidisciplinary rehabilitation on upper and lower limb spasticity in post-stroke patients

Objectives. The purpose of this study was to examine the effects of combined botulinum toxin type A (BoNT-A) and inpatient multidisciplinary (MD) rehabilitation therapy on the improvement of upper and lower limb function in post-stroke patients. Methods. In this retrospective study, a 12-day inpatient treatment protocol was implemented on 51 post-stroke patients with spasticity. Assessments were performed on the day of admission, at discharge, and at 3 months following discharge. Results. At the time of discharge, all of the evaluated items showed a statistically significant improvement. Only the Functional Reach Test (FRT) showed a statistically significant improvement at 3 months. In subgroup analyses, the slowest walking speed group showed a significantly greater change ratio of the 10 Meter Walk Test relative to the other groups, from the time of admission to discharge. This group showed a greater FRT change ratio than the other groups from the time of admission to the 3-month follow-up. Conclusion. Inpatient combined therapy of simultaneous injections of BoNT-A to the upper and lower limbs and MD may improve motor function.

Applicability of the Two-Step Thickened Water Test in Patients With Poststroke Dysphagia: A Novel Assessment Tool for Paste Food Aspiration

This study evaluated the clinical usefulness of the newly developed Two-Step Thickened Water Test (TTWT) in identifying patients with poststroke dysphagia at risk of aspiration of paste food. The study subjects were 110 poststroke patients (mean age, 73 ± 10 years). The TTWT comprises a bedside pretest (tongue protrusion, vocalization, voluntary cough, and dry swallow) and a direct swallowing test using 4 mL of thickened water. Fiberoptic endoscopic evaluation of swallowing determined the subjects ability to swallow the paste food. Based on the test results and endoscopic evaluation, we calculated the TTWTs sensitivity and specificity in identifying paste food aspiration. We also calculated these values when normal water was used instead of thickened water in a direct swallowing test. The prevalence of dysphagia for paste food was 41% in our study group. The sensitivity and specificity of the TTWT in identifying dysphagia for paste food was 93% and 88%, respectively. The specificity decreased to 78.5% when normal water was used, with no decrease in sensitivity. The test was completed in less than 10 minutes, with no adverse events in any subject. Our data suggest that the TTWT might be a useful assessment tool for evaluating the risk of paste food aspiration in patients with poststroke dysphagia.

Effects of botulinum toxin A therapy and multidisciplinary rehabilitation on lower limb spasticity classified by spastic muscle echo intensity in post-stroke patients

ABSTRACT Objectives: The purpose of the present study was to investigate retrospectively the relationship between botulinum toxin type A plus multidisciplinary rehabilitation and muscle echo intensity in post-stroke patients with spasticity. The primary aim was to investigate whether the effects of the intervention on the improvement of spasticity depend on muscle echo intensity, and the secondary aim was to investigate whether the motor function of the lower limbs depends on muscle echo intensity. Methods: A 12-day inpatient protocol was designed for 102 post-stroke patients with spasticity due to lower limb paralysis. Muscle echo intensity of the triceps surae muscle was measured by ultrasonography, and the patients were categorized into four groups based on Heckmatt scale grades (Grades I–IV). Results: All four groups classified by the Heckmatt scale showed significant pre-to-post-intervention differences in the knee and ankle modified Ashworth scale scores (p < 0.05). Grades I–III patient groups showed a significant improvement in lower limb motor function following intervention. Grade IV patients did not show a significant improvement in lower limb motor function. Conclusions: We observed significant improvements in the modified Ashworth scale scores after botulinum toxin type A and multidisciplinary rehabilitation therapy on post-stroke patients with spasticity. Although patients with lower muscle echo intensity demonstrated improvements in motor function, the improvement was poor in those with higher muscle echo intensity.