Koki Ikuno

Effects of peripheral sensory nerve stimulation plus task-oriented training on upper extremity function in patients with subacute stroke: a pilot randomized crossover trial

Objective: To investigate the feasibility of peripheral sensory nerve stimulation combined with task-oriented training in patients with stroke during inpatient rehabilitation. Design: A pilot randomized crossover trial. Setting: Two rehabilitation hospitals. Subjects: Twenty-two patients with subacute stroke. Interventions: Participants were randomly assigned to two groups and underwent two weeks of training in addition to conventional inpatient rehabilitation. The immediate group underwent peripheral sensory nerve stimulation combined with task-oriented training in the first week, followed by another week with task-oriented training alone. The delayed group underwent the same training in reverse order. Main measures: Outcome measures were the level of fatigue and Wolf Motor Function Test. Patients were assessed at baseline, one and two weeks. Results: All participants completed the study with no adverse events. There was no significant difference in level of fatigue between each treatment. From baseline to one week, the immediate group showed larger improvements than the delayed groups in the Wolf Motor Function Test (decrease in mean time (± SD) from 41.9 ± 16.2 seconds to 30.6 ± 11.4 seconds versus from 46.8 ± 19.4 seconds to 42.9 ± 14.7 seconds, respectively) but the difference did not reach significance after Bonferroni correction (P = 0.041). Within-group comparison showed significant improvements in the Wolf Motor Function Test mean time after the peripheral sensory nerve stimulation combined with task-oriented training periods in each group (P < 0.01). Conclusion: Peripheral sensory nerve stimulation is feasible in clinical settings and may enhance the effects of task-oriented training in patients with subacute stroke.

Effects of galvanic vestibular stimulation combined with physical therapy on pusher behavior in stroke patients: A case series

BACKGROUND A recent study investigated the effects of galvanic vestibular stimulation (GVS) on pusher behavior (PB) in post-stroke patients. However, there have been no reports about the effects of multisession GVS on PB. OBJECTIVE The purpose of this study was to investigate the feasibility and effects of multisession GVS combined with physical therapy for PB in stroke patients. METHODS Two stroke patients who showed PB were enrolled. The ABAB single-case design was used. Each phase lasted 1 wk. In phases A1 and A2, the patients underwent a 60-min-long physical therapy session 5 days a week. In phases B1 and B2, they underwent GVS for 20 min before each physical therapy session, and then the same physical therapy program as in phases A1 and A2 were performed. PB was evaluated using the Scale for Contraversive Pushing (SCP) and the Burke Lateropulsion Scale (BLS). Outcomes were tested at the baseline and after each phase. RESULTS In both patients, the SCP scores were reduced only during phase B2. Although the BLS scores improved at the A1 phase, a larger improvement was seen at the two B phases. CONCLUSIONS Multisession GVS combined with physical therapy may have positive effects on PB in clinical setting.

Feasibility study of a combined treatment of electromyography-triggered neuromuscular stimulation and mirror therapy in stroke patients: A randomized crossover trial

BACKGROUND Mirror therapy (MT) and electromyography-triggered neuromuscular stimulation (ETMS) are both effective treatments for impaired upper limbs following stroke. A combination of these two treatments (ETMS-MT) may result in greater gain than either treatment alone. OBJECTIVES The feasibility and possible effects of ETMS-MT upon upper extremity function were investigated in stroke patients. METHODS Thirteen post-acute stroke patients were randomly assigned to an immediate ETMS-MT group or a delayed ETMS-MT group and then underwent an 8-week training program. The immediate ETMS-MT group received ETMS-MT in addition to physical and occupational therapy (PT+OT) for 4 weeks. They then received only PT+OT for the next 4 weeks. In the delayed ETMS-MT group, interventions were provided in the reverse order. The main outcome measure was the Fugl-Meyer Assessment (FMA). RESULTS The immediate ETMS-MT group showed significantly greater gain in FMA in the first 4 weeks. The delayed ETMS-MT group showed significantly greater gain in active range of motion during the latter 4 weeks. No adverse effects were reported following ETMS-MT. CONCLUSION ETMS-MT might be as effective as independent MT or ETMS without causing any side effects. Future research should focus upon the direct comparisons between independent and combined interventions.

Effect of a cognitive task during obstacle crossing in hemiparetic stroke patients

Stroke patients are at a higher risk of falling than the community-dwelling elderly, and many falls are due to contact with an obstacle. This study compared the effects of the simultaneous addition of a cognitive task during obstacle crossing between stroke patients and community-dwelling older adults (control subjects). Participants comprised 20 stroke patients who could walk with or without supervision and 20 control subjects matched for age and height with the stroke patients. Participants were asked to cross a 4-cm-high obstacle while walking at a self-selected speed. The number of failures and the spatial and temporal parameters were compared between a single-task condition (i.e., crossing task only) and a dual-task condition (i.e., verbal fluency task: listing vegetables or animals). Under the dual-task condition, six stroke patients (30%) and three community-dwelling elderly individuals (15%) failed to complete the motor task. Task failure was only due to heel-obstacle contact after toe clearance. In both groups, obstacle-heel distance after clearance was reduced, and the time from heel contact to toe clearance and stride time were significantly increased under dual-task condition versus single-task condition. In addition, group-task interaction for the time from heel contact to toe clearance of the obstacle was significant; this increase in time was significantly greater under dual-task condition in stroke patients than in control subjects. Obstacle crossing in stroke patients involved an increase in crossing performance time and a risk of heel-obstacle contact after crossing. These tendencies appeared stronger under the dual-task condition.

Influence of the stimulus parameters of galvanic vestibular stimulation on unilateral spatial neglect.

Galvanic vestibular stimulation (GVS) stimulates the vestibular system electrically with low-amplitude direct current through surface electrodes applied to the left and right mastoids. The effects of GVS on unilateral spatial neglect (USN) in poststroke patients were recently reported, but the influence of the current intensity and application duration of GVS on USN has not been sufficiently investigated. Here we explored the influence of these stimulus parameters on USN. We recruited seven patients with right-hemisphere stroke and left-sided USN (four female) for this single-blind, sham-controlled cross-over trial. Their scores on the line cancellation test were measured under three stimulation conditions [left-cathodal/right-anodal GVS (L-GVS), right-cathodal/left-anodal GVS, and sham] at three time points (before the start of GVS, 10 min after the start of GVS, and 20 min after the start of GVS). The GVS intensity was set below the sensory threshold and differed among the patients (0.4–2.0 mA). The cancellation scores were significantly increased after 10 and 20 min L-GVS, with a greater increase observed after the latter (P<0.0001). The other stimulus conditions had no significant effect. There was a significant positive correlation between the change in the increase in the cancellation score with L-GVS and the total charge (r=0.81, P=0.0004). The effect of GVS on USN may depend on its application duration, current intensity, and polarity.

Sensory Electrical Stimulation for Recovery of Hand and Arm Function in Stroke Patients: A Review of the Literature

Background: Sensory amplitude electrical stimulation has been reported to induce changes in corticospinal excitability. The aim of this review is to evaluate the effects of sensory electrical stimulation on hand and arm function in stroke patients. Methods: A literature search was undertaken to locate papers that used sensory electrical stimulation in stroke patients. The methodological quality of each study was assessed using the Physiotherapy Evidence Database (PEDro) score. Results: Ten studies were considered suitable for inclusion in this review. Six of the 10 studies provided the PEDro score, with the mean (standard deviation) score being 5.7 (1.0). There were no adverse effects in any of the studies. In only one study, the patients with acute stroke were included. There was much study of patients with mild arm hemiparesis. Most studies reported that sensory electrical stimulation was delivered at 10 Hz with pulse duration of 1 millisecond for 2 hours at the paretic wrist (median and/or ulnar nerve). Five studies reported sensory stimulation should not be used in isolation, but rather in combination with task training, to improve arm and hand function. Conclusions: Sensory electrical stimulation may improve hand and arm function if it combines with functional task training in patients with mild arm paresis but there are no studies with high methodological quality. In addition, it is uncertain whether sensory electrical stimulation would be of benefit for patients with severe paresis and be effective in the acute phase. Therefore, the results of this review remain inconclusive due to a lack of suitable randomized controlled trials.

Perception of postural limits and falls in community-dwelling elderly people

An important prerequisite in performing diverse movements safely and without falling in daily life is postural limits. Postural limits decreases with age. The accurate perception of postural limits is interpreted as a potential safety factor to prevent the planning of movements that create loss of balance. The main purpose of this study was to investigate the relation between perception of postural limits and falls in 163 community-dwelling elderly people. The experimental protocol required subjects first to estimate the maximum-distance forward reach and then execute that. The error in estimated reach distance(ED) was defined as the difference between actual and estimated forward reaches, with positive values of error representing underestimates and negative value representing overestimates. The ED was interpreted to reflect perception of postural limits. Other assessments included incidence of falls in the previous year, Functional Reach Test (FRT), Falls Efficacy scale (FES). Then we explored whether ED, FRT, and FES are associated with falls in older adults. The mean value of ED in multiple-fallers was negative and significantly smaller than that in non-fallers. In logistic regression analysis, ED and FES were detected as risk factors for multiple falls. The results suggested that perception of postural limits was one of the important risk factors for falls in community-dwelling elderly people.

Comparison of the Effect of Sensory-Level and Conventional Motor-Level Neuromuscular Electrical Stimulations on Quadriceps Strength After Total Knee Arthroplasty: A Prospective Randomized Single-Blind Trial

OBJECTIVE To compare sensory-level neuromuscular electrical stimulation (NMES) and conventional motor-level NMES in patients after total knee arthroplasty. DESIGN Prospective randomized single-blind trial. SETTING Hospital total arthroplasty center: inpatients. PARTICIPANTS Patients with osteoarthritis (N=66; mean age, 73.5±6.3y; 85% women) were randomized to receive either sensory-level NMES applied to the quadriceps (the sensory-level NMES group), motor-level NMES (the motor-level NMES group), or no stimulation (the control group) in addition to a standard rehabilitation program. INTERVENTIONS Each type of NMES was applied in 45-minute sessions, 5d/wk, for 2 weeks. MAIN OUTCOME MEASURES Data for the quadriceps maximum voluntary isometric contraction, the leg skeletal muscle mass determined using multiple-frequency bioelectrical impedance analysis, the timed Up and Go test, the 2-minute walk test, the visual analog scale, and the range of motion of the knee were measured preoperatively and at 2 and 4 weeks after total knee arthroplasty. RESULTS The motor-level NMES (P=.001) and sensory-level NMES (P=.028) groups achieved better maximum voluntary isometric contraction results than did the control group. The motor-level NMES (P=.003) and sensory-level NMES (P=.046) groups achieved better 2-minute walk test results than did the control group. Some patients in the motor-level NMES group dropped out of the experiment because of discomfort. CONCLUSIONS Motor-level NMES significantly improved muscle strength and functional performance more than did the standard program alone. Motor-level NMES was uncomfortable for some patients. Sensory-level NMES was comfortable and improved muscle strength and functional performance more than did the standard program alone.