Masahito Mihara

Role of the prefrontal cortex in human balance control

Although recent studies have demonstrated cortical involvement in human balance control, there is insufficient information regarding the regions of the cerebral cortex that contribute to human balance control and their mechanism of action. Using a functional near-infrared spectroscopic system, we investigated perturbation-related cortical activation. External perturbations were provided with and without the preceding auditory warning signals 2 s before the perturbation. Statistical analysis by applying the general linear model showed significant activation in the prefrontal cortex, including the dorsolateral prefrontal cortex and frontal eye field after external perturbation, regardless of the preceding auditory warning signals. A time-line analysis revealed similar temporal profiles for prefrontal activation in 2 different conditions. Based on the contrast between the 2 conditions, we detected enhanced activation in the right posterior parietal cortex and supplementary motor area in the condition where the auditory warning signals were provided. We presumed that prefrontal involvement may be relevant to adequate allocation of visuospatial attention. Our results may facilitate the understanding of cortical mechanisms for balance control in humans and the underlying pathophysiology of falls.

Frontal regions involved in learning of motor skill—A functional NIRS study

To investigate cerebral mechanisms underlying learning of motor skill, we assessed serial changes of cortical activation patterns during a pursuit rotor (PR) task in 18 right-handed, healthy subjects using a functional near-infrared spectroscopy (fNIRS) system. Subjects performed the task with the right hand for 30 s alternated with 30-s rest for 8 repetitions (cycle1 to 8). Gains in motor skill were evaluated by time for keeping the stylus on the target (max 30 s), surface EMG patterns and trajectories of the arm. Performance improved with repetitions of the task cycles (12.9/17.1/19.3/20.0/21.1/22.2/23.6/23.9 s on average) and reached plateau at the 7th cycle. Reciprocal EMG patterns and steady trajectories were associated with acquisition of the motor skill. Task-related increases of oxygenated hemoglobin (oxyHb) were observed in the channels covering the sensorimotor cortex (SMC), premotor and prefrontal regions. There were also task-related decreases of deoxygenated hemoglobin (deoxyHb) in these areas although the changes were smaller compared with those of oxyHb. The center of task-related increases of oxyHb was initially located in the presupplementary motor area (preSMA) and shifted caudally to the supplementary motor area (SMA) with cycle repetitions. The ratios of oxyHb changes in preSMA to SMA significantly decreased with task repetitions. DeoxyHb changes confirmed the activation patterns. These data suggest that preSMA plays an important role in the early phase of motor learning while the SMA might be more involved in the late learning phase of the motor skill.

Cerebellar ataxia rehabilitation trial in degenerative cerebellar diseases.

Objective. To investigate short- and long-term effects of intensive rehabilitation on ataxia, gait, and activities of daily living (ADLs) in patients with degenerative cerebellar disease. Methods. A total of 42 patients with pure cerebellar degeneration were randomly assigned to the immediate group or the delayed-entry control group. The immediate group received 2 hours of inpatient physical and occupational therapy, focusing on coordination, balance, and ADLs, on weekdays and 1 hour on weekends for 4 weeks. The control group received the same intervention after a 4-week delay. Short-term outcome was compared between the immediate and control groups. Long-term evaluation was done in both groups at 4, 12, and 24 weeks after the intervention. Outcome measures included the assessment and rating of ataxia, Functional Independence Measure, gait speed, cadence, functional ambulation category, and number of falls. Results. The immediate group showed significantly greater functional gains in ataxia, gait speed, and ADLs than the control group. Improvement of truncal ataxia was more prominent than limb ataxia. The gains in ataxia and gait were sustained at 12 weeks and 24 weeks, respectively. At least 1 measure was better than at baseline at 24 weeks in 22 patients. Conclusions. Short-term benefit of intensive rehabilitation was evident in patients with degenerative cerebellar diseases. Although functional status tended to decline to the baseline level within 24 weeks, gains were maintained in more than half of the participants.

Near-infrared Spectroscopy–mediated Neurofeedback Enhances Efficacy of Motor Imagery–based Training in Poststroke Victims A Pilot Study

Background and Purpose— Despite the findings that motor imagery and execution are supposed to share common neural networks, previous studies using imagery-based rehabilitation have revealed inconsistent results. In the present study, we investigated whether feedback of cortical activities (neurofeedback) using near-infrared spectroscopy could enhance the efficacy of imagery-based rehabilitation in stroke patients. Methods— Twenty hemiplegic patients with subcortical stroke received 6 sessions of mental practice with motor imagery of the distal upper limb in addition to standard rehabilitation. Subjects were randomly allocated to REAL and SHAM groups. In the REAL group, cortical hemoglobin signals detected by near-infrared spectroscopy were fed back during imagery. In the SHAM group, irrelevant randomized signals were fed back. Upper limb function was assessed using the finger and arm subscales of the Fugl-Meyer assessment and the Action Research Arm Test. Results— The hand/finger subscale of the Fugl-Meyer assessment showed greater functional gain in the REAL group, with a significant interaction between time and group (F2,36=15.5; P<0.001). A significant effect of neurofeedback was revealed even in severely impaired subjects. Imagery-related cortical activation in the premotor area was significantly greater in the REAL group than in the SHAM group (T58=2.4; P<0.05). Conclusions— Our results suggest that near-infrared spectroscopy–mediated neurofeedback may enhance the efficacy of mental practice with motor imagery and augment motor recovery in poststroke patients with severe hemiparesis.

Neurofeedback Using Real-Time Near-Infrared Spectroscopy Enhances Motor Imagery Related Cortical Activation

Accumulating evidence indicates that motor imagery and motor execution share common neural networks. Accordingly, mental practices in the form of motor imagery have been implemented in rehabilitation regimes of stroke patients with favorable results. Because direct monitoring of motor imagery is difficult, feedback of cortical activities related to motor imagery (neurofeedback) could help to enhance efficacy of mental practice with motor imagery. To determine the feasibility and efficacy of a real-time neurofeedback system mediated by near-infrared spectroscopy (NIRS), two separate experiments were performed. Experiment 1 was used in five subjects to evaluate whether real-time cortical oxygenated hemoglobin signal feedback during a motor execution task correlated with reference hemoglobin signals computed off-line. Results demonstrated that the NIRS-mediated neurofeedback system reliably detected oxygenated hemoglobin signal changes in real-time. In Experiment 2, 21 subjects performed motor imagery of finger movements with feedback from relevant cortical signals and irrelevant sham signals. Real neurofeedback induced significantly greater activation of the contralateral premotor cortex and greater self-assessment scores for kinesthetic motor imagery compared with sham feedback. These findings suggested the feasibility and potential effectiveness of a NIRS-mediated real-time neurofeedback system on performance of kinesthetic motor imagery. However, these results warrant further clinical trials to determine whether this system could enhance the effects of mental practice in stroke patients.

Sustained prefrontal activation during ataxic gait: A compensatory mechanism for ataxic stroke?

There is accumulated evidence that cortical reorganization plays an important role in motor recovery after supratentorial stroke. However neural mechanisms underlying functional recovery of ataxia after infratentorial stroke remain unclear. We investigated cortical activations during ataxic gait in patients with infratentorial stroke to test the hypothesis that cerebral cortices were involved in compensatory mechanisms for ataxic gait. Twelve patients with infratentorial stroke (mean duration+/-S.D. from the onset: 88.3+/-44.8 days) and 11 age-matched healthy subjects participated in this study. All patients had predominant ataxia without severe hemiparesis. We measured cortical activation as assessed by task-related increase of oxygenated hemoglobin during gait on a treadmill using functional near-infrared spectroscopy. Task consisted of three repetitions of gait period alternated with rest period. In controls, cortical activations in the lateral and medial prefrontal cortex during the acceleration phase tended to be attenuated during the steady phase of the gait period while these activations were sustained throughout the gait period in ataxic patients. Repeated measures ANOVA for cortical activation revealed significant interactions (p<0.005) between phase (acceleration/steady) and group (control/stroke) in the medial and lateral prefrontal regions. These results suggest that sustained prefrontal activation during ataxic gait might be relevant to compensatory mechanisms for ataxic gait after infratentorial stroke.

Cortical changes underlying balance recovery in patients with hemiplegic stroke.

Balance problems are a major sequelae of stroke and are implicated in poor recovery of activities of daily living. In a cross-sectional study, using 50-channel event-related functional near-infrared spectroscopy we previously reported a significant correlation between individual balance ability after stroke and postural perturbation-related cortical activation in the supplementary motor area (SMA) and the prefrontal cortex. However, the neural mechanisms underlying balance recovery after stroke remain unclear. Herein, we examined the cortical involvement in balance recovery after stroke by determining longitudinal regional cortical activation changes in patients with hemiplegic stroke. Twenty patients with subcortical stroke admitted to our hospital for post-acute inpatient rehabilitation participated in this study. Before and after intensive inpatient physical and occupational therapy rehabilitation, we evaluated cortical activation associated with external postural perturbations induced by combined brisk forward and backward movement on a platform. Postural perturbation-related cortical activation in the SMA of the affected and unaffected hemispheres was significantly increased after intensive rehabilitation. The increment of the postural-perturbation-related oxygenated hemoglobin signals in the SMA of the unaffected hemisphere was significantly correlated with the gain in balance function measured by the Berg Balance Scale. These findings support the conclusion that the SMA plays an important role in postural balance control, and suggest that the SMA is a crucial area for balance recovery after hemiplegic stroke.

Cortical control of postural balance in patients with hemiplegic stroke.

Despite its remarkable effect on the activities of daily living, the precise mechanism underlying balance control after stroke remains to be elucidated. In this study, we investigated the cortical activation induced by postural perturbation in 20 patients with stroke using a 50-channel event-related functional near-infrared spectroscopy. A combination of brisk forward and backward movements of a platform without any prior cue was used as an external postural perturbation. Multi-participant analysis of oxygenated hemoglobin signals showed postural perturbation-related cortical activation in the prefrontal cortical areas in both hemispheres as well as the premotor and parietal association cortical areas in the unaffected hemisphere. Regression analysis using the individual Berg Balance Scale as the regressor showed a significant positive correlation between balance ability and the postural perturbation-related changes in oxygenated hemoglobin signals in the supplementary motor areas and prefrontal cortical areas in both hemispheres. Consistent with the previous findings in healthy participants, these findings suggest that the broad cortical network, including the prefrontal, premotor, supplementary motor, and parietal cortical areas in both hemispheres, was essential for balance control even in poststroke patients.

The "pulvinar sign" in a case of paraneoplastic limbic encephalitis associated with non-Hodgkin's lymphoma.

This paper reports a 59 year old woman with paraneoplastic limbic encephalitis associated with diffuse large B cell lymphoma. Her brain magnetic resonance imaging scan showed bilateral posterior thalamic hyperintensities, similar to the “pulvinar sign”. Her symptoms included progressive psychiatric disturbance and resembled the initial symptoms of variant Creutzfeldt–Jakob disease (vCJD). Clinicians should consider this treatable disorder in the differential diagnosis of vCJD.

Impaired Motor Learning by a Pursuit Rotor Test Reduces Functional Outcomes During Rehabilitation of Poststroke Ataxia

Background. Motor learning is essential to gain skills with neurorehabilitation. Objective. To investigate whether capacity for motor learning affects rehabilitation outcome and its relevant brain activation in ataxic patients with stroke. Methods. Twelve patients presenting with ataxia admitted for inpatient rehabilitation 2 to 3 months after infratentorial stroke and 6 control subjects performed 8 repetitions of 30-second pursuit rotor (PR) task. Cortical oxygenated hemoglobin (oxyHb) signals were measured using functional near-infrared spectroscopy. Results. Both patients and controls learned the PR skill, although the gains in PR performance were significantly lower in patients. In patients, the less learning significantly correlated with smaller rehabilitation gains assessed by the Functional Independence Measure. The Fugl-Meyer score for coordination and balance did not change. Center of task-related increase of cortical oxyHb signals shifted from the presupplementary motor area (preSMA) to the supplementary motor area (SMA) with task repetitions in controls but not in patients. Accordingly, serial changes of ratio of oxyHb increase in the preSMA to SMA (preSMA/SMA ratio) were significantly different between the groups. In patients and controls, gains in PR performance and changes of the preSMA/SMA ratio correlated. Conclusions. Impaired motor sequence learning by the PR task was correlated with reduced rehabilitation gains for ataxic patients with stroke.