Min Ho Chun

Combination transcranial direct current stimulation and virtual reality therapy for upper extremity training in patients with subacute stroke.

OBJECTIVE To investigate the effects of combination cathodal transcranial direct current stimulation (tDCS) and virtual reality (VR) therapy for upper extremity (UE) training in patients with subacute stroke. DESIGN Pilot randomized controlled trial. Patients were randomly assigned to 1 of 3 groups: group A received cathodal tDCS, group B received VR, and group C received combination therapy (cathodal tDCS was simultaneously applied during VR therapy). SETTING University hospital. PARTICIPANTS Patients (N=59) with impaired unilateral UE motor function after stroke. INTERVENTION Fifteen sessions of treatment over a 3-week period. MAIN OUTCOME MEASURES The Modified Ashworth Scale, manual muscle test (MMT), Manual Function Test (MFT), Fugl-Meyer Scale (FMS), and Box and Block Test were used to assess UE function. To evaluate activities of daily living, the Korean-Modified Barthel Index (K-MBI) was used. All outcomes were measured before and immediately after treatment. RESULTS After treatment, all groups demonstrated significant improvements in MMT, MFT, FMS, and K-MBI scores. The change in MFT and FMS scores was different between the 3 groups. Post hoc analysis revealed that the improvement of MFT and FMS scores in group C was significantly higher than those of the other 2 groups. CONCLUSIONS In the present pilot study, the combination of brain stimulation using tDCS and peripheral arm training using VR could facilitate a stronger beneficial effect on UE impairment than using each intervention alone. This combination therapy might be a helpful method to enhance recovery of the paretic UE in patients with stroke.

The Effect of Virtual Reality Training on Unilateral Spatial Neglect in Stroke Patients

Objective To investigate the effect of virtual reality training on unilateral spatial neglect in stroke patients. Method Twenty-four stroke patients (14 males and 10 females, mean age=64.7) who had unilateral spatial neglect as a result of right hemisphere stroke were recruited. All patients were randomly assigned to either the virtual reality (VR) group (n=12) or the control group (n=12). The VR group received VR training, which stimulated the left side of their bodies. The control group received conventional neglect therapy such as visual scanning training. Both groups received therapy for 30 minutes a day, five days per week for three weeks. Outcome measurements included star cancellation test, line bisection test, Catherine Bergego scale (CBS), and the Korean version of modified Barthel index (K-MBI). These measurements were taken before and after treatment. Results There were no significant differences in the baseline characteristics and initial values between the two groups. The changes in star cancellation test results and CBS in the VR group were significantly higher than those of the control group after treatment. The changes in line bisection test score and the K-MBI in the VR group were not statistically significant. Conclusion This study suggests that virtual reality training may be a beneficial therapeutic technique on unilateral spatial neglect in stroke patients.

Effect of high- and low-frequency repetitive transcranial magnetic stimulation on visuospatial neglect in patients with acute stroke: a double-blind, sham-controlled trial.

OBJECTIVE To compare the therapeutic effect of low- and high-frequency repetitive transcranial magnetic stimulation (rTMS) of the posterior parietal cortex (PPC) in patients with acute stroke with visuospatial neglect. DESIGN This study was a prospective, double-blind, sham-controlled trial. Data are presented from 27 patients (15 men, 12 women; mean age, 67.0y) randomly assigned to receive 10 sessions of low-frequency (1Hz) rTMS over the nonlesioned PPC, high-frequency (10Hz) rTMS over the lesioned PPC, or sham stimulation. SETTING National university hospital. PARTICIPANTS Patients (N=27) diagnosed with visuospatial neglect after stroke. INTERVENTION Ten sessions of rTMS over a 2-week period. MAIN OUTCOME MEASURES The severity of visuospatial neglect was assessed pre- and posttreatment using the Motor-Free Visual Perception Test, line bisection test, star cancellation test, and Catherine Bergego Scale. RESULTS When comparing the differences in the Motor-Free Visual Perception Test, line bisection test, star cancellation test, Catherine Bergego Scale, and Korean-Modified Barthel Index (K-MBI) scores before and after treatment according to group, we found that changes in the line bisection test and K-MBI scores were significantly different between 3 groups. In the post hoc analysis, the improvement in the line bisection test score in the high-frequency rTMS group was statistically significant compared with that in the sham stimulation group (high vs sham P=.03, low vs sham P=.09, high vs low P=.58), and the improvements in the K-MBI scores of the 2 rTMS groups were statistically significant compared with those in the sham stimulation group (high vs sham P<.01, low vs sham P=.02, high vs low P=.75). CONCLUSIONS These results indicate that high-frequency rTMS is effective in the treatment of visuospatial neglect in patients with acute stroke.

Effect of repetitive transcranial magnetic stimulation on cognition and mood in stroke patients: a double-blind, sham-controlled trial.

Kim BR, Kim DY, Chun MH, Yi JH, Kwon JS: Effect of repetitive transcranial magnetic stimulation on cognition and mood in stroke patients: A double-blind, sham-controlled trial. Objective:This study examined whether repetitive transcranial magnetic stimulation applied over the left dorsolateral prefrontal cortex (DLPFC) affected cognition or mood in poststroke patients. Design:The study was a single-center, prospective, double-blind, sham-controlled preliminary study. Eighteen patients (10 males and 8 females; average age, 62.9 yrs) were enrolled. All participants were randomly assigned to one of three treatment groups: low-frequency (1 Hz) stimulation, high-frequency (10 Hz) stimulation, and sham stimulation (control). Each patient underwent 10 consecutive treatment sessions (five times per week for 2 wks). A Computerized Neuropsychological Test was used to evaluate cognitive function, the Tower of London test was used to assess executive function, the Modified Barthel Index score was used to assess activity of daily living function, and the Beck Depression Inventory was used to assess mood status. These evaluations were conducted in all patients before and after treatment. Results:Treatment had no significant effect on any cognitive function parameter, including the Tower of London scores, in any of the three groups. In contrast, high-frequency repetitive transcranial magnetic stimulation resulted in significantly lower Beck Depression Inventory scores compared with baseline and compared with the other two groups. The Modified Barthel Index scores significantly increased in all three groups. Conclusions:These preliminary data suggest that there was a positive effect on mood, but the study was not powered to detect any measurable effect on cognition.

The effect of repetitive transcranial magnetic stimulation on fibromyalgia: a randomized sham-controlled trial with 1-mo follow-up.

Objectives The aim of this study was to determine whether low-frequency repetitive transcranial magnetic stimulation (rTMS) applied to the right dorsolateral prefrontal cortex or high-frequency rTMS applied to the left motor cortex could influence pain level or mood status in patients with intractable fibromyalgia. Design Fifteen women with fibromyalgia were randomized to low-frequency (1 Hz), high-frequency (10 Hz), or sham stimulation. The patients underwent ten consecutive sessions according to rTMS protocol. The number of tender points and the Korean version of the Fibromyalgia Impact Questionnaire were used to assess disease status, a visual analog scale was used to measure level of pain, and the Beck Depression Inventory was used to assess mood status. All subjects were evaluated before, immediately after, and 1 mo after rTMS. Results In the low-frequency group, the Beck Depression Inventory scores significantly decreased from baseline to 1 mo after rTMS. The visual analog scale and Korean version of the Fibromyalgia Impact Questionnaire scores significantly decreased immediately after rTMS. In the high-frequency group, the visual analog scale and Beck Depression Inventory scores were significantly decreased immediately after rTMS. Conclusions Low-frequency rTMS may play a role in the long-term treatment of fibromyalgia. Notably, the findings of this study are the first to show that the right dorsolateral prefrontal cortex or the left motor cortex rTMS could have an antidepressive and pain-modulating effect in patients with fibromyalgia.

The Effect of Transcranial Direct Current Stimulation on Neglect Syndrome in Stroke Patients

Objective To examine whether transcranial direct current stimulation (tDCS) applied over the posterior parietal cortex (PPC) improves visuospatial attention in stroke patients with left visuospatial neglect. Methods Patients were randomly assigned to 1 of 3 treatment groups: anodal tDCS over the right PPC, cathodal tDCS over the left PPC, or sham tDCS. Each patient underwent 15 sessions of tDCS (5 sessions per week for 3 weeks; 2 mA for 30 minutes in each session). Outcome measures were assessed before treatment and 1 week after completing the treatment. Results From pre- to post-treatment, there was an improvement in the motor-free visual perception test (MVPT), line bisection test (LBT), star cancellation test (SCT), Catherine Bergego Scale (CBS), Korean version of Modified Barthel Index (K-MBI), and Functional Ambulation Classification in all 3 groups. Improvements in the MVPT, SCT, and LBT were greater in the anodal and cathodal groups than in the sham group. However, improvements in other outcomes were not significantly different between the 3 groups, although there was a tendency for improved CBS or K-MBI scores in the anodal and cathodal groups, as compared with the sham group. Conclusion The study results indicated that the facilitatory effect of anodal tDCS applied over the right PPC, and the inhibitory effect of cathodal tDCS applied over the left PPC, improved symptoms of visuospatial neglect. Thus, tDCS could be a successful adjuvant therapeutic modality to recover neglect symptom, but this recovery might not lead to improvements in activities of daily living function and gait function.

Prediction of lower limb motor outcomes based on transcranial magnetic stimulation findings in patients with an infarct of the anterior cerebral artery

Abstract The aim was to investigate the relationship between transcranial magnetic stimulation (TMS) at the early stage of stroke and 6-month motor outcome for patients with anterior cerebral artery territory infarct. Patients were classified into TMS(+) and TMS(−) groups. At the 6-month evaluation, lower limb motor function for the TMS(+) group was significantly better than those for the TMS(−) group. Thus, early TMS evaluation is useful for predicting recovery of lower limb motor function in patients experiencing this type of stroke.

Evaluation of Salivary Aspiration in Brain- Injured Patients With Tracheostomy

Objective To determine the useful tool for evaluating salivary aspiration in brain-injured patients with tracheostomy. Methods Radionuclide salivagram and laryngoscopy was done in 27 brain-injured patients with tracheostomy. During salivagram, 99mTc sulfur colloid was placed sublingually in the supine position, and 50-minute dynamic images and 2-hour delayed images were obtained. Salivary aspiration was detected when the tracer was entered into the major airways or lung parenchyma. Laryngoscopy was done by otolaryngologists, and saliva aspiration, saliva pooling, and vocal cord palsy were evaluated. Videofluoroscopic swallowing study was done in patients who were able to undergo the test. Results The detection rate of salivary aspiration was 44.4% with salivagram, and 29.6% with laryngoscopy. The correlation of the two tests was 70.4%. Of the laryngoscopy findings, salivary pooling had significant correlation with positive salivagram results (p=0.04). Frequent need of suction correlated with salivary aspiration in both salivagram (p=0.01) and laryngoscopy (p=0.01). Patients with negative results in salivagram or laryngoscopy had higher rates of progressing to oral feeding or tapering tracheostomy. Two patients developed aspiration pneumonia, and both patients only showed aspiration in salivagram. Conclusion Brain-injured patients with tracheostomy have a high risk of salivary aspiration. Evaluation of salivary aspiration is important, as it may predict aspiration pneumonia and aids in clinical decisions of oral feeding or tracheostomy removal. Salivagram is more sensitive than laryngoscopy, but laryngoscopy may be useful for evaluating structural abnormalities or for follow-up examinations to assess the changes.

Efficacy and safety of NABOTA in post-stroke upper limb spasticity: a phase 3 multicenter, double-blinded, randomized controlled trial.

Botulinum toxin A is widely used in the clinics to reduce spasticity and improve upper limb function for post-stroke patients. Efficacy and safety of a new botulinum toxin type A, NABOTA (DWP450) in post-stroke upper limb spasticity was evaluated in comparison with Botox (onabotulinum toxin A). A total of 197 patients with post-stroke upper limb spasticity were included in this study and randomly assigned to NABOTA group (n=99) or Botox group (n=98). Wrist flexors with modified Ashworth Scale (MAS) grade 2 or greater, and elbow flexors, thumb flexors and finger flexors with MAS 1 or greater were injected with either drug. The primary outcome was the change of wrist flexor MAS between baseline and 4weeks post-injection. MAS of each injected muscle, Disability Assessment Scale (DAS), and Caregiver Burden Scale were also assessed at baseline and 4, 8, and 12weeks after the injection. Global Assessment Scale (GAS) was evaluated on the last visit at 12weeks. The change of MAS for wrist flexor between baseline and 4weeks post-injection was -1.44±0.72 in the NABOTA group and -1.46±0.77 in the Botox group. The difference of change between both groups was 0.0129 (95% confidence interval -0.2062-0.2319), within the non-inferiority margin of 0.45. Both groups showed significant improvements regarding MAS of all injected muscles, DAS, and Caregiver Burden Scale at all follow-up periods. There were no significant differences in all secondary outcome measures between the two groups. NABOTA demonstrated non-inferior efficacy and safety for improving upper limb spasticity in stroke patients compared to Botox.

Effect of Repetitive Transcranial Magnetic Stimulation on Patients With Dysarthria After Subacute Stroke

Objective To evaluate whether repetitive transcranial magnetic stimulation (rTMS) could improve dysarthria in stroke patients at the subacute stage. Methods This study was a prospective, randomized, double-blind controlled trial. Patients who had unilateral middle cerebral artery infarction were enrolled. In patients in the rTMS group, we found hot spots by searching for the evoked motor potential of the orbicularis oris on the non-affected side. We performed rTMS at a low frequency (1 Hz), 1,500 stimulations/day, 5 days a week for 2 weeks on the hotspots. We used the same protocol in the sham stimulation group patients as that in the rTMS group, except that the angle of the coil was perpendicular to the skull rather than tangential to it. The patients in both groups received speech therapy for 30 minutes, 5 days a week from a skilled speech therapist. The speech therapist measured the Urimal Test of Articulation and Phonology, alternative motion rates, sequential motion rates, and maximal phonation time before and after intervention sessions. Results Forty-two patients were enrolled in this study and 20 completed the study. Statistical analysis revealed significant improvements on the dysarthria scales in both groups. The sequential motion rate (SMR)-PǝTǝKǝ showed significantly greater improvement in the rTMS group patients than in the sham stimulation group. Conclusion Patients in the rTMS group showed greater improvement in articulation than did patients in the sham rTMS group. Therefore, rTMS can have a synergistic effect with speech therapy in treating dysarthria after stroke.