Po-Yi Tsai

Efficacy of Coupling Inhibitory and Facilitatory Repetitive Transcranial Magnetic Stimulation to Enhance Motor Recovery in Hemiplegic Stroke Patients

Background and Purpose— Although there has been extensive research on the effectiveness of repetitive transcranial magnetic stimulation (rTMS) to improve patients’ motor performance after experiencing chronic stroke, explicit findings on the coupling of different rTMS protocols are meager. We designed this sham-controlled randomized study to investigate the potential for a consecutive suppressive-facilitatory TMS protocol to improve motor outcomes after chronic stroke. Methods— Fifty-four chronic hemiplegic stroke patients were allocated across 4 groups to undergo 20 daily sessions of (1) 1 Hz rTMS over the contralesional primary motor cortex (M1) and then intermittent theta burst stimulation over the ipsilesional M1 (group A); (2) contralesional sham stimulation and then ipsilesional real intermittent theta burst stimulation (group B); (3) contralesional real 1 Hz rTMS and then ipsilesional sham stimulation (group C); or (4) bilateral sham-control procedures (group D). We tested cortical excitability and motor activity assessments at the baseline, postpriming rTMS, and postconsequent rTMS periods. Results— At post, group A showed greater muscle strength, Fugl-Meyer Assessment (FMA), Wolf Motor Function test, and reaction time improvement in comparison with group B (P<0.001≈0.003) and group C (P=0.001≈0.003). Correlation analyses in group A revealed a close relation between contralesional map area decrement and Wolf Motor Function test gain (P=0.005; r=−0.75), and also revealed ipsilesional map area increment and reaction time decrement (P=0.02; r=−0.87). We detected no such relations in the other 3 groups. Conclusions— Our clinical trials established an extended timeframe during which conditioning could be safely continued and produced more favorable outcomes in facilitating motor performance and ameliorating interhemispheric imbalance than those obtained from single-course rTMS modulation alone.

Functional magnetic stimulation in constipation associated with Parkinson's disease.

OBJECTIVE The aims of this study were: (i) to investigate the effect of functional magnetic stimulation on total colonic transit time in patients with Parkinsons disease; (ii) to compare the changes in dynamic recto-anal behaviour during filling and defaecation in response to this regimen; and (iii) to study the carry-over effects with a 3-month follow-up. DESIGN A longitudinal, prospective before-after trial. SUBJECTS Sixteen patients with Parkinsons disease enrolled in this study. No subject withdrew from the study as a result of serious adverse events. METHODS A 3-week magnetic conditioning protocol, consisting of a 20-min stimulation session twice daily. Colonic transit time, Knowles-Eccersley-Scott Symptom Questionnaire and the dynamics of defecography were carried out before the intervention and on the final day of the protocol. RESULTS AND CONCLUSION There was a statistically significant reduction in colonic transit time and in the questionnaire score following the intervention. The difference in the anorectal angles between resting and evacuating process and the changes in pelvic floor descent all reached significance after the intervention. The therapeutic effects that achieved significance remained constant in the 3-month follow-up result. Functional magnetic stimulation may facilitate colonic motility in Parkinsons disease and straighten the anorectal angle, allowing smooth access of rectal contents to the anal canal.

Early recognition of pelvic floor dyssynergia and colorectal assessment in Parkinson's disease associated with bowel dysfunction.

Slow colonic transit time (CTT) and pelvic floor dyssynergia (PFD) are major contributors to constipation in patients with Parkinsons disease (PD). However, no symptom survey yet exists that effectively differentiates the contributing aetiologies. The significance of individual pelvic floor musculature behaviours and their relationship with colorectal dysmotility in constipated patients with PD are still controversial and need further clarification. We aimed to investigate how differentiated constipation‐related symptoms of PD patients with constipation may identify constipation groupings and to register the pathophysiological features of the pelvic musculature.

Inhibitory repetitive transcranial magnetic stimulation of the contralesional premotor and primary motor cortices facilitate poststroke motor recovery.

PURPOSE The premotor cortex plays a major role in motor planning and control, exhibiting hierarchical importance comparable to that of the primary motor cortex (M1). In this study, we compared the effects of cPMd modulation, which was achieved using inhibitory repetitive transcranial magnetic stimulation (rTMS), with those of contralesional M1 (cM1) modulation, to elucidate the roles of both regions on longitudinal motor recovery following a stroke. METHODS Forty-four patients who had sustained hemiplegia for 3 to 12 months were randomly allocated to a cPMd group, cM1 group, or sham group and received 10 sessions of 1-Hz rTMS. The Medical Research Council (MRC) Scale, Fugl-Meyer Assessment (FMA), Wolf Motor Function Test (WMFT), and a cortical excitability test were administered pre- and post- rTMS intervention. RESULTS cPMd modulation yielded significant improvements in MRC, FMA, and WMFT scores compared with sham stimulation and a significant effect on cortical excitability suppression equivalent to that of cM1 modulation, but engendered effects on motor improvement inferior to those of cM1 modulation. CONCLUSIONS In patients with chronic stroke, the cPMd can fulfill a role similar to that of the cM1 in interhemispheric imbalance, which can be ameliorated by applying inhibitory rTMS to achieve substantial motor restoration.

Effects of intravascular laser irradiation of blood in mitochondria dysfunction and oxidative stress in adults with chronic spinal cord injury.

OBJECTIVE This study investigated the clinical effects of intravascular laser irradiation of blood (ILIB) therapy on oxidative stress and mitochondrial dysfunction in subjects with chronic spinal cord injury (SCI) resulting from trauma. BACKGROUND DATA Little is known about how ILIB may generate antioxidant defenses in humans, and there is still a lack of randomized, sham-control studies to indicate its influence on different metabolic pathways. METHODS Twenty-four chronic SCI subjects (assigned to a sham and a study group), and 12 normal subjects were recruited. The study group underwent 1 h daily of ILIB for 15 days over 3 weeks. The sham group underwent ILIB with no laser power. RESULTS Baseline measurements established higher oxidative stress and mitochondrial dysfunction in the SCI subjects than in the normal subjects. At day 15 of therapy, the study group revealed a significantly higher mitochondrial DNA (mtDNA) copy number, white blood cell adenosine triphosphate (WBC ATP) synthesis, and total antioxidant capacity (TAC) with significantly reduced malondialdehyde (MDA), than did the sham group. The study group intragroup comparison revealed significantly increased mtDNA copy numbers, WBC ATP synthesis, and TAC, with significantly reduced MDA, compared with its baseline measurements. The sham group intragroup comparisons demonstrated no statistical differences. Low-density lipoprotein (LDL) in the study group was significantly reduced at days 10 and 15, with significantly higher high-density lipoprotein (HDL) at day 45. CONCLUSIONS Our study results contribute to the knowledge about the effectiveness of ILIB in alleviating oxidative stress and mitochondrial dysfunction in chronic SCI patients.

Outcomes of common peroneal nerve lesions after surgical repair with acidic fibroblast growth factor.

BACKGROUND There have been no clinical trials concerning the effect of acidic fibroblast growth factor (aFGF) on human peripheral nerve lesions. Our interest was focused on the question of whether a repair strategy incorporating growth factors could be applied to repair of common peroneal nerve lesions. METHODS This study involved three groups of patients with common peroneal nerve lesions: group 1 (n = 21) received surgical repair with fibrin glue added with aFGF; group 2 (n = 8) received surgical repair only; group 3 (n = 16) did not receive any surgical intervention. All patients received electrophysiologic examinations and physical examination at baseline, 6 months, and 12 months postsurgically. RESULTS Group 1 demonstrated significantly increased average muscle strength score by 0.4299 and 0.5045 at 6 and 12 months after the operation (p = 0.0197 and 0.0297, respectively). In groups 2 and 3 patients, however, significant increase of average muscle strength scores was not achieved either at 6 or 12 months postoperatively. During the first follow-up evaluation the average muscle strength score in group 1 (3.06 +/- 1.60) was significantly higher than those in group 2 (1.04 +/- 0.86) and group 3 (1.65 +/- 1.43) (p = 0.005). However, significant difference was not achieved during the second follow-up evaluation. CONCLUSION This study demonstrated the potential of this innovative repair strategy with aFGF treatment to facilitate nerve regeneration and motor function recovery following peripheral nerve lesions.

Corticospinal Integrity and Motor Impairment Predict Outcomes After Excitatory Repetitive Transcranial Magnetic Stimulation: A Preliminary Study

OBJECTIVE To identify the effective predictors for therapeutic outcomes based on intermittent theta-burst stimulation (iTBS). DESIGN A sham-controlled, double-blind parallel study design. SETTING A tertiary hospital. PARTICIPANTS People with stroke (N=72) who presented with unilateral hemiplegia. INTERVENTIONS Ten consecutive sessions of real or sham iTBS were implemented with the aim of enhancing hand function. Patients were categorized into 4 groups according to the presence (MEP+) or absence (MEP-) of motor-evoked potentials (MEPs) and grip strength according to the Medical Research Council (MRC) scale. MAIN OUTCOME MEASURES Cortical excitability, Wolf Motor Function Test (WMFT), finger-tapping task (FT), and simple reaction time were performed before and after the sessions. RESULTS MEPs and the MRC scale were predictive of iTBS therapeutic outcomes. Group A (MEP+, MRC>1) exhibited the greatest WMFT change (7.6±2.3, P<.001), followed by group B (MEP-, MRC>1; 5.2±2.2 score change) and group C (MEP-, MRC=0; 2.3±1.5 score change). These improvements were correlated significantly with baseline motor function and ipsilesional maximum MEP amplitude. CONCLUSIONS The effectiveness of iTBS modulation for poststroke motor enhancement depends on baseline hand grip strength and the presence of MEPs. Our findings indicate that establishing neurostimulation strategies based on the proposed electrophysiological and clinical criteria can allow iTBS to be executed with substantial precision. Effective neuromodulatory strategies can be formulated by using electrophysiological features and clinical presentation information as guidelines.

Efficacy of Synchronous Verbal Training During Repetitive Transcranial Magnetic Stimulation in Patients With Chronic Aphasia

Background and Purpose— Although multiple studies have suggested that repetitive transcranial magnetic stimulation (rTMS) may facilitate recovery after stroke, the efficacy of synchronous speech therapy integrated with an rTMS protocol has yet to be determined. We investigated language responses to this strategy and determined the longevity of the resulting therapeutic outcomes. Methods— Forty-five patients with stroke who presented with nonfluent aphasia were randomly assigned to the TMSsyn group and underwent synchronous picture-naming training together with contralesional 1 Hz-rTMS for 10 daily sessions. The TMSsub group underwent subsequent picture-naming activity after the primed 1 Hz-rTMS, and the TMSsham group received concurrent naming task along with the sham 1 Hz-rTMS. The Concise Chinese Aphasia test and the picture-naming test were performed before, immediately, and after 3 months of the intervention. Results— TMSsyn showed significantly superior results in Concise Chinese Aphasia test score (P<0.001), expression and description subtests (P<0.001), and action (P=0.02) and object naming activity (P=0.008); the superior results lasted for 3 months (P=0.005), in comparison with the TMSsub and TMSsham groups. Conclusions— We established a real-time model that involved implementing verbal tasks together with the rTMS protocol. Our results confirmed that the strategy yielded favorable outcomes that were of considerable longevity. The results also indicated that the rTMS protocol and language training can be combined to achieve outcomes superior to those obtained when used separately. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT02120508.

Interactive 3-dimensional virtual reality rehabilitation for patients with chronic imbalance and vestibular dysfunction

BACKGROUND Chronic imbalance is common in patients with vestibular dysfunction. Vestibular rehabilitation is effective in improving upright balance control. Vestibular rehabilitation exercises, such as Cawthorne-Cooksey exercises, include simple repetitive movements and have limited feedback and adaptive training protocols. Interactive systems based on virtual reality (VR) technology may improve vestibular rehabilitation. OBJECTIVE The objective of this study was to examine the effectiveness of an interactive 3-dimensional VR system for vestibular rehabilitation. METHODS In 49 subjects with vestibular dysfunction, VR rehabilitation exercises were performed in 6 sessions. Before and after rehabilitation, subjects were evaluated for performance of the training exercises; the center of pressure was measured for 20 seconds and balance indices were determined. RESULTS Five training scores (total 6) showed a significant improvement. For balance indices in condition of non-stimulation, all of them (total 5) showed a trend of improvement, in which there was a significant improvement in mean mediolateral. For balance indices in condition of post-stimulation, there was a significant improvement in statokinesigram and maximum mediolateral. CONCLUSIONS The VR rehabilitation exercises were effective in improving upright balance control in patients with vestibular dysfunction.

Long-Term Sacral Magnetic Stimulation for Refractory Stress Urinary Incontinence

OBJECTIVE To evaluate the effects of sacral magnetic stimulation (SMS) on functional and urodynamic improvement in patients with refractory stress urinary incontinence (SUI). DESIGN A sham-controlled, double-blind, parallel study design with a 4.5-month follow-up. SETTING A tertiary hospital. PARTICIPANTS Women (age, 45-75y) with SUI refractory to first-line management (N=34) were allocated to either an experimental (n=20) group or a sham (n=14) group. INTERVENTIONS The SMS protocol consisted of 5-Hz, 20-minute treatments administered over the bilateral third sacral roots, with the intensity set at approximately 70% of the maximal output, for 12 consecutive weekdays. MAIN OUTCOME MEASURES Urodynamic assessments and 2 life stress questionnaires, namely, the Urge-Urinary Distress Inventory (U-UDI) and the Overactive Bladder Questionnaire (OAB-q), were administered pre- and post-SMS intervention. We administered the U-UDI (primary outcome measure) and the OAB-q at 3-week intervals during the follow-up period until 18 weeks after the final intervention. RESULTS The experimental group exhibited significant improvements in both U-UDI and OAB-q scores postintervention (P=.011-.014) and at follow-up visits (P<.001-.007) compared with the sham group. In addition, significant increases in bladder capacity, urethral functional length, and the pressure transmission ratio (P=.009-.033) were noted postintervention. Multivariate regression analysis revealed that patients with more severe symptoms benefited more from SMS. A poorer baseline U-UDI score and a shorter urethral functional length were associated with a greater response to SMS. CONCLUSIONS Our observations of a greater response to SMS in patients with more severe SUI than in those with mild symptoms, as well as the long-term benefits of the treatment, confirm the efficacy of SMS in treating SUI.