Satoshi Miyano

Evaluation and treatment of shoulder subluxation in hemiplegia : Relationship between subluxation and pain

Shoulder subluxation in hemiplegic patients has been recognized as a difficult problem to manage. In the study contained herein, our aims are to evaluate shoulder subluxation, to clarify if shoulder subluxation causes pain, and to discuss the treatment of shoulder subluxation. The study included 75 hemiplegic patients with shoulder subluxation. Each patient was evaluated for the degree of shoulder pain, motor recovery of the upper limb, and shoulder range of motion. Some indexes for evaluating subluxation were measured with radiographs of the shoulders. Arthrograms of the affected shoulder joint were taken in 23 patients. The following results were found: (1) shoulder pain was significant more frequently in left hemiplegia; (2) vertical disparity was strongly correlated with discrepancy of the descendant ratio; (3) severe inferior subluxation had a tendency to show medial displacement of the humeral head; (4) there were correlations between shoulder pain and shoulder range of motion, especially external rotation; (5) adhesive changes in the arthrograms were seen in most subjects. These results indicate that there is no relation between shoulder subluxation and pain, and adhesive capsulitis is a main cause of shoulder pain. We conclude that correct positioning and shoulder range of motion exercises are advisable in hemiplegic patients with shoulder subluxation.

Dynamic Postural Control in Patients with Hemiparesis

Ikai T, Kamikubo T, Takehara I, Nishi M, Miyano M: Dynamic postural control in patients with hemiparesis. Am J Phys Med Rehabil 2003;82:463–469. Objective Decreased postural stability is a common problem associated with hemiparesis secondary to stroke. The purpose of this study was to evaluate dynamic postural control in patients with hemiparesis and in normal subjects matched for age. Design Quantitative posturography (EquiTest System) was performed to assess the response of subjects to sudden perturbations. A total of 59 patients with hemiparesis and 98 healthy volunteers were evaluated. All the patients were able to walk inside their house without lower limb orthoses. Both the patients and the healthy volunteers were subjected to forward and backward perturbations while standing on a movable force platform. Balance responses were analyzed in terms of weight symmetry, latency, amplitude (relative response strength), and strength symmetry. They were also subjected to toes-up and toes-down perturbations to evaluate their response to a disruptive balance force. Results The response latency to perturbations was longer and the response strength was weaker on the paretic side of patients with hemiparesis. The dynamic postural control was impaired in patients with hemiparesis as compared with healthy subjects. Conclusion The results suggest that patients with hemiparesis tend to fall easily and that the risk of falls toward the paretic side is high.

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.

Prevention of secondary osteoporosis postmenopause in hemiplegia

Ikai T, Uematsu M, Eun SS, Kimura C, Hasegawa C, Miyano S: Prevention of secondary osteoporosis postmenopause in hemiplegia. Am J Phys Med Rehabil 2001;80:169–174. ObjectivesTo study secondary osteoporosis postmenopause in women with hemiplegia and to show the therapeutic effects of etidronate and how osteoporotic conditions relate to the activities of daily living (ADL). DesignEighty-one postmenopausal women with hemiplegia were admitted within 6 mo of their first cerebrovascular accident. The bone mineral density (BMD) and biochemical markers of bone turnover were measured at the time of admission. Forty women (treatment group) received a 2-wk administration of etidronate. Forty-one women (control group) were not administered etidronate. ResultsAfter completing a 3-mo rehabilitation program, BMD levels were remeasured. ADL was evaluated by FIMTM. The low ADL group had a larger decrease in BMD than the high ADL group. For the control group, the BMD rate of change on the paretic side of the femoral neck was −9.6%/3 mo for the low ADL group. BMD loss was reduced significantly by the administration of etidronate for the low ADL group. ConclusionsResults indicate that ADL corresponds to the progression of osteoporosis in postmenopausal women with hemiplegia and that increasing the level of ADL will reduce the progression of osteoporosis. Use of etidronate has also been proven to have a suppressive effect on the BMD decrease in women.

Influence of isoflurane concentration and hypoxia on functional magnetic resonance imaging for the detection of bicuculline-induced neuronal activation.

Our present study shows that transient changes in relative cerebral blood volume (rCBV) induced by stimulation with bicuculline under six different conditions of anesthesia can be detected with high spatial resolution functional magnetic resonance imaging (fMRI). Bicuculline was administered at a low dose to induce neural activation, and no seizure activity was noted. Of the six conditions, the maximal reaction to bicuculline was observed under 1.5% isoflurane in 60% nitrogen and 40% oxygen. Our results imply that the rCBV changes under this level of isoflurane anesthesia with body temperature maintained at 37.5°C are probably suitable for further fMRI studies.

Role of Brain-Derived Neurotrophic Factor in Beneficial Effects of Repetitive Transcranial Magnetic Stimulation for Upper Limb Hemiparesis after Stroke.

Background Repetitive transcranial magnetic stimulation (rTMS) can improve upper limb hemiparesis after stroke but the mechanism underlying its efficacy remains elusive. rTMS seems to alter brain-derived neurotrophic factor (BDNF) and such effect is influenced by BDNF gene polymorphism. Objectives To investigate the molecular effects of rTMS on serum levels of BDNF, its precursor proBDNF and matrix metalloproteinase-9 (MMP-9) in poststroke patients with upper limb hemiparesis. Methods Poststroke patients with upper limb hemiparesis were studied. Sixty-two patients underwent rehabilitation plus rTMS combination therapy and 33 patients underwent rehabilitation monotherapy without rTMS for 14 days at our hospital. One Hz rTMS was applied over the motor representation of the first dorsal interosseous muscle on the non-lesional hemisphere. Fugl-Meyer Assessment and Wolf Motor Function (WMFT) were used to evaluate motor function on the affected upper limb before and after intervention. Blood samples were collected for analysis of BDNF polymorphism and measurement of BDNF, proBDNF and MMP-9 levels. Results Two-week combination therapy increased BDNF and MMP-9 serum levels, but not serum proBDNF. Serum BDNF and MMP-9 levels did not correlate with motor function improvement, though baseline serum proBDNF levels correlated negatively and significantly with improvement in WMFT (ρ = -0.422, p = 0.002). The outcome of rTMS therapy was not altered by BDNF gene polymorphism. Conclusions The combination therapy of rehabilitation plus low-frequency rTMS seems to improve motor function in the affected limb, by activating BDNF processing. BDNF and its precursor proBDNF could be potentially suitable biomarkers for poststroke motor recovery.

Behavioural recovery correlated with MRI in a rat experimental stroke model

Primary objective : To characterize a necrotic lesion using MRI and motor recovery using behavioural methods. Research design : Stroke model based on two steps: (1) development of a lesion using MR-imaging parameters and (2) behavioural recovery. Methods and procedures : Seventy male Sprague-Dawley rats were used. A focal lesion of the right sensorimotor cortex was induced photochemically. Main outcomes and results : The maximum volume of oedema and the lesion damage was reached by ¨ 6 hours. In the lesion area, the apparent diffusion coefficient (ADC) increased from 6 hours, then decreased from 24 hours. All animals spontaneously recovered motor function by day 10, despite the continued presence of the cortical lesion. Conclusions : The results show that this model mimics a core lesion, as well as the late phase in a human stroke episode. This model might be used for longitudinal study of the basic mechanisms of motor recovery.

Histochemical characterization of skeletal muscles in rats with photochemically-induced stroke.

Primary objective: The aim of this study was to assess skeletal muscle showing a complete functional recovery after induction of pan-necrotic lesions in the right sensorimotor cortex in rats. Research design and methods: A focal lesion of the right sensorimotor cortex was induced photochemically. Rats were divided into three groups; the sham-operated group (CON), Stroke (RB) and Stroke plus severed right sciatic nerve (RBD). Main outcomes and results: All RB rats showed complete functional recovery in the beam-walking test within 10 days. The score of CON rats was 7 for 21 days. The wet weight of the soleus muscle (SOL) only in the RB and RBD was significantly greater than in the CON. The cross-sectional area of type I fibres was increased in SOL. Conclusions: It was concluded that the functional recovery was mainly due to increased wet weight and cross-sectional area of type I SOL fibres, which probably reflected the functional reorganization and neuromodulation in the non-damaged contralateral sensorimotor cortex and ipsilateral sensorimotor cortex lateral to the lesion identified in a previous study.

Functional evaluation of vascular hemiparetics and traditional Japanese houses

Purpose: To study the functional status of vascular hemiparetics in outpatient clinics in Japan. Method: Following five functional tasks were evaluated to (1) pick up a pencil from the floor, (2) stand up from the floor, (3) sit up straight, (4) squat, (5) ambulate as far as possible. Patients were asked whether they added handrails and used a bed or a Japanese Futon. Results: Sixty-three of 85 patients were able to pick up a pencil from the floor and to stand up from the floor. Patients with poor motor recovery of the lower extremities were able get into and out of a bathtub as well as patients with good motor recovery. All patients who could not ambulate for more than 100 m and could not stand up from the floor began to use beds after their strokes. Conclusions: Ninety-five per cent of patients who could stand up from the floor were able to get into and out of bathtubs. All of the patients who could not stand up from the floor started to use beds.

Comparison of Functional Outcome between Lacunar Infarction and Branch Atheromatous Disease in Lenticulostriate Artery Territory.

BACKGROUND Branch atheromatous disease (BAD) is differentiated from lacunar infarction (LI). BAD is often associated with neurological deterioration in the acute stage, but outcome of BAD patients in the chronic stage is unclear. We aimed to explore the outcome of BAD in the lenticulostriate artery (LSA) territory in comparison with those of LI from the viewpoint of activities of daily living (ADLs). METHODS We retrospectively investigated patients who were admitted within 3 days after stroke onset. The patients underwent daily rehabilitation during hospitalization. BAD in LSA territory was defined by the presence of lesion representing 3 or more consecutive horizontal slices in magnetic resonance imaging. Patients having atrial fibrillation or more than 50% stenosis of the large artery in magnetic resonance angiography were excluded. We retrieved data on clinical characteristics and evaluation from medical records. RESULTS Subjects were 41 BAD and 35 LI patients. There was little difference in baseline characteristics. The National Institutes of Health Stroke Scale score was significantly higher in BAD patients (P < .05). The Barthel Index (BI) score and the Brunnstrom recovery stage were lower in BAD patients at admission (P < .05 and P < .05). Hospital stay was longer in BAD patients (P < .01), but the BI score at discharge was not different. To ambulate, 8 BAD and 1 LI patients depended on orthoses (P < .05), and 21 BAD and 7 LI patients used canes (P < .01). Multivariable analysis demonstrated that BAD lesion was correlated with AFO use independent of age and sex. CONCLUSIONS BAD patients can obtain ADLs similar to LI patients. However, many BAD patients require canes and/or orthoses.