Seiji Etoh

Effects of intensive repetition of a new facilitation technique on motor functional recovery of the hemiplegic upper limb and hand

Objective: To study the effects on the hemiplegic upper limb of repetitive facilitation exercises (RFEs) using a novel facilitation technique, in which the patients intention to move the hemiplegic upper limb or finger was followed by realization of the movement using multiple sensory stimulations. Methods: Twenty-three stroke patients were enrolled in a cross-over study in which 2-week RFE sessions (100 repetitions each of five-to-eight types of facilitation exercise per day) were alternated with 2-week conventional rehabilitation (CR) sessions, for a total of four sessions. Treatments were begun with the 2-week RFE session in one group and the 2-week CR session in the second group. Results: After the first 2-week RFE session, both groups showed improvements in the Brunnstrom stages of the upper limb and the hand, in contrast to the small improvements observed during the first CR session. The Simple Test for Evaluating Hand Function (STEF) score, which evaluates the ability of manipulating objects, in both groups improved during both sessions. After the second 2-week RFE and CR sessions, both groups showed little further improvement except in the STEF score. Conclusion: The novel RFEs promoted the functional recovery of the hemiplegic upper limb and hand to a greater extent than the CR sessions.

Anti-spastic effects of the direct application of vibratory stimuli to the spastic muscles of hemiplegic limbs in post-stroke patients.

Objective: To investigate whether the direct application of vibratory stimuli inhibits spasticity and improves motor function in the hemiplegic upper limbs of post-stroke patients. Design: Prospective pilot study. Setting: University hospital rehabilitation centre. Subjects: Fourteen post-stroke patients (mean age = 57.3 years; SD = 19.1 years). Interventions: A hand and forearm stimulation device and an upper-arm stimulation device, consisting of vibrators, a wooden frame and a cloth strap, applied to the upper limbs of subjects. Main measures: The modified Ashworth scale (MAS) score, F-wave parameters and motor-function parameters (finger tapping, active range of motion and the simple test for evaluating hand function). Results: Subjects showed significant and potentially durable improvements in MAS score (p < 0.01), F-wave parameters (p < 0.01) and motor-function parameters (p < 0.05). The MAS score, F-wave parameters and motor-function parameters dropped below the baseline values after vibratory stimulation. The MAS score and F-wave parameters remained significantly below the baseline 30 minutes after stimulation. Conclusions: The direct application of vibratory stimuli is an effective non-pharmacological anti-spastic treatment that could facilitate stroke rehabilitation. These results provide good evidence of potential short-term benefits of anti-spastic vibratory therapy in post-stroke patients in terms of decreased muscle tonus and improved motor function.

Benefits of a Repetitive Facilitative Exercise Program for the Upper Paretic Extremity After Subacute Stroke A Randomized Controlled Trial

Background. Repetitive facilitative exercise (RFE), a combination of high repetition rate and neurofacilitation, is a recently developed approach to the rehabilitation of stroke-related limb impairment. Preliminary investigations have been encouraging, but a randomized controlled evaluation has yet to be performed. Objectives. To compare the efficacy of RFE with that of conventional rehabilitation in adults with subacute stroke. Methods. A total of 52 adults with stroke-related upper-limb impairment (Brunnstrom stage ≥III) of 3 to 13 weeks’ duration participated in this randomized, controlled, observer-blinded trial. Participants were randomized into 2 groups and received treatment on a 4-week, 40 min/d, 5 d/wk schedule. Those assigned to RFE received 100 standardized movements of at least 5 joints of their affected upper extremity, whereas those in the control group participated in a conventional upper-extremity rehabilitation program. Primary and secondary outcomes (improvement in group Action Research Arm Test [ARAT] and Fugl-Meyer Arm [FMA] scores, respectively) were assessed at the end of training. Results. In all, 49 participants (26 receiving RFE) completed the trial. ARAT and FMA scores at baseline were 19 ± 21 and 39 ± 21 (mean ± standard deviation). Evaluation at the trial’s completion revealed significantly larger improvements in the RFE group than in the control group in both ARAT (F = 7.52; P = .009) and FMA (F = 5.98; P = .019) scores. Conclusions. These findings suggest that RFE may be more effective than conventional rehabilitation in lessening impairment and improving upper-limb motor function during the subacute phase of stroke.

Improvements in limb kinetic apraxia by repetition of a newly designed facilitation exercise in a patient with corticobasal degeneration.

Corticobasal degeneration is a progressive neurological disorder characterized by a combination of parkinsonism and cortical dysfunction such as limb kinetic apraxia, alien limb phenomenon, and dementia. To study the effect of repetitive facilitation exercise (RFE) in a patient with corticobasal degeneration, we used a newly designed facilitation exercise designed to elicit movements isolated from the synergy in hemiplegia. This exercise included movements of each isolated finger using stretch reflex and skin-muscle reflex and repetitive movements demanded in activities of daily living (ADL) and manipulating objects. To evaluate improvements in hand functions by RFE, 1-week RFE sessions for the hand were administered alternatively to the left or right hand. The number of finger taps by the hand increased during each 1-week RFE session for the hand, but did not increase during 1-week sessions without RFE. After 1 month of treatment, the patients difficulties in ADL, including wearing clothes, manipulating objects and cooking, decreased. Our results suggest the importance of the repetition of facilitation exercises and movements in ADL for recovery in patients with degenerative neurogenic diseases.

Fatiguing intermittent lower limb exercise influences corticospinal and corticocortical excitability in the nonexercised upper limb

BACKGROUND It has recently been reported that unilateral fatiguing exercise affects not only the motor area innervating the exercising muscle but also the ipsilateral motor area innervating homologous nonexercised muscle. OBJECTIVE This study was designed to clarify the effects of fatiguing intermittent lower limb exercise on the excitability of the motor cortex representation of nonexercised muscles in the arm. METHODS Eight subjects performed an intermittent leg press exercise composed of three bouts of 5-minute leg press (T1, T2, and T3) at 50% of maximal voluntary contraction separated by a 2-minute rest. Motor-evoked potentials (MEP), short interval intracortical inhibition (SICI), and intracortical facilitation (ICF), using paired-pulse transcranial magnetic stimulation, were assessed in two nonexercised arm muscles (first dorsal interosseous muscle: FDI, n = 8; biceps brachii muscle: BB, n = 6) and one exercised leg muscle (quadriceps femoris muscle: QF, n = 6) before and immediately after each bout of exercise and for 30 minutes during recovery after the end of the third exercise bout (Experiment 1). Experiment 2 was the same as Experiment 1, except that the test pulse intensity was adjusted to produce a given amplitude of MEP(TEST) at each time point. RESULTS MEPs and SICI in the exercised QF muscle were depressed at all time points during and after fatigue. In contrast, MEPs in nonexercised arm muscles were facilitated from T1-T3 (T3, only FDI), but were then depressed for up to 20 minutes in the recovery period. SICI was reduced in both muscles during T1-T3 and remained depressed until 20 minutes into recovery. ICF was unchanged in arm muscles but depressed in QF over T1-T3. CONCLUSIONS The current study indicates that muscle fatigue induced by exercise of a large lower limb muscle group has powerful effects on the excitability of both SICI and the corticospinal projection to muscles of the nonexercised upper limb.

Effects of thermal therapy combining sauna therapy and underwater exercise in patients with fibromyalgia

Fibromyalgia syndrome (FMS) is a chronic disorder that is characterized by widespread pain with localized tenderness. We aimed to investigate whether thermal therapy combining sauna therapy and underwater exercise improved pain, symptoms, and quality of life (QOL) in FMS patients. Forty-four female FMS patients who fulfilled the American College of Rheumatology (ACR) criteria received 12-week thermal therapy program comprising sauna therapy once daily for 3 days/week and underwater exercise once daily for 2 days/week. Pain, symptoms, and QOL were assessed using a pain visual analog scale (VAS), a fibromyalgia impact questionnaire (FIQ), and a short form 36-item questionnaire (SF-36), respectively. All of the patients reported significant reductions in pain and symptoms of 31-77% after the 12-week thermal therapy program, which remained relatively stable (28-68%) during the 6-month follow-up period (that is, the thermal therapy program improved both the short-term and the long-term VAS and FIQ scores). Improvements were also observed in the SF-36 score. Thermal therapy combining sauna therapy and underwater exercise improved the QOL as well as the pain and symptoms of FMS patients.

Effects of repetitive trascranial magnetic stimulation on repetitive facilitation exercises of the hemiplegic hand in chronic stroke patients.

OBJECTIVE To investigate whether multiple sessions of 1-Hz repetitive transcranial magnetic stimulation (rTMS) facilitates the effect of repetitive facilitation exercises on hemiplegic upper-limb function in chronic stroke patients. DESIGN Randomized double-blinded crossover study. PATIENTS Eighteen patients with hemiplegia of the upper limb. METHODS Patients were assigned to 2 groups: a motor-before-sham rTMS group, which performed motor rTMS sessions for 2 weeks followed by sham rTMS sessions for 2 weeks; or a motor-following-sham rTMS group, which performed sham rTMS sessions for 2 weeks followed by motor rTMS sessions for 2 weeks. Patients received 1-Hz rTMS to the unaffected motor cortex for 4 min and performed repetitive facilitation exercises for 40 min during motor rTMS sessions. The Fugl-Meyer Assessment, Action Research Arm Test (ARAT) and Simple Test for Evaluating Hand Function were used to evaluate upper-limb function. The Modified Ashworth Scale and F-wave were measured to evaluate spasticity. RESULTS Motor function improved significantly during the motor, but not sham, rTMS sessions. ARAT score gains were 1.5 (0-4.0) (median, interquartile range) during the motor rTMS session, and 0 (-0.8-1.8) during the sham rTMS session (p = 0.04). Spasticity did not significantly change during either session. CONCLUSION Multiple sessions of 1-Hz rTMS facilitated the effects of repetitive facilitation exercises in improving motor function of the affected upper limb, but did not change spasticity.

Functional vibratory stimulation on the hand facilitates voluntary movements of a hemiplegic upper limb in a patient with stroke.

The use of a new device consisting of a small vibrator to deliver functional vibratory stimulation (FVS) to the arm resulted in improvements of flexion of the hemiparetic shoulder in a man with thalamic bleeding. FVS delivered to the palm enabled the patient to repeat flexing his hemiparetic shoulder to manipulate objects with his hand. The functions of the patients hemiparetic shoulder and fingers improved after treatments using FVS for 1 month. We examined whether FVS of the hemiplegic upper limb could facilitate voluntary movements of the limb by increasing the excitability of the motor cortex or the spinal motor neurons using somatosensory-evoked potentials, transcranial magnetic stimulation, F-wave, and single photon emission computed tomography. Our results did not detect an increase of excitability in the motor cortex or in spinal motor neurons by FVS.

New functional vibratory stimulation device for extremities in patients with stroke.

The utility of a new device that delivers functional vibratory stimulation to the extremities was studied in 13 patients with stroke. We hypothesized that vibratory stimulation of the hemiplegic lower limb would increase gait speed in these patients. The device consisted of one battery, two small vibrators and a connecting wire. The small vibrators were stabilized on the anterior tibial muscle and gluteus medius muscle by a bandage. An analysis of the effects of functional vibratory stimulation on hemiplegic lower limb on gait speed indicated that gait speed was greater during stimulation than without. These results suggest that the new device of functional vibratory stimulation is useful for treatment in patients with stroke.

Repetitive facilitative exercise under continuous electrical stimulation for severe arm impairment after sub-acute stroke: A randomized controlled pilot study

Abstract Objective: To investigate the effectiveness of repetitive facilitative exercise (RFE) under surface neuromuscular electrical stimulation (NMES) in patients with post-stroke hemiplegia. Methods: This randomized, controlled, observer-blinded, pilot trial randomized 27 adults with severe arm impairment [Fugl-Meyer Arm scale (FMA) ≤ 20] due to stroke of 3–13 weeks duration into three groups and provided treatment on a 4-week, 40 minutes/day, 5 days/week schedule. The RFE-under-NMES group were given 100–150 repetitions of standardized movements of shoulder, elbow and wrist joints of their affected arm with concurrent low-amplitude NMES for each corresponding musculature. The RFE group was given the same exercise regimen but without NMES. The control group was treated with a conventional arm rehabilitation programme without NMES. FMA was assessed at baseline and 4 weeks. Results: All 27 participants (nine in each group) completed the trial. At 4 weeks, the RFE-under-NMES group evidenced significantly greater improvement compared with the control group on the FMA (p = 0.003), but not with the RFE group (p = 0.092). The RFE group showed improvement compared with the control group, but it was not significant (p = 0.199). Conclusions: RFE under NMES is feasible in clinical settings and may be more effective than conventional rehabilitation in lessening arm impairment after sub-acute stroke.