Sinikka H. Peurala

Cutaneous electrical stimulation may enhance sensorimotor recovery in chronic stroke

Objective: To investigate whether cutaneous electrical stimulation has a role in the enhancement of sensorimotor function in chronic stroke. Subjects and setting: Fifty-nine patients with chronic stroke received cutaneous stimulation during their three-week-long inpatient rehabilitation. Thirty-two received active treatment in the paretic hand and eight received no-current placebo treatment in the paretic hand. Nineteen patients received active stimulation of the paretic foot. None received stimulation in both upper and lower limbs. Intervention: Cutaneous stimulation was delivered twice daily via a special glove/sock electrode. Main outcome measures: Modified Motor Assessment Scale, 10-metre walking test, paretic limb function, limb skin sensation and somatosensory evoked potentials (SEP) were performed before and after the treatment. Results: Modified Motor Assessment Scale (p < 0.001), 10-metre walking test (p < 0.05), paretic hand function (p < 0.01), upper limb skin sensation (p < 0.01) and SEP normality classification of paretic upper limb (p < 0.01) and paretic lower limb (p < 0.5) improved significantly in the treatment group (n = 51) after three weeks of stimulation. When active hand treatment and placebo hand treatment were compared, a significant improvement in the sensory and motor function was observed only in the actively treated group. Conclusions: Cutaneous stimulation had positive effects in the motor performance, limb sensation and the configuration of SEP of the paretic limb in chronic stroke patients.

Effects of intensive therapy using gait trainer or floor walking exercises early after stroke.

OBJECTIVE To analyse the effects of gait therapy for patients after acute stroke in a randomized controlled trial. METHODS Fifty-six patients with a mean of 8 days post-stroke participated in: (i) gait trainer exercise; (ii) walking training over ground; or (iii) conventional treatment. Patients in the gait trainer exercise and walking groups practiced gait for 15 sessions over 3 weeks and received additional physiotherapy. Functional Ambulatory Category and several secondary outcome measures assessing gait and mobility were administered before and after rehabilitation and at 6-month follow-up. Patients also evaluated their own effort. RESULTS Walking ability improved more with intensive walk training compared with conventional treatment; median Functional Ambulatory Category was zero in all patients at the start of the study, but it was 3 in both walk-training groups and 0.5 in the conventional treatment group at the end of the therapy. Median Functional Ambulatory Category was 4 in both walk-training groups and 2.5 in conventional treatment group at 6-month follow-up. Mean accomplished walking distance was not different between the gait trainer exercise and over ground walking groups. Borg scale indicated more effort in over ground walking. Secondary outcomes also indicated improvements. CONCLUSION Exercise therapy with walking training improved gait function irrespective of the method used, but the time and effort required to achieve the results favour the gait trainer exercise. Early intensive gait training resulted in better walking ability than did conventional treatment.

Effectiveness of constraint-induced movement therapy on activity and participation after stroke: a systematic review and meta-analysis of randomized controlled trials

Objective: To examine the effect of constraint-induced movement therapy and modified constraint-induced movement therapy on activity and participation of patients with stroke (i.e. the effect of different treatment durations and frequency) by reviewing the results of randomized controlled trials. Data sources: A systematic literature search was conducted in MEDLINE, CINAHL, EMBASE, PEDro, OTSeeker, CENTRAL and by manual search. Review methods: Randomized controlled trials for patients over 18 years old with stroke and published in Finnish, Swedish, English or German were included. Studies were collected up to the first week in May 2011. The evidence was high, moderate, low or no evidence according to the quality of randomized controlled trial and the results of meta-analyses. Results: Search resulted in 30 papers reporting constraint-induced movement therapy, including 27 randomized controlled trials published between 2001 and 2011. Constraint-induced movement therapy practice for 60–72 hours over two weeks produced better mobility (i.e. ability to carry, move and handle objects) with high evidence compared to control treatment. Constraint-induced movement therapy for 20–56 hours over two weeks, 30 hours over three weeks and 15–30 hours over 10 weeks improved mobility of the affected upper extremity. However, with self-care as an outcome measure, only 30 hours of constraint-induced movement therapy practice over three weeks demonstrated an improvement. Conclusion: Constraint-induced movement therapy and modified constraint-induced movement therapy proved to be effective on affected hand mobility and to some extent self-care on the World Health Organization’s International Classification of Functioning, Disability and Health activity and participation component, but further studies are needed to find out the optimal treatment protocols for constraint-induced movement therapy.

How much exercise does the enhanced gait-oriented physiotherapy provide for chronic stroke patients?

Abstract.Background and Purpose:Physical exercise therapy in sensorimotor rehabilitation of stroke patients includes active and repetitive exercise and task-specific training. The time spent in active practice is fundamental. The purpose of this study was to analyse what was the actual amount of exercise and content of the performed exercise of the three-week gait-oriented physiotherapy program for chronic stroke patients in an in-patient setting.Methods:Twenty ambulatory post-stroke patients participated in an in-patient rehabilitation period during which a special effort was made to enhance gait training and the amount of therapy and its contents were recorded in structured form. Baseline and postintervention gait ability assessments were made, but the analysis concentrated on participation records in different forms of therapy.Results:Patients received 19 hours of instructed physiotherapy in three weeks and together with self-initiated training they practised for 28 hours. The practice time in the upright position was 62% of the total duration of the instructed physiotherapy and 35% was performed while sitting. This amount of exercise resulted in improvement of the gait tests.Conclusions:In order to improve gait in the chronic state of disease, a sufficient amount of gait rehabilitation practice can be obtained with a combination of electromechanical gait trainer exercises, physiotherapy, instructed exercise groups and self-initiated training.

Evidence for the effectiveness of walking training on walking and self-care after stroke. A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE To examine the effect of randomized controlled trials of walking training on walking and self-care in patients with stroke. DATA SOURCES MEDLINE, CINAHL, Embase, PEDro, OTSeeker, Central, and manual search to the end of August 2012. STUDY SELECTION English, Finnish, Swedish, or German language walking training randomized controlled trials for patients over 18 years of age with stroke. DATA SYNTHESIS The meta-analyses included 38 randomized controlled trials from 44 reports. There was high evidence that in the subacute stage of stroke, specific walking training resulted in improved walking speed and distance compared with traditional walking training of the same intensity. In the chronic stage, walking training resulted in increased walking speed and walking distance compared with no/placebo treatment, and increased walking speed compared with overall physio-therapy. On average, 24 training sessions for 7 weeks were needed. CONCLUSION Walking training improves walking capacity and, to some extent, self-care in different stages of stroke, but the training frequency should be fairly high.

Gait reveals bilateral adaptation of motor control in patients with chronic unilateral stroke

Background and aims: Functional brain imaging has shown that bilateral brain reorganization may occur after unilateral cerebral damage. The present study searched for evidence of bilateral motor control changes in gait in patients with chronic unilateral stroke. Methods: Gait variables (temporal and spatial parameters, footprint peak times (FPPT) and footfall times (FFT)) were recorded in 48 patients with chronic unilateral stroke at their preferred speed, and in 10 healthy volunteers walking from very slowly to very fast on a pressure sensor walkway. The data were divided into 4 groups according to gait velocity. The functional outcome of stroke was measured by the Barthel Index. Results: Patients’ gait variables reflected their hemiparetic gait pattern. Slower patients had prolonged stance, FPPT and FFT on the non-affected side (NS), and prolonged swing and shorter FPPT and FFT on the affected side (AS). The magnitude of the asymmetry index of these parameters was inversely associated with velocity performance and, at the same time, it characterized how much the control of the clinically healthy (NS) side was altered during walking. Bilateral changes in kinetic and footfall variables in the chronic stage of unilateral stroke were present. Conclusions: Patients chose their preferred walking velocity using stereotyped, alternative gait patterns, in which the contribution of the NS was larger than that of the AS. Alternative gait patterns may partly demonstrate compensatory behavioral strategies adapted by patients.

Footprint peak time and functional ambulation profile reflect the potential for hemiparetic gait recovery.

Objective: Gait disturbances were monitored in patients with chronic stroke with a walkway built with pressure sensors in order to assess whether detailed gait and footprint information could provide verification for the potential for gait recovery. Methods: Gait variables (footprint peak times, temporal and spatial parameters and Functional Ambulation Profile, FAP, scores), were first recorded in 25 patients with chronic stroke at their preferred speed and 10 healthy volunteers walking from very slow to very fast. Patients and controls were divided into four groups based on the velocity performance. Secondly, the effect of rehabilitation on the footprint peak times was evaluated in another group of 20 chronic stroke patients. Results and conclusions: The footprint peak time behaviour of different patients with chronic stroke reflected their hemiparetic gait pattern. The slower patients had prolonged footprint peak times on the non-affected side (NS) and shorter values on the lateral footprint on the affected side (AS). The increased gait velocity and the FAP scores decreased the footprint peak times on both sides, especially on the NS. The rehabilitation increased the gait velocity with 18.2%, decreased the duration of the mid-foot and forefoot peak times on the NS and the lateral mid-foot peak times on the AS. A detailed analysis of the individual gait performance allows more accurate assessment of the potential for gait recovery.

Restoration of Normal Cortical Excitability and Gait Ability in Acute Stroke after Intensive Rehabilitation

Methods Testing was performed on the 9th, 24th and 32nd days from the occurrence of stroke. The time to walk 10 m, the distance walked in 6 min and the Modified Motor Assessment Scale scores (0–48) [1] were assessed. The primary motor cortex (M1) excitability was tested by MR-image-guided transcranial magnetic stimulation (Nexstim Ltd, Helsinki, Finland) [2] . Monophasic stimulation pulses were delivered with a Magstim 200 (Magstim Company Ltd, Whitland, UK) using a figure-of-eight-shaped 70mm coil. The optimal stimulation sites to activate the tibialis anterior muscles were determined as the sites where stimulation consistently produced the largest motor evoked potential (MEP) at a suprathreshold stimulus intensity and the resting motor threshold (MT) for these sites was evaluated. Five stimuli at 130% of MT were delivered to elicit the silent period (SP) during 20% of the tibialis anterior maximal voluntary contraction. Muscle activity and SP were measured with a continuous online surface EMG. The SP duration was assessed from the start of the preceding MEP until the return of voluntary activity. The white matter tract integrity was evaluated by DTI [3, 4] . Initially, a DTI sequence with 12 directions and b-values of 0 and 1,000 s/mm 2 was used (19 slices, slice thickness = 5.0 mm). At 6 months, a DTI sequence with 30 directions and b-values of 0 and 1,000 s/mm 2 was applied (23 slices, slice thickness = 5.0 mm). Four regions of interest were analyzed: the left and right pontes, as well as the left and right M1. Because of 2 different DTI sequences, the quantitative measurements of the fractional anisotropy (FA) and apparent diffusion coefficient values were calculated as ratios of values in the lesioned and nonlesioned hemispheres. To visualize, tractography was applied to the regions of interest of the left and right pontes (DTI task card, Siemens; copyright Massachusetts General Hospital, USA). Our patient used a maximum of 1 h/day in order to walk successfully for 20 min. Training was done each workday for 3 weeks. Training progression was achieved by decreasing manual guidance and reliance on walking aids. She also received other gaitoriented physiotherapy, such as standing exercises, for 55 min each workday.

Virtual reality based robotic therapy for stroke rehabilitation: An initial study

The stroke rate will increase as the population ages. Lots of methods on stroke rehabilitation have been developed in the world. The therapy method based on the mirror box illusion helps the limb practice after stroke. Mirror therapy could be combined to virtual reality (VR) rehabilitation to enhance its effect, using robot to realize the position and force manipulation. Robotic device provide one way to regulate the amount and intensity of movement of the plegic limb and to focus more time on more task-specific and complex functional movements. The purpose of this study is to propose a robot assistant for stroke rehabilitation by utilizing virtual reality technology and sensory feedback, to recover stroke patients with upper limb hemiplegia hemiparesis in generating motor images and gaining limb function. The aim of our work is to design, develop and test a VR-based robotic therapy system in order to help stroke patients evoking motor image and acquire motor abilities especially for forearm, hands, and feet, using the VR-Mirror.

Walking Training and Functioning Among Elderly Persons With Stroke: Results of a Prospective Cohort Study

To determine if 65‐ to 85‐year‐old persons who had a stroke within the previous 3‐36 months can improve functioning and quality of life during walking rehabilitation.