Takatoshi Hara

Effects of botulinum toxin A therapy and multidisciplinary rehabilitation on upper and lower limb spasticity in post-stroke patients

Objectives. The purpose of this study was to examine the effects of combined botulinum toxin type A (BoNT-A) and inpatient multidisciplinary (MD) rehabilitation therapy on the improvement of upper and lower limb function in post-stroke patients. Methods. In this retrospective study, a 12-day inpatient treatment protocol was implemented on 51 post-stroke patients with spasticity. Assessments were performed on the day of admission, at discharge, and at 3 months following discharge. Results. At the time of discharge, all of the evaluated items showed a statistically significant improvement. Only the Functional Reach Test (FRT) showed a statistically significant improvement at 3 months. In subgroup analyses, the slowest walking speed group showed a significantly greater change ratio of the 10 Meter Walk Test relative to the other groups, from the time of admission to discharge. This group showed a greater FRT change ratio than the other groups from the time of admission to the 3-month follow-up. Conclusion. Inpatient combined therapy of simultaneous injections of BoNT-A to the upper and lower limbs and MD may improve motor function.

The Efficacy of High-Frequency Repetitive Transcranial Magnetic Stimulation for Improving Apathy in Chronic Stroke Patients

Although repetitive transcranial magnetic stimulation (rTMS) for hemiparesis is beneficial, so far no study has examined the usefulness of rTMS for apathy. Thirteen patients with chronic stroke were assigned randomly to 2 groups: rTMS group (n = 7) and sham stimulation group (n = 6). The patients received 5 sessions of either high-frequency rTMS over the region spanning from the dorsal anterior cingulate cortex (dACC) to medial prefrontal cortex (mPFC) or sham stimulation for 5 days. The severity of apathy was evaluated using the Apathy Scale (AS) and the severity of depression was evaluated using the Quick Inventory of Depressive Symptomatology (QIDS) serially before and after the 5-day protocol. The AS and QIDS scores were significantly improved in the rTMS group, although they were not changed in the sham stimulation group. The degree of change in the AS score was significantly greater in the rTMS group than that in the sham stimulation group. The degree of change in the QIDS score was greater in the rTMS group than that in the sham stimulation group, although the difference was not statistically significant. The application of high frequency rTMS over the dACC and mPFC may be a useful intervention for apathy due to stroke.

Does a combined intervention program of repetitive transcranial magnetic stimulation and intensive occupational therapy affect cognitive function in patients with post-stroke upper limb hemiparesis?

Low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) to the contralesional hemisphere and intensive occupational therapy (iOT) have been shown to contribute to a significant improvement in upper limb hemiparesis in patients with chronic stroke. However, the effect of the combined intervention program of LF-rTMS and iOT on cognitive function is unknown. We retrospectively investigated whether the combined treatment influence patients Trail-Making Test part B (TMT-B) performance, which is a group of easy and inexpensive neuropsychological tests that evaluate several cognitive functions. Twenty-five patients received 11 sessions of LF-rTMS to the contralesional hemisphere and 2 sessions of iOT per day over 15 successive days. Patients with right- and left-sided hemiparesis demonstrated significant improvements in upper limb motor function following the combined intervention program. Only patients with right-sided hemiparesis exhibited improved TMT-B performance following the combined intervention program, and there was a significant negative correlation between Fugl-Meyer Assessment scale total score change and TMT-B performance. The results indicate the possibility that LF-rTMS to the contralesional hemisphere combined with iOT improves the upper limb motor function and cognitive function of patients with right-sided hemiparesis. However, further studies are necessary to elucidate the mechanism of improved cognitive function.

Effects of botulinum toxin A therapy and multidisciplinary rehabilitation on lower limb spasticity classified by spastic muscle echo intensity in post-stroke patients

ABSTRACT Objectives: The purpose of the present study was to investigate retrospectively the relationship between botulinum toxin type A plus multidisciplinary rehabilitation and muscle echo intensity in post-stroke patients with spasticity. The primary aim was to investigate whether the effects of the intervention on the improvement of spasticity depend on muscle echo intensity, and the secondary aim was to investigate whether the motor function of the lower limbs depends on muscle echo intensity. Methods: A 12-day inpatient protocol was designed for 102 post-stroke patients with spasticity due to lower limb paralysis. Muscle echo intensity of the triceps surae muscle was measured by ultrasonography, and the patients were categorized into four groups based on Heckmatt scale grades (Grades I–IV). Results: All four groups classified by the Heckmatt scale showed significant pre-to-post-intervention differences in the knee and ankle modified Ashworth scale scores (p < 0.05). Grades I–III patient groups showed a significant improvement in lower limb motor function following intervention. Grade IV patients did not show a significant improvement in lower limb motor function. Conclusions: We observed significant improvements in the modified Ashworth scale scores after botulinum toxin type A and multidisciplinary rehabilitation therapy on post-stroke patients with spasticity. Although patients with lower muscle echo intensity demonstrated improvements in motor function, the improvement was poor in those with higher muscle echo intensity.

The Effect of Selective Transcranial Magnetic Stimulation with Functional Near-Infrared Spectroscopy and Intensive Speech Therapy on Individuals with Post-Stroke Aphasia

Purpose: To examine the efficacy of selective repetitive transcranial magnetic stimulation (rTMS) therapy guided by functional near-infrared spectroscopy (fNIRS) combined with intensive speech therapy (iST) on post-stroke patients with aphasia. Material and Methods: Eight right-handed patients with aphasia in the chronic stage after stroke were grouped into left and right hemisphere-activated for a language task based on pre-intervention fNIRS. Those with left hemisphere activation received 1-Hz TMS to the right inferior frontal gyrus (RtIFG; low-frequency rTMS [LFS] group), and those with right hemisphere activation received 10-Hz TMS to the RtIFG (high-frequency rTMS [HFS] group). The patients underwent an 11-day program of rTMS and iST. Results: Both groups showed a significant improvement in language function as measured by Standard Language Test of Aphasia (SLTA) total score at post-intervention relative to pre-intervention. Furthermore, the pre-to-post SLTA change scores were not statistically different between the groups. Comparison of pre- and post-intervention fNIRS revealed a resolution of the imbalance of interhemispheric inhibition in the LFS group and activation of the target hemisphere in the HFS group. Conclusions: The administration of fNIRS-guided selective rTMS therapy and iST to post-stroke patients with aphasia induced a significant improvement in language function, with both groups demonstrating a similar degree of improvement.

The Effect of Repeated Botulinum Toxin A Therapy Combined with Intensive Rehabilitation on Lower Limb Spasticity in Post-Stroke Patients

Objectives: This study is a retrospective investigation of the effects of repetitive botulinum toxin A therapy (BoNT-A) and intensive rehabilitation (IR) on lower limb spasticity in post-stroke patients. Methods: Thirty-five post-stroke patients was included in this study and received BoNT-A for the first time. A 12-day inpatient protocol was with 4 cycles of the treatment protocol. The severity of spasticity, motor function and brace status were evaluated. Results: The modified Ashworth Scale (MAS) score of ankle dorsiflexors, range of motion, walking speed and balancing ability were significantly improved after cycle 1. The improvement of spasticity and motor function was persistent through cycles 2–4. One-third of brace users were able to discontinue the use of a brace. All of these brace users showed a forward gait pattern prior to therapy. Conclusions: Repeated BoNT-A combined with IR improved lower limb spasticity in post-stroke patients. Our results suggest that patients who show the forward gait pattern prior to therapy may be able to discontinue the use of their brace after therapy.

Diffusion Tensor Imaging Evaluation of Neural Network Development in Patients Undergoing Therapeutic Repetitive Transcranial Magnetic Stimulation following Stroke

We aimed to investigate plastic changes in cerebral white matter structures using diffusion tensor imaging following a 15-day stroke rehabilitation program. We compared the detection of cerebral plasticity between generalized fractional anisotropy (GFA), a novel tool for investigating white matter structures, and fractional anisotropy (FA). Low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) of 2400 pulses applied to the nonlesional hemisphere and 240 min intensive occupation therapy (OT) daily over 15 days. Motor function was evaluated using the Fugl-Meyer assessment (FMA) and Wolf Motor Function Test (WMFT). Patients underwent diffusion tensor magnetic resonance imaging (MRI) on admission and discharge, from which bilateral FA and GFA values in Brodmann area (BA) 4 and BA6 were calculated. Motor function improved following treatment (p < 0.001). Treatment increased GFA values for both the lesioned and nonlesioned BA4 (p < 0.05, p < 0.001, resp.). Changes in GFA value for BA4 of the lesioned hemisphere were significantly inversely correlated with changes in WMFT scores (R2 = 0.363, p < 0.05). Our findings indicate that the GFA may have a potentially more useful ability than FA to detect changes in white matter structures in areas of fiber intersection for any such future investigations.

Improvement of higher brain dysfunction after brain injury by repetitive transcranial magnetic stimulation and intensive rehabilitation therapy: case report

Repetitive transcranial magnetic stimulation (rTMS) and intensive cognitive rehabilitation (CR) were administered to two patients with cognitive dysfunction following brain injury. The first case was a 67-year-old man who presented with memory dysfunction, attention dysfunction, and decreased insight following diffuse axonal injury. High-frequency rTMS (10 Hz, 2400 pulses/day) targeting the anterior cingulate using a navigation system and CR were administered for 12 days at 1 year from the onset of injury. The patient showed improved neuropsychological performance and activities of daily living. In addition, single photon emission computer tomography with 99mTc-ECD showed improved perfusion in the anterior cingulate gyrus. The second case was a 68-year-old man who presented with dysfunction of memory, attention, and executive function following a cerebral infarction in the middle cerebral artery region within the right hemisphere. This patient received 12 days (except for Sundays) of low-frequency rTMS (1 Hz, 1200 pulses/day) targeting the left dorsolateral prefrontal cortex and the left posterior parietal cortex and CR. Following this intervention, the patient’s neuropsychological performance and activities of daily living improved. Furthermore, single photon emission computer tomography showed changes in perfusion in the rTMS target sites and areas surrounding the targets. We have shown the safety and efficacy of rTMS therapy using a navigation system combined with intensive CR on two patients with cognitive dysfunction following brain injury. In addition, we observed changes in the areas around the rTMS target sites in brain imaging data.

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.