Takatsugu Okamoto

A multi-center study on low-frequency rTMS combined with intensive occupational therapy for upper limb hemiparesis in post-stroke patients

BackgroundBoth low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) have been recently reported to be clinically beneficial for post-stroke patients with upper limb hemiparesis. Based on these reports, we developed an inpatient combination protocol of these two modalities for the treatment of such patients. The aims of this pilot study were to confirm the safety and feasibility of the protocol in a large number of patients from different institutions, and identify predictors of the clinical response to the treatment.MethodsThe study subjects were 204 post-stroke patients with upper limb hemiparesis (mean age at admission 58.5 ± 13.4 years, mean time after stroke 5.0 ± 4.5 years, ± SD) from five institutions in Japan. During 15-day hospitalization, each patient received 22 treatment sessions of 20-min low-frequency rTMS and 120-min intensive OT daily. Low-frequency rTMS of 1 Hz was applied to the contralesional hemisphere over the primary motor area. The intensive OT, consisting of 60-min one-to-one training and 60-min self-exercise, was provided after the application of low-frequency rTMS. Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) were performed serially. The physiatrists and occupational therapists involved in this study received training prior to the study to standardize the therapeutic protocol.ResultsAll patients completed the protocol without any adverse effects. The FMA score increased and WMFT log performance time decreased significantly at discharge, relative to the respective values at admission (change in FMA score: median at admission, 47 points; median at discharge, 51 points; p < 0.001. change in WMFT log performance time: median at admission, 3.23; median at discharge, 2.51; p < 0.001). These changes were persistently seen up to 4 weeks after discharge in 79 patients. Linear regression analysis found no significant relationship between baseline parameters and indexes of improvement in motor function.ConclusionsThe 15-day inpatient rTMS plus OT protocol is a safe, feasible, and clinically useful neurorehabilitative intervention for post-stroke patients with upper limb hemiparesis. The response to the treatment was not influenced by age or time after stroke onset. The efficacy of the intervention should be confirmed in a randomized controlled study including a control group.

EFFECTIVENESS OF A COMPREHENSIVE DAY TREATMENT PROGRAM FOR REHABILITATION OF PATIENTS WITH ACQUIRED BRAIN INJURY IN JAPAN

OBJECTIVE To assess the effectiveness of a day treatment program with a comprehensive team approach for treating outpatients with acquired brain injury, which is offered by the Kanagawa Rehabilitation Hospital. DESIGN Non-randomized controlled study. SUBJECTS Twenty-five program graduates and 12 control patients with acquired brain injury. METHODS A prospective study using 25 brain-injured patients with cognitive dysfunction who were provided with a comprehensive day treatment program at Kanagawa Rehabilitation Hospital. The 25 enrolled patients had treatment sessions lasting 2-4 hours for 2 days a week over a 3-6-month period. Functional Independence Measure/Functional Assessment Measure (FIM/FAM) and the Community Integration Questionnaire (CIQ) were administered before and after the program to compare outcomes between the 25 program participants and the 12 control patients who did not receive the day treatment program. RESULTS Significant improvements in speech intelligibility, problem solving, memory, attention and social integration scores in the FIM/FAM and scores in social integration and productive activity in the CIQ were evident in the enrolled subjects. In addition, 9 of the 25 patients returned to work or school. CONCLUSION These results demonstrate the effectiveness of this program in helping to rehabilitate patients with acquired brain injury.

Cerebral blood flow in patients with diffuse axonal injury--examination of the easy Z-score imaging system utility.

To evaluate the utility of easy Z‐score imaging system (eZIS) in 27 diffuse axonal injury (DAI) cases. Twenty‐seven DAI patients were examined with an magnetic resonance imaging (MRI) T2* sequence and with eZIS (seven women, 20 men; age range, 19–35 years; median age: 26.6 years). In this investigation, we excluded patients who exhibited complications such as acute subdural hematoma, acute epidural hematoma, intracerebral hematoma, or brain contusion. We examined the neuropsychological tests and correlated with findings from MRI/eZIS. Furthermore, we evaluated the degree of ventricular enlargement in the bifrontal cerebroventricular index (CVI). Patients were divided into two groups: the enlargement group (bifrontal CVI > 35%, 12 patients) and the non‐enlargement group (bifrontal CVI < 35%, 15 patients). All of the patients showed cognitive deficits as observed from the neuropsycological test results. Fifteen out of 27 patients by MRI T1/T2 weighted images and fluid attenuated inversion recovery (FLAIR), 22 out of 27 patients by MRI T2* weighted images and 24 out of 27 patients by eZIS showed abnormal findings. In MRI T2* weighted imaging, the white matter from the frontal lobe, corpus callosum, and brainstem showed abnormal findings. With eZIS, 22 patients (81.5%) showed blood flow degradation in the frontal lobe, and 12 patients (44.4%) in cingulate gyrus. In the enlargement group, Functional Independence Measure, Mini‐Mental State Examination, Verbal IQ (VIQ)/Full Scale IQ (FIQ), Trail Making Test‐B (TMT‐B), and Non‐paired of Miyake Paired Test were significantly lower. Amongst 12 patients without ventricular enlargement who had no abnormal findings in MRI T1/T2 weighted images and FLAIR, abnormal findings were detectable in seven patients with MRI T2* weighted imaging and to 10 patients with eZIS. Results of the MRI examination alone cannot fully explain DAI frontal lobe dysfunction. However, addition of the eZIS‐assisted analysis derived from the single photon emission computed tomography (SPECT) data enabled us to understand regions where blood flow was decreased, i.e., where neuronal functions conceivably might be reduced.

Association Between 7 Days Per Week Rehabilitation and Functional Recovery of Patients With Acute Stroke: A Retrospective Cohort Study Based on the Japan Rehabilitation Database

OBJECTIVE To test the hypothesis that functional outcome of patients with stroke who receive 7d/wk of rehabilitation is generally better than that of similar patients who undergo 5 or 6d/wk of rehabilitation. DESIGN Retrospective cohort study. SETTING Acute hospitals. PARTICIPANTS From the Japan Rehabilitation Database, which includes data on 8033 patients with acute stroke collected between January 2005 and December 2013, we included 3072 patients with stroke who were admitted to the acute hospitals and received 7d/wk of rehabilitation. INTERVENTION Seven days per week of rehabilitation was defined as rehabilitation therapy administrated by a physical or occupational therapist on every weekday, Saturday, and Sunday. MAIN OUTCOME MEASURE Favorable functional independence in daily living, defined as a modified Rankin Scale score of 0 to 2 at the time of discharge. RESULTS A total of 1075 (35.0%) patients received 7d/wk of rehabilitation. Univariate analysis demonstrated a significant difference in favorable functional recovery between the 7d/wk rehabilitation group and non-7d/wk rehabilitation group (43.3% vs 37.6%, respectively; P=.002). Multivariate logistic regression analysis using the generalized estimating equations method showed that 7d/wk of rehabilitation was independently associated with favorable functional recovery. CONCLUSIONS Our cohort analysis demonstrated that 7d/wk of rehabilitation in early rehabilitation for patients with acute stroke can lead to functional recovery.

Examination by Near-Infrared Spectroscopy for Evaluation of Piano Performance as a Frontal Lobe Activation Task

The purpose of this study was to reveal the activation of the frontal lobe in piano performance by the use of near-infrared spectroscopy. Participants wereseven healthy volunteer music college students. The results of the examination showed a tendency towards an increase in total hemoglobin volume over a wider area in the frontal part of the brain during an appropriate piano task compared with an easy piano task or the Keio version of the Wisconsin Card Sorting Test. The results suggest that piano performance is recognized as a frontal lobe-activating task and that performance of an appropriate piano task can be expected to elicit wider activation of the frontal lobe than an easy one.

Validity and reliability of the Japanese version of the FIM + FAM in patients with cerebrovascular accident

Abstract Background and aim: The study aim was to investigate the validity and reliability of the Functional Independence Measure and Functional Assessment Measure (FIM + FAM), which is unfamiliar in Japan, by using its Japanese version (FIM + FAM-j) in patients with cerebrovascular accident (CVA). Material and methods: Forty-two CVA patients participated. Criterion validity was examined by correlating the full scale and subscales of FIM + FAM-j with several well-established measurements using Spearman’s correlation coefficient. Reliability was evaluated by internal consistency (tested by Cronbach’s alpha coefficient) and intra-rater reliability (tested by Kendall’s tau correlation coefficient). Results: Good-to-excellent criterion validity was found between the full scale and motor subscales of the FIM + FAM-j and the Barthel Index, National Institutes of Health Stroke Scale, modified Rankin Scale, and lower extremity Brunnstrom Recovery Stage. High internal consistency was observed within the full-scale FIM + FAM-j and the motor and cognitive subscales (Cronbach’s alphas were 0.968, 0.954, and 0.948, respectively). Additionally, good intra-rater reliability was observed within the full scale and motor subscales, and excellent reliability for the cognitive subscales (taus were 0.83, 0.80, and 0.98, respectively). Conclusion and significance: This study showed that the FIM + FAM-j demonstrated acceptable levels of validity and reliability when used for CVA as a measure of disability.

Effect of baseline brain activity on response to low-frequency rTMS/intensive occupational therapy in poststroke patients with upper limb hemiparesis: A near-infrared spectroscopy study

Abstract Background: The beneficial effects of the combination therapy of low-frequency repetitive transcranial magnetic stimulation of nonlesional hemisphere and intensive occupational therapy (LF-rTMS/OT) on upper limb hemiparesis have been well established in poststroke patients. However, there is no information on the effect of brain activity on LF-rTMS/OT treatment outcome. Method: A total of 59 poststroke patients with upper limb hemiparesis received 15-day LF-rTMS/OT. Motor function of the affected upper limb was evaluated before and after the treatment. We also conducted functional near-infrared spectroscopy (fNIRS) before the treatment and calculated the laterality index (LI) based on the change in oxy-hemoglobin in the primary sensorimotor cortex and supplementary motor cortex. The correlation between LI before LF-rTMS/OT and observed improvement in upper limb motor function was analyzed. Results: Motor recovery was significantly more pronounced in patients with unaffected hemisphere dominance in both hemispheres (LI of −1 to 0) than in those with affected hemisphere dominance in the lesional hemisphere (LI of 0 to 1). There was a significant negative correlation between LI and improvement in upper limb motor function. Discussion: The results demonstrated that patients with a shift in brain activity to the noninjured cerebral cortex exhibited better motor recovery following LF-rTMS/OT. The findings suggest that evaluation of brain asymmetry before LF-rTMS/OT with fNIRS can help predict the response to LF-rTMS/OT.

Low-Frequency rTMS and Intensive Occupational Therapy Improve Upper Limb Motor Function and Cortical Reorganization Assessed by Functional Near-Infrared Spectroscopy in a Subacute Stroke Patient

There is still no agreement on the most suitable time and modality for application of repetitive transcranial magnetic stimulation (rTMS) to improve motor recovery in subacute stroke patients. The underlying mechanism of motor recovery following low-frequency rTMS is considered to be modulation of the interhemispheric asymmetry. On the other hand, the cortical balance of brain activity during the acute to chronic phase of stroke is reported to be unstable. Therefore, we conducted this study to clarify the time course of the interhemispheric asymmetry and the effect of application of low-frequency rTMS combined with occupational therapy on motor recovery and cortical imbalance of brain activity in a subacute stroke patient. The interhemispheric asymmetry in this patient with new-onset subcortical cerebral infarction and upper limb hemiparesis was evaluated longitudinally using functional near-infrared spectroscopy with finger tasks. A nonlesional hemisphere-dominant activation pattern was observed on day 28 after onset. On day 56 after onset, a bilaterally eminent activation pattern was observed. Low-frequency rTMS was applied on day 109 after stroke onset when the cortical activity shifted to the nonlesional hemisphere. The treatment resulted in improvement in motor function of the affected upper limb and a shift in brain activation to the lesional hemisphere. Our report is the first to describe the therapeutic benefits of low-frequency rTMS as assessed by longitudinal neuroimaging for functional recovery and interhemispheric asymmetry in a subacute stroke patient.

Utility of the Revised Version of the Ability for Basic Movement Scale in Predicting Ambulation during Rehabilitation in Poststroke Patients

OBJECTIVE This study aims to test the hypothesis that the Revised Version of the Ability for Basic Movement Scale (ABMSII) can predict ambulation during rehabilitation in poststroke patients. SUBJECTS AND METHODS The study included first-ever stroke patients who were admitted to the rehabilitation ward and were dependent in walking. ABMSII scores were assessed by physical therapists on admission to the hospital. Functional ambulation category (FAC) was assessed every 2 weeks during hospitalization. The primary outcome was independent ambulation, defined as 4 points or higher on the FAC. RESULTS After setting the inclusion criteria, data of 374 stroke patients (mean age: 70 years, 153 women) were eligible for the analysis. Of these, 193 patients achieved independent ambulation during hospitalization. The ABMSII score was significantly higher in the patients who regained independent walking ability than in those who required assistance in walking. Based on receiver operating characteristic curve analysis, an ABMSII score of 16 points or higher had a sensitivity of 93% and a specificity of 71%. Kaplan-Meier curve analysis after log-rank test demonstrated a significantly higher event rate in patients with an ABMSII score of 16 or higher compared to those with an ABMSII score lower than 16. Univariate and multivariate Cox regression analyses identified the ABMSII score as a significant and independent predictor of ambulation during rehabilitation. CONCLUSION Our results suggest that the ABMSII score is a potentially useful tool to predict ambulation during rehabilitation in poststroke patients.

Responsiveness of the functioning and disability parts of the International Classification of Functioning, Disability, and Health core sets in postacute stroke patients

To study the responsiveness of the International Classification of Functioning, Disability, and Health (ICF) core set with respect to human functioning and disability in stroke patients. Postacute stroke patients who were admitted to the convalescent rehabilitation wards were included in this observational cohort study. The comprehensive ICF core set for neurological conditions for postacute care and the ICF rehabilitation set were evaluated at admission and discharge using five-grade qualifiers. Extension indexes were calculated for entire two ICF core sets. Responsiveness was measured as change in the extension indexes in the ICF core sets. The correlation between changes in ICF core sets and improvement in the Functional Independence Measure (FIM) was analyzed using Spearman’s correlation coefficient. The study included 108 poststroke patients (49 women, mean age 70.8 years, mean FIM score improvement: 23.0). The mean percentage of categories that showed changes with at least one qualifier level was 19.5% in the comprehensive ICF core set for neurological conditions for postacute care and 35.9% in the ICF rehabilitation set. Effect sizes in each ICF core set were moderate to large (0.79–0.80). Improvement in the two ICF core sets correlated significantly with changes in the FIM score. Our results indicate that functioning and disability parts of these two ICF core sets can detect changes in functioning and disability in patients who receive an inpatient rehabilitation program for postacute stroke.