Tomokazu Noma

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.

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.

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.

Novel neuromuscular electrical stimulation system for the upper limbs in chronic stroke patients: a feasibility study.

ObjectiveThe aim of this study was to assess the feasibility of applying a novel neuromuscular electrical stimulation system, targeting shoulder flexion, elbow extension, wrist extension, and individual finger extensions, to improve motor control and function of the hemiparetic upper limbs in chronic stroke patients. DesignFifteen participants with chronic (>1 yr after cerebrovascular accident) upper limb hemiparesis were enrolled. The subjects underwent upper limb training for 60 mins per day, 6 days per week, for 2 wks, using both a shoulder-and-elbow stimulation device and a wrist-and-finger stimulation device developed by the study investigators. Outcomes were assessed using the upper extremity component of the Fugl-Meyer assessment, the action research arm test, and the modified Ashworth scale before and after intervention. ResultsAll patients completed the training successfully using the neuromuscular electrical stimulation system without any safety incidents or other complications reported. Nonparametric statistical analyses indicated significant improvements in the upper extremity component of the Fugl-Meyer assessment and action research arm test scores, both at P < 0.01. There were also significant reductions in modified Ashworth scale scores for the elbow and the wrist flexor, both at P < 0.01. ConclusionsThe multimuscle stimulation approach and method presented in this study seem feasible, and the improvements of upper limb motor control and functional test in chronic stroke patients justify further controlled investigation.

Effects of repetitive facilitative exercise with neuromuscular electrical stimulation, vibratory stimulation and repetitive transcranial magnetic stimulation of the hemiplegic hand in chronic stroke patients

Aim: Repetitive facilitative exercise (RFE) is a developed approach to the rehabilitation of hemiplegia. RFE can be integrated with neuromuscular electrical stimulation (NMES), direct application of vibratory stimulation (DAVS) and repetitive transcranial magnetic stimulation (rTMS). The aims of the present study were to retrospectively compare the effects of RFE and NMES, DAVS with those of RFE and rTMS, and to determine the maximal effect of the combination of RFE with NMES, DAVS, rTMS and pharmacological treatments in stroke patients. Subjects and methods: Thirty-three stroke patients were enrolled and divided into three groups: 15 who received RFE with rTMS (4 min) (TMS4 alone), 9 who received RFE with NMES, DAVS (NMES, DAVS alone) and 9 who received RFE with NMES, DAVS and rTMS (10 min) (rTMS10 + NMES, DAVS). The subjects performed the Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT) before and after the 2-week session. The 18 patients in the NMES, DAVS alone and rTMS10 + NMES, DAVS group underwent the intervention for 4 weeks. Result: There were no significant differences in the increases in the FMA, ARAT scores in the three groups. The FMA or ARAT scores in the NMES, DAVS alone and the rTMS10 + NMES, DAVS group were increased significantly. The FMA and ARAT scores were significantly improved after 4 weeks in the NMES, DAVS alone group. Discussion: RFE with NMES, DAVS may be more effective than RFE with rTMS for the recovery of upper-limb function. Patients who received RFE with NMES, DAVS and pharmacological treatments showed significant functional recovery.

Novel Neuromuscular Electrical Stimulation System for Treatment of Dysphagia after Brain Injury

The purpose of this study was to compare the effects of a novel neuromuscular electrical stimulation (NMES) to the effects of conventional treatment in patients with dysphagia after brain injury. In total, 26 patients were non-randomly divided into an experimental group (n = 12) and a control group (n = 14). The experimental group received NMES intervention followed by conventional treatment, including thermal-tactile stimulation with intensive repetition of a dry-swallow task. The control group received conventional treatment without NMES. NMES at a fixed pulse duration of 50 μs and a frequency of 50 Hz was delivered over the skin areas above the motor point of the target muscles, i.e., the bilateral geniohyoid, mylohyoid/anterior belly of the digastric, and thyrohyoid muscles, using a high-voltage pulsed-current device. The two groups received 40-min treatments once a day, 5 days per week, for 8 weeks. Outcome, assessed before and 8 weeks after treatment, was evaluated with regard to the videofluoroscopic dysphagia scale (VDS), the anterior and superior displacement of the hyoid bone and larynx, and the functional oral intake scale. Both groups exhibited improvement, but the experimental group exhibited more significant improvement in the displacement of the hyoid bone and larynx, VDS-total score, and VDS-pharyngeal score than the control group did. The results suggest that NMES combined with conventional treatment is superior to conventional treatment alone in patients with dysphagia following treatment for brain injury. Further investigations are necessary to examine the effects of NMES in patients with more varied types of diseases.

Stroke Patient with Mirror Movement of the Affected Hand Due to an Ipsilateral Motor Pathway Confirmed by Transcranial Magnetic Stimulation: A Case Report

ABSTRACT A stroke patient with right hemiplegia and mirror movement underwent transcranial magnetic stimulation (TMS) and somatosensory-evoked potential (SEP) testing. The motor-evoked potentials (MEPs) of both abductor pollicis brevis muscles after stimulating the unaffected right hemisphere showed similar latencies, and were potentially produced by corticospinal tracts from the same motor cortex. N20 responses of SEPs were recorded at C4′ after contralateral stimulation of the unaffected left median nerve, but not stimulation of the affected right median nerve. The mirror movements and motor recovery might have utilized an ipsilateral motor pathway between the unaffected hemisphere and the affected hand.