Efficacy and safety of very early mobilization after thrombolysis in acute ischemic stroke: a randomized clinical trial.

BACKGROUND: Stroke has a deleterious impact on human health due to its high incidence, degree of disabling sequelae and mortality, constituting one of the main causes of death and disability worldwide. OBJECTIVES: This study aimed to assess the efficacy and safety of very early mobilization (VEMG) after thrombolysis in functional recovery in patients with acute ischemic stroke. METHODS: The present study was an open, prospective, randomized study, with no blinded outcome, carried out in the stroke unit of a tertiary referral hospital located in Salvador-Bahia, Brazil. The primary outcome was the level of functional independence. Secondary outcomes were functional mobility, balance, complications within 7 days of hospitalization and 90 days after hospital discharge, and length of stay. OUTCOMES: A total of 104 patients with ischemic stroke who received thrombolytic treatment between August 2020 and July 2021 were prospectively recruited to the study. Of these, 51 patients received VEMG within 24 h of the ictus and another 53 patients receiving usual care (UCG) with mobilization 24 h after the ictus. When compared to the usual care, the VEMG group was not associated with a significant reduction in the risk of the primary outcome (relative risk [95% confidence intervals]: 0.74 [0.339-1.607]) or any of the secondary outcomes. CONCLUSION: In this study, the strategy of early mobilization after thrombolysis in ischemic stroke was safe, but without evidence of short-term benefit. Brazilian Registry of Clinical Trials under the registry (registry number: RBR-8bgcs3).

Clinical outcomes report in different brachial plexus injury surgeries: a systematic review.

Brachial plexus injury is a lesion that results in loss of function of the arm, and there are multiple ways of surgically approaching its treatment. Controlled trials that compare all surgical repair strategies and their clinical outcomes have not been performed. A systematic review was conducted to identify all articles that reported clinical outcomes in different surgeries (nerve transfer, nerve graft, neurolysis, end-to-end, multiple interventions, and others). Advanced search in PubMed was performed using the Mesh terms "brachial plexus injury" as the main topic and "surgery" as a subtopic, obtaining a total of 2153 articles. The clinical data for eligibility extraction was focused on collecting motor, sensory, pain, and functional recovery. A statistical analysis was performed to find the superior surgical techniques in terms of motor recovery, through the assessment of heterogeneity between groups, and of relationships between surgery and motor recovery. The frequency and the manner in which clinical outcomes are recording were described. The differences that correspond to the demographics and procedural factors were not statistically significant among groups (p > 0.05). Neurolysis showed the highest proportion of motor recovery (85.18%), with significant results between preoperative and post-operative motor assessment (p = 0.028). The proportion of motor recovery in each group according to the surgical approach differed significantly (X2 = 82.495, p = 0.0001). The motor outcome was the most reported clinical outcome (97.56%), whereas the other clinical outcomes were reported in less than 15% of the included articles. Unexpectedly, neurolysis, a technique displaced by new surgical alternatives such as nerve transfer/graft, demonstrated the highest proportion of motor recovery. Clinical outcomes such as pain, sensory, and functional recovery were infrequently reported. These results introduce the need to re-evaluate neurolysis through comparative clinical trials, as well as to standardize the way in which clinical outcomes are reported.

Robot-Assisted Therapy and Constraint-Induced Movement Therapy for Motor Recovery in Stroke: Results From a Randomized Clinical Trial.

Background: Stroke is one of the leading causes of adult disability, and up to 80% of stroke survivors undergo upper extremity motor dysfunction. Constraint-Induced Movement Therapy (CIMT) and Robot-Assisted Therapy (RT) are used for upper limb stroke rehabilitation. Although CIMT and RT are different techniques, both are beneficial; however, their results must be compared. The objective is to establish the difference between RT and CIMT after a rehabilitation program for chronic stroke patients. Method: This is a randomized clinical trial, registered at ClinicalTrials.gov (ID number NCT02700061), in which patients with stroke received sessions of RT or CIMT protocol, combined with a conventional rehabilitation program for 12 weeks. The primary outcome was measured by Wolf Motor Function Test (WMFT) and Fugl-Meyer Assessment-Upper Limb (FMA-UL). Activities of daily living were also assessed. Results: Fifty one patients with mild to moderate upper limb impairment were enrolled in this trial, 25 women and 26 men, mean age of 60,02 years old (SD 14,48), with 6 to 36 months after stroke onset. Function significantly improved regardless of the treatment group. However, no statistical difference was found between both groups as p-values of the median change of function measured by WMFT and FMA were 0.293 and 0.187, respectively. Conclusion: This study showed that Robotic Therapy (RT) was not different from Constraint-Induced Movement Therapy (CIMT) regardless of the analyzed variables. There was an overall upper limb function, motor recovery, functionality, and activities of daily living improvement regardless of the interventions. At last, the combination of both techniques should be considered in future studies.

Corticospinal vs Rubrospinal Revisited: An Evolutionary Perspective for Sensorimotor Integration.

The knowledge about how different subsystems participate and interplay in sensorimotor control is fundamental to understand motor deficits associated with CNS injury and movement recovery. The role of corticospinal (CS) and rubrospinal (RS) projections in motor control has been extensively studied and compared, and it is clear that both systems are important for skilled movement. However, during phylogeny, the emerging cerebral cortex took a higher hierarchical role controlling rubro-cerebellar circuits. Here, we present anatomical, neurophysiological, and behavioral evidence suggesting that both systems modulate complex segmental neuronal networks in a parallel way, which is important for sensorimotor integration at spinal cord level. We also highlight that, although specializations exist, both systems could be complementary and potentially subserve motor recovery associated with CNS damage.

Immunization with neural-derived peptides increases neurogenesis in rats with chronic spinal cord injury.

AIMS: Immunization with neural-derived peptides (INDP) has demonstrated to be a promising therapy to achieve a regenerative effect in the chronic phase of the spinal cord injury (SCI). Nevertheless, INDP-induced neurogenic effects in the chronic stage of SCI have not been explored. METHODS AND RESULTS: In this study, we analyzed the effect of INDP on both motor and sensitive function recovery; afterward, we assessed neurogenesis and determined the production of cytokines (IL-4, IL-10, and TNF alpha) and neurotrophic factors (BDNF and GAP-43). During the chronic stage of SCI, rats subjected to INDP showed a significant increase in both motor and sensitive recovery when compared to the control group. Moreover, we found a significant increase in neurogenesis, mainly at the central canal and at both the dorsal and ventral horns of INDP-treated animals. Finally, INDP induced significant production of antiinflammatory and regeneration-associated proteins in the chronic stages of SCI. CONCLUSIONS: These findings suggest that INDP has a neurogenic effect that could improve motor and sensitive recovery in the chronic stage of SCI. Moreover, our results also envision the use of INDP as a possible therapeutic strategy for other trauma-related disorders like traumatic brain injury.

Efectos de la espasticidad en la recuperación motora posterior a un ACV / Effects of spasticity on motor recovery after a stroke

Resumen Antecedentes: el proceso rehabilitador orientado a la recuperación motora posterior a un Ataque Cerebro Vascular (ACV), es un proceso complejo asociado con la aparición de signos positivos y negativos posterior a un daño de moto neurona superior (MNS). Objetivo: describir cuales son las efectos de la espasticidad en el proceso rehabilitador posterior a un ACV. Material y método: se realizó una revisión narrativa, a través de un plan de búsqueda por parte de tres revisores, explorando la base de datos PubMed, donde se utilizaron los términos MesH: Spasticity AND Motor Recovery AND Stroke, los límites de búsqueda fueron revisiones y ensayos clínicos en humanos y animales, publicados en los últimos 10 años con textos completos en inglés y español. Resultado: 71 artículos que cumplían con los criterios de búsqueda, fueron identificados, se seleccionaron 21 (16 ensayos clínicos y 5 revisiones), los que fueron analizados a través de las guías Caspe y se utilizaron para la confección de esta revisión. Conclusión: si bien existe amplia evidencia científica, esta no es concluyente, planteando que la espasticidad es fuente de compromiso funcional y discapacidad, pero no siempre es perjudicial, ya sus efectos pueden ser beneficiosos y en ocasiones no necesita tratamiento.

Background and Aim: The rehabilitation process oriented to motor recovery after a stroke is a complex process associated with the appearance of positive and negative signs after motor neuron damage. The aim was to describe the effects of spasticity in the rehabilitation process after a stroke. Methods: Three reviewers, exploring the PubMed database, carried out, a narrative review through a search plan, the terms MesH: Spasticity AND Motor Recovery AND Stroke were used; the search limits were reviews and clinical trials in humans and animals, published in the last 10 years with full texts in English and Spanish. Results: Seventy-one articles that met the search criteria were identified, 21 were selected (16 clinical trials and 5 reviews), which were analyzed through the CASPE guide and used for the preparation of this review. Conclusion: Although there is broad scientific evidence, this is not conclusive, stating that spasticity is a source of functional commitment and disability, but it is not always harmful, and its effects can be beneficial and sometimes do not need treatment.

Estimulación térmica para la recuperación motora pos accidente cerebrovascular: revisión sistemática / Thermal Stimulation to motor recovery after stroke; Systematic Review

Objetivo: determinar si existe evidencia científica que avale la efectividad de la estimulación térmica (ET) en la recuperación de la función motora, cuando se adiciona a un tratamiento convencional en pacientes pos accidente cerebrovascular (ACV). Estratégia de búsqueda: se incluyeron en la búsqueda estudios clínicos aleatorizados, las bases de datos usadas fueron: Medline, PEDro, Lilacs, Central, Cinahl y Rehabilitation & Sport Medicine Source. Selección de estudios: se seleccionaron cinco artículos que cumplían con nuestros criterios de elegibilidad y se evaluó el riesgo de sesgo según el método de Cochrane. Síntesis de resultados: todos los estudios muestran que la ET en combinación a un programa de rehabilitación física mejora significativamente (p<0,05) a corto plazo el movimiento y función. Conclusión: en pacientes con ACV agudo moderado a severo, existe evidencia a corto plazo que adicionar ET a un programa de rehabilitación física convencional facilita la recuperación motora comparado con un programa de visita.

Aim: Determine if there is scientific evidence supporting the effectiveness of Thermal Stimulation (TS) on recovery of motor function, when added to conventional therapy in patients with stroke. search strategy: Included only Randomized Clinical Trials, databases were used: Medline, PEDro, Lilacs, Central, Cinahl and Rehabilitation & Sport Medicine Source. Selection of Studies: Five studies that met our eligibility criteria and the risk of bias are evaluated according to the method of Cochrane. Summary of results: All studies show that TS in combination to a physical rehabilitation program significantly improved (p <0.05) in the short-term movement and function. Conclusion: In acute stroke patients with moderate to severe, there is evidence that short-term TS added to a conventional physical rehabilitation program facilitate motor recovery compared to a visit program.

Neurophysiologic predictors of motor function in stroke.

PURPOSE: Understanding the neural mechanisms of stroke recovery is of paramount importance for neurorehabilitation. METHODS: For this purpose, we analyzed several TMS and EEG variables and their association with motor recovery. Thirty-five subjects with chronic stroke were recruited. The neurophysiological examination included assessments by transcranial magnetic stimulation (TMS), intra- and inter-hemispheric EEG coherence in different frequency bands (e.g. alpha (8-13 Hz)) as determined by quantitative electroencephalography (qEEG). Motor function was measured by Fugl-Meyer (FM). Multiple univariate and multivariate linear regression analyses were performed to identify the predictors for FM. RESULTS: Multivariate analyses, showed a significant interaction effect of motor threshold (MT) in the lesioned hemisphere and beta coherence in the unlesioned hemisphere. This interaction suggests that higher beta activity in the unlesioned hemisphere strengthens the negative association between MT and FM scores. CONCLUSIONS: Our results suggest that MT in the lesioned hemisphere is the strongest predictors of motor recovery after stroke. Moreover, cortical activity in the unlesioned hemisphere measured by qEEG provides additional information, specifying the association between MT and FM scores. Therefore, complementary application of EEG and TMS can help constitute a better model of the lesioned and the unlesioned hemispheres that supports the importance of bihemispheric activity in recovery.

Lewis, Fischer 344, and sprague-dawley rats display differences in lipid peroxidation, motor recovery, and rubrospinal tract preservation after spinal cord injury.

The rat is the most common animal model for the preclinical validation of neuroprotective therapies in spinal cord injury (SCI). Lipid peroxidation (LP) is a hallmark of the damage triggered after SCI. Free radicals react with fatty acids causing cellular and membrane disruption. LP accounts for a considerable amount of neuronal cell death after SCI. To better understand the implications of inbred and outbred rat strain selection on preclinical SCI research, we evaluated LP after laminectomy sham surgery and a severe contusion of the T9 spinal cord in female Sprague-Dawley (SPD), Lewis (LEW), and Fischer 344 (F344) rats. Further analysis included locomotor recovery using the Basso, Beattie, and Bresnahan (BBB) scale and retrograde rubrospinal tract tracing. LEW had the highest levels of LP products 72 h after sham surgery and SCI, significantly different from both F344 and SPD. SPD rats had the fastest functional recovery and highest BBB scores; these were not significantly different to F344. However, LEW rats achieved the lowest BBB scores throughout the 2-month follow-up, yielding significant differences when compared to SPD and F344. To see if the improvement in locomotion was secondary to an increase in axon survival, we evaluated rubrospinal neurons (RSNs) via retrograde labeling of the rubrospinal tract and quantified cells at the red nuclei. The highest numbers of RSNs were observed in SPD rats then F344; the lowest counts were seen in LEW rats. The BBB scores significantly correlated with the amount of positively stained RSN in the red nuclei. It is critical to identify interstrain variations as a potential confound in preclinical research. Multi-strain validation of neuroprotective therapies may increase chances of successful translation.

Respuesta eléctrica de la corteza contralateral al área de infarto en pacientes con enfermedad cerebrovascular isquémica / Electric response of the contralateral cortex to the myocardial infarction area in patients with ischemic cerebrovascular disease

Se realizó un estudio observacional, descriptivo, longitudinal y prospectivo de 28 pacientes con enfermedad cerebrovascular isquémica, ingresados en el Servicio de Enfermedades Cerebrovasculares del Hospital General Docente "Dr. Juan Bruno Zayas Alfonso" de Santiago de Cuba, desde enero hasta diciembre del 2011, con vistas a evaluar la respuesta eléctrica de la corteza cerebral contralateral al área de infarto y su papel en la recuperación motora de los afectados hemipléjicos por la lesión. La valoración de la actividad eléctrica se efectuó mediante el análisis cuantitativo del electroencefalograma digital y la de la recuperación funcional, por el índice de Barthel. En la serie la edad media fue de 67,2 años ± 2, predominó el sexo masculino y todos los pacientes presentaron alteración de la actividad eléctrica cortical, de los cuales, 39,3 % la manifestaba en el hemisferio contralateral al área de infarto, con una peor recuperación motora a los 6 meses de evolución. Por último, la afectación eléctrica de la corteza cerebral contralateral al área de infarto constituye una manifestación observada frecuentemente en pacientes con enfermedades cerebrovasculares isquémicas, lo que influye de manera negativa en su recuperación motora.

An observational, descriptive, longitudinal and prospective study of 28 patients with ischemic cerebrovascular disease, admitted in the Cerebrovascular Diseases Service of "Dr. Juan Bruno Zayas Alfonso" Teaching General Hospital in Santiago de Cuba was carried out from January to December, 2011, with the objective of evaluating the electric response from the contralateral cerebral cortex to the myocardial infarction area and its role in the motor recovery of the affected hemiplegic patients. The evaluation of the electric activity was made by means of the quantitative analysis of the digital electroencephalogram, and that of the functional recovery through the Barthel index. In the series the mean age was of 67.2 years ± 2, the male sex prevailed and all the patients presented changes of the electrical cortical activity, of which, 39.3% manifested it in the contralateral hemisphere to the myocardial infarction area, with a worse motor recovery after 6 months of the clinical course. Lastly, the electric damage of the contralateral cerebral cortex to the myocardial infarction area constitutes a frequently observed manifestation in patients with ischemic cerebrovascular diseases, what influences in a negative way in their motor recovery.

Recuperación motora y funcional en pacientes con afasia secundaria a un ictus / Motor and functional recovery in patients with aphasia secondary to stroke

Introducción: se realizó un estudio observacional y prospectivo. Objetivo: evaluar la recuperación motora y funcional en pacientes con afasia secundaria a un ictus, incorporados al Programa de Restauración Neurológica del Centro Internacional de Restauración Neurológica. Métodos: se estudiaron 132 pacientes durante los años 2007-2012, en tratamiento durante 4 sem. Se agruparon según la presencia o no de afasia. Se compararon ambos grupos, según la recuperación motora y funcional, mediante la Escala Escandinava del Ictus y el índice de Barthel, respectivamente. Resultados: los grupos estudiados no presentaron diferencias significativas en cuanto a edad, sexo, condición motora y funcional inicial, tiempo de evolución y factores de riesgo vascular. La recuperación motora resultó significativa en ambos grupos (p=0,00), aunque el porcentaje de recuperación motora resultó superior en los pacientes con ictus no afásicos. La recuperación funcional resultó significativa en ambos grupos (p=0,00), existió una recuperación cualitativamente superior en el ictus no afásico donde se identificó una mejora en las habilidades manipulativas (p=0,00), que no resultó significativa en el ictus con afasia. Conclusión: ambos grupos se beneficiaron con el tratamiento aplicado, sin embargo, los pacientes afásicos experimentaron menor recuperación motora y funcional, en comparación con los pacientes no afásicos

Introduction: an observational and prospective study was carried out. Objective: to evaluate motor and functional recovery in patients with aphasia secondary to a stroke, who were included in the Neurological Restoration Program of International Center of Neurological Restoration. Methods: 132 patients were studied from 2007 to 2012; they were in treatment during 4 weeks and they were grouped according to the presence or absence of aphasia. Comparisons between both groups were carried out according to their motor and functional recovery by using Scandinavian Stroke Scale and Barthel Index respectively. Results: significant differences were not found in the studied groups concerning age, sex, motor and functional initial conditions, evolution time and vascular risk factors. Motor recovery was significant in both groups (p=0,00), although motor recovery percent was higher in the patients with non aphasic stroke. Functional recovery was significant in both groups (p=0,00), a higher quality recovery was seen in non aphasic stroke patients, and improvement was identified in hand abilities (p=0,00) which was not significant in stroke with aphasia. Conclusion: both groups were benefitted with the applied treatment, however, the aphasic patients experienced a lower motor and functional recovery, in comparison with the non aphasic patients

La neurorrehabilitación como alternativa esencial en el abordaje terapéutico de las ataxias cerebelosas / Neurorehabilitation as an essential alternative in the therapeutic approach to cerebellar ataxias

Introducción: la ataxia cerebelosa constituye uno de los trastornos motores más complejos asociada a enfermedades neurológicas. Objetivo: destacar la efectividad de la neurorrehabilitación en la reducción del deterioro de las funciones motoras en pacientes atáxicos. Fuente de datos: revisión de la literatura publicada sin límite de fecha y hasta septiembre del 2012, en las bases de datos MedLine, Embase, Hinari, Lilacs y SciELO; estrategia de búsqueda con vocabulario controlado y la inclusión de las siguientes palabras clave: ataxia, neurorrehabilitación, recuperación motora. Se tomaron los criterios de especialistas en neurorrehabilitación del Centro internacional de Restauración Neurológica. Resultados: la terapia física es el factor esencial del proceso de rehabilitación en los pacientes con ataxia, incluye adiestramiento, ejercicios y manipulación física del cuerpo del paciente con la intención de restaurar el movimiento, el equilibrio y la coordinación. Las estrategias terapéuticas en los pacientes con ataxia cerebelosa requieren un enfoque intensivo e interdisciplinario. La recuperación motora en ellos está muy relacionada con el incremento de la capacidad de fuerza después de la aplicación de programas de rehabilitación. En la medida en que aumentan los niveles de fuerza, comienzan a aparecer signos de recuperación en el comportamiento motor, desde actividades tan simples como realizar transferencias de una posición a otra, hasta las más complejas, como es caminar. Conclusiones: el comportamiento motor de los pacientes con ataxia cerebelosa se modifica significativamente con el empleo de la neurorrehabilitación, con registro de mejorías notables en los trastornos de la postura y la marcha, el movimiento y la fuerza

Introduction: cerebellar ataxia is one of the most complex motor impairments derived from neurological diseases. Objective: to highlight the effectiveness of neurorehabilitation of the motor functions in patients with cerebellar ataxia. Data source: systematic literature review of documents published up to September 2012 in MEDLINE, EMBASE, HINARI LILACS and SciELO, search strategy using controlled vocabulary and the keywords ataxia, neurorehabilitation and motor recovery. Several criteria from specialists in neurorehabilitation in the International Center of Neurological Restoration were consulted in and taken into consideration. Results: the physical therapy is the essential factor of the rehabilitation process for ataxic patients and includes training, exercising and physical handling of the patient's body aimed at recovering movement, balance and coordination. The therapeutic strategies for patients with cerebellar ataxia require an intensive and interdisciplinary approach. Motor function recovery was very much related to significant strength increase after implementation of the rehab program. As the strength levels rise, there begins to appear signs of recovery in the patient's motor behavior that covers moving from one position to another including turning up to the most complex ones like walking. Conclusions: the motor behavior of patients suffering cerebellar ataxia can be significantly modified with neurorehabilitation, leading to significant reduction on posture, gait, movement and strength impairments

Modulation of inhibitory systems to enhance motor rehabilitation: insights for the use of noninvasive brain stimulation

Motor impairment following stroke is a leading cause of disability in adults. Despite advances in motor rehabilitation techniques, many adult stroke survivors never approach full functional recovery. Intriguingly, children exhibit better rehabilitation outcomes when compared to adults suffering from comparable brain injuries, yet the reasons for this remain unclear. A common explanation is that neuroplasticity in adults is substantially limited following stroke, thus constraining the brain's ability to reorganize in response to neurological insult. This explanation, however, does not suffice for there is much evidence suggesting that neuroplasticity in adults is not limited following stroke. We hypothesize that diminished functional recovery in adults is in part due to inhibitory neuronal interactions, such as transcallosal inhibition, that serve to optimize motor performance as the brain matures. Following stroke, these inhibitory interactions pose rigid barriers to recovery by inhibiting activity in the affected regions and hindering recruitment of compensatory pathways. In contrast, children exhibit better rehabilitation outcomes in part because they have not fully developed the inhibitory interactions that impede functional recovery in adults. We suggest that noninvasive brain stimulation can be used in the context of motor rehabilitation following stroke to reduce the effects of existing inhibitory connections, effectively returning the brain to a state that is more amenable to rehabilitation. We conclude by discussing further research to explore this hypothesis and its implications.(AU)

Modulation of inhibitory systems to enhance motor rehabilitation: insights for the use of noninvasive brain stimulation

Motor impairment following stroke is a leading cause of disability in adults. Despite advances in motor rehabilitation techniques, many adult stroke survivors never approach full functional recovery. Intriguingly, children exhibit better rehabilitation outcomes when compared to adults suffering from comparable brain injuries, yet the reasons for this remain unclear. A common explanation is that neuroplasticity in adults is substantially limited following stroke, thus constraining the brain's ability to reorganize in response to neurological insult. This explanation, however, does not suffice for there is much evidence suggesting that neuroplasticity in adults is not limited following stroke. We hypothesize that diminished functional recovery in adults is in part due to inhibitory neuronal interactions, such as transcallosal inhibition, that serve to optimize motor performance as the brain matures. Following stroke, these inhibitory interactions pose rigid barriers to recovery by inhibiting activity in the affected regions and hindering recruitment of compensatory pathways. In contrast, children exhibit better rehabilitation outcomes in part because they have not fully developed the inhibitory interactions that impede functional recovery in adults. We suggest that noninvasive brain stimulation can be used in the context of motor rehabilitation following stroke to reduce the effects of existing inhibitory connections, effectively returning the brain to a state that is more amenable to rehabilitation. We conclude by discussing further research to explore this hypothesis and its implications