Local muscle injection of botulinum toxin type a synergistically improves the beneficial effects of repetitive transcranial magnetic stimulation and intensive occupational therapy in post-stroke patients with spastic upper limb hemiparesis.

BACKGROUND: The purpose of this study was to determine whether local injection of botulinum toxin type A (BoNT-A) into the spastic muscles has any added benefits to repetitive transcranial magnetic stimulation (RTMS)/occupational therapy (OT) in patients with spastic upper limb hemiparesis. METHODS: The study subjects of 80 post-stroke patients with spastic upper limb hemiparesis (age: 60.2 ± 13.0 years, time after stroke: 55.3 ± 43.0 months), were divided into the BoNT-A plus RTMS/OT group and RTMS/OT group. BoNT-A was injected into the spastic muscles (total dose: 240 units) before RTMS/OT. The latter included 12 sessions of 40 min RTMS over the non-lesional hemisphere and 240-min intensive OT daily over 15 days. Spasticity was evaluated by the modified Ashworth scale (MAS) and the motor function of the affected upper limb was evaluated serially with Fugl-Meyer Assessment and Wolf Motor Function Tests. RESULTS: Both groups showed significant improvements in spasticity and motor function. The addition of BoNT-A resulted in better improvement in FMA score and MAS of finger flexor muscles (p < 0.05). CONCLUSIONS: The triple-element protocol of local injection of BoNT-A into spastic finger muscles, RTMS and intensive OT, is a promising therapeutic program for post-stroke spastic upper limb hemiparesis, although its significance should be confirmed in randomized, placebo-controlled trials.

Continuous theta-burst stimulation combined with occupational therapy for upper limb hemiparesis after stroke: a preliminary study.

The purpose of this study was to assess the safety, feasibility and efficacy of continuous theta-burst stimulation (cTBS) combined with intensive occupational therapy (OT) for upper limb hemiparesis after stroke. Ten patients with history of stroke and upper limb hemiparesis (age 62.0 ± 11.1 years, time since stroke 95.7 ± 70.2 months, mean ± SD) were studied. Each patient received 13 sessions, each comprising 160 s of cTBS applied to the skull on the area of the non-lesional hemisphere (using a 70-mm figure-8 coil, three pulse bursts at 50 Hz, repeated every 200 ms, i.e., 5 Hz, with total stimulation of 2,400 pulses), followed by intensive OT (comprising 120-min one-to-one training and 120-min self-training) during 15-day hospitalization. The motor function of the affected upper limb was evaluated by Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) on the days of admission and discharge. All patients completed the 15-day protocol without any adverse effects. Treatment significantly increased the FMA score (from 46.6 ± 8.7 to 51.6 ± 8.2 points, p < 0.01) and shortened the log performance time of WMFT (from 2.5 ± 1.1 to 2.2 ± 1.2 s, p < 0.01). The 15-day protocol of cTBS combined with intensive OT is a safe and potentially useful therapeutic modality for upper limb hemiparesis after stroke.

Bihemispheric repetitive transcranial magnetic stimulation combined with intensive occupational therapy for upper limb hemiparesis after stroke: a preliminary study.

We investigated the safety, feasibility, and efficacy of the combination of bihemispheric repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) for upper limb hemiparesis in poststroke patients. The study participants were eight poststroke patients with upper limb hemiparesis (age at intervention: 62.8±4.9 years, time after stroke: 84.3±87.2 months, mean±SD). During 15 days of hospitalization, each patient received 10 sessions of 40-min bihemispheric rTMS and 240-min intensive OT (120-min one-to-one training and 120-min self-training). One session of bihemispheric rTMS comprised the application of both 1 and 10 Hz rTMS (2000 stimuli for each hemisphere). The Fugl-Meyer Assessment, Wolf Motor Function Test, and the Modified Ashworth Scale were administered on the day of admission and at discharge. All patients completed the treatment without any adverse effects. Motor function of the affected upper limb improved significantly, on the basis of changes in Fugl-Meyer Assessment and Wolf Motor Function Test (P<0.05, each). A significant decrease in the Modified Ashworth Scale score was noted in the elbow, wrist, and finger flexors of the affected upper limb (P<0.05, each). The combination of bihemispheric rTMS and intensive OT was safe and feasible therapy for poststroke hemiparetic patients, and improved motor function of the hemiparetic upper limb in poststroke patients. The findings provide a new avenue for the treatment of patients with poststroke hemiparesis.

Functional cortical reorganization after low-frequency repetitive transcranial magnetic stimulation plus intensive occupational therapy for upper limb hemiparesis: evaluation by functional magnetic resonance imaging in poststroke patients.

BACKGROUND: Low-frequency repetitive transcranial magnetic stimulation of the nonlesional hemisphere combined with occupational therapy significantly improves motor function of the affected upper limb in poststroke hemiparetic patients, but the recovery mechanism remains unclear. AIMS: To investigate the recovery mechanism using functional magnetic resonance imaging. METHODS: Forty-seven poststroke hemiparetic patients were hospitalized to receive 12 sessions of 40-min low-frequency repetitive transcranial magnetic stimulation over the nonlesional hemisphere and daily occupational therapy for 15 days. Motor function was evaluated with the Fugl-Meyer Assessment and Wolf Motor Function Test. The functional magnetic resonance imaging with motor tasks was performed at admission and discharge. The laterality index of activated voxel number in Brodmann areas 4 and 6 on functional magnetic resonance imaging was calculated (laterality index range of -1 to +1). Patients were divided into two groups based on functional magnetic resonance imaging findings before the intervention: group 1: patients who showed bilateral activation (n = 27); group 2: patients with unilateral activation (n = 20). RESULTS: Treatment resulted in improvement in Fugl-Meyer Assessment and Wolf Motor Function Test in the two groups (P < 0·01). The treatment also resulted in a significant increase in laterality index in group 1 (P < 0·05), suggesting a shift in activated voxels to the lesional hemisphere. Patients of group 2 showed a significant increase in lesional hemisphere activation (P < 0·05). CONCLUSIONS: The results of serial functional magnetic resonance imaging indicated that our proposed treatment can induce functional cortical reorganization, leading to motor functional recovery of the affected upper limb. Especially, it seems that neural activation in the lesional hemisphere plays an important role in such recovery in poststroke hemiparetic patients.

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

BACKGROUND: Both 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. METHODS: The 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. RESULTS: All 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. CONCLUSIONS: The 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.

Risk factors for second hip fractures among elderly patients.

BACKGROUND: Hip fractures following falls by the elderly, which increase with age, are increasing in number annually. The incidence of refracture (second hip fractures) has been reported to be 5%-10% in Japan and is expected to increase with the aging of the population in the future. Therefore, through a retrospective cohort study, we attempted to clarify the risk factors associated with second hip fractures. METHODS: A total of 400 patients were consecutively treated for hip fracture at a single orthopedic hospital between January 2001 and December 2007. We excluded 16 subjects: 11 patients who died within a year after a hip fracture and 5 who were <50 years of age. The remaining 384 patients, consisting of 64 men and 320 women, were chosen as the study subjects. The mean age of the subjects at the time of the initial fracture was 83.1 +/- 9.0 years (range 51-102 years). Age, sex, interval between the two fractures, body mass index (BMI), length of bed-rest periods and of rehabilitation periods, living place after an initial fracture, and complicating diseases were determined from medical records. Furthermore, effectors of second hip fractures were extracted using the Cox proportional hazard model. RESULTS: In all, 384 patients were observed for 1140.0 person-years (mean: 3.0 +/- 1.4 years per patient) following the initial hip fracture. During the observation period, 49 second hip fractures were identified, giving an overall incidence of 0.043 per person-year. The second fracture occurred within 3 years in 85.7% (42 patients). Dementia and respiratory disease were recognized as being significantly related to refracture. Using a Cox proportional hazard model, dementia showed a significant influence, with the hazard ratio (HR) 1.87 [95% confidence interval (CI) 1.02-3.41; P = 0.042]. Respiratory diseases also were associated with second hip fracture (HR 4.41, 95% CI 2.33-8.34; P < 0.001). CONCLUSIONS: In this study, 85.7% of refractures occurred within 3 years of the first fracture, with dementia and respiratory disease being the complicating factors that influenced refracture.