Functional Brain Stimulation in a Chronic Stroke Survivor With Moderate Impairment.

OBJECTIVE: To determine the impact of transcranial direct current stimulation (tDCS) combined with repetitive, task-specific training (RTP) on upper-extremity (UE) impairment in a chronic stroke survivor with moderate impairment. METHOD: The participant was a 54-yr-old woman with chronic, moderate UE hemiparesis after a single stroke that had occurred 10 yr before study enrollment. She participated in 45-min RTP sessions 3 days/wk for 8 wk. tDCS was administered concurrent to the first 20 min of each RTP session. RESULTS: Immediately after intervention, the participant demonstrated marked score increases on the UE section of the Fugl-Meyer Scale and the Motor Activity Log (on both the Amount of Use and the Quality of Movement subscales). CONCLUSION: These data support the use of tDCS combined with RTP to decrease impairment and increase UE use in chronic stroke patients with moderate impairment. This finding is crucial, given the paucity of efficacious treatment approaches in this impairment level.

Navigated Transcranial Magnetic Stimulation: A Biologically Based Assay of Lower Extremity Impairment and Gait Velocity.

Objectives. (a) To determine associations among motor evoked potential (MEP) amplitude, MEP latency, lower extremity (LE) impairment, and gait velocity and (b) determine the association between the presence of a detectable MEP signal with LE impairment and with gait velocity. Method. 35 subjects with chronic, stable LE hemiparesis were undergone TMS, the LE section of the Fugl-Meyer Impairment Scale (LE FM), and 10-meter walk test. We recorded presence, amplitude, and latency of MEPs in the affected tibialis anterior (TA) and soleus (SO). Results. MEP presence was associated with higher LEFM scores in both the TA and SO. MEP latency was larger in subjects with lower LEFM and difficulty walking. Conclusion. MEP latency appears to be an indicator of LE impairment and gait. Significance. Our results support the precept of using TMS, particularly MEP latency, as an adjunctive LE outcome measurement and prognostic technique.

Giving Them a Hand: Wearing a Myoelectric Elbow-Wrist-Hand Orthosis Reduces Upper Extremity Impairment in Chronic Stroke.

OBJECTIVE: To determine the immediate effect of a portable, myoelectric elbow-wrist-hand orthosis on paretic upper extremity (UE) impairment in chronic, stable, moderately impaired stroke survivors. DESIGN: Observational cohort study. SETTING: Outpatient rehabilitation clinic. PARTICIPANTS: Participants exhibiting chronic, moderate, stable, poststroke, UE hemiparesis (N=18). INTERVENTIONS: Subjects were administered a battery of measures testing UE impairment and function. They then donned a fabricated myoelectric elbow-wrist-hand orthosis and were again tested on the same battery of measures while wearing the device. MAIN OUTCOME MEASURES: The primary outcome measure was the UE Section of the Fugl-Meyer Scale. Subjects were also administered a battery of functional tasks and the Box and Block (BB) test. RESULTS: Subjects exhibited significantly reduced UE impairment while wearing the myoelectric elbow-wrist-hand orthosis (FM: t17=8.56, P<.0001) and increased quality in performing all functional tasks while wearing the myoelectric elbow-wrist-hand orthosis, with 3 subtasks showing significant increases (feeding [grasp]: z=2.251, P=.024; feeding [elbow]: z=2.966, P=.003; drinking [grasp]: z=3.187, P=.001). Additionally, subjects showed significant decreases in time taken to grasp a cup (z=1.286, P=.016) and increased gross manual dexterity while wearing a myoelectric elbow-wrist-hand orthosis (BB test: z=3.42, P<.001). CONCLUSIONS: Results suggest that UE impairment, as measured by the Fugl-Meyer Scale, is significantly reduced when donning a myoelectric elbow-wrist-hand orthosis, and these changes exceeded the Fugl-Meyer Scale's clinically important difference threshold. Further, utilization of a myoelectric elbow-wrist-hand orthosis significantly increased gross manual dexterity and performance of certain functional tasks. Future work will integrate education sessions to increase subjects' ability to perform multijoint functional movements and attain consistent functional changes.

Changing Their Minds: Enhancing Poststroke Occupational Performance Using Transcranial Direct Current Stimulation.

Stroke remains a leading cause of disability, with survivors experiencing long-term decrements in independence and quality of life. Occupational therapists (OTs) employ numerous neurorehabilitative treatment approaches to remediate impairments that are impeding performance. OTs also use physical agent modalities to facilitate increased participation and success in therapy. One such modality is transcranial direct current stimulation (tDCS), a form a noninvasive brain stimulation that can be overlaid onto task practice and delivers a constant, low intensity current into the brain. tDCS is safe, portable, and efficacious in remediating a variety of deficits, yet is not consistently incorporated into clinical practice. The authors discuss the mechanisms, safety, evidence, and potential applications of tDCS to enhance outcomes for this growing population.

Moving Forward by Stimulating the Brain: Transcranial Direct Current Stimulation in Post-Stroke Hemiparesis.

Stroke remains a leading cause of disability worldwide, with a majority of survivors experiencing long term decrements in motor function that severely undermine quality of life. While many treatment approaches and adjunctive strategies exist to remediate motor impairment, many are only efficacious or feasible for survivors with active hand and wrist function, a population who constitute only a minority of stroke survivors. Transcranial direct current stimulation (tDCS), a type of non-invasive brain stimulation, has been increasingly utilized to increase motor function following stroke as it is able to be used with stroke survivors of varying impairment levels, is portable, is relatively inexpensive and has few side effects and contraindications. Accordingly, in recent years the number of studies investigating its efficacy when utilized as an adjunct to motor rehabilitation regimens has drastically increased. While many of these trials have reported positive and promising efficacy, methodologies vary greatly between studies, including differences in stimulation parameters, outcome measures and the nature of physical practice. As such, an urgent need remains, centering on the need to investigate these methodological differences and synthesize the most current evidence surrounding the application of tDCS for post-stroke motor rehabilitation. Accordingly, the purpose of this paper is to provide a detailed overview of the most recent tDCS literature (published 2014-2015), while highlighting these variations in methodological approach, as well to elucidate the mechanisms associated with tDCS and post-stroke motor re-learning and neuroplasticity.

Integrating Mental Practice with Task-specific Training and Behavioral Supports in Poststroke Rehabilitation: Evidence, Components, and Augmentative Opportunities.

Stroke remains a leading cause of death, with most survivors experiencing long-term deficits in motor function. Upper extremity (UE) hemiparesis constitutes one of the most common and disabling poststroke impairments. Many contemporary rehabilitative methods target reacquisition of UE motor skills. One such intervention is mental practice (MP), which involves mental rehearsal without physical execution of the movement. MP has not been consistently integrated into clinical environments. This article discusses the scientific rationale for MPs, highlights evidence supporting their use, discusses components of the repetitive task-specific practice regimens accompanying MP, and discusses possible augmentative strategies and areas for research.

The National Institutes of Health Stroke Scale Lacks Validity in Chronic Hemiparetic Stroke.

BACKGROUND: The National Institutes of Health Stroke Scale (NIHSS) is purported to be associated with long-term outcomes. This study determined the concurrent validity of the NIHSS with the Stroke Impact Scale (SIS), a previously validated measure of health status in chronic stroke survivors. METHODS: The NIHSS and the SIS were administered to 147 subjects before participation in a multicenter, randomized, controlled trial. A Spearman's rho was used to determine correlations between NIHSS total score and (1) SIS physical dimension scores, (2) SIS overall perception of recovery scores, and (3) the SIS activities and independent activities of daily living (ADL/IADL) scores. SIS score variation and medians between subjects who scored a zero versus a nonzero on the NIHSS was also assessed. RESULTS: There was no association between total NIHSS scores and SIS physical dimension scores, SIS overall perception of recovery scores, and SIS ADL/IADL scores (P = -.036, P = .782; P = -.039, P = .640; P = -.054, P = .520; respectively). Lastly, significant variation and similar median scores on the SIS were found between those scoring a zero on the NIHSS versus those who did not score a zero. CONCLUSIONS: The NIHSS has no association with health status in chronic stroke and lacks association with measures of impairment and functional limitation. From these findings, we conclude that the NIHSS has poor validity to discern long-term poststroke outcomes and is not associated with health status. Because of possible limitation in the NIHSS's ability to accurately determine outcomes in this population, we recommend restriction of its use to the acute stage of recovery.