Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS) Nerve Stimulation Enhances Task-Oriented Training in Chronic, Severe Motor Deficit After Stroke: A Randomized Trial Impact of Time on Improvement of Outcome After Stroke Interpreting estimates of treatment effects: implications for managed care. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials Somatosensory stimulation enhances the effects of training functional hand tasks in patients with chronic stroke. Modulation of human corticomotor excitability by somatosensory input. Effects of somatosensory stimulation on motor function in chronic cortico-subcortical strokes Increase in hand muscle strength of stroke patients after somatosensory stimulation Retention of upper limb function in stroke survivors who have received constraint-induced movement therapy: the EXCITE randomised trial Effects of Somatosensory Stimulation on Motor Function After Subacute Stroke
Background : Constraint-induced movement therapy ( CIMT ) is among the most developed training approaches for motor restoration of the upper extremity ( UE ) . Methods : Very Early Constraint-Induced Movement during Stroke Rehabilitation ( VECTORS ) was a single-blind phase II trial of CIMT during acute inpatient rehabilitation comparing traditional UE therapy with dose-matched and high-intensity CIMT protocol s. Participants were adaptively r and omized on rehabilitation admission , and received 2 weeks of study -related treatments . The primary endpoint was the total Action Research Arm Test ( ARAT ) score on the more affected side at 90 days after stroke onset . A mixed model analysis was performed . Results : A total of 52 participants ( mean age 63.9 ± 14 years ) were r and omized 9.65 ± 4.5 days after onset . Mean NIHSS was 5.3 ± 1.8 ; mean total ARAT score was 22.5 ± 15.6 ; 77 % had ischemic stroke . Groups were equivalent at baseline on all r and omization variables . As expected , all groups improved with time on the total ARAT score . There was a significant time x group interaction ( F = 3.1 , p < 0.01 ) , such that the high intensity CIT group had significantly less improvement at day 90 . No significant differences were found between the dose-matched CIMT and control groups at day 90 . MRI of a sub sample showed no evidence of activity-dependent lesion enlargement . Conclusion : Constraint-induced movement therapy ( CIMT ) was equally as effective but not superior to an equal dose of traditional therapy during inpatient stroke rehabilitation . Higher intensity CIMT result ed in less motor improvement at 90 days , indicating an inverse dose-response relationship . Motor intervention trials should control for dose , and higher doses of motor training can not be assumed to be more beneficial , particularly early after stroke Background and Purpose — A sensory-based intervention called peripheral nerve stimulation can enhance outcomes of motor training for stroke survivors with mild-to-moderate hemiparesis . Further research is needed to establish whether this paired intervention can have benefit in cases of severe impairment ( almost no active movement ) . Methods — Subjects with chronic , severe poststroke hemiparesis ( n=36 ) were r and omized to receive 10 daily sessions of either active or sham stimulation ( 2 hours ) immediately preceding intensive task-oriented training ( 4 hours ) . Upper extremity movement function was assessed using Fugl – Meyer Assessment ( primary outcome measure ) , Wolf Motor Function Test , and Action Research Arm Test at baseline , immediately post intervention and at 1-month follow-up . Results — Statistically significant difference between groups favored the active stimulation group on Fugl – Meyer at postintervention ( 95 % confidence interval [ CI ] , 1.1–6.9 ; P=0.008 ) and 1-month follow-up ( 95 % CI , 0.6–8.3 ; P=0.025 ) , Wolf Motor Function Test at postintervention ( 95 % CI , −0.21 to −0.02 ; P=0.020 ) , and Action Research Arm Test at postintervention ( 95 % CI , 0.8–7.3 ; P=0.015 ) and 1-month follow-up ( 95 % CI , 0.6–8.4 ; P=0.025 ) . Only the active stimulation condition was associated with ( 1 ) statistically significant within-group benefit on all outcomes at 1-month follow-up and ( 2 ) improvement exceeding minimal detectable change , as well as minimal clinical ly significant difference , on ≥1 outcomes at ≥1 time points after intervention . Conclusions — After stroke , active peripheral nerve stimulation paired with intensive task – oriented training can effect significant improvement in severely impaired upper extremity movement function . Further confirmatory studies that consider a larger group , as well as longer follow-up , are needed . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT02633215 Background and Purpose — Longitudinal conducted studies show that neurologic and functional recovery show faster recovery in the first weeks poststroke . The aim of the present study was to study the effects of progress of time on observed improvements in motor strength , synergisms , and activities during the first 16 weeks poststroke . Methods — Based on data from a previous study , 101 patients with first-ever ischemic middle cerebral artery strokes were prospect ively investigated during the first 16 weeks after stroke . Progress of time was categorized into 8 biweekly time intervals and was used as the independent covariate in a first-order longitudinal regression model . The biweekly time change ( progress of time ) was related to improvement in upper and lower limb motor recovery assessed with Fugl-Meyer score and Motricity Index , reduction in visuospatial inattention based on the letter cancellation task , and improvement in walking ability , dexterity , and activities of daily living measured with the Functional Ambulation Categories , Action Research Arm test , and Barthel Index . Results — Time explained a significant change of 8.4 ( 42 % ) measurement units on the Barthel Index for the first 10 weeks poststroke , 1.1 ( 22 % ) measurement units on Functional Ambulation Categories , and 19 % on the Action Research Arm test for the first 6 and 8 weeks poststroke . Approximately 25 % ( for Fugl-Meyer – arm ) to 26 % ( for Motricity Index – arm ) of the significant change in measurements units was explained by time alone for the upper limb compared with 33 % for Fugl-Meyer – leg and 39 % for Motricity Index – leg of the lower limb . Time accounted for a reduction of 16 % in the letter cancellation task . Observed associations did not change after controlling for covariates such as age , gender , hemisphere of stroke , type of stroke , or intervention . Conclusion — Progress of time is an independent covariate that reflects spontaneous recovery of body functions and activities explaining ≈16 % to 42 % of the observed improvements in the first 6 to 10 weeks after stroke onset How should health care professionals choose among the many therapies cl aim ed to be efficacious for treating specific disorders ? The practice of evidence -based medicine provides an answer . Advocates of this approach urge health care professionals to base treatment choices on the best evidence from systematic research on both the efficacy and adverse effects of various therapeutic alternatives . Ideally , health care professionals would compare different treatments by referring to r and omized , double-blind , head-to-head trials that compared the treatment options . Although individual medications are typically well research ed when these placebo-controlled studies are performed , studies that directly compare treatments are rare . In the absence of direct head-to-head trials , other evidence comes from indirect comparisons of two or more therapies by examining individual studies involving each treatment . This article provides an introductory review of methods of such indirect comparisons of therapies across studies , provides examples of how these methods can be used to make treatment decisions , and presents a general overview of relevant issues and statistics for readers interested in underst and ing these methods more thoroughly Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more OBJECTIVE To test the hypothesis that somatosensory stimulation would enhance the effects of training functional h and tasks immediately after practice and 1 day later in chronic subcortical stroke patients . DESIGN Single-blinded and r and omized , crossover study . SETTING Human research laboratory . PARTICIPANTS Nine chronic subcortical stroke patients . INTERVENTIONS Three separate sessions of motor training preceded by ( 1 ) synchronous peripheral nerve stimulation ( PNS ) , ( 2 ) no stimulation , or ( 3 ) asynchronous PNS . MAIN OUTCOME MEASURES Time to complete the Jebsen-Taylor H and Function Test ( JTHFT time ) and corticomotor excitability tested with transcranial magnetic stimulation . RESULTS After familiarization practice , during which all patients reached a performance plateau , training under the effects of PNS reduced JTHFT time by 10 % beyond the post-familiarization plateau . This behavioral gain was accompanied by a specific reduction in GABAergically mediated intracortical inhibition in the motor cortex . These findings were not observed after similar practice under the influence of no stimulation or asynchronous PNS sessions . CONCLUSIONS Somatosensory stimulation may enhance the training of functional h and tasks in patients with chronic stroke , possibly through modulation of intracortical GABAergic pathways In humans , somatosensory stimulation results in increased corticomotoneuronal excitability to the stimulated body parts . The purpose of this study was to investigate the underlying mechanisms . We recorded motor evoked potentials ( MEPs ) to transcranial magnetic stimulation ( TMS ) from abductor pollicis brevis ( APB ) , first dorsal interosseous ( FDI ) , and abductor digiti minimi ( ADM ) muscles . MEP amplitudes , recruitment curves ( RC ) , intracortical inhibition ( ICI ) , intracortical facilitation ( ICF ) , resting ( rMT ) and active motor thresholds ( aMT ) were recorded before and after a 2-h period of ulnar nerve electrical stimulation at the wrist . Somatosensory input was monitored by recording somatosensory evoked potentials . To differentiate excitability changes at cortical vs. subcortical sites , we recorded supramaximal peripheral M-responses and MEPs to brainstem electrical stimulation ( BES ) . In order to investigate the involvement of GABAergic mechanisms , we studied the influence of lorazepam ( LZ ) ( a GABA(A ) receptor agonist ) relative to that of dextromethorphan ( DM ) ( an NMDA receptor antagonist ) and placebo in a double-blind design . We found that somatosensory stimulation increased MEP amplitudes to TMS only in the ADM , confirming a previous report . This effect was blocked by LZ but not by either DM or placebo and lasted between 8 and 20 min in the absence of ( i ) changes in MEPs elicited by BES , ( ii ) amplitudes of early somatosensory-evoked potentials or ( iii ) M-responses . We conclude that somatosensory stimulation elicited a focal increase in corticomotoneuronal excitability that outlasts the stimulation period and probably occurs at cortical sites . The antagonistic effect of LZ supports the hypothesis of GABAergic involvement as an operating mechanism Somatosensory stimulation enhances aspects of motor function in patients with chronic , predominantly subcortical infa rcts . We investigated the effects of somatosensory stimulation on motor function in stroke patients with predominantly cortical involvement in the middle cerebral artery territory in a double-blind , pseudor and omized crossover trial . Motor performance was evaluated with the Jebsen-Taylor test before , after 2-hour somatosensory stimulation , and after subsequent motor training ( n = 11 ) . In one experimental session , patients were su bmi tted to median nerve stimulation ( MNS ) and in the other session , to control stimulation ( CS ) . The order of the sessions was counterbalanced across patients . Improvement in performance in the Jebsen-Taylor test after somatosensory stimulation and after motor training was significantly greater in the MNS session than in the CS session . Additionally , patients who received MNS in the second session maintained the beneficial effects of training 30 days later . A single MNS session improves h and motor function in patients with chronic cortico-subcortical strokes and appears to favor consolidation of training effects .  Somatosensory stimulation may be an adjuvant tool for stroke rehabilitation in patients with cortical lesions It has been proposed that somatosensory input in the form of peripheral nerve stimulation can influence functional measures of motor performance . We studied the effects of median nerve stimulation on pinch muscle strength ( a function mediated predominantly by median nerve innervated muscles ) in the affected h and of chronic stroke patients . A 2‐hour period of median nerve stimulation elicited an increase in pinch strength that outlasted the stimulation period . The improvement in muscle strength correlated with stimulus intensity and was identified in the absence of motor training . These results suggest that somatosensory stimulation may be a promising adjuvant to rehabilitation of the motor deficits in stroke patients BACKGROUND The aim of constraint-induced movement therapy ( CIMT ) is to promote use of a limb that is functionally impaired after a stroke . In one form of CIMT to treat upper limb impairment , use of the less severely affected arm is restricted for many hours each weekday over 2 consecutive weeks . The EXCITE trial has previously shown the efficacy of this intervention for patients 3 - 9 months poststroke who were followed-up for the next 12 months . We assessed the retention of improvements 24 months after the intervention . METHODS In the EXCITE trial , 106 of 222 participants who had mild to moderate poststroke impairments were r and omly assigned to receive CIMT rather than usual and customary care . We assessed this group of patients every 4 months for the primary outcome measure of impaired upper limb function , as measured with the Wolf motor function test ( WMFT ) and the motor activity log ( MAL ) . Health-related quality of life , measured with the stroke impact scale ( SIS ) , was a secondary outcome measure . Analysis was per protocol . This trial is registered with Clinical Trials.gov , number NCT00057018 . FINDINGS The effects at 24 months after treatment did not decline from those at 12 months for time taken to complete the WMFT ( -0.32 s , 95 % CI -3.70 to 3.06 ) , for weight lifted in the WMFT ( -1.39 kg , -2.74 to -0.04 ) , for WMFT grip strength ( -4.39 kg , -6.91 to -1.86 ) , for amount of use in the MAL ( -0.17 , -0.38 to 0.04 ) , or for how well the limb was used in the MAL ( -0.14 , -0.34 to 0.06 ) . The additional changes were in the direction of increased therapeutic effect . For the strength components of the WMFT , p<0.0001 . INTERPRETATION Patients who have mild to moderate impairments 3 - 9 months poststroke have substantial improvement in functional use of the paretic upper limb and quality of life 2 years after a 2-week CIMT intervention . Thus , this intervention has persistent benefits Background . Previous works showed potentially beneficial effects of a single session of peripheral nerve sensory stimulation ( PSS ) on motor function of a paretic h and in patients with subacute and chronic stroke . Objective . To investigate the influence of the use of different stimulus intensities over multiple sessions ( repetitive PSS [ RPSS ] ) paired with motor training . Methods . To address this question , 22 patients were r and omized within the second month after a single hemispheric stroke in a parallel design to application of 2-hour RPSS at 1 of 2 stimulus intensities immediately preceding motor training , 3 times a week , for 1 month . Jebsen — Taylor test ( JTT , primary endpoint measure ) , pinch force , Functional Independence Measure ( FIM ) , and corticomotor excitability to transcranial magnetic stimulation were measured before and after the end of the treatment month . JTT , FIM scores , and pinch force were reevaluated 2 to 3 months after the end of the treatment . Results . Baseline motor function tests were comparable across the 2 RPSS intensity groups . JTT improved significantly in the lower intensity RPSS group but not in the higher intensity RPSS group at month 1 . This difference between the 2 groups reduced by months 2 to 3 . Conclusions . These results indicate that multiple sessions of RPSS could facilitate training effects on motor function after subacute stroke depending on the intensity of stimulation . It is proposed that careful dose — response studies are needed to optimize parameters of RPSS stimulation before design ing costly , larger , double-blind , multicenter clinical trials
Background .
Enhancement of sensory input in the form of repetitive peripheral sensory stimulation ( RPSS ) can enhance excitability of the motor cortex and upper limb performance .
To perform a systematic review and meta- analysis of effects of RPSS compared with control stimulation on improvement of motor outcomes in the upper limb of subjects with stroke .