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Stiff knee gait (SKG), a common occurrence after the onset of stroke, is caused by hyperactivity of the rectus femoris during the swing phase. Another cause of SKG is the weakness of push-off in hemiparetic gait. Prior research did not consider the effect of the magnitude of knee extensors in their subjects.Does the cause of SKG differ between patients with high and low knee extensor activities during the swing phase?We examined 38 patients with chronic stroke hemiplegia who presented with SKG. After placing an inertia sensor and an electromyogram, patients walked 10 m at a comfortable speed. All patients were categorized per the sign of the principal component 2 (PC2) as a component with large factor loadings of knee extensors attained from the electromyographic amplitude during the early swing phase of the paretic limb. Then, the kinematic parameters of knee flexion and other gait parameters in each group were compared, and a correlation analysis was performed.In the high PC2 group, the timing of peak knee flexion during the swing phase was early, and vastus lateralis activity during the preswing phase negatively correlated with the knee-flexion angle during the swing phase. In the low PC2 group, the angular velocity of ankle plantar flexion at the toe-off was slow, which positively correlated with the knee-flexion angle during the swing phase.The cause of SKG could be an inappropriate activity of the vastus lateralis rather than the rectus femoris in patients with high knee extensor activity and slow plantar-flexion velocity at toe-off in patients with low knee extensor activity. Not all causes of SKG in patients with hemiplegia are common, and different treatment strategies are needed per the individuality of spastic knee extensor activity.

Cockayne syndrome is a rare DNA repair disorder marked by premature aging, poor growth, and intellectual disability. Neurological complications such as seizures, movement disorder, and stroke have been reported. Hemiplegic migraine has not been reported in association with Cockayne syndrome.We report a male with Cockayne syndrome due to biallelic heterozygous pathogenic variants in ERCC6 who presented repeatedly with transient focal neurological deficits and headache, which were consistent with hemiplegic migraine. Two siblings also had Cockayne syndrome and presented with similar symptoms.Our patient was originally diagnosed based on clinical suspicion and then confirmed by targeted exome analysis of genes associated with Cockayne syndrome. The family's research exome sequencing data were reanalyzed to identify variants in genes known to cause familial hemiplegic migraine. No variants in the genes known to cause familial hemiplegic migraine were identified.This is a novel association of familial hemiplegic migraine in three full siblings with Cockayne syndrome. Hemiplegic migraine has not previously been described as part of the Cockayne syndrome presentation. A separate genetic cause of familial hemiplegic migraines was not identified in an exome-based analysis of genes known to cause this condition. This report may represent an expansion of the Cockayne syndrome phenotype.

We analyzed the clinical symptoms of hemiplegic migraine (HM) and their relevance in four Japanese patients considered to have ATP1A2 mutations as a cause. Sequencing of ATP1A2 was performed using the Sanger method in 43 blood samples from clinically suspected patients with familial HM. Subsequently, algorithm analysis, allele frequency determination, and three-dimensional structure analysis of the recognized variants were performed, and the recognized variants were evaluated. We found four heterozygous missense mutations in ATP1A2 (Case 1: p.R51C; Case 2: p.R65L; Case 3: p.A269P; Case 4: p.D999H), three of which had not been reported to date. These four mutations may also affect the structure of the protein products, as assessed using a three-dimensional structural analysis. In all four cases, the clinical symptoms included visual, sensory, motor, and verbal symptoms and the frequency and duration of headache attacks varied. Additionally, oral administration of a combination of lomerizine hydrochloride and topiramate had a partial effect in three cases. We report four missense mutations in ATP1A2. This report will be useful for the future analysis of mutations and clinical types in Asians, as well as Westerners, with migraine.

Children with hemiplegia often demonstrate gait deviations including increased variability and asymmetry. Step-to-step gait variability decreases over childhood and increases in the presence of neurologic dysfunction. Gait variability in children with hemiplegia should therefore be interpreted in reference to age-related norms RESEARCH QUESTION: Does conversion of the enhanced gait variability index (eGVI) to age-normalized z-scores improve interpretation of gait variability in children with hemiplegia?Ten children (11.2 +/- 4.1 years) with hemiparetic gait due to stroke were recruited for a small prospective pilot intervention study. Participants walked at self-selected speed over an instrumented walkway while barefeet and while wearing shoes. eGVI values from baseline sessions were calculated and converted to age-normalized z-scores (eGVIThere were no differences in raw eGVI or eGVIWe suggest that eGVI values in children be converted to z-scores or otherwise age-normalized so as not to inflate the degree of variability reported in clinical pediatric populations. Future work with larger samples will offer greater insight into gait variability in various clinical pediatric populations.

Alternating hemiplegia of childhood (AHC) pathophysiology suggests predisposition to sedation and anesthesia complications.Hypotheses: 1) AHC patients experience high rates of sedation-anesthesia complications. 2) ATP1A3 mutation genotype positivity, age, and AHC severity correlate with more severe complications. 3) Prior short QTc correlates with cardiac rhythm complications.Analysis of 34 consecutive AHC patients who underwent sedation or anesthesia. Classification of complications: mild (not requiring intervention), moderate (intervention), severe (intervention, risk for permanent injury or potential life-threatening emergency).Fisher Exact test, Spearman correlations.These patients underwent 129 procedures (3.79 ± 2.75 procedures/patient). Twelve (35%) experienced complications during at least one procedure. Fourteen/129 procedures (11%) manifested one or more complications (2.3% mild, 7% moderate, 1.6% severe). Of the total 20 observed complications, six (33.3%) were severe: apneas (2), seizures (2), bradycardia (1), ventricular fibrillation that responded to resuscitation (1). Moderate complications: non-life-threatening bradycardias, apneas, AHC spells or seizures. Complications occurred during sedation or anesthesia and during procedures or recovery periods. Patients with disease-associated ATP1A3 variants were more likely to have moderate or severe complications. There was no correlation between complications and age or AHC severity. Presence of prior short QTc correlated with cardiac rhythm complications. After this series was analyzed, another patient had severe recurrent laryngeal dystonia requiring tracheostomy following anesthesia with intubation.During sedation or anesthesia, AHC patients, particularly those with ATP1A3 variants and prior short QTc, are at risk for complications consistent with AHC pathophysiology. Increased awareness is warranted during planning, performance, and recovery from such procedures.

The aim of the study is to evaluate the evidence supporting the efficacy of botulinum toxin type A (BTA) injections in lower limb of hemiplegic patients, after stroke or cerebrovascular accident, and their gait analysis. This study included: randomized controlled trials (RCTs), non-randomized or controlled clinical trials (CCTs) or cluster trials, clinical trials of various phases (I-III), interrupted time series (ITS) studies with at least three data points before and after the intervention, controlled before and after (CBA) studies, prospective and retrospective comparative cohort studies, case-control and multicentred studies. The patients included in these studies had similar characteristics: age over 18 years, history of stroke and following hemiplegia, minimum modified Ashworth scale (MAS) score of 2 and duration since stroke over 6 months. The number of studies included in this review was 21. A meta-analysis was performed on a fraction of them depending on the reported index and the methodology as reported in detail in the results section. MAS score, following BTA injections, was significantly improved (Hedges' g: -1.17; 95% CI: -1.66, 0.67; p 0.001). The same applied for the 10 Meter Walk Test (MWT) (-0.35; 95% CI: -0.68, -0.02; p = 0.016). The gait velocity showed improvement, yet without statistical significance (0.27; 95% CI: -0.09, 0.63; p = 0.285). We concluded that botulinum toxin injections showed effectiveness on lower limb hypertonia reduction of hemiplegic patients after stroke. Apart from significantly reducing the MAS scores, 10 MWT was also improved. However, more research is required in order to determine the advancement in specific gait and posture parameters.

Background Contralateral C7 (CC7) nerve transfer has successfully restored hand function in patients with spastic hemiplegia from chronic central nervous system injuries. However, little is known about the morphology and anatomy of the donor C7 nerve root in patients undergoing this procedure. This study quantified intraoperative measurements of donor C7 nerve roots during CC7 transfer surgery for spastic hemiplegia in patients treated at a high-volume center to describe observed anatomical variations for successful direct anastomosis. Methods A database of images from 21 patients (2 females, 19 males) undergoing CC7 surgery was searched for photographic data that contained a standard ruler measuring donor C7 nerve root length after surgical sectioning and before transfer. Two independent observers analyzed these images and recorded C7 nerve root diameter, length, and branch lengths. Results Mean (SD) values of donor C7 nerve measurements were length, 53.5 (8.0) mm; diameter, 5.1 (0.9) mm; branch length following surgical sectioning, 18.3 (6.3) mm. Right-sided donor C7 nerve roots yielded significantly longer branches compared with left-sided donor C7 nerve roots (P = 0.01). Other patient factors such as age, sex, or laterality of brain injury did not influence intraoperative anatomy. Conclusions We report detailed intraoperative measurements of the donor C7 root during CC7 nerve transfer for spastic hemiplegia. These findings describe existing variation in surgical C7 nerve root anatomy in patients undergoing this procedure and may serve as a general reference for the expected donor C7 length in successful direct anastomosis.

Objective To evaluate the effectiveness of botulinum toxin A (BTX-A) in the treatment of hemiplegic shoulder pain. Data Sources PubMed, EMBASE, Elsevier, Springer, Cochrane Library, Physiotherapy Evidence Database, CNKI, and VIP were researched from the earliest records to September 1, 2020. Study Selection Randomized controlled trials that compared shoulder BTX-A injections vs a control intervention in patients with a history of hemiplegic shoulder pain after stroke were selected. Among the 620 records screened, 9 trials with 301 eligible patients were included. Data Extraction Outcome data were pooled according to follow-up intervals (1, 2, 4, and 12 wk). The primary evaluation indices were pain reduction (visual analog scale [VAS] score) and range of motion (ROM) improvement. The second evaluation indices were upper limb functional improvement, spasticity improvement, and incidence of adverse events. Cochrane risk-of-bias was used to assess the methodological quality of studies independently by 2 evaluators. Data Synthesis Meta-analysis revealed a statistically significant decrease in the VAS score in the BTX group vs the control group at 1, 4, and 12 weeks postinjection (wk 1: standardized mean difference [SMD], 0.91; 95% confidence interval [CI], 0.27 to 1.54; wk 4: SMD, 1.63; 95% CI, 0.76 to 2.51; wk 12: SMD, 1.96; 95% CI, 1.44 to 2.47). Furthermore, the meta-analysis demonstrated a statistically significant increase in abduction at 1, 4, and 12 weeks postinjection (wk 1: SMD, 3.71; 95% CI, 0 to 7.41; wk 4: SMD, 8.8; 95% CI, 2.22 to 15.37; wk 12: SMD, 19.59; 95% CI, 9.05 to 30.13) and external rotation at 1, 2, 4 weeks postinjection (wk 1: SMD, 5.67; 95% CI, 0.88 to 10.47; wk 2: SMD, 9.62; 95% CI, 5.57 to 13; wk 4: SMD, 6.89; 95% CI, 2.45 to 11.33) in the BTX group. Conclusions BTX-A injection provided greater analgesic effects and increased shoulder abduction and external rotation ROM compared with steroid or placebo injection for the treatment of HSP.

We report a 5-year-old male with a PDHA1 variant who presented with alternating hemiplegia of childhood and later developed developmental regression, basal ganglia injury and episodic lactic acidosis. Enzyme assay in lymphocytes confirmed a diagnosis of Pyruvate Dehydrogenase Complex (PDC) deficiency. His mother who was heterozygous for the same variant suffered from ophthalmoplegia, chronic migraine and developed flaccid paralysis at 36 years of age. PDHA1 is the most common genetic cause of PDC deficiency and presents with a myriad of neurological phenotypes including neonatal form with lactic acidosis, non-progressive infantile encephalopathy, Leigh syndrome subtype and intermittent ataxia. The presentations in our 2 patients contribute to the clinical heterogeneity of this neurogenetic condition.

Objective To compare the prefrontal cortex (PFC) activation and task performance during single- and dual-task conditions between typically developing (TD) children and children with hemiplegic cerebral palsy (HCP). Design A prospective, comparative design. Setting Research laboratory. Participants Participants (N=21) included 12 TD children (age, 6.0±1.1y) and 9 children with HCP (age, 7.2±3.1). Interventions Not applicable. Main Outcome Measures PFC activation was assessed by measuring the concentration of oxygenated hemoglobin while the children performed a shape-matching task with their more affected arm while sitting on a stable (single task) vs dynamic surface (dual task). The task performance was assessed with the total number of shapes matched, dual-task cost, and reaction time (RT). Results For both conditions, the children with HCP exhibited greater PFC activation, matched a fewer shapes, and had slower RT than the TD children. These differences were accentuated during the dual-task condition and the dual-task cost was greater. An increase in the PFC activation during the dual-task condition was tightly correlated with a higher dual-task cost in children with HCP (r=0.77, P=.01). Conclusions Children with HCP appear to have a heightened amount of PFC activity while performing a dual task. The greater cortical activity may be a result of the finite attentional resources that are shared between both the motor as well as cognitive demands of the task. The cognitive-motor interference is likely exacerbated in children with HCP because of the structural and functional brain changes as a result of an insult to the developing brain.

Objective The purpose of this study was to determine the immediate effects of ankle non-elastic taping on balance and gait ability in patients with chronic stroke. Methods Thirty patients (inpatients and outpatients) with stroke were randomly assigned to 2 groups: the non-elastic taping group (n = 15) and the placebo-taping group (n = 15). Patients in the non-elastic taping group received Endura sports taping for their ankle joint, and patients in the placebo-taping group received Endura fix tape for their ankle joint. The Balance System SD assessed balance, and the GAITRite system assessed gait ability. We recorded measurements before and after intervention. Results The non-elastic taping group showed a significant improvement in static and dynamic standing balance (P ≤ .001) after intervention; in addition, this group showed significant increases in the velocity, cadence, step length, and stride length of gait (P ≤ .001) after intervention. However, the placebo-taping group showed no significant improvements in standing balance and gait ability after intervention (P >.05). Furthermore, significant differences in static and dynamic standing balance, cadence, and velocity were observed between the 2 groups after intervention (P ≤ .001). Conclusions Our results demonstrate that the application of ankle non-elastic taping is effective at improving balance and gait abilities in patients with stroke. Ankle non-elastic taping appears to be an effective method to facilitate active rehabilitation in patients with hemiplegia.

Background Ankle–foot orthoses with plantarflexion resistance (AFO-Ps) improve knee flexion in the stance phase on the paretic side in patients with hemiparesis. However, AFO-Ps decrease ankle power generation in the late stance phase and do not improve the knee flexion in the swing phase based on insufficient push-off at the late stance, resulting in lower toe clearance. Research question This study sought to investigate the effect of an AFO with dorsiflexion resistance, which was implemented by our developed device with spring–cam mechanism attached to the AFO-P (Gait Solution; Pacific Supply Co., Ltd., Japan), on kinetics and kinematics in the lower limb during gait in patients with hemiparesis. Methods Eleven patients with hemiparesis due to stroke walked on a 7-m walkway at a self-selected comfortable pace in the following conditions: (a) walking using the AFO-P with the proposed device with a spring–cam mechanism (AFO-PCAM), (b) walking using the AFO-P without our device (AFO-P), and (c) walking using no device (barefoot condition). Gait kinematics and kinetics were collected using a three-dimensional motion analysis system and four ground-reaction force plates. Changes in all parameters from the barefoot to AFO-PCAM and AFO-P conditions were compared using the Wilcoxon signed-rank test. Results In the AFO-PCAM condition, decrease in the maximum ankle power generation in the late-stance phase was significantly smaller than that in the AFO-P condition (p = 0.041). We noted a significant higher change in knee flexion in the paretic swing phase in the AFO-PCAM condition relative to that in the AFO-P condition (p = 0.016). The effect size for the comparisons of change was large (r ≧ 0.5). Significance Our device facilitated the realization of the ankle plantarflexion power in the late-stance phase because of dorsiflexion resistance, increasing the knee flexion angle during the swing phase.

Study Design This is a blinded randomized clinical trial. Introduction Sensorimotor exercises may be an effective, noninvasive treatment modality for treating patients with pediatric spastic hemiplegic cerebral palsy (CP). Purpose of the Study We aim to evaluate the effect of sensorimotor exercises on the proprioceptive capability among children with spastic hemiplegic CP. Methods This randomized clinical trial was performed on children with spastic hemiplegic CP. Thirty children aged 8 to 12 years old, with spastic hemiplegic CP, were randomly selected and equally divided into experimental and control groups (N = 15 for each). A joint positioning test was used to measure the patients' baseline proprioceptive ability. The exercise program included sensory and motor exercises which lasted for 8 weeks (three 60-min sessions per week). The data were analyzed by using Welch and paired-sample t-test at the significance level of P Results The results indicated that the proprioceptive capability of the upper limb could significantly improve (P = .001, effect size = 0.41, observed power = 0.99) by using simultaneous exercising of the sensorimotor complex. The mean increased from 8.53 ± 1.6 to 10.53 ± 1.19 in the experimental group, whereas it changed from 6.66 ± 3.44 to 6.73 ± 3.15 in the control group. Discussion In consistent with other studies, the exercises used in the present study enhanced the proprioceptive capability but not sensory performance of the hands of children with hemiplegic. Synchronous sensory and motor training in children with hemiplegic CP may improve the function and organization of the somatosensory cortex and reduce sensory disturbances. Although parents were subjectively satisfied with the outcome of the exercises, such as independency and life style, however these recordings were not measured in this study. Conclusion Implementing simultaneous sensorimotor exercises can improve the proprioceptive capability of the hand. Therefore, these exercises can be used in the rehabilitation programs to meet the children's needs with hemiplegic CP.

This study aims to evaluate whether the upper extremity spasticity and hemiplegic posture have any effect on the morphology of the carpal tunnel and median nerve in stroke patients. Nerve conduction studies (NCS) were performed in 46 stroke patients and compared to those of 30 healthy controls. The cross-sectional area (CSA) of the carpal tunnel (CT) and median nerve (wrist/mid-forearm levels) was assessed by ultrasonography. The mean ages of the stroke and control group were 55.6 ± 13.5 and 56 ± 12.1 years, respectively. The median spasticity score of the forearm pronators and wrist flexor muscles was 2 (0–4) according to the Modified Ashworth Scale (MAS). The compound muscle action potential (CMAP) of the median nerve was reduced (10,093 ± 4,451 mV) when compared to non-paretic side (11,615 ± 4,397 mV) (p:0.02) and the CSA of the CT was thinner on the paretic side (1.9 ± 0.3 cm2 vs 2.08 ± 0.2 cm2) (p:0.03). Pronator spasticity had no significant effect on the CSA of the median nerve and NCS at the forearm level. The CSA of the median nerve at the wrist was significantly thicker in patients with the wrist flexor spasticity graded II (MAS) and above compared to those with spasticity graded I and below (9.5 ± 1.7 mm2 and 8.7 ± 1.7 mm2 respectively) (p:0.03). However, the thickening of the median nerve didn’t cause significant abnormalities in NCS. This study shows that in stroke patients, wrist flexor spasticity and hemiplegic wrist posture can cause explicit morphological changes in the CT and median nerve albeit normal findings on NCS.

One of the major problems with walking encountered by patients with spastic hemiplegia is diminished toe clearance due to spasticity of their leg muscles. To improve their walking, a specialized robot assist for ankle movements (RE-Gait) has been utilized. The present study examined the neurophysiological effects whether spinal cord reciprocal Ia inhibition (RI) in the leg was altered by using RE-Gait. Sixteen patients with a clinical diagnosis of stroke were divided into the two groups, RE-Gait walking group (Group R) and normal (controlled) walking group (Group C). In each group, they walked on a flat floor for 15 min with or without RE-Gait. The depression of soleus (Sol) H-reflexes conditioned by common peroneal nerve stimuli with the conditioning-test (C-T) intervals of 1, 2, 3, and 4 ms were assessed before and immediately after each walking session. After the intervention, the LSM (SE) of Sol H-reflex amplitude with 1, 2 and 3 ms C-T interval conditions were significantly decreased in group R (1 ms: 88.15 (4.60), 2 ms: 86.37 (4.60), 3 ms: 89.68 (4.62)) compared to group C (1 ms: 105.57 (4.56), 2 ms: 100.89 (4.58), 3 ms: 107.72 (4.58)) [1 ms: p = 0.012, 2 ms: p = 0.035, 3 ms: p = 0.011]. Walking assistive robot that targets ankle movements might be a new rehabilitation tool for regulating spinal cord excitability.

Walking training is an essential intervention to improve the function in stroke patients. However, only a limited number of gait training strategies are available for stroke patients with relatively severe disabilities.Is underwater gait training or overground gait training more effective in severe stroke patients?A total of 21 patients with severe hemiplegic stroke were randomly assigned to the experimental and control groups. All participants (n = 21) received 60-minute sessions of general physical therapy, 5 times a week for a period of 12 weeks. Additionally, the experimental and control groups underwent underwater and overground walking training, respectively, for 30 min twice times a week for 12 weeks. Postural assessment for stroke score, center of pressure path length and velocity, step time and step length difference, and walking velocity were measured before and after the 12-week training.Both groups showed a significant decrease in the center of pressure path length and velocity after the intervention compared to the values before the intervention (p .05). However, there was no significant difference in the center of pressure path length and velocity changes after training between the two groups (p .05). In the walking variables, the step length difference changes after training between the two groups showed a significant difference (p .05). In the experimental group, the step length difference increased after the intervention compared to that before the intervention (+4.55 cm), whereas that of the control group decreased (-1.25 cm).In severe stroke patients, underwater gait training can be effective for improving balancing ability, but it may be less effective on the improvement of gait function than overground walking.KCT0002587 (https://cris.nih.go.kr).

This study aimed to identify very early incidence of hemiplegic shoulder pain within 72hours (HSP), how clinical assessment was related to pain at 8-10 week follow-up and explore current standard therapy/management.Observational, prospective.Teaching hospital hyper-acute and follow-up stroke services.121 consecutive patients with confirmed cerebral infarct/haemorrhage recruited within 72hours of stroke onset.N/A.Subjective report of pain severity and aggravating factors: using numerical rating scales and pain questionnaire (ShoulderQ), shoulder abductor and flexor muscle strength (Oxford MRC Scale), Neer's Test of sub-acromial pain, shoulder subluxation and soft tissue shoulder palpation.At initial assessment (72hours), 35% (42/121) reported HSP. At follow-up (8-10 weeks), 44% (53/121) had pain: pain persisted in 32 of the original 42, resolved in 10 and had developed since initial assessment in 21. Pain at follow-up was associated with a statistically significant higher frequency of severe shoulder muscle weakness (MRC grade ≤2) and gleno-humeral subluxation at initial assessment. Soft tissue palpation and Neer's Test detected pain but did not predict development of HSP. 50/121 patients had 140 therapy interventions, particularly targeted to those with a higher HSP risk.This study reports HSP at an earlier time point after stroke than previous publications. Patients with severe arm weakness and/or shoulder subluxation within 72hours are at significantly higher risk of HSP at 8-10 weeks. These data highlight the high incidence of HSP, the non-standardized therapy approach, and can inform sample size calculations for future intervention studies.NCT02574000 (clinicaltrials.gov).

Purpose Hemiplegic patients often experience malnutrition and feeding risks due to disabilities and inadequate nursing support; nursing roles regarding mealtime assistance remain unclear in China. Therefore, this study aimed to clarify the core knowledge and skills of nursing competency regarding mealtime assistance for hemiplegic patients in China. Methods A cross-sectional survey of self-administered questionnaire to 640 nurses (response rate: 57.7%) from two tertiary teaching hospitals and two sanatoriums was conducted. Survey content included 25 items regarding the mealtime assistance competency plus 6 items on demographic characteristics. The factor structure of the 25 items was explored and verified by exploratory and confirmatory factor analysis. Its reliability was confirmed by Cronbach's alpha. Results Three factors including 22 items with a cumulative rate of 60.9% were identified: “Assistance knowledge and skills for acute period”, “Knowledge about assistance and guidance for recovery period,” and “Professional basic knowledge regarding hemiplegia.” Its reliability was ensured with Cronbach's alpha ranging from .86 to .96. In addition, evidence for its construct validity was obtained, as structural equation modeling revealed a good fit to the data within the allowable range based on various fit indices. Conclusion This study clarified the core knowledge and skills regarding mealtime assistance competency for hemiplegic patients, with “Assistance for acute period” most concerned, followed by “assistance and guidance for recovery period,” and “Professional basic knowledge,” and the latter two need more attention. Obtained results can provide useful evidence for competent nursing practice to improve the quality of mealtime assistance for hemiplegic patients in China.

Objective To evaluate the effect of a single session of tDCS over the primary motor cortex of the lower limb (M1-LL) vs. placebo on the walking performance in chronic hemiplegic patients. Patients and methods Randomized, cross-over, double-blinded study. Eighteen patients with initially complete hemiplegia and poststroke delay >6 months were included. Each patient received a single session of anodal stimulation (2 mA, 20 min) over M1-LL (a-tDCS condition) and a pseudostimulation session (SHAM condition). The order of the two sessions was randomly assigned, with an 11-day interval between the two sessions. The anodal electrode was centered on the hotspot identified with Transcranial magnetic stimulation. The cathode was placed above the contralesional orbitofrontal cortex. Walking performance was evaluated with the Wade test and the 6-minute walk test (6MWT), gait parameters with GAITRite, and balance with posturography. These tests were performed during and 1 hour after the stimulation. Baseline assessments were performed the day before and 10 days after each session. Results The comparison between the 6MWT under a-tDCS vs. SHAM conditions demonstrated a nonsignificant positive effect of the stimulation by 15% during stimulation (p = 0.360) and a significant positive effect of 25% 1 hour after stimulation (p = 0.038). No significant differences were observed for the other evaluations. Discussion These results showed a significant positive effect of a single session of anodal tDCS of the M1-LL in chronic hemiplegic patients. This proof-of-concept study supports the conduct of clinical studies evaluating the effectiveness of a walking training program associated with iterative tDCS stimulation. Conflict of interest The authors reported no conflict of interest.

Acute stroke assessment is classically supported by clinical localization whereby presenting disabilities are associated with key arterial territories in the brain. Clinical localization skills are rarely taught to nonneurologists; yet, these skills are essential to the provision of evidence-based nursing care of stroke, enabling rapid patient identification, diagnosis, and ultimately, the delivery of acute treatment. This article explores the process of clinical localization in relation to the physiology affected by stroke vascular insufficiency. Elements of the neurologic examination are described as they relate to discreet areas in the brain and the National Institutes of Health Stroke Scale.

Background Bilateral hemispheric dysfunction is devastating to consciousness. We present a unique case of a patient who developed bilateral middle cerebral artery infarcts with significant neurological improvement post bilateral thrombolysis in cerebral infarction (TICI) 3 thrombectomies. Case Description The patient is a 64-year-old woman who presented 3 hours after her husband was awakened and found her with left hemiplegia. She had a history of atrial fibrillation and had her apixaban held for 5 days before the coronary angiogram that she received the day before arrival. Upon presentation, she was antigravity on the right side and withdrawing on the left side. Computed tomography angiogram showed a right M1 occlusion and an left M2 occlusion. Computed tomography perfusion revealed a mismatch with large penumbra, and she was taken for mechanical thrombectomy. Mechanical thrombectomy was performed using a combination of stent retriever and aspiration catheter with a TICI 3 revascularization. By the following morning, the patient was full strength on the right and antigravity on the left with a left facial droop. The patient recovered her speech and was fully oriented before leaving for rehabilitation on postoperative day 3. Conclusions The transient hypercoagulable state that was created with the withdrawal of apixaban likely increased our patient's risk of stroke. The literature supports continuing oral anticoagulants for endovascular procedures. The devastating consequences of thromboembolic events, whether stroke or pulmonary embolism, can be catastrophic, but luckily, mechanical thrombectomy provides the means to minimize the morbidity and mortality from bilateral infarctions.

A new method is introduced quantifying the velocity-dependent muscle response during gait in spastic muscles of children with Cerebral Palsy. The velocity-dependent muscle activation Index is calculated during a 3-dimensional gait analysis using segment angular velocity and the Instantaneous Mean Frequency calculated from surface electromyography. Typical developed children (n = 11) and children with hemiplegia (n = 11) aging from 8 to 19 years participated in the study. The rectus femoris and the medial gastrocnemius were assessed by calculating the velocity dependent muscle activation Index and the modified Ashworth Scale. Greater velocity-dependent muscle activation Index values for both medial gastrocnemius and rectus femoris muscles were associated with greater Ashworth Scale. Post hoc analysis revealed significant lower velocity-dependent muscle activation Index means in the Typical developed group compared with Ashworth Scale scores of 1, 2, 3, and 5. In addition, velocity-dependent muscle activation Index for Ashworth Scale 0, 1, and 2 were significantly lower than for Ashworth Scale 3 and 5. The velocity dependent muscle activation Index showed negative low correlation with walking speed and cadence. Findings show that spastic muscles can be quantified during dynamic functional task such as walking. Future studies should investigate the reliability of the velocity-dependent muscle activation Index that may be used for the assessment of spasticity management such as Botulinum toxin A interventions.

Objective To propose an artificial intelligence (AI)-based decision-making rule in modified Ashworth scale (MAS) that draws maximum agreement from multiple human raters and to analyze how various biomechanical parameters affect scores in MAS. Design Prospective observational study. Setting Two university hospitals. Participants Hemiplegic adults with elbow flexor spasticity due to acquired brain injury (N=34). Intervention Not applicable. Main Outcome Measures Twenty-eight rehabilitation doctors and occupational therapists examined MAS of elbow flexors in 34 subjects with hemiplegia due to acquired brain injury while the MAS score and biomechanical data (ie, joint motion and resistance) were collected. Nine biomechanical parameters that quantify spastic response described by the joint motion and resistance were calculated. An AI algorithm (or artificial neural network) was trained to predict the MAS score from the parameters. Afterwards, the contribution of each parameter for determining MAS scores was analyzed. Results The trained AI agreed with the human raters for the majority (82.2%, Cohen’s kappa=0.743) of data. The MAS scores chosen by the AI and human raters showed a strong correlation (correlation coefficient=0.825). Each biomechanical parameter contributed differently to the different MAS scores. Overall, angle of catch, maximum stretching speed, and maximum resistance were the most relevant parameters that affected the AI decision. Conclusions AI can successfully learn clinical assessment of spasticity with good agreement with multiple human raters. In addition, we could analyze which factors of spastic response are considered important by the human raters in assessing spasticity by observing how AI learns the expert decision. It should be noted that few data were collected for MAS3; the results and analysis related to MAS3 therefore have limited supporting evidence.

Purpose This trial aimed to validate the effectiveness of using the Gait Exercise Assist Robot (GEAR) in patients with hemiplegia after primary stroke. Methods The study design was open-label randomized controlled trial. Twenty-six patients with hemiplegia after primary stroke admitted to the comprehensive inpatient rehabilitation wards were enrolled and randomized to a group using GEAR in gait training and a control group. The intervention period was 4 weeks. Evaluations were conducted at admission, during intervention period, 8 weeks from start of intervention, and at discharge. Primary outcome measure was improvement efficiency of Functional Independence Measure (FIM)-walk score (FIM-walk improvement efficiency) that was calculated at the time of achieving FIM-walk score 5 (supervision level) during the intervention period or as weekly gain in FIM-walk score during 4 weeks for those who did not achieve score 5. Results FIM-walk improvement efficiency was .7 ± .4 in GEAR group and .4 ± .3 in control group, and was significantly higher in GEAR group (P = .01). The FIM-walk score gain after 4 weeks was significantly higher in the GEAR group (P = .01), but there were no significant differences between 2 groups after 8 weeks and at discharge. Conclusions Gait training using GEAR for 4 weeks improved walking ability of subacute stroke patients. GEAR contributes to early improvement of walking ability probably by the knee flexion assist during swing phase on the paralyzed side thereby increasing the volume of training, and by the finely adjustable stance/swing assist mechanism for the paralyzed limb which optimizes the training difficulty level.

Background Dynamic analyses of walking rely on the 3D ground reaction forces (GRF) under each foot, while only the resultant force of both limbs may be recorded on a single-belt instrumented treadmill or when both feet touch the same force platform. Research question This study aims to develop a robust decomposition of the shear GRF to complete the most accurate decomposition of the vertical GRF [ 8 ]. Methods A retrospective study of 374 healthy adults records (age: 22.8 ± 2.6 years, speed: 1.34 ± 0.28 m/s) and of 434 patient records (age: 21.3 ± 17.8 years, speed: 0.64 ± 0.19 m/s) were used in a machine learning process to develop a robust predictive model to decompose the fore-aft GRF. The lateral GRF was decomposed by resolving the equilibrium of transverse moments around the center of pressure. Results A predictive linear model of the fore-aft GRF under the back foot every 5% of the double contact phase was obtained from 2 predictors: the total fore-aft GRF and the vertical GRF under the back foot. Each predictor uses a time series of 31 samples before and during the double contact. The model performs accurately in healthy (median[IQR] error of 3.0[2.2–4.1]%) and in clinical gaits (7.7[4.7–13.4]%). The error in lateral GRF decomposition is of 5.7[3.9–10.2]% in healthy gaits and of 12.0[7.2–19.2]% in patients under the back foot and about half of that under the front foot. Significance The decomposition of shear GRFs achieved in this study supports the mechanics of walking. It provides outstanding accuracy in healthy gait and also applies to neurologic and orthopedic disorders. Together with the vertical GRF decomposition [ 8 ], this approach for the shear components paves the way for robust single limb GRF determination on a single-belt instrumented treadmill or when both feet touch the same force platform in normal and clinical gait analysis.

Objective To report the demographic, clinical and paraclinical characteristics as well as the outcomes during follow-up visits of HHE syndrome in Niger. Patients and methods It was a retrospective study conducted at the Neurology Outpatient Clinic of the National Hospital of Niamey (Niger) between May 2003 and May 2018. Results During the period of study, 882 patients with epilepsy aged 20 years or less were seen in consultation among whom we collected 22 cases of HHE syndrome with a hospital prevalence of 2.5%. They were 14 men and 8 women (sex ratio = 1.75) with a mean age of 3.76 years (range: 1 and 20 years). At the time of diagnosis, 81.8% of patients were aged under 6 years. The antecedent of febrile convulsions in childhood was found in only 31.8% of cases. The mean age of onset of hemiplegia was 1.9 years (range: 9 months and 5 years). The mean age of onset of epileptic seizures was 2.94 years (range: 1 and 8 years). The mean interval between the onset of hemiplegia and onset of epileptic seizures was 9 months (range: 1 month and 4 years). 31.8% of patients had a delay of acquisitions at the time of diagnosis. 95.5% of patients had drug-resistant epilepsy. Conclusion HHE syndrome is still seen in the countries of Sub-Saharan Africa. The high morbidity and mortality in children with HHE syndrome highlight the need to improve emergency care for febrile clonic seizures in childhood and the early and adequate management of infectious diseases in the child.

Objective The purpose of this study was to investigate the therapeutic effects of a newly developed shoulder robot on poststroke hemiplegic shoulder pain. Design Prospective, single-blind randomized controlled trial. Setting Inpatient department of a tertiary university hospital. Participants Hemiplegic shoulder pain patients (N=38) were consecutively recruited and randomly assigned to an intervention or control group. Interventions A newly developed robot was designed to perform joint mobilization and stretching exercises with patients lying in the supine position. Conventional physical therapy directed at both improving upper extremity mechanics and reducing neurologic injury was performed twice per day in both groups. In the intervention group, additional robotic-assisted shoulder rehabilitation therapy was administered for 30 minutes per day, 5 times per week for 4 weeks. Main Outcome Measures The visual analog scale was the primary outcome, and the pain-free passive range of motion of the shoulder joint, the Korean version of the Shoulder Disability Questionnaire, and ultrasonographic grades were the secondary outcomes. The outcomes were evaluated at baseline (T0), postintervention (T1), and a 4-week follow-up (T2). Results Significant time and group interaction effects were found on the visual analog scale, in the abduction passive range of motion, and on the Shoulder Disability Questionnaire (F2,33=16.384, P=.002; F2,33=10.609, P=.012; F2,33=32.650, P=.008, respectively). Significantly higher improvements in these outcome measures were observed in the intervention group than in the control group at T1 after post hoc analysis (P Conclusions A prototype shoulder rehabilitation robot as an adjuvant therapy improves hemiplegic shoulder pain and self-reported shoulder-related disability.

Hemiplegia is the classic condition resulting from a stroke. To assist in recovery, the overflow method can be employed to stimulate the affected limb, using the healthy contralateral lower limb (LL) to activate the plegic upper limb (UL) musculature. The aim of this study was to evaluate the immediate effect of overflow using the PNF method on the plegic upper limb muscles of post-stroke individuals in the acute and chronic stages, as well as on the muscles of healthy individuals. A total of 22 individuals participated in the work, comprising 8 healthy individuals (control group), 6 post-stroke acute stage individuals (acute group), and 8 post-stroke chronic stage individuals (chronic group). The participants were assessed using a questionnaire with sections for personal and disease data and application of the ICF scale and the Fugl-Meyer index. The three groups were submitted to electromyographic evaluation, using the posterior deltoid (PD), anterior deltoid (AD), pectoralis major (PM), and external oblique (EO) muscles in four different positions: P1 (resting the UL, with the LL contralateral to the affected limb positioned in diagonal); P2 (resting the UL, with manual resistance in the contralateral LL); P3 (affected UL positioned in diagonal, with manual resistance in the contralateral LL) e P4 (affected UL positioned in diagonal, with fixed point and manual resistance in the contralateral LL). The electromyography results revealed no significant differences between most of the positions for the four muscles evaluated (p > 0.05). However, high clinical relevance (d > 0.8) was found for muscle activation in positions 2 and 4. It could be concluded that for post-stroke individuals in the acute and chronic stages, overflow using PNF effectively increased activation of the PD, AD, PM, and EO muscles in the P2, as well as position 4.

Despite extensive literature showing damages in the sensorimotor projection fibers of children with hemiplegic cerebral palsy (HCP), little is known about how these damages affect the global brain network. In this study, we assess the relationship between the structural integrity of sensorimotor projection fibers and the integrity of intergyral association white matter connections in children with HCP. Diffusion tensor imaging was performed in 10 children with HCP and 16 typically developing children. We estimated the regional and global white-matter connectivity using a region-of-interest (ROI)-based approach and a whole-brain gyrus-based parcellation method. Using the ROI-based approach, we tracked the spinothalamic (STh), thalamocortical (ThC), corticospinal (CST), and sensorimotor U- (SMU) fibers. Using the whole-brain parcellation method, we tracked the short-, middle-, and long-range association fibers. We observed for the more affected hemisphere of children with HCP: (i) an increase in axial diffusivity (AD), mean diffusivity (MD), and radial diffusivity (RD) for the STh and ThC fibers; (ii) a decrease in fractional anisotropy (FA) and an increase in MD and RD for the CST and SMU fibers; in (iii) a decrease in FA and an increase in AD, MD, and RD for the middle- and long-range association fibers; and (iv) an association between the integrity of sensorimotor projection and intergyral association fibers. Our findings indicate that altered structural integrity of the sensorimotor projection fibers disorganizes the intergyral association white matter connections among local and distant regions in children with HCP.

Active exercise for upper limb training has been widely used to improve hemiplegic upper limb function, and its effect may be boosted by extrinsic visual feedback. The passive movement of the hemiplegic upper limb is also commonly used. We conducted a functional near-infrared spectroscopy experiment to compare cortical activation during the following three conditions: active left upper limb movement (on the hemiplegic sides in stroke patients), with or without extrinsic motor performance visual feedback (LAV, LAnV), and passive left upper limb movement (hemiplegic sides in stroke patients) (LP) in stroke patients and healthy controls. Twenty patients with right hemispheric stroke and 20 healthy controls were recruited for this study. Hemodynamic changes were detected during left upper limb movements (on the hemiplegic sides in stroke patients) under the above three conditions in the sensorimotor cortex (SMC), supplementary motor area (SMA), and premotor cortex (PMC). There was no significant difference in the level of cortical activation between patients with stroke and healthy subjects during the three conditions. Both the LAV and LAnV induced significantly higher activation in the contralateral SMA and PMC than in the LP. Extrinsic visual feedback led to additional activation in the contralateral PMC and SMA, but this was not statistically significant. Our study indicates that active upper-limb movement appears to induce higher cortical activation than that elicited by passive movement in both stroke patients and the healthy population. Extrinsic motor performance in the form of visual feedback provided during active movement may facilitate sensorimotor areas over the contralateral hemisphere.

In recent decades, the research traditions of (first-person) embodied cognition and of (third-person) social cognition have approached the study of self-awareness with relative independence. However, neurological disorders of self-awareness offer a unifying perspective to empirically investigate the contribution of embodiment and social cognition to self-awareness. This study focused on a neuropsychological disorder of bodily self-awareness following right-hemisphere damage, namely anosognosia for hemiplegia (AHP). A previous neuropsychological study has shown AHP patients, relative to neurological controls, to have a specific deficit in third-person, allocentric inferences in a story-based, mentalisation task. However, no study has tested directly whether verbal awareness of motor deficits is influenced by either perspective-taking or centrism, and if these deficits in social cognition are correlated with damage to anatomical areas previously linked to mentalising, including the supramarginal and superior temporal gyri and related limbic white matter connections. Accordingly, two novel experiments were conducted with right-hemisphere stroke patients with (n = 17) and without AHP (n = 17) that targeted either their own (egocentric, experiment 1) or another stooge patient’s (experiment 2) motor abilities from a first-or-third person (allocentric in Experiment 2) perspective. In both experiments, neurological controls showed no significant difference between perspectives, suggesting that perspective-taking deficits are not a general consequence of right-hemisphere damage. More specifically, experiment 1 found AHP patients were more aware of their own motor paralysis when asked from a third compared to a first-person perspective, using both group level and individual level analysis. In experiment 2, AHP patients were less accurate than controls in making allocentric, third-person perspective judgements about the stooge patient, but with only a trend towards significance and with no within-group, difference between perspectives. Deficits in egocentric and allocentric third-person perspective taking were associated with lesions in the middle frontal gyrus, superior temporal and supramarginal gyri, with white matter disconnections more predominate in deficits in allocentricity. This study confirms previous clinical and empirical investigations on the selectivity of first-person motor awareness deficits in anosognosia for hemiplegia and experimentally demonstrates for the first time that verbal egocentric 3PP-taking can positively influence 1PP body awareness.

Graphical abstract, Highlights • Cerebral palsy adolescents had stronger proprioceptive BOLD-responses. • Cerebral palsy adolescents had worse sensorimotor performance. • Stronger BOLD-responses were associated with worse sensorimotor performance., Cerebral palsy (CP) is a motor disorder where the motor defects are partly due to impaired proprioception. We studied cortical proprioceptive responses and sensorimotor performance in adolescents with CP and their typically-developed (TD) peers. Passive joint movements were used to stimulate proprioceptors during functional magnetic resonance imaging (fMRI) session to quantify the proprioceptive responses whose associations to behavioral sensorimotor performance were also examined. Twenty-three TD (15 females, age: mean ± standard deviation 14.2 ± 2.4 years) and 18 CP (12 females, age: mean ± standard deviation, 13.8 ± 2.3 years; 12 hemiplegic, 6 diplegic) participants were included in this study. Participants’ index fingers and ankles were separately stimulated at 3 Hz and 1 Hz respectively with pneumatic movement actuators. Regions-of-interest were used to quantify BOLD-responses from the primary sensorimotor (SM1) and secondary (SII) somatosensory cortices and were compared across the groups. Associations between responses strengths and sensorimotor performance measures were also examined. Proprioceptive responses were stronger for the individuals with CP compared to their TD peers in SM1 (p

Hemiplegic stroke patients often suffered from equinovarus foot which result in plantar pressure overload over lateral sole. 3D printing is a promising technique utilized in orthosis fabrication, and the effects on plantar pressure remains unclear. The aim in this study focus on the effect of 3D printed ankle foot orthosis, by measuring plantar parameters.Ten patients with first-ever unilateral stroke were enrolled in this study. All patients performed 10-m walk test in 3 conditions, including ambulation with 3D printed hinged ankle foot orthosis, anterior ankle foot orthosis, and bare foot. The plantar contact area, maximum force, and peak pressure were collected and evaluate using Pedar X in-sole system. Plantar parameters symmetric analysis was conducted to assess the similarity between hemiplegic leg and unaffected leg. We used Quebec User Evaluation of Satisfaction with Assistive Technology questionnaire to survey patients' subjective satisfaction.Walking with 3D printed ankle foot orthosis revealed significant increase in medial midfoot peak pressure compared to bare foot walking. Plantar parameters symmetric analysis illustrated more even medial midfoot contact area compared to bare foot walking. In satisfaction survey, walking with 3D printed ankle foot orthosis outweighs anterior ankle foot orthosis in fitting and durableness.Dynamic plantar pressure measurement is useful for evaluation of equinovarus deformity in hemiplegic stroke patients. Wearing 3D printed ankle foot orthosis increase plantar pressure in medial midfoot area. And medial midfoot contact area is also more symmetry.

In post-stroke patients, shifts in the center of gravity may affect joint movement patterns of the paraplegic lower limb during walking. The impact of changes in ankle dorsiflexion angle and trailing limb angle due to slight weight-shifting is unknown. This study aimed to investigate the effect of the abovementioned parameters on gait characteristics measured by trunk acceleration.During walking, the ankle dorsiflexion angle and trailing limb angle were assessed using two-dimensional motion analysis. Shifts in the center of gravity were assessed to evaluate symmetry, regularity, and sway of trunk movements by calculating the harmonic ratio, autocorrelation coefficient, and root mean square using a wearable trunk accelerometer.Ankle dorsiflexion angle showed a significant negative correlation with the root mean square of the anteroposterior axis (r = -0.460, p = 0.005). Trailing limb angle was significantly correlated with the autocorrelation coefficient of the vertical axis (r = 0.585, p 0.001) and root mean square of the vertical (r = -0.579, p 0.001), mediolateral (r = -0.474, p = 0.004), and anteroposterior axes (r = -0.548, p = 0.001). Trailing limb angle was a significant predictor (autocorrelation coefficient vertical axis, p = 0.001; root mean square vertical axis, p = 0.001; mediolateral axis, p = 0.007; anteroposterior axis, p = 0.001).Trailing limb angle can indicate the acquisition of forward propulsion during walking; an increase in it may contribute to improvements of the regular vertical movement ability and stability of the center of gravity sway.

We administered a discrepancy-based measure of anosognosia for hemiplegia (AHP) to a group of 42 right-brain-damaged (RBD) and left-brain-damaged (LBD) stroke patients with varying levels of functional motor ability. In addition to the expected (anosognosic) pattern of overestimation of motor function in some RBD patients, we found an equal and opposite underestimation in some others, both RBD and LBD. We also found that around a quarter of self-estimation error could be predicted directly from actual ability, such that patients with poorer motor function tended to overestimate, and vice versa. This pattern suggests that some misestimation is attributable simply to statistical regression. However, even after adjusting for this regression effect, levels of overestimation were significantly greater in RBD patients, while LBD patients were more likely to underestimate their motor ability.

The purpose of this study was to investigate the effect of comprehensive postural instructions and range of motion (ROM) exercises via educational videos for shoulder injury prevention and functional improvement of the hemiplegic shoulder after acute stroke.In this prospective cohort study, 48 subacute stroke patients with hemiplegia were enrolled and divided into 2 groups (23 in experimental group and 25 in control group). In the control group (n = 25), the patients performed conventional rehabilitation for 5 days per week. In the experimental group (n = 23), the patients received not only conventional rehabilitation but also additional postural instructions and regular ROM exercises via educational videos for hemiplegic shoulders for 15 minutes twice per day for 5 days per week during their hospital stay. Main outcome measures, including the presence and severity of pain, motor function, and sonography on hemiplegic shoulder, were assessed.More motor recovery improvement was found in the experimental group (P.05). In the supraspinatus tendon, a significantly increased frequency in tendinopathy or tear was observed between admission (12%) and before discharge (40%) in the control group (P.05), but no difference was observed in the experimental group. In the subdeltoid bursa, effusion or bursitis was significantly reduced between admission (30.4%) and before discharge (8.7%) in the experimental group (P.05).These findings suggest that comprehensive postural instructions and ROM exercises via educational videos during inpatient rehabilitation for subacute stroke patients could improve motor recovery and limit shoulder injury in stroke patients with hemiplegia.

Background Action-planning and execution deficits in children with hemiplegic cerebral palsy (HCP) are potentially due to deficits in the integration of sensory information, such as vision, with motor output. Aims To determine differences in anticipatory visual patterns in children with HCP compared to typically developing (TD) children, and to assess visuomotor coordination in children with HCP. Methods and procedures We included 13 children with HCP (Age = 6.8 + 2.9 yrs) and 15 TD children (Age = 5.8 + 1.1 yrs). The experimental task used in this study is a valid action-planning task, which consisted of initially reaching and grasping an object placed at a fixed position, followed by placing the object in a random target position. Visual patterns were recorded using a head-mounted eye-tracker system and arm movements were recorded using motion capture (120 Hz). Outcomes and results Children with HCP had delayed anticipatory gaze time and longer latency than TD children during the planning and execution phases. Children with HCP also had a higher frequency of gaze shifts, longer reaction times (RT) and movement times (MT) than TD children. Conclusions and implications Children with HCP may have deficits in anticipatory vision, which potentially affected planning and executing a goal-directed action. Therapeutic interventions focusing on improving visuomotor coordination may improve the motor performance in children with HCP.

Goal To examine the effects of botulinum toxin type A (BoNT-A) treatment combined with intensive rehabilitation for gait compared with intensive rehabilitation alone in patients with chronic stroke. Materials and Methods A comparative case series design was used. Subjects were 19 patients with chronic stroke and spastic hemiplegia. In 9 patients (group I), BoNT-A was injected into spastic muscles of the affected lower limbs, followed by a 4-week inpatient intensive rehabilitation program. In the other 10 patients (group II), a 4-week inpatient intensive rehabilitation program alone was first provided (control period) followed by the same treatment protocol in group I. The Modified Ashworth Scale (MAS) scores, range of motion (ROM), gait speed in the 10-Meter Walking Test, 6-Minute Walking Distance Test (6MD) scores, Timed Up and Go Test (TUG) scores, and Berg Balance Scale scores were evaluated every 4 weeks following baseline assessments. Results All results except for the MAS score of knee flexor and the ROM of knee flexion improved in group I and the gait speed, 6MD, and TUG scores improved in group II. Intergroup comparisons at week 4 showed significantly greater improvements in the MAS score of ankle plantar flexor, ROM of ankle dorsiflexion, and 6MD in group I than in group II ( P = .016, .011, and .009, respectively). Conclusions BoNT-A treatment for lower-limb spasticity, combined with intensive rehabilitation, was effective in improving spasticity and the 6MD compared with intensive rehabilitation alone in patients with chronic stroke.

GLUT1 deficiency syndrome (GLUT1DS) is a well described neurometabolic disorder that results from impaired glucose transport into the central nervous system. GLUT1DS classically presents with infantile-onset epilepsy, progressive microcephaly, developmental delay, ataxia, dystonia, and spasticity, but a minority of patients may manifest with paroxysmal non-epileptic phenomena including hemiparesis (Wang et al., 2002). We report for the first time cerebral perfusion changes during an acute episode of hemiparesis in a 9 year old child with GLUT1DS. The patient presented as a code stroke with her second episode of acute-onset left hemiparesis and altered mental status. Emergency MRI of brain demonstrated normal diffusion-weighted imaging, but arterial spin label perfusion weighted imaging (ASL-PWI) showed regional hypoperfusion of the right cerebral hemisphere and magnetic resonance angiography (MRA) revealed distally restricted flow related enhancement in the right MCA. The patient's deficits resolved entirely within several hours from onset. Repeat MRI one month later was normal. Our report suggests that GLUT1DS-related hemiplegic events are associated with transient lateralized cerebrovascular hypoperfusion similar to that described in hemiplegic migraine and other pediatric stroke mimics. The underlying pathophysiology for this phenomenon in GLUT1DS is not known, but may relate to cortical energy failure or abnormal cerebral microvasculature.

Background Hemiconvulsion-hemiplegia-epilepsy (HHE) involves infantile-onset acute hemiconvulsive febrile status epilepticus with subsequent unilateral cerebral atrophy and hemiparesis. Chronic epilepsy later develops, typically involving refractory focal seizures; however, the underlying pathophysiology of this epilepsy is not well understood. Patient We present a boy who had a typical acute presentation of HHE at 23 months, but an unusual evolution to chronic epilepsy in which the initially unaffected hemisphere was significantly abnormal. His initial acute presentation was right-sided hemiconvulsive febrile status epilepticus, with subsequent left cerebral hemiatrophy and hemiparesis affecting the right face, arm and leg. Focal seizures began at 5 years and were refractory to medical treatment. At 9 years, video EEG monitoring showed a striking pattern of interictal slow spike-wave and paroxysmal fast activity, maximal over the right, initially unaffected, hemisphere. He had primarily focal tonic seizures involving left-sided stiffening, also appearing to originate from the right hemisphere. Following left functional hemispherotomy he became seizure-free and parents reported improved cognitive function, attention and quality of life. Discussion This boy had classic features of Lennox-Gastaut syndrome, but expressed almost exclusively over the right hemisphere, which was initially unaffected in his acute presentation of HHE. His evolution to “hemi-Lennox-Gastaut-like phenotype” illustrates the importance of monitoring chronic epilepsy in patients with HHE; early surgical intervention might prevent pathologic recruitment of bilateral secondary networks leading to the refractory seizures and cognitive impairment associated with Lennox-Gastaut syndrome.

OBJECTIVE To explore the feasibility and safety of a single-lead, fully implantable peripheral nerve stimulation system for the treatment of chronic shoulder pain in stroke survivors. PARTICIPANTS Participants with moderate to severe shoulder pain not responsive to conservative therapies for six months. METHODS During the trial phase, which included a blinded sham introductory period, a percutaneous single-lead peripheral nerve stimulation system was implanted to stimulate the axillary nerve of the affected shoulder. After a three-week successful trial, participants received an implantable pulse generator with an electrode placed to stimulate the axillary nerve of the affected shoulder. Outcomes included pain, pain interference, pain-free external rotation range of motion, quality of life, and safety. Participants were followed for 24 months. RESULTS Twenty-eight participants underwent trial stimulation and five participants received an implantable pulse generator. The participants who received the implantable generator experienced an improvement in pain severity (p = 0.0002). All five participants experienced a 50% or greater pain reduction at 6 and 12 months, and four experienced at least a 50% reduction at 24 months. There was an improvement in pain interference (p

Clarifying the biomechanics of cane-assisted gait in elderly individuals and patients with gait disorders is important for developing better therapeutic interventions in the fields of rehabilitation and orthopedics. However, if the foot and the cane in the ipsilateral hand are placed on the same force plate simultaneously, the force plate cannot separate the forces as it records the sum of the forces. To overcome this indeterminacy problem of the ground reaction force (GRF) and the center of pressure (COP) in cane-assisted gait analysis, a method to partition the GRF and COP using an instrumented cane with a force transducer has been proposed. However, the accuracy and precision of the estimated GRF and COP has not been evaluated previously. We therefore reestablished a framework to partition the foot and cane forces during walking using an instrumented cane with a triaxial force sensor and evaluated the accuracy and precision of the method using a force plate array. Cane-assisted gait of healthy adults and hemiplegic patients were measured. Mean accuracy and precision associated with the GRF and COP measurements were approximately 0.4±1.4N and 0.2±2.7mm, respectively, indicating that the separations of the GRF and COP were sufficiently accurate for kinetic gait analysis. Although some methodological limitations certainly apply, this system will serve as a useful tool for improved therapeutic interventions.

There are a plethora of cognitive sequelae in addition to neglect and extinction that arise with unilateral right hemispheric stroke (RHS). Cognitive deficits following non-dominant (right) hemisphere stroke are common with unilateral neglect and extinction being the most recognized examples. The severity of RHS is usually underestimated by the National Institutes of Health Stroke Scale (NIHSS), which in terms of lateralized right hemisphere cognitive deficits, tests only for visual inattention/extinction. They account for 2 out of 42 total possible points. Additional neuropsychiatric sequelae include but are not limited to deficiencies in affective prosody comprehension and production (aprosodias), understanding and expressing facial emotions, empathy, recognition of familiar faces, anxiety, mania, apathy, and psychosis. These sequelae have a profound impact on patients' quality of life; affecting communication, interpersonal relationships, and the ability to fulfill social roles. They also pose additional challenges to recovery. There is presently a gap in the literature regarding a cohesive overview of the significant cognitive sequelae following RHS. This paper serves as a narrative survey of the current understanding of the subject, with particular emphasis on neuropsychiatric poststroke syndromes not predominantly associated with left hemisphere lesions (LHL), bilateral lesions, hemiplegia, or paralysis. A more comprehensive understanding of the neuropsychological consequences of RHS extending beyond the typical associations of unilateral neglect and extinction may have important implications for clinical practice, including the ways in which clinicians approach diagnostics, treatment, and rehabilitation.

Since the description of anosognosia for hemiplegia by Babinski (who also stressed the links between anosognosia and right hemisphere damage) both motivational and cognitive mechanisms have been advanced to explain this awareness disorder. In this review I will discuss first the neurophysiological mechanisms that can impede the discovery of the motor deficits contralateral to the brain lesion and then suggest that some instances of anosognosia for left-sided hemiplegia may also be due to motivational mechanisms of denial. Among the cognitive mechanisms, sensory feedback and intentional feed-forward disorders can lead to a poor awareness of the motor defects, whereas denial mechanisms could result from an interaction between the right hemisphere dominance for emotions and the anxiety raised by the catastrophic consequences of the brain damage. In particular, a maladaptive reaction to the personal implications of the brain lesion could be revealed by the presence of an implicit acknowledgement of the motor defect.

Contralateral C7 (CC7) nerve transfer surgery was shown to significantly improve the spasticity condition and the motor function of paralyzed arms. However, the involvement of the white matter tract in the recovery process is not well established. We here investigated the possible biologic explanation for this phenomenon. A 62-year-old female patient, who suffered from spastic hemiparesis due to intracranial hemorrhage, underwent CC7 transfer surgery 13 years after the initial stroke event. Six months after the surgery, the patient's Modified Ashworth Scale and Fugl-Myere score improved, even though no specific rehabilitation programs were applied. Diffusion tensor imaging (DTI) was performed before and 6 months after the surgery. The pre-surgery DTI showed both ipsilesional and contralesional CST from the cerebral peduncles to the cortices. After surgery, however, only the contralesional CST was observed. In conclusion, functional alterations of the brain white matter tract after CC7 nerve transfer surgery possibly provided a neurophysiological substrate for ameliorating the spasticity and improving the motor function in a spastic hemiplegia patient.

Background Motor imagery (MI) training may benefit children with congenital hemiplegia, but reports on MI ability are mixed. This study considered individual patterns of performance to better understand MI ability in children with hemiplegia. Method Twenty children with hemiplegia (7–13 years; 10 with right hemiplegia), completed a MI task, IQ estimate and functional tests. Children with hemiplegia scoring above chance on the MI task were compared to a group of age-matched peers. The performance patterns of those scoring below chance were considered individually. Results Three children with right hemiplegia were excluded due to low IQ. Seven of 10 children with left hemiplegia and three of seven with right hemiplegia performed MI at an equivalent level to peers without hemiplegia. The seven children with hemiplegia who scored significantly below chance scored lower on functional tests, but differences here failed to reach an adjusted significance level. Four of the seven appeared engaged in MI, but performed very poorly. The remaining three had unique performance patterns explored in more detail. Conclusion Motor imagery deficits are not universally observed in children with congenital hemiplegia and individual performance should be examined before completing group analyses. Recommendations for exclusions and reporting in future studies are made.