Abnormal cognitive planning and movement smoothness control for a complex shoulder/elbow motor task in stroke survivors

PURPOSE: Cortical function is not well understood in stroke survivors with persistent dyscoordination. The study purpose was two-fold: 1) characterize cognitive planning time and cognitive effort level for a circle-drawing motor task in stroke survivors using shoulder/elbow muscles and 2) identify the relationship between cognitive effort level and movement smoothness. METHODS: Twelve stroke survivors with shoulder/elbow coordination deficits (>12 mo) and eight controls were enrolled. The motor task was to draw a circle on a horizontal surface using only shoulder/elbow muscles. Outcome measures were: EEG-derived cognitive planning time, cognitive effort level, and movement smoothness. Comparisons between stroke and controls were made using t-tests. The Pearson's correlation model was analyzed to determine the relationship between movement smoothness and cognitive effort level. RESULTS: Stroke subjects showed a statistically significant prolonged motor planning time versus controls for both lesion and non-lesion sides (p=0.013 and 0.049, respectively). They also showed a statistically significant elevated effort level versus controls for both sides (p=0.016 and 0.013). The patients exhibited statistically significant poor movement smoothness in the medial/lateral and forward/backward movement directions versus controls (p=0.035 and 0.037, respectively). For stroke, there was a significant correlation between cognitive effort level on the non-lesion side and smoothness of movement in the medial/lateral and forward/backward directions (r=0.54, p=0.036 and r=0.76, p=0.002, respectively). On the lesion side, results were mixed (r=0.268, p=0.2 r=0.59, p=0.023, respectively). CONCLUSIONS: Stroke survivors with upper limb motor deficits exhibit a longer cognitive planning time and elevated cognitive effort for performance of a complex shoulder/elbow motor coordination task. The elevated cognitive effort level was associated with poor (jerky) motor performance, suggesting a potential role of the CNS in controlling movement smoothness of the arm.     

Electrical stimulation of wrist extensors in poststroke hemiplegia.

BACKGROUND AND PURPOSE: It has been suggested that cyclic neuromuscular electrical stimulation (ES) may enhance motor recovery after stroke. We have investigated the effects of ES of the wrist extensors on impairment of wrist function and on upper-limb disability in patients being rehabilitated after acute stroke. METHODS: We recruited 60 hemiparetic patients (mean age, 68 years) 2 to 4 weeks after stroke into a randomized, controlled, parallel-group study comparing standard rehabilitation treatment with standard treatment plus ES of wrist extensors (3 times 30 minutes daily for 8 weeks). Isometric strength of wrist extensors was measured using a device built for that purpose. Upper-limb disability was assessed with use of the Action Research Arm Test (ARAT). Observations were continued for 32 weeks (24 weeks after the finish of ES or the control intervention phase). RESULTS: The change in isometric strength of wrist extensors (at an angle of 0 degrees extension) was significantly greater in the ES group than the control group at both 8 and 32 weeks (P=0.004, P=0.014 by Mann Whitney U test). At week 8 the grasp and grip subscores of the ARAT increased significantly in the ES group compared with that in the control group (P=0.013 and P=0.02, respectively); a similar trend was seen for the total ARAT score (P=0.11). In the subgroup of 33 patients with some residual wrist extensor strength at study entry (moment at 0 degrees extension >0), the ARAT total score had increased at week 8 by a mean of 21.1 (SD, 12.7) in the ES group compared with 10.3 (SD, 9.0) in the control group (P=0.024, Mann Whitney U test); however, at 32 weeks the differences between these 2 subgroups were no longer statistically significant. CONCLUSIONS: ES of the wrist extensors enhances the recovery of isometric wrist extensor strength in hemiparetic stroke patients. Upper-limb disability was reduced after 8 weeks of ES therapy, with benefits most apparent in those with some residual motor function at the wrist. However, it is not clear how long the improvements in upper-limb disability are maintained after ES is discontinued.     

Muscle weakness and cocontraction in upper limb hemiparesis: relationship to motor impairment and physical disability

The purpose of this article is to describe the relationship between poststroke upper limb muscle weakness and cocontraction, and clinical measures of upper limb motor impairment and physical disability. Electrormyographic (EMG) activity of the paretic and nonparetic wrist flexors and extensors of 26 chronic stroke survivors were recorded during isometric wrist flexion and extension. The root mean square (RMS) of the EMG signal was used as a measure of strength of contraction. A ratio of RMS of antagonist and agonist muscles was used as a measure of cocontraction. Upper limb motor impairment and physical disability were assessed with the Fugl-Meyer motor assessment (FMA) and the arm motor ability test (AMAT), respectively. The strength of muscle contraction was significantly stronger in the nonparetic limb (P < 0.001). The degree of cocontraction was significantly greater in the paretic limb (P < 0.001). The strength of muscle contraction in the paretic limb correlated significantly with FMA (r = 0.62 to 0.87, P < or = 0.001) and AMAT (r = 0.66 to 0.80, P < or = 0.001) scores. Similarly, the degree of cocontraction correlated significantly with FMA (r = -0. 70 to -0.64, P < or = 0.001) and AMAT (r = -0. 72 to -0.62, P < or = 0.001) scores. Muscle weakness and degree of cocontraction correlate significantly with motor impairment and physical disability in upper limb hemiplegia. This relationship may provide insights toward development of specific interventions. However, additional studies are needed to demonstrate a cause and effect relationship.     

A novel approach to stroke rehabilitation: robot-aided sensorimotor stimulation

OBJECTIVE: In patients with stroke, the authors tested whether additional sensorimotor training of the paralyzed or paretic upper limb delivered by a robotic device enhanced motor outcome. METHODS: Fifty-six patients with stroke and hemiparesis or hemiplegia received standard poststroke multidisciplinary rehabilitation, and were randomly assigned either to receive robotic training (at least 25 hours) or exposure to the robotic device without training. Outcomes were assessed by the same masked raters, before treatment began and at the end of treatment, with the upper extremity component of the Fugl-Meyer Motor Assessment, the Motor Status score, the Motor Power score, and Functional Independence Measurement. RESULT: The robot treatment and control group had comparable clinical characteristics, lesion size, and pretreatment impairment scores. By the end of treatment, the robot-trained group demonstrated improvement in motor outcome for the trained shoulder and elbow (Motor Power score, p < 0.001; Motor Status score, p < 0. 01) that did not generalize to untrained wrist and hand. The robot-treated group also demonstrated significantly improved functional outcome (Functional Independence Measurement-Motor, p < 0. 01). CONCLUSION: Robot-delivered quantitative and reproducible sensorimotor training enhanced the motor performance of the exercised shoulder and elbow. The robot-treated group also demonstrated improved functional outcome. When added to standard multidisciplinary rehabilitation, robotics provides novel therapeutic strategies that focus on impairment reduction and improved motor performance.     

卒中偏瘫患者出院后习得性废用发展情况的调查研究

目的 调查卒中亚急性期偏瘫患者出院后习得性废用发展情况，分析习得性废用与患者人口学因素、 临床特点及功能恢复的相关性。 方法 前瞻性连续纳入2018年7月-2019年12月期间南方医科大学深圳医院预备出院的卒中偏瘫患 者。收集患者一般资料和临床特点，并在出院后4周、8周和12周用运动活动记录表（motor activity log， MAL）评估患者的习得性废用情况，在出院前3 d，出院后4周、8周和12周用改良Ashworth指数测试肘 腕屈肌群肌张力，偏瘫上肢功能测试香港版、Fugl-Meyer评定量表上肢部分和箱块测试评价上肢功 能，功能独立性评定评价日常生活能力。对各随访时间点MAL与其他评估量表、人口学因素和临床特 点进行相关性分析。 结果 研究完成随访患者47例，男性36例（76.6%），平均年龄58.74±11.08岁，平均发病时间 48.00±28.38 d，其中缺血性卒中32例（68.1%），出血性卒中15例（31.9%）。MAL的患手使用频率/ 患者活动质量在出院后4周、8周和12周时分别为2.66（1.38～4.03）分/2.87（1.03～3.56）分、3.30 （1.93～4.41）分/3.17（1.55～3.77）分和3.59（2.00～4.33）分/3.28（2.00～3.96）分，除8周与12周 之间的患手使用频率差异无统计学意义之外，其他时间点之间差异均具有统计学意义。各随访时间 点患者肘屈肌群张力变化差异无统计学意义（P =0.076），其余功能表现均显著恢复（均P <0.05）。出 院后4周、8周和12周各时间点，MAL与年龄呈一般正相关（ρ=0.33～0.39），与发病时间呈一般负相关 （ρ=-0.49～-0.33），与肘腕部屈肌张力呈一般至中等负相关（ρ=-0.58～-0.38），与日常生活能力 呈一般至中等正相关（ρ=0.30～0.60），与上肢运动功能呈一般至强正相关（ρ=0.49～0.76）。 结论 卒中亚急性期偏瘫患者出院后患肢仍然可以保持显著的功能恢复，但依然面临习得性废用 的挑战，且习得性废用与年龄、发病时间、腕肘屈肌群张力、日常生活生活能力和上肢功能相关。     

Involuntary paretic wrist/finger flexion forces and EMG increase with shoulder abduction load in individuals with chronic stroke

ObjectiveClinical observations of the flexion synergy in individuals with chronic hemiparetic stroke describe coupling of shoulder, elbow, wrist, and finger joints. Yet, experimental quantification of the synergy within a shoulder abduction (SABD) loading paradigm has focused only on shoulder and elbow joints. The paretic wrist and fingers have typically been studied in isolation. Therefore, this study quantified involuntary behavior of paretic wrist and fingers during concurrent activation of shoulder and elbow.MethodsEight individuals with chronic moderate-to-severe hemiparesis and four controls participated. Isometric wrist/finger and thumb flexion forces and wrist/finger flexor and extensor electromyograms (EMG) were measured at two positions when lifting the arm: in front of the torso and at maximal reaching distance. The task was completed in the ACT^3D robotic device with six SABD loads by paretic, non-paretic, and control limbs.ResultsConsiderable forces and EMG were generated during lifting of the paretic arm only, and they progressively increased with SABD load. Additionally, the forces were greater at the maximal reach position than at the position front of the torso.ConclusionsFlexion of paretic wrist and fingers is involuntarily coupled with certain shoulder and elbow movements.SignificanceActivation of the proximal upper limb must be considered when seeking to understand, rehabilitate, or develop devices to assist the paretic hand.     

Evaluation of a German version of the Rivermead Mobility Index (RMI) in acute and chronic stroke patients

The English Rivermead Mobility Index (RMI) has been proposed as a simple, valid and reliable measure in stroke rehabilitation. A German version was established and validated in two centres. In centre A 46 acute (median: 3.0 days after onset) and in centre B 151 chronic (median: 88.0 days after onset) stroke patients participated. Interrater reliability of the German RMI was tested in 12 subjects in the acute stage of stroke and was found to be statistically significant (r = 0.98, P < 0.0001). In centre A, a statistically significant correlation was found between the German RMI and the 10-m walk time at baseline (r = 0.73, P < 0.0001) and after three weeks (r = 0.92, P < 0.0001). In centre B, the German RMI correlated significantly with the motor part of the Functional Independence Measure (motor-FIM) on admission (r = 0.78, P < 0.0001) and after three weeks (r = 0.79, P < 0.0001), respectively. The change of the RMI correlated significantly with the change in 10-m walk time in acute patients (r = 0.87, P < 0.0001) and with the change in motor-FIM in chronic patients (r = 0.54, P < 0.0001). A moderate ceiling-effect was detected in the chronic study population. The German RMI appears to be a reliable, valid and responsive measure for mobility disability in acute and chronic stroke patients.     

Recovery of submaximal upper limb force production is correlated with better arm position control and motor impairment early after a stroke

Objective

This study determined whether recovery of upper limb position control using submaximal force production correlates with an improvement in functional arm impairment during early recovery from stroke.

Methods

Ten consecutive inpatients were recruited from a stroke unit. Each patient was in early recovery (<8 weeks post-lesion) from their first ever stroke. Evaluations of submaximal continuous force production and position control, maximal force production at the shoulder and a clinical outcome measure of motor impairment (Fugl-Meyer score; FM) were performed 20 days post-stroke as a baseline and then once a week for the following four weeks.

Results

Submaximal force production and its modulation during a position-holding task improved in early recovery after stroke, whereas maximal force production did not. Better modulation of submaximal force production enabled improved arm position control which was significantly correlated to the changes in FM score of motor impairment during recovery.

Conclusions

This study demonstrated that improvement in submaximal force modulation can operate as a mechanism enabling better motor behaviour such as arm position control during early recovery from a stroke.

Significance

Future rehabilitation strategies may benefit from adding submaximal force development and modulation to early interventions after stroke.     

Use of botulinum toxin in stroke patients with severe upper limb spasticity.

OBJECTIVES--Spasticity can contribute to poor recovery of upper limb function after stroke. This is a preliminary evaluation of the impact of botulinum toxin treatment on disability caused by upper limb spasticity after stroke. METHODS--Seventeen patients with severe spasticity and a non-functioning arm were treated with intramuscular botulinum A neurotoxin (median age at treatment 54.5 years; median time between onset of stroke and treatment 1.5 years). Baseline and assessments two weeks after treatment were compared to assess efficacy. The duration of improvement in disability was documented. Outcome measures used were; passive range of movement at the shoulder, elbow, wrist, and fingers; modified Ashworth scale to assess spasticity of biceps and forearm finger flexors; an eight point scale to assess the degree of difficulty experienced by the patient or carer for each functional problem defined before treatment; the presence of upper limb pain. The biceps, forearm finger flexors, and flexor carpiulnaris were treated with intramuscular botulinum toxin. Up to a total dose of 400-1000 mouse units (MU) of Dysport (Speywood) or 100-200 MU of BOTOX (Allergan) was used in each patient. RESULTS--Functional problems reported by the patients before treatment were difficulty with cleaning the palm, cutting fingernails, putting the arm through a sleeve, standing and walking balance, putting on gloves, and rolling over in bed. Hand hygiene improved in 14 of 17 patients; difficulty with sleeves improved in four of 16; standing and walking balance improved in one of four; shoulder pain improved in six of nine; wrist pain improved in five of six. Passive range of movement at shoulder, elbow, and wrist improved after treatment. Benefit was noted within two weeks and lasted one to 11 months. No adverse effects occurred. CONCLUSION--This preliminary study suggests that intramuscular botulinum toxin is a safe and effective treatment for reducing disability in patients with severe upper limb spasticity.     

Robot-aided sensorimotor arm training improves outcome in patients with chronic stroke

Thirty patients with chronic stroke received 6 weeks of sensorimotor robotic training in a pilot study that targeted motor function of the affected shoulder and elbow. The impairment and disability scores were stable during a 2-month observation/measurement period, improved significantly by program completion, and remained robust in the 3-month follow-up. Task-specific motor training attenuated a chronic neurologic deficit well beyond the expected period for improvement after stroke.     

Upper and lower extremity robotic devices for rehabilitation and for studying motor control

PURPOSE OF REVIEW: The successful motor rehabilitation of stroke, traumatic brain-injured and spinal cord-injured patients requires an intensive and task-specific therapy approach. Budget constraints limit a hand-to-hand therapy approach, so that intelligent machines may offer a solution to promote motor recovery and obtain a better understanding of motor control. This new field of automated or robot-assisted motor rehabilitation has emerged since the 1990s. RECENT FINDINGS: This article will present clinically viable devices for upper and lower extremity rehabilitation. The MIT-Manus and the Mirror-Image Motion Enabler robot, which enable unrestricted unilateral or bilateral shoulder and elbow movement, consistently proved superior on the motor impairment level. The ARM guide, which assisted reaching in a straight-line trajectory, and the Bi-Manu-Track, which enabled the bilateral practice of a forearm and wrist movement, are currently being tested. For gait rehabilitation after stroke, the electromechanical gait trainer, GT I, has proved effective compared with treadmill training with body weight support. The Lokomat, consisting of a treadmill and a powered exoskeleton, lessened the therapeutic effort compared with manually assisted treadmill training in spinal cord-injured patients. Future developments will see more degrees of freedom, improved man-machine interaction and the implementation of virtual reality. SUMMARY: Technical possibilities are one aspect, but multi-centre trials and a consideration of the unsubstantiated fears among therapists of being replaced by machines will decide on the successful implementation of this most promising field to the benefit of patients.     

Double representation of the wrist and elbow in human motor cortex

Movements of the fingers, hand and arm involve overlapping neural representations in primary motor cortex (M1). Monkey M1 exhibits a core–surround organisation in which cortical representation of the hand and fingers is surrounded by representations of the wrist, elbow and shoulder. A potentially homologous organisation in human M1 has only been observed in a single study, a functional MRI (fMRI) study by [J.D. Meier, T.N. Aflalo, S. Kastner & M.S. Graziano.(2008) J Neurophysiol, 100(4), 1800–1812]. The results of their study suggested a double representation of the wrist in human M1, an unprecedented finding. Our purpose was to document and simultaneously provide evidence that would extend the presence of double representation of the wrist to that of the elbow. Using fMRI, we observed somatotopic maps in M1 and the supplementary motor area (SMA), the only other cortical area that showed robust within‐limb somatotopy during self‐timed finger, wrist and elbow movements. We observed double wrist and elbow representation that bracketed finger fMRI responses in M1 and the SMA. Our results show that the cortical locations of these double representations are well predicted by local cortical anatomy. Double representation of the wrist and elbow is important because it violates the traditional somatotopic progression in M1 but it is consistent with the representation of synergistic movements involving adjacent effectors.     

Clinimetric evaluation of a new overall disability scale in immune mediated polyneuropathies

OBJECTIVES: To determine the validity, reliability, and responsiveness of a new overall disability sum score in immune mediated polyneuropathies. METHODS: Three impairment measures (MRC sum score, sensory sum score, grip strength (Vigorimeter)) and three disability scales (an overall disability sum score (ODSS), Hughes' functional scale (f score), Rankin scale) were assessed in a cross sectional group of 113 clinically stable patients (83 with Guillain-Barré syndrome, 22 with chronic inflammatory demyelinating polyneuropathy (CIDP), eight with a gammopathy related polyneuropathy). The ODSS was also used serially in 20 patients with recently diagnosed Guillain-Barré syndrome (n = 7) or CIDP (n = 13) and changing clinical conditions. Multiple regression studies were performed to compare the impact of impairment disturbances (independent variables) on the various disability scales (dependent variable). RESULTS: Moderate to good construct validity (stable group: Spearman's rank test (absolute values), r = 0.41-0.79; longitudinal group: multiple correlation coefficient, R = 0.69-0.89; p < 0.006 for all associations) and reliability (intraclass correlation coefficient, R = 0.90-0.95; p < 0.0001) were demonstrated for the ODSS. Its SRM values were high (> 0.8), indicating good responsiveness. Impairment measures accounted for a higher variance proportion of the ODSS compared with the f score and Rankin (R = 0.64 v 0.56 and 0.45, respectively). CONCLUSIONS: All clinimetric requirements were met by the overall (arm and leg) disability sum score in immune mediated polyneuropathies. Its use is therefore suggested in evaluating immune mediated polyneuropathies.     

Prediction of Upper Limb use Three Months after Stroke: A Prospective Longitudinal Study

BackgroundA major goal of upper limb (UL) rehabilitation after stroke is to facilitate the use of the paretic arm in daily life activities.PurposeTo examine if UL impairment two weeks after stroke can predict real-life UL use at three months. Furthermore, to identify additional factors which contribute to future UL use, and characteristics of patients who do not achieve normal UL use.MethodsThis study included patients with stroke ≥ 18 years. UL impairment was assessed by Fugl-Meyer upper extremity motor assessment (FM). Use ratio between affected and unaffected UL was assessed with accelerometers at three months after stroke. The association between FM score and UL use ratio was investigated with linear regression models and adjusted for secondary variables. Non-normal use was examined by a logistic regression.ResultsEighty-seven patients were included. FM score two weeks after stroke predicted 38% of the variance in UL use ratio three months after stroke. A multivariate regression model predicted 55%, and the significant predictors were FM, motor-evoked potential (MEP) status, and neglect. Non-normal use could be predicted with a high accuracy based on MEP and/or neglect. In a logistic regression sensitivity for prediction of non-normal use was 0.93 and specificity was 0.75.ConclusionBetter baseline capacity of the paretic UL predicted increased use of the arm and hand in daily life. Non-normal UL use could be predicted reliably based on the absence of MEPs and/or presence of neglect.     

Grip strength is a representative measure of muscle weakness in the upper extremity after stroke

Background: Muscle weakness is the most common impairment in the upper extremity after stroke, leading to a reduced ability to use the arm and the hand in daily activities. Grip strength is easier to measure than precise, but more time-consuming, isokinetic and isometric arm muscle strength measurements. It would therefore be advantageous in a clinical setting if grip strength could be used as a proxy for muscle strength in the entire upper extremity.

Objective: To investigate the association between grip strength and isometric and isokinetic arm muscle strength in persons with chronic stroke.

Methods: Forty-five persons with mild-to-moderate paresis in the upper extremity, at least 6 months post-stroke participated. Isometric grip strength was measured with a computerized grip dynamometer and arm strength (isometric shoulder abduction and elbow flexion as well as isokinetic elbow extension and flexion) with an isokinetic dynamometer. Pearson’s correlation coefficient was used to determine the association between the muscle strength measurements.

Results: There were significant correlations (p < .0001) between grip strength and all arm strength measurements in both the more affected (r = 0.77–0.82) and the less affected upper extremity (r = 0.65–0.82).

Conclusion: This cross-sectional study showed that grip strength is strongly associated with muscle strength in the arm in persons in the chronic phase after stroke. As grip strength is easy to measure and less time-consuming than arm muscle strength measurements, this implies that grip strength can be a representative measure of muscle weakness of the entire upper extremity in the chronic phase after stroke.     

Effects of acupuncture treatment on poststroke motor recovery and physical function: a pilot study

This pilot study obtained preliminary data on the effects of acupuncture treatment combined with a standard inpatient stroke rehabilitation program on poststroke motor recovery and physical function. Thirty-two patients with acute stroke were recruited and randomized to 1 of 2 treatment arms: standard rehabilitation (control group) or a combination of acupuncture and standard rehabilitation (acupuncture group). Baseline and discharge assessments were obtained on motor recovery as measured by the Fugl-Meyer (FM) Assessment and on physical function as measured by the Functional Independence Measure (FIM). Comparisons were made between the acupuncture and control group in total FM and FIM as well as for each subscale of the FM and FIM. No differences between treatment groups were found in the total FM or the total FIM. However, statistically significant benefit due to acupuncture was observed for the FM lower extremity motor function subscale (P = 0.01) and the tub/shower transfer mobility subscale of the FIM (P = 0.03). Marginally significant benefit due to acupuncture was noted for the toilet transfer mobility subscale of the FIM (P = 0.09). The effectiveness of acupuncture as an adjunct to standard poststroke rehabilitation programs may be demonstrated when more specific measures of stroke motor recovery and physical function are used.     

急性缺血性脑卒中患者认知损害的危险因素分析

目的探讨急性缺血性脑卒中患者出现认知损害的危险因素,为预防脑卒中后认知损害提供依据。方法回顾性分析2015年1月至2018年9月住院的103例急性缺血性脑卒中患者的临床资料,所有入组病例均在入院第2天空腹采集肘静脉血测定血脂、同型半胱氨酸、空腹血糖及糖化血红蛋白。参照2019年美国糖尿病学会发布的"糖尿病医学诊疗标准"制定血糖控制标准(空腹血糖4.4~7.2mmol·L-1,糖化血红蛋白<6.5%)。发病第10~14天(病情稳定排除谵妄等情况)进行北京版蒙特利尔认知评估(MoCA)量表测评,将MoCA评分<26分为认知损害组(64例)和MoCA≥26分为无认知损害组(39例),通过统计学分析探讨急性缺血性脑卒中出现认知损害的危险因素。结果与无认知损害组比较,认知损害患者年龄偏大(P=0.013)、美国国立卫生研究院卒中量表(NIHSS)评分较高(P=0.016);认知损害组空腹血糖、糖化血红蛋白水平高于无认知损害组,且血糖控制达标情况较无认知损害组差(分别P=0.001,P=0.045,P=0.006,P=0.001)。结论高龄、NIHSS评分高、空腹血糖升高及血糖水平控制达标差是急性缺血性脑卒中患者出现认知损害的危险因素之一,血糖作为可控因素,严格控制血糖可能有助于预防急性缺血性脑卒中后认知损害的发生。     

Differences between flexion and extension synergy-driven coupling at the elbow,wrist, and fingers of individuals with chronic hemiparetic stroke

ObjectiveThe flexion and extension synergies were quantified at the paretic elbow, forearm, wrist, and finger joints within the same group of participants for the first time. Differences in synergy expression at each of the four joints were examined, as were the ways these differences varied across the joints.MethodsTwelve post-stroke individuals with chronic moderate-to-severe hemiparesis and six age-matched controls participated. Participants generated isometric shoulder abduction (SABD) and shoulder adduction (SADD) at four submaximal levels to progressively elicit the flexion and extension synergies, respectively. Isometric joint torques and EMG were recorded from shoulder, elbow, forearm (radio-ulnar), wrist, and finger joints and muscles.ResultsSABD elicited strong wrist and finger flexion torque that increased with shoulder torque level. SADD produced primarily wrist and finger flexion torque, but magnitudes at the wrist were less than during SABD. Findings contrasted with those at the elbow and forearm, where torques and EMG generated due to SABD and SADD were opposite in direction.ConclusionsFlexion and extension synergy expression are more similar at the hand than at the shoulder and elbow. Specific bulbospinal pathways that may underlie flexion and extension synergy expression are discussed.SignificanceWhole-limb behavior must be considered when examining paretic hand function in moderately-to-severely impaired individuals.     

缺血性卒中后焦虑抑郁与认知功能障碍的关系研究

目的 探讨缺血性卒中后焦虑抑郁与认知功能障碍的关系。 方法 选取2017年1月-2018年3月邯郸市第一医院收治的首发缺血性卒中患者98例,同期非缺血性 卒中入院的患者50例作为对照组。分别进行汉密尔顿焦虑量表（Hamilton anxiety scale,HAMA）、汉密 尔顿抑郁量表（Hamilton depression scale,HAMD）、日常生活能力量表(activity of daily living scale,ADL)、 蒙特利尔认知评估量表（Montreal cognitive assessment,MOCA）和NIHSS评测。比较两组的认知功能 障碍和焦虑、抑郁发生情况;对卒中组的ADL、MoCA、NIHSS评分与HAMA、HAMD评分进行相关性分析; 对ADL、MoCA、NIHSS评分进行相关性分析。 结果 卒中组中62例（63.3%）患者存在认知功能障碍,存在焦虑者53例（54.1%）,抑郁者42例 （42.9%）,对照组中存在认知功能障碍者14例（28%）,存在焦虑者17例（34.0%）,抑郁者9例（18.0%）。 卒中组MoCA和ADL评分均低于对照组,差异均有统计学意义。卒中组HAMA评分与ADL、MoCA和NIHSS 评分相关系数分别为r =-0.526（P＜0.001）、r =-0.592（P＜0.001）和r =0.412（P＜0.001）;HAMD评分 与ADL、MoCA和NIHSS评分的相关系数分别为r =-0.490（P＜0.001）、r =-0.571（P＜0.001）和r =0.606 （P＜0.001）;ADL与MoCA、NIHSS评分的相关系数分别为r =0.933（P＜0.001）和r =-0.842（P＜0.001）; MoCA与NIHSS评分的相关系数为r =-0.911（P＜0.001）。 结论 ①缺血性卒中后焦虑及抑郁的发生率较高且与认知功能障碍相关;②缺血性卒中后焦虑、 抑郁越重,其神经功能缺损的程度越重,日常生活能力越差。     

Association of cerebral palsy with other disabilities in children with perinatal arterial ischemic stroke

The association of cerebral palsy with other disabilities in children with perinatal stroke has not been well-studied. We examined this association in 111 children with perinatal stroke: 67 with neonatal presentation, and 44 with delayed presentation. Seventy-six children (68%) had cerebral palsy, which was hemiplegic in 66 and tri- or quadriplegic in 10. Fifty-five (72%) children with cerebral palsy had at least one other disability: 45 (59%) had a cognitive/speech impairment (moderate-severe in 20), and 36 (47%) had epilepsy (moderate-severe in 11). In children with neonatal presentation, cerebral palsy was associated with epilepsy (P = 0.0076) and cognitive impairment (P = 0.0001). These associations could not be tested in children with delayed presentation because almost all children in this group had cerebral palsy. In another analysis with multivariate logistic regression for children with cerebral palsy, children who had both neonatal presentation and history of cesarean-section delivery were more likely to have epilepsy (P = 0.001). Children with cerebral palsy after perinatal stroke who had neonatal presentation were more likely to have severe cognitive impairment (odds ratio, 7.78; 95% confidence interval, 1.80-47.32) or severe epilepsy (odds ratio, 6.64; 95% confidence interval, 1.21-69.21) than children with delayed presentation. Children with cerebral palsy after perinatal stroke are likely to have an additional disability; those with neonatal presentation are more likely to have a severe disability.