Wataru Kakuda

The Jikei University School of Medicine, Edo, Tōkyō, Japan

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Publications (42)67.09 Total impact

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    ABSTRACT: Background: The purpose of this study was to determine whether local injection of botulinum toxin type A (BoNT-A) into the spastic muscles has any added benefits to repetitive transcranial magnetic stimulation (RTMS)/occupational therapy (OT) in patients with spastic upper limb hemiparesis. Methods: The study subjects of 80 post-stroke patients with spastic upper limb hemiparesis (age: 60.2 ± 13.0 years, time after stroke: 55.3 ± 43.0 months), were divided into the BoNT-A plus RTMS/OT group and RTMS/OT group. BoNT-A was injected into the spastic muscles (total dose: 240 units) before RTMS/OT. The latter included 12 sessions of 40 min RTMS over the non-lesional hemisphere and 240-min intensive OT daily over 15 days. Spasticity was evaluated by the modified Ashworth scale (MAS) and the motor function of the affected upper limb was evaluated serially with Fugl-Meyer Assessment and Wolf Motor Function Tests. Results: Both groups showed significant improvements in spasticity and motor function. The addition of BoNT-A resulted in better improvement in FMA score and MAS of finger flexor muscles (p < 0.05). Conclusions: The triple-element protocol of local injection of BoNT-A into spastic finger muscles, RTMS and intensive OT, is a promising therapeutic program for post-stroke spastic upper limb hemiparesis, although its significance should be confirmed in randomized, placebo-controlled trials. © 2014 S. Karger AG, Basel.
    European neurology. 10/2014; 72(5-6):290-298.
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    ABSTRACT: The effects of testosterone on functional recovery in stroke patients have not previously been studied. The purpose of the study was to determine the effects of pre-rehabilitation serum testosterone levels on functional recovery in male stroke patients. In total, 111 male stroke patients admitted to our department were enrolled in the study (age: 74 ± 10 years, days from stroke onset: 36 ± 14 days). Serum concentration of free testosterone (Free-T) was measured upon admission. Patients were also evaluated using the Functional Independence Measure (FIM) at admission and discharge. The main outcome variable was FIM at discharge. Correlations between Free-T and FIM were evaluated using Spearman's rank-order correlation coefficients. We performed multivariate linear regression analysis to assess the effects of testosterone on functional outcome with adjustment for patient background variables. In addition, we added a subgroup analysis based on age. The average Free-T serum concentration was 4.7 ± 1.7 pg/ml. There was a significant positive correlation between Free-T and discharge FIM. The multivariate linear regression model showed that Free-T concentration was significantly associated with FIM at discharge (β = 0.09; P = 0.01). In the subgroup analysis, Free-T had significant association with discharge FIM only in patients under 76 years old (β = 0.24; P < 0.001). Our data suggest that serum Free-T levels have a positive effect for discharge FIM in male stroke patients.
    Neurologia medico-chirurgica 09/2014; · 0.49 Impact Factor
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    Nobuyuki Sasaki, Wataru Kakuda, Masahiro Abo
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    ABSTRACT: Abstract Background: High- and low-frequency repetitive transcranial magnetic stimulation (HF-rTMS and LF-rTMS) has been shown to be beneficial for upper limb hemiparesis in patients with acute stroke. However, no study has examined the usefulness of bilateral application of HF- and LF-rTMS (BL-rTMS). Methods: Fifty-eight hemiparetic patients with acute stroke were randomly assigned into two groups: HF-rTMS group and BL-rTMS group. All patients were scheduled to receive five sessions of either HF-rTMS over the lesional hemisphere or BL-rTMS over both hemispheres for 5 days. Motor function of the affected upper limb was evaluated using the Brunnstrom Recovery Stage (BRS) for upper-limb and hand-fingers, grip strength and tapping frequency, before the first session and after the last session of rTMS. Results: Improvement of BRS for the upper limb and hand/finger was significantly greater in the BL-rTMS group than the HF-rTMS group (p < 0.01). Improvement in grip strength and tapping frequency was also greater in the BL-rTMS group, although the differences were not statistically significant. Conclusions: The proposed BL-rTMS is safe and feasible and showed a greater improvement of BRS of the affected upper limb compared to HF-rTMS. This novel rTMS approach may be a useful intervention for hemiparetic patients with acute stroke.
    Brain Injury 08/2014; · 1.51 Impact Factor
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    ABSTRACT: The purpose of this study was to assess the safety, feasibility and efficacy of continuous theta-burst stimulation (cTBS) combined with intensive occupational therapy (OT) for upper limb hemiparesis after stroke. Ten patients with history of stroke and upper limb hemiparesis (age 62.0 ± 11.1 years, time since stroke 95.7 ± 70.2 months, mean ± SD) were studied. Each patient received 13 sessions, each comprising 160 s of cTBS applied to the skull on the area of the non-lesional hemisphere (using a 70-mm figure-8 coil, three pulse bursts at 50 Hz, repeated every 200 ms, i.e., 5 Hz, with total stimulation of 2,400 pulses), followed by intensive OT (comprising 120-min one-to-one training and 120-min self-training) during 15-day hospitalization. The motor function of the affected upper limb was evaluated by Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) on the days of admission and discharge. All patients completed the 15-day protocol without any adverse effects. Treatment significantly increased the FMA score (from 46.6 ± 8.7 to 51.6 ± 8.2 points, p < 0.01) and shortened the log performance time of WMFT (from 2.5 ± 1.1 to 2.2 ± 1.2 s, p < 0.01). The 15-day protocol of cTBS combined with intensive OT is a safe and potentially useful therapeutic modality for upper limb hemiparesis after stroke.
    Acta neurologica Belgica. 04/2014;
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    ABSTRACT: ABSTRACT Background: The combination protocol of repetitive transcranial magnetic stimulation (RTMS) and intensive occupational therapy (OT) improves motor function of the paretic upper limb in poststroke patients. However, the effect of RTMS/OT on motor neuron excitability remains to be investigated. The purpose of this study was to determine the effect of 15-day application of RTMS/OT on motor neuron excitability in such patients using neurophysiological studies including F-wave parameter measurements. Subjects and Methods: Ten post-stroke patients with spastic upper limb hemiparesis were studied (mean age: 57.4±8.1 years, ±SD). Patients were hospitalized for 15 days to receive RTMS/OT. One session of 40-min low-frequency RTMS and two sessions of 120-min intensive OT were provided daily. Neurophysiological studies including F-wave parameters measurements were performed on the days of admission/discharge. Motor function and spasticity of the affected upper limb were evaluated on the same time points. Results: RTMS/OT significantly improved motor function of the affected upper limb. RTMS/OT decreased the modified Ashworth scale in the affected upper limb (p<0.05), but did not change F-wave frequency in either upper limb. However, both F-mean/M ratio and F-max/M ratio significantly decreased in the affected upper limb (all p<0.05). Conclusions: The 15-day protocol of LF-RTMS/OT produced significant reduction of motor neuron excitability. RTMS/OT can potentially produce significant reduction in upper limb spasticity in the affected upper limb, although this finding should be confirmed in a larger number of patients.
    The International journal of neuroscience 02/2014; · 0.86 Impact Factor
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    Ryo Momosaki, Masahiro Abo, Wataru Kakuda
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    ABSTRACT: The purpose of this study was to clarify the safety and feasibility of a 6-day protocol of bilateral repetitive transcranial magnetic stimulation (rTMS) combined with intensive swallowing rehabilitation for chronic poststroke dysphagia. In-hospital treatment was provided to 4 poststroke patients (age at treatment: 56-80 years; interval between onset of stroke and treatment: 24-37 months) with dysphagia. Over 6 consecutive days, each patient received 10 sessions of rTMS at 3 Hz applied to the pharyngeal motor cortex bilaterally, followed by 20 min of intensive swallowing rehabilitation exercise. The swallowing function was evaluated by the Penetration Aspiration Scale (PAS), Modified Mann Assessment of Swallowing Ability (MMASA), Functional Oral Intake Scale (FOIS), laryngeal elevation delay time (LEDT) and Repetitive Saliva-Swallowing Test (RSST) on admission and at discharge. All patients completed the 6-day treatment protocol and none showed any adverse reactions throughout the treatment. The combination treatment improved laryngeal elevation delay time in all patients. Our proposed protocol of rTMS plus swallowing rehabilitation exercise seems to be safe and feasible for chronic stroke dysphagia, although its efficacy needs to be confirmed in a large number of patients.
    Case Reports in Neurology 01/2014; 6(1):60-7.
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    ABSTRACT: Recently, the usefulness of neuromuscular electrical stimulation and repetitive transcranial magnetic stimulation for poststroke dysphagia has been reported. However, there is no report that describes the effectiveness of functional magnetic stimulation (FMS) for dysphagia. The purpose of this study is to clarify the effectiveness of FMS for poststroke dysphagia. Twenty poststroke dysphagic patients (age at treatment: 51-80 years; interval between onset of stroke and treatment: 6 to 36 months) were randomly assigned to a real group or a sham group. In the real group, FMS of 30 Hz was applied for suprahyoid muscles in a 20-sec train using a parabolic coil for 10 min (total 1200 pulses). In the sham group, sham stimulation was applied for 10 min at the same site. Swallowing function was evaluated by the timed water swallow test, interswallow interval (ISI), swallowing volume velocity (speed), and volume per swallow (capacity) were measured before and after stimulation. All patients completed the stimulation and none showed any adverse reactions throughout the stimulation. The improvement of speed and capacity of swallowing after stimulation was significantly larger in the real group compared with the sham group (all p < 0.05). However, no significant difference in the ISI was found between the groups. FMS using a parabolic coil can potentially improve swallowing function in poststroke dysphagic patients.
    Neuromodulation 12/2013; · 1.19 Impact Factor
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    ABSTRACT: Many poststroke patients suffer functional motor limitation of the affected upper limb, which is associated with diminished health-related quality of life. The aim of this study is to conduct a randomized, multicenter, comparative study of low-frequency repetitive transcranial magnetic stimulation combined with intensive occupational therapy, NEURO (NovEl intervention Using Repetitive TMS and intensive Occupational therapy) versus constraint-induced movement therapy in poststroke patients with upper limb hemiparesis. In this randomized controlled study of NEURO and constraint-induced movement therapy, 66 poststroke patients with upper limb hemiparesis were randomly assigned at 2:1 ratio to low-frequency repetitive transcranial magnetic stimulation plus occupational therapy (NEURO group) or constraint-induced movement therapy (constraint-induced movement therapy group) for 15 days. Fugl-Meyer Assessment and Wolf Motor Function Test and Functional Ability Score of Wolf Motor Function Test were used for assessment. No differences in patients' characteristics were found between the two groups at baseline. The Fugl-Meyer Assessment score was significantly higher in both groups after the 15-day treatment compared with the baseline. Changes in Fugl-Meyer Assessment scores and Functional Ability Score of Wolf Motor Function Test were significantly higher in the NEURO group than in the constraint-induced movement therapy group, whereas the decrease in the Wolf Motor Function Test log performance time was comparable between the two groups (changes in Fugl-Meyer Assessment score, NEURO: 5·39 ± 4·28, constraint-induced movement therapy: 3·09 ± 4·50 points; mean ± standard error of the mean; P < 0·05) (changes in Functional Ability Score of Wolf Motor Function Test, NEURO: 3·98 ± 2·99, constraint-induced movement therapy: 2·09 ± 2·96 points; P < 0·05). The results of the 15-day rehabilitative protocol showed the superiority of NEURO relative to constraint-induced movement therapy; NEURO improved the motion of the whole upper limb and resulted in functional improvement in activities of daily living.
    International Journal of Stroke 09/2013; · 2.75 Impact Factor
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    ABSTRACT: Few studies have explored the refinement of asymmetry in regional cerebral blood flow in relation to behavioral improvement after treatment. The purpose of this retrospective pilot study was to identify cerebral cortical regions with improved perfusion that correlated with improvement of upper limb motor function after repetitive transcranial magnetic stimulation (rTMS). The study subjects were 33 post-stroke patients with upper limb hemiparesis who underwent rTMS combined with intensive occupational therapy (mean±SD age: 64.9±11.2years; time since onset of stroke: 57.3±45.9months). Fugl-Meyer Assessment (FMA) and the Wolf Motor Function Test (WMFT) were applied before and after treatment to evaluate motor function in the affected upper limb. Regional brain perfusion was measured by single-photon emission computed tomography, and the percentages of asymmetry values (asymmetry index [AI]) for 52 bilateral regions of interest were calculated. The change in AI was calculated as the post-intervention minus pre-intervention values. Changes in AI in the superior and middle frontal areas correlated significantly and negatively with changes in FMA score (superior: r=-0.406, P=0.03, R(2)=0.251; middle: r=-0.437, P<0.001, R(2)=0.306), but not with changes in WMFT log performance time. Changes in AI less than zero reflect improved perfusion, suggesting that upper limb motor function improvement in post-stroke patients reflects evolution of brain perfusion in the superior and middle frontal areas.
    Journal of Neuroradiology 07/2013; · 1.24 Impact Factor
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    ABSTRACT: We investigated the safety, feasibility, and efficacy of the combination of bihemispheric repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) for upper limb hemiparesis in poststroke patients. The study participants were eight poststroke patients with upper limb hemiparesis (age at intervention: 62.8±4.9 years, time after stroke: 84.3±87.2 months, mean±SD). During 15 days of hospitalization, each patient received 10 sessions of 40-min bihemispheric rTMS and 240-min intensive OT (120-min one-to-one training and 120-min self-training). One session of bihemispheric rTMS comprised the application of both 1 and 10 Hz rTMS (2000 stimuli for each hemisphere). The Fugl-Meyer Assessment, Wolf Motor Function Test, and the Modified Ashworth Scale were administered on the day of admission and at discharge. All patients completed the treatment without any adverse effects. Motor function of the affected upper limb improved significantly, on the basis of changes in Fugl-Meyer Assessment and Wolf Motor Function Test (P<0.05, each). A significant decrease in the Modified Ashworth Scale score was noted in the elbow, wrist, and finger flexors of the affected upper limb (P<0.05, each). The combination of bihemispheric rTMS and intensive OT was safe and feasible therapy for poststroke hemiparetic patients, and improved motor function of the hemiparetic upper limb in poststroke patients. The findings provide a new avenue for the treatment of patients with poststroke hemiparesis.Wir untersuchten die Sicherheit, Durchführbarkeit und Wirksamkeit der Kombination aus bihemisphärischer repetitiver transkranieller Magnetstimulation (rTMS) und intensiver Ergotherapie bei Patienten mit Hemiparese der oberen Extremitäten nach Schlaganfall. Die Studienteilnehmer waren acht Patienten mit Hemiparese der oberen Extremitäten nach Schlaganfall (Alter zum Zeitpunkt der Intervention: 62.8±4.9 Jahre, Zeit nach Schlaganfall: 84.3±87.2 Monate, mittlere±Sta). Im Laufe des 15-tägigen Krankenhausaufenthalts erhielt jeder Patient insgesamt 10 Anwendungen à 40 Minuten bihemisphärischer rTMS und 240 Minuten intensive Ergotherapie (120 Minuten Einzeltraining und 120 Min. Eigentraining). Eine Anwendung bihemisphärischer rTMS bestand aus der Anwendung von 1 und 10 Hz rTMS (2000 Stimuli pro Hemisphäre). Der Fugl-Meyer-Score, der motorische Funktionstest nach Wolf und die modifizierte Ashworth-Skala wurden am Tag der Aufnahme und Entlassung angewendet. Alle Patienten schlossen die Behandlung ohne unerwünschte Ereignisse ab. Die motorische Funktion der betroffenen oberen Extremität wies ausgehend von den Veränderungen beim Fugl-Meyer-Score und beim motorischen Funktionstest nach Wolf (je P<0.05) eine signifikante Verbesserung auf. Eine signifikante Abnahme des Scores bei der modifizierten Ashworth-Skala wurde bei den Ellbogen-, Handgelenks- und Fingerbeugern in der betroffenen oberen Extremität beobachtet (je P<0.05). Die Kombination bihemisphärischer rTMS und intensiver Ergotherapie war eine sichere und durchführbare Therapie bei hemiparetischen Patienten nach Schlaganfall, die die motorische Funktion der hemiparetischen oberen Extremität verbesserte. Die Ergebnisse eröffnen neue Wege für die Behandlung von hemiparetischen Patienten nach Schlaganfall.En este estudio se ha investigado la seguridad, la viabilidad y la eficacia de la combinación de estimulación magnética transcraneal repetitiva (EMTr) bihemisférica con una terapia ocupacional intensiva (TO) para el tratamiento de hemiparesia del miembro superior en pacientes con ictus. En el estudio participaron ocho sujetos con ictus y hemiparesia del miembro superior (edad en el momento de la intervención: 62.8±4.9 años, tiempo transcurrido tras el ictus: 84.3±87.2 meses, media±DE). A lo largo de 15 días de hospitalización, cada uno de los pacientes recibió 10 sesiones de EMTr bihemisférica de 40 minutos y TO de 240 minutos (120 minutos de terapia individual y 120 minutos de autoterapia). En una sesión de EMTr bihemisférica se aplicaba una EMTr de 1 y 10 Hz (2000 estímulos para cada hemisferio). La puntuación Fugl-Meyer, la prueba de función motora de Wolf y la Escala modificada de Ashworth fueron llevadas a cabo en el día de la admisión y en el momento del alta. Todos los pacientes finalizaron el tratamiento sin presentar ningún efecto adverso. Se observó una mejora significativa de la función motora del miembro superior afectado, de acuerdo con la puntuación Fugl-Meyer y la prueba de función motora de Wolf (P<0.05, respectivamente). Asimismo, se observó una disminución significativa de la puntuación de la Escala modificada de Ashworth en el codo, la muñeca y los flexores de los dedos del miembro superior afectado (P<0.05, respectivamente). Se concluyó que la combinación de EMTr bihemisférica y TO intensiva es un método de tratamiento seguro y viable para pacientes hemiparéticos, además de mejorar la función motora del miembro superior hemiparético en individuos con ictus. Dichos hallazgos ofrecen un nuevo método de tratamiento de pacientes con hemiparesia postictus.Nous avons étudié l'innocuité, la faisabilité et l'efficacité de la combinaison de stimulation magnétique transcrânienne répétitive bihémispherique (SMTr) et d'ergothérapie intensive (EI) pour une hémiparésie du membre supérieur chez les patients post-AVC. Les participants à l'étude étaient huit patients post-AVC souffrant d'hémiparésie du membre supérieur (âge au moment de l'intervention: 62.8 ± 4.9 ans, délai après l'accident vasculaire cérébral : 84.3 ± 87.2 mois, moyenne ± écart-type). Pendant 15 jours d'hospitalisation, chaque patient a reçu 10 séances de 40 min de SMTr bihémispherique et 240 min d'EI (120 min avec formateur en individuel et 120 min en traitement autonome). Une séance de SMTr bihémispherique comprend l'application de stimuli de rTMS de 1 et 10 Hz (2000 stimuli pour chaque hémisphère). L'évaluation de Fugl-Meyer, le test de la fonction motrice de Wolf et l'échelle d'Ashworth modifiée ont été administrés le jour de l'admission et celui de la sortie. Tous les patients ont suivi le traitement sans effets indésirables. La fonction motrice du membre supérieur atteint s'est améliorée de façon significative, sur la base des changements observés dans l'évaluation de Fugl-Meyer et le test de la fonction motrice de Wolf (P <0.05, chacun). Une diminution significative du score sur l'échelle d'Ashworth modifiée a été notée au niveau du coude, du poignet et fléchisseurs des doigts du membre supérieur atteint (P <0.05, chacun). La combinaison de SMTr bihémispherique et d'ergothérapie intensive constitue une thérapie sûre et pratique pour des patients hémiplégiques, pour l'amélioration de la fonction motrice du membre supérieur hémiplégique chez les patients post-AVC. Ces résultats fournissent une nouvelle voie de traitement pour les patients atteints d'hémiparésie post-AVC.
    International journal of rehabilitation research. Internationale Zeitschrift fur Rehabilitationsforschung. Revue internationale de recherches de readaptation 06/2013; · 0.36 Impact Factor
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    ABSTRACT: The aim of this study was to assess the effects of botulinum toxin type A (BoNT-A) injection with home-based functional training for passive and active motor function, over a 6-month period in post-stroke patients with upper limb spasticity. We studied 190 patients with at least 6-month history of stroke. They received injections of BoNT-A in upper limb muscles and detailed one-to-one instructions for home-based functional training. At baseline (before therapy), and at 1-, 3- and 6-month follow-up, Fugl-Meyer assessment (FMA) and Wolf motor function test (WMFT) were used to assess active motor function, the modified Ashworth scale (MAS) for assessment of spasticity, and the range of motion (ROM) for passive motor function. The total score for upper limb and scores of categories A and B of the FMA increased significantly at 1, 3 and 6 months, while the FMA score for category D increased significantly at 3 and 6 months, but not at 1 month. Significant decreases in the MAS scores were noted in all muscles examined at 1, 3 and 6 months, compared with baseline. The ROM for elbow joint extension significantly improved at 1, 3, and 6 months, while that for wrist joint extension increased significantly at 1 month, but not 3 or 6 months, compared with baseline. The results suggest that comprehensive improvement of motor function requires improvement of motor function in the proximal part of the upper limb and that BoNT-A followed by rehabilitation reduces spasticity and improves motor function of fingers.
    Acta neurologica Belgica. 05/2013;
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    ABSTRACT: BACKGROUND: Low-frequency repetitive transcranial magnetic stimulation of the nonlesional hemisphere combined with occupational therapy significantly improves motor function of the affected upper limb in poststroke hemiparetic patients, but the recovery mechanism remains unclear. AIMS: To investigate the recovery mechanism using functional magnetic resonance imaging. METHODS: Forty-seven poststroke hemiparetic patients were hospitalized to receive 12 sessions of 40-min low-frequency repetitive transcranial magnetic stimulation over the nonlesional hemisphere and daily occupational therapy for 15 days. Motor function was evaluated with the Fugl-Meyer Assessment and Wolf Motor Function Test. The functional magnetic resonance imaging with motor tasks was performed at admission and discharge. The laterality index of activated voxel number in Brodmann areas 4 and 6 on functional magnetic resonance imaging was calculated (laterality index range of -1 to +1). Patients were divided into two groups based on functional magnetic resonance imaging findings before the intervention: group 1: patients who showed bilateral activation (n = 27); group 2: patients with unilateral activation (n = 20). RESULTS: Treatment resulted in improvement in Fugl-Meyer Assessment and Wolf Motor Function Test in the two groups (P < 0·01). The treatment also resulted in a significant increase in laterality index in group 1 (P < 0·05), suggesting a shift in activated voxels to the lesional hemisphere. Patients of group 2 showed a significant increase in lesional hemisphere activation (P < 0·05). CONCLUSIONS: The results of serial functional magnetic resonance imaging indicated that our proposed treatment can induce functional cortical reorganization, leading to motor functional recovery of the affected upper limb. Especially, it seems that neural activation in the lesional hemisphere plays an important role in such recovery in poststroke hemiparetic patients.
    International Journal of Stroke 05/2013; · 2.75 Impact Factor
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    ABSTRACT: OBJECTIVE: It is difficult to stimulate leg motor areas with magnetic current using a figure-of-eight coil due to the deep anatomical location of the areas. However, a double cone coil is useful for stimulating deep brain regions. We postulated that the use of the same coil may allow repetitive transcranial magnetic stimulation (rTMS) to modulate the neural activity of the same areas. The purpose of this study is to investigate the effect of high-frequency rTMS applied over bilateral leg motor areas with a double cone coil on walking function after stroke. MATERIALS AND METHODS: Eighteen post-stroke hemiparetic patients with gait disturbances attended two experimental sessions with more than 24 h apart, in a cross-over, double-blind paradigm. In one session, high-frequency rTMS of 10 Hz was applied over the leg motor area bilaterally in a 10-s train using a double cone coil for 20 min (total 2,000 pulses). In the other session, sham stimulation was applied for 20 min at the same site. To assess walking function, walking velocity, and Physiological Cost Index (PCI) were evaluated serially before, immediately after, and 10 and 20 min after each stimulation. RESULTS: The walking velocity was significantly higher for 20 min after stimulation in the high-frequency rTMS group than the sham group. PCI was lower in the high-frequency rTMS group than the sham group, but this was significant only immediately after stimulation. CONCLUSIONS: High-frequency rTMS of bilateral leg motor areas using a double cone coil can potentially improve walking function in post-stroke hemiparetic patients.
    Acta Neurologica Scandinavica 02/2013; · 2.47 Impact Factor
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    ABSTRACT: Abstract Objective: A double cone coil enables delivery of magnetic stimulation to leg motor areas and modulates neural activities of the areas. It is expected that combined application of facilitatory rTMS with the coil and physical therapy would improve walking function after stroke. The purpose of this study is to clarify the clinical effect of an in-patient protocol featuring rTMS with a double cone coil and mobility training for gait disturbance after stroke. Subjects and methods: Nineteen post-stroke hemiparetic patients with gait disturbance were studied (aged 56.2 ± 11.9 years). During the 13-day hospitalization, each patient received 20 sessions of high-frequency rTMS and mobility training featuring treadmill training. In one rTMS session, 2000 pulses of 10-Hz rTMS were delivered over bilateral leg motor areas using the double cone coil. Walking velocity, Physiological Cost Index (PCI) and Timed Up and Go Test (TUG) were evaluated on the day of admission and discharge. Results: The protocol was completed without any adverse effects in all patients. The combination treatment significantly increased walking velocity (p < 0.05) and decreased PCI (p < 0.05), decreased the performance time for TUG (p < 0.05). Conclusions: The protocol featuring high-frequency rTMS and mobility training is safe and feasible and can improve walking function after stroke.
    Brain Injury 01/2013; 27(9):1080-6. · 1.51 Impact Factor
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    ABSTRACT: Aim: To assess the safety and clinical efficacy of low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) combined with intensive speech therapy (ST) in poststroke patients with aphasia. Subjects and Methods: Twenty-four patients with left-hemispheric stroke and aphasia were subjected. During 11-day hospitalization, each patient received 10 treatment sessions consisting of 40-min 1-Hz LF-rTMS and 60-min intensive ST, excluding Sundays. The scalp area for stimulation was selected based on the findings of fMRI with language tasks and the type of aphasia. LF-rTMS was applied to the inferior frontal gyrus (IGF) for patients with nonfluent aphasia and to the superior temporal gyrus (STG) for patients with fluent aphasia. Results: On pretreatment fMRI, the most activated areas were in the left hemisphere (n = 16) and right hemisphere (n = 8). The types of aphasia were nonfluent (n = 14) and fluent (n = 10). The LF-rTMS was applied to the right STG (n = 5), left STG (n = 5), right IFG (n = 11) and left IFG (n = 3). Nonfluent aphasic patients showed significant improvement of auditory comprehension, reading comprehension and repetition. Fluent aphasic patients showed significant improvement in spontaneous speech only. Conclusion: The fMRI with aphasic type-based therapeutic LF-rTMS/intensive ST for chronic aphasia seems feasible and a potentially useful neurorehabilitative protocol.
    European Neurology 08/2012; 68(4):199-208. · 1.50 Impact Factor
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    ABSTRACT: This study evaluated the clinical usefulness of the newly developed Two-Step Thickened Water Test (TTWT) in identifying patients with poststroke dysphagia at risk of aspiration of paste food. The study subjects were 110 poststroke patients (mean age, 73 ± 10 years). The TTWT comprises a bedside pretest (tongue protrusion, vocalization, voluntary cough, and dry swallow) and a direct swallowing test using 4 mL of thickened water. Fiberoptic endoscopic evaluation of swallowing determined the subject's ability to swallow the paste food. Based on the test results and endoscopic evaluation, we calculated the TTWT's sensitivity and specificity in identifying paste food aspiration. We also calculated these values when normal water was used instead of thickened water in a direct swallowing test. The prevalence of dysphagia for paste food was 41% in our study group. The sensitivity and specificity of the TTWT in identifying dysphagia for paste food was 93% and 88%, respectively. The specificity decreased to 78.5% when normal water was used, with no decrease in sensitivity. The test was completed in less than 10 minutes, with no adverse events in any subject. Our data suggest that the TTWT might be a useful assessment tool for evaluating the risk of paste food aspiration in patients with poststroke dysphagia.
    Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 06/2012;
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    ABSTRACT: OBJECTIVES: The purpose of this study was to test the effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) over the non-lesional hemisphere on motor neuron excitability of the paretic upper limb in post-stroke patients by electrophysiological examination. MATERIALS AND METHODS: Thirteen post-stroke patients with spastic upper limb hemiparesis were studied (age, 57.5 ± 11.1 years; time after stroke, 55.2 ± 51.4 months). Low-frequency rTMS of 1 Hz was applied for 20 min to the motor cortex of the non-lesional hemisphere. The M-response amplitude and F-wave parameters were recorded in the abductor pollicis brevis muscle following stimulation of the median nerve in both the affected and unaffected upper limbs. The F-wave frequency, F-max/M ratio (ratio of maximum F-wave amplitude to M-response amplitude), and F-mean/M ratio (the ratio of mean F-wave amplitude to the M-response amplitude) were measured before and after the 20-min rTMS, analyzed for both limbs. RESULTS: Application of low-frequency rTMS did not result in significant changes in the frequency of F-wave and F-max/M ratio in both upper limbs, but significantly decreased F-mean/M ratio in the affected upper limb (P < 0.005), but not in the unaffected limb. CONCLUSIONS: Low-frequency rTMS applied to the non-lesional hemisphere might be potentially useful therapeutically for post-stroke patients with spastic upper limb hemiparesis.
    Acta Neurologica Scandinavica 04/2012; · 2.47 Impact Factor
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    ABSTRACT: Botulinum toxin type A (BoNT-A) has been reported to be an effective treatment for limb spasticity after stroke. However, the reduction in the spasticity after BoNT-A injection alone does not ensure an improvement in the active motor function of the affected limb. The aim of this study was to clarify the clinical effects of a BoNT-A injection, followed by home-based functional training on not only the passive but also the active motor function of the affected spastic upper limb in poststroke hemiparetic patients. Eighty poststroke patients with spastic upper limb hemiparesis were studied. The severity of hemiparesis was categorized as Brunnstrom stage of 3 for hand-fingers in all patients. BoNT-A (maximum dose of 240 U) was injected into the target muscles of the affected upper limb after a clinical evaluation using the modified Ashworth scale, range of motion, Fugl-Meyer Assessment, and the Wolf Motor Function Test. Following the injection, occupational therapists provided home-based functional training for each patient on a one-to-one basis. The follow-up evaluation was performed 4 weeks after the injection. A significant improvement was found in the modified Ashworth scale and range of motion. The changes in the Fugl-Meyer Assessment and the Wolf Motor Function Test indicated a significant improvement in the active motor function of the affected upper limb. In conclusions, our proposed protocol of a BoNT-A injection, followed by home-based functional training seems to have the potential to improve the active motor function of the affected upper limb after stroke, although the efficacy should be confirmed in a randomized-controlled trial.
    International journal of rehabilitation research. Internationale Zeitschrift fur Rehabilitationsforschung. Revue internationale de recherches de readaptation 03/2012; 35(2):146-52. · 0.36 Impact Factor
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    Wataru Kakuda, Masahiro Abo
    Latest Findings in Intellectual and Developmental Disabilities Research, 02/2012; , ISBN: 978-953-307-865-6
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    ABSTRACT: Both low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) have been recently reported to be clinically beneficial for post-stroke patients with upper limb hemiparesis. Based on these reports, we developed an inpatient combination protocol of these two modalities for the treatment of such patients. The aims of this pilot study were to confirm the safety and feasibility of the protocol in a large number of patients from different institutions, and identify predictors of the clinical response to the treatment. The study subjects were 204 post-stroke patients with upper limb hemiparesis (mean age at admission 58.5 ± 13.4 years, mean time after stroke 5.0 ± 4.5 years, ± SD) from five institutions in Japan. During 15-day hospitalization, each patient received 22 treatment sessions of 20-min low-frequency rTMS and 120-min intensive OT daily. Low-frequency rTMS of 1 Hz was applied to the contralesional hemisphere over the primary motor area. The intensive OT, consisting of 60-min one-to-one training and 60-min self-exercise, was provided after the application of low-frequency rTMS. Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) were performed serially. The physiatrists and occupational therapists involved in this study received training prior to the study to standardize the therapeutic protocol. All patients completed the protocol without any adverse effects. The FMA score increased and WMFT log performance time decreased significantly at discharge, relative to the respective values at admission (change in FMA score: median at admission, 47 points; median at discharge, 51 points; p < 0.001. change in WMFT log performance time: median at admission, 3.23; median at discharge, 2.51; p < 0.001). These changes were persistently seen up to 4 weeks after discharge in 79 patients. Linear regression analysis found no significant relationship between baseline parameters and indexes of improvement in motor function. The 15-day inpatient rTMS plus OT protocol is a safe, feasible, and clinically useful neurorehabilitative intervention for post-stroke patients with upper limb hemiparesis. The response to the treatment was not influenced by age or time after stroke onset. The efficacy of the intervention should be confirmed in a randomized controlled study including a control group.
    Journal of NeuroEngineering and Rehabilitation 01/2012; 9(1):4. · 2.57 Impact Factor