This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.

/pdf/guidelines-for-management-of-ischaemic-stroke-and-transient-1bttxqchx4.pdf

Guidelines for management of ischaemic stroke and transient ischaemic attack 2008

Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. In this Review, we aimed to provide an overview of the available evidence on interventions for motor recovery after stroke through the evaluation of systematic reviews, supplemented by recent randomised controlled trials. Most trials were small and had some design limitations. Improvements in recovery of arm function were seen for constraint-induced movement therapy, electromyographic biofeedback, mental practice with motor imagery, and robotics. Improvements in transfer ability or balance were seen with repetitive task training, biofeedback, and training with a moving platform. Physical fitness training, high-intensity therapy (usually physiotherapy), and repetitive task training improved walking speed. Although the existing evidence is limited by poor trial designs, some treatments do show promise for improving motor recovery, particularly those that have focused on high-intensity and repetitive task-specific practice.

https://www.thelancet.com/pdfs/journals/laneur/PIIS1474-4422(09)70150-4.pdf

Motor recovery after stroke: a systematic review

Stroke Care 2: Stroke rehabilitation

This brief review examines some of the methods used to infer central control strategies from surface electromyogram (EMG) recordings. Among the many uses of the surface EMG in studying the neural control of movement, the review critically evaluates only some of the applications. The focus is on the relations between global features of the surface EMG and the underlying physiological processes. Because direct measurements of motor unit activation are not available and many factors can influence the signal, these relations are frequently misinterpreted. These errors are compounded by the counterintuitive effects that some system parameters can have on the EMG signal. The phenomenon of crosstalk is used as an example of these problems. The review describes the limitations of techniques used to infer the level of muscle activation, the type of motor unit recruited, the upper limit of motor unit recruitment, the average discharge rate, and the degree of synchronization between motor units. Although the global surface EMG is a useful measure of muscle activation and assessment, there are limits to the information that can be extracted from this signal.

The extraction of neural strategies from the surface EMG

High-resistance strength training (HRST) is one of the most widely practiced forms of physical activity, which is used to enhance athletic performance, augment musculo-skeletal health and alter body aesthetics. Chronic exposure to this type of activity produces marked increases in muscular strength, which are attributed to a range of neurological and morphological adaptations. This review assesses the evidence for these adaptations, their interplay and contribution to enhanced strength and the methodologies employed. The primary morphological adaptations involve an increase in the cross-sectional area of the whole muscle and individual muscle fibres, which is due to an increase in myofibrillar size and number. Satellite cells are activated in the very early stages of training; their proliferation and later fusion with existing fibres appears to be intimately involved in the hypertrophy response. Other possible morphological adaptations include hyperplasia, changes in fibre type, muscle architecture, myofilament density and the structure of connective tissue and tendons. Indirect evidence for neurological adaptations, which encompasses learning and coordination, comes from the specificity of the training adaptation, transfer of unilateral training to the contralateral limb and imagined contractions. The apparent rise in whole-muscle specific tension has been primarily used as evidence for neurological adaptations; however, morphological factors (e.g. preferential hypertrophy of type 2 fibres, increased angle of fibre pennation, increase in radiological density) are also likely to contribute to this phenomenon. Changes in inter-muscular coordination appear critical. Adaptations in agonist muscle activation, as assessed by electromyography, tetanic stimulation and the twitch interpolation technique, suggest small, but significant increases. Enhanced firing frequency and spinal reflexes most likely explain this improvement, although there is contrary evidence suggesting no change in cortical or corticospinal excitability. The gains in strength with HRST are undoubtedly due to a wide combination of neurological and morphological factors. Whilst the neurological factors may make their greatest contribution during the early stages of a training programme, hypertrophic processes also commence at the onset of training.

http://performancetrainingsystems.net/Resources/Adaptations_to_Strength_Training.pdf

The adaptations to strength training : morphological and neurological contributions to increased strength.

Development of recommendations for SEMG sensors and sensor placement procedures.

Spinal orthoses are common in the treatment of various conditions that affect the spine. They encompass both the spine and pelvis and thus have implications for pelvic and lower-limb motion during walking in addition to a direct effect on spinal motion. The role of the spine in walking is largely ill-defined, and the consequences of restricted spinal motion on walking have yet to be explored. This study investigated the effect of spinal restriction on gait in able-bodied persons. Gait analyses were performed on 10 able-bodied subjects as they walked at five different speeds that were distributed across their comfortable range of speeds. Data were collected during walking with and without spinal restriction by a fiberglass body jacket, which is similar to a thoracolumbosacral orthosis (TLSO). With spinal restriction, peak-to-peak (PP) pelvic obliquity and rotation were significantly reduced across all walking speeds (p < 0.001), while PP pelvic tilt was significantly reduced at only the fastest walking speeds (p = 0.017). PP hip abduction-adduction motion was significantly reduced with spinal restriction across all speeds (p < 0.001), while PP hip flexion-extension significantly increased at only the slow and very slow speeds (p < 0.001 and p = 0.023, respectively). A better understanding of the effects of restricted spinal motion on gait may help clinicians predict and avoid development of additional problems from TLSO use or surgical restriction of spinal motion. An awareness of these issues will enable clinicians to monitor patients for problems that may result from decreased spine and pelvic motion.

/pdf/systematic-review-of-the-effect-of-robot-aided-therapy-on-2s0c9l69dr.pdf

Systematic review of the effect of robot-aided therapy on recovery of the hemiparetic arm after stroke.

The aim of this paper is to review briefly our understanding of the phenomenon of spasticity based in current evidence.

Spasticity: Clinical perceptions, neurological realities and meaningful measurement

Objective: To investigate the impact of upper extremity deficit in subjects with tetraplegia. Setting: The United Kingdom and The Netherlands. Study design: Survey among the members of the Dutch and UK Spinal Cord Injury (SCI) Associations. Main outcome parameter: Indication of expected improvement in quality of life (QOL) on a 5-point scale in relation to improvement in hand function and seven other SCI-related impairments. Results: In all, 565 subjects with tetraplegia returned the questionnaire (overall response of 42%). Results in the Dutch and the UK group were comparable. A total of 77% of the tetraplegics expected an important or very important improvement in QOL if their hand function improved. This is comparable to their expectations with regard to improvement in bladder and bowel function. All other items were scored lower. Conclusion: This is the first study in which the impact of upper extremity impairment has been assessed in a large sample of tetraplegic subjects and compared to other SCI-related impairments that have a major impact on the life of subjects with SCI. The present study indicates a high impact as well as a high priority for improvement in hand function in tetraplegics.

/pdf/survey-of-the-needs-of-patients-with-spinal-cord-injury-45x3kc6hr0.pdf

Survey of the needs of patients with spinal cord injury: impact and priority for improvement in hand function in tetraplegics

The isolated contributions of motor unit recruitment and firing rate variations to the median frequency of the electromyogram's power density spectrum were determined. Orderly stimulation of the cat gastrocnemius motor units via nerve electrodes gave rise to linearly increasing median frequency regardless of the action potential firing rate of the active motor units. Increase in the discharge rate of all the motor units resulted in nearly constant median frequency. It was concluded that the increasing average conduction velocity during motor unit recruitment is the major contributor to variations in the electromyogram median frequency. The possibility of using the median frequency as the index to identify the recruitment control strategies employed by various muscles during increasing force contraction is suggested.

Hermanus J. Hermens

Papers

Development of recommendations for SEMG sensors and sensor placement procedures.

Systematic review of the effect of robot-aided therapy on recovery of the hemiparetic arm after stroke.

Spasticity: Clinical perceptions, neurological realities and meaningful measurement

Survey of the needs of patients with spinal cord injury: impact and priority for improvement in hand function in tetraplegics

Electromyogram power spectra frequencies associated with motor unit recruitment strategies