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Arterial ischaemic stroke (AIS) can cause disabling hemiparesis in children. We aimed to test whether contralesional, inhibitory repetitive transcranial magnetic stimulation (rTMS) could affect interhemispheric inhibition to improve hand function in chronic subcortical paediatric AIS. Patients were eligible for this parallel, randomised trial if they were in the SickKids Children's Stroke Program and had subcortical AIS more than 2 years previously, had transcallosal sparing, were more than 7 years of age, had hand motor impairment, had no seizures or dyskinesia, and were taking no drugs that alter cortical excitability. Patients were paired for age and weakness and were randomised within each pair to sham treatment or inhibitory, low-frequency rTMS over contralesional motor cortex (20 min, 1200 stimuli) once per day for 8 days. An occupational therapist did standardised tests of hand function at days 1 (baseline), 5, 10, and 17 (1 week post-treatment), and the primary outcomes were changes in grip strength and the Melbourne assessment of upper extremity function (MAUEF) between baseline and day 10. Patients, parents, and occupational therapists were blinded to treatment allocation. Analysis was per protocol. Ten patients with paediatric stroke were enrolled (median age 13·25 [IQR 10·08–16·78] years, mean time post-stroke 6·33 [SD 3·56] years): four with mild weakness, two with moderate weakness, and four with severe weakness. A repeated-measures ANOVA showed a significant interaction between time and the effect of treatment on grip strength (p=0·03). At day 10, grip strength was 2·28 (SD 1·01) kg greater than baseline in the rTMS group and 2·92 (1·20) kg less than baseline in the sham group (p=0·009). Benefits in mean grip strength persisted at day 17 (2·63 [0·56] kg greater than baseline with rTMS and 1·00 [0·70] kg less than baseline with sham treatment; p=0·01). Day 10 MAUEF score improved by more in the rTMS group than in the sham group (7·25 [3·8] vs 0·79 [1·3] points greater than baseline; p=0·002), but this benefit did not persist to day 17. Function of the unaffected hand remained stable. rTMS was well tolerated with no serious adverse events. Contralesional inhibitory rTMS was safe and feasible for patients with paediatric subcortical AIS, and seemed to improve hand function in patients with hemiparesis. Further studies are required to confirm the potential role of rTMS in paediatric neurorehabilitation. Canadian Stroke Consortium; Canadian Institutes of Health Research; American Academy of Neurology Foundation; Alberta Heritage Foundation for Medical Research.

Purpose To test whether long-term cortical adaptations occur bilaterally following chronic unilateral training with a simple motor task. Methods Participants ( n  = 34) were randomly allocated to a training or control groups. Only the former completed a 4-week maximal-intensity isometric training of the right first dorsal interosseus muscle through key pinching. Maximal strength was assessed bilaterally in four different movements progressively less similar to the training task: key, tip and tripod pinches, and handgrip. Transcranial magnetic stimulation was used to probe, in the left and right primary hand motor cortices, a number of standard tests of cortical excitability, including thresholds, intra-cortical inhibition and facilitation, transcallosal inhibition, and sensory-motor integration. Results Training increased strength in the trained hand, but only for the tasks specifically involving the trained muscle (key +8.5 %; p  < 0.0005; tip +7.2 %; p  = 0.02). However, the effect size was small and below the cutoff for meaningful change. Handgrip and tripod pinch were instead unaffected. There was a similar improvement in strength in the untrained hand, i.e., a cross-education effect (key +6.4 %; p  = 0.02; tip +4.7 %; p  = 0.007). Despite these changes in strength, no significant variation was observed in any of the neurophysiological parameters describing cortico-spinal and intra-cortical excitability, inter-hemispheric inhibition, and cortical sensory-motor integration. Conclusions A 4-week maximal-intensity unilateral training induced bilaterally spatial- and task-specific strength gains, which were not associated to direct or crossed cortical adaptations. The observed long-term stability of neurophysiological parameters might result from homeostatic plasticity phenomena, aimed at restoring the physiological inter-hemispheric balance of neural activity levels perturbed by the exercise. Trial registration number ClinicalTrials.gov identifier NCT02010398.

The effectiveness of transcranial direct current stimulation (tDCS) placed over the motor hotspot (thought to represent the primary motor cortex (M1)) to modulate motor network excitability is highly variable. The premotor cortex—particularly the dorsal premotor cortex (PMd)—may be a promising alternative target to reliably modulate motor excitability, as it influences motor control across multiple pathways, one independent of M1 and one with direct connections to M1. This double-blind, placebo-controlled preliminary study aimed to differentially excite motor and premotor regions using high-definition tDCS (HD-tDCS) with concurrent functional magnetic resonance imaging (fMRI). HD-tDCS applied over either the motor hotspot or the premotor cortex demonstrated high inter-individual variability in changes on cortical motor excitability. However, HD-tDCS over the premotor cortex led to a higher number of responders and greater changes in local fMRI-based complexity than HD-tDCS over the motor hotspot. Furthermore, an analysis of individual motor hotspot anatomical locations revealed that, in more than half of the participants, the motor hotspot is not located over anatomical M1 boundaries, despite using a canonical definition of the motor hotspot. This heterogeneity in stimulation site may contribute to the variability of tDCS results. Altogether, these preliminary findings provide new considerations to enhance tDCS reliability.

Background Complex peripheral nerve injuries of the hand include at least 300,000 cases per year in Europe. The standard treatment involves a microsurgical end-to-end suture of traumatic sensory nerve lesions of the hand without a gap. The objective of this study protocol is to evaluate whether the additional use of a chitosan nerve tube in primary repair of traumatic sensory nerve lesions of the hand without a gap has an effect on the recovery of sensitivity. Methods/Design We planned a randomized double-blind controlled multicenter trial with a parallel group design in order to show superiority for the additional use of a chitosan nerve tube. This study will enroll 100 participants with traumatic sensory nerve lesions of the hand without a gap from three Trauma Care Centers. Participants will be randomized in a 1:1 ratio to primary microsurgical repair of the injured nerve with the additional use of a chitosan nerve tube or direct tension free microsurgical repair of the injured nerve alone. The static two-point discrimination of the injured finger after 6 months will be the primary outcome parameter. Discussion In the proposed study, the additional use of a chitosan nerve tube for a primary microsurgical repair of traumatic sensory nerve lesions of the hand without a gap will be evaluated in a prospective randomized double-blind controlled multicenter trial for the first time to create the highest possible evidence for the procedure. Trial registration ClinicalTrials.gov Identifier: NCT02372669 . Protocol Registration Receipt on 27 February 2015.

Human skin relies on cutaneous receptors that output digital signals for tactile sensing in which the intensity of stimulation is converted to a series of voltage pulses. We present a power-efficient skin-inspired mechanoreceptor with a flexible organic transistor circuit that transduces pressure into digital frequency signals directly. The output frequency ranges between 0 and 200 hertz, with a sublinear response to increasing force stimuli that mimics slow-adapting skin mechanoreceptors. The output of the sensors was further used to stimulate optogenetically engineered mouse somatosensory neurons of mouse cortex in vitro, achieving stimulated pulses in accordance with pressure levels. This work represents a step toward the design and use of large-area organic electronic skins with neural-integrated touch feedback for replacement limbs.

Tremor is one of the most common movement disorders. It does not usually respond to first-line drug treatments (e.g. propranolol, primidone, anticholinergics, gabapentin and clonazepam) due to side effects and frequent dose limitations. Botulinum toxin type A (BoNT-A) has been widely used to treat tremor, but its efficacy and safety are uncertain. To evaluate the efficacy and safety of BoNT-A in the treatment of hand tremor. We searched the MEDLINE, EMBASE, PsycINFO and Cochrane Library databases for relevant randomised controlled trials of the effects of BoNT-A injections on tremors, up to 20 February 2020. A meta-analysis of comparative effects was performed using R studio software, and publication bias was examined using Egger's test. Six studies examining a total of 245 participants with tremor were included in the meta-analysis. The primary outcome of meta-analysis showed no difference in clinical tremor scale scores between the BoNT-A group versus the placebo group (standardised mean difference (SMD): -0.42, 95% confidence interval (CI): -1.94 to 1.10; I2 = 96%). For clinical tremor scale scores, subgroup analyses suggested that the BoNT-A group may differ in terms of multiple sclerosis (MS) related tremor (SMD: -1.10; 95% CI: -2.17 to -0.04; I2 = 79%) compared to a placebo, but the difference did not exist in the outcome of essential tremor (ET) or hand tremor (MD: -1.31; 95% CI: -3.39; 1.31; I2 = 97%). Grip strength (MD: -1.25, 95% CI: -5.99 to 3.50, I2 = 97%) was slightly lower in the BoNT-A group, but the difference was not significant. The incidence of adverse events (AEs), including hand weakness (RR: 2.96, 95% CI: 1.40 to 6.24, I2 = 37%), was significantly greater in the BoNT-A group than in the placebo group. Two studies were assessed as having an overall low risk of bias. Our study confirms that BoNT-A injections are unlikely to have an impact on patients with hand tremors. However, subgroup analysis suggested that BoNT-A injections could have possible benefits in MS-related tremor. While moderate to severe hand weakness AEs often limits their use in clinical practice, additional well-designed double-blind, placebo-controlled trials are needed to provide more robust conclusions.

Video-assisted thoracoscopic sympathectomy (VTS) is effective in treating palmar hyperhidrosis (PH). However, it is no consensus over which segment should undergo VTS to maximize efficacy and minimize the complications of compensatory hyperhidrosis (CH). This study was designed to compare the efficiency and side effects of VTS of different segments in the treatment of PH. A comprehensive search of PubMed, Ovid MEDLINE, EMBASE, Web of Science, ScienceDirect, the Cochrane Library, Scopus and Google Scholar was performed to identify studies comparing VTS of different segments for treatment of PH. The data was analyzed by Revman 5.3 software and SPSS 18.0. A total of eight randomized controlled trials (RCTs) involving 1200 patients were included. Meta-analysis showed that single segment/low segments VTS could reduce the risk of moderate/severe CH compared with multiple segments/high segments. The risk of total CH had a similar trend. In the subgroup analysis of single segment VTS, no significant differences were found between T2/T3 VTS and other segments in postoperative CH and degree of CH. T4 VTS showed better efficacy in limiting CH compared with other segments. T4 appears to be the best segment for the surgical treatment of PH. Our findings require further validation in more high-quality, large-scale randomized controlled trials.

Background Many stroke survivors suffer from sensory impairments of their affected upper limb (UL). Although such impairments can affect the ability to use the UL in everyday activities, very little attention is paid to sensory impairments in stroke rehabilitation. The purpose of this trial is to investigate if sensory re-learning in combination with task-specific training may prove to be more effective than task-specific training alone to improve sensory function of the hand, dexterity, the ability to use the hand in daily activities, perceived participation, and life satisfaction. Methods/design This study is a single-blinded pilot randomized controlled trial (RCT) with two treatment arms. The participants will be randomly assigned either to sensory re-learning in combination with task-specific training (sensory group) or to task-specific training only (control group). The training will consist of 2.5 h of group training per session, 2 times per week for 5 weeks. The primary outcome measures to assess sensory function are as follows: Semmes-Weinstein monofilament, Shape/Texture Identification (STI™) test, Fugl-Meyer Assessment—upper extremity (FMA-UE; sensory section), and tactile object identification test. The secondary outcome measures to assess motor function are as follows: Box and Block Test (BBT), mini Sollerman Hand Function Test (mSHFT), Modified Motor Assessment Scale (M-MAS), and Grippit. To assess the ability to use the hand in daily activities, perceived participation, and life satisfaction, the Motor Activity Log (MAL), Canadian Occupational Performance Measure (COPM), Stroke Impact Scale (SIS) participation domain, and Life Satisfaction checklist will be used. Assessments will be performed pre- and post-training and at 3-month follow-up by independent assessors, who are blinded to the participants’ group allocation. At the 3-month follow-up, the participants in the sensory group will also be interviewed about their general experience of the training and how effective they perceived the training. Discussion The results from this study can add new knowledge about the effectiveness of sensory re-learning in combination with task-specific training on UL functioning after stroke. If the new training approach proves efficient, the results can provide information on how to design a larger RCT in the future in persons with sensory impairments of the UL after stroke. Trial registration ClinicalTrials.gov, NCT03336749 . Registered on 8 November 2017.

Background Waiting five to six minutes before measuring a train-of-four (TOF) after a 50-Hz tetanic stimulation or post-tetanic count (PTC) in order to allow the facilitation of transmission to subside is commonly recommended but is based on limited evidence. The purpose of this study was to measure the TOF responses after PTC in one hand and to compare the responses with those in the contralateral (control) hand. Methods Twenty-two adult patients undergoing elective surgery under opioid-desflurane anesthesia were fitted with sensors to measure displacement of their thumbs in response to ulnar nerve stimulation. Rocuronium 0.6 mg·kg −1 was administered and TOF stimulation was applied to both sides. One side was randomized to PTC (50-Hz tetanus followed by a three-second pause and 15 1-Hz stimuli) when the opposite (control) side recovered to 10% first twitch (T1) height. Train-of-four stimulation was continued bilaterally every 20 sec until 30 min after PTC. Comparisons of the T1 and TOF ratio (T4/T1) were made at two, five, ten, 20, and 30 min. Results The mean (standard deviation [SD]) T1 value in the PTC arm was 11.8 (7.1)% just before PTC. The T1 values were significantly greater in the PTC arm at two, five, and ten minutes, with mean (SD) differences of 6.3 (6.7)%, 9.4 (6.8)%, and 7.4 (3.9)%, respectively ( P = 0.008). There were no significant differences in T1 values between groups at 20 and 30 min, and no statistically significant differences in T4/T1 values at any time. Conclusion A small but clinically insignificant increase in T1 is seen for at least ten minutes after PTC without any detectable change in T4/T1 values. The TOF responses are reliable as early as one minute after PTC.

We aimed to bring a more understandable and applicable technique to the literature instead of “massage therapy” in CTS. We compared our new technique with the splint wear, of which the efficacy in CTS has been proven with many studies. Eighty-four patients between 31 and 65 years of age were included in the study. The patients were divided into two equal groups. In the first group, splint and “ Madenci ” hand massage technique were applied, and in the second group only splint was applied. A splint was provided for all patients with tendon and nerve gliding exercises, and also when needed analgesic drugs were given. When the pretreatment and posttreatment parameters were compared via repetitive measurement analysis, it was found that PGA and MDPGA were significantly decreased in both groups ( P  = 0.001), whereas grip strength was significantly increased ( P  = 0.001). While no statistically significant difference was found between the groups regarding pretreatment values ( P  > 0.05), the posttreatment PGA, MDPGA, and grip strength scores were significantly improved in Group I compared to Group II ( P  < 0.05). To the best our knowledge, the present study is the first and largest study in the literature conducted on the massage technique that will contribute to the treatment of CTS. As this new massage technique is easy for self-application, cheap, and practical, every patient with CTS can apply the massage to him/herself easily.