Een kwestie van gezond verstand

Rede, In verkorte vorm uitgesproken ter aanvaarding van de bijzondere leerstoel Neurorevalidatie aan het Erasmus MC, faculteit der Geneeskunde van de Erasmus Universiteit Rotterdam op 11 oktober 2013 Bewijs van effectiviteit en bewijs van efficiëntie. Dat wordt meer en meer het motto in de gezondheidszorg. Wat werkt voor wie, voor wie niet en hoe kan het sneller en vooral goedkoper? En, zoals Robert Dijkgraaf dat ironisch formuleert: “Wie kan die bewijzen beter leveren dan de wetenschap, de hofleverancier van zekerheden in onzekere tijden?” Dit geldt ook voor de neurorevalidatie, dat deel van de revalidatiegeneeskunde dat zich richt op het behandelen en voorkomen van de gevolgen van niet-aangeboren hersenaandoeningen (NAH). Een NAH legt grote druk op het individu, op zijn mantelzorgers en op de maatschappij. Het verbeteren van de effectiviteit en efficiëntie van de neurorevalidatie is een continue noodzaak en vormt het centrale thema van mijn leerstoel. De gevolgen van NAH worden echter bepaald door een kluwen van mechanismen die op elkaar ingrijpen en specifiek zijn voor het letsel, die de patiënt typeren of zijn fysieke en sociale leefomgeving. Wetenschap en maatschappij treffen elkaar in de neurorevalidatie. Interventies worden, soms serieel in de tijd soms parallel, gericht op medische, sensomotorische, psychische, linguïstische en sociale problematiek. De omgeving van de patiënt zoals mantelzorgers en werkgevers, wordt betrokken in de behandeling en schotten in het Nederlandse zorgstelsel moeten worden geslecht om tot een optimaal resultaat te komen. De vragen die ontstaan wanneer gezondheidszorg en maatschappij elkaar treffen kunnen niet altijd opgelost worden door wetenschappelijk onderzoek

Complex regional pain syndrome 1 : a study on pain and motor impairments

This thesis, is compiled of publications on reflex sympathetic dystrophy (RSD) or Complex Regional Pain Syndrome type 1 (CRPS 1), as it was renamed by the committee on taxonomy of the International Association for the Study of Pain (IASP). It is a puzzling syndrome both from a clinical point of view as well as in the perspective of basic pain science. Therapies rendered may vary and include physical therapy, occupational therapy, physical immobilization, surgical or chemical sympathectomies, pharmacotherapy and psychological treatment. A well accepted treatment algorithm is lacking and treatment regimens hardly seem driven by the progress made in basic pain science. The leading thread of this thesis is the concept of CRPS 1 as a neuropathic pain syndrome of unknown etiology involving multiple and timedependent mechanisms. It is discussed that besides the affected extremity also spinal and suprapinal structures may become involved. The scope of the publications varies from clinical studies on pain management performed in the context of an interdisciplinary rehabilitation team, to experimental studies on motor impairments and immunology. The clinical and experimental work was at least partly performed before the introduction of the t= complex regional pain syndrome 1. It is for this reason that the reader may encounter the t= reflex sympathetic dystrophy in some chapters

Transcranial direct current stimulation in post-stroke sub-acute aphasia: Study protocol for a randomized controlled trial

Background: Transcranial direct current stimulation (tDCS) is a promising new technique to optimize the effect of regular Speech and Language Therapy (SLT) in the context of aphasia rehabilitation. The present study focuses on the effect of tDCS provided during SLT in the sub-acute stage after stroke. The primary aim is to evaluate the potential effect of tDCS on language functioning, specifically on word-finding, as well as generalization effects to verbal communication. The secondary aim is to evaluate its effect on social participation and quality of life, and its cost-effectiveness. Methods: We strive to include 58 stroke patients with aphasia, enrolled in an inpatient or outpatient stroke rehabilitation program, in a multicenter, double-blind, randomized controlled trial with two parallel groups and 6 months' follow-up. Patients will participate in two separate intervention weeks, with a pause of 2 weeks in between, in the context of their regular aphasia rehabilitation program. The two intervention weeks comprise daily 45-minute sessions of word-finding therapy, combined with either anodal tDCS over the left inferior frontal gyrus (1 mA, 20 minutes; experimental condition) or sham-tDCS over the same region (control condition). The primary outcome measure is word-finding. Secondary outcome measures are verbal communication, social participation, quality of life, and cost-effectiveness of the intervention. Discussion: Our results will contribute to the discussion on whether tDCS should be implemented in regular aphasia rehabilitation programs for the sub-acute post-stroke population in terms of (cost-)effectiveness. Trial registration: Nederlands Trail Register: NTR4364. Registered on 21 February 2014

Comparison of two configurations of transcranial direct current stimulation for treatment of aphasia

Objective: To compare 2 configurations of transcranial direct current stimulation (tDCS) for treatment of aphasia. Design: Randomized cross-over study. Subjects: Patients with chronic post-stroke aphasia (n = 13). Methods: TDCS was combined with word-finding therapy in 3 single sessions. In session 1, sham-tDCS/ pseudo-stimulation was applied. In sessions 2 and 3, 2 active configurations were provided in random order: Anodal tDCS over the left inferior frontal gyrus (l-IFG) and anodal tDCS over the left posterior superior temporal gyrus (l-STG). The optimal configuration was determined per individual based on a pre-set improvement in naming trained (> 20%) and untrained picture items (> 10%). Results: Overall, participants improved on trained items (median = 50%; interquartile range = 20-85) and post-treatment performance was highest in the active l-IFG condition (p = 0.040). Of the 13 participants, 6 (46%) showed relevant improvement during active tDCS; either in the l-IFG condition (n = 4; 31%) or in both the l-IFG and l-STG conditions (n = 2; 15%). On the untrained items there was no improvement (median = 0%; interquartile range = 0-0). Conclusion: This randomized cross-over single-session protocol to determine an optimal tDCS configuration for treatment of aphasia suggests that only performance on trained items can be used as guidance for configuration, and that it is relevant for half of the patients. For this subgroup, the l-IFG configuration is the optimal choice

Change in Right Inferior Longitudinal Fasciculus Integrity Is Associated With Naming Recovery in Subacute Poststroke Aphasia

Background. Despite progress made in understanding functional reorganization patterns underlying recovery in subacute aphasia, the relation between recovery and changes in white matter structure remains unclear. Objective. To investigate changes in dorsal and ventral language white matter tract integrity in relation to naming recovery in subacute poststroke aphasia. Methods. Ten participants with aphasia after left-hemisphere stroke underwent language testing and diffusion tensor imaging twice within 3 months post onset, with a 1-month interval between sessions. Deterministic tractography was used to bilaterally reconstruct the superior longitudinal fasciculus (SLF), inferior fronto-occipital fasciculus (IFOF), inferior longitudinal fasciculus (ILF), middle longitudinal fasciculus (MdLF), and uncinate fasciculus (UF). Per tract, the mean fractional anisotropy (FA) was extracted as a measure of microstructural integrity. Naming accuracy was assessed with the Boston Naming Test (BNT). Correlational analyses were performed to investigate the relationship between changes in FA values and change in BNT score. Results. A strong positive correlation was found between FA change in the right ILF within the ventral stream and change on the BNT (r = 0.91, P <.001). An increase in FA in the right ILF was associated with considerable improvement of naming accuracy (range BNT change score: 12-14), a reduction with limited improvement or slight deterioration. No significant correlations were found between change in naming accuracy and FA change in any of the other right or left ventral and dorsal language tracts. Conclusions. Naming recovery in subacute aphasia is associated with change in the integrity of the right ILF

The accuracy of the detection of body postures and movements using a physical activity monitor in people after a stroke

Background: In stroke rehabilitation not only are the levels of physical activity important, but body postures and movements performed during one’s daily-life are also important. This information is provided by a new one-sensor accelerometer that is commercially available, low-cost, and user-friendly. The present study examines the accuracy of this activity monitor (Activ8) in detecting several classes of body postures and movements in people after a stroke. Methods: Twenty-five people after a stroke participated in an activity protocol with either basic activities or daily-life activities performed in a laboratory and/or at home. Participants wore an Activ8 on their less-affected thigh. The primary outcome was the difference in registered time for the merged class “upright position” (standing/walking/running) between the Activ8 and the video recording (the reference method). Secondar

Memory self-efficacy and psychosocial factors in stroke

Objective: To explore whether Memory Self-efficacy is related to depression, neuroticism and coping in patients after stroke, as it is in healthy elderly subjects. Design: A cross-sectional design. The relation between Memory Self-efficacy and psychosocial factors was analysed using a Mann-Whitney U test and non-parametric Spearman correlations. Patients: Seventeen male and 6 female patients after stroke from an inpatient rehabilitation setting were included. Methods: Memory Self-efficacy, depression, neuroticism and coping were assessed with validated questionnaires. Patients with severe aphasia, subarachnoidal haemorrhage or subdural haematomas were excluded. Results: As in healthy elderly subjects, higher depression ratings are significantly related to lower Memory Self-efficacy ratings (Z=-2.13; p=0.033). Lower Memory Self-efficacy seems related to higher neuroticism ratings and a more passive coping style score (Z=-1.54; p=0.123; Z=-1.42; p=0.155, respectively). The Spearman correlations confirm these finding (p<0.10). Conclusion: This study replicated the relationships between Memory Self-efficacy and depression and neuroticism found in a healthy population, in an inpatient stroke population. Future research on Memory Self-efficacy in patients after stroke should focus on other potential determinants such as awareness and, ultimately, on the effectiveness and efficacy of interventions aimed at Memory Self-efficacy to improve participation and quality of life. © 2008 The Authors. Journal Compilatio

A Sensor-Based Feedback Device Stimulating Daily Life Upper Extremity Activity in Stroke Patients:A Feasibility Study

This study aims to evaluate the feasibility and explore the efficacy of the Arm Activity Tracker (AAT). The AAT is a device based on wrist-worn accelerometers that provides visual and tactile feedback to stimulate daily life upper extremity (UE) activity in stroke patients. Methods: A randomised, crossover within-subject study was conducted in sub-acute stroke patients admitted to a rehabilitation centre. Feasibility encompassed (1) adherence: the dropout rate and the number of participants with insufficient AAT data collection; (2) acceptance: the technology acceptance model (range: 7–112) and (3) usability: the system usability scale (range: 0–100). A two-way ANOVA was used to estimate the difference between the baseline, intervention and control conditions for (1) paretic UE activity and (2) UE activity ratio. Results: Seventeen stroke patients were included. A 29% dropout rate was observed, and two participants had insufficient data collection. Participants who adhered to the study reported good acceptance (median (IQR): 94 (77–111)) and usability (median (IQR): 77.5 (75–78.5)-). We found small to medium effect sizes favouring the intervention condition for paretic UE activity (η2G = 0.07, p = 0.04) and ratio (η2G = 0.11, p = 0.22). Conclusion: Participants who adhered to the study showed good acceptance and usability of the AAT and increased paretic UE activity. Dropouts should be further evaluated, and a sufficiently powered trial should be performed to analyse efficacy.</p

No effect of anodal tDCS on motor cortical excitability and no evidence for responders in a large double-blind placebo-controlled trial

Background: Transcranial direct current stimulation (tDCS) has emerged as a non-invasive brain stimulation technique. Most studies show that anodal tDCS increases cortical excitability. However, this effect has been found to be highly variable. Objective: To test the effect of anodal tDCS on cortical excitability and the interaction effect of two participant-specific factors that may explain individual differences in sensitivity to anodal tDCS: the Brain Derived Neurotrophic Factor Val66Met polymorphism (BDNF genotype) and the latency difference between anterior-posterior and lateromedial TMS pulses (APLM latency). Methods: In 62 healthy participants, cortical excitability over the left motor cortex was measured before and after anodal tDCS at 2 mA for 20 min in a pre-registered, double-blind, randomized, placebo-controlled trial with repeated measures. Results: We did not find a main effect of anodal tDCS, nor an interaction effect of the participant-specific predictors. Moreover, further analyses did not provide evidence for the existence of responders and non-responders. Conclusion: This study indicates that anodal tDCS at 2 mA for 20 min may not reliably affect cortical excitability

Predicting Upper Limb Motor Impairment Recovery after Stroke: A Mixture Model

Objective: Spontaneous recovery is an important determinant of upper extremity recovery after stroke and has been described by the 70% proportional recovery rule for the Fugl–Meyer motor upper extremity (FM-UE) scale. However, this rule is criticized for overestimating the predictability of FM-UE recovery. Our objectives were to develop a longitudinal mixture model of FM-UE recovery, identify FM-UE recovery subgroups, and internally validate the model predictions. Methods: We developed an exponential recovery function with the following parameters: subgroup assignment probability, proportional recovery coefficient rk, time constant in weeks τk, and distribution of the initial FM-UE scores. We fitted the model to FM-UE measurements of 412 first-ever ischemic stroke patients and cross-validated endpoint predictions and FM-UE recovery cluster assignment. Results: The model distinguished 5 subgroups with different recovery parameters (r1 = 0.09, τ1 = 5.3, r2 = 0.46, τ2 = 10.1, r3 = 0.86, τ3 = 9.8, r4 = 0.89, τ4 = 2.7, r5 = 0.93, τ5 = 1.2). Endpoint FM-UE was predicted with a median absolute error of 4.8 (interquartile range [IQR] = 1.3–12.8) at 1 week poststroke and 4.2 (IQR = 1.3–9.8) at 2 weeks. Overall accuracy of assignment to the poor (subgroup 1), moderate (subgroups 2 and 3), and good (subgroups 4 and 5) FM-UE recovery clusters was 0.79 (95% equal-tailed interval [ETI] = 0.78–0.80) at 1 week poststroke and 0.81 (95% ETI = 0.80–0.82) at 2 weeks. Interpretation: FM-UE recovery reflects different subgroups, each with its own recovery profile. Cross-validation indicates that FM-UE endpoints and FM-UE recovery clusters can be well predicted. Results will contribute to the understanding of upper limb recovery patterns in the first 6 months after stroke. ANN NEUROL 2020