Speech rehabilitation in dysarthria after stroke: a systematic review of the studies

Efficacy of acupuncture therapy for spastic paralysis in post-stroke patients: a systematic review and meta-analysis

BACKGROUND

Despite the potentially good efficacy of acupuncture therapy in the management of post-stroke spastic paralysis demonstrated in previous studies, further verification through meta-analysis can be conducive to eliminating the inconclusive of treatment outcomes in prior findings. This systematic review and meta-analysis were thus performed to comprehensively investigate the effects of acupuncture on the daily living abilities, upper and lower limb motor function, and related functional indices of post-stroke patients with spastic paralysis.

METHODS

We conducted a computer search to collect data from PubMed, PEDro, Clinical SportDiscus, and Scopus. The inclusion criteria followed the Population-Intervention-Comparison-Outcome (PICO) principle. Literature screening, data extraction, and quality assessment of the research articles were performed by two independent investigators. Standard mean difference and 95% confidence intervals of the data were analyzed using either a random-effects model or a fixed-effects model.

RESULTS

Acupuncture therapy appeared to be effective in mitigating the limb pain of post-stroke patients with spastic paralysis (RR = -0.04, 95% CI: -0.26, 0.17), ameliorating their daily life ability (RR = 4.66, 95% CI: -0.74, 10.05), and improving their hand function (RR = 0.65, 95% CI: 0.40, 0.90) and lower limb function (RR = 0.35, 95% CI: 0.09, 0.62).

CONCLUSION

Acupuncture therapy provides more pronounced improvement in the daily life ability and limb motor function of post-stroke patients with spastic paralysis than conventional treatment regimens. Thus, acupuncture therapy can be a viable treatment option for the management of spastic paralysis following stroke.

A multicenter study on the sex difference of dysfunctions among rehabilitation outpatients in China

Dysfunction is a common clinical symptom among rehabilitation patients; however, whether there are sex differences in dysfunctions remains unclear. Therefore, this study aimed to explore this issue by examining a large sample of the population with dysfunctional problems. A multi-stage sampling scheme was used to select the rehabilitation outpatients as study participants. A total of 3415 participants from 21 medical institutions in seven cities in China were included in the final analysis. The measurement included general characteristics (age, sex, educational level, marital status, and household income) and disease-related characteristics (dysfunctions, self-care ability, vital signs, disease status, and disease course). The logistic regression was used to analyse the sex difference in dysfunctions among rehabilitation outpatients. Among 3415 rehabilitation outpatients, the mean age of participants was 45.3 years (SD:24.9), and more than half (54.0%) were male. The male patients were more likely to have cognitive impairment (OR = 1.74; 95% CI = 1.42, 2.13), speech disorders (OR = 2.00; 95% CI = 1.62, 2.48), dysphagia (OR = 1.55; 95% CI = 1.12, 2.16), and multiple dysfunctions (OR = 2.00; 95% CI = 1.57, 2.54) than female. Female patients were more likely to have motor dysfunctions (OR = 0.63; 95% CI = 0.50, 0.78). There are sex differences in dysfunctions among rehabilitation outpatients. This sex difference may provide potential clinical value for the treatment of rehabilitation patients.

Anomalies of Midbrain/Hindbrain Development: Malformations of Cerebellum: Diagnosis, Classification, and Rehabilitative Hypothesis

Extensive research has been conducted on the cerebellum, making it one of the most thoroughly investigated regions of the brain. It plays a fundamental role not only in motor control but also in motor learning and cognition. The development of the cerebellum is a lengthy process, beginning during the embryonic period up to the first years of life. This slow and protracted process makes it a vulnerable organ liable to different insults, responsible for many developmental disorders such as Dandy–Walker syndrome, medulloblastoma, dystroglicanopathy, pontocerebellar hypoplasia, thubulinopathies, and Jubert syndrome. Due to several factors, the true prevalence of cerebellar malformations is not known in most cases. The cerebellum undergoes development through following four fundamental stages:

(1) Identification of the cerebellar region at the boundary between the midbrain and hindbrain.

(2) Establishment of two cell proliferation compartments: firstly, Purkinje cells and deep cerebellar nuclei emerge from the ventricular zone of the metencephalic alar plate; secondly, granule cell precursors are generated from a separate proliferation compartment known as the upper rhombic lip.

(3) Migration of granule cells toward the interior: granule precursor cells constitute the external granular layer (EGL), and during the initial postnatal year, granule cells migrate inward to their final position in the internal granular layer.

(4) Formation of cerebellar circuitry and subsequent differentiation.

Based on different types of involvement of the structures detected in the brain magnetic resonance, the classification of brainstem and cerebellar anomalies is divided into three categories: (1) mainly the cerebellum, (2) mainly the brain stem, and (3) both involved. This review will outline the developmental processes of the cerebellum and delve into common developmental disorders associated with it, including the Dandy–Walker syndrome, cerebellar hypoplasia, rhomboencephalosynapsis, lissencephaly, and gray matter heterotopias.

Polymicrogyria, Cobblestone Malformations, and Tubulin Mutation (Overmigration beyond Pial Limiting Membrane): Diagnosis, Treatment, and Rehabilitation Approach

Polymicrogyria, cobblestone malformations, and tubulinopathies constitute a group of neuronal migration abnormalities beyond the pial limiting membrane. Their etiopathogenesis remains unclear, with proposed environmental and genetic factors, including copy number variations and single-gene disorders, recently categorized.

Polymicrogyria features numerous small circumvolutions separated by large, shallow grooves, often affecting the perisylvian cortex with various presentations. Clinical manifestations vary depending on lesion degree, extent, and location, commonly including epilepsy, encephalopathies, spastic tetraparesis, mental retardation, and cortical function deficits.

Cobblestone malformations exhibit a Roman-like pavement cortex, affecting both hemispheres symmetrically due to disruption of the glia limitans, frequently linked to glycosyltransferase gene mutations. Classified separately from lissencephaly type II, they are associated with congenital muscular dystrophy syndromes such as Fukuyama congenital muscular dystrophy, Walker–Warburg syndrome, and muscle–eye–brain disease.

Tubulinopathies encompass diverse cerebral malformations resulting from α-tubulin isotype gene variants, exhibiting a wide clinical spectrum including motor/cognitive impairment, facial diplegia, strabismus, and epilepsy.

Diagnosis relies on magnetic resonance imaging (MRI) with age-specific protocols, highlighting the gray–white junction as a polymicrogyria marker, though neonatal diagnosis may be challenging due to technical and brain maturity issues.

To date, no effective treatments are available and management include physiotherapy, speech and language therapy, and vision training program for oculomotor disabilities; antiepileptic drugs are commonly necessary, and most severe forms usually require specific nutritional support.

Schizencephaly: Etiopathogenesis, Classification, Therapeutic, and Rehabilitative Approach

Schizencephaly is an uncommon anomaly in neuronal migration characterized by complete clefts that extend from the pia mater to the ependymal surface of the ventricular system. These clefts are encompassed by displaced gray matter and filled with cerebrospinal fluid. Typically, they are found most often in the frontal lobe or the area around the lateral sulcus and can occur on one or both sides. The size, location, and type of these clefts carry significant clinical and prognostic implications. Moreover, they are frequently associated with other central nervous system malformations, including the absence of the septum pellucidum, septo-optic dysplasia, optic nerve hypoplasia, pachygyria, polymicrogyria, cortical dysplasia, heterotopia, and dysplasia of the corpus callosum. Occurrence of schizencephaly is almost always sporadic but its etiopathogenesis is yet to be fully understood. Most likely environmental factors, including exposure to teratogens, viral infections, and maternal factors, operate jointly with genetic defects. To date COL4A1, EMX2, SHH, and SIX3 are the genes identified as possible pathogenetic target. It is interesting to notice that schizencephaly is commonly seen in abandoned or adopted children, as proof of causative effect of intrautero insults. Clinical presentations widely vary and symptoms include a spectrum of cognitive impairment, limb paresis/tetraparesis, and epileptic seizures either with early or late onset; anyway, none of these symptoms is ever-present and patients with schizencephaly can also have normal neurocognitive and motor development. Diagnostic gold standard for schizencephaly is magnetic resonance imaging, which allows to identify and characterize typical clefts. Treatment of schizencephaly is symptomatic and supportive and depends on the severity of morbidity resulting from the malformation. Therapy includes antiepileptic drugs, psychomotor rehabilitation, and in selected cases surgical approach.

Defects of Midbrain/Hindbrain Development: Defects of Anteroposterior and Dorsoventral Patterning

The knowledge regarding the midbrain and the hindbrain (MBHB) malformations has been progressively increased in recent years, thanks to the advent of neuroimaging and genetic technologies. Many classifications have been proposed in order to well describe all of these patterns. The most complete and detailed one is based on the genetic and embryologic features that allow an easier and effective knowledge of these disturbs. It categorizes them into four primary groups: (1) Malformations resulting from early anteroposterior and dorsoventral patterning defects or the misspecification of MBHB germinal zones.(2) Malformations linked to later generalized developmental disorders that notably impact the brain stem and cerebellum, with a pathogenesis that is at least partially comprehended.(3) Localized brain malformations significantly affecting the brain stem and cerebellum, with a pathogenesis that is partly or largely understood, encompassing local proliferation, migration, and axonal guidance.(4) Combined hypoplasia and atrophy observed in presumed prenatal-onset degenerative disorders. Regarding diagnosis, brain stem malformations are typically identified during prenatal assessments, particularly when they are linked with anomalies in the cerebellum and cerebrum. Magnetic resonance imaging is the primary neuroimaging method in the evaluation of these malformations. The clinical characteristics of individuals with malformations in the midbrain or hindbrain are generally nonspecific. Common findings at presentation are hypotonia, motor retardation, ataxia, variable degree of intellectual disability, and abnormal eye movement (e.g., nystagmus, abnormal saccades, oculomotor apraxia, strabismus, and abnormal smooth pursuit). The complexity and the number of these MBHB malformations are constantly increasing. We will provide an overview of MBHB disorders, focusing on embryology, genetic, clinical, and neuroradiology features that could be helpful for clinicians and neuroscientist to understand process of these conditions.

Targeted deep brain stimulation of the motor thalamus improves speech and swallowing motor functions after cerebral lesions

Speech and swallowing are complex motor acts that depend upon the integrity of input neural signals from motor cortical areas to control muscles of the head and neck. Lesions damaging these neural pathways result in weakness of key muscles causing dysarthria and dysphagia, leading to profound social isolation and risk of aspiration and suffocation. Here we show that Deep Brain Stimulation (DBS) of the motor thalamus improved speech and swallowing functions in two participants with dysarthria and dysphagia. First, we proved that DBS increased excitation of the face motor cortex, augmenting motor evoked potentials, and range and speed of motion of orofacial articulators in n = 10 volunteers with intact neural pathways. Then, we demonstrated that this potentiation led to immediate improvement in swallowing functions in a patient with moderate dysphagia and profound dysarthria as a consequence of a traumatic brain lesion. In this subject and in another with mild dysarthria, we showed that DBS immediately ameliorated impairments of respiratory, phonatory, resonatory, and articulatory control thus resulting in a clinically significant improvement in speech intelligibility. Our data provide first-in-human evidence that DBS can be used to treat dysphagia and dysarthria in people with cerebral lesions.

Do proprioceptive training strategies with dual-task exercises positively influence gait parameters in chronic stroke? A systematic review

OBJECTIVE

This study aims to assess the impact of proprioceptive training strategies with dual-task exercises on gait in people with chronic stroke.

STUDY DESIGN

Systematic review.

PATIENTS

Chronic stroke.

METHODS

Searches were conducted in accordance with PRISMA guidelines and PICOS criteria. PubMed, Web of Science, and Scopus databases were systematically searched from November 2020 to February 2022, for eligible clinical trials. Two independent reviewers thoroughly screened potential articles for relevance and assessed the methodology quality. In accordance with the GRADE, PICOS criteria, and Cochrane risk of bias tools, the authors included articles concerning the effectiveness of dual-task in proprioceptive training on gait parameters in people with chronic stroke.

RESULTS

Of 3075 identified studies, 11 articles met the inclusion criteria: 7 were randomized clinical trials, 1 was not randomized, and 3 were observational studies. The overall quality of evidence, assessed using the GRADE framework, was high, indicating a high level of confidence in the systematic review's findings. The papers involved 393 stroke patients; 241 underwent dual-task in proprioceptive training, with 152 participants in other stroke rehabilitation; within the dual-task group, 71 engaged in cognitive tasks, and 170 participated in motor tasks. dual-task in proprioceptive training improved gait speed, cadence, stride time, stride length, and step length. The best effects were observed with training 3 times a week for 4 weeks, with each session lasting 30 minutes, on speed, cadence, stride length, and step length.

CONCLUSION

Current evidence suggests that proprioceptive training strategies with dual-task exercises improved walking abilities in people with chronic stroke. Specifically, it enhanced gait speed, a key indicator of clinical severity.

Mapping the development process of transcutaneous neuromuscular electrical stimulation devices for neurorehabilitation, the associated barriers and facilitators, and its applicability to acquired dysarthria: a qualitative study of manufacturers' perspectives

PURPOSE

The fragmented nature of the medical device market limits our understanding of how particular sub-markets navigate the device development process. Despite the widespread use of transcutaneous neuromuscular electrical stimulation (NMES), its use for acquired dysarthria treatment has not been sufficiently explored. This study aims to provide a preliminary understanding of the stages involved in the development of NMES devices designed for neurorehabilitation. It also aims to investigate manufacturers' perceptions concerning factors that facilitate or impede its development and determine its applicability for acquired dysarthria.

MATERIALS AND METHODS

In-depth semi-structured online interviews were conducted with eight NMES device manufacturers located across Europe, North America and Oceania. The interviews were video-recorded, automatically transcribed, manually reviewed, and analysed using a qualitative content analysis.

RESULTS

NMES device development for neurorehabilitation involves six complex phases with sequential and overlapping activities. Some emerging concepts were comparable to established medical device models, while others were specific to NMES. Its adaptability to different neurological disorders, the positive academia-industry collaborations, the industry's growth prospects and the promising global efforts for standardised regulations are all key facilitators for its development. However, financial, political, regulatory, and natural constraints emerged as barriers. Indications and challenges for the applicability of NMES for acquired dysarthria treatment were also discussed.

CONCLUSION

The findings provide a foundation for further investigations on the NMES market sub-sector, particularly in the context of neurorehabilitation. The study also provides insights into the potential adoption of NMES for acquired dysarthria, which can serve as a reference for future research.

Smartphone-Based Speech Therapy for Poststroke Dysarthria: Pilot Randomized Controlled Trial Evaluating Efficacy and Feasibility

BACKGROUND

Dysarthria is a common poststroke speech disorder affecting communication and psychological well-being. Traditional speech therapy is effective but often poses challenges in terms of accessibility and patient adherence. Emerging smartphone-based therapies may offer promising alternatives for the treatment of poststroke dysarthria.

OBJECTIVE

This study aimed to assess the efficacy and feasibility of smartphone-based speech therapy for improving speech intelligibility in patients with acute and early subacute poststroke dysarthria. This study also explored the impact of the intervention on psychological well-being, user experience, and overall feasibility in a clinical setting.

METHODS

Participants were divided into 2 groups for this randomized, evaluator-blinded trial. The intervention group used a smartphone-based speech therapy app for 1 hour per day, 5 days per week, for 4 weeks, with guideline-based standard stroke care. The control group received standard guideline-based stroke care and rehabilitation. Speech intelligibility, psychological well-being, quality of life, and user acceptance were assessed using repeated measures ANOVA.

RESULTS

In this study, 40 patients with poststroke dysarthria were enrolled, 32 of whom completed the trial (16 in each group). The intervention group showed significant improvements in speech intelligibility compared with the control group. This was evidenced by improvements from baseline (F1,30=34.35; P<.001), between-group differences (F1,30=6.18; P=.02), and notable time-by-group interactions (F1,30=6.91; P=.01). Regarding secondary outcomes, the intervention led to improvements in the percentage of correct consonants over time (F1,30=5.57; P=.03). In addition, significant reductions were noted in the severity of dysarthria in the intervention group over time (F1,30=21.18; P<.001), with a pronounced group effect (F1,30=5.52; P=.03) and time-by-group interaction (F1,30=5.29; P=.03). Regarding quality of life, significant improvements were observed as measured by the EQ-5D-3L questionnaire (F1,30=13.25; P<.001) and EQ-VAS (F1,30=7.74; P=.009) over time. The adherence rate to the smartphone-based app was 64%, with over half of the participants completing all the sessions. The usability of the app was rated high (system usability score 80.78). In addition, the intervention group reported increased self-efficacy in using the app compared with the control group (F1,30=10.81; P=.003).

CONCLUSIONS

The smartphone-based speech therapy app significantly improved speech intelligibility, articulation, and quality of life in patients with poststroke dysarthria. These findings indicate that smartphone-based speech therapy can be a useful assistant device in the management of poststroke dysarthria, particularly in the acute and early subacute stroke stages.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05146765; https://clinicaltrials.gov/ct2/show/NCT05146765.

Congenital/Primitive Hydrocephalus: Classification, Clinical Aspects, and Rehabilitation Approach

Hydrocephalus is a heterogeneous disorder of cerebrospinal fluid (CSF) flow that leads to abnormal enlargement of the brain ventricles. The prevalence of infant hydrocephalus is approximately one case per 1,000 births. Hydrocephalus occurs due to an imbalance between the production and the absorption of CSF. The causes of hydrocephalus secondary to CSF overproduction are papilloma of the choroid plexus and rarely diffuse hyperplasia of the villi. All the other hydrocephalus forms are secondary to obstruction to normal CSF reabsorption and are also known as obstructive hydrocephalus. According to the location of obstruction, obstructive hydrocephalus can be defined as communicating, when caused by extraventricular obstruction of the CSF flow or decreased resorption of CSF distal to the fourth ventricle in the cisterns of the base or in the subarachnoid spaces, or as not communicating, in case of intraventricular obstruction to fluid flow. There is a third category, common in preterm infants, called external hydrocephalus which is secondary to delayed development of arachnoid function. Hydrocephalus leads to an increase in intraventricular pressure because of the lack of the mechanism regulating the homeostasis of the CSF flow. Increased intraventricular pressure is responsible for the clinical symptoms in affected child. Clinical presentation varies with age. In the neonatal period, prolonged or frequent apneic or bradycardic events, increasing head circumference, presence of sunsetting eyes or upward gaze palsy, evidence of full or tense anterior/posterior fontanelle, and splayed cranial sutures are signs of increased intracranial pressure. In infants, the most common signs are progressive macrocephaly, irritability, nausea/vomiting, headache, gait changes, and regression of developmental milestones. The extent of brain damage depends on the cause that led to hydrocephalus, the patient's age, and the rapidity of onset. The surgical treatment modalities consist of endoscopic ventriculostomy of the third ventricle and ventriculoperitoneal or ventriculoatrial CSF shunt.

At the Basis of Brain Malformations: Brain Plasticity, Developmental Neurobiology, and Considerations for Rehabilitation

From early age in the human brain occurs plasticity process that influences its development. The functioning of the brain is governed by its neuronal connectivity and the synaptic dynamics of these connections. A neuron, over thousands of synapses, can receive a large number of inputs and produce different outputs leading to the consolidation and integration of memory. Synaptic plasticity is the set of experience-dependent changes in neuronal pathways that support acquired habits. It is the ability of the nervous system to reshape connectivity between neurons, changing the functional and structural organization of neuronal circuits that allows us to adapt to the multiple and continuous changes in the environment and leading to processes such as cognitive development and the ability to learn. Synaptic plasticity is mainly due to short- and long-term mechanisms. Short-term synaptic plasticity refers to changes in synaptic strength that occurs very quickly (from one-thousandth of a second to 5 minutes) and are temporary and decay over minutes (maximum 30 minutes). Long-term synaptic plasticity is defined by a long-lasting, activity-dependent change in synaptic efficacy, last from hours up to a lifetime (from 30 minutes to weeks, months, and years) and is thought to constitute the basis of learning and memory. A significant difference occurs in the nature of the change; short-term plasticity adds only a functional change, whereas long-term plasticity causes not only functional but also structural changes. Aside from genetic factors and metabolic processes, brain development is mediated also by environmental factors. Interaction with the environment plays a key role in the development and growth of neural networks and neuroplasticity. Environmental interactions that can modify and increase the development of neural networks and intelligence in children are several and are herein discussed.

Microcephaly and Its Related Syndromes: Classification, Genetic, Clinical, and Rehabilitative Considerations

Microcephaly, a form of cortical cortex malformation, results from abnormal cellular production and proliferation, identified when the occipital frontal head circumference (OFC) falls two or more standard deviations (SDs) below the expected average for age, gender, and population. Severity is classified based on SD: mild (OFC < 2 SD) or severe (OFC < 3 SD). While microcephaly can lead to developmental delay, intellectual disability, epilepsy, and cerebral palsy, not all cases exhibit these issues. Classified as primary/congenital or secondary/postnatal, microcephaly can stem from genetic or acquired factors in both types. Congenital microcephaly origins vary, while secondary microcephaly is characterized by normal OFC at birth, followed by a decrease within the first year, often associated with progressive cognitive and motor impairments. Primary hereditary microcephaly (MCPH), or microcephaly vera, is genetically diverse, with 28 related genes (MCPH1 to MCPH28) encoding proteins linked to centrosomes and progenitor cell mitosis in the brain ventricle's neuroepithelium. Defects in deoxyribonucleic acid (DNA) repair pathways (e.g., NBN, FANCA, ATR, ATM genes) can lead to microcephaly by impairing DNA repair. Enzyme deficiencies in metabolic pathways may also contribute, causing toxic metabolite accumulation or essential metabolite loss (microcephaly of metabolic origin). Acquired congenital microcephaly may result from ischemic or infectious processes, drugs, radiation, maternal diseases during pregnancy, with damage influenced by fetal genetics, environmental interactions, developmental stage, and exposure intensity/duration. Diagnostic workup includes electroencephalogram, ophthalmological, auditory, magnetic resonance imaging, metabolic, echocardiogram, and infection screening tests, alongside genetic evaluations like cytogenetic studies, fluorescence in situ hybridization, comparative genomic microarray-hybridization, single-nucleotide microarray-polymorphism, and exome sequencing. Symptomatic treatment is available, and genetic counseling is crucial for affected families.

Malformations of the Cerebral Commissures

Malformations of the cerebral commissures are abnormalities involving the structures which connect the brain hemispheres. The main cerebral commissures are the anterior commissure, the hippocampal commissure, and the corpus callosum, which is the largest and best known of the three and connects the neocortex of the two cerebral hemispheres. Commissures of more reduced extension are the posterior commissure and the habenular commissure. They derive embryologically from the same structure, the commensurate plate. Any interference in the embryological development of the brain commissures may cause an anomaly of all the three commissures or of a single commissure, as well as any combination of anomalies of each of them.

Each of these three commissural traits may be absent, isolated, or in combination. The abnormality of the commissures, in addition, can be complete or partial, with dysplasia of the meninges, with multicystic dysplasia of the interhemispheric meninges, in the context of Aicardi syndrome or with the presence of interhemispheric lipomas.

The complete agenesis of the commissures (“classic” form) is the most common form and encompasses more than a third of the cases. In complete agenesis, by definition, both the corpus callosum and the hippocampal commissure are totally absent.

Anomalies of the commissural structures associated with dysplasia of the meninges include the agenesis of the corpus callosum with interhemispheric cysts (a complex spectrum of clinical and neuroradiological conditions characterized by the associated presence of an interhemispheric cyst formed by communicating cavities) and the agenesis of commissures with interhemispheric lipomas that are usually located in the subarachnoid space.

Genes responsible for axonal migration to the commissural plate and those responsible for crossing and connections with the neurons of the contralateral hemisphere are multiple, so that malformations of the cerebral commissure/corpus callosum can be found in numerous malformative syndromes with other multiple associated abnormalities.

Holoprosencephaly: The Disease and Its Related Disabilities

Holoprosencephaly (HPE), the most prevalent developmental anomaly affecting the forebrain in humans, occurs in approximately 1 in 16,000 liveborn neonates, with an incidence reaching 1 in 250 in conceptuses. This condition is distributed worldwide. HPE is etiologically heterogeneous, and its pathogenesis is variable. Environmental, teratogenic, genetic, or metabolic factors can contribute to the development of HPE. Notably, maternal insulin-dependent diabetes mellitus and maternal alcoholism are among the primary causative factors. HPE may be linked to various well-defined multiple malformation syndromes characterized by a normal karyotype, such as Smith–Lemli–Opitz's, Pallister–Hall's, or velocardiofacial syndrome. Alternatively, it can be associated with chromosomal abnormalities. (i.e., Patau's syndrome and, less frequently, Edwards' syndrome or Down's syndrome). The major genes implicated in HPE are SHH, ZIC2, SIX3, and TGIF. The range of HPE is extensive, covering diverse neuropathological phenotypes of varying severity. Three classical types of HPE can be distinguished in increasing order of severity: lobar HPE, characterized by separated right and left ventricles with some continuity across the frontal cortex; semilobar HPE, featuring a partial separation; and the most severe form, alobar HPE, where there is a single brain ventricle and the absence of an interhemispheric fissure. Additionally, there are other variations of HPE, ranging in severity, including the less severe interhemispheric median HPE (also known as middle interhemispheric variant). The phenotypic spectrum of HPE is highly extensive, encompassing severe cerebral malformations to microforms. Children with HPE often encounter numerous medical challenges; among them neurological disorders, craniofacial malformations, endocrine disorders, oral and motor dysfunction, and dysfunction of the autonomic nervous system. Neurologic problems, such as cerebral palsy and seizures, are common. The diagnosis of HPE is typically made prenatally, relying primarily on ultrasound and magnetic resonance imaging examinations. The prognosis for individuals with HPE is largely dependent on its underlying causes. Those with cytogenetic abnormalities, in particular, face a significantly poorer prognosis, with only 2% surviving beyond 1 year.

Acoustic and Physiological Voice Assessment And Maximum Phonation Time In Patients With Different Types Of Dysarthria

OBJECTIVE

To compare the maximum phonation time of /a/, acoustic glottal source parameters, and physiological measures in patients with dysarthria.

METHOD

Thirteen patients were classified according to dysarthria type and divided into functional profiles (hypofunctional, hyperfunctional, and mixed). Assessments of maximum phonation time of /a/, glottal source parameters, electroglottography, and nasometry were performed. Results were compared between groups using ANOVA and Tukey posthoc tests.

RESULTS

The highest fundamental frequency differed significantly between groups, with the hyperfunctional profile showing higher values than the other participant groups. Reductions in the maximum phonation time of /a/ and alterations in acoustic glottal source parameters and electroglottography measures were observed in all groups, with no significant differences between them. The remaining measures did not differ between groups.

CONCLUSION

The maximum phonation times for /a/ were reduced in all participant groups, suggesting air escape during phonation. The presence of alterations in several glottal source parameters in all participant groups is indicative of noise, tremor, and vocal instability. Lastly, the high fundamental frequency in patients with a hyperfunctional profile reinforces the presence of vocal instability. These findings suggest that, although the characteristics observed in the assessments were consistent with expectations of patients with dysarthria, it is difficult to perform a differential diagnosis of this condition based on acoustic and physiological parameters alone.

Identifying profiles of stroke patients benefitting from additional training: a latent class analysis approach

OBJECTIVE

To identify profiles of stroke patient benefitting from additional training, using latent class analysis.

DESIGN

Retrospective observational study.

PATIENTS

Patients with stroke (n = 6,875) admitted to 42 recovery rehabilitation units in Japan between January 2005 and March 2016 who were registered in the Japan Association of Rehabilitation Database.

METHODS

The main outcome measure was the difference in Functional Independence Measure (FIM) scores between admission and discharge (referred to as "gain"). The effect of additional training, categorized as usual care (no additional training), self-exercise, training with hospital staff, or both exercise (combining self-exercise and training with hospital staff), was assessed through multiple regression analyses of latent classes.

RESULTS

Applying inclusion and exclusion criteria, 1185 patients were classified into 7 latent classes based on their admission characteristics (class size n = 82 (7%) to n = 226 (19%)). Patients with class 2 characteristics (right hemiparesis and modified dependence in the motor-FIM and cognitive-FIM) had positive FIM gain with additional training (95% confidence interval (95% CI) 0.49-3.29; p < 0.01). One-way analysis of variance revealed that training with hospital staff (95% CI 0.07-16.94; p < 0.05) and both exercises (95% CI 5.38-15.13; p < 0.01) led to a significantly higher mean FIM gain than after usual care.

CONCLUSION

Additional training in patients with stroke with right hemiparesis and modified dependence in activities of daily living was shown to improve activities of daily living. Training with hospital staff combined with self-exercise is a promising rehabilitation strategy for these patients.

Therapeutic robots for post-stroke rehabilitation

Stroke is a prevalent, severe, and disabling health-care issue on a global scale, inevitably leading to motor and cognitive deficits. It has become one of the most significant challenges in China, resulting in substantial social and economic burdens. In addition to the medication and surgical interventions during the acute phase, rehabilitation treatment plays a crucial role in stroke care. Robotic technology takes distinct advantages over traditional physical therapy, occupational therapy, and speech therapy, and is increasingly gaining popularity in post-stroke rehabilitation. The use of rehabilitation robots not only alleviates the workload of healthcare professionals but also enhances the prognosis for specific stroke patients. This review presents a concise overview of the application of therapeutic robots in post-stroke rehabilitation, with particular emphasis on the recovery of motor and cognitive function.

The combination of accent method and phonemic contrast: an innovative strategy to improve speech production on post-stroke dysarthria

INTRODUCTION

Speech production includes segmental and suprasegmental features, which interact and cooperate with each other. Impaired speech production is common in individuals with post-stroke dysarthria. The commonly used phonemic contrast therapy and Accent Method in clinical practice can improve the segmental and suprasegmental aspects, respectively. This study aimed to explore the feasibility and immediate effectiveness of the combination of specific rhythm patterns of the Accent Method and phonemic contrast on speech production.

METHODS

Fifteen poststroke dysarthria patients (12 males and three females) first received accentuation task of three rhythm patterns (Largo-slow, Andante-medium, Allegro-fast) and later received speech task in appropriate rhythm patterns combined with phonemic contrast materials and non-phonemic contrast materials. Speech parameters were analyzed by considering speech clarity and prosody.

RESULTS

The results showed that the number of correct target syllables, sentence clarity, and standard deviation of intensity increased significantly, and the average length of pauses and abnormal pause times decreased significantly in Andante (medium) compared to other rhythms. The number of correct target syllables, sentence clarity, and standard deviation of intensity increased significantly compared with those in the non-phonemic contrast in Andante (medium).

CONCLUSION

The combination of phonemic contrast and Accent Method was verified to have an immediate effect on speech production in Mandarin speakers with post-stroke dysarthria and could be further validated in other diseases with impaired speech production in the clinic in the future.

Transient Worsening of Dysphagia and Dysarthria after Treatment with Botulinum Toxin in Patients with Acquired Brain Injury

Although botulinum toxin is widely considered an effective and safe treatment for a variety of neurological conditions (such as disabling spasticity), local or systemic adverse effects have often been reported. This study describes three cases of patients with severe acquired brain injury who were receiving speech therapy for recovering dysphagia and dysarthria but showed worsening of these symptoms after receiving BoNT treatment for motor spasticity. To increase clinicians' knowledge of these adverse effects, we present our cases and explore their significance to avoid major complications such as aspiration pneumonia.

A survey of technologies for automatic Dysarthric speech recognition

Speakers with dysarthria often struggle to accurately pronounce words and effectively communicate with others. Automatic speech recognition (ASR) is a powerful tool for extracting the content from speakers with dysarthria. However, the narrow concept of ASR typically only covers technologies that process acoustic modality signals. In this paper, we broaden the scope of this concept that the generalized concept of ASR for dysarthric speech. Our survey discussed the systems encompassed acoustic modality processing, articulatory movements processing and audio-visual modality fusion processing in the application of recognizing dysarthric speech. Contrary to previous surveys on dysarthric speech recognition, we have conducted a systematic review of the advancements in this field. In particular, we introduced state-of-the-art technologies to supplement the survey of recent research during the era of multi-modality fusion in dysarthric speech recognition. Our survey found that audio-visual fusion technologies perform better than traditional ASR technologies in the task of dysarthric speech recognition. However, training audio-visual fusion models requires more computing resources, and the available data corpus for dysarthric speech is limited. Despite these challenges, state-of-the-art technologies show promising potential for further improving the accuracy of dysarthric speech recognition in the future.

Single-Cell RNA-Seq Reveals Changes in Cell Subsets in the Cortical Microenvironment during Acute Phase of Ischemic Stroke Rats

BACKGROUND

Ischemic stroke, the most common stroke type, has threatened human life and health. Currently, intravenous thrombolysis and endovascular thrombectomy are the mainstream treatment methods, but they may cause cerebral ischemia-reperfusion injury (CIRI), which aggravates brain injury. Consequently, it is worthwhile to start with a study of CIRI mechanism to identify better prevention and treatment methods. Applying single-cell RNA sequencing (scRNA-seq) technology to further understand the biological functions of various cell types in CIRI will facilitate the intervention of CIRI.

METHODS

This study aimed to establish a rat middle cerebral artery occlusion (MCAO) model to simulate cerebral ischemia-reperfusion, perform enzymatic hydrolysis, and suspend cerebral cortex tissue edema. Single-cell transcriptome sequencing was used, combined with cluster analysis, t-distributed stochastic neighbor embedding (t-SNE) visualization, and other bioinformatics methods to distinguish cell subgroups while using gene ontology (GO) function enrichment and Kyoto encyclopedia of genes and genomes (KEGG) pathway enrichment to reveal the biological function of each cell subgroup.

RESULTS

We identified 21 brain clusters with cell type-specific gene expression patterns and cell subpopulations, as well as 42 marker genes representing different cell subpopulations. The number of cells in clusters 0-3 increased significantly in MCAO group compared to that in the sham group, and nine-cell subpopulations exhibited remarkable differences in the number of genes. Subsequently, GO and KEGG analyses were performed on the top 40 differentially expressed genes (DEGs) in the six cell subpopulations with significant differences. These results indicate that biological processes and signaling pathways are involved in different cell subpopulations.

CONCLUSIONS

ScRNA-seq revealed the diversity of cell differentiation and the unique information of cell subpopulations in the cortex of rats with acute ischemic stroke, providing novel insight into the pathological process and drug discovery in stroke.

Changes in ultrasonic vocalizations after unilateral cerebral ischemia in a rat stroke model

Stroke frequently results in communication impairments that negatively impact quality of life and overall recovery, yet the biological mechanisms underlying these changes are not well understood. Ultrasonic vocalizations (USVs) in rodent models of disease and aging have been used to improve our understanding of the biological mechanisms that underlie vocal deficits and their response to interventions. Changes in USVs after middle cerebral artery occlusion (MCAO) in mice have been reported, yet rat models have significant anatomical and behavioral advantages over mice, including the ability to vocally train rats with an established paradigm. We sought to determine whether a unilateral MCAO rat stroke model provides a biologically and behaviorally relevant way to study post stroke vocalization deficits. We hypothesized that left MCAO would be associated with changes in USVs. Six weeks after MCAO or sham-control surgery, USVs were recorded in rats using an established mating paradigm. Stroke was associated with differences in USV acoustics including more frequent use of simple calls characterized by shorter durations and restricted bandwidths. These parameters were also found to correlate with post stroke lingual weakness. This is the first study to describe changes to rat USVs using a stroke model. These results suggest the unilateral MCAO rat stroke model is a biologically and behaviorally relevant model to understand how stroke affects vocal behaviors.

Comparison of Tongue Acupuncture and Traditional Acupuncture in the Treatment of Poststroke Dysarthria: A Meta-Analysis and Tongue Acupuncture System Classification Evaluation

OBJECTIVE

To discuss whether tongue acupuncture is more effective than traditional acupuncture in the treatment of poststroke dysarthria and explore the advantage of tongue acupuncture treatment parameters.

METHODS

We evaluated the efficacy of tongue acupuncture compared with traditional acupuncture through a rigorous meta-analysis process. The included studies were from eight databases in English and Chinese. The Cochrane risk of bias assessment tool was used to evaluate the quality of studies. Stata15.1 software was used for meta-analysis and sensitivity analysis. Tongue acupuncture therapeutic parameters were classified and counted based on tongue acupoint location, acupuncture manipulation, and the number of manipulations. Subgroup analysis was used to compare the differences between various treatment parameters. Outcome The meta-analysis eventually included a total of 9 studies. Tongue acupuncture is superior to traditional acupuncture in clinical efficacy [OR = 3.62, 95%Cl (2.24, 5.85), P < 0.0001], FDA score [SMD = -1.99, 95%Cl (-3.77, -0.21), P=0.028], and NIHSS score [WMD = 0.86, 95%Cl (0.15, 1.57), P=0.017, I2 = 31.7%] in the treatment of poststroke dysarthria. According to the classified statistics of tongue acupuncture treatment parameters, there are three kinds of tongue acupuncture points in 9 studies: lingual surface, sublingual, and both lingual surface and sublingual acupoints. The operation methods include the oblique stabbing of the root of the tongue, twisting after stabbing, and acupoint pricking. The number of operation methods varies from 1 to 3.

CONCLUSION

Tongue acupuncture outperforms traditional acupuncture in terms of clinical efficacy, FDA score, and NIHSS score in the treatment of poststroke dysarthria. The curative effect of sublingual acupoints is better than that of lingual surface acupoints, the combined use of multiple manipulations is better than that of a single manipulation, and acupuncture manipulation has a cumulative effect. PROSPERO registration number: CRD42021285722.

L4-to-L4 nerve root transfer for hindlimb hemiplegia after hypertensive intracerebral hemorrhage

There is no effective treatment for hemiplegia after hypertensive intracerebral hemorrhage. Considering that the branches of L4 nerve roots in the lumbar plexus root control the movement of the lower extremity anterior and posterior muscles, we investigated a potential method of nerve repair using the L4 nerve roots. Rat models of hindlimb hemiplegia after a hypertensive intracerebral hemorrhage were established by injecting autogenous blood into the posterior limb of internal capsule. The L4 nerve root on the healthy side of model rats was transferred and then anastomosed with the L4 nerve root on the affected side to drive the extensor and flexor muscles of the hindlimbs. We investigated whether this method can restore the flexible movement of the hindlimbs of paralyzed rats after hypertensive intracerebral hemorrhage. In a beam-walking test and ladder rung walking task, model rats exhibited an initial high number of slips, but improved in accuracy on the paretic side over time. At 17 weeks after surgery, rats gained approximately 58.2% accuracy from baseline performance and performed ankle motions on the paretic side. At 9 weeks after surgery, a retrograde tracing test showed a large number of fluoro-gold-labeled motoneurons in the left anterior horn of the spinal cord that supports the L4-to-L4 nerve roots. In addition, histological and ultramicrostructural findings showed axon regeneration of motoneurons in the anterior horn of the spinal cord. Electromyography and paw print analysis showed that denervated hindlimb muscles regained reliable innervation and walking coordination improved. These findings suggest that the L4-to-L4 nerve root transfer method for the treatment of hindlimb hemiplegia after hypertensive intracerebral hemorrhage can improve the locomotion of hindlimb major joints, particularly of the distal ankle. Findings from study support that the L4-to-L4 nerve root transfer method can effectively repair the hindlimb hemiplegia after hypertensive intracerebral hemorrhage. All animal experiments were approved by the Animal Ethics Committee of the First Affiliated Hospital of Nanjing Medical University (No. IACUC-1906009) in June 2019.

Feasibility of a standardized protocol for respiratory training with intermitted positive pressure breathing ventilator application in dysphonia and dysarthria

BACKGROUND

Brain damage can affect several functions related to speech production leading to dysphonia and dysarthria. Most rehabilitation treatments focus on articulation training rather than on pneumophonic coordination and respiratory muscle strength. Respiratory training using an intermitted positive pressure breathing (IPPB) ventilator can be used for this last purpose; no agreement on a standard protocol has been reached to date.

AIM

To evaluate the feasibility and the effectiveness of a standardized incremental protocol of respiratory training using IPPB to treat dysphonia and dysarthria.

DESIGN

Case series study.

SETTING

Neuropsychological Rehabilitation Unit in an Italian Neurorehabilitation Division.

POPULATION

Thirty-two subjects with dysphonia and dysarthria resulting from neurological lesion.

METHODS

Participants were assessed using clinical evaluation scales (GIRBAS scale of dysphonia, Robertson dysarthria profile), respiratory function test, and arterial blood gas analysis in air. The evaluations were performed at baseline and after 20 sessions of respiratory training with IPPB. The protocol provided a default increment of ventilator parameters. All subjects also underwent a standard speech and language therapy treatment. A satisfaction survey to assess acceptability and the Goal Attainment Scale were applied.

RESULTS

All participants fulfilled the protocol. No complications or discomfort were reported. Subjects' satisfaction at survey was 97.7%. After respiratory training, all respiratory function parameters increased, but only maximal voluntary ventilation (MVV), maximum inspiratory pressure (MIP), and maximum expiratory pressure (MEP) were statistically significant (P<0.05). Clinical evaluation scales significantly improved (P<0.05). Correlation between respiratory function parameters and clinical evaluation scales showed a moderate correlation between MVV, MEP, MIP, and Robertson dysarthria profile (P<0.01). A weak correlation was found between MIP, MVV, and GIRBAS scale (P<0.05).

CONCLUSIONS

Our protocol showed to be practical and well-tolerated. After respiratory training, MVV, MIP and MEP improved in significantly. Clinical scale scores improved in all participants.

CLINICAL REHABILITATION IMPACT

Respiratory training using IPPB ventilator can be useful in implementing speech and language treatments in subjects with dysphonia and dysarthria linked to brain injury.

Role of imaging in early diagnosis of acute ischemic stroke: a literature review

Stroke is a serious health condition that is responsible for more than 5% of total deaths. Near 20% of patients experiencing stroke die every year, resulting in the stroke being at the top of the list of preventable causes of death. Once an acute stroke is suspected, a golden hour of less than an hour is available to prevent the undesirable consequences. Since neuroimaging is mandatory in the diagnosis of stroke, the proper use of neuroimaging could help saving time and planning the right treatment for the patient. Some of the available imaging methods help us with rapid results, while others benefit us from a more accurate diagnosis. Hereby, we aim to provide a clinical review of the advantages and disadvantages of different available neuroimaging methods in approaching acute stroke to help clinicians choose the best method according to the settings.