Whatever the hell this is, obviously not written for survivors and zero help to getting survivors recovered.
Flexor carpi radialis H-reflex in different body positions in patients with post-stroke
Jia-Yin Ma1, 
Jia-Jia Wu1,2, 
Mou-Xiong Zheng1,2,3, 
Xu-Yun Hua1,2,3, 
Chun-Lei Shan1,2,4* and 
Jian-Guang Xu2,4*- 1Center of Rehabilitation Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- 2Engineering Research Center of Traditional Chinese Medicine Intelligent Rehabilitation, Ministry of Education, Shanghai, China
- 3Department of Traumatology and Orthopedics, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- 4School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
Background: Spinal stretch reflex (SSR) hyperexcitability reflected by the H-reflex has been reported in more strongly affected extremities after stroke. The H-reflex in the lower extremities is modulated by body position normally and alternatively modulated post-stroke.
Objective: This study aimed to preliminarily explore how upper extremity (UE) H-reflexes are modulated by body position after stroke, which remains unknown.
Materials and methods: Three patients after stroke with hemiparesis/hemiplegia were included. Bilateral flexor carpi radialis (FCR) H-reflexes were examined in the supine position while standing. Other clinical evaluations include the modified Ashworth scale (MAS) and postural stability measurement.
Results: The three cases herein showed that (1) SSR excitability was higher in more strongly affected UEs than less-affected UEs, (2) down-modulation of SSR excitability occurred in less-affected UEs in static standing compared with the supine position, but modulation of SSR excitability in more-affected UEs varied, and (3) bilateral UE SSR excitability in case 3 was down-modulated the most. Moreover, case 3 showed no difference in muscle tone of the more affected UE between supine and standing positions, and case 3 showed the best postural stability.
Conclusion: Spinal stretch reflex hyperexcitability in strongly affected UEs could commonly occur in different phases of recovery after stroke. Down-modulation of SSR excitability could occur in less-affected UEs in the standing position compared with the supine position, while modulation of SSR excitability might be altered in strongly affected UEs and vary in different phases of recovery. There could be some correlation between postural control and UE SSR hyperexcitability. The H-reflex may help to offer a new perspective on rehabilitation evaluation and interventions to promote UE motor control after stroke.
Introduction
Upper extremity (UE) movement dysfunction is the most common and stable symptom in stroke survivors (1), often presenting with increased flexion synergy patterns or spasticity and difficulty in voluntary isolated movements. Flexion synergy patterns are observed in patients with hemiplegia in different body positions (2) and during dynamic activities (3), which seriously affect their activities of daily life.
It is widely accepted that the increase in flexion synergy patterns is mediated by an exaggerated spinal stretch reflex (SSR). The H-reflex has been usually employed as a measure of SSR excitability to investigate spinal neuronal pathway health in patients with neurological disorders. It is evoked by low-intensity electrical stimulation of the Ia afferent, resulting in the monosynaptic excitation of motor neurons. Changes in H-reflex amplitude are usually used to assess different types of inhibition acting on Ia afferent terminals, including homosynaptic depression, presynaptic inhibition, reciprocal Ia inhibition, Ib inhibition, and recurrent inhibition (4).
It has been reported that SSR hyperexcitability is reflected by the H-reflex in more strongly affected upper and lower extremities after stroke (5, 6). Several studies found that the soleus H-reflex varies in different body positions and is specifically down-modulated when sitting or standing compared with the prone position in healthy participants (7, 8). One previous study has also shown that the soleus H-reflex was up-modulated on both sides when standing compared with the prone position in patients with spasticity after stroke (5). Collectively, most previous studies focused on the relationship between soleus H-reflex modulation and postural control in healthy adults and patients with upper motor neuron disease. Although it has been reported that increased flexion synergy patterns in more strongly affected UEs were significantly associated with impaired postural control after stroke (9), UE H-reflex characteristics in different body positions, and at different phases of stroke recovery remain unknown. Thus, we hypothesized that H-reflex modulation in UEs might vary in different body positions in patients after stroke, and modulation of SSR excitability in UEs might be correlated to postural control.
The objective of this study was to preliminarily explore how UE H-reflexes were modulated by different body positions after stroke. The study presented three cases in different phases of stroke recovery. The muscle chosen for the H-reflex examination was the flexor carpi radialis (FCR), which has been commonly used. Furthermore, measurements of the modified Ashworth scale (MAS) in two different body positions as well as postural stability in static standing were also assessed. We hope that this study can provide new perspectives for evaluation and intervention in the rehabilitation of strongly affected UEs after stroke.
Patient perspective
The patients enrolled in this study had been participating actively in rehabilitation before the study commenced, and they had a great interest in learning about their motor recovery in their UE. Thus, they agreed to be enrolled in the study and were well informed regarding the study's purpose and their rights as participants.
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