Figure 1
Thalamotomy target and multimodal rehabilitation components.
(A) Postoperative axial T2-weighted magnetic resonance imaging showing a coagulation lesion (red circle) within the left ventro-oralis/ventral intermediate nucleus border zone following stereotactic thalamotomy.
(B) Components of fine motor training: (B-1) “origami,” a Japanese paper-craft art (10 min; such as square box and crane); (B-2) pegboard tasks (13 min; such as single-fingertip rotation and grasp-and-hold); (B-3) putty exercises (7 min; including stretching and pressing, rolling). Task difficulty was progressively adjusted to the patient’s performance.
(C) Transcutaneous electrical nerve stimulation: Surface electrodes were placed over the muscle bellies of the right flexor carpi radialis and flexor carpi ulnaris. Stimulation parameters: 50 Hz, 250 μs pulse width, and 6 mA (sensory-level intensity); device: ITO ESPURGE (ITO Co., Ltd., Kawaguchi, Japan).
(D) Vibratory stimulation to the right upper limb: five 1-minute bouts at 35 Hz, with the right hand and distal forearm placed on a vibrating platform (Personal Power Plate; Performance Health Systems, Northbrook, IL, USA).
Abbreviations: Vo, ventro-oralis nucleus; Vim, ventral intermediate nucleus.
Video 1
Preoperative writing performance. Recorded approximately 1 month before thalamotomy. The video also shows the patient grasping her right forearm with her left hand to assess a sensory trick; however, no observable changes in symptoms were evident. Note: Owing to privacy masking, fine details, such as pen pressure and stroke terminals, may not be fully visible; however, clinical assessment confirmed severe disturbances.
Table 1
Immediate within-session effects and clinical outcomes before and after thalamotomy.
| WITHIN-SESSION CHANGES (POD 1–POD 6) (FIXED 15-CHARACTER SENTENCE; SECONDS; NRS 0–10). | |||||
|---|---|---|---|---|---|
| POD | INTERVENTIONS | WRITING TIME, SECONDS | SATISFACTION, NRS (0–10) | ||
| PRE | POST | PRE | POST | ||
| 1 | ① + ② | 84.2 | 79.6 | 3 | 3 |
| 3 | ① + ② | 79.1 | 69.4 | 3 | 4 |
| 5 | ① + ② + ③ | 67.6 | 54.3 | 4 | 6 |
| 6 | ① + ② + ③ | 63.4 | 48.7 | 4 | 6 |
| PREOPERATIVE AND POSTOPERATIVE CLINICAL MEASURES | |||||
| ITEM | PREOPERATIVE | INITIAL (POD 1) | FINAL (POD 6) | ||
| WCRS | |||||
| dystonic posture | |||||
| Elbow score | 0 | 0 | 0 | ||
| Wrist score | 2 | 1 | 1 | ||
| Finger score | 3 | 3 | 3 | ||
| Latency of dystonia | 2 | 1 | 1 | ||
| Writing tremor | 1 | 0 | 0 | ||
| Writing movement score | 12 | 4 | 4 | ||
| Writing speed score | 2 | 1 | 1 | ||
| BBT, blocks | |||||
| Right hand | – | 51 | 57 | ||
| Left hand | – | 59 | 61 | ||
| NHPT, seconds | |||||
| Right hand | – | 22.3 | 20.5 | ||
| Left hand | – | 19.6 | 18.9 | ||
| EQ-5D-5L (index) | – | 0.612 | 0.772 | ||
| EQ-VAS (0–100), points | – | 40 | 70 | ||
| Barthel Index (0–100) | – | 100 | 100 | ||
| Functional Independence Measure (18–126) | – | 126 | 126 | ||
[i] Abbreviations: BBT, Box and Block Test; EQ-5D-5L, EuroQol 5-Dimension 5-Level; EQ-VAS, EuroQol Visual Analog Scale; FIM, Functional Independence Measure; NHPT, Nine-Hole Peg Test; NRS, numerical rating scale; POD, postoperative day; WCRS, Writer’s Cramp Rating Scale.
Interventions: ① Transcutaneous electrical nerve stimulation (TENS); ② fine motor training; ③ vibratory stimulation.
Note: The WCRS scores markedly decreased after surgery (Preoperative vs. Initial) but remained unchanged across postoperative assessment points. Higher scores indicate improvement in BBT, EQ-5D-5L, EQ-VAS, Barthel Index, and FIM; lower scores indicate faster performance in the NHPT and reduced severity in the WCRS. —: Not assessed. The preoperative WCRS was assessed by a neurosurgeon, while postoperative measures were assessed by an occupational therapist.
Video 2
Handwriting performance at the initial postoperative (POD) 1 and final POD 6 assessments. A comparison between POD 1 and 6 revealed a reduction in writing time and an observable reduction in the wrist flexion angle during writing at the final assessment.
Figure 2
Handwriting of a fixed 15-character sentence at the initial (A, postoperative day [POD 1]) and final (B, POD 6) assessments; showing a lighter stroke appearance, with intact stroke terminals and stable trajectories. The sentence reads: “Even as I watch the bright festivities with which others celebrate the New Year, the ‘spring’ that comes to me is no more than a modest, middling sort of good fortune” [めでたさも中ぐらいなりおらが春].
Abbreviations: POD, postoperative day.