External counterpulsation enhances neuroplasticity to promote stroke recovery

Improving tissue perfusion in peri-infarct cortex could enhance neuroplasticity and improve functional recovery after stroke.1 Treatments that enhance corticomotor function may benefit motor recovery. However, the effects of cerebral blood flow augmentation on corticomotor excitability have not been explored in humans. External counterpulsation (ECP) is a non-invasive method to improve perfusion of vital organs.2 It operates by applying ECG-triggered pressure to the lower extremities during diastole by means of air-filled cuffs. The diastolic augmentation of blood flow and the reduction of systolic afterload increases blood flow to the heart, brain and kidneys. In patients who had ischaemic stroke, ECP enhances cerebral blood flow velocities and can be associated with improvement in the neurological outcome.3 ECP may improve cerebral perfusion and collateral blood supply in ischaemic stroke by augmenting blood pressure and cerebral blood flow velocity.4 The effects of ECP on corticomotor excitability are unknown. We aimed to explore the effects of ECP on corticomotor excitability and upper limb motor recovery. We hypothesised that enhancing cerebral blood flow with ECP will facilitate ipsilesional corticomotor excitability and improve upper limb performance at the subacute stage of recovery after ischaemic stroke. First-ever ischaemic stroke patients with upper limb impairment with onset between 4 days and 21 days were enrolled. Exclusion criteria were cardioembolic stroke, sustained hypertension (systolic >180 mm Hg or diastolic >100 mm Hg), bleeding diathesis, vascular malformation, epilepsy, pregnancy, metal or electronic implants, severe head injury, severe systemic diseases and malignancy. Patients were randomised (1:1) to either real or sham ECP. ECP was performed using an ECP system (MC2, Vamed Medical Instrument Company, Foshan, China). Both groups completed 10 sessions of ECP for 1 hour per day, delivered over …