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Tang J, Xie Y, Fang R, Tan H, Zeng S, Wen Z, Sun X, Yao T, Wang S, Xie L, Wu D. The mechanism of Sangdantongluo granule in treating post-stroke spasticity based on multimodal fMRI combined with TMS: Study protocol. Contemp Clin Trials Commun 2024; 39:101317. [PMID: 38948333 PMCID: PMC11214411 DOI: 10.1016/j.conctc.2024.101317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 07/02/2024] Open
Abstract
Introduction Post-stroke spasticity (PSS) is among the prevalent complications of stroke, greatly affecting motor function recovery and reducing patients' quality of life without timely treatment. Sangdantongluo granule, a modern traditional Chinese patent medicine, has significant clinical efficacy in treating PSS. However, the mechanism of Sangdantongluo granule in treating PSS is still unknown. We designed this study to explore the mechanism of Sangdantongluo granule in treating PSS through multimodal functional magnetic resonance imaging (fMRI) combined with transcranial magnetic stimulation (TMS). Methods and analysis In a single-center, randomized, double-blind, parallel placebo-controlled study, 60 PSS patients will be recruited in China and randomly assigned to either the experimental or control groups at a ratio of 1:1. For eight weeks, Sangdantongluo granule or placebo will be utilized for intervention. The main outcome is the Modified Ashworth Scale (MAS), the secondary outcome includes the Fugl-Meyer Assessment Scale-upper Extremity (FMA-UE), National Institute of Health Stroke Scale (NIHSS), and Modified Rankin Scale (mRS), the mechanism measure is the changes in cortical excitability and multimodal fMRI at baseline and after eight weeks. Ethics and dissemination This study was approved by the Ethics Committee of the Affiliated Hospital of Hunan Academy of Traditional Chinese Medicine (approval number: [202364]). Clinical trial registration Chinese Clinical Trial Registry, identifier: ChiCTR2300074793. Registered on 16 August 2023.
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Affiliation(s)
- Jie Tang
- Graduate School, Hunan University of Chinese Medicine, Changsha, 410208, China
- Department of Neurology, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, 410006, China
| | - Yao Xie
- Department of Neurology, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, 410006, China
| | - Rui Fang
- Institute of Clinical Pharmacology, Hunan Academy of Chinese Medicine, Changsha, 410006, China
| | - Huizhong Tan
- Graduate School, Hunan University of Chinese Medicine, Changsha, 410208, China
- Department of Neurology, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, 410006, China
| | - Shanshan Zeng
- Graduate School, Hunan University of Chinese Medicine, Changsha, 410208, China
- Department of Neurology, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, 410006, China
| | - Zan Wen
- Graduate School, Hunan University of Chinese Medicine, Changsha, 410208, China
- Department of Neurology, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, 410006, China
| | - Xiongxing Sun
- Graduate School, Hunan University of Chinese Medicine, Changsha, 410208, China
- Department of Neurology, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, 410006, China
| | - Ting Yao
- Department of Neurology, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, 410006, China
| | - Shiliang Wang
- Department of Neurology, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, 410006, China
| | - Le Xie
- Department of Neurology, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, 410006, China
| | - Dahua Wu
- Department of Neurology, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, 410006, China
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Ti CHE, Hu C, Yuan K, Chu WCW, Tong RKY. Uncovering the Neural Mechanisms of Inter-Hemispheric Balance Restoration in Chronic Stroke Through EMG-Driven Robot Hand Training: Insights From Dynamic Causal Modeling. IEEE Trans Neural Syst Rehabil Eng 2024; 32:1-11. [PMID: 38051622 DOI: 10.1109/tnsre.2023.3339756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
EMG-driven robot hand training can facilitate motor recovery in chronic stroke patients by restoring the interhemispheric balance between motor networks. However, the underlying mechanisms of reorganization between interhemispheric regions remain unclear. This study investigated the effective connectivity (EC) between the ventral premotor cortex (PMv), supplementary motor area (SMA), and primary motor cortex (M1) using Dynamic Causal Modeling (DCM) during motor tasks with the paretic hand. Nineteen chronic stroke subjects underwent 20 sessions of EMG-driven robot hand training, and their Action Reach Arm Test (ARAT) showed significant improvement ( β =3.56, [Formula: see text]). The improvement was correlated with the reduction of inhibitory coupling from the contralesional M1 to the ipsilesional M1 (r=0.58, p=0.014). An increase in the laterality index was only observed in homotopic M1, but not in the premotor area. Additionally, we identified an increase in resting-state functional connectivity (FC) between bilateral M1 ( β =0.11, p=0.01). Inter-M1 FC demonstrated marginal positive relationships with ARAT scores (r=0.402, p=0.110), but its changes did not correlate with ARAT improvements. These findings suggest that the improvement of hand functions brought about by EMG-driven robot hand training was driven explicitly by task-specific reorganization of motor networks. Particularly, the restoration of interhemispheric balance was induced by a reduction in interhemispheric inhibition from the contralesional M1 during motor tasks of the paretic hand. This finding sheds light on the mechanistic understanding of interhemispheric balance and functional recovery induced by EMG-driven robot training.
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Chen S, Zhang X, Chen X, Zhou Z, Cong W, Chong K, Xu Q, Wu J, Li Z, Lin W, Shan C. The assessment of interhemispheric imbalance using functional near-infrared spectroscopic and transcranial magnetic stimulation for predicting motor outcome after stroke. Front Neurosci 2023; 17:1231693. [PMID: 37655011 PMCID: PMC10466792 DOI: 10.3389/fnins.2023.1231693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/02/2023] [Indexed: 09/02/2023] Open
Abstract
Objective To investigate changes in interhemispheric imbalance of cortical excitability during motor recovery after stroke and to clarify the relationship between motor function recovery and alterations in interhemispheric imbalance, with the aim to establish more effective neuromodulation strategies. Methods Thirty-one patients underwent assessments of resting motor threshold (RMT) using transcranial magnetic stimulation (TMS); the cortical activity of the primary motor cortex (M1), premotor cortex (PMC), and supplementary motor area (SMA) using functional near-infrared spectroscopy (fNIRS); as well as motor function using upper extremity Fugl-Meyer (FMA-UE). The laterality index (LI) of RMT and fNIRS were also calculated. All indicators were measured at baseline(T1) and 1 month later(T2). Correlations between motor function outcome and TMS and fNIRS metrics at baseline were analyzed using bivariate correlation. Results All the motor function (FMA-UE1, FMA-UE2, FMA-d2) and LI-RMT (LI-RMT1 and LI-RMT2) had a moderate negative correlation. The higher the corticospinal excitability of the affected hemisphere, the better the motor outcome of the upper extremity, especially in the distal upper extremity (r = -0.366, p = 0.043; r = -0.393, p = 0.029). The greater the activation of the SMA of the unaffected hemisphere, the better the motor outcome, especially in the distal upper extremity (r = -0.356, p = 0.049; r = -0.367, p = 0.042). There was a significant moderate positive correlation observed between LI-RMT2 and LI-SMA1 (r = 0.422, p = 0.018). The improvement in motor function was most significant when both LI-RMT1 and LI-SMA1 were lower. Besides, in patients dominated by unaffected hemisphere corticospinal excitability during motor recovery, LI-(M1 + SMA + PMC)2 exhibited a significant moderate positive association with the proximal upper extremity function 1 month later (r = 0.642, p = 0.007). Conclusion The combination of both TMS and fNIRS can infer the prognosis of motor function to some extent. Which can infer the role of both hemispheres in recovery and may contribute to the development of effective individualized neuromodulation strategies.
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Affiliation(s)
- Songmei Chen
- Department of Rehabilitation Medicine, Shanghai No.3 Rehabilitation Hospital, Shanghai, China
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiaolin Zhang
- Department of Rehabilitation Medicine, Shanghai No.3 Rehabilitation Hospital, Shanghai, China
| | - Xixi Chen
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhiqing Zhou
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Weiqin Cong
- Department of Rehabilitation Medicine, Shanghai No.3 Rehabilitation Hospital, Shanghai, China
| | - KaYee Chong
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qing Xu
- Department of Rehabilitation Medicine, Shanghai No.3 Rehabilitation Hospital, Shanghai, China
| | - Jiali Wu
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhaoyuan Li
- Department of Rehabilitation Medicine, Shanghai No.3 Rehabilitation Hospital, Shanghai, China
| | - Wanlong Lin
- Department of Rehabilitation Medicine, Shanghai No.3 Rehabilitation Hospital, Shanghai, China
| | - Chunlei Shan
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Center of Rehabilitation Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Engineering Research Center of Traditional Chinese Medicine Intelligent Rehabilitation, Ministry of Education, Shanghai, China
- Institute of rehabilitation, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Hayes L, Taga M, Charalambous CC, Raju S, Lin J, Schambra HM. The distribution of transcallosal inhibition to upper extremity muscles is altered in chronic stroke. J Neurol Sci 2023; 450:120688. [PMID: 37224604 PMCID: PMC10330477 DOI: 10.1016/j.jns.2023.120688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/25/2023] [Accepted: 05/11/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To determine if the distribution of transcallosal inhibition (TI) acting on proximal and distal upper extremity muscles is altered in chronic stroke. METHODS We examined thirteen healthy controls and sixteen mildly to moderately impaired chronic stroke patients. We used transcranial magnetic stimulation (TMS) to probe TI from the contralesional onto ipsilesional hemisphere (assigned in controls). We recorded the ipsilateral silent period in the paretic biceps (BIC) and first dorsal interosseous (FDI). We measured TI strength, distribution gradient (TI difference between muscles), and motor impairment (Fugl-Meyer Assessment). RESULTS Both groups had stronger TI acting on their FDIs than BICs (p < 0.001). However, stroke patients also had stronger TI acting on their BICs than controls (p = 0.034), resulting in a flatter distribution of inhibition (p = 0.028). In patients, stronger FDI inhibition correlated with less hand impairment (p = 0.031); BIC inhibition was not correlated to impairment. CONCLUSION TI is more evenly distributed to the paretic FDI and BIC in chronic stroke. The relative increase in proximal inhibition does not relate to better function, as it does distally. SIGNIFICANCE The results expand our knowledge about segment-specific neurophysiology and its relevance to impairment after stroke.
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Affiliation(s)
- Leticia Hayes
- Department of Neurology, NYU Grossman School of Medicine, New York, United States.
| | - Myriam Taga
- Department of Neurology, NYU Grossman School of Medicine, New York, United States.
| | - Charalambos C Charalambous
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus; Center for Neuroscience and Integrative Brain Research (CENIBRE), University of Nicosia Medical School, Nicosia, Cyprus.
| | - Sharmila Raju
- Department of Neurology, NYU Grossman School of Medicine, New York, United States.
| | - Jing Lin
- Department of Rehabilitation Medicine, NYU Grossman School of Medicine, New York, United States.
| | - Heidi M Schambra
- Department of Neurology, NYU Grossman School of Medicine, New York, United States; Department of Rehabilitation Medicine, NYU Grossman School of Medicine, New York, United States.
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Hudson HM, Guggenmos DJ, Azin M, Vitale N, McKenzie KA, Mahnken JD, Mohseni P, Nudo RJ. Broad Therapeutic Time Window for Driving Motor Recovery After TBI Using Activity-Dependent Stimulation. Neurorehabil Neural Repair 2023; 37:384-393. [PMID: 36636754 DOI: 10.1177/15459683221145144] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND After an acquired injury to the motor cortex, the ability to generate skilled movements is impaired, leading to long-term motor impairment and disability. While rehabilitative therapy can improve outcomes in some individuals, there are no treatments currently available that are able to fully restore lost function. OBJECTIVE We previously used activity-dependent stimulation (ADS), initiated immediately after an injury, to drive motor recovery. The objective of this study was to determine if delayed application of ADS would still lead to recovery and if the recovery would persist after treatment was stopped. METHODS Rats received a controlled cortical impact over primary motor cortex, microelectrode arrays were implanted in ipsilesional premotor and somatosensory areas, and a custom brain-machine interface was attached to perform the ADS. Stimulation was initiated either 1, 2, or 3 weeks after injury and delivered constantly over a 4-week period. An additional group was monitored for 8 weeks after terminating ADS to assess persistence of effect. Results were compared to rats receiving no stimulation. RESULTS ADS was delayed up to 3 weeks from injury onset and still resulted in significant motor recovery, with maximal recovery occurring in the 1-week delay group. The improvements in motor performance persisted for at least 8 weeks following the end of treatment. CONCLUSIONS ADS is an effective method to treat motor impairments following acquired brain injury in rats. This study demonstrates the clinical relevance of this technique as it could be initiated in the post-acute period and could be explanted/ceased once recovery has occurred.
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Affiliation(s)
- Heather M Hudson
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - David J Guggenmos
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Meysam Azin
- Department of Electrical Engineering and Computer Science, Case Western Reserve University, Cleveland, OH, USA
| | - Nicholas Vitale
- Department of Electrical Engineering, Stanford University, Stanford, CA, USA
| | - Katelyn A McKenzie
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jonathan D Mahnken
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Pedram Mohseni
- Department of Electrical Engineering and Computer Science, Case Western Reserve University, Cleveland, OH, USA
| | - Randolph J Nudo
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
- Landon Center on Aging, University of Kansas Medical Center, Kansas City, KS, USA
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Mirdamadi JL, Xu J, Arevalo-Alas KM, Kam LK, Borich MR. State-dependent interhemispheric inhibition reveals individual differences in motor behavior in chronic stroke. Clin Neurophysiol 2023; 149:157-167. [PMID: 36965468 PMCID: PMC10101934 DOI: 10.1016/j.clinph.2023.02.177] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/05/2023] [Accepted: 02/26/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To investigate state-dependent interhemispheric inhibition (IHI) in chronic stroke survivors compared to neurotypical older adult controls, and test whether abnormal IHI modulation was associated with upper extremity motor behavior. METHODS Dual-coil transcranial magnetic stimulation (TMS) measured IHI bi-directionally, between non-lesioned and lesioned motor cortex (M1) in two activity states: (1) at rest and (2) during contralateral isometric hand muscle contraction. IHI was tested by delivering a conditioning stimulus 8-msec or 50-msec prior to a test stimulus over contralateral M1. Paretic motor behavior was assessed by clinical measures of impairment, strength, and dexterity, and mirroring activity in the non-paretic hand. RESULTS Stroke survivors demonstrated reduced IHI at rest, and less IHI modulation (active - rest) compared to controls. Individual differences in IHI modulation were related to motor behavior differences where greater IHI modulation was associated with greater motor impairment and more mirroring. In contrast, there were no relationships between IHI at rest and motor behavior. CONCLUSIONS Abnormal state-dependent interhemispheric circuit activity may be more sensitive to post-stroke motor deficits than when assessed in a single motor state. SIGNIFICANCE Characterizing state-dependent changes in neural circuitry may enhance models of stroke recovery and inform rehabilitation interventions.
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Affiliation(s)
- Jasmine L Mirdamadi
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jing Xu
- Department of Kinesiology, University of Georgia, Athens, GA, USA
| | - Karla M Arevalo-Alas
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Liana K Kam
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael R Borich
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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Salazar CA, Feng W, Bonilha L, Kautz S, Jensen JH, George MS, Rowland NC. Transcranial Direct Current Stimulation for Chronic Stroke: Is Neuroimaging the Answer to the Next Leap Forward? J Clin Med 2023; 12:2601. [PMID: 37048684 PMCID: PMC10094806 DOI: 10.3390/jcm12072601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023] Open
Abstract
During rehabilitation, a large proportion of stroke patients either plateau or begin to lose motor skills. By priming the motor system, transcranial direct current stimulation (tDCS) is a promising clinical adjunct that could augment the gains acquired during therapy sessions. However, the extent to which patients show improvements following tDCS is highly variable. This variability may be due to heterogeneity in regions of cortical infarct, descending motor tract injury, and/or connectivity changes, all factors that require neuroimaging for precise quantification and that affect the actual amount and location of current delivery. If the relationship between these factors and tDCS efficacy were clarified, recovery from stroke using tDCS might be become more predictable. This review provides a comprehensive summary and timeline of the development of tDCS for stroke from the viewpoint of neuroimaging. Both animal and human studies that have explored detailed aspects of anatomy, connectivity, and brain activation dynamics relevant to tDCS are discussed. Selected computational works are also included to demonstrate how sophisticated strategies for reducing variable effects of tDCS, including electric field modeling, are moving the field ever closer towards the goal of personalizing tDCS for each individual. Finally, larger and more comprehensive randomized controlled trials involving tDCS for chronic stroke recovery are underway that likely will shed light on how specific tDCS parameters, such as dose, affect stroke outcomes. The success of these collective efforts will determine whether tDCS for chronic stroke gains regulatory approval and becomes clinical practice in the future.
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Affiliation(s)
- Claudia A. Salazar
- Department of Neurosurgery, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
- Center for Biomedical Imaging, University of South Carolina, Columbia, SC 29208, USA
- Department of Neuroscience, College of Graduate Studies, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Leonardo Bonilha
- Department of Neurology, College of Medicine, Emory University, Atlanta, GA 30322, USA
- Department of Neurology, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Steven Kautz
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
- Ralph H. Johnson VA Medical Center, Charleston, SC 29401, USA
| | - Jens H. Jensen
- Center for Biomedical Imaging, University of South Carolina, Columbia, SC 29208, USA
- Department of Neuroscience, College of Graduate Studies, Medical University of South Carolina, Charleston, SC 29425, USA
- Department of Radiology and Radiological Science, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Mark S. George
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
- Ralph H. Johnson VA Medical Center, Charleston, SC 29401, USA
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Nathan C. Rowland
- Department of Neurosurgery, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
- Center for Biomedical Imaging, University of South Carolina, Columbia, SC 29208, USA
- Department of Neuroscience, College of Graduate Studies, Medical University of South Carolina, Charleston, SC 29425, USA
- Department of Neurology, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
- Ralph H. Johnson VA Medical Center, Charleston, SC 29401, USA
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Clinical Effectiveness of Non-Immersive Virtual Reality Tasks for Post-Stroke Neuro-Rehabilitation of Distal Upper-Extremities: A Case Report. J Clin Med 2022; 12:jcm12010092. [PMID: 36614892 PMCID: PMC9820917 DOI: 10.3390/jcm12010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
A library of non-immersive Virtual Reality (VR) tasks were developed for post-stroke rehabilitation of distal upper extremities. The objective was to evaluate the rehabilitation impact of the developed VR-tasks on a patient with chronic stroke. The study involved a 50-year-old male patient with chronic (13 month) stroke. Twenty VR therapy sessions of 45 min each were given. Clinical scales, cortical-excitability measures, functional MRI (fMRI), and diffusion tensor imaging (DTI) data were acquired pre-and post-therapy to evaluate the motor recovery. Increase in Fugl-Meyer Assessment (wrist/hand) by 2 units, Barthel Index by 5 units, Brunnstrom Stage by 1 unit, Addenbrooke's Cognitive Examination by 3 units, Wrist Active Range of Motion by 5° and decrease in Modified Ashworth Scale by 1 unit were observed. Ipsilesional Motor Evoked Potential (MEP) amplitude (obtained using Transcranial Magnetic Stimulation) was increased by 60.9µV with a decrease in Resting Motor Threshold (RMT) by 7%, and contralesional MEP amplitude was increased by 56.2µV with a decrease in RMT by 7%. The fMRI-derived Laterality Index of Sensorimotor Cortex increased in precentral-gyrus (from 0.28 to 0.33) and in postcentral-gyrus (from 0.07 to 0.3). The DTI-derived FA-asymmetry decreased in precentral-gyrus (from 0.029 to 0.024) and in postcentral-gyrus (from 0.027 to 0.017). Relative reduction in task-specific performance metrics, i.e., time taken to complete the task (31.6%), smoothness of trajectory (76.7%), and relative percentage error (80.7%), were observed from day 1 to day 20 of the VR therapy. VR therapy resulted in improvement in clinical outcomes in a patient with chronic stroke. The research also gives insights to further improve the overall system of rehabilitation.
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Lee Friesen C, Lawrence M, Ingram TGJ, Boe SG. Home-based portable fNIRS-derived cortical laterality correlates with impairment and function in chronic stroke. Front Hum Neurosci 2022; 16:1023246. [PMID: 36569472 PMCID: PMC9780676 DOI: 10.3389/fnhum.2022.1023246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction Improved understanding of the relationship between post-stroke rehabilitation interventions and functional motor outcomes could result in improvements in the efficacy of post-stroke physical rehabilitation. The laterality of motor cortex activity (M1-LAT) during paretic upper-extremity movement has been documented as a useful biomarker of post-stroke motor recovery. However, the expensive, labor intensive, and laboratory-based equipment required to take measurements of M1-LAT limit its potential clinical utility in improving post-stroke physical rehabilitation. The present study tested the ability of a mobile functional near-infrared spectroscopy (fNIRS) system (designed to enable independent measurement by stroke survivors) to measure cerebral hemodynamics at the motor cortex in the homes of chronic stroke survivors. Methods Eleven chronic stroke survivors, ranging widely in their level of upper-extremity motor deficit, used their stroke-affected upper-extremity to perform a simple unilateral movement protocol in their homes while a wireless prototype fNIRS headband took measurements at the motor cortex. Measures of participants' upper-extremity impairment and function were taken. Results Participants demonstrated either a typically lateralized response, with an increase in contralateral relative oxyhemoglobin (ΔHbO), or response showing a bilateral pattern of increase in ΔHbO during the motor task. During the simple unilateral task, M1-LAT correlated significantly with measures of both upper-extremity impairment and function, indicating that participants with more severe motor deficits had more a more atypical (i.e., bilateral) pattern of lateralization. Discussion These results indicate it is feasible to gain M1-LAT measures from stroke survivors in their homes using fNIRS. These findings represent a preliminary step toward the goals of using ergonomic functional neuroimaging to improve post-stroke rehabilitative care, via the capture of neural biomarkers of post-stroke motor recovery, and/or via use as part of an accessible rehabilitation brain-computer-interface.
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Affiliation(s)
- Christopher Lee Friesen
- Laboratory for Brain Recovery and Function, Dalhousie University, Halifax, NS, Canada
- Axem Neurotechnology, Halifax, NS, Canada
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada
| | - Michael Lawrence
- Laboratory for Brain Recovery and Function, Dalhousie University, Halifax, NS, Canada
- Axem Neurotechnology, Halifax, NS, Canada
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada
| | - Tony Gerald Joseph Ingram
- Laboratory for Brain Recovery and Function, Dalhousie University, Halifax, NS, Canada
- Axem Neurotechnology, Halifax, NS, Canada
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada
| | - Shaun Gregory Boe
- Laboratory for Brain Recovery and Function, Dalhousie University, Halifax, NS, Canada
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada
- School of Health and Human Performance, Dalhousie University, Halifax, NS, Canada
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
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Restoring After Central Nervous System Injuries: Neural Mechanisms and Translational Applications of Motor Recovery. Neurosci Bull 2022; 38:1569-1587. [DOI: 10.1007/s12264-022-00959-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/29/2022] [Indexed: 11/06/2022] Open
Abstract
AbstractCentral nervous system (CNS) injuries, including stroke, traumatic brain injury, and spinal cord injury, are leading causes of long-term disability. It is estimated that more than half of the survivors of severe unilateral injury are unable to use the denervated limb. Previous studies have focused on neuroprotective interventions in the affected hemisphere to limit brain lesions and neurorepair measures to promote recovery. However, the ability to increase plasticity in the injured brain is restricted and difficult to improve. Therefore, over several decades, researchers have been prompted to enhance the compensation by the unaffected hemisphere. Animal experiments have revealed that regrowth of ipsilateral descending fibers from the unaffected hemisphere to denervated motor neurons plays a significant role in the restoration of motor function. In addition, several clinical treatments have been designed to restore ipsilateral motor control, including brain stimulation, nerve transfer surgery, and brain–computer interface systems. Here, we comprehensively review the neural mechanisms as well as translational applications of ipsilateral motor control upon rehabilitation after CNS injuries.
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Khademi F, Naros G, Nicksirat A, Kraus D, Gharabaghi A. Rewiring Cortico-Muscular Control in the Healthy and Poststroke Human Brain with Proprioceptive β-Band Neurofeedback. J Neurosci 2022; 42:6861-6877. [PMID: 35940874 PMCID: PMC9463986 DOI: 10.1523/jneurosci.1530-20.2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 11/21/2022] Open
Abstract
In severely affected stroke survivors, cortico-muscular control is disturbed and volitional upper limb movements often absent. Mental rehearsal of the impaired movement in conjunction with sensory feedback provision are suggested as promising rehabilitation exercises. Knowledge about the underlying neural processes, however, remains vague. In male and female chronic stroke patients with hand paralysis, a brain-computer interface controlled a robotic orthosis and turned sensorimotor β-band desynchronization during motor imagery (MI) of finger extension into contingent hand opening. Healthy control subjects performed the same task and received the same proprioceptive feedback with a robotic orthosis or visual feedback only. Only when proprioceptive feedback was provided, cortico-muscular coherence (CMC) increased with a predominant information flow from the sensorimotor cortex to the finger extensors. This effect (1) was specific to the β frequency band, (2) transferred to a motor task (MT), (3) was proportional to subsequent corticospinal excitability (CSE) and correlated with behavioral changes in the (4) healthy and (5) poststroke condition; notably, MI-related enhancement of β-band CMC in the ipsilesional premotor cortex correlated with motor improvements after the intervention. In the healthy and injured human nervous system, synchronized activation of motor-related cortical and spinal neural pools facilitates, in accordance with the communication-through-coherence hypothesis, cortico-spinal communication and may, thereby, be therapeutically relevant for functional restoration after stroke, when voluntary movements are no longer possible.SIGNIFICANCE STATEMENT This study provides insights into the neural processes that transfer effects of brain-computer interface neurofeedback to subsequent motor behavior. Specifically, volitional control of cortical oscillations and proprioceptive feedback enhances both cortical activity and behaviorally relevant connectivity to the periphery in a topographically circumscribed and frequency-specific way. This enhanced cortico-muscular control can be induced in the healthy and poststroke brain. Thereby, activating the motor cortex with mental rehearsal of the impaired movement and closing the loop by robot-assisted feedback synchronizes ipsilesional premotor cortex and spinal neural pools in the β frequency band. This facilitates, in accordance with the communication-through-coherence hypothesis, cortico-spinal communication and may, thereby, be therapeutically relevant for functional restoration after stroke, when voluntary movements are no longer possible.
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Affiliation(s)
- Fatemeh Khademi
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen 72076, Germany
| | - Georgios Naros
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen 72076, Germany
| | - Ali Nicksirat
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen 72076, Germany
| | - Dominic Kraus
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen 72076, Germany
| | - Alireza Gharabaghi
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen 72076, Germany
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12
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Comparison of transcallosal inhibition between hemispheres and its relationship with motor behavior in patients with severe upper extremity impairment after subacute stroke. J Stroke Cerebrovasc Dis 2022; 31:106469. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 03/20/2022] [Indexed: 10/18/2022] Open
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13
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Efficacy of contralaterally controlled functional electrical stimulation compared to cyclic neuromuscular electrical stimulation and task-oriented training for recovery of hand function after stroke: study protocol for a multi-site randomized controlled trial. Trials 2022; 23:397. [PMID: 35549747 PMCID: PMC9097385 DOI: 10.1186/s13063-022-06303-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multi-site studies in stroke rehabilitation are important for determining whether a technology and/or treatment can be successfully administered by sites other than the originating site and with similar positive outcomes. This study is the first multi-site clinical trial of a novel intervention for post-stroke upper limb rehabilitation called contralaterally controlled functional electrical stimulation (CCFES). Previous pilot and single-site studies showed positive effects of CCFES on upper limb impairment and hand dexterity in stroke survivors. The main purpose of this study is to confirm and demonstrate the efficacy of CCFES in a larger group of most likely responders across multiple clinical sites. METHODS Up to 129 stroke survivors with moderate to severe upper extremity hemiparesis at 4 clinical trial sites will be randomized to CCFES, cyclic neuromuscular electrical stimulation (cNMES), or task-oriented-training (TOT). Participants will receive 12 weeks of group-specific therapy. Blinded assessments of upper limb impairment and activity limitation, quality of life, and neurophysiology will be used to compare outcomes at baseline, after treatment, and up to 6 months post-treatment. The primary endpoint is change in dexterity from baseline to 6 months post-treatment. DISCUSSION Loss of hand function following stroke is a major rehabilitation problem affecting millions of people per year globally. More effective rehabilitation therapies are needed to restore hand function in these individuals. This study will determine whether CCFES therapy produces greater improvements in upper extremity function than cNMES or TOT, and will begin to elucidate the different mechanisms underlying each of the three treatments. This multi-site study is a critical step in advancing a novel method of rehabilitation toward clinical translation and widespread dissemination. TRIAL REGISTRATION ClinicalTrials.gov NCT03574623 . Registered prior to first enrollment; July 2, 2018.
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14
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Mohan A, Knutson JS, Cunningham DA, Widina M, O'Laughlin K, Arora T, Li X, Sakaie K, Wang X, Uchino K, Plow EB. Contralaterally Controlled Functional Electrical Stimulation Combined With Brain Stimulation for Severe Upper Limb Hemiplegia-Study Protocol for a Randomized Controlled Trial. Front Neurol 2022; 13:869733. [PMID: 35599736 PMCID: PMC9117963 DOI: 10.3389/fneur.2022.869733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/01/2022] [Indexed: 12/05/2022] Open
Abstract
Background Approximately two-thirds of stroke survivors experience chronic upper limb paresis, and of them, 50% experience severe paresis. Treatment options for severely impaired survivors are often limited. Rehabilitation involves intensively engaging the paretic upper limb, and disincentivizing use of the non-paretic upper limb, with the goal to increase excitability of the ipsilesional primary motor cortex (iM1) and suppress excitability of the undamaged (contralesional) motor cortices, presumed to have an inhibitory effect on iM1. Accordingly, brain stimulation approaches, such as repetitive transcranial magnetic stimulation (rTMS), are also given to excite iM1 and/or suppress contralesional motor cortices. But such approaches aimed at ultimately increasing iM1 excitability yield limited functional benefit in severely impaired survivors who lack sufficient ipsilesional substrate. Aim Here, we test the premise that combining Contralaterally Controlled Functional Electrical Stimulation (CCFES), a rehabilitation technique that engages the non-paretic upper limb in delivery of neuromuscular electrical stimulation to the paretic upper limb, and a new rTMS approach that excites intact, contralesional higher motor cortices (cHMC), may have more favorable effect on paretic upper limb function in severely impaired survivors based on recruitment of spared, transcallosal and (alternate) ipsilateral substrate. Methods In a prospective, double-blind, placebo-controlled RCT, 72 chronic stroke survivors with severe distal hand impairment receive CCFES plus cHMC rTMS, iM1 rTMS, or sham rTMS, 2X/wk for 12wks. Measures of upper limb motor impairment (Upper Extremity Fugl Meyer, UEFM), functional ability (Wolf Motor-Function Test, WMFT) and perceived disability are collected at 0, 6, 12 (end-of-treatment), 24, and 36 wks (follow-up). TMS is performed at 0, 12 (end-of-treatment), and 36 wks (follow-up) to evaluate inter-hemispheric and ipsilateral mechanisms. Influence of baseline severity is also characterized with imaging. Conclusions Targeting of spared neural substrates and rehabilitation which engages the unimpaired limb in movement of the impaired limb may serve as a suitable combinatorial treatment option for severely impaired stroke survivors. ClinicalTrials No NCT03870672.
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Affiliation(s)
- Akhil Mohan
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Jayme S. Knutson
- Department of Physical Medicine and Rehabilitation, MetroHealth System, Cleveland, OH, United States
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University, Cleveland, OH, United States
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland FES Center, Cleveland, OH, United States
| | - David A. Cunningham
- Department of Physical Medicine and Rehabilitation, MetroHealth System, Cleveland, OH, United States
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University, Cleveland, OH, United States
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland FES Center, Cleveland, OH, United States
| | - Morgan Widina
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Kyle O'Laughlin
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Tarun Arora
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Xin Li
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Ken Sakaie
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Xiaofeng Wang
- Respiratory Institute Biostatistics Core, Lerner Research Institute, Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Ela B. Plow
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
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15
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Malfitano C, Rossetti A, Scarano S, Malloggi C, Tesio L. Efficacy of Repetitive Transcranial Magnetic Stimulation for Acute Central Post-stroke Pain: A Case Study. Front Neurol 2021; 12:742567. [PMID: 34858311 PMCID: PMC8631781 DOI: 10.3389/fneur.2021.742567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/22/2021] [Indexed: 01/10/2023] Open
Abstract
Although rare, central post-stroke pain remains one of the most refractory forms of neuropathic pain. Repetitive transcranial magnetic stimulation (rTMS) has been reported to be effective in chronic cases. However, there are no data on the effects in the acute and subacute phases after stroke. In this study, we present a case of a patient with thalamic stroke with acute onset of pain and paresthesia who was responsive to rTMS. After a right thalamic stroke, a 32-year-old woman presented with drug-resistant pain and paresthesia on the left side of the body. There were no motor or sensory deficits, except for blunted thermal sensation and allodynia on light touch. Ten daily sessions were performed, where 10 Hz rTMS was applied to the hand area of the right primary motor cortex, 40 days after stroke. Before rTMS treatment (T0), immediately after treatment conclusion (T1), and 1 month after treatment (T2), three pain questionnaires were administered, and cortical responses to single and paired-pulse TMS were assessed. Eight healthy participants served as controls. At T0, when the patient was experiencing the worst pain, the excitability of the ipsilesional motor cortex was reduced. At T1 and T2, the pain scores and paresthesia' spread decreased. The clinical improvement was paralleled by the recovery in motor cortex excitability of the affected hemisphere, in terms of both intra- and inter-hemispheric connections. In this subacute central post-stroke pain case, rTMS treatment was associated with decreased pain and motor cortex excitability changes.
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Affiliation(s)
- Calogero Malfitano
- Department of Neurorehabilitation Sciences, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italy
| | - Angela Rossetti
- Department of Neurorehabilitation Sciences, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italy
| | - Stefano Scarano
- Department of Neurorehabilitation Sciences, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italy.,Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milano, Italy
| | - Chiara Malloggi
- Department of Neurorehabilitation Sciences, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italy
| | - Luigi Tesio
- Department of Neurorehabilitation Sciences, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milano, Italy.,Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milano, Italy
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16
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Contralesional Cathodal Transcranial Direct Current Stimulation Does Not Enhance Upper Limb Function in Subacute Stroke: A Pilot Randomized Clinical Trial. Neural Plast 2021; 2021:8858394. [PMID: 34426738 PMCID: PMC8380180 DOI: 10.1155/2021/8858394] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 03/21/2021] [Accepted: 06/24/2021] [Indexed: 11/18/2022] Open
Abstract
Transcranial direct current stimulation (tDCS) has the potential to improve upper limb motor outcomes after stroke. According to the assumption of interhemispheric inhibition, excessive inhibition from the motor cortex of the unaffected hemisphere to the motor cortex of the affected hemisphere may worsen upper limb motor recovery after stroke. We evaluated the effects of active cathodal tDCS of the primary motor cortex of the unaffected hemisphere (ctDCSM1UH) compared to sham, in subjects within 72 hours to 6 weeks post ischemic stroke. Cathodal tDCS was intended to inhibit the motor cortex of the unaffected hemisphere and hence decrease the inhibition from the unaffected to the affected hemisphere and enhance motor recovery. We hypothesized that motor recovery would be greater in the active than in the sham group. In addition, greater motor recovery in the active group might be associated with bigger improvements in measures in activity and participation in the active than in the sham group. We also explored, for the first time, changes in cognition and sleep after ctDCSM1UH. Thirty subjects were randomized to six sessions of either active or sham ctDCSM1UH as add-on interventions to rehabilitation. The NIH Stroke Scale (NIHSS), Fugl-Meyer Assessment of Motor Recovery after Stroke (FMA), Barthel Index (BI), Stroke Impact Scale (SIS), and Montreal Cognitive Assessment (MoCA) were assessed before, after treatment, and three months later. In the intent-to-treat (ITT) analysis, there were significant GROUP∗TIME interactions reflecting stronger gains in the sham group for scores in NIHSS, FMA, BI, MoCA, and four SIS domains. At three months post intervention, the sham group improved significantly compared to posttreatment in FMA, NIHSS, BI, and three SIS domains while no significant changes occurred in the active group. Also at three months, NIHSS improved significantly in the sham group and worsened significantly in the active group. FMA scores at baseline were higher in the active than in the sham group. After adjustment of analysis according to baseline scores, the between-group differences in FMA changes were no longer statistically significant. Finally, none of the between-group differences in changes in outcomes after treatment were considered clinically relevant. In conclusion, active CtDCSM1UH did not have beneficial effects, compared to sham. These results were consistent with other studies that applied comparable tDCS intensities/current densities or treated subjects with severe upper limb motor impairments during the first weeks post stroke. Dose-finding studies early after stroke are necessary before planning larger clinical trials.
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17
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Cao X, Wang Z, Chen X, Liu Y, Wang W, Abdoulaye IA, Ju S, Yang X, Wang Y, Guo Y. White matter degeneration in remote brain areas of stroke patients with motor impairment due to basal ganglia lesions. Hum Brain Mapp 2021; 42:4750-4761. [PMID: 34232552 PMCID: PMC8410521 DOI: 10.1002/hbm.25583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/15/2021] [Accepted: 06/25/2021] [Indexed: 12/14/2022] Open
Abstract
Diffusion tensor imaging (DTI) studies have revealed distinct white matter (WM) characteristics of the brain following diseases. Beyond the lesion‐symptom maps, stroke is characterized by extensive structural and functional alterations of brain areas remote to local lesions. Here, we further investigated the structural changes over a global level by using DTI data of 10 ischemic stroke patients showing motor impairment due to basal ganglia lesions and 11 healthy controls. DTI data were processed to obtain fractional anisotropy (FA) maps, and multivariate pattern analysis was used to explore brain regions that play an important role in classification based on FA maps. The WM structural network was constructed by the deterministic fiber‐tracking approach. In comparison with the controls, the stroke patients showed FA reductions in the perilesional basal ganglia, brainstem, and bilateral frontal lobes. Using network‐based statistics, we found a significant reduction in the WM subnetwork in stroke patients. We identified the patterns of WM degeneration affecting brain areas remote to the lesions, revealing the abnormal organization of the structural network in stroke patients, which may be helpful in understanding of the neural mechanisms underlying hemiplegia.
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Affiliation(s)
- Xuejin Cao
- Department of Neurology, Southeast University Zhongda Hospital, Medical School of Southeast University, Nanjing, China
| | - Zan Wang
- Department of Neurology, Southeast University Zhongda Hospital, Medical School of Southeast University, Nanjing, China
| | - Xiaohui Chen
- Department of Radiology, Zhongda Hospital, Jiangsu Key Laboratory of Molecular and Functional Imaging, Medical School of Southeast University, Nanjing, China
| | - Yanli Liu
- Department of Rehabilitation, Southeast University Zhongda Hospital, Nanjing, China
| | - Wei Wang
- Department of Radiology, Zhongda Hospital, Jiangsu Key Laboratory of Molecular and Functional Imaging, Medical School of Southeast University, Nanjing, China
| | - Idriss Ali Abdoulaye
- Department of Neurology, Southeast University Zhongda Hospital, Medical School of Southeast University, Nanjing, China
| | - Shenghong Ju
- Department of Radiology, Zhongda Hospital, Jiangsu Key Laboratory of Molecular and Functional Imaging, Medical School of Southeast University, Nanjing, China
| | - Xi Yang
- Department of Rehabilitation, Southeast University Zhongda Hospital, Nanjing, China
| | - Yuancheng Wang
- Department of Radiology, Zhongda Hospital, Jiangsu Key Laboratory of Molecular and Functional Imaging, Medical School of Southeast University, Nanjing, China
| | - Yijing Guo
- Department of Neurology, Southeast University Zhongda Hospital, Medical School of Southeast University, Nanjing, China.,Department of Neurology, Lishui People's Hospital, Southeast University Zhongda Hospital Lishui Branch, Nanjing, China
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18
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Katz DI, Dwyer B. Clinical Neurorehabilitation: Using Principles of Neurological Diagnosis, Prognosis, and Neuroplasticity in Assessment and Treatment Planning. Semin Neurol 2021; 41:111-123. [PMID: 33663002 DOI: 10.1055/s-0041-1725132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neurorehabilitation aspires to restore a person to his or her fullest potential after incurring neurological dysfunction. In medical rehabilitation, diagnosis involves assessment of medical conditions and their effects on functioning. It is usually a team effort that involves an amalgam of diagnostic assessments by multiple disciplines, leading to a collection of rehabilitative treatment plans and goals. This article discusses a clinical neurological paradigm, using rigorous clinical assessment of neuropathological and clinical diagnosis, along with prognostication of natural history and recovery. In the context of the role of neuroplasticity in recovery, this paradigm can add significant value to rehabilitation team management and planning. It contributes to enhanced understanding of neurological impairments and syndromes as they relate to functional disability, aiding in targeting deficits and setting treatment goals. Rehabilitation strategies and goals should be informed by natural history and prognosis, and viewed in the framework of the stage of recovery. Prognostic formulations should suggest an emphasis on restorative versus compensatory strategies for functional problems. Treatment planning should be informed by evidence on how interventions modulate brain reorganization in promoting recovery. Strategies that promote adaptive neuroplasticity should be favored, especially with restorative efforts, and evidence supporting optimal techniques, timing, and dosing of rehabilitation should be considered in treatment planning.
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Affiliation(s)
- Douglas I Katz
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Encompass Health Braintree Rehabilitation Hospital, Braintree, Massachusetts
| | - Brigid Dwyer
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Encompass Health Braintree Rehabilitation Hospital, Braintree, Massachusetts
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19
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Tian D, Izumi SI, Suzuki E. Modulation of Interhemispheric Inhibition between Primary Motor Cortices Induced by Manual Motor Imitation: A Transcranial Magnetic Stimulation Study. Brain Sci 2021; 11:brainsci11020266. [PMID: 33669827 PMCID: PMC7923080 DOI: 10.3390/brainsci11020266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 11/18/2022] Open
Abstract
Imitation has been proven effective in motor development and neurorehabilitation. However, the relationship between imitation and interhemispheric inhibition (IHI) remains unclear. Transcranial magnetic stimulation (TMS) can be used to investigate IHI. In this study, the modification effects of IHI resulting from mirror neuron system (MNS) activation during different imitations are addressed. We measured IHI between homologous primary motor cortex (M1) by analyzing the ipsilateral silent period (iSP) evoked by single-pulse focal TMS during imitation and analyzed the respective IHI modulation during and after different patterns of imitation. Our main results showed that throughout anatomical imitation, significant time-course changes of iSP duration through the experiment were observed in both directions. iSP duration declined from the pre-imitation time point to the post-imitation time point and did not return to baseline after 30 min rest. We also observed significant iSP reduction from the right hemisphere to the left hemisphere during anatomical and specular imitation, compared with non-imitative movement. Our findings indicate that using anatomical imitation in action observation and execution therapy promotes functional recovery in neurorehabilitation by regulating IHI.
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Affiliation(s)
- Dongting Tian
- Department of Physical Medicine and Rehabilitation, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan; (S.-i.I.); (E.S.)
- Correspondence:
| | - Shin-ichi Izumi
- Department of Physical Medicine and Rehabilitation, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan; (S.-i.I.); (E.S.)
- Department of Physical Medicine and Rehabilitation, Tohoku University Graduate School of Biomedical Engineering, Sendai 980-8575, Japan
| | - Eizaburo Suzuki
- Department of Physical Medicine and Rehabilitation, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan; (S.-i.I.); (E.S.)
- Department of Physical Therapy, Yamagata Prefectural University of Health Sciences, 260 Kamiyanagi, Yamagata 990-2212, Japan
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20
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Edwards JD, Black SE, Boe S, Boyd L, Chaves A, Chen R, Dukelow S, Fung J, Kirton A, Meltzer J, Moussavi Z, Neva J, Paquette C, Ploughman M, Pooyania S, Rajji TK, Roig M, Tremblay F, Thiel A. Canadian Platform for Trials in Noninvasive Brain Stimulation (CanStim) Consensus Recommendations for Repetitive Transcranial Magnetic Stimulation in Upper Extremity Motor Stroke Rehabilitation Trials. Neurorehabil Neural Repair 2021; 35:103-116. [PMID: 33410386 DOI: 10.1177/1545968320981960] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective. To develop consensus recommendations for the use of repetitive transcranial magnetic stimulation (rTMS) as an adjunct intervention for upper extremity motor recovery in stroke rehabilitation clinical trials. Participants. The Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim) convened a multidisciplinary team of clinicians and researchers from institutions across Canada to form the CanStim Consensus Expert Working Group. Consensus Process. Four consensus themes were identified: (1) patient population, (2) rehabilitation interventions, (3) outcome measures, and (4) stimulation parameters. Theme leaders conducted comprehensive evidence reviews for each theme, and during a 2-day Consensus Meeting, the Expert Working Group used a weighted dot-voting consensus procedure to achieve consensus on recommendations for the use of rTMS as an adjunct intervention in motor stroke recovery rehabilitation clinical trials. Results. Based on best available evidence, consensus was achieved for recommendations identifying the target poststroke population, rehabilitation intervention, objective and subjective outcomes, and specific rTMS parameters for rehabilitation trials evaluating the efficacy of rTMS as an adjunct therapy for upper extremity motor stroke recovery. Conclusions. The establishment of the CanStim platform and development of these consensus recommendations is a first step toward the translation of noninvasive brain stimulation technologies from the laboratory to clinic to enhance stroke recovery.
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Affiliation(s)
- Jodi D Edwards
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.,University of Ottawa, Ottawa, Ontario, Canada
| | - Sandra E Black
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Shaun Boe
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lara Boyd
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Arthur Chaves
- Memorial University, St John's, Newfoundland, Canada
| | - Robert Chen
- Toronto Western Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | | | - Joyce Fung
- McGill University, Montreal, Quebec, Canada
| | - Adam Kirton
- University of Calgary, Calgary, Alberta, Canada
| | | | | | - Jason Neva
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Tarek K Rajji
- University of Toronto, Toronto, Ontario, Canada.,Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Marc Roig
- McGill University, Montreal, Quebec, Canada
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21
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Affiliation(s)
- Assia Jaillard
- IRMaGe, Inserm-US17 CNRS-UMS3552 UGA CHU Grenoble Alpes (CHUGA), Grenoble, France (A.J.).,Université Grenoble Alpes, AGEIS, EA 7407, France (A.J.).,Pôle Recherche, CHUGA, France (A.J.)
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22
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Lin YL, Potter-Baker KA, Cunningham DA, Li M, Sankarasubramanian V, Lee J, Jones S, Sakaie K, Wang X, Machado AG, Plow EB. Stratifying chronic stroke patients based on the influence of contralesional motor cortices: An inter-hemispheric inhibition study. Clin Neurophysiol 2020; 131:2516-2525. [PMID: 32712080 PMCID: PMC7487004 DOI: 10.1016/j.clinph.2020.06.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 05/29/2020] [Accepted: 06/02/2020] [Indexed: 01/27/2023]
Abstract
OBJECTIVE A recent "bimodal-balance recovery" model suggests that contralesional influence varies based on the amount of ipsilesional reserve: inhibitory when there is a large reserve, but supportive when there is a low reserve. Here, we investigated the relationships between contralesional influence (inter-hemispheric inhibition, IHI) and ipsilesional reserve (corticospinal damage/impairment), and also defined a criterion separating subgroups based on the relationships. METHODS Twenty-four patients underwent assessment of IHI using Transcranial Magnetic Stimulation (ipsilateral silent period method), motor impairment using Upper Extremity Fugl-Meyer (UEFM), and corticospinal damage using Diffusion Tensor Imaging and active motor threshold. Assessments of UEFM and IHI were repeated after 5-week rehabilitation (n = 21). RESULTS Relationship between IHI and baseline UEFM was quadratic with criterion at UEFM 43 (95%conference interval: 40-46). Patients less impaired than UEFM = 43 showed stronger IHI with more impairment, whereas patients more impaired than UEFM = 43 showed lower IHI with more impairment. Of those made clinically-meaningful functional gains in rehabilitation (n = 14), more-impaired patients showed further IHI reduction. CONCLUSIONS A criterion impairment-level can be derived to stratify patient-subgroups based on the bimodal influence of contralesional cortex. Contralesional influence also evolves differently across subgroups following rehabilitation. SIGNIFICANCE The criterion may be used to stratify patients to design targeted, precision treatments.
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Affiliation(s)
- Yin-Liang Lin
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Physical Therapy and Assistive Technology, National Yang-Ming University, Taipei, Taiwan
| | - Kelsey A Potter-Baker
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Advanced Platform Technology Center, Louis Stokes Cleveland Department of Veteran's Affairs, Cleveland, OH, USA; Department of Health and Biomedical Sciences, University of Texas Rio Grande Valley, Edinburg, TX, USA
| | - David A Cunningham
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Physical Medicine and Rehabilitation, Case Western Reserve University, Cleveland, OH, USA; MetroHealth Rehabilitation Institute of Ohio, MetroHealth Medical Center, Cleveland, OH, USA; Cleveland Functional Electrical Stimulation Center, Louis Stokes Cleveland Department of Veteran's Affairs, Cleveland, OH, USA
| | - Manshi Li
- Respiratory Institute Biostatistics Core, Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Vishwanath Sankarasubramanian
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - John Lee
- Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic, OH, USA
| | - Stephen Jones
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ken Sakaie
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaofeng Wang
- Respiratory Institute Biostatistics Core, Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Ela B Plow
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic, OH, USA.
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23
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Min YS, Jang KE, Park E, Kim AR, Kang MG, Cheong YS, Kim JH, Jung SH, Park J, Jung TD. Prediction of Motor Recovery in Patients with Basal Ganglia Hemorrhage Using Diffusion Tensor Imaging. J Clin Med 2020; 9:E1304. [PMID: 32370089 PMCID: PMC7290831 DOI: 10.3390/jcm9051304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 11/17/2022] Open
Abstract
Predicting prognosis in patients with basal ganglia hemorrhage is difficult. This study aimed to investigate the usefulness of diffusion tensor imaging in predicting motor outcome after basal ganglia hemorrhage. A total of 12 patients with putaminal hemorrhage were included in the study (aged 50 ± 12 years), 8 patients were male (aged 46 ± 11 years) and 4 were female (aged 59 ± 9 years). We performed diffusion tensor imaging and measured clinical outcome at baseline (pre) and 3 weeks (post1), 3 months (post2), and 6 months (post3) after the initial treatment. In the affected side of the brain, the mean fractional anisotropy (FA) value on pons was significantly higher in the good outcome group than that in the poor outcome group at pre (p = 0.004) and post3 (p = 0.025). Pearson correlation analysis showed that mean FA value at pre significantly correlated with the sum of the Brunnstrom motor recovery stage scores at post3 (R = 0.8, p = 0.002). Change in the FA ratio on diffusion tractography can predict motor recovery after hemorrhagic stroke.
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Affiliation(s)
- Yu-Sun Min
- Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea; (Y.-S.M.); (E.P.); (A.-R.K.)
- Department of Rehabilitation Medicine, Kyungpook National University Hospital, Daegu 41944, Korea; (J.-H.K.); (S.-H.J.)
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Kyung Eun Jang
- Department of Medical and Biomedical Engineering, Kyungpook National University, Daegu 41944, Korea;
| | - Eunhee Park
- Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea; (Y.-S.M.); (E.P.); (A.-R.K.)
- Department of Rehabilitation Medicine, Kyungpook National University Hospital, Daegu 41944, Korea; (J.-H.K.); (S.-H.J.)
| | - Ae-Ryoung Kim
- Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea; (Y.-S.M.); (E.P.); (A.-R.K.)
- Department of Rehabilitation Medicine, Kyungpook National University Hospital, Daegu 41944, Korea; (J.-H.K.); (S.-H.J.)
| | - Min-Gu Kang
- Department of Physical Medicine and Rehabilitation, Dong-A University College of Medicine, Busan 49201, Korea;
| | - Youn-Soo Cheong
- Department of Rehabilitation Medicine, Maryknoll Hospital, Busan 48972, Korea;
| | - Ju-Hyun Kim
- Department of Rehabilitation Medicine, Kyungpook National University Hospital, Daegu 41944, Korea; (J.-H.K.); (S.-H.J.)
| | - Seung-Hwan Jung
- Department of Rehabilitation Medicine, Kyungpook National University Hospital, Daegu 41944, Korea; (J.-H.K.); (S.-H.J.)
| | - Jaechan Park
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu 41944, Korea
- Biomedical Research Institute, School of Medicine, Kyungpook National University, Daegu 41944, Korea
| | - Tae-Du Jung
- Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea; (Y.-S.M.); (E.P.); (A.-R.K.)
- Department of Rehabilitation Medicine, Kyungpook National University Hospital, Daegu 41944, Korea; (J.-H.K.); (S.-H.J.)
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24
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Wilkins KB, Dewald JPA, Yao J. Intervention-induced changes in neural connectivity during motor preparation may affect cortical activity at motor execution. Sci Rep 2020; 10:7326. [PMID: 32355238 PMCID: PMC7193567 DOI: 10.1038/s41598-020-64179-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 04/07/2020] [Indexed: 12/22/2022] Open
Abstract
Effective interventions have demonstrated the ability to improve motor function by reengaging ipsilesional resources, which appears to be critical and feasible for hand function recovery even in individuals with severe chronic stroke. However, previous studies focus on changes in brain activity related to motor execution. How changes in motor preparation may facilitate these changes at motor execution is still unclear. To address this question, 8 individuals with severe chronic hemiparetic stroke participated in a device-assisted intervention for seven weeks. We then quantified changes in both coupling between regions during motor preparation and changes in topographical cortical activity at motor execution for both hand opening in isolation and together with the shoulder using high-density EEG. We hypothesized that intervention-induced changes in cortico-cortico interactions during motor preparation would lead to changes in activity at motor execution specifically towards an increased reliance on the ipsilesional hemisphere. In agreement with this hypothesis, we found that, following the intervention, individuals displayed a reduction in coupling from ipsilesional M1 to contralesional M1 within gamma frequencies during motor preparation for hand opening. This was followed by a reduction in activity in the contralesional primary sensorimotor cortex during motor execution. Similarly, during lifting and opening, a shift to negative coupling within ipsilesional M1 from gamma to beta frequencies was accompanied by an increase in ipsilesional primary sensorimotor cortex activity following the intervention. Together, these results show that intervention-induced changes in coupling within or between motor regions during motor preparation may affect cortical activity at execution.
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Affiliation(s)
- Kevin B Wilkins
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, 645 N Michigan Ave, Suite 1100, Chicago, IL, 60611, USA
- Northwestern University Interdepartmental Neuroscience, Northwestern University, 320 E. Superior St, Chicago, IL, 60611, USA
| | - Julius P A Dewald
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, 645 N Michigan Ave, Suite 1100, Chicago, IL, 60611, USA
- Northwestern University Interdepartmental Neuroscience, Northwestern University, 320 E. Superior St, Chicago, IL, 60611, USA
- Department of Biomedical Engineering, Northwestern University, 2145 Sheridan Road, Evanston, IL, 60208, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, 345 East Superior Street, Chicago, IL, 60611, USA
| | - Jun Yao
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, 645 N Michigan Ave, Suite 1100, Chicago, IL, 60611, USA.
- Northwestern University Interdepartmental Neuroscience, Northwestern University, 320 E. Superior St, Chicago, IL, 60611, USA.
- Department of Biomedical Engineering, Northwestern University, 2145 Sheridan Road, Evanston, IL, 60208, USA.
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25
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Palmer JA, Wheaton LA, Gray WA, Saltão da Silva MA, Wolf SL, Borich MR. Role of Interhemispheric Cortical Interactions in Poststroke Motor Function. Neurorehabil Neural Repair 2019; 33:762-774. [PMID: 31328638 DOI: 10.1177/1545968319862552] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background/Objective. We investigated interhemispheric interactions in stroke survivors by measuring transcranial magnetic stimulation (TMS)-evoked cortical coherence. We tested the effect of TMS on interhemispheric coherence during rest and active muscle contraction and compared coherence in stroke and older adults. We evaluated the relationships between interhemispheric coherence, paretic motor function, and the ipsilateral cortical silent period (iSP). Methods. Participants with (n = 19) and without (n = 14) chronic stroke either rested or maintained a contraction of the ipsilateral hand muscle during simultaneous recordings of evoked responses to TMS of the ipsilesional/nondominant (i/ndM1) and contralesional/dominant (c/dM1) primary motor cortex with EEG and in the hand muscle with EMG. We calculated pre- and post-TMS interhemispheric beta coherence (15-30 Hz) between motor areas in both conditions and the iSP duration during the active condition. Results. During active i/ndM1 TMS, interhemispheric coherence increased immediately following TMS in controls but not in stroke. Coherence during active cM1 TMS was greater than iM1 TMS in the stroke group. Coherence during active iM1 TMS was less in stroke participants and was negatively associated with measures of paretic arm motor function. Paretic iSP was longer compared with controls and negatively associated with clinical measures of manual dexterity. There was no relationship between coherence and. iSP for either group. No within- or between-group differences in coherence were observed at rest. Conclusions. TMS-evoked cortical coherence during hand muscle activation can index interhemispheric interactions associated with poststroke motor function and potentially offer new insights into neural mechanisms influencing functional recovery.
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Affiliation(s)
| | | | | | | | - Steven L Wolf
- 1 Emory University, Atlanta, GA, USA
- 2 Atlanta VA Visual and Neurocognitive Center of Excellence, Decatur, GA, USA
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26
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Cunningham DA, Knutson JS, Sankarasubramanian V, Potter-Baker KA, Machado AG, Plow EB. Bilateral Contralaterally Controlled Functional Electrical Stimulation Reveals New Insights Into the Interhemispheric Competition Model in Chronic Stroke. Neurorehabil Neural Repair 2019; 33:707-717. [PMID: 31315515 DOI: 10.1177/1545968319863709] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background. Upper-limb chronic stroke hemiplegia was once thought to persist because of disproportionate amounts of inhibition imposed from the contralesional on the ipsilesional hemisphere. Thus, one rehabilitation strategy involves discouraging engagement of the contralesional hemisphere by only engaging the impaired upper limb with intensive unilateral activities. However, this premise has recently been debated and has been shown to be task specific and/or apply only to a subset of the stroke population. Bilateral rehabilitation, conversely, engages both hemispheres and has been shown to benefit motor recovery. To determine what neurophysiological strategies bilateral therapies may engage, we compared the effects of a bilateral and unilateral based therapy using transcranial magnetic stimulation. Methods. We adopted a peripheral electrical stimulation paradigm where participants received 1 session of bilateral contralaterally controlled functional electrical stimulation (CCFES) and 1 session of unilateral cyclic neuromuscular electrical stimulation (cNMES) in a repeated-measures design. In all, 15 chronic stroke participants with a wide range of motor impairments (upper extremity Fugl-Meyer score: 15 [severe] to 63 [mild]) underwent single 1-hour sessions of CCFES and cNMES. We measured whether CCFES and cNMES produced different effects on interhemispheric inhibition (IHI) to the ipsilesional hemisphere, ipsilesional corticospinal output, and ipsilateral corticospinal output originating from the contralesional hemisphere. Results. CCFES reduced IHI and maintained ipsilesional output when compared with cNMES. We found no effect on ipsilateral output for either condition. Finally, the less-impaired participants demonstrated a greater increase in ipsilesional output following CCFES. Conclusions. Our results suggest that bilateral therapies are capable of alleviating inhibition on the ipsilesional hemisphere and enhancing output to the paretic limb.
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Affiliation(s)
- David A Cunningham
- 1 Case Western Reserve University, Cleveland, OH, USA.,2 MetroHealth Medical Center, Cleveland, OH, USA.,3 Cleveland Functional Electrical Stimulation Center, OH, USA
| | - Jayme S Knutson
- 1 Case Western Reserve University, Cleveland, OH, USA.,2 MetroHealth Medical Center, Cleveland, OH, USA.,3 Cleveland Functional Electrical Stimulation Center, OH, USA
| | | | - Kelsey A Potter-Baker
- 5 Louis Stokes Cleveland Department of Veteran's Affairs, Cleveland, OH, USA.,6 Cleveland Clinic, OH, USA
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27
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Guggisberg AG, Koch PJ, Hummel FC, Buetefisch CM. Brain networks and their relevance for stroke rehabilitation. Clin Neurophysiol 2019; 130:1098-1124. [PMID: 31082786 DOI: 10.1016/j.clinph.2019.04.004] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 03/04/2019] [Accepted: 04/08/2019] [Indexed: 12/21/2022]
Abstract
Stroke has long been regarded as focal disease with circumscribed damage leading to neurological deficits. However, advances in methods for assessing the human brain and in statistics have enabled new tools for the examination of the consequences of stroke on brain structure and function. Thereby, it has become evident that stroke has impact on the entire brain and its network properties and can therefore be considered as a network disease. The present review first gives an overview of current methodological opportunities and pitfalls for assessing stroke-induced changes and reorganization in the human brain. We then summarize principles of plasticity after stroke that have emerged from the assessment of networks. Thereby, it is shown that neurological deficits do not only arise from focal tissue damage but also from local and remote changes in white-matter tracts and in neural interactions among wide-spread networks. Similarly, plasticity and clinical improvements are associated with specific compensatory structural and functional patterns of neural network interactions. Innovative treatment approaches have started to target such network patterns to enhance recovery. Network assessments to predict treatment response and to individualize rehabilitation is a promising way to enhance specific treatment effects and overall outcome after stroke.
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Affiliation(s)
- Adrian G Guggisberg
- Division of Neurorehabilitation, Department of Clinical Neurosciences, University Hospital Geneva, Switzerland.
| | - Philipp J Koch
- Defitech Chair of Clinical Neuroengineering, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI), Swiss Federal Institute of Technology (EPFL), 1202 Geneva, Switzerland; Defitech Chair of Clinical Neuroengineering, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI), Swiss Federal Institute of Technology Valais (EPFL Valais), Clinique Romande de Réadaptation, 1951 Sion, Switzerland
| | - Friedhelm C Hummel
- Defitech Chair of Clinical Neuroengineering, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI), Swiss Federal Institute of Technology (EPFL), 1202 Geneva, Switzerland; Defitech Chair of Clinical Neuroengineering, Center for Neuroprosthetics (CNP) and Brain Mind Institute (BMI), Swiss Federal Institute of Technology Valais (EPFL Valais), Clinique Romande de Réadaptation, 1951 Sion, Switzerland; Department of Clinical Neuroscience, University Hospital Geneva, 1202 Geneva, Switzerland
| | - Cathrin M Buetefisch
- Depts of Neurology, Rehabilitation Medicine, Radiology, Emory University, Atlanta, GA, USA
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28
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Hu J, Li C, Hua Y, Zhang B, Gao BY, Liu PL, Sun LM, Lu RR, Wang YY, Bai YL. Constrained-induced movement therapy promotes motor function recovery by enhancing the remodeling of ipsilesional corticospinal tract in rats after stroke. Brain Res 2018; 1708:27-35. [PMID: 30471245 DOI: 10.1016/j.brainres.2018.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/29/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
Abstract
Constraint-induced movement therapy (CIMT), which forces the use of the impaired limb by restraining the unaffected limb, has been used extensively for the recovery of limb motor function after stroke. However, the underlying mechanism of CIMT remains unclear. Diffusion tensor imaging (DTI) is a well-known neuroimaging technique that reflects the microstructure of white matter tracts and potential changes associated with different treatments. The aim of this study is to use DTI imaging to determine how corticospinal tract (CST) fibers remodel in ischemic rats with CIMT. In the present study, rats were randomly divided into three groups: a middle cerebral artery occlusion group (MCAO), a therapeutic group (MCAO + CIMT), and a sham-operated group (sham). A plaster cast was used to restrict the unaffected limb of the rats in the MCAO + CIMT group for 14 days. The Catwalk system was used to assess the limb motor function of rats. Fractional anisotropy (FA) and the average diffusion coefficient (ADC) of the CST were quantified through DTI. The expression of the c-Jun-N-terminal kinase signaling pathway (JNK) was examined after 14 days of CIMT. We found that CIMT could accelerate and enhance motor function recovery, and the MCAO + CIMT group showed significantly increased FA values in the ipsilesional posterior limb of internal capsule (PLIC) compared with the MCAO group. In addition, we found no significant difference in the ratio of phosphorylated-JNK/total-JNK among the three groups, whereas the expression of P-JNK decreased significantly in the chronic phase of stroke. In conclusion, CIMT-induced functional recovery following ischemic stroke through facilitation of the remodeling of ipsilesional CST, and restoration after ischemic stroke may be associated with the declining value of the ratio of P-JNK/JNK.
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Affiliation(s)
- Jian Hu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Ce Li
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yan Hua
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Bei Zhang
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Bei-Yao Gao
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Pei-Le Liu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Li-Min Sun
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Rong-Rong Lu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yu-Yuan Wang
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China.
| | - Yu-Long Bai
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China.
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29
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Bertolucci F, Chisari C, Fregni F. The potential dual role of transcallosal inhibition in post-stroke motor recovery. Restor Neurol Neurosci 2018; 36:83-97. [PMID: 29439366 DOI: 10.3233/rnn-170778] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Up to now, the mechanism of motor impairment and recovery after stroke has been thought to be based on the interhemispheric competition model. According to this model, which assumes that suppressing the excitability of contralesional hemisphere will enhance recovery by reducing transcallosal inhibition (TCI) of the stroke hemisphere, many clinical trials used non-invasive brain stimulation to improve motor function. Despite some positive findings, meta-analysis shows an important source of variability in the results, questioning whether the interhemispheric competition model would be exhaustive enough to explain the positive results or whether other mechanisms could explain the motor effects of inhibitory stimulation in the contralesional hemisphere. The goal of this study was to review the relationship between increased TCI and motor impairment after stroke.A systematic review of clinical studies investigating TCI through transcranial magnetic stimulation (TMS) in stroke patients and the relationship of this metric with motor recovery was then performed. After a literary search in PubMed eleven articles were included. The potential role of several covariates was examined and discussed.Overall, the importance of TCI as a putative mechanism for stimulation of the contralesional hemisphere seems to depend on the baseline motor function. In other words, from evidence coming mostly from chronic patients, modulation of abnormal TCI seems to be useful for patients with good motor function and less important in patients with poor motor function. TCI seems to be negatively correlated with mirror movements of the paretic hand. It can be inferred that suppressing the activity of the contralesional hemisphere could be beneficial for patients with good residual motor function and strong TCI, but not for those with poor motor function and weak TCI. Baseline motor function and measure of TCI should be taken into account for stratification of patients in clinical trials and for the design of customized treatment.
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Affiliation(s)
- Federica Bertolucci
- Department of Neuroscience, Unit of Neurorehabilitation, University Hospital of Pisa, Italy.,Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, USA
| | - Carmelo Chisari
- Department of Neuroscience, Unit of Neurorehabilitation, University Hospital of Pisa, Italy
| | - Felipe Fregni
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, USA
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30
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León Ruiz M, Rodríguez Sarasa M, Sanjuán Rodríguez L, Benito-León J, García-Albea Ristol E, Arce Arce S. Evidencias actuales sobre la estimulación magnética transcraneal y su utilidad potencial en la neurorrehabilitación postictus: Ampliando horizontes en el tratamiento de la enfermedad cerebrovascular. Neurologia 2018; 33:459-472. [DOI: 10.1016/j.nrl.2016.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 03/07/2016] [Accepted: 03/08/2016] [Indexed: 12/17/2022] Open
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31
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León Ruiz M, Rodríguez Sarasa M, Sanjuán Rodríguez L, Benito-León J, García-Albea Ristol E, Arce Arce S. Current evidence on transcranial magnetic stimulation and its potential usefulness in post-stroke neurorehabilitation: Opening new doors to the treatment of cerebrovascular disease. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2016.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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32
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Filatova OG, van Vliet LJ, Schouten AC, Kwakkel G, van der Helm FCT, Vos FM. Comparison of Multi-Tensor Diffusion Models' Performance for White Matter Integrity Estimation in Chronic Stroke. Front Neurosci 2018; 12:247. [PMID: 29740269 PMCID: PMC5925961 DOI: 10.3389/fnins.2018.00247] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 03/29/2018] [Indexed: 01/23/2023] Open
Abstract
Better insight into white matter (WM) alterations after stroke onset could help to understand the underlying recovery mechanisms and improve future interventions. MR diffusion imaging enables to assess such changes. Our goal was to investigate the relation of WM diffusion characteristics derived from diffusion models of increasing complexity with the motor function of the upper limb. Moreover, we aimed to evaluate the variation of such characteristics across different WM structures of chronic stroke patients in comparison to healthy subjects. Subjects were scanned with a two b-value diffusion-weighted MRI protocol to exploit multiple diffusion models: single tensor, single tensor with isotropic compartment, bi-tensor model, bi-tensor with isotropic compartment. From each model we derived the mean tract fractional anisotropy (FA), mean (MD), radial (RD) and axial (AD) diffusivities outside the lesion site based on a WM tracts atlas. Asymmetry of these measures was correlated with the Fugl-Meyer upper extremity assessment (FMA) score and compared between patient and control groups. Eighteen chronic stroke patients and eight age-matched healthy individuals participated in the study. Significant correlation of the outcome measures with the clinical scores of stroke recovery was found. The lowest correlation of the corticospinal tract FAasymmetry and FMA was with the single tensor model (r = -0.3, p = 0.2) whereas the other models reported results in the range of r = -0.79 ÷ -0.81 and p = 4E-5 ÷ 8E-5. The corticospinal tract and superior longitudinal fasciculus showed most alterations in our patient group relative to controls. Multiple compartment models yielded superior correlation of the diffusion measures and FMA compared to the single tensor model.
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Affiliation(s)
- Olena G. Filatova
- Department of Biomechanical Engineering, Delft University of Technology, Delft, Netherlands
- Quantitative Imaging Group, Department of Imaging Physics, Delft University of Technology, Delft, Netherlands
| | - Lucas J. van Vliet
- Quantitative Imaging Group, Department of Imaging Physics, Delft University of Technology, Delft, Netherlands
| | - Alfred C. Schouten
- Department of Biomechanical Engineering, Delft University of Technology, Delft, Netherlands
- Laboratory for Biomechanical Engineering, Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands
| | - Gert Kwakkel
- Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, Amsterdam Neurosciences, VU University Medical Center, Amsterdam, Netherlands
| | | | - Frans M. Vos
- Quantitative Imaging Group, Department of Imaging Physics, Delft University of Technology, Delft, Netherlands
- Department of Radiology, Academic Medical Center, Amsterdam, Netherlands
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33
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Novaes MM, Palhano-Fontes F, Peres A, Mazzetto-Betti K, Pelicioni M, Andrade KC, dos Santos AC, Pontes-Neto O, Araujo D. Neurofunctional changes after a single mirror therapy intervention in chronic ischemic stroke. Int J Neurosci 2018; 128:966-974. [DOI: 10.1080/00207454.2018.1447571] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Morgana M Novaes
- Brain Institute/Onofre Lopes University Hospital, Federal University of Rio Grande Do Norte (UFRN), Natal-RN, Brazil
| | - Fernanda Palhano-Fontes
- Brain Institute/Onofre Lopes University Hospital, Federal University of Rio Grande Do Norte (UFRN), Natal-RN, Brazil
| | - Andre Peres
- Brain Institute/Onofre Lopes University Hospital, Federal University of Rio Grande Do Norte (UFRN), Natal-RN, Brazil
| | - Kelley Mazzetto-Betti
- Radiology Division, Department of Internal Medicine, Ribeirao Preto School of Medicine, University of Sao Paulo (USP), Ribeirao Preto-SP, Brazil
| | - Maristela Pelicioni
- Radiology Division, Department of Internal Medicine, Ribeirao Preto School of Medicine, University of Sao Paulo (USP), Ribeirao Preto-SP, Brazil
| | - Kátia C Andrade
- Brain Institute/Onofre Lopes University Hospital, Federal University of Rio Grande Do Norte (UFRN), Natal-RN, Brazil
| | - Antonio Carlos dos Santos
- Radiology Division, Department of Internal Medicine, Ribeirao Preto School of Medicine, University of Sao Paulo (USP), Ribeirao Preto-SP, Brazil
| | - Octavio Pontes-Neto
- Radiology Division, Department of Internal Medicine, Ribeirao Preto School of Medicine, University of Sao Paulo (USP), Ribeirao Preto-SP, Brazil
| | - Draulio Araujo
- Brain Institute/Onofre Lopes University Hospital, Federal University of Rio Grande Do Norte (UFRN), Natal-RN, Brazil
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34
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Eng D, Zewdie E, Ciechanski P, Damji O, Kirton A. Interhemispheric motor interactions in hemiparetic children with perinatal stroke: Clinical correlates and effects of neuromodulation therapy. Clin Neurophysiol 2017; 129:397-405. [PMID: 29289841 DOI: 10.1016/j.clinph.2017.11.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 11/10/2017] [Accepted: 11/17/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Brain stimulation and constraint therapy may enhance function after perinatal stroke but mechanisms are unknown. We characterized interhemispheric interactions (IHI) in hemiparetic children and explored their relationship to motor function and neuromodulation. METHODS Forty-five hemiparetic perinatal stroke subjects aged 6-19 years completed a clinical trial of repetitive-transcranial magnetic stimulation (rTMS) and constraint therapy. Paired-pulse TMS measured IHI in cases and normal controls. Suprathreshold conditioning stimuli preceded contralateral test stimuli bidirectionally: stroke to non-stroke (SNS) and non-stroke to stroke (NSS). Primary outcome was the interhemispheric ratio (IHR) between conditioned and test only MEP amplitudes X100 (<100 implied inhibition). Motor outcomes at baseline and post-intervention were compared to IHR. RESULTS Procedures were well tolerated. IHI occurred bidirectionally in controls. Eighteen stroke participants had complete data. IHR were increased in stroke participants in both directions. SNS IHR was >100 (facilitation) in 39% of measurements and correlated with better motor function. NSS IHR correlated with poorer motor function. Intervention-induced clinical change was not associated with IHR. CONCLUSIONS Interhemispheric interactions are altered and related to clinical function, but not necessarily neuromodulation, in children with perinatal stroke. SIGNIFICANCE Adding interhemispheric interactions to evolving models of developmental plasticity following early injury may advance neuromodulation strategies.
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Affiliation(s)
- Derek Eng
- Calgary Pediatric Stroke Program, Alberta Children's Hospital, Calgary, Alberta T3B6A8, Canada; Department of Neurosciences, University of Calgary, Calgary, Alberta T2N1N4, Canada
| | - Ephrem Zewdie
- Calgary Pediatric Stroke Program, Alberta Children's Hospital, Calgary, Alberta T3B6A8, Canada
| | - Patrick Ciechanski
- Calgary Pediatric Stroke Program, Alberta Children's Hospital, Calgary, Alberta T3B6A8, Canada; Department of Neurosciences, University of Calgary, Calgary, Alberta T2N1N4, Canada
| | - Omar Damji
- Calgary Pediatric Stroke Program, Alberta Children's Hospital, Calgary, Alberta T3B6A8, Canada; Department of Neurosciences, University of Calgary, Calgary, Alberta T2N1N4, Canada
| | - Adam Kirton
- Calgary Pediatric Stroke Program, Alberta Children's Hospital, Calgary, Alberta T3B6A8, Canada; Departments of Pediatrics and Clinical Neurosciences, Alberta Children's Hospital, Calgary, Alberta T3B6A8, Canada; Department of Neurosciences, University of Calgary, Calgary, Alberta T2N1N4, Canada; Alberta Children's Hospital Research Institute, Calgary, Alberta T3B6A8, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta T2N1N4, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta T2N1N4, Canada.
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35
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Guggisberg AG, Nicolo P, Cohen LG, Schnider A, Buch ER. Longitudinal Structural and Functional Differences Between Proportional and Poor Motor Recovery After Stroke. Neurorehabil Neural Repair 2017; 31:1029-1041. [PMID: 29130824 DOI: 10.1177/1545968317740634] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Evolution of motor function during the first months after stroke is stereotypically bifurcated, consisting of either recovery to about 70% of maximum possible improvement ("proportional recovery, PROP") or in little to no improvement ("poor recovery, POOR"). There is currently no evidence that any rehabilitation treatment will prevent POOR and favor PROP. OBJECTIVE To perform a longitudinal and multimodal assessment of functional and structural changes in brain organization associated with PROP. METHODS Fugl-Meyer Assessments of the upper extremity and high-density electroencephalography (EEG) were obtained from 63 patients, diffusion tensor imaging from 46 patients, at 2 and 4 weeks (T0) and at 3 months (T1) after stroke onset. RESULTS We confirmed the presence of 2 distinct recovery patterns (PROP and POOR) in our sample. At T0, PROP patients had greater integrity of the corticospinal tract (CST) and greater EEG functional connectivity (FC) between the affected hemisphere and rest of the brain, in particular between the ventral premotor and the primary motor cortex. POOR patients suffered from degradation of corticocortical and corticofugal fiber tracts in the affected hemisphere between T0 and T1, which was not observed in PROP patients. Better initial CST integrity correlated with greater initial global FC, which was in turn associated with less white matter degradation between T0 and T1. CONCLUSIONS These findings suggest links between initial CST integrity, systems-level cortical network plasticity, reduction of white matter atrophy, and clinical motor recovery after stroke. This identifies candidate treatment targets.
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Affiliation(s)
- Adrian G Guggisberg
- 1 Geneva University Hospital, Geneva, Switzerland.,2 University of Geneva, Geneva, Switzerland
| | - Pierre Nicolo
- 1 Geneva University Hospital, Geneva, Switzerland.,2 University of Geneva, Geneva, Switzerland
| | - Leonardo G Cohen
- 3 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Armin Schnider
- 1 Geneva University Hospital, Geneva, Switzerland.,2 University of Geneva, Geneva, Switzerland
| | - Ethan R Buch
- 3 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
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Low E, Crewther SG, Ong B, Perre D, Wijeratne T. Compromised Motor Dexterity Confounds Processing Speed Task Outcomes in Stroke Patients. Front Neurol 2017; 8:484. [PMID: 28983276 PMCID: PMC5613174 DOI: 10.3389/fneur.2017.00484] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/30/2017] [Indexed: 11/13/2022] Open
Abstract
Most conventional measures of information processing speed require motor responses to facilitate performance. However, although not often addressed clinically, motor impairment, whether due to age or acquired brain injury, would be expected to confound the outcome measure of such tasks. The current study recruited 29 patients (20 stroke and 9 transient ischemic attack) with documented reduction in dexterity of the dominant hand, and 29 controls, to investigate the extent to which 3 commonly used processing speed measures with varying motor demands (a Visuo-Motor Reaction Time task, and the Wechsler Adult Intelligence Scale-IV Symbol Search and Coding subtests) may be measuring motor-related speed more so than cognitive speed. Analyses include correlations between indices of cognitive and motor speed obtained from two other tasks (Inspection Time and Pegboard task, respectively) with the three speed measures, followed by hierarchical regressions to determine the relative contribution of cognitive and motor speed indices toward task performance. Results revealed that speed outcomes on tasks with relatively high motor demands, such as Coding, were largely reflecting motor speed in individuals with reduced dominant hand dexterity. Thus, findings indicate the importance of employing measures with minimal motor requirements, especially when the assessment of speed is aimed at understanding cognitive rather than physical function.
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Affiliation(s)
- Essie Low
- Department of Neurology, Sunshine Hospital, Western Health, Melbourne, VIC, Australia.,Department of Psychology and Counselling, School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia
| | - Sheila Gillard Crewther
- Department of Neurology, Sunshine Hospital, Western Health, Melbourne, VIC, Australia.,Department of Psychology and Counselling, School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia
| | - Ben Ong
- Department of Psychology and Counselling, School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia
| | - Diana Perre
- Department of Psychology, Sunshine Hospital, Western Health, Melbourne, VIC, Australia
| | - Tissa Wijeratne
- Department of Neurology, Sunshine Hospital, Western Health, Melbourne, VIC, Australia.,Department of Psychology and Counselling, School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia.,Department of Medicine, Melbourne Medical School, University of Melbourne, Western Health Sunshine Hospital, St Albans, VIC, Australia.,Department of Medicine, University of Rajarata, Anuradhapura, Sri Lanka
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37
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Hallett M, Di Iorio R, Rossini PM, Park JE, Chen R, Celnik P, Strafella AP, Matsumoto H, Ugawa Y. Contribution of transcranial magnetic stimulation to assessment of brain connectivity and networks. Clin Neurophysiol 2017; 128:2125-2139. [PMID: 28938143 DOI: 10.1016/j.clinph.2017.08.007] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 07/31/2017] [Accepted: 08/12/2017] [Indexed: 01/01/2023]
Abstract
The goal of this review is to show how transcranial magnetic stimulation (TMS) techniques can make a contribution to the study of brain networks. Brain networks are fundamental in understanding how the brain operates. Effects on remote areas can be directly observed or identified after a period of stimulation, and each section of this review will discuss one method. EEG analyzed following TMS is called TMS-evoked potentials (TEPs). A conditioning TMS can influence the effect of a test TMS given over the motor cortex. A disynaptic connection can be tested also by assessing the effect of a pre-conditioning stimulus on the conditioning-test pair. Basal ganglia-cortical relationships can be assessed using electrodes placed in the process of deep brain stimulation therapy. Cerebellar-cortical relationships can be determined using TMS over the cerebellum. Remote effects of TMS on the brain can be found as well using neuroimaging, including both positron emission tomography (PET) and functional magnetic resonance imaging (fMRI). The methods complement each other since they give different views of brain networks, and it is often valuable to use more than one technique to achieve converging evidence. The final product of this type of work is to show how information is processed and transmitted in the brain.
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Affiliation(s)
- Mark Hallett
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD, USA.
| | - Riccardo Di Iorio
- Department of Geriatrics, Institute of Neurology, Neuroscience and Orthopedics, Catholic University, Policlinic A. Gemelli Foundation, Rome, Italy
| | - Paolo Maria Rossini
- Department of Geriatrics, Institute of Neurology, Neuroscience and Orthopedics, Catholic University, Policlinic A. Gemelli Foundation, Rome, Italy; Brain Connectivity Laboratory, IRCCS San Raffaele Pisana, Rome, Italy
| | - Jung E Park
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD, USA; Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Robert Chen
- Krembil Research Institute, University of Toronto, Toronto, Canada; Department of Medicine (Neurology), University of Toronto, Toronto, Canada
| | - Pablo Celnik
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, USA
| | - Antonio P Strafella
- Krembil Research Institute, University of Toronto, Toronto, Canada; Morton and Gloria Shulman Movement Disorder Unit & E.J. Safra Parkinson Disease Program, Toronto Western Hospital, UHN, Canada; Research Imaging Centre, Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Ontario, Canada
| | | | - Yoshikazu Ugawa
- Department of Neurology, School of Medicine, Fukushima Medical University, Japan; Fukushima Global Medical Science Center, Advanced Clinical Research Center, Fukushima Medical University, Japan
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Toward precision medicine: tailoring interventional strategies based on noninvasive brain stimulation for motor recovery after stroke. Curr Opin Neurol 2017; 30:388-397. [DOI: 10.1097/wco.0000000000000462] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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39
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Sankarasubramanian V, Machado AG, Conforto AB, Potter-Baker KA, Cunningham DA, Varnerin NM, Wang X, Sakaie K, Plow EB. Inhibition versus facilitation of contralesional motor cortices in stroke: Deriving a model to tailor brain stimulation. Clin Neurophysiol 2017; 128:892-902. [PMID: 28402865 DOI: 10.1016/j.clinph.2017.03.030] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 03/08/2017] [Accepted: 03/14/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The standard approach to brain stimulation in stroke is based on the premise that ipsilesional M1 (iM1) is important for motor function of the paretic upper limb, while contralesional cortices compete with iM1. Therefore, the approach typically advocates facilitating iM1 and/or inhibiting contralesional M1 (cM1). But, this approach fails to elicit much improvement in severely affected patients, who on account of extensive damage to ipsilesional pathways, cannot rely on iM1. These patients are believed to instead rely on the undamaged cortices, especially the contralesional dorsal premotor cortex (cPMd), for support of function of the paretic limb. Here, we tested for the first time whether facilitation of cPMd could improve paretic limb function in severely affected patients, and if a cut-off could be identified to separate responders to cPMd from responders to the standard approach to stimulation. METHODS In a randomized, sham-controlled crossover study, fifteen patients received the standard approach of stimulation involving inhibition of cM1 and a new approach involving facilitation of cPMd using repetitive transcranial magnetic stimulation (rTMS). Patients also received rTMS to control areas. At baseline, impairment [Upper Extremity Fugl-Meyer (UEFMPROXIMAL, max=36)] and damage to pathways [fractional anisotropy (FA)] was measured. We measured changes in time to perform proximal paretic limb reaching, and neurophysiology using TMS. RESULTS Facilitation of cPMd generated more improvement in severely affected patients, who had experienced greater damage and impairment than a cut-off value of FA (0.5) and UEFMPROXIMAL (26-28). The standard approach instead generated more improvement in mildly affected patients. Responders to cPMd showed alleviation of interhemispheric competition imposed on iM1, while responders to the standard approach showed gains in ipsilesional excitability in association with improvement. CONCLUSIONS A preliminary cut-off level of severity separated responders for standard approach vs. facilitation of cPMd. SIGNIFICANCE Cut-offs identified here could help select candidates for tailored stimulation in future studies so patients in all ranges of severity could potentially achieve maximum benefit in function of the paretic upper limb.
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Affiliation(s)
| | - Andre G Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Adriana B Conforto
- Neurology Clinical Division, Neurology Department, Hospital das Clinicas, São Paulo University, 05508-090 São Paulo, SP, Brazil; Hospital Israelita Albert Einstein, 05652-900 São Paulo, SP, Brazil
| | - Kelsey A Potter-Baker
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - David A Cunningham
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA; School of Biomedical Sciences, Kent State University, Kent, OH 44242, USA
| | - Nicole M Varnerin
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Ken Sakaie
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Ela B Plow
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA; Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195, USA; Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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40
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Palmer JA, Zarzycki R, Morton SM, Kesar TM, Binder-Macleod SA. Characterizing differential poststroke corticomotor drive to the dorsi- and plantarflexor muscles during resting and volitional muscle activation. J Neurophysiol 2017; 117:1615-1624. [PMID: 28077661 DOI: 10.1152/jn.00393.2016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 12/16/2016] [Accepted: 01/08/2017] [Indexed: 12/20/2022] Open
Abstract
Imbalance of corticomotor excitability between the paretic and nonparetic limbs has been associated with the extent of upper extremity motor recovery poststroke, is greatly influenced by specific testing conditions such as the presence or absence of volitional muscle activation, and may vary across muscle groups. However, despite its clinical importance, poststroke corticomotor drive to lower extremity muscles has not been thoroughly investigated. Additionally, whereas conventional gait rehabilitation strategies for stroke survivors focus on paretic limb foot drop and dorsiflexion impairments, most contemporary literature has indicated that paretic limb propulsion and plantarflexion impairments are the most significant limiters to poststroke walking function. The purpose of this study was to compare corticomotor excitability of the dorsi- and plantarflexor muscles during resting and active conditions in individuals with good and poor poststroke walking recovery and in neurologically intact controls. We found that plantarflexor muscles showed reduced corticomotor symmetry between paretic and nonparetic limbs compared with dorsiflexor muscles in individuals with poor poststroke walking recovery during active muscle contraction but not during rest. Reduced plantarflexor corticomotor symmetry during active muscle contraction was a result of reduced corticomotor drive to the paretic muscles and enhanced corticomotor drive to the nonparetic muscles compared with the neurologically intact controls. These results demonstrate that atypical corticomotor drive exists in both the paretic and nonparetic lower limbs and implicate greater severity of corticomotor impairments to plantarflexor vs. dorsiflexor muscles during muscle activation in stroke survivors with poor walking recovery.NEW & NOTEWORTHY The present study observed that lower-limb corticomotor asymmetry resulted from both reduced paretic and enhanced nonparetic limb corticomotor excitability compared with neurologically intact controls. The most asymmetrical corticomotor drive was observed in the plantarflexor muscles of individuals with poor poststroke walking recovery. This suggests that neural function of dorsi- and plantarflexor muscles in both paretic and nonparetic limbs may play a role in poststroke walking function, which may have important implications when developing targeted poststroke rehabilitation programs to improve walking ability.
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Affiliation(s)
- Jacqueline A Palmer
- Division of Physical Therapy, School of Medicine, Emory University, Atlanta, Georgia
| | - Ryan Zarzycki
- Department of Physical Therapy, University of Delaware, Newark, Delaware.,Graduate Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware; and
| | - Susanne M Morton
- Department of Physical Therapy, University of Delaware, Newark, Delaware.,Graduate Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware; and
| | - Trisha M Kesar
- Division of Physical Therapy, School of Medicine, Emory University, Atlanta, Georgia
| | - Stuart A Binder-Macleod
- Department of Physical Therapy, University of Delaware, Newark, Delaware.,Graduate Program in Biomechanics and Movement Science, University of Delaware, Newark, Delaware; and
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41
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Ipsilesional High Frequency Repetitive Transcranial Magnetic Stimulation Add-On Therapy Improved Diffusion Parameters of Stroke Patients with Motor Dysfunction: A Preliminary DTI Study. Neural Plast 2016; 2016:6238575. [PMID: 27840742 PMCID: PMC5093297 DOI: 10.1155/2016/6238575] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 08/31/2016] [Indexed: 12/22/2022] Open
Abstract
Purpose. The aim of this study was to evaluate the effects of high frequency repetitive transcranial magnetic stimulation (HF-rTMS) on stroke patients with motor dysfunction and to investigate the underlying neural mechanism. Methods. Fifteen stroke patients were assigned to the rTMS treatment (RT) group and conventional treatment (CT) group. Patients in the RT received 10 Hz rTMS stimulation on the ipsilesional primary motor cortex for 10 days plus conventional treatment of CT, which consisted of acupuncture and antiplatelet aggregation medication. Difference in fractional anisotropy (FA) between pretreatment and posttreatment and between two groups was determined. Correlations between FA values and neurological assessments were also calculated. Results. Both groups significantly improved the neurological function after treatment. rTMS-treated patients showed better improvement in Fugl-Meyer Assessment (FMA) score and increased FA value in motor-related white matter and gray matter cortices compared with CT-treated patients and pretreatment status. Besides, the increased FA value in the ipsilesional posterior limb of the internal capsule in RT group was significantly correlated with the improved FMA score. Significance. HF-rTMS could be a supplement therapy to CT in improving motor recovery in patients with stroke. And this benefit effect may be achieved through modulating the ipsilesional corticospinal tracts and motor-related gray matter cortices.
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42
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Young BM, Stamm JM, Song J, Remsik AB, Nair VA, Tyler ME, Edwards DF, Caldera K, Sattin JA, Williams JC, Prabhakaran V. Brain-Computer Interface Training after Stroke Affects Patterns of Brain-Behavior Relationships in Corticospinal Motor Fibers. Front Hum Neurosci 2016; 10:457. [PMID: 27695404 PMCID: PMC5025476 DOI: 10.3389/fnhum.2016.00457] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 08/30/2016] [Indexed: 12/11/2022] Open
Abstract
Background: Brain–computer interface (BCI) devices are being investigated for their application in stroke rehabilitation, but little is known about how structural changes in the motor system relate to behavioral measures with the use of these systems. Objective: This study examined relationships among diffusion tensor imaging (DTI)-derived metrics and with behavioral changes in stroke patients with and without BCI training. Methods: Stroke patients (n = 19) with upper extremity motor impairment were assessed using Stroke Impact Scale (SIS), Action Research Arm Test (ARAT), Nine-Hole Peg Test (9-HPT), and DTI scans. Ten subjects completed four assessments over a control period during which no training was administered. Seventeen subjects, including eight who completed the control period, completed four assessments over an experimental period during which subjects received interventional BCI training. Fractional anisotropy (FA) values were extracted from each corticospinal tract (CST) and transcallosal motor fibers for each scan. Results: No significant group by time interactions were identified at the group level in DTI or behavioral measures. During the control period, increases in contralesional CST FA and in asymmetric FA (aFA) correlated with poorer scores on SIS and 9-HPT. During the experimental period (with BCI training), increases in contralesional CST FA were correlated with improvements in 9-HPT while increases in aFA correlated with improvements in ARAT but with worsening 9-HPT performance; changes in transcallosal motor fibers positively correlated with those in the contralesional CST. All correlations p < 0.05 corrected. Conclusion: These findings suggest that the integrity of the contralesional CST may be used to track individual behavioral changes observed with BCI training after stroke.
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Affiliation(s)
- Brittany M Young
- Department of Radiology, University of Wisconsin Hospital and Clinics, University of Wisconsin - Madison, MadisonWI, USA; Medical Scientist Training Program, University of Wisconsin - Madison, MadisonWI, USA; Neuroscience Training Program, University of Wisconsin - Madison, MadisonWI, USA
| | - Julie M Stamm
- Department of Radiology, University of Wisconsin Hospital and Clinics, University of Wisconsin - Madison, Madison WI, USA
| | - Jie Song
- Department of Radiology, University of Wisconsin Hospital and Clinics, University of Wisconsin - Madison, MadisonWI, USA; Department of Biomedical Engineering, University of Wisconsin - Madison, MadisonWI, USA
| | - Alexander B Remsik
- Department of Radiology, University of Wisconsin Hospital and Clinics, University of Wisconsin - Madison, Madison WI, USA
| | - Veena A Nair
- Department of Radiology, University of Wisconsin Hospital and Clinics, University of Wisconsin - Madison, Madison WI, USA
| | - Mitchell E Tyler
- Department of Biomedical Engineering, University of Wisconsin - Madison, Madison WI, USA
| | - Dorothy F Edwards
- Department of Kinesiology and Department of Medicine, University of Wisconsin - Madison, MadisonWI, USA; Department of Neurology, University of Wisconsin - Madison, MadisonWI, USA
| | - Kristin Caldera
- Department of Orthopedics and Rehabilitation, University of Wisconsin - Madison, Madison WI, USA
| | - Justin A Sattin
- Department of Neurology, University of Wisconsin - Madison, Madison WI, USA
| | - Justin C Williams
- Neuroscience Training Program, University of Wisconsin - Madison, MadisonWI, USA; Department of Biomedical Engineering, University of Wisconsin - Madison, MadisonWI, USA; Department of Neurosurgery, University of Wisconsin - Madison, MadisonWI, USA
| | - Vivek Prabhakaran
- Department of Radiology, University of Wisconsin Hospital and Clinics, University of Wisconsin - Madison, MadisonWI, USA; Medical Scientist Training Program, University of Wisconsin - Madison, MadisonWI, USA; Neuroscience Training Program, University of Wisconsin - Madison, MadisonWI, USA; Department of Orthopedics and Rehabilitation, University of Wisconsin - Madison, MadisonWI, USA; Department of Psychology and Department of Psychiatry, University of Wisconsin - Madison, MadisonWI, USA
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Cunningham DA, Varnerin N, Machado A, Bonnett C, Janini D, Roelle S, Potter-Baker K, Sankarasubramanian V, Wang X, Yue G, Plow EB. Stimulation targeting higher motor areas in stroke rehabilitation: A proof-of-concept, randomized, double-blinded placebo-controlled study of effectiveness and underlying mechanisms. Restor Neurol Neurosci 2016; 33:911-26. [PMID: 26484700 DOI: 10.3233/rnn-150574] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE To demonstrate, in a proof-of-concept study, whether potentiating ipsilesional higher motor areas (premotor cortex and supplementary motor area) augments and accelerates recovery associated with constraint induced movement. METHODS In a randomized, double-blinded pilot clinical study, 12 patients with chronic stroke were assigned to receive anodal transcranial direct current stimulation (tDCS) (n = 6) or sham (n = 6) to the ipsilesional higher motor areas during constraint-induced movement therapy. We assessed functional and neurophysiologic outcomes before and after 5 weeks of therapy. RESULTS Only patients receiving tDCS demonstrated gains in function and dexterity. Gains were accompanied by an increase in excitability of the contralesional rather than the ipsilesional hemisphere. CONCLUSIONS Our proof-of-concept study provides early evidence that stimulating higher motor areas can help recruit the contralesional hemisphere in an adaptive role in cases of greater ipsilesional injury. Whether this early evidence of promise translates to remarkable gains in functional recovery compared to existing approaches of stimulation remains to be confirmed in large-scale clinical studies that can reasonably dissociate stimulation of higher motor areas from that of the traditional primary motor cortices.
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Affiliation(s)
- David A Cunningham
- Department of Biomedical Engineering, Lerner Research Inst., Cleveland Clinic, Cleveland, OH, USA.,School of Biomedical Sciences, Kent State University, Kent, OH, USA
| | - Nicole Varnerin
- Department of Biomedical Engineering, Lerner Research Inst., Cleveland Clinic, Cleveland, OH, USA
| | - Andre Machado
- Center for Neurological Restoration, Neurosurgery, Neurological Inst., Cleveland Clinic, Cleveland, OH, USA
| | - Corin Bonnett
- Department of Biomedical Engineering, Lerner Research Inst., Cleveland Clinic, Cleveland, OH, USA
| | - Daniel Janini
- Department of Biomedical Engineering, Lerner Research Inst., Cleveland Clinic, Cleveland, OH, USA
| | - Sarah Roelle
- Department of Biomedical Engineering, Lerner Research Inst., Cleveland Clinic, Cleveland, OH, USA
| | - Kelsey Potter-Baker
- Department of Biomedical Engineering, Lerner Research Inst., Cleveland Clinic, Cleveland, OH, USA
| | | | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, OH, USA
| | - Guang Yue
- Human Performance & Engineering Laboratory, Kessler Foundation Research Center, West Orange, NJ, USA
| | - Ela B Plow
- Department of Biomedical Engineering, Lerner Research Inst., Cleveland Clinic, Cleveland, OH, USA.,Center for Neurological Restoration, Neurosurgery, Neurological Inst., Cleveland Clinic, Cleveland, OH, USA.,Department of Physical Medicine & Rehab, Neurological Inst., Cleveland Clinic, Cleveland, OH, USA
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44
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Cassidy JM, Chu H, Chen M, Kimberley TJ, Carey JR. Interhemispheric Inhibition Measurement Reliability in Stroke: A Pilot Study. Neuromodulation 2016; 19:838-847. [PMID: 27333364 DOI: 10.1111/ner.12459] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/02/2016] [Accepted: 04/29/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Reliable transcranial magnetic stimulation (TMS) measures for probing corticomotor excitability are important when assessing the physiological effects of noninvasive brain stimulation. The primary objective of this study was to examine test-retest reliability of an interhemispheric inhibition (IHI) index measurement in stroke. MATERIALS AND METHODS Ten subjects with chronic stroke (≥6 months) completed two IHI testing sessions per week for three weeks (six testing sessions total). A single investigator measured IHI in the contra-to-ipsilesional primary motor cortex direction and in the opposite direction using bilateral paired-pulse TMS. Weekly sessions were separated by 24 hours with a 1-week washout period separating testing weeks. To determine if motor-evoked potential (MEP) quantification method affected measurement reliability, IHI indices computed from both MEP amplitude and area responses were found. Reliability was assessed with two-way, mixed intraclass correlation coefficients (ICC(3,k) ). Standard error of measurement and minimal detectable difference statistics were also determined. RESULTS With the exception of the initial testing week, IHI indices measured in the contra-to-ipsilesional hemisphere direction demonstrated moderate to excellent reliability (ICC = 0.725-0.913). Ipsi-to-contralesional IHI indices depicted poor or invalid reliability estimates throughout the three-week testing duration (ICC= -1.153-0.105). The overlap of ICC 95% confidence intervals suggested that IHI indices using MEP amplitude vs. area measures did not differ with respect to reliability. CONCLUSIONS IHI indices demonstrated varying magnitudes of reliability irrespective of MEP quantification method. Several strategies for improving IHI index measurement reliability are discussed.
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Affiliation(s)
- Jessica M Cassidy
- Department of Physical Medicine and Rehabilitation, Programs in Physical Therapy and Rehabilitation Science, University of Minnesota, Minneapolis, MN, USA
| | - Haitao Chu
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Mo Chen
- Institute for Engineering in Medicine, University of Minnesota, Minneapolis, MN
| | - Teresa J Kimberley
- Department of Physical Medicine and Rehabilitation, Programs in Physical Therapy and Rehabilitation Science, University of Minnesota, Minneapolis, MN, USA
| | - James R Carey
- Department of Physical Medicine and Rehabilitation, Programs in Physical Therapy and Rehabilitation Science, University of Minnesota, Minneapolis, MN, USA
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45
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Julkunen P, Määttä S, Säisänen L, Kallioniemi E, Könönen M, Jäkälä P, Vanninen R, Vaalto S. Functional and structural cortical characteristics after restricted focal motor cortical infarction evaluated at chronic stage - Indications from a preliminary study. Clin Neurophysiol 2016; 127:2775-2784. [PMID: 27417053 DOI: 10.1016/j.clinph.2016.05.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 05/04/2016] [Accepted: 05/10/2016] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess the inter-hemispheric differences in neuronal function and structure of the motor cortex in a small group of chronic stroke patients having suffered a restricted ischemic lesion affecting hand motor representation. GABAergic intracortical inhibition, known to be affected by stroke lesion, was also investigated. METHODS Eight patients exhibiting little or no motor impairment were studied using transcranial magnetic stimulation (TMS) and diffusion weighted imaging (DWI) >15months from diagnosis. Resting motor threshold (MT) for 50μV and 2mV motor evoked potentials, and short-interval intracortical inhibition (SICI) were measured from hand muscles. Apparent diffusion coefficients (ADCs) were analyzed from the DWI for the primary motor cortex (M1), the supplementary motor area (SMA) and thalamus for reflecting changes in neuronal organization. RESULTS The MTs did not differ between the affected (AH) and unaffected hemisphere (UH) in 50μV responses, while the MTs for 2mV responses were higher (p=0.018) in AH. SICI was weakened in AH (p=0.008). ADCs were higher in the affected M1 compared to the unaffected M1 (p=0.018) while there were no inter-hemispheric differences in SMA or thalamus. CONCLUSIONS Inter-hemispheric asymmetry and neuronal organization demonstrated abnormalities in the M1. However, no confident inference can be made whether the observed alterations in neurophysiological and imaging measures have causal role for motor rehabilitation in these patients. SIGNIFICANCE Neurophysiological changes persist and are detectable using TMS years after stroke even though clinical symptoms have normalized.
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Affiliation(s)
- Petro Julkunen
- Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finland; Department of Applied Physics, University of Eastern Finland, Kuopio, Finland.
| | - Sara Määttä
- Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finland; Department of Clinical Neurophysiology, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Laura Säisänen
- Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finland; Department of Clinical Neurophysiology, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Elisa Kallioniemi
- Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finland; Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Mervi Könönen
- Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finland; Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Pekka Jäkälä
- Department of Neurology, Kuopio University Hospital, Kuopio, Finland; Department of Neurology, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland; Department of Clinical Radiology, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Selja Vaalto
- Department of Clinical Neurophysiology, Helsinki University Hospital, Helsinki, Finland; Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland
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46
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Reliability of TMS metrics in patients with chronic incomplete spinal cord injury. Spinal Cord 2016; 54:980-990. [DOI: 10.1038/sc.2016.47] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 02/18/2016] [Accepted: 02/28/2016] [Indexed: 12/26/2022]
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Simis M, Di Lazzaro V, Kirton A, Pennisi G, Bella R, Kim YH, Takeuchi N, Khedr EM, Rogers LM, Harvey R, Koganemaru S, Turman B, Tarlacı S, Gagliardi RJ, Fregni F. Neurophysiological measurements of affected and unaffected motor cortex from a cross-sectional, multi-center individual stroke patient data analysis study. Neurophysiol Clin 2016; 46:53-61. [PMID: 26970808 DOI: 10.1016/j.neucli.2016.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 12/28/2015] [Accepted: 01/25/2016] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES Transcranial magnetic stimulation (TMS) has been used to measure cortical excitability as a functional measurement of corticomotor pathways. Given its potential application as an assessment tool in stroke, we aimed to analyze the correlation of TMS parameters with clinical features in stroke using data from 10 different centers. METHODS Data of 341 patients with a clinical diagnosis of stroke were collected from studies assessing cortical excitability using TMS. We used a multivariate regression model in which the baseline cortical excitability parameter "resting Motor Threshold (rMT)" was the main outcome and the demographic, anatomic and clinical characteristics were included as independent variables. RESULTS The variable "severity of motor deficit" consistently remained significant in predicting rMT in the affected hemisphere, with a positive β coefficient, in the multivariate models after sensitive analyses and adjusting for important confounders such as site center. Additionally, we found that the correlations between "age" or "time since stroke" and the rMT in the affected hemisphere were significant, as well as the interaction between "time since stroke" and "severity of motor deficit". CONCLUSIONS We have shown that severity of motor deficit is an important predictor for rMT in the affected hemisphere. Additionally, time since stroke seems to be an effect modifier for the correlation between motor deficit and rMT. In the unaffected motor cortex, these correlations were not significant. We discuss these findings in the context of stroke rehabilitation.
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Affiliation(s)
- Marcel Simis
- Harvard Medical School, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Laboratory of Neuromodulation, Boston, USA; Santa Casa Medical School, Division of Neurology, Sao Paulo, Brazil; University of Sao Paulo Medical School General Hospital, Physical and Rehabilitation Medicine Institute, Sao Paulo, Brazil
| | | | - Adam Kirton
- University of Calgary, Alberta Children's Hospital Research Institute, Calgary Pediatric Stroke Program, Calgary, Alberta, Canada
| | - Giovanni Pennisi
- University of Catania, Section of Neurosciences, Department GF Ingrassia, Catania, Italy
| | - Rita Bella
- University of Catania, Section of Neurosciences, Department GF Ingrassia, Catania, Italy
| | - Yun-Hee Kim
- Sungkyunkwan University, School of Medicine, Samsung Medical Center, Heart Vascular Stroke Institute, Department of Physical and Rehabilitation Medicine, Seoul, Republic of Korea
| | - Naoyuki Takeuchi
- Tohoku University Graduates School of Medicine, Department of Physical Medicine and Rehabilitation, Sendai, Japan
| | - Eman M Khedr
- Assiut University Hospital, Faculty of Medicine, Department of Neurology, Assiut, Egypt
| | - Lynn M Rogers
- Rehabilitation Institute of Chicago, Sensory Motor Performance Program, Chicago, USA; Northwestern University Feinberg School of Medicine, Department of Physical Medicine and Rehabilitation, Chicago, USA
| | - Richard Harvey
- Rehabilitation Institute of Chicago, Sensory Motor Performance Program, Chicago, USA; Northwestern University Feinberg School of Medicine, Department of Physical Medicine and Rehabilitation, Chicago, USA
| | - Satoko Koganemaru
- Kyoto University Graduate School of Medicine, Human Brain Research Center, Kyoto, Japan
| | - Bulent Turman
- Bond University, School of Medicine, Robina, Australia
| | | | | | - Felipe Fregni
- Harvard Medical School, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Laboratory of Neuromodulation, Boston, USA.
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Potter-Baker KA, Varnerin NM, Cunningham DA, Roelle SM, Sankarasubramanian V, Bonnett CE, Machado AG, Conforto AB, Sakaie K, Plow EB. Influence of Corticospinal Tracts from Higher Order Motor Cortices on Recruitment Curve Properties in Stroke. Front Neurosci 2016; 10:79. [PMID: 27013942 PMCID: PMC4781847 DOI: 10.3389/fnins.2016.00079] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 02/18/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Recruitment curves (RCs) acquired using transcranial magnetic stimulation are commonly used in stroke to study physiologic functioning of corticospinal tracts (CST) from M1. However, it is unclear whether CSTs from higher motor cortices contribute as well. OBJECTIVE To explore whether integrity of CST from higher motor areas, besides M1, relates to CST functioning captured using RCs. METHODS RCs were acquired for a paretic hand muscle in patients with chronic stroke. Metrics describing gain and overall output of CST were collected. CST integrity was defined by diffusion tensor imaging. For CST emerging from M1 and higher motor areas, integrity (fractional anisotropy) was evaluated in the region of the posterior limb of the internal capsule, the length of CST and in the region of the stroke lesion. RESULTS We found that output and gain of RC was related to integrity along the length of CST emerging from higher motor cortices but not the M1. CONCLUSIONS Our results suggest that RC parameters in chronic stroke infer function primarily of CST descending from the higher motor areas but not M1. RCs may thus serve as a simple, in-expensive means to assess re-mapping of alternate areas that is generally studied with resource-intensive neuroimaging in stroke.
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Affiliation(s)
- Kelsey A Potter-Baker
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation Cleveland, OH, USA
| | - Nicole M Varnerin
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation Cleveland, OH, USA
| | - David A Cunningham
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic FoundationCleveland, OH, USA; School of Biomedical Sciences, Department of Neuroscience, Kent State UniversityKent, OH, USA
| | - Sarah M Roelle
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation Cleveland, OH, USA
| | | | - Corin E Bonnett
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation Cleveland, OH, USA
| | - Andre G Machado
- Center for Neurological Restoration, Neurosurgery, Neurological Institute, Cleveland Clinic Foundation Cleveland, OH, USA
| | - Adriana B Conforto
- Neurology Clinical Division, Neurology Department, Clinics Hospital, São Paulo UniversitySão Paulo, Brazil; Hospital Israelita Albert EinsteinSão Paulo, Brazil
| | - Ken Sakaie
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic Foundation Cleveland, OH, USA
| | - Ela B Plow
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic FoundationCleveland, OH, USA; Center for Neurological Restoration, Neurosurgery, Neurological Institute, Cleveland Clinic FoundationCleveland, OH, USA; Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic FoundationCleveland, OH, USA
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49
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Julkunen P, Könönen M, Määttä S, Tarkka IM, Hiekkala SH, Säisänen L, Vanninen R, Karhu J, Jäkälä P. Longitudinal study on modulated corticospinal excitability throughout recovery in supratentorial stroke. Neurosci Lett 2016; 617:88-93. [DOI: 10.1016/j.neulet.2016.02.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 02/05/2016] [Accepted: 02/06/2016] [Indexed: 10/22/2022]
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50
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Models to Tailor Brain Stimulation Therapies in Stroke. Neural Plast 2016; 2016:4071620. [PMID: 27006833 PMCID: PMC4781989 DOI: 10.1155/2016/4071620] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 12/30/2015] [Accepted: 01/04/2016] [Indexed: 11/18/2022] Open
Abstract
A great challenge facing stroke rehabilitation is the lack of information on how to derive targeted therapies. As such, techniques once considered promising, such as brain stimulation, have demonstrated mixed efficacy across heterogeneous samples in clinical studies. Here, we explain reasons, citing its one-type-suits-all approach as the primary cause of variable efficacy. We present evidence supporting the role of alternate substrates, which can be targeted instead in patients with greater damage and deficit. Building on this groundwork, this review will also discuss different frameworks on how to tailor brain stimulation therapies. To the best of our knowledge, our report is the first instance that enumerates and compares across theoretical models from upper limb recovery and conditions like aphasia and depression. Here, we explain how different models capture heterogeneity across patients and how they can be used to predict which patients would best respond to what treatments to develop targeted, individualized brain stimulation therapies. Our intent is to weigh pros and cons of testing each type of model so brain stimulation is successfully tailored to maximize upper limb recovery in stroke.
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