Author: Luk, Ka Yan
Title: The effectiveness of combination of low frequency repetitive transcranial magnetic stimulation and structured physiotherapy training program on restoring upper extremity function for patients after stroke
Degree: DHSc
Year: 2018
Subject: Hong Kong Polytechnic University -- Dissertations
Magnetic brain stimulation
Arm -- Paralysis -- Treatment
Cerebrovascular disease -- Patients -- Rehabilitation
Department: Faculty of Health and Social Sciences
Pages: 181 pages : color illustrations
Language: English
Abstract: Background: The incidence of stroke has an increasing trend in the aging population worldwide. The contribution of stroke to the disability-adjusted life-years lost remains a great challenge. Impairment in upper limb function is a particularly challenging area in stroke rehabilitation. Less than half of the stroke survivors attain satisfactory upper limb recovery three to six months post-stroke. More recently, repetitive transcranial magnetic stimulation (rTMS), has garnered increasing attention in stroke rehabilitation. This study aimed to determine the effectiveness of low-frequency rTMS on the contralesional M1 combined with a structured upper limb motor exercise training program on restoring upper limb function with change in motor evoked potential over the lesioned cortex in patients with subacute stroke. Methods: Individuals who were 60 years of age or older and diagnosed with a first-ever stroke were recruited. Those fulfilled all eligibility criteria were randomly allocated to either experimental group or sham control group. Both groups underwent 10 sessions of low-frequency rTMS over the contra-lesional M1 region with 1200 repetitions of 1 Hz at 90% of the resting motor threshold over a 2-week period. The sham group, received sham rTMS stimulation. Two 15-min structured upper limb exercises followed immediately after each stimulation session. The participants continued to engage in the same upper limb exercise program twice weekly for another 10 weeks after the 2-week stimulation period had ended. Evaluation of upper limb function, (Fugl-Meyer Motor Assessment, Box and Block test, Action Research Arm test, Nine Hole Peg Test, grip strength), motor evoked potential (MEP) of the first dorsal interosseous muscle on both sides, and Stroke Impact Scale was performed at baseline, at the end of the 2-week stimulation period, and at 12-week follow-up by blinded assessors.
Results: Twenty-four individuals (mean age, 66.2 ± 4.7 years old) participated in the study, and the mean duration since stroke onset was 14.3 ± 6.5 weeks. One subject from each group dropped out due to personal reasons, otherwise all subjects completed all intervention and assessments as scheduled. Analysis of covariance revealed significant group × time interaction effect in various outcomes, including motor evoked potentials recorded in the paretic upper limb (F = 4.944, p = .037), Box and Block test (F = 4.365, p = .049), Fugl-Meyer Assessment score (F = 7.428 p = .013) and Action Research Arm Test (F = 11.435 p = .003), with the experimental group attaining more improvement than the sham group. Post-hoc analysis showed that the treatment effect was significant immediately after the 2-week stimulation period (FMA p =.001; ARMT p = .002; B&B p =.004), and that the effect was well maintained at 12-week follow-up (FMA p = .001; ARMT p =.006; B&B p =.001). A strong association was found between the changes of MEP on the lesioned side and those of the Fugl-Meyer Motor Assessment and Action Research Arm Test scores in the experimental group throughout the study period (p<0.05). There were no reports of adverse events and discomfort during the study period. There were also no hospital admission due to falls or other medical conditions. Conclusion: In summary, low-frequency rTMS applied to the contralesional motor cortex combined with upper limb exercise training were more effective in increasing the magnitude of MEP evoked from the motor cortex of the lesioned hemisphere and motor performance in the paretic upper limb, when compared with sham stimulation and same exercise program. rTMS is safe and feasible to be introduced as an adjunct treatment in subacute stroke rehabilitation.
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