Clinical Observation And Longitudinal Fmri Study Of Transcranial Magnetic Stimulation In The Treatment Of Upper Limb Motor Dysfunction Caused By Spasticity After Stroke

ObjectiveThe patients,who with motor dysfunction caused by ischemic stroke spasticity in the rehabilitation,were treated with low-frequency repetitive transcranial magnetic stimulation(rTMS)combined with rehabilitation training.The longitudinal observation of the changes of cerebral cortical function and the improvement of limb motor dysfunction caused by stroke before and after rehabilitation treatment by using functional magnetic resonance imaging(fMRI)combined with clinical behavioral scale.The qualitative and quantitative analysis of the dynamic process of activation and remodeling of the motor cortex was aim to explore the relationship among exercise cortical compensation,recombination and recovery of limb motor function.It provides a new basis and explores a possible recovery mechanism about the low frequency rTMS treatment of motor dysfunction caused by spasticity after stroke.MethodsTotally 50 patients,who meet the inclusion criteria and exclusion criteria,are recruited from the department of rehabilitation and the ward of neurology in Fuzhou General Hospital.And only 47 cases completed data collection finally,which were randomly divided into two groups by the randomized controlled trial design.The treatment group(1Hz rTMS+conventional rehabilitation therapy)with24 cases and the control group(sham rTMS+conventional rehabilitation therapy)with 23 cases.And all of the treatments were conducted once a day,5 days per week and totally 8 weeks.The clinical behavior of evaluations including the modified Ashworth scale(MAS),upper limb Fugl-Meyer scale(FMA-UE)and Barthel index(BI)were examined for all patients before and after 8 weeks of intervention,also,there will perform the fMRI examination with 5 patients who were randomly selected in the two groups.The purpose was to observe the changes of activation area and activation intensity of brain functional area before and after the treatment.Resultsl.Before the treatment,there was no significant difference between the two groups in the general clinical data and FMA-UE,MAS and BI(P>0.05)and also there was no significant difference between the patients who was randomly selected for the fMRI examination in the general clinical data and clinical behavioral data(P>0.05).2.A11 measurements including the FMA-UE,MAS and BI in both groups were significantly improved than those before treatment(P<0.05)after the rehabilitation intervention.And the treatment group's efficacy was better than the control group.3.The difference was statistically significant(P<0.01)of two groups of patients examined for fMRI which the value of the laterality index(LI)increased,and the treatment group increased value is greater than the control group.The increase of LI was positively correlated with the improvement of MAS in the treatment group(r = 0.78,P<0.05).The increase of LI was positively correlated with the improvement of MAS in the control group(r=0.53,P<0.05).4.The results of the two groups of patients who undergoing the fMRI examination show that,the activation area was included bilateral brain's sensorimotor area,supplementary motor area,and ipsilateral brain's primary motor area,premotor cortex,cingulate gyrus,middle frontal gyrus and the contralateral brain's under the top lobule,inferior frontal gyrus in the treatment group.And the activation area was included bilateral brain's sensorimotor area,supplementary motor area,primary motor area,inferior frontal gyrus,and ipsilateral brain's cingulate gyrus,superior parietal lobule and the contralateral brain's thalamus,on the edge of the back,inferior temporal gyrus in the treatment group.Conclusions1.Low-frequency rTMS combined with rehabilitation training and rehabilitation training alone can improve motor dysfunction in patients with spasticity caused by the rehabilitation of stroke.Three was a synergistic effect between low-frequency rTMS and rehabilitation training,which can relieve spasm further,improve motor function and improve the ability of daily life.2.The functional area of premotor cortex,supplementary motor area,cingulate motor area which was related to the motor function,not only control muscle coordination and muscle tension,but also promote spasticity in patients with limb spasm after stroke.3.The change of the bilateral brain activation area was the main activation area at contralateral brain early and it gradually transitioned to the ipsilateral brain,which conformed to the laws of the reorganization of brain functional area after stroke.The low-frequency rTMS and rehabilitation training play a catalytic role in this process.4.Low-frequency rTMS not only reduce the excitability of the contralateral cortex significantly and promote to the ipsilateral cortical excitability increasingly,but also accelerated the main motor function area of the brain transfer the contralateral to the ipsilateral area.It was helpful for improving the motor function and making the recovery period shorter.