Neuroplasticity Findings for Rehabilitation of the Upper Limb Post Stroke: Comparison of MRI results to Standardized Outcomes of a Randomized Controlled Pilot Study.

Research Report
Population: Adult

Gregory Thomas Thielman, PT, EdD, ATC, Associate Professor of Physical Therapy, Unoversity of the Sciences

Feroze Mohamed, PhD, Associate Professor Radiology, Temple University

Scott Faro, MD, Professor Radiology, Temple University

Keywords: Plasticity, Rehabilitation, Stroke, MRI

Training in the virtual environment in post-stroke rehab has been established as an approach for neurorehabilitation; robot-assisted training program is based on the understanding that numerous repetitions of functionally oriented movements can stimulate cortical reorganization. Comparing real world task related training (TRT) to robotic arm therapy (REO), this randomized controlled study specifically measured sensorimotor recovery, neuroplasticity, and kinematic changes. Exploratory MRI data is expected to yield information on neuroplastic changes of the cortex. Based on prior work in this area it was expected that greater cortical changes would be apparent post training for the TRT group that is engaged in greater problem solving.
Eighteen post stroke subjects participated in this randomized controlled trial, all scoring between 20 and 44 on the Upper-Arm subsection of the Fugl-Meyer Scale, and demonstrating trunk movement during the pretest reaching performance. Rehabilitative sessions lasted between 50 and 65 minutes, 2-3 times a week for 4-6 weeks. The TRT group performed reaching activities at varied locations across the workspace using the paretic upper-limb, while the REO group performed active, passive and active assistive movement with the arm supported in the robotic device, moving toward virtual targets as seen on the computer screen. Auditory sensor feedback encouraging maintenance of the trunk against the chair back was systematically and equally faded throughout the training. Using a pretest/posttest design, rehabilitative effects were determined using scales at each level of the ICF model. Testing included task based Functional MRI BOLD images as well as resting state BOLD images acquired using a standard echo planar gradient echo sequence, with a 12 channel head coil.
Results at the end of the first level analysis revealed BOLD activation in the motor cortex area involved in these training tasks. Increased activation of the contralesional primary motor & dorsolateral prefrontal cortices, as well as expected supplementary motor cortex activation and ipsilateral cerebellum were evident when using the affected side. A 2 (Training Group) x 2 (Pre-/Posttests) ANOVA was used to reveal improvements for both techniques on the Motor Activity Log, the Wolf Motor Function Test, elbow extension active range of motion and the Reaching Performance Scale.
An increase in neurotransmitter activity was correlated with an increase in blood flow and metabolic activity, indicating BOLD fMRI is a valid measure of neural activity in the brain. More efficient reaching movements were evident post training for individuals trained in each group- with an increase in peak velocity and a decrease in deceleration time, with ROM and strength changes of the paretic upper extremity.
Both protocols used environmental feedback as a means to enhance motor learning. However, the degree of changes evident varied per protocol and may be due to the appropriateness of one technique for certain participation levels and the other technique for others.

Thielman, Gregory Thomas, PT, EdD, ATC; Mohamed, Feroze , PhD; Faro, Scott , MD. Neuroplasticity Findings for Rehabilitation of the Upper Limb Post Stroke: Comparison of MRI results to Standardized Outcomes of a Randomized Controlled Pilot Study.. Poster Presentation. IV STEP Conference, American Physical Therapy Association, Columbus, OH, July 17, 2016. Online.