Abstract
Background:
The combination of motor imagery (MI) and afferent input with electrical stimulation (ES) enhances the excitability of the corticospinal tract compared with motor imagery alone or electrical stimulation alone. However, its therapeutic effect is unknown in patients with hemiparetic stroke. We performed a preliminary examination of the therapeutic effects of MI + ES on upper extremity (UE) motor function in patients with chronic stroke.
Methods:
A total of 10 patients with chronic stroke demonstrating severe hemiparesis participated. The imagined task was extension of the affected finger. Peripheral nerve electrical stimulation was applied to the radial nerve at the spiral groove. MI + ES intervention was conducted for 10 days. UE motor function as assessed with the Fugl–Meyer assessment UE motor score (FMA-UE), the amount of the affected UE use in daily life as assessed with a Motor Activity Log (MAL-AOU), and the degree of hypertonia in flexor muscles as assessed with the Modified Ashworth Scale (MAS) were evaluated before and after intervention. To assess the change in spinal neural circuits, reciprocal inhibition between forearm extensor and flexor muscles with the H reflex conditioning-test paradigm at interstimulus intervals (ISIs) of 0, 20, and 100 ms were measured before and after intervention.
Results:
UE motor function, the amount of the affected UE use, and muscle hypertonia in flexor muscles were significantly improved after MI + ES intervention (FMA-UE: p < 0.01, MAL-AOU: p < 0.01, MAS: p = 0.02). Neurophysiologically, the intervention induced restoration of reciprocal inhibition from the forearm extensor to the flexor muscles (ISI at 0 ms: p = 0.03, ISI at 20 ms: p = 0.03, ISI at 100 ms: p = 0.01).
Introduction
Upper motor dysfunction is a common problem in patients with stroke and disrupts activities of daily living and eventually worsens quality of life.1,2 Recently, several rehabilitation approaches have been developed to improve upper extremity (UE) motor function. Previous research has shown that intensive use of the paretic upper limb contributes to improved motor function, even though the motor recovery period has already passed.3–6 However, intensive use of the paretic upper limb is impossible for patients with severe upper limb paralysis, because they cannot voluntarily control the paretic hand. Therefore, other rehabilitative approaches for severely impaired patients are needed. As an alternative approach, motor imagery (MI) can be applied to patients regardless of the degree of motor paralysis. MI is defined as a dynamic state during which the representation of a given motor act is internally rehearsed within working memory without any overt motor output.7 Functional imaging studies have revealed that brain activity during motor execution and MI is largely shared in motor networks, such as the primary motor area, supplementary motor area, and premotor area.8–10 Also, transcranial magnetic stimulation (TMS) studies reported that excitability of the corticospinal tract (CST) is significantly higher during MI in comparison with baseline.11–15 Based on these observations, MI has been applied for rehabilitation of patients with hemiparetic stroke, and the positive therapeutic effects on UE motor function have been reported.16–20 However, the effect size differs among the studies,19 and is lower with regard to motor recovery of the paretic hand.20 To obtain clinically significant improvement, ingenuity to strengthen the therapeutic effect of MI is thought to be necessary.
The combination of MI and afferent input with electrical stimulation (ES) is an approach to enhance the therapeutic effect of MI. The effectiveness of ES for modulation of the excitability of the CST and improvement of dexterity performance of the paretic hand has been reported in patients with mild to moderate paralysis.21,22 Moreover, the additive effect of MI and ES has been reported in healthy adults. Saito and colleagues reported that a combination of MI and peripheral nerve ES enhances the excitability of the CST compared with MI alone or ES alone.23 In addition, Kaneko and colleagues reported that the combination of MI and electrical muscular stimulation reproduces the excitability of the CST at levels similar to voluntary muscle contraction.24 However, its therapeutic effects for motor function in patients with stroke are unknown. Therefore, we performed a preliminary examination of the therapeutic effects of a combination of MI and peripheral nerve ES (MI + ES) on UE motor function in patients with severe paralysis. The aim of this study is to investigate the feasibility and potential of the therapeutic effect for future randomized controlled trials.[…]
Figure 1. The experimental setup of the intervention with combination of motor imagery and electrical stimulation (MI + ES).
TBI Rehabilitation 