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[ARTICLE] Cerebral Reorganization in Subacute Stroke Survivors after Virtual Reality-Based Training: A Preliminary Study – Full Text



Functional magnetic resonance imaging (fMRI) is a promising method for quantifying brain recovery and investigating the intervention-induced changes in corticomotor excitability after stroke. This study aimed to evaluate cortical reorganization subsequent to virtual reality-enhanced treadmill (VRET) training in subacute stroke survivors.


Eight participants with ischemic stroke underwent VRET for 5 sections per week and for 3 weeks. fMRI was conducted to quantify the activity of selected brain regions when the subject performed ankle dorsiflexion. Gait speed and clinical scales were also measured before and after intervention.


Increased activation in the primary sensorimotor cortex of the lesioned hemisphere and supplementary motor areas of both sides for the paretic foot (p < 0.01) was observed postintervention. Statistically significant improvements were observed in gait velocity (p < 0.05). The change in voxel counts in the primary sensorimotor cortex of the lesioned hemisphere is significantly correlated with improvement of 10 m walk time after VRET (r = −0.719).


We observed improved walking and increased activation in cortical regions of stroke survivors after VRET training. Moreover, the cortical recruitment was associated with better walking function. Our study suggests that cortical networks could be a site of plasticity, and their recruitment may be one mechanism of training-induced recovery of gait function in stroke. This trial is registered with ChiCTR-IOC-15006064.

1. Introduction

Gait impairment is a common consequence of stroke, and the decreases in gait velocity, stride length, and cadence are hallmark features of gait pattern alterations in stroke survivors [12]. Previous studies found that early intervention with physical therapy and gait training to restore walking after stroke was recommended to improve motor function and decrease disability [34]. As gait impairments are a result of deficient neuromuscular control, a better understanding of the impact and mechanism of those interventions on gait pattern recovery after stroke is therefore essential.

Environmental factors act as critical determinants for the level of community ambulation of stroke patient [5]. The development of computers has resulted in virtual reality (VR) tools which can create life-like scenarios via visual, auditory, and tactile feedback and can provide subjects with a safe and stimulating learning environment [6]. VR has been increasingly used in poststroke rehabilitation; therapy interventions using VR may improve motor function for those patients [715]. VR system might represent the main neural substrate for relearning or resuming impaired motor functions following stroke. A key challenge in neurorehabilitation is to establish optimal training protocols for the given patient [10]. VR could provide a person with senses of encouragement and accomplishment [1619]. However, two main concerns need to be investigated. What kind of rehabilitation strategies can combine with VR, and what degree for those VR combined rehabilitation strategies can facilitate stroke patients? Recently, motor relearning strategies can be applied in VR-enhanced treadmill (VRET) training by numerous movement repetitions and a multisensory approach to stimulate brain plasticity and patients receive visual feedback which is close to real-life experience [12]. While the positive benefits of VRET exercise on gait speed, cadence, step length, community walking time, and balance have been demonstrated [7911121415], the associated changes of brain activity with this training have not been investigated yet.

Advances in imaging, such as blood oxygenation level-dependent functional magnetic resonance imaging (fMRI), have been allowed for the observation of changes in cerebral plasticity and the exploration of recovery mechanisms. The control of gait involves the planning and execution from multiple cortical areas, such as secondary and premotor cortex [11]. Ankle dorsiflexion is an important kinematic aspect of the gait cycle. Using ankle movement, Enzinger et al. [20] observed increased activation in the unlesioned hemisphere associated with increasing functional impairment of the paretic leg in patients with stroke. fMRI studies of patients after stroke have suggested that VR could increase neural activations in the primary motor areas and improve lateralization of primary sensorimotor cortex (SMC) activity [2123]. We hypothesized that recovery of lower limb function after VRET would be associated with changes in brain activation during ankle dorsiflexion.

Therefore, the primary aim of this preliminary study was to investigate if functional reorganization takes place after VRET in subacute stroke survivors with gait impairment, using fMRI and an ankle dorsiflexion paradigm. Correlation between clinical scale changes after VERT and brain activation alterations was also studied to see the relations of the induction of cortical plasticity and functional recovery in subacute stroke survivors. We hope that the results of the current study could help to understand the mechanism of VRET as an early intervention for gait recovery for stroke.

2. Methods

2.1. Participants

Eight stroke survivors were recruited in this study, aged 41–72 years (mean: 58.38 years) and included 6 males and 2 females (Table 1 and Figure 1). Inclusion criteria: (i) 18 to 80 years in ages; (ii) right-foot dominant; (iii) first incident of ischemic cortical or subcortical stroke which resulted in gait impairment; (iv) stroke was confirmed by MRI within the past 3 months of inclusion; (v) at least 10° of dorsiflexion is available at the ankle. Exclusion criteria: (i) contraindication to MRI scan (implanted medical devices incompatible with MRI testing or claustrophobia); (ii) history of stroke resulted in function impairment; (iii) history of mental disorder or the use of antipsychotic medication; (iv) cognitive impairment (Mini-Mental State Examination score of less than 24 points); (v) unable to speak or hear; (vi) history of recent deep vein thrombosis of the lower limbs; (vii) recent myocardial infarction; (viii) medically unstable; (ix) existing lower extremity pathology. This study was approved by the Ethics Committee of the First Affiliated Hospital of Sun Yat-sen University (SYSU), and all subjects provided informed consent before the experiments.

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Figure 1
Axial structural T1-weighted MRI scans at the level of maximum infarct volume for each patient. And right hemisphere patients flipped on the sagittal axis for better comparison.


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