The Role of Baseline Functional MRI as a Predictor of Post-Stroke Rehabilitation Efficacy in Patients with Moderate to Severe Upper Extremity Dysfunction

I can see no use in predicting failure to recover.

 The Role of Baseline Functional MRI as a Predictor of Post-Stroke Rehabilitation Efficacy in Patients with Moderate to Severe Upper Extremity Dysfunction 

Reza Almasi Ghaleh¹, Sarvenaz Rahimibarghani¹, Niloofar Shirzad¹, Ailar Ahangari¹, Mohammad-Reza Nazem-Zadeh², Abolfazl Mahmoudi Aqeel Abadi², Abbas Tafakhori³, Hamid R. Fateh^1,4*
1Physical Medicine and Rehabilitation Department, Shariati Hospital, Tehran University of Medical Science, Tehran, Iran.
²Medical Physics and Biomedical Engineering Department, Research Center for Molecular and Cellular Imaging, Advanced Medical Technologies and Equipment Institute, Tehran University of Medical Sciences, Tehran, Iran.
³Neurology Department, Iranian Center of Neurological Research, Neuroscience Institute, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran.
⁴Neuromuscular Research Center, Tehran University of Medical Sciences, Tehran, Iran.
DOI: 10.4236/jbbs.2022.1212039   PDF   HTML   XML   18 Downloads   104 Views  

Abstract

Introduction: Upper extremity impairment is one of the common complications following a stroke. There are numerous rehabilitation strategies to address this problem. However, patients with moderate to severe upper limb disabilities respond differently to the same rehabilitation protocol. Apart from each patient’s unique characteristics, there are specific brain reorganizing patterns that affect the post-rehabilitation response rate. Functional magnetic resonance imaging (fMRI) determines brain activation area and connectivity patterns and has been utilized in the neurorehabilitation field.  

Material and Methods: Six stroke patients who suffered from moderate to severe upper extremity dysfunction were enrolled in this pilot study. Upper extremity function tests including the Fugl-Meyer assessment test for upper extremity (FMA-UE), and Wolf Motor Function Test (WMFT) were utilized before and after completing an intensive rehabilitation. The intensive rehabilitation program was conducted one hour a day for five days per week for four weeks. Moreover, fMRI was applied before initiating rehabilitation. The regions of interest were those associated with movement, including Brodmann areas (BA) BA1-BA6. 

Results: Six stroke patients in the sub-acute to chronic phase and ages ranging between 33 - 75 years were enrolled. All patients showed an improvement in upper limb function after four weeks of rehabilitation. Patient number one (Pt1) had the most improvement in FMA-UE, while patient number four (Pt4) recovered the most measured by WMFT. Pt1 demonstrated increased activity in all contralesional regions, whereas Pt4 had only increased activity in ipsilesional areas. Furthermore, patients with greater activation in the ipsilesional BA6 (Pt1, Pt4, Pt5, and Pt6) had better responses to the rehabilitation therapy.  

Conclusion: Patients with greater activation in the baseline fMRI, particularly ipsilesional BA6, had a better response to the intensive rehabilitation therapy. However, the patients with the most severe hand dysfunction showed lesser improvement despite the same brain activity as others in the initial fMRI.

Keywords

Stroke, Functional MRI, Rehabilitation, Upper Extremity

Share and Cite:

Ghaleh, R. , Rahimibarghani, S. , Shirzad, N. , Ahangari, A. , Nazem-Zadeh, M. , Aqeel Abadi, A. , Tafakhori, A. and Fateh, H. (2022) The Role of Baseline Functional MRI as a Predictor of Post-Stroke Rehabilitation Efficacy in Patients with Moderate to Severe Upper Extremity Dysfunction. Journal of Behavioral and Brain Science, 12, 658-669. doi: 10.4236/jbbs.2022.1212039.

1. Introduction

Stroke is one of the most important causes of disability worldwide. The incidence and mortality of stroke are increasing due to the growing elderly population [1] [2]. Contralateral upper limb hemiparesis is the most prevalent impairment following a stroke, affecting more than 80% of acute stroke patients and more than 40% of chronic ones. Upper-extremity motor paresis may be accompanied by additional neurological symptoms that impede motor function recovery, necessitating targeted rehabilitation therapy [3].

The primary goal of post-stroke management is to re-establish daily activities through different rehabilitation methods despite the residual impairments [4]. Neurological recovery follows a nonlinear, logarithmic pattern, meaning that most recovery is expected in the first three months after a stroke. Furthermore, recovery from a stroke can be characterized as an improvement in several outcomes, starting with biological and neurologic changes that appear to improve performance and activity-based behavioral measures. Adaptation, regeneration, and neuroplasticity are the three fundamental mechanisms in brain recovery following a stroke. Adaptation happens by using alternate physical movements or equipment to compensate for functional loss. Regeneration is known as the growth of damaged neural cells into new tissue to restore function. The main recovery mechanism is neuroplasticity, characterized by alterations or rewiring within the neural network [3] [4] [5].

Functional disabilities after a stroke affect the patient’s quality of life and leave a significant financial burden on society [6]. In addition, only a few patients with severe hand dysfunction will show promising results after the rehabilitation program [7]. However, it is relatively difficult to predict the recovery outcome and success rate only based on the clinical data in severely disabled patients. Thus, a prognostic tool to determine long-term motor recovery in terms of rehabilitation efficacy costs many expenses. Previous clinical studies have suggested the effectiveness of intensive motor training paired with repetitive transcranial magnetic stimulation (rTMS), muscular electrical stimulation, brain-computer interfaces, and robotic devices in upper limb rehabilitation in stroke patients [8] [9].

Notably, stroke patients are more likely to have permanent functional deficits because the non-activated brain has a limited neuroplasticity capacity. Neuroplasticity is also affected by the type of intervention, the patient’s age, the location of the lesion, and handedness. Therefore, tools like functional magnetic resonance imaging (fMRI) are utilized to investigate brain activity and the influence of neurorehabilitation methods on neuroplasticity in addition to clinical disability assessment tools. FMRI has an excellent spatial resolution, allowing researchers to gain insight into the brain reorganization process and its associated functional recovery after stroke neurorehabilitation [10]. In general, fMRI captures the blood oxygen level-dependent (BOLD) signal is captured using T2*-weighted imaging. Higher neuron activity is associated with higher blood flow in the related areas, increasing the oxyhemoglobin-to ratio and the signal [11]. Task performance during fMRI causes hemodynamic response function (HRF) in the motor cortex area, which changes the BOLD signal recorded by the MRI machine.

We conducted this study using the fMRI as a prognostic tool for upper limb functional recovery after intensive rehabilitation from a stroke. Although these findings should not exclude the most severe patients from rehabilitation therapy, but also help to define the realistic rehab consequences for both therapist and patients.(So you're pushing the tyranny of low expectations because you have completely failed at your job of getting survivors 100% recovered. I'd fire you all as failures.)

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