Somatosensory Cortex Repetitive Transcranial Magnetic Stimulation and Associative Sensory Stimulation of Peripheral Nerves Could Assist Motor and Sensory Recovery After Stroke

Aristela de Freitas Zanona, Andressa Claudia Romeiro da Silva, Adriana Baltar do Rego Maciel, Livia Shirahige Gomes do Nascimento, Amanda Bezerra da Silva, Nadia Bolognini, Katia Monte-Silva, Aristela de Freitas Zanona, Andressa Claudia Romeiro da Silva, Adriana Baltar do Rego Maciel, Livia Shirahige Gomes do Nascimento, Amanda Bezerra da Silva, Nadia Bolognini, Katia Monte-Silva

Abstract

Background: We investigated whether transcranial magnetic stimulation (rTMS) over the primary somatosensory cortex (S1) and sensory stimulation (SS) could promote upper limb recovery in participants with subacute stroke.

Methods: Participants were randomized into four groups: rTMS/Sham SS, Sham rTMS/SS, rTMS/SS, and control group (Sham rTMS/Sham SS). Participants underwent ten sessions of sham or active rTMS over S1 (10 Hz, 1,500 pulses, 120% of resting motor threshold, 20 min), followed by sham or active SS. The SS involved active sensory training (exploring features of objects and graphesthesia, proprioception exercises), mirror therapy, and Transcutaneous electrical nerve stimulation (TENS) in the region of the median nerve in the wrist (stimulation intensity as the minimum intensity at which the participants reported paresthesia; five electrical pulses of 1 ms duration each at 10 Hz were delivered every second over 45 min). Sham stimulations occurred as follows: Sham rTMS, coil was held while disconnected from the stimulator, and rTMS noise was presented with computer loudspeakers with recorded sound from a real stimulation. The Sham SS received therapy in the unaffected upper limb, did not use the mirror and received TENS stimulation for only 60 seconds. The primary outcome was the Body Structure/Function: Fugl-Meyer Assessment (FMA) and Nottingham Sensory Assessment (NSA); the secondary outcome was the Activity/Participation domains, assessed with Box and Block Test, Motor Activity Log scale, Jebsen-Taylor Test, and Functional Independence Measure.

Results: Forty participants with stroke ischemic (n = 38) and hemorrhagic (n = 2), men (n = 19) and women (n = 21), in the subacute stage (10.6 ± 6 weeks) had a mean age of 62.2 ± 9.6 years, were equally divided into four groups (10 participants in each group). Significant somatosensory improvements were found in participants receiving active rTMS and active SS, compared with those in the control group (sham rTMS with sham SS). Motor function improved only in participants who received active rTMS, with greater effects when active rTMS was combined with active SS.

Conclusion: The combined use of SS with rTMS over S1 represents a more effective therapy for increasing sensory and motor recovery, as well as functional independence, in participants with subacute stroke.

Clinical trial registration: [clinicaltrials.gov], identifier [NCT03329807].

Keywords: neurological rehabilitation; occupational therapy; physical therapists; rTMS; somatosensory cortex; stroke.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 de Freitas Zanona, Romeiro da Silva, do Rego Maciel, Gomes do Nascimento, Bezerra da Silva, Bolognini and Monte-Silva.

Figures

FIGURE 1
FIGURE 1
CONSORT flowchart of the study. BBT, Box and Block test; FIM, Functional Independence Measure; FMA-Motor, upper limb Fugl-Meyer for motor function; FMA-Sensory, upper limb Fugl-Meyer assessment for sensory function; JTT, Jebsen-Taylor Hand Function Test; MAL, Motor Activity Long test;. NSA, Nottingham Sensory Assessment; SS, Sensory Stimulation. rTMS, repetitive Transcranial Magnetic Stimulation.
FIGURE 2
FIGURE 2
Demonstration of the therapeutic environment of repetitive transcranial magnetic stimulation (rTMS) and sensory stimulation. M1, primary motor cortex; S1, primary somatosensory córtex. Participants who were part of the active rTMS/SS group received 20 min of rTMS over S1 followed by the active sensory training: the participant has to haptically explore different textures of familiar objects and to recognize their different characteristics. First with both hands (intramodal calibration) and eyes open (cross-modal calibration) then using only the affected hand and eyes closed (Carey et al., 2011). Firstly, we required to explore the object with eyes closed and both hands, then with only the affected hand and eyes closed. The final part of the training consisted in Mirror Therapy in addition to transcutaneous electrical nerve stimulation (TENS). (A) rTMS on S1, 20 min. (B) Active sensory training, 20–25 min. (C) Mirror therapy/TENS, 40–45 min.
FIGURE 3
FIGURE 3
Proportion of subjects who reached the minimal clinically important difference (MCID) for each group. *p-value < 0.05 Chi square. BBT, Box and Block Test; FMA-Sensory, upper limb Fugl-Meyer assessment for sensory function; FMA-Motor, upper limb Fugl-Meyer assessment for motor function; FIM, Functional Independence Measure; MAL, Motor Activity Log; QOM, the quality of upper limb movement of Motor Activity Long test; MAL-AOM, amount of upper limb movement of Motor Activity Long test. SS, sensory stimulation; rTMS, repetitive transcranial magnetic stimulation.

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