The effect of sensory-motor training on brain activation and functional recovery in chronic stroke survivors

Zastron, Tania (2018-10)

Thesis (PhD)--Stellenbosch University, 2018.

Thesis

ENGLISH ABSTRACT: Introduction: Functional loss is greatly determined by postural control impairment in chronic stroke survivors causing reduced ability to execute activities of daily living, impaired mobility and increases the risk of falling. It is known that the basal ganglia network play an important role in postural control, however the effect of sensory-manipulated balance training on structural connectivity in chronic stroke survivors remains unknown. Objective: To assess the influence of sensory-manipulated balance training, i.e. sensory-motor training (SMT), on structural connectivity and functional recovery in chronic stroke survivors. Study design: Double-blind randomised controlled trial. Methods: Twenty-two individuals with chronic stroke (≥6 months post-stroke) were randomly divided into two groups, namely the sensory-motor training (SMT; n = 12) and attention-matched control group (CON; n = 10). The SMT group participated in task-specific balance training, which focused on manipulating the visual, vestibular and somatosensory systems, three times a week for 45 to 60-minute sessions, over an eight-week period. The CON group attended educational talks regarding various lifestyle topics for the same duration as the SMT group. Both interventions were delivered by experienced clinical exercise therapists and were executed in a group setting. Primary outcome measures included changes in structural connectivity strength (diffusion tensor magnetic resonance imaging (MRI) scan), postural sway and sensory dependency (modified Clinical Test for Sensory Interaction and Balance (m-CTSIB), as well as functional mobility (Timed-Up and Go (TUG). Structural connectivity strength was specifically investigated between the twosubcortical basal ganglia nuclei, caudate and lentiform nucleus, with other regions of interest. Furthermore, the m-CTSIB and TUG tests were executed with APDM’s Mobility LabTMbody-worn inertial sensors. Secondary outcome measures were health-related quality of life (Short Form Health Survey (SF-36)) and fall efficacy (Fall Efficacy Scale - International (FES-I)). Participants were tested pre- and post-intervention. Results: Diffusion tensor MRI results showed interaction effects for increased connectivity strength between the basal ganglia and sensory-motorfronto-parietal areas in the SMT group (n = 5; p<0.05), where as the CON group (n = 4 ) presented increased structural connectivity in the higher cognitive orbitotemporal and frontal lobe areas (p<0.05). For the behavioural outcome measures, interaction effects were found for turning performance(p = 0.02), perceived physical functioning (p = 0.005) and fall efficacy (p= 0.03). Moreover, the SMT group (n = 12) showed improved postural sway when standing on a foam pad with eyes open (p = 0.04, ES = 0.61M, 95% CI= -0.27 to 1.36), reduced somatosensory dependence (p = 0.02, ES = 0.63M,95% CI = -0.24 to 1.40), improved turning performance (p≤0.05) as well as improvements in perceived physical (p = 0.01, ES = 0.52M, 95% CI = -0.33to 1.29) and social functioning (p = 0.02, ES = 1.03L, 95% CI = 0.11 to 1.80)after participating in the SMT programme. Lastly, a group difference wasobserved for perceived physical (p = 0.003, ES = 0.90L, 95% CI = -0.05 to1.70) and social functioning (p = 0.02, ES = 1.01L, 95% CI = 0.04 to 1.81) at post-intervention. Conclusions: This study highlights postural control-related improvements induced by SMT, which may be associated with structural connectivity changes in chronic stroke survivors. Therefore, the preliminary results support the notion that the human brain has the ability to undergo activity-dependent neuroplasticity.

AFRIKAANSE OPSOMMING: Inleiding: Funksionele verlies word grootliks bepaal deur aantasting van postuurbeheer in individue met kroniese beroerte, wat veroorsaak dat die vermoë om alledaagse aktiwiteite uit te voer verswak, mobiliteit aangetas word en valrisiko verhoog. Dit is bekend dat die basale ganglia ’n belangrike rol in postuurbeheer speel, maar die effek van sensories-gemanipuleerde balans-oefening op strukturele konnektiwiteit in individue met kroniese beroerte bly onbekend. Doelwit: Om die invloed van sensories-gemanipuleerde balansoefening, d.i. sensories-motoriese oefening (SMO), op strukturele konnektiwiteit en funksionele herstel te evalueer in individue met kroniese beroerte. Studie ontwerp: Dubbelblind ewekansige gekontroleerde proefneming. Metodes: Twee-en-twintig individue met kroniese beroerte (≥6 maandegelede) is ewekansig in twee groepe verdeel, naamlik die sensories-motorieseoefening (SMO; n = 12) en gelyke-aandag kontrolegroep (KON; n = 10). Die SMO-groep het drie keer per week in 45- tot 60 minuut sessies deelgeneem aan taak-spesifieke balansoefeninge, wat gefokus het op die manipulering van die visuele, vestibulêre en somato sensoriese stelsels oor ’n tydperk van agt weke. Die KON-groep het opvoedkundige praatjies met betrekking tot verskeie onderwerpe oor lewenstyl bygewoon vir dieselfde tydsduur as die SMO-groep. Beide intervensies was deur ervare kliniese oefenterapeute gelewer en in groepsverband uitgevoer. Primêre uitkomstes het die sterkte van strukturele konnektiwiteit (diffusion tensor magnetic resonance imaging (MRI) scan), postuurswaai en sensoriese afhanklikheid (modified Clinical Test for Sensory Interaction and Balance (m-CTSIB)), sowel as funksionele mobiliteit (Timed-Up and Go (TUG)) ingesluit. Die sterkte van strukturele konnektiwiteit was spesifiek ondersoek tussen die twee subkortikale basale ganglia kerne, koudaat en lensvormige kern, met ander areas van belang. Verder was diem-CTSIB en TUG-toetse uitgevoer met APDM se Mobility LabTM traagheidsensors. Sekondêre uitkomstes was gesondheidsverwante lewenskwaliteit (Short Form Health Survey (SF-36)) en valpersepsie (Fall Efficacy Scale - International (FES-I)).Deelnemers was voor- en na-intervensie getoets. Resultate: Diffusion tensor MRI resultate het interaksie effekte vir ver-hoogde konnektiwiteitsterkte tussen die basale ganglia en sensories-motoriesefronto-pariëtale areas in die SMO-groep (n = 5; p<0.05) getoon, terwyl die KON-groep (n = 4) verhoogde strukturele konnektiwiteit in die hoër orbito-temporale- en frontale lobareas (p<0.05) getoon het. Vir die gedragsuitkomste was interaksie effekte gevind vir omdraai-prestasie (p = 0.02), self-waargenome fisiese funksionering (p = 0.005) en valpersepsie (p = 0.03). Verder het die SMO-groep (n = 12) die volgende getoon: verbeterde postuurswaai wanneer daar op ’n sponsmat met oop oë gestaan word (p = 0.04, ES = 0.61M,95% CI = -0.27 to 1.36), verlaagde somatosensoriese afhanklikheid (p = 0.02,ES = 0.63M, 95% CI = -0.24 to 1.40), verbeterde omdraai-prestasie (p≤0.05) sowel as ’n verbetering in self-waargenome fisiese- (p = 0.01, ES = 0.52M,95% CI = -0.33 to 1.29) en sosiale funksionering (p = 0.02, ES = 1.03L,95% CI = 0.11 to 1.80) na deelname aan die SMO-program. Laastens was ’n groepsverskil opgemerk vir waargenome fisiese- (p = 0.003, ES = 0.90L,95% CI = -0.05 to 1.70) en sosiale funksionering (p = 0.02, ES = 1.01L, 95%CI = 0.04 to 1.81) na-intervensie. Gevolgtrekkings: Hierdie studie beklemtoon postuurbeheer verwante verbeteringe wat deur SMO geïnduseer is, en word geassosieer met veranderinge instrukturele konnektiwiteit in individue met kroniese beroerte. Die voorlopige resultate ondersteun daarom die idee dat die menslike brein die vermoë het om aktiwiteits-afhanklike neuroplastisiteit te ondergaan.

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