INFLUENCE OF TRANSCRANIAL DIRECT CURRENT STIMULATION ON ENHANCEMENT OF HAND FUNCTION IN STROKE PATIENTS

Transcription

1 INFLUENCE OF TRANSCRANIAL DIRECT CURRENT STIMULATION ON ENHANCEMENT OF HAND FUNCTION IN STROKE PATIENTS Thesis Submitted In Partial Fulfillment for the Requirement Of Master Degree in Physical Therapy By BASMA HUSSIEN MOHAMED B.Sc. in Physical Therapy Department of Physical Therapy for Neuromuscular Disorder and its Surgery Prof. Dr. MAGDY AHMED ARAFA Professor of Physical Therapy For Neuromuscular Disorders and its Surgery Vice Dean for Environmental Affairs and the Community Development Faculty of Physical therapy Cairo University. SUPERVISORS Dr. HATEM ANWAR EL MASRY Assist prof of Neurology,for Department of Neurology Faculty of Medicine Bane Sawef University. Faculty of Physical Therapy Cairo University 2012

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3 Acknowledgement First and above all, I pray thanking ALLAH for his blessing giving me the patience and effort to complete and achieve this work. and It is a great pleasure to express my deepest sincere appreciation and gratitude to prof. Dr. MAGDY AHMED ARAFA, Professor of Physical Therapy, Neuromuscular Disorders and its Surgery Department, Cairo University, for his valuable supervision and kind advices.he gave me a great deal of his valuable time and effort.his mastery advice, constructive criticism and continuous support that enable me to achieve this work. I would like to acknowledge Dr. HATEM ANWAR EL MASRY, Assistant professor of Neurology, Faculty of medicine, Bane Sawef University, for his supervision, valuable instruction, careful reading and unlimited encouragement throughout the whole work from the beginning to the end. I am greatly honored to express my deepest thanks to my subjects for their co- operation and patience. I

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5 Influence of Transcranial Direct Current Stimulation on Enhancement of Hand Function in Stroke Patients/Basma Hussein Mohamed; Supervisors: Prof. Dr. Magdy Ahmed Arafa, Professor of Physical Therapy for Neuromuscular Disorders and its Surgery, Faculty of Physical Therapy, Cairo University; Dr. Hatem Anwar EL Masry, Assistant proffessor of Neurology, Faculty of Medicine, Bane Sawef University ;Master thesis ABSTRACT The Purpose: Of this study to assess the effect of transcraial direct stimulation on enhancing recovery of paretic hand in stroke patients. Subjects: Thirty stroke subjects (both males and females) with hand function problems, their age ranges from years participated in the study. Methods: Subjects were divided into two equal groups: Group A was treated with transcranial direct current stimulation in combination with selective physical therapy program; Group B was treated with selective physical therapy program only. The hand function was assessed by hand Dynamometer, Jebsen Taylor hand function Test and Modified Asthworth scale.measurements was performed pretreatment and post treatment. The protocol was 3days/weeks for successive 6 weeks.results: Our studying showed significant difference between the two groups concerning the power grip and hand spasticity but showed no significant differences in Jebsen hand function test. Conclusion: Transcranial direct current stimulation with selective hand exercises help in improve the hand function activities. Key Words Transcrainal direct current stimulation, hand function, stroke. II

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7 Contents Acknowledgment I Abstract... II List of tables. V List of figures VI List of abbreviations VII Chapter (I): INTRODUTION..1 I - Statement of the problem.2 II-Purpose of the study:..2 III - Significance of the study..3 V - Delimitations.4 VI - Limitations...4 Chapter (II): LITERATURE REVIEW. 5 I-Cerebral vascular accident 5 II-Normal hand function..5 III-Normal grip and Pinch strength.7 IV-Evaluation of the hand..10 V-Neurologically Mediated Impairment of the hand following 12 VII-Trans Direct Current Stimulation 15 Chapter (III): MATERIALs AND METHODES..29 Chapter (IV): RESULTS..48 Chapter (V): DISCUSSION.62 Chapter (VI): SUMMARY AND CONCLUSION.68 Summary 68 Conclusion.69 Recommendations.70 References 71 Arabic summary 86 III

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9 LIST OF FIGURES FIGEUR NAME Page 1. Hand anatomy Non invasive brain stimulation Depolarization and hyper polarization of pyramidal 24 cells. 4. The Jamar adjustable hand dynamometer Galvanic stimulation apparatus Procedure of power Grip Evaluation. 7. Turning card Small objects task Stimulated feeding task Stacking checkers task Picking up large light objects Picking up large objects task Anterior-posterior mid line Eye-brow line Location of upper and lower point of motor area line Location of hand area at 2/5 of Motor area line Anodal tdcs Frequency distribution of the affected side and the 46 cause of the lesion in both groups (A and B). 19. Changes in the mean values of power grip strength of the affected side pre and post treatment in-group (B). 20. Changes in pre and post treatment mean values of 49 power grip strength in both groups (A & B). 21. Changes in pre and post treatment mean values of 51 grades of spasticity of hand flexors in-group (A). 22. Changes in pre and post treatment mean values of the 52 grades of spasticity of long flexors hand muscle in - group (B). 23. Comparison of pre and post treatment means values of 53 grades of spasticity of hand flexor between groups (A and B). 24. Change in pre and post treatment mean values of the of 54 functional capabilities of the hand within group (B) 25. Comparison of pre and post treatment mean values of the hand functional activities between group A and B. 55 IV

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11 LIST OF TABLES TABLE NAME Page 1. Adult Data for Lafayette Model Dynamometer 8 Averages of Grip Strength in kg. 2. Average force of the power and precision grip in persons with equal representation of both sexes in kg forces (Wynn Parry 1981). 3. Variation of the force of the power grip according to 9 age in kg. 4. Average electrode current density according to 21 electrode size. 5. Modified Ashworth Scale General characteristics of patients in both groups 47 (A&B). 7. Frequency distribution of the affected side and cause of 49 lesion in both groups (A & B) 8. Changes in pre and post treatment mean values of 51 power grip strength of the affected side in group (A). 9. Changes in pre and post treatment mean values of 52 power grip strength of the affected side in group (B). 10. Comparisons of pre and post treatment mean values of 53 power grip strength of the affected side. 11. Changes in pre and post treatment mean values of the 54 grades of spasticity of hand in group (A). 12. Changes in pre and post treatment mean values of the 55 grades of spasticity of hand in group (B). 13. Comparison of the mean values of grades of spasticity 56 pre and post treatment between groups A and B 14. Changes in the mean values of the functional 57 capabilities of the hand pre and post treatment in group (A). 15. Change in pre and post treatment mean values of the of 66 functional capabilities of the hand in group (B) 16. Demonstrates the comparison of the mean values Comparison of pre and post treatment mean values of the hand functional activities between group (A and B). 68 V

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13 List of abbreviations ADL : Activities of daily living CIMT : Constraint induced movement therapy CNS : Central nervous system DC : Direct current FMRI : Functional magnetic resonance imaging MEPs : Motor Evoked Potentials JTT : Jebsen Taylor hand-function test M1 : Primary motor cortex NMDA: N-methyl-D-aspartate tdcs : Transcranial direct current stimulation TMS : Transcranial magntic stimulation ROM : Range of motion VI

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15 Chapter I Introduction

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17 CHAPTER I INTRODUCTION Stroke is defined as an interruption of the blood supply to any part of the brain. This occurs when a blood vessel transporting blood, and oxygen, to the brain is blocked by a blood clot (ischemic stroke) or when a blood vessel is damaged, causing blood to leak out into the brain (hemmorhagic stroke) (Darling,2011). Cerebro vascular accident is a sudden disturbance of brain function resulting from an interference with the blood supply to the brain or brain hemorrhage (Richard,2001).Stroke is a major cause of mortality and morbidity in elderly people (Ramnemark and Gustafsan,2000). Stroke is the most common neurological disorder that represents a major cause of disability. It is the significant health problem that needs an extensive and continuous rehabilitation (Dally and Ruff, 2000). Clinically, a number of defects are possible after stroke, including impairments of motor, sensory and perceptual functions. Motor deficits are characterized by paralysis or weakness on the side of the body opposite to the side of the lesion (O'sullivan and Schmitz, 1994). Stroke affects almost 1 million subjects in the European community each year. While most patients regain walking ability, a severe upper limb paresis with no volitional hand and finger activity, affecting a third of stroke survivors, has a poor prognosis. (Kamper, 2003). Stroke is the main cause of long-term disability among adults in industrialized countries, and is responsible for2 4% of total health-care expenses More than 60% of stroke survivors suffer from persistent neurological deficits that impair activities of daily living (i.e. dressing, eating, self-care and personal hygiene) (Nudo, 2003). 1

18 Impaired hand functions among the most frequently persisting consequences of stroke paralysis of the hand or upper limb occurs acutely in up to 87% of all stroke survivors. (Lai et al., 2002). Trans cranial direct current stimulation (tdcs) is a non invasive, painless cortical stimulation technique that is well tolerated, does not elicit auditory or somatosensory perceptions beyond the initial minute of application. (Paulus, 2001). Anodal Trancranial direct current stimulation (tdcs) of the lesioned primary motor cortex in patients with chronic stroke results in an improvement in the distal motor skill as measured by the Jebsen Taylor Hand Function Test. (Hummel et al., 2007). Transcranial direct-current stimulation is a procedure used to polarize brain regions through the non-invasive application of weak direct currents. Anodal transcranial direct current stimulation of the human motor cortex enhances the cortical excitability, which is caused by neuronal depolarization. (Wassermann, 2005). This study investigates the effect of transcranial direct current stimulation on the motor area to enhancement the hand function in stroke patients. I. Statement of the problem: Is transcranial direct current stimulation has an effect on motor function of the paretic hand in stroke patients? II. Purpose of the study: To study the effect of transcraial direct stimulation on enhancing recovery of paretic hands in stroke patients. 2

19 III. Significance of the study: Recovery of motor function after stroke is typically incomplete. Twothirds of stroke patients are unable to take part in activities of daily living with their paretic hand to the extent; they were before and only a few are able to carry out professional work. Modulation of excitability in motor regions of affected hemisphere by transcranial direct current stimulation may contribute to improvements in motor function of paretic hand. There were many procedures used to improve the paretic hand but the Transcranial direct current stimulation (tdcs) is a portable, safe, noninvasive, brain stimulation technique and a powerful method to facilitate the hand function. It remains a desirable goal to develop strategies to improve the beneficial effects of neuro rehabilitative treatments. IV. Subjects: The intake criteria for selection of subjects: All patients had a cereber vascular accident. All of them were three months at least since the time of stroke onset at the start of treatment program. All of them should be free of unstable medical conditions, or any illness that may increase the risk of stimulation, e.g., neurological diseases such as epilepsy or acute eczema on the placed electrodes The study done in Bane Sawef University Hospital.The patients were classified into two groups: each group consisted of fifteen subjects with equal representation from both sexes. 3

20 Group A (Study group): The study group included 15 hemipartic patients from both sexes. Those patients received transcranial direct current stimulation in combination with selective physical therapy program. Group B (Control group): The Control group included 15 hemipartic patients from both sexes.those patients received the selective physical therapy program only. V. Delimitations: 1-Thirty stroke patients from both sex with age ranged from 40 to 60 years. 2-The duration of illness more than three months and less than six months. 3-The patients had practice no function of hand. VI. Limitations: 1-Physical and psychological status of the patients may affect the treatments. 2-Personal and individual differences between patients and their effect on the treatment outcome. VII. Hypotheses: There is no significant effect of transcranial direct current stimulation of motor region in the affected hemisphere on paretic hand in stroke. VIII. Basic assumptions: The following assumptions were assumed for development of this study: 1- All subjects will exert their maximum efforts during the study. 2- The calibration of the equipments that will be used in this study must be precise and insured to minimize any source. 4