title: Cortical activation changes and improved motor function in stroke patients after focal spasticity therapy--an interventional study applying repeated fMRI.
abstract: BACKGROUND
  Impaired dominant hand function in stroke patients is a common clinical problem. Functional improvement after focal spasticity therapy is well documented but knowledge about central correlates is sparse. Brain activity was therefore followed during therapy with repeated functional magnetic resonance imaging (fMRI). The purpose was to analyse motor function and central nervous system (CNS) correlates in response to a standardized motor task in stroke patients after a comprehensive focal spasticity therapy.
  
  
  METHODS
  Six consecutive first-time chronic stroke patients [4 women; mean age (SD) 66 (10) years] with right-sided hand paresis and spasticity were studied. Peripheral effects after focal spasticity management including intramuscular botulinum toxin type A (BoNT-A) injections were assessed on 3 occasions (baseline, 6 and 12 weeks) with functional tests. Brain effects were assessed on the same occasions by fMRI blood oxygen level dependent (BOLD) technique during a standardized motor task focusing on the motor and pre-motor cortex (Brodmann areas, BA4a, BA4p & BA6). For reference 10 healthy individuals [5 women; mean age (SD) of 51(8) years], were studied twice with ≥ 6 weeks interval.
  
  
  RESULTS
  After therapy there was a significant reduction in spasticity and functional improvement in 5 of 6 patients. In response to the motor task there was a ~1.5 - 3% increase in brain activity in the motor and pre-motor cortex. At baseline, this increase was larger in the non-injured (ipsilateral) than in the contralateral hemisphere. Compared with healthy subjects the patients showed a significantly (2-4.5 times) higher brain activity, especially on the ipsilateral side. After therapy, there was a larger decrease in the ipsilateral and a minor decrease in the contralateral response, i.e. a clear lateralization of left-to-right in a normalizing direction in all areas.
  
  
  CONCLUSIONS
  Comprehensive focal spasticity management was also in this study associated with brain reorganization in a "normalizing" left/right lateralization direction in addition to improved motor function. Furthermore, quantification of BOLD intensity in specified BAs showed reduced neuronal "over-activity" in the injured brain after therapy.
authors.affiliation: Division of Rehabilitation Medicine, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden. ulla.bergfeldt@vgregion.se.|Present address: Center for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital/Moelndal, House U1, 5th floor, SE- 431 80, Moelndal, Sweden. ulla.bergfeldt@vgregion.se.
authors.forename: Ulla
authors.initials: U
authors.lastname: Bergfeldt
authors.affiliation: SMILE, Stockholm Medical Imaging Laboratory, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden. tomas.jonsson@karolinska.se.|Department of Diagnostic Medical Physics, Karolinska University Hospital Huddinge, Stockholm, Sweden. tomas.jonsson@karolinska.se.
authors.forename: Tomas
authors.initials: T
authors.lastname: Jonsson
authors.affiliation: Department of Molecular & Clinical Medicine/Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. lennart.bergfeldt@gu.se.
authors.forename: Lennart
authors.initials: L
authors.lastname: Bergfeldt
authors.affiliation: Division of Rehabilitation Medicine, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden. per.julin@ki.se.|SMILE, Stockholm Medical Imaging Laboratory, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden. per.julin@ki.se.
authors.forename: Per
authors.initials: P
authors.lastname: Julin
mesh_terms: D000368:Aged; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D001931:Brain Mapping; D003131:Combined Modality Therapy; D005081:Exercise Therapy / Q000379:methods*; D005260:Female; D006225:Hand / Q000503:physiopathology*; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009044:Motor Cortex / Q000503:physiopathology*; D009128:Muscle Spasticity / Q000209:etiology / Q000628:therapy*; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D020521:Stroke / Q000150:complications / Q000628:therapy*; D016896:Treatment Outcome
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A