Effect of Motor Relearning Combined with tDCS on Motor Function of Lower Extremities and Gait in Patients with Cerebral Infarction and 3D Gait Analysis

Jing XU, Su ZHENG*, Yuanhong XU, Lili JI, Chao QUAN

Department of rehabilitation medicine，Taihe Hospital (Hubei University of Medicine), Shiyan 442000, China

Abstract [Objectives] To observe the effect of motor relearning combined with transcranial direct current stimulation on the motor function of lower extremities in patients with cerebral infarction, and to observe its effect on gait by 3D gait analysis. [Methods] 60 patients with cerebral infarction who met the inclusion criteria were randomly divided into 3 groups according to the order of treatment (n=20). Group A received motor relearning treatment, group B received transcranial direct current stimulation treatment, group C received motor relearning combined with transcranial direct current stimulation, and the curative effect was observed after 5 courses of treatment. [Results] Before treatment, FMA, MBI, spatio-temporal parameters for 3D gait analysis (gait frequency, gait cycle, stride length, gait speed, stride length deviation, double support) and lower limb joint motion parameters (affected side stride length, maximum hip flexion, maximum hip extension, maximum knee flexion, maximum knee extension, stance phase, swing phase) were compared among the three groups. After treatment, the FMA and MBI of the three groups increased, and the spatio-temporal parameters for 3D gait analysis (gait frequency, gait cycle, gait speed, double support) and the lower limb joint motion parameters (affected side stride length, maximum hip flexion, maximum hip extension, maximum knee flexion, swing phase) were all improved, while the spatio-temporal parameters (stride length and stride length deviation) and the lower limb joint motion parameters (maximum knee extension and stance phase) decreased. Compared with those before treatment, there were significant differences among the three groups (P<0.05). Through the comparison between groups, it was found that the FMA, MBI, spatio-temporal parameters for 3D gait analysis (gait frequency, gait cycle, gait speed, double support) and lower limb joint motion parameters (affected side stride length, maximum hip flexion, maximum hip extension, maximum knee flexion, swing phase) in group C were significantly higher than those in group A and B, while the spatio-temporal parameters (stride length and stride length deviation) and lower limb joint motion parameters (maximum knee extension and stance phase) in group C were significantly lower than those in group A and group B, and the difference was statistically significant (P<0.05). [Conclusions] Motor relearning combined with transcranial direct current stimulation could increase MBI and FMA, improve gait spatio-temporal parameters and lower limb joint motion parameters, and correct abnormal gait in patients with cerebral infarction.

Key words Motor relearning, Transcranial direct current stimulation, Cerebral infarction, Lower extremities, Motor function, 3D gait analysis

1 Introduction

Cerebral infarction is a common clinical cerebrovascular disease, and it has the characteristics of high mortality, high incidence, high recurrence rate, high disability rate, multiple complications and so on. The incidence of cerebral infarction has increased by 8.3% per year in the middle-aged and elderly population in China. It has gradually become one of the diseases that seriously endanger people’s health and life safety[1]. With the progress of modern medicine, the mortality rate of patients has decreased slightly, but many surviving patients have varying degrees of dysfunction, dominated by lower limb dysfunction. The recovery degree of the dysfunction seriously affects the patients’ ability of walking and daily living[2]. Motor relearning therapy is a kind of exercise therapy, and it mainly promotes the reorganization of brain function through repeated movement training. It has gradually become one of the important methods to improve patients’ motor function and daily living ability in the field of rehabilitation medicine. 3D gait analysis uses 3D gait analyzer to quantitatively and accurately analyze the spatio-temporal and kinematic parameters of patients’ walking, and objectively evaluate the patients’ walking ability. It has gradually become the "gold standard" for gait evaluation of hemiplegic patients with cerebral infarction[4]. The purpose of this study was to investigate the effect of motor relearning combined with transcranial direct current stimulation (tDCS) on lower limb function in patients with cerebral infarction, and its effect on gait in patients with cerebral infarction was evaluated by 3D gait analyzer.

2 Clinical data and methods

2.1 Clinical data60 patients with cerebral infarction who were hospitalized in the rehabilitation center from January 2019 to December 2020 and met the inclusion criteria were randomly divided into motor relearning group (n=20), tDCS group (n=20) and motor relearning+tDCS group (n=20). Motor relearning group was marked as group A, tDCS group as group B, motor relearning+tDCS group as group C. There was no significant difference in the general data among the three groups (P>0.05), as shown in Table 1.

Table 1 Comparison of general data of three groups of patients

2.1.2Diagnostic criteria. Patients with cerebral infarction were confirmed by MRI or CT and were in accordance withChineseDiagnosticGuidelineforAcuteCerebralIschemicStroke(2014)[5].

2.1.3Inclusion criteria. Those who met the diagnostic criteria and did not undergo systematic rehabilitation treatment for the first time, and suffered from lower limb paralysis; those aged between 40 and 60; those with stable condition, no progress or aggravation; patients with a course of disease greater than or equal to 1 month and less than 5 months; those without cognitive and speech impairment; patients who voluntarily participated in the treatment of this program with and informed consent, and approval by the Medical Ethics Committee of Taihe Hospital of Shiyan City.

2.1.4Exclusion criteria. Patients with cardiovascular diseases including coronary heart disease, myocardial infarction or other serious diseases such as tumors; those with lower limb rheumatoid arthritis, knee osteoarthritis or joint spasm that affect motor relearning and training.

2.2 MethodsAll patients were given corresponding support and symptomatic treatment in the department of neurology, and this program was given after no progress or new disease.

2.2.1Motor relearning. Refer to theCodeofPracticeforCommonRehabilitationTechniques(2012Edition). The main contents include: from lying position to bedside training (basic movement components of sitting up, analysis of normal turning over and sitting movements,etc.), standing balance training (basic movement components of standing balance, analysis of normal standing balance movements), sitting position balance training (basic movement components of sitting position balance, functional movement analysis of normal sitting position balance,etc.), standing up and sitting down training (basic movement components of standing up and sitting down, normal standing up and sitting movement analysis), walking training (basic movement components of walking, normal walking movement analysis,etc.). Once a day, training 40 min each time, 6 d a week for a course of treatment, a total of 5 courses of treatment.

2.2.2Transcranial direct current stimulation[6]. The anode of transcranial direct current stimulation was placed on the M1 area of the affected side of the patients with cerebral infarction and the cathode was placed on the contralateral forehead. The current intensity was 2.0 mA, the time was 20 min, once a day, 6 d a week as a course of treatment, a total of 5 courses of treatment.

2.2.3Grouping. Group A received motor relearning, group B received transcranial direct current stimulation, and group C received motor relearning combined with transcranial direct current stimulation. The curative effect was observed after a total of 5 courses of treatment.

2.2.4Evaluation of rehabilitation function. Lower limb motor function was evaluated by lower limb FMA score[7], ability of daily living was evaluated by MBI[8], body control ability was evaluated by TCT[9].

2.2.53D gait analysis[10]. GaitWatch gait analyzer (produced by Zhanghe Company) was used to evaluate the spatio-temporal parameters and lower limb joint motion parameters of patients before and after treatment.

3 Results and analysis

3.1 Comparison of FMA and MBI scores among the three groupsTable 2 showed that there was no significant difference in FMA and MBI among the three groups before treatment (P>0.05). After treatment, the FMA and MBI of the three groups were increased, and there were significant differences in group A, group B and group C compared with those before treatment (P<0.05). After treatment, FMA and MBI in group C were significantly higher than those in group A and group B, and the difference was statistically significant (P<0.05).

Table 2 Comparison of FMA and MBI scores among the three groups of patients points)

3.2 Comparison of spatio-temporal parameters among the three groups of patientsAs can be seen from Table 3, there was no significant difference in the spatio-temporal parameters (gait frequency, gait cycle, stride length, gait speed, stride length deviation and double support) among the three groups before treatment (P>0.05). After intervention treatment, the gait frequency, gait cycle, gait speed and double support of the three groups were all increased, and the stride length and stride length deviation were all decreased. Compared with those before treatment, there were significant differences among the three groups (P<0.05). After treatment, the gait frequency, gait cycle, gait speed and double support in group C were significantly higher than those in group A and group B, and the stride length and stride length deviation in group C were significantly lower than those in group A and group B (P<0.05).

Table 3 Spatio-temporal parameters of three groups of patients

3.3 Comparison of lower limb joint motion parameters among the three groupsTable 4 showed that there was no significant difference in lower limb joint motion parameters (affected side stride length, maximum hip flexion, maximum hip extension, maximum knee flexion, maximum knee extension, stance phase, swing phase) among the three groups before treatment (P>0.05). After intervention treatment, the affected side stride length, maximum hip flexion, maximum hip extension, maximum knee flexion, swing phase of the three groups were all increased, while the maximum knee extension and stance phase were decreased. Compared with those before treatment, there were significant differences among the three groups (P<0.05). After treatment, the affected side stride length, maximum hip flexion, maximum hip extension, maximum knee flexion and swing phase in group C were significantly higher than those in group A and group B, while the maximum knee extension and stance phase in group C were significantly lower than those in group A and group B (P<0.05).

Table 4 Three groups of lower limb joint motion parameters

4 Discussion

Cerebral infarction is the necrosis or softening of brain tissue caused by cerebral blood supply disorder due to various reasons, and unilateral limb and facial dysfunction often occurs clinically[11]. In the functional disorders of patients with cerebral infarction, lower limb dysfunction is a common clinical complication, which will increase the risk of fall, affect the patients’ ability of walking and daily life, and cause a heavy burden to the family and society[12]. Therefore, the effective improvement and recovery of lower limb function in patients with cerebral infarction plays an important role in rehabilitation medicine[13]. Studies have shown that the reorganization of neural mechanism is one of the important reasons for the functional recovery of patients with cerebral infarction, and it is an important basis of rehabilitation treatment[14].

3D gait analysis is a kind of motion evaluation technology, which can comprehensively analyze the kinematics and dynamics of gait according to the 3D gait analysis system, and can analyze the gait accurately and objectively. It has been widely used in rehabilitation. At the same time, 3D gait analyzer can also help rehabilitation doctors to master and evaluate the condition and therapeutic effect. Therefore, in this experiment, motor relearning combined with transcranial direct current stimulation was used to treat patients with cerebral infarction, its effect on the function of lower limbs was observed, and 3D gait analysis was used to accurately and objectively evaluate the gait of patients before and after treatment. This study showed that after treatment, FMA and MBI in group C were significantly higher than those in group A and group B (P<0.05). Using the 3D gait analyzer, it was found that the gait frequency, gait cycle, gait speed and double support in group C were significantly higher than those in group A and group B, and the stride length and stride length deviation in group C were significantly lower than those in group A and group B. The difference was statistically significant (P<0.05). The affected side stride length, maximum hip flexion, maximum hip extension, maximum knee flexion and swing phase in group C were significantly higher than those in group A and group B, while the maximum knee extension and stance phase in group C were significantly lower than those in group A and group B (P<0.05). The results showed that motor relearning combined with transcranial direct current stimulation could improve the motor function and activities of daily life of patients with cerebral infarction, correct and improve the spatio-temporal parameters of gait and lower limb joint motion parameters. The 3D gait analyzer could objectively and accurately evalu-ate the abnormal gait, and could be regarded as a method to evaluate and diagnose the gait of hemiplegic patients with cerebral infarction.