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© Borgis - New Medicine 2/2011, s. 52-56
*Madalina Cosmulescu1,2, Orest Bolbocean1, Georgiana Mazilu1, Karol Borzecki2, Cristian Dinu Popescu1
The use of Transcranial Magnetic Stimulation and Thermography in the examination of patients with Multiple Sclerosis
1University of Medicine and Pharmacy “Gr. T. Popa” Iasi, Romania, PhD-program
2South Tees University Hospitals NHS Trust, York Hospitals NHS Trust, UK
The majority of patients with Multiple Sclerosis have motor dysfunction from the early onset of the disease. Both acute presentations and subsequent relapses of the disease contribute to the worsening of the motor deficits that can develop into quadriplegia. Quantification of the deficits is performed using EDSS scale (1, 7) which can quantify the gait deficits among other parameters.
Aim. The present study looked at the variability of both cortical and peripheral latencies on a group of RRMS patients at rest and after exercise on an ergonomic bicycle.
Material and methods. Furthermore the thermography investigation was performed by looking at the tissue located in posterior lodge of the calf back before and after exercise.
Results. The results found were that the shortening of the cortical latency after completion of physical activities was associated with a low temperature of the tissue.
Conclusions. Physical therapy improves at least transiently the motor cortex excitability as well as the velocities of the nervous impulse. Heat loss can be related to partial involvement of the motor units in the muscle contraction but also to the exaggerated losses by altering the sympathetic tone (10, 12).
Multiple sclerosis is a disease of young adults characterized by an association of impaired pyramidal, cerebellar, brain stem, visual, sensory, neuropsychological and bladder dysfunctions. Motor dysfunction is present in approximately 42% of patients (1), amplified along with evolution of the disease. Worsening can occur both as the consequence of the sequence of outbursts that adds new deficits but also in the primary progressive type. The deficits are quantified using EDSS scale, also known as the Kurtzke scale (1, 7). Paradoxically the patient identifies the upper limb motor deficits later, due to initial complaints of gait. The severity of motor dysfunction can be assessed by pyramidal functional system score (FS-P), which also influences the EDSS result (2, 8). Minor motor deficits correspond to FS grade 2, mild or moderate paraparesis, hemiparesis, monoparesis fall in FS grade 3. Tetraparesis, hemiparesis, paraparesis or monoplegia are rated with FS grade 4. Score 5 corresponds to the functional motor paraplegia, hemiplegia and tetraparesis. FS grade 6 is attributed to tetraplegia. There is a correlation between EDSS and motor functional system score. EDSS value is achieved by the maximum value of at least one FS parameter.
A patient who has a functional system score of 2 finds hard to walk the same distance in the usual time without having an obvious disability.
Demyelinating disease of the central motor neurons produces a disruption of nerve impulse transmission reflected in motor evoked potential (MEP) obtained with the use of transcranial magnetic stimulation (TMS) (3, 8, 11). Another ongoing hypothesis is linked to the fact that some motor units will not be involved in voluntary muscle contractions because of the central motor neurons’ pathology. In turn, muscle contraction generates heat that is removed at least in part by the circulatory system and is subsequently modulated according to thermoregulatory mechanisms.
Materials and Methods
A group of 12 patients with RRMS (relapsing/remitting multiple sclerosis) was studied: 4 men and 8 women aged between 20 and 48 years. MEP parameters obtained from the patients examined were compared with those measured in a group of 18 healthy volunteers aged between 20 and 50 years. Patients were examined using TMS (3, 8, 11) single pulse type in order to obtain central, cervical and lumbar latency values. The device used was a Magstim Rapid type capable of generating a magnetic field of 1.2 Tesla, produced in 2007 with an eight-shaped magnet of 7 cm in diameter. The magnet was placed both on the cortical projection of hand anatomy, but also with an angulation required to stimulate the medial cortex, a corresponding representation of the leg. For MEP registration, surface electrodes were used, placed in the first interosseous space for the adductor halucis longus muscle and the anterior tibial muscle. After recording the cortical latencies, stimulations were performed at the C7 root and L5 root with the same butterfly-shaped coil placed latero-dorsally, both on the right and on the left side. The same surface electrodes were used to record cervical and lumbar latency. Taking the difference between the central and peripheral latencies we have calculated separately the CMCT (4, 6, 9) for the upper and lower limb. This type of investigation was conducted before and after bicycle ergometer exercise performed for a total time of 5 minutes.
A thermal camera FLIR A320 type was used on the examined skin areas, with individual setting of heat emission and automatic correction of the reflected temperature, distance and relative humidity. The color code is blue, green, yellow, red and white, where blue color is the coldest and white, the warmest area. The thermal parameters of the posterior calf tissues were registered both before and after the exercise.
The control group (3) was composed of five healthy volunteers (2 men and 3 women) aged between 20 and 30 years, using the same investigation protocol as patients with MS. Statistical analysis of results was performed using STATISTICA 6.0 (StatSoft Inc.,USA) software package. Results are presented as mean values and standard deviation (M ± sd). Results were considered statistically significant at 5% (p < 0.05).
Table 1. Mean and Standard deviation of MEP parameters obtained in healthy volunteers and patients with MS – before exercise.
|MEP Parameters||Volunteers||MS-Patients||p (student T test)|
|Cortical Latency upper limb (ms)||21.18 ± 1.08||24.18 ± 3.620||0.003|
|Cervical Latency (ms)||12.96 ± 1.22||12.12 ± 1.640||0.09|
|CMCT upper limb (ms)||8.35 ± 1.05||11.41 ± 3.600||0.006|
|Cortical Latency lower limb (ms)||27.5 ± 1.68||35.5 ± 10.96||0.006|
|Lumbar Latency (ms)||11.66 ± 1.93||12.67 ± 1.540||0.07|
|CMCT lower limb (ms)||15.83 ± 2.29||22.82 ± 10.19||0.008|
Table 2. Mean and Standard deviation of MEP parameters obtained in healthy volunteers and patients with MS – after exercise.
|Cortical Latency upper limb (ms)||21.18 ± 1.08||22.85 ± 3.31|
|Cervical Latency (ms)||12.96 ± 1.22||11.35 ± 1.63|
|CMCT upper limb (ms)||8.35 ± 1.05||11.44 ± 3.58|
|Cortical Latency lower limb (ms)||27.5 ± 1.68||34.31 ± 11.57|
|Lumbar Latency (ms)||11.66 ± 1.93||12.52 ± 1.79|
|CMCT lower limb (ms)||15.83 ± 2.29||21.66 ± 10.74|
In patients with Multiple Sclerosis, recorded results were increased in all MEP parameters obtained with the use of transcranial magnetic stimulation (8). No significant changes were reported in peripheral cervical and lumbar latencies.
Statistically significant changes were noted in terms of both cortical latency and CMCT for the upper and lower limbs in MS patients compared to the healthy volunteers.
As expected, the largest changes in CMCT (4, 6, 9) were found by measuring the differences between cortical and the lumbar latencies.
After practicing the exercise bicycle ergometer for 5 minutes there were no statistically significant changes in MEP parameters both in healthy volunteers and patients with MS, although there were slight decreases in the initial lag time.
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