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Sex Differences in Neuromodulation Treatment Approaches for Traumatic Brain Injury: A Scoping Review. J Head Trauma Rehabil 2020; 35:412-429. [PMID: 33165154 DOI: 10.1097/htr.0000000000000631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Neuromodulatory brain stimulation interventions for traumatic brain injury (TBI)-related health sequelae, such as psychiatric, cognitive, and pain disorders, are on the rise. Because of disproportionate recruitment and epidemiological reporting of TBI-related research in men, there is limited understanding of TBI development, pathophysiology, and treatment intervention outcomes in women. With data suggesting sex-related variances in treatment outcomes, it is important that these gaps are addressed in emerging, neuromodulatory treatment approaches for TBI populations. METHODS Four research databases (PubMED, EMBASE, CINAHL, and PsycINFO) were electronically searched in February 2020. DESIGN This PRISMA Scoping Review (PRISMA-ScR)-guided report contextualizes the importance of reporting sex differences in TBI + neuromodulatory intervention studies and summarizes the current state of reporting sex differences when investigating 3 emerging interventions for TBI outcomes. RESULTS Fifty-four studies were identified for the final review including 12 controlled trials, 16 single or case series reports, and 26 empirical studies. Across all studies reviewed, 68% of participants were male, and only 7 studies reported sex differences as a part of their methodological approach, analysis, or discussion. CONCLUSION This review is hoped to update the TBI community on the current state of evidence in reporting sex differences across these 3 neuromodulatory treatments of post-TBI sequelae. The proposed recommendations aim to improve future research and clinical treatment of all individuals suffering from post-TBI sequelae.
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Mensen A, Bodart O, Thibaut A, Wannez S, Annen J, Laureys S, Gosseries O. Decreased Evoked Slow-Activity After tDCS in Disorders of Consciousness. Front Syst Neurosci 2020; 14:62. [PMID: 33100977 PMCID: PMC7546425 DOI: 10.3389/fnsys.2020.00062] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/28/2020] [Indexed: 12/20/2022] Open
Abstract
Due to life-saving medical advances, the diagnosis and treatment of disorders of consciousness (DOC) has become a more commonly occurring clinical issue. One recently developed intervention option has been non-invasive transcranial direct current stimulation. This dichotomy of patient responders may be better understood by investigating the mechanism behind the transcranial direct current stimulation (tDCS) intervention. The combination of transcranial magnetic stimulation and electroencephalography (TMS-EEG) has been an important diagnostic tool in DOC patients. We therefore examined the neural response using TMS-EEG both before and after tDCS in seven DOC patients (four diagnosed as in a minimally conscious state and three with unresponsive wakefulness syndrome). tDCS was applied over the dorsolateral prefrontal cortex, while TMS pulses were applied to the premotor cortex. None of the seven patients showed relevant behavioral change after tDCS. We did, however, find that the overall evoked slow activity was reduced following tDCS intervention. We also found a positive correlation between the strength of the slow activity and the amount of high-frequency suppression. However, there was no significant pre-post tDCS difference in high frequencies. In the resting-state EEG, we observed that both the incidence of slow waves and the positive slope of the wave were affected by tDCS. Taken together, these results suggest that the tDCS intervention can reduce the slow-wave activity component of bistability, but this may not directly affect high-frequency activity. We hypothesize that while reduced slow activity may be necessary for the recovery of neural function, especially consciousness, this alone is insufficient.
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Affiliation(s)
- Armand Mensen
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Olivier Bodart
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium.,Department of Neurology, University Hospital of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium.,Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States
| | - Sarah Wannez
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Jitka Annen
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium.,Centre du Cerveau2, University Hospital of Liège, Liège, Belgium
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Zhang R, Zhang L, Guo Y, Shi L, Gao J, Wang X, Hu Y. Effects of High-Definition Transcranial Direct-Current Stimulation on Resting-State Functional Connectivity in Patients With Disorders of Consciousness. Front Hum Neurosci 2020; 14:560586. [PMID: 33100996 PMCID: PMC7546763 DOI: 10.3389/fnhum.2020.560586] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 08/26/2020] [Indexed: 12/23/2022] Open
Abstract
Recently a positive treatment effect on disorders of consciousness (DOCs) with high-definition transcranial direct-current stimulation (HD-tDCS) has been reported; however, the neural modulation mechanisms of this treatment’s efficacy need further investigation. To better understand the processing of HD-tDCS interventions, a long-lasting HD-tDCS protocol was applied to 15 unresponsive wakefulness syndrome (UWS) patients and 20 minimally conscious states (MCS) patients in this study. Ten minutes of resting-state electroencephalograms (EEGs) were recorded from the patients, and the coma recovery scale-revised scores (CRS-Rs) were assessed for each patient from four time-points (T0, T1, T2, and T3). Brain networks were constructed by calculating the EEG spectral connectivity using the debiased weighted phase lag index (dwPLI) and then quantified the network information transmission efficiency by graph theory. We found that there was an increasing trend in local and global information processing of beta and gamma bands in resting-state functional brain networks during the 14 days of HD-tDCS modulation for MCS patients. Furthermore, the increased functional connectivity not only occurred in the local brain area surrounding the stimulation position but was also present across more global brain areas. Our results suggest that long-lasting HD-tDCS on the precuneus may facilitate information processing among neural populations in MCS patients.
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Affiliation(s)
- Rui Zhang
- School of Electrical Engineering, Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Brain Science and Brain-Computer Interface Technology, Zhengzhou, China
| | - Lipeng Zhang
- School of Electrical Engineering, Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Brain Science and Brain-Computer Interface Technology, Zhengzhou, China
| | - Yongkun Guo
- The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Li Shi
- Department of Automation, Tsinghua University, Beijing, China.,Beijing National Research Center for Information Science and Technology, Beijing, China
| | - Jinfeng Gao
- School of Electrical Engineering, Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Brain Science and Brain-Computer Interface Technology, Zhengzhou, China
| | - Xinjun Wang
- The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuxia Hu
- School of Electrical Engineering, Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Brain Science and Brain-Computer Interface Technology, Zhengzhou, China
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Martens G, Kroupi E, Bodien Y, Frasso G, Annen J, Cassol H, Barra A, Martial C, Gosseries O, Lejeune N, Soria-Frisch A, Ruffini G, Laureys S, Thibaut A. Behavioral and electrophysiological effects of network-based frontoparietal tDCS in patients with severe brain injury: A randomized controlled trial. NEUROIMAGE-CLINICAL 2020; 28:102426. [PMID: 32977212 PMCID: PMC7511767 DOI: 10.1016/j.nicl.2020.102426] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 08/31/2020] [Accepted: 09/08/2020] [Indexed: 12/31/2022]
Abstract
Behavioral and EEG effects of multifocal frontoparietal tDCS are investigated in patients with severe brain injury. No behavioral treatment effect was identified at the group level while EEG complexity increased in low frequency bands. Electrophysiological changes were not translated into behavioral changes at the group level.
Background Transcranial direct current stimulation (tDCS) may promote the recovery of severely brain-injured patients with disorders of consciousness (DOC). Prior tDCS studies targeted single brain regions rather than brain networks critical for consciousness recovery. Objective Investigate the behavioral and electrophysiological effects of multifocal tDCS applied over the frontoparietal external awareness network in patients with chronic acquired DOC. Methods Forty-six patients were included in this randomized double-blind sham-controlled crossover trial (median [interquartile range]: 46 [35 – 59] years old; 12 [5 – 47] months post injury; 17 unresponsive wakefulness syndrome, 23 minimally conscious state (MCS) and 6 emerged from the MCS). Multifocal tDCS was applied for 20 min using 4 anodes and 4 cathodes with 1 mA per electrode. Coma Recovery Scale-Revised (CRS-R) assessment and 10 min of resting state electroencephalogram (EEG) recordings were acquired before and after the active and sham sessions. Results At the group level, there was no tDCS behavioral treatment effect. However, following active tDCS, the EEG complexity significantly increased in low frequency bands (1–8 Hz). CRS-R total score improvement was associated with decreased baseline complexity in those bands. At the individual level, after active tDCS, new behaviors consistent with conscious awareness emerged in 5 patients. Conversely, 3 patients lost behaviors consistent with conscious awareness. Conclusion The behavioral effect of multifocal frontoparietal tDCS varies across patients with DOC. Electrophysiological changes were observed in low frequency bands but not translated into behavioral changes at the group level.
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Affiliation(s)
- Géraldine Martens
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau2 - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium.
| | | | - Yelena Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA; Laboratory for Neuroimaging in Coma and Consciousness, Massachusetts General Hospital, Boston, MA, USA
| | - Gianluca Frasso
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
| | - Jitka Annen
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau2 - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium
| | - Helena Cassol
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau2 - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium
| | - Alice Barra
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau2 - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium
| | - Charlotte Martial
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau2 - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau2 - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium
| | - Nicolas Lejeune
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium; Centre Hospitalier Neurologique William Lennox, Saint-Luc University Clinics, Université Catholique de Louvain, Belgium
| | | | | | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau2 - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium; Centre du Cerveau2 - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium; Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, USA
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Transcranial magnetic stimulation-evoked connectivity reveals modulation effects of repetitive transcranial magnetic stimulation on patients with disorders of consciousness. Neuroreport 2020; 30:1307-1315. [PMID: 31714484 DOI: 10.1097/wnr.0000000000001362] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Several studies have investigated possible role of repetitive transcranial magnetic stimulation (rTMS) in patients with disorder of consciousness (DOC). But the details of patients' brain responses to the rTMS are yet to be disclosed. The aim of the study is to explore the neural electrical responses of DOC patients to rTMS modulation. DOC Patients [14 vegetative state, seven minimally conscious state (MCS)] and healthy subjects were enrolled and received one session of rTMS. The TMS-electroencephalogram was recorded at before and immediately after rTMS stimulation. TMS-evoked potentials as well as TMS-evoked connectivity were proposed to capture the effective connectivity alteration induced by rTMS. Significant changes of TMS-evoked potential were found in the healthy group but not in DOC patients. TMS-evoked connectivity was significantly enhanced by the rTMS in healthy and MCS groups. In addition, the enhancement was positively correlated with patients' Coma Recovery Scale-Revised scores. Global synchrony of the TMS-evoked connectivity matrix significantly enhanced by rTMS in the control and MCS groups but not in vegetative state patients. Furthermore, after rTMS stimulation, the similarity of TMS-evoked connectivity patterns between pairwise patients was significantly raised in MCS patients. But no significant changes were found in vegetative state patients. TMS-evoked connectivity reveals that rTMS can effectively modulate effective connectivity of MCS patients, but no evidence of changes in vegetative state patients.
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Carrière M, Mortaheb S, Raimondo F, Annen J, Barra A, Binda Fossati MC, Chatelle C, Hermann B, Martens G, Di Perri C, Laureys S, Thibaut A. Neurophysiological Correlates of a Single Session of Prefrontal tDCS in Patients with Prolonged Disorders of Consciousness: A Pilot Double-Blind Randomized Controlled Study. Brain Sci 2020; 10:brainsci10070469. [PMID: 32708119 PMCID: PMC7408434 DOI: 10.3390/brainsci10070469] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/11/2020] [Accepted: 07/17/2020] [Indexed: 11/16/2022] Open
Abstract
Background. Transcranial direct current stimulation (tDCS) over the left dorsolateral prefrontal cortex (lDLPFC) was reported to promote the recovery of signs of consciousness in some patients in a minimally conscious state (MCS), but its electrophysiological effects on brain activity remain poorly understood. Objective. We aimed to assess behavioral (using the Coma Recovery Scale-Revised; CRS-R) and neurophysiological effects (using high density electroencephalography; hdEEG) of lDLPFC-tDCS in patients with prolonged disorders of consciousness (DOC). Methods. In a double-blind, sham-controlled, crossover design, one active and one sham tDCS (2 mA, 20 min) were delivered in a randomized order. Directly before and after tDCS, 10 min of hdEEG were recorded and the CRS-R was administered. Results. Thirteen patients with severe brain injury were enrolled in the study. We found higher relative power at the group level after the active tDCS session in the alpha band in central regions and in the theta band over the frontal and posterior regions (uncorrected results). Higher weighted symbolic mutual information (wSMI) connectivity was found between left and right parietal regions, and higher fronto-parietal weighted phase lag index (wPLI) connectivity was found, both in the alpha band (uncorrected results). At the group level, no significant treatment effect was observed. Three patients showed behavioral improvement after the active session and one patient improved after the sham. Conclusion. We provide preliminary indications that neurophysiological changes can be observed after a single session of tDCS in patients with prolonged DOC, although they are not necessarily paralleled with significant behavioral improvements.
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Affiliation(s)
- Manon Carrière
- Brain2 Clinic, Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; (S.M.); (F.R.); (J.A.); (A.B.); (M.C.B.F.); (C.C.); (G.M.); (C.D.P.); (S.L.); (A.T.)
- Correspondence:
| | - Sepehr Mortaheb
- Brain2 Clinic, Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; (S.M.); (F.R.); (J.A.); (A.B.); (M.C.B.F.); (C.C.); (G.M.); (C.D.P.); (S.L.); (A.T.)
| | - Federico Raimondo
- Brain2 Clinic, Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; (S.M.); (F.R.); (J.A.); (A.B.); (M.C.B.F.); (C.C.); (G.M.); (C.D.P.); (S.L.); (A.T.)
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC Lab, F-75013 Paris, France;
| | - Jitka Annen
- Brain2 Clinic, Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; (S.M.); (F.R.); (J.A.); (A.B.); (M.C.B.F.); (C.C.); (G.M.); (C.D.P.); (S.L.); (A.T.)
| | - Alice Barra
- Brain2 Clinic, Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; (S.M.); (F.R.); (J.A.); (A.B.); (M.C.B.F.); (C.C.); (G.M.); (C.D.P.); (S.L.); (A.T.)
| | - Maria C. Binda Fossati
- Brain2 Clinic, Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; (S.M.); (F.R.); (J.A.); (A.B.); (M.C.B.F.); (C.C.); (G.M.); (C.D.P.); (S.L.); (A.T.)
| | - Camille Chatelle
- Brain2 Clinic, Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; (S.M.); (F.R.); (J.A.); (A.B.); (M.C.B.F.); (C.C.); (G.M.); (C.D.P.); (S.L.); (A.T.)
| | - Bertrand Hermann
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC Lab, F-75013 Paris, France;
- ICU, Hôpital Européen Georges Pompidou, APHP, Université de Paris, F-75013 Paris, France
| | - Géraldine Martens
- Brain2 Clinic, Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; (S.M.); (F.R.); (J.A.); (A.B.); (M.C.B.F.); (C.C.); (G.M.); (C.D.P.); (S.L.); (A.T.)
| | - Carol Di Perri
- Brain2 Clinic, Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; (S.M.); (F.R.); (J.A.); (A.B.); (M.C.B.F.); (C.C.); (G.M.); (C.D.P.); (S.L.); (A.T.)
| | - Steven Laureys
- Brain2 Clinic, Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; (S.M.); (F.R.); (J.A.); (A.B.); (M.C.B.F.); (C.C.); (G.M.); (C.D.P.); (S.L.); (A.T.)
| | - Aurore Thibaut
- Brain2 Clinic, Coma Science Group, GIGA Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; (S.M.); (F.R.); (J.A.); (A.B.); (M.C.B.F.); (C.C.); (G.M.); (C.D.P.); (S.L.); (A.T.)
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Prefrontal cortex transcranial direct-current stimulation putatively enhances electroencephalography classification resolution of binary responses in a minimal conscious state patient. Clin Neurophysiol 2020; 131:2148-2149. [PMID: 32682242 DOI: 10.1016/j.clinph.2020.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 06/18/2020] [Indexed: 11/20/2022]
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Zhang X, Liu B, Li N, Li Y, Hou J, Duan G, Wu D. Transcranial Direct Current Stimulation Over Prefrontal Areas Improves Psychomotor Inhibition State in Patients With Traumatic Brain Injury: A Pilot Study. Front Neurosci 2020; 14:386. [PMID: 32508560 PMCID: PMC7251071 DOI: 10.3389/fnins.2020.00386] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 03/30/2020] [Indexed: 01/10/2023] Open
Abstract
Objectives Many post-traumatic patients with minimally conscious state are complicated by psychomotor inhibition state (PIS), which impedes further rehabilitation. The treatment of PIS is not satisfactory. This pilot study aimed to investigate effects of anodal transcranial direct current stimulation (A-tDCS) on PIS in post-traumatic patients and examine the altered cortical activation after tDCS using non-linear electroencephalogram (EEG). Methods The study included 10 patients with post-traumatic PIS. An A–B design was used. The patients received 4 weeks of sham tDCS during Phase A, and they received A-tDCS over the prefrontal area and left dorsolateral prefrontal cortex (DLPFC) for 4 weeks (40 sessions) during Phase B. Conventional treatments were administered throughout both phases. JFK Coma Recovery Scale-Revised (CRS-R), apathy evaluation scale (AES), and the EEG non-linear indices of approximate entropy (ApEn) and cross approximate entropy (C-ApEn) were measured before Phase A, before Phase B, and after Phase B. Results After A-tDCS treatment, CRS-R and AES were improved significantly. ApEn and C-ApEn results showed that the local cortical connection of bilateral sensorimotor areas with their peripheral areas could be activated by affected painful stimuli, while bilateral cerebral hemispheres could be activated by the unaffected painful-stimuli condition. Linear regression analysis revealed that the affected sensorimotor cortex excitability and unaffected local and distant cortical networks connecting the sensorimotor area to the prefrontal area play a major role in AES improvement. Conclusion A-tDCS over the prefrontal area and left DLPFC improves PIS. The recovery might be related to increased excitability in local and distant cortical networks connecting the sensorimotor area to the prefrontal area. Thus, tDCS may be an alternative treatment for post-traumatic PIS.
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Affiliation(s)
- Xu Zhang
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Baohu Liu
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Nan Li
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Yuanyuan Li
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Jun Hou
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Guoping Duan
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Dongyu Wu
- Department of Rehabilitation, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
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Wang X, Guo Y, Zhang Y, Li J, Gao Z, Li Y, Zhou T, Zhang H, He J, Cong F. Combined Behavioral and Mismatch Negativity Evidence for the Effects of Long-Lasting High-Definition tDCS in Disorders of Consciousness: A Pilot Study. Front Neurosci 2020; 14:381. [PMID: 32410950 PMCID: PMC7198816 DOI: 10.3389/fnins.2020.00381] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 03/27/2020] [Indexed: 11/17/2022] Open
Abstract
Objective To evaluate the effects of long-term High-definition transcranial direct current stimulation (HD-tDCS) over precuneus on the level of consciousness (LOC) and the relationship between Mismatch negativity (MMN) and the LOC over the therapy period in patients with Disorders of consciousness (DOCs). Methods We employed a with-in group repeated measures design with an anode HD-tDCS protocol (2 mA, 20 min, the precuneus) on 11 (2 vegetative state and nine minimally conscious state) patients with DOCs. MMN and Coma Recovery Scale-Revised (CRS-R) scores were measured at four time points: before the treatment of HD-tDCS (T0), after a single session of HD-tDCS (T1), after the treatment of 7 days (T2) and 14 days (T3). A frequency-deviant oddball paradigm with two deviation magnitudes (standard stimulus: 1000 Hz, small deviant stimuli: 1050 Hz, large deviant stimuli: 1200 Hz) was adopted to elicit MMN. Results Significant improvements of CRS-R score were found after 7-day (T2) and 14-day (T3) treatment compared with baseline (T0). Regarding the MMN, significant improvements of MMN amplitudes were observed after a single session of stimulation (T1), 7-day (T2) and 14-day treatment (T3) compared with baseline (T0). Additionally, there were significant negative correlations between CRS-R scores and MMN amplitudes elicited by both large and small deviant stimuli. Conclusion Long-term HD-tDCS over precuneus might improve signs of consciousness in patients with DOCs as measured by CRS-R total scores, and MMN could be an assistant assessment in the course of tDCS treatment.
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Affiliation(s)
- Xiaoyu Wang
- School of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, Dalian, China
| | - Yongkun Guo
- Department of Neurosurgery, Zhengzhou Central Hospital, Zhengzhou, China.,Department of Neurosurgery, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yunge Zhang
- School of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, Dalian, China
| | - Jinju Li
- Department of Neurosurgery, Zhengzhou Central Hospital, Zhengzhou, China
| | - Zhongqi Gao
- School of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, Dalian, China
| | - Yingxin Li
- School of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, Dalian, China
| | - Tianlin Zhou
- School of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, Dalian, China
| | - Hui Zhang
- Department of Neurosurgery, Zhengzhou Central Hospital, Zhengzhou, China
| | - Jianghong He
- Department of Neurosurgery, People's Liberation Army General Hospital, Beijing, China
| | - Fengyu Cong
- School of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, Dalian, China.,Faculty of Information Technology, University of Jyväskylä, Jyväskylä, Finland
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60
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Shou Z, Li Z, Wang X, Chen M, Bai Y, Di H. Non-invasive brain intervention techniques used in patients with disorders of consciousness. Int J Neurosci 2020; 131:390-404. [PMID: 32238043 DOI: 10.1080/00207454.2020.1744598] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aim of the study: With the development of emergency medicine and intensive care technology, the number of people who survive with disorders of consciousness (DOC) has dramatically increased. The diagnosis and treatment of such patients have attracted much attention from the medical community. From the latest evidence-based guidelines, non-invasive brain intervention (NIBI) techniques may be valuable and promising in the diagnosis and conscious rehabilitation of DOC patients.Methods: This work reviews the studies on NIBI techniques for the assessment and intervention of DOC patients.Results: A large number of studies have explored the application of NIBI techniques in DOC patients. The NIBI techniques include transcranial magnetic stimulation, transcranial electric stimulation, music stimulation, near-infrared laser stimulation, focused shock wave therapy, low-intensity focused ultrasound pulsation and transcutaneous auricular vagus nerve stimulation.Conclusions: NIBI techniques present numerous advantages such as being painless, safe and inexpensive; having adjustable parameters and targets; and having broad development prospects in treating DOC patients.
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Affiliation(s)
- Zeyu Shou
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Aging and Cancer Biology of Zhejiang Province, Hangzhou Normal University, Hangzhou, China
| | - Zhilong Li
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Aging and Cancer Biology of Zhejiang Province, Hangzhou Normal University, Hangzhou, China
| | - Xueying Wang
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Aging and Cancer Biology of Zhejiang Province, Hangzhou Normal University, Hangzhou, China
| | - Miaoyang Chen
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Aging and Cancer Biology of Zhejiang Province, Hangzhou Normal University, Hangzhou, China
| | - Yang Bai
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Aging and Cancer Biology of Zhejiang Province, Hangzhou Normal University, Hangzhou, China
| | - Haibo Di
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Key Laboratory of Aging and Cancer Biology of Zhejiang Province, Hangzhou Normal University, Hangzhou, China
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61
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Network Mapping of Connectivity Alterations in Disorder of Consciousness: Towards Targeted Neuromodulation. J Clin Med 2020; 9:jcm9030828. [PMID: 32197485 PMCID: PMC7141258 DOI: 10.3390/jcm9030828] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/11/2020] [Indexed: 12/11/2022] Open
Abstract
Disorder of consciousness (DoC) refers to a group of clinical conditions that may emerge after brain injury, characterized by a varying decrease in the level of consciousness that can last from days to years. An understanding of its neural correlates is crucial for the conceptualization and application of effective therapeutic interventions. Here we propose a quantitative meta-analysis of the neural substrate of DoC emerging from functional magnetic resonance (fMRI) and positron emission tomography (PET) studies. We also map the relevant networks of resulting areas to highlight similarities with Resting State Networks (RSNs) and hypothesize potential therapeutic solutions leveraging network-targeted noninvasive brain stimulation. Available literature was reviewed and analyzed through the activation likelihood estimate (ALE) statistical framework to describe resting-state or task-dependent brain activation patterns in DoC patients. Results show that task-related activity is limited to temporal regions resembling the auditory cortex, whereas resting-state fMRI data reveal a diffuse decreased activation affecting two subgroups of cortical (angular gyrus, middle frontal gyrus) and subcortical (thalamus, cingulate cortex, caudate nucleus) regions. Clustering of their cortical functional connectivity projections identify two main altered functional networks, related to decreased activity of (i) the default mode and frontoparietal networks, as well as (ii) the anterior salience and visual/auditory networks. Based on the strength and topography of their connectivity profile, biophysical modeling of potential brain stimulation solutions suggests the first network as the most feasible target for tES, tDCS neuromodulation in DoC patients.
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Combined behavioral and electrophysiological evidence for a direct cortical effect of prefrontal tDCS on disorders of consciousness. Sci Rep 2020; 10:4323. [PMID: 32152347 PMCID: PMC7062738 DOI: 10.1038/s41598-020-61180-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 02/19/2020] [Indexed: 12/11/2022] Open
Abstract
Severe brain injuries can lead to long-lasting disorders of consciousness (DoC) such as vegetative state/unresponsive wakefulness syndrome (VS/UWS) or minimally conscious state (MCS). While behavioral assessment remains the gold standard to determine conscious state, EEG has proven to be a promising complementary tool to monitor the effect of new therapeutics. Encouraging results have been obtained with invasive electrical stimulation of the brain, and recent studies identified transcranial direct current stimulation (tDCS) as an effective approach in randomized controlled trials. This non-invasive and inexpensive tool may turn out to be the preferred treatment option. However, its mechanisms of action and physiological effects on brain activity remain unclear and debated. Here, we stimulated 60 DoC patients with the anode placed over left-dorsolateral prefrontal cortex in a prospective open-label study. Clinical behavioral assessment improved in twelve patients (20%) and none deteriorated. This behavioral response after tDCS coincided with an enhancement of putative EEG markers of consciousness: in comparison with non-responders, responders showed increases of power and long-range cortico-cortical functional connectivity in the theta-alpha band, and a larger and more sustained P300 suggesting improved conscious access to auditory novelty. The EEG changes correlated with electric fields strengths in prefrontal cortices, and no correlation was found on the scalp. Taken together, this prospective intervention in a large cohort of DoC patients strengthens the validity of the proposed EEG signatures of consciousness, and is suggestive of a direct causal effect of tDCS on consciousness.
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63
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Jezierska-Wozniak K, Sinderewicz E, Czelejewska W, Wojtacha P, Barczewska M, Maksymowicz W. Influence of Bone Marrow-Derived Mesenchymal Stem Cell Therapy on Oxidative Stress Intensity in Minimally Conscious State Patients. J Clin Med 2020; 9:E683. [PMID: 32138308 PMCID: PMC7141306 DOI: 10.3390/jcm9030683] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/28/2020] [Indexed: 12/11/2022] Open
Abstract
Neurological disorders, including minimally conscious state (MCS), may be associated with the presence of high concentrations of reactive oxygen species within the central nervous system. Regarding the documented role of mesenchymal stem cells (MSCs) in oxidative stress neutralization, the aim of this study is to evaluate the effect of bone marrow-derived MSC (BM-MSC) transplantation on selected markers of oxidative stress in MCS patients. Antioxidant capacity was measured in cerebrospinal fluid (CSF) and plasma collected from nine patients aged between 19 and 45 years, remaining in MCS for 3 to 14 months. Total antioxidant capacity, ascorbic acid and ascorbate concentrations, superoxide dismutase, catalase, and peroxidase activity were analyzed and the presence of tested antioxidants in the CSF and plasma was confirmed. Higher ascorbic acid (AA) content and catalase (CAT) activity were noted in CSF relative to plasma, whereas superoxide dismutase (SOD) activity and total antioxidant capacity were higher in plasma relative to CSF. Total antioxidant capacity measured in CSF was greater after BM-MSC transplantations. The content of ascorbates was lower and CAT activity was higher both in CSF and plasma after the administration of BM-MSC. The above results suggest that MSCs modulate oxidative stress intensity in MCS patients, mainly via ascorbates and CAT activity.
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Affiliation(s)
- Katarzyna Jezierska-Wozniak
- Department of Neurosurgery, Laboratory of Regenerative Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Warszawska 30 Str., 10-082 Olsztyn, Poland; (E.S.); (W.C.)
- Department of Neurosurgery, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Warszawska 30 Str., 10-082 Olsztyn, Poland; (M.B.); (W.M.)
| | - Emilia Sinderewicz
- Department of Neurosurgery, Laboratory of Regenerative Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Warszawska 30 Str., 10-082 Olsztyn, Poland; (E.S.); (W.C.)
- Department of Neurosurgery, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Warszawska 30 Str., 10-082 Olsztyn, Poland; (M.B.); (W.M.)
| | - Wioleta Czelejewska
- Department of Neurosurgery, Laboratory of Regenerative Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Warszawska 30 Str., 10-082 Olsztyn, Poland; (E.S.); (W.C.)
- Department of Neurosurgery, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Warszawska 30 Str., 10-082 Olsztyn, Poland; (M.B.); (W.M.)
| | - Pawel Wojtacha
- Department of Industrial and Food Microbiology, Faculty of Food Sciences, University of Warmia and Mazury in Olsztyn, Plac Cieszynski 1 Str., 10-726 Olsztyn, Poland;
| | - Monika Barczewska
- Department of Neurosurgery, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Warszawska 30 Str., 10-082 Olsztyn, Poland; (M.B.); (W.M.)
| | - Wojciech Maksymowicz
- Department of Neurosurgery, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Warszawska 30 Str., 10-082 Olsztyn, Poland; (M.B.); (W.M.)
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Cai T, Xia X, Zhang H, Guo Y, Bai Y. High-definition transcranial direct current stimulation modulates neural activities in patients with prolonged disorders of consciousness. Brain Stimul 2019; 12:1619-1621. [DOI: 10.1016/j.brs.2019.08.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 08/31/2019] [Indexed: 11/30/2022] Open
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Li S, Dong X, Sun W, Zhao N, Yu G, Shuai L. Effects of transcranial direct current stimulation on patients with disorders of consciousness after traumatic brain injury: study protocol for a randomized, double-blind controlled trial. Trials 2019; 20:596. [PMID: 31623656 PMCID: PMC6796458 DOI: 10.1186/s13063-019-3680-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 08/24/2019] [Indexed: 12/31/2022] Open
Abstract
Background Disorders of consciousness (DOC) after traumatic brain injury (TBI) raise the mortality of patients, restrict the rehabilitation of patients with TBI, and increase the physical and economic burden that TBI imposes on patients and their families. Thus, treatment to promote early awakening in DOC after TBI is of vital importance. Various treatments have been reported, but there is no advanced evidence base to support them. Transcranial direct current stimulation (tDCS) has shown great potential in promoting neuroelectrochemical effects. This protocol is for a double-blind, randomized, controlled, clinical trial aiming to research the effects and safety of conventional rehabilitation combined with tDCS therapy in patients with DOC after TBI. Methods/design Eighty patients with DOC after TBI will be randomized into one of two groups receiving conventional rehabilitation combined with sham tDCS or conventional rehabilitation combined with active tDCS. The intervention period in each of the two groups will last 4 weeks (20 min per day, 6 days per week). Primary outcomes (Glasgow Outcome Scale (GOS)) will be measured at baseline and the end of every week from the first to the fourth week. Secondary outcomes will be measured at baseline and the end of the fourth week. Adverse events and untoward effects will be measured during each treatment. Discussion Patients with central nervous system lesions have received tDCS as a painless, non-invasive, easily applied and effective therapy for several decades, and there has been some evidence in recent years showing partial improvement on the level of consciousness of partial patients with DOC. However, reports mainly focus on the patients in a minimally conscious state (MCS), and there is a lack of large-sample clinical trials. This protocol presents an objective design for a randomized controlled trial that aims to study the effectiveness of conventional rehabilitation combined with tDCS therapy for DOC after TBI, to evaluate its safety, and to explore effective and economical therapeutic methods. Trial registration Chinese Clinical Trial Registry, ChiCTR1800014808. Registered on 7 February 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3680-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shilin Li
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China.,First Clinical Medical School, Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China
| | - Xiangli Dong
- Department of Psychosomatic Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China
| | - Weiming Sun
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China. .,First Clinical Medical School, Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China.
| | - Na Zhao
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China.,First Clinical Medical School, Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China
| | - Guohua Yu
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China.,First Clinical Medical School, Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China
| | - Lang Shuai
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China.,First Clinical Medical School, Nanchang University, Nanchang, Jiangxi Province, 330006, People's Republic of China
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66
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Martens G, Fregni F, Carrière M, Barra A, Laureys S, Thibaut A. Single tDCS session of motor cortex in patients with disorders of consciousness: a pilot study. Brain Inj 2019; 33:1679-1683. [PMID: 31523995 DOI: 10.1080/02699052.2019.1667537] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Primary Objective: Patients with disorders of consciousness (DOC) face a lack of treatments and risk of misdiagnosis, potentially due to motor impairment. Transcranial direct current stimulation (tDCS) showed promising results over the prefrontal cortex in DOC and over the primary motor cortex (M1) in stroke. Tis pilot study aimed at evaluating the behavioral effects of M1 tDCS in patients with DOC.Research Design: In this randomized double-blind sham-controlled crossover trial, we included 10 patients (49 ± 22 years, 7 ± 13 months since injury, 4 unresponsive wakefulness syndrome, 6 minimally conscious state, 5 traumatic etiologies).Methods and Procedures: One session of tDCS (2 mA for 20 min) and one session of sham tDCS were applied over M1 in a randomized order with a washout period of minimum 24 h and behavioral effects were assessed using the CRS-R. At the group level, no treatment effect was identified on the total score (p = .55) and on the motor subscale (p = .75). Two patients responded to tDCS by showing a new sign of consciousness (visual pursuit and object localization).Conclusions: One session of M1 tDCS failed to improve behavioral responsiveness in patients with DOC. Other application strategies should be tested.
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Affiliation(s)
- Géraldine Martens
- Coma Science Group, GIGA Consciousness, University of Liege, Liège, Belgium.,Centre du Cerveau2 - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium
| | - Felipe Fregni
- Harvard Medical School, Neuromodulation Center, Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Manon Carrière
- Coma Science Group, GIGA Consciousness, University of Liege, Liège, Belgium.,Centre du Cerveau2 - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium
| | - Alice Barra
- Coma Science Group, GIGA Consciousness, University of Liege, Liège, Belgium.,Centre du Cerveau2 - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liege, Liège, Belgium.,Centre du Cerveau2 - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liege, Liège, Belgium.,Centre du Cerveau2 - Centre intégré pluridisciplinaire de l'étude du cerveau, de la cognition et de la conscience, University Hospital of Liège, Liège, Belgium.,Harvard Medical School, Neuromodulation Center, Spaulding Rehabilitation Hospital, Boston, MA, USA
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67
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Zhang Y, Lu J, Du J, Huo S, Li R, Song W. Neural correlates of different behavioral response to transcranial direct current stimulation between patients in the unresponsive wakefulness syndrome and minimally conscious state. Neurol Sci 2019; 41:75-82. [DOI: 10.1007/s10072-019-04034-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 07/31/2019] [Indexed: 01/18/2023]
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68
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Saleem GT, Ewen JB, Crasta JE, Slomine BS, Cantarero GL, Suskauer SJ. Single-arm, open-label, dose escalation phase I study to evaluate the safety and feasibility of transcranial direct current stimulation with electroencephalography biomarkers in paediatric disorders of consciousness: a study protocol. BMJ Open 2019; 9:e029967. [PMID: 31401607 PMCID: PMC6701812 DOI: 10.1136/bmjopen-2019-029967] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Children with disorders of consciousness (DOC) represent the highest end of the acquired brain injury (ABI) severity spectrum for survivors and experience a multitude of functional impairments. Current clinical management in DOC uses behavioural evaluation measures and interventions that fail to (1) describe the physiological consequences of ABI and (2) elicit functional gains. In paediatric DOC, there is a critical need to develop evidence-based interventions to promote recovery of basic responses to improve rehabilitation and aid decision-making for medical teams and caregivers. The purpose of this investigation is to examine the safety, tolerability and feasibility of transcranial direct current stimulation (tDCS) in children with DOC. METHODS AND ANALYSIS This study is an open-label dose escalation trial evaluating the safety, tolerability and feasibility of tDCS in 10 children (5-17 years) receiving inpatient rehabilitation for DOC. This study will follow a modified rule-based design, allowing for intrapatient escalation, where a cohort of patients will be assigned to an initial tDCS current of 0.5 or 1 mA based on participant's head circumference and according to the safety data available in other paediatric populations. The subsequent assignment of increased current (1 or 2 mA) according to the prespecified rules will be based on the clinical observation of adverse events in the patients. The study will include up to three, 20 min sessions of anodal tDCS (sham, 0.5 or 1 mA, 1 or 2 mA) applied over the dorsolateral prefrontal cortex. The primary outcomes are adverse events, pain associated with tDCS and intolerable disruption of inpatient care. Secondary outcomes are changes in electroencephalography (EEG) phase-locking and event-related potential components and the Coma Recovery Scale-Revised total score from prestimulation to poststimulation. ETHICS AND DISSEMINATION The Johns Hopkins IRB (#IRB00174966) approved this study. Trial results will be disseminated through journals and conferences. REGISTRATION NUMBER NCT03618849.
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Affiliation(s)
- Ghazala T Saleem
- Kennedy Krieger Institute, Baltimore, Maryland, USA
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua Benjamin Ewen
- Kennedy Krieger Institute, Baltimore, Maryland, USA
- Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jewel E Crasta
- Kennedy Krieger Institute, Baltimore, Maryland, USA
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Gabriela Lucila Cantarero
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stacy J Suskauer
- Kennedy Krieger Institute, Baltimore, Maryland, USA
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Lin Y, Liu T, Huang Q, Su Y, Chen W, Gao D, Tian X, Huang T, Zhen Z, Han T, Ye H, Wang Y. Electroencephalography and Functional Magnetic Resonance Imaging-Guided Simultaneous Transcranial Direct Current Stimulation and Repetitive Transcranial Magnetic Stimulation in a Patient With Minimally Conscious State. Front Neurosci 2019; 13:746. [PMID: 31417339 PMCID: PMC6685103 DOI: 10.3389/fnins.2019.00746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 07/05/2019] [Indexed: 12/23/2022] Open
Abstract
Objective A minimally conscious state (MCS) is characterized by discernible behavioral evidence of consciousness that cannot be reproduced consistently. This condition is highly challenging to treat. Recent studies have demonstrated the potential therapeutic effect of non-invasive brain stimulation in patients with MCS. In one patient in an MCS, we delivered simultaneous transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) based on an individual brain network analysis and evaluated the therapeutic effect. Methods The directional transfer function (DTF) was calculated based on electroencephalograph (EEG) analysis. Global brain connectivity was calculated based on functional magnetic resonance imaging (fMRI) analysis. By referring to the EEG and fMRI results, we identified inferior parietal lobes (IPLs) as targets. In the 2-week treatment period, 14 sessions were applied to the identified bilateral parietal regions. Simultaneous 1.5-mA anodal tDCS and 5-Hz rTMS were delivered for 20 min per hemisphere in each session. Clinical evaluation scores were recorded weekly throughout the treatment. A second patient given the routine treatment was evaluated as a control. Results The clinical scores of patient 1 with MCS improved after 2 weeks of stimulation treatment, and the effect lasted for up to 1 month. EEG analysis showed a significant increase (p < 0.001) in the DTF value in the gamma band in a bilateral set of posterior regions, and fMRI showed a trend toward normalized activity in the IPLs. The clinical scores of patient 2 with coma did not improve much after 2 weeks of routine treatment. The EEG analysis showed a significant increase (p = 0.021) in the DTF value in the gamma band in a bilateral set of posterior regions. Conclusion The application of EEG and fMRI to characterize the functional connectivity features of the network in an MCS patient provided a reasonable and accurate stimulation target and verified the changes in functional connectivity resulting from stimulation.
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Affiliation(s)
- Yicong Lin
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tiaotiao Liu
- School of Biomedical Engineering, Tianjin Medical University, Tianjin, China
| | - Qian Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Daiquan Gao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xin Tian
- School of Biomedical Engineering, Tianjin Medical University, Tianjin, China
| | - Taicheng Huang
- State Key Laboratory of Cognitive Neuroscience and Learning and IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, China
| | - Zonglei Zhen
- State Key Laboratory of Cognitive Neuroscience and Learning and IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, China
| | - Tao Han
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hong Ye
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuping Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,The Beijing Key Laboratory of Neuromodulation, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
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Efficiency of Repetitive Transcranial Direct Current Stimulation of the Dorsolateral Prefrontal Cortex in Disorders of Consciousness: A Randomized Sham-Controlled Study. Neural Plast 2019; 2019:7089543. [PMID: 31308848 PMCID: PMC6594311 DOI: 10.1155/2019/7089543] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/26/2019] [Accepted: 05/23/2019] [Indexed: 12/20/2022] Open
Abstract
Conventional transcranial direct current stimulation (tDCS) targeting the left dorsolateral prefrontal cortex (DLPFC) could improve arousal in disorders of consciousness (DOC). However, the comparative effectiveness of anodal stimulation of the left DLPFC and the electrophysiological effect of tDCS are yet to be determined. In this randomized sham-controlled design, patients were separated into three groups (left/right anodal tDCS, sham). Data on the clinical assessments and EEG were collected at baseline and after 2 weeks of tDCS. The outcome at 3-month follow-up was evaluated using the Glasgow Outcome Scale-Extended. Results showed that sessions of the left tDCS facilitated the excitability of the prefrontal cortex, whereas only one patient had a positive outcome. Targeting the right DLPFC was less effective, merely leading to activation of the stimulation site, with no effect on the state of arousal. Moreover, sham stimulation had minimal or no effect on any of the outcomes. These results provide evidence for a hemispheric asymmetry of tDCS effects in patients with DOC. Left anodal tDCS might be more effective for modulating cortical excitability compared to tDCS on the right DLPFC. However, future studies with large sample sizes are needed to confirm these findings. This trial is registered with NCT03809936.
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71
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Thibaut A, Schiff N, Giacino J, Laureys S, Gosseries O. Therapeutic interventions in patients with prolonged disorders of consciousness. Lancet Neurol 2019; 18:600-614. [DOI: 10.1016/s1474-4422(19)30031-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 12/21/2022]
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Zaninotto AL, El-Hagrassy MM, Green JR, Babo M, Paglioni VM, Benute GG, Paiva WS. Transcranial direct current stimulation (tDCS) effects on traumatic brain injury (TBI) recovery: A systematic review. Dement Neuropsychol 2019; 13:172-179. [PMID: 31285791 PMCID: PMC6601308 DOI: 10.1590/1980-57642018dn13-020005] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Traumatic brain injury (TBI) is a major cause of chronic disability. Less than a
quarter of moderate and severe TBI patients improved in their cognition within 5
years. Non-invasive brain stimulation, including transcranial direct current
stimulation (tDCS), may help neurorehabilitation by boosting adaptive
neuroplasticity and reducing pathological sequelae following TBI.
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Affiliation(s)
- Ana Luiza Zaninotto
- Speech and Feeding Disorders Lab, MGH Institute of Health Professions (MGH IHP), Boston, USA
| | - Mirret M El-Hagrassy
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School (HMS), Boston, USA
| | - Jordan R Green
- Speech and Feeding Disorders Lab, MGH Institute of Health Professions (MGH IHP), Boston, USA
| | - Maíra Babo
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Department of Neurology, São Paulo, SP, Brazil
| | - Vanessa Maria Paglioni
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Department of Neurology, São Paulo, SP, Brazil
| | | | - Wellingson Silva Paiva
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Department of Neurology, São Paulo, SP, Brazil
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Bai Y, Xia X, Wang Y, He J, Li X. Electroencephalography quadratic phase self-coupling correlates with consciousness states and restoration in patients with disorders of consciousness. Clin Neurophysiol 2019; 130:1235-1242. [PMID: 31163368 DOI: 10.1016/j.clinph.2019.04.710] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 03/27/2019] [Accepted: 04/09/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of this study was to explore the role for quadratic phase coupling within electroencephalography (EEG) oscillations in the diagnosis of consciousness and consciousness restoration for disorders of consciousness (DOC). METHODS Fifty-one DOC patients were enrolled in this study. For each patient, a Coma Recovery Scale-Revised (CRS-R) score and 20-min resting-state EEG were recorded. Consciousness recovery was assessed with a CRS-R score at a three-month follow-up. Twenty healthy subjects were included as controls. General harmonic wavelet transform-based bicoherence was used to quantify the quadratic phase coupling characteristics of the EEG oscillations. RESULTS Quadratic phase self-coupling (QPSC) at the delta (QPSC_delta), theta (QPSC_theta) and alpha (QPSC_alpha) bands were closely correlated with patient CRS-R scores. Particularly, the QPSC_theta value could significantly differentiate between vegetative state (VS) patients, minimally conscious state (MCS) patients and healthy control subjects. As compared to VS patients, patients with MCS had a lower QPSC_theta value on the left as well as a higher QPSC_alpha value in right frontal regions. The frontal QPSC_theta value showed significant differences between recovered and unrecovered patients. CONCLUSION QPSC characteristics could differentiate between consciousness states and show a predictive ability for the recovery of consciousness in DOC patients. SIGNIFICANCE Changes in QPSC accompany consciousness injury and restoration in DOC patients. A QPSC assessment is helpful in the diagnosis and prognosis of DOC patients.
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Affiliation(s)
- Yang Bai
- Department of Basic Medical Science, School of Medicine, Hangzhou Normal University, Hangzhou, Zhejiang 311121, China; International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, Zhejiang 311121, China
| | - Xiaoyu Xia
- Department of Neurosurgery, PLA Army General Hospital, Beijing 100700, China
| | - Yong Wang
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao 066004, China
| | - Jianghong He
- Department of Neurosurgery, PLA Army General Hospital, Beijing 100700, China
| | - Xiaoli Li
- State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing 100875, China.
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Guo Y, Bai Y, Xia X, Li J, Wang X, Dai Y, Dang Y, He J, Liu C, Zhang H. Effects of Long-Lasting High-Definition Transcranial Direct Current Stimulation in Chronic Disorders of Consciousness: A Pilot Study. Front Neurosci 2019; 13:412. [PMID: 31114475 PMCID: PMC6502996 DOI: 10.3389/fnins.2019.00412] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/11/2019] [Indexed: 11/23/2022] Open
Abstract
Transcranial direct current stimulation (tDCS) recently was shown to benefit rehabilitation of patients with disorders of consciousness (DOC). However, high-Definition tDCS (HD-tDCS) has not been applied in DOC. In this study, we tried to use HD-tDCS protocol (2 mA, 20 min, the precuneus, and sustaining 14 days) to rehabilitate 11 patients with DOC. Electroencephalography (EEG) and Coma Recovery Scale–Revised (CRS-R) scores were recorded at before (T0), after a single session (T1), after 7 days’ (T2), and 14 days’ HD-tDCS (T3) to assess the modulation effects. EEG coherence was measured to evaluate functional connectivity during the experiment. It showed that 9 patients’ scores increased compared with the baseline. The central-parietal coherence significantly decreased in the delta band in patients with DOC. EEG coherence might be useful for assessing the effect of HD-tDCS in patients with DOC. Long-lasting HD-tDCS over the precuneus is promising for the treatment of patients with DOC.
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Affiliation(s)
- Yongkun Guo
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Yang Bai
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.,Department of Basic Medical Science, School of Medicine, Hangzhou Normal University, Hangzhou, China
| | - Xiaoyu Xia
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Jinju Li
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Xiaoli Wang
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Yiwu Dai
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Yuanyuan Dang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Chunying Liu
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Hui Zhang
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
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Bourdillon P, Hermann B, Sitt JD, Naccache L. Electromagnetic Brain Stimulation in Patients With Disorders of Consciousness. Front Neurosci 2019; 13:223. [PMID: 30936822 PMCID: PMC6432925 DOI: 10.3389/fnins.2019.00223] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 02/26/2019] [Indexed: 12/27/2022] Open
Abstract
Severe brain injury is a common cause of coma. In some cases, despite vigilance improvement, disorders of consciousness (DoC) persist. Several states of impaired consciousness have been defined, according to whether the patient exhibits only reflexive behaviors as in the vegetative state/unresponsive wakefulness syndrome (VS/UWS) or purposeful behaviors distinct from reflexes as in the minimally conscious state (MCS). Recently, this clinical distinction has been enriched by electrophysiological and neuroimaging data resulting from a better understanding of the physiopathology of DoC. However, therapeutic options, especially pharmacological ones, remain very limited. In this context, electroceuticals, a new category of therapeutic agents which act by targeting the neural circuits with electromagnetic stimulations, started to develop in the field of DoC. We performed a systematic review of the studies evaluating therapeutics relying on the direct or indirect electro-magnetic stimulation of the brain in DoC patients. Current evidence seems to support the efficacy of deep brain stimulation (DBS) and non-invasive brain stimulation (NIBS) on consciousness in some of these patients. However, while the latter is non-invasive and well tolerated, the former is associated with potential major side effects. We propose that all chronic DoC patients should be given the possibility to benefit from NIBS, and that transcranial direct current stimulation (tDCS) should be preferred over repetitive transcranial magnetic stimulation (rTMS), based on the literature and its simple use. Surgical techniques less invasive than DBS, such as vagus nerve stimulation (VNS) might represent a good compromise between efficacy and invasiveness but still need to be further investigated.
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Affiliation(s)
- Pierre Bourdillon
- Department of Neurosurgery, Adolphe de Rothschild Foundation, Paris, France
- Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
- Inserm U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
| | - Bertrand Hermann
- Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
- Inserm U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
- Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Jacobo D. Sitt
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
- Inserm U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
| | - Lionel Naccache
- Sorbonne Université, Faculté de Médecine Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
- Inserm U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
- Department of Neurophysiology, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
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O'Donnell JC, Browne KD, Kilbaugh TJ, Chen HI, Whyte J, Cullen DK. Challenges and demand for modeling disorders of consciousness following traumatic brain injury. Neurosci Biobehav Rev 2019; 98:336-346. [PMID: 30550859 PMCID: PMC7847278 DOI: 10.1016/j.neubiorev.2018.12.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/02/2018] [Accepted: 12/11/2018] [Indexed: 12/29/2022]
Abstract
Following severe traumatic brain injury (TBI), many patients experience coma - an unresponsive state lacking wakefulness or awareness. Coma rarely lasts more than two weeks, and emergence involves passing through a state of wakefulness without awareness of self or environment. Patients that linger in these Disorders of Consciousness (DoC) undergo clinical assessments of awareness for diagnosis into Unresponsive Wakefulness Syndrome (no awareness, also called vegetative state) or Minimally Conscious State (periodic increases in awareness). These diagnoses are notoriously inaccurate, offering little prognostic value. Recovery of awareness is unpredictable, returning within weeks, years, or never. This leaves patients' families with difficult decisions and little information on which to base them. Clinical studies have made significant advancements, but remain encumbered by high variability, limited data output, and a lack of necessary controls. Herein we discuss the clear and present need to establish a preclinical model of TBI-induced DoC, the significant challenges involved, and how such a model can be applied to support DoC research.
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Affiliation(s)
- John C O'Donnell
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Kevin D Browne
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Todd J Kilbaugh
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - H Isaac Chen
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, United States
| | - D Kacy Cullen
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States; Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, United States.
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Cavinato M, Genna C, Formaggio E, Gregorio C, Storti SF, Manganotti P, Casanova E, Piperno R, Piccione F. Behavioural and electrophysiological effects of tDCS to prefrontal cortex in patients with disorders of consciousness. Clin Neurophysiol 2019; 130:231-238. [DOI: 10.1016/j.clinph.2018.10.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/04/2018] [Accepted: 10/24/2018] [Indexed: 10/27/2022]
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Straudi S, Bonsangue V, Mele S, Craighero L, Montis A, Fregni F, Lavezzi S, Basaglia N. Bilateral M1 anodal transcranial direct current stimulation in post traumatic chronic minimally conscious state: a pilot EEG-tDCS study. Brain Inj 2019; 33:490-495. [PMID: 30632807 DOI: 10.1080/02699052.2019.1565894] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE We tested the preliminary effects of bilateral anodal transcranial direct current stimulation (tDCS) in patients with disorders of consciousness. DESIGN Open label pilot study. SUBJECTS Ten chronic (greater than 12 months) patients in a minimally conscious state (MCS) following severe traumatic brain injury. METHODS The patients received 10 sessions of bilateral M1 anodal tDCS. Behavioural changes were assessed with the Coma Recovery Scale-Revised (CRS-R) before stimulation (T-1, T0), after five sessions (T1), at the end of the stimulation (T2), after two weeks (T3) and after three months (T4). Moreover, an EEG assessment was conducted. RESULTS Eight out of 10 patients showed new clinical signs of consciousness; specifically, a 2-point CRS-R improvement was detected in the last follow-up (p = 0.004). EEG upper α bandwidth was greater in the parietal site at T1 (p < 0.034). In addition, we found a significant correlation between behavioral and EEG indices at T1 (r = 0.89; p = 0.001). CONCLUSION This preliminary study presents several limitations (small sample size and no control group). However, it provides important initial data that can be used to design randomized clinical trials testing this novel approach in MCS and to further explore EEG as a neural marker for the effects of tDCS.
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Affiliation(s)
- Sofia Straudi
- a Neuroscience and Rehabilitation Department , Ferrara University Hospital , Ferrara , Italy
| | - Valentina Bonsangue
- a Neuroscience and Rehabilitation Department , Ferrara University Hospital , Ferrara , Italy
| | - Sonia Mele
- b Biomedical and Specialty Surgical Sciences Department , Ferrara University , Ferrara , Italy
| | - Laila Craighero
- b Biomedical and Specialty Surgical Sciences Department , Ferrara University , Ferrara , Italy
| | - Andrea Montis
- c Sardinian Health Trust , Neurorehabilitation Unit, San Martino Hospital , Oristano , Italy
| | - Felipe Fregni
- d Department of Physical Medicine and Rehabilitation, Harvard Medical School , Neuromodulation Center, Spaulding Rehabilitation Hospital , Boston , MA , USA
| | - Susanna Lavezzi
- a Neuroscience and Rehabilitation Department , Ferrara University Hospital , Ferrara , Italy
| | - Nino Basaglia
- a Neuroscience and Rehabilitation Department , Ferrara University Hospital , Ferrara , Italy
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Li Y, Luo X, Wan M, Li J, Wang H, Wei D, Feng H. The effectiveness of non-invasive brain stimulation on arousal and alertness in patients in coma or persistent vegetative state after traumatic brain injury: Protocol of systematic review and network meta-analysis. Medicine (Baltimore) 2018; 97:e12321. [PMID: 30212977 PMCID: PMC6155968 DOI: 10.1097/md.0000000000012321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/21/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Traumatic brain injury is a leading cause of death and disability worldwide. The survivors usually suffer from disorders of consciousness, especially coma state and persistent vegetative state. For these patients, there is no standard treatment for them, but non-invasive brain stimulations are considered as relatively more acceptable treatments. However, the knowledge regarding the relative effectiveness and the rank of the effectiveness of the non-invasive brain stimulations is limited. Thus, in this study, we aim to conduct a systematic review and network meta-analysis to evaluate the effect of non-invasive train stimulations on arousal and alertness in patients in a coma or persistent vegetative state after traumatic brain injury. METHODS AND ANALYSIS A comprehensive search strategy will be performed in the relevant databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Wan Fang Data). The random or quasi-random controlled trails focusing on the effectiveness of the non-invasive brain stimulations will be included. The risk of bias for the included studies will be appraised using the Cochrane collaboration tool for assessing risk of bias. The standard pairwise meta-analysis and a Bayesian network meta-analysis will be conducted. ETHICS AND DISSEMINATION This research is a systematic review and network meta-analysis. Thus, there is no requirement of ethical approval and patient informed consent. PROSPERO REGISTRATION NUMBER CRD42018104945.
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Affiliation(s)
- Yabin Li
- Department of Neurological Rehabilitation, Rehabilitation Central Hospital of Gansu Province
| | - Xianggui Luo
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Miao Wan
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Jiao Li
- Department of Neurological Rehabilitation, Rehabilitation Central Hospital of Gansu Province
| | - Hongxia Wang
- Department of Neurological Rehabilitation, Rehabilitation Central Hospital of Gansu Province
| | - Dang Wei
- Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Haixia Feng
- Department of Neurological Rehabilitation, Rehabilitation Central Hospital of Gansu Province
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80
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Randomized controlled trial of home-based 4-week tDCS in chronic minimally conscious state. Brain Stimul 2018; 11:982-990. [DOI: 10.1016/j.brs.2018.04.021] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 04/26/2018] [Accepted: 04/28/2018] [Indexed: 12/17/2022] Open
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Differential Role of Prefrontal and Parietal Cortices in Controlling Level of Consciousness. Curr Biol 2018; 28:2145-2152.e5. [PMID: 29937348 DOI: 10.1016/j.cub.2018.05.025] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/29/2018] [Accepted: 05/09/2018] [Indexed: 12/23/2022]
Abstract
Consciousness is determined both by level (e.g., being awake versus being anesthetized) and content (i.e., the qualitative aspects of experience). Subcortical areas are known to play a causal role in regulating the level of consciousness [1-9], but the role of the cortex is less well understood. Clinical and correlative data have been used both to support and refute a role for prefrontal and posterior cortices in the level of consciousness [10-22]. The prefrontal cortex has extensive reciprocal connections to wake-promoting centers in the brainstem and diencephalon [23, 24], and hence is in a unique position to modulate level of consciousness. Furthermore, a recent study suggested that the prefrontal cortex might be important in regulating level of consciousness [25] but causal evidence, and a comparison with more posterior cortical sites, is lacking. Therefore, to test the hypothesis that prefrontal cortex plays a role in regulating level of consciousness, we attempted to reverse sevoflurane anesthesia by cholinergic or noradrenergic stimulation of the prefrontal prelimbic cortex and two areas of parietal cortex in rat. General anesthesia was defined by loss of the righting reflex, a widely used surrogate measure in rodents. We demonstrate that cholinergic stimulation of prefrontal cortex, but not parietal cortex, restored wake-like behavior, despite continuous exposure to clinically relevant concentrations of sevoflurane anesthesia. Noradrenergic stimulation of the prefrontal and parietal areas resulted in electroencephalographic activation but failed to produce any signs of wake-like behavior. We conclude that cholinergic mechanisms in prefrontal cortex can regulate the level of consciousness.
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82
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Xia X, Yang Y, Guo Y, Bai Y, Dang Y, Xu R, He J. Current Status of Neuromodulatory Therapies for Disorders of Consciousness. Neurosci Bull 2018; 34:615-625. [PMID: 29916112 DOI: 10.1007/s12264-018-0244-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/25/2018] [Indexed: 11/26/2022] Open
Abstract
Treatment for disorders of consciousness (DOCs) is still a Gordian knot. Evidence-based guidelines on the treatment of DOC patients are not currently available, while neuromodulation techniques are seen as a potential treatment. Multiple neuromodulation therapies have been applied. This article reviews the most relevant studies in the literature in order to describe a clear picture of the current state of neuromodulation therapies that could be used to treat DOC patients. Both invasive and non-invasive brain stimulation is discussed. Significant behavioral improvements in prolonged DOCs under neuromodulation therapies are rare. The efficacy of various such therapies remains a matter of debate. Further clinical investigations of existing techniques in larger samples properly controlling for spontaneous recovery are needed, and new approaches are awaited.
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Affiliation(s)
- Xiaoyu Xia
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Yi Yang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Yongkun Guo
- Department of Neurosurgery, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, 450007, China
| | - Yang Bai
- International Vegetative State and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, 311121, China
| | - Yuanyuan Dang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Ruxiang Xu
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China
| | - Jianghong He
- Department of Neurosurgery, PLA Army General Hospital, Beijing, 100700, China.
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Abstract
PURPOSE OF REVIEW Very few options exist for patients who survive severe traumatic brain injury but fail to fully recover and develop a disorder of consciousness (e.g. vegetative state, minimally conscious state). RECENT FINDINGS Among pharmacological approaches, Amantadine has shown the ability to accelerate functional recovery. Although with very low frequency, Zolpidem has shown the ability to improve the level of consciousness transiently and, possibly, also in a sustained fashion. Among neuromodulatory approaches, transcranial direct current stimulation has been shown to transiently improve behavioral responsiveness, but mostly in minimally conscious patients. New evidence for thalamic deep brain stimulation calls into question its cost/benefit trade-off. SUMMARY The growing understanding of the biology of disorders of consciousness has led to a renaissance in the development of therapeutic interventions for patients with disorders of consciousness. High-quality evidence is emerging for pharmacological (i.e. Amantadine) and neurostimulatory (i.e. transcranial direct current stimulation) interventions, although further studies are needed to delineate preconditions, optimal dosages, and timing of administration. Other exciting new approaches (e.g. low intensity focused ultrasound) still await systematic assessment. A crucial future direction should be the use of neuroimaging measures of functional and structural impairment as a means of tailoring patient-specific interventions.
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84
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To WT, De Ridder D, Hart J, Vanneste S. Changing Brain Networks Through Non-invasive Neuromodulation. Front Hum Neurosci 2018; 12:128. [PMID: 29706876 PMCID: PMC5908883 DOI: 10.3389/fnhum.2018.00128] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 03/19/2018] [Indexed: 01/10/2023] Open
Abstract
Background/Objective: Non-invasive neuromodulation techniques, such as repetitive Transcranial Magnetic Stimulation (rTMS) and transcranial Direct Current Stimulation (tDCS), have increasingly been investigated for their potential as treatments for neurological and psychiatric disorders. Despite widespread dissemination of these techniques, the underlying therapeutic mechanisms and the ideal stimulation site for a given disorder remain unknown. Increasing evidence support the possibility of non-invasive neuromodulation affecting a brain network rather than just the local stimulation target. In this article, we present evidence in a clinical setting to support the idea that non-invasive neuromodulation changes brain networks. Method: This article addresses the idea that non-invasive neuromodulation modulates brain networks, rather than just the local stimulation target, using neuromodulation studies in tinnitus and major depression as examples. We present studies that support this hypothesis from different perspectives. Main Results/Conclusion: Studies stimulating the same brain region, such as the dorsolateral prefrontal cortex (DLPFC), have shown to be effective for several disorders and studies using different stimulation sites for the same disorder have shown similar results. These findings, as well as results from studies investigating brain network connectivity on both macro and micro levels, suggest that non-invasive neuromodulation affects a brain network rather than just the local stimulation site targeted. We propose that non-invasive neuromodulation should be approached from a network perspective and emphasize the therapeutic potential of this approach through the modulation of targeted brain networks.
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Affiliation(s)
- Wing Ting To
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, TX, United States
| | - Dirk De Ridder
- Department of Surgical Sciences, Section of Neurosurgery, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - John Hart
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, TX, United States
| | - Sven Vanneste
- School of Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, TX, United States
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85
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Werner C, Byhahn M, Hesse S. Non-invasive brain stimulation to promote alertness and awareness in chronic patients with disorders of consciousness: Low-level, near-infrared laser stimulation vs. focused shock wave therapy. Restor Neurol Neurosci 2018; 34:561-9. [PMID: 27080072 DOI: 10.3233/rnn-150624] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE In order to promote alertness and awareness in patients with severe disorders of consciousness (DOC) frontal near infrared laser stimulation (N-LT) or transcranial focused shock wave therapy (F-SWT) might be an option. The study compared both techniques in severe chronic DOC patients. METHODS Sixteen DOC patients were allocated to two groups (A and B). A three week baseline either followed a frontal N-LT (0,1 mJ/mm2, 10 min per session), five times a week over four weeks (group A), or a F-SWT (0,1 mJ/mm2, 4000 stimuli per session) three times a week over four weeks (group B). The primary variable was the revised Coma Recovery Scale (r-CRS, 0-23), blindly assessed. RESULTS Both groups improved in the r-CRS over time, but revealed no differences between groups. One patient of group B had a focal seizure in the third therapy week. One patient with akinetic mutism improved most and three patients with global hypoxia did not improve at all. CONCLUSIONS Both options might be an option to increase alertness and awareness of chronic DOC patients. An akinetic mutism seems to be a positive and severe cerebral hypoxia a negative predictor. Epileptic seizures are a potential unwanted side effect. More clinical studies are warranted.
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Affiliation(s)
- Cordula Werner
- Medical Park Berlin Humboldtmühle, Neurologische Rehabilitation, Charité - Universitätsmedizin Berlin, Germany
| | - Manuela Byhahn
- Haus Havelblick, Department for intensive care nursing, Havelschanze, Berlin, Germany
| | - Stefan Hesse
- Medical Park Berlin Humboldtmühle, Neurologische Rehabilitation, Charité - Universitätsmedizin Berlin, Germany
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Naro A, Bramanti A, Leo A, Bramanti P, Calabrò RS. Metaplasticity: A Promising Tool to Disentangle Chronic Disorders of Consciousness Differential Diagnosis. Int J Neural Syst 2017; 28:1750059. [PMID: 29370729 DOI: 10.1142/s0129065717500599] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The extent of cortical reorganization after brain injury in patients with Vegetative State/Unresponsive Wakefulness Syndrome (UWS) and Minimally Conscious State (MCS) depends on the residual capability of modulating synaptic plasticity. Neuroplasticity is largely abnormal in patients with UWS, although the fragments of cortical activity may exist, while patients MCS show a better cortical organization. The aim of this study was to evaluate cortical excitability in patients with disorders of consciousness (DoC) using a transcranial direct current stimulation (TDCS) metaplasticity protocol. To this end, we tested motor-evoked potential (MEP) amplitude, short intracortical inhibition (SICI), and intracortical facilitation (ICF). These measures were correlated with the level of consciousness (by the Coma Recovery Scale-Revised, CRS-R). MEP amplitude, SICI, and ICF strength were significantly modulated following different metaplasticity TDCS protocols only in the patients with MCS. SICI modulations showed a significant correlation with the CRS-R score. Our findings demonstrate, for the first time, a partial preservation of metaplasticity properties in some patients with DoC, which correlates with the level of awareness. Thus, metaplasticity assessment may help the clinician in differentiating the patients with DoC, besides the clinical evaluation. Moreover, the responsiveness to metaplasticity protocols may identify the subjects who could benefit from neuromodulation protocols.
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Affiliation(s)
- Antonino Naro
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Messina, Italy
| | | | - Antonino Leo
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Messina, Italy
| | | | - Rocco Salvatore Calabrò
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Messina, Italy
- S.S. 113, Contrada Casazza, 98124 Messina, Italy
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87
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Bai Y, Xia X, Wang Y, Guo Y, Yang Y, He J, Li X. Fronto-parietal coherence response to tDCS modulation in patients with disorders of consciousness. Int J Neurosci 2017; 128:587-594. [PMID: 29160761 DOI: 10.1080/00207454.2017.1403440] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Yang Bai
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao, China
| | - Xiaoyu Xia
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Yong Wang
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao, China
| | - Yongkun Guo
- Department of Neurosurgery, Zheng Zhou Central Hospital, Zhengzhou, China
| | - Yi Yang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Xiaoli Li
- State Key Laboratory of Cognitive Neuroscience and Learning, IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, China
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88
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Zhang Y, Song W, Du J, Huo S, Shan G, Li R. Transcranial Direct Current Stimulation in Patients with Prolonged Disorders of Consciousness: Combined Behavioral and Event-Related Potential Evidence. Front Neurol 2017; 8:620. [PMID: 29209270 PMCID: PMC5702306 DOI: 10.3389/fneur.2017.00620] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/06/2017] [Indexed: 12/13/2022] Open
Abstract
Background The electrophysiological evidence supporting the therapeutic efficacy of multiple transcranial direct current stimulation (tDCS) sessions on consciousness improvement in patients with prolonged disorders of consciousness (DOCs) has not been firmly established. Objectives To assess the effects of repeated tDCS in patients with prolonged DOCs by Coma Recovery Scale-Revised (CRS-R) score and event-related potential (ERP). Method Using a sham-controlled randomized double-blind design, 26 patients were randomly assigned to either a real [five vegetative state (VS) and eight minimally conscious state (MCS) patients] or sham (six VS and seven MCS patients) stimulation group. The patients in the real stimulation group underwent 20 anodal tDCS sessions of the left dorsolateral prefrontal cortex (DLPFC) over 10 consecutive working days. The CRS-R score and P300 amplitude and latency in a hierarchical cognitive assessment were recorded to evaluate the consciousness level before tDCS and immediately after the 20 sessions. Results The intra-group CRS-R analysis revealed a clinically significant improvement in the MCS patients in the real stimulation group. The inter-group CRS-R analysis showed a significant difference in CRS-R between VS and MCS patients at baseline in both the real and sham stimulation groups. The intra-group ERP analysis revealed a significant increase in P300 amplitude after tDCS in the MCS patients in the real stimulation group, but no significant differences in P300 latency. For the inter-group ERP analysis, we observed significant differences regarding the presence of P300 at baseline between the VS and MCS patients in both groups. Conclusion The repeated anodal tDCS of the left DLPFC could produce clinically significant improvements in MCS patients. The observed tDCS-related consciousness improvements might be related to improvements in attention resource allocation (reflected by the P300 amplitude). The findings support the use of tDCS in clinical practice and ERP might serve as an efficient electrophysiological assessment tool in patients with DOCs.
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Affiliation(s)
- Ye Zhang
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Weiqun Song
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Jubao Du
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Su Huo
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Guixiang Shan
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Ran Li
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
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89
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Mancuso M, Abbruzzese L, Canova S, Landi G, Rossi S, Santarnecchi E. Transcranial Random Noise Stimulation Does Not Improve Behavioral and Neurophysiological Measures in Patients with Subacute Vegetative-Unresponsive Wakefulness State (VS-UWS). Front Hum Neurosci 2017; 11:524. [PMID: 29163104 PMCID: PMC5681535 DOI: 10.3389/fnhum.2017.00524] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/16/2017] [Indexed: 11/20/2022] Open
Abstract
Background: The absence of efficient treatments capable to promote central nervous system recovery in patients in vegetative state (VS) due to a severe acquired brain injury highlights the need of exploring alternative neuromodulatory treatments that can lead to neurobehavioral gains. Some encouraging preliminary observations suggest that transcranial direct current stimulation could be effective in disorders of consciousness (DoC) patients, especially when applied on the dorsolateral prefrontal cortex (DLPFC) in patients with minimally conscious state (MCS) but not in those with VS. Objective: The primary aim of the present study was to verify if the application of transcranial random noise stimulation (tRNS) on the DLPFC might favor improvements of consciousness recovery in subacute VS-UWS. Methods: Nine patients with DoC due to traumatic brain injury (n = 1), anoxia (n = 3), and vascular damage (n = 5), have undergone a randomized, double-blind, sham-controlled, neuromodulatory trial with tRNS of bilateral DLPFC. All patients were in a post-acute phase and the DoC onset ranged from 30 days to 4 months. The diagnosis of DoC was based on internationally established criteria from the Multi-Society Task Force on PVS, and classified as VS or MCS using the JFK Coma Recovery Scale-Revised scores (CRS-R). We used CRS-R, Synek Scale, Ad-Hoc semi-quantitative scale and the Clinical Global Impression-Improvement scale to measure behavioral and electrophysiological changes during tRNS intervention. All patients were also treated with daily conventional rehabilitation treatment. Results: No significant differences emerged between active and sham groups regarding improvements of level of consciousness, as well as on electroencephalographic data. Only one patient showed emergence from VS-UWS, evolving from VS to MCS after the tRNS stimulation, at a distance of 3 weeks from the enrolment into the study. Conclusion: Repeated applications of tRNS of the DLPFC, even if applied in a subacute phase of VS-UWS state, did not modify behavioral and neurophysiological outcomes differently than sham stimulation.
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Affiliation(s)
| | | | | | - Giulia Landi
- Siena Brain Investigation and Neuromodulation Lab, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Simone Rossi
- Siena Brain Investigation and Neuromodulation Lab, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Emiliano Santarnecchi
- Siena Brain Investigation and Neuromodulation Lab, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Cognitive Neurology, Harvard Medical School, Boston, MA, United States
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90
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Long-lasting repetitive transcranial magnetic stimulation modulates electroencephalography oscillation in patients with disorders of consciousness. Neuroreport 2017; 28:1022-1029. [DOI: 10.1097/wnr.0000000000000886] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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91
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Bikson M, Paneri B, Mourdoukoutas A, Esmaeilpour Z, Badran BW, Azzam R, Adair D, Datta A, Fang XH, Wingeier B, Chao D, Alonso-Alonso M, Lee K, Knotkova H, Woods AJ, Hagedorn D, Jeffery D, Giordano J, Tyler WJ. Limited output transcranial electrical stimulation (LOTES-2017): Engineering principles, regulatory statutes, and industry standards for wellness, over-the-counter, or prescription devices with low risk. Brain Stimul 2017; 11:134-157. [PMID: 29122535 DOI: 10.1016/j.brs.2017.10.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 09/16/2017] [Accepted: 10/15/2017] [Indexed: 01/17/2023] Open
Abstract
We present device standards for low-power non-invasive electrical brain stimulation devices classified as limited output transcranial electrical stimulation (tES). Emerging applications of limited output tES to modulate brain function span techniques to stimulate brain or nerve structures, including transcranial direct current stimulation (tDCS), transcranial alternating current stimulation (tACS), and transcranial pulsed current stimulation (tPCS), have engendered discussion on how access to technology should be regulated. In regards to legal regulations and manufacturing standards for comparable technologies, a comprehensive framework already exists, including quality systems (QS), risk management, and (inter)national electrotechnical standards (IEC). In Part 1, relevant statutes are described for medical and wellness application. While agencies overseeing medical devices have broad jurisdiction, enforcement typically focuses on those devices with medical claims or posing significant risk. Consumer protections regarding responsible marketing and manufacture apply regardless. In Part 2 of this paper, we classify the electrical output performance of devices cleared by the United States Food and Drug Administration (FDA) including over-the-counter (OTC) and prescription electrostimulation devices, devices available for therapeutic or cosmetic purposes, and devices indicated for stimulation of the body or head. Examples include iontophoresis devices, powered muscle stimulators (PMS), cranial electrotherapy stimulation (CES), and transcutaneous electrical nerve stimulation (TENS) devices. Spanning over 13 FDA product codes, more than 1200 electrical stimulators have been cleared for marketing since 1977. The output characteristics of conventional tDCS, tACS, and tPCS techniques are well below those of most FDA cleared devices, including devices that are available OTC and those intended for stimulation on the head. This engineering analysis demonstrates that with regard to output performance and standing regulation, the availability of tDCS, tACS, or tPCS to the public would not introduce risk, provided such devices are responsibly manufactured and legally marketed. In Part 3, we develop voluntary manufacturer guidance for limited output tES that is aligned with current regulatory standards. Based on established medical engineering and scientific principles, we outline a robust and transparent technical framework for ensuring limited output tES devices are designed to minimize risks, while also supporting access and innovation. Alongside applicable medical and government activities, this voluntary industry standard (LOTES-2017) further serves an important role in supporting informed decisions by the public.
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Affiliation(s)
- Marom Bikson
- The City College of New York, Department of Biomedical Engineering, New York, NY 10031, USA.
| | - Bhaskar Paneri
- The City College of New York, Department of Biomedical Engineering, New York, NY 10031, USA
| | - Andoni Mourdoukoutas
- The City College of New York, Department of Biomedical Engineering, New York, NY 10031, USA
| | - Zeinab Esmaeilpour
- The City College of New York, Department of Biomedical Engineering, New York, NY 10031, USA
| | - Bashar W Badran
- U.S. Army Research Laboratory, Aberdeen Proving Ground, MD, USA; Department of Psychology, University of New Mexico, Albuquerque, NM, USA
| | | | - Devin Adair
- The City College of New York, Department of Biomedical Engineering, New York, NY 10031, USA
| | | | - Xiao Hui Fang
- The City College of New York, Department of Biomedical Engineering, New York, NY 10031, USA
| | | | - Daniel Chao
- Halo Neuroscience Inc., San Francisco, CA 94103, USA
| | - Miguel Alonso-Alonso
- Harvard Medical School, Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Boston, MA, USA
| | - Kiwon Lee
- Ybrain Inc., Sampyeong-dong, Seongnam-si, South Korea
| | - Helena Knotkova
- MJHS Institute for Innovation in Palliative Care, New York, NY, USA; Department of Family and Social Medicine, Albert Einstein College of Medicine, The Bronx, NY, USA
| | - Adam J Woods
- Center for Cognitive Aging and Memory, McKnight Brain Institute, Department of Clinical and Health Psychology, University of Florida, USA
| | | | | | - James Giordano
- Department of Neurology and Neuroethics Studies Program, Pellegrino Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC, USA
| | - William J Tyler
- Arizona State University, School of Biological and Health Systems Engineering, Tempe, AZ 85287, USA
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92
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Zhang Y, Song W. Transcranial direct current stimulation in disorders of consciousness: a review. Int J Neurosci 2017; 128:255-261. [PMID: 28918680 DOI: 10.1080/00207454.2017.1381094] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Ye Zhang
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Weiqun Song
- Department of Rehabilitation Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
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93
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Ragazzoni A, Cincotta M, Giovannelli F, Cruse D, Young GB, Miniussi C, Rossi S. Clinical neurophysiology of prolonged disorders of consciousness: From diagnostic stimulation to therapeutic neuromodulation. Clin Neurophysiol 2017; 128:1629-1646. [DOI: 10.1016/j.clinph.2017.06.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/17/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
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94
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Xie Q, Ni X, Yu R, Li Y, Huang R. Chronic disorders of consciousness. Exp Ther Med 2017; 14:1277-1283. [PMID: 28810588 DOI: 10.3892/etm.2017.4639] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 02/17/2017] [Indexed: 01/19/2023] Open
Abstract
Over the last 20 years, studies have provided greater insight into disorders of consciousness (DOC), also known as altered state of consciousness. Increased brain residual functions have been identified in patients with DOC due to the successful application of novel next-generation imaging technologies. Many unconscious patients have now been confirmed to retain considerable cognitive functions. It is hoped that greater insight regarding the psychological state of patients may be achieved through the use of functional magnetic resonance imaging and brain-computer interfaces. However, issues surrounding the research and treatment of DOC remain problematic. These include differing opinions on the definition of consciousness, difficulties in diagnosis, assessment, prognosis and/or treatment, and newly emerging ethical, legal and social issues. To overcome these, appropriate care must be offered to patients with DOC by clinicians and families, as DOC patients may now be considered to live in more than just a vegetative state. The present article reviews the controversy surrounding the definition of consciousness and the reliability of novel technologies, prognostic prediction, communication with DOC patients and treatment methods. The ethical and social issues surrounding the treatment of DOC and future perspectives are also considered.
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Affiliation(s)
- Qiuyou Xie
- Coma Research Group, Center for Hyperbaric Oxygen and Neurorehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Command, Guangzhou, Guangdong 510010, P.R. China
| | - Xiaoxiao Ni
- Coma Research Group, Center for Hyperbaric Oxygen and Neurorehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Command, Guangzhou, Guangdong 510010, P.R. China
| | - Ronghao Yu
- Coma Research Group, Center for Hyperbaric Oxygen and Neurorehabilitation, Neuroscience Institute, Guangzhou General Hospital of Guangzhou Command, Guangzhou, Guangdong 510010, P.R. China
| | - Yuanqing Li
- Center for Brain Computer Interfaces and Brain Information Processing, South China University of Technology, Guangzhou, Guangdong 510641, P.R. China
| | - Ruiwang Huang
- Centre for Studies of Psychological Application, Guangdong Key Laboratory of Mental Health and Cognitive Science, School of Psychology, South China Normal University, Guangzhou, Guangdong 510631, P.R. China
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95
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de Amorim RLO, Brunoni AR, de Oliveira MAF, Zaninotto ALC, Nagumo MM, Guirado VMDP, Neville IS, Benute GRG, de Lucia MCS, Paiva WS, de Andrade AF, Teixeira MJ. Transcranial Direct Current Stimulation for Post-Concussion Syndrome: Study Protocol for a Randomized Crossover Trial. Front Neurol 2017; 8:164. [PMID: 28512443 PMCID: PMC5411433 DOI: 10.3389/fneur.2017.00164] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 04/07/2017] [Indexed: 01/13/2023] Open
Abstract
Background Mild traumatic brain injury (MTBI) represents 70–80% of all treated brain injuries. A considerable proportion of MTBI patients experience post-concussion symptoms for a prolonged period after MTBI, and these symptoms are diagnosed as persistent post-concussion syndrome (PPCS). PPCS is defined as a range of physical, cognitive, and emotional symptoms. However, memory and executive dysfunction seems to be one of the most debilitating symptoms. Recently, non-invasive brain stimulation has been studied as a potential treatment method for traumatic brain injury (TBI) patients. Therefore, our primary goal is to verify the effects of transcranial direct current stimulation (tDCS) in patients with PPCS who demonstrate cognitive deficits in long-term episodic memory, working memory, and executive function following MTBI. Methods/design This is a randomized crossover trial of patients with a history of MTBI with cognitive deficits in memory and executive function. Thirty adult patients will be randomized in a crossover manner to receive three weekly sessions of anodal tDCS (2 mA) at left dorsolateral prefrontal cortex, left temporal cortex, and sham stimulation that will be performed at 7-day intervals (washout period). The clinical diagnosis of PPCS will be determined using the Rivermead Post-Concussion Symptoms Questionnaire. Patients who meet the inclusion criteria will be assessed with a neuropsychological evaluation. A new battery of computerized neuropsychological tests will be performed before and immediately after each stimulation. Statistical analysis will be performed to determine trends of cognitive improvement. Discussion There is paucity of studies regarding the use of tDCS in TBI patients, and although recent results showed controversial data regarding the effects of tDCS in such patients, we will address specifically patients with PPCS and MTBI and no brain abnormalities on CT scan other than subarachnoid hemorrhage. Moreover, due to the missing information on literature regarding the best brain region to be studied, we will evaluate two different regions to find immediate effects of tDCS on memory and executive dysfunction. Clinical Trial Registration www.ClinicalTrials.gov, identifier NCT02292589 (https://register.clinicaltrials.gov).
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Affiliation(s)
| | - André Russowsky Brunoni
- Division of Psychiatry and Psychology, University Hospital of São Paulo University, São Paulo, Brazil
| | | | | | - Marcia Mitie Nagumo
- Division of Neurosurgery, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Iuri Santana Neville
- Division of Neurosurgery, University of São Paulo Medical School, São Paulo, Brazil
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96
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Zhao H, Qiao L, Fan D, Zhang S, Turel O, Li Y, Li J, Xue G, Chen A, He Q. Modulation of Brain Activity with Noninvasive Transcranial Direct Current Stimulation (tDCS): Clinical Applications and Safety Concerns. Front Psychol 2017; 8:685. [PMID: 28539894 PMCID: PMC5423956 DOI: 10.3389/fpsyg.2017.00685] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 04/19/2017] [Indexed: 11/13/2022] Open
Abstract
Transcranial direct current stimulation (tDCS) is a widely-used tool to induce neuroplasticity and modulate cortical function by applying weak direct current over the scalp. In this review, we first introduce the underlying mechanism of action, the brief history from discovery to clinical scientific research, electrode positioning and montages, and parameter setup of tDCS. Then, we review tDCS application in clinical samples including people with drug addiction, major depression disorder, Alzheimer's disease, as well as in children. This review covers the typical characteristics and the underlying neural mechanisms of tDCS treatment in such studies. This is followed by a discussion of safety, especially when the current intensity is increased or the stimulation duration is prolonged. Given such concerns, we provide detailed suggestions regarding safety procedures for tDCS operation. Lastly, future research directions are discussed. They include foci on the development of multi-tech combination with tDCS such as with TMS and fMRI; long-term behavioral and morphological changes; possible applications in other research domains, and more animal research to deepen the understanding of the biological and physiological mechanisms of tDCS stimulation.
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Affiliation(s)
- Haichao Zhao
- Faculty of Psychology, Southwest UniversityChongqing, China
| | - Lei Qiao
- Faculty of Psychology, Southwest UniversityChongqing, China
| | - Dongqiong Fan
- Faculty of Psychology, Southwest UniversityChongqing, China
| | - Shuyue Zhang
- School of Education, Guangxi UniversityNanning, China
| | - Ofir Turel
- Department of Information systems and Decision Sciences, College of Business and Economics, California State University, FullertonFullerton, CA, USA
| | - Yonghui Li
- Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of SciencesBeijing, China
| | - Jun Li
- National Key Laboratory of Cognitive Neuroscience and Learning, IDG/McGovern Institute for Brain Research, Beijing Normal UniversityBeijing, China
| | - Gui Xue
- National Key Laboratory of Cognitive Neuroscience and Learning, IDG/McGovern Institute for Brain Research, Beijing Normal UniversityBeijing, China
| | - Antao Chen
- Faculty of Psychology, Southwest UniversityChongqing, China
| | - Qinghua He
- Faculty of Psychology, Southwest UniversityChongqing, China.,Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of SciencesBeijing, China.,Southwest University Branch, Collaborative Innovation Center of Assessment toward Basic Education Quality at Beijing Normal UniversityChongqing, China
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97
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Xia X, Bai Y, Zhou Y, Yang Y, Xu R, Gao X, Li X, He J. Effects of 10 Hz Repetitive Transcranial Magnetic Stimulation of the Left Dorsolateral Prefrontal Cortex in Disorders of Consciousness. Front Neurol 2017; 8:182. [PMID: 28515709 PMCID: PMC5413493 DOI: 10.3389/fneur.2017.00182] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 04/18/2017] [Indexed: 11/13/2022] Open
Abstract
Background While repetitive transcranial magnetic stimulation (rTMS) has been applied in treatment of patients with disorders of consciousness (DOC), a standardized stimulation protocol has not been proposed, and its therapeutic effects are inconsistently documented. Objectives To assess the efficacy of rTMS in improving consciousness in patients with persistent minimally conscious state (MCS) or unresponsive wakefulness syndrome (UWS), previously known as vegetative state (VS). Method A prospective single-blinded study, with selected subjects, was carried out. In total, 16 patients (5 MCS and 11 VS/UWS) with chronic DOC were included. All patients received active 10 Hz rTMS at the left dorsolateral prefrontal cortex (DLPFC), at one session per day, for 20 consecutive days. A single daily session of stimulation consisted of 1,000 pulses (10 s of 10 Hz trains; repeated 10 times with an inter-train interval of 60 s; and 11 min and 40 s for total session). The main outcome measures were changes in the total score on the JFK Coma Recovery Scale-Revised (CRS-R) scale. Additional measures were the impressions of caregivers after the conclusion of the interventions, which were assessed using the Clinical Global Impression-Improvement (CGI-I) scale. Results The CRS-R scores were increased in all 5 MCS patients and 4 of 11 VS/UWS patients, while a significant enhancement of CRS-R scores was observed compared to the baseline in all participants (p = 0.007). However, the improvement was more notable in MCS patients (p = 0.042) than their VS/UWS counterparts (p = 0.066). Based on the CGI-I scores, two patients improved considerably, two improved, six minimally improved, six experienced no change, and none deteriorated. Good concordance was seen between the CGI-I result and the increases in CRS-R scores. Conclusion Treatment of 10 Hz multisession rTMS applied to the left DLPFC is promising for the rehabilitation of DOC patients, especially those in MCS. Further validation with a cohort of a larger sample size is required.
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Affiliation(s)
- Xiaoyu Xia
- School of Medicine, Tsinghua University, Beijing, China.,Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Yang Bai
- Institute of Electrical Engineering, Yanshan University, Qinhuangdao, China
| | | | - Yi Yang
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Ruxiang Xu
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
| | - Xiaorong Gao
- School of Medicine, Tsinghua University, Beijing, China
| | - Xiaoli Li
- State Key Laboratory of Cognitive Neuroscience and Learning, IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, PLA Army General Hospital, Beijing, China
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98
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Dimitri D, De Filippis D, Galetto V, Zettin M. Evaluation of the effectiveness of transcranial direct current stimulation (tDCS) and psychosensory stimulation through DOCS scale in a minimally conscious subject. Neurocase 2017; 23:96-104. [PMID: 28347207 DOI: 10.1080/13554794.2017.1305112] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The aim of our study was to assess the effectiveness of transcranial direct current stimulation (tDCS) on alertness improvement in a patient in a minimally conscious state (MCS) by means of disorders of consciousness scale combined with psycho-sensory stimulation. The effects of tDCS on muscle hypertonia through the Ashworth scale were also examined. tDCS was performed through a two-channel intra-cephalic stimulator. After stimulation, the patient followed a psychosensory stimulation training. Results pointed out an increase in DOCunit score, as well as an increase in alertness maintenance and an improvement in muscle hypertonia, although a MCS state persisted.
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Affiliation(s)
- Danilo Dimitri
- a Department of Psychology , University of Turin , Torin , Italy
| | | | - Valentina Galetto
- a Department of Psychology , University of Turin , Torin , Italy.,b Brain Imaging Group , University of Turin , Torin , Italy
| | - Marina Zettin
- a Department of Psychology , University of Turin , Torin , Italy.,b Brain Imaging Group , University of Turin , Torin , Italy
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99
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Estraneo A, Pascarella A, Moretta P, Masotta O, Fiorenza S, Chirico G, Crispino E, Loreto V, Trojano L. Repeated transcranial direct current stimulation in prolonged disorders of consciousness: A double-blind cross-over study. J Neurol Sci 2017; 375:464-470. [PMID: 28320187 DOI: 10.1016/j.jns.2017.02.036] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 01/15/2017] [Accepted: 02/15/2017] [Indexed: 10/20/2022]
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Thibaut A, Wannez S, Donneau AF, Chatelle C, Gosseries O, Bruno MA, Laureys S. Controlled clinical trial of repeated prefrontal tDCS in patients with chronic minimally conscious state. Brain Inj 2017; 31:466-474. [DOI: 10.1080/02699052.2016.1274776] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Aurore Thibaut
- Coma Science Group, GIGA-research, University of Liège, Liège, Belgium
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Wannez
- Coma Science Group, GIGA-research, University of Liège, Liège, Belgium
| | | | - Camille Chatelle
- Coma Science Group, GIGA-research, University of Liège, Liège, Belgium
- Laboratory for NeuroImaging of Coma and Consciousness, Massachusetts General Hospital, Boston, MA, USA
| | - Olivia Gosseries
- Coma Science Group, GIGA-research, University of Liège, Liège, Belgium
| | | | - Steven Laureys
- Coma Science Group, GIGA-research, University of Liège, Liège, Belgium
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