Combined Transcranial Direct Current Stimulation and Virtual Reality-Based Paradigm for Upper Limb Rehabilitation in Individuals with Restricted Movements. A Feasibility Study with a Chronic Stroke Survivor with Severe Hemiparesis

Post-Stroke Rehabilitation of Distal Upper Limb with New Perspective Technologies: Virtual Reality and Repetitive Transcranial Magnetic Stimulation-A Mini Review

Upper extremity motor impairment is the most common sequelae in patients with stroke. Moreover, its continual nature limits the optimal functioning of patients in the activities of daily living. Because of the intrinsic limitations in the conventional form of rehabilitation, the rehabilitation applications have been expanded to technology-driven solutions, such as Virtual Reality and Repetitive Transcranial Magnetic Stimulation (rTMS). The motor relearning processes are influenced by variables, such as task specificity, motivation, and feedback provision, and a VR environment in the form of interactive games could provide novel and motivating customized training solutions for better post-stroke upper limb motor improvement. rTMS being a precise non-invasive brain stimulation method with good control of stimulation parameters, has the potential to facilitate neuroplasticity and hence a good recovery. Although several studies have discussed these forms of approaches and their underlying mechanisms, only a few of them have specifically summarized the synergistic applications of these paradigms. To bridge the gaps, this mini review presents recent research and focuses precisely on the applications of VR and rTMS in distal upper limb rehabilitation. It is anticipated that this article will provide a better representation of the role of VR and rTMS in distal joint upper limb rehabilitation in patients with stroke.

Recovering arm function in chronic stroke patients using combined anodal HD-tDCS and virtual reality therapy (ReArm): a study protocol for a randomized controlled trial

BACKGROUND

After a stroke, 80% of the chronic patients have difficulties to use their paretic upper limb (UL) in activities of daily life (ADL) even after rehabilitation. Virtual reality therapy (VRT) and anodal transcranial direct current stimulation (tDCS) are two innovative methods that have shown independently to positively impact functional recovery of the paretic UL when combined with conventional therapy. The objective of the project will be to evaluate the impact of adding anodal high-definition (HD)-tDCS during an intensive 3-week UL VRT and conventional therapy program on paretic UL function in chronic stroke.

METHODS

The ReArm project is a quadruple-blinded, randomized, sham-controlled, bi-centre, two-arm parallel, and interventional study design. Fifty-eight chronic (> 3 months) stroke patients will be recruited from the Montpellier and Nimes University Hospitals. Patients will follow a standard 3-week in-patient rehabilitation program, which includes 13 days of VRT (Armeo Spring, 1 × 30 min session/day) and conventional therapy (3 × 30 min sessions/day). Twenty-nine patients will receive real stimulation (4x1 anodal HD-tDCS montage, 2 mA, 20 min) to the ipsilesional primary motor cortex during the VRT session and the other 29 patients will receive active sham stimulation (2 mA, 30 s). All outcome measures will be assessed at baseline, at the end of rehabilitation and again 3 months later. The primary outcome measure will be the wolf motor function test. Secondary outcomes will include measures of UL function (Box and Block Test), impairment (Fugl Meyer Upper Extremity), compensation (Proximal Arm Non-Use), ADL (Actimetry, Barthel Index). Other/exploratory outcomes will include pain, fatigue, effort and performance, kinematics, and motor cortical region activation during functional motor tasks.

DISCUSSION

This will be the first trial to determine the impact of adding HD-tDCS during UL VRT and conventional therapy in chronic stroke patients. We hypothesize that improvements in UL function will be greater and longer-lasting with real stimulation than in those receiving sham.

TRIAL REGISTRATION

The ReArm project was approved by The French Research Ethics Committee, (Comité de Protection des Personnes-CPP SUD-EST II, N°ID-RCB: 2019-A00506-51, http://www.cppsudest2.fr/ ). The ReArm project was registered on ClinicalTrials.gov ( NCT04291573 , 2nd March 2020.

Clinical Effects of Immersive Multimodal BCI-VR Training after Bilateral Neuromodulation with rTMS on Upper Limb Motor Recovery after Stroke. A Study Protocol for a Randomized Controlled Trial

Background and Objectives: The motor sequelae after a stroke are frequently persistent and cause a high degree of disability. Cortical ischemic or hemorrhagic strokes affecting the cortico-spinal pathways are known to cause a reduction of cortical excitability in the lesioned area not only for the local connectivity impairment but also due to a contralateral hemisphere inhibitory action. Non-invasive brain stimulation using high frequency repetitive magnetic transcranial stimulation (rTMS) over the lesioned hemisphere and contralateral cortical inhibition using low-frequency rTMS have been shown to increase the excitability of the lesioned hemisphere. Mental representation techniques, neurofeedback, and virtual reality have also been shown to increase cortical excitability and complement conventional rehabilitation. Materials and Methods: We aim to carry out a single-blind, randomized, controlled trial aiming to study the efficacy of immersive multimodal Brain-Computer Interfacing-Virtual Reality (BCI-VR) training after bilateral neuromodulation with rTMS on upper limb motor recovery after subacute stroke (>3 months) compared to neuromodulation combined with conventional motor imagery tasks. This study will include 42 subjects in a randomized controlled trial design. The main expected outcomes are changes in the Motricity Index of the Arm (MI), dynamometry of the upper limb, score according to Fugl-Meyer for upper limb (FMA-UE), and changes in the Stroke Impact Scale (SIS). The evaluation will be carried out before the intervention, after each intervention and 15 days after the last session. Conclusions: This trial will show the additive value of VR immersive motor imagery as an adjuvant therapy combined with a known effective neuromodulation approach opening new perspectives for clinical rehabilitation protocols.

Effectiveness of a combined transcranial direct current stimulation and virtual reality-based intervention on upper limb function in chronic individuals post-stroke with persistent severe hemiparesis: a randomized controlled trial

BACKGROUND

Functional impairments derived from the non-use of severely affected upper limb after stroke have been proposed to be mitigated by action observation and imagination-based techniques, whose effectiveness is enhanced when combined with transcranial direct current stimulation (tDCS). Preliminary studies in mildly impaired individuals in the acute phase post-stroke show intensified effects when action is facilitated by tDCS and mediated by virtual reality (VR) but the effectiveness in cases of severe impairment and chronic stroke is unknown. This study investigated the effectiveness of a combined tDCS and VR-based intervention in the sensorimotor function of chronic individuals post-stroke with persistent severe hemiparesis compared to conventional physical therapy.

METHODS

Twenty-nine participants were randomized into an experimental group, who received 30 minutes of the combined tDCS and VR-based therapy and 30 minutes of conventional physical therapy, or a control group, who exclusively received conventional physical therapy focusing on passive and active assistive range of motion exercises. The sensorimotor function of all participants was assessed before and after 25 one-hour sessions, administered three to five times a week, using the upper extremity subscale of the Fugl-Meyer Assessment, the time and ability subscales of the Wolf Motor Function Test, and the Nottingham Sensory Assessment.

RESULTS

A clinically meaningful improvement of the upper limb motor function was consistently revealed in all motor measures after the experimental intervention, but not after conventional physical therapy. Similar limited effects were detected in the sensory function in both groups.

CONCLUSION

The combined tDCS and VR-based paradigm provided not only greater but also clinically meaningful improvement in the motor function (and similar sensory effects) in comparison to conventional physical therapy.

Electroencephalogram-based neurofeedback training in persons with stroke: A scoping review in occupational therapy

BACKGROUND

Neurofeedback training targets the relevant brain response under minimal stress. It could be a promising approach for the treatment of patients with brain injury.

OBJECTIVE

This review aimed to examine the existing literature to confirm the effectiveness of applied electroencephalogram (EEG)-based neurofeedback training in the area of occupational therapy for upper limb stroke rehabilitation.

METHOD

All relevant literature published until July 1, 2020 in five prominent databases (PubMed, CINAHL, PsycINFO, MEDLINE Complete, and Web of Science) was reviewed, based on the five-step review framework proposed by Arksey and O'Malley.

RESULTS

After a thorough review, a total of 14 studies were included in this review. Almost studies reported significant improvements as a result of EEG-based neurofeedback training, but this had not always account for the differences in effectiveness between groups. However, the results of these studies suggested that neurofeedback training was effective as compared to the traditional treatment and more effective in combination with EEG than that with simple equipment application.

CONCLUSION

This review demonstrated the effectiveness of the combination of occupational therapy and EEG-based neurofeedback training. Most of these treatments are intended for inpatients, but they may be more effective for outpatients, especially if customized to their requirements. Also, such explorations to assess the suitability of the treatment for patient rehabilitation will help reduce barriers to effective interventions. An analysis of the opinions of participants and experts through satisfaction surveys will be helpful.

Virtual reality and non-invasive brain stimulation for rehabilitation applications: a systematic review

The present article reports the results of a systematic review on the potential benefits of the combined use of virtual reality (VR) and non-invasive brain stimulation (NIBS) as a novel approach for rehabilitation. VR and NIBS are two rehabilitation techniques that have been consistently explored by health professionals, and in recent years there is strong evidence of the therapeutic benefits of their combined use. In this work, we reviewed research articles that report the combined use of VR and two common NIBS techniques, namely transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS). Relevant queries to six major bibliographic databases were performed to retrieve original research articles that reported the use of the combination VR-NIBS for rehabilitation applications. A total of 16 articles were identified and reviewed. The reviewed studies have significant differences in the goals, materials, methods, and outcomes. These differences are likely caused by the lack of guidelines and best practices on how to combine VR and NIBS techniques. Five therapeutic applications were identified: stroke, neuropathic pain, cerebral palsy, phobia and post-traumatic stress disorder, and multiple sclerosis rehabilitation. The majority of the reviewed studies reported positive effects of the use of VR-NIBS. However, further research is still needed to validate existing results on larger sample sizes and across different clinical conditions. For these reasons, in this review recommendations for future studies exploring the combined use of VR and NIBS are presented to facilitate the comparison among works.

Analysis of the Factors Related to the Effectiveness of Transcranial Current Stimulation in Upper Limb Motor Function Recovery after Stroke: a Systematic Review

Transcranial direct current stimulation is one of the non-invasive techniques whose main mechanism of action is based on its modulation of cortical excitability. The objective of this study is to analyze the variables (i.e, demographics, clinicals, stimulation parameters) that could influence into the responses during rehabilitation of the upper extremity in patients with stroke. Our systematic review has been performed by searching full-text articles published from January 2008 to December 2018 in Embase, Medline, PubMed and Cochrane Library databases. Studies with adult patients with ischemic or hemorrhagic stroke at any stage of evolution were included. We compared interventions with any type of transcranial direct current stimulation (anodal, cathodal or bihemispheric, also known as dual) regarding improvement of upper extremity motor function. We included 14 studies with 368 patients, of whom almost 89% have ischemic etiology and more than half are males. Most patients were considered subacute or chronic, while only two studies were selected with patients in the acute phase. Different methods of using transcranial direct current stimulation with several complementary therapies were identified, such as virtual reality, robot therapy, Occupational Therapy, Physiotherapy, Constraint Induced Movement Therapy or Peripheral Nerve Stimulation. In conclusion, there is not significant evidence due to heterogeneity of clinical data and therapies. Clinical studies with greater number of participants and protocols standardized could outline this assessment in future studies.

Compensatory Relearning Following Stroke: Cellular and Plasticity Mechanisms in Rodents

von Monakow’s theory of diaschisis states the functional ‘standstill’ of intact brain regions that are remote from a damaged area, often implied in recovery of function. Accordingly, neural plasticity and activity patterns related to recovery are also occurring at the same regions. Recovery relies on plasticity in the periinfarct and homotopic contralesional regions and involves relearning to perform movements. Seeking evidence for a relearning mechanism following stroke, we found that rodents display many features that resemble classical learning and memory mechanisms. Compensatory relearning is likely to be accompanied by gradual shaping of these regions and pathways, with participating neurons progressively adapting cortico-striato-thalamic activity and synaptic strengths at different cortico-thalamic loops – adapting function relayed by the striatum. Motor cortex functional maps are progressively reinforced and shaped by these loops as the striatum searches for different functional actions. Several cortical and striatal cellular mechanisms that influence motor learning may also influence post-stroke compensatory relearning. Future research should focus on how different neuromodulatory systems could act before, during or after rehabilitation to improve stroke recovery.

Do Robotics and Virtual Reality Add Real Progress to Mirror Therapy Rehabilitation? A Scoping Review

BACKGROUND

Mirror therapy has been used in rehabilitation for multiple indications since the 1990s. Current evidence supports some of these indications, particularly for cerebrovascular accidents in adults and cerebral palsy in children. Since 2000s, computerized or robotic mirror therapy has been developed and marketed.

OBJECTIVES

To map the extent, nature, and rationale of research activity in robotic or computerized mirror therapy and the type of evidence available for any indication. To investigate the relevance of conducting a systematic review and meta-analysis on these therapies.

METHOD

Systematic scoping review. Searches were conducted (up to May 2018) in the Cochrane Library, Google Scholar, IEEE Xplore, Medline, Physiotherapy Evidence Database, and PsycINFO databases. References from identified studies were examined.

RESULTS

In sum, 75 articles met the inclusion criteria. Most studies were publicly funded (57% of studies; n = 43), without disclosure of conflict of interest (59% of studies; n = 44). The main outcomes assessed were pain, satisfaction on the device, and body function and activity, mainly for stroke and amputees patients and healthy participants. Most design studies were case reports (67% of studies; n = 50), with only 12 randomized controlled trials with 5 comparing standard mirror therapy versus virtual mirror therapy, 5 comparing second-generation mirror therapy versus conventional rehabilitation, and 2 comparing other interventions.

CONCLUSION

Much of the research on second-generation mirror therapy is of very low quality. Evidence-based rationale to conduct such studies is missing. It is not relevant to recommend investment by rehabilitation professionals and institutions in such devices.