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Li LL, Wu JJ, Li KP, Jin J, Xiang YT, Hua XY, Zheng MX, Xu JG. Comparative efficacy of different noninvasive brain stimulation protocols on upper-extremity motor function and activities of daily living after stroke: a systematic review and network meta-analysis. Neurol Sci 2024; 45:3641-3681. [PMID: 38520639 DOI: 10.1007/s10072-024-07437-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/29/2024] [Indexed: 03/25/2024]
Abstract
The objectives of the study were to systematically evaluate the rehabilitation effect of noninvasive brain stimulation (NIBS) on upper extremity motor function and activities of daily living in stroke patients and to prioritize various stimulation protocols for reliable evidence-based medical recommendations in patients with upper extremity motor dysfunction after stroke. Web of Science, PubMed, Embase, Cochrane Library, CNKI, Wanfang, VIP, and CBM were searched to collect all randomized controlled trials (RCTs) of NIBS to improve upper extremity motor function in stroke patients. The retrieval time was from the establishment of all databases to May 2023. According to the Cochrane system evaluation manual, the quality of the included studies was evaluated, and the data were extracted. Statistical analysis was carried out by using RevMan 5.3, R 4.3.0, and Stata 17.0 software. Finally, 94 RCTs were included, with a total of 5546 patients. Meta-analysis showed that NIBS improved the Fugl-Meyer assessment (FMA) score (mean difference (MD) = 6.51, 95% CI 6.20 ~ 6.82, P < 0.05), MBI score (MD = 7.69, 95% CI 6.57 ~ 8.81, P < 0.05), ARAT score (MD = 5.06, 95% CI 3.85 ~ 6.27, P < 0.05), and motor evoked potential (MEP) amplitude. The modified Ashworth scale score (MD = - 0.37, 95% CI - 0.60 to - 0.14, P < 0.05), National Institutes of Health Stroke Scale score (MD = - 2.17, 95% CI - 3.32 to - 1.11, P < 0.05), incubation period of MEP (MD = - 0.72, 95% CI - 1.06 to - 0.38, P < 0.05), and central motor conduction time (MD = - 0.90, 95% CI - 1.29 to - 0.50, P < 0.05) were decreased in stroke patients. Network meta-analysis showed that the order of interventions in improving FMA scores from high to low was anodal-transcranial direct current stimulation (tDCS) (surface under the cumulative ranking curve (SUCRA) = 83.7%) > cathodal-tDCS (SUCRA = 80.2%) > high-frequency (HF)-repetitive transcranial magnetic stimulation (rTMS) (SUCRA = 68.5%) > low-frequency (LF)-rTMS (SUCRA = 66.5%) > continuous theta burst stimulation (cTBS) (SUCRA = 54.2%) > bilateral-tDCS (SUCRA = 45.2%) > intermittent theta burst stimulation (iTBS) (SUCRA = 34.1%) > sham-NIBS (SUCRA = 16.0%) > CR (SUCRA = 1.6%). In terms of improving MBI scores, the order from high to low was anodal-tDCS (SUCRA = 88.7%) > cathodal-tDCS (SUCRA = 85.4%) > HF-rTMS (SUCRA = 63.4%) > bilateral-tDCS (SUCRA = 56.0%) > LF-rTMS (SUCRA = 54.2%) > iTBS (SUCRA = 32.4%) > sham-NIBS (SUCRA = 13.8%) > CR (SUCRA = 6.1%). NIBS can effectively improve upper extremity motor function and activities of daily living after stroke. Among the various NIBS protocols, anodal-tDCS demonstrated the most significant intervention effect, followed by cathodal-tDCS and HF-rTMS.
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Affiliation(s)
- Ling-Ling Li
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Jia-Jia Wu
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- Department of Rehabilitation Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China
| | - Kun-Peng Li
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Jing Jin
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Yun-Ting Xiang
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Xu-Yun Hua
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
- Department of Traumatology and Orthopedics, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China.
| | - Mou-Xiong Zheng
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
- Department of Traumatology and Orthopedics, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 200437, China.
| | - Jian-Guang Xu
- Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
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Kolbaşı EN, Huseyinsinoglu BE, Ozdemir Z, Bayraktaroglu Z, Soysal A. Effectiveness of Intermittent Theta Burst Stimulation to Enhance Upper Extremity Recovery After Stroke: A Pilot Study. Arch Phys Med Rehabil 2024:S0003-9993(24)01045-1. [PMID: 38862033 DOI: 10.1016/j.apmr.2024.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 05/09/2024] [Accepted: 05/17/2024] [Indexed: 06/13/2024]
Abstract
OBJECTIVES To first investigate the effectiveness of modified constraint-ınduced movement therapy (mCIMT) in low-functioning patients with stroke (PwS). Second, we aimed to investigate the efficiency of intermittent theta-burst stimulation (iTBS), applied on intermittent days, in addition to the mCIMT in PwS. DESIGN A randomized, sham-controlled, single-blinded study. SETTING Outpatient clinic. PARTICIPANTS Fifteen PwS (age [mean±SD]: 66.3±9.2 years; 53% female) who were in the first 1 to 12 months after the incident were included in the study. INTERVENTIONS PwS were divided into 3 groups: (1) mCIMT alone; (2) mCIMT + sham iTBS; (3) mCIMT + iTBS. Each group received 15 sessions of mCIMT (1 hour/session, 3 sessions/week). iTBS was applied with 600 pulses on impaired M1 before mCIMT. MAIN OUTCOME MEASURES Upper extremity (UE) impairment was assessed with the Fugl-Meyer Test (FMT-UE), whereas the motor function was evaluated with the Wolf-Motor Function Test (WMFT). Motor Activity Log-28 (MAL-28) was used to evaluate the amount of use and how well (How Well Scale) the impaired UE movements. RESULTS With-in-group analysis revealed that all groups had statistically significant improvements based on the FMT-UE and MAL-28 (p<.05). However, the performance time and arm strength variables of WMFT were only increased in the mCIMT + iTBS group (p<.05). The only between-group difference was observed in the intracortical facilitation in favor of the mCIMT + iTBS group (p<.05). The effect size of iTBS was f=0.18. CONCLUSIONS Our findings suggest that mCIMT with and without the application of iTBS has increased the UE motor function in low-functioning PwS. iTBS applied on intermittent days may have additional benefits as an adjunct therapy for facilitating cortical excitability, increasing the speed and strength of the impaired UE as well as decreasing disability.
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Affiliation(s)
- Esma Nur Kolbaşı
- Department of Physiotherapy and Rehabilitation, Istanbul Medeniyet University, Istanbul; Physiotherapy and Rehabilitation Department, Institute of Graduate Studies, Istanbul University-Cerrahpaşa, Istanbul
| | - Burcu Ersoz Huseyinsinoglu
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul.
| | - Zeynep Ozdemir
- Department of Neurology, Bakırkoy Prof Dr Mazhar Osman Training and Research Hospital for Psychiatric, Neurologic and Neurosurgical Diseases, Istanbul Health Sciences University, Istanbul
| | - Zubeyir Bayraktaroglu
- Department of Physiology, International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Aysun Soysal
- Department of Neurology, Bakırkoy Prof Dr Mazhar Osman Training and Research Hospital for Psychiatric, Neurologic and Neurosurgical Diseases, Istanbul Health Sciences University, Istanbul
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Xiao XZ, Li R, Xu C, Liang S, Yang M, Zhong H, Huang X, Ma J, Xie Q. Closed-loop transcutaneous auricular vagus nerve stimulation for the improvement of upper extremity motor function in stroke patients: a study protocol. Front Neurol 2024; 15:1379451. [PMID: 38903173 PMCID: PMC11188480 DOI: 10.3389/fneur.2024.1379451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/27/2024] [Indexed: 06/22/2024] Open
Abstract
Background Transcutaneous auricular vagus nerve stimulation (taVNS) has garnered attention for stroke rehabilitation, with studies demonstrating its benefits when combined with motor rehabilitative training or delivered before motor training. The necessity of concurrently applying taVNS with motor training for post-stroke motor rehabilitation remains unclear. We aimed to investigate the necessity and advantages of applying the taVNS concurrently with motor training by an electromyography (EMG)-triggered closed-loop system for post-stroke rehabilitation. Methods We propose a double-blinded, randomized clinical trial involving 150 stroke patients assigned to one of three groups: concurrent taVNS, sequential taVNS, or sham control condition. In the concurrent group, taVNS bursts will synchronize with upper extremity motor movements with EMG-triggered closed-loop system during the rehabilitative training, while in the sequential group, a taVNS session will precede the motor rehabilitative training. TaVNS intensity will be set below the pain threshold for both concurrent and sequential conditions and at zero for the control condition. The primary outcome measure is the Fugl-Meyer Assessment of Upper Extremity (FMA-UE). Secondary measures include standard upper limb function assessments, as well as EMG and electrocardiogram (ECG) features. Ethics and dissemination Ethical approval has been granted by the Medical Ethics Committee, affiliated with Zhujiang Hospital of Southern Medical University for Clinical Studies (2023-QX-012-01). This study has been registered on ClinicalTrials (NCT05943431). Signed informed consent will be obtained from all included participants. The findings will be published in peer-reviewed journals and presented at relevant stakeholder conferences and meetings. Discussion This study represents a pioneering effort in directly comparing the impact of concurrent taVNS with motor training to that of sequential taVNS with motor training on stroke rehabilitation. Secondly, the incorporation of an EMG-triggered closed-loop taVNS system has enabled the automation and individualization of both taVNS and diverse motor training tasks-a novel approach not explored in previous research. This technological advancement holds promise for delivering more precise and tailored training interventions for stroke patients. However, it is essential to acknowledge a limitation of this study, as it does not delve into examining the neural mechanisms underlying taVNS in the context of post-stroke rehabilitation.
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Affiliation(s)
- Xue-Zhen Xiao
- Zhuhai Fudan Innovation Institute, Zhuhai, Guangdong, China
- BrainClos Co., Ltd., Shenzhen, Guangdong, China
| | - Rongdong Li
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
- Rehabilitation Medicine School of Southern Medical University, Guangzhou, Guangdong, China
| | - Chengwei Xu
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
- Rehabilitation Medicine School of Southern Medical University, Guangzhou, Guangdong, China
| | - Siqi Liang
- BrainClos Co., Ltd., Shenzhen, Guangdong, China
| | - Meng Yang
- School of Biomedical Engineering, Shenzhen University, Shenzhen, Guangdong, China
| | - Haili Zhong
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Xiyan Huang
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Jingjing Ma
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Qiuyou Xie
- Department of Rehabilitation Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
- Rehabilitation Medicine School of Southern Medical University, Guangzhou, Guangdong, China
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Horinouchi T, Nezu T, Saita K, Date S, Kurumadani H, Maruyama H, Kirimoto H. Transcutaneous auricular vagus nerve stimulation enhances short-latency afferent inhibition via central cholinergic system activation. Sci Rep 2024; 14:11224. [PMID: 38755234 PMCID: PMC11099104 DOI: 10.1038/s41598-024-61958-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 05/12/2024] [Indexed: 05/18/2024] Open
Abstract
The present study examined the effects of transcutaneous auricular vagus nerve stimulation (taVNS) on short-latency afferent inhibition (SAI), as indirect biomarker of cholinergic system activation. 24 healthy adults underwent intermittent taVNS (30 s on/30 s off, 30 min) or continuous taVNS at a frequency of 25 Hz (15 min) along with earlobe temporary stimulation (15 min or 30 min) were performed in random order. The efficiency with which the motor evoked potential from the abductor pollicis brevis muscle by transcranial magnetic stimulation was attenuated by the preceding median nerve conditioning stimulus was compared before taVNS, immediately after taVNS, and 15 min after taVNS. Continuous taVNS significantly increased SAI at 15 min post-stimulation compared to baseline. A positive correlation (Pearson coefficient = 0.563, p = 0.004) was observed between baseline SAI and changes after continuous taVNS. These results suggest that 15 min of continuous taVNS increases the activity of the cholinergic nervous system, as evidenced by the increase in SAI. In particular, the increase after taVNS was more pronounced in those with lower initial SAI. This study provides fundamental insight into the clinical potential of taVNS for cholinergic dysfunction.
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Affiliation(s)
- Takayuki Horinouchi
- Department of Sensorimotor Neuroscience, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8553, Japan
- Japan Society for the Promotion of Science, Tokyo, Japan
| | - Tomohisa Nezu
- Department of Clinical Neuroscience and Therapeutics, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8553, Japan.
| | - Kazuya Saita
- Department of Psychosocial Rehabilitation, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shota Date
- Department of Analysis and Control of Upper Extremity Function, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Kurumadani
- Department of Analysis and Control of Upper Extremity Function, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8553, Japan
| | - Hikari Kirimoto
- Department of Sensorimotor Neuroscience, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8553, Japan.
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Baroni A, Antonioni A, Fregna G, Lamberti N, Manfredini F, Koch G, D’Ausilio A, Straudi S. The Effectiveness of Paired Associative Stimulation on Motor Recovery after Stroke: A Scoping Review. Neurol Int 2024; 16:567-589. [PMID: 38804482 PMCID: PMC11130975 DOI: 10.3390/neurolint16030043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024] Open
Abstract
Paired associative stimulation (PAS) is a non-invasive brain stimulation technique combining transcranial magnetic stimulation and peripheral nerve stimulation. PAS allows connections between cortical areas and peripheral nerves (C/P PAS) or between cortical regions (C/C PAS) to be strengthened or weakened by spike-timing-dependent neural plasticity mechanisms. Since PAS modulates both neurophysiological features and motor performance, there is growing interest in its application in neurorehabilitation. We aimed to synthesize evidence on the motor rehabilitation role of PAS in stroke patients. We performed a literature search following the PRISMA Extension for Scoping Reviews Framework. Eight studies were included: one investigated C/C PAS between the cerebellum and the affected primary motor area (M1), seven applied C/P PAS over the lesional, contralesional, or both M1. Seven studies evaluated the outcome on upper limb and one on lower limb motor recovery. Although several studies omit crucial methodological details, PAS highlighted effects mainly on corticospinal excitability, and, more rarely, an improvement in motor performance. However, most studies failed to prove a correlation between neurophysiological changes and motor improvement. Although current studies seem to suggest a role of PAS in post-stroke rehabilitation, their heterogeneity and limited number do not yet allow definitive conclusions to be drawn.
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Affiliation(s)
- Andrea Baroni
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.B.); (G.F.); (N.L.); (F.M.); (G.K.); (A.D.); (S.S.)
- Department of Neuroscience, Ferrara University Hospital, 44124 Ferrara, Italy
| | - Annibale Antonioni
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.B.); (G.F.); (N.L.); (F.M.); (G.K.); (A.D.); (S.S.)
- Department of Neuroscience, Ferrara University Hospital, 44124 Ferrara, Italy
- Doctoral Program in Translational Neurosciences and Neurotechnologies, University of Ferrara, 44121 Ferrara, Italy
| | - Giulia Fregna
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.B.); (G.F.); (N.L.); (F.M.); (G.K.); (A.D.); (S.S.)
- Doctoral Program in Translational Neurosciences and Neurotechnologies, University of Ferrara, 44121 Ferrara, Italy
| | - Nicola Lamberti
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.B.); (G.F.); (N.L.); (F.M.); (G.K.); (A.D.); (S.S.)
| | - Fabio Manfredini
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.B.); (G.F.); (N.L.); (F.M.); (G.K.); (A.D.); (S.S.)
- Department of Neuroscience, Ferrara University Hospital, 44124 Ferrara, Italy
| | - Giacomo Koch
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.B.); (G.F.); (N.L.); (F.M.); (G.K.); (A.D.); (S.S.)
- Center for Translational Neurophysiology of Speech and Communication (CTNSC), Italian Institute of Technology (IIT), 44121 Ferrara, Italy
- Non Invasive Brain Stimulation Unit, Istituto di Ricovero e Cura a Carattere Scientifico Santa Lucia, 00179 Rome, Italy
| | - Alessandro D’Ausilio
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.B.); (G.F.); (N.L.); (F.M.); (G.K.); (A.D.); (S.S.)
- Center for Translational Neurophysiology of Speech and Communication (CTNSC), Italian Institute of Technology (IIT), 44121 Ferrara, Italy
| | - Sofia Straudi
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.B.); (G.F.); (N.L.); (F.M.); (G.K.); (A.D.); (S.S.)
- Department of Neuroscience, Ferrara University Hospital, 44124 Ferrara, Italy
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Zeng Y, Cheng R, Zhang L, Fang S, Zhang S, Wang M, Lv Q, Dai Y, Gong X, Liang F. Clinical Comparison between HD-tDCS and tDCS for Improving Upper Limb Motor Function: A Randomized, Double-Blinded, Sham-Controlled Trial. Neural Plast 2024; 2024:2512796. [PMID: 38585306 PMCID: PMC10999289 DOI: 10.1155/2024/2512796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/15/2023] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Background Stroke is a common and frequently occurring disease among middle-aged and elderly people, with approximately 55%-75% of patients remaining with upper limb dysfunction. How to promote the recovery of motor function at an early stage is crucial to the life of the patient. Objectives This study aimed to investigate whether high-definition transcranial direct current stimulation (HD-tDCS) of the primary motor cortex (M1) functional area in poststroke patients in the subacute phase is more effective in improving upper limb function than conventional tDCS. Methods This randomized, sham-controlled clinical trial included 69 patients with subcortical stroke. They were randomly divided into the HD-tDCS, anodal tDCS (a-tDCS), and sham groups. Each group received 20 sessions of stimulation. The patients were assessed using the Action Research Arm Test, Fugl-Meyer score for upper extremities, Motor Function Assessment Scale, and modified Barthel index (MBI) pretreatment and posttreatment. Results The intragroup comparison scores improved after 4 weeks of treatment. The HD-tDCS group showed a slightly greater, but nonsignificant improvement as compared to a-tDCS group in terms of mean change observed in function of trained items. The MBI score of the HD-tDCS group was maintained up to 8 weeks of follow-up and was higher than that in the a-tDCS group. Conclusion Both HD-tDCS and a-tDCS can improve upper limb motor function and daily activities of poststroke patients in the subacute stage. This trial is registered with ChiCTR2000031314.
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Affiliation(s)
- Yaqin Zeng
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Ruidong Cheng
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Li Zhang
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Shan Fang
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Shaomin Zhang
- Qiushi Academy for Advanced Studies, Zhejiang University, Hangzhou, Zhejiang, China
| | - Minmin Wang
- Qiushi Academy for Advanced Studies, Zhejiang University, Hangzhou, Zhejiang, China
| | - Qian Lv
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yunlan Dai
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xinyi Gong
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Feng Liang
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
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Meng H, Houston M, Zhang Y, Li S. Exploring the Prospects of Transcranial Electrical Stimulation (tES) as a Therapeutic Intervention for Post-Stroke Motor Recovery: A Narrative Review. Brain Sci 2024; 14:322. [PMID: 38671974 PMCID: PMC11047964 DOI: 10.3390/brainsci14040322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/12/2024] [Accepted: 03/23/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Stroke survivors often have motor impairments and related functional deficits. Transcranial Electrical Stimulation (tES) is a rapidly evolving field that offers a wide range of capabilities for modulating brain function, and it is safe and inexpensive. It has the potential for widespread use for post-stroke motor recovery. Transcranial Direct Current Stimulation (tDCS), Transcranial Alternating Current Stimulation (tACS), and Transcranial Random Noise Stimulation (tRNS) are three recognized tES techniques that have gained substantial attention in recent years but have different mechanisms of action. tDCS has been widely used in stroke motor rehabilitation, while applications of tACS and tRNS are very limited. The tDCS protocols could vary significantly, and outcomes are heterogeneous. PURPOSE the current review attempted to explore the mechanisms underlying commonly employed tES techniques and evaluate their prospective advantages and challenges for their applications in motor recovery after stroke. CONCLUSION tDCS could depolarize and hyperpolarize the potentials of cortical motor neurons, while tACS and tRNS could target specific brain rhythms and entrain neural networks. Despite the extensive use of tDCS, the complexity of neural networks calls for more sophisticated modifications like tACS and tRNS.
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Affiliation(s)
- Hao Meng
- Department of Physical Medicine & Rehabilitation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Michael Houston
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204, USA;
| | - Yingchun Zhang
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL 33146, USA;
| | - Sheng Li
- Department of Physical Medicine & Rehabilitation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
- TIRR Memorial Hermann Hospital, Houston, TX 77030, USA
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Iandolo R, Avci E, Bommarito G, Sandvig I, Rohweder G, Sandvig A. Characterizing upper extremity fine motor function in the presence of white matter hyperintensities: A 7 T MRI cross-sectional study in older adults. Neuroimage Clin 2024; 41:103569. [PMID: 38281363 PMCID: PMC10839532 DOI: 10.1016/j.nicl.2024.103569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 01/19/2024] [Accepted: 01/21/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND White matter hyperintensities (WMH) are a prevalent radiographic finding in the aging brain studies. Research on WMH association with motor impairment is mostly focused on the lower-extremity function and further investigation on the upper-extremity is needed. How different degrees of WMH burden impact the network of activation recruited during upper limb motor performance could provide further insight on the complex mechanisms of WMH pathophysiology and its interaction with aging and neurological disease processes. METHODS 40 healthy elderly subjects without a neurological/psychiatric diagnosis were included in the study (16F, mean age 69.3 years). All subjects underwent ultra-high field 7 T MRI including structural and finger tapping task-fMRI. First, we quantified the WMH lesion load and its spatial distribution. Secondly, we performed a data-driven stratification of the subjects according to their periventricular and deep WMH burdens. Thirdly, we investigated the distribution of neural recruitment and the corresponding activity assessed through BOLD signal changes among different brain regions for groups of subjects. We clustered the degree of WMH based on location, numbers, and volume into three categories; ranging from mild, moderate, and severe. Finally, we explored how the spatial distribution of WMH, and activity elicited during task-fMRI relate to motor function, measured with the 9-Hole Peg Test. RESULTS Within our population, we found three subgroups of subjects, partitioned according to their periventricular and deep WMH lesion load. We found decreased activity in several frontal and cingulate cortex areas in subjects with a severe WMH burden. No statistically significant associations were found when performing the brain-behavior statistical analysis for structural or functional data. CONCLUSION WMH burden has an effect on brain activity during fine motor control and the activity changes are associated with varying degrees of the total burden and distributions of WMH lesions. Collectively, our results shed new light on the potential impact of WMH on motor function in the context of aging and neurodegeneration.
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Affiliation(s)
- Riccardo Iandolo
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Esin Avci
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Giulia Bommarito
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ioanna Sandvig
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Gitta Rohweder
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Stroke Unit, Department of Medicine, St Olav's University Hospital, Trondheim, Norway
| | - Axel Sandvig
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Neurology and Clinical Neurophysiology, St. Olav's University Hospital, Trondheim, Norway; Department of Clinical Neurosciences, Division of Neuro, Head and Neck, Umeå University Hospital, Umeå, Sweden; Department of Community Medicine and Rehabilitation, Umeå University Hospital, Umeå, Sweden.
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9
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Herr T, Kleger P, Strauss S, Szeska C, Khalil N, Badran BW, Weymar M, Grothe M. Effect of non-invasive transcutaneous auricular vagus nerve stimulation on cerebral motor excitability-Study protocol for a randomized, sham controlled trial. Front Neurol 2024; 14:1341898. [PMID: 38283680 PMCID: PMC10811126 DOI: 10.3389/fneur.2023.1341898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Transcutaneous auricular vagus nerve stimulation (taVNS) is becoming increasingly established in the treatment of various neurological and psychiatric diseases. However, only a few studies have focused on the overall influence of taVNS on cortical excitability in general. The planned study will investigate the effect of taVNS on the excitability of the motor cortex in young healthy subjects. The aim of the study is to gain better understand of the physiological mechanism of taVNS to contribute to new fields of application of taVNS in new areas such as the treatment of stroke or multiple sclerosis. This protocol describes a single-center, prospective, double blind, sham-controlled trial that evaluates the effect of taVNS on motor cortex excitability with a planned sample size of 30 participants. The effect of taVNS is investigated by neuronavigation and electromyography (EMG) coupled transcranial magnetic stimulation (TMS) applied before and after taVNS stimulation. The following parameters are assessed: resting motor threshold (RMT), active motor threshold (AMT), recruitment curve (RC), short intracortical inhibition (SICI), intracortical facilitation (ICF). All parameters will be assessed for taVNS on the basis of perception threshold and tolerance threshold. All investigations performed in the study were reviewed and approved by the local ethics committee of the University Medical Center Greifswald (study reference number: BB048/22). Clinical trial registration www.drks.de, number: DRKS00029937.
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Affiliation(s)
- Thorsten Herr
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Paula Kleger
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Sebastian Strauss
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Christoph Szeska
- Department of Biological Psychology and Affective Science, Faculty of Human Sciences, University of Potsdam, Potsdam, Germany
| | - Nura Khalil
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Bashar W. Badran
- Department of Psychiatry and Behavioral Sciences, Neuro-X Lab, Medical University of South Carolina, Charleston, SC, United States
| | - Mathias Weymar
- Department of Biological Psychology and Affective Science, Faculty of Human Sciences, University of Potsdam, Potsdam, Germany
- Faculty of Health Sciences Brandenburg, University of Potsdam, Potsdam, Germany
| | - Matthias Grothe
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
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10
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Hu M, Qin B, Li T, Wei C, Su D, Tan Z. Efficacy of rTMS for poststroke epilepsy and its effects on patients' cognitive function and depressive status. BMC Neurol 2024; 24:25. [PMID: 38216859 PMCID: PMC10785375 DOI: 10.1186/s12883-024-03531-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 01/08/2024] [Indexed: 01/14/2024] Open
Abstract
OBJECTIVE This study aimed to investigate the efficacy of rTMS in the treatment of poststroke epilepsy and the effect of rTMS on patients' cognitive function and depressive status. METHODS One hundred and twenty-one poststroke epilepsy patients with mild cognitive impairment and depressive status admitted to the Department of Neurology of the Second People's Hospital of Nanning from January 1, 2017, to April 31, 2023, were selected and divided into the rTMS treatment group (treated group) and the control group. MMSE scores and HAMD scores were recorded before and after treatment. The frequency of EEG spiky waves recorded before and after treatment within 24 h and the frequency of any clinical seizure form (the number of clinical seizures within 1 month after treatment) and changes in observed indices before and after treatment were calculated. The differences between the data of the two groups were analyzed, to further assess the efficacy of rTMS in the treatment of poststroke epilepsy and the rTMS' effects on cognition and depression. RESULTS Compared with drug treatment alone, rTMS significantly decreased clinical seizures and epileptiform discharges after stroke, especially in patients with lesions in the frontal, temporal, and parietal lobes. Compared with drug treatment alone, rTMS treatment can effectively reduce cognitive impairment and mood disorders, such as depression, especially for patients with lesions in the frontal and temporal lobes. The results of this experiment suggest that rTMS treatment does not increase adverse effects. CONCLUSION rTMS reduces clinical seizures while improving cognitive impairment and depression in patients with epilepsy. Therefore, we suggest that low-frequency rTMS can be used as an adjunctive treatment for patients with epilepsy and provide some ideas and references for the treatment of epilepsy with cognitive impairment and depression.
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Affiliation(s)
- Minting Hu
- Department of Neurology, The Second People's Hospital of Nanning, Nanning, China
| | - Bailing Qin
- Department of Neurology, The Second People's Hospital of Nanning, Nanning, China.
| | - Tong Li
- Department of Neurology, The Second People's Hospital of Nanning, Nanning, China
| | - Chunyan Wei
- Department of Neurology, The Second People's Hospital of Nanning, Nanning, China
| | - Dajing Su
- Department of Neurology, The Second People's Hospital of Nanning, Nanning, China
| | - Zuocai Tan
- Department of Neurology, The Second People's Hospital of Nanning, Nanning, China
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11
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Yildiz A, Ahmed I, Mustafaoglu R, Kesiktas FN. Effects of robot-assisted arm training on respiratory muscle strength, activities of daily living, and quality of life in patients with stroke: a single-blinded randomized controlled trial. Physiother Theory Pract 2024:1-9. [PMID: 38165122 DOI: 10.1080/09593985.2023.2299727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Post-stroke clinical changes not only affect extremities and trunk muscles but also the respiratory muscles. PURPOSE To determine the effect of robot-assisted arm training with conventional rehabilitation (CombT) on respiratory muscle strength, activities of daily living (ADL), and quality of life in patients with stroke and to compare the results with conventional rehabilitation (CR). METHODS It was a two-arm, single-blinded, randomized controlled trial in which 66 patients were randomly allocated to either CombT or CR to receive 30 sessions (5/week) over 6 weeks. The respiratory muscle strength (maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP)), activities of daily life (ABILHAND questionnaire), and quality of life (Stroke Impact Scale (SIS)) were measured before and 6 weeks after training. RESULTS The CombT group showed significantly better MIP, MEP, and performance in ADLs after 6 weeks of training compared to the CR group (p < .01). The effect size was large for MIP (d = 0.9) and MEP (d = 0.9), whereas medium for performance in ADLs (d = 0.62). Also, the SIS-arm strength (p < .01), hand function (p = .04), ADLs (p = .02), and recovery (p = .04) were significantly better in CombT group with a medium (d = 0.6, d = 0.5, d = 0.5, and d = 0.5, respectively) effect size compared with CR group. CONCLUSIONS Both CombT and CR groups improved respiratory muscle strength, performance in ADLs, and quality of life in patients with stroke. However, CombT appears to offer more comprehensive benefits, highlighting its valuable role in respiratory and functional recovery after stroke.
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Affiliation(s)
- Abdurrahim Yildiz
- Department of Physiotherapy and Rehabilitation, Sakarya University of Applied Sciences, Sakarya, Türkiye
| | - Ishtiaq Ahmed
- Pain in Motion International Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Rustem Mustafaoglu
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Fatma Nur Kesiktas
- Istanbul Physical Medicine and Rehabilitation Training and Research Hospital, University of Health Sciences, Istanbul, Türkiye
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12
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Alfredo L, David R, Juan‐José B, Sergio L, Raúl F. Combination of different noninvasive brain stimulation treatments for upper limb recovery in stroke patients: A systematic review. Brain Behav 2024; 14:e3370. [PMID: 38376018 PMCID: PMC10823455 DOI: 10.1002/brb3.3370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/27/2023] [Accepted: 12/01/2023] [Indexed: 02/21/2024] Open
Abstract
We report a review of Pubmed (Medline), CENTRAL, Web of Science, and Scopus to test the effectiveness of the combined application of repetitive transcranial magnetic stimulation and transcranial direct current stimulation in the improvement of different functional variables of the upper limb in people with stroke. Two independent reviewers assessed eligibility and evaluated the quality of the studies. Five articles were included in the final review according to the inclusion criteria: Most show statistically significant differences in motor function improvement in favor of the experimental group, but not in activity. Due to the heterogeneity of the observed studies, the results should be interpreted with caution-more high-quality studies are needed to investigate the effectiveness of these interventions in different stages of stroke patients.
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Affiliation(s)
- Lerín‐Calvo Alfredo
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La SalleUniversidad Autónoma de MadridAravacaMadridSpain
- Clínica Neuron Madrid RíoMadridSpain
- Grupo de Investigación Clínico‐Docente sobre Ciencias de la Rehabilitación (INDOCLIN)CSEU La Salle, UAMAravacaMadridSpain
| | | | | | - Lerma‐Lara Sergio
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La SalleUniversidad Autónoma de MadridAravacaMadridSpain
- Motion in Brains Research GroupAravacaMadridSpain
| | - Ferrer‐Peña Raúl
- Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La SalleUniversidad Autónoma de MadridAravacaMadridSpain
- Grupo de Investigación Clínico‐Docente sobre Ciencias de la Rehabilitación (INDOCLIN)CSEU La Salle, UAMAravacaMadridSpain
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13
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Fox-Hesling J, Wisseman D, Kantak S. Noninvasive cerebellar stimulation and behavioral interventions: A crucial synergy for post-stroke motor rehabilitation. NeuroRehabilitation 2024; 54:521-542. [PMID: 38943401 DOI: 10.3233/nre-230371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
BACKGROUND Improvement of functional movements after supratentorial stroke occurs through spontaneous biological recovery and training-induced reorganization of remnant neural networks. The cerebellum, through its connectivity with the cortex, brainstem and spinal cord, is actively engaged in both recovery and reorganization processes within the cognitive and sensorimotor systems. Noninvasive cerebellar stimulation (NiCBS) offers a safe, clinically feasible and potentially effective way to modulate the excitability of spared neural networks and promote movement recovery after supratentorial stroke. NiCBS modulates cerebellar connectivity to the cerebral cortex and brainstem, as well as influences the sensorimotor and frontoparietal networks. OBJECTIVE Our objective was twofold: (a) to conduct a scoping review of studies that employed NiCBS to influence motor recovery and learning in individuals with stroke, and (b) to present a theory-driven framework to inform the use of NiCBS to target distinct stroke-related deficits. METHODS A scoping review of current research up to August 2023 was conducted to determine the effect size of NiCBS effect on movement recovery of upper extremity function, balance, walking and motor learning in humans with stroke. RESULTS Calculated effect sizes were moderate to high, offering promise for improving upper extremity, balance and walking outcomes after stroke. We present a conceptual framework that capitalizes on cognitive-motor specialization of the cerebellum to formulate a synergy between NiCBS and behavioral interventions to target specific movement deficits. CONCLUSION NiCBS enhances recovery of upper extremity impairments, balance and walking after stroke. Physiologically-informed synergies between NiCBS and behavioral interventions have the potential to enhance recovery. Finally, we propose future directions in neurophysiological, behavioral, and clinical research to move NiCBS through the translational pipeline and augment motor recovery after stroke.
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Affiliation(s)
| | - Darrell Wisseman
- Moss Rehabilitation, Elkins Park, PA, USA
- Department of Physical Therapy, Arcadia University, Glenside, PA, USA
| | - Shailesh Kantak
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
- Department of Physical Therapy, Arcadia University, Glenside, PA, USA
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA, USA
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14
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Tang Z, Liu T, Liu Y, Han K, Su W, Zhao J, Chi Q, Zhang X, Zhang H. Different doses of intermittent theta burst stimulation for upper limb motor dysfunction after stroke: a study protocol for a randomized controlled trial. Front Neurosci 2023; 17:1259872. [PMID: 37869516 PMCID: PMC10585036 DOI: 10.3389/fnins.2023.1259872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/20/2023] [Indexed: 10/24/2023] Open
Abstract
Background Upper limb motor recovery is one of the important goals of stroke rehabilitation. Intermittent theta burst stimulation (iTBS), a new type of repetitive transcranial magnetic stimulation (rTMS), is considered a potential therapy. However, there is still no consensus on the efficacy of iTBS for upper limb motor dysfunction after stroke. Stimulus dose may be an important factor affecting the efficacy of iTBS. Therefore, we aim to investigate and compare the effects and neural mechanisms of three doses of iTBS on upper limb motor recovery in stroke patients, and our hypothesis is that the higher the dose of iTBS, the greater the improvement in upper limb motor function. Methods This prospective, randomized, controlled trial will recruit 56 stroke patients with upper limb motor dysfunction. All participants will be randomized in a 1:1:1:1 ratio to receive 21 sessions of 600 pulses active iTBS, 1,200 pulses active iTBS, 1,800 pulses active iTBS, or 1,800 pulses sham iTBS in addition to conventional rehabilitation training. The primary outcome is the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) score from baseline to end of intervention, and the secondary outcomes are the Wolf Motor Function Test (WMFT), Grip Strength (GS), Modified Barthel Index (MBI), and Stroke Impact Scale (SIS). The FMA-UE, MBI, and SIS are assessed pre-treatment, post-treatment, and at the 3-weeks follow-up. The WMFT, GS, and resting-state functional magnetic resonance imaging (rs-fMRI) data will be obtained pre- and post-treatment. Discussion The iTBS intervention in this study protocol is expected to be a potential method to promote upper limb motor recovery after stroke, and the results may provide supportive evidence for the optimal dose of iTBS intervention.
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Affiliation(s)
- Zhiqing Tang
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Tianhao Liu
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Ying Liu
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Kaiyue Han
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Wenlong Su
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
- University of Health and Rehabilitation Sciences, Qingdao, China
| | - Jingdu Zhao
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Qianqian Chi
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Xiaonian Zhang
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Hao Zhang
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
- University of Health and Rehabilitation Sciences, Qingdao, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
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