Enhancement of Motor Recovery through Left Dorsolateral Prefrontal Cortex Stimulation after Acute Ischemic Stroke

Comparison of the efficacy of different protocols of repetitive transcranial magnetic stimulation and transcranial direct current stimulation on motor function, activities of daily living, and neurological function in patients with early stroke: a systematic review and network meta-analysis

BACKGROUND

The application of transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) in patients with early stroke has recently received considerable attention, but the optimal protocol remains inconclusive. This study intends to evaluate and compare the effects of different protocols of tDCS and rTMS on improving motor function, activities of daily living (ADL), and neurological function in patients with early stroke, and to comprehensively assess their efficacy and safety.

METHODS

MEDLINE, Embase, Cochrane Library, and Web of Science were searched. Risk of bias (RoB) was assessed using the Cochrane Risk of Bias 2.0 tool, and Bayesian NMA was conducted using R4.3.1 and Stata16.

RESULTS

The results of NMA showed that after early intervention, bilateral application of high- and low-frequency rTMS (BL-rTMS) performed best in improving the upper extremity motor function at the end of intervention (SUCRA: 92.8%) and 3 months (SUCRA: 95.4%). Besides, low-frequency rTMS (LF-rTMS) performed best in improving the lower extremity motor function (SUCRA: 67.7%). BL-rTMS was the most effective in ameliorating the ADL at the end of intervention (SUCRA: 100%) and 3 months (SUCRA: 85.6%). In terms of the NIHSS scores, BL-rTMS had the highest probability of being the most effective measure at the end of intervention (SUCRA: 99.7%) and 3 months (SUCRA: 97.05%). Besides, LF-rTMS (0%), 5 Hz-rTMS (0%), and intermittent theta-burst stimulation (iTBS) (0%) all exhibited a good safety profile.

CONCLUSION

BL-rTMS is the optimal stimulation protocol for improving upper extremity motor function, ADL, and neurological function in early stroke, with long-term efficacy.

Transcranial direct current stimulation for upper extremity motor dysfunction in poststroke patients: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of transcranial direct current stimulation in poststroke patients with upper extremity motor dysfunction using a systematic review and meta-analysis.

DATA SOURCES

We searched the Web of Science, Cochrane Library, EMBASE, and PubMed for randomized controlled trials investigating the effects of both active and sham stimulation up until January 27, 2024.

REVIEW METHODS

Efficacy, including the upper extremity Fugl-Meyer Assessment, Action Research Arm Test, Barthel Index, and safety, were assessed. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool and the Physiotherapy Evidence Database Scale. Meta-analysis was performed using the RevMan 5.4 software.

RESULTS

Forty-four studies with 1555 participants were included. Transcranial direct current stimulation proved effective in improving upper extremity motor function (standardized mean difference = 0.22, 95% confidence interval: 0.12-0.32, P < 0.001) and Barthel Index (mean difference = 4.65, 95% confidence interval: 2.82-6.49, P < 0.001). Subgroup analysis revealed the highest transcranial direct current stimulation efficacy in patients with subacute stroke. Both anodal and cathodal stimulation were effective against upper extremity motor dysfunction. C3/C4 was the most effective stimulus target. Optimal stimulation parameters included stimulus current densities <0.057 mA/cm2 for 20-30 min and <30 sessions. Adverse effects and dropouts during follow-up showed that transcranial direct current stimulation is safe and feasible.

CONCLUSIONS

Our findings suggest that both anodal and cathodal stimulation were significantly effective in subacute stroke patients, particularly when preceding other treatments and when C3/C4 is targeted.

Anodal transcranial direct current stimulation over the right primary somatosensory cortex increases cough reflex sensitivity: a pilot randomised controlled crossover trial

Background

The cough reflex is a protective reflex of the human body. Increases or decreases in cough reflex sensitivity may be related to chronic cough, aspiration pneumonia and other diseases. The right primary somatosensory cortex (RS1) is the main activation centre for the urge to cough. Here, we discuss the effects of transcranial direct current stimulation (tDCS) of RS1 on the cough reflex and urge to cough. In addition, we explored the role of the left dorsolateral prefrontal cortex (lDLPFC) in cough using tDCS.

Methods

24 healthy young adults completed this pilot randomised controlled crossover experiment. Each person was tested three times, receiving, in random order, anodal tDCS of RS1 or lDLPFC or sham stimulation. The current intensity was set to 2 mA, the stimulation time was 30 min and the interval between any two stimuli was ≥1 week. After each intervention, the citric acid cough challenge test was used immediately to assess the urge to cough and cough reflex sensitivity.

Results

The cough reflex thresholds, expressed as LogC2 and LogC5, were significantly reduced after RS1 anodal stimulation compared to sham stimulation, accompanied by increased urge-to-cough sensitivity (urge-to-cough log-log slope 1.19±0.40 point·L·g-1 versus 0.92±0.33 point·L·g-1, p=0.001), but the threshold for the urge to cough did not change significantly. There were no significant changes in the urge to cough and cough reflex sensitivity after tDCS anodal lDLPFC stimulation.

Conclusion

Anodal tDCS stimulation of the RS1 can increase urge-to-cough sensitivity and reduce cough reflex threshold. The effects of tDCS on cough reflex, as well as the underlying mechanisms driving those effects, should be explored further.

Relationship between temporal dynamics of intrinsic brain activity and motor function remodeling in patients with acute BGIS

Background

patients with acute basal ganglia ischemic stroke (BGIS) show changes in local brain activity represented by the amplitude of low-frequency fluctuation (ALFF), but the time-varying characteristics of this local nerve activity are still unclear. This study aimed to investigate the abnormal time-varying local brain activity of patients with acute BGIS by using the ALFF method combined with the sliding-window approach.

Methods

In this study, 34 patients with acute BGIS with motor dysfunction and 44 healthy controls (HCs) were recruited. The dynamic amplitude of low-frequency fluctuation (dALFF) was employed to detect the alterations in brain activity induced by acute BGIS patients. A two-sample t-test comparison was performed to compare the dALFF value between the two groups and a Spearman correlation analysis was conducted to assess the relationship between the local brain activity abnormalities and clinical characteristics.

Results

Compared with HCs, the activity of neurons in the left temporal pole (TP), parahippocampal gyrus (paraHIP), middle occipital gyrus (MOG), dorsolateral superior frontal gyrus (SFGdl), medial cingulate cortex (MCC), right rectus, precuneus (PCu) and right cerebellum crus1 were significantly increased in patients with BGIS. In addition, we found that there was a negative correlation (r = -0.458, p = 0.007) between the dALFF value of the right rectus and the scores of the National Institutes of Health Stroke Scale (NIHSS), and a positive correlation (r = 0.488, 0.499, p < 0.05) with the scores of the Barthel Index scale (BI) and the Fugl Meyer motor function assessment (FMA). ROC analysis results demonstrated that the area under the curves (AUC) of the right rectus was 0.880, p<0.001.

Conclusion

The pattern of intrinsic brain activity variability was altered in patients with acute BGIS compared with HCs. The abnormal dALFF variability might be a potential tool to assess motor function in patients with acute BGIS and potentially inform the diagnosis of this disease.

Non-invasive brain stimulation for limb motor function and daily living activity improvement in acute stroke: A meta-analysis

OBJECTIVE

To evaluate the effect of non-invasive brain stimulation (NIBS) in improving limb motor dysfunction and daily living activity during at the phase of acute stroke.

MATERIALS AND METHODS

Randomized controlled trials about the effect of NIBS on hemiparesis in acute stroke were retrieved from databases of China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), Wanfang Data, CBM, PubMed, Embase, Cochrane Library, and Web of Science from inception until January 3rd 2022. The quality of the trials was assessed, and the data were extracted according to the Cochrane Handbook for Systematic Reviews of Interventions. A statistical analysis was carried out using Review Manager 5.3 and STATA 14. The effect size was evaluated by using the weighed mean difference (WMD) and a 95% confidence interval (CI). The stability and sensitivity of the results and sources of heterogeneity were also analyzed.

RESULTS

12 studies involving 639 patients were included. Our meta-analysis showed that NIBS could improve the Fugl-Meyer Assessment (weighed mean difference = 3.96, 95% confidence interval = 3.45 to 4.48) and Barthel Index (weighed mean difference = 12.29, 95% confidence interval = 4.93 to 19.66), while reducing the National Institutes of Health Stroke Scale (weighed mean difference = -2.37, 95% confidence interval = -3.43 to -1.31).

CONCLUSION

NIBS is effective in improving paretic limb motor function and activities of daily living in patients during at the phase of acute stroke.

Resting-state functional connectivity for determining outcomes in upper extremity function after stroke: A functional near-infrared spectroscopy study

OBJECTIVE

Functional near-infrared spectroscopy (fNIRS) is a non-invasive and promising tool to map the brain functional networks in stroke recovery. Our study mainly aimed to use fNIRS to detect the different patterns of resting-state functional connectivity (RSFC) in subacute stroke patients with different degrees of upper extremity motor impairment defined by Fugl-Meyer motor assessment of upper extremity (FMA-UE). The second aim was to investigate the association between FMA-UE scores and fNIRS-RSFC among different regions of interest (ROIs) in stroke patients.

METHODS

Forty-nine subacute (2 weeks-6 months) stroke patients with subcortical lesions were enrolled and were classified into three groups based on FMA-UE scores: mild impairment (n = 17), moderate impairment (n = 13), and severe impairment (n = 19). All patients received FMA-UE assessment and 10-min resting-state fNIRS monitoring. The fNIRS signals were recorded over seven ROIs: bilateral dorsolateral prefrontal cortex (DLPFC), middle prefrontal cortex (MPFC), bilateral primary motor cortex (M1), and bilateral primary somatosensory cortex (S1). Functional connectivity (FC) was calculated by correlation coefficients between each channel and each ROI pair. To reveal the comprehensive differences in FC among three groups, we compared FC on the group level and ROI level. In addition, to determine the associations between FMA-UE scores and RSFC among different ROIs, Spearman's correlation analyses were performed with a significance threshold of p < 0.05. For easy comparison, we defined the left hemisphere as the ipsilesional hemisphere and flipped the lesional right hemisphere in MATLAB R2013b.

RESULTS

For the group-level comparison, the one-way ANOVA and post-hoc t-tests (mild vs. moderate; mild vs. severe; moderate vs. severe) showed that there was a significant difference among three groups (F = 3.42, p = 0.04) and the group-averaged FC in the mild group (0.64 ± 0.14) was significantly higher than that in the severe group (0.53 ± 0.14, p = 0.013). However, there were no significant differences between the mild and moderate group (MD ± SE = 0.05 ± 0.05, p = 0.35) and between the moderate and severe group (MD ± SE = 0.07 ± 0.05, p = 0.16). For the ROI-level comparison, the severe group had significantly lower FC of ipsilesional DLPFC-ipsilesional M1 [p = 0.015, false discovery rate (FDR)-corrected] and ipsilesional DLPFC-contralesional M1 (p = 0.035, FDR-corrected) than those in the mild group. Moreover, the result of Spearman's correlation analyses showed that there were significant correlations between FMA-UE scores and FC of the ipsilesional DLPFC-ipsilesional M1 (r = 0.430, p = 0.002), ipsilesional DLPFC-contralesional M1 (r = 0.388, p = 0.006), ipsilesional DLPFC-MPFC (r = 0.365, p = 0.01), and ipsilesional DLPFC-contralesional DLPFC (r = 0.330, p = 0.021).

CONCLUSION

Our findings indicate that different degrees of post-stroke upper extremity impairment reflect different RSFC patterns, mainly in the connection between DLPFC and bilateral M1. The association between FMA-UE scores and the FC of ipsilesional DLPFC-associated ROIs suggests that the ipsilesional DLPFC may play an important role in motor-related plasticity. These findings can help us better understand the neurophysiological mechanisms of upper extremity motor impairment and recovery in subacute stroke patients from different perspectives. Furthermore, it sheds light on the ipsilesional DLPFC-bilateral M1 as a possible neuromodulation target.

Barriers to Enrollment in Post-Stroke Brain Stimulation in a Racially and Ethnically Diverse Population

BACKGROUND AND PURPOSE

Brain stimulation is an adjuvant strategy to promote rehabilitation after stroke. Here, we evaluated the influence of inclusion/exclusion criteria on enrollment in a transcranial direct current stimulation (tDCS) trial in the context of a racially/ethnically diverse acute stroke service at University of Texas Southwestern (UTSW).

METHODS

3124 (59.7 ± 14.5 years) racially/ethnically diverse (38.4% non-Hispanic white, (W), Hispanic (H) 22%, African American (AA) 33.5%, Asian (A) 2.3%) patients were screened in the acute stroke service at UTSW. Demographics, stroke characteristics, and reasons for exclusion were recorded prospectively.

RESULTS

2327 (74.5%) patients had a verified stroke. Only 44 of them (1.9%) were eligible. Causes for exclusion included in order of importance: (1) magnitude of upper extremity (UE) motor impairment, (2) prior strokes (s), (3) hemorrhagic stroke, (4) psychiatric condition or inability to follow instructions, and (5) old age, of these (2) and (4) were more common in AA patients but not in other minorities. 31 of the 44 eligible individuals were enrolled (W 1.68%, H 1.37%, AA .77%, A 3.774%). 90.5% of verified stroke patients did not exhibit contraindications for stimulation.

CONCLUSIONS

3 main conclusions emerged: (a) The main limitations for inclusion in brain stimulation trials of motor recovery were magnitude of UE motor impairments and stroke lesion characteristics, (b) most stroke patients could be stimulated with tDCS without safety concerns and (c) carefully tailored inclusion criteria could increase diversity in enrollment.Clinical Trial Registration-URL: http://clinicaltrials.gov. Unique identifier: NCT01007136.

Influence of Transcranial Direct Current Stimulation Dosage and Associated Therapy on Motor Recovery Post-stroke: A Systematic Review and Meta-Analysis

Purpose

(1) To determine the impact of transcranial direct current stimulation (tDCS) applied alone or combined with other therapies on the recovery of motor function after stroke and (2) To determine tDCS dosage effect.

Methods

Randomized controlled trials comparing the effects of tDCS with sham, using the Barthel Index (BI), the upper and lower extremity Fugl–Meyer Assessment (FMA), and the Modified Ashworth Scale (MAS), were retrieved from PubMed, Medline (EBSCO), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) from their inception to June 2021. Calculations for each assessment were done for the overall effect and associated therapy accounting for the influence of stroke severity or stimulation parameters.

Results

A total of 31 studies involving metrics of the BI, the upper extremity FMA, the lower extremity FMA, and the MAS were included. tDCS combined with other therapies was beneficial when assessed by the BI (mean difference: 6.8; P < 0.01) and these studies typically had participants in the acute stage. tDCS effects on the upper and lower extremity FMA are unclear and differences between the sham and tDCS groups as well as differences in the associated therapy type combined with tDCS potentially influenced the FMA results. tDCS was not effective compared to sham for the MAS. Stimulation types (e.g., anodal vs. cathodal) did not influence these results and dosage parameters were not associated with the obtained effect sizes. Conventional therapy associated with tDCS typically produced greater effect size than assisted therapy. The influence of stroke severity is unclear.

Conclusion

Potential benefits of tDCS can vary depending on assessment tool used, duration of stroke, and associated therapy. Mechanistic studies are needed to understand the potential role of stimulation type and dosage effect after stroke. Future studies should carefully conduct group randomization, control for duration of stroke, and report different motor recovery assessments types.

Systematic Review Registration

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021290670].

Inter trial coherence of low-frequency oscillations in the course of stroke recovery

OBJECTIVE

The aim was to find a sensitive method to highlight the remodeling of the brain's bioelectric activity in post-stroke repair.

METHODS

Fifteen mild upper limb paretic stroke patients and age-matched healthy controls were included. Repeated trials of finger tapping around the 10th and 100th days after stroke onset were recorded with a 128-channel EEG. Power spectra and Inter Trial Coherence (ITC) calculations were synchronized to tappings. ITC was correlated with motor performance.

RESULTS

ITC, in low frequency bands, designates the motor related bioelectric activity in channel space in both healthy subjects and patients. Ten days after stroke onset, delta-theta ITC was severely reduced compared to baseline, while three months later ITC reorganized partially over the ipsilesional central-parietal areas reflecting the improvement of motor networks. Decreased ITC in the central-parietal area remained significant compared to controls. Delta band ITC over the dorsolateral-prefrontal cortex correlates with the performance on Nine Hole Peg Test. At post-recovery, non-paretic hand tappings show significantly decreased delta-theta ITC over the supplementary motor area, which reflects network remodeling.

CONCLUSIONS

Inter Trial Coherence is a useful measure of brain reorganization during stroke recovery.

SIGNIFICANCE

Delta- theta ITC is a sensitive indicator of impaired motor execution.

The effects of transcranial direct current stimulation on upper-limb function post-stroke: A meta-analysis of multiple-session studies

OBJECTIVE

To systematically review how patient characteristics and/or transcranial direct current stimulation (tDCS) parameters influence tDCS effectiveness in respect to upper limb function post-stroke.

METHODS

Three electronic databases were searched for sham-controlled randomised trials using the Fugl-Meyer Assessment for upper extremity as outcome measure. A meta-analysis and nine subgroup-analyses were performed to identify which tDCS parameters yielded the greatest impact on upper limb function recovery in stroke patients.

RESULTS

Eighteen high-quality studies (507 patients) were included. tDCS applied in a chronic stage yields greater results than tDCS applied in a (sub)acute stage. Additionally, patients with low baseline upper limb impairments seem to benefit more from tDCS than those with high baseline impairments. Regarding tDCS configuration, all stimulation types led to a significant improvement, but only tDCS applied during therapy, and not before therapy, yielded significant results. A positive dose-response relationship was identified for current/charge density and stimulation duration, but not for number of sessions.

CONCLUSION

Our results demonstrate that tDCS improves upper limb function post-stroke. However, its effectiveness depends on numerous factors. Especially chronic stroke patients improved, which is promising as they are typically least amenable to recovery.

SIGNIFICANCE

The current work highlights the importance of several patient-related and protocol-related factors regarding tDCS effectiveness.

Evidence-Based Guidelines and Secondary Meta-Analysis for the Use of Transcranial Direct Current Stimulation in Neurological and Psychiatric Disorders

BACKGROUND

Transcranial direct current stimulation has shown promising clinical results, leading to increased demand for an evidence-based review on its clinical effects.

OBJECTIVE

We convened a team of transcranial direct current stimulation experts to conduct a systematic review of clinical trials with more than 1 session of stimulation testing: pain, Parkinson's disease motor function and cognition, stroke motor function and language, epilepsy, major depressive disorder, obsessive compulsive disorder, Tourette syndrome, schizophrenia, and drug addiction.

METHODS

Experts were asked to conduct this systematic review according to the search methodology from PRISMA guidelines. Recommendations on efficacy were categorized into Levels A (definitely effective), B (probably effective), C (possibly effective), or no recommendation. We assessed risk of bias for all included studies to confirm whether results were driven by potentially biased studies.

RESULTS

Although most of the clinical trials have been designed as proof-of-concept trials, some of the indications analyzed in this review can be considered as definitely effective (Level A), such as depression, and probably effective (Level B), such as neuropathic pain, fibromyalgia, migraine, post-operative patient-controlled analgesia and pain, Parkinson's disease (motor and cognition), stroke (motor), epilepsy, schizophrenia, and alcohol addiction. Assessment of bias showed that most of the studies had low risk of biases, and sensitivity analysis for bias did not change these results. Effect sizes vary from 0.01 to 0.70 and were significant in about 8 conditions, with the largest effect size being in postoperative acute pain and smaller in stroke motor recovery (nonsignificant when combined with robotic therapy).

CONCLUSION

All recommendations listed here are based on current published PubMed-indexed data. Despite high levels of evidence in some conditions, it must be underscored that effect sizes and duration of effects are often limited; thus, real clinical impact needs to be further determined with different study designs.

Therapeutic Effects of Diagonal-Transcranial Direct Current Stimulation on Functional Recovery in Acute Stroke: A Pilot Study

BACKGROUND

Peak neurologic recovery from acute stroke occurs within the first 3 months, and continues at a slower pace for 6 months.

OBJECTIVE/HYPOTHESIS

The aim of this pilot study is to clarify the safety and feasibility of multiple diagonal-transcranial direct current stimulation (d-tDCS) sessions up to 3 months with electrodes placed diagonally over the lesional dorsolateral prefrontal cortex and contralesional primary motor cortex for upper limb hemiparesis in acute stroke.

METHODS

Five patients with acute stroke (2 with intracerebral hemorrhage and 3 with cerebral infarction) with upper limb paresis participated. d-tDCS (1 mA, 20 min per day) combined with conventional rehabilitation was given starting 7-21 days after stroke onset. Each session consisted of 10 d-tDCS over 2 weeks and patients received 2 sessions in the acute phase and 2 sessions in the subacute phase for a total 40 treatments. Motor function was assessed using Fugl-Meyer Assessment for upper extremity (FMA-UE) before and after each session, and the period to achieve 70% of maximal potential recovery in FMA-UE was evaluated.

RESULTS

All 5 patients completed the intervention and showed no adverse effects throughout the protocol. Of these, 3 (60%) achieved 70% predicted scores within 2 months. Regarding therapeutic gains of FMA-UE in each of the 10 sessions in the acute phase, 4 sessions showed great recovery, 3 sessions showed moderate recovery, and 3 sessions showed poor recovery.

CONCLUSION

These findings suggest that d-tDCS over 3 months may be safe and feasible for acute stroke patients in the acute to subacute phases and have therapeutic potential to promote recovery of upper limb function, although further randomized, double-blind, sham-controlled trial is warranted with larger sample size.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

The Effect of Continuous Theta-Burst Transcranial Magnetic Stimulation Combined with Prism Adaptation on the Neglect Recovery in Stroke Patients

OBJECTIVES

This study was designed to investigate the effect of prism adaptation (PA) combined with continuous theta-burst transcranial magnetic stimulation (cTBS) on the neglect recovery of stroke patients with unilateral neglect.

METHODS

A total of 14 stroke patients with unilateral neglect were randomly assigned to 2 groups including an intervention group undergone PA combined with cTBS over the left intact parietal cortex and a control group. PA combined with sham cTBS was perfomed for 2 weeks in 10 daily sessions. Before and after the intervention, patients were evaluated for visuospatial neglect measured using the Star Cancellation Test (SCT), Line Bisection Task (LBT), Figure Copying Test, and Clock Drawing Task. Neurological function was evaluated using the Modified Rankin Scale (MRS).

RESULTS

Both groups (PA alone and PA+ cTBS) showed improvement in their neglected symptoms (measured by SCT, LBT, Figure Copying Test, and Clock Drawing Task), and in their disability in the neurological function (measured by MRS) (P< .05).

CONCLUSIONS

The results of the present study showed that, transcranial magnetic stimulation did not increase the effect of PA on neglect symptoms in stroke patients.

Sequential dual-site High-Definition transcranial Direct Current Stimulation (HD-tDCS) treatment in chronic subjective tinnitus: study protocol of a double-blind, randomized, placebo-controlled trial

Background

Chronic tinnitus is a highly prevalent symptom, with many patients reporting considerable effects of tinnitus on quality of life. No clear evidence-based treatment options are currently available. While counseling-based methods are valuable in some cases, they are not sufficiently effective for all tinnitus patients. Neuromodulation techniques such as high-definition transcranial direct current stimulation (HD-tDCS) are proposed to have positive effects on tinnitus severity but, to date, these effects have not been proven conclusively. The proposed trial will investigate the hypothesis that chronic tinnitus patients receiving HD-tDCS will report a positive effect on the impact of tinnitus on daily life, as compared to patients receiving sham stimulation.

Methods

This study proposes a randomized, double-blind, placebo-controlled trial with parallel group design. A total of 100 chronic tinnitus patients will be randomly allocated to an experimental group or a sham group, with allocation stratified according to gender and tinnitus severity. Patient and researcher will be blinded to the patient’s allocation. Patients will undergo six sessions of sequential dual-site HD-tDCS of the left temporal area and the right dorsolateral prefrontal cortex. Evaluations will take place at baseline, immediately following treatment, and at three and six months after the start of the therapy. The primary outcome measure is the change in Tinnitus Functional Index (TFI) score. Secondary outcome measures include audiological measurements, cortical auditory evoked potentials, the Repeatable Battery for the Assessment of Neuropsychological Status adjusted for hearing-impaired individuals (RBANS-H), and supplementary questionnaires probing tinnitus severity and additional symptoms. By use of a linear regression model, the effects of HD-tDCS compared to sham stimulation will be assessed.

Discussion

The objective of this study is to evaluate whether HD-tDCS can reduce the impact of tinnitus on daily life in chronic tinnitus patients. To date, published trials on the effects of HD-tDCS on tinnitus suffer from a lack of standardization and few randomized controlled trials exist. The proposed study will be the first adequately powered trial to investigate the effects of sequential dual-site HD-tDCS on tinnitus severity.

Trial registration

ClinicalTrials.gov, NCT03754127. Registered on 22 November 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3594-y) contains supplementary material, which is available to authorized users.

Searching for the optimal tDCS target for motor rehabilitation

BACKGROUND

Transcranial direct current stimulation (tDCS) has been investigated over the years due to its short and also long-term effects on cortical excitability and neuroplasticity. Although its mechanisms to improve motor function are not fully understood, this technique has been suggested as an alternative therapeutic method for motor rehabilitation, especially those with motor function deficits. When applied to the primary motor cortex, tDCS has shown to improve motor function in healthy individuals, as well as in patients with neurological disorders. Based on its potential effects on motor recovery, identifying optimal targets for tDCS stimulation is essential to improve knowledge regarding neuromodulation as well as to advance the use of tDCS in clinical motor rehabilitation.

METHODS AND RESULTS

Therefore, this review discusses the existing evidence on the application of four different tDCS montages to promote and enhance motor rehabilitation: (1) anodal ipsilesional and cathodal contralesional primary motor cortex tDCS, (2) combination of central tDCS and peripheral electrical stimulation, (3) prefrontal tDCS montage and (4) cerebellar tDCS stimulation. Although there is a significant amount of data testing primary motor cortex tDCS for motor recovery, other targets and strategies have not been sufficiently tested. This review then presents the potential mechanisms and available evidence of these other tDCS strategies to promote motor recovery.

CONCLUSIONS

In spite of the large amount of data showing that tDCS is a promising adjuvant tool for motor rehabilitation, the diversity of parameters, associated with different characteristics of the clinical populations, has generated studies with heterogeneous methodologies and controversial results. The ideal montage for motor rehabilitation should be based on a patient-tailored approach that takes into account aspects related to the safety of the technique and the quality of the available evidence.