Effectiveness of a single session of dual-transcranial direct current stimulation in combination with upper limb robotic-assisted rehabilitation in chronic stroke patients: a randomized, double-blind, cross-over study

Dual-tDCS combined with sensorimotor training promotes upper limb function in subacute stroke patients: A randomized, double-blinded, sham-controlled study

BACKGROUND

Dual transcranial direct current stimulation (tDCS) over the bilateral primary somatosensory cortex (PSC) has potential benefits in stroke. In addition, compared with traditional rehabilitation training, sensorimotor training can significantly improve the sensorimotor function of patients. However, the efficacy of dual-tDCS combined with sensorimotor training in patients with subacute stroke is unknown.

OBJECTIVE

To assess whether dual-tDCS may enhance the efficacy of sensorimotor training on the upper limb functions in patients with subacute stroke. In addition, this study aims to explore the potential clinical mechanism of this combination therapy.

METHODS

We randomized 52 individuals with first-ever, unilateral subcortical stroke into the experimental group (n = 26) and the control group (n = 26). Patients in the experimental group received 20 min of dual-tDCS over the PSC and 40 min of sensorimotor training each session, while patients in the control group received sham dual-tDCS. The treatment cycle was a 1-h session of therapy each day, 5 days per week for 4 weeks. The Fugl-Meyer Assessment of Upper Extremity (FMA-UE) subscale, Action Research Arm Test (ARAT), Box and Block test (BBT), Erasmus MC revised Nottingham sensory assessment scale (Em-NSA), Neurometer sensory nerve quantitative detector (CPT), the Barthel index (BI), and Hospital Anxiety and Depression Scale (HADS) were used to assess upper limb function, activities of daily living (ADL), and mental health before and after the 4-week treatment period. In addition, functional near-infrared spectroscopy (fNIRS) was used to explore potential clinical brain mechanisms.

RESULTS

Both groups showed significant improvement in all clinical scales (All p < 0.05) after treatment. Compared with sham-tDCS plus sensorimotor training, active dual-tDCS coupled with sensorimotor training can significantly improve the FMA-UE, ARAT, Em-NSA-Stereognosis, and CPT-2K Hz. In addition, dual-tDCS combined with sensorimotor training can significantly activate the left pre-Motor and supplementary motor cortex (PM-SMC) and enhance the functional connection between the left somatosensory association cortex (SAC) and RPM-SMC. Furthermore, the difference of FMA-UE in the experimental group was positively correlated with the functional connectivity of RPM-SMC-LSAC (r = 0.815, p < 0.001).

CONCLUSION

Dual-tDCS over the PSC combined with sensorimotor training can improve upper limb sensory and motor dysfunction, enhance ADL, and alleviate depression and anxiety for subacute stroke patients. Our results indicated that RPM-SMC-LSAC may be potential therapeutic targets for dual-tDCS in upper limb rehabilitation on stroke.

Is the Combination of Robot-Assisted Therapy and Transcranial Direct Current Stimulation Useful for Upper Limb Motor Recovery? A Systematic Review with Meta-Analysis

Stroke is the third leading cause of disability in the world, and effective rehabilitation is needed to improve lost functionality post-stroke. In this regard, robot-assisted therapy (RAT) and transcranial direct current stimulation (tDCS) are promising rehabilitative approaches that have been shown to be effective in motor recovery. In the past decade, they have been combined to study whether their combination produces adjuvant and greater effects on stroke recovery. The aim of this study was to estimate the effectiveness of the combined use of RATs and tDCS in the motor recovery of the upper extremities after stroke. After reviewing 227 studies, we included nine randomised clinical trials (RCTs) in this study. We analysed the methodological quality of all nine RCTs in the meta-analysis. The analysed outcomes were deficit severity, hand dexterity, spasticity, and activity. The addition of tDCS to RAT produced a negligible additional benefit on the effects of upper limb function (SMD -0.09, 95% CI -0.31 to 0.12), hand dexterity (SMD 0.12, 95% CI -0.22 to 0.46), spasticity (SMD 0.04, 95% CI -0.24 to 0.32), and activity (SMD 0.66, 95% CI -1.82 to 3.14). There is no evidence of an additional effect when adding tDCS to RAT for upper limb recovery after stroke. Combining tDCS with RAT does not improve upper limb motor function, spasticity, and/or hand dexterity. Future research should focus on the use of RAT protocols in which the patient is given an active role, focusing on the intensity and dosage, and determining how certain variables influence the success of RAT.

Effect of transcranial direct current stimulation in combination with robotic therapy in upper limb impairments in people with stroke: a systematic review

Background

Stroke is a devastating condition, which not only affects patients’ activity, but also is a primary reason for the psychosocial impact on them, their caregivers, and the healthcare system. Transcranial direct current stimulation (tDCS) modulates cortical activity, encouraging neuro-modulation and motor recovery in stroke rehabilitation. Robotic therapy (RT) provides repetitive, high-intensity, interactive, task-specific intervention and can measure changes while providing feedback to people with stroke.

Objectives

This study aimed to evaluate and summarize the scientific literature systematically to investigate the combined effect of tDCS and RT in patients with stroke.

Methods

Four databases (MEDLINE, Web of Science, ScienceDirect, & PEDro) were searched for clinical trials investigating the effect of RT and tDCS in stroke patients with upper limb impairment. PEDro scale was used for the quality assessment of included studies.

Results

The search yielded 208 articles. A total of 213 patients with stroke who had upper limb impairment were studied. In the majority of the trials, RT combined with tDCS lead to positive improvement in various measures of upper limb function and spasticity.

Conclusions

RT along with tDCS is an effective mode of rehabilitation, although no additional effects of tDCS plus RT in comparison with RT alone were reported. Large, robust studies are needed, so that health care providers and researchers can make better decisions about merging tDCS and RT in stroke rehabilitation settings in the future.

Effectiveness of robot-assisted arm exercise on arm and hand function in stroke survivors - A systematic review and meta-analysis

Objective: To examine the treatment effect of commercially available robotic-assisted devices, compared to traditional occupational- and physiotherapy on arm and hand function in persons with stroke. Methods: A systematic literature search was conducted in Medline, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials up to January 2022. Randomized controlled trials (RCT's) involving persons with stroke of all ages and robot-assisted exercise as method for arm and hand function, compared to traditional therapy methods were included. Three authors performed the selection independently. The quality of evidence across studies was assessed using GRADE. Results: Eighteen RCT's were included in the study. A random effects meta-analysis showed a statistically significantly higher treatment effect in the robotic-assisted exercise group (p=<0.0001) compared to the traditional treatment group, with a total effect size of 0.44 (CI = 0.22-0.65). Heterogeneity was high, measured with I2 of 65%). Subgroup analyses showed no significant effects of the type of robotic device, treatment frequency or duration of intervention. Discussion and conclusion: Even though the analysis showed significant improvement in arm and hand function in favor of the robotic-assisted exercise group, the results in this systematic review should be interpreted with caution. This is due to high heterogeneity among the studies included and the presence of possible publication bias. Results of this study highlight the need for larger and more methodological robust RCT's, with a focus on reporting training intensity during robotic exercise.

Improving Upper Limb and Gait Rehabilitation Outcomes in Post-Stroke Patients: A Scoping Review on the Additional Effects of Non-Invasive Brain Stimulation When Combined with Robot-Aided Rehabilitation

Robot-aided rehabilitation (RAR) and non-invasive brain stimulation (NIBS) are the two main interventions for post-stroke rehabilitation. The efficacy of both approaches in combination has not been well established yet. The importance of coupling these interventions, which both enhance brain plasticity to promote recovery, lies in augmenting the rehabilitation potential to constrain the limitation in daily living activities and the quality of life following stroke. This review aimed to evaluate the evidence of NIBS coupled with RAR in improving rehabilitation outcomes of upper limb and gait motor impairment in adult individuals with stroke. We included 18 clinical trials in this review. All studies were highly heterogeneous concerning the technical characteristics of robotic devices and NIBS protocols. However, the studies reported a global improvement in body structure and function and activity limitation for the upper limb, which were non-significant between the active and control groups. Concerning gait training protocols, the active group outperformed the control group in improving walking capacity and recovery. According to this review, NIBS and RAR in combination are promising but not yet largely recommendable as a systematic approach for stroke rehabilitation as there is not enough data about this. Therefore, more homogenous clinical trials are required, pointing out the best characteristics of the combined therapeutic protocols.

Bimanual motor skill learning after stroke: Combining robotics and anodal tDCS over the undamaged hemisphere: An exploratory study

Background

Since a stroke can impair bimanual activities, enhancing bimanual cooperation through motor skill learning may improve neurorehabilitation. Therefore, robotics and neuromodulation with transcranial direct current stimulation (tDCS) are promising approaches. To date, tDCS has failed to enhance bimanual motor control after stroke possibly because it was not integrating the hypothesis that the undamaged hemisphere becomes the major poststroke hub for bimanual control.

Objective

We tested the following hypotheses: (I) In patients with chronic hemiparetic stroke training on a robotic device, anodal tDCS applied over the primary motor cortex of the undamaged hemisphere enhances bimanual motor skill learning compared to sham tDCS. (II) The severity of impairment correlates with the effect of tDCS on bimanual motor skill learning. (III) Bimanual motor skill learning is less efficient in patients than in healthy individuals (HI).

Methods

A total of 17 patients with chronic hemiparetic stroke and 7 healthy individuals learned a complex bimanual cooperation skill on the REAplan® neurorehabilitation robot. The bimanual speed/accuracy trade-off (biSAT), bimanual coordination (biCo), and bimanual force (biFOP) scores were computed for each performance. In patients, real/sham tDCS was applied in a crossover, randomized, double-blind approach.

Results

Compared to sham, real tDCS did not enhance bimanual motor skill learning, retention, or generalization in patients, and no correlation with impairment was noted. The healthy individuals performed better than patients on bimanual motor skill learning, but generalization was similar in both groups.

Conclusion

A short motor skill learning session with a robotic device resulted in the retention and generalization of a complex skill involving bimanual cooperation. The tDCS strategy that would best enhance bimanual motor skill learning after stroke remains unknown.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT02308852, identifier: NCT02308852.

Effects of Transcranial Direct Current Stimulation Combined With Neuromuscular Electrical Stimulation on Upper Extremity Motor Function in Patients With Stroke

OBJECTIVE

The aim of the study was to investigate the treatment effects of transcranial direct current stimulation combined with neuromuscular electrical stimulation on the motor function of upper extremity in persons with stroke.

DESIGN

This study was a pilot double-blind randomized controlled trial. Twenty-six patients due to stroke onset of more than 6 mos were randomly allocated to three groups: transcranial direct current stimulation combined with neuromuscular electrical stimulation group, transcranial direct current stimulation group, or control group. In addition to conventional rehabilitation, all subjects received one of the three protocols in a total of 15 sessions for 3 wks.

RESULTS

A significant difference among the three groups was found for the change scores of the Fugl-Meyer Assessment upper extremity subscale from pretreatment to 1-mo follow-up (P = 0.02), in favor of the transcranial direct current stimulation combined with neuromuscular electrical stimulation group. Moreover, the transcranial direct current stimulation combined with neuromuscular electrical stimulation group showed significant within-group improvement on the Fugl-Meyer Assessment upper extremity (from preintervention to postintervention, P = 0.01) and the Action Research Arm Test (from preintervention to postintervention and to 1-mo postintervention, P = 0.03 and P = 0.04, respectively).

CONCLUSIONS

This preliminary study reveals that combining transcranial direct current stimulation and neuromuscular electrical stimulation with regular rehabilitation programs may enhance better upper extremity functional improvement than regular rehabilitation programs alone in patients with chronic stroke.

Effect of Transcranial Direct Current Stimulation Combined with Rehabilitation on Arm and Hand Function in Stroke Patients: A Systematic Review and Meta-Analysis

Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that may enhance motor recovery after stroke. We performed a systematic review and meta-analysis to assess the efficacy of tDCS combined with rehabilitation on arm and hand function after stroke. Electronic databases were searched from their inception to September 2021. We performed a systematic review of selected randomized controlled trials, and methodological qualities were measured using the PEDro (Physiotherapy Evidence Database) scale. We calculated the standardized mean difference for effect size using the Comprehensive Meta-Analysis 3.0 software. We selected 28 studies for the systematic review and 20 studies for the meta-analysis. The overall effect size was 0.480 (95% CI [0.307; 0.653], p < 0.05), indicating a moderate effect size of tDCS combined with rehabilitation for upper extremity function in stroke survivors. The tDCS with occupational therapy/physical therapy (0.696; 95% CI [0.390; 1.003], p < 0.05) or virtual reality therapy (0.510; 95% CI [0.111; 0.909], p < 0.05) was also significantly more effective than other treatments. This meta-analysis of 20 randomized controlled trials provides further evidence that tDCS combined with rehabilitation, especially occupational therapy/physical therapy and virtual reality therapy, may benefit upper extremity function of the paretic upper limb in stroke patients.

Transcranial direct current stimulation combined with robotic therapy for upper and lower limb function after stroke: a systematic review and meta-analysis of randomized control trials

BACKGROUND

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation method able to modulate neuronal activity after stroke. The aim of this systematic review was to determine if tDCS combined with robotic therapy (RT) improves limb function after stroke when compared to RT alone.

METHODS

A search for randomized controlled trials (RCTs) published prior to July 15, 2021 was performed. The main outcome was function assessed with the Fugl-Meyer motor assessment for upper extremities (FM/ue) and 10-m walking test (10MWT) for the lower limbs. As secondary outcomes, strength was assessed with the Motricity Index (MI) or Medical Research Council scale (MRC), spasticity with the modified Ashworth scale (MAS), functional independence with the Barthel Index (BI), and kinematic parameters.

RESULTS

Ten studies were included for analysis (n = 368 enrolled participants). The results showed a non-significant effect for tDCS combined with RT to improve upper limb function [standardized mean difference (SMD) = - 0.12; 95% confidence interval (CI): - 0.35-0.11)]. However, a positive effect of the combined therapy was observed in the lower limb function (SMD = 0.48; 95% CI: - 0.15-1.12). Significant results favouring tDCS combined with RT were not found in strength (SMD = - 0.15; 95% CI: - 0.4-0.1), spasticity [mean difference (MD) =  - 0.15; 95% CI: - 0.8-0.5)], functional independence (MD = 2.5; 95% CI: - 1.9-6.9) or velocity of movement (SMD = 0.06; 95% CI: - 0.3-0.5) with a "moderate" or "low" recommendation level according to the GRADE guidelines.

CONCLUSIONS

Current findings suggest that tDCS combined with RT does not improve upper limb function, strength, spasticity, functional independence or velocity of movement after stroke. However, tDCS may enhance the effects of RT alone for lower limb function. tDCS parameters and the stage or type of stroke injury could be crucial factors that determine the effectiveness of this therapy.

The adjunct of transcranial direct current stimulation to Robot-assisted therapy in upper limb post-stroke treatment

Transcranial direct current stimulation (TDCS) and robot-assisted therapy (RAT) proved to be promising interventions in post-stroke rehabilitation. However, the effects of combining the two treatments are not significantly clear. To determine the effects of combined therapy using transcranial direct current stimulation (tDCS) with robot-assisted therapy (RAT) in the impairment of the upper limb in stroke rehabilitation. The Cochrane Library, MEDLINE, Embase, Google Scholar, and Trial Registries were systematically searched for randomised controlled trials in May 2020. As the outcome, the Fugl-Meyer Assessment score (FMS) was used. A pairwise and a network meta-analysis were performed. 5 RCTs with RAT versus RAT + tDCS groups and 21 RCTs with RAT versus the control group with 892 people were analysed. Of these studies, 10 RCTs evaluated acute-subacute (<8 weeks) people, while 16 chronic people. By analysing the FMS with a pair-wise meta-analysis, we demonstrate significant improvements only in the RAT alone compared to the control (acute-subacute, SMD:4.09 (1.31, 6.87) and chronic, SMD:2.22 (0.99, 3.45)). Instead, performing a network meta-analysis, through an analysis of the surface under the cumulative ranking curve (SUCRA) we report a ranking of the effectiveness of the interventions. We assess SUCRA in acute-subacute stroke: Control:0.23, RAT + tDCS:0.31, RAT:0.96 and in chronic stroke: Control:0.06, RAT + tDCS:0.62, RAT:0.82. RAT is, respectively, 96% and 82% likely to be the best-ranked treatment. Despite the limitations, this network meta-analysis appears to demonstrate through the rank of interventions that adding tDCS to RAT is not useful in upper-limb stroke rehabilitation.

Robotic assistive and rehabilitation devices leading to motor recovery in upper limb: a systematic review

PURPOSE

Stroke, spinal cord injury and other neuromuscular disorders lead to impairments in the human body. Upper limb impairments, especially hand impairments affect activities of daily living (ADL) and reduce the quality of life. The purpose of this review is to compare and evaluate the available robotic rehabilitation and assistive devices that can lead to motor recovery or maintain the current motor functional level.

METHODS

A systematic review was conducted of the literature published in the years from 2016-2021, to focus on the most recent rehabilitation and assistive devices available in the market or research environments.

RESULTS

A total of 230 studies published between 2016 and 2021 were identified from various databases. 107 were excluded with various reasons. Twenty-eight studies were taken into detailed review, to determine the efficacy of robotic devices in improving upper limb impairments or maintaining the current level from getting worse.

CONCLUSION

It was concluded that with a good strategy and treatment plan; appropriate and regular use of these robotic rehabilitation and assistive devices do lead to improvements in current conditions of most of the subjects and prolonged use may lead to motor recovery.Implications for RehabilitationStroke, accidents, spinal cord injuries and other neuromuscular disorders lead to impairments. Upper limb impairments have a tremendous adverse affect on ADL and reduces quality of life drastically.Advancement in technology has led to the designing of many robotic assistive and rehabilitation devices to assist in motor recovery or aid in ADL.This review analyses different available devices for rehabilitation and assistance and points out that use of these devices in time does help in motor recovery. Most of the studies reviewed showed improvements for the user.Future devices should be more portable and easier to use from home.

Effects of home-based dual-hemispheric transcranial direct current stimulation combined with exercise on upper and lower limb motor performance in patients with chronic stroke

PURPOSE

This study aimed to determine the effects of home-based dual-hemispheric transcranial direct current stimulation (dual-tDCS) combined with exercise on motor performance in patients with chronic stroke.

MATERIALS AND METHODS

We allocated 24 participants to the active or sham group. They completed 1-h home-based exercise after 20-min dual-tDCS at 2-mA, thrice a week for 4 weeks. The patients were assessed using the Fugl-Meyer Assessment (FMA), Wolf Motor Function Test, Timed Up and Go test, Five Times Sit-to-Stand Test, Six-meter Walk Test, and muscle strength assessment.

RESULTS

Compared with the sham group, the active group showed improved FMA scores, which were sustained for at least 1 month. There was no between-group difference in the outcomes of the functional tasks.

CONCLUSION

Home-based dual-tDCS could facilitate motor recovery in patients with chronic stroke with its effect lasting for at least 1 month. However, its effects on functional tasks remain unclear. tDCS is safe and easy for home-based self-administration for patients who can use their paretic arms. This could benefit patients without access to health care centres or in situations requiring physical distancing. This home-based tDCS combined with exercise has the potential to be incorporated into telemedicine in stroke rehabilitation.IMPLICATIONS FOR REHABILITATIONTwelve sessions of home-based dual-tDCS combined with exercises (3 days/week for 4 weeks) facilitated upper and lower limb motor recovery in patients with chronic stroke compared with exercise alone, with a post-effect for at least 1 month.Home-based tDCS could be safe and easily self-administrable by patients who can use their paretic arms.This intervention could be beneficial for patients living in the community without easy access to a health care centre or in situations where physical distancing is required.

Effects of Robotic Therapy Associated With Noninvasive Brain Stimulation on Upper-Limb Rehabilitation After Stroke: Systematic Review and Meta-analysis of Randomized Clinical Trials

BACKGROUND

Robot-assisted therapy and noninvasive brain stimulation (NIBS) are promising strategies for stroke rehabilitation.

OBJECTIVE

This systematic review and meta-analysis aims to evaluate the evidence of NIBS as an add-on intervention to robotic therapy in order to improve outcomes of upper-limb motor impairment or activity in individuals with stroke.

METHODS

This study was performed according to the PRISMA Protocol and was previously registered on the PROSPERO Platform (CRD42017054563). Seven databases and gray literature were systematically searched by 2 reviewers, and 1176 registers were accessed. Eight randomized clinical trials with upper-limb body structure/function or activity limitation outcome measures were included. Subgroup analyses were performed according to phase poststroke, device characteristics (ie, arm support, joints involved, unimanual or bimanual training), NIBS paradigm, timing of stimulation, and number of sessions. The Grade-Pro Software was used to assess quality of the evidence.

RESULTS

A nonsignificant homogeneous summary effect size was found both for body structure function domain (mean difference [MD] = 0.15; 95% CI = -3.10 to 3.40; P = 0.93; I² = 0%) and activity limitation domain (standard MD = 0.03; 95% CI = -0.28 to 0.33; P = 0.87; I² = 0%).

CONCLUSIONS

According to this systematic review and meta-analysis, at the moment, there are not enough data about the benefits of NIBS as an add-on intervention to robot-assisted therapy on upper-limb motor function or activity in individuals with stroke.

Unskilled shooters improve both accuracy and grouping shot having as reference skilled shooters cortical area: An EEG and tDCS study

Transcranial direct current stimulation (tDCS) has been used as a non-invasive method for enhanced motor and cognitive abilities. However, no previous study has investigated if the tDCS application in unskilled shooters on cortical sites, selected based on the cortical activity of skilled shooters, improves the accuracy and shot grouping. Sixty participants were selected, which included 10 skilled shooters and 50 unskilled shooters. After we identified the right dorsolateral prefrontal cortex (DLPFC) as the area with the highest activity in skilled shooters, we applied anodal tDCS over the right DLPFC in the unskilled shooters under two conditions: sham-tDCS (placebo) and real-tDCS (anodal tDCS). We also analyzed electroencephalography. Our results indicated that anodal tDCS application enhanced the shot accuracy (p = 0.001). Furthermore, the beta power in the EEG recording was higher in the left DLPFC, left and right parietal cortex (p = 0,001) after applying anodal tDCS, while the low-gamma power was higher in the right DLPFC in sham-tDCS (p = 0.001) and right parietal cortex after anodal-tDCS (p = 0.001). Our findings indicate that anodal tDCS can improve accuracy and shot grouping when applied over the unskilled shooters' right DLPFC. Furthermore, beta and low-gamma bands are influenced by anodal tDCS over the right DLPFC, which may be predictive of skill improvement.

Neurophysiological signatures of hand motor response to dual-transcranial direct current stimulation in subacute stroke: a TMS and MEG study

Background

Dual transcranial direct current stimulation (tDCS) to the bilateral primary motor cortices (M1s) has potential benefits in chronic stroke, but its effects in subacute stroke, when behavioural effects might be expected to be greater, have been relatively unexplored. Here, we examined the neurophysiological effects and the factors influencing responsiveness of dual-tDCS in subacute stroke survivors.

Methods

We conducted a randomized sham-controlled crossover study in 18 survivors with first-ever, unilateral subcortical ischaemic stroke 2–4 weeks after stroke onset and 14 matched healthy controls. Participants had real dual-tDCS (with an ipsilesional [right for controls] M1 anode and a contralesional M1 [left for controls] cathode; 2 mA for 20mins) and sham dual-tDCS on separate days, with concurrent paretic [left for controls] hand exercise. Using transcranial magnetic stimulation (TMS) and magnetoencephalography (MEG), we recorded motor evoked potentials (MEPs), the ipsilateral silent period (iSP), short-interval intracortical inhibition, and finger movement-related cortical oscillations before and immediately after tDCS.

Results

Stroke survivors had decreased excitability in ipsilesional M1 with a relatively excessive transcallosal inhibition from the contralesional to ipsilesional hemisphere at baseline compared with controls, as quantified by decreased MEPs and increased iSP duration. Dual-tDCS led to increased MEPs and decreased iSP duration in ipsilesional M1. The magnitude of the tDCS-induced MEP increase in stroke survivors was predicted by baseline contralesional-to-ipsilesional transcallosal inhibition (iSP) ratio. Baseline post-movement synchronization in α-band activity in ipsilesional M1 was decreased after stroke compared with controls, and its tDCS-induced increase correlated with upper limb score in stroke survivors. No significant adverse effects were observed during or after dual-tDCS.

Conclusions

Task-concurrent dual-tDCS in subacute stroke can safely and effectively modulate bilateral M1 excitability and inter-hemispheric imbalance and also movement-related α-activity.

Effect of Transcranial Direct Current Stimulation Combined With Xbox-Kinect Game Experience on Upper Limb Movement in Down Syndrome: A Case Report

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique used to enhance local synaptic efficacy and modulate the electrical activity of the cortex in neurological disorders. Researchers have sought to combine this type of stimulation with well-established therapeutic modalities, such as motor training involving Xbox Kinect games, which has demonstrated promising results. Thus, this study aimed to determine whether tDCS can enhance upper limb motor training in an eight-year-old child with Down Syndrome (DS) (cognitive age: five years, based on the Wechsler Intelligence Scale for Children). The evaluations consisted of three-dimensional analysis of upper limb kinematics during a reaching task performed before, after10 session, and one month after the intervention. The intervention protocol involved 1 20-min sessions of tDCS over the primary motor cortex at an intensity of 1 mA during Xbox Kinect game training involving an upper limb motor task. The analysis of the kinematic data revealed that in the pre-intervention evaluation, the dominant limb executed the task slowly and over a long path. These aspects improved at the post-intervention and follow-up evaluations, as demonstrated by the shorter total movement duration (3.05 vs. 1.58 vs. 1.52 s, respectively). Similar changes occurred with the non-dominant upper limb; a significant increase in movement velocity at the post-intervention and follow-up evaluations was observed (0.53 vs. 0.54 vs. 0.85 m/s, respectively). The present case report offers preliminary data from a protocol study, and the results confirm the notion that anodal tDCS combined with upper limb motor training leads to improvements in different kinematic variables.

Evaluating the effects of tDCS in stroke patients using functional outcomes: a systematic review

Background and purpose: Transcranial direct current stimulation (tDCS) has been extensively studied over the past 20 years to promote functional motor recovery after stroke. However, tDCS clinical relevance still needs to be determined. The present systematic review aims to determine whether tDCS applied to the primary motor cortex (M1) in stroke patients can have a positive effect on functional motor outcomes.Materials and methods: Two databases (Medline & Scopus) were searched for randomized, double-blinded, sham-controlled trials pertaining to the use of M1 tDCS on cerebral stroke patients, and its effects on validated functional motor outcomes. When data were provided, effect sizes were calculated. PROSPERO registration number: CRD42018108157Results: 46 studies (n = 1291 patients) met inclusion criteria. Overall study quality was good (7.69/10 on the PEDro scale). Over half (56.5%) the studies were on chronic stroke patients. There seemed to be a certain pattern of recurring parameters, but tDCS protocols still remain heterogeneous. Overall results were positive (71.7% of studies found that tDCS has positive results on functional motor outcomes). Effect-sizes ranged from 0 to 1.33. No severe adverse events were reported.Conclusion: Despite heterogeneous stimulation parameters, outcomes and patient demographics, tDCS seems to be complementary to classical and novel rehabilitation approaches. With minimal adverse effects (if screening parameters are respected), none of which were serious, and a high potential to improve recovery when using optimal parameters (i.e.: 20 min of stimulation, at 2 mA with 25 or 35cm² electrodes that are regularly humidified), tDCS could potentially be ready for clinical applications.Implications for RehabilitationtDCS could potentially be ready for clinical application.Evidence of very low to very high quality is available on the effectiveness of tDCS to improve motor control following stroke.This should with caution be focused on the primary motor cortex.

Effectiveness of upper-limb robotic-assisted therapy in the early rehabilitation phase after stroke: A single-blind, randomised, controlled trial

BACKGROUND

Upper-limb robotic-assisted therapy (RAT) is promising for stroke rehabilitation, particularly in the early phase. When RAT is provided as partial substitution of conventional therapy, it is expected to be at least as effective or might be more effective than conventional therapy. Assessments have usually been restricted to the first 2 domains of the International classification of functioning, disability and health (ICF).

OBJECTIVE

This was a pragmatic, multicentric, single-blind, randomized controlled trial to evaluate the effectiveness of upper-limb RAT used as partial substitution to conventional therapy in the early phase of stroke rehabilitation, following the 3 ICF domains.

METHODS

We randomized 45 patients with acute stroke into 2 groups (conventional therapy, n=22, and RAT, n=23). Both interventions were dose-matched regarding treatment duration and lasted 9 weeks. The conventional therapy group followed a standard rehabilitation. In the RAT group, 4 sessions of conventional therapy (25%) were substituted by RAT each week. RAT consisted of moving the paretic upper limb along a reference trajectory while the robot provided assistance as needed. A blinded assessor evaluated participants before, just after the intervention and 6 months post-stroke, according to the ICF domains UL motor impairments, activity limitations, and social participation restriction.

RESULTS

In total, 28 individuals were assessed after the intervention. The following were more improved in the RAT than conventional therapy group at 6 months post-stroke: gross manual dexterity (Box and Block test +7.7 blocks; P=0.02), upper-limb ability during functional tasks (Wolf Motor Function test +12%; P=0.02) and patient social participation (Stroke Impact Scale +18%; P=0.01). Participants' abilities to perform manual activities and activities of daily living improved similarly in both groups.

CONCLUSION

For the same duration of daily rehabilitation, RAT combined with conventional therapy during the early rehabilitation phase after stroke is more effective than conventional therapy alone to improve gross manual dexterity, upper-limb ability during functional tasks and patient social participation.

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.