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Tseng SC, Cherry D, Ko M, Fisher SR, Furtado M, Chang SH. The effects of combined transcranial brain stimulation and a 4-week visuomotor stepping training on voluntary step initiation in persons with chronic stroke-a pilot study. Front Neurol 2024; 15:1286856. [PMID: 38450075 PMCID: PMC10915046 DOI: 10.3389/fneur.2024.1286856] [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: 08/31/2023] [Accepted: 02/02/2024] [Indexed: 03/08/2024] Open
Abstract
Purpose Evidence suggests that transcranial direct current stimulation (tDCS) can enhance motor performance and learning of hand tasks in persons with chronic stroke (PCS). However, the effects of tDCS on the locomotor tasks in PCS are unclear. This pilot study aimed to: (1) determine aggregate effects of anodal tDCS combined with step training on improvements of the neural and biomechanical attributes of stepping initiation in a small cohort of persons with chronic stroke (PCS) over a 4-week training program; and (2) assess the feasibility and efficacy of this novel approach for improving voluntary stepping initiation in PCS. Methods A total of 10 PCS were randomly assigned to one of two training groups, consisting of either 12 sessions of VST paired with a-tDCS (n = 6) or sham tDCS (s-tDCS, n = 4) over 4 weeks, with step initiation (SI) tests at pre-training, post-training, 1-week and 1-month follow-ups. Primary outcomes were: baseline vertical ground reaction force (B-vGRF), response time (RT) to initiate anticipatory postural adjustment (APA), and the retention of B-VGRF and RT. Results a-tDCS paired with a 4-week VST program results in a significant increase in paretic weight loading at 1-week follow up. Furthermore, a-tDCS in combination with VST led to significantly greater retention of paretic BWB compared with the sham group at 1 week post-training. Clinical implications The preliminary findings suggest a 4-week VST results in improved paretic limb weight bearing (WB) during SI in PCS. Furthermore, VST combined with a-tDCS may lead to better retention of gait improvements (NCT04437251) (https://classic.clinicaltrials.gov/ct2/show/NCT04437251).
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Affiliation(s)
- Shih-Chiao Tseng
- Neuromechanics Laboratory, Department of Physical Therapy, University of Texas Medical Branch, Galveston, TX, United States
| | - Dana Cherry
- Neuromechanics Laboratory, Department of Physical Therapy, University of Texas Medical Branch, Galveston, TX, United States
| | - Mansoo Ko
- Neuromechanics Laboratory, Department of Physical Therapy, University of Texas Medical Branch, Galveston, TX, United States
| | - Steven R. Fisher
- Neuromechanics Laboratory, Department of Physical Therapy, University of Texas Medical Branch, Galveston, TX, United States
| | - Michael Furtado
- Department of Physical Therapy, University of North Texas Health Science Center at Fort Worth, Fort Worth, TX, United States
| | - Shuo-Hsiu Chang
- Neuromuscular Plasticity Laboratory, Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, TX, United States
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Fan Z, Xi X, Wang T, Li H, Maofeng W, Li L, Lü Z. Effect of tDCS on corticomuscular coupling and the brain functional network of stroke patients. Med Biol Eng Comput 2023; 61:3303-3317. [PMID: 37667074 DOI: 10.1007/s11517-023-02905-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 08/09/2023] [Indexed: 09/06/2023]
Abstract
Transcranial direct current stimulation (tDCS) is an emerging brain intervention technique that has gained growing attention in recent years in the rehabilitation area. In this paper, we investigated the efficacy of tDCS in the rehabilitation process of stroke patients, utilizing corticomuscular coupling (CMC) and brain functional network analysis. Specifically, we examined changes in CMC relationships between the treatment and control groups before and after rehabilitation by transfer entropy (TE), and constructed brain functional networks by TE. We further calculated features of the functional networks, including node degree, global efficiency, clustering coefficient, characteristic path length, and small world index. Our results demonstrate that CMC in patients increased significantly after treatment, with greater improvements in the tDCS group, particularly within the beta and gamma bands. In addition, the functional brain network analysis revealed enhanced connectivity between brain regions, improved information processing capacity, and increased transmission efficiency in patients as their condition improved. Notably, treatment with tDCS resulted in more significant improvements than the sham group, with a statistically significant difference observed after rehabilitation treatment (p < 0.05). These findings provide compelling evidence regarding the role of tDCS in the treatment of stroke and highlight the potential of this approach in stroke rehabilitation. The use of tDCS for therapeutic interventions in stroke rehabilitation can significantly improve the coupling of patients' functional brain networks. Also, using Transfer Entropy (TE) as a characteristic of CMC, tDCS was found to significantly enhance patients' TE, i.e. enhanced CMC.
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Affiliation(s)
- Zhuyao Fan
- HDU-ITMO Joint Institute, Hangzhou Dianzi University, Hangzhou, 310018, China
- School of Automation, Hangzhou Dianzi University, Hangzhou, 310018, China
| | - Xugang Xi
- HDU-ITMO Joint Institute, Hangzhou Dianzi University, Hangzhou, 310018, China.
- School of Automation, Hangzhou Dianzi University, Hangzhou, 310018, China.
| | - Ting Wang
- HDU-ITMO Joint Institute, Hangzhou Dianzi University, Hangzhou, 310018, China
- School of Automation, Hangzhou Dianzi University, Hangzhou, 310018, China
| | - Hangcheng Li
- Hangzhou Mingzhou Naokang Rehabilitation Hospital, Hangzhou, 311215, China
| | - Wang Maofeng
- Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, 322100, China
| | - Lihua Li
- School of Automation, Hangzhou Dianzi University, Hangzhou, 310018, China
| | - Zhong Lü
- Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, 322100, China
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Non-invasive brain stimulation as therapeutic approach for ischemic stroke: Insights into the (sub)cellular mechanisms. Pharmacol Ther 2022; 235:108160. [PMID: 35183592 DOI: 10.1016/j.pharmthera.2022.108160] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 01/12/2023]
Abstract
Although spontaneous recovery can occur following ischemic stroke due to endogenous neuronal reorganization and neuroplastic events, the degree of functional improvement is highly variable, causing many patients to remain permanently impaired. In the last decades, non-invasive brain stimulation (NIBS) techniques have emerged as potential add-on interventions to the standard neurorehabilitation programs to improve post-stroke recovery. Due to their ability to modulate cortical excitability and to induce neuroreparative processes in the brain, multiple studies have assessed the safety, efficacy and (sub)cellular mechanisms of NIBS following ischemic stroke. In this review, an overview will be provided of the different NIBS techniques that are currently being investigated in (pre)clinical stroke studies. The NIBS therapies that will be discussed include transcranial magnetic stimulation, transcranial direct current stimulation and extremely low frequency electromagnetic stimulation. First, an overview will be given of the cellular mechanisms induced by NIBS that are associated with enhanced stroke outcome in preclinical models. Furthermore, the current knowledge on safety and efficacy of these NIBS techniques in stroke patients will be reviewed.
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Thibaut A, Shie VL, Ryan CM, Zafonte R, Ohrtman EA, Schneider JC, Fregni F. A review of burn symptoms and potential novel neural targets for non-invasive brain stimulation for treatment of burn sequelae. Burns 2021; 47:525-537. [PMID: 33293156 PMCID: PMC8685961 DOI: 10.1016/j.burns.2020.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/30/2020] [Accepted: 06/06/2020] [Indexed: 12/12/2022]
Abstract
Burn survivors experience myriad associated symptoms such as pain, pruritus, fatigue, impaired motor strength, post-traumatic stress, depression, anxiety, and sleep disturbance. Many of these symptoms are common and remain chronic, despite current standard of care. One potential novel intervention to target these post burn symptoms is transcranial direct current stimulation (tDCS). tDCS is a non-invasive brain stimulation (NIBS) technique that modulates neural excitability of a specific target or neural network. The aim of this work is to review the neural circuits of the aforementioned clinical sequelae associated with burn injuries and to provide a scientific rationale for specific NIBS targets that can potentially treat these conditions. We ran a systematic review, following the PRISMA statement, of tDCS effects on burn symptoms. Only three studies matched our criteria. One was a feasibility study assessing cortical plasticity in chronic neuropathic pain following burn injury, one looked at the effects of tDCS to reduce pain anxiety during burn wound care, and one assessed the effects of tDCS to manage pain and pruritus in burn survivors. Current literature on NIBS in burn remains limited, only a few trials have been conducted. Based on our review and results in other populations suffering from similar symptoms as patients with burn injuries, three main areas were selected: the prefrontal region, the parietal area and the motor cortex. Based on the importance of the prefrontal cortex in the emotional component of pain and its implication in various psychosocial symptoms, targeting this region may represent the most promising target. Our review of the neural circuitry involved in post burn symptoms and suggested targeted areas for stimulation provide a spring board for future study initiatives.
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Affiliation(s)
- Aurore Thibaut
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States; GIGA-Institute and Neurology Department, University of Liège and University Hospital of Liège, Liège, Belgium
| | - Vivian L Shie
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States
| | - Colleen M Ryan
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Shriners Hospitals for Children-Boston, Boston, MA, United States
| | - Ross Zafonte
- Massachusetts General Hospital and Brigham and Women's Hospital, Boston, United States
| | - Emily A Ohrtman
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States
| | - Jeffrey C Schneider
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States.
| | - Felipe Fregni
- Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States.
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O'Leary GH, Jenkins DD, Coker-Bolt P, George MS, Kautz S, Bikson M, Gillick BT, Badran BW. From adults to pediatrics: A review noninvasive brain stimulation (NIBS) to facilitate recovery from brain injury. PROGRESS IN BRAIN RESEARCH 2021; 264:287-322. [PMID: 34167660 DOI: 10.1016/bs.pbr.2021.01.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Stroke is a major problem worldwide that impacts over 100 million adults and children annually. Rehabilitation therapy is the current standard of care to restore functional impairments post-stroke, however its effects are limited and many patients suffer persisting functional impairments and life-long disability. Noninvasive Brain Stimulation (NIBS) has emerged as a potential rehabilitation treatment option in both adults and children with brain injury. In the last decade, Transcranial Magnetic Stimulation (TMS), Transcranial Direct Current Stimulation (tDCS) and Transcutaneous Auricular Vagus Nerve Stimulation (taVNS) have been investigated to improve motor recovery in adults post-stroke. These promising adult findings using NIBS, however, have yet to be widely translated to the area of pediatrics. The limited studies exploring NIBS in children have demonstrated safety, feasibility, and utility of stimulation-augmented rehabilitation. This chapter will describe the mechanism of NIBS therapy (cortical excitability, neuroplasticity) that underlies its use in stroke and motor function and how TMS, tDCS, and taVNS are applied in adult stroke treatment paradigms. We will then discuss the current state of NIBS in early pediatric brain injury and will provide insight regarding practical considerations and future applications of NIBS in pediatrics to make this promising treatment option a viable therapy in children.
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Affiliation(s)
- Georgia H O'Leary
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Dorothea D Jenkins
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Patricia Coker-Bolt
- Division of Occupational Therapy, College of Health Professions, Medical University of South Carolina, Charleston, SC, United States
| | - Mark S George
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States; Ralph H. Johnson VA Medical Center, Charleston, SC, United States
| | - Steve Kautz
- Ralph H. Johnson VA Medical Center, Charleston, SC, United States; Department of Health Sciences and Research, Medical University of South Carolina, Charleston, SC, United States
| | - Marom Bikson
- Department of Biomedical Engineering, City College of New York, New York, NY, United States
| | - Bernadette T Gillick
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Bashar W Badran
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States.
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Elsner B, Kugler J, Pohl M, Mehrholz J. Transcranial direct current stimulation (tDCS) for improving activities of daily living, and physical and cognitive functioning, in people after stroke. Cochrane Database Syst Rev 2020; 11:CD009645. [PMID: 33175411 PMCID: PMC8095012 DOI: 10.1002/14651858.cd009645.pub4] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Stroke is one of the leading causes of disability worldwide. Functional impairment, resulting in poor performance in activities of daily living (ADL) among stroke survivors is common. Current rehabilitation approaches have limited effectiveness in improving ADL performance, function, muscle strength, and cognitive abilities (including spatial neglect) after stroke, with improving cognition being the number one research priority in this field. A possible adjunct to stroke rehabilitation might be non-invasive brain stimulation by transcranial direct current stimulation (tDCS) to modulate cortical excitability, and hence to improve these outcomes in people after stroke. OBJECTIVES To assess the effects of tDCS on ADL, arm and leg function, muscle strength and cognitive abilities (including spatial neglect), dropouts and adverse events in people after stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase and seven other databases in January 2019. In an effort to identify further published, unpublished, and ongoing trials, we also searched trials registers and reference lists, handsearched conference proceedings, and contacted authors and equipment manufacturers. SELECTION CRITERIA This is the update of an existing review. In the previous version of this review, we focused on the effects of tDCS on ADL and function. In this update, we broadened our inclusion criteria to compare any kind of active tDCS for improving ADL, function, muscle strength and cognitive abilities (including spatial neglect) versus any kind of placebo or control intervention. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and risk of bias, extracted data, and applied GRADE criteria. If necessary, we contacted study authors to ask for additional information. We collected information on dropouts and adverse events from the trial reports. MAIN RESULTS We included 67 studies involving a total of 1729 patients after stroke. We also identified 116 ongoing studies. The risk of bias did not differ substantially for different comparisons and outcomes. The majority of participants had ischaemic stroke, with mean age between 43 and 75 years, in the acute, postacute, and chronic phase after stroke, and level of impairment ranged from severe to less severe. Included studies differed in terms of type, location and duration of stimulation, amount of current delivered, electrode size and positioning, as well as type and location of stroke. We found 23 studies with 781 participants examining the effects of tDCS versus sham tDCS (or any other passive intervention) on our primary outcome measure, ADL after stroke. Nineteen studies with 686 participants reported absolute values and showed evidence of effect regarding ADL performance at the end of the intervention period (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.13 to 0.44; random-effects model; moderate-quality evidence). Four studies with 95 participants reported change scores, and showed an effect (SMD 0.48, 95% CI 0.02 to 0.95; moderate-quality evidence). Six studies with 269 participants assessed the effects of tDCS on ADL at the end of follow-up and provided absolute values, and found improved ADL (SMD 0.31, 95% CI 0.01 to 0.62; moderate-quality evidence). One study with 16 participants provided change scores and found no effect (SMD -0.64, 95% CI -1.66 to 0.37; low-quality evidence). However, the results did not persist in a sensitivity analysis that included only trials with proper allocation concealment. Thirty-four trials with a total of 985 participants measured upper extremity function at the end of the intervention period. Twenty-four studies with 792 participants that presented absolute values found no effect in favour of tDCS (SMD 0.17, 95% CI -0.05 to 0.38; moderate-quality evidence). Ten studies with 193 participants that presented change values also found no effect (SMD 0.33, 95% CI -0.12 to 0.79; low-quality evidence). Regarding the effects of tDCS on upper extremity function at the end of follow-up, we identified five studies with a total of 211 participants (absolute values) without an effect (SMD -0.00, 95% CI -0.39 to 0.39; moderate-quality evidence). Three studies with 72 participants presenting change scores found an effect (SMD 1.07; 95% CI 0.04 to 2.11; low-quality evidence). Twelve studies with 258 participants reported outcome data for lower extremity function and 18 studies with 553 participants reported outcome data on muscle strength at the end of the intervention period, but there was no effect (high-quality evidence). Three studies with 156 participants reported outcome data on muscle strength at follow-up, but there was no evidence of an effect (moderate-quality evidence). Two studies with 56 participants found no evidence of effect of tDCS on cognitive abilities (low-quality evidence), but one study with 30 participants found evidence of effect of tDCS for improving spatial neglect (very low-quality evidence). In 47 studies with 1330 participants, the proportions of dropouts and adverse events were comparable between groups (risk ratio (RR) 1.25, 95% CI 0.74 to 2.13; random-effects model; moderate-quality evidence). AUTHORS' CONCLUSIONS: There is evidence of very low to moderate quality on the effectiveness of tDCS versus control (sham intervention or any other intervention) for improving ADL outcomes after stroke. However, the results did not persist in a sensitivity analyses including only trials with proper allocation concealment. Evidence of low to high quality suggests that there is no effect of tDCS on arm function and leg function, muscle strength, and cognitive abilities in people after stroke. Evidence of very low quality suggests that there is an effect on hemispatial neglect. There was moderate-quality evidence that adverse events and numbers of people discontinuing the treatment are not increased. Future studies should particularly engage with patients who may benefit the most from tDCS after stroke, but also should investigate the effects in routine application. Therefore, further large-scale randomised controlled trials with a parallel-group design and sample size estimation for tDCS are needed.
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Affiliation(s)
- Bernhard Elsner
- Department of Public Health, Dresden Medical School, Technical University Dresden, Dresden, Germany
- Department of Physiotherapy, SRH Hochschule für Gesundheit Gera, 07548 Gera, Germany
| | - Joachim Kugler
- Department of Public Health, Dresden Medical School, Technical University Dresden, Dresden, Germany
| | - Marcus Pohl
- Neurological Rehabilitation, Helios Klinik Schloss Pulsnitz, Pulsnitz, Germany
| | - Jan Mehrholz
- Department of Public Health, Dresden Medical School, Technical University Dresden, Dresden, Germany
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Jones KT, Johnson EL, Tauxe ZS, Rojas DC. Modulation of auditory gamma-band responses using transcranial electrical stimulation. J Neurophysiol 2020; 123:2504-2514. [PMID: 32459551 DOI: 10.1152/jn.00003.2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Auditory gamma-band (>30 Hz) activity is a biomarker of cortical excitation/inhibition (E/I) balance in autism, schizophrenia, and bipolar disorder. We provide a comprehensive account of the effects of transcranial alternating current stimulation (tACS) and transcranial direct current stimulation (tDCS) on gamma responses. Forty-five healthy young adults listened to 40-Hz auditory click trains while electroencephalography (EEG) data were collected to measure stimulus-related gamma activity immediately before and after 10 min of 1 mA tACS (40 Hz), tDCS, or sham stimulation to left auditory cortex. tACS, but not tDCS, increased gamma power and phase locking to the auditory stimulus. However, both tACS and tDCS strengthened the gamma phase connectome, and effects persisted beyond the stimulus. Finally, tDCS strengthened the coupling of gamma activity to alpha oscillations after termination of the stimulus. No effects were observed in prestimulus gamma power, the gamma amplitude connectome, or any band-limited alpha measure. Whereas both stimulation techniques synchronize gamma responses between regions, tACS also tunes the magnitude and timing of gamma responses to the stimulus. Results reveal dissociable neurophysiological changes following tACS and tDCS and demonstrate that clinical biomarkers can be altered with noninvasive neurostimulation, especially frequency-tuned tACS.NEW & NOTEWORTHY Gamma frequency-tuned transcranial alternating current stimulation (tACS) adjusts the magnitude and timing of auditory gamma responses, as compared with both sham stimulation and transcranial direct current stimulation (tDCS). However, both tACS and tDCS strengthen the gamma phase connectome, which is disrupted in numerous neurological and psychiatric disorders. These findings reveal dissociable neurophysiological changes following two noninvasive neurostimulation techniques commonly applied in clinical and research settings.
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Affiliation(s)
- Kevin T Jones
- Colorado State University, Department of Psychology, Fort Collins, Colorado.,University of California-San Francisco, Department of Neurology, Neuroscape, San Francisco, California
| | - Elizabeth L Johnson
- University of California-Berkeley, Helen Wills Neuroscience Institute, Berkeley, California.,Wayne State University, Institute of Gerontology, Life-Span Cognitive Neuroscience Program, Detroit, Michigan
| | - Zoe S Tauxe
- Colorado State University, Department of Psychology, Fort Collins, Colorado.,University of California-San Diego, Department of Psychology, San Diego, California
| | - Donald C Rojas
- Colorado State University, Department of Psychology, Fort Collins, Colorado
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Enhancing Stroke Recovery Across the Life Span With Noninvasive Neurostimulation. J Clin Neurophysiol 2020; 37:150-163. [DOI: 10.1097/wnp.0000000000000543] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Kim JS, Kim DH, Kim HJ, Jung KJ, Hong J, Kim DY. Effect of Repetitive Transcranial Magnetic Stimulation in Post-stroke Patients with Severe Upper-Limb Motor Impairment. BRAIN & NEUROREHABILITATION 2019; 13:e3. [PMID: 36744269 PMCID: PMC9879525 DOI: 10.12786/bn.2020.13.e3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/04/2019] [Accepted: 10/06/2019] [Indexed: 11/08/2022] Open
Abstract
Repetitive transcranial magnetic stimulation (rTMS) has been known to improve the motor function through modulation of excitability in the cerebral cortex. However, most studies with rTMS were limited to post-stroke patients with mild to moderate motor impairments. The effect of rTMS on severe upper-limb motor impairment remains unclear. Therefore, this study investigated the effects of rTMS on the upper extremity function in post-stroke patients with severe upper-limb motor impairment. Subjects were divided into 3 groups, low-, high-frequency rTMS and control group were received stimulation 10 times for 2 weeks. The motor scale of Fugl-Meyer Assessment (FMA) and cortical excitability on the unaffected hemisphere were measured before and after performing 10 rTMS sessions. The motor scale of upper extremity FMA (UE-FMA) and shoulder component of the UE-FMA were significantly improved in both low- and high-frequency rTMS groups. However, no significant improvement was observed in the wrist and hand components. No significant differences were noted in low- and high-frequency rTMS groups. The amplitude of motor evoked potential on the unaffected hemisphere showed a significant decrease in the low- and high-frequency stimulation groups. rTMS may be helpful in improving upper extremity motor function even in post-stroke patients with severe upper-limb motor impairment.
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Affiliation(s)
- Ju Sun Kim
- Department of Rehabilitation Medicine and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Hyun Kim
- Department of Physical Medicine and Rehabilitation, Veterans Health Service Medical Center, Seoul, Korea
| | - Hyun Jung Kim
- Department of Rehabilitation Medicine and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kang Jae Jung
- Department of Physical Medicine and Rehabilitation, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Korea
| | - Juntaek Hong
- Department of Rehabilitation Medicine and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Deog Young Kim
- Department of Rehabilitation Medicine and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
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Effects of a tailored strength training program of the upper limb combined with transcranial direct current stimulation (tDCS) in chronic stroke patients: study protocol for a randomised, double-blind, controlled trial. BMC Sports Sci Med Rehabil 2019; 11:8. [PMID: 31139420 PMCID: PMC6534822 DOI: 10.1186/s13102-019-0120-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/17/2019] [Indexed: 11/17/2022]
Abstract
Background A significant proportion of individuals are left with poor residual functioning of the affected arm after a stroke. This has a great impact on the quality of life and the ability for stroke survivors to live independently. While strengthening exercises have been recommended to improve arm function, their benefits are generally far from optimal due to the lack of appropriate dosing in terms of intensity. One way to address this problem is to develop better tools that could predict an individual’s potential for recovery and then adjust the intensity of exercise accordingly. In this study, we aim at determining whether an individualized strengthening program based on the integrity of the corticospinal tract, as reflected in the amplitude of motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation (TMS), in conjunction with transcranial direct current stimulation (tDCS), could lead to more optimal outcomes in terms of arm function in chronic stroke patients. Methods This multicentre, double-blinded, randomised controlled trial will aim to recruit 84 chronic stroke patients. Before and after training, participants will undergo a clinical evaluation, assessing motor recovery of the affected arm (Fugl-Meyer Stroke Assessment-FMA) and a TMS evaluation to assess the integrity of the corticospinal tract, as reflected in MEP amplitude. Based on their baseline MEPs amplitude, participants will be stratified into three groups of training intensity levels determined by the one-repetition maximum (1RM); 1) low: 35–50% 1 RM (MEPs < 50 μV); 2) moderate: 50–65% 1RM (MEPs 50-120 μV); and 3) high: 70–80% 1RM (MEPs > 120 μV). Training will target the affected arm (3 times/week for 4 weeks). In addition, participants will be randomly allocated into two tDCS groups (real vs. sham) and tDCS will be applied in an anodal montage during the exercise. Discussion This study will determine whether an individualized strength training intervention in chronic stroke survivors can lead to improved arm function. In addition, we will also determine whether combining anodal tDCS over the lesioned hemisphere with strength training can lead to further improvement in arm function, when compared to sham tDCS. Trial registration ClinicalTrials.gov Identifier: NCT02915185. Registered September 21 2016.
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Ojardias E, Azé OD, Luneau D, Mednieks J, Condemine A, Rimaud D, Chassagne F, Giraux P. The Effects of Anodal Transcranial Direct Current Stimulation on the Walking Performance of Chronic Hemiplegic Patients. Neuromodulation 2019; 23:373-379. [PMID: 31124218 DOI: 10.1111/ner.12962] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 02/11/2019] [Accepted: 02/27/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the effect of a single session of tDCS over the primary motor cortex of the lower limb (M1-LL) vs. placebo on the walking performance in chronic hemiplegic patients. PATIENTS AND METHODS Randomized, cross-over, double-blinded study. Eighteen patients with initially complete hemiplegia and poststroke delay >6 months were included. Each patient received a single session of anodal stimulation (2 mA, 20 min) over M1-LL (a-tDCS condition) and a pseudostimulation session (SHAM condition). The order of the two sessions was randomly assigned, with an 11-day interval between the two sessions. The anodal electrode was centered on the hotspot identified with Transcranial magnetic stimulation. The cathode was placed above the contralesional orbitofrontal cortex. Walking performance was evaluated with the Wade test and the 6-minute walk test (6MWT), gait parameters with GAITRite, and balance with posturography. These tests were performed during and 1 hour after the stimulation. Baseline assessments were performed the day before and 10 days after each session. RESULTS The comparison between the 6MWT under a-tDCS vs. SHAM conditions demonstrated a nonsignificant positive effect of the stimulation by 15% during stimulation (p = 0.360) and a significant positive effect of 25% 1 hour after stimulation (p = 0.038). No significant differences were observed for the other evaluations. DISCUSSION These results showed a significant positive effect of a single session of anodal tDCS of the M1-LL in chronic hemiplegic patients. This proof-of-concept study supports the conduct of clinical studies evaluating the effectiveness of a walking training program associated with iterative tDCS stimulation. CONFLICT OF INTEREST The authors reported no conflict of interest.
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Affiliation(s)
- Etienne Ojardias
- Univ Lyon, UJM Saint-Etienne, Laboratoire Interuniversitaire de Biologie de la Motricité, EA, 7424, 42023, Saint-Etienne, France.,CHU Saint-Etienne, Service Médecine Physique et Réadaptation, F-42055, Saint-Etienne, France
| | - Oscar Dagbémabou Azé
- Univ Lyon, UJM Saint-Etienne, Laboratoire Interuniversitaire de Biologie de la Motricité, EA, 7424, 42023, Saint-Etienne, France.,Laboratoire de Biomécanique et de Performance, Institut National de la Jeunesse, de l'Education Physique et du Sport (INJEPS)/ Université d'Abomey-Calavi (UAC), Porto-Novo, Bénin, Africa
| | - Davy Luneau
- Univ Lyon, UJM Saint-Etienne, Laboratoire Interuniversitaire de Biologie de la Motricité, EA, 7424, 42023, Saint-Etienne, France
| | - Janis Mednieks
- CHU Saint-Etienne, Service Médecine Physique et Réadaptation, F-42055, Saint-Etienne, France.,Department of Neurology and Neurosurgery, Riga Stradins University, Riga, Latvia
| | - Agnès Condemine
- CHU Saint-Etienne, Service Médecine Physique et Réadaptation, F-42055, Saint-Etienne, France
| | - Diana Rimaud
- Univ Lyon, UJM Saint-Etienne, Laboratoire Interuniversitaire de Biologie de la Motricité, EA, 7424, 42023, Saint-Etienne, France.,CHU Saint-Etienne, Service Médecine Physique et Réadaptation, F-42055, Saint-Etienne, France
| | - Fanette Chassagne
- Ecole Nationale Supérieure des Mines de Saint-Etienne, CIS-EMSE, Sainbiose, F-42023, Saint-Etienne, France
| | - Pascal Giraux
- Univ Lyon, UJM Saint-Etienne, Laboratoire Interuniversitaire de Biologie de la Motricité, EA, 7424, 42023, Saint-Etienne, France.,CHU Saint-Etienne, Service Médecine Physique et Réadaptation, F-42055, Saint-Etienne, France
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Kirton A. Advancing non-invasive neuromodulation clinical trials in children: Lessons from perinatal stroke. Eur J Paediatr Neurol 2017; 21:75-103. [PMID: 27470654 DOI: 10.1016/j.ejpn.2016.07.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 06/21/2016] [Accepted: 07/02/2016] [Indexed: 12/18/2022]
Abstract
Applications of non-invasive brain stimulation including therapeutic neuromodulation are expanding at an alarming rate. Increasingly established scientific principles, including directional modulation of well-informed cortical targets, are advancing clinical trial development. However, high levels of disease burden coupled with zealous enthusiasm may be getting ahead of rational research and evidence. Experience is limited in the developing brain where additional issues must be considered. Properly designed and meticulously executed clinical trials are essential and required to advance and optimize the potential of non-invasive neuromodulation without risking the well-being of children and families. Perinatal stroke causes most hemiplegic cerebral palsy and, as a focal injury of defined timing in an otherwise healthy brain, is an ideal human model of developmental plasticity. Advanced models of how the motor systems of young brains develop following early stroke are affording novel windows of opportunity for neuromodulation clinical trials, possibly directing neuroplasticity toward better outcomes. Reviewing the principles of clinical trial design relevant to neuromodulation and using perinatal stroke as a model, this article reviews the current and future issues of advancing such trials in children.
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Affiliation(s)
- Adam Kirton
- Departments of Pediatrics and Clinical Neurosciences, Cumming School of Medicine, Hotchkiss Brain Institute and Alberta Children's Hospital Research Institute, 2888 Shaganappi Trail NW, Calgary, AB T3B6A8, Canada.
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tDCS over left M1 or DLPFC does not improve learning of a bimanual coordination task. Sci Rep 2016; 6:35739. [PMID: 27779192 PMCID: PMC5078840 DOI: 10.1038/srep35739] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 10/04/2016] [Indexed: 12/21/2022] Open
Abstract
Previously, transcranial direct current stimulation (tDCS) over the primary motor cortex (M1) has resulted in improved performance in simple motor tasks. For a complex bimanual movement, studies using functional magnetic resonance imaging and transcranial magnetic stimulation indicated the involvement of the left dorsolateral prefrontal cortex (DLPFC) as well as left M1. Here we investigated the relative effect of up-regulating the cortical function in left DLPFC and left M1 with tDCS. Participants practised a complex bimanual task over four days while receiving either of five stimulation protocols: anodal tDCS applied over M1, anodal tDCS over DLPFC, sham tDCS over M1, sham tDCS over DLPFC, or no stimulation. Performance was measured at the start and end of each training day to make a distinction between acquisition and consolidation. Although task performance improved over days, no significant difference between stimulation protocols was observed, suggesting that anodal tDCS had little effect on learning the bimanual task regardless of the stimulation sites and learning phase (acquisition or consolidation). Interestingly, cognitive performance as well as corticomotor excitability did not change following stimulation. Accordingly, we found no evidence for behavioural or neurophysiological changes following tDCS over left M1 or left DLPFC in learning a complex bimanual task.
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Peters HT, Richards L, Basobas BA, Faieta JM, Page SJ. Changing Their Minds: Enhancing Poststroke Occupational Performance Using Transcranial Direct Current Stimulation. J Mot Behav 2016; 49:8-19. [DOI: 10.1080/00222895.2016.1191417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Heather T. Peters
- Division of Occupational Therapy, The Ohio State University, Columbus, Ohio, USA
- B.R.A.I.N. Laboratory (Better Rehabilitation and Assessment for Improved Neuro-recovery), Ohio State University, Columbus, Ohio, USA
| | - Lorie Richards
- Occupational Therapy, University of Utah, Salt Lake City, Utah, USA
| | - Brittani A. Basobas
- Division of Occupational Therapy, The Ohio State University, Columbus, Ohio, USA
- B.R.A.I.N. Laboratory (Better Rehabilitation and Assessment for Improved Neuro-recovery), Ohio State University, Columbus, Ohio, USA
| | - Julie M. Faieta
- Division of Occupational Therapy, The Ohio State University, Columbus, Ohio, USA
- B.R.A.I.N. Laboratory (Better Rehabilitation and Assessment for Improved Neuro-recovery), Ohio State University, Columbus, Ohio, USA
| | - Stephen J. Page
- Division of Occupational Therapy, The Ohio State University, Columbus, Ohio, USA
- B.R.A.I.N. Laboratory (Better Rehabilitation and Assessment for Improved Neuro-recovery), Ohio State University, Columbus, Ohio, USA
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Elsner B, Kugler J, Pohl M, Mehrholz J. Transcranial direct current stimulation (tDCS) for improving activities of daily living, and physical and cognitive functioning, in people after stroke. Cochrane Database Syst Rev 2016; 3:CD009645. [PMID: 26996760 PMCID: PMC6464909 DOI: 10.1002/14651858.cd009645.pub3] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Stroke is one of the leading causes of disability worldwide. Functional impairment, resulting in poor performance in activities of daily living (ADLs) among stroke survivors is common. Current rehabilitation approaches have limited effectiveness in improving ADL performance, function, muscle strength and cognitive abilities (including spatial neglect) after stroke, but a possible adjunct to stroke rehabilitation might be non-invasive brain stimulation by transcranial direct current stimulation (tDCS) to modulate cortical excitability, and hence to improve ADL performance, arm and leg function, muscle strength and cognitive abilities (including spatial neglect), dropouts and adverse events in people after stroke. OBJECTIVES To assess the effects of tDCS on ADLs, arm and leg function, muscle strength and cognitive abilities (including spatial neglect), dropouts and adverse events in people after stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library; 2015, Issue 2), MEDLINE (1948 to February 2015), EMBASE (1980 to February 2015), CINAHL (1982 to February 2015), AMED (1985 to February 2015), Science Citation Index (1899 to February 2015) and four additional databases. In an effort to identify further published, unpublished and ongoing trials, we searched trials registers and reference lists, handsearched conference proceedings and contacted authors and equipment manufacturers. SELECTION CRITERIA This is the update of an existing review. In the previous version of this review we focused on the effects of tDCS on ADLs and function. In this update, we broadened our inclusion criteria to compare any kind of active tDCS for improving ADLs, function, muscle strength and cognitive abilities (including spatial neglect) versus any kind of placebo or control intervention. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and risk of bias (JM and MP) and extracted data (BE and JM). If necessary, we contacted study authors to ask for additional information. We collected information on dropouts and adverse events from the trial reports. MAIN RESULTS We included 32 studies involving a total of 748 participants aged above 18 with acute, postacute or chronic ischaemic or haemorrhagic stroke. We also identified 55 ongoing studies. The risk of bias did not differ substantially for different comparisons and outcomes.We found nine studies with 396 participants examining the effects of tDCS versus sham tDCS (or any other passive intervention) on our primary outcome measure, ADLs after stroke. We found evidence of effect regarding ADL performance at the end of the intervention period (standardised mean difference (SMD) 0.24, 95% confidence interval (CI) 0.03 to 0.44; inverse variance method with random-effects model; moderate quality evidence). Six studies with 269 participants assessed the effects of tDCS on ADLs at the end of follow-up, and found improved ADL performance (SMD 0.31, 95% CI 0.01 to 0.62; inverse variance method with random-effects model; moderate quality evidence). However, the results did not persist in a sensitivity analysis including only trials of good methodological quality.One of our secondary outcome measures was upper extremity function: 12 trials with a total of 431 participants measured upper extremity function at the end of the intervention period, revealing no evidence of an effect in favour of tDCS (SMD 0.01, 95% CI -0.48 to 0.50 for studies presenting absolute values (low quality evidence) and SMD 0.32, 95% CI -0.51 to 1.15 (low quality evidence) for studies presenting change values; inverse variance method with random-effects model). Regarding the effects of tDCS on upper extremity function at the end of follow-up, we identified four studies with a total of 187 participants (absolute values) that showed no evidence of an effect (SMD 0.01, 95% CI -0.48 to 0.50; inverse variance method with random-effects model; low quality evidence). Ten studies with 313 participants reported outcome data for muscle strength at the end of the intervention period, but in the corresponding meta-analysis there was no evidence of an effect. Three studies with 156 participants reported outcome data on muscle strength at follow-up, but there was no evidence of an effect.In six of 23 studies (26%), dropouts, adverse events or deaths that occurred during the intervention period were reported, and the proportions of dropouts and adverse events were comparable between groups (risk difference (RD) 0.01, 95% CI -0.02 to 0.03; Mantel-Haenszel method with random-effects model; low quality evidence; analysis based only on studies that reported either on dropouts, or on adverse events, or on both). However, this effect may be underestimated due to reporting bias. AUTHORS' CONCLUSIONS At the moment, evidence of very low to moderate quality is available on the effectiveness of tDCS (anodal/cathodal/dual) versus control (sham/any other intervention) for improving ADL performance after stroke. However, there are many ongoing randomised trials that could change the quality of evidence in the future. Future studies should particularly engage those who may benefit most from tDCS after stroke and in the effects of tDCS on upper and lower limb function, muscle strength and cognitive abilities (including spatial neglect). Dropouts and adverse events should be routinely monitored and presented as secondary outcomes. They should also address methodological issues by adhering to the Consolidated Standards of Reporting Trials (CONSORT) statement.
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Affiliation(s)
- Bernhard Elsner
- Dresden Medical School, Technical University DresdenDepartment of Public HealthFetscherstr. 74DresdenSachsenGermany01307
- SRH Fachhochschule für Gesundheit Gera gGmbHLehrstuhl TherapiewissenschaftenGeraGermany07548
| | - Joachim Kugler
- Technical University DresdenDepartment of Public Health, Dresden Medical SchoolLöscherstr. 18DresdenGermanyD‐01307
| | - Marcus Pohl
- Helios Klinik Schloss PulsnitzNeurological RehabilitationWittgensteiner Str. 1PulsnitzSaxonyGermany01896
| | - Jan Mehrholz
- Technical University DresdenDepartment of Public Health, Dresden Medical SchoolLöscherstr. 18DresdenGermanyD‐01307
- Private Europäische Medizinische Akademie der Klinik Bavaria in Kreischa GmbHWissenschaftliches InstitutAn der Wolfsschlucht 1‐2KreischaGermany01731
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Otal B, Dutta A, Foerster Á, Ripolles O, Kuceyeski A, Miranda PC, Edwards DJ, Ilić TV, Nitsche MA, Ruffini G. Opportunities for Guided Multichannel Non-invasive Transcranial Current Stimulation in Poststroke Rehabilitation. Front Neurol 2016; 7:21. [PMID: 26941708 PMCID: PMC4764713 DOI: 10.3389/fneur.2016.00021] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 02/09/2016] [Indexed: 12/21/2022] Open
Abstract
Stroke is a leading cause of serious long-term disability worldwide. Functional outcome depends on stroke location, severity, and early intervention. Conventional rehabilitation strategies have limited effectiveness, and new treatments still fail to keep pace, in part due to a lack of understanding of the different stages in brain recovery and the vast heterogeneity in the poststroke population. Innovative methodologies for restorative neurorehabilitation are required to reduce long-term disability and socioeconomic burden. Neuroplasticity is involved in poststroke functional disturbances and also during rehabilitation. Tackling poststroke neuroplasticity by non-invasive brain stimulation is regarded as promising, but efficacy might be limited because of rather uniform application across patients despite individual heterogeneity of lesions, symptoms, and other factors. Transcranial direct current stimulation (tDCS) induces and modulates neuroplasticity, and has been shown to be able to improve motor and cognitive functions. tDCS is suited to improve poststroke rehabilitation outcomes, but effect sizes are often moderate and suffer from variability. Indeed, the location, extent, and pattern of functional network connectivity disruption should be considered when determining the optimal location sites for tDCS therapies. Here, we present potential opportunities for neuroimaging-guided tDCS-based rehabilitation strategies after stroke that could be personalized. We introduce innovative multimodal intervention protocols based on multichannel tDCS montages, neuroimaging methods, and real-time closed-loop systems to guide therapy. This might help to overcome current treatment limitations in poststroke rehabilitation and increase our general understanding of adaptive neuroplasticity leading to neural reorganization after stroke.
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Affiliation(s)
| | - Anirban Dutta
- INRIA (Sophia Antipolis), Université Montpellier, Montpellier, France
| | | | | | - Amy Kuceyeski
- Department of Radiology, Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - Pedro C. Miranda
- Institute of Biophysics and Biomedical Engineering (IBEB), Faculdade de Ciências, Universidade de Lisboa, Lisboa, Portugal
| | - Dylan J. Edwards
- Non-Invasive Brain Stimulation and Human Motor Control Laboratory, Burke-Cornell Medical Research Institute, White Plains, NY, USA
| | - Tihomir V. Ilić
- Department of Clinical Neurophysiology, Medical Faculty of Military Medical Academy, University of Defense, Belgrade, Serbia
| | - Michael A. Nitsche
- Leibniz Research Centre for Working Environment and Human Factors, Technical University of Dortmund, Dortmund, Germany
- Department of Neurology, University Medical Hospital Bergmannsheil, Bochum, Germany
| | - Giulio Ruffini
- Neuroelectrics Barcelona, Barcelona, Spain
- Starlab Barcelona, Barcelona, Spain
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Lagogianni C, Thomas S, Lincoln N. Examining the relationship between fatigue and cognition after stroke: A systematic review. Neuropsychol Rehabil 2016; 28:57-116. [PMID: 26787096 DOI: 10.1080/09602011.2015.1127820] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Many stroke survivors experience fatigue, which is associated with a variety of factors including cognitive impairment. A few studies have examined the relationship between fatigue and cognition and have obtained conflicting results. The aim of the current study was to review the literature on the relationship between fatigue and cognition post-stroke. The following databases were searched: EMBASE (1980-February, 2014), PsycInfo (1806-February, 2014), CINAHL (1937-February, 2014), MEDLINE (1946-February, 2014), Ethos (1600-February, 2014) and DART (1999-February, 2014). Reference lists of relevant papers were screened and the citation indices of the included papers were searched using Web of Science. Studies were considered if they were on adult stroke patients and assessed the following: fatigue with quantitative measurements (≥ 3 response categories), cognition using objective measurements, and the relationship between fatigue and cognition. Overall, 413 papers were identified, of which 11 were included. Four studies found significant correlations between fatigue and memory, attention, speed of information processing and reading speed (r = -.36 to .46) whereas seven studies did not. Most studies had limitations; quality scores ranged from 9 to 14 on the Critical Appraisal Skills Programme Checklists. There was insufficient evidence to support or refute a relationship between fatigue and cognition post-stroke. More robust studies are needed.
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Affiliation(s)
- Christodouli Lagogianni
- a Division of Rehabilitation & Ageing, Medical School , University of Nottingham , Nottingham , UK.,b Queens Medical Centre , Nottingham , UK
| | - Shirley Thomas
- a Division of Rehabilitation & Ageing, Medical School , University of Nottingham , Nottingham , UK.,b Queens Medical Centre , Nottingham , UK
| | - Nadina Lincoln
- a Division of Rehabilitation & Ageing, Medical School , University of Nottingham , Nottingham , UK.,b Queens Medical Centre , Nottingham , UK
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Pisegna JM, Kaneoka A, Pearson WG, Kumar S, Langmore SE. Effects of non-invasive brain stimulation on post-stroke dysphagia: A systematic review and meta-analysis of randomized controlled trials. Clin Neurophysiol 2016; 127:956-968. [PMID: 26070517 PMCID: PMC5326549 DOI: 10.1016/j.clinph.2015.04.069] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 03/19/2015] [Accepted: 04/25/2015] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The primary aim of this review is to evaluate the effects of non-invasive brain stimulation on post-stroke dysphagia. METHODS Thirteen databases were systematically searched through July 2014. Studies had to meet pre-specified inclusion and exclusion criteria. Each study's methodological quality was examined. Effect sizes were calculated from extracted data and combined for an overall summary statistic. RESULTS Eight randomized controlled trials were included. These trials revealed a significant, moderate pooled effect size (0.55; 95% CI=0.17, 0.93; p=0.004). Studies stimulating the affected hemisphere had a combined effect size of 0.46 (95% CI=-0.18, 1.11; p=0.16); studies stimulating the unaffected hemisphere had a combined effect size of 0.65 (95% CI=0.14, 1.16; p=0.01). At long-term follow up, three studies demonstrated a large but non-significant pooled effect size (0.81, p=0.11). CONCLUSIONS This review found evidence for the efficacy of non-invasive brain stimulation on post-stroke dysphagia. A significant effect size resulted when stimulating the unaffected rather than the affected hemisphere. This finding is in agreement with previous studies implicating the plasticity of cortical neurons in the unaffected hemisphere. SIGNIFICANCE Non-invasive brain stimulation appears to assist cortical reorganization in post-stroke dysphagia but emerging factors highlight the need for more data.
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Affiliation(s)
- Jessica M Pisegna
- Boston University Medical Center, FGH Building 820 Harrison Ave., Boston, MA 02118, United States; Boston University, Sargent College, 635 Commonwealth Ave., Boston, MA 02215, United States.
| | - Asako Kaneoka
- Boston University Medical Center, FGH Building 820 Harrison Ave., Boston, MA 02118, United States; Boston University, Sargent College, 635 Commonwealth Ave., Boston, MA 02215, United States.
| | - William G Pearson
- Georgia Regents University, 1120 15th St., Augusta, GA 30912, United States.
| | - Sandeep Kumar
- Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215, United States.
| | - Susan E Langmore
- Boston University Medical Center, FGH Building 820 Harrison Ave., Boston, MA 02118, United States; Boston University, Sargent College, 635 Commonwealth Ave., Boston, MA 02215, United States.
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Ashoori A, Eagleman DM, Jankovic J. Effects of Auditory Rhythm and Music on Gait Disturbances in Parkinson's Disease. Front Neurol 2015; 6:234. [PMID: 26617566 PMCID: PMC4641247 DOI: 10.3389/fneur.2015.00234] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 10/22/2015] [Indexed: 12/05/2022] Open
Abstract
Gait abnormalities, such as shuffling steps, start hesitation, and freezing, are common and often incapacitating symptoms of Parkinson’s disease (PD) and other parkinsonian disorders. Pharmacological and surgical approaches have only limited efficacy in treating these gait disorders. Rhythmic auditory stimulation (RAS), such as playing marching music and dance therapy, has been shown to be a safe, inexpensive, and an effective method in improving gait in PD patients. However, RAS that adapts to patients’ movements may be more effective than rigid, fixed-tempo RAS used in most studies. In addition to auditory cueing, immersive virtual reality technologies that utilize interactive computer-generated systems through wearable devices are increasingly used for improving brain–body interaction and sensory–motor integration. Using multisensory cues, these therapies may be particularly suitable for the treatment of parkinsonian freezing and other gait disorders. In this review, we examine the affected neurological circuits underlying gait and temporal processing in PD patients and summarize the current studies demonstrating the effects of RAS on improving these gait deficits.
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Affiliation(s)
- Aidin Ashoori
- Columbia University College of Physicians & Surgeons , New York, NY , USA
| | - David M Eagleman
- Department of Neuroscience, Baylor College of Medicine , Houston, TX , USA
| | - Joseph Jankovic
- Department of Neurology, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine , Houston, TX , USA
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Koganemaru S, Fukuyama H, Mima T. Two is More Than One: How to Combine Brain Stimulation Rehabilitative Training for Functional Recovery? Front Syst Neurosci 2015; 9:154. [PMID: 26617497 PMCID: PMC4639697 DOI: 10.3389/fnsys.2015.00154] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 10/26/2015] [Indexed: 01/24/2023] Open
Abstract
A number of studies have shown that non-invasive brain stimulation has an additional effect in combination with rehabilitative therapy to enhance functional recovery than either therapy alone. The combination enhances use-dependent plasticity induced by repetitive training. The neurophysiological mechanism of the effects of this combination is based on associative plasticity. However, these effects were not reported in all cases. We propose a list of possible strategies to achieve an effective association between rehabilitative training with brain stimulation for plasticity: (1) control of temporal aspect between stimulation and task execution; (2) the use of a shaped task for the combination; (3) the appropriate stimulation of neuronal circuits where use-dependent plastic changes occur; and (4) phase synchronization between rhythmically patterned brain stimulation and task-related patterned activities of neurons. To better utilize brain stimulation in neuro-rehabilitation, it is important to develop more effective techniques to combine them.
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Affiliation(s)
- Satoko Koganemaru
- Brain Integrative Science, Kyoto University School of Medicine Sakyo-ku, Kyoto, Japan ; Human Brain Research Center, Kyoto University School of Medicine Sakyo-ku, Kyoto, Japan
| | - Hidenao Fukuyama
- Human Brain Research Center, Kyoto University School of Medicine Sakyo-ku, Kyoto, Japan
| | - Tatsuya Mima
- Human Brain Research Center, Kyoto University School of Medicine Sakyo-ku, Kyoto, Japan
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Chang MC, Kim DY, Park DH. Enhancement of Cortical Excitability and Lower Limb Motor Function in Patients With Stroke by Transcranial Direct Current Stimulation. Brain Stimul 2015; 8:561-6. [PMID: 25736569 DOI: 10.1016/j.brs.2015.01.411] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 11/25/2014] [Accepted: 01/23/2015] [Indexed: 11/28/2022] Open
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Doeltgen SH, Bradnam LV, Young JA, Fong E. Transcranial non-invasive brain stimulation in swallowing rehabilitation following stroke — A review of the literature. Physiol Behav 2015; 143:1-9. [DOI: 10.1016/j.physbeh.2015.02.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 02/11/2015] [Accepted: 02/16/2015] [Indexed: 01/20/2023]
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Jones KT, Stephens JA, Alam M, Bikson M, Berryhill ME. Longitudinal neurostimulation in older adults improves working memory. PLoS One 2015; 10:e0121904. [PMID: 25849358 PMCID: PMC4388845 DOI: 10.1371/journal.pone.0121904] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 02/05/2015] [Indexed: 01/09/2023] Open
Abstract
An increasing concern affecting a growing aging population is working memory (WM) decline. Consequently, there is great interest in improving or stabilizing WM, which drives expanded use of brain training exercises. Such regimens generally result in temporary WM benefits to the trained tasks but minimal transfer of benefit to untrained tasks. Pairing training with neurostimulation may stabilize or improve WM performance by enhancing plasticity and strengthening WM-related cortical networks. We tested this possibility in healthy older adults. Participants received 10 sessions of sham (control) or active (anodal, 1.5 mA) tDCS to the right prefrontal, parietal, or prefrontal/parietal (alternating) cortices. After ten minutes of sham or active tDCS, participants performed verbal and visual WM training tasks. On the first, tenth, and follow-up sessions, participants performed transfer WM tasks including the spatial 2-back, Stroop, and digit span tasks. The results demonstrated that all groups benefited from WM training, as expected. However, at follow-up 1-month after training ended, only the participants in the active tDCS groups maintained significant improvement. Importantly, this pattern was observed for both trained and transfer tasks. These results demonstrate that tDCS-linked WM training can provide long-term benefits in maintaining cognitive training benefits and extending them to untrained tasks.
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Affiliation(s)
- Kevin T. Jones
- Memory and Brain Laboratory, Department of Psychology, University of Nevada, Reno, Nevada, United States of America
- Cognitive Neuropsychology Lab, Department of Neurology, Georgetown University Medical Center, Washington, District of Columbia, United States of America
| | - Jaclyn A. Stephens
- Memory and Brain Laboratory, Department of Psychology, University of Nevada, Reno, Nevada, United States of America
| | - Mahtab Alam
- Department of Biomedical Engineering, The City College of New York, New York, New York, United States of America
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York, New York, New York, United States of America
| | - Marian E. Berryhill
- Memory and Brain Laboratory, Department of Psychology, University of Nevada, Reno, Nevada, United States of America
- * E-mail:
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Fregni F, Nitsche MA, Loo CK, Brunoni AR, Marangolo P, Leite J, Carvalho S, Bolognini N, Caumo W, Paik NJ, Simis M, Ueda K, Ekhitari H, Luu P, Tucker DM, Tyler WJ, Brunelin J, Datta A, Juan CH, Venkatasubramanian G, Boggio PS, Bikson M. Regulatory Considerations for the Clinical and Research Use of Transcranial Direct Current Stimulation (tDCS): review and recommendations from an expert panel. CLINICAL RESEARCH AND REGULATORY AFFAIRS 2015; 32:22-35. [PMID: 25983531 PMCID: PMC4431691 DOI: 10.3109/10601333.2015.980944] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The field of transcranial electrical stimulation (tES) has experienced significant growth in the past 15 years. One of the tES techniques leading this increased interest is transcranial direct current stimulation (tDCS). Significant research efforts have been devoted to determining the clinical potential of tDCS in humans. Despite the promising results obtained with tDCS in basic and clinical neuroscience, further progress has been impeded by a lack of clarity on international regulatory pathways. We therefore convened a group of research and clinician experts on tDCS to review the research and clinical use of tDCS. In this report, we review the regulatory status of tDCS, and we summarize the results according to research, off-label and compassionate use of tDCS in the following countries: Australia, Brazil, France, Germany, India, Iran, Italy, Portugal, South Korea, Taiwan and United States. Research use, off label treatment and compassionate use of tDCS are employed in most of the countries reviewed in this study. It is critical that a global or local effort is organized to pursue definite evidence to either approve and regulate or restrict the use of tDCS in clinical practice on the basis of adequate randomized controlled treatment trials.
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Affiliation(s)
- F Fregni
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - M A Nitsche
- Department of Clinical Neurophysiology, Georg-August-University, Göttingen, Germany
| | - C K Loo
- School of Psychiatry & The Black Dog Institute, University of New South Wales, Sydney, Australia
| | - A R Brunoni
- Service of Interdisciplinary Neuromodulation, Department and Institute of Psychiatry, University of São Paulo, São Paulo, Brazil and Division of Neurology, Santa Casa Medicak School, Sao Paulo, Brazil
| | - P Marangolo
- Department of Experimental and Clinical Medicine, University Politecnica delle Marche, Ancona, and IRCCS Fondazione Santa Lucia, Roma, Italy
| | - J Leite
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA ; Neuropsychophysiology Laboratory, CIPsi, School of Psychology (EPsi), University of Minho, Campus de Gualtar, Braga, Portugal
| | - S Carvalho
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA ; Neuropsychophysiology Laboratory, CIPsi, School of Psychology (EPsi), University of Minho, Campus de Gualtar, Braga, Portugal
| | - N Bolognini
- Department of Psychology, University of Milano Bicocca, and Laboratory of Neuropsychology, IRCC Instituto Auxologico Italiano, Milano, Italy
| | - W Caumo
- Laboratory of Pain & Neuromodulation at Hospital de Clínicas de Porto Alegre at UFRGS
| | - N J Paik
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
| | - M Simis
- Service of Interdisciplinary Neuromodulation, Department and Institute of Psychiatry, University of São Paulo, São Paulo, Brazil and Division of Neurology, Santa Casa Medicak School, Sao Paulo, Brazil
| | - K Ueda
- National Cardiovascular Center, Osaka, Japan
| | - H Ekhitari
- Translational Neuroscience Program, Institute for Cognitive Science Studies, Tehran, Iran ; Neurocognitive Laboratory, Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran
| | - P Luu
- Electrical Geodesics, Inc., and University of Oregon, Eugene, Oregon, USA
| | - D M Tucker
- Electrical Geodesics, Inc., and University of Oregon, Eugene, Oregon, USA
| | - W J Tyler
- Virginia Tech Carilion Research Institute, Department of Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine, and School of Biomedical Engineering and Sciences, Virginia Tech, Roanoke, VA USA
| | - J Brunelin
- EA 4615, Centre Hospitalier le Vinatier, Université de Lyon, F-69003, Université Claude Bernard Lyon I, Bron, France
| | - A Datta
- Department of Biomedical Engineering, Neural Engineering Laboratory, The City College of the City University of New York New York, NY, USA
| | - C H Juan
- Institute of Cognitive Neuroscience, National Central University, Taiwan
| | - G Venkatasubramanian
- Translational Psychiatry Laboratory, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - P S Boggio
- Social and Cognitive Neuroscience Laboratory and Developmental Disorders Program, Center for Healthy and Biological Sciences, Mackenzie Presbyterian University, Sao Paulo, Brazil
| | - M Bikson
- Department of Biomedical Engineering, Neural Engineering Laboratory, The City College of the City University of New York New York, NY, USA
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Sattler V, Acket B, Raposo N, Albucher JF, Thalamas C, Loubinoux I, Chollet F, Simonetta-Moreau M. Anodal tDCS Combined With Radial Nerve Stimulation Promotes Hand Motor Recovery in the Acute Phase After Ischemic Stroke. Neurorehabil Neural Repair 2015; 29:743-54. [DOI: 10.1177/1545968314565465] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Objective. The question of the best therapeutic window in which noninvasive brain stimulation (NIBS) could potentiate the plastic changes for motor recovery after a stroke is still unresolved. Most of the previous NIBS studies included patients in the chronic phase of recovery and very few in the subacute or acute phase. We investigated the effect of transcranial direct current stimulation (tDCS) combined with repetitive peripheral nerve stimulation (rPNS) on the time course of motor recovery in the acute phase after a stroke. Methods. Twenty patients enrolled within the first few days after a stroke were randomized in 2 parallel groups: one receiving 5 consecutive daily sessions of anodal tDCS over the ipsilesional motor cortex in association with rPNS and the other receiving the same rPNS combined with sham tDCS. Motor performance (primary endpoint: Jebsen and Taylor Hand Function Test [JHFT]) and transcranial magnetic stimulation cortical excitability measures were obtained at baseline (D1), at the end of the treatment (D5), and at 2 and 4 weeks’ follow-up (D15 and D30). Results. The time course of motor recovery of the 2 groups of patients was different and positively influenced by the intervention (Group × Time interaction P = .01). The amount of improvement on the JHFT was greater at D15 and D30 in the anodal tDCS group than in the sham group. Conclusion. These results show that early cortical neuromodulation with anodal tDCS combined with rPNS can promote motor hand recovery and that the benefit is still present 1 month after the stroke.
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Affiliation(s)
- Virginie Sattler
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Inserm, Imagerie cérébrale et handicaps neurologiques UMR 825, Toulouse, France
- Université de Toulouse, Toulouse, France
| | - Blandine Acket
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Inserm, Imagerie cérébrale et handicaps neurologiques UMR 825, Toulouse, France
- Université de Toulouse, Toulouse, France
| | - Nicolas Raposo
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Inserm, Imagerie cérébrale et handicaps neurologiques UMR 825, Toulouse, France
| | - Jean-François Albucher
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Inserm, Imagerie cérébrale et handicaps neurologiques UMR 825, Toulouse, France
| | - Claire Thalamas
- Centre d’Investigation Clinique, CHU Purpan, Toulouse, France
| | - Isabelle Loubinoux
- Inserm, Imagerie cérébrale et handicaps neurologiques UMR 825, Toulouse, France
| | - François Chollet
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Inserm, Imagerie cérébrale et handicaps neurologiques UMR 825, Toulouse, France
- Université de Toulouse, Toulouse, France
| | - Marion Simonetta-Moreau
- Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Inserm, Imagerie cérébrale et handicaps neurologiques UMR 825, Toulouse, France
- Université de Toulouse, Toulouse, France
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Transcranial direct current stimulation for motor recovery of upper limb function after stroke. Neurosci Biobehav Rev 2014; 47:245-59. [DOI: 10.1016/j.neubiorev.2014.07.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 07/25/2014] [Accepted: 07/28/2014] [Indexed: 01/20/2023]
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Jones KT, Gözenman F, Berryhill ME. Enhanced long-term memory encoding after parietal neurostimulation. Exp Brain Res 2014; 232:4043-54. [PMID: 25200180 DOI: 10.1007/s00221-014-4090-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 08/29/2014] [Indexed: 12/11/2022]
Abstract
Neurostimulation, e.g., transcranial direct current stimulation (tDCS), shows promise as an effective cognitive intervention. In spite of low spatial resolution, limited penetration, and temporary influence, evidence highlights tDCS-linked cognitive benefits in a range of cognitive domains. The left posterior parietal cortex (PPC) is an accessible node in frontoparietal networks engaged during long-term memory (LTM). Here, we tested the hypothesis that tDCS can facilitate LTM by pairing LTM encoding and retrieval with PPC stimulation. Healthy young adults performed a verbal LTM task (California Verbal Learning Task) with four different stimulation parameters. In Experiment 1, we applied tDCS to left PPC during LTM encoding. In Experiment 2, we applied tDCS just prior to retrieval to test the temporal specificity of tDCS during a LTM task. In later experiments, we tested hemispheric specificity by replicating Experiment 1 while stimulating the right PPC. Experiment 1 showed that tDCS applied during LTM encoding improved the pace of list learning and enhanced retrieval after a short delay. Experiment 2 indicated anodal left PPC tDCS only improved LTM when applied during encoding, and not during maintenance. Experiments 3 and 4 confirmed that tDCS effects were hemisphere specific and that no effects were found after right PPC stimulation during encoding. These findings indicate that anodal tDCS to the PPC helps verbal LTM in healthy young adults under certain conditions. First, when it is applied to the left, not the right, PPC and second, when it is applied during encoding.
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Affiliation(s)
- Kevin T Jones
- Program in Cognitive and Brain Sciences, Department of Psychology, University of Nevada, Reno, 1664 North Virginia Street, Mail Stop 296, Reno, NV, 89557, USA,
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Kim YJ, Ku J, Cho S, Kim HJ, Cho YK, Lim T, Kang YJ. Facilitation of corticospinal excitability by virtual reality exercise following anodal transcranial direct current stimulation in healthy volunteers and subacute stroke subjects. J Neuroeng Rehabil 2014; 11:124. [PMID: 25135003 PMCID: PMC4148539 DOI: 10.1186/1743-0003-11-124] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 07/14/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is growing evidence that the combination of non-invasive brain stimulation and motor skill training is an effective new treatment option in neurorehabilitation. We investigated the beneficial effects of the application of transcranial direct current stimulation (tDCS) combined with virtual reality (VR) motor training. METHODS In total, 15 healthy, right-handed volunteers and 15 patients with stroke in the subacute stage participated. Four different conditions (A: active wrist exercise, B: VR wrist exercise, C: VR wrist exercise following anodal tDCS (1 mV, 20 min) on the left (healthy volunteer) or affected (stroke patient) primary motor cortex, and D: anodal tDCS without exercise) were provided in random order on separate days. We compared during and post-exercise corticospinal excitability under different conditions in healthy volunteers (A, B, C, D) and stroke patients (B, C, D) by measuring the changes in amplitudes of motor evoked potentials in the extensor carpi radialis muscle, elicited with single-pulse transcranial magnetic stimulation. For statistical analyses, a linear mixed model for a repeated-measures covariance pattern model with unstructured covariance within groups (healthy or stroke groups) was used. RESULTS The VR wrist exercise (B) facilitated post-exercise corticospinal excitability more than the active wrist exercise (A) or anodal tDCS without exercise (D) in healthy volunteers. Moreover, the post-exercise corticospinal facilitation after tDCS and VR exercise (C) was greater and was sustained for 20 min after exercise versus the other conditions in healthy volunteers (A, B, D) and in subacute stroke patients (B, D). CONCLUSIONS The combined effect of VR motor training following tDCS was synergistic and short-term corticospinal facilitation was superior to the application of VR training, active motor training, or tDCS without exercise condition. These results support the concept of combining brain stimulation with VR motor training to promote recovery after a stroke.
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Affiliation(s)
| | | | | | | | | | | | - Youn Joo Kang
- Department of Rehabilitation Medicine, Eulji Hospital, Eulji University School of Medicine, Hagye dong, Nowongu, Seoul 139-711, South Korea.
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Convento S, Bolognini N, Fusaro M, Lollo F, Vallar G. Neuromodulation of parietal and motor activity affects motor planning and execution. Cortex 2014; 57:51-9. [DOI: 10.1016/j.cortex.2014.03.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 02/26/2014] [Accepted: 03/09/2014] [Indexed: 12/18/2022]
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Fujiyama H, Hyde J, Hinder MR, Kim SJ, McCormack GH, Vickers JC, Summers JJ. Delayed plastic responses to anodal tDCS in older adults. Front Aging Neurosci 2014; 6:115. [PMID: 24936185 PMCID: PMC4047559 DOI: 10.3389/fnagi.2014.00115] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 05/22/2014] [Indexed: 11/24/2022] Open
Abstract
Despite the abundance of research reporting the neurophysiological and behavioral effects of transcranial direct current stimulation (tDCS) in healthy young adults and clinical populations, the extent of potential neuroplastic changes induced by tDCS in healthy older adults is not well understood. The present study compared the extent and time course of anodal tDCS-induced plastic changes in primary motor cortex (M1) in young and older adults. Furthermore, as it has been suggested that neuroplasticity and associated learning depends on the brain-derived neurotrophic factor (BDNF) gene polymorphisms, we also assessed the impact of BDNF polymorphism on these effects. Corticospinal excitability was examined using transcranial magnetic stimulation before and following (0, 10, 20, 30 min) anodal tDCS (30 min, 1 mA) or sham in young and older adults. While the overall extent of increases in corticospinal excitability induced by anodal tDCS did not vary reliably between young and older adults, older adults exhibited a delayed response; the largest increase in corticospinal excitability occurred 30 min following stimulation for older adults, but immediately post-stimulation for the young group. BDNF genotype did not result in significant differences in the observed excitability increases for either age group. The present study suggests that tDCS-induced plastic changes are delayed as a result of healthy aging, but that the overall efficacy of the plasticity mechanism remains unaffected.
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Affiliation(s)
- Hakuei Fujiyama
- Human Motor Control Laboratory, School of Medicine, University of Tasmania Hobart, TAS, Australia ; Movement Control and Neuroplasticity Research Group, Department of Kinesiology KU Leuven, Leuven, Belgium
| | - Jane Hyde
- Human Motor Control Laboratory, School of Medicine, University of Tasmania Hobart, TAS, Australia
| | - Mark R Hinder
- Human Motor Control Laboratory, School of Medicine, University of Tasmania Hobart, TAS, Australia
| | - Seok-Jin Kim
- Human Motor Control Laboratory, School of Medicine, University of Tasmania Hobart, TAS, Australia ; Motor Behavior Laboratory, Department of Physical Education, Seoul National University Seoul, South Korea
| | - Graeme H McCormack
- Wicking Dementia Research and Education Centre, University of Tasmania Hobart, TAS, Australia
| | - James C Vickers
- Wicking Dementia Research and Education Centre, University of Tasmania Hobart, TAS, Australia
| | - Jeffery J Summers
- Human Motor Control Laboratory, School of Medicine, University of Tasmania Hobart, TAS, Australia ; Research Institute for Sport and Exercise Sciences, Liverpool John Moores University Liverpool, UK
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The ineffective role of cathodal tDCS in enhancing the functional motor outcomes in early phase of stroke rehabilitation: an experimental trial. BIOMED RESEARCH INTERNATIONAL 2014; 2014:547290. [PMID: 24895588 PMCID: PMC4026962 DOI: 10.1155/2014/547290] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 03/31/2014] [Indexed: 12/22/2022]
Abstract
Transcranial direct current stimulation (tDCS) is a noninvasive technique that could improve the rehabilitation outcomes in stroke, eliciting neuroplastic mechanisms. At the same time conflicting results have been reported in subacute phase of stroke, when neuroplasticity is crucial. The aim of this double-blind, randomized, and sham-controlled study was to determine whether a treatment with cathodal tDCS before the rehabilitative training might augment the final outcomes (upper limb function, hand dexterity and manual force, locomotion, and activities of daily living) in respect of a traditional rehabilitation for a sample of patients affected by ischemic stroke in the subacute phase. An experimental group (cathodal tDCS plus rehabilitation) and a control group (sham tDCS plus rehabilitation) were assessed at the beginning of the protocol, after 10 days of stimulation, after 30 days from ending of stimulation, and at the end of inpatient rehabilitation. Both groups showed significant improvements for all the assessed domains during the rehabilitation, except for the manual force, while no significant differences were demonstrated between groups. These results seem to indicate that the cathodal tDCS, provided in an early phase of stroke, does not lead to a functional improvement. To depict a more comprehensive scenario, further studies are needed.
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Ayache SS, Farhat WH, Zouari HG, Hosseini H, Mylius V, Lefaucheur JP. Stroke rehabilitation using noninvasive cortical stimulation: motor deficit. Expert Rev Neurother 2014; 12:949-72. [DOI: 10.1586/ern.12.83] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Elsner B, Kugler J, Pohl M, Mehrholz J. Transcranial direct current stimulation (tDCS) for improving function and activities of daily living in patients after stroke. Cochrane Database Syst Rev 2013:CD009645. [PMID: 24234980 DOI: 10.1002/14651858.cd009645.pub2] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Stroke is one of the leading causes of disability worldwide. Functional impairment resulting in poor performance in activities of daily living (ADLs) among stroke survivors is common. Current rehabilitation approaches have limited effectiveness in improving ADL performance and function after stroke, but a possible adjunct to stroke rehabilitation might be non-invasive brain stimulation by transcranial direct current stimulation (tDCS) to modulate cortical excitability and hence to improve ADL performance and function. OBJECTIVES To assess the effects of tDCS on generic activities of daily living (ADLs) and motor function in people with stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (March 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, May 2013), MEDLINE (1948 to May 2013), EMBASE (1980 to May 2013), CINAHL (1982 to May 2013), AMED (1985 to May 2013), Science Citation Index (1899 to May 2013) and four additional databases. In an effort to identify further published, unpublished and ongoing trials, we searched trials registers and reference lists, handsearched conference proceedings and contacted authors and equipment manufacturers. SELECTION CRITERIA We included only randomised controlled trials (RCTs) and randomised controlled cross-over trials (from which we analysed only the first period as a parallel-group design) that compared tDCS versus control in adults with stroke for improving ADL performance and function. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality (JM and MP) and extracted data (BE and JM). If necessary, we contacted study authors to ask for additional information. We collected information on dropouts and adverse events from the trial reports. MAIN RESULTS We included 15 studies involving a total of 455 participants. Analysis of six studies involving 326 participants regarding our primary outcome, ADL, showed no evidence of an effect in favour of tDCS at the end of the intervention phase (mean difference (MD) 5.31 Barthel Index (BI) points; 95% confidence interval (CI) -0.52 to 11.14; inverse variance method with random-effects model), whereas at follow-up (MD 11.13 BI points; 95% CI 2.89 to 19.37; inverse variance method with random-effects model), we found evidence of an effect. However, the confidence intervals were wide and the effect was not sustained when only studies with low risk of bias were included. For our secondary outcome, upper limb function, we analysed eight trials with 358 participants, which showed evidence of an effect in favour of tDCS at the end of the intervention phase (MD 3.45 Upper Extremity Fugl-Meyer Score points (UE-FM points); 95% CI 1.24 to 5.67; inverse variance method with random-effects model) but not at the end of follow-up three months after the intervention (MD 9.23 UE-FM points; 95% CI -13.47 to 31.94; inverse variance method with random-effects model). These results were sensitive to inclusion of studies at high risk of bias. Adverse events were reported and the proportions of dropouts and adverse events were comparable between groups (risk difference (RD) 0.00; 95% CI -0.02 to 0.03; Mantel-Haenszel method with random-effects model). AUTHORS' CONCLUSIONS At the moment, evidence of very low to low quality is available on the effectiveness of tDCS (anodal/cathodal/dual) versus control (sham/any other intervention) for improving ADL performance and function after stroke. Future research should investigate the effects of tDCS on lower limb function and should address methodological issues by routinely reporting data on adverse events and dropouts and allocation concealment, and by performing intention-to-treat analyses.
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Affiliation(s)
- Bernhard Elsner
- Department of Public Health, Dresden Medical School, Technical University Dresden, Fetscherstr. 74, Dresden, Sachsen, Germany, 01307
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Butler AJ, Shuster M, O'Hara E, Hurley K, Middlebrooks D, Guilkey K. A meta-analysis of the efficacy of anodal transcranial direct current stimulation for upper limb motor recovery in stroke survivors. J Hand Ther 2013; 26:162-70; quiz 171. [PMID: 22964028 DOI: 10.1016/j.jht.2012.07.002] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 07/13/2012] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Systematic review and meta-analysis. INTRODUCTION Prior reviews on the effects of anodal transcranial direct current stimulation (a-tDCS) have shown the effectiveness of a-tDCS on corticomotor excitability and motor function in healthy individuals but nonsignificant effect in subjects with stroke. PURPOSE To summarize and evaluate the evidence for the efficacy of a-tDCS in the treatment of upper limb motor impairment after stroke. METHODS A meta-analysis of randomized controlled trials that compared a-tDCS with placebo and change from baseline. RESULTS A pooled analysis showed a significant increase in scores in favor of a-tDCS (standard mean difference [SMD]=0.40, 95% confidence interval [CI]=0.10-0.70, p=0.010, compared with baseline). A similar effect was observed between a-tDCS and sham (SMD=0.49, 95% CI=0.18-0.81, p=0.005). CONCLUSION This meta-analysis of eight randomized placebo-controlled trials provides further evidence that a-tDCS may benefit motor function of the paretic upper limb in patients suffering from chronic stroke. LEVEL OF EVIDENCE Level 1a.
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Affiliation(s)
- Andrew J Butler
- Department of Physical Therapy, School of Nursing and Health Professions, Georgia State University, Atlanta, Georgia 30303, USA.
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Marquez J, van Vliet P, McElduff P, Lagopoulos J, Parsons M. Transcranial direct current stimulation (tDCS): does it have merit in stroke rehabilitation? A systematic review. Int J Stroke 2013; 10:306-16. [PMID: 24148111 DOI: 10.1111/ijs.12169] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 05/22/2013] [Indexed: 01/20/2023]
Abstract
Transcranial direct current stimulation has been gaining increasing interest as a potential therapeutic treatment in stroke recovery. We performed a systematic review with meta-analysis of randomized controlled trials to collate the available evidence in adults with residual motor impairments as a result of stroke. The primary outcome was change in motor function or impairment as a result of transcranial direct current stimulation, using any reported electrode montage, with or without adjunct physical therapy. The search yielded 15 relevant studies comprising 315 subjects. Compared with sham, cortical stimulation did not produce statistically significant improvements in motor performance when measured immediately after the intervention (anodal stimulation: facilitation of the affected cortex: standardized mean difference = 0.05, P = 0.71; cathodal stimulation: inhibition of the nonaffected cortex: standardized mean difference = 0.39, P = 0.08; bihemispheric stimulation: standardized mean difference = 0.24, P = 0.39). When the data were analyzed according to stroke characteristics, statistically significant improvements were evident for those with chronic stroke (standardized mean difference = 0.45, P = 0.01) and subjects with mild-to-moderate stroke impairments (standardized mean difference = 0.37, P = 0.02). Transcranial direct current stimulation is likely to be effective in enhancing motor performance in the short term when applied selectively to patients with stroke. Given the range of stimulation variables and heterogeneous nature of stroke, this modality is still experimental and further research is required to determine its clinical merit in stroke rehabilitation.
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Affiliation(s)
- Jodie Marquez
- School of Health Sciences, University of Newcastle, Callaghan, Newcastle, NSW, Australia
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Kim GW, Ko MH. Facilitation of corticospinal tract excitability by transcranial direct current stimulation combined with voluntary grip exercise. Neurosci Lett 2013; 548:181-4. [DOI: 10.1016/j.neulet.2013.05.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 04/16/2013] [Accepted: 05/15/2013] [Indexed: 10/26/2022]
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Flöel A. tDCS-enhanced motor and cognitive function in neurological diseases. Neuroimage 2013; 85 Pt 3:934-47. [PMID: 23727025 DOI: 10.1016/j.neuroimage.2013.05.098] [Citation(s) in RCA: 263] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 04/15/2013] [Accepted: 05/23/2013] [Indexed: 12/19/2022] Open
Abstract
Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation tool that is now being widely used in neuroscientific and clinical research in humans. While initial studies focused on modulation of cortical excitability, the technique quickly progressed to studies on motor and cognitive functions in healthy humans and in patients with neurological diseases. In the present review we will first provide the reader with a brief background on the basic principles of tDCS. In the main part, we will outline recent studies with tDCS that aimed at enhancing behavioral outcome or disease-specific symptoms in patients suffering from mild cognitive impairment, Alzheimer's disease, movement disorders, and epilepsy, or persistent deficits after stroke. The review will close with a summary statement on the present use of tDCS in the treatment of neurological disorders, and an outlook to further developments in this realm. tDCS may be an ideal tool to be administered in parallel to intensive cognitive or motor training in neurological disease, but efficacy for the areas of activities and participation still needs to be established in controlled randomized trials. Its use in reducing disease-specific symptoms like dystonia or epileptic seizures is still unclear.
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Affiliation(s)
- Agnes Flöel
- Department of Neurology, Center for Stroke Research, and NeuroCure Cluster of Excellence, Charité University Medicine, Germany.
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Transcranial direct current stimulation in stroke rehabilitation: a review of recent advancements. Stroke Res Treat 2013; 2013:170256. [PMID: 23533955 PMCID: PMC3600193 DOI: 10.1155/2013/170256] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 12/17/2012] [Accepted: 01/14/2013] [Indexed: 01/25/2023] Open
Abstract
Transcranial direct current stimulation (tDCS) is a promising technique to treat a wide range of neurological conditions including stroke. The pathological processes following stroke may provide an exemplary system to investigate how tDCS promotes neuronal plasticity and functional recovery. Changes in synaptic function after stroke, such as reduced excitability, formation of aberrant connections, and deregulated plastic modifications, have been postulated to impede recovery from stroke. However, if tDCS could counteract these negative changes by influencing the system's neurophysiology, it would contribute to the formation of functionally meaningful connections and the maintenance of existing pathways. This paper is aimed at providing a review of underlying mechanisms of tDCS and its application to stroke. In addition, to maximize the effectiveness of tDCS in stroke rehabilitation, future research needs to determine the optimal stimulation protocols and parameters. We discuss how stimulation parameters could be optimized based on electrophysiological activity. In particular, we propose that cortical synchrony may represent a biomarker of tDCS efficacy to indicate communication between affected areas. Understanding the mechanisms by which tDCS affects the neural substrate after stroke and finding ways to optimize tDCS for each patient are key to effective rehabilitation approaches.
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Feng WW, Bowden MG, Kautz S. Review of transcranial direct current stimulation in poststroke recovery. Top Stroke Rehabil 2013; 20:68-77. [PMID: 23340073 DOI: 10.1310/tsr2001-68] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Motor impairment, dysphagia, aphasia, and visual impairment are common disabling residual deficits experienced by stroke survivors. Recently, many novel rehabilitative modalities have been investigated for their potential to ameliorate such deficits and to improve functional outcomes. Noninvasive brain stimulation techniques, such as transcranial direct current stimulation (tDCS), have emerged as a promising tool to facilitate stroke recovery. tDCS can alter cortical excitability to induce brain plasticity by modulating the lesioned, contralesional, or bilateral hemispheres with various stimulation modalities. Along with peripheral therapies, tDCS can lead to subsequent sustained behavioral and clinical gains in patients with stroke. In this review, we summarize characteristics of tDCS (method of stimulation, safety profile, and mechanism) and its application in the treatment of various stroke-related deficits, and we highlight future directions for tDCS in this capacity.
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Affiliation(s)
- Wuwei Wayne Feng
- Department of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
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Kan B, Dundas JE, Nosaka K. Effect of transcranial direct current stimulation on elbow flexor maximal voluntary isometric strength and endurance. Appl Physiol Nutr Metab 2013; 38:734-9. [PMID: 23980731 DOI: 10.1139/apnm-2012-0412] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The effects of transcranial direct current stimulation (tDCS) on maximal voluntary isometric contraction (MVC) strength and the time to failure (TTF) in an isometric (30% MVC) muscle endurance test of the elbow flexors were investigated. Fifteen men (mean age, 27.7 ± 8.4 years) were tested for MVC strength and TTF 2 times, separated by a 60-min rest. During the last 10 min of the rest period, 1 of 2 tDCS treatments or 1 sham intervention session was administered, in a randomized order, with 1 week between sessions. In the tDCS intervention, a 2 mA direct current was delivered for 10 min through an anode placed on the scalp, overlying the right motor cortical representation of the left arm; a cathode was secured over the right shoulder. In the sham intervention, the current was delivered for the first 30 s only. No significant differences between the first and second tDCS sessions were evident for MVC strength or TTF. For MVC strength (baseline, 66.0 ± 11.4 Nm), postintervention measures decreased by 5.9% ± 4.2% (p < 0.05), but no significant difference in the changes was evident between tDCS and sham sessions. TTF did not change significantly from preintervention (309.2 ± 91.6 s) to postintervention (327.2 ± 128.5 s), and there was no significant difference between interventions. It was concluded that the tDCS intervention did not affect muscle function, perhaps because of ceiling effects, in which the intervention does not enhance muscle function further when muscle function is already maximal.
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Affiliation(s)
- Benjamin Kan
- School of Exercise and Health Sciences, Centre for Exercise and Sports Science Research, Edith Cowan University, 270 Joondalup Drive, Joondalup, WA 6027, Australia
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The ABC of tDCS: Effects of Anodal, Bilateral and Cathodal Montages of Transcranial Direct Current Stimulation in Patients with Stroke-A Pilot Study. Stroke Res Treat 2013; 2013:837595. [PMID: 23365790 PMCID: PMC3556891 DOI: 10.1155/2013/837595] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 11/20/2012] [Accepted: 11/21/2012] [Indexed: 11/17/2022] Open
Abstract
Transcranial direct current stimulation (tDCS) is a noninvasive technique that is emerging as a prospective therapy for different neurologic disorders. Previous studies have demonstrated that anodal and cathodal stimulation can improve motor performance in terms of dexterity and manual force. The objective of this study was to determine whether different electrodes' setups (anodal, cathodal, and simultaneous bilateral tDCS) provide different motor performance and which montage was more effective. As secondary outcome, we have asked to the patients about their satisfaction, and to determine if the bilateral tDCS was more uncomfortable than unilateral tDCS. Nine patients with stroke in subacute phase were enrolled in this study and randomly divided in three groups. Our results showed that tDCS was an effective treatment if compared to Sham stimulation (P = 0.022). In particular, anodal stimulation provided the higher improvement in terms of manual dexterity. Cathodal stimulation seemed to have a little effect in terms of force improvement, not observed with other setups. Bipolar stimulation seemed to be the less effective. No significant differences have been noted for the different set-ups for patients' judgment. These results highlight the potential efficacy of tDCS for patients with stroke in subacute phase.
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Abstract
Stroke is a leading cause of disability, and the number of stroke survivors continues to rise. Traditional neurorehabilitation strategies aimed at restoring function to weakened limbs provide only modest benefit. New brain stimulation techniques designed to augment traditional neurorehabilitation hold promise for reducing the burden of stroke-related disability. Investigators discovered that repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), and epidural cortical stimulation (ECS) can enhance neural plasticity in the motor cortex post-stroke. Improved outcomes may be obtained with activity-dependent stimulation, in which brain stimulation is contingent on neural or muscular activity during normal behavior. We review the evidence for improved motor function in stroke patients treated with rTMS, tDCS, and ECS and discuss the mediating physiological mechanisms. We compare these techniques to activity-dependent stimulation, discuss the advantages of this newer strategy for stroke rehabilitation, and suggest future applications for activity-dependent brain stimulation.
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Elsner B, Kugler J, Pohl M, Mehrholz J. Transcranial direct current stimulation (tDCS) for improving function and activities of daily living in patients after stroke. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009645] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Bastani A, Jaberzadeh S. Does anodal transcranial direct current stimulation enhance excitability of the motor cortex and motor function in healthy individuals and subjects with stroke: a systematic review and meta-analysis. Clin Neurophysiol 2011; 123:644-57. [PMID: 21978654 DOI: 10.1016/j.clinph.2011.08.029] [Citation(s) in RCA: 177] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 08/16/2011] [Accepted: 08/20/2011] [Indexed: 10/17/2022]
Abstract
The primary aim of this review is to evaluate the effects of anodal transcranial direct current stimulation (a-tDCS) on corticomotor excitability and motor function in healthy individuals and subjects with stroke. The secondary aim is to find a-tDCS optimal parameters for its maximal effects. Electronic databases were searched for studies into the effect of a-tDCS when compared to no stimulation. Studies which met the inclusion criteria were assessed and methodological quality was examined using PEDro and Downs and Black (D&B) assessment tools. Data from seven studies revealed increase in corticomotor excitability with a small but significant effect size (0.31 [0.14, 0.48], p=0.0003) in healthy subjects and data from two studies in subjects with stroke indicated significant results with moderate effect size (0.59 [0.24, 0.93], p=0.001) in favor of a-tDCS. Likewise, studies examining motor function demonstrated a small and non-significant effect (0.39 [-0.17, 0.94], p=0.17) in subjects with stroke and a large but non-significant effect (0.92 [-1.02, 2.87], p=0.35) in healthy subjects in favor of improvement in motor function. The results also indicate that efficacy of a-tDCS is dependent on current density and duration of application. A-tDCS increases corticomotor excitability in both healthy individuals and subjects with stroke. The results also show a trend in favor of motor function improvement following a-tDCS. A-tDCS is a non-invasive, cheap and easy-to-apply modality which could be used as a stand-alone technique or as an adds-on technique to enhance corticomotor excitability and the efficacy of motor training approaches. However, the small sample size of the included studies reduces the strength of the presented evidences and any conclusion in this regard should be considered cautiously.
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Affiliation(s)
- A Bastani
- Department of Physiotherapy, School of Primary Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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Abstract
Background Recent review of the available evidence on interventions for motor recovery after stroke, showed that improvements in recovery of arm function were seen for constraint-induced movement therapy, electromyographic biofeedback, mental practice with motor imagery, and robotics. Similar improvement in transfer ability or balance were seen with repetitive task training, biofeedback, and training with a moving platform. Walking speed was improved by physical fitness training, high-intensity physiotherapy and repetitive task training. However, most of these trials were small and had design limitations. Material/Methods In this article, randomized control trials (RCT’s) published in 2009 of rehabilitation therapies for acute (≤2 weeks), sub-acute (2 to 12 weeks) and chronic (≥12 weeks) stroke was reviewed. A Medline search was performed to identify all RCT’s in stroke rehabilitation in the year 2009. The search strategy that was used for PubMed is presented in the Appendix 1. The objective was to examine the effectiveness of these treatment modalities in stroke rehabilitation. Results This generated 35 RCT’s under 5 categories which were found and analyzed. The methodological quality was assessed by using the PEDro scale for external and internal validity. Conclusions These trials were primarily efficacy studies. Most of these studies enrolled small numbers of patient which precluded their clinical applicability (limited external validity). However, the constraint induced movement therapy (CIT), regularly used in chronic stroke patients did not improve affected arm-hand function when used in acute stroke patients at ≤4 weeks. Intensive CIT did not lead to motor improvement in arm-hand function. Robotic arm treatment helped decrease motor impairment and improved function in chronic stroke patients only. Therapist provided exercise programs (when self-administered by patients during their off-therapy time in a rehabilitation setting) did improve arm-hand function. Tai Chi exercises helped improve balance and weight bearing. Exercise programs for community dwelling stroke patient helped maintain and even improve their functional state.
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Affiliation(s)
- Meheroz H Rabadi
- Department of Neurology, Veterans Affairs Medical Center, Oklahoma University, Oklahoma City, OK 73104, USA.
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