Early transcranial direct current stimulation with modified constraint-induced movement therapy for motor and functional upper limb recovery in hospitalized patients with stroke: A randomized, multicentre, double-blind, clinical trial

BACKGROUND

Constraint-induced movement therapy (CIMT) and transcranial direct current stimulation (tDCS) are used to reduce interhemispheric imbalance after stroke, which is why the combination of these therapies has been used for neurological recovery, but not in the acute phase.

OBJECTIVES

To evaluate the effectiveness of combining active or sham bihemispheric tDCS with modified CIMT (mCIMT) for the recovery of the Upper Limb (UL) in hospitalized patients with acute and subacute stroke.

METHODS

This randomized controlled, double-blind, placebo-controlled, parallel group clinical trial was executed between September 2018 to March 2021 recruited 70 patients. The patients were randomized to one of two groups to receive treatment for 7 consecutive days, which included 20 min of active or sham bihemispheric tDCS daily (anodal ipsilesional and cathodal contralesional), with an mCIMT protocol. The primary outcome was the difference in the evolution of motor and functional upper limb recovery with assessment on days 0, 5, 7, 10 and 90. The secondary outcomes were independence in activities of daily living (ADL) and quality of life.

RESULTS

The active group presented a statistically significant gap compared to the simulated group throughout the trend in the scores of the FMA (motor function and joint pain) and WMFT (functional ability and weight to box) (p < 0.05) and showed a minimal clinically important difference (FMA: difference between groups of 4.9 points [CI: 0.007- 9.799]; WMFT: difference between groups of 6.54 points [CI: 1.10-14.15]). In the secondary outcomes, there was a significant difference between the groups in ADL independence (Functional Independence Measure: difference of 8.63 [CI: 1.37-18.64]) and perceived recovery of quality of life evaluated at 90 days (p = 0.0176).

CONCLUSIONS

Combining mCIMT with bihemispheric tDCS in patients hospitalized with acute-subacute stroke allows us to maximize the motor and functional recovery of the paretic upper limb in the early stages and independence in ADL, maintaining the effects over time.

The Effects of Unilateral Versus Bilateral Motor Training on Upper Limb Function in Adults with Chronic Stroke: A Systematic Review

OBJECTIVES

Rehabilitation goals for chronic stroke patients are largely focused around regaining functional ability and independence, with particular focus on upper limb motor function. Unilateral and Bilateral motor training may help achieve this. Our objective was to evaluate and compare the effects of unilateral and bilateral motor training on upper limb motor function in chronic stroke patients.

MATERIALS AND METHODS

A comprehensive literature search was conducted until June 2020 through several electronic databases (CENTRAL, Medline, CINAHL, EBSCO, AMED and PEDro) to identify relevant studies. Studies that used the Fugl Meyer Assessment (FMA) as a minimum, to assess upper limb motor function following unilateral versus bilateral training in chronic stroke patients, qualified for inclusion within the review. Randomised controlled trial (RCT), cohort study and cross-sectional study designs were considered. The Cochrane risk of bias tool was used to assess Randomised Controlled Trials (RCTs). The findings were qualitatively synthesised.

RESULTS

From a total of 838 studies identified, 7 RCTs were included in this review. All except one of the studies included reported an unclear risk of bias, with one low risk of bias reported. Overall, the studies reported that unilateral and bilateral training improved upper limb function in chronic stroke patients. Improvements between interventions were equivocal. Bilateral upper limb training however may be more efficacious for increasing upper limb strength and quality of movement, with unilateral training more beneficial for recovering functional ability for activities of daily living.

CONCLUSION

While the findings of the included studies support the use of unilateral and bilateral motor training post chronic stroke, the seven studies that were included methodologically all presented with limitations, hence strong conclusions cannot be drawn and further research is warranted.