Abstract
Background
Transcranial direct current stimulation (tDCS) is an effective neuromodulation adjunct to repetitive motor training in promoting motor recovery post-stroke. Finger tracking training is motor training whereby people with stroke use the impaired index finger to trace waveform-shaped lines on a monitor. Our aims were to assess the feasibility and safety of a telerehabilitation program consisting of tDCS and finger tracking training through questionnaires on ease of use, adverse symptoms, and quantitative assessments of motor function and cognition. We believe this telerehabilitation program will be safe and feasible, and may reduce patient and clinic costs.
Methods
Six participants with hemiplegia post-stroke [mean (SD) age was 61 (10) years; 3 women; mean (SD) time post-stroke was 5.5 (6.5) years] received five 20-min tDCS sessions and finger tracking training provided through telecommunication. Safety measurements included the Digit Span Forward Test for memory, a survey of symptoms, and the Box and Block test for motor function. We assessed feasibility by adherence to treatment and by a questionnaire on ease of equipment use. We reported descriptive statistics on all outcome measures.
Results
Participants completed all treatment sessions with no adverse events. Also, 83.33% of participants found the set-up easy, and all were comfortable with the devices. There was 100% adherence to the sessions and all recommended telerehabilitation.
Conclusions
tDCS with finger tracking training delivered through telerehabilitation was safe, feasible, and has the potential to be a cost-effective home-based therapy for post-stroke motor rehabilitation.
Background
Post-stroke motor function deficits stem not only from neurons killed by the stroke, but also from down-regulated excitability in surviving neurons remote from the infarct [1]. This down-regulation results from deafferentation [2], exaggerated interhemispheric inhibition [3], and learned non-use [4]. Current evidence suggests that post-stroke motor rehabilitation therapies should encourage upregulating neurons and should target neuroplasticity through intensive repetitive motor practice [5, 6]. Previously, our group has examined the feasibility and efficacy of a custom finger tracking training program as a way of providing people with stroke with an engaging repetitive motor practice [7, 8, 9]. In this program, the impaired index finger is attached to an electro-goniometer, and participants repeatedly move the finger up and down to follow a target line that is drawn on the display screen. In successive runs, the shape, frequency and amplitude of target line is varied, which forces the participant to focus on the tracking task. In one study, we demonstrated a 23% improvement in hand function (as measured by the Box and Block test; minimal detectable change is 18% [10]) after participants with stroke completed the tracking training program [9]. While our study did not evaluate changes in activity in daily life (ADL) or quality of life (because efficacy of the treatment was not the study objective), the Box and Block test is moderately correlated (r = 0.52) to activities in daily life and quality of life (r = 0.59) [11]. In addition, using fMRI, we showed that training resulted in an activation transition from ipsilateral to contralateral cortical activation in the supplementary motor area, primary motor and sensory areas, and the premotor cortex [9].
Recently, others have shown that anodal transcranial direct current stimulation (tDCS) can boost the beneficial effects of motor rehabilitation, with the boost lasting for at least 3 months post-training [12]. Also, bihemispheric tDCS stimulation (anodal stimulation to excite the ipsilateral side and cathodal stimulation to downregulate the contralateral side) in combination with physical or occupational therapy has been shown to provide a significant improvement in motor function (as measured by Fugl-Meyer and Wolf Motor Function) compared to a sham group [13]. Further, a recent meta-analysis of randomized-controlled trials comparing different forms of tDCS shows that cathodal tDCS is a promising treatment option to improve ADL capacity in people with stroke [14]. Compared to transcutaneous magnetic stimulation (TMS), tDCS devices are inexpensive and easier to operate. Improvement in upper limb motor function can appear after only five tDCS sessions [15], and there are no reports of serious adverse events when tDCS has been used in human trials for periods of less than 40 min at amplitudes of less than 4 mA [16].
Moreover, tDCS stimulation task also seems beneficial for other impairments commonly seen in people post-stroke. Stimulation with tDCS applied for 20 sessions of 30 min over a 4-week period has been shown to decrease depression and improve quality of life in people after a stroke [17, 18]. Four tDCS sessions for 10 min applied over the primary and sensory cortex in eight patients with sensory impairments more than 10 months post-stroke enhanced tactile discriminative performance [19]. Breathing exercises with tDCS stimulation seems to be more effective than without stimulation in patient with chronic stroke [20], and tDCS has shown promise in treating central post-stroke pain [21]. Finally, preliminary research on the effect of tDCS combined with training on resting-state functional connectivity shows promise to better understand the mechanisms behind inter-subject variability regarding tDCS stimulation [22].
Motor functional outcomes in stroke have declined at discharge from inpatient rehabilitation facilities [23, 24], likely a result of the pressures to reduce the length of stay at inpatient rehabilitation facilities as part of a changing and increasingly complex health care climate [25, 26]. Researchers, clinicians, and administrators continue to search for solutions to facilitate and post-stroke rehabilitation after discharge. Specifically, there has been considerable interest in low-cost stroke therapies than can be administered in the home with only a modest level of supervision by clinical professionals.
Home telerehabilitation is a strategy in which rehabilitation in the patient’s home is guided remotely by the therapist using telecommunication technology. If patients can safely apply tDCS to themselves at home, combining telerehabilitation with tDCS would be an easy way to boost therapy without costly therapeutic face-to-face supervision. For people with multiple sclerosis, the study of Charvet et al. (2017) provided tDCS combined with cognitive training, delivered through home telerehabilitation, and demonstrated greater improvement on cognitive measures compared to those who received just the cognitive training [27]. The authors demonstrated the feasibility of remotely supervised, at-home tDCS and established a protocol for safe and reliable delivery of tDCS for clinical studies [28]. Some evidence shows that telerehabilitation approaches are comparable to conventional rehabilitation in improving activities of daily living and motor function for stroke survivors [29, 30], and that telemedicine for stroke is cost-effective [31, 32]. A study in 99 people with stroke receiving training using telerehabilitation (either with home exercise program or robot assisted therapy with home program) demonstrated significant improvements in quality of life and depression [33].
A recent search of the literature suggests that to date, no studies combine tDCS with repetitive tracking training in a home telerehabilitation setting to determine whether the combination leads to improved motor rehabilitation in people with stroke. Therefore, the aim of this pilot project was to explore the safety, usability and feasibility of the combined system. For the tDCS treatment, we used a bihemispheric montage with cathodal tDCS stimulation to suppress the unaffected hemisphere in order to promote stroke recovery [34, 35, 36, 37]. For the repetitive tracking training therapy, we used a finger tracking task that targets dexterity because 70% of people post-stroke are unable to use their hand with full effectiveness after stroke [38]. Safety was assessed by noting any decline of 2 points or more in the cognitive testing that persists over more than 3 days. We expect day to day variations of 1 digit. Motor decline is defined by a decline of 6 blocks on the Box and Block test due to muscle weakness. This is based on the minimal detectable change (5.5 blocks/min) [10]. The standard error of measurement is at least 2 blocks for the paretic and stronger side. We expect possible variations in muscle tone that could influence the scoring of the test. Usability was assessed through a questionnaire and by observing whether the participant, under remote supervision, could don the apparatus and complete the therapy sessions. Our intent was to set the stage for a future clinical trial to determine the efficacy of this approach.
Methods
Participants
Participants were recruited from a database of people with chronic stroke who had volunteered for previous post-stroke motor therapy research studies at the University of Minnesota. Inclusion criteria were: at least 6 months post-stroke; at least 10 degrees of active flexion and extension motion at the index finger; awareness of tactile sensation on the scalp; and a score of greater than or equal to 24 (normal cognition) on the Mini-Mental State Examination (MMSE) to be cognitively able to understand instructions to don and use the devices [39]. We excluded those who had a seizure within past 2 years, carried implanted medical devices incompatible with tDCS, were pregnant, had non-dental metal in the head or were not able to understand instructions on how to don and use the devices. The study was approved by the University of Minnesota IRB and all enrolled participants consented to be in the study.
Apparatus
tDCS was applied using the StarStim Home Research Kit (NeuroElectrics, Barcelona, Spain). The StarStim system consists of a Neoprene head cap with marked positions for electrode placement, a wireless cap-mounted stimulator and a laptop control computer. Saline-soaked, 5 cm diameter sponge electrodes were used. For electrode placement, we followed a bihemispheric montage [14] involving cathodal stimulation on the unaffected hemisphere with the anode positioned at C3 and the cathode at C4 for participants with left hemisphere stroke, and vice versa for participants with right hemisphere stroke. Stimulation protocols were set by the investigator on a web-based application that communicated with the tDCS control computer. A remote access application (TeamViewer) was also installed on the control computer, as was a video conferencing application (Skype).
Fig. 1Participant with right hemiparesis receiving transcranial direct current magnetic stimulation (tDCS) in their home simultaneous while performing the finger movement tracking task on the tracking computer (left). The tDCS computer (right) shows the supervising investigator, located off-site, who communicated with the participant through the video conferencing application, controlled the tDCS stimulator through web-based software, and controlled the tracking protocols. (Permission was obtained from the participant for the publication of this picture)
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TBI Rehabilitation 