Archive for category tDCS/rTMS

[Abstract] Transcranial direct current stimulation and repetitive functional task-oriented programme for upper limb functional rehabilitation in stroke survivors

Abstract

Introduction

Recovery of upper limb motor function remains a major challenge to stroke rehabilitation experts and stroke survivors alike. Stimulation of the motor cortex by noninvasive brain stimulators and therapy focused on repetitive functional activities can increase upper limb functioning after stroke. Hence, this study was designed to determine therapeutic efficacy of transcranial direct current stimulation (tDCS) and repetitive functional task-oriented programme (RFTOP) for upper limb functional rehabilitation in stroke survivors.

Materials and Methods

A single-blind randomized control trial involving 78 individuals with sub-acute and chronic stroke. They were randomized into three groups: Group 1: Anodal tDCS + RFTOP; Group 2: Cathodal tDCS + RFTOP; Group 3: RFTOP only. Participants had two sessions of therapy in a week for six weeks. Upper limb function was assessed using Fugl-Meyer Assessment Upper Extremity (FMA-UE) and Box and Block Test (BBT). Significance was set at p < 0.05.

Results

Baseline comparison of the groups showed no significant difference (FMA-UE: p = 0.237; BBT: p = 0.183). All groups showed statistical significant difference between baseline and post intervention in scores of FMA-UE (p ≤ 0.001) and BBT (p < 0.001). Mean difference comparison showed statistical significant difference among groups for FMA-UE hand domain (p = 0.009) and BBT (p = <0.001). Post hoc analysis showed the difference among the groups was between anodal against cathodal and anodal against control.

Conclusion

tDCS and RFTOP were efficacious for upper limb functional rehabilitation in stroke survivors. Anodal tDCS showed better clinical improvement compared to Cathodal tDCS.

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[ARTICLE] Effectiveness of a combined transcranial direct current stimulation and virtual reality-based intervention on upper limb function in chronic individuals post-stroke with persistent severe hemiparesis: a randomized controlled trial – Full Text

Abstract

Background

Functional impairments derived from the non-use of severely affected upper limb after stroke have been proposed to be mitigated by action observation and imagination-based techniques, whose effectiveness is enhanced when combined with transcranial direct current stimulation (tDCS). Preliminary studies in mildly impaired individuals in the acute phase post-stroke show intensified effects when action is facilitated by tDCS and mediated by virtual reality (VR) but the effectiveness in cases of severe impairment and chronic stroke is unknown. This study investigated the effectiveness of a combined tDCS and VR-based intervention in the sensorimotor function of chronic individuals post-stroke with persistent severe hemiparesis compared to conventional physical therapy.

Methods

Twenty-nine participants were randomized into an experimental group, who received 30 minutes of the combined tDCS and VR-based therapy and 30 minutes of conventional physical therapy, or a control group, who exclusively received conventional physical therapy focusing on passive and active assistive range of motion exercises. The sensorimotor function of all participants was assessed before and after 25 one-hour sessions, administered three to five times a week, using the upper extremity subscale of the Fugl-Meyer Assessment, the time and ability subscales of the Wolf Motor Function Test, and the Nottingham Sensory Assessment.

Results

A clinically meaningful improvement of the upper limb motor function was consistently revealed in all motor measures after the experimental intervention, but not after conventional physical therapy. Similar limited effects were detected in the sensory function in both groups.

Conclusion

The combined tDCS and VR-based paradigm provided not only greater but also clinically meaningful improvement in the motor function (and similar sensory effects) in comparison to conventional physical therapy.

Background

Functional impairment of the upper limbs is a common sequelae after stroke that affects up to 85% of the survivors [1] and persists, with a certain degree of severity, in 30 to 60% of the cases, six months after the onset, limiting the complete recovery of functional use to only 5 to 20% of them [23]. Given the incidence of upper limb deficits after stroke, and its impact on the participation in activities of daily living [1], social life [4], and quality of life [5], rehabilitation is an imperative goal of physical and occupational therapy.

Although there is no standard intervention for improving upper limb function after stroke [6], functional recovery is believed to occur in response to active exercise and to motor inclusion of the affected limb in task-oriented activities [78]. Consequently, severe impairment of the upper limb function that prevents voluntary movements represents a major challenge to conventional interventions. As proof, less functional recovery is expected from individuals post-stroke who present more impaired motor conditions upon inclusion in rehabilitation programs [9].

Conventional approaches to chronic severe hemiparesis are focused on providing a passive range of motion exercises to preserve the mobility and flexibility of the affected extremity [10] or to compensate for the impaired function by training the less affected limb in unimanual task-oriented exercises [11]. Although passive exercises can produce proprioceptive input to motor pathways [12] and compensation can facilitate some degree of self-sufficiency [11], the absence of self-triggered movements and non-use of the affected limb may lead to a reduced sensorimotor representation in the available neural circuits over time [13] and, consequently, diminish the possibility for clinical improvement [11], an effect that is known as ‘learned non-use’ [14].

Different therapeutic interventions have been proposed to overcome the neural and functional decline caused by this effect, by modulating the excitability of the motor cortex circuitry in the absence of movement [15]. Motor imagery, the mental execution of a movement without any overt movement or muscle activation [16], has been shown to induce a spatial and temporal recruitment of motor cortical areas that mirrors the modulation produced during real motor practice [16,17,18]. Interestingly, motor imagery is not restricted to individuals with a degree of residual function and, in contrast to passive exercises, still incorporates voluntary drive [16]. Although its application to severely impaired function in individuals with chronic stroke has produced promising improvements [19], stroke can affect the ability to understand and practice different aspects of motor imagery, a technique that is already inherently complex [20]. Mirror therapy, an intervention based on staring at the reflected movements of the non-paretic limb on a mirror placed in the person’s midsagittal plane, as if they were produced by the affected side [21], can potentially overcome the difficulty in imagining the movement, while similarly modulating the activity of the primary motor cortex. Different studies have evidenced an increase in M1 excitability or increased ipsilateral activation, although the findings have been somewhat inconsistent [22]. Although mirror therapy has shown effectiveness in improving motor function in individuals with chronic stroke with mild to moderate impairment [2324], its effect on severely impaired individuals with stroke has been reported as being limited to a small effect on tactile sensation [25]. The capacity of motor imagery and mirror therapy to modulate brain activity in the ipsilesional hemisphere is supported by the mirror neuron system theory [26] and suggests that such interventions may be functionally akin to preparatory and executive motor processes [27].

Non-invasive brain stimulation, such as transcranial magnetic stimulation and transcranial direct current stimulation (tDCS) have been proved to modulate cortical excitability through the application of a magnetic field or low-intensity electric current to the scalp using a coil or saline-soaked electrodes, respectively. When applied to the primary motor cortex, it may prime neuroplasticity and motor learning effects [28], which have been shown to improve motor function after stroke [2930]. While current evidence suggests a similar potential effectiveness of both techniques [3132], the overall lower costs, lower safety risks, and potential to be applied concurrently during rehabilitation of tDCS can facilitate its clinical integration [33]. In contrast to the inconsistent results in its earlier stages, tDCS has shown positive results at improving motor function of the paretic upper limb in chronic stroke [3435]. Interestingly, the combination of tDCS and mirror therapy has shown additive effects on motor performance [36] and, similarly, its combination with motor imagery has been reported to modulate not only the neural correlates of movement [37,38,39], but also the motor performance of upper limb tasks [4041].

The addition of tDCS to a motor observation and execution task mediated by virtual reality (VR) has been found to augment motor improvement after stroke [4243], which could be supported by an increased short-term corticospinal facilitation [44]. The capacity of VR to provide controlled multi-modal stimulation in one or more sensory channels [45] has also motivated its use in motor observation and imagery [46,47,48]. Its capacity to allow users to perform virtual movements in a non-physical reality without executing the motor action in the real world is especially interesting, allowing the participation of individuals with severe impairments in the upper limb function in self-triggered tasks, thus closing the loop of interaction-stimulation [49]. Additionally, VR-based interventions alone have shown to promote substantial recovery not only in the acute phase but also within the chronic phase post-stroke [50,51,52].

Our preliminary studies suggests that a paradigm combining tDCS and a VR-based motor observation task triggered by conscious active responses can provide a feasible and well-accepted rehabilitation framework for individuals with chronic stroke and severely affected upper limb function [5354]. We hypothesized that this paradigm could also provide sensorimotor benefits to this population, when compared to conventional physical therapy. The objective of this study was, therefore, to determine the effectiveness of the combined tDCS and VR-based intervention in the upper limb motor and sensory function of severely impaired individuals with chronic stroke in comparison to conventional physical therapy.[…]

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Fig. 2 Experimental setup. Participants sat in a chair with their arms on a table, upon which a laptop was located. The intervention provided visual and auditory stimulation through the screen (a) and speakers (b) of the laptop, respectively, vibrotactile feedback through three independent vibrators (c), and transcranial direct current stimulation (d). Interaction was allowed through gaze, detected by a portable eye-tracking bar (e) and muscular activity and movement, detected by the gyroscopes, accelerometers, and/or surface electromyographic activity of a motion control armband (f)

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[ARTICLE] Transcranial electrostimulation with special waveforms enhances upper-limb motor function in patients with chronic stroke: a pilot randomized controlled trial – Full Text

Abstract

Background

Transcranial direct current stimulation (tDCS) and intermittent theta burst stimulation (iTBS) were both demonstrated to have therapeutic potentials to rapidly induce neuroplastic effects in various rehabilitation training regimens. Recently, we developed a novel transcranial electrostimulation device that can flexibly output an electrical current with combined tDCS and iTBS waveforms. However, limited studies have determined the therapeutic effects of this special waveform combination on clinical rehabilitation. Herein, we investigated brain stimulation effects of tDCS-iTBS on upper-limb motor function in chronic stroke patients.

Methods

Twenty-four subjects with a chronic stroke were randomly assigned to a real non-invasive brain stimulation (NIBS; who received the real tDCS + iTBS output) group or a sham NIBS (who received sham tDCS + iTBS output) group. All subjects underwent 18 treatment sessions of 1 h of a conventional rehabilitation program (3 days a week for 6 weeks), where a 20-min NIBS intervention was simultaneously applied during conventional rehabilitation. Outcome measures were assessed before and immediately after the intervention period: Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Jebsen-Taylor Hand Function Test (JTT), and Finger-to-Nose Test (FNT).

Results

Both groups showed improvements in FMA-UE, JTT, and FNT scores after the 6-week rehabilitation program. Notably, the real NIBS group had greater improvements in the JTT (p = 0. 016) and FNT (p = 0. 037) scores than the sham NIBS group, as determined by the Mann–Whitney rank-sum test.

Conclusions

Patients who underwent the combined ipsilesional tDCS-iTBS stimulation with conventional rehabilitation exhibited greater impacts than did patients who underwent sham stimulation-conventional rehabilitation in statistically significant clinical responses of the total JTT time and FNT after the stroke. Preliminary results of upper-limb functional recovery suggest that tDCS-iTBS combined with a conventional rehabilitation intervention may be a promising strategy to enhance therapeutic benefits in future clinical settings.

Introduction

Neuromodulation is an evolving therapy for rehabilitation after a stroke and is also used to improve motor function in the lesioned cortex. Recently, studies indicated that neuromodulation could enhance neuroplasticity, the ability of the brain to reorganize or relearn in response to a new stimulus, resulting in facilitation of motor sensory recovery in stroke patients [1,2,3]. Transcranial direct current stimulation (tDCS), a non-invasive brain stimulation (NIBS) technique, is contemporarily important as it can modulate neuroplasticity in advanced rehabilitation medicine, such as pain, depression and, addictive diseases [4,5,6]. tDCS can selectively change the excitability of the regional cortex non-invasively and safely [7]. In addition, tDCS has been explored as a treatment option for stroke, particularly for upper/lower-limb motor function [8,9,10,11]. However, studies reported only 10% ~ 30% improvement in forearm motor function after stroke rehabilitation. Optimal stimulation strategies of tDCS to improve plasticity and enhance motor learning need to be determined.

Recovery as a result of traditional stroke rehabilitation often has poor outcomes and long rehabilitation times. Therefore, developing a more-effective therapeutic device is an important issue for stroke rehabilitation. To develop an optimal tDCS protocol to improve motor function, we designed and implemented a prototype of a novel transcranial electrostimulation device that can flexibly output an electrical current waveform by combining DC and theta burst waveforms [12]. Theta burst stimulation (TBS) was originally a novel waveform of repetitive transcranial magnetic stimulation (rTMS) that is more rapid and efficacious than rTMS [13]. Numerous studies determined that TBS has more advantages than other traditional waveforms of rTMS, such as long-lasting effects on motor-evoked potentials (MEPs) and neuronal excitability after a shorter stimulation duration [14,15,16], and it was associated with fewer adverse events [17]. It is well known that the most widely used TBS patterns are intermittent (i)TBS and continuous (c)TBS. iTBS consists of a 2-s train of TBS repeated every 10 s for a total of 190 s which produces long-term potentiation (LTP)-like effects, whereas cTBS consists of three-pulse bursts at 50 Hz repeated every 200 ms for 40 s, which induces long-term depression (LTD)-like cortical plasticity [1418,19,20].

Use of an rTMS protocol with iTBS in chronic stroke patients was shown to significantly increase ipsilesional M1 excitability, enhanced MEP amplitudes, and improve upper-limb motor functions [1521,22,23]. One recent meta-analysis showed that the standardized mean difference (SMD) of iTBS was 0.60 (p = 0.018), whereas that for cTBS was 0.35 (p = 0.138) for the recovery of upper-limb motor outcomes in stroke patients, indicating that iTBS was more beneficial than cTBS in motor recovery after a stroke [24]. Therefore, modulation of cortical plasticity induced by iTBS may have therapeutic potential for patients with post-stroke motor disorders.

Both rTMS and tDCS can cause physiological effects and indirectly modulate deep-brain locations via neural circuits [2526]. In general, rTMS therapy is usually applied before undertaking occupational therapy for patients with motor function deficits, due to the bulky size of the rTMS device. On the contrary, the lightweight, portable tDCS device can be directly worn on a patient’s head during active rehabilitation exercises, which was associated with augmentation of synaptic plasticity [27,28,29]. However, most traditional transcranial stimulators have only a DC waveform mode at present. Thus, our novel transcranial burst electrostimulator was designed to develop an effective and optimal therapeutic system for patients who need rehabilitation therapy. We previously demonstrated that compared to conventional anodal tDCS, the combined DC-iTBS electrostimulator induced LTP-like plasticity as evident from significantly enhanced MEP amplitudes for at least 30 min in animal experiments [12].

With the excellent efficacy of previously combined stimulation, we report a pilot randomized controlled study to examine the combined effects of DC-iTBS and conventional rehabilitation (CR) on upper-limb motor function as measured by the Fugl-Meyer Assessment upper extremity (FMA-UE), Finger-to-Nose test (FNT), and Jebsen-Taylor hand function test (JTT) in patients with chronic stroke compared to a sham intervention. To our knowledge, this is the first randomized controlled trial (RCT) to apply tDCS with iTBS to facilitate upper-limb motor function in chronic stroke patients. We also expected that the novel DC-iTBS stimulation combined with rehabilitation of the upper extremities would result in greater improvements and have potential to become a routine treatment strategy for stroke patients at hospitals and residential rehabilitation facilities.[…]

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[ARTICLE] A novel glasses-free virtual reality rehabilitation system on improving upper limb motor function among patients with stroke: a feasibility pilot study – Full Text

Abstract

Background

Virtual reality (VR) technology is increasingly used in stroke rehabilitation. This study aimed to investigate the effectiveness of using the glasses-free VR training to improve motor function of upper limb in patients with stroke.

Methods

Twelve patients with stroke were recruited to participate in the intervention of 3 weeks. At the baseline and post intervention, two times of evaluation including Fugl-Meyer upper-extremity scale (FMS-UE), transcranial magnetic stimulation (TMS) measurement and motion evaluation were performed.

Results

No significant difference was observed between two groups at baseline evaluation. After the intervention, the FMS-UE scores presented a greater improvement in the VR group compared with the control group. TMS measurement showed that there was significant difference in cortex latency and central motor conduction time between two groups after the intervention, but no significant difference in the amplitude of motor event potential was observed. In addition, there was a significant correlation between game scores and FMS-UE scores.

Conclusions

The novel glasses-free VR training was at least as effective as conventional occupational therapy in upper limb motor function, improving nerve conduction time and corticospinal excitability in patient with stroke.

1. Introduction

Stroke is among the leading cause of long-term disability with up to 85% of patients with stroke experience upper limb motor deficits [1]. Motor function of upper limb, in particular the hand function, occupies more than 60% of the physical function for an individual [2]. However, the recovery of upper limb motor function post stroke is clinical challenging, and the outcomes of upper limb rehabilitation remains unsatisfactory [1]. The loss of control input from the brain is believed to be a contributor to muscle spasm and flaccid paresis, leading to the difficulty in performing daily activities and reduced quality of life among patients with stroke [3]. Additionally, early literature also suggested that there was a significant descending information flow which potentially reflected the recruitment of motor neurons from the supplementary motor area [4]. Thus, the recovery of the corticospinal pathway is likely to be a precondition of motor function improvement for patients with stroke [4,5].

Virtual reality (VR) technology has emerged as a promising intervention to facilitate functional recovery among patients with stroke [6]. VR intervention provides interactive tasks within a computer-generated virtual environment which incorporates auditory and visual feedback [7]. It has the advantage to increase users’ motivation by providing the high intensity repetitive tasks [8]. A previous review demonstrated the potential benefits of VR to improve upper limb function and activities of daily living (ADL) function in patients with stroke [9]. However, the clinical effectiveness of VR systems in the recovery of hand function remains unsatisfied [9]. The high complexity of the hand represents a challenge to accurately capture and simulate the movements of the hands and fingers [6,10,11].Thus, stroke patients could not obtain precise and timely feedback from the VR system, which contribute to poor clinical outcome [9,12]. Although gloves or other wearable devices with built-in motion sensors are often adopted in some VR systems to capture hand movements, these wearable items place extraneous load on the users which reduce motion velocity and increases the difficulty of training for patients with stroke [13,14]. Leap Motion© Controller (LMC) is a device designed to capture the fine motions of hands and fingers [6]. Compared with other devices, LMC has the benefits of low-cost and easiness to use [15]. To date, three studies were found that had trialed the LMC as part of a VR training system to capture hand movements in patients with stroke, and reported improvements in Wolf motor function test (WMFT) scores and performance time [6], higher hand abilities and grasp force [16], and increased Fugl-Meyer scale (FMS) scores and Box-and-Blocks Test scores [17]. These studies demonstrated the feasibility and potential benefits of LMC-based VR training in improving upper limb motor function among stroke patients. It should be noted that only a two-dimension (2D) display was used in those studies, which would not provide a stereoscopic virtual environment for patients with stroke.

The neurological mechanism of VR training to improve upper limb motor function in patients with stroke mainly involved two aspects, cortical reorganization [6] and the recovery of corticospinal tract [18]. Wang et al. [6] observed an increase in activation intensity from functional magnetic resonance imaging (fMRI) of the lesioned hemisphere in sub-acute stroke patients after four weeks of Leap Motion-based VR training. This finding provided support that Leap Motion-based VR intervention promote neuroplasticity which contribute to functional improvement [6,19].

The integrity of the corticospinal tract was demonstrated to be associated with motor function recovery in chronic stroke patients [2021]. A previous study suggested the positive relationship between the integrity of corticospinal tract and upper limb motor recovery in patients with cerebrovascular accidents [18]. Another research reported an improvement in the functional integrity of ipsilateral corticospinal tract and upper limb motor function after two weeks of VR training in patients with subacute stroke [22]. The author stated that stroke patients with higher motor evoked potentials (MEPs) had a significantly greater FMS and WMFT scores than those with MEP absence. It suggested that functional recovery of upper limb post stroke may be related to the ipsilesional corticospinal tract [2223]. However, there is still a lack of evidence whether neural conduction time would change after the VR training among stroke patients, and more research is needed.

Our institute has recently developed a novel glasses-free VR rehabilitation system that addressed the issues of external sensors to capture hands and finger motion of the existence VR system discussed above. This study was aimed to investigate whether the novel VR rehabilitation system was able to facilitate the recovery of upper limb motor function, as well as the corticospinal tract in patients with stroke. We hypothesized that after the glasses-free VR training, there would be an improvement in upper limb motor function and the function of corticospinal tract among patients with stroke.[…]

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Figure 2
Figure 2. The glasses-free VR rehabilitation system. (A) A participant with stroke was using the glasses-free VR rehabilitation system to do VR training; (B) HSTDB projected 3D effect to a viewer; (C) Schematic diagram of the glasses-free VR rehabilitation system; (D) Leap Motion Controller.

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[ARTICLE] Recovering arm function in chronic stroke patients using combined anodal HD-tDCS and virtual reality therapy (ReArm): a study protocol for a randomised controlled trial – Full Text

Figure 4
Figure 4. Anodal HD-tDCS applied to the ipsilesional primary motor cortex during an ARMEO virtual reality therapy session using the right upper limb. The patient is setup on the ARMEO exoskeleton equipped with the HD-tDCS cap comprising a Starstim NIC-power box delivering the current on the back and 5 electrodes located on the left primary motor cortex in a 4×1 HD-tDCS montage with anode on the C3 location.


Abstract

Background

After a stroke, 80% of the chronic patients have difficulties to use their paretic upper limb (UL) in activities of daily life (ADL) even after rehabilitation. Virtual reality therapy (VRT) and anodal transcranial direct current stimulation (tDCS) are two innovative methods that have shown independently to positively impact functional recovery of the paretic UL when combined with conventional therapy. The objective of the project will be to evaluate the impact of adding anodal high-definition (HD)-tDCS during an intensive 3-weeks UL VRT and conventional therapy program on paretic UL function in chronic stroke.

Methods

The ReArm project is a quadruple-blinded, randomized, sham-controlled, bi-centre, two-arm parallel, and interventional study design. Fifty-eight chronic (> 3 months) stroke patients will be recruited from the Montpellier and Nimes University Hospitals. Patients will follow a standard 3-weeks in-patient rehabilitation program, which includes 13 days of VRT (Armeo Spring, 1x30min session/day) and conventional therapy (3x30min sessions/day). Twenty-nine patients will receive real stimulation (4×1 anodal HD-tDCS montage, 2mA, 20min) to the ipsilesional primary motor cortex during the VRT session and the other 29 patients will receive active sham stimulation (2mA, 30s). All outcome measures will be assessed at baseline, at the end of rehabilitation and again 3 months later. The primary outcome measure will be the wolf motor function test. Secondary outcomes will include measures of UL function (Box and Block test), impairment (Fugl Meyer Upper Extremity), compensation (Proximal Arm Non-Use), ADL (Actimetry, Barthel Index), pain, fatigue, effort and performance, kinematics and motor cortical region activation during functional motor tasks.

Discussion

This will be the first trial to determine the impact of adding HD-tDCS during UL VRT and conventional therapy in chronic stroke patients. We hypothesise that improvements in UL function will be greater and longer-lasting with real stimulation than in those receiving sham.[…]

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

Abstract

Purpose

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

Materials and methods

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

Results

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

Conclusion

Home-based dual-tDCS could facilitate motor recovery in patients with chronic stroke with its effect lasting for at least 1 month. However, its effects on functional tasks remain unclear. tDCS is safe and easy for home-based self-administration for patients who can use their paretic arms. This could benefit patients without access to health care centres or in situations requiring physical distancing. This home-based tDCS combined with exercise has the potential to be incorporated into telemedicine in stroke rehabilitation.

  • IMPLICATIONS FOR REHABILITATION
  • Twelve sessions of home-based dual-tDCS combined with exercises (3 days/week for 4 weeks) facilitated upper and lower limb motor recovery in patients with chronic stroke compared with exercise alone, with a post-effect for at least 1 month.
  • Home-based tDCS could be safe and easily self-administrable by patients who can use their paretic arms.
  • This intervention could be beneficial for patients living in the community without easy access to a health care centre or in situations where physical distancing is required.

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[Abstract] Transcranial direct current stimulation (tDCS) in the management of epilepsy: a systematic review

Highlights

  • TDCS is a non-invasive brain stimulation technique able to induce changes in cortical excitability that outlast the period of stimulation.
  • This Systematic Review encompassed human tDCS trials in participants with epilepsy that reported either seizure frequency or related surrogate outcomes.
  • Preliminary evidence suggests that cathodal tDCS targeted at the irritative zone may lead to better seizure control in drug-resistant focal epilepsy.
  • Cathodal tDCS is overall safe and not directly associated with seizures in adults and children with drug-resistant epilepsy.

Abstract

Background

Current therapies for the management of epilepsy are still suboptimal for several patients due to inefficacy, major adverse events, and unavailability. Transcranial direct current stimulation (tDCS), an emergent non-invasive neuromodulation technique, has been tested in epilepsy samples over the past two decades to reduce either seizure frequency or electroencephalogram (EEG) epileptiform discharges.

Objectives

To perform a systematic review of the evidence regarding the effectiveness and safety of tDCS interventions in epilepsy.

Methods

A systematic review was performed in accordance with PRISMA guidelines (PROSPERO record CRD42020160292). A thorough electronic search was completed in MEDLINE, EMBASE, CENTRAL and Scopus databases for trials that applied tDCS interventions to children and adults with epilepsy of any cause, from inception to April 30, 2020.

Results

Twenty-seven studies fulfilled eligibility criteria, including nine sham-controlled and 18 uncontrolled trials or case reports/series. Samples consisted mainly of drug-resistant focal epilepsy patients that received cathodal tDCS stimulation targeted at the site with maximal EEG abnormalities. At follow-up, 84% (21/25) of the included studies reported a reduction in seizure frequency and in 43% (6/14) a decline in EEG epileptiform discharge rate was observed. No serious adverse events were reported.

Conclusions

Cathodal tDCS is both a safe and probably effective technique for seizure control in patients with drug-resistant focal epilepsy. However, published trials are heterogeneous regarding samples and methodology. More and larger sham-controlled randomized trials are needed, preferably with mechanistic informed stimulation protocols, to further advance tDCS therapy in the management of epilepsy.

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[NEWS] Future stroke rehabilitation could include robotic therapy – NeuroNews International

29 January 2021 

Dylan J Edwards

At the North American Neuromodulation Society (NANS) virtual meeting (15–16 January), Dylan J Edwards, director of the Moss Rehabilitation Research Institute and director of Human Motor Recovery Laboratory (Philadelphia, USA), presented his proof-of-concept results for a study he led looking at transcranial electrical stimulation (TES) paired with robotic assisted therapies in stroke recovery.

Edwards noted that TES can be used as a monotherapy, but he is interested in its use in combination with other therapies (speech, occupational, physical, robotics, drugs). In this case the combination is physical therapy using robot-assisted therapies.

Edwards stated this current research was motivated by a 2010 clinical trial published in the New England Journal of Medicine which compared robot assisted therapy with intensive comparison therapy, over 12 weeks and 36 sessions. The primary end point of this study was the Fugl-Meyer Assessment, and according to Edwards it showed a, “small but significant improvement in motor function that was sustained after the 12 week intervention”.

Edwards commented, “Robot therapy is not the only method of performing intensive physical-type therapy, however, it makes sense because the robot does not tire, and the therapy is really structured and consistent, and that’s important when you’re looking to apply a supplementary therapy so that you have a stable behavioural therapy upon which to test the supplement.”

Edwards reports he carried out a study in 2009 investigating transcranial stimulation in chronic post stroke hemiparesis in a small group of subjects. They showed that anodal transcranial direct current stimulation (tDCS) of 2mA for 20 minutes could raise the excitability of the corticospinal tract. Edwards said this made them question if they could embark on a period of robotic training for a session lasting 45 to 60 minutes after the tDCS session and what would happen to that potential. From this Edwards claims they showed that the increase in corticospinal excitement could be sustained during that robot therapy. So these therapies could plausibly co-exist physiologically.

The hypothesis of Edwards current trial is that robot therapy and tDCS would lead to a greater improvement than robot therapy with sham tDCS on the upper extremity Fugl-Meyer (UEFM) scale. They also assessed motor function using the Wolf motor function test. Eighty-two patients with right hemiparesis completed the trial. Each subject had three sessions of tDCS a week for 12 weeks. Sessions lasted one hour and were accompanied by alternating shoulder, elbow, and wrist robotic training amounting to around one thousand repetitions. The primary endpoint was 12 weeks and there was a six month follow-up.

The subjects were randomised between the real and the sham stimulation, although participants wore the same electrodes and were all tDCS naïve.

Edwards explained how they carried out robot therapies. Patients place their affected limb into the robot handle which has a display monitor in front of it. Then using the robotic device, patients aim to hit certain targets represented on the display. Edwards noted that this can be used as either an assessment or a training tool.

While Edwards was able to point to other studies which showed positive results for TES and robot-assisted therapy, such as Allman et al, 2016, and Giacobbe et al, 2013, he reported that in the case of his study, “The tDCS did not confirm an advantage over sham stimulation in this context.”

However, he added, “We haven’t ruled out a potentially faster recovery trajectory in the tDCS group, and the results for that could not be answered by the design of this study. But that does warrant further exploration given that the two other studies I presented did have a shorter number of sessions, by about a third of what we did. If tCDS could indeed lead to fewer sessions being required for the same clinical benefit, that warrants further investigation.”

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[VIDEO] Trans-Cranial Direct Current Stimulation (tDCS) explained – What is tDCS & what are the benefits? – YouTube

Trans-Cranial Direct Current Stimulation (tDCS) is a type of Non-Invasive Brain Stimulation (NIBS) therapy that works by using a small electric current to gently stimulate the Brain.

tDCS can be an effective treatment for addiction and cravings, depression and fibromyalgia. It can also be helpful in the treatment and management of conditions such as acquired brain injury, chronic pain, cognitive enhancement, fatigue, headaches, movements disorders (eg. Parkinson’s), stroke and tinnitus.

During treatment, people sit comfortably whilst small sponge electrodes are positioned over targeted areas of the brain. The electrodes are held in place using soft velcro straps and deliver a low-intensity direct electric current to the underlying brain.

One of the most important aspects of tDCS is that the changes in brain activity persist for some time after the end of the treatment session. This creates an important “window of opportunity” after treatment during which the brain is more “plastic” and more likely to change. People usually perform specific activities or exercises during and after each treatment, to further help retrain the Brain and get better results.

At The Perth Brain Centre, we provide very specific targeted exercises to help maximise the benefits of therapy.

Visit us at https://www.perthbraincentre.com.au/

Visit our Blog: https://www.perthbraincentre.com.au/n…

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[ARTICLE] Efficacy of repetitive transcranial magnetic stimulation for post-stroke depression: a systematic review and meta-analysis of randomized clinical trials – Full Text

ABSTRACT

We aimed to conduct a meta-analysis to evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with post-stroke depression (PSD). Six relevant electronic databases (PubMed, CENTRAL, Embase, Web of Science, CINAHL, and PsycINFO) were searched. Randomized controlled trials (RCTs) that compared rTMS with control condition for PSD were included. The mean change in depression symptom scores was defined as the primary efficacy outcome. Secondary outcomes included the remission rate of depression, stroke recovery, and cognitive function recovery. In total, 7 RCTs with 351 participants were included. At post-treatment, rTMS was significantly more effective than the control condition, with a standardized mean difference (SMD) of -1.15 (95%CI: -1.62 to -0.69; P<0.001, I2=71%) and remission with an odds ratio (OR) of 3.46 (95%CI: 1.68 to 7.12; P<0.001; I2=11%). As for stroke recovery, rTMS was also better than the control condition (SMD=-0.67, 95%CI: -1.02 to -0.32; P<0.001). However, no significant difference was found for cognitive function recovery between the two groups (SMD=4.07, 95%CI: -1.41 to 9.55; P=0.15). To explore the potential moderators for the primary outcome, a series of subgroup and sensitivity analyses were performed. The results implied that rTMS may be more effective in Asian samples than in North American samples (P=0.03). In conclusion, from the current evidence in this study, rTMS could be an effective treatment for patients with PSD. Further clinical studies with larger sample sizes and clearer subgroup definitions are needed to confirm these outcomes.

INTRODUCTION

Stroke is one of the major public health concerns in the world, because of its high morbidity, mortality, and disability rates and serious financial burden (1). As one of the major obstacles in the process of stroke recovery, post-stroke depression (PSD) has attracted more and more attention (2). Studies have shown that PSD is associated with increased physical disabilities, impaired cognitive and social function, poor quality of life, and high risk of stroke recurrence and suicidality (3). Therefore, the treatment for PSD could benefit stroke functional recovery (4).

Several treatment options are now available for PSD, including medications, psychotherapy, and physiotherapy (5 67). Antidepressants are widely used in various somatic diseases with depression (8), but there are many concerns focused on their safety. Due to the fact that many people who suffer from stroke are elderly or middle-aged with multiple risk factors of arteriosclerotic cardiovascular disease, antidepressants are usually cautiously prescribed for these people because of their common side effects such as blood pressure instability and QT interval prolongation (9,10). Some studies have demonstrated the efficacy of psychological therapy for PSD patients (11). However, most people worldwide, especially in low-income countries, cannot access it.

Compared to medication, physiotherapy have been demonstrated to be safer for elderly people. Among the techniques, repetitive transcranial magnetic stimulation (rTMS) is one of the most important means for PSD patients (12). rTMS uses an electromagnetic coil applied to the scalp to produce a magnetic field. It causes cortical neurons in corresponding areas and neurons in distant areas to discharge, thereby regulating the function of the local cortex and related brain networks (13,14).

In the past decades, rTMS has been widely used in the treatment of psychiatric disorders, especially for major depressive disorder (MDD) (15). A number of studies have shown that rTMS is effective and safe for MDD patients (16). The possible mechanism could be a series of physiological effects induced by the focused magnetic field on specific brain regions, increasing the level of brain-derived neurotrophic factors (BDNF) and enhancing glucose metabolism in the cortex and other specific neural networks (17). However, whether rTMS is likewise effective for PSD patients remains unknown. Some studies have demonstrated promising results, but the conclusions are limited by the small sample size (18 1920). Therefore, a well-designed meta-analysis to pool the comprehensive clinical evidence is needed to guide the application of rTMS in PSD patients.[…]

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