[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…

[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 6–⁷). 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 19–²⁰). 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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[Abstract + References] Canadian Platform for Trials in Noninvasive Brain Stimulation (CanStim) Consensus Recommendations for Repetitive Transcranial Magnetic Stimulation in Upper Extremity Motor Stroke Rehabilitation Trials

Abstract

Objective. To develop consensus recommendations for the use of repetitive transcranial magnetic stimulation (rTMS) as an adjunct intervention for upper extremity motor recovery in stroke rehabilitation clinical trials. 

Participants. The Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim) convened a multidisciplinary team of clinicians and researchers from institutions across Canada to form the CanStim Consensus Expert Working Group. 

Consensus Process. Four consensus themes were identified: (1) patient population, (2) rehabilitation interventions, (3) outcome measures, and (4) stimulation parameters. Theme leaders conducted comprehensive evidence reviews for each theme, and during a 2-day Consensus Meeting, the Expert Working Group used a weighted dot-voting consensus procedure to achieve consensus on recommendations for the use of rTMS as an adjunct intervention in motor stroke recovery rehabilitation clinical trials. 

Results. Based on best available evidence, consensus was achieved for recommendations identifying the target poststroke population, rehabilitation intervention, objective and subjective outcomes, and specific rTMS parameters for rehabilitation trials evaluating the efficacy of rTMS as an adjunct therapy for upper extremity motor stroke recovery. 

Conclusions. The establishment of the CanStim platform and development of these consensus recommendations is a first step toward the translation of noninvasive brain stimulation technologies from the laboratory to clinic to enhance stroke recovery.

References

1.	Veerbeek, JM, van Wegen, E, van Peppen, R, et al. What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PLoS One. 2014;9:e87987. Google Scholar | Crossref | Medline | ISI
2.	Boyd, LA, Vidoni, ED, Wessel, BD. Motor learning after stroke: is skill acquisition a prerequisite for contralesional neuroplastic change? Neurosci Lett. 2010;482:21-25. Google Scholar | Crossref | Medline | ISI
3.	Dimyan, MA, Cohen, LG. Neuroplasticity in the context of motor rehabilitation after stroke. Nat Rev Neurol. 2011;7:76-85. Google Scholar | Crossref | Medline | ISI
4.	Arya, KN, Verma, R, Garg, RK, Sharma, VP, Agarwal, M, Aggarwal, GG. Meaningful task-specific training (MTST) for stroke rehabilitation: a randomized controlled trial. Top Stroke Rehabil. 2012;19:193-211. Google Scholar | Crossref | Medline | ISI
5.	French, B, Thomas, LH, Coupe, J, et al. Repetitive task training for improving functional ability after stroke. Cochrane Database Syst Rev. 2016;(11):CD006073. Google Scholar | Medline
6.	Kimberley, TJ, Samargia, S, Moore, LG, Shakya, JK, Lang, CE. Comparison of amounts and types of practice during rehabilitation for traumatic brain injury and stroke. J Rehabil Res Dev. 2010;47:851-862. Google Scholar | Crossref | Medline
7.	Teasell, R, Meyer, MJ, Foley, N, Salter, K, Willems, D. Stroke rehabilitation in Canada: a work in progress. Top Stroke Rehabil. 2009;16:11-19. Google Scholar | Crossref | Medline | ISI
8.	Barrett, M, Snow, JC, Kirkland, MC, et al. Excessive sedentary time during in-patient stroke rehabilitation. Top Stroke Rehabil. 2018;25:366-374. Google Scholar | Medline
9.	Rossi, S, Hallett, M, Rossini, PM, Pascual-Leone, A; Safety of TMS Consensus Group . Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clin Neurophysiol. 2009;120:2008-2039. Google Scholar | Crossref | Medline | ISI
10.	Koganemaru, S, Mima, T, Thabit, MN, et al. Recovery of upper-limb function due to enhanced use-dependent plasticity in chronic stroke patients. Brain. 2010;133:3373-3384. Google Scholar | Crossref | Medline
11.	Corti, M, Patten, C, Triggs, W. Repetitive transcranial magnetic stimulation of motor cortex after stroke: a focused review. Am J Phys Med Rehabil. 2012;91:254-270. Google Scholar | Crossref | Medline | ISI
12.	Pascual-Leone, A, Pridmore, H. Transcranial magnetic stimulation (TMS). Aust N Z J Psychiatry. 1995;29:698. Google Scholar | Medline
13.	Di Lazzaro, V, Rothwell, JC. Corticospinal activity evoked and modulated by non-invasive stimulation of the intact human motor cortex. J Physiol. 2014;592:4115-4128. Google Scholar | Crossref | Medline | ISI
14.	Di Lazzaro, V, Dileone, M, Pilato, F, et al. Modulation of motor cortex neuronal networks by rTMS: comparison of local and remote effects of six different protocols of stimulation. J Neurophysiol. 2011;105:2150-2156. Google Scholar | Crossref | Medline | ISI
15.	Hamada, M, Hanajima, R, Terao, Y, et al. Origin of facilitation in repetitive, 1.5 ms interval, paired pulse transcranial magnetic stimulation (rPPS) of the human motor cortex. Clin Neurophysiol. 2007;118:1596-1601. Google Scholar | Crossref | Medline
16.	Takeuchi, N, Chuma, T, Matsuo, Y, Watanabe, I, Ikoma, K. Repetitive transcranial magnetic stimulation of contralesional primary motor cortex improves hand function after stroke. Stroke. 2005;36:2681-2686. Google Scholar | Crossref | Medline | ISI
17.	van Lieshout, ECC, Visser-Meily, JMA, Neggers, SFW, van der Worp, HB, Dijkhuizen, RM. Brain stimulation for arm recovery after stroke (B-STARS): protocol for a randomised controlled trial in subacute stroke patients. BMJ Open. 2017;7:e016566. Google Scholar | Crossref | Medline
18.	Thiel, A, Black, SE, Rochon, EA, et al. Non-invasive repeated therapeutic stimulation for aphasia recovery: a multilingual, multicenter aphasia trial. J Stroke Cerebrovasc Dis. 2015;24:751-758. Google Scholar | Crossref | Medline
19.	Harvey, RL, Edwards, D, Dunning, K, et al. Randomized sham-controlled trial of navigated repetitive transcranial magnetic stimulation for motor recovery in stroke. Stroke. 2018;49:2138-2146. Google Scholar | Crossref | Medline
20.	Lefaucheur, JP, Aleman, A, Baeken, C, et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): an update (2014-2018). Clin Neurophysiol. 2020;131:474-528. Google Scholar | Crossref | Medline
21.	Kwakkel, G, Lannin, NA, Borschmann, K, et al. Standardized measurement of sensorimotor recovery in stroke trials: consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable. Int J Stroke. 2017;12:451-461. Google Scholar | SAGE Journals | ISI
22.	Pollock, A, Farmer, SE, Brady, MC, et al. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev. 2014;2014(11):CD010820. Google Scholar
23.	Coupar, F, Pollock, A, Rowe, P, Weir, C, Langhorne, P. Predictors of upper limb recovery after stroke: a systematic review and meta-analysis. Clin Rehabil. 2012;26:291-313. Google Scholar | SAGE Journals | ISI
24.	Hatem, SM, Saussez, G, Della Faille, M, et al. Rehabilitation of motor function after stroke: a multiple systematic review focused on techniques to stimulate upper extremity recovery. Front Hum Neurosci. 2016;10:442. Google Scholar | Crossref | Medline
25.	Hao, Z, Wang, D, Zeng, Y, Liu, M. Repetitive transcranial magnetic stimulation for improving function after stroke. Cochrane Database Syst Rev. 2013;(5):CD008862. Google Scholar | Medline
26.	Sebastianelli, L, Versace, V, Martignago, S, et al. Low-frequency rTMS of the unaffected hemisphere in stroke patients: a systematic review. Acta Neurol Scand. 2017;136:585-605. Google Scholar | Crossref | Medline
27.	Hsu, WY, Cheng, CH, Liao, KK, Lee, IH, Lin, YY. Effects of repetitive transcranial magnetic stimulation on motor functions in patients with stroke: a meta-analysis. Stroke. 2012;43:1849-1857. Google Scholar | Crossref | Medline | ISI
28.	Paolucci, S, Antonucci, G, Grasso, MG, et al. Early versus delayed inpatient stroke rehabilitation: a matched comparison conducted in Italy. Arch Phys Med Rehabil. 2000;81:695-700. Google Scholar | Crossref | Medline | ISI
29.	Jorgensen, HS, Nakayama, H, Raaschou, HO, Vive-Larsen, J, Stoier, M, Olsen, TS. Outcome and time course of recovery in stroke. Part II: time course of recovery. The Copenhagen Stroke Study. Arch Phys Med Rehabil. 1995;76:406-412. Google Scholar | Crossref | Medline | ISI
30.	Hayward, KS, Schmidt, J, Lohse, KR, et al. Are we armed with the right data? Pooled individual data review of biomarkers in people with severe upper limb impairment after stroke. Neuroimage Clin. 2017;13:310-319. Google Scholar | Crossref | Medline
31.	Bembenek, JP, Kurczych, K, KarliNski, M, Czlonkowska, A. The prognostic value of motor-evoked potentials in motor recovery and functional outcome after stroke—a systematic review of the literature. Funct Neurol. 2012;27:79-84. Google Scholar | Medline | ISI
32.	Boyd, LA, Hayward, KS, Ward, NS, et al. Biomarkers of stroke recovery: Consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable. Int J Stroke. 2017;12:480-493. Google Scholar | SAGE Journals | ISI
33.	Langhorne, P, Bernhardt, J, Kwakkel, G. Stroke rehabilitation. Lancet. 2011;377:1693-1702. Google Scholar | Crossref | Medline | ISI
34.	Zhang, L, Xing, G, Fan, Y, Guo, Z, Chen, H, Mu, Q. Short- and long-term effects of repetitive transcranial magnetic stimulation on upper limb motor function after stroke: a systematic review and meta-analysis. Clin Rehabil. 2017;31:1137-1153. Google Scholar | SAGE Journals | ISI
35.	Xiang, H, Sun, J, Tang, X, Zeng, K, Wu, X. The effect and optimal parameters of repetitive transcranial magnetic stimulation on motor recovery in stroke patients: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2019;33:847-864. Google Scholar | SAGE Journals | ISI
36.	O’Brien, AT, Bertolucci, F, Torrealba-Acosta, G, Huerta, R, Fregni, F, Thibaut, A. Non-invasive brain stimulation for fine motor improvement after stroke: a meta-analysis. Eur J Neurol. 2018;25:1017-1026. Google Scholar | Crossref | Medline
37.	Farmer, SE, Durairaj, V, Swain, I, Pandyan, AD. Assistive technologies: can they contribute to rehabilitation of the upper limb after stroke? Arch Phys Med Rehabil. 2014;95:968-985. Google Scholar | Crossref | Medline | ISI
38.	Agosta, S, Galante, E, Ferraro, F, Pascual-Leone, A, Oster, J, Battelli, L. Report of a delayed seizure after low frequency repetitive transcranial magnetic stimulation in a chronic stroke patient. Clin Neurophysiol. 2016;127:1736-1737. Google Scholar | Crossref | Medline
39.	Kumar, N, Padma Srivastava, MV, Verma, R, Sharma, H, Modak, T. Can low-frequency repetitive transcranial magnetic stimulation precipitate a late-onset seizure in a stroke patient? Clin Neurophysiol. 2016;127:1734-1736. Google Scholar | Crossref | Medline
40.	Liepert, J, Zittel, S, Weiller, C. Improvement of dexterity by single session low-frequency repetitive transcranial magnetic stimulation over the contralesional motor cortex in acute stroke: a double-blind placebo-controlled crossover trial. Restor Neurol Neurosci. 2007;25:461-465. Google Scholar | Medline | ISI
41.	Nitsche, MA . Co-incidence or causality? Seizures after slow rTMS in stroke patients. Clin Neurophysiol. 2016;127:1020-1021. Google Scholar | Crossref | Medline
42.	Lefaucheur, JP, Andre-Obadia, N, Antal, A, et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clin Neurophysiol. 2014;125:2150-2206. Google Scholar | Crossref | Medline | ISI
43.	Ameli, M, Grefkes, C, Kemper, F, et al. Differential effects of high-frequency repetitive transcranial magnetic stimulation over ipsilesional primary motor cortex in cortical and subcortical middle cerebral artery stroke. Ann Neurol. 2009;66:298-309. Google Scholar | Crossref | Medline | ISI
44.	Park, CH, Kou, N, Ward, NS. The contribution of lesion location to upper limb deficit after stroke. J Neurol Neurosurg Psychiatry. 2016;87:1283-1286. Google Scholar | Crossref | Medline | ISI
45.	Parikh, RM, Robinson, RG, Lipsey, JR, Starkstein, SE, Fedoroff, JP, Price, TR. The impact of poststroke depression on recovery in activities of daily living over a 2-year follow-up. Arch Neurol. 1990;47:785-789. Google Scholar | Crossref | Medline
46.	MacIntosh, BJ, Edwards, JD, Kang, M, et al. Post-stroke fatigue and depressive symptoms are differentially related to mobility and cognitive performance. Front Aging Neurosci. 2017;9:343. Google Scholar | Crossref | Medline
47.	Ginex, V, Veronelli, L, Vanacore, N, Lacorte, E, Monti, A, Corbo, M. Motor recovery in post-stroke patients with aphasia: the role of specific linguistic abilities. Top Stroke Rehabil. 2017;24:428-434. Google Scholar | Crossref | Medline
48.	Cunningham, DA, Machado, A, Janini, D, et al. Assessment of inter-hemispheric imbalance using imaging and noninvasive brain stimulation in patients with chronic stroke. Arch Phys Med Rehabil. 2015;96(4 suppl):S94-S103. Google Scholar | Crossref | Medline
49.	Casaubon, LK, Boulanger, JM, Glasser, E, et al. Canadian Stroke Best Practice Recommendations: acute inpatient stroke care guidelines, update 2015. Int J Stroke. 2016;11:239-252. Google Scholar | SAGE Journals | ISI
50.	Teasell, R, Norine, F, Richardson, M, Allen, L, Cotoi, A. Outpatient Stroke Rehabilitation 2018. Accessed December 7, 2020. http://www.ebrsr.com/ Google Scholar
51.	Peurala, SH, Kantanen, MP, Sjogren, T, Paltamaa, J, Karhula, M, Heinonen, A. Effectiveness of constraint-induced movement therapy on activity and participation after stroke: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2012;26:209-223. Google Scholar | SAGE Journals | ISI
52.	Hubbard, IJ, Parsons, MW, Neilson, C, Carey, LM. Task-specific training: evidence for and translation to clinical practice. Occup Ther Int. 2009;16:175-189. Google Scholar | Crossref | Medline | ISI
53.	Wattchow, KA, McDonnell, MN, Hillier, SL. Rehabilitation interventions for upper limb function in the first four weeks following stroke: a systematic review and meta-analysis of the evidence. Arch Phys Med Rehabil. 2018;99:367-382. Google Scholar | Crossref | Medline
54.	Waddell, KJ, Birkenmeier, RL, Moore, JL, Hornby, TG, Lang, CE. Feasibility of high-repetition, task-specific training for individuals with upper-extremity paresis. Am J Occup Ther. 2014;68:444-453. Google Scholar | Crossref | Medline | ISI
55.	Almhdawi, KA, Mathiowetz, VG, White, M, delMas, RC. Efficacy of occupational therapy task-oriented approach in upper extremity post-stroke rehabilitation. Occup Ther Int. 2016;23:444-456. Google Scholar | Crossref | Medline
56.	Askim, T, Indredavik, B, Vangberg, T, Haberg, A. Motor network changes associated with successful motor skill relearning after acute ischemic stroke: a longitudinal functional magnetic resonance imaging study. Neurorehabil Neural Repair. 2009;23:295-304. Google Scholar | SAGE Journals | ISI
57.	Hebert, D, Lindsay, MP, McIntyre, A, et al. Canadian stroke best practice recommendations: stroke rehabilitation practice guidelines, update 2015. Int J Stroke. 2016;11:459-484. Google Scholar | SAGE Journals | ISI
58.	Kunkel, A, Kopp, B, Muller, G, et al. Constraint-induced movement therapy for motor recovery in chronic stroke patients. Arch Phys Med Rehabil. 1999;80:624-628. Google Scholar | Crossref | Medline | ISI
59.	Harris, JE, Eng, JJ, Miller, WC, Dawson, AS. A self-administered Graded Repetitive Arm Supplementary Program (GRASP) improves arm function during inpatient stroke rehabilitation: a multi-site randomized controlled trial. Stroke. 2009;40:2123-2128. Google Scholar | Crossref | Medline | ISI
60.	Thrane, G, Friborg, O, Anke, A, Indredavik, B. A meta-analysis of constraint-induced movement therapy after stroke. J Rehabil Med. 2014;46:833-842. Google Scholar | Crossref | Medline
61.	Pedlow, K, Lennon, S, Wilson, C. Application of constraint-induced movement therapy in clinical practice: an online survey. Arch Phys Med Rehabil. 2014;95:276-282. Google Scholar | Crossref | Medline
62.	Viana, R, Teasell, R. Barriers to the implementation of constraint-induced movement therapy into practice. Top Stroke Rehabil. 2012;19:104-114. Google Scholar | Crossref | Medline | ISI
63.	Fleet, A, Che, M, Mackay-Lyons, M, et al. Examining the use of constraint-induced movement therapy in Canadian neurological occupational and physical therapy. Physiother Can. 2014;66:60-71. Google Scholar | Crossref | Medline
64.	Connell, LA, McMahon, NE, Harris, JE, Watkins, CL, Eng, JJ. A formative evaluation of the implementation of an upper limb stroke rehabilitation intervention in clinical practice: a qualitative interview study. Implement Sci. 2014;9:90. Google Scholar | Crossref | Medline
65.	Hiscock, A, Miller, S, Rothwell, J, Tallis, RC, Pomeroy, VM. Informing dose-finding studies of repetitive transcranial magnetic stimulation to enhance motor function: a qualitative systematic review. Neurorehabil Neural Repair. 2008;22:228-249. Google Scholar | SAGE Journals | ISI
66.	Graef, P, Dadalt, MLR, Rodrigues, D, Stein, C, Pagnussat, AS. Transcranial magnetic stimulation combined with upper-limb training for improving function after stroke: a systematic review and meta-analysis. J Neurol Sci. 2016;369:149-158. Google Scholar | Crossref | Medline
67.	Abo, M, Kakuda, W, Momosaki, R, et al. Randomized, multicenter, comparative study of NEURO versus CIMT in poststroke patients with upper limb hemiparesis: the NEURO-VERIFY Study. Int J Stroke. 2014;9:607-612. Google Scholar | SAGE Journals | ISI
68.	Foley, N, McClure, JA, Meyer, M, Salter, K, Bureau, Y, Teasell, R. Inpatient rehabilitation following stroke: amount of therapy received and associations with functional recovery. Disabil Rehabil. 2012;34:2132-2138. Google Scholar | Crossref | Medline | ISI
69.	Jette, DU, Latham, NK, Smout, RJ, Gassaway, J, Slavin, MD, Horn, SD. Physical therapy interventions for patients with stroke in inpatient rehabilitation facilities. Phys Ther. 2005;85:238-248. Google Scholar | Crossref | Medline | ISI
70.	Hayward, KS, Brauer, SG. Dose of arm activity training during acute and subacute rehabilitation post stroke: a systematic review of the literature. Clin Rehabil. 2015;29:1234-1243. Google Scholar | SAGE Journals | ISI
71.	Lohse, KR, Lang, CE, Boyd, LA. Is more better? Using metadata to explore dose-response relationships in stroke rehabilitation. Stroke. 2014;45:2053-2058. Google Scholar | Crossref | Medline | ISI
72.	Lang, CE, Lohse, KR, Birkenmeier, RL. Dose and timing in neurorehabilitation: prescribing motor therapy after stroke. Curr Opin Neurol. 2015;28:549-555. Google Scholar | Crossref | Medline
73.	Dromerick, AW, Lang, CE, Birkenmeier, RL, et al. Very early constraint-induced movement during stroke rehabilitation (VECTORS): a single-center RCT. Neurology. 2009;73:195-201. Google Scholar | Crossref | Medline | ISI
74.	Santisteban, L, Teremetz, M, Bleton, JP, Baron, JC, Maier, MA, Lindberg, PG. Upper limb outcome measures used in stroke rehabilitation studies: a systematic literature review. PLoS One. 2016;11:e0154792. Google Scholar | Crossref | Medline | ISI
75.	Hong, I, Bonilha, HS. Psychometric properties of upper extremity outcome measures validated by Rasch analysis: a systematic review. Int J Rehabil Res. 2017;40:1-10. Google Scholar | Crossref | Medline
76.	Kirton, A, Chen, R, Friefeld, S, Gunraj, C, Pontigon, AM, Deveber, G. Contralesional repetitive transcranial magnetic stimulation for chronic hemiparesis in subcortical paediatric stroke: a randomised trial. Lancet Neurol. 2008;7:507-513. Google Scholar | Crossref | Medline | ISI
77.	Noorkoiv, M, Rodgers, H, Price, CI. Accelerometer measurement of upper extremity movement after stroke: a systematic review of clinical studies. J Neuroeng Rehabil. 2014;11:144. Google Scholar | Crossref | Medline | ISI
78.	Geyh, S, Kurt, T, Brockow, T, et al. Identifying the concepts contained in outcome measures of clinical trials on stroke using the International Classification of Functioning, Disability and Health as a reference. J Rehabil Med. 2004(44 suppl):56-62. Google Scholar | Crossref | Medline | ISI
79.	Bushnell, C, Bettger, JP, Cockroft, KM, et al. Chronic stroke outcome measures for motor function intervention trials: expert panel recommendations. Circ Cardiovasc Qual Outcomes. 2015;8(6 suppl 3):S163-S169. Google Scholar | Crossref | Medline
80.	Van der Lee, JH, De Groot, V, Beckerman, H, Wagenaar, RC, Lankhorst, GJ, Bouter, LM. The intra- and interrater reliability of the action research arm test: a practical test of upper extremity function in patients with stroke. Arch Phys Med Rehabil. 2001;82:14-19. Google Scholar | Crossref | Medline | ISI
81.	Bonita, R, Beaglehole, R. Recovery of motor function after stroke. Stroke. 1988;19:1497-1500. Google Scholar | Crossref | Medline | ISI
82.	Banks, JL, Marotta, CA. Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials: a literature review and synthesis. Stroke. 2007;38:1091-1096. Google Scholar | Crossref | Medline | ISI
83.	Quinn, TJ, Dawson, J, Walters, MR, Lees, KR. Reliability of the modified Rankin Scale: a systematic review. Stroke. 2009;40:3393-3395. Google Scholar | Crossref | Medline | ISI
84.	Pike, S, Lannin, NA, Wales, K, Cusick, A. A systematic review of the psychometric properties of the Action Research Arm Test in neurorehabilitation. Aust Occup Ther J. 2018;65:449-471. Google Scholar | Crossref | Medline
85.	Alt Murphy, M, Resteghini, C, Feys, P, Lamers, I. An overview of systematic reviews on upper extremity outcome measures after stroke. BMC Neurol. 2015;15:29. Google Scholar | Crossref | Medline
86.	Law, M, Baptiste, S, McColl, M, Opzoomer, A, Polatajko, H, Pollock, N. The Canadian Occupational Performance Measure: an outcome measure for occupational therapy. Can J Occup Ther. 1990;57:82-87. Google Scholar | SAGE Journals
87.	Duncan, PW, Wallace, D, Lai, SM, Johnson, D, Embretson, S, Laster, LJ. The Stroke Impact Scale version 2.0. Evaluation of reliability, validity, and sensitivity to change. Stroke. 1999;30:2131-2140. Google Scholar | Crossref | Medline | ISI
88.	Kirton, A, Ciechanski, P, Zewdie, E, et al. Transcranial direct current stimulation for children with perinatal stroke and hemiparesis. Neurology. 2017;88:259-267. Google Scholar | Crossref | Medline
89.	Yang, SY, Lin, CY, Lee, YC, Chang, JH. The Canadian occupational performance measure for patients with stroke: a systematic review. J Phys Ther Sci. 2017;29:548-555. Google Scholar | Crossref | Medline
90.	Katzan, IL, Thompson, NR, Lapin, B, Uchino, K. Added value of patient-reported outcome measures in stroke clinical practice. J Am Heart Assoc. 2017;6:e005356. Google Scholar | Crossref | Medline
91.	Stewart, JC, Cramer, SC. Patient-reported measures provide unique insights into motor function after stroke. Stroke. 2013;44:1111-1116. Google Scholar | Crossref | Medline | ISI
92.	Sullivan, JE, Espe, LE, Kelly, AM, Veilbig, LE, Kwasny, MJ. Feasibility and outcomes of a community-based, pedometer-monitored walking program in chronic stroke: a pilot study. Top Stroke Rehabil. 2014;21:101-110. Google Scholar | Crossref | Medline
93.	Vetrovsky, T, Cupka, J, Dudek, M, et al. A pedometer-based walking intervention with and without email counseling in general practice: a pilot randomized controlled trial. BMC Public Health. 2018;18:635. Google Scholar | Crossref | Medline
94.	Zhang, L, Xing, G, Shuai, S, et al. Low-frequency repetitive transcranial magnetic stimulation for stroke-induced upper limb motor deficit: a meta-analysis. Neural Plast. 2017;2017:2758097. Google Scholar | Crossref | Medline
95.	Rossini, PM, Burke, D, Chen, R, et al. Non-invasive electrical and magnetic stimulation of the brain, spinal cord, roots and peripheral nerves: Basic principles and procedures for routine clinical and research application. An updated report from an I.F.C.N. Committee. Clin Neurophysiol. 2015;126:1071-1107. Google Scholar | Crossref | Medline | ISI
96.	Le, Q, Qu, Y, Tao, Y, Zhu, S. Effects of repetitive transcranial magnetic stimulation on hand function recovery and excitability of the motor cortex after stroke: a meta-analysis. Am J Phys Med Rehabil. 2014;93:422-430. Google Scholar | Crossref | Medline
97.	Ludemann-Podubecka, J, Bosl, K, Nowak, DA. Repetitive transcranial magnetic stimulation for motor recovery of the upper limb after stroke. Prog Brain Res. 2015;218:281-311. Google Scholar | Crossref | Medline
98.	Liepert, J, Restemeyer, C, Kucinski, T, Zittel, S, Weiller, C. Motor strokes: the lesion location determines motor excitability changes. Stroke. 2005;36:2648-2653. Google Scholar | Crossref | Medline | ISI
99.	Shimizu, T, Hosaki, A, Hino, T, et al. Motor cortical disinhibition in the unaffected hemisphere after unilateral cortical stroke. Brain. 2002;125(pt 8):1896-1907. Google Scholar | Crossref | Medline | ISI
100.	Volz, LJ, Vollmer, M, Michely, J, Fink, GR, Rothwell, JC, Grefkes, C. Time-dependent functional role of the contralesional motor cortex after stroke. Neuroimage Clin. 2017;16:165-174. Google Scholar | Crossref | Medline
101.	Khedr, EM, Abdel-Fadeil, MR, Farghali, A, Qaid, M. Role of 1 and 3 Hz repetitive transcranial magnetic stimulation on motor function recovery after acute ischaemic stroke. Eur J Neurol. 2009;16:1323-1330. Google Scholar | Crossref | Medline | ISI
102.	Sasaki, N, Mizutani, S, Kakuda, W, Abo, M. Comparison of the effects of high- and low-frequency repetitive transcranial magnetic stimulation on upper limb hemiparesis in the early phase of stroke. J Stroke Cerebrovasc Dis. 2013;22:413-418. Google Scholar | Crossref | Medline | ISI
103.	Seniow, J, Bilik, M, Lesniak, M, Waldowski, K, Iwanski, S, Czlonkowska, A. Transcranial magnetic stimulation combined with physiotherapy in rehabilitation of poststroke hemiparesis: a randomized, double-blind, placebo-controlled study. Neurorehabil Neural Repair. 2012;26:1072-1079. Google Scholar | SAGE Journals | ISI
104.	Etoh, S, Noma, T, Ikeda, K, et al. Effects of repetitive transcranial magnetic stimulation on repetitive facilitation exercises of the hemiplegic hand in chronic stroke patients. J Rehabil Med. 2013;45:843-847. Google Scholar | Crossref | Medline
105.	Avenanti, A, Coccia, M, Ladavas, E, Provinciali, L, Ceravolo, MG. Low-frequency rTMS promotes use-dependent motor plasticity in chronic stroke: a randomized trial. Neurology. 2012;78:256-264. Google Scholar | Crossref | Medline | ISI
106.	Fregni, F, Boggio, PS, Valle, AC, et al. A sham-controlled trial of a 5-day course of repetitive transcranial magnetic stimulation of the unaffected hemisphere in stroke patients. Stroke. 2006;37:2115-2122. Google Scholar | Crossref | Medline | ISI
107.	Emara, TH, Moustafa, RR, Elnahas, NM, et al. Repetitive transcranial magnetic stimulation at 1 Hz and 5 Hz produces sustained improvement in motor function and disability after ischaemic stroke. Eur J Neurol. 2010;17:1203-1209. Google Scholar | Crossref | Medline | ISI
108.	Takeuchi, N, Tada, T, Toshima, M, Matsuo, Y, Ikoma, K. Repetitive transcranial magnetic stimulation over bilateral hemispheres enhances motor function and training effect of paretic hand in patients after stroke. J Rehabil Med. 2009;41:1049-1054. Google Scholar | Crossref | Medline | ISI
109.	Conforto, AB, Anjos, SM, Saposnik, G, et al. Transcranial magnetic stimulation in mild to severe hemiparesis early after stroke: a proof of principle and novel approach to improve motor function. J Neurol. 2012;259:1399-1405. Google Scholar | Crossref | Medline | ISI
110.	Park, E, Kim, YH, Chang, WH, Kwon, TG, Shin, YI. Interhemispheric modulation of dual-mode, noninvasive brain stimulation on motor function. Ann Rehabil Med. 2014;38:297-303. Google Scholar | Crossref | Medline
111.	Malcolm, MP, Triggs, WJ, Light, KE, et al. Repetitive transcranial magnetic stimulation as an adjunct to constraint-induced therapy: an exploratory randomized controlled trial. Am J Phys Med Rehabil. 2007;86:707-715. Google Scholar | Crossref | Medline | ISI
112.	Wassermann, EM . Risk and safety of repetitive transcranial magnetic stimulation: report and suggested guidelines from the International Workshop on the Safety of Repetitive Transcranial Magnetic Stimulation, June 5-7, 1996. Electroencephalogr Clin Neurophysiol. 1998;108:1-16. Google Scholar | Crossref | Medline
113.	Muellbacher, W, Ziemann, U, Boroojerdi, B, Hallett, M. Effects of low-frequency transcranial magnetic stimulation on motor excitability and basic motor behavior. Clin Neurophysiol. 2000;111(6):1002-1007. Google Scholar | Crossref | Medline
114.	Houdayer, E, Degardin, A, Cassim, F, Bocquillon, P, Derambure, P, Devanne, H. The effects of low- and high-frequency repetitive TMS on the input/output properties of the human corticospinal pathway. Exp Brain Res. 2008;187:207-217. Google Scholar | Crossref | Medline
115.	Heide, G, Witte, OW, Ziemann, U. Physiology of modulation of motor cortex excitability by low-frequency suprathreshold repetitive transcranial magnetic stimulation. Exp Brain Res. 2006;171:26-34. Google Scholar | Crossref | Medline | ISI
116.	de Jesus, DR, Favalli, GP, Hoppenbrouwers, SS, et al. Determining optimal rTMS parameters through changes in cortical inhibition. Clin Neurophysiol. 2014;125:755-762. Google Scholar | Crossref | Medline | ISI
117.	Kantak, SS, Fisher, BE, Sullivan, KJ, Winstein, CJ. Effects of different doses of low frequency rTMS on motor corticospinal excitability. J Neurol Neurophysiol. 2010; 1:1000102. doi:10.4172/2155-9562.1000102 Google Scholar | Crossref
118.	Pascual-Leone, A, Cohen, LG, Hallett, M. Cortical map plasticity in humans. Trends Neurosci. 1992;15:13-14. Google Scholar | Crossref | Medline
119.	Liepert, J, Storch, P, Fritsch, A, Weiller, C. Motor cortex disinhibition in acute stroke. Clin Neurophysiol. 2000;111:671-676. Google Scholar | Crossref | Medline | ISI
120.	Siebner, HR, Rothwell, J. Transcranial magnetic stimulation: new insights into representational cortical plasticity. Exp Brain Res. 2003;148:1-16. Google Scholar | Crossref | Medline | ISI
121.	Ahdab, R, Ayache, SS, Brugieres, P, Farhat, WH, Lefaucheur, JP. The hand motor hotspot is not always located in the hand knob: a neuronavigated transcranial magnetic stimulation study. Brain Topogr. 2016;29:590-597. Google Scholar | Crossref | Medline
122.	Liao, WW, Whitall, J, Wittenberg, GF, Barton, JE, McCombe Waller, S. Not all brain regions are created equal for improving bimanual coordination in individuals with chronic stroke. Clin Neurophysiol. 2019;130:1218-1230. Google Scholar | Crossref | Medline
123.	Julkunen, P, Saisanen, L, Danner, N, et al. Comparison of navigated and non-navigated transcranial magnetic stimulation for motor cortex mapping, motor threshold and motor evoked potentials. Neuroimage. 2009;44:790-795. Google Scholar | Crossref | Medline | ISI
124.	Saisanen, L, Julkunen, P, Niskanen, E, et al. Motor potentials evoked by navigated transcranial magnetic stimulation in healthy subjects. J Clin Neurophysiol. 2008;25:367-372. Google Scholar | Crossref | Medline | ISI
125.	Sparing, R, Buelte, D, Meister, IG, Paus, T, Fink, GR. Transcranial magnetic stimulation and the challenge of coil placement: a comparison of conventional and stereotaxic neuronavigational strategies. Hum Brain Mapp. 2008;29:82-96. Google Scholar | Crossref | Medline | ISI
126.	Cincotta, M, Giovannelli, F, Borgheresi, A, et al. Optically tracked neuronavigation increases the stability of hand-held focal coil positioning: evidence from “transcranial” magnetic stimulation-induced electrical field measurements. Brain Stimul. 2010;3:119-123. Google Scholar | Crossref | Medline

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[WEB PAGE] Rewiring stroke survivors brains could alleviate depression

by University of South Australia

Large doses of repetitive trans cranial magnetic stimulation significantly improve post-stroke depression. Credit: UniSA

University of South Australia researchers have made a major breakthrough in the treatment of depression after stroke, using a high frequency brain stimulation device to improve low moods.

A trial led by UniSA stroke researcher Dr. Brenton Hordacre has found that large doses of repetitive transcranial magnetic stimulation (rTMS) significantly improve post-stroke depression by increasing brain activity.

Previous studies have experimented with the use of rTMS but this is the first time that a large treatment dose—30,000 electromagnetic pulses delivered over two weeks—have been trialed, showing positive changes in brain function.

The findings, published in the Journal of Neurology, could signal a non-invasive, alternative treatment for post-stroke depression in place of medication, which can have negative side effects for many people.

South Australians are set to benefit from this research with the brain stimulation device now available at UniSA’s City West campus to treat stroke patients suffering depression.

The $40,000 brain stimulator, partly funded by the Honda Foundation, could also potentially improve motor recovery, helping stroke patients develop new connections in the damaged brain.

“The advantage of using TMS to treat depression is that it has relatively few side effects compared to pharmacological treatments,” Dr. Hordacre says. “It can also be delivered over several sessions but the improvements in depression last well beyond that period.”

An estimated 500,000 people in Australia are living with the effects of a stroke, and this figure jumps by 56,000 each year as a result of people suffering either an ischaemic (clot) stroke or a cerebral hemorrhage (bleed).

One in three people experience depression within five years of their stroke, mostly in the first year, although it can occur at any time.

“A stroke is a life-changing event in itself, bringing about personality, mood and emotional changes, so there is a very strong link between stroke, depression and anxiety,” Dr. Hordacre says.

Antidepressants and psychotherapy are commonly used to treat depression post-stroke, but rTMS gives patients another option in the wake of these findings.

Adelaide resident Saran Chamberlain was one of 11 chronic stroke survivors who took part in Dr. Hordacre’s trial, receiving 10 sessions of high frequency rTMS for depression.

Saran suffered a stroke in 2013 at the age of 38. She was not a typical candidate (non-smoker, healthy and young) but a stressful job and long work hours are believed to be the main factors in her case.

She was initially left completely paralyzed on the left side, and was prescribed medication to deal with the ensuing depression.

“When I heard about this trial using repetitive brain stimulation I was keen to try it to see if it made any difference,” Saran said. “It did, and the effects lasted several months. I am still on antidepressants but I have reduced the dosage quite markedly. This really has made a difference to my life!”

Dr. Hordacre says the benefits of UniSA’s brain stimulation device will extend beyond the community, with the university’s allied health students trained to deliver the treatment under supervision.

The treatment will be officially launched in the new year.

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[ARTICLE] Baseline Motor Impairment Predicts Transcranial Direct Current Stimulation Combined with Physical Therapy-Induced Improvement in Individuals with Chronic Stroke – Full Text

Abstract

Transcranial direct current stimulation (tDCS) can enhance the effect of conventional therapies in post-stroke neurorehabilitation. The ability to predict an individual’s potential for tDCS-induced recovery may permit rehabilitation providers to make rational decisions about who will be a good candidate for tDCS therapy. We investigated the clinical and biological characteristics which might predict tDCS plus physical therapy effects on upper limb motor recovery in chronic stroke patients. A cohort of 80 chronic stroke individuals underwent ten to fifteen sessions of tDCS plus physical therapy. The sensorimotor function of the upper limb was assessed by means of the upper extremity section of the Fugl-Meyer scale (UE-FM), before and after treatment. A backward stepwise regression was used to assess the effect of age, sex, time since stroke, brain lesion side, and basal level of motor function on UE-FM improvement after treatment. Following the intervention, UE-FM significantly improved (), and the magnitude of the change was clinically important (mean 6.2 points, 95% CI: 5.2–7.4). The baseline level of UE-FM was the only significant predictor (, , ) of tDCS response. These findings may help to guide clinical decisions according to the profile of each patient. Future studies should investigate whether stroke severity affects the effectiveness of tDCS combined with physical therapy.

1. Introduction

Transcranial direct current stimulation (tDCS) is an emerging technique with the potential to enhance the effect of therapeutic approaches in post-stroke rehabilitation [1, 2]. According to the interhemispheric competition model [3, 4], anodal tDCS is applied to increase the excitability of the lesioned hemisphere. In contrast, cathodal tDCS is applied to decrease the excitability of the nonlesioned hemisphere. Lastly, bihemispheric tDCS involves anodal and cathodal tDCS applied simultaneously [5].

Regarding the effects of each tDCS method, it is suggested that bihemispheric tDCS has a more significant effect on chronic stroke [6–8]. Moreover, the positive effect of each tDCS approach on stroke motor recovery has been elucidated by previous studies [9–13]. Notably, recent systematic reviews reported the improvement of upper limb (UL) sensorimotor functions and improvement of activities of daily living following tDCS in post-stroke individuals [8–10, 14].

Despite its great potential, post-stroke subjects show different responses to tDCS. Furthermore, the variability of tDCS effectiveness limits its implementation as standard patient care [15]. A better understating of individual characteristics for predicting motor recovery in responding to treatment should be considered a crucial component for post-stroke rehabilitation.

Following a stroke, neural reorganization, due to spontaneous recovery or induced by therapeutic interventions, is influenced by clinical and biological factors [16–18]. Some of these factors might help to predict therapy-mediated motor recovery [18–21], i.e., stroke chronicity [22, 23], sex [24, 25], age [23, 26], prestroke hemispheric dominance [18], and time since stroke [17].

Initial motor impairment can also predict motor outcomes [27]. Post-stroke motor recovery is highly variable [15], and individuals could present mild to severe motor impairment [28]. Overall, the initial (i.e., baseline) motor impairment is a strong predictor of functional improvement; e.g., moderate motor impairment is associated with better recovery than severe impairment in post-stroke survivors [29].

Notably, previous studies employing tDCS combined with physical therapy included patients with different motor impairment levels and reported heterogeneous results [30–32]. The variability of tDCS response could be related to different aspects related to the technique or the patient’s characteristics. Regarding the tDCS, the parameters of the technique, the ideal number of sessions, and the most appropriate stimulation site (lesioned hemisphere, nonlesioned hemisphere, or both hemispheres) should be considered. Concerning the post-stroke individuals, it is important to consider the motor impairment, the location and size of the lesion, and the previous condition of the subject. The most appropriate supporting therapy should also be considered. The heterogeneous results could be related to one or more of these factors (reviewed in Simonetta-Moreau [33]).

Considering predictive factors that might guide stroke recovery, recent studies suggest the development of algorithms or models to determine functional recovery following rehabilitation in either acute or chronic post-stroke individuals [5, 34]. Although there is an increasing number of studies using tDCS in stroke rehabilitation and its relevance for clinical practice, it is unknown whether personal factors, e.g., age and sex, may predict the magnitude of the effect of tDCS on functional recovery [33]. Moreover, UL sensorimotor impairments (e.g., disrupted interjoint coordination, spasticity, and loss of dexterity) are common after stroke and persist in the chronic stage [35, 36]. These deficits may lead to decreased quality of life and social participation. Thus, this study was aimed at investigating if clinical and biological characteristics might predict the tDCS plus physical therapy effects on UL motor recovery in chronic stroke individuals. This knowledge might help to guide clinical decisions according to the clinical profile of each patient as well as to enhance clinical evidence-based practice for neurorehabilitation.[…]

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[ARTICLE] Using Transcranial Direct Current Stimulation to Augment the Effect of Motor Imagery-Assisted Brain-Computer Interface Training in Chronic Stroke Patients—Cortical Reorganization Considerations – Full Text

Abstract

Introduction: Transcranial direct current stimulation (tDCS) has been shown to modulate cortical plasticity, enhance motor learning and post-stroke upper extremity motor recovery. It has also been demonstrated to facilitate activation of brain-computer interface (BCI) in stroke patients. We had previously demonstrated that BCI-assisted motor imagery (MI-BCI) can improve upper extremity impairment in chronic stroke participants. This study was carried out to investigate the effects of priming with tDCS prior to MI-BCI training in chronic stroke patients with moderate to severe upper extremity paresis and to investigate the cortical activity changes associated with training.

Methods: This is a double-blinded randomized clinical trial. Participants were randomized to receive 10 sessions of 20-min 1 mA tDCS or sham-tDCS before MI-BCI, with the anode applied to the ipsilesional, and the cathode to the contralesional primary motor cortex (M1). Upper extremity sub-scale of the Fugl-Meyer Assessment (UE-FM) and corticospinal excitability measured by transcranial magnetic stimulation (TMS) were assessed before, after and 4 weeks after intervention.

Results: Ten participants received real tDCS and nine received sham tDCS. UE-FM improved significantly in both groups after intervention. Of those with unrecordable motor evoked potential (MEP-) to the ipsilesional M1, significant improvement in UE-FM was found in the real-tDCS group, but not in the sham group. Resting motor threshold (RMT) of ipsilesional M1 decreased significantly after intervention in the real-tDCS group. Short intra-cortical inhibition (SICI) in the contralesional M1 was reduced significantly following intervention in the sham group. Correlation was found between baseline UE-FM score and changes in the contralesional SICI for all, as well as between changes in UE-FM and changes in contralesional RMT in the MEP- group.

Conclusion: MI-BCI improved the motor function of the stroke-affected arm in chronic stroke patients with moderate to severe impairment. tDCS did not confer overall additional benefit although there was a trend toward greater benefit. Cortical activity changes in the contralesional M1 associated with functional improvement suggests a possible role for the contralesional M1 in stroke recovery in more severely affected patients. This has important implications in designing neuromodulatory interventions for future studies and tailoring treatment.

Introduction

Post-stroke recovery of upper extremity (UE) function remains a challenge. Less than 15% of stroke survivors with severe impairment experience complete motor recovery (1, 2). Intensive and repetitive practice is effective for motor recovery (3), but is labor-intensive and costly. More effective rehabilitation strategies that will deliver better functional outcomes without increasing cost of care are needed.

Motor imagery (MI), or mental practice is a mental rehearsal process of a specific movement without physical performance to enhance post-stroke upper extremity motor recovery (4–10). It has been demonstrated to be a safe, self-paced method to improve motor performance in athletes (6) and is effective in augmenting the effects of motor practice in stroke patients (7–9).

MI shares similar neural substrates with motor execution (11, 12). Functional neural changes induced by MI is similar to that of short-term motor learning (5) with corresponding changes in corticospinal excitability and reorganization of motor representation have been demonstrated with MI (4, 13).

Robot-assisted training is typically applied to deliver intensive, task-specific training in rehabilitation of motor function, but has also been used to provide appropriate sensorimotor integration through guidance of movement along a trajectory (14–18). The coupling of MI and robot-assisted arm movement through brain computer interface (MI-BCI) has been postulated to enhance sensorimotor integration by bridging the motor intent and providing appropriate somatosensory feedback through passive manipulation of the paretic arm, thereby guiding activity-dependent cortical plasticity through feedback on brain activity (19). Our previous studies of MI-BCI in chronic stroke demonstrated better improvement in motor function with fewer repetitions in the same time of training (20, 21). Others have found similar benefit using BCI-driven orthoses for rehabilitation of severe UE paresis (22).

Transcranial direct current stimulation (tDCS) is a non-invasive method of modulating corticospinal excitability by changing the firing threshold of neuronal membrane and modifying spontaneous activity according to the direction of current, such that cathodal tDCS decreases cortical excitability while anodal tDCS increases it (23–25). Good functional recovery has frequently been associated with a rebalancing of interhemispheric inhibition (17, 26). Based on this, cathodal tDCS is applied to the contralesional primary motor cortex (M1) and anodal tDCS to the ipsilesional M1 to enhance corticospinal excitability. This is the paradigm most frequently studied to enhance motor recovery after stroke (27–31), and has thus far yielded mixed results (32).

Additionally, tDCS has also been explored as a priming tool to improve the accuracy of BCI, both in healthy subjects (33, 34) and in stroke patients with mixed results (35, 36). We had previously reported the preliminary results of the first ever study to investigate the effect of a course of training with BCI-assisted motor imagery (MI-BCI) with tDCS priming (simultaneous anodal stimulation to the ipsilesional M1 and cathodal stimulation to the contralesional M1) prior to each session, compared to MI-BCI with sham tDCS, on recovery of chronic stroke patients with moderate to severe impairment (37). This population was chosen as they have the most difficulty engaging in active motor task training. The stimulation protocol was selected based on the intent to rebalance transcallosal inhibition, as suggested by previous studies (28, 30, 38). Clinical improvement was observed post-training, with online BCI accuracies being significantly better in the tDCS group, compared to the sham group.

The neurobiological principles that govern post-stroke recovery of motor function are incompletely understood. While task-specific training, and MI as an extension, is applied based on principles of activity-dependent cortical plasticity, and non-invasive brain stimulation is applied based on rebalancing of interhemispheric inhibitions, a more detailed understanding of the cortical reorganization associated with the combination of therapeutic modalities, and indeed of the recovery process itself, is required in order to tailor therapeutic approaches. TMS may be used to probe these changes in cortical excitability. Here we report the changes in cortical activity associated with this training protocol, which will inform the design of future studies.[…]

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[ARTICLE] Novel TMS for Stroke and Depression (NoTSAD): Accelerated Repetitive Transcranial Magnetic Stimulation as a Safe and Effective Treatment for Post-stroke Depression – Full Text

Background: Post-stroke depression (PSD) affects up to 50% of stroke survivors, reducing quality of life, and increasing adverse outcomes. Conventional therapies to treat PSD may not be effective for some patients. Repetitive transcranial magnetic stimulation (rTMS) is well-established as an effective treatment for Major Depressive Disorder (MDD) and some small trials have shown that rTMS may be effective for chronic PSD; however, no trials have evaluated an accelerated rTMS protocol in a subacute stroke population. We hypothesized that an accelerated rTMS protocol will be a safe and viable option to treat PSD symptoms.

Methods: Patients (N = 6) with radiographic evidence of ischemic stroke within the last 2 weeks to 6 months with Hamilton Depression Rating Scale (HAMD-17) scores >7 were recruited for an open label study using an accelerated rTMS protocol as follows: High-frequency (20-Hz) rTMS at 110% resting motor threshold (RMT) was applied to the left dorsolateral prefrontal cortex (DLPFC) during five sessions per day over four consecutive days for a total of 20 sessions. Safety assessment and adverse events were documented based on the patients’ responses following each day of stimulation. Before and after the 4-days neurostimulation protocol, outcome measures were obtained for the HAMD, modified Rankin Scale (mRS), functional independence measures (FIM), and National Institutes of Health Stroke Scales (NIHSS). These same measures were obtained at 3-months follow up.

Results: HAMD significantly decreased (Wilcoxon p = 0.03) from M = 15.5 (2.81)−4.17 (0.98) following rTMS, a difference which persisted at the 3-months follow-up (p = 0.03). No statistically significant difference in FIM, mRS, or NIHSS were observed. No significant adverse events related to the treatment were observed and patients tolerated the stimulation protocol well overall.

Conclusions: This pilot study indicates that an accelerated rTMS protocol is a safe and viable option, and may be an effective alternative or adjunctive therapy for patients suffering from PSD. Future randomized, controlled studies are needed to confirm these preliminary findings.

Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04093843.

Introduction

The interplay between depression and cerebrovascular disease is complex and clinically important. Post-stroke depression (PSD) is the most common neuropsychological complication of stroke, with a prevalence of ~33% (1) in stroke survivors. PSD adversely influences outcomes by reducing quality of life, increasing caregiver burden, and increasing early mortality as much as ten-fold (2–4). As acute stroke interventions continue to improve, stroke survivorship and associated morbidity will also increase, making the need to explore innovative treatments for PSD even more urgent.

Despite the significant clinical burden of PSD, there are limited treatment options to prevent or reduce its severity. Psychotherapy and pharmacotherapy are well-established as treatments of choice in major depression, however a subset of patients do not respond to either of these first-line therapies (5). Selective Serotonin Reuptake Inhibitor (SSRI) use has been associated with increased risk of hemorrhagic complications as well as increased risk of falls in the elderly, while other studies have shown that SSRIs are actually associated with increased risk for stroke, myocardial infarction, and all-cause mortality (6). A recent meta-analysis for stroke patients concluded that antidepressants did not significantly improve patients’ general recovery, achieved varied response rates, and were not tolerated due to adverse effects (7). Compliance, communication problems, and lack of access to psychiatric care are further challenges to treating PSD.

Repetitive transcranial magnetic stimulation (rTMS) may represent an effective treatment option that mitigates the issues associated with the standard PSD interventions. The FDA approved rTMS for patients with Major Depressive Disorder (MDD) in 2008 (8). The typical rTMS protocol that has been used effectively for major depression is 5 days per week for 4–6 weeks. Conventional rTMS paradigms have been studied in the PSD population, and many studies including a meta-analysis have shown that conventional rTMS is likely effective for chronic, refractory PSD (9, 10). However, these conventional paradigms may be inconvenient for patients with limited transportation access and may limit compliancy of patients. Therefore, an accelerated protocol which minimizes the number of days needed to complete the full treatment may be more accessible to patients and may increase compliancy. While there have been some accelerated rTMS paradigms that have been designed to treat conditions such as alcohol withdrawal and treatment-resistant depression (11–14), similar accelerated protocols have not been studied in patients suffering from PSD. Applying accelerated rTMS to the PSD population comes with unique and complex factors. For example, the theoretical risk of seizure using an accelerated protocol may be higher, and this risk may increase even further in patients in the acute to subacute stroke period. Therefore, it is important to study the safety of an accelerated protocol in this population. In addition, the period immediately following cerebrovascular ischemia potentially represents a biologically unique phase amenable to intervention given that both neuroplasticity as well as recurrent stroke risk are highest during this time (15, 16).

There is a clear medical need to further address the impact of rTMS for PSD and to optimize stimulation parameters. We hypothesized that an accelerated 4-days rTMS protocol would be a safe and viable method for treating PSD and would help ameliorate depressive symptoms.[…]

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[ARTICLE] Virtual reality and non-invasive brain stimulation for rehabilitation applications: a systematic review – Full Text

Abstract

The present article reports the results of a systematic review on the potential benefits of the combined use of virtual reality (VR) and non-invasive brain stimulation (NIBS) as a novel approach for rehabilitation. VR and NIBS are two rehabilitation techniques that have been consistently explored by health professionals, and in recent years there is strong evidence of the therapeutic benefits of their combined use. In this work, we reviewed research articles that report the combined use of VR and two common NIBS techniques, namely transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS). Relevant queries to six major bibliographic databases were performed to retrieve original research articles that reported the use of the combination VR-NIBS for rehabilitation applications. A total of 16 articles were identified and reviewed. The reviewed studies have significant differences in the goals, materials, methods, and outcomes. These differences are likely caused by the lack of guidelines and best practices on how to combine VR and NIBS techniques. Five therapeutic applications were identified: stroke, neuropathic pain, cerebral palsy, phobia and post-traumatic stress disorder, and multiple sclerosis rehabilitation. The majority of the reviewed studies reported positive effects of the use of VR-NIBS. However, further research is still needed to validate existing results on larger sample sizes and across different clinical conditions. For these reasons, in this review recommendations for future studies exploring the combined use of VR and NIBS are presented to facilitate the comparison among works.

Background

Virtual reality (VR) is a medium that is typically composed of an interactive computer simulation which detects the actions and position of the subject, additionally, it replaces or augments the feedback (e.g., visual, auditory, haptic) to the user, providing a sensation of presence in the simulation [1,2,3]. The last decade has witnessed a drastic improvement in computer graphics and computational power, which in turn, have paved the road to more realistic virtual- and augmented-reality systems and experiences, with applications in entertainment, gaming, e-commerce, architecture, interior design, manufacture, education, health and medicine [4]. Regarding rehabilitation, there is strong evidence supporting the use of VR therapy [5,6,7] in the treatment of pain, phobias, post-traumatic stress disorder (PTSD) [5], eating disorders [8], mental disorders, such as anxiety, schizophrenia and autism [9], and chemical abuse [10]. Moreover, VR has proven to be an important tool for exposure therapy [11]. Interestingly, a recent review on the medical literature has revealed that no reports of photosensitive epilepsy evoked by the use of VR headset [12].

Non-invasive brain stimulation (NIBS) techniques, in turn, have been consistently studied in the treatment of neuropsychiatric diseases as methods to modify or modulate the cortical excitability [13], and plasticity in the cerebral cortex [13, 14]. The two most common techniques used for NIBS are transcranial magnetic stimulation (TMS) and transcranial electrical stimulation (tES). As the name suggests, TMS uses magnetic fields, more specifically, their rapid change to induce a short pulse of electric current on the cortex, which in turn generates action potentials with a depth up to 5 cm. The application of the magnetic fields is carried out by a magnetic coil that is placed near the scalp over the cortical region of interest. TMS can be used in different ways, as single-pulse, repetitive TMS pulses (rTMS) [15, 16], or intermittent theta burst stimulation (iTBS) when magnetic pulses are intermittently applied in a specific burst [17]. NIBS with TMS have been used for the treatment of depression and schizophrenia [18, 19], pain [18], obsessive–compulsive disorder, Parkinson’s disease, epilepsy, task-related dystonia, and tic disorders [19]. On the other hand, tES relies on the passage of a weak electric current between electrodes placed on the scalp, thus stimulating the brain tissues between the electrodes. Depending on the type of electric current that is used, tES can be further divided into transcranial direct current stimulation (tDCS), alternating current stimulation (tACS), and random noise stimulation (tRNS) [20]; with tDCS being the most common type [14]. As tDCS possesses polarity, it can be anodal or cathodal, thus depolarizing or hyperpolarizing the resting membrane potential, respectively. This is reflected as an increase or decrease on the cortical excitability, respectively [20, 21]. Reported therapeutic applications of tDCS include treatment of pain, Parkinson’s disease, Alzheimer’s disease, motor disorders, stroke, aphasia, multiple sclerosis, epilepsy, depression, schizophrenia, and substance abuse [13]. In studies using TMS and tES, a “sham” (placebo) condition is often used as control. For tES, the sham condition consists in administering real tES to the subject during only few seconds at the beginning of the experiment to mimic the perception and experience of real stimulation. In TMS, there are two approaches for the sham condition: in one approach a TMS coil is placed in a position and orientation that evokes the somatosensory effects of real TMS but brain stimulation is absent; on the other approach, a sham TMS coil that resembles a regular TMS coil but is equipped with a magnetic shield that attenuates the magnetic field, additionally, electrical stimulation can be used to replicate the somatosensory effects of real TMS [22].

Recently, evidence has emerged showing promising therapeutic applications for the combined use of VR and tES (more specifically tDCS) [23,24,25,26], as well as VR and TMS [27,28,29], with outcomes not achievable by using either technique individually. Despite the reported promising results, the literature still lacks a systematic review covering the reported methods, outcomes, and potential therapeutic applications in neurological rehabilitation, on the combination of VR and NIBS techniques. This review aims to fill this gap, by reporting, comparing, and discussing studies that used VR-NIBS therapy for rehabilitation applications. Moreover, this review provides recommendations for future studies in the field to facilitate their development and comparison.[…]

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Example of a stationary VR system where the user actions are mapped to the virtual tennis player through a controller. Different viewpoints for the same VE are presented: a 1PP, b 1PP-mirror and c 3PP