Posts Tagged Transcranial Direct Current Stimulation

[Abstract] Timing-dependent interaction effects of tDCS with mirror therapy on upper extremity motor recovery in patients with chronic stroke: A randomized controlled pilot study

Highlights

  • The priming effect of dual tDCS was important to facilitate motor recovery in combination with mirror therapy in stroke.

Abstract

This study was a randomized, controlled pilot trial to investigate the timing-dependent interaction effects of dual transcranial direct current stimulation (tDCS) in mirror therapy (MT) for hemiplegic upper extremity in patients with chronic stroke. Thirty patients with chronic stroke were randomly assigned to three groups: tDCS applied before MT (prior-tDCS group), tDCS applied during MT (concurrent-tDCS group), and sham tDCS applied randomly prior to or concurrent with MT (sham-tDCS group). Dual tDCS at 1 mA was applied bilaterally over the ipsilesional M1 (anodal electrode) and the contralesional M1 (cathodal electrode) for 30 min. The intervention was delivered five days per week for two weeks. Upper extremity motor performance was measured using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE), the Action Research Arm Test (ARAT), and the Box and Block Test (BBT). Assessments were administered at baseline, post-intervention, and two weeks follow-up. The results indicated that concurrent-tDCS group showed significant improvements in the ARAT in relation to the prior-tDCS group and sham-tDCS group at post-intervention. Besides, a trend toward greater improvement was also found in the FMA-UE for the concurrent-tDCS group. However, no statistically significant difference in the FMA-UE and BBT was identified among the three groups at either post-intervention or follow-up. The concurrent-tDCS seems to be more advantageous and time-efficient in the context of clinical trials combining with MT. The timing-dependent interaction factor of tDCS to facilitate motor recovery should be considered in future clinical application.

via Timing-dependent interaction effects of tDCS with mirror therapy on upper extremity motor recovery in patients with chronic stroke: A randomized controlled pilot study – Journal of the Neurological Sciences

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[Abstract] Treatments for Poststroke Motor Deficits and Mood Disorders: A Systematic Review for the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Guidelines for Stroke Rehabilitation

Abstract

Background: Early rehabilitation after stroke is essential to help reduce disability.
Purpose: To summarize evidence on the benefits and harms of nonpharmacologic and pharmacologic treatments for motor deficits and mood disorders in adults who have had stroke.
Data Sources: English-language searches of multiple electronic databases from April 2009 through July 2018; targeted searches to December 2018 for studies of selective serotonin reuptake inhibitors (SSRIs) or serotonin–norepinephrine reuptake inhibitors.
Study Selection: 19 systematic reviews and 37 randomized controlled trials addressing therapies for motor deficits or mood disorders in adults with stroke.
Data Extraction: One investigator abstracted the data, and quality and GRADE assessment were checked by a second investigator.
Data Synthesis: Most interventions (for example, SSRIs, mental practice, mirror therapy) did not improve motor function. High-quality evidence did not support use of fluoxetine to improve motor function. Moderate-quality evidence supported use of cardiorespiratory training to improve maximum walking speed and repetitive task training or transcranial direct current stimulation to improve activities of daily living (ADLs). Low-quality evidence supported use of robotic arm training to improve ADLs. Low-quality evidence indicated that antidepressants may reduce depression, whereas the frequency and severity of antidepressant-related adverse effects was unclear. Low-quality evidence suggested that cognitive behavioral therapy and exercise, including mind–body exercise, may reduce symptoms of depression and anxiety.
Limitation: Studies were of poor quality, interventions and comparators were heterogeneous, and evidence on harms was scarce.
Conclusion: Cardiorespiratory training, repetitive task training, and transcranial direct current stimulation may improve ADLs in adults with stroke. Cognitive behavioral therapy, exercise, and SSRIs may reduce symptoms of poststroke depression, but use of SSRIs to prevent depression or improve motor function was not supported.
Primary Funding Source: U.S. Department of Veterans Affairs, Veterans Health Administration.

via Treatments for Poststroke Motor Deficits and Mood Disorders | Annals of Internal Medicine | American College of Physicians

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[ARTICLE] A Novel tDCS Sham Approach Based on Model-Driven Controlled Shunting – Full Text

Abstract

Background

Transcranial direct current stimulation (tDCS), a non-invasive brain stimulation technique able to transiently modulate brain activity, is surging as one of the most promising therapeutic solutions in many neurological and psychiatric disorders. However, profound limitations exist in current placebo (sham) protocols that limit single- and double-blinding, especially in non-naïve subjects.

Objective

/hypothesis: To ensure better blinding and strengthen reliability of tDCS studies and trials, we tested a new optimization algorithm aimed at creating an “active” sham tDCS condition (ActiSham hereafter) capable of inducing the same scalp sensations perceived during real stimulation, while preventing currents from reaching the cortex and cause changes in brain excitability.

Methods

A novel model-based multielectrode technique —optimizing the location and currents of a set of small electrodes placed on the scalp— was used to control the relative amount of current delivered transcranially in real and placebo multichannel tDCS conditions. The presence, intensity and localization of scalp sensations during tDCS was evaluated by means of a specifically designed questionnaire administered to the participants. We compared blinding ratings by directly addressing subjects’ ability to discriminate across conditions for both traditional (Bifocal-tDCS and -Sham, using sponge electrodes) and our novel multifocal approach (both real Multifocal-tDCS and ActiSham). Changes in corticospinal excitability were monitored based on Motor Evoked Potentials (MEPs) recorded via concurrent Transcranial Magnetic Stimulation (TMS) and electromyography (EMG).

Results

Subjects perceived Multifocal-tDCS and ActiSham similarly in terms of both scalp sensations and their localization on the scalp, whereas traditional Bifocal stimulation was rated as more painful and annoying compared to its Sham counterpart. Additionally, differences in scalp localization were reported for active/sham Bifocal-tDCS. As for MEPs amplitude, a main effect of stimulation was found when comparing Bifocal-Sham and ActiSham (F(1,13)= 6.67, p=.023), with higher MEPs amplitudes after the application of Bifocal-Sham.

Conclusions

Compared to traditional Bifocal-tDCS, ActiSham offers better participants’ blinding by inducing very similar scalp sensations to those of real Multifocal tDCS both in terms of intensity and localization, while not affecting corticospinal excitability.

Introduction

Non-invasive Brain Stimulation (NIBS) techniques are used to modulate brain activity in a safe and well-tolerated way [1]. In particular, Transcranial direct current stimulation (tDCS), uses low-intensity electrical currents to modulate cortical excitability in a polarity-specific manner [1]. Classical tDCS montages consist of two rectangular sponge electrodes with a contact area of ∼25-35 cm2, where electrical current between 0.5mA and 4mA flows from a positively charged electrode (anode) to a negative one (cathode)[2] passing through various tissue compartments including skin, muscle, bone, cerebrospinal fluid and brain. Due to its safety and relatively low-cost, tDCS experiments have been widely carried out to investigate human neurophysiology and to test its application as a new potential therapeutic solution for neurological and psychiatric conditions. To ensure adequate understanding of the observed effects, however, researchers need to rely on valid and approved control placebo conditions, a fundamental requirement in randomized controlled trials. Traditional standard sham protocols consist on an initial ramp up of the current, followed by a short stimulation period (usually for 5-60 seconds) and a final ramp down [[3][4][5]], (i.e., Fade In of current, brief real Stimulation, Fade-Out; commonly known as “FISSFO” protocol), an approach thought to cause sensory stimulation similar to real tDCS without affecting cortico-spinal excitability [6]. However, both these assumptions (i.e., adequate blinding and absence of effects on the brain) are still under examination. FISSFO sham has been considered effective in providing a proper blinding when compared with real tDCS at 1mA for 20 minutes [6], becoming the standard for sham tDCS [7]. The rationale stems from participants’ reports in which the cutaneous perceptions that generally cue subjects on tDCS being effectively delivered (i.e., tingling or itching sensation), have been mostly reported during the first 30-60 seconds of stimulation to then gradually decrease, possibly due to habituation [4]. However, a recent investigation has revealed that even naïve subjects (N=192) are capable of distinguishing classic sham stimulation (FISSFO) from active tDCS when delivered at 1 mA for 20 minutes over the left dorsolateral prefrontal cortex (DLPFC) [8]. Prior experiments had already suggested blinding inefficacy when real tDCS is applied at 1.5-2 mA, even for only 10 minutes [9,10]. Accordingly, non-naïve subjects seem more capable of distinguishing real from sham tDCS [11] and extreme individual variability has been reported with regard to sensibility to stimulation intensity and duration, with subjects being able to perceive tDCS even at very low intensity (i.e., 400 μA) [11].

On the other hand, additional sham protocols have been developed with modified durations of ramp up/down, or even delivering constant low intensity currents (0.016 or 0.034 mA) [7,12,13]. However, these approaches have not been properly tested on large sample of patients/subjects, with no data on the effects of such alternative sham protocols on the brain, while inconsistent results on many neurophysiological parameters have been documented when adopting such modified approaches [13].

Beyond the single or double blinding efficacy of FISSFO and related approaches [14], an element of interest is the question of whether tDCS effects are due to cortical interaction of the generated electric fields or from peripheral nervous system (PNS) stimulation. Since the ramp-up/ramp-down method for blinding decreases both cortical and peripheral stimulation, they cannot help disentangling cortical and peripheral effects. In addition, cortical effects of the brief period of real stimulation during sham protocols may not completely be excluded [15].

An additional challenge is the fact that the induced tDCS electric field is conditioned by the heterogeneity of cortical and non-cortical tissues, as well as by the complexity of cortical geometry [16]. In recent years, this has been addressed by the use of multichannel tDCS systems in combination with realistic finite element modeling of current propagation in the head derived from subject neuroimaging data (e.g. MRI, fMRI) [17,18]. The rationale for multifocal stimulation resides on both the need for more targeted stimulation of the cortex, as well as the notion that brain regions operate in networks and communicate with each other’s through modulatory interactions [[19][20][21]]. Realistic physical models provide a crucial element for better experimental understanding and control of the electric fields generated by tDCS.

In the present study, we investigate a novel approach to sham stimulation based on controlled shunting of currents via a model-based quantification of transcutaneous and transcranial effects. Specifically, the novel sham tDCS solution benefits from the use of an optimization algorithm allowing tDCS montages to be tailored in such a way that zero or very low magnitude electric fields are delivered on the brain, while medium to high intensity currents are maintained in at least some scalp electrodes, thus eliciting scalp sensations necessary for blinding. Notably, this allows to maintain the stimulation ON for the entire duration of sham tDCS, therefore inducing scalp sensations similar to real tDCS, while avoiding known limitations of the FISSFO protocol. We hypothesize that such montage (Active Sham, ActiSham hereafter) (i) will generate scalp sensations similar to a Multifocal (real) tDCS montage based on the same electrodes’ location and identical stimulation intensity/duration; and that (ii) ActiSham will not induce changes in cortico-spinal excitability (CSE), as assessed through Motor Evoked Potentials (MEPs) induced by Transcranial Magnetic Stimulation (TMS) as an index of corticospinal excitability. If successful, this and similar other approaches for improved sham stimulation could contribute to more efficient design of future tDCS research studies and clinical trials.

Methods

Study design

Fourteen subjects participated in 4 randomized tDCS stimulation visits, spaced 7±3 days to ensure no carryover effects. The tDCS conditions were: real Bifocal-tDCS, Bifocal-Sham, real Multifocal-tDCS and ActiSham. Each session lasted approximately 90 minutes during which participants seated in a comfortable chair with their eyes open. To measure changes in corticospinal excitability, single pulse TMS was applied over the left primary motor cortex (M1) at the beginning and the end of each stimulation session. Somatosensory sensations elicited by tDCS were addressed by means of ad-hoc questionnaires. See dedicated sections below for further details about tools and procedures.

Participants

Fourteen healthy right-handed naïve subjects (25.4 years ± 2.1; 5 males) were recruited at the University Campus of Siena, School of Medicine (Siena, Italy). Possible contraindications to either TMS or tDCS were assessed by means of a screening questionnaire [22]. Exclusion criteria included: history of seizures, head injury, pacemakers or other implanted medical devices, metallic objects in the head, hearing impairments, medications altering cortical excitability or other significant medical concerns. All participants gave written informed consent prior to participating to the study. The research proposal and associated methodologies were approved by the local ethical committee in accordance with the principles of the Declaration of Helsinki.

tDCS

tDCS sessions lasted 15 minutes, with electrode types, scalp montages and stimulation intensities customized for each tDCS protocol (Figure 1). Transcranial stimulation was delivered using a “Starstim 8” brain stimulator controlled via Bluetooth using a laptop computer (Neuroelectrics, Barcelona, Spain). For canonical Bifocal-tDCS (active or sham), stimulation was delivered through traditional 5×7 cm rectangular sponge electrodes, with a contact area of 35 cm2 (SPONSTIM, Neuroelectrics, Barcelona, Spain). Before current delivery, electrodes were soaked with 15 ml of sterile sodium chloride solution (0.9%). For Multichannel stimulation conditions (real and ActiSham), current was instead delivered using circular Ø 20 mm PISTIM electrodes (Neuroelectrics, Barcelona, Spain) with an Ag/AgCl core and a gel/skin contact area of 3.14 cm2. Electrodes were filled with a conductive gel before the tDCS intervention. To further improve current conductivity, the scalp was gently rubbed with an alcohol solution at the beginning of each session. Electrodes were inserted in a neoprene cap with available positions following the 10/20 EEG system.

Figure 1

Figure 1Study design. (A) Active stimulation was delivered for 15 minutes, (30 seconds of ramp up and down). Corticospinal excitability was measured via TMS three times prior to stimulation (Pre-10, Pre-5 and Pre-0) and compared with post measurements collected up to 15 minutes after stimulation (Post-0, Post-5, Post-10, Post-15). Halfway through the protocol (i.e., at minute 7), subjects were asked to rate stimulation-related annoyance and pain levels. tDCS montages for Multifocal-tDCS (B), ActiSham (C), Bifocal-tDCS and Bifocal-Sham (D) are shown.

[…]

Continue —-> A Novel tDCS Sham Approach Based on Model-Driven Controlled Shunting – ScienceDirect

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[Abstract] Effects of Bihemispheric Transcranial Direct Current Stimulation on Upper Extremity Function in Stroke Patients: A randomized Double-Blind Sham-Controlled Study

Abstract

Background and Purpose

Transcranial direct current stimulation (tDCS) is a treatment used in the rehabilitation of stroke patients aiming to improve functionality of the plegic upper extremity. Currently, tDCS is not routinely used in post stroke rehabilitation. The aim of this study was to establish the effects of bihemspheric tDCS combined with physical therapy (PT) and occupational therapy (OT) on upper extremity motor function.

Methods

Thirty-two stroke inpatients were randomised into 2 groups. All patients received 15 sessions of conventional upper extremity PT and OT over 3 weeks. The tDCS group (n = 16) also received 30 minutes of bihemispheric tDCS and the sham group (n = 16) 30 minutes of sham bihemispheric tDCS simultaneously to OT. Patients were evaluated before and after treatment using the Fugl Meyer upper extremity (FMUE), functional independence measure (FIM), and Brunnstrom stages of stroke recovery (BSSR) by a physiatrist blind to the treatment group

Results

The improvement in FIM was higher in the tDCS group compared to the sham group (P = .001). There was a significant within group improvement in FMUE, FIM and BSSR in those receiving tDCS (P = .001). There was a significant improvement in FIM in the chronic (> 6months) stroke sufferers who received tDCS when compared to those who received sham tDCS and when compared to subacute stroke (3-6 months) sufferers who received tDCS/sham.

Conclusions

Upper extremity motor function in hemiplegic stroke patients improves when bihemispheric tDCS is used alongside conventional PT and OT. The improvement in functionality is greater in chronic stroke patients.

via Effects of Bihemispheric Transcranial Direct Current Stimulation on Upper Extremity Function in Stroke Patients: A randomized Double-Blind Sham-Controlled Study – ScienceDirect

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[ARTICLE] Combining transcranial direct-current stimulation with gait training in patients with neurological disorders: a systematic review – Full Text

Abstract

Background

Transcranial direct-current stimulation (tDCS) is an easy-to-apply, cheap, and safe technique capable of affecting cortical brain activity. However, its effectiveness has not been proven for many clinical applications.

Objective

The aim of this systematic review was to determine whether the effect of different strategies for gait training in patients with neurological disorders can be enhanced by the combined application of tDCS compared to sham stimulation. Additionally, we attempted to record and analyze tDCS parameters to optimize its efficacy.

Methods

A search in Pubmed, PEDro, and Cochrane databases was performed to find randomized clinical trials that combined tDCS with gait training. A chronological filter from 2010 to 2018 was applied and only studies with variables that quantified the gait function were included.

Results

A total of 274 studies were found, of which 25 met the inclusion criteria. Of them, 17 were rejected based on exclusion criteria. Finally, 8 trials were evaluated that included 91 subjects with stroke, 57 suffering from Parkinson’s disease, and 39 with spinal cord injury. Four of the eight assessed studies did not report improved outcomes for any of its variables compared to the placebo treatment.

Conclusions

There are no conclusive results that confirm that tDCS can enhance the effect of the different strategies for gait training. Further research for specific pathologies, with larger sample sizes and adequate follow-up periods, are required to optimize the existing protocols for applying tDCS.

Introduction

Difficulty to walk is a key feature of neurological disorders [1], so much so that recovering and/or maintaining the patient’s walking ability has become one of the main aims of all neurorehabilitation programs [2]. Additionally, the loss of this ability is one of the most significant factors negatively impacting on the social and professional reintegration of neurological patients [3].

Strategies for gait rehabilitation traditionally focus on improving the residual ability to walk and compensation strategies. Over the last years, a new therapeutic paradigm has been established based on promoting neuroplasticity and motor learning, which has led to the development of different therapies employing treadmills and partial body-weight support, as well as robotic-assisted gait training [4]. Nevertheless, these new paradigms have not demonstrated superior results when compared to traditional therapies [5,6,7], and therefore recent studies advise combining therapies to enhance their therapeutic effect via greater activation of neuroplastic mechanisms [8].

Transcranial direct-current stimulation (tDCS) is an intervention for brain neuromodulation consisting of applying constant weak electric currents on the patient’s scalp in order to stimulate specific brain areas. The application of the anode (positive electrode) to the primary motor cortex causes an increase in neuron excitability whereas stimulation with the cathode (negative electrode) causes it to decrease [9].

The effectiveness of tDCS has been proven for treating certain pathologies such as depression, addictions, fibromyalgia, or chronic pain [10]. Also, tDCS has shown to improve precision and motor learning [11] in healthy volunteers. Improvements in the functionality of upper limbs and fine motor skills of the hand with paresis have been observed in patients with stroke using tDCS, although the results were somewhat controversial [1213]. Similarly, a Cochrane review on the effectiveness of tDCS in treating Parkinson’s disease highlights the great potential of the technique to improve motor skills, but the significance level of the evidence was not enough to clearly recommend it [14]. In terms of gait rehabilitation, current studies are scarce and controversial [10].

Furthermore, tDCS is useful not only as a therapy by itself but also in combination with other rehabilitation strategies to increase their therapeutic potential; in these cases, the subjects’ basal activity and the need for combining the stimulation with the behavior to be enhanced have been highlighted. Several studies have combined tDCS with different modalities of therapeutic exercising, such as aerobic exercise to increase the hypoalgesic effect in patients with fibromyalgia [15] or muscle strengthening to increase functionality in patients suffering from knee osteoarthritis [16]. Along these lines, various studies have combined tDCS with gait training in patients with neurological disorders, obtaining rather disparate outcomes [17,18,19,20]. As a result, the main aim of this systematic review was to determine whether the application of tDCS can enhance the effectiveness of other treatment strategies for gait training. Additionally, as a secondary objective, we attempted to record and identify the optimal parameters of the applied current since they are key factors for its effectiveness. […]

 

Continue —>  Combining transcranial direct-current stimulation with gait training in patients with neurological disorders: a systematic review | Journal of NeuroEngineering and Rehabilitation | Full Text

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[Abstract + References] Motor stroke recovery after tDCS: a systematic review

Abstract

The purpose of the present study was to investigate the effects of transcranial direct current stimulation (tDCS) on motor recovery in adult patients with stroke, taking into account the parameters that could influence the motor recovery responses. The second aim was to identify the best tDCS parameters and recommendations available based on the enhanced motor recovery demonstrated by the analyzed studies. Our systematic review was performed by searching full-text articles published before February 18, 2019 in the PubMed database. Different methods of applying tDCS in association with several complementary therapies were identified. Studies investigating the motor recovery effects of tDCS in adult patients with stroke were considered. Studies investigating different neurologic conditions and psychiatric disorders or those not meeting our methodologic criteria were excluded. The main parameters and outcomes of tDCS treatments are reported. There is not a robust concordance among the study outcomes with regard to the enhancement of motor recovery associated with the clinical application of tDCS. This is mainly due to the heterogeneity of clinical data, tDCS approaches, combined interventions, and outcome measurements. tDCS could be an effective approach to promote adaptive plasticity in the stroke population with significant positive premotor and postmotor rehabilitation effects. Future studies with larger sample sizes and high-quality studies with a better standardization of stimulation protocols are needed to improve the study quality, further corroborate our results, and identify the optimal tDCS protocols.

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[WEB SIDE] RPW Technology Announces The Launch Of Liftid Neurostimulation

OSSINING, N.Y.Aug. 16, 2019 /PRNewswire/ — RPW Technology, LLC introduces Liftid Neurostimulation (www.GetLiftid.com), a transcranial direct current stimulation (tDCS) recreational device for consumers that can improve attention, productivity, and memory through mild electrical stimulation. Liftid uses a constant, low-level electric current, passed through two electrodes placed on the forehead area, to stimulate the brain. tDCS is one of the hottest categories in neuroscience today and supported by over 4,000 published studies.

Maximize attention and elevate performance with LIFTiD Neurostimulation.

 

Dr. Ted Schwartz, MD, a New York based neurosurgeon and RPW’s lead scientist, explains, “As has been shown in several studies, tDCS delivers a small amount of electrical current to the cerebral cortex, rendering neurons in the brain more likely to fire. As a result, the user demonstrates increased abilities, alertness and focus.”

In today’s world, most working professionals, college and grad students, video gamers, musicians, and athletes are chemically stimulating their brains through caffeine, sugar, snacks, and performance enhancers. Liftid Neurostimulation uses a safe and effective technology as an alternative to these forms of chemical stimulation.

RPW Technology is proud to be on the forefront of this emerging technology by bringing to market a tDCS device for healthy individuals (ages 18 & up) that is stylish, extremely lightweight (70 grams) including a soft, comfortable, adjustable headband, and easy to operate. Designed and developed by a team of world renowned neuroscientists, Liftid is preset for a 20 minute stimulation session and has many unique features built-in to the device. Using Liftid Neurostimulation for 20 minutes a day trains the brain to maximize attention, focus, alertness, and memory, thus putting the Liftid user in the right mindset to accomplish tasks and elevate performance.

For more information, purchase, and/or instructional video, please visit the Liftid Neurostimulation website at: www.GetLiftid.com. Unit price is $149.00, which includes an attractive and functional storage case with custom accessories and free shipping within the United States. Liftid is packaged for retail sales.

RPW Technology is a New York startup dedicated to the development and marketing of transcranial electrical stimulation devices. The company, in association with Dr. Schwartz and several neuroscientists, set out to develop a high quality, hi-tech, recreational tDCS device to introduce to consumers worldwide.

Contact for RPW Technology, LLC:
Bridget Argana
Orca Communications Unlimited, LLC
bridget.argana@orcapr.com
(480) 231-3582

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SOURCE RPW Technology, LLC

via RPW Technology Announces The Launch Of Liftid Neurostimulation | BioSpace

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[Abstract] Comparison between Transcranial Direct Current Stimulation and Acupuncture on Upper Extremity Rehabilitation in Stroke: A Single-Blind Randomized Controlled Trial

Abstract

Objective: To compare the effects of transcranial direct current stimulation (TDCS) with traditional Chinese acupuncture on upper-extremity (UE) function among patients with stroke.

Materials and Methods: Participants with subacute to chronic stroke who had moderate to severe UE functional impairment were randomly allocated to the TDCS or electro-acupuncture group, then underwent three weeks of physical therapy and occupational therapy, with 20 minutes of a-TDCS (2 mA) or electro-acupuncture applied during training once weekly. Primary outcome was determined using the Fugl-Meyer Assessment of motor recovery at 1-month follow-up.

Results: The 18 participants were allocated into two groups. Fugl-Meyer Assessment increased in both the TDCS and electroacupuncture groups (5.00±3.08, p=0.001 and 7.4±4.9, p=0.002, respectively). However, no difference was found between groups, and no significant difference was observed in grip strength and task specific performance in both groups.

Conclusion: The application of TDCS might provide benefits in recovering hand motor function among patients with subacute to chronic stroke but does not go beyond those of electro-acupuncture.

via Comparison between Transcranial Direct Current Stimulation and Acupuncture on Upper Extremity Rehabilitation in Stroke: A Single-Blind Randomized Controlled Trial | Hathaiareerug | JOURNAL OF THE MEDICAL ASSOCIATION OF THAILAND

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[WEB PAGE] The Use of Noninvasive Brain Stimulation, Specifically Transcranial Direct Current Stimulation After Stroke

Motor impairment is a leading cause of disability after stroke. Approaches such as noninvasive brain stimulation are being investigated to attempt to increase effectiveness of stroke rehabilitation interventions. There are several types of noninvasive brain stimulation: repetitive transcranial magnetic stimulation, transcranial direct stimulation (tDCS), transcranial alternative current stimulation, and transcranial pulsed ultrasound to name a few. Of the types of noninvasive brain stimulation, repetitive transcranial magnetic stimulation and tDCS have been most extensively tested to modulate brain activity and potentially behavior. These two techniques have distinctive modes of action. Repetitive transcranial magnetic stimulation directly stimulates neurons in the brain and, given the appropriate conditions, leads to new action potentials. On the other hand, tDCS polarizes neuronal tissue including neurons and glia modulating ongoing firing patterns. There are also differences in cost, utility, and knowledge skill required to apply tDCS and repetitive transcranial magnetic stimulation. Transcranial direct stimulation is relatively inexpensive, easy to administer, portable, and may be applied while undergoing therapy, with lasting excitability changes detectable up to 90 minutes after administration. Repetitive transcranial magnetic stimulation equipment is bulkier, expensive, technically more challenging, and a patient’s head must remain still when treatment is being applied therefore needs to be administered before or after a session of rehabilitation. Because of these differences, tDCS has been more accessible and has rapidly grew as a potential tool to be used in neurorehabilitation to facilitate retraining of activities of daily living (ADL) capacity and possibly to improve restoration of neurological function after stroke.

There are three current stimulation approaches using tDCS to modulate corticomotor regions after stroke. In anodal stimulation mode, the anode electrode is placed over the lesioned brain area and a reference electrode is applied over the contralateral orbitofrontal cortex. Anodal tDCS is placed over the ipsilesional hemisphere to improve the responses of perilesional areas to training protocols. In cathodal stimulation, the cathode electrode is placed over the nonlesioned brain area and reference electrode over the contralateral (ipsilesional) orbitofrontal cortex. This approach has been predicated on the hypothesis that the nonstroke hemisphere will be inhibited by tDCS resulting in an increased activation of the ipsilesional hemisphere due to rebalancing of a presumably abnormal interhemispheric interaction. Although some studies have shown this approach to be beneficial, the causative role of interhemispheric interaction imbalance has been recently challenged and refuted.1 Thus, if cathodal stimulation approaches are beneficial, the behavioral effect cannot be explained by a presumed correction of abnormal interhemispheric connectivity. Finally, dual tDCS approach involves simultaneous application of the anode over the ipsilesional and the cathode over the contralesional side. Here again, the intended mechanism of action is to rebalance the presumably abnormal interhemispheric interaction.

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CLINICAL QUESTIONS ADDRESSED

What is the best tDCS type and electrical configuration? What are the effects of tDCS with rehabilitation program for upper limb recovery after stroke?

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RESEARCH FINDINGS OF tDCS

This short article discusses data obtained from a network meta-analysis of randomized controlled trials and a recent meta-analysis. The network meta-analysis included 12 randomized controlled trials including 284 participants examining the effect of tDCS on ADL function in the acute, subacute, and chronic phases after stroke.2 The meta-analysis included 9 studies with 371 participants in any stage after stroke.3

The network meta-analysis found evidence of a significant moderate effect in favor of cathodal tDCS without significant effects of dual tDCS, anodal tDCS, or sham tDCS. There was no difference in safety (as assessed by dropouts and adverse events) between sham tDCS, physical rehabilitation, cathodal tDCS, dual tDCS, and anodal tDCS. Elsner in a previous review of tDCS in 2016 found an effect on improving ADL, as well as function of the arm and lower limb, muscle strength, and cognition. Thus, the findings from the most recent meta-analysis indicating cathodal that tDCS improves ADL capacity are in line with previous meta-analyses. Of note, there was no evidence of an effect of either cathodal or other tDCS stimulation approaches on upper paretic limb impairment after stroke as measured by the Fugl-Meyer scale.

A meta-analysis that included participants in any stage after the stroke showed that tDCS in conjunction with multiple sessions of rehabilitation had no significant effect over delivering therapy alone for upper limb impairment and activity after stroke. This negative finding might be due to patient’s being in an acute, subacute, or chronic stage after stroke as well as variations in the type of therapy performed paired with tDCS (ie, conventional vs. constraint-induced movement therapy vs. robot protocol).

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RECOMMENDATIONS FOR PHYSIATRIC PRACTICE

There seems to be a modest effect supporting the use of tDCS as a co-adjuvant of rehabilitation interventions to improve ADLs after stroke. Cathodal tDCS seems to be the most promising approach, especially when applied early after the stroke. However, the evidence remains preliminary and does not warrant a widespread change in clinical rehabilitation practice at this time.

There is no evidence supporting the use of tDCS to improve motor impairment (as measured by the FMS) at this point.

Importantly, tDCS remains as a very safe intervention, with no differences in safety when real vs. control tDCS is applied.

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REFERENCES

1. Xu J, Branscheidt M, Schambra H, et al: Rethinking interhemispheric imbalance as a target for stroke neurorehabilitation. Ann Neurol 2019;85:502–13

2. Elsner B, Kwakkel G, Kugler J, et al: Transcranial direct current stimulation (tDCS) for improving capacity in activities and arm function after stroke: a network meta-analysis of randomised controlled trials. J Neuroeng Rehabil 2017;14:

3. Tedesco Triccas L, Burridge J, Hughes A, et al: Multiple sessions of transcranial direct current stimulation and upper extremity rehabilitation in stroke: a review and meta-analysis. Clin Neurophysiol2016;127:946–55

via The Use of Noninvasive Brain Stimulation, Specifically Trans… : American Journal of Physical Medicine & Rehabilitation

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[ARTICLE] Searching for the optimal tDCS target for motor rehabilitation – Full Text

Abstract

Background

Transcranial direct current stimulation (tDCS) has been investigated over the years due to its short and also long-term effects on cortical excitability and neuroplasticity. Although its mechanisms to improve motor function are not fully understood, this technique has been suggested as an alternative therapeutic method for motor rehabilitation, especially those with motor function deficits. When applied to the primary motor cortex, tDCS has shown to improve motor function in healthy individuals, as well as in patients with neurological disorders. Based on its potential effects on motor recovery, identifying optimal targets for tDCS stimulation is essential to improve knowledge regarding neuromodulation as well as to advance the use of tDCS in clinical motor rehabilitation.

Methods and results

Therefore, this review discusses the existing evidence on the application of four different tDCS montages to promote and enhance motor rehabilitation: (1) anodal ipsilesional and cathodal contralesional primary motor cortex tDCS, (2) combination of central tDCS and peripheral electrical stimulation, (3) prefrontal tDCS montage and (4) cerebellar tDCS stimulation. Although there is a significant amount of data testing primary motor cortex tDCS for motor recovery, other targets and strategies have not been sufficiently tested. This review then presents the potential mechanisms and available evidence of these other tDCS strategies to promote motor recovery.

Conclusions

In spite of the large amount of data showing that tDCS is a promising adjuvant tool for motor rehabilitation, the diversity of parameters, associated with different characteristics of the clinical populations, has generated studies with heterogeneous methodologies and controversial results. The ideal montage for motor rehabilitation should be based on a patient-tailored approach that takes into account aspects related to the safety of the technique and the quality of the available evidence.

Introduction

Transcranial Direct Current Stimulation (tDCS) is a non-invasive brain stimulation technique which delivers a constant electric current over the scalp to modulate cortical excitability [1,2,3]. Different montages of tDCS may induce diverse effects on brain networks, which are directly dependent on the electrodes positioning and polarity. While anodal tDCS is believed to enhance cortical excitability, cathodal tDCS diminishes the excitation of stimulated areas, and these electrodes montages define the polarity-specific effects of the stimulation [4,5,6]. Due to the effects of tDCS on modulating cortical excitability, especially when applied to the primary motor cortex [2], this method of brain stimulation has been intensively investigated for motor function improvement both in healthy subjects [78] and in various neurological pathologies [910]. Neurological conditions that may obtain benefits from the use of tDCS include Stroke [11,12,13,14], Parkinson’s disease [15], Multiple Sclerosis [1617], among others.

The mechanisms of action underlying the modulation of neuronal activity induced by tDCS are still not completely understood. However, studies have demonstrated that the electric current generated by tDCS interferes in the resting membrane potential of neuronal cells, which modulates spontaneous brain circuits activity [1,2,3]. Some studies have suggested that tDCS could have an effect on neuronal synapsis’ strength, altering the activity of NMDA and GABA receptors, thus triggering plasticity process, such as long-term potentiation (LTP) and long-term depression (LTD) [1819]. The long-term effects of tDCS are also thought to be associated to changes in protein synthesis and gene expression [2021]. Additionally, neuroimaging study showed blood flow changes following stimulation, which may be related to a direct effect of tDCS over blood flow, with an increase in oxygen supply on cortical areas and subsequent enhancement of neuronal excitability [22]. Given these mechanisms, tDCS seems to be a potential valuable tool to stimulate brain activity and plasticity following a brain damage.

The advantages of using tDCS include its low cost, ease of application, and safety. To date, there is no evidence of severe adverse events following tDCS in healthy individuals, as well as in patients with neurological conditions, such as stroke [2324]. Among the potential side effects presented after this type of stimulation, the most common ones consist of burn sensation, itching, transient skin irritation, tingling under the electrode, headache, and low intensity discomfort [25]. As serious and irreversible side effects have not been reported, tDCS is considered a relatively safe and tolerable strategy of non-invasive brain stimulation.

The modifications of physiological and clinical responses induced by tDCS are extremely variable, as this type of stimulation can induce both adaptive or maladaptive plastic changes, and a wide spectrum of tDCS parameters influence the effects of this technique. Electrodes combination, montage and shape can easily interfere in the enhancement or inhibition of cortical excitability [626]. Other parameters that may influence these outcomes include current intensity, current flow direction, skin preparation, and stimulation intervals [32728] . In addition, in clinical populations, the heterogeneity of the brain lesions can also influence the inconsistency in tDCS effects [29]. Despite the goal of tDCS of modulating cortical areas by using different parameters, some studies have showed that, by altering cortical excitability, the electrical field could reach subcortical structures, such as basal ganglia, due to brain connections between cortical and subcortical areas [30,31,32,33]. This potential effect on deeper brain structure has supported the broad investigation of tDCS in various disorders, even if the cortical region under stimulating electrode is not directly linked to the neurological condition being investigated. Indeed, the current variable and moderate effect sizes from clinical tDCS studies in stroke encourage researchers to test alternative targets to promote motor recovery in this condition.

In this review, we discuss evidence on the application of four different tDCS montages to promote and enhance motor rehabilitation: [1] anodal tDCS ipsilateral and cathodal tDCS bilateral, [2] combination of central and peripheral stimulation, [3] prefrontal montage and [4] cerebellar stimulation.[…]

 

Continue —> Searching for the optimal tDCS target for motor rehabilitation | Journal of NeuroEngineering and Rehabilitation | Full Text

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Fig. 1 Motor cortex stimulation in a scenario where the left hemisphere was lesioned. Figure a Anodal stimulation of left primary motor cortex: anode over the left M1 and cathode over the right supraorbital region. Figure b Cathodal stimulation of right primary motor cortex: cathode over the right M1 and anode over the left supraorbital region. Figure c Bilateral stimulation: anode over the affected hemisphere (left) and cathode over the non-affected hemisphere (right)

 

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