Transcranial direct current stimulation for upper extremity spasticity rehabilitation in stroke survivors: A systematic review of randomized controlled trials

Stretching exercises in managing spasticity: effectiveness, risks, and adjunct therapies

Spasticity is a component of upper motor neuron disorders and can be seen in neurological conditions like stroke and multiple sclerosis. Although the incidence rate of spasticity is unknown, it can put pressure on the health condition of those with spasticity, and there is no absolute effective way to control it. In the past, stretching exercises were an accessible tool for physical therapists to manage and control spasticity, but opinions on the optimal dose, aftereffects, and mechanism of effects were controversial. Therefore, this article tries to provide an overview of the effectiveness and risks of stretching exercises. Furthermore, there are several adjunct therapies, such as brain stimulation and botulinum injection, that can increase the effectiveness of a simple stretch by increasing cortical excitability and reducing muscle tone and their role is evaluated in this regard. The results of this study propose that several prospective and case studies have demonstrated the benefits of stretching to control spasticity, but it seems that other methods such as casting can be more effective than a simple stretch. Therefore, it is better to use stretching in combination with other therapeutic regimes to increase its effectivity of it.

Combined robot-assisted therapy virtual reality for upper limb rehabilitation in stroke survivors: a systematic review of randomized controlled trials

BACKGROUND

Upper limb impairments are among the most common consequences following a stroke. Recently, robot-assisted therapy (RT) and virtual reality (VR) have been used to improve upper limb function in stroke survivors.

OBJECTIVES

This review aims to investigate the effects of combined RT and VR on upper limb function in stroke survivors and to provide recommendations for researchers and clinicians in the medical field.

METHODS

We searched PubMed, SCOPUS, REHABDATA, PEDro, EMBASE, and Web of Science from inception to March 28, 2024. Randomized controlled trials (RCTs) involving stroke survivors that compared combined RT and VR interventions with either passive (i.e., sham, rest) or active (i.e., traditional therapy, VR, RT) interventions and assessed outcomes related to upper limb function (e.g., strength, muscle tone, or overall function) were included. The Cochrane Collaboration tool was used to evaluate the methodological quality of the included studies.

RESULTS

Six studies were included in this review. In total, 201 patients with stroke (mean age 57.84 years) were involved in this review. Four studies were considered 'high quality', while two were considered as 'moderate quality' on the Cochrane Collaboration tool. The findings showed inconsistent results for the effects of combined RT and VR interventions on upper limb function poststroke.

CONCLUSION

In conclusion, there are potential effects of combined RT and VR interventions on improving upper limb function, but further research is needed to confirm these findings, understand the underlying mechanisms, and assess the consistency and generalizability of the results.

Combined noninvasive brain stimulation virtual reality for upper limb rehabilitation poststroke: A systematic review of randomized controlled trials

Upper limb impairments are common consequences of stroke. Noninvasive brain stimulation (NIBS) and virtual reality (VR) play crucial roles in improving upper limb function poststroke. This review aims to evaluate the effects of combined NIBS and VR interventions on upper limb function post-stroke and to provide recommendations for future studies in the rehabilitation field. PubMed, MEDLINE, PEDro, SCOPUS, REHABDATA, EMBASE, and Web of Science were searched from inception to November 2023. Randomized controlled trials (RCTs) encompassed patients with a confirmed stroke diagnosis, administrated combined NIBS and VR compared with passive (i.e., rest) or active (conventional therapy), and included at least one outcome assessing upper limb function (i.e., strength, spasticity, function) were selected. The quality of the included studies was assessed using the Cochrane Collaboration tool. Seven studies met the eligibility criteria. In total, 303 stroke survivors (Mean age: 61.74 years) were included in this review. According to the Cochrane Collaboration tool, five studies were classified as "high quality," while two were categorized as "moderate quality". There are mixed findings for the effects of combined NIBS and VR on upper limb function in stroke survivors. The evidence for the effects of combined transcranial direct current stimulation and VR on upper limb function post-stroke is promising. However, the evidence regarding the effects of combined repetitive transcranial magnetic stimulation and VR on upper limb function is limited. Further randomized controlled trials with long-term follow-up are strongly warranted.

Noninvasive brain stimulation for spasticity rehabilitation in multiple sclerosis: A systematic review of randomized controlled trials

OBJECTIVE

To investigate the effects of noninvasive brain stimulation (NIBS) on spasticity in people with multiple sclerosis (PwMS).

LITERATURE SURVEY

We searched PubMed, SCOPUS, MEDLINE, REHABDATA, PEDro, CINAHL, AMED, and Web of Science until December 2022.

METHODOLOGY

Studies were selected if they included PwMS, used transcranial direct current stimulation (tDCS) or repetitive transcranial magnetic stimulation (rTMS) as a main intervention, and were randomized controlled trials (RCTs) including at least one outcome measure evaluating spasticity. Two researchers individually screened the selected studies. The study's quality was assessed using the Cochrane Collaborations tool. The researchers decided that the meta-analysis was not possible because the treatment interventions varied among the selected studies.

SYNTHESIS

In total, 147 studies were reviewed. Of them, nine studies met the eligibility criteria and included 193 PwMS (mean age = 43.2 years), 54.4% of whom were female. Eight studies were considered "high" quality and one was considered "moderate" quality. Seven studies that used rTMS demonstrated a significant decrease in spasticity in PwMS after the intervention. The remaining studies that provided tDCS did not show meaningful effects.

CONCLUSIONS

The evidence for the influences of rTMS on spasticity in PwMS is promising. The evidence for the impact of tDCS on spasticity in PwMS was limited. Further RCTs with long-term follow-ups are encouraged.

Novel approaches to motoneuron disease/ALS treatment using non-invasive brain and spinal stimulation: IFCN handbook chapter

Non-invasive brain stimulation techniques have been exploited in motor neuron disease (MND) with multifold objectives: to support the diagnosis, to get insights in the pathophysiology of these disorders and, more recently, to slow down disease progression. In this review, we consider how neuromodulation can now be employed to treat MND, with specific attention to amyotrophic lateral sclerosis (ALS), the most common form with upper motoneuron (UMN) involvement, taking into account electrophysiological abnormalities revealed by human and animal studies that can be targeted by neuromodulation techniques. This review article encompasses repetitive transcranial magnetic stimulation methods (including low-frequency, high-frequency, and pattern stimulation paradigms), transcranial direct current stimulation as well as experimental findings with the newer approach of trans-spinal direct current stimulation. We also survey and discuss the trials that have been performed, and future perspectives.

Effects of robotic therapy associated with noninvasive brain stimulation on motor function in individuals with incomplete spinal cord injury: A systematic review of randomized controlled trials

CONTEXT

Motor deficits are among the most common consequences of incomplete spinal cord injury (SCI). These impairments can affect patients' levels of functioning and quality of life. Combined robotic therapy and non-invasive brain stimulation (NIBS) have been used to improve motor impairments in patients with corticospinal tract lesions.

OBJECTIVES

To examine the effects of combined robotic therapy and NIBS on motor function post incomplete SCI.

METHODS

PubMed, SCOPUS, MEDLINE, PEDro, Web of Science, REHABDATA, CINAHL, and EMBASE were searched from inception until July 2023. The Physiotherapy Evidence Database (PEDro) scale was employed to evaluate the selected studies quality.

RESULTS

Of 557 studies, five randomized trials (n = 122), with 25% of participants being females, were included in this review. The PEDro scores ranged from eight to nine, with a median score of nine. There were variations in treatment protocols and outcome measures, resulting in heterogeneous findings. The findings showed revealed evidence for the impacts of combined robotic therapy and NIBS on motor function in individuals with incomplete SCI.

CONCLUSIONS

Combined robotic training and NIBS may be safe for individuals with incomplete SCI. The existing evidence concerning its effects on motor outcomes in individuals with SCI is limited. Further experimental studies are needed to understand the effects of combined robotic training and NIBS on motor impairments in SCI populations.

Neuro-orthopaedic assessment and management in patients with prolonged disorders of consciousness: A review

BACKGROUND

Following a severe acquired brain injury, neuro-orthopaedic disorders are commonplace. While these disorders can impact patients' functional recovery and quality of life, little is known regarding the assessment, management and treatment of neuro-orthopaedic disorders in patients with disorders of consciousness (DoC).

OBJECTIVE

To describe neuro-orthopaedic disorders in the context of DoC and provide insights on their management and treatment.

METHODS

A review of the literature was conducted focusing on neuro-orthopaedic disorders in patients with prolonged DoC.

RESULTS

Few studies have investigated the prevalence of spastic paresis in patients with prolonged DoC, which is extremely high, as well as its correlation with pain. Pilot studies exploring the effects of pharmacological treatments and physical therapy show encouraging results yet have limited efficacy. Other neuro-orthopaedic disorders, such as heterotopic ossification, are still poorly investigated.

CONCLUSION

The literature of neuro-orthopaedic disorders in patients with prolonged DoC remains scarce, mainly focusing on spastic paresis. We recommend treating neuro-orthopaedic disorders in their early phases to prevent complications such as pain and improve patients' recovery. Additionally, this approach could enhance patients' ability to behaviourally demonstrate signs of consciousness, especially in the context of covert awareness.

Chronic Functional Adaptations Induced by the Application of Transcranial Direct Current Stimulation Combined with Exercise Programs: A Systematic Review of Randomized Controlled Trials

The present systematic review aimed to determine the chronic effects of the combination of transcranial direct current stimulation (tDCS) and exercise on motor function and performance outcomes. We performed a systematic literature review in the databases MEDLINE and Web of Science. Only randomized control trials that measured the chronic effect of combining exercise (comprising gross motor tasks) with tDCS during at least five sessions and measured any type of motor function or performance outcome were included. A total of 22 interventions met the inclusion criteria. Only outcomes related to motor function or performance were collected. Studies were divided into three groups: (a) healthy population (n = 4), (b) neurological disorder population (n = 14), and (c) musculoskeletal disorder population (n = 4). The studies exhibited considerable variability in terms of tDCS protocols, exercise programs, and outcome measures. Chronic use of tDCS in combination with strength training does not enhance motor function in healthy adults. In neurological disorders, the results suggest no additive effect if the exercise program includes the movements pretending to be improved (i.e., tested). However, although evidence is scarce, tDCS may enhance exercise-induced adaptations in musculoskeletal conditions characterized by pain as a limiting factor of motor function.

Combined treatment of nerve growth factor and transcranical direct current stimulations to improve outcome in children with vegetative state after out-of-hospital cardiac arrest

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is one of the most dramatic events in pediatric age and, despite advanced neurointensive care, the survival rate remains low. Currently, no effective treatments can restore neuronal loss or produce significant improvement in these patients. Nerve Growth Factor (NGF) is a neurotrophin potentially able to counteract many of the deleterious effects triggered by OHCA. Transcranial Direct Current Stimulation (tDCS) has been reported to be neuroprotective in many neurological diseases, such as motor deficit and cognitive impairment. Children with the diagnosis of chronic vegetative state after OHCA were enrolled. These patients underwent a combined treatment of intranasal administration of human recombinant NGF (hr-NGF), at a total dose of 50 gamma/kg, and tDCS, in which current intensity was increased from zero to 2 mA from the first 5 s of stimulation and maintained constant for 20 min. The treatment schedule was performed twice, at one month distance each. Neuroradiogical evaluation with Positron Emission Tomography scan (PET), Single Photon Emission Computed Tomography (SPECT), Electroencephalography (EEG) and Power Spectral Density of the brain (PSD) was determined before the treatment and one month after the end. Neurological assessment was deepened by using modified Ashworth Scale, Gross Motor Function Measure, and Disability Rating Scale.

RESULTS

Three children with a chronic vegetative state secondary to OHCA were treated. The combined treatment with hr-NGF and tDCS improved functional (PET and SPECT) and electrophysiological (EEG and PSD) assessment. Also clinical conditions improved, mainly for the reduction of spasticity and with the acquisition of voluntary finger movements, improved facial mimicry and reaction to painful stimuli. No side effects were reported.

CONCLUSIONS

These promising preliminary results and the ease of administration of this treatment make it worthwhile to be investigated further, mainly in the early stages from OHCA and in patients with better baseline neurological conditions, in order to explore more thoroughly the benefits of this new approach on neuronal function recovery after OHCA.

Transcranial-Direct-Current-Stimulation Accelerates Motor Recovery After Cortical Infarction in Mice: The Interplay of Structural Cellular Responses and Functional Recovery

BACKGROUND

Transcranial direct current stimulation (tDCS) promotes recovery after stroke in humans. The underlying mechanisms, however, remain to be elucidated. Animal models suggest tDCS effects on neuroinflammation, stem cell proliferation, neurogenesis, and neural plasticity.

OBJECTIVE

In a longitudinal study, we employed tDCS in the subacute and chronic phase after experimental focal cerebral ischemia in mice to explore the relationship between functional recovery and cellular processes.

METHODS

Mice received photothrombosis in the right motor cortex, verified by Magnetic Resonance Imaging. A composite neuroscore quantified subsequent functional deficits. Mice received tDCS daily: either 5 sessions from day 5 to 9, or 10 sessions with days 12 to 16 in addition. TDCS with anodal or cathodal polarity was compared to sham stimulation. Further imaging to assess proliferation and neuroinflammation was performed by immunohistochemistry at different time points and Positron Emission Tomography at the end of the observation time of 3 weeks.

RESULTS

Cathodal tDCS at 198 kC/m² (220 A/m²) between days 5 and 9 accelerated functional recovery, increased neurogenesis, decreased microglial activation, and mitigated CD16/32-expression associated with M1-phenotype. Anodal tDCS exerted similar effects on neurogenesis and microglial polarization but not on recovery of function or microglial activation. TDCS on days 12 to 16 after stroke did not induce any further effects, suggesting that the therapeutic time window was closed by then.

CONCLUSION

Overall, data suggest that non-invasive neuromodulation by tDCS impacts neurogenesis and microglial activation as critical cellular processes influencing functional recovery during the early phase of regeneration from focal cerebral ischemia.