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Zhang JJ, Sui Y, Sack AT, Bai Z, Kwong PWH, Sanchez Vidana DI, Xiong L, Fong KNK. Theta burst stimulation for enhancing upper extremity motor functions after stroke: a systematic review of clinical and mechanistic evidence. Rev Neurosci 2024; 0:revneuro-2024-0030. [PMID: 38671584 DOI: 10.1515/revneuro-2024-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024]
Abstract
This systematic review aimed to evaluate the effects of different theta burst stimulation (TBS) protocols on improving upper extremity motor functions in patients with stroke, their associated modulators of efficacy, and the underlying neural mechanisms. We conducted a meta-analytic review of 29 controlled trials published from January 1, 2000, to August 29, 2023, which investigated the effects of TBS on upper extremity motor, neurophysiological, and neuroimaging outcomes in poststroke patients. TBS significantly improved upper extremity motor impairment (Hedge's g = 0.646, p = 0.003) and functional activity (Hedge's g = 0.500, p < 0.001) compared to controls. Meta-regression revealed a significant relationship between the percentage of patients with subcortical stroke and the effect sizes of motor impairment (p = 0.015) and functional activity (p = 0.018). Subgroup analysis revealed a significant difference in the improvement of upper extremity motor impairment between studies using 600-pulse and 1200-pulse TBS (p = 0.002). Neurophysiological studies have consistently found that intermittent TBS increases ipsilesional corticomotor excitability. However, evidence to support the regional effects of continuous TBS, as well as the remote and network effects of TBS, is still mixed and relatively insufficient. In conclusion, TBS is effective in enhancing poststroke upper extremity motor function. Patients with preserved cortices may respond better to TBS. Novel TBS protocols with a higher dose may lead to superior efficacy compared with the conventional 600-pulse protocol. The mechanisms of poststroke recovery facilitated by TBS can be primarily attributed to the modulation of corticomotor excitability and is possibly caused by the recruitment of corticomotor networks connected to the ipsilesional motor cortex.
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Affiliation(s)
- Jack Jiaqi Zhang
- Department of Rehabilitation Sciences, 26680 The Hong Kong Polytechnic University , Hong Kong SAR, China
| | - Youxin Sui
- Department of Rehabilitation Sciences, 26680 The Hong Kong Polytechnic University , Hong Kong SAR, China
| | - Alexander T Sack
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Zhongfei Bai
- Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Centre), School of Medicine, Tongji University, Shanghai, China
| | - Patrick W H Kwong
- Department of Rehabilitation Sciences, 26680 The Hong Kong Polytechnic University , Hong Kong SAR, China
| | | | - Li Xiong
- Clinical Trials Centre, 26469 The Eighth Affiliated Hospital of Sun Yat-Sen University , Shenzhen, China
| | - Kenneth N K Fong
- Department of Rehabilitation Sciences, 26680 The Hong Kong Polytechnic University , Hong Kong SAR, China
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Zhang Y, Chu M, Zheng Y, Zhang F, Yu H, Ye X, Xie H, Chen J, Qian Z, Zeng C, Chen W, Pei Z, Zhang Y, Chen J. Effects of Combined Use of Intermittent Theta Burst Stimulation and Cognitive Training on Poststroke Cognitive Impairment: A Single-Blind Randomized Controlled Trial. Am J Phys Med Rehabil 2024; 103:318-324. [PMID: 37792502 DOI: 10.1097/phm.0000000000002344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
OBJECTIVE Poststroke cognitive impairment substantially affects patients' quality of life. This study explored the therapeutic efficacy of intermittent theta burst stimulation combined with cognitive training for poststroke cognitive impairment. DESIGN The experimental group received intermittent theta burst stimulation and cognitive training, whereas the control group only received cognitive training, both for 6 wks. The outcome measures were the Loewenstein Occupational Therapy Cognitive Assessment, modified Barthel Index, transcranial Doppler ultrasonography, and functional near-infrared spectroscopy. RESULTS After therapy, between-group comparisons revealed a substantial difference in the Loewenstein Occupational Therapy Cognitive Assessment scores ( P = 0.024). Improvements in visuomotor organization and thinking operations were more noticeable in the experimental group than in the other groups ( P = 0.017 and P = 0.044, respectively). After treatment, the resistance index of the experimental group differed from that of the control group; channels 29, 37, and 41 were activated ( P < 0.05). The active locations were the left dorsolateral prefrontal cortex, prefrontal polar cortex, and left Broca's region. CONCLUSIONS Intermittent theta burst stimulation combined with cognitive training had a superior effect on improving cognitive function and everyday activities compared with cognitive training alone, notably in visuomotor organization and thinking operations. Intermittent theta burst stimulation may enhance cognitive performance by improving network connectivity.
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Affiliation(s)
- Youmei Zhang
- From the Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China (Youmei Z, Hangkai X, Jing C, Chao Z, Jianer C); The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China (Youmei Z, Yanjun Z, Hangkai X, Jing C, Chao Z, Jianer C); Zhejiang Rehabilitation Medical Center, Hangzhou, Zhejiang, China (Feilan Z, Hong Y, Xiancong Y, Jing C, Zhiyong Q, Chao Z, Jianer C); Beihang University, Hangzhou Innovation Institute, Hangzhou, Zhejiang, China (Weihai C, Zhongcai P, Yue Z); and The Seconditions Hospital of Anhui Medical University, Hefei, An hui, China (Minmin C)
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Bian L, Zhang L, Huang G, Song D, Zheng K, Xu X, Dai W, Ren C, Shen Y. Effects of Priming Intermittent Theta Burst Stimulation With High-Definition tDCS on Upper Limb Function in Hemiparetic Patients With Stroke: A Randomized Controlled Study. Neurorehabil Neural Repair 2024:15459683241233259. [PMID: 38357884 DOI: 10.1177/15459683241233259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
BACKGROUND Preconditioning with cathodal high-definition transcranial direct current stimulation (HD-tDCS) can potentiate cortical plasticity induced by intermittent theta burst stimulation (iTBS) and enhance the after-effects of iTBS in healthy people. However, it is unclear whether this multi-modal protocol can enhance upper limb function in patients with stroke. OBJECTIVE The aim of this study was to investigate whether priming iTBS with cathodal HD-tDCS over the ipsilesional M1 can augment upper limb motor recovery in poststroke patients. METHODS A total of 66 patients with subacute stroke were randomly allocated into 3 groups. Group 1 received priming iTBS with HD-tDCS (referred to as the tDCS + iTBS group), Group 2 received non-priming iTBS (the iTBS group), and Group 3 received sham stimulation applied to the ipsilesional M1. One session was performed per day, 5 days per week, for 3 consecutive weeks. In Group 1, iTBS was preceded by a 20-minute session of cathodal HD-tDCS at a 10-minute interval. The primary outcome measure was the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) score. Moreover, the secondary outcome measures for muscle strength and spasticity were the Motricity Index-Upper Extremity (MI-UE) and the Modified Ashworth Scale Upper-Extremity (MAS-UE), respectively, and the Hong Kong Version of the Functional Test for the Hemiplegic Upper Extremity (FTHUE-HK) and the Modified Barthel Index (MBI) for activity and participation. RESULTS Significant differences were detected in the changes in FMA-UE, MI-UE, and MBI scores between the 3 groups from baseline to post-intervention (χ2FMA-UE = 10.856, P = .004; χ2MI-UE = 6.783, P = .034; χ2MBI = 9.608, P = .008). Post hoc comparisons revealed that the priming iTBS group demonstrated substantial improvements in FMA-UE (P = .004), MI-UE (P = .028), and MBI (P = 0.006) compared with those in the sham group. However, no significant difference was observed between the iTBS group and the sham group. Moreover, no significant differences were found in the changes in MAS-UE or FTHUE-HK between the groups. CONCLUSIONS Priming iTBS with HD-tDCS over the ipsilesional M1 cortex had beneficial effects on augmenting upper limb motor recovery and enhancing daily participation among subacute stroke patients.
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Affiliation(s)
- Li Bian
- Department of Rehabilitation Medicine, Wuxi Central Rehabilitation Hospital, The Affiliated Mental Health Center of Jiangnan University, Wuxi, Jiangsu, China
| | - Li Zhang
- Department of Rehabilitation Medicine, Wuxi Central Rehabilitation Hospital, The Affiliated Mental Health Center of Jiangnan University, Wuxi, Jiangsu, China
| | - Guilan Huang
- Department of Rehabilitation Medicine, Wuxi Central Rehabilitation Hospital, The Affiliated Mental Health Center of Jiangnan University, Wuxi, Jiangsu, China
| | - Da Song
- Department of Rehabilitation Medicine, Wuxi Central Rehabilitation Hospital, The Affiliated Mental Health Center of Jiangnan University, Wuxi, Jiangsu, China
| | - Kai Zheng
- Department of Rehabilitation Medicine, Wuxi Central Rehabilitation Hospital, The Affiliated Mental Health Center of Jiangnan University, Wuxi, Jiangsu, China
| | - Xinlei Xu
- Department of Rehabilitation Medicine, Wuxi Central Rehabilitation Hospital, The Affiliated Mental Health Center of Jiangnan University, Wuxi, Jiangsu, China
| | - Wenjun Dai
- Rehabilitation Medicine Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Caili Ren
- Department of Rehabilitation Medicine, Wuxi Central Rehabilitation Hospital, The Affiliated Mental Health Center of Jiangnan University, Wuxi, Jiangsu, China
| | - Ying Shen
- Rehabilitation Medicine Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Dai L, Zhang W, Zhang H, Fang L, Chen J, Li X, Yu H, Song J, Chen S, Zheng B, Zhang Y, Li Z. Effects of robot-assisted upper limb training combined with intermittent theta burst stimulation (iTBS) on cortical activation in stroke patients: A functional near-infrared spectroscopy study. NeuroRehabilitation 2024; 54:421-434. [PMID: 38640179 DOI: 10.3233/nre-230355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
BACKGROUND The therapeutic effect and mechanism of robot-assisted upper limb training (RT) combined with intermittent theta burst stimulation (iTBS) for stroke patients are unclear. OBJECTIVE The purpose of this study was to evaluate changes in brain activation after combination therapy and RT alone using functional near-infrared spectroscopy (fNIRS). METHODS Patients were randomly assigned to two groups (iTBS + RT Group, n = 18, and RT Group, n = 18). Training was conducted five times a week for four weeks. fNIRS was used to measure changes in oxyhemoglobin in both the primary motor cortex (M1) and pre-motor and supplementary motor area (pSMA) during affected limb movement. Fugl-Meyer Assessment-Upper Extremity (FMA-UE) was employed for evaluating the function of upper limbs. RESULTS Thirty-two patients with subacute stroke completed the study. The cortex of both hemispheres was extensively activated prior to treatment in the RT group. After training, overactivation decreased. The brain activation of the combined treatment group transferred to the affected side after the treatment. There was a notable enhancement in the FMA-UE scores for both groups, with the combined group's progress significantly surpassing that of the RT group. CONCLUSION RT combined with iTBS can improve the motor function of stroke patients and promote the balance between cerebral hemispheres.
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Affiliation(s)
- Lei Dai
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Wanying Zhang
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Huihuang Zhang
- The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Linjie Fang
- Zhejiang Rehabilitation Medical Center, Hangzhou, China
| | - Jianer Chen
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
- The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
- Zhejiang Rehabilitation Medical Center, Hangzhou, China
| | - Xiang Li
- Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Hong Yu
- Zhejiang Rehabilitation Medical Center, Hangzhou, China
| | - Jianfei Song
- Zhejiang Rehabilitation Medical Center, Hangzhou, China
| | - Shishi Chen
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Beisi Zheng
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yujia Zhang
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zhongyi Li
- Hangzhou Innovation Institute, Beihang University, Hangzhou, China
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Xie H, Li X, Xu G, Huo C, Fan Y, Li Z, Dou Z. Effects of transcranial magnetic stimulation on dynamic functional networks in stroke patients as assessed by functional near-infrared spectroscopy: a randomized controlled clinical trial. Cereb Cortex 2023; 33:11668-11678. [PMID: 37885140 DOI: 10.1093/cercor/bhad404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 10/28/2023] Open
Abstract
Studies have shown that there is heterogeneity in the efficacy bewteen the low-frequency (LF) and high-frequency (HF) repetitive transcranial magnetic stimulation (rTMS), but the neural mechanisms underlying the differences in efficacy remain unclear. This study aimed to investigate the specific effects of LF- and HF-rTMS on cortial functional network and the process of neural regulation. A total of sixty-eight patients with hemiplegic motor impairment after stroke were randomly allocated to one of three groups: the LF-rTMS, HF-rTMS, and sham groups. Tissue concentrations of oxyhaemoglobin and deoxyhaemoglobin oscillations in cerebral cortex regions were measured by functional near-infrared spectroscopy (fNIRS) in the resting and rTMS states. Four specific time-windows were divided from the trial duration to observe dynamic changes in cortical haemodynamic responses. Compared with sham, LF-rTMS significantly induced the activation of the contralesional superior frontal cortex and premotor cortex, and continuously regulated ipsilesional hemisphere functional networks in stroke patients. However, HF-rTMS did not induce a significant neurovascular coupling response. Our study provided evidence that LF- and HF-rTMS interventions induced different neurovascular coupling responses and demonstrated the cortical functional network change process of rTMS in specific time-windows. These findings may help to understand the differences in the efficacy of rTMS modalities.
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Affiliation(s)
- Hui Xie
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing 100086, China
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
- Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, National Research Center for Rehabilitation Technical Aids, Beijing 100176, China
| | - Xin Li
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Gongcheng Xu
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing 100086, China
- Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, National Research Center for Rehabilitation Technical Aids, Beijing 100176, China
| | - Congcong Huo
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing 100086, China
- Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, National Research Center for Rehabilitation Technical Aids, Beijing 100176, China
| | - Yubo Fan
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing 100086, China
| | - Zengyong Li
- Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, National Research Center for Rehabilitation Technical Aids, Beijing 100176, China
| | - Zulin Dou
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
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Chen S, Zhang S, Yang W, Chen Y, Wang B, Chen J, Li X, Xie L, Huang H, Zeng Y, Tian L, Ji W, Wei X, Lan Y, Li H. The effectiveness of intermittent theta burst stimulation for upper limb motor recovery after stroke: a systematic review and meta-analysis of randomized controlled trials. Front Neurosci 2023; 17:1272003. [PMID: 37901439 PMCID: PMC10602812 DOI: 10.3389/fnins.2023.1272003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/21/2023] [Indexed: 10/31/2023] Open
Abstract
Background Intermittent theta burst stimulation (iTBS) is a promising noninvasive therapy to restore the excitability of the cortex, and subsequently improve the function of the upper extremities. Several studies have demonstrated the effectiveness of iTBS in restoring upper limb function and modulating cortical excitability. We aimed to evaluate the effects of iTBS on upper limb motor recovery after stroke. Objective The purpose of this article is to evaluate the influence of intermittent theta-burst stimulation on upper limb motor recovery and improve the quality of life. Method A literature search was conducted using PubMed, EMBASE, MEDLINE, The Cochrane Library, Web of Science, and CBM, including only English studies, to identify studies that investigated the effects of iTBS on upper limb recovery, compared with sham iTBS used in control groups. Effect size was reported as standardized mean difference (SMD) or weighted mean difference (WMD). Results Ten studies were included in the meta-analysis. The results of the meta-analysis indicated that when compared to the control group, the iTBS group had a significant difference in the Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT) (WMD: 3.20, 95% CI: 1.42 to 4.97; WMD: 3.72, 95% CI: 2.13 to 5.30, respectively). In addition, there was also a significant improvement in the modified Ashworth scale (MAS) compared to the sham group (WMD: -0.56; 95% CI: -0.85 to -0.28). More evidence is still needed to confirm the effect of Barthel Index (BI) scores after interventions. However, no significant effect was found for the assessment of Motor Evoked Potential (MEP) amplitude and MEP latency (SMD: 0.35; 95% CI: -0.21 to 0.90; SMD: 0.35, 95% CI: -0.18 to 0.87; SMD: 0.03, 95% CI: -0.49 to 0.55; respectively). Conclusion Our results showed that iTBS significantly improved motor impairment, functional activities, and reduced muscle tone of upper limbs, thereby increasing the ability to perform Activities of Daily Living (ADL) in stroke patients, while there were no significant differences in MEPs. In conclusion, iTBS is a promising non-invasive brain stimulation as an adjunct to therapy and enhances the therapeutic effect of conventional physical therapy. In the future, more randomized controlled trials with large sample sizes, high quality, and follow-up are necessary to explore the neurophysiological effects. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023392739.
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Affiliation(s)
- Songbin Chen
- Department of Rehabilitation Medicine, Shenzhen Hospital, Southern Medical University, Shenzhen, China
- Department of Rehabilitation Medicine, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Shunxi Zhang
- Department of Rehabilitation Medicine, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Wenqing Yang
- Department of Rehabilitation Medicine, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Yujie Chen
- Department of Rehabilitation Medicine, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Bingshui Wang
- Department of Rehabilitation Medicine, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Jixiang Chen
- Department of Rehabilitation Medicine, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Xiaotong Li
- Department of Rehabilitation Medicine, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Lanfang Xie
- Department of Rehabilitation Medicine, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Huangjie Huang
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yangkang Zeng
- Department of Rehabilitation Medicine, Shenzhen University General Hospital, Shenzhen, China
| | - Lingling Tian
- Department of Rehabilitation Medicine, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Wenxue Ji
- Department of Rehabilitation Medicine, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Xijun Wei
- Department of Rehabilitation Medicine, Shenzhen Hospital, Southern Medical University, Shenzhen, China
| | - Yue Lan
- Department of Rehabilitation Medicine, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Hai Li
- Department of Rehabilitation Medicine, Shenzhen Hospital, Southern Medical University, Shenzhen, China
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Tang Z, Liu T, Liu Y, Han K, Su W, Zhao J, Chi Q, Zhang X, Zhang H. Different doses of intermittent theta burst stimulation for upper limb motor dysfunction after stroke: a study protocol for a randomized controlled trial. Front Neurosci 2023; 17:1259872. [PMID: 37869516 PMCID: PMC10585036 DOI: 10.3389/fnins.2023.1259872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/20/2023] [Indexed: 10/24/2023] Open
Abstract
Background Upper limb motor recovery is one of the important goals of stroke rehabilitation. Intermittent theta burst stimulation (iTBS), a new type of repetitive transcranial magnetic stimulation (rTMS), is considered a potential therapy. However, there is still no consensus on the efficacy of iTBS for upper limb motor dysfunction after stroke. Stimulus dose may be an important factor affecting the efficacy of iTBS. Therefore, we aim to investigate and compare the effects and neural mechanisms of three doses of iTBS on upper limb motor recovery in stroke patients, and our hypothesis is that the higher the dose of iTBS, the greater the improvement in upper limb motor function. Methods This prospective, randomized, controlled trial will recruit 56 stroke patients with upper limb motor dysfunction. All participants will be randomized in a 1:1:1:1 ratio to receive 21 sessions of 600 pulses active iTBS, 1,200 pulses active iTBS, 1,800 pulses active iTBS, or 1,800 pulses sham iTBS in addition to conventional rehabilitation training. The primary outcome is the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) score from baseline to end of intervention, and the secondary outcomes are the Wolf Motor Function Test (WMFT), Grip Strength (GS), Modified Barthel Index (MBI), and Stroke Impact Scale (SIS). The FMA-UE, MBI, and SIS are assessed pre-treatment, post-treatment, and at the 3-weeks follow-up. The WMFT, GS, and resting-state functional magnetic resonance imaging (rs-fMRI) data will be obtained pre- and post-treatment. Discussion The iTBS intervention in this study protocol is expected to be a potential method to promote upper limb motor recovery after stroke, and the results may provide supportive evidence for the optimal dose of iTBS intervention.
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Affiliation(s)
- Zhiqing Tang
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Tianhao Liu
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Ying Liu
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Kaiyue Han
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Wenlong Su
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
- University of Health and Rehabilitation Sciences, Qingdao, China
| | - Jingdu Zhao
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Qianqian Chi
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Xiaonian Zhang
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Hao Zhang
- School of Rehabilitation, Capital Medical University, Beijing, China
- China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
- University of Health and Rehabilitation Sciences, Qingdao, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
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Hill G, Johnson F, Uy J, Serrada I, Benyamin B, Van Den Berg M, Hordacre B. Moderate intensity aerobic exercise may enhance neuroplasticity of the contralesional hemisphere after stroke: a randomised controlled study. Sci Rep 2023; 13:14440. [PMID: 37660093 PMCID: PMC10475034 DOI: 10.1038/s41598-023-40902-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 08/18/2023] [Indexed: 09/04/2023] Open
Abstract
Upregulation of neuroplasticity might help maximize stroke recovery. One intervention that appears worthy of investigation is aerobic exercise. This study aimed to determine whether a single bout of moderate intensity aerobic exercise can enhance neuroplasticity in people with stroke. Participants were randomly assigned (1:1) to a 20-min moderate intensity exercise intervention or remained sedentary (control). Transcranial magnetic stimulation measured corticospinal excitability of the contralesional hemisphere by recording motor evoked potentials (MEPs). Intermittent Theta Burst Stimulation (iTBS) was used to repetitively activate synapses in the contralesional primary motor cortex, initiating the early stages of neuroplasticity and increasing excitability. It was surmised that if exercise increased neuroplasticity, there would be a greater facilitation of MEPs following iTBS. Thirty-three people with stroke participated in this study (aged 63.87 ± 10.30 years, 20 male, 6.13 ± 4.33 years since stroke). There was an interaction between Time*Group on MEP amplitudes (P = 0.009). Participants allocated to aerobic exercise had a stronger increase in MEP amplitude following iTBS. A non-significant trend indicated time since stroke might moderate this interaction (P = 0.055). Exploratory analysis suggested participants who were 2-7.5 years post stroke had a strong MEP facilitation following iTBS (P < 0.001). There was no effect of age, sex, resting motor threshold, self-reported physical activity levels, lesion volume or weighted lesion load (all P > 0.208). Moderate intensity cycling may enhance neuroplasticity in people with stroke. This therapy adjuvant could provide opportunities to maximize stroke recovery.
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Affiliation(s)
- Gabrielle Hill
- Clinical Rehabilitation, College of Nursing and Health Sciences, Flinders University, Adelaide, 5042, Australia
| | - Finn Johnson
- Allied Health and Human Performance, University of South Australia, Adelaide, 5000, Australia
| | - Jeric Uy
- Allied Health and Human Performance, University of South Australia, Adelaide, 5000, Australia
| | - Ines Serrada
- Allied Health and Human Performance, University of South Australia, Adelaide, 5000, Australia
| | - Beben Benyamin
- Australian Centre for Precision Health, Allied Health and Human Performance, University of South Australia, Adelaide, 5000, Australia
- South Australian Health and Medical Research Institute, Adelaide, 5000, Australia
| | - Maayken Van Den Berg
- Clinical Rehabilitation, College of Nursing and Health Sciences, Flinders University, Adelaide, 5042, Australia
| | - Brenton Hordacre
- Innovation, IMPlementation and Clinical Translation (IIMPACT) in Health, University of South Australia, City East Campus, GPO Box 2471, Adelaide, 5001, Australia.
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From Molecule to Patient Rehabilitation: The Impact of Transcranial Direct Current Stimulation and Magnetic Stimulation on Stroke-A Narrative Review. Neural Plast 2023; 2023:5044065. [PMID: 36895285 PMCID: PMC9991485 DOI: 10.1155/2023/5044065] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/10/2022] [Accepted: 11/28/2022] [Indexed: 03/04/2023] Open
Abstract
Stroke is a major health problem worldwide, with numerous health, social, and economic implications for survivors and their families. One simple answer to this problem would be to ensure the best rehabilitation with full social reintegration. As such, a plethora of rehabilitation programs was developed and used by healthcare professionals. Among them, modern techniques such as transcranial magnetic stimulation and transcranial direct current stimulation are being used and seem to bring improvements to poststroke rehabilitation. This success is attributed to their capacity to enhance cellular neuromodulation. This modulation includes the reduction of the inflammatory response, autophagy suppression, antiapoptotic effects, angiogenesis enhancement, alterations in the blood-brain barrier permeability, attenuation of oxidative stress, influence on neurotransmitter metabolism, neurogenesis, and enhanced structural neuroplasticity. The favorable effects have been demonstrated at the cellular level in animal models and are supported by clinical studies. Thus, these methods proved to reduce infarct volumes and to improve motor performance, deglutition, functional independence, and high-order cerebral functions (i.e., aphasia and heminegligence). However, as with every therapeutic method, these techniques can also have limitations. Their regimen of administration, the phase of the stroke at which they are applied, and the patients' characteristics (i.e., genotype and corticospinal integrity) seem to influence the outcome. Thus, no response or even worsening effects were obtained under certain circumstances both in animal stroke model studies and in clinical trials. Overall, weighing up risks and benefits, the new transcranial electrical and magnetic stimulation techniques can represent effective tools with which to improve the patients' recovery after stroke, with minimal to no adverse effects. Here, we discuss their effects and the molecular and cellular events underlying their effects as well as their clinical implications.
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Gao B, Wang Y, Zhang D, Wang Z, Wang Z. Intermittent theta-burst stimulation with physical exercise improves poststroke motor function: A systemic review and meta-analysis. Front Neurol 2022; 13:964627. [PMID: 36110393 PMCID: PMC9468864 DOI: 10.3389/fneur.2022.964627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background Intermittent theta-burst stimulation (iTBS) is an optimized rTMS modality that could modulate the excitability of neural structures. Several studies have been conducted to investigate the efficacy of iTBS in improving the motor function of stroke patients. However, the specific role of iTBS in motor function recovery after stroke is unclear. Hence, in our study, we performed a meta-analysis to investigate the efficacy of iTBS for the motor function improvement of stroke patients. Methods MEDLINE, Embase, and Cochrane Library were searched until May 2022 for randomized controlled trials (RCTs). Results Thirteen RCTs with 334 patients were finally included in our study. The primary endpoints were the Fugl-Meyer assessment scale (FMA) and Motor Assessment Scale (MAS) change from baseline. We found that iTBS led to a significant reduction in FMA score (P = 0.002) but not in MAS score (P = 0.24) compared with the sham group. Moreover, standard 600-pulse stimulation showed a better effect on motor function improvement than the sham group (P = 0.004), however, 1200-pulse iTBS showed no effect on motor function improvement after stroke (P = 0.23). The effect of iTBS for improving motor function only exists in chronic stroke patients (P = 0.02) but not in subacute patients (P = 0.27). Conclusion This study supports that iTBS has good efficacy for improving motor function in stroke patients. Therefore, standard 600-pulse stimulation iTBS therapy is proper management and treatment for chronic stroke.
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Affiliation(s)
- Bixi Gao
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Stroke Research, Soochow University, Suzhou, China
| | - Yunjiang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Stroke Research, Soochow University, Suzhou, China
- Department of Neurosurgery, Yancheng Third People's Hospital, Yancheng, China
| | - Dingding Zhang
- Department of Anesthesia, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zongqi Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Stroke Research, Soochow University, Suzhou, China
- *Correspondence: Zongqi Wang
| | - Zhong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Stroke Research, Soochow University, Suzhou, China
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Chen G, Lin T, Wu M, Cai G, Ding Q, Xu J, Li W, Wu C, Chen H, Lan Y. Effects of repetitive transcranial magnetic stimulation on upper-limb and finger function in stroke patients: A systematic review and meta-analysis of randomized controlled trials. Front Neurol 2022; 13:940467. [PMID: 35968309 PMCID: PMC9372362 DOI: 10.3389/fneur.2022.940467] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background Repetitive transcranial magnetic stimulation (rTMS) is a promising intervention for stroke rehabilitation. Several studies have demonstrated the effectiveness of rTMS in restoring motor function. This meta-analysis aimed to summarize the current evidence of the effect of rTMS in improving upper limb function and fine motor recovery in stroke patients. Methods Three online databases (Web of Science, PubMed, and Embase) were searched for relevant randomized controlled trials. A total of 45 studies (combined n = 2064) were included. Random effects model was used for meta-analysis and effect size was reported as standardized mean difference (SMD). Results rTMS was effective in improving fine motor function in stroke patients (SMD, 0.38; 95% CI 0.19–0.58; P = 0). On subgroup analyses, for post-stroke functional improvement of the upper extremity, bilateral hemisphere stimulation was more effective than unilateral stimulation during the acute phase of stroke, and a regimen of 20 rTMS sessions produced greater improvement than <20 sessions. In the subacute phase of stroke, affected hemispheric stimulation with a 40-session rTMS regimen was superior to unaffected hemispheric stimulation or bilateral hemispheric stimulation with <40 sessions. Unaffected site stimulation with a 10-session rTMS regimen produced significant improvement in the chronic phase compared to affected side stimulation and bilateral stimulation with >10 rTMS sessions. For the rTMS stimulation method, both TBS and rTMS were found to be significantly more effective in the acute phase of stroke, but TBS was more effective than rTMS. However, rTMS was found to be more effective than TBS stimulation in patients in the subacute and chronic phases of stroke. rTMS significantly improved upper limb and fine function in the short term (0–1-month post-intervention) and medium term (2–5 months), but not for upper limb function in the long term (6 months+). The results should be interpreted with caution due to significant heterogeneity. Conclusions This updated meta-analysis provides robust evidence of the efficacy of rTMS treatment in improving upper extremity and fine function during various phases of stroke. Systematic Review Registration https://inplasy.com/inplasy-2022-5-0121/, identifier: INPLASY202250121.
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Affiliation(s)
- Gengbin Chen
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
- Postgraduate Research Institute, Guangzhou Sport University, Guangzhou, China
| | - Tuo Lin
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Manfeng Wu
- Department of Rehabilitation Medicine, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Guiyuan Cai
- Department of Rehabilitation Medicine, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Qian Ding
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Jiayue Xu
- Department of Rehabilitation Medicine, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Wanqi Li
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Cheng Wu
- Department of Rehabilitation Medicine, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Hongying Chen
- Department of Rehabilitation Medicine, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Yue Lan
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
- Guangzhou Key Laboratory of Aging Frailty and Neurorehabilitation, Guangzhou, China
- *Correspondence: Yue Lan
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Huang W, Chen J, Zheng Y, Zhang J, Li X, Su L, Li Y, Dou Z. The Effectiveness of Intermittent Theta Burst Stimulation for Stroke Patients With Upper Limb Impairments: A Systematic Review and Meta-Analysis. Front Neurol 2022; 13:896651. [PMID: 35873775 PMCID: PMC9298981 DOI: 10.3389/fneur.2022.896651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background Upper limb impairments are one of the most common health problems of stroke, affecting both motor function and independence in daily life. It has been demonstrated that intermittent theta burst stimulation (iTBS) increases brain excitability and improves upper limb function. Our study sought to determine the role of iTBS in stroke recovery. Objective The purpose of this study was to determine the efficacy of iTBS in individuals with upper limb impairments following stroke. Methods The databases used included Cumulative Index to PubMed, EMBASE, ESCBOhost, The Cochrane Library, Chinese Biomedical Database, Web of Science, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Technology Periodical Database (VIP), and WanFang Database. Studies published before November 2021 were included. Each participant received an iTBS-based intervention aimed at improving activity levels or impairment, which was compared to usual care, a sham intervention, or another intervention. The primary outcome measure was a change in upper limb function assessment. Secondary outcomes included impairment, participation, and quality of life measures. Result A total of 18 studies (n = 401 participants) that met the inclusion criteria were included in this study. There was a slight change in the upper limb function of the iTBS group compared with the control group, as measured by the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) score (mean difference 2.70, 95% CI −0.02 to 5.42, p = 0.05). Significant improvement in resting motor threshold (RMT) and motor-evoked potential (MEP) was also observed in the meta-analysis of iTBS (MD 3.46, 95% CI 2.63 to 4.28, p < 0.00001); (MD 1.34, 95% CI 1.17 to 1.51, P < 0.00001). In addition, we got similar results when the studies were using the Modified Barthel Index (MBI) assessment (mean difference of 7.34, 95% CI 0.47 to 14.21, p = 0.04). Conclusion Our study established the efficacy of iTBS in improving motor cortical plasticity, motor function, and daily functioning in stroke patients. However, the review requires evidence from additional randomized controlled trials and high-quality research. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/
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Affiliation(s)
- Wenhao Huang
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiayi Chen
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yadan Zheng
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jin Zhang
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xin Li
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Liujie Su
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yinying Li
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zulin Dou
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Tang Z, Han K, Wang R, Zhang Y, Zhang H. Excitatory Repetitive Transcranial Magnetic Stimulation Over the Ipsilesional Hemisphere for Upper Limb Motor Function After Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2022; 13:918597. [PMID: 35795793 PMCID: PMC9251503 DOI: 10.3389/fneur.2022.918597] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/11/2022] [Indexed: 11/18/2022] Open
Abstract
Background Repetitive transcranial magnetic stimulation (rTMS) is a promising therapy to promote recovery of the upper limb after stroke. According to the regulation of cortical excitability, rTMS can be divided into excitatory rTMS and inhibitory rTMS, and excitatory rTMS includes high-frequency rTMS (HF-rTMS) or intermittent theta-burst stimulation (iTBS). We aimed to evaluate the effects of excitatory rTMS over the ipsilesional hemisphere on upper limb motor recovery after stroke. Methods Databases of PubMed, Embase, ISI Web of Science, and the Cochrane Library were searched for randomized controlled trials published before 31 December 2021. RCTs on the effects of HF-rTMS or iTBS on upper limb function in patients diagnosed with stroke were included. Two researchers independently screened the literature, extracted the data, and assessed quality. The meta-analysis was performed by using Review Manager Version 5.4 software. Results Fifteen studies with 449 participants were included in this meta-analysis. This meta-analysis found that excitatory rTMS had significant efficacy on upper limb motor function (MD = 5.88, 95% CI, 3.32–8.43, P < 0.001), hand strength (SMD = 0.53, 95% CI, 0.04–1.01, P = 0.03), and hand dexterity (SMD = 0.76, 95% CI, 0.39–1.14, P < 0.001). Subgroup analyses based on different types of rTMS showed that both iTBS and HF-rTMS significantly promoted upper limb motor function (iTBS, P < 0.001; HF-rTMS, P < 0.001) and hand dexterity (iTBS, P = 0.01; HF-rTMS, P < 0.001) but not hand strength (iTBS, P = 0.07; HF-rTMS, P = 0.12). Further subgroup analysis based on the duration of illness demonstrated that applying excitatory rTMS during the first 3 months (<1 month, P = 0.01; 1–3 months, P = 0.001) after stroke brought significant improvement in upper limb motor function but not in the patients with a duration longer than 3 months (P = 0.06). We found that HF-rTMS significantly enhanced the motor evoked potential (MEP) amplitude of affected hemisphere (SMD = 0.82, 95% CI, 0.32–1.33, P = 0.001). Conclusion Our study demonstrated that excitatory rTMS over the ipsilesional hemisphere could significantly improve upper limb motor function, hand strength, and hand dexterity in patients diagnosed with stroke. Both iTBS and HF-rTMS which could significantly promote upper limb motor function and hand dexterity, and excitatory rTMS were beneficial to upper limb motor function recovery only when applied in the first 3 months after stroke. HF-rTMS could significantly enhance the MEP amplitude of the affected hemisphere. High-quality and large-scale randomized controlled trials in the future are required to confirm our conclusions. Clinical Trial Registration www.crd.york.ac.uk/prospero/, identifier: CRD42022312288.
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Affiliation(s)
- Zhiqing Tang
- School of Rehabilitation, Capital Medical University, Beijing, China
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Kaiyue Han
- School of Rehabilitation, Capital Medical University, Beijing, China
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Rongrong Wang
- School of Rehabilitation, Capital Medical University, Beijing, China
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Yue Zhang
- School of Rehabilitation, Capital Medical University, Beijing, China
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Hao Zhang
- School of Rehabilitation, Capital Medical University, Beijing, China
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
- Cheeloo College of Medicine, Shandong University, Jinan, China
- University of Health and Rehabilitation Sciences, Qingdao, China
- *Correspondence: Hao Zhang
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Krese KA, Donnelly KZ, Etingen B, Bender Pape TL, Chaudhuri S, Aaronson AL, Shah RP, Bhaumik DK, Billups A, Bedo S, Wanicek-Squeo MT, Bobra S, Herrold AA. Feasibility of a Combined Neuromodulation and Yoga Intervention for Mild Traumatic Brain Injury and Chronic Pain: Protocol for an Open-label Pilot Trial. JMIR Res Protoc 2022; 11:e37836. [PMID: 35704372 PMCID: PMC9244651 DOI: 10.2196/37836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/16/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Mild traumatic brain injury (mTBI) and chronic pain often co-occur and worsen rehabilitation outcomes. There is a need for improved multimodal nonpharmacologic treatments that could improve outcomes for both conditions. Yoga is a promising activity-based intervention for mTBI and chronic pain, and neuromodulation through transcranial magnetic stimulation is a promising noninvasive, nonpharmacological treatment for mTBI and chronic pain. Intermittent theta burst stimulation (iTBS) is a type of patterned, excitatory transcranial magnetic stimulation. iTBS can induce a window of neuroplasticity, making it ideally suited to boost the effects of treatments provided after it. Thus, iTBS may magnify the impacts of subsequently delivered interventions as compared to delivering those interventions alone and accordingly boost their impact on outcomes. OBJECTIVE The aim of this study is to (1) develop a combined iTBS+yoga intervention for mTBI and chronic pain, (2) assess the intervention's feasibility and acceptability, and (3) gather preliminary clinical outcome data on quality of life, function, and pain that will guide future studies. METHODS This is a mixed methods, pilot, open-labeled, within-subject intervention study. We will enroll 20 US military veteran participants. The combined iTBS+yoga intervention will be provided in small group settings once a week for 6 weeks. The yoga intervention will follow the LoveYourBrain yoga protocol-specifically developed for individuals with TBI. iTBS will be administered immediately prior to the LoveYourBrain yoga session. We will collect preliminary quantitative outcome data before and after the intervention related to quality of life (TBI-quality of life), function (Mayo-Portland Adaptability Index), and pain (Brief Pain Inventory) to inform larger studies. We will collect qualitative data via semistructured interviews focused on intervention acceptability after completion of the intervention. RESULTS This study protocol was approved by Edward Hines Jr Veterans Administration Hospital Institutional Review Board (Hines IRB 1573116-4) and was prospectively registered on ClinicalTrials.gov (NCT04517604). This study includes a Food and Drug Administration Investigational Device Exemption (IDE: G200195). A 2-year research plan timeline was developed. As of March 2022, a total of 6 veterans have enrolled in the study. Data collection is ongoing and will be completed by November 2022. We expect the results of this study to be available by October 2024. CONCLUSIONS We will be able to provide preliminary evidence of safety, feasibility, and acceptability of a novel combined iTBS and yoga intervention for mTBI and chronic pain-conditions with unmet treatment needs. TRIAL REGISTRATION ClinicalTrials.gov NCT04517604; https://www.clinicaltrials.gov/ct2/show/NCT04517604. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/37836.
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Affiliation(s)
- Kelly A Krese
- Brain Innovation Center, Shirley Ryan AbilityLab, Chicago, IL, United States
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | | | - Bella Etingen
- Center for Innovation in Complex Chronic Healthcare & Research Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Theresa L Bender Pape
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Center for Innovation in Complex Chronic Healthcare & Research Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Sarmistha Chaudhuri
- Department of Physical Medicine and Rehabilitation, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Alexandra L Aaronson
- Mental Health Service Line, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Psychiatry, Feinberg School of Medicine, Northwestern University, Hines, IL, United States
| | - Rachana P Shah
- Department of Physical Medicine and Rehabilitation, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Dulal K Bhaumik
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Psychiatry, University of Illinois Chicago, Chicago, IL, United States
| | - Andrea Billups
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Sabrina Bedo
- Department of Physical Medicine and Rehabilitation, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Recreation Therapy, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Mary Terese Wanicek-Squeo
- Recreation Therapy, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Sonia Bobra
- Department of Radiology, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Radiology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
| | - Amy A Herrold
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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Bai Z, Zhang J, Fong KNK. Effects of transcranial magnetic stimulation in modulating cortical excitability in patients with stroke: a systematic review and meta-analysis. J Neuroeng Rehabil 2022; 19:24. [PMID: 35193624 PMCID: PMC8862292 DOI: 10.1186/s12984-022-00999-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/28/2022] [Indexed: 12/13/2022] Open
Abstract
Background Transcranial magnetic stimulation (TMS) has attracted plenty of attention as it has been proved to be effective in facilitating motor recovery in patients with stroke. The aim of this study was to systematically review the effects of repetitive TMS (rTMS) and theta burst stimulation (TBS) protocols in modulating cortical excitability after stroke. Methods A literature search was carried out using PubMed, Medline, EMBASE, CINAHL, and PEDro, to identify studies that investigated the effects of four rTMS protocols—low and high frequency rTMS, intermittent and continuous TBS, on TMS measures of cortical excitability in stroke. A random-effects model was used for all meta-analyses. Results Sixty-one studies were included in the current review. Low frequency rTMS was effective in decreasing individuals’ resting motor threshold and increasing the motor-evoked potential of the non-stimulated M1 (affected M1), while opposite effects occurred in the stimulated M1 (unaffected M1). High frequency rTMS enhanced the cortical excitability of the affected M1 alone. Intermittent TBS also showed superior effects in rebalancing bilateral excitability through increasing and decreasing excitability within the affected and unaffected M1, respectively. Due to the limited number of studies found, the effects of continuous TBS remained inconclusive. Motor impairment was significantly correlated with various forms of TMS measures. Conclusions Except for continuous TBS, it is evident that these protocols are effective in modulating cortical excitability in stroke. Current evidence does support the effects of inhibitory stimulation in enhancing the cortical excitability of the affected M1. Supplementary Information The online version contains supplementary material available at 10.1186/s12984-022-00999-4.
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Affiliation(s)
- Zhongfei Bai
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China.,Department of Occupational Therapy, Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), Shanghai, China.,Department of Rehabilitation Sciences, Tongji University School of Medicine, Shanghai, China
| | - Jiaqi Zhang
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China
| | - Kenneth N K Fong
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China.
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Mittal N, Majdic BC, Sima AP, Peterson CL. The effect of intermittent theta burst stimulation on corticomotor excitability of the biceps brachii in nonimpaired individuals. Neurosci Lett 2021; 764:136220. [PMID: 34499999 PMCID: PMC8572155 DOI: 10.1016/j.neulet.2021.136220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/10/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
Intermittent theta burst stimulation (iTBS) is a form of repetitive transcranial magnetic stimulation (TMS) that can increase corticomotor excitability in distal upper limb muscles, but the effect on the more proximal biceps is unknown. The study objective was to determine the effect of iTBS on corticomotor excitability of the biceps brachii in non-impaired individuals. Ten individuals completed three sessions, and an additional ten individuals completed one session in a secondary study; each session included sham and active iTBS. Resting and active motor thresholds (RMT, AMT) were determined prior to sham and active iTBS. Motor evoked potentials (MEPs) in response to single pulse TMS served as our measure of corticomotor excitability. In our primary cohort, MEPs were recorded with biphasic stimulation to accurately capture the same neurons affected by biphasic iTBS. MEPs were recorded at an intensity of 120% of RMT, or for instances of high RMTs, 100% of the maximum stimulator output (MSO), at baseline, and 10, 20, and 30 minutes after iTBS. MEPs were normalized by the maximum voluntary isometric muscle activity. In the secondary, MEPs were recorded with monophasic stimulation, which increased our ability to record MEPs at 120% of RMT. Linear mixed effects models were used to determine the effect of iTBS on normalized MEPs (nMEPs), with analyses to evaluate the interaction of the biceps AMT:RMT ratio as a measure of corticomotor conductance. Change in nMEPs from baseline did not differ for the active and sham conditions (p = 0.915 ) when MEPs were assessed with biphasic stimulation. With MEPs assessed by monophasic stimulation, there was an increase in biceps nMEPs after active iTBS, and no change in nMEPs after sham. Our results suggest that when RMTs are expected to be high when measured with biphasic stimulation, monophasic stimulation can better capture changes in MEPs induced by iTBS, and biphasic stimulation appears limited in its ability to capture changes in biceps MEPs in nonimpaired individuals. In both cohorts, increased corticomotor excitability after iTBS occurred when the biceps AMT:RMT ratio was high. Thus, the AMT:RMT ratio may be a predictive measure to evaluate the potential for iTBS to increase biceps corticomotor excitability.
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Affiliation(s)
- Neil Mittal
- Virginia Commonwealth University, Biomedical Engineering, College of Engineering, Virginia Commonwealth University, College of Engineering, Rehabilitation Engineering to Advance Ability Lab, Biotech Eight, 737 N 5(th) Street, Richmond, VA 23219, United States.
| | - Blaize C Majdic
- Virginia Commonwealth University, Biomedical Engineering, College of Engineering, Virginia Commonwealth University, College of Engineering, Rehabilitation Engineering to Advance Ability Lab, Biotech Eight, 737 N 5(th) Street, Richmond, VA 23219, United States
| | - Adam P Sima
- Virginia Commonwealth University, Department of Biostatistics, Virginia Commonwealth University, VCU School of Medicine, Department of Biostatistics, Box 980032, Richmond, VA 23298-0032, United States
| | - Carrie L Peterson
- Virginia Commonwealth University, Biomedical Engineering, College of Engineering, Virginia Commonwealth University, College of Engineering, Rehabilitation Engineering to Advance Ability Lab, Biotech Eight, 737 N 5(th) Street, Richmond, VA 23219, United States
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Chen SC, Yang LY, Adeel M, Lai CH, Peng CW. Transcranial electrostimulation with special waveforms enhances upper-limb motor function in patients with chronic stroke: a pilot randomized controlled trial. J Neuroeng Rehabil 2021; 18:106. [PMID: 34193179 PMCID: PMC8244182 DOI: 10.1186/s12984-021-00901-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/23/2021] [Indexed: 12/04/2022] Open
Abstract
Background Transcranial direct current stimulation (tDCS) and intermittent theta burst stimulation (iTBS) were both demonstrated to have therapeutic potentials to rapidly induce neuroplastic effects in various rehabilitation training regimens. Recently, we developed a novel transcranial electrostimulation device that can flexibly output an electrical current with combined tDCS and iTBS waveforms. However, limited studies have determined the therapeutic effects of this special waveform combination on clinical rehabilitation. Herein, we investigated brain stimulation effects of tDCS-iTBS on upper-limb motor function in chronic stroke patients. Methods Twenty-four subjects with a chronic stroke were randomly assigned to a real non-invasive brain stimulation (NIBS; who received the real tDCS + iTBS output) group or a sham NIBS (who received sham tDCS + iTBS output) group. All subjects underwent 18 treatment sessions of 1 h of a conventional rehabilitation program (3 days a week for 6 weeks), where a 20-min NIBS intervention was simultaneously applied during conventional rehabilitation. Outcome measures were assessed before and immediately after the intervention period: Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Jebsen-Taylor Hand Function Test (JTT), and Finger-to-Nose Test (FNT). Results Both groups showed improvements in FMA-UE, JTT, and FNT scores after the 6-week rehabilitation program. Notably, the real NIBS group had greater improvements in the JTT (p = 0. 016) and FNT (p = 0. 037) scores than the sham NIBS group, as determined by the Mann–Whitney rank-sum test. Conclusions Patients who underwent the combined ipsilesional tDCS-iTBS stimulation with conventional rehabilitation exhibited greater impacts than did patients who underwent sham stimulation-conventional rehabilitation in statistically significant clinical responses of the total JTT time and FNT after the stroke. Preliminary results of upper-limb functional recovery suggest that tDCS-iTBS combined with a conventional rehabilitation intervention may be a promising strategy to enhance therapeutic benefits in future clinical settings. Trial registration: ClinicalTrials.gov Identifier: NCT04369235. Registered on 30 April 2020.
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Affiliation(s)
- Shih-Ching Chen
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan
| | - Ling-Yu Yang
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
| | - Muhammad Adeel
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan.,International PhD Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
| | - Chien-Hung Lai
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chih-Wei Peng
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan. .,International PhD Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan. .,School of Gerontology Health Management, College of Nursing, Taipei Medical University, 250 Wuxing Street, Taipei, 11031, Taiwan.
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18
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Chen YH, Chen CL, Huang YZ, Chen HC, Chen CY, Wu CY, Lin KC. Augmented efficacy of intermittent theta burst stimulation on the virtual reality-based cycling training for upper limb function in patients with stroke: a double-blinded, randomized controlled trial. J Neuroeng Rehabil 2021; 18:91. [PMID: 34059090 PMCID: PMC8166006 DOI: 10.1186/s12984-021-00885-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 05/25/2021] [Indexed: 11/11/2022] Open
Abstract
Background Virtual reality and arm cycling have been reported as effective treatments for improving upper limb motor recovery in patients with stroke. Intermittent theta burst stimulation (iTBS) can increase ipsilesional cortical excitability, and has been increasingly used in patients with stroke. However, few studies examined the augmented effect of iTBS on neurorehabilitation program. In this study, we investigated the augmented effect of iTBS on virtual reality-based cycling training (VCT) for upper limb function in patients with stroke. Methods In this randomized controlled trial, 23 patients with stroke were recruited. Each patient received either 15 sessions of iTBS or sham stimulation in addition to VCT on the same day. Outcome measures were assessed before and after the intervention. Primary outcome measures for the improvement of upper limb motor function and spasticity were Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and Modified Ashworth Scale Upper-Extremity (MAS-UE). Secondary outcome measures for activity and participation were Action Research Arm Test (ARAT), Nine Hole Peg Test (NHPT), Box and Block Test (BBT) and Motor Activity Log (MAL), and Stroke Impact Scale (SIS). Wilcoxon signed-rank tests were performed to evaluate the effectiveness after the intervention and Mann–Whitney U tests were conducted to compare the therapeutic effects between two groups. Results At post-treatment, both groups showed significant improvement in FMA-UE and ARAT, while only the iTBS + VCT group demonstrated significant improvement in MAS-UE, BBT, NHPT, MAL and SIS. The Mann–Whitney U tests revealed that the iTBS + VCT group has presented greater improvement than the sham group significantly in MAS-UE, MAL-AOU and SIS. However, there were no significant differences in the changes of the FMA-UE, ARAT, BBT, NHPT and MAL-QOM between groups. Conclusions Intermittent TBS showed augmented efficacy on VCT for reducing spasticity, increasing actual use of the affected upper limb, and improving participation in daily life in stroke patients. This study provided an integrated innovative intervention, which may be a promising therapy to improve upper limb function recovery in stroke rehabilitation. However, this study has a small sample size, and thus a further larger-scale study is warranted to confirm the treatment efficacy. Trial registration This trial was registered under ClinicalTrials.gov ID No. NCT03350087, retrospectively registered, on November 22, 2017
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Affiliation(s)
- Yu-Hsin Chen
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Ling Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan. .,Graduate Institute of Early Intervention, Chang Gung University, Taoyuan, Taiwan.
| | - Ying-Zu Huang
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Neuroscience Research Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou, Taiwan.,Institute of Cognitive Neuroscience, National Central University, Taoyuan, Taiwan
| | - Hsieh-Ching Chen
- Department of Industrial and Management, National Taipei University of Technology, Taipei, Taiwan
| | - Chung-Yao Chen
- Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ching-Yi Wu
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Occupational Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Keh-Chung Lin
- School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
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19
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Meng Y, Zhang D, Hai H, Zhao YY, Ma YW. Efficacy of coupling intermittent theta-burst stimulation and 1 Hz repetitive transcranial magnetic stimulation to enhance upper limb motor recovery in subacute stroke patients: A randomized controlled trial. Restor Neurol Neurosci 2021; 38:109-118. [PMID: 32039879 DOI: 10.3233/rnn-190953] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Both 1 Hz repetitive transcranial magnetic stimulation (rTMS) and intermittent theta-burst stimulation (iTBS) are reported to benefit upper limb motor function rehabilitation in patients with stroke. However, the efficacy of combining 1 Hz rTMS and iTBS has not been adequately explored. OBJECTIVE We aimed to compare the effects of 1 Hz rTMS and the combination of 1 Hz rTMS and iTBS on the upper limb motor function in the subacute phase post-stroke. METHODS Twenty-eight participants were randomly assigned to three groups: Group A (1 Hz rTMS over the contralesional primary motor cortex (M1) and iTBS over the ipsilesional M1), Group B (contralesional 1 Hz rTMS and ipsilesional sham iTBS), and Group C (contralesional sham 1 Hz rTMS and ipsilesional sham iTBS). The participants received the same conventional rehabilitation accompanied by sessions of transcranial magnetic stimulation for two weeks (5 days one week). Motor-evoked potential (MEP), upper extremity Fugl-Meyer Assessment (UE-FMA), and Barthel Index (BI) were performed before and after the sessions. RESULTS Group A showed greater UE-FMA, BI, and MEP amplitude improvement and more significant decrement in MEP latency compared to Group B and Group C in testable patients. Correlation analyses in Group A revealed a close relation between ipsilesional MEP amplitude increment and UE-FMA gain. CONCLUSIONS The combining of 1 Hz rTMS and iTBS protocol in the present study is tolerable and more beneficial for motor improvement than the single use of 1 Hz rTMS in patients with subacute stroke.
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Affiliation(s)
- Ying Meng
- Department of Rehabilitation Medicine, the First Affiliated Hospital of China Medical University, Shenyang, China
| | - Dai Zhang
- Department of Rehabilitation Medicine, the First Affiliated Hospital of China Medical University, Shenyang, China
| | - Hong Hai
- Department of Rehabilitation Medicine, the First Affiliated Hospital of China Medical University, Shenyang, China
| | - Ying-Yu Zhao
- Department of Rehabilitation Medicine, the First Affiliated Hospital of China Medical University, Shenyang, China
| | - Yue-Wen Ma
- Department of Rehabilitation Medicine, the First Affiliated Hospital of China Medical University, Shenyang, China
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20
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Kuo IJ, Tang CW, Tsai YA, Tang SC, Lin CJ, Hsu SP, Liang WK, Juan CH, Zich C, Stagg CJ, Lee IH. Neurophysiological signatures of hand motor response to dual-transcranial direct current stimulation in subacute stroke: a TMS and MEG study. J Neuroeng Rehabil 2020; 17:72. [PMID: 32527268 PMCID: PMC7291576 DOI: 10.1186/s12984-020-00706-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 06/01/2020] [Indexed: 11/11/2022] Open
Abstract
Background Dual transcranial direct current stimulation (tDCS) to the bilateral primary motor cortices (M1s) has potential benefits in chronic stroke, but its effects in subacute stroke, when behavioural effects might be expected to be greater, have been relatively unexplored. Here, we examined the neurophysiological effects and the factors influencing responsiveness of dual-tDCS in subacute stroke survivors. Methods We conducted a randomized sham-controlled crossover study in 18 survivors with first-ever, unilateral subcortical ischaemic stroke 2–4 weeks after stroke onset and 14 matched healthy controls. Participants had real dual-tDCS (with an ipsilesional [right for controls] M1 anode and a contralesional M1 [left for controls] cathode; 2 mA for 20mins) and sham dual-tDCS on separate days, with concurrent paretic [left for controls] hand exercise. Using transcranial magnetic stimulation (TMS) and magnetoencephalography (MEG), we recorded motor evoked potentials (MEPs), the ipsilateral silent period (iSP), short-interval intracortical inhibition, and finger movement-related cortical oscillations before and immediately after tDCS. Results Stroke survivors had decreased excitability in ipsilesional M1 with a relatively excessive transcallosal inhibition from the contralesional to ipsilesional hemisphere at baseline compared with controls, as quantified by decreased MEPs and increased iSP duration. Dual-tDCS led to increased MEPs and decreased iSP duration in ipsilesional M1. The magnitude of the tDCS-induced MEP increase in stroke survivors was predicted by baseline contralesional-to-ipsilesional transcallosal inhibition (iSP) ratio. Baseline post-movement synchronization in α-band activity in ipsilesional M1 was decreased after stroke compared with controls, and its tDCS-induced increase correlated with upper limb score in stroke survivors. No significant adverse effects were observed during or after dual-tDCS. Conclusions Task-concurrent dual-tDCS in subacute stroke can safely and effectively modulate bilateral M1 excitability and inter-hemispheric imbalance and also movement-related α-activity.
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Affiliation(s)
- I-Ju Kuo
- Institute of Brain Science, Brain Research Center, National Yang-Ming University, No.155, Sec. 2, Linong St., Beitou Dist, Taipei City, 112, Taiwan.,Department of Neurosurgery, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou Dist, Taipei City, 112, Taiwan
| | - Chih-Wei Tang
- Institute of Brain Science, Brain Research Center, National Yang-Ming University, No.155, Sec. 2, Linong St., Beitou Dist, Taipei City, 112, Taiwan.,Department of Neurology, Far Eastern Memorial Hospital, No.21, Sec. 2, Nanya S. Rd., Banqiao Dist, New Taipei City, 220, Taiwan
| | - Yun-An Tsai
- Department of Neurosurgery, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou Dist, Taipei City, 112, Taiwan
| | - Shuen-Chang Tang
- Department of Neurosurgery, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou Dist, Taipei City, 112, Taiwan
| | - Chun-Jen Lin
- Institute of Brain Science, Brain Research Center, National Yang-Ming University, No.155, Sec. 2, Linong St., Beitou Dist, Taipei City, 112, Taiwan.,Division of Cerebrovascular Diseases, Neurological Institute, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou Dist, Taipei City, 112, Taiwan
| | - Shih-Pin Hsu
- Institute of Brain Science, Brain Research Center, National Yang-Ming University, No.155, Sec. 2, Linong St., Beitou Dist, Taipei City, 112, Taiwan
| | - Wei-Kuang Liang
- Institute of Cognitive Neuroscience, National Central University, No.300, Zhongda Rd., Zhongli Dist, Taoyuan City, 320, Taiwan
| | - Chi-Hung Juan
- Institute of Cognitive Neuroscience, National Central University, No.300, Zhongda Rd., Zhongli Dist, Taoyuan City, 320, Taiwan
| | - Catharina Zich
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK.,Oxford Centre for Human Brain Activity, Wellcome Centre for Integrative Neuroimaging, Department of Psychiatry, University of Oxford, Oxford, OX3 7JX, UK.,MRC Brain Network Dynamics Unit, University of Oxford, Oxford, OX1 3TH, UK
| | - Charlotte J Stagg
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK.,Oxford Centre for Human Brain Activity, Wellcome Centre for Integrative Neuroimaging, Department of Psychiatry, University of Oxford, Oxford, OX3 7JX, UK.,MRC Brain Network Dynamics Unit, University of Oxford, Oxford, OX1 3TH, UK
| | - I-Hui Lee
- Institute of Brain Science, Brain Research Center, National Yang-Ming University, No.155, Sec. 2, Linong St., Beitou Dist, Taipei City, 112, Taiwan. .,Division of Cerebrovascular Diseases, Neurological Institute, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou Dist, Taipei City, 112, Taiwan.
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21
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Zhang JJ, Fong KNK. Effects of priming intermittent theta burst stimulation on upper limb motor recovery after stroke: study protocol for a proof-of-concept randomised controlled trial. BMJ Open 2020; 10:e035348. [PMID: 32152174 PMCID: PMC7064082 DOI: 10.1136/bmjopen-2019-035348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/11/2020] [Accepted: 02/19/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Intermittent theta burst stimulation (iTBS), a form of repetitive transcranial magnetic stimulation (rTMS), delivered to the ipsilesional primary motor cortex (M1), appears to enhance the brain's response to rehabilitative training in patients with stroke. However, its clinical utility is highly subject to variability in different protocols. New evidence has reported that preceding iTBS, with continuous theta burst stimulation (cTBS) may stabilise and even boost the facilitatory effect of iTBS on the stimulated M1, via metaplasticity. The aim of this study is to investigate the effects of iTBS primed with cTBS (ie, priming iTBS), in addition to robot-assisted training (RAT), on the improvement of the hemiparetic upper limb functions of stroke patients and to explore potential sensorimotor neuroplasticity using electroencephalography (EEG). METHODS AND ANALYSIS A three-arm, subjects and assessors-blinded, randomised controlled trial will be performed with patients with chronic stroke. An estimated sample of 36 patients will be needed based on the prior sample size calculation. All participants will be randomly allocated to receive 10 sessions of rTMS with different TBS protocols (cTBS+iTBS, sham cTBS+iTBS and sham cTBS+sham iTBS), three to five sessions per week, for 2-3 weeks. All participants will receive 60 min of RAT after each stimulation session. Primary outcomes will be assessed using Fugl-Meyer Assessment-Upper Extremity scores and Action Research Arm Test. Secondary outcomes will be assessed using kinematic outcomes generated during RAT and EEG. ETHICS AND DISSEMINATION Ethical approval has been obtained from The Human Subjects Ethics Sub-committee, University Research Committee of The Hong Kong Polytechnic University (reference number: HSEARS20190718003). The results yielded from this study will be presented at international conferences and sent to a peer-review journal to be considered for publication. TRIAL REGISTRATION NUMBER NCT04034069.
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Affiliation(s)
- Jack Jiaqi Zhang
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Kenneth N K Fong
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China
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22
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Enhancing Stroke Recovery Across the Life Span With Noninvasive Neurostimulation. J Clin Neurophysiol 2020; 37:150-163. [DOI: 10.1097/wnp.0000000000000543] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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23
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van Lieshout ECC, van der Worp HB, Visser-Meily JMA, Dijkhuizen RM. Timing of Repetitive Transcranial Magnetic Stimulation Onset for Upper Limb Function After Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2019; 10:1269. [PMID: 31849827 PMCID: PMC6901630 DOI: 10.3389/fneur.2019.01269] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/15/2019] [Indexed: 01/10/2023] Open
Abstract
Background: Repetitive transcranial magnetic stimulation (rTMS) is a promising intervention to promote upper limb recovery after stroke. We aimed to identify differences in the efficacy of rTMS treatment on upper limb function depending on the onset time post-stroke. Methods: We searched PubMed, Embase, and the Cochrane Library to identify relevant RCTs from their inception to February 2018. RCTs on the effects of rTMS on upper limb function in adult patients with stroke were included. Study quality and risk of bias were assessed independently by two authors. Meta-analyses were performed for outcomes on individual upper limb outcome measures (function or activity) and for function and activity measures jointly, categorized by timing of treatment initiation. Timing of treatment initiation post-stroke was categorized as follows: acute to early subacute (<1 month), early subacute (1–3 months), late subacute (3–6 months), and chronic (>6 months). Results: We included 38 studies involving 1,074 stroke patients. Subgroup analysis demonstrated benefit of rTMS applied within the first month post-stroke [MD = 9.31; 95% confidence interval (6.27–12.34); P < 0.0001], but not in the early subacute phase (1–3 months post-stroke) [MD = 1.14; 95% confidence interval (−5.32 to 7.59), P = 0.73) or chronic phase (>6 months post-stroke) [MD = 1.79; 95% confidence interval (−2.00 to 5.59]; P = 0.35), when assessed with a function test [Fugl-Meyer Arm test (FMA)]. There were no studies within the late subacute phase (3–6 months post-stroke) that used the FMA. Tests at the level of function revealed improved upper limb function after rTMS [SMD = 0.43; 95% confidence interval (0.02–0.75); P = 0.0001], but tests at the level of activity did not, independent of rTMS onset post-stroke [SMD = 0.17; 95% confidence interval (−0.09 to 0.44); P = 0.19]. Heterogeneities in the results of the individual studies included in the main analyses were large, as suggested by funnel plot asymmetry. Conclusions: Based on the FMA, rTMS seems more beneficial only when started in the first month post-stroke. Tests at the level of function are likely more sensitive to detect beneficial rTMS effects on upper limb function than tests at the level of activity. However, heterogeneities in treatment designs and outcomes are high. Future rTMS trials should include the FMA and work toward a core set of outcome measures.
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Affiliation(s)
- Eline C C van Lieshout
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands.,Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Johanna M A Visser-Meily
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, De Hoogstraat Rehabilitation, Utrecht, Netherlands.,Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Rick M Dijkhuizen
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
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Chen YJ, Huang YZ, Chen CY, Chen CL, Chen HC, Wu CY, Lin KC, Chang TL. Intermittent theta burst stimulation enhances upper limb motor function in patients with chronic stroke: a pilot randomized controlled trial. BMC Neurol 2019; 19:69. [PMID: 31023258 PMCID: PMC6485156 DOI: 10.1186/s12883-019-1302-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 04/11/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Intermittent theta burst stimulation (iTBS) is a form of repetitive transcranial stimulation that has been used to enhance upper limb (UL) motor recovery. However, only limited studies have examined its efficacy in patients with chronic stroke and therefore it remains controversial. METHODS This was a randomized controlled trial that enrolled patients from a rehabilitation department. Twenty-two patients with first-ever chronic and unilateral cerebral stroke, aged 30-70 years, were randomly assigned to the iTBS or control group. All patients received 1 session per day for 10 days of either iTBS or sham stimulation over the ipsilesional primary motor cortex in addition to conventional neurorehabilitation. Outcome measures were assessed before and immediately after the intervention period: Modified Ashworth Scale (MAS), Fugl-Meyer Assessment Upper Extremity (FMA-UE), Action Research Arm Test (ARAT), Box and Block test (BBT), and Motor Activity Log (MAL). Analysis of covariance was adopted to compare the treatment effects between groups. RESULTS The iTBS group had greater improvement in the MAS and FMA than the control group (η2 = 0.151-0.233; p < 0.05), as well as in the ARAT and BBT (η2 = 0.161-0.460; p < 0.05) with large effect size. Both groups showed an improvement in the BBT, and there were no significant between-group differences in MAL changes. CONCLUSIONS The iTBS induced greater gains in spasticity decrease and UL function improvement, especially in fine motor function, than sham TBS. This is a promising finding because patients with chronic stroke have a relatively low potential for fine motor function recovery. Overall, iTBS may be a beneficial adjunct therapy to neurorehabilitation for enhancing UL function. Further larger-scale study is warranted to confirm the findings and its long-term effect. TRIAL REGISTRATION This trial was registered under ClinicalTrials.gov ID No. NCT01947413 on September 20, 2013.
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Affiliation(s)
- Yu-Jen Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, 5, Fushing Street, Kuei-Shan District, Taoyuan City, 33305, Taiwan
| | - Ying-Zu Huang
- Neuroscience Research Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou, Taiwan.,Institute of Cognitive Neuroscience, National Central University, Taoyuan, Taiwan.,Medical School, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Yao Chen
- Medical School, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chia-Ling Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, 5, Fushing Street, Kuei-Shan District, Taoyuan City, 33305, Taiwan. .,Graduate Institute of Early Intervention, Chang Gung University, Taoyuan, Taiwan.
| | - Hsieh-Ching Chen
- Department of Industrial and Management, National Taipei University of Technology, Taipei, Taiwan
| | - Ching-Yi Wu
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, 5, Fushing Street, Kuei-Shan District, Taoyuan City, 33305, Taiwan.,Department of Occupational Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Keh-Chung Lin
- School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzu-Ling Chang
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, 5, Fushing Street, Kuei-Shan District, Taoyuan City, 33305, Taiwan
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25
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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. [PMID: 30773896 DOI: 10.1177/0269215519829897] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The primary aim of this meta-analysis was to evaluate the effects of repetitive transcranial magnetic stimulation (rTMS) on limb movement recovery post-stroke and cortex excitability, to explore the optimal parameters of rTMS and suitable stroke population. Second, adverse events were also included. DATA SOURCES The databases of PubMed, EBSCO, MEDLINE, the Cochrane Central Register of Controlled Trials, EBM Reviews-Cochrane Database, the Chinese National Knowledge Infrastructure, and the Chinese Science and Technology Journals Database were searched for randomized controlled trials exploring the effects of rTMS on limb motor function recovery post-stroke before December 2018. REVIEW METHODS The effect sizes of rTMS on limb motor recovery, the effect size of rTMS stimulation parameters, and different stroke population were summarized by calculating the standardized mean difference (SMD) and the 95% confidence interval using fixed/random effect models as appropriate. RESULTS For the motor function assessment, 42 eligible studies involving 1168 stroke patients were identified. The summary effect size indicated that rTMS had positive effects on limb motor recovery (SMD = 0.50, P < 0.00001) and activities of daily living (SMD = 0.82, P < 0.00001), and motor-evoked potentials of the stimulated hemisphere differed according to the stimulation frequency, that is, the high-frequency group (SMD = 0.57, P = 0.0006), except the low-frequency group (SMD = -0.27, P = 0.05). No significant differences were observed among the stimulation parameter subgroups except for the sessions subgroup ( P = 0.02). Only 10 included articles reported transient mild discomfort after rTMS. CONCLUSIONS rTMS promoted the recovery of limb motor function and changed the cortex excitability. rTMS may be better for early and pure subcortical stroke patients. Regarding different stimulation parameters, the number of stimulation sessions has an impact on the effect of rTMS.
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Affiliation(s)
- Huifang Xiang
- 1 Department of Rehabilitation Medicine, Chonggang General Hospital, Chongqing, China
| | - Jing Sun
- 2 Department of Gastrointestinal Neonatal Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xiang Tang
- 3 Department of Neurology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kebin Zeng
- 3 Department of Neurology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiushu Wu
- 3 Department of Neurology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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26
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Gavaret M, Marchi A, Lefaucheur JP. Clinical neurophysiology of stroke. HANDBOOK OF CLINICAL NEUROLOGY 2019; 161:109-119. [PMID: 31307595 DOI: 10.1016/b978-0-444-64142-7.00044-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Stroke constitutes the third most common cause of death and the leading cause of acquired neurologic handicap. During ischemic stroke, very early after the onset of the focal perfusion deficit, excitotoxicity triggers a number of events that can further contribute to tissue death. Such events include peri-infarct depolarizations and spreading depolarizations (SDs) within the ischemic penumbra. SDs spread slowly through continuous gray matter at a typical velocity of 2-5mm/min. SDs exacerbate neuronal injury through prolonged ionic breakdown and SD-related hypoperfusion (spreading ischemia). Scalp EEG alone is not yet sufficient to reliably diagnose SDs. Hyperexcitability occurs in parallel, both in the acute and chronic phases of stroke. Stroke is a common cause of new-onset epileptic seizures after middle age and is the leading cause of symptomatic epilepsy in adults. The last part of this chapter is dedicated to noninvasive neurophysiologic techniques that can be used to promote stroke rehabilitation. These techniques mainly include repetitive transcranial magnetic stimulation and tDCS. These approaches are based on the concept of interhemispheric rivalry and aim at modulating the imbalance of cortical activities between both hemispheres resulting from stroke.
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Affiliation(s)
- Martine Gavaret
- INSERM UMR894, Paris Descartes University, Paris, France; Service de Neurophysiologie Clinique, Centre Hospitalier Sainte Anne, Paris, France.
| | - Angela Marchi
- Service de Neurophysiologie Clinique, Centre Hospitalier Sainte Anne, Paris, France
| | - Jean-Pascal Lefaucheur
- Service de Physiologie-Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France; EA 4391, Université Paris Est Créteil, Créteil, France
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Platz T, Adler-Wiebe M, Roschka S, Lotze M. Enhancement of motor learning by focal intermittent theta burst stimulation (iTBS) of either the primary motor (M1) or somatosensory area (S1) in healthy human subjects. Restor Neurol Neurosci 2018; 36:117-130. [PMID: 29439364 DOI: 10.3233/rnn-170774] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Motor rehabilitation after brain damage relies on motor re-learning as induced by specific training. Non-invasive brain stimulation (NIBS) can alter cortical excitability and thereby has a potential to enhance subsequent training-induced learning. Knowledge about any priming effects of NIBS on motor learning in healthy subjects can help to design targeted therapeutic applications in brain-damaged subjects. OBJECTIVE To examine whether complex motor learning in healthy subjects can be enhanced by intermittent theta burst stimulation (iTBS) to primary motor or sensory cortical areas. METHODS Eighteen young healthy subjects trained eight different arm motor tasks (arm ability training, AAT) once a day for 5 days using their left non-dominant arm. Except for day 1 (baseline), training was performed after applying an excitatory form of repetitive transcranial magnetic stimulation (iTBS) to either (I) right M1 or (II) S1, or (III) sham stimulation to the right M1. Subjects were randomly assigned to conditions I, II, or III. RESULTS A principal component analysis of the motor behaviour data suggested eight independent motor abilities corresponding to the 8 trained tasks. AAT induced substantial motor learning across abilities with generalisation to a non-trained test of finger dexterity (Nine-Hole-Peg-Test, NHPT). Participants receiving iTBS (to either M1 or S1) showed better performance with the AAT tasks over the period of training compared to sham stimulation as well as a bigger improvement with the generalisation task (NHPT) for the trained left hand after training completion. CONCLUSION Priming with an excitatory repetitive transcranial magnetic stimulation as iTBS of either M1 or S1 can enhance motor learning across different sensorimotor abilities.
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Affiliation(s)
- Thomas Platz
- BDH-Klinik Greifswald, Centre for Neurorehabilitation, Intensive and Ventilation Care, Spinal Cord Injury Unit, Ernst-Moritz-Arndt-Universität, Greifswald, Germany
| | - Marija Adler-Wiebe
- BDH-Klinik Greifswald, Centre for Neurorehabilitation, Intensive and Ventilation Care, Spinal Cord Injury Unit, Ernst-Moritz-Arndt-Universität, Greifswald, Germany
| | - Sybille Roschka
- BDH-Klinik Greifswald, Centre for Neurorehabilitation, Intensive and Ventilation Care, Spinal Cord Injury Unit, Ernst-Moritz-Arndt-Universität, Greifswald, Germany
| | - Martin Lotze
- Department of Functional Imaging, Center for Diagnostic Radiology and Neuroradiology, Ernst-Moritz-Arndt-Universität, Greifswald, Germany
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Priming With 1-Hz Repetitive Transcranial Magnetic Stimulation Over Contralesional Leg Motor Cortex Does Not Increase the Rate of Regaining Ambulation Within 3 Months of Stroke. Am J Phys Med Rehabil 2018; 97:339-345. [DOI: 10.1097/phm.0000000000000850] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Khan FR, Chevidikunnan MF. Effectiveness of central plus peripheral stimulation (CPPS) on post stroke upper limb motor rehabilitation. Brain Inj 2017; 31:1494-1500. [PMID: 28956646 DOI: 10.1080/02699052.2017.1377353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE This study was to assess the motor-cortex integrity and reaction time of the upper limb in patients early after stroke after CPPS approach with Theta Burst Stimulation (TBS) an repetitive Trans-cranial Magnetic Stimulation (TMS) paradigm and Neuromuscular Electrical Stimulation (NMES). METHODS Ten patients and ten age matched controls underwent three experimental sessions in three consecutive weeks. First-week W1 (TBS) with TBS alone, second-week W2 (NMES) with NMES alone and third-week W3 (TBS + NMES) with both TBS and NMES given sequentially. Cortical excitability was assessed with single pulse TMS stimulator before and immediately after the three interventions for Resting Motor Threshold (RMT) from the ipsilesional and contralesional hemisphere in the corresponding first dorsal interossei muscle of the ipsilateral and contralateral hand. Post intervention functional assessment was done with 9 Hole Peg Test (9PHT) for change in reaction time (RT) for both ipsilataral and contralateral hand. RESULTS All the three interventions showed significant improvement from the baseline, however W3 (TBS + NMES) showed significantly greater improvement when compared to other interventions in RMT and 9 HPT. CONCLUSION CPPS with TBS and NMES showed synergistic effect in both electrophysiological and clinical assessment. A combined approach (CPPS) may be more effective for post-stroke motor rehabilitation.
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Affiliation(s)
- Fayaz Rahman Khan
- a Department of Physical Therapy, Faculty of Applied Medical Science , King Abdulaziz University , Jeddah , Saudi Arabia
| | - Mohamed Faisal Chevidikunnan
- a Department of Physical Therapy, Faculty of Applied Medical Science , King Abdulaziz University , Jeddah , Saudi Arabia
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Fong PY, Chuang WY, Huang YZ, Chang CH. Safety of carotid artery stent in repetitive transcranial magnetic stimulation-The histopathological proof from swine carotid artery. Neurosci Lett 2017; 657:194-198. [PMID: 28782579 DOI: 10.1016/j.neulet.2017.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 07/24/2017] [Accepted: 08/01/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Repetitive transcranial magnetic stimulation (rTMS), including theta burst stimulation (TBS), is considered helpful for functional recovery in post-stroke patients. However, the safety is a common concern forusingr TMS for neuro-rehabilitation and research in patients with stents. METHOD Prolonged continuous theta burst stimulation (cTBS) with 1200 pulses at 50% of maximum output of Magstim Super Rapid2 was delivered in three different angles to a carotid stent placed in an isolated fresh swine carotid artery or on a table at a distance of 5cm. The possible migration and temperature change of the stent caused by cTBS was monitored by video recording and a digital thermometer, respectively. Histopathological study with hematoxylin and eosin stain were done on the vessel wall to identify possible micro thermal injury. RESULTS Stents in vessels did not cause any significant morphology change, such as thermal damage, after cTBS was given at three different angles. Neither visible migration nor significant temperature elevation was induced by cTBS. CONCLUSION There was no temperature change, thermal injury or migration after prolonged TBS at a high intensity, suggesting TBS is safe for clinical neuro-rehabilitation and physiological assessments in stroke patients with vascular stents.
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Affiliation(s)
- Po-Yu Fong
- Movement Disorder Division, Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Neuroscience Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Wen-Yu Chuang
- Department of Pathology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ying-Zu Huang
- Movement Disorder Division, Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Neuroscience Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan; Institute of Cognitive Neuroscience, National Central University, Taoyuan, Taiwan
| | - Chien-Hung Chang
- School of Medicine, Chang Gung University, Taoyuan, Taiwan; Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Electrical Engineering, College of Engineering, Chang Gung University, 259 Wen-Hwa 1 st Road, Kweishan, Taoyuan 333, Taiwan.
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Theta burst stimulation a new paradigm of non-invasive brain stimulation for post-stroke upper limb motor rehabilitation. Turk J Phys Med Rehabil 2017; 63:193-196. [PMID: 31453452 DOI: 10.5606/tftrd.2017.417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 07/26/2016] [Indexed: 11/21/2022] Open
Abstract
Objectives The aim of this study was to perform a brief review of studies which investigated the effects of theta burst stimulation (TBS) as a new paradigm of non-invasive brain stimulation on the upper limb motor function in patients with stroke. Materials and methods We searched studies published between January 1990 and October 2015 at PubMed, Medline, Cochrane, and CINAHL databases using the following key words: stroke and theta burst stimulation. Results Eleven of 67 studies met the inclusion criteria. Of these, six studies used multiple sessions of TBS intervention. The results of the selected studies showed a significant improvement in the upper limb motor functions in nine studies, whereas one study did not show any change after the TBS intervention. One of the selected study showed a negative trend in motor functions after the application of TBS. Conclusion Our study showed that TBS had a positive effect on motor recovery in patients with stroke. Combination of both intermittent TBS to the ipsilesional hemisphere and continuous TBS to the contralesional hemispheres would be more effective than the single application of any one of these technique.
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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. [PMID: 28786336 DOI: 10.1177/0269215517692386] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective: The aim of this study was to evaluate the short- and long-term effects as well as other parameters of repetitive transcranial magnetic stimulation (rTMS) on upper limb motor functional recovery after stroke. Data sources: The databases of PubMed, Medline, Science Direct, Cochrane, and Embase were searched for randomized controlled studies reporting effects of rTMS on upper limb motor recovery published before October 30, 2016. Review methods: The short- and long-term mean effect sizes as well as the effect size of rTMS frequency of pulse, post-stroke onset, and theta burst stimulation patterns were summarized by calculating the standardized mean difference (SMD) and the 95% confidence interval using fixed/random effect models as appropriate. Results: Thirty-four studies with 904 participants were included in this systematic review. Pooled estimates show that rTMS significantly improved short-term (SMD, 0.43; P < 0.001) and long-term (SMD, 0.49; P < 0.001) manual dexterity. More pronounced effects were found for rTMS administered in the acute phase of stroke (SMD, 0.69), subcortical stroke (SMD, 0.66), 5-session rTMS treatment (SMD, 0.67) and intermittent theta burst stimulation (SMD, 0.60). Only three studies reported mild adverse events such as headache and increased anxiety . Conclusions: Five-session rTMS treatment could best improve stroke-induced upper limb dyskinesia acutely and in a long-lasting manner. Intermittent theta burst stimulation is more beneficial than continuous theta burst stimulation. rTMS applied in the acute phase of stroke is more effective than rTMS applied in the chronic phase. Subcortical lesion benefit more from rTMS than other lesion site.
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Affiliation(s)
- Lan Zhang
- Department of Radiology & Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China
| | - Guoqiang Xing
- Department of Radiology & Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China
- Lotus Biotech.com LLC., John Hopkins University-MCC, Rockville, Maryland, USA
| | - Youlin Fan
- Department of Radiology & Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China
| | - Zhiwei Guo
- Department of Radiology & Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China
| | - Huaping Chen
- Department of Radiology & Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China
| | - Qiwen Mu
- Department of Radiology & Imaging Institute of Rehabilitation and Development of Brain Function, The Second Clinical Medical College of North Sichuan Medical College Nanchong Central Hospital, Nanchong, China
- Peking University Third Hospital, Beijing, China
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Hsu CC, Lee WK, Shyu KK, Chang HH, Yeh TK, Hsu HT, Chang CY, Lan GY, Lee PL. Study of Repetitive Movements Induced Oscillatory Activities in Healthy Subjects and Chronic Stroke Patients. Sci Rep 2016; 6:39046. [PMID: 27976723 PMCID: PMC5157038 DOI: 10.1038/srep39046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 11/17/2016] [Indexed: 11/29/2022] Open
Abstract
Repetitive movements at a constant rate require the integration of internal time counting and motor neural networks. Previous studies have proved that humans can follow short durations automatically (automatic timing) but require more cognitive efforts to track or estimate long durations. In this study, we studied sensorimotor oscillatory activities in healthy subjects and chronic stroke patients when subjects were performing repetitive finger movements. We found the movement-modulated changes in alpha and beta oscillatory activities were decreased with the increase of movement rates in finger lifting of healthy subjects and the non-paretic hands in stroke patients, whereas no difference was found in the paretic-hand movements at different movement rates in stroke patients. The significant difference in oscillatory activities between movements of non-paretic hands and paretic hands could imply the requirement of higher cognitive efforts to perform fast repetitive movements in paretic hands. The sensorimotor oscillatory response in fast repetitive movements could be a possible indicator to probe the recovery of motor function in stroke patients.
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Affiliation(s)
- Chuan-Chih Hsu
- Division of Cardiovascular Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Wai-Keung Lee
- Department of Rehabilitation, Tao Yuan General Hospital, Taoyuan, Taiwan
| | - Kuo-Kai Shyu
- Department of Electrical Engineering, National Central University, Taoyuan City 32001, Taiwan
| | - Hsiao-Huang Chang
- Division of Cardiovascular Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ting-Kuang Yeh
- Science Education Center, National Taiwan Normal University, Taipei, Taiwan
| | - Hao-Teng Hsu
- Department of Electrical Engineering, National Central University, Taoyuan City 32001, Taiwan
| | - Chun-Yen Chang
- Science Education Center, National Taiwan Normal University, Taipei, Taiwan
| | - Gong-Yau Lan
- Section of General Diagnostic Radiology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Po-Lei Lee
- Department of Electrical Engineering, National Central University, Taoyuan City 32001, Taiwan
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Song W, Amer A, Ryan D, Martin JH. Combined motor cortex and spinal cord neuromodulation promotes corticospinal system functional and structural plasticity and motor function after injury. Exp Neurol 2015; 277:46-57. [PMID: 26708732 DOI: 10.1016/j.expneurol.2015.12.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 12/07/2015] [Accepted: 12/15/2015] [Indexed: 11/29/2022]
Abstract
An important strategy for promoting voluntary movements after motor system injury is to harness activity-dependent corticospinal tract (CST) plasticity. We combine forelimb motor cortex (M1) activation with co-activation of its cervical spinal targets in rats to promote CST sprouting and skilled limb movement after pyramidal tract lesion (PTX). We used a two-step experimental design in which we first established the optimal combined stimulation protocol in intact rats and then used the optimal protocol in injured animals to promote CST repair and motor recovery. M1 was activated epidurally using an electrical analog of intermittent theta burst stimulation (iTBS). The cervical spinal cord was co-activated by trans-spinal direct current stimulation (tsDCS) that was targeted to the cervical enlargement, simulated from finite element method. In intact rats, forelimb motor evoked potentials (MEPs) were strongly facilitated during iTBS and for 10 min after cessation of stimulation. Cathodal, not anodal, tsDCS alone facilitated MEPs and also produced a facilitatory aftereffect that peaked at 10 min. Combined iTBS and cathodal tsDCS (c-tsDCS) produced further MEP enhancement during stimulation, but without further aftereffect enhancement. Correlations between forelimb M1 local field potentials and forelimb electromyogram (EMG) during locomotion increased after electrical iTBS alone and further increased with combined stimulation (iTBS+c-tsDCS). This optimized combined stimulation was then used to promote function after PTX because it enhanced functional connections between M1 and spinal circuits and greater M1 engagement in muscle contraction than either stimulation alone. Daily application of combined M1 iTBS on the intact side and c-tsDCS after PTX (10 days, 27 min/day) significantly restored skilled movements during horizontal ladder walking. Stimulation produced a 5.4-fold increase in spared ipsilateral CST terminations. Combined neuromodulation achieves optimal motor recovery and substantial CST outgrowth with only 27 min of daily stimulation compared with 6h, as in our prior study, making it a potential therapy for humans with spinal cord injury.
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Affiliation(s)
- Weiguo Song
- Department of Physiology, Pharmacology and Neuroscience, City College of the City University of New York, New York, NY 10031, USA
| | - Alzahraa Amer
- Department of Physiology, Pharmacology and Neuroscience, City College of the City University of New York, New York, NY 10031, USA
| | - Daniel Ryan
- Department of Physiology, Pharmacology and Neuroscience, City College of the City University of New York, New York, NY 10031, USA
| | - John H Martin
- Department of Physiology, Pharmacology and Neuroscience, City College of the City University of New York, New York, NY 10031, USA.
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Singh AM, Neva JL, Staines WR. Aerobic exercise enhances neural correlates of motor skill learning. Behav Brain Res 2015; 301:19-26. [PMID: 26706889 DOI: 10.1016/j.bbr.2015.12.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 12/10/2015] [Accepted: 12/13/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Repetitive, in-phase bimanual motor training tasks can expand the excitable cortical area of the trained muscles. Recent evidence suggests that an acute bout of moderate-intensity aerobic exercise can enhance the induction of rapid motor plasticity at the motor hotspot. However, these changes have not been investigated throughout the entire cortical representation. Furthermore, it is unclear how exercise-induced changes in excitability may relate to motor performance. We investigated whether aerobic exercise could enhance the neural correlates of motor learning. We hypothesized that the combination of exercise and training would increase the excitable cortical area to a greater extent than either exercise or training alone, and that the addition of exercise would enhance performance on a motor training task. METHODS 25 young, healthy, right-handed individuals were recruited and divided into two groups and three experimental conditions. The exercise group performed exercise alone (EX) and exercise followed by training (EXTR) while the training group performed training alone (TR). RESULTS The combination of exercise and training increased excitability within the cortical map of the trained muscle to a greater extent than training alone. However, there was no difference in performance between the two groups. These results indicate that exercise may enhance the cortical adaptations to motor skill learning.
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Affiliation(s)
- Amaya M Singh
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada.
| | - Jason L Neva
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
| | - W Richard Staines
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
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Koganemaru S, Fukuyama H, Mima T. Two is More Than One: How to Combine Brain Stimulation Rehabilitative Training for Functional Recovery? Front Syst Neurosci 2015; 9:154. [PMID: 26617497 PMCID: PMC4639697 DOI: 10.3389/fnsys.2015.00154] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 10/26/2015] [Indexed: 01/24/2023] Open
Abstract
A number of studies have shown that non-invasive brain stimulation has an additional effect in combination with rehabilitative therapy to enhance functional recovery than either therapy alone. The combination enhances use-dependent plasticity induced by repetitive training. The neurophysiological mechanism of the effects of this combination is based on associative plasticity. However, these effects were not reported in all cases. We propose a list of possible strategies to achieve an effective association between rehabilitative training with brain stimulation for plasticity: (1) control of temporal aspect between stimulation and task execution; (2) the use of a shaped task for the combination; (3) the appropriate stimulation of neuronal circuits where use-dependent plastic changes occur; and (4) phase synchronization between rhythmically patterned brain stimulation and task-related patterned activities of neurons. To better utilize brain stimulation in neuro-rehabilitation, it is important to develop more effective techniques to combine them.
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Affiliation(s)
- Satoko Koganemaru
- Brain Integrative Science, Kyoto University School of Medicine Sakyo-ku, Kyoto, Japan ; Human Brain Research Center, Kyoto University School of Medicine Sakyo-ku, Kyoto, Japan
| | - Hidenao Fukuyama
- Human Brain Research Center, Kyoto University School of Medicine Sakyo-ku, Kyoto, Japan
| | - Tatsuya Mima
- Human Brain Research Center, Kyoto University School of Medicine Sakyo-ku, Kyoto, Japan
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Bates KA, Rodger J. Repetitive transcranial magnetic stimulation for stroke rehabilitation-potential therapy or misplaced hope? Restor Neurol Neurosci 2015; 33:557-69. [DOI: 10.3233/rnn-130359] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Wischnewski M, Schutter DJLG. Efficacy and Time Course of Theta Burst Stimulation in Healthy Humans. Brain Stimul 2015; 8:685-92. [PMID: 26014214 DOI: 10.1016/j.brs.2015.03.004] [Citation(s) in RCA: 174] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 03/12/2015] [Accepted: 03/20/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In the past decade research has shown that continuous (cTBS) and intermittent theta burst stimulation (iTBS) alter neuronal excitability levels in the primary motor cortex. OBJECTIVE Quantitatively review the magnitude and time course on cortical excitability of cTBS and iTBS. METHODS Sixty-four TBS studies published between January 2005 and October 2014 were retrieved from the scientific search engine PubMED and included for analyses. The main inclusion criteria involved stimulation of the primary motor cortex in healthy volunteers with no motor practice prior to intervention and motor evoked potentials as primary outcome measure. RESULTS ITBS applied for 190 s significantly increases cortical excitability up to 60 min with a mean maximum potentiation of 35.54 ± 3.32%. CTBS applied for 40 s decreases cortical excitability up to 50 min with a mean maximum depression of -22.81 ± 2.86%, while cTBS applied for 20 s decreases cortical excitability (mean maximum -27.84 ± 4.15%) for 20 min. CONCLUSION The present findings offer normative insights into the magnitude and time course of TBS-induced changes in cortical excitability levels.
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Affiliation(s)
- Miles Wischnewski
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, the Netherlands.
| | - Dennis J L G Schutter
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, the Netherlands
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Repetitive transcranial magnetic stimulation for motor recovery of the upper limb after stroke. PROGRESS IN BRAIN RESEARCH 2015; 218:281-311. [DOI: 10.1016/bs.pbr.2014.12.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Chervyakov AV, Poydasheva AG, Korzhova JE, Suponeva NA, Chernikova LA, Piradov MA. Repetitive transcranial magnetic stimulation in neurology and psychiatry. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:7-18. [DOI: 10.17116/jnevro20151151127-18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Kukke SN, de Campos AC, Damiano D, Alter KE, Patronas N, Hallett M. Cortical activation and inter-hemispheric sensorimotor coherence in individuals with arm dystonia due to childhood stroke. Clin Neurophysiol 2014; 126:1589-98. [PMID: 25499610 DOI: 10.1016/j.clinph.2014.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 11/04/2014] [Accepted: 11/05/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Dystonia is a disabling motor disorder often without effective therapies. To better understand the genesis of dystonia after childhood stroke, we analyzed electroencephalographic (EEG) recordings in this population. METHODS Resting spectral power of EEG signals over bilateral sensorimotor cortices (Powrest), resting inter-hemispheric sensorimotor coherence (Cohrest), and task-related changes in power (TRPow) and coherence (TRCoh) during wrist extension were analyzed in individuals with dystonia (age 20±3years) and healthy volunteers (age 17±5years). RESULTS Ipsilesional TRPow decrease was significantly lower in patients than controls during the more affected wrist task. Force deficits of the affected wrist correlated with reduced alpha TRPow decrease on the ipsilesional and not the contralesional hemisphere. Cohrest was significantly lower in patients than controls, and correlated with more severe dystonia and poorer hand function. Powrest and TRCoh were similar between groups. CONCLUSIONS The association between weakness and cortical activation during wrist extension highlights the importance of ipsilesional sensorimotor activation on function. Reduction of Cohrest in patients reflects a loss of inter-hemispheric connectivity that may result from structural changes and neuroplasticity, potentially contributing to the development of dystonia. SIGNIFICANCE Cortical and motor dysfunction are correlated in patients with childhood stroke and may in part explain the genesis of dystonia.
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Affiliation(s)
- Sahana N Kukke
- Biomedical Engineering Department, The Catholic University of America, USA; Rehabilitation Medicine Department, National Institutes of Health Clinical Center, USA; National Institute of Neurological Disorders and Stroke, National Institutes of Health, USA
| | | | - Diane Damiano
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center, USA
| | - Katharine E Alter
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center, USA; Mount Washington Pediatric Hospital, USA
| | - Nicholas Patronas
- Radiology Department, National Institutes of Health Clinical Center, USA
| | - Mark Hallett
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, USA.
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Frantzidis CA, Vivas AB, Tsolaki A, Klados MA, Tsolaki M, Bamidis PD. Functional disorganization of small-world brain networks in mild Alzheimer's Disease and amnestic Mild Cognitive Impairment: an EEG study using Relative Wavelet Entropy (RWE). Front Aging Neurosci 2014; 6:224. [PMID: 25206333 PMCID: PMC4144118 DOI: 10.3389/fnagi.2014.00224] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 08/08/2014] [Indexed: 11/13/2022] Open
Abstract
Previous neuroscientific findings have linked Alzheimer's Disease (AD) with less efficient information processing and brain network disorganization. However, pathological alterations of the brain networks during the preclinical phase of amnestic Mild Cognitive Impairment (aMCI) remain largely unknown. The present study aimed at comparing patterns of the detection of functional disorganization in MCI relative to Mild Dementia (MD). Participants consisted of 23 cognitively healthy adults, 17 aMCI and 24 mild AD patients who underwent electroencephalographic (EEG) data acquisition during a resting-state condition. Synchronization analysis through the Orthogonal Discrete Wavelet Transform (ODWT), and directional brain network analysis were applied on the EEG data. This computational model was performed for networks that have the same number of edges (N = 500, 600, 700, 800 edges) across all participants and groups (fixed density values). All groups exhibited a small-world (SW) brain architecture. However, we found a significant reduction in the SW brain architecture in both aMCI and MD patients relative to the group of Healthy controls. This functional disorganization was also correlated with the participant's generic cognitive status. The deterioration of the network's organization was caused mainly by deficient local information processing as quantified by the mean cluster coefficient value. Functional hubs were identified through the normalized betweenness centrality metric. Analysis of the local characteristics showed relative hub preservation even with statistically significant reduced strength. Compensatory phenomena were also evident through the formation of additional hubs on left frontal and parietal regions. Our results indicate a declined functional network organization even during the prodromal phase. Degeneration is evident even in the preclinical phase and coexists with transient network reorganization due to compensation.
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Affiliation(s)
- Christos A Frantzidis
- Laboratory of Medical Physics, Faculty of Health Sciences, Medical School, Aristotle University of Thessaloniki Thessaloniki, Greece
| | - Ana B Vivas
- Psychology Department, City College, The University of Sheffield International Faculty Thessaloniki, Greece
| | - Anthoula Tsolaki
- Laboratory of Medical Physics, Faculty of Health Sciences, Medical School, Aristotle University of Thessaloniki Thessaloniki, Greece ; Greek Association of Alzheimer's Disease and related Disorders Thessaloniki, Greece
| | - Manousos A Klados
- Laboratory of Medical Physics, Faculty of Health Sciences, Medical School, Aristotle University of Thessaloniki Thessaloniki, Greece
| | - Magda Tsolaki
- 3rd Department of Neurology, Medical School, Aristotle University of Thessaloniki Thessaloniki, Greece
| | - Panagiotis D Bamidis
- Laboratory of Medical Physics, Faculty of Health Sciences, Medical School, Aristotle University of Thessaloniki Thessaloniki, Greece
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Lefaucheur JP, André-Obadia N, Antal A, Ayache SS, Baeken C, Benninger DH, Cantello RM, Cincotta M, de Carvalho M, De Ridder D, Devanne H, Di Lazzaro V, Filipović SR, Hummel FC, Jääskeläinen SK, Kimiskidis VK, Koch G, Langguth B, Nyffeler T, Oliviero A, Padberg F, Poulet E, Rossi S, Rossini PM, Rothwell JC, Schönfeldt-Lecuona C, Siebner HR, Slotema CW, Stagg CJ, Valls-Sole J, Ziemann U, Paulus W, Garcia-Larrea L. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clin Neurophysiol 2014; 125:2150-2206. [PMID: 25034472 DOI: 10.1016/j.clinph.2014.05.021] [Citation(s) in RCA: 1249] [Impact Index Per Article: 124.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/09/2014] [Accepted: 05/13/2014] [Indexed: 12/11/2022]
Abstract
A group of European experts was commissioned to establish guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS) from evidence published up until March 2014, regarding pain, movement disorders, stroke, amyotrophic lateral sclerosis, multiple sclerosis, epilepsy, consciousness disorders, tinnitus, depression, anxiety disorders, obsessive-compulsive disorder, schizophrenia, craving/addiction, and conversion. Despite unavoidable inhomogeneities, there is a sufficient body of evidence to accept with level A (definite efficacy) the analgesic effect of high-frequency (HF) rTMS of the primary motor cortex (M1) contralateral to the pain and the antidepressant effect of HF-rTMS of the left dorsolateral prefrontal cortex (DLPFC). A Level B recommendation (probable efficacy) is proposed for the antidepressant effect of low-frequency (LF) rTMS of the right DLPFC, HF-rTMS of the left DLPFC for the negative symptoms of schizophrenia, and LF-rTMS of contralesional M1 in chronic motor stroke. The effects of rTMS in a number of indications reach level C (possible efficacy), including LF-rTMS of the left temporoparietal cortex in tinnitus and auditory hallucinations. It remains to determine how to optimize rTMS protocols and techniques to give them relevance in routine clinical practice. In addition, professionals carrying out rTMS protocols should undergo rigorous training to ensure the quality of the technical realization, guarantee the proper care of patients, and maximize the chances of success. Under these conditions, the therapeutic use of rTMS should be able to develop in the coming years.
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Affiliation(s)
- Jean-Pascal Lefaucheur
- Department of Physiology, Henri Mondor Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, France; EA 4391, Nerve Excitability and Therapeutic Team, Faculty of Medicine, Paris Est Créteil University, Créteil, France.
| | - Nathalie André-Obadia
- Neurophysiology and Epilepsy Unit, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France; Inserm U 1028, NeuroPain Team, Neuroscience Research Center of Lyon (CRNL), Lyon-1 University, Bron, France
| | - Andrea Antal
- Department of Clinical Neurophysiology, Georg-August University, Göttingen, Germany
| | - Samar S Ayache
- Department of Physiology, Henri Mondor Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, France; EA 4391, Nerve Excitability and Therapeutic Team, Faculty of Medicine, Paris Est Créteil University, Créteil, France
| | - Chris Baeken
- Department of Psychiatry and Medical Psychology, Ghent Experimental Psychiatry (GHEP) Lab, Ghent University, Ghent, Belgium; Department of Psychiatry, University Hospital (UZBrussel), Brussels, Belgium
| | - David H Benninger
- Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Roberto M Cantello
- Department of Translational Medicine, Section of Neurology, University of Piemonte Orientale "A. Avogadro", Novara, Italy
| | | | - Mamede de Carvalho
- Institute of Physiology, Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, Portugal
| | - Dirk De Ridder
- Brai(2)n, Tinnitus Research Initiative Clinic Antwerp, Belgium; Department of Neurosurgery, University Hospital Antwerp, Belgium
| | - Hervé Devanne
- Department of Clinical Neurophysiology, Lille University Hospital, Lille, France; ULCO, Lille-Nord de France University, Lille, France
| | - Vincenzo Di Lazzaro
- Department of Neurosciences, Institute of Neurology, Campus Bio-Medico University, Rome, Italy
| | - Saša R Filipović
- Department of Neurophysiology, Institute for Medical Research, University of Belgrade, Beograd, Serbia
| | - Friedhelm C Hummel
- Brain Imaging and Neurostimulation (BINS) Laboratory, Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Satu K Jääskeläinen
- Department of Clinical Neurophysiology, Turku University Hospital, University of Turku, Turku, Finland
| | - Vasilios K Kimiskidis
- Laboratory of Clinical Neurophysiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Giacomo Koch
- Non-Invasive Brain Stimulation Unit, Neurologia Clinica e Comportamentale, Fondazione Santa Lucia IRCCS, Rome, Italy
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
| | - Thomas Nyffeler
- Perception and Eye Movement Laboratory, Department of Neurology, University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Antonio Oliviero
- FENNSI Group, Hospital Nacional de Parapléjicos, SESCAM, Toledo, Spain
| | - Frank Padberg
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - Emmanuel Poulet
- Department of Emergency Psychiatry, CHU Lyon, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France; EAM 4615, Lyon-1 University, Bron, France
| | - Simone Rossi
- Brain Investigation & Neuromodulation Lab, Unit of Neurology and Clinical Neurophysiology, Department of Neuroscience, University of Siena, Siena, Italy
| | - Paolo Maria Rossini
- Brain Connectivity Laboratory, IRCCS San Raffaele Pisana, Rome, Italy; Institute of Neurology, Catholic University, Rome, Italy
| | - John C Rothwell
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, London, United Kingdom
| | | | - Hartwig R Siebner
- Department of Neurology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark; Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | | | - Charlotte J Stagg
- Oxford Centre for Functional MRI of the Brain (FMRIB), Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Josep Valls-Sole
- EMG Unit, Neurology Service, Hospital Clinic, Department of Medicine, University of Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Ulf Ziemann
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard Karls University, Tübingen, Germany
| | - Walter Paulus
- Department of Clinical Neurophysiology, Georg-August University, Göttingen, Germany
| | - Luis Garcia-Larrea
- Inserm U 1028, NeuroPain Team, Neuroscience Research Center of Lyon (CRNL), Lyon-1 University, Bron, France; Pain Unit, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France
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Gharabaghi A, Kraus D, Leão MT, Spüler M, Walter A, Bogdan M, Rosenstiel W, Naros G, Ziemann U. Coupling brain-machine interfaces with cortical stimulation for brain-state dependent stimulation: enhancing motor cortex excitability for neurorehabilitation. Front Hum Neurosci 2014; 8:122. [PMID: 24634650 PMCID: PMC3942791 DOI: 10.3389/fnhum.2014.00122] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 02/19/2014] [Indexed: 12/20/2022] Open
Abstract
Motor recovery after stroke is an unsolved challenge despite intensive rehabilitation training programs. Brain stimulation techniques have been explored in addition to traditional rehabilitation training to increase the excitability of the stimulated motor cortex. This modulation of cortical excitability augments the response to afferent input during motor exercises, thereby enhancing skilled motor learning by long-term potentiation-like plasticity. Recent approaches examined brain stimulation applied concurrently with voluntary movements to induce more specific use-dependent neural plasticity during motor training for neurorehabilitation. Unfortunately, such approaches are not applicable for the many severely affected stroke patients lacking residual hand function. These patients require novel activity-dependent stimulation paradigms based on intrinsic brain activity. Here, we report on such brain state-dependent stimulation (BSDS) combined with haptic feedback provided by a robotic hand orthosis. Transcranial magnetic stimulation (TMS) of the motor cortex and haptic feedback to the hand were controlled by sensorimotor desynchronization during motor-imagery and applied within a brain-machine interface (BMI) environment in one healthy subject and one patient with severe hand paresis in the chronic phase after stroke. BSDS significantly increased the excitability of the stimulated motor cortex in both healthy and post-stroke conditions, an effect not observed in non-BSDS protocols. This feasibility study suggests that closing the loop between intrinsic brain state, cortical stimulation and haptic feedback provides a novel neurorehabilitation strategy for stroke patients lacking residual hand function, a proposal that warrants further investigation in a larger cohort of stroke patients.
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Affiliation(s)
- Alireza Gharabaghi
- Division of Functional and Restorative Neurosurgery, Division of Translational Neurosurgery, Department of Neurosurgery, Eberhard Karls University Tuebingen Tuebingen, Germany ; Neuroprosthetics Research Group, Department of Integrative Neuroscience, Werner Reichardt Centre, Eberhard Karls University Tübingen, Germany
| | - Dominic Kraus
- Division of Functional and Restorative Neurosurgery, Division of Translational Neurosurgery, Department of Neurosurgery, Eberhard Karls University Tuebingen Tuebingen, Germany ; Neuroprosthetics Research Group, Department of Integrative Neuroscience, Werner Reichardt Centre, Eberhard Karls University Tübingen, Germany
| | - Maria T Leão
- Division of Functional and Restorative Neurosurgery, Division of Translational Neurosurgery, Department of Neurosurgery, Eberhard Karls University Tuebingen Tuebingen, Germany ; Neuroprosthetics Research Group, Department of Integrative Neuroscience, Werner Reichardt Centre, Eberhard Karls University Tübingen, Germany
| | - Martin Spüler
- Department of Computer Engineering, Wilhelm-Schickard Institute for Computer Science, Eberhard Karls University Tuebingen Tuebingen, Germany
| | - Armin Walter
- Department of Computer Engineering, Wilhelm-Schickard Institute for Computer Science, Eberhard Karls University Tuebingen Tuebingen, Germany
| | - Martin Bogdan
- Department of Computer Engineering, Wilhelm-Schickard Institute for Computer Science, Eberhard Karls University Tuebingen Tuebingen, Germany ; Department of Computer Engineering, University of Leipzig Leipzig, Germany
| | - Wolfgang Rosenstiel
- Department of Computer Engineering, Wilhelm-Schickard Institute for Computer Science, Eberhard Karls University Tuebingen Tuebingen, Germany
| | - Georgios Naros
- Division of Functional and Restorative Neurosurgery, Division of Translational Neurosurgery, Department of Neurosurgery, Eberhard Karls University Tuebingen Tuebingen, Germany ; Neuroprosthetics Research Group, Department of Integrative Neuroscience, Werner Reichardt Centre, Eberhard Karls University Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology and Stroke, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tuebingen Tuebingen, Germany
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Frantzidis CA, Ladas AKI, Vivas AB, Tsolaki M, Bamidis PD. Cognitive and physical training for the elderly: evaluating outcome efficacy by means of neurophysiological synchronization. Int J Psychophysiol 2014; 93:1-11. [PMID: 24472698 DOI: 10.1016/j.ijpsycho.2014.01.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 01/17/2014] [Accepted: 01/20/2014] [Indexed: 10/25/2022]
Abstract
Recent neuroscientific research has demonstrated that both healthy and pathological aging induces alterations in the co-operative capacity of neuronal populations in the brain. Both compensatory and neurodegenerative mechanisms contribute to neurophysiological synchronization patterns, which provide a valuable marker for age-related cognitive decline. In this study, we propose that neuroplasticity-based training may facilitate coherent interaction of distant brain regions and consequently enhance cognitive performance in elderly people. If this is true, this would make neurophysiological synchronization a valid outcome measure to assess the efficacy of non-pharmacological interventions to prevent or delay age-related cognitive decline. The present study aims at providing an objective, synchronization-based tool to assess cognitive and/or physical interventions, adopting the notion of Relative Wavelet Entropy. This mathematical model employs a robust and parameter-free synchronization metric. By using data mining techniques, a distance value was computed for all participants so as to quantify the proximity of their individual profile to the mean group synchronization increase. In support of our hypothesis, results showed a significant increase in synchronization, for four electrode pairs, in the intervention group as compared to the active control group. It is concluded that the novel introduction of neurophysiological synchronization features could be used as a valid and reliable outcome measure; while the distance-based analysis could provide a reliable means of evaluating individual benefits.
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Affiliation(s)
- Christos A Frantzidis
- Laboratory of Medical Physics, Department of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Greece.
| | - Aristea-Kiriaki I Ladas
- Psychology Department, The University of Sheffield International Faculty, City College, Thessaloniki, Greece.
| | - Ana B Vivas
- Psychology Department, The University of Sheffield International Faculty, City College, Thessaloniki, Greece.
| | - Magda Tsolaki
- 3rd Department of Neurology, Medical School, Aristotle University of Thessaloniki, Greece.
| | - Panagiotis D Bamidis
- Laboratory of Medical Physics, Department of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Greece.
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Stinear C, Ackerley S, Byblow W. Rehabilitation is Initiated Early After Stroke, but Most Motor Rehabilitation Trials Are Not. Stroke 2013; 44:2039-45. [DOI: 10.1161/strokeaha.113.000968] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Cathy Stinear
- From the Department of Medicine, University of Auckland, Private Bag, New Zealand (C.S., S.A.); Department of Sport & Exercise Science, University of Auckland, Private Bag, New Zealand (W.B.); and Centre for Brain Research, University of Auckland, Private Bag, New Zealand (C.S., S.A., W.B.)
| | - Suzanne Ackerley
- From the Department of Medicine, University of Auckland, Private Bag, New Zealand (C.S., S.A.); Department of Sport & Exercise Science, University of Auckland, Private Bag, New Zealand (W.B.); and Centre for Brain Research, University of Auckland, Private Bag, New Zealand (C.S., S.A., W.B.)
| | - Winston Byblow
- From the Department of Medicine, University of Auckland, Private Bag, New Zealand (C.S., S.A.); Department of Sport & Exercise Science, University of Auckland, Private Bag, New Zealand (W.B.); and Centre for Brain Research, University of Auckland, Private Bag, New Zealand (C.S., S.A., W.B.)
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47
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“Functional rTMS”: Putting the brain to work to enhance brain stimulation post-stroke? Clin Neurophysiol 2013; 124:215-6. [DOI: 10.1016/j.clinph.2012.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 08/22/2012] [Accepted: 08/23/2012] [Indexed: 11/16/2022]
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Abstract
Stroke is a leading cause of disability, and the number of stroke survivors continues to rise. Traditional neurorehabilitation strategies aimed at restoring function to weakened limbs provide only modest benefit. New brain stimulation techniques designed to augment traditional neurorehabilitation hold promise for reducing the burden of stroke-related disability. Investigators discovered that repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), and epidural cortical stimulation (ECS) can enhance neural plasticity in the motor cortex post-stroke. Improved outcomes may be obtained with activity-dependent stimulation, in which brain stimulation is contingent on neural or muscular activity during normal behavior. We review the evidence for improved motor function in stroke patients treated with rTMS, tDCS, and ECS and discuss the mediating physiological mechanisms. We compare these techniques to activity-dependent stimulation, discuss the advantages of this newer strategy for stroke rehabilitation, and suggest future applications for activity-dependent brain stimulation.
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