Effects of transcranial direct current stimulation for post-stroke depression: A systematic review and meta-analysis

Stroke Rehabilitation: Synopsis of the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

In July 2024, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DOD) released a joint update of their 2019 clinical practice guideline (CPG) for the management of stroke rehabilitation. This synopsis is a condensed version of the 2024 CPG, highlighting the key aspects of the guideline development process and describing the major recommendations.

METHODS

The VA/DOD Evidence-Based Practice Work Group convened a joint VA/DOD guideline development work group (WG) that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy CPGs. The guideline WG conducted a patient focus group, developed key questions, and systematically searched and evaluated the literature (English-language publications from 1 July 2018 to 2 May 2023). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to evaluate the evidence. The WG developed 47 recommendations along with algorithms for stroke rehabilitation in the inpatient and outpatient settings. Stakeholders outside the WG reviewed the CPG before approval by the VA/DOD Evidence-Based Practice Work Group.

RECOMMENDATIONS

This synopsis summarizes where evidence is strongest to support guidelines in crucial areas relevant to primary care physicians: transition to community (case management, psychosocial or behavioral interventions); motor therapy (task-specific practice, mirror therapy, rhythmic auditory stimulation, electrical stimulation, botulinum toxin for spasticity); dysphagia, aphasia, and cognition (chin tuck against resistance, respiratory muscle strength training); and mental health (selective serotonin reuptake inhibitor use, psychotherapy, mindfulness-based therapies for treatment but not prevention of depression).

The effect of transcranial direct current stimulation and inhibitory control training on depression and anxiety among post-stroke individuals

BACKGROUND

Recent research has highlighted the role of fronto-parietal brain networks and cognitive control in mood disorders. Transcranial direct current stimulation (tDCS) and computer-based cognitive training are used in post-stroke rehabilitation. This study examined the combined effects ofof computer-based inhibitory control training (ICCT) and anodal tDCS on post-stroke depression and anxiety.

METHODS

Thirty-five participants were randomly assigned to one of three groups: active tDCS treatment (A), sham tDCS treatment with ICCT (T), or active tDCS with ICCT (AT), for a duration of ten days. Primary outcome measures included the Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HAM-D), and Spielberger's State-Trait Anxiety Inventory (STAI-S/T). Statistical analysis was performed using a Mixed-model Analysis of Variance, with supplementary Bayesian analysis.

RESULTS

The AT group showed a significant improvement in BDI scores (p < .001), whereas no significant effects were observed on the HAM-D, STAI-T, or STAI-S scales.

CONCLUSIONS

The combination of tDCS and ICCT reduced depressive symptoms as measured by the BDI; while no significant effects were found with either treatment alone. Further research is needed to explore the mechanisms behind the synergistic effects in the treatment of post-stroke mood disorders.

Effects and safety of transcranial direct current stimulation on multiple health outcomes: an umbrella review of randomized clinical trials

Transcranial direct current stimulation (tDCS), which delivers a direct current to the brain, emerged as a non-invasive potential therapeutic in treating a range of neurological and neuropsychiatric disorders. However, a comprehensive quantitative evidence synthesis on the effects of tDCS on a broad range of mental illnesses is lacking. Here, we systematically assess the certainty of the effects and safety of tDCS on several health outcomes using an umbrella review of randomized controlled trials (RCTs). The methodological quality of each included original meta-analysis was assessed by the A Measurement Tool for Assessing Systematic Reviews 2 (AMSTAR2), and the certainty of the evidence for each effect was evaluated with Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). We followed an a priori protocol (PROSPERO CRD42023458700). We identified 15 meta-analyses of RCTs (AMSTAR 2; high 3, moderate 3, and low 9) that included 282 original articles, covering 22 unique health endpoints across 22 countries and six continents. From meta-analyses of RCTs supported by very low to high certainty of evidence, it was found that tDCS improved symptoms related to post-stroke, including post-stroke depression scale score (equivalent standardized mean difference [eSMD], 1.61 [95% confidence level, 0.72-2.50]; GRADE=moderate), activities of daily living independence (7.04 [3.41-10.67]; GRADE=high), motor recovery of upper and lower extremity (upper extremity: 0.15 [0.06-0.24], GRADE=high; lower extremity: 0.10 [0.03-0.16], GRADE=high), swallowing performance (GRADE=low), and spasticity (GRADE=moderate). In addition, tDCS had treatment effects on symptoms of several neurological and neuropsychiatric disorders, including obsessive-compulsive disorder (0.81 [0.44-1.18]; GRADE=high), pain in fibromyalgia (GRADE=low), disease of consciousness (GRADE=low), insight score (GRADE=moderate) and working memory (0.34 [0.01-0.67]; GRADE=high) in schizophrenia, migraine-related pain (-1.52 [-2.91 to -0.13]; GRADE=high), attention-deficit/hyperactivity disorder (reduction in overall symptom severity: 0.24 [0.04-0.45], GRADE=low; reduction in inattention: 0.56 [0.02-1.11], GRADE=low; reduction in impulsivity: 0.28 [0.04-0.51], GRADE=low), depression (GRADE=low), cerebellar ataxia (GRADE=low), and pain (GRADE=very low). Importantly, tDCS induced an increased number of reported cases of treatment-emergent mania or hypomania (0.88 [0.62-1.13]; GRADE=moderate). We found varied levels of evidence for the effects of tDCS with multiple neurological and neuropsychiatric conditions, from very low to high certainty of evidence. tDCS was effective for people with stroke, obsessive-compulsive disorder, fibromyalgia, disease of consciousness, schizophrenia, migraine, attention-deficit/hyperactivity disorder, depression, cerebellar ataxia, and pain. Therefore, these findings suggest the benefit of tDCS for several neurological and neuropsychiatric disorders; however, further studies are needed to understand the underlying mechanism and optimize its therapeutic potential.

Effectiveness of non-pharmacological therapies for treating post-stroke depression: A systematic review and network meta-analysis

OBJECTIVE

Post-stroke depression (PSD) is a common neurological and psychiatric sequelae following a stroke, often surpassing the primary effects of the stroke due to its strong correlation with high mortality rates. In recent years, non-pharmacological therapy has garnered significant attention as a supplementary treatment for PSD, becoming widely adopted in clinical practice. However, the efficacy of specific intervention strategies remains unclear. This study aimed to conduct a network meta-analysis (NMA) of published studies to compare the efficacy of different non-pharmacological therapies for treating PSD.

METHOD

We systematically searched five databases from inception through March 2024 to identify randomized controlled trials (RCTs) evaluating non-pharmacological therapies for the treatment of PSD. We considered individual intervention and intervention class. Intervention classes included traditional Chinese medicine (TCM), non-invasive electrotherapy stimulation (NIES), psychotherapy (PT), exercise therapy, hyperbaric oxygen, and combined interventions. The NMA was conducted using R and Stata software, following a frequency-based methodology. Assessment of methodological quality and risk of bias was conducted using the Risk of Bias assessment tool 2.0. Therapies were ranked using the P-score, and box-plots visualization, meta-regression, and sensitivity analysis, were performed to assess transitivity, heterogeneity, and consistency, respectively.

RESULTS

The NMA included 43 studies with a total of 3138 participants. Random-effects models revealed significant efficacy for acupuncture (ACUP) (P-score = 0.92; pooled standardized mean difference (95% CI): -3.12 (-4.63 to -1.60)) and transcranial direct current stimulation (P-score = 0.85; -2.78 (-5.06 to -0.49)) compared to the treatment as usual (TAU) group. In categorical comparisons, TCM_PT (P-score = 0.82; -1.91 (-3.54 to -0.28)), TCM (P-score = 0.79; -1.65 (-2.33 to -0.97)), and NIES (P-score = 0.74; -1.54 (-2.62 to -0.46)) showed significant differences compared to TAU group. Furthermore, our results indicated no significant difference between PT and the control groups. However, Confidence in Network Meta-Analysis results indicated very low overall evidence grade.

CONCLUSION

Limited evidence suggests that ACUP may be the most effective non-pharmacological therapy for improving PSD, and TCM_PT is the best intervention class. However, the evidence quality is very low, underscoring the need for additional high-quality RCTs to validate these findings, particularly given the limited number of RCTs available for each therapy.

Transcranial direct current stimulation (tDCS) for neurological disability among subacute stroke survivors to improve multiple domains in health-related quality of life: Randomized controlled trial protocol

OBJECTIVES

The primary goal of the current proposal is to fill the gaps in the literature by studying the effectiveness of transcranial direct current stimulation (tDCS) on lifestyle parameters, and physical, behavioral, and cognitive functions among stroke survivors, and understanding the factors that mediate the effects of various domains related to Health-related Quality of life (HRQoL) improvements.

METHODS

Anticipated 64 volunteer subacute stroke survivors (>7 days to 3 months post stroke) aged 40-75 years with National Institutes of Health stroke scale (NIHSS) score of >10 and Mini-Mental State Examination (MMSE) score between 18 and 23 will be randomly assigned at a ratio of 1:1 to receive either: (1) 20 sessions of anodal tDCS or (2) sham tDCS in addition to conventional rehabilitation. Battery driven tDCS will be applied at 2 mA intensity to the dorsolateral prefrontal cortex and primary motor cortex for 20 minutes. The primary endpoints of study will be 36-Item Short Form Survey (SF-36) post intervention at 4 weeks. The secondary outcomes will include Stroke Specific Quality of Life Scale (SS_QOL), Montreal cognitive assessment (MCA), Beck Anxiety Inventory (BAI), Fugl-Meyer Assessment (FMA), 10 m walk test and Modified Barthel Activities of daily living (ADL) Index. At 0.05 level of significance, data normality, within group and between group actual differences will be analyzed with a moderate scope software.

DISCUSSION

Our knowledge of this technique and its use is expanding daily as tDCS motor recovery studies-mostly single-center studies-in either single session or many sessions have been completed and shown positive results. The field is prepared for a multi-center, carefully planned, sham-controlled, double-blinded tDCS study to comprehensively examine its feasibility and effectiveness in enhancing outcomes in stroke population.

CONCLUSION

The function of Transcranial Direct Current Stimulation in aiding stroke recuperation will be ascertained.

Dual-tDCS combined with sensorimotor training promotes upper limb function in subacute stroke patients: A randomized, double-blinded, sham-controlled study

BACKGROUND

Dual transcranial direct current stimulation (tDCS) over the bilateral primary somatosensory cortex (PSC) has potential benefits in stroke. In addition, compared with traditional rehabilitation training, sensorimotor training can significantly improve the sensorimotor function of patients. However, the efficacy of dual-tDCS combined with sensorimotor training in patients with subacute stroke is unknown.

OBJECTIVE

To assess whether dual-tDCS may enhance the efficacy of sensorimotor training on the upper limb functions in patients with subacute stroke. In addition, this study aims to explore the potential clinical mechanism of this combination therapy.

METHODS

We randomized 52 individuals with first-ever, unilateral subcortical stroke into the experimental group (n = 26) and the control group (n = 26). Patients in the experimental group received 20 min of dual-tDCS over the PSC and 40 min of sensorimotor training each session, while patients in the control group received sham dual-tDCS. The treatment cycle was a 1-h session of therapy each day, 5 days per week for 4 weeks. The Fugl-Meyer Assessment of Upper Extremity (FMA-UE) subscale, Action Research Arm Test (ARAT), Box and Block test (BBT), Erasmus MC revised Nottingham sensory assessment scale (Em-NSA), Neurometer sensory nerve quantitative detector (CPT), the Barthel index (BI), and Hospital Anxiety and Depression Scale (HADS) were used to assess upper limb function, activities of daily living (ADL), and mental health before and after the 4-week treatment period. In addition, functional near-infrared spectroscopy (fNIRS) was used to explore potential clinical brain mechanisms.

RESULTS

Both groups showed significant improvement in all clinical scales (All p < 0.05) after treatment. Compared with sham-tDCS plus sensorimotor training, active dual-tDCS coupled with sensorimotor training can significantly improve the FMA-UE, ARAT, Em-NSA-Stereognosis, and CPT-2K Hz. In addition, dual-tDCS combined with sensorimotor training can significantly activate the left pre-Motor and supplementary motor cortex (PM-SMC) and enhance the functional connection between the left somatosensory association cortex (SAC) and RPM-SMC. Furthermore, the difference of FMA-UE in the experimental group was positively correlated with the functional connectivity of RPM-SMC-LSAC (r = 0.815, p < 0.001).

CONCLUSION

Dual-tDCS over the PSC combined with sensorimotor training can improve upper limb sensory and motor dysfunction, enhance ADL, and alleviate depression and anxiety for subacute stroke patients. Our results indicated that RPM-SMC-LSAC may be potential therapeutic targets for dual-tDCS in upper limb rehabilitation on stroke.

Study protocol of a double-blind randomized control trial of transcranial direct current stimulation in post-stroke fatigue

Rationale

Post-stroke fatigue (PSF) is a frequent problem in stroke survivors and often hinders their rehabilitation. PSF is difficult to treat, and pharmacological therapy is often ineffective. Transcranial direct current stimulation (tDCS) can modulate motor, sensory, cognitive and behavioral responses, as it alters neuronal activity by delivering a small amount of current via the scalp to the cortex, resulting in prolonged alterations to brain function. tDCS has been studied for the treatment of fatigue associated with other neurological diseases, namely, multiple sclerosis, Parkinson's disease and post-polio syndrome.

Aims

This proposed project will examine the effect of tDCS on PSF.

Sample size estimates

We will recruit 156 participants aged 18 to 80 with chronic stroke and allocate them equally to two groups (i.e., n = 78 per group).

Methods and design

This proposed project will be a double-blind randomized control trial. The participants will be randomly divided into two groups. The control group will receive sham tDCS, and the treatment group will receive active tDCS. The latter treatment will involve application of a constant 2-mA current via one 5 × 5-cm anodal electrode positioned on the scalp over the C3 or C4 positions (motor cortex) of the lesioned hemisphere and one cathodal electrode positioned at the ipsilateral shoulder in two 20-min sessions per day for 5 days. The period of follow-up will be 4 weeks.

Study outcomes

The primary outcome measure will be a change in fatigue severity, as measured using the modified fatigue impact scale (MFIS). The participants' scores on the MFIS (total score and physical, cognitive and psychosocial subscores) will be collected before treatment (T0), after 10 treatment sessions, i.e., 1 day after the fifth treatment day (T1), and 1 week (T2), 2 weeks (T3) and 4 weeks (T4) thereafter. Both per-protocol analysis and intention-to-treat analysis will be performed.

Discussion

This proposed project will provide proof-of-concept, i.e., demonstrate the benefits of tDCS for the treatment of PSF. The beneficiaries are the subjects participated in the study. This will stimulate further research to optimize tDCS parameters for the treatment of PSF.

Clinical trial registration

www.Chictr.org.cn, identifier: ChiCTR2100052515.

Application of Transcranial Direct and Alternating Current Stimulation (tDCS and tACS) on Major Depressive Disorder

The exploration of brain stimulation methods offers a promising avenue to overcome the shortcomings of traditional drug therapies and psychological treatments for major depressive disorder (MDD). Over the past years, there has been an increasing focus on transcranial electrical stimulation (tES), notably for its ease of use and potentially fewer side effects. This chapter delves into the use of transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS), which are key components of tES, in managing depression. It begins by introducing tDCS and tACS, summarizing their action mechanisms. Following this introduction, the chapter provides an in-depth analysis of existing meta-analyses, systematic reviews, clinical studies, and case reports that have applied tES in MDD treatment. It also considers the role of tES in personalized medicine by looking at specific patient groups and evaluating research on possible biomarkers that could predict how patients with MDD respond to tES therapy.

Non-invasive brain stimulation for treating post-stroke depression: A network meta-analysis

OBJECTIVE

To compare the antidepressant effects and tolerability of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) treatments in patients with post-stroke depression (PSD).

METHODS

We included randomized controlled trials comparing active stimulation with sham stimulation. Primary outcomes were the depression score after treatment, presented as standardized mean differences with 95% confidence intervals. Response/remission and long-term antidepressant efficacy were also examined. We estimated effect-size using pairwise and Bayesian network meta-analysis (NMA) with random-effects model.

RESULTS

We identified 33 studies (total n = 1793). In NMA, 5 of 6 treatment strategies were associated with higher effect compared with sham therapy: dual rTMS (standardized mean differences = -1.5; 95% confidence interval = -2.5 to -0.57), dual LFrTMS (-1.5, -2.4 to -0.61), dual tDCS (-1.1, -1.5 to -0.62), HFrTMS (-1.1, -1.3 to -0.85) and LFrTMS (-0.90, -1.2 to -0.6). And dual rTMS, dual LFrTMS or HFrTMS may be more effective than other interventions for achieving antidepressant effects. Regarding secondary outcomes, rTMS can promote depression remission and response, and alleviate depression for at least 1 month. rTMS and tDCS were well tolerated.

CONCLUSIONS

Bilateral rTMS and HFrTMS are considered top-priority non-invasive brain stimulation (NIBS) interventions for improving PSD. Dual tDCS and LFrTMS are also efficient.

SIGNIFICANCE

The findings of this study provide evidence for considering NIBS techniques as alternative or add-on treatments for patients with PSD. This work also emphasizes the need for future clinical trials to address the inadequacies identified in this review to optimize methodological quality.