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Levin MF, Berman S, Weiss N, Parmet Y, Baniña MC, Frenkel-Toledo S, Soroker N, Solomon JM, Liebermann DG. ENHANCE proof-of-concept three-arm randomized trial: effects of reaching training of the hemiparetic upper limb restricted to the spasticity-free elbow range. Sci Rep 2023; 13:22934. [PMID: 38129527 PMCID: PMC10739929 DOI: 10.1038/s41598-023-49974-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
Post-stroke motor recovery processes remain unknown. Timescales and patterns of upper-limb (UL) recovery suggest a major impact of biological factors, with modest contributions from rehabilitation. We assessed a novel impairment-based training motivated by motor control theory where reaching occurs within the spasticity-free elbow range. Patients with subacute stroke (≤ 6 month; n = 46) and elbow flexor spasticity were randomly allocated to a 10-day UL training protocol, either personalized by restricting reaching to the spasticity-free elbow range defined by the tonic stretch reflex threshold (TSRT) or non-personalized (non-restricted) and with/without anodal transcranial direct current stimulation. Outcomes assessed before, after, and 1 month post-intervention were elbow flexor TSRT angle and reach-to-grasp arm kinematics (primary) and stretch reflex velocity sensitivity, clinical impairment, and activity (secondary). Results were analyzed for 3 groups as well as those of the effects of impairment-based training. Clinical measures improved in both groups. Spasticity-free range training resulted in faster and smoother reaches, smaller (i.e., better) arm-plane path length, and closer-to-normal shoulder/elbow movement patterns. Non-personalized training improved clinical scores without improving arm kinematics, suggesting that clinical measures do not account for movement quality. Impairment-based training within a spasticity-free elbow range is promising since it may improve clinical scores together with arm movement quality.Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique Identifier: NCT02725853; Initial registration date: 01/04/2016.
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Affiliation(s)
- Mindy F Levin
- Faculty of Medicine and Health Sciences, School of Physical and Occupational Therapy, McGill University, 3654 Promenade Sir William Osler, Montreal, QC, H3G 1Y5, Canada.
- Center for Interdisciplinary Research in Rehabilitation (CRIR), Montreal, QC, Canada.
| | - Sigal Berman
- Department of Industrial Engineering and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- The Zlotowski Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Neta Weiss
- Department of Industrial Engineering and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yisrael Parmet
- Department of Industrial Engineering and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Melanie C Baniña
- Faculty of Medicine and Health Sciences, School of Physical and Occupational Therapy, McGill University, 3654 Promenade Sir William Osler, Montreal, QC, H3G 1Y5, Canada
- Center for Interdisciplinary Research in Rehabilitation (CRIR), Montreal, QC, Canada
| | - Silvi Frenkel-Toledo
- Department of Physical Therapy, Ariel University, Ariel, Israel
- Department of Neurological Rehabilitation, Loewenstein Rehabilitation Hospital, Ra'anana, Israel
| | - Nachum Soroker
- Department of Neurological Rehabilitation, Loewenstein Rehabilitation Hospital, Ra'anana, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - John M Solomon
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India
- Centre for Comprehensive Stroke Rehabilitation and Research, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Dario G Liebermann
- Department of Physical Therapy, Faculty of Medicine, Stanley Steyer School of Health Professions, Tel Aviv University, POB 39040, 61390, Ramat Aviv, Tel Aviv, Israel.
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Banduni O, Saini M, Singh N, Nath D, Kumaran SS, Kumar N, Srivastava MVP, Mehndiratta A. Post-Stroke Rehabilitation of Distal Upper Limb with New Perspective Technologies: Virtual Reality and Repetitive Transcranial Magnetic Stimulation-A Mini Review. J Clin Med 2023; 12:jcm12082944. [PMID: 37109280 PMCID: PMC10142518 DOI: 10.3390/jcm12082944] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/12/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023] Open
Abstract
Upper extremity motor impairment is the most common sequelae in patients with stroke. Moreover, its continual nature limits the optimal functioning of patients in the activities of daily living. Because of the intrinsic limitations in the conventional form of rehabilitation, the rehabilitation applications have been expanded to technology-driven solutions, such as Virtual Reality and Repetitive Transcranial Magnetic Stimulation (rTMS). The motor relearning processes are influenced by variables, such as task specificity, motivation, and feedback provision, and a VR environment in the form of interactive games could provide novel and motivating customized training solutions for better post-stroke upper limb motor improvement. rTMS being a precise non-invasive brain stimulation method with good control of stimulation parameters, has the potential to facilitate neuroplasticity and hence a good recovery. Although several studies have discussed these forms of approaches and their underlying mechanisms, only a few of them have specifically summarized the synergistic applications of these paradigms. To bridge the gaps, this mini review presents recent research and focuses precisely on the applications of VR and rTMS in distal upper limb rehabilitation. It is anticipated that this article will provide a better representation of the role of VR and rTMS in distal joint upper limb rehabilitation in patients with stroke.
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Affiliation(s)
- Onika Banduni
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi (IITD), New Delhi 110016, India
| | - Megha Saini
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi (IITD), New Delhi 110016, India
| | - Neha Singh
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi (IITD), New Delhi 110016, India
| | - Debasish Nath
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi (IITD), New Delhi 110016, India
| | - S Senthil Kumaran
- Department of Nuclear Medicine and Resonance, All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India
| | - Nand Kumar
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India
| | - M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India
| | - Amit Mehndiratta
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi (IITD), New Delhi 110016, India
- Department of Biomedical Engineering, All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India
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3
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Shared and distinct voxel-based lesion-symptom mappings for spasticity and impaired movement in the hemiparetic upper limb. Sci Rep 2022; 12:10169. [PMID: 35715476 PMCID: PMC9206020 DOI: 10.1038/s41598-022-14359-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/06/2022] [Indexed: 12/17/2022] Open
Abstract
Hemiparesis and spasticity are common co-occurring manifestations of hemispheric stroke. The relationship between impaired precision and force in voluntary movement (hemiparesis) and the increment in muscle tone that stems from dysregulated activity of the stretch reflex (spasticity) is far from clear. Here we aimed to elucidate whether variation in lesion topography affects hemiparesis and spasticity in a similar or dis-similar manner. Voxel-based lesion-symptom mapping (VLSM) was used to assess the impact of lesion topography on (a) upper limb paresis, as reflected by the Fugl-Meyer Assessment scale for the upper limb and (b) elbow flexor spasticity, as reflected by the Tonic Stretch Reflex Threshold, in 41 patients with first-ever stroke. Hemiparesis and spasticity were affected by damage to peri-Sylvian cortical and subcortical regions and the putamen. Hemiparesis (but not spasticity) was affected by damage to the corticospinal tract at corona-radiata and capsular levels, and by damage to white-matter association tracts and additional regions in the temporal cortex and pallidum. VLSM conjunction analysis showed only a minor overlap of brain voxels where the existence of damage affected both hemiparesis and spasticity, suggesting that control of voluntary movement and regulation of muscle tone at rest involve largely separate parts of the motor network.
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4
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Design of a virtual reality rehabilitation system for upper limbs that inhibits compensatory movement. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2022. [DOI: 10.1016/j.medntd.2021.100110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Asbee J, Parsons TD. Effects of Transcranial Direct Current Stimulation on Cognitive and Affective Outcomes Using Virtual Stimuli: A Systematic Review. CYBERPSYCHOLOGY, BEHAVIOR AND SOCIAL NETWORKING 2021; 24:699-714. [PMID: 33625878 DOI: 10.1089/cyber.2020.0301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Transcranial direct current stimulation (tDCS) is a noninvasive form of brain stimulation used to influence neural activity. While early tDCS studies primarily used static stimuli, there is growing interest in dynamic stimulus presentations using virtual environments (VEs). This review attempts to convey the state of the field. This is not a quantitative meta-analysis as there are not yet enough studies following consistent protocols and/or reporting adequate data. In addition to reviewing the state of the literature, this review includes an exploratory analysis of the available data. Following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, studies were culled from several databases. Results from this review reveal differences between online and offline stimulation. While offline stimulation did not influence affective and cognitive outcomes, online stimulation led to small changes in affect and cognition. Future studies should include randomized controlled trials with larger samples. Furthermore, greater care needs to be applied to full data reporting (e.g., means, standard deviations, and data for their nonsignificant findings) to improve our understanding of the combined effects of virtual stimuli with tDCS.
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Affiliation(s)
- Justin Asbee
- Department of Psychology, University of North Texas, Denton, Texas, USA
- Computational Neuropsychology & Simulation (CNS) Laboratory, University of North Texas, Denton, Texas, USA
| | - Thomas D Parsons
- Computational Neuropsychology & Simulation (CNS) Laboratory, University of North Texas, Denton, Texas, USA
- College of Information, University of North Texas, Denton, Texas, USA
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A novel glasses-free virtual reality rehabilitation system on improving upper limb motor function among patients with stroke: A feasibility pilot study. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2021. [DOI: 10.1016/j.medntd.2021.100069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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7
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Lackritz H, Parmet Y, Frenkel-Toledo S, Baniña MC, Soroker N, Solomon JM, Liebermann DG, Levin MF, Berman S. Effect of post-stroke spasticity on voluntary movement of the upper limb. J Neuroeng Rehabil 2021; 18:81. [PMID: 33985543 PMCID: PMC8117272 DOI: 10.1186/s12984-021-00876-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/03/2021] [Indexed: 11/17/2022] Open
Abstract
Background Hemiparesis following stroke is often accompanied by spasticity. Spasticity is one factor among the multiple components of the upper motor neuron syndrome that contributes to movement impairment. However, the specific contribution of spasticity is difficult to isolate and quantify. We propose a new method of quantification and evaluation of the impact of spasticity on the quality of movement following stroke. Methods Spasticity was assessed using the Tonic Stretch Reflex Threshold (TSRT). TSRT was analyzed in relation to stochastic models of motion to quantify the deviation of the hemiparetic upper limb motion from the normal motion patterns during a reaching task. Specifically, we assessed the impact of spasticity in the elbow flexors on reaching motion patterns using two distinct measures of the ‘distance’ between pathological and normal movement, (a) the bidirectional Kullback–Liebler divergence (BKLD) and (b) Hellinger’s distance (HD). These measures differ in their sensitivity to different confounding variables. Motor impairment was assessed clinically by the Fugl-Meyer assessment scale for the upper extremity (FMA-UE). Forty-two first-event stroke patients in the subacute phase and 13 healthy controls of similar age participated in the study. Elbow motion was analyzed in the context of repeated reach-to-grasp movements towards four differently located targets. Log-BKLD and HD along with movement time, final elbow extension angle, mean elbow velocity, peak elbow velocity, and the number of velocity peaks of the elbow motion were computed. Results Upper limb kinematics in patients with lower FMA-UE scores (greater impairment) showed greater deviation from normality when the distance between impaired and normal elbow motion was analyzed either with the BKLD or HD measures. The severity of spasticity, reflected by the TSRT, was related to the distance between impaired and normal elbow motion analyzed with either distance measure. Mean elbow velocity differed between targets, however HD was not sensitive to target location. This may point at effects of spasticity on motion quality that go beyond effects on velocity. Conclusions The two methods for analyzing pathological movement post-stroke provide new options for studying the relationship between spasticity and movement quality under different spatiotemporal constraints.
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Affiliation(s)
- Hadar Lackritz
- Department of Industrial Engineering and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yisrael Parmet
- Department of Industrial Engineering and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Silvi Frenkel-Toledo
- Faculty of Health Sciences, Department of Physical Therapy, Ariel University, Ariel, Israel.,Department of Neurological Rehabilitation, Loewenstein Hospital, Ra'anana, Israel
| | - Melanie C Baniña
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.,Center for Interdisciplinary Research in Rehabilitation (CRIR), Montreal, QC, Canada
| | - Nachum Soroker
- Department of Neurological Rehabilitation, Loewenstein Hospital, Ra'anana, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - John M Solomon
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India.,Centre for Comprehensive Stroke Rehabilitation and Research, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Dario G Liebermann
- Department of Physical Therapy, Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mindy F Levin
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.,Center for Interdisciplinary Research in Rehabilitation (CRIR), Montreal, QC, Canada
| | - Sigal Berman
- Department of Industrial Engineering and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel. .,The Zlotowski Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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8
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Molero-Chamizo A, Salas Sánchez Á, Álvarez Batista B, Cordero García C, Andújar Barroso R, Rivera-Urbina GN, Nitsche MA, Alameda Bailén JR. Bilateral Motor Cortex tDCS Effects on Post-Stroke Pain and Spasticity: A Three Cases Study. Front Pharmacol 2021; 12:624582. [PMID: 33967758 PMCID: PMC8098051 DOI: 10.3389/fphar.2021.624582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 03/25/2021] [Indexed: 01/02/2023] Open
Abstract
Stroke patients frequently suffer from chronic limb pain, but well-suited treatment approaches have been not established so far. Transcranial direct current stimulation (tDCS) is a safe and non-invasive brain stimulation technique that alters cortical excitability, and it has been shown that motor cortex tDCS can reduce pain. Some data also suggest that spasticity may be improved by tDCS in post-stroke patients. Moreover, multiple sessions of tDCS have shown to induce neuroplastic changes with lasting beneficial effects in different neurological conditions. The aim of this pilot study was to explore the effect of multiple anodal tDCS (atDCS) sessions on upper limb pain and spasticity of stroke patients, using a within-subject, crossover, sham-controlled design. Brain damage was of similar extent in the three patients evaluated, although located in different hemispheres. The results showed a significant effect of 5 consecutive sessions of atDCS, compared to sham stimulation, on pain evaluated by the Adaptive Visual Analog Scales -AVAS-, and spasticity evaluated by the Fugl-Meyer scale. In two of the patients, pain was completely relieved and markedly reduced, respectively, only after verum tDCS. The pain improvement effect of atDCS in the third patient was considerably lower compared to the other two patients. Spasticity was significantly improved in one of the patients. The treatment was well-tolerated, and no serious adverse effects were reported. These findings suggest that multiple sessions of atDCS are a safe intervention for improving upper limb pain and spasticity in stroke patients, although the inter-individual variability is a limitation of the results. Further studies including longer follow-up periods, more representative patient samples and individualized stimulation protocols are required to demonstrate the efficacy and safety of tDCS for improving limb symptoms in these patients.
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Affiliation(s)
| | | | | | | | | | | | - Michael A Nitsche
- Leibniz Research Centre for Working Environment and Human Factors, Dortmund, Germany.,Department of Neurology, University Medical Hospital Bergmannsheil, Bochum, Germany
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Tonic stretch reflex threshold as a measure of spasticity after stroke: Reliability, minimal detectable change and responsiveness. Clin Neurophysiol 2021; 132:1226-1233. [PMID: 33867256 DOI: 10.1016/j.clinph.2021.02.390] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/14/2021] [Accepted: 02/22/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine inter-rater reliability, minimal detectable change and responsiveness of Tonic Stretch Reflex Threshold (TSRT) as a quantitative measure of elbow flexor spasticity. METHODS Elbow flexor spasticity was assessed in 55 patients with sub-acute stroke by determining TSRT, the angle of spasticity onset at rest (velocity = 0°/s). Elbow flexor muscles were stretched 20 times at different velocities. Dynamic stretch-reflex thresholds, the elbow angles corresponding to the onset of elbow flexor EMG at each velocity, were used for TSRT calculation. Spasticity was also measured with the Modified Ashworth Scale (MAS). In a sub-group of 44 subjects, TSRT and MAS were measured before and after two weeks of an upper-limb intervention. RESULTS The intraclass correlation coefficient was 0.65 and the 95% minimal detectable change was 32.4°. In the treated sub-group, TSRT, but not MAS significantly changed. TSRT effect size and standardized response mean were 0.40 and 0.35, respectively. Detection of clinically meaningful improvements in upper-limb motor impairment by TSRT change scores ranged from poor to excellent. CONCLUSIONS Evaluation of stroke-related elbow flexor spasticity by TSRT has good inter-rater reliability. Test responsiveness is low, but better than that of the MAS. SIGNIFICANCE TSRT may be used to complement current scales of spasticity quantification.
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Elsner B, Kugler J, Pohl M, Mehrholz J. Transcranial direct current stimulation (tDCS) for improving activities of daily living, and physical and cognitive functioning, in people after stroke. Cochrane Database Syst Rev 2020; 11:CD009645. [PMID: 33175411 PMCID: PMC8095012 DOI: 10.1002/14651858.cd009645.pub4] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Stroke is one of the leading causes of disability worldwide. Functional impairment, resulting in poor performance in activities of daily living (ADL) among stroke survivors is common. Current rehabilitation approaches have limited effectiveness in improving ADL performance, function, muscle strength, and cognitive abilities (including spatial neglect) after stroke, with improving cognition being the number one research priority in this field. A possible adjunct to stroke rehabilitation might be non-invasive brain stimulation by transcranial direct current stimulation (tDCS) to modulate cortical excitability, and hence to improve these outcomes in people after stroke. OBJECTIVES To assess the effects of tDCS on ADL, arm and leg function, muscle strength and cognitive abilities (including spatial neglect), dropouts and adverse events in people after stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase and seven other databases in January 2019. In an effort to identify further published, unpublished, and ongoing trials, we also searched trials registers and reference lists, handsearched conference proceedings, and contacted authors and equipment manufacturers. SELECTION CRITERIA This is the update of an existing review. In the previous version of this review, we focused on the effects of tDCS on ADL and function. In this update, we broadened our inclusion criteria to compare any kind of active tDCS for improving ADL, function, muscle strength and cognitive abilities (including spatial neglect) versus any kind of placebo or control intervention. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and risk of bias, extracted data, and applied GRADE criteria. If necessary, we contacted study authors to ask for additional information. We collected information on dropouts and adverse events from the trial reports. MAIN RESULTS We included 67 studies involving a total of 1729 patients after stroke. We also identified 116 ongoing studies. The risk of bias did not differ substantially for different comparisons and outcomes. The majority of participants had ischaemic stroke, with mean age between 43 and 75 years, in the acute, postacute, and chronic phase after stroke, and level of impairment ranged from severe to less severe. Included studies differed in terms of type, location and duration of stimulation, amount of current delivered, electrode size and positioning, as well as type and location of stroke. We found 23 studies with 781 participants examining the effects of tDCS versus sham tDCS (or any other passive intervention) on our primary outcome measure, ADL after stroke. Nineteen studies with 686 participants reported absolute values and showed evidence of effect regarding ADL performance at the end of the intervention period (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.13 to 0.44; random-effects model; moderate-quality evidence). Four studies with 95 participants reported change scores, and showed an effect (SMD 0.48, 95% CI 0.02 to 0.95; moderate-quality evidence). Six studies with 269 participants assessed the effects of tDCS on ADL at the end of follow-up and provided absolute values, and found improved ADL (SMD 0.31, 95% CI 0.01 to 0.62; moderate-quality evidence). One study with 16 participants provided change scores and found no effect (SMD -0.64, 95% CI -1.66 to 0.37; low-quality evidence). However, the results did not persist in a sensitivity analysis that included only trials with proper allocation concealment. Thirty-four trials with a total of 985 participants measured upper extremity function at the end of the intervention period. Twenty-four studies with 792 participants that presented absolute values found no effect in favour of tDCS (SMD 0.17, 95% CI -0.05 to 0.38; moderate-quality evidence). Ten studies with 193 participants that presented change values also found no effect (SMD 0.33, 95% CI -0.12 to 0.79; low-quality evidence). Regarding the effects of tDCS on upper extremity function at the end of follow-up, we identified five studies with a total of 211 participants (absolute values) without an effect (SMD -0.00, 95% CI -0.39 to 0.39; moderate-quality evidence). Three studies with 72 participants presenting change scores found an effect (SMD 1.07; 95% CI 0.04 to 2.11; low-quality evidence). Twelve studies with 258 participants reported outcome data for lower extremity function and 18 studies with 553 participants reported outcome data on muscle strength at the end of the intervention period, but there was no effect (high-quality evidence). Three studies with 156 participants reported outcome data on muscle strength at follow-up, but there was no evidence of an effect (moderate-quality evidence). Two studies with 56 participants found no evidence of effect of tDCS on cognitive abilities (low-quality evidence), but one study with 30 participants found evidence of effect of tDCS for improving spatial neglect (very low-quality evidence). In 47 studies with 1330 participants, the proportions of dropouts and adverse events were comparable between groups (risk ratio (RR) 1.25, 95% CI 0.74 to 2.13; random-effects model; moderate-quality evidence). AUTHORS' CONCLUSIONS: There is evidence of very low to moderate quality on the effectiveness of tDCS versus control (sham intervention or any other intervention) for improving ADL outcomes after stroke. However, the results did not persist in a sensitivity analyses including only trials with proper allocation concealment. Evidence of low to high quality suggests that there is no effect of tDCS on arm function and leg function, muscle strength, and cognitive abilities in people after stroke. Evidence of very low quality suggests that there is an effect on hemispatial neglect. There was moderate-quality evidence that adverse events and numbers of people discontinuing the treatment are not increased. Future studies should particularly engage with patients who may benefit the most from tDCS after stroke, but also should investigate the effects in routine application. Therefore, further large-scale randomised controlled trials with a parallel-group design and sample size estimation for tDCS are needed.
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Affiliation(s)
- Bernhard Elsner
- Department of Public Health, Dresden Medical School, Technical University Dresden, Dresden, Germany
- Department of Physiotherapy, SRH Hochschule für Gesundheit Gera, 07548 Gera, Germany
| | - Joachim Kugler
- Department of Public Health, Dresden Medical School, Technical University Dresden, Dresden, Germany
| | - Marcus Pohl
- Neurological Rehabilitation, Helios Klinik Schloss Pulsnitz, Pulsnitz, Germany
| | - Jan Mehrholz
- Department of Public Health, Dresden Medical School, Technical University Dresden, Dresden, Germany
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Davidowitz I, Parmet Y, Frenkel-Toledo S, Baniña MC, Soroker N, Solomon JM, Liebermann DG, Levin MF, Berman S. Relationship Between Spasticity and Upper-Limb Movement Disorders in Individuals With Subacute Stroke Using Stochastic Spatiotemporal Modeling. Neurorehabil Neural Repair 2019; 33:141-152. [PMID: 30744528 DOI: 10.1177/1545968319826050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Spasticity is common in patients with stroke, yet current quantification methods are insufficient for determining the relationship between spasticity and voluntary movement deficits. This is partly a result of the effects of spasticity on spatiotemporal characteristics of movement and the variability of voluntary movement. These can be captured by Gaussian mixture models (GMMs). OBJECTIVES To determine the influence of spasticity on upper-limb voluntary motion, as assessed by the bidirectional Kullback-Liebler divergence (BKLD) between motion GMMs. METHODS A total of 16 individuals with subacute stroke and 13 healthy aged-equivalent controls reached to grasp 4 targets (near-center, contralateral, far-center, and ipsilateral). Two-dimensional GMMs (angle and time) were estimated for elbow extension motion. BKLD was computed for each individual and target, within the control group and between the control and stroke groups. Movement time, final elbow angle, average elbow velocity, and velocity smoothness were computed. RESULTS Between-group BKLDs were much larger than within control-group BKLDs. Between-group BKLDs for the near-center target were lower than those for the far-center and contralateral targets, but similar to that for the ipsilateral target. For those with stroke, the final angle was lower for the near-center target, and the average velocity was higher. Velocity smoothness was lower for the near-center than for the ipsilateral target. Elbow flexor and extensor passive muscle resistance (Modified Ashworth Scale) strongly explained BKLD values. CONCLUSIONS Results support the view that individuals with poststroke spasticity have a velocity-dependent reduction in active elbow joint range and that BKLD can be used as an objective measure of the effects of spasticity on reaching kinematics.
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Affiliation(s)
| | - Yisrael Parmet
- 1 Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | | | - Melanie C Baniña
- 4 McGill University, Montréal, Canada.,5 Center for Interdisciplinary Research in Rehabilitation (CRIR), Montréal, Canada
| | - Nachum Soroker
- 3 Loewenstein Hospital, Ra'anana, Israel.,6 Tel-Aviv University, Israel
| | | | | | - Mindy F Levin
- 2 Ariel University, Israel.,3 Loewenstein Hospital, Ra'anana, Israel
| | - Sigal Berman
- 1 Ben-Gurion University of the Negev, Beer-Sheva, Israel
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12
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Fuentes Calderón MA, Miralles AN, Pimienta MJ, Estella JMG, Ledesma MJS. Analysis of the Factors Related to the Effectiveness of Transcranial Current Stimulation in Upper Limb Motor Function Recovery after Stroke: a Systematic Review. J Med Syst 2019; 43:69. [PMID: 30737601 DOI: 10.1007/s10916-019-1193-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/30/2019] [Indexed: 02/08/2023]
Abstract
Transcranial direct current stimulation is one of the non-invasive techniques whose main mechanism of action is based on its modulation of cortical excitability. The objective of this study is to analyze the variables (i.e, demographics, clinicals, stimulation parameters) that could influence into the responses during rehabilitation of the upper extremity in patients with stroke. Our systematic review has been performed by searching full-text articles published from January 2008 to December 2018 in Embase, Medline, PubMed and Cochrane Library databases. Studies with adult patients with ischemic or hemorrhagic stroke at any stage of evolution were included. We compared interventions with any type of transcranial direct current stimulation (anodal, cathodal or bihemispheric, also known as dual) regarding improvement of upper extremity motor function. We included 14 studies with 368 patients, of whom almost 89% have ischemic etiology and more than half are males. Most patients were considered subacute or chronic, while only two studies were selected with patients in the acute phase. Different methods of using transcranial direct current stimulation with several complementary therapies were identified, such as virtual reality, robot therapy, Occupational Therapy, Physiotherapy, Constraint Induced Movement Therapy or Peripheral Nerve Stimulation. In conclusion, there is not significant evidence due to heterogeneity of clinical data and therapies. Clinical studies with greater number of participants and protocols standardized could outline this assessment in future studies.
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Affiliation(s)
| | | | - Mauricio Jaramillo Pimienta
- Departament of Neurosurgery, Universitary Hospital of Salamanca, Paseo de San Vicente, 58-182, 37007, Salamanca, Spain
| | - Jesús María Gonçalves Estella
- Departament of Neurosurgery, Universitary Hospital of Salamanca, Paseo de San Vicente, 58-182, 37007, Salamanca, Spain
| | - María José Sánchez Ledesma
- Departament of Surgery, University of Salamanca, Alfonso X el Sabio s/n, 37007, Salamanca, Spain.,VisualMed Systems Group, University of Salamanca, Patio Escuelas 1, 37008, Salamanca, Spain
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