Do Higher Transcranial Direct Current Stimulation Doses Lead to Greater Gains in Upper Limb Motor Function in Post-Stroke Patients?

Transcranial direct current stimulation for upper extremity motor dysfunction in poststroke patients: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of transcranial direct current stimulation in poststroke patients with upper extremity motor dysfunction using a systematic review and meta-analysis.

DATA SOURCES

We searched the Web of Science, Cochrane Library, EMBASE, and PubMed for randomized controlled trials investigating the effects of both active and sham stimulation up until January 27, 2024.

REVIEW METHODS

Efficacy, including the upper extremity Fugl-Meyer Assessment, Action Research Arm Test, Barthel Index, and safety, were assessed. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool and the Physiotherapy Evidence Database Scale. Meta-analysis was performed using the RevMan 5.4 software.

RESULTS

Forty-four studies with 1555 participants were included. Transcranial direct current stimulation proved effective in improving upper extremity motor function (standardized mean difference = 0.22, 95% confidence interval: 0.12-0.32, P < 0.001) and Barthel Index (mean difference = 4.65, 95% confidence interval: 2.82-6.49, P < 0.001). Subgroup analysis revealed the highest transcranial direct current stimulation efficacy in patients with subacute stroke. Both anodal and cathodal stimulation were effective against upper extremity motor dysfunction. C3/C4 was the most effective stimulus target. Optimal stimulation parameters included stimulus current densities <0.057 mA/cm2 for 20-30 min and <30 sessions. Adverse effects and dropouts during follow-up showed that transcranial direct current stimulation is safe and feasible.

CONCLUSIONS

Our findings suggest that both anodal and cathodal stimulation were significantly effective in subacute stroke patients, particularly when preceding other treatments and when C3/C4 is targeted.

Comparative efficacy of different noninvasive brain stimulation protocols on upper-extremity motor function and activities of daily living after stroke: a systematic review and network meta-analysis

The objectives of the study were to systematically evaluate the rehabilitation effect of noninvasive brain stimulation (NIBS) on upper extremity motor function and activities of daily living in stroke patients and to prioritize various stimulation protocols for reliable evidence-based medical recommendations in patients with upper extremity motor dysfunction after stroke. Web of Science, PubMed, Embase, Cochrane Library, CNKI, Wanfang, VIP, and CBM were searched to collect all randomized controlled trials (RCTs) of NIBS to improve upper extremity motor function in stroke patients. The retrieval time was from the establishment of all databases to May 2023. According to the Cochrane system evaluation manual, the quality of the included studies was evaluated, and the data were extracted. Statistical analysis was carried out by using RevMan 5.3, R 4.3.0, and Stata 17.0 software. Finally, 94 RCTs were included, with a total of 5546 patients. Meta-analysis showed that NIBS improved the Fugl-Meyer assessment (FMA) score (mean difference (MD) = 6.51, 95% CI 6.20 ~ 6.82, P < 0.05), MBI score (MD = 7.69, 95% CI 6.57 ~ 8.81, P < 0.05), ARAT score (MD = 5.06, 95% CI 3.85 ~ 6.27, P < 0.05), and motor evoked potential (MEP) amplitude. The modified Ashworth scale score (MD =  - 0.37, 95% CI - 0.60 to - 0.14, P < 0.05), National Institutes of Health Stroke Scale score (MD =  - 2.17, 95% CI - 3.32 to - 1.11, P < 0.05), incubation period of MEP (MD =  - 0.72, 95% CI - 1.06 to - 0.38, P < 0.05), and central motor conduction time (MD =  - 0.90, 95% CI - 1.29 to - 0.50, P < 0.05) were decreased in stroke patients. Network meta-analysis showed that the order of interventions in improving FMA scores from high to low was anodal-transcranial direct current stimulation (tDCS) (surface under the cumulative ranking curve (SUCRA) = 83.7%) > cathodal-tDCS (SUCRA = 80.2%) > high-frequency (HF)-repetitive transcranial magnetic stimulation (rTMS) (SUCRA = 68.5%) > low-frequency (LF)-rTMS (SUCRA = 66.5%) > continuous theta burst stimulation (cTBS) (SUCRA = 54.2%) > bilateral-tDCS (SUCRA = 45.2%) > intermittent theta burst stimulation (iTBS) (SUCRA = 34.1%) > sham-NIBS (SUCRA = 16.0%) > CR (SUCRA = 1.6%). In terms of improving MBI scores, the order from high to low was anodal-tDCS (SUCRA = 88.7%) > cathodal-tDCS (SUCRA = 85.4%) > HF-rTMS (SUCRA = 63.4%) > bilateral-tDCS (SUCRA = 56.0%) > LF-rTMS (SUCRA = 54.2%) > iTBS (SUCRA = 32.4%) > sham-NIBS (SUCRA = 13.8%) > CR (SUCRA = 6.1%). NIBS can effectively improve upper extremity motor function and activities of daily living after stroke. Among the various NIBS protocols, anodal-tDCS demonstrated the most significant intervention effect, followed by cathodal-tDCS and HF-rTMS.

Efficacy of the use of video games on mood, anxiety and depression in stroke patients: preliminary findings of a randomised controlled trial

BACKGROUND

In the different published studies, there is no consensus on the efficacy of virtual reality as an adjuvant treatment of mood states.

AIM

The aim of this study is to evaluate the impact of no immersive virtual reality with the Nintendo Switch device in rehabilitation treatment on mood, anxiety and depression in stroke patients admitted to neurorehabilitation units.

METHODS

Fifty-eight patients admitted to neurorehabilitation units underwent a 1:3 multicentre randomised clinical trial. The intervention group consisted of 17 patients and the control group of 41 patients. The intervention group performed 6 virtual reality sessions together with the conventional treatment, and the control group performed only the conventional rehabilitation sessions. Primary and secondary clinical outcomes were measured before and six weeks after the intervention.

RESULTS

Comparing the intervention group and control group, the anxiety levels of the intervention group decreased compared to the results observed in the control group (p = 0.01), as did the dependence of the intervention group (0.015). On the other hand, the results obtained after the intervention by the control group for anxiety (0.479) and depression (0.292) were not statistically significant.

CONCLUSION

Rehabilitation VR used as an adjuvant treatment to conventional treatment has a beneficial impact on the neurological status and state of anxiety of stroke patients admitted to neurorehabilitation units.

TRIAL REGISTRATION

Registered in the https://clinicaltrials.gov/ repository (NTC NCT05143385). Protocol registration date 7 October 2021, retrospectively registered.

Transcranial direct current stimulation in physical therapy treatment for adults after stroke: A systematic review

BACKGROUND

Stroke is a clinical syndrome that can cause neurological disorders due to a reduction or interruption in the blood flow at the brain level. Transcranial direct current stimulation (TDCS) is a non-invasive electrotherapy technique with the ability to modulate the function of nervous tissue.

OBJECTIVE

The aim of this review is to analyze the effects derived from the application of the TDCS for post-stroke patients on functionality and mobility.

METHODS

The data search was conducted in PubMed, PEDro, Cochrane Library, Web of Science and Scopus between July and August 2023. The search focused on randomized clinical trials conducted in the period of 2019-2023, and according to the selection criteria, seven studies were obtained.

RESULTS

The results found are mainly focused on the analysis of the scales Fugl-Meyer Assessment for Upper Extremity and Wolf Motor Function Test.

CONCLUSION

The application of TDCS presents benefits in post-stroke individuals on functionality, mobility and other secondary studied variables.

Effects of neurofeedback training combined with transcranial direct current stimulation on motor imagery: A randomized controlled trial

Introduction

Neurofeedback (NFB) training and transcranial direct current stimulation (tDCS) have been shown to individually improve motor imagery (MI) abilities. However, the effect of combining both of them with MI has not been verified. Therefore, the aim of this study was to examine the effect of applying tDCS directly before MI with NFB.

Methods

Participants were divided into an NFB group (n = 10) that performed MI with NFB and an NFB + tDCS group (n = 10) that received tDCS for 10 min before MI with NFB. Both groups performed 60 MI trials with NFB. The MI task was performed 20 times without NFB before and after training, and μ-event-related desynchronization (ERD) and vividness MI were evaluated.

Results

μ-ERD increased significantly in the NFB + tDCS group compared to the NFB group. MI vividness significantly increased before and after training.

Discussion

Transcranial direct current stimulation and NFB modulate different processes with respect to MI ability improvement; hence, their combination might further improve MI performance. The results of this study indicate that the combination of NFB and tDCS for MI is more effective in improving MI abilities than applying them individually.