Effects of the addition of transcranial direct current stimulation to virtual reality therapy after stroke: A pilot randomized controlled trial

Viana, Ricardo; Laurentino, Glória Elizabeth Carneiro; Souza, Renata M. C. R. de; Fonseca, Jader Barbosa; Filho, Edivaldo Mendes; Dias, Sibelle; Teixeira-Salmela, Luci Fuscaldi; Monte-Silva, Kátia

doi:10.3233/nre-141065

Cited by 117 publications

(97 citation statements)

References 59 publications

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“…1, Table 2) [22–29]. We found no concerns on risk of a publication bias in the included studies based on either PEDro [12] (Table 3) or Jadad [13] scores (Table 4).…”

Section: Resultsmentioning

confidence: 95%

“…We used random-effects model to account for this duplication (between-study variance τ 2 = 0.46; heterogeneity index I 2 = 71%). We grouped individual studies based on tDCS montage as anodal [24,25,28], cathodal [23–25,27] or bihemispheric [22,26,29] (Fig. 2A) as well as based on the mean post-stroke duration as acute stroke [23–25,28] or chronic stroke [22,26,27,29] (mean time post-stroke ≤1 month or ≥2.5 years, respectively; Fig.…”

Section: Resultsmentioning

confidence: 99%

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Transcranial Direct Current Stimulation Post-Stroke Upper Extremity Motor Recovery Studies Exhibit a Dose–Response Relationship

et al. 2016

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Background and purpose Transcranial direct current stimulation (tDCS) has shown mixed results in post-stroke motor recovery, possibly because of tDCS dose differences. The purpose of this meta-analysis was to explore whether the outcome has a dose–response relationship with various dose-related parameters. Methods The literature was searched for double-blind, randomized, sham-controlled clinical trials investigating the role of tDCS (≥5 sessions) in post-stroke motor recovery as measured by the Fugl-Meyer Upper Extremity (FM-UE) scale. Improvements in FM-UE scores were compared between active and sham groups by calculating standardized mean differences (Hedge’s g) to derive a summary effect size. Inverse-variance-weighted linear meta-regression across individual studies was performed between various tDCS parameters and Hedge’s g to test for dose–response relationships. Results Eight studies with total of 213 stroke subjects were included. Summary Hedge’s g was statistically significant in favor of the active group (Hedge’s g = 0.61, p = 0.02) suggesting moderate effect. Specifically, studies that used bihemispheric tDCS montage (Hedge’s g = 1.30, p = 0.08) or that recruited chronic stroke patients (Hedge’s g = 1.23, p = 0.02) showed large improvements in the active group. A positive dose–response relationship was found with current density (p = 0.017) and charge density (p = 0.004), but not with current amplitude. Moreover, a negative dose–response relationship was found with electrode size (p < 0.001, smaller electrodes were more effective). Conclusions Our meta-analysis and meta-regression results suggest superior motor recovery in the active group when compared to the sham group and dose–response relationships relating to electrode size, charge density and current density. These results need to be confirmed in future dedicated studies.

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“…1, Table 2) [22–29]. We found no concerns on risk of a publication bias in the included studies based on either PEDro [12] (Table 3) or Jadad [13] scores (Table 4).…”

Section: Resultsmentioning

confidence: 95%

Section: Resultsmentioning

confidence: 99%

Transcranial Direct Current Stimulation Post-Stroke Upper Extremity Motor Recovery Studies Exhibit a Dose–Response Relationship

et al. 2016

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“…Four studies [43,[45][46][47] used the FMA as the primary measure of UL motor impairment. Provision of real stimulation resulted in a significant Hedges g of 0.75 (95% CI 0.15-1.35; P < .02; moderate effect size) for FMA scores (Figure 2A, Table 2).…”

Section: Effects Of Provision Of Nibs On Ul Motor Improvement Assessementioning

confidence: 99%

“…Four of 5 studies [43,[45][46][47] used clinical assessments to quantify UL motor improvement at the impairment and activity levels. Routinely used in studies involving individuals with stroke, these clinical assessments have good psychometric properties [49][50][51].…”

Section: Choice Of Outcome Measurementioning

confidence: 99%

Virtual Reality and Noninvasive Brain Stimulation in Stroke: How Effective Is Their Combination for Upper Limb Motor Improvement?—A Meta‐Analysis

Subramanian

Prasanna

2018

PM&R

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Background Efforts to augment post‐stroke upper limb (UL) motor improvement include the use of newer interventions such as noninvasive brain stimulation (NIBS) and task practice in virtual reality environments (VEs). Despite increasing interest in using a combination of these 2 interventions, the effectiveness of this combination to enhance UL motor improvement outcomes has not been examined. Objective To evaluate the effectiveness of a combination of NIBS and task practice in a VE to augment post‐stroke UL motor improvement. Methods We conducted a systematic search of the published literature using standard methodology. The Down and Black checklist and the Physiotherapy Evidence Database Research Organization Scale were used to assess study quality. We compared changes in UL impairment and activity levels between active stimulation and sham or other interventions using standardized mean differences and derived a summary effect size. Results We retrieved 5 studies that examined the role of a combination of NIBS and task practice in a VE to optimize UL motor improvement. These 5 studies included 3 randomized controlled trials, 1 cross‐sectional study, and 1 crossover study. There was level 1a evidence that the combination was beneficial in subacute stroke. There was level 1b evidence that provision of real stimulation was not superior to sham stimulation in chronic stroke. Effect sizes favoring the combination were moderate for improvements in UL impairment and small for activity levels. Conclusions Preliminary evidence supports the effectiveness of this combination in subacute stroke. Emergent questions need to be addressed to derive maximum benefit of this combination to augment post‐stroke UL motor improvement. Level of Evidence I

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“…In addition, Viana et al reported improvement of wrist spasticity in their anodal tDCS group (10). Collectively, these results suggest that anodal tDCS over the motor cortex may exert a beneficial role in reducing the degree of spasticity.…”

Section: Introductionmentioning

confidence: 99%

Transient Changes in Brain Metabolites after Transcranial Direct Current Stimulation in Spastic Cerebral Palsy: A Pilot Study

et al. 2017

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BackgroundMuscle spasticity is a disability caused by damage to the pyramidal system. Standard treatments for spasticity include muscle stretching, antispastic medications, and tendon release surgeries, but treatment outcomes remain unsatisfactory. Anodal transcranial direct current stimulation (tDCS) in patients with muscle spasticity is known to result in significant improvement in spastic tone (p < 0.001). However, the mechanism of action by which tDCS treatment affects spasticity remains unclear. This pilot study aimed to investigate the effect of anodal tDCS upon brain metabolites in the left basal ganglia and ipsilateral primary motor cortex (M1) in children with spastic cerebral palsy (CP).Materials and methodsThis study consisted of three steps: a baseline evaluation, a treatment period, and a follow-up period. During the treatment period, patients were given 20 min of 1 mA anodal tDCS over the left M1 for five consecutive days. Outcomes were compared between pre- and immediate posttreatment in terms of brain metabolites, Tardieu scales, and the quality of upper extremity skills test.ResultsTen patients with spastic CP were enrolled. Following tDCS, there were significant increases in the ratio of N-acetylaspartate (NAA)/creatine (Cr) (p = 0.030), choline (Cho)/Cr (p = 0.043), and myoinositol (mI)/Cr (p = 0.035) in the basal ganglia. Moreover, increased glutamine–glutamate (Glx)/Cr ratio in the left M1 (p = 0.008) was found. In addition, we also observed improvements in the extent of spasticity and hand function (p = 0.028).ConclusionFive consecutive days of anodal tDCS over the left M1 appeared statistically to reduce the degree of spasticity and increase NAA, Cho, mI, and Glx. Future research studies, involving a larger sample size of spastic CP patients undergoing tDCS is now warranted.

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Effects of the addition of transcranial direct current stimulation to virtual reality therapy after stroke: A pilot randomized controlled trial

Cited by 117 publications

References 59 publications

Transcranial Direct Current Stimulation Post-Stroke Upper Extremity Motor Recovery Studies Exhibit a Dose–Response Relationship

Transcranial Direct Current Stimulation Post-Stroke Upper Extremity Motor Recovery Studies Exhibit a Dose–Response Relationship

Virtual Reality and Noninvasive Brain Stimulation in Stroke: How Effective Is Their Combination for Upper Limb Motor Improvement?—A Meta‐Analysis

Transient Changes in Brain Metabolites after Transcranial Direct Current Stimulation in Spastic Cerebral Palsy: A Pilot Study

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