Stance Phase Gait Training Post Stroke Using Simultaneous Transcranial Direct Current Stimulation and Motor Learning-Based Virtual Reality-Assisted Therapy: Protocol Development and Initial Testing

Abstract

Gait deficits are often persistent after stroke, and current rehabilitation methods do not restore normal gait for everyone. Targeted methods of focused gait therapy that meet the individual needs of each stroke survivor are needed. Our objective was to develop and test a combination protocol of simultaneous brain stimulation and focused stance phase training for people with chronic stroke (>6 months). We combined Transcranial Direct Current Stimulation (tDCS) with targeted stance phase therapy using Virtual Reality (VR)-assisted treadmill training and overground practice. The training was guided by motor learning principles. Five users (>6 months post-stroke with stance phase gait deficits) completed 10 treatment sessions. Each session began with 30 min of VR-assisted treadmill training designed to apply motor learning (ML)-based stance phase targeted practice. During the first 15 min of the treadmill training, bihemispheric tDCS was simultaneously delivered. Immediately after, users completed 30 min of overground (ML)-based gait training. The outcomes included the feasibility of protocol administration, gait speed, Timed Up and Go (TUG), Functional Gait Assessment (FGA), paretic limb stance phase control capability, and the Fugl–Meyer for lower extremity coordination (FMLE). The changes in the outcome measures (except the assessments of stance phase control capability) were calculated as the difference from baseline. Statistically and clinically significant improvements were observed after 10 treatment sessions in gait speed (0.25 ± 0.11 m/s) and FGA (4.55 ± 3.08 points). Statistically significant improvements were observed in TUG (2.36 ± 3.81 s) and FMLE (4.08 ± 1.82 points). A 10-session intervention combining tDCS and ML-based task-specific gait rehabilitation was feasible and produced clinically meaningful improvements in lower limb function in people with chronic gait deficits after stroke. Because only five users tested the new protocol, the results cannot be generalized to the whole population. As a contribution to the field, we developed and tested a protocol combining brain stimulation and ML-based stance phase training for individuals with chronic stance phase deficits after stroke. The protocol was feasible to administer; statistically and/or clinically significant improvements in gait function across an array of gait performance measures were observed with this relatively short treatment protocol.

Comparison of a single session of tDCS on cerebellum vs. motor cortex in stroke patients: a randomized sham-controlled trial

“…Recently, Salameh et al. investigated the effect of combined VR and tDCS stimulation and found it to be effective in the rehabilitation of gait and lower-limb function [ 114 ]. In the current study, we also found that the combined therapy was effective; however, other studies that used tDCS stimulation of the M1 and cerebellum together [ 50 , 65 ] did not use a similar intervention combination.…”

Targeting CNS Neural Mechanisms of Gait in Stroke Neurorehabilitation

“…Others have published preliminary work on adding brain stimulation methods to the treatment of the lower limb after stroke [ 49 , 51 , 52 , 53 , 54 , 55 ], and the results are somewhat promising [ 49 , 51 , 52 , 53 , 54 , 55 ]. In chronic stroke, one recent study demonstrated the feasibility of administering targeted tDCS brain stimulation during stance phase walking training, designed and framed within neuroplastic motor learning principles [ 56 ].…”

Short term effects of anodal cerebellar vs. anodal cerebral transcranial direct current stimulation in stroke patients, a randomized control trial

“…Tran-scranial direct current stimulation (tDCS) is a priming technique that modulates membrane potential and initiates synaptic plasticity in the area of application as well as the adjacent neural networks ( Stagg and Nitsche, 2011 ). TDCS stimulation in addition to therapies including conventional rehabilitation, robotics based rehabilitation, virtual reality, physical therapy and other techniques is a promising intervention to enhance motor performance, balance and gait in stroke patients ( Geroin et al, 2011 ; Seo et al, 2017 ; Picelli et al, 2018 ; Ehsani et al, 2022 ; Salameh et al, 2022 ).…”