You really think that insurance is going to pay for rehab for chronic patients? Or patients will private pay for this with NO PROTOCOL and no 100% recovery?
Effectiveness of a combined transcranial direct current stimulation and virtual reality-based intervention on upper limb function in chronic individuals post-stroke with persistent severe hemiparesis: a randomized controlled trial
Journal of NeuroEngineering and Rehabilitation volume 18, Article number: 108 (2021)
Abstract
Background
Functional impairments derived from the non-use of severely affected upper limb after stroke have been proposed to be mitigated by action observation and imagination-based techniques, whose effectiveness is enhanced when combined with transcranial direct current stimulation (tDCS). Preliminary studies in mildly impaired individuals in the acute phase post-stroke show intensified effects when action is facilitated by tDCS and mediated by virtual reality (VR) but the effectiveness in cases of severe impairment and chronic stroke is unknown. This study investigated the effectiveness of a combined tDCS and VR-based intervention in the sensorimotor function of chronic individuals post-stroke with persistent severe hemiparesis compared to conventional physical therapy.
Methods
Twenty-nine participants were randomized into an experimental group, who received 30 minutes of the combined tDCS and VR-based therapy and 30 minutes of conventional physical therapy, or a control group, who exclusively received conventional physical therapy focusing on passive and active assistive range of motion exercises. The sensorimotor function of all participants was assessed before and after 25 one-hour sessions, administered three to five times a week, using the upper extremity subscale of the Fugl-Meyer Assessment, the time and ability subscales of the Wolf Motor Function Test, and the Nottingham Sensory Assessment.
Results
A clinically meaningful improvement(NOT RECOVERY!) of the upper limb motor function was consistently revealed in all motor measures after the experimental intervention, but not after conventional physical therapy. Similar limited effects were detected in the sensory function in both groups.
Conclusion
The combined tDCS and VR-based paradigm provided not only greater but also clinically meaningful improvement in the motor function (and similar sensory effects) in comparison to conventional physical therapy.
Background
Functional impairment of the upper limbs is a common sequelae after stroke that affects up to 85% of the survivors [1] and persists, with a certain degree of severity, in 30 to 60% of the cases, six months after the onset, limiting the complete recovery of functional use to only 5 to 20% of them [2, 3]. Given the incidence of upper limb deficits after stroke, and its impact on the participation in activities of daily living [1], social life [4], and quality of life [5], rehabilitation is an imperative goal of physical and occupational therapy.
Although there is no standard intervention for improving upper limb function after stroke [6], functional recovery is believed to occur in response to active exercise and to motor inclusion of the affected limb in task-oriented activities [7, 8]. Consequently, severe impairment of the upper limb function that prevents voluntary movements represents a major challenge to conventional interventions. As proof, less functional recovery is expected from individuals post-stroke who present more impaired motor conditions upon inclusion in rehabilitation programs [9].
Conventional approaches to chronic severe hemiparesis are focused on providing a passive range of motion exercises to preserve the mobility and flexibility of the affected extremity [10] or to compensate for the impaired function by training the less affected limb in unimanual task-oriented exercises [11]. Although passive exercises can produce proprioceptive input to motor pathways [12] and compensation can facilitate some degree of self-sufficiency [11], the absence of self-triggered movements and non-use of the affected limb may lead to a reduced sensorimotor representation in the available neural circuits over time [13] and, consequently, diminish the possibility for clinical improvement [11], an effect that is known as ‘learned non-use’ [14].
Different therapeutic interventions have been proposed to overcome the neural and functional decline caused by this effect, by modulating the excitability of the motor cortex circuitry in the absence of movement [15]. Motor imagery, the mental execution of a movement without any overt movement or muscle activation [16], has been shown to induce a spatial and temporal recruitment of motor cortical areas that mirrors the modulation produced during real motor practice [16,17,18]. Interestingly, motor imagery is not restricted to individuals with a degree of residual function and, in contrast to passive exercises, still incorporates voluntary drive [16]. Although its application to severely impaired function in individuals with chronic stroke has produced promising improvements [19], stroke can affect the ability to understand and practice different aspects of motor imagery, a technique that is already inherently complex [20]. Mirror therapy, an intervention based on staring at the reflected movements of the non-paretic limb on a mirror placed in the person’s midsagittal plane, as if they were produced by the affected side [21], can potentially overcome the difficulty in imagining the movement, while similarly modulating the activity of the primary motor cortex. Different studies have evidenced an increase in M1 excitability or increased ipsilateral activation, although the findings have been somewhat inconsistent [22]. Although mirror therapy has shown effectiveness in improving motor function in individuals with chronic stroke with mild to moderate impairment [23, 24], its effect on severely impaired individuals with stroke has been reported as being limited to a small effect on tactile sensation [25]. The capacity of motor imagery and mirror therapy to modulate brain activity in the ipsilesional hemisphere is supported by the mirror neuron system theory [26] and suggests that such interventions may be functionally akin to preparatory and executive motor processes [27].
Non-invasive brain stimulation, such as transcranial magnetic stimulation and transcranial direct current stimulation (tDCS) have been proved to modulate cortical excitability through the application of a magnetic field or low-intensity electric current to the scalp using a coil or saline-soaked electrodes, respectively. When applied to the primary motor cortex, it may prime neuroplasticity and motor learning effects [28], which have been shown to improve motor function after stroke [29, 30]. While current evidence suggests a similar potential effectiveness of both techniques [31, 32], the overall lower costs, lower safety risks, and potential to be applied concurrently during rehabilitation of tDCS can facilitate its clinical integration [33]. In contrast to the inconsistent results in its earlier stages, tDCS has shown positive results at improving motor function of the paretic upper limb in chronic stroke [34, 35]. Interestingly, the combination of tDCS and mirror therapy has shown additive effects on motor performance [36] and, similarly, its combination with motor imagery has been reported to modulate not only the neural correlates of movement [37,38,39], but also the motor performance of upper limb tasks [40, 41].
The addition of tDCS to a motor observation and execution task mediated by virtual reality (VR) has been found to augment motor improvement after stroke [42, 43], which could be supported by an increased short-term corticospinal facilitation [44]. The capacity of VR to provide controlled multi-modal stimulation in one or more sensory channels [45] has also motivated its use in motor observation and imagery [46,47,48]. Its capacity to allow users to perform virtual movements in a non-physical reality without executing the motor action in the real world is especially interesting, allowing the participation of individuals with severe impairments in the upper limb function in self-triggered tasks, thus closing the loop of interaction-stimulation [49]. Additionally, VR-based interventions alone have shown to promote substantial recovery not only in the acute phase but also within the chronic phase post-stroke [50,51,52].
Our preliminary studies suggests that a paradigm combining tDCS and a VR-based motor observation task triggered by conscious active responses can provide a feasible and well-accepted rehabilitation framework for individuals with chronic stroke and severely affected upper limb function [53, 54]. We hypothesized that this paradigm could also provide sensorimotor benefits to this population, when compared to conventional physical therapy. The objective of this study was, therefore, to determine the effectiveness of the combined tDCS and VR-based intervention in the upper limb motor and sensory function of severely impaired individuals with chronic stroke in comparison to conventional physical therapy.
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