Transcranial Direct Current Stimulation to Optimise Participation in Stroke Rehabilitation – A Sham-Controlled Cross-Over Feasibility Study

You don't even understand the problem you are supposedly trying to solve, fatigue and attentional decline. It is fuckingly simple, you don't have EXACT STROKE REHAB PROTOCOLS WITH EXACT NUMBER OF REPETITIONS.  If you said do this exercise 10-15 million times and you will get this rehab result your patient would start counting and work themselves to exhaustion, fatigue would  not exist when that goal is out there to be achieved.  Solve the correct problem. EXACT STROKE PROTOCOLS, not guidelines.

Transcranial Direct Current Stimulation to Optimise Participation in Stroke Rehabilitation – A Sham-Controlled Cross-Over Feasibility Study

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Christopher Etherton-Beer, Yee Lui, Miranda Radalj, ...

First Published May 22, 2020 Brief Report

https://doi.org/10.1177/2633105520922181

Article information

Abstract

Background:

Fatigue and attentional decline limit the duration of many therapy sessions in older adults post stroke. Transcranial direct current stimulation (tDCS) may facilitate participation in rehabilitation, potentially via reduced fatigue and improved sustained attention poststroke.

Objective:

To evaluate whether tDCS results in an increase in the number of completed rehabilitation therapy sessions in stroke survivors.

Methods:

Nineteen participants were randomly allocated to receive 10 sessions of 2-mA anodal (excitatory) tDCS, or sham tDCS, applied to the left dorsolateral prefrontal cortex (DLPFC) for 20 minutes within 1 hour prior to the first rehabilitation therapy session of the day. After a 2-day washout period, participants then crossed-over. Researchers applying the tDCS, and those recording measures were blinded to group allocation. The number of first rehabilitation therapy sessions completed as planned, as well as the total duration of rehabilitation therapy, were used to determine the influence of tDCS on participation in stroke rehabilitation.

Results:

The total number of first therapy sessions completed as planned did not vary according to group allocation (111 of 139 sessions for tDCS, 110 of 147 sessions for sham treatment; chi-square 1.0; P = .31).

Conclusions:

Our results suggest that, while tDCS to the DLPFC was well tolerated, it did not significantly influence the number of completed rehabilitation therapy sessions in stroke survivors.

Keywords Stroke rehabilitation, transcranial direct current stimulation, fatigue, attention, noninvasive brain stimulation

Introduction

Attention deficits may affect the ability of older adults to engage in rehabilitation post stroke.¹ In addition, fatigue is very common post stroke. Fatigue is a complex impairment. Reduced cortical excitability is postulated to be one factor contributing to poststroke fatigue.² Thus, fatigue and attentional decline may limit rehabilitation therapy session duration in older adults poststroke.^1,2 Because rehabilitation is typically offered only in the initial months poststroke, it is critical that stroke survivors engage in as much therapy as possible during this time. The mean physiotherapy session treatment duration in a large published series was 38 ± 17 minutes.³ We identified that many patients, particularly those with severe stroke, are not able to stay alert for the duration of their therapy sessions and often cannot complete their therapy due to fatigue, attentional decline, or loss of concentration. In local audit data, the mean session duration of therapy sessions among 14 stroke survivors in the Bentley Hospital Stroke Rehabilitation Unit (SRU) was 34 ± 23 minutes. These published international data, and our local data, are both far below the recommended durations of rehabilitation therapy (at least 3 hours a day of scheduled therapy)⁴ suggesting the importance of investigating interventions that can improve duration and the number of therapy sessions.
There is preliminary evidence that noninvasive brain stimulation (NIBS) can enhance alertness and attention poststroke.^5,6 Compared with other NIBS techniques such as repetitive transcranial magnetic stimulation, transcranial direct current stimulation (tDCS) offers a reliable safety profile,⁷ affordability, ease of application, and sophisticated sham mode which allows for blinded control in clinical trial settings.⁸ Transcranial direct current stimulation is one of the most commonly used adjuvant NIBS techniques and has been shown to augment the recovery of upper limb movement and function and to assist in the management of dysphasia, visual neglect, and language dysfunction poststroke.⁹
Transcranial direct current stimulation acts to modulate cortical excitability by application of weak electrical currents (up to 2 mA)¹⁰ via electrodes applied to the scalp. Depending on the current polarity, neuronal firing rates increase or decrease due to changes in resting membrane potentials, with anodal tDCS increasing the likelihood of neuronal firing and cathodal tDCS decreasing the likelihood of neuronal firing.¹¹ It has been shown to be safe even when applied acutely (within two days) to the stroke-affected cortex.¹² Previous research has shown stroke survivors demonstrated greater accuracy, but not speed, on a test of executive attention following one session of tDCS compared with sham stimulation.^5,6 The application of tDCS to the DLPFC has been shown to enhance cognitive functions including working memory, visuomotor coordination, and decision-making in healthy individuals,^13,14 and in people with dementias or Parkinson disease.^15-17 The after-effects of tDCS on cortical excitability are likely modulated by N-methyl-d-aspartate (NMDA) receptor-dependent processes, and a number of investigations have shown that longer term changes can be induced in neuronal networks, including cognitive-attentional networks.⁹
The main adverse effect of tDCS which has been documented include a mild tingling or itching sensation, usually at the site of the cathodal electrode, which is common at the beginning of stimulation.⁷ An expert panel have provided recommendations for clinical and research use which clearly set out safety parameters.¹⁸
The available data suggest that tDCS may reduce fatigue and improve sustained attention poststroke. However, there are no data on longer term effects of tDCS with regard to sustained attention or clinical benefits, such as improved participation in rehabilitation, in older stroke survivors. We, therefore, designed the present study to test the hypothesis that tDCS applied to the DLPFC, compared with sham treatment, would be associated with an increase in the duration of rehabilitation therapy sessions in stroke survivors.