Useless. A lot of words to say nothing specific.
Modulation of brain plasticity in stroke: a novel model for neurorehabilitation
Giovanni Di Pino, Giovanni Pellegrino, Giovanni Assenza, Fioravante Capone, Florinda Ferreri, Domenico Formica, Federico Ranieri, Mario Tombini, Ulf Ziemann, John C. Rothwell and Vincenzo Di Lazzaro
Nat. Rev. Neurol.
advance online publication 9 September 2014; doi:10.1038/nrneurol.2014.162
Abstract
| Noninvasive brain stimulation (NIBS) techniques can be used to monitor and modulate the excitability of intracortical neuronal circuits. Long periods of cortical stimulation can produce lasting effects on brain function, paving the way for therapeutic applications of NIBS in chronic neurological disease. The potential of NIBS in stroke rehabilitation has been of particular interest, because stroke is the main cause of permanent disability in industrial nations, and treatment outcomes often fail to meet the expectations of patients. Despite promising reports from many clinical trials on NIBS for stroke recovery, the number of studies reporting a null effect remains a concern. One possible explanation is that the interhemispheric competition model—which posits that suppressing the excitability of the hemisphere not affected by stroke will enhance recovery by reducing interhemispheric inhibition of the stroke hemisphere, and forms the rationale for many studies—is oversimplified or even incorrect. Here, we critically review the proposed mechanisms of synaptic and functional reorganization after stroke, and suggest a bimodal balance–recovery model that links interhemispheric balancing and functional recovery to the structural reserve spared by the lesion. The proposed model could enable NIBS to be tailored to the needs of individual patients.Nat. Rev. Neurol.
advance online publication 9 September 2014; doi:10.1038/nrneurol.2014.162
Introduction
Stroke is among the principal causes of death worldwide, and although most stroke survivors achieve at least some spontaneous recovery after the ictus, it remains the main cause of permanent disability in Europe and the USA. 1–3The only existing treatment for stroke is tissue plasminogen activator, which can salvage tissue at risk in the penumbra of a brain infarct and reduce future disability if administered within a few hours after stroke onset.4No treatments specifically designed to restore function through repair of damaged tissue have been developed to date. Current best practice in stroke management is to reduce initial impact, take precautions to avoid the further burden of complications, and maximize functional ability through extensive physiotherapy.Although early rehabilitative interventions can improve arm function above what would be achieved by natural recovery alone,
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the majority of patients are still unable to use the affected hand and/or arm for simple activities of daily living 6 months after the stroke.6Robot-assisted therapy has been proposed as an excellent low-cost way to increase the amount of therapy that an individual patient receives, because a robot can deliver a higher amount of exercise in the same time than can a human physiotherapist,7but in controlled trials robot-assisted therapy has shown disappointingly little additional benefit over conventional regimes of intensive physiotherapy.8,9The lack of effective neurorepair after stroke and the limitations of functional recovery attained by physio-therapy have led researchers to consider alternative approaches that improve the scope for recovery by enhancing the natural plasticity of the sensorimotor system. If recovery depends on ‘relearning’ new patterns of activity to maximize the use of remaining undamaged brain, interventions that increase plasticity, and thereby the ability to learn, should improve recovery. Two approaches are of great current interest: pharmaco logical interventions and noninvasive brain stimulation (NIBS). In this Review, we focus on NIBS. Although NIBS has been used to improve gait, neglect symptoms and lan-guage after stroke, we will concentrate here on its appli-cation to recovery of arm and hand function, because most studies have assessed the efficacy of NIBS on upper limb function.More than 350 articles have been published on trans-cranial stimulation in stroke since 2012. These include more than 50 small clinical trials that evaluated the potential for NIBS to enhance recovery of hand and arm function. Recent meta-analyses disagree on the effective-ness of these techniques: two Cochrane reviews do not support the use of repetitive transcranial magnetic stimu-lation (rTMS)10or transcranial direct current stimu lation (tDCS)11in stroke rehabilitation, whereas two other systematic reviews conclude that NIBS can have a moder-ate benefit in terms of stroke recovery, with few major adverse effects.12,13Here, we discuss the factors that have contributed to the slow progress of accepting NIBS as a part of routine clinical practice, and suggest ways to develop the use of NIBS in stroke rehabilitation.
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the majority of patients are still unable to use the affected hand and/or arm for simple activities of daily living 6 months after the stroke.6Robot-assisted therapy has been proposed as an excellent low-cost way to increase the amount of therapy that an individual patient receives, because a robot can deliver a higher amount of exercise in the same time than can a human physiotherapist,7but in controlled trials robot-assisted therapy has shown disappointingly little additional benefit over conventional regimes of intensive physiotherapy.8,9The lack of effective neurorepair after stroke and the limitations of functional recovery attained by physio-therapy have led researchers to consider alternative approaches that improve the scope for recovery by enhancing the natural plasticity of the sensorimotor system. If recovery depends on ‘relearning’ new patterns of activity to maximize the use of remaining undamaged brain, interventions that increase plasticity, and thereby the ability to learn, should improve recovery. Two approaches are of great current interest: pharmaco logical interventions and noninvasive brain stimulation (NIBS). In this Review, we focus on NIBS. Although NIBS has been used to improve gait, neglect symptoms and lan-guage after stroke, we will concentrate here on its appli-cation to recovery of arm and hand function, because most studies have assessed the efficacy of NIBS on upper limb function.More than 350 articles have been published on trans-cranial stimulation in stroke since 2012. These include more than 50 small clinical trials that evaluated the potential for NIBS to enhance recovery of hand and arm function. Recent meta-analyses disagree on the effective-ness of these techniques: two Cochrane reviews do not support the use of repetitive transcranial magnetic stimu-lation (rTMS)10or transcranial direct current stimu lation (tDCS)11in stroke rehabilitation, whereas two other systematic reviews conclude that NIBS can have a moder-ate benefit in terms of stroke recovery, with few major adverse effects.12,13Here, we discuss the factors that have contributed to the slow progress of accepting NIBS as a part of routine clinical practice, and suggest ways to develop the use of NIBS in stroke rehabilitation.
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