Design strategies to improve patient motivation during robot-aided rehabilitation

You don't understand ONE GODDAMN THING ABOUT SURVIVOR MOTIVATION, DO YOU? You create 100% recovery protocols and your survivor will be motivated to do the millions of reps needed because they are looking forward to 100% recovery. GET THERE! And get out of stroke research, you don't belong there!

The problem is stroke researchers are not motivated to solve stroke. What the fuck is your solution to that failure? We still don't know how to motivate stroke medical 'professionals' to solve stroke to 100% recovery!

 

 

Design strategies to improve patient motivation during robot-aided rehabilitation

• Roberto Colombo,
• Fabrizio Pisano,
• Alessandra Mazzone,
• Carmen Delconte,
• Silvestro Micera,
• M Chiara Carrozza,
• Paolo Dario &
• Giuseppe Minuco 

Journal of NeuroEngineering and Rehabilitation volume 4, Article number: 3 (2007) Cite this article

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Abstract

Background

Motivation is an important factor in rehabilitation and frequently used as a determinant of rehabilitation outcome. Several factors can influence patient motivation and so improve exercise adherence. This paper presents the design of two robot devices for use in the rehabilitation of upper limb movements, that can motivate patients during the execution of the assigned motor tasks by enhancing the gaming aspects of rehabilitation. In addition, a regular review of the obtained performance can reinforce in patients' minds the importance of exercising and encourage them to continue, so improving their motivation and consequently adherence to the program. In view of this, we also developed an evaluation metric that could characterize the rate of improvement and quantify the changes in the obtained performance.

Methods

Two groups (G1, n = 8 and G2, n = 12) of patients with chronic stroke were enrolled in a 3-week rehabilitation program including standard physical therapy (45 min. daily) plus treatment by means of robot devices (40 min., twice daily) respectively for wrist (G1) and elbow-shoulder movements (G2). Both groups were evaluated by means of standard clinical assessment scales and the new robot measured evaluation metric. Patients' motivation was assessed in 9/12 G2 patients by means of the Intrinsic Motivation Inventory (IMI) questionnaire.

Results

Both groups reduced their motor deficit and showed a significant improvement in clinical scales and the robot measured parameters. The IMI assessed in G2 patients showed high scores for interest, usefulness and importance subscales and low values for tension and pain subscales.

Conclusion

Thanks to the design features of the two robot devices the therapist could easily adapt training to the individual by selecting different difficulty levels of the motor task tailored to each patient's disability. The gaming aspects incorporated in the two rehabilitation robots helped maintain patients' interest high during execution of the assigned tasks by providing feedback on performance. The evaluation metric gave a precise measure of patients' performance and thus provides a tool to help therapists promote patient motivation and hence adherence to the training program.

Stroke patients’ motivation for home-based upper extremity rehabilitation with eHealth tools

You don't understand ONE GODDAMN THING ABOUT SURVIVOR MOTIVATION, DO YOU? You create 100% recovery protocols and your survivor will be motivated to do the millions of reps needed because they are looking forward to 100% recovery. GET THERE!

 Stroke patients’ motivation for home-based upper extremity rehabilitation with eHealth tools

A.J. Langerak

,

P. D’Olivo

,

O.S.A. Thijm

,

G.R.H. Regterschot

,

C.G.M. Meskers

,

M.C. Rozendaal

, show all

Received 19 May 2023, Accepted 05 Jan 2024, Published online: 09 Feb 2024

• Cite this article
• https://doi.org/10.1080/09638288.2024.2304091
• CrossMark

In this article

• Abstract
• Implications for rehabilitation
• Introduction
• Materials and methods
• Results
• Discussion
• Conclusion
• Acknowledgements
• Disclosure statement
• Additional information
• References
• Appendixes

 

Abstract

Purpose

eHealth-based exercise therapies were developed to increase stroke patients’ adherence to home-based motor rehabilitation. However, these eHealth tools face a rapid decrease in use after a couple of weeks. This study investigates stroke patients’ motivation for home-based upper extremity rehabilitation with eHealth tools and their relation with Basic Psychological Needs.

Materials and methods

This is a qualitative study using thematic analysis. We conducted semi-structured interviews with stroke patients with upper extremity motor impairments, who were discharged home from a rehabilitation centre, after they interacted with a novel eHealth coach demonstrator in their homes for five consecutive days.

Results

We included ten stroke patients. Thematic analysis resulted in eight themes for home-based rehabilitation motivation: Curiosity, Rationale, Choice, Optimal challenge, Reference, Encouragement, Social Support and Trustworthiness. Those themes are embedded into three Basic Psychological Needs: “Autonomy”, “Competence”, and “Relatedness”.

Conclusion

Eight motivational themes related to the three Basic Psychological Needs describe stroke patients’ motivation for home-based upper extremity rehabilitation. We recommend considering those themes when developing a home-based eHealth intervention for stroke patients to increase the alignment of eHealth tools to the patient’s needs and reduce motivational decreases in home-based rehabilitation.

Implications for rehabilitation

• Stroke patients show motivational decreases and decreased use of eHealth tools in home-based rehabilitation after a couple of weeks.

• Eight motivational themes describe home-based rehabilitation motivation in stroke patients: Curiosity, Rationale, Choice, Optimal challenge, Reference, Encouragement, Social Support and Trustworthiness.

• Those themes are embedded into three Basic Psychological Needs: “Autonomy”, “Competence”, and “Relatedness”.

• Those themes should be considered when developing a home-based eHealth intervention for stroke patients to increase the alignment of eHealth tools to the patient’s needs and reduce motivational decreases in home-based rehabilitation.

Editorial: Critical Care After Stroke

 You don't understand, do you?  Successful reperfusion is only the first step in survivor recovery. If you would stop the 5 causes of the neuronal cascade of death in the first days you could save billions of neurons, vastly reducing your 30-day death rate.

And yes, I'm arrogant enough to think I know more about what needs to be done than you do. Arrogance only exists if you don't know what you're talking about. I do.

Editorial: Critical Care After Stroke

Rajiv Advani^1,2*, Roland Faigle³ and Sang-Bae Ko⁴

• ¹Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
• ²Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
• ³Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
• ⁴Department of Neurology, Department of Critical Care Medicine, Seoul National University College of Medicine, Seoul, South Korea

Editorial on the Research Topic
Critical Care After Stroke

Stroke, as an entity comprising both acute ischemic stroke (AIS) and Intracerebral Hemorrhage (ICH), is the second leading cause of global mortality (1). Although advances in the management of AIS, in particular endovascular therapy for large vessel occlusion, have led to improved functional outcomes (2), 3-month mortality in those undergoing treatment remains substantial. Despite surgical intervention and changes in recommendations for acute medical management for ICH in recent years (3), 30 day mortality is as high as 46% (4). Critical Care After Stroke is therefore of upmost importance to improve functional outcomes and reduce mortality in both the short term and longer term follow up.

Endovascular Therapy (EVT) is now the standard of care for patients presenting with a large vessel occlusion in the anterior circulation (5), blood pressure management thereafter, however, is not standardized. In their mini review, Peng et al. address one of the elephants in the room, namely that, despite successful reperfusion, many patients do not regain functional independence. Their review identifies blood pressure (BP) optimization as an area of focus in those with hemodynamic variability and vast BP fluctuations. Ongoing trials are addressing the role of BP, but post-hoc analyses from several thrombectomy trials suggest that high systolic BP trajectories in the first 24 h post procedure are associated with an increased risk of poor outcome. An individual, autoregulation-guided approach to BP, seems to increase the chances of a good clinical outcome.

Hong et al.'s review on hemorrhagic transformation after an AIS highlights the associated risk of poor outcome and increased mortality. The mechanism of hemorrhagic transformation is explained by disruption of the blood-brain barrier and reperfusion injury that leads to leakage of peripheral blood cells. In AIS this transformation may be a natural progression of tissue ischemia that is facilitated, and thus worsened, by reperfusion therapy. There are several strategies that can be considered for management of hemorrhagic transformation in AIS, including neurosurgical intervention and medical management. The medical management is individual and can be summarized as reversal of coagulopathy, management of BP, temperature regulation, and supportive neurocritical care with a focus on reducing hematoma expansion and maintaining the integrity of the blood-brain barrier. Regarding the latter, the authors point out the role of matrix metalloproteinases and the need for more research around these biological and molecular mechanisms.

Kobata et al. review recent updates in neurosurgical interventions for spontaneous ICH. Neurosurgical interventions are a matter of debate and clinical practice varies greatly globally. The minimally invasive surgery plus alteplase for intracerebral hemorrhage evacuation (MISTIE) III trial demonstrated a reduction in mortality compared to medical treatment. Despite the overall reduction in mortality, no improved functional outcome categorized as a modified Rankin Scale 0–3 was observed. Ongoing randomized controlled trials such as the Early miNimally invasive Removal of Intra-Cerebral Hemorrhage (ENRICH) trial, the Minimally Invasive Endoscopic Surgical Treatment with Apollo/Artemis in Patients with Brain Hemorrhage (INVEST) trial, and the Dutch Intracerebral Hemorrhage Surgery Trial (DIST) are further addressing the optimal treatment for ICH. The authors point out that the outcome of surgical treatment is also dependent on the site and surgeon experience, something that should be taken into consideration when interpreting results for clinical practice.

Gao L. et al. address end-of-life care and the underlying decision-making process and associated prognostic uncertainties as a pivotal part of a stroke physician's challenge in the clinical setting. Patients suffering a stroke, especially those who require critical care, are commonly unable to actively participate in the care decision-making processes, and care decisions rest on the shoulders of surrogate decision-makers. Decision-making around many aspects of critical care can be challenging; surgical interventions, intensive care unit treatment, artificial nutrition, tracheostomy, withdrawal of life-sustaining care to name a few. This mini review highlights the difficulties in outcome prognostication, and provide strategies to address uncertainty and elicit goals of care.(They are not even trying for recovery. Words matter!) The authors conclude that clear communication regarding decision-making, prognostication, and patients' and surrogates' wishes after stroke are pivotal in all care settings, but especially in the critical care unit.

This topic also includes publications on the evaluation of the patient safety climate in acute care (Bohmann et al.), the impact of blood pressure and volume contraction in acute stroke (Bahouth et al.), early initiation of renal replacement therapy in ICH (Schenk et al.), reduction of intracranial pressure mediated through surgical intervention (Al-Kawaz et al.), individual predictors of mortality in ICH (Gao B. et al.; Sun et al.), and Subarachnoidal hemorrhage (Yang et al.; He et al.), the impact of atrial fibrillation Wu et al. and prolonged QT interval Ahn et al. on clinical outcomes in AIS patients, as well as other reports of original research showcasing the diversity in critical care by Mazza et al. and Nguyen et al.

The publications in this fascinating Research Topic have highlighted its multifaceted nature and comprise molecular and biological mechanisms, epidemiology, reviews of current literature of hot topics in the field of stroke care, outcome prediction, and prognostication and communication to name a few. The publications also point out areas for further research. This Research Topic highlights that Critical Care After Stroke poses substantial clinical challenges in a rapidly evolving area of stroke research.

Author Contributions

RA drafted the manuscript. RF and S-BK contributed with conceptualization and editing of the final version. The final version was approved by all authors.

 

Self-management interventions for adults with stroke: A scoping review.

I don't understand and thus would never be able to tell my staff what needs to be done. 

Self-management interventions for adults with stroke: A scoping review.

Chronic Diseases and Translational Medicine , Volume 7(3) , Pgs. 139-148.

NARIC Accession Number: J87400.  What's this?
ISSN: 2095-882X.
Author(s): Ruksakulpiwat, Suebsarn ; Zhou, Wendie.
Publication Year: 2021.
Number of Pages: 10.
Abstract: Study systematically identified and analyzed randomized controlled trials (RCTs) of self-management interventions for adults with stroke. A scoping review on stroke and self-management interventions was conducted based on the methodology of Arksey and O'Malley, following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. PubMed, Embase, Web of Science, CINAHL Plus Full Text, Medline Plus Full Text, and Cochrane Central Register of Controlled Trials were searched from inception to July 2020 to identify relevant studies. Fifty-four RCTs met the inclusion criteria. The most popular study design is comparing a self-management intervention to usual care or waitlist control condition. Physical activity is the most common intervention topic, and interventions were mainly delivered face to face. Most interventions were located in inpatient and multiple settings. Interventions were conducted by various providers, with nurses the most common provider group. Symptom management was the most frequently reported outcome domain that improved. Self-management interventions benefit the symptom management of stroke patients a lot. The reasonable time for intervention is at least 6 to 12 months. Multifarious intervention topics, delivery formats, and providers are adopted mostly to meet the multiple needs of this population. Physical activity was the most popular topic currently. Studies comparing the effect of different types of self-management interventions are required in the future.
Descriptor Terms: INTERVENTION, LITERATURE REVIEWS, OUTCOMES, SELF CARE, STROKE.


Can this document be ordered through NARIC's document delivery service*?: Y.
Get this Document: https://www.sciencedirect.com/science/article/pii/S2095882X21000220?via%3Dihub.

Citation: Ruksakulpiwat, Suebsarn , Zhou, Wendie. (2021). Self-management interventions for adults with stroke: A scoping review.  Chronic Diseases and Translational Medicine , 7(3), Pgs. 139-148. Retrieved 11/24/2021, from REHABDATA database.

 

Exploiting telerobotics for sensorimotor rehabilitation: a locomotor embodiment

I don't understand, but then the only thing that will make my gait better is curing my spasticity.  You could put a gun to my head and tell me to straighten my foot while walking and you'd have to kill me since I don't have control of that.  I'm hoping that I never am pulled over by cops where they tell me to put both hands on the roof and spread your legs. I'd fail just like having to alternately touch your nose with the index finger of each hand as a sobriety test.

Exploiting telerobotics for sensorimotor rehabilitation: a locomotor embodiment

• Min Hyong Koh,
• Sheng-Che Yen,
• Lester Y. Leung,
• Sarah Gans,
• Keri Sullivan,
• Yasaman Adibnia,
• Misha Pavel &
• Christopher J. Hasson 

Journal of NeuroEngineering and Rehabilitation volume 18, Article number: 66 (2021) Cite this article

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Abstract

Background

Manual treadmill training is used for rehabilitating locomotor impairments but can be physically demanding for trainers. This has been addressed by enlisting robots, but in doing so, the ability of trainers to use their experience and judgment to modulate locomotor assistance on the fly has been lost. This paper explores the feasibility of a telerobotics approach for locomotor training that allows patients to receive remote physical assistance from trainers.

Methods

In the approach, a trainer holds a small robotic manipulandum that shadows the motion of a large robotic arm magnetically attached to a locomoting patient's leg. When the trainer deflects the manipulandum, the robotic arm applies a proportional force to the patient. An initial evaluation of the telerobotic system’s transparency (ability to follow the leg during unassisted locomotion) was performed with two unimpaired participants. Transparency was quantified by the magnitude of unwanted robot interaction forces. In a small six-session feasibility study, six individuals who had prior strokes telerobotically interacted with two trainers (separately), who assisted in altering a targeted gait feature: an increase in the affected leg’s swing length.

Results

During unassisted walking, unwanted robot interaction forces averaged 3−4 N (swing–stance) for unimpaired individuals and 2−3 N for the patients who survived strokes. Transients averaging about 10 N were sometimes present at heel-strike/toe-off. For five of six patients, these forces increased with treadmill speed during stance (R² = .99; p < 0.001) and increased with patient height during swing (R² = .71; p = 0.073). During assisted walking, the trainers applied 3.0 ± 2.8 N (mean ± standard deviation across patients) and 14.1 ± 3.4 N of force anteriorly and upwards, respectively. The patients exhibited a 20 ± 21% increase in unassisted swing length between Days 1−6 (p = 0.058).

Conclusions

The results support the feasibility of locomotor assistance with a telerobotics approach. Simultaneous measurement of trainer manipulative actions, patient motor responses, and the forces associated with these interactions may prove useful for testing sensorimotor rehabilitation hypotheses. Further research with clinicians as operators and randomized controlled trials are needed before conclusions regarding efficacy can be made.

Background

Locomotor impairments can arise from injuries or disease processes that disrupt sensorimotor operations, such as spinal cord injuries and stroke. Locomotor training may be incorporated into a rehabilitation program. One approach uses a treadmill because it allows tight control over walking speed and terrain and facilitates the use of a body-weight support system [1, 2]. During treadmill training, human trainers can provide physical assistance to facilitate limb movement and support trunk stabilization [3]. High-volumes of task-orientated practice can promote neuroplasticity [4]. Although treadmill training has shown positive results for patient populations, including individuals who have had strokes [5, 6] or incomplete spinal cord injuries [7, 8], the overall efficacy is not unambiguously superior to other methods such as over-ground training or general exercise regimens [2, 9,10,11,12,13]. Explaining the inability of manual treadmill training to consistently meet expectations presents a grand challenge due to high investigational variability (e.g., eligibility criteria and intervention parameters [14]).

When providing physical assistance to elicit targeted modifications of a patient’s locomotor pattern, human trainers must contend with relatively complex patient dynamics. This includes the gravitational and inertial forces associated with the large wobbling mass [15] of a patient’s upper body, which is alternately supported by multi-link segmental chains (the legs) during locomotion. Further, the joints spanning these segments are actuated by a redundant set of viscoelastic muscles [16] controlled by a possibly impaired nervous system. Trainers also face significant sensorimotor constraints. They often need to produce large forces while kneeling or sitting with a limited view of a patient’s body and need to keep up with rapidly swinging patient limbs to prevent unintended interaction forces, which demands predictive control processes due to sensorimotor delays [17]. The combination of complex interactive dynamics, high forces, and rapid movements creates a challenging task that may limit trainer effectiveness.

One way to address the physical limitations of human trainers is to enlist the help of robots [18,19,20]. However, in doing so, human trainers have been relegated to a supervisory role. At the same time, robotic gait training outcomes have not proven dependably better than conventional rehabilitation approaches for spinal cord injury [21, 22] or stroke [23,24,25,26,27]. Giving trainers more online control of the robotic system (trainer-in-the-loop) could improve rehabilitation outcomes. The rationale is that trainers can use their experience and judgment to customize locomotor assistance on the fly, and their relatively high degree of motor execution variability could be a feature instead of a bug. Self-generated (intrinsic) variability can promote the exploration of novel motor actions that drive learning [28, 29]. Could this also hold for variability injected from an external source, i.e., from a trainer to a patient? If so, these advantages could be masked by trainer fatigue or other sensorimotor encumbrances. These points lead to the principal question: Would treadmill training outcomes improve if trainers remained in control, were relieved of high physical demands, and received augmented feedback about their patient interactions? Telerobotics, or robotics with a human operator in the control loop [30], may provide a viable approach to answering this question.

Although telerobotics has been broadly researched, for example, in areas related to telesurgery (see [30] for a review), rehabilitation applications with continuous physical interaction between clinicians and patients are more limited. Most existing telehealth approaches only permit visual and auditory communication [31,32,33,34]. One study investigated the feasibility of remote haptic communication using an exoskeleton to record the movements of patients who have had strokes; these movements were subsequently played back using an exoskeleton worn by therapists [35]. By feeling the patients' movements through the exoskeleton, the therapists were able to identify abnormal movement patterns. Although the results are promising, the therapists did not command the robotic system to apply forces to patients. Others have recently explored impedance-based telerobotics approaches for upper-extremity rehabilitation [36, 37], but such techniques have yet to be tested in clinical populations. In general, there is a significant need for telerobotics approaches that allow real-time bidirectional physical interaction between trainers and patients [38], which, in addition to benefits associated with human–human interaction (see previous paragraph) may be useful with heightened disease transmission risks.

 

More at link.

 

Inhibition versus facilitation of contralesional motor cortices in stroke: Deriving a model to tailor brain stimulation

I don't understand. 

Inhibition versus facilitation of contralesional motor cortices in stroke: Deriving a model to tailor brain stimulation

 Vishwanath Sankarasubramanian a, 

Andre G. Machado b, 

Adriana B. Conforto c,d, 

Kelsey A. Potter-Baker a,

David A. Cunningham a,e, 

Nicole M. Varnerin a, 

Xiaofeng Wang f, 

Ken Sakaie g, 

Ela B. Plow a,b,h,

a Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
b Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195, USA
c Neurology Clinical Division, Neurology Department, Hospital das Clinicas, São Paulo University, 05508-090 São Paulo, SP, Brazil
d Hospital Israelita Albert Einstein, 05652-900 São Paulo, SP, Brazil
e School of Biomedical Sciences, Kent State University, Kent, OH 44242, USA
f  Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
g Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH 44195, USA
h Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195, USA
a r t i c l e i n f o
 Article history:
Accepted 14 March 2017Available online 21 March 2017
Keywords:
Diffusion tensor imagingMotor cortexPremotor cortexNeuronal plasticityRehabilitationStrokeTranscranial magnetic stimulation
h i g h l i g h t s

 Mildly affected chronic stroke patients improved upon paretic upper limb reaching with standardinhibitory 1Hz rTMS of contralesional motor cortex.

 Severely affected patients improved with a new method involving facilitatory 5Hz rTMS of contrale-sional dorsal premotor cortex.

 A preliminary cut-off level of damage/impairment separated responders to each form of stimulation.

a b s t r a c t

Objective:
 The standard approach to brain stimulation in stroke is based on the premise that ipsilesionalM1(iM1)is important for motor function of the paretic upper limb, while contralesional cortices compete with iM1. Therefore, the approach typically advocates facilitating iM1 and/or inhibiting contralesionalM1 (cM1). But, this approach fails to elicit much improvement in severely affected patients, who on account of extensive damage to ipsilesional pathways, cannot rely on iM1. These patients are believed to instead rely on the undamaged cortices, especially the contralesional dorsal premotor cortex(cPMd), for support of function of the paretic limb. Here, we tested for the first time whether facilitation of cPMd could improve paretic limb function in severely affected patients, and if a cut-off could be identified to separate responders to cPMd from responders to the standard approach to stimulation.
Methods:
 In a randomized, sham-controlled crossover study, fifteen patients received the standard approach of stimulation involving inhibition of cM1 and a new approach involving facilitation of cPMdusing repetitive transcranial magnetic stimulation (rTMS). Patients also received rTMS to control areas.At baseline, impairment [Upper Extremity Fugl-Meyer (UEFM PROXIMAL, max=36)] and damage to path-ways [fractional anisotropy (FA)] was measured. We measured changes in time to perform proximal paretic limb reaching, and neurophysiology using TMS.
Results:
 Facilitation of cPMd generated more improvement in severely affected patients, who had expe-rienced greater damage and impairment than a cut-off value of FA (0.5) and UEFM PROXIMAL
 (26–28). The standard approach instead generated more improvement in mildly affected patients. Responders to cPMd showed alleviation of interhemispheric competition imposed on iM1, while responders to the standard approach showed gains in ipsilesional excitability in association with improvement.
Conclusions:

A preliminary cut-off level of severity separated responders for standard approach vs. facilitation of cPMd

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

Show all authors

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.