Abstract
The primary aim of this study was to evaluate and compare the effectiveness of two specific Non-Invasive Brain Stimulation (NIBS) paradigms, the repetitive Transcranial Magnetic Stimulation (rTMS), and transcranial Direct Current Stimulation (tDCS), in the upper limb rehabilitation of patients with stroke. Short and long term outcomes (after 3 and 6 months, respectively) were evaluated. We measured, at multiple time points, the manual dexterity using a validated clinical scale (ARAT), electroencephalography auditory event related potentials, and neuropsychological performances in patients with chronic stroke of middle severity. Thirty four patients were enrolled and randomized. The intervention group was treated with a NIBS protocol longer than usual, applying a second cycle of stimulation, after a washout period, using different techniques in the two cycles (rTMS/tDCS). We compared the results with a control group treated with sham stimulation. We split the data analysis into three studies. In this first study we examined if a cumulative effect was clinically visible. In the second study we compared the effects of the two techniques. In the third study we explored if patients with minor cognitive impairment have most benefit from the treatment and if cognitive and motor outcomes were correlated. We found that the impairment in some cognitive domains cannot be considered an exclusion criterion for rehabilitation with NIBS. ERP improved, related to cognitive and attentional processes after stimulation on the motor cortex, but transitorily. This effect could be linked to the restoration of hemispheric balance or by the effects of distant connections. In our study the effects of the two NIBS were comparable, with some advantages using tDCS vs. rTMS in stroke rehabilitation. Finally we found that more than one cycle (2–4 weeks), spaced out by washout periods, should be used, only in responder patients, to obtain clinical relevant results.
Highlights
Motor and cognitive impairment are frequent aftermaths of brain damage after a stroke
We evaluated the differences between a first priming cycle with repetitive Transcranial Magnetic Stimulation (rTMS) followed by transcranial Direct Current Stimulation (tDCS) and first priming with tDCS followed by rTMS
The sham group had shorter latencies compared to other groups
Summary
Motor and cognitive impairment are frequent aftermaths of brain damage after a stroke. Many authors reports cognitive deficits in 12–56% of stroke patients and reduced performances in several cognitive domains in 32% (Ebrahim et al, 1985; Tatemichi et al, 1994; Patel et al, 2002). Dysfunctions in the use of upper limb and in functional walking are among the more common consequences for many stroke survivors. Only 5% of adult stroke survivors regain full function of the upper limb and 20% do not recover any functional use. The severity of cognitive impairment negatively correlates with motor and functional recovery achieved in stroke patients after rehabilitation. A cognitive assessment should be used to select patients that could have the best benefits from rehabilitation (Patel et al, 2002; Mehta et al, 2003; Saxena et al, 2007; Rabadi et al, 2008)
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