Abstract
Motor practice is an essential part of upper limb motor recovery following stroke. To be effective, it must be intensive with a high number of repetitions. Despite the time and effort required, gains made from practice alone are often relatively limited, and substantial residual impairment remains. Using non-invasive brain stimulation to modulate cortical excitability prior to practice could enhance the effects of practice and provide greater returns on the investment of time and effort. However, determining which cortical area to target is not trivial. The implications of relevant conceptual frameworks such as Interhemispheric Competition and Bimodal Balance Recovery are discussed. In addition, we introduce the STAC (Structural reserve, Task Attributes, Connectivity) framework, which incorporates patient-, site-, and task-specific factors. An example is provided of how this framework can assist in selecting a cortical region to target for priming prior to reaching practice poststroke. We suggest that this expanded patient-, site-, and task-specific approach provides a useful model for guiding the development of more successful approaches to neuromodulation for enhancing motor recovery after stroke.
Highlights
MH-L conceptualized, designed, and wrote this submission, critically revised it, had final approval of the version to be published, and is accountable for all aspects of the work
To move poststroke neuromodulation to the level of development, a more specific model is needed for identifying cortical areas that could contribute to motor recovery and be targeted for motor priming
RH contributed to design of this paper, collected data presented, helped critically revise it, had final approval of the version to be published, and is accountable for all aspects of the work
Summary
Upper limb motor impairment following stroke is highly prevalent and often persists even after intensive rehabilitation efforts [1,2,3,4] It is one of the most disabling of stroke sequela, limiting functional independence and precluding return to work and other roles [5]. Non-invasive brain stimulation offers a potential method of enhancing the effects of practice and giving patients greater returns on their investment of time and effort. Stimulation can be used to temporarily inhibit or facilitate the underlying cortical area for a sustained period of time after the stimulation ends (usually 20–40 min) In this way, non-invasive brain stimulation could be used to “prime” relevant cortical areas before a bout of practice, potentially enhancing the effects of practice. Conceptual models that could offer such guidance are considered below
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