Trans Cranial Brain Stimulation for Stroke Rehabilitation
Condition: Stroke
MeSH terms: Stroke
Study type: Interventional

Summary: 
      Noninvasive brain stimulation (NIBS) refers to a group of modalities that are used to induce
      electric currents to and within the brain for diagnostic or therapeutic purposes. Two major
      types of NIBS techniques are currently in use on humans for clinical and research
      applications: Transcranial Magnetic Stimulation (TMS) and Transcranial Current Stimulation
      (tCS). Moreover, the studies evaluating the clinical benefit of mental practice in stroke so
      far are mostly small feasibility studies, while the few randomized controlled trials reported
      had relatively small sample sizes. As such, the evidence for mental practice in the treatment
      of movement disorders following stroke, and other neurological conditions, remains somewhat
      anecdotal. Purpose of our research is to show the effect of combining brain stimulation and
      mental imagery on functional recovery of upper limb in stroke.
    

Detailed description: 
      TITLE Effect of Transcranial Stimulation augmented with Mental Imagery in Upper Limb Stroke
      Rehabilitation: A Randomized Controlled Trial

      Mr. Faizan Zaffar Kashoo

      Department of Physical Therapy and Health rehabilitation, College of Applied Medical
      sciences. Majmaah University. KSA

      INTRODUCTION

      Noninvasive brain stimulation (NIBS) refers to a group of modalities that are used to induce
      electric currents to and within the brain for diagnostic or therapeutic purposes [1-4]. A
      growing body of evidence suggests that NIBS techniques may have a promising role in the
      diagnosis, monitoring, and treatment of a variety of neurological and psychiatric conditions
      [5-9]. The therapeutic potential of NIBS stems from the capacity to evoke immediate and
      sustained modulation of neural network activity through alterations in neuronal excitation.
      The induced neuromodulation can be either excitatory or inhibitory, depending on the
      polarity, frequency, and duration of the stimulation [2, 10]. Moreover, the ability to induce
      directional modulation further enhances the therapeutic possibilities of NIBS, as the
      necessary direction of the brain excitability for recovery varies with different disease
      conditions [10, 11].

      Two major types of NIBS techniques are currently in use on humans for clinical and research
      applications: Transcranial Magnetic Stimulation (TMS) and Transcranial Current Stimulation
      (tCS) [12]. TMS uses a varying magnetic field to induce weak electric currents in the brain.
      It can be delivered as a single pulse or as a train of pulses. Single-pulse TMS is typically
      used to study brain physiology and plasticity [3, 13-16], whereas repetitive-pulse TMS (rTMS)
      is commonly used to elicit neuromodulation and neuroplasticity, and can result in prolonged
      excitability changes that outlast the stimulation period [6, 15]. Typically, the direction of
      neuromodulation is driven by the frequency at which the stimulation is performed, such that
      high-frequency rTMS increases cortical excitability and low-frequency rTMS decreases cortical
      excitability [17]. However, theta burst stimulation (a variation of high frequency rTMS) can
      induce either depression or facilitation of cortical excitability, depending on burst-train
      duration, such that intermittent theta burst stimulation increases cortical excitability and
      continuous theta burst stimulation decreases cortical excitability [18].

      tCS refers to the application of direct or alternating current on a specific region of the
      brain, transmitted via electrodes attached to the scalp. A wide range of tCS modalities
      exists, but only a few have been well-studied. Transcranial direct current stimulation
      (tDCS), (or "Transcranial Micropolarization"), is the most commonly used type of tCS [2,
      19-25]. It employs a battery-driven stimulator to deliver weak direct currents (0.5-2.0 mA)
      through contact electrodes over the scalp. The current flow modulates neuronal excitability
      by altering the resting membrane potential of the neurons and produces aftereffects (i.e.,
      prolonged changes in neuronal excitability) that are thought to be driven by Glutamatergic
      and GABAergic synapsic plasticity [26]. tDCS can be used to elicit an excitatory (anodal) or
      inhibitory (cathodal) effect, depending on the polarity of stimulation. Specifically, anodal
      stimulation has a depolarizing effect, which increases neuronal excitability; whereas,
      cathodal stimulation has a hyperpolarizing effect, which decreases neuronal excitability [1,
      19, 27, 28].

      Much interest has been raised by the potential of mental practice of motor tasks, also called
      'motor imagery', as a neuro-rehabilitation technique to enhance motor recovery following
      stroke 29-31. The appeal of motor imagery as a potentially effective neuro-rehabilitation
      technique is popular, which is reflected in multiple reviews of relatively few reported
      clinical evaluations. Moreover, the studies evaluating the clinical benefit of mental
      practice in stroke so far are mostly small feasibility studies, while the few randomized
      controlled trials reported had relatively small sample sizes. As such, the evidence for
      mental practice in the treatment of movement disorders following stroke, and other
      neurological conditions, remains somewhat anecdotal. Purpose of our research is to show the
      effect of combined effect of brain stimulation and mental imagery.

      RESEARCH HYPOTHESIS

      There will be a significant difference between control and experimental groups.

      NULL HYPOTHESIS

      There will be no significant difference between control and experimental groups.

      STUDY DESIGN (TYPE OF STUDY)

      Doubled blinded randomized controlled trial.

      STUDY POPULATION AND SAMPLING

      Chronic stroke and random sampling

      DATA COLLECTION METHODS AND INSTRUMENTS

      Procedure:

      The electrodes will be placed at the premotor cortex over the scalp corresponding to the
      topographical representation of upper limb on the contralateral cerebral hemisphere.

      Transcranial direct stimulation for 30 minutes, 5 days a week for 2 weeks Mental imagery as
      visual imagery shown to the patient with the help of videotape.

      Instrumentation:

      Fugl Meyers Scale ARAT

      Activities:

      exercises: 1. stacking blocks; 2. flipping scrapbook pages; 3. nine-hole pegboard; 4.
      grabbing saucepan and pouring water into a cup; and 5. opening hand to grasp and pick up cup.

      DATA ANALYSIS METHODS

      An appropriate quantitative statistical method will be used

      STUDY PERIOD

      2 year
    

Intervention name(s): Real Transcranial direct stimulation+Mental Imagery; Sham Transcranial Direct Stimulation +Mental Imagery
Intervention type(s): Other; Other
Intervention description(s): The subject will be practicing mental imagery along with mental imagery. A video of the task will be played in front of the patient and the subject will be asked to perform the mental practice of the activity.The video will be played thrice.The electrodes will be placed at the premotor cortex over the scalp corresponding to the topographical representation of upper limb on the contralateral cerebral hemisphere.Transcranial direct current stimulation (tDCS), (or "Transcranial Micropolarization"), is the most commonly used type of tCS [2, 19-25]. It employs a battery-driven stimulator to deliver weak direct currents (1.5 mA) through contact electrodes over the scalp. The current flow modulates neuronal excitability by altering the resting membrane potential of the neurons and produces aftereffects.Transcranial magnetic stimulation for 30 minutes, 5 days a week for 2 weeks.Transcranial direct stimulation for 30 minutes, 5 days a week for 2 weeks; The electrodes will be placed at the premotor cortex over the scalp corresponding to the topographical representation of upper limb on the contralateral cerebral hemisphere.Transcranial direct current stimulation (tDCS), (or "Transcranial Micropolarization"), is the most commonly used type of tCS [2, 19-25]. It employs a battery-driven stimulator to deliver weak direct currents (1.5 mA) through contact electrodes over the scalp. The current flow modulates neuronal excitability by altering the resting membrane potential of the neurons and produces aftereffects.Transcranial magnetic stimulation for 30 minutes, 5 days a week for 2 weeks.Transcranial direct stimulation for 30 minutes, 5 days a week for 2 weeks
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Transcranial magnetic stimulation
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment