Motor Performance in Chronic Stroke Patients
Condition: Stroke
MeSH terms: Stroke
Study type: Observational

Summary: 
      This study will determine in stroke patients whether stimulation of the injured side of the
      brain combined with stimulation of the weak hand can temporarily improve motor function of
      the paralyzed hand. It will also examine whether stimulation of the healthy side of the brain
      combined with stimulation of the weak hand can temporarily improve motor function in the
      paralyzed hand.

      Healthy adult volunteers and adults who have had a stroke more than 3 months before entering
      the study may be eligible to participate. Candidates are screened with a physical and
      neurological examination. Stroke patients also have magnetic resonance imaging (MRI), a test
      that uses a strong magnetic field and radio waves to obtain images of the brain.

      Participants perform several tasks (described below) in a practice session and then during
      five more sessions on separate days. They perform the tasks before and after undergoing
      transcranial direct current stimulation (tDCS) plus electrical stimulation (ES), and during a
      procedure that involves sham stimulation. For tDCS, small rubber electrodes are soaked with
      water and taped to the subject's head, one above the eye and the other on the back of the
      head. The current passes between the two electrodes. For ES, two pairs of electrodes are
      attached to the subject's wrist with a paste. A very short pulse of current is passed between
      the electrodes, creating an electrical field that stimulates the brain. For the sham
      stimulation, the electrodes are similarly placed, but there is no stimulation. The tasks are:

        -  Jebsen-Taylor test: Subjects write, lift small common objects like paper clips, and
           perform activities like turning pages, stacking checkers or lifting large objects. They
           do these tasks as fast as possible.

        -  Pinch force: Subjects press a wedged instrument between their thumb and index finger as
           hard as they can. There are several trials every 10 seconds.

        -  Speed tapping: Subjects press a key on a keyboard as quickly as possible for 10 seconds.

        -  Simple reaction time task: Subjects perform a quick wrist movement as quickly as
           possible in response to a "go" signal presented on a computer monitor. Muscle activity
           in the forearm is recorded using electrodes.

        -  Motor sequence learning/Learning a finger movement sequence: Subjects practice a finger
           movement exercise on a keyboard by pressing keys that correspond to a number displayed
           on a video screen.

        -  Visual analog scales: Subjects complete three questionnaires about their attention,
           fatigue, and mood.

        -  Sensory monitoring: Subjects are blindfolded and asked to judge the difference in
           various sensations, such as the feel of plastic domes with gratings, vibration, or a
           plastic hair applied to their fingertip.

        -  Scoring MRC scale: The muscle strength of the subject's hands is measured.

        -  Fugl-Meyer scale: The subject's ability to move his or her limbs is measured.

        -  Mini-mental state examination: The subject's mental ability is measured briefly.

        -  Handedness questionnaire: The subject's dominant hand is determined.

      Participants also undergo transcranial magnetic stimulation (TMS) and electromyography (EMG)
      before, during and after these activities. For TMS, a wire coil is held on the scalp. A brief
      electrical current is passed through the coil, creating a magnetic pulse that stimulates the
      brain. The effect of TMS on the muscles is detected with small electrodes taped to the skin
      of the arms or legs. EMG measures the electrical activity of the muscles. For this test,
      small electrodes are taped to the skin over the muscle.
    

Detailed description: 
      There is no universally accepted strategy to promote recovery of motor function after chronic
      stroke, the main cause of long-term disability among adults. It is desirable to develop
      strategies to improve motor function in stroke patients. Recently a study in stroke patients
      demonstrated that transcranial direct current cortical stimulation (tDCS) in association with
      motor training leads to improvements of performance and motor learning. Similarly,
      somatosensory stimulation (peripheral nerve stimulation, PNS) of the paretic hand in stroke
      patients results in improvement of performance and motor learning (Celnik, unpublished data).

      Objective:

      The purpose of this protocol is to apply tDCS to the motor cortex of the affected hemisphere
      (tDCS affected) in combination with PNS of the paretic hand of patients with chronic stroke,
      to test the hypothesis that combined tDCS affected with PNS will lead to more prominent
      improvement in motor performance of functional relevant tasks in the paretic hand relative to
      either intervention alone.

      Furthermore, recent studies have demonstrated that the unaffected hemisphere exerts
      abnormally high inhibitory influence over the affected hemisphere. This abnormality might
      adversely influence motor recovery. Therefore a further purpose of the study is to apply tDCS
      to the unaffected hemisphere (tDCS unaffected) to test the hypothesis that down regulation of
      activity in the intact hemisphere, in combination with PNS of the affected hemisphere, will
      elicit more prominent improvement in functional relevant tasks than either intervention
      alone.

      Study population:

      We plan to study patients with chronic strokes and healthy age, gender and hand dominance
      matched volunteers.

      Design:

      To test the hypothesis each subject will participate in 13 sessions in a double blind design.
      The order that patients and controls will receive the interventions will be randomized.

      Outcome measures:

      Primary outcome measure will be the total time to complete functional relevant tasks of the
      hand, Jebsen-Tailor-Test (JTT). Secondary outcomes are tapping speed with one finger; simple
      reaction times (SRT); pinch force; and number of correct keyboard piano sequences played in
      30sec with the paretic hand. To better understand the mechanisms underlying the proposed
      behavioral gains, we will use transcranial magnetic stimulation (TMS) to identify
      corticomotor excitability changes.
    

Keywords: Cortical Reorganization; Motor Function; Somatosensory Stimulation; Rehabilitation; Transcranial Direct Current Stimulation (tDCS); Direct Current Stimulation; Stroke; Healthy Volunteer