Use of Transcranial Direct Current Stimulation (tDCS) Coupled With Constraint Induced Movement Therapy in Stroke Patient

Study Overview
=================
Brief Summary
-----------------
The purpose of this study is to determine whether noninvasive brain stimulation associated with motor learning offers an additional benefit than motor learning alone in patients with stroke. The investigators hypothesis is that active transcranial direct current stimulation (tDCS) combined with constraint induced movement therapy (CIMT) will induce a greater motor function improvement as compared with sham tDCS combined with CIMT.

Detailed Description
-----------------
In this 3 experiments study we will evaluate the effect of tDCS and constraint induced movement therapy (CIMT) in stroke patients (exp 1) as well as in healthy subjects (control population - exp 2). Finally we will investigate the effect of tACS - transcranial alternating current stimulation - as an alternative to tDCS, on motor function in healthy subjects (exp 3). The two experiments on tDCS are parallels (exp 1 & 2), while the experiment on tACS uses a crossover design (exp 3). For stroke patients (Exp1), our primary outcome measure is a clinical scale (Jebsen-Taylor Hand Function Test), while for healthy subjects (Exp 2) we investigate the effect of tDCS and CIMIT on cortico-spinal excitability using TMS - transcranial magnetic stimulation. Finally, for the third experiment using tACS, our primary outcome is cortical oscillation, as measured by EEG - electroencephalogram.

Official Title
-----------------
Effects of Transcranial DC Stimulation Coupled With Constraint Induced Movement Therapy on Motor Function in Stroke Patients

Conditions
-----------------
Stroke, Healthy

Intervention / Treatment
-----------------
* Device: transcranial direct current stimulation (tDCS)
* Procedure: constraint induced movement therapy (CIMT)
* Device: transcranial alternating current stimulation (tACS)


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: All subjects must be between the ages of 18-90 and must not be pregnant. Additional Entry criteria for Stroke subject enrollment: First-time clinical ischemic or hemorrhagic cerebrovascular accident - evidenced by a radiological (or physician's) report; Weakness, defined as score of less than 55 (out of 66) on arm motor Fugl-Meyer (FM) scale Stroke onset >6 months prior to study enrollment. Exclusion Criteria: Significant pre-stroke disability; Major depression, as defined by Hamilton Depression (HAM-D) scale grater then or equal 17 if needed (history of depression before the stroke); Any substantial decrease in alertness, language reception, or attention that might interfere with understanding instructions for motor testing; Excessive pain in any joint of the paretic extremity (not applicable to severe stroke subjects); Contraindications to single pulse Transcranial Magnetic Stimulation (TMS) (TMS will be used to measure cortical excitability) such as metal head implants history of seizures unexplained loss of consciousness metal in the head frequent or severe headaches or neck pain implanted brain medical devices. Contraindications to tDCS metal in the head implanted brain medical devices Advanced liver, kidney, cardiac, or pulmonary disease; A terminal medical diagnosis consistent with survival < 1 year; Coexistent major neurological or psychiatric disease as to decrease number of confounders; A history of significant alcohol or drug abuse in the prior 6 months; Use of carbamazepine and amitriptyline; Subjects may not be actively enrolled in a separate intervention study targeting stroke recovery and Subjects may not have already received constraint induced motor therapy and/or tDCS treatment for stroke; History of epilepsy before stroke (or episodes of seizures within the last six months). Subjects with global aphasia and deficits of comprehension Pregnancy

Ages Eligible for Study
-----------------
Minimum Age: 18 Years
Maximum Age: 90 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
Accepts Healthy Volunteers

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: active tDCS + CIMT - stroke patients<br>Participants will receive 5 sessions of tDCS over the primary motor cortex (M1). We will use the following stimulation parameters: intensity of 1mA and for the first 40 minutes of constraint induced movement therapy (CIMT - 10 consecutive sessions Monday- Friday). | Device: transcranial direct current stimulation (tDCS)<br>* Subjects will be stimulated at 1 mA for 40 minutes.<br>Procedure: constraint induced movement therapy (CIMT)<br> <br> |
| Experimental: active tDCS + CIMT - Healthy<br>Participants will receive one session of tDCS over the primary motor cortex (M1). We will use the following stimulation parameters: intensity of 1mA and for the first 40 minutes of constraint induced movement therapy (CIMT) | Device: transcranial direct current stimulation (tDCS)<br>* Subjects will be stimulated at 1 mA for 40 minutes.<br>Procedure: constraint induced movement therapy (CIMT)<br> <br> |
| Experimental: tACS - Healthy Subjects<br>The investigators will have 40 healthy subjects who will undergo one session of treatment with active tACS (in which the order in which they receive either sham or active transcranial alternating current stimulation (tACS) stimulation will be randomized). | Device: transcranial alternating current stimulation (tACS)<br>* Subjects will be stimulated at 15Hz for 20 minutes.<br>|
| Sham Comparator: sham tDCS + CIMT - stroke patients<br>Participants will receive 5 sessions of tDCS over the primary motor cortex (M1). We will use the following stimulation parameters: intensity of 1mA and for the first 40 minutes of constraint induced movement therapy (CIMT - 10 consecutive sessions Monday- Friday). For the sham session, tDCS is turned off after 30seconds. | Device: transcranial direct current stimulation (tDCS)<br>* Subjects will be stimulated at 1 mA for 40 minutes.<br>Procedure: constraint induced movement therapy (CIMT)<br> <br> |
| Sham Comparator: sham tDCS + CIMT - Healthy<br>Participants will receive one session of tDCS over the primary motor cortex (M1). We will use the following stimulation parameters: intensity of 1mA and for the first 40 minutes of constraint induced movement therapy (CIMT). The sham stimulation consists of 30 seconds of stimulation at the beginning of the 40 min of treatment. | Device: transcranial direct current stimulation (tDCS)<br>* Subjects will be stimulated at 1 mA for 40 minutes.<br>Procedure: constraint induced movement therapy (CIMT)<br> <br> |
| Sham Comparator: sham tACS - Healthy Subjects<br>The investigators will have 40 healthy subjects who will undergo one day of treatment with sham tACS. All participants received active and sham stimulation in a randomized order. | Device: transcranial alternating current stimulation (tACS)<br>* Subjects will be stimulated at 15Hz for 20 minutes.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Jebsen Taylor Hand Function Test | Jebsen Taylor Hand Function Test: measures hand function in real-life activities, by evaluating the time required to perform 7 different tasks. We used the non-cronstrained hand for the assessments. The sum of the different tasks was used for the analysis. | 2 weeks | 
| Cortical Excitability | Motor evoked potential (MEP) Using Transcranial Magnetic Stimulation (TMS), MEP were recorded before and after tDCS (both active and sham). The percentage of change in MEP (post versus pre intervention) between the two groups (active and sham) were used for the comparison. | 1 hour | 
| Cortical Oscillations - EEG | Recording took place in a dim-lighted room set up with acoustic and electric isolation. EEG was acquired from 64-channels HydroCel Geodesic Sensor Net (Electrical Geodesic Inc., Eugene, OH) and recorded using Net Station running on a MacIntosh G4 computer. Alpha power were used as the main outcome measure. The difference values (e.g., post minus pre tACS) were used for the analysis. The alpha frequency is a brain oscillation that takes place especially when subjects are in a relaxed state, especially eyes closed. In the motor cortex, a decrease in alpha power has been seen during motor performance. Therefore, it could be speculated that a decrease in power in this study would indicate more engagement in motor cortex during the motor performance. | 15 minutes | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Stroke, Transcranial direct current stimulation, Motor function