BACKGROUND: Intensive motor training is a therapeutic intervention that
supports recovery of movement function after stroke by capitalizing on the brain’s
capacity for neuroplastic change. Peripheral nerve stimulation and transcranial direct
current stimulation are neuromodulation techniques that can upregulate neuroplasticity
and, in turn, enhance outcomes of motor training after stroke. Few studies have
investigated possible adjuvant effects between peripheral nerve stimulation, transcranial
direct current stimulation, and intensive motor training.
OBJECTIVE: This proof-of-concept study investigated whether timing
variations in neuromodulation paired with robot-assisted motor training effect
differential outcomes for subjects with chronic, moderate-to-severe upper extremity
impairment after stroke.
METHODS: Ten subjects in the chronic phase (>12 months after stroke) of
recovery completed the study. Subjects received 10 daily sessions of transcranial direct
current stimulation either at the start (n = 4) or at
the end (n = 6) of peripheral nerve stimulation
preceding intensive motor training. Pre-post changes in motor function (Fugl-Meyer
Assessment; Stroke Impact Scale) and neuroplasticity (transcranial magnetic stimulation)
were assessed by condition.
RESULTS: Significant improvement in Stroke Impact Scale
(p = 0.02) and no change in Fugl-Meyer Assessment were associated with
the start condition. No changes in Stroke Impact Scale and Fugl-Meyer
Assessment were associated with the end condition. Only 1 subject in the
start group had measurable neuroplastic responses and demonstrated an
increase in ipsilesional cortical map volume. Only 1 subject in the end
group had measurable neuroplastic responses and demonstrated a decrease in ipsilesional
cortical map volume. Opposite shifts in ipsilesional cortical centers of gravity occurred
relative to condition.
CONCLUSION: In cases of moderate-to-severe impairment after stroke,
transcranial direct current stimulation at the start, rather than the end, of peripheral
nerve stimulation prior to motor training may effect better functional outcomes. Future
research with a larger sample size is needed to validate the findings of this
proof-of-concept study.
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