- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT02166619
tDCS in Poststroke on Upper Limb Rehabilitation
Transcranial Direct Current Stimulation in Rehabilitation of Chronic Stroke Patients: Multicenter Clinical Trial
Study Overview
Detailed Description
Patients will undergo behavioral and electrophysiological evaluation before, immediately after, 30 and 90 days after 10 sessions (follow ups). They will be submitted to the following evaluations: (i) Fugl-Meyer Scale; (ii) Jebsen-Taylor hand functional test; (iii) Box-Block test; (iv) Motor Activity Log - 30; (v) Geriatric Depression Scale - 15; (vi) Beck Depression Inventory; (vii) Stroke Impact Scale; (viii) Hand Grip Strength and (iv) Modified Ashworth Scale. In addition, one question of motivation will be answered by patients in different stages of the treatment: (i) motivation regarding their own life at the beginning and ending of the treatment; (ii) daily motivation at the beginning of each session; (iii) motivation of the last week at the fifth and tenth sessions; (iv) motivation regarding their own life at 30 and 90 days after the ending of the treatment. A visual scale will be used to assess patient's motivation through five potential answers: "very little", "little", "more or less", "very much" and "extremely".
Electrophysiological measures will be performed before and after each session and in follow ups.
Evaluation of brain activity will be performed using single-pulse transcranial magnetic stimulation (TMS-p) only in Recife Centre. Magnetic stimulation (Neurosoft, Russia) will be applied through a figure-8 coil to determine motor cortex representation of first dorsal interosseus muscle (hotspot) and performed the following electrophysiological measures, in both cerebral hemispheres, to assess cortical activity: (i) Motor Evoked Potential (MEP); (ii) Active motor threshold (AMT) and (iii) Silent period (PS).
Evaluation of brain activity will be performed using single-pulse transcranial magnetic stimulation (TMS-p) only in Recife Centre. Magnetic stimulation (Neurosoft, Russia) will be applied through a figure-8 coil kept at a 45 degree angle relative to the sagittal line and pointed to the anterior region of the skull. Firstly, patients will be instructed to sit in a chair and to search a comfortable position. TMS-p will be applied in both motor cortex, healthy and injured, to determine the cortical representation of first dorsal interosseus muscle. The hotspot will be considered the most excitable area, with more intense motor evoked potential (MEP), measured by electromyography.
The following electrophysiological measures will be performed in both cerebral hemispheres to assess cortical activity:
(i) Motor Evoked Potential (MEP) : the intensity of magnetic stimulator is adjusted to produce an average MEP of 1.0 mV. TMS-p will be applied in the area of cortical representation of the first dorsal interosseous and mean responses to stimuli should reach 0.8 mV to 1.2 mV.
(ii) Active motor threshold (AMT) : will be request to the patient to perform contraction of the first interosseous muscle and then, will be given ten pulses by TMS-p to determinate active motor threshold. Motor threshold corresponds to the lowest intensity of TMS-p to produce a MEP of 50 μV in 50% of the pulses applied to the hotspot.
(iii) Silent period (PS) : is the interval of time that usually is observed absence of electromyographic activity. Occurs immediately after the registration of MEP during voluntary contraction of the target muscle (PEMvc - motor evoked potentials recorded during voluntary contraction). Higher the intensity of the magnetic stimulation, longer the duration of PS.
During tDCS application, patients will be seated in a comfortable chair with head and arms rests. Current will be applied by a DC stimulator (NeuroConn, Germany) using a pair of saline-soaked sponge electrodes (surface 24 cm²).
Bihemispheric tDCS will be applied to primary motor cortex (M1) in left and right hemispheres. These points correspond to C3 and C4 according to International 10-20 EEG system. Anode will be placed to M1 in affected hemisphere, while the cathode is positioned to M1 over the unaffected hemisphere. Parameters of current intensity and duration (dose) used were previously established in poststroke patients: 2 mA stimulation intensity for 20 minutes with current ramping up and down of 10 seconds each.
Sham tDCS has been used in several studies to evaluate the effect of active tDCS. In placebo stimulation, intensity and electrode's positions are the same as in the active group, however, current duration is only 30 seconds, with current ramping up and down of 10 seconds each. Moreover, the electrostimulation device is automatically turned off without patient's perception. Thus, patients experience early sensations (mild to moderate tingling) in stimulation site without inducing effect. Moreover, after each tDCS session, patients will answer adverse effects questionnaire.
After apply tDCS, 40 minutes of individual and intensive physical therapy session will be performed. Goals of the physical therapy protocol were discussed based in neuroplasticity principles by a group of experienced physiotherapists. Physical therapy activities will be focused on rehabilitation of upper limb and will cover the following purposes: flexibility, transfer and posture, coordination, balance and sensorial stimulation. Depending on patient's ability, a program of activities for each purpose will be adapted by a trained physical therapist.
The study will be conducted simultaneously in three research centers in Brazil: Applied Neuroscience Laboratory (LANA), Universidade Federal de Pernambuco (UFPE), Pernambuco, Brazil; D'Or Institute for Research and Education (ID'Or), Botafogo, Rio de Janeiro, Brazil and at the University Center Augusto Mota (UNISUAM), Bonsucesso Unit, Rio de Janeiro, Brazil.
Study Type
Enrollment (Anticipated)
Phase
- Phase 2
Contacts and Locations
Study Contact
- Name: Kátia Monte-Silva, PhD
- Phone Number: +55 81 88631322
- Email: monte.silvakk@gmail.com
Study Contact Backup
- Name: Déborah Marques, PT
- Phone Number: +55 81 97479444
- Email: deby.marques@gmail.com
Study Locations
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-
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Rio de Janeiro, Brazil
- Recruiting
- D'Or Institute for Research and Education (ID'Or)
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Contact:
- Fernanda Moll, PhD
- Email: fernandanrn@hotmail.com
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Principal Investigator:
- Fernanda Moll, PhD
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Rio de Janeiro, Brazil
- Recruiting
- University Center Augusto Mota (UNISUAM)
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Contact:
- Érika Rodrigues, PhD
- Phone Number: +55 21 9971244796
- Email: erikacrodrigues@gmail.com
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Contact:
- Laura Oliveira, PhD
- Phone Number: +55 21 934844107
- Email: lauraoliveira.ft@gmail.com
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Sub-Investigator:
- Zaira Lima, PT
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Sub-Investigator:
- Camilla Polonini, PT
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Sub-Investigator:
- Érica Vianna, PT
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Sub-Investigator:
- Débora Silva
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Sub-Investigator:
- Carlos Horsczaruk
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PE
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Recife, PE, Brazil, 50670-900
- Recruiting
- Applied Neuroscience Laboratory, Universidade Federal de Pernambuco
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Contact:
- Adriana Baltar, PT
- Phone Number: +55 81 91296401
- Email: adrianabaltarmaciel@gmail.com
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Contact:
- Maíra Souza, PT
- Phone Number: +55 81 89496886
- Email: mairasouza77@gmail.com
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Sub-Investigator:
- Déborah Marques, PT
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Sub-Investigator:
- Maíra Souza, PT
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Sub-Investigator:
- Adriana Ribeiro, MSc
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Primary or recurrent, ischemic or hemorrhagic stroke, confirmed by computed tomography or magnetic resonance imaging
- Chronic Stroke (> 12 months)
- Sensorimotor sequelae in an upper limb due to stroke
- Score ≥ 18 at Folstein Mini Mental State Examination
- Score ≥ 4 at Ashworth Scale
- Minimal active wrist movement (flexion and extension)
- At least one pinch movement
Exclusion Criteria:
- Prior neurological diseases
- Multiple brain lesions
- Metal implant in the skull and face
- Pacemaker
- History of seizures
- Epilepsy
- Pregnancy
- Hemodynamic instability
- Performing physical therapy elsewhere during the period of intervention
- Score > 59 at the Fugl-Meyer Assessment of Motor Recovery after Stroke
- Traumatic or orthopedic lesion limiting the range of motion of upper limb
Study Plan
How is the study designed?
Design Details
- Primary Purpose: TREATMENT
- Allocation: RANDOMIZED
- Interventional Model: PARALLEL
- Masking: DOUBLE
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: tDCS + physical therapy
Firstly, patients will undergo electrophysiological evaluation: motor evoked potential, motor threshold and silent period in both hemispheres.
After those procedures, bihemispheric tDCS will be applied with duration of 20 minutes, intensity of 2 mA where anodal electrode will be on the affected hemisphere and the cathodal electrode, on the non-affected hemisphere.
After tDCS, patients will be submitted to 40 minutes of physical therapy protocol.
Experimental sessions will be repeated five times per week to complete 10 sessions.
|
Bihemispheric tDCS involves application of very low-amplitude direct currents (2 mA or less) via surface scalp electrodes. It produces a sub-sensory level of electrical stimulation wich remains imperceptible by most people during application. In a small percentage of patients, it may cause minimal discomfort with a mild tingling sensation, which usually disappears after a few seconds. Depending on the polarity, tDCS can increase or decrease corticomotor excitability. Anodal tDCS is able to facilitate neurons depolarization - increasing cortical excitability - while, on the other hand, cathodal tDCS hyperpolarizes the resting membrane potential, reducing the neuronal firing and the cortical excitability. Other: Physical Therapy
Other Names:
|
Sham Comparator: Sham tDCS + physical therapy
Firstly, patients will undergo electrophysiological evaluation: motor evoked potential, motor threshold and silent period in both hemispheres.
After those procedures, bihemispheric sham tDCS will be applied.
Anodal electrode will be on the affected hemisphere and the cathodal electrode, on the non-affected hemisphere.
Sham tDCS will be performed by ramping current flow for the first 10 seconds of stimulation, but switching the stimulator off after 30 seconds.
After bihemispheric sham tDCS, patients will be submitted to 40 minutes of physical therapy protocol.
Experimental sessions will be repeated five times per week to complete 10 sessions.
|
Bihemispheric tDCS involves application of very low-amplitude direct currents (2 mA or less) via surface scalp electrodes. It produces a sub-sensory level of electrical stimulation wich remains imperceptible by most people during application. In a small percentage of patients, it may cause minimal discomfort with a mild tingling sensation, which usually disappears after a few seconds. Depending on the polarity, tDCS can increase or decrease corticomotor excitability. Anodal tDCS is able to facilitate neurons depolarization - increasing cortical excitability - while, on the other hand, cathodal tDCS hyperpolarizes the resting membrane potential, reducing the neuronal firing and the cortical excitability. Other: Physical Therapy
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Change in Fugl-Meyer assessment of paretic upper limb motor function
Time Frame: baseline, after sessions, 30 and 90 days
|
Fugl-Meyer assessment is used to measure motor control recovery.
It is a 226-point scoring system that includes the following sessions: range of motion, pain, sensation, motor function of upper and lower limbs, balance and coordination/velocity.
We will apply only two sessions: upper limb motor function and coordination/velocity.
These sessions totalize 66 points.The instrument provides a reliable and valid measure of specific motor function that is also sensitive to change.
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baseline, after sessions, 30 and 90 days
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Change from Motor Activity Log-30
Time Frame: baseline, after sessions, 30 and 90 days
|
MAL is a scripted, structured interview to measure real-world upper extremity function.
It was developed to measure the effects of therapy on the most impaired arm following stroke.
Consists of 30 activities of daily living such as using a towel, brushing teeth and picking up a glass.
For a specified time period post-stroke, patients are asked about the extent of activity performance and how well it was performed by the most impaired arm.
Response scale ranges from 0 (never used) to 5 (same as pre-stroke).
Scores average for activity frequency comprises the Amount of use scale (AOU); the mean of scores for how well the activity was performed comprises Quality of movement (QOM).
Ideally, ratings are obtained from patient and as well as the caregiver.
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baseline, after sessions, 30 and 90 days
|
Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Change from Jebsen-Taylor Hand Function Test
Time Frame: baseline, after sessions, 30 and 90 days
|
Jebsen-Taylor Hand Function Test was designed to provide short, objective test of hand functions commonly used in daily living activities.
Targeted patient population included adults with neurological and musculoskeletal conditions involving hand disabilities, although there may be other patient populations with other hand dysfunction which may be appropriate.
The test was developed to be used by health professionals working in restoration of hand function.
It consists of seven items that includes a range of fine motor, weighted and unweighted hand function activities.
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baseline, after sessions, 30 and 90 days
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Collaborators and Investigators
Publications and helpful links
Study record dates
Study Major Dates
Study Start
Primary Completion (Anticipated)
Study Completion (Anticipated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Estimate)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- ChronicStroke_tDCS_rehab
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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