Improvement of Upper Extremity Deficit after Constraint-Induced Movement Therapy Combined with and without Preconditioning Stimulation Using Dual-hemisphere Transcranial Direct Current Stimulation and Peripheral Neuromuscular Stimulation in Chronic Stroke Patients: A Pilot Randomized Controlled Trial

Takashi Takebayashi, Kayoko Takahashi, Misa Moriwaki, Tomosaburo Sakamoto, Kazuhisa Domen, Takashi Takebayashi, Kayoko Takahashi, Misa Moriwaki, Tomosaburo Sakamoto, Kazuhisa Domen

Abstract

In this study, we investigated the effects of dual-hemisphere transcranial direct current stimulation (dual-tDCS) of both the affected (anodal tDCS) and non-affected (cathodal tDCS) primary motor cortex, combined with peripheral neuromuscular electrical stimulation (PNMES), on the effectiveness of constraint-induced movement therapy (CIMT) as a neurorehabilitation intervention in chronic stroke. We conducted a randomized controlled trial of feasibility, with a single blind assessor, with patients recruited from three outpatient clinics. Twenty chronic stroke patients were randomly allocated to the control group, receiving conventional CIMT, or the intervention group receiving dual-tDCS combined with PNMES before CIMT. Patients in the treatment group first underwent a 20-min period of dual-tDCS, followed immediately by PNMES, and subsequent CIMT for 2 h. Patients in the control group only received CIMT (with no pretreatment stimulation). All patients underwent two CIMT sessions, one in the morning and one in the afternoon, each lasting 2 h, for a total of 4 h of CIMT per day. Upper extremity function was assessed using the Fugl-Meyer Assessment (primary outcome), as well as the amount of use (AOU) and quality of movement (QOM) scores, obtained via the Motor Activity Log (secondary outcome). Nineteen patients completed the study, with one patient withdrawing after allocation. Compared to the control group, the treatment improvement in upper extremity function and AOU was significantly greater in the treatment than control group (change in upper extremity score, 9.20 ± 4.64 versus 4.56 ± 2.60, respectively, P < 0.01, η2 = 0.43; change in AOU score, 1.10 ± 0.65 versus 0.62 ± 0.85, respectively, P = 0.02, η2 = 0.52). There was no significant effect of the intervention on the QOM between the intervention and control groups (change in QOM score, 1.00 ± 0.62 versus 0.71 ± 0.72, respectively, P = 0.07, η2 = 0.43; treatment versus control). Our findings suggest a novel pretreatment stimulation strategy based on dual-tDCS and PNMES may enhance the therapeutic benefit of CIMT.

Keywords: constraint-induced movement therapy; neuromuscular stimulation; rehabilitation; stroke; transcranial direct current stimulation; upper extremity.

Figures

Figure 1
Figure 1
Daily rehabilitation protocol in the treatment group. Dual-tDCS, dual-hemisphere transcranial direct current stimulation; PNMES, peripheral neuromuscular electrical stimulation; CIMT, constraint-induced movement therapy.
Figure 2
Figure 2
Flow-chart of patient enrollment in the study. Dual-tDCS, dual-hemisphere transcranial direct current stimulation; PNMES, peripheral neuromuscular electrical stimulation; CIMT, constraint-induced movement therapy.

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