Concomitant Use of Transcranial Direct Current Stimulation and Computer-Assisted Training for the Rehabilitation of Attention in Traumatic Brain Injured Patients: Behavioral and Neuroimaging Results

Katiuscia Sacco, Valentina Galetto, Danilo Dimitri, Elisabetta Geda, Francesca Perotti, Marina Zettin, Giuliano C Geminiani, Katiuscia Sacco, Valentina Galetto, Danilo Dimitri, Elisabetta Geda, Francesca Perotti, Marina Zettin, Giuliano C Geminiani

Abstract

Divided attention (DA), the ability to distribute cognitive resources among two or more simultaneous tasks, may be severely compromised after traumatic brain injury (TBI), resulting in problems with numerous activities involved with daily living. So far, no research has investigated whether the use of non-invasive brain stimulation associated with neuropsychological rehabilitation might contribute to the recovery of such cognitive function. The main purpose of this study was to assess the effectiveness of 10 transcranial direct current stimulation (tDCS) sessions combined with computer-assisted training; it also intended to explore the neural modifications induced by the treatment. Thirty-two patients with severe TBI participated in the study: 16 were part of the experimental group, and 16 part of the control group. The treatment included 20' of tDCS, administered twice a day for 5 days. The electrodes were placed on the dorso-lateral prefrontal cortex. Their location varied across patients and it depended on each participant's specific area of damage. The control group received sham tDCS. After each tDCS session, the patient received computer-assisted cognitive training on DA for 40'. The results showed that the experimental group significantly improved in DA performance between pre- and post-treatment, showing faster reaction times (RTs), and fewer omissions. No improvement was detected between the baseline assessment (i.e., 1 month before treatment) and the pre-training assessment, or within the control group. Functional magnetic resonance imaging (fMRI) data, obtained on the experimental group during a DA task, showed post-treatment lower cerebral activations in the right superior temporal gyrus (BA 42), right and left middle frontal gyrus (BA 6), right postcentral gyrus (BA 3) and left inferior frontal gyrus (BA 9). We interpreted such neural changes as normalization of previously abnormal hyperactivations.

Keywords: attention; cerebral plasticity; cognitive rehabilitation; functional magnetic resonance imaging (fMRI); transcranial direct current stimulation (tDCS); traumatic brain injury (TBI).

Figures

Figure 1
Figure 1
Experimental design. DA, Divided Attention; RBANS, Repeatable Battery for the Assessment of the Neuropsychological Status; BDI, Beck’s Depression Inventory; AES, Apathy Evaluation Scale.
Figure 2
Figure 2
Divided Attention (DA): Average scores obtained at T0 (Baseline), T1 (pre-Treatment) and T2 (post-Treatment) by the experimental group and the control group. Reaction time (RT) is expressed in milliseconds. RT; OE, Omission Errors. Asterisks indicate when the difference between performances is statistically significant.
Figure 3
Figure 3
Results of pre-treatment functional magnetic resonance imaging (fMRI) analysis (N = 11; p < 2.3965e−10).
Figure 4
Figure 4
Results of post-minus pre-treatment fMRI analysis (N = 11; p < 0.000002).

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