tdcs in stroke rehabilitation

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Transcranial Direct Current Stimulation (tDCS) in Stroke Rehabilitation By Md. Kafiul Islam Jan 26, 2013 A Literature Review

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Transcranial Direct Current Stimulation (tDCS) in Stroke Rehabilitation

By

Md. Kafiul Islam

Jan 26, 2013

A Literature Review

Introduction

• What is tDCS– Non-invasive, painless brain stimulation

– Constant, low-intensity DC by 2 electrodes

• Types of Stimulation– Anodal : Excites neural activity

– Cathodal : Inhibits neural activity

• Advantages– Cheap, non-invasive, painless and safe

– Easy to administer and equipment is portable

– Least side effect (slight itching or tingling on scalp)

Valuable tool for treatment of stroke recoveryand other neuropsychiatric conditions

• Depression, anxiety, Parkinson’s disease, and chronic pain

• Cognitive improvement

Introduction (Cont…)

• Stroke– Rapid loss of brain function due to disturbance in the blood supply to the

brain

– Brain cells (Neurons) suddenly die because of a lack of oxygen

• After Effect– Inter-hemisphere Imbalance

– Inability to move one or more limbs on one side of body

– Inability to understand or formulate speech

– Inability to see one side of the visual field

Paper-1 Review

Transcranial direct current stimulation: a

noninvasive tool to facilitate stroke

recovery

Arch Neurol. 2008 December

Review: Paper-1

UEFM: Measure of neurological and motor function.

Paper-2 Review

Noninvasive Brain Stimulation in Stroke Rehabilitation

NeuroRx. 2006

Review: Paper-2

Review at the effects of TMS and tDCS on motor cortical function and motorperformance in healthy volunteers and in patients with stroke.

Findings: Both techniques have been proved to either enhance or suppress cortical excitability

Studies of cortical plasticity after stroke suggest that the damaged cortex has thepotential for extensive reorganization

Paper-3 Review

Transcranial Direct Current Stimulation of the Unaffected Hemisphere in Stroke Patients

Neuroreport. 2005

Review: Paper-3

Recovery of function after a stroke is determined by a balance of activity in the neural networkinvolving both the affected and the unaffected brain hemispheres. Increased activity in theaffected hemisphere can promote recovery, while excessive activity in the unaffectedhemisphere may represent a maladaptive strategy

• Findings– both cathodal stimulation of the unaffected hemisphere and anodal stimulation of the

affected hemisphere (but not sham transcranial direct current stimulation) improvedmotor performance significantly.

Motor performance change (%) compared with baseline after stimulation of the primary motor cortex of the unaffected hemisphere (cathodal stimulation), stimulation of the primary motor cortex of the

affected hemisphere (anodal stimulation)

Paper-4 Review

Clinical research with transcranial direct current stimulation (tDCS): Challenges and future

directions

Neuroreport. 2005

Paper-4 Review

TDCS dosage(1) Current dosage (measured in amperes);

(2) Duration of stimulation; and

(3) Electrode montage (size and position of all electrodes).

Parameters of StimulationTDCS parameters can vary widely and several factors need to be defined. These

factors include electrode size and positioning, intensity, duration of stimulation,number of sessions per day, and interval between sessions. By varying theseparameters, different amounts of electric current can be delivered, thusinducing diverse physiologic effects.

Paper-5 Review

Excitability Changes Induced in the Human Motor Cortex by Weak Transcranial Direct Current

Stimulation

J. Physiol. 2000

Review: Paper-5

Cortical excitability change during current flow

Polarity-specific after-effect of DC stimulation

Findings

Excitation could be achieved selectively by anodal stimulationand inhibition by cathodal stimulation

By varying the current intensity and duration, the strength andduration of the aftereffects could be controlled

The authors demonstrated in the intact human the possibility of a noninvasive modulation of motor cortex excitability by the application of weak direct current through the scalp

Electrode Shape & Salinity

(a1 and b1): Modeled electrode-sponge finite element geometry. The head model comprised of 4 concentric blocks (skin, skull, CSF,

brain). The electrode and sponge pad had 0.5 and 2.5 mm thickness, respectively. 2 mA of total current was applied to 35 cm2 pads

(boundary current density 0.0057 A/m2).

(a2 and b2): For saline soaked sponge (1.4 S/m), current density was concentrated at electrode edges, with higher values observed

at the rectangular electrode corners. Both panels plotted to the peak current density for the rectangular electrode (0.041 A/m2).

(a3 and b3): Re-plotting these panels to a maximum current density of 0.029 A/m2, emphasize that outside of the rectangular

electrode corners, the typical current density around the circular electrode is higher.

(a4 and b4): Decreasing sponge salinity (0.05 S/m) resulted in significantly more uniform electrode current densities, and reduced

peak current densities for both rectangular and circular pads to approximately the same values

Comparison of the skin current density profiles for area matched rectangular and circular pads

Electrode montage in stroke

Findings:

•Bilateral tDCS, anodal tDCS and cathodal tDCS were shown to be associated with

significant improvements on the JTT.

•Bilateral and extra-cephalic stimulation do not induce effects on motor function

•Effects of tDCS are task-dependent and might be different for neuropsychiatric

conditions, such as stroke

Changes in the main outcome (Jebsen–Taylor Hand Motor Function Test – as measured in seconds) in each electrode

montage. Columns indicate mean changes and bars indicate standard error of the mean.

Summary Note on tDCSBrain function under the anodal electrode site is enhanced by roughly 20 to 40%

when the current density (concentration of amperage under the electrode) exceeds

40 μA/cm2 (260 μA/inch2). The cathode reduces brain function under the electrode

site by 10 to 30% at the fore-mentioned current density. Anodal stimulation is the

most common form of tDCS as most applications require enhanced brain function.