Combining Robotic Training and Non-Invasive Brain Stimulation in Severe Upper Limb-Impaired Chronic Stroke Patients

Abstract

Previous studies suggested that both robot-assisted rehabilitation and non-invasive brain stimulation can produce a slight improvement in severe chronic stroke patients. It is still unknown whether their combination can produce synergistic and more consistent improvements. Safety and efficacy of this combination has been assessed within a proof-of-principle, double-blinded, semi-randomized, sham-controlled trial. Inhibitory continuous Theta Burst Stimulation (cTBS) was delivered on the affected hemisphere, in order to improve the response to the following robot-assisted therapy via a homeostatic increase of learning capacity. Twenty severe upper limb-impaired chronic stroke patients were randomized to robot-assisted therapy associated with real or sham cTBS, delivered for 10 working days. Eight real and nine sham patients completed the study. Change in Fugl-Meyer was chosen as primary outcome, while changes in several quantitative indicators of motor performance extracted by the robot as secondary outcomes. The treatment was well-tolerated by the patients and there were no adverse events. All patients achieved a small, but significant, Fugl-Meyer improvement (about 5%). The difference between the real and the sham cTBS groups was not significant. Among several secondary end points, only the Success Rate (percentage of targets reached by the patient) improved more in the real than in the sham cTBS group. This study shows that a short intensive robot-assisted rehabilitation produces a slight improvement in severe upper-limb impaired, even years after the stroke. The association with homeostatic metaplasticity-promoting non-invasive brain stimulation does not augment the clinical gain in patients with severe stroke.

Transcutaneous Vagus Nerve Stimulation Combined with Robotic Rehabilitation Improves Upper Limb Function after Stroke

“…Several studies have explored the possibility to potentiate the effect of robotic therapy by the association with noninvasive human brain stimulation techniques, such as repetitive transcranial magnetic stimulation (rTMS), that can induce neuroplasticity via long-term potentiation-/depression- (LTP-/LTD-) like phenomena [ 4 ]. Although intriguing, the evidence in support of this strategy remains low [ 5 , 6 ]. Indeed, the literature analysis of the published data seems to demonstrate that the association of rTMS with robotic training has the same clinical gain derived from robotic therapy alone.…”

Interindividual variability in response to continuous theta-burst stimulation in healthy adults

“…Application of cTBS to M1 and other brain areas has been used to measure abnormalities in cortical plasticity and to assess therapeutic responses to interventions aimed at restoring normal cortical plasticity in several neurological and psychiatric disorders, including Alzheimer’s disease (Freitas et al, 2011a), autism spectrum disorders and fragile X syndrome (Oberman et al, 2010, 2012, 2014, 2016), dementia (Cantone et al, 2014), epilepsy (Carrette et al, 2016), essential tremor (Chuang et al, 2014), hemispatial neglect (Cazzoli et al, 2012; Koch et al, 2012), major depression (Li et al, 2014), multiple sclerosis (Mori et al, 2013), obsessive-compulsive disorders (Wu et al, 2010; Suppa et al, 2014), Parkinson’s disease (Koch et al, 2009), schizophrenia (Poulet et al, 2009; Eberle et al, 2010; McClintock et al, 2011), stroke (Ackerley et al, 2010; Hsu et al, 2012; Di Lazzaro et al, 2013, 2016), tinnitus (Forogh et al, 2014), and Tourette syndrome (Suppa et al, 2014). …”

Literature Review on the Effects of tDCS Coupled with Robotic Therapy in Post Stroke Upper Limb Rehabilitation

“…The adjunct of non-invasive interventions, such as the electrical brain stimulation or magnetic brain stimulation (Di Lazzaro et al, 2016), might be used to speed-up and maximize the potential benefit of rehabilitation treatments. In particular, transcranial Direct Current Stimulation (tDCS) may play an important role in stroke recovery since its capability to modify cortical excitability and neural activity (Lefaucheur, 2016; Lefaucheur et al, 2017).…”