To Combine or Not to Combine Physical Therapy With tDCS for Stroke With Shoulder Pain? Analysis From a Combination Randomized Clinical Trial for Rehabilitation of Painful Shoulder in Stroke

Abstract

Purpose: Transcranial Direct Current Stimulation (tDCS) is an intervention that seems to be an ideal tool to enhance the effects of rehabilitation therapies given it facilitates generation of plasticity in the stimulated brain area. In stroke this strategy has been highly utilized; however, the results have been mixed. In this trial we have evaluated the analgesic and functional effects of Transcranial Direct Current Stimulation (tDCS) combined with physiotherapy in stroke survivors with shoulder pain.Methods: Twenty-six stroke surviving adults with shoulder pain received 10 sessions of passive mobilization and performed upper limb exercises using a cycle ergometer, combined with active or sham tDCS. The intensity of pain in the hemiplegic shoulder was measured using the Visual Analog Scale (VAS); secondary outcomes were the level of motor impairment, handgrip strength, range of motion, motor function of the upper limbs, and quality of life (QOL) assessed before and after 10 sessions and 1 month after the end of the treatment.Results: A clinically important pain reduction (3 points) was found in both groups and was maintained at follow-up; there was no significant difference between groups (p = 0.3). Similarly, the shoulder range of motion improved, motor function and quality of life improved showed no significant differences between groups. One result that needs to be underscored is that both groups had a significant effect size toward improvement in all of these outcomes.Conclusions: We discuss in this study that tDCS is not a useful combination strategy when the physical therapy has a large effect by itself and we also review other negative trials of combined therapy under this framework of ceiling effect of the main physical therapy.Trial registry: Trial registration: Brazilian Registry of Clinical Trials, RBR-8F5MNY (http://www.ensaiosclinicos.gov.br/rg/RBR-8f5mny/). Registered on June 2, 2017.Beginning of the recruitment of the volunteers: august, 2017.

Exploring the Potential of Transcranial Direct Current Stimulation for Relieving Central Post-Stroke Pain: A Randomized Controlled Pilot Study

“…However, their long-term effects on pain and effectiveness in treating CPSP are still being explored. Studies have yielded mixed results, with some reporting no significant improvement in pain reduction with tDCS compared to the sham group [ 42 ], which is consistent with the findings of this study. Further studies using various methodologies are required to fully understand the potential benefits of tDCS in CPSP.…”

Transcranial direct current stimulation in physical therapy treatment for adults after stroke: A systematic review

“…Table 1 represents the data related to the number of individuals and groups of each investigation, the variables analyzed in each study and the follow-up time. In addition, Table 1 contains the score obtained on the PEDro scale to analyze the methodological quality, all selected articles show a level from good to excellent with scores higher than 7 (Andressa de Souza et al, 2021;Ehsani, Mortezanejad, Yosephi, Daniali, & Jaberzadeh, 2022;Kashoo et al, 2022;Klomjai et al, 2022;Llorens et al, 2021;Pires et al, 2023;Tedla et al, 2022) and even reaching a score of 9 (Tedla et al, 2022) or 10 (Andressa de Souza et al, 2021) in some cases. Appendix B includes the localization where studies were conducted.…”

“…Functionality was the most analyzed variable in most of the studies, especially through the Fugl-Meyer Assessment of Motor Recovery after Stroke Scale for Upper Extremity (FMA -UE), considering that almost all clinical trials analyzed the effects on deficits in the upper limb. Specifically, this variable was included in 6 of the articles (Andressa de Souza et al, 2021;Kashoo et al, 2022;Klomjai et al, 2022;Llorens et al, 2021;Pires et al, 2023;Tedla et al, 2022), likewise, the variable Wolf Motor Function Test (WMFT) was also normally used (Klomjai et al, 2022;Llorens et al, 2021;Tedla et al, 2022). The effects on gait, balance, and lower limb functionality have also been studied (Ehsani et al, 2022;Klomjai et al, 2022;Tedla et al, 2022), as well as spasticity associated with electromyographic recording (EMG) (Ehsani et al, 2022), and shoulder pain, strength, and range of motion (ROM) (Andressa de Souza et al, 2021).…”

“…Specifically, this variable was included in 6 of the articles (Andressa de Souza et al, 2021;Kashoo et al, 2022;Klomjai et al, 2022;Llorens et al, 2021;Pires et al, 2023;Tedla et al, 2022), likewise, the variable Wolf Motor Function Test (WMFT) was also normally used (Klomjai et al, 2022;Llorens et al, 2021;Tedla et al, 2022). The effects on gait, balance, and lower limb functionality have also been studied (Ehsani et al, 2022;Klomjai et al, 2022;Tedla et al, 2022), as well as spasticity associated with electromyographic recording (EMG) (Ehsani et al, 2022), and shoulder pain, strength, and range of motion (ROM) (Andressa de Souza et al, 2021). Quality of life values (SSQOL: Stroke Specific Quality of Life Scale) (Andressa de Souza et al, (Pires et al, 2023) and Haemodynamic response (MFV: Mean Blood Flow Velocity) (Klomjai et al, 2022) were also included as outcome measures.…”

“…The follow-up time ranged between 1 and 2 postintervention assessments, usually at the end of the intervention period (Kashoo et al, 2022;Llorens et al, 2021;Pires et al, 2023;Tedla et al, 2022) with a maximum follow-up of one month (Andressa de Souza et al, 2021;Ehsani et al, 2022;Klomjai et al, 2022). All information on the variables included in each study and follow-up times is available in Table 1.…”