Transcranial Direct Current Stimulation decreases time to recovery after a motor stroke vs. other localisation of or non-stroken-

1. Shortened time to recovery of
sensorimotor skills following physical
therapy with simultaneously applied
transcranial direct current stimulation
(tDCS)
SETH TASBIHGOU
SEBASTIAAN VAN JOLE
28-10-2014
“THE FUTURE OF STROKE
REHABILIATION”

2. (1: COSTELLO & CROCKFORD 2014)
RESEARCH PROBLEM
People with a stroke in the
primary motor cortex experience:
• Paresis
• Paralysis
• Sensory deficits
• Paresthesias
It takes months of rehabilitation
to recover

3. HypothesisPrevious researchtDCS
Anodal stimulation
of the primary motor cortex
shortens time to recovery
of motor skills in male hemi-
plegic post-stroke patients
as measured by faster decrease
on Fugel-Meyer Assessment
Enhancement of
motor learning
after stimulation
of the motor cortex
(3: Saucedo & Zhang 2013)
Safe
Non-invasive
Effective
(2: Coffmann & Clark 2014)
BACKGROUND & HYPOTHESIS
Anode Cathode

4. 50%
Physical therapy
+
tDCS
Physical therapy
+
sham
50%
INFORMED CONSENT FORMS WILL BE PRESENTED AFTER TRANSFER FROM THE
STROKE CARE UNIT TO THE REHABILITATION CENTER
NO FURTHER ETHICAL CONCERNS
DESIGN: RANDOMIZED PLACEBO-CONTROLLED TRIAL
3 outcomes:
Primary: FAMS (4)
Secondary: Days to Release
Tertiairy: MOCA (5)
3 outcomes:
Primary: FAMS (4)
Secondary: Days to Release
Tertiairy: MOCA (5)

5. INCLUSION AND EXCLUSION CRITERIA
Inclusion:
• Adults (18-64 years)
• Males
• ‘First’ Unilateral Ischemic Stroke
• Modified Rankin Scale: 4-5
• Groninger Rehabilitation Centre
Exclusion:
• Prior disabilities
• Malignant hypertension not
responding to treatment
• Short-term life-threatening disease
• Intracranial vascular malformations

6. (6: HORVATH & CARTER 2013)
(7: LUCULANO & KADOSH 2013)ADDRESSING CRITICISMS
• inter-subject variability: previous literature revealed extensive
between- and within-group variation; therefore this study has a
comprehensive inclusion and exclusion criteria
• intra-subject reliability: the tDCS response in individuals will be
measured over time
• sham stimulation: our subjects are properly blinded by receiving
sham stimulation of 0,1 mA
• motor and cognitive interference: control of patient activity during
treatment; cognitive differences must be taken into account.
• electric current influences: instruct research assistants to follow
identical procedures, e.g. identical electrode positioning,
• The mental cost: Montreal Cognitive Assessment (MOCA) (5), first
and 15th therapy sensition; minimize repetition effects.

7. FUGL-MEYER ASSESSMENT
Assesses upper and lower exetremity
sensorimotor function:
• Reflexes
• Volitional Movements
• Coordination
• Speed
• Sensation
• Passive Motion
Items are scored on a 3
point scale:
• 0=cannot be
performed
• 1=performs partially
• 2=performs fully
Maximum is 226 points
(5: Fugl-Meyer & Jaasko 1975)
(8: Sanford & Moreland 1993)

8. SAMPLE SIZE - POWER ANALYSIS
Reliability of 95%: 1,96
Power of 80%: 0,84
Standard Deviation: 49
Treatment group: 105 individuals + 20% dropout = 126 individuals
Placebo: 126 individuals
105
20
49)84,096,1(2
2
22
=
⋅+
=n
(8: Sanford & Moreland 2013)
(9: Bronnsum-Hansen & Davidsen et al. 2001)

9. (10: Nederlandse ahrtstichting 2013)
(11: Hope & Seghier et al. 2013)
(12: IBM SPSS)
FEASIBILITY & STATISTICS & BUDGET
statistical analysis:
• comparing mean improvement
between two groups
• continuous data
• normally distributed
• t-test (using SPSS)
feasibility:
± 21000 male stroke patients in the
Netherlands each year, of which 85%
ischemic stroke (17850), and 500 of them
are treated each year in the Groninger
Rehabilitation Centre, thus feasible in 1 year
estimation of costs:
Tools
tDCS: €1000 * 2: € 2000
Conduction gel: € 50
Amrex sponge elctrodes: € 600
FMAS questionnaires: € 0
MOCA questionnaires: € 0
Services
Research assistants: € 500
Statistical consult: € 230
Training assistant: € 600
€ 4000

10. EXPECTED OUTCOMES & IMPLICATIONS
tDCS as an innovative therapy enhancement for patients who are
recovering from a stroke
shortened rehabilitation times lower the financial burden of stroke
results can be used as groundwork for use of tDCS in other fields
faster and/or larger increase in FMAS scores and…
shortened stay in the rehabilitation center…
versus stroke patients following regular physical therapy

11. QUESTION TIME

12. REFERENCES
1. Costello F, Crockford D, Dewey D. Functional MR Imaging [Internet]. 2014 [cited 20
14 Oct 20]. Available from: http://www.mrcentre.ca/research/FunctionalMR
2. Coffman BA, Clark VP, Parasuraman R. Battery powered thought: enhancement of a
ttention, learning, and memory in healthy adults using transcranial direct current sti
mulation. Neuroimage. 2014 Jan 15;85 Pt 3:895–908.
3. Saucedo Marquez CM, Zhang X, Swinnen SP, Meesen R, Wenderoth N. Task-specifi
c effect of transcranial direct current stimulation on motor learning. Front Hum Neur
osci. 2013 Jan;7:333.
4. Fugl-Meyer A, Jaasko L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic
patient. A method for evaluation of physical performance. Scand J Rehabil Med. 19
75;(7):13–31.
5. Nasreddine ZS, Phillips NA, Bedirian V, Charbonneau S, Whitehead V, Collin I, et al.
The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive
impairment. J Am Geriatr Soc 2005 Apr;53(4):695-699.
6. Horvath JC, Carter O, Forte JD. Transcranial direct current stimulation: five importa
nt issues we aren't discussing (but probably should be). Front Syst Neurosci 2014 Ja
n 24;8:2.

13. REFERENCES CONT.
7. Luculano T, Cohen Kadosh R. The mental cost of cognitive enhancement. J
Neurosci 2013 Mar 6;33(10):4482-4486.
8. Sanford J, Moreland J, Swanson L, Stratford P, Gowland C. Reliability of the
Fugl-Meyer Assessment for Testing Motor Performance in Patients Followin
g Stroke. Phys Ther. 1993;73(7):447–54.
9. Bronnum-Hansen H, Davidsen M, Thorvaldsen P, Danish MONICA Study Gro
up. Long-term survival and causes of death after stroke. Stroke 2001 Sep;32(
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10. Nederlandse Hartstichting. Aantal ziekenhuisopnamen voor hart- en vaatziek
ten naar ziektebeeld en geslacht in Nederland 2010. 2010; Available at:
https://www.hartstichting.nl/downloads/grafiek-opname-ziektebeeld-geslac
ht. Accessed 10/20, 2014.
11. Hope TMH, Seghier ML, Leff AP, Price CJ. Predicting outcome and recovery
after stroke with lesions extracted from MRI images. NeuroImage Clin. 2013
Jan;2:424–33.
12. IBM Cooperation. Statistical Package for the Social Sciences. 2013 August 1
3, 2013;22.