Effects of transcranial direct current stimulation combined with virtual reality training on upper limb function of stroke patient: a pilot randomized controlled single-blind trial_West China Medical Journal

Authors：

LIU Yuanwen , HUANG Li , ZHANG Shuxian , AI Yinan , LI Lili ,  HU Xiquan

Department of Rehabilitation Medicine, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630,P. R. China;

Corresponding?author：

HU Xiquan, Email: xiquhu@hotmail.com

Keywords：

Transcranial direct current stimulation; Virtual reality; Function; Upper limb; Stroke

DOI：

10.7507/1002-0179.202003112

Video：

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Objective To investigate the effects of transcranial direct current stimulation (tDCS) combined with virtual reality (VR) on upper limb dysfunction of stroke patients.Methods Patients with stroke who were hospitalized in the Department of Rehabilitation Medicine, the Third Affiliated Hospital of Sun Yat-Sen University from July 2018 to January 2020 were selected. The patients were divided into tDCS group, VR group and combined treatment group by random number table method. All three groups received conventional rehabilitation treatment. Based on this, tDCS group received 2.0 mA tDCS treatment, VR group received 20 min VR treatment, and combined treatment group received the same tDCS and VR treatment. Before and 4 weeks after treatment, the Fugl-Meyer assessment-upper limb (FMA-UL), Wolf motor function test (WMFT) and modified barthel index (MBI) were used to evaluate the upper limb motor function and activities of daily life (ADL) of the three groups.Results A total of 45 patients were included, 15 in each group. No adverse reactions or fall off occurred during the treatment. Before treatment, there were no significant difference in FMA-UL, WMFT-Times, WMFT functional ability scores (WMFT-FAS), and MBI between the three groups (P>0.05). After 4 weeks of treatment, the FMA-UL, WMFT-Times, WMFT-FAS, and MBI scores of the three groups were significantly improved compared with those before treatment (P<0.05); the MBI score of the combination treatment group was significantly better than the tDCS group and VR group, and the FMA-UL was significantly better than the tDCS group, and the differences were statistically significant (P<0.05). Also, there were no significant differences in the improvement of FMA-UL, WMFT-Times, WMFT-FAS, and MBI scores between the tDCS group and the VR group (P>0.05); the differences of FMA-UL, WMFT-Times, WMFT-FAS, and MBI scores before and after treatment in the combined treatment group, which were significantly better than those in tDCS group and VR group (P<0.05). Conclusion tDCS combined with virtual reality can significantly improve the upper limb motor function and ADL ability of stroke patients, and the effect is superior to tDCS or VR treatment solely.

Citation： LIU Yuanwen, HUANG Li, ZHANG Shuxian, AI Yinan, LI Lili, HU Xiquan. Effects of transcranial direct current stimulation combined with virtual reality training on upper limb function of stroke patient: a pilot randomized controlled single-blind trial. West China Medical Journal, 2020, 35(5): 544-549. doi: 10.7507/1002-0179.202003112 Copy

1.	Gurbuz N, Afsar SI, Aya? S, et al. Effect of mirror therapy on upper extremity motor function in stroke patients: a randomized controlled trial. J Phys Ther Sci, 2016, 28(9): 2501-2506.
2.	Pollock A, Farmer SE, Brady MC, et al. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev, 2014(11): CD010820.
3.	Elsner B, Kugler J, Pohl M, et al. Transcranial direct current stimulation (tDCS) for improving aphasia in adults with aphasia after stroke. Cochrane Database Syst Rev, 2019, 5: CD009760.
4.	Shaker HA, Sawan SAE, Fahmy EM, et al. Effect of transcranial direct current stimulation on cognitive function in stroke patients. Egypt J Neurol Psychiatr Neurosurg, 2018, 54(1): 32.
5.	Elsner B, Kwakkel G, Kugler J, et al. Transcranial direct current stimulation (tDCS) for improving capacity in activities and arm function after stroke: a network meta-analysis of randomised controlled trials. J Neuroeng Rehabil, 2017, 14(1): 95.
6.	Laver KE, Lange B, George S, et al. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev, 2017(11): CD008349.
7.	Lee SJ, Chun MH. Combination transcranial direct current stimulation and virtual reality therapy for upper extremity training in patients with subacute stroke. Arch Phys Med Rehabil, 2014, 95(3): 431-438.
8.	Viana RT, Laurentino GE, Souza RJ, et al. Effects of the addition of transcranial direct current stimulation to virtual reality therapy after stroke: a pilot randomized controlled trial. Neuro Rehabilitation, 2014, 34(3): 437-446.
9.	中華醫學會神經病學分會, 中華醫學會神經病學分會腦血管病學組. 中國各類主要腦血管病診斷要點 2019. 中華神經科雜志, 2019, 52(9): 710-715.
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11.	Duff SV, He J, Nelsen MA, et al. Interrater reliability of the wolf motor function test-functional ability scale: why it matters. Neurorehabil Neural Repair, 2015, 29(5): 436-443.
12.	Tedesco Triccas L, Burridge JH, Hughes AM, et al. Multiple sessions of transcranial direct current stimulation and upper extremity rehabilitation in stroke: a review and meta-analysis. Clin Neurophysiol, 2016, 127(1): 946-955.
13.	Butler AJ, Shuster M, O’Hara E, et al. A meta-analysis of the efficacy of anodal transcranial direct current stimulation for upper limb motor recovery in stroke survivors. J Hand Ther, 2013, 26(2): 162-170.
14.	Fleming MK, Rothwell JC, Sztriha L, et al. The effect of transcranial direct current stimulation on motor sequence learning and upper limb function after stroke. Clin Neurophysiol, 2017, 128(7): 1389-1398.
15.	尹昱, 左秀芹, 呂艷玲, 等. 經顱直流電刺激對腦卒中患者上肢運動功能障礙的療效. 中國康復理論與實踐, 2015, 21(7): 830-833.
16.	Marquez JL, Conley AC, Karayanidis F, et al. Determining the benefits of transcranial direct current stimulation on functional upper limb movement in chronic stroke. Int J Rehabil Res, 2017, 40(2): 138-145.
17.	Lüdemann-Podubecká J, B?sl K, Rothhardt S, et al. Transcranial direct current stimulation for motor recovery of upper limb function after stroke. Neurosci Biobehav Rev, 2014, 47: 245-259.
18.	唐朝正, 陳創, 丁政, 等. 經顱直流電刺激應用于腦卒中上肢和手功能康復的研究進展. 中華物理醫學與康復雜志, 2017, 39(5): 391-396.
19.	湯從智, 蔡倩, 楊璽, 等. 經顱直流電刺激介入任務導向性訓練對腦卒中患者上肢功能障礙的影響. 中華物理醫學與康復雜志, 2019, 41(8): 570-574.
20.	Stagg CJ, Nitsche MA. Physiological basis of transcranial direct current stimulation. Neuroscientist, 2011, 17(1): 37-53.
21.	Stagg CJ, Lin RL, Mezue M, et al. Widespread modulation of cerebral perfusion induced during and after transcranial direct current stimulation applied to the left dorsolateral prefrontal cortex. J Neurosci, 2013, 33(28): 11425-11431.
22.	肖湘, 黃東鋒, 梁斌. 虛擬現實訓練對亞急性期腦卒中患者上肢運動功能的影響. 中國康復醫學雜志, 2019, 34(9): 1049-1053.
23.	劉遠文, 潘翠環, 葉正茂, 等. 虛擬現實機器手對腦卒中患者手運動功能及日常生活活動的效果. 中國康復理論與實踐, 2017, 23(1): 19-22.
24.	翟藝, 徐秀林. 基于虛擬現實技術的上肢康復訓練系統發展現狀. 中國康復理論與實踐, 2014(10): 908-910.
25.	Malik AN, Masood T. Effects of virtual reality training on mobility and physical function in stroke. J Pak Med Assoc, 2017, 67(10): 1618-1620.
26.	Brunner I, Skouen JS, Hofstad H, et al. Virtual reality training for upper extremity in subacute stroke (VIRTUES): a multicenter RCT. Neurology, 2017, 89(24): 2413-2421.
27.	Subramanian SK, Prasanna SS. Virtual reality and noninvasive brain stimulation in stroke: how effective is their combination for upper limb motor improvement?-A meta-analysis. PMR, 2018, 10(11): 1261-1270.
28.	賈杰. 創新與循證并進中樞與外周交融—ISP RM 2016 上肢及手功能康復研究專題報道. 中華物理醫學與康復雜志, 2016, 38(7): 550-554.
29.	賈杰. “中樞-外周-中樞”閉環康復—腦卒中后手功能康復新理念. 中國康復醫學雜志, 2016, 31(11): 1180-1182.
30.	Hatem SM, Saussez G, Della Faille M, et al. Rehabilitation of motor function after stroke: a multiple systematic review focused on techniques to stimulate upper extremity recovery. Front Hum Neurosci, 2016, 10: 442.
31.	Schaefer SY, Patterson CB, Lang CE. Transfer of training between distinct motor tasks after stroke: implications for task-specific approaches to upper-extremity neurorehabilitation. Neurorehabil Neural Repair, 2013, 27(7): 602-612.

1. Gurbuz N, Afsar SI, Aya? S, et al. Effect of mirror therapy on upper extremity motor function in stroke patients: a randomized controlled trial. J Phys Ther Sci, 2016, 28(9): 2501-2506.
2. Pollock A, Farmer SE, Brady MC, et al. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev, 2014(11): CD010820.
3. Elsner B, Kugler J, Pohl M, et al. Transcranial direct current stimulation (tDCS) for improving aphasia in adults with aphasia after stroke. Cochrane Database Syst Rev, 2019, 5: CD009760.
4. Shaker HA, Sawan SAE, Fahmy EM, et al. Effect of transcranial direct current stimulation on cognitive function in stroke patients. Egypt J Neurol Psychiatr Neurosurg, 2018, 54(1): 32.
5. Elsner B, Kwakkel G, Kugler J, et al. Transcranial direct current stimulation (tDCS) for improving capacity in activities and arm function after stroke: a network meta-analysis of randomised controlled trials. J Neuroeng Rehabil, 2017, 14(1): 95.
6. Laver KE, Lange B, George S, et al. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev, 2017(11): CD008349.
7. Lee SJ, Chun MH. Combination transcranial direct current stimulation and virtual reality therapy for upper extremity training in patients with subacute stroke. Arch Phys Med Rehabil, 2014, 95(3): 431-438.
8. Viana RT, Laurentino GE, Souza RJ, et al. Effects of the addition of transcranial direct current stimulation to virtual reality therapy after stroke: a pilot randomized controlled trial. Neuro Rehabilitation, 2014, 34(3): 437-446.
9. 中華醫學會神經病學分會, 中華醫學會神經病學分會腦血管病學組. 中國各類主要腦血管病診斷要點 2019. 中華神經科雜志, 2019, 52(9): 710-715.
10. 王玉龍. 康復功能評定學. 3 版. 北京: 人民衛生出版社, 2018.
11. Duff SV, He J, Nelsen MA, et al. Interrater reliability of the wolf motor function test-functional ability scale: why it matters. Neurorehabil Neural Repair, 2015, 29(5): 436-443.
12. Tedesco Triccas L, Burridge JH, Hughes AM, et al. Multiple sessions of transcranial direct current stimulation and upper extremity rehabilitation in stroke: a review and meta-analysis. Clin Neurophysiol, 2016, 127(1): 946-955.
13. Butler AJ, Shuster M, O’Hara E, et al. A meta-analysis of the efficacy of anodal transcranial direct current stimulation for upper limb motor recovery in stroke survivors. J Hand Ther, 2013, 26(2): 162-170.
14. Fleming MK, Rothwell JC, Sztriha L, et al. The effect of transcranial direct current stimulation on motor sequence learning and upper limb function after stroke. Clin Neurophysiol, 2017, 128(7): 1389-1398.
15. 尹昱, 左秀芹, 呂艷玲, 等. 經顱直流電刺激對腦卒中患者上肢運動功能障礙的療效. 中國康復理論與實踐, 2015, 21(7): 830-833.
16. Marquez JL, Conley AC, Karayanidis F, et al. Determining the benefits of transcranial direct current stimulation on functional upper limb movement in chronic stroke. Int J Rehabil Res, 2017, 40(2): 138-145.
17. Lüdemann-Podubecká J, B?sl K, Rothhardt S, et al. Transcranial direct current stimulation for motor recovery of upper limb function after stroke. Neurosci Biobehav Rev, 2014, 47: 245-259.
18. 唐朝正, 陳創, 丁政, 等. 經顱直流電刺激應用于腦卒中上肢和手功能康復的研究進展. 中華物理醫學與康復雜志, 2017, 39(5): 391-396.
19. 湯從智, 蔡倩, 楊璽, 等. 經顱直流電刺激介入任務導向性訓練對腦卒中患者上肢功能障礙的影響. 中華物理醫學與康復雜志, 2019, 41(8): 570-574.
20. Stagg CJ, Nitsche MA. Physiological basis of transcranial direct current stimulation. Neuroscientist, 2011, 17(1): 37-53.
21. Stagg CJ, Lin RL, Mezue M, et al. Widespread modulation of cerebral perfusion induced during and after transcranial direct current stimulation applied to the left dorsolateral prefrontal cortex. J Neurosci, 2013, 33(28): 11425-11431.
22. 肖湘, 黃東鋒, 梁斌. 虛擬現實訓練對亞急性期腦卒中患者上肢運動功能的影響. 中國康復醫學雜志, 2019, 34(9): 1049-1053.
23. 劉遠文, 潘翠環, 葉正茂, 等. 虛擬現實機器手對腦卒中患者手運動功能及日常生活活動的效果. 中國康復理論與實踐, 2017, 23(1): 19-22.
24. 翟藝, 徐秀林. 基于虛擬現實技術的上肢康復訓練系統發展現狀. 中國康復理論與實踐, 2014(10): 908-910.
25. Malik AN, Masood T. Effects of virtual reality training on mobility and physical function in stroke. J Pak Med Assoc, 2017, 67(10): 1618-1620.
26. Brunner I, Skouen JS, Hofstad H, et al. Virtual reality training for upper extremity in subacute stroke (VIRTUES): a multicenter RCT. Neurology, 2017, 89(24): 2413-2421.
27. Subramanian SK, Prasanna SS. Virtual reality and noninvasive brain stimulation in stroke: how effective is their combination for upper limb motor improvement?-A meta-analysis. PMR, 2018, 10(11): 1261-1270.
28. 賈杰. 創新與循證并進中樞與外周交融—ISP RM 2016 上肢及手功能康復研究專題報道. 中華物理醫學與康復雜志, 2016, 38(7): 550-554.
29. 賈杰. “中樞-外周-中樞”閉環康復—腦卒中后手功能康復新理念. 中國康復醫學雜志, 2016, 31(11): 1180-1182.
30. Hatem SM, Saussez G, Della Faille M, et al. Rehabilitation of motor function after stroke: a multiple systematic review focused on techniques to stimulate upper extremity recovery. Front Hum Neurosci, 2016, 10: 442.
31. Schaefer SY, Patterson CB, Lang CE. Transfer of training between distinct motor tasks after stroke: implications for task-specific approaches to upper-extremity neurorehabilitation. Neurorehabil Neural Repair, 2013, 27(7): 602-612.

West China Medical Journal

Effects of transcranial direct current stimulation combined with virtual reality training on upper limb function of stroke patient: a pilot randomized controlled single-blind trial

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