Combined Transcranial Direct Current Stimulation and Virtual Reality-Based Paradigm for Upper Limb Rehabilitation in Individuals with Restricted Movements. A Feasibility Study with a Chronic Stroke Survivor with Severe Hemiparesis
- 257 Downloads
Impairments of the upper limb function are a major cause of disability and rehabilitation. Most of the available therapeutic options are based on active exercises and on motor and attentional inclusion of the affected arm in task oriented movements. However, active movements may not be possible after severe impairment of the upper limbs. Different techniques, such as mirror therapy, motor imagery, and non-invasive brain stimulation have been shown to elicit cortical activity in absence of movements, which could be used to preserve the available neural circuits and promote motor learning. We present a virtual reality-based paradigm for upper limb rehabilitation that allows for interaction of individuals with restricted movements from active responses triggered when they attempt to perform a movement. The experimental system also provides multisensory stimulation in the visual, auditory, and tactile channels, and transcranial direct current stimulation coherent to the observed movements. A feasibility study with a chronic stroke survivor with severe hemiparesis who seemed to reach a rehabilitation plateau after two years of its inclusion in a physical therapy program showed clinically meaningful improvement of the upper limb function after the experimental intervention and maintenance of gains in both the body function and activity. The experimental intervention also was reported to be usable and motivating. Although very preliminary, these results could highlight the potential of this intervention to promote functional recovery in severe impairments of the upper limb.
KeywordsVirtual reality tDCS Eye-tracking Surface electromyography Upper limb paresis Monoparesis, stroke
This study was funded in part by Ministerio de Economía y Competitividad of Spain (Project TIN2014–61975-EXP and Grant BES-2014-068218) and by Universitat Politècnica de València (Grant PAID-10-14 and Grant PAID-10-16).
Compliance with Ethical standards
Conflict of Interest
The authors declare that they have no conflict of interest.
All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments.
- 3.Pollock, A., Farmer, S. E., Brady, M. C., Langhorne, P., Mead, G. E., Mehrholz, J., and van Wijck, F., Interventions for improving upper limb function after stroke. Cochrane Database Syst. Rev. 11, 2014. https://doi.org/10.1002/14651858.CD010820.pub2.
- 7.Hunter, S. M., Crome, P., Sim, J., and Pomeroy, V. M., Effects of Mobilization and Tactile Stimulation on Recovery of the Hemiplegic Upper Limb: A Series of Replicated Single-System Studies. Arch. Phys. Med. Rehabil. 89:2003–2010, 2008. https://doi.org/10.1016/j.apmr.2008.03.016.CrossRefPubMedGoogle Scholar
- 9.Lum, P. S., Mulroy, S., Amdur, R. L., Requejo, P., Prilutsky, B. I., and Dromerick, A. W., Gains in upper extremity function after stroke via recovery or compensation: Potential differential effects on amount of real-world limb use. Top. Stroke Rehabil. 16:237–253, 2009. https://doi.org/10.1310/tsr1604-237.CrossRefPubMedGoogle Scholar
- 11.Deconinck, F. J. A., Smorenburg, A. R. P., Benham, A., Ledebt, A., Feltham, M. G., and Savelsbergh, G. J. P., Reflections on Mirror Therapy: A Systematic Review of the Effect of Mirror Visual Feedback on the Brain. Neurorehabil. Neural Repair. 29:349–361, 2014. https://doi.org/10.1177/1545968314546134.CrossRefPubMedGoogle Scholar
- 17.Gatti, R., Rocca, M. A., Fumagalli, S., Cattrysse, E., Kerckhofs, E., Falini, A., and Filippi, M., The effect of action observation/execution on mirror neuron system recruitment: an fMRI study in healthy individuals. Brain Imaging Behav. 11:565–576, 2017. https://doi.org/10.1007/s11682-016-9536-3.CrossRefPubMedGoogle Scholar
- 19.Grundmann, L., Rolke, R., Nitsche, M. A., Pavlakovic, G., Happe, S., Treede, R. D., Paulus, W., and Bachmann, C. G., Effects of transcranial direct current stimulation of the primary sensory cortex on somatosensory perception. Brain Stimul. 4:253–260, 2011. https://doi.org/10.1016/j.brs.2010.12.002.CrossRefPubMedGoogle Scholar
- 20.von Rein, E., Hoff, M., Kaminski, E., Sehm, B., Steele, C. J., Villringer, A., and Ragert, P., Improving motor performance without training: the effect of combining mirror visual feedback with transcranial direct current stimulation. J. Neurophysiol. 113:2383–2389, 2015. https://doi.org/10.1152/jn.00832.2014.CrossRefGoogle Scholar
- 21.Kim, Y. J., Ku, J., Cho, S., Kim, H. J., Cho, Y. K., Lim, T., and Kang, Y. J., Facilitation of corticospinal excitability by virtual reality exercise following anodal transcranial direct current stimulation in healthy volunteers and subacute stroke subjects. J. Neuroeng. Rehabil. 11:124, 2014. https://doi.org/10.1186/1743-0003-11-124.CrossRefPubMedPubMedCentralGoogle Scholar
- 22.S. Bermúdez i Badia, G.G. Fluet, R. Llorens, J.E. Deutsch, Virtual Reality for Sensorimotor Rehabilitation Post Stroke: Design Principles and Evidence. In: Neurorehabilitation Technol., Second edi, Springer, 2016: pp. 573–603. https://doi.org/10.1007/978-3-319-28603-7_28.
- 24.Colomer, C., Llorens, R., Noé, E., and Alcañiz, M., Effect of a mixed reality-based intervention on arm, hand, and finger function on chronic stroke. J. Neuroeng. Rehabil. 13, 2016. https://doi.org/10.1186/s12984-016-0153-6.
- 26.Poole, A., and Ball, L. J., Eye Tracking in Human-Computer Interaction and Usability Research: Current Status and Future Prospects. Encycl. Human-Computer Interact.:211–219, 2005. https://doi.org/10.4018/978-1-59140-562-7.
- 27.R. Merletti, A. Botter, A. Troiano, E. Merlo, M.A. Minetto, Technology and instrumentation for detection and conditioning of the surface electromyographic signal: State of the art, Clin. Biomech. 24 (2009) 122–134. https://doi.org/10.1016/j.clinbiomech.2008.08.006.
- 31.Lang, C. E., Edwards, D. F., Birkenmeier, R. L., and Dromerick, A. W., Estimating Minimal Clinically Important Differences of Upper-Extremity Measures Early After Stroke. Arch. Phys. Med. Rehabil. 89:1693–1700, 2008. https://doi.org/10.1016/j.apmr.2008.02.022.CrossRefPubMedPubMedCentralGoogle Scholar
- 35.R. Teasell, Evidence-Based Review of Stroke Rehabilitation - Background Concepts in Stroke Rehabilitation, 2016. http://www.ebrsr.com/evidence-review/3-background-concepts-stroke-rehabilitation.
- 36.Cameirão, M. S., Badia, S. B. I., Duarte, E., Frisoli, A., and Verschure, P. F. M. J., The combined impact of virtual reality neurorehabilitation and its interfaces on upper extremity functional recovery in patients with chronic stroke. Stroke. 43:2720–2728, 2012. https://doi.org/10.1161/STROKEAHA.112.653196.CrossRefPubMedGoogle Scholar
- 37.K.E. Laver, S. George, S. Thomas, J.E. Deutsch, M. Crotty, Virtual reality for stroke rehabilitation. In: Cochrane Database Syst. Rev., 2015: pp. 1–107. https://doi.org/10.1002/14651858.CD008349.pub3.
- 40.K. Figlewski, J.U. Blicher, J. Mortensen, K.E. Severinsen, J.F. Nielsen, H. Andersen, Transcranial Direct Current Stimulation Potentiates Improvements in Functional Ability in Patients With Chronic Stroke Receiving Constraint-Induced Movement Therapy, Stroke. (2016). http://stroke.ahajournals.org/content/early/2016/11/29/STROKEAHA.116.014988.abstract.
- 42.Viana, R. T., Laurentino, G. E. C., Souza, R. J. P., Fonseca, J. B., Silva Filho, E. M., Dias, S. N., Teixeira-Salmela, L. F., and Monte-Silva, K. K., Effects of the addition of transcranial direct current stimulation to virtual reality therapy after stroke: A pilot randomized controlled trial. NeuroRehabilitation. 34:437–446, 2014. https://doi.org/10.3233/NRE-141065.PubMedGoogle Scholar
- 44.Bowering, K. J., O’Connell, N. E., Tabor, A., Catley, M. J., Leake, H. B., Moseley, G. L., and Stanton, T. R., The Effects of Graded Motor Imagery and Its Components on Chronic Pain: A Systematic Review and Meta-Analysis. J. Pain. 14:3–13, 2013. https://doi.org/10.1016/j.jpain.2012.09.007.CrossRefPubMedGoogle Scholar