Transcranial Direct Current stimulation for post-stroke gait rehab

目前的康复方法无法恢复许多中风幸存者的正常步态，导致对 其他原因包括反复跌倒、社区活动受限和生活质量差。这项工作的主要目标是 这项研究旨在测试一种治疗持续性步态的新方法的有效性和神经生理机制 同时无创脑刺激与经颅直接电刺激相结合治疗卒中后脑功能障碍 电流刺激(TDC)和步态训练。理论基础：外周定向步态疗法是由 大脑功能改变。TDCs已被证明在康复和治疗过程中可以增强大脑功能的变化 改善结果。其易用性和安全性使tdcs成为与同步步态配对的理想技术。 训练方法。上肢研究显示，10个疗程的双半球tdcs联合 与治疗后的微小变化相比，运动疗法在临床上有意义的改善 独自一人。我们进行了初步研究，证明了建议的可行性和容忍性。 干预。我们的第一个单节交叉试点研究展示了tdcs组合的潜在好处。 与单纯的步态治疗相比，步态训练的效果更好。我们的第二个为期10个环节的试点研究显示， 干预并显示出临床改善。下一个重要的步骤是在随机的 对照研究。我们将使用双半球tdcs蒙太奇，它可以解决一种关键的适应性神经整形。 中风后运动恢复的机制，即重新平衡大脑半球之间的相互作用1) 促进下肢残存自体运动输出通路和2)抑制 来自对侧方运动区的跨颧骨抑制。研究设计：纳入50例慢性卒中患者 有步态缺陷的受试者(6个月)。受试者将被随机分成10组，每组进行两种主动tdcs步态 训练或假tdcs步态训练。步态训练将在基于跑步机的虚拟现实中完成 以偏瘫肢体为目标的单肢站姿较长的环境。目标1是确定是否 同时进行tdcs和步态训练相结合，可以更好地改善步态表现。 与单独的步态训练相比。主要的结果衡量标准将是步态速度，以10- 米步行试验(TMWT)和偏瘫患者单肢站立持续时间。次要结果衡量标准将评估 步态相关功能域的各种组成部分，将包括以下内容：时空步态 不对称性；另一种与步速相关的测量(计时起跳(TUG))；地面反作用力；步态 运动学；步态协调性的测量(步态评估和干预工具)；感觉的测量- 运动障碍(Fugl-Meyer)；功能性步态测量(功能性步态评估)；动态平衡 (MiniBEST测试)。目的2是描述双半球tdcs反应的神经可塑性脑改变的特征。 结合步态训练。观察指标为：1)同侧皮质脊髓兴奋性(运动诱发 潜在募集曲线(MEP-RC)，2)大脑半球间兴奋性的不对称性(双侧MEP-RC比率)，3) 双侧初级运动区之间的功能连接(静息状态功能磁共振 成像(RS-fMRI))。目标3是确定预测步态改善的因素。 训练。我们将评估步速变化与偏瘫患者单肢站立之间的关系。 结构和功能储备的持续时间和基线评估(根据皮质脊髓束病变 负荷、临床损害、功能连通性)和tdcs诱导的电流密度模型。重要意义： 这项研究将解决VA患者群体的一个重要问题。我们将第一次进行测试 双侧大脑半球TDCs能否加强慢性卒中患者的步态训练并评估神经可塑性 这种治疗方法涉及的机制。TDCS与高效的基于VR的步态训练相结合 一种新的治疗方法，由有希望的初步数据驱动，并由 多学科专业知识。

Current rehabilitation methods fail to restore normal gait for many stroke survivors leading to dependence on others, recurrent falls, limitations in community ambulation and poor quality of life. The main objective of this study is to test both efficacy and neurophysiological mechanisms of a novel approach to treat persistent gait deficits after stroke with a combination of simultaneous non-invasive brain stimulation with transcranial Direct Current Stimulation (tDCS) and gait training. Rationale: Peripherally directed gait therapies are driven by functional brain changes. tDCS has been shown to enhance functional brain changes during rehabilitation and improve outcomes. Its ease of use and safety makes tDCS an ideal technology to pair with simultaneous gait training methods. Upper limb studies showed that 10-session bihemispheric tDCS in combination with movement therapy produced clinically meaningful improvement compared with minor changes after therapy alone. We conducted pilot studies that demonstrated both feasibility and tolerability of the proposed intervention. Our first single-session crossover pilot study demonstrated a potential benefit of tDCS combined with gait training compared with gait therapy alone. Our second 10-session pilot study showed feasibility of the intervention and demonstrated clinical improvements. The next important step is to test it in a randomized control study. We will use a bihemispheric tDCS montage that can address a key adaptive neuroplastic mechanism involved in post-stroke motor recovery, that is rebalancing interhemispheric interaction by 1) facilitation of the residual ipsilesional motor output pathways for the lower extremity and 2) suppression of transcallosal inhibition from the contralesional motor regions. Study Design: We will enroll 50 chronic stroke subjects (>6 months) with gait deficits. Subjects will be randomized to 10 sessions of either active tDCS+gait training or sham tDCS+gait training. Gait training will be accomplished in the treadmill-based Virtual Reality environment targeting longer single limb stance with the paretic limb. Aim 1 is to determine whether the combination of simultaneous tDCS and gait training produces greater improvement in gait performance compared to gait training alone. The primary outcome measure will be both gait speed as measured by 10- Meter Walk test (TMWT) and paretic single limb stance duration. Secondary outcome measures will assess various components of gait-related functional domains and will include the following: spatiotemporal gait asymmetry; another gait-speed-related measure (Timed Up and Go (TUG)); Ground Reaction Force; gait kinematics; a measure of gait coordination (Gait Assessment and Intervention Tool); a measure of sensory- motor impairment (Fugl-Meyer); a functional gait measure (Functional Gait Assessment); and dynamic balance (miniBEST test). Aim 2 is to characterize the neuroplastic brain changes in response to bihemispheric tDCS combined with gait training. Outcome measures are 1) ipsilateral corticospinal excitability (motor evoked potential recruitment curve (MEP-rc)),2) asymmetry of interhemispheric excitability (bilateral MEP-rc ratio), 3) functional connectivity between bilateral primary motor regions (resting state functional Magnetic Resonance Imaging (rs-fMRI)). Aim 3 is to identify factors that predict gait improvement in response to tDCS with gait training. We will evaluate the relationship between changes in gait speed and paretic single limb stance duration and baseline assessment of structural and functional reserve (according to corticospinal tract lesion load, clinical impairment, functional connectivity) and tDCS induced current density modeling. Significance: This study will address an important problem for the VA patient population. We will test for the first time whether bihemispheric tDCS can enhance gait training in chronic stroke and evaluate neuroplastic mechanisms involved in this therapeutic approach. Combination of tDCS and efficient VR-based gait training is a novel therapeutic approach that is being driven by promising preliminary data and supported by multidisciplinary expertise.