Transcranial Direct Current Stimulation and Robotic Training in Chronic Stroke

描述（由申请人提供）：运动技能训练和经颅直流电刺激（tDCS）已分别显示可改变人类皮质兴奋性并增强运动功能。它们的组合对于增强中风患者的运动恢复是有吸引力的，这是目前全球正在进行大量研究的领域。我们以前曾提出，经颅直流电刺激（tDCS）作为一种补充治疗工具，在物理神经康复的成功可能取决于一个更精确的知识的情况下，这两种技术的相互作用，以及随后的行为结果。为了测试这一点，我们应用tDCS与常规参数（极性，位置，强度和持续时间），但操纵应用程序的时间与一个简单的机器人运动练习任务，在偏瘫患者的受影响的肌肉。我们展示了时间的深刻影响。我们发现，在一个会话的实践中的性能改善是不同的影响，根据应用程序的时间tDCS。仅20分钟的机器人视觉训练，导致运动速度优先增加而不损失准确性。在任何时间点应用tDCS都消除了这种效果，但当在训练前应用tDCS时，这种效果被平滑度的改善所取代。运动平稳性与运动学习的更高级阶段相关，并且与功能临床量表具有高度相关性。我们首次表明，tDCS应用的时机具有功能意义，在训练之前应用tDCS可能有利于自愿行为，并且tDCS效应可能不仅仅是训练效应的添加剂，而是可能改变训练效应的性质。我们在一项随机对照临床试验中单独报告了12周以上的上肢机器人训练可以改善慢性中风患者的临床功能。根据我们对tDCS和机器人训练的研究结果，我们假设在tDCS之前重复进行相同的机器人训练，会导致比单独进行机器人训练更大的持续和功能变化。在拟定的训练研究中，66例稳定的慢性卒中患者将在机器人上肢训练前随机接受假或真实的tDCS，并将在3个水平的变化进行评估：（i）临床，（ii）运动学和（iii）神经生理学。我们将确定临床功能是否可以通过tDCS机器人训练、运动的精确运动学方面以及作为功能改善基础的皮质生理学变化来改善和维持。

DESCRIPTION (provided by applicant): Motor skill training and transcranial direct current stimulation (tDCS) have separately been shown to alter cortical excitability and enhance motor function in humans. Their combination is appealing for augmenting motor recovery in stroke patients, and this is an area presently under heavy investigation globally. We had previously proposed that the success of transcranial direct current stimulation (tDCS) as a complementary therapeutic tool in physical neurorehabilitation may be contingent upon a more precise knowledge of the circumstances under which the two techniques interact, and the subsequent behavioral outcome. To test this we applied tDCS with conventional parameters (polarity, location, intensity and duration), but manipulated the timing of application in relation to a simple robotic motor practice task, in affected muscles of hemiplegic patients. We showed a profound effect of timing. We showed that performance improvement over one session of practice was differentially affected by tDCS depending on the timing of application. 20 mins of robotic visuomotor training only, led to a preferential increase in movement speed without a loss of accuracy. tDCS applied at any of the timings obliterated this effect, yet when tDCS was applied before training, the effect was substituted for an improvement in smoothness. Movement smoothness is associated with more advanced stages of motor learning and has high correlation with functional clinical scales. We showed for the first time that the timing of tDCS application has functional significance, that tDCS applied prior to training can be beneficial for voluntary behavior, and that tDCS effects may not simply be additive to training effects, but may change the nature of the training effect. We have separately reported in a randomized-controlled clinical trial, that upperlimb robotic training alone over 12 weeks can improve clinical function of chronic stroke patients. Based on our results with tDCS and robotic training, we hypothesize that the same repeated sessions of robotic training, but preceded by tDCS, would lead to a sustained and functional change greater than robotic training alone. In the proposed training study, 66 stable chronic stroke patients will be randomized to receive sham or real tDCS prior to robotic upperlimb training, and will be assessed at 3 levels of change: (i) clinical, (ii) kinematic, and (iii) neurophysiologic. We will determine if clinical function can be improved and sustained with tDCS-robotic training, the precise kinematic aspects of movement, and cortical physiology changes that underlie functional improvements.