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

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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.	中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国各类主要脑血管病诊断要点 2019. 中华神经科杂志, 2019, 52(9): 710-715.
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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, 吕艳玲, 等. 经颅直流电刺激对脑卒中患者上肢运动功能障碍的疗效. 中国康复理论与实践, 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, Bösl 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, 陈创, 丁政, 等. 经颅直流电刺激应用于脑卒中上肢和手功能康复的研究进展. 中华物理医学与康复杂志, 2017, 39(5): 391-396.
19.	汤从智, 蔡倩, 杨玺, 等. 经颅直流电刺激介入任务导向性训练对脑卒中患者上肢功能障碍的影响. 中华物理医学与康复杂志, 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, 黄东锋, 梁斌. 虚拟现实训练对亚急性期脑卒中患者上肢运动功能的影响. 中国康复医学杂志, 2019, 34(9): 1049-1053.
23.	刘远文, 潘翠环, 叶正茂, 等. 虚拟现实机器手对脑卒中患者手运动功能及日常生活活动的效果. 中国康复理论与实践, 2017, 23(1): 19-22.
24.	翟艺, 徐秀林. 基于虚拟现实技术的上肢康复训练系统发展现状. 中国康复理论与实践, 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.	贾杰. 创新与循证并进中枢与外周交融—ISP RM 2016 上肢及手功能康复研究专题报道. 中华物理医学与康复杂志, 2016, 38(7): 550-554.
29.	贾杰. “中枢-外周-中枢”闭环康复—脑卒中后手功能康复新理念. 中国康复医学杂志, 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, Ayaş 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. 中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国各类主要脑血管病诊断要点 2019. 中华神经科杂志, 2019, 52(9): 710-715.
10. 王玉龙. 康复功能评定学. 3 版. 北京: 人民卫生出版社, 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, 吕艳玲, 等. 经颅直流电刺激对脑卒中患者上肢运动功能障碍的疗效. 中国康复理论与实践, 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, Bösl 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, 陈创, 丁政, 等. 经颅直流电刺激应用于脑卒中上肢和手功能康复的研究进展. 中华物理医学与康复杂志, 2017, 39(5): 391-396.
19. 汤从智, 蔡倩, 杨玺, 等. 经颅直流电刺激介入任务导向性训练对脑卒中患者上肢功能障碍的影响. 中华物理医学与康复杂志, 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, 黄东锋, 梁斌. 虚拟现实训练对亚急性期脑卒中患者上肢运动功能的影响. 中国康复医学杂志, 2019, 34(9): 1049-1053.
23. 刘远文, 潘翠环, 叶正茂, 等. 虚拟现实机器手对脑卒中患者手运动功能及日常生活活动的效果. 中国康复理论与实践, 2017, 23(1): 19-22.
24. 翟艺, 徐秀林. 基于虚拟现实技术的上肢康复训练系统发展现状. 中国康复理论与实践, 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. 贾杰. 创新与循证并进中枢与外周交融—ISP RM 2016 上肢及手功能康复研究专题报道. 中华物理医学与康复杂志, 2016, 38(7): 550-554.
29. 贾杰. “中枢-外周-中枢”闭环康复—脑卒中后手功能康复新理念. 中国康复医学杂志, 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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