NHMRC Early Career Research Fellow, The University of South Australia
Characteristics of the brain can help tailor therapies in stroke
Stroke is a global leading cause of disability requiring extensive and lengthy periods of rehabilitation aimed at restoring function. Therapies which help people recovery following stroke utilise the brains unique ability to learn and change - known as neuroplasticity. Function of the damaged brain area is taken over by nearby brain regions and can help compensate for the injury. However, despite this intriguing ability of the brain, recovery following stroke is often incomplete, with survivors forced to life with lifelong impairments such as arm or leg weakness, difficulty with speech or cognitive issues. Treatments which improve the level of recovery by enhancing the neuroplasticity process would be highly valued by patients, family members and health service providers as it may provide a more complete and efficient recovery.
One approach is to stimulate the brain tissue with an electric current. Several studies have shown that brain stimulation is able to increase brain activity and improve recovery following stroke. However, this approach does not appear to be one-size-fits-all with recent studies reporting a high level of variability in response to brain stimulation. As a result, brain stimulation does not provide a reliable and consistent response across all stroke survivors and this has limited any possibility of this treatment being used clinically. It is perhaps unreasonable to assume that one therapy approach could be used as a ‘magic bullet’ and be suitable for every individual since each brain is unique as a result of different life experiences, genetics or characteristics of the injury.
My research investigates neural characteristics following stroke that predict response to brain stimulation therapy. A series of studies will be presented at the World Congress for Neurorehabilitation which will show that brain connectivity following stroke can predict, with a high level of accuracy, who will respond to brain stimulation and who won’t. The significance of this work lies in the opportunity to harness the full potential of brain stimulation by specifically targeting the patients who will benefit most from this therapy. The ability to do so could assist clinical uptake of brain stimulation as a treatment and assist those patients who are desperate for a greater level of recovery. This body of work is an exciting and novel advance in brain stimulation therapy for stroke and has potential to accelerate clinical translation of this treatment.
Abstract: Motor skill learning is critical in post-stroke motor recovery, but little is known about its underlying neural substrates. Recently, using a new visuomotor skill learning paradigm involving a speed/accuracy trade-off in healthy individuals we identified three subpopulations based on their behavioral trajectories: fitters (in whom improvement in speed or accuracy coincided with deterioration in the other parameter), shifters (in whom speed and/or accuracy improved without degradation of the other parameter), and non-learners. We aimed to identify the neural substrates underlying the first stages of motor skill learning in chronic hemiparetic stroke patients and to determine whether specific neural substrates were recruited in shifters versus fitters. During functional magnetic resonance imaging (fMRI), 23 patients learned the visuomotor skill with their paretic upper limb. In the whole-group analysis, correlation between activation and motor skill learning was restricted to the dorsal prefrontal cortex of the damaged hemisphere (DLPFCdamh: r = -0.82) and the dorsal premotor cortex (PMddamh: r = 0.70); the correlations was much lesser (-0.16 < r > 0.25) in the other regions of interest. In a subgroup analysis, significant activation was restricted to bilateral posterior parietal cortices of the fitters and did not correlate with motor skill learning. Conversely, in shifters significant activation occurred in the primary sensorimotor cortexdamh and supplementary motor areadamh and in bilateral PMd where activation changes correlated significantly with motor skill learning (r = 0.91). Finally, resting-state activity acquired before learning showed a higher functional connectivity in the salience network of shifters compared with fitters (qFDR < 0.05). These data suggest a neuroplastic compensatory reorganization of brain activity underlying the first stages of motor skill learning with the paretic upper limb in chronic hemiparetic stroke patients, with a key role of bilateral PMd.
Pub.: 20 Jun '15, Pinned: 27 Sep '17
Abstract: The assessment of neuroplasticity after stroke through functional magnetic resonance imaging (fMRI) analysis is a developing field where the objective is to better understand the neural process of recovery and to better target rehabilitation interventions. The challenge in this population stems from the large amount of individual spatial variability and the need to summarize entire brain maps by generating simple, yet discriminating features to highlight differences in functional connectivity. Independent vector analysis (IVA) has been shown to provide superior performance in preserving subject variability when compared with widely used methods such as group independent component analysis. Hence, in this paper, graph-theoretical (GT) analysis is applied to IVA-generated components to effectively exploit the individual subjects' connectivity to produce discriminative features. The analysis is performed on fMRI data collected from individuals with chronic stroke both before and after a 6-week arm and hand rehabilitation intervention. Resulting GT features are shown to capture connectivity changes that are not evident through direct comparison of the group t-maps. The GT features revealed increased small worldness across components and greater centrality in key motor networks as a result of the intervention, suggesting improved efficiency in neural communication. Clinically, these results bring forth new possibilities as a means to observe the neural processes underlying improvements in motor function.
Pub.: 25 Jun '15, Pinned: 27 Sep '17
Abstract: Brain areas within the motor system interact directly or indirectly during motor-imagery and motor-execution tasks. These interactions and their functionality can change following stroke and recovery. How brain network interactions reorganize and recover their functionality during recovery and treatment following stroke are not well understood. To contribute to answering these questions, we recorded blood oxygenation-level dependent (BOLD) functional magnetic resonance imaging (fMRI) signals from 10 stroke survivors and evaluated dynamical causal modeling (DCM)-based effective connectivity among three motor areas: primary motor cortex (M1), pre-motor cortex (PMC) and supplementary motor area (SMA), during motor-imagery and motor-execution tasks. We compared the connectivity between affected and unaffected hemispheres before and after mental practice and combined mental practice and physical therapy as treatments. The treatment (intervention) period varied in length between 14 to 51 days but all patients received the same dose of 60 h of treatment. Using Bayesian model selection (BMS) approach in the DCM approach, we found that, after intervention, the same network dominated during motor-imagery and motor-execution tasks but modulatory parameters suggested a suppressive influence of SM A on M1 during the motor-imagery task whereas the influence of SM A on M1 was unrestricted during the motor-execution task. We found that the intervention caused a reorganization of the network during both tasks for unaffected as well as for the affected hemisphere. Using Bayesian model averaging (BMA) approach, we found that the intervention improved the regional connectivity among the motor areas during both the tasks. The connectivity between PMC and M1 was stronger in motor-imagery tasks whereas the connectivity from PMC to M1, SM A to M1 dominated in motor-execution tasks. There was significant behavioral improvement (p = 0.001) in sensation and motor movements because of the intervention as reflected by behavioral Fugl-Meyer (FMA) measures, which were significantly correlated (p = 0.05) with a subset of connectivity. These findings suggest that PMC and M1 play a crucial role during motor-imagery as well as during motor-execution task. In addition, M1 causes more exchange of causal information among motor areas during a motor-execution task than during a motor-imagery task due to its interaction with SM A. This study expands our understanding of motor network involved during two different tasks, which are commonly used during rehabilitation following stroke. A clear understanding of the effective connectivity networks leads to a better treatment in helping stroke survivors regain motor ability.
Pub.: 04 Aug '15, Pinned: 27 Sep '17
Abstract: Non-invasive stimulation of the brain using transcranial direct current stimulation (tDCS) during motor rehabilitation can improve the recovery of movements in individuals with stroke. However, the neural substrates that underlie the clinical improvements are not well understood. In this proof-of-principle open-label pilot study, five individuals with stroke received 10 sessions of tDCS while undergoing usual care physical/occupational therapy for the arm and hand. Motor impairment as indexed by the Upper Extremity Fugl Meyer assessment was significantly reduced after the intervention. Resting state fMRI connectivity increased between ipsilesional motor cortex and contralesional premotor cortex after the intervention. These findings provide preliminary evidence that the neural underpinnings of tDCS coupled with rehabilitation exercises, may be mediated by interactions between motor and premotor cortex. The latter, of which has been shown to play an important role in the recovery of movements post-stroke. Our data suggest premotor cortex could be tested as a target region for non-invasive brain-stimulation to enhance connectivity between regions that might be beneficial for stroke motor recovery.
Pub.: 17 Mar '16, Pinned: 27 Sep '17
Abstract: Recent developments in functional magnetic resonance imaging (fMRI) have catalyzed a new field of translational neuroscience. Using fMRI to monitor the aspects of task-related changes in neural activation or brain connectivity, investigators can offer feedback of simple or complex neural signals/patterns back to the participant on a quasireal-time basis [real-time-fMRI-based neurofeedback (rt-fMRI-NF)]. Here, we introduce some background methodology of the new developments in this field and give a perspective on how they may be used in neurorehabilitation in the future.The development of rt-fMRI-NF has been used to promote self-regulation of activity in several brain regions and networks. In addition, and unlike other noninvasive techniques, rt-fMRI-NF can access specific subcortical regions and in principle any region that can be monitored using fMRI including the cerebellum, brainstem and spinal cord. In Parkinson's disease and stroke, rt-fMRI-NF has been demonstrated to alter neural activity after the self-regulation training was completed and to modify specific behaviours.Future exploitation of rt-fMRI-NF could be used to induce neuroplasticity in brain networks that are involved in certain neurological conditions. However, currently, the use of rt-fMRI-NF in randomized, controlled clinical trials is in its infancy.
Pub.: 24 May '16, Pinned: 27 Sep '17
Abstract: Recent research has demonstrated the importance of global changes to the functional organization of brain network following stroke. Resting functional magnetic resonance imaging (R-fMRI) is a non-invasive tool that enables the measurement of functional connectivity (FC) across the entire brain while placing minimal demands on the subject. For these reasons, it is a uniquely appealing tool for studying the distant effects of stroke. However, R-fMRI studies rely on a number of premises that cannot be assumed without careful validation in the context of stroke. Here, we describe strategies to identify and mitigate confounds specific to R-fMRI research in cerebrovascular disease. Five main topics are discussed: (a) achieving adequate co-registration of lesioned brains, (b) identifying and removing hemodynamic lags in resting BOLD, (c) identifying other vascular disruptions that affect the resting BOLD signal, (d) selecting an appropriate control cohort, and (e) acquiring sufficient fMRI data to reliably identify FC changes. For each topic, we provide guidelines for steps to improve the interpretability and reproducibility of FC-stroke research. We include a table of confounds and approaches to identify and mitigate each. Our recommendations extend to any research using R-fMRI to study diseases that might alter cerebrovascular flow and dynamics or brain anatomy.
Pub.: 26 May '17, Pinned: 27 Sep '17
Abstract: Cerebral plasticity-inducing approaches like repetitive transcranial magnetic stimulation (rTMS) are of high interest in situations where reorganization of neural networks can be observed, e.g., after stroke. However, an increasing number of studies suggest that improvements in motor performance of the stroke-affected hand following modulation of primary motor cortex (M1) excitability by rTMS shows a high interindividual variability. We here tested the hypothesis that in stroke patients the interindividual variability of behavioral response to excitatory rTMS is related to interindividual differences in network connectivity of the stimulated region. Chronic stroke patients (n = 14) and healthy controls (n = 12) were scanned with functional magnetic resonance imaging (fMRI) while performing a simple hand motor task. Dynamic causal modeling (DCM) was used to investigate effective connectivity of key motor regions. On two different days after the fMRI experiment, patients received either intermittent theta-burst stimulation (iTBS) over ipsilesional M1 or control stimulation over the parieto-occipital cortex. Motor performance and TMS parameters of cortical excitability were measured before and after iTBS. Our results revealed that patients with better motor performance of the affected hand showed stronger endogenous coupling between supplemental motor area (SMA) and M1 before starting the iTBS intervention. Applying iTBS to ipsilesional M1 significantly increased ipsilesional M1 excitability and decreased contralesional M1 excitability as compared to control stimulation. Individual behavioral improvements following iTBS specifically correlated with neural coupling strengths in the stimulated hemisphere prior to stimulation, especially for connections targeting the stimulated M1. Combining endogenous connectivity and behavioral parameters explained 82% of the variance in hand motor performance observed after iTBS. In conclusion, the data suggest that the individual susceptibility to iTBS after stroke is influenced by interindividual differences in motor network connectivity of the lesioned hemisphere.
Pub.: 28 Jun '17, Pinned: 27 Sep '17
Abstract: Stroke is a leading cause of adult motor disability. Despite recent progress, recovery of motor function after stroke is usually incomplete. This double blind, Sham-controlled, crossover study was designed to test the hypothesis that non-invasive stimulation of the motor cortex could improve motor function in the paretic hand of patients with chronic stroke. Hand function was measured using the Jebsen-Taylor Hand Function Test (JTT), a widely used, well validated test for functional motor assessment that reflects activities of daily living. JTT measured in the paretic hand improved significantly with non-invasive transcranial direct current stimulation (tDCS), but not with Sham, an effect that outlasted the stimulation period, was present in every single patient tested and that correlated with an increment in motor cortical excitability within the affected hemisphere, expressed as increased recruitment curves (RC) and reduced short-interval intracortical inhibition. These results document a beneficial effect of non-invasive cortical stimulation on a set of hand functions that mimic activities of daily living in the paretic hand of patients with chronic stroke, and suggest that this interventional strategy in combination with customary rehabilitative treatments may play an adjuvant role in neurorehabilitation.
Pub.: 07 Jan '05, Pinned: 27 Sep '17
Abstract: Transcranial direct current stimulation is a painless, non-invasive brain stimulation technique that allows one to induce polarity-specific excitability changes in the human brain. Here, we investigated, for the first time in a 'proof of principle' study, the behavioural effect of transcranial direct current stimulation on visuospatial attention in both healthy controls and stroke patients suffering from left visuospatial neglect. We applied anodal, cathoP:dal or sham transcranial direct current stimulation (57 microA/cm(2), 10 min) to the left or right posterior parietal cortex. Using a visual detection task in a group of right-handed healthy individuals (n = 20), we observed that transcranial direct current stimulation enhanced or impaired performance depending on stimulation parameters (i.e. current polarity) and stimulated hemisphere. These results are in good accordance with classic models of reciprocal interhemispheric competition ('rivalry'). In a second experiment, we investigated the potential of transcranial direct current stimulation to ameliorate left visuospatial neglect (n = 10). Interestingly, both the inhibitory effect of cathodal transcranial direct current stimulation applied over the unlesioned posterior parietal cortex and the facilitatory effect of anodal transcranial direct current stimulation applied over the lesioned posterior parietal cortex reduced symptoms of visuospatial neglect. Taken together, our findings suggest that transcranial direct current stimulation applied over the posterior parietal cortex can be used to modulate visuospatial processing and that this effect is exerted by influencing interhemispheric reciprocal networks. These novel findings also suggest that a transcranial direct current stimulation-induced modulation of interhemispheric parietal balance may be used clinically to ameliorate visuospatial attention deficits in neglect patients.
Pub.: 17 Jun '09, Pinned: 27 Sep '17
Abstract: Transcranial direct current stimulation, a form of non-invasive brain stimulation, is showing increasing promise as an adjunct therapy in rehabilitation following stroke. However, although significant behavioural improvements have been reported in proof-of-principle studies, the underlying mechanisms are poorly understood. The rationale for transcranial direct current stimulation as therapy for stroke is that therapeutic stimulation paradigms increase activity in ipsilesional motor cortical areas, but this has not previously been directly tested for conventional electrode placements. This study was performed to test directly whether increases in ipsilesional cortical activation with transcranial direct current stimulation are associated with behavioural improvements in chronic stroke patients. Patients at least 6 months post-first stroke participated in a behavioural experiment (n = 13) or a functional magnetic resonance imaging experiment (n = 11), each investigating the effects of three stimulation conditions in separate sessions: anodal stimulation to the ipsilesional hemisphere; cathodal stimulation to the contralesional hemisphere; and sham stimulation. Anodal (facilitatory) stimulation to the ipsilesional hemisphere led to significant improvements (5-10%) in response times with the affected hand in both experiments. This improvement was associated with an increase in movement-related cortical activity in the stimulated primary motor cortex and functionally interconnected regions. Cathodal (inhibitory) stimulation to the contralesional hemisphere led to a functional improvement only when compared with sham stimulation. We show for the first time that the significant behavioural improvements produced by anodal stimulation to the ipsilesional hemisphere are associated with a functionally relevant increase in activity within the ipsilesional primary motor cortex in patients with a wide range of disabilities following stroke.
Pub.: 14 Dec '11, Pinned: 27 Sep '17
Abstract: Motor skill learning is one of the key components of motor function recovery after stroke, especially recovery driven by neurorehabilitation. Transcranial direct current stimulation can enhance neurorehabilitation and motor skill learning in stroke patients. However, the neural mechanisms underlying the retention of stimulation-enhanced motor skill learning involving a paretic upper limb have not been resolved. These neural substrates were explored by means of functional magnetic resonance imaging. Nineteen chronic hemiparetic stroke patients participated in a double-blind, cross-over randomized, sham-controlled experiment with two series. Each series consisted of two sessions: (i) an intervention session during which dual transcranial direct current stimulation or sham was applied during motor skill learning with the paretic upper limb; and (ii) an imaging session 1 week later, during which the patients performed the learned motor skill. The motor skill learning task, called the 'circuit game', involves a speed/accuracy trade-off and consists of moving a pointer controlled by a computer mouse along a complex circuit as quickly and accurately as possible. Relative to the sham series, dual transcranial direct current stimulation applied bilaterally over the primary motor cortex during motor skill learning with the paretic upper limb resulted in (i) enhanced online motor skill learning; (ii) enhanced 1-week retention; and (iii) superior transfer of performance improvement to an untrained task. The 1-week retention's enhancement driven by the intervention was associated with a trend towards normalization of the brain activation pattern during performance of the learned motor skill relative to the sham series. A similar trend towards normalization relative to sham was observed during performance of a simple, untrained task without a speed/accuracy constraint, despite a lack of behavioural difference between the dual transcranial direct current stimulation and sham series. Finally, dual transcranial direct current stimulation applied during the first session enhanced continued learning with the paretic limb 1 week later, relative to the sham series. This lasting behavioural enhancement was associated with more efficient recruitment of the motor skill learning network, that is, focused activation on the motor-premotor areas in the damaged hemisphere, especially on the dorsal premotor cortex. Dual transcranial direct current stimulation applied during motor skill learning with a paretic upper limb resulted in prolonged shaping of brain activation, which supported behavioural enhancements in stroke patients.
Pub.: 10 Dec '14, Pinned: 27 Sep '17
Abstract: Transcranial Direct Current Stimulation (tDCS) is a neuromodulatory technique that delivers a low-intensity, direct current to cortical areas with the purpose of modulating underlying brain activity. Recent studies have reported inconsistencies in tDCS outcomes. The underlying assumption of many tDCS studies has been that replication of electrode montage equates to replicating stimulation conditions. It is possible however that anatomical difference between subjects, as well as inherent inaccuracies in montage placement, could affect current flow to targeted areas. The hypothesis that stimulation of a defined brain region will be stable under small displacements was tested. Approach: Initially, we compared the total simulated current flowing through ten specific brain areas for four commonly used tDCS montages: F3-Fp2, C3-Fp2, Fp1-F4, and P3-P4 using the software tool COMETS. The effect of a slight (~1cm in each of four directions) anode displacement on the simulated regional current density for each of the four tDCS montages was then determined. Current flow was calculated and compared through 10 segmented brain areas to determine the effect of montage type and displacement. The regional currents, as well as the localised current densities, were compared with the original electrode location, for each of these new positions. Results: Recommendations for montages that maximise stimulation current for the ten brain regions are considered. We noted that the extent to which stimulation is affected by electrode displacement varies depending on both area and montage type. The F3-Fp2 montage was found to be the least stable with up to 38% change in average current density in the left frontal lobe while the Fp1-F4 montage was found to the most stable exhibiting only 1% change when electrodes were displaced. Significance: These results indicate that even relatively small changes in stimulation electrode placement appear to result in surprisingly large changes in current densities and distribution.
Pub.: 20 Sep '17, Pinned: 27 Sep '17
Abstract: Physical training is known to be an effective intervention to improve sensorimotor impairments after stroke. However, the link between brain plastic changes, assessed by transcranial magnetic stimulation (TMS), and sensorimotor recovery in response to physical training is still misunderstood. We systematically reviewed reports of randomized controlled trials (RCTs) involving the use of TMS over the primary motor cortex (M1) to probe brain plasticity after upper-limb physical training interventions in people with stroke.We searched 5 databases for articles published up to October 2016, with additional studies identified by hand-searching. RCTs had to investigate pre/post-intervention changes in at least one TMS outcome measure. Two independent raters assessed the eligibility of potential studies and reviewed the selected articles' quality by using 2 critical appraisal scales.In total, 14 reports of RCTs (pooled participants=358; mean 26±12 per study) met the selection criteria. Overall, 11 studies detected plastic changes with TMS in the presence of clinical improvements after training, and these changes were more often detected in the affected hemisphere by using map area and motor evoked potential (MEP) latency outcome measures. Plastic changes mostly pointed to increased M1/corticospinal excitability and potential interhemispheric rebalancing of M1 excitability, despite sometimes controversial results among studies. Also, the strength of the review observations was affected by heterogeneous TMS methods and upper-limb interventions across studies as well as several sources of bias within the selected studies.The current evidence encourages the use of TMS outcome measures, especially MEP latency and map area to investigate plastic changes in the brain after upper-limb physical training post-stroke. However, more studies involving rigorous and standardized TMS procedures are needed to validate these observations.
Pub.: 06 Jun '17, Pinned: 27 Sep '17
Abstract: Repetitive peripheral magnetic stimulation (rPMS) is a form of therapy that creates painless stimulation of deep muscle structures to improve motor function in people with physical impairment from brain or nerve disorders. Use of rPMS for people after stroke has been identified as a feasible approach to improve activities of daily living and functional ability. However, no systematic reviews have assessed the findings of available trials. The effect and safety of this intervention for people after stroke currently remain uncertain.To assess the effect of rPMS for improving activities of daily living and functional ability in people after stroke.We searched the Cochrane Stroke Group Trials Register (August 2016), the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (August 2016), MEDLINE Ovid (November 2016), Embase Ovid (August 2016), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) in Ebsco (August 2016), PsycINFO Ovid (August 2016), the Allied and Complementary Medicine Database (AMED) Ovid (August 2016), Occupational Therapy Systematic Evaluation of Evidence (OTseeker) (August 2016), the Physiotherapy Evidence Database (PEDro) (October 2016), and ICHUSHI Web (October 2016). We also searched five ongoing trial registries, screened reference lists, and contacted experts in the field. We placed no restrictions on the language or date of publication when searching the electronic databases.We included randomised controlled trials (RCTs) conducted to assess the therapeutic effect of rPMS for people after stroke. Comparisons eligible for inclusion were (1) active rPMS only compared with 'sham' rPMS (a very weak form of stimulation or a sound only); (2) active rPMS only compared with no intervention; (3) active rPMS plus rehabilitation compared with sham rPMS plus rehabilitation; and (4) active rPMS plus rehabilitation compared with rehabilitation only.Two review authors independently assessed studies for inclusion. The same review authors assessed methods and risk of bias and extracted data. We contacted trial authors to ask for unpublished information if necessary. We resolved all disagreements through discussion.We included three trials (two RCTs and one cross-over trial) involving 121 participants. Blinding of participants and physicians was well reported in all trials, and overall risk of bias was low. We found no clear effect of rPMS on activities of daily living at the end of treatment (mean difference (MD) -3.00, 95% confidence interval (CI) -16.35 to 10.35; low-quality evidence) and at the end of follow-up (MD -2.00, 95% CI -14.86 to 10.86; low-quality evidence). Investigators in one study with 63 participants observed no statistical difference in improvement of upper limb function at the end of treatment (MD 2.00, 95% CI -4.91 to 8.91) and at the end of follow-up (MD 4.00, 95% CI -2.92 to 10.92). One trial with 18 participants showed that rPMS treatment was not associated with improved muscle strength at the end of treatment (MD 3.00, 95% CI -2.44 to 8.44). Another study reported a significant decrease in spasticity of the elbow at the end of follow-up (MD -0.48, 95% CI -0.93 to -0.03). No studies provided information on lower limb function and death. Based on the GRADE approach, we judged the certainty of evidence related to the primary outcome as low owing to the small sample size of one study.Available trials provided inadequate evidence to permit any conclusions about routine use of rPMS for people after stroke. Additional trials with large sample sizes are needed to determine an appropriate rPMS protocol as well as long-term effects. We identified three ongoing trials and will include these trials in the next review update.
Pub.: 24 Jun '17, Pinned: 27 Sep '17
Abstract: Combining repetitive transcranial magnetic stimulation (rTMS) with brain-computer interface (BCI) training can address motor impairment after stroke by down-regulating exaggerated inhibition from the contralesional hemisphere and encouraging ipsilesional activation. The objective was to evaluate the efficacy of combined rTMS+BCI, compared to sham rTMS+BCI, on motor recovery after stroke in subjects with lasting motor paresis.Three stroke subjects approximately one year post-stroke participated in three weeks of combined rTMS (real or sham) and BCI, followed by three weeks of BCI alone. Behavioral and electrophysiological differences were evaluated at baseline, after three weeks, and after six weeks of treatment.Motor improvements were observed in both real rTMS+BCI and sham groups, but only the former showed significant alterations in inter-hemispheric inhibition in the desired direction and increased relative ipsilesional cortical activation from fMRI. In addition, significant improvements in BCI performance over time and adequate control of the virtual reality BCI paradigm were observed only in the former group.When combined, the results highlight the feasibility and efficacy of combined rTMS+BCI for motor recovery, demonstrated by increased ipsilesional motor activity and improvements in behavioral function for the real rTMS+BCI condition in particular. Our findings also demonstrate the utility of BCI training alone, as demonstrated by behavioral improvements for the sham rTMS+BCI condition. This study is the first to evaluate combined rTMS and BCI training for motor rehabilitation and provides a foundation for continued work to evaluate the potential of both rTMS and virtual reality BCI training for motor recovery after stroke.
Pub.: 16 Sep '17, Pinned: 27 Sep '17
Abstract: Stroke remains a leading cause of adult disability, and the recovery of motor function after stroke is crucial for the patient to regain independence. However, making accurate predictions of a patient's motor recovery and outcome is difficult when based on clinical assessment alone. Clinical assessment of motor impairment within a few days of stroke can help to predict subsequent recovery, while neurophysiological and neuroimaging biomarkers of corticomotor structure and function can help to predict both motor recovery and motor outcome after stroke. The combination of biomarkers can provide clinically useful information when planning the personalised rehabilitation of a patient. These biomarkers can also be used for patient selection and stratification in trials investigating rehabilitation interventions that are initiated early after stroke. Ongoing multicentre trials that incorporate motor biomarkers could help to bring their use into routine clinical practice.
Pub.: 19 Sep '17, Pinned: 27 Sep '17
Abstract: Transcranial alternating current stimulation (tACS) is used to modulate brain oscillations to measure changes in cognitive function. It is only since recently that brain activity in human subjects during tACS can be investigated. The present study aims to investigate the phase relationship between the external tACS signal and concurrent brain activity. Subjects were stimulated with tACS at individual alpha frequency during eyes open and eyes closed resting states. Electrodes were placed at Cz and Oz, which should affect parieto-occipital areas most strongly. Source space magnetoencephalography (MEG) data were used to estimate phase coherence between tACS and brain activity. Phase coherence was significantly increased in areas in the occipital pole in eyes open resting state only. The lag between tACS and brain responses showed considerable inter-individual variability. In conclusion, tACS at individual alpha frequency entrains brain activity in visual cortices. Interestingly, this effect is state dependent and is clearly observed with eyes open but only to a lesser extent with eyes closed.
Pub.: 03 Jun '16, Pinned: 27 Sep '17
Abstract: To select a movement, specific neuronal populations controlling particular features of that movement need to be activated, whereas other populations are downregulated. The selective (dis)inhibition of cortical sensorimotor populations is governed by rhythmic neural activity in the alpha (8-12 Hz) and beta (15-25 Hz) frequency range. However, it is unclear whether and how these rhythms contribute independently to motor behavior. Building on a recent dissociation of the sensorimotor alpha- and beta-band rhythms, we test the hypothesis that the beta-band rhythm governs the disinhibition of task-relevant neuronal populations, whereas the alpha-band rhythm suppresses neurons that may interfere with task performance. Cortical alpha- and beta-band rhythms were manipulated with transcranial alternating current stimulation (tACS) while human participants selected how to grasp an object. Stimulation was applied at either 10 or 20 Hz and was imposed on the sensorimotor cortex contralaterally or ipsilaterally to the grasping hand. In line with task-induced changes in endogenous spectral power, the effect of the tACS intervention depended on the frequency and site of stimulation. Whereas tACS stimulation generally increased movement selection times, 10 Hz stimulation led to relatively faster selection times when applied to the hemisphere ipsilateral to the grasping hand, compared with other stimulation conditions. These effects occurred selectively when multiple movements were considered. These observations functionally differentiate the causal contribution of alpha- and beta-band oscillations to movement selection. The findings suggest that sensorimotor beta-band rhythms disinhibit task-relevant populations, whereas alpha-band rhythms inhibit neuronal populations that could interfere with movement selection.This study shows dissociable effects of 10 Hz and 20 Hz tACS on the duration of movement selection. These observations have two elements of general relevance. First, the finding that alpha- and beta-band oscillations contribute independently to movement selection provides insight in how oscillations orchestrate motor behavior, which is key to understand movement selection deficits in neurodegenerative disorders. Second, the findings highlight the potential of 10 Hz stimulation as a neurophysiologically grounded intervention to enhance human performance. In particular, this intervention can potentially be exploited to boost rehabilitation after neural damage by targeting the unaffected hemisphere.
Pub.: 19 Aug '16, Pinned: 27 Sep '17
Abstract: Transcranial alternating current stimulation (tACS) can entrain ongoing brain oscillations and modulate the motor system in a frequency-dependent manner. Recent animal studies have demonstrated that the phase of a sinusoidal current also has an important role in modulation of neuronal activity. However, the phase effects of tACS on the human motor system are largely unknown. Here, we systematically investigated the effects of tACS phase and frequency on the primary motor cortex (M1) by using motor evoked potentials (MEPs) with transcranial magnetic stimulation (TMS). First, we compared the phase effects (90°, 180°, 270° or 360°) of 10 and 20 Hz tACS on MEPs. The 20 Hz tACS significantly increased M1 excitability compared with the 10 Hz tACS at 90° phase only. Second, we studied the 90° phase effect on MEPs at different tACS frequencies (5, 10, 20 or 40 Hz). The 20 vs. 10 Hz difference was again observed, but the 90° phase in 5 and 40 Hz tACS did not influence M1 excitability. Third, the 90° phase effects of 10 and 20 Hz tACS were compared with sham stimulation. The 90° phase of 20 Hz tACS enhanced MEP amplitudes compared with sham stimulation, but there was no significant effect of 10 Hz tACS. Taken together, we assume that the differential 90° phase effects on 20 Hz and 10 Hz tACS can be attributed to the neural synchronization modulated by tACS. Our results further underline that phase and frequency are the important factors in the effects of tACS on M1 excitability.
Pub.: 09 Sep '16, Pinned: 27 Sep '17
Abstract: Despite recent success in analyzing brain oscillations recorded during transcranial alternating current stimulation (tACS), the field still requires further research to establish standards in artifact removal methods. This includes taking a step back from the removal of the tACS artifact and thoroughly characterizing the to-be-removed artifact. A recent study by Noury et al. (2016) contributed importantly to this endeavour by showing the existence of nonlinear artefacts in the tACS signal as seen by MEG and EEG. Unfortunately however this paper conveys the message that current artifact removal attempts have failed altogether and that—based on these available tools—brain oscillations recorded during tACS cannot be analyzed using MEG and EEG. Here we want to balance this overly pessimistic conclusion: In-depth reanalyses of our own data and phantom-head measurements indicate that nonlinearities can occur, but only when technical limits of the stimulator are reached. As such they are part of the “real” stimulation and not a specific MEG analysis problem. Future tACS studies should consider these technical limits to avoid any nonlinear modulations of the tACS artifact. We conclude that even with current approaches, brain oscillations recorded during tACS can be meaningfully studied in many practical cases.
Pub.: 22 Nov '16, Pinned: 27 Sep '17
Abstract: Gamma and beta oscillations are routinely observed in motor-related brain circuits during movement preparation and execution. Entrainment of gamma or beta oscillations via transcranial alternating current stimulation (tACS) over primary motor cortex (M1) has opposite effects on motor performance, suggesting a causal role of these brain rhythms for motor control. However, it is largely unknown which brain mechanisms characterize these changes in motor performance brought about by tACS. In particular, it is unclear whether these effects result from brain activity changes only in the targeted areas or within functionally connected brain circuits. Here we investigated this issue by applying gamma-band and beta-band tACS over M1 in healthy humans during a visuomotor task and concurrent functional magnetic resonance imaging (fMRI). Gamma tACS indeed improved both the velocity and acceleration of visually triggered movements, compared with both beta tACS and sham stimulation. Beta tACS induced a numerical decrease in velocity compared with sham stimulation, but this was not statistically significant. Crucially, gamma tACS induced motor performance enhancements correlated with changed BOLD activity in the stimulated M1. Moreover, we found frequency- and task-specific neural compensatory activity modulations in the dorsomedial prefrontal cortex (dmPFC), suggesting a key regulatory role of this region in motor performance. Connectivity analyses revealed that the dmPFC interacted functionally with M1 and with regions within the executive motor system. These results suggest a role of the dmPFC for motor control and show that tACS-induced behavioral changes not only result from activity modulations underneath the stimulation electrode but also reflect compensatory modulation within connected and functionally related brain networks. More generally, our results illustrate how combined tACS-fMRI can be used to resolve the causal link between cortical rhythms, brain systems, and behavior.Recent research has suggested a causal role for gamma oscillations during movement preparation and execution. Here we combine transcranial alternating current stimulation (tACS) with functional magnetic resonance imaging (fMRI) to identify the neural mechanisms that accompany motor performance enhancements triggered by gamma tACS over the primary motor cortex. We show that the tACS-induced motor performance enhancements correlate with changed neural activity in the stimulated area and modulate, in a frequency- and task-specific manner, the neural activity in the dorsomedial prefrontal cortex. This suggests a regulatory role of this region for motor control. More generally, we show that combined tACS-fMRI can elucidate the causal link between brain oscillations, neural systems, and behavior.
Pub.: 25 Nov '16, Pinned: 27 Sep '17
Abstract: We previously showed that brief application of 2 mA (peak-to-peak) transcranial currents alternating at 10 Hz significantly reduces motion adaptation in humans. This is but one of many behavioral studies showing that weak currents applied to the scalp modulate neural processing. Transcranial stimulation has been shown to improve perception, learning, and a range of clinical symptoms. Few studies, however, have measured the neural consequences of transcranial current stimulation. We capitalized on the strong link between motion perception and neural activity in the middle temporal (MT) area of the macaque monkey to study the neural mechanisms that underlie the behavioral consequences of transcranial alternating current stimulation (tACS). First, we observed that 2 mA currents generated substantial intracranial fields, which were much stronger in the stimulated hemisphere (0.12 V/m) than on the opposite side of the brain (0.03 V/m). Second, we found that brief application of tACS at 10 Hz reduced spike-frequency adaptation of MT neurons and led to a broad-band increase in the power-spectrum of local field potentials. Together these findings provide a direct demonstration that weak electric fields applied to the scalp significantly affect neural processing in the primate brain and that this includes a hitherto unknown mechanism that attenuates sensory adaptation.Transcranial stimulation has been claimed to improve perception, learning, and a range of clinical symptoms. Little is known, however, how transcranial current stimulation generates such effects and the search for better stimulation protocols proceeds largely by trial and error. We investigated, for the first time, the neural consequences of stimulation in the monkey brain. We found that even brief application of alternating current stimulation reduced the effects of adaptation on single neuron firing rates and local field potentials; this mechanistic insight explains previous behavioral findings and suggest a novel way to modulate neural information processing using transcranial currents. In addition, by developing an animal model to help understand transcranial stimulation, this study will aid the rational design of stimulation protocols for the treatment of mental illnesses, and the improvement of perception and learning.
Pub.: 01 Feb '17, Pinned: 27 Sep '17
Abstract: Transcranial alternating current stimulation (tACS) is widely used to entrain or modulate brain oscillations in order to investigate causal relationships between oscillations and cognition.
Pub.: 30 Apr '17, Pinned: 27 Sep '17
Abstract: Multitasking is associated with the generation of stimulus-locked theta (4-7 Hz) oscillations arising from prefrontal cortex (PFC). Transcranial alternating current stimulation (tACS) is a non-invasive brain stimulation technique that influences endogenous brain oscillations. Here, we investigate whether applying alternating current stimulation within the theta frequency band would affect multitasking performance, and explore tACS effects on neurophysiological measures. Brief runs of bilateral PFC theta-tACS were applied while participants were engaged in a multitasking paradigm accompanied by electroencephalography (EEG) data collection. Unlike an active control group, a tACS stimulation group showed enhancement of multitasking performance after a 90-minute session (F1,35 = 6.63, p = 0.01, ηp2 = 0.16; effect size = 0.96), coupled with significant modulation of posterior beta (13-30 Hz) activities (F1,32 = 7.66, p = 0.009, ηp2 = 0.19; effect size = 0.96). Across participant regression analyses indicated that those participants with greater increases in frontal theta, alpha and beta oscillations exhibited greater multitasking performance improvements. These results indicate frontal theta-tACS generates benefits on multitasking performance accompanied by widespread neuronal oscillatory changes, and suggests that future tACS studies with extended treatments are worth exploring as promising tools for cognitive enhancement.
Pub.: 01 Jun '17, Pinned: 27 Sep '17
Abstract: Introduction: Transcranial alternating current stimulation (tACS) is emerging as an interventional tool to modulate different functions of the brain, potentially by interacting with intrinsic ongoing neuronal oscillations. Functionally different intrinsic alpha oscillations are found throughout the cortex. Yet it remains unclear whether tACS is capable of specifically modulating the somatosensory mu-rhythm in amplitude. Objectives: We used tACS to modulate mu-alpha oscillations in amplitude. When compared to sham stimulation we expected a modulation of mu-alpha oscillations but not visual alpha oscillations by tACS. Methods: Individual mu-alpha frequencies were determined in 25 participants. Subsequently, blocks of tACS with individual mu-alpha frequency and sham stimulation were applied over primary somatosensory cortex (SI). Electroencephalogram (EEG) was recorded before and after either stimulation or sham. Modulations of mu-alpha and, for control, visual alpha amplitudes were then compared between tACS and sham. Results: Somatosensory mu-alpha oscillations decreased in amplitude after tACS was applied at participants' individual mu-alpha frequency. No changes in amplitude were observed for sham stimulation. Furthermore, visual alpha oscillations were not affected by tACS or sham, respectively. Conclusion: Our results demonstrate the capability of tACS to specifically modulate the targeted somatosensory mu-rhythm when the tACS frequency is tuned to the individual endogenous rhythm and applied over somatosensory areas. Our results are in contrast to previously reported amplitude increases of visual alpha oscillations induced by tACS applied over visual cortex. Our results may point to a specific interaction between our stimulation protocol and the functional architecture of the somatosensory system.
Pub.: 12 Sep '17, Pinned: 27 Sep '17
Abstract: We recently reported that spatial and nonspatial attention deficits in stroke patients with hemispatial neglect are correlated at 2 weeks postonset with widespread alterations of interhemispheric and intrahemispheric functional connectivity (FC) measured with resting-state functional magnetic resonance imaging across multiple brain networks. The mechanisms underlying neglect recovery are largely unknown. In this study, we test the hypothesis that recovery of hemispatial neglect correlates with a return of network connectivity toward a normal pattern, herein defined as "network normalization."We measured attention deficits with a neuropsychological battery and FC in a large cohort of stroke patients at, on average, 2 weeks (n = 99), 3 months (n = 77), and 12 months (n = 64) postonset. The relationship between behavioral improvement and changes in FC was analyzed both in terms of a priori regions and networks known to be abnormal subacutely and in a data-driven manner.Attention deficit recovery was mostly complete by 3 months and was significantly correlated with a normalization of abnormal FC across many networks. Improvement of attention deficits, independent of initial severity, was correlated with improvements of previously depressed interhemispheric FC across attention, sensory, and motor networks, and a restoration of the normal anticorrelation between dorsal attention/motor regions and default-mode/frontoparietal regions, particularly in the damaged hemisphere.These results demonstrate that abnormal network connectivity in hemispatial neglect is behaviorally relevant. A return toward normal network interactions, and presumably optimal information processing, is therefore a systems-level mechanism that is associated with improvements of attention over time after focal injury. Ann Neurol 2016.
Pub.: 10 Jun '16, Pinned: 27 Sep '17
Abstract: Deficits following stroke are classically attributed to focal damage, but recent evidence suggests a key role of distributed brain network disruption. We measured resting functional connectivity (FC), lesion topography, and behavior in multiple domains (attention, visual memory, verbal memory, language, motor, and visual) in a cohort of 132 stroke patients, and used machine-learning models to predict neurological impairment in individual subjects. We found that visual memory and verbal memory were better predicted by FC, whereas visual and motor impairments were better predicted by lesion topography. Attention and language deficits were well predicted by both. Next, we identified a general pattern of physiological network dysfunction consisting of decrease of interhemispheric integration and intrahemispheric segregation, which strongly related to behavioral impairment in multiple domains. Network-specific patterns of dysfunction predicted specific behavioral deficits, and loss of interhemispheric communication across a set of regions was associated with impairment across multiple behavioral domains. These results link key organizational features of brain networks to brain-behavior relationships in stroke.
Pub.: 13 Jul '16, Pinned: 27 Sep '17
Abstract: Background After cerebral ischemia, disruption and subsequent reorganization of functional connections occur both locally and remote to the lesion. Recently, complexity of brain connectivity has been described using graph theory, a mathematical approach that depicts important properties of complex systems by quantifying topologies of network representations. Functional and dynamic changes of brain connectivity can be reliably analyzed via electroencephalography (EEG) recordings even when they are not yet reflected in structural changes of connections. Objective We tested whether and how ischemic stroke in the acute stage may determine changes in small-worldness of cortical networks as measured by cortical sources of EEG. Methods Graph characteristics of EEG of 30 consecutive stroke patients in acute stage (no more than 5 days after the event) were examined. Connectivity analysis was performed using eLORETA in both hemispheres. Results Network rearrangements were mainly detected in delta, theta, and alpha bands when patients were compared with healthy subjects. In delta and alpha bands similar findings were observed in both hemispheres regardless of the side of ischemic lesion: bilaterally decreased small-worldness in the delta band and bilaterally increased small-worldness in the alpha2 band. In the theta band, bilaterally decreased small-worldness was observed only in patients with stroke in the left hemisphere. Conclusions After an acute stroke, brain cortex rearranges its network connections diffusely, in a frequency-dependent modality probably in order to face the new anatomical and functional frame.
Pub.: 12 Aug '16, Pinned: 27 Sep '17
Abstract: Li Wang, Jingna Zhang, Ye Zhang, Linqiong Sang, Rubing Yan, Chen Liu, Mingguo Qiu Digital Medicine 2016 2(2):72-79 Objective: The objective of this study was to analyze the functional brain activation in acute stroke patients during motor execution (ME) and motor imagery (MI) and to discuss the association between damaged brain structure and impaired brain function in stroke patients. Methods: The functional magnetic resonance imaging technique was used to observe activation of the brain during ME/MI of the upper limbs in 12 acute stroke patients (with the left brain damage) and 12 healthy controls. Results: During ME, the stroke patients appeared to be activated more strongly than the healthy controls in the ipsilateral primary motor areas. The MI of the affected hand in the stroke patients was not significantly different from that of the healthy hand. The nonmotor areas, the angular gyrus, and the fusiform gyrus were also activated during ME/MI. Conclusion: Structural damage in the brain is associated with the activation of brain function in acute stroke patients. Ipsilateral inhibition is reduced in stroke patients during ME and the damaged brain needs to recruit more brain areas to complete the desired action due to motion difficulties resulting from brain damage. The participation of nonmotor brain areas in ME/MI indicates that cortical reorganization may contribute to the restoration of motor function following stroke. MI can be used to improve injured brain areas, helping with the rehabilitation of stroke patients.
Pub.: 30 Aug '16, Pinned: 27 Sep '17
Abstract: After stroke, the less affected upper-limb shows slight but substantial and longterm motor deficits . Kinematically, this is reflected by an increased segmentation of movements. Here, we aim to define how these changes in behavior are accompanied by changes in brain activation.Twenty-one sub-acute post-stroke patients with a first-ever unilateral ischemic stroke of the middle cerebral artery participated in this study twice: within the first 6 weeks post-stroke and after 6 weeks of rehabilitation. Participants performed a self-paced flexion/extion of the elbow with the less-affected upper-limb. Its kinematic features were analysed and related to the observed fMRI activations during task execution. Results were compared with those of 12 healthy controls with no history of neurological or orthopeadic disease.Initially, post-stroke patients showed an extended activation of the primary sensorimotor cortex, with an additional recruitment of both the middle temporal and rolandic opercularis areas. After intervention, the rolandic opercularis which is involved in movement visualization  remained activated.Movements of the less affected upper-limb were not only atypical in motor outcome, but were also abnormally controlled. This indicates a disturbance of the bihemispheric motor network that is marked by: - an overload of the non-damaged hemisphere; - the employment of alternative control strategies to ensure optimal task execution.
Pub.: 28 Sep '16, Pinned: 27 Sep '17
Abstract: Recent studies using resting-state functional magnetic resonance imaging (rs-fMRI) demonstrated that changes in functional connectivity (FC) after stroke correlate with recovery. The aim of this study was to explore whether combining motor learning to dual transcranial direct current stimulation (dual-tDCS, applied over both primary motor cortices (M1)) modulated FC in stroke patients. Twenty-two chronic hemiparetic stroke patients participated in a baseline rs-fMRI session. One week later, dual-tDCS/sham was applied during motor skill learning (intervention session); one week later, the retention session started with the acquisition of a run of rs-fMRI imaging. The intervention + retention sessions were performed once with dual-tDCS and once with sham in a randomised, cross-over, placebo-controlled, double-blind design. A whole-brain independent component analysis based ANOVA demonstrated no changes between baseline and sham sessions in the somatomotor network, whereas a FC increase was observed one week after dual-tDCS compared to baseline (qFDR < 0.05, t(63) = 4.15). A seed-based analysis confirmed specific stimulation-driven changes within a network of motor and premotor regions in both hemispheres. At baseline and one week after sham, the strongest FC was observed between the M1 and dorsal premotor cortex (PMd) of the undamaged hemisphere. In contrast, one week after dual-tDCS, the strongest FC was found between the M1 and PMd of the damaged hemisphere. Thus, a single session of dual-tDCS combined with motor skill learning increases FC in the somatomotor network of chronic stroke patients for one week.
Pub.: 09 Nov '16, Pinned: 27 Sep '17
Abstract: The primary motor cortex (M1) is often abnormally recruited in stroke patients with motor disabilities. However, little is known about the alterations in the causal connectivity of M1 following stroke. The purpose of the present study was to investigate whether the effective connectivity of the ipsilesional M1 is disturbed in stroke patients who show different outcomes in hand motor function. 23 patients with left-hemisphere subcortical stroke were selected and divided into two subgroups: partially paralyzed hands (PPH) and completely paralyzed hands (CPH). Further, 24 matched healthy controls (HCs) were recruited. A voxel-wise Granger causality analysis (GCA) on the resting-state fMRI data between the ipsilesional M1 and the whole brain was performed to explore differences between the three groups. Our results showed that the influence from the frontoparietal cortices to ipsilesional M1 was diminished in both stroke subgroups and the influence from ipsilesional M1 to the sensorimotor cortices decreased greater in the CPH group than in the PPH group. Moreover, compared with the PPH group, the decreased influence from ipsilesional M1 to the contralesional cerebellum and from the contralesional superior parietal lobe to ipsilesional M1 were observed in the CPH group, and their GCA values were positively correlated with the FMA scores; Conversely, the increased influence from ipsilesional M1 to the ipsilesional middle frontal gyrus and middle temporal gyrus were observed, whose GCA values were negatively correlated with the FMA scores. This study suggests that the abnormalities of casual flow in the ipsilesional M1 are related to the severity of stroke-hand dysfunction, providing valuable information to understand the deficits in resting-state effective connectivity of motor execution and the frontoparietal motor control network during brain plasticity following stroke.
Pub.: 16 Nov '16, Pinned: 27 Sep '17
Abstract: In recent years, there has been considerable research interest in the study of brain connectivity using the resting state functional magnetic resonance imaging (rsfMRI). Studies have explored the brain networks and connection between different brain regions. These studies have revealed interesting new findings about the brain mapping as well as important new insights in the overall organization of functional communication in the brain network. In this paper, after a general discussion of brain networks and connectivity imaging, the brain connectivity and resting state networks are described with a focus on rsfMRI imaging in stroke studies. Then, techniques for preprocessing of the rsfMRI for stroke patients are reviewed, followed by brain connectivity processing techniques. Recent research on brain connectivity using rsfMRI is reviewed with an emphasis on stroke studies. The authors hope this paper generates further interest in this emerging area of computational neuroscience with potential applications in rehabilitation of stroke patients.
Pub.: 16 Nov '16, Pinned: 27 Sep '17
Abstract: Publication date: Available online 9 November 2016 Source:Brain Stimulation Author(s): Georgios Naros, Alireza Gharabaghi Background Unlike in healthy controls, sensorimotor β-desynchronization (β-ERD) is compromised in stroke patients, i.e., the more severe the patient's motor impairment, the less β-ERD. This, in turn, provides a target substrate for therapeutic brain self-regulation and neurofeedback. Objective Transcranial alternating current stimulation (tACS) has been shown to modulate brain oscillations during and after stimulation, and may thus facilitate brain self-regulation during neurofeedback interventions. Methods Twenty severely impaired, chronic stroke patients performed kinesthetic motor-imagery while a brain-robot interface transformed β-ERD (17–23 Hz) of the ipsilesional sensorimotor cortex into opening of the paralyzed hand by a robotic orthosis. In a parallel group design, β-tACS (20 Hz, 1.1 mA peak-to-peak amplitude) was applied to the lesioned motor cortex either continuously (c-tACS) before or intermittently (i-tACS) during the intervention. Physiological effects of β-tACS were studied using electroencephalography. The patients' ability for brain self-regulation was captured by neurofeedback performance metrics. Results i-tACS - but not c-tACS - improved the classification accuracy of the neurofeedback intervention in comparison to baseline. This effect was mediated via the increased specificity of the classification, i.e., reduced variance of resting oscillations. Neither i-tACS nor c-tACS had aftereffects following the stimulation period. Conclusion β-tACS may constitute an adjunct neuromodulation technique during neurofeedback-based interventions for stroke rehabilitation.
Pub.: 14 Nov '16, Pinned: 27 Sep '17
Abstract: Several approaches to rehabilitation of the hand following a stroke have emerged over the last two decades. These treatments, including repetitive task practice (RTP), robotically assisted rehabilitation and virtual rehabilitation activities, produce improvements in hand function but have yet to reinstate function to pre-stroke levels-which likely depends on developing the therapies to impact cortical reorganization in a manner that favors or supports recovery. Understanding cortical reorganization that underlies the above interventions is therefore critical to inform how such therapies can be utilized and improved and is the focus of the current investigation. Specifically, we compare neural reorganization elicited in stroke patients participating in two interventions: a hybrid of robot-assisted virtual reality (RAVR) rehabilitation training and a program of RTP training. Ten chronic stroke subjects participated in eight 3-h sessions of RAVR therapy. Another group of nine stroke subjects participated in eight sessions of matched RTP therapy. Functional magnetic resonance imaging (fMRI) data were acquired during paretic hand movement, before and after training. We compared the difference between groups and sessions (before and after training) in terms of BOLD intensity, laterality index of activation in sensorimotor areas, and the effective connectivity between ipsilesional motor cortex (iMC), contralesional motor cortex, ipsilesional primary somatosensory cortex (iS1), ipsilesional ventral premotor area (iPMv), and ipsilesional supplementary motor area. Last, we analyzed the relationship between changes in fMRI data and functional improvement measured by the Jebsen Taylor Hand Function Test (JTHFT), in an attempt to identify how neurophysiological changes are related to motor improvement. Subjects in both groups demonstrated motor recovery after training, but fMRI data revealed RAVR-specific changes in neural reorganization patterns. First, BOLD signal in multiple regions of interest was reduced and re-lateralized to the ipsilesional side. Second, these changes correlated with improvement in JTHFT scores. Our findings suggest that RAVR training may lead to different neurophysiological changes when compared with traditional therapy. This effect may be attributed to the influence that augmented visual and haptic feedback during RAVR training exerts over higher-order somatosensory and visuomotor areas.
Pub.: 21 Sep '17, Pinned: 27 Sep '17
Abstract: Advanced lesion mapping and connectivity analyses are currently the main tools used to understand the mechanisms underlying post-stroke cognitive deficits. However, the factors contributing to pre-stroke architecture of cognitive networks are often ignored, even though they reportedly play a decisive role in the manifestation of cognitive impairment in neurodegeneration. The present review on post-stroke cognitive deficits therefore adopts the concept of brain and cognitive reserve, which was originally developed to account for the individual differences in the course of aging and neurodegenerative diseases. By focusing on spatial neglect, a typical network disorder, it is discussed how individual susceptibility to stroke lesion might explain the reported discrepancies in lesion anatomy, non-spatial deficits and recovery courses. A detailed analysis of the literature reveals that premorbid brain (age, brain atrophy, previous strokes, leukoaraiosis, genetic factors, etc.) and cognitive reserve (IQ, life experience, education, occupation, premorbid cognitive impairment, etc.) greatly impact the brain's capacity for compensation. Furthermore, the interaction between pre-stroke brain/cognitive reserve and the degree of stroke-induced system impairment (e.g., hypoperfusion, lesion load) determines both the extent of neglect symptoms variability and the course of recovery. Premorbid brain/cognitive reserves should thus be considered to: (i) understand the mechanisms of post-stroke cognitive disorders and sufficiently explain their inter-individual variability; (ii) provide a prognosis for cognitive recovery and hence post-stroke dependency; (iii) identify individual targets for cognitive rehabilitation: in the case of reduced brain/cognitive reserve, neglect might occur even with a confined lesion, and non-spatial training of general attentional capacity should represent the main therapeutic target also for treatment of neglect; this might be true also for non-cognitive domains, e.g., motor deficit. This alternative view of how neglect and other cognitive deficits occur and recover promotes discussion about plasticity and recovery to a general rather than a single stroke-based domain, providing more efficiency in recovery research.
Pub.: 05 Jan '17, Pinned: 27 Sep '17
Abstract: Responses to non-invasive brain stimulation are highly variable between subjects. Resting state functional connectivity was investigated as a marker of plasticity induced by anodal transcranial direct current stimulation (tDCS). Twenty-six healthy adults (15 male, 26.4±6.5 years) were tested. Experiment 1 investigated whether functional connectivity could predict modulation of corticospinal excitability following anodal tDCS. Experiment 2 determined test-retest reliability of connectivity measures. Three minutes of electroencephalography was recorded and connectivity was quantified with the debiased weighted phase lag index. Anodal (1mA, 20 minutes) or sham tDCS was applied to the left primary motor cortex (M1), with a change in motor evoked potential amplitude recorded from the right first dorsal interosseous used as a marker of tDCS response. Connectivity in the high beta frequency (20-30 Hz) between an electrode approximating the left M1 (C3) and electrodes overlying the left parietal cortex was a strong predictor of tDCS response (cross validated R(2) =0.69). Similar relationships were observed for alpha (8-13 Hz; R(2) =0.64), theta (4-7 Hz; R(2) = 0.53) and low beta (14-19 Hz; R(2) =0.58) frequencies, however test-retest reliability of connectivity measures was strongest for the high beta frequency model (ICC=0.65; good reliability). Further investigation of the high beta model found that greater connectivity between C3 and a cluster of electrodes approximately overlying the left parietal cortex was associated with stronger responses to anodal (rho=0.61, p=0.03), but not sham tDCS (rho=0.43, p=0.14). Functional connectivity is a strong predictor of the neuroplastic response to tDCS and may be one important characteristic to assist targeted tDCS application. This article is protected by copyright. All rights reserved.
Pub.: 20 Dec '16, Pinned: 27 Sep '17
Abstract: At the present time, there is enormous interest in methods of non-invasive brain stimulation. These interact with ongoing neural activity, mainly in cerebral cortex, and have measureable effects on behaviours in healthy people. More intriguingly, they appear to have effects on synaptic plasticity that persist even after stimulation has ceased. This has led, as might be expected, to the proposal that brain stimulation methods might be therapeutically useful in rehabilitation. The rationale is that physical therapy involves learning new patterns of activity to compensate for those lost to the stroke. Enhanced "plasticity" produced by brain stimulation might increase the ability to learn and enhance therapy. However, if things really were as simple as this, brain stimulation would be on its way to becoming a standard addition to treatment in all departments of rehabilitation. The fact that this has not happened means that something is not quite correct. Is the theory untenable, or are the methods of stimulation suboptimal?
Pub.: 31 Dec '16, Pinned: 27 Sep '17
Abstract: While several studies have shown that focal lesions affect the communication between structurally normal regions of the brain, and that these changes may correlate with behavioural deficits, their impact on brain's information processing capacity is currently unknown. Here we test the hypothesis that focal lesions decrease the brain's information processing capacity, of which changes in functional connectivity may be a measurable correlate. To measure processing capacity, we turned to whole brain computational modelling to estimate the integration and segregation of information in brain networks. First, we measured functional connectivity between different brain areas with resting state functional magnetic resonance imaging in healthy subjects (n = 26), and subjects who had suffered a cortical stroke (n = 36). We then used a whole-brain network model that coupled average excitatory activities of local regions via anatomical connectivity. Model parameters were optimized in each healthy or stroke participant to maximize correlation between model and empirical functional connectivity, so that the model's effective connectivity was a veridical representation of healthy or lesioned brain networks. Subsequently, we calculated two model-based measures: 'integration', a graph theoretical measure obtained from functional connectivity, which measures the connectedness of brain networks, and 'information capacity', an information theoretical measure that cannot be obtained empirically, representative of the segregative ability of brain networks to encode distinct stimuli. We found that both measures were decreased in stroke patients, as compared to healthy controls, particularly at the level of resting-state networks. Furthermore, we found that these measures, especially information capacity, correlate with measures of behavioural impairment and the segregation of resting-state networks empirically measured. This study shows that focal lesions affect the brain's ability to represent stimuli and task states, and that information capacity measured through whole brain models is a theory-driven measure of processing capacity that could be used as a biomarker of injury for outcome prediction or target for rehabilitation intervention.
Pub.: 24 Mar '17, Pinned: 27 Sep '17
Abstract: To support the recovery of disability and the reduced functional capacity influencing the independence of daily life after focal brain lesions like stroke, the application of noninvasive brain stimulation (NIBS) by repetitive transcranial magnetic stimulation or transcranial electric stimulation has been found useful in the last decades. Still, a positive influence on the recovery seems to be restricted to specific subgroups of patients. Therefore, a closer look on individual parameters influencing the recovery course and the effect of NIBS is needed.Neuroimaging studies investigated alterations in neuronal network settings during the recovery process from stroke and can explain a relevant amount of variance in residual motor function. In this regard for instance, the microstructural integrity of the corticospinal tract and its influence on cortical and subcortical functional and structural connectivity alterations shows a relevant impact on individual recovery from the acute to the chronic state.Based on this understanding, a 'one-suits-all' NIBS strategy for clinical application appears insufficient and understanding of therapeutic susceptibility to NIBS gained from structural and functional imaging studies will help to develop patient-tailored NIBS-based interventional strategies towards precision medicine, as a promising future prospective within this field.
Pub.: 27 May '17, Pinned: 27 Sep '17
Abstract: Rehabilitation is the main therapeutic approach for reducing poststroke functional deficits in the affected upper limb; however, significant between-patient variability in rehabilitation efficacy indicates the need to target patients who are likely to have clinically significant improvement after treatment. Many studies have determined robust predictors of recovery and treatment gains and yielded many great results using linear approachs. Evidence has emerged that the nonlinearity is a crucial aspect to study the inter-areal communication in human brains and abnormality of oscillatory activities in the motor system is linked to the pathological states. In this study, we hypothesized that combinations of linear and nonlinear (cross-frequency) network connectivity parameters are favourable biomarkers for stratifying patients for upper limb rehabilitation with increased accuracy. We identified the biomarkers by using 37 prerehabilitation electroencephalogram (EEG) datasets during a movement task through effective connectivity and logistic regression analyses. The predictive power of these biomarkers was then tested by using 16 independent datasets (i.e. construct validation). In addition, 14 right handed healthy subjects were also enrolled for comparisons. The result shows that the beta plus gamma or theta network features provided the best classification accuracy of 92%. The predictive value and the sensitivity of these biomarkers were 81.3% and 90.9%, respectively. Subcortical lesion, the time poststroke and initial Wolf Motor Function Test (WMFT) score were identified as the most significant clinical variables affecting the classification accuracy of this predictive model. Moreover, 12 of 14 normal controls were classified as having favourable recovery. In conclusion, EEG-based linear and nonlinear motor network biomarkers are robust and can help clinical decision making.
Pub.: 15 Jun '17, Pinned: 27 Sep '17
Abstract: Biomarkers derived from neural activity of the brain present a vital tool for the prediction and evaluation of post-stroke motor recovery, as well as for real-time biofeedback opportunities.In order to encapsulate recovery-related reorganization of brain networks into such biomarkers, we have utilized the generalized measure of association (GMA) and graph analyses, which include global and local efficiency, as well as hemispheric interdensity and intradensity. These methods were applied to electroencephalogram (EEG) data recorded during a study of 30 stroke survivors (21 male, mean age 57.9 years, mean stroke duration 22.4 months) undergoing 12 weeks of intensive therapeutic intervention.We observed that decreases of the intradensity of the unaffected hemisphere are correlated (r s =-0.46;p<0.05) with functional recovery, as measured by the upper-extremity portion of the Fugl-Meyer Assessment (FMUE). In addition, high initial values of local efficiency predict greater improvement in FMUE (R (2)=0.16;p<0.05). In a subset of 17 subjects possessing lesions of the cerebral cortex, reductions of global and local efficiency, as well as the intradensity of the unaffected hemisphere are found to be associated with functional improvement (r s =-0.60,-0.66,-0.75;p<0.05). Within the same subgroup, high initial values of global and local efficiency, are predictive of improved recovery (R (2)=0.24,0.25;p<0.05). All significant findings were specific to the 12.5-25 Hz band.These topological measures show promise for prognosis and evaluation of therapeutic outcomes, as well as potential application to BCI-enabled biofeedback.
Pub.: 08 Jul '17, Pinned: 27 Sep '17
Abstract: There is currently a dearth of treatment options for stroke or traumatic brain injury that can restore cognitive and motor function. Regenerative and translational medicine have ushered forth promising new methods for mediating recovery in the central nervous system, the most salient of which are rehabilitation and stem cell therapies that, when combined, result in more pronounced recovery than one approach alone.
Pub.: 18 Jul '17, Pinned: 27 Sep '17