Dual-tDCS Enhances Online Motor Skill Learning and Long-Term Retention in Chronic Stroke Patients.

BACKGROUND: Since motor learning is a key component for stroke recovery, enhancing motor skill learning is a crucial challenge for neurorehabilitation. Transcranial direct current stimulation (tDCS) is a promising approach for improving motor learning. The aim of this trial was to test the hypothesis that dual-tDCS applied bilaterally over the primary motor cortices (M1) improves online motor skill learning with the paretic hand and its long-term retention. METHODS: Eighteen chronic stroke patients participated in a randomized, cross-over, placebo-controlled, double bind trial. During separate sessions, dual-tDCS or sham dual-tDCS was applied over 30 min while stroke patients learned a complex visuomotor skill with the paretic hand: using a computer mouse to move a pointer along a complex circuit as quickly and accurately as possible. A learning index involving the evolution of the speed/accuracy trade-off was calculated. Performance of the motor skill was measured at baseline, after intervention and 1 week later. RESULTS: After sham dual-tDCS, eight patients showed performance worsening. In contrast, dual-tDCS enhanced the amount and speed of online motor skill learning compared to sham (p < 0.001) in all patients; this superiority was maintained throughout the hour following. The speed/accuracy trade-off was shifted more consistently after dual-tDCS (n = 10) than after sham (n = 3). More importantly, 1 week later, online enhancement under dual-tDCS had translated into superior long-term retention (+44%) compared to sham (+4%). The improvement generalized to a new untrained circuit and to digital dexterity. CONCLUSION: A single-session of dual-tDCS, applied while stroke patients trained with the paretic hand significantly enhanced online motor skill learning both quantitatively and qualitatively, leading to successful long-term retention and generalization. The combination of motor skill learning and dual-tDCS is promising for improving post-stroke neurorehabilitation.

Organisation of inhospital acute stroke care and minimum criteria for stroke care units. Recommendations of the Belgian Stroke Council.

There is ample evidence from randomized trials that for patients with stroke, stroke unit care is superior to care in general medical or neurological wards. This evidence, which has been adopted by international guidelines has to be implemented into daily stroke care. This consensus document prepared by the Belgian Stroke Council provides a set of minimum criteria to meet international standards for stroke care. It is intended to provide help in the creation of stroke units in centers who do not currently have one and to provide a benchmark for centres already having organised stroke care.

Role of the ipsilateral primary motor cortex in controlling the timing of hand muscle recruitment.

The precise contribution of the ipsilateral primary motor cortex (iM1) to hand movements remains controversial. To address this issue, we elicited transient virtual lesions of iM1 by means of transcranial magnetic stimulation (TMS) in healthy subjects performing either a grip-lift task or a step-tracking task with their right dominant hand. We found that, irrespective of the task, a virtual lesion of iM1 altered the timing of the muscle recruitment. In the grip-lift task, this led to a less coordinated sequence of grip and lift movements and in the step-tracking task, to a perturbation of the movement trajectory. In the step-tracking task, we have demonstrated that disrupting iM1 activity may, depending on the TMS delay, either advance or delay the muscle recruitment. The present study suggests that iM1 plays a critical role in hand movements by contributing to the setting of the muscle recruitment timing, most likely through either inhibitory or facilitatory transcallosal influences onto the contralateral M1 (cM1). iM1 would therefore contribute to shape precisely the muscular command originating from cM1.

Long-latency motor evoked potentials in congenital hemiplegia.

OBJECTIVE: To investigate long-latency motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation in congenital hemiplegia (CH) and to seek for correlation with paretic hand movement deficits. METHODS: MEPs were recorded from the first dorsal interosseous of both hands in 12 CH patients and 12 age-matched controls; dexterity and upper limb function were quantitatively assessed in both groups. RESULTS: In CH patients, long-latency MEPs, occurring much later than the commonly reported MEPs, were frequently observed in the paretic and non-paretic hands. Four distinct groups of long-latency MEPs were found, each cluster being identified by its mean latency, namely 35, 85, 160 and 225 ms. The residual dexterity of the paretic hand was correlated with the presence of contralateral MEPs with a 20 and 225 ms latency and was negatively correlated with ipsilateral MEPs, irrespective of their latency. In controls, only few MEPs with a latency of 225 ms were found in 4 out of 12 subjects. CONCLUSIONS: The pattern of MEPs found in CH patients differs dramatically from that reported in adult stroke patients, suggesting that long-latency MEPs are a rather distinctive consequence of early corticospinal lesions. The hypothesis that a given cluster of long-latency MEPs is mediated by a particular pathway appears very unlikely. Rather, we suggest that an exacerbation of cortical and/or spinal excitability is at the origin of these long-latency MEPs.

[Plasticity of motor maps in primates: recent advances and therapeutical perspectives]. / Plasticité des aires motrices corticales: progrès récents et perspectives thérapeutiques.

In the past decade, there have been considerable advances in understanding the neuronal bases of sensory and motor map reorganisation in adults and it is now clear that cortical representations are not invariant and stable, but rather, are dynamic and can continuously be modified. In human subjects, substantial advances in this field have been possible because of the spectacular development of non-invasive imaging and brain stimulation techniques. This review addresses specific questions about the capacity of motor maps in adult primates, including man, to change in response to behaviourally relevant experiences or as a result of central or peripheral lesion. The first part of this review deals with recent progress in understanding the role of the primary motor cortex (M1) in both motor control and cognition. The organisation and function of multiple "non-primary" motor areas located rostrally to the primary motor cortex and in the cingulate cortex are also discussed. This review then focuses on advances made in understanding motor cortex plasticity in different conditions. Firstly, since representations in M1 have been shown to change after motor learning, the contribution of M1 in motor learning has been insinuated; arguments against and in favour of this view are discussed. In addition, data suggesting that intracortical circuitry of M1 may play a role in map reorganisation following motor learning are also evaluated. Secondly, a large body of evidence from both animal and human observations is reviewed that confirms that M1 representations can also be altered as a result of changes in availability of effectors or following sensory deprivation. The mechanisms underlying such a plasticity of cortical maps following peripheral lesions are increasingly well understood. Thirdly, we discuss data showing that a corticospinal system lesion can lead to a complete reorganisation of the area allocated to the hand representation in the primary motor cortex or to a reorganization of the whole network of motor areas responsible for voluntary movements. As a conclusion, therapeutical perspectives that result from a better understanding of those various mechanisms responsible for motor map plasticity are briefly discussed.

Event-related TMS over the right posterior parietal cortex induces ipsilateral visuo-spatial interference.

The right posterior parietal cortex (PPC) is implicated in visuo-spatial processing, as illustrated by patients with visuo-spatial neglect, but the precise time-course of its contribution is still an open question. In the present study we assessed whether single-pulse transcranial magnetic stimulation (TMS) can interfere with the performance of normal subjects in a standard visuo-spatial task. Participants had to perform a landmark task while TMS was applied over the right PPC, the homologue region in the left hemisphere or the right primary motor cortex. Stimulation was time-locked to the stimulus presentation with a stimulus onset asynchrony (SOA) varying between 50 and 200 ms. Our results indicate that TMS interfered mainly with the visuo-spatial task when applied over the right PPC at an early stage (50 ms post-stimulus). The interference effect of single-pulse TMS in the present visuo-spatial processing is revealed by a processing cost for ipsilateral targets. These results are in agreement with neuropsychological and brain imaging studies showing a right hemispheric dominance in visuo-spatial processing but add crucial information about the time-course of visuo-spatial processing within the right PPC.