Bi-hemispheric transcranial direct current stimulation for upper-limb hemiparesis in acute stroke: a randomized, double-blind, sham-controlled trial.

BACKGROUND AND PURPOSE: Neuromodulation is a promising approach to increasing motor recovery in stroke; however, to date, there is a scarcity of evidence documenting the clinical potential of transcranial direct current stimulation (tDCS) administered in the acute phase of stroke. The present study aims to examine the clinical effects of a treatment involving the application of tDCS in the acute stage post-stroke. METHODS: This was a randomized, double-blind, sham-controlled trial. A cohort of 32 stroke patients with severe motor impairment underwent 5 days of treatment with real or sham bi-hemispheric tDCS over the motor cortex. During the treatment, tDCS was applied twice per day (two daily applications each of 15 min), starting 48 to 72 h after stroke onset. RESULTS: We found statistically significant improvements after both real and sham tDCS treatments in primary (hand grip strength, Motricity Index) and secondary (National Institutes of Health Stroke Scale score, Barthel Index) outcomes. Patients receiving real tDCS showed a larger improvement of upper-limb muscle strength at the end of treatment phase; this advantage was no longer present after 6 months. CONCLUSIONS: Transcranial direct current stimulation may be used to accelerate the rate of upper-limb motor recovery during the spontaneous recovery period.

Motivation and attention following hemispheric stroke.

Spatial neglect (SN) is an extremely common disorder of attention; it is most frequently a consequence of stroke, especially to the right cerebral hemisphere. The current view of SN is that it is not a unitary deficit but a multicomponent syndrome. Crucially, it has been repeatedly shown that it has a considerable negative impact on rehabilitation outcome. Although a number of behavioral and pharmacological therapies have been developed, none of these appears to be applicable to all patients with SN or has proved unequivocally successful in clinical trials. One potential avenue for therapeutic intervention in neglect relates to the interaction between motivation and attention. A number of investigators, including ourselves, have observed a possible motivational component to the syndrome and showed that motivational stimulation can temporarily improve attention in patients with SN. In this chapter we review previous work looking at how motivation can modulate attention in healthy individuals and how it may be affected by neurological disease before discussing how motivational impairments may contribute to neglect, and how motivation has been used to modulate neglect. In the final section, we present recent experimental work examining how reward interacts with attentional biases in patients with SN. In this study, we adapted the classic Landmark task to explore the mechanisms behind the effect of reward in SN, and found that centrally located stimuli that were explicitly associated with reward appeared to improve neglect and reduce rightward bias. Our results suggest that positive motivation, in the form of anticipated monetary reward, may influence attentional bias via more general mechanisms, such as alerting and task engagement, rather than directly increasing salience of items in contralesional space. We conclude by discussing how motivation might be practically integrated into the rehabilitation of patients with this debilitating disorder.