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• W4292319783 abstract "HomeStrokeVol. 53, No. 10Home-Based Transcranial Direct Current Stimulation: Are We There Yet? Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBHome-Based Transcranial Direct Current Stimulation: Are We There Yet? Kyrana Tsapkini Kyrana TsapkiniKyrana Tsapkini Correspondence to: Kyrana Tsapkini, PhD, Department of Cognitive Science, Johns Hopkins School of Medicine, 600 N. Wolfe St, Phipps 4-446, Baltimore, MD 21287-7613. Email E-mail Address: [email protected] https://orcid.org/0000-0001-6020-5532 Department of Neurology (K.T.), Johns Hopkins School of Medicine, Baltimore MD. Department of Cognitive Science (K.T.), Johns Hopkins School of Medicine, Baltimore MD. Search for more papers by this author Originally published17 Aug 2022https://doi.org/10.1161/STROKEAHA.122.040113Stroke. 2022;53:3002–3003This article is a commentary on the followingHome-Based Transcranial Direct Current Stimulation to Enhance Cognition in Stroke: Randomized Controlled TrialOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 17, 2022: Ahead of Print This editorial addresses the article by Ko et al,1 published in Stroke, on the effectiveness of home transcranial direct current stimulation (tDCS) as an adjunct for previously shown effective in-home computerized cognition treatment for poststroke cognitive rehabilitation.2 Previous studies, among which the largest is Fridriksson et al’s3 study of nonfutility in the use of tDCS in poststroke language rehabilitation (2018),3 have advocated for further investigation of tDCS applications in poststroke rehabilitation, and the present study is a worthy sequel. This is the first effectiveness study that adds to previous feasibility studies of home-based, remotely supervised tDCS.4 Several aspects of the paper are of special interest as they are the themes of current research: (1) the focus on cognitive, nonlanguage, deficits poststroke, something that is a new and exciting field of investigation,5 (2) the possibility of transferring neuromodulation (tDCS) from the clinical setting to the home for continuous rehabilitation for chronic conditions, using home-based devices and computerized cognitive training,6 and (3) the application of neuromodulation in long-term and individualized schemes (6 months). The current study addresses all 3 of these prerequisites that would advocate broader application of tDCS for at-home use in poststroke rehabilitation.See related article, p 2992I would like to discuss the design and results of the study, and then critically address concerns about neuromodulation in poststroke rehabilitation.Although the present study is not large (comprising 26 poststroke patients, with either left- (LH) or right-hemisphere (RH) damage who were randomized in 2 arms), it is the largest to-date, double-blind, randomized sham-controlled trial in the field for home-based tDCS and has the longest use of tDCS (4 weeks, 5 sessions per week) along with computerized cognitive rehabilitation. Neuromodulation and language/cognitive rehabilitation studies, in general, frequently face the criticism of not being large, ie, not on the scale of pharmacological studies. This limitation is understandable as these patients usually face a combination of motor, cognitive and emotional challenges on a daily basis. The high compliance (87%) in the study attests to the feasibility of home-based tDCS devices. So, this new study is an important proof-of-concept, albeit preliminary, as the authors admit. But is feasibility accompanied by effectiveness for nonlanguage cognitive rehabilitation? The preliminary study by Ko et al1 provide an answer: “yes, under certain conditions.”Probably the most important findings of the study are that tDCS is more beneficial on a global cognitive measure, such as the Montreal Cognitive Assessment for patients with moderate rather than mild impairments, and for those with LH rather than RH stroke. Are these differences important? The question of who will improve is an important one, not only in poststroke rehabilitation but also in rehabilitation of other neurological diseases. Unfocused populations and confounding patient conditions are among the main reasons that large trials may fail. Therefore, it is imperative to fine-tune the targeted population in clinical trials, and the findings of the present study provide key insights in this direction.With regard to the finding that patients with moderate impairment benefited more from tDCS than those with mild improvement, one could claim that this would be expected. The relative merits and limitations of methods to measure and quantify improvement continue to challenge the science of rehabilitation. Patients with moderate impairment have more capacity to improve, and it might be easier, for example, to improve 30 degrees in absolute percentage scale from 40 to 70 than from 70 to 100 (a perfect score indicating full recovery). Several methods to quantify individual patient’s improvement have been suggested, such as potential maximal gain,7 which quantifies improvement in percent of remaining potential gain thereby homogenizing the effect of initial performance. Future studies of home-based tDCS should employ several methods to better characterize individual improvements.The novel finding that patients with LH stroke improved more than those with RH stroke after LH tDCS, in combination with the impact of baseline performance on the effect of tDCS, (the latter finding replicating 8), has 2 implications. The first is that patients with LH stroke are more impaired in executive functions (targeted by the treatment) or the Montreal Cognitive Assessment (which measured global cognitive outcome) than are patients with RH stroke, and therefore, they showed more improvement. The second implication is that it is more beneficial to target the compromised (but probably still functioning) areas than noncompromised areas. That is, the LH dorsolateral prefrontal cortex that was targeted by tDCS in both groups was in the compromised hemisphere in patients with LH stroke but in the noncompromised hemisphere in the patients with RH stroke. To resolve this issue, a study would be needed in which patients with LH and RH stroke are matched for the targeted executive functions and Montreal Cognitive Assessment at baseline, and the right DLPFC is targeted for patients with RH stroke. The present results nevertheless confirm the principle of functional targeting (at least for the LH) as advocated by Bikson and Rahman,9 in which only active cells and networks are changed by weak stimulation, namely those that are engaged by the behavioral task.The most important contribution of this recent study is that it allows us to form hypotheses to move forward. To answer the question whether we are ready to implement home-based tDCS, we need larger randomized clinical trials that: (1) target patients with LH stroke with executive functions rehabilitation, and (2) target patients with RH stroke with executive functions rehabilitation and RH stimulation. Such trials should be stratified by symptom severity for both lesion sites and should implement hemisphere-specific language outcomes. Despite the preliminary nature of this study on the efficacy of home-based tDCS, the present study provides new hope for patients with stroke and their families for accessible and continuous rehabilitation of cognitive symptoms.Article InformationAcknowledgmentsThe author has reviewed and approved the submitted document.Sources of FundingDr Tsapkini has been supported by grants from National Institutes of Health (NIH; National Institute of Deafness and Communication Disorders through award R01 DC014475, National Institute of Aging through award R01 AG068881), Johns Hopkins University Science of Learning, Pamela Mars Institute as well as monetary and equipment donations from private donors.Disclosures Dr Tsapkini has no patents or equity to disclose.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page 3003.Correspondence to: Kyrana Tsapkini, PhD, Department of Cognitive Science, Johns Hopkins School of Medicine, 600 N. Wolfe St, Phipps 4-446, Baltimore, MD 21287-7613. Email [email protected].eduReferences1. Ko MH, Yoon JY, Jo YJ, Son MN, Kim DS, Kim GW, Won YH, Park SH, Seo JH, Kim YH. Home-based transcranial direct current stimulation to enhance cognition in stroke: randomized controlled trial.Stroke. 2022; 53:2992–3001. doi: 10.1161/STROKEAHA.121.037629LinkGoogle Scholar2. van de Ven RM, Murre JM, Veltman DJ, Schmand BA. Computer-based cognitive training for executive functions after stroke: a systematic review.Front Hum Neurosci. 2016; 10:150. doi: 10.3389/fnhum.2016.00150CrossrefGoogle Scholar3. Fridriksson J, Rorden C, Elm J, Sen S, George MS, Bonilha L. Transcranial direct current stimulation vs Sham stimulation to treat Aphasia after stroke: a randomized clinical trial.JAMA Neurol. 2018; 75:1470–1476. doi: 10.1001/jamaneurol.2018.2287CrossrefGoogle Scholar4. Palm U, Kumpf U, Behler N, Wulf L, Kirsch B, Wörsching J, Keeser D, Hasan A, Padberg F. Home use, remotely supervised, and remotely controlled transcranial direct current stimulation: a systematic review of the available evidence.Neuromodulation. 2018; 21:323–333. doi: 10.1111/ner.12686CrossrefGoogle Scholar5. Hillis AE. Developments in treating the nonmotor symptoms of stroke.Exp Rev Neurother. 2020, 20:567–576. doi: 10.1080/14737175.2020.1763173CrossrefGoogle Scholar6. Knotkova H, Clayton A, Stevens M, Riggs A, Charvet LE & Bikson M. Home-based patient-delivered remotely supervised transcranial direct current stimulation.Knotkova H, Nitsche M, Bikson M, Woods A (eds) In: Practical Guide to Transcranial Direct Current Stimulation. Springer, Cham; 2019:379–405.Google Scholar7. Kristinsson S, Basilakos A, Elm J, Spell LA, Bonilha L, Rorden C, den Ouden DB, Cassarly C, Sen S, Hillis AE, et al. Individualized response to semantic versus phonological aphasia therapies in stroke.Brain Commun. 2021; 3:fcab17. doi: 10.1093/braincomms/fcab174CrossrefGoogle Scholar8. de Aguiar V, Paolazzi CL, Miceli G. tDCS in post-stroke aphasia: the role of stimulation parameters, behavioral treatment and patient characteristics.Cortex. 2015; 63:296–316. doi: 10.1016/j.cortex.2014.08.015CrossrefGoogle Scholar9. Bikson M, Rahman A. Origins of specificity during tDCS: anatomical, activity-selective, and input-bias mechanisms.Front Hum Neurosci. 2013; 7:688. doi: 10.3389/fnhum.2013.00688CrossrefGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesHome-Based Transcranial Direct Current Stimulation to Enhance Cognition in Stroke: Randomized Controlled TrialMyoung-Hwan Ko, et al. Stroke. 2022;53:2992-3001 October 2022Vol 53, Issue 10 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.122.040113PMID: 35975665 Originally publishedAugust 17, 2022 Keywordsstroke rehabilitationlanguageEditorialstranscranial direct current stimulationcognitionPDF download Advertisement SubjectsCognitive ImpairmentNeurostimulation" @default.
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