Motor learning guided therapy with and without TDCS for stroke patients

with apraxia of speech : a randomized control trial

Lay Summary:
The current standard of care for rehabilitation of patients with aphasia and apraxia
of speech after stroke is conventional speech and language therapy (SLT). Due to
economic realities on most stroke units, SLT can often not be given with optimal
intensity in the first weeks after the stroke. Developing new adjuvant therapies
which may render SLT sessions more effective is thus one approach to improve
rehabilitation outcomes. Recent studies in post-stroke aphasia have shown that
brain stimulation in patients with chronic aphasia improves recovery from apraxia of
speech.
Transcranial direct current stimulation (tDCS) is a new method to modulate brain
activity (e.g inhibiting contralateral over-activation). Evidence from multiple studies
in sub-acute stroke suggest that these new technique, when applied in conjunction
with conventional SLT, may help to normalize brain activation patterns and might
yield better rehabilitation outcomes than SLT alone. We propose a pilot study to
investigate the safety, feasibility and efficacy of this new non-invasive brain
stimulation method as an adjuvant therapy for subacute post-stroke aphasia with
apraxia of speech.
We will assess if a combination of brain stimulation and speech and language
therapy will improve language recovery. We will quantify language recovery
(expressive and comprehensive skills) using specific tests, commonly used by
speech and language therapists (the apraxia battery for adults).
We will invite patients recently admitted to the stroke unit at Burke Rehabilitation
Hospital, to participate in our research project. Once patients consent to our study
we will randomly assign them to one of two experimental groups. All groups of
patients will be setup to receive 5 sessions of brain stimulation during their usual
rehabilitation sessions. Patients will be aware that they may or may not receive
brain stimulation. One of those groups (treatment groups) will receive brain
stimulation (tDCS), while in the second group, patients will be set up with the
stimulation devices but will not receive real stimulation (placebo group). By
comparing the extent of aphasia recovery between groups, we will determine the
benefits attributable to brain stimulation relative to SLT alone.

Study purpose and rationale

Stroke patients, especially in the subacute stage show increased transcallosal
inhibition resulting from an imbalance between the intact and affected

hemispheres, where the intact hemisphere shows increased excitability while the
affected hemisphere shows decreased excitability (1). This inhibitory activity in the
intact hemisphere seems to interfere with functional language recovery. Noninvasive brain stimulation techniques employing transcranial direct current
stimulation (tDCS) can modify the excitability of neuron pools (2) as measured for
example, by motor evoked potentials (MEP).
Recently, bihemispheric brain stimulation consisting of anodic ipsilesional
stimulation over the left Brocas area and cathodic contralesional stimulation over
the right homologue of Brocas area has been used to modulate mechanisms of
transcallosal inhibition and thus to promote recovery in apraxia of speech in
patients with chronic aphasia (4).
The rationale for utilising tDCS as a complementary therapy in neurorehabilitation is
mainly to decrease the cortical excitability in contralesional regions, which are
presumed to hinder optimal recovery. Current evidence suggests that righthemispheric activation in aphasic patients represents a maladaptive strategy, and
hence tDCS will be aimed at suppressing activation in right inferior frontal gyrus.
With this randomized control trial, we seek to directly compare the effect of
inhibitory stimulation over right inferior frontal gyrus, using TDCS with and without
SLT. By measuring the degree of structural and functional connectivity between the
stimulation site in the right inferior frontal gyrus and primary language centers in
the affected left hemisphere (as indirect measure of transcallosal inhibition), we
hope to identify patients which will respond better to this type of therapy than
others. Because stroke rehabilitation does improve language recovery and because
patients receive most of their intense rehabilitation therapy in the subacute phase
when transcallosal inhibition is increased, we will use brain stimulation during daily
speech and language therapy to enhance language recovery of patients with
subacute stroke by modulating the brains inhibitory influence.
Our aims for this study are to:
Aim 1: To test the hypothesis that non-invasive brain stimulation using transcranialdirect current in combination with conventional SLT results in better aphasia
recovery at 1 and 30 days after end of treatment than SLT with sham stimulation.
Aim 2: To test the hypothesis that there will be no difference in the frequency of
adverse events between the treatment groups.
Aim 3: To test the hypothesis that there is a differential influence of attention, time
to treatment, infarct location and bilingualism on the treatment effect.
Aim 4: To test the hypothesis that the extent of functional and structural
connectivity between the stimulation site over the triangular part of the right
inferior frontal gyrus and the left hemisphere primary language centers determines
effectiveness of the therapy.