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or tDCS improve the outcome of behavioral aphasia therapy in subacute aphasia?
Abstracts / Clinical Neurophysiology 128 (2017) e1–e163
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Figure 1: Preserved ipsilateral tibialis anterior (TA) motor map in same hemisphere as seizure focus. Data are shown for a patient with a right hemisphere seizure focus. Right hemisphere stimulation in this patient produced either a left (panel A) or right (panel B) TA MEP. Color coded right hemisphere composite map of the left TA in orange and right TA in white are shown in panels C and D.
doi:10.1016/j.clinph.2016.10.174
P049 Chronic post stroke central pain: Increased success rate of chronic epidural motor cortex stimulation using somatotopic, navigated repetitive TMS for patient selection and implant placement—M. Thordstein a,*, K. Gatzinsky b, G. Pegenius b (a Linköping University Hospital, Linköping, Sweden, b Sahlgrenska Univ. Hospital, Neurosurgery, Gothenburg, Sweden) ⇑
Corresponding author.
Introduction: The outcome at group level of neuromodulation for central pain using stimulation of motor cortices is limited, though for some, there are large effects. Thus, there is a need for selection of patients. Methods: 15 patients with refractory central post stroke pain had somatotopically directed, placebo controlled, motor cortex stimulation with navigated rTMS (nrTMS). Symptoms were reported one week before and two weeks after the procedure. The optimal stimulation positions were transferred to an intraoperatively used neuronavigation system and verified by epidural stimulation. Here, an electrode was sewn to the dura mater. Patients reported symptoms, intermittently up to 12 months after the operation. Results: Of the 15 patients evaluated, seven were rejected since they did not respond to nrTMS. Of the eight that did respond, four are waiting for- and four have had the procedure. Of the four with implant all report an, on the whole, positive, clinically meaningful effect. Discussion: The value of Evidence Based Medicine is beginning to be reconsidered. The kind of procedure described above may considerably improve the outcome of this invasive procedure for severe central pain, making it sound from economical and ethical perspectives. doi:10.1016/j.clinph.2016.10.175
P050 Does rTMS and/or tDCS improve the outcome of behavioral aphasia therapy in subacute aphasia?—I. Rubi-Fessen a,*, A. Thiel b, A. Hartmann c, A. Riecker a, A. Zumbandsen b, V. Limmroth c, W.- D. Heiss c,d (a RehaNova Rehabilitation Hospital, Cologne, Germany, b McGill University, Montreal, Canada, c Hospitals of the City of Cologne, Cologne, Germany, d Max Planck Institute for Metabolism Research, Cologne, Germany) ⇑
Corresponding author.
Introduction: For several years non invasive brain stimulation (NIBS) techniques like rTMS and tDCS were used in combination with speech and language therapy. There is evidence that both techniques are able to enhance behavioral treatment effects by inhibiting right Broca’s area and thereby facilitating reintegration of perilesional activation. However, to date, there is a lack of systematic randomized trials comparing the effectiveness of the two techniques. Question: Does additive, inhibitory rTMS or tDCS over right Broca’s area for two weeks enhance behavioral treatment effects in patients with subacute poststroke aphasia? Method: Protocol and participants: In a multicenter, multilingual (German, English, French) clinical trial 90 right-handed participants with subacute aphasia after ischemic stroke in the left MCA territory are randomly assigned to: rTMS-group, tDCS-group, or Sham-group. Participants receive 10 sessions of 45 min speech and language therapy after/during rTMS, tDCS or sham stimulation over two weeks. Stimulation protocol: Inhibitory (1 Hz) rTMS or cathodal tDCS over right pars triangularis (BA 44/45). Outcome measures: Primary multilingual outcome measures are the Boston Naming Test (BNT), a verbal fluency test, and the Token Test. Secondary outcome measures are the Aachen Aphasia Test (German), the Western Aphasia Battery (English) and the Montreal-Toulouse Language Assessment Battery for Aphasia (French). Outcome measures are assessed the day before and the day after the treatment period and after a 30 days follow-up time. Summary: This study will be the first multilingual, multinational randomized trial comparing the additive effects of two NIBS
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Abstracts / Clinical Neurophysiology 128 (2017) e1–e163
techniques on the outcome of aphasia therapy in patients with subacute aphasia. Literature: Thiel et al. (2015) Non-invasive repeated therapeutic stimulation for aphasia recovery: A multilingual, multicenter aphasia trial. J Stroke Cerebrovasc, 24 (4): 751–758. Rubi-Fessen et al. (2015) Add-on effects of rTMS on subacute aphasia therapy: Enhanced improvement of functional communication and basic linguistic skills. A randomized controlled study. Arch Phys Med Rehab, 96: 1935–1944. Thiel et al. (2013) Effects of noninvasive brain stimulation on language networks and recovery in early poststroke aphasia. Stroke, 44: 2240–2246.
Figure 2.
doi:10.1016/j.clinph.2016.10.176
P052 Investigation of the influence of the parieto-premotor network on the motor cortex in writer’s cramp using transcranial magnetic stimulation (TMS)—J.E. Park a,b,*, P. Mathew b, M. Villegas b, P. Srivanitchapoom c, T. Wu b, M. Hallett b (a Dongguk University Ilsan Hospital, Neurology, Goyang, South Korea, b National Institutes of Health, Bethesda, United States, c Mahidol University, Bangkok, Thailand) ⇑
Corresponding author.
Objective: We aimed to study the influence of the parietopremotor network on the motor cortex in patients with writer’s cramp. Background: The parietal and premotor cortices have been shown to be involved in right-handed writing. It has also been shown that the connectivity between these regions may be reduced in writer’s cramp, a type of task-specific focal hand dystonia. Methods: We used a three single-pulse TMS paradigm (preconditioning, conditioning and test pulse) to sequentially stimulate the left posterior parietal cortex (PPC), left ventral premotor cortex (PMv) and the left motor cortex (M1). A paired-pulse TMS paradigm was used to probe the functional connectivity of the PMv and M1, as well as the PPC and M1 prior to the three single-pulse TMS paradigm. Results: 8 right-handed healthy volunteers (mean age 55 years, standard error 4 years) and 8 right-handed patients with writer’s cramp (mean age 62 years, standard error 2 years) completed the
Figure 1.
The premotor-to-motor inhibition was found to reverse in healthy volunteers (shown in figure 2, as nostatistical significance was seen amongst the test and triple conditions), while no effects were seen in patients.
study. We confirmed the presence of premotor-to-motor inhibition in the healthy volunteer group at interstimulus intervals (ISI) s of 4 ms and 8 ms, while this was not seen in the patient group. Facilitatory influences from the posterior parietal cortex was seen in both groups (ISIs of 4 ms and 6 ms in the healthy group, and 6 ms in the patient group). Conclusions: We confirmed that in healthy volunteers, the PPC appears to have an influence on the PMv, resulting in reversal of the inhibition seen with PMv paired-pulse stimuli. This along with premotor-to-motor inhibition, was not seen in patients with writer’s cramp. Facilitatory parietal influences on M1, on the other hand, appear to be intact in these patients. These results suggest that the connectivity between PPC and M1 is intact in patients with writer’s cramp, while the connectivity between PPC and PMv, and PMv and M1 appears altered. doi:10.1016/j.clinph.2016.10.177
P053 Double blind randomized controlled clinical trial of frontoparietal tDCS in patients with disorders of consciousness— G. Martens a,*, A. Thibaut b, S. Laureys a (a Coma Science Group, GIGA Research (ULg), Liège, Belgium, b Spaulding Hospital, Laboratory of Neuromodulation, Boston, United States) ⇑
Corresponding author.
Objectives: To assess the effects of frontoparietal transcranial direct current stimulation (tDCS) in patients with disorders of consciousness using the Coma Recovery Scale-Revised (CRS-R) in a randomized double blind sham controlled cross-over study. Methods: This study was performed on patients in unresponsive wakefulness syndrome (UWS), minimal conscious state (MCS), and emergence of MCS (EMCS). We enrolled 15 patients (UWS = 7, MCS = 7, EMCS = 1; average age = 44.6 ± 14.4; 7 traumatic patients and 8 non-traumatic). Two session of tDCS were delivered, using either anodal or sham stimulation in a randomized order. Frontoparietal areas were stimulated using a current of 1 mA during 20 min. Consciousness was assessed with the CRS-R before and after each stimulation. Results: A tendency of improvement was observed after the real tDCS session (p = 0.075) while no significant change was found after the sham session (p = 0.205). It was noticed that a higher percentage (43%) of patients in MCS increased their CRS-R score after an actual tDCS; compared to only 14% of patients in UWS. Conclusion: Some improvements were observed further to tDCS stimulations. Based on a larger sample of patients, the positive effect
e31
Figure 1: Preserved ipsilateral tibialis anterior (TA) motor map in same hemisphere as seizure focus. Data are shown for a patient with a right hemisphere seizure focus. Right hemisphere stimulation in this patient produced either a left (panel A) or right (panel B) TA MEP. Color coded right hemisphere composite map of the left TA in orange and right TA in white are shown in panels C and D.
doi:10.1016/j.clinph.2016.10.174
P049 Chronic post stroke central pain: Increased success rate of chronic epidural motor cortex stimulation using somatotopic, navigated repetitive TMS for patient selection and implant placement—M. Thordstein a,*, K. Gatzinsky b, G. Pegenius b (a Linköping University Hospital, Linköping, Sweden, b Sahlgrenska Univ. Hospital, Neurosurgery, Gothenburg, Sweden) ⇑
Corresponding author.
Introduction: The outcome at group level of neuromodulation for central pain using stimulation of motor cortices is limited, though for some, there are large effects. Thus, there is a need for selection of patients. Methods: 15 patients with refractory central post stroke pain had somatotopically directed, placebo controlled, motor cortex stimulation with navigated rTMS (nrTMS). Symptoms were reported one week before and two weeks after the procedure. The optimal stimulation positions were transferred to an intraoperatively used neuronavigation system and verified by epidural stimulation. Here, an electrode was sewn to the dura mater. Patients reported symptoms, intermittently up to 12 months after the operation. Results: Of the 15 patients evaluated, seven were rejected since they did not respond to nrTMS. Of the eight that did respond, four are waiting for- and four have had the procedure. Of the four with implant all report an, on the whole, positive, clinically meaningful effect. Discussion: The value of Evidence Based Medicine is beginning to be reconsidered. The kind of procedure described above may considerably improve the outcome of this invasive procedure for severe central pain, making it sound from economical and ethical perspectives. doi:10.1016/j.clinph.2016.10.175
P050 Does rTMS and/or tDCS improve the outcome of behavioral aphasia therapy in subacute aphasia?—I. Rubi-Fessen a,*, A. Thiel b, A. Hartmann c, A. Riecker a, A. Zumbandsen b, V. Limmroth c, W.- D. Heiss c,d (a RehaNova Rehabilitation Hospital, Cologne, Germany, b McGill University, Montreal, Canada, c Hospitals of the City of Cologne, Cologne, Germany, d Max Planck Institute for Metabolism Research, Cologne, Germany) ⇑
Corresponding author.
Introduction: For several years non invasive brain stimulation (NIBS) techniques like rTMS and tDCS were used in combination with speech and language therapy. There is evidence that both techniques are able to enhance behavioral treatment effects by inhibiting right Broca’s area and thereby facilitating reintegration of perilesional activation. However, to date, there is a lack of systematic randomized trials comparing the effectiveness of the two techniques. Question: Does additive, inhibitory rTMS or tDCS over right Broca’s area for two weeks enhance behavioral treatment effects in patients with subacute poststroke aphasia? Method: Protocol and participants: In a multicenter, multilingual (German, English, French) clinical trial 90 right-handed participants with subacute aphasia after ischemic stroke in the left MCA territory are randomly assigned to: rTMS-group, tDCS-group, or Sham-group. Participants receive 10 sessions of 45 min speech and language therapy after/during rTMS, tDCS or sham stimulation over two weeks. Stimulation protocol: Inhibitory (1 Hz) rTMS or cathodal tDCS over right pars triangularis (BA 44/45). Outcome measures: Primary multilingual outcome measures are the Boston Naming Test (BNT), a verbal fluency test, and the Token Test. Secondary outcome measures are the Aachen Aphasia Test (German), the Western Aphasia Battery (English) and the Montreal-Toulouse Language Assessment Battery for Aphasia (French). Outcome measures are assessed the day before and the day after the treatment period and after a 30 days follow-up time. Summary: This study will be the first multilingual, multinational randomized trial comparing the additive effects of two NIBS
e32
Abstracts / Clinical Neurophysiology 128 (2017) e1–e163
techniques on the outcome of aphasia therapy in patients with subacute aphasia. Literature: Thiel et al. (2015) Non-invasive repeated therapeutic stimulation for aphasia recovery: A multilingual, multicenter aphasia trial. J Stroke Cerebrovasc, 24 (4): 751–758. Rubi-Fessen et al. (2015) Add-on effects of rTMS on subacute aphasia therapy: Enhanced improvement of functional communication and basic linguistic skills. A randomized controlled study. Arch Phys Med Rehab, 96: 1935–1944. Thiel et al. (2013) Effects of noninvasive brain stimulation on language networks and recovery in early poststroke aphasia. Stroke, 44: 2240–2246.
Figure 2.
doi:10.1016/j.clinph.2016.10.176
P052 Investigation of the influence of the parieto-premotor network on the motor cortex in writer’s cramp using transcranial magnetic stimulation (TMS)—J.E. Park a,b,*, P. Mathew b, M. Villegas b, P. Srivanitchapoom c, T. Wu b, M. Hallett b (a Dongguk University Ilsan Hospital, Neurology, Goyang, South Korea, b National Institutes of Health, Bethesda, United States, c Mahidol University, Bangkok, Thailand) ⇑
Corresponding author.
Objective: We aimed to study the influence of the parietopremotor network on the motor cortex in patients with writer’s cramp. Background: The parietal and premotor cortices have been shown to be involved in right-handed writing. It has also been shown that the connectivity between these regions may be reduced in writer’s cramp, a type of task-specific focal hand dystonia. Methods: We used a three single-pulse TMS paradigm (preconditioning, conditioning and test pulse) to sequentially stimulate the left posterior parietal cortex (PPC), left ventral premotor cortex (PMv) and the left motor cortex (M1). A paired-pulse TMS paradigm was used to probe the functional connectivity of the PMv and M1, as well as the PPC and M1 prior to the three single-pulse TMS paradigm. Results: 8 right-handed healthy volunteers (mean age 55 years, standard error 4 years) and 8 right-handed patients with writer’s cramp (mean age 62 years, standard error 2 years) completed the
Figure 1.
The premotor-to-motor inhibition was found to reverse in healthy volunteers (shown in figure 2, as nostatistical significance was seen amongst the test and triple conditions), while no effects were seen in patients.
study. We confirmed the presence of premotor-to-motor inhibition in the healthy volunteer group at interstimulus intervals (ISI) s of 4 ms and 8 ms, while this was not seen in the patient group. Facilitatory influences from the posterior parietal cortex was seen in both groups (ISIs of 4 ms and 6 ms in the healthy group, and 6 ms in the patient group). Conclusions: We confirmed that in healthy volunteers, the PPC appears to have an influence on the PMv, resulting in reversal of the inhibition seen with PMv paired-pulse stimuli. This along with premotor-to-motor inhibition, was not seen in patients with writer’s cramp. Facilitatory parietal influences on M1, on the other hand, appear to be intact in these patients. These results suggest that the connectivity between PPC and M1 is intact in patients with writer’s cramp, while the connectivity between PPC and PMv, and PMv and M1 appears altered. doi:10.1016/j.clinph.2016.10.177
P053 Double blind randomized controlled clinical trial of frontoparietal tDCS in patients with disorders of consciousness— G. Martens a,*, A. Thibaut b, S. Laureys a (a Coma Science Group, GIGA Research (ULg), Liège, Belgium, b Spaulding Hospital, Laboratory of Neuromodulation, Boston, United States) ⇑
Corresponding author.
Objectives: To assess the effects of frontoparietal transcranial direct current stimulation (tDCS) in patients with disorders of consciousness using the Coma Recovery Scale-Revised (CRS-R) in a randomized double blind sham controlled cross-over study. Methods: This study was performed on patients in unresponsive wakefulness syndrome (UWS), minimal conscious state (MCS), and emergence of MCS (EMCS). We enrolled 15 patients (UWS = 7, MCS = 7, EMCS = 1; average age = 44.6 ± 14.4; 7 traumatic patients and 8 non-traumatic). Two session of tDCS were delivered, using either anodal or sham stimulation in a randomized order. Frontoparietal areas were stimulated using a current of 1 mA during 20 min. Consciousness was assessed with the CRS-R before and after each stimulation. Results: A tendency of improvement was observed after the real tDCS session (p = 0.075) while no significant change was found after the sham session (p = 0.205). It was noticed that a higher percentage (43%) of patients in MCS increased their CRS-R score after an actual tDCS; compared to only 14% of patients in UWS. Conclusion: Some improvements were observed further to tDCS stimulations. Based on a larger sample of patients, the positive effect