Standard upper limb therapy treatment with or without non-invasive brain stimulation to assist recovery after stroke

This study aims to (1) Look at how easy it will be, over a 9 month period, to recruit 34 to 40 people presenting to Sir Charles Gairdner Hospital (SCGH) who have had a particular type of stroke and as a result are unable to use their hand/arm; (2) record techniques used by physiotherapists and occupational therapists to help these people to use their affected arm after stroke; (3) study the effects of a safe low current electrical stimulation (transcranial direct current stimulation - tDCS) to the healthy side of the brain to reduce its dampening down effect on activity in the stroke affected brain. Stimulation, via electrodes placed on the scalp, will be applied at the same time as the affected arm is being treated. This study will recruit patients within 1 week after their stroke. They will be randomly split into two groups: group 1 will receive treatment to their affected arm plus tDCS to the healthy side of the brain and group 2 will receive treatment to their affected arm plus ‘pretend electrical stimulation’ (sham tDCS) to the brain. Both groups will receive 10 rehabilitation sessions over a period of 2 weeks (i.e. 5 days of treatment, 2 days rest, 5 days of treatment). All sessions will last for 30 minutes consisting of upper limb rehabilitation plus ctDCS or sham tDCS respectively. Transcranial direct current stimulation (tDCS) is a commonly used non-invasive stimulation technique, which modulates cortical excitability by applying a weak direct current (1-2 mA) to the scalp overlying the area of the brain that it is intended to stimulate. 2 tDCS is usually applied via saline-soaked sponge electrodes applied to the skin.which are connected to a battery driven direct current stimulator. tDCS is a painless procedure which has been shown to have no major adverse effects, it uses relatively inexpensive equipment and is easy to apply in a clinical setting. Three different tDCS electrode montages are used to enhance upper limb recovery after stroke: (1) anodal stimulation (atDCS) to increase excitability of intact parts of the damaged hemisphere (stroke side); (2) cathodal stimulation (ctDCS) to decrease excitability of the brain tissue on the contralesional hemisphere (healthy side), (3) bihemispheric tDCS which involves an anode electrode over the affected side (to increase excitability), with a cathode electrode on the unaffected side (to decrease excitability and therefore enhance the effect of the anodal electrode). For the purposes of this study we will be investigating the effects of ctDCS over the unaffected hemisphere during standard upper limb rehabilitation. A total of 10 sessions over a period of 2 weeks, each session lasting for 30 minutes. Follow up assessments will last for 3 months after the 2-week intervention phase. "Standard upper limb therapy" will be defined in phases I & II of this study. The principal investigator will conduct a retrospective notes audit of all MCA ischaemic strokes admitted at SCGH between January - September 2011. Documentation from therapists will be collated as key phrases. In phase II the principal investigator will conduct focus groups with relevant therapists in the area in order to define key terminology and obtain and document a consensus outlining what truly is standard upper limb rehabilitation. This standard package of care will then be followed in Phase III as upper limb rehabilitation.