Evaluation of Autonomic Modulation in Stroke After Transcranial Direct Current Stimulation and Treadmill Training

Stroke Clinical Trial

Official title:

Evaluation of Autonomic Modulation in the Hemiparetic Patients After Transcranial Direct Current Stimulation (tDCS) and Treadmill Training: Clinical Trial, Controlled, a Randomized, Double-blind

Clinical Trial Details — Status: Not yet recruiting

Administrative data

• NCT number: NCT02956096
• Other study ID #: u64963ep
• Status: Not yet recruiting
• Phase: N/A
• First received: September 30, 2016
• Last updated: November 22, 2016
• Start date: December 2016
• Est. completion date: November 2017

Study information

• Verified date: September 2016
• Source: University of Nove de Julho
• Contact: Glauber Heinz, Postgraduate
• Phone: 5511970883072
• Email: glauber.heinz[@]hotmail.com
• Is FDA regulated: No
• Health authority: Brazil: Ethics Committee
• Study type: Interventional

Clinical Trial Summary

Introduction: Patients post-stroke may have autonomic dysfunction, with increased blood pressure, heart rate (HR) and increased risk of sudden death. Studies have shown that transcranial direct-current stimulation (tDCS) can modulate the autonomic nervous system in healthy subjects, but little is known about these effects in stroke.

Objective: To evaluate the effect of tDCS after treadmill training in the autonomic nervous system modulation in patients post-stroke.

Description:

Introduction: Patients post-stroke may have autonomic dysfunction, with increased blood pressure, heart rate (HR) and increased risk of sudden death. Studies have shown that transcranial direct-current stimulation (tDCS) can modulate the autonomic nervous system in healthy subjects, but little is known about these effects in stroke.

Objective: To evaluate the effect of tDCS after treadmill training in the autonomic nervous system modulation in patients post-stroke.

Methods: Clinical study, crossover, controlled, randomized, double-blind individuals with hemiparesis after stroke adults. Patients will undergo a spirometric evaluation (Harbor protocol modified with constant speed, determined by the individual and the incline of the treadmill with incremented 2.5% every 2 minutes). The next day will begin with one of the two randomized protocols, one week interval between them: 1 (tDCS active and treadmill), 2 (tDCS placebo and treadmill). Each protocol will last 40 minutes (20min of tDCS over 20min mat). They will be evaluated heart rate variability (HRV) and blood pressure variability (VPA) before a minute for the protocols and in the recovery phase, for 15 minutes. 2mA current intensity, the anode electrode over the left temporal cortex and cathode on the contralateral deltoid muscle. Considering the neurophysiological effects of noninvasive techniques neuromodulators plasticity before the modulation of the autonomic nervous system, it is concluded that this study shows potential for the discovery of a new therapeutic tool in the rehabilitation of patients with stroke and hypertension. The hypothesis is that increasing the excitability of the left insular cortex, a modulation of the autonomic nervous system in controlling the variability in systolic blood pressure and heart rate is possible in conjunction with aerobic training, can provide greater hemodynamic effectiveness and decrease the time training. It is also understood that the study may have impact on the reduction of public costs spent on the rehabilitation of patients with stroke.

Recruitment information / eligibility

• Status: Not yet recruiting
• Enrollment: 30
• Est. completion date: November 2017
• Est. primary completion date: May 2017
• Accepts healthy volunteers: No
• Gender: Both
• Age group: 21 Years to 74 Years

Eligibility

Inclusion Criteria:

• present hemiparesis due to stroke for more than 6 months;

• Commitment mild or moderate motor in the lower member (20 to 31 points), according to the scores of Fugl-Meyer test

• comfortable walking speed on the ground between 0.3 and 1.15 m / s;

• Rating between levels 04-06 on Functional Mobility Scale (FMS) - Functional Mobility Scale and ambulate at least 50 meters

• Presentation of the AVE imaging

• Science Signature regarding the free and informed consent (WIC).

Exclusion Criteria:

• present cognitive impairment (mini mental) with scores below 24 points;

• visual impairment that may interfere with the performance of the tests;

• severe heart failure (congestive heart failure, angina, peripheral vascular disease), pacemaker use, ß-blockers and propranolol;

• contraindications to the use of tDCS (brain implants of metal clips near the region to be stimulated, history of recurrent seizures, recurrent epilepsy and brain tumors, brain pacemaker and / or plates or metal devices in place of stimulation tDCS)

• irregular menstrual cycle or be in the menstrual period during the evaluation;

• No medical certificate for treadmill exercise test

Study Design

Allocation: Randomized, Intervention Model: Crossover Assignment, Masking: Double Blind (Subject, Investigator), Primary Purpose: Treatment

Related Conditions & MeSH terms

• Stroke

Intervention

Device:
• Transcranial direct current stimulation (tDCS)
The active tDCS and placebo will be applied to anode electrode on left temporal cortex placed on the scalp in the region T3. The cathode electrode on the middle deltoid muscle contralateral to the anode.
• training on the running belt
The running in the treadmill will be held on a single training session and the speed of the cardiopulmonary exercise testing and slope from 60 to 80% of the maximum achieved in cardiopulmonary testing, in order that the patient reaches 60% to 70% of the heart rate reserve.

Locations

Country	Name	City	State
Brazil	University Nove de Julho	São Paulo	SP

Sponsors (1)

Lead Sponsor	Collaborator
University of Nove de Julho

Country where clinical trial is conducted

Brazil, 

References & Publications (33)

Al-Qudah ZA, Yacoub HA, Souayah N. Disorders of the Autonomic Nervous System after Hemispheric Cerebrovascular Disorders: An Update. J Vasc Interv Neurol. 2015 Oct;8(4):43-52. — View Citation

Billinger SA, Arena R, Bernhardt J, Eng JJ, Franklin BA, Johnson CM, MacKay-Lyons M, Macko RF, Mead GE, Roth EJ, Shaughnessy M, Tang A; American Heart Association Stroke Council.; Council on Cardiovascular and Stroke Nursing.; Council on Lifestyle and Cardiometabolic Health.; Council on Epidemiology and Prevention.; Council on Clinical Cardiology.. Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Aug;45(8):2532-53. doi: 10.1161/STR.0000000000000022. — View Citation

Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377-81. — View Citation

Brunoni AR, Amadera J, Berbel B, Volz MS, Rizzerio BG, Fregni F. A systematic review on reporting and assessment of adverse effects associated with transcranial direct current stimulation. Int J Neuropsychopharmacol. 2011 Sep;14(8):1133-45. doi: 10.1017/S1461145710001690. Review. — View Citation

Christensen H, Boysen G, Christensen AF, Johannesen HH. Insular lesions, ECG abnormalities, and outcome in acute stroke. J Neurol Neurosurg Psychiatry. 2005 Feb;76(2):269-71. — View Citation

Colivicchi F, Bassi A, Santini M, Caltagirone C. Prognostic implications of right-sided insular damage, cardiac autonomic derangement, and arrhythmias after acute ischemic stroke. Stroke. 2005 Aug;36(8):1710-5. — View Citation

De Raedt S, De Vos A, De Keyser J. Autonomic dysfunction in acute ischemic stroke: an underexplored therapeutic area? J Neurol Sci. 2015 Jan 15;348(1-2):24-34. doi: 10.1016/j.jns.2014.12.007. Review. — View Citation

Eckardt M, Gerlach L, Welter FL. Prolongation of the frequency-corrected QT dispersion following cerebral strokes with involvement of the insula of Reil. Eur Neurol. 1999;42(4):190-3. — View Citation

Graham HK, Harvey A, Rodda J, Nattrass GR, Pirpiris M. The Functional Mobility Scale (FMS). J Pediatr Orthop. 2004 Sep-Oct;24(5):514-20. — View Citation

Kang J, Hong JH, Jang MU, Kim BJ, Bae HJ, Han MK. Cardioembolism and Involvement of the Insular Cortex in Patients with Ischemic Stroke. PLoS One. 2015 Oct 21;10(10):e0139540. doi: 10.1371/journal.pone.0139540. — View Citation

Kluding PM, Tseng BY, Billinger SA. Exercise and executive function in individuals with chronic stroke: a pilot study. J Neurol Phys Ther. 2011 Mar;35(1):11-7. doi: 10.1097/NPT.0b013e318208ee6c. — View Citation

Lista Paz A, González Doniz L, Ortigueira García S, Saleta Canosa JL, Moreno Couto C. Respiratory Muscle Strength in Chronic Stroke Survivors and Its Relation With the 6-Minute Walk Test. Arch Phys Med Rehabil. 2016 Feb;97(2):266-72. doi: 10.1016/j.apmr.2015.10.089. — View Citation

Macey PM, Wu P, Kumar R, Ogren JA, Richardson HL, Woo MA, Harper RM. Differential responses of the insular cortex gyri to autonomic challenges. Auton Neurosci. 2012 May 21;168(1-2):72-81. doi: 10.1016/j.autneu.2012.01.009. — View Citation

Macko RF, Ivey FM, Forrester LW, Hanley D, Sorkin JD, Katzel LI, Silver KH, Goldberg AP. Treadmill exercise rehabilitation improves ambulatory function and cardiovascular fitness in patients with chronic stroke: a randomized, controlled trial. Stroke. 2005 Oct;36(10):2206-11. — View Citation

Makovac E, Thayer JF, Ottaviani C. A meta-analysis of non-invasive brain stimulation and autonomic functioning: Implications for brain-heart pathways to cardiovascular disease. Neurosci Biobehav Rev. 2016 May 13. pii: S0149-7634(16)30036-7. doi: 10.1016/j.neubiorev.2016.05.001. [Epub ahead of print] Review. — View Citation

Montenegro RA, Farinatti Pde T, Fontes EB, Soares PP, Cunha FA, Gurgel JL, Porto F, Cyrino ES, Okano AH. Transcranial direct current stimulation influences the cardiac autonomic nervous control. Neurosci Lett. 2011 Jun 15;497(1):32-6. doi: 10.1016/j.neulet.2011.04.019. — View Citation

Nagai M, Hoshide S, Kario K. The insular cortex and cardiovascular system: a new insight into the brain-heart axis. J Am Soc Hypertens. 2010 Jul-Aug;4(4):174-82. doi: 10.1016/j.jash.2010.05.001. Review. — View Citation

Noetscher GM, Yanamadala J, Makarov SN, Pascual-Leone A. Comparison of cephalic and extracephalic montages for transcranial direct current stimulation--a numerical study. IEEE Trans Biomed Eng. 2014 Sep;61(9):2488-98. — View Citation

Oppenheimer SM, Gelb A, Girvin JP, Hachinski VC. Cardiovascular effects of human insular cortex stimulation. Neurology. 1992 Sep;42(9):1727-32. — View Citation

Oppenheimer SM, Kedem G, Martin WM. Left-insular cortex lesions perturb cardiac autonomic tone in humans. Clin Auton Res. 1996 Jun;6(3):131-40. — View Citation

Pang MY, Eng JJ, Dawson AS, Gylfadóttir S. The use of aerobic exercise training in improving aerobic capacity in individuals with stroke: a meta-analysis. Clin Rehabil. 2006 Feb;20(2):97-111. Review. — View Citation

Roth EJ. Heart disease in patients with stroke. Part II: Impact and implications for rehabilitation. Arch Phys Med Rehabil. 1994 Jan;75(1):94-101. Review. — View Citation

Ruggiero DA, Mraovitch S, Granata AR, Anwar M, Reis DJ. A role of insular cortex in cardiovascular function. J Comp Neurol. 1987 Mar 8;257(2):189-207. — View Citation

Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, Elkind MS, George MG, Hamdan AD, Higashida RT, Hoh BL, Janis LS, Kase CS, Kleindorfer DO, Lee JM, Moseley ME, Peterson ED, Turan TN, Valderrama AL, Vinters HV; American Heart Association Stroke Council, Council on Cardiovascular Surgery and Anesthesia.; Council on Cardiovascular Radiology and Intervention.; Council on Cardiovascular and Stroke Nursing.; Council on Epidemiology and Prevention.; Council on Peripheral Vascular Disease.; Council on Nutrition, Physical Activity and Metabolism.. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Jul;44(7):2064-89. doi: 10.1161/STR.0b013e318296aeca. — View Citation

Scheitz JF, Erdur H, Haeusler KG, Audebert HJ, Roser M, Laufs U, Endres M, Nolte CH. Insular cortex lesions, cardiac troponin, and detection of previously unknown atrial fibrillation in acute ischemic stroke: insights from the troponin elevation in acute ischemic stroke study. Stroke. 2015 May;46(5):1196-201. doi: 10.1161/STROKEAHA.115.008681. — View Citation

Smith AC, Saunders DH, Mead G. Cardiorespiratory fitness after stroke: a systematic review. Int J Stroke. 2012 Aug;7(6):499-510. doi: 10.1111/j.1747-4949.2012.00791.x. Review. — View Citation

Sörös P, Hachinski V. Cardiovascular and neurological causes of sudden death after ischaemic stroke. Lancet Neurol. 2012 Feb;11(2):179-88. doi: 10.1016/S1474-4422(11)70291-5. Review. — View Citation

Tokgözoglu SL, Batur MK, Topçuoglu MA, Saribas O, Kes S, Oto A. Effects of stroke localization on cardiac autonomic balance and sudden death. Stroke. 1999 Jul;30(7):1307-11. — View Citation

Triposkiadis F, Karayannis G, Giamouzis G, Skoularigis J, Louridas G, Butler J. The sympathetic nervous system in heart failure physiology, pathophysiology, and clinical implications. J Am Coll Cardiol. 2009 Nov 3;54(19):1747-62. doi: 10.1016/j.jacc.2009.05.015. Review. — View Citation

van de Port IG, Kwakkel G, Wittink H. Systematic review of cardiopulmonary exercise testing post stroke: Are we adhering to practice recommendations? J Rehabil Med. 2015 Nov;47(10):881-900. doi: 10.2340/16501977-2031. Review. — View Citation

Vandermeeren Y, Jamart J, Ossemann M. Effect of tDCS with an extracephalic reference electrode on cardio-respiratory and autonomic functions. BMC Neurosci. 2010 Mar 16;11:38. doi: 10.1186/1471-2202-11-38. — View Citation

Verberne AJ, Owens NC. Cortical modulation of the cardiovascular system. Prog Neurobiol. 1998 Feb;54(2):149-68. Review. — View Citation

Xiong L, Leung H, Chen XY, Han JH, Leung T, Soo Y, Wong E, Chan A, Lau A, Wong KS. Preliminary findings of the effects of autonomic dysfunction on functional outcome after acute ischemic stroke. Clin Neurol Neurosurg. 2012 May;114(4):316-20. doi: 10.1016/j.clineuro.2011.10.037. — View Citation

* Note: There are 33 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Heart rate variability	Cardiac Frequency Variability (HRV) as measured by spectral analysis by Finomiter (FMS, Finapres Measurement Systems, Arnhem, Netherlands), in ms²	1 years	Yes
Secondary	Blood pressure variability	Blood Pressure Variability (BPV) as measured by spectral analysis by Finomiter (FMS, Finapres Measurement Systems, Arnhem, Netherlands), in mmHg	1 years	Yes

External Links

•   Link
•   Link
•   Link
•   Link