Annals of Physical and Rehabilitation Medicine 63 (2020) 81–84
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Letter to the editor
Could non-invasive brain stimulation help treat
dysarthria? A single-case study
A R T I C L E I N F O
Keywords:
Language
Dysarthria
Speech rehabilitation
Brain stimulation
Dear Editor,
Dysarthria is a motor speech disorder that can occur following
brain damage. It is characterized by impairments in producing the
movements needed to articulate words [1] but does not affect
other language processing domains such as writing and compre-
hension.
Several rehabilitation approaches have been developed to
improve dysarthria; they involve intensive exercise or alternative/
augmentative communication devices but have shown no strong
beneficial effects [2]. Recent studies in neuro-modulation have
effectively used non-invasive brain stimulation to treat post-stroke
aphasia [3, for a review]. Anodal transcranial direct current
stimulation (tDCS) of the left inferior frontal gyrus (IFG) has been
found to mitigate language articulation impairments in aphasia
[4,5]. Moreover, recent findings from healthy individuals showed
that cathodal tDCS over the right cerebellum improved perfor-
mance in a sequenced articulation task [6], which suggests
promising perspectives for treating motor speech disorders.
To the best of our knowledge, tDCS has never been used in
the context of dysarthria. However, the aforementioned
studies suggest that modulating brain areas involved in speech
articulation and motor control, such as the IFG and cerebellum,
could contribute to dysarthria recovery. Moreover, tDCS
has been found to induce long-lasting alterations of cortical
excitability, by mimicking long-term potentiation and depression
[7] and by modulating gamma-aminobutyric acid and glutamate
concentrations [8]. Because both the IFG and the cerebellum are
part of a complex network implicated in speech articulation [9],
we hypothesized that inducing long-lasting alterations of cortical
excitability in these regions could be effective in dysarthria
recovery.
Here, we describe a single-case study of language rehabilitation
in a young man with severe chronic dysarthria after severe
traumatic brain injury (TBI), despite management by classical
speech therapy twice a week. We assessed whether tDCS coupled
with active training could help attenuate the speech disorder in
https://doi.org/10.1016/j.rehab.2019.06.011
1877-0657/
C 2019 Elsevier Masson SAS. All rights reserved.
this patient. Indeed, previous studies of TBI suggested that tDCS
combined with active behavioral training can facilitate cortical
reorganization and consolidation of learning in specific neural
networks [10], as in stroke patients [7]. Moreover, previous
literature on post-stroke aphasia demonstrated an improvement
with tDCS in oral production for some patients [5], which provides
a possible rationale for applying tDCS in dysarthria.
To this purpose, we compared 2 tDCS protocols based on the
literature, in which the right cerebellum [6] or left IFG [4,5] was
stimulated by using cathodal or anodal polarities, respectively,
coupled with speech therapy in one patient. Possible changes in
brain integrity after tDCS were assessed by using diffusion tensor
imaging (DTI), before and after the rehabilitation procedure.
At age 19, our right-handed, 21-year-old, native French-
speaking patient experienced TBI. He spent 1 month in a coma,
with an initial score of 5 on the Glasgow Coma Scale. The first
cerebral MRI, performed at 2 weeks after the TBI, showed diffuse
axonal injury in both hemispheres, predominantly in the right
temporal lobe, corpus callosum, bilateral basal ganglia, bilateral
internal capsule, and both peduncles. At 3 years after TBI, the
patient remained severely impaired, with right hemiparesis,
cerebellar syndrome, and pseudo-bulbar palsy and persistent
severe chronic dysarthria (see Supplementary Table for the
neuropsychological evaluation). Naming, repetition, and reading
were impaired, as was automatic language, with no further
impairments in written and oral language and no signs of aphasic
agraphia or oral facial apraxia. The lesional substrate of the
articulatory impairments was attributed to a bi-genicular lesion
(Fig. 1).
The rehabilitation procedure lasted 8 weeks and is described in
Fig. 2. It was approved by the local ethics committee, and the study
followed the ethical standards of the 1964 Declaration of Helsinki.
Language evaluation included tests for facial-apraxia, automat-
ic language, repetition, naming, and reading. The tasks were
selected from the Protocole d’examen linguistique de l’aphasie
Montréal-Toulouse [11], a language assessment battery for
evaluating language impairments in French-speaking adults, with
the exception of the repetition task, which was chosen from the
Batterie d’évaluation clinique de la dysarthrie [12]. The score for
automatic language, repetition, naming, and reading was calculat-
ed as a combination of words (1 point if the word was produced
with no articulatory errors) and voice (1 point if the word was
produced aloud/not whispered). The maximum possible score was
30 for automatic language, 66 for repetition, 31 for naming, and
33 for reading.
MRI with DTI sequences was performed before and after the
rehabilitation procedure by using a Philips 3 T MRI Ingenia system
(Philips Medical Systems, Best, The Netherlands; parameters: b-
value 800 s/mm2; 32 directions; voxel size 2 mm isotropic; TR/TE
8495/100 ms; EPI factor 55). T2 FLAIR and T1 SWI sequences were
added for anatomical reference and axonal damage assessment.
82 Letter to the editor / Annals of Physical and Rehabilitation Medicine 63 (2020) 81–84

Fig. 1. A, B. Diffuse axonal injury (black spots) on susceptibility weighted MR images with bilateral lesions at the medial part of the cerebral peduncles and in both striatum. D,
E. Coronal reconstructions of the pyramidal tract based on 3-D FLAIR sequences and merged with diffusion tensor tractography. C, F. Track-density imaging shows a slight
lower density of fibers on the right pyramidal tract. G, H. Corpus callosum axonal injury on diffusion tensor tractography and track-density imaging. I. 3-D SAG FLAIR sequence
demonstrates corpus callosum defect. J. Tractography of the pyramidal tracts (yellow and blue) and corpus callosum (orange) with a large defect on the corpus of the CC
(orange arrow). K. Coronal reconstruction of the track density map with no significant change between the 2 MRI scans at 2 weeks after traumatic brain injury and at 3 years.

Fig. 2. The 21-year-old male patient participated in an 8-week rehabilitative treatment combining speech therapy and functional brain stimulation (transcranial direct
current stimulation [tDCS]) targeting the right cerebellum (R. Cb-tDCS) or the left inferior frontal gyrus (L. IFG-tDCS). Language was evaluated before the rehabilitative
protocol (T0, T1), at the end of each stimulation protocol (T2, T3 and T4) and 15 days after the end of the whole rehabilitative procedure (T5).

The post-processing tractography steps were performed with a
Philips extended workspace (Portal from Philips, Medical Imaging,
Best, The Netherlands) with Mrtrix3 package software (J.-D.
Tournier, Brain Research Institute, Melbourne, Australia). Regions
of interest were placed to include the corpus callosum at midline
and both the precentral gyri and the cerebral peduncles. A track
density map was reconstructed on the basis of a full-brain
probabilistic tracking of 1 million fibers with an interpolated
resolution of 0.3 mm [13].
tDCS involved use of a battery-driven stimulator (NeuroConn,
GmbH, Germany) with a pair of surface-soaked electrodes.
Cerebellar stimulation consisted of 20 min of 2 mA direct current
with the cathode electrode (5  5 cm) centered on the cerebellum
(3 cm lateral to the inion on the right cerebellum) [6] and the anode
(5  5 cm) placed on the right deltoid muscle (Cb-tDCS). IFG
stimulation (IFG-tDCS) consisted of 20 min of 1 mA direct current
with the anodic electrode (5  7 cm) centered over the left IFG (BA
44/45, F5 of the 10–20 system for electroencephalography) and the
cathode centered on the contralateral supraorbital region (FP2) [4,5].
Under both conditions, the patient received concurrent speech
therapy on a daily basis for 2 weeks, excluding weekends (5 days/
week). Thus, the patient received 10 cerebellar tDCS sessions and
10 IFG-tDCS sessions. During each rehabilitation session, the
patient and speech therapist were seated face to face and the
patient was asked to repeat simple and more complex sounds in a
progressive manner starting from syllables, to disyllabic words,
and finally short sentences. Two stimuli lists, of 12 words
organized by sounds, were alternated on a daily basis. Each list
contained from 3 to 8 words of 1 to 2 syllables; 18 sentences with
up to 8 syllables were also used (e.g., ‘‘Il a lu le livre de Louis’’). The
speech therapy sessions lasted about 30 min each day and were
combined with tDCS during the first 20 min. The stimulus lists
used remained constant despite the change in stimulation
protocols. The speech and language rehabilitation program
performed during this study was more intensive (5 sessions per
week) than the speech and language therapy the patient
underwent before inclusion in this study (2 sessions per week),
which on top of repetition, also comprised spontaneous speech,
 Letter to the editor / Annals of Physical and Rehabilitation Medicine 63 (2020) 81–84
Fig. 3. Results from the language evaluations during the 8-week rehabilitative period in (from left to right and top to bottom) automatic language, reading, repetition, and
naming. The gray lines reflect the patient’s performance in producing words with no articulatory errors and the black lines the ability to produce the sounds aloud.
reading, and picture description following the principles of the
Promoting Aphasia Communication Effectiveness (PACE) protocol.
After the treatment, the patient showed improved intelligibili-
ty, particularly after Cb-tDCS (Fig. 3), for voice but not words.
Performance concerning the reading task improved (for voice only)
between the 2 pre-tests and after Cb-tDCS but not IFG-tDCS.
Repetition for voice and words was improved after Cb-tDCS, with
an additional improvement after IFG-tDCS for voice only. We
observed no improvement in naming. For all language and
articulatory evaluations, no long-term improvement was eviden-
ced.
Because of no significant morphologic modification observed
on MRI before and after the rehabilitative procedure, only lesion
analysis after the rehabilitation procedure is reported. We found
no significant changes between the 2 MRI scans, whether in
targeted or full tractography (Fig. 1).
The finding of an improvement in intelligibility after Cb-tDCS
suggests the possibility of using this technique in patients with
motor speech disorders. This effect appears specific, particularly
for automatic language, because we observed no improvement
during the 2 pre-tests or after IFG-tDCS. A similar conclusion can be
proposed for reading, although the baseline was not stable in this
task. These results agree with the role of the cerebellum in speech
production that can be modulated by tDCS, although articulatory
impairment per se was not improved, as suggested previously in
healthy individuals [6]. The lack of improvement in abilities not
trained for specifically during tDCS seems to suggest that tDCS can
enhance the effect of speech therapy for only abilities in active
training.
The mechanisms underlying the observed effect of Cb-tDCS
should be discussed with caution. The absence of a long-term effect
together with no modification of white-matter organization on the
second DTI strongly argues against structural brain reorganization.
Improvement likely involves more a functional brain-plasticity
process. The cumulative effect of Cb-tDCS and IFG-tDCS on
repetition likely involves a different network of areas and suggests
that the mechanism underlying recovery depends on many
variables such as brain lesion topography, delay after onset, the
precise nature of the impairment, and treatment type.
83
The finding of an effect on speech vocal sound after cerebellar
stimulation is compatible with the anatomical organization of
neural control of speech [14]. Indeed, the cerebellum is part of a
network involved in speech articulation that includes areas such as
the anterior cingulate, supplementary motor area, and basal
ganglia and is also connected to the ventral portion of the sensory-
motor cortex. This region ultimately projects to the articulatory
muscles via the corticobulbar tract and the oro-facial motor nuclei,
which has been shown to somatotopically arrange speech
articulator representations [9]. Cerebellar tDCS may have modu-
lated the activity of this complex network, thereby improving
speech production.
Results from this single-case report should be interpreted
with caution. Indeed, a sham phase was not included in the
experimental design and the 1-week wash-out period did not
allow for assessing possible long-term improvements after the
rehabilitative intervention. The lack of a sham phase limits the
possibility to exclude language improvements due to the
increased intensity of the daily intervention. However, the fact
that: 1) the improvement was found not only in abilities that
were trained daily and 2) the stimuli used for the daily speech
therapy sessions were not the same as those used during
language evaluations, allow for partially excluding this issue.
Moreover, the clinical nature of the intervention did not allow for
2 different speech therapists for the therapy sessions and the
language evaluations, although the speech therapist was blinded
to the stimulation protocol used between each language
assessment. Finally, we noted some variability in the patient’s
pre-test scores. However, the pre–post design adopted and the
rapid performance impairment 1 week after Cb-tDCS can be
considered to favour an effect of Cb-tDCS and as a further control
for practice effects.
Well-designed single-case studies allow for exploring the exact
pathophysiological mechanisms involved in these cases and
testing new therapeutic approaches. Considering the severity of
the speech disorder and the absence of side effects in our patient,
we believe that repetitive Cb-tDCS could be a possible treatment
for patients with dysarthria. However, further research is essential
before any recommendations can be made.
84 Letter to the editor / Annals of Physical and Rehabilitation Medicine 63 (2020) 81–84
Disclosure of interest
The authors declare that they have no competing interest.
Funding
The authors received no specific funding for this work.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://doi.dx.org/10.1016/j.rehab.2019.06.011.
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Francesco Panicof,*, Manel Ben-Romdhaneb, Timothee Jacquessonc,d,e,
Stuart Nashb, Francois Cottonc,d,e, Jacques Luautéa,b,e,**
a
Inserm UMR-S 1028, CNRS UMR 529, ImpAct, Centre de Recherche en
Neurosciences de Lyon, université Lyon-1, 16, avenue Lépine, 69676 Bron,
France
b
Service de rééducation neurologique, Hôpital Henry-Gabrielle, Hôpital
Neurologique, Hospices Civils de Lyon, Lyon, France
c
Imaging department, Centre Hospitalier Lyon Sud, Hospices Civils de
Lyon, 69310 Pierre Bénite, France
d
CREATIS, CNRS UMR 5220, INSERM U1044, Université Lyon 1, INSA Lyon,
69100 Villeurbanne, France
e
Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
f
Department of Psychology, University of Campania ‘‘Luigi Vanvitelli’’,
Viale Ellittico 31, 81100 Caserta, Italy
*Corresponding author. Department of Psychology, University of
Campania ‘‘Luigi Vanvitelli’’, Viale Ellittico 31, 81100 Caserta, Italy
**Co-corresponding author. Inserm UMR-S 1028, CNRS UMR 529,
ImpAct, Centre de Recherche en Neurosciences de Lyon, université
Lyon-1, 16, avenue Lépine, 69676 Bron, France
E-mail addresses: francesco.panico@unicampania.it (F. Panico).,
jacques.luaute@chu-lyon.fr (J. Luauté).
Received 20 March 2019
Accepted 22 June 2019
Available online xxx