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Stroke. Author manuscript; available in PMC 2010 June 1.
Published in final edited form as: Stroke. 2010 June ; 41(6): 1229–1236. doi:10.1161/STROKEAHA.109.576785.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Using transcranial direct current stimulation (tDCS) to treat stroke patients with aphasia
Julie Baker, Ph.D., Chris Rorden, Ph.D., and Julius Fridriksson, Ph.D. Department of Communication Sciences & Disorders, University of South Carolina
Background and Purpose—Recent research suggests that increased left hemisphere cortical activity, primarily of the left frontal cortex, is associated with improved naming performance in stroke patients with aphasia (PWA). Our aim was to determine if anodal transcranial direct current stimulation (A-tDCS), a method thought to increase cortical excitability, would improve naming accuracy in PWA when applied to the scalp overlying the left frontal cortex. Methods—Ten patients with chronic stroke-induced aphasia received five days of A-tDCS (1 mA; 20 min) and five days of sham tDCS (S-tDCS; 20 min, order randomized) while performing a computerized anomia treatment. tDCS positioning was guided using a priori functional MRI results for each individual during an overt naming task to ensure the active electrode was placed over structurally-intact cortex. Results—Results revealed significantly improved naming accuracy of treated items (F(1,9) = 5.72, p < 0.040) following A-tDCS as compared to S-tDCS. Patients who demonstrated the most improvement were those with perilesional areas closest to the stimulation site. Crucially, this treatment effect persisted at least one-week post-treatment. Conclusions—Our findings suggest that A-tDCS over the left frontal cortex can lead to enhanced naming accuracy in PWA and, if proved to be effective in larger studies, may provide a supplementary treatment approach for anomia. Keywords anomia; brain stimulation; functional magnetic resonance imaging (fMRI); neuronal plasticity; recovery of function
A relationship between aphasia recovery and functional brain changes of the damaged left hemisphere (LH) has recently been demonstrated.1,2 More specifically, in a review of functional neuroimaging studies investigating treatment-induced aphasia recovery, improved speech production was found to be dependent upon left frontal cortical activation.3 Another recent study revealed that increased cortical activity in preserved LH areas, particularly the frontal cortex, is associated with greater naming accuracy in patients with aphasia (PWA).4 These studies are based on observations of brain activation, however, and are generally interpreted as supporting the notion that intact regions of the LH play a crucial role in aphasia recovery. Our aim was to test this prediction by manipulating (rather than merely observing)
Corresponding author: Julie M. Baker, Ph.D., Department of Communication Sciences & Disorders, University of South Carolina, Tel: (843) 792-2712, Fax: (803) 777-3081, email@example.com. Conflict of Interest: None
10 Therefore. P4. In the present study. and a score above 93. 20-min) and S-tDCS (20-min) while concurrently performing a computerized anomia treatment. and relatively painless method for modulating cortical activity.44) participated in the current study. patients were not asked to perform a language task during the tDCS session. the patients varied with regard to their performance on diagnostic measures.5 (M = 69. the active electrode was placed on the scalp overlying the left frontal cortex. Secondly. while the reference electrode was placed on the right shoulder. SD = 11. was related to naming improvements in PWA.to 81-years (M = 65.4 Outcome measures included naming performance of both treated and untreated items following A-tDCS and StDCS. a noninvasive. Finally. the study was also designed to address the methodological limitations from the recent work by Monti and colleagues9 and to therefore incorporate the following: 1) optimized electrode positioning. tDCS delivers a weak polarizing electrical current to the cortex through a pair of electrodes. 10 patients with chronic aphasia underwent two separate weeks (five days per week) of A-tDCS (1 mA. which provides an overall measure of severity. Additionally. SD = 68. P7. recent work by Monti and colleagues9 challenges such a simple interpretation. the Aphasia Quotient (AQ). Subtest 6 (Inventory of Articulation Characteristics) of the Apraxia Battery for Stroke. which was approved by the University of South Carolina’s Institutional Review Board. Patients varied greatly with regard to time poststroke onset.97). AQ scores in the current study ranged from 26. in which lower scores denote more severe aphasia.60. Page 2 activation of the left frontal cortex through the application of transcranial direct current stimulation (tDCS). Consequently. with results typically demonstrating that language processing can be improved by applying A-tDCS to the LH. electrodes were placed on the same scalp coordinate for each patient regardless of aphasia type or severity. Author manuscript. 10-min) applied to Broca’s area resulted in an improved ability to name pictures in eight patients with chronic nonfluent aphasia. while the main goal of the present study was to determine if A-tDCS would improve naming accuracy in PWA when applied to the left frontal cortex. and P8) were classified with nonfluent aphasia. available in PMC 2010 June 1. P9. Aphasia assessment using the Western Aphasia Battery-Revised (WAB-R)11 revealed that six (P2. The WAB-R also yields a composite score. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Patients Materials & Methods Ten patients (five females) with chronic.36. P3.6–8 However. specifically of the left frontal cortex.3 to 93. and P10) of the ten patients were classified with fluent aphasia. while the remaining four patients (P1. brief administration of tDCS. the range of time post-stroke onset was 10 to 242 months (M = 64. We suggest three reasons that may help demonstrate why A-tDCS led to a null result. brain excitability can either be increased via anodal stimulation (A-tDCS) or decreased via cathodal stimulation (C-tDCS). there was only a single. in which C-tDCS (2mA. First. safe. SD = 25. The location and polarity of the active electrode was chosen based on the previously discussed evidence demonstrating that increased activation in the LH. P6. whereas other previous studies that found effects following A-tDCS. 2) multiple administrations of tDCS. For instance.50. Additionally.8 is considered to be within normal limits. and 3) a combined linguistic task. . no effects were noted following A-tDCS or sham (placebo-like) tDCS (StDCS). coupled the stimulation with a relevant task to engage the brain area. P5. We hypothesized that multiple administrations of A-tDCS to the scalp overlying the left frontal cortex would improve naming accuracy in PWA by exciting the underlying cortex causing even greater cortical activation. During both types of tDCS.Baker et al.6. and extent of brain damage (Table 1). lesion location. and depending on the polarity of the current flow.42).5 Previous work suggests that tDCS can modulate linguistic performances in both healthy and neurological patients. stroke-induced aphasia aged 45. it is quite probable that the targeted region may not have been intact in some if not all of the patients.
As for those patients who were not included. coordinates of the area of the left frontal cortex with the highest level of activation during correct naming on the previously completed fMRI naming task were entered into MRIreg. MRI data collection relied on a Siemens Trio 3T system.13 Hence.18 The location of voxels with the highest Z-scores in the left frontal cortex associated with correct naming for each patient is listed in Table 3. a computer program that allows for the identification of a region of the scalp near a particular brain region Stroke. All 15 patients from the previous fMRI study4 were considered for participation in the current study but only the current 10 patients were able to participate. a visual description scale designed for patients with limited verbal skills. 5) native English speaker. Author manuscript. and P8) presented with apraxia of speech (AOS. 3) previous brain surgery. coupled with the remaining stimulation type. was administered for five consecutive days followed by a seven-day rest period to avoid carry-over effects. Table 2).15 The stimulation and treatment task combination lasted for 20-min each session. and 6) been a participant in a previous study that included functional magnetic resonance imaging (fMRI) examination. blood pressure and heart rate were measured before and after each session. 4) pre-morbidly right-handed. Thus. Exclusion criteria were: 1) seizures during the previous 36months. a stimulation intensity of 1 mA was chosen given that no significant adverse effects have been reported at this intensity. and 4) medications that raise the seizure threshold. Whereas previous research has revealed an improvement in naming among aphasic patients following a single tDCS session. 3) < 85-years of age.Baker et al.16 To assess cardiovascular arousal. baseline naming tests. coupled with either A-tDCS or S-tDCS. and post-treatment naming testing. in which some aphasic patients showed improved picture naming following as few as five sessions with our computerized anomia treatment task. These coordinates were targeted for placement of the anode electrode.9 the current study design reflected evidence suggesting that multiple treatment sessions are associated with improved treatment outcome in aphasia. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript . another five-day treatment period was administered. a total of five consecutive days were devoted to each treatment phase. treatment administration. four had relocated out of state and one was unable to fit the current study requirements into his schedule which included full-time employment. a time chosen based on previous tDCS research which demonstrated that tDCS administration is safe up to 20-min.8 Finally. 2) > 6-months post-stroke onset. see Fridriksson and colleagues. available in PMC 2010 June 1.17 fMRI Task & Procedure Previously acquired high-resolution T1-MRI and fMRI results associated with an overt picture naming task were utilized in order to determine placement of the anode electrode on a patientby-patient basis. Next. we suggest that the current patient sample was ideal for an exploratory study as it included a group with a wide range of aphasia severities and varying biographical and lesion demographics.14 as well as following five treatment sessions utilizing clinician-administered anomia treatment in a separate study. P3. Specific inclusion criteria were: 1) onetime stroke in the LH. P2. P6. Page 3 Adults-Second Edition (ABA-2)12 revealed that five patients (P1. The computerized anomia treatment. Additionally. Study Design Diagnostic testing was followed by electrode positioning. Electrode Positioning In order to locate the cortical region to be stimulated by the anode electrode. 2) sensitive scalp.4 which was used to guide the location of cortical stimulation in the present study. For details on the naming task as well as the scanning parameters and data analyses. discomfort ratings were recorded following the end of each session using the Wong-Baker FACES Pain Rating Scale. We chose to administer five treatment sessions per phase based on our previous findings.
Half of the patients began treatment with A-tDCS during the first week and then proceeded to S-tDCS during the second week. Ascension Technology. Patients were randomly assigned to stimulation using a random number generator. and word length. For S-tDCS. the untreated word lists were controlled for word frequency. S-tDCS). transportation. This cap was carefully fitted on the patient prior to the start of each tDCS administration in order to accurately position the anode electrode in the same area from one day to the next. while the other half received the opposite order. and high-frequency nouns. .20 semantic content (categories such as animals. During both A-tDCS and S-tDCS. available in PMC 2010 June 1.14 This treatment occurred concurrently with the application of tDCS and lasted for 20-min per session. Salt Lake City. Each picture appeared an equal amount of times and occurred randomly during the 20-min session. To determine generalization from treated to untreated items. medium-. see Fridriksson and colleagues. tDCS tDCS (1 mA) was delivered for 20-min per session via two saline-soaked sponge electrodes (5 × 5 cm) and a constant current stimulator (Phoresor® II PM850. the desired cortical region was located and demarcated on a latex cap worn by the patient. Outcome Measures To determine whether the patients’ ability to name the treated items improved over the course of each treatment phase (A-TDCS vs. Author manuscript. a computerized naming test consisting of the 25 treated nouns for each phase was administered at baseline. Page 4 (www. medium-. while the other half received the opposite order. To avoid potential confounding factors arising from placing electrodes of two polarities near the brain. This type of computerized treatment was utilized in a previous study and demonstrated to be useful in improving the naming abilities in PWA.). The untreated word lists (untreated List A and untreated List B) were each comprised of 50 color pictures depicting low-. Half of the patients received List A during the first week of treatment and then List B during the second week. For details on the treatment. Burlington.. etc. VT). the cap was removed and the electrodes were held in place with self-adhesive bandages. Treatment Stimuli The computerized treatment included two separate word lists (List A and List B). the reference cathode electrode was placed on the right shoulder (Figure 1). The two word lists were controlled for word frequency.html). Each word list was comprised of 25 color pictures depicting low-. and high-frequency nouns. the stimulator was turned off following 30 s of stimulation since the perceived sensations of tDCS on the skin have been found to fade away by the first 30 s of administration. two additional untargeted word lists (one for each stimulation type) were administered.19 Thus. This was accomplished on a patient-by-patient basis and was therefore tailored for each individual to ensure the active electrode was placed over structurally-intact rather destroyed cortex. immediately following the fifth (and final) session of each treatment phase (T1). 18 semantic content. and word length (number of syllables per word). and one-week following the final session of each treatment phase (T2) to examine performance maintenance. Iomed® Inc. The treated and untreated word lists were combined NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Stroke. Following positioning. patients were blinded to stimulation type.mricro.com/mrireg.Baker et al. the anode electrode was placed over the pre-designated area on the scalp overlying the left frontal cortex. Utah) that was placed out of the patients’ sight behind a partition. as it is hard to infer which electrode is influencing performance. Utilizing MRIreg and a magnetic positioning tracker system (Flock of Birds. Similar to the treated word lists. Anomia Treatment The self-administered anomia treatment consisted of a picture-word matching task.
range = 0–25) at T2. as well as discomfort ratings were compared between both tDCS conditions utilizing Mann-Whitney U tests. T2) as factors. and ten treatment sessions.745). Responses were audio-recorded and later transcribed and scored by two speech-language pathologists (SLPs) who were blinded to the stimulation type (A-TDCS vs. Neither the analysis of the main effect of time (F(1. time) was conducted for the treated items. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Results All patients tolerated tDCS well and no adverse effects related to the application of tDCS were demonstrated. Stroke. Illinois). six testing sessions.mricro.81. A 2×2 repeated measures ANOVA (stimulation. Therefore. two-tailed p < 0. . along with the MannWhitney U tests.9) = 0. T1 vs. range = 0–25) at T1 (immediately after treatment termination). as well as to determine the influence of the two sets of word lists that were utilized for treatment and testing for both treated and untreated items.116. The total number of treatment and testing sessions was seventeen per patient.1/25 (SD = 9.015. Following S-tDCS treatment.2/25 (SD = 8. range = 0–25) at baseline. 21 in which a medium effect size (0. Treated Items During the A-tDCS phase. S-tDCS).0 software package (SPSS.140) was found. using SPSS Version 15. 15.95 p< 0. range = 0–25) at T1. which were executed.9) = 0. Inc. available in PMC 2010 June 1. Analysis of the main effect of stimulation type revealed that statistically more treated items were named correctly following A-tDCS as compared to S-tDCS (F(1. Changes in blood pressure and heart rate from pre. Finally. During the S-tDCS phase.79.to post-tDCS administrations.2/25 (SD = 9. Our hypothesis was that tDCS would enhance treatment. Chicago. made tie-breaking decisions. and 17.. the mean number of correctly named treated items was 14. p < 0. To estimate the magnitude of this statistically significant effect.9) = 5.112. correlation analyses were performed to examine the relationships between treatment outcome and patient demographics. who was also blinded. a 2×2 repeated measures analysis of variance (ANOVA) was performed for both treated and untreated items using stimulation type (A-TDCS.53. t(9)=1. the mean number of correctly named treated items was 14. Page 5 (treated List A was combined with untreated List A and vice versa for List B) during testing to equal 75 items. Pictures representing each item were displayed on a laptop computer screen.8/25 (SD = 9.07. p < 0.7/25 (SD = 9.040). Statistics To examine the effect of tDCS on treatment outcome. All ANOVAs were performed using ezANOVA (www. a third SLP.6/25 (SD = 9. and patients were asked to overtly name each picture as soon as it was displayed.Baker et al. and type of item (treated vs.44.741) or the analysis of the interaction (stimulation. range = 0–24) at baseline. the total increase in correct naming responses for the entire group was 15 items at T1 and 11 items at T2 (Table 4). we used the generalized eta squared as suggested for repeated measures designs by Olejnik and Algina. untreated). S-tDCS) and time (T1. including one diagnostic testing session. time) reached statistical significance (F(1. Following A-tDCS treatment. we conducted a post-hoc (uncorrected) 1-tailed t-tests that revealed a benefit for tDCS versus sham at both the T1 and T2 (t(9)=2.60 p< 0. Additional 2×2 repeated measures ANOVAs were performed to determine the influence of stimulation order on treatment outcome for both treated and untreated words. administration attempt (baseline vs. range = 0–25) at T2 (one-week following treatment termination).com/ezanova). Note that treatment outcome was determined as change in correct naming at the end of treatment compared to baseline.69. T2). and 15. 17. Author manuscript. the total increase in correct naming responses for the entire group was 36 treated items at T1 and 35 treated items at T2. In cases of disagreement. All patients completed both treatment phases and all accompanying testing sessions.72.042).
p < 0. and 30. we conducted a planned (uncorrected) 1-tailed t-tests that revealed a benefit for tDCS versus sham at both the T1 and T2 (t(9)=1. Author manuscript. Correlations NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Word Lists Multiple correlations were performed to examine the relationship between naming performance following A-tDCS treatment and the following variables: 1) age. Discomfort Ratings Patient discomfort ratings ranged between 0 and 2 out of 5 (mean = 0. Following A-tDCS treatment. SD = 0. Heart Rate Changes in blood pressure and heart rate from pre.25.155) or untreated items (F(1.90 p< 0. p < 0.584.812).35. diastolic blood pressure (p < 0. the total increase in correct naming responses for the entire group was 3 items at T1 and 15 items at T2 (Table 4).05) relationships were revealed (Table 5). No difference in treatment outcome between the usage of List A and List B was found for the treated items (F(1. and 6) AOS severity as measured by the ABA-2.36. the total increase in correct naming responses for the entire group was 40 untreated items at T1 and 42 untreated items at T2.641) from pre. range = 0–47) at baseline.9) = 0. 31. 3) months post-stroke onset.to post-tDCS administration did not differ between A-tDCS and S-tDCS. p < 0. p < 0.3/50 (SD = 18.9) = 0. Accordingly. and heart rate (p < 0.12.5/50 (SD = 18.to post-tDCS administration were calculated to determine if the measures were comparable in both tDCS conditions. Neither the analysis of the main effect of time (F(1.880.464).045. To determine whether the word lists differed in difficulty.9) = 220.127.116.11/50 (SD = 17.073).948). time) reached statistical significance (F(1.24. range = 0–48) at T2.844. To estimate the magnitude of this effect. time) was performed.9) = 5.39) during S-tDCS.9) = 0. 4) lesion size measured in cc3.89 p< 0.15.9) = 0.56) during A-tDCS and ranged between 0 and 2 out of 5 (mean = 0.373) or the analysis of the interaction (stimulation.63. A 2×2 repeated measures ANOVA (stimulation. range = 0–50) at T1. 2×2 repeated measures ANOVA (list.21 in which a medium effect size (0. we performed a post-hoc analysis here consistent with our prediction that tDCS leads to improved naming performance compared to sham. Statistical analysis revealed that the discomfort ratings were comparable between A-tDCS and Stroke. p < 0.167) was revealed.742) or untreated items (F(1. a 2×2 repeated measures ANOVA (order of treatment. the mean number of correctly named untreated items was 28. SD = 0. During the S-tDCS phase.382). p < 0. Following S-tDCS treatment. 5) aphasia severity as measured by the AQ from the WAB-R. Mann-Whitney U tests revealed that changes in systolic blood pressure (p < 0.72.Baker et al.18. Page 6 Treatment Generalization During the A-tDCS phase.9/50 (SD = 18.880. 28.9) = 0. . As with treated items. p < 0. No significant (p < 0.046). Treatment Order To determine whether the order of stimulation affected treatment outcome. time) did not reach two-tailed statistical significance (F(1. Blood Pressure. time) was performed and revealed that an order effect was not present for the treated items (F(1. range = 0–48) at baseline. t(9)=1.6/50 (SD = 18. range = 0–48) at T1.1/50 (SD = 18. available in PMC 2010 June 1. we used generalized eta squared. range = 0–50) at T2. the mean number of correctly named untreated items was 27. 2) years of education.373). and 31.
it may be possible that the positive treatment outcome revealed in the current study following A-tDCS to the left frontal cortex may be specific to naming improvements. this study demonstrated that improvements in naming performance were maintained for at least one-week post-treatment. as an order effect was not revealed between A-tDCS and S-tDCS nor was a difference revealed for the difficulty level between words lists A and B. Similar to the present research. Therefore. education level. lesion size. Author manuscript. Furthermore. statistically more treated items were named correctly following A-tDCS as compared to S-tDCS and numerically more untreated items were named correctly following A-tDCS as compared to S-tDCS. For instance. While our small sample size (n = 10) makes strong conclusions impossible. and although the specific cortical location may vary. it presumably improved the patients’ ability to name pictures by focally stimulating function of the left frontal cortex. the present study included 10 patients with chronic.. stroke-induced aphasia who each underwent five sessions of A-tDCS (1 mA.4 Results from the present study reinforce this finding. and AOS severity) (Table 5). Primarily. and naming accuracy in PWA.477). indicating that patients did not report a difference in comfort level between the two conditions. . While the current study revealed a statistically significant enhancement for A-tDCS. individual patients exhibited a wide range of treatment outcomes. Various observations can help explain why A-tDCS over a region of the left frontal cortex improved the naming abilities in PWA. the patient (P8) with the longest time post-stroke (242- Stroke. especially the left frontal cortex. Finally.6–8 The difference in treatment outcome between A-tDCS and S-tDCS could not be explained by unspecific arousal differences.23 Therefore.22. Page 7 S-tDCS (Mann-Whitney U. it is probable that improved speech and language functioning following aphasia treatment relies. differences could not be explained by scalp sensation attributed to the different stimulation types. The results suggest that A-tDCS significantly improves naming accuracy in PWA. that the present results do not discount the role of the RH in aphasia recovery. Explicitly. p < 0. however. Additionally.1–4 It is important to note. as several studies have revealed that right hemisphere regions reflect a compensatory network. a recent fMRI study investigated the activation of both hemispheres in 15 patients with chronic aphasia during an overt picture naming task. age. Thus. this region has been revealed to be exceedingly important for aphasia recovery. 20-min) and five sessions of S-tDCS (20-min) combined with a computerized anomia treatment. We suggest that treatment success was not related to biographical factors (e. aphasia severity. on spared LH regions.to post-tDCS administrations were found to be comparable across both tDCS conditions. Understanding this variability may be important in optimizing treatment and justifying the clinical benefit for tDCS. The results revealed a positive linear relationship between intensity of activation of the LH. These findings are in agreement with previous evidence demonstrating that A-tDCS over the LH improves language processing. For instance. other studies have implicated the LH in aphasia recovery. and the administration of A-tDCS to other areas of the LH and possibly even the RH may improve the performance of other linguistic functions in PWA. as changes in the patients’ blood pressure and heart rate recordings from pre. since A-tDCS increases cortical excitability. as it suggests that improved naming in PWA is supported by the left frontal cortex. we believe that these are important considerations for the development of future studies. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Discussion To better understand the effect of tDCS upon aphasia recovery. available in PMC 2010 June 1. at least partly.Baker et al. differences could not be attributed to the order of stimulation type or word list difficulty. as patients did not report a difference in their comfort levels between A-tDCS and S-tDCS. we feel it is important to speculate regarding the source of this variability.g.
First. suffered damage to left frontal cortex. The current experimental design necessarily limits the inferences that can be drawn from this study. Additionally. and thus. available in PMC 2010 June 1.. Page 8 months). For instance. future studies should consider the inclusion of functional communication measurements to determine the functional relevance of tDCS. one could imagine a situation where beneficial changes are preferentially sustained through a Hebbian process. and second most severe aphasia according to the WAB-R (AQ: 27.2 cc3). in which decreased cortical activation elicited by C-tDCS might inhibit picture naming. and P8) who benefitted the most from A-tDCS had frontal lobe damage. Author manuscript. it is possible that stimulating areas closest to a patient’s perilesional area will result in the greatest amount of naming improvement (as presumably the residual portions of a damaged module are often crucial for rehabilitation). it was presumed that the opposite outcome might be true. two of the patients (P4 and P7) performed nearly at ceiling during baseline testing. This was a clinical decision based on our hypothesis. That is. while detrimental changes have no long-term consequences. this latter speculation cannot be verified with the present data since our study only included frontal lobe stimulation. and P8) displayed clear improvements following A-tDCS as compared to S-tDCS. had limited room for improvement. while the remaining four patients (P1. A-tDCS entrains parts of the network that need to be up-regulated. These observations lead us to speculate on two possible reasons why some of our patients benefitted from tDCS more than others. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Stroke. Three out of these latter four patients (P1. three of the four patients (P1. Interestingly. Clearly. we do not have evidence to comment on the intriguing beneficial effect for C-tDCS reported by Monti and colleagues.9 While it is convenient to consider increased and decreased cortical excitability as being mutually exclusive. thus.g. both AOS and nonfluent aphasia are associated with damage to the left frontal cortex. P9. it may be possible that PWA who benefit the most from A-tDCS to the left frontal cortex are those with either or both AOS and nonfluent aphasia. it is possible that measuring reaction time rather than just naming accuracy could have revealed a more sensitive measure of performance change for those patients who performed nearly at ceiling during baseline testing (e. P2. Specifically. and P10) displayed improvements following both A-tDCS and S-tDCS. For example. not all of the patients showed improved naming. P5. provides clear directions for future research..g. it is important for future tDCS studies to conduct follow-up testing at longer intervals (e. Additionally. one-month. whereas most of the patients who showed less improvement tended to have posterior damage.5) displayed improved naming. which suggested that naming performance is positively correlated with cortical excitability. P2. while our findings provide clear evidence regarding the beneficial role of AtDCS.24 which was the area stimulated in the present study. which. In this scenario. and P8) presented with AOS and two of the four (P1 and P8) were classified as having nonfluent aphasia. in turn. Finally. Therefore. whereas C-tDCS stimulation encourages downregulation of other portions of the same network. P5. largest lesion (342. 6–8 Therefore. This decision was also based on the results of numerous studies suggesting greater benefit associated with A-tDCS compared to C-tDCS. Secondly. twoweeks. etc. .) to determine if treatment effects endure past one-week post-treatment. the current study did not assess functional language abilities. we concede that it is possible that both AtDCS and C-tDCS may be beneficial. therefore. This suggests that frontal lobe stimulation is most beneficial for patients with frontal lobe damage whereas posterior stimulation may be more beneficial for those PWA who also present with primarily posterior damage. However. One important caveat related to the present work is that it did not address the effect of C-tDCS upon naming. Other patients (P3. P4 and P7).Baker et al. It should also be noted that the one of these four particular patients who did not present with AOS (P5). followup testing was performed relatively soon following treatment completion. one patient (P6) presented with very severe speech and language deficits and did not produce a single correct naming response during any of the six testing sessions.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Acknowledgments Sources of Funding: This work was supported by the following grants: DC008355 (PI: JF). semantic content (e. Hesse S. Picchioni D. [PubMed: 18303984] 7. it is possible that more sessions (> 5 sessions).8 Furthermore. ES. 6. Activity in preserved left hemisphere regions predicts anomia severity in aphasia. there was a wide range of treatment outcomes among the current patients. Mattu U. Higgins. Solomon JM. 5. the current treatment was designed to reveal that the inclusion of tDCS could supplement behavioral aphasia treatment due to its portability and simplicity of application. [PubMed: 15753425] Stroke.. [PubMed: 17525865] 2. References 1. further investigation involving greater number of patients is needed to confirm the effect revealed in the current pilot study. Curr Opin Neurol 2007.g. Pursley RH. Wierenga CE. Bacon-Moore A. Functional MRI of language in aphasia: A review of the literature and the methodological challenges. these findings suggest that tDCS can aid in anomia recovery among stroke patients. Washington. Moser D.25:9–15. . may provide a supplementary treatment approach for anomia. J Cogn Neurosci.Baker et al. White KD. Briggs RW. Kirker SG. DC: American Psychiatric Press. 2009 In Press.. Jenrich W. Lomarev M. Recovery and treatment of aphasia after stroke: functional imaging studies. Safety and cognitive effect of frontal DC brain polarization in healthy individuals. Restor Neurol Neurosci 2007. Bonilha L.20:1415–1422.64:872–875. Moreover.20:667–673... Brain Stimulation Therapies for Clinicians. Crosson B. MS. Baker JM. as is always the case with exploratory research. Birn RM. Knecht S. In closing. Finally. 3. incorporating more higher-frequency words for patients with severe aphasia and more lower-frequency words for patients with mild aphasia). the current study demonstrates that A-tDCS to the scalp overlying the left frontal cortex can significantly improve naming accuracy in some PWA and. Neurology 2005. Raymer AM. [PubMed: 17473391] 8. Michka O. [PubMed: 17992087] 4. Given the beneficial effect observed after five 20-min anodal tDCS (1 mA) sessions. Combined transcranial direct current stimulation and robot-assisted arm training in subacute stroke patients: a pilot study. as is almost always the case with aphasia treatment. Chang YL. Flöel A. as long as current safety guidelines are strictly followed. Non-invasive brain stimulation improves language learning. Rather.g. Braun AR. Postman-Caucheteux WA. McArdle J. DC009571 (PI: JF & CR). and NS054266 (PI: CR). Single-trial fMRI shows contralesional activity linked to overt naming errors in chronic aphasic patients. Sherod MD. Schonhardt EM. George. Breitenstein C. Grafman J.17:157–177.g. this study provides further evidence suggesting that preserved regions of the LH are important for aphasia recovery. Bardeleben A. McGregor K. J Cogn Neurosci 2008. modifying word lists by selecting words that are meaningful and functionally relevant for each patient). Cereb Cortex. Wasserman EM. Butman JA. 2009 In Press. available in PMC 2010 June 1. Conway TW. lengthening the time for patients with slower reaction time). Sato S. and greater stimulation intensity (> 1 mA) could have elicited even greater success. However. This could be accomplished by manipulating factors such as overall word frequency (e. 2008. Benjamin M. Fridriksson J. if proved effective by larger studies. Crinion JT. Gopinath KS. Author manuscript. it is straightforward to speculate that improved treatment outcome could be obtained by tailoring the treatment to better fit individual patients. Rorden C. Page 9 It is imperative to note that the positive treatment outcome associated with the administration of anodal tDCS combined with an anomia treatment does not lessen the importance of clinicianadministered aphasia treatment. Iyer MB. but nevertheless. Neuropsychol Rev 2007. and the time interval between the picture display and onset of the spoken word (e. Werner C. Rösser N. Leff AP. longer sessions (> 20-min).
Page 10 9. Monti A. Padberg F. Crinion J. Moser D. Meister IG. Foley NC. Balduyck S. Brain 2005. Barker PB. [PubMed: 3344163] 18. Dafotakis M. Frances. De Boissezon X. Breese EL. Right anterior superior temporal activation predicts auditory sentence comprehension following aphasic stroke. Kertesz. Démonet JF. Puel M.127:1479–1487. Maurer K. Mameli F.30:2487–2498. Western Aphasia Battery-Revised.70:290–298. [PubMed: 13680518] 14. Frequency Analysis of English Usage. Ferrucci R. Moser D. Palm U. [PubMed: 15090478] NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript Stroke. [PubMed: 18096677] 10.46:261–268. WN. Bézy C. 2000.79:451–453. Mrakic-Sposta S. Morrow-Odom KL. 13. Hum Brain Mapp 2009a. Vesselinov R. Wong DL. [PubMed: 16234297] 23. Inc. Enhancing language performance with non-invasive brain stimulation—a transcranial direct current stimulation study in healthy humans. Transcranial direct current stimulation (tDCS). 2. Reisinger E. 12. Apraxia Battery for Adults. Keeser D. Marceglia S. Re-examining the brain regions crucial for orchestrating speech articulation. Fridriksson A. Priori A. Algina J. Pain in children: comparison of assessment scales. Price CJ. [PubMed: 19164782] 15. Vergari M. Right hemisphere activation in recovery from aphasia: lesion effect or function recruitment? Neurology 2008. San Antonio: Harcourt Assessment. Improved naming after transcranial direct current stimulation in aphasia.45:1812–1822.40:853–858. Cardebat D. [PubMed: 14677402] 20. [PubMed: 17292928] 16. Cogiamanian F. Baker JM. Zago S. Fintescu Z. Nitsche M. Teasell RW.56:249– 254. Whiteside J. Marie N. Skin lesions after treatment with transcranial direct current stimulation (tDCS). Speechley MR. Jacobs MA. . Top Stroke Rehabil 2003. Fink GR. Fridriksson J. Brain 2004. [PubMed: 19294641] 19. A. Boston: Houghton Mifflin. Cortical mapping of naming errors in aphasia. Inc. J Neurol Neurosurg Psychiatry 2008. Shaw H. Treating visual speech perception to improve speech production in nonfluent aphasia. H. 2007. available in PMC 2010 June 1. Psychol Methods 2003. Fridriksson J. Baker C. Neuropsychologia 2007.14:9–17. Brain Stimulat 2008. Neural correlates of phonological and semantic-based anomia treatment in aphasia.1:386–387. Olejnik S. [PubMed: 18209203] 24.10:66–76. Dabul. Sparing R.. Hillis AE. Rehabilitation of aphasia: more is better. Paulus W.Baker et al. 1982.8:434–447. Eoute D. Neuropsychologia 2008. Moser D. [PubMed: 17804023] 11. Baylis GC. Work M. Baker JM. Rorden C. OR: CC Publications. Generalized eta and omega squared statistics: measures of effect size for some common research designs. [PubMed: 14664681] 22. Author manuscript. BL. Fridriksson J. Bonilha L. Pediatr Nurs 1988. Raboyeau G. Kucera. Suppl Clin Neurophysiol 2003.128:2858–2871. 21. Schiller C. Thirugnanasambandam N. 17. Tigard. Bhogal SK. Stroke 2009b. Rorden C.
NIH-PA Author Manuscript Stroke. Example of the treatment set-up. while the reference cathode electrode (c) was placed over the right shoulder. The constant current stimulator (d) was placed out of the patients’ sight behind a partition.Baker et al. the anode electrode (b) was placed over the predesignated area on the scalp overlying the left frontal cortex. Author manuscript. available in PMC 2010 June 1. Page 11 NIH-PA Author Manuscript NIH-PA Author Manuscript Figure 1. Patients trained on a computerized picture-word matching task (a) while receiving transcranial direct current stimulation (tDCS). . During both anodal tDCS and sham tDCS treatment phases.
BA 48.60 Baker et al. BA 40. and BA 42 64 Damage involves BA 44. the anterior insula.31 68. BA 42.44 * Measured in years † Measured in months Stroke. BA 37.60 39 Damage involves posterior portion of BA 21as well as BA 22.42 64. and putamen.50 SD 11.2 48. BA 39.92 29. BA 42. and insula.39 56. BA 37.49 342. ‡ BA: Brodmann’s area § Measured in cc3 NIH-PA Author Manuscript Page 12 NIH-PA Author Manuscript NIH-PA Author Manuscript . and middle and inferior portions of BA 6. BA 45. Author manuscript. BA 41.23 40. BA 22. BA 44. BA 39) with extension into the occipital lobe 102 14 Damage involves BA 45. and the middle and anterior insula Post-Stroke Onset† Lesion Location‡ Lesion Size§ 87.42 23. only minor involvement of BA 44 Damage involves BA 6. BA 21.45 48. as well as damage to BA 22. BA 40.57 56.00 2. and the posterior portion of BA 38 Complete destruction of BA 44.13 74. and inferior portion of BA 40 60 57 Damage involves BA 22. anterior portion of BA 38. available in PMC 2010 June 1. BA 38. and BA 39 14 242 44 Damage mostly involving BA 37 and inferior portion of the left precuneus Entire MCA distribution and portions of the anterior medial frontal lobe. BA 45. P Sex Age* 1 M 60 2 M 53 3 F 45 4 F 75 5 M 58 6 F 64 7 F 71 8 M 72 9 F 81 10 M 76 M 65.15 96. deep white matter involvement including the pyramidal tract 10 Damage involves portions of BA 22.Table 1 Biographical information and lesion description Education* 16 12 14 12 12 16 18 12 16 12 14. BA 48. basal ganglia involvement Damage mostly involves middle and posterior portions of the temporal lobe (BA 20.76 8.
Author manuscript.7 51.8 93.05 7.0 9.8 80.9 7. available in PMC 2010 June 1. Page 13 NIH-PA Author Manuscript NIH-PA Author Manuscript . Maximum score of 100 ‡ Maximum score of 60 Stroke.2 5.7 2.95 10 9.15 9.8 3.5 9.05 8.7 72. Score > 5 signifies presence of apraxia of speech NIH-PA Author Manuscript Baker et al.6 89.75 7.9 9.6 67.0 27.85 9.8 8.Table 2 Diagnostic testing information Western Aphasia Battery-Revised Auditory Comprehension* Aphasia Type Broca’s Anomic Broca’s Anomic Anomic Broca’s Anomic Broca’s Anomic Anomic 36 7 2 46 1 30 3 10 2 11 4 4 44 3 10 12 38 6 17 10 8.15 6.85 5.5 8.30 0 26.4 8.3 9.1 4.65 9.9 0.1 Repetition* Naming* AQ† Boston Naming Test-2‡ Apraxia Battery for Adults-2§ P 4 8 4 9 9 1 9 1 7 9 Content* Fluency* 1 8 2 9 3 7 4 10 5 9 6 2 7 9 8 2 9 7 10 9 * Maximum score of 10 † AQ: Aphasia Quotient.7 7.0 8.7 7.5 7.5 3.3 91.6 92. § Range of scores: 0–15.
‡ BA: Brodmann’s area NIH-PA Author Manuscript Page 14 NIH-PA Author Manuscript NIH-PA Author Manuscript . Author manuscript.org) Stroke. y.Table 3 Coordinates and location of voxels with the highest Z-scores associated with correct naming/location of the anode electrode z* 60 12 4 46 44 14 10 30 16 12 Precentral gyrus 6 Inferior frontal gyrus 44 Superior frontal gyrus 9 Inferior frontal gyrus 45 Middle frontal gyrus 46 Precentral gyrus 6 Precentral gyrus 6 Middle frontal gyrus 10 Precentral gyrus 6 Precentral gyrus 6 Location† BA‡ Baker et al. & z: Montreal Neurological Institute coordinates † Anatomical locations were determined using the Talairach Daemon (www. P x* y* 1 39 15 2 55 4 3 36 52 4 48 4 5 44 6 6 28 46 7 54 20 8 12 46 9 52 16 10 60 2 * x.talairach. available in PMC 2010 June 1.
Table 4 Change in the number of correctly named treated and untreated items between post-treatment testing and baseline testing following anodal tDCS (A-tDCS) and sham tDCS (S-tDCS) 1-Week Post-Treatment > Baseline A-tDCS Treated Items 8 3 5 1 6 0 1 3 5 3 35 11 42 6 10 9 15 2 1 6 0 3 1 0 1 1 0 0 0 2 2 0 0 1 2 5 5 0 2 9 1 2 10 1 S-tDCS Treated Items A-tDCS Untreated Items S-tDCS Untreated Items Baker et al. Author manuscript. Immediate Post-Treatment > Baseline P 2 1 1 2 1 0 1 1 2 2 3 A-tDCS Treated Items S-tDCS Treated Items A-tDCS Untreated Items S-tDCS Untreated Items 1 5 0 17 2 5 4 6 3 10 10 3 4 1 0 1 5 6 0 6 6 0 0 0 7 1 1 1 8 2 2 2 9 3 3 1 10 3 1 5 Stroke. available in PMC 2010 June 1. Total 36 15 40 NIH-PA Author Manuscript Page 15 NIH-PA Author Manuscript NIH-PA Author Manuscript .
152 0.05).229 0.030 0.252 0.Table 5 Correlations matrix for treatment outcome (change scores) and biographical information.535 0.402 0.290 0.048 0. measured by Subset 6 from the Apraxia Battery for Adults-Second Edition Stroke. # Treated and untreated items combined NIH-PA Author Manuscript Baker et al.105 0. Page 16 NIH-PA Author Manuscript NIH-PA Author Manuscript . Age* 0. available in PMC 2010 June 1.182 0. Author manuscript.126 0.043 0.175 0.233 0.186 0. None of the relationships reached significance (p < 0.613 0.306 Education* Post-onset† Lesion size‡ Aphasia severity§ AOS severity|| Treated items Untreated items Total items# * Measured in years † Measured in months ‡ Measured in cc3 § Measured by the Aphasia Quotient from the Western Aphasia Battery-Revised || AOS: Apraxia of speech.049 0.
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