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. 2019 May 21;5(5):CD009760.
doi: 10.1002/14651858.CD009760.pub4.

Transcranial direct current stimulation (tDCS) for improving aphasia in adults with aphasia after stroke

Bernhard Elsner  1 , Joachim Kugler, Marcus Pohl, Jan Mehrholz
Affiliations

Transcranial direct current stimulation (tDCS) for improving aphasia in adults with aphasia after stroke

Bernhard Elsner et al. Cochrane Database Syst Rev. .

Abstract

Background: Stroke is one of the leading causes of disability worldwide and aphasia among survivors is common. Current speech and language therapy (SLT) strategies have only limited effectiveness in improving aphasia. A possible adjunct to SLT for improving SLT outcomes might be non-invasive brain stimulation by transcranial direct current stimulation (tDCS) to modulate cortical excitability and hence to improve aphasia.

Objectives: To assess the effects of tDCS for improving aphasia in people who have had a stroke.

Search methods: We searched the Cochrane Stroke Group Trials Register (June 2018), CENTRAL (Cochrane Library, June 2018), MEDLINE (1948 to June 2018), Embase (1980 to June 2018), CINAHL (1982 to June 2018), AMED (1985 to June 2018), Science Citation Index (1899 to June 2018), and seven additional databases. We also searched trial registers and reference lists, handsearched conference proceedings and contacted authors and equipment manufacturers.

Selection criteria: We included only randomised controlled trials (RCTs) and randomised controlled cross-over trials (from which we only analysed the first period as a parallel group design) comparing tDCS versus control in adults with aphasia due to stroke.

Data collection and analysis: Two review authors independently assessed trial quality and risk of bias, and extracted data. If necessary, we contacted study authors for additional information. We collected information on dropouts and adverse events from the trials.

Main results: We included 21 trials involving 421 participants in the qualitative synthesis. Three studies with 112 participants used formal outcome measures for our primary outcome measure of functional communication - that is, measuring aphasia in a real-life communicative setting. There was no evidence of an effect (standardised mean difference (SMD) 0.17, 95% confidence interval (CI) -0.20 to 0.55; P = 0.37; I² = 0%; low quality of evidence; inverse variance method with random-effects model; higher SMD reflecting benefit from tDCS; moderate quality of evidence). At follow-up, there also was no evidence of an effect (SMD 0.14, 95% CI -0.31 to 0.58; P = 0.55; 80 participants ; 2 studies; I² = 0%; very low quality of evidence; higher SMD reflecting benefit from tDCS; moderate quality of evidence).For our secondary outcome measure, accuracy in naming nouns at the end of intervention, there was evidence of an effect (SMD 0.42, 95% CI 0.19 to 0.66; P = 0.0005; I² = 0%; 298 participants; 11 studies; inverse variance method with random-effects model; higher SMD reflecting benefit from tDCS; moderate quality of evidence). There was an effect for the accuracy in naming nouns at follow-up (SMD 0.87, 95% CI 0.25 to 1.48; P = 0.006; 80 participants; 2 studies; I² = 32%; low quality of evidence); however the results were not statistically significant in our sensitivity analysis regarding the assumptions of the underlying correlation coefficient for imputing missing standard deviations of change scores. There was no evidence of an effect regarding accuracy in naming verbs post intervention (SMD 0.19, 95% CI -0.68 to 1.06; P = 0.67; I² = 0%; 21 participants; 3 studies; very low quality of evidence). We found no studies examining the effect of tDCS on cognition in people with aphasia after stroke. We did not find reported serious adverse events and the proportion of dropouts and adverse events was comparable between groups (odds ratio (OR) 0.54, 95% CI 0.21 to 1.37; P = 0.19; I² = 0%; Mantel-Haenszel method with random-effects model; 345 participants; 15 studies; low quality of evidence).

Authors' conclusions: Currently there is no evidence of the effectiveness of tDCS (anodal tDCS, cathodal tDCS and Dual-tDCS) versus control (sham tDCS) for improving functional communication in people with aphasia after stroke (low quality of evidence). However, there is limited evidence that tDCS may improve naming performance in naming nouns (moderate quality of evidence), but not verbs (very low quality of evidence) at the end of the intervention period and possibly also at follow-up. Further methodologically rigorous RCTs with adequate sample size calculation are needed in this area to determine the effectiveness of this intervention. Data on functional communication and on adverse events should routinely be collected and presented in further publications as well as data at follow-up. Further study on the relationship between language/aphasia and cognition may be required, and improved cognitive assessments for patients with aphasia developed, prior to the use of tDCS to directly target cognition in aphasia. Authors should state total values at post-intervention as well as their corresponding change scores with standard deviations.

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Conflict of interest statement

Bernhard Elsner: none known Joachim Kugler: none known Marcus Pohl: none known Jan Mehrholz: none known

Figures

1
1
Study flow diagram. Please note, that the numbers of full texts is not necessarily equal to the numbers of included studies, since two of included studies (Meinzer 2016, Shah‐Basak 2015) have been published in two full texts each.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study
3
3
Funnel plot of comparison: 1 tDCS alone or tDCS plus speech and language therapy (SLT) or any other approach for improving aphasia versus sham tDCS alone or sham tDCS plus SLT or any other approach for improving aphasia, or no intervention, outcome: 1.3 Language impairment: accuracy of naming post intervention
1.1
1.1. Analysis
Comparison 1 tDCS plus speech and language therapy (SLT) versus sham tDCS plus SLT for improving aphasia, Outcome 1 Functional communication post intervention.
1.2
1.2. Analysis
Comparison 1 tDCS plus speech and language therapy (SLT) versus sham tDCS plus SLT for improving aphasia, Outcome 2 Functional communication at follow‐up.
1.3
1.3. Analysis
Comparison 1 tDCS plus speech and language therapy (SLT) versus sham tDCS plus SLT for improving aphasia, Outcome 3 Language impairment: accuracy of naming nouns post intervention.
1.4
1.4. Analysis
Comparison 1 tDCS plus speech and language therapy (SLT) versus sham tDCS plus SLT for improving aphasia, Outcome 4 Language impairment: accuracy of naming nouns at follow‐up.
1.5
1.5. Analysis
Comparison 1 tDCS plus speech and language therapy (SLT) versus sham tDCS plus SLT for improving aphasia, Outcome 5 Language impairment: accuracy of naming verbs post intervention.
1.6
1.6. Analysis
Comparison 1 tDCS plus speech and language therapy (SLT) versus sham tDCS plus SLT for improving aphasia, Outcome 6 Safety: dropouts and adverse events until post intervention.
2.1
2.1. Analysis
Comparison 2 Planned subgroup analysis by time since stroke: acute or subacute versus chronic, Outcome 1 Functional communication at the end of intervention phase.
3.1
3.1. Analysis
Comparison 3 Planned subgroup analysis by location of stimulation (lesioned or non‐lesioned hemisphere) and type of stimulation (A‐tDCS, C‐tDCS, S‐tDCS), Outcome 1 Functional communication at the end of intervention phase.
4.1
4.1. Analysis
Comparison 4 Post‐hoc subgroup analysis: subtype of aphasia (fluent, non‐fluent or mixed populations), Outcome 1 Language impairment: accuracy of naming nouns post intervention.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Dos Santos 2017 {published data only}
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Fiori 2013 {published data only}
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Flöel 2011 {published data only}
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Fridriksson 2018 {published data only}
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Kang 2011 {published data only}
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Marangolo 2011 {published data only}
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Marangolo 2013b {published data only}
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Marangolo 2013c {published data only}
    1. Marangolo P, Fiori V, Paola M, Cipollari S, Razzano C, Oliveri M, et al. Differential involvement of the left frontal and temporal regions in verb naming: a tDCS treatment study. Restorative Neurology & Neuroscience 2013; Vol. 31, issue 1:63‐72. [1878‐3627] - PubMed
Marangolo 2018a {published data only}
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Meinzer 2016 {published data only}
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Monti 2008a {published data only}
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Polanowska 2013 {published data only}
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Rosso 2014 {published data only}
    1. Rosso C, Perlbarg V, Valabregue R, Arbizu C, Ferrieux S, Alshawan B, et al. Broca's area damage is necessary but not sufficient to induce after‐effects of cathodal tDCS on the unaffected hemisphere in post‐stroke aphasia. Brain Stimulation 2014; Vol. 7, issue 5:627‐35. [1935‐861X] - PubMed
Shah‐Basak 2015 {published data only}
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Spielmann 2016 {published data only}
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Turkeltaub 2017 {published data only}
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Volpe 2014 {published data only}
    1. NCT02249819. Evaluating Anodal tDCS Preceding Aphasia Therapy. clinicaltrials.gov/show/nct02249819 (first received 26 September 2014).
You 2011 {published data only}
    1. You DS, Kim DY, Chun MH, Jung SE, Park SJ. Cathodal transcranial direct current stimulation of the right Wernicke's area improves comprehension in subacute stroke patients. Brain and Language 2011;119(1):1‐5. - PubMed

References to studies excluded from this review

Fiori 2011 {published data only}
    1. Fiori V, Coccia M, Marinelli CV, Vecchi V, Bonifazi S, Ceravolo MG, et al. Transcranial direct current stimulation improves word retrieval in healthy and nonfluent aphasic subjects. Journal of Cognitive Neuroscience 2011;23(9):2309‐23. - PubMed
Fridriksson 2011 {published data only}
    1. Fridriksson J, Richardson JD, Baker JM, Rorden C. Transcranial direct current stimulation improves naming reaction time in fluent aphasia. Stroke 2011;42:819‐21. - PMC - PubMed
Holland 2011 {published data only}
    1. Holland R, Leff AP, Josephs O, Galea JM, Desikan M, Price CJ, et al. Speech facilitation by left inferior frontal cortex stimulation. Current Biology 2011;21(16):1403‐7. - PMC - PubMed
Lee 2013 {published data only}
    1. Lee SY, Cheon HJ, Yoon KJ, Chang WH, Kim YH. Effects of dual transcranial direct current stimulation for aphasia in chronic stroke patients. Annals of Rehabilitation Medicine 2013; Vol. 37, issue 5:603‐10. [2234‐0645] - PMC - PubMed
Monti 2008b {published data only}
    1. Monti A, Cogiamanian F, Marceglia S, Ferrucci R, Mameli F, Mrakic‐Sposta S, et al. Improved naming after transcranial direct current stimulation in aphasia. Journal of Neurology, Neurosurgery, and Psychiatry 2008;79(4):451‐3. - PubMed
NCT02514044 {published data only}
    1. NCT02514044. Dextroamphetamine and tDCS to Improve the Fluency. clinicaltrials.gov/show/NCT02514044 (first received 3 August 2015).
NCT03486782 {published data only}
    1. NCT03486782. Dual site‐dual channel non‐invasive brain stimulation for language and cognitive function in stroke patients. clinicaltrials.gov/show/NCT03486782 (first received 3 April 2018).
Richardson 2015 {published data only}
    1. Richardson J, Datta A, Dmochowski J, Parra LC, Fridriksson J. Feasibility of using high‐definition transcranial direct current stimulation (HD‐tDCS) to enhance treatment outcomes in persons with aphasia. NeuroRehabilitation 2015, issue 1:115‐26. - PMC - PubMed
Vines 2011 {published data only}
    1. Vines BW, Norton AC, Schlaug G. Applying transcranial direct current stimulation in combination with melodic intonation therapy facilitates language recovery for Broca's aphasic patients. Stroke 2007;38(2):519.
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References to studies awaiting assessment

Mac Kay 2015 {published data only}
    1. Mac Kay A, Rodrigues Da Silva F, Chao JCT, Devido Dos Santos M, Gagliardi RJ. Effects of transcranial direct current stimulation on naming tasks in aphasic subjects after stroke. Journal of the Neurological Sciences 2015:e354.
NCT02840370 {published data only}
    1. NCT02840370. Effect of stimulation of the prefrontal cortex on language production in aphasic patients. clinicaltrials.gov/show/nct02840370 (first received 21 July 2016).

References to ongoing studies

ChiCTR‐IOR‐16010297 {published data only}
    1. ChiCTR‐IOR‐16010297. Transcranial direct current stimulation (tDCS) combined semantic navigation training to improve aphasia. www.chictr.org.cn/hvshowproject.aspx?id=10861 (first received unknown date). [ChiCTR‐IOR‐16010297]
ChiCTR‐TRC‐14005072 {published data only}
    1. ChiCTR‐TRC‐14005072. Effect of transcranial direct current stimulation on apraxia of speech. www.chictr.org.cn/com/25/showprojen.aspx?proj=4503 (first received unknown date). [ChiCTR‐TRC‐14005072]
DRKS00011116 {published data only}
    1. DRKS00011116. Effects of transcranial direct current stimulation (tDCS) on patients with apraxia of speech: a combined tDCS‐fMRI study. www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DR... (first received 31 August 2017). [DRKS00011116]
JPRN‐UMIN000008467 {published data only}
    1. JPRN‐UMIN000008467. Transcranial direct current stimulation combined with speech therapy among patients with aphasia. apps.who.int/trialsearch/Trial.aspx?TrialID=JPRN‐UMIN000008467 (first received unknown date).
NCT00854893 {published data only}
    1. NCT00854893. Enhance of language learning with neurostimulation. clinicaltrials.gov/show/NCT00854893 (first received 3 March 2009).
NCT01486654 {published data only}
    1. NCT01486654. Transcranial direct current stimulation and aphasia language therapy. clinicaltrials.gov/show/NCT01486654 (first received 6 December 2011).
NCT01651884 {published data only}
    1. NCT01651884. Effects of tDCS versus HD‐tDCS for stroke rehabilitation. clinicaltrials.gov/show/NCT01651884 (first received 27 July 2012).
NCT01701713 {published data only}
    1. NCT01701713. TDCS in acute stroke. clinicaltrials.gov/show/NCT01701713 (first received 5 October 2012).
NCT02020421 {published data only}
    1. NCT02020421. Non‐invasive repeated therapeutic stimulation for aphasia recovery. clinicaltrials.gov/show/NCT02020421 (first received 24 December 2013).
    1. Thiel A, Black SE, Rochon EA, Lanthier S, Hartmann A, Chen JL, et al. Non‐invasive repeated therapeutic stimulation for aphasia recovery: a multilingual, multicenter aphasia trial. Journal of Stroke & Cerebrovascular Diseases. 2015/03/05 2015; Vol. 24, issue 4:751‐8. [1532‐8511: (Electronic)] - PubMed
NCT02101398 {published data only}
    1. NCT02101398. Study of the effect of transcranial stimulations in aphasic subject within a year of their stroke. clinicaltrials.gov/show/nct02101398 (first received 2 April 2014).
NCT02226796 {published data only}
    1. NCT02226796. Transcranial direct stimulation (tDCS) and behavioral intervention in aphasia. clinicaltrials.gov/show/nct02226796 (first received 27 August 2014).
NCT02395874 {published data only}
    1. NCT02395874. tDCS and speech therapy to improve aphasia. clinicaltrials.gov/show/nct02395874 (first received 24 March 2015).
NCT02461355 {published data only}
    1. NCT02461355. Transcranial direct current stimulation for post‐stroke aphasia. clinicaltrials.gov/show/NCT02461355 (first received 3 June 2015).
NCT02540109 {published data only}
    1. NCT02540109. Targeted Electrotherapy for Aphasia Stroke Rehabilitation (TEASER) ‐ phase II multi‐center study. clinicaltrials.gov/show/nct02540109 (first received 3 September 2015).
NCT02612753 {published data only}
    1. NCT02612753. Interest of combining speech therapy with a non‐invasive brain stimulation (tDCS) for the aphasic patient. clinicaltrials.gov/show/nct02612753 (first received 24 November 2015).
NCT02622945 {published data only}
    1. NCT02622945. Effects of transcranial direct current stimulation in post‐stroke aphasia. clinicaltrials.gov/show/nct02622945 (first received 7 December 2015).
NCT02674490 {published data only}
    1. NCT02674490. Stimulating language in subacute stroke. clinicaltrials.gov/show/nct02674490 (first received 4 February 2016).
NCT02801864 {published data only}
    1. NCT02801864. tDCS as an adjuvant to intensive speech therapy for chronic post stroke aphasia. clinicaltrials.gov/show/nct02801864 (first received 16 June 2016).
NCT02901574 {published data only}
    1. NCT02901574. Cerebellar transcranial direct current stimulation and aphasia treatment. clinicaltrials.gov/show/nct02901574 (first received 15 September 2016).
    1. Sebastian R, Tippett D, Celnik P, Hillis AE. Cerebellar transcranial direct stimulation to augment aphasia therapy. Stroke Conference: American Heart Association/American Stroke Association 2017 International Stroke Conference and State‐of‐the‐Science Stroke Nursing Symposium. USA. 2017.
NCT03164213 {published data only}
    1. NCT03164213. Facilitation of brain plasticity for language recovery in patients with aphasia due to stroke. clinicaltrials.gov/show/nct03164213 (first received 23 May 2017).
NCT03272906 {published data only}
    1. NCT03272906. Clinical feasibility of transcranial direct current stimulation with standard aphasia therapy. clinicaltrials.gov/show/nct03272906 (first received 6 September 2017).
NCT03297450 {published data only}
    1. NCT03297450. tDCS and aphasia therapy in the acute phase after stroke. clinicaltrials.gov/show/nct03297450 (first received 29 September 2017).
NCT03305614 {published data only}
    1. NCT03305614. tDCS and aphasia therapy in the chronic phase after stroke. clinicaltrials.gov/show/nct03305614 (first received 10 October 2017).

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