Transcranial direct current stimulation and EEG-based motor imagery BCI for upper limb stroke rehabilitation After vs. priming effects of anodal transcranial direct current stimulation on upper extremity motor recovery in patients with subacute stroke. Combined Transcranial Direct Current Stimulation and Robot-Assisted Arm Training in Subacute Stroke Patients Effects of dual transcranial direct current stimulation on post-stroke unilateral visuospatial neglect Effects of brain polarization on reaction times and pinch force in chronic stroke The Effects of Transcranial Stimulation on Paretic Lower Limb Motor Excitability During Walking Bihemispheric brain stimulation facilitates motor recovery in chronic stroke patients Combination transcranial direct current stimulation and virtual reality therapy for upper extremity training in patients with subacute stroke. Brain stimulation paired with novel locomotor training with robotic gait orthosis in chronic stroke: a feasibility study. Effects of anodal and cathodal transcranial direct current stimulation combined with robotic therapy on severely affected arms in chronic stroke patients. Effectiveness and neural mechanisms associated with tDCS delivered to premotor cortex in stroke rehabilitation: study protocol for a randomized controlled trial Noninvasive Brain Stimulation May Improve Stroke-Related Dysphagia: A Pilot Study Effect of Transcranial Direct Current Stimulation of Function in Patients with Stroke Effects of the addition of transcranial direct current stimulation to virtual reality therapy after stroke: a pilot randomized controlled trial. Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Non-invasive cortical stimulation improves post-stroke attention decline. Transcranial Direct Current Stimulation to Primary Motor Area Improves Hand Dexterity and Selective Attention in Chronic Stroke The ABC of tDCS: Effects of Anodal, Bilateral and Cathodal Montages of Transcranial Direct Current Stimulation in Patients with Stroke—A Pilot Study Facilitating effects of transcranial direct current stimulation on motor imagery brain-computer interface with robotic feedback for stroke rehabilitation. Enhancing the Working Memory of Stroke Patients Using tDCS How does transcranial DC stimulation of the primary motor cortex alter regional neuronal activity in the human brain? The Ineffective Role of Cathodal tDCS in Enhancing the Functional Motor Outcomes in Early Phase of Stroke Rehabilitation: An Experimental Trial Modulation of event-related desynchronization during motor imagery with transcranial direct current stimulation (tDCS) in patients with chronic hemiparetic stroke A double-blinded randomised controlled trial exploring the effect of anodal transcranial direct current stimulation and uni-lateral robot therapy for the impaired upper limb in sub-acute and chronic stroke. Effects of non-invasive cortical stimulation on skilled motor function in chronic stroke. Neural substrates underlying stimulation-enhanced motor skill learning after stroke. Combination of transcranial direct current stimulation and methylphenidate in subacute stroke Optimizing recovery potential through simultaneous occupational therapy and non-invasive brain-stimulation using tDCS. Dual-tDCS Enhances Online Motor Skill Learning and Long-Term Retention in Chronic Stroke Patients Low-Frequency Repetitive TMS Plus Anodal Transcranial DCS Prevents Transient Decline in Bimanual Movement Induced by Contralesional Inhibitory rTMS After Stroke Non-invasive brain stimulation enhances fine motor control of the hemiparetic ankle: implications for rehabilitation Transcranial direct current stimulation of the unaffected hemisphere in stroke patients Effect of Anodal Versus Cathodal Transcranial Direct Current Stimulation on Stroke Rehabilitation Enhancing Motor Performance by Anodal Transcranial Direct Current Stimulation in Subacute Stroke Patients Effects on decreasing upper-limb poststroke muscle tone using transcranial direct current stimulation: a randomized sham-controlled study. Aftereffects of 2 Noninvasive Brain Stimulation Techniques on Corticospinal Excitability in Persons With Chronic Stroke: A Pilot Study Transcranial DC stimulation (tDCS): A tool for double-blind sham-controlled clinical studies in brain stimulation The effect of single session bi-cephalic transcranial direct current stimulation on gait performance in sub-acute stroke: A pilot study. Combined transcranial direct current stimulation and robot-assisted gait training in patients with chronic stroke: a preliminary comparison Immediate and Late Modulation of Interhemipheric Imbalance With Bilateral Transcranial Direct Current Stimulation in Acute Stroke Raised corticomotor excitability of M1 forearm area following anodal tDCS is sustained during robotic wrist therapy in chronic stroke. Effect of Transcranial Direct Current Stimulation on Motor Recovery in Patients with Subacute Stroke Transcranial Microelectrostimulation Activates Fast Mechanisms of Brain Plasticity Impact of tDCS on cerebral autoregulation in aging and in patients with cerebrovascular diseases Transcranial direct current stimulation: electrode montage in stroke
Clinical studies had shown that EEG-based motor imagery Brain-Computer Interface ( MI-BCI ) combined with robotic feedback is effective in upper limb stroke rehabilitation , and transcranial Direct Current Stimulation ( tDCS ) combined with other rehabilitation techniques further enhanced the facilitating effect of tDCS . This motivated the current clinical study to investigate the effects of combining tDCS with MI-BCI and robotic feedback compared to sham-tDCS for upper limb stroke rehabilitation . The stroke patients recruited were r and omized to receive 20 minutes of tDCS or sham-tDCS prior to 10 sessions of 1-hour MI-BCI with robotic feedback for 2 weeks . The online accuracies of detecting motor imagery from idle condition were assessed and offline accuracies of classifying motor imagery from background rest condition were assessed from the EEG of the evaluation and therapy parts of the 10 rehabilitation sessions respectively . The results showed no evident differences between the online accuracies on the evaluation part from both groups , but the offline analysis on the therapy part yielded higher averaged accuracies for subjects who received tDCS ( n=3 ) compared to  sham-tDCS ( n=2 ) . The results suggest towards tDCS effect in modulating motor imagery in stroke , but a more conclusive result can be drawn when more data are collected in the ongoing study PURPOSE Transcranial direct current stimulation ( tDCS ) of the motor cortex seems to be effective in improving motor performance in patients with chronic stroke , while some recent findings have reported conflicting results for the subacute phase . We aim ed to verify whether upper extremity motor rehabilitation could be enhanced by treatment with tDCS administered before a rehabilitative session . METHODS H and dexterity and force in 16 individuals with subacute stroke were assessed before ( T0 ) and after anodal stimulation ( T1 ) and after a successive session of motor rehabilitation ( T2 ) in a double-blind , r and omized , sham-controlled , crossover trial . To confirm the value of the device as a specific effector , behavioral tests were also administered . RESULTS Anodal and sham stimulation plus rehabilitation significantly improved manual dexterity ( repeated-measure Anova : A-tDCS : p = 0.005 ; S-tDCS : p = 0.042 ) . Post hoc analysis revealed a significant stimulation effect only for A-tDCS ( p = 0.013 between T0 and T1 ) and not for S-tDCS , whereas the rehabilitation effect ( between T1 and T2 ) was not significant in either group . H and force and behavioral features were unchanged . CONCLUSIONS Anodal brain stimulation improves h and dexterity but does not increase the effectiveness of the rehabilitation directly . These results suggest the presence of aftereffects , not priming effects , of A-tDCS superimposed onto motor learning phenomena Background . No rehabilitation intervention has effectively improved functional use of the arm and h and in patients with severe upper limb paresis after stroke . Pilot studies suggest the potential for transcranial direct current stimulation and bilateral robotic training to enhance gains . Objective . In a double-blind , r and omized trial the combination of these interventions was tested . Methods . This study r and omized 96 patients with an ischemic supratentorial lesion of 3 to 8 weeks ’ duration with severe impairment of motor control with a Fugl-Meyer score ( FMS ) for the upper limb < 18 into 3 groups . For 6 weeks , group A received anodal stimulation of the lesioned hemisphere , group B received cathodal stimulation of the nonlesioned side for 20 minutes at 2.0 mA , and group C received sham stimulation . The electrodes were placed over the h and area and above the contralateral orbit . Contemporaneously , the subjects practice d 400 repetitions each of 2 different bilateral movements on a robotic assistive device . Results . The groups were matched at onset . The FMS improved in all patients at 6 weeks ( P < .001 ) . No between-group differences were found ; initial versus finish FMS scores were 7.8 ± 3.8 versus 19.1 ± 14.4 in group A , 7.9 ± 3.4 versus 18.8 ± 10.5 in group B , and 8.2 ± 4.4 versus 19.2 ± 15.0 in group C. No significant changes between groups were present at 3 months . Conclusions . Neither anodal nor cathodal transcranial direct current stimulation enhanced the effect of bilateral arm training in this exploratory trial of patients with cortical involvement and severe weakness . Unilateral h and training and upregulation of the nonlesioned hemisphere might also be tried in this population Based on the interhemispheric inhibition model of unilateral visuospatial neglect ( USN ) after stroke , the effects of dual-mode transcranial direct current stimulation ( tDCS ) over the parietal cortices were assessed in a double-blind r and om-order cross-over experiment . Ten chronic right hemispheric stroke patients ( 4 men ; mean age : 62.6 years ) with USN were recruited . All participants underwent three r and omly arranged tDCS sessions : ( 1 ) dual-mode , anodal tDCS over the right posterior parietal cortex ( PPC ) and cathodal tDCS over the left PPC ; ( 2 ) single-mode , anodal tDCS over the right PPC ; and ( 3 ) sham mode . Each session lasted 20min . Before and immediately after the stimulation , a line bisection test and star cancelation test were carried out . In the line bisection test , significant improvements were observed after both the dual- and the  single-mode tDCS  ( p<0.05 ) , but not after sham stimulation . Statistical analysis showed a significant interaction between time and tDCS mode , where the dual tDCS had a stronger effect than the single or sham stimulation modes ( p<0.05 ) . The star cancelation test did not show any significant change . These results suggest that dual tDCS over the bilateral PPC is an effective method for the treatment of USN in stroke patients Background Previous studies showed that anodal transcranial DC stimulation ( tDCS ) applied to the primary motor cortex of the affected hemisphere ( M1affected hemisphere ) after subcortical stroke transiently improves performance of complex tasks that mimic activities of daily living ( ADL ) . It is not known if relatively simpler motor tasks are similarly affected . Here we tested the effects of tDCS on pinch force ( PF ) and simple reaction time ( RT ) tasks in patients with chronic stroke in a double-blind cross-over Sham-controlled experimental design . Results Anodal tDCS shortened reaction times and improved pinch force in the paretic h and relative to Sham stimulation , an effect present in patients with higher impairment . Conclusion tDCS of M1affected hemisphere can modulate performance of motor tasks simpler than those previously studied , a finding that could potentially benefit patients with relatively higher impairment levels Abstract : Balanced transcallosal inhibition sustains symmetrical corticomotor excitability and assists the performance of bimanual voluntary movements . After stroke , transcallosal inhibition becomes asymmetric . This finding raised the notion that reducing poststroke asymmetry in transcallosal inhibition might prime the motor system before training and lead to improvements in walking recovery . In this study , we examined three neuromodulatory protocol s applied during walking to determine if they could increase ipsilesional and decrease contralesional motor excitability in patients with chronic stroke .  Inhibitory repetitive transcranial magnetic stimulation and inhibitory paired associative stimulation were applied to the contralesional motor system , and facilitatory anodal transcranial direct current stimulation was applied to the ipsilesional motor system . We tested the bilateral modulatory effects of each stimulation protocol on the tibialis anterior , medial gastrocnemius , medial hamstrings , and vastus lateralis of nine patients with chronic stroke . All stimulation protocol s increased paretic limb and decreased nonparetic limb motor excitability . There was no statistical difference in the extent of modulation between these stimulation protocol s. This result suggests these three protocol s are promising c and i date priming mechanisms for testing the hypothesis in a future study that reducing the poststroke asymmetry of between-hemisphere motor excitability will enhance the effect of gait therapy Objective : Motor recovery after stroke depends on the integrity of ipsilesional motor circuits and interactions between the ipsilesional and contralesional hemispheres . In this sham-controlled r and omized trial , we investigated whether noninvasive modulation of regional excitability of bilateral motor cortices in combination with physical and occupational therapy improves motor outcome after stroke . Methods : Twenty chronic stroke patients were r and omly assigned to receive 5 consecutive sessions of either 1 ) bihemispheric transcranial direct current stimulation ( tDCS ) ( anodal tDCS to upregulate excitability of ipsilesional motor cortex and cathodal tDCS to downregulate excitability of contralesional motor cortex ) with simultaneous physical/occupational therapy or 2 ) sham stimulation with simultaneous physical/occupational therapy .  Changes in motor impairment ( Upper Extremity Fugl-Meyer ) and motor activity ( Wolf Motor Function Test ) assessment s were outcome measures while functional imaging parameters were used to identify neural correlates of motor improvement . Results : The improvement of motor function was significantly greater in the real stimulation group ( 20.7 % in Fugl-Meyer and 19.1 % in Wolf Motor Function Test scores ) when compared to the sham group ( 3.2 % in Fugl-Meyer and 6.0 % in Wolf Motor Function Test scores ) . The effects outlasted the stimulation by at least 1 week . In the real-stimulation group , stronger activation of intact ipsilesional motor regions during paced movements of the affected limb were found postintervention whereas no significant activation changes were seen in the control group . Conclusions : The combination of bihemispheric tDCS and peripheral sensorimotor activities improved motor functions in chronic stroke patients that outlasted the intervention period . This novel approach may potentiate cerebral adaptive processes that facilitate motor recovery after stroke . Classification of evidence : This study provides Class I evidence that for adult patients with ischemic stroke treated at least 5 months after their first and only stroke , bihemispheric tDCS and simultaneous physical/occupational therapy given over 5 consecutive sessions significantly improves motor function as measured by the Upper Extremity Fugl-Meyer assessment ( raw change treated 6.1 ± 3.4 , sham 1.2 ± 1.0 ) OBJECTIVE To investigate the effects of combination cathodal transcranial direct current stimulation ( tDCS ) and virtual reality ( VR ) therapy for upper extremity ( UE ) training in patients with subacute stroke . DESIGN Pilot r and omized controlled trial . Patients were r and omly assigned to 1 of 3 groups : group A received cathodal tDCS , group B received VR , and group C received combination therapy ( cathodal tDCS was simultaneously applied during VR therapy ) . SETTING University hospital . PARTICIPANTS Patients ( N=59 ) with impaired unilateral UE motor function after stroke . INTERVENTION Fifteen sessions of treatment over a 3-week period . MAIN OUTCOME MEASURES The Modified Ashworth Scale , manual muscle test ( MMT ) , Manual Function Test ( MFT ) , Fugl-Meyer Scale ( FMS ) , and Box and Block Test were used to assess UE function . To evaluate activities of daily living , the Korean-Modified Barthel Index ( K-MBI ) was used . All outcomes were measured before and immediately after treatment . RESULTS After treatment , all groups demonstrated significant improvements in MMT , MFT , FMS , and K-MBI scores . The change in MFT and FMS scores was different between the 3 groups . Post hoc analysis revealed that the improvement of MFT and FMS scores in group C was significantly higher than those of the other 2 groups . CONCLUSIONS In the present pilot study , the combination of brain stimulation using tDCS and peripheral arm training using VR could facilitate a stronger beneficial effect on UE impairment than using each intervention alone . This combination therapy might be a helpful method to enhance recovery of the paretic UE in patients with stroke OBJECTIVES 1 ) To investigate the feasibility of combining transcranial direct current stimulation ( tDCS ) to the lower extremity ( LE ) motor cortex with novel locomotor training to facilitate gait in subjects with chronic stroke and low ambulatory status , and 2 ) to obtain insight from study subjects and their caregivers to inform future trial design . METHODS Double-blind , r and omized controlled study with additional qualitative exploratory descriptive design . One-month follow-up.10 subjects with stroke were recruited and r and omized to active tDCS or sham tDCS for 12 sessions . Both groups participated in identical locomotor training with a robotic gait orthosis ( RGO ) following each tDCS session . RGO training protocol was design ed to harness cortical neuroplasticity . Data analysis included assessment of functional and participation outcome measures and qualitative thematic analysis . RESULTS Eight subjects completed the study . Both groups demonstrated trends toward improvement , but the active tDCS group showed greater improvement than the sham group . Qualitative analyses indicated beneficial effects of this combined intervention . CONCLUSIONS It is feasible to combine tDCS targeting the LE motor cortex with our novel locomotor training . It appears that tDCS has the potential to enhance the effectiveness of gait training in chronic stroke . Insights from participants provide additional guidance in design ing future trials OBJECTIVE The purpose of this study was to examine the effects of combined therapy using transcranial direct current stimulation ( tDCS ) with robot-assisted arm training ( AT ) for impairment of the upper limb in chronic stroke patients , and to clarify whether differences exist in the effect of anodal tDCS on the affected hemisphere ( tDCS(a ) + AT ) and cathodal tDCS on the unaffected hemisphere ( tDCS(c ) + AT ) . METHODS Subjects in this r and omized , double-blinded , crossover study comprised 18 chronic stroke patients with moderate-to-severe arm paresis . Each patient underwent 2 different treatments : tDCS(a ) + AT ; and tDCS(c ) + AT . Each intervention was administered for 5 days , and comprised AT with 1 mA of tDCS during the first 10 min . Outcomes were identified as changes in Fugl-Meyer Assessment ( FMUL ) , modified Ashworth scale ( MAS ) and Motor Activity Log ( MAL ) for the upper limb . RESULTS Both interventions showed significant improvements in FMUL and MAS , but not in MAL . Distal spasticity was significantly improved with tDCS(c ) + AT compared with tDCS(a ) + AT for right hemispheric lesions ( median -1 vs 0 ) , but not for left hemispheric lesions . CONCLUSION Although this study demonstrated that combined therapy could achieve limited effects in the hemiplegic arm of chronic stroke patients , a different effect of polarity of tDCS was seen for patients with right hemispheric lesions Background More than 60 % of stroke survivors experience residual deficits of the paretic upper limb/h and . St and ard rehabilitation generates modest gains . Stimulation delivered to the surviving Primary Motor Cortex in the stroke-affected hemisphere has been considered a promising adjunct . However , recent trials challenge its advantage . We discuss our pilot clinical trial that aims to address factors implicated in divergent success of the approach . We assess safety , feasibility and efficacy of targeting an alternate locus during rehabilitation- the premotor cortex . In anticipating variance across patients , we measure neural markers differentiating response from non-response . Methods / Design In a r and omized , sham-controlled , double-blinded pilot clinical study , patients with chronic stroke ( n = 20 ) are assigned to receive transcranial direct current stimulation delivered to the premotor cortex or sham during  rehabilitation of the paretic arm/h and . Patients receive the design ated intervention for 30 min , twice a day for 3 days a week for 5 weeks . We assess h and function and patients ’ reports of use of paretic h and . A general linear mixed methods model will analyze changes from pre- to post-intervention . Responders and non-responders will be compared upon baseline level of function , and neural substrates , including function and integrity of output tracts , bi-hemispheric balance , and lesion profile . Incidence of adverse events will be compared using Fisher ’s Exact test , while rigor of blinding will be assessed with Chi-square analysis to ascertain feasibility . Discussion Variable success of cortical stimulation in rehabilitation can be related to gaps in theoretical basis and clinical investigation . Given that most patients with severe deficits have damage to the primary motor cortex or its output pathways , it would be futile to target stimulation to this site . We suggest targeting premotor cortex because it contributes substantially to descending output , a role that is amplified with greater damage to the motor cortex . With regards to clinical investigation , paired cortical stimulation in rehabilitation has been compared to rehabilitation alone in unblinded trials or to unconvincing sham conditions . Transcranial direct current stimulation , a noninvasive technique of brain stimulation , which offers a more effective placebo and has a favorable safety-feasibility profile , may improve scientific rigor . Neural markers of response would help inform patient selection for future clinical trials so we can address limitations of recent negative studies .Trial registration Background and Purpose — Treatment options for stroke-related dysphagia are currently limited . In this study , we investigated whether noninvasive brain stimulation in combination with swallowing maneuvers facilitates swallowing recovery in dysphagic stroke patients during early stroke convalescence . Methods — Fourteen patients with subacute unilateral hemispheric infa rct ion were r and omized to anodal transcranial direct current stimulation ( tDCS ) versus sham stimulation to the sensorimotor cortical representation of swallowing in the unaffected hemisphere over the course of 5 consecutive days with concurrent st and ardized swallowing maneuvers . Severity of dysphagia was measured using a vali date d swallowing scale , Dysphagia Outcome and Severity scale , before the first and after the last session of tDCS or sham . The effect of tDCS was analyzed in a multivariate linear regression model using changes in Dysphagia Outcome and Severity Scale as the outcome variable after adjusting for the effects of other potential confounding variables such as the National Institutes of Health Stroke Scale and Dysphagia Outcome and Severity scale scores at baseline , acute ischemic lesion volumes , patient age , and time from stroke onset to stimulation . Results — Patients who received anodal tDCS gained 2.60 points of improvement in Dysphagia Outcome and Severity scale scores compared to patients in the sham stimulation group who showed an improvement of 1.25 points ( P=0.019 ) after controlling for the effects of other aforementioned variables . Six out 7 ( 86 % ) patients in tDCS stimulation group gained at least 2 points of improvement compared with 3 out 7 ( 43 % ) patients in the sham group ( P=0.107 ) . Conclusions — Because brain stem swallowing centers have bilateral cortical innervations , measures that enhance cortical input and sensorimotor control of brain stem swallowing may be beneficial for dysphagia recovery [ Purpose ] The purpose of this study was to determine the effect of transcranial direct current stimulation ( tDCS ) on the upper limb of function of patients with post-stroke hemiplegia . [ Subjects ] Twenty subjects were r and omly allocated to either the upper tDCS group or the functional training group , with 10 subjects in each group . [ Methods ] The two groups received functional training for thirty minutes a day , five days a week for four weeks . The tDCS group additionally received tDCS for 20 minutes . The outcome was assessed by the Box and Block test ( BBT ) , grip strength , and the Fugl-Meyer assessment ( FMA ) . [ Results ] There were significant improvements between pre- and post- intervention in both groups , in the BBT , grip strength , and the upper limb and lower lims sub-items of the FMA . The tDCS group showed significantly greater improvements than the control group in the BBT , and upper limb and lower limb sub-items of the FMA . [ Conclusion ] These findings suggest that tDCS may be more beneficial than functional training for improving the upper and lower limb functions of chronic stroke patients BACKGROUND Upper limb ( UL ) impairment is the most common disabling deficit following a stroke . Previous studies have suggested that transcranial direct current stimulation ( tDCS ) enhances the effect of conventional therapies . OBJECTIVE This pilot double-blind r and omized control trial aim ed to determine whether or not tDCS , combined with Wii virtual reality therapy ( VRT ) , would be superior to Wii therapy alone in improving upper limb function and quality of life in chronic stroke individuals . METHODS Twenty participants were r and omly assigned either to an experimental group that received VRT and tDCS , or a control group that received VRT and sham tDCS . The therapy was delivered over 15 sessions with 13 minutes of active or sham anodal tDCS , and one hour of virtual reality therapy . The outcomes included were determined using the Fugl-Meyer scale , the Wolf motor function test , the modified Ashworth scale ( MAS ) , grip strength , and the stroke specific quality of life scale ( SSQOL ) . Minimal clinical ly important differences ( MCID ) were observed when assessing outcome data . RESULTS Both groups demonstrated gains in all evaluated areas , except for the SSQOL-UL domain . Differences between groups were only observed in wrist spasticity levels in the experimental group , where more than 50 % of the participants achieved the MCID . CONCLUSIONS These findings support that tDCS , combined with VRT therapy , should be investigated and clarified further BACKGROUND AND PURPOSE To improve the accuracy of early postonset prediction of motor recovery in the flaccid hemiplegic arm , the effects of change in motor function over time on the accuracy of prediction were evaluated , and a prediction model for the probability of regaining dexterity at 6 months was developed . METHODS In 102 stroke patients , dexterity and paresis were measured with the  Action Research Arm Test , Motricity Index , and Fugl-Meyer motor evaluation .  For model development , 23 c and i date determinants were selected . Logistic regression analysis was used for prognostic factors and model development . RESULTS At 6 months , some dexterity in the paretic arm was found in 38 % , and complete functional recovery was seen in 11.6 % of the patients . Total anterior circulation infa rcts , right hemisphere strokes , homonymous hemianopia , visual gaze deficit , visual inattention , and paresis were statistically significant related to a poor arm function . Motricity Index leg scores of at least 25 points in the first week and Fugl-Meyer arm scores of 11 points in the second week increasing to 19 points in the fourth week raised the probability of developing some dexterity ( Action Research Arm Test > or=10 points ) from 74 % ( positive predictive value [ PPV ] , 0.74 ; 95 % confidence interval [ CI ] , 0.63 to 0.86 ) to 94 % ( PPV , 0.83 ; 95 % CI , 0.76 to 0.91 ) at 6 months . No change in probabilities of prediction dexterity was found after 4 weeks . CONCLUSIONS Based on the Fugl-Meyer scores of the flaccid arm , optimal prediction of arm function outcome at 6 months can be made within 4 weeks after onset . Lack of voluntary motor control of the leg in the first week with no emergence of arm synergies at 4 weeks is associated with poor outcome at 6 months PURPOSE Attention decline after stroke is common and hampers the rehabilitation process , and non-invasive transcranial direct current stimulation ( tDCS ) has the potential to elicit behavioral changes by modulating cortical excitability . The authors tested the hypothesis that a single session of non-invasive cortical stimulation with excitatory anodal tDCS applied to the left dorsolateral prefrontal cortex ( DLPFC ) can improve attention in stroke patients . METHODS Ten patients with post-stroke cognitive decline ( MMSE 25 ) and 10 age-matched healthy controls participated in this double blind , sham-controlled , crossover study involving the administration of real ( 2 mA for 20 min ) or sham stimulation ( 2 mA for 1 min ) to the left DLPFC . Attention was measured using a computerized Go/No-Go test before and after intervention . Improvements in accuracy and speed after stimulation relative to baseline were compared for real and sham stimulations . RESULTS In healthy controls , no significant improvement in Go/No-Go test was observed after either real or sham stimulation . However , in stroke patients , tDCS led to a significant improvement in response accuracy at 1 hour post-stimulation relative to baseline , and this improvement was maintained until 3 hours post-stimulation ( P < 0.05 ) , whereas sham stimulation did not lead to a significant improvement in response accuracy ( P > 0.05 ) . Changes in reaction times were comparable for the two stimulations ( P > 0.05 ) . CONCLUSION Non invasive anodal tDCS applied to the left DLPFC was found to improve attention versus sham stimulation in stroke patients , which suggests that non-invasive cortical intervention could potentially be used during rehabilitative training to improve attention Objective The aim of this study was to determine whether transcranial direct current stimulation ( tDCS ) applied to the primary motor h and area modulates h and dexterity and selective attention after stroke . Design This study was a double-blind , placebo-controlled , r and omized crossover trial involving subjects with chronic stroke . Ten stroke survivors with some pinch strength in the paretic h and received three different tDCS interventions assigned in r and om order in separate sessions — anodal tDCS targeting the primary motor area of the lesioned hemisphere ( M1lesioned ) , cathodal tDCS applied to the contralateral hemisphere ( M1nonlesioned ) , and sham tDCS — each for 20 mins . The primary outcome measures were Purdue pegboard test scores for h and dexterity and response time in the color-word Stroop test for selective attention . Pinch strength of the paretic h and was the secondary outcome . Results Cathodal tDCS to M1nonlesioned significantly improved affected h and dexterity ( by 1.1 points on the Purdue pegboard unimanual test , P = 0.014 ) and selective attention ( 0.6 secs faster response time on the level 3 Stroop interference test for response inhibition , P = 0.017 ) , but not pinch strength . The outcomes were not improved with anodal tDCS to M1lesioned or sham tDCS . Conclusions Twenty minutes of cathodal tDCS to M1nonlesioned can promote both paretic h and dexterity and selective attention in people with chronic stroke Transcranial direct current stimulation ( tDCS ) is a noninvasive technique that is emerging as a prospect i ve therapy for different neurologic disorders . Previous studies have demonstrated that anodal and cathodal stimulation can improve motor performance in terms of dexterity and manual force . The objective of this study was to determine whether different electrodes ' setups ( anodal , cathodal , and simultaneous bilateral tDCS ) provide different motor performance and which montage was more effective . As secondary outcome , we have asked to the patients about their satisfaction , and to determine if the bilateral tDCS was more uncomfortable than unilateral tDCS .  Nine patients with stroke in subacute phase were enrolled in this study and r and omly divided in three groups . Our results showed that tDCS was an effective treatment if compared to Sham stimulation ( P = 0.022 ) . In particular , anodal stimulation provided the higher improvement in terms of manual dexterity . Cathodal stimulation seemed to have a little effect in terms of force improvement , not observed with other setups . Bipolar stimulation seemed to be the less effective . No significant differences have been noted for the different set-ups for patients ' judgment . These results highlight the potential efficacy of tDCS for patients with stroke in subacute phase OBJECTIVE To investigate the efficacy and effects of transcranial direct current stimulation ( tDCS ) on motor imagery brain-computer interface ( MI-BCI ) with robotic feedback for stroke rehabilitation . DESIGN A sham-controlled , r and omized controlled trial . SETTING Patients recruited through a hospital stroke rehabilitation program . PARTICIPANTS Subjects ( N=19 ) who incurred a stroke 0.8 to 4.3 years prior , with moderate to severe upper extremity functional impairment , and passed BCI screening . INTERVENTIONS Ten sessions of 20 minutes of tDCS or sham before 1 hour of MI-BCI with robotic feedback upper limb stroke rehabilitation for 2 weeks . Each rehabilitation session comprised 8 minutes of evaluation and 1 hour of therapy . MAIN OUTCOME MEASURES Upper extremity Fugl-Meyer Motor Assessment ( FMMA ) scores measured end-intervention at week 2 and follow-up at week 4 , online BCI accuracies from the evaluation part , and laterality coefficients of the electroencephalogram ( EEG ) from the therapy part of the 10 rehabilitation sessions . RESULTS FMMA score improved in both groups at week 4 , but no intergroup differences were found at any time points . Online accuracies of the evaluation part from the tDCS group were significantly higher than those from the sham group . The EEG laterality coefficients from the therapy part of the tDCS group were significantly higher than those of the sham group . CONCLUSIONS The results suggest a role for tDCS in facilitating motor imagery in stroke Jo JM , Kim Y-H , Ko M-H , Ohn SH , Joen B , Lee KH : Enhancing the working memory of stroke patients using tDCS . Am J Phys Med Rehabil 2009;88:404–409 . Objectives : We investigated whether anodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex affected the working memory performance of patients after a stroke . Design : Ten patients ( mean age 47.7 yrs ) with cognitive deficits after a first-ever stroke participated in this single-blind , crossover , and sham-controlled experiment . Each patient was r and omly assigned to undergo two transcranial direct current stimulation sessions : anodal dorsolateral prefrontal cortex and sham stimulation within 48 hrs of a washout period . All participants performed a two-back working memory task before and after the administration of the transcranial direct current stimulation . Accuracy ( correction rate ) , recognition accuracy ( correction rate-commission error rate ) , and response time were measured during each experiment . Results : Repeated- measures analysis of variance indicated a significant interaction effect of transcranial direct current stimulation type and time on the recognition accuracy . Post hoc analyses revealed a significant difference between prestimulation and poststimulation in the anodal stimulation group but not in the sham stimulation group . Regarding the accuracy , the paired t test indicated significant improvement only after anodal transcranial direct current stimulation without a significant interaction effect between the two transcranial direct current stimulation types . The response time was not significantly different in the anodal and sham stimulation groups . Conclusion : Our results demonstrated that anodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex was associated with enhanced working memory performance as indexed by the recognition accuracy in patients after a stroke Transcranial direct current stimulation ( tDCS ) of the primary motor h and area ( M1 ) can produce lasting polarity-specific effects on corticospinal excitability and motor learning in humans . In 16 healthy volunteers , O positron emission tomography ( PET ) of regional cerebral blood flow ( rCBF ) at rest and during finger movements was used to map lasting changes in regional synaptic activity following 10 min of tDCS ( + /-1 mA ) . Bipolar tDCS was given through electrodes placed over the left M1 and right frontopolar cortex . Eight subjects received anodal or cathodal tDCS  of the left M1 , respectively . When compared to sham tDCS , anodal and cathodal tDCS induced widespread increases and decreases in rCBF in cortical and subcortical areas . These changes in rCBF were of the same magnitude as task-related rCBF changes during finger movements and remained stable throughout the 50-min period of PET scanning . Relative increases in rCBF after real tDCS compared to sham tDCS were found in the left M1 , right frontal pole , right primary sensorimotor cortex and posterior brain regions irrespective of polarity . With the exception of some posterior and ventral areas , anodal tDCS increased rCBF in many cortical and subcortical regions compared to cathodal tDCS . Only the left dorsal premotor cortex demonstrated an increase in movement related activity after cathodal tDCS , however , modest compared with the relatively strong movement-independent effects of tDCS . Otherwise , movement related activity was unaffected by tDCS . Our results indicate that tDCS is an effective means of provoking sustained and widespread changes in regional neuronal activity . The extensive spatial and temporal effects of tDCS need to be taken into account when tDCS is used to modify brain function Transcranial direct current stimulation ( tDCS ) is a noninvasive technique that could improve the rehabilitation outcomes in stroke , eliciting neuroplastic mechanisms . At the same time conflicting results have been reported in subacute phase of stroke , when neuroplasticity is crucial . The aim of this double-blind , r and omized , and sham-controlled study was to determine whether a treatment with cathodal tDCS before the rehabilitative training might augment the final outcomes ( upper limb function , h and dexterity and manual force , locomotion , and activities of daily living ) in respect of a traditional rehabilitation for a sample of patients affected by ischemic stroke in the subacute phase . An experimental group ( cathodal tDCS plus rehabilitation ) and a control group ( sham tDCS plus rehabilitation ) were assessed at the beginning of the protocol , after 10 days of stimulation , after 30 days from ending of stimulation , and at the end of inpatient rehabilitation . Both groups showed significant improvements for all the assessed domains during the rehabilitation , except for the manual force , while no significant differences were demonstrated between groups . These results seem to indicate that the cathodal tDCS , provided in an early phase of stroke , does not lead to a functional improvement . To depict a more comprehensive scenario , further studies are needed Electroencephalogram-based brain – computer interface ( BCI ) has been developed as a new neurorehabilitative tool for patients with severe hemiparesis . However , its application has been limited because of difficulty detecting stable brain signals from the affected hemisphere . It has been reported that transcranial direct current stimulation ( tDCS ) can modulate event-related desynchronization ( ERD ) in healthy persons . The objective of this study was to test the hypothesis that anodal tDCS could modulate ERD in patients with severe hemiparetic stroke . The participants were six patients with chronic hemiparetic stroke ( mean age , 56.8 ± 9.5 years ; mean time from the onset , 70.0 ± 19.6 months ; Fugl-Meyer Assessment upper extremity motor score , 30.8 ± 16.5 ) . We applied anodal tDCS ( 10 min , 1 mA ) and sham stimulation over the affected primary motor cortex in a r and om order . ERD of the mu rhythm ( mu ERD ) with motor imagery of extension of the affected finger was assessed before and after anodal tDCS and sham stimulation . Mu ERD of the affected hemisphere increased significantly after anodal tDCS , whereas it did not change after sham stimulation . Our results show that anodal tDCS can increase mu ERD in patients with hemiparetic stroke , indicating that anodal tDCS could be used as a conditioning tool for BCI in stroke patients BACKGROUND Neurorehabilitation technologies such as robot therapy ( RT ) and transcranial Direct Current Stimulation ( tDCS ) can promote upper limb ( UL ) motor recovery after stroke . OBJECTIVE To explore the effect of anodal tDCS with uni-lateral and three-dimensional RT for the impaired UL in people with sub-acute and chronic stroke . METHODS A pilot r and omised controlled trial was conducted . Stroke participants had 18 one-hour sessions of RT ( ArmeoSpring ) over eight weeks during which they received 20 minutes of either real tDCS or sham tDCS during each session . The primary outcome measure was the Fugl-Meyer assessment ( FMA ) for UL impairments and secondary were : UL function , activities and stroke impact collected at baseline , post-intervention and three-month follow-up . RESULTS 22 participants ( 12 sub-acute and 10 chronic ) completed the trial . No significant difference was found in FMA between the real and sham tDCS groups at post-intervention and follow-up ( p = 0.123 ) . A significant ' time ' x ' stage of stroke ' was found for FMA ( p = 0.016 ) . A higher percentage improvement was noted in UL function , activities and stroke impact in people with sub-acute compared to chronic stroke . CONCLUSIONS Adding tDCS did not result in an additional effect on UL impairment in stroke . RT may be of more benefit in the sub-acute than chronic phase Stroke is a leading cause of adult motor disability . Despite recent progress , recovery of motor function after stroke is usually incomplete . This double blind , Sham-controlled , crossover study was design ed to test the hypothesis that non-invasive stimulation of the motor cortex could improve motor function in the paretic h and of patients with chronic stroke .  H and function was measured using the Jebsen-Taylor H and Function Test ( JTT ) , a widely used , well vali date d test for functional motor assessment that reflects activities of daily living . JTT measured in the paretic h and improved significantly with non-invasive transcranial direct current stimulation ( tDCS ) , but not with Sham , an effect that outlasted the stimulation period , was present in every single patient tested and that correlated with an increment in motor cortical excitability within the affected hemisphere , expressed as increased recruitment curves ( RC ) and reduced short-interval intracortical inhibition . These results document a beneficial effect of non-invasive cortical stimulation on a set of h and functions that mimic activities of daily living in the paretic h and of patients with chronic stroke , and suggest that this interventional strategy in combination with customary rehabilitative treatments may play an adjuvant role in neurorehabilitation Motor skill learning is one of the key components of motor function recovery after stroke , especially recovery driven by neurorehabilitation . Transcranial direct current stimulation can enhance neurorehabilitation and motor skill learning in stroke patients . However , the neural mechanisms underlying the retention of stimulation-enhanced motor  skill  learning involving a paretic upper limb have not been resolved . These neural substrates were explored by means of functional magnetic resonance imaging . Nineteen chronic hemiparetic stroke patients participated in a double-blind , cross-over r and omized , sham-controlled experiment with two series . Each series consisted of two sessions : ( i ) an intervention session during which dual transcranial direct current stimulation or sham was applied during motor skill learning with the paretic upper limb ; and ( ii ) an imaging session 1 week later , during which the patients performed the learned motor skill . The motor skill learning task , called the ' circuit game ' , involves a speed/accuracy trade-off and consists of moving a pointer controlled by a computer mouse along a complex circuit as quickly and accurately as possible . Relative to the sham series , dual transcranial direct current stimulation applied bilaterally over the primary motor cortex during motor skill learning with the paretic upper limb result ed in ( i ) enhanced online motor skill learning ; ( ii ) enhanced 1-week retention ; and ( iii ) superior transfer of performance improvement to an untrained task . The 1-week retention 's enhancement driven by the intervention was associated with a trend towards normalization of the brain activation pattern during performance of the learned motor skill relative to the sham series . A similar trend towards normalization relative to sham was observed during performance of a simple , untrained task without a speed/accuracy constraint , despite a lack of behavioural difference between the dual transcranial direct current stimulation and sham series . Finally , dual transcranial direct current stimulation applied during the first session enhanced continued learning with the paretic limb 1 week later , relative to the sham series . This lasting behavioural enhancement was associated with more efficient recruitment of the motor skill learning network , that is , focused activation on the motor-premotor areas in the damaged hemisphere , especially on the dorsal premotor cortex . Dual transcranial direct current stimulation applied during motor skill learning with a paretic upper limb result ed in prolonged shaping of brain activation , which supported behavioural enhancements in stroke patients Noninvasive transcranial direct current stimulation ( tDCS ) and methylpheni date ( MP ) are associated with motor recovery after stroke . Based on the potentially complementary mechanisms of these interventions , we examined whether there is an interactive effect between MP and tDCS . In this preliminary study , we r and omized subacute stroke subjects to receive tDCS alone , MP alone or combination of tDCS and MP . A blinded rater measured safety , h and function , and cortical excitability before and after treatment . None of the treatments caused any major or severe adverse effects or induced significant differences in cortical excitability . Analysis of variance of gain score , as measured by Purdue pegboard test , showed a significant between-group difference ( F(2,6)=12.167 , p=0.008 ) . Post hoc analysis showed that the combination treatment effected greater Purdue pegboard gain scores than tDCS alone ( p=0.017 ) or MP alone ( p=0.01 ) . Our preliminary data with nine subjects shows an interesting dissociation between motor function improvement and lack of motor corticospinal plasticity changes as indexed by transcranial magnetic stimulation in subacute stroke subjects PURPOSE It is thought that following a stroke the contralesional motor region exerts an undue inhibitory influence on the lesional motor region which might limit recovery . Pilot studies have shown that suppressing the contralesional motor region with cathodal transcranial Direct Current Stimulation ( tDCS ) can induce a short lasting functional benefit ; greater and longer lasting effects might be achieved with combining tDCS with simultaneous occupational therapy ( OT ) and applying this intervention for multiple sessions . METHODS We carried out a r and omized , double blind , sham controlled study of chronic stroke patients receiving either 5 consecutive days of cathodal tDCS ( for 30 minutes ) applied to the contralesional motor region and simultaneous OT , or sham tDCS+OT .  RESULTS we showed that cathodal tDCS+OT result ed in significantly more improvement in Range-Of-Motion in multiple joints of the paretic upper extremity and in the Upper-Extremity Fugl-Meyer scores than sham tDCS+OT , and that the effects lasted at least one week post-stimulation . Improvement in motor outcome scores was correlated with decrease in fMRI activation in the contralesional motor region exposed to cathodal stimulation . CONCLUSIONS This suggests that cathodal tDCS combined with OT leads to significant motor improvement after stroke due to a decrease in the inhibitory effect that the contralesional hemisphere exerts onto the lesional hemisphere Background : Since motor learning is a key component for stroke recovery , enhancing motor skill learning is a crucial challenge for neurorehabilitation . Transcranial direct current stimulation ( tDCS ) is a promising approach for improving motor learning . The aim of this trial was to test the hypothesis that dual-tDCS applied bilaterally over the primary motor cortices ( M1 ) improves online motor skill learning with the paretic h and and its long-term retention . Methods : Eighteen chronic stroke patients participated in a r and omized , cross-over , placebo-controlled , double bind trial . During separate sessions , dual-tDCS or sham dual-tDCS was applied over 30 min while stroke patients learned a complex visuomotor skill with the paretic h and : using a computer mouse to move a pointer along a complex circuit as quickly and accurately as possible . A learning index involving the evolution of the speed/accuracy trade-off was calculated . Performance of the motor skill was measured at baseline , after intervention and 1 week later . Results : After sham dual-tDCS , eight patients showed performance worsening . In contrast , dual-tDCS enhanced the amount and speed of online motor skill learning compared to sham ( p < 0.001 ) in all patients ; this superiority was maintained throughout the hour following . The speed/accuracy trade-off was shifted more consistently after dual-tDCS ( n = 10 ) than after sham ( n = 3 ) . More importantly , 1 week later , online enhancement under dual-tDCS had translated into superior long-term retention ( + 44 % ) compared to sham ( + 4 % ) . The improvement generalized to a new untrained circuit and to digital dexterity . Conclusion : A single-session of dual-tDCS , applied while stroke patients trained with the paretic h and significantly enhanced online motor skill learning both quantitatively and qualitatively , leading to successful long-term retention and generalization . The combination of motor skill learning and dual-tDCS is promising for improving post-stroke neurorehabilitation Background . Low-frequency repetitive transcranial magnetic stimulation ( rTMS ) over the unaffected motor cortex may improve motor function of the paretic h and after stroke . However , low-frequency rTMS might adversely affect bimanual movement by decreasing transcallosal function . Objective . The authors investigated whether combined administration of rTMS and transcranial direct current stimulation ( tDCS ) prevents deterioration of bimanual movement induced by low-frequency rTMS over the unaffected hemisphere . Methods . A total of 27 participants with chronic subcortical stroke were r and omly assigned to receive either 1 Hz rTMS over the unaffected hemisphere , anodal tDCS over the affected hemisphere , or a combination of rTMS and tDCS .  All patients performed a pinching motor-training task after stimulation . Bimanual movement and transcallosal inhibition ( TCI ) were evaluated after stimulation . Results . rTMS and rTMS-tDCS enhanced the motor training effect on the paretic h and . rTMS decreased bimanual coordination and reduced TCI from the unaffected to the affected hemisphere ( TCIunaff-aff ) . rTMS-tDCS changed TCI balance of both hemispheres but did not affect bimanual coordination or TCIunaff-aff . The change in bimanual coordination was negatively correlated with TCIunaff-aff . Following stimulation , improvement in the pinch force in the paretic h and was negatively correlated with TCI balance . Conclusions . Inhibitory rTMS over the unaffected hemisphere transiently caused deterioration of bimanual movements for the current task in stroke patients . This short-term decline was prevented by combined administration of low-frequency rTMS over the unaffected hemisphere and anodal tDCS over the affected hemisphere . These responses to bihemispheric stimulation suggest possible caution and opportunities for the rehabilitation of h and function after stroke We set out to answer two questions with this study : 1 . Can stroke patients improve voluntary control of their paretic ankle by practising a visuo-motor ankle-tracking task ? 2 . Are practice effects enhanced with non-invasive brain stimulation ? A carefully selected sample of chronic stroke patients able to perform the experimental task attended three data collection sessions . Facilitatory transcranial direct current stimulation ( tDCS ) was applied in a r and om order over the lower limb primary motor cortex of the lesioned hemisphere or the non-lesioned hemisphere or sham stimulation was delivered over the lesioned hemisphere . In each session , tDCS was applied as patients practice d tracking a sinusoidal waveform for 15 min using dorsiflexion – plantarflexion movements of their paretic ankle . The difference in tracking error prior to , and after , the 15 min of practice was calculated . A practice effect was revealed following sham stimulation , and this effect was enhanced with tDCS applied over the lesioned hemisphere . The practice effect observed following sham stimulation was eliminated by tDCS applied over the non-lesioned hemisphere . The study provides the first evidence that non-invasive brain stimulation applied to the lesioned motor cortex of moderate- to well-recovered stroke patients enhances voluntary control of the paretic ankle . The results provide a basis for examining whether this enhanced ankle control can be induced in patients with greater impairments and whether enhanced control of a single or multiple lower limb joints improves hemiparetic gait patterns Recovery of function after a stroke is determined by a balance of activity in the neural network involving both the affected and the unaffected brain hemispheres . Increased activity in the affected hemisphere can promote recovery , while excessive activity in the unaffected hemisphere may represent a maladaptive strategy . We therefore investigated whether reduction of the excitability in the unaffected hemisphere by cathodal transcranial direct current stimulation could result in motor performance improvement in stroke patients . We compared these results with excitability-enhancing anodal transcranial direct current stimulation of the affected hemisphere and sham transcranial direct current stimulation . Both cathodal stimulation of the unaffected hemisphere and anodal stimulation of the affected hemisphere ( but not sham transcranial direct current stimulation ) improved motor performance significantly . These results suggest that the appropriate modulation of bihemispheric brain structures can promote motor function recovery Objective . We compared the long-term effect of anodal versus cathodal transcranial direct current stimulation ( tDCS ) on motor recovery in patients after subacute stroke . Methods . Forty patients with ischemic stroke undergoing rehabilitation were r and omly assigned to 1 of 3 groups : Anodal , Cathodal ( over-affected and unaffected hemisphere , respectively ) , and Sham . Each group received tDCS at an intensity of 2 mA for 25 minutes daily for 6 consecutive days over of the motor cortex h and area . Patients were assessed with the National Institutes of Health Stroke Scale ( NIHSS ) , Orgogozo ’s MCA scale ( OMCASS ) , the Barthel index ( BI ) , and the Medical Research Council ( MRC ) muscle strength scale at baseline , after the sixth tDCS session and then 1 , 2 , and 3 months later . Motor cortical excitability was measured with transcranial magnetic stimulation ( TMS ) at baseline and after the sixth session . Results . By the 3-month follow-up , all groups had improved on all scales with P values ranging from .01 to .0001 . Improvement was equal in the Anodal and Cathodal groups . When these treated groups were combined and compared with Sham , significant interactions were seen for the OMCASS and BI scales of functional ability ( P = .002 for each ) . There was increased cortical excitability of the affected hemisphere in all groups with the changes being greater in the real versus sham groups . There were borderline significant improvements in muscle strength . Conclusion . A brief course of 2 types of tDCS stimulation is superior to sham stimulation in enhancing the effect of rehabilitation training to improve motor recovery after stroke Kim DY , Ohn SH , Yang EJ , Park C-I , Jung KJ : Enhancing Motor Performance by Anodal Transcranial Direct Current Stimulation in Subacute Stroke Patients . Objective : To investigate whether anodal transcranial direct current stimulation enhances motor performance in the paretic h and of subacute poststroke patients and how long the improvement persisted after the session . Design : Ten subacute poststroke patients who suffered stoke within 12 wks were recruited for this single-blinded , sham-controlled , crossover study . Anodal transcranial direct current stimulation or sham stimulation was r and omly delivered on the hot spot of the first dorsal interosseous in the affected hemisphere . The duration of transcranial direct current stimulation was 20 mins and sham was 30 secs. The Box and Block test and finger acceleration measurement were performed before , during , immediately after , and 30 and 60 mins after anodal or sham stimulation to assess time-dependent changes in motor performance . Results : Finger acceleration measurement and Box and Block test were significantly improved after anodal transcranial direct current stimulation compared with sham stimulation ( P < 0.05 ) . Anodal transcranial direct current stimulation significantly improved Box and Block test for at least 60 mins and finger acceleration until 30 mins after stimulation ( P < 0.05 ) without significant differences in attention and fatigue . Conclusions : Anodal transcranial direct current stimulation on the affected hemisphere can enhance motor performance of the hemiparetic h and transiently , outlasting the stimulation session OBJECTIVE To assess the efficacy of transcranial direct current stimulation ( tDCS ) on decreasing  upper-limb ( UL ) muscle tone after stroke . DESIGN A prospect i ve , sham-controlled , r and omized controlled trial with 4-weeks follow-up . R and omization into the tDCS group or the control group . SETTING Rehabilitation education and research hospital . PARTICIPANTS In patients ( N=90 , 45 per group ; age range , 15 - 70y ; 69 men , 21 women ; duration of stroke , 2 - 12mo ) with poststroke UL spasticity . No participant withdrew because of adverse effects . INTERVENTION The tDCS group received tDCS to the primary sensorimotor cortex of the affected side with cathodal stimulation , 20 minutes per day , 5 days per week , for 4 weeks and conventional physical therapy . The control group received sham stimulation ( same area as the tDCS group ) and conventional physical therapy . MAIN OUTCOME MEASURES Modified Ashworth scale ( MAS ) , Fugl-Meyer Assessment of motor recovery , and Barthel Index . All outcomes were measured at admission , after treatment , and after follow-up . A clinical ly important difference ( CID ) was defined as a reduction of ≥1 in the MAS score . RESULTS Compared with the sham tDCS group , the active tDCS group had significantly more patients with a clinical ly important difference after treatment ( 80 % and 78 % vs 6 % and 9 % ) and at 4-week follow-up ( 84 % and 82 % vs 7 % and 4 % ) , and UL motor function and activities of daily living ( ADL ) assessment improved more significantly in the active tDCS group ( Fugl-Meyer Assessment of motor recovery from 12 [ range , 4 - 26 ] to 22 [ range , 7 - 50 ] to 32 [ range , 28 - 41 ] , Barthel Index from 55 [ range , 0 - 85 ] to 85 [ range , 5 - 100 ] to 90 [ range , 10 - 100 vs Fugl-Meyer Assessment of motor recovery from 8 [ range , 3 - 34 ] to 10 [ range , 8 - 25 ] to 15 [ range , 6 - 40 ] , Barthel Index from 55 [ range , 25 - 95 ] to 65 [ range , 30 - 100 ] to 75 [ range , 40 - 100 ] , respectively , P<.01 ) . CONCLUSIONS UL muscle tone after stroke can be decreased using cathodal tDCS . Combined with conventional physical therapy , tDCS appears to improve motor function and ADL . Cathodal tDCS over ipsilesional primary sensorimotor cortex may inhibit primary sensorimotor cortex hyperactivation , result ing in significant reductions in muscle tone Background and Purpose : Noninvasive brain stimulation , including repetitive transcranial magnetic stimulation ( rTMS ) and transcranial direct current stimulation ( tDCS ) , have gained popularity in the stroke rehabilitation literature . Little is known about the time course and duration of effects of noninvasive brain stimulation on corticospinal excitability in individuals with stroke . We examined the aftereffects of a single session of high-frequency rTMS ( 5 Hz ) and anodal tDCS on corticospinal excitability in the same sample of participants with chronic stroke . Methods : Ten individuals with chronic stroke participated in this r and omized cross-over study . Participants received 1 session of rTMS and 1 session of tDCS , with 1 week between sessions . During the rTMS session , 5-Hz rTMS ( total of 1200 stimuli ) was administered to the ipsilesional primary motor cortex ( M1 ) . For anodal tDCS , 1 mA of direct current was delivered to the ipsilesional M1 for 20 minutes . Motor evoked potentials were measured before and after ( immediately , 15 minutes , 30 minutes , and 60 minutes ) each stimulation session . Results : Both 5-Hz rTMS and anodal tDCS significantly increased corticospinal excitability for 30 to 60 minutes after stimulation . There was no statistically significant difference between the 2 stimulation techniques in their effects on motor evoked potentials . No changes in measures of motor or cognitive performance were observed . Discussion and Conclusion : Both 5-Hz rTMS and anodal tDCS induced effects on corticospinal excitability in persons with chronic stroke lasting at least 1 hour after stimulation . In the absence of concurrent motor practice , neither form of stimulation applied in a single session was associated the changes in motor performance . These approaches to increased cortical excitability may be of value as adjuncts to training . Video Abstract available : See Video ( Supplemental Digital Content 1 , http://links.lww.com/JNPT/A83 ) for more insights from the authors OBJECTIVE Brain polarization in the form of transcranial direct current stimulation ( tDCS ) , which influences motor function and learning processes , has been proposed as an adjuvant strategy to enhance training effects in Neurorehabilitation . Proper testing in Neurorehabilitation requires double-blind sham-controlled study design s. Here , we evaluated the effects of tDCS and sham stimulation ( SHAM ) on healthy subjects and stroke patients ' self-report measures of attention , fatigue , duration of elicited sensations and discomfort . METHODS tDCS or SHAM was in all cases applied over the motor cortex . Attention , fatigue , and discomfort were self rated by study participants using visual analog scales . Duration of perceived sensations and the ability to distinguish tDCS from Sham sessions were determined . Investigators question ing the patients were blind to the intervention type . RESULTS tDCS and SHAM elicited comparably minimal discomfort and duration of sensations in the absence of differences in attention or fatigue , and could not be distinguished from SHAM by study participants nor investigators . CONCLUSIONS Successful blinding of subjects and investigators and ease of application simultaneously with training protocol s supports the feasibility of using tDCS in double-blind , sham-controlled r and omized trials in clinical Neurorehabilitation . SIGNIFICANCE tDCS could evolve into a useful tool , in addition to TMS , to modulate cortical activity in Neurorehabilitation PURPOSE Non-invasive brain stimulation with transcranial direct current stimulation ( tDCS ) modulates cortical excitability and improves upper limb motor performance when applied to chronic stroke patients . The objective was to evaluate whether tDCS can influence gait function in sub-acute stroke patients . METHODS We assessed the effect of single session , bi-cephalic tDCS on gait performance in 14 subacute patients with stroke involving the cerebral hemisphere ( 2 - 8 weeks post-stroke ) in a double-blinded , sham-controlled study . Patients were r and omly allocated to receive either active ( n = 7 ) or sham ( n = 7 ) tDCS . The anodal electrode was placed on the scalp over the ipsilesional lower limb primary motor cortex and the cathode was placed over the contralesional leg motor cortex . Gait performance was measured using the Timed Up and Go test and the Performance Oriented Mobility Assessment before and after active or sham tDCS . RESULTS The tDCS group was significantly quicker in the Timed Up and Go test in the tDCS group , compared to the sham group ( p = 0.018 ) . The Performance Oriented Mobility Assessment was not different between groups ( p = 0.897 ) . CONCLUSIONS This is the first study to examine the effects of tDCS on gait in stroke patients in the sub-acute stage . Active tDCS improved gait performance ( Timed Up and Go ) in stroke patients , despite no changes to limb biomechanics of the hemiparetic side ( Performance Oriented Mobility Assessment ) , as compared to sham stimulation . These results suggest that tDCS could be used as a therapeutic adjunct for gait rehabilitation following stroke Objective : To evaluate whether robot-assisted gait training combined with transcranial direct current stimulation is more effective than robot-assisted gait training alone or conventional walking rehabilitation for improving walking ability  in stroke patients . Design : Pilot r and omized clinical trial . Setting : Rehabilitation unit of a university hospital . Subjects : Thirty patients with chronic stroke . Interventions : All patients received ten 50-minute treatment sessions , five days a week , for two consecutive weeks . Group 1 ( n = 10 ) underwent a robot-assisted gait training combined with transcranial direct current stimulation ; group 2 ( n = 10 ) underwent a robot-assisted gait training combined with sham transcranial direct current stimulation ; group 3 ( n = 10 ) performed overground walking exercises . Main measures : Patients were evaluated before , immediately after and two weeks post treatment . Primary outcomes : six-minute walking test , 10-m walking test . Results : No differences were found between groups 1 and 2 for all primary outcome measures at the after treatment and follow-up evaluations . A statistically significant improvement was found after treatment in performance on the six-minute walking test and the 10-m walking test in favour of group 1 ( six-minute walking test : 205.20 ± 61.16 m ; 10-m walking test : 16.20 ± 7.65 s ) and group 2 ( six-minute walking test : 182.5 ± 69.30 m ; 10-m walking test : 17.71 ± 8.20 s ) compared with group 3 ( six-minute walking test : 116.30 ± 75.40 m ; 10-m walking test : 26.30 ± 14.10 s ) . All improvements were maintained at the follow-up evaluation . Conclusions : In the present pilot study transcranial direct current stimulation had no additional effect on  robot-assisted gait training in patients with chronic stroke . Larger studies are required to confirm these preliminary findings BACKGROUND Significant changes in neurophysiological and clinical outcomes in chronic stroke had been reported after tDCS ; but there is a paucity of data in acute stroke . OBJECTIVE We aim ed to evaluate whether a tDCS-induced modulation of primary motor cortex excitability in patients with acute stroke enhances motor recovery associated with rehabilitation and induces differential neuroplasticity . METHODS We conducted two experiments in acute stroke patients . In experiment 1 ( 14 patients ) , we tested the immediate effects of bilateral tDCS alone as compared to sham tDCS on recovery . Experiment 2 ( 20 patients ) was design ed to assess effects of bilateral tDCS delivered together with constraint-induced movement therapy ( CIMT ) . In this experiment , we included a longer follow-up ( 3 months ) and measured , in addition to the same clinical outcomes of experiment 1 , changes of motor cortex excitability and the amount of promoted LTP-like activity . RESULTS Despite the expected improvement at 1 week , none of the clinical measures showed any different modulation in dependence of CIMT and tDCS . On the neurophysiological assessment s , on the other h and , the Real_tDCS group , compared to Sham_tDCS group , showed a reduction of inter-hemispheric imbalance when considering the differences of motor evoked potential between both 3-month and 1 week follow up ( P = 0.007 ) and three month and baseline ( P = 0.015 ) . CONCLUSIONS Despite the lack of additional clinical changes , real bilateral tDCS , together with CIMT , significantly reduces inter-hemispheric imbalance between affected and unaffected hemispheres . These findings may shed light on plasticity changes in acute stroke and its potential impact in chronic phases PURPOSE Anodal transcranial direct current stimulation ( tDCS ) can transiently increase corticomotor excitability of intrinsic h and muscles and improve upper limb function in patients with chronic stroke . As a preliminary study , we tested whether increased corticomotor excitability would be similarly observed in muscles acting about the wrist , and remain present during robotic training involving active wrist movements , in six chronic stroke patients with residual motor deficit . METHODS Transcranial magnetic stimulation ( TMS ) generated motor evoked potentials ( MEP ) in the flexor carpi radialis ( FCR ) and provided a measure of corticomotor excitability and short-interval cortical inhibition ( SICI ) before and immediately after a period of tDCS ( 1 mA , 20 min , anode and TMS applied to the lesioned hemisphere ) , and robotic wrist training ( 1hr ) . RESULTS Following tDCS , the same TMS current strength evoked an increased MEP amplitude ( mean 168 + /- 22%SEM ; p < 0.05 ) , that remained increased after robot training ( 166 + /- 23 % ; p < 0.05 ) . Conditioned MEPs were of significantly lower amplitude relative to unconditioned MEPs prior to tDCS ( 62 + /- 6 % , p < 0.05 ) , but not after tDCS ( 89 + /- 14 % , p = 0.40 ) , or robot training ( 91 + /- 8 % , p = 0.28 ) , suggesting that the increased corticomotor excitability is associated with reduced intracortical inhibition . CONCLUSION The persistence of these effects after robotic motor training , indicates that a motor learning and retraining program can co-exist with tDCS-induced changes in cortical motor excitability , and supports the concept of combining brain stimulation with physical therapy to promote recovery after brain injury Kim DY , Lim JY , Kang EK , You DS , Oh MK , Oh BM , Paik NJ : Effect of transcranial direct current stimulation on motor recovery in patients with subacute stroke . Objective : To test the hypothesis that 10 sessions of transcranial direct current stimulation combined with occupational therapy elicit more improvement in motor function of the paretic upper limb than sham stimulation in patients with subacute stroke . Design : Eighteen patients with subacute stroke with h and motor impairment were r and omly assigned to one of the three 10-day sessions of ( a ) anodal transcranial direct current stimulation over the affected motor cortex , ( b ) cathodal transcranial direct current stimulation over the unaffected motor cortex , or ( c ) sham stimulation . Blinded evaluators assessed upper limb motor impairment and global functional state with the Fugl-Meyer Assessment score and the Modified Barthel Index at baseline , 1 day after stimulation , and 6 mos after stimulation . Results : Baseline scores for Fugl-Meyer Assessment and Modified Barthel Index were comparable in all groups ( P > 0.05 ) . At 6-mo follow-up , cathodal transcranial direct current stimulation led to a greater improvement in Fugl-Meyer Assessment than the sham procedure ( P < 0.05 ) . There was a significant inverse correlation between baseline Fugl-Meyer Assessment and Fugl-Meyer Assessment increase at 6 mos ( r = −0.846 ; P < 0.01 ) . Conclusions : Our results suggest a potentially beneficial effect of noninvasive cortical stimulation during rehabilitative motor training of patients who have suffered from subacute strokes It is reasonable to assume a priori that brain properties ( activities ) are self-coordinated at every stage of ontogeny and to examine , in this context , slow electrical brain activity ( 0.5–6.0 Hz ) and brain plasticity ( rapid recovery of functions after brain damage ) , which are characteristic of early childhood . From this st and point , it is conceivable that stimulation of the brain by weak pulsed current ranging in frequency from 1 to 10 Hz ( hereinafter , microelectrostimulation , MES ) would activate the mechanisms of brain plasticity .  MES is advantageous in that it is noninvasive , acts gently , and its action on the brain can be targeted . Therefore , it is possible to use MES for treatment of patients at acute stages of brain disorders [ 1–3 ] Following seminal articles on the technique and underlying mechanisms of transcranial direct current stimulation ( tDCS ) at the turn of this century,1 tDCS has gained special attention in neurorehabilitative research , given its ability to modulate brain function in a polarity-specific manner in stroke patients together with an excellent safety profile.2 However , an important safety concern emerged recently with regard to its impact on cerebral autoregulation , given a report on decreased autoregulation after 15 minutes anodal tDCS ( atDCS ) over primary motor cortex ( M1 ) in young healthy subjects.3  Cerebral autoregulation , assessed by vasomotor reactivity ( VMR ) , reflects the autonomic ability of cerebral arterioles to dilate following a vasodilatory stimulus . It is consistently decreased in patients with cerebrovascular diseases,4 and has been linked to stroke risk.5 Thus , a decrease of VMR after atDCS may be harmful to patients with already impaired VMR , such as stroke patients .4 Importantly , > 40 ongoing trials with stroke patients and atDCS  are registered on www . clinical trials.gov as of May 2014 . Thus , the concerns raised by Vernieri et al.3 may carry important clinical implication Neurophysiological and computer modelling studies have shown that electrode montage is a critical parameter to determine the neuromodulatory effects of transcranial direct current stimulation ( tDCS ) . We tested these results clinical ly by systematic ally investigating optimal tDCS electrode montage in stroke . Ten patients received in a counterbalanced and r and omised order the following conditions of stimulation ( i ) anodal stimulation of affected M1 ( primary motor cortex ) and cathodal stimulation of unaffected M1 ( ‘ bilateral tDCS ’ ) ; ( ii ) anodal stimulation of affected M1 and cathodal stimulation of contralateral supraorbital area ( ‘ anodal tDCS ’ ) ; ( iii ) cathodal stimulation of unaffected M1 and anodal stimulation of contralateral supraorbital area ( ‘ cathodal tDCS ’ ) ; ( iv ) anodal stimulation of affected M1 and cathodal stimulation of contralateral deltoid muscle ( ‘ extra-cephalic tDCS ’ ) and ( v ) sham stimulation . We used the Jebsen – Taylor Test ( JTT ) as a widely accepted measure of upper limb function . Bilateral tDCS , anodal tDCS and cathodal tDCS were shown to be associated with significant improvements on the JTT . Placing the reference electrode in an extracephalic position and use of sham stimulation did not induce any significant effects . This small sham controlled cross-over clinical trial is important to provide additional data on the clinical effects of tDCS in stroke and for planning and design ing future large tDCS trials in patients with stroke
BACKGROUND Stroke is one of the leading causes of disability worldwide .
Functional impairment , result ing in poor performance in activities of daily living ( ADLs ) among stroke survivors is common .
Current rehabilitation approaches have limited effectiveness in improving ADL performance , function , muscle strength and cognitive abilities ( including spatial neglect ) after stroke , but a possible adjunct to stroke rehabilitation might be non-invasive brain stimulation by transcranial direct current stimulation ( tDCS ) to modulate cortical excitability , and hence to improve ADL performance , arm and leg function , muscle strength and cognitive abilities ( including spatial neglect ) , dropouts and adverse events in people after stroke .
OBJECTIVES To assess the effects of tDCS on ADLs , arm and leg function , muscle strength and cognitive abilities ( including spatial neglect ) , dropouts and adverse events in people after stroke .
In the previous version of this review we focused on the effects of tDCS on ADLs and function .