***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: 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 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 ) 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 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 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 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 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 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 stim 
    Output:
    
Transcranial direct current stimulation is likely to be effective in enhancing motor performance in the short term when applied selectively to patients with stroke .