***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 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 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 Objective : To assess and to compare the reliability of the Modified Tardieu Scale with the Modified Ashworth Scale in patients with severe brain injury and impaired consciousness . Design : Cross-sectional observational comparison study . Setting : An early rehabilitation centre for adults with neurological disorders . Subjects : Thirty patients with impaired consciousness due to severe cerebral damage of various aetiologies . Measurement protocol : Four experienced physical therapists rated each patient in a r and omized order once daily for two consecutive days . Shoulder , elbow , wrist , hip , knee and ankle spasticity were assessed by the use of Modified Tardieu Scale and Modified Ashworth Scale data collection procedures . Main outcome measures : Test - retest and inter-rater reliability ( k = kappa value ) of the Modified Tardieu Scale and the Modified Ashworth Scale .  Results : The test-retest reliability of the Modified Ashworth Scale was moderate to good ( k = 0.47 - 0.62 ) and of the Modified Tardieu Scale moderate to very good ( k = 0.52 - 0.87 ) . Test - retest reliability was significantly higher within the Modified Tardieu Scale in comparison with the Modified Ashworth Scale ( Z<1.96 ; p<0.05 ) except for shoulder extensor and internal rotator muscles ( Z<1.96 ; p<0.05 ) . Although inter-rater reliability of both scales was poor to moderate ( Modified Ashworth Scale : k = 0.16 - 0.42 ; Modified Tardieu Scale : k = 0.29 - 0.53 ) , significantly higher k-values were revealed with the Modified Tardieu Scale for all tested muscle groups ( Z<1.96 ; p<0.05 ) except for wrist extensors ( Z<1.96 ; p<0.05 ) . Conclusion : In patients with severe brain injury and impaired consciousness the Modified Tardieu Scale provides higher test-retest and inter-rater reliability compared with the Modified Ashworth  Scale and may therefore be a more valid spasticity scale in adults BACKGROUND Resistance from antagonistic muscle groups might be a crucial factor reducing function in chronic hemiparesis . The resistance due to spastic co-contraction might be reduced by botulinum toxin injections . We assessed the effects of abobotulinumtoxinA injection in the upper limb muscles on muscle tone , spasticity , active movement , and function . METHODS In this r and omised , placebo-controlled , double-blind study , we enrolled adults ( aged 18 - 80 years ) at least 6 months after stroke or brain trauma from 34 neurology or rehabilitation clinics in Europe and the USA . Eligible participants were r and omly allocated in a 1:1:1 ratio with a computer-generated list to receive a single injection session of abobotulinumtoxinA 500 U or 1000 U or placebo into the most hypertonic muscle group among the elbow , wrist , or finger flexors ( primary target muscle group [ PTMG ] ) , and into at least two additional muscle groups from the elbow , wrist , or finger flexors or shoulder extensors . Patients and investigators were masked to treatment allocation . The primary endpoint was the change in muscle tone ( Modified Ashworth Scale [ MAS ] ) in the PTMG from baseline to 4 weeks . Secondary endpoints were Physician Global Assessment ( PGA ) at week 4 and change from baseline to 4 weeks in the perceived function ( Disability Assessment Scale [ DAS ] ) in the principal target of treatment , selected by the patient together with physician from four functional domains ( dressing , hygiene , limb position , and pain ) . Analysis was by intention to treat . This study is registered with Clinical Trials.gov , number NCT01313299 . FINDINGS 243 patients were r and omly allocated to placebo ( n=81 ) , abobotulinumtoxinA 500 U ( n=81 ) , or abobotulinumtoxinA 1000 U ( n=81 ) . Mean change in MAS score from baseline at week 4 in the PTMG was -0·3 ( SD 0·6 ) in the placebo group ( n=79 ) , -1·2 ( 1·0 ) in the abobotulinumtoxinA 500 U group ( n=80 ; difference -0·9 , 95 % CI -1·2 to -0·6 ; p<0·0001 vs placebo ) , and -1·4 ( 1·1 ) in the abobotulinumtoxinA 1000 U group ( n=79 ; -1·1 , -1·4 to -0·8 ; p<0·0001 vs placebo ) . Mean PGA score at week 4 was 0·6 ( SD 1·0 ) in the placebo group ( n=78 ) , 1·4 ( 1·1 ) in the abobotulinumtoxinA 500 U group ( n=80 ; p=0·0003 vs placebo ) , and 1·8 ( 1·1 ) in the abobotulinumtoxinA 1000 U group ( n=78 ; p<0·0001 vs placebo ) . Mean change from baseline at week 4 in DAS score for the principal target of treatment was -0·5 ( 0·7 ) in the placebo group ( n=79 ) , -0·7 ( 0·8 ) in the abobotulinumtoxinA 500 U group ( n=80 ; p=0·2560 vs placebo ) , and -0·7 ( 0·7 ) in the abobotulinumtoxinA 1000 U group ( n=78 ; p=0·0772 vs placebo ) . Three serious adverse events occurred in each group and none were treatment related ; two result ed in death ( from pulmonary oedema in the placebo group and a pre-existing unspecified cardiovascular disorder in the abobotulinumtoxinA 500 U group ) . Adverse events that were thought to be treatment related occurred in two ( 2 % ) , six ( 7 % ) , and seven ( 9 % ) patients in the placebo , abobotulinumtoxinA 500 U , and abobotulinumtoxinA 1000 U groups , respectively . The most common treatment-related adverse event was mild muscle weakness . All adverse events were mild or moderate . INTERPRETATION AbobotulinumtoxinA at doses of 500 U or 1000 U injected into upper limb muscles provided tone reduction and clinical benefit in hemiparesis . Future research into the treatment of spastic paresis with botulinum toxin should use active movement and function as primary outcome measures . FUNDING Ipsen Transcranial direct current stimulation ( tDCS ) 
    Output:
    
There was moderate-to-low quality of evidence for no effect of tDCS on improving spasticity at the end of the intervention period .
There were no studies examining the effect of tDCS on improving spasticity at long-term follow-up .
There is moderate-to-low quality evidence for no effect of tDCS on improving spasticity in people with stroke