***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: Objective : To investigate the long-term behavioral and neurophysiologic effects of combined time-locked repetitive transcranial magnetic stimulation ( rTMS ) and physical therapy ( PT ) intervention in chronic stroke patients with mild motor disabilities . Methods : Thirty patients were enrolled in a double-blind , r and omized , single-center clinical trial . Patients received 10 daily sessions of 1 Hz rTMS over the intact motor cortex . In different groups , stimulation was either real ( rTMSR ) or sham ( rTMSS ) and was administered either immediately before or after PT . Outcome measures included dexterity , force , interhemispheric inhibition , and corticospinal excitability and were assessed for 3 months after the end of treatment . Results : Treatment induced cumulative rebalance of excitability in the 2 hemispheres and a reduction of interhemispheric inhibition in the rTMSR groups . Use-dependent improvements were detected in all groups . Improvements in trained abilities were small and transitory in rTMSS patients . Greater behavioral and neurophysiologic outcomes were found after rTMSR , with the group receiving rTMSR before PT ( rTMSR-PT ) showing robust and stable improvements and the other group ( PT-rTMSR ) showing a slight improvement decline over time . Conclusion : Our findings indicate that priming PT with inhibitory rTMS is optimal to boost use-dependent plasticity and rebalance motor excitability and suggest that time-locked rTMS is a valid and promising approach for chronic stroke patients with mild motor impairment . Classification of evidence : This interventional study provides Class I evidence that time-locked rTMS before or after physical therapy improves measures of dexterity and force in the affected limb in patients with chronic deficits more than 6 months poststroke . Neurology ® 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 The objective of this pilot study was to examine alterations in motor unit ( MU ) control properties , ( i.e. MU recruitment and firing rate ) after stroke utilizing a recently developed high-yield surface electromyogram ( EMG ) decomposition technique . Two stroke subjects participated in this study .  A sensor array was used to record surface EMG signals from the first dorsal interosseous ( FDI ) muscle during voluntary isometric contraction at varying force levels . The recording was performed in both paretic and contralateral muscles using a matched force protocol . Single motor unit activity was extracted using the  surface EMG decomposition  software from Delsys Inc. The results from the two stroke subjects indicate a reduction in the mean motor unit firing rate and a compression of motor unit recruitment range in paretic muscle as compared with the contralateral muscles . These findings provide further evidence of spinal motoneuron involvement after a hemispheric brain lesion , and help us to underst and the complex origins of stroke induced muscle weakness OBJECTIVE Repetitive transcranial magnetic stimulation ( rTMS ) has been recognized as a promising intervention for treatment of stroke patients . However , most previous reports have described the short-term effects of rTMS on motor performance . We conducted a sham-controlled trial to evaluate long-term effects of high-frequency rTMS on motor recovery in subacute stroke patients . METHODS Twenty-eight patients were r and omly divided into two groups , and received either real or control rTMS . Both treatments were accompanied by motor practice . A daily dose of 1000 pulses of subthreshold 10 Hz rTMS was applied over the primary motor cortex of the affected hemisphere for 10 days within one month after onset of stroke . Motor function was assessed before and after treatment , and 3 months after the stroke . RESULTS Motor function improved in both groups after treatment ; however , patients who received real rTMS experienced additional improvement in motor function of the affected upper limb . Over 3 months after the stroke , the time and type of intervention for the Motoricity Index of the affected upper extremity showed significant interaction . CONCLUSION Positive long-term effects on motor recovery could be achieved after 10 daily sessions of high-frequency rTMS in conjunction with motor practice during the sub-acute period of stroke Low-frequency repetitive transcranial magnetic stimulation ( rTMS ) of the unaffected hemisphere can enhance function of the paretic h and in patients with mild motor impairment . Effects of low-frequency rTMS to the contralesional motor cortex at an early stage of mild to severe hemiparesis after stroke are unknown . In this pilot , r and omized , double-blind clinical trial we compared the effects of low-frequency rTMS or sham rTMS as add-on therapies to outpatient customary rehabilitation , in 30 patients within 5–45 days after ischemic stroke , and mild to severe h and paresis . The primary feasibility outcome was compliance with the interventions . The primary safety outcome was the proportion of intervention-related adverse events . Performance of the paretic h and in the Jebsen – Taylor test and pinch strength were secondary outcomes . Outcomes were assessed at baseline , after ten sessions of treatment administered over 2 weeks and at 1 month after end of treatment . Baseline clinical features were comparable across groups . For the primary feasibility outcome , compliance with treatment was 100 % in the active group and 94 % in the sham group . There were no serious intervention-related adverse events . There were significant improvements in performance in the Jebsen – Taylor test ( mean , 12.3 % 1 month after treatment ) and pinch force ( mean , 0.5 Newtons ) in the active group , but not in the sham group . Low-frequency rTMS to the contralesional motor cortex early after stroke is feasible , safe and potentially effective to improve function of the paretic h and , in patients with mild to severe hemiparesis . These promising results will be valuable to design larger r and omized clinical trials [ 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 . Transcranial direct current stimulation ( tDCS ) of the motor cortex can enhance the performance of a paretic upper extremity after stroke . Reported effects on lower limb ( LL ) function are sparse . Objective . The authors examined whether tDCS can increase the force production of the paretic quadriceps . Methods . In this double-blind , crossover , sham-controlled experimental design , 8 participants with chronic subcortical stroke performed knee extension using their hemiparetic leg before , during , and after anodal or sham tDCS of the LL motor cortex representation in the affected hemisphere . Affected h and -grip force was also recorded . Results . The maximal knee-extension force increased by 21 N ( 13.2 % , P < .01 ) during anodal tDCS compared with baseline and sham stimulation . The increase persisted less than 30 minutes . Maximal h and -grip force did not change . Conclusions . Anodal tDCS transiently enhanced knee extensor strength . The modest increase was specific to the LL . Thus , tDCS might augment the rehabilitation of stroke patients when combined with lower extremity strengthening or functional training 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 — A recent report has demonstrated that the contralesional primary motor cortex ( M1 ) inhibited the ipsilesional M1 via an abnormal transcallosal inhibition ( TCI ) in stroke patients . We studied whether a decreased excitability of the contralesional M1 induced by 1 Hz repetitive transcranial magnetic stimulation ( rTMS ) caused an improved motor performance of the affected h and in stroke patients by releasing the TCI . Methods — We conducted a double-blind study of real versus sham rTMS in stroke patients . After patients had well- performed motor training to minimize the possibility of motor training during the motor measurement , they were r and omly assigned to receive a subthreshold rTMS at the contralesional M1 ( 1 Hz , 25 minutes ) or sham stimulation . Results — When compared with sham stimulation , rTMS reduced the amplitude of motor-evoked potentials in contralesional M1 and the TCI duration , and rTMS immediately induced an improvement in pinch acceleration of the affected h and , although a plateau in motor performance had been reached by the previous motor training . This improvement in motor function after rTMS was significantly correlated with a reduced TCI duration . Conclusions — We have demonstrated that a disruption of the TCI by the contralesional M1 virtual lesion caused a paradoxical functional facilitation of the affected h and in stroke patients ; this suggests a new neurorehabilitative strategy for stroke patients 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 Introduction . Restoration of upper extremity ( UE ) functional use remains a challenge for individuals following stroke .  Repetitive transcranial magnetic stimulation ( rTMS ) is a noninvasive modality that modulates cortical excitability and is being explored as a means to potentially ameliorate these deficits . The purpose of this study was to evaluate , in the presence of chronic stroke , the effects of low-frequency rTMS to the contralesional hemisphere as an adjuvant to functional task practice ( FTP ) , to improve UE functional ability . Methods . Twenty-two individuals with chronic stroke and subsequent moderate UE deficits were r and omized to receive 16 sessions ( 4 times/week for 4 weeks ) of either real-rTMS or sham-rTMS followed by 1-hour of paretic UE FTP . Results . No differences in UE outcomes were revealed 
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RESULTS R and om effects models indicated improvements in paretic limb force after tDCS and rTMS rehabilitation .
We found positive effects on force production in the two sets of stimulation protocol s : ( a ) increasing cortical activity in the ipsilesional hemisphere and ( b ) decreasing cortical activity in the contralesional hemisphere .
Moreover , across acute , subacute , and chronic phases , tDCS and rTMS improved force production .
CONCLUSION Cumulative meta-analytic results revealed that tDCS and rTMS rehabilitation protocol s successfully improved paretic limb force production capabilities