Investigating the Feasibility of Combining Virtual Reality and Bilateral Transcranial Direct Stimulation to Improve Upper Limb Recovery in Patients With Stroke

The WMFT is a standardized assessment used to measure upper extremity motor ability through the performance of 17 tasks that include both functional and strength components. Rated using the 6-point scale ranging from 0 (no attempt) to 5 (normal movement). The total performance time and quality of movement are recorded, with lower scores indicating lower levels of functioning.

The FMA-UE is a comprehensive quantitative measure designed to evaluate motor function, coordination, and reflex activity of the affected upper limb following stroke. It uses a 3-point ordinal scale (0 = cannot perform, 1 = performs partially, 2 = performs fully), with a maximum score of 66 points for the upper extremity. It is considered the gold standard for assessment of upper limb motor recovery.

The BBT is a validated measure of gross manual dexterity that evaluates how many 1-inch wooden blocks a participant can transfer from one compartment to another within 60 seconds using one hand. The apparatus consists of a wooden box divided into two equal sections containing 150 small cubes. The test begins with the unaffected upper limb to allow practice and establish a baseline performance. Participants are then instructed to move as many blocks as possible, one at a time, over the partition within the time limit. The score is defined as the total number of blocks successfully transferred within 60 seconds.

Corticospinal excitability will be evaluated using transcranial magnetic stimulation (TMS) to measure motor evoked potentials (MEPs) elicited by TMS in both the affected and unaffected motor cortices (Wassermann et al., 2008). Electromyographic (EMG) activity will be monitored in real-time during TMS application, with MEPs recorded bilaterally from the first dorsal interosseous (FDI)

Functional magnetic resonance imaging (fMRI), a specialized form of MRI, will be utilized to assess brain activity and neural connectivity. The fMRI protocol will employ a block design paradigm, with each scanning session lasting 6 minutes and divided into six blocks. Each block will consist of 15 repetitions of 2-second contractions, separated by 30-second rest intervals (Wen et al., 2014). During the task, participants will be instructed to squeeze a rubber ball with their affected hand at an intensity corresponding to 30% of their maximum voluntary contraction force (Cheng et al., 2021; Ismail et al., 2014). Visual cues will be displayed to assist participants in achieving the target force level (Könönen et al., 2012).

The Stroke Specific Quality of Life Scale (SS-QOL) is a self-report questionnaire designed to assess quality of life. The 49 items on the SS-QOL measure are divided into 12 domains, which include family roles, language, mobility, mood, personality, self-care, social roles, thinking, upper extremity function, vision, energy, and work/productivity. Each of the 49 items is evaluated on a consistent five-point scale. Each item's responses are summed up, and the composite score that results varies from a minimum of 49 to a maximum of 245; higher scores indicate a better quality of life. The SS-QOL-49 has been translated into Arabic, and it has good validity and reliability for patients with stroke (Sallam et al., 2019).

The Stroke Impact Scale (SIS) is a specific self-report measure used to assess health status in individuals after a stroke. It includes 16 items that assess different aspects of daily functioning: 7 items cover basic and instrumental activities of daily living, 8 items focus on mobility, and 1 item evaluates hand function. Each item is rated on a 5-point Likert scale, ranging from 1 (unable to complete) to 5 (no difficulty at all) (P. Duncan et al., 2003; P. W. Duncan et al., 2003). Higher scores reflect a better health-related quality of life among patients with stroke (P. W. Duncan et al., 2003). The SIS-16 is a valid and reliable tool for evaluating quality of life in patients with stroke (Chou et al., 2015).