Synchronized Brain and Hand Stimulation After Stroke

Inclusion criteria

• Male or female (either right or left handed) with unilateral hemiparesis after stroke;
• Stroke onset of at least six months prior to the time of participation;
• Ability to elicit motor evoked potential in the Extensor digitorum communis (EDC) muscle
• Ability to grasp, as indicated by a score of at least 1 (out of 2) on the finger mass flexion and cylindrical grasp items of Upper Extremity Fugl-Meyer scale
• age between 18-80 years

Exclusion criteria

• Presence of severe aphasia , measured by cognitive and/or language impairments that preclude the ability to follow simple instructions;
• Excessive spasticity of wrist and finger muscles, defined as a Modified Ashworth Score more than or equal to 3, which may limit the ability to open the hand/fingers;
• Diagnosis of neurological disorders other than stroke, which may confound the results;
• Has touch and proprioceptive sensory deficits determined via a score of 0 on the position sense section (section H) of the Fugl Meyer Upper Extremity assessment proprioception, which may limit the ability to report excessive amount of tingling due to hand stimulation
• History of seizure or epilepsy as the effects of TMS are not tested in individuals with seizures or epilepsy;
• Orthopaedic/musculoskeletal conditions (eg, arthritis) affecting the upper extremity, which may limit the ability to move the affected hand
• Presence of metallic implants in the head or neck for TMS;
• Currently or planning to become pregnant, as the effects of TMS are not tested not pregnant women;
• Difficulty maintaining alertness or remaining still for MRI;
• Ferromagnetic metallic implants, pacemakers, other implanted devices, or ventilators (for MRI);
• Bodyweight > 300 lbs due to MRI scanner dimensions
• Psychiatric diagnosis according to the criteria of the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-V), or who are on psychotropic medication, which may confound the results
• Cognitive impairments, defined as a score of < 23 on the Mini Mental Status Examination, which may limit the ability to follow the commands in the study
• Excessive pain > equal to 5 on Visual Analog Scale in the more-affected upper extremity, which may limit the ability to participate in the study
• History of schizophrenia, Bipolar disorder (type I or II) [Answer yes to questions 16 and items of the (hypo) maniac module of the The Mini International Neuropsychiatric Interview], current moderate, severe depression (Scores of >10 on Patient Health Questionnaire-9) and other neurological or medical conditions that could confound results.
• Life expectancy less than the duration of the study
• Hemispatial neglect, which may limit the ability to pay attention to the affected hand
• Participating in concurrent therapy, which may confound the results
• We will exclude children because although stroke may occur in children, the protocol is addressing stoke in adults and the devices are not approved for use in children