CASE REPORT
Functional Brain Stimulation in a Chronic Stroke
Survivor With Moderate Impairment
Heather T. Peters, MOT, OTR/L, is PhD Candidate,
Department of Occupational Therapy and B.R.A.I.N.
Laboratory, Ohio State University Medical Center,
Columbus; heather.tanksley@osumc.edu
Janell Pisegna, MOT, OTR/L, is Occupational
Therapist, Licking Memorial Hospital, Newark, NJ.
Julie Faieta, MOT, OTR/L, is PhD Student, Department
of Occupational Therapy and B.R.A.I.N. Laboratory, Ohio
State University Medical Center, Columbus.
Stephen J. Page, PhD, MS, MOT, OTR/L, FAHA,
FACRM, FAOTA, is Associate Professor, Department of
Occupational Therapy and B.R.A.I.N. Laboratory, Ohio
State University Medical Center, Columbus.
The American Journal of Occupational Therapy
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Heather T. Peters, Janell Pisegna, Julie Faieta, Stephen J. Page
OBJECTIVE. To determine the impact of transcranial direct current stimulation (tDCS) combined with
repetitive, task-specific training (RTP) on upper-extremity (UE) impairment in a chronic stroke survivor with
moderate impairment.
METHOD. The participant was a 54-yr-old woman with chronic, moderate UE hemiparesis after a single
stroke that had occurred 10 yr before study enrollment. She participated in 45-min RTP sessions 3 days/wk
for 8 wk. tDCS was administered concurrent to the first 20 min of each RTP session.
RESULTS. Immediately after intervention, the participant demonstrated marked score increases on the UE
section of the Fugl–Meyer Scale and the Motor Activity Log (on both the Amount of Use and the Quality of
Movement subscales).
CONCLUSION. These data support the use of tDCS combined with RTP to decrease impairment and
increase UE use in chronic stroke patients with moderate impairment. This finding is crucial, given the paucity
of efficacious treatment approaches in this impairment level.
Peters, H. T., Pisegna, J., Faieta, J., & Page, S. J. (2017). Case Report—Functional brain stimulation in a chronic
stroke survivor with moderate impairment. American Journal of Occupational Therapy, 71, 7103190080.
https://doi.org/10.5014/ajot.2017.025247
S troke remains a leading cause of disability (Krishnamurthi et al., 2013)
in the United States, with 795,000 new strokes occurring annually
(Mozaffarian et al., 2016). One of the most common poststroke impairments is
upper-extremity (UE) hemiparesis, which severely undermines quality of life
(Gordon et al., 2004). Although many approaches aim to reduce UE impair-
ment, most are efficacious only in survivors with minimal impairment (Page &
Peters, 2014; Wolf et al., 2008), a group constituting only 20% of the
poststroke population (Wolf & Binder-MacLeod, 1983).
The most effective UE treatment approaches promote neuroplastic re-
organization and motor recovery through repetitive, task-specific training (RTP)
of the affected UE, but such practice is not always feasible for the majority of
stroke survivors with moderate to severe UE impairment. Indeed, these survivors
typically exhibit little to no active hand and wrist function, making task practice
alone difficult to implement. Transcranial direct current stimulation (tDCS) de-
livers a constant, low current to upregulate or downregulate activity in targeted
brain regions. It is portable and safe (Poreisz, Boros, Antal, & Paulus, 2007), and
the device can be easily worn without interfering with movement attempts, in-
cluding in people with moderate to severe UE impairment.
Although many studies have demonstrated the efficacy of tDCS when
combined with motor rehabilitation (Peters, Edwards, Wortman-Jutt, & Page,
2016), virtually all of them recruited participants with minimal impairment
7103190080p1
 (Butler et al., 2013; Rocha et al., 2016), used short-term
regimens (Ang et al., 2015; Bolognini et al., 2015), or
used physical practice interventions that were not occu-
pation based (Kasashima-Shindo et al., 2015; Triccas
et al., 2015). Moreover, although two recent meta-analyses
that examined the effect of tDCS on UE impairment
(Butler et al., 2013; Elsner, Kugler, Pohl, & Mehrholz,
2013) found a significant effect of tDCS compared with
sham, the included studies almost exclusively recruited
participants with minimal impairment in the chronic
stage of recovery, thus limiting the generalizability of
these results. Therefore, a gap remains, centering on the
need to examine the efficacy of tDCS combined with
task-specific motor rehabilitation in stroke survivors with
moderate UE hemiparesis.
To bridge this gap, the aim of this study was to de-
termine the efficacy of tDCS when combined with RTP
on affected UE impairment and UE use in a chronic stroke
survivor with moderate impairment. We hypothesized
that this combined approach would decrease UE im-
pairment and increase UE use in daily activities.
Method
Participant
The participant was a 54-yr-old woman who had expe-
rienced a right hemisphere ischemic cortical stroke 10 yr
before study enrollment. She demonstrated stable UE
deficits at baseline, scoring a 26 and a 27 at the first and
second baseline testing sessions, respectively. This par-
ticipant lived outside of commuting distance from the
laboratory but was able to accommodate the protocol
through travel and hotel boarding 2 nights/wk for the
duration of the study.
Outcome Measures
After screening was done and the participant had signed an
approved consent form, assessments were administered
twice before intervention (no greater than 1 wk apart and
less than 2 wk before the start of the intervention) to
ensure the stability of UE deficits. Assessments were also
administered immediately afterward and at 2 mo post-
intervention. All testing was performed in a quiet testing
room adjacent to our laboratory by the same rater (a
trained and licensed occupational therapist) at all time
points, to increase reliability. Outcome measures were
chosen to assess not only UE impairment but also affected
limb use in daily activities outside of the laboratory.
UE Section of the Fugl–Meyer Assessment. The UE Sec-
tion of the Fugl–Meyer Assessment (UEFM; Fugl-Meyer,
7103190080p2
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Jääskö, Leyman, Olsson & Steglind, 1975) was used to
determine changes in UE impairment. This measure as-
sesses movement at all affected UE joints as well as
strength, coordination, and hypertonia. Each item is scored
using a 2- or 3-point ordinal scale (0 5 cannot perform, 1 5
performs partially, 2 5 performs fully) for a total possible
score of 66 points. A score increase of at least 4.25 yields
a clinically important difference in people with mild to
moderate impairment due to stroke (Page, Fulk, & Boyne,
2012). The UEFM has been shown to have impressive
test–retest reliability, interrater reliability, and construct
validity (Di Fabio & Badke, 1990; Duncan, Propst, &
Nelson, 1983).
Motor Activity Log. An integral component of facili-
tating neuroplasticity is reintegration of the affected limb
into daily activities. Therefore, the Motor Activity Log
(MAL; van der Lee, Beckerman, Knol, de Vet, & Bouter,
2004) was administered to quantify changes in the par-
ticipant’s UE use. Respondents rate, on a 6-point ordinal
scale, how often (0 5 never used to 5 5 used prestroke
amount) and how well (0 5 very poor to 5 5 same as
prestroke) they had been able to use the affected UE in 30
various daily activities in the past wk. These scores are
added together and divided by the total number of items
to obtain scores for each of the subscales. Although there
is currently no established minimal clinically important
difference in this population, previous research has in-
dicated that the MAL is a valid and reliable scale of arm
use and movement quality in real-world settings (van der
Lee et al., 2004).
Apparatus
tDCS is a form of noninvasive brain stimulation that
delivers a constant, low current into the brain, causing
alterations in activity in brain regions under the electrode
sites (Lefaucheur et al., 2017). To be specific, anodal
stimulation causes excitation of cortical structures,
potentially leading to increased synaptic communica-
tion and long-term potentiation (Nitsche & Paulus,
2000). For the treatment of UE impairment, anodal
stimulation is delivered to the affected primary motor
cortex, ideally alongside rehabilitative therapies, to facil-
itate neuroplasticity and augment motor recovery. In-
deed, an increasing body of literature has suggested that
anodal stimulation delivered as an adjunct to physical
practice increases UE motor function in chronic stroke
(Butler et al., 2013).
tDCS was delivered through saline-soaked electrode
sponges (3 in. · 4.75 in.) using a Chattanooga Ionto™
system (Patterson Medical, Warrenville, IL). The an-
odal electrode was placed over the UE representation
May/June 2017, Volume 71, Number 3
 on the affected primary motor cortex (C3 or C4, based
on the international 10/20 electroencephalogram sys-
tem), and the reference electrode was placed over the
contralateral supraorbital region (Fp1 or Fp2, based
on the international 10/20 electroencephalogram sys-
tem). For this study, 2 mA of stimulation were de-
livered for the first 20 min of the RTP intervention, at
which point the stimulator automatically turned off
and therapy continued uninterrupted for the remaining
25 min.
Intervention
The RTP of the affected limb is the foundation on which
neurorehabilitative therapies are based, and it has been
shown to facilitate neuroplasticity and cortical reorgani-
zation after stroke (Woldag & Hummelsheim, 2002). In
light of this, an RTP intervention was chosen as the basis
for the therapy regimen, which consisted of 45-min RTP
sessions occurring 3 days/wk for 8 wk. The same therapist
administered all sessions for the duration of the inter-
vention. Tasks were chosen on the basis of extensive pilot
work in which RTP was integrated alongside various ad-
junctive interventions such as mental practice, modified
constraint-induced therapy, and electrical stimulation
(Page, Levine, & Leonard, 2005, 2007). Moreover, this
intervention represents current best practice in UE motor
rehabilitation, which emphasizes repetitive, goal-directed
use of the affected limb.
During these pilot RTP experiences, our laboratory
staff identified a list of nearly 60 activities of daily living
that many stroke patients wish to relearn. From this list,
various activities were identified that were meaningful
to the participant and appropriate given her impairment
level, based on the therapist’s clinical judgment; spe-
cifically, she focused intensely on the following four
activities: (1) brushing hair; (2) bringing a toothbrush to
her mouth while standing at a sink; (3) simulated meal
preparation in a kitchen environment (i.e., cutting, scooping,
pan frying, and pouring tasks); and (4) home manage-
ment tasks, such as sweeping and picking up laundry
from the floor. Within each of these activities, tasks
were broken down into manageable parts (i.e., part–
whole practice) until the participant achieved proficiency,
at which point the parts were put together to form a
complete activity. For example, within the activity of hair
brushing, the participant first repetitively practiced using
elbow flexion to bring the hairbrush to her head. Once
this component was mastered, she practiced forearm su-
pination to point the hairbrush in the direction of her
hair. Then, these two components were combined to
complete the full activity.
The American Journal of Occupational Therapy
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Results
Over the course of the 8-wk intervention the participant
reported a minor tingling and itching sensation under the
electrode site, which is consistent with previous studies
that have used tDCS (Nitsche & Paulus, 2001). The
participant never requested that the stimulation be
stopped, and there were no adverse events associated with
this protocol.
Scores on all outcome measures are listed in Table 1.
The participant demonstrated stability of UE deficits
before intervention, scoring a 26 and a 27 on the first and
second UEFM pretests, respectively. She demonstrated a
6.5-point increase on the UEFM immediately after the
intervention and a 7.5-point increase at 2 mo post-
intervention. Her performance on the MAL yielded an
increase of 0.46 points in amount of use and in the
quality of use of the affected arm from baseline to the first
posttest. Moreover, she continued to increase use of her
affected arm 2 mo postintervention, exhibiting an in-
crease of 0.70 and 0.63 on the Amount of Use and
Quality of Use subscales, respectively.
Discussion
A growing body of research has indicated that tDCS
combined with motor rehabilitation decreases UE im-
pairment and increases UE function in chronic stroke
survivors; however, the vast majority of this research has
been conducted on people with minimal impairment, a
group that comprises only a small minority of the poststroke
population. Furthermore, many of the studies have in-
corporated physical practice regimens that require expensive
equipment (e.g., robotics, virtual reality) or non–task-based
therapies, despite the well-established and widely rec-
ognized importance of task-specific training in pro-
moting neuroplasticity (Hubbard, Parsons, Neilson, &
Carey, 2009; Nudo & Friel, 1999). To bridge this gap, in
the current case study we investigated the effects of an 8-wk
regimen of RTP and tDCS on affected arm outcomes in a
chronic stroke survivor with moderate impairment.
Immediately after the 8-wk intervention, the partic-
ipant demonstrated a 6.5-point increase on the UEFM.
Table 1. Participant’s Scores on Outcome Measures
Measure Pre Post 1 Post 2 Change at Post 1 Change at Post 2
UEFM 26.5 33 34 16.5 17.5
QOM 1.0 1.46 1.63 10.46 10.63
AOU 0.97 1.43 1.67 10.46 10.70
Note. AOU 5 Amount of Use subscale; Pre 5 the result of the average score
of both pretests; QOM 5 Quality of Movement subscale; UEFM 5 Upper
Extremity Section of the Fugl–Meyer Assessment.
7103190080p3
 Moreover, she continued to improve after completion
of the study, demonstrating a 7.5-point increase 2 mo
postintervention. These scores surpassed the minimal
clinically important difference threshold of 4.25 points
(Page et al., 2012), meaning that these changes likely
conferred a functional benefit. Indeed, over the course
of therapy this participant demonstrated increased pro-
ficiency in activities such as teeth brushing, pouring, and
scooping with a spoon, likely as a result of marked in-
creases in supination, elbow extension, and shoulder
flexion. Furthermore, compensatory movement patterns
also diminished over the course of treatment; specifically,
she demonstrated an increased ability to pour water out
of a cup using controlled elbow extension and shoulder
flexion, without recruiting lateral trunk flexion and
shoulder elevation and abduction. These UE impairment
reductions are in accord with recent reviews of tDCS
combined with motor rehabilitation in chronic stroke
(Butler et al., 2013; Peters et al., 2016). However, it is
important to note that this woman had more severe
impairment than most participants enrolled in previous
studies, suggesting that tDCS may be effective in the
rapidly expanding population of stroke survivors with
moderate impairment. These gains are comparable to
other approaches that require expensive, cumbersome
equipment (Kasashima-Shindo et al., 2015; Triccas et al.,
2015) or high-intensity regimens (Wolf et al., 2008),
making this approach a practical adjunct for rehabilitative
practice.
Although reductions in UE impairment alone are not
sufficient to warrant implementation of an intervention,
the participant also demonstrated increased scores on the
MAL, indicating that she used her affected arm more
frequently and proficiently in daily tasks. It is important
to note that she continued to increase the use of her
affected arm in daily activities on both the Quality of
Movement and Amount of Use subscales of the MAL at
the 2-mo follow-up. Increased scores on MAL items were
also consistent with specific gains on the UEFM; spe-
cifically, she demonstrated increased supination on the
UEFM, which translated into increased frequency and
quality of movement during teeth brushing and turning a
doorknob. In addition, the participant reported increased
frequency and proficiency when opening a refrigerator,
wiping off a counter, operating a light switch, steadying
herself while standing, and pulling chairs away from or
toward a table before sitting down, likely as a result of an
increased ability to simultaneously extend the elbow and
flex the shoulder.
Taken together, these data add to the growing body of
literature indicating that tDCS combined with RTP in-
7103190080p4
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creases UE outcomes after stroke. Because this was a single
case study we cannot make generalizations about the
treatment efficacy in the larger population of chronic
stroke survivors with moderate impairment; however, a
larger study is currently underway that is using this exact
regimen to determine the long-term outcomes in a larger
sample of participants with moderate to severe im-
pairment. Also, given the chronicity of the participant’s
stroke and the fact that there were no other rehabilita-
tive treatments being delivered during the study time
frame, these gains likely were a direct result of the study
intervention.
Implications for Occupational
Therapy Practice
Occupational therapists apply a variety of physical
treatment approaches to remediate physical impairments
that impede occupational performance. Practitioners also
apply physical agent modalities to facilitate increased
participation and success in therapy. Many adjunctive
technologies and treatment approaches, however, require
expensive, cumbersome equipment (e.g., robotics) that
is not realistic in many clinical environments or cannot
be overlaid onto functional activities. Moreover, many
commonly used treatment approaches are only efficacious
in stroke survivors exhibiting some degree of active hand
and wrist function, a group that includes only a minority
of the stroke survivor population. tDCS bridges these
gaps, because it is portable, inexpensive, and able to
be administered concurrent with a variety of functional,
occupation-based tasks regardless of impairment level.
Although more research is needed to determine optimal
stimulation parameters and dosing, existing evidence
suggests that tDCS may constitute a promising adjunct to
occupational therapy practice that can be easily and cost-
effectively integrated into clinical environments.
Conclusion
tDCS combined with RTP decreased UE impairment and
increased UE use in a chronic stroke survivor with mod-
erate impairment immediately and 2 mo after interven-
tion. The treatment protocol is simple to deliver, relatively
inexpensive, and easily incorporated alongside rehabili-
tative therapies. The risk associated with tDCS is mi-
nuscule and is far outweighed by the potential benefits of
its use. Future studies that recruit larger sample sizes, in-
corporate a double-blind study design, and include a control
group are needed to determine the efficacy of tDCS com-
bined with RTP in this population. s
May/June 2017, Volume 71, Number 3
 Acknowledgments
This case study was funded by LSVT Global.
References
Ang, K. K., Guan, C., Phua, K. S., Wang, C., Zhao, L., Teo,
W. P., . . . Chew, E. (2015). Facilitating effects of trans-
cranial direct current stimulation on motor imagery
brain–computer interface with robotic feedback for
stroke rehabilitation. Archives of Physical Medicine and
Rehabilitation, 96(Suppl.), S79–S87. https://doi.org/10.1016/
j.apmr.2014.08.008
Bolognini, N., Convento, S., Banco, E., Mattioli, F., Tesio, L.,
& Vallar, G. (2015). Improving ideomotor limb apraxia
by electrical stimulation of the left posterior parietal cor-
tex. Brain, 138, 428–439. https://doi.org10.1093/brain/
awu343
Butler, A. J., Shuster, M., O’Hara, E., Hurley, K., Middlebrooks,
D., & Guilkey, K. (2013). A meta-analysis of the efficacy
of anodal transcranial direct current stimulation for up-
per limb motor recovery in stroke survivors. Journal of
Hand Therapy, 26, 162–170. https://doi.org/10.1016/j.
jht.2012.07.002
Di Fabio, R. P., & Badke, M. B. (1990). Relationship of
sensory organization to balance function in patients with
hemiplegia. Physical Therapy, 70, 542–548.
Duncan, P. W., Propst, M., & Nelson, S. G. (1983). Reliabil-
ity of the Fugl–Meyer Assessment of sensorimotor recov-
ery following cerebrovascular accident. Physical Therapy,
63, 1606–1610.
Elsner, B., Kugler, J., Pohl, M., & Mehrholz, J. (2013). Trans-
cranial direct current stimulation (tDCS) for improving
function and activities of daily living in patients after stroke.
Cochrane Database of Systematic Reviews, 2013, CD009645.
https://doi.org/10.1002/14651858.CD009645.pub2
Fugl-Meyer, A. R., Jääskö, L., Leyman, I., Olsson, S., & Steglind,
S. (1975). The post-stroke hemiplegic patient. 1. A method
for evaluation of physical performance. Scandinavian Journal
of Rehabilitation Medicine, 7, 13–31.
Gordon, N. F., Gulanick, M., Costa, F., Fletcher, G., Franklin,
B. A., Roth, E. J., & Shephard, T. (2004). Physical activity
and exercise recommendations for stroke survivors: An
American Heart Association scientific statement from
the Council on Clinical Cardiology, Subcommittee on
Exercise, Cardiac Rehabilitation, and Prevention; the
Council on Cardiovascular Nursing; the Council on Nutri-
tion, Physical Activity, and Metabolism; and the Stroke
Council. Stroke, 35, 1230–1240. https://doi.org/10.1161/
01.STR.0000127303.19261.19
Hubbard, I. J., Parsons, M. W., Neilson, C., & Carey, L. M.
(2009). Task-specific training: Evidence for and transla-
tion to clinical practice. Occupational Therapy Interna-
tional, 16, 175–189. https://doi.org10.1002/oti.275
Kasashima-Shindo, Y., Fujiwara, T., Ushiba, J., Matsushika,
Y., Kamatani, D., Oto, M., . . . Liu, M. (2015). Brain–
computer interface training combined with transcranial
direct current stimulation in patients with chronic severe
hemiparesis: Proof of concept study. Journal of Rehabili-
The American Journal of Occupational Therapy
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/936158/ on 04/12/2017 Terms of Use: http://AOTA.org/terms
tation Medicine, 47, 318–324. https://doi.org/10.2340/
16501977-1925
Krishnamurthi, R. V., Feigin, V. L., Forouzanfar, M. H.,
Mensah, G. A., Connor, M., Bennett, D. A., . . . Murray,
C.; GBD Stroke Experts Group. (2013). Global and re-
gional burden of first-ever ischaemic and haemorrhagic
stroke during 1990–2010: Findings from the Global Bur-
den of Disease Study 2010. Lancet Global Health, 1,
e259–e281. https://doi.org/10.1016/S2214-109X(13)70089-5
Lefaucher, J., Antal, A., Ayache, S. S., Benninger, D. H.,
Brunelin, J., Cogiamanian, F., . . . Paulus, W. (2017).
Evidence-based guidelines on the therapeutic use of
transcranial direct current stimulation (tDCS). Clinical
Neurophysiology, 128, 56–92. https://doi.org/10.1016/
j.clinph.2016.10.087
Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K.,
Blaha, M. J., Cushman, M., . . . Turner, M. B.; American
Heart Association Statistics Committee and Stroke Statis-
tics Subcommittee. (2016). Heart disease and stroke
statistics—2016 update: A report from the American Heart
Association. Circulation, 133, e38–e360. https://doi.
org/10.1161/CIR.000000000000035026673558
Nitsche, M., & Paulus, W. (2000). Excitability changes induced
in the human motor cortex by weak transcranial direct
current stimulation. Journal of Physiology, 15, 633–639.
https://doi.org/10.1111/j.1469-7793.2000.t01-1-00633.x
Nitsche, M. A., & Paulus, W. (2001). Sustained excitability
elevations induced by transcranial DC motor cortex stim-
ulation in humans. Neurology, 57, 1899–1901. https://doi.
org10.1212/WNL.57.10.1899
Nudo, R. J., & Friel, K. M. (1999). Cortical plasticity after
stroke: Implications for rehabilitation. Revue Neurologique,
155, 713–717.
Page, S. J., Fulk, G. D., & Boyne, P. (2012). Clinically im-
portant differences for the upper-extremity Fugl–Meyer
Scale in people with minimal to moderate impairment
due to chronic stroke. Physical Therapy, 92, 791–798.
https://doi.org/10.2522/ptj.20110009
Page, S. J., Levine, P., & Leonard, A. C. (2005). Effects of mental
practice on affected limb use and function in chronic stroke.
Archives of Physical Medicine and Rehabilitation, 86, 399–402.
https://doi.org/10.1016/j.apmr.2004.10.002
Page, S. J., Levine, P., & Leonard, A. (2007). Mental practice
in chronic stroke: Results of a randomized, placebo-
controlled trial. Stroke, 38, 1293–1297. https://doi.org/
10.1161/01.STR.0000260205.67348.2b
Page, S. J., & Peters, H. (2014). Mental practice: Applying
motor PRACTICE and neuroplasticity principles to in-
crease upper extremity function. Stroke, 45, 3454–3460.
https://doi.org/10.1161/STROKEAHA.114.004313
Peters, H. T., Edwards, D. J., Wortman-Jutt, S., & Page, S. J.
(2016). Moving forward by stimulating the brain: Trans-
cranial direct current stimulation in post-stroke hemipa-
resis. Frontiers in Human Neuroscience, 10, 394. https://
doi.org/10.3389/fnhum.2016.00394
Poreisz, C., Boros, K., Antal, A., & Paulus, W. (2007). Safety aspects
of transcranial direct current stimulation concerning healthy
subjects and patients. Brain Research Bulletin, 72, 208–214.
https://doi.org/10.1016/j.brainresbull.2007.01.004
7103190080p5
 Rocha, S., Silva, E., Foerster, Á., Wiesiolek, C., Chagas,
A. P., Machado, G., . . . Monte-Silva, K. (2016). The
impact of transcranial direct current stimulation (tDCS)
combined with modified constraint-induced movement
therapy (mCIMT) on upper limb function in chronic
stroke: A double-blind randomized controlled trial. Dis-
ability and Rehabilitation, 38, 653–660. https://doi.org/
10.3109/09638288.2015.1055382
Triccas, L. T., Burridge, J. H., Hughes, A., Verheyden, G.,
Desikan, M., & Rothwell, J. (2015). A double-blinded
randomised controlled trial exploring the effect of anodal
transcranial direct current stimulation and uni-lateral ro-
bot therapy for the impaired upper limb in sub-acute and
chronic stroke. NeuroRehabilitation, 37, 181–191. https://
doi.org/10.3233/NRE-151251
van der Lee, J. H., Beckerman, H., Knol, D. L., de Vet, H. C.,
& Bouter, L. M. (2004). Clinimetric properties of the
7103190080p6
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/936158/ on 04/12/2017 Terms of Use: http://AOTA.org/terms
Motor Activity Log for the assessment of arm use in hemi-
paretic patients. Stroke, 35, 1410–1414. https://doi.org/
10.1161/01.STR.0000126900.24964.7e
Woldag, H., & Hummelsheim, H. (2002). Evidence-based
physiotherapeutic concepts for improving arm and hand
function in stroke patients: A review. Journal of Neurology,
249, 518–528. https://doi.org/10.1007/s004150200058
Wolf, S. L., & Binder-MacLeod, S. A. (1983). Electromyo-
graphic biofeedback applications to the hemiplegic patient:
Changes in upper extremity neuromuscular and functional
status. Physical Therapy, 63, 1393–1403.
Wolf, S. L., Winstein, C. J., Miller, J. P., Thompson, P. A.,
Taub, E., Uswatte, G., . . . Clark, P. C. (2008). Retention
of upper limb function in stroke survivors who have re-
ceived constraint-induced movement therapy: The EXCITE
randomised trial. Lancet Neurology, 7, 33–40. https://doi.org/
10.1016/S1474-4422(07)70294-6
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