Brain Stimulation and Rehabilitation for Adults With Chronic, Severe Arm Motor Impairment After Stroke

The overarching goal of this program of research is to develop a therapy that produces
meaningful and persistent improvements in function of the more-affected arm in stroke
survivors with severe, chronic hemiparesis. No treatment with an established evidence base is
available now for this large group, who have barely perceptible voluntary movement of the
more-affected fingers and wrist. The lab of E. Taub and G. Uswatte has developed an expanded
version of Constraint-Induced Movement therapy (CIMT) for this population that has evidence
of efficacy for improving use in daily life of the more-affected arm from a case series and
small randomized controlled trial (RCT). The original version of CIMT is a form of physical
rehabilitation that has evidence of efficacy from multiple RCTs for improving use in daily
life of the more-affected arm in adults with mild to moderate hemiparesis after stroke. CIMT
has also been shown to produce neuroplastic changes in both grey and white matter structures.
Expanded CIMT (eCIMT) combines CIMT with neurodevelopmental techniques (NDT) for managing
tone. Studies from by J. Szaflarski and by others suggest that priming CNS tissue for
training by electrically stimulating the brain regions that control the target function with
excitatory intermittent theta burst stimulation (iTBS) augments the benefits of
neurorehabilitation. This pilot study will evaluate the feasibility of combining eCIMT with
brain stimulation by iTBS and, on a preliminary basis, will evaluate whether this combination
therapy boosts treatment outcomes relative to eCIMT alone.

Inclusion Criteria:

- stroke

- > 12 months after stroke onset

- severe hemiparesis of more-affected arm

Exclusion Criteria:

- substantial use of the more-affected arm in daily life

- frailty or insufficient stamina to carry out the requirements of the therapy

- other neurological or musculoskeletal problems, including pain, affecting the
more-affected arm

- severe cognitive deficits