Raised corticomotor excitability of M1 forearm area following anodal tDCS is sustained during robotic wrist therapy in chronic stroke

Purpose: Anodal transcranial direct current stimulation (tDCS) can transiently increase corticomotor excitability of intrinsic hand muscles and improve upper limb function in patients with chronic stroke. As a preliminary study, we tested whether increased corticomotor excitability would be similarly observed in muscles acting about the wrist, and remain present during robotic training involving active wrist movements, in six chronic stroke patients with residual motor deficit. Methods: Transcranial magnetic stimulation ( TMS) generated motor evoked potentials ( MEP) in the flexor carpi radialis ( FCR) and provided a measure of corticomotor excitability and short-interval cortical inhibition ( SICI) before and immediately after a period of tDCS ( 1 mA, 20 min, anode and TMS applied to the lesioned hemisphere), and robotic wrist training ( 1hr). Results: Following tDCS, the same TMS current strength evoked an increased MEP amplitude ( mean 168 +/- 22% SEM; p < 0.05), that remained increased after robot training ( 166 +/- 23%; p < 0.05). Conditioned MEPs were of significantly lower amplitude relative to unconditioned MEPs prior to tDCS ( 62 +/- 6%, p < 0.05), but not after tDCS ( 89 +/- 14%, p = 0.40), or robot training ( 91 +/- 8%, p = 0.28), suggesting that the increased corticomotor excitability is associated with reduced intracortical inhibition. Conclusion: The persistence of these effects after robotic motor training, indicates that a motor learning and retraining program can co-exist with tDCS-induced changes in cortical motor excitability, and supports the concept of combining brain stimulation with physical therapy to promote recovery after brain