TRANScranial Direct Current Stimulation for POst-stroke Motor Recovery - a Phase II sTudy (TRANSPORT 2)
Phase: PHASE2
Conditions: Stroke, Ischemic, Motor Activity, Upper Extremity Paralysis
Sponsor: Duke University

TRANScranial direct current stimulation for 
POst-stroke motor Recovery - a phase II sTudy 
(TRANSPORT2)
cIRB Protocol Number: 2018-4092
National Clinical Trial (NCT) Identified Number: NCT03826030
Principal Investigators: Wayne Feng, MD, MS;
Gottfried Schlaug, MD, PhD; Caitlyn Meinzer, PhD
IDE Sponsor: N/A
Funded by: NINDS
Version Number:  v5.0
 October 1, 2020

 
ii
Table of Contents
STATEMENT OF COMPLIANCE
1
1
PROTOCOL SUMMARY
1
1.1
Synopsis
1
1.2
Schema
2
1.3
Schedule of Activities (SoA)
3
2
INTRODUCTION
1
2.1
Study Background
1
2.2
Study rationale
1
2.3
Risk/Benefit Assessment
7
2.3.1
Known Potential Risks
7
2.3.2
Known Potential Benefits
8
2.3.3
Protection of Potential Risks
8
3
OBJECTIVES AND ENDPOINTS
9
4
STUDY DESIGN
11
4.1
Overall Design
11
4.2
Scientific Rationale for Study Design
11
4.3
Justification for Dose
12
4.4
End of Study Definition
12
5
STUDY POPULATION
12
5.1
Inclusion Criteria
12
5.2
Exclusion Criteria
12
5.3
Screen Failures
13
5.4
Strategies for Recruitment and Retention
13
5.5
Participants in a Research Training Study
15
6
STUDY INTERVENTION
17
6.1
Study Intervention(s) Administration
17

 
iii
6.1.1
Study Intervention Description
17
6.1.2
Dosing and Administration
18
6.2
Preparation/Handling/Storage/Accountability
18
6.2.1
Acquisition and accountability
18
6.2.2
Product Storage and Stability
19
6.2.3
Preparation
19
6.3
Measures to Minimize Bias: Randomization and Blinding
19
6.4
Study Intervention Compliance
20
7
STUDY INTERVENTION DISCONTINUATION AND SUBJECT  DISCONTINUATION/WITHDRAWAL
20
7.1
Discontinuation of Study Intervention
20
7.2
Subject Withdrawal from the Study
21
7.3
Lost to Follow-Up
21
8
STUDY ASSESSMENTS AND PROCEDURES
21
8.1
Efficacy Assessments
21
8.1.2 Obtaining Exploratory Aim  Measures
22
8.1.2.1 Imaging Measures
22
8.1.2.2 TMS Measures
23
8.2
Adverse Events and Serious Adverse Events
23
8.2.1
Definition of Adverse Events (AE)
23
8.2.2
Definition of Serious Adverse Events (SAE)
24
8.2.3
Classification of an Adverse Event
24
8.2.3.1
Severity of Event
24
8.2.3.2
Relationship to Study INTERVENTION
25
8.2.3.3
Expectedness
25
8.2.4
Time Period and Frequency for Event Assessment and Follow-Up
25
8.2.5
Adverse Event Reporting
26
8.2.6
Serious Adverse Event Reporting
26

 
iv
8.3
Unanticipated Problems
26
8.3.1
Definition of Unanticipated Problems (UP)
26
8.3.2
Unanticipated Problem Reporting
27
8.3.3
Reporting Unanticipated Problems to Participants
27
9
STATISTICAL CONSIDERATIONS
27
9.1
Statistical Hypotheses
28
9.2
Sample Size Determination
28
9.3
Populations for Analyses
29
9.4
Statistical Analyses
29
9.4.1
General Approach
29
9.4.2
Analysis of the Primary Efficacy Endpoint(s)
29
9.4.3
Analysis of the Secondary Endpoint(s)
30
9.4.4
Safety Analyses
30
9.4.5
Baseline Descriptive Statistics
30
9.4.6
Sub-Group Analyses
31
9.4.7
Tabulation of Individual participant Data
31
10
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS
31
10.1
Regulatory, Ethical, and Study Oversight Considerations
31
10.1.1
Informed Consent Process
31
10.1.1.1
Consent/assent and Other Informational Documents Provided to participants
31
10.1.1.2
Consent Procedures and Documentation
31
10.1.2
Study Discontinuation and Closure
32
10.1.3
Confidentiality and Privacy
32
10.1.4
Future Use of Stored Specimens and Data
33
10.1.5 Key Roles and Study Governance
33
10.1.6 Safety Oversight
33
10.1.7 Clinical Monitoring
34

 
v
10.1.8 Quality Assurance and Quality Control
34
10.1.9 Data Handling and Record Keeping
34
10.1.9.1 Data Collection and Management Responsibilities
34
10.1.9.2 Study Records Retention
35
10.1.1.10 Protocol Deviations
35
10.1.1.11 Publication and Data Sharing Policy
35
10.1.12 Conflict of Interest Policy
36
10.2
Additional Considerations
36
10.3
Abbreviations
37
10.4
Protocol Amendment History
40
11
REFERENCES
41

 
1
STATEMENT OF COMPLIANCE
The trial will be conducted in accordance with International Conference on Harmonization Good 
Clinical Practice (ICH GCP), applicable United States (US) Code of Federal Regulations (CFR), 
and the NIH/NINDS Terms and Conditions of Award. The Principal Investigators will assure that 
no deviation from, or changes to the protocol will take place without prior agreement from the 
sponsor and documented approval from the Central Institutional Review Board (cIRB), except 
where necessary to eliminate an immediate hazard(s) to the trial subjects. All personnel involved 
in the conduct of this study have completed Human Subjects Protection and ICH GCP Training.
The protocol, informed consent form(s), recruitment materials, and all subject materials will be 
submitted to the IRB for review and approval.  Approval of both the protocol and the consent form 
must be obtained before any subject is enrolled.  Any amendment to the protocol will require 
review and approval by the cIRB before the changes are implemented to the study.  All changes 
to the consent form will be cIRB approved; a determination will be made regarding whether a new 
consent needs to be obtained from subjects who provided consent, using a previously approved 
consent form.
1
PROTOCOL SUMMARY
1.1
SYNOPSIS 
Title:
TRANScranial direct current stimulation for POst-stroke motor 
Recovery- a phase II sTudy (TRANSPORT2)
Study Description:
TRANSPORT2 is a phase II multi-center transcranial direct current 
stimulation (tDCS) dosing selection study based on the preliminary 
efficacy, safety, tolerability and feasibility. 
Objectives:
Primary Objective: To determine whether there is an overall 
treatment effect among 3 dosing groups (sham+mCIMT, 2 
mA+mCIMT, and 4 mA+mCIMT) on day 15 (± 2 days) after the start 
of the intervention in the Fugl-Meyer Upper-Extremity (FM-UE) scale, 
a measure of motor impairment. Additional outcome measures 
include the Wolf-Motor-Function-Test (WMFT), a measure of 
functional motor activity, and the Stroke-Impact-Scale (SIS), a 
measure of quality of life. Sustained benefit will be assessed at day 
45 (± 5 days) and day 105 (± 10 days). 
Secondary Objectives: To confirm that the proposed intervention is 
safe (no significant differences in rate of adverse events), tolerable 
(no significant differences in discomfort as measured by Visual-
Analog-Scale), and feasible to administer in a multi-site trial (>80% 
of 
subjects 
complete 
the 
treatment 
protocol 
and 
no 
unexplained/unresolved variability by site).
Exploratory Objectives: To examine whether wCST-LL (structural 
assessment of integrity of descending motor tract) or MEPs 
(functional assessment of integrity of descending motor tract) or 
combination of both are correlated with changes in FM-UE scale, and 
evaluate the utility of these measures as biomarkers for patient 
selection criteria in the future confirmatory Phase III study. We also 

 
2
aim to examine whether structural and functional changes within 
descending motor tracts correlate with changes in motor impairment 
and functional motor activity.
Endpoints:
Primary Endpoint: Fugl-Meyer Upper-Extremity (FM-UE) scale a 
measure of motor impairment; 
Secondary Endpoints: Wolf Motor Function Test (WMFT) time 
score, a measure of functional motor activity; Stroke-Impact-Scale 
hand subscale as an assessment of patient-centered quality of life.
Study Population:
Subject who is 18-80 years of age of any gender or ethnicity, who 
had first-ever unihemispheric ischemic stroke in past 30-180 days 
resulting in unilateral limb weakness with FM-UE ≤ 54 (out of 66) that 
is stable across two baseline visits at the time of randomization and 
an mRS ≤ 2 pre-stroke. We are planning to enroll 129 subjects across 
three arms. 
Phase:
2
Description 
of 
Sites/Facilities Enrolling 
Subjects:
Subject recruitment will occur at approximately 15 enrolling sites in 
the USA.
Description 
of 
Study 
Intervention:
There are 3 intervention arms:  sham, 2 mA, and 4 mA tDCS 
combined with modified Constrained-Induced Movement Therapy 
(mCIMT). The tDCS session is 30 minutes, and mCIMT is 120 
minutes per session, 10 intervention sessions are completed over a 
2-week (14 days) period.
Study Duration:
48 months
Subject Duration:
Approximately 4 months
1.2
SCHEMA
Please Refer to Section 1.3, Schedule of Activities, for details

 
3
1.3
SCHEDULE OF ACTIVITIES (SOA)
1. A urine pregnancy test for all women of child-bearing potential will be given at this visit.
2. Randomization ONLY occurs at 1st Treatment Session
3. This visit can be broken up over several days. All baseline activities need to take place prior to Day 1 treatment activities. Please see MOP and FAQs for more details on this visit.
4. End of Treatment ONLY occurs at Final Treatment Session
Baseline 1
Baseline 23 – 
Follow Up 1
Follow Up 2
Follow Up 3
Event
Day -20 to -7
Day -6 to 1
Treatment Sessions
(1-10)
Day 15 ±2
Day 45 ±5
Day 105 ±10
End of Study
Informed Consent
X
Inclusion/Exclusion1
X
 
 
 
 
 
Demographics
X
Montreal Cognitive Assessment (MOCA)
X
 
 
 
 
 
Medical and Social History
(Including Pre-Stroke Modified Rankin Scale (mRS)
X
 
 
 
 
 
 
Medication Checklist
X
X
 
 
 
 
 
Vital signs
X
 
 
 
 
 
 
Fugl-Meyer Assessment– Upper Extremity Scale
X
X
 
X
X
X
 
NIH Stroke Scale (NIHSS)
X
 
 
 
 
 
Transcranial Magnetic Stimulation (TMS)
 
X1
 
X
 
 
 
Randomization
 
X2
 
 
 
 
tDCS Treatment Activation Code Request
(Retrieved at beginning of every Treatment Session)
X
tDCS Questionnaires
(Pre-Stimulation, Post-Stimulation, Post mCIMT)
 
 
X
 
 
 
 
tDCS
 
 
X
 
 
 
 
Modified Constraint Induced Movement Therapy 
(mCIMT)
 
 
X
 
 
 
 
Wolf Motor Function Test (WMFT)
 
X
 
X
X
X
 
Stroke Impact Scale (SIS)
 
X
 
X
X
X
 
MRI
 
X1
 
X
 
 
 
Concomitant Therapy
X
X
X
Blindedness Assessment 
 
 
  X4
 
 
 
 
Visual Analog Scale
 
 
  X4
 
 
 
 
End of Study
 
 
 
 
 
 
X

 
1
2
INTRODUCTION
2.1
STUDY BACKGROUND
There are 795,000 new strokes each year in the 
US1, and stroke is a leading cause of long-term 
disability leaving more than half of stroke survivors 
with residual impairments, with motor deficits being 
the most common deficits after stroke2-6. The costs 
associated with health services, lost wages and 
productivity are estimated to be several billion 
dollars per year. The development of effective 
approaches that can enhance motor recovery and 
reduce disability remains an important priority for 
healthcare professionals, patients and caregivers, 
and society in general.  
Despite the growing interest in improving motor 
recovery after a stroke with invasive7, 8 and non-
invasive9 brain stimulation such as tDCS, new 
equipment to increase motor activities10, 
11, 
pharmacological approaches12, and stem cell 
therapies13, 
several 
key 
questions 
remain 
unanswered: Can any therapy improve neurologic 
function beyond the brain’s spontaneous recovery 
ability14-17? What is the adequate dose and intensity 
of an intervention18? What is the optimal period of an 
intervention14, 
19? 
Which 
brain 
regions 
and 
physiological processes must be relatively intact 
and can be targeted to improve functional 
outcome20? Can the combination of a peripheral rehabilitation activity with a centrally acting 
technique/tool (such as tDCS) lead to an enhancement of brain plasticity?
2.2
STUDY RATIONALE 
A.1. The role of non-invasive brain stimulation in facilitating stroke recovery and the 
effects of different electrode montages 
Non-invasive brain stimulation (NIBS) might have two potentially synergistic ways of modulating 
brain function that in turn can enhance recovery from a stroke. First, it has been shown in well-
designed studies that non-invasive brain stimulation can enhance brain plasticity21, 22 and 
remodeling of motor tracts23; simultaneously, NIBS can interfere in a stroke-induced abnormal 
inter-hemispheric imbalance in transcallosal inhibition24-26. This imbalance model implies that 
there is decreased activity in the ipsi-lesional motor regions, excessive (uninhibited) activity in the 
contralesional motor regions, and that excessive (i.e., uninhibited) activity in the contralesional 
motor area will, in turn, lead to increased transcallosal inhibition of motor regions on the lesional 
hemisphere (Fig. 1A). Neurophysiological studies in chronic stroke patients strongly support this 
model by showing that disinhibition of contralesional motor regions coexists with increased 
inhibition of ipsilesional motor regions resulting in an imbalance of inter-hemispheric interactions25, 
27, 28. Second, Imaging studies in well-recovered patients have shown that brain reorganization 
during the recovery phase is associated with re-activation or over-activation of motor and 
premotor networks in the lesional hemisphere and that transient activation of the ipsilateral 
Fig. 1A-D: Inter-hemispheric Imbalance and 
Electrode Montages to rectify this imbalance.

 
2
(contralesional) motor cortex occurs but does not seem to be associated with good outcome29-31. 
Three different electrode montages have provided empirical support that NIBS can modulate the 
inter-hemispheric imbalance in inhibition. Anodal stimulation of the lesional hemisphere32, 33 can 
up-regulate its cortical excitability (Fig. 1B); cathodal stimulation of the contra-lesional 
hemisphere can down-regulate its excessive cortical excitability34, 35 which in turn decreases the 
transcallosal inhibition of the lesional hemisphere (Fig. 1C); Bi-hemispheric stimulation with 
anodal stimulation of the lesional hemisphere and cathodal stimulation of the non-lesional 
hemisphere36-38 can do both physiological processes at the same time (Fig. 1D). All three 
montages demonstrated improvements of motor functions in proof-of-concept studies, although 
a meta-analysis found that a bihemispheric montage might have the strongest effect39. 
Similarly, two studies40, 41 in healthy subjects showed stronger motor learning effects after bi-
hemispheric stimulation than after uni-hemispheric stimulation. A recent meta-analysis revealed 
that a bihemispheric montage up to 2 mA in chronic stroke patients (Fig 2) has higher odds of 
demonstrating tDCS efficacy with a summary effect of 1.30 (-0.14, 2.75)39. This includes two tDCS 
studies by Co-PI Dr. Schlaug: a bi-hemispheric study36 with a larger effect than an independently 
conducted uni-hemispheric study (cathodal stimulation of the contralesional hemisphere) showing 
a smaller effect42. 
A.2. Rigorous experimental studies have proven that tDCS modulates brain activity and 
affects behavior that draws on targeted brain regions. 
tDCS includes the use of an electrode that is typically large enough to have an impact on a 
network of motor, premotor and sensory cortices (all of them have been shown to play a role in 
the recovery of sensorimotor function). The use of a battery-operated device allows tDCS to be 
combined with a peripheral rehabilitation technique in real-time (e.g., simultaneous constraint-
induced movement therapy while tDCS is delivered).
Fig 2: Meta-analysis indicating the bihemispheric montage demonstrates higher FM-UE change scores than anodal or 
cathodal montage. Chronic studies highlighted in blue. 

 
3
The 
concept 
of 
therapeutically 
applying 
electricity on excitable tissues such as the brain 
is not new. Effects of direct currents on animal 
and human brain tissue prompted a novel 
approach of non-invasive brain stimulation with 
weak direct currents, which came to be known 
as tDCS43. tDCS provides a sub-threshold 
stimulus that modulates the likelihood that 
neurons will fire by decreasing (cathodal 
stimulation) or increasing excitability (anodal 
stimulation) 
without 
inducing 
any 
action 
potential43, 44. The prolonged sensory, motor and 
cognitive effects of tDCS have been attributed to 
a persistent bidirectional modification of post-
synaptic connections similar to long-term 
potentiation (LTP) and long-term depression 
(LTD)-like effects45. Dextromethorphan, an N-
methyl-D-aspartate 
(NMDA) 
antagonist 
suppressed both anodal and cathodal tDCS 
effects, strongly suggesting the involvement of 
NMDA receptors in both types of DC-induced 
neuroplasticity46. In contrast, Carbamazepine selectively eliminated anodal effects47. Since 
Carbamazepine stabilizes the membrane potential through voltage-gated sodium channels 
(stabilizing the inactivated state of sodium channels), the results were interpreted as indicative 
that after-effects of anodal tDCS require a depolarization of membrane potentials. Ardolino and 
colleagues48 also proposed a non-synaptic mechanism involving changes in membrane 
excitability and ionic shifts. Some studies have already examined changes in blood flow directly 
under the electrode as well as in remote regions as surrogate markers of the biological activity 
exerted by tDCS49-52. Other studies have examined tDCS modulation of indirect measures of 
blood flow using the BOLD effect either by itself or in combination with sensorimotor or cognitive 
tasks53-64. MR spectroscopy has been used to examine the modulation of certain neurotransmitter-
receptor systems to better understand the excitatory and inhibitory effects of tDCS57, 65-67. We 
showed in a combined tDCS-MRI experiment that an 8-minute stimulation (anodal and cathodal) 
to the right motor cortex repeated 3 times with 8-minute gaps between stimulations modulates 
regional blood flow response (as measured by arterial spin labeling) in the underlying motor region 
and modality-specific effects were seen in the after-stimulation phase (Fig. 3, above). Regional 
CBF changes under the anodal and to a slightly lesser degree under the cathodal electrode 
showed a significant correlation with applied current levels52. Modulating activity in the motor 
cortex via tDCS has been demonstrated to affect implicit and explicit finger sequence learning in 
healthy subjects40, 68-74. Some studies have shown substantial evidence that effects lasted for up 
to a week while one study even found motor learning effects of multisession tDCS in healthy 
subjects to last for at least 3 months72.  
A.3. The need for higher current dose while maintaining safety
Theoretical knowledge regarding safety and tolerability of tDCS is based on physical aspects of 
this technique and data from both animal and human studies, suggesting “no significant risk for 
human subjects at currents ranging from 0.5 to 2.0 mA for up to 40 minutes75-81. Commonly 
reported side effects occur at the site where the electrodes are placed and are mostly minor 
issues75, 76 such as local scalp itching, tingling or burning sensations, transient mild headaches, 
contact dermatitis82 or rarely stimulation-induced skin lesions83, 84, which were mainly due to 
inadequately applying contact media. 
Fig 3. Average CBF changes (normalized to zero) for the anodal 
and cathodal condition across 4 assessments. Comparing the 
changes between the anodal and cathodal conditions, we found 
significant differences in the relative CBF increases (p<0.001) 
when the stimulation was turned ON and when the stimulation 
was switched OFF (p<0.05), and relative CBF differences in the 
changes between first and second OFF time points (p<0.05)

 
4
The size of the electrode pad also matters 
in term of safety and tolerability. Electrode 
size determines current density which is 
defined as current/electrode contact area.  
Current density at 4 mA is approximately 
0.11 mA/cm2 with a pad size of 5×7cm². The 
charge density even at 4 mA for 30 minutes 
(Fig. 4, right) is considerably below the 
safety threshold determined by invasive 
stimulation techniques80 and is ~ 4% of the 
safety limit established in an animal study79. 
While underdosing is possible, lack of 
published data at higher currents and 
theoretical concerns of safety has led researchers to avoid higher tDCS current than 2 mA in 
stroke patients. A meta-analysis indeed showed a dose-response relationship with motor 
improvement and current up to 2 mA39. The Phase I current escalation study of tDCS (PI Feng, 
NINDS P20 GM109040) found that doses up to 4 mA are safe and tolerable to ischemic 
stroke patients (manuscript is highlighted in the Brain Stimulation Journal cover page and 
accompanied by an editorial)85, 86. There were no second-degree skin burns, clinical seizures, 
or DWI abnormalities. Furthermore, no subjects discontinued from the trial.  Thus, while this phase 
I study suggests that doses up to 4 mA are safe and tolerable, it is not clear whether a dose-
response relationship in treatment effect would extend beyond 2 mA. It is a logical next step to 
test a dose effect in a phase II multicenter study while we continue to collect data on safety and 
tolerability. 
A.4. The choice of a peripheral rehabilitation therapy
Several studies have shown that the combined effects of tDCS or other non-invasive brain 
stimulation technique and a peripheral rehabilitation therapy typically elicit behavioral changes 
and subsequent improvement of motor functions greater than when either intervention is done by 
itself35-37, 42, 87. If the variance and effect (or the duration and intensity) from peripheral 
rehabilitation therapy is not well controlled and balanced across the groups, the real effect from 
tDCS is likely contaminated and attenuated. For example, various peripheral rehabilitation 
therapies have been tested in combination with tDCS such as customary occupational/physical 
therapy36, 88, robot-assisted therapy89 and virtual reality therapy38. Although we do know from 
experimental studies that combining peripheral stimulation with central stimulation will increase 
synaptic plasticity, it is harder to determine whether tDCS in combination with untested peripheral 
rehabilitation is efficacious as the efficacy of these peripheral rehabilitation therapies by 
themselves have not been proven21. 
One peripheral therapy, namely constraint-induced movement therapy (CIMT), has been tested 
in an NIH- funded multi-center trial and demonstrated to be effective in improving motor function 
in patients between 3-9 months after stroke.19 CIMT focuses on peripheral sensorimotor 
stimulation targeting the known phenomenon of “learned nonuse” of the affected hand14, 19. CIMT 
has two principal components90: 1) Constraint - restraining of the unaffected upper extremity (UE), 
typically in a mitten, and 2) Inducement - training of the hemiparetic UE using a shaping and 
repetitive exercise paradigm. Shaping is defined as the development of a new behavior by the 
reinforcement of successive approximations of closer approximation and the extinguishing of 
preceding approximation of the behavior. More recently, The VECTOR study which enrolled 
subjects in the subacute phase demonstrated that stroke patients responded better to a modified 
CIMT (2 hours of shaping and at least 6 hours on constraints for 10 sessions over a 14 day period) 
rather than the high-intensity CIMT14.  There is often a concern that patients eligible for CIMT 
might have only limited impairments, and that too few patients would be eligible. The mean score 
Fig. 4: Safety limits of tDCS in animal studies and comparison 
to human dosage

 
5
of FM-UE scale91 from patients included in the EXCITE trial was 42.5 (SD 11.7) for the CIMT 
group and 41.1 (SD 12.9) for the usual care group. Thus, even a patient with an FM-UE score of 
around 30 was eligible for the EXCITE trial19.  Furthermore, we are planning to include patients 
that correspond to both the higher and lower functioning groups in the EXCITE trial to have as 
many eligible subjects as possible. However, the baseline disability will be adjusted for in both 
the randomization and analysis to ensure that the treatment groups are balanced. The lower-
functioning subjects in the EXCITE trial had at least 10° of active wrist extension, at least 10° of 
thumb abduction/extension, and at least 10° of extension in at least 2 additional digits. Higher-
functioning subjects demonstrated at least 20° of wrist extension and at least 10° of active 
extension of each metacarpophalangeal and interphalangeal joint of all digits19. The assembled 
TRANSPORT2 team include several key personnel from the EXCITE and VECTOR trial to ensure 
that mCIMT, the peripheral rehabilitation therapy in our TRANSPORT2 trial, is done with the 
highest level of consistency across sites. Using a standardized intervention and providing 
experienced trainers and oversight for other sites, will minimize the variance that a peripheral 
rehabilitation therapy could introduce, and it will increase the odds to detect efficacy from tDCS.
A.5. Timing of the proposed intervention
Determining the best timing for a proposed tDCS intervention is complicated. It is well 
acknowledged that there are many confounders and uncertainties for conducting stroke recovery 
trials in the subacute phase, such as, ongoing challenging medical issues; robust spontaneous 
recovery; lack of validated patient selection tool in the acute or subacute phase, etc. It is also true 
that our prior meta-analysis demonstrated that tDCS trial is likely to be successful in the chronic 
phase than in the subacute phase based on the data from existing studies39. However, there are 
several study design deficits in the existing tDCS trials that have been carried out in the subacute 
stage which may explain the failures. Arguing for earlier intervention is that the natural biological 
recovery process early after a stroke can be robust15-17 and has not been well harnessed by the 
stroke rehabilitation trials. We are not discouraged by challenges of early intervention. Instead, 
we followed the reviewers’ recommendation to extend the trial to the subacute phase (i.e. as early 
as one month after stroke). We developed several procedures and processes to mitigate these 
risks. For example, we will require a stable deficit (≤2 points change in FM-UE scale in two 
screening assessments) for eligibility. We will also balance these patients during the 
randomization process by stratifying randomization on time from stroke onset (≤ 90 days or > 90 
days) to ensure a good balance of subjects in the three arms, further mitigating expected 
variability. In addition, we will include ‘time from stroke onset to randomization’ as a covariate in 
the model and record additional rehabilitation therapy outside of the 14 day intervention. We will 
carefully conduct both intent-to-treat and per-protocol analysis to delineate these challenges. 
A.6. The need of a multi-center Phase II study for examining tDCS efficacy
Table 2 below provides a sense of the variability of reported mean changes (and standard 
deviations) of FM-UE scale from 3 different studies with bihemispheric stimulation montage in 
chronic stroke patients. Several possible explanations for this variability in effect size include the 
type of peripheral rehabilitation therapy, the severity of functional motor impairment at baseline, 
the number of sessions, small sample size, and the lack of a central adjudication of the outcome 
measure. A large, multicenter, double-blinded, sham-controlled Phase II trial with a centrally 
adjudicated assessment of the preliminary effect of several doses of tDCS will yield the necessary 
rigorous, reproducible results necessary before a definitive Phase III trial is justified.

 
6
Fig. 6: Scatter plot and 
correlation for wCST-LL vs. Initial 
motor impairment. Both FM-UE 
(7B) and wCST-LL (7A) predict 
outcome in two different 
cohorts, but wCST-LL offers 
superior prediction of 3-month 
outcome (R2=0.47) than FM-UE 
(R2=0.11) in the subgroup with 
severe initial impairment (7C+D).
Table 2: Characteristics of tDCS and peripheral rehabilitation therapies in three studies using a bihemisphericc
tDCS montage.
Study Characteristics
Baseline
Change
Sample size
1:1 
allocation
Current
per 
session
Length of intervention
Peripheral therapy
Active 
Stim.
Sham 
Stim.
Active 
Stim.
Sham 
Stim.
36
20
1.5 mA 
× 
30 
min. 
5 sessions (1 hour per 
session)
Customized 
Occupational therapy
38.2 ± 
13.3
39.8 ± 
11.5
5.60 ± 
1. 93
1.15 ± 
0.85
37
14
2.0 mA 
× 
40 
min. 
10 sessions for up to 4 
hours per session
Variant of mCIMT
25.4 ± 
10.8
27.6 ± 
18.2
5.90 ± 
5.06
1.40 ± 
3.41
38
20
2.0 mA 
× 
13 
min. 
15 sessions over 5 weeks 
(1 hour per session)
Virtual reality training
41.3 ± 
16.2
39.2 ± 
17.6
9.30 ± 
5.70
7.50 ± 
7.10
A.7. Structural and functional biomarkers for patient selection and therapy response 
Recently, 
novel 
neuroimaging 
and/or 
neurophysiological 
measures have been investigated 
to 
provide 
a 
quantitative 
assessment of the injury to 
descending motor tract after a 
stroke and to reveal a patient’s 
motor recovery potential. Both 
Motor-evoked Potentials (MEP) 
by transcranial magnetic 
stimulation (TMS) and 
weighted 
corticospinal 
tract lesion load (wCST-
LL; Fig 5) are methods to 
assess the impact of a 
stroke 
lesion onto the corticospinal tract. Two studies suggested that the presence of MEPs could aid 
subject selection for both noninvasive89 and invasive brain stimulation study92 – subjects with 
MEPs are more likely to show improvements than subjects without MEPs. Similarly, a two-
center study led by Drs. Feng and Schlaug demonstrated that wCST-LL could effectively predict 
motor recovery from the acute phase to 3 months (Fig 6A) and wCST-LL of ≥7.0cc in the acute 
phase would lead to poor motor recovery (FM-UE ≤25 out of 66) at 3 months16. Overall, wCST-
LL provided a more graded and sensitive measure of CST injury than the clinical assessment and 
Fig. 5: Weighted CST-Lesion Load using a canonical probabilistic 
tract and lesion overlap.

 
7
correlated better with motor outcomes, especially in the severely impaired subgroup (Fig 6C and 
D). wCST-LL in the chronic phase is also correlated with the motor impairment measured by FM-
UE scale93. Furthermore, a slight variation of a CST-lesion load variable was found to be a 
predictor of improvement in an experimental trial in chronic stroke patients20. It has not been 
formally investigated whether MEPs or wCST-LL or a combination of both can be used as both a 
predictive and prognostic biomarker in the same study. 
A8. Choice of outcome measures for tDCS stroke motor recovery. 
The comparison among the three groups requires a highly 
standardized measure of outcome that is relevant and suitable for the 
clinical question, valid for the population studied, and meaningful for 
the patients.  As stroke represents a leading global cause of adult 
disability, important considerations for any study of stroke 
rehabilitation are impairment reduction, recovery of functional skills, 
and quality of life improvement (Fig. 7). These three aspects 
represent a hierarchy with the quality of life improvements predicated 
on functional improvements, and similarly, functional improvements 
first require a reduction in impairment. As such, this TRANSPORT2 
trial is designed using a primary outcome of FM-UE, a commonly 
recommended primary outcome measure94. However, in accordance 
with regulatory authorities and expert panels, who now recommend 
addressing all of these issues above, the Wolf-Motor Function Test (to illustrate a functional motor 
improvement) and the Stroke Impact Scale-Hand (to show quality of life enhancement) will be 
measured as secondary outcome measures to comprehensively assess the efficacy of tDCS for 
stroke motor recovery94. In a prior tDCS study by PI Schlaug, it has been shown that the change 
in the FM-UE scale is highly correlated with the change in the WFMT (Pearson correlation 
coefficient=-0.62, p=0.004). All these three scales have excellent psychometric property94. 
Nevertheless, our phase II study would provide the necessary data to assess the interplay of 
these three outcome measures, and we do not rule out the possibility of considering other primary 
outcomes than FM-UE scale in a confirmatory phase III study. 
2.3
RISK/BENEFIT ASSESSMENT  
2.3.1
KNOWN POTENTIAL RISKS  

General Risk Loss of Confidentiality: It is expected that this risk will be low because of 
numerous safeguards that will be in place, including standard data management procedures 
at the NDMC.
●
tDCS: Extensive animal and human evidence and theoretical knowledge indicate that tDCS 
protocols up to 2 mA are safe and tolerable75-77. Recently, a Phase I study evaluated the safety 
and tolerability of tDCS doses up to 4mA in patients with ischemic strokes; the study used a 
3+3 study design and escalate dose to 4mA without meeting pre-specified safety rules. 
Overall, tDCS incurs no significant risk to human subjects per FDA determination. Commonly 
reported side effects in the literature are as follows: skin redness under the electrode, skin 
irritation with itching, tingling, burning sensation, and transient headache (which is mostly due 
to the tight elastic headband that holds the electrode in place). Any skin injury is a very rare 
side effect (1 out of 1000). Theoretical risks at high dose (e.g., 4mA) might involve second 
degree skin burns and clinical seizures, but these risks were not observed in the phase 1 
safety study. Subjects will be carefully monitored for any potential safety or tolerability issues 
during each interventional session. 
Fig. 7: Hierarchies of 
Recovery

 
8
●
MRI:  MRIs will be done using equipment similar to that used for clinical MRI (either 1.5 or 3.0 
T). The current revision of the US Food and Drug Administration guidelines (US Department 
of Health and Human Services, Food and Drug Administration, Center for Devices and 
Radiological Health, Guidance for the submission of premarket notifications for magnetic 
resonance diagnostic devices, Washington, DC. November 14, 1998) applies to this study. 
These guidelines state that magnetic resonance imaging systems with main static magnetic 
field strengths of 4.0 T (a measure of magnetic strength) and less, such as the ones used for 
this study, can qualify as non-significant risk devices. Because the MRI machine acts like a 
large magnet, it could move iron-containing objects in the MRI room during the examination, 
which could, in the process, possibly harm the subject. Magnetic media such as credit cards, 
etc. and watches near the coil may also be damaged. Precautions have been taken to prevent 
such an event from happening; loose metal objects, like key chains or paper clips, are not 
allowed in the MRI room. If a subject has a piece of metal in your body, such as a fragment in 
your eye, aneurysm clips, ear implants, spinal nerve stimulators, or a pacemaker, subject will 
not be allowed into the MRI room and cannot have an MRI. At times during the test, subject 
may be asked not to swallow for a while which can be uncomfortable.
●
TMS: Single or paired-pulse TMS (not rTMS) will be used to determine the resting motor 
threshold as well as the amplitude of motor evoked potential on the affected and unaffected 
hemisphere. Although extremely rare, seizures have been described with single-pulse TMS, 
mainly in subjects who have a history of seizure. In some case reports, it was difficult to 
differentiate seizures from fainting or a convulsive syncope. The TMS coil makes noise, much 
like a loud pop when it produces its magnetic energy. Subject may or may not feel thumb 
twitch depending on the strength of the TMS pulse, but subject might also feel your facial 
muscles twitch slightly just around the eye. It is not painful. TMS can cause heating or 
movement of metallic objects in or near the head. In addition, the inactivation of pacemakers, 
medication pumps, cochlear prostheses and other implantable hardware may occur but 
subject with these metal implants is typically excluded from the study. 
●
Modified constraint-induced movement therapy (mCIMT): The modified version of CIMT 
is about 120 minutes of therapy per session; it is less intensive than the original version of 
CIMT but still more intensive than conventional occupational therapy. It has been widely used 
in the clinical practice by rehabilitation therapists. It may cause muscle fatigue or mild 
soreness as a result of exercise which usually resolves within 12-24 hours. 
●
Motor Assessments: Motor assessments may occasionally cause fatigue. 
2.3.2
KNOWN POTENTIAL BENEFITS 
Every subject will receive 120 minutes of mCIMT per session for 10 sessions over the two-week 
study period regardless of which tDCS dose group they are randomized. mCIMT is proven to be 
effective in improving upper extremity motor function by a prior NIH-funded multi-center study 
called The Extremity Constraint-Induced Therapy Evaluation (EXCITE) Trial.19 The modified 
version was also demonstrated in the VECTOR trial.14 It is likely that subject will experience some 
degree of motor improvement by participating in this study. 
Additionally, it is hoped that the study team will gain valuable knowledge from the study. 
Successful completion of the study will help the researchers better understand the transcranial 
direct current stimulation, choose a right dose/current group, select the right stroke subjects based 
on neuroimaging or electrophysiological tool, and potentially develop a new rehabilitation modality 
for post-stroke motor recovery in the future.
2.3.3
PROTECTION OF POTENTIAL RISKS 

 
9
●
General Risk Loss of Confidentiality: Subject confidentiality is strictly held in trust by the 
participating investigators, their staff, and the sponsor(s) and their agents. Therefore, the 
study protocol, documentation, data, and other information generated will be held in strict 
confidence. No information about the study or data will be released to any unauthorized third 
party without prior written approval of the sponsor. 
●
The study monitor, other authorized representatives of the sponsor, and representatives 
of the NCC, NDMC, cIRB may inspect all documents and records required to be 
maintained by the investigator, including but not limited to, medical records for the subjects 
in this study. The clinical study site will permit access to such records.
●
The study subject’s contact information will be securely stored at each clinical site for 
internal use during the study. At the end of the study, all records will continue to be kept 
in a secure location for the duration specified by the StrokeNet Standard Operating 
Procedure (SOP) or longer as dictated by cIRB and local institutional regulations.
●
Study subject research data, which is for purposes of statistical analysis and scientific 
reporting, will be transmitted to and stored for the duration of the study and analysis at the 
NDMC. The study data entry and study management systems used by clinical sites and 
by the NDMC research staff will be secured and password protected. At the end of the 
study, all study databases will be de-identified and a Public Use Dataset (PUDS) will be 
archived with NINDS.
●
tDCS: In order to protect research subjects, study staff have to strictly follow inclusion and 
exclusion criteria of this study (see 5.3.3. for exclusion criteria). We will record all adverse 
events during the intervention phase of this study and serious adverse events during the 
follow-up period. In addition, subject will fill out a tolerability questionnaire for every tDCS 
session.
●
MRI: In order to protect research subjects, study staff have to strictly follow inclusion and 
exclusion criteria of this study (see 5.3.3. for exclusion criteria). A trial site specific MR 
screening form is used before MRI scan to determine MRI eligibility. The subjects will be 
excluded from the study if he/she has contraindication for MRI or cannot tolerate the MRI 
scanner. Headphones or earplugs and padding around the head are provided to the study 
subject to minimize the noise associated with the MR scanning and increase a subject’s 
comfort. 
●
TMS: In order to protect research subjects, study staff have to strictly follow inclusion and 
exclusion criteria of this study (see 5.3.3. for exclusion criteria). In addition, sites need to follow 
site specific TMS policy and procedure to ensure the safety of subjects. TMS is applied by 
only trained staff. There will be a training workshop at the beginning of the study. The risk of 
seizures with single or paired pulse TMS is extremely rare. Subject with a history of seizures 
will be excluded from this study. 
●
mCIMT: Each therapist will be trained with mCIMT protocol prior to treating any subject and 
will expect to adhere to the training manuals. A short break of up to 5mins can be offered by 
the therapist during the session if the subject expresses being fatigued. 
●
Motor assessment: Fatigue is unlikely during the motor assessments. However, if it does 
happen, then study staff will adjust the pace of the assessments.
3
OBJECTIVES AND ENDPOINTS
OBJECTIVES
ENDPOINTS
JUSTIFICATION FOR ENDPOINTS

 
10
Primary
FM-UE scale
 
FM-UE 
scale 
is 
the 
primary 
outcome and a measure of motor 
impairment
WMFT 
time 
score
WMFT is a secondary outcome and 
a measure of functional motor 
activity
To determine whether there is an 
initial overall treatment effect among 
3 dosing groups: 
●
sham + mCIMT
●
2 mA + mCIMT
●
4 mA + mCIMT
Efficacy is measured at day 15 after 
the initiation of the intervention. 
SIS 
Hand 
Subscale
SIS Hand subscale is a secondary 
outcome and a measure of the 
quality of life
Secondary
Rate of adverse 
events
Safety needs to be monitored in a 
phase II study
Visual 
Analog 
Scale
Visual Analog Scale measures 
tolerability
To 
confirm 
that 
the 
proposed 
intervention is safe, tolerable, and 
feasible to administer in a multi-site 
trial setting
Treatment 
completion rate
80% of treatment completion rate 
across 
sites 
without 
unexplained/unresolved variability 
is a measure of feasibility.
Tertiary/Exploratory 
To 
examine 
whether 
wCST-LL 
(structural assessment of integrity of 
descending motor tract) or MEPs 
(functional assessment of integrity of 
descending 
motor 
tract) 
or 
combination of both are correlated 
wCST-LL 
(structural)
wCST-LL is a structural measure of 
integrity of descending motor tract 
using brain MRI that has shown 
promise 
in 
predicting 
motor 
outcomes.

 
11
with changes in FM-UE scale, and 
evaluate the utility of these measures 
as biomarkers for subject selection 
criteria in the future confirmatory 
Phase III study
MEPs (functional)
MEPs is a functional measure 
integrity of descending motor tract 
using TMS that has shown promise 
in predicting motor outcomes, but 
two of them have not been collected 
and compared in the same study.
To examine whether functional or 
structural changes in motor tracts 
correlate with changes in impairment 
and functional motor activity induced 
by the intervention.
Motor 
Evoked 
Potentials 
(MEPs) 
and 
Diffusion 
tensor 
imaging MRI.
MEPs can change in response to 
rehabilitation; 
Functional 
and 
structural aspects of motor tracts 
and the interaction between motor 
regions change after intervention. 
This change can be captured by 
comparing TMS and MRI measures 
before and after treatment
4
STUDY DESIGN 
4.1
OVERALL DESIGN
The TRANSPORT2 (TRANScranial direct current stimulation current for Post-stroke mOtor 
Recovery – a phase II sTudy) trial will test an overall hypothesis that a combination of 
bihemispheric tDCS stimulation at 2 mA or 4 mA, along with mCIMT, will lead to a greater 
sustained motor improvement on day 15 ( 2 days) after the start of the intervention as compared 
to sham stimulation. Sustained benefits will be assessed at day 45 (± 5 days) and day 105 (± 10 
days) after the start of the intervention.  This multicenter, phase II, sham-controlled 3-arm study 
will randomize 129 subjects in a 1:1:1 allocation ratio per arm (sham, 2 mA, or 4 mA tDCS), and 
treat subjects with the assigned dose of tDCS for 30 minutes (± 6) and mCIMT for 120 minutes (± 
24) of active time, for 10 sessions over a 14 day period. However, the total time of mCIMT will be 
less than 150 minutes.
4.2
SCIENTIFIC RATIONALE FOR STUDY DESIGN
Motor impairment is the most common deficit after stroke, and effective motor recovery therapies 
are still lacking95, 96. The degree of structural and/or functional injury to the descending motor 
pathways, quantified by the weighted corticospinal tract -lesion load (wCST-LL) and motor evoked 
potentials (MEPs), determines the natural outcome and the response to an experimental 
intervention16, 17, 20, 97-99. Other forms of neuroplasticity contributing to recovery include unmasking 
of pre-existing or new synaptic contacts through axonal sprouting, changes in myelination, and 
reorganization of peri-lesional or homologous areas of the contralesional hemisphere23, 30, 100-102. 
Plasticity-enhancing tools that have an additive effect are needed. One such tool is transcranial 
direct current stimulation (tDCS), a non-invasive brain stimulation technique, which can modulate 
motor cortical excitability, modify a stroke-induced abnormal inter-hemispheric imbalance, and 
increase synaptic plasticity when combined with a peripheral sensorimotor stimulation21, 37, 43, 47, 
76, 103. Although several single-center proof-of-concept studies have demonstrated promising 
results for tDCS’ potential to reduce motor impairment, results are mixed with a wide-range of 
effect sizes and standard deviations32, 34, 36-38, 42, 88, 104. 

 
12
The promise of tDCS is unlikely to be realized without a well-designed multi-center phase II study 
that increases the level of scientific rigor by addressing the following deficiencies from previous 
studies: (1) Applying higher stimulation dosage: A meta-analysis suggests a dose-response 
relationship between current density and motor improvement39. We recently showed that 4 mA 
(double the previously used maximal dose) was safe and tolerable to stroke patients in a phase I 
dose escalation study; (2) Using a bihemispheric stimulation montage as literature39-41 indicated 
that bihemispheric stimulation (anodal over affected motor region and cathodal over 
contralesional region) is better than unihemispheric stimulation; (3) Improving Blinding of tDCS 
devices to eliminate bias from investigator, therapist and subject; (4) Adding central adjudication 
of outcomes; and (5) Choosing an effective, standardized and quantifiable peripheral 
rehabilitation therapy- Constraint-Induced Movement Therapy(CIMT)19, as the control treatment; 
(6) Choice of comprehensive outcomes measures.
4.3
JUSTIFICATION FOR DOSE
As stated above in §4.2 (1) and (2), up to 4 mA was safe and tolerable for stroke patients in a 
published phase I dose escalation study. Dose-response relationship and superior efficacy of 
bihemispheric montage by prior meta-analysis motivated us to design TRANSPORT2 to compare 
the 4 mA tDCS with the traditional 2 mA tDCS and sham stimulation as a control, where all 3 
groups receive mCIMT as adjunctive peripheral rehabilitation therapy. 10 sessions (30 minutes 
of tDCS stimulation ± 6 minutes and 120 minutes ± 24 minutes of mCIMT per session) will be 
applied over a 14 day period.  
4.4
END OF STUDY DEFINITION
Subject is considered to complete the study if he/she has completed the last visit on day 105.
5
STUDY POPULATION
5.1
INCLUSION CRITERIA
Each subject must meet all of the following criteria to participate in this study:
1) 18-80 years old; and
2) First-ever unihemispheric ischemic stroke radiologically verified and occurred within the past 
30-180 days; and
3) >10° of active wrist extension, >10° of thumb abduction/extension, and > 10° of extension in at 
least 2 additional digits; and
4) Unilateral limb weakness with a Fugl-Meyer Upper Extremity score of ≤ 54 (out of 66) to avoid 
ceiling effects; and
5) An absolute difference of FM-UE scores between the two baseline assessments that is ≤ 2 
points indicating stable motor impairment; if subject is not stable, then he/she will be invited for a 
reassessment after 7-14 days (but no more than 3 reassessments); and
6) Pre-stroke mRS ≤2; and
7) Signed informed consent by the subject or Legally Authorized Representative (LAR).
5.2
EXCLUSION CRITERIA
Each Subject who meets any of the following criteria will be excluded from the study: 

 
13
1) Primary intracerebral hematoma, subarachnoid hemorrhage or bi-hemispheric or bilateral 
brainstem ischemic strokes; 
2) Medication use at the time of study that may interfere with tDCS, including but not limited to 
carbamazepine, flunarizine, sulpiride, rivastigmine, dextromethorphan; 
3) Other co-existent neuromuscular disorders (pre- or post-stroke) affecting upper extremity motor 
function;
4) Other neurological disorders (pre- or post-stroke) affecting subject’s ability to participate in the 
study;
5) Moderate to severe cognitive impairment defined as Montreal Cognitive Assessment (MOCA) 
score < 18/30;
6) History of medically uncontrolled depression or other neuro-psychiatric disorders despite 
medications either before or after stroke that may affect subject’s ability to participate in the study;
7) Uncontrolled hypertension despite medical treatment(s) at the time of randomization, defined 
as SBP≥185 mmHg or DBP≥110 mmHg (patient can be treated, reassessed and randomized 
later); 
8) Presence of any MRI/tDCS/TMS risk factors including but not limited to: 
8a) an electrically, magnetically or mechanically activated metallic or nonmetallic implant 
including cardiac pacemaker, intracerebral vascular clips or any other electrically sensitive 
support system; 
8b) a non-fixed metallic part in any part of the body, including a previous metallic injury to 
eye; 
8c) pregnancy (effects of MRI, TMS, and tDCS on the fetus are unknown); 
8d) history of seizure disorder or post-stroke seizure; 
8e) preexisting scalp lesion under the intended electrode placement or a bone defect or 
hemicraniectomy;
9) Planning to move from the local area within the next 6 months;
10) Life expectancy less than 6 months;
11) Has received Botulinum toxin injection to the affected upper extremity in the past 3 months 
prior to randomization or expectation that Botulinum will be given to the Upper Extremity prior to 
the completion of the last follow-up visit;
12) Concurrent enrollment in another investigational stroke recovery study; 
13) Doesn’t speak sufficient English to comply with study procedures;
14) Expectation that subject cannot comply with study procedures and visits.
5.3
SCREEN FAILURES
Screen failure is defined as a subject that signs a consent form but not randomized. The primary 
reason for screen failure is mainly due to inclusion/exclusion criteria.  A minimal set of screen 
failure information is required to ensure transparent reporting of screen failure subjects, to meet 
the Consolidated Standards of Reporting Trials (CONSORT) publishing requirements and to 
respond to queries from regulatory authorities. Minimal information includes demographics, 
details of screen failure, and which eligibility criteria were not met. 
5.4
STRATEGIES FOR RECRUITMENT AND RETENTION 
We will recruit 129 stroke subjects at  approximately 15 sites over a 3.5-year period. In this 
section, we will address the possibility of insufficient subject recruitment/retention and quality 
control issues that we have already installed and others that could come up during this trial. (1) 
Detailed pre-submission epidemiology assessment, feasibility survey, and site selection: 
Based on the detailed feasibility assessment through StrokeNet, our prior experience with stroke 
recovery trials including the completed Telerehabilitation Trial, patient volume and the experience 
with tDCS/TMS/mCIMT at StrokeNet sites, and enthusiasm for participation, approximately 15 

 
14
sites that responded to the survey who are capable of conducting this trial based on the criteria 
will be selected. We will initiate the trial with 12 sites with an expected 4-6 subjects enrolled per 
site per year to ensure 129 patients’ enrollment over the 3.5-year recruitment period. (2) Careful 
budgetary consideration: Funds are specifically allocated for the study coordinator to pre-
screen potential subjects at the beginning of the trial. Subjects will be adequately reimbursed for 
the cost of traveling and parking given the number of intervention sessions of this trial. This will 
alleviate the burden on the participant side and improve enrollment and retention. (3) Close 
monitoring of subject enrollment/retention: We will utilize central risk-based monitoring to 
rapidly identify sites which deviate from the protocol and work closely with the NINDS Stroke 
Trials Network NCC and NDMC to address potential issues with subject enrollment, retention. 
Sites who fail to recruit or have a higher than expected drop-out rate after recruitment will be put 
on hold until an appropriate corrective action plan is developed and implemented. If the problem 
subsequently persists, the site will be replaced with a new site from the pool that can meet the 
requirements of the trial. (4) Multi-level quality control process: First; a required in-person 
workshop for investigators and team members from each site and subsequent annual online 
certification and recertification in the primary outcome measure; Second; selected site visits if 
needed by co-investigators to ensure the adherence of mCIMT protocol. Additional quality control 
of data entry vetting will be implemented through NDMC; Third; videotaping of primary outcome 
assessment for use in central adjudication purpose. Lastly, a strict blinding process will be 
implemented to ensure local investigator, therapist, subjects and outcome assessor are all 
separated and blinded to treatment assignments. (5) Sharing of Best Practices: We will plan for 
“share and learn” sessions on the topic of patient recruitment and quality control within 
TRANSPORT2 sites as well as other trials within StrokeNet. We will promote effective subject 
recruitment and quality control strategies throughout the study period. 
Specific recruitment plans are as follows:
●
Subjects will be identified in both the inpatient hospital setting or outpatient clinics or research 
subjects database;
●
Clinicians and study personnel involved in clinical care of the subjects will identify the potential 
subjects for the study, evaluate the fit by checking the matching selection criteria, introduce 
the study to the subjects, offer further details of the study if the subject is interested.
●
Once enrolled, study coordinators will send regular reminders of appointment dates, times 
and locations by approved communication channels like phone and mail address
●   Throughout the trial, the recruitment of women and minorities will be closely monitored and    
compared to expected rates as specified in the following enrollment table; specifically the trial 
anticipates that males and females will be enrolled at approximately equal rates; approximately 
85% of subjects will be non-Hispanic or Latino of which approximately 2% American Indian or 
Alaskan native, 9% Asian, 2% native Hawaiian or other pacific islander, 25% black or African 
American, and 63% White; among the approximately 15% of Hispanic or Latino subjects all are 
anticipated to be White”. If at any point recruitment has significantly deviated from these targets, 
corrective action measures including, but not limited to, consultation with local patient advocacy 
and minority interest groups, retraining of study coordinators, and the development of 
racially/gender sensitive recruitment material will be considered. These strategies will be 
considered before adding sites with a disproportionate catchment of the target racial group, as 
this strategy would resolve imbalances within the trial but does not address the 

 
15
equity/accessibility 
concerns 
within 
each 
site’s 
community.
A pre-screen interview will be conducted via phone or telehealth/ video software, for those 
who are interested in the clinical trial.  The process may take 10-15 minutes and screen the 
subject with the following questions:  
(1) age between 18-80 years old;
(2) date of stroke onset is less than 180 days; 
(3) first-ever stroke;
(3) has minimal movement of wrist and at least 2 fingers;  
(5) can speak sufficient English; 
(6) can commit to 10 research sessions (5 days per week for 2 weeks; each session lasts 
approximately 2-3 hours); 
(7) has no metallic (including shrapnel injuries) or electronic implants; 
(8) can provide a list of currently taken medications; 
If the answer to these 8 questions is “yes”, then the potential participant will be invited to the 
local study site for the baseline assessment for consent and further eligibility determination. The 
IRB-approved prescreening interviewscriptwill be recommended to administer the screening 
questions. The purpose of prescreening prior to the in-person baseline visit is to reduce the 
number of screen failures. 
5.5
PARTICIPANTS IN A RESEARCH TRAINING STUDY
We will recruit up to 12 participants per site in this research training study to train and standardize 
mCIMT, outcome assessments (FM-UE scale, WMFT and the SIS) and diagnostic tests (TMS, 
MRI) and tDCS prior to the first enrollment in the TRANSPORT2 clinical trial. In addition, after 
every 4th participant is enrolled/randomized in the clinical trial, each site will be required to 
demonstrate fidelity in these study procedures again. The participants for the research training 
study can be either stroke patient or healthy control. Each participant may consent for one or 
more study procedure. The same participant can be recruited again for ongoing fidelity 

 
16
assessments. Any stroke patient who is consented to be part of the Research Training Study CAN 
NOT be recruited for the TRANSPORT2 clinical trial.
The inclusion and exclusion for the research training study participant if he/she is a 
participant with a stroke are as followed:
Inclusion criteria:
Each participant must meet all of the following criteria to participate in this study:
1) 18-80 years old of any gender; and
2) history of stroke with various degree of upper extremity weakness
3) Signed informed consent by the subject or Legally Authorized Representative (LAR).
Exclusion criteria:
Each participant who meets any of the following criteria will be excluded from the study: 
1) Presence of any MRI/TMS/tDCS risk factors including but not limited to: 
a) an electrically, magnetically or mechanically activated metallic or nonmetallic implant 
including cardiac pacemaker, intracerebral vascular clips or any other electrically 
sensitive support system; 
b) a non-fixed metallic part in any part of the body, including a previous metallic injury to 
eye; 
c) pregnancy (effects of MRI or TMS on the fetus are unknown); 
d) history of seizure disorder or post-stroke seizure; 
e) preexisting scalp lesion under the intended electrode placement or a bone defect or 
hemicraniectomy;
2) Concurrent enrollment in another investigational stroke study; 
3) Doesn’t speak sufficient English to comply with study procedures;
The inclusion and exclusion for the research training study participant if he/she is a 
healthy participant are as followed:
Inclusion criteria:
Each participant must meet all of the following criteria to participate in this study:
1) 18-80 years old of any gender; and
2) Signed informed consent by the subject or Legally Authorized Representative (LAR).
Exclusion criteria:
Each participant who meets any of the following criteria will be excluded from the study: 
1) Presence of any MRI/TMS/tDCS risk factors including but not limited to: 
a) an electrically, magnetically or mechanically activated metallic or nonmetallic implant 
including cardiac pacemaker, intracerebral vascular clips or any other electrically 
sensitive support system; 
b) a non-fixed metallic part in any part of the body, including a previous metallic injury to 
eye; 
c) pregnancy (effects of MRI or TMS on the fetus are unknown); 
d) preexisting scalp lesion under the intended electrode placement or a bone defect or 
hemicraniectomy;
2) Doesn’t speak sufficient English to comply with study procedures;
For the mCIMT and outcome assessments, each site will enroll ≥ 1 participant with a stroke to 
train and standardize the intervention and outcome assessments. The intervention session and 
evaluation sessions will be videotaped and uploaded to a secure and HIPAA compliant site for 

 
17
the central evaluators to determine if local therapists and evaluators meet fidelity criteria. 
Feedback will be provided to the local therapists and evaluators. A second study participate will 
be enrolled to repeat the training process above until the fidelity criteria are met.  We anticipate 
that up to 3 participants will be needed for training and standardization purposes of mCIMT and 
the outcome assessments.
For the TMS procedure, each site will enroll ≥ 1 participant with a stroke or healthy participant to 
train and standardize the TMS procedure. The local investigator and team members will 
demonstrate their ability to apply TMS to obtain resting motor threshold and other TMS 
parameters. The data collection process will be videotaped and the TMS data will be uploaded to 
a secure and HIPAA complaint site and then evaluated by the study team, and feedback will be 
provided to the sites.
For the MRI procedure, each site will enroll ≥ 1 participant with a stroke or healthy participant to 
train and standardize MR imaging procedure. The local investigator and team members will 
demonstrate their ability to use the selected MR sequences and successfully obtain MR images. 
The MRI data will be uploaded to a secure and HIPAA compliant site and then evaluated by the 
study PIs and feedback will be provided to the sites. If the study PIs detect any problems with the 
data or insufficiencies in the data acquisition, then the site PI will be asked to recruit another pilot 
participant to demonstrate efficiency and fidelity with the TMS and/or MRI acquisition. 
For the tDCS, each site will enroll ≥ 1 participant with a stroke to train and get familiar with the 
device. The local investigator and team members will demonstrate their ability to use the device. 
A co-investigator is available over the phone or a HIPPA compliant video software for question or 
feedback or troubleshooting. 
The research MRI scans performed for this study are different from those that would be used for 
a clinical evaluation.  Since the MRI scans are not designed for clinical use. We will not provide 
any medical reading interpretation of the scans to the participants and not including any reading 
of the scans into the medical records. Nevertheless, should the neurologist, who has extensive 
experience in neuroimaging including MR images find anything unusual in the images, we will 
communicate this to the participant and to the primary care physician of the participant if the 
participant instructs us to do so.
6
STUDY INTERVENTION
6.1
STUDY INTERVENTION(S) ADMINISTRATION
6.1.1
STUDY INTERVENTION DESCRIPTION
Transcranial Direct Current Stimulation (tDCS): 
tDCS will be delivered to the study subjects through two electrodes (5 × 7=35 cm²) via a direct 
current delivery device. In the bihemispheric montage, the anodal electrode will be placed over 
the ipsi-lesional and the cathodal electrode over the contra-lesional motor cortex (C3 and C4 
using the international 10 –20 EEG electrode systems). Electrode pads will be disposed after 
each week or 5 sessions. Pads will not be shared across subjects. Stimulation will last for 30 
minutes (± 6)minutes for each session. Subject will receive either sham, 2 mA or 4 mA. Records 
of current will be checked and kept separately without unbinding the sites.  

 
18
mCIMT:
The mCIMT protocol in this study is adapted from a protocol published in the EXCITE and 
VECTOR trials14, 19.  The premise of the strategy is that repetitive object grasping and 
manipulation practice reduces the effects of “learned non-use.” mCIMT will be delivered 120 
minutes (± 24)minutes a day (with the first 30 minutes (± 6)minutes simultaneously with tDCS 
stimulation) for 10 sessions over 2 weeks with the unaffected arm in a constraining mitt for at least 
6 hours/day during waking hours. Subjects will not be allowed to use the constrained hand within 
the task effort. The tasks attempted during the therapy session will be menu driven.  Activities will 
be selected from a task menu, and an activity log kept demonstrating what tasks have been 
attempted.  Each activity will be carried out for 15-30 minutes and activities selected should be 
challenging yet feasible for the subject, contextually appropriate (i.e., with regards to interests) 
and challenge movements that need improvement.
Training will primarily consist of task practice (TP) activities designed to promote increased use 
of the affected upper extremity during functional activities. These activities simulate activities of 
daily living (ADL) and instrumental activities of daily living (IADL), i.e., common daily activities. If 
a subject is unable to perform TP activities, the trainer may select activities from a menu of 
adaptive task practice (ATP) activities. ATP activities are comprised of the basic units or 
components of larger activities employed in TP. ATP activities focus on improving skills such as 
grasp, manipulation, dexterity, gross motor control, endurance, timing, and active range of motion. 
Whenever possible, ATP should be transitioned into TP activities as the subject’s skill level 
increases.  The subjects will be provided with feedback (specific knowledge of results about a 
subject’s performance over a session); coaching (suggestions verbally to improve 
performance); modeling (physically demonstrate a task with the purpose of improving a subject’s 
performance); and encouragement (providing motivation to subjects verbally to promote maximal 
effort). Patients will wear the mitt for at least 6 hours of waking hours at home. Behavioral 
techniques to enhance mitt use outside of the research laboratory will include the use of a 
behavioral contract daily schedule, and encouragement from the supervising therapist to practice 
2 to 3 specific tasks daily at home. A behavior contract will be provided to the subject at the end 
of the first intervention session. 
6.1.2
DOSING AND ADMINISTRATION
Subjects will be 1:1:1 randomized to sham, 2 mA, or 4 mA group. Investigator, therapist and the 
subject will not be informed of the group assignment. All subjects will be prepared in the same 
way. tDCS will be executed by entering WebDCU-generated code in the computer, which will 
initiate one of the three interventions according to the group to which the subjects was 
randomized: sham, 2 mA or 4 mA. Thirty minutes of tDCS (including sham) will be accompanied 
by 120 (±24) minutes of mCIMT with both starting at the same time, overlapping for the first 30 
(±6) minutes, and leaving the remaining 90 minutes for mCIMT only. tDCS is delivered by a small, 
battery-operated device, portable (e.g., can be mounted to a belt) and it does not interfere with 
mCIMT.
6.2
PREPARATION/HANDLING/STORAGE/ACCOUNTABILITY
6.2.1
ACQUISITION AND ACCOUNTABILITY
In order for a new medical product to reach patients, it must first be proven safe and effective and 
then be approved for use by the governing regulatory body. Clinical trials are the vehicle to bring 
these innovative technologies to subjects and evaluate them in support of regulatory approval.  In 
clinical research the products are still investigational, these products are treated differently than 

 
19
those items used in general medical practice. After all, using an unapproved product that is not 
fully vetted for safety and efficacy outside of the trial protocol requirements could result in risks to 
subjects. 
Failure to account for and manage study materials could affect the acceptability of the data 
collected from a trial, or even termination of a study completely. Both sponsors and investigators 
have responsibility for device accountability and can be held accountable if problems are 
identified.
Accountability:
●
The site investigator is responsible for the investigational product/device accountability at 
the trial site
●
The site investigational product/device should be stored in accordance with the applicable 
regulatory requirements.
●
The site investigator should ensure that the investigational product/device are used only 
in accordance with the approved protocol.
6.2.2
PRODUCT STORAGE AND STABILITY
The device should be accessible by the study team only. The device, including the battery, wires, 
and electrode pads will be checked before and at the end of each session. Each site will be 
dispensed with two tDCS systems (one for use and another for backup). Any issue should be 
reported immediately to the site investigator and further to the tDCS core team 
6.2.3
PREPARATION
tDCS core personnel will prepare and test the tDCS system before dispensing to the site staff. 
The site staffs will attend a required onsite training workshop to gain knowledge how to operate 
the tDCS system.  
6.3
MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING
On the randomization day, a study coordinator or a team 
member will log into WebDCUTM to randomize subjects 
who have been consented and found eligible. Briefly, at 
the beginning of each intervention session, the 
coordinator will complete  tDCS Treatment Activation 
Code Request to obtain a new tDCS treatment activation 
code daily. Each day, the coordinator will need to enter 
the new code into the tDCS machine which will translate 
the code to the appropriate stimulation voltage using a 
pre-loaded script (Fig 8, right).  The treating therapist is 
only to conduct mCIMT on the study subject, another 
study team member should conduct concurrent tDCS 
stimulation session to avoid potential bias.  
Subjects will be allocated equally among the three 
treatment 
arms 
using 
a 
covariate 
adaptive 
randomization algorithm which controls for serious 
imbalances in covariates considered to have an impact 
Fig 8. Schematic of interface between tDCS 
control, dual-channel tDCS delivery system, 
and WebDCUTM interface.

 
20
on outcome; specifically, study site, time from stroke, and baseline motor impairment measured 
using FM-UE scale. At the time of randomization, serious imbalances in these covariates will be 
accounted for using a minimal sufficient balance approach105. That is, at the time of 
randomization, an overall treatment imbalance and imbalance in each of the covariates is 
assessed. If no imbalances exceed the tolerated threshold, the subject is randomized according 
to the specified allocation ratio (1:1:1). If an unacceptable level of imbalance exists, the algorithm 
will determine whether the current allocation ratio improves or exacerbates the current imbalance 
and adjust the ratio accordingly. The detailed randomization scheme and source codes will be 
provided in the Randomization Plan document. 
6.4
STUDY INTERVENTION COMPLIANCE
Compliance with study treatment will be centrally monitored.
7
STUDY INTERVENTION DISCONTINUATION AND SUBJECT DISCONTINUATION/WITHDRAWAL
7.1
DISCONTINUATION OF STUDY INTERVENTION
Discontinuation from tDCS and mCIMT intervention does not mean discontinuation from the 
study, and remaining study outcome assessments should be completed as indicated by the study 
protocol.  If a clinically significant finding is identified (including, but not limited to changes from 
baseline) after enrollment, the investigator or qualified designee will determine if any change in 
subject management is needed. Any new clinically relevant finding will be reported as an adverse 
event (AE).  An investigator may discontinue or withdraw a subject from study intervention for the 
following reasons:
●
Pregnancy, but it is unlikely as woman of child-bearing potential will have urine pregnancy 
test to confirm or exclude the possibility of a pregnancy.
●
Significant study intervention non-compliance, defined as missing >2 sessions out of 10 
sessions and unable to make it up within the 2 week/14 days intervention period;
●
If any adverse event (AE), laboratory abnormality, other medical condition or situation occurs 
such that continued participation in the study intervention would not be in the best interest of 
the subject.
●
Disease progression (e.g., 4 points or more increases in the NIHSS score or recurrent stroke) 
which requires discontinuation of the study intervention. 
●
If a subject meets an exclusion criterion (either newly developed or not previously recognized) 
that precludes further study participation.
●
Subject suffers another stroke, neurological or neuromuscular disease during the study period 
that may have an impact on motor recovery.
The reason for intervention discontinuation from the study will be recorded on the Case Report 
Form (CRF). The subject should continue to be followed and have all study assessments.
7.2
SUBJECT WITHDRAWAL FROM THE STUDY

 
21
Subjects are free to withdraw from participation in the study at any time upon request. The reason 
for subject withdrawal from the study will be recorded on the Case Report Form (CRF).  Subjects 
who sign the informed consent form, and are randomized and receive the study intervention, and 
subsequently withdraw will not be replaced.
7.3
LOST TO FOLLOW-UP
A subject will be considered lost to follow-up if he or she fails to return for three scheduled visits 
and is unable to be contacted by the study site staff. 
The following actions must be taken if a subject fails to return to the clinic for a required study 
visit:
●
The site will attempt to contact the subject and reschedule the missed visit within 2 weeks and 
counsel the subject on the importance of maintaining the assigned visit schedule and 
ascertain if the subject wishes to and/or should continue in the study.
●
Before a subject is deemed lost to follow-up, the investigator or designee will make every 
effort to regain contact with the subject (where possible, ≥3 telephone calls if necessary). 
These contact attempts should be documented in subject’s study file. 
8
STUDY ASSESSMENTS AND PROCEDURES
8.1
EFFICACY ASSESSMENTS 
Primary Objectives (Efficacy Outcomes):  To determine whether there is an overall intervention 
effect among 3 dosing groups (sham+mCIMT, 2 mA+mCIMT, and 4 mA+mCIMT) at day 15 after 
initiation of the intervention in the Fugl-Meyer Upper-Extremity (FM-UE) scale106, a measure of 
motor impairment. FM-UE scale consists of a 33-item assessment which provides a global 
assessment of UE motor impairment. A rater observes 30 voluntary UE motions and 14 voluntary 
LE motions, 6 tendon tap responses, and provides an ordinal rating (2=near normal 
ability/response, 1=partial ability, 0=unable to perform/no response). FM-UE scale is a proven 
scale with excellent intra-rater reliability (0.99), inter-rater reliability (0.99), test-retest reliability 
(0.94 –0.99), and internal consistency (0.97). 107-109
Secondary efficacy outcome measures include the Wolf-Motor-Function-Test (WMFT)110-112, a 
measure of functional motor activity, and the Stroke-Impact-Scale (SIS)113, a measure of the 
quality of life at day 15 after initiation of the intervention. These efficacy outcomes will be 
collected at the baseline, day 15, day 45 and day 105. WMFT quantifies upper extremity (UE) 
motor ability through timed and functional tasks. It is a 17-item assessment providing a measure 
of UE functional ability.  In this test, participants are timed as they complete 17 tasks that 
involve movements and interactions with objects (e.g., placing hand on table, picking up a soda 
can).  These activities begin with those involving only shoulder movements and progress to 
those requiring distal control of fine motor movements.  In addition, subject’s movement will be 
assessed for meeting “Essential Elements” (specific elements) that must be accomplished in 
order for the task to be deemed complete” vs. “Desired Elements” which are other qualitative 
elements that should be included in the task but are not necessary for completion” (please refer 
to details in the Outcome Assessments MOP, located in the WebDCU Toolbox). 115
SIS is a stroke-specific, self-report, health status measure assessing multidimensional stroke 
outcomes.113, 114The current 3.0 version includes 59 items and assesses 8 domains: strength (4 

 
22
items), hand function (5 items), Activities of Daily Living / Instrumental Activities of Daily Living 
(ADL/IADL, 10 items), mobility (9 items), communication (7 items), emotion (9 items), memory 
and thinking (7 items), and participation (8 items). The SIS hand function domain is a valid and 
reliable measure that is well aligned with TRANSPORT2 specific aims. It has face validity for 
clinical meaningfulness and this self-report measure of hand function corresponds well with other 
outcomes. While the specific effects of the Intervention are expected to Influence the hand 
function domain the most, we also expect several non-specific effects on health status generally 
and the composite physical performance and social participation domains contained in the full 
SIS. This was true for the EXCITE trial which established the efficacy of mCIMT. 
8.1.2 EXPLORATORY AIMS MEASURES 
8.1.2.1 IMAGING MEASURES
We will determine two imaging measures: weighted corticospinal tract lesion load (wCST-LL) 
that be derived from the pre-intervention MRI and the fractional anisotropy (FA) measure that 
will be derived from the pre- and post-intervention MRI. These imaging measures support the 
exploratory aims/objectives outlined in section 3 above.
wCST-LL: Three MRI sequences (T1-weighted, T2-weighted, and FLAIR imaging) will be used 
to define and quantify the stroke lesion. A 3D map of this lesion will be overlaid onto a canonical 
corticospinal tract which was derived from a group of elderly healthy control subjects and exists 
in our lab as a representative map of the CST; (see Feng et al., 2015 for details). The overlap 
area between the lesion and the canonical CST will constitute our measure of wCST-LL. The 
weighting of the lesion load is related to the probabilistic nature of the tract and its geometric 
changes while it traverses from the cortex through the internal capsule into the brainstem. The 
wCST-LL is a continuous measure expressed in cubic centimeter (cc) with 2 decimals.  
Corticospinal Tract - fractional anisotropy values (CST-FA): FA values are derived from an 
MRI sequence called diffusion tensor imaging (DTI). FA values will be determined in maps of the 
CST. Canonical maps of the CST (stretching from the posterior limb of the internal capsules to 
the lower brainstem) exist in our laboratory and have been previously described (see Zheng and 
Schlaug, 2015 for details). FA is a measure of tract integrity or how well fibers are aligned in one 
direction in a tract. Values are between 0-1. Fractional anisotropy values tell us something about 
the direction of water flow. If the value is closer to 1, water flows along major fiber tracts in one 
particular directions, which means that the fibers are healthy and well aligned. Typically, on the 
side of the stroke, we might see a decrease in FA or water not only flowing in one direction but 
multiple directions, reflecting a degeneration of a fibers in a tract as an effect of the stroke. FA 
values derived from a template of the CST on the lesional and contralesional hemisphere will be 
determined in the pre-intervention MRI and post-intervention MRI and changes in these FA values 
will be correlated with behavioral changes within the three treatment groups as specified in the 
SAP. 
8.1.2.2 TMS MEASURES
We will determine two TMS measures: presence of Motor Evoked Potential (MEP) and 
amplitude of MEPs. These TMS measures support the exploratory aims/objectives outlined in 
section 3 above.

 
23
Presence or absence of Motor Evoked Potential (MEP): The resting motor threshold (rMT) is 
the lowest stimulus intensity of TMS that gives a recordable MEP from abductor pollicis brevis (50 
𝜇V peak-to-peak). It is a measure of global motor system excitability at both cortex and spinal 
cord level. This parameter will be categorized into a binary variable (Present/1 or Absent/0) for 
the purpose of analysis. Present/1 means there is a recordable MEP, Absent/0 means there is no 
recordable MEP. Presence of MEP in a subject with a stroke typically suggests some degree of 
preservation of the corticospinal tract. It is possible that MEP is absent on the affected limb despite 
applying the stimulus on the lesional hemisphere if the CST is severely injured. rMT from non-
paretic side is collected as well and serves as a reference to the paretic side. It is estimated that 
~20% of patients may not have a recordable MEP from this study. If it turns out that only < 10% 
of patients do not have MEP and the number of subjects in the absent group is too small. We will 
use an alternative to analyze the data. We will use asymmetric index {i.e. (absolute value rMT on 
the affected side – absolute value of rMT on the unaffected side) / absolute value rMT on the 
affected side). If MEP is absent, a value of 100 % maximum stimulator output (MSO) will be 
assigned as rMT. If MEP is present, the rMT (% MSO required to produce 50 𝜇V peak-to-peak 
using PEST algorithm) will be compared between baseline and post-therapy sessions. 
Size of the Motor Evoked Potential (MEP) The size of MEP (i.e. the peak to peak amplitude of 
a stable MEP that is ≥1 mV) provides an estimate of the extent of corticospinal tract and motor 
neuron activation by the magnetic stimulation. This is only done if the patient has a recordable 
MEP first. If patient does not have a recordable MEP, the amplitude of MEP will be set as 0. If the 
patient has a recordable MEP, the % MSO required to produce 1 mV peak-to-peak using PEST 
algorithm will be determined on baseline and post-therapy sessions. This value will be used as a 
testing stimulus (TS) in the paired-pulse stimulation (below) and therefore will be called as testing 
motor threshold (tMT). Patients with non-recordable 1 mV peak-to-peak MEP will be applied 100% 
MSO as TS in paired-pulse stimulation routine. 20 MEP at tMT with 4-7 seconds inter-pulse 
interval will be collected to determine the size of MEP. Comparison of MEP size will be performed 
between baseline and post-therapy sessions using baseline visit tMT to ensure that same 
stimulus intensity when comparing MEP size. The size of MEP from the non-paretic side will be 
collected as well and serves as a reference to the paretic side.
8.2
ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS
A tDCS questionnaire will be used in each intervention session to assess the common adverse 
events or tolerability issues associated with its use. Adverse events, including serious adverse 
events will be collected during the intervention period. Only serious adverse events or clinically 
related (possibly or definitely) adverse events will be collected after intervention period. Please 
refer to AE reporting section for details. 
8.2.1
DEFINITION OF ADVERSE EVENTS (AE)
An adverse event (AE) is defined as any new untoward medical occurrence or worsening of a 
preexisting medical condition in a clinical investigation subject administered study intervention 
and that does not necessarily have a causal relationship with this intervention. An AE can 
therefore be any unfavorable and unintended sign (such as an abnormal laboratory finding), 
symptom, or disease temporally associated with the use of the investigational intervention, 
whether or not considered related to the investigational intervention. Adverse events can be 
spontaneously reported or elicited during open-ended questioning, examination, or evaluation of 
a subject. 
8.2.2
DEFINITION OF SERIOUS ADVERSE EVENTS (SAE) 

 
24
A SAE is any untoward medical occurrence that:

results in death;

is life-threatening (defined as an event in which the participant was at risk of death at the 
time of the event; it does not refer to an event which hypothetically might have caused 
death if it were more severe);

requires inpatient hospitalization or causes prolongation of existing hospitalization;

results in persistent or significant disability/incapacity;

is a congenital anomaly/birth defect;

is an important medical event (defined as a medical event(s) that may not be immediately 
life-threatening or result in death or hospitalization but, based upon appropriate medical 
and scientific judgment, may jeopardize the subject or may require intervention (e.g., 
medical, surgical) to prevent one of the other serious outcomes listed in the definition 
above. Examples of such events include, but are not limited to, intensive treatment in an 
emergency room or at home for allergic bronchospasm; blood dyscrasias or convulsions 
that do not result in hospitalization.)
The definition of SAE excludes the following hospitalizations:

A visit to the emergency room or other hospital department < 24 hours, that does not 
result in admission (unless considered an important medical or life-threatening event);

Elective surgery, planned prior to signing consent;

Admissions as per protocol for a planned medical/surgical procedure;

Routine health assessment requiring admission for baseline/trending of health status 
(e.g., routine colonoscopy);

Medical/surgical admission other than to remedy ill health and planned prior to entry 
into the study (appropriate documentation is required in these cases);

Admission encountered for another life circumstance that carries no bearing on health 
status and requires no medical/surgical intervention (e.g., lack of housing, economic 
inadequacy, caregiver respite, family circumstances, administrative reason).
8.2.3
CLASSIFICATION OF AN ADVERSE EVENT
8.2.3.1
SEVERITY OF EVENT
The severity of AEs will be reported using the grading system outlined in the NCI Common 
Terminology Criteria for Adverse Events Version 4.03 (CTCAE). The CTCAE provides a grading 
(severity) scale for each AE term and AEs are listed alphabetically within categories based on 
anatomy or pathophysiology. The CTCAE displays Grades 1-5 with unique clinical descriptions 
of severity for each AE based on this general guidance:
 The complete definitions of these grades are: 

Grade 1: Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; 
intervention not indicated AE. 

Grade 2: Moderate; minimal, local or noninvasive intervention indicated; limiting age-
appropriate instrumental activities of daily living (preparing meals, shopping for groceries 
or clothes, using the telephone, managing money, etc.). 

Grade 3: Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting self-care 
activities of daily living (bathing, dressing and undressing, feeding self, using the toilet, 
taking medications, and not bedridden). 

 
25

Grade 4: Life-threatening consequences; urgent intervention indicated. 

Grade 5: Death related to AE.
8.2.3.2
RELATIONSHIP TO STUDY INTERVENTION
All adverse events (AEs) must have their relationship to study intervention assessed by the 
clinician who examines and evaluates the subject based on temporal relationship and his/her 
clinical judgment. The degree of certainty about causality will be graded using the categories 
below. In a clinical trial, the study product must always be suspect. 
1.
Unrelated: The temporal relationship between treatment exposure and the adverse event 
is unreasonable or incompatible and/or adverse event is clearly due to extraneous causes 
(e.g., underlying disease, environment);
2.
Unlikely: Must have both of the following 2 conditions, but may have reasonable or only 
tenuous temporal relationship to intervention:

Could readily have been produced by the subject’s clinical state, or environmental 
or other interventions.

Does not follow known pattern of response to intervention.
3.
Reasonable Possibility: Must have at least 2 of the following 3 conditions:

Has a reasonable temporal relationship to intervention.

Could not readily have been produced by the subject’s clinical state or 
environmental or other interventions.

Follows a known pattern of response to intervention.
4.
Definitely: Must have all 3 of the following conditions:

Has a reasonable temporal relationship to intervention.

Could not possibly have been produced by the subject’s clinical state or have been 
due to environmental or other interventions

Follows a known pattern of response to intervention.
8.2.3.3
EXPECTEDNESS 
In general, expected adverse reactions are AEs that are known to occur for the study intervention 
being studied and should be collected in a standard, systematic format using a grading scale 
based on functional assessment or magnitude of reaction. Identify the source of the reference 
safety information used to determine the expectedness of the AE (e.g., IB, approved labeling). 
Expectedness is assessed based on the awareness of AEs previously observed, not on the basis 
of what might be anticipated from the properties of the study intervention. An AE will be considered 
unexpected if the nature, severity, or frequency of the event is not consistent with the risk 
information previously described for the study intervention.
8.2.4
TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND FOLLOW-UP
The IMSM who is independent of any involvement with the study will monitor the study with regard 
to the safety concerns when adverse events or serious adverse event occurs. The IMSM will 
review all SAEs and determine whether they are related to study drug administration (as 
described above); a query to the site will be generated to amend the AE narrative if necessary for 

 
26
any questions or clarifications regarding an event. Periodically throughout the study, the Executive 
Committee and the IMSM will review reports on the incidence rates of all reported AEs, whether 
serious or not and blinded to treatment assignment. Should such monitoring uncover issues that 
may threaten subject safety (e.g., unexpectedly high rate of AEs), a notification will be sent to the 
DSMB liaison for review proposing further actions to be taken, if any. Two statistical reports will 
be generated semiannually (unless requested at an alternative interval by the IMSM or DSMB) – 
an open report to be distributed to the Executive Committee and IMSM, and a closed report to be 
distributed only to the DSMB. Each semi-annual report will provide cumulative summary statistics 
on enrollment, subject status in the study, baseline characteristics, protocol violations, safety data 
(including a summary of the most frequent and most serious AEs, and a listing of all subjects who 
were terminated from the study and the reason for termination), and data management/quality 
information. The open report statistics will be provided for the overall study with no separation of 
intervention groups. The closed report will provide cumulative summary statistics by partially 
blinded intervention group to DSMB members, the NIH liaison, and the project’s unblinded 
statistician. All people with access to the closed reports are fully independent of trial operation 
and have no impact on subject recruitment, intervention, and assessment. If the DSMB wishes to 
be completely unblinded for these reports, a sealed identification envelope will be provided to the 
DSMB liaison; this envelope can be opened at the discretion of the DSMB. 
8.2.5
ADVERSE EVENT REPORTING 
Required reporting must be submitted through the StrokeNet WebDCUTM as described and within 
the timeframes described in NIH StrokeNet Network Standard Operating Procedure ADM 12 
Central Institutional Review Board (cIRB) Reporting    https://www.nihstrokenet.org/docs/default-
source/strokenet-sops/adm12_cirb_reporting_060314.pdf?sfvrsn=2.
8.2.6
SERIOUS ADVERSE EVENT REPORTING 
All SAEs are required to be reported in WebDCUTM within 24 hours of the study site being made 
aware of the occurrence of the SAE. The investigators are required to provide relevant information 
such as description of the SAE, date/time of onset and resolution, severity and seriousness, action 
taken, and suspected relationship to the study intervention. Reporting of SAEs will trigger 
notification of the event to the Project Manager (PM). After reviewing the SAE for completeness 
and accuracy, the PM will forward the SAE to the MSM who will conduct an independent review 
of each SAE to determine its relationship to the study intervention along with other elements. 
Within 72 hours of receipt of the SAE for review, the IMSM will enter his opinion into WebDCUTM 
as to whether the SAE is, in fact, serious, unexpected, and related to the study drug.  After the 
submission of the initial SAE Report, the site investigator at the corresponding clinical site will be 
responsible for obtaining follow-up information about the event and reporting it in WebDCUTM. 
8.3
UNANTICIPATED PROBLEMS
8.3.1
DEFINITION OF UNANTICIPATED PROBLEMS (UP)
The Office for Human Research Protections (OHRP) considers unanticipated problems involving 
risks to subjects or others to include, in general, any incident, experience, or outcome that meets 
all of the following criteria:
●
Unexpected in terms of nature, severity, or frequency given (a) the research procedures that 
are described in the protocol-related documents, such as the Institutional Review Board (IRB)-
approved research protocol and informed consent document; and (b) the characteristics of 
the subject population being studied;

 
27
●
Related or possibly related to participation in the research (“possibly related” means there is 
a reasonable possibility that the incident, experience, or outcome may have been caused by 
the procedures involved in the research); and
●
Suggests that the research places subjects or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or recognized.
This definition could include an unanticipated adverse device effect, any serious adverse effect 
on health or safety or any life-threatening problem or death caused by, or associated with, a 
device, if that effect, problem, or death was not previously identified in nature, severity, or degree 
of incidence in the investigational plan or application (including a supplementary plan or 
application), or any other unanticipated serious problem associated with a device that relates to 
the rights, safety, or welfare of subjects (21 CFR 812.3(s)).
8.3.2
 UNANTICIPATED PROBLEM REPORTING 
The investigator will report unanticipated problems (UPs) to the cIRB. The UP report will include 
the following information:
●
Protocol identifying information: protocol title and site name;
●
A detailed description of the event, incident, experience, or outcome; 
●
An explanation of the basis for determining that the event, incident, experience, or outcome 
represents a UP; 
●
A description of any changes to the protocol or other corrective actions that have been taken 
or are proposed in response to the UP.
To satisfy the requirement for prompt reporting, UPs will be reported using the following timeline:
●
UPs that are serious adverse events (SAEs) will be reported to the cIRB within 10 days of the 
investigator becoming aware of the event. 
●
Any other UP will be reported to the DCC/study sponsor within 5 days of the investigator 
becoming aware of the problem. 
●
All UPs should be reported to appropriate institutional officials (as required by an institution’s 
written reporting procedures), the supporting agency head (or designee), and the Office for 
Human Research Protections (OHRP) within 1 month of the IRB’s receipt of the report of the 
problem from the investigator. 
8.3.3
REPORTING UNANTICIPATED PROBLEMS TO PARTICIPANTS 
Unanticipated problems judged after review by the TRANSPORT2 protocol PIs, cIRB, DSMB, or 
NINDS to require changes to the informed consent, study protocol, or background knowledge and 
training provided to sites will be communicated to all participating site PIs by the National 
Coordinating Center (NCC) or NDMC. This will be accomplished by email and may be 
supplemented by request for confirmation of receipt and follow-up by phone, all with assistance 
of the relevant Regional Coordinating Center when necessary. Any change in protocol or risk of 
the research will be communicated by site staff, by phone (supplemented by other means as 
necessary), to active intervention arm participants or their caretakers/other contacts.
9
STATISTICAL CONSIDERATIONS 

 
28
9.1
STATISTICAL HYPOTHESES
●
Primary Efficacy Endpoint(s): 
The primary null hypothesis is that there is no difference in the least-squares mean estimate of 
the change in FM-UE scale on Day 15 after the initiation of the 14 day intervention among the 
three dose groups. 
●
Secondary Efficacy Endpoint(s):
The secondary null hypothesis is that there is no difference in the least-squares mean estimate 
of the change in Wolf-Motor Functional Test (WMFT) time score and Stroke Impact Scale (version 
3.0, SIS) hand subscale.  
9.2
SAMPLE SIZE DETERMINATION
A change of 4.25-7.25 points on the FM-UE scale is considered to be a meaningful clinically 
important difference (MCID)116. This study is powered under the assumption that mCIMT alone, 
will at least achieve this intervention effect (4.5) and furthermore intervention with either 2 mA or 
4 mA tDCS will further increase the change in FM-UE scale from the baseline by 4.5 points (i.e., 
a minimum intervention effect of 9.0). Secondly, based on the meta-analysis of previous trials 
assessing tDCS in stroke patients39, a conservative estimate of the intervention variability is 
defined as SD = 7. Based on these assumptions, the current study requires 31 subjects per arm 
to estimate the 90% confidence interval for the treatment effect in each arm with a standard error 
of ± 1.3, assuming an ANOVA-type testing approach which is more conservative than the 
proposed analysis model which includes multiple time points and adjusts for covariates. 
This level of precision was determined to be sufficiently informative to plan a Phase III trial. 
Specifically, the confidence interval for a clinically meaningful treatment effect will exclude the 
hypothesized null effect size of 4.5; that is, the estimate and 90% confidence interval for a clinically 
meaningful treatment might be 9.0 (6.9, 11.1). Moreover, the choice of standard error represents 
a balance between the level of precision in the estimate and the number of subjects/resources 
expended during this phase of investigation (Fig. 9, below). Further, if the estimate of the 
standard deviation were overly conservative, the precision of the treatment effect estimate would 
increase. (N.B. Planning estimates of the null treatment effect size, 4.5, do not impact power as 
long as the MCID from stimulation remains at 4.5 points.)  
In addition, with a sample size of 31 subjects per group, a two-sided type I error rate of 10%, and 
standard deviation of 7, if the true pattern of mean changes is 4.5, 9.0, and 9.0 for the sham, 2 
mA, and 4 mA groups respectively, we would have 83% power to reject the null hypothesis. A 
10% type I error rate was selected in consideration of the track record for safety in the intervention, 
the relative cost of committing a type I and type II error with respect to trial duration, subject 
utilization, and the remaining need for a subsequently planned Phase III trial should the current 
trial demonstrate promising results.   Based on a conservative estimate from the EXCITE and 
VECTOR trial14, 19, 8% of subjects are expected to complete less than 10 full sessions of tDCS + 
mCIMT in the specified 14 day time-window. Thus, the sample size is inflated for the cross-over 
in treatment effect using an inflation factor of 1/(1-0.08)2.117 In addition, up to 15% of subjects may 
be lost to follow-up prior to collection of the primary outcomes at the 3-month follow-up visit. 

 
29
Therefore, an inflation of 115% is used to account for the missing samples in the ITT primary 
analysis.  As a result, the final estimated sample size is 43 per group (or 129 subjects in total). 
Finally, considering the longitudinal nature of the design and adjustment for key covariates, the 
power will be maintained when using an auto-regressive (1) correlation structure regardless of 
the degree of correlation between FM-UE scale measured on proximal visits or the strength of 
the covariates as predictors. We elected not to further reduce the sample size both because a 
robust estimate of these quantities is not currently available, and to retain sufficient power to 
evaluate secondary hypotheses. 
9.3
POPULATIONS FOR ANALYSES
●
Intent-to-treat (ITT) population
All analyses will be conducted under the ITT principle. That is, the evaluable sample includes all 
randomized subjects, regardless of whether or not the subjects completed the study protocol; 
where subjects are classified according to the intervention assignment, they are randomized into. 
●
Per-protocol (PP) population
Sensitivity of the primary findings will be assessed using a per-protocol sample defined as all 
subjects who (a) complete at least 8 out of 10 sessions of the intervention; (b) complete the FM-
UE scale with all three post-intervention visits; (c) do not experience a recurrent clinical stroke or 
other pre-specified illness known to impact upper extremity motor functioning during the study 
period (i.e., Bone fracture in the affected arm, newly diagnosed neuromuscular disease, cervical 
spine injury.); and (d) do not receive any other forms of rehabilitation therapy after 2 weeks of 
intervention. The intent of this analysis sample is to assess the maximum possible treatment effect 
achievable with tDCS at a dose of either 2 mA or 4 mA. It is anticipated that <50% of subjects will 
receive additional forms of rehabilitation therapy after the 14 day intervention (subjects enrolled 
in the subacute phase are the ones who have likely received additional rehabilitation therapy), 
however, if this percentage exceeds 50% the PP sample will exclude criteria (d). 
9.4
STATISTICAL ANALYSES
Details of the statistical analyses are provided in the Statistical Analysis Plan.
9.4.1
GENERAL APPROACH
The goal of this proposed phase-2 clinical trial is assessing whether bihemispheric transcranial 
Direct Current Stimulation (tDCS) at 2 mA or 4 mA, when combined with modified constraint-
induced movement therapy (mCIMT) will evoke a motor impairment reduction as measured by 
the Fugl-Meyer Upper Extremity (FM-UE) scale immediately after the 14 day intervention and at 
the time of 1 and 3 months follow-up when compared to sham stimulation combined with mCIMT. 
The central hypothesis is that tDCS, a non-invasive brain stimulation technique, can enhance 
current post-stroke motor recovery by inducing plasticity and potentiating the brain to be receptive 
to proven rehabilitation techniques (i.e., mCIMT).  However, it is not known whether the current 
maximum dose (2 mA) is sufficient or whether a higher dose (4 mA) may evoke a better response 
while maintaining a similar safety and tolerability profile.
9.4.2
ANALYSIS OF THE PRIMARY EFFICACY ENDPOINT(S)
The change in FM-UE Scale in each treatment arm will be modeled using generalized linear mixed 
effects repeated measures model, where the dependent variable is the change from baseline in 

 
30
FM-UE to post-intervention visit; the model is adjusted for intervention arm, baseline FM-UE, time 
from stroke, visit and site; and the primary outcome is the fitted estimate at day 15. Model 
assumptions, including normality, will be assessed and appropriate transformations will be used 
in keeping with best practices and conventional approaches in the literature. If the primary null 
hypothesis is rejected, all pairwise secondary hypotheses will be tested using a Dunnet type 
multiple comparisons correction118, 119.
9.4.3
ANALYSIS OF THE SECONDARY ENDPOINT(S)
Aim 1 will also test the secondary null hypotheses that there is no difference in the least-squares 
mean estimate of the change in Wolf-Motor Functional Test (WMFT) time score and Stroke Impact 
Scale (SIS, version 3) hand subscale at day 15. The procedure described above will be repeated 
for each of the secondary endpoints with the type-I error rate adjusted using a Bonferroni type 
gate-keeping procedure to sequentially test the hierarchical null hypotheses120, 121. That is, if the 
primary null hypothesis (i.e., no difference in the change in FM-UE Scale between the three 
groups) is rejected, the secondary null hypothesis of no difference with respect to WMFT time 
score will be assessed; if that null hypothesis is also rejected, then the null hypothesis of no 
difference in the SIS hand subscale will be tested.  
9.4.4
SAFETY ANALYSES
Safety: Analysis Method
IMSM and Data and Safety Monitoring Board (DSMB) will receive periodic safety reports of all 
reportable adverse events including serious adverse events (SAEs) if there are any. All clinical 
safety endpoints and SAEs will be summarized by AE code (as provided on the AE CRF) 
regarding the frequency of the event, the number of subjects having the event, severity, and 
relatedness to the study treatment. Clinically important adverse events include:
●
Severe headache
●
Second-degree skin burn
●
Clinical seizure
●
Neurological deterioration (≥ 4-point increase in NIHSS)
The proportion of subjects experiencing each of these events will be provided in the closed report 
by intervention arm with two-sided 95% CIs and unadjusted relative risks. Based on the Phase I 
dose-escalation study, no subjects experienced any of the clinically important adverse events. 
Fisher’s exact tests will be used to assess intervention group differences in the rates of clinically 
important adverse events. 
Tolerability: Analysis Method
Tolerability will primarily be measured through the use of the Visual-Analog scale (VAS), a 10- 
point scale ranging from 0 (No Discomfort) to 10 (Extreme Discomfort). For the primary analysis, 
any subject who requests to be withdrawn from the study due to procedure related issues will be 
imputed as a 10 on the Visual-Analog Scale. Differences in tolerability will be assessed using a 
Kruskal-Wallis test at a 10% type-I error rate. 
9.4.5
BASELINE DESCRIPTIVE STATISTICS

 
31
The characteristic of subjects at baseline will be tabulated ordered by 3 dose groups. p value is 
based on ANOVA if the variable is continuous and is based on Chi-squared test if the variable is 
categorical. 
9.4.6
SUB-GROUP ANALYSES
In pre-specified subgroup analyses, the primary analysis (§9.4.2) will be repeated but include an 
interaction effect between sex/gender or race/ethnicity and intervention arm. Differential effects 
of tDCS by sex/gender or race/ethnicity are not anticipated, and therefore the trial is not powered 
specifically for these subgroup analyses, but these subgroup analyses will allow any unexpected 
large variations to be identified and regardless of outcome will assist with planning a Phase III 
trial which will account for differences if identified here.
Additional analyses are specified in the statistical analysis plan (SAP).
9.4.7
TABULATION OF INDIVIDUAL PARTICIPANT DATA
Individual subject data will not be listed or tabulate by measure and time point. Only summarized 
data by dose group and time points and measures will be presented. 
 
10
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS
10.1
REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS
10.1.1 INFORMED CONSENT PROCESS
10.1.1.1 CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS PROVIDED TO PARTICIPANTS
Consent forms describing in detail the study intervention, study procedures, and risks are given 
to the subject, and written documentation of informed consent is required prior to starting 
intervention/administering study intervention.  
10.1.1.2 CONSENT PROCEDURES AND DOCUMENTATION
Informed consent is a process that is initiated prior to the individual’s agreement to participate in 
the study and continues throughout the individual’s study participation. Consent forms will be 
Institutional Review Board (IRB)-approved, and the subject will be asked to read and review the 
document. The investigator will explain the research study to the subject/LAR and answer any 
questions that may arise. A verbal explanation will be provided in terms suited to the subject’s 
comprehension of the purposes, procedures, and potential risks of the study and their rights as 
research subjects.  Subject/LAR will have the opportunity to carefully review the written consent 
form and ask questions before signing. Subject/LAR should have the opportunity to discuss the 
study with their family or surrogates or think about it prior to agreeing to participate. Subject/LAR 
will sign the informed consent document prior to any procedures being done specifically for the 
study. Subject who is cognitively capable will sign informed consent; If subject is unable to provide 
written informed consent due to cognitive impairment (e.g., NIH Stroke Scale Level of Cognition 
Questions 1-3 combined score >= 3), a Legally Authorized Representative (LAR) will sign 
informed consent instead. During the follow-up visit, subject who was initially cognitively impaired 

 
32
will be reassessed his/her cognition by study team member, if subject regains cognitive capability, 
he/she will be given an opportunity to decide if he/she still wants to remain in the study.  
Subject/LAR must be informed that participation is voluntary and that they may withdraw from the 
study at any time, without prejudice. A copy of the informed consent document will be given to 
the subject/LAR for their records. The informed consent process will be conducted and 
documented in the source document (including the date), and the form signed before the subject 
undergoes any study-specific procedures. The rights and welfare of the subjects will be protected 
by emphasizing to them that the quality of their medical care will not be adversely affected if they 
decline to participate in this study.
In an effort to review informed consent forms in a timely manner, enrolling sites will upload a pdf 
of the signed informed consent form, into the password protected clinical trial management 
system, WebDCUTM. The PDF file will be linked to the subject ID but will be stored on a secure 
server separate from the study’s CRF data. The secure server on which these files are stored is 
not backed up to prevent copies of files containing individually identifiable health information from 
being copied and stored on non-NDMC back up servers. The files on these servers can only be 
accessed by designated NDMC study personnel. NDMC staff will remotely monitor the informed 
consent forms and issues identified will be relayed to the clinical site for corrective and 
preventative action. After remote monitoring is complete, the PDF file containing the informed 
consent form will be permanently deleted from the secure server. If a subject must be re-
consented, the process will repeat itself. 
10.1.2 STUDY DISCONTINUATION AND CLOSURE
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause. Written notification, documenting the reason for study suspension or 
termination, will be provided by the suspending or terminating party to study subjects, investigator, 
funding agency, and regulatory authorities if applicable.  If the study is prematurely terminated or 
suspended, the Principal Investigator (PI) will promptly inform study subjects, the cIRB, and 
sponsor and will provide the reason(s) for the termination or suspension.  Study subjects will be 
contacted, as applicable, and be informed of changes to study visit schedule.
Circumstances that may warrant termination or suspension include, but are not limited to:
●
Determination of unexpected, significant, or unacceptable risk to subjects
●
Demonstration of efficacy that would warrant stopping   
●
Insufficient compliance with protocol requirements
●
Data that are not sufficiently complete and/or evaluable
●
Determination that the primary endpoint has been met
●
Determination of futility
The study may resume once concerns about safety, protocol compliance, and data quality are 
addressed, and satisfy the sponsor, and/or the cIRB.
10.1.3 CONFIDENTIALITY AND PRIVACY 
Subject confidentiality and privacy are strictly held in trust by the participating investigators, their 
staff, and the sponsor(s) and their interventions. The study protocol, documentation, data, and all 
other information generated will be held in strict confidence. No information concerning the study, 
or the data will be released to any unauthorized third party without a prior written approval of the 
sponsor. All research activities will be conducted in as private a setting as possible.

 
33
The IMSM, other authorized representatives of the sponsor, representatives of the NDMC, NCC, 
and cIRB, regulatory agencies may inspect all documents and records required to be maintained 
by the investigator, including but not limited to, medical records (office, clinic, or hospital) and 
pharmacy records for the subjects in this study. The clinical study site will permit access to such 
records.
The study subject’s contact information will be securely stored at each clinical site for internal use 
during the study. At the end of the study, all records will continue to be kept in a secure location 
for the duration specified by the StrokeNet Standard Operating Procedure (SOP) or longer as 
dictated by cIRB and local institutional regulations.
Study subject research data, which is for purposes of statistical analysis and scientific reporting, 
will be transmitted to and stored at the NDMC. Subjects and their research data will be identified 
by a unique study identification number. The study data entry and study management systems 
used by clinical sites and by NDMC research staff will be secured and password protected. At the 
end of the study, all study databases will be de-identified and a Public Use Dataset (PUDS) will 
be archived at the NINDS data repository.
10.1.4 FUTURE USE OF STORED SPECIMENS AND DATA 
Data collected for this study will be analyzed and stored at the NDMC. After the study is 
completed, the de-identified, archived data will be transmitted to and stored in the NINDS Data 
Repository, for use by other researchers including those outside of the study, per StrokeNet SOP 
ADM 04 and in accordance with de-identification procedures of GCP 05. Permission to transmit 
data to these NINDS repositories will be included in the informed consent.
10.1.5 STUDY GOVERNANCE AND ORGANIZATIONAL STRUCTURE
The research team will be governed by an Executive Committee, which will oversee several other 
Committees and Cores. The committees will provide oversight of specific aspects of data 
collection, management, analysis, interpretation, and manuscript preparation, and will convene 
regularly by web-assisted teleconferences, and in person at annual meetings. Apart from the Data 
and Safety Monitoring Board (DSMB) appointed by NINDS, the committees will include the PIs 
from MUSC and BIDMC, the NCC and NDMC, and representatives from the participating sites. 
Four committees will be set up to oversee the trial - Executive Committee; Advisory Committee; 
Publications Committee and Data and Safety Monitoring Committee (NINDS-appointed)
10.1.6 SAFETY OVERSIGHT
The NINDS will create the DSMB for the TRANSPORT2 trial. Their main responsibilities will 
include review of the research protocol and ongoing study activities, including review of data 
quality and completeness; review of fidelity to the study protocol; review of adequacy of subject 
recruitment and retention; review of AEs; making recommendations to the NINDS and the study 
Co-PIs concerning trial continuation, modification, or conclusion. The DSMB will meet regularly in 
person or by teleconference, typically on a semi-annual basis, to monitor the cumulative safety 
data during subject follow-up. The in-person format is recommended for the initial meeting and 
then annually, when possible. In no instance, should more than 12 months elapse between DSMB 
reviews of cumulative safety data after the first subject has enrolled. 
The DSMB will monitor the study according to the guidelines specified in the study protocol and 
the operating procedures established at the initial meeting unless the DSMB determines during 

 
34
the course of the trial that modification of the guidelines is in the best interest of the study and its 
subjects. Except as explicitly authorized by the DSMB, it is critical that study investigators remain 
masked to the interim data because knowledge of emerging trends between intervention arms 
may influence subject enrollment, management, and evaluation, thus compromising the study by 
introducing bias. The DSMB decides in their first meeting if DSMB members will be unmasked. If 
the DSMB decides to remain masked, they should consider assigning one DSMB member, when 
possible a clinician, to be unmasked to intervention assignment. The unmasked DSMB member 
may decide to unmask other DSMB members as indicated, for example, based on concerns over 
imbalances between study groups in rates of SAEs. Transcranial direct current stimulation is 
classified as “non-significant risk” device per FDA regulation, there have been no SAEs reported 
in the literature. However, we still implement the process to systematically monitor safety events 
for the protection of study subjects. 
10.1.7 CLINICAL MONITORING
Clinical site monitoring is conducted to ensure that the rights and well-being of human subjects 
are protected, that the reported trial data are accurate, complete, and verifiable, and that the 
conduct of the trial is in compliance with the currently approved protocol/amendment(s), with 
GCP, with applicable FDA regulations (21 CFR 312), and with the FDA’s “Guidance for Industry 
Oversight of Clinical Investigations — A Risk-Based Approach to Monitoring.” 
●
Monitoring for this study will be performed by the NDMC centrally, on site, and remotely. 
●
Per the study’s monitoring plan, monitoring will include a combination of on-site 
monitoring (to verify data entered into the WebDCU™ database against source 
documents and query inaccuracies between the source documents and WebDCU™ 
database), remote monitoring (source document verification, including verification of 
written consent, may be performed remotely by reviewing source documents that have 
been uploaded into WebDCU™ or via remote access to electronic medical records), and 
central monitoring (using web-based data validation rules, data manager review of 
entered data, statistical analysis, and ongoing review of site metrics). 
●
The NDMC, study co-PIs, and the appropriate site PIs will be provided copies of monitoring 
reports within 30 days of site visits. 
Further details of clinical site monitoring are documented in the study’s Monitoring Plan. The 
Monitoring Plan describes in detail who will conduct the monitoring, at what frequency monitoring 
will be done, at what level of detail monitoring will be performed, and the distribution of monitoring 
reports. 
10.1.8 QUALITY ASSURANCE AND QUALITY CONTROL
Site staffs are required to attend an onsite in-person workshop (training on the study protocol, 
tDCS system operation, TMS procedure, MRI protocol and mCIMT protocol) before initiating the 
study. Subsequently, staffs are required to take annual online certification and recertification in 
primary outcome measure. Quality control (QC) procedures will be implemented beginning with 
the data entry system and data QC checks that will be run on the database will be generated. Any 
missing data or data anomalies will be communicated to the site(s) for clarification/resolution. 
Following written procedures as detailed in the monitoring plan, the monitors will verify that the 
clinical trial is conducted, and data are generated, documented (recorded), and reported in 
compliance with the protocol, International Conference on Harmonization Good Clinical Practice 
(ICH GCP), and applicable regulatory requirements (e.g., Good Laboratory Practices (GLP), 

 
35
Good Manufacturing Practices (GMP)). The investigational site will provide direct access to all 
trial related sites, source data/documents, and reports for the purpose of monitoring and auditing 
by the sponsor, and inspection by local and regulatory authorities.
10.1.9 DATA HANDLING AND RECORD KEEPING 
10.1.9.1 DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES 
Data collection is the responsibility of the clinical trial staff at the site under the supervision of the 
site principal investigator. The investigator is responsible for ensuring the accuracy, 
completeness, legibility, and timeliness of the data reported. All source documents should be 
completed in a neat, legible manner to ensure accurate interpretation of data. Black ink is required 
to ensure clarity of reproduced copies. When making changes or corrections, cross out the 
original entry with a single line, and initial and date the change. DO NOT ERASE, OVERWRITE, 
OR USE CORRECTION FLUID OR TAPE ON THE ORIGINAL. Copies of the electronic CRF 
(eCRF) will be provided for use as source documents and maintained for recording data for each 
subject enrolled in the study. Data reported in the eCRF derived from source documents should 
be consistent with the source documents, or the discrepancies should be explained and captured 
in a progress note and maintained in the subject’s official electronic study record. Clinical data 
will be entered into WebDCUTM. The data system includes password protection and internal 
quality checks, such as automatic range checks, to identify data that appear inconsistent, 
incomplete, or inaccurate. Clinical data will be entered directly from the source documents.
10.1.9.2 STUDY RECORDS RETENTION 
Study documents should be retained for the duration specified by the StrokeNet SOP. These 
documents should be retained for a longer period, however, if required by local regulations. No 
records will be destroyed without the written consent of the sponsor, if applicable. It is the 
responsibility of the sponsor to inform the investigator when these documents no longer need to 
be retained. 
10.1.1.10 PROTOCOL DEVIATIONS 
A protocol deviation is any noncompliance with the clinical trial protocol, International Conference 
on Harmonization Good Clinical Practice (ICH GCP), or Manual of Procedures (MOP) 
requirements. The noncompliance may be either on the part of the subject, the investigator, or 
the study site staff. As a result of deviations, corrective actions are to be developed by the site 
and implemented promptly after review and approval by the NCC. 
These practices are consistent with ICH E6 
•
4.5 Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3 
•
5.1 Quality Assurance and Quality Control, section 5.1.1 
•
5.20 Noncompliance, sections 5.20.1, and 5.20.2. 
It is the responsibility of the site investigator to use continuous vigilance to identify and report 
deviations within 10 working days of identification of the protocol deviation, or within 10 working 
days of the scheduled protocol-required activity.  All deviations must be addressed in study source 
documents and reported t via WebDCU for review by the TRANSPORT2 NCC Project Manager.  
Protocol deviations must be sent to the cIRB within 10 days if deviation requires prompt reporting. 
All other deviations will be reported at the time of continuing review. The site investigator is 
responsible for knowing and adhering to the reviewing cIRB requirements. Further details about 
the handling of protocol deviations are included in the MOP.

 
36
10.1.1.11 PUBLICATION AND DATA SHARING POLICY
TRANSPORT2 study will be conducted in accordance with the following publication and data 
sharing policies and regulations.  National Institutes of Health (NIH) Public Access Policy, which 
ensures that the public has access to the published results of NIH funded research. It requires 
scientists to submit final peer-reviewed journal manuscripts that arise from NIH funds to the digital 
archive PubMed Central upon acceptance for publication. This study will comply with the NIH 
Data Sharing Policy and Policy on the Dissemination of NIH-Funded Clinical Trial Information and 
the Clinical Trials Registration and Results Information Submission rule. As such, this trial will be 
registered at ClinicalTrials.gov, and results information from this trial will be submitted to 
ClinicalTrials.gov. In addition, every attempt will be made to publish results in peer-reviewed 
journals.  Data from this study may be requested from other researchers two years after the 
completion of the primary endpoint by contacting the NINDS (CRliason@ninds.nih.gov ). 
Data generated through this project will be shared according to StrokeNet SOP ADM 04 regarding 
the Network Data Sharing Policy Data Sharing Policy. In summary, the goals of this Data and 
Resource Sharing Policy are to make available final data from StrokeNet clinical trials to the 
research community, while safeguarding the privacy of trial subjects and protecting confidential 
and proprietary data. 
Upon database lock, the NDMC statisticians will generate data files from each data table 
corresponding to each electronic CRF in the database. In compliance with the HIPAA regulations, 
each data table will be stripped of any and all personal identifiers and will undergo a de-
identification process. Furthermore, the NDMC statisticians will create a minimum number of 
derived variables that would be necessary to ensure reproducibility of the primary analysis.
Within 1 year from the acceptance of the primary manuscript for publication OR no later than 2 
years from the database lock the PUDS will be submitted to the NINDS data repository, along 
with the final version of the study protocol, the data dictionary, and a user guide (or a “Readme” 
file) regarding the data files, including an explanation of any derived variables. Once PUDS are 
available, any researcher (study investigator or otherwise) wishing to receive them can contact 
the NINDS (CRLiaison@ninds.nih.gov). All manuscripts, abstracts, and press releases using the 
study data must acknowledge the StrokeNet investigators and the NINDS as the study sponsor 
with the relevant grant numbers.
To expedite and track external data sharing, the TRANSPORT2 team plans to create a website 
that serves as a resource and informational site for potential external investigators and 
collaborators. The website will include the TRANSPORT2 publication policy, the data sharing 
procedures and policies, timelines, and contact information. All published TRANSPORT2 
manuscripts, abstracts, and brief descriptions of ongoing projects will be posted on the website 
maintained by the StrokeNet NCC. 
10.1.12 CONFLICT OF INTEREST POLICY
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical.  Therefore, any actual conflict of interest of persons who have 
a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed and 
managed. Furthermore, persons who have a perceived conflict of interest will be required to have 
such conflicts managed in a way that is appropriate to their participation in the design and conduct 
of this trial.  The study leadership in conjunction with the NINDS has established policies and 

 
37
procedures for all study group members to disclose all conflicts of interest and will create a 
mechanism for the management of all reported dualities of interest.
10.2
ADDITIONAL CONSIDERATIONS
 
Source Documents and Access to Source Data: 
Each participating site will maintain appropriate medical and research records for this trial, in 
compliance with ICH E6 and regulatory and institutional requirements for the protection of 
confidentiality of subjects. As part of participating in an NINDS-sponsored trial, each site will 
permit authorized representatives of NINDS and regulatory agencies to examine (and when 
permitted by applicable law, to copy) clinical records for the purposes of quality assurance 
reviews, audits, and evaluation of the study safety, progress, and data validity. 
Data will be collected using CRFs whenever possible, but source data to be collected will also 
include copies of provider notes, laboratory results, and imaging reports. Subjects’ participation 
in the study will be documented in the electronic medical record unless prohibited by local 
regulations.
In an effort to review informed consent forms in a timely manner, enrolling sites will upload a pdf 
of the signed informed consent form, into the password protected clinical trial management 
system, WebDCUTM.  The PDF file will be linked to the subject ID but will be stored on a secure 
server separate from the study’s CRF data.  The secure server on which these files are stored is 
not backed up to prevent copies of files containing Individually identifiable health information 
from being copied and stored on non-NDMC back up servers.   The files on these servers can 
only be accessed by designated study personnel upon entry of a second password.  NDMC 
staff will remotely monitor the informed consent forms and issues identified will be relayed to the 
clinical site for corrective and preventative action.  After remote monitoring is complete, the PDF 
file containing the informed consent form will be permanently deleted from the secure server.  If 
a subject must be re-consented, the process will repeat itself.
10.3
ABBREVIATIONS
ADL
 Activities of Daily Living
AE
Adverse Event
CFR
Code of Federal Regulations
CST-FA
Corticospinal Tract - fractional anisotropy values
CONSORT
Consolidated Standards of Reporting Trials
CRF
Case Report Form
DCC
Data Coordinating Center
DSMB
Data Safety Monitoring Board

 
38
eCRF
Electronic Case Report Forms
FDA
Food and Drug Administration
FFR
Federal Financial Report
FM-UE
Fugl-Meyer Upper Extremity
GCP
Good Clinical Practice
GLP
Good Laboratory Practices
GMP
Good Manufacturing Practices
HIPAA
Health Insurance Portability and Accountability Act 
IADL
Instrumental Activities of Daily Living
IDE
Investigational Device Exemption
IND
Investigational New Drug Application
IRB
Institutional Review Board
ITT
Intention-To-Treat
mCIMT
modified Constraint-Induced Movement Therapy
MEP
Motor evoked potential
MOP
Manual of Procedures
MSDS
Material Safety Data Sheet
MUSC
Medical University of South Carolina
NDMC
National Data Management Center
NCT
National Clinical Trial
NIH 
National Institutes of Health
NIH IC
NIH Institute or Center
NINDS
National Institute of Neurological Disorders and Stroke
OHRP
Office for Human Research Protections
PI
Principal Investigator
QA
Quality Assurance
QC
Quality Control

 
39
SAE
Serious Adverse Event
SAP
Statistical Analysis Plan
SMC
Safety Monitoring Committee
SOA
Schedule of Activities
SOP
Standard Operating Procedure
tDCS
Transcranial direct current stimulation
TMS
Transcranial magnetic stimulation
TRANSPORT2
TRANScranial direct current stimulation for POst-stroke motor Recovery – a phase II sTudy
UP
Unanticipated Problem
US
United States
wCST-LL
weighted CorticoSpinal Tract – Lesion Load
WMFT
Wolf Motor Function Test

 
40
10.4
PROTOCOL AMENDMENT HISTORY
Version
Date
Description of Change 
Brief Rationale
5
11/9/20
Version and Date Update on Title Page
5
11/9/20
Update number of sites to 15 throughout protocol
3 additional sites were added to 
original 12
5
11/9/20
Clarified schema and schedule of activities 1st 
qualifying baseline days -20 through -7 and 2nd 
qualifying baseline days -6 through 1
Clarification
5
11/9/20
Added that baseline visit 2 can be broken up over 
several days. All baseline activities need to take 
place prior to treatment visit activities start.
Clarification
5
11/9/20
Superscript 4 in schedule of activities denotes an 
activity that only takes place at final treatment 
session.
Clarification
5
11/9/20
30 minute dose of tDCS updated to include (± 6) 
minute window throughout
Although variation unlikely it is 
possible due to interruption and 
technical variation, a deviation of 
less than 20% (24-36 minutes) is 
considered within the tolerated 
window of receiving a full dose
5
11/9/20
120 minute dose of mCIMT updated to include (± 
24) minute window throughout protocol
Although variation unlikely it is 
possible due to interruption and 
technical variation, a deviation of 
less than 20% (96- 144 minutes) is 
considered within the tolerated 
window of receiving a full dose
5
11/9/20
Phone screen was updated to prescreen interview 
throughout protocol
Allows for the use of video for 
prescreening
5
11/9/20
Updated the number of possible training subjects 
from 5 to 12
Staff changes have required more 
training subjects than originally 
thought
5
11/9/20
Removed randomization and generate a code 
corresponding to in the following sentence.
tDCS will be executed by entering WebDCU-
generated code in the computer, which will 
initiate one of the three interventions according to 
the group to which the subjects was randomized
Clarification
5
11/9/20
Added: On the randomization day, a study 
coordinator or a team member will log into 
WebDCUTM to randomize subjects who have been 
consented and found eligible. Briefly, at the 
beginning of each intervention session, the 
coordinator will complete tDCS Treatment 
Activation Code Request to obtain a new tDCS 
treatment activation code daily. Each day, the 
coordinator will need to enter the new code into 
the tDCS machine which will translate the code to 
the appropriate stimulation voltage using a pre-
loaded script
Clarification
5
11/9/20
Removed: In addition, real-time confirmation of 
the correct randomization code will occur as 
Clarification

 
41
follows. First, at the time of randomization, the 
study coordinator or any designed person will 
receive a randomization code that will be entered 
into the controller. The controller will return a 
confirmation code to be entered into WebDCU. 
This will ensure that the randomization code was 
entered correctly, and the subject is receiving the 
correct dose before the initiation of intervention. 
Each site will only enroll one subject at a time.
5
11/9/20
Added: overall treatment imbalance and
That is, at the time of randomization, an overall 
treatment imbalance and imbalance in each of the 
covariates is assessed.
Clarification
5
11/9/20
Added: In an effort to review informed consent 
forms in a timely manner, enrolling sites will 
upload a pdf of the signed informed consent form, 
into the password protected clinical trial 
management system, WebDCUTM. The PDF file will 
be linked to the subject ID but will be stored on a 
secure server separate from the study’s CRF data. 
The secure server on which these files are stored 
is not backed up to prevent copies of files 
containing 
individually 
identifiable 
health 
information from being copied and stored on non-
NDMC back up servers. The files on these servers 
can only be accessed by designated NDMC study 
personnel. NDMC staff will remotely monitor the 
informed consent forms and issues identified will 
be relayed to the clinical site for corrective and 
preventative action. After remote monitoring is 
complete, the PDF file containing the informed 
consent form will be permanently deleted from 
the secure server. If a subject must be re-
consented, the process will repeat itself.
5
11/9/20
Removed: The informed consent will be obtained 
by either the site PI or other members of the study 
team who are designed to perform this task on the 
Delegation of Authority Log. Subject/LAR will be 
asked to explain back the study to confirm his/her 
understanding of the study and its procedures. In 
an effort to review informed consent forms in a 
timely manner, enrolling sites will upload a pdf of 
the signed informed consent form, into the 
password protected clinical trial management 
system - WebDCUTM.  
5
11/9/20
Removed: DCU Added: NDMC
5
11/9/20
Removed 
Data 
Coordination 
Unit 
from 
abbreviations

 
42

 
43
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