Effects of tDCS on Post-stroke Fatigue and Inflammation
Phase: NA
Conditions: Stroke, Fatigue, Chronic Stroke, Stroke Sequelae
Sponsor: Medical University of South Carolina

Protocol version 2 
Date: 28 Mar 2022 
 
TITLE: Effects of tDCS on Post-stroke Fatigue and Inflammation 
 
IRB Protocol Number: 118687 
 
PI: Dr. John H. Kindred 
Research Associate 
Division of Physical Therapy 
Department of Rehabilitation Sciences 
College of Health Professions 
Medical University of South Carolina 
 
 

Protocol version 2 
Date: 28 Mar 2022 
 
BACKGROUND / SIGNIFICANCE 
Stroke is the most common cause of long-term disability in the United States. Fatigue is a common sequela of 
stroke and many other neurological conditions. There is no universally accepted definition of fatigue or post-
stroke fatigue. However, it is generally accepted that fatigue can be dichotomized into fatigability, an objectively 
measured decline in physical or cognitive performance, and the perception of fatigue (Kluger et al. 2014, Enoka 
et al. 2021). The perception of fatigue is defined as a feeling of weariness/tiredness or mismatch between an 
individual’s perceived and actual effort that negatively affects their ability to perform physical, cognitive, and 
social activities that is not alleviated with rest. A model of post-stroke fatigue (PSF) is presented Figure 1 
(adapted from Enoka et al. 2021). Even though the negative impacts of fatigue on quality of life and 
social/physical activity participation post-stroke are well known, there are currently no evidence-based 
treatments for post-stroke fatigue (PSF, Hinkle et al. 
2017). The development of effective treatments is 
lacking in part due to the complex and poorly 
understood pathophysiology of PSF. The recent NIH-
sponsored workshop “Beyond the Symptom: The 
Biology of Fatigue” highlighted this fact and called for 
more extensive research into the mechanisms and 
treatments of fatigue. While specific mechanisms of 
individual patients are unknown, altered immune 
function, i.e., inflammation (Wen et al. 2018), changes 
in tissue metabolism (Roelcke et al. 1997), disruptions 
in interoception (Gonzalez Campo et al. 2020 ), and 
altered neural network function (Høgestøl et al. 2019) 
have been implicated across neurological conditions. 
 
Specific to stroke, a meta-analysis reported the 
prevalence of PSF is 50% (Cumming et al. 2016). A 
recent survey of stroke survivors listed PSF treatments 
as the second most prioritized area of need behind 
walking/mobility 
(Rudberg 
et 
al. 
2020). 
When 
dichotomizing the survey’s respondents by age, 
younger stroke survivors reported PSF treatment as 
their number one priority area. The latest scientific 
statement from the American Heart Association 
spotlights the inflammatory and altered cortical excitability components of PSF (Hinkle et al. 2017). Transcranial 
direct current stimulation (tDCS) has been reported to affect inflammation and cortical excitability. A recent small 
tDCS study reported beneficial effects on PSF but did not investigate conclusive mechanisms of action or 
response (De Doncker et al. 2021). Our contribution to this line of inquiry will be to further test the clinical effects 
of tDCS on PSF and measure markers of inflammation within the central nervous system and peripheral 
circulation. We expect to identify a link between inflammation and PSF which will significantly contribute to a 
better understanding of the pathophysiology of fatigue and establish neuromodulatory therapies, such as tDCS, 
as effective treatments for PSF. 
 
INNOVATION 
The effect of tDCS on non-neuronal cell populations has received little attention to date. Basic and pre-clinical 
research shows small electrical currents, such as the ones used by tDCS, can induce cell differentiation and 
migration (reviewed by Pelletier and Cicchetti 2015) and alter immune cell function leading to reduced 
inflammatory markers (Rabenstein et al. 2019, Zhang et al. 2021). Studies in humans have shown reduced 
circulating inflammatory cytokines after five days of tDCS (Osteoarthritis, Suchting et al. 2020). Stroke is known 
to induce neuroinflammatory/immune responses and certain inflammatory/immune markers remain elevated one 
year post incident (Beamer et al. 1998). Inflammation has also been shown to interfere with rehabilitation and 
could possibly contribute to post-stroke depression (reviewed by Fang et al. 2019). There are reports of anodal-
tDCS (a-tDCS) leading to reduced fatigue severity post-stroke and in MS. However, these reports have relatively 
Figure 1: A model defining post-stroke fatigue, adapted from a schema 
of fatigue in multiple sclerosis by Enoka et al. (2021). An individuals 
current State fatigue is measured on a 0-10 Visual Analogue Scale 
(f-VAS) representing their perception of fatigue at the moment of 
assessment. The most common method to assess and diagnos clinical 
fatigue is the Fatigue Severity Scale (FSS), which is thought to measure 
the effect of fatigue on an individual’s perceived ability to perform tasks. 

Protocol version 2 
Date: 28 Mar 2022 
 
small samples and did not identify/investigate possible mechanisms of effects/response. This pilot project is 
innovative because it uses a multimodal approach to investigate the effects of tDCS on measures of cortical 
excitability and effects on inflammation, which likely play roles in the development and severity of PSF. Future 
investigations derived from this line of inquiry have the opportunity to greatly enhance our understanding of the 
pathophysiological mechanisms of PSF, identify effective neuromodulatory therapies, and pinpoint a phenotypic 
response criterion for future clinical trials, i.e. individuals with PSF due to inflammation. An additional innovation 
is using MR spectroscopy to measure markers of nervous system 
inflammation. MR spectroscopy is a well-established tool. However, its use in 
assessing metabolite changes with neuromodulatory therapies is not 
common due to most tDCS research focusing on cortical excitability and/or 
neural network function. Using MR spectroscopy will allow us to quantify in-
vivo changes in metabolites and inflammatory markers in individuals with PSF 
in response to tDCS.  
 
APPROACH 
Recruitment and Consent 
Prospective participants will be recruited from our bioinformatics enabled 
post-stroke recruitment database which is maintained by the NIH Center of 
Biomedical Research Excellence in Stroke Recovery at the Medical 
University of South Carolina. This database, RESTORE, contains over 1200 
individuals post-stroke who have consented to be contacted for research 
purposes. Veterans from our VA-approved recruitment data have agreed to 
have their contact information placed in RESTORE and their veteran-status 
is highlighted. Prospective participants more than six months post-stroke will 
be identified by their response to question 4 of the Personal Health 
Questionnaire Depression Scale (PHQ-8) stored in their database record. A 
response of 2 or 3 indicates “Feeling tired or having little energy” on at least 
half the days over the last 2 weeks. Veterans who participated in the recently 
completed VA RR&D sponsored study “Fatigue and Mobilility in Stroke: a 
Biomechanical and Neurophysiological Investigation” (IK1 RX0003126, CDA-
1, PI: Kindred JH) will be preferentially contacted and recruited to participate 
in this project. Initial contact will be made with prospective participants via 
telephone. The project basics will be explained and interested individuals will 
be invited to our research laboratory for final eligibility screening and consent. 
Full inclusion and exclusion criteria are listed in the “Protection for Human 
Subjects” section. Once consented, participants will complete a set of 
questionnaires to assess levels of state and trait fatigue, depression, anxiety, 
and pain. State fatigue is defined as a participant’s instantaneous perception 
of fatigue and is measured on a 0-10 visual analogue scale (f-VAS) with 0 
signifying no feelings of fatigue and 10 representing the most fatigued an 
individuals could imagine. Trait fatigue refers to an individual’s perception of 
fatigability, i.e. how fatigue affects their ability to perform activities of daily 
living and participate in social and physical activities. The most common 
instrument used to measure trait fatigue is the Fatigue Severity Scale (FSS, 
Krupp et al. 1997). The FSS is a nine-question, scored on a 1-7 likert scale, 
self-reported questionnaire assessing the impact of fatigue on a variety of 
activites over the last seven days. An average score of 4 on the FSS signifies 
clinically relevant fatigue (total FSS score ≥ 36). Additional clinical tests and 
questionnaires will be performed to measure physical disability (gait speed), 
balance, and quality of life. Women of childbearing potential will perform a 
urinalysis to determine pregnancy status. Pregnant women will be excluded 
due to unknown effects of tDCS on fetal development and mother’s milk. The 
Figure 2: Research protocol timeline. 
Three additional followup phone-calls to 
assess fatigue will be performed 1,2, and 
4 weeks post the participants’ last tDCS 
treatment. 

Protocol version 2 
Date: 28 Mar 2022 
 
full list of questionnaires and clinical measures is presented in Table 1. The primary outcome for this study is 
trait fatigue measured by the FSS. 
 
Study Design and a-tDCS Treatment 
This pilot proposal is a randomized longitudinal single-blind sham-controlled intervention. Individuals with PSF 
will be randomly assigned to the sham or a-tDCS treatment group. Before and after five consecutive days of a-
tDCS applied bilaterally over the left and right lower extremity motor cortex, PSF and nervous system and 
peripheral inflammation will be measured, similar to De Doncker et al. (2021). The tDCS treatment will consist 
of twenty minutes of 4 mA a-tDCS delivered via two carbon rubber electrodes placed inside sponge pads (1x1 
tDCS, Soterix, USA). The current will be ramped up 4 mA over 30 seconds. Each electrode has a surface area 
of 70 cm2, resulting in a current density of 0.06 mA/cm2 and a charge density of 1.1 C/cm2, which are within 
current safety guidelines (Bikson et al. 2016). The anode electrode will be centered on the interhemispheric 
fissure and the central sulcus. This area was chosen due to its previous use in fatigue studies using 
neuromodulation (multiple sclerosis, Ferrucci et al. 2014; fibromyalgia, Altas et al. 2019; Stroke, De Doncker et 
al. 2021). The motor cortex is being used more often in neuromodulation studies due to its structural and 
functional connectivity to cortical and subcortical networks/nodes, e.g. basal ganglia, cingulate cortex. The 
cathodal electrode will be placed on the nonparetic shoulder. Modeling of cephalic and extracephalic tDCS 
montages indicates that extracephalic placement of the cathode leads to deeper current flow in the 
somatosensory cortex (Noetscher et al. 2014). The sham tDCS procedure will be performed in the same manner 
as active a-tDCS, however, the current will be ramped up and down over 30 seconds (Fridricksson et al. 2018). 
Figure 2 displays the protocol timeline. Days 2-6 will be consecutive, no more than 36 hours will be allowed 
between treatment visits. If more than 36 hours elapses the participant will be withdrawn from the study. The 
mearsurement of state fatigue, via f-VAS, will be performed before and after each tDCS treatment visit. Follow-
up assessments of state and trait fatigue will be performed via phone at one (Follow-up 1), two (Follow-up 2), 
and four weeks post-treatment (Follow-up 3). The primary study outcome will be the comparison of the FSS 
scores obtain at baseline (Visit 1) and one week post-tDCS (Follow-up 1).  
 
Neuroimaging 
Anatomical and spectroscopic images (T1, T2, 1H-MRS) will be acquired using the Center for Biomedical Imaging 
at MUSC’s standard imaging protocols. The T1 and T2 images will be used for the computation of stroke lesion 
locations and volumes. The T1 images will also be used to guide the corticomotor response (CMR) testing listed 
below. We will use Single-voxel MEshcher-GArwood Point RESolved Spectroscopy (MEGA-PRESS) 1H-MRS to 
assess central nervous system inflammation. Voxels will be placed in the basal ganglia and insular cortex in both 
hemispheres. Basal ganglia voxels will be placed with the anterior border abutting the anterior portion of the 
lentiform nucleus and as medial as possible to avoid the ventricles (Pretzsch et al. 2019). The basal ganglia 
have been previously implicated in fatigue post-stroke (Tang et al. 2010) and in multiple sclerosis (Roelcke et al. 
1997, Tellez et al. 2008). The insular cortex is a prominent brain region involved in interoception. Interoception 
is the sensing, integrating, interpreting and regulating self-signals and has been theorized to contribute to fatigue 
(Stephan et al. 2016, Enoka et al. 2021) and implicated in fatigue in multiple sclerosis (Gonzalez Campo et al. 
2020). Levels of Myo-inositol (MI), total creatine (tCr), and choline (CHO) and their ratios to N-acetylaspartate 
(NAA) will be quantified as markers of inflammation (reviewed by Chang et al. 2015). Spectroscopy data will be 
analyzed using the freely available LCModel software as in our previous works (Moss et al. 2018, 2019). Pre 
and post tDCS intervention spectroscopy values will be compared to determine changes in inflammatory markers 
associated with the intervention. The mearsurement of state fatigue will be performed before and after each 
imaging session. 
 
Blood collection and analysis 
Before and after five days of tDCS treatment, participants will provide a blood sample for the measurement of 
pro-inflammatory cytokines. These cytokines include interleukin- (IL) 1, 6, and 10, tumor necrosis factor (TNF) 
α, and c-reactive protein. Whole blood will be collected in EDTA-treated tubes and separated into plasma, 
immune cells (buffy coat), and red blood cells. Separated samples will be frozen and stored until the end of the 
study. Once all samples are collected they will undergo Simple PlexTM microfluidic ELLA platform immunoassay 
(ProteinSimple, USA) analysis for listed cytokines (Leligdowicz et al. 2017, Burke et al. 2021). State fatigue will 

Protocol version 2 
Date: 28 Mar 2022 
 
be measured just prior to blood collection. Blood will be collected at the South Carolina Clinical and Translational 
Research Institute (SCTR), located on the MUSC/VA shared campus, by skilled medical staff.  
 
Corticomotor Response (CMR) 
The CMR of the paretic and non-paretic tibialis anterior will be measured immediately before and after the tDCS 
intervention using neuronavigated single- and paired-pulse TMS (Brainsight, Rogue Research, CAN) to identify 
is changes in the CMR are associated with changes in PSF fatigue severity. Preliminary, unpublished, data from 
our lab indentifed a link between asymmetries in intracortical facilitation (ICF) between the lesioned and non-
lesioned hemishperes and PSF severity. Single-pulse TMS will be used to measure resting motor threshold 
(rMT) and motor evoked potential amplitude (MEPamp) and latency (MEPlat). Paired-pulse TMS will be used to 
assess glutamatergic activity signified by intracortical facilitation (ICF). Prior to the participants' first interventional 
visit, a 7x5 grid will be placed over the participants' acquired 3D T1 image. The middle grid point will be centered 
on the intersection between the interhemispheric fissure and central sulcus. Surface electromyography (sEMG) 
electrodes will be placed over the left and right TA. The CMR assessment will begin with the identification of the 
stimulator powers required to elicit a consistent response in the paretic and non-paretic TA. Once these power 
levels have been determined a single TMS pulse at each of the identified power outputs will be delivered over 
the respective grid points. The gridpoint resulting in the largest MEPamp for each muscle will be determined to be 
the “hotspot” (Kindred et al. 2021). Resting MT will be assessed using simple adaptive parameter estimation by 
sequential testing (PEST, Borckhardt et al. 2006) measured at the respective hotspots. Next, 20 single TMS 
pulses will be delivered at 120% rMT for measurement of MEPamp and MEPlat. Paired-pulse TMS will be applied 
to measure ICF with the conditioning pulse delivered at 80% rMT followed by the conditioned pulse at 120% 
rMT, using an interstimulus interval of 10 ms,. The recorded sEMG signals will be analyzed using the standard 
laboratory operating procedures (Kindred et al. 2019, 2020). Neurophysiological variables before and after the 
tDCS interventional will be compared to determine if changes in PSF severity are associated with changes in 
the CMR. State fatigue will be measured pre and post the CMR assessment.  
 
Table 1: Clinical Outcome Measures 
Domain 
Instrument 
Fatigue (State) 
Visual Analogue Scale 
Fatigue (Trait) 
* Fatigue Severity Scale (FSS) (Krupp et al. 1989) 
Modified Fatigue Impact Scale (mFIS) (Fisk et al. 1994) 
Fatigue Assessment Scale (FAS) (Michielsen et al. 2003) 
Anxiety 
Hospital Anxiety and Depression Scale (Zigmond and Snaith 1983) 
Depression 
Patient Health Questionnaire 9 (PHQ-9) (Spitzer and Williams 1999) 
Pain 
Defense and Veterans Pain Rating Scale (DVPRS) (Polomano et al. 2016) 
Physical Function / Mobility 
10 m walk over GAITRite (Kindred et al. 2019) 
Community Participation / 
Quality of Life 
Standard Form 36 (Anderson et al. 1996) 
 
* Primary outcome measure for Aim 1 
 
Statistical Analysis 
Aim 1 Hypothesis: Five days of a-tDCS applied to the lower extremity motor cortex will result in a reduction of 
PSF severity in individuals with chronic stroke. A two-factor, between-subjects factor of GROUP (active a-tDCS, 
sham) and within-subjects factor of TIMEPOINT (pre, post), mixed model ANOVA will be used to test this 
hypothesis. The primary outcome variable for this analysis is the FSS scores. We will also calculate measures 
of effect size to power future studies.  
 
Aim 2 Hypothesis: Five days of a-tDCS applied to the lower extremity motor cortex will result in a reduction of 
inflammatory markers within the central nervous system and the peripheral blood. Pre- and post-intervention 
markers of inflammation will be compared using a mixed model, two-factor ((between-subjects factor of GROUP 
(active a-tDCS, sham) and within-subjects factor of TIMEPOINT (pre, post)), ANOVA. Each outcome measure 
(MI, tCR, IL-1, TNF-α, etc) will be tested independently.  
 

Protocol version 2 
Date: 28 Mar 2022 
 
Additional Analyses: Examine the possible relationship between PSF severity and inflammatory markers. This 
relationship may provide mechanistic insight into the effect of tDCS on PSF and allow us to possibly predict 
future responders/non-responders to a-tDCS treatments of PSF. Pearson’s correlations will be calculated 
between baseline measures of inflammation and FSS scores to determine a possible role of current state 
inflammation on PSF severity. Correlations between the change in FSS scores and inflammation, pre- and post-
a-tDCS, will be calculated to provide preliminary evidence of a possible mechanism of reduced inflammation and 
improved PSF.  
 
Potential Problems / Solutions 
Some groups have reported a 50% response rate to tDCS. Due to our small sample, non-responders may reduce 
our statistical power. A post-hoc response analysis, defined as a change greater than the minimally clinically 
important difference of 0.45 (Nordin et al. 2016), will be performed to power future studies. Placing the 1H-MRS 
voxel within the basal ganglia is a logical starting place based on the published literature. However, it is possible 
that inflammatory markers outside this region are as influential or more so than basal ganglia measures. Future 
work may be required to determine which brain regions are best to assess with 1H-MRS. Another limitation is 
that only a-tDCS is being tested. Cathodal tDCS (c-tDCS) has been reported to have similar long-term effects 
on gene expression and protein synthesis. The benefits of tDCS on fatigue, to date, have mostly investigated a-
tDCS although future investigations need to determine if c-tDCS may be a viable treatment option. Another area 
that will need to be addressed in future studies is if our post-intervention measurements of metabolite changes 
reflect the last episode of treatment or if they are indicative of long-term changes in response to tDCS. Future 
studies will also need to assess the optimal intervention length and follow-up periods. 
 
Biostatistical Justification 
This pilot work is based on a similar study investigating a-tDCS’ effects on post-stroke fatigue (De Doncker et 
al. 2021). The FSS is the primary measure of fatigue severity and the minimally clinically important difference 
(MCID) was reported to be 0.45 (Nordin et al. 2016), with changes greater than this resulting in reported 
improvements in QOL. To detect this level of change with 80% power and an alpha = 0.05 between two groups 
using a within-between-subjects interaction ANOVA a minimum sample of 8 individuals in each group is 
required. We will enroll 24 participants (12 a-tDCS, 12 sham) to account for any drop-out, loss to follow-up, or 
complications during data collection. We have projected to perform recruitment and data collection activities 
over nine months. 
 
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Wen, H., Weymann, K. B., Wood, L., & Wang, Q. M. (2018). Inflammatory Signaling in Post-Stroke Fatigue and 
Depression. Eur Neurol, 80(3-4), 138-148.  
Zhang, S., Cheng, S., Zhang, Z., Wang, C., Wang, A., & Zhu, W. (2021). Related risk factors associated with 
post-stroke fatigue: a systematic review and meta-analysis. Neurol Sci, 42(4), 1463-1471.  
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatr Scand, 
67(6), 361-370. 
 
 
 

Protocol version 2 
Date: 28 Mar 2022 
 
INCLUSION OF INDIVIDUALS ACROSS THE LIFESPAN 
 
Prospective participants will be aged 35-80 years. This age range excludes young adults which are generally 
accepted to have a higher level of innate neuroplasticity. This selection range incorporate the age-phenome 
knowledge base age groups developed by Geifman, Cohen, and Rubin (2013). Aggregate data on age, race, 
and gender of each participant will be provided to the NICHD at fixed intervals. Although we do not anticipate 
differential treatment effects based on age, our analyses will explore clinically important differences due to age.  
 
Exclusion of Children 
Stroke is a condition most commonly associated with advanced age and the prevalence of stroke in children is 
very low. Importantly, these cases may differ in their etiology from the subjects we propose to study. As such, 
we will not enroll any children in this study. 
 
Maximum Age 
Aged nervous systems are known to be less-plastic and may not respond to neuromodulatory therapies as well 
as younger nervous systems. To reduce the possible effects of aging on the effectiveness of this pilot 
intervention we will limit enrollment to participants between 35 and 80 years of age (adult to aged groups 
defined by Geifman, Cohen, and Rubin (2013)).  
 
 
References 
Geifman, N., Cohen, R., & Rubin, E. (2013). Redefining meaningful age groups in the context of disease. Age 
(Dordr), 35(6), 2357-2366. doi:10.1007/s11357-013-9510-6 
 
 
 

Protocol version 2 
Date: 28 Mar 2022 
 
INCLUSION OF WOMEN AND MINORITIES 
 
All eligible subjects of both sexes and all minorities will be encouraged to participate in the proposed non-
invasive brain stimulation treatment for post-stroke fatigue. Study participants will be recruited from the South 
Carolina Lowcountry tri-county area, which comprises Berkeley, Charleston, and Dorchester counties. The 
2020 US Census1 reported a population of approximately 800k individuals in the tri-county area with women 
making up 51.3% of the population. The racial and ethnic composition of the counties was White (69.2%), 
Black (25.7%), Hispanic (5.9%), Two or More Races (2.3%), Asian (2.1% ), American Indian & Alaska Native 
(< 1%), and Native Hawaiian & Other Pacific Islander (< 1%). Women are reported to be approximately 53.5% 
of new and recurrent strokes2. As this number is similar to the population we will use the population statistic for 
our recruitment, especially as our recruitment is of only 24 individuals.  
 
We will monitor the diversity of the sample on a monthly basis and if recruitment target(s) are not adequate, we 
will take appropriate measures to improve diversity in recruitment.  
 
Specific Plans for Maximizing Inclusion of Women and Minorities 
Inclusion of Women: Inclusion or exclusion of participants will not differ based on sex and we aim to recruit 
similar numbers of males and females. 
 
Inclusion of Minorities: Inclusion or exclusion of participants will not differ based on race/ethnicity. Based on the 
available literature on barriers to minority participation in clinical studies, we also will take the following 
additional steps to ensure representative enrollment of minority groups: 
 
1. Emphasize that the goal is to recruit patients regardless of race or ethnicity. To assuage common 
suspicions that a specific race or ethnicity is being targeted,3-5 we will make clear to potential 
participants and their parents/guardians that patients of all races and ethnicities are being recruited. 
 
2. Clearly explain that the purpose of informed consent is to protect, not relinquish, participants’ rights. 
In several studies on the barriers to minority participation in clinical studies, participants have 
reported that they perceive the process of written, informed consent as relinquishing, rather than 
protecting, their rights.6-8 We will attempt to mitigate this source of distrust by explaining the intent 
of the informed consent process and emphasize the rights that the consent document enshrines. 
 
3. Use straightforward and easy-to-understand language in consent forms. Participants’ concerns 
about providing informed consent also relate to “not understanding technical legal and medical 
terminology”6 and “difficulty in fully understanding the complexities of research”6. We will attempt to 
mitigate this barrier to minority participation by taking extra care to write consent forms in easy-to-
understand, straightforward language.  
 
References 
1. US Census Bureau, www.census.gov, Accessed 28 Feb 2022 
 
2. Virani, S. S., Alonso, A., Aparicio, …, and Tsao, C. W. (2021). Heart Disease and Stroke Statistics - 2021 
Update: A Report From the American Heart Association. Circulation, 143(8), e254-e743. 
 
 
 

Protocol version 2 
Date: 28 Mar 2022 
 
RECRUITMENT AND RETENTION PLAN 
 
Recruitment of Participants 
Prospective participants will be recruited from multiple sources including RESTORE, ClinicalTrials.gov, and 
advertisements placed throughout the community (e.g. flyers posted in community centers and electronic flyers 
posted on social media sites). RESTORE is a bioinformatics-enabled database that contains over 1100 stroke 
survivors that have consented to be contacted for participation in research studies. This database is 
maintained by the NIH Center Of Biomedical Research Excellence (COBRE) for Stroke Recovery at the 
Medical University of South Carolina.  
 
Research staff will search RESTORE for potential research participants and make initial contact via phone. 
Research staff will also respond to inquiries received from the community via phone. The research activities 
will be explained to prospective participants by the research staff. If the prospective participants express 
interest in partaking in the study they will be invited to the laboratory to confirm eligibility and provide written 
consent.  
 
Retention 
Enrolled participants will receive $100 USD as remuneration for their participation in the proposed study. 
Remuneration will be delivered by pre-paid debit-type card that will be loaded at pre-determined milestones 
(after initial MRI, after each (5) treatment visit, after follow-up phone calls. 
 
 

Protocol version 2 
Date: 28 Mar 2022 
 
RISKS TO HUMAN PARTICIPANTS 
 
Dr. Kindred (PI) will be performing the proposed intervention at the College of Health Professions Research 
building on the Medical University of South Carolina campus. The research building is staffed with licensed 
clinical professions, physical and occupational therapists, and all research staff are trained in emergency 
procedures. Research staff also have basic life support (BLS) training from the American Red Cross, or 
equivalent. All investigators and research staff have completed computer-based CITI Human Subjects 
Research ethical and safety training, as required by the Medical University of South Carolina and the 
associated IRB. All research activity, informed consents, and continuing reviews will be reviewed by MUSC’s 
IRB, before the research is started and continuing reviews will occur annually. The research staff will ensure 
that all information needed for the continuing reviews are available to the IRB in accordance with the IRB’s 
requirements. 
 
Human Subjects Involvement and Characteristics and Design 
A total of 24 adults, between 35 and 80 years of age, with unilateral strokes more than 6 months post event will 
be recruited and enrolled over a one year period. The proposed randomized, single-blind, sham-controlled, trial 
will investigate the effects of anodal transcranial direct current stimulation (tDCS) on post-stroke fatigue and 
markers of inflammation. Participants will be randomly assigned to the active a-tDCS or sham group. Clinical 
and inflammatory markers will be assessed pre and post five consecutive days of a-tDCS applied to the motor 
cortex. 
 
The inclusion/exclusion criteria for the study are as follows: 
 
Inclusion Criteria: 
1. 
Men and Women, any race or ethnicity, ages 35-80 years 
2. 
6+ months post-stroke 
3. 
Average Fatigue Severity Score (FSS) >= 4 (indicates clinically significant fatigue) 
4. 
Self-reports persistent fatigue for at least the past 6 months 
5. 
Able to walk 10m unassisted 
 
Exclusion Criteria: 
1. 
Absolute contraindications to MRI, TMS, tDCS 
2. 
Inability to follow 3-step instructions 
3. 
Multiple strokes on opposite hemispheres 
4. 
Diagnosis of comorbid neurological conditions (e.g. multiple sclerosis, Parkinson’s disease, and 
dementia) 
5. 
Severe hypertension (resting SBP > 200 mmHg or DBP > 120) 
6. 
Cerebellar or brainstem strokes 
7. 
Hospital Anxiety and Depression Scale (HADS) score > 7, depression or anxiety 
8. 
Pregnancy 
 
 
Study Procedures, Materials, and Potential Risks 
Source of Materials 
Data will be in the form of structured interviews, self-reported rating scales and questionnaires, surface 
electromyography recorded transcranial magnetic (TMS) evoked potentials, and MRIs. No identifiable 
information is expected to be collected outside of the consent process. Once consented individuals will be 
assigned a non-identifiable research ID number that will be used to mark/track collected data. 
 
Research Procedures and Potential Risks 
Although unlikely, it is possible that some participants may experience distress when asked questions 
pertaining to their feelings of fatigue, depression, anxiety, or pain. Some participants may also experience 

Protocol version 2 
Date: 28 Mar 2022 
 
distress during MRI sessions or TMS assessments. However, previous and ongoing research by our research 
group indicates that these risks are minimal.  
 
Specific risks, which are all low/minimal, associated with the research procedures are as follows: 
 
tDCS: Commonly reported side effects are as follows: local skin irritation with light itching/tingling/ burning, mild 
headache, or nausea. There have also been rare cases of mild burns at the procedure site.  
 
TMS: There is a very low risk of a seizure after TMS. The risk of seizure induction by this protocol has been 
thoroughly assessed and the TMS parameters have been chosen to be well within published safety guidelines 
for the conduct of TMS studies in human subjects.  
 
Blood Draw / Venipuncture: Risks associated with blood draws include momentary discomfort and/or bruising. 
Infection, excess bleeding, clotting, or fainting is possible, although unlikely.  
 
MRI: There have been no ill effects reported from exposure to the magnetism or radio waves used in this test. 
A known risk is that the magnet could attract certain kinds of metal. Therefore, we will perform a detailed 
screening, provided by the Center for Biomedical Imaging (CBI), before any participants are imaged.  
 
Walking Tests: Some of the activities performed during this study will be performed while the participants are 
walking or standing. During these activities, participants may lose their balance or become unsteady.  
 
Pregnancy: We do not know if the study intervention will affect mother’s milk or an unborn fetus. Therefore, 
breast-feeding and pregnant women are not allowed to take part in the study. If a potential participant is 
pregnant or become pregnant they will be removed from the study as there may be risks to the embryo or fetus 
that are unknown at this time.  
 
Randomization: The treatment you receive may prove to be less effective or to have more side effects than the 
other study treatment(s) or other available treatments. 
 
Loss of Confidentiality: There is a risk of loss of confidentiality or personal health information. We will collect 
the participants age, date of stroke, sex, and racial/ethnicity to classify our sample and for use as influencing 
factors on intervention effectiveness. 
 
Unknown Risks: The experimental treatments may have unknown side effects. The researchers will let you 
know if they learn anything during the course of the study that might make you change your mind about 
participating in the study. 
 
Adequacy of Protection Against Risks 
Informed Consent Procedures 
All personnel are trained in the responsible conduct of human research. Informed consent will be collected by 
the on-site study coordinators (Mr. Brian Cence, Mrs. Alyssa Chesnutt) or the PI (Dr. John Kindred). All study 
personnel will be familiar with the treatment protocol. This will ensure each person collecting informed consent 
is familiar with all aspects of the study. Individuals obtaining informed consent will role-play the consent 
procedures with the PI until they demonstrate competency. 
 
Written/signed informed consent will be collected in a private and interruption-free room inside the study offices 
inside the College of Health Professions Research building. Potential candidates will not be required to decide 
to participate at this initial visit, though that possibility will be available. If potential participants wish to discuss 
participation with their families and/or significant others, or other healthcare providers they will be encouraged 
to do so. The informed consent document will outline, a) the sponsorship of the study; b) the nature, purpose, 
and procedures of the research study; c) the voluntary nature of participation (i.e., participation is not required, 
participation can be discontinued at any time); d) the duration of the study; e) potential risk and discomforts, as 

Protocol version 2 
Date: 28 Mar 2022 
 
well as benefits of participating; f) that all information will be kept confidential subject to the provisions of state 
and federal law; and g) compensation. Participants will be informed that they can discontinue their participation 
in the study at any time and that this decision will not influence future healthcare or research participation at 
MUSC. Private information collected as part of the informed consent process is the participants full name and 
signature. 
 
Protections Against Risk 
Specific mitigation plans for each of the known risks are provided below: 
 
tDCS: To reduce the chance for an adverse event (AE)/reaction electrode preparation and contact will be 
constantly checked. Research staff will also engage with the participants during intervention application and 
monitor the participants’ physiological and emotional state. Our research group has performed over 100 tDCS 
sessions with no adverse or serious adverse events. 
 
TMS: To minimize risk, we will be using single- and paired-pulse TMS, as the majority of adverse events in the 
literature have occurred after repetitive TMS and we will follow published safety guidelines. Individuals with a 
history of seizures, you will not be allowed to participate in this portion of the study. Participants will undergo 
IRB approved screening prior to enrollment. 
 
Blood Draw / Venipuncture: To reduce venipuncture risks, all procedures will be performed by licensed nursing 
staff at the South Carolina Clinical and Translational Research Institute on the medical campus.  
 
MRI: We will perform a detailed screening, provided by the Center for Biomedical Imaging (CBI), before any 
participants are imaged. If there is any question about potentially hazardous metal within a participant’s body, 
they will be excluded from participation in this research study. We will also keep the examining room locked so 
that no one carrying metal objects can enter while participants are in the scanner.  
 
Walking Tests: To ensure that participants do not fall they will wear a safety harness that is attached to the 
ceiling. The harness will prevent participants from hitting the ground in the event they lose their balance or 
become unsteady. 
 
Pregnancy: All prospective participants of childbearing potential will be required to undergo urinalysis to 
determine pregnancy status. 
 
Loss of Confidentiality: To minimize this risk, we will use a non-identifiable research id number to label all 
collected data. Any data collected on physical media will be stored in locked file cabinets where only 
authorized research personnel have access. Electronically collected data will be stored on secured password 
protected IT network resources. 
 
Potential Benefits of the Proposed Research 
Post-stroke fatigue is well known but poorly understood phenomenon that significantly contributes to a poorer 
quality of life. The proposed research has the potential to reduce the impact of post-stroke fatigue leading to 
improvements in physical, cognitive, and emotional health. The potential benefit of improving function and 
quality of life in individuals with post-stroke fatigue outweigh the minimal risks associated with the study’s 
procedures.  
 
Importance of the Knowledge to be Gained 
Another benefit is this proposal is the possibility of improving our knowledge of the inflammatory contributions 
to post-stroke fatigue. Increasing our mechanistic knowledge may guide future refinement and development of 
treatments for post-stroke fatigue. As stated, the risks associated with the proposed research are minimal 
leading to a favorable cost-benefit analysis.  
 
 

Protocol version 2 
Date: 28 Mar 2022 
 
DATA SAFETY AND MONITORING PLAN 
 
This section is based on the recommendations in NIDA’s “Guidelines for Developing a Data and Safety 
Monitoring Plan” (www.drugabuse.gov/funding/dsmbsop.html). 
 
Summary of the Protocol 
The intervention being studied is a five-session anodal transcranial direct current stimulation (tDCS) 
intervention delivered over five consecutive days. Measures of post-stroke fatigue and inflammation (central 
inflammation measured by magnetic resonance spectroscopy and peripheral markers measured via blood 
analysis) will be made before and after the intervention. 
 
Trial Management. The study will be primarily managed from the Functional Neurostimulation Laboratory (Dr. 
Kindred, PI) within the Division of Physical Therapy within the College of Health Professions at the Medical 
University of South Carolina. The target population is adults more than six months post-stroke with clinically 
present fatigue (average Fatigue Severity Scale > 4). 
 
Data Management and Analysis 
The primary outcome of the study is the change in post-stroke fatigue severity (fatigue severity scale (FSS), 
pre- and post-intervention) and markers of central (measured using magnetic resonance spectroscopy (MRS)) 
and peripheral (measured via blood analysis) inflammatory markers. Analyses will be guided by the specific 
hypotheses of the study. Post-hoc exploratory analyses will be conducted with two-tailed tests and more 
conservative statistical procedures which guard against Type I error (e.g., Tukey tests). All primary hypotheses 
will be tested at level of significance α=0.05. We will also estimate the effect sizes of interest and provide 95% 
confidence intervals for them. 
 
Quality Assurance 
Data quality will be monitored by random inspection of the completed forms by research staff/PI.  
 
Regulatory Issues. All unexpected Adverse Events (AEs) will be reported to the MUSC IRB within 10 working 
days. Serious AEs (SAEs) will be reported within 24-business hours. Follow-up of all unexpected and serious 
AEs will also be reported to the IRB. All AEs will be reviewed weekly by the PI and yearly by the IRB. Any 
significant actions taken by the local IRB and protocol changes will be relayed to NIH. AEs and SAEs occurring 
during the course of the trial will be collected, documented, and reported in accordance with IRB requirements.  
 
Definition of AE and SAE 
Adverse events are defined as any untoward medical occurrence that may present itself during treatment or 
administration of an intervention, and which may or may not have a causal relationship with the treatment. 
Serious adverse events are defined as any medical occurrence that: 
• 
Results in death, 
• 
Is life-threatening, 
• 
Requires inpatient hospitalization or prolongation of existing hospitalization, 
• 
Results in persistent or significant disability/incapacity, 
• 
Is a congenital anomaly/birth defect. OR 
• 
Requires intervention to prevent one of the above outcomes. 
 
 
 
Documentation and Reporting 
AEs/SAEs will be documented and reported as per IRB requirements. Research staff will identify adverse 
events and obtain all available information to assess severity, seriousness, study relatedness, expectedness, 
outcome, and the need for change or discontinuation in the study intervention. Adverse events will generally be 
documented on AE Logs and AE Case Report Forms (CRFs). Additional relevant AE information, if available, 
will be documented in a progress note in the research record as appropriate to allow monitoring and evaluating 

Protocol version 2 
Date: 28 Mar 2022 
 
of the AE. If the AE meets the definition for serious, appropriate SAE protocol specific reporting forms will be 
completed and disseminated to the appropriate persons and within the designated timeframes as indicated 
above. For each AE/SAE recorded, the research staff will follow the AE/SAE until resolution, stabilization or 
until the subject is no longer in the. 
 
When a reportable SAE is identified, the PI and/or Study Coordinator will initiate an SAE form, and the 
following individuals will be notified by facsimile transmission, email and/or telephone within 24-business hours 
of the initial notification of the SAE: 
 
i. 
The PI and laboratory clinical staff will provide oversight, consultation, assessment, and documentation 
as appropriate of the SAE. 
ii. 
The research staff will notify the MUSC IRB and complete the AE report form in conjunction with the PI. 
The MUSC IRB meets monthly and is located at 165 Cannon Street, Rm. 501, Charleston, SC 29425. 
Communication with the IRB is through email, memos, official IRB forms, and online reporting. 
iii. 
The NIH program officer. 
 
If complete information is not available when the initial 24-hour SAE report is disseminated, follow-up 
information will be gathered to enable a complete assessment and outcome of the event. This information may 
include hospital discharge records, autopsy reports, clinic records, etc. The research staff will attach copies of 
source documents to the SAE report for review by the PIs and for forwarding to the NIH program officer as 
appropriate within 2 weeks of the initial SAE report. In addition, the PIs will provide a signed, dated SAE 
summary report, which will be sent to the NIH Medical Safety Officer within two weeks of the initial SAE report. 
 
We will report adverse events to the MUSC IRB online as soon as possible, but no later than 10 working days 
after the investigators first learns of the event. The MUSC IRB AE reporting requirements are as follows: All 
deaths that occur during the study or 30 days post termination from the study are required to be reported as 
adverse events even if they are expected or unrelated. Other adverse events are reportable to the MUSC IRB 
if the AE is unexpected AND related or possibly related AND serious or more prevalent than expected. All 
three criteria must be met for an AE to be reported to the MUSC IRB. The IRB definition of unexpected is that 
the AE is not identified in nature, severity or frequency in the current protocol, informed consent, investigator 
brochure or with other current risk information. The definition of related is that there is a reasonable possibility 
that the adverse event may have been caused by the device or intervention. Reportable AEs are reviewed by 
the IRB Chair and reported to the IRB Board at the next meeting. 
 
Trial Safety 
The potential risks and benefits and methods to minimize these risks are outlined in Section 3.1, Protection of 
Human Subjects Section. Protocols for reported AEs and SAEs are outlined above. All unexpected AE and 
SAEs will be monitored until resolved. A detailed summary of all AEs will be prepared weekly by the research 
staff and relayed to the PI. Study procedures will follow as much as possible the FDA’s Good Clinical Practice 
Guidelines (www.fda.gov/oc/gcp).  All requests by subject’s physicians and other medical providers will be 
referred directly to PI. 
 
DSMP Administration 
The PI will be responsible for ensuring participants’ safety on a daily basis.  
 
The PI will examine the database for missing data, unexpected distributions or responses, and outliers. We will 
report results at the end of the trial. 
 
DSM Board 
A DMSB is not required as the intervention is considered minimal risk and the minimal duration of the trial. 
 
Confidentiality will be maintained during all phases of the trial including monitoring, preparation of interim 
results, review, and response to monitoring recommendations. 

Protocol version 2 
Date: 28 Mar 2022 
 
ClinicalTrials.gov Requirements 
In accordance with Public Law 110-85, the proposed trial will be registered with ClinicalTrials.gov. Applicable 
requirements regarding results reporting will be adhered to.