Please select the eligibility criteria that correspond to the clinical trial below.
Title: ENHANCE: Enhancing Brain Plasticity for Sensorimotor Recovery in Spastic Hemiparesis
Brief Summary: Many people who have had a stroke have problems recovering the use of their affected arm and these problems may persist for a long time. The investigators' research will test new ways to boost recovery by using non-painful brain stimulation together with training of arm movements using basic science principles. The training program will be done using the latest technology in rehabilitation such as virtual reality and robotics. The investigators will compare three groups of patients who have had a stroke. Each group will receive different combinations of brain stimulation and arm training. Another aspect of this proposal is that the investigators will do the same training programs in three different countries - Canada, Israel and India. In this way, the investigators will combine knowledge and skills to create training programs that can be applied anywhere in the world and that are not necessarily limited to high-income countries. Also, by combining expertise, the investigators will help to build the capacity to do research in India, a middle-income country that has great potential to contribute new knowledge to rehabilitation medicine.


Options:
A: Inclusion Criteria:

* ischemic or hemorrhagic stroke leading to unilateral deficits in motor function with significant impact on independence and daily activities at the beginning of rehabilitation
* less than 10 weeks after stroke onset.

Exclusion Criteria:

* epileptic seizures
* metallic objects in the brain
* presence of implants or neural stimulators
* pregnancy
* sleep deprivation
* recent traumatic brain injury
* delirium or disturbed vigilance
* inability to participate in 1h treatment sessions
* severe language comprehension deficits
* skull breach
* new stroke lesions during rehabilitation
* medical complications
B: Inclusion Criteria:

* First-ever stroke patients
* Subacute stage (less than 4 weeks)
* Total Fugl-Meyer Assessment (FMA) score under 84

Exclusion Criteria:

* Major active neurological disease or psychiatric disease
* A history of seizure
* Metallic implants in their brain
C: Inclusion Criteria:

1. first ever cortical or cortical/subcortical stroke confirmed by MRI/CT and medically stable;
2. sub-acute stage of stroke (3 wk to 6 mo post-stroke);
3. arm paresis (Chedoke-McMaster Arm Scale of 2-6 /7; Gowland et al. 1993) but able to perform voluntary elbow flexion/extension of at least 30° per direction;
4. elbow flexor and/or extensor spasticity (\> 1+/4 on Modified Ashworth Scale; Ashworth 1964; Bohannon and Smith 1987);
5. able to provide informed consent.

Exclusion Criteria:

1. major neurological (other than stroke) / neuromuscular / orthopaedic problems or pain that may interfere with interpretation of results;
2. major cognitive deficits (a score \<20 on the Montreal Cognitive Assessment, Nasreddine et al. 2005);
3. history of psychiatric disorders, alcohol or drug abuse, skin sensitivity, seizures, migraines, metal in cranium and other implants (cochlear, cardiac);
4. taking medications (e.g. epileptic and psychoactive drugs) that could affect brain activity (Poreisz 2007).
D: Inclusion Criteria:

* first ever haemorrhagic or ischaemic subcortical stroke more than 9 months prior to study enrollment
* upper extremity impairment of 11-45 on the Fugl-Meyer assessment scale

Exclusion Criteria:

* epilepsy
* neglect
* cognitive impairment
* other neurological or psychiatric diseases
* severe arm pain
* spasticity score \>2 on the Modified Ashworth Scale in the shoulder or elbow
* contraindications to TMS or tDCS (cranial implants, ventricular shunts, pacemakers, intrathecal pumps)
* grip strength \<10kg as measured by a dynamometer
* participation in other interventions or trials targeting stroke motor recovery.

Answer: C