Inclusion and Exclusion Criteria

Among the 260 subjects screened between February 2017 and December 2020, 80 chronic stroke patients were enrolled in this study (for details please see flow chart, Figure 1). All eligible and consenting patients were screened (with a pre-clinical and neurophysiological assessment) by the research team. The following inclusion criteria were applied: single stroke confirmed by brain imaging (MRI or CT); ability to understand and follow the instructions given by doctors and therapists (Mini Mental State Evaluation ≥24)²¹; basal Modified Ashworth Scale score <3; basal Fugl–Meyer score ≥3 (so that the upper limb was not completely paralyzed); and stability of upper limb deficit in the 2 pre-treatment evaluations, in order to avoid “Hawthorne effect.”^22,23 The exclusion criteria were: chronic paretic limb deformities; absence of voluntary movements at the proximal part of the upper limb (shoulder and elbow); severe neglect (assessed by Pizzamiglio’s battery for unilateral spatial neglect²⁴); epilepsy; contraindications to tDCS and TMS (eg, pacemakers, metal implants); previous neurosurgical interventions; and severe upper limb osteoporosis, upper limb strength or joint movement limitation due to previous fractures or surgical interventions.

Flow chart of the study.

Abbreviations: tDCS, transcranial direct current stimulation.