Tele-CE in Severe Stroke

Effect of Home-based Cross-education on Lower Limb Neuroplasticity in Severe Stroke

The goal of this clinical trial is to determine the effects of home-based cross-education on lower limb neuroplasticity in severe stroke.

The main questions the investigators aim to answer are:

• What are the effects of home-based cross-education on lower limb neuroplasticity?
• What are the effects of home-based cross-education on lower limb function?
• Is home-based cross-education feasible to administer and accepted by participants?

Participants will take part in ten home-based, remotely supervised sessions, during which participants will either perform unilateral skill and strength training of the unaffected lower limb (Tele-Cross Education or Tele-CE) or cognitive training and unilateral movements of the unaffected lower limb (Tele-control). Each participant will experience measures of brain and spinal activity and motor function testing before and after both sessions (Tele-CE and Tele-control). Each participant will also be asked to fill out a feedback questionnaire to assess acceptability after intervention sessions (Tele-CE and Tele-control).

Inclusion Criteria:

• Single, monohemispheric stroke
• Chronic stroke (> 6 months prior)
• Severe stroke (Fugl-Meyer Lower Extremity motor scale score < 21 or 6 Minute Walk Test distance < 300m)

Exclusion Criteria:

• Use of anti-spasticity medications
• Existence of other neurological disorders
• Have brainstem or cerebellar lesions.
• Mini-Mental State Examiniation score of <21, to ensure participants have the cognitive capacity to consent and can understand instructions both in-person and during remote supervision.
• Non-English-speaking individuals
• Bone, joint or soft tissue injury
• Uncontrolled medical conditions (such as uncontrolled hypertension, untreated cardiac disease, or untreated pulmonary disease)
• Unable to see the tablet and zoom screen
• Unable to move non-paretic ankle (< 5 degrees of ankle ROM)
• Fugl-Meyer Lower Extremity sensory scale score < 6

TMS exclusion criteria

• Previous adverse reaction to TMS
• Skull abnormalities or fractures
• Concussion within the prior 6 months
• Unexplained, recurring headaches
• Implanted cardiac pacemaker
• Metal implants in the head or face
• History of seizures or epilepsy
• Use of medications that could alter cortical excitability or increase risk of seizure (e.g., antidepressants, antipsychotics, anxiolytics, anticonvulsants)
• Current pregnancy

PNS exclusion criteria

• Skin hypersensitivity at any sites of stimulation, including the scalp, thoracolumbar spine, and peripheral limbs
• History of contact dermatitis at any of the sites of stimulation
• History of allodynia and/or hyperalgesia
• Active skin infection
• Skin lesions
• Deep vein thrombosis
• Any other skin or scalp condition that could be aggravated by stimulation
• Implanted electronic, metallic, or highly conductive devices near site of stimulation that cannot be removed without permission from a health professional