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BackgroundTranscranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that has shown promise for rehabilitation after stroke. Ipsilesional anodal tDCS (a-tDCS) over the motor cortex increases corticospinal excitability, while contralesional cathodal tDCS (c-tDCS) restores interhemispheric balance, both resulting in offline improved reaction times of delayed voluntary upper-extremity movements. We aimed to investigate whether tDCS would also have a beneficial effect on delayed leg motor responses after stroke. In addition, we identified whether variability in tDCS effects was associated with the level of leg motor function.MethodsIn a cross-over design, 13 people with chronic stroke completed three 15-min sessions of anodal, cathodal and sham stimulation over the primary motor cortex on separate days in an order balanced across participants. Directly after stimulation, participants performed a comprehensive set of lower-extremity tasks involving the paretic tibialis anterior (TA): voluntary ankle-dorsiflexion, gait initiation, and backward balance perturbation. For all tasks, TA onset latencies were determined. In addition, leg motor function was determined by the Fugl-Meyer Assessment – leg score (FMA-L). Repeated measures ANOVA was used to reveal tDCS effects on reaction times. Pearson correlation coefficients were used to establish the relation between tDCS effects and leg motor function.ResultsFor all tasks, TA reaction times did not differ across tDCS sessions. For gait initiation and backward balance perturbation, differences between sham and active stimulation (a-tDCS or c-tDCS) did not correlate with leg motor function. Yet, for ankle dorsiflexion, individual reaction time differences between c-tDCS and sham were strongly associated with FMA-L, with more severely impaired patients exhibiting slower paretic reaction times following c-tDCS.ConclusionWe found no evidence for offline tDCS-induced benefits. Interestingly, we found that c-tDCS may have unfavorable effects on voluntary control of the paretic leg in severely impaired patients with chronic stroke. This finding points at potential vicarious control from the unaffected hemisphere to the paretic leg. The absence of tDCS-induced effects on gait and balance, two functionally relevant tasks, shows that such motor behavior is inadequately stimulated by currently used tDCS applications.Trial registrationThe study is registered in the Netherlands Trial Register (NL5684; April 13th, 2016).

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Reactive balance recovery often requires stepping responses to regain postural stability following a sudden change in posture. The monitoring of postural stability has been linked to neuroelectrical markers such as the N1 potential and midfrontal theta frequency dynamics. Here, we investigated the role of cortical midfrontal theta dynamics during balance monitoring following foot landing of a reactive stepping response to recover from whole-body balance perturbations. We hypothesized that midfrontal theta dynamics reflect the engagement of a behavioral monitoring system, and therefore that theta would increase time-locked to the moment of foot strike after a stepping response, coinciding with a re-assessment of postural balance to determine if an additional step is necessary. We recorded high-density EEG and kinematic data of 15 healthy young participants while they stood on a platform that delivered multi-directional balance perturbations. Participants were instructed to recover balance with a single step utilizing either their left or right leg (in separate blocks). We used targeted spatial filtering (generalized eigen decomposition) in combination with time–frequency analysis of the EEG data to investigate whether theta dynamics increase following foot strike event. In line with our hypothesis, the results indicate that the foot strike event elicits a midfrontal theta power increase, though only for backward stepping. Counter to our expectations, however, this theta power increase was positively correlated with the margin of stability at foot strike, suggesting a different role of foot strike related theta from monitoring stability. Post-hoc analysis suggests that midfrontal theta dynamics following foot landing may instead facilitate adaptation of stability margins at subsequent stepping responses. We speculate that increase of theta power following foot strikes was not related to stability monitoring but instead may indicate cortical dynamics related to performance monitoring of the balance response.

IntroductionPeople with stroke often exhibit balance impairments, even in the chronic phase. Perturbation-based balance training (PBT) is a therapy that has yielded promising results in healthy elderly and several patient populations. Here, we present a threefold approach showing changes in people with chronic stroke after PBT on the level of recruitment of automatic postural responses (APR), step parameters and step quality. In addition, we provide insight into possible correlations across these outcomes and their changes after PBT.MethodsWe performed a complementary analysis of a recent PBT study. Participants received a 5-week PBT on the Radboud Fall simulator. During pre- and post-intervention assessments participants were exposed to platform translations in forward and backward directions. We performed electromyography of lower leg muscles to identify changes in APR recruitment. In addition, 3D kinematic data of stepping behavior was collected. We determined pre-post changes in muscle onset, magnitude and modulation of recruitment, step characteristics, and step quality. Subsequently, we determined whether improvements in step or muscle characteristics were correlated with improved step quality.ResultsWe observed a faster gastrocnemius muscle onset in the stance and stepping leg during backward stepping. During forward stepping we found a trend toward a faster tibialis anterior muscle onset in the stepping leg. We observed no changes in modulation or magnitude of muscle recruitment. Leg angles improved by 2.3° in forward stepping and 2.5° in backward stepping. The improvement in leg angle during forward stepping was accompanied by a −4.1°change in trunk angle, indicating a more upright position. Step length, duration and velocity improved in both directions. Changes in spatiotemporal characteristics were strongly correlated with improvements in leg angle, but no significant correlations were observed of muscle onset or recruitment with leg or trunk angle.ConclusionPBT leads to a multi-factorial improvement in onset of APR, spatiotemporal characteristics of stepping, and reactive step quality in people with chronic stroke. However, current changes in APR onset were not correlated with improvement in step quality. Therefore, we suggest that, in addition to spatiotemporal outcomes, other characteristics of muscle recruitment or behavioral substitution may induce step quality improvement after PBT.