In this study, we investigated the effects of dual-hemisphere transcranial direct current stimulation (dual-tDCS) of both the affected (anodal tDCS) and non-affected (cathodal tDCS) primary motor cortex, combined with peripheral neuromuscular electrical stimulation (PNMES), on the effectiveness of constraint-induced movement therapy (CIMT) as a neurorehabilitation intervention in chronic stroke. We conducted a randomized controlled trial of feasibility, with a single blind assessor, with patients recruited from three outpatient clinics. Twenty chronic stroke patients were randomly allocated to the control group, receiving conventional CIMT, or the intervention group receiving dual-tDCS combined with PNMES before CIMT. Patients in the treatment group first underwent a 20-min period of dual-tDCS, followed immediately by PNMES, and subsequent CIMT for 2 h. Patients in the control group only received CIMT (with no pretreatment stimulation). All patients underwent two CIMT sessions, one in the morning and one in the afternoon, each lasting 2 h, for a total of 4 h of CIMT per day. Upper extremity function was assessed using the Fugl-Meyer Assessment (primary outcome), as well as the amount of use (AOU) and quality of movement (QOM) scores, obtained via the Motor Activity Log (secondary outcome). Nineteen patients completed the study, with one patient withdrawing after allocation. Compared to the control group, the treatment improvement in upper extremity function and AOU was significantly greater in the treatment than control group (change in upper extremity score, 9.20 ± 4.64 versus 4.56 ± 2.60, respectively, P < 0.01, η2 = 0.43; change in AOU score, 1.10 ± 0.65 versus 0.62 ± 0.85, respectively, P = 0.02, η2 = 0.52). There was no significant effect of the intervention on the QOM between the intervention and control groups (change in QOM score, 1.00 ± 0.62 versus 0.71 ± 0.72, respectively, P = 0.07, η2 = 0.43; treatment versus control). Our findings suggest a novel pretreatment stimulation strategy based on dual-tDCS and PNMES may enhance the therapeutic benefit of CIMT.

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A 79-year-old man was diagnosed with left thalamic hemorrhage. On admission, the Functional Independence Measure (FIM) motor score was 13 points, and the Food Intake Level Scale (FILS) was Level 2, with the patient needing enteral nutrition. Six months after stroke onset, the FIM motor score had improved to 38 points and the dysphagia to FILS Level 7. The patient was able to ingest easy-to-swallow food orally three times a day, but only after postural adjustment with rotation of the head. Seven months after stroke onset, the FIM motor score had reached 45 points but without further improvement in swallowing function. Videofluoroscopic swallowing evaluation (VF) revealed that the persistence of dysphagia was due to osteophytes on the cervical vertebrae caused by diffuse idiopathic skeletal hyperostosis. On surgical removal of the osteophytes, swallowing function improved to FILS Level 9; the patient was able to ingest normal food in a seated position without postural adjustment. One year after stroke onset, the patient was discharged with an FIM motor score of 59 points and FILS Level 9. At the 2-year follow-up, there was minimal recurrence of the osteophytes, and both motor and swallowing functions were maintained at the same level as at discharge. This case suggests that dysphagia in elderly patients may be due to multiple disorders, and that surgical intervention may occasionally be effective.