{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T00:10:01Z","timestamp":1788307801588,"version":"build-2803163510"},"reference-count":34,"publisher":"MDPI AG","issue":"23","license":[{"start":{"date-parts":[[2023,11,21]],"date-time":"2023-11-21T00:00:00Z","timestamp":1700524800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"FAPES\/Brazil","award":["983\/2022 P: 2022-B92KF"],"award-info":[{"award-number":["983\/2022 P: 2022-B92KF"]}]},{"name":"FAPES\/Brazil","award":["88882.385245\/2019-01"],"award-info":[{"award-number":["88882.385245\/2019-01"]}]},{"name":"CAPES\/Brazil","award":["983\/2022 P: 2022-B92KF"],"award-info":[{"award-number":["983\/2022 P: 2022-B92KF"]}]},{"name":"CAPES\/Brazil","award":["88882.385245\/2019-01"],"award-info":[{"award-number":["88882.385245\/2019-01"]}]},{"name":"FACITEC\/Brazil","award":["983\/2022 P: 2022-B92KF"],"award-info":[{"award-number":["983\/2022 P: 2022-B92KF"]}]},{"name":"FACITEC\/Brazil","award":["88882.385245\/2019-01"],"award-info":[{"award-number":["88882.385245\/2019-01"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Sensors"],"abstract":"<jats:p>Stroke is a debilitating clinical condition resulting from a brain infarction or hemorrhage that poses significant challenges for motor function restoration. Previous studies have shown the potential of applying transcranial direct current stimulation (tDCS) to improve neuroplasticity in patients with neurological diseases or disorders. By modulating the cortical excitability, tDCS can enhance the effects of conventional therapies. While upper-limb recovery has been extensively studied, research on lower limbs is still limited, despite their important role in locomotion, independence, and good quality of life. As the life and social costs due to neuromuscular disability are significant, the relatively low cost, safety, and portability of tDCS devices, combined with low-cost robotic systems, can optimize therapy and reduce rehabilitation costs, increasing access to cutting-edge technologies for neuromuscular rehabilitation. This study explores a novel approach by utilizing the following processes in sequence: tDCS, a motor imagery (MI)-based brain-computer interface (BCI) with virtual reality (VR), and a motorized pedal end-effector. These are applied to enhance the brain plasticity and accelerate the motor recovery of post-stroke patients. The results are particularly relevant for post-stroke patients with severe lower-limb impairments, as the system proposed here provides motor training in a real-time closed-loop design, promoting cortical excitability around the foot area (Cz) while the patient directly commands with his\/her brain signals the motorized pedal. This strategy has the potential to significantly improve rehabilitation outcomes. The study design follows an alternating treatment design (ATD), which involves a double-blind approach to measure improvements in both physical function and brain activity in post-stroke patients. The results indicate positive trends in the motor function, coordination, and speed of the affected limb, as well as sensory improvements. The analysis of event-related desynchronization (ERD) from EEG signals reveals significant modulations in Mu, low beta, and high beta rhythms. Although this study does not provide conclusive evidence for the superiority of adjuvant mental practice training over conventional therapy alone, it highlights the need for larger-scale investigations.<\/jats:p>","DOI":"10.3390\/s23239302","type":"journal-article","created":{"date-parts":[[2023,11,21]],"date-time":"2023-11-21T12:12:13Z","timestamp":1700568733000},"page":"9302","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":31,"title":["Unraveling Transformative Effects after tDCS and BCI Intervention in Chronic Post-Stroke Patient Rehabilitation\u2014An Alternative Treatment Design Study"],"prefix":"10.3390","volume":"23","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6294-5179","authenticated-orcid":false,"given":"J\u00e9ssica P. S.","family":"Lima","sequence":"first","affiliation":[{"name":"Postgraduate Program in Biotechnology, Federal University of Espirito Santo (UFES), Vitoria 29047-105, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1534-0708","authenticated-orcid":false,"given":"Leticia A.","family":"Silva","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Electrical Engineering, Federal University of Espirito Santo (UFES), Vitoria 29075-910, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8937-031X","authenticated-orcid":false,"given":"Denis","family":"Delisle-Rodriguez","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Neuroengineering, Edmond and Lily Safra International Institute of Neurosciences, Macaiba 59288-899, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1654-3320","authenticated-orcid":false,"given":"Vivianne F.","family":"Cardoso","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Biotechnology, Federal University of Espirito Santo (UFES), Vitoria 29047-105, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2196-2490","authenticated-orcid":false,"given":"Ester M.","family":"Nakamura-Palacios","sequence":"additional","affiliation":[{"name":"Laboratory of Cognitive Sciences and Neuropsychopharmacology, Federal University of Esp\u00edrito Santo, Vitoria 29040-090, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1185-2773","authenticated-orcid":false,"given":"Teodiano F.","family":"Bastos-Filho","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Biotechnology, Federal University of Espirito Santo (UFES), Vitoria 29047-105, Brazil"},{"name":"Postgraduate Program in Electrical Engineering, Federal University of Espirito Santo (UFES), Vitoria 29075-910, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,11,21]]},"reference":[{"key":"ref_1","first-page":"641","article-title":"Stroke","volume":"11","author":"Hankey","year":"2016","journal-title":"Lancet"},{"key":"ref_2","unstructured":"WHO (2017). Stroke, Cerebrovascular Accident."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"149","DOI":"10.1016\/0966-6362(96)01064-8","article-title":"Hemiparetic gait following stroke. Part II: Recovery and physical the therapy","volume":"4","author":"Richards","year":"1996","journal-title":"Gait Posture"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1186\/s13561-023-00439-6","article-title":"The costs associated with stroke care continuum: A systematic review","volume":"13","year":"2023","journal-title":"Health Econ. Rev."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Elsner, B., Kugler, J., Pohl, M., and Mehrholz, J. (2020). Transcranial direct current stimulation (tDCS) for improving activities of daily living, and physical and cognitive functioning, in people after stroke. Cochrane Database Syst. Rev.","DOI":"10.1002\/14651858.CD009645.pub4"},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Mehrholz, J., Thomas, S., Kugler, J., Pohl, M., and Elsner, B. (2020). Electromechanical-assisted training for walking after stroke. Cochrane Database Syst. Rev.","DOI":"10.1002\/14651858.CD006185.pub5"},{"key":"ref_7","first-page":"205","article-title":"Induction of Neuroplasticity by Transcranial Direct Current Stimulation","volume":"6","author":"Mohammadi","year":"2016","journal-title":"J. Biomed. Phys. Eng."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"934","DOI":"10.1016\/j.neuroimage.2013.05.098","article-title":"tDCS-enhanced motor and cognitive function in neurological diseases","volume":"85","year":"2014","journal-title":"NeuroImage"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1016\/j.neulet.2016.03.056","article-title":"Transcranial direct current stimulation is not effective in the motor strength and gait recovery following motor incomplete spinal cord injury during Lokomat\u00ae gait training","volume":"620","author":"Kumru","year":"2016","journal-title":"Neurosci. Lett."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1016\/j.brainres.2014.07.021","article-title":"Timing-dependent priming effects of tDCS on ankle motor skill learning","volume":"1581","author":"Sriraman","year":"2014","journal-title":"Brain Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"948","DOI":"10.3389\/fneur.2020.00948","article-title":"Using Transcranial Direct Current Stimulation to Augment the Effect of Motor Imagery-Assisted Brain-Computer Interface Training in Chronic Stroke Patients-Cortical Reorganization Considerations","volume":"11","author":"Chew","year":"2020","journal-title":"Front. Neurol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1016\/j.neuroimage.2005.12.003","article-title":"Mu rhythm (de)synchronization and EEG single-trial classification of different motor imagery tasks","volume":"31","author":"Pfurtscheller","year":"2006","journal-title":"Neuroimage"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"253","DOI":"10.1177\/155005941104200411","article-title":"A large clinical study on the ability of stroke patients to use an EEG-based motor imagery brain-computer interface","volume":"42","author":"Ang","year":"2011","journal-title":"Clin. EEG Neurosci."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1123","DOI":"10.1109\/5.939829","article-title":"Motor imagery and direct brain-computer communication","volume":"89","author":"Pfurtscheller","year":"2001","journal-title":"Proc. IEEE"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"529","DOI":"10.3389\/fnhum.2018.00529","article-title":"Can a Subjective Questionnaire Be Used as Brain-Computer Interface Performance Predictor?","volume":"12","author":"Rimbert","year":"2019","journal-title":"Front. Hum. Neurosci."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"988","DOI":"10.1109\/TNSRE.2020.2974056","article-title":"A Low-Cost Lower-Limb Brain-Machine Interface Triggered by Pedaling Motor Imagery for Post-Stroke Patients Rehabilitation","volume":"28","author":"Cardoso","year":"2020","journal-title":"IEEE Trans. Neural Syst. Rehabil. Eng."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"787","DOI":"10.1109\/TCDS.2019.2959055","article-title":"Toward Improving Engagement in Neural Rehabilitation: Attention Enhancement Based on Brain-Computer Interface and Audiovisual Feedback","volume":"12","author":"Wang","year":"2020","journal-title":"IEEE Trans. Cogn. Dev. Syst."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Rodriguez-Ugarte, M.S., I\u00e1\u00f1ez, E., Ortiz-Garcia, M., and Azor\u00edn, J.M. (2018). Effects of tDCS on Real-Time BCI Detection of Pedaling Motor Imagery. Sensors, 18.","DOI":"10.3390\/s18041136"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"016047","DOI":"10.1088\/1741-2552\/acb73b","article-title":"EEG changes during passive movements improve the motor imagery feature extraction in BCIs-based sensory feedback calibration","volume":"20","author":"Silva","year":"2023","journal-title":"J. Neural Eng."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1186\/1743-0003-11-35","article-title":"Computer game-based upper extremity training in the home environment in stroke persons: A single subject design","volume":"11","author":"Slijper","year":"2014","journal-title":"J. Neuroeng. Rehabil."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1386","DOI":"10.1161\/STROKEAHA.108.530584","article-title":"Responsiveness and validity of three outcome measures of motor function after stroke rehabilitation","volume":"40","author":"Hsieh","year":"2009","journal-title":"Stroke"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1590\/S1413-35552012005000085","article-title":"Adapta\u00e7\u00e3o transcultural e an\u00e1lise das propriedades psicom\u00e9tricas do Balance Evaluation Systems Test e do MiniBESTest em idosos e indiv\u00edduos com doen\u00e7a de Parkinson: Aplica\u00e7\u00e3o do modelo Rasch","volume":"17","author":"Maia","year":"2013","journal-title":"Braz. J. Phys. Ther."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2096","DOI":"10.1161\/STROKEAHA.106.475921","article-title":"Improvements in speed-based gait classifications are meaningful","volume":"38","author":"Schmid","year":"2007","journal-title":"Stroke"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2019","DOI":"10.3109\/09638281003797406","article-title":"Reliability of the Semmes Weinstein Monofilaments to measure coetaneous sensibility in the feet of healthy subjects","volume":"32","author":"Collins","year":"2010","journal-title":"Disabil. Rehabil."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1559325816685467","DOI":"10.1177\/1559325816685467","article-title":"Mechanisms and Effects of Transcranial Direct Current Stimulation","volume":"15","author":"Giordano","year":"2017","journal-title":"Dose-Response"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"9115","DOI":"10.1523\/JNEUROSCI.2184-09.2009","article-title":"Modulation of cerebellar excitability by polarity-specific noninvasive direct current stimulation","volume":"29","author":"Galea","year":"2009","journal-title":"J. Neurosci."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"156","DOI":"10.1016\/j.neulet.2016.01.045","article-title":"The role of the cerebellum in motor imagery","volume":"617","author":"Cengiz","year":"2016","journal-title":"Neurosci. Lett."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"692304","DOI":"10.3389\/fnhum.2021.692304","article-title":"Brain Functional Changes in Stroke Following Rehabilitation Using Brain-Computer Interface-Assisted Motor Imagery with and without tDCS: A Pilot Study","volume":"15","author":"Hu","year":"2021","journal-title":"Front. Hum. Neurosci."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"446","DOI":"10.1161\/STROKEAHA.111.636258","article-title":"Characterizing and identifying risk for falls in the LEAPS study: A randomized clinical trial of interventions to improve walking poststroke","volume":"43","author":"Tilson","year":"2012","journal-title":"Stroke"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1682\/JRRD.2007.01.0014","article-title":"Balance, falls, and bone health: Role of exercise in reducing fracture risk after stroke","volume":"45","author":"Eng","year":"2008","journal-title":"J. Rehabil. Res. Dev."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1161\/STR.0000000000000098","article-title":"Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals from the American Heart Association\/American Stroke Association","volume":"47","author":"Winstein","year":"2016","journal-title":"Stroke"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"166","DOI":"10.1177\/1545968307305523","article-title":"Sensory loss in hospital-admitted people with stroke: Characteristics, associated factors, and relationship with function","volume":"22","author":"Tyson","year":"2008","journal-title":"Neurorehabilit. Neural Repair"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1016\/j.brs.2019.10.019","article-title":"Transcranial direct current stimulation associated with physical-therapy in acute stroke patients\u2014A randomized, triple blind, sham-controlled study","volume":"13","author":"Bornheim","year":"2020","journal-title":"Brain Stimul."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"635351","DOI":"10.3389\/fnhum.2021.635351","article-title":"Enhancement of Event-Related Desynchronization in Motor Imagery Based on Transcranial Electrical Stimulation","volume":"15","author":"Xie","year":"2021","journal-title":"Front. Hum. Neurosci."}],"container-title":["Sensors"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1424-8220\/23\/23\/9302\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T21:25:53Z","timestamp":1760131553000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1424-8220\/23\/23\/9302"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,11,21]]},"references-count":34,"journal-issue":{"issue":"23","published-online":{"date-parts":[[2023,12]]}},"alternative-id":["s23239302"],"URL":"https:\/\/doi.org\/10.3390\/s23239302","relation":{},"ISSN":["1424-8220"],"issn-type":[{"value":"1424-8220","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,11,21]]}}}