BCI-FES Therapy for Stroke Rehabilitation

Open to people ages 18-80

1. Age18-80 years inclusively at time of consent;
2. Radiologically confirmed stroke, ischemic or intracerebral hemorrhage (ICH) in etiology, with day of onset at least 26 weeks prior to day of randomization
3. Gait velocity<0.8 m/s at screening and baseline visits.
4. Foot-drop in affected limb as defined by dorsiflexion active range of motion (AROM) via goniometry in seated position foot dangling is less than passive range of motion and less than 15 degrees.
5. Plantarflexors spasticity<3 on modified Ashworth Scale;
6. Can walk >10 m (with or without ankle foot orthosis (AFO), and cane or walker permitted) at a supervised level;
7. Can tolerate FES with pain no more than 4 on pain analog scale and has adequate muscle response of dorsiflexion ≥10 degrees;
8. Passive Range of Motion at least 0 degrees ankle dorsiflexion in subtalar neutral or with FES

1. A major, active, coexistent medical, neurological (apart from stroke) or psychiatric disease (apart from stroke), including alcoholism or dementia, orthopedic injuries, that substantially affects gait. **Because old orthopedic injuries may or may not affect gait, at the discretion of the site's study PI, exclusion criterion #2 related to orthopedic injuries can be waived if the injury was not on the stroke affected side and the joint/muscles are back to normal motor and range of motion function.
2. A major medical disorder that substantially reduces the likelihood that a subject will be able to comply with all study procedures or safely complete study procedures. This includes, but not limited to documented serious cardiac conditions, serious pulmonary conditions, legal blindness, end stage renal or liver disease, pulmonary embolism or deep venous thrombosis.
3. Resting systolic blood pressure above 170, diastolic blood pressure above 100 at screening and baseline evaluations
4. Implanted electronic device (e.g. pacemaker) or skull metallic implants (e.g. cranioplasty plate covering the leg motor area);
5. Deficits in communication that interfere with reasonable study participation: language or attention impairment (score>1 on NIH Stroke Scale items 9 and 11, respectively)
6. Significant cognitive impairment, defined as Montreal Cognitive Assessment score < 22 (For those with aphasia: **Because Montreal Cognitive Assessment scores may be difficult to interpret for patients with aphasia, at the discretion of the site's study PI, exclusion criterion #5 ("MoCA score cannot be <22") can be waived)
7. A new symptomatic stroke occurs apart from the index stroke during the screening process and prior to randomization
8. Life expectancy < 6 months

9. Skin breakdown over electrical stimulation sites;

   10. Received chemical denervation (eg Botox) to legs in the preceding 6 months, or

   expectation that chemical denervation will be administered to the leg prior to expected completion of the study

   11. Unable or unwilling to perform study procedures/therapy, or expectation of

   non-compliance with study procedures/therapy

   12. Pregnancy; 13. Significant pain (visual analog scale >4), chest pain, or shortness of breath with

   walking.

   14. Receiving any outside concurrent physical therapy involving the lower extremities

   after enrollment in the study up to 1 month post treatment

   15. Any general medical condition and psychosocial situation that substantially interferes

   with reasonable participate in study appointments

   16. Non-English speaking, such that subject does not speak sufficient English to comply

   with study procedures

   17. Concurrent enrollment in another investigational interventional study 18. Severe depression, defined as Geriatric Depression Scale Score >11: **Because

   Geriatric Depression scale scores may be difficult to interpret for some patients, at the discretion of the site's study PI, exclusion criterion #17 ("Geriatric Depression score cannot be >11") can be waived)

   19. Concurrent use of FES orthosis for gait. 20. A new symptomatic stroke occurs apart from the index stroke during the screening

   process and prior to randomization

   If TMS Eligible (note that potential subjects who do not qualify for TMS will not be excluded from the main study, they will only be excluded from undergoing TMS procedures):

   21. TMS: Metallic hardware on the scalp (e.g. vascular clips or cranioplasty mesh) 22. TMS: Implanted medication pumps, intracardiac line, or central venous catheter 23. TMS: History of cortical stroke or other cortical lesion such as brain tumor 24. TMS: Prior diagnosis of seizure or epilepsy 25. TMS: Any electrical, mechanical, or magnetic implants 26. TMS: History of neurosurgery 27. TMS: uncontrolled Migraine headaches 28. TMS: Any current medications that affect seizure threshold such as tricyclic

   antidepressants and neuroleptics

   29. TMS: Unstable medical conditions