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Low frequency (≤ 1 Hz) repetitive transcranial magnetic stimulation (rTMS) can affect the excitability of the cerebral cortex and synaptic plasticity. Although this is a common method for clinical treatment of cerebral infarction, whether it promotes the recovery of motor function remains controversial. Twenty patients with cerebral infarction comb...
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Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive technique of cortical stimulation. Although the exact mechanism of action is not clearly understood, it has been postulated that rTMS action on pain depends most on stimulation sites and stimulation parameters. Most studies concern high-frequency rTMS of the primary motor cortex...
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... Similar to the results of other authors [38,39], in our study, the tendency of both LFand HF-rTMS treatment to increase the functional independence of patients was observed, even though, in our case, there was no significant difference compared to the control group. ...
Background and Objectives: Stroke is a major cause of death and disability worldwide; therefore, transcranial magnetic stimulation (TMS) is being widely studied and clinically applied to improve motor deficits in the affected arm. However, recent studies indicate that the function of both arms can be affected after stroke. It currently remains unknown how various TMS methods affect the function of the ipsilesional upper extremity. Materials and Methods: Thirty-five subacute stroke patients with upper extremity motor deficits were enrolled in this study and randomly allocated into three groups, receiving either (1) low-frequency rTMS over the contralesional hemisphere; (2) high-frequency rTMS over the ipsilesional hemisphere; or (3) no stimulation. Experimental groups received 10 rTMS sessions over two weeks alongside standard rehabilitation, and the control group received the same procedures except for rTMS. Both affected and unaffected upper extremity motor function was evaluated using hand grip strength and Functional Independence Measure (FIM) tests before and after rehabilitation (7 weeks apart). Results: All groups showed significant improvement in both the affected and unaffected hand grip and FIM scores (p < 0.05). HF-rTMS led to a notably higher increase in unaffected hand grip strength than the control group (p = 0.007). There was no difference in the improvement in affected upper extremity motor function between the groups. The FIM score increase was lower in the control group compared to experimental groups, although not statistically significant. Conclusions: This study demonstrates the positive effect of ipsilesional HF-rTMS on the improvement in unaffected arm motor function and reveals the positive effect of both LF- and HF-rTMS on the affected upper extremity motor function recovery.
... TMS at 1 Hz can aid in the reorganization of regional cortical functions by regulating cortical excitability, which affects neural function. In general, TMS 1 Hz can inhibit cortical hemisphere excitability stimulation, facilitate interhemispheric excitability balance, increase contralateral hemisphere excitability, or decrease contralateral hemisphere excitability to promote motor function restoration [19]. TMS 1 Hz can improve brain plasticity and inhibition intracortical in a brain that does not have lesions, also having a positive effect on finger motor skills and hand function [2]. ...
... Only 65% of studies performed the intention to treat analysis. Therefore, 88% of the selected studies 1,17,[30][31][32][33]35,36,[43][44][45][46][47][49][50][51][53][54][55][56][57]59,60 have moderate-to-high methodological quality ( Figure 2). ...
... Twenty-one studies 1,17,[30][31][32][33]35,36,[43][44][45][46]48,[50][51][52][53][54][56][57][58][59] assessed the effects of NIBS combined with other therapies on FMA-UE but only 16 studies 1,17,[30][31][32][33]35,36,48,50,53,54,[56][57][58][59] (n = 722) were included in this meta-analysis (Table 1). Five studies [43][44][45][46]51,52 were excluded due to unclear reported data on FMA-UE score. ...
... Twenty-one studies 1,17,[30][31][32][33]35,36,[43][44][45][46]48,[50][51][52][53][54][56][57][58][59] assessed the effects of NIBS combined with other therapies on FMA-UE but only 16 studies 1,17,[30][31][32][33]35,36,48,50,53,54,[56][57][58][59] (n = 722) were included in this meta-analysis (Table 1). Five studies [43][44][45][46]51,52 were excluded due to unclear reported data on FMA-UE score. ...
Background:
Several studies have investigated the effect of noninvasive brain stimulation (NIBS) on upper limb motor function in stroke, but the evidence so far is conflicting.
Objective:
We aimed to determine the effect of NIBS on upper limb motor impairment, functional performance, and participation in activities of daily living after stroke.
Method:
Literature search was conducted for randomized controlled trials (RCTs) assessing the effect of "tDCS" or "rTMS" combined with other therapies on upper extremity motor recovery after stroke. The outcome measures were Fugl-Meyer Assessment of Upper Extremity (FMA-UE), Wolf Motor Function Test (WMFT), and Barthel Index (BI). The mean difference (MD) and 95%CI were estimated for motor outcomes. Cochrane risk of bias tool was used to assess the quality of evidence.
Result:
Twenty-five RCTs involving 1102 participants were included in the review. Compared to sham stimulation, NIBS combined with other therapies has effectively improved FMA-UE (MD0.97 [95%CI, 0.09 to 1.86; p = .03]) and BI score (MD9.11 [95%CI, 2.27 to 15.95; p = .009]) in acute/sub-acute stroke (MD1.73 [95%CI, 0.61 to 2.85; p = .003]) but unable to modify FMA-UE score in chronic stroke (MD-0.31 [95%CI, -1.77 to 1.15; p = .68]). Only inhibitory (MD3.04 [95%CI, 1.76 to 4.31; I2 = 82%, p < .001] protocol is associated with improved FMA-UE score. Twenty minutes of stimulation/session for ≥20 sessions was found to be effective in improving FMA-UE score (Stimulation time: ES0.45; p ≤ .001; Sessions: ES0.33; p ≤ .001). The NIBS did not produce any significant improvement in WMFT as compared to sham NIBS (MD0.91 [95% CI, -0.89 to 2.70; p = .32]).
Conclusion:
Moderate to high-quality evidence suggested that NIBS combined with other therapies is effective in improving upper extremity motor impairment and participation in activities of daily living after acute/sub-acute stroke.
... These conclusions cannot be extrapolated to other neuromodulation interventions such as rTMS [62,63] or anodal tDCS administered during the first days and weeks after stroke. For instance, Andrade et al. [11] reported that functional independence assessed with the Barthel Index improved significantly more after anodal tDCS of the premotor or primary motor cortex in the affected hemisphere than after sham stimulation, in subjects at 1-3 months after stroke. ...
Transcranial direct current stimulation (tDCS) has the potential to improve upper limb motor outcomes after stroke. According to the assumption of interhemispheric inhibition, excessive inhibition from the motor cortex of the unaffected hemisphere to the motor cortex of the affected hemisphere may worsen upper limb motor recovery after stroke. We evaluated the effects of active cathodal tDCS of the primary motor cortex of the unaffected hemisphere (ctDCSM1UH) compared to sham, in subjects within 72 hours to 6 weeks post ischemic stroke. Cathodal tDCS was intended to inhibit the motor cortex of the unaffected hemisphere and hence decrease the inhibition from the unaffected to the affected hemisphere and enhance motor recovery. We hypothesized that motor recovery would be greater in the active than in the sham group. In addition, greater motor recovery in the active group might be associated with bigger improvements in measures in activity and participation in the active than in the sham group. We also explored, for the first time, changes in cognition and sleep after ctDCSM1UH. Thirty subjects were randomized to six sessions of either active or sham ctDCSM1UH as add-on interventions to rehabilitation. The NIH Stroke Scale (NIHSS), Fugl-Meyer Assessment of Motor Recovery after Stroke (FMA), Barthel Index (BI), Stroke Impact Scale (SIS), and Montreal Cognitive Assessment (MoCA) were assessed before, after treatment, and three months later. In the intent-to-treat (ITT) analysis, there were significant GROUP*TIME interactions reflecting stronger gains in the sham group for scores in NIHSS, FMA, BI, MoCA, and four SIS domains. At three months post intervention, the sham group improved significantly compared to posttreatment in FMA, NIHSS, BI, and three SIS domains while no significant changes occurred in the active group. Also at three months, NIHSS improved significantly in the sham group and worsened significantly in the active group. FMA scores at baseline were higher in the active than in the sham group. After adjustment of analysis according to baseline scores, the between-group differences in FMA changes were no longer statistically significant. Finally, none of the between-group differences in changes in outcomes after treatment were considered clinically relevant. In conclusion, active CtDCSM1UH did not have beneficial effects, compared to sham. These results were consistent with other studies that applied comparable tDCS intensities/current densities or treated subjects with severe upper limb motor impairments during the first weeks post stroke. Dose-finding studies early after stroke are necessary before planning larger clinical trials.
1. Introduction
Stroke is a leading cause of disability worldwide. Hand paresis affects up to 80% of the subjects in the acute phase after ischemic stroke and substantially contributes to disability [1, 2]. Over the past several decades, transcranial direct current stimulation (tDCS) has emerged as a potential tool to enhance upper limb motor recovery [3–9].
The motor cortex of the unaffected hemisphere (M1UH) may have a maladaptive role in motor recovery by overinhibition of the motor cortex of the affected hemisphere (M1AH) according to the theory of interhemispheric inhibition [10]. Cathodal tDCS to inhibit M1UH (ctDCSM1UH) and hence disinhibit M1AH has been investigated as a potential add-on therapy to upper limb rehabilitation. Until now, there is limited information about the effects of ctDCSM1UH during the first weeks after stroke when mechanisms of neuroplasticity are more active. Effective rehabilitation strategies delivered in this early phase are deemed pivotal to enhance recovery [11–17]. Meta-analyses concluded that ctDCSM1UH may be beneficial for improvement of upper limb function when delivered in the chronic phase, but not at earlier stages after stroke [8, 18]. However, most of the research included subjects in chronic than in early stages.
Only five studies focused on the effects of ctDCSM1UH in the subacute phase after stroke [12, 13, 15, 16]. In the acute phase, up to seven days after stroke according to the definition of the Stroke Recovery and Rehabilitation Roundtable taskforce [19], two studies assessed the effects of tDCS. In summary, the time of stroke onset varied from less than 10 days to less than 10 weeks; the numbers of treatment sessions were 2, 6, 9, 10, 15, or 30; treatment was administered on consecutive days in most studies except for one [16]; current intensities were 1, 1.5, or 2 mA with estimated current densities varying from 0.029 to 0.08 mA/cm². In regard to timing (before, during, or after other rehabilitation intervention), two out of seven trials delivered tDCS before therapy [12, 13], four during therapy [13, 15–17], and one did not include any therapy [20]. Rehabilitation interventions were very diverse, including physical therapy, occupational therapy, robot-aided therapy, or motor practice.
In addition to the paucity of data and the variety of paradigms in the few studies that addressed the effects of ctDCSUH in the subacute stage, a systematic review concluded that there is limited information about adverse events of tDCS in subjects post stroke [21].
The main objective of this study was to assess safety. Our primary findings, published elsewhere, showed that the active intervention was safe, compared to sham [22]. We also collected preliminary data regarding efficacy to inform plans for larger trials.
We hypothesized that motor recovery would be greater in the active than in the sham group. In addition, greater motor recovery in the active group might be associated with bigger improvements in measures in activity and participation in the active than in the sham group. Effects of ctDCSUH on cognition or sleep in stroke are largely unknown [23–25]. For this reason, we also assessed, for the first time, measures of cognition and sleep before and after treatment.
Here, we report the results of changes in the following secondary outcome measures of this pilot clinical trial: motor performance, spasticity, and use of the paretic upper limb in activities of daily living, as well as neurological impairment, disability, quality of life, sleep, and cognition.
2. Materials and Methods
2.1. Design
The study was a randomized parallel, two-arm, double-blind, sham-controlled clinical trial performed at the Albert Einstein Hospital from April, 2015, to September, 2017. The protocol was approved by the hospital’s Ethics Committee and registered at clinicaltrials.gov (NCT 024555427). The research was conducted according to standards of the declaration of Helsinki and Brazilian regulations and with institutional guidelines. Informed consent was required from all participants and could be provided in writing by proxies for those unable to sign due to severe motor impairment. The independent Hospital Israelita Albert Einstein Institutional Review Board reviewed the clinical research and informed consent forms, every six months.
2.2. Participants
We included subjects in the acute (up to 7 days) or early subacute (from 7 days to 3 months) phases after stroke [19]. Inclusion criteria are as follows: ; ischemic stroke at least 72 hours and up to six weeks before enrollment, confirmed by CT or MRI; upper limb paresis defined as a minimum score of 1 in subitem 5a or 5b of the National Institutes of Health Stroke Scale (NIHSS) [26]; and ability to understand the protocol and provide informed consent.
Exclusion criteria are as follows: advanced systemic disease; clinical instability such as uncontrolled cardiac arrhythmia or heart failure; dementia; history of prior stroke affecting the corticospinal tract of M1UH; strokes affecting the cerebellum or cerebellar pathways; contraindications to tDCS [27]; prior to stroke [26]; pregnancy; contraindication for physical therapy; and comprehension aphasia.
Demographic characteristics, history of hypertension, diabetes mellitus or prior stroke, handedness, performance of thrombolysis for ischemic strokes, time from stroke, and side, type, and etiology of stroke were registered in all subjects. Involvement of primary motor cortex and/or the posterior limb of the internal capsule in brain MRIs (fluid-attenuated inversion recovery images) performed on 3T scanners prior to treatment was also assessed by an experienced neuroradiologist, blinded to group assignment.
2.3. Experimental Protocol
2.3.1. Enrolment, Randomization, and Blinding
Recruitment was performed from our hospital admissions and from the community [28]. A computer-generated randomization schedule (10 blocks of 4 subjects) was created with randomization.com for allocation to either the active or sham ctDCSM1UH group at a 1 : 1 ratio. Subjects were consecutively enrolled in the study. For instance, if three patients had been included in the study, patient 4 was assigned the condition specified for the fourth included patient. Block randomization assures that a determined proportion of subjects will be included in each group after a certain number of subjects have been included, keeping the proportions of participants in the active and sham groups as similar as possible to desired proportions throughout the study [29].
The randomization table was kept in a locked cabinet and in password-protected files, accessible only to the investigator who administered tDCS and the principal investigator.
Patients and researchers who administered physical therapy or evaluated outcomes were not aware of group assignment.
2.3.2. Intervention
Participants underwent three sessions of treatment per week over two weeks (total of six sessions) (Figure 1). In each session, a rubber sponge anode () soaked in saline solution was placed over the ipsilesional supraorbital area and fixed by a nonconducting, nonabsorbent elastic strap. The cathode was placed on the contralesional C3/C4 position according to the EEG 10-20 reference system [27, 30]. The intensity of stimulation was 1 mA, and ramps up and down lasted for 10 seconds (DC-stimulator plus, Neuroconn, Germany).
... Of these, 189 articles were omitted for several reasons, as described in Figure 1. Finally, 26 studies (Chang et al., 2010;Wang et al., 2012Wang et al., , 2016Wang et al., , 2019Kakuda et al., 2013;Cha et al., 2014;Chieffo et al., 2014;Elkholy et al., 2014;Ji et al., 2014;Kim et al., 2014b;Cha and Kim, 2015;Ji and Kim, 2015;Lin et al., 2015Lin et al., , 2019Choi et al., 2016;Du et al., 2016;Rastgoo et al., 2016;Cha and Kim, 2017;Forogh et al., 2017;Guan et al., 2017;Meng and Song, 2017;Chen, 2018;Huang et al., 2018;Zhao et al., 2018;Koch et al., 2019;Liu et al., 2019) were included (24 two-arm and 2 threearm trials) in the quantitative synthesis, providing information on 30 comparisons among five different rTMS interventions (Figure 1). ...
... Of the 26 enrolled studies, 22 (Chang et al., 2010;Wang et al., 2012;Cha et al., 2014;Elkholy et al., 2014;Ji et al., 2014;Kim et al., 2014b;Cha and Kim, 2015;Ji and Kim, 2015;Lin et al., 2015Lin et al., , 2019Du et al., 2016;Wang et al., 2016;Cha and Kim, 2017;Forogh et al., 2017;Guan et al., 2017;Meng and Song, 2017;Chen, 2018;Huang et al., 2018;Zhao et al., 2018;Koch et al., 2019;Liu et al., 2019;Wang et al., 2019) were RCTs, while the remaining studies were crossover trials (Kakuda et al., 2013;Chieffo et al., 2014;Choi et al., 2016;Rastgoo et al., 2016). Overall, 943 participants (aged 57.17 ± 11.95 years; 610 [65%] men) were randomized to treatment. ...
... The baseline characteristics were equivalent between competing treatments. Among 18 studies (Chang et al., 2010;Wang et al., 2012Wang et al., , 2016Wang et al., , 2019Chieffo et al., 2014;Elkholy et al., 2014;Lin et al., 2015Lin et al., , 2019Du et al., 2016;Rastgoo et al., 2016;Forogh et al., 2017;Guan et al., 2017;Meng and Song, 2017;Chen, 2018;Huang et al., 2018;Zhao et al., 2018;Koch et al., 2019;Liu et al., 2019) that reported the FMA as the primary outcome measure, the group comparing LF-rTMS versus sham was the most accepted comparison (Figure 2) Kim et al., 2014b;Kim, 2015, 2017;Ji and Kim, 2015;Lin et al., 2019) used speed as a measure of lower extremity function, while 12 studies Elkholy et al., 2014;Kim et al., 2014b;Choi et al., 2016;Rastgoo et al., 2016;Wang et al., 2016;Forogh et al., 2017;Chen, 2018;Huang et al., 2018;Zhao et al., 2018;Koch et al., 2019;Lin et al., 2019) also reported balance function. Cortical excitability (MEP amplitude) was assessed in six studies (Wang et al., 2012Cha et al., 2014;Du et al., 2016;Cha and Kim, 2017;Huang et al., 2018). ...
Transcranial magnetic stimulation, a type of noninvasive brain stimulation, has become an ancillary therapy for motor function rehabilitation. Most previous studies have focused on the effects of repetitive transcranial magnetic stimulation (rTMS) on motor function in stroke patients. There have been relatively few studies on the effects of different modalities of rTMS on lower extremity motor function and corticospinal excitability in patients with stroke. The MEDLINE, Embase, Cochrane Library, ISI Science Citation Index, Physiotherapy Evidence Database, China National Knowledge Infrastructure Library, and ClinicalTrials.gov databases were searched. Parallel or crossover randomized controlled trials that addressed the effectiveness of rTMS in patients with stroke, published from inception to November 28, 2019, were included. Standard pairwise meta-analysis was conducted using R version 3.6.1 with the "meta" package. Bayesian network analysis using the Markov chain Monte Carlo algorithm was conducted to investigate the effectiveness of different rTMS protocol interventions. Network meta-analysis results of 18 randomized controlled trials regarding lower extremity motor function recovery revealed that low-frequency rTMS had better efficacy in promoting lower extremity motor function recovery than sham stimulation. Network meta-analysis results of five randomized controlled trials demonstrated that high-frequency rTMS led to higher amplitudes of motor evoked potentials than low-frequency rTMS or sham stimulation. These findings suggest that rTMS can improve motor function in patients with stroke, and that low-frequency rTMS mainly affects motor function, whereas high-frequency rTMS increases the amplitudes of motor evoked potentials. More high-quality randomized controlled trials are needed to validate this conclusion. The work was registered in PROSPERO (registration No. CRD42020147055) on April 28, 2020.
... As the modern medicine advances, the mortality rate of cerebral infarction is decreasing annually, but with an increasing morbidity rate and about 30 to 36 % of patients still suffer from the dysfunction of upper limbs at 6 mo after onset or longer [1] . Therapeutic regimen in recovery period of cerebral infarction directly reflects the morbidity and life quality of patients, and rehabilitation, as the major method for treatment, includes the targeted training for motor, linguistic and thinking functions, but the improvement in some patients remains poor [2,3] . Hyperbaric oxygen treatment refers to the inhalation of oxygen under the pressure over one barometric pressure, providing novel thought for the treatment of patients with nerve injury, and improving the postoperative nerve function as per the current evidence [4] . ...
... Auch der zweite Ansatzpunkt, die Reduktion der kontraläsionellen M1-Aktivität mittels inhibitorischer rTMS, kann in der subakuten Phase nach Schlaganfall zu einer Verbesserung der Motorik führen [63][64][65][66][67]. So konnten wir bspw. in früheren Studien bei Patienten in der späten Subakutphase, 2 ± 1 Monate nach Schlaganfall, zeigen, dass 1 Hz-rTMS (600 Pulse, 100 % RMT) nicht nur die motorische Performanz der paretischen Hand verbesserte, sondern dass diese Verbesserung sowohl mit einer Reduktion der Überaktivität in den stimulierten sowie ipsiläsionellen Regionen als auch mit einer Reduktion der inhibitorischen Einflüsse des kontraläsionellen M1 assoziiert war [69,70]. ...
Zusammenfassung
Im Bereich der non-invasiven Hirnstimulation stellen die transkranielle Magnetstimulation (engl. transcranial magnetic stimulation, TMS) sowie die transkranielle Gleichstromstimulation (engl. transcranial direct current stimulation, tDCS) bis heute die wichtigsten Techniken zur Modulation kortikaler Erregbarkeit dar. Beide Verfahren induzieren Nacheffekte, welche die Zeit der reinen Stimulation überdauern, und ebnen damit den Weg für ihren therapeutischen Einsatz beim Schlaganfall. In diesem Übersichtsartikel diskutieren wir die aktuelle Datenlage TMS- und tDCS-vermittelter Therapien für die häufigsten schlaganfallbedingten Defizite wie Hemiparese, Aphasie und Neglect. Darüber hinaus adressieren wir mögliche Einschränkungen der gegenwärtigen Ansätze und zeigen Ansatzpunkte auf, um Neuromodulation nach Schlaganfall effektiver zu gestalten und damit das Outcome der Patienten zu verbessern.
... Thrombolytic therapy is a commonly used method for the treatment of ACI, and the optimal treatment scheme is still controversial. It is extremely difficult to completely cure cerebral vascular diseases due to brain tissue necrosis, which is likely to cause lifelong neurological dysfunction diseases to patients [17,18]. Therefore, by comparing the clinical efficacy of intra-arterial thrombolysis and arteriovenous thrombolysis combined with mechanical thrombectomy on ACI, and further analyzing the nerve injury of patients, this experiment is of great significance to the future clinical treatment of ACI patients for thrombolysis. ...
Objective:
To investigate the effects of arteriovenous thrombolysis combined with mechanical thrombectomy on clinical efficacy, neurological function, and the changes of nerve injury markers of acute cerebral infarct (ACI) patients.
Methods:
A total of 143 cases with ACI admitted to our hospital from June 2017 to June 2019 were elected as research subjects. Among them, 69 cases of patients who received treatment of arteriovenous thrombolysis were considered as group A, and 74 cases of patients who received treatment of arteriovenous thrombolysis combined with mechanical thrombectomy were considered as group B. NIHSS score, clinical efficacy, vascular recanalization, adverse reactions, hemodynamics, neurological injury indexes, duration of coma, length of hospital stay, and prognosis of patients in the two groups were compared.
Results:
After treatment, the NIHSS score of group A was higher than that of group B (P < 0.05), the clinical efficacy of group B was better than that of group A, and the incidence of adverse reactions was lower than that of group A (P < 0.05). There was no difference in vascular recanalization rate, duration of coma, and prognosis between the two groups (P > 0.05). Length of hospital stay, maximum peak velocity after treatment (Vs), and mean flow rate (Vm) of group A were lower than those of group B, while vascular resistance index (RI), pulsatility index (PI), serum glutamic acid (Glu), neuron-specific enolase (NES), and S100β protein detected by enzyme-linked immunosorbent assay (ELISA) of group A were higher than those of group B (P < 0.05).
Conclusion:
Arteriovenous thrombolysis combined with mechanical thrombectomy has a significant effect on ACI, with high safety and quick effect. In addition, it has a stronger effect on improving and protecting the neurological function of patients, which is worth promoting in clinical practice.
... In the postacute stage after stroke, most studies concerned LF-rTMS protocols delivered to the ''unaffected", contralesional motor cortex. During the 2014-2018 period of this review, 11 shamcontrolled studies were published with protocols based on 5 to 30 daily sessions of LF-rTMS (Wang et al., 2014b;Blesneag et al., 2015;Lin et al., 2015b: Lüdemann-Podubecká et al., 2015Matsuura et al., 2015;Zheng et al., 2015;Du et al., 2016a;Li et al., 2016b;Meng and Song, 2017;Huang et al., 2018b;Long et al., 2018) (Table 3). ...
... Eight studies aimed at assessing clinical changes produced by a contralesional LF-rTMS protocol on upper limb motor function (Wang et al., 2014b;Lüdemann-Podubecká et al., 2015;Matsuura et al., 2015;Zheng et al., 2015;Du et al., 2016a;Li et al., 2016b;Meng and Song, 2017;Long et al., 2018). In one study (Lüdemann-Podubecká et al., 2015), the impact of rTMS differed according to the location of stroke in the dominant or nondominant hemisphere: contralesional LF-rTMS was only beneficial for hand dexterity in patients with stroke in the dominant hemisphere. ...
A group of European experts reappraised the guidelines on the therapeutic efficacy of repetitive transcranial magnetic stimulation (rTMS) previously published in 2014 [Lefaucheur et al., Clin Neurophysiol 2014;125:2150-206]. These updated recommendations take into account all rTMS publications, including data prior to 2014, as well as currently reviewed literature until the end of 2018. Level A evidence (definite efficacy) was reached for: high-frequency (HF) rTMS of the primary motor cortex (M1) contralateral to the painful side for neuropathic pain; HF-rTMS of the left dorsolateral prefrontal cortex (DLPFC) using a figure-of-8 or a H1-coil for depression; low-frequency (LF) rTMS of contralesional M1 for hand motor recovery in the post-acute stage of stroke. Level B evidence (probable efficacy) was reached for: HF-rTMS of the left M1 or DLPFC for improving quality of life or pain, respectively, in fibromyalgia; HF-rTMS of bilateral M1 regions or the left DLPFC for improving motor impairment or depression, respectively, in Parkinson's disease; HF-rTMS of ipsilesional M1 for promoting motor recovery at the post-acute stage of stroke; intermittent theta burst stimulation targeted to the leg motor cortex for lower limb spasticity in multiple sclerosis; HF-rTMS of the right DLPFC in posttraumatic stress disorder; LF-rTMS of the right inferior frontal gyrus in chronic post-stroke non-fluent aphasia; LF-rTMS of the right DLPFC in depression; and bihemispheric stimulation of the DLPFC combining right-sided LF-rTMS (or continuous theta burst stimulation) and left-sided HF-rTMS (or intermittent theta burst stimulation) in depression. Level A/B evidence is not reached concerning efficacy of rTMS in any other condition. The current recommendations are based on the differences reached in therapeutic efficacy of real vs. sham rTMS protocols, replicated in a sufficient number of independent studies. This does not mean that the benefit produced by rTMS inevitably reaches a level of clinical relevance.
... Clinical studies have found that patients with stroke have altered their collaborative working ability of multiple brain regions, such as decreased connectivity between the premotor area and the primary motor area, increased inhibition of the affected hemisphere, and functional connectivity of these abnormalities are significantly correlated with the degree of motor function decline (36)(37)(38). As we known, rTMS could regulate the magnitude of transcallosal inhibition and influence the information interaction of brain functional regions (14,39). Studies have shown that the activation of the ipsilateral primary motor area (M1) is associated with motor function recovery and amelioration (40,41). ...
Objective: To investigate the effects of low frequency transcranial magnetic stimulation (LF-rTMS) combined with motor imagery (MI) on upper limb motor function during stroke rehabilitation.
Background: Hemiplegic upper extremity activity obstacle is a common movement disorder after stroke. Compared with a single intervention, sequential protocol or combination of several techniques has been proven to be better for alleviating motor function disorder. Non-invasive neuromodulation techniques such as repetitive transcranial magnetic stimulation (rTMS) and motor imagery (MI) have been verified to augment the efficacy of rehabilitation.
Methods:Participants were randomly assigned to 2 intervention cohorts: (1) experimental group (rTMS+MI group) was applied at 1 Hz rTMS over the primary motor cortex of the contralesional hemisphere combined with audio-based MI; (2) control group (rTMS group) received the same therapeutic parameters of rTMS combined with audiotape-led relaxation. LF-rTMS protocol was conducted in 10 sessions over 2 weeks for 30 min. Functional measurements include Wolf Motor Function Test (WMFT), the Fugl-Meyer Assessment Upper Extremity (UE-FMA) subscore, the Box and Block Test (BBT), and the Modified Barthel index (MBI) were conducted at baseline, the second week (week 2) and the fourth week (week 4).
Results: All assessments of upper limb function improved in both groups at weeks 2 and 4. In particular, significant differences were observed between two groups at end-intervention and after intervention (p < 0.05). In these findings, we saw greater changes of WMFT (p < 0.01), UE-FMA (p < 0.01), BBT (p < 0.01), and MBI (p < 0.001) scores in the experimental group.
Conclusions: LF-rTMS combined with MI had a positive effect on motor function of upper limb and can be used for the rehabilitation of upper extremity motor recovery in stroke patients.
