Abstract
Introduction. Restoration of upper extremity (UE) functional use remains a challenge for individuals following stroke. Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive modality that modulates cortical excitability and is being explored as a means to potentially ameliorate these deficits. The purpose of this study was to evaluate, in the presence of chronic stroke, the effects of low-frequency rTMS to the contralesional hemisphere as an adjuvant to functional task practice (FTP), to improve UE functional ability. Methods. Twenty-two individuals with chronic stroke and subsequent moderate UE deficits were randomized to receive 16 sessions (4 times/week for 4 weeks) of either real-rTMS or sham-rTMS followed by 1-hour of paretic UE FTP. Results. No differences in UE outcomes were revealed between the real-rTMS and sham-rTMS intervention groups. After adjusting for baseline differences, no differences were revealed in contralesional cortical excitability postintervention. In a secondary analysis, data pooled across both groups revealed small, but statistically significant, improvements in UE behavioral measures. Conclusions. rTMS did not augment changes in UE motor ability in this population of individuals with chronic stroke. The chronicity of our participant cohort and their degree of UE motor impairment may have contributed to inability to produce marked effects using rTMS.
Highlights
Restoration of upper extremity (UE) functional use remains a challenge for individuals following stroke
With the cerebral hemispheres functionally coupled and balanced, application of low-frequency Repetitive transcranial magnetic stimulation (rTMS) to one hemisphere results in a decrease in the interhemispheric inhibition (IHI) from the stimulated to the unstimulated hemisphere [10,11,12]
Potential participants were excluded if they met any of the following criteria: (1) history of epilepsy, brain tumor, learning disorder, intellectual or developmental disabilities, drug or alcohol abuse, dementia, major head trauma, or major psychiatric illness, (2) history or radiographic evidence of arterio-venous malformation, intracortical hemorrhage, subarachnoid hemorrhage, or bilateral cerebrovascular disease, (3) history of implanted pacemaker or medication pump, metal plate in skull, or metal objects in the eye or skull, (4) use of medications known to lower seizure threshold, (5) pregnancy, (6) pain in paretic UE that would interfere with movement, (7) inability to follow 3step instructions, (8) orthopedic condition in back or upper extremity, (9) impaired corrected vision that would alter kinematics of reaching, or (10) previous exposure to rTMS
Summary
Restoration of upper extremity (UE) functional use remains a challenge for individuals following stroke. The persistence of UE impairments and the resultant inability to use the arm and hand prevents many individuals from returning to work, representing significant socioeconomic impact on the individual, the healthcare systems and society at large. While these problems are well recognized, little progress has been made in demonstrating substantive UE recovery in this population. Decreased ipsilesional cortical excitability contributes directly to decreased drive to Stroke Research and Treatment the corticospinal tract limiting activation of the contralateral musculature, and produces an imbalance between the two hemispheres as inhibition to the contralesional hemisphere is compromised [7]. With the cerebral hemispheres functionally coupled and balanced, application of low-frequency rTMS to one hemisphere results in a decrease in the interhemispheric inhibition (IHI) from the stimulated to the unstimulated hemisphere [10,11,12]
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