Feasibility and Potential Value of TMS for Upper Extremity Motor Assessment at the Bedside During Acute Stroke Hospitalization

Abstract

<h3>Research Objectives</h3> To assess the feasibility of collecting transcranial magnetic stimulation (TMS) measures at the bedside during acute stroke hospitalization and to associate TMS neurophysiology with upper extremity (UE) behavioral measures. <h3>Design</h3> The Stroke Motor reHabilitation and Recovery sTudy (SMaHRT; https://www.clinicaltrials.gov/ct2/show/NCT03485040?term=NCT03485040&draw=2&rank=1) is a prospective, observational cohort study <h3>Setting</h3> Inpatient neurology service, Massachusetts General Hospital, a large academic medical center. <h3>Participants</h3> Twenty-seven individuals (65.44 ± 12.52 years) with first-ever stroke resulting in UE weakness, who were 18 years or older, could follow simple commands in English and had no contraindications to receiving ipsilesional TMS were eligible for and included in this study. TMS was performed within 5.2 ± 2.2 days of stroke. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Feasibility of collecting TMS measures including motor evoked potentials (MEPs), resting motor threshold (RMT), cortical silent period (cSP) and ipsilateral silent period (iSP) at the hospital bedside was assessed. The main behavioral measures collected included upper extremity Fugl-Meyer Assessment (FMA-UE), grip strength, shoulder abduction finger extension (SAFE) score and 9-hole peg test. <h3>Results</h3> MEPs, RMT, cSP and iSP were collected in at least one hemisphere for 26/42 participants, of whom 15 participants did not receive testing due to medical and discharge factors. A mobile TMS cart facilitated efficient equipment transport. Additionally, coordination with nursing and use of hospital-bed or bedside chair positioning features maximized successful testing. Patients' whose lesioned hemisphere was MEP+ compared to MEP- at acute hospitalization had better affected FMA-UE, SAFE, 9HPT and grip strength scores (p<0.01). Lower RMT values were also associated with better affected FMA-UE (rho=-0.6, p<0.05), SAFE (rho=-0.5, p=0.07), and Grip Strength (rho=-0.4, p=0.23) scores. There were no clear linear trends between cSP or iSP and any behavioral outcome. <h3>Conclusions</h3> Several TMS measures are feasible to perform during acute stroke hospitalization. Interdisciplinary coordination, a mobile TMS cart, and participant positioning are essential to successful TMS testing at the hospital bedside. In addition to MEP, RMT has added value for relating to UE motor behavior during acute stroke hospitalization. <h3>Author(s) Disclosures</h3> See "Faculty Disclosures" task tab