Repetitive Transcranial Magnetic Stimulation as an Adjunct to Constraint-Induced Therapy

Abstract

Objective-To test the potential adjuvant effect of repetitive transcranial magnetic stimulation (rTMS) on motor learning in a group of stroke survivors undergoing constraint-induced therapy (CIT) for upper-limb hemiparesis.Design-This was a prospective randomized, double-blind, sham-controlled, parallel group study. Nineteen individuals, one or more years poststroke, were randomized to either a rTMS + CIT (n = 9) or a sham rTMS + CIT (n = 10) group and participated in the 2-wk intervention.Results-Regardless of group assignment, participants demonstrated significant gains on the primary outcome measures: the Wolf Motor Function Test (WMFT) and the Motor Activity Log (MAL)-Amount of Use, and on secondary outcome measures including the Box and Block Test (BBT) and the MAL-How Well. Participants receiving rTMS failed to show differential improvement on either primary outcome measure.Conclusions-Although this study provided further evidence that even relatively brief sessions of CIT can have a substantial effect, it provided no support for adjuvant use of rTMS. KeywordsStroke; Neuronal Plasticity; Transcranial Magnetic Stimulation; Rehabilitation; Hemiparesis Since its introduction as a noninvasive method to stimulate the human brain, 1 repetitive transcranial magnetic stimulation (rTMS) has provided a potential means to modulate cortical excitability and function. Depending on essential parameters of the stimulation frequency and number of trains of stimuli, rTMS can produce lasting up-or down-regulation of the corticospinal system. At higher frequencies (≥5 Hz) rTMS has been shown to increase excitability in the motor nervous system. 2-4 The extent to which these effects persist over time

Bihemispheric brain stimulation facilitates motor recovery in chronic stroke patients

“…Notably, a previous study in which constraint-induced movement therapy was administered (consecutively, but not simultaneously) with rTMS revealed no significant differences between real and sham stimulation on motor function of chronic stroke patients. 8 Thus, the concurrent modulation of cortical excitability and peripheral sensorimotor stimulation has the potential to enhance motor improvement and corresponding plastic changes more significantly than any one intervention by itself.…”

“…5,6 The model of interhemispheric imbalance provides a framework for developing hypotheses based on its 2 facets: 1) upregulating excitability of intact portions of the ipsilesional motor cortex and 2) downregulating excitability of the contralesional motor cortex to modulate its unrestrained inhibitory influence on ipsilesional regions. 2,4 Pilot and proof-ofprinciple studies, using either rTMS [7][8][9][10] or tDCS, [11][12][13][14] have shown both approaches to have beneficial effects on motor skills and motor learning. Furthermore, the combination of tDCS and peripheral stimulation (e.g., peripheral nerve stimulation or peripheral sensorimotor activities) seems to enhance the effects of each intervention by itself.…”

Effects of Repetitive Transcranial Magnetic Stimulation on Motor Functions in Patients With Stroke

“…28,29,35,36,38,41 However, other reports did not show measurable therapeutic effects of rTMS on motor function after stroke. [42][43][44] Because of the inconsistent findings and methodological discrepancies across these trials, there is a lack of consensus regarding the effect of rTMS on motor recovery in patients with stroke.…”

A Review of Neuromodulation in the Neurorehabilitation

“…Some studies, including randomized double-blind studyand sham stimulationcontrolled trial, have assessed their effects on motor function in people with stroke and TBI. The findings have been inconsistent [51][52][53][54].…”