The effects of repetitive proprioceptive stimulation on corticomotor representation in intact and hemiplegic individuals

Hybrid robot-assisted gait training for motor function in subacute stroke: a single-blind randomized controlled trial

Background

Robot-assisted gait training (RAGT) is a practical treatment that can complement conventional rehabilitation by providing high-intensity repetitive training for patients with stroke. RAGT systems are usually either of the end-effector or exoskeleton types. We developed a novel hybrid RAGT system that leverages the advantages of both types.

Objective

This single-blind randomized controlled trial evaluated the beneficial effects of the novel RAGT system both immediately after the intervention and at the 3-month follow-up in nonambulatory patients with subacute stroke.

Methods

We recruited 40 patients with subacute stroke who were equally randomized to receive conventional rehabilitation either alone or with the addition of 15 RAGT sessions. We assessed lower-extremity motor function, balance, and gait performance by using the following tools: active range of motion (AROM), manual muscle test (MMT), the Fugl–Meyer Assessment (FMA) lower-extremity subscale (FMA-LE) and total (FMA-total), Postural Assessment Scale for Stroke (PASS), Berg Balance Scale (BBS), Tinetti Performance-Oriented Mobility Assessment (POMA) balance and gait subscores, and the 3-m and 6-m walking speed and Timed Up and Go (TUG) tests. These measurements were performed before and after the intervention and at the 3-month follow-up.

Results

Both groups demonstrated significant within-group changes in the AROM, MMT, FMA-LE, FMA-total, PASS, BBS, POMA, TUG, and 3-m and 6-m walking speed tests before and after intervention and at the 3-month follow-up (p < 0.05). The RAGT group significantly outperformed the control group only in the FMA-LE (p = 0.014) and total (p = 0.002) assessments.

Conclusion

Although the novel hybrid RAGT is effective, strong evidence supporting its clinical effectiveness relative to controls in those with substantial leg dysfunction after stroke remains elusive.

Trial registration The study was registered with an International Standard Randomized Controlled Trial Number, ISRCTN, ISRCTN15088682. Registered retrospectively on September 16, 2016, at https://www.isrctn.com/ISRCTN15088682

Effect of proprioceptive stimulation using a soft robotic glove on motor activation and brain connectivity in stroke survivors

OBJECTIVE

Soft-robotic-assisted training may improve motor function during post-stroke recovery, but the underlying physiological changes are not clearly understood. We applied a single-session of intensive proprioceptive stimulation to stroke survivors using a soft robotic glove to delineate its short-term influence on brain functional activity and connectivity.

APPROACH

In this study, we utilized task-based and resting-state functional magnetic resonance imaging (fMRI) to characterize the changes in different brain networks following a soft robotic intervention. Nine stroke patients with hemiplegic upper limb engaged in resting-state and motor-task fMRI. The motor tasks comprised two conditions: active movement of fingers (active task) and glove-assisted active movement using a robotic glove (glove-assisted task), both with visual instruction. Each task was performed using bilateral hands simultaneously or the affected hand only. The same set of experiments was repeated following a 30-minute treatment of continuous passive motion (CPM) using a robotic glove.

MAIN RESULTS

On simultaneous bimanual movement, increased activation of supplementary motor area (SMA) and primary motor area (M1) were observed after CPM treatment compared to the pre-treatment condition, both in active and glove-assisted task. However, when performing the tasks solely using the affected hand, the phenomena of increased activity were not observed either in active or glove-assisted task. The comparison of the resting-state fMRI between before and after CPM showed the connectivity of the supramarginal gyrus and SMA was increased in the somatosensory network and salience network.

SIGNIFICANCE

This study demonstrates how passive motion exercise activates M1 and SMA in the post-stroke brain. The effective proprioceptive motor integration seen in bimanual exercise in contrast to the unilateral affected hand exercise suggests that the unaffected hemisphere might reconfigure connectivity to supplement damaged neural networks in the affected hemisphere. The somatosensory modulation rendered by the intense proprioceptive stimulation would affect the motor learning process in stroke survivors.

Assessment of Motor Cortex in Active, Passive and Imagery Wrist Movement Using Functional MRI

Background:

Functional Magnetic resonance imaging (fMRI) measures the small fluctuation of blood flow happening during task-fMRI in brain regions.

Objective:

This research investigated these active, imagery and passive movements in volunteers design to permit a comparison of their capabilities in activating the brain areas.

Material and Methods:

In this applied research, the activity of the motor cortex during the right-wrist movement was evaluated in 10 normal volunteers under active, passive, and imagery conditions. T2* weighted, three-dimensional functional images were acquired using a BOLD sensitive gradient-echo EPI (echo planar imaging) sequence with echo time (TE) of 30 ms and repetition time (TR) of 2000 ms. The functional data, which included 248 volumes per subject and condition, were acquired using the blocked design paradigm. The images were analyzed by the SPM12 toolbox, MATLAB software.

Results:

The findings determined a significant increase in signal intensity of the motor cortex while performing the test compared to the rest time (p< 0.05). It was also observed that the active areas in hand representation of the motor cortex are different in terms of locations and the number of voxels in different wrist directions. Moreover, the findings showed that the position of active centers in the brain is different in active, passive, and imagery conditions.

Conclusion:

Results confirm that primary motor cortex neurons play an essential role in the processing of complex information and are designed to control the direction of movement. It seems that the findings of this study can be applied for rehabilitation studies.

Somatotopic Specificity of Perceptual and Neurophysiological Changes Associated with Visuo-proprioceptive Realignment

When visual and proprioceptive estimates of hand position disagree (e.g., viewing the hand underwater), the brain realigns them to reduce mismatch. This perceptual change is reflected in primary motor cortex (M1) excitability, suggesting potential relevance for hand movement. Here, we asked whether fingertip visuo-proprioceptive misalignment affects only the brain's representation of that finger (somatotopically focal), or extends to other parts of the limb that would be needed to move the misaligned finger (somatotopically broad). In Experiments 1 and 2, before and after misaligned or veridical visuo-proprioceptive training at the index finger, we used transcranial magnetic stimulation to assess M1 representation of five hand and arm muscles. The index finger representation showed an association between M1 excitability and visuo-proprioceptive realignment, as did the pinkie finger representation to a lesser extent. Forearm flexors, forearm extensors, and biceps did not show any such relationship. In Experiment 3, participants indicated their proprioceptive estimate of the fingertip, knuckle, wrist, and elbow, before and after misalignment at the fingertip. Proprioceptive realignment at the knuckle, but not the wrist or elbow, was correlated with realignment at the fingertip. These results suggest the effects of visuo-proprioceptive mismatch are somatotopically focal in both sensory and motor domains.

Customizing Robot-Assisted Passive Neurorehabilitation Exercise Based on Teaching Training Mechanism

Passive movement is an important mean of rehabilitation for stroke survivors in the early stage or with greater paralysis. The upper extremity robot is required to assist therapists with passive movement during clinical rehabilitation, while customizing is one of the crucial issues for robot-assisted upper extremity training, which fits the patient-centeredness. Robot-assisted teaching training could address the need well. However, the existing control strategies of teaching training are usually commanded by position merely, having trouble to achieve the efficacy of treatment by therapists. And deficiency of flexibility and compliance comes to the training trajectory. This research presents a novel motion control strategy for customized robot-assisted passive neurorehabilitation. The teaching training mechanism is developed to coordinate the movement of the shoulder and elbow, ensuring the training trajectory correspondence with human kinematics. Furthermore, the motion trajectory is adjusted by arm strength to realize dexterity and flexibility. Meanwhile, the torque sensor employed in the human-robot interactive system identifies movement intention of human. The goal-directed games and feedbacks promote the motor positivity of stroke survivors. In addition, functional experiments and clinical experiments are investigated with a healthy adult and five recruited stroke survivors, respectively. The experimental results present that the suggested control strategy not only serves with safety training but also presents rehabilitation efficacy.

A Single Session of Robot-Controlled Proprioceptive Training Modulates Functional Connectivity of Sensory Motor Networks and Improves Reaching Accuracy in Chronic Stroke

BACKGROUND

Passive robot-generated arm movements in conjunction with proprioceptive decision making and feedback modulate functional connectivity (FC) in sensory motor networks and improve sensorimotor adaptation in normal individuals. This proof-of-principle study investigates whether these effects can be observed in stroke patients.

METHODS

A total of 10 chronic stroke patients with a range of stable motor and sensory deficits (Fugl-Meyer Arm score [FMA] 0-65, Nottingham Sensory Assessment [NSA] 10-40) underwent resting-state functional magnetic resonance imaging before and after a single session of robot-controlled proprioceptive training with feedback. Changes in FC were identified in each patient using independent component analysis as well as a seed region-based approach. FC changes were related to impairment and changes in task performance were assessed.

RESULTS

A single training session improved average arm reaching accuracy in 6 and proprioception in 8 patients. Two networks showing training-associated FC change were identified. Network C1 was present in all patients and network C2 only in patients with FM scores >7. Relatively larger C1 volume in the ipsilesional hemisphere was associated with less impairment ( r = 0.83 for NSA, r = 0.73 for FMA). This association was driven by specific regions in the contralesional hemisphere and their functional connections (supramarginal gyrus with FM scores r = 0.82, S1 with NSA scores r = 0.70, and cerebellum with NSA score r = -0.82).

CONCLUSION

A single session of robot-controlled proprioceptive training with feedback improved movement accuracy and induced FC changes in sensory motor networks of chronic stroke patients. FC changes are related to functional impairment and comprise bilateral sensory and motor network nodes.

Modality-specific Changes in Motor Cortex Excitability After Visuo-proprioceptive Realignment

Spatial realignment of visual and proprioceptive estimates of hand position is necessary both to keep the estimates in register over time and to compensate for sensory perturbations. Such realignment affects perceived hand position, which the brain must use to plan hand movements. We would therefore expect visuo-proprioceptive realignment to affect the motor system at some level, but the physiological basis of this interaction is unknown. Here, we asked whether activity in primary motor cortex (M1), a well-known substrate of motor control, shows evidence of change after visuo-proprioceptive realignment. In two sessions each, 32 healthy adults experienced spatially misaligned or veridical visual and proprioceptive information about their static left index finger. Participants indicated perceived finger position with no performance feedback or knowledge of results. Using TMS over the M1 representation of the misaligned finger, we found no average difference between sessions. However, regression analysis indicated that, in the misaligned session only, proprioceptive realignment was linked with a decrease in M1 activity and visual realignment was linked with an increase in M1 activity. Proprioceptive and visual realignment were inversely related to each other. These results suggest that visuo-proprioceptive realignment does indeed have a physiological impact on the motor system. The lack of a between-session mean difference in M1 activity suggests that the basis of the effect is not the multisensory realignment computation itself, independent of modality. Rather, the changes in M1 are consistent with a modality-specific neural mechanism, such as modulation of somatosensory cortex or dorsal stream visual areas that impact M1.

Shared somatosensory and motor functions in musicians

Skilled individuals are characterized by fine-tuned perceptual and motor functions. Here, we tested the idea that the sensory and motor functions of highly-trained individuals are coupled. We assessed the relationships among multifaceted somatosensory and motor functions of expert pianists. The results demonstrated a positive covariation between the acuity of weight discrimination and the precision of force control during piano keystrokes among the pianists but not among the non-musicians. However, neither the age of starting musical training nor the total amount of life-long piano practice was correlated with these sensory-motor functions in the pianists. Furthermore, a difference between the pianists and non-musicians was absent for the weight discrimination acuity but present for precise force control during keystrokes. The results suggest that individuals with innately superior sensory function had finer motor control only in a case of having undergone musical training. Intriguingly, the tactile spatial acuity of the fingertip was superior in the pianists compared with the non-musicians but was not correlated with any functions representing fine motor control among the pianists. The findings implicate the presence of two distinct mechanisms of sensorimotor learning elicited by musical training, which occur either independently in individual sensorimotor modalities or through interacting between modalities.

Sensory Plasticity in Human Motor Learning

There is accumulating evidence from behavioral, neurophysiological, and neuroimaging studies that the acquisition of motor skills involves both perceptual and motor learning. Perceptual learning alters movements, motor learning, and motor networks of the brain. Motor learning changes perceptual function and the sensory circuits of the brain. Here, we review studies of both human limb movement and speech that indicate that plasticity in sensory and motor systems is reciprocally linked. Taken together, this points to an approach to motor learning in which perceptual learning and sensory plasticity have a fundamental role.

Continuous passive movement does not influence motor maps in healthy adults

Hand weakness following stroke is often associated with a reduced representation of the hand in the primary motor cortex. Meaningful sensory input can induce sensorimotor reorganization in the brain, but the after-effect of continuous passive motion (CPM) on the cortical representation is unknown. The purpose of this study was to determine whether repeated sessions of continuous passive movement of the thumb induce a lasting increase in the motor cortical representation of a thumb muscle in healthy adults. Thirteen right-handed healthy adults (mean age 24.3 ± 4.3 years) participated in the study. Single-pulse Transcranial Magnetic Stimulation (TMS) was delivered over the motor area of the target muscle (abductor pollicis brevis) before and/or after a thirty minute session of thumb CPM administered on three consecutive days. TMS was also delivered 5 days after cessation of the CPM intervention. The response to TMS (motor evoked potential) was recorded in the target muscle with surface EMG. Resting motor threshold (RMT), motor evoked potential amplitude at a specified intensity, and the area and volume of the cortical representation of the target muscle were measured. Thumb CPM had no significant effect on TMS parameters (p > 0.05 all measures) and performance of an attention task remained unchanged within and across CPM sessions. The results suggest that three sessions of repetitive passive thumb movement is not sufficient to induce a change in the cortical representation of the thumb and is unlikely to reverse the decreased representation of the affected hand following stroke.

Structure of plasticity in human sensory and motor networks due to perceptual learning

As we begin to acquire a new motor skill, we face the dual challenge of determining and refining the somatosensory goals of our movements and establishing the best motor commands to achieve our ends. The two typically proceed in parallel, and accordingly it is unclear how much of skill acquisition is a reflection of changes in sensory systems and how much reflects changes in the brain's motor areas. Here we have intentionally separated perceptual and motor learning in time so that we can assess functional changes to human sensory and motor networks as a result of perceptual learning. Our subjects underwent fMRI scans of the resting brain before and after a somatosensory discrimination task. We identified changes in functional connectivity that were due to the effects of perceptual learning on movement. For this purpose, we used a neural model of the transmission of sensory signals from perceptual decision making through to motor action. We used this model in combination with a partial correlation technique to parcel out those changes in connectivity observed in motor systems that could be attributed to activity in sensory brain regions. We found that, after removing effects that are linearly correlated with somatosensory activity, perceptual learning results in changes to frontal motor areas that are related to the effects of this training on motor behavior and learning. This suggests that perceptual learning produces changes to frontal motor areas of the brain and may thus contribute directly to motor learning.

Perceptual learning in sensorimotor adaptation

Motor learning often involves situations in which the somatosensory targets of movement are, at least initially, poorly defined, as for example, in learning to speak or learning the feel of a proper tennis serve. Under these conditions, motor skill acquisition presumably requires perceptual as well as motor learning. That is, it engages both the progressive shaping of sensory targets and associated changes in motor performance. In the present study, we test the idea that perceptual learning alters somatosensory function and in so doing produces changes to human motor performance and sensorimotor adaptation. Subjects in these experiments undergo perceptual training in which a robotic device passively moves the subject's arm on one of a set of fan-shaped trajectories. Subjects are required to indicate whether the robot moved the limb to the right or the left and feedback is provided. Over the course of training both the perceptual boundary and acuity are altered. The perceptual learning is observed to improve both the rate and extent of learning in a subsequent sensorimotor adaptation task and the benefits persist for at least 24 h. The improvement in the present studies varies systematically with changes in perceptual acuity and is obtained regardless of whether the perceptual boundary shift serves to systematically increase or decrease error on subsequent movements. The beneficial effects of perceptual training are found to be substantially dependent on reinforced decision-making in the sensory domain. Passive-movement training on its own is less able to alter subsequent learning in the motor system. Overall, this study suggests perceptual learning plays an integral role in motor learning.

Cortical activation during executed, imagined, observed, and passive wrist movements in healthy volunteers and stroke patients

Motor imagery, passive movement, and movement observation have been suggested to activate the sensorimotor system without overt movement. The present study investigated these three covert movement modes together with overt movement in a within-subject design to allow for a fine-grained comparison of their abilities in activating the sensorimotor system, i.e. premotor, primary motor, and somatosensory cortices. For this, 21 healthy volunteers underwent functional magnetic resonance imaging (fMRI). In addition we explored the abilities of the different covert movement modes in activating the sensorimotor system in a pilot study of 5 stroke patients suffering from chronic severe hemiparesis. Results demonstrated that while all covert movement modes activated sensorimotor areas, there were profound differences between modes and between healthy volunteers and patients. In healthy volunteers, the pattern of neural activation in overt execution was best resembled by passive movement, followed by motor imagery, and lastly by movement observation. In patients, attempted overt execution was best resembled by motor imagery, followed by passive movement, and lastly by movement observation. Our results indicate that for severely hemiparetic stroke patients motor imagery may be the preferred way to activate the sensorimotor system without overt behavior. In addition, the clear differences between the covert movement modes point to the need for within-subject comparisons.

Neural control of rhythmic arm cycling after stroke

Disordered reflex activity and alterations in the neural control of walking have been observed after stroke. In addition to impairments in leg movement that affect locomotor ability after stroke, significant impairments are also seen in the arms. Altered neural control in the upper limb can often lead to altered tone and spasticity resulting in impaired coordination and flexion contractures. We sought to address the extent to which the neural control of movement is disordered after stroke by examining the modulation pattern of cutaneous reflexes in arm muscles during arm cycling. Twenty-five stroke participants who were at least 6 mo postinfarction and clinically stable, performed rhythmic arm cycling while cutaneous reflexes were evoked with trains (5 × 1.0-ms pulses at 300 Hz) of constant-current electrical stimulation to the superficial radial (SR) nerve at the wrist. Both the more (MA) and less affected (LA) arms were stimulated in separate trials. Bilateral electromyography (EMG) activity was recorded from muscles acting at the shoulder, elbow, and wrist. Analysis was conducted on averaged reflexes in 12 equidistant phases of the movement cycle. Phase-modulated cutaneous reflexes were present, but altered, in both MA and LA arms after stroke. Notably, the pattern was "blunted" in the MA arm in stroke compared with control participants. Differences between stroke and control were progressively more evident moving from shoulder to wrist. The results suggest that a reduced pattern of cutaneous reflex modulation persists during rhythmic arm movement after stroke. The overall implication of this result is that the putative spinal contributions to rhythmic human arm movement remain accessible after stroke, which has translational implications for rehabilitation.

Mirror symmetric bimanual movement priming can increase corticomotor excitability and enhance motor learning

Repetitive mirror symmetric bilateral upper limb may be a suitable priming technique for upper limb rehabilitation after stroke. Here we demonstrate neurophysiological and behavioural after-effects in healthy participants after priming with 20 minutes of repetitive active-passive bimanual wrist flexion and extension in a mirror symmetric pattern with respect to the body midline (MIR) compared to an control priming condition with alternating flexion-extension (ALT). Transcranial magnetic stimulation (TMS) indicated that corticomotor excitability (CME) of the passive hemisphere remained elevated compared to baseline for at least 30 minutes after MIR but not ALT, evidenced by an increase in the size of motor evoked potentials in ECR and FCR. Short and long-latency intracortical inhibition (SICI, LICI), short afferent inhibition (SAI) and interhemispheric inhibition (IHI) were also examined using pairs of stimuli. LICI differed between patterns, with less LICI after MIR compared with ALT, and an effect of pattern on IHI, with reduced IHI in passive FCR 15 minutes after MIR compared with ALT and baseline. There was no effect of pattern on SAI or FCR H-reflex. Similarly, SICI remained unchanged after 20 minutes of MIR. We then had participants complete a timed manual dexterity motor learning task with the passive hand during, immediately after, and 24 hours after MIR or control priming. The rate of task completion was faster with MIR priming compared to control conditions. Finally, ECR and FCR MEPs were examined within a pre-movement facilitation paradigm of wrist extension before and after MIR. ECR, but not FCR, MEPs were consistently facilitated before and after MIR, demonstrating no degradation of selective muscle activation. In summary, mirror symmetric active-passive bimanual movement increases CME and can enhance motor learning without degradation of muscle selectivity. These findings rationalise the use of mirror symmetric bimanual movement as a priming modality in post-stroke upper limb rehabilitation.

Does sensory transcutaneous electrical stimulation enhance motor recovery following a stroke? A systematic review

BACKGROUND

Somatosensory input may lead to long-lasting cortical plasticity enhanced by motor recovery in patients with neurological impairments. Sensory transcutaneous electrical stimulation (TENS) is a relatively risk-free and easy-to-implement modality for rehabilitation.

OBJECTIVE

The authors systematically examine the effects of sensory TENS on motor recovery after stroke.

METHODS

Eligible randomized or quasi-randomized trials were identified via searches of computerized databases. Two assessors reviewed independently the eligibility and methodological quality of the retrieved articles.

RESULTS

In all, 15 articles satisfied the inclusion criteria. Methodological quality was generally good, with a mean (standard deviation) PEDro score of 6.7/10 (1.2). Although the majority of studies reported significant effects on at least 1 outcome measure, effect sizes were generally small. Meta-analysis could not be performed for the majority of outcome measures because of variability between studies and insufficient data. A moderate effect was determined for force production of the ankle dorsiflexors and for the Timed Up and Go test.

CONCLUSIONS

Sensory stimulation via TENS may be beneficial to enhance aspects of motor recovery following a stroke, particularly when used in combination with active training. Because of the great variability between studies, particularly in terms of the timing of the intervention after the stroke, the outcome measures used, and the stimulation protocols, insufficient data are available to provide guidelines about strategies and efficacy.

The effect of long-term TENS on persistent neuroplastic changes in the human cerebral cortex

The long-term effect of daily somatosensory stimulation with transcutaneous electrical nerve stimulation (TENS) on reorganization of the motor cortex was investigated in a group of neurologically intact humans. The scalp representation of the corticospinal projection to the finger (APB, ADM) and forearm (FCR, ECR) muscles was mapped by means of transcranial magnetic stimulation (TMS) before and after a 3-week intervention period, using map area and volume, and topographical overlaps between the cortical motor representations of these muscles as primary dependent measures. Findings revealed a significant increase in cortical motor representation of all four muscles for the TENS group from pre to posttest (all, P ≤ 0.026). No significant changes in cortical motor representations were observed in the control group. The present observations highlight the potential benefit of sensory training by means of TENS as a useful complementary therapy in neurorehabilitation.

Cortical and spinal excitability changes after robotic gait training in healthy participants

BACKGROUND

Recent studies have proposed a role for robotic gait training in participants with acquired brain injury, but the effects on the excitability of cortical and spinal neurons even in healthy participants are uncertain.

OBJECTIVE

To investigate changes in corticospinal excitability in healthy participants after active and passive robotic gait training in a driven gait orthosis (DGO), the Lokomat.

METHODS

Thirteen healthy participants took part in 2 experiments. Each participant performed 20 minutes of active and passive gait training in a DGO. Motor evoked potentials (MEP), short-interval intracortical inhibition (SICI), intracortical facilitation (ICF), F-wave frequency, and Mmax were measured in the right tibialis anterior muscle before and after training.

RESULTS

Active training led to a decline in MEP amplitude and F-wave frequency. The MEP decline was associated with subjective muscle fatigue. Passive training induced a decrease in SICI lasting for 20 minutes after training.

CONCLUSIONS

The decline in MEP after active training is most likely because of central fatigue, whereas the decreased F-wave frequency might represent short-term plastic changes in the spinal cord. The decrease in SICI after passive training probably reflects a decrease in intracortical GABA activity, which could benefit the acquisition of new motor skills.

Sensory dysfunction following stroke: incidence, significance, examination, and intervention

Recent studies have provided evidence of the widespread incidence of sensory dysfunction following stroke. The importance of these findings lies in the association between sensory loss poststroke and poorer outcomes in motor capacity, functional abilities, length of inpatient stay, and quality of life. Since literature suggests that clinicians can use information about clients' sensory status to predict rehabilitation outcomes and select appropriate interventions, the accuracy of somatosensory assessment is extremely clinically relevant. However, many of the clinical tests that are commonly used to examine sensation have not been found to be valid or reliable. Emerging evidence supports the efficacy of several interventions that target the sensory systems. This article reviews the incidence, significance, examination, and interventions for sensory dysfunction following stroke and summarizes the important characteristics of interventions directed at somatosensation.

New advances in the rehabilitation of CNS diseases applying rTMS

Transcranial magnetic stimulation (TMS) can directly stimulate the CNS, modifying the brain's plasticity to enhance the behavior of the paretic extremities. Studies with low-frequency repetitive TMS (rTMS) on the intact hemisphere and those with high frequencies on the affected hemisphere could increase the speed of movement in the hand affected by CNS injury. Stimulation of the motor pathway may contribute to faster improvement in patients with spinal cord injury. Symptoms of Parkinson's disease (such as cognition and working memory, neglect syndrome and global aphasia) can be influenced by rTMS. However, the site of stimulation and the parameters of rTMS are different. Processes that contribute to the behavior of rTMS include the modification of brain plasticity, induction of neurogenesis, growth of new fibers in the spinal cord or all of these together. According to previous research, rTMS may be suitable as an add-on therapy to rehabilitation in CNS diseases.