A Systematic Review and Meta-Analysis on the Use of Repetitive Transcranial Magnetic Stimulation for Spasticity Poststroke

Interventional neurorehabilitation for glioma patients: A systematic review

Harnessing the neuroplastic potential of the human brain is being increasingly recognized as an important neuro-oncological paradigm to facilitate safe resection of brain tumors while preserving neurological function and quality of life. Interventional neurorehabilitation, employing both invasive and noninvasive neuromodulation techniques, represents an important emerging therapeutic strategy to induce or enhance neural plasticity to promote functional recovery in brain tumor patients. This study aimed to conduct a comprehensive review of interventional neurorehabilitation techniques for glioma patients.

Methods

In accordance with PRISMA guidelines, searches of Medline, Embase, Web of Science, APA PsycINFO, and Cochrane were undertaken from database inception to November 28, 2023. Studies reporting on neuromodulation applied to glioma patients were included.

Results

Seven studies reporting findings from 118 patients met the inclusion criteria. Three neuromodulation techniques were identified and included transcranial magnetic stimulation (TMS) reported in 5 out of 7 (71.4%) studies; transcranial direct current stimulation (tDCS); and continuous cortical electrical stimulation (cCES) using grid electrodes, reported in one study each. All studies applying noninvasive stimulation to ameliorate postoperative deficits demonstrated an improvement on at least one outcome measure. The 2 studies applying tDCS and cCES to induce plasticity reported evidence of functional reorganization.

Conclusions

There is emerging evidence of benefits of neuromodulation to improve postoperative outcome in glioma patients. In the current literature, noninvasive stimulation has shown to have a favorable safety profile. Large-scale, double-blind, sham-controlled trials are warranted to further investigate the effectiveness of these interventions for modulating different cognitive networks in patients undergoing glioma surgery.

Facilitating Corticomotor Excitability of the Contralesional Hemisphere Using Non-Invasive Brain Stimulation to Improve Upper Limb Motor Recovery from Stroke-A Scoping Review

Upper limb weakness following stroke poses a significant global psychosocial and economic burden. Non-invasive brain stimulation (NIBS) is a potential adjunctive treatment in rehabilitation. However, traditional approaches to rebalance interhemispheric inhibition may not be effective for all patients. The supportive role of the contralesional hemisphere in recovery of upper limb motor function has been supported by animal and clinical studies, particularly for those with severe strokes. This review aims to provide an overview of the facilitation role of the contralesional hemisphere for post-stroke motor recovery. While more studies are required to predict responses and inform the choice of NIBS approach, contralesional facilitation may offer new hope for patients in whom traditional rehabilitation and NIBS approaches have failed.

Comparison of Bilateral Versus Unilateral 5 Hz or 1 Hz Repetitive Transcranial Magnetic Stimulation in Subacute Stroke: Assessment of Motor Function in a Randomized Controlled Study

PURPOSE

Repetitive transcranial magnetic stimulation (rTMS) can enhance brain plasticity after stroke. At low frequencies, rTMS has an inhibitory effect, whereas at high frequencies, it has an excitatory effect. Combining both frequencies in bilateral stimulation is a new rTMS protocol under investigation, especially in the subacute stage.

METHODS

Fifty-five patients with subacute stroke were divided into four groups according to the rTMS protocol delivered: bilateral, inhibitory, excitatory, and control groups. All groups received concomitant task-oriented physiotherapy. Pretreatment to posttreatment assessment was performed twice, immediately after sessions and 1 month later. Volitional motor control was evaluated by Fugl-Meyer and Wolf motor function tests, and for spasticity, the Ashworth scale was used.

RESULTS

All groups showed significant improvement. Bilateral, inhibitory, and excitatory groups showed same efficacy, but the bilateral protocol was superior in spasticity. No correlations were found between improvement and stroke duration and site except for spasticity.

CONCLUSIONS

Bilateral rTMS shows a comparable effect to inhibitory and excitatory rTMS in improving motor disability in subacute stroke. However, it is superior for spasticity.

Functional near-infrared spectroscopy in non-invasive neuromodulation

ABSTRACT

Non-invasive cerebral neuromodulation technologies are essential for the reorganization of cerebral neural networks, which have been widely applied in the field of central neurological diseases, such as stroke, Parkinson's disease, and mental disorders. Although significant advances have been made in neuromodulation technologies, the identification of optimal neurostimulation parameters including the cortical target, duration, and inhibition or excitation pattern is still limited due to the lack of guidance for neural circuits. Moreover, the neural mechanism underlying neuromodulation for improved behavioral performance remains poorly understood. Recently, advancements in neuroimaging have provided insight into neuromodulation techniques. Functional near-infrared spectroscopy, as a novel non-invasive optical brain imaging method, can detect brain activity by measuring cerebral hemodynamics with the advantages of portability, high motion tolerance, and anti-electromagnetic interference. Coupling functional near-infrared spectroscopy with neuromodulation technologies offers an opportunity to monitor the cortical response, provide real-time feedback, and establish a closed-loop strategy integrating evaluation, feedback, and intervention for neurostimulation, which provides a theoretical basis for development of individualized precise neurorehabilitation. We aimed to summarize the advantages of functional near-infrared spectroscopy and provide an overview of the current research on functional near-infrared spectroscopy in transcranial magnetic stimulation, transcranial electrical stimulation, neurofeedback, and brain-computer interfaces. Furthermore, the future perspectives and directions for the application of functional near-infrared spectroscopy in neuromodulation are summarized. In conclusion, functional near-infrared spectroscopy combined with neuromodulation may promote the optimization of central neural reorganization to achieve better functional recovery from central nervous system diseases.

Testing spasticity mechanisms in chronic stroke before and after intervention with contralesional motor cortex 1 Hz rTMS and physiotherapy

BACKGROUND

Previous studies showed that repetitive transcranial magnetic stimulation (rTMS) reduces spasticity after stroke. However, clinical assessments like the modified Ashworth scale, cannot discriminate stretch reflex-mediated stiffness (spasticity) from passive stiffness components of resistance to muscle stretch. The mechanisms through which rTMS might influence spasticity are also not understood.

METHODS

We measured the effects of contralesional motor cortex 1 Hz rTMS (1200 pulses + 50 min physiotherapy: 3×/week, for 4-6 weeks) on spasticity of the wrist flexor muscles in 54 chronic stroke patients using a hand-held dynamometer for objective quantification of the stretch reflex response. In addition, we measured the excitability of three spinal mechanisms thought to be related to post-stroke spasticity: post-activation depression, presynaptic inhibition and reciprocal inhibition before and after the intervention. Effects on motor impairment and function were also assessed using standardized stroke-specific clinical scales.

RESULTS

The stretch reflex-mediated torque in the wrist flexors was significantly reduced after the intervention, while no change was detected in the passive stiffness. Additionally, there was a significant improvement in the clinical tests of motor impairment and function. There were no significant changes in the excitability of any of the measured spinal mechanisms.

CONCLUSIONS

We demonstrated that contralesional motor cortex 1 Hz rTMS and physiotherapy can reduce the stretch reflex-mediated component of resistance to muscle stretch without affecting passive stiffness in chronic stroke. The specific physiological mechanisms driving this spasticity reduction remain unresolved, as no changes were observed in the excitability of the investigated spinal mechanisms.

Measuring resistance to externally induced movement of the wrist joint in chronic stroke patients using an objective hand-held dynamometer

Objective

We evaluated the resistance to externally induced wrist extension in chronic stroke patients. We aimed to objectively measure and distinguish passive (muscle and soft tissue stiffness) and active (spasticity and spastic dystonia) components of the resistance.

Methods

We used a hand-held dynamometer, which measures torque, joint movement and electromyography (EMG) simultaneously, to assess the resistance to externally induced wrist extension. Slow and fast stretches were applied to the affected and unaffected wrists in 57 chronic stroke patients (57 ± 11 years). We extracted from the data parameters that represent passive and muscle activity components and assessed the validity, test-retest reliability and the clinical utility of the measurement.

Results

The analysis showed (1) a significant difference in the passive and muscle activity components between the affected and unaffected sides; (2) a significant correlation between passive and muscle activity components and the modified Ashworth scale (MAS); (3) a significant difference between the subgroups of patients stratified by the MAS; (4) an excellent intra-rater reliability on each of the passive and muscle activity components with intra-class coefficients between 0.92 and 0.99; (5) and small measurement error.

Conclusions

Using a hand-held dynamometer, we were able to objectively measure the resistance to muscle stretch in the wrist joint in chronic stroke patients and discriminate muscle overactivity components from muscle and soft tissue stiffness. We demonstrated validity, test-retest reliability and the clinical utility of the measurement.

Significance

Quantification of the different components of resistance to externally induced movement enables the objective evaluation of neurorehabilitation effects in chronic stroke patients.

Spasticity evaluation and management tools

Spasticity is a complex and often disabling symptom for patients with upper motor neuron syndromes. Although spasticity arises from neurological disease, it often cascades into muscle and soft tissue changes, which may exacerbate symptoms and further hamper function. Effective management therefore hinges on early recognition and treatment. To this end, the definition of spasticity has expanded over time to more accurately reflect the spectrum of symptoms experienced by persons with this disorder. Once identified, clinical and research quantitative assessments of spasticity are hindered by the uniqueness of presentations both for individuals and for specific neurological diagnoses. Objective measures in isolation often fail to reflect the complex functional impact of spasticity. Multiple tools exist to quantitatively or qualitatively assess the severity of spasticity, including clinician and patient-reported measures as well as electrodiagnostic, mechanical, and ultrasound measures. A combination of objective and patient-reported outcomes is likely required to better reflect the burden of spasticity symptoms in an individual. Therapeutic options exist for the treatment of spasticity along a broad spectrum from nonpharmacologic to interventional procedures. Treatment strategies may include exercise, physical agent modalities, oral medications, injections, pumps, and surgery. Optimal spasticity management most often requires a multimodal approach, combining pharmacological management with interventions that match the functional needs, goals, and preferences of the patient. Physicians and other healthcare providers who manage spasticity must be familiarized with the full array of spasticity interventions and must frequently reassess results of treatment to ensure the patient's goals of treatment are met.

Anti-spastic effect of contralesional dorsal premotor cortex stimulation in stroke patients with moderate-to-severe spastic paresis: a randomized, controlled pilot trial

OBJECTIVE

This study aimed at investigating the effect of a single-session repetitive transcranial magnetic stimulation (rTMS) of the contralesional dorsal premotor cortex on poststroke upper-limb spasticity.

MATERIAL AND METHODS

The study consisted of the following three independent parallel arms: inhibitory rTMS (n = 12), excitatory rTMS (n = 12), and sham stimulation (n = 13). The primary and secondary outcome measures were the Modified Ashworth Scale (MAS) and F/M amplitude ratio, respectively. A clinically meaningful difference was defined as a reduction in at least one MAS score.

RESULTS

There was a statistically significant change in MAS score within only the excitatory rTMS group over time [median (interquartile range) of - 1.0 (- 1.0 to - 0.5), p = 0.004]. However, groups were comparable in terms of median changes in MAS scores (p > 0.05). The proportions of patients achieving at least one MAS score reduction (9/12 in the excitatory rTMS group, 5/12 in the inhibitory rTMS group, and 5/13 in the control group) were also comparable (p = 0.135). For the F/M amplitude ratio, main time effect, main intervention effect, and time-intervention interaction effect were not statistically significant (p > 0.05).

CONCLUSIONS

Modulation of the contralesional dorsal premotor cortex with a single-session of excitatory or inhibitory rTMS does not appear to have an immediate anti-spastic effect beyond sham/placebo. The implication of this small study remains unclear and further studies into excitatory rTMS for the treatment of moderate-to-severe spastic paresis in poststroke patients should be undertaken.

CLINICAL TRIAL REGISTRATION NO

NCT04063995 (clinicaltrials.gov).

Neurorehabilitation in Multiple Sclerosis-A Review of Present Approaches and Future Considerations

Multiple sclerosis is an increasingly prevalent disease, representing the leading cause of non-traumatic neurological disease in Europe and North America. The most common symptoms include gait deficits, balance and coordination impairments, fatigue, spasticity, dysphagia and an overactive bladder. Neurorehabilitation therapeutic approaches aim to alleviate symptoms and improve the quality of life through promoting positive immunological transformations and neuroplasticity. The purpose of this study is to evaluate the current treatments for the most debilitating symptoms in multiple sclerosis, identify areas for future improvement, and provide a reference guide for practitioners in the field. It analyzes the most cited procedures currently in use for the management of a number of symptoms affecting the majority of patients with multiple sclerosis, from different training routines to cognitive rehabilitation and therapies using physical agents, such as electrostimulation, hydrotherapy, cryotherapy and electromagnetic fields. Furthermore, it investigates the quality of evidence for the aforementioned therapies and the different tests applied in practice to assess their utility. Lastly, the study looks at potential future candidates for the treatment and evaluation of patients with multiple sclerosis and the supposed benefits they could bring in clinical settings.

The effectiveness and safety of repetitive transcranial magnetic stimulation on spasticity after upper motor neuron injury: A systematic review and meta-analysis

To systematically evaluate the effectiveness and safety of repetitive transcranial magnetic stimulation (rTMS) on spasticity after upper motor neuron (UMN) injury. Eight electronic databases were searched from inception to August 6, 2022. Randomized controlled trials (RCTs) investigating the effectiveness and safety of rTMS on spasticity after UMN injury were retrieved. Two reviewers independently screened studies, extracted data, and assessed the risk of bias. Review Manager 5.3 and Stata 14.0 software were used to synthesize data. The certainty of the evidence was appraised with the Grade of Recommendation, Assessment, Development and Evaluation tool. Forty-two studies with a total of 2,108 patients were included. The results of meta-analysis revealed that, compared with control group, rTMS could significantly decrease scores of the Modified Ashworth Scale (MAS) in patients with UMN injury. The subgroup analysis discovered that rTMS effectively decreased the MAS scores in patients with stroke. Meanwhile, rTMS treatment > 10 sessions has better effect and rTMS could decrease the MAS scores of upper limb. Thirty-three patients complained of twitching facial muscles, headache and dizziness, etc. In summary, rTMS could be recommended as an effective and safe therapy to relieve spasticity in patients with UMN injury. However, due to high heterogeneity and limited RCTs, this conclusion should be treated with caution.

Repetitive transcranial magnetic stimulation of the primary motor cortex in stroke survivors-more than motor rehabilitation: A mini-review

Stroke is a leading cause of morbidity and mortality among elderly populations worldwide. During the early phase of stroke, restoring blood circulation is of utmost importance to protect neurons from further injury. Once the initial condition is stabilized, various rehabilitation techniques can be applied to help stroke survivors gradually regain their affected functions. Among these techniques, transcranial magnetic stimulation (TMS) has emerged as a novel method to assess and modulate cortical excitability non-invasively and aid stroke survivors in the rehabilitation process. Different cortical regions have been targeted using TMS based on the underlying pathology and distorted function. Despite the lack of a standard operational procedure, repetitive TMS (rTMS) of the primary motor cortex (M1) is considered a promising intervention for post-stroke motor rehabilitation. However, apart from the motor response, mounting evidence suggests that M1 stimulation can be employed to treat other symptoms such as dysphagia, speech impairments, central post-stroke pain, depression, and cognitive dysfunction. In this mini-review, we summarize the therapeutic uses of rTMS stimulation over M1 in stroke survivors and discuss the potential mechanistic rationale behind it.

Effects of Peripheral Electromagnetic Fields on Spasticity: A Systematic Review

Electromagnetic fields are emerging as a therapeutic option for patients with spasticity. They have been applied at brain or peripheral level. The effects of electromagnetic fields applied to the brain have been extensively studied for years in spasticity, but not so at the peripheral level. Therefore, the purpose of our work is to analyze the effects of electromagnetic fields, applied peripherally to spasticity. A systematic review was conducted resulting in 10 clinical trials. The frequency ranged from 1 Hz to 150 Hz, with 25 Hz being the most commonly used and the intensity it was gradually increased but there was low homogeneity in how it was increased. Positive results on spasticity were found in 80% of the studies: improvements in stretch reflex threshold, self questionnaire about difficulties related to spasticity, clinical spasticity score, performance scale, Ashworth scale, spastic tone, Hmax/Mmax Ratio and active and passive dorsal flexion. However, results must be taken with caution due to the large heterogeneity and the small number of articles. In future studies, it would be interesting to agree on the parameters to be used, as well as the way of assessing spasticity, to be more objective in the study of their effectiveness.

Non-invasive brain stimulation in rehabilitation

Non-invasive brain stimulation (NIBS) has been seen more common in rehabilitation settings. It can be used for the treatment of stroke, spinal cord injury, traumatic brain injury and multiple sclerosis, as well as for some diagnostic neurophysiological measurements. Two major modalities of NIBS are transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS). As an add-on therapy to conventional rehabilitative treatments, the main goal of NIBS is to create neuromodulation by inhibiting or activating neural activity in the targeted cortical region. Indications for therapeutic NIBS in neurorehabilitation are motor recovery, aphasia, neglect, dysphagia, cognitive disorders, spasticity, and central pain. The NIBS can be regarded a safe technique with appropriate patient selection and defined treatment parameters. This review provides an overview on NIBS modalities, specifically TMS and tDCS, the working mechanisms, the stimulation techniques, areas of use, neuronavigation systems and safety considerations.

A Meta-Analysis: Whether Repetitive Transcranial Magnetic Stimulation Improves Dysfunction Caused by Stroke with Lower Limb Spasticity

Objective

To evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in improving lower limb spasticity after stroke.

Methods

The PubMed, Web of Science, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), China Biology Medicine (CBM) disc, China Science and Technology Journal Database (VIP), and Wanfang databases were searched online from their inception to May 2021 for randomized controlled trials (RCTs) involving repetitive transcranial magnetic stimulation for lower extremity spasticity after stroke. Valid data were extracted from the included literature, and the quality evaluation was conducted with the Cochrane Handbook for Systematic Reviews of Interventions along with the Physiotherapy Evidence Database scale (PE-Dro scale). The data that met the quality requirements were systematically analysed using Review Manager 5.4 software.

Results

A total of 554 patients from seven articles (nine studies) were quantitatively analysed. Outcomes included the Modified Ashworth Scale (MAS), Fugl-Meyer Assessment of Lower Extremity (FMA-LE), Modified Barthel Index (MBI), and Timed Up and Go (TUG), measured as the effect of rTMS compared with controls conditions after treatment. The systematic review showed that rTMS reduced MAS and increased MBI scores, respectively (SMD = -0.24, 95% CI [-0.45, -0.03], P = 0.02; MD = 6.14, 95% CI [-3.93,8.35], P ＜ 0.00001), compared with control conditions. Low-frequency rTMS (LF-rTMS) significantly improved FMA-LE scores (SMD = 0.32, 95% CI [0.13, 0.51], P = 0.001). However, there was no significant difference in FMA-LE scores when using high-frequency rTMS (HF-rTMS) (P > 0.1) and in TUG times (P > 0.1) between the treatment and control groups.

Conclusions

rTMS was effective in improving spasticity and activities of daily living. LF-rTMS has positive clinical effects on enhancing motor function in patients who experience lower extremity spasticity after stroke. To better validate the above conclusions, more multicentre, high-quality, and double-blind randomized controlled trials are needed.

Cerebellar Intermittent Theta-Burst Stimulation Reduces Upper Limb Spasticity After Subacute Stroke: A Randomized Controlled Trial

Objective: This study aims to explore the efficacy of cerebellar intermittent theta-burst stimulation (iTBS) on upper limb spasticity in subacute stroke patients.

Methods: A total of 32 patients with upper limb spasticity were enrolled and randomly assigned to treatment with cerebellar iTBS or sham stimulation before conventional physical therapy daily for 2 weeks. The primary outcomes included the modified Ashworth scale (MAS), the modified Tardieu scale (MTS), and the shear wave velocity (SWV). The secondary outcomes were the H-maximum wave/M-maximum wave amplitude ratio (H_max/M_max ratio), motor-evoked potential (MEP) latency and amplitude, central motor conduction time (CMCT), and the Barthel Index (BI). All outcomes were evaluated at baseline and after 10 sessions of intervention.

Results: After the intervention, both groups showed significant improvements in the MAS, MTS, SWV, and BI. In addition, patients treated with cerebellar iTBS had a significant increase in MEP amplitude, and patients treated with sham stimulation had a significant decrease in H_max/M_max ratio. Compared with the sham stimulation group, the MAS, MTS, and SWV decreased more in the cerebellar iTBS group.

Conclusion: Cerebellar iTBS is a promising adjuvant tool to reinforce the therapeutic effect of conventional physical therapy in upper limb spasticity management after subacute stroke (Chinese Clinical Trial Registry: ChiCTR1900026516).

Effectiveness of High-Frequency Transcranial Magnetic Stimulation and Physical Exercise in Women With Fibromyalgia: A Randomized Controlled Trial

OBJECTIVE

Fibromyalgia (FM) is characterized by chronic widespread pain and both physical and emotional alterations, which in turn may affect the individual's quality of life. Thus, interventions aimed at treating such symptoms, without increasing fatigue, are needed. The aim of this study was to explore the effect of high-frequency transcranial magnetic stimulation (HF-TMS) and physical exercise (PE) on pain, impact of FM, physical conditioning, and emotional status in women with FM.

METHODS

Forty-nine women with FM were randomly allocated to: (1) a PE group (PEG, n = 16), who underwent an 8-week (two 60-minute sessions/wk) low-intensity PE program; (2) a TMS group (TMSG, n = 17) receiving a 2-week (five 20-minute sessions/wk) HF-TMS intervention; and (3) a control group (CG, n = 16). Pain (ie, perceived pain and average pressure pain threshold), perceived impact of FM (ie, overall impact, symptoms, and perceived physical function), physical conditioning (ie, endurance and functional capacity, fatigue, gait velocity, and power), and emotional status (ie, anxiety, depression, stress, and satisfaction) were assessed at baseline (T0) and after the intervention (T1, at 2 weeks for TMSG and at 8 weeks for PEG and CG).

RESULTS

The TMSG showed significant improvement in all studied variables after the intervention except for satisfaction, whereas the PEG showed improved average pressure pain threshold, perceived overall impact of FM and total score, endurance and functional capacity, velocity and power, anxiety, depression, and stress. In contrast, the CG showed no improvements in any variable.

CONCLUSION

Both PE and HF-TMS are effective in improving pain, impact of FM, physical conditioning, and emotional status in people with FM; HF-TMS achieved larger improvements in emotional status than PE.

IMPACT

TMS and PE have similar benefits for physical status, whereas TMS has greater benefits than PE for emotional status in women with FM.

Neuromodulation Therapies for Spasticity Control: Now and Beyond

Spasticity is a major cause of disability following upper motor neuron (UMN) injury. The diagnosis and treatment of spasticity has been a focus of clinicians and researchers alike. In recent years, there have been significant advances both in strategies for spasticity assessment and in the development of novel treatments. Currently, several well-established spasticity management techniques fall into the major categories of physiotherapy, pharmacotherapy, and surgical management. The majority of recent developments in all of these broad categories have focused more on methods of neuromodulation instead of simple symptomatic treatment, attempting to address the underlying cause of spasticity more directly. The following narrative review briefly discusses the causes and clinical assessment of spasticity and also details the wide variety of current and developing treatment approaches for this often-debilitating condition.

The Current State of Knowledge on the Clinical and Methodological Aspects of Extracorporeal Shock Waves Therapy in the Management of Post-Stroke Spasticity-Overview of 20 Years of Experiences

In many patients after stroke, spasticity develops over time, resulting in a decrease in the patient's independence, pain, worsening mood, and, consequently, lower quality of life. In the last ten years, a rich arsenal of physical agents to reduce muscle tone such as extracorporeal shock therapy (ESWT) wave has come through. The aim of this narrative review article is to present the current state of knowledge on the use of ESWT as a supplement to the comprehensive rehabilitation of people after stroke suffering from spasticity. The PubMed and PEDro databases were searched for papers published in English from January 2000 to December 2020, 22 of which met inclusion criteria for clinical studies related to post-stroke spasticity management with ESWT. A total of 22 studies including 468 post-stroke patients-11 reports with the upper limb (267 patients) and 10 reports within the lower limb (201 patients), as well as one report including both upper and lower limb. We focused our attention on clinical and methodological aspects. Therefore, we performed the assessment of enrolled studies in terms of methodological quality using the PEDro and level of evidence using the National Institute for Health and Clinical Excellence (NICE) guidelines. Furthermore, we indicated implications for clinical practice in using ESWT for post-stroke spasticity management. Moreover, we discussed a suggestion for future research directions. In conclusion, an ESWT effectively reduces muscle tone in people with spastic limb after stroke. Further, ESWT is safe and free of undesirable side effects. The mechanism of action of ESWT on muscles affected by spasticity is still unknown. To date, no standard parameters of ESWT in post-stroke spasticity regarding intensity, frequency, location, and the number of sessions has been established. Further research, meeting the highest standards, is needed to establish uniform muscle stimulation parameters using ESWT.

Impact of Repetitive Transcranial Magnetic Stimulation on Neurocognition and Oxidative Stress in Relapsing-Remitting Multiple Sclerosis: A Case Report

Multiple sclerosis (MS) is a neurodegenerative condition whose manifestation and clinical evolution can present themselves in very different ways. Analogously, its treatment has to be personalized and the patient's response may be idiosyncratic. At this moment there is no cure for it, in addition to its clinical course sometimes being torpid, with a poor response to any treatment. However, Transcranial Magnetic Stimulation (TMS) has demonstrated its usefulness as a non-invasive therapeutic tool for the treatment of some psychiatric and neurodegenerative diseases. Some studies show that the application of rTMS implies improvement in patients with MS at various levels, but the effects at the psychometric level and the redox profile in blood have never been studied before, despite the fact that both aspects have been related to the severity of MS and its evolution. Here we present the case of a woman diagnosed with relapsing-remitting multiple sclerosis (RRMS) at the age of 33, with a rapid progression of her illness and a poor response to different treatments previously prescribed for 9 years. In view of the patient's clinical course, a compassionate treatment with rTMS for 1 year was proposed. Starting from the fourth month of treatment, when reviewing the status of her disease, the patient denoted a clear improvement at different levels. There followed out psychometric evaluations and blood analyses, that showed both an improvement in her neuropsychological functions and a reduction in oxidative stress in plasma, in correspondence with therTMS treatment.

Repetitive transcranial magnetic stimulation as an alternative therapy for stroke with spasticity: a systematic review and meta-analysis

Repetitive transcranial magnetic stimulation (rTMS) and intermittent theta-burst stimulation (iTBS) can be used to manage post-stroke spasticity, but a meta-analysis of the recent randomized-controlled trials (RCTs) is lacking. Our aim is to perform a meta-analysis of the RCTs that investigated the efficacy of rTMS in patients with post-stroke spasticity. PubMed, Embase, and Cochrane Library databases were searched for eligible papers published up to February 2020. The primary outcome was the Modified Ashworth Scale (MAS), measured as the effect of rTMS compared with controls and after rTMS (using a change score calculated separately in the active and sham treatment groups). Finally, five papers and eight data sets were included. rTMS had no significant benefit on MAS in patients with post-stroke spasticity compared to sham treatment (WMD = - 0.29, 95% CI - 0.58, 0.00; P = 0.051). When analyzing the change score in the treatment groups, a significant effect of rTMS was observed (WMD = - 0.27, 95% CI - 0.51, - 0.04; P = 0.024). When analyzing the change score in the sham treatment groups, no significant effect of sham treatment was observed, indicating no placebo effect (WMD = 0.32, 95% CI: - 0.40, 1.04; P = 0.387). We included the sample size, year of publication, percentage of male patients, and age difference in each study as covariates, and performed a meta-regression. The results showed no association between these variables and the MAS. Compared with sham stimulation, rTMS did not show a significant reduction in MAS for the patients who experienced post-stroke spasticity, but the patients reported a better outcome in MAS on a before-after scenario.

Repetitive transcranial magnetic stimulation in stroke rehabilitation: review of the current evidence and pitfalls

Acute brain ischemia causes changes in several neural networks and related cortico-subcortical excitability, both in the affected area and in the apparently spared contralateral hemisphere. The modulation of these processes through modern techniques of noninvasive brain stimulation, namely repetitive transcranial magnetic stimulation (rTMS), has been proposed as a viable intervention that could promote post-stroke clinical recovery and functional independence. This review provides a comprehensive summary of the current evidence from the literature on the efficacy of rTMS applied to different clinical and rehabilitative aspects of stroke patients. A total of 32 meta-analyses published until July 2019 were selected, focusing on the effects on motor function, manual dexterity, walking and balance, spasticity, dysphagia, aphasia, unilateral neglect, depression, and cognitive function after a stroke. Only conventional rTMS protocols were considered in this review, and meta-analyses focusing on theta burst stimulation only were excluded. Overall, both HF-rTMS and LF-rTMS have been shown to be safe and well-tolerated. In addition, the current literature converges on the positive effect of rTMS in the rehabilitation of all clinical manifestations of stroke, except for spasticity and cognitive impairment, where definitive evidence of efficacy cannot be drawn. However, routine use of a specific paradigm of stimulation cannot be recommended yet due to a significant level of heterogeneity of the studies in terms of protocols to be set and outcome measures that have to be used. Future studies need to preliminarily evaluate the most promising protocols before going on to multicenter studies with large cohorts of patients in order to achieve a definitive translation into daily clinical practice.

Repetitive transcranial magnetic stimulation in stroke rehabilitation: review of the current evidence and pitfalls

Acute brain ischemia causes changes in several neural networks and related cortico-subcortical excitability, both in the affected area and in the apparently spared contralateral hemisphere. The modulation of these processes through modern techniques of noninvasive brain stimulation, namely repetitive transcranial magnetic stimulation (rTMS), has been proposed as a viable intervention that could promote post-stroke clinical recovery and functional independence. This review provides a comprehensive summary of the current evidence from the literature on the efficacy of rTMS applied to different clinical and rehabilitative aspects of stroke patients. A total of 32 meta-analyses published until July 2019 were selected, focusing on the effects on motor function, manual dexterity, walking and balance, spasticity, dysphagia, aphasia, unilateral neglect, depression, and cognitive function after a stroke. Only conventional rTMS protocols were considered in this review, and meta-analyses focusing on theta burst stimulation only were excluded. Overall, both HF-rTMS and LF-rTMS have been shown to be safe and well-tolerated. In addition, the current literature converges on the positive effect of rTMS in the rehabilitation of all clinical manifestations of stroke, except for spasticity and cognitive impairment, where definitive evidence of efficacy cannot be drawn. However, routine use of a specific paradigm of stimulation cannot be recommended yet due to a significant level of heterogeneity of the studies in terms of protocols to be set and outcome measures that have to be used. Future studies need to preliminarily evaluate the most promising protocols before going on to multicenter studies with large cohorts of patients in order to achieve a definitive translation into daily clinical practice.

The effect of anti-gravity treadmill training for knee osteoarthritis rehabilitation on joint pain, gait, and EMG: Case report

INTRODUCTION

To date, the anti-gravity treadmill (AlterG), as a representative method of Lower body positive pressure (LBPP) treadmills, has been rarely reported for knee osteoarthritis (KOA) rehabilitation. The purpose of this case study was to setup the clinical protocol example for AlterG intervention on KOA and evaluate treatment effectiveness by 3D gait analysis combined with free EMG to explore the kinematic gait parameter changes.

PATIENT CONCERNS

A 65-year-old female patient (BMI = 26, mild obesity) undergoing "more than 7 years of KOA." The activity of the right knee joint was obviously limited and she suffered from severe pain over the past month.

DIAGNOSIS

Due to the patient's symptoms and radiographic findings, she was diagnosed with acute attack of KOA.

INTERVENTIONS

The patient has performed clinical function evaluation and gait analysis combined at pretreatment, post-treatment, and 4 months follow-up assessment. AlterG training was performed 6 days/week for 2 weeks, with up to 30 min of training per session. The training protocol included two major parts, walking and squatting in AlterG.

OUTCOMES

After 2 weeks of AlterG intervention, the 10-m walking test (10 MWT) and Timed-up-and-go (TUG) test improved significantly post-treatment, whereas the Visual Analog Scale (VAS) score decreased post-treatment. The Modified Barthel Index improved post-treatment and the patient restored basic community walk after treatment. The temporal parameter results showed that stride length (%height), mean velocity (%height), and cadence gradually increased before treatment, after treatment, and at 4-month follow-up. The right range of motion (ROM) of knee flexion-extension were gradually increased. Meanwhile, the synchronized EMG data showed that the RMS (root means square) values of the rectus femoris, semitendinosus, and biceps femoris at post-treatment were improved to different degrees than at pretreatment.

CONCLUSION

We found that for this patient with KOA, AlterG relieved pain, and was also effective at improving spatio-temporal parameters, knee flexion/extension gait pattern, and corresponding muscle strength, thereby restoring certain community activities.