Intermittent theta burst stimulation enhances upper limb motor function in patients with chronic stroke: a pilot randomized controlled trial

Repetitive Transcranial Magnetic Stimulation for Motor Recovery After Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials With Low Risk of Bias

OBJECTIVES

Repetitive transcranial magnetic stimulation (rTMS) has shown promising results in enhancing motor recovery after stroke, but nuances regarding its use, such as the impact of the type and site of stimulation, are not yet established. We aimed to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) with low risk of bias to investigate the effect of rTMS on motor recovery after both ischemic and hemorrhagic stroke.

MATERIALS AND METHODS

Three databases were searched systematically for all RCTs reporting comparisons between rTMS (including theta-burst stimulation) and either no stimulation or sham stimulation up to August 19, 2022. The primary outcome measure was the Fugl-Meyer Assessment for Upper Extremity (FMA-UE). Secondary outcome measures comprised the Action Research Arm Test, Box and Block Test, Modified Ashworth Scale for the wrist, and modified Rankin Scale (mRS).

RESULTS

A total of 37 articles reporting 48 unique comparisons were included. Pooled mean FMA-UE scores were significantly higher in the experimental group than the control group after intervention (MD = 5.4 [MD = 10.7 after correction of potential publication bias], p < 0.001) and at the last follow-up (MD = 5.2, p = 0.031). On subgroup analysis, the improvements in FMA-UE scores, both after intervention and at the last follow-up, were significant in the acute/subacute stage of stroke (within six months) and for patients with more severe baseline motor impairment. Both contralesional and ipsilesional stimulation yielded significant improvements in FMA-UE at the first assessment after rTMS but not at the last follow-up, while the improvements from bilateral rTMS only achieved statistical significance at the last follow-up. Among the secondary outcome measures, only mRS was significantly improved in the rTMS group after intervention (MD = -0.5, p = 0.013) and at the last follow-up (MD = -0.9, p = 0.001).

CONCLUSIONS

Current literature supports the use of rTMS for motor recovery after stroke, especially when done within six months and for patients with more severe stroke at baseline. Future studies with larger sample sizes may be helpful in clarifying the potential of rTMS in poststroke rehabilitation.

Intermittent theta burst stimulation vs. high-frequency repetitive transcranial magnetic stimulation for post-stroke dysfunction: a Bayesian model-based network meta-analysis of RCTs

OBJECTIVE

This research aims to comprehensively assess the efficacy of intermittent theta-burst stimulation (iTBS) vs. high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) in post-stroke dysfunction.

MATERIALS AND METHODS

Until January 2024, extensive electronic database searches were conducted (PubMed, Embase, Cochrane Library, Web of Science, etc.). Fugl-Meyer Assessment for Upper Extremities (FMA-UE) was used to assess upper limb (UL) dysfunction; post-stroke dysphagia (PSD) was identified by Standardized Swallowing Assessment (SSA), Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS), and Penetration/Aspiration Scale (PAS). Results were analyzed by network meta-analysis (NMA), and the mean difference (MD) and 95% confidence intervals (95% CI) were also reported. We conducted a descriptive analysis due to the inability to synthesize data on post-stroke cognitive impairment (PSCI).

RESULTS

19 studies were included for NMA analysis. For UL disorder, the efficacy of treatments was ranked as HF-rTMS [MD (95%CI):3.00 (1.69,4.31)], iTBS [MD (95%CI): 2.16 (0.84, 3.50)], and sham stimulation (reference). For PSD, the efficacy of treatment to reduce scores of FEDSS or SSA were iTBS [FEDSS, MD (95%CI): -0.80 (-1.13, -0.47); SSA, MD (95%CI): -3.37 (-4.36, -2.38)], HF-rTMS [FEDSS, MD (95%CI): -0.43 (-0.76, -0.10); SSA, MD (95%CI): -2.62 (-3.91, -1.35)], and sham stimulation(reference). Descriptive analysis of PSCI found that both iTBS and HF-rTMS were effective in improving PSCI.

CONCLUSIONS

HF-rTMS demonstrates superior efficacy in UL dysfunction, while iTBS is more effective in PSD. Clinicians should carefully evaluate the type and severity of post-stroke dysfunction in each patient to select the most appropriate treatment.

The effectiveness of theta burst stimulation for motor recovery after stroke: a systematic review

BACKGROUND

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Motor dysfunction is a common sequela, which seriously affects the lives of patients. Theta burst stimulation (TBS) is a new transcranial magnetic therapy for improving motor dysfunction after stroke. However, there remains a lack of studies on the mechanism, theoretical model, and effectiveness of TBS in improving motor dysfunction following stroke.

OBJECTIVE

This paper provides a comprehensive overview and assessment of the current impact of TBS on motor rehabilitation following stroke and analyzes potential factors contributing to treatment effect disparities. The aim is to offer recommendations for further refining the TBS treatment approach in subsequent clinical studies while also furnishing evidence for devising tailored rehabilitation plans for stroke patients.

METHODS

This study was conducted following PRISMA guidelines. PubMed, Embase, Web of Science, and the Cochrane Library were searched systematically from the establishment of the database to February 2024. Relevant studies using TBS to treat patients with motor dysfunction after stroke will be included. Data on study characteristics, interventions, outcome measures, and primary outcomes were extracted. The Modified Downs and Black Checklist was used to assess the potential bias of the included studies, and a narrative synthesis of the key findings was finally conducted.

RESULTS

The specific mechanism of TBS in improving motor dysfunction after stroke has not been fully elucidated, but it is generally believed that TBS can improve the functional prognosis of patients by regulating motor cortical excitability, inducing neural network reorganization, and regulating cerebral circulation metabolism. Currently, most relevant clinical studies are based on the interhemispheric inhibition model (IHI), the vicariation model, and the bimodal balance-recovery model. Many studies have verified the effectiveness of TBS in improving the motor function of stroke patients, but the therapeutic effect of some studies is controversial.

CONCLUSION

Our results show that TBS has a good effect on improving motor function in stroke patients, but more large-scale, high-quality, multicenter studies are still necessary in the future to further clarify the mechanism of TBS and explore the optimal TBS treatment.

Posture-dependent modulation of marmoset cortical motor maps detected via rapid multichannel epidural stimulation

Recent neuroimaging and electrophysiological studies have suggested substantial short-term plasticity in the topographic maps of the primary motor cortex (M1). However, previous methods lack the temporal resolution to detect rapid modulation of these maps, particularly in naturalistic conditions. To address this limitation, we previously developed a rapid stimulation mapping procedure with implanted cortical surface electrodes. In this study, employing our previously established procedure, we examined rapid topographical changes in forelimb M1 motor maps in three awake male marmoset monkeys. The results revealed that although the hotspot (the location in M1 that elicited a forelimb muscle twitch with the lowest stimulus intensity) remained constant across postures, the stimulus intensity required to elicit the forelimb muscle twitch in the perihotspot region and the size of motor representations were posture-dependent. Hindlimb posture was particularly effective in inducing these modulations. The angle of the body axis relative to the gravitational vertical line did not alter the motor maps. These results provide a proof of concept that a rapid stimulation mapping system with chronically implanted cortical electrodes can capture the dynamic regulation of forelimb motor maps in natural conditions. Moreover, they suggest that posture is a crucial variable to be controlled in future studies of motor control and cortical plasticity. Further exploration is warranted into the neural mechanisms regulating forelimb muscle representations in M1 by the hindlimb sensorimotor state.

Effect of intermittent theta burst stimulation on upper limb function in stroke patients: a systematic review and meta-analysis

Background

Stroke is a serious health issue that affects individuals, families, and society. Particularly, the upper limb dysfunction caused by stroke significantly reduces the quality of life for patients and may lead to psychological issues. Current treatment modalities are not fully effective in helping patients regain upper limb motor function to optimal levels. Therefore, there is an urgent need to explore new rehabilitation methods to address this issue.

Objective

The purpose of this meta-analysis and systematic review is to explore the effects of intermittent theta burst stimulation (iTBS) on upper limb function in stroke patients.

Methods

We searched PubMed, Cochrane Library, Embase, Web of Science, PEDro and China National Knowledge Internet as of April 8, 2024. Retrieved a total of 100 articles. Standardized mean differences (SMDs) and 95% confidence intervals (CI) were calculated.

Results

The study included a total of 9 trials and involved 224 patients. The results demonstrate that compared to the control group, iTBS therapy significantly improved Fugl-Meyer assessment-upper extremity (FMA-UE) scores (SMD = 0.88; 95% CI = 0.11-1.66; P = 0.03, I 2 = 84%), Action Research Arm Test (ARAT) scores (SMD = 0.83; 95% CI = 0.16-1.50; P = 0.02, I 2 = 57%), and Barthel Index (BI) scores (SMD = 0.93; 95% CI = 0.53-1.32; P < 0.0001, I 2 = 0%) in stroke patients.

Conclusions

The comprehensive evidence suggests that iTBS has superior effects in improving upper limb function and activities of daily living in stroke patients.

Effectiveness of Intermittent Theta Burst Stimulation to Enhance Upper Extremity Recovery After Stroke: A Pilot Study

OBJECTIVES

To first investigate the effectiveness of modified constraint-ınduced movement therapy (mCIMT) in low-functioning patients with stroke (PwS). Second, we aimed to investigate the efficiency of intermittent theta-burst stimulation (iTBS), applied on intermittent days, in addition to the mCIMT in PwS.

DESIGN

A randomized, sham-controlled, single-blinded study.

SETTING

Outpatient clinic.

PARTICIPANTS

Fifteen PwS (age [mean±SD]: 66.3±9.2 years; 53% female) who were in the first 1 to 12 months after the incident were included in the study.

INTERVENTIONS

PwS were divided into 3 groups: (1) mCIMT alone; (2) mCIMT + sham iTBS; (3) mCIMT + iTBS. Each group received 15 sessions of mCIMT (1 hour/session, 3 sessions/week). iTBS was applied with 600 pulses on impaired M1 before mCIMT.

MAIN OUTCOME MEASURES

Upper extremity (UE) impairment was assessed with the Fugl-Meyer Test (FMT-UE), whereas the motor function was evaluated with the Wolf-Motor Function Test (WMFT). Motor Activity Log-28 (MAL-28) was used to evaluate the amount of use and how well (How Well Scale) the impaired UE movements.

RESULTS

With-in-group analysis revealed that all groups had statistically significant improvements based on the FMT-UE and MAL-28 (p<.05). However, the performance time and arm strength variables of WMFT were only increased in the mCIMT + iTBS group (p<.05). The only between-group difference was observed in the intracortical facilitation in favor of the mCIMT + iTBS group (p<.05). The effect size of iTBS was f=0.18.

CONCLUSIONS

Our findings suggest that mCIMT with and without the application of iTBS has increased the UE motor function in low-functioning PwS. iTBS applied on intermittent days may have additional benefits as an adjunct therapy for facilitating cortical excitability, increasing the speed and strength of the impaired UE as well as decreasing disability.

Theta burst stimulation for enhancing upper extremity motor functions after stroke: a systematic review of clinical and mechanistic evidence

This systematic review aimed to evaluate the effects of different theta burst stimulation (TBS) protocols on improving upper extremity motor functions in patients with stroke, their associated modulators of efficacy, and the underlying neural mechanisms. We conducted a meta-analytic review of 29 controlled trials published from January 1, 2000, to August 29, 2023, which investigated the effects of TBS on upper extremity motor, neurophysiological, and neuroimaging outcomes in poststroke patients. TBS significantly improved upper extremity motor impairment (Hedge's g = 0.646, p = 0.003) and functional activity (Hedge's g = 0.500, p < 0.001) compared to controls. Meta-regression revealed a significant relationship between the percentage of patients with subcortical stroke and the effect sizes of motor impairment (p = 0.015) and functional activity (p = 0.018). Subgroup analysis revealed a significant difference in the improvement of upper extremity motor impairment between studies using 600-pulse and 1200-pulse TBS (p = 0.002). Neurophysiological studies have consistently found that intermittent TBS increases ipsilesional corticomotor excitability. However, evidence to support the regional effects of continuous TBS, as well as the remote and network effects of TBS, is still mixed and relatively insufficient. In conclusion, TBS is effective in enhancing poststroke upper extremity motor function. Patients with preserved cortices may respond better to TBS. Novel TBS protocols with a higher dose may lead to superior efficacy compared with the conventional 600-pulse protocol. The mechanisms of poststroke recovery facilitated by TBS can be primarily attributed to the modulation of corticomotor excitability and is possibly caused by the recruitment of corticomotor networks connected to the ipsilesional motor cortex.

Effects of the intermittent theta burst stimulation on gait, balance and lower limbs motor function in stroke: study protocol for a double-blind randomised controlled trial with multimodal neuroimaging assessments

INTRODUCTION

Approximately, 50% of stroke survivors experience impaired walking ability 6 months after conventional rehabilitation and standard care. However, compared with upper limb motor function, research on lower limbs rehabilitation through non-invasive neuromodulation like repetitive transcranial magnetic stimulation (rTMS) has received less attention. Limited evidence exists regarding the effectiveness of intermittent theta-burst stimulation (iTBS), an optimised rTMS modality, on lower limbs rehabilitation after stroke. This study aims to evaluate the effects of iTBS on gait, balance and lower limbs motor function in stroke recovery while also exploring the underlying neural mechanisms using longitudinal analysis of multimodal neuroimaging data.

METHODS AND ANALYSIS

In this double-blinded randomised controlled trial, a total of 46 patients who had a stroke will be randomly assigned in a 1:1 ratio to receive either 15 sessions of leg motor area iTBS consisting of 600 pulses or sham stimulation over the course of 3 weeks. Additionally, conventional rehabilitation therapy will be administered following the (sham) iTBS intervention. The primary outcome measure will be the 10 m walking test. Secondary outcomes include the Fugl-Meyer assessment of the lower extremity, Timed Up and Go Test, Functional Ambulation Category Scale, Berg Balance Scale, modified Barthel Index, Mini-Mental State Examination, montreal cognitive assessment, tecnobody balance assessment encompassing both static and dynamic stability evaluations, surface electromyography recording muscle activation of the lower limbs, three-dimensional gait analysis focusing on temporal and spatial parameters as well as ground reaction force measurements, corticomotor excitability tests including resting motor threshold, motor evoked potential and recruitment curves and multimodal functional MRI scanning. Outcome measures will be collected prior to and after the intervention period with follow-up at 3 weeks.

ETHICS AND DISSEMINATION

The study has received approval from the Medical Research Ethics Committee of Wuxi Mental Health Center/Wuxi Central Rehabilitation Hospital (no. WXMHCCIRB2023LLky078). Results will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2300077431.

Comparative efficacy of different noninvasive brain stimulation protocols on upper-extremity motor function and activities of daily living after stroke: a systematic review and network meta-analysis

The objectives of the study were to systematically evaluate the rehabilitation effect of noninvasive brain stimulation (NIBS) on upper extremity motor function and activities of daily living in stroke patients and to prioritize various stimulation protocols for reliable evidence-based medical recommendations in patients with upper extremity motor dysfunction after stroke. Web of Science, PubMed, Embase, Cochrane Library, CNKI, Wanfang, VIP, and CBM were searched to collect all randomized controlled trials (RCTs) of NIBS to improve upper extremity motor function in stroke patients. The retrieval time was from the establishment of all databases to May 2023. According to the Cochrane system evaluation manual, the quality of the included studies was evaluated, and the data were extracted. Statistical analysis was carried out by using RevMan 5.3, R 4.3.0, and Stata 17.0 software. Finally, 94 RCTs were included, with a total of 5546 patients. Meta-analysis showed that NIBS improved the Fugl-Meyer assessment (FMA) score (mean difference (MD) = 6.51, 95% CI 6.20 ~ 6.82, P < 0.05), MBI score (MD = 7.69, 95% CI 6.57 ~ 8.81, P < 0.05), ARAT score (MD = 5.06, 95% CI 3.85 ~ 6.27, P < 0.05), and motor evoked potential (MEP) amplitude. The modified Ashworth scale score (MD =  - 0.37, 95% CI - 0.60 to - 0.14, P < 0.05), National Institutes of Health Stroke Scale score (MD =  - 2.17, 95% CI - 3.32 to - 1.11, P < 0.05), incubation period of MEP (MD =  - 0.72, 95% CI - 1.06 to - 0.38, P < 0.05), and central motor conduction time (MD =  - 0.90, 95% CI - 1.29 to - 0.50, P < 0.05) were decreased in stroke patients. Network meta-analysis showed that the order of interventions in improving FMA scores from high to low was anodal-transcranial direct current stimulation (tDCS) (surface under the cumulative ranking curve (SUCRA) = 83.7%) > cathodal-tDCS (SUCRA = 80.2%) > high-frequency (HF)-repetitive transcranial magnetic stimulation (rTMS) (SUCRA = 68.5%) > low-frequency (LF)-rTMS (SUCRA = 66.5%) > continuous theta burst stimulation (cTBS) (SUCRA = 54.2%) > bilateral-tDCS (SUCRA = 45.2%) > intermittent theta burst stimulation (iTBS) (SUCRA = 34.1%) > sham-NIBS (SUCRA = 16.0%) > CR (SUCRA = 1.6%). In terms of improving MBI scores, the order from high to low was anodal-tDCS (SUCRA = 88.7%) > cathodal-tDCS (SUCRA = 85.4%) > HF-rTMS (SUCRA = 63.4%) > bilateral-tDCS (SUCRA = 56.0%) > LF-rTMS (SUCRA = 54.2%) > iTBS (SUCRA = 32.4%) > sham-NIBS (SUCRA = 13.8%) > CR (SUCRA = 6.1%). NIBS can effectively improve upper extremity motor function and activities of daily living after stroke. Among the various NIBS protocols, anodal-tDCS demonstrated the most significant intervention effect, followed by cathodal-tDCS and HF-rTMS.

Priming constraint-induced movement therapy with intermittent theta burst stimulation to enhance upper extremity recovery in patients with stroke: protocol for a randomized controlled study

BACKGROUND

The treatments based on motor control and motor learning principles have gained popularity in the last 20 years, as well as non-invasive brain stimulations that enhance neuroplastic changes after stroke. However, the effect of intermittent theta burst stimulation (iTBS) in addition to evidence-based, intensive neurorehabilitation approaches such as modified constraint-induced movement therapy (mCIMT) is yet to be investigated.

AIM

We aim to establish a protocol for a randomized controlled study investigating the efficiency of mCIMT primed with iTBS after stroke.

METHODS

In this randomized controlled, single-blind study, patients with stroke (N = 17) will be divided into 3 groups: (a) mCIMT + real iTBS, (b) mCIMT + sham iTBS, and (c) mCIMT alone. 600-pulse iTBS will be delivered to the primary motor cortex on the ipsilesional hemisphere, and then, patients will receive mCIMT for 1 h/session, 3 sessions/week for 5 weeks. Upper extremity recovery will be assessed with Fugl-Meyer Test-Upper Extremity and Wolf Motor Function Test. Electrophysiological assessments, such as Motor-Evoked Potentials, Resting Motor Threshold, Short-Intracortical Inhibition, and Intracortical Facilitation, will also be included.

CONCLUSIONS

In this study, a protocol of an ongoing intervention study investigating the effectiveness of iTBS on ipsilesional M1 prior to the mCIMT in patients with stroke is proposed. This will be the first study to research priming mCIMT with iTBS and it may have the potential to reveal the true effect of the iTBS when it is added to the high-quality neurorehabilitation approaches.

TRIAL REGISTRATION

Trial registration number: NCT05308667.

Synergistic efficacy of repetitive peripheral magnetic stimulation on central intermittent theta burst stimulation for upper limb function in patients with stroke: a double-blinded, randomized controlled trial

BACKGROUND

Non-invasive techniques such as central intermittent theta burst stimulation (iTBS) and repetitive peripheral magnetic stimulation (rPMS) have shown promise in improving motor function for patients with stroke. However, the combined efficacy of rPMS and central iTBS has not been extensively studied. This randomized controlled trial aimed to investigate the synergistic effects of rPMS and central iTBS in patients with stroke.

METHOD

In this study, 28 stroke patients were randomly allocated to receive either 1200 pulses of real or sham rPMS on the radial nerve of the affected limb, followed by 1200 pulses of central iTBS on the ipsilesional hemisphere. The patients received the intervention for 10 sessions over two weeks. The primary outcome measures were the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and the Action Research Arm Test (ARAT). Secondary outcomes for activities and participation included the Functional Independence Measure-Selfcare (FIM-Selfcare) and the Stroke Impact Scale (SIS). The outcome measures were assessed before and after the intervention.

RESULTS

Both groups showed significant improvement in FMA-UE and FIM-Selfcare after the intervention (p < 0.05). Only the rPMS + iTBS group had significant improvement in ARAT-Grasp and SIS-Strength and activity of daily living (p < 0.05). However, the change scores in all outcome measures did not differ between two groups.

CONCLUSIONS

Overall, the study's findings suggest that rPMS may have a synergistic effect on central iTBS to improve grasp function and participation. In conclusion, these findings highlight the potential of rPMS as an adjuvant therapy for central iTBS in stroke rehabilitation. Further large-scale studies are needed to fully explore the synergistic effects of rPMS on central iTBS.

TRIAL REGISTRATION

This trial was registered under ClinicalTrials.gov ID No.NCT04265365, retrospectively registered, on February 11, 2020.

Theta-burst stimulation as a therapeutic tool in neurological pathology: a systematic review

TBS (theta-burst stimulation) is a novel therapeutic approach in a wide range of neurological diseases. The present systematic review aims to identify the various protocols used in the last years, to assess study quality and to offer a general overview of the current state of the literature. The systematic review was conducted according to the Preferred Reporting Item for Systematic Review and Meta-Analyses (PRISMA) guidelines. We applied the following inclusion criteria: (1) population over 18 years old with diagnosed neurological disorders, (2) patients treated with sessions of theta-burst stimulation, (3) randomized-controlled clinical trials, (4) articles in the English language, and (5) studies that report response and score reduction on a validated scale of the investigated disorder or remission rates. We included in the final analysis 56 randomized controlled trials focusing on different neurological pathologies (stroke, Parkinson`s disease, multiple sclerosis, tinnitus, dystonia, chronic pain, essential tremor and tic disorder), and we extracted data regarding study design, groups and comparators, sample sizes, type of coil, stimulation parameters (frequency, number of pulses, intensity, stimulation site etc.), number of sessions, follow-up, assessment through functional connectivity and neurological scales used. We observed a great interstudy heterogenicity that leads to a difficulty in drawing plain conclusions. TBS protocols have shown promising results in improving various symptoms in patients with neurological disorders, but larger and more coherent studies, using similar stimulation protocols and evaluation scales, are needed to establish guideline recommendations.

Effects of Priming Intermittent Theta Burst Stimulation With High-Definition tDCS on Upper Limb Function in Hemiparetic Patients With Stroke: A Randomized Controlled Study

BACKGROUND

Preconditioning with cathodal high-definition transcranial direct current stimulation (HD-tDCS) can potentiate cortical plasticity induced by intermittent theta burst stimulation (iTBS) and enhance the after-effects of iTBS in healthy people. However, it is unclear whether this multi-modal protocol can enhance upper limb function in patients with stroke.

OBJECTIVE

The aim of this study was to investigate whether priming iTBS with cathodal HD-tDCS over the ipsilesional M1 can augment upper limb motor recovery in poststroke patients.

METHODS

A total of 66 patients with subacute stroke were randomly allocated into 3 groups. Group 1 received priming iTBS with HD-tDCS (referred to as the tDCS + iTBS group), Group 2 received non-priming iTBS (the iTBS group), and Group 3 received sham stimulation applied to the ipsilesional M1. One session was performed per day, 5 days per week, for 3 consecutive weeks. In Group 1, iTBS was preceded by a 20-minute session of cathodal HD-tDCS at a 10-minute interval. The primary outcome measure was the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) score. Moreover, the secondary outcome measures for muscle strength and spasticity were the Motricity Index-Upper Extremity (MI-UE) and the Modified Ashworth Scale Upper-Extremity (MAS-UE), respectively, and the Hong Kong Version of the Functional Test for the Hemiplegic Upper Extremity (FTHUE-HK) and the Modified Barthel Index (MBI) for activity and participation.

RESULTS

Significant differences were detected in the changes in FMA-UE, MI-UE, and MBI scores between the 3 groups from baseline to post-intervention (χ2FMA-UE = 10.856, P = .004; χ2MI-UE = 6.783, P = .034; χ2MBI = 9.608, P = .008). Post hoc comparisons revealed that the priming iTBS group demonstrated substantial improvements in FMA-UE (P = .004), MI-UE (P = .028), and MBI (P = 0.006) compared with those in the sham group. However, no significant difference was observed between the iTBS group and the sham group. Moreover, no significant differences were found in the changes in MAS-UE or FTHUE-HK between the groups.

CONCLUSIONS

Priming iTBS with HD-tDCS over the ipsilesional M1 cortex had beneficial effects on augmenting upper limb motor recovery and enhancing daily participation among subacute stroke patients.

Theta burst stimulation: what role does it play in stroke rehabilitation? A systematic review of the existing evidence

Various post-stroke dysfunctions often result in poor long-term outcomes for stroke survivors, but the effect of conventional treatments is limited. In recent years, lots of studies have confirmed the effect of repetitive transcranial magnetic stimulation (rTMS) in stroke rehabilitation. As a new pattern of rTMS, theta burst stimulation (TBS) was proved recently to yield more pronounced and long-lasting after-effects than the conventional pattern at a shorter stimulation duration. To explore the role of TBS in stroke rehabilitation, this review summarizes the existing evidence from all the randomized controlled trials (RCTs) so far on the efficacy of TBS applied to different post-stroke dysfunctions, including cognitive impairment, visuospatial neglect, aphasia, dysphagia, spasticity, and motor dysfunction. Overall, TBS promotes the progress of stroke rehabilitation and may serve as a preferable alternative to traditional rTMS. However, it's hard to recommend a specific paradigm of TBS due to the limited number of current studies and their heterogeneity. Further high-quality clinical RCTs are needed to determine the optimal technical settings and intervention time in stroke survivors.

Effects of robot-assisted upper limb training combined with intermittent theta burst stimulation (iTBS) on cortical activation in stroke patients: A functional near-infrared spectroscopy study

BACKGROUND

The therapeutic effect and mechanism of robot-assisted upper limb training (RT) combined with intermittent theta burst stimulation (iTBS) for stroke patients are unclear.

OBJECTIVE

The purpose of this study was to evaluate changes in brain activation after combination therapy and RT alone using functional near-infrared spectroscopy (fNIRS).

METHODS

Patients were randomly assigned to two groups (iTBS + RT Group, n = 18, and RT Group, n = 18). Training was conducted five times a week for four weeks. fNIRS was used to measure changes in oxyhemoglobin in both the primary motor cortex (M1) and pre-motor and supplementary motor area (pSMA) during affected limb movement. Fugl-Meyer Assessment-Upper Extremity (FMA-UE) was employed for evaluating the function of upper limbs.

RESULTS

Thirty-two patients with subacute stroke completed the study. The cortex of both hemispheres was extensively activated prior to treatment in the RT group. After training, overactivation decreased. The brain activation of the combined treatment group transferred to the affected side after the treatment. There was a notable enhancement in the FMA-UE scores for both groups, with the combined group's progress significantly surpassing that of the RT group.

CONCLUSION

RT combined with iTBS can improve the motor function of stroke patients and promote the balance between cerebral hemispheres.

Cortico-cortical stimulation and robot-assisted therapy (CCS and RAT) for upper limb recovery after stroke: study protocol for a randomised controlled trial

BACKGROUND

Since birth, during the exploration of the environment to interact with objects, we exploit both the motor and sensory components of the upper limb (UL). This ability to integrate sensory and motor information is often compromised following a stroke. However, to date, rehabilitation protocols are focused primarily on recovery of motor function through physical therapies. Therefore, we have planned a clinical trial to investigate the effect on functionality of UL after a sensorimotor transcranial stimulation (real vs sham) in add-on to robot-assisted therapy in the stroke population.

METHODS

A randomised double-blind controlled trial design involving 32 patients with a single chronic stroke (onset > 180 days) was planned. Each patient will undergo 15 consecutive sessions (5 days for 3 weeks) of paired associative stimulation (PAS) coupled with UL robot-assisted therapy. PAS stimulation will be administered using a bifocal transcranial magnetic stimulator (TMS) on the posterior-parietal cortex and the primary motor area (real or sham) of the lesioned hemisphere. Clinical, kinematics and neurophysiological changes will be evaluated at the end of protocol and at 1-month follow-up and compared with baseline. The Fugl-Meyer assessment scale will be the primary outcome. Secondly, kinematic variables will be recorded during the box-and-block test and reaching tasks using video analysis and inertial sensors. Single pulse TMS and electroencephalography will be used to investigate the changes in local cortical reactivity and in the interconnected areas.

DISCUSSION

The presented trial shall evaluate with a multimodal approach the effects of sensorimotor network stimulation applied before a robot-assisted therapy training on functional recovery of the upper extremity after stroke. The combination of neuromodulation and robot-assisted therapy can promote an increase of cortical plasticity of sensorimotor areas followed by a clinical benefit in the motor function of the upper limb.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05478434. Registered on 28 Jul 2022.

Determining the Optimal Stimulation Sessions for TMS-Induced Recovery of Upper Extremity Motor Function Post Stroke: A Randomized Controlled Trial

To find out the optimal treatment sessions of repetitive transcranial magnetic stimulation (TMS) over the primary motor cortex (M1) for upper extremity dysfunction after stroke during the 6-week treatment and to explore its mechanism using motor-evoked potentials (MEPs) and resting-state functional magnetic resonance imaging (rs-fMRI), 72 participants with upper extremity motor dysfunction after ischemic stroke were randomly divided into the control group, 10-session, 20-session, and 30-session rTMS groups. Low-frequency (1 Hz) rTMS over the contralesional M1 was applied in all rTMS groups. The motor function of the upper extremity was assessed before and after treatment. In addition, MEPs and rs-fMRI data were analyzed to detect its effect on brain reorganization. After 6 weeks of treatment, there were significant differences in the Fugl-Meyer Assessment of the upper extremity and the Wolf Motor Function Test scores between the 10-session group and the 30-session group and between the 20- and 30-session groups and the control group, while there was no significant difference between the 20-session group and the 30-session group. Meanwhile, no significant difference was found between the 10-session group and the control group. The 20-session group of rTMS decreased the excitability of the contralesional corticospinal tract represented by the amplitudes of MEPs and enhanced the functional connectivity of the ipsilesional M1 or premotor cortex with the the precentral gyrus, postcentral gyrus, and cingulate gyrus, etc. In conclusion, the 20-session of rTMS protocol is the optimal treatment sessions of TMS for upper extremity dysfunction after stroke during the 6-week treatment. The potential mechanism is related to its influence on the excitability of the corticospinal tract and the remodeling of corticomotor functional networks.

Different doses of intermittent theta burst stimulation for upper limb motor dysfunction after stroke: a study protocol for a randomized controlled trial

Background

Upper limb motor recovery is one of the important goals of stroke rehabilitation. Intermittent theta burst stimulation (iTBS), a new type of repetitive transcranial magnetic stimulation (rTMS), is considered a potential therapy. However, there is still no consensus on the efficacy of iTBS for upper limb motor dysfunction after stroke. Stimulus dose may be an important factor affecting the efficacy of iTBS. Therefore, we aim to investigate and compare the effects and neural mechanisms of three doses of iTBS on upper limb motor recovery in stroke patients, and our hypothesis is that the higher the dose of iTBS, the greater the improvement in upper limb motor function.

Methods

This prospective, randomized, controlled trial will recruit 56 stroke patients with upper limb motor dysfunction. All participants will be randomized in a 1:1:1:1 ratio to receive 21 sessions of 600 pulses active iTBS, 1,200 pulses active iTBS, 1,800 pulses active iTBS, or 1,800 pulses sham iTBS in addition to conventional rehabilitation training. The primary outcome is the Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) score from baseline to end of intervention, and the secondary outcomes are the Wolf Motor Function Test (WMFT), Grip Strength (GS), Modified Barthel Index (MBI), and Stroke Impact Scale (SIS). The FMA-UE, MBI, and SIS are assessed pre-treatment, post-treatment, and at the 3-weeks follow-up. The WMFT, GS, and resting-state functional magnetic resonance imaging (rs-fMRI) data will be obtained pre- and post-treatment.

Discussion

The iTBS intervention in this study protocol is expected to be a potential method to promote upper limb motor recovery after stroke, and the results may provide supportive evidence for the optimal dose of iTBS intervention.

Effects of central intermittent theta-burst stimulation combined with repetitive peripheral magnetic stimulation on upper limb function in stroke patients

Background

Intermittent theta-burst stimulation and repetitive peripheral magnetic stimulation can improve motor function in poststroke patients, but the therapeutic effect of this combination remains unclear.

Objective

To determine the effects of central intermittent theta-burst stimulation and repetitive peripheral magnetic stimulation on upper limb function.

Methods

Fifty-six subacute stroke patients were randomly assigned to three groups: the CMS (n = 18), peripheral magnetic stimulation (PMS) (n = 19) and CPS (n = 19) groups. The CMS group received intermittent theta-burst stimulation and peripheral false stimulation, while the PMS group received repetitive peripheral magnetic stimulation and central false stimulation once a day for five days a week over four weeks. The CPS group received intermittent theta-burst stimulation and repetitive peripheral magnetic stimulation simultaneously once daily for four weeks. The Fugl-Meyer Assessment, Action Research Arm Test, Modified Barthel Index and Modified Ashworth Scale evaluated outcomes before and after four weeks of treatment.

Results

The motor function scores of all groups were significantly increased after treatment compared with before treatment, while the Modified Ashworth Scale score showed no significant change. There was a significant difference in the motor function score of the CPS group compared with that of the CMS and PMS groups, but there was no significant improvement in the Modified Ashworth Scale score.

Conclusion

Combining the two treatment methods can improve patients' motor function and daily living abilities but cannot improve muscle tone.

The Effect of Cerebellar rTMS on Modulating Motor Dysfunction in Neurological Disorders: a Systematic Review

The effectiveness of cerebellar repetitive transcranial magnetic stimulation (rTMS) on motor dysfunction in patients with neurological disorders has received increasing attention because of its potential for neuromodulation. However, studies on the neuromodulatory effects, parameters, and safety of rTMS implementation in the cerebellum to alleviate motor dysfunction are limited. This systematic review aimed to evaluate the effectiveness and safety of cerebellar rTMS treatment for motor dysfunction caused by neurological disorders and to review popular stimulation parameters. Five electronic databases-Medline, Web of Science, Scopus, Cochrane Library, and Embase-were searched for relevant research published from inception to July 2022. All randomized controlled trials (RCTs) that reported the effects of cerebellar rTMS combined with behavioral rating scales on motor dysfunction were eligible for enrollment. Additionally, reference lists of the enrolled studies were manually checked. Among 1156 articles screened, 21 RCTs with 666 subjects were included. rTMS conducted on the cerebellum showed an improvement in stroke (spasticity, balance, and gait), cervical dystonia, Parkinson's disease (tremor), cerebellar ataxia, and essential tremor but not in multiple sclerosis. The 8-shaped coil with a diameter of 70 mm was determined as the most common therapeutic choice. None of the studies reported severe adverse events except mild side effects in three. Therefore, rTMS appears to be a promising and safe technique for the treatment of motor dysfunction, targeting the cerebellum to induce motor behavioral improvement. Further rigorous RCTs, including more samples and longer follow-up periods, are required to precisely explore the effective stimulation parameters and possible mechanisms.

Non-invasive Brain Stimulation Techniques for the Improvement of Upper Limb Motor Function and Performance in Activities of Daily Living After Stroke: A Systematic Review and Network Meta-analysis

OBJECTIVE

To compare the efficacy of non-invasive brain stimulation (NiBS) such as transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), theta-burst stimulation (TBS), and transcutaneous vagus nerve stimulation (taVNS) in upper limb stroke rehabilitation.

DATA SOURCES

PubMed, Web of Science, and Cochrane databases were searched from January 2010 to June 2022.

DATA SELECTION

Randomized controlled trials (RCTs) assessing the effects of "tDCS", "rTMS", "TBS", or "taVNS" on upper limb motor function and performance in activities of daily livings (ADLs) after stroke.

DATA EXTRACTION

Data were extracted by 2 independent reviewers. Risk of bias was evaluated with the Cochrane Risk of Bias tool.

DATA SYNTHESIS

87 RCTs with 3750 participants were included. Pairwise meta-analysis showed that all NiBS except continuous TBS (cTBS) and cathodal tDCS were significantly more efficacious than sham stimulation for motor function (standardized mean difference [SMD] range 0.42-1.20), whereas taVNS, anodal tDCS, and both low and high frequency rTMS were significantly more efficacious than sham stimulation for ADLs (SMD range 0.54-0.99). NMA showed that taVNS was more effective than cTBS (SMD:1.00; 95% CI (0.02-2.02)), cathodal tDCS (SMD:1.07; 95% CI (0.21-1.92)), and Physical rehabilitation alone (SMD:1.46; 95% CI (0.59-2.33)) for improving motor function. P-score found that taVNS is best ranked treatment in improving motor function (SMD: 1.20; 95% CI (0.46-1.95)) and ADLs (SMD:1.20; 95% CI (0.45-1.94)) after stroke. After taVNS, excitatory stimulation protocols (intermittent TBS, anodal tDCS, and HF-rTMS) are most effective in improving motor function and ADLs after acute/sub-acute (SMD range 0.53-1.63) and chronic stroke (SMD range 0.39-1.16).

CONCLUSIONS

Evidence suggests that excitatory stimulation protocols are the most promising intervention in improving upper limb motor function and performance in ADLs. taVNS appeared to be a promising intervention for stroke patients, but further large RCTs are required to confirm its relative superiority.

Evidence of rTMS for Motor or Cognitive Stroke Recovery: Hype or Hope?

BACKGROUND

Evidence of efficacy of repetitive transcranial magnetic stimulation (rTMS) for stroke recovery is hampered by an unexplained variability of reported effect sizes and an insufficient understanding of mechanisms of action. We aimed to (1) briefly summarize evidence of efficacy, (2) identify critical factors to explain the reported variation in effects, and (3) provide mechanism-based recommendations for future trials.

METHODS

We performed a systematic review of the literature according to Cochrane and PRISMA Protocols. We included trials with ≥10 patients per treatment group. We classified outcome measures according to the International Classification of Functioning, Disability, and Health. Meta-analysis was done when at least 3 trials were reported on the same construct. In case of significant summary effect sizes with significant heterogeneity, we used sensitivity analyses to test for correlations and differences between found individual effect sizes and possible effect modifiers such as patient-, repetitive transcranial magnetic stimulation-, and trial characteristics.

RESULTS

We included 57 articles (N=2595). Funnel plots showed no publication bias. We found significant effect sizes at the level of body function (upper limb synergies, muscle strength, language functioning, global cognitive functioning, visual/spatial inattention) with repetitive transcranial magnetic stimulation within or beyond 3 months after stroke. We also found significant effect sizes at the level of activities. We found no subgroup differences or significant correlations between individual summary effect sizes and any tested possible effect modifier.

CONCLUSIONS

Repetitive transcranial magnetic stimulation holds the potential to benefit a range of motor and cognitive outcomes after stroke, but the evidence of efficacy is challenged by unexplained heterogeneity across many small sampled trials. We propose large trials with the collection of individual patient data on baseline severity and brain network integrity with sufficiently powered subgroup analyses, as well as protocolized time-locked training of the target behavior. Additional neurophysiological and biomechanical data may help in understanding mechanisms and identifying biomarkers of treatment efficacy.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: CRD42022300330.

Immediate Effects of Intermittent Theta Burst Stimulation on Primary Motor Cortex in Stroke Patients: A Concurrent TMS-EEG Study

The neurophysiological effect of intermittent theta burst stimulation (iTBS) has been examined with TMS-electromyography (EMG)-based outcomes in healthy people; however, its effects in intracortical excitability and inhibition are largely unknown in patients with stroke. Concurrent transcranial magnetic stimulation and electroencephalogram (TMS-EEG) recording can be used to investigate both intracortical excitatory and inhibitory circuits of the primary motor cortex (M1) instantly and the property of brain networks at once. This study was to investigate the immediate effects of iTBS on intracortical excitatory and inhibitory circuits, neural connectivity, and network properties in patients with chronic stroke, using TMS-EEG and TMS-EMG approaches. In this randomized, sham-controlled, crossover study, 20 patients with chronic stroke received two separate stimulation conditions: a single-session iTBS or sham stimulation applied to the ipsilesional M1, in two separate visits, with a washout period of five to seven days between the two visits. A battery of TMS-EMG and TMS-EEG measurements were taken before and immediately after stimulation during the visit. Compared with sham stimulation, iTBS was effective in enhancing the amplitude of ipsilesional MEPs (p = 0.015) and P30 of TMS-evoked potentials located at the ipsilesional M1 (p = 0.037). However, iTBS did not show superior effects on ipsilesional intracortical facilitation, cortical silent period, or short-interval intracortical inhibition. Regarding the effects on TMS-related oscillations, and neural connectivity, comparisons of iTBS and sham did not yield any significant differences. iTBS facilitates intracortical excitability in patients with chronic stroke, but it does not show modulatory effects in intracortical inhibition.

Does noninvasive brain stimulation combined with other therapies improve upper extremity motor impairment, functional performance, and participation in activities of daily living after stroke? A systematic review and meta-analysis of randomized controlled trial

BACKGROUND

Several studies have investigated the effect of noninvasive brain stimulation (NIBS) on upper limb motor function in stroke, but the evidence so far is conflicting.

OBJECTIVE

We aimed to determine the effect of NIBS on upper limb motor impairment, functional performance, and participation in activities of daily living after stroke.

METHOD

Literature search was conducted for randomized controlled trials (RCTs) assessing the effect of "tDCS" or "rTMS" combined with other therapies on upper extremity motor recovery after stroke. The outcome measures were Fugl-Meyer Assessment of Upper Extremity (FMA-UE), Wolf Motor Function Test (WMFT), and Barthel Index (BI). The mean difference (MD) and 95%CI were estimated for motor outcomes. Cochrane risk of bias tool was used to assess the quality of evidence.

RESULT

Twenty-five RCTs involving 1102 participants were included in the review. Compared to sham stimulation, NIBS combined with other therapies has effectively improved FMA-UE (MD0.97 [95%CI, 0.09 to 1.86; p = .03]) and BI score (MD9.11 [95%CI, 2.27 to 15.95; p = .009]) in acute/sub-acute stroke (MD1.73 [95%CI, 0.61 to 2.85; p = .003]) but unable to modify FMA-UE score in chronic stroke (MD-0.31 [95%CI, -1.77 to 1.15; p = .68]). Only inhibitory (MD3.04 [95%CI, 1.76 to 4.31; I² = 82%, p < .001] protocol is associated with improved FMA-UE score. Twenty minutes of stimulation/session for ≥20 sessions was found to be effective in improving FMA-UE score (Stimulation time: ES0.45; p ≤ .001; Sessions: ES0.33; p ≤ .001). The NIBS did not produce any significant improvement in WMFT as compared to sham NIBS (MD0.91 [95% CI, -0.89 to 2.70; p = .32]).

CONCLUSION

Moderate to high-quality evidence suggested that NIBS combined with other therapies is effective in improving upper extremity motor impairment and participation in activities of daily living after acute/sub-acute stroke.

Clinical observation of acupuncture combined with modern rehabilitation in the treatment of limb motor dysfunction after ischemic stroke: A randomized controlled trial

BACKGROUND

Motor dysfunction is a common sequela of ischemic stroke. This study aimed to explore the effective treatment of ischemic stroke by combining acupuncture and modern rehabilitation training.

METHODS

This study was a single-center, randomized controlled clinical trial conducted at the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, 90 cases were finally included, divided into 45 cases each in the body acupuncture group and the head acupuncture group.

INTERVENTIONS

Both groups received basic drug treatment, modern rehabilitation training, and basic life care guidance; the body acupuncture group was treated with reference to acupuncture points from the classic textbook of acupuncture and moxibustion, and the head acupuncture group was given Zhu's scalp acupuncture treatment based on the body acupuncture group. Primary outcome index: unassisted muscle strength grading scale; secondary outcome index: assessment of activities of daily living; simplified Fugl-Meyer motor function rating scale.

RESULTS

The Barthel scale score, Manual Muscle Testing scale score (upper and lower limbs), and simplified Fugl-Meyer scale score (upper and lower limbs) in the 2 groups were improved (P ≤ .05), and the efficacy of the head-acupuncture group was better than that of the body-acupuncture group (P ≤ .05); there was no significant improvement in the simplified Fugl-Meyer scale (hand) score in both groups (P ≥ .05). There was no significant improvement in these scores (P ≥ .05). The difference in efficiency between the 2 groups was not statistically significant (P ≤ .05), and the apparent efficiency in the cephalic needle group was higher than that in the body needle group (P ≤ .05).

CONCLUSIONS

Simultaneous treatment with Zhu's scalp acupuncture and body acupuncture combined with modern rehabilitation training can significantly improve limb motor function in patients with ischemic stroke, and its efficacy is better than that of body acupuncture alone combined with modern rehabilitation training.

Effects of repetitive transcranial magnetic stimulation on sequelae in patients with chronic stroke: A systematic review and meta-analysis of randomized controlled trials

Background

Stroke is the second leading cause of death worldwide, with a large proportion of survivors suffering from motor dysfunction and neuropsychiatric sequelae. Repetitive transcranial magnetic stimulation (rTMS) is a promising stroke rehabilitation intervention and is effective in improving neurological system function in stroke patients. In the current systemic review and meta-analysis, an overview of the most recent studies regarding the effectiveness of rTMS's potential to help chronic stroke patients recover from sequelae was provided.

Methods

Relevant randomized controlled trials were retrieved from three online databases (Web of Science, Medline, and Embase). A total of 25 RCTs (N = 535 participants) were included. A meta-analysis was performed using a fixed-effects model or a random-effects model, and effect sizes were reported as weighted mean differences or standardized mean differences.

Results

Administration of rTMS significantly improved upper limb function, hand function, and muscle tone in stroke patients throughout the chronic phase [≥6 months], but not lower limb mobility and strength. In terms of cognitive function, rTMS has a considerable positive impact on patients' cognitive performance. rTMS also alleviated apathy in stroke patients more than post-stroke depressive symptoms regarding mental functioning. Balance and walking function, as well as functional activities of daily living, of patients were dramatically improved by rTMS. However, the current conclusions should be taken carefully due to the small sample size of the meta-analysis.

Conclusions

This is the first meta-analysis of rTMS treatment in patients with chronic stroke to inform the selection of the optimal treatment strategy for patients with chronic stroke, which demonstrated that rTMS treatment has the potential to improve the effects of sequelae by improving upper limb function, hand function, and muscle tone.

Systematic review registration

https://inplasy.com/inplasy-2022-7-0095/, identifier: INPLASY202270095.

Intermittent theta-burst stimulation with physical exercise improves poststroke motor function: A systemic review and meta-analysis

Background

Intermittent theta-burst stimulation (iTBS) is an optimized rTMS modality that could modulate the excitability of neural structures. Several studies have been conducted to investigate the efficacy of iTBS in improving the motor function of stroke patients. However, the specific role of iTBS in motor function recovery after stroke is unclear. Hence, in our study, we performed a meta-analysis to investigate the efficacy of iTBS for the motor function improvement of stroke patients.

Methods

MEDLINE, Embase, and Cochrane Library were searched until May 2022 for randomized controlled trials (RCTs).

Results

Thirteen RCTs with 334 patients were finally included in our study. The primary endpoints were the Fugl-Meyer assessment scale (FMA) and Motor Assessment Scale (MAS) change from baseline. We found that iTBS led to a significant reduction in FMA score (P = 0.002) but not in MAS score (P = 0.24) compared with the sham group. Moreover, standard 600-pulse stimulation showed a better effect on motor function improvement than the sham group (P = 0.004), however, 1200-pulse iTBS showed no effect on motor function improvement after stroke (P = 0.23). The effect of iTBS for improving motor function only exists in chronic stroke patients (P = 0.02) but not in subacute patients (P = 0.27).

Conclusion

This study supports that iTBS has good efficacy for improving motor function in stroke patients. Therefore, standard 600-pulse stimulation iTBS therapy is proper management and treatment for chronic stroke.

Barriers to Enrollment in Post-Stroke Brain Stimulation in a Racially and Ethnically Diverse Population

BACKGROUND AND PURPOSE

Brain stimulation is an adjuvant strategy to promote rehabilitation after stroke. Here, we evaluated the influence of inclusion/exclusion criteria on enrollment in a transcranial direct current stimulation (tDCS) trial in the context of a racially/ethnically diverse acute stroke service at University of Texas Southwestern (UTSW).

METHODS

3124 (59.7 ± 14.5 years) racially/ethnically diverse (38.4% non-Hispanic white, (W), Hispanic (H) 22%, African American (AA) 33.5%, Asian (A) 2.3%) patients were screened in the acute stroke service at UTSW. Demographics, stroke characteristics, and reasons for exclusion were recorded prospectively.

RESULTS

2327 (74.5%) patients had a verified stroke. Only 44 of them (1.9%) were eligible. Causes for exclusion included in order of importance: (1) magnitude of upper extremity (UE) motor impairment, (2) prior strokes (s), (3) hemorrhagic stroke, (4) psychiatric condition or inability to follow instructions, and (5) old age, of these (2) and (4) were more common in AA patients but not in other minorities. 31 of the 44 eligible individuals were enrolled (W 1.68%, H 1.37%, AA .77%, A 3.774%). 90.5% of verified stroke patients did not exhibit contraindications for stimulation.

CONCLUSIONS

3 main conclusions emerged: (a) The main limitations for inclusion in brain stimulation trials of motor recovery were magnitude of UE motor impairments and stroke lesion characteristics, (b) most stroke patients could be stimulated with tDCS without safety concerns and (c) carefully tailored inclusion criteria could increase diversity in enrollment.Clinical Trial Registration-URL: http://clinicaltrials.gov. Unique identifier: NCT01007136.

Effects of repetitive transcranial magnetic stimulation on upper-limb and finger function in stroke patients: A systematic review and meta-analysis of randomized controlled trials

Background

Repetitive transcranial magnetic stimulation (rTMS) is a promising intervention for stroke rehabilitation. Several studies have demonstrated the effectiveness of rTMS in restoring motor function. This meta-analysis aimed to summarize the current evidence of the effect of rTMS in improving upper limb function and fine motor recovery in stroke patients.

Methods

Three online databases (Web of Science, PubMed, and Embase) were searched for relevant randomized controlled trials. A total of 45 studies (combined n = 2064) were included. Random effects model was used for meta-analysis and effect size was reported as standardized mean difference (SMD).

Results

rTMS was effective in improving fine motor function in stroke patients (SMD, 0.38; 95% CI 0.19-0.58; P = 0). On subgroup analyses, for post-stroke functional improvement of the upper extremity, bilateral hemisphere stimulation was more effective than unilateral stimulation during the acute phase of stroke, and a regimen of 20 rTMS sessions produced greater improvement than <20 sessions. In the subacute phase of stroke, affected hemispheric stimulation with a 40-session rTMS regimen was superior to unaffected hemispheric stimulation or bilateral hemispheric stimulation with <40 sessions. Unaffected site stimulation with a 10-session rTMS regimen produced significant improvement in the chronic phase compared to affected side stimulation and bilateral stimulation with >10 rTMS sessions. For the rTMS stimulation method, both TBS and rTMS were found to be significantly more effective in the acute phase of stroke, but TBS was more effective than rTMS. However, rTMS was found to be more effective than TBS stimulation in patients in the subacute and chronic phases of stroke. rTMS significantly improved upper limb and fine function in the short term (0-1-month post-intervention) and medium term (2-5 months), but not for upper limb function in the long term (6 months+). The results should be interpreted with caution due to significant heterogeneity.

Conclusions

This updated meta-analysis provides robust evidence of the efficacy of rTMS treatment in improving upper extremity and fine function during various phases of stroke.

Systematic Review Registration

https://inplasy.com/inplasy-2022-5-0121/, identifier: INPLASY202250121.

The Effectiveness of Intermittent Theta Burst Stimulation for Stroke Patients With Upper Limb Impairments: A Systematic Review and Meta-Analysis

Background

Upper limb impairments are one of the most common health problems of stroke, affecting both motor function and independence in daily life. It has been demonstrated that intermittent theta burst stimulation (iTBS) increases brain excitability and improves upper limb function. Our study sought to determine the role of iTBS in stroke recovery.

Objective

The purpose of this study was to determine the efficacy of iTBS in individuals with upper limb impairments following stroke.

Methods

The databases used included Cumulative Index to PubMed, EMBASE, ESCBOhost, The Cochrane Library, Chinese Biomedical Database, Web of Science, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Technology Periodical Database (VIP), and WanFang Database. Studies published before November 2021 were included. Each participant received an iTBS-based intervention aimed at improving activity levels or impairment, which was compared to usual care, a sham intervention, or another intervention. The primary outcome measure was a change in upper limb function assessment. Secondary outcomes included impairment, participation, and quality of life measures.

Result

A total of 18 studies (n = 401 participants) that met the inclusion criteria were included in this study. There was a slight change in the upper limb function of the iTBS group compared with the control group, as measured by the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) score (mean difference 2.70, 95% CI −0.02 to 5.42, p = 0.05). Significant improvement in resting motor threshold (RMT) and motor-evoked potential (MEP) was also observed in the meta-analysis of iTBS (MD 3.46, 95% CI 2.63 to 4.28, p < 0.00001); (MD 1.34, 95% CI 1.17 to 1.51, P < 0.00001). In addition, we got similar results when the studies were using the Modified Barthel Index (MBI) assessment (mean difference of 7.34, 95% CI 0.47 to 14.21, p = 0.04).

Conclusion

Our study established the efficacy of iTBS in improving motor cortical plasticity, motor function, and daily functioning in stroke patients. However, the review requires evidence from additional randomized controlled trials and high-quality research.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/

Effects of Non-Invasive Brain Stimulation on Post-Stroke Spasticity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

In recent years, the potential of non-invasive brain stimulation (NIBS) for the therapeutic effect of post-stroke spasticity has been explored. There are various NIBS methods depending on the stimulation modality, site and parameters. The purpose of this study is to evaluate the efficacy of NIBS on spasticity in patients after stroke. This systematic review and meta-analysis was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. PUBMED (MEDLINE), Web of Science, Cochrane Library and Excerpta Medica Database (EMBASE) were searched for all randomized controlled trials (RCTs) published before December 2021. Two independent researchers screened relevant articles and extracted data. This meta-analysis included 14 articles, and all included articles included 18 RCT datasets. The results showed that repetitive transcranial magnetic stimulation (rTMS) (MD = −0.40, [95% CI]: −0.56 to −0.25, p < 0.01) had a significant effect on improving spasticity, in which low-frequency rTMS (LF-rTMS) (MD = −0.51, [95% CI]: −0.78 to −0.24, p < 0.01) and stimulation of the unaffected hemisphere (MD = −0.58, [95% CI]: −0.80 to −0.36, p < 0.01) were beneficial on Modified Ashworth Scale (MAS) in patients with post-stroke spasticity. Transcranial direct current stimulation (tDCS) (MD = −0.65, [95% CI]: −1.07 to −0.22, p < 0.01) also had a significant impact on post-stroke rehabilitation, with anodal stimulation (MD = −0.74, [95% CI]: −1.35 to −0.13, p < 0.05) being more effective in improving spasticity in patients. This meta-analysis revealed moderate evidence that NIBS reduces spasticity after stroke and may promote recovery in stroke survivors. Future studies investigating the mechanisms of NIBS in addressing spasticity are warranted to further support the clinical application of NIBS in post-stroke spasticity.

Excitatory Repetitive Transcranial Magnetic Stimulation Over the Ipsilesional Hemisphere for Upper Limb Motor Function After Stroke: A Systematic Review and Meta-Analysis

Background

Repetitive transcranial magnetic stimulation (rTMS) is a promising therapy to promote recovery of the upper limb after stroke. According to the regulation of cortical excitability, rTMS can be divided into excitatory rTMS and inhibitory rTMS, and excitatory rTMS includes high-frequency rTMS (HF-rTMS) or intermittent theta-burst stimulation (iTBS). We aimed to evaluate the effects of excitatory rTMS over the ipsilesional hemisphere on upper limb motor recovery after stroke.

Methods

Databases of PubMed, Embase, ISI Web of Science, and the Cochrane Library were searched for randomized controlled trials published before 31 December 2021. RCTs on the effects of HF-rTMS or iTBS on upper limb function in patients diagnosed with stroke were included. Two researchers independently screened the literature, extracted the data, and assessed quality. The meta-analysis was performed by using Review Manager Version 5.4 software.

Results

Fifteen studies with 449 participants were included in this meta-analysis. This meta-analysis found that excitatory rTMS had significant efficacy on upper limb motor function (MD = 5.88, 95% CI, 3.32–8.43, P < 0.001), hand strength (SMD = 0.53, 95% CI, 0.04–1.01, P = 0.03), and hand dexterity (SMD = 0.76, 95% CI, 0.39–1.14, P < 0.001). Subgroup analyses based on different types of rTMS showed that both iTBS and HF-rTMS significantly promoted upper limb motor function (iTBS, P < 0.001; HF-rTMS, P < 0.001) and hand dexterity (iTBS, P = 0.01; HF-rTMS, P < 0.001) but not hand strength (iTBS, P = 0.07; HF-rTMS, P = 0.12). Further subgroup analysis based on the duration of illness demonstrated that applying excitatory rTMS during the first 3 months (<1 month, P = 0.01; 1–3 months, P = 0.001) after stroke brought significant improvement in upper limb motor function but not in the patients with a duration longer than 3 months (P = 0.06). We found that HF-rTMS significantly enhanced the motor evoked potential (MEP) amplitude of affected hemisphere (SMD = 0.82, 95% CI, 0.32–1.33, P = 0.001).

Conclusion

Our study demonstrated that excitatory rTMS over the ipsilesional hemisphere could significantly improve upper limb motor function, hand strength, and hand dexterity in patients diagnosed with stroke. Both iTBS and HF-rTMS which could significantly promote upper limb motor function and hand dexterity, and excitatory rTMS were beneficial to upper limb motor function recovery only when applied in the first 3 months after stroke. HF-rTMS could significantly enhance the MEP amplitude of the affected hemisphere. High-quality and large-scale randomized controlled trials in the future are required to confirm our conclusions.

Clinical Trial Registration

www.crd.york.ac.uk/prospero/, identifier: CRD42022312288.

Priming Intermittent Theta Burst Stimulation for Hemiparetic Upper Limb After Stroke: A Randomized Controlled Trial

BACKGROUND

Intermittent theta burst stimulation (iTBS) creates a state with increased excitability that permits treatment modalities to induce neuroplasticity and motor learning. Continuous theta burst stimulation before iTBS may induce metaplasticity and boost the facilitatory effect of iTBS. This study investigated the effects of priming iTBS (ie, applying continuous theta burst stimulation before iTBS) on poststroke hemiparetic upper limb recovery.

METHODS

In this randomized controlled trial, 42 patients with chronic stroke were recruited and randomly allocated to 10 sessions of either priming iTBS, nonpriming iTBS, or sham stimulation to the ipsilesional motor cortex, immediately before robot-assisted training. Outcomes included Fugl-Meyer Assessment-Upper Extremity, Action Research Arm Test and mean movement velocity during each robot-assisted training session. Twenty-one patients were enrolled for measuring the sensorimotor beta event-related desynchronization induced by either mirror visual feedback or movement.

RESULTS

The Fugl-Meyer Assessment-Upper Extremity scores revealed a significant time-by-group interaction (P=0.011). Priming and nonpriming iTBS were both superior to sham stimulation in post hoc comparisons; however, the superiority was diminished at follow-up. Among patients with a higher functioning upper limb, priming iTBS yielded a significantly greater improvement in Fugl-Meyer Assessment-Upper Extremity scores than nonpriming iTBS (P=0.025) and sham stimulation (P=0.029) did. No significant interaction was found when analyzing the Action Research Arm Test and mean movement velocity. Priming iTBS enhanced the patients' mirror visual feedback-induced high beta sensorimotor event-related desynchronization over their ipsilesional hemisphere.

CONCLUSIONS

Priming and nonpriming iTBS are both superior to sham stimulation in enhancing treatment gains from robot-assisted training, and patients with a higher functioning upper limb may experience more benefits from priming iTBS. Priming iTBS may facilitate poststroke motor learning by enhancing the permissiveness of the ipsilesional sensorimotor area to therapeutic sensory modalities, such as the mirror visual feedback.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04034069.

Impact of operator experience on transcranial magnetic stimulation

•

Response variability to transcranial magnetic stimulation (TMS) is a crucial issue.

•

An operator’s experience in TMS may affect the result of resting motor threshold measurement.

•

A beginner may have higher consistency in 1 mV motor evoked potential with practice.

Objective

To determine the impact of an operator’s experience on transcranial magnetic stimulation (TMS) measurement.

Methods

Operator B (beginner), operator E (expert), and 30 healthy participants joined the study consisting of two experiments. In each experiment, each operator performed a TMS protocol on each participant in a random order.

Results

Compared with operator E, operator B exhibited higher resting motor threshold (RMT) in experiment I (60.1 ± 13.0 vs. 57.4 ± 10.9% maximal stimulation output, p = 0.017) and the difference disappeared in experiment II (p = 0.816). In 1-mV motor evoked potential (MEP) measurement, operator B exhibited higher standard deviation indicating lower consistency in experiment I compared with experiment II (1.05 ± 0.40 vs. 1.05 ± 0.16 mV with unequal variances, p = 0.001) and had poor intrarater reliability between the experiments (intraclass correlation coefficient = −0.130). There was no difference in the results of active motor threshold, silent period, paired-pulse stimulation, or continuous theta burst stimulation between the operators.

Conclusions

An operator’s experience in TMS may affect the results of RMT measurement. With practice, a beginner may choose a more precise stimulation location and have higher consistency in 1-mV MEP measurement.

Significance

We recommend that a beginner needs to practice for precise stimulation locations before conducting a trial or clinical practice.

Combining Repetitive Transcranial Magnetic Stimulation and Video Game-Based Training to Improve Dexterity in Parkinson's Disease: Study Protocol of a Randomized Controlled Trial

Introduction: Patients with Parkinson's disease (PD) often exhibit difficulties with dexterity during the performance of activities of daily living (ADL) due to dysfunctional supplementary motor area (SMA). The aim of this clinical trial protocol work is to describe how the effectiveness of a combined repetitive transcranial magnetic stimulation (rTMS) over SMA and video-game-based skill training (VBT) in PD will be evaluated. The short and long-term benefits are assessed.

Methods and analysis: A single-blind (patients) stratified (based on Hoehn & Yahr) parallel randomized sham-controlled rTMS-VBT study with a baseline and two follow-up measurements (3 and 12 weeks) is being conducted. These measurements include the dexterity questionnaire 24 (DextQ-24) as a primary outcome, and nine hole peg test and coin rotation task as main secondary dexterity outcomes. Further secondary outcomes will be the subscale II of the movement disorders society unified PD rating scale (MDS-UPDRS) to assess improvements on overall ADL and the Parkinson's Disease Questionnaire-39 to assess quality of life. Thirty-six outpatients (from one neurorehabilitation center) with PD (diagnosis based on brain bank criteria) will be recruited who report difficulties with dexterity in performing ADL. All PD patients will receive a 45-min VBT three times a week for 3 weeks. The PD patients randomized in the experimental group will receive VBT preceded by real rTMS, being intermittent theta burst (iTBS) stimulation sessions. The PD patients randomized to the control group receive a VBT with sham rTMS.

Discussion: The study will provide evidence to determine whether a combined iTBS and VBT skill intervention is more effective than a VBT intervention alone to improve dexterity in PD.

Ethics and dissemination: The study was approved by the Ethics Committee for Northwest and Central Switzerland (EKNZ), Switzerland 2019–00433. The study will be conducted in accordance with the Helsinki Declaration and the Guidelines of Good Clinical Practice. Informed consent will be signed prior to subject enrolment. Dissemination will include submission to international peer-reviewed professional journals and presentation at international congresses.

The study protocol has been registered in the clinicaltrials.gov registry with the identification code: NCT04699149.

Capturing Neuroplastic Changes after iTBS in Patients with Post-Stroke Aphasia: A Pilot fMRI Study

Intermittent theta-burst stimulation (iTBS) is a high-efficiency transcranial magnetic stimulation (TMS) paradigm that has been applied to post-stroke aphasia (PSA). However, its efficacy mechanisms have not been clarified. This study aimed to explore the immediate effects of iTBS of the primary motor cortex (M1) of the affected hemisphere, on the functional activities and connectivity of the brains of PSA patients. A total of 16 patients with aphasia after stroke received iTBS with 800 pulses for 300 s. All patients underwent motor, language, and cognitive assessments and resting-state functional MRI scans immediately before and after the iTBS intervention. Regional, seed-based connectivity, and graph-based measures were used to test the immediate functional effects of the iTBS intervention, including the fractional amplitude of low-frequency fluctuation (fALFF), degree centrality (DC), and functional connectivity (FC) of the left M1 area throughout the whole brain. The results showed that after one session of iTBS intervention, the fALFF, DC, and FC values changed significantly in the patients' brains. Specifically, the DC values were significantly higher in the right middle frontal gyrus and parts of the left parietal lobe (p < 0.05), while fALFF values were significantly lower in the right medial frontal lobe and parts of the left intracalcarine cortex (p < 0.05), and the strength of the functional connectivity between the left M1 area and the left superior frontal gyrus was reduced (p < 0.05). Our findings provided preliminary evidences that the iTBS on the ipsilesional M1 could induce neural activity and functional connectivity changes in the motor, language, and other brain regions in patients with PSA, which may promote neuroplasticity and functional recovery.

Effects of cognitive motor dual-task training on stroke patients: A RCT-based meta-analysis

Based on a randomized controlled trial (RCT), this meta-analysis aimed to comprehensively analyze the effects of cognitive motor dual-task training (CMDT) on stroke patients. The electronic databases PubMed, Embase, and the Cochrane Library were searched for papers on the influence of CMDT on stroke patients. Weighted mean difference (WMD) and 95% confidence interval (95% CI) were used as effect sizes. Cochran's Q and I² tests were performed for heterogeneity. Thirteen articles involving 326 patients were included in the study. The meta-analysis showed that CMDT significantly improved the walking balance of patients with stroke (P = 0.01). In addition, CMDT significantly improved the gait ability of patients with stroke (P < 0.0001). Furthermore, CMDT had a significant effect on the improvement of upper limb ability in patients with stroke (P < 0.00001). CMDT could significantly improve balance ability, gait, and upper limb function in patients with chronic stroke, which is worthy of clinical promotion.

The Corticospinal Excitability Can Be Predicted by Spontaneous Electroencephalography Oscillations

Transcranial magnetic stimulation (TMS) has a wide range of clinical applications, and there is growing interest in neural oscillations and corticospinal excitability determined by TMS. Previous studies have shown that corticospinal excitability is influenced by fluctuations of brain oscillations in the sensorimotor region, but it is unclear whether brain network activity modulates corticospinal excitability. Here, we addressed this question by recording electroencephalography (EEG) and TMS measurements in 32 healthy individuals. The resting motor threshold (RMT) and active motor threshold (AMT) were determined as markers of corticospinal excitability. The least absolute shrinkage and selection operator (LASSO) was used to identify significant EEG metrics and then correlation analysis was performed. The analysis revealed that alpha2 power in the sensorimotor region was inversely correlated with RMT and AMT. Innovatively, graph theory was used to construct a brain network, and the relationship between the brain network and corticospinal excitability was explored. It was found that the global efficiency in the theta band was positively correlated with RMT. Additionally, the global efficiency in the alpha2 band was negatively correlated with RMT and AMT. These findings indicated that corticospinal excitability can be modulated by the power spectrum in sensorimotor regions and the global efficiency of functional networks. EEG network analysis can provide a useful supplement for studying the association between EEG oscillations and corticospinal excitability.

Transcranial electrostimulation with special waveforms enhances upper-limb motor function in patients with chronic stroke: a pilot randomized controlled trial

Background

Transcranial direct current stimulation (tDCS) and intermittent theta burst stimulation (iTBS) were both demonstrated to have therapeutic potentials to rapidly induce neuroplastic effects in various rehabilitation training regimens. Recently, we developed a novel transcranial electrostimulation device that can flexibly output an electrical current with combined tDCS and iTBS waveforms. However, limited studies have determined the therapeutic effects of this special waveform combination on clinical rehabilitation. Herein, we investigated brain stimulation effects of tDCS-iTBS on upper-limb motor function in chronic stroke patients.

Methods

Twenty-four subjects with a chronic stroke were randomly assigned to a real non-invasive brain stimulation (NIBS; who received the real tDCS + iTBS output) group or a sham NIBS (who received sham tDCS + iTBS output) group. All subjects underwent 18 treatment sessions of 1 h of a conventional rehabilitation program (3 days a week for 6 weeks), where a 20-min NIBS intervention was simultaneously applied during conventional rehabilitation. Outcome measures were assessed before and immediately after the intervention period: Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Jebsen-Taylor Hand Function Test (JTT), and Finger-to-Nose Test (FNT).

Results

Both groups showed improvements in FMA-UE, JTT, and FNT scores after the 6-week rehabilitation program. Notably, the real NIBS group had greater improvements in the JTT (p = 0. 016) and FNT (p = 0. 037) scores than the sham NIBS group, as determined by the Mann–Whitney rank-sum test.

Conclusions

Patients who underwent the combined ipsilesional tDCS-iTBS stimulation with conventional rehabilitation exhibited greater impacts than did patients who underwent sham stimulation-conventional rehabilitation in statistically significant clinical responses of the total JTT time and FNT after the stroke. Preliminary results of upper-limb functional recovery suggest that tDCS-iTBS combined with a conventional rehabilitation intervention may be a promising strategy to enhance therapeutic benefits in future clinical settings.

Trial registration: ClinicalTrials.gov Identifier: NCT04369235. Registered on 30 April 2020.

Augmented efficacy of intermittent theta burst stimulation on the virtual reality-based cycling training for upper limb function in patients with stroke: a double-blinded, randomized controlled trial

Background

Virtual reality and arm cycling have been reported as effective treatments for improving upper limb motor recovery in patients with stroke. Intermittent theta burst stimulation (iTBS) can increase ipsilesional cortical excitability, and has been increasingly used in patients with stroke. However, few studies examined the augmented effect of iTBS on neurorehabilitation program. In this study, we investigated the augmented effect of iTBS on virtual reality-based cycling training (VCT) for upper limb function in patients with stroke.

Methods

In this randomized controlled trial, 23 patients with stroke were recruited. Each patient received either 15 sessions of iTBS or sham stimulation in addition to VCT on the same day. Outcome measures were assessed before and after the intervention. Primary outcome measures for the improvement of upper limb motor function and spasticity were Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and Modified Ashworth Scale Upper-Extremity (MAS-UE). Secondary outcome measures for activity and participation were Action Research Arm Test (ARAT), Nine Hole Peg Test (NHPT), Box and Block Test (BBT) and Motor Activity Log (MAL), and Stroke Impact Scale (SIS). Wilcoxon signed-rank tests were performed to evaluate the effectiveness after the intervention and Mann–Whitney U tests were conducted to compare the therapeutic effects between two groups.

Results

At post-treatment, both groups showed significant improvement in FMA-UE and ARAT, while only the iTBS + VCT group demonstrated significant improvement in MAS-UE, BBT, NHPT, MAL and SIS. The Mann–Whitney U tests revealed that the iTBS + VCT group has presented greater improvement than the sham group significantly in MAS-UE, MAL-AOU and SIS. However, there were no significant differences in the changes of the FMA-UE, ARAT, BBT, NHPT and MAL-QOM between groups.

Conclusions

Intermittent TBS showed augmented efficacy on VCT for reducing spasticity, increasing actual use of the affected upper limb, and improving participation in daily life in stroke patients. This study provided an integrated innovative intervention, which may be a promising therapy to improve upper limb function recovery in stroke rehabilitation. However, this study has a small sample size, and thus a further larger-scale study is warranted to confirm the treatment efficacy.

Trial registration This trial was registered under ClinicalTrials.gov ID No. NCT03350087, retrospectively registered, on November 22, 2017

Influence of iTBS on the Acute Neuroplastic Change After BCI Training

Objective: Brain-computer interface (BCI) training is becoming increasingly popular in neurorehabilitation. However, around one third subjects have difficulties in controlling BCI devices effectively, which limits the application of BCI training. Furthermore, the effectiveness of BCI training is not satisfactory in stroke rehabilitation. Intermittent theta burst stimulation (iTBS) is a powerful neural modulatory approach with strong facilitatory effects. Here, we investigated whether iTBS would improve BCI accuracy and boost the neuroplastic changes induced by BCI training. Methods: Eight right-handed healthy subjects (four males, age: 20-24) participated in this two-session study (BCI-only session and iTBS+BCI session in random order). Neuroplastic changes were measured by functional near-infrared spectroscopy (fNIRS) and single-pulse transcranial magnetic stimulation (TMS). In BCI-only session, fNIRS was measured at baseline and immediately after BCI training. In iTBS+BCI session, BCI training was followed by iTBS delivered on the right primary motor cortex (M1). Single-pulse TMS was measured at baseline and immediately after iTBS. fNIRS was measured at baseline, immediately after iTBS, and immediately after BCI training. Paired-sample t-tests were used to compare amplitudes of motor-evoked potentials, cortical silent period duration, oxygenated hemoglobin (HbO2) concentration and functional connectivity across time points, and BCI accuracy between sessions. Results: No significant difference in BCI accuracy was detected between sessions (p > 0.05). In BCI-only session, functional connectivity matrices between motor cortex and prefrontal cortex were significantly increased after BCI training (p's < 0.05). In iTBS+BCI session, amplitudes of motor-evoked potentials were significantly increased after iTBS (p's < 0.05), but no change in HbO2 concentration or functional connectivity was observed throughout the whole session (p's > 0.05). Conclusions: To our knowledge, this is the first study that investigated how iTBS targeted on M1 influences BCI accuracy and the acute neuroplastic changes after BCI training. Our results revealed that iTBS targeted on M1 did not influence BCI accuracy or facilitate the neuroplastic changes after BCI training. Therefore, M1 might not be an effective stimulation target of iTBS for the purpose of improving BCI accuracy or facilitate its effectiveness; other brain regions (i.e., prefrontal cortex) are needed to be further investigated as potentially effective stimulation targets.

Virtual reality for limb motor function, balance, gait, cognition and daily function of stroke patients: A systematic review and meta-analysis

AIMS

To explore the beneficial effects of virtual reality (VR) interventions on upper- and lower-limb motor function, balance, gait, cognition and daily function outcomes in stroke patients.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

DATA SOURCES

English databases (PubMed, EMBASE, the Cochrane Library, CINAHL, Web of Science, Physiotherapy Evidence Database, ProQuest Dissertations and Theses) and Chinese databases (Chinese BioMedical Literature Service System, WANFANG, CNKI) and the Clinical Trial Registry Platform were systematically searched from inception until December 2019. Additionally, reference lists of the included studies were manually searched.

REVIEW METHODS

The methodological quality of studies was scored with the Cochrane 'risk-of-bias tool' and PEDro scale from the Physiotherapy Evidence Database by two independent evaluators.

RESULTS

In total, 87 studies with 3540 participants were included. Stroke patients receiving VR interventions showed significant improvements in Fugl-Meyer assessment of Upper Extremity, Action Research Arm Test, Wolf Motor Function Test, Fugl-Meyer Assessment of Lower Extremity, Functional Ambulation Classification, Berg Balance Scale, Time Up and Go, Velocity, Cadence, Modified Barthel Index and Functional Independence Measure. However, differences between VR intervention and traditional rehabilitation groups were not significant for Box-Block Test, 10 m Walk Test, Auditory Continuous Performance Test, Mini-Mental State Examination and Visual Continuous Performance Test.

CONCLUSION

This review suggests that VR interventions effectively improve upper- and lower-limb motor function, balance, gait and daily function of stroke patients, but have no benefits on cognition.

IMPACT

This review identified the positive effects of VR-assisted rehabilitation on upper- and lower-limb motor function, balance, gait and daily function of stroke patients. And, we verified the duration of VR intervention affects some health benefits. The benefit of VR on cognitive function requires further investigation through large-scale multicentre RCTs.

From adults to pediatrics: A review noninvasive brain stimulation (NIBS) to facilitate recovery from brain injury

Stroke is a major problem worldwide that impacts over 100 million adults and children annually. Rehabilitation therapy is the current standard of care to restore functional impairments post-stroke, however its effects are limited and many patients suffer persisting functional impairments and life-long disability. Noninvasive Brain Stimulation (NIBS) has emerged as a potential rehabilitation treatment option in both adults and children with brain injury. In the last decade, Transcranial Magnetic Stimulation (TMS), Transcranial Direct Current Stimulation (tDCS) and Transcutaneous Auricular Vagus Nerve Stimulation (taVNS) have been investigated to improve motor recovery in adults post-stroke. These promising adult findings using NIBS, however, have yet to be widely translated to the area of pediatrics. The limited studies exploring NIBS in children have demonstrated safety, feasibility, and utility of stimulation-augmented rehabilitation. This chapter will describe the mechanism of NIBS therapy (cortical excitability, neuroplasticity) that underlies its use in stroke and motor function and how TMS, tDCS, and taVNS are applied in adult stroke treatment paradigms. We will then discuss the current state of NIBS in early pediatric brain injury and will provide insight regarding practical considerations and future applications of NIBS in pediatrics to make this promising treatment option a viable therapy in children.

Improvement of P ost S troke D ysphagia by I ntermittent T heta B urst S timulation

The present study aims to investigate the efficacy ofi ntermittent theta burst stimulation(iTBS) on post stroke dysphagia and its effect on the motor cortical excitability of thesuprahyoid muscle A total of 40 patients with post stroke dysphagia were randomlydivided into the iTBS and the sham stimulation groups, with the conduction of motorcortical iTBS and sham stimulation of the supraglottal muscle on the affected side,respectively . Swallowing function was assessed before (T0), immediately after (T1), andtwo weeks after (T2) cessation of the intervention using the water swallowing test (WST),standard swallowing assessment (SSA), Murray secretion scale (MSS), and PenetrationAspiration Scale ( PAS). The bilateral motor evoked potentials (MEP) of the suprahyoidmuscle were recorded After the intervention, the PAS, WST, SSA, and MSS scores weresignificantly improved in both groups (p < 0.05). The iTBS group showed a greaterchange in the PAS sco re than the sham stimulation group at T1 (p < 0.05) and a greaterchange in the WST and MSS scores at T2 (p < 0.05). The amplitude of the MEP wave ofthe suprahyoid muscle in the affected hemisphere was significantly higher in the iTBSgroup at T1 and in t he healthy hemisphere at T2 (p < 0.05). T he feasibility of applyingiTBS to the affected hemisphere for the treatment of post stroke dysphagia was directlyanalyzed for the first time. ITBS combined with conventional swallowing therapy couldbe adopted as a rehabilitation strategy to improve post stroke dysphagia.

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.

Multifocal transcranial stimulation in chronic ischemic stroke: A phase 1/2a randomized trial

BACKGROUND AND PURPOSE

Repetitive transcranial magnetic stimulation (rTMS) may promote recovery of motor function after stroke by inducing functional reorganization of cortical circuits. The objective of this study was to examine whether multifocal cortical stimulation using a new wearable transcranial rotating permanent magnet stimulator (TRPMS) can promote recovery of motor function after stroke by inducing functional reorganization of cortical circuits.

METHODS

Thirty³⁰ patients with chronic ischemic stroke and stable unilateral weakness were enrolled in a Phase 1/2a randomized double-blind sham-controlled clinical trial to evaluate safety and preliminary efficacy. Bilateral hemispheric stimulation was administered for 20 sessions 40 min each over 4 weeks. The primary efficacy endpoint was the change in functional MRI BOLD activation immediately after end of treatment. Secondary efficacy endpoints were clinical scales of motor function, including the Fugl-Meyer motor arm score, ARAT, grip strength, pinch strength, gait velocity, and NIHSS.

RESULTS

TRPMS treatment was well-tolerated with no device-related adverse effects. Active treatment produced a significantly greater increase in the number of active voxels on fMRI than sham treatment (median +48.5 vs -30, p = 0.038). The median active voxel number after active treatment was 8.8-fold greater than after sham (227.5 vs 26, p = 0.016). Although the statistical power was inadequate to establish clinical endpoint benefits, numerical improvements were demonstrated in 5 of 6 clinical scales of motor function. The treatment effects persisted over a 3-month duration of follow-up.

CONCLUSIONS

Multifocal bilateral TRPMS was safe and showed significant fMRI changes suggestive of functional reorganization of cortical circuits in patients with chronic ischemic stroke. A larger randomized clinical trial is warranted to verify recovery of motor function.

Effects of priming intermittent theta burst stimulation on upper limb motor recovery after stroke: study protocol for a proof-of-concept randomised controlled trial

INTRODUCTION

Intermittent theta burst stimulation (iTBS), a form of repetitive transcranial magnetic stimulation (rTMS), delivered to the ipsilesional primary motor cortex (M1), appears to enhance the brain's response to rehabilitative training in patients with stroke. However, its clinical utility is highly subject to variability in different protocols. New evidence has reported that preceding iTBS, with continuous theta burst stimulation (cTBS) may stabilise and even boost the facilitatory effect of iTBS on the stimulated M1, via metaplasticity. The aim of this study is to investigate the effects of iTBS primed with cTBS (ie, priming iTBS), in addition to robot-assisted training (RAT), on the improvement of the hemiparetic upper limb functions of stroke patients and to explore potential sensorimotor neuroplasticity using electroencephalography (EEG).

METHODS AND ANALYSIS

A three-arm, subjects and assessors-blinded, randomised controlled trial will be performed with patients with chronic stroke. An estimated sample of 36 patients will be needed based on the prior sample size calculation. All participants will be randomly allocated to receive 10 sessions of rTMS with different TBS protocols (cTBS+iTBS, sham cTBS+iTBS and sham cTBS+sham iTBS), three to five sessions per week, for 2-3 weeks. All participants will receive 60 min of RAT after each stimulation session. Primary outcomes will be assessed using Fugl-Meyer Assessment-Upper Extremity scores and Action Research Arm Test. Secondary outcomes will be assessed using kinematic outcomes generated during RAT and EEG.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from The Human Subjects Ethics Sub-committee, University Research Committee of The Hong Kong Polytechnic University (reference number: HSEARS20190718003). The results yielded from this study will be presented at international conferences and sent to a peer-review journal to be considered for publication.

TRIAL REGISTRATION NUMBER

NCT04034069.

Theta burst stimulation for upper limb motor dysfunction in patients with stroke: A protocol of systematic review and meta-analysis

BACKGROUND

Upper limb dysfunction is one of common sequelae of stroke which limits daily activities and decreases quality of life of patients, as well as increasing caregiving burden on families. Theta burst stimulation (TBS) is considered to be a beneficial therapy for post-stroke patients with upper limb motor dysfunction, but there is a lack of a high quality evidence. We aim to investigate the effectiveness and safety of TBS for upper limb motor dysfunction in patients with stroke.

METHODS

The following databases will be searched: PubMed, EMBASE, The Cochrane Library, Web of Science, China Biology Medicine (CBM), China National Knowledge infrastructure (CNKI), Technology Periodical Database (VIP) and WanFang Data from the inception to October 2019. All relevant randomized controlled trials (RCTs) using TBS to treat poststroke patients with upper limb motor dysfunction will be included. The primary outcome is Upper Limb Fugl-Meyer Assessment (UL-FMA). Secondary outcomes will include Action Research Arm Test (ARAT), Box and Block Test (BBT), Wolf Motor Function Test (WMFT), Motor Assessment Scale (MAS), Nine Hole Peg Test (NHPT), Grip strength and other scales evaluating the upper limb motor function. Adverse effects will also be evaluated. Two reviewers will screen studies, extract data and assess the risk of bias of included studies independently. Data analysis will be conducted using Review Manager software (RevMan, version 5.3.5) and R software (version 3.6.1).

RESULTS

Our SR will be conducted according to AMSTAR 2.0 and reported in compliance with PRISMA. The findings of this SR will be disseminated through peer-reviewed publications or conference presentations.

CONCLUSION

Our study will provide evidence for the effectiveness and safety of theta burst stimulation for upper limb motor dysfunction in patients with stroke.

ETHICS AND DISSEMINATION

This systematic review (SR) does not require formal ethical approval since no privacy health information will be included. The findings of this SR will be disseminated through peer-reviewed publications or conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42019142462.