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Rezaei K, Kordi Yoosefinejad A, Moslemi Haghighi F, Razeghi M. Evaluation of Contralateral Limb Cross Education and High-Frequency Repetitive Transcranial Magnetic Stimulation on Functional Indices of the Affected Upper Limb in Subacute Phase of Stroke. Stroke Res Treat 2023; 2023:4387667. [PMID: 38148954 PMCID: PMC10751172 DOI: 10.1155/2023/4387667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 12/28/2023] Open
Abstract
Background Stroke is one of the causes of long-term morbidity. Despite rehabilitation strategies, most survivors live with motor deficits in the upper limbs. Objectives The aim of the study was to compare the effect of contralateral cross education (CE) and high-frequency repetitive magnetic stimulation (HF-rTMS) on the function of upper extremity in subacute phase of stroke. Methods Forty patients were randomly assigned into 4 groups. Group "A" received physical therapy (PT) for 10 sessions, 3 times per week. Group "B" received PT and HF-rTMS as follows: stimulation of 20 Hz for 5 s, intertrain interval for 50 s, 20 trains, 2000 pulses at 90% resting motor threshold, and conventional PT. Group "C" was treated with CE and PT. In group "D," HF-rTMS, CE, and PT were administered. Results Significant differences were found in the Fugl-Meyer scale between "A" and "C" (P = 0.01), "A" and "D" (P = 0.02), and "B" and "C" groups (P = 0.01). In the box-block test, there were significant differences between "A" and "B" (P = 0.01), "A" and "C" (P < 0.001), "B" and "D" (P = 0.001), and "B" and "C" groups (P = 0.01). Statistical differences were observed in grip strength between "A" and "B" (P = 0.01) and "A" and "C" groups (P = 0.02). Conclusions It is suggested that clinicians select the therapeutic methods in line with their expected goal. When the goal is to improve upper extremity function, CE+PT could be more effective than HF-rTMS+PT. Also, CE+PT and HF-rTMS+PT were more effective than CE+HF-rTMS+PT at improving grip strength. Therefore, combining several methods would not always lead to better results.
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Affiliation(s)
- Katayoon Rezaei
- Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
- Rehabilitation Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Kordi Yoosefinejad
- Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
- Rehabilitation Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farzaneh Moslemi Haghighi
- Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohsen Razeghi
- Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
- Rehabilitation Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Sánchez-Cuesta FJ, González-Zamorano Y, Arroyo-Ferrer A, Moreno-Verdú M, Romero-Muñoz JP. Repetitive Transcranial Magnetic Stimulation of Primary Motor Cortex for stroke upper limb motor sequelae rehabilitation: A systematic review. NeuroRehabilitation 2023; 52:329-348. [PMID: 37005900 DOI: 10.3233/nre-220306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND: Repetitive Transcranial Magnetic Stimulation (rTMS) over the primary motor cortex (M1) has been used to treat stroke motor sequelae regulating cortical excitability. Early interventions are widely recommended, but there is also evidence showing interventions in subacute or chronic phases are still useful. OBJECTIVE: To synthetize the evidence of rTMS protocols to improve upper limb motor function in people with subacute and/or chronic stroke. METHODS: Four databases were searched in July 2022. Clinical trials investigating the effectiveness of different rTMS protocols on upper limb motor function in subacute or chronic phases post-stroke were included. PRISMA guidelines and PEDro scale were used. RESULTS: Thirty-two studies representing 1137 participants were included. Positive effects of all types of rTMS protocols on upper limb motor function were found. These effects were heterogeneous and not always clinically relevant or related to neurophysiological changes but produced evident changes if evaluated with functional tests. CONCLUSION: rTMS interventions over M1 are effective for improving upper limb motor function in people with subacute and chronic stroke. When rTMS protocols were priming physical rehabilitation better effects were achieved. Studies considering minimal clinical differences and different dosing will help to generalize the use of these protocols in clinical practice.
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Affiliation(s)
- Francisco José Sánchez-Cuesta
- Facultad de Ciencias Experimentales, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain
| | - Yeray González-Zamorano
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain
- Department of Physiotherapy, Occupational Therapy, Rehabilitation and Physical Medicine, King Juan Carlos University, Alcorcón, Spain
| | - Aída Arroyo-Ferrer
- Facultad de Ciencias Experimentales, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain
| | - Marcos Moreno-Verdú
- Facultad de Ciencias Experimentales, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain
| | - Juan Pablo Romero-Muñoz
- Facultad de Ciencias Experimentales, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain
- Brain Damage Unit, Beata María Ana Hospital, Madrid, Spain
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Bai Z, Zhang J, Fong KNK. Effects of transcranial magnetic stimulation in modulating cortical excitability in patients with stroke: a systematic review and meta-analysis. J Neuroeng Rehabil 2022; 19:24. [PMID: 35193624 PMCID: PMC8862292 DOI: 10.1186/s12984-022-00999-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/28/2022] [Indexed: 12/13/2022] Open
Abstract
Background Transcranial magnetic stimulation (TMS) has attracted plenty of attention as it has been proved to be effective in facilitating motor recovery in patients with stroke. The aim of this study was to systematically review the effects of repetitive TMS (rTMS) and theta burst stimulation (TBS) protocols in modulating cortical excitability after stroke. Methods A literature search was carried out using PubMed, Medline, EMBASE, CINAHL, and PEDro, to identify studies that investigated the effects of four rTMS protocols—low and high frequency rTMS, intermittent and continuous TBS, on TMS measures of cortical excitability in stroke. A random-effects model was used for all meta-analyses. Results Sixty-one studies were included in the current review. Low frequency rTMS was effective in decreasing individuals’ resting motor threshold and increasing the motor-evoked potential of the non-stimulated M1 (affected M1), while opposite effects occurred in the stimulated M1 (unaffected M1). High frequency rTMS enhanced the cortical excitability of the affected M1 alone. Intermittent TBS also showed superior effects in rebalancing bilateral excitability through increasing and decreasing excitability within the affected and unaffected M1, respectively. Due to the limited number of studies found, the effects of continuous TBS remained inconclusive. Motor impairment was significantly correlated with various forms of TMS measures. Conclusions Except for continuous TBS, it is evident that these protocols are effective in modulating cortical excitability in stroke. Current evidence does support the effects of inhibitory stimulation in enhancing the cortical excitability of the affected M1. Supplementary Information The online version contains supplementary material available at 10.1186/s12984-022-00999-4.
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Affiliation(s)
- Zhongfei Bai
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China.,Department of Occupational Therapy, Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), Shanghai, China.,Department of Rehabilitation Sciences, Tongji University School of Medicine, Shanghai, China
| | - Jiaqi Zhang
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China
| | - Kenneth N K Fong
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China.
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Hildesheim FE, Silver AN, Dominguez-Vargas AU, Andrushko JW, Edwards JD, Dancause N, Thiel A. Predicting Individual Treatment Response to rTMS for Motor Recovery After Stroke: A Review and the CanStim Perspective. FRONTIERS IN REHABILITATION SCIENCES 2022; 3:795335. [PMID: 36188894 PMCID: PMC9397689 DOI: 10.3389/fresc.2022.795335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/17/2022] [Indexed: 11/13/2022]
Abstract
Background Rehabilitation is critical for reducing stroke-related disability and improving quality-of-life post-stroke. Repetitive transcranial magnetic stimulation (rTMS), a non-invasive neuromodulation technique used as stand-alone or adjunct treatment to physiotherapy, may be of benefit for motor recovery in subgroups of stroke patients. The Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim) seeks to advance the use of these techniques to improve post-stroke recovery through clinical trials and pre-clinical studies using standardized research protocols. Here, we review existing clinical trials for demographic, clinical, and neurobiological factors which may predict treatment response to identify knowledge gaps which need to be addressed before implementing these parameters for patient stratification in clinical trial protocols. Objective To provide a review of clinical rTMS trials of stroke recovery identifying factors associated with rTMS response in stroke patients with motor deficits and develop research perspectives for pre-clinical and clinical studies. Methods A literature search was performed in PubMed, using the Boolean search terms stroke AND repetitive transcranial magnetic stimulation OR rTMS AND motor for studies investigating the use of rTMS for motor recovery in stroke patients at any recovery phase. A total of 1,676 articles were screened by two blinded raters, with 26 papers identified for inclusion in this review. Results Multiple possible factors associated with rTMS response were identified, including stroke location, cortical thickness, brain-derived neurotrophic factor (BDNF) genotype, initial stroke severity, and several imaging and clinical factors associated with a relatively preserved functional motor network of the ipsilesional hemisphere. Age, sex, and time post-stroke were generally not related to rTMS response. Factors associated with greater response were identified in studies of both excitatory ipsilesional and inhibitory contralesional rTMS. Heterogeneous study designs and contradictory data exemplify the need for greater protocol standardization and high-quality controlled trials. Conclusion Clinical, brain structural and neurobiological factors have been identified as potential predictors for rTMS response in stroke patients with motor impairment. These factors can inform the design of future clinical trials, before being considered for optimization of individual rehabilitation therapy for stroke patients. Pre-clinical models for stroke recovery, specifically developed in a clinical context, may accelerate this process.
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Affiliation(s)
- Franziska E. Hildesheim
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, QC, Canada
- Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim), Montréal, QC, Canada
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
| | - Alexander N. Silver
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, QC, Canada
- Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim), Montréal, QC, Canada
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
| | - Adan-Ulises Dominguez-Vargas
- Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim), Montréal, QC, Canada
- Centre interdisciplinaire de recherche sur le cerveau et l'apprentissage (CIRCA), Université de Montréal, Montréal, QC, Canada
- Département de Neurosciences, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
| | - Justin W. Andrushko
- Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim), Montréal, QC, Canada
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jodi D. Edwards
- Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim), Montréal, QC, Canada
- University of Ottawa Heart Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Numa Dancause
- Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim), Montréal, QC, Canada
- Centre interdisciplinaire de recherche sur le cerveau et l'apprentissage (CIRCA), Université de Montréal, Montréal, QC, Canada
- Département de Neurosciences, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
| | - Alexander Thiel
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, QC, Canada
- Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim), Montréal, QC, Canada
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
- *Correspondence: Alexander Thiel
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Veldema J, Nowak DA, Gharabaghi A. Resting motor threshold in the course of hand motor recovery after stroke: a systematic review. J Neuroeng Rehabil 2021; 18:158. [PMID: 34732203 PMCID: PMC8564987 DOI: 10.1186/s12984-021-00947-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/13/2021] [Indexed: 12/24/2022] Open
Abstract
Background Resting motor threshold is an objective measure of cortical excitability. Numerous studies indicate that the success of motor recovery after stroke is significantly determined by the direction and extent of cortical excitability changes. A better understanding of this topic (particularly with regard to the level of motor impairment and the contribution of either cortical hemisphere) may contribute to the development of effective therapeutical strategies in this cohort. Objectives This systematic review collects and analyses the available evidence on resting motor threshold and hand motor recovery in stroke patients. Methods PubMed was searched from its inception through to 31/10/2020 on studies investigating resting motor threshold of the affected and/or the non-affected hemisphere and motor function of the affected hand in stroke cohorts. Results Overall, 92 appropriate studies (including 1978 stroke patients and 377 healthy controls) were identified. The analysis of the data indicates that severe hand impairment is associated with suppressed cortical excitability within both hemispheres and with great between-hemispheric imbalance of cortical excitability. Favorable motor recovery is associated with an increase of ipsilesional motor cortex excitability and reduction of between-hemispheric imbalance. The direction of change of contralesional motor cortex excitability depends on the amount of hand motor impairment. Severely disabled patients show an increase of contralesional motor cortex excitability during motor recovery. In contrast, recovery of moderate to mild hand motor impairment is associated with a decrease of contralesional motor cortex excitability. Conclusions This data encourages a differential use of rehabilitation strategies to modulate cortical excitability. Facilitation of the ipsilesional hemisphere may support recovery in general, whereas facilitation and inhibition of the contralesional hemisphere may enhance recovery in severe and less severely impaired patients, respectively.
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Affiliation(s)
- Jitka Veldema
- Institute for Neuromodulation and Neurotechnology, Department of Neurosurgery and Neurotechnology, University Hospital and University of Tübingen, Otfried-Mueller-Str.45, 72076, Tübingen, Germany.
| | - Dennis Alexander Nowak
- Department of Neurology, VAMED Hospital Kipfenberg, Konrad-Regler-Straße 1, 85110, Kipfenberg, Germany
| | - Alireza Gharabaghi
- Institute for Neuromodulation and Neurotechnology, Department of Neurosurgery and Neurotechnology, University Hospital and University of Tübingen, Otfried-Mueller-Str.45, 72076, Tübingen, Germany
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6
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Chen Q, Shen D, Sun H, Ke J, Wang H, Pan S, Liu H, Wang D, Su M, Fang Q. Effects of coupling inhibitory and facilitatory repetitive transcranial magnetic stimulation on motor recovery in patients following acute cerebral infarction. NeuroRehabilitation 2021; 48:83-96. [PMID: 33361618 DOI: 10.3233/nre-201606] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The treatment for patients suffering from motor dysfunction following stroke using continuous repetitive transcranial magnetic stimulation (rTMS) has the potential to be beneficial for recovery. However, the impact of explicit results on the coupling of various rTMS protocols on motor treatment in patients following acute cerebral infarction remain unexplored. OBJECTIVE The current study aims to design a sham-controlled randomized report to explore the capability of consecutive suppressive-facilitatory rTMS method to increase the motor results following acute stroke. METHODS A hundred ischemic stroke patients suffering from motor disorder were randomly assigned to obtain 4 week sessions of (1)10 Hz over the ipsilesional primary motor cortex (M1) and next 1 Hz over the contralesional M1; (2) contralesional sham stimulation and next ipsilesional real 10 Hz; (3) contralesional real 1 Hz rTMS and next ipsilesional sham stimulation; or (4) bilateral sham-control procedures. At 24 hours before and after the intervention, we obtained cortical excitability data from study subjects. At baseline, after treatment and 3 months follow up, we additionally evaluated patients with the clinical assessments. RESULTS At post-intervention, group A showed greater motor improvements in FMA, FMA-UL, NIHSS, ADL and mRS values than group B, group C and group D, that were continued for at least 3 months after the completion of the treatment time. Specifically, it is shown in the cortical excitability study that the motor-evoked potential (MEP) amplitude and resting motor threshold (rMT) more significantly improved in group A than other groups. The improvement in motor function and change in motor cortex excitability exhibit a significant correlation in the affected hemisphere. The combined 1 Hz and 10 Hz stimulation treatment showed a synergistic effect. CONCLUSIONS Facilitatory rTMS and coupling inhibitory produced extra satisfactory results in facilitating the motor's recovery in the subacute and acute phase following stroke compared to that acquired from alone single-course modulation.
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Affiliation(s)
- Qingmei Chen
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.,Department of Physical Medicine & Rehabilitation, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Dan Shen
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Haiwei Sun
- Department of Emergency Medicine, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Jun Ke
- Department of Medical Imaging, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Hongxia Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Shenjie Pan
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Haoyu Liu
- Department of Physical Medicine & Rehabilitation, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Dapeng Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Min Su
- Department of Physical Medicine & Rehabilitation, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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Mancuso V, Stramba-Badiale C, Cavedoni S, Pedroli E, Cipresso P, Riva G. Virtual Reality Meets Non-invasive Brain Stimulation: Integrating Two Methods for Cognitive Rehabilitation of Mild Cognitive Impairment. Front Neurol 2020; 11:566731. [PMID: 33117261 PMCID: PMC7561425 DOI: 10.3389/fneur.2020.566731] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/24/2020] [Indexed: 11/17/2022] Open
Abstract
Mild cognitive impairment (MCI) refers to a subtle, general cognitive decline with a detrimental impact on elderlies' independent living and quality of life. Without a timely diagnosis, this condition can evolve into dementia over time, hence the crucial need for early detection, prevention, and rehabilitation. For this purpose, current neuropsychological interventions have been integrated with (i) virtual reality, which immerses the user in a controlled, ecological, and safe environment (so far, both virtual reality-based cognitive and motor rehabilitation have revealed promising positive outcomes); and (ii) non-invasive brain stimulation, i.e., transcranial magnetic or electric brain stimulation, which has emerged as a promising cognitive treatment for MCI and Alzheimer's dementia. To date, these two methods have been employed separately; only a few studies (limited to motor rehabilitation) have suggested their integration. The present paper suggests to extend this integration to cognitive rehabilitation as well as to provide a multimodal stimulation that could enhance cognitive training, resulting in a more efficient rehabilitation.
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Affiliation(s)
- Valentina Mancuso
- Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Chiara Stramba-Badiale
- Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Silvia Cavedoni
- Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Elisa Pedroli
- Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy.,Department of Psychology, E-Campus University, Novedrate, Italy
| | - Pietro Cipresso
- Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy.,Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy
| | - Giuseppe Riva
- Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy.,Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy
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White Matter Biomarkers Associated with Motor Change in Individuals with Stroke: A Continuous Theta Burst Stimulation Study. Neural Plast 2019; 2019:7092496. [PMID: 30863437 PMCID: PMC6378804 DOI: 10.1155/2019/7092496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/08/2018] [Indexed: 11/18/2022] Open
Abstract
Continuous theta burst stimulation (cTBS) is a form of noninvasive repetitive brain stimulation that, when delivered over the contralesional hemisphere, can influence the excitability of the ipsilesional hemisphere in individuals with stroke. cTBS applied prior to skilled motor practice interventions may augment motor learning; however, there is a high degree of variability in individual response to this intervention. The main objective of the present study was to assess white matter biomarkers of response to cTBS paired with skilled motor practice in individuals with chronic stroke. We tested the effects of stimulation of the contralesional hemisphere at the site of the primary motor cortex (M1c) or primary somatosensory cortex (S1c) and a third group who received sham stimulation. Within each stimulation group, individuals were categorized into responders or nonresponders based on their capacity for motor skill change. Baseline diffusion tensor imaging (DTI) indexed the underlying white matter microstructure of a previously known motor learning network, named the constrained motor connectome (CMC), as well as the corticospinal tract (CST) of lesioned and nonlesioned hemispheres. Across practice, there were no differential group effects. However, when categorized as responders vs. nonresponders using change in motor behaviour, we demonstrated a significant difference in CMC microstructural properties (as measured by fractional anisotropy (FA)) for individuals in M1c and S1c groups. There were no significant differences between responders and nonresponders in clinical baseline measures or microstructural properties (FA) in the CST. The present study identifies a white matter biomarker, which extends beyond the CST, advancing our understanding of the importance of white matter networks for motor after stroke.
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Neva J, Brown K, Wadden K, Mang C, Borich M, Meehan S, Boyd L. The effects of five sessions of continuous theta burst stimulation over contralesional sensorimotor cortex paired with paretic skilled motor practice in people with chronic stroke. Restor Neurol Neurosci 2019; 37:273-290. [PMID: 31227676 PMCID: PMC7886006 DOI: 10.3233/rnn-190916] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In individuals with chronic stroke, impairment of the paretic arm may be exacerbated by increased contralesional transcallosal inhibition (TCI). Continuous theta burst stimulation (cTBS) can decrease primary motor cortex (M1) excitability and TCI. However, contralesional cTBS shows inconsistent effects after stroke. Variable effects of cTBS could stem from failure to pair stimulation with skilled motor practice or a focus of applying cTBS over M1. OBJECTIVE Here, we investigated the effects of pairing cTBS with skilled practice on motor learning and arm function. We considered the differential effects of stimulation over two different brain regions: contralesional M1 (M1c) or contralesional primary somatosensory cortex (S1c). METHODS 37 individuals with chronic stroke participated in five sessions of cTBS and paretic arm skilled practice of a serial targeting task (STT); participants received either cTBS over M1c or S1c or sham before STT practice. Changes in STT performance and Wolf Motor Function Test (WMFT) were assessed as primary outcomes. Assessment of bilateral corticospinal, intracortical excitability and TCI were secondary outcomes. RESULTS cTBS over sensorimotor cortex did not improve STT performance and paretic WMFT-rate beyond sham cTBS. TCI was reduced bi-directionally following the intervention, regardless of stimulation group. In addition, we observed an association between STT performance change and paretic WMFT-rate change in the M1c stimulation group only. CONCLUSIONS Multiple sessions of STT practice can improve paretic arm function and decrease TCI bilaterally, with no additional benefit of prior cTBS. Our results suggest that improvement in STT practice following M1c cTBS scaled with change in paretic arm function in some individuals. Our results highlight the need for a better understanding of the mechanisms of cTBS to effectively identify who may benefit from this form of brain stimulation.
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Affiliation(s)
- J.L. Neva
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - K.E. Brown
- Graduate Studies in Rehabilitation Sciences, University of British Columbia, Vancouver Canada
| | - K.P. Wadden
- Graduate Studies in Rehabilitation Sciences, University of British Columbia, Vancouver Canada
| | - C.S. Mang
- Graduate Studies in Rehabilitation Sciences, University of British Columbia, Vancouver Canada
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - M.R. Borich
- Department of Rehabilitation Medicine, Division of Physical Therapy, School of Medicine, Emory University, Atlanta, GA, USA
| | - S.K. Meehan
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - L.A. Boyd
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
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Abstract
BACKGROUND AND PURPOSE The IV STEP conference challenged presenters and participants to consider the state of science in rehabilitation, highlighting key area of progress since the previous STEP conference related to prediction, prevention, plasticity, and participation in rehabilitation. KEY POINTS Emerging from the thought-provoking discussions was recognition of the progress we have made as a profession and a call for future growth. In this summary article, we present a recap of the key points and call for action. We review the information presented and the field at large as it relates to the 4 Ps: prediction, prevention, plasticity, and participation. RECOMMENDATIONS FOR PRACTICE Given that personalized medicine is an increasingly important approach that was clearly woven throughout the IV STEP presentations, we took the liberty of adding a fifth "P," Personalized, in our discussion of the future direction of the profession.
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Carey JR, Chen M, Streib CD. Video evidence of improved hand function following repetitive transcranial magnetic stimulation combined with physical therapy in stroke: a case report. Clin Case Rep 2018; 6:792-797. [PMID: 29744058 PMCID: PMC5930225 DOI: 10.1002/ccr3.1455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 01/11/2018] [Accepted: 01/29/2018] [Indexed: 11/17/2022] Open
Abstract
In a 46‐year‐old female 6 months poststroke who presented with minimal paretic hand function, repetitive transcranial magnetic stimulation (rTMS), and exercises considerably improved her function beyond that accomplished with conventional rehabilitation. However, intermittent rTMS (2 sessions/week) was required to sustain the benefits. Research is required to determine the critical frequency of intermittent rTMS needed to sustain functional gains long term.
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Affiliation(s)
- James R Carey
- Division of Physical Therapy and Division of Rehabilitation Science University of Minnesota Minneapolis Minnesota
| | - Mo Chen
- Department of Psychiatry Institute for Engineering in Medicine University of Minnesota Minneapolis Minnesota
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12
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Johnson NN, Carey J, Edelman BJ, Doud A, Grande A, Lakshminarayan K, He B. Combined rTMS and virtual reality brain-computer interface training for motor recovery after stroke. J Neural Eng 2018; 15:016009. [PMID: 28914232 PMCID: PMC5821060 DOI: 10.1088/1741-2552/aa8ce3] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Combining repetitive transcranial magnetic stimulation (rTMS) with brain-computer interface (BCI) training can address motor impairment after stroke by down-regulating exaggerated inhibition from the contralesional hemisphere and encouraging ipsilesional activation. The objective was to evaluate the efficacy of combined rTMS + BCI, compared to sham rTMS + BCI, on motor recovery after stroke in subjects with lasting motor paresis. APPROACH Three stroke subjects approximately one year post-stroke participated in three weeks of combined rTMS (real or sham) and BCI, followed by three weeks of BCI alone. Behavioral and electrophysiological differences were evaluated at baseline, after three weeks, and after six weeks of treatment. MAIN RESULTS Motor improvements were observed in both real rTMS + BCI and sham groups, but only the former showed significant alterations in inter-hemispheric inhibition in the desired direction and increased relative ipsilesional cortical activation from fMRI. In addition, significant improvements in BCI performance over time and adequate control of the virtual reality BCI paradigm were observed only in the former group. SIGNIFICANCE When combined, the results highlight the feasibility and efficacy of combined rTMS + BCI for motor recovery, demonstrated by increased ipsilesional motor activity and improvements in behavioral function for the real rTMS + BCI condition in particular. Our findings also demonstrate the utility of BCI training alone, as shown by behavioral improvements for the sham rTMS + BCI condition. This study is the first to evaluate combined rTMS and BCI training for motor rehabilitation and provides a foundation for continued work to evaluate the potential of both rTMS and virtual reality BCI training for motor recovery after stroke.
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Affiliation(s)
- N N Johnson
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN 55455, USA
| | - J Carey
- Department of Physical Therapy, University of Minnesota, Minneapolis, MN 55455, USA
| | - B J Edelman
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN 55455, USA
| | - A Doud
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN 55455, USA
| | - A Grande
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN 55455, USA
| | - K Lakshminarayan
- Department of Neurology, University of Minnesota, Minneapolis, MN 55455, USA
| | - B He
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN 55455, USA
- Institute for Engineering in Medicine, University of Minnesota, Minneapolis, MN 55455, USA
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Gillick BT, Gordon AM, Feyma T, Krach LE, Carmel J, Rich TL, Bleyenheuft Y, Friel K. Non-Invasive Brain Stimulation in Children With Unilateral Cerebral Palsy: A Protocol and Risk Mitigation Guide. Front Pediatr 2018; 6:56. [PMID: 29616203 PMCID: PMC5864860 DOI: 10.3389/fped.2018.00056] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 02/26/2018] [Indexed: 01/04/2023] Open
Abstract
Non-invasive brain stimulation has been increasingly investigated, mainly in adults, with the aims of influencing motor recovery after stroke. However, a consensus on safety and optimal study design has not been established in pediatrics. The low incidence of reported major adverse events in adults with and without clinical conditions has expedited the exploration of NIBS in children with paralleled purposes to influence motor skill development after neurological injury. Considering developmental variability in children, with or without a neurologic diagnosis, adult dosing and protocols may not be appropriate. The purpose of this paper is to present recommendations and tools for the prevention and mitigation of adverse events (AEs) during NIBS in children with unilateral cerebral palsy (UCP). Our recommendations provide a framework for pediatric NIBS study design. The key components of this report on NIBS AEs are (a) a summary of related literature to provide the background evidence and (b) tools for anticipating and managing AEs from four international pediatric laboratories. These recommendations provide a preliminary guide for the assessment of safety and risk mitigation of NIBS in children with UCP. Consistent reporting of safety, feasibility, and tolerability will refine NIBS practice guidelines contributing to future clinical translations of NIBS.
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Affiliation(s)
- Bernadette T Gillick
- Physical Therapy Division, Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Andrew M Gordon
- Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY, United States
| | - Tim Feyma
- Gillette Children's Specialty Healthcare, Pediatric Neurology, St. Paul, MN, United States
| | - Linda E Krach
- Courage Kenny Rehabilitation Institute, Minneapolis, MN, United States
| | - Jason Carmel
- Weill-Cornell Medical College, Blythedale Children's Hospital, Burke Medical Research Institute, White Plains, NY, United States
| | - Tonya L Rich
- Rehabilitation Science, University of Minnesota, Minneapolis, MN, United States
| | - Yannick Bleyenheuft
- Institute of Neuroscience (IoNS), Universite catholique de Louvain, Brussels, Belgium
| | - Kathleen Friel
- Weill-Cornell Medical College, Blythedale Children's Hospital, Burke Medical Research Institute, White Plains, NY, United States
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14
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Non-invasive Cerebellar Stimulation: a Promising Approach for Stroke Recovery? THE CEREBELLUM 2017; 17:359-371. [DOI: 10.1007/s12311-017-0906-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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15
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Interhemispheric Pathways Are Important for Motor Outcome in Individuals with Chronic and Severe Upper Limb Impairment Post Stroke. Neural Plast 2017; 2017:4281532. [PMID: 29348943 PMCID: PMC5733869 DOI: 10.1155/2017/4281532] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/27/2017] [Accepted: 08/08/2017] [Indexed: 11/17/2022] Open
Abstract
Background Severity of arm impairment alone does not explain motor outcomes in people with severe impairment post stroke. Objective Define the contribution of brain biomarkers to upper limb motor outcomes in people with severe arm impairment post stroke. Methods Paretic arm impairment (Fugl-Meyer upper limb, FM-UL) and function (Wolf Motor Function Test rate, WMFT-rate) were measured in 15 individuals with severe (FM-UL ≤ 30/66) and 14 with mild–moderate (FM-UL > 40/66) impairment. Transcranial magnetic stimulation and diffusion weight imaging indexed structure and function of the corticospinal tract and corpus callosum. Separate models of the relationship between possible biomarkers and motor outcomes at a single chronic (≥6 months) time point post stroke were performed. Results Age (ΔR20.365, p = 0.017) and ipsilesional-transcallosal inhibition (ΔR20.182, p = 0.048) explained a 54.7% (p = 0.009) variance in paretic WMFT-rate. Prefrontal corpus callous fractional anisotropy (PF-CC FA) alone explained 49.3% (p = 0.007) variance in FM-UL outcome. The same models did not explain significant variance in mild–moderate stroke. In the severe group, k-means cluster analysis of PF-CC FA distinguished two subgroups, separated by a clinically meaningful and significant difference in motor impairment (p = 0.049) and function (p = 0.006) outcomes. Conclusion Corpus callosum function and structure were identified as possible biomarkers of motor outcome in people with chronic and severe arm impairment.
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Kimberley TJ, Novak I, Boyd L, Fowler E, Larsen D. Stepping Up to Rethink the Future of Rehabilitation: IV STEP Considerations and Inspirations. Pediatr Phys Ther 2017; 29 Suppl 3:S76-S85. [PMID: 28654481 PMCID: PMC6013833 DOI: 10.1097/pep.0000000000000435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE The IV STEP conference challenged presenters and participants to consider the state of science in rehabilitation, highlighting key area of progress since the previous STEP conference related to prediction, prevention, plasticity, and participation in rehabilitation. KEY POINTS Emerging from the thought-provoking discussions was recognition of the progress we have made as a profession and a call for future growth. In this summary article, we present a recap of the key points and call for action. We review the information presented and the field at large as it relates to the 4 Ps: prediction, prevention, plasticity, and participation. RECOMMENDATIONS FOR PRACTICE Given that personalized medicine is an increasingly important approach that was clearly woven throughout the IV STEP presentations, we took the liberty of adding a fifth "P," Personalized, in our discussion of the future direction of the profession.
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Affiliation(s)
- Teresa Jacobson Kimberley
- Department of Physical Medicine, Division of Physical Therapy and Rehabilitation Science, University of Minnesota, Minneapolis (T.J.K.); Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Camperdown, Australia (I.N.); Department of Physical Therapy and Djavad Mowafaghian Centre for Brain Health, The University of British Columbia, Vancouver, British Columbia (L.B.); Department of Orthopaedic Surgery, Center for Cerebral Palsy, University of California, Los Angeles (E.F.); and School of Health and Rehabilitation Sciences, The Ohio State University, Columbus (D.L.)
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Lin YL, Potter-Baker KA. Using theoretical models from adult stroke recovery to improve use of noninvasive brain stimulation for children with congenital hemiparesis. J Neurophysiol 2017; 118:1435-1438. [PMID: 28539399 DOI: 10.1152/jn.00258.2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/23/2017] [Accepted: 05/23/2017] [Indexed: 11/22/2022] Open
Abstract
Noninvasive brain stimulation has been widely used for adults with stroke to improve upper limb motor function. A recent study by Kirton and colleagues (Kirton A, Ciechanski P, Zewdie E, Andersen J, Nettel-Aguirre A, Carlson H, Carsolio L, Herrero M, Quigley J, Mineyko A, Hodge J, Hill M. Neurology 88: 259-267, 2017) applied noninvasive brain stimulation to children with congenital hemiparesis but found no significant effect of noninvasive brain stimulation on motor function. Here, we explore theories about cortical reorganization in both adult and children with hemiparesis and discuss how to improve the approaches of noninvasive brain stimulation to generate optimal motor improvement and development for children with congenital hemiparesis.
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Affiliation(s)
- Yin-Liang Lin
- Department of Biomedical Engineering, Cleveland Clinic Foundation, Cleveland, Ohio
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18
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Carey JR, Chappuis DM, Finkelstein MJ, Frost KL, Leuty LK, McNulty AL, Oddsson LIE, Seifert EM, Kimberley TJ. Importance and Difficulties of Pursuing rTMS Research in Acute Stroke. Phys Ther 2017; 97:310-319. [PMID: 28426872 PMCID: PMC5803765 DOI: 10.1093/ptj/pzx005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 12/11/2016] [Indexed: 12/19/2022]
Abstract
Although much research has been done on repetitive transcranial magnetic stimulation (rTMS) in chronic stroke, only sparse research has been done in acute stroke despite the particularly rich potential for neuroplasticity in this stage. We attempted a preliminary clinical trial in one active, high-quality inpatient rehabilitation facility (IRF) in the -United States. But after enrolling only 4 patients in the grant period, the study was stopped because of low enrollment. The purpose of this paper is to offer a perspective describing the important physiologic rationale for including rTMS in the early phase of stroke, the reasons for our poor patient enrollment in our attempted study, and recommendations to help future studies succeed. We conclude that, if scientists and clinicians hope to enhance stroke outcomes, more attention must be directed to leveraging conventional rehabilitation with neuromodulation in the acute phase of stroke when the capacity for neuroplasticity is optimal. Difficulties with patient enrollment must be addressed by reassessing traditional inclusion and exclusion criteria. Factors that shorten patients' length of stay in the IRF must also be reassessed at all policy-making levels to make ethical decisions that promote higher functional outcomes while retaining cost consciousness.
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Affiliation(s)
- James R. Carey
- J. R. Carey, PT, PhD, Division of Physical Therapy and Division of Rehabilitation Science, University of Minnesota, 420 Delaware St SE, Minneapolis, MN 55455 (USA). Address all correspondence to Dr Carey at:
| | - Diane M. Chappuis
- D. M. Chappuis, MD, Physical Medicine and Rehabilitation, Courage Kenny Rehabilitation Institute, Minneapolis, Minnesota
| | | | - Kate L. Frost
- K. L. Frost, Graduate Program in Rehabilitation Science, University of Minnesota
| | - Lynette K. Leuty
- L. K. Leuty, PT, DPT, Physical Medicine and Rehabilitation, Courage Kenny Rehabilitation Institute
| | - Allison L. McNulty
- A. L. McNulty, PT, DPT, Physical Medicine and Rehabilitation, Courage Kenny Rehabilitation Institute
| | - Lars I. E. Oddsson
- L.I.E. Oddsson, PhD, Division of -Rehabilitation Science, University of -Minnesota
| | - Erin M. Seifert
- E. M. Seifert, PT, DPT, Physical Medicine and Rehabilitation, Courage Kenny Rehabilitation Institute
| | - Teresa J. Kimberley
- T. J. Kimberley, PT, PhD, Division of Physical Therapy and Division of Rehabilitation Science, University of Minnesota
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Frost KL, Carey JR, Broback TW, Carlson NL, Daggett CA, Dalbec MM, Mueller BA. N-of-1 Trial in Person with Pontine Stroke Receiving Repetitive Transcranial Magnetic Stimulation to Improve Hand Function. JOURNAL OF NEUROIMAGING IN PSYCHIATRY & NEUROLOGY 2017; 2:36-42. [PMID: 29435516 PMCID: PMC5807012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Stroke characteristics vary widely between individuals making it difficult to assess the value of stroke rehabilitation interventions. To eliminate inter-subject variability, this study used an N-of-1 randomized, controlled design to explore the efficacy of repetitive transcranial magnetic stimulation (rTMS) in one unique individual with pontine stroke. We hypothesized that five days of active 6-Hz primed, low-frequency rTMS to the contralesional primary motor area (M1), combined with finger movement tracking training, would accomplish greater gains in hand function than sham rTMS combined with tracking training. We assessed hand function (Box and Block test and finger tracking test), cortical activation (laterality index during functional magnetic resonance imaging), and cortical excitability (interhemispheric inhibition testing (IHI) with transcranial magnetic stimulation (TMS)). Diffusion tensor imaging (DTI) assessed the integrity of his corticospinal tracts at baseline. Results showed no improvement in the Box and Block or finger tracking tests, unreliable IHI findings, and no change in laterality index following active rTMS. DTI suggested truncation of the left corticospinal tract (CST) at the pons. His non-dexterous hand movements combined with no elicitable motor evoked potentials with TMS to ipsilesional M1 and his DTI findings lead us to speculate a reticulospinal mechanism for preserving his rudimentary paretic hand control. We conclude that rTMS combined with tracking training was not effective in the absence of CST pathways and that research is needed to confirm markers of reticulospinal function in humans as an alternative to defective CST function.
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Affiliation(s)
- Kate L. Frost
- Division of Rehabilitation Science, University of Minnesota, MN, USA
| | - James R. Carey
- Division of Rehabilitation Science, University of Minnesota, MN, USA,Division of Physical Therapy, University of Minnesota, MN, USA,Correspondence to: Dr. James Carey, PhD, PT, Professor, Department of Physical Medicine & Rehabilitation Clinic, University of Minnesota Health Clinics & Surgery Center, Floor 3, 909 Fulton St. SE-Mail Code 2121CJ, Minneapolis, MN 55455, USA, Tel: 651-276-5563,
| | | | | | | | - Megan M. Dalbec
- Division of Physical Therapy, University of Minnesota, MN, USA
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20
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Rich TL, Menk J, Krach LE, Feyma T, Gillick BT. Repetitive Transcranial Magnetic Stimulation/Behavioral Intervention Clinical Trial: Long-Term Follow-Up of Outcomes in Congenital Hemiparesis. J Child Adolesc Psychopharmacol 2016; 26:598-605. [PMID: 26905272 PMCID: PMC5335747 DOI: 10.1089/cap.2015.0157] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to examine long-term outcomes of nonpharmacological intervention in children and adolescents with stroke utilizing repetitive transcranial magnetic stimulation (rTMS) to the primary motor cortex combined with constraint- induced movement therapy (CIMT) to improve motor function in the paretic hand. Outcome measures included function, satisfaction, and medical status review. METHODS Fourteen of the original 19 participants (74%) from our rTMS/CIMT clinical trial (real rTMS+CIMT, n = 8; and sham rTMS+CIMT, n = 6) were evaluated. The median age of the subjects at follow up was 13.4 years (range 11-20 years old, 50% male). Median time to follow-up was 47.5 months (range 21-57 months). Descriptive statistics were conducted using frequencies and counts. Motor performance was measured using the Assisting Hand Assessment (AHA) and Canadian Occupational Performance Measure (COPM). Satisfaction was reported with use of the COPM and TMS Tolerance Survey. Open-ended interview was conducted for feedback on study experience and subjective perspectives of current functional status. RESULTS Overall, seven of eight individuals who received real rTMS and five of six individuals who received sham rTMS maintained or improved AHA scores. Six of 14 participants reported new onset of co-occurring conditions (four individuals in the real rTMS group, two individuals in the sham rTMS group). The majority (86%) of participants reported study satisfaction. Review of medical status revealed co-occurring conditions including: Epilepsy, obsessive-compulsive disorder, anxiety, depression, unspecified mood disorder, and undiagnosed inattentiveness. CONCLUSIONS Long-term outcomes of rTMS/CIMT in pediatric stroke were investigated. Variability in performance and unattributed symptoms were noted. Considering the prevalence of co-occurring conditions in children and adolescents with stroke, new-onset symptoms were not attributed to original intervention. With the small sample size, the impact of rTMS on long-term outcomes cannot be fully determined from these data. Characterizing long-term outcomes through performance, participant perspectives, and medical status allows comprehensive assessment of rTMS/CIMT intervention efficacy.
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Affiliation(s)
- Tonya L. Rich
- Rehabilitation Science, University of Minnesota, Minneapolis, Minnesota
| | - Jeremiah Menk
- Clinical and Translational Science Institute, Minneapolis, Minnesota
| | - Linda E. Krach
- Courage Kenny Rehabilitation Institute, part of Allina Health, Minneapolis, Minnesota
| | - Timothy Feyma
- Gillette Children's Specialty Healthcare, St. Paul, Minnesota
| | - Bernadette T. Gillick
- Department of Physical Medicine and Rehabilitation, Program in Physical Therapy, University of Minnesota, Medical School, Minneapolis, Minnesota
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21
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Subramanian SK, Chilingaryan G, Sveistrup H, Levin MF. Depressive symptoms influence use of feedback for motor learning and recovery in chronic stroke. Restor Neurol Neurosci 2016; 33:727-40. [PMID: 26444639 DOI: 10.3233/rnn-150508] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Sensorimotor impairments and depressive symptoms (PSD) influence arm motor recovery post-stroke. Feedback provision improves upper limb motor learning in patients with chronic stroke but factors including PSD may affect ability to use feedback. We evaluated the influence of PSD on the ability to use auditory feedback for upper limb recovery and motor learning in patients with chronic stroke. METHODS Participants (n = 24) practiced 72 pointing movements/session (6 targets, 12 sessions, randomized) with auditory feedback on movement speed and trunk displacement. The presence of PSD (Beck's Depression Inventory; BDI-II) was assessed at pre-intervention (PRE). Arm motor impairment (Fugl-Meyer Assessment, shoulder horizontal adduction, shoulder flexion, elbow extension ranges, trunk displacement) and arm use (Motor Activity Log) were assessed at PRE, immediately after (POST) and retention (3 mos; RET). Participants were divided into two groups based on BDI-II scores: ≥ 14/63 (DEP group; n = 8; score: 20.5 ± 7.5) and ≤ 13/63 (no PSD (ND) group; n = 16; score: 5.0 ± 3.8). Changes in impairment and arm use levels were assessed (mixed-model ANOVAs). RESULTS All participants improved arm use. DEP had lower Fugl-Meyer scores, used more compensatory trunk displacement and had lower shoulder horizontal adduction range compared to ND. CONCLUSION The presence of PSD diminished the ability to use auditory feedback for arm motor recovery and motor learning.
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Affiliation(s)
- Sandeep K Subramanian
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada.,Feil-Oberfeld Research Centre, Jewish Rehabilitation Hospital site of Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Laval, Quebec, Canada
| | - Gevorg Chilingaryan
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada.,Feil-Oberfeld Research Centre, Jewish Rehabilitation Hospital site of Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Laval, Quebec, Canada
| | - Heidi Sveistrup
- School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Mindy F Levin
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada.,Feil-Oberfeld Research Centre, Jewish Rehabilitation Hospital site of Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Laval, Quebec, Canada
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Gillick B, Menk J, Mueller B, Meekins G, Krach LE, Feyma T, Rudser K. Synergistic effect of combined transcranial direct current stimulation/constraint-induced movement therapy in children and young adults with hemiparesis: study protocol. BMC Pediatr 2015; 15:178. [PMID: 26558386 PMCID: PMC4642615 DOI: 10.1186/s12887-015-0498-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/27/2015] [Indexed: 11/10/2022] Open
Abstract
Background Perinatal stroke occurs in more than 1 in 2,500 live births and resultant congenital hemiparesis necessitates investigation into interventions which may improve long-term function and decreased burden of care beyond current therapies (http://www.cdc.gov/ncbddd/cp/data.html). Constraint-Induced Movement Therapy (CIMT) is recognized as an effective hemiparesis rehabilitation intervention . Transcranial direct current stimulation as an adjunct treatment to CIMT may potentiate neuroplastic responses and improve motor function. The methodology of a clinical trial in children designed as a placebo-controlled, serial –session, non-invasive brain stimulation trial incorporating CIMT is described here. The primary hypotheses are 1) that no serious adverse events will occur in children receiving non-invasive brain stimulation and 2) that children in the stimulation intervention group will show significant improvements in hand motor function compared to children in the placebo stimulation control group. Methods/design A randomized, controlled, double-blinded clinical trial. Twenty children and/or young adults (ages 8–21) with congenital hemiparesis, will be enrolled. The intervention group will receive ten 2-hour sessions of transcranial direct current stimulation combined with constraint-induced movement therapy and the control group will receive sham stimulation with CIMT. The primary outcome measure is safety assessment of transcranial direct current stimulation by physician evaluation, vital sign monitoring and symptom reports. Additionally, hand function will be evaluated using the Assisting Hand Assessment, grip strength and assessment of goals using the Canadian Occupational Performance Measure. Neuroimaging will confirm diagnoses, corticospinal tract integrity and cortical activation. Motor cortical excitability will also be examined using transcranial magnetic stimulation techniques. Discussion Combining non-invasive brain stimulation and CIMT interventions has the potential to improve motor function in children with congenital hemiparesis beyond each intervention independently. Such a combined intervention has the potential to benefit an individual throughout their lifetime. Trial registration Clinicaltrials.gov, NCT02250092Registered 18 September 2014
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Affiliation(s)
- Bernadette Gillick
- University of Minnesota, 420 Delaware Street SE, MMC 388, Minneapolis, MN, 55455, USA.
| | - Jeremiah Menk
- Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, MN, 55455, USA.
| | - Bryon Mueller
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, 55455, USA.
| | - Gregg Meekins
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA.
| | - Linda E Krach
- Courage Kenny Rehabilitation Institute, part of Allina Health, 800 East 28th Street, Minneapolis, MN, 55407, USA.
| | - Timothy Feyma
- Department of Neurology, Gillette Children's Specialty Healthcare, 200 University Ave E, Saint Paul, MN, 55101, USA.
| | - Kyle Rudser
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA.
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Auriat AM, Neva JL, Peters S, Ferris JK, Boyd LA. A Review of Transcranial Magnetic Stimulation and Multimodal Neuroimaging to Characterize Post-Stroke Neuroplasticity. Front Neurol 2015; 6:226. [PMID: 26579069 PMCID: PMC4625082 DOI: 10.3389/fneur.2015.00226] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 10/12/2015] [Indexed: 01/09/2023] Open
Abstract
Following stroke, the brain undergoes various stages of recovery where the central nervous system can reorganize neural circuitry (neuroplasticity) both spontaneously and with the aid of behavioral rehabilitation and non-invasive brain stimulation. Multiple neuroimaging techniques can characterize common structural and functional stroke-related deficits, and importantly, help predict recovery of function. Diffusion tensor imaging (DTI) typically reveals increased overall diffusivity throughout the brain following stroke, and is capable of indexing the extent of white matter damage. Magnetic resonance spectroscopy (MRS) provides an index of metabolic changes in surviving neural tissue after stroke, serving as a marker of brain function. The neural correlates of altered brain activity after stroke have been demonstrated by abnormal activation of sensorimotor cortices during task performance, and at rest, using functional magnetic resonance imaging (fMRI). Electroencephalography (EEG) has been used to characterize motor dysfunction in terms of increased cortical amplitude in the sensorimotor regions when performing upper limb movement, indicating abnormally increased cognitive effort and planning in individuals with stroke. Transcranial magnetic stimulation (TMS) work reveals changes in ipsilesional and contralesional cortical excitability in the sensorimotor cortices. The severity of motor deficits indexed using TMS has been linked to the magnitude of activity imbalance between the sensorimotor cortices. In this paper, we will provide a narrative review of data from studies utilizing DTI, MRS, fMRI, EEG, and brain stimulation techniques focusing on TMS and its combination with uni- and multimodal neuroimaging methods to assess recovery after stroke. Approaches that delineate the best measures with which to predict or positively alter outcomes will be highlighted.
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Affiliation(s)
- Angela M Auriat
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia , Vancouver, BC , Canada
| | - Jason L Neva
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia , Vancouver, BC , Canada
| | - Sue Peters
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia , Vancouver, BC , Canada
| | - Jennifer K Ferris
- Graduate Program in Neuroscience, Faculty of Medicine, University of British Columbia , Vancouver, BC , Canada
| | - Lara A Boyd
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia , Vancouver, BC , Canada ; Graduate Program in Neuroscience, Faculty of Medicine, University of British Columbia , Vancouver, BC , Canada
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24
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A Comparison of Primed Low-frequency Repetitive Transcranial Magnetic Stimulation Treatments in Chronic Stroke. Brain Stimul 2015. [PMID: 26198365 DOI: 10.1016/j.brs.2015.06.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Preceding low-frequency repetitive transcranial magnetic stimulation (rTMS) with a bout of high-frequency rTMS called priming potentiates the after-effects of the former in healthy adults. The utility of primed rTMS in stroke remains under-explored despite its theoretical benefits in enhancing cortical excitability and motor function. OBJECTIVE To ascertain the efficacy of priming in chronic stroke by comparing changes in cortical excitability and paretic hand function following three types of primed low-frequency rTMS treatments. METHODS Eleven individuals with chronic stroke participated in this repeated-measures study receiving three treatments to the contralesional primary motor cortex in randomized order: 6 Hz primed 1 Hz rTMS, 1 Hz primed 1 Hz rTMS, and sham 6 Hz primed active 1 Hz rTMS. Within- and between-treatment differences from baseline in cortical excitability and paretic hand function from baseline were analyzed using mixed effects linear models. RESULTS 6 Hz primed 1 Hz rTMS produced significant within-treatment differences from baseline in ipsilesional cortical silent period (CSP) duration and short-interval intracortical inhibition. Compared to 1 Hz priming and sham 6 Hz priming of 1 Hz rTMS, active 6 Hz priming generated significantly greater decreases in ipsilesional CSP duration. These heightened effects were not observed for intracortical facilitation or interhemispheric inhibition excitability measures. CONCLUSION Our findings demonstrate the efficacy of 6 Hz primed 1 Hz rTMS in probing homeostatic plasticity mechanisms in the stroke brain as best demonstrated by differences CSP duration and SICI from baseline. Though 6 Hz priming did not universally enhance cortical excitability across measures, our findings pose important implications in non-invasive brain stimulation application in stroke rehabilitation.
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