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

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.

Intermittent theta burst stimulation combined with cognitive training improves cognitive dysfunction and physical dysfunction in patients with post-stroke cognitive impairment

OBJECTIVE

Post-stroke cognitive impairment (PSCI) is a common complication of stroke. Intermittent theta burst stimulation (iTBS) can inducing motor learning. We observed the effects of combination of iTBS with cognitive training on physical/cognitive dysfunctions in PSCI patients.

METHODS

PSCI patients treated with basic treatment & cognitive training (Control group)/iTBS & cognitive training (iTBS group) were enrolled, with Mini-mental State Examination (MMSE)/Montreal Cognitive Assessment (MoCA)/Frontal Assessment Battery (FAB)/barthel index (BI)/Upper Limb Fugl-Meyer Assessment (U-FMA)/Action Research Arm Test (ARAT) scores compared. Gait spatiotemporal parameters/dynamic parameters were analyzed by 3D gait analysis. Correlations between MMSE/MoCA scores and gait parameters in PSCI patients after iTBS & cognitive training were analyzed by Spearman analysis.

RESULTS

Increased MMSE/MoCA/FAB/BI/U-FMA/ARAT scores, step speed, step frequency, stride length, step width, step length on the affected side, percentage of swing phase on the affected side, hip joint flexion angle on the affected side, knee joint flexion angle on the affected side, and ankle plantar flexion angle on the affected side and reduced gait period on the affected side and percentage of stance phase on the affected side were found in patients of both groups after treatment, with the effects in the iTBS group more profound.

CONCLUSION

iTBS & cognitive training obviously improved the cognitive function scores/upper limb function scores/gait parameters in PSCI patients versus cognitive training treatment. After combination therapy, the MMSE/MoCA scores of PSCI patients were significantly correlated with gait parameters. This provided more data support for iTBS & cognitive training application in the rehabilitation treatment of PSCI patients.

The effects of rTMS on motor recovery after stroke: a systematic review of fMRI studies

Repetitive transcranial magnetic stimulation (rTMS) has been widely used in motor rehabilitation after stroke, and functional magnetic resonance imaging (fMRI) has been used to investigate the neural mechanisms of motor recovery during stroke therapy. However, there is no review on the mechanism of rTMS intervention for motor recovery after stroke based on fMRI explicitly. We aim to reveal and summarize the neural mechanism of the effects of rTMS on motor function after stroke as measured by fMRI. We carefully performed a literature search using PubMed, EMBASE, Web of Science, and Cochrane Library databases from their respective inceptions to November 2022 to identify any relevant randomized controlled trials. Researchers independently screened the literature, extracted data, and qualitatively described the included studies. Eleven studies with a total of 420 poststroke patients were finally included in this systematic review. A total of 338 of those participants received fMRI examinations before and after rTMS intervention. Five studies reported the effects of rTMS on activation of brain regions, and four studies reported results related to brain functional connectivity (FC). Additionally, five studies analyzed the correlation between fMRI and motor evaluation. The neural mechanism of rTMS in improving motor function after stroke may be the activation and FCs of motor-related brain areas, including enhancement of the activation of motor-related brain areas in the affected hemisphere, inhibition of the activation of motor-related brain areas in the unaffected hemisphere, and changing the FCs of intra-hemispheric and inter-hemispheric motor networks.

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.

Combination of different noninvasive brain stimulation treatments for upper limb recovery in stroke patients: A systematic review

We report a review of Pubmed (Medline), CENTRAL, Web of Science, and Scopus to test the effectiveness of the combined application of repetitive transcranial magnetic stimulation and transcranial direct current stimulation in the improvement of different functional variables of the upper limb in people with stroke. Two independent reviewers assessed eligibility and evaluated the quality of the studies. Five articles were included in the final review according to the inclusion criteria: Most show statistically significant differences in motor function improvement in favor of the experimental group, but not in activity. Due to the heterogeneity of the observed studies, the results should be interpreted with caution-more high-quality studies are needed to investigate the effectiveness of these interventions in different stages of stroke patients.

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.

Acupuncture combined with repeated transcranial magnetic stimulation for upper limb motor function after stroke: A systematic review and meta-analysis

BACKGROUND

Upper limb motor dysfunction after stroke is an important factor affecting patients' motor function and daily life. Acupuncture and repetitive transcranial magnetic stimulation are effective methods for stroke rehabilitation. However, a systematic and comprehensive overview of the combined efficacy of the two is lacking.

OBJECTIVE

Through a systematic review and meta-analysis of randomized controlled trials, this study aimed to assess the effectiveness of acupuncture combined with repetitive transcranial magnetic stimulation on upper extremity motor function in post-stroke patients.

METHODS

The relevant randomized controlled trials on acupuncture combined with repetitive transcranial magnetic stimulation in the treatment of upper limb motor disorders after stroke were searched in PubMed, Embase, Cochrane Library, Web of Science CNKI, VIP, Wanfang, and CBM databases. After screening clinical trials that met the inclusion criteria, data extraction was conducted independently by two investigators. Meta-analysis was performed using RevMan 5.4 software.

RESULTS

After the screening, 18 articles were included, with a total of 1083 subjects. The results of meta-analysis showed that combination therapy could effectively improve the patients' upper limb motor function (MD = 7.77, 95%CI [6.32, 9.22], P < 0.05), ability of daily living (MD = 8.53, 95%CI [6.28, 10.79], P < 0.05), and hemiplegic shoulder pain (MD = - 1.72, 95%CI [- 2.26, - 1.18], P < 0.05). Meanwhile, for neurophysiological indexes, combined treatment could significantly shorten the latency of motor evoked potential and central motor conduction time (MD = - 1.42, 95%CI [- 2.14, - 0.71], P < 0.05); (MD = - 0.47, 95%CI [- 0.66, - 0.29], P < 0.05), and also could increase the amplitude of motor evoked potential (SMD = 0.71, 95%CI [0.28, 1.14], P < 0.05).

CONCLUSION

According to the results of the meta-analysis, we can conclude that acupuncture combined with repeated transcranial magnetic stimulation can significantly improve the upper limb motor function and daily living ability of stroke patients.