Systematic review of parameters of stimulation, clinical trial design characteristics, and motor outcomes in non-invasive brain stimulation in stroke

Clinical implementation, barriers, and unmet needs of rTMS and neuro-navigation systems in stroke rehabilitation: a nationwide survey in South Korea

Objective

The objective of this study was to determine the implementation, clinical barriers, and unmet needs of repetitive transcranial magnetic stimulation (rTMS) and neuro-navigation systems for stroke rehabilitation.

Design

We employed a nationwide survey via Google Forms (web and mobile) consisting of 36 questions across rTMS and neuro-navigation systems, focusing on their implementation, perceptions, and unmet needs in stroke recovery. The survey targeted physiatrists registered in the Korean Society for Neuro-rehabilitation and in rehabilitation hospitals in South Korea.

Results

Of 1,129 surveys distributed, 122 responses were analyzed. Most respondents acknowledged the effectiveness of rTMS in treating post-stroke impairments; however, they highlighted significant unmet needs in standardized treatment protocols, guidelines, education, device usability, and insurance coverage. Unmet needs for neuro-navigation were also identified; only 7.4% of respondents currently used such systems, despite acknowledging their potential to enhance treatment accuracy. Seventy percent of respondents identified lack of prescription coverage, time and errors in preparation, and device cost as barriers to clinical adoption of neuro-navigation systems.

Conclusion

Despite recognition of the potential of rTMS in stroke rehabilitation, there is a considerable gap between research evidence and clinical practice. Addressing these challenges, establishing standardized protocols, and advancing accessible neuro-navigation systems could significantly enhance the clinical application of rTMS, offering a more personalized, effective treatment modality for stroke recovery.

Kinematic descriptors of arm reaching movement are sensitive to hemisphere-specific immediate neuromodulatory effects of transcranial direct current stimulation post stroke

Transcranial direct current stimulation (tDCS) exerts beneficial effects on motor recovery after stroke, presumably by enhancement of adaptive neural plasticity. However, patients with extensive damage may experience null or deleterious effects with the predominant application mode of anodal (excitatory) stimulation of the damaged hemisphere. In such cases, excitatory stimulation of the non-damaged hemisphere might be considered. Here we asked whether tDCS exerts a measurable effect on movement quality of the hemiparetic upper limb, following just a single treatment session. Such effect may inform on the hemisphere that should be excited. Using a single-blinded crossover experimental design, stroke patients and healthy control subjects were assessed before and after anodal, cathodal and sham tDCS, each provided during a single session of reaching training (repeated point-to-point hand movement on an electronic tablet). Group comparisons of endpoint kinematics at baseline-number of peaks in the speed profile (NoP; smoothness), hand-path deviations from the straight line (SLD; accuracy) and movement time (MT; speed)-disclosed greater NoP, larger SLD and longer MT in the stroke group. NoP and MT revealed an advantage for anodal compared to sham stimulation of the lesioned hemisphere. NoP and MT improvements under anodal stimulation of the non-lesioned hemisphere correlated positively with the severity of hemiparesis. Damage to specific cortical regions and white-matter tracts was associated with lower kinematic gains from tDCS. The study shows that simple descriptors of movement kinematics of the hemiparetic upper limb are sensitive enough to demonstrate gain from neuromodulation by tDCS, following just a single session of reaching training. Moreover, the results show that tDCS-related gain is affected by the severity of baseline motor impairment, and by lesion topography.

A systematic review of vestibular stimulation in post-stroke visual neglect

Unilateral visual neglect is a condition that negatively impacts the lives of many stroke survivors. Studies have investigated different forms of vestibular stimulation as a potential therapy, but evidence is yet to be systematically reviewed. We therefore reviewed the effects of vestibular stimulation on outcomes of neglect and activities of daily living (ADL) for people with visual neglect. We searched relevant databases up until September 2022. Eligible articles included any form of vestibular stimulation, study design, or control condition. Included participants were 18 years or older, presenting with neglect following a haemorrhagic or ischaemic stroke. Relevant outcomes were clinically validated measures of neglect and ADL. Cochrane risk of bias tools were used to assess study quality. Meta-analyses and narrative methods were used to synthesize the data. Our search returned 17 relevant studies comprising 180 participants. Meta-analyses showed no difference between galvanic vestibular stimulation and sham conditions on outcomes, whereas caloric vestibular stimulation led to improvement compared to pre-stimulation scores. Narrative syntheses showed mixed results. Clinical and methodological heterogeneity was found both within and between studies. Overall, results were inconsistent regarding the effects of vestibular stimulation as a treatment for neglect. Further trials are warranted but require more careful methodological planning.

Contralesional Anodal Transcranial Direct Current Stimulation Promotes Intact Corticospinal Tract Axonal Sprouting and Functional Recovery After Traumatic Brain Injury in Mice

BACKGROUND

Anodal transcranial direct current stimulation (AtDCS), a neuromodulatory technique, has been applied to treat traumatic brain injury (TBI) in patients and was reported to promote functional improvement. We evaluated the effect of contralesional AtDCS on axonal sprouting of the intact corticospinal tract (CST) and the underlying mechanism in a TBI mouse model to provide more preclinical evidence for the use of AtDCS to treat TBI.

METHODS

TBI was induced in mice by a contusion device. Then, the mice were subjected to contralesional AtDCS 5 days per week followed by a 2-day interval for 7 weeks. After AtDCS, motor function was evaluated by the irregular ladder walking, narrow beam walking, and open field tests. CST sprouting was assessed by anterograde and retrograde labeling of corticospinal neurons (CSNs), and the effect of AtDCS was further validated by pharmacogenetic inhibition of axonal sprouting using clozapine-N-oxide (CNO).

RESULTS

TBI resulted in damage to the ipsilesional cortex, while the contralesional CST remained intact. AtDCS improved the skilled motor functions of the impaired hindlimb in TBI mice by promoting CST axon sprouting, specifically from the intact hemicord to the denervated hemicord. Furthermore, electrical stimulation of CSNs significantly increased the excitability of neurons and thus activated the mechanistic target of rapamycin (mTOR) pathway.

CONCLUSIONS

Contralesional AtDCS improved skilled motor following TBI, partly by promoting axonal sprouting through increased neuronal activity and thus activation of the mTOR pathway.

NSF DARE-transforming modeling in neurorehabilitation: a patient-in-the-loop framework

In 2023, the National Science Foundation (NSF) and the National Institute of Health (NIH) brought together engineers, scientists, and clinicians by sponsoring a conference on computational modelling in neurorehabiilitation. To facilitate multidisciplinary collaborations and improve patient care, in this perspective piece we identify where and how computational modelling can support neurorehabilitation. To address the where, we developed a patient-in-the-loop framework that uses multiple and/or continual measurements to update diagnostic and treatment model parameters, treatment type, and treatment prescription, with the goal of maximizing clinically-relevant functional outcomes. This patient-in-the-loop framework has several key features: (i) it includes diagnostic and treatment models, (ii) it is clinically-grounded with the International Classification of Functioning, Disability and Health (ICF) and patient involvement, (iii) it uses multiple or continual data measurements over time, and (iv) it is applicable to a range of neurological and neurodevelopmental conditions. To address the how, we identify state-of-the-art and highlight promising avenues of future research across the realms of sensorimotor adaptation, neuroplasticity, musculoskeletal, and sensory & pain computational modelling. We also discuss both the importance of and how to perform model validation, as well as challenges to overcome when implementing computational models within a clinical setting. The patient-in-the-loop approach offers a unifying framework to guide multidisciplinary collaboration between computational and clinical stakeholders in the field of neurorehabilitation.

Non-invasive brain stimulation for functional recovery in animal models of stroke: A systematic review

Motor and cognitive dysfunction occur frequently after stroke, severely affecting a patient´s quality of life. Recently, non-invasive brain stimulation (NIBS) has emerged as a promising treatment option for improving stroke recovery. In this context, animal models are needed to improve the therapeutic use of NIBS after stroke. A systematic review was conducted based on the PRISMA statement. Data from 26 studies comprising rodent models of ischemic stroke treated with different NIBS techniques were included. The SYRCLE tool was used to assess study bias. The results suggest that both repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) improved overall neurological, motor, and cognitive functions and reduced infarct size both in the short- and long-term. For tDCS, it was observed that either ipsilesional inhibition or contralesional stimulation consistently led to functional recovery. Additionally, the application of early tDCS appeared to be more effective than late stimulation, and tDCS may be slightly superior to rTMS. The optimal stimulation protocol and the ideal time window for intervention remain unresolved. Future directions are discussed for improving study quality and increasing their translational potential.

Effects of repetitive transcranial magnetic stimulation over the contralesional dorsal premotor cortex on upper limb function in severe ischaemic stroke: study protocol for a randomised controlled trial

INTRODUCTION

Repetitive transcranial magnetic stimulation (rTMS) is an evidence-based treatment widely recommended to promote hand motor recovery after ischaemic stroke. However, the therapeutic efficacy of rTMS over the motor cortex in stroke patients is currently restricted and heterogeneous. This study aimed to determine whether excitatory rTMS over the contralesional dorsal premotor cortex (cPMd) facilitates the functional recovery of the upper limbs during the postacute stage of severe ischaemic stroke.

METHODS AND ANALYSIS

This study will be conducted as a single-blind, controlled, randomised study, in which 44 patients with poststroke hemiplegia with a course of disease ranging from 1 week to 3 months and Fugl-Meyer upper limb score ≤22 will be enrolled. The study participants will be randomly assigned to groups A (n=22) and B (n=22). The two groups are based on routine rehabilitation training and drug treatment; group A will be treated with low-frequency (1 Hz) rTMS over the contralesional primary motor cortex (cM1), and group B will be treated with high-frequency (10 Hz) rTMS over cPMd. For 2 weeks, rTMS will be administered once a day, 5 days a week. The primary outcome is the Fugl-Meyer assessment of the upper limb. The secondary outcomes include the Arm Subscore of the Motricity Index, Hong Kong edition of Functional Test for the Hemiplegic Upper Extremity, Modified Barthel Index and Modified Ashworth Scale score of the paralysed pectoralis major and biceps brachii. Furthermore, data of diffusion tensor imaging and functional MRI will be collected. These outcomes will be assessed before and after the completion of the intervention.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of the First Affiliated Hospital of Nanjing Medical University (2020 SR-266). The findings of this study will be spread through networks of scientists, professionals and the general public as well as peer-reviewed scientific papers and presentations at pertinent conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2000038049.

tDCS does not add effect to foot drop stimulator and gait training in improving clinical parameters and neuroplasticity biomarkers in chronic post-stroke: randomized controlled trial

BACKGROUND

Transcranial direct current stimulation (tDCS) and foot drop stimulators (FDS) are widely used for stroke rehabilitation. However, no study has investigated if tDCS could boost the effects of FDS and gait training in improving clinical parameters and neuroplasticity biomarkers of chronic post-stroke subjects.

OBJECTIVE

To investigate the effects of combining tDCS and FDS on motor impairment, functional mobility, and brain-derived neurotrophic factor (BDNF) serum levels. Also, to evaluate the effects of this protocol on the insulin-like growth factor-1 (IGF-1), insulin growth factor-binding proteins-3 (IGFBP-3), interleukin (IL) 6 and 10, and tumor necrosis factor-α (TNF-α) levels.

METHODS

Thirty-two chronic post-stroke individuals were randomized to tDCS plus FDS or sham tDCS plus FDS groups. Both groups underwent ten gait training sessions for two weeks using a FDS device and real or sham tDCS. Blood samples and clinical data were acquired before and after the intervention. Motor impairment was assessed by the Fugl-Meyer Assessment and functional mobility using the Timed up and Go test.

RESULTS

Both groups improved the motor impairment and functional mobility and increased the BDNF levels. Both groups also increased the IL-10 and decreased the cortisol, IL-6, and TNF-α levels. No difference was observed between groups.

CONCLUSION

tDCS did not add effect to FDS and gait training in improving clinical parameters and neuroplasticity biomarkers in chronic post-stroke individuals. Only FDS and gait training might be enough for people with chronic stroke to modify some clinical parameters and neuroplasticity biomarkers.

Intermittent tetraburst stimulation combined with transcranial direct current stimulation once weekly for treatment-resistant depression: a case report

BACKGROUND

Single-time non-invasive brain stimulation was carried out using the two-technique approach on a patient suffering from treatment-resistant depression. Five treatment sessions given at weekly intervals resulted in a significant improvement in the Patient Health Questionnaire-9 score for up to 6 weeks. The findings of this study could pave the way for a more efficient less resource-intensive time- and budget-saving technique of employing non-invasive brain stimulation for patients with treatment-resistant depression by minimizing the number of stimulation sessions.

CASE PRESENTATION

A 67-year-old married non-Latino white American woman suffering from treatment-resistant depression received intermittent tetraburst stimulation in combination with transcranial direct current stimulation weekly for 5 consecutive weeks. Diagnostic transcranial magnetic stimulation showed an observable electrophysiological change. The patient reported a drastic improvement in Patient Health Questionnaire-9 score up until 6-week follow-up and expressed satisfaction with the treatment.

CONCLUSIONS

This case study suggests that a streamlined protocol for using non-invasive brain stimulation could prove more effective for patients and healthcare providers in terms of safety in comparison to the present guidelines.

Neurophysiological biomarkers of motor improvement from Constraint-Induced Movement Therapy and Robot-Assisted Therapy in participants with stroke

Background

The mechanism of stroke recovery is related to the reorganization of cerebral activity that can be enhanced by rehabilitation therapy. Two well established treatments are Robot-Assisted Therapy (RT) and Constraint-Induced Movement Therapy (CIMT), however, it is unknown whether there is a difference in the neuroplastic changes induced by these therapies, and if the modifications are related to motor improvement. Therefore, this study aims to identify neurophysiological biomarkers related to motor improvement of participants with chronic stroke that received RT or CIMT, and to test whether there is a difference in neuronal changes induced by these two therapies.

Methods

This study included participants with chronic stroke that took part in a pilot experiment to compare CIMT vs. RT. Neurophysiological evaluations were performed with electroencephalography (EEG) and transcranial magnetic stimulation (TMS), pre and post rehabilitation therapy. Motor function was measured by the Wolf Motor Function Test (WMFT) and Fugl-Meyer Assessment Upper Limb (FMA-UL).

Results

Twenty-seven participants with chronic stroke completed the present study [mean age of 58.8 years (SD ± 13.6), mean time since stroke of 18.2 months (SD ± 9.6)]. We found that changes in motor threshold (MT) and motor evoked potential (MEP) in the lesioned hemisphere have a positive and negative correlation with WMFT improvement, respectively. The absolute change in alpha peak in the unlesioned hemisphere and the absolute change of the alpha ratio (unlesioned/lesioned hemisphere) is negatively correlated with WMFT improvement. The decrease of EEG power ratio (increase in the lesioned hemisphere and decrease in the unlesioned hemisphere) for high alpha bandwidths is correlated with better improvement in WMFT. The variable "type of treatment (RT or CIMT)" was not significant in the models.

Conclusion

Our results suggest that distinct treatments (RT and CIMT) have similar neuroplastic mechanisms of recovery. Moreover, motor improvements in participants with chronic stroke are related to decreases of cortical excitability in the lesioned hemisphere measured with TMS. Furthermore, the balance of both EEG power and EEG alpha peak frequency in the lesioned hemisphere is related to motor improvement.

Poststroke rehabilitation using repetitive transcranial magnetic stimulation during pregnancy: A case report

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is a form of magnetic stimulation therapy used to treat depression, migraine, and motor function impairment in patients with stroke. As there is little research on the effects of rTMS in pregnant women, it is not widely used in these patients. This case report aimed to demonstrate the safety of rTMS in pregnant patients.

CASE SUMMARY

After much consideration, we applied rTMS to treat recent stroke and hemiplegia in a 34-year-old pregnant woman. The patient received 45 sessions of low-frequency treatment over the course of 10 wk. We closely monitored the mother and fetus for potential side effects; the results showed significant improvement in the patient's motor function, with no harmful effects on the mother or fetus during pregnancy or after delivery. The patient’s fine motor and walking functions improved after treatment. This case is the first instance of a stroke patient treated with rTMS during pregnancy.

CONCLUSION

This case demonstrates that rTMS could be used to improve motor function recovery in stroke patients during pregnancy.

Connectomic insight into unique stroke patient recovery after rTMS treatment

An improved understanding of the neuroplastic potential of the brain has allowed advancements in neuromodulatory treatments for acute stroke patients. However, there remains a poor understanding of individual differences in treatment-induced recovery. Individualized information on connectivity disturbances may help predict differences in treatment response and recovery phenotypes. We studied the medical data of 22 ischemic stroke patients who received MRI scans and started repetitive transcranial magnetic stimulation (rTMS) treatment on the same day. The functional and motor outcomes were assessed at admission day, 1 day after treatment, 30 days after treatment, and 90 days after treatment using four validated standardized stroke outcome scales. Each patient underwent detailed baseline connectivity analyses to identify structural and functional connectivity disturbances. An unsupervised machine learning (ML) agglomerative hierarchical clustering method was utilized to group patients according to outcomes at four-time points to identify individual phenotypes in recovery trajectory. Differences in connectivity features were examined between individual clusters. Patients were a median age of 64, 50% female, and had a median hospital length of stay of 9.5 days. A significant improvement between all time points was demonstrated post treatment in three of four validated stroke scales utilized. ML-based analyses identified distinct clusters representing unique patient trajectories for each scale. Quantitative differences were found to exist in structural and functional connectivity analyses of the motor network and subcortical structures between individual clusters which could explain these unique trajectories on the Barthel Index (BI) scale but not on other stroke scales. This study demonstrates for the first time the feasibility of using individualized connectivity analyses in differentiating unique phenotypes in rTMS treatment responses and recovery. This personalized connectomic approach may be utilized in the future to better understand patient recovery trajectories with neuromodulatory treatment.

Presbyphagia: Dysphagia in the elderly

Dysphagia has been classified as a “geriatric syndrome” and can lead to serious complications that result in a tremendous burden on population health and healthcare resources worldwide. A characteristic age-related change in swallowing is defined as “presbyphagia.” Medical imaging has shown some changes that seriously affect the safety and efficacy of swallowing. However, there is a general lack of awareness of the effects of aging on swallowing function and a belief that these changes are part of normal aging. Our review provides an overview of presbyphagia, which has been a neglected health problem for a long time. Attention and awareness of dysphagia in the elderly population should be strengthened, and targeted intervention measures should be actively implemented.

Upper Limb Function Recovery by Combined Repetitive Transcranial Magnetic Stimulation and Occupational Therapy in Patients with Chronic Stroke According to Paralysis Severity

Repetitive transcranial magnetic stimulation (rTMS) with intensive occupational therapy improves upper limb motor paralysis and activities of daily living after stroke; however, the degree of improvement according to paralysis severity remains unverified. Target activities of daily living using upper limb functions can be established by predicting the amount of change after treatment for each paralysis severity level to further aid practice planning. We estimated post-treatment score changes for each severity level of motor paralysis (no, poor, limited, notable, and full), stratified according to Action Research Arm Test (ARAT) scores before combined rTMS and intensive occupational therapy. Motor paralysis severity was the fixed factor for the analysis of covariance; the delta (post-pre) of the scores was the dependent variable. Ordinal logistic regression analysis was used to compare changes in ARAT subscores according to paralysis severity before treatment. We implemented a longitudinal, prospective, interventional, uncontrolled, and multicenter cohort design and analyzed a dataset of 907 patients with stroke hemiplegia. The largest treatment-related changes were observed in the Limited recovery group for upper limb motor paralysis and the Full recovery group for quality-of-life activities using the paralyzed upper limb. These results will help predict treatment effects and determine exercises and goal movements for occupational therapy after rTMS.

Cerebral Hemodynamic Changes during Unaffected Handgrip Exercises in Stroke Patients: An fNIRS Study

This study aimed to assess the effect of the altered strength of the sound limb on the hemodynamics in the affected brain of stroke patients. We recruited 20 stroke patients to detect changes in the HbO concentrations in the bilateral prefrontal cortex (PFC), sensorimotor cortex (SMC), and occipital lobe (OL). We performed functional near-infrared spectroscopy (fNIRS) to detect changes in oxyhemoglobin (HbO) concentrations in regions of interest (ROIs) in the bilateral cerebral hemispheres of stroke patients while they performed 20%, 50%, and 80% maximal voluntary contraction (MVC) levels of handgrip tasks with the unaffected hands. The results suggest that when patients performed handgrip tasks with 50% of the MVC force, SMC in the affected cerebral hemisphere was strongly activated and the change in the HbO concentration was similar to that of the handgrip with 80% of MVC. When the force was 50% of MVC, the SMC in the affected hemisphere showed a more proportional activation than that at 80% MVC. Overall, this research suggests that stroke patients with a poor upper limb function should perform motor training with their sound hands at 50% of the MVC grip task to activate the ipsilesional hemisphere.

Self-regulation of the brain's right frontal Beta rhythm using a brain-computer interface

Neural oscillations, or brain rhythms, fluctuate in a manner reflecting ongoing behavior. Whether these fluctuations are instrumental or epiphenomenal to the behavior remains elusive. Attempts to experimentally manipulate neural oscillations exogenously using noninvasive brain stimulation have shown some promise, but difficulty with tailoring stimulation parameters to individuals has hindered progress in this field. We demonstrate here using electroencephalography (EEG) neurofeedback in a brain-computer interface that human participants (n = 44) learned over multiple sessions across a 6-day period to self-regulate their Beta rhythm (13-20 Hz), either up or down, over the right inferior frontal cortex. Training to downregulate Beta was more effective than training to upregulate Beta. The modulation was evident only during neurofeedback task performance but did not lead to offline alteration of Beta rhythm characteristics at rest, nor to changes in subsequent cognitive behavior. Likewise, a control group (n = 38) who underwent training to up or downregulate the Alpha rhythm (8-12 Hz) did not exhibit behavioral changes. Although the right frontal Beta rhythm has been repeatedly implicated as a key component of the brain's inhibitory control system, the present data suggest that its manipulation offline prior to cognitive task performance does not result in behavioral change in healthy individuals. Whether this form of neurofeedback training could serve as a useful therapeutic target for disorders with dysfunctional inhibitory control as their basis remains to be tested in a context where performance is abnormally poor and neural dynamics are different.

Rehabilitation Interventions Combined with Noninvasive Brain Stimulation on Upper Limb Motor Function in Stroke Patients

(1) Background: This systematic review aimed to focus on the effects of rehabilitation interventions combined with noninvasive brain stimulation on upper limb motor function in stroke patients. (2) Methods: PubMed, MEDLINE, and CINAHL were used for the literature research. Articles were searched using the following terms: "Stroke OR CVA OR cerebrovascular accident" AND "upper limb OR upper extremity" AND "NIBS OR Non-Invasive Brain Stimulation" OR "rTMS" OR "repetitive transcranial magnetic stimulation" OR "tDCS" OR "transcranial direct current stimulation" AND "RCT" OR randomized control trial." In total, 12 studies were included in the final analysis. (3) Results: Analysis using the Physiotherapy Evidence Database scale for qualitative evaluation of the literature rated eight articles as "excellent" and four as "good." Combined rehabilitation interventions included robotic therapy, motor imagery using brain-computer interaction, sensory control, occupational therapy, physiotherapy, task-oriented approach, task-oriented mirror therapy, neuromuscular electrical stimulation, and behavior observation therapy. (4) Conclusions: Although it is difficult to estimate the recovery of upper limb motor function in stroke patients treated with noninvasive brain stimulation alone, a combination of a task-oriented approach, occupational therapy, action observation, wrist robot-assisted rehabilitation, and physical therapy can be effective.

After 55 Years of Neurorehabilitation, What Is the Plan?

Neurological disorders often cause severe long-term disabilities with substantial activity limitations and participation restrictions such as community integration, family functioning, employment, social interaction and participation. Increasing understanding of brain functioning has opened new perspectives for more integrative interventions, boosting the intrinsic central nervous system neuroplastic capabilities in order to achieve efficient behavioral restitution. Neurorehabilitation must take into account the many aspects of the individual through a comprehensive analysis of actual and potential cognitive, behavioral, emotional and physical skills, while increasing awareness and understanding of the new self of the person being dealt with. The exclusive adoption by the rehabilitator of objective functional measures often overlooks the values and goals of the disabled person. Indeed, each individual has their own rhythm, unique life history and personality construct. In this challenging context, it is essential to deepen the assessment through subjective measures, which more adequately reflect the patient’s perspective in order to shape genuinely tailored instead of standardized neurorehabilitation approaches. In this overly complex panorama, where confounding and prognostic factors also strongly influence potential functional recovery, the healthcare community needs to rethink neurorehabilitation formats.

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/

Spatially bivariate EEG-neurofeedback can manipulate interhemispheric inhibition

Human behavior requires inter-regional crosstalk to employ the sensorimotor processes in the brain. Although external neuromodulation techniques have been used to manipulate interhemispheric sensorimotor activity, a central controversy concerns whether this activity can be volitionally controlled. Experimental tools lack the power to up- or down-regulate the state of the targeted hemisphere over a large dynamic range and, therefore, cannot evaluate the possible volitional control of the activity. We addressed this difficulty by using the recently developed method of spatially bivariate electroencephalography (EEG)-neurofeedback to systematically enable the participants to modulate their bilateral sensorimotor activities. Here, we report that participants learn to up- and down-regulate the ipsilateral excitability to the imagined hand while maintaining constant contralateral excitability; this modulates the magnitude of interhemispheric inhibition (IHI) assessed by the paired-pulse transcranial magnetic stimulation (TMS) paradigm. Further physiological analyses revealed that the manipulation capability of IHI magnitude reflected interhemispheric connectivity in EEG and TMS, which was accompanied by intrinsic bilateral cortical oscillatory activities. Our results show an interesting approach for neuromodulation, which might identify new treatment opportunities, e.g., in patients suffering from a stroke.

Homotopic contralesional excitation suppresses spontaneous circuit repair and global network reconnections following ischemic stroke

Understanding circuit-level manipulations that affect the brain's capacity for plasticity will inform the design of targeted interventions that enhance recovery after stroke. Following stroke, increased contralesional activity (e.g. use of the unaffected limb) can negatively influence recovery, but it is unknown which specific neural connections exert this influence, and to what extent increased contralesional activity affects systems- and molecular-level biomarkers of recovery. Here, we combine optogenetic photostimulation with optical intrinsic signal imaging to examine how contralesional excitatory activity affects cortical remodeling after stroke in mice. Following photothrombosis of left primary somatosensory forepaw (S1FP) cortex, mice either recovered spontaneously or received chronic optogenetic excitation of right S1FP over the course of 4 weeks. Contralesional excitation suppressed perilesional S1FP remapping and was associated with abnormal patterns of stimulus-evoked activity in the unaffected limb. This maneuver also prevented the restoration of resting-state functional connectivity (RSFC) within the S1FP network, RSFC in several networks functionally distinct from somatomotor regions, and resulted in persistent limb-use asymmetry. In stimulated mice, perilesional tissue exhibited transcriptional changes in several genes relevant for recovery. Our results suggest that contralesional excitation impedes local and global circuit reconnection through suppression of cortical activity and several neuroplasticity-related genes after stroke, and highlight the importance of site selection for targeted therapeutic interventions after focal ischemia.

Intensity matters: protocol for a randomized controlled trial exercise intervention for individuals with chronic stroke

Rationale

Cardiovascular exercise is an effective method to improve cardiovascular health outcomes, but also promote neuroplasticity during stroke recovery. Moderate-intensity continuous cardiovascular training (MICT) is an integral part of stroke rehabilitation, yet it may remain a challenge to exercise at sufficiently high intensities to produce beneficial adaptations to neuroplasticity. High-intensity interval training (HIIT) could provide a viable alternative to achieve higher intensities of exercise by using shorter bouts of intense exercise interspersed with periods of recovery.

Methods and design

This is a two-arm, parallel-group multi-site RCT conducted at the Jewish Rehabilitation Hospital (Laval, Québec, Canada) and McMaster University (Hamilton, Ontario, Canada). Eighty participants with chronic stroke will be recruited at both sites and will be randomly allocated into a HIIT or MICT individualized exercise program on a recumbent stepper, 3 days per week for 12 weeks. Outcomes will be assessed at baseline, at 12 weeks post-intervention, and at an 8-week follow-up.

Outcomes

The primary outcome is corticospinal excitability, a neuroplasticity marker in brain motor networks, assessed with transcranial magnetic stimulation (TMS). We will also examine additional markers of neuroplasticity, measures of cardiovascular health, motor function, and psychosocial responses to training.

Discussion

This trial will contribute novel insights into the effectiveness of HIIT to promote neuroplasticity in individuals with chronic stroke.

Trial registration

ClinicalTrials.govNCT03614585. Registered on 3 August 2018

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06359-w.

Effects of high frequency rTMS of contralesional dorsal premotor cortex in severe subcortical chronic stroke: protocol of a randomized controlled trial with multimodal neuroimaging assessments

Background

Previous studies have revealed that low frequency repeated transcranial magnetic stimulation (rTMS) on the contralesional primary motor cortex (cM1) is less effective in severe stroke patients with poor neural structural reserve than in patients with highly reserved descending motor pathway. This may be attributed to the fact that secondary motor cortex, especially contralesional dorsal premotor cortex (cPMd), might play an important compensatory role in the motor function recovery of severely affected upper extremity. The main purpose of this study is to compare the effectiveness of low frequency rTMS on cM1 and high frequency rTMS on cPMd in subcortical chronic stroke patients with severe hemiplegia. By longitudinal analysis of multimodal neuroimaging data, we hope to elucidate the possible mechanism of brain reorganization following different treatment regimens of rTMS therapy, and to determine the cut-off of stimulation strategy selection based on the degree of neural structural reserve.

Methods/design

The study will be a single-blinded randomized controlled trial involving a total of 60 subcortical chronic stroke patients with severe upper limb motor impairments. All patients will receive 3 weeks of conventional rehabilitation treatment, while they will be divided into three groups and receive different rTMS treatments: cM1 low frequency rTMS (n = 20), cPMd high frequency rTMS (n = 20), and sham stimulation group (n = 20). Clinical functional assessment, multimodal functional MRI (fMRI) scanning, and electrophysiological measurement will be performed before intervention, 3 weeks after intervention, and 4 weeks after the treatment, respectively.

Discussion

This will be the first study to compare the effects of low-frequency rTMS of cM1 and high-frequency rTMS of cPMd. The outcome of this study will provide a theoretical basis for clarifying the bimodal balance-recovery model of stroke, and provide a strategy for individualized rTMS treatment for stroke in future studies and clinical practice.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1900027399. Registered on 12 Nov 2019, http://www.chictr.org.cn/showproj.aspx?proj=43686.

Influence of Transcranial Direct Current Stimulation Dosage and Associated Therapy on Motor Recovery Post-stroke: A Systematic Review and Meta-Analysis

Purpose

(1) To determine the impact of transcranial direct current stimulation (tDCS) applied alone or combined with other therapies on the recovery of motor function after stroke and (2) To determine tDCS dosage effect.

Methods

Randomized controlled trials comparing the effects of tDCS with sham, using the Barthel Index (BI), the upper and lower extremity Fugl–Meyer Assessment (FMA), and the Modified Ashworth Scale (MAS), were retrieved from PubMed, Medline (EBSCO), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) from their inception to June 2021. Calculations for each assessment were done for the overall effect and associated therapy accounting for the influence of stroke severity or stimulation parameters.

Results

A total of 31 studies involving metrics of the BI, the upper extremity FMA, the lower extremity FMA, and the MAS were included. tDCS combined with other therapies was beneficial when assessed by the BI (mean difference: 6.8; P < 0.01) and these studies typically had participants in the acute stage. tDCS effects on the upper and lower extremity FMA are unclear and differences between the sham and tDCS groups as well as differences in the associated therapy type combined with tDCS potentially influenced the FMA results. tDCS was not effective compared to sham for the MAS. Stimulation types (e.g., anodal vs. cathodal) did not influence these results and dosage parameters were not associated with the obtained effect sizes. Conventional therapy associated with tDCS typically produced greater effect size than assisted therapy. The influence of stroke severity is unclear.

Conclusion

Potential benefits of tDCS can vary depending on assessment tool used, duration of stroke, and associated therapy. Mechanistic studies are needed to understand the potential role of stimulation type and dosage effect after stroke. Future studies should carefully conduct group randomization, control for duration of stroke, and report different motor recovery assessments types.

Systematic Review Registration

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021290670].

Effects of combining two techniques of non-invasive brain stimulation in subacute stroke patients: a pilot study

Background

Strokes have recently become a leading cause of disability among Thai people. Non-invasive brain stimulation (NIBS) seems to give promising results in stroke recovery when combined with standard rehabilitation programs.

Objective

To evaluate the combined effect of low-frequency repetitive transcranial magnetic stimulation (rTMS) and cathodal transcranial direct current stimulation (tDCS) over the non-lesional primary motor cortex on upper limb motor recovery in patients with subacute stroke. No reports of a combination of these two techniques of NIBS were found in the relevant literature.

Methods

This pilot study was a double-blinded, randomized controlled trial of ten patients with subacute stroke admitted to the Rehabilitation Medicine Inpatient Unit, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. They were randomized into two groups: five in an active and five in a sham intervention group. Fugl-Meyer’s upper extremity motor score (FMA-UE) and Wolf Motor Function Test (WMFT) were used to assess motor recovery at baseline, immediately, and 1 week after stimulation.

Results

A two-way repeated ANOVA (mixed design) showed a significant improvement in FMA-UE scores in the active intervention group both immediately and 1 week after stimulation in comparison to the baseline, [time, F (2, 16) = 27.44, p < 0.001, time x group interaction, F (2, 16) = 13.29, p < 0.001]. Despite no statistical significance, a trend toward higher WMFT scores was shown in the active intervention group.

Conclusions

A single session of low-frequency rTMS and cathodal tDCS over the non-lesional primary motor cortex may enhance upper limb motor recovery in patients with subacute stroke.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02607-3.

Repeated Sessions of Transcranial Direct Current Stimulation on Adolescents With Autism Spectrum Disorder: Study Protocol for a Randomized, Double-Blind, and Sham-Controlled Clinical Trial

Background: Social-emotional difficulties are a core symptom of autism spectrum disorder (ASD). Accordingly, individuals with ASD have problems with social cognition such as recognizing emotions from other peoples' faces. Various results from functional magnetic resonance imaging and electroencephalography studies as well as eye-tracking data reveal a neurophysiological basis of these deficits by linking them to abnormal brain activity. Thus, an intervention targeting the neural origin of ASD impairments seems warranted. A safe method able to influence neural activity is transcranial direct current stimulation (tDCS). This non-invasive brain stimulation method has already demonstrated promising results in several neuropsychiatric disorders in adults and children. The aim of this project is to investigate the effects of tDCS on ASD symptoms and their neural correlates in children and adolescents with ASD. Method: This study is designed as a double-blind, randomized, and sham-controlled trial with a target sample size of 20 male participants (aged 12-17 years) diagnosed with ASD. Before randomization, the participants will be stratified into comorbid depression, comorbid ADHS/conduct disorder, or no-comorbidity groups. The intervention phase comprises 10 sessions of anodal or sham tDCS applied over the left prefrontal cortex within 2 consecutive weeks. To engage the targeted brain regions, participants will perform a social cognition training during the stimulation. TDCS-induced effects on ASD symptoms and involved neural circuits will be investigated through psychological, neurophysiological, imaging, and behavioral data at pre- and post-measurements. Tolerability will be evaluated using a standardized questionnaire. Follow-up assessments 1 and 6 months after the intervention will examine long-lasting effects. Discussion: The results of this study will provide insights into the changeability of social impairments in ASD by investigating social and emotional abilities on different modalities following repeated sessions of anodal tDCS with an intra-simulation training. Furthermore, this trial will elucidate the tolerability and the potential of tDCS as a new treatment approach for ASD in adolescents. Clinical Trial Registration: The study is ongoing and has been registered in the German Registry of Clinical Trials (DRKS00017505) on 02/07/2019.

Contralesional Cathodal Transcranial Direct Current Stimulation Does Not Enhance Upper Limb Function in Subacute Stroke: A Pilot Randomized Clinical Trial

Transcranial direct current stimulation (tDCS) has the potential to improve upper limb motor outcomes after stroke. According to the assumption of interhemispheric inhibition, excessive inhibition from the motor cortex of the unaffected hemisphere to the motor cortex of the affected hemisphere may worsen upper limb motor recovery after stroke. We evaluated the effects of active cathodal tDCS of the primary motor cortex of the unaffected hemisphere (ctDCSM1_UH) compared to sham, in subjects within 72 hours to 6 weeks post ischemic stroke. Cathodal tDCS was intended to inhibit the motor cortex of the unaffected hemisphere and hence decrease the inhibition from the unaffected to the affected hemisphere and enhance motor recovery. We hypothesized that motor recovery would be greater in the active than in the sham group. In addition, greater motor recovery in the active group might be associated with bigger improvements in measures in activity and participation in the active than in the sham group. We also explored, for the first time, changes in cognition and sleep after ctDCSM1_UH. Thirty subjects were randomized to six sessions of either active or sham ctDCSM1_UH as add-on interventions to rehabilitation. The NIH Stroke Scale (NIHSS), Fugl-Meyer Assessment of Motor Recovery after Stroke (FMA), Barthel Index (BI), Stroke Impact Scale (SIS), and Montreal Cognitive Assessment (MoCA) were assessed before, after treatment, and three months later. In the intent-to-treat (ITT) analysis, there were significant GROUP∗TIME interactions reflecting stronger gains in the sham group for scores in NIHSS, FMA, BI, MoCA, and four SIS domains. At three months post intervention, the sham group improved significantly compared to posttreatment in FMA, NIHSS, BI, and three SIS domains while no significant changes occurred in the active group. Also at three months, NIHSS improved significantly in the sham group and worsened significantly in the active group. FMA scores at baseline were higher in the active than in the sham group. After adjustment of analysis according to baseline scores, the between-group differences in FMA changes were no longer statistically significant. Finally, none of the between-group differences in changes in outcomes after treatment were considered clinically relevant. In conclusion, active CtDCSM1_UH did not have beneficial effects, compared to sham. These results were consistent with other studies that applied comparable tDCS intensities/current densities or treated subjects with severe upper limb motor impairments during the first weeks post stroke. Dose-finding studies early after stroke are necessary before planning larger clinical trials.

Effects of coupling inhibitory and facilitatory repetitive transcranial magnetic stimulation on motor recovery in patients following acute cerebral infarction

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.

Transcranial direct current stimulation (tDCS) for improving activities of daily living, and physical and cognitive functioning, in people after stroke

BACKGROUND

Stroke is one of the leading causes of disability worldwide. Functional impairment, resulting in poor performance in activities of daily living (ADL) among stroke survivors is common. Current rehabilitation approaches have limited effectiveness in improving ADL performance, function, muscle strength, and cognitive abilities (including spatial neglect) after stroke, with improving cognition being the number one research priority in this field. A possible adjunct to stroke rehabilitation might be non-invasive brain stimulation by transcranial direct current stimulation (tDCS) to modulate cortical excitability, and hence to improve these outcomes in people after stroke.

OBJECTIVES

To assess the effects of tDCS on ADL, arm and leg function, muscle strength and cognitive abilities (including spatial neglect), dropouts and adverse events in people after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase and seven other databases in January 2019. In an effort to identify further published, unpublished, and ongoing trials, we also searched trials registers and reference lists, handsearched conference proceedings, and contacted authors and equipment manufacturers.

SELECTION CRITERIA

This is the update of an existing review. In the previous version of this review, we focused on the effects of tDCS on ADL and function. In this update, we broadened our inclusion criteria to compare any kind of active tDCS for improving ADL, function, muscle strength and cognitive abilities (including spatial neglect) versus any kind of placebo or control intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and risk of bias, extracted data, and applied GRADE criteria. If necessary, we contacted study authors to ask for additional information. We collected information on dropouts and adverse events from the trial reports.

MAIN RESULTS

We included 67 studies involving a total of 1729 patients after stroke. We also identified 116 ongoing studies. The risk of bias did not differ substantially for different comparisons and outcomes. The majority of participants had ischaemic stroke, with mean age between 43 and 75 years, in the acute, postacute, and chronic phase after stroke, and level of impairment ranged from severe to less severe. Included studies differed in terms of type, location and duration of stimulation, amount of current delivered, electrode size and positioning, as well as type and location of stroke. We found 23 studies with 781 participants examining the effects of tDCS versus sham tDCS (or any other passive intervention) on our primary outcome measure, ADL after stroke. Nineteen studies with 686 participants reported absolute values and showed evidence of effect regarding ADL performance at the end of the intervention period (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.13 to 0.44; random-effects model; moderate-quality evidence). Four studies with 95 participants reported change scores, and showed an effect (SMD 0.48, 95% CI 0.02 to 0.95; moderate-quality evidence). Six studies with 269 participants assessed the effects of tDCS on ADL at the end of follow-up and provided absolute values, and found improved ADL (SMD 0.31, 95% CI 0.01 to 0.62; moderate-quality evidence). One study with 16 participants provided change scores and found no effect (SMD -0.64, 95% CI -1.66 to 0.37; low-quality evidence). However, the results did not persist in a sensitivity analysis that included only trials with proper allocation concealment. Thirty-four trials with a total of 985 participants measured upper extremity function at the end of the intervention period. Twenty-four studies with 792 participants that presented absolute values found no effect in favour of tDCS (SMD 0.17, 95% CI -0.05 to 0.38; moderate-quality evidence). Ten studies with 193 participants that presented change values also found no effect (SMD 0.33, 95% CI -0.12 to 0.79; low-quality evidence). Regarding the effects of tDCS on upper extremity function at the end of follow-up, we identified five studies with a total of 211 participants (absolute values) without an effect (SMD -0.00, 95% CI -0.39 to 0.39; moderate-quality evidence). Three studies with 72 participants presenting change scores found an effect (SMD 1.07; 95% CI 0.04 to 2.11; low-quality evidence). Twelve studies with 258 participants reported outcome data for lower extremity function and 18 studies with 553 participants reported outcome data on muscle strength at the end of the intervention period, but there was no effect (high-quality evidence). Three studies with 156 participants reported outcome data on muscle strength at follow-up, but there was no evidence of an effect (moderate-quality evidence). Two studies with 56 participants found no evidence of effect of tDCS on cognitive abilities (low-quality evidence), but one study with 30 participants found evidence of effect of tDCS for improving spatial neglect (very low-quality evidence). In 47 studies with 1330 participants, the proportions of dropouts and adverse events were comparable between groups (risk ratio (RR) 1.25, 95% CI 0.74 to 2.13; random-effects model; moderate-quality evidence).  AUTHORS' CONCLUSIONS: There is evidence of very low to moderate quality on the effectiveness of tDCS versus control (sham intervention or any other intervention) for improving ADL outcomes after stroke. However, the results did not persist in a sensitivity analyses including only trials with proper allocation concealment. Evidence of low to high quality suggests that there is no effect of tDCS on arm function and leg function, muscle strength, and cognitive abilities in people after stroke. Evidence of very low quality suggests that there is an effect on hemispatial neglect. There was moderate-quality evidence that adverse events and numbers of people discontinuing the treatment are not increased. Future studies should particularly engage with patients who may benefit the most from tDCS after stroke, but also should investigate the effects in routine application. Therefore, further large-scale randomised controlled trials with a parallel-group design and sample size estimation for tDCS are needed.

Low frequency transcranial magnetic stimulation in subacute ischemic stroke: Number of sessions that altered cortical excitability

BACKGROUND

Cortical reorganization between both cerebral hemispheres plays an important role in regaining the affected upper extremity motor function post-stroke.

OBJECTIVES

The purpose of the current study was to investigate the recommended number of contra-lesion low frequency repetitive transcranial magnetic stimulation (LF-rTMS) sessions that could enhance cortical reorganization post-stroke.

METHODS

Forty patients with right hemiparetic subacute ischemic stroke with an age range between 50-65 yrs were randomly assigned into two equal groups: control (GA) and study (GB) groups. Both groups were treated with a selected physical therapy program for the upper limb. Sham and real contra-lesion LF-rTMS was conducted for both groups daily for two consecutive weeks. Sequential changes of cortical excitability were calculated by the end of each session.

RESULTS

The significant enhancement in the cortical excitability was observed at the fourth session in favor of the study group (GB). Sequential rate of change in cortical excitability was significant for the first eight sessions. From the ninth session onwards, no difference could be detected between groups.

CONCLUSION

The pattern of recovery after stroke is extensive and not all factors could be controlled. Application of LF-rTMS in conjugation with a selected physical therapy program for the upper limb from four to eight sessions seems to be efficient.

Neurostimulation and Reach-to-Grasp Function Recovery Following Acquired Brain Injury: Insight From Pre-clinical Rodent Models and Human Applications

Reach-to-grasp is an evolutionarily conserved motor function that is adversely impacted following stroke and traumatic brain injury (TBI). Non-invasive brain stimulation (NIBS) methods, such as transcranial magnetic stimulation and transcranial direct current stimulation, are promising tools that could enhance functional recovery of reach-to-grasp post-brain injury. Though the rodent literature provides a causal understanding of post-injury recovery mechanisms, it has had a limited impact on NIBS protocols in human research. The high degree of homology in reach-to-grasp circuitry between humans and rodents further implies that the application of NIBS to brain injury could be better informed by findings from pre-clinical rodent models and neurorehabilitation research. Here, we provide an overview of the advantages and limitations of using rodent models to advance our current understanding of human reach-to-grasp function, cortical circuitry, and reorganization. We propose that a cross-species comparison of reach-to-grasp recovery could provide a mechanistic framework for clinically efficacious NIBS treatments that could elicit better functional outcomes for patients.

Multi-Phase Cross-modal Learning for Noninvasive Gene Mutation Prediction in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer and the fourth most common cause of cancer-related death worldwide. Understanding the underlying gene mutations in HCC provides great prognostic value for treatment planning and targeted therapy. Radiogenomics has revealed an association between non-invasive imaging features and molecular genomics. However, imaging feature identification is laborious and error-prone. In this paper, we propose an end-to-end deep learning framework for mutation prediction in APOB, COL11A1 and ATRX genes using multiphasic CT scans. Considering intra-tumour heterogeneity (ITH) in HCC, multi-region sampling technology is implemented to generate the dataset for experiments. Experimental results demonstrate the effectiveness of the proposed model.

The lasting effects of 1Hz repetitive transcranial magnetic stimulation on resting state EEG in healthy subjects

Repetitive Transcranial magnetic stimulation (rTMS) is a noninvasive brain stimulation technique that able to influence cortical excitability. Low-frequency rTMS (stimulation frequency ≤1Hz) induces long-lasting inhibitory effects on cortical excitability. In order to study the effects of 1Hz rTMS of the motor cortex on neuronal activity, 20 healthy subjects were recruited to receive rTMS, and electroencephalography (EEG) in resting condition with eye open were recorded before rTMS, at 0min, 20min, 40min, 60min after rTMS. In multiple frequency bands, power values on each channel were calculated, and functional connectivity between two channels was assessed using phase synchronization. We found an increase in power of theta-band oscillations in the frontal and the central brain areas immediately after rTMS. And alpha resting power in the central-parietal brain area did not change immediately after rTMS, but increased at 20min after rTMS. Moreover, there is a widespread increase in functional connectivity after rTMS in the theta band, whereas widespread decreases in the functional connectivity were found in the alpha band after rTMS. At the same time, there was no significant recovery on power and functional connectivity at 60min after rTMS. These results provide an evidence for a transient reorganization of neuronal activity after 1Hz rTMS over the motor cortex. In addition, low-frequency rTMS produces widespread long-lasting alterations in cortical functional connectivity.

Does neuromodulation transcranial direct current stimulation (tDCS) associated with peripheral stimulation through exercise to walk have an impact on falls in people with Parkinson's disease?

Parkinson's disease (PD) is one of the most prevalent neurodegenerative diseases in the world, with a high degree of disability. Among the various therapeutic possibilities, brain stimulation appears in a promising approach, with deep brain stimulation (DBS) being the best described and successful, yet it has the limitation of being invasive. In this context we present transcranial direct current stimulation (tDCS), a non-invasive treatment that brings a new perspective when thinking about treatment of neurological diseases. It is easy to handle, low cost, few side effects and good adherence to patients. TDCS presents good evidence for clinical practice, but when it comes to PD the results obtained are inconclusive and some protocols have not yet been tested. In this hypothesis we propose that the use of tDCS applied in the supplemental motor areas, together with a gait training, can facilitate the motor learning and modulate the neurons for better potentiation of the exercises together with patients with walking difficulties due to PD.

High-frequency rTMS with two different inter-train intervals improves upper limb motor function at the early stage of stroke

Objective

This study aimed to explore the therapeutic effect of high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) with two different inter-train intervals (ITIs) on upper limb motor function in the early period of stroke.

Methods

We recruited 48 post-stroke patients in the early period and randomly divided them into three cohorts: the sham group, the short ITI (8 s) group, and the long ITI (28 s) group. HF-rTMS was delivered at 20 Hz. The amplitude of motor evoked potentials at the affected cortical region, representing the abductor pollicis brevis muscle, reflected cortical excitability. At baseline, immediately after treatment, and 1 month after treatment, we evaluated the recovery of upper limb motor function using Brunnstrom recovery stages (BRSs) and the Fugl–Meyer Assessment for upper extremity (FMA-UE), and assessed functional independence using the Barthel Index (BI).

Results

HF-rTMS with two different ITIs significantly improved upper limb functional recovery relative to the sham group, but there was no significant difference in cortical excitability changes or BRS, FMA-UE, or BI scores between the different ITI groups.

Conclusions

At the early post-stroke stage, HF-rTMS with short ITIs generates a similar therapeutic effect to HF-rTMS with long ITIs, suggesting that treatment times can be decreased.

Evaluating the effects of tDCS in stroke patients using functional outcomes: a systematic review

Background and purpose: Transcranial direct current stimulation (tDCS) has been extensively studied over the past 20 years to promote functional motor recovery after stroke. However, tDCS clinical relevance still needs to be determined. The present systematic review aims to determine whether tDCS applied to the primary motor cortex (M1) in stroke patients can have a positive effect on functional motor outcomes.Materials and methods: Two databases (Medline & Scopus) were searched for randomized, double-blinded, sham-controlled trials pertaining to the use of M1 tDCS on cerebral stroke patients, and its effects on validated functional motor outcomes. When data were provided, effect sizes were calculated. PROSPERO registration number: CRD42018108157Results: 46 studies (n = 1291 patients) met inclusion criteria. Overall study quality was good (7.69/10 on the PEDro scale). Over half (56.5%) the studies were on chronic stroke patients. There seemed to be a certain pattern of recurring parameters, but tDCS protocols still remain heterogeneous. Overall results were positive (71.7% of studies found that tDCS has positive results on functional motor outcomes). Effect-sizes ranged from 0 to 1.33. No severe adverse events were reported.Conclusion: Despite heterogeneous stimulation parameters, outcomes and patient demographics, tDCS seems to be complementary to classical and novel rehabilitation approaches. With minimal adverse effects (if screening parameters are respected), none of which were serious, and a high potential to improve recovery when using optimal parameters (i.e.: 20 min of stimulation, at 2 mA with 25 or 35cm² electrodes that are regularly humidified), tDCS could potentially be ready for clinical applications.Implications for RehabilitationtDCS could potentially be ready for clinical application.Evidence of very low to very high quality is available on the effectiveness of tDCS to improve motor control following stroke.This should with caution be focused on the primary motor cortex.

Effects of Transcranial Direct Current Stimulation (tDCS) and Exercises Treadmill on Autonomic Modulation of Hemiparetic Patients Due To Stroke-Clinic Test, Controlled, Randomized, Double-Blind

Background: After a Stroke, there is an autonomic nervous system (ANS) changes. Transcranial Direct Current Stimulation (tDCS) can promote the reorganization of the affected circuits.

Objective: To evaluate the effects of tDCS applied before a session of physical activity on the treadmill, in the modulation of the autonomic nervous system of post-stroke patients.

Methodology: Cross-over study, were randomized 12 adult hemiparetic subjects in 2 groups, Group 1 (active tDCS before exercise on the treadmill) and Group 2 (sham tDCS before exercise on the treadmill). Stimulation times were 20 min; treadmill time was 20 min. The heart rate variability (HRV) and Variability of Systolic Blood Pressure (VSBP) were evaluated for 15 min, in 3 periods (pre and post tDCS and during exercise recovery on the treadmill).

Results: There was no difference in the VSBP and the HRV between the groups, compared with the baseline data; however, in the intragroup analysis, the parasympathetic modulation after active tDCS increased by 18% over baseline by the RMSSD with IC 95% (−7.85 to −0.34). In group 1, the post-tDCS active and post-exercise periods presented a value of variance above baseline, indicating a better prognosis. In group 2, there was a significant reduction of 38% of Variance values (p = 0.003) after tDCS sham.

Conclusion: tDCS does not generate immediate effects on HRV and VSBP, except for intragroup comparison, which has greater participation in parasympathetic modulation in the group receiving active tDCS.

Intermittent theta burst stimulation applied during early rehabilitation after stroke: study protocol for a randomised controlled trial

INTRODUCTION

Intermittent theta burst stimulation (iTBS) applied to primary motor cortex (M1) has been shown to modulate both the excitability and connectivity of the motor system. A recent proof-of-principle study, based on a small group of hospitalised patients with acute ischemic stroke, suggested that iTBS applied to the ipsilesional M1 combined with physical therapy early after stroke can amplify motor recovery with lasting after effects. A randomised controlled clinical trial using a double-blind design is warranted to justify the implementation of iTBS-assisted motor rehabilitation in neurorehabilitation from an acute ischaemic stroke.

METHODS/DESIGN

We investigate the effects of daily iTBS on early motor rehabilitation after stroke in an investigator-initiated, longitudinal randomised controlled trial. Patients (n=150) with hemiparesis receive either iTBS (600 pulses) applied to the ipsilesional motor cortex (M1) or a control stimulation (ie, coil placement over the parieto-occipital vertex in parallel to the interhemispheric fissure and with a tilt of 45°). On 8 consecutive workdays, a 45 min arm-centred motor training follows the intervention . The relative grip strength, defined as the grip force ratios of the affected and unaffected hands, serves as the primary outcome parameter. Secondary outcome parameters are measures of arm function (Action Research Arm Test, Fugl-Meyer Motor Scale), stroke severity (National Institutes of Health Stroke Scale), stroke-induced disability (modified Rankin Scale, Barthel Index), duration of inpatient rehabilitation, quality of life (EuroQol 5D), motor evoked potentials and the resting motor threshold of the ipsilesional M1.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Commission of the Medical Faculty, University of Cologne, Germany (reference number 15-343). Data will be disseminated through peer-reviewed publications and presentations at conferences. Study title: Theta-Burst Stimulation in Early Rehabilitation after Stroke (acronym: TheSiReS). Study registration at German Registry for Clinical Trials (DRKS00008963) and at ClinicalTrials.gov (NCT02910024).

Cortical gamma-synchrony measured with magnetoencephalography is a marker of clinical status and predicts clinical outcome in stroke survivors

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The outcome of stroke survivors is difficult to anticipate.

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Gamma synchrony is a reliable measure of brain function and reserve.

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Gamma synchrony is measured with MEG in stroke survivors undergoing rehab.

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Auditory-entrained gamma synchrony correlates with clinical status and outcome.

Background

The outcome of stroke survivors is difficult to anticipate. While the extent of the anatomical brain lesion is only poorly correlated with the prognosis, functional measures of cortical synchrony, brain networks and cortical plasticity seem to be good predictors of clinical recovery. In this field, gamma (>30 Hz) cortical synchrony is an ideal marker of brain function, as it plays a crucial role for the integration of information, it is an indirect marker of Glutamate/GABA balance and it directly estimates the reserve of parvalbulin-positive neurons, key players in synaptic plasticity. In this study we measured gamma synchronization driven by external auditory stimulation with magnetoencephalography and tested whether it was predictive of the clinical outcome in stroke survivors undergoing intensive rehabilitation in a tertiary rehabilitation center.

Material and methods

Eleven stroke survivors undergoing intensive rehabilitation were prospectively recruited. Gamma synchrony was measured non-invasively within one month from stroke onset with magnetoencephalography, both at rest and during entrainment with external 40 Hz amplitude modulated binaural sounds. Lesion location and volume were quantitatively assessed through a high-resolution anatomical MRI. Barthel index (BI) and Functional Independence Measure (FIM) scales were measured at the beginning and at the end of the admission to the rehabilitation unit.

Results

The spatial distribution of cortical gamma synchrony was altered, and the physiological right hemispheric dominance observed in healthy controls was attenuated or lost. Entrained gamma synchronization (but not resting state gamma synchrony) showed a very high correlation with the clinical status at both admission and discharge (both BI and FIM). Neither clinical status nor gamma synchrony showed a correlation with lesion volume.

Conclusions

Cortical gamma synchrony related to auditory entrainment can be reliably measured in stroke patients. Gamma synchrony is strongly associated with the clinical outcome of stroke survivors undergoing rehabilitation.

Versatility of Repetitive Transcranial Magnetic Stimulation in the Treatment of Poststroke Dysphagia

Various techniques and courses of treatment have been researched, proposed, and implemented to evaluate and treat poststroke dysphagia (PSD) which is one of the main medical conditions affecting not only elderly people, as previously assumed, but also in recent years younger populations as well. The effectiveness of therapeutic methods depends mainly on the expertise of an interdisciplinary team of therapists, as well as on the timely application of the treatment. The present review discusses the therapeutic benefits of repetitive transcranial magnetic stimulation (rTMS) in patients suffering from PSD regardless of the location of the lesion. The use of rTMS directly manipulates cortical brain stimulation to restore neuroplasticity in the affected brain areas. This review presents a synopsis of the available literature on the patient along with a discussion on the effectiveness of rTMS as a safe and easy to use promising technique in the rehabilitation of dysphagic patients. Although the results from the studies so far have been largely positive in that direction, the question still remains whether larger scale and longitudinal studies will be able to corroborate the aspiring future of rTMS. Therefore, research questions to advance further investigation on the application and future of this technique are much in need.

Brain networks and their relevance for stroke rehabilitation

Stroke has long been regarded as focal disease with circumscribed damage leading to neurological deficits. However, advances in methods for assessing the human brain and in statistics have enabled new tools for the examination of the consequences of stroke on brain structure and function. Thereby, it has become evident that stroke has impact on the entire brain and its network properties and can therefore be considered as a network disease. The present review first gives an overview of current methodological opportunities and pitfalls for assessing stroke-induced changes and reorganization in the human brain. We then summarize principles of plasticity after stroke that have emerged from the assessment of networks. Thereby, it is shown that neurological deficits do not only arise from focal tissue damage but also from local and remote changes in white-matter tracts and in neural interactions among wide-spread networks. Similarly, plasticity and clinical improvements are associated with specific compensatory structural and functional patterns of neural network interactions. Innovative treatment approaches have started to target such network patterns to enhance recovery. Network assessments to predict treatment response and to individualize rehabilitation is a promising way to enhance specific treatment effects and overall outcome after stroke.

Effects of transcranial direct current stimulation over the Broca's area on tongue twister production

PURPOSE

The present study aimed to explore the short-term effect of anodal transcranial direct current stimulation (tDCS) on tongue twister production.

METHOD

Thirty healthy native Cantonese adult speakers were randomly assigned to the anodal tDCS group or the sham tDCS group. Anodal tDCS of 2 mA was applied over the Broca's area of the brain. The stimulation lasted for 20 min for the anodal tDCS group and 30 s for the sham tDCS group. The participants were instructed to produce a list of tongue twisters before, immediately after and 4 h after tDCS.

RESULT

Speech rate and response accuracy measured immediately after stimulation were significantly faster and higher, respectively, than before stimulation. Although there was no change in speech rate measured at 4 h after stimulation, response accuracy at that time point was significantly lower than that measured immediately after stimulation. However, there were no significant differences between the anodal tDCS and sham tDCS groups in either speech rate or response accuracy.

CONCLUSION

The findings revealed that a single session of anodal tDCS over the Broca's area did not significantly improve speech production during tongue twister production.

Effects of high- and low-frequency repetitive transcranial magnetic stimulation on motor recovery in early stroke patients: Evidence from a randomized controlled trial with clinical, neurophysiological and functional imaging assessments

Background

Repetitive transcranial magnetic stimulation (rTMS) can modulate cortical excitability, and may be beneficial for motor recovery after stroke. However, the neuroplasticity effects of rTMS have not been thoroughly investigated in the early stage after stroke.

Objective

To comprehensively assess the effects of high- and low-frequency repetitive transcranial magnetic stimulations on motor recovery in early stroke patients, using a randomized controlled trial based on clinical, neurophysiological and functional imaging assessments.

Methods

Sixty hospitalized, first-ever ischemic stroke patients (within 2 weeks after stroke) with motor deficits were randomly allocated to receive, in addition to standard physical therapy, five consecutive sessions of either: (1) High-frequency (HF) rTMS at 10 Hz over the ipsilesional primary motor cortex (M1); (2) Low-frequency (LF) rTMS at 1 Hz over the contralesional M1; (3) sham rTMS. The primary outcome measure was a motor impairment score (Upper Extremity Fugl-Meyer) evaluated at baseline, after rTMS intervention, and at 3-month follow-up. Cortical excitability and functional magnetic resonance imaging (fMRI) data were obtained within 24 h before and after rTMS intervention. Analyses of variance were conducted to compare the recovery effects among the three rTMS groups, assessed using clinical, neurophysiological and fMRI tests.

Results

Motor improvement was significantly larger in the two rTMS groups than in the control group. The HF-rTMS group showed significantly increased cortical excitability and motor-evoked fMRI activation in ipsilesional motor areas, whereas the LF-rTMS group had significantly decreased cortical excitability and motor-evoked fMRI activation in contralesional motor areas. Activity in ipsilesional motor cortex significantly correlated with motor function, after intervention as well as at 3-month follow-up.

Conclusion

HF- and LF-rTMS can both improve motor function by modulating motor cortical activation in the early phase of stroke.

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rTMS is an effective neurorehabilitative strategy for enhancing motor recovery in the early stage after stroke.

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Effects of high- versus low-frequency rTMS on motor regions reflect different neuroplastic mechanisms supporting motor recovery.

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Functional reorganization of the ipsilesional M1 after stroke plays a critical role in long-term motor recovery.

The potential dual role of transcallosal inhibition in post-stroke motor recovery

Up to now, the mechanism of motor impairment and recovery after stroke has been thought to be based on the interhemispheric competition model. According to this model, which assumes that suppressing the excitability of contralesional hemisphere will enhance recovery by reducing transcallosal inhibition (TCI) of the stroke hemisphere, many clinical trials used non-invasive brain stimulation to improve motor function. Despite some positive findings, meta-analysis shows an important source of variability in the results, questioning whether the interhemispheric competition model would be exhaustive enough to explain the positive results or whether other mechanisms could explain the motor effects of inhibitory stimulation in the contralesional hemisphere. The goal of this study was to review the relationship between increased TCI and motor impairment after stroke.A systematic review of clinical studies investigating TCI through transcranial magnetic stimulation (TMS) in stroke patients and the relationship of this metric with motor recovery was then performed. After a literary search in PubMed eleven articles were included. The potential role of several covariates was examined and discussed.Overall, the importance of TCI as a putative mechanism for stimulation of the contralesional hemisphere seems to depend on the baseline motor function. In other words, from evidence coming mostly from chronic patients, modulation of abnormal TCI seems to be useful for patients with good motor function and less important in patients with poor motor function. TCI seems to be negatively correlated with mirror movements of the paretic hand. It can be inferred that suppressing the activity of the contralesional hemisphere could be beneficial for patients with good residual motor function and strong TCI, but not for those with poor motor function and weak TCI. Baseline motor function and measure of TCI should be taken into account for stratification of patients in clinical trials and for the design of customized treatment.

The Combined Use of Transcranial Direct Current Stimulation and Robotic Therapy for the Upper Limb

Neurologic disorders such as stroke and cerebral palsy are leading causes of long-term disability and can lead to severe incapacity and restriction of daily activities due to lower and upper limb impairments. Intensive physical and occupational therapy are still considered main treatments, but new adjunct therapies to standard rehabilitation that may optimize functional outcomes are being studied. Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that polarizes underlying brain regions through the application of weak direct currents through electrodes on the scalp, modulating cortical excitability. Increased interest in this technique can be attributed to its low cost, ease of use, and effects on human neural plasticity. Recent research has been performed to determine the clinical potential of tDCS in diverse conditions such as depression, Parkinson's disease, and motor rehabilitation after stroke. tDCS helps enhance brain plasticity and seems to be a promising technique in rehabilitation programs. A number of robotic devices have been developed to assist in the rehabilitation of upper limb function after stroke. The rehabilitation of motor deficits is often a long process requiring multidisciplinary approaches for a patient to achieve maximum independence. These devices do not intend to replace manual rehabilitation therapy; instead, they were designed as an additional tool to rehabilitation programs, allowing immediate perception of results and tracking of improvements, thus helping patients to stay motivated. Both tDSC and robot-assisted therapy are promising add-ons to stroke rehabilitation and target the modulation of brain plasticity, with several reports describing their use to be associated with conventional therapy and the improvement of therapeutic outcomes. However, more recently, some small clinical trials have been developed that describe the associated use of tDCS and robot-assisted therapy in stroke rehabilitation. In this article, we describe the combined methods used in our institute for improving motor performance after stroke.

Repetitive Peripheral Sensory Stimulation and Upper Limb Performance in Stroke: A Systematic Review and Meta-analysis

BACKGROUND

Enhancement of sensory input in the form of repetitive peripheral sensory stimulation (RPSS) can enhance excitability of the motor cortex and upper limb performance.

OBJECTIVE

To perform a systematic review and meta-analysis of effects of RPSS compared with control stimulation on improvement of motor outcomes in the upper limb of subjects with stroke.

METHODS

We searched studies published between 1948 and December 2017 and selected 5 studies that provided individual data and applied a specific paradigm of stimulation (trains of 1-ms pulses at 10 Hz, delivered at 1 Hz). Continuous data were analyzed with means and standard deviations of differences in performance before and after active or control interventions. Adverse events were also assessed.

RESULTS

There was a statistically significant beneficial effect of RPSS on motor performance (standard mean difference between active and control RPSS, 0.67; 95% CI, 0.09-1.24; I² = 65%). Only 1 study included subjects in the subacute phase after stroke. Subgroup analysis of studies that only included subjects in the chronic phase showed a significant effect (1.04; 95% CI, 0.66-1.42) with no heterogeneity. Significant results were obtained for outcomes of body structure and function as well as for outcomes of activity limitation according to the International Classification of Function, Disability and Health, when only studies that included subjects in the chronic phase were analyzed. No serious adverse events were reported.

CONCLUSIONS

RPSS is a safe intervention with potential to become an adjuvant tool for upper extremity paresis rehabilitation in subjects with stroke in the chronic phase.

Randomized Sham-Controlled Trial of Navigated Repetitive Transcranial Magnetic Stimulation for Motor Recovery in Stroke

Background and Purpose- We aimed to determine whether low-frequency electric field navigated repetitive transcranial magnetic stimulation to noninjured motor cortex versus sham repetitive transcranial magnetic stimulation avoiding motor cortex could improve arm motor function in hemiplegic stroke patients when combined with motor training. Methods- Twelve outpatient US rehabilitation centers enrolled participants between May 2014 and December 2015. We delivered 1 Hz active or sham repetitive transcranial magnetic stimulation to noninjured motor cortex before each of eighteen 60-minute therapy sessions over a 6-week period, with outcomes measured at 1 week and 1, 3, and 6 months after end of treatment. The primary end point was the percentage of participants improving ≥5 points on upper extremity Fugl-Meyer score 6 months after end of treatment. Secondary analyses assessed changes on the upper extremity Fugl-Meyer and Action Research Arm Test and Wolf Motor Function Test and safety. Results- Of 199 participants, 167 completed treatment and follow-up because of early discontinuation of data collection. Upper extremity Fugl-Meyer gains were significant for experimental ( P<0.001) and sham groups ( P<0.001). Sixty-seven percent of the experimental group (95% CI, 58%-75%) and 65% of sham group (95% CI, 52%-76%) improved ≥5 points on 6-month upper extremity Fugl-Meyer ( P=0.76). There was also no difference between experimental and sham groups in the Action Research Arm Test ( P=0.80) or the Wolf Motor Function Test ( P=0.55). A total of 26 serious adverse events occurred in 18 participants, with none related to the study or device, and with no difference between groups. Conclusions- Among patients 3 to 12 months poststroke, goal-oriented motor rehabilitation improved motor function 6 months after end of treatment. There was no difference between the active and sham repetitive transcranial magnetic stimulation trial arms. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02089464.