1
|
Li R, Liu S, Li T, Yang K, Wang X, Wang W. The stratified effects of repetitive transcranial magnetic stimulation in upper limb motor impairment recovery after stroke: a meta-analysis. Front Neurol 2024; 15:1369836. [PMID: 38628695 PMCID: PMC11020108 DOI: 10.3389/fneur.2024.1369836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 03/11/2024] [Indexed: 04/19/2024] Open
Abstract
Background The recovery of upper extremity motor impairment after stroke remains a challenging task. The clinical effectiveness of repetitive transcranial magnetic stimulation (rTMS), which is believed to aid in the recovery process, is still uncertain. Methods A systematic search was conducted in Medline (Ovid), Cochrane and Embase electronic databases from March 28, 2014, to March 28, 2023. The inclusion criteria consisted of randomized controlled trials that assessed the effects of rTMS on the recovery of upper limb motor impairment among stroke patients. Various measurements, including the Fugl Meyer Assessment Upper Extremity Scale (FMA-UE), Brunnstrom recovery stage, Action Research Arm Test (ARAT), and Barthel index, were evaluated both before and after the intervention. Results Nineteen articles with 865 patients were included. When considering only the rTMS parameters, both inhibitory and excitatory rTMS improved FMA-UE (MD = 1.87, 95% CI = [0.88]-[2.86], p < 0.001) and Barthel index (MD = 9.73, 95% CI = [4.57]-[14.89], p < 0.001). When considering only the severity of upper limb hemiplegia, both less severe (MD = 1.56, 95% CI = [0.64]-[2.49], p < 0.001) and severe (MD = 2.05, 95% CI = [1.09]-[3.00], p < 0.001) hemiplegia benefited from rTMS based on FMA-UE. However, when considering the rTMS parameters, severity of hemiplegia and stroke stages simultaneously, inhibitory rTMS was found to be significantly effective for less severe hemiplegia in the acute and subacute phases (MD = 4.55, 95% CI = [2.49]-[6.60], p < 0.001), but not in the chronic phase based on FMA-UE. For severe hemiplegia, inhibitory rTMS was not significantly effective in the acute and subacute phases, but significantly effective in the chronic phase (MD = 2.10, 95% CI = [0.75]-[3.45], p = 0.002) based on FMA-UE. Excitatory rTMS was found to be significantly effective for less severe hemiplegia in the acute and subacute phases (MD = 1.93, 95% CI = [0.58]-[3.28], p = 0.005) based on FMA-UE. The improvements in Brunnstrom recovery stage and ARAT need further research. Conclusion The effectiveness of rTMS depends on its parameters, severity of hemiplegia, and stroke stages. It is important to consider all these factors together, as any single grouping method is incomplete.
Collapse
Affiliation(s)
- Ran Li
- Department of Rehabilitation Center, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Sihan Liu
- Capital Medical University Eighth Clinical School, Beijing, China
| | - Tianyuan Li
- Capital Medical University Eighth Clinical School, Beijing, China
| | - Kun Yang
- Department of Evidence-based Medicine, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Xue Wang
- Department of Medical Library, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Wenjiao Wang
- Department of Medical Library, Xuan Wu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
2
|
van Lieshout ECC, van der Worp HB, Visser-Meily JMA, Dijkhuizen RM. Timing of Repetitive Transcranial Magnetic Stimulation Onset for Upper Limb Function After Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2019; 10:1269. [PMID: 31849827 PMCID: PMC6901630 DOI: 10.3389/fneur.2019.01269] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/15/2019] [Indexed: 01/10/2023] Open
Abstract
Background: Repetitive transcranial magnetic stimulation (rTMS) is a promising intervention to promote upper limb recovery after stroke. We aimed to identify differences in the efficacy of rTMS treatment on upper limb function depending on the onset time post-stroke. Methods: We searched PubMed, Embase, and the Cochrane Library to identify relevant RCTs from their inception to February 2018. RCTs on the effects of rTMS on upper limb function in adult patients with stroke were included. Study quality and risk of bias were assessed independently by two authors. Meta-analyses were performed for outcomes on individual upper limb outcome measures (function or activity) and for function and activity measures jointly, categorized by timing of treatment initiation. Timing of treatment initiation post-stroke was categorized as follows: acute to early subacute (<1 month), early subacute (1–3 months), late subacute (3–6 months), and chronic (>6 months). Results: We included 38 studies involving 1,074 stroke patients. Subgroup analysis demonstrated benefit of rTMS applied within the first month post-stroke [MD = 9.31; 95% confidence interval (6.27–12.34); P < 0.0001], but not in the early subacute phase (1–3 months post-stroke) [MD = 1.14; 95% confidence interval (−5.32 to 7.59), P = 0.73) or chronic phase (>6 months post-stroke) [MD = 1.79; 95% confidence interval (−2.00 to 5.59]; P = 0.35), when assessed with a function test [Fugl-Meyer Arm test (FMA)]. There were no studies within the late subacute phase (3–6 months post-stroke) that used the FMA. Tests at the level of function revealed improved upper limb function after rTMS [SMD = 0.43; 95% confidence interval (0.02–0.75); P = 0.0001], but tests at the level of activity did not, independent of rTMS onset post-stroke [SMD = 0.17; 95% confidence interval (−0.09 to 0.44); P = 0.19]. Heterogeneities in the results of the individual studies included in the main analyses were large, as suggested by funnel plot asymmetry. Conclusions: Based on the FMA, rTMS seems more beneficial only when started in the first month post-stroke. Tests at the level of function are likely more sensitive to detect beneficial rTMS effects on upper limb function than tests at the level of activity. However, heterogeneities in treatment designs and outcomes are high. Future rTMS trials should include the FMA and work toward a core set of outcome measures.
Collapse
Affiliation(s)
- Eline C C van Lieshout
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands.,Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Johanna M A Visser-Meily
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, De Hoogstraat Rehabilitation, Utrecht, Netherlands.,Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Rick M Dijkhuizen
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| |
Collapse
|
3
|
Tyler M, Skinner K, Prabhakaran V, Kaczmarek K, Danilov Y. Translingual Neurostimulation for the Treatment of Chronic Symptoms Due to Mild-to-Moderate Traumatic Brain Injury. Arch Rehabil Res Clin Transl 2019; 1:100026. [PMID: 33543056 PMCID: PMC7853385 DOI: 10.1016/j.arrct.2019.100026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To compare the efficacy of high- and low-frequency noninvasive translingual neurostimulation (TLNS) plus targeted physical therapy (PT) for treating chronic balance and gait deficits due to mild-to-moderate traumatic brain injury (mmTBI). DESIGN Participants were randomized 1:1 in a 26-week double-blind phase 1/2 study (NCT02158494) with 3 consecutive treatment stages: in-clinic, at-home, and no treatment. Arms were high-frequency pulse (HFP) and low-frequency pulse (LFP) TLNS. SETTING TLNS plus PT training was initiated in-clinic and then continued at home. PARTICIPANTS Participants (N=44; 18-65y) from across the United States were randomized into the HFP and LFP (each plus PT) arms. Forty-three participants (28 women, 15 men) completed at least 1 stage of the study. Enrollment requirements included an mmTBI ≥1 year prior to screening, balance disorder due to mmTBI, a plateau in recovery with current PT, and a Sensory Organization Test (SOT) score ≥16 points below normal. INTERVENTIONS Participants received TLNS (HFP or LFP) plus PT for a total of 14 weeks (2 in-clinic and 12 at home), twice daily, followed by 12 weeks without treatment. MAIN OUTCOME MEASURES The primary endpoint was change in SOT composite score from baseline to week 14. Secondary variables (eg, Dynamic Gait Index [DGI], 6-minute walk test [6MWT]) were also collected. RESULTS Both arms had a significant (P<.0001) improvement in SOT scores from baseline at weeks 2, 5, 14 (primary endpoint), and 26. DGI scores had significant improvement (P<.001-.01) from baseline at the same test points; 6MWT evaluations after 2 weeks were significant. The SOT, DGI, and 6MWT scores did not significantly differ between arms at any test point. There were no treatment-related serious adverse events. CONCLUSIONS Both the HFP+PT and LFP+PT groups had significantly improved balance scores, and outcomes were sustained for 12 weeks after discontinuing TLNS treatment. Results between arms did not significantly differ from each other. Whether the 2 dosages are equally effective or whether improvements are because of provision of PT cannot be conclusively established at this time.
Collapse
Key Words
- 6MWT, 6-minute walk test
- AE, adverse event
- ANOVA, analysis of variance
- Balance
- DGI, Dynamic Gait Index
- Facial nerve
- Gait
- HFP, high-frequency pulse
- ITP, in-clinic training program
- LFP, low-frequency pulse
- Neurostimulation
- PSQI, Pittsburgh Sleep Quality Index
- PT, physical therapy
- PoNS, portable neuromodulation stimulator
- Rehabilitation
- SOT, Sensory Organization Test
- TBI, traumatic brain injury
- TLNS, translingual neurostimulation
- Trigeminal nerve
- mmTBI, mild-to-moderate traumatic brain injury
Collapse
Affiliation(s)
- Mitchell Tyler
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Kinesiology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Kim Skinner
- Department of Kinesiology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Vivek Prabhakaran
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Kurt Kaczmarek
- Department of Kinesiology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Yuri Danilov
- Department of Kinesiology, University of Wisconsin-Madison, Madison, Wisconsin
| |
Collapse
|
4
|
Park JW, Kim SB, Lee KW, Lee JH, Park JG, Lee SJ. Effects of Hand Training During the Aftereffect Period of Low-Frequency rTMS in Subacute Stroke Patients. Ann Rehabil Med 2018; 42:521-527. [PMID: 30180520 PMCID: PMC6129708 DOI: 10.5535/arm.2018.42.4.521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 10/19/2017] [Indexed: 01/09/2023] Open
Abstract
Objective To investigate the effects of hand training using low-frequency repetitive transcranial magnetic stimulation (rTMS) within the aftereffect period on hand function in patients with subacute stroke. Methods The subacute stroke patients with hand weaknesses were divided randomly into two groups. Patients in the intervention group underwent hand training within the aftereffect period, that is, immediately after receiving low-frequency rTMS treatment. Patients in the control group underwent hand training 2 hours after the low-frequency rTMS treatment. A manual function test (MFT) for ‘grasp and pinch’ and ‘hand activities’; a manual muscle test (MMT) for ‘grasp’, ‘release’, and ‘abductor pollicis brevis (APB)’; and the Modified Ashworth Scale for finger flexion were performed and measured before and immediately after combined therapy as well as 2 weeks after combined therapy. Results Thirty-two patients with hand weakness were enrolled in this study. The intervention group patients showed more improvements in grasp MMT and MMT APB tested immediately after combined therapy. However, the changes in all measurements were not significantly different between the two groups 2 weeks after the combined therapy. In both groups, hand functions improved significantly immediately after combined therapy and 2 weeks after combined therapy. Conclusion Hand training immediately after low-frequency rTMS showed more rapid improvement in the motor power of hands than hand training conducted 2 hours after low-frequency rTMS. Our results suggest that conducting hand training immediately after low-frequency rTMS could be an improved useful therapeutic option in subacute stroke patients.
Collapse
Affiliation(s)
- Joo Won Park
- Department of Physical Medicine and Rehabilitation and Regional Cardiocerebrovascular Center, Dong-A University College of Medicine, Busan, Korea
| | - Sang Beom Kim
- Department of Physical Medicine and Rehabilitation and Regional Cardiocerebrovascular Center, Dong-A University College of Medicine, Busan, Korea
| | - Kyeong Woo Lee
- Department of Physical Medicine and Rehabilitation and Regional Cardiocerebrovascular Center, Dong-A University College of Medicine, Busan, Korea
| | - Jong Hwa Lee
- Department of Physical Medicine and Rehabilitation and Regional Cardiocerebrovascular Center, Dong-A University College of Medicine, Busan, Korea
| | - Jin Gee Park
- Department of Physical Medicine and Rehabilitation and Regional Cardiocerebrovascular Center, Dong-A University College of Medicine, Busan, Korea
| | - Sook Joung Lee
- Department of Physical Medicine and Rehabilitation, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| |
Collapse
|
5
|
Melnikova EA. [The peculiarities of the application of transcranial magnetic therapy and electrical stimulation for the treatment of the patients presenting with various types of stroke]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOĬ FIZICHESKOĬ KULTURY 2016; 92:12-17. [PMID: 26852496 DOI: 10.17116/kurort2015512-17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
In this article, the results of the authors' research, including analysis of the clinical and instrumental data concerning 203 patients with, stroke are presented. It is shown that the clinical effectiveness of the transcranial methods incorporated in the combined rehabilitation programs depends on the type of stroke and localization of the lesions. Specifically, the patients presenting with ischemic stroke of hemispheric localization experienced a neurophysiologically confirmed significant clinical improvement that became apparent after the consistent application of transcranial magnetic therapy and micropolarization. In the patients with ischemic stroke of stem localization, the positive influence on psychomotor recovery was achieved with the application of transcranial magnetic therapy, but transcranial micropolarization did not have an appreciable effect on the recovery of such patients. The patients presenting with hemorrhagic stroke did not experience any significant improvement of psychomotor parameters from transcranial magnetic therapy and transcranial micropolarization. The likely mechanism underlying the recovery of psychomotor processes under effect of transcranial magnetic therapy in the patients with ischemic stroke is the normalization of the frequency of interaction between brain structures. In addition, in the patients with ischemic stroke of hemispheric localization and in the patients with hemorrhagic stroke electrical myostimulation has a marked impact on the psychomotor recovery only in case of functional treatment. In the patients suffering from ischemic stroke of stem localization non-functional electromyostimulation significantly improves motor functions and cognitive motor control.
Collapse
Affiliation(s)
- E A Melnikova
- State autonomous healthcare facility 'Moscow Research and Practical Centre for Medical Rehabilitation, Restorative and Sports Medicine', Moscow Health Department, Moscow, Russian Federation, 105120
| |
Collapse
|
6
|
Andrade SM, Santos NA, Fernández-Calvo B, Boggio PS, Oliveira EA, Ferreira JJ, Sobreira A, Morgan F, Medeiros G, Cavalcanti GS, Gadelha ID, Duarte J, Marrocos J, Silva MA, Rufino T, Nóbrega SR. Stroke Treatment Associated with Rehabilitation Therapy and Transcranial DC Stimulation (START-tDCS): a study protocol for a randomized controlled trial. Trials 2016; 17:56. [PMID: 26822418 PMCID: PMC4731905 DOI: 10.1186/s13063-016-1186-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 01/19/2016] [Indexed: 11/16/2022] Open
Abstract
Background Traditional treatment for motor impairment after stroke includes medication and physical rehabilitation. The transcranial direct current stimulation associated with a standard physical therapy program may be an effective therapeutic alternative for these patients. Methods This study is a sham-controlled, double-blind, randomized clinical trial aiming to evaluate the efficacy of transcranial direct current stimulation in activities of daily living and motor function post subacute stroke. In total there will be 40 patients enrolled, diagnosed with subacute, ischemic, unilateral, non-recurring stroke. Participants will be randomized to two groups, one with active stimulation and the other with a placebo current. Patients and investigators will be blinded. Everyone will receive systematic physical therapy, based on constraint-induced movement therapy. The intervention will be applied for 10 consecutive days. Patients will undergo three functional assessments: at baseline, week 2, and week 4. Neuropsychological tests will be performed at baseline and week 4. Adverse effects will be computed at each session. On completion of the baseline measures, randomization will be conducted using random permuted blocks. The randomization will be concealed until group allocation. Discussion This study will investigate the combined effects of transcranial direct current stimulation and physical therapy on functional improvement after stroke. We tested whether the combination of these treatments is more effective than physical therapy alone when administered in the early stages after stroke. Trial registration NCT02156635 - May 30, 2014. Randomization is ongoing (40 participants randomized as of the end of December 2015).
Collapse
Affiliation(s)
- Suellen M Andrade
- Cognitive Neuroscience and Behavior Program, Federal University of Paraíba, João Pessoa, Brazil.
| | - Natanael A Santos
- Perception, Neurosciences and Behavior Laboratory, Federal University of Paraíba, João Pessoa, Brazil.
| | | | - Paulo S Boggio
- Cognitive Neuroscience Laboratory and Developmental Disorders Program, Mackenzie Presbyterian University, São Paulo, Brazil.
| | - Eliane A Oliveira
- Center for Research in Human Movement Sciences, Federal University of Paraíba, João Pessoa, Brazil.
| | - José J Ferreira
- Study Group of Human Movement, Federal University of Paraíba, João Pessoa, Brazil.
| | - Amanda Sobreira
- Center for Research in Human Movement Sciences, Federal University of Paraíba, João Pessoa, Brazil.
| | - Felipe Morgan
- Center for Research in Human Movement Sciences, Federal University of Paraíba, João Pessoa, Brazil.
| | - Germana Medeiros
- Study Group of Human Movement, Federal University of Paraíba, João Pessoa, Brazil.
| | - Gyovanna S Cavalcanti
- Center for Research in Human Movement Sciences, Federal University of Paraíba, João Pessoa, Brazil.
| | - Ingrid D Gadelha
- Center for Research in Human Movement Sciences, Federal University of Paraíba, João Pessoa, Brazil.
| | - Jader Duarte
- Study Group of Human Movement, Federal University of Paraíba, João Pessoa, Brazil.
| | - Joercia Marrocos
- Center for Research in Human Movement Sciences, Federal University of Paraíba, João Pessoa, Brazil.
| | - Michele A Silva
- Center for Research in Human Movement Sciences, Federal University of Paraíba, João Pessoa, Brazil.
| | - Thatiana Rufino
- Study Group of Human Movement, Federal University of Paraíba, João Pessoa, Brazil.
| | - Sanmy R Nóbrega
- Neuromuscular Adaptations Laboratory, Federal University of São Carlos, São Carlos, Brazil.
| |
Collapse
|
7
|
Melnikova EA. [Approaches to the clinical classification of the functional status in patients with stroke]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOĬ FIZICHESKOĬ KULTURY 2015; 92:4-12. [PMID: 26595962 DOI: 10.17116/kurort201544-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The article presents the results of original investigation that included a detailed clinical analysis of 203 patients with stroke undergoing rehabilitation. The significance of pathogenic type of stroke and localization of the lesion in the brain are demonstrated. <<Rehabilitation subgroups>> are distinguished among the patients with ischemic stroke of hemispheric and stem localization, and hemorrhagic hemispheric stroke. For each ((rehabilitation subgroup) a detailed description of the key indicators of the neurological status, results of cognitive and psychological tests based on general and local rehabilitation scales are presented. The prognostic value of the (rehabilitation activities profile) scale for stroke patients is estimated.
Collapse
Affiliation(s)
- E A Melnikova
- Moscow Department of Public Health, Moscow Center for Research and Practice in Rehabilitation, Restorative and Sports Medicine, ul. Zemlyanoy val, 53, Moscow, Russian Federation, 105120
| |
Collapse
|
8
|
Wessel MJ, Zimerman M, Hummel FC. Non-invasive brain stimulation: an interventional tool for enhancing behavioral training after stroke. Front Hum Neurosci 2015; 9:265. [PMID: 26029083 PMCID: PMC4432668 DOI: 10.3389/fnhum.2015.00265] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 04/23/2015] [Indexed: 01/20/2023] Open
Abstract
Stroke is the leading cause of disability among adults. Motor deficit is the most common impairment after stroke. Especially, deficits in fine motor skills impair numerous activities of daily life. Re-acquisition of motor skills resulting in improved or more accurate motor performance is paramount to regain function, and is the basis of behavioral motor therapy after stroke. Within the past years, there has been a rapid technological and methodological development in neuroimaging leading to a significant progress in the understanding of the neural substrates that underlie motor skill acquisition and functional recovery in stroke patients. Based on this and the development of novel non-invasive brain stimulation (NIBS) techniques, new adjuvant interventional approaches that augment the response to behavioral training have been proposed. Transcranial direct current, transcranial magnetic, and paired associative (PAS) stimulation are NIBS techniques that can modulate cortical excitability, neuronal plasticity and interact with learning and memory in both healthy individuals and stroke patients. These techniques can enhance the effect of practice and facilitate the retention of tasks that mimic daily life activities. The purpose of the present review is to provide a comprehensive overview of neuroplastic phenomena in the motor system during learning of a motor skill, recovery after brain injury, and of interventional strategies to enhance the beneficial effects of customarily used neurorehabilitation after stroke.
Collapse
Affiliation(s)
- Maximilian J Wessel
- Brain Imaging and Neurostimulation (BINS) Laboratory, Department of Neurology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Máximo Zimerman
- Brain Imaging and Neurostimulation (BINS) Laboratory, Department of Neurology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany ; Institute of Cognitive Neurology (INECO) , Buenos Aires , Argentina
| | - Friedhelm C Hummel
- Brain Imaging and Neurostimulation (BINS) Laboratory, Department of Neurology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany ; Favaloro University , Buenos Aires , Argentina
| |
Collapse
|
9
|
Zheng CJ, Liao WJ, Xia WG. Effect of combined low-frequency repetitive transcranial magnetic stimulation and virtual reality training on upper limb function in subacute stroke: a double-blind randomized controlled trail. ACTA ACUST UNITED AC 2015; 35:248-254. [DOI: 10.1007/s11596-015-1419-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/13/2015] [Indexed: 02/01/2023]
|