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Abstract
Objective: To investigate the long-term behavioral and neurophysiologic effects of combined time-locked repetitive transcranial magnetic stimulation (rTMS) and physical therapy (PT) intervention in chronic stroke patients with mild motor disabilities.
Methods: Thirty patients were enrolled in a double-blind, randomized, single-center clinical trial. Patients received 10 daily sessions of 1 Hz rTMS over the intact motor cortex. In different groups, stimulation was either real (rTMSR) or sham (rTMSS) and was administered either immediately before or after PT. Outcome measures included dexterity, force, interhemispheric inhibition, and corticospinal excitability and were assessed for 3 months after the end of treatment.
Results: Treatment induced cumulative rebalance of excitability in the 2 hemispheres and a reduction of interhemispheric inhibition in the rTMSR groups. Use-dependent improvements were detected in all groups. Improvements in trained abilities were small and transitory in rTMSS patients. Greater behavioral and neurophysiologic outcomes were found after rTMSR, with the group receiving rTMSR before PT (rTMSR-PT) showing robust and stable improvements and the other group (PT-rTMSR) showing a slight improvement decline over time.
Conclusion: Our findings indicate that priming PT with inhibitory rTMS is optimal to boost use-dependent plasticity and rebalance motor excitability and suggest that time-locked rTMS is a valid and promising approach for chronic stroke patients with mild motor impairment.
Classification of evidence: This interventional study provides Class I evidence that time-locked rTMS before or after physical therapy improves measures of dexterity and force in the affected limb in patients with chronic deficits more than 6 months poststroke. Neurology® 2012;78:256–264
GLOSSARY
- ANOVA=
- analysis of variance;
- B&B=
- Box and Block test;
- FDI=
- first dorsal interosseous;
- iSP=
- ipsilateral silent period;
- JHFT=
- Jebsen-Taylor Hand Function Test;
- NHPT=
- Nine-Hole Peg Test;
- PT=
- physical therapy;
- rMT=
- resting motor threshold;
- rTMS=
- repetitive transcranial magnetic stimulation;
- rTMSR=
- real repetitive transcranial magnetic stimulation;
- rTMSS=
- sham repetitive transcranial magnetic stimulation
Footnotes
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Study funding: Supported by Istituto Italiano di Tecnologia SEED2009 (Prot.n.21538) to A.A.; Ministero Istruzione Università e Ricerca (PRIN) to A.A., E.L., L.P., M.G.C.; Bologna University (RFO) and Servizi Integrati d'Area (Ser.In.ar) to A.A., E.L.
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Supplemental data at www.neurology.org
- Received December 25, 2010.
- Accepted September 13, 2011.
- Copyright © 2012 by AAN Enterprises, Inc.
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