Does a combination treatment of repetitive transcranial magnetic stimulation and occupational therapy improve upper limb muscle paralysis equally in patients with chronic stroke caused by cerebral hemorrhage and infarction?

Abstract

The clinical presentation of stroke is usually more severe in patients with intracerebral hemorrhage (ICH) than in those with cerebral infarction (CI); recovery of stroke-related muscle paralysis is influenced and limited by the type of stroke. To date, many patients have been treated by neurorehabilitation; however, the changes in the recovery of motor paralysis depending on the type of stroke, ICH or CI, have not been established. This study aimed to determine this difference in improvement of upper extremity paralysis using 2-week in-hospital N ov E l intervention U sing R epetitive transcranial magnetic stimulation combined with O ccupational therapy (NEURO). We scrutinized the medical records of all patients with poststroke (ICH or CI) upper extremity muscle paralysis using Fugl-Meyer assessments (FMAs) who had been admitted to 6 hospitals between March 2010 and December 2018 for rehabilitation treatment. This was a multiinstitutional, open-label, retrospective cohort study without control patients. We evaluated the effects of NEURO on patients with CI and ICH by dividing them into 2 groups according to the type of stroke, after adjustment for age, sex, dominant hand, affected hand side, time since stroke, and prediction of recovery capacity in the upper extremity. The study included 1716 (CI [n = 876] and ICH [n = 840]) patients who had undergone at least 2 FMAs and had experienced stroke at least 6 months before. The type of stroke had no effect on the outcomes (changes in the FMA-upper extremity score, F [4,14.0] = 2.05, P = .09, partial η 2 = 0.01). Patients from all 5 groups equally benefited from the treatment (improvement in FMA scores) according to the sensitivity analysis-stratified analysis ( F = 0.08 to 1.94, P > .16, partial η 2 < 0.001). We conclude that NEURO can be recommended for chronic stroke patients irrespective of the type of stroke.

Predicting Individual Treatment Response to rTMS for Motor Recovery After Stroke: A Review and the CanStim Perspective

“…Table 1 provides an overview of included studies, and Figure 3 illustrates the variation in study design, rTMS protocol, time post-stroke and number of sessions across studies. Half of the included studies (13/26), encompassing a large majority of the patient population, were single-arm, non-randomized retrospective or prospective studies (21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)36). Eleven studies included a sham-control condition either in a crossover or parallel-group design (16,20,(33)(34)(35)(37)(38)(39)(40)(41)(42).…”

“…In terms of rTMS protocols, 10 studies used excitatory rTMS (17,21,22,33,34,36,39) or iTBS (18,37,38) targeting ipsilesional M1 (17,18,21,22,34,(36)(37)(38)(39) or ipsilesional S1 (33), with either a single session (18,33,34,36,37,39) or a total of 10 sessions (17,21,22,38) of intervention. A total of 13 studies used inhibitory rTMS over contralesional M1, with a range from 5 up to 30 intervention sessions (19,20,(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)41). Two studies used both inhibitory contralesional, as well as excitatory ipsilesional rTMS over M1 (35,40), and a single study measured the effects of a single session of excitatory contralesional rTMS on M1, dorsal premotor cortex (dPMC), and anterior intraparietal sulcus (aIPS) (16).…”

“…For the purpose of this review, we defined acute stroke as < 2 weeks since stroke onset, chronic stroke as > 6 months since stroke onset, and subacute stroke as falling in between these two categories (12). Over half of the studies (16/26) included chronic patients only (23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38), three studies included subacute, as well as chronic patients (39)(40)(41), four studies included subacute patients only (19)(20)(21)(22), and three studies included acute patients (16)(17)(18). The female to male ratio of all patients included in the studies was approximately 1:2 (males n = 2,596, 65.31%), with one study not reporting the sex of participants (40).…”

“…The majority of included studies described no association between certain demographic variables, such as age and sex, and treatment response (21,22,(30)(31)(32)(33). A single study of 12 chronic stroke patients found that increasing age was correlated with less recovery of motor function, as reflected by less increase in grip strength 1 h after a single session of excitatory rTMS over ipsilesional M1 (36).…”

Capturing Neuroplastic Changes after iTBS in Patients with Post-Stroke Aphasia: A Pilot fMRI Study

“…After the iTBS intervention, the fALFF value in the right frontal part was reduced, suggesting that iTBS attenuated neuronal activity in the contralateral brain. According to the interhemispheric inhibition theory [ 53 , 54 ], the affected hemisphere is inhibited for a certain period after brain injury, while the healthy hemisphere is excited, a condition that is not conducive to functional recovery after stroke. iTBS acting on the left impaired M1 area can inhibit brain activity in the right medial frontal lobe, and some studies [ 55 , 56 ] have shown that right frontal lobe excitability is closely related to the recovery of language status after stroke.…”