Prediction of Motor Recovery in the Upper Extremity for Repetitive Transcranial Magnetic Stimulation and Occupational Therapy Goal Setting in Patients With Chronic Stroke: A Retrospective Analysis of Prospectively Collected Data

Abstract

Recovery from motor paralysis is facilitated by affected patients' recognition of the need for and practice of their own exercise goals. Neurorehabilitation has been proposed and used for the treatment of motor paralysis in stroke, and its effect has been verified. If an expected score for the neurorehabilitation effect can be calculated using the Fugl-Meyer Motor Assessment (FMA), a global assessment index, before neurorehabilitation, such a score will be useful for optimizing the treatment application criteria and for setting a goal to enhance the treatment effect. Therefore, this study verified whether the responsiveness to a treatment method, the NovEl intervention using repetitive transcranial magnetic stimulation and occupational therapy (NEURO), in patients with post-stroke upper extremity (UE) motor paralysis could be predicted by the pretreatment FMA score. No control group was established in this study for NEURO treatment. To analyze the recovery of the motor function in the UE, delta-FMA was calculated from the pre-and post-FMA scores obtained during NEURO treatment. The probability of three levels of treatment responsiveness was evaluated in association with delta-FMA score (<5, 5≤ delta-FMA <10, and ≥10 as non-responders; responders; and hyper-responders, respectively) according to the reported minimal clinically important difference (MCID). The association of the initial FMA scores with post-FMA scores, from the status of the treatment responsiveness, was determined by multinomial logistic regression analysis. Finally, 1,254 patients with stroke, stratified by FMA scores were analyzed. About 45% of the patients who had FMA scores ranging from 30 to 40 before treatment showed improvement over the MCID by NEURO treatment (odds ratio = 0.93, 95% CI = 0.92-0.95). Furthermore, more than 25% of the patients with more severe initial values, ranging from 26 to 30, improved beyond the MCID calculated in the acute phase Hamaguchi et al. Motor Recovery Predictions in Stroke (odds ratio = 0.87, 95% CI = 0.85-0.89). These results suggest that the evaluated motor function score of the UE before NEURO treatment can be used to estimate the possibility of a patient recovering beyond MCID in the chronic phase. This study provided clinical data to estimate the effect of NEURO treatment by the pretreatment FMA-UE score.

Do somatosensory deficits predict efficacy of neurorehabilitation using neuromuscular electrical stimulation for moderate to severe motor paralysis of the upper limb in chronic stroke?

“…For improvement of the FMA, it has been reported that baseline motor function predicts motor function recovery following various interventions, such as constraint-induced movement therapy (CIMT), repetitive transcranial magnetic stimulation (rTMS), transcranial direct current (rTMS), transcranial direct current stimulation (tDCS), and robot therapy (RT). 36 – 41 This study using NMES also suggested that baseline motor function predicted motor function recovery, as in these previous studies.…”

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).…”

Predictive models for response to non-invasive brain stimulation in stroke: A critical review of opportunities and pitfalls

“…It is of note that the procedures for determining a responsiveness metric differ across studies and there is no unique and universally accepted way. Some examples are computing absolute (delta) or relative changes (percentage, ratio) to control stimulation (e.g., [26]) or to baseline (e.g., [27,28]), reporting of proportional change (e.g. [29]), applying cut-off-based procedures (median split e.g., [27], splitting based on the minimal clinically important difference e.g., [30]) towards more complex approaches such as the use of composite scores (e.g.…”