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January 11, 2012

Low-frequency rTMS promotes use-dependent motor plasticity in chronic stroke
A randomized trial

January 24, 2012 issue
78 (4) 256-264

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

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Information & Authors

Information

Published In

Neurology®
Volume 78Number 4January 24, 2012
Pages: 256-264
PubMed: 22238412

Publication History

Received: December 25, 2010
Accepted: September 13, 2011
Published online: January 11, 2012
Published in print: January 24, 2012

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Disclosure

Prof. Avenanti serves as Academic Editor for PLoS ONE and Reviewing Editor for Frontiers in Emotion Science and receives research support from Ministero Istruzione Università Ricerca and Istituto Italiano di Tecnologia. Dr. Coccia reports no disclosures. Prof. Ladavas serves as an Associate Editor for Neuropsychologia and receives research support from Ministero Italiano Università e Ricerca (MIUR), Progetti di Ricerca di Interesse Nazionale, and Fondazione Cassa di Risparmio di Cesena. Prof. Provinciali serves as Associate Editor of Neurological Sciences. Prof. Ceravolo serves as an Assistant Editor for the European Journal of Physical and Rehabilitation Medicine.

Authors

Affiliations & Disclosures

A. Avenanti, PhD
From the Dipartimento di Psicologia (A.A., E.L.), Università di Bologna, Bologna; Centro studi e ricerche in Neuroscienze Cognitive Polo Scientifico-Didattico di Cesena (A.A., E.L.), Cesena; Clinica di Neuroriabilitazione (M.C., M.G.C.) and Clinica Neurologica (L.P.), Dipartimento di Medicina Sperimentale e Clinica, Università Politecnica delle Marche, Az Ospedaliero Universitaria, “Ospedali Riuniti,” Ancona, Ancona, Italy.
M. Coccia, MD
From the Dipartimento di Psicologia (A.A., E.L.), Università di Bologna, Bologna; Centro studi e ricerche in Neuroscienze Cognitive Polo Scientifico-Didattico di Cesena (A.A., E.L.), Cesena; Clinica di Neuroriabilitazione (M.C., M.G.C.) and Clinica Neurologica (L.P.), Dipartimento di Medicina Sperimentale e Clinica, Università Politecnica delle Marche, Az Ospedaliero Universitaria, “Ospedali Riuniti,” Ancona, Ancona, Italy.
E. Ladavas, PhD
From the Dipartimento di Psicologia (A.A., E.L.), Università di Bologna, Bologna; Centro studi e ricerche in Neuroscienze Cognitive Polo Scientifico-Didattico di Cesena (A.A., E.L.), Cesena; Clinica di Neuroriabilitazione (M.C., M.G.C.) and Clinica Neurologica (L.P.), Dipartimento di Medicina Sperimentale e Clinica, Università Politecnica delle Marche, Az Ospedaliero Universitaria, “Ospedali Riuniti,” Ancona, Ancona, Italy.
L. Provinciali, MD
From the Dipartimento di Psicologia (A.A., E.L.), Università di Bologna, Bologna; Centro studi e ricerche in Neuroscienze Cognitive Polo Scientifico-Didattico di Cesena (A.A., E.L.), Cesena; Clinica di Neuroriabilitazione (M.C., M.G.C.) and Clinica Neurologica (L.P.), Dipartimento di Medicina Sperimentale e Clinica, Università Politecnica delle Marche, Az Ospedaliero Universitaria, “Ospedali Riuniti,” Ancona, Ancona, Italy.
M.G. Ceravolo, MD
From the Dipartimento di Psicologia (A.A., E.L.), Università di Bologna, Bologna; Centro studi e ricerche in Neuroscienze Cognitive Polo Scientifico-Didattico di Cesena (A.A., E.L.), Cesena; Clinica di Neuroriabilitazione (M.C., M.G.C.) and Clinica Neurologica (L.P.), Dipartimento di Medicina Sperimentale e Clinica, Università Politecnica delle Marche, Az Ospedaliero Universitaria, “Ospedali Riuniti,” Ancona, Ancona, Italy.

Notes

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.
Correspondence & reprint requests to Dr. Avenanti: [email protected]

Author Contributions

A.A., E.L., L.P., and M.G.C. conceived and designed the study. A.A. (neurophysiological assessment), M.C. (behavioral testing), L.P., and M.G.C. (clinical screening) conducted the study. A.A. and M.C. analyzed the data. A.A. wrote the paper.

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