Aki Yokoi

A multi-center study on low-frequency rTMS combined with intensive occupational therapy for upper limb hemiparesis in post-stroke patients

BackgroundBoth low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) have been recently reported to be clinically beneficial for post-stroke patients with upper limb hemiparesis. Based on these reports, we developed an inpatient combination protocol of these two modalities for the treatment of such patients. The aims of this pilot study were to confirm the safety and feasibility of the protocol in a large number of patients from different institutions, and identify predictors of the clinical response to the treatment.MethodsThe study subjects were 204 post-stroke patients with upper limb hemiparesis (mean age at admission 58.5 ± 13.4 years, mean time after stroke 5.0 ± 4.5 years, ± SD) from five institutions in Japan. During 15-day hospitalization, each patient received 22 treatment sessions of 20-min low-frequency rTMS and 120-min intensive OT daily. Low-frequency rTMS of 1 Hz was applied to the contralesional hemisphere over the primary motor area. The intensive OT, consisting of 60-min one-to-one training and 60-min self-exercise, was provided after the application of low-frequency rTMS. Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) were performed serially. The physiatrists and occupational therapists involved in this study received training prior to the study to standardize the therapeutic protocol.ResultsAll patients completed the protocol without any adverse effects. The FMA score increased and WMFT log performance time decreased significantly at discharge, relative to the respective values at admission (change in FMA score: median at admission, 47 points; median at discharge, 51 points; p < 0.001. change in WMFT log performance time: median at admission, 3.23; median at discharge, 2.51; p < 0.001). These changes were persistently seen up to 4 weeks after discharge in 79 patients. Linear regression analysis found no significant relationship between baseline parameters and indexes of improvement in motor function.ConclusionsThe 15-day inpatient rTMS plus OT protocol is a safe, feasible, and clinically useful neurorehabilitative intervention for post-stroke patients with upper limb hemiparesis. The response to the treatment was not influenced by age or time after stroke onset. The efficacy of the intervention should be confirmed in a randomized controlled study including a control group.

Anti-spastic effect of low-frequency rTMS applied with occupational therapy in post-stroke patients with upper limb hemiparesis

Objective: To determine the effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with occupational therapy (OT) on the spasticity of the hemiparetic upper limb after stroke. Subjects and methods: The study subjects were 39 post-stroke patients with spastic upper limb hemiparesis (age: 56.5 ± 16.0 years, time after onset: 50.3 ± 37.8 months). At admission, the severity of hemiparesis was categorized as Brunnstrom stage 3–5 for hand–fingers. During 15-day hospitalization, each patient received 22 sessions of low-frequency rTMS applied to the non-lesional hemisphere and OT (one-to-one training and self-training). The spasticity of finger and wrist flexors of the affected upper limb was evaluated using the modified Ashworth scale (MAS) on the day of admission and discharge and 4 weeks after discharge. Each subject underwent Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT). Results: The low-frequency rTMS/OT protocol significantly decreased the MAS scores for both finger and wrist flexors at discharge and at 4 weeks after discharge. In addition, the low-frequency rTMS/OT protocol significantly increased the FMA score and shortened the WMFT performance time. Conclusions: The 15-day in-patient protocol of low-frequency rTMS/OT is potentially suitable for reducing spasticity as well as improving motor function on the affected upper limb after stroke.

Six-day course of repetitive transcranial magnetic stimulation plus occupational therapy for post-stroke patients with upper limb hemiparesis: A case series study

Purpose. To clarify the safety and feasibility of a 6-day protocol of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with intensive occupational therapy (OT) for upper limb hemiparesis. Methods. In-hospital combination treatment was provided for 5 post-stroke patients with upper limb hemiparesis after more than 12 months of the onset of stroke. Over 6 consecutive days, each patient received 10 sessions of combination treatment with 1 Hz rTMS and intensive OT (one-on-one training and self-training). Motor function in the affected upper limb was evaluated by Fugl-Meyer Assessment (FMA), Wolf Motor Function Test (WMFT), Ten-Second Test at admission, discharge, and 4 weeks after treatment. Results. All patients completed the 6-day treatment protocol and none showed any adverse effects throughout the treatment. At the end of treatment, improvements in the scores of FMA, WMFT, and Ten-Second Test were found in all patients. No deterioration of improved upper limb function was observed at 4 weeks after the treatment. Conclusions. Our proposed protocol of combination treatment seems to be safe and feasible for post-stroke patients with upper limb hemiparesis, although the efficacy of the protocol needs to be confirmed in a large number of patients.

Combination Treatment of Low-Frequency rTMS and Occupational Therapy with Levodopa Administration: An Intensive Neurorehabilitative Approach for Upper Limb Hemiparesis After Stroke

ABSTRACT The combination treatment of low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy was applied with concomitant oral administration of levodopa in five post-stroke patients with upper limb hemiparesis (age at treatment: 56–66 years; interval between onset of stroke and treatment: 18–143 months) as a 15-day inpatient protocol. Daily levodopa administration of 100 mg was initiated 1 week before admission and continued until 4 weeks after discharge. Low-frequency rTMS of 1 Hz was applied to the contralesional hemisphere for 40 min daily (two 20-min sessions) combined with intensive occupational therapy consisting of 60-min one-on-one training and 60-min self-exercise. Motor function of the affected upper limb was serially evaluated with the Fugl–Meyer Assessment and the Wolf Motor Function Test. At the end of the treatment, all patients showed improved motor function in the affected upper limbs. In some patients, the improvement was maintained until 4 weeks after discharge. No patient showed any adverse effect from the intervention. Our proposed protocol featuring levodopa administration, low-frequency rTMS, and intensive occupational therapy could provide a safe and feasible intervention for upper limb hemiparesis after stroke.

Application of combined 6-Hz primed low-frequency rTMS and intensive occupational therapy for upper limb hemiparesis after stroke.

INTRODUCTION The purpose of this study was to clarify the safety, feasibility and efficacy of 6-Hz primed low-frequency repetitive transcranial magnetic stimulation (rTMS) applied with intensive occupational therapy (OT) for upper limb hemiparesis after stroke. SUBJECTS AND METHODS Eleven patients with history of stroke and upper limb hemiparesis (age at intervention: 61.0 ± 13.7 years, time after stroke onset: 70.2 ± 39.8 months) were studied. Each patient received 22 sessions of 6-Hz primed low-frequency rTMS (10-min 6-Hz priming stimulation followed by 20-min low-frequency rTMS of 1-Hz) applied to the non-lesional hemisphere plus intensive OT comprising 60-min one-to-one training and 60-min self-training during 15-day hospitalization. The motor function of the affected upper limb was evaluated by Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) on the days of admission and discharge. RESULTS All patients completed the 15-day protocol without any adverse effects. The treatment increased the FMA score (from 42.2 ± 6.9 to 45.6 ± 7.2 points, p< 0.005) and shortened the log performance time of WMFT (from 3.26 ± 1.21 to 2.81 ± 1.26 sec, p< 0.05). CONCLUSIONS The 15-day protocol of 6-Hz primed low-frequency rTMS combined with intensive OT seems safe and a potentially useful therapeutic modality for upper limb hemiparesis after stroke.

Baseline Severity of Upper Limb Hemiparesis Influences the Outcome of Low-Frequency rTMS Combined With Intensive Occupational Therapy in Patients Who Have Had a Stroke

To clarify whether the efficacy of combined low‐frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) depends on baseline severity of upper limb hemiparesis after stroke.

Low-frequency rTMS combined with intensive occupational therapy for upper limb hemiparesis after brain tumour resection

Objective: To assess the safety, feasibility and efficacy of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with occupational therapy (OT) in a hemiparetic patient who had undergone brain tumour resection. Participant: A 39-year-old right-handed woman underwent brain tumour resection and presented 5 years later with right upper limb hemiparesis. At admission, she was considered to have reached a probable plateau state of motor functional recovery of the affected upper limb in spite of conventional occupational therapy. Intervention: Low-frequency rTMS with 1 Hz applied to the right primary motor cortex followed by intensive occupational therapy (one-on-one training and self-training) was provided daily during the 15-day hospitalization. Main outcome measures: Fugl-Meyer Assessment and Wolf Motor Function Test were conducted serially to evaluate motor function on the affected upper limb. Results: Neither adverse effect nor deterioration of neurological symptoms was recognized during the treatment period. The 15-day combination protocol improved motor function of the right upper limb and further improvement was noted 4 weeks after discharge. Conclusion: The proposed protocol of low-frequency rTMS with intensive occupational therapy is a potentially useful rehabilitative programme for upper limb hemiparesis after brain tumour resection.