Ryo Momosaki

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.

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.

Therapeutic application of 6-Hz-primed low-frequency rTMS combined with intensive speech therapy for post-stroke aphasia

Objective: To clarify the safety, feasibility and efficacy of 6-Hz-primed low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with intensive speech therapy (ST) for post-stroke aphasic patients. Methods: Four adult patients with history of left hemispheric stroke and with motor-dominant aphasia were studied. During 11-day hospitalization, each patient received 18 treatment sessions consisting of 10-min 6-Hz priming stimulation followed by 20-min 1-Hz low-frequency rTMS and intensive ST for 60 min daily. Both the priming stimulation and low-frequency rTMS were applied to the right frontal lobe. The intensive ST was provided on one-to-one basis. Language function was assessed by Standard Language Test of Aphasia (SLTA), Supplementary Test of SLTA (SLTA-ST), and the Japanese version of Western Aphasia Battery (WAB) within 2 weeks prior to the admission and on the day of discharge. Results: The in-patient protocol was successfully completed by all patients without any adverse effects. Each patient showed an increase in the correct answer rate after the intervention. Improvement was found in both expressive and recessive language modalities in all patients. Conclusions: The protocol of 6-Hz-primed low-frequency rTMS and intensive ST for post-stroke aphasia was safe and feasible, suggesting its potential usefulness in the treatment of this population.

High-frequency rTMS applied over bilateral leg motor areas combined with mobility training for gait disturbance after stroke: A preliminary study

Abstract Objective: A double cone coil enables delivery of magnetic stimulation to leg motor areas and modulates neural activities of the areas. It is expected that combined application of facilitatory rTMS with the coil and physical therapy would improve walking function after stroke. The purpose of this study is to clarify the clinical effect of an in-patient protocol featuring rTMS with a double cone coil and mobility training for gait disturbance after stroke. Subjects and methods: Nineteen post-stroke hemiparetic patients with gait disturbance were studied (aged 56.2 ± 11.9 years). During the 13-day hospitalization, each patient received 20 sessions of high-frequency rTMS and mobility training featuring treadmill training. In one rTMS session, 2000 pulses of 10-Hz rTMS were delivered over bilateral leg motor areas using the double cone coil. Walking velocity, Physiological Cost Index (PCI) and Timed Up and Go Test (TUG) were evaluated on the day of admission and discharge. Results: The protocol was completed without any adverse effects in all patients. The combination treatment significantly increased walking velocity (p < 0.05) and decreased PCI (p < 0.05), decreased the performance time for TUG (p < 0.05). Conclusions: The protocol featuring high-frequency rTMS and mobility training is safe and feasible and can improve walking function 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.

Bilateral Repetitive Transcranial Magnetic Stimulation Combined with Intensive Swallowing Rehabilitation for Chronic Stroke Dysphagia: A Case Series Study

The purpose of this study was to clarify the safety and feasibility of a 6-day protocol of bilateral repetitive transcranial magnetic stimulation (rTMS) combined with intensive swallowing rehabilitation for chronic poststroke dysphagia. In-hospital treatment was provided to 4 poststroke patients (age at treatment: 56-80 years; interval between onset of stroke and treatment: 24-37 months) with dysphagia. Over 6 consecutive days, each patient received 10 sessions of rTMS at 3 Hz applied to the pharyngeal motor cortex bilaterally, followed by 20 min of intensive swallowing rehabilitation exercise. The swallowing function was evaluated by the Penetration Aspiration Scale (PAS), Modified Mann Assessment of Swallowing Ability (MMASA), Functional Oral Intake Scale (FOIS), laryngeal elevation delay time (LEDT) and Repetitive Saliva-Swallowing Test (RSST) on admission and at discharge. All patients completed the 6-day treatment protocol and none showed any adverse reactions throughout the treatment. The combination treatment improved laryngeal elevation delay time in all patients. Our proposed protocol of rTMS plus swallowing rehabilitation exercise seems to be safe and feasible for chronic stroke dysphagia, although its efficacy needs to be confirmed in a large number of patients.

Role of Brain-Derived Neurotrophic Factor in Beneficial Effects of Repetitive Transcranial Magnetic Stimulation for Upper Limb Hemiparesis after Stroke.

Background Repetitive transcranial magnetic stimulation (rTMS) can improve upper limb hemiparesis after stroke but the mechanism underlying its efficacy remains elusive. rTMS seems to alter brain-derived neurotrophic factor (BDNF) and such effect is influenced by BDNF gene polymorphism. Objectives To investigate the molecular effects of rTMS on serum levels of BDNF, its precursor proBDNF and matrix metalloproteinase-9 (MMP-9) in poststroke patients with upper limb hemiparesis. Methods Poststroke patients with upper limb hemiparesis were studied. Sixty-two patients underwent rehabilitation plus rTMS combination therapy and 33 patients underwent rehabilitation monotherapy without rTMS for 14 days at our hospital. One Hz rTMS was applied over the motor representation of the first dorsal interosseous muscle on the non-lesional hemisphere. Fugl-Meyer Assessment and Wolf Motor Function (WMFT) were used to evaluate motor function on the affected upper limb before and after intervention. Blood samples were collected for analysis of BDNF polymorphism and measurement of BDNF, proBDNF and MMP-9 levels. Results Two-week combination therapy increased BDNF and MMP-9 serum levels, but not serum proBDNF. Serum BDNF and MMP-9 levels did not correlate with motor function improvement, though baseline serum proBDNF levels correlated negatively and significantly with improvement in WMFT (ρ = -0.422, p = 0.002). The outcome of rTMS therapy was not altered by BDNF gene polymorphism. Conclusions The combination therapy of rehabilitation plus low-frequency rTMS seems to improve motor function in the affected limb, by activating BDNF processing. BDNF and its precursor proBDNF could be potentially suitable biomarkers for poststroke motor recovery.

Functional Magnetic Stimulation Using a Parabolic Coil for Dysphagia After Stroke

Recently, the usefulness of neuromuscular electrical stimulation and repetitive transcranial magnetic stimulation for poststroke dysphagia has been reported. However, there is no report that describes the effectiveness of functional magnetic stimulation (FMS) for dysphagia. The purpose of this study is to clarify the effectiveness of FMS for poststroke dysphagia.

Swallowing analysis for semisolid food texture in poststroke dysphagic patients.

BACKGROUND Our objective was to determine the texture of semisolid foods that are appropriate for poststroke dysphagic patients. METHODS Subjects included 52 poststroke dysphagic patients (72 ± 8 years of age) who were trained with semisolid foods and required the evaluation of swallowing function. Fifty-two homogeneous semisolid foods not requiring mastication were given. Texture were measured twice using a rheometer (TPU-2S; Yamaden Co. Ltd., Tokyo, Japan). Texture characteristics were as follows: hardness, 1873 to 19,510 N/m(2) (mean 9,129 N/m(2)); cohesiveness, 0.13 to 0.67 (mean 0.32); adhesiveness, 2 to 878 J/m(3) (mean 209 J/m(3)); and gumminess, 546 to 8781 N/m(2) (mean 2908 N/m(2)). Patients sat during fiberoptic endoscopic evaluation and ingested a single semisolid food. The patients were asked to swallow 4 g of food, and the texture, pharyngeal residue, penetration into the larynx, and aspiration were evaluated. We observed and noted the association between the texture of foods and swallowing movements by videoendoscopy. RESULTS Evaluating food texture by endoscopy revealed significant differences in adhesiveness according to residue deposition and significant differences in gumminess according to aspiration. CONCLUSIONS We identified the textures of different semisolid foods as being either appropriate or inappropriate for poststroke dysphagic patients.