The Effectiveness of Combination of Low Frequency Repetitive Transcranial Magnetic Stimulation With Structured Physiotherapy Training Program on Restoring Upper Extremity Function for Patients After Stroke
Phase: NA
Conditions: Stroke
Sponsor: Queen Elizabeth Hospital, Hong Kong

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THE EFFECTIVENESS OF COMBINATION OF 
LOW FREQUENCY REPETITIVE 
TRANSCRANIAL MAGNETIC STIMULATION 
AND STRUCTURED PHYSIOTHERAPY 
TRAINING PROGRAM ON RESTORING 
UPPER EXTREMITY FUNCTION FOR 
PATIENTS AFTER STROKE 
 
STUDY PROTOCOL 
 
 
 
 
NCT02490371 
15 DEC 2017 
 
 

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Chapter  
Methodology 
2.1. Study design 
This was a double-blind randomized controlled trial; both assessors and patients 
were blinded to group allocation. Figure 1 illustrates the overall study design. The study 
was registered in the clinical trial system at registry.gov (reference number: NCT 
02490371). 
 
2.2. Participant recruitment 
2.2.1 Inclusion and exclusion criteria 
A convenient sampling method was adopted. Patients who were diagnosed with 
their first-ever stroke and referred to the Physiotherapy Department at Queen Elizabeth 
Hospital for post-stroke rehabilitation between November 2015 to December 2016 were 
screened for eligibility by an independent physiotherapist using criteria shown in Table 
1. 

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Figure 1: Experimental design and patient flow 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patients with stroke screened 
for eligibility 
Included 
Excluded 
- If the eligibility criteria 
were not fulfilled 
rTMS + structured exercise group 
Sham rTMS + structured exercise group 
Experimental group  
1. 
Low frequency rTMS over contralesional 
M1 for 10 sessions 
2. 
Structured upper limb training program 
Sham control group 
1. 
Sham rTMS over contralesional M1 
for 10 sessions 
2. 
Structured upper limb training 
program 
Baseline assessment by blinded assessors (week 0) 
Interventions 
Re-assessment after training (week 2) 
Randomization & allocation 
concealment 
Enrollment 
Follow-up 
Follow-up assessment (week 12) 
Structured upper limb training program continued for 
10 weeks  

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Table 1. Inclusion and exclusion criteria  
Inclusion criteria: 
Exclusion criteria: 
1. 
First episode of stroke; 
2. 
Aged 60 or more; 
3. Muscle strength of grade <5 and >2 
based on manual muscle testing of 
the hand or fingers on the paretic 
side; 
4. Time since stroke onset > 1 month 
and < 6 months; 
 
1. 
Mini Mental State Test score ≤ 24;  
2. 
Mental illness; 
3. 
Contra-indications to rTMS 
according to guidelines formulated 
by Wassermann (e.g., intracranial 
implants, epilepsy, cardiac 
pacemaker, implanted medication 
pumps); 
4 
Unstable cardio-pulmonary 
condition. 
 
2.2.2. 
Sample size estimation 
The sample size was estimated from previously published data on one of the 
primary outcome measures, the motor-evoked potential (MEP). In a study involving a 
sample of 20 people by Takeuchi et al. (Takeuchi et al. 2008), a significant improvement 
in MEP was shown in the intervention group. The estimated effect size was about 0.6. 
Based on this, with the power set at 90% and p < 0.05, the minimum estimated sample 
size would be 22. When considering a 10% attrition rate, the minimum sample size 
required would be 24 individuals with stroke. 

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2.3 Randomization and allocation concealment 
The recruited individuals were randomly assigned to either the experimental group 
or the sham group by drawing a pre-set sealed opaque envelope. The group allocation 
was determined by the results of a randomized table set with 4 × 6 blocks with an 
allocation ratio of 1:1. The results were printed and placed in separate envelopes. The 
envelopes were then numbered and put in sequence. Once the individual was recruited, 
he or she was assigned the next envelope in the sequence. The randomization was done 
by a researcher who was not involved in the outcome assessments. 
The details of the clinical trial were explained to the potential participants by the 
investigators, and written informed consent was obtained before the commencement of 
data collection (Appendix I, II, III and IV). This trial protocol was approved by the 
Research Ethics Committee (Kowloon Central/Kowloon East) of the Hospital Authority 
(Appendix V), and the Human Research Ethics Subcommittee of the Hong Kong 
Polytechnic University (Appendix VI). 
 
 

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2.4. Intervention protocol 
The experimental group received 10 sessions of rTMS treatment and a structured 
upper limb training program, whereas the sham control group received sham rTMS and 
structured upper limb training only. In addition, both groups received the structured 
upper limb physiotherapy training program 2 sessions per week for another 10 weeks 
after the 10 sessions of rTMS or sham stimulation had ended. The details of the treatment 
protocol for each group are described below. 
 
2.4.1 Preparation of participants for brain stimulation 
The brain stimulation was conducted by a trained physiotherapist in Queen 
Elizabeth Hospital who had received formal training on brain stimulation and had more 
than 5 years of experienced in neurological in rehabilitation field. All participants had 
been screened for TMS safety at the time of recruitment using a standardized screening 
form (Appendix VII).  All TMS procedures took place in the TMS suite located in the 
Physiotherapy Department of Queen Elizabeth Hospital. 
 
 

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The participants were seated in an inclined chair with both the hand and the neck 
well supported with a cushion. The hotspots over the primary cortical regions in both 
hemispheres were identified in the initial assessment session. The hotspot was identified 
using the Magstim Rapid Stimulator (Magstim Company, Whitland, UK). The 
stimulator was equipped with figure-of-eight stimulating electrodes that were connected 
to the neuronavigation system. The skin around the first dorsal interosseous (FDI) 
muscles of both hands was rubbed with an alcohol swab for at least one minute to prepare 
the skin for electromyographic (EMG) measurement. Two EMG positive and negative 
electrodes were placed over the muscle belly while the ground electrode was placed over 
the ulnar styloid process.  
The hotspot and motor threshold of the contralesional or ipsilesional primary motor 
cortex were determined by placing the coil tangentially to the scalp over the hand area 
of the respective M1. The stimulation site (hotspot) was determined as the location 
where application of TMS at a slightly suprathreshold intensity induced the highest 
amplitude of MEP in the FDI muscle. The resting motor threshold (rMT) was defined 
as the intensity that elicited the MEP at a level of > 50 mV in at least 5 of 10 consecutive 
stimulations. The rMT was set as the baseline for the stimulation intensity. Once the 

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hotspot was determined, the placement of the coil on the hotspot was marked as the 
target point in the navigation system so that the accuracy of site stimulation for 
subsequent treatment sessions could be ensured. The electromyography signals were 
amplified (2500V/V), bandpass filtered (-1-5k Hz), and digitized for recording with 
ADC sampling rate of 3kHz by a built-in EMG device in Brainsight 2 (Brainsight 2, 
Rogue Research Inc., Montreal, Canada). 
 
2.4.2 Experimental group 
      The participants in the experimental group underwent transcranial magnetic 
stimulation over hotspot at contralesional M1 region on weekdays over a 2-week period 
(i.e., 10 sessions), using a Magstim Rapid Stimulator (Magstim Company, Whitland, 
UK). We used a figure-of-eight coil (each loop 70 mm in diameter) for delivering the 
stimulation. The stimulation protocol of rTMS used was at a low frequency of 1 Hz with 
a stimulus intensity of 90% of rMT for a total of 1200 pulses in each session. This low-
frequency protocol was adopted because the stimulation parameters were shown to result 
in down-regulation of motor cortical excitability over the contralesional cortex (Boggio 
et al., 2006). For frequencies from 0.2 to 1 Hz (low frequency), which favor the 
manifestation of the long-lasting inhibitory phase, may lead to cortical inhibition. 
Conversely, frequencies >2 Hz can mask the inhibitory phase of the preceding pulse, 

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thereby maintaining the neurons in a state of excitation (Moliadze et al. 2003).  A meta-
analysis by Zhang et al. (2017) found that low frequency rTMS was more beneficial than 
high frequency rTMS, and that rTMS administered to the contralesional hemisphere 
elicited better improvements in upper limb motor recovery than when applied to the 
lesioned hemisphere (Zhang et al., 2017).  
The participants in the experimental group also underwent structured upper limb 
exercise training conducted by a registered physiotherapist in Queen Elizabeth Hospital. 
Each participant exercised at his or her own pace and was encouraged to perform the 
exercise continuously for thirty minutes in each session. In the treatment sessions during 
the first 2 weeks, the participants performed the 30-minute exercise training immediately 
after the brain stimulation. For the subsequent 10 weeks, the participants continued to 
receive exercise training twice per week. In each exercise session, two modes of 
exercises with 15 minutes for each were offered to improve task performance and 
dexterity of the paretic upper limb. The specific exercises included: 1. reach and grasp 
exercises: stacking cones or placing cones, and 2. fine motor control exercises of the 
hand .  
 
2.4.3 Sham group 

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The sham group received sham rTMS with a trained physiotherapist. All 
procedures were exactly the same (identifying the hotspot, etc.), except that sham rTMS 
was given. Sham stimulation was conducted by positioning the coil at an angle of 90 
degrees relative to the scalp instead of tangentially to the hotspot, but the coil produced 
the same sounds as in real rTMS. This strategy allowed the magnitude of the field 
delivered to be decreased but did not eliminate it (Lisanby et al., 2001) and created a 
similar sensation. The participants in the sham control group underwent the same upper 
limb exercise program as those in the experimental group. 
 
 
 

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2.5. Outcome assessment 
 
2.5.1 Blinded assessors 
Two independent physiotherapists with more than 3 years of relevant experience in 
neurological rehabilitation were responsible for conducting the evaluations at different 
time points. These assessors were blinded to group allocation. Evaluations were 
performed at 3 different time points (figure 6): baseline measurement (Time 0), post-
brain stimulation (Time 1), and 12-week follow-up (Time 2) (Figure 6).  
A meeting and workshop conducted by the chief investigator were conducted to 
familiarize the two assessors with the assessment tools and procedures before the trial 
officially commenced. Regular discussions were conducted at three-month intervals for 
quality assurance purpose. 
Figure 6: Measurement schedule 
 
 
Time 0   
• Baseline Assessment
• Fugl Meyer Assessment, Action Research Arm Test, Grip Strength, Reaction 
Time, Box and Block Test, Nine Hole Peg Test, Motor Evoked Potential, Stroke 
Impact Scale 
Time 1
• After 10 sessions of brain/sham stimulation and upper limb exercise training 
(2 weeks after baseline assessment)
Time 2
• After 10 weeks of upper limb exercise training (12 weeks after baseline 
assessment)

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2.6 Outcome measures 
A battery of assessment tools was chosen to evaluate the participants across the 
domains of International Classification of Function, Disability, and Health endorsed by 
the World Health Organization (i.e., body functions/structures, activity and participation 
WHO Disability Assessment Schedule (WHO 2010). The upper-extremity portion of the 
Fugl-Meyer Motor Assessment Scale (FMA) (Fugl-Meyer et al., 1975) was the primary 
behavioral measure outcome of arm function, whereas the motor evoked potential (MEP) 
was the primary physiological measure. Secondary measures included grip force 
(Takeuchi et al., 2008), the Action Research Arm Test (ARAT), the Nine Hole Pegboard 
test (NHPT), the Box and Block test, the reaction time test, and the Stroke Impact Scale 
(SIS).  
 
2.6.1. Measures of body structures/function 
2.6.1.1 Fugl-Meyer assessment (FMA) 
In the upper-extremity portion of the Fugl-Meyer Motor Assessment Scale (FMA) 
(Appendix VIII), 25 test items included measurement of movement, coordination, and 
reflex action of the different parts of the paretic upper extremity. The score could range 

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from 0 to 66. Better motor function was reflected by a higher FMA score (Fugl et al., 
1975). The FMA scores have been shown to have high construct validity, test-retest and 
interrater reliability (Platz et al., 2005). The minimum clinically important difference 
MCID of FMA was 5.2 points for the upper extremity portion (Wagner et al., 2008).  
 
2.6.1.2 Motor evoked potential (MEP) 
To obtain the MEP of the FDI, EMG activity was measured using silver–silver 
chloride (Ag-AgCl) electrodes placed on the skin overlying the FDI. The peak-to-peak 
MEP amplitude was recorded, which reflects cortical excitability (Malcolm et al., 2007) 
(Figure 7). Ten averaged MEPs evoked from the M1 hotspot on both the ipsilesional and 
contralesional sides of dies at 120% rMT were recorded using the Magstim 200 
(Magstim Company, Whitland, UK). If the EMG could not be triggered at 100% of the 
resting motor threshold, the MEP was defined as “cannot be triggered” and set at zero. 
If the MEP was absent when stimulating the lesioned hemisphere by the stroke, the 
motor hotspot was defined as being symmetrical to the contra-lesional hemisphere. The 
signal was amplified, bandpass filtered (1-5k Hz), and digitized for off-line analysis with 
ADC sampling rate of 3kHz by a built-in EMG device in Brainsight 2 (Brainsight 2, 
Rogue Research Inc., Montreal, Canada).  

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2.6.1.3 Grip strength 
Isometric hand grip strength was evaluated using the Jamar dynamometer for the 
paretic hand. The test was conducted in accordance with the standard position of the 
American Society of Hand Therapists (Figure 8) (i.e., sitting, shouldered in neutral 
rotation and adducted, elbow flexed at 90 degrees, forearm and wrist in neutral). 
Participants were instructed to grasp the dynamometer with maximal effort and sustain 
for 5 seconds (Chen et al., 2009). The force generated (in kg) was registered. Three trials 
were conducted and a brief rest period was provided between trials. The mean value of 
three trials was used for subsequent analysis. According to Bohannon (1986), the grip 
test has excellent test-retest reliability (ICC = 0.84-0.99) in the measurement of patients 
with neurological dysfunction. The MCID for stroke patients was 5.0kg and 6.2kg for 
the affected dominant and non-dominant hands (Lang et al, 2008). 
 
 
 
 

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2.6.2 Measures of activity 
2.6.2.1 Action research arm test (ARAT) 
The 19-item ARAT has four subscales that assess various aspects of upper limb 
function (i.e., pinch, grip, grasp, and gross motor) (Appendix XI) (Figure 9). Each item 
was rated on a 4-point scale from 0 to 4. A higher ARAT score was indicative of better 
upper limb function. The intra-rater and inter-rater reliability of ARAT have been found 
to be good (Platz et al., 2005). The MCID for chronic stroke was 10% of the measure of 
the total range (i.e., 5.7 points) (Lee et al., 2001). 
 
 
 
2.6.2.2 Nine-Hole peg test (NHPT) 
The NHPT measures finger dexterity. A nine-hole peg board was positioned in 
midline of the participant. The container consisting of the pegs was oriented towards the 
paretic hand. The participants were asked to remove the pegs from the container, one at 
a time, and place them into the holes on the board as fast as able (Figure 10). They were 
then required to take each peg from the hole, one at a time, and put it back into the 

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container. The time taken to complete the test (in seconds) was recorded using a 
stopwatch. The NHPT has excellent test-retest reliability when used in individuals with 
stroke (ICC = 0.85) (Platz et al., 2005). The minimal detectable change (MDC) of the 
NHPT was 32.78 seconds (Chen et al., 2009). For those who were unable to perform the 
test within 10 minutes despite the best effort, and a value of 600s would be entered for 
these cases for data analysis purpose.  
 
 
2.6.2.3 Box and Block test 
The Box and Block test measures the gross manual activity of the upper limb. The 
number of blocks transferred over the partition from one side of the compartment to the 
other within a one-minute time period was recorded (Figure 11). A higher number 
indicated better function. The interrater reliability of the Box and Block test was high 
(ICC = 0.99) with an MDC value of 5.5 blocks per minute and a percentage change of 
18% (Chen et al., 2009).  
 
 

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2.6.2.4 Reaction time test 
The simple reaction time was tested using a software program designed by the 
Hong Kong Polytechnic University. Two pictures (apple and dragon fruit) were shown 
on the screen and appeared for random periods of time (ranging from 180 ms to 200 ms). 
The image of the apple appeared first as a cue to prepare the participant before the image 
of the dragon fruit was displayed. Participants were required to press the space bar of 
the computer once the picture of the dragon fruit appeared on the screen. This same 
process was repeated until the data for five trials were obtained. The time gap between 
the appearance of the visual signal and the participant pressing the space bar was 
recorded by the system. The average of five trials was used for analysis. 
 
2.6.3. Measure of participation 
 
2.6.3.1. Stroke Impact Scale (SIS) 
The 59-item Stroke Impact Scale (SIS) is a self-reported measure of health status 
(Appendix X). It is designed to measure various domains of stroke outcomes, including 
activities of daily living/instrumental activities of daily living (ADL/IADL), strength, 
mobility, hand function, memory and thinking, communication, emotion, and 
participation. Each item was rated on a 5-point scale, yielding a possible score range 

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from 0 to 100. Lower scores were indicative of increasing difficulty experienced by the 
participants in accomplishing the tasks described in the test. The MCID of the strength, 
ADL/IADL, mobility and hand function domains was 9.2, 5.9, 4.5 and 17.8 respectively 
(Lin et al., 2010).  
 
2.7 Procedures for reporting and monitoring adverse events 
During the treatment procedures, one case physiotherapist was responsible for the 
participant, monitoring changes, rectifying the intervention, recording any change of 
condition, and reporting any adverse events. According to the Hospital Authority 
regulations and guideline, the physiotherapist reported adverse events to the supervisor 
who reported it through the Accident or Incident Reporting System within 48 hours. 
 
2.8. Statistical analysis 
The software package SPSS 21.0 for Windows (IBM, Armonk, NY, USA) was 
used for statistical analysis. The demographic characteristics of the participants and 
outcome variables at baseline were compared using the Chi-square test (for nominal 
data), Mann-Whitney U test (for ordinal data), and independent t-test (for continuous 

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data). Next, for each continuous outcome measure (FMA, MEP, GS, ARAT, B&B, RT), 
a 2 × 3 two-way repeated measures ANOVA (mixed design; within-subject factor: time; 
between-subject factor: group) was used to determine whether there was a significant 
treatment effect on each of the outcome variables (i.e., significant group × time 
interaction effect). If any substantial difference was found in particular baseline 
characteristics between the two groups, the variables would be entered as covariates in 
the above ANOVA model. Post-hoc analysis was then performed to examine the within-
group changes over time using paired t-tests and between-group differences in change 
score at week 2 and week 12 using independent t-tests.   
For analysis of the NHPT, because the failure cases were assigned a value of 600s, 
non-parametric statistics was used. Friedman test and post-hoc Wilcoxon test were used 
to examine the within-group changes over time, while Mann-Whitney U test was used 
to examine the difference between the two groups at week 2 and 12. 
Next, for those clinical outcome variables that yielded a significant treatment effect 
(i.e., significant group × time interaction effect), Pearson’s product moment correlation 
coefficients were used to determine the degree of correlation between changes in these 
variables and those in MEP on both sides. 

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Intention to treat analysis was first conducted. Any missing data would be 
substituted using the last-observation-carried-forward (LOCF) method. This was 
followed by on-protocol analysis, in which only those participants who completed all 
outcome assessments were included. 
The alpha was set at 0.05, except for post-hoc tests where the alpha was adjusted 
to 0.025 (i.e., Bonferroni correction) because of the 2 comparisons made (within-group 
analysis: baseline Vs week 2; week 2 Vs week 12; between-group comparison of change 
score: week 2 and week 12).