Cortical Excitability Sequential Changes in Response to Transcranial Magnetic Stimulation Post Stroke
Condition: Stroke, Cardiovascular
MeSH terms: Stroke; Myocardial Infarction
Study type: Interventional

Summary: 
      This study was conducted to investigate the cortical excitability changes per session in
      response to the application of low frequency repetitive transcranial magnetic stimulation
      *LF-rTMS* on the contralesional hemisphere and its impact upon the upper limb motor
      performance post stroke. As well as, the minimum and maximum number of (LF-rTMS) sessions
      that would be recommended to achieve boosted enhancement in the cortical excitability
      findings and subsequently its impact upon the functional performance of the upper limb in
      stroke patients.Half of the patients were treated with the contralesional (LF-rTMS) in
      addition to conventional upper limb physical therapy interventions, while the other half
      received the conventional upper limb physical therapy interventions.
    

Detailed description: 
      Forty first ever ischemic stroke patients (3 to 6 months) were recruited and randomly
      assigned into two groups. Intervention for the study group consisted of 10 therapeutic( LF-
      rTMS) sessions, applied daily for two consecutive weeks in addition to their conventional
      upper limb physical therapy program. 1-hertz *HZ* stimulation was delivered at 90% of the
      contralesional Active Motor Threshold *cAMT* for 20 minutes over the contralesional motor'
      hot spot'. Sequential cortical excitability changes were examined by recording the
      contralesional Active Motor Threshold *cAMT* and the ipsilesional Active Motor Threshold
      *iAMT* at the end of every session for all patients in both groups throughout the 10
      therapeutic consecutive sessions, While the sequential cortical excitability rate of change
      was measured by calculating the difference in the sessional values of (cAMT and iAMT) between
      two successive recordings throughout the 10 therapeutic consecutive sessions. Active motor
      threshold was assessed by the visible election of the contralateral first dorsal interosseous
      *FDI*. Upper limb motor performance was assessed using the Fugal-Myer Assessment Upper
      Extremity scale *FMA-UE* and hand grip dynamometer before and after the whole treatment
      protocol for all patients in both groups. All the forty patients had successfully
      accomplished the study procedures. The post treatment findings for cortical excitability and
      upper limb motor performance declared considerable difference between both groups. It was
      concluded that Four sessions is the recommended minimal number of (LF-rTMS) sessions that
      revealed highest significant difference in cortical excitability findings between both
      groups, relying on both the sessional findings of (cAMT) and the sessional findings of
      (iAMT). Also, The maximum recommended number of the inhibitory (rTMS) sessions that showed
      boosted enhancement in cortical excitability in relation to the control group was Eight
      sessions after which there was a plateau in the findings of the sequential rate of change
      either for the (cAMT) or the (iAMT) findings. Recovery of the upper limb motor function is
      closely related to the regain of cortical interhemispheric balance in stroke patients.
      Further research is needed to reveal whether the sequential changes in cortical excitability
      is correlated to the stroke onset or the degree of the general motor impairment post stroke.
      Also, further studies are recommended to figure out whether the recovery of the upper limb
      motor function is related to implemented number of inhibitory (rTMS) sessions.
    

Intervention name(s): (LF-rTMS) group; Control group
Intervention type(s): Device; Other
Intervention description(s): The (LF-rTMS) (low frequency repetitive transcranial magnetic stimulation) group received 1-hertz (HZ) stimulation at 90% of motor threshold to the "hot spot" of the primary cerebral cortex, using a 70-mm figure- 8 coil and Magstim Rapid2 stimulator (Magstim Company, USA). Contralesional 1 HZ *rTMS* applied over the primary motor area "hot spot" at 90% of Active motor threshold . Each rTMS session consisted of 1,200pulses; lasting 20 minutes The optimal site of stimulation on the skull are known as the "hot spot" . "Hot spots" were found by searching for loci that triggered maximum visible contraction in the contralateral first dorsal interosseous *FDI* muscle, while the patient is contracting his whole limb as much as possible .; neurodevelopmental technique (NDT) ( including Bobath and Brunnstrom approaches , proprioceptor and exteroceptor stimulation for the weak and inhibition for the hyperactive muscle groups, proprioceptive neuromuscular facilitation (PNF) specific techniques, Approximation and weight bearing, placing technique). Task-oriented training (moving, grasping and releasing bottles ,cups , small toys). Active participation of the whole hemiparetic upper extremity in different motor task training with coordination and Bilateral arm training exercise.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Randomized controlled study design were the recruited patients were randomly allocated into two groups (control group(GA) and study group(GB)) by random generator using permuted blocks of different sizes. The treatment for all patients in both groups was conducted daily ﬁve days per week for 2 consecutive weeks.The control group (GA) received their conventional physical therapy upper limb physical therapy interventions.
The study group (GB) received contralesional low frequency repetitive transcranial magnetic stimulation (LF-rTMS) in addition to the conventional upper limb physical therapy interventions. All the selected patients were with mild to moderate motor impairments (according to National Institutes of Health Stroke Scale *NIHSS* and with mild upper limb spasticity ( according to modified ashworths scale *MAS* 1 or 1+) from both sexes who met all the inclusion criteria after signing an institutionally approved informed consent form prior to data collection.
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Cortical excitability sequential change; Transcranial Magnetic stimulation; Recommended number of sessions; Upper limb motor performance