Niche Trial: Navigated Inhibitory rTMS to Contralesional Hemisphere Trial

A pivotal, prospective, multi-center, randomized, controlled, double-blinded study combining active Nexstim NBS-guided 1Hz rTMS or sham-rTMS targeting the healthy hemisphere with standardized task oriented rehabilitation will be conducted in patients with post-stroke motor impairment. The therapy will be provided for 6 weeks and primary outcome assessed 6 months later.


Eligibility Criteria:
Inclusion Criteria :

* ≥ 18 years of age
* An ischemic or hemorrhagic stroke suffered 3-12 months prior to the study;
* no other known brain abnormalities by history;
* A one-sided stroke resulting in upper extremity paresis
* A Chedoke-McMaster Stroke Assessment arm stage and hand stage of 3-6 for the affected limb

Exclusion Criteria

* Implanted metallic parts of implanted electronic devices, including pacemakers, defibrillators, or implant medication pump;
* Pregnant or trying to become pregnant; Lack of pregnancy established in females of child-bearing potential by a negative urine pregnancy test at screening.
* Active alcohol abuse, illicit drug use or drug abuse or significant mental illness
* Patients suffering from depression as measured by a score of \>10 on the Patient Health Questionnaire (PHQ9). For clarity, patients diagnosed with depression which is controlled with stable anti-depressive medication and in whom PHQ9 is \<10 are eligible to participate in the trial.
* History of epilepsy, defined as at least two unprovoked seizures occurring greater than 24 hours apart or diagnosis of an epilepsy syndrome, OR a seizure within the last 12 months.
* Any condition that would prevent the subject from giving voluntary informed consent;
* An implanted brain stimulator;
* Any metal in head with the exception of dental work or any ferromagnetic metal elsewhere in the body;
* Enrolled or plans to enroll in an interventional trial during this study;
* Scalp wounds or infections;
* Claustrophobia precluding MRI;
* A fixed contraction deformity in the affected limb that would prevent normal dexterity if patient were neurologically intact;
* Excessive spasticity as indicated by the Modified Ashworth Spasticity (MAS) Scale \>2/4 in either elbow flexors, wrist flexors or finger flexors of the affected limb;i
* previous stroke with residual deficits (TIAs not a reason for exclusion);
* premorbid (retrospective) modified Rankin Scale (mRS) score ≥2 of any aetiology;
* a concurrent progressive neurologic disorder, acute coronary syndrome, severe heart disease (NYHA Classification \> 3), or other major medical condition,
* confirmed or suspected lower-limb fracture preventing mobilization,
* patients requiring palliative care
* patients planning to undergo any other occupational therapy during the 6 week active treatment period of the trial (see section 5.2 for study schedule) than what is provided in the study
* A recent injection of botulinium toxin to the affected upper limb in the last 3 months, or the need of an injection of botulinum toxin anytime during the study period and follow up.
* A recent injection of phenol to the affected upper limb in the last 6 months, or the need of an injection of phenol anytime during the study period and follow up.
* Ataxia as measured by a score \> 1 on item 7 (limb ataxia) of the NIH stroke scale.
* Severe sensory deficits as measured by a score of 2 on item 8 of the NIH stroke scale.
* Severe aphasia as measured by a score of \> 2 on item 9 (best language) of the NIH stroke scale.
* Severe neglect as measured by a score of 2 on item 11 (extinction and inattention) of the NIH stroke scale.
* Patients unable to comprehend or follow verbal commands
* Based on PI's or local physician's assessment patient unable to tolerate the trial procedure due to medical condition
* A Mini mental status exam (MMSE) \<25.