You try explaining this in simple words that you want this intervention to your hospital! Does your hospital even have any of this equipment?
Synergistic efficacy of repetitive peripheral magnetic stimulation on central intermittent theta burst stimulation for upper limb function in patients with stroke: a double-blinded, randomized controlled trial
Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 49 (2024)
Abstract
Background
Non-invasive techniques such as central intermittent theta burst stimulation (iTBS) and repetitive peripheral magnetic stimulation (rPMS) have shown promise in improving motor function for patients with stroke. However, the combined efficacy of rPMS and central iTBS has not been extensively studied. This randomized controlled trial aimed to investigate the synergistic effects of rPMS and central iTBS in patients with stroke.
Method
In this study, 28 stroke patients were randomly allocated to receive either 1200 pulses of real or sham rPMS on the radial nerve of the affected limb, followed by 1200 pulses of central iTBS on the ipsilesional hemisphere. The patients received the intervention for 10 sessions over two weeks. The primary outcome measures were the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and the Action Research Arm Test (ARAT). Secondary outcomes for activities and participation included the Functional Independence Measure-Selfcare (FIM-Selfcare) and the Stroke Impact Scale (SIS). The outcome measures were assessed before and after the intervention.
Results
Both groups showed significant improvement(But how close to 100% recovery? If you didn't measure that your research completely failed!) in FMA-UE and FIM-Selfcare after the intervention (p < 0.05). Only the rPMS + iTBS group had significant improvement in ARAT-Grasp and SIS-Strength and activity of daily living (p < 0.05). However, the change scores in all outcome measures did not differ between two groups.
Conclusions
Overall, the study’s findings suggest that rPMS may have a synergistic effect on central iTBS to improve grasp function and participation. In conclusion, these findings highlight the potential of rPMS as an adjuvant therapy for central iTBS in stroke rehabilitation. Further large-scale studies are needed to fully explore the synergistic effects of rPMS on central iTBS.
Trial registration
This trial was registered under ClinicalTrials.gov ID No.NCT04265365, retrospectively registered, on February 11, 2020.
Background
Stroke is a leading cause of death and disability worldwide, with impaired upper limb motor function being a common outcome for stroke survivors. According to the Global Burden of stroke 2019, stroke had become the second most common causes of death (11.6% of all deaths [95% uncertainty interval, 10.8–12.2%]) and the third most common causes of disability (5.7% of disability-adjusted life years from all causes [95% uncertainty interval, 5.1–6.2]) in the world [1]. Among people experiencing stroke episodes, impaired motor function of upper extremities often had adverse effects on the daily activities [2] and participation [3]. In 70% of stroke patients, upper limb involvement was responsible for long-term impairment of daily function and activities [4, 5].
Even with traditional neurorehabilitation programs, approximately 50–60% of stroke patients still experience chronic motor limitations [6]. To address this, non-invasive brain stimulation such as central theta burst stimulation (TBS), a novel form of repetitive transcranial magnetic stimulation (rTMS), have been used to treat these patients [7]. Central TBS has been found to have persistent effects on motor evoked potentials (MEPs) [8, 9]. The bimodal balance-recovery model has been proposed as the underlying mechanism for central rTMS [10]. This model combined the concepts of interhemispheric competition and vicariation effects of the intact hemisphere in patients with stroke [10]. The hypothesis posited that there was a reduction in cortical excitability within the impaired hemisphere, accompanied by an increase in transcallosal inhibitory signaling originating from the intact hemisphere [10]. To facilitate cortical excitability in the impaired hemisphere, intermittent TBS (iTBS) is applied, while continuous TBS (cTBS) is utilized to reduce transcallosal inhibitory signals in the intact hemisphere [11]. A recent meta-analysis has shown that iTBS outperforms cTBS in terms of promoting upper limb motor recovery in stroke patients [12]. Therefore, iTBS was selected for this study.
Repetitive peripheral magnetic stimulation (rPMS) is another non-invasive brain stimulation technique that targets the peripheral motor nerve through both direct and indirect activation [13,14,15]. The transmission of direct activation occurred through the sensorimotor nerve, whereas indirect activation was facilitated by the mechanoreceptor nerve [13,14,15]. It has been hypothesized that rPMS could induce neuroplasticity and cortical reorganization [13,14,15]. Prior research has demonstrated increased motor evoked potential (MEP) amplitudes in the upper limb following rPMS application [16,17,18,19]. One study demonstrated the potential of rPMS to enhance distal motor function [20], and another showed its effectiveness in improving proximal muscle strength in early subacute stroke patients [21]. Recent studies further underscore the positive impact of rPMS on upper motor function assessed by Fugl-Meyer Assessment (FMA) during the subacute and acute phases of stroke [21, 22]. Furthermore, FMA-Upper Extremity (FMA-UE) includes proximal and distal domain [23, 24]. Considering that most patients with stroke suffered from flexor spasticity in the upper limb, which limited their ability to open hands for object manipulation. Thus, we chose the radial nerve for the delivery of rPMS, which is essential for the recovery of skilled hand prehension [25].
To date, the majority of studies have focused on the effects of integrating rPMS with rehabilitation programs [20,21,22] for patients with stroke. Currently, one study showed that central rTMS combined with rPMS altered cerebellar and frontoparietal cortical activity via functional magnetic images [26]. One study combined rTMS with rPMS to improved patient’s spasticity and motor function [27]. While the individual benefits of central rTMS and rPMS have been documented in previous studies [26, 27], our rationale for combining them is based on emerging evidence that rPMS can modulate motor cortical excitability in the central nervous system [13,14,15]. Furthermore, the iTBS was proved to have more enduring effects than the conventional rTMS [2, 28]. This concept is still relatively novel, and no studies have explored the synergistic effects of central iTBS when combined with peripheral rPMS. Therefore, we hypothesized that applying rPMS to the radial nerve might enhance the effectiveness of central iTBS over the primary motor cortex, leading to improvement in motor function, activities, and participation. This is the first randomized controlled trial investigating the synergistic efficacy of rPMS on central iTBS in treating upper limb dysfunction in patients with stroke.
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