Primed(theta burst stimulation) Physical Therapy Enhances Recovery of Upper Limb Function in Chronic Stroke Patients

Is this good enough to writeup a stroke protocol on this? The senior researcher/mentor should do this as a matter of course for all  rehabilitation research.
http://nnr.sagepub.com/content/30/4/339.full

1. Suzanne J. Ackerley, PhD1
2. Winston D. Byblow, PhD1
3. P. Alan Barber, FRACP1,2
4. Hayley MacDonald1
5. Andrew McIntyre-Robinson1
6. Cathy M. Stinear, PhD1⇑

1. ¹University of Auckland, Auckland, New Zealand
2. ²Auckland City Hospital, Auckland, New Zealand

1. Cathy M. Stinear, PhD, Centre for Brain Research, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. Email: c.stinear@auckland.ac.nz

 

Abstract

Background. Recovery of upper limb function is important for regaining independence after stroke.  

Objective. To test the effects of priming upper limb physical therapy with intermittent theta burst stimulation (iTBS), a form of noninvasive brain stimulation.  

Methods. Eighteen adults with first-ever chronic monohemispheric subcortical stroke participated in this randomized, controlled, triple-blinded trial. Intervention consisted of priming with real or sham iTBS to the ipsilesional primary motor cortex immediately before 45 minutes of upper limb physical therapy, daily for 10 days. Changes in upper limb function (Action Research Arm Test [ARAT]), upper limb impairment (Fugl-Meyer Scale), and corticomotor excitability, were assessed before, during, and immediately, 1 month and 3 months after the intervention. Functional magnetic resonance images were acquired before and at one month after the intervention.  

Results. Improvements in ARAT were observed after the intervention period when therapy was primed with real iTBS, but not sham, and were maintained at 1 month. These improvements were not apparent halfway through the intervention, indicating a dose effect. Improvements in ARAT at 1 month were related to balancing of corticomotor excitability and an increase in ipsilesional premotor cortex activation during paretic hand grip.  

Conclusions. Two weeks of iTBS-primed therapy improves upper limb function at the chronic stage of stroke, for at least 1 month postintervention, whereas therapy alone may not be sufficient to alter function. This indicates a potential role for iTBS as an adjuvant to therapy delivered at the chronic stage.

Introduction

Upper limb (UL) impairment is common after stroke and recovery of function is important for regaining independence in activities of daily living.¹ Rehabilitation of the UL involves repetitive motor practice to promote use-dependent neuroplasticity and functional recovery, and primarily occurs in the first 6 months after stroke.^2⇓-4 Whether further gains are possible beyond this time has been a matter of ongoing debate.⁵ Therapy may need to be primed in order to realize the potential for further gains in function at the chronic stage.⁶ Noninvasive brain stimulation techniques can be used to prime the motor cortex by promoting long-term potentiation–like plasticity⁷ and rendering the primary motor cortex (M1) more receptive to input from other cortical areas for a greater response to therapy.^8⇓⇓-11

In healthy individuals, the balance of excitability between the 2 cerebral hemispheres is symmetric. At the chronic stage after stroke, the ipsilesional M1 is typically underexcitable and interhemispheric inhibition between the hemispheres is asymmetric, reinforcing an imbalance in corticomotor excitability between hemispheres.^12,13 Better clinical outcomes for the affected hand and arm are seen when asymmetry of corticomotor excitability is reduced.¹⁴

Noninvasive brain stimulation techniques that increase the excitability of the ipsilesional motor cortex may promote reorganization within ipsilesional M1 and improve the symmetry of corticomotor excitability between hemispheres.^9,10 A protocol of repetitive transcranial magnetic stimulation (rTMS), called intermittent theta burst stimulation (iTBS), may act as a priming stimulus to facilitate excitability and promote use-dependent plasticity.^15,16 Ipsilesional M1 iTBS followed by a single dose of UL practice at the chronic stage after stroke is more beneficial than UL practice alone.^17,18 However, one study has investigated the effects of multiple sessions combining iTBS with UL therapy in chronic stroke patients, with a negative result.¹⁹ There was no difference between real and sham treatment groups for any hand function outcome measure.

The aim of this study was to examine the effects of priming UL physical therapy with iTBS of ipsilesional M1 in subcortical stroke patients at the chronic stage. We hypothesized that UL function would be improved immediately and one month after intervention in the PRIMED group (receiving real iTBS and physical therapy) and exceed any benefit made by the CONTROL group (receiving sham iTBS and physical therapy). We also hypothesized improved UL function may be associated with balancing of cortical activity toward symmetry between the hemispheres, assessed with neurophysiology and neuroimaging measures. 

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