Skip to main content

Continuous theta-burst stimulation combined with occupational therapy for upper limb hemiparesis after stroke: a preliminary study

Abstract

The purpose of this study was to assess the safety, feasibility and efficacy of continuous theta-burst stimulation (cTBS) combined with intensive occupational therapy (OT) for upper limb hemiparesis after stroke. Ten patients with history of stroke and upper limb hemiparesis (age 62.0 ± 11.1 years, time since stroke 95.7 ± 70.2 months, mean ± SD) were studied. Each patient received 13 sessions, each comprising 160 s of cTBS applied to the skull on the area of the non-lesional hemisphere (using a 70-mm figure-8 coil, three pulse bursts at 50 Hz, repeated every 200 ms, i.e., 5 Hz, with total stimulation of 2,400 pulses), followed by intensive OT (comprising 120-min one-to-one training and 120-min self-training) during 15-day hospitalization. The motor function of the affected upper limb was evaluated by Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) on the days of admission and discharge. All patients completed the 15-day protocol without any adverse effects. Treatment significantly increased the FMA score (from 46.6 ± 8.7 to 51.6 ± 8.2 points, p < 0.01) and shortened the log performance time of WMFT (from 2.5 ± 1.1 to 2.2 ± 1.2 s, p < 0.01). The 15-day protocol of cTBS combined with intensive OT is a safe and potentially useful therapeutic modality for upper limb hemiparesis after stroke.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3

References

  1. Khedr EM, Ahmed MA, Fathy N, Rothwell JC (2005) Therapeutic trial of repetitive transcranial magnetic stimulation after acute ischemic stroke. Neurology 65:466–468

    PubMed  Article  Google Scholar 

  2. Fregni F, Boggio PS, Valle AC, Rocha RR, Duarte J, Ferreira MJ et al (2006) A sham-controlled trial of a 5-day course of repetitive transcranial magnetic stimulation of the unaffected hemisphere in stroke patients. Stroke 37:2115–2122

    PubMed  Article  Google Scholar 

  3. Fitzgerald PB, Brown TL, Marston NA, Daskalakis ZJ, De Castella A, Kulkarni J (2003) Transcranial magnetic stimulation in the treatment of depression: a double-blind, placebo-controlled trial. Arch Gen Psychiatry 60:1002–1008

    PubMed  Google Scholar 

  4. George MS, Lisanby SH, Avery D, McDonald WM, Durkalski V, Pavlicova M, Anderson B, Naha Z, Bulow P, Zarkowski P, Holtzheimer PE 3rd, Schwartz T, Sackeim HA (2010) Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Arch Gen Psychiatry 67:507–516

    PubMed  Article  Google Scholar 

  5. Lomarev MP, Kanchana S, Bara-Jimenez W, Iyer M, Wassermann EM, Hallett M (2006) Placebo-controlled study of rTMS for the treatment of Parkinson’s disease. Mov Disord 21:325–331

    PubMed  Article  Google Scholar 

  6. Pascual-Leone A, Valls-Sole J, Wasserman EM, Hallet M (1994) Responses to rapid-rate transcranial magnetic stimulation of the human motor cortex. Brain 117:847–858

    PubMed  Article  Google Scholar 

  7. Chen R, Classen J, Gerloff C, Celnik P, Wassermann EM, Hallett M et al (1997) Depression of motor cortex excitability by low-frequency transcranial magnetic stimulation. Neurology 48:1398–1403

    CAS  PubMed  Article  Google Scholar 

  8. Wu T, Sommer M, Tergau F, Paulus W (2000) Lasting influence of repetitive transcranial magnetic stimulation on intracortical excitability in human subjects. Neurosci Lett 287:37–40

    CAS  PubMed  Article  Google Scholar 

  9. Ebner HR, Rothwell J (2003) Transcranial magnetic stimulation: new insight into representational cortical plasticity. Exp Brain Res 148:1–16

    Article  Google Scholar 

  10. Cooke SF, Bliss TV (2006) Plasticity in the human central nervous system. Brain 129:1659–1673

    CAS  PubMed  Article  Google Scholar 

  11. Huang YZ, Chen RS, Rothwell JC, Wen HY (2007) The after-effect of human theta burst stimulation is NMDA receptor dependent. Clin Neurophysiol 118:1028–1032

    CAS  PubMed  Article  Google Scholar 

  12. Huang YZ, Rothwell JC, Chen RS, Lu CS, Chuang WL (2011) The theoretical model of theta burst form of repetitive transcranial magnetic stimulation. Clin Neurophysiol 122:1011–1018

    PubMed Central  PubMed  Article  Google Scholar 

  13. Ridding MC, Rothwell JC (2007) Is there a future for therapeutic use of transcranial magnetic stimulation? Nat Rev Neurosci 8:559–567

    CAS  PubMed  Article  Google Scholar 

  14. Huang YZ, Edwards MJ, Rounis E, Bhatia KP, Rothwell JC (2005) Theta burst stimulation of the human motor cortex. Neuron 45:201–206

    CAS  PubMed  Article  Google Scholar 

  15. Gentner R, Wankerl K, Reinsberger C, Zeller D, Classen J (2008) Depression of human corticospinal excitability induced by magnetic theta burst stimulation: evidence of rapid polarity-reversing metaplasticity. Cereb Cortex 18:2046–2053

    PubMed  Article  Google Scholar 

  16. Kakuda W, Abo M, Kaito N, Ishikawa A, Taguchi K, Yokoi A (2010) Six-day course of repetitive transcranial magnetic stimulation plus occupational therapy for post stroke patients with upper limb hemiparesis: a case series study. Disabil Rehabil 32:801–807

    PubMed  Article  Google Scholar 

  17. Kakuda W, Abo M, Kobayashi K, Momosaki R, Yokoi A, Fukuda A et al (2010) Low-frequency repetitive transcranial magnetic stimulation and intensive occupational therapy for poststroke patients with upper limb hemiparesis: preliminary study of a 15-day protocol. Int J Rehabil Res 33:339–345

    PubMed  Article  Google Scholar 

  18. Gladstone DJ, Danells CJ, Black SE (2002) The Fugl-Meyer assessment of motor recovery after stroke: a critical review of its measurement properties. Neurorehabil Neural Repair 16:232–240

    PubMed  Article  Google Scholar 

  19. Platz T, Pinkowski C, van Wijck F, Kim IH, di Bella P, Johnson G (2005) Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, action research arm test and box and block test: a multicentre study. Clin Rehabil 19:404–411

    PubMed  Article  Google Scholar 

  20. Morris DM, Uswatte G, Crago JE, Cook EW III, Taub E (2001) The reliability of the Wolf motor function test for assessing upper extremity function after stroke. Arch Phys Med Rehabil 82:750–755

    CAS  PubMed  Article  Google Scholar 

  21. Wolf SL, Thompson PA, Morris DM, Rose DK, Winstein CJ, Taub E et al (2005) The EXCITE trial: attributes of the Wolf motor function test in patients with subacute stroke. Neurorehabil Neural Repair 19:194–205

    PubMed  Article  Google Scholar 

  22. Wolf SL, Winstein CJ, Miller JP, Taub E, Uswatte G, Morris D, for the EXCITE Investigators et al (2006) Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: The EXCITE randomized clinical trial. JAMA 296:2095–2104

    CAS  PubMed  Article  Google Scholar 

  23. Nyffeler T, Wurtz P, Lüscher HR, Hess CW, Senn W, Pflugshaupt T et al (2006) Extending lifetime of plastic changes in the human brain. Eur J Neurosci 24:2961–2966

    PubMed  Article  Google Scholar 

  24. Nyffeler T, Cazzoli D, Hess CW, Müri RM (2009) One session of repeated parietal theta burst stimulation trains induces long-lasting improvement of visual neglect. Stroke 408:2791–2796

    Article  Google Scholar 

  25. Gamboa OL, Antal A, Moliadze V, Paulus W (2010) Simply longer is not better: reversal of theta burst after-effect with prolonged stimulation. Exp Brain Res 204:181–187

    PubMed Central  PubMed  Article  Google Scholar 

  26. Cazzoli D, Müri RM, Schumacher R, von Arx S, Chaves S, Gutbrod K et al (2012) Theta burst stimulation reduces disability during the activities of daily living in spatial neglect. Brain 135:3426–3439

    PubMed  Article  Google Scholar 

Download references

Acknowledgments

The authors gratefully acknowledge the support and the participation of the patients in the study. Funding for this study was provided by a Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science.

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Masahiro Abo.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Yamada, N., Kakuda, W., Kondo, T. et al. Continuous theta-burst stimulation combined with occupational therapy for upper limb hemiparesis after stroke: a preliminary study. Acta Neurol Belg 114, 279–284 (2014). https://doi.org/10.1007/s13760-014-0294-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13760-014-0294-y

Keywords

  • Stroke
  • Upper limb hemiparesis
  • Theta-burst stimulation
  • Occupational therapy