rTMS and CIMT for Neurofunctional Recovery in Chronic Stroke

Background: The purpose of the study was to investigate the effect of high frequency rTMS with constraint induced movement therapy (CIMT) on Upper extremity motor function. Clinical Stroke Assessment Scales and fMRI was used to assess the response of CIMT with rTMS on blood oxygenation-level dependent (BOLD) sequence component. Methodology: RCT was conducted at All India Institute of Medical Sciences, New Delhi, on chronic stroke patients (N=60) between 12 to 36 months of index event with atleast 10° of wrist extension, 10° of thumb abduction, Brunnstorm stage 2-4; NIHSS 4–20. Patients were randomized to CIMT alone (Group A n=30) & rTMS with CIMT (Group B n=30). rTMS (10 Hz, 750 pulses with 110%RMT) was administered for 3 weeks (5days/week). Radiological Assessment of the patients was done with fMRI (BOLD) along with assessment of Fugl Meyer (FM), Barthel Index, and modified Rankin Scales (MRS) at baseline, 3 weeks (Post intervention) & 3 month (follow up) Results: FM showed statistically significant improvement in group B as compared to group A at 3 weeks (95%CI: -12.4 to -9.3, p=0.003) and 3months (95%CI: 7.4 to 4.2, p=0.01). Repeated measure ANOVA showed that the mean groups were different at all-time points indicating some degree of improvement in all the subjects (F=3.4, p=0.01; F=5.4, p=0.002). The BOLD cluster activation was compared between two groups; there was increase in the number of clusters found in Group B. Conclusion: Both the groups showed improvement, increased cluster count showing alterations in cortical activations (fMRI-BOLD) after CIMT with rTMS in patients with chronic stroke indicated more degree of clinical improvement in upper extremity function.