Primed Physical Therapy Enhances Recovery of Upper Limb Function in Chronic Stroke Patients.

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.

A neurophysiological basis for the coordination between hand and foot movement.

Hand and foot movements are made more reliably when both limbs move in the same direction at the same time (isodirectional) compared with when they are made in opposite directions (anisodirectional). We hypothesized that M1 intracortical facilitation may subserve hand-foot coordination and reveal correlates that explain the preference for hand-foot movements to be performed in an isodirectional pattern. To test our hypothesis we investigated behavioral kinematics of hand-foot coordination (experiment 1) and neurophysiological measures of corticomotor excitability and intracortical facilitation (experiment 2) in 17 healthy young adults. As expected, coordination became unstable in the anisodirectional pattern but not the isodirectional pattern, as confirmed in measures of wrist and ankle relative phase error and stability (both P < 0.001). Short-latency paired-pulse TMS was used to elicit motor evoked potentials (MEPs) and produce short-latency intracortical facilitation (sICF) in right extensor carpi radialis (ECR) and flexor carpi radialis (FCR) in the presence and absence of right ankle plantarflexion/dorsiflexion (P < 0.015). An isodirectional preference was confirmed by facilitation of FCR MEPs and TMS-induced wrist flexion during ankle plantarflexion (both P < 0.025) but no evidence of modulation of any particular "I wave" during foot movement compared with rest. A novel finding was the association between loss of stability of the anisodirectional pattern (experiment 1) and the modulation of corticomotor excitability in support of the isodirectional pattern (experiment 2) (P < 0.05). The preference for isodirectional hand-foot movements appears not to depend on M1 intracortical facilitation.