The effects of combined repetitive transcranial magnetic stimulation and transcranial direct current stimulation on motor function in patients with stroke.

BACKGROUND: Both transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), when provided to stroke patients in combination with motor training, enhance therapeutic efficacy and motor function. However, the majority of previous studies have only examined a single treatment modality. OBJECTIVE: The authors investigated the modulating influence of combination dual-mode brain stimulation upon bihemispheric stimulation with motor training in stroke patients. METHODS: Twenty stroke patients with hemiparesis underwent five randomly arranged sessions of diverse combinations of rTMS and tDCS. We applied cathodal or anodal tDCS over the contralesional primary motor cortex (cM1) and 10 Hz rTMS over the ipsilesional primary motor cortex (iM1) in a simultaneous or preconditioning method including sham stimulation. Immediately after dual-mode stimulation, sequential hand motor training was performed for 5 minutes. The total pulses of rTMS and the duration of tDCS and motor training were the same for all sessions. Cortical excitability and sequential motor performance were evaluated before and after each session. RESULTS: Motor function and corticomotor excitability following simultaneous stimulation via cathodal tDCS over the cM1 combined with 10 Hz rTMS over the iM1 were significantly increased after the intervention, with significantly greater motor improvement than seen with other treatment conditions (P < 0.05). CONCLUSION: For the combination of bihemispheric rTMS and tDCS, simultaneous stimulation of cathodal tDCS and 10 Hz rTMS results in better motor performance in stroke patients than other combination methods. This result seemed to be related to effective modulation of interhemispheric imbalance of cortical excitability by dual-mode stimulation.

Interhemispheric modulation of dual-mode, noninvasive brain stimulation on motor function.

OBJECTIVE: To investigate the effects of simultaneous, bihemispheric, dual-mode stimulation using repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) on motor functions and cortical excitability in healthy individuals. METHODS: Twenty-five healthy, right-handed volunteers (10 men, 15 women; mean age, 25.5 years) were enrolled. All participants received four randomly arranged, dual-mode, simultaneous stimulations under the following conditions: condition 1, high-frequency rTMS over the right primary motor cortex (M1) and sham tDCS over the left M1; condition 2, high-frequency rTMS over the right M1 and anodal tDCS over the left M1; condition 3, high-frequency rTMS over the right M1 and cathodal tDCS over the left M1; and condition 4, sham rTMS and sham tDCS. The cortical excitability of the right M1 and motor functions of the left hand were assessed before and after each simulation. RESULTS: Motor evoked potential (MEP) amplitudes after stimulation were significantly higher than before stimulation, under the conditions 1 and 2. The MEP amplitude in condition 2 was higher than both conditions 3 and 4, while the MEP amplitude in condition 1 was higher than condition 4. The results of the Purdue Pegboard test and the box and block test showed significant improvement in conditions 1 and 2 after stimulation. CONCLUSION: Simultaneous stimulation by anodal tDCS over the left M1 with high-frequency rTMS over the right M1 could produce interhemispheric modulation and homeostatic plasticity, which resulted in modulation of cortical excitability and motor functions.

Effects of dual-mode non-invasive brain stimulation on motor function.

The purpose of this study was to investigate the effects of dual-mode non-invasive brain stimulation (NBS) on motor function and cortical excitability using both repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) over the bilateral primary motor cortices (M1s) of healthy individuals. Fifteen healthy right-handed volunteers (8 women; mean age 23.2 years) participated in this sham-controlled random-ordered crossover study. All of the participants received four randomly arranged dual-mode stimulations with a 24-h washout period: condition 1, preconditioning with cathodal tDCS over the left M1 followed by 10 Hz rTMS over the right M1; condition 2, preconditioning Lt. anodal tDCS followed by Rt. 10 Hz rTMS; condition 3, Lt. sham tDCS followed by Rt. 10 Hz rTMS; and condition 4, Lt. sham tDCS followed by Rt. sham rTMS. Corticomotor excitability and motor function were assessed in the left hand before and after stimulation. The motor evoked potential (MEP) amplitudes significantly increased after dual-mode stimulation in conditions 1 and 3, and significantly decreased in condition 2. The MEP latency became significantly shorter in condition 1. The motor function tests revealed a significant improvement in the Purdue pegboard test in condition 1, and in the box and block tests in conditions 1 and 3. The preconditioning tDCS over the contralateral M1 modulated the effects of subsequent rTMS on cortical excitability and motor function.

Effective method of combining rTMS and motor training in stroke patients.

PURPOSE: Enhanced therapeutic effects of repetitive transcranial magnetic stimulation (rTMS) on the motor function of stroke patients when provided in combination with motor training have been reported. The objective of this study was to determine the most effective method for combining rTMS and motor training in stroke patients. METHODS: Fourteen stroke patients were enrolled. All patients participated in two randomly arranged intervention sessions, each of which incorporated a differently combined rTMS and motor training method. With an interleaved combination method (ICM), an rTMS train and a short period of motor training were interleaved and repeated. With a preconditioning combination method (PCM), rTMS trains were applied as preconditioning, followed by repeated blocks of motor training. The total rTMS pulses and total duration of motor training were the same in both sessions. RESULTS: Performance of a sequential finger motor task improved significantly after both the ICM and PCM interventions: movement accuracy increased and movement time decreased. The PCM-associated improvements were significantly greater than the ICM-associated improvements. Performance in the Purdue Pegboard Test and Nine-Hole Peg Test also improved significantly after both interventions but without a significant difference between the two interventions. Cortical excitability improved after both the ICM and PCM interventions but without a significant difference between the two. CONCLUSIONS: In combining rTMS and motor training, preconditioning with rTMS followed by motor training is more effective than interleaving the rTMS and motor training to facilitate the motor performance of stroke patients.

Relationship between gross motor function and daily functional skill in children with cerebral palsy.

OBJECTIVE: To investigate the relationship between gross motor function and daily functional skill in children with cerebral palsy (CP) and to explore how this relationship is moderated by the Gross Motor Function Classification System, Bimanual Fine Motor Function (BFMF), neuromotor types, and limb distribution of CP. METHODS: A cross-sectional survey of 112 children with CP (range, 4 years to 7 years and 7 months) was performed. Gross motor function was assessed with the Gross Motor Function Measure-66 (GMFM-66) and functional skill was assessed with the Pediatric Evaluation of Disability Inventory-Functional Skills Scale (PEDI-FSS). RESULTS: GMFM-66 scores explained 49.7%, 67.4%, and 26.1% of variance in the PEDI-FSS scores in the self-care, mobility, and social function domains, respectively. Significant moderation by the distribution of palsy and BFMF classification levels II, III, and IV was found in the relationship between GMFM-66 and PEDI-FSS self-care. Further significant moderation by the distribution of palsy was also observable in the relationship between GMFM-66 and PEDI-FSS mobility. CONCLUSION: These findings suggest that limb distribution and hand function must be considered when evaluating gross motor function and functional skills in children with CP, especially in unilateral CP.

Clinical, Electrophysiological Findings in Adult Patients with Non-traumatic Plexopathies.

OBJECTIVE: To ascertain the etiology of non-traumatic plexopathy and clarify the clinical, electrophysiological characteristics according to its etiology. METHOD: We performed a retrospective analysis of 63 non-traumatic plexopathy patients that had been diagnosed by nerve conduction studies (NCS) and needle electromyography (EMG). Clinical, electrophysiological, imaging findings were obtained from medical records. RESULTS: We identified 36 cases with brachial plexopathy (BP) and 27 cases with lumbosacral plexopathy (LSP). The causes of plexopathy were neoplastic (36.1%), thoracic outlet syndrome (TOS) (25.0%), radiation induced (16.7%), neuralgic amyotrophy (8.3%), perioperative (5.6%), unknown (8.3%) in BP, while neoplastic (59.3%), radiation induced (22.2%), neuralgic amyotrophy (7.4%), psoas muscle abscess (3.7%), and unknown (7.4%) in LSP. In neoplastic plexopathy, pain presented as the first symptom in most patients (82.8%), with the lower trunk of the brachial plexus predominantly involved. In radiation induced plexopathy (RIP), pain was a common initial symptom, but the proportion was smaller (50%), and predominant involvements of bilateral lumbosacral plexus and whole trunk of brachial or lumbosacral plexus were characteristic. Myokymic discharges were noted in 41.7% patients with RIP. Abnormal NCS finding in the medial antebrachial cutaneous nerve was the most sensitive to diagnose TOS. Neuralgic amyotrophy of the brachial plexus showed upper trunk involvement in all cases. CONCLUSION: By integrating anatomic, pathophysiologic knowledge with detailed clinical assessment and the results of ancillary studies, physicians can make an accurate diagnosis and prognosis.