Efficacy of coupling repetitive transcranial magnetic stimulation and physical therapy to reduce upper-limb spasticity in patients with stroke: a randomized controlled trial.

ABSTRACT

OBJECTIVE: To assess the efficacy of inhibitory repetitive transcranial magnetic stimulation (rTMS) for decreasing upper-limb muscle tone after chronic stroke. DESIGN: A randomized sham-controlled trial with a 4-week follow-up. SETTING: Research hospital. PARTICIPANTS: Patients with stroke (N=20) with poststroke upper limb spasticity. INTERVENTIONS: The experimental group received rTMS to the primary motor cortex of the unaffected side (1500 pulses; 1Hz; 90% of resting motor threshold for the first dorsal interosseous muscle) in 10 sessions, 3d/wk, and physical therapy (PT). The control group received sham stimulation and PT. MAIN OUTCOME MEASURES: Modified Ashworth scale (MAS), upper-extremity Fugl-Meyer assessment, FIM, range of motion, and stroke-specific quality-of-life scale. All outcomes were measured at baseline, after treatment (postintervention), and at a 4-week follow-up. A clinically important difference was defined as a reduction of ≥1 in the MAS score. RESULTS: Friedman test revealed that PT is efficient for significantly reducing the upper limb spasticity of patients only when it is associated with rTMS. In the experimental group, 90% of the patients at postintervention and 55.5% at follow-up showed a decrease of ≥1 in the MAS score, representing clinically important differences. In the control group, 30% of the patients at postintervention and 22.2% at follow-up experienced clinically meaningful changes. There were no differences between the groups at any time for any of the other outcome measures, indicating that both groups demonstrated similar behaviors over time for all variables. CONCLUSIONS: rTMS associated with PT can be beneficial in reducing poststroke spasticity. However, more studies are needed to clarify the clinical changes underlying the reduction in spasticity induced by noninvasive brain stimulations.