Repetitive Transcranial Magnetic Stimulation (rTMS) to Promote Hand Recovery in Stroke

The proposed research penetrates the problem of hemiparesis following stroke. This problem
devastates quality of life in thousands of people each year. The brain shows remarkable
ability to reorganize under certain conditions, including after stroke. Unfortunately, some
changes are maladaptive and leave the individual with additional loss of function beyond
that caused directly by the ischemic damage. Specifically, motor neurons in the
ipsilesional (stroke) hemisphere that have survived the stroke can undergo a loss of
excitability due to exaggerated interhemispheric inhibition imposed on them from neurons in
the contralesional (non-stroke) hemisphere through transcallosal pathways. Fortunately, the
maladaptive reorganization is reversible, even in chronic stroke, through forced-use and
forced-learning paradigms with the paretic limb. But we postulate that the effectiveness of
behavioral training can be richly enhanced when combined with electrophysiologic
intervention that also affects neural excitability. Repetitive transcranial magnetic
stimulation (rTMS) is a potent and noninvasive way to influence the excitability of the
brain. rTMS, at low stimulation frequencies, depresses neural function. By stimulating the
contralesional motor cortex at low frequency, thereby depressing interhemispheric
inhibition, a net excitatory effect (disinhibition) is induced upon the ipsilesional motor
cortex. Furthermore, it has been shown in animals and in healthy humans that the depressive
effect on the stimulated hemisphere can be magnified by preceding the low-frequency rTMS
with 6-hz "priming" rTMS. We will call this arrangement 6-Hz primed low-frequency rTMS. We
contend that by combining 6-Hz primed low-frequency rTMS with behavioral motor learning
training unprecedented improvements in recovery from hemiparesis can be achieved. We have
recently demonstrated the safety of a single treatment of 6-Hz primed low-frequency rTMS in
stroke but a large gap in knowledge still exists in not knowing the effect of serial
treatments of 6-Hz primed low-frequency rTMS combined with motor learning training.
Failure to address this gap only perpetuates the use of conservative strategies in stroke
rehabilitation, which may rob individuals of their fullest possible recovery.

Our long-term goal is to maximize motor recovery following stroke. The objective of this
proposal is to integrate the excitability effects induced exogenously by rTMS with those
produced endogenously by motor learning to produce a powerful yet safe interactive effect
leading to improved recovery from hemiparesis. The central hypothesis is that serial
treatments of 6-Hz primed low-frequency rTMS combined with motor learning training will be
effective and safe. Our research team is uniquely qualified to execute this project because
of 1) special training in rTMS undertaken by the PI in the laboratory of an international
leader in rTMS, 2) participation of this leader as a consultant, 3) participation of a
neuroscientist with expertise in stroke neuroplasticity as a consultant, 4) participation of
a recognized expert in cerebrovascular disease as a co-investigator, 5) conducting the study
in the University of Minnesota's General Clinical Research Center to maximize protection of
patients, and 6) inclusion of the Center for Magnetic Resonance Research for studying brain
reorganization.

The specific aims of this project are to:

Specific Aim #1. Determine the efficacy of using serial treatments of 6-Hz primed
low-frequency rTMS, in isolation and in combination with motor learning training, to improve
hand function in stroke.

Forty subjects with stroke (with partial movement in weak hand, able to walk 100 feet, able
to follow directions, no history of seizures, no medical devices or metal incompatible with
mri) will be randomly assigned in equal numbers to one of four treatment groups: The
rTMSonly group will receive 5 treatments of rTMS to the primary motor area (M1) of the
contralesional hemisphere consisting of 10 min. of 6-Hz ("priming") rTMS at 90% of resting
motor threshold interrupted into 20 trains of 5-s duration with 25-s intervals between
trains then followed immediately by 10 additional min. of 1-Hz ("low-frequency") rTMS
continuously at 90% of resting motor threshold. Treatments will be every other day over two
weeks. The Trackonly group will receive 5 treatments of computerized finger tracking
training every other day for two weeks. The rTMScombined group will receive the same rTMS
as the rTMSonly group and it will be alternated with the same tracking training as the
Trackonly group until 5 days of each have occurred over a two-week period. The rTMSsham
group will receive the same rTMS procedures, including similar sound, but no magnetic
stimulation will occur. The four treatments have a 2x2 factorial design, with rTMS and
tracking as the factors, which allows estimation of any synergistic effects of rTMS combined
with tracking. Behavioral gains in the paretic hand will be measured with finger
prehension/dexterity tests, finger tracking accuracy, subject self ratings and examiner
ratings. The working hypotheses are:

1. the rTMScombined group will show greater improvements in paretic hand function than the
rTMSonly and Trackonly groups at posttest and at one-month follow-up, and

2. the rTMSonly and Trackonly groups will show greater improvements than the rTMSsham
group.

Specific Aim #2. Explore the neural mechanism associated with 6-Hz primed low-frequency rTMS
combined with tracking training.

Following the treatments described in Aim #1, M1 excitability will be measured with
paired-pulse TMS testing in the ipsilesional hemisphere. This testing will allow for
examination of both cortical inhibition and excitation. In addition, brain reorganization
associated with voluntary activation will be measured with functional MRI yielding data on
volume and signal intensity of active voxels during paretic finger tracking. The working
hypotheses are:

1. the rTMScombined group will show greater increases in cortical excitability and brain
reorganization in the ipsilesional hemisphere than the rTMSonly and Trackonly groups
at posttest and at one-month follow-up,

2. the rTMSonly and Trackonly groups will show greater increases than the rTMSsham
group.

Specific Aim #3. Determine the safety of serial 6-Hz primed low-frequency rTMS treatments in
stroke.

Associated with the treatments described in Aim #1, adverse effects will be measured through
observation for seizures at the time of treatment. Neurocognitive tests will measure mood,
verbal comprehension, perceptual organization, working memory and processing speed. Also, a
finger tracking test will measure motor control in the nonparetic hand. The working
hypothesis is:

1. five 6-Hz primed low-frequency rTMS treatments, given alone or in combination with motor
learning training, will not produce any seizure activity or any other serious adverse
effect.