A sham stimulation-controlled trial of rTMS of the unaffected hemisphere in stroke patients Low-frequency rTMS promotes use-dependent motor plasticity in chronic stroke Theta-burst stimulation of the left hemisphere accelerates recovery of hemispatial neglect Transcranial Magnetic Stimulation Combined with Speech and Language Training in Early Aphasia Rehabilitation: A Randomized Double-Blind Controlled Pilot Study Theory for the development of neuron selectivity: orientation specificity and binocular interaction in visual cortex Effects of Noninvasive Brain Stimulation on Language Networks and Recovery in Early Poststroke Aphasia Theta burst stimulation reduces disability during the activities of daily living in spatial neglect. A Comparison of Primed Low-frequency Repetitive Transcranial Magnetic Stimulation Treatments in Chronic Stroke Rehabilitation Interventions for Unilateral Neglect after Stroke: A Systematic Review from 1997 through 2012 Transcranial magnetic stimulation in mild to severe hemiparesis early after stroke: a proof of principle and novel approach to improve motor function Facilitation of muscle evoked responses after repetitive cortical stimulation in man Effects of Repetitive Transcranial Magnetic Stimulation in Aphasic Stroke: A Randomized Controlled Pilot Study Efficacy of Coupling Inhibitory and Facilitatory Repetitive Transcranial Magnetic Stimulation to Enhance Motor Recovery in Hemiplegic Stroke Patients Effect of Repetitive Transcranial Magnetic Stimulation on Patients with Brain Injury and Dysphagia A Sham-Controlled Trial of a 5-Day Course of Repetitive Transcranial Magnetic Stimulation of the Unaffected Hemisphere in Stroke Patients A multi-center study on low-frequency rTMS combined with intensive occupational therapy for upper limb hemiparesis in post-stroke patients Repetitive Transcranial Magnetic Stimulation of Contralesional Primary Motor Cortex Improves Hand Function After Stroke Combination Protocol of Low-Frequency rTMS and Intensive Occupational Therapy for Post-stroke Upper Limb Hemiparesis: a 6-year Experience of More Than 1700 Japanese Patients Repetitive transcranial magnetic stimulation to hemispatial neglect in patients after stroke: an open-label pilot study. Theta Burst Stimulation of the Human Motor Cortex Effects of repetitive trascranial magnetic stimulation on repetitive facilitation exercises of the hemiplegic hand in chronic stroke patients. Does Inhibitory Repetitive Transcranial Magnetic Stimulation Augment Functional Task Practice to Improve Arm Recovery in Chronic Stroke? Effect of Low-Frequency Repetitive Transcranial Magnetic Stimulation on Naming Abilities in Early-Stroke Aphasic Patients: A Prospective, Randomized, Double-Blind Sham-Controlled Study Low-frequency rTMS in patients with subacute ischemic stroke: clinical evaluation of short and long-term outcomes and neurophysiological assessment of cortical excitability Increase in Short-Interval Intracortical Facilitation of the Motor Cortex after Low-Frequency Repetitive Magnetic Stimulation of the Unaffected Hemisphere in the Subacute Phase after Stroke Repetitive transcranial magnetic stimulation at 1Hz and 5Hz produces sustained improvement in motor function and disability after ischaemic stroke. Recovery of motor disability and spasticity in post-stroke after repetitive transcranial magnetic stimulation (rTMS) Noninvasive Brain Stimulation for Treatment of Right- and Left-Handed Poststroke Aphasics Theta Burst Stimulation in the Rehabilitation of the Upper Limb Role of 1 and 3 Hz repetitive transcranial magnetic stimulation on motor function recovery after acute ischaemic stroke. Post-stroke reorganization of hand motor area: a 1-year prospective follow-up with focal transcranial magnetic stimulation Acute Remapping within the Motor System Induced by Low-Frequency Repetitive Transcranial Magnetic Stimulation Bilateral high- and low-frequency rTMS in acute stroke patients with hemiparesis: A comparative study with unilateral high-frequency rTMS Efficacy of coupling repetitive transcranial magnetic stimulation and physical therapy to reduce upper-limb spasticity in patients with stroke: a randomized controlled trial. Inhibitory repetitive transcranial magnetic stimulation of the contralesional premotor and primary motor cortices facilitate poststroke motor recovery. Modulation of N400 in chronic non-fluent aphasia using low frequency Repetitive Transcranial Magnetic Stimulation (rTMS) Modulating cortical excitability in acute stroke: A repetitive TMS study Inhibition of the unaffected motor cortex by 1 Hz repetitive transcranical magnetic stimulation enhances motor performance and training effect of the paretic hand in patients with chronic stroke. Effects of repetitive transcranial magnetic stimulation of the unaffected hemisphere leg motor area in patients with subacute stroke and substantial leg impairment: A pilot study. Inhibition of the contralesional dorsal premotor cortex improves motor function of the affected hand following stroke. Non-Invasive Brain Stimulation in Neglect Rehabilitation: An Update Comparison of the effects of high- and low-frequency repetitive transcranial magnetic stimulation on upper limb hemiparesis in the early phase of stroke. Vicarious function within the human primary motor cortex? A longitudinal fMRI stroke study. Dual-Hemisphere Repetitive Transcranial Magnetic Stimulation for Rehabilitation of Poststroke Aphasia Repetitive transcranial magnetic stimulation over bilateral hemispheres enhances motor function and training effect of paretic hand in patients after stroke. Transcallosal inhibition in chronic subcortical stroke Improvement of dexterity by single session low-frequency repetitive transcranial magnetic stimulation over the contralesional motor cortex in acute stroke: a double-blind placebo-controlled crossover trial. Utilizing repetitive transcranial magnetic stimulation to improve language function in stroke patients with chronic non-fluent aphasia. Repetitive transcranial magnetic stimulation for rehabilitation of poststroke dysphagia: A randomized, double-blind clinical trial rTMS Combined With Task-Oriented Training to Improve Symmetry of Interhemispheric Corticomotor Excitability and Gait Performance After Stroke Contralesional repetitive transcranial magnetic stimulation for chronic hemiparesis in subcortical paediatric stroke: a randomised trial The Persistent and Broadly Modulating Effect of Inhibitory rTMS in Nonfluent Aphasic Patients Effects of repetitive transcranial magnetic stimulation on motor recovery and motor cortex excitability in patients with stroke: a randomized controlled trial. Randomized, Multicenter, Comparative Study of NEURO versus CIMT in Poststroke Patients with Upper Limb Hemiparesis: The NEURO-VERIFY Study Add-on Effects of Repetitive Transcranial Magnetic Stimulation on Subacute Aphasia Therapy: Enhanced Improvement of Functional Communication and Basic Linguistic Skills. A Randomized Controlled Study. The Effectiveness of 1Hz rTMS Over the Primary Motor Area of the Unaffected Hemisphere to Improve Hand Function After Stroke Depends on Hemispheric Dominance Long-term effects of continuous theta-burst stimulation in visuospatial neglect Effects of repetitive transcranial magnetic stimulation on lower extremity spasticity and motor function in stroke patients
The authors investigated the use of slow-frequency repetitive transcranial magnetic stimulation ( rTMS ) to the unaffected hemisphere to decrease interhemispheric inhibition of the lesioned hemisphere and improve motor function in patients within 12 months of a stroke . Patients showed a significant decrease in simple and choice reaction time and improved performance of the Purdue Pegboard test with their affected h and after rTMS of the motor cortex in the intact hemisphere as compared with sham rTMS Objective : To investigate the long-term behavioral and neurophysiologic effects of combined time-locked repetitive transcranial magnetic stimulation ( rTMS ) and physical therapy ( PT ) intervention in chronic stroke patients with mild motor disabilities . Methods : Thirty patients were enrolled in a double-blind , r and omized , single-center clinical trial . Patients received 10 daily sessions of 1 Hz rTMS over the intact motor cortex . In different groups , stimulation was either real ( rTMSR ) or sham ( rTMSS ) and was administered either immediately before or after PT . Outcome measures included dexterity , force , interhemispheric inhibition , and corticospinal excitability and were assessed for 3 months after the end of treatment . Results : Treatment induced cumulative rebalance of excitability in the 2 hemispheres and a reduction of interhemispheric inhibition in the rTMSR groups . Use-dependent improvements were detected in all groups . Improvements in trained abilities were small and transitory in rTMSS patients . Greater behavioral and neurophysiologic outcomes were found after rTMSR , with the group receiving rTMSR before PT ( rTMSR-PT ) showing robust and stable improvements and the other group ( PT-rTMSR ) showing a slight improvement decline over time . Conclusion : Our findings indicate that priming PT with inhibitory rTMS is optimal to boost use-dependent plasticity and rebalance motor excitability and suggest that time-locked rTMS is a valid and promising approach for chronic stroke patients with mild motor impairment . Classification of evidence : This interventional study provides Class I evidence that time-locked rTMS before or after physical therapy improves measures of dexterity and force in the affected limb in patients with chronic deficits more than 6 months poststroke . Neurology ® Objective : Cortico-cortical circuits originating from the posterior parietal cortex ( PPC ) of the intact left hemisphere ( LH ) may become hyperexcitable in patients with hemispatial neglect due to a right hemispheric ( RH ) stroke . Methods : In the current r and omized , double-blind , sham-controlled study , we investigated safety and efficacy of continuous theta-burst stimulation ( cTBS ) in 10 sessions over 2 weeks applied over the intact PPC of the LH in subacute ischemic stroke patients .  Severity of neglect was assessed through the st and ardized Behavioral Inattention Test ( BIT ) . We also measured , by means of bifocal transcranial magnetic stimulation ( TMS ) , how cTBS modified the excitability of the parieto-frontal functional connections in the intact LH . Results : We found that 2 weeks of cTBS , but not sham cTBS , were effective in improving neglect symptoms as measured by BIT score . BIT scores improved by 16.3 % after 2 weeks of cTBS and 22.6 % at 1 month follow-up . We also found that hyperexcitability of LH parieto-frontal circuits was reduced following treatment with real but not sham cTBS . Conclusion : These findings suggest that a 2-week course of cTBS over the LH PPC may be a potential effective strategy in accelerating recovery from visuospatial neglect in subacute stroke patients , possibly counteracting the hyperexcitability of LH parieto-frontal circuits . Classification of evidence : This study provides Class III evidence that left posterior parietal cortex theta-burst stimulation improves hemispatial neglect for up to 2 weeks after treatment Abstract Background : Functional neuroimaging studies with poststroke aphasia patients have shown increased activation of the unaffected hemisphere , which hypothetically reflects a maladaptive strategy of brain reorganization . Objective : We investigated whether repetitive transcranial magnetic stimulation ( rTMS ) inhibiting the right-hemisphere homologue of Broca ’s area improves language restitution if combined with speech/ language therapy . Methods : Forty aphasic patients during the subacute phase of ischemic stroke were r and omized to a 3-week aphasia rehabilitation protocol in combination with real or sham rTMS .  Naming , repetition , and comprehension were assessed using the Boston Diagnostic Aphasia Examination at baseline , immediately after therapy , and 15 weeks after completing treatment . Results : Although language functions improved in both experimental and control groups after 3 weeks , only slight group differences in degree of recovery were revealed between patients receiving rTMS and control participants . Follow-up revealed that severely aphasic rTMS patients demonstrated significantly greater improvement than patients receiving sham stimulation in repetition . Conclusions : Inhibitory rTMS applied to the right frontal language homologue is not effective for all poststroke aphasia patients , although it might benefit selected patients The development of  stimulus selectivity in the primary sensory cortex of higher vertebrates is considered in a general mathematical framework . A synaptic evolution scheme of a new kind is proposed in which incoming patterns rather than converging afferents compete . The change in the efficacy of a given synapse depends not only on instantaneous pre- and postsynaptic activities but also on a slowly varying time-averaged value of the postsynaptic activity . Assuming an appropriate nonlinear form for this dependence , development of selectivity is obtained under quite general conditions on the sensory environment . One does not require nonlinearity of the neuron 's integrative power nor does one need to assume any particular form for intracortical circuitry . This is first illustrated in simple cases , e.g. , when the environment consists of only two different stimuli presented alternately in a r and om manner . The following formal statement then holds : the state of the system converges with probability 1 to points of maximum selectivity in the state space . We next consider the problem of early development of  orientation selectivity and binocular interaction in primary visual cortex . Giving the environment an appropriate form , we obtain orientation tuning curves and ocular dominance comparable to what is observed in normally reared adult cats or monkeys . Simulations with binocular input and various types of normal or altered environments show good agreement with the relevant experimental data . Experiments are suggested that could test our theory further Background and Purpose — Modulation of activity in language networks using repetitive transcranial magnetic stimulation ( rTMS ) may possibly support recovery from poststroke aphasia . Case series and feasibility studies seem to indicate a therapeutic effect ; however , r and omized sham-controlled , proof-of-principle studies relating clinical effects to activation patterns are missing . Methods — Twenty-four patients with subacute poststroke aphasia were r and omized to a 10-day protocol of 20-minute inhibitory 1 Hz rTMS over the right triangular part of the posterior inferior frontal gyrus or sham stimulation , followed by 45 minutes of speech and language therapy .  Activity in language networks was measured with O-15-water  positron emission  tomography during verb generation before and after treatment . Language performance was assessed using the Aachen Aphasia Test battery . Results — The primary outcome measure , global Aachen Aphasia Test score change , was significantly higher in the rTMS group ( t test , P=0.003 ) . Increases were largest for subtest naming ( P=0.002 ) and tended to be higher for comprehension , token test , and writing ( P<0.1 ) . Patients in the rTMS group activated proportionally more voxels in the left hemisphere after treatment than before ( difference in activation volume index ) compared with sham-treated patients ( t test , P=0.002).There was a moderate but significant linear relationship between activation volume index change and global Aachen Aphasia Test score change ( r2=0.25 ; P=0.015 ) . Conclusions — Ten sessions of inhibitory rTMS over the right posterior inferior frontal gyrus , in combination with speech and language therapy , significantly improve language recovery in subacute ischemic stroke and favor recruitment of left-hemispheric language networks Left-sided spatial neglect is a common neurological syndrome following right-hemispheric stroke . The presence of spatial neglect is a powerful predictor of poor rehabilitation outcome . In one influential account of spatial neglect , interhemispheric inhibition is impaired and leads to a pathological hyperactivity in the contralesional hemisphere , result ing in a biased attentional allocation towards the right hemifield . Inhibitory transcranial magnetic stimulation can reduce the hyperactivity of the contralesional , intact hemisphere and thereby improve spatial neglect symptoms . However , it is not known whether this improvement is also relevant to the activities of daily living during spontaneous behaviour . The primary aim of the present study was to investigate whether the repeated application of continuous theta burst stimulation trains could ameliorate spatial neglect on a quantitative measure of the activities of daily living during spontaneous behaviour . We applied the Catherine Bergego Scale , a st and ardized observation question naire that can validly and reliably detect the presence and severity of spatial neglect during the activities of daily living . Eight trains of continuous theta burst stimulation were applied over two consecutive days on the contralesional , left posterior parietal cortex in patients suffering from subacute left spatial neglect , in a r and omized , double-blind , sham-controlled design , which also included a control group of neglect patients without stimulation . The results showed a 37 % improvement in the spontaneous everyday behaviour of the neglect patients after the repeated application of continuous theta burst stimulation . Remarkably , the improvement persisted for at least 3 weeks after stimulation . The amelioration of spatial neglect symptoms in the activities of daily living was also generally accompanied by significantly better performance in the neuropsychological tests . No significant amelioration in symptoms was observed after sham stimulation or in the control group without stimulation . These results provide Class I evidence that continuous theta burst stimulation is a viable add-on therapy in neglect rehabilitation that facilitates recovery of normal everyday behaviour BACKGROUND Preceding low-frequency repetitive transcranial magnetic stimulation ( rTMS ) with a bout of high-frequency rTMS called priming potentiates the after-effects of the former in healthy adults . The utility of primed rTMS in stroke remains under-explored despite its theoretical benefits in enhancing cortical excitability and motor function . OBJECTIVE To ascertain the efficacy of priming in chronic stroke by comparing changes in cortical excitability and paretic h and function following three types of primed low-frequency rTMS treatments . METHODS Eleven individuals with chronic stroke participated in this repeated- measures study receiving three treatments to the contralesional primary motor cortex in r and omized order : 6 Hz primed 1 Hz rTMS , 1 Hz primed 1 Hz rTMS , and sham 6 Hz primed active 1 Hz rTMS . Within- and between-treatment differences from baseline in cortical excitability and paretic h and function from baseline were analyzed using mixed effects linear models . RESULTS 6 Hz primed 1 Hz rTMS produced significant within-treatment differences from baseline in ipsilesional cortical silent period ( CSP ) duration and short-interval intracortical inhibition . Compared to 1 Hz priming and sham 6 Hz priming of 1 Hz rTMS , active 6 Hz priming generated significantly greater decreases in ipsilesional CSP duration . These heightened effects were not observed for intracortical facilitation or interhemispheric inhibition excitability measures . CONCLUSION Our findings demonstrate the efficacy of 6 Hz primed 1 Hz rTMS in probing homeostatic plasticity mechanisms in the stroke brain as best demonstrated by differences CSP duration and SICI from baseline . Though 6 Hz priming did not universally enhance cortical excitability across measures , our findings pose important implication s in non-invasive brain stimulation application in stroke rehabilitation A systematic review of the effectiveness of rehabilitation for persons with unilateral neglect ( UN ) after stroke was conducted by search ing the computerized data bases from 1997 through 2012 . R and omized controlled trials ( RCTs ) of neglect treatment strategies for stroke patients which used the Behavioral Inattention Test ( BIT ) as the primary outcome measure were eligible for inclusion . Out of 201 studies initially identified , 12 RCTs covering 277 participants were selected for analysis . All had the same weakness of low power with smaller sample s and limitation in the blinding of the design .  Prism Adaptation ( PA )  was the most commonly used intervention while continuous Theta-burst stimulation ( cTBS ) appeared to be a new approach . Meta- analysis showed that for immediate effects , the BIT conventional subscore had a significant and large mean effect size ( ES = 0.76 ; 95 % CI 0.28–1.23 ; p = 0.002 ) whereas the BIT total score showed a modestly significant mean ES ( ES = 0.55 ; 95 % CI 0.16–0.94 ; p = 0.006 ) . No significant mean ES in sensitivity analysis was found for long-lasting effects across all BIT outcomes . PA appeared to be the most effective intervention based on the results of pooled analysis . More rigorous studies should be done on repetitive transcranial magnetic stimulation ( rTMS ) before it can be concluded that it is a promising treatment for UN Low-frequency repetitive transcranial magnetic stimulation ( rTMS ) of the unaffected hemisphere can enhance function of the paretic h and in patients with mild motor impairment . Effects of low-frequency rTMS to the contralesional motor cortex at an early stage of mild to severe hemiparesis after stroke are unknown . In this pilot , r and omized , double-blind clinical trial we compared the effects of low-frequency rTMS or sham rTMS as add-on therapies to outpatient customary rehabilitation , in 30 patients within 5–45 days after ischemic stroke , and mild to severe h and paresis . The primary feasibility outcome was compliance with the interventions . The primary safety outcome was the proportion of intervention-related adverse events . Performance of the paretic h and in the Jebsen – Taylor test and pinch strength were secondary outcomes . Outcomes were assessed at baseline , after ten sessions of treatment administered over 2 weeks and at 1 month after end of treatment . Baseline clinical features were comparable across groups . For the primary feasibility outcome , compliance with treatment was 100 % in the active group and 94 % in the sham group . There were no serious intervention-related adverse events . There were significant improvements in performance in the Jebsen – Taylor test ( mean , 12.3 % 1 month after treatment ) and pinch force ( mean , 0.5 Newtons ) in the active group , but not in the sham group . Low-frequency rTMS to the contralesional motor cortex early after stroke is feasible , safe and potentially effective to improve function of the paretic h and , in patients with mild to severe hemiparesis . These promising results will be valuable to design larger r and omized clinical trials Abstract The technique of repetitive transcranial magnetic stimulation ( rTMS ) allows cortical motor areas to be activated by trains of magnetic stimuli at different frequencies and intensities . In this paper , we studied long-term neurophysiological effects of rTMS delivered to the motor cortex at 5 Hz with an intensity of 120 % of motor threshold . Each stimulus of the train produced muscle-evoked potentials ( MEPs ) in h and and forearm muscles , which gradually increased in size from the first to the last shock . After the end of the train , the response to a single-test stimulus remained enhanced for 600–900 ms . In contrast , the train had no effect on the size of the MEPs evoked by transcranial electrical stimulation , while it suppressed H-reflexes in forearm muscles for 900 ms . We conclude that rTMS of these parameters increases the excitability of the motor cortex and that this effect outlasts the train for almost 1 s. At the spinal level , rTMS may increase presynaptic inhibition of Ia afferent fibers responsible for the H-reflex Background and Purpose — Although functional imaging studies suggest that recruitment of contralesional areas hinders optimal functional reorganization in patients with aphasic stroke , only limited evidence is available on the efficacy of noninvasive brain stimulation such as repetitive transcranial magnetic stimulation aim ed at suppression of contralateral overactivation . Methods — In this r and omized , controlled , blinded pilot study , the effect of 1-Hz repetitive transcranial magnetic stimulation over right-hemispheric Broca homolog in subjects with poststroke aphasia in the subacute stage was examined . According to their group allocation , patients received , in addition to conventional speech and language therapy , multiple sessions of repetitive transcranial magnetic stimulation either over the right-hemispheric inferior frontal gyrus ( intervention group ) or over the vertex ( control group ) . The primary outcome parameter was the change in laterality indices as quantified by activation positron emission tomography before and after the 2-week intervention period . The clinical efficacy was evaluated with the Aachen Aphasia Test . Results — At baseline , no group differences were discovered for age , laterality indices , or mean Aachen Aphasia Test scores . Four patients were lost to follow-up , but none due to side effects of the transcranial magnetic stimulation . Positron emission tomography revealed an activation shift toward the right hemisphere in the control group ( P=0.0165 ) , which was absent in the intervention group . Furthermore , the latter improved significantly clinical ly by a mean of 19.8 points in the Aachen Aphasia Test total score ( P=0.002 ) , whereas the control group did not . There was however no clear linear relationship between the extent of laterality shift and clinical improvement ( r=0.193 , P = nonsignificant ) . Conclusions — Repetitive transcranial magnetic stimulation might be an effective , safe , and feasible complementary therapy for poststroke aphasia Background and Purpose — Although there has been extensive research on the effectiveness of repetitive transcranial magnetic stimulation ( rTMS ) to improve patients ’ motor performance after experiencing chronic stroke , explicit findings on the coupling of different rTMS protocol s are meager . We design ed this sham-controlled r and omized study to investigate the potential for a consecutive suppressive-facilitatory TMS protocol to improve motor outcomes after chronic stroke . Methods — Fifty-four chronic hemiplegic stroke patients were allocated across 4 groups to undergo 20 daily sessions of ( 1 ) 1 Hz rTMS over the contralesional primary motor cortex ( M1 ) and then intermittent theta burst stimulation over the ipsilesional M1 ( group A ) ; ( 2 ) contralesional sham stimulation and then ipsilesional real intermittent theta burst stimulation ( group B ) ; ( 3 ) contralesional real 1 Hz rTMS and then ipsilesional sham stimulation ( group C ) ; or ( 4 ) bilateral sham-control procedures ( group D ) . We tested cortical excitability and motor activity assessment s at the baseline , postpriming rTMS , and postconsequent rTMS periods . Results — At post , group A showed greater muscle strength , Fugl-Meyer Assessment ( FMA ) , Wolf Motor Function test , and reaction time improvement in comparison with group B ( P<0.001≈0.003 ) and group C ( P=0.001≈0.003 ) . Correlation analyses in group A revealed a close relation between contralesional map area decrement and Wolf Motor Function test gain ( P=0.005 ; r=−0.75 ) , and also revealed ipsilesional map area increment and reaction time decrement ( P=0.02 ; r=−0.87 ) . We detected no such relations in the other 3 groups . Conclusions — Our clinical trials established an extended timeframe during which conditioning could be safely continued and produced more favorable outcomes in facilitating motor performance and ameliorating interhemispheric imbalance than those obtained from single-course rTMS modulation alone Objective To investigate the effect of repetitive transcranial magnetic stimulation ( rTMS ) on recovery of the swallowing function in patients with a brain injury . Method Patients with a brain injury and dysphagia were enrolled . Patients were r and omly assigned to sham , and low and high frequency stimulation groups . We performed rTMS at 100 % of motor evoked potential ( MEP ) threshold and a 5 Hz frequency for 10 seconds and then repeated this every minute in the high frequency group . In the low frequency group , magnetic stimulation was conducted at 100 % of MEP threshold and a 1 Hz frequency . The sham group was treated using the same parameters as the high frequency group , but the coil was rotated 90 ° to create a stimulus noise . The treatment period was 2 weeks ( 5 days per week , 20 minutes per session ) . We evaluated the Functional Dysphagia Scale ( FDS ) and the Penetration Aspiration Scale ( PAS ) with a videofluoroscopic swallowing study before and after rTMS . Results Thirty patients were enrolled , and mean patient age was 68.2 years . FDS and PAS scores improved significantly in the low frequency group after rTMS , and American Speech- Language Hearing Association National Outcomes Measurements System Swallowing Scale scores improved in the sham and low frequency groups . FDS and PAS scores improved significantly in the low frequency group compared to those in the other groups . Conclusion We demonstrated that low frequency rTMS facilitated the recovery of swallowing function in patients with a brain injury , suggesting that rTMS is a useful modality to recover swallowing function Background and Purpose — It has been recently shown that a single session of repetitive transcranial magnetic stimulation ( rTMS ) of the unaffected hemisphere can improve motor function in stroke patients ; however , this improvement is short-lasting . We therefore conducted a r and omized , sham-controlled , phase II trial to evaluate whether five sessions of low-frequency rTMS can increase the magnitude and duration of these effects and whether this approach is safe . Methods — Fifteen patients with chronic stroke were r and omized to receive active or sham rTMS of the unaffected hemisphere . A blinded rater assessed motor function and corticospinal excitability at baseline , during and after 2 weeks of treatment . Safety was assessed using a neuropsychologic battery and electroencephalogram . Results — Active rTMS result ed in a significant improvement of the motor function performance in the affected h and that lasted for 2 weeks . These effects were not observed in the sham rTMS group ( affected and unaffected h and ) and in the unaffected h and in the active rTMS group . Corticospinal excitability decreased in the stimulated , unaffected hemisphere and increased in the affected hemisphere . There was a significant correlation between motor function improvement and corticospinal excitability change in the affected hemisphere . Cognitive performance and electroencephalogram were not changed significantly throughout the trial in both groups of treatment . Conclusions — These results support and extend the findings of previous studies on rTMS in stroke patients because five consecutive sessions of rTMS increased the magnitude and duration of the motor effects . Furthermore , this increased dose of rTMS is not associated with cognitive adverse effects and /or epileptogenic activity Background Both low-frequency repetitive transcranial magnetic stimulation ( rTMS ) and intensive occupational therapy ( OT ) have been recently reported to be clinical ly beneficial for post-stroke patients with upper limb hemiparesis . Based on these reports , we developed an inpatient combination protocol of these two modalities for the treatment of such patients . The aims of this pilot study were to confirm the safety and feasibility of the protocol in a large number of patients from different institutions , and identify predictors of the clinical response to the treatment . Methods The study subjects were 204 post-stroke patients with upper limb hemiparesis ( mean age at admission 58.5 ± 13.4 years , mean time after stroke 5.0 ± 4.5 years , ± SD ) from five institutions in Japan . During 15-day hospitalization , each patient received 22 treatment sessions of 20-min low-frequency rTMS and 120-min intensive OT daily . Low-frequency rTMS of 1 Hz was applied to the contralesional hemisphere over the primary motor area . The intensive OT , consisting of 60-min one-to-one training and 60-min self-exercise , was provided after the application of low-frequency rTMS . Fugl-Meyer Assessment ( FMA ) and Wolf Motor Function Test ( WMFT ) were performed serially . The physiatrists and occupational therapists involved in this study received training prior to the study to st and ardize the therapeutic protocol . Results All patients completed the protocol without any adverse effects . The FMA score increased and WMFT log performance time decreased significantly at discharge , relative to the respective values at admission ( change in FMA score : median at admission , 47 points ; median at discharge , 51 points ; p < 0.001 . change in WMFT log performance time : median at admission , 3.23 ; median at discharge , 2.51 ; p < 0.001 ) . These changes were persistently seen up to 4 weeks after discharge in 79 patients . Linear regression analysis found no significant relationship between baseline parameters and indexes of improvement in motor function . Conclusions The 15-day inpatient rTMS plus OT protocol is a safe , feasible , and clinical ly useful neurorehabilitative intervention for post-stroke patients with upper limb hemiparesis . The response to the treatment was not influenced by age or time after stroke onset . The efficacy of the intervention should be confirmed in a r and omized controlled study including a control group Background and Purpose — A recent report has demonstrated that the contralesional primary motor cortex ( M1 ) inhibited the ipsilesional M1 via an abnormal transcallosal inhibition ( TCI ) in stroke patients . We studied whether a decreased excitability of the contralesional M1 induced by 1 Hz repetitive transcranial magnetic stimulation ( rTMS ) caused an improved motor performance of the affected h and in stroke patients by releasing the TCI . Methods — We conducted a double-blind study of real versus sham rTMS in stroke patients . After patients had well- performed motor training to minimize the possibility of motor training during the motor measurement , they were r and omly assigned to receive a subthreshold rTMS at the contralesional M1 ( 1 Hz , 25 minutes ) or sham stimulation . Results — When compared with sham stimulation , rTMS reduced the amplitude of motor-evoked potentials in contralesional M1 and the TCI duration , and rTMS immediately induced an improvement in pinch acceleration of the affected h and , although a plateau in motor performance had been reached by the previous motor training . This improvement in motor function after rTMS was significantly correlated with a reduced TCI duration . Conclusions — We have demonstrated that a disruption of the TCI by the contralesional M1 virtual lesion caused a paradoxical functional facilitation of the affected h and in stroke patients ; this suggests a new neurorehabilitative strategy for stroke patients Several years ago , we proposed a combination protocol of repetitive transcranial magnetic stimulation ( rTMS ) and intensive occupational therapy ( OT ) for upper limb hemiparesis after stroke . Subsequently , the number of patients treated with the protocol has increased in Japan . We aim ed to present the latest data on our proposed combination protocol for post-stroke upper limb hemiparesis as a result of a multi-institutional study . After confirming that a patient met the inclusion criteria for the protocol , they were scheduled to receive the 15-day inpatient protocol . In the protocol , two sessions of 20-min rTMS and 120-min occupational therapy were provided daily , except for Sundays and the days of admission/discharge . Motor function of the affected upper limb was evaluated by the Fugl-Meyer assessment ( FMA ) and Wolf motor function test ( WMFT ) at admission/discharge and at 4 weeks after discharge if possible . A total of 1725 post-stroke patients were studied ( mean age at admission 61.4 ± 13.0 years ) . The scheduled 15-day protocol was completed by all patients . At discharge , the increase in FMA score , shortening in performance time of WMFT , and increase in functional ability scale ( FAS ) score of WMFT were significant ( FMA score 46.8 ± 12.2 to 50.9 ± 11.4 points , p < 0.001 ; performance time of WMFT 2.57 ± 1.32 to 2.21 ± 1.33 , p < 0.001 ; FAS score of WMFT 47.4 ± 14 . to 51.4 ± 14.3 points , p < 0.001 ) . Our proposed combination protocol can be a potentially safe and useful therapeutic intervention for upper limb hemiparesis after stroke , although its efficacy should be confirmed in a r and omized controlled study OBJECTIVE To test whether multiple sessions of inhibitory low-frequency repetitive transcranial magnetic stimulation ( rTMS ) applied to the left parietal area can improve hemispatial neglect after stroke . DESIGN An open-label design . PATIENTS Seven consecutive patients with hemispatial neglect after right hemispheric stroke were compared with 7 retrospectively recruited control patients . METHODS Seven patients received a session of 1 Hz rTMS to the left parietal area immediately prior to occupational therapy for 10 days . Seven control patients received only behavioural therapy . RESULTS Baseline values of the line bisection test and the Albert test were comparable in the two groups . The stimulation group showed a greater improvement in the line bisection test than did the control group . However , no differences were found between the two groups according to the Albert test . CONCLUSION In this pilot study , low-frequency rTMS application to the non-affected left parietal area was found to be safe and to improve line bisection test , which suggests that non-invasive cortical stimulation has a potential role as an adjuvant strategy during cognitive rehabilitation training in patients with hemispatial neglect . A prospect i ve r and omized , sham-controlled study is required to determine the beneficial role of non-invasive cortical stimulation on hemispatial neglect It has been 30 years since the discovery that repeated electrical stimulation of neural pathways can lead to long-term potentiation in hippocampal slices . With its relevance to processes such as learning and memory , the technique has produced a vast literature on mechanisms of synaptic plasticity in animal models . To date , the most promising method for transferring these methods to humans is repetitive transcranial magnetic stimulation ( rTMS ) , a noninvasive method of stimulating neural pathways in the brain of conscious subjects through the intact scalp . However , effects on synaptic plasticity reported are often weak , highly variable between individuals , and rarely last longer than 30 min . Here we describe a very rapid method of conditioning the human motor cortex using rTMS that produces a controllable , consistent , long-lasting , and powerful effect on motor cortex physiology and behavior after an application period of only 20 - 190 OBJECTIVE To investigate whether multiple sessions of 1-Hz repetitive transcranial magnetic stimulation ( rTMS ) facilitates the effect of repetitive facilitation exercises on hemiplegic upper-limb function in chronic stroke patients . DESIGN R and omized double-blinded crossover study . PATIENTS Eighteen patients with hemiplegia of the upper limb . METHODS Patients were assigned to 2 groups : a motor-before-sham rTMS group , which performed motor rTMS sessions for 2 weeks followed by sham rTMS sessions for 2 weeks ; or a motor-following-sham rTMS group , which performed sham rTMS sessions for 2 weeks followed by motor rTMS sessions for 2 weeks . Patients received 1-Hz rTMS to the unaffected motor cortex for 4 min and performed repetitive facilitation exercises for 40 min during motor rTMS sessions . The Fugl-Meyer Assessment , Action Research Arm Test ( ARAT ) and Simple Test for Evaluating H and Function were used to evaluate upper-limb function . The Modified Ashworth Scale and F-wave were measured to evaluate spasticity . RESULTS Motor function improved significantly during the motor , but not sham , rTMS sessions . ARAT score gains were 1.5 ( 0 - 4.0 ) ( median , interquartile range ) during the motor rTMS session , and 0 ( -0.8 - 1.8 ) during the sham rTMS session ( p = 0.04 ) . Spasticity did not significantly change during either session . CONCLUSION Multiple sessions of 1-Hz rTMS facilitated the effects of repetitive facilitation exercises in improving motor function of the affected upper limb , but did not change spasticity Introduction . Restoration of upper extremity ( UE ) functional use remains a challenge for individuals following stroke .  Repetitive transcranial magnetic stimulation ( rTMS ) is a noninvasive modality that modulates cortical excitability and is being explored as a means to potentially ameliorate these deficits . The purpose of this study was to evaluate , in the presence of chronic stroke , the effects of low-frequency rTMS to the contralesional hemisphere as an adjuvant to functional task practice ( FTP ) , to improve UE functional ability . Methods . Twenty-two individuals with chronic stroke and subsequent moderate UE deficits were r and omized to receive 16 sessions ( 4 times/week for 4 weeks ) of either real-rTMS or sham-rTMS followed by 1-hour of paretic UE FTP . Results . No differences in UE outcomes were revealed between the real-rTMS and sham-rTMS intervention groups . After adjusting for baseline differences , no differences were revealed in contralesional cortical excitability postintervention . In a secondary analysis , data pooled across both groups revealed small , but statistically significant , improvements in UE behavioral measures . Conclusions . rTMS did not augment changes in UE motor ability in this population of individuals with chronic stroke . The chronicity of our participant cohort and their degree of UE motor impairment may have contributed to inability to produce marked effects using rTMS Background and Purpose . Functional brain imaging studies with aphasia patients have shown increased cortical activation in the right hemisphere language homologues , which hypothetically may represent a maladaptive strategy that interferes with aphasia recovery . The aim of this study was to investigate whether low-frequency repetitive transcranial magnetic stimulation ( rTMS ) over the Broca 's homologues in combination with speech/ language therapy improves naming in early-stroke aphasia patients . Methods . 26 right-h and ed aphasic patients in the early stage ( up to 12 weeks ) of a first-ever left hemisphere ischemic stroke were r and omized to receive speech and language therapy combined with real or sham rTMS . Prior to each 45-minute therapeutic session ( 15 sessions , 5 days a week ) , 30 minutes of 1-Hz rTMS was applied . Outcome measures were obtained at baseline , immediately after 3 weeks of experimental treatment and 15 weeks ; posttreatment using the Computerized Picture Naming Test . Results . Although both groups significantly improved their naming abilities after treatment , no significant differences were noted between the rTMS and sham stimulation groups . The additional analyses have revealed that the rTMS subgroup with a lesion including the anterior part of language area showed greater improvement primarily in naming reaction time 15 weeks after completion of the therapeutic treatment . Improvement was also demonstrated in functional communication abilities . Conclusions . Inhibitory rTMS of the unaffected right inferior frontal gyrus area in combination with speech and language therapy can not be assumed as an effective method for all poststroke aphasia patients . The treatment seems to be beneficial for patients with frontal language area damage , mostly in the distant time after finishing rTMS procedure Rationale : Repetitive transcranial magnetic stimulation ( rTMS ) is used alone or in combination with physiotherapy for rehabilitation of stroke patients . TMS mapping can also quantify the excitability of the motor area in both the ipsilesional ( IL ) and contralateral ( CL ) hemisphere . Objective : This study is the first to measure the dynamics of cortical excitability by TMS mapping before and after treatment with low-frequency ( LF ) rTMS in the contralesional hemisphere at three different timepoints . Furthermore , the patients were clinical ly evaluated during the same visit as the mapping to establish both short and long-term outcomes after rTMS treatment . Methods and Results : A total of 16 participants with acute ischemic stroke were assessed 10 days post-stroke by TMS mapping . The patients were r and omized into two equal groups : a real rTMS group and a sham group . The rTMS group received LF-rTMS to the contralesional hemisphere for 10 days , starting on the first day after the first mapping . Each subject was also evaluated by mapping on days 45 and 90 after stroke onset . The primary clinical outcome measured was the Fugl-Meyer Assessment for Upper Extremity ( FMA-UE ) on days 10 , 45 and 90 post-stroke . At 10 days after stroke onset , both groups presented low excitability in the lesion side and high excitability in the non-affected side . In the real rTMS group , at 45 days after stroke , a downward trend in the excitability of the contralesional hemisphere and an upward trend in the excitability of the lesioned side were observed . At 90 days after stroke , a tendency toward balanced excitability between both hemispheres was observed . In the sham group , at both 45 and 90 days , we observed increased excitability in the non-affected side compared to the side with the lesioned motor area . At 45 days , the real rTMS group demonstrated a better recovery of the upper limb motor function than the sham group , but at 90 days , there was no significant difference between the two groups . Discussion : These results demonstrated that LF-rTMS treatment enhances rebalance of the excitability patterns in both hemispheres and led us to question the “ one size fits all ” approach widely used in rTMS interventions . Abbreviations : Amax = maximum amplitude , Amean = AM = averaged amplitude , APB = abductor pollicis brevis , CL = contralesional , DTI = diffusion tensor imaging , EEG = electroencephalography , EMG = electromyography , FMA-UE = Fugl-Meyer Assessment for Upper Extremity , HS = hot spot , IHC = interhemispheric functional connectivity , IL = ipsilesional , LF-rTMS = low-frequency repetitive transcranial magnetic stimulation , MCA = middle cerebral artery , MEP(s ) = motor evoked potential(s ) , NIBS = non-invasive brain stimulation , rMT = resting motor threshold , RP = responsive points , rTMS = repetitive transcranial magnetic stimulation , TMS = transcranial magnetic Low-frequency repetitive transcranial magnetic stimulation of the unaffected hemisphere ( UH-LF-rTMS ) in patients with stroke can decrease interhemispheric inhibition from the unaffected to the affected hemisphere and improve h and dexterity and strength of the paretic h and . The objective of this proof-of-principle study was to explore , for the first time , effects of UH-LF-rTMS as add-on therapy to motor rehabilitation on short-term intracortical inhibition ( SICI ) and intracortical facilitation ( ICF ) of the motor cortex of the unaffected hemisphere ( M1UH ) in patients with ischemic stroke . Eighteen patients were r and omized to receive , immediately before rehabilitation treatment , either active or sham UH-LF-rTMS , during two weeks . Resting motor threshold ( rMT ) , SICI , and ICF were measured in M1UH before the first session and after the last session of treatment . There was a significant increase in ICF in the active group compared to the sham group after treatment , and there was no significant differences in changes in rMT or SICI . ICF is a measure of intracortical synaptic excitability , with a relative contribution of spinal mechanisms . ICF is typically upregulated by glutamatergic agonists and downregulated by gabaergic antagonists . The observed increase in ICF in the active group , in this hypothesis-generating study , may be related to M1UH reorganization induced by UH-LF-rTMS BACKGROUND Repetitive transcranial magnetic stimulation ( rTMS ) is a simple and non-invasive method of augmenting motor recovery after stroke , probably mediated by restoring inter-hemispheric activation balance . This placebo-controlled pilot study examined the possible benefit of stimulating the lesioned hemisphere ( 5-Hz rTMS ) or inhibiting the contra-lesional hemisphere ( 1-Hz rTMS ) on clinical recovery of motor function in patients with ischaemic stroke and assessed the sustainability of the response . METHODS Sixty patients with ischaemic stroke ( > 1 month from onset ) with mild-to-moderate hemiparesis were r and omized to receive 10 daily sessions of either sham rTMS , 5-Hz ipsi-lesional rTMS or 1-Hz contra-lesional rTMS , in addition to a st and ard physical therapy protocol . Serial assessment s were made over a period of 12 weeks by the thumb-index finger tapping test ( FT ) , Activity Index ( AI ) score and the modified Rankin Scale ( mRS ) . RESULTS In contrast to control patients , those receiving active rTMS as ipsi-lesional 5-Hz stimulation or 1-Hz contra-lesional stimulation showed statistically significant improvement on the FT test , AI scores and mRS score at 2 weeks , and the effect was sustained over the 12-week observation period . No significant adverse events were observed during treatment in either group . CONCLUSIONS Repetitive TMS has beneficial effects on motor recovery that can be translated to clinical ly meaningful improvement in disability in patients with post-stroke hemiparesis , with a well-sustained effect . The similarity of inhibitory and stimulatory rTMS in producing these effects supports the inter-hemispheric balance hypothesis and encourages further research into their use in long-term neurorehabilitation programmes of patients with stroke Lately it has been indicated that the stimulation of both sides of the motor cortices with different frequencies of rTMS can improve the behaviour of a paretic arm . We studied the effect of rTMS in severe cases of post-stroke after nearly 10 years . They had wide hemispheric lesion and their paresis had not changed for more than 5 years . The majority of patients could not move their fingers on the affected side . In our study we examined whether the active movement could be induced by rTMS even several years after stroke and which hemisphere ( affected or unaffected ) stimulated by rTMS would be the best location for attenuating the spasticity and for developing movement in the paretic arm . Sixty-four patients ( more than 5 years after stroke in a stable state ) were followed for 3 months . They were treated with rTMS with 1 Hz at 30 % of 2.3 T 100 stimuli per session twice a day for a week . The area to be stimulated was chosen according to the evoked movement by TMS in the paretic arm . That way , four groups were created and compared . In group A , where both hemispheres were stimulated ( because of the single stimulation of TMS could induce movement from both sides of hemispheres ) the spasticity decreased but the movement could not be influenced . A highly significant improvement in spasticity , in movement induction and in the behaviour of paresis was observed in group B , where before treatment , there was no evoked movement in the paretic arm from stimulating either hemispheres of the brain . For treatment we stimulated the unaffected hemisphere from where the intact arm is moved ( ipsilateral to the paretic side ) . In both groups C ( contralateral hemisphere to the paretic arm ) and D ( ipsilaterally evoked movement in the paretic arm ) , the spasticity decreased during the first week , but the movement of the paretic arm improved only in group C. It seems that spasticity can be modified by the stimulation either the affected or the unaffected hemisphere , but the induction of movement can be achieved only by the stimulation of an intact motor pathway and its surrounding area ( groups B and C ) . The improvement in paretic extremities can be achieved with rTMS even after years of stroke when the traditional rehabilitation has failed Background : Accumulating evidence from single case studies , small case series and r and omized controlled trials seems to suggest that inhibitory noninvasive brain stimulation ( NIBS ) over the contralesional inferior frontal gyrus ( IFG ) of right-h and ers in conjunction with speech and language therapy ( SLT ) improves recovery from poststroke aphasia . Application of inhibitory NIBS to improve recovery in left-h and ed patients has not yet been reported . Methods : A total of 29 right-h and ed subacute poststroke aphasics were r and omized to receive either 10 sessions of SLT following 20 min of inhibitory repetitive transcranial magnetic stimulation ( rTMS ) over the contralesional IFG or 10 sessions of SLT following sham stimulation ; 2 left-h and ers were treated according to the same protocol with real rTMS .  Language activation patterns were assessed with positron emission tomography prior to and after the treatment ; 95 % confidence intervals for changes in language performance scores and the activated brain volumes in both hemispheres were derived from TMS- and sham-treated right-h and ed patients and compared to the same parameters in left-h and ers . Results : Right-h and ed patients treated with rTMS showed better recovery of language function in global aphasia test scores ( t test , p < 0.002 ) as well as in picture-naming performance ( ANOVA , p = 0.03 ) than sham-treated right-h and ers . In treated right-h and ers , a shift of activation to the ipsilesional hemisphere was observed , while sham-treated patients consoli date d network activity in the contralesional hemisphere ( repeated- measures ANOVA , p = 0.009 ) . Both left-h and ed patients also improved , with 1 patient within the confidence limits of TMS-treated right-h and ers ( 23 points , 15.9 - 28.9 ) and the other patient within the limits of sham-treated subjects ( 8 points , 2.8 - 14.5 ) . Both patients exhibited only a very small interhemispheric shift , much less than expected in TMS-treated right-h and ers , and more or less consoli date d initially active networks in both hemispheres . Conclusion : Inhibitory rTMS over the nondominant IFG appears to be a safe and effective treatment for right-h and ed poststroke aphasics . In the 2 cases of left-h and ed aphasics no deterioration of language performance was observed with this protocol . However , therapeutic efficiency is less obvious and seems to be more related to the dominance pattern prior to the stroke than to the TMS intervention Background . Noninvasive cortical stimulation could represent an add-on treatment to enhance motor recovery after stroke . However , its clinical value , including anticipated size and duration of the treatment effects , remains largely unknown . Objective . The authors design ed a small semi-r and omized clinical trial to explore whether long-lasting clinical ly important gains can be achieved by adding theta burst stimulation ( TBS ) , a form of repetitive transcranial magnetic stimulation ( TMS ) , to a rehabilitation program for the h and . Methods . A total of 41 chronic stroke patients received excitatory TBS to the ipsilesional hemisphere or inhibitory TBS to the contralesional hemisphere in 2 centers ; each active group was compared with a group receiving sham TBS . TBS was followed by physical therapy for 10 working days . Patients and therapists were blinded to the type of TBS . Primary outcome measures ( 9-hole Peg Test [ 9HPT ] , Jebsen Taylor Test [ JTT ] , and grip and pinch-grip dynamometry ) were assessed 4 , 30 , and 90 days post treatment . The clinical ly important difference was defined as 10 % of the maximum score . Results . There were no differences between the active treatment and sham groups in any of the outcome measures . All patients achieved small sustainable improvements—9HPT , 5 % of maximum ( confidence interval [ CI ] = 3%-7 % ) ; JTT , 5.7 % ( CI = 3%-8 % ) ; and grip strength , 6 % ( CI = 2%-10%)—all below the defined clinical ly important level . Conclusions . Cortical stimulation did not augment the gains from a late rehabilitation program . The effect size anticipated by the authors was overestimated . These results can improve the design of future work on therapeutic uses of TMS BACKGROUND AND PURPOSE The purpose of this study was to compare the long-term effect of five daily sessions of 1 vs. 3 Hz repetitive transcranial magnetic stimulation ( rTMS ) on motor recovery in acute stroke . METHODS A total of 36 patients with acute ischaemic stroke participated in the study . The patients were r and omly assigned into one of three groups ; the first and second groups received real rTMS ; 1 and 3 Hz and third group received sham stimulation , daily for 5 days . Motor disability was assessed before and after the last session , and then after first , second and third month . Cortical excitability was assessed before and after the second and fifth session . The outcome measure was clinical disability at 3 months post-rTMS  . RESULTS No significant differences were found in basal rating scales between the three groups . At the 3-month time point , both of the real rTMS groups had improved significantly more in different rating scales than the sham group ; in addition , the 1 Hz group performed better than the 3 Hz group . Measures of cortical excitability immediately after the last session showed that the 1 Hz group had reduced excitability of the non-stroke hemisphere and increased excitability of the stroke hemisphere , whereas the 3 Hz group only showed increased excitability of the stroke hemisphere . CONCLUSION These results confirm that five daily sessions of rTMS over motor cortex using either 1 Hz over the unaffected hemisphere or 3 Hz over the affected hemisphere can enhance recovery . At 3 months , the improvement was more pronounced in 1 Hz group OBJECTIVE Focal transcranial magnetic stimulation was used to test prospect ively corticospinal excitability changes and reorganization of first dorsal interosseous ( FDI ) motor cortical representation in 31 patients who experienced a first ischemic stroke in the middle cerebral artery territory . All had severe h and palsy at onset . METHODS Patients were assessed clinical ly with the Medical Research Council , Rankin , the National Institutes of Health stroke scales and Barthel Index at days 1 , 8 , 30 , 90 , 180 and 360 after stroke . The following parameters of FDI  motor evoked potential ( MEPS ) to focal transcranial magnetic stimulation were measured at the same delays : motor threshold , MEP amplitude , excitable cortical area , hot spot and center of gravity of FDI motor maps on affected and unaffected hemispheres . Correlations were sought between clinical and electrophysiological parameters . RESULTS In patients whose affected motor cortex remained excitable at day 1 , motor thresholds were not significantly different between sides and were similar to those of controls . Persistence of MEP on the affected side at day 1 was a strong predictor of good recovery . If present at day 1 , MEPs recorded in affected FDI were significantly smaller than of the opposite side or in normals and progressively recovered up to day 360 . In these patients , area of excitable cortex remained stable throughout the entire study . At day 1 , amplitudes of MEPs obtained in unaffected FDI were significantly larger than later . Between days 1 and 360 , we observed a significant displacement of center of gravity of motor maps towards more frontal regions on the affected side while no change was noted on the unaffected side . CONCLUSIONS Our data confirm the early prognosis value of transcranial magnetic stimulation in stroke . They indicate that the brain insult induces a transient hyperexcitability of the unaffected motor cortex . The evolution of FDI motor maps along the course of recovery mostly reflect corticospinal excitability changes but might also reveal some degree of brain plasticity . Most modifications observed occurred within 3 months of stroke onset Repetitive transcranial magnetic stimulation ( rTMS ) of human primary motor cortex ( M1 ) changes cortical excitability at the site of stimulation and at distant sites without affecting simple motor performance . The aim of this study was to explore how rTMS changes regional excitability and how the motor system compensates for these changes . Using functional brain imaging , activation was mapped at rest and during freely selected finger movements after 30 min of 1 Hz rTMS . rTMS increased synaptic activity in the stimulated left M1 and induced widespread changes in activity throughout areas engaged by the task . In particular , movement-related activity in the premotor cortex of the nonstimulated hemisphere increased after 1 Hz rTMS . Analyses of effective connectivity confirmed that the stimulated part of M1 became less responsive to input from premotor and mesial motor areas . Conversely , after rTMS our results were consistent with increased coupling between an inferomedial portion of left M1 and anterior motor areas . These results are important for three reasons . First , they show changes in motor excitability to central inputs from other cortical areas ( as opposed to peripheral or exogenous inputs used in previous studies ) . Second , they suggest that maintenance of task performance may involve activation of premotor areas contralateral to the site of rTMS , similar to that seen in stroke patients . Third , changes in motor activations at the site of rTMS suggest an rTMS-induced remodeling of motor representations during movement . This remapping may provide a neural substrate for acute compensatory plasticity of the motor system in response to focal lesions such as stroke Abstract Background : High- and low-frequency repetitive transcranial magnetic stimulation ( HF-rTMS and LF-rTMS ) has been shown to be beneficial for upper limb hemiparesis in patients with acute stroke . However , no study has examined the usefulness of bilateral application of HF- and LF-rTMS ( BL-rTMS ) . Methods : Fifty-eight hemiparetic patients with acute stroke were r and omly assigned into two groups : HF-rTMS group and BL-rTMS group . All patients were scheduled to receive five sessions of either HF-rTMS over the lesional hemisphere or BL-rTMS over both hemispheres for 5 days . Motor function of the affected upper limb was evaluated using the Brunnstrom Recovery Stage ( BRS ) for upper-limb and h and -fingers , grip strength and tapping frequency , before the first session and after the last session of rTMS . Results : Improvement of BRS for the upper limb and h and /finger was significantly greater in the BL-rTMS group than the HF-rTMS group ( p < 0.01 ) . Improvement in grip strength and tapping frequency was also greater in the BL-rTMS group , although the differences were not statistically significant . Conclusions : The proposed BL-rTMS is safe and feasible and showed a greater improvement of BRS of the affected upper limb compared to HF-rTMS . This novel rTMS approach may be a useful intervention for hemiparetic patients with acute stroke OBJECTIVE To assess the efficacy of inhibitory repetitive transcranial magnetic stimulation ( rTMS ) for decreasing upper-limb muscle tone after chronic stroke . DESIGN A r and omized 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 clinical ly 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 clinical ly important differences . In the control group , 30 % of the patients at postintervention and 22.2 % at follow-up experienced clinical ly 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 PURPOSE The premotor cortex plays a major role in motor planning and control , exhibiting hierarchical importance comparable to that of the primary motor cortex ( M1 ) . In this study , we compared the effects of cPMd modulation , which was achieved using inhibitory repetitive transcranial magnetic stimulation ( rTMS ) , with those of contralesional M1 ( cM1 ) modulation , to eluci date the roles of both regions on longitudinal motor recovery following a stroke . METHODS Forty-four patients who had sustained hemiplegia for 3 to 12 months were r and omly allocated to a cPMd group , cM1 group , or sham group and received 10 sessions of 1-Hz rTMS . The Medical Research Council ( MRC ) Scale , Fugl-Meyer Assessment ( FMA ) , Wolf Motor Function Test ( WMFT ) , and a cortical excitability test were administered pre- and post- rTMS intervention . RESULTS cPMd modulation yielded significant improvements in MRC , FMA , and WMFT scores compared with sham stimulation and a significant effect on cortical excitability suppression equivalent to that of cM1 modulation , but engendered effects on motor improvement inferior to those of cM1 modulation . CONCLUSIONS In patients with chronic stroke , the cPMd can fulfill a role similar to that of the cM1 in interhemispheric imbalance , which can be ameliorated by applying inhibitory rTMS to achieve substantial motor restoration Low frequency Repetitive Transcranial Magnetic Stimulation ( rTMS ) has previously been applied to language homologues in non-fluent population s of persons with aphasia yielding significant improvements in behavioral language function up to 43 months post stimulation . The present study aim ed to investigate the electrophysiological correlates associated with the application of rTMS through measurement of the semantic based N400 Event-related brain potentials ( ERP ) component . Low frequency ( 1 Hz ) rTMS was applied to the anterior portion of the homologue to Broca 's area ( pars triangularis ) , for 20 min per day for 10 days , using a stereotactic neuronavigational system . Twelve non-fluent persons with aphasia , 2 - 6 years post stroke were stimulated . Six participants were r and omly assigned to receive real stimulation and six participants were r and omly assigned to receive a blind sham control condition .  ERP measures were recorded at baseline , 1 week and 2 months subsequent to stimulation . The findings demonstrate treatment related changes observed in the stimulation group when compared to the placebo control group at 2 months post stimulation indicating neuromodulation of N400 as a result of rTMS . No treatment related changes were identified in the stimulation group , when compared to the sham group from baseline to 1 week post stimulation . The electrophysiological results represent the capacity of rTMS to modulate neural language networks and measures of lexical-semantic function in participants with non-fluent aphasia and suggest that time may be an important factor in brain reorganization subsequent to rTMS OBJECTIVE Changes in cerebral cortex excitability have been demonstrated after a stroke and are considered relevant for recovery . Repetitive transcranial magnetic stimulation ( rTMS ) of the brain can modulate cerebral cortex excitability and , when rTMS is given as theta burst stimulation ( TBS ) , LTP- or LTD-like changes can be induced . The aim of present study was to evaluate the effects of TBS on cortical excitability in acute stroke . METHODS In 12 acute stroke patients , we explored the effects of facilitatory TBS of the affected hemisphere and of inhibitory TBS of the unaffected hemisphere on cortical excitability to single-pulse transcranial magnetic stimulation ( TMS ) on both sides . The effects produced by TBS in patients were compared with those observed in a control group of age-matched healthy individuals . RESULTS In patients , both the facilitatory TBS of the affected motor cortex and the inhibitory TBS of the unaffected motor cortex produced a significant increase of the amplitude of MEPs evoked by stimulation of the affected hemisphere . The effects observed in patients were comparable to those observed in controls . CONCLUSIONS Facilitatory TBS over the stroke hemisphere and inhibitory TBS over the intact hemisphere in acute phase enhance the excitability of the lesioned motor cortex . SIGNIFICANCE TBS might be useful to promote cortical plasticity in stroke patients OBJECTIVE Recent reports demonstrated that low-frequency repetitive transcranial magnetic stimulation ( rTMS ) over the unaffected hemisphere improved the affected h and function in chronic stroke patients . We investigated whether 1 Hz rTMS improved the motor learning of the affected h and in patients after stroke . DESIGN A double-blind study . PATIENTS Twenty patients with chronic subcortical stroke . METHODS The patients were r and omly assigned to receive either a sub-threshold rTMS over the unaffected hemisphere ( 1 Hz , 25 minutes ) or sham stimulation , and all patients performed a pinching task after stimulation . We evaluated the motor function of the affected h and and the excitatory and inhibitory function of the affected motor cortex by transcranial magnetic stimulation . RESULTS Compared with sham stimulation , rTMS induced an increase in the excitability of the affected motor cortex(p < 0.001 ) and an improvement in acceleration of the affected h and ( p = 0.006 ) . Moreover , the effect of motor training on pinch force was enhanced by rTMS ( p < 0.001 ) . These improvement in the motor function lasted for one week after rTMS and motor training ( p < 0.001 ) . CONCLUSION rTMS improved the motor learning of the affected h and in patients after stroke ; thus , it can apply as anew rehabilitation strategy for patients after stroke OBJECTIVE To evaluate the effects of repetitive transcranial magnetic stimulation ( rTMS ) on mobility among patients with substantial leg impairment after subacute stroke . DESIGN Double-blinded , stratified , r and omized trial involving a sham control group . PARTICIPANTS Patients who developed unilateral hemiplegia after first-ever subacute stroke and underwent inpatient stroke rehabilitation . METHODS The 15-day intervention programme used in the present study included the application of rTMS ( 1 Hz , 15 min ) over the leg motor area of the unaffected hemisphere , followed by 45 min physical therapy . Overall , 32 participants were r and omly assigned to receive either real rTMS or sham stimulation . Clinical assessment s , including the Postural Assessment Scale for Stroke Patients ( PASS ) , balance subscale of the Performance Oriented Mobility Assessment ( POMA-b ) , Fugl-Meyer Assessment , Barthel Index ( BI ) , and Timed Up and Go test , were performed immediately before and after the intervention . RESULTS Both groups demonstrated significant improvements in all the test results over time . At the post-test assessment , the patients in the real rTMS group demonstrated greater improvements in the PASS , POMA , and BI scores than did the patients in the sham rTMS group . In addition , a significantly higher number of patients in the real rTMS group regained mobility at the post-test assessment compared with the corresponding number of patients in the sham rTMS group . CONCLUSION Application of 1-Hz rTMS may improve mobility among patients with substantial leg impairment after subacute stroke BACKGROUND AND PURPOSE Numerous studies have shown that repetitive transcranial magnetic stimulation ( rTMS ) over the primary motor cortex ( M1 ) may improve motor function of the affected h and after stroke . The effects of 1 Hz rTMS applied over the contralesional dorsal premotor cortex ( PMd ) on h and function and cortical neurophysiology in subacute stroke were examined . METHODS Ten subacute stroke patients with mild h and motor impairment were enrolled in a prospect i ve , double-blind , r and omized , placebo-controlled , crossover study with two intervention sessions . 1 Hz rTMS was applied over the contralesional PMd ( real rTMS , 900 pulses at 110 % of the motor threshold ; sham rTMS , 900 pulses at 0 % of the motor threshold ) . Tests of h and function ( Jebsen-Taylor h and function test , box and block test ) and neurophysiological evaluations ( resting motor threshold , motor evoked potentials , cortical silent period , ipsilateral silent period ) were obtained from both h and s and hemispheres prior to ( baseline ) and after each treatment . RESULTS H and function tests revealed significant improvement of motor function of the affected but not of the unaffected h and after real rTMS only . Neither intervention changed the neurophysiological measures in comparison to baseline . CONCLUSION One hertz rTMS over the contralesional PMd improves motor function of the affected h and in subacute stroke . The PMd may be a novel rTMS target to treat motor impairment after stroke Here , we review the effects of non-invasive brain stimulation such as transcranial magnetic stimulation ( TMS ) or transcranial direct current stimulation ( tDCS ) in the rehabilitation of neglect . We found 12 studies including 172 patients ( 10 TMS studies and 2 tDCS studies ) fulfilling our search criteria .  Activity of daily living measures such as the Barthel Index or , more specifically for neglect , the Catherine Bergego Scale were the outcome measure in three studies . Five studies were r and omized controlled trials with a follow-up time after intervention of up to 6 weeks . One TMS study fulfilled criteria for Class I and one for Class III evidence . The studies are heterogeneous concerning their methodology , outcome measures , and stimulation parameters making firm comparisons and conclusions difficult . Overall , there are however promising results for theta-burst stimulation , suggesting that TMS is a powerful add-on therapy in the rehabilitation of neglect patients BACKGROUND Recently , high-frequency repetitive transcranial magnetic stimulation ( HF-rTMS ) and low-frequency rTMS ( LF-rTMS ) are reported to improve motor function significantly in chronic hemiparetic stroke patients . However , few studies have investigated the safety and efficacy of these rTMS modalities introduced during the early phase of stroke . The purpose of this study was to clarify the rTMS modality that is more beneficial for upper limb hemiparesis in the early phase of stroke using a r and omized controlled trial . METHODS Twenty-nine patients with a hemispheric stroke lesion in the early phase of stroke were examined . Patients were r and omly assigned into 3 groups : the HF-rTMS group ( 10 Hz rTMS to the lesional hemisphere [ n = 9 ] ) , the LF-rTMS group ( 1 Hz rTMS to the nonlesional hemisphere [ n = 11 ] ) , and the sham stimulation group [ n = 9 ] ) . Patients received sessions for 5 consecutive days . Grip strength and tapping frequency were assessed before and after the intervention . Motor improvement of the affected upper limb after intervention was compared among the 3 groups . RESULTS All patients completed the 5-day protocol . Both the HF-rTMS and LF-rTMS groups had significant increases in both grip strength and tapping frequency . Comparison of the extent of improvement showed a more significant increase in grip strength and tapping frequency in the HF-rTMS group compared to the sham stimulation group ( each P < .05 ) , and no difference between the LF-rTMS group and the sham stimulation group . CONCLUSIONS HF-rTMS applied to the lesional hemisphere in the early phase of stroke was more beneficial for motor improvement of the affected upper limb than LF-rTMS While experimental studies in the monkey have shown that motor recovery after partial destruction of the h and motor cortex was based on adjacent motor reorganization , functional MRI ( fMRI ) studies with isolated primary motor cortical stroke have not yet been reported in humans . Based on experimental data , we design ed a study to test if recovery after stroke within primary motor cortex ( M1 ) was associated with reorganization within the surrounding motor cortex , i.e. the motor cortex was able to vicariate . Since motor recovery is time-dependent and might be inflected according to the tested task , the delay after stroke and two motor tasks were included in our design . We examined four patients with one ischaemic stroke limited to M1 , and four sex- and age-matched healthy controls in a temporally balanced prospect i ve longitudinal fMRI study over three sessions : < 20 days , 4 months and 2 years after stroke . The paradigm included two motor tasks , finger tapping ( FT ) and finger extension ( FE ) . Distinct patterns of motor activation were observed with time for FT and FE . At the first session , FT-related activation was lateralized in the ipsilateral hemisphere while FE-related activation was contralateral , involving bilateral cerebellar regions for both tasks . From 4 months , skilled motor recovery was associated with contralateral dorsal premotor and sensorimotor cortex and ipsilateral cerebellum motor-related activations , leading to lateralized motor patterns for both tasks . For the left recovered h and , FT and FE-related activations within M1 were more dorsal in patients than in controls . This dorsal shift progressively increased over 2 years , reflecting functional reorganization in the motor cortex adjacent to the lesion . In addition , patients showed a reverse representation of FT and FE within M1 , corresponding to a greater dorsal shift for FT than for FE . This functional dissociation might reflect the structural subdivision of M1 with two distinct finger motor representations within M1 . Recovery of FT , located within the lesioned depth of the rol and ic sulcus in controls , might be related to the re-emergence of a new representation in the intact dorsal M1 , while FE , located more dorsally , underwent minor reorganization . This is the first fMRI study of humans presenting with isolated M1 stroke comparable with experimental lesions in animals . Despite the small number of patients , our findings showing the re-emergence of a fingers motor task in the intact dorsal M1 instead of in ventral M1 are consistent with ' vicariation ' models of stroke recovery Background . Recent neuroimaging studies on poststroke aphasia revealed maladaptive cortical changes in both hemispheres , yet their functional contribution in language recovery remains elusive . The aim of this study was to evaluate the long-term efficacy of dual-hemisphere repetitive transcranial magnetic stimulation ( rTMS ) on poststroke aphasia . Methods . Thirty patients with subacute poststroke nonfluent aphasia were r and omly allocated to receive real or sham rTMS . Each patient received 1000 rTMS pulses ( 1 Hz at 110 % of resting motor threshold [ rMT ] over the right unaffected Broca ’s area and 1000 pulses ( 20 Hz at 80 % rMT ) over the left affected Broca ’s area for 10 consecutive days followed by speech/ language training . The language section of the Hemispheric Stroke Scale ( HSS ) , the Stroke Aphasic Depression Question naire – Hospital Version ( SADQ-H ) , and the National Institutes of Health Stroke Scale ( NIHSS ) were measured before , immediately after the 10 sessions , and 1 and 2 months after the last session . Results . At baseline , there were no significant differences between groups in demographic and clinical rating scales . However , there was a significantly greater improvement in the HSS language score as well as in the SADQ-H after real rTMS compared with sham rTMS , which remained significant 2 months after the end of the treatment sessions . Conclusion . This is the first clinical study of dual-hemisphere rTMS in poststroke aphasia . Combining dual-hemisphere rTMS with language training might be a feasible treatment for nonfluent aphasia ; further multicenter studies are needed to confirm this result OBJECTIVE The interhemispheric competition model proposes that the functional recovery of motor deficits in patients after stroke can be achieved by increasing the excitability of the affected hemisphere or decreasing the excitability of the unaffected hemisphere . We investigated whether bilateral repetitive transcranial magnetic stimulation might improve the paretic h and in patients after stroke . DESIGN A double-blind study . PATIENTS Thirty patients with chronic subcortical stroke . METHODS The patients were r and omly assigned to receive 1 Hz repetitive transcranial magnetic stimulation over the unaffected hemisphere , 10 Hz repetitive transcranial magnetic stimulation over the affected hemisphere , or bilateral repetitive transcranial magnetic stimulation comprising both the 1 Hz and 10 Hz repetitive transcranial magnetic stimulation . All patients underwent motor training following repetitive transcranial magnetic stimulation . RESULTS Bilateral repetitive transcranial magnetic stimulation and 1 Hz repetitive transcranial magnetic stimulation immediately improved acceleration in the paretic h and . Compared with 1 Hz repetitive transcranial magnetic stimulation , bilateral repetitive transcranial magnetic stimulation decreased the inhibitory function of the affected motor cortex and enhanced the effect of motor training on pinch force . Moreover , this effect of motor training lasted for one week . On the other h and , 10 Hz repetitive transcranial magnetic stimulation had no effect on the motor function . CONCLUSION Bilateral repetitive transcranial magnetic stimulation improved the motor training effect on the paretic h and of patients after stroke more than unilateral stimulation in pinch force ; this might indicate a new neurorehabilitative strategy for stroke Movements of the paretic h and in patients with chronic subcortical stroke are associated with high interhemispheric inhibition ( IHI ) targeting the motor cortex in the lesioned hemisphere relative to healthy controls . The purpose of this investigation was to determine whether this abnormality also involves IHI operating during movements of the non-paretic h and . Here , we studied IHI in the process of generation of voluntary index finger movements by the paretic and non-paretic h and s in a simple reaction time paradigm in a group of patients with chronic subcortical stroke . With movements of the non-paretic index finger , IHI targeting the contralateral primary motor cortex ( (c)M1 ) decreased progressively to turn into facilitation at around movement onset , similar to healthy controls . In contrast , movements of the paretic index finger result ed in significantly deeper inhibition at all premovement timings relative to the non-paretic h and . In conclusion , these results document a deeper premovement IHI with paretic than non-paretic h and movements of patients with chronic subcortical stroke , a possible mechanism underlying deficits in motor control PURPOSE Increasing evidence suggests that the contralesional motor cortex ( M1 ) inhibits the ipsilesional M1 in stroke patients . This inhibition could impair motor function of the affected h and . We investigated if inhibitory 1~Hz repetitive transcranial magnetic stimulation ( rTMS ) over the contralesional M1 improved motor performance of the affected h and in acute stroke . METHODS A double-blind study of real versus placebo rTMS was conducted . Twelve patients early after subcortical stroke ( mean : 7 days ) received 1200 stimuli of real and placebo rTMS in a crossover design . The sequence of stimulations was counterbalanced across subjects . Stimulus intensity was subthreshold ( 90 % of motor threshold at rest ) . Motor function was tested by grip strength recordings and Nine Hole Peg Test ( NHPT ) executions before and after each rTMS session . RESULTS Compared to sham stimulation , real rTMS  improved NHPT results but not grip strength in the affected h and . No change of performance was observed for the unaffected h and . NHPT baseline repetitions in a subgroup of patients indicated stable motor performance prior to the rTMS sessions . CONCLUSIONS The study suggests that therapeutic rTMS applications over the contralesional hemisphere are feasible in acute stroke patients and can transiently improve dexterity of the affected h and . RTMS may become an additional tool for early neurorehabilitation Transcranial magnetic stimulation ( TMS ) has been shown to significantly improve language function in patients with non-fluent aphasia(1 ) . In this experiment , we demonstrate the administration of low-frequency repetitive TMS ( rTMS ) to an optimal stimulation site in the right hemisphere in patients with chronic non-fluent aphasia . A battery of st and ardized language measures is administered in order to assess baseline performance . Patients are subsequently r and omized to either receive real rTMS or initial sham stimulation . Patients in the real stimulation undergo a site-finding phase , comprised of a series of six rTMS sessions administered over five days ; stimulation is delivered to a different site in the right frontal lobe during each of these sessions . Each site-finding session consists of 600 pulses of 1 Hz rTMS , preceded and followed by a picture-naming task . By comparing the degree of transient change in naming ability elicited by stimulation of c and i date sites , we are able to locate the area of optimal response for each individual patient . We then administer rTMS to this site during the treatment phase . During treatment , patients undergo a total of ten days of stimulation over the span of two weeks ; each session is comprised of 20 min of 1 Hz rTMS delivered at 90 % resting motor threshold . Stimulation is paired with an fMRI-naming task on the first and last days of treatment . After the treatment phase is complete , the language battery obtained at baseline is repeated two and six months following stimulation in order to identify rTMS-induced changes in performance . The fMRI-naming task is also repeated two and six months following treatment . Patients who are r and omized to the sham arm of the study undergo sham site-finding , sham treatment , fMRI-naming studies , and repeat language testing two months after completing sham treatment . Sham patients then cross over into the real stimulation arm , completing real site-finding , real treatment , fMRI , and two- and six-month post-stimulation language testing OBJECTIVE This r and omized , sham-controlled , double-blind study was conducted to investigate the effects of high-frequency versus low-frequency repetitive transcranial magnetic stimulation ( rTMS ) on patients with poststroke dysphagia during early rehabilitation . METHODS Forty patients with poststroke dysphagia were r and omized to receive five daily sessions of sham , 3-Hz ipsilesional , or 1-Hz contralesional rTMS .  Swallowing function , the severity of stroke and functional disability , and cortical excitability were examined before , immediately after five daily sessions , as well as the first , second , and third month after the last session . RESULTS At baseline , no significant differences between groups were observed in terms of demographic and clinical rating scales . However , a significantly greater improvement in swallowing function as well as functional disability was observed after real rTMS when compared with sham rTMS , which remained 3 months after the end of the treatment sessions . In addition , 1-Hz rTMS increased cortical excitability of the affected hemisphere and decreased that of the non-affected hemisphere ; however , 3-Hz rTMS only increased cortical excitability of the affected hemisphere . CONCLUSION rTMS ( both high and low frequency ) improved swallowing recovery in patients with poststroke dysphagia , and the effects lasted for at least 3 months . SIGNIFICANCE rTMS appears to be a beneficial therapeutic modality for patients with dysphagia during the early phase of stroke Background . The model of interhemispheric competition after stroke has been established for the upper but not for the lower extremity . Repetitive transcranial magnetic stimulation ( rTMS ) of the brain has been shown to modulate cortical excitability . Objective . The purpose of this study was to investigate the effects of rTMS followed by task-oriented training on cortical excitability and walking performance in individuals with chronic stroke . Methods . A total of 24 patients with average Fugl-Meyer lower limb scores of 17.88 ± 5.27 and average walking speeds of 63.81 ± 18.25 cm/s were r and omized into an experimental group and a control group . Participants received rTMS ( experimental group ) or sham rTMS ( control group ) followed by task-oriented training ( 30 minutes ) for 10 sessions over 2 weeks . Repetitive TMS was applied at a 1-Hz frequency over the leg area of the motor cortex of the unaffected hemisphere for 10 minutes . Outcomes , including motor-evoked potential ( MEP ) , lower-extremity Fugl-Meyer score , and gait performance , were measured before and after training . Results . Decreased interhemispheric asymmetry of the amplitude of the MEP was noted after rTMS and task-oriented training . Improvement in spatial asymmetry of gait was comparable with increased symmetry in interhemispheric excitability . Motor control and walking ability were also significantly improved after rTMS and task-oriented training . Conclusions . rTMS enhances the effect of task-oriented training in those with chronic stroke , especially by increasing gait spatial symmetry and corticomotor excitability symmetry BACKGROUND Arterial ischaemic stroke ( AIS ) can cause disabling hemiparesis in children . We aim ed to test whether contralesional , inhibitory repetitive transcranial magnetic stimulation ( rTMS ) could affect interhemispheric inhibition to improve h and function in chronic subcortical paediatric AIS . METHODS Patients were eligible for this parallel , r and omised trial if they were in the SickKids Children 's Stroke Program and had subcortical AIS more than 2 years previously , had transcallosal sparing , were more than 7 years of age , had h and motor impairment , had no seizures or dyskinesia , and were taking no drugs that alter cortical excitability . Patients were paired for age and weakness and were r and omised within each pair to sham treatment or inhibitory , low-frequency rTMS over contralesional motor cortex ( 20 min , 1200 stimuli ) once per day for 8 days . An occupational therapist did st and ardised tests of h and function at days 1 ( baseline ) , 5 , 10 , and 17 ( 1 week post-treatment ) , and the primary outcomes were changes in grip strength and the Melbourne assessment of upper extremity function ( MAUEF ) between baseline and day 10 . Patients , parents , and occupational therapists were blinded to treatment allocation . Analysis was per protocol . FINDINGS Ten patients with paediatric stroke were enrolled ( median age 13.25 [ IQR 10.08 - 16.78 ] years , mean time post-stroke 6.33 [ SD 3.56 ] years ) : four with mild weakness , two with moderate weakness , and four with severe weakness . A repeated- measures ANOVA showed a significant interaction between time and the effect of treatment on grip strength ( p=0.03 ) . At day 10 , grip strength was 2.28 ( SD 1.01 ) kg greater than baseline in the rTMS group and 2.92 ( 1.20 ) kg less than baseline in the sham group ( p=0.009 ) . Benefits in mean grip strength persisted at day 17 ( 2.63 [ 0.56 ] kg greater than baseline with rTMS and 1.00 [ 0.70 ] kg less than baseline with sham treatment ; p=0.01 ) . Day 10 MAUEF score improved by more in the rTMS group than in the sham group ( 7.25 [ 3.8 ] vs 0.79 [ 1.3 ] points greater than baseline ; p=0.002 ) , but this benefit did not persist to day 17 . Function of the unaffected h and remained stable . rTMS was well tolerated with no serious adverse events . INTERPRETATION Contralesional inhibitory rTMS was safe and feasible for patients with paediatric subcortical AIS , and seemed to improve h and function in patients with hemiparesis . Further studies are required to confirm the potential role of rTMS in paediatric neurorehabilitation . FUNDING Canadian Stroke Consortium ; Canadian Institutes of Health Research ; American Academy of Neurology Foundation ; Alberta Heritage Foundation for Medical Research Background . While prior preliminary studies have broadened our underst and ing of how repetitive transcranial magnetic stimulation ( rTMS ) improves language outcomes in stroke patients with nonfluent aphasia , the evidence base of the effectiveness of this method remains inadequate . Objective . In this study , we aim ed to strengthen the evidence that this approach improves language performance and to identify characteristics of patients predisposed to benefit most from this treatment . Methods . Fifty-six stroke patients with nonfluent aphasia were r and omly allocated to a real or a sham stimulation group : Group A ( n = 33 ) , who underwent 10 sessions of 1-Hz rTMS over the contralesional pars triangularis ( PTr ) , and Group B ( n = 23 ) , who received sham 1-Hz stimulation . We performed the Picture Naming Test and the Concise Chinese Aphasia Test ( CCAT ) at the baseline , post-rTMS intervention , and at 3-month follow-up . Results . Group A showed significantly greater improvement than Group B in CCAT scoring ( P < .001 ) , object-naming accuracy ( P = .01 ) , and naming reaction time ( P = .004 ) . The CCAT scoring and naming testing changes for Group A were persistent at 3 months following intervention ( P = .008 ) . Patients who had a lower contralesional rest motor threshold ( rMT ) were predisposed to a favorable therapeutic outcome ( P = .006 ) , independent of aphasia type , severity , and duration . Conclusions . The results of this study provide evidence that inhibitory rTMS , through downregulating the circuitry of the right pars triangularis ( PTr ) , achieves a persistent and broadly modulating effect , irrespective of aphasia severity and subtype . Patients who show lower rMT in the right motor system would seem to benefit the most from inhibitory rTMS BACKGROUND AND PURPOSE Repetitive transcranial magnetic stimulation ( rTMS ) changes the excitability of the motor cortex and thereby has the potential to enhance motor recovery after stroke . This r and omized , sham-controlled , double-blind study was to compare the effects of high-frequency versus low-frequency rTMS on motor recovery during the early phase of stroke and to identify the neurophysiological correlates of motor improvements . METHODS A total of 69 first-ever ischemic stroke patients with motor deficits were r and omly allocated to receive five daily sessions of 3-Hz ipsilesional rTMS , 1-Hz contralesional rTMS or sham rTMS in addition to st and ard physical therapy . Outcome measures included motor deficits , neurological scores and cortical excitability , which were assessed at baseline , after the intervention and at 3-month follow-up . RESULTS The rTMS groups manifested greater motor improvements than the control group , which were sustained for at least 3 months after the end of the treatment sessions . 1-Hz rTMS over the unaffected hemisphere produced more profound effects than 3-Hz rTMS in facilitating upper limb motor performance . There was a significant correlation between motor function improvement and motor cortex excitability change in the affected hemisphere . CONCLUSIONS Repetitive transcranial magnetic stimulation is a beneficial neurorehabilitative strategy for enhancing motor recovery in the acute and subacute phase after stroke Background Many poststroke patients suffer functional motor limitation of the affected upper limb , which is associated with diminished health-related quality of life . Aims The aim of this study is to conduct a r and omized , multicenter , comparative study of low-frequency repetitive transcranial magnetic stimulation combined with intensive occupational therapy , NEURO ( NovEl intervention Using Repetitive TMS and intensive Occupational therapy ) versus constraint-induced movement therapy in poststroke patients with upper limb hemiparesis . Methods In this r and omized controlled study of NEURO and constraint-induced movement therapy , 66 poststroke patients with upper limb hemiparesis were r and omly assigned at 2:1 ratio to low-frequency repetitive transcranial magnetic stimulation plus occupational therapy ( NEURO group ) or constraint-induced movement therapy ( constraint-induced movement therapy group ) for 15 days . Fugl – Meyer Assessment and Wolf Motor Function Test and Functional Ability Score of Wolf Motor Function Test were used for assessment . Results No differences in patients ' characteristics were found between the two groups at baseline . The Fugl – Meyer Assessment score was significantly higher in both groups after the 15-day treatment compared with the baseline . Changes in Fugl – Meyer Assessment scores and Functional Ability Score of Wolf Motor Function Test were significantly higher in the NEURO group than in the constraint-induced movement therapy group , whereas the decrease in the Wolf Motor Function Test log performance time was comparable between the two groups ( changes in Fugl – Meyer Assessment score , NEURO : 5·39 ± 4·28 , constraint-induced movement therapy : 3·09 ± 4·50 points ; mean ± st and ard error of the mean ; P < 0·05 ) ( changes in Functional Ability Score of Wolf Motor Function Test , NEURO : 3·98 ± 2·99 , constraint-induced movement therapy : 2·09 ± 2·96 points ; P < 0·05 ) . Conclusions The results of the 15-day rehabilitative protocol showed the superiority of NEURO relative to constraint-induced movement therapy ; NEURO improved the motion of the whole upper limb and result ed in functional improvement in activities of daily living OBJECTIVE To determine to what extent repetitive transcranial magnetic stimulation ( rTMS ) combined with speech and language therapy improves functional communication and basic linguistic skills of individuals with subacute aphasia . DESIGN R and omized , blinded , and sham-controlled study . SETTING Neurologic rehabilitation hospital . PARTICIPANTS Participants ( N=30 ) with subacute aphasia after stroke . INTERVENTIONS During a 2-week treatment period , half of the participants received 10 sessions of 20-minute inhibitory 1-Hz rTMS over the right inferior frontal gyrus ( Brodmann area 45 ) , and the other half received sham stimulation . Directly thereafter , all the participants underwent 45 minutes of speech and language therapy . MAIN OUTCOME MEASURES Aachen Aphasia Test , Amsterdam-Nijmegen Everyday Language Test ( ANELT ) , a naming screening , and subscales of the FIM , all assessed the day before and the day after treatment period . RESULTS The participants who received real rTMS significantly improved with respect to all 10 measures of basic linguistic skills and functional communication , whereas sham-treated participants significantly improved in only 6 of 10 measures ( paired t tests , P<.05 ) . There was a significant difference in the gains made by the 2 groups on 5 of 10 measures including functional communication ( ANELT ) ( repeated- measures analysis of variance , P≤.05 ) . CONCLUSIONS For the first time , this study has demonstrated that basic linguistic skills as well as functional communication are bolstered by combining rTMS and behavioral language therapy in patients with subacute aphasia OBJECTIVE Inhibition of motor cortex excitability of the contralesional hemisphere may improve dexterity of the affected h and after stroke . METHODS 40 patients ( 17 dominant hemispheric stroke , 23 non-dominant hemispheric stroke ) with a mild to moderate upper limb motor impairment were enrolled in a double-blind , r and omized , placebo-controlled trial with two parallel-groups . Both groups received 15 daily sessions of motor training preceded by either 1 Hz rTMS or sham rTMS .  Behavioral and neurophysiological evaluations were performed at baseline , after the first week and after the third week of treatment , and after a 6 months follow-up . RESULTS In both groups motor function of the affected h and improved significantly . Patients with stroke of the non-dominant hemisphere made a similar improvement , regardless of whether the motor training was preceded by sham or 1 Hz rTMS . Patients with stroke of the dominant hemisphere had a less favorable improvement than those with stroke of the non-dominant hemisphere after motor training preceded by sham rTMS . However , when 1 Hz rTMS preceded the motor training , patients with stroke of the dominant hemisphere made a similar improvement as those with stroke of the non-dominant hemisphere . INTERPRETATION Motor recovery of the affected upper limb after stroke is determined by dominance of the affected hemisphere . Stroke of the dominant hemisphere is associated with per se poorer improvement of the affected h and . 1 Hz rTMS over the contralesional M1 significantly improves dexterity of the affected h and in patients with stroke of the dominant hemisphere , but not in those with stroke of the non-dominant hemisphere Objective To investigate whether the efficacy of continuous theta-burst stimulation ( cTBS ) for improving visuospatial neglect can be enhanced by providing more days of stimulation and more stimulation trains per day . Methods In a prospect i ve study , right-h and ed patients with right hemisphere stroke and visuospatial neglect were r and omized to cTBS or sham cTBS treatment for 2 weeks and were followed up for 4 weeks . The cTBS group received active cTBS over the posterior parietal cortex of the unaffected hemisphere , combined with conventional rehabilitation therapy .  Changes in scores for two paper – pencil tests for visuospatial neglect ( star cancellation and line bisection ) were evaluated . Results In each group , 10 patients completed follow up . Compared with the sham group , star cancellation test scores in the cTBS group were improved by 37.03 % at the end of treatment and by 47.21 % after 4 weeks ’ follow up , and the line bisection score improved by 21.37 % at the end of treatment and by 35.99 % after 4 weeks ’ follow up . Conclusions These results suggest that the efficacy of cTBS in visuospatial neglect can be enhanced and prolonged by increasing the days of stimulation and the number of stimulation trains per day over the left posterior parietal cortex Abstract Purpose : To investigate the effect of low-frequency repetitive transcranial magnetic stimulation ( rTMS ) on lower extremity ( LE ) spasticity , motor function and motor neurone excitability in chronic stroke patients . Method : This study was a r and omised sham-controlled cross-over trial with 1-week follow-up . A total of 20 post-stroke patients were r and omised to receive active ( n = 10 ) or sham ( n = 10 ) rTMS . Fourteen of them ( 7 in each group ) crossed over to the sham or active rTMS after a washout period of 1 month . Interventions consist of five consecutive daily sessions of active or sham rTMS to the unaffected lower extremity motor area ( 1000 pulses ; 1 Hz ; 90 % of the tibialis anterior motor threshold ) . Outcome measures were modified modified ashworth scale ( MMAS ) , the H-reflex , lower extremity section of Fugl – Mayer assessment ( LE-FMA ) and timed UP and GO ( TUG ) test . All outcomes were measured at three levels in each intervention period : pre- and post-intervention and 1-week follow-up . Results : Friedman ’s test revealed significant improvement in MMAS score only after active rTMS . This improvement lasted for one week after the active rTMS . Repeated measure analysis of variance ( ANOVA ) showed significant time*intervention interaction for LE-FMA . There are no differences between groups for the MMAS and LE-FMA . No significant change in Hmax/Mmax ratio and TUG test was noted . Conclusion : Low-frequency rTMS over the LE motor area can improve clinical measures of muscle spasticity and motor function . More studies are needed to clarify the changes underlying this improvement in spasticity . Implication s for Rehabilitation Spasticity is a common disorder and one of the causes of long-term disability after stroke . Physical therapy modalities , oral medications , focal intervention and surgical procedures have been used for spasticity reduction . Beneficial effect of the repetitive transcranial magnetic stimulation ( rTMS ) for post-stroke upper extremity spasticity reduction and motor function improvement was demonstrated in previous studies . This study shows amelioration of lower extremity spasticity and motor function improvement after five daily sessions of inhibitory rTMS to the unaffected brain hemisphere which lasted for at least 1 week following the intervention
The aim of this review was to summarize the evidence for the effectiveness of low-frequency ( LF ) repetitive transcranial magnetic stimulation ( rTMS ) over the unaffected hemisphere in promoting functional recovery  after stroke .