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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 215-219

Effectiveness of transcranial magnetic stimulation in stroke patients: a mini-review


University Institute of Applied Health Sciences, Chandigarh University NH-95, Chandigarh–Ludhiana Highway, Mohali, Punjab, India

Date of Submission28-Apr-2022
Date of Acceptance20-May-2022
Date of Web Publication17-Jun-2022

Correspondence Address:
Ms. Priyanka Sindwani
University Institute of Applied Health Sciences, Chandigarh University NH-95, ChandigarhLudhiana Highway, Mohali, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_60_22

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  Abstract 

Transcranial magnetic stimulation (TMS) is normally used for the effects of stroke on corticomotor satisfaction, intracortical function, and interhemispheric interactions. The interhemispheric inhibition model states that the detection of motor function after a stroke is linked to a re-evaluation of asymmetric interhemispheric inhibition and corticomotor excitability. This model creates a reason to use neuromodulation techniques to reduce the excitement of the unaffected motor cortex and to facilitate the excitement of the affected motor cortex. However, the proof base for using neuromodulation strategies to decorate motor recovery after a stroke is not blanketed. Among stroke patients, TMS has become increasingly popular, as variations in neuronal sensitivity generated via modifications in the ionic balance of activated neurons are accountable for the quick-time period consequences of TMS. But, to be effective and accurate in treating sufferers, we gathered information from several sources, including articles with the terms TMS and stroke rehabilitation in the title. The previous research has mostly relied on randomized controlled trials; hence, a review of age studies with carefully determined inclusion criteria is required. The most important findings from this study’s implications and relevance are that TMS is somewhat beneficial, but there are still considerably more advances to be made for accurate and effective results.

Keywords: Neurorehabilitation, stroke, transcranial magnetic stimulation


How to cite this article:
Sindwani P, Chauhan P. Effectiveness of transcranial magnetic stimulation in stroke patients: a mini-review. MGM J Med Sci 2022;9:215-9

How to cite this URL:
Sindwani P, Chauhan P. Effectiveness of transcranial magnetic stimulation in stroke patients: a mini-review. MGM J Med Sci [serial online] 2022 [cited 2022 Jul 6];9:215-9. Available from: http://www.mgmjms.com/text.asp?2022/9/2/215/347700




  Introduction Top


Transcranial magnetic stimulation (TMS) may be a popular growing tool for stroke. Rehabilitation strategies that promote functional recovery are shown to enhance people’s standard of living life with a stroke.[1] There are few therapies as successful as TMS, which stimulates neurons inside the cerebral cortex with the scale, which is safe and has minimum discomfort. TMS is one of the most recent treatments for a variety of ailments and mental disorders. This system attracts weak electrical impulses to certain parts of the brain by assembling a brief but powerful magnetic flux that activates column elements in the brain without causing pain.[2] It is been described as a special depletion of neurons within the pallium, between 1.5 and 2 cm below the cranial bone using specific magnetic pulses.[3] The quick-term outcomes of TMS are caused by changes in neuronal sensitivity, which in turn is caused by adjustments within the ionic balance of active neurons. The long-term outcomes of TMS appear like an obsession with synaptic transitions among cortical neurons, also known as continual depression and prolonged-term electricity. Moreover, TMS may make adjustments in the results of neurotransmitter structures on glutamate AMPA receptor/NMDA receptor expression (influencing calcium) and axes.

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive stimulation that causes an electric current to be generated in the brain tissue. rTMS is considered a unique treatment modality to enhance motor function in stroke patients who suffer from cortical degeneration.[1] Although acute stroke has been remarkably advanced in terms of its treatment, a large number of patients have been left with a disability that affects their functional independence and quality of life, even though dementia is the most common cause in the world. As the total number of stroke survivors is probably growing due to demographic changes in our adult communities, new strategies are needed to enhance nerve resuscitation.[2]

Stroke is a worldwide disorder with excessive rates of long-time period incapacity, around 25–74% of stroke survivors require extraordinary help for everyday living, especially due to upper limb hemiplegia.[3]

Stroke frequently ends up in neuronal loss of life and everlasting disorder. It can cause serious damage to the cortical region, impair control, and lead to a decrease in autonomy and quality of life. The Stroke Roundtable Consortium proposes that the first 24 h as a hyperacute section, the first 7 days as a crucial phase, the first 3 months as a critical phase, 4-6 months as a late sub-acute phase, and the last 6 months as an incurable phase.[4] TMS has attracted lots of attention because it is powerful in supporting motor restoration in sufferers of stroke. Stroke is the leading explanation for disability. Opportunity and effective methods of stroke restoration are sought to beat the regulations of traditional treatment options. rTMS emerges as a promising device in this context. The neurophysiological results of stroke are decided especially in the affected location, and there is no clear proof of hyperexcitability of the unaffected hemisphere or choppy interhemispheric obstruction.

This suggests that assisting the immediate happiness of the affected M1 may be more effective than suppressing the unaffected M1 pleasure to promote post-stroke recovery.[5]


  Eligibility Top


The included studies had a randomized design of any kind with treatment modalities for stroke recovery using TMS. Both participants and researchers have to contribute to regular treatment sessions. Adults (aged 18 years, dependent on database search terms) with a confirmed diagnosis of stroke of any type, and at any time point after stroke, are included. Healthy adults are additionally covered in the analysis of the examined, including stroke patients and a non-stroke control group.


  Materials and methods Top


We searched all English articles using the following databases: PubMed with filters to search English articles, and articles from 2018 to 2022 to get knowledge about the advancement criteria in the upcoming years. The following keywords were used in the searches: TMS, stroke, rehabilitation, and transcranial magnetic stimulation, and articles not relevant to the topic and do not show the relation among TMS, stroke rehabilitation, etc. were excluded. We identified 40 pieces of information via the searches after the removal of duplicates. No additional records from other sources were identified. We excluded 200 studies after screening the titles and abstracts, primarily because the studies were on repetitive TMS, comparative look at, aphasia, and other illnesses. We also excluded 265 case studies, ongoing trials, retrospective studies, non-English language publications, and completely irrelevant articles. After further assessment, a total of eight studies were considered to meet the review inclusion criteria, from which only three studies are included as randomized controlled trials (RCTs). [Figure 1] depicts the strategy and review of evidence.
Figure 1: Flowchart of the studies approach and review proof

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  Results Top


The results illustrated succinctly in the table have been depicted based on the authors that used RCTs in their studies. Bai et al.[6] aimed to systematically assess the effects of rTMS and theta-burst stimulation (TBS) protocols in modulating cortical excitability after stroke with 10 durations of low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) stepped forward the cortical excitability of the unaffected M1 and measured the usage of an intensity-tracking technique that the intensity induces motor-evoked potentials (MEPs) of 1 mV by using a single-pulse TMS. Whereas Korzhova et al.[5] aimed to conduct a scientific evaluation and meta-assessment of all courses assessing the efficacy of rTMS in remedying spasticity, the implied effect size value and hence the 95% confidence c programming language were −0.80 and (−1.12, −0.49), respectively; in the course of a gaggle of real stimulation, in the case of simulated stimulation, those parameters were 0.15 and (−0.30, −0.00), respectively. However, Kang et al.[7] assess the recuperation consequences of extra electric-powered stimulation (ES) blended with LF-rTMS and motor imagery (MI) education on an upper extremity (UE) motor characteristic following stroke, with interventions had been achieved 5 days for a week for 2 weeks, for a total of 10 classes. All individuals were given the identical dosage of conventional rehabilitation at some point during the commentary period. TMS represents a non-invasive, rapid, safe, and reproducible prognostic device post-stroke, which might remedy prognostic uncertainties during stroke.[8],[9]

LF-rTMS did not merely suppress the cortical excitability of unaffected M1. Higher frequency (HF)-rTMS is more effective on the cortical excitability of only the affected M1. Spasticity did not decrease. ES added to LF-rTMS + MI treatment improved the recovery of motor function in paretic UEs compared with LF-rTMS + MI alone.

The results of the RCT data have been presented in [Table 1].
Table 1: Results of RCT data are presented in a summary form

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  Discussion Top


This comparison investigated the results of TMS in stroke sufferers. The meta-analysis conducted by McDonnell and Stinear[4] advised that the unaffected M1 patients with stroke emerge as not hyper-activated for the duration of active contraction and resting, indicated via the non-sizeable variations on abbreviated mental test, osteopathic manipulative therapy, and MEPs when compared with healthy controls.

To the high satisfaction of their facts, this advocated that motor impairment at the acute/subacute stage grows to be not due to immoderate pre-movement. The study by Xu et al. cannot exclude the possibility that the interhemispheric imbalance evolved, presumably due to the maladaptation of cortical reorganization or observed non-use, also may prevent the recovery of motor abilities, in a situation in which many studies have demonstrated the beneficial effects of LF-rTMS to the unaffected M1 in patients with persistent stroke.[10]

Korzhova et al.[5] believe that statistically large variations among organizations of actual stimulation and simulation had been verified for the utilization of excessive-frequency repetitive TMS or iTBS mode of M1 vicinity of the spastic leg (P=0.0002). In this, the statistically large impact of repetitive TMS on spasticity was found only for the advanced lesions in the brain stem and funiculus. To create a clearer variety of the antispasmodic effects of repetitive TMS on other lesion ranges, especially in patients with hemispheric stroke, similar research is needed.[10]

The study done by Mantell et al. suggested that in their study the modifications within the TMS electric-powered fields as a result of lesions are not effortlessly captured through a homogeneous version together with cerebrospinal fluid (CSF) thickness, curvature, or quantity. This shows the want for individualized and practical modeling to manual practical programs of TMS in stroke. Rehabilitation to seize idiosyncrasies, e.g., versions in morphology and resultant anatomy, their study has a few barriers also as they assign conductivity values based on literature values. These conductivity values can vary among individuals, so they are difficult to predict in a pediatric brain that is undergoing a variety of brain development methods affecting each gray matter and white matter. Additionally, they assumed that the lesions were CSF-filled volumes, rather like each other. In addition to CSF, glial scarring and other inactive tissues will fill the lesion area, which could also affect conductivity in the vicinity.[1]

The latest review recognized 141 rTMS and 132 tDCS research for limb impairment after stroke and concluded that the evidence does no longer exist in using those techniques in ordinary rehabilitation exercises. This look also located that most researches using TMS measures of motor cortex characteristics after stroke have small sample sizes and a high diploma of methodological variability. Those factors probably contributed to a loss of sensitivity for a few measures, such as silent period duration and intracortical facilitation; greater research with larger samples is needed to apprehend the results of stroke on motor cortex characteristics in each hemisphere. A dilemma of this study is the high heterogeneity among studies, probably reflecting the huge variation among the experimental protocols and presentation of sufferers’ submit stroke. Records had been most effectively blended, while the TMS degree (e.g., short-interval intracortical inhibition or MEP amplitude) became recorded in a similar way between studies, in keeping with the techniques posted.[11]

Stroke represents a major purpose of functional incapacity with expanded prevalence. Therefore, it is vital that stroke forecasts are timely and correct. So far, several biomarkers have been investigated to count on the survival of stroke survivors, including TMS among the bilateral. rTMS progressed the impact of motor education on the affected person’s hand after a stroke and further to the blended stimulation of the stimulus; this may indicate a new neurorehabilitative strategy for stroke.[11]

RCTs will provide scientific proof of the impact of re-evaluation of r-TMS on a huge pattern of stroke sufferers. In particular, we expect to see much better performance in clinical trials and batteries, showing significant improvements in the cognitive and behavioral traits of LHN within the r-TMS organization compared with the SHAM control group. In addition, we expect that this significant clinical improvement in the r-TMS group may also be reported on a specific scale that assesses motor independence in daily life activities. Finally, the inhibitory r-TMS in the left parietal cortex does not show a specific effect of r-TMS contractions in LHN neurophysiological correlates.[7]

There are several limitations to the present study. First, the little range of contributors who have been all enrolled from one center may additionally affect the statistical importance of our consequences. But, regardless of a tiny low sample length, the primary outcome was great inside the gift to observe. Secondly, because we meant to analyze the effect of extra ES, we did not lay out an effect group with rTMS because of the only intervention. Thirdly, the long-term impact of the intervention is unknown as only pre-intervention and immediate postintervention check scores were compared; we did not conduct any neurophysiological research that could mirror medical development. Therefore, the scientific efficacy of the LF-rTMS + MI + ES intervention mentioned within the gift examination must be verified through randomized managed trials with a bigger pattern length and lengthy-time period.[6]

The authors did not find superior effects of LF-rTMS applied to the unaffected M1 against sham stimulation in improving post-stroke upper limb motor functions.[8] Standard TMS represents a non-invasive, rapid, safe, and reproducible prognostic device post-stroke that might remedy prognostic uncertainties in instances of stroke.[9]


  Conclusion Top


We concluded that TMS is effective in stroke patients but still many advancements are pending for correct conclusion. However, the received data can be useful for improving the appearance of future rTMS trials and implementation in routine stroke rehabilitation procedures. Positive experiences, such as the provision of short breaks each day, may impact clinical rehabilitation programs aimed at improving patient satisfaction. The explanation and response from the standard vehicle recovery appointment at regular intervals after a stroke are also informed to patients. Negative emotions may be limited or avoided by the introduction of transparent or repetitive information in future tests. The experiences and preferences of stroke patients might be useful within the design of future rTMS studies and therefore the implementation of rTMS in clinical care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Karatzetzou S, Tsiptsios D, Terzoudi A, Aggeloussis N, Vadikolias K Transcranial magnetic stimulation implementation on stroke prognosis. Neurol Sci 2022;43:873-88.  Back to cited text no. 1
    
2.
Mantell KE, Sutter EN, Shirinpour S, Nemanich ST, Lench DH, Gillick BT, et al. Evaluating transcranial magnetic stimulation (TMS) induced electric fields in pediatric stroke. Neuroimage Clin 2021;29:102563.  Back to cited text no. 2
    
3.
Grefkes C, Fink GR Recovery from stroke: Current concepts and future perspectives. Neurol Res Pract 2020;2:17.  Back to cited text no. 3
    
4.
McDonnell MN, Stinear CM TMS measures of motor cortex function after stroke: A meta-analysis. Brain Stimul 2017;10:721-34.  Back to cited text no. 4
    
5.
Korzhova J, Sinitsyn D, Chervyakov A, Poydasheva A, Zakharova M, Suponeva N, et al. Transcranial and spinal cord magnetic stimulation in treatment of spasticity: A literature review and meta-analysis. Eur J Phys Rehabil Med 2018;54:75-84.  Back to cited text no. 5
    
6.
Bai Z, Zhang J, Fong KNK Effects of transcranial magnetic stimulation in modulating cortical excitability in patients with stroke: A systematic review and meta-analysis. J Neuroeng Rehabil 2022; 19:24.  Back to cited text no. 6
    
7.
Kang JH, Kim MW, Park KH, Choi YA The effects of additional electrical stimulation combined with repetitive transcranial magnetic stimulation and motor imagery on upper extremity motor recovery in the subacute period after stroke: A preliminary study. Medicine (Baltimore) 2021;100:e27170.  Back to cited text no. 7
    
8.
Di Gregorio F, La Porta F, Casanova E, Magni E, Bonora R, Ercolino MG, et al. Efficacy of repetitive transcranial magnetic stimulation combined with visual scanning treatment on cognitive and behavioral symptoms of left hemispatial neglect in right hemispheric stroke patients: Study protocol for a randomized controlled trial. Trials 2021;22:24.  Back to cited text no. 8
    
9.
Takeuchi N, Tada T, Toshima M, Matsuo Y, Ikoma K Repetitive transcranial magnetic stimulation over bilateral hemispheres enhances motor function and training effect of paretic hand in patients after stroke. J Rehabil Med 2009;41:1049-54.  Back to cited text no. 9
    
10.
Zhang L, Xing G, Shuai S, Guo Z, Chen H, McClure MA, et al. Low-frequency repetitive transcranial magnetic stimulation for stroke-induced upper limb motor deficit: A meta-analysis. Neural Plast 2017;2017:2758097.  Back to cited text no. 10
    
11.
Ting WK, Fadul FA, Fecteau S, Ethier C Neurostimulation for stroke rehabilitation. Front Neurosci 2021;15:649459.  Back to cited text no. 11
    


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