Low-frequency Transcranial Magnetic Stimulation To Enhance Motor Recovery In The Subacute Phase After Stroke

• Motor function of the paretic hand evaluated with the Jebsen-Taylor test [ Time Frame: Baseline, two weeks, 1 month, 3 and six months after end of treatment ] [ Designated as safety issue: No ]
  
• Number of Participants with Adverse Events as a Measure of Safety and Tolerability [ Time Frame: Baseline, two weeks, 1 month, 3 and six months after end of treatment ] [ Designated as safety issue: Yes ]
  
• Number of patients able to comply with the protocol [ Time Frame: Baseline, two weeks, 1 month, 3 and six months after end of treatment ] [ Designated as safety issue: No ]
  

• Force of the paretic hand [ Time Frame: Baseline, two weeks, 1 month, 3 and six months after end of treatment ] [ Designated as safety issue: No ]
  
• Fugl-Meyer evaluation of motor performance (upper limb) [ Time Frame: Baseline, two weeks, 1 month, 3 and six months after end of treatment ] [ Designated as safety issue: No ]
  
• Disability evaluated with the modified Rankin scale [ Time Frame: Baseline, two weeks, 1 month, 3 and six months after end of treatment ] [ Designated as safety issue: No ]
  
• Functional Independence Measure [ Time Frame: Baseline, two weeks, 1 month, 3 and six months after end of treatment ] [ Designated as safety issue: No ]
  
• Neurological impairment evaluated with the NIH Stroke Scale [ Time Frame: Baseline, two weeks, 1 month, 3 and six months after end of treatment ] [ Designated as safety issue: No ]
  
• Measures of corticomotor excitability evaluated with transcranial magnetic stimulation [ Time Frame: Baseline, two weeks, 1 month, 3 and six months after end of treatment ] [ Designated as safety issue: No ]
  

Stroke is a major cause of disability and worldwide. Hand motor impairment is frequent after stroke. Even mild impairments of the upper limb negatively impact disability and quality of life in these patients significantly contributes to disability. Therapeutic alternatives for hand motor rehabilitation are deeply needed.

Repetitive transcranial magnetic stimulation (rTMS) has emerged as a potential tool to improve hand motor performance after stroke. While high-frequency rTMS (HF-rTMS) often increases motor cortical excitability, LF-rTMS often has the opposite effect. Up-regulation of excitability in the affected hemisphere by HF-rTMS or down-regulation of the UH by LF-rTMS can restore the balance in inter-hemispheric inhibition and hence, facilitate movement of the paretic hand Both strategies, as well as the combination of both, have yielded encouraging results when applied in proof-of-principle, single-session studies to patients with mild hand motor impairment in the subacute and chronic stages after stroke. However, few rTMS studies included patients less than six months after stroke, and effects of LF-rTMS of the unaffected hemisphere in patients with severe motor impairment in the subacute phase have not been yet reported.

The investigators opted for a novel approach to enhance hand motor recovery, by examining feasibility, safety and preliminary efficacy of either active or sham LF-rTMS of the UH or sham rTMS as add-on therapies to outpatient customary rehabilitation, to patients with mild to severe hand paresis, within 5-45 days after unilateral ischemic stroke. The investigators hypothesize that, at this stage, LF-rTMS will be feasible even in patients with severe motor deficits, will have minimal adverse events and will enhance effects of customary rehabilitation on hand motor performance.