A case series on combining repetitive transcranial magnetic stimulation with conventional rehabilitation therapies for upper limb motor-function restoration

This case series reports the integration of repetitive transcranial magnetic stimulation (rTMS) with conventional rehabilitation therapies in three early subacute ischemic stroke patients with upper limb motor impairment. In Malaysia, data on the combination of rTMS with intensive rehabilitation for stroke patients remains limited. The three patients with completely paretic upper limb, began therapy on post-stroke day 20, 16, and 15, respectively. They received rTMS sessions with inhibitory protocols targeting the contralesional primary motor area (M1) at 1 Hz, 5 days per week for 2 weeks (10 sessions). Each session included 1800 pulses at 120% resting motor threshold for 40 minutes, followed by 60 minutes of upper limb motor-function training. Outpatient occupational therapy was then continued for 3 months. All patients showed neurological and functional recovery as measured by the Medical Research Council scale and Fugl-Meyer Assessment-Upper Extremity Motor. The gains were observed immediately after the 10 rTMS sessions and persisted at 3 months post-stroke. Furthermore, all patients also achieved total independence in daily activities, with Modified Barthel Index scores of 99-100. No serious adverse events were reported. This case series suggests that combining rTMS with conventional rehabilitation therapies during the early subacute phase may enhance upper limb motor function recovery in stroke patients.