Baseline Severity of Upper Limb Hemiparesis Influences the Outcome of Low-Frequency rTMS Combined With Intensive Occupational Therapy in Patients Who Have Had a Stroke

Objective: To clarify whether the efficacy of combined low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) depends on baseline severity of upper limb hemiparesis after stroke. Design: Retrospective comparative study. Setting: Department of Rehabilitation Medicine at a university hospital. Subjects: Fifty-two patients who had sustained a stroke and had upper limb hemiparesis (age: 57 +/- 13 years; time after onset: 50 +/- 33 months). Based on the Brunnstrom stage for hand-fingers at admission, patients were divided into a Stage 3 group (n = 13), a Stage 4 group (n = 20), and a Stage 5 group (n = 19). Interventions: During a 15-day hospitalization, each patient underwent 22 sessions of 20-minute low-frequency rTMS that was applied to the non-lesional hemisphere and 120 minutes of intensive OT (one-on-one training and self-training). Main outcome measures: Motor function of the affected upper limb was evaluated with the Fugl-Meyer Assessment and the Wolf Motor Function Test (WMFT) on the days of admission and discharge. WMFT performance time data were log-transformed. Results: The Fugl-Meyer Assessment score increased significantly in all patients (from 40.2 +/- 12.2 to 43.4 +/- 11.8 points, P < .001), but the score increase was significantly larger in the Stage 4 group than in the other two groups (2.1 +/- 2.3 points in the Stage 3 group, 5.1 +/- 2.9 points in the Stage 4 group, and 2.3 +/- 1.8 points in the Stage 5 group, all P < .05). Similarly, the WMFT performance time decreased significantly in all patients (from 3.27 +/- 0.90 to 2.96 +/- 1.10, P < .001), but the difference in the extent of the decrease was significant between Stage 3 and Stage 4 groups and between Stage 3 and Stage 5 groups (0.04 +/- 0.07 in the Stage 3 group, 0.41 +/- 0.29 in the Stage 4 group, and 0.35 +/- 0.31 in the Stage 5 group, all P < .01). Conclusions: Our 15-day protocol of low-frequency rTMS and intensive OT is potentially promising in improving motor function of the affected upper limb. The extent of motor improvement by the intervention seemed to be influenced by the severity of upper limb hemiparesis at study entry. PM R 2011;3:516-522