THE EFFICACY OF TRANSCRANIAL MAGNETIC

STIMULATION ON IMPROVING
MOTORIC FUNCTIONAL IMPAIRMENT
OF POST ISCHEMIC STROKE PATIENTS

Iin Tammasse1, Nadya Sumolang1, Khumaira Santa1

1

Faculty of Medicine Hasanuddin University

Introduction

Stroke is the 1st leading cause of death in Indonesia (15,4%). In 2007, prevalence of
Stroke was 8.2 per 1000 population on 33 provinces in Indonesia (Indonesia Basic Health
Research 2007). Stroke accounted for 99/100 000 age-gender-standardized death rate and
685/100 000 age-gender-standardized disability-adjusted life years lost (Karyana et al. 2014,
Kusuma et al. 2009). Thus, further investigation into treatments to decrease the number of post
stroke disability are critical to undertake.
Stroke is defined by the World Health Organization as a clinical syndrome consisting of
rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral
function lasting more than 24 hours or leading to death with no apparent cause other than a
vascular origin (Hatano, 1976). Classification based on the TOAST system identifies the
mechanism that leads to five categories: (1) Large-artery atherosclerosis, (2) Cardioembolism
(3) Small-artery occlusion (lacune) (4) Acute stroke of other determined etiology (5) Stroke of
undetermined etiology (Harold et al. 1993)
Approximately two thirds of stroke survivors have residual neurological deficits that
impair function and approximately 50% are left with disabilities making them dependent on
others for activities of daily living (Greshan GE et al. 1975). Previous studies have found that
among the more common are physical impairments in upper limb use and in functional walking.
Upper limb dysfunction remains an important hurdle for many stroke survivors. Only 5% of
adult stroke survivors regain full function of the upper limb and 20% regain no functional use.
In addition, the other common concern for post-stroke patients is whether they would regain
independent walking (Duncan P et al, 1198).
Advances have occurred in the prevention and treatment of stroke during the past
decade. One of the current methods to treat post stroke disability is TMS. Transcranial magnetic
stimulation (TMS) is a noninvasive method by which weak electrical currents are induced in the
brain by a rapidly changing magnetic field. The magnetic field passes through the skull,
inducing mild electric currents in the brain, which excite and depolarize neurons in the brain
(Almaraz et al. 2010). TMS has shown promising results in improving gait, a major cause of
disability, and may provide a therapeutic alternative.
As it is a relatively new form of treatment, there are less data on the side effect or longterm efficacy. Some studies had addressed the efficacy of TMS for the treatment of motoric
impairment of post-stroke patients (Table 1).
This study attempts to assess the efficacy of TMS intervention on improving motoric
function of post-stroke patients. In particular, we measured the patients motoric impairment
using the European Stroke Scale and compare the result before and after receiving TMS
intervention.
Table 1: TMS studies as a treatment for stroke patient

Author

Study Design

Population

Intervention

Duratio

(Lee et al.

Case-control

s
29 patients

rTMS was

n
2 weeks Patients were

2014)

study

with

applied to

found to be

subacute

the hand

significantly

stroke

motor cortex

associated

for 10

with a

minutes with

response to

10 Hz

rTMS

11 patients

frequency
A. active 6

Outcome

(Cassidy et

Crossover ,

5 weeks Significant

al. 2015)

double blind

Hz priming

within-

trial

t-active 1 Hz

treatment

rTMS, B.

differences

active 1 Hz

from

priming t

baseline in

active 1 Hz

ipsilesional

rTMS, and

cortical

C. sham 6

silent period

Hz

(CSP)

priming t-

duration and

active 1 Hz

short-

rTMS

interval
intracortical
During

inhibition.
Improved the

right hand for 10

kinematics

dominant

minutes

weeks-

of finger and

15 patients

applied to

grasp

with a first

the vertex

months

movements

subcortical

(control

after

in the

ischemic

stimulation)

stroke

affected

(Nowak et

Crossover

15 adult

al. 2008)

investigation

1-Hz rTMS

and

hand

contralesion
al M1
3

(Trompetto

Case-control

21

Stimulation

5 days

Subgroup

et al. 2000)

study

patients

of the motor

A1: the hand

affected by

cortex was

motor score

stroke (12

performed

was 0; Only

male, 9

with a

two patients

female;

Magstim 200

of group B

aged

stimulator

showed

3990

plegic hand

years)

muscles at
T1;only one
of the
patients of
group C had
some degree
of hand
movement at

(Weiduscha Randomized,

10 rght-

1-Hz

(T1)
Better

t et al.

controlled,

handed

repetitive

months

clinical

2010)

blinded study

patients

transcranial

improvement

magnetic

stimulation
over righthemispheric
Broca
Materials and Method
Study population
The study population consisted 124 post-ischemic stroke patients, who were undergoing
TMS intervention in a clinic in Indonesia and followed up during January 2015 to September
2015. Inclusion criteria for this study are patients with post non-hemorrhagic stroke that has
motoric functional impairment. All patients had to received MRI scan before undergoing TMS
intervention. Finally, all patients that passed the inclusion criteria were taken as total sample.

Clinical outcome
The primary outcome measures the therapeutic efficacy of TMS intervention, using the
European Stroke Scale (ESS). The European Stroke scale can be used as an instrument for
matching of treatment groups as well as for evaluation of the patients level of impairment. The
scale consists of 14 items selected on the basis of their specificity and their prognostic value.
The 14 items are level of consciousness, comprehension, speech, visual field, gaze, facial
movement, maintenance of arm position, arm raising, wrist extension, finger strength,
maintenance of leg position, leg flexing, foot dorsiflexion, and gait (L. Hantson et al. 1994). All
patients were evaluated by one consultant neurologist who runs a neurology clinic. Outcome
data were retrieved from the Electronic Patient Records.
Statistical analysis
Paired T-test was used to assess the statistical significance of the sample. P<0.05 was
considered statistically significant. We compared the calculated value with the table value. If the
result show no difference between the pre-TMS intervention and post-TMS intervention. Thus,
the null hypothesis is accepted.

Results
Clinical characteristic of the study population
The clinical characteristics of the study population are shown in Table 1. The mean age
was 56.65 years old. Seventy seven subjects (62.1%) were males and forty seven of subjects
(37.9%) were females. There were 124 subjects who suffered motoric functional impairment
due to stroke attack.

Characteristic
Age
Sex
Male
Female

Total Number (%)

Mean +/- SD
56.65 +/- 11.489

77 (62.1)
47 (37.9)

Significant motoric improvement post-TMS intervention

A parametric paired t-test analysis was performed as describe in the method to compare
pre- and post- the ESS score. The mean of pre- score was 70,19 and the mean of post-score was
85,68 with respectively standard deviation of 18,264 and 13,372. Thus, there was an average
improvement score of 15,48 using ESS score (0-100) with a standard deviation of 11,03.
(p<0,05)

Pre

Post

T-

test resulted in a t value of -15,63 and with two tail critical value of 1,98 with a confidence
interval of 95%. Thus, there is a significant overall improvement as a result of TMS
intervention. The graph below indicates an association in comparison of pre- and post- score of
ESS. There is a clear improvement in ESS score.

Figure A. Significant elevation of ESS Score of stroke patients with post TMS
Intervention. There was an average elevation of 15,48 from pre to post ESS score. (CI=95%)
(p<0,05)
Discussion
Our result showed that the improvement of motoric impairment was significantly
correlated using European Stroke Scale. This study indicated that there is improvement on
motor functions such as facial movement, hand movement and gait.
Multiple reports previously done in TMS and stroke have confirmed the positive link
between TMS and hand movement ,as Nowak et al.(2008) has found application of rTMS to the
contralesional M1 improved the kinematics of finger and grasp movements in the affected hand.
Previous studies have shown several methods to improve patients motoric function
using different scale. Konecny et al. (2011) studied there were changes in facial movement,
evaluated with the house-Brackmann Grading System (hBDS) after given orofacial therapy. The
study was focused merely on patients with facial paresis. Meanwhile our study addressed
motoric impairment in general, including but not limited to facial paresis.
Berger et al. (2006) measured the horizontal eye-in-head and head-on-trunk deviation.
The measurements were done at the bedside of patients with acute left- or right-sided stroke. It
concluded that a marked spontaneous horizontal deviation of the eye and the head observed ~
1.5 days post-stroke is not a symptom associated with acute cerebral lesion per se, nor is a
general symptom of right hemisphere lesion, but rather is a specific sign of a spatial neglect.
Our study has clearly demonstrated that TMS improve patients situation with an
average European Stroke Scale elevation of 15.48 and the result is considered significant. The
observation of this study is consistent with a former study done by Khedr et al.(2005) showing
10 consecutive days of rTMS employed as an add-on intervention to normal physical and drug
therapies improves immediate clinical outcome in early stroke patients, assessed using
Scandinavian Stroke Scale (SSS), NIH Stroke Scale (NIHSS), Barthel Index Scale (BI).
Conclusion

From this study, we can conclude that TMS is a technology that can be used to treat patients
with post-ischaemic stroke motoric impairment and prevent further disability in the future. TMS
intervention has been proven to be effective to improve patients clinical condition.
We suggested for deeper investigation and analysis to be conducted on TMS regarding the
treatment of other subtypes of stroke. We also see that there is a possibility of TMS to be used
as solution for other motoric related disorder.