The Effect of Non-invasive Brain Stimulation rTMS on Hand Muscles in Chronic Stroke Patients.

The goal of this study is to determine the efficacy of a high-dose of a excitatory-specific patterned Transcranial Magnetic Stimulation (i.e., intermittent theta-burst stimulation - iTBS) protocol as a neuromodulatory tool on the neuromotor recovery (corticospinal excitability and motor performance) in individuals with chronic stroke using either the conventional iTBS protocol (600 pulses; iTBS600) or a high dose iTBS protocols (a total of 2400 pulses) over a single spot (Focal iTBS; FiTBS2400) and 4 spots (Diffuse iTBS: DiTBS2400) on the ipsilesional hemisphere. The use of this approach aims to potentially maximize motor recovery in chronic stroke by harnessing corticospinal plasticity and modulating motor learning behavior.

Inclusion criteria

• Age >=21 years old of any race or gender
• First-ever ischemic or hemorrhagic stroke (neuroimaging verified) at least 3 months from stroke onset
• Unilateral arm weakness measured by FM-UM scale <= 62 out of 66
• Inducible rest motor threshold and testing motor threshold recorded from the affected first dorsal interosseous (FDI) muscle from the study subject

Exclusion criteria

• Bilateral strokes (infarcts and/or hematoma)
• Other co-existent neuromuscular disorders affecting upper extremity motor impairment.
• History of medically uncontrolled depression or other neuropsychiatric disorders despite medications either before or after a stroke that may affect the subject's ability to participate in the study.
• Uncontrolled hypertension despite medical treatment(s) at the time of randomization, defined as SBP≥185 mmHg or DBP≥110 mmHg (patient can be treated, reassessed and randomized later).
• Presence of any MRI/rTMS risk factors including but not limited to:

• an electrically, magnetically, or mechanically activated metallic or nonmetallic implant including cardiac pacemaker, intracerebral vascular clips or any other electrically sensitive support system.
• a non-fixed metallic part in any part of the body, including a previous metallic injury to the eye.
• history of seizure disorder before stroke or seizure after stroke.
• preexisting scalp lesion or bone defect or hemicraniectomy.
• Concurrent enrollment in another interventional stroke recovery study.
• Concerns that the subject cannot comply with study procedures and visits.
• Pregnant individuals