Repetitive Transcranial Magnetic Stimulation Facilitates Effective Gait Rehabilitation in Patients with Traumatic Brain Injury

Forshee, C. MPT CBIS, Foreman, J., Masel, B. MDTransitional Learning Center • Galveston, Texas

Background

Rehabilitation after a TBI can be a long, intensive process that requires further development to fully address the consequence of a severe TBI.

Gait rehab after a TBI has always been primarily focused on the physical output of an impaired function and not adequately focused on the unseen source- the brain.

Transcranial magnetic stimulation (TMS) is a non-invasive technique used to modulate the excitability of discrete cortical areas using electromagnetic induction. Repetitive TMS is a series of stimuli used to increase or decrease neural activation, depending on the frequency of the stimuli, resulting in an effect that outlasts the treatment.

Impaired muscle function caused by a TBI may be a result of asymmetric interhemispheric balance. The corticomotor area that controls each muscle group is mediated by its counterpart in the contralateral hemisphere. When one hemisphere is damaged, the other develops uninhibited control causing tone and spasticity.

Repetitive TMS can improve motor control to the affected muscles by down-regulating the excessive activity of the contralesional hemisphere. This restoration of muscle control may prove to be a significant adjunct to standard therapy.

Objective

Use rTMS to increase quality of lower extremity control in post acute TBI patient

Experimental Design

SubjectPost acute TBI, previous physical therapy, mostly wheelchair dependent

Initial Assessment Gait analysis (GAITRite)

Condition 1: 2 single-point canes, bilat supra-malleolar orthosis, shoes, and verbal cues Condition 2: no assistive devices, bare feet, verbal cues and contact guard asst.

Range of MotionSpasticity (Tardieu)

TreatmentrTMS: 20 trains of 30 stimuli @ 50 Hz, Right Tibialis Anterior PT: 45 mins: stretching, strengthening, and gait training rTMS immediately followed by PT daily.After 18 sessions over 4 weeks, gait, ROM, and spasticity were retested.

Discussion

rTMS appears to increase effects of physical therapy and should be utilized for the rehabilitation of TBI patients

Navigation- and Analysis-Software

Polaris-Camera3D-Tracking

Magnetic Stimulator-Nexstim TMS

Stimulation Coil

Tracking Tools

EMG

Navigation display

EMG displayAverage Step Length Increases After 4 Weeks of Daily rTMS and PT

0

5

10

15

20

25

30

35

40

45

Average Step Length (cm)

2 SPC 20.3 39.06

Bare Feet 9.79 22.22

12-Jun 6-Jul

Acknowledgements

Moody Foundation

Bibliography

Demirtas-Tatlidede, A., Vahabzadeh-Hagh, A., Bernabeu, M., Tormos, J., Pascual-Leone, A. (2012). Noninvasive brain stimulation in traumatic brain injury. J Head Trauma Rehabil. 27, 274-292.

Carr, J., Shepherd, R. (2003). Stroke rehabilitation: guidelines for exercise and training to optimize motor skill. London, United Kingdom. Butterworth-Heinemann.

The Essential Brain Injury Guide (2009). Brain Injury Association of America, Inc.

Gait Velocity Increases After 4 Weeks of Daily rTMS and PT

0

5

10

15

20

25

30

Gait Velocity (cm/sec)

2 SPC 19.8 23.9

Bare Feet 8.6 18

12-Jun 6-Jul

Step Length Equalizes Within Condition After Daily rTMS and PT

19.62

-0.04

40.03

12.52

38.09

28.08

21.5822.85

-5

0

5

10

15

20

25

30

35

40

45

12-Jun 6-Jul

Step Length (cm)

2 SPC- Left

2 SPC- Right

……….

Bare Feet- Left

Bare Feet- Right

Results

Range of motion: Right- no change; Left- 129-146° (+13%)Spasticity (first catch): Right- 95-85°; Left- 109-93°

Adding rTMS to therapy regiment yielded greater gait improvement

Increased control of leg muscles allowed quicker, more controlled gait Increased mobility without wheelchair, decreased burden of care

Fig. 1: Asymmetric interhemispheric balance caused by TBI

Fig. 2: Down-regulating the dominate side via rTMS restores

interhemispheric control

Fig. 3: TMS setup

Fig. 4 & 5: TMS and EMG display