Cerebellar Theta Burst Stimulation on Walking Function in Stroke Patients: A Randomized Clinical Trial

Effects of cerebellar repetitive transcranial magnetic stimulation on stroke rehabilitation: A systematic review and meta-analysis

BACKGROUND

Cerebellum has been a emerging target for non-invasive brain stimulation (NIBS) on post-stroke patients in recent years. While research is emerging on the impact of cerebellar repetitive transcranial magnetic stimulation (rTMS) on post-stroke patients, and its integrated effect remain unclear.

OBJECTIVES

The objective of this review is to evaluate the efficacy of cerebellar rTMS on stroke rehabilitation.

METHODS

We searched PubMed, EMBASE, and Web of Science databases from inception to 31 March 2024 for randomized controlled trials (RCTs) and case studies reporting effects of cerebellar rTMS on patients with stroke.

RESULTS

This review included 18 studies (n = 638 participants), consisting of 14 RCTs and 4 case reports. A total of 6 studies focused on post-stroke dysphagia, while 12 studies investigated post-stroke motor dysfunction. Comparative analysis between treatment and control groups revealed statistically significant improvements in swallowing function, as measured by the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) (P = 0.02), the Penetration Aspiration Scale (PAS) (P < 0.001), and the Standardised Swallowing Assessment (SSA) (P < 0.001). Moreover, cerebellar rTMS treatment showed significant enhancements in balance abilities and activity of daily living among stroke patients, as indicated by significant increases in the Berg Balance Scale (BBS) (P = 0.003) and the Barthel Index (BI) (P = 0.04) compared to the control group.

CONCLUSIONS

Existing evidence suggests that cerebellar rTMS holds promise in mitigating post-stroke swallowing dysfunction and motor dysfunction. Stimulation by cerebellar rTMS appears to be an efficacious technique for enhancing stroke rehabilitation.

Effects of Cerebellar Transcranial Magnetic Stimulation on the Motor Function of Patients With Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

As the core of motor control and learning, the cerebellum is crucial for maintaining posture, regulating muscle tone, and coordinating movement. In recent years, there has been an increase in the number of studies on the application of cerebellar transcranial magnetic stimulation (cTMS) to motor dysfunction in patients with stroke. This review aims to analyze cTMS efficacy for stroke patients and further explore the specific effects of different stages of the disease, stimulation modes, stimulation intensity, and treatment duration.

METHODS

Six databases were searched comprehensively-CNKI, Wanfang, Web of Science, PubMed, The Cochrane Library, and Embase-to collect randomized controlled trials (RCTs) up to October 2024 that investigated the improvement of physical motor dysfunction in stroke patients using cTMS. Two researchers screened the literature, extracted data, and independently assessed the quality and risk of bias of the included studies using the PEDro scale and the Cochrane Risk of Bias Assessment Tool 2. Meta-analysis was performed using RevMan 5.4.

RESULTS

A total of 20 RCTs with 812 participants were included. Meta-analysis and sensitivity analysis revealed that cTMS significantly improved BBS (Random, MD = 5.19, 95%CI = 3.66-6.72, p < 0.00001), enhanced FMA-LE scores (Random, MD = 1.88, 95%CI = 0.76-3.01, p = 0.001), shortened the TUG (Fix, MD = -1.64, 95%CI = -2.60 to -0.68, p = 0.0008), and 10MWT durations (Fix, MD = -7.66, 95%CI = -12.33 to -2.99, p = 0.001), and increased MEP amplitudes (Fix, MD = 0.45, 95%CI = 0.04-0.87, p = 0.03). Subgroup analysis of the BBS showed that cTMS had a significant effect on patients with stroke in the subacute phase (p < 0.00001), with improvements observed using HF-rTMS (p < 0.0001), iTBS (p < 0.00001), and intensities ≤ 80%RMT (< 80% RMT, p < 0.0001; 80% RMT, p < 0.00001). cTMS consistently demonstrated superior effects compared to controls across different intervention durations (5-10 sessions, p = 0.009; 11-20 sessions, p < 0.00001; > 20 sessions, p < 0.00001).

CONCLUSION

cTMS effectively improves motor function in patients with stroke, particularly during the subacute phase with excitatory stimulation and moderate intensities (≤ 80%RMT).

TRIAL REGISTRATION

PROSPERO number: CRD42024540604.

Effects of cerebellar non-invasive brain stimulation on balance and gait performance in individuals with stroke: a systematic review and meta-analysis

INTRODUCTION

Non-invasive brain stimulation (NIBS) is widely used for motor recovery after stroke. Recent studies have investigated the efficacy of cerebellar NIBS (cNIBS) in enhancing lower limb functional recovery in individuals with stroke. Thus, this study aims to investigate the effect of cNIBS on balance and gait recovery in individuals with stroke.

EVIDENCE ACQUISITION

A systematic literature search was conducted in CINAHL, Cochrane Library, MEDLINE, Physiotherapy Evidence Database, PsyclNFO, PubMed, and Scopus from inception to April 29, 2024. Randomized controlled trials (RCTs) that investigated the effects of cNIBS on gait or balance performance in individuals with stroke were included. Studies involving participants with cerebellar or brainstem stroke were excluded. Two researchers independently conducted study selection and data extraction and examined the methodological quality of the included RCTs and the certainty of evidence. A random-effects meta-analysis was performed to estimate the between-group mean difference (MD) or standardized MD (SMD) based on pre-post changes along with the 95% confidence interval (CI).

EVIDENCE SYNTHESIS

Fourteen RCTs involving 382 participants were included. The methodological quality of the included studies ranged from fair to excellent. Compared with sham conditions, cNIBS significantly improved balance, as measured using the Berg Balance Scale (MD=4.17, 95% CI=2.28-6.05, P<0.01, low certainty of evidence); walking speed, as assessed using the 10-m walk test and 25-Feet Walk Test (SMD=-0.36, 95% CI=-0.68 to -0.03, P=0.03, moderate certainty of evidence); and functional mobility, as measured using the Timed Up and Go test (MD: -3.34, 95% CI=-5.14 to -1.54, P<0.01, low certainty of evidence).

CONCLUSIONS

With low-to-moderate certainty, the evidence indicates that cNIBS, including tDCS and TMS, can improve balance in individuals with stroke. cNIBS is also a promising approach to facilitate gait and functional mobility in stroke survivors. Future studies should determine optimal stimulation protocols and elucidate the mechanisms underlying the treatment effects.

Exploring cerebellar transcranial magnetic stimulation in post-stroke limb dysfunction rehabilitation: a narrative review

This review delves into the emerging field of cerebellar Transcranial Magnetic Stimulation (TMS) in the rehabilitation of limb dysfunction following a stroke. It synthesizes findings from randomized controlled trials and case studies, examining the efficacy, safety, and underlying mechanisms of cerebellar TMS. The review outlines advancements in TMS technologies, such as low-frequency repetitive TMS, intermittent Theta Burst Stimulation, and Cerebello-Motor Paired Associative Stimulation, and their integration with physiotherapy. The role of the cerebellum in motor control, the theoretical underpinnings of cerebellar stimulation on motor cortex excitability, and the indirect effects on cognition and motor learning are explored. Additionally, the review discusses current challenges, including coil types, safety, and optimal timing and modes of stimulation, and suggests future research directions. This comprehensive analysis highlights cerebellar TMS as a promising, though complex, approach in stroke rehabilitation, offering insights for its clinical optimization.

The effectiveness of theta burst stimulation for motor recovery after stroke: a systematic review

BACKGROUND

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Motor dysfunction is a common sequela, which seriously affects the lives of patients. Theta burst stimulation (TBS) is a new transcranial magnetic therapy for improving motor dysfunction after stroke. However, there remains a lack of studies on the mechanism, theoretical model, and effectiveness of TBS in improving motor dysfunction following stroke.

OBJECTIVE

This paper provides a comprehensive overview and assessment of the current impact of TBS on motor rehabilitation following stroke and analyzes potential factors contributing to treatment effect disparities. The aim is to offer recommendations for further refining the TBS treatment approach in subsequent clinical studies while also furnishing evidence for devising tailored rehabilitation plans for stroke patients.

METHODS

This study was conducted following PRISMA guidelines. PubMed, Embase, Web of Science, and the Cochrane Library were searched systematically from the establishment of the database to February 2024. Relevant studies using TBS to treat patients with motor dysfunction after stroke will be included. Data on study characteristics, interventions, outcome measures, and primary outcomes were extracted. The Modified Downs and Black Checklist was used to assess the potential bias of the included studies, and a narrative synthesis of the key findings was finally conducted.

RESULTS

The specific mechanism of TBS in improving motor dysfunction after stroke has not been fully elucidated, but it is generally believed that TBS can improve the functional prognosis of patients by regulating motor cortical excitability, inducing neural network reorganization, and regulating cerebral circulation metabolism. Currently, most relevant clinical studies are based on the interhemispheric inhibition model (IHI), the vicariation model, and the bimodal balance-recovery model. Many studies have verified the effectiveness of TBS in improving the motor function of stroke patients, but the therapeutic effect of some studies is controversial.

CONCLUSION

Our results show that TBS has a good effect on improving motor function in stroke patients, but more large-scale, high-quality, multicenter studies are still necessary in the future to further clarify the mechanism of TBS and explore the optimal TBS treatment.

Effect of theta burst stimulation on lower extremity motor function improvement and balance recovery in patients with stroke: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

To investigate the therapeutic benefits of theta burst stimulation on lower-limb motor dysfunction and balance recovery in patients with stroke.

METHODS

A literature search was performed across CNKI, CBM, WanFang, VIP, PubMed, Embase, Cochrane Library, and Web of Science until November 2023. The Methodological quality of included studies was assessed by using the Cochrane risk-of-bias tool and the PEDro scale, and the meta-analysis was performed by using RevMan 5.3 software. Two independent researchers screened the literature and extracted basic information on participants, interventions, comparisons, outcomes, and studies.

RESULTS

Eight studies, including cTBS and iTBS, with 290 participants meeting the inclusion criteria for this systematic review, and 7 studies including only iTBS with 230 participants were included in this meta-analysis. The methodological quality of the studies included ranged from moderate to high. The results showed iTBS had significantly higher scores on the Berg Balance Scale (BBS) than the control group. (MD = 4.57, 95% CI: 1.76 to 7.38, Z = 3.19, P = .001). Subgroup analysis showed CRB-iTBS markedly improved BBS scores (MD = 4.52, 95% CI: 1.78 to 7.27, Z = 3.23, P = .001), whereas LE M1-iTBS did not exhibit a significant enhancement in BBS scores (MD = 6.10, 95% CI: -7.34 to 19.53, Z = 0.89, P = .37); iTBS showed no significant increase in lower-limb motor function (FMA-LE) (MD = 1.80, 95% CI: -1.10 to 4.69, Z = 1.22, P = .22). Subgroup analysis revealed both CRB-iTBS and LE M1-iTBS interventions were not effective in improving FMA-LE (MD = 3.15, 95% CI: -4.70 to 11.00, Z = .79, P = .43; MD = 1.05, 95% CI: -2.20 to 4.30, Z = .63, P = .53); iTBS significantly reduced the MEP latency (P = .004), but did not show a significant improvement in walking performance (10 MWT), mobility (TUG), or activities of daily living [M(BI)] (P > .05).

CONCLUSION

Based the current study, iTBS can increase patients' balance function. The CRB-iTBS protocol is more effective than the LE M1-iTBS protocol. Additionally, iTBS may be a promising therapy tending to enhance lower-limb motor function, walking performance, mobility, and activities of daily living.

Effects of motor imagery-based brain-computer interface-controlled electrical stimulation on lower limb function in hemiplegic patients in the acute phase of stroke: a randomized controlled study

Background

Lower limb motor dysfunction is one of the most serious consequences of stroke; however, there is insufficient evidence for optimal rehabilitation strategies. Improving lower limb motor function through effective rehabilitation strategies is a top priority for stroke patients. Neuroplasticity is a key factor in the recovery of motor function. The extent to which neuroplasticity-based rehabilitation therapy using brain-computer interface (BCI) is effective in treating lower limb motor dysfunction in acute ischemic stroke patients has not been extensively investigated.

Objective

This study aimed to assess the impact of BCI rehabilitation on lower limb motor dysfunction in individuals with acute ischemic stroke by evaluating motor function, walking ability, and daily living activities.

Methods

This study was conducted in a randomized controlled trial, involving 64 patients with acute ischemic stroke who experienced lower limb motor dysfunction. All patients were divided into two groups, with 32 patients assigned to the control group was given conventional rehabilitation once a day for 70 min, 5 times a week for 2 weeks, and the experimental group (n = 32) was given BCI rehabilitation on top of the conventional rehabilitation for 1 h a day, 30 min of therapy in the morning and an additional 30 min in the afternoon, for a total of 20 sessions over a two-week period. The primary outcome was lower extremity motor function, which was assessed using the lower extremity portion of the Fugl-Meyer Rating Scale (FMA-LE), and the secondary endpoints were the Functional Ambulation Scale (FAC), and the Modified Barthel index (MBI).

Results

After 20 sessions of treatment, both groups improved in motor function, walking function, and activities of daily living, and the improvements in FMA-LE scores (p < 0.001), FAC (p = 0.031), and MBI (p < 0.001) were more pronounced in the experimental group compared with the control group.

Conclusion

Conventional rehabilitation therapy combined with BCI rehabilitation therapy can improve the lower limb motor function of hemiplegic patients with stroke, enhance the patient's ability to perform activities of daily living, and promote the improvement of walking function, this is an effective rehabilitation policy to promote recovery from lower extremity motor function disorders.

Efficacy of Cerebellar Transcranial Magnetic Stimulation for Post-stroke Balance and Limb Motor Function Impairments: Meta-analyses of Random Controlled Trials and Resting-State fMRI Studies

This study aimed to investigate the potential therapeutic effects of cerebellar transcranial magnetic stimulation (TMS) on balance and limb motor impairments in stroke patients. A meta-analysis of randomized controlled trials was conducted to assess the effects of cerebellar TMS on balance and motor impairments in stroke patients. Additionally, an activation likelihood estimation (ALE) meta-analysis was performed on resting-state functional magnetic resonance imaging (fMRI) studies to compare spontaneous neural activity differences between stroke patients and healthy controls using measures including the amplitude of low frequency fluctuation (ALFF), fractional ALFF (fALFF), and regional homogeneity (ReHo). The analysis included 10 cerebellar TMS studies and 18 fMRI studies. Cerebellar TMS treatment demonstrated significant improvements in the Berg Balance Scale score (p < 0.0001) and the Fugl-Meyer Assessment lower extremity score (p < 0.0001) compared to the control group in stroke patients. Additionally, spontaneous neural activity alterations were identified in motor-related regions after stroke, including the precentral gyrus, putamen, thalamus, and paracentral lobule. Cerebellar TMS shows promise as a therapeutic intervention to enhance balance and lower limb motor function in stroke patients. It is easy for clinical application and addresses the limitations of insufficient direct stimulation depth on the leg area of the cortex. However, further research combining neuroimaging outcomes with clinical measurements is necessary to validate these findings.

Effects of Cerebellar Non-Invasive Stimulation on Neurorehabilitation in Stroke Patients: An Updated Systematic Review

The cerebellum is emerging as a promising target for noninvasive brain stimulation (NIBS). A systematic review was conducted to evaluate the effects of cerebellar NIBS on both motor and other symptoms in stroke rehabilitation, its impact on functional ability, and potential side effects (PROSPERO number: CRD42022365697). A systematic electronic database search was performed by using PubMed Central (PMC), EMBASE, and Web of Science, with a cutoff date of November 2023. Data extracted included study details, NIBS methodology, outcome measures, and results. The risk of bias in eligible studies was also assessed. Twenty-two clinical studies involving 1016 participants were finally included, with a focus on outcomes related to post-stroke motor recovery (gait and balance, muscle spasticity, and upper limb dexterity) and other functions (dysphagia and aphasia). Positive effects were observed, especially on motor functions like gait and balance. Some efficiency was also observed in dysphagia rehabilitation. However, findings on language recovery were preliminary and inconsistent. A slight improvement in functional ability was noted, with no serious adverse effects reported. Further studies are needed to explore the effects of cerebellar NIBS on post-stroke non-motor deficits and to understand how cerebellar engagement can facilitate more precise treatment strategies for stroke rehabilitation.

Cerebellar transcranial magnetic stimulation for improving balance capacity and activity of daily living in stroke patients: a systematic review and meta-analysis

BACKGROUND

The application of cerebellar transcranial magnetic stimulation (TMS) in stroke patients has received increasing attention due to its neuromodulation mechanisms. However, studies on the effect and safety of cerebellar TMS to improve balance capacity and activity of daily living (ADL) for stroke patients are limited. This systematic review and meta-analysis aimed to investigate the effect and safety of cerebellar TMS on balance capacity and ADL in stroke patients.

METHOD

A systematic search of seven electronic databases (PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, Wanfang and Chinese Scientific Journal) were conducted from their inception to October 20, 2023. The randomized controlled trials (RCTs) of cerebellar TMS on balance capacity and/or ADL in stroke patients were enrolled. The quality of included studies were assessed by Physiotherapy Evidence Database (PEDro) scale.

RESULTS

A total of 13 studies involving 542 participants were eligible. The pooled results from 8 studies with 357 participants showed that cerebellar TMS could significantly improve the post-intervention Berg balance scale (BBS) score (MD = 4.24, 95%CI = 2.19 to 6.29, P < 0.00001; heterogeneity, I2 = 74%, P = 0.0003). The pooled results from 4 studies with 173 participants showed that cerebellar TMS could significantly improve the post-intervention Time Up and Go (TUG) (MD=-1.51, 95%CI=-2.8 to -0.22, P = 0.02; heterogeneity, I2 = 0%, P = 0.41). The pooled results from 6 studies with 280 participants showed that cerebellar TMS could significantly improve the post-intervention ADL (MD = 7.75, 95%CI = 4.33 to 11.17, P < 0.00001; heterogeneity, I2 = 56%, P = 0.04). The subgroup analysis showed that cerebellar TMS could improve BBS post-intervention and ADL post-intervention for both subacute and chronic stage stroke patients. Cerebellar high frequency TMS could improve BBS post-intervention and ADL post-intervention. Cerebellar TMS could still improve BBS post-intervention and ADL post-intervention despite of different cerebellar TMS sessions (less and more than 10 TMS sessions), different total cerebellar TMS pulse per week (less and more than 4500 pulse/week), and different cerebellar TMS modes (repetitive TMS and Theta Burst Stimulation). None of the studies reported severe adverse events except mild side effects in three studies.

CONCLUSIONS

Cerebellar TMS is an effective and safe technique for improving balance capacity and ADL in stroke patients. Further larger-sample, higher-quality, and longer follow-up RCTs are needed to explore the more reliable evidence of cerebellar TMS in the balance capacity and ADL, and clarify potential mechanisms.

Theta-burst stimulation as a therapeutic tool in neurological pathology: a systematic review

TBS (theta-burst stimulation) is a novel therapeutic approach in a wide range of neurological diseases. The present systematic review aims to identify the various protocols used in the last years, to assess study quality and to offer a general overview of the current state of the literature. The systematic review was conducted according to the Preferred Reporting Item for Systematic Review and Meta-Analyses (PRISMA) guidelines. We applied the following inclusion criteria: (1) population over 18 years old with diagnosed neurological disorders, (2) patients treated with sessions of theta-burst stimulation, (3) randomized-controlled clinical trials, (4) articles in the English language, and (5) studies that report response and score reduction on a validated scale of the investigated disorder or remission rates. We included in the final analysis 56 randomized controlled trials focusing on different neurological pathologies (stroke, Parkinson`s disease, multiple sclerosis, tinnitus, dystonia, chronic pain, essential tremor and tic disorder), and we extracted data regarding study design, groups and comparators, sample sizes, type of coil, stimulation parameters (frequency, number of pulses, intensity, stimulation site etc.), number of sessions, follow-up, assessment through functional connectivity and neurological scales used. We observed a great interstudy heterogenicity that leads to a difficulty in drawing plain conclusions. TBS protocols have shown promising results in improving various symptoms in patients with neurological disorders, but larger and more coherent studies, using similar stimulation protocols and evaluation scales, are needed to establish guideline recommendations.

Comparative efficacy of different repetitive transcranial magnetic stimulation protocols for lower extremity motor function in stroke patients: a network meta-analysis

Background

Lower extremity motor dysfunction is one of the most severe consequences after stroke, restricting functional mobility and impairing daily activities. Growing evidence suggests that repetitive transcranial magnetic stimulation (rTMS) can improve stroke patients' lower extremity motor function. However, there is still controversy about the optimal rTMS protocol. Therefore, we compared and analyzed the effects of different rTMS protocols on lower extremity motor function in stroke patients using network meta-analysis (NMA).

Methods

We systematically searched CNKI, WanFang, VIP, CBM, PubMed, Embase, Web of Science, and Cochrane Library databases (from origin to 31 December 2023). Randomized controlled trials (RCTs) or crossover RCTs on rTMS improving lower extremity motor function in stroke patients were included. Two authors independently completed article screening, data extraction, and quality assessment. RevMan (version 5.4) and Stata (version 17.0) were used to analyze the data.

Results

A total of 38 studies with 2,022 patients were eligible for the NMA. The interventions included HFrTMS-M1, LFrTMS-M1, iTBS-Cerebellum, iTBS-M1, dTMS-M1, and Placebo. The results of NMA showed that LFrTMS-M1 ranked first in FMA-LE and speed, and HFrTMS-M1 ranked first in BBS, TUGT, and MEP amplitude. The subgroup analysis of FMA-LE showed that HFrTMS-M1 was the best stimulation protocol for post-stroke time > 1 month, and LFrTMS-M1 was the best stimulation protocol for post-stroke time ≤ 1 month.

Conclusion

Considering the impact of the stroke phase on the lower extremity motor function, the current research evidence shows that HFrTMS-M1 may be the preferred stimulation protocol to improve the lower extremity motor function of patients for post-stroke time > 1 month, and LFrTMS-M1 for post-stroke time ≤ 1 month. However, the above conclusion needs further analysis and validation by more high-quality RCTs.Systematic Review Registration:www.crd.york.ac.uk/prospero/, identifier (CRD42023474215).

Theta burst stimulation: what role does it play in stroke rehabilitation? A systematic review of the existing evidence

Various post-stroke dysfunctions often result in poor long-term outcomes for stroke survivors, but the effect of conventional treatments is limited. In recent years, lots of studies have confirmed the effect of repetitive transcranial magnetic stimulation (rTMS) in stroke rehabilitation. As a new pattern of rTMS, theta burst stimulation (TBS) was proved recently to yield more pronounced and long-lasting after-effects than the conventional pattern at a shorter stimulation duration. To explore the role of TBS in stroke rehabilitation, this review summarizes the existing evidence from all the randomized controlled trials (RCTs) so far on the efficacy of TBS applied to different post-stroke dysfunctions, including cognitive impairment, visuospatial neglect, aphasia, dysphagia, spasticity, and motor dysfunction. Overall, TBS promotes the progress of stroke rehabilitation and may serve as a preferable alternative to traditional rTMS. However, it's hard to recommend a specific paradigm of TBS due to the limited number of current studies and their heterogeneity. Further high-quality clinical RCTs are needed to determine the optimal technical settings and intervention time in stroke survivors.

Noninvasive cerebellar stimulation and behavioral interventions: A crucial synergy for post-stroke motor rehabilitation

BACKGROUND

Improvement of functional movements after supratentorial stroke occurs through spontaneous biological recovery and training-induced reorganization of remnant neural networks. The cerebellum, through its connectivity with the cortex, brainstem and spinal cord, is actively engaged in both recovery and reorganization processes within the cognitive and sensorimotor systems. Noninvasive cerebellar stimulation (NiCBS) offers a safe, clinically feasible and potentially effective way to modulate the excitability of spared neural networks and promote movement recovery after supratentorial stroke. NiCBS modulates cerebellar connectivity to the cerebral cortex and brainstem, as well as influences the sensorimotor and frontoparietal networks.

OBJECTIVE

Our objective was twofold: (a) to conduct a scoping review of studies that employed NiCBS to influence motor recovery and learning in individuals with stroke, and (b) to present a theory-driven framework to inform the use of NiCBS to target distinct stroke-related deficits.

METHODS

A scoping review of current research up to August 2023 was conducted to determine the effect size of NiCBS effect on movement recovery of upper extremity function, balance, walking and motor learning in humans with stroke.

RESULTS

Calculated effect sizes were moderate to high, offering promise for improving upper extremity, balance and walking outcomes after stroke. We present a conceptual framework that capitalizes on cognitive-motor specialization of the cerebellum to formulate a synergy between NiCBS and behavioral interventions to target specific movement deficits.

CONCLUSION

NiCBS enhances recovery of upper extremity impairments, balance and walking after stroke. Physiologically-informed synergies between NiCBS and behavioral interventions have the potential to enhance recovery. Finally, we propose future directions in neurophysiological, behavioral, and clinical research to move NiCBS through the translational pipeline and augment motor recovery after stroke.

The Effect of Cerebellar rTMS on Modulating Motor Dysfunction in Neurological Disorders: a Systematic Review

The effectiveness of cerebellar repetitive transcranial magnetic stimulation (rTMS) on motor dysfunction in patients with neurological disorders has received increasing attention because of its potential for neuromodulation. However, studies on the neuromodulatory effects, parameters, and safety of rTMS implementation in the cerebellum to alleviate motor dysfunction are limited. This systematic review aimed to evaluate the effectiveness and safety of cerebellar rTMS treatment for motor dysfunction caused by neurological disorders and to review popular stimulation parameters. Five electronic databases-Medline, Web of Science, Scopus, Cochrane Library, and Embase-were searched for relevant research published from inception to July 2022. All randomized controlled trials (RCTs) that reported the effects of cerebellar rTMS combined with behavioral rating scales on motor dysfunction were eligible for enrollment. Additionally, reference lists of the enrolled studies were manually checked. Among 1156 articles screened, 21 RCTs with 666 subjects were included. rTMS conducted on the cerebellum showed an improvement in stroke (spasticity, balance, and gait), cervical dystonia, Parkinson's disease (tremor), cerebellar ataxia, and essential tremor but not in multiple sclerosis. The 8-shaped coil with a diameter of 70 mm was determined as the most common therapeutic choice. None of the studies reported severe adverse events except mild side effects in three. Therefore, rTMS appears to be a promising and safe technique for the treatment of motor dysfunction, targeting the cerebellum to induce motor behavioral improvement. Further rigorous RCTs, including more samples and longer follow-up periods, are required to precisely explore the effective stimulation parameters and possible mechanisms.

Effectiveness of cerebellar vermis intermittent theta-burst stimulation in improving trunk control and balance function for patients with subacute stroke: a randomised controlled trial protocol

INTRODUCTION

Balance impairments frequently occur after stroke. Achieving effective core trunk stability is the key to improving balance ability. However, there is still a lack of advanced well-defined rehabilitation protocols for balance improvement in patients with stroke. Intermittent theta-burst stimulation (iTBS) is a non-invasive brain activity modulation strategy that can produce long-term potentiation. The cerebellar vermis is a fundamental structure involved in balance and motor control. However, no study has demonstrated the therapeutic effect and potential mechanism of cerebellar vermis iTBS on balance after stroke.

METHODS AND ANALYSIS

This study will be a prospective single-centre double-blind randomised controlled clinical trial with a 3-week intervention and 3-week follow-up. Eligible participants will be randomly allocated to the experimental group or the control group in a 1:1 ratio. After routine conventional physical therapy, patients in the experimental group will receive cerebellar vermis iTBS, whereas patients in the control group will receive sham stimulation. The overall intervention period will be 5 days a week for 3 consecutive weeks. The outcomes will be measured at baseline (T0), 3 weeks postintervention (T1) and at the 3-week follow-up (T2). The primary outcomes are Berg Balance Scale and Trunk Impairment Scale scores. The secondary outcomes are balance test scores via the Balance Master system, muscle activation of the trunk and lower limbs via the surface electromyography recordings, cerebral cortex oxygen concentrations measured via the resting-state functional near-infrared spectroscopy, Fugl-Meyer Assessment of Lower Extremity and Barthel index scores.

ETHICS AND DISSEMINATION

This study was approved by the West China Hospital Clinical Trials and Biomedical Ethics Committee of Sichuan University. All participants will sign the informed consent form voluntarily. The results of this study will be published in peer-reviewed journals and disseminated at academic conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2200065369.

Cerebellum-Cerebrum paired target magnetic stimulation on balance function and brain network of patients with stroke: A functional near-infrared spectroscopy pilot study

Transcranial magnetic stimulation (TMS) modulation over the cerebellum, primary motor cortex, and supplementary motor cortex individually can improve the balance function of patients with stroke. However, whether their combination could have a better balance modulation effect is uncertain. Therefore, we hypothesized that performing TMS over a combination of these targets can regulate the balance function of patients with stroke. We compared the effects of one-session TMS on eye-open and eye-closed balance conditions in patients with stroke, using different target pairs of unilateral cerebellar (CB-single), cerebellar-primary motor cortex (CB-M1), and cerebellar-supplementary motor area (CB-SMA) targets. A total of 31 patients with stroke were enrolled and randomly divided into three groups to receive single sessions of intermittent theta burst stimulation each. Functional near-infrared spectrum data on resting and standing task states (eye-open and eye-closed) and center of pressure parameters (eye-open and eye-closed) were collected before and after the intervention. Compared with the results in the CB-single group, five intergroup differences in the changes in the center of pressure parameters in the CB-M1 group and two significant differences in the CB-SMA group were observed after one session of intermittent theta burst stimulation. In the CB-SMA group, 12 out of the 14 parameters improved significantly in the EC condition after the intervention. Meanwhile, the functional near-infrared spectrum results showed that the CB-SMA group exhibited a significant inhibitory pattern in the resting-state functional connectivity, which was not observed in the other two groups. In conclusion, we believe that paired targeting of the CB-SMA can reshape the brain network and improve the balance function of patients with stroke.

Targeting Cerebellum with Non-Invasive Transcranial Magnetic or Current Stimulation after Cerebral Hemispheric Stroke-Insights for Corticocerebellar Network Reorganization: A Comprehensive Review

Non-invasive brain stimulation (NIBS) has emerged as one of the methods implemented in stroke rehabilitation. Cerebellar stimulation has gained research interest as an alternative strategy to cortical stimulation, based on the role of the cerebellum and corticocerebellar tracts in different motor and cognitive functions. This review investigates the role of the cerebellum in motor and cognitive rehabilitation following cerebral stroke using NIBS techniques combined with other therapies (e.g., speech or physical therapy). Fifteen randomized clinical trials were included. The majority of the literature findings point towards the cerebellum as a promising neurostimulation target following stroke of the cerebral cortex. Findings concern mostly rehabilitation of gait and balance, where cathodal transcranial direct current stimulation (tDCS) and intermittent theta-burst stimulation (iTBS) of the contralesional cerebellar hemisphere produce, in the presented clinical sample, improved performance and plasticity changes in the corticocerebellar network, combined with other rehabilitation methods. Data regarding aphasia rehabilitation are scarce, with right cerebellar tDCS exercising some impact in individual linguistic functions combined with language therapy. Based on recent data concerning cerebellar functions and corticocerebellar networks, along with the development of clinical protocols regarding non-invasive cerebellar (NICS) application, the cerebellum can prove a crucial intervention target in rehabilitation following stroke.

Intermittent theta-burst stimulation with physical exercise improves poststroke motor function: A systemic review and meta-analysis

Background

Intermittent theta-burst stimulation (iTBS) is an optimized rTMS modality that could modulate the excitability of neural structures. Several studies have been conducted to investigate the efficacy of iTBS in improving the motor function of stroke patients. However, the specific role of iTBS in motor function recovery after stroke is unclear. Hence, in our study, we performed a meta-analysis to investigate the efficacy of iTBS for the motor function improvement of stroke patients.

Methods

MEDLINE, Embase, and Cochrane Library were searched until May 2022 for randomized controlled trials (RCTs).

Results

Thirteen RCTs with 334 patients were finally included in our study. The primary endpoints were the Fugl-Meyer assessment scale (FMA) and Motor Assessment Scale (MAS) change from baseline. We found that iTBS led to a significant reduction in FMA score (P = 0.002) but not in MAS score (P = 0.24) compared with the sham group. Moreover, standard 600-pulse stimulation showed a better effect on motor function improvement than the sham group (P = 0.004), however, 1200-pulse iTBS showed no effect on motor function improvement after stroke (P = 0.23). The effect of iTBS for improving motor function only exists in chronic stroke patients (P = 0.02) but not in subacute patients (P = 0.27).

Conclusion

This study supports that iTBS has good efficacy for improving motor function in stroke patients. Therefore, standard 600-pulse stimulation iTBS therapy is proper management and treatment for chronic stroke.