Authors:
Naoyuki Takeuchi, MD, PhD
Masahiko Toshima, MD
Takayo Chuma, MD
Yuichiro Matsuo, MD
Katsunori Ikoma, MD, PhD

Affiliations:
From the Department of
Rehabilitation Medicine, Hospital of
Hokkaido University, Sapporo, Japan
(NT, TC, YM, KI); and Carres
Sapporo, Hospital of Tokeidai,
Sapporo, Japan (MT).

Correspondence:
All correspondence and requests for
reprints should be addressed to
Naoyuki Takeuchi, Department of
Rehabilitation, Hospital of Hokkaido
University, North 14 West 5 Sapporo
060-0814, Japan.

Disclosures:
This work was supported by research
project grant-in-aid for scientific
research no. 17300179 from the
Japan Society for the Promotion of
Science.
0894-9115/08/8701-0074/0
American Journal of Physical
Medicine & Rehabilitation
Copyright © 2007 by Lippincott
Williams & Wilkins
DOI: 10.1097/PHM.0b013e31815e7055

Stroke

CASE REPORT

Repetitive Transcranial Magnetic
Stimulation of the Unaffected
Hemisphere in a Patient Who Was
Forced to Use the Affected Hand
ABSTRACT
Takeuchi N, Toshima M, Chuma T, Matsuo Y, Ikoma K: Repetitive transcranial
magnetic stimulation of the unaffected hemisphere in a patient who was forced to
use the affected hand. Am J Phys Med Rehabil 2008;87:74 –77.
We present a case report of a 56-yr-old chronic stroke patient with right
hemiparesis who was treated with repetitive transcranial magnetic stimulation
(rTMS) therapy. Before stroke, the patient had suffered an accident that led to
paralysis and contracture of the left upper limb, and, subsequently, he was forced
to use only his right upper limb for routine activities, despite right hemiparesis. We
performed subthreshold rTMS (1 Hz, 25 mins) and sham stimulation of the
contralesional primary motor cortex (M1) at different times. Immediately after
rTMS, the patient was able to write characters with increased speed and accuracy, and this effect continued for more than 7 days; however, this was not the
case after sham stimulation. Moreover, the writing practice after rTMS improved
the patient’s pinch force.
Key Words: Repetitive Transcranial Magnetic Stimulation, Rehabilitation, ConstraintInduced Movement Therapy, Stroke

R

ecent reports have demonstrated that repetitive transcranial magnetic
stimulation (rTMS; 1 Hz) of the contralesional primary motor cortex (M1)
improved the functioning of the affected hand in chronic stroke patients.1– 4
Inhibition of the excitability of the contralesional M1 by using 1-Hz rTMS
results in a decrease in transcallosal inhibition from the contralesional to the
ipsilesional M1 and an increase in the excitability of the ipsilesional M1; this
ultimately leads to improved motor function in the affected hand.1 It is expected
that this method will be used as a new rehabilitation therapy for stroke patients;
however, approaches to enhance and sustain the effects of rTMS are unclear.
We present a chronic stroke patient who was forced to use his affected hand
for routine activities because of contracture of the unaffected hand. An improvement in the functioning of the affected hand was observed after the use of 1-Hz
rTMS; this suggests that a combination of rTMS and motor training, such as
forced limb use, can improve motor function in stroke patients. Therefore, we

74

Am. J. Phys. Med. Rehabil. ● Vol. 87, No. 1

studied whether rTMS therapy could improve the
functional ability of this patient.

CASE REPORT
A 56-yr-old, right-handed male developed cortical cerebral hemorrhage (in the left precentral
gyrus) 8 mos ago. He had suffered a fracture of the
left forelimb and secondary infection of the left
forelimb at 6 yrs of age, and subsequently he had
been unable to move his left upper limb because of
contracture of the wrist and elbow; however, he
was able to move his left fingers. Therefore, he was
forced to use his right upper limb despite the right
hemiparesis caused by stroke. After physical and
occupational therapy, he was able to walk and eat
with a spoon, using his right hand. During testing
of our protocol, his Fugl–Meyer score5 was determined to be 60/66 (arm), 23/24 (hand), and 17/34
(leg). His modified Ashworth score6 was 1/3 (arm),
1/3 (hand), and 1/3 (leg). The patient did not exhibit apraxia, aphasia, agnosia, or memory deficit.
He provided written, informed consent, and the
protocol for the use of rTMS was approved by the
local ethical committee of the Hokkaido University
Graduate School of Medicine.
A day before simulation, the patient familiarized himself with the task of writing and pinch
force evaluation. Subsequently, the patient participated in two sessions that tested the influences of
noninvasive cortical stimulation in the form of
rTMS and sham stimulation. The rTMS session was
conducted a week after the sham session to rule
out the placebo effect of sham stimulation. The
pinch force was measured before stimulation (pre)
and after stimulation (post-1, immediately after
stimulation; post-2, 30 mins after stimulation; and
post-3, 7 days after stimulation). For more than 1
mo before the study, the patient practiced writing
characters for more than 15 mins/day, because his
chief complaint was related to the impairment of
his writing ability. However, he was unable to write
efficiently, and his ability of writing was stabilized.
Therefore, in addition to the evaluation of the
pinch force, we evaluated his writing performance,
and we conducted further writing practices after
rTMS. The patient practiced writing his address for
15 mins after the stimulation and for 15 mins/day
until the post-3 session. We selected five Chinese
characters (a part of his address) that he had frequently practiced writing before this study. The
maximum pinch force of the affected hand was
determined, using a pinch gauge (Pinch Meter
SPR-641; Sakai Medical, Tokyo, Japan). To measure
the pinch force, the subject was instructed to use
only his thumb and index finger. In each session,
10 pinch force measurements were averaged.
rTMS was performed using a 70-mm figureeight coil and a Magstim Rapid stimulator (MagsJanuary 2008

tim Company, Dyfed, UK). The coil was placed
tangentially over the contralesional M1 at the optimal site for the first dorsal interosseous muscle.
The optimal site was defined as the location where
stimulation at a slightly suprathreshold intensity
elicited the largest magnetically evoked potentials
in the first dorsal interosseous. Electromyographic
activity was recorded, using silver–silver chloride
electrodes positioned in a belly tendon montage on
the skin overlying the first dorsal interosseous, and
the signal was amplified, filtered (50 –2000 Hz),
and digitized at a sampling rate of 5000 Hz for
offline analysis (Neuropack, Nihon Koden, Tokyo,
Japan). The resting motor threshold was defined as
the lowest stimulator output that could induce
magnetically evoked potentials with a peak-to-peak
amplitude greater than 50 mV in at least half of the
10 trials. rTMS was applied for 25 mins at a frequency of 1 Hz and an intensity of 90% resting
motor threshold. Sham stimulation was applied
with the coil positioned perpendicular to the scalp
of the contralesional M1 at the same frequency and
intensity as real rTMS.
The pinch force was evaluated, using analysis
of variance for repeated measures with time (pre,
post-1, post-2, and post-3) and conditions (rTMS
and sham). A post hoc analysis was performed,
using the Bonferroni correction. The significance
level was set at 0.05.
The patient did not exhibit any adverse side
effects during the course of this study. After rTMS,
he could write characters with increased speed and
accuracy (Fig. 1). A repeated-measures analysis of
variance demonstrated a significant interaction between the time and conditions (P ⫽ 0.004) and a
significant effect of time (P ⬍ 0.001) on the pinch
force. Post hoc tests revealed that the pinch force
did not change immediately after rTMS (pre,
5.37 ⫾ 0.27 kg; post-1, 5.51 ⫾ 0.23 kg); however, it
improved with subsequent writing practice (pre vs.
post-2 [5.92 ⫾ 0.21 kg], p ⫽ 0.002; pre vs. post-3
[5.90 ⫾ 0.18 kg], P ⫽ 0.003). No significant change
in the pinch force was observed during the sham
session (pre, 5.38 ⫾ 0.21 kg; post-1, 5.28 ⫾ 0.27
kg; pre, 5.40 ⫾ 0.28 kg; post-1, 5.37 ⫾ 0.27 kg).
The Fugl–Meyer and modified Ashworth scores of
the patient did not change after rTMS.

DISCUSSION
This is the first report demonstrating the use
of 1-Hz rTMS for improving the functioning of the
affected hand of a chronic stroke patient who had
suffered contracture in the unaffected hand.
Recent reports have demonstrated that the application of 1-Hz rTMS to the contralesional M1
improves the functioning of the affected hand in
stroke patients.1– 4 In the present study, the improvement in the functioning of the affected hand
rTMS for a Chronic Stroke Patient

75

FIGURE 1 The patient was able to write characters
with increased speed and accuracy immediately after repetitive transcranial magnetic stimulation (rTMS). A, Sample: Five
Chinese characters. B, Before rTMS: Total
writing time was 39.1 secs. C, Immediately after rTMS (post-1): Total writing
time was 34.1 secs. D, Thirty minutes
after rTMS (post-2): Total writing time
was 33.8 secs. E, Seven days after rTMS
(post-3): Total writing time was 34.1 secs.

after rTMS persisted for more than 7 days. However, it remains uncertain whether the effect of a
single rTMS for stroke patients can be sustained4
or not.1 rTMS at 1 Hz can increase the excitability
of the ipsilesional M1 by reducing transcallosal
inhibition from the contralesional M1.1,3 The increase in the excitability of the motor cortex was
considered essential for motor learning.7,8 Considering these findings, the increased excitability of
the ipsilesional M1 after rTMS may contribute to
reorganization of the ipsilesional M1 after motor
learning. Therefore, interventions such as motor
training after rTMS might be important for sustaining the effects of rTMS. In the present study, it
is possible that motor function testing and writing
practice after rTMS might have served as forms of
motor training and helped to sustain the effects of
rTMS.
In stroke patients, constraint-induced movement therapy (CIMT) can enhance the functional
recovery of the affected limb by enforcing its use.9,10
The beneficial effects of this therapy are associated
with an increase in the excitability of the affected
motor cortex. The immobilization of the unaffected
arm that induces a reduction in the excitability of the
unaffected motor cortex is also considered important.9 The application of 1-Hz rTMS to the contrale-

76

Takeuchi et al.

sional M1 can induce downregulation of the contralesional M11 and upregulation of the ipsilesional M1.3
Therefore, the mechanism of action of 1-Hz rTMS
and CIMT may be related.11 Considering that the
conceptual basis for CIMT is that stroke patients must
use only their affected hand for routine activities,12
our patient underwent a type of CIMT because he was
forced to use his affected hand, because of contracture of the unaffected hand. In our study, rTMS
improved the motor function of the patient’s affected
hand, suggesting that rTMS therapy might enhance
the effect of CIMT in stroke patients.
This study has some limitations that should be
considered. First, the potential effect of rTMS-independent motor learning should be considered
because of the crossover design of this study. However, the motor function of the affected hand was
improved after rTMS and motor training, but not
after sham stimulation and motor training. Moreover, it was considered that the motor function of
the affected hand had reached a plateau because of
the motor training before stimulation. Therefore, it
was unlikely that motor training after sham stimulation had influenced the functional improvement
of the affected hand after rTMS. Second, the patient
might feel the difference between the active and
sham stimulation. This sham stimulation produced
no cortical stimulation, but it produced the auditory artifact as control stimulation.13 We used a
stimulation intensity of 90% resting motor threshold that did not induce contraction of the hand
muscles. Moreover, the patient was naı̈ve to rTMS
and reported that he had received active treatment
after sham stimulation. Therefore, it is unlikely
that the difference between sham and rTMS influenced the results of this study. However, further
investigation using a double-blind study with more
subjects is required to evaluate the effects of rTMS.
Our results demonstrate that rTMS of the contralesional M1 can lead to improved motor function of the affected hand in chronic stroke patients
with contracture of the unaffected hand. Further,
the results of this study suggest that the combination of rTMS and CIMT might be useful in facilitating the recovery of stroke patients.
REFERENCES
1. Takeuchi N, Chuma T, Matsuo Y, Watanabe I, Ikoma K:
Repetitive transcranial magnetic stimulation of contralesional primary motor cortex improves hand function after
stroke. Stroke 2005;36:2681–6
2. Mansur CG, Fregni F, Boggio PS, et al: A sham stimulationcontrolled trial of rTMS of the unaffected hemisphere in
stroke patients. Neurology 2005;64:1802–4
3. Fregni F, Boggio PS, Valle AC, et al: A sham-controlled trial
of a 5-day course of repetitive transcranial magnetic stimulation of the unaffected hemisphere in stroke patients.
Stroke 2006;37:2115–22
4. Boggio PS, Alonso-Alonso M, Mansur CG, et al: Hand function improvement with low-frequency repetitive transcra

Am. J. Phys. Med. Rehabil. ● Vol. 87, No. 1

nial magnetic stimulation of the unaffected hemisphere in
a severe case of stroke. Am J Phys Med Rehabil 2006;85:
927–30
5. Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S:
The post-stroke hemiplegic patient. 1. A method for evaluation of physical performance. Scand J Rehabil Med 1975;
7:13–31
6. Bohannon RW, Smith MB: Interrater reliability of a modified Ashworth scale of muscle spasticity, Phys Ther 1987;
57:206–7
7. Pascual-Leone A, Tarazona F, Keenan J, Tormos JM, Hamilton R, Catala MD: Transcranial magnetic stimulation and
neuroplasticity. Neuropsychologia 1999;37:207–17
8. Muellbacher W, Ziemann U, Wissel J, et al: Early consolidation in human primary motor cortex. Nature 2002;415:
640–4

9. Liepert J, Miltner WHR, Bauder H, et al: Motor cortex
plasticity during constraint-induced movement therapy in
stroke patients. Neurosci Lett 1998;250:5–8
10. Kobayashi M, Hutchinson S, Theoret H, Schlaug G, Pascual-Leone A: Effects of constraint-induced movement
therapy on patients with chronic motor deficits after stroke:
a replication. Stroke 1999;30:586–92
11. Kobayashi M, Hutchinson S, Theoret H, Schlaug PascualLeone AG: Repetitive TMS of the motor cortex improves
ipsilateral sequential simple finger movements. Neurology
2004;62:91–8
12. Dobkin BH: Strategies for stroke rehabilitation. Lancet
Neurol 2004;3:528–36
13. Lisanby SH, Gutman D, Luber B, Schroeder C, Sackeim HA:
Sham TMS: intracerebral measurement of the induced electrical field and the induction of motor-evoked potentials.
Biol Psychiatry 2001;49:460–3

BOOK REVIEW

EBM Guidelines für Allgemeinmedizin
Edited by Ikka Kunnamo, editor in chief, and editors
Erwin Rebhandl, Susanne Rabady, Frank Mader. 1427
pages. Published 2006 by Verlagshaus der Ärzte, Wien,
Austria. Printed in Slovenia. ISBN 3-901 488-27-8.
Like all other physicians, general practitioners have to
cope with a rapidly growing amount of new medical
knowledge. The textbook Evidence Based Medicine for
General Practice, is the German translation of Evidence
Based Medicine Guidelines 1 and is intended to support
general practitioners in their clinical decisions, with the
latest evidence available.
The book is organized into 48 chapters, thus reflecting both the WHO-ICD 10 classification and medical
specialties. Each chapter is well structured and covers,
in accordance with the ICD-10, the epidemiology and
pathophysiology of respective human conditions and
diseases. Therapeutic and management strategies are
described profoundly and comprehensively, including
prevention and rehabilitation procedures (although primarily as a therapeutic option or concept). A wealth of
illustrations assists the user who may not be familiar
with the physical appearance of a particular disease or
condition. Using the GRADE Working Group recommendations,2 the level of evidence is provided for both
the treatment and for diagnostic tests, which makes this
book unique.
The book shares an inherent weakness of textbooks:
it does not provide cutting-edge knowledge, because it
cannot take into account the most recent research. From
DOI:10.1097/PHM.0b013e31815e6dd0

January 2008

a physical medicine and rehabilitation specialist’s perspective, the book fails to provide general practitioners with the
necessary information to optimally promote the functioning and health of their patients. Surprisingly
enough, physical medicine is categorized as a subspecialty of orthopedics. The conceptual framework of preventive and rehabilitation medicine, as well as its salutogenetic approach to promote patients’ functioning and
health, remains undescribed. It is hard to comprehend
why preventive and rehabilitative exercise and training,
therapeutic interventions administered as physical medicine, and rehabilitation treatment modalities are summarized in a chapter entitled Sports Medicine.
In summary, this textbook, featuring the traditional
medical perspective, can be recommended to both general practitioners and medical specialists seeking optimal diagnosis and treatment for their patients.
Rating: ❊❊❊❊
Gerold Ebenbichler
Katharina Kerschan-Schindl
University Clinics of PM&R
Vienna Medical University
Vienna, Austria

Thomas Brockow
Karl Ludwig Resch
German Institute of Health Research
Bad Elster, Germany
REFERENCES
1. Kunnamo I (ed): Evidence Based Medicine Guidelines. Helsinki,
Duodecim Medical Publications Ltd, 2005
2. Atkins D, Best D, Briss PA, et al : Grading quality of evidence and
strength of recommendations. BMJ . 2004;328:1490

Book Reviews

77