Repetitive Transcranial Magnetic Stimulation Facilitates Effective Gait Rehabilitation in Patients with Traumatic Brain Injury Forshee, C. MPT CBIS, Foreman, J., Masel, B. MD Transitional Learning Center • Galveston, Texas Background Average Step Length Increases After 4 Weeks of Daily rTMS and PT Rehabilitation after a TBI can be a long, intensive process that requires further development to fully address the consequence of a severe TBI. EMG display Magnetic Stimulator -Nexstim TMS 45 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. Polaris-Camera 3D-Tracking 40 Navigation display 35 Average Step Length (cm) Stimulation Coil 30 25 20 15 Tracking Tools 10 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. Navigation- and Analysis-Software 5 0 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. 12-Jun 6-Jul 2 SPC 20.3 39.06 Bare Feet 9.79 22.22 EMG Fig. 3: TMS setup Results Range of motion: Right- no change; Left- 129-146° (+13%) Spasticity (first catch): Right- 95-85°; Left- 109-93° Step Length Equalizes Within Condition After Daily rTMS and PT Adding rTMS to therapy regiment yielded greater gait improvement 45 40 Step Length (cm) Increased control of leg muscles allowed quicker, more controlled gait 40.03 38.09 35 Increased mobility without wheelchair, decreased burden of care 28.08 30 22.85 25 20 15 2 SPC- Left 2 SPC- Right Fig. 1: Asymmetric interhemispheric balance caused by TBI Fig. 2: Down-regulating the dominate side via rTMS restores interhemispheric control 21.58 19.62 12.52 rTMS appears to increase effects of physical therapy and should be utilized for the rehabilitation of TBI patients 10 ………. 5 Bare Feet- Left 0 Bare Feet- Right -5 Discussion -0.04 12-Jun 6-Jul Objective Use rTMS to increase quality of lower extremity control in post acute TBI patient Gait Velocity Increases After 4 Weeks of Daily rTMS and PT Experimental Design 30 25 Subject Post 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 Motion Spasticity (Tardieu) Treatment rTMS: 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. Fig. 4 & 5: TMS and EMG display 20 Gait Velocity (cm/sec) Acknowledgements 15 Moody Foundation 10 5 0 2 SPC Bare Feet 12-Jun 6-Jul 19.8 23.9 8.6 18 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.