Rehabilitation with rTMS
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Masahiro Abo • Wataru Kakuda
Rehabilitation with rTMS
Masahiro Abo Wataru Kakuda
Department of Rehabilitation Medicine Department of Rehabilitation Medicine
The Jikei University School of Medicine The Jikei University School of Medicine
Tokyo, Japan Tokyo, Japan
ISBN 978-3-319-20981-4 ISBN 978-3-319-20982-1 (eBook)
DOI 10.1007/978-3-319-20982-1
Library of Congress Control Number: 2015957197
Springer Cham Heidelberg New York Dordrecht London
© Springer International Publishing Switzerland 2015
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Contents
1 rTMS and Its Potential Use in Stroke Rehabilitation ............................ 1
2 rTMS for Upper Limb Hemiparesis after Stroke .................................. 9
3 rTMS for Poststroke Aphasia................................................................... 73
4 rTMS for Poststroke Dysphagia .............................................................. 89
5 rTMS for Lower Limb Hemiparesis after Stroke .................................. 109
6 rTMS in the Acute Phase of Stroke ......................................................... 127
7 Case Presentation (Including TMS Device Handling Instructions) ..... 139
8 Future Challenges of rTMS Treatment ................................................... 185
Index ................................................................................................................. 205
v
Authors
Masahiro Abo, Professor & Chairman, Department of Rehabilitation Medicine,
The Jikei University School of Medicine
Wataru Kakuda, Associate Professor, Department of Rehabilitation Medicine,
The Jikei University School of Medicine
Nobuyuki Sasaki, Associate professor, Department of Rehabilitation Medicine,
International University of Health and Welfare
Toru Takekawa, Department of Rehabilitation Medicine, The Jikei University
School of Medicine
Ryo Momosaki, Department of Rehabilitation Medicine, The Jikei University
School of Medicine
Naoki Yamada, Department of Rehabilitation Medicine, The Jikei University
School of Medicine
Takatoshi Hara, Department of Rehabilitation Medicine, The Jikei University
School of Medicine
Yasuhide Nakayama, Department of Rehabilitation Medicine, The Jikei University
School of Medicine
Motoi Watanabe, Department of Rehabilitation Medicine, The Jikei University
School of Medicine
Junichi Nishimura, Department of Rehabilitation, Shimizu Hospital, The
Kyosaikai Medical Foundation
Takahiro Kondo, Department of Rehabilitation, Shimizu Hospital, The Kyosaikai
Medical Foundation
Yusuke Haga, Department of Rehabilitation, Tokyo General Hospital, The
Kenkoukai Medical Foundation
vii
viii Authors
Yoshihide Ishizuka, Department of Rehabilitation, Tokyo General Hospital, The
Kenkoukai Medical Foundation
Toru Kurosaki, Department of Rehabilitation, Nishi-Hiroshima Rehabilitation
Hospital, The Houwakai Medical Corporation
Facilities Conducting rTMS Treatment
as of November 1, 2014
The Jikei University Hospital (Minato-Ku, Tokyo)
The Jikei University Daisan Hospital (Komae, Tokyo)
Shimizu Hospital, The Kyosaikai Medical Foundation (Kurayoshi, Tottori)
Tokyo General Hospital, The Kenkoukai Medical Foundation (Nakano-Ku, Tokyo)
Nishi-Hiroshima Rehabilitation Hospital, The Houwakai Medical Corporation
(Hiroshima, Hiroshima)
Kimura Hospital, The Jujinkai Medical Corporation (Sabae, Fukui)
Kyoto Ohara Memorial Hospital, The Koryokai Medical Corporation (Kyoto,
Kyoto)
Hakodate Shintoshi Hospital, The Yushinkai Medical Association (Hakodate,
Hokkaido)
Kousei Hospital, The Corporate Medical Association Rokushinkai (Kobe, Hyogo)
Izumi Memorial Hospital, The Izenkai (Adachi-Ku, Tokyo)
Shin-Yurigaoka General Hospital, The Sanseikai (Kawasaki, Kanagawa)
ix
(Upper limb hemiparesis) (Aphasia)
(Dysphagia) (Lower limb hemiparesis)
• Out of the 11 facilities mentioned above, the Jikei University Hospital and
Shimizu Hospital treat “upper limb hemiparesis” and “aphasia.”
• The Jikei University Daisan Hospital treats “upper limb hemiparesis,” “aphasia,”
“dysphagia” and “lower limb hemiparesis.”
• The other eight facilities only treat “upper limb hemiparesis.”
xi
Introduction
In 1998, while studying at the Karolinska Institutet, I was blessed with the opportu-
nity to use a magnetic stimulation device. I was surprised at how easily cerebral
cortex could be stimulated with this device, and I still remember, as if it had been
yesterday, the “tremor of excitement” that I felt when imagining that some day this
magnetic stimulation device would contribute to the development of new therapies
in the field of rehabilitation. For the clinical application of magnetic stimulation
therapy, I first repeatedly conducted basic experiments using rat models of brain
injury and stopped these temporarily after gaining first insights. Then, aiming to
challenge the notion accepted worldwide that neurological sequelae of stroke will
not improve in the chronic stage, to help patients who suffer from the neurological
sequelae of stroke, and to further develop rehabilitation medicine, I made a point of
calling on Dr. Wataru Kakuda, one of the authors and editors of this book, to return
from Stanford University, and eventually in April 2008 we began to conduct
NEURO therapy.
In Treatment Approaches for the Recovery of Fine Motor Functions of the Hand
and Finger by Use of rTMS and Intensive Occupational Therapy – Latest
Rehabilitation Methods for the Treatment of Post-stroke Upper Limb Hemiparesis
(Miwa-Shoten Ltd.), which was published in July 2010, we introduced “NEURO”
(a treatment protocol using rTMS treatment in combination with intensive rehabili-
tation), which our department developed and promoted for the first time in the
world. In particular, during the last few years this NEURO therapy has been widely
featured in the media, such as on TV, and an unending stream of patients have vis-
ited our department. To date more than 3000 patients with neurological sequelae of
stroke, not only from throughout Japan but also from abroad, have visited our out-
patient department. As a result, the number of patients who have undergone NEURO
therapy has increased rapidly, and as of October 2014, in total more than 2000
patients have received the therapy at 13 affiliated and collaborative hospitals
throughout Japan.
This book is a practical guide on “rTMS treatment and rehabilitation for the
treatment of neurological sequelae of stroke.” We have found that rTMS in combi-
nation with rehabilitation is useful not only for the treatment of poststroke upper
xiii
xiv Introduction
limb hemiparesis but also for the treatment of other neurological sequelae of stroke,
namely, aphasia, dysphagia, and lower limb hemiparesis and have published many
research papers on this topic in international journals. Research resulted in as many
as 14 research papers on the use of rTMS for the treatment of the neurological
sequelae of stroke that can be accessed on PubMed (from 2010 to October 2014).
Thus, it is no exaggeration to say that this book was written based on clinical data
obtained from cases that we were involved in ourselves.
Since magnetic stimulation devices are currently approved for testing and not as
therapeutic equipment, magnetic stimulation therapies such as NEURO are con-
ducted based on the approval of the ethics committee of each institution that we
collaborate with. Until recently, it was recommended that the upper limit of mag-
netic stimulation pulses should be 5000 pulses per week. However, according to the
“Recommendations for Transcranial Magnetic Stimulation (TMS)” by the
Committee on Brain Stimulation Methods of the Japanese Society of Clinical
Neurophysiology (JSCN) in the Japanese Journal for Clinical Neurophysiology
Vol. 40, No. 1, 2012, the upper limit of magnetic stimulation should be up to 15,000
pulses per week. Accordingly, magnetic stimulation conducted as in the case of
NEURO therapy, which involves low-frequency stimulation with 14,400 pulses per
week, is within the range of the upper limit recommended by the JSCN.
Finally, I want to express my gratitude to all members of the 13 hospitals who
have banded together in the same spirit and cooperated in this clinical project. I
hope that this book will be used by patients who suffer from neurological sequelae
of stroke and their families and will serve as a reference for TMS treatment, which
is one of a number of approaches to therapeutic rehabilitation.
October, 2014 Masahiro Abo
Chapter 1
rTMS and Its Potential Use
in Stroke Rehabilitation
1 The Principle Behind TMS
The first report on the application of transcranial magnetic stimulation (TMS) as a
new cerebral cortex stimulation technique that can be used as an alternative to direct
electrical stimulation in humans was published in the Lancet in 1985. Barker [1]
succeeded in painless recording of motor evoked potentials (MEPs) from the mus-
cles of the hand and finger by transcranially applying a magnetic field, generated by
an electric current passing through a circular coil, over the primary motor area of the
cerebral cortex.
TMS consists of the TMS device main unit and a stimulation coil that is con-
nected thereto (p. 119). The stimulation parameters (e.g., frequency, intensity, train
duration) are set on the TMS device main unit, and TMS is conducted by applying
the stimulation coil to the surface of the skull. Recently, there are also TMS devices
with a cooling system that prevent an increase in the temperature of the coil, thus
enabling prolonged continuous stimulation.
The principle by which the cerebral cortex is stimulated by TMS is based on the
famous Faraday’s law on electromagnetic induction. As shown in Fig. 1.1, when an
electric current flows within a circular coil, a magnetic field (magnetic flux) is gen-
erated perpendicular to the plane of the coil and reaches the cerebral cortex after
passing through soft tissues and the skull. To generate such a magnetic field, it is
important that the electric current flowing through the coil is not a steady-state cur-
rent but constantly changes its velocity.
In fact, the more rapidly the electric current flows, the greater becomes the mag-
netic field that is generated. The magnetic field that reaches the cerebral cortex
generates an eddy current that is perpendicular to this magnetic field, and thus paral-
lel to the plane of the coil (skull). The direction of the eddy current that is generated
here is opposite to the direction of the electric current that flows through the coil.
This eddy current acts on interneurons (that flow parallel to the skull) located in the
cerebral cortex, and eventually also affects neurons throughout the brain stem and
© Springer International Publishing Switzerland 2015 1
M. Abo, W. Kakuda, Rehabilitation with rTMS,
DOI 10.1007/978-3-319-20982-1_1
2 1 rTMS and Its Potential Use in Stroke Rehabilitation
Figure-8 coil
An electric current is
flowing through the coil
Magnetic A magnetic field is generated perpendicular
field to the plane of the coil, and passes through the skull
Skull
An eddy current is generated
Eddy current (in opposite direction to the electric
current that flows through the coil)
in the cerebral cortex
Corticospinal neuron
The eddy current stimulates an interneuron
Interneuron
Corticospinal neurons, etc. are stimulated
Fig. 1.1 Mechanism through which TMS stimulates the cerebral cortex
spinal cord that descend from the cerebral cortex. Thus, evidently TMS results in
“transcranial” magnetic stimulation, but what actually affects the neurons is the
eddy current that is generated in vivo by “magnetic stimulation.”
The magnetic stimulation waves that are produced by TMS can be monophasic or
biphasic waveforms. The biggest difference between these two kinds of waveforms is
the number of neurons that are stimulated. More specifically, in the case of biphasic
stimulation, which causes the electric current that flows through the coil to become
bidirectional, more neurons are stimulated, and this stimulus reaches over a wider area
than in case of monophasic stimulation. Regarding these differences, monophasic
stimulation is considered appropriate for examinations in which MEPs, etc. are
induced, and biphasic stimulation, which has a greater impact on the cerebral cortex,
is considered to be more appropriate for therapeutic purposes such as described later.
The electric current that flows through the coil generates a magnetic field, which
in turn generates an eddy current in vivo that flows in opposite direction to the elec-
tric current that is generated by the coil. Then interneurons are stimulated by this
eddy current.
Schematic representation of the magnetic fields that are generated by these two
types of stimulation coils (the higher the area is located, the greater is the magnetic
field that is generated). While in the case of the circular coil the magnetic field at the
center of the loop becomes almost zero (in this figure represented as “a hollow”),
in case of the figure-8 coil the maximum magnetic field is in the center of the coil
(at the intersection of the two loops) (in this figure represented as “a peak”).
