BACKGROUND: Non-invasive techniques such as central intermittent theta burst stimulation (iTBS) and repetitive peripheral magnetic stimulation (rPMS) have shown promise in improving motor function for patients with stroke. However, the combined efficacy of rPMS and central iTBS has not been extensively studied. This randomized controlled trial aimed to investigate the synergistic effects of rPMS and central iTBS in patients with stroke.
METHODS: In this study, 28 stroke patients were randomly allocated to receive either 1200 pulses of real or sham rPMS on the radial nerve of the affected limb, followed by 1200 pulses of central iTBS on the ipsilesional hemisphere. The patients received the intervention for 10 sessions over two weeks. The primary outcome measures were the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and the Action Research Arm Test (ARAT). Secondary outcomes for activities and participation included the Functional Independence Measure-Selfcare (FIM-Selfcare) and the Stroke Impact Scale (SIS). The outcome measures were assessed before and after the intervention.
RESULTS: Both groups showed significant improvement in FMA-UE and FIM-Selfcare after the intervention (p < 0.05). Only the rPMS + iTBS group had significant improvement in ARAT-Grasp and SIS-Strength and activity of daily living (p < 0.05). However, the change scores in all outcome measures did not differ between two groups.
CONCLUSIONS: Overall, the study\'s findings suggest that rPMS may have a synergistic effect on central iTBS to improve grasp function and participation. In conclusion, these findings highlight the potential of rPMS as an adjuvant therapy for central iTBS in stroke rehabilitation. Further large-scale studies are needed to fully explore the synergistic effects of rPMS on central iTBS.
BACKGROUND: This trial was registered under ClinicalTrials.gov ID No.NCT04265365, retrospectively registered, on February 11, 2020.

Spasticity, characterized by a velocity-dependent increase in muscle tone and exaggerated reflexes, is a common complication in individuals with upper motor neuron syndrome, such as stroke survivors. Sensitization, the heightened responsiveness of the nervous system to sensory stimuli, has emerged as a potential cause of spasticity. This perspective article explores three emerging treatments targeting sensitization. Recent studies have investigated novel treatment modalities for spasticity, including Extracorporeal Shockwave Therapy (ESWT), repetitive peripheral magnetic stimulation (rPMS), and needling. ESWT has shown promising results in reducing spasticity in both the upper and lower extremities, potentially through mechanisms such as nitric oxide production, rheological property changes, and neuromuscular transmission dysfunction. rPMS offers a non-invasive approach that may reduce spasticity by increasing sensory input, enhancing cortical activation, and exerting tissue-softening effects. Needling has also demonstrated positive effects on spasticity reduction. The high heterogeneity observed indicates the need for more rigorous research to confirm these findings. Recently, mechanical needling and sterile water injection invented by the author is also promising for reducing spasticity through removing sensitization. In conclusion, the emerging treatment options discussed in this perspective article provide promising avenues for addressing sensitization in spasticity and improving motor function. However, further research is needed to validate their findings, optimize treatment protocols, and investigate their long-term effects on motor recovery and overall quality of life in individuals with spasticity.

Stroke is a central nervous system disease that causes structural lesions and functional impairments of the brain, resulting in varying types, and degrees of dysfunction. The bimodal balance-recovery model (interhemispheric competition model and vicariation model) has been proposed as the mechanism of functional recovery after a stroke. We analyzed how combinations of motor observation treatment approaches, transcranial electrical (TES) or magnetic (TMS) stimulation and peripheral electrical (PES) or magnetic (PMS) stimulation techniques can be taken as accessorial physical therapy methods on symptom reduction of stroke patients. We suggest that top-down and bottom-up stimulation techniques combined with action observation treatment synergistically might develop into valuable physical therapy strategies in neurorehabilitation after stroke. We explored how TES or TMS intervention over the contralesional hemisphere or the lesioned hemisphere combined with PES or PMS of the paretic limbs during motor observation followed by action execution have super-additive effects to potentiate the effect of conventional treatment in stroke patients. The proposed paradigm could be an innovative and adjunctive approach to potentiate the effect of conventional rehabilitation treatment, especially for those patients with severe motor deficits.

Paired corticomotoneuronal stimulation (or electrical PCMS: ePCMS) is the repetitive pairing of an electrical stimulus to a nerve with a transcranial magnetic stimulation of the primary motor cortex (TMS-of-M1) to noninvasively influence spinal plasticity. We compared ePCMS with the new painless PCMS protocol pairing a magnetic stimulus to the nerve with TMS-of-M1 (mPCMS) in the preactivated tibial anterior muscle (TA). Sixteen healthy adults participated in two sessions (mPCMS, ePCMS), each with 180 pairs of [low-intensity TMS-of-M1 + nerve stimulation] at 0.2 Hz. TA motor-evoked potentials (MEP) to single-pulse TMS at pre-PCMS, immediately and 30 min after PCMS, were cluster-analyzed to discriminate responders and non-responders. Paired-pulse TMS-of-M1 and F-waves were also tested and BDNF polymorphism influence was explored. Both PCMS protocols significantly increased MEP amplitudes (n = 9 responders each), but the time-course differed with mPCMS inducing larger MEP increase over time. The number of BDNF-methionine carriers tended to be larger than Val66Val in mPCMS and the reverse in ePCMS, thus warranting further investigations. The MEP changes of the preactivated TA likely occurred at the pre-motoneuronal level and larger mPCMS after-effects over time may be related to the afferents recruited. mPCMS seems relevant to be tested in future studies as a painless noninvasive approach to induce sustained pre-motoneuronal plasticity in spinal cord injury.

BACKGROUND: Electrical stimulation therapy is effective for patients with dysphagia. However, because of the pain, strong stimulation cannot be applied. Although magnetic stimulation induces less pain, there are no reports on magnetic stimulation being synchronised with a swallowing reflex.
OBJECTIVE: This study aimed to determine whether it is possible to induce magnetic stimulation during a voluntary swallowing using electromyography (EMG)-triggered peripheral magnetic stimulation and to evaluate its effect on healthy individuals.
METHODS: A total of 20 healthy adults in seated position were instructed to swallow saliva and 10 ml of barium under videofluoroscopy. For concomitant use of magnetic stimulation, a magnetic stimulus for suprahyoid muscles at 30 Hz frequency was applied for 2 s when the EMG level in the sternohyoid muscle exceeded the threshold. During the voluntary swallowing, the movement of the hyoid bone and opening width of the upper oesophageal sphincter (UES) were measured. Furthermore, pressure topography was evaluated in 6 subjects using high-resolution manometry.
RESULTS: The magnetic stimulation significantly extended the movement time of the hyoid bone (p < 0.001). During liquid deglutition, significant increases were observed in the anterior maximum movement distance of the hyoid bone (p < 0.05), opening width of the UES (p < 0.001) and anterior movement distance of the hyoid bone at the maximum UES opening (p < 0.01). In the pressure topography, the maximum pressure immediately after UES closure significantly decreased with magnetic stimulation (p < 0.05).
CONCLUSIONS: EMG-triggered peripheral magnetic stimulation made it possible to apply magnetic stimulation during a voluntary swallowing.

Repetitive peripheral magnetic stimulation (rPMS) is a non-invasive stimulator that can induce strong muscle contraction in selective regions. This study aimed to measure acute changes in skeletal muscle thickness induced by rPMS following a low-intensity exercise. Fifteen healthy young men performed an isometric knee extensor exercise at 30% of maximum strength consisting of three sets of 10 contractions on their dominant leg. rPMS was then applied on the vastus lateralis (VL) at the maximum intensity of the rPMS device. Muscle thicknesses of the rectus femoris (RF) and VL were measured using an ultrasound device and were compared among baseline, post-exercise, and post-rPMS. There were significant increases in muscle thickness of both the RF and VL post-exercise compared with baseline values (RF: baseline; 24.7 ± 2.4, post-exercise; 25.3 ± 2.4 mm, p = .034, VL: baseline; 27.0 ± 2.8, post-exercise; 27.4 ± 2.8 mm, p = .006). Compared with post-exercise, there was a significant increase post-rPMS in only the VL (VL: post-rPMS; 28.3 ± 2.9 mm, p = .002). These findings suggest that low-intensity isometric exercise can induce acute increases in muscle thickness (muscle swelling) in synergist muscles, and rPMS following exercise can induce further acute muscle swelling via repetitive muscle contraction.

UNASSIGNED: Both repetitive peripheral magnetic stimulation (rPMS) and transcutaneous electrical current stimulation (TES) could elicit the limb movements; it is still unclear how subjective sensation is changed according to the amount of limb movements. We investigated the pain and discomfort induced by newly developed rPMS and TES of peripheral nerves in the dorsal forearm.
UNASSIGNED: The subjects were 12 healthy adults. The stimulus site was the right dorsal forearm; thus, when stimulated, wrist dorsiflexion was induced. The rPMS was delivered by the new stimulator, Pathleader at 10 stimulus intensity levels, and TES intensity was in 1-mA increments. The duration of each stimulation was 2 s. The analysis parameters were subjective pain and discomfort, measured by a numerical rating scale. The rating scale at corresponding levels of integrated range of movement (iROM) induced by rPMS or TES was compared. The subjective values were analyzed by two-way repeated measures ANOVA with the stimulus conditions (rPMS, TES) and the seven levels of iROM (20-140 ºs).
UNASSIGNED: In the rPMS experiments, stimuli were administered to all subjects at all stimulus intensities. In the TES experiments, none of the subjects dropped out between 1 and 16 mA, but there were dropouts at each of the intensities as follows: 1 subject at 17 mA, 20 mA, 22 mA, 23 mA, 27 mA, 29 mA and 2 subjects at 21 mA, 24 mA, 26 mA. The main effects of the stimulus conditions and iROM were significant for pain and discomfort. Post hoc analysis demonstrated that pain and discomfort in rPMS were significantly lower compared to TES when the iROM was above 60 ºs and 80 ºs, respectively.
UNASSIGNED: New rPMS stimulator, Pathleader, caused less pain and discomfort than TES, but this was only evident when comparatively large joint movements occurred.

Background: Spasticity is common among patients with stroke. Repetitive peripheral magnetic stimulation (rPMS) is a painless and noninvasive therapy that is a promising approach to reducing spasticity. However, the central mechanism of this therapy remains unclear. Changes in cortical activity and decreased spasticity after rPMS intervention require further exploration. The aim of this study was to explore the electroencephalography (EEG) mu rhythm change and decrease in spasticity after rPMS intervention in patients with stroke. Materials and methods: A total of 32 patients with spasticity following stroke were recruited in this study and assigned to the rPMS group (n = 16) or sham group (n = 16). The modified Ashworth scale, modified Tardieu scale, and Fugl-Meyer assessment of the upper extremity were used to assess changes in upper limb spasticity and motor function. Before and after the rPMS intervention, EEG evaluation was performed to detect EEG mu rhythm changes in the brain. Results: After one session of rPMS intervention, spasticity was reduced in elbow flexors (p < 0.05) and wrist flexors (p < 0.05). Upper limb motor function measured according to the Fugl-Meyer assessment was improved (p < 0.05). In the rPMS group, the power of event-related desynchronization decreased in the mu rhythm band (8-12 Hz) in the contralesional hemisphere (p < 0.05). Conclusions: The results indicate that rPMS intervention reduced spasticity. Cortical activity changes may suggest this favorable change in terms of its neurological effects on the central nervous system.

BACKGROUND: It is very difficult for patients with severe upper extremity (UE) paresis after stroke to achieve full recovery because of the lack of a definitive approach for improving severe UE paresis immediately after onset.
OBJECTIVE: to investigate the effects of repetitive peripheral magnetic stimulation (rPMS) on severe UE paresis during early acute phase of stroke.
METHODS: Nineteen participants with severe UE disability met the criteria. 10 subjects received 15-20 minutes of rPMS prior to standard care per session, while 9 age- and severity-matched subjects received two times 20 minutes of standard care. Outcome measures included UE motor section of the Fugl-Meyer Motor Assessment Scale (FMA-UE), Wolf motor function test (WMFT), and box and block test (BBT).
RESULTS: The rPMS group received treatment (average sessions: 7.8) after a median 9.2 days from stroke (16.5 sessions after 5 days for control). To adjust the different treatment durations, we defined \"progress rate\" as the gains of UE function scores divided by treatment duration. The progress rate was significantly different in FMA-UE and WMFT, but not in BBT.
CONCLUSIONS: The present study suggested beneficial effects of rPMS on severe UE paresis during early acute phase of stroke.

OBJECTIVE: The aim of the present study was to investigate the role of maturation on the etiology of neuromuscular fatigue induced by repeated maximal voluntary isometric contractions (MVIC).
METHODS: Nine prepubertal boys (9.9 ± 1.3 years), eight male adolescents (13.6 ± 1.3 years) and eleven men (23.4 ± 3.0 years) performed a series of repeated isometric MVICs of the knee extensors until the MVIC torque reached 60% of its initial value. Magnetic stimulations were delivered to the femoral nerve every five MVICs to follow the course of voluntary activation level (VA) and the potentiated twitch torque (Qtwpot).
RESULTS: Task failure was reached after 52.9 ± 12.7, 42.6 ± 12.5, and 26.6 ± 6.3 repetitions in boys, adolescents and men, respectively. VA remained unchanged in men whereas it decreased significantly and similarly in boys and adolescents (p < 0.001). In contrast, Qtwpot remained unchanged in boys and decreased significantly less in adolescents than adults (p < 0.05).
CONCLUSIONS: Children and adolescents experience less peripheral and more central fatigue than adults. However, adolescents experience more peripheral fatigue than children for a comparable amount of central fatigue. This finding supports the idea that the tolerance of the central nervous system to peripheral fatigue could increase during maturation.