rTMS Over Dorsolateral Prefrontal Cortex Augments Dual-Task Training for Mobility, Balance and Cognition in Sub-Acute Stroke: A Randomized Controlled Trial.
Lei Yang, Xiaoying Lin, Jingyi Lu and 5 others
Adding rTMS to dual-task exercise did not improve dual-task walking speed over exercise alone, but did shorten dual-task timed-up-and-go time and improve balance in 30 sub-acute stroke patients over 2 weeks.
Key findings
1Dual-task walking speed, one of the two primary outcomes, did not differ significantly between the rTMS and sham groups under either cognitive task (p = 0.226 with serial subtraction; p = 0.176 with verbal fluency).
2Dual-task timed-up-and-go time, the other primary outcome, improved more in the rTMS group than sham (p = 0.022 with serial subtraction; p = 0.028 with verbal fluency), and dual-task step length with serial subtraction also favoured rTMS (p = 0.001).
3Balance (Mini-BESTest, p = 0.018) and balance confidence (ABC, p = 0.006) both showed significantly greater improvement in the rTMS group than sham, and MoCA scores also favoured rTMS (p = 0.039).
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What it does not show
Only 30 participants at a single site, so the study is underpowered for anything but large effects. The intervention lasted 2 weeks and there was no follow-up, so it is unknown whether the gains lasted beyond that window. The DLPFC target was located by surface anatomy (the '5 cm rule') rather than MRI-guided neuronavigation, which may have introduced variability in where the coil actually sat. Blinding of participants and the assessor was not formally verified with a questionnaire. Only two cognitive tasks (serial subtraction and verbal fluency) were used as the dual-task load; working memory and reaction-time tasks were not tested. The sample was restricted to sub-acute stroke with mild to moderate impairment, so the findings may not apply to chronic stroke or to patients with more severe deficits. No participants dropped out, which means the intention-to-treat and per-protocol analyses are the same and the result may be optimistic.
Declared interests
Funded by government programmes in Yunnan Province, China (Kunming Health Science and Technology Talent Training Project and the Chuncheng Project). No industry or device-manufacturer funding. The authors declare no conflicts of interest.
The easy way to misread this
Do not read the positive balance and cognitive results as evidence that rTMS 'improves walking' — the primary dual-task walking speed showed no significant group difference (p = 0.226 and p = 0.176). Also, both groups received the full dual-task exercise programme and both improved substantially; the rTMS effect is an incremental addition on top of exercise, not a standalone treatment.
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