Therapeutic Application of High-Frequency rTMS Combined with Intensive Occupational Therapy for Pediatric Stroke Patients with Upper Limb Hemiparesis: A Case Series Study


Low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) applied to the non-lesional hemisphere is reported to significantly improve motor function of the affected upper limb in adult stroke patients with hemiparesis. For pediatric stroke patients, the beneficial effects of LF-rTMS have been already confirmed in a randomized controlled study. However, there is no report of therapeutic application of high-frequency rTMS (HF-rTMS) in this patient population. In this case series study, we introduced HF-rTMS combined with intensive occupational therapy (OT) in two pediatric hemiparetic patients. We studied two children (8- and 9-year-old boys, both right-handed) with post-stroke upper limb hemiparesis (chronic phase). Both patients underwent 22 treatment sessions of HF-rTMS/OT during 15-day hospitalization. The HF-rTMS was applied over the lesional motor cortex at a frequency of 10Hz for 15 minutes in each session. One session of intensive OT consisted of 30-min one-to-one training and 30-min self-exercise. Motor function of the affected upper limb was serially evaluated with Fugl-Meyer Assessment (FMA), Wolf Motor Function Test (WMFT), Simple Test for Evaluating hand Function (STEF), and Ten-second Test. Neither of the patients showed any adverse effects. Both patients showed improvement of motor function in the affected upper limb and were able to use the affected upper limb in some activities of daily living. In the two post-stroke pediatric patients, HF-rTMS/OT was safe and improved upper limb muscle function. Confirmation of these effects in a larger population is needed.

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M. Niimi, W. Kakuda, T. Takekawa, R. Momosaki, T. Hara, H. Ito, Y. Kameda and M. Abo, "Therapeutic Application of High-Frequency rTMS Combined with Intensive Occupational Therapy for Pediatric Stroke Patients with Upper Limb Hemiparesis: A Case Series Study," Journal of Behavioral and Brain Science, Vol. 3 No. 2, 2013, pp. 188-193. doi: 10.4236/jbbs.2013.32019.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] N. Agrawal, S. C. Johnston, Y. W. Wu, S. Sidney and H. J. Fullerton, “Imaging Data Reveal a Higher Pediatric Stroke Incidence than Prior US Estimates,” Stroke, Vol. 40, No. 11, 2009, pp. 3415-3421. doi:10.1161/STROKEAHA.109.564633
[2] V. Ganesan, M. Prengler, M. A. McShane, A. M. Wade and F. J. Kirkham, “Investigation of Risk Factors in Children with Arterial Ischemic Stroke,” Annals of Neurology, Vol. 53, No. 2, 2003, pp. 167-173. doi:10.1002/ana.10423
[3] M. F. Rafay, A. M. Pontigon, J. Chiang, M. Adams, D. A. Jarvis, F. Silver, D. Macgregor and G. A. Deveber, “Delay to Diagnosis in Acute Pediatric Arterial Ischemic Stroke,” Stroke, Vol. 40, No. 1, 2009, pp. 58-64. doi:10.1161/STROKEAHA.108.519066
[4] J. A. Zimmer, B. P. Garg, L. S. Williams and M. R. Golomb, “Age-Related Variation in Presenting Signs of Childhood Arterial Ischemic Stroke,” Pediatric Neurology, Vol. 37, No. 3, 2007, pp. 171-175. doi:10.1016/j.pediatrneurol.2007.05.010
[5] M. Steinlin, I. Pfister, J. Pavlovic, R. Everts, E. Boltshauser, A. Capone Mori, D. Gubser Mercati, C. A. Hanggeli, E. Keller, J. Luetschg, J. Marcoz, G. P. Ramelli, E. Roulet Perez, T. Schmitt-Mechelke, M. Weissert and Swiss Societies of Paediatric Neurology and Neonatology, “The First Three Years of the Swiss Neuropaediatric Stroke Registry (SNPSR): A Population-Based Study of Incidence, Symptoms and Risk Factors,” Neuropediatrics, Vol. 36, No. 2, 2005, pp. 90-97. doi:10.1055/s-2005-837658
[6] V. Ganesan, A. Hogan, N. Shack, A. Gordon, E. Isaacs and F. J. Kirkham, “Outcome after Ischaemic Stroke in Childhoo d,” Developmental Medicine & Child Neurology, Vol. 42, No. 7, 2000, pp. 455-461. doi:10.1017/S0012162200000852
[7] B. B Johansson, “Current Trends in Stroke Rehabilitation. A Review with Focus on Brain Plasticity,” Acta Neurologica Scandinavica, Vol. 123, No. 3, 2011, pp. 147-159. doi:10.1111/j.1600-0404.2010.01417.x
[8] W. Kakuda, M. Abo, K. Kobayashi, R. Momosaki, A. Yokoi, A. Fukuda, A. Ishikawa, H. Ito and A. Tominaga, “Low-Frequency Repetitive Transcranial Magnetic Stimulation and Intensive Occupational Therapy for Poststroke Patients with Upper Limb Hemiparesis: Preliminary Study of a 15-Day Protocol,” International Journal of Rehabilitation Research, Vol. 33, No. 4, 2010, pp. 339345. doi:10.1097/MRR.0b013e32833cdf10
[9] A. Kirton, R. Chen, S. Friefeld, C. Gunraj, A. M. Pontigon and G. Deveber, “Contralesional Repetitive Transcranial Magnetic Stimulation for Chronic Hemiparesis in Subcortical Paediatric Stroke: a Randomised Trial,” The Lancet Neurology, Vol. 7, No. 6, 2008, pp. 507-513. doi:10.1016/S1474-4422(08)70096-6
[10] E. M. Wassermann, “Risk and Safety of Repetitive Transcranial Magnetic Stimulation: Report and Suggested Guidelines from the International Workshop on the Safety of Repetitive Transcranial Magnetic Stimulation, June 5-7, 1996,” Electroencephalography and Clinical Neurophysiology, Vol. 108, No. 1, 1998, pp. 1-16. doi:10.1016/S0168-5597(97)00096-8
[11] D. J. Gladstone, C. J. Danells and S. E. Black, “The FuglMeyer Assessment of Motor Recovery after Stroke: A Critical Review of its Measurement Properties,” Neurorehabilitation and Neural Repair, Vol. 16, No. 3, 2002, pp. 232-240. doi:10.1177/154596802401105171
[12] D. M. Morris, G. Uswatte, J. E. Crago, E. W. Cook and E. Taub, “The Reliability of the Wolf Motor Function Test for Assessing Upper Extremity Function after Stroke,” Archives of Physical Medicine and Rehabilitation, Vol. 82, No. 6, 2002, pp. 750-755. doi:10.1053/apmr.2001.23183
[13] T. Kaneko and T. Muraki, “Development and Standardization of the Hand Function Test,” Bulletin of Allied Medical Sciences Kobe, Vol. 6, 1990, pp. 49-54.
[14] T. Hatanaka, T. Koyama, M. Kanematsu, N. Takahashi, K. Matsumoto and K. Domen, “A New Evaluation Method for Upper Extremity Dexterity of Patients with Hemiparesis after Stroke: The 10-Second Tests,” International Journal of Rehabilitation Research, Vol. 30, No. 3, 2007, pp. 243-247. doi:10.1097/MRR.0b013e3282ab961d
[15] A. C. Valle, K. Dionisio, N. B. Pitskel, A. Pascual-Leone, F. Orsati, M. J. Ferreira, P. S. Boggio, M. C. Lima, S. P. Rigonatti and F. Fregni, “Low and High Frequency Repetitive Transcranial Magnetic Stimulation for the Treatment of Spasticity,” Developmental Medicine & Child Neurology, Vol. 49, No. 7, 2007, pp. 534-538. doi:10.1111/j.1469-8749.2007.00534.x
[16] S. Rossi, M. Hallett, P. M. Rossini, A. Pascual-Leone and Safety of TMS Consensus Group, “Safety, Ethical Considerations and Application Guidelines for the Use of Transcranial Magnetic Stimulation in Clinical Practice and Research,” Clinical Neurophysiology, Vol. 120, No. 12, 2009, pp. 2008-2039. doi:10.1016/j.clinph.2009.08.016
[17] N. Murase, J. Duque, R. Mazzocchio and L. G. Cohen, “Influence of Interhemispheric Interactions on Motor Function in Chronic Stroke,” Annals of Neurology, Vol. 55, No. 3, 2004, pp. 400-409. doi:10.1002/ana.10848
[18] N. Takeuchi, T. Chuma, Y. Matsuo, I. Watanabe and K. Ikoma, “Repetitive Transcranial Magnetic Stimulation of Contralesional Primary Motor Cortex Improves Hand Function after Stroke,” Stroke, Vol. 36, No. 12, 2005, pp. 2681-2686. doi:10.1161/01.STR.0000189658.51972.34
[19] F. Fregni, P. S. Boggio, A. C. Valle, R. R. Rocha, J. Duarte, M. J. Ferreira, T. Wagner, S. Fecteau, S. P. Rigonatti, M. Riberto, S. D. Freedman and A. Pascual-Leone, “A Sham-Controlled Trial of a 5-Day Course of Repetitive Transcranial Magnetic Stimulation of the Unaffected Hemisphere in Stroke Patients,” Stroke, Vol. 37, No. 8, 2006, pp. 2115-2122. doi:10.1161/01.STR.0000231390.58967.6b
[20] F. Heinen, F. X. Glocker, U. Fietzek, B. U. Meyer, C. H. Lucking and R. Korinthenberg, “Absence of Transcallosal Inhibition Following Focal Magnetic Stimulation in Pre-school Children,” Annals of Neurology, Vol. 43, No. 5, 1998, pp. 608-612. doi:10.1002/ana.410430508
[21] K. Muller, F. Kass-Iliyya and M. Reitz, “Ontogeny of Ipsilateral Corticospinal Projections: A Developmental Study with Transcranial Magnetic Stimulation,” Annals of Neurology, Vol. 42, No. 5, 1997, pp. 705-711. doi:10.1002/ana.410420506
[22] R. Benecke, B. U. Meyer and H. J. Freund, “Reorganisation of Descending Motor Pathways in Patients after Hemispherectomy and Severe Hemispheric Lesions Demonstrated by Magnetic Brain Stimulation,” Experimental Brain Research, Vol. 83, No. 2, 1991, pp. 419-426. doi:10.1007/BF00231167
[23] M. V. Johnston, “Plasticity in the Developing Brain: Implications for Rehabilitation,” Developmental Disabilities Research Reviews, Vol. 15, No. 2, 2009, pp. 94-101. doi:10.1002/ddrr.64
[24] K. Brady and T. Garcia, “Constraint-Induced Movement Therapy (CIMT): Pediatric Applications,” Developmental Disabilities Research Reviews, Vol. 15, No. 2, 2009, pp. 102-111. doi:10.1002/ddrr.59
[25] A. Gordon, A. Connelly, B. Neville, F. Vargha-Khadem, N. Jessop, T. Murphy and V. Ganesan, “Modified Constraint-Induced Movement Therapy after Childhood Stroke,” Developmental Medicine & Child Neurology, Vol. 49, No. 1, 2007, pp. 23-27. doi:10.1017/S0012162207000072.x

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