What is the role of a physician in performing repetitive Transcranial Magnetic Stimulation (rTMS) for post-stroke rehabilitation?

Role of the Physician in rTMS for Post-Stroke Rehabilitation

The physician's primary role in rTMS for post-stroke rehabilitation is to lead the multidisciplinary team in patient selection, protocol design, safety monitoring, and integration of rTMS as an adjunct to conventional therapy, not as a standalone treatment. 1

Core Physician Responsibilities

Patient Selection and Assessment

• Screen all post-stroke patients for eligibility by assessing motor impairment severity, time since stroke, and presence of contraindications to rTMS 1
• Determine optimal candidates based on neurophysiological characteristics, such as presence or absence of motor evoked potentials, which predict treatment response 1
• Exclude patients with seizure history, metallic implants, or cardiac pacemakers per international safety guidelines 2
• Assess baseline functional status using standardized measures for motor function, cognition, aphasia, or neglect depending on target deficit 1, 3

Protocol Design and Individualization

• Select stimulation parameters based on the specific deficit: high-frequency rTMS (≥5 Hz) to the affected hemisphere increases cortical excitability, while low-frequency rTMS (≤1 Hz) to the unaffected hemisphere decreases maladaptive inhibition 1, 2
• Determine treatment intensity and duration: typically 10-20 sessions over 2-4 weeks, with each session lasting 20-30 minutes 3, 4
• Choose stimulation site based on lesion location and functional mapping—affected hemisphere for excitatory protocols, unaffected hemisphere for inhibitory protocols 3
• Integrate rTMS timing with conventional therapy: administer rTMS immediately before physical, occupational, or speech therapy sessions to prime neuroplasticity 1, 5

Multidisciplinary Team Leadership

• Coordinate with physical therapists, occupational therapists, and speech-language pathologists to ensure rTMS is delivered as an adjunct to task-specific training, not in isolation 1
• Ensure the rehabilitation team understands that rTMS modulates cortical excitability to enhance the effects of concurrent behavioral therapy 1
• Establish clear communication protocols for reporting adverse effects or lack of response 1

Safety Monitoring and Adverse Event Management

• Monitor for common side effects including scalp tingling, headache, and transient discomfort during each session 2
• Watch for serious complications such as seizures, which are rare but preventable by adhering to international safety guidelines 1, 2
• Adjust or discontinue treatment if patients develop intolerable side effects or show no response after 5-10 sessions 3, 4

Outcome Assessment and Documentation

• Measure functional outcomes using validated scales specific to the targeted deficit: Fugl-Meyer Assessment for motor function, Western Aphasia Battery for language, or line bisection test for neglect 1, 3, 5
• Reassess at regular intervals (baseline, mid-treatment, end of treatment, and follow-up) to determine treatment efficacy 3, 4
• Document treatment parameters, response, and adverse events to contribute to protocol optimization and identification of response phenotypes 1

Evidence-Based Treatment Algorithms

For Upper Extremity Motor Impairment

• Apply low-frequency rTMS (1 Hz) to the contralesional motor cortex OR high-frequency rTMS (≥5 Hz) to the ipsilesional motor cortex immediately before intensive task-specific upper limb training 1
• Combine with constraint-induced movement therapy for patients with some active wrist and finger extension 1
• Continue for minimum 10 sessions over 2 weeks, with each session followed by 30-60 minutes of occupational therapy 3, 4

For Aphasia

• Apply low-frequency rTMS (1 Hz) to the right inferior frontal gyrus to reduce maladaptive right hemisphere overactivation 1, 3
• Deliver immediately before speech-language therapy focused on functional communication tasks 1
• Initiate within 4 weeks post-stroke when possible, though chronic patients may also benefit 3

For Hemispatial Neglect

• Apply low-frequency rTMS (1 Hz) to the left parietal cortex to rebalance interhemispheric inhibition 5
• Administer immediately before occupational therapy with visual scanning training and functional tasks 1, 5
• Monitor using line bisection test and cancellation tasks at baseline and after every 5 sessions 5

Critical Pitfalls and How to Avoid Them

Pitfall 1: Using rTMS as Monotherapy

• Never prescribe rTMS without concurrent conventional rehabilitation therapy 1
• The evidence consistently shows rTMS works as an adjunct to prime neuroplasticity, not as a standalone intervention 1, 3

Pitfall 2: Inadequate Patient Selection

• Do not apply rTMS to patients with subcortical strokes and absent motor evoked potentials, as they are unlikely to respond 1
• Post-hoc analyses show response rates of 67% in patients with preserved cortical integrity versus 27% without 1

Pitfall 3: Inconsistent Stimulation Parameters

• Avoid varying frequency, intensity, or coil positioning mid-treatment without documented rationale 1
• Lack of standardization is a major barrier to clinical translation 1

Pitfall 4: Ignoring Time Windows

• Acute/subacute stroke patients (≤3 months) show better response (effect size 0.69) compared to chronic patients (effect size 0.52) 3
• However, chronic patients still benefit, so do not exclude them based solely on time since stroke 3, 4

Pitfall 5: Failure to Monitor for Non-Response

• If no improvement is seen after 10 sessions, reassess the protocol rather than continuing indefinitely 3, 4
• Consider alternative stimulation parameters, different target sites, or discontinuation 1

Physician Qualifications and Training Requirements

• Physicians should have experience in stroke rehabilitation and understanding of neuroplasticity principles 1
• Formal training in rTMS administration including safety protocols, coil positioning, and parameter selection is essential 1
• Knowledge of neuroanatomy and functional brain mapping is required to individualize treatment targets 1
• If specialized expertise is unavailable, refer patients to centers with organized stroke rehabilitation teams that include rTMS capabilities 1

Current Guideline Status

• The World Stroke Organization (2023) recommends rTMS as an adjunct to upper extremity therapy at the "Essential" resource level 1
• The Third Stroke Recovery and Rehabilitation Roundtable (2024) provides Level A evidence for low-frequency rTMS for hand function and Level B evidence for tDCS in motor rehabilitation 1
• Despite guideline recognition, rTMS has not yet changed standard rehabilitation practice due to barriers in protocol standardization and identification of treatment response phenotypes 1