***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The authors investigated the use of slow-frequency repetitive transcranial magnetic stimulation ( rTMS ) to the unaffected hemisphere to decrease interhemispheric inhibition of the lesioned hemisphere and improve motor function in patients within 12 months of a stroke . Patients showed a significant decrease in simple and choice reaction time and improved performance of the Purdue Pegboard test with their affected h and after rTMS of the motor cortex in the intact hemisphere as compared with sham rTMS Objective : To investigate the long-term behavioral and neurophysiologic effects of combined time-locked repetitive transcranial magnetic stimulation ( rTMS ) and physical therapy ( PT ) intervention in chronic stroke patients with mild motor disabilities . Methods : Thirty patients were enrolled in a double-blind , r and omized , single-center clinical trial . Patients received 10 daily sessions of 1 Hz rTMS over the intact motor cortex . In different groups , stimulation was either real ( rTMSR ) or sham ( rTMSS ) and was administered either immediately before or after PT . Outcome measures included dexterity , force , interhemispheric inhibition , and corticospinal excitability and were assessed for 3 months after the end of treatment . Results : Treatment induced cumulative rebalance of excitability in the 2 hemispheres and a reduction of interhemispheric inhibition in the rTMSR groups . Use-dependent improvements were detected in all groups . Improvements in trained abilities were small and transitory in rTMSS patients . Greater behavioral and neurophysiologic outcomes were found after rTMSR , with the group receiving rTMSR before PT ( rTMSR-PT ) showing robust and stable improvements and the other group ( PT-rTMSR ) showing a slight improvement decline over time . Conclusion : Our findings indicate that priming PT with inhibitory rTMS is optimal to boost use-dependent plasticity and rebalance motor excitability and suggest that time-locked rTMS is a valid and promising approach for chronic stroke patients with mild motor impairment . Classification of evidence : This interventional study provides Class I evidence that time-locked rTMS before or after physical therapy improves measures of dexterity and force in the affected limb in patients with chronic deficits more than 6 months poststroke . Neurology ® Malcolm MP , Triggs WJ , Light KE , Gonzalez Rothi LJ , Wu S , Reid K , Nadeau SE : Repetitive transcranial magnetic stimulation as an adjunct to constraint-induced therapy : an exploratory r and omized controlled trial . Am J Phys Med Rehabil 2007;86:707–715 . Objective : To test the potential adjuvant effect of repetitive transcranial magnetic stimulation ( rTMS ) on motor learning in a group of stroke survivors undergoing constraint-induced therapy ( CIT ) for upper-limb hemiparesis . Design : This was a prospect i ve r and omized , double-blind , sham-controlled , parallel group study . Nineteen individuals , one or more years poststroke , were r and omized to either a rTMS + CIT ( n = 9 ) or a sham rTMS + CIT ( n = 10 ) group and participated in the 2-wk intervention . Results : Regardless of group assignment , participants demonstrated significant gains on the primary outcome measures : the Wolf Motor Function Test ( WMFT ) and the Motor Activity Log (MAL)–Amount of Use , and on secondary outcome measures including the Box and Block Test ( BBT ) and the MAL – How Well . Participants receiving rTMS failed to show differential improvement on either primary outcome measure . Conclusions : Although this study provided further evidence that even relatively brief sessions of CIT can have a substantial effect , it provided no support for adjuvant use of rTMS Low-frequency repetitive transcranial magnetic stimulation ( rTMS ) of the unaffected hemisphere can enhance function of the paretic h and in patients with mild motor impairment . Effects of low-frequency rTMS to the contralesional motor cortex at an early stage of mild to severe hemiparesis after stroke are unknown . In this pilot , r and omized , double-blind clinical trial we compared the effects of low-frequency rTMS or sham rTMS as add-on therapies to outpatient customary rehabilitation , in 30 patients within 5–45 days after ischemic stroke , and mild to severe h and paresis . The primary feasibility outcome was compliance with the interventions . The primary safety outcome was the proportion of intervention-related adverse events . Performance of the paretic h and in the Jebsen – Taylor test and pinch strength were secondary outcomes . Outcomes were assessed at baseline , after ten sessions of treatment administered over 2 weeks and at 1 month after end of treatment . Baseline clinical features were comparable across groups . For the primary feasibility outcome , compliance with treatment was 100 % in the active group and 94 % in the sham group . There were no serious intervention-related adverse events . There were significant improvements in performance in the Jebsen – Taylor test ( mean , 12.3 % 1 month after treatment ) and pinch force ( mean , 0.5 Newtons ) in the active group , but not in the sham group . Low-frequency rTMS to the contralesional motor cortex early after stroke is feasible , safe and potentially effective to improve function of the paretic h and , in patients with mild to severe hemiparesis . These promising results will be valuable to design larger r and omized clinical trials Background and Purpose — Although there has been extensive research on the effectiveness of repetitive transcranial magnetic stimulation ( rTMS ) to improve patients ’ motor performance after experiencing chronic stroke , explicit findings on the coupling of different rTMS protocol s are meager . We design ed this sham-controlled r and omized study to investigate the potential for a consecutive suppressive-facilitatory TMS protocol to improve motor outcomes after chronic stroke . Methods — Fifty-four chronic hemiplegic stroke patients were allocated across 4 groups to undergo 20 daily sessions of ( 1 ) 1 Hz rTMS over the contralesional primary motor cortex ( M1 ) and then intermittent theta burst stimulation over the ipsilesional M1 ( group A ) ; ( 2 ) contralesional sham stimulation and then ipsilesional real intermittent theta burst stimulation ( group B ) ; ( 3 ) contralesional real 1 Hz rTMS and then ipsilesional sham stimulation ( group C ) ; or ( 4 ) bilateral sham-control procedures ( group D ) . We tested cortical excitability and motor activity assessment s at the baseline , postpriming rTMS , and postconsequent rTMS periods . Results — At post , group A showed greater muscle strength , Fugl-Meyer Assessment ( FMA ) , Wolf Motor Function test , and reaction time improvement in comparison with group B ( P<0.001≈0.003 ) and group C ( P=0.001≈0.003 ) . Correlation analyses in group A revealed a close relation between contralesional map area decrement and Wolf Motor Function test gain ( P=0.005 ; r=−0.75 ) , and also revealed ipsilesional map area increment and reaction time decrement ( P=0.02 ; r=−0.87 ) . We detected no such relations in the other 3 groups . Conclusions — Our clinical trials established an extended timeframe during which conditioning could be safely continued and produced more favorable outcomes in facilitating motor performance and ameliorating interhemispheric imbalance than those obtained from single-course rTMS modulation alone Background and Purpose — It has been recently shown that a single session of repetitive transcranial magnetic stimulation ( rTMS ) of the unaffected hemisphere can improve motor function in stroke patients ; however , this improvement is short-lasting . We therefore conducted a r and omized , sham-controlled , phase II trial to evaluate whether five sessions of low-frequency rTMS can increase the magnitude and duration of these effects and whether this approach is safe . Methods — Fifteen patients with chronic stroke were r and omized to receive active or sham rTMS of the unaffected hemisphere . A blinded rater assessed motor function and corticospinal excitability at baseline , during and after 2 weeks of treatment . Safety was assessed using a neuropsychologic battery and electroencephalogram . Results — Active rTMS result ed in a significant improvement of the motor function performance in the affected h and that lasted for 2 weeks . These effects were not observed in the sham rTMS group ( affected and unaffected h and ) and in the unaffected h and in the active rTMS group . Corticospinal excitability decreased in the stimulated , unaffected hemisphere and increased in the affected hemisphere . There was a significant correlation between motor function improvement and corticospinal excitability change in the affected hemisphere . Cognitive performance and electroencephalogram were not changed significantly throughout the trial in both groups of treatment . Conclusions — These results support and extend the findings of previous studies on rTMS in stroke patients because five consecutive sessions of rTMS increased the magnitude and duration of the motor effects . Furthermore , this increased dose of rTMS is not associated with cognitive adverse effects and /or epileptogenic activity Background and Purpose — A recent report has demonstrated that the contralesional primary motor cortex ( M1 ) inhibited the ipsilesional M1 via an abnormal transcallosal inhibition ( TCI ) in stroke patients . We studied whether a decreased excitability of the contralesional M1 induced by 1 Hz repetitive transcranial magnetic stimulation ( rTMS ) caused an improved motor performance of the affected h and in stroke patients by releasing the TCI . Methods — We conducted a double-blind study of real versus sham rTMS in stroke patients . After patients had well- performed motor training to minimize the possibility of motor training during the motor measurement , they were r and omly assigned to receive a subthreshold rTMS at the contralesional M1 ( 1 Hz , 25 minutes ) or sham stimulation . Results — When compared with sham stimulation , rTMS reduced the amplitude of motor-evoked potentials in contralesional M1 and the TCI duration , and rTMS immediately induced an improvement in pinch acceleration of the affected h and , although a plateau in motor performance had been reached by the previous motor training . This improvement in motor function after rTMS was significantly correlated with a reduced TCI duration . Conclusions — We have demonstrated that a disruption of the TCI by the contralesional M1 virtual lesion caused a paradoxical functional facilitation of the affected h and in stroke patients ; this suggests a new neurorehabilitative strategy for stroke patients BACKGROUND AND PURPOSE Repetitive transcranial magnetic stimulation ( rTMS ) may enhance plastic changes in the human cortex and modulation of behavior . However , the underlying neural mechanisms have not been sufficiently investigated . We examined the clinical effects and neural correlates of high-frequency rTMS coupled with motor training in patients with hemiparesis after stroke . METHODS Twenty-one patients were r and omly divided into two groups , and received either real or sham rTMS . Ten daily sessions of 1,000 pulses of real or sham rTMS were applied at 10 Hz over the primary motor cortex of the affected hemisphere , coupled with sequential finger motor training of the paretic h and . Functional MRIs were obtained before and after training using sequential finger motor tasks , and performances were assessed . RESULTS Following rTMS intervention , movement accuracy of sequential finger motor tasks showed significantly greater improvement in the real group than in the sham group ( p < 0.05 ) . Real rTMS  modulated areas of brain activation during performance of motor tasks with a significant interaction effect in the sensorimotor cortex , thalamus , and cau date nucleus . Patients in the real rTMS group also showed significantly enhanced activation in the affected hemisphere compared to the sham rTMS group . CONCLUSION According to these results , a 10 day course of high-frequency rTMS coupled with motor training improved motor performance through modulation of activities in the cortico-basal ganglia-thalamocortical circuits Repetitive transcranial magnetic stimulation of the motor cortex ( rTMS ) can be used to modify motor cortical excitability in human subjects . At stimulus intensities near to or above resting motor threshold , low-frequency rTMS ( approximately 1 Hz ) decreases motor cortical excitability , whereas high-frequency rTMS ( 5 - 20 Hz ) can increase excitability . We investigated the effect of 10 min of intermittent rTMS on motor cortical excitability in normal subjects at two frequencies ( 2 or 6 Hz ) . Three low intensities of stimulation ( 70 , 80 , and 90 % of active motor threshold ) and sham stimulation were used . The number of stimuli were matched between conditions . Motor cortical excitability was investigated by measurement of the motor-evoked potential ( MEP ) evoked by single magnetic stimuli in the relaxed first dorsal interosseus muscle . The intensity of the single stimuli was set to evoke baseline MEPs of approximately 1 mV in amplitude . Both 2- and 6-Hz stimulation , at 80 % of active motor threshold , reduced the magnitude of MEPs for approximately 30 min ( P < 0.05 ) . MEPs returned to baseline values after a weak voluntary contraction . Stimulation at 70 and 90 % of active motor threshold and sham stimulation did not induce a significant group effect on MEP magnitude . However , the intersubject response to rTMS  at 90 % of active motor threshold was highly variable , with some subjects showing significant MEP facilitation and others inhibition . These results suggest that , at low stimulus intensities , the intensity of stimulation may be as important as frequency in determining the effect of rTMS on motor cortical excitability OBJECTIVE To investigate whether multiple sessions of 1-Hz repetitive transcranial magnetic stimulation ( rTMS ) facilitates the effect of repetitive facilitation exercises on hemiplegic upper-limb function in chronic stroke patients . DESIGN R and omized double-blinded crossover study . PATIENTS Eighteen patients with hemiplegia of the upper lim 
    Output:
    
Conclusions : rTMS  promoted the recovery of limb motor function and changed the cortex excitability .
rTMS may be better for early and pure subcortical stroke patients .
Regarding different stimulation parameters , the number of stimulation sessions has an impact on the effect of rTMS