Effect of Graded Motor Imagery Combined With Repetitive Transcranial Magnetic Stimulation on Upper Extremity Motor Function in Stroke Patients: A Randomized Controlled Trial

OBJECTIVE:To investigate the efficacy of graded motor imagery therapy (GMI) and repetitive transcranial magnetic stimulation (rTMS) on upper extremity function alone and in combination in patients with stroke. DESIGN:This was a prospective randomized controlled trial. SETTING:A rehabilitation hospital. PARTICIPANTS:Participants (N=56) were randomized into GMI (n=19), rTMS (n=18), or combined groups (n=19). INTERVENTIONS:There were 2 interventions: (1) 20 minutes of 1 Hz rTMS. (2) 30 minutes of GMI. In addition to this, all participants receive conventional rehabilitation including 120 minutes of physical therapy and occupational therapy daily. All treatments were administered once a day, 5 days a week, for 4 weeks. The Fugl-Meyer assessment of upper extremity (FMA-UE), Action Research Arm Test (ARAT), modified Barthel Index (MBI), motor activity log (MAL), and motor evoked potential (MEP) were assessed in a blinded manner at baseline and 4 weeks after treatment, respectively. MAIN OUTCOME MEASURES:The primary endpoint was the improvement from baseline in FMA-UE for stroke patients at 4 weeks. RESULTS:After 4 weeks of treatment, the FMA-UE scores in the GMI, rTMS, and combined groups were higher than those at baseline assessment, with statistically significant differences among the 3 groups (P=.009). The efficacy of the combined group was significantly better than that of the GMI and rTMS groups (P=.015, P=.043, respectively). In the motor activity log-amount of use (MAL-AOU) score, the efficacy of the combined group was better than that of the rTMS group (P=.035). CONCLUSIONS:Both GMI and rTMS were effective in improving upper extremity function in patients with stroke, but the combination of the 2 techniques was more effective. However, GMI was better than rTMS in improving the interest of stroke patients in active training.