rTMS + CCFES Therapy for Severe Stroke

(rTMS+CCFES Trial)

Overseen By Kyle J. O'Laughlin, MS

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: The Cleveland Clinic

Must not be taking: Anticonvulsants, Antidepressants

Disqualifiers: Metal implant, Seizures, Alcohol abuse, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: 34

Duration: 12 weeks

72 Participants Needed

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial explores a new therapy that combines brain and electrical stimulation to aid upper limb recovery after a severe stroke. It compares three approaches: stimulating the intact side of the brain with the Conventional rTMS approach (Repetitive Transcranial Magnetic Stimulation), the damaged side with the New rTMS approach, or using a placebo with Sham rTMS. The goal is to determine which method best enhances hand and arm movement. Individuals who experienced a stroke over six months ago and have severe difficulty moving their upper limbs may be suitable candidates, particularly if they can follow simple instructions and have completed occupational therapy. As an unphased trial, this study offers a chance to contribute to groundbreaking research that could enhance stroke recovery therapies.

Will I have to stop taking my current medications?

The trial requires that you stop taking anticonvulsants or antidepressants that are not safe to use with TMS (a type of brain stimulation).

Is there any evidence suggesting that this trial's treatments are likely to be safe?

Research shows that repetitive transcranial magnetic stimulation (rTMS) is generally safe for treating movement issues. Studies have found that combining rTMS with contralaterally controlled functional electrical stimulation (CCFES) can help stroke patients regain use of their arms and hands. Importantly, rTMS is well-tolerated, with few serious side effects reported.

Previous studies have shown that using CCFES with rTMS improves recovery without major side effects. This treatment stimulates specific brain areas without surgery, reducing risks. While mild headaches or scalp discomfort can occur, they are usually short-lived and manageable.

This trial tests two methods: the standard rTMS approach and a new rTMS technique. Both aim to boost recovery by stimulating different brain areas. Safety data from earlier studies and the non-invasive nature of rTMS suggest that these treatments are safe options for improving arm and hand function after a stroke. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about rTMS combined with CCFES therapy for severe stroke because it introduces a novel approach to rehabilitation. Unlike traditional methods like physical therapy and occupational therapy, this treatment uses a combination of repetitive Transcranial Magnetic Stimulation (rTMS) and Contralaterally Controlled Functional Electrical Stimulation (CCFES) to specifically target brain activity and muscle movement. This technique aims to enhance neuroplasticity, which is the brain's ability to reorganize itself, potentially leading to more effective recovery of motor function. The innovative aspect of using CCFES to practice functional tasks with the paretic hand also sets it apart, offering a more targeted and interactive therapy option for patients.

What evidence suggests that this trial's treatments could be effective for severe stroke recovery?

This trial will evaluate the effectiveness of combining rTMS (repetitive transcranial magnetic stimulation) with CCFES (contralaterally controlled functional electrical stimulation) for stroke recovery. Studies have shown that CCFES can improve hand and arm function more effectively than other electrical stimulation methods. Specifically, for patients with long-term moderate to severe hand issues after a stroke, 12 weeks of CCFES improved hand movement. In this trial, one group will use the conventional rTMS method, which targets the damaged side of the brain, combined with CCFES. Another group will use a new rTMS method, targeting the healthy side of the brain, alongside CCFES. A third group will involve CCFES with sham rTMS. Both active treatment groups aim to help patients regain better control of their affected limbs. ^{6 7 8 9 10}

Who Is on the Research Team?

Ela Plow, PhD

Principal Investigator

Lerner Research Institute; Cleveland Clinic Foundation

Are You a Good Fit for This Trial?

This trial is for adults aged 18-90 who had a severe stroke at least 6 months ago, resulting in significant upper limb weakness. They must be able to follow commands and have no recent history of seizures or substance abuse. People with metal head implants, pacemakers, or those on certain medications cannot join.

Inclusion Criteria

I can move my shoulder and elbow enough to place my hand on my lap for exercises.

It has been over 6 months since I had a stroke.

I finished occupational therapy over 2 months ago and am not currently in therapy.

Exclusion Criteria

You have a metal implant in your head.

Cardiac pacemaker or other programmable implant

You had problems with alcohol or drugs within the last 10 years.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants receive 12 weeks of treatment with CCFES and rTMS, including 10 sessions per week of self-administered exercises and 2 sessions per week of lab-based task practice

12 weeks

10 sessions per week (home-based), 2 sessions per week (in-person)

Follow-up

Participants are monitored for safety and effectiveness after treatment, with assessments at 24 and 36 weeks

24 weeks

Assessments at 24 and 36 weeks

What Are the Treatments Tested in This Trial?

Interventions

• Contralaterally Controlled Functional Electrical Stimulation
• Conventional rTMS approach
• New rTMS approach
• Sham rTMS approach

Trial Overview The study tests if a new rTMS approach targeting the undamaged brain hemisphere combined with CCFES therapy improves arm function in severe stroke patients more than conventional rTMS or sham treatments.

How Is the Trial Designed?

Group I: CCFES + rTMS facilitating iM1 Active Control 2 Interventions

This rTMS paradigm is the "Conventional Approach".Facilitation of M1 will be achieved using 5Hz rTMS. After rTMS, the participant will participate in one hour of CCFES-mediated functional task practice. The therapist will instruct and guide the participants in practicing functional tasks with their paretic hand with the assistance of CCFES. Tasks will involve using the paretic hand to pick up, manipulate, and release objects commonly used in daily life. Early sessions will focus on simpler tasks, such as practicing opening the hand adequately to acquire an object.

Group II: CCFES + rTMS facilitating cHMC Active Control 2 Interventions

This rTMS paradigm is the "New Approach". Facilitation of the intact hemisphere target (cHMC) will be achieved using 5Hz rTMS. After rTMS, the participant will participate in one hour of CCFES-mediated functional task practice. The therapist will instruct and guide the participants in practicing functional tasks with their paretic hand with the assistance of CCFES. Tasks will involve using the paretic hand to pick up, manipulate, and release objects commonly used in daily life. Early sessions will focus on simpler tasks, such as practicing opening the hand adequately to acquire an object.

Group III: CCFES + Sham rTMS Placebo Group 2 Interventions

This rTMS paradigm is the "Sham Approach". Immediately after sham rTMS, the participant will participate in one hour of CCFES-mediated functional task practice. The therapist will instruct and guide the participants in practicing functional tasks with their paretic hand with the assistance of CCFES. Tasks will involve using the paretic hand to pick up, manipulate, and release objects commonly used in daily life. Early sessions will focus on simpler tasks, such as practicing opening the hand adequately to acquire an object.

Who Is Running the Clinical Trial?

The Cleveland Clinic

Lead Sponsor

Trials

1,072

Recruited

1,377,000+

Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)

Collaborator

Trials

2,103

Recruited

2,760,000+

Published Research Related to This Trial

In a case study of two stroke patients, 6-Hz primed low-frequency rTMS applied to the contralesional primary motor area successfully disrupted cortical activation, suggesting a potential mechanism for enhancing motor function by disinhibiting the ipsilesional motor area.

While one subject showed positive changes in intracortical inhibition and facilitation, the other did not exhibit behavioral improvements, highlighting the importance of combining rTMS with behavioral training to maximize recovery outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

6-Hz primed low-frequency rTMS to contralesional M1 in two cases with middle cerebral artery stroke. Carey, JR., Anderson, DC., Gillick, BT., et al.[2021]

The study found that contralesional repetitive transcranial magnetic stimulation (rTMS) was safe and well-tolerated in 10 chronic stroke patients, with no adverse effects like seizures or worsening motor function, indicating its potential as a noninvasive treatment option.

There was a positive relationship between the integrity of transcallosal motor fibers and motor improvement after rTMS, suggesting that rTMS may enhance neuroplasticity in the brain, which could be useful for rehabilitation in severe chronic stroke patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Long-term effects of contralesional rTMS in severe stroke: safety, cortical excitability, and relationship with transcallosal motor fibers. Demirtas-Tatlidede, A., Alonso-Alonso, M., Shetty, RP., et al.[2018]

In a study involving 18 healthy subjects, real low-frequency (1 Hz) rTMS applied to the right primary motor cortex significantly increased regional cerebral blood flow in the left motor cortex during right hand movement, indicating enhanced brain activity, although this did not translate to improved motor performance.

The same rTMS effects were observed in two stroke patients, suggesting that low-frequency rTMS may promote beneficial brain connectivity and plasticity, highlighting its potential as a therapeutic tool in stroke rehabilitation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Neural substrates of low-frequency repetitive transcranial magnetic stimulation during movement in healthy subjects and acute stroke patients. A PET study. Conchou, F., Loubinoux, I., Castel-Lacanal, E., et al.[2021]

In a study involving 8 chronic stroke patients and 8 healthy subjects, navigated low-frequency rTMS significantly increased excitability in the non-stimulated motor cortex of stroke patients, leading to improved motor function, particularly in tasks like finger tapping and pinch force.

The effects of rTMS were more pronounced in stroke patients compared to healthy controls, suggesting that this intervention may effectively enhance motor responses in individuals with residual motor deficits after a stroke.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Enhanced motor function and its neurophysiological correlates after navigated low-frequency repetitive transcranial magnetic stimulation over the contralesional motor cortex in stroke. Bashir, S., Vernet, M., Najib, U., et al.[2018]

High-frequency rTMS (20 and 25 Hz) applied to the motor cortex of chronic stroke patients may increase the risk of seizures, as indicated by EMG bursts and muscle excitation observed during the study.

Despite the safety concerns, the study found no significant increase in motor cortex excitability or improvement in hand strength after rTMS, suggesting that the stimulation parameters used may not be effective for rehabilitation in this population.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Safety study of high-frequency transcranial magnetic stimulation in patients with chronic stroke. Lomarev, MP., Kim, DY., Richardson, SP., et al.[2016]

Repetitive transcranial magnetic stimulation (rTMS) has gained popularity for its ability to modulate brain activity, but safety considerations are crucial, especially with the recent updates to safety guidelines published in 2021.

The guidelines emphasize the importance of screening for risks, monitoring for adverse events, and specific safety measures when using rTMS, particularly in patients with conditions like stroke and traumatic brain injury.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Safety Review for Clinical Application of Repetitive Transcranial Magnetic Stimulation. Kim, WS., Paik, NJ.[2023]

A systematic review of 19 trials with 588 participants found that repetitive transcranial magnetic stimulation (rTMS) did not significantly improve functional recovery or motor function in stroke patients compared to sham therapy.

While rTMS was generally safe with few mild side effects reported, the current evidence does not support its routine use for stroke treatment, indicating a need for further research to establish effective protocols.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Repetitive transcranial magnetic stimulation for improving function after stroke. Hao, Z., Wang, D., Zeng, Y., et al.[2023]

A patient with treatment-resistant depression (TRD) showed unexpected improvement after experiencing a seizure during repetitive transcranial magnetic stimulation (rTMS), suggesting a potential link between seizure activity and therapeutic effects in TRD.

While rTMS is generally safe, known adverse events include headaches and seizures; this case highlights an unusual outcome where a seizure may have contributed to the patient's improvement, warranting further investigation into the mechanisms of rTMS.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Treatment-Resistant Depression Entering Remission Following a Seizure during the Course of Repetitive Transcranial Magnetic Stimulation. Kim, JW., Bae, KY., Kim, SW., et al.[2020]

Repetitive transcranial magnetic stimulation (rTMS) was found to be safe for a patient with an implanted subdural cortical electrode, showing no serious adverse effects during treatment.

Ex-vivo experiments indicated that rTMS caused only a slight increase in coil temperature and no displacement of the electrodes, suggesting that rTMS can be safely applied in clinical settings for patients with such implants.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Safety of repetitive transcranial magnetic stimulation in patients with implanted cortical electrodes. An ex-vivo study and report of a case. Phielipp, NM., Saha, U., Sankar, T., et al.[2019]

After a stroke, the contralesional hemisphere can become hyperexcitable, which may hinder recovery; however, some patients show beneficial contralesional activity, suggesting its complex role in motor recovery.

Therapies like brain-computer interface (BCI) and transcranial magnetic stimulation (TMS) can target either hemisphere to enhance recovery, with TMS showing promise in improving outcomes by either exciting the ipsilesional cortex or inhibiting the contralesional cortex.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Role of the Contralesional vs. Ipsilesional Hemisphere in Stroke Recovery. Dodd, KC., Nair, VA., Prabhakaran, V.[2020]

Repetitive transcranial magnetic stimulation (rTMS) has not been thoroughly studied for side effects, with the main known risk being the acute production of seizures.

While tissue damage from rTMS is unlikely, there are concerns about potential cognitive effects and the possibility of long-term changes in brain function that have not yet been fully understood.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Side effects of repetitive transcranial magnetic stimulation. Wassermann, EM.[2005]

Citations

1. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC10915254/

The efficacy of contralaterally controlled functional electrical ... The results of this study provide strong evidence that shows CCFES being a better electrical stimulation modality compared to conventional NMES.

2. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC3561720/

Contralaterally Controlled Functional Electrical Stimulation for ... It is being studied to evaluate its efficacy in improving recovery of arm and hand function and ankle dorsiflexion in chronic and subacute stroke patients. The ...

3. frontiersin.org frontiersin.org/journals/neurology/articles/10.3389/fneur.2022.1010975/full

Effectiveness of contralaterally controlled functional ... This study aimed to compare the efficacy of contralaterally controlled functional electrical stimulation (CCFES) vs. neuromuscular electrical stimulation (NMES)

4. ahajournals.org ahajournals.org/doi/10.1161/STROKEAHA.116.013791

Contralaterally Controlled Functional Electrical Stimulation ... Among participants with chronic moderate to severe hand impairment after stroke, 12 weeks of CCFES therapy improved manual dexterity more than ...

5. trialsjournal.biomedcentral.com trialsjournal.biomedcentral.com/articles/10.1186/s13063-022-06303-y

Efficacy of contralaterally controlled functional electrical ... This study will determine whether CCFES therapy produces greater improvements in upper extremity function than cNMES or TOT.

6. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC9117963/

Contralaterally Controlled Functional Electrical Stimulation ... Approximately two-thirds of stroke survivors experience chronic upper limb paresis, and of them, 50% experience severe paresis.

7. clinicaltrials.gov clinicaltrials.gov/study/NCT03870672

rTMS Plus CCFES-mediated Functional Task Practice for ... This study is a necessary and important step in the development of a new therapy for upper limb functional recovery in patients with severe motor impairment ...

8. pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov/35599736/

Contralaterally Controlled Functional Electrical Stimulation ... Aim: Here, we test the premise that combining Contralaterally Controlled Functional Electrical Stimulation (CCFES), a rehabilitation technique ...

9. researchgate.net researchgate.net/publication/360276501_Contralaterally_Controlled_Functional_Electrical_Stimulation_Combined_With_Brain_Stimulation_for_Severe_Upper_Limb_Hemiplegia-Study_Protocol_for_a_Randomized_Controlled_Trial

Contralaterally Controlled Functional Electrical Stimulation ... Up to 50% of stroke survivors have persistent, severe upper extremity paresis even after receiving rehabilitation. Repetitive transcranial ...

10. systematicreviewsjournal.biomedcentral.com systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-025-02794-3

Repetitive transcranial magnetic stimulation for motor function ... This study aimed to systematically evaluate the safety and effectiveness of repetitive transcranial magnetic stimulation (rTMS) in treating motor dysfunction ...