Effectiveness of Low-Frequency Repetitive Transcranial Magnetic Stimulation to Contralesional Motor Cortex Combined with Conventional Rehabilitation in Sub-Acute Stroke: A Pilot Study

Background: Upper limb motor impairment persists in up to 80% of stroke survivors and remains one of the most challenging goals in rehabilitation medicine. Low-frequency repetitive transcranial magnetic stimulation (rTMS) applied to the contralesional motor cortex is supported by growing evidence as an adjunct to conventional rehabilitation, yet published data from the Indian subcontinent are sparse. This study describes the application and functional outcomes of 1 Hz rTMS to the contralesional primary motor cortex combined with conventional rehabilitation in five patients with subacute stroke.

Methods: Five patients with first-ever, unilateral, subcortical subacute stroke and Brunnstrom Stage 2 – 4 upper limb hemiparesis received low-frequency rTMS (1 Hz, 1,200 pulses/session, 90% resting motor threshold) applied over the contralesional M1, followed immediately by conventional neurological physiotherapy and occupational therapy. Outcomes assessed included the Modified Rankin Scale (mRS), Barthel Index (BI), Functional Independence Measure – Functional Assessment Measure (FIM-FAM), and the Fugl-Meyer Assessment (FMA, total score). Paired t-tests and Wilcoxon Signed-Rank exact tests were performed; effect sizes were computed as Cohen’s d and rank-biserial correlation.

Results: All five patients demonstrated consistent improvement across all outcome measures. Mean improvements: mRS −1.0 grade (21.7% reduction); BI +25.0±5.0 points (78.1% increase); FIM-FAM +26.4±5.6 points (21.1% increase); FMA +25.0±2.9 points (36.7% increase). All patients exceeded the Minimum Clinically Important Difference (MCID) for the Barthel Index (≥10 points). Effect sizes were very large (Cohen’s d: BI=5.00, FIM=4.68, FM=8.58; rank-biserial r=1.00 for all scales). No adverse events were recorded.

Conclusion: Low-frequency rTMS to contralesional M1 combined with conventional rehabilitation produced clinically meaningful and consistent functional gains across all outcome measures in all five patients with subacute stroke. These preliminary findings support the feasibility and efficacy signal of this approach and provide the impetus for a planned multicentre randomised controlled trial.