Efficacy of Repetitive Transcranial Magnetic Stimulation (Ipsilateral Cortex) along with Physiotherapy to Contralateral Side on Tone and Function of Subacute Stroke Survivors: Protocol for a Randomised Controlled Trial

Introduction: Following a stroke, the resultant injury causes hyperexcitability of the contralesional hemisphere, leading to an interhemispheric imbalance and contralateral motor dysfunction. Repetitive Transcranial Magnetic Stimulation (rTMS) is a non invasive brain stimulation technique that has been investigated for its ability to hasten stroke recovery by stimulating the ipsilesional motor cortex or inhibiting the contralesional hemisphere. Need of the study: Stroke is a major cause of impairment, with a significant number of survivors experiencing motor impairments that affect their quality of life and independence. rTMS modulates cortical excitability and plasticity and has been shown to improve motor recovery after stroke. However, the exact parameters, timing and targets of rTMS remain undefined, which contributes to its variable clinical evidence. Some research focusing on the unaffected hemisphere suggests that ipsilateral cortical stimulation may be one means to decrease interhemispheric inhibition and promote recovery. A better understanding of the mechanisms underlying these phenomena might be useful in improving stroke treatment and intervention strategies. Aim: The present research aims to determine the effectiveness of a standard physiotherapy protocol for the contralateral side combined with rTMS of the ipsilateral (contralesional) cortex in improving tone and function in subacute stroke survivors. Materials and Methods: A randomised controlled trial involving 60 subacute stroke patients will be conducted, in which the patients will be divided into two groups: Group A (experimental) and Group B (control), using a random number sequence with a 1:1 allocation ratio. The experimental group will receive rTMS along with standard physiotherapy, while the control group will receive placebo rTMS alongside standard physiotherapy. This study will take place in the outpatient department of Ravi Nair Physiotherapy College and Acharya Vinobha Bhave Rural Hospital from April 2024 to March 2025. Each group will receive five intervention sessions per week for four weeks. The Modified Ashworth Scale (MAS), Stroke Rehabilitation Assessment of Movement (STREAM), Functional Reach Test (FRT) and 10-Metre Walk Test (10-MWT) will be used to assess each patient before and after therapy. The paired t-test will be employed to test the outcome variables for the pre-post results. The Kolmogorov-Smirnov test will be used to assess the normality of the data. If the data are normally distributed, a parametric test will be performed; if normality is violated, a non parametric test will be carried out, with a significance level set at p-value <0.05.