Our study was designed to investigate the effect of cerebellar intermittent theta burst stimulation (iTBS) combined with conventional rehabilitation methods on balance, gait and disease anxiety in patients with ischemic stroke who have residual balance and gait disturbance, using clinical measurement parameters.
Loss of balance and gait functions, which are neurological impairments related to stroke, are among the common functional losses depending on the affected brain region. Reduced independence in daily living activities can lead to increased anxiety during ambulation, risk of falling and fear of falling. Studies have shown that applying theta burst stimulation (TBS) to the cerebellum has long-term effects on the excitability of the cerebello-thalamo-cortical pathways and stimulates synaptic plasticity through various mechanisms. In the literature, there are studies examining the effects of cerebellar iTBS on balance and walking functions in stroke patients, but the number of studies are quite limited. This study was planned as a prospective, randomized, sham-controlled clinical study. According to the statistical analysis 30 patients who were registered at Ankara Bilkent City Hospital Physical Therapy and Rehabilitation Hospital between February 2022 and April 2023 and met the study criteria were included. The patients were divided into two groups: active (n=15) and sham (n=15). Each group received 30 sessions of either active or sham cerebellar iTBS (CRB-iTBS). Additionally, patients received therapeutic interventions from a physiotherapist, including range of motion exercises, stretching, neurophysiological exercises, balance-coordination training, active-assistive mobilization, and exercises for daily living. The CRB-iTBS treatment targeted the cerebellum on the opposite side to the cerebral lesions, administered in a total of 30 sessions, twice a day with a 5-minute interval between sessions, over a period of 3 weeks. Each stimulation session consisted of 3-burst pulses at a frequency of 50 Hz, with a 10-second repetitive cycle of 2-second stimulations lasting a total of 190 seconds, delivering 600 pulses per session. Each day, a total of 1200 pulses were administered over two sessions, spaced 5 minutes apart. Patients in the sham CRB-iTBS group received the same protocol with a sham coil that visually resembled the active coil. Clinical evaluations were conducted three times for each patient: Baseline (before treatment), 3rd week (at the and of treatment), and 6th week.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
SINGLE
Enrollment
30
Magstim Rapid2 Magnetic Stimulator (Magstim, Whitland Dyfed, UK), 70 mm Figure-of-eight Coil
Magstim Rapid2 Magnetic Stimulator (Magstim, Whitland Dyfed, UK), 70 mm Figure-of-eight Sham Coil
Ankara Bilkent City Hospital
Ankara, Turkey (Türkiye)
Berg Balance Scale (BBS)
This is a scale used to evaluate patients' balance during 14 different activities. These activities include: sitting to standig, standing unsupported, sitting unsupported, standing to sitting, transfers, standing unsupported with eyes closed, standing with feet together, reaching forward while standing, picking up an object from the floor, looking back over the shoulder on both the right and left sides, turning 360 degrees, placing a foot on a stool, standing in a toe-heel position, and standing on one foot. The total score after performing the test determines the predicted risk of falls. The minimum score on the test is 0, and the maximum score is 56. Scores are classified as follows: 0-20 indicates a high risk of falling, 21-40 indicates a moderate risk of falling, and 41-56 indicates a low risk of falling.
Time frame: Baseline (before treatment), 3rd week (at the end of treatment), 6th week
Gait Analysis- Step Length
The Zebris FDM Type 3 (Zebris Medical GmbH, Germany) device was used to record spatiotemporal data during walking. This system consists of a 3-meter straight platform, with two 1-meter maneuvering platforms at the start and end. It is equipped with sensors and computer software for data analysis. The data collected in the study included step length (cm).
Time frame: Baseline (before treatment), 3rd week (at the end of treatment), 6th week
Gait Analysis- Step Width
The Zebris FDM Type 3 (Zebris Medical GmbH, Germany) device was used to record spatiotemporal data during walking. This system consists of a 3-meter straight platform, with two 1-meter maneuvering platforms at the start and end. It is equipped with sensors and computer software for data analysis. The data collected in the study included step width (cm).
Time frame: Baseline (before treatment), 3rd week (at the end of treatment), 6th week
Gait Analysis- Walking Speed
The Zebris FDM Type 3 (Zebris Medical GmbH, Germany) device was used to record spatiotemporal data during walking. This system consists of a 3-meter straight platform, with two 1-meter maneuvering platforms at the start and end. It is equipped with sensors and computer software for data analysis. The data collected in the study included walking speed (km/h).
This platform is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional.
Time frame: Baseline (before treatment), 3rd week (at the end of treatment), 6th week
International Falls Efficacy Scale (FES-I)
Patients are evaluated for their level of concern about the risk of falling during 16 different activities. A score of 1 reflects no concern, while a score of 4 reflects a high level of concern. Total scores range from 16 to 64, with higher scores indicating greater anxiety about falling and lower self-confidence during activities.
Time frame: Baseline (before treatment), 3rd week (at the end of treatment), 6th week
Barthel Index for Activities of Daily Living (BI)
The Barthel Index (BI) was used to assess physical independence in daily activities on ten-item scale. These items are: feeding, bathing, grooming, dressing, bowels, bladder, toilet use, transfer (bed to chair and back), mobility (on level surfaces). Score of 0 indicating complete dependence and a score of 100 indicating complete independence.
Time frame: Baseline (before treatment), 3rd week (at the end of treatment), 6th week
Stroke Specific Quality of Life Scale (SS-QOL)
The Stroke-Specific Quality of Life Scale (SS-QOL) assesses the functionality and quality of life in stroke patients through 49 questions across 12 categories. These categories include: thinking, upper extremity functions, vision, work/productivity, social roles, self-care, personality, mood, mobility, language, family roles, and energy. Scoring is done on a scale from 1 to 5, with a total score ranging from 49 to 245. A score of 49 indicates very low quality of life, while a score of 245 indicates high quality of life.
Time frame: Baseline (before treatment), 3rd week (at the end of treatment), 6th week
Hospital Anxiety and Depression Scale (HADS)
Hospital Anxiety and Depression Scale (HADS) consists of 14 questions, which are to be answered based on the patient's experience over the past few days while hospitalized. Seven of the questions assess depression, and seven assess anxiety levels. Separate scoring is done for anxiety and depression. The score may range between 0 and 21 per subscale. Higher scores indicate higher levels of anxiety and depression.
Time frame: Baseline (before treatment), 3rd week (at the end of treatment), 6th week