A noninvasive treatment offers hope for patients with stroke.
By Carmen Peota
The 46-year-old woman, whose life was upended by a stroke a few months earlier, can’t unclench her left fist and struggles to pick up a wooden block. After several herky-jerky attempts, she finally scoops one into fingers still curled tightly around her thumb. A couple of weeks later, after treatment with repetitive transcranial magnetic stimulation (rTMS) at the University of Minnesota, she extends her fingers and grasps a grape with relative ease.
The woman had read about the noninvasive procedure, which uses a coil about the size of a man’s hand to deliver magnetic currents to the brain, and asked her neurologist about it. He referred her to professor of physical therapy James Carey (B.S. ’72, M.S. ’78, Ph.D. ’88), who had just started offering it to patients with stroke at the M Health Clinics and Surgery Center in January. He has investigated the treatment—which has been around since the 1980s and is more commonly used to treat depression—for much longer.
Carey began pursuing the idea of using rTMS with people who’d had a stroke a dozen years ago. At the time, he was researching neuroplasticity: the ability of the brain to form and reorganize synaptic connections. Research suggested rTMS might help that process along in patients with stroke. In 2005, Carey went to Boston to study with Harvard’s Dr. Alvaro Pascual-Leone, who was using rTMS with stroke patients. When Carey returned to Minnesota, he got a National Institutes of Health grant enabling him to purchase rTMS equipment. He decided to focus on hand function, in part because it’s a primary concern for people who have had strokes and also because the area of the brain controlling the hand is relatively large.
The targets of rTMS are neurons in the damaged area of the brain that survived the stroke. “We are trying to resurrect those neurons out of their dormancy into a higher level of excitability so that they can be voluntarily recruited by the person to produce function,” Carey explains.
In his research, Carey has sought to show that it works. And to some extent, he’s done that. A study published in 2013 in Developmental Medicine and Child Neurology found rTMS was effective and safe in children who’d had a stroke. But in a study of adults with stroke published in 2014, he couldn’t show a group benefit of rTMS in adults. And he notes the literature on rTMS is mixed as well. “I have to say that some of the trials are disappointing,” he admits.
Yet in Carey’s studies there were always individuals who responded to rTMS. “Along the way, patients declared, ‘I really benefit from this, and I’d like to continue it,’” Carey says, noting they were even willing to pay out of pocket for it. He would explain that there was no clinical venue for the treatment. But recently, he began to wonder if he should make rTMS available to those who asked for it. Many were desperate for help.
He approached University of Minnesota Physicians about offering it in the clinic, suggesting it could be done within a framework that would be safe and fair for patients, all of whom would need to meet certain criteria: They couldn’t have had a seizure within two years or take medications putting them at risk for seizure, and they couldn’t have metal in their heads. They’d need their doctor’s approval. Carey himself would receive no remuneration for the treatments (a 10-session series costs about $2,400), and he would stop the treatments after five sessions if there were no signs of progress. The 46-year-old woman who picked up the block was his first patient.
In April, she was back for a “booster.” Carey measured the distance from her eyebrows to the top of her skull and marked a spot before placing the electromagnetic coil on the crown of her head. He turned on the machine, looked at a screen, and moved the coil. When he found the spot he wanted, he held it there while the machine pulsed, sounding like a ruler rapping on a table, rapidly for 10 minutes and then slowly for another 10.
Neither therapist nor patient was sure whether the rTMS that seemed to help her before will do so this day. “It’s all experimental,” she says. She hopes what Carey is learning by treating her will benefit others. He hopes it will one day be a tool that all physical therapists can use. In the meantime, both are willing to continue the experiment. For her the stakes are high: “I’ve got a whole life to live and people are depending on me,” she says. “I don’t have time to fool around.”