Brain Stimulation After Stroke: TMS and tDCS
Non-invasive brain stimulation uses magnetic fields or weak electrical currents applied through the scalp to change the activity of brain areas involved in movement or language. It is used as an add-on to rehabilitation, not as a stand-alone treatment.
Types of stimulation
- Repetitive transcranial magnetic stimulation (rTMS): a coil placed over the head produces magnetic pulses that can increase or decrease activity in a target area
- Transcranial direct current stimulation (tDCS): a weak current is applied through electrodes on the scalp
Further reading: the guide “Stroke” and the articles Stroke Rehabilitation: Ischaemic and Haemorrhagic Stroke and Life at Home After Stroke: Work, Family and Daily Routine.
What does the evidence show?
Research results are mixed. A Cochrane review of rTMS did not find clear evidence of improved daily activities [1]. More recent evidence-based guidelines judged some rTMS protocols as probably effective for motor recovery in particular stroke phases [2]. A Cochrane review of tDCS found evidence that it may improve daily activities, with low certainty [3]. The benefit is therefore modest and varies between patients.
Who may benefit?
Brain stimulation is considered for selected patients, combined with intensive physiotherapy, occupational or speech therapy in the same session or period. It is not suitable for everyone; for example, a history of epilepsy or metal implants in the head requires careful assessment.
How does it work?
After a stroke, the balance of activity between the two hemispheres (halves of the brain) changes. Non-invasive brain stimulation aims to influence the excitability of brain areas involved in movement or language, so that the brain may respond better to training. Repetitive transcranial magnetic stimulation (rTMS) uses a magnetic coil held against the head; transcranial direct current stimulation (tDCS) uses a weak electrical current through electrodes on the scalp. Neither requires surgery or anaesthesia. Stimulation is usually combined with, or given just before, physiotherapy, occupational therapy or speech therapy.
Assessment before treatment
Suitability is decided by a PM&R specialist focused on neurorehabilitation after examination and review of imaging and medical history. Important questions include the type and location of the stroke, the stage of recovery, the therapy goals and safety factors. Stimulation may not be appropriate for people with epilepsy or a history of seizures, metal implants in the head, implanted electronic devices such as pacemakers, or certain other conditions.
What to expect during a course
A course usually consists of several sessions over a number of weeks. Sessions last from a few minutes to around half an hour, and the patient is awake and seated. Side effects are generally mild and temporary, such as a headache, scalp discomfort or tingling. Seizures with rTMS are rare but possible, which is why screening is important. Results vary between patients; evidence suggests possible benefit in some, but improvement cannot be guaranteed, and active training remains the core of treatment.
What families can do
- Help the patient keep practising the exercises set by the team between sessions
- Report any new headache, seizure or unusual symptom promptly
- Bring a list of all medicines to the assessment
When to see your physical medicine and rehabilitation specialist
After acute hospital care, the rehabilitation process is best led and advised by a physician specialised in physical medicine and rehabilitation (PM&R, also called physiatry). At home, too, it is worth consulting a PM&R specialist, who examines the patient, sets goals and guides therapy and supportive treatments together with the physiotherapist and the wider team. Ask for a review if:
- function is getting worse instead of better, or progress has stalled for several weeks
- new pain, stiffness, swelling or falls appear
- mood, sleep, swallowing or bladder control change
- you are wondering whether a robotic or other advanced therapy might be suitable
Whether robotic or other advanced therapies are suitable is decided by a PM&R specialist focused on neurorehabilitation. Prof. Dr. Engin Çakar works in this field and can be consulted online or in person; otherwise, consult a PM&R specialist near you.
Call emergency services immediately for sudden new weakness, facial drooping, difficulty speaking, a severe headache or loss of consciousness: these can be signs of a new stroke.
Frequently asked questions
Is it painful? rTMS can cause a tapping sensation or mild headache; tDCS usually causes a tingling feeling.
Can it replace physiotherapy? No. Its purpose is to support the effect of active therapy. See Robot-assisted rehabilitation.
Is brain stimulation suitable in the chronic phase? Studies include patients in both the early and chronic phases. Whether it is reasonable for an individual patient is decided after a specialist assessment.
Is it the same as electroconvulsive therapy? No. Non-invasive brain stimulation for stroke rehabilitation does not aim to cause a seizure and is performed while the patient is awake.
Assessment and contact
You can request an appointment or a second-opinion review of existing reports and imaging: Contact & second opinion (WhatsApp). This page is general health information. Diagnosis and treatment decisions are made individually after examination.
Sources
- Hao Z, et al. Repetitive transcranial magnetic stimulation for improving function after stroke. Cochrane Database Syst Rev. 2013. PMID: 23728683
- Lefaucheur JP, et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): An update (2014-2018). Clin Neurophysiol. 2020. PMID: 31901449
- Elsner B, et al. Transcranial direct current stimulation (tDCS) for improving activities of daily living, and physical and cognitive functioning, in people after stroke. Cochrane Database Syst Rev. 2020. PMID: 33175411