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Simultaneous rTMS and piano playing improve hand dexterity and induce changes in cortical excitability in a professional pianist affected by multiple sclerosis: a case report
A. Nuara, L. Straffi, F. Spagnolo, P. Rossi, G. Comi, M. Comola, L. Leocani (Milan, IT)
Introduction: Motor learning is a fundamental process of neurorehabilitation. One of its neurophysiological substrates -modulation cortex excitability- provides the rationale for non invasive brain stimulation techniques, such as repetitive transcranial stimulation (rTMS). Therefore, association of neuromotor rehabilitation and rTMS may be more effective than their use alone. The objective of this study was to assess the effectiveness of simultaneous rTMS and piano playing in improving hand dexterity and inducing changes in cortical excitability in a professional pianist affected by multiple sclerosis undergoing a 3-week period intensive neurorehabilitation.
Methods: A 39 y.o. pianist affected by multiple sclerosis with a bimanual (L>R) sensory-motor impairment due to 3 cervical relapses in the previous 3-12 months underwent 3-weeks neurorehabilitation sessions (twice a day, 5 days a week) together with treatment sessions of H-coil rTMS (10 Hz, bilateral fronto-parietal cortex) simultaneously to piano exercises performed during waiting times. Before (T0) and at the end (T1) of the study, functional (Nine-Hole-Peg-Test, Pinch, Jamar, MIDI sequencing) and neurophysiological tests (focal cortical mapping at 115% MT) were performed. Nine hole peg test and MIDI sequencing were also collected before and after each rTMS-piano session.
Results: At T1, the patient improved at NHPT in both hands (Right: 27.1'' vs 15.45'' ; Left 49.5'' vs 36.4'') and in piano performance. We found a decrease of cortical map motor area in both hemispheres (R>L). Improvement of these parameters occurring within single sessions was more evident in the first week of treatment.
Discussion and Conclusion: Improvement of hand dexterity and changes in cortical excitability can be explained through several mechanisms: rTMS applied simultaneously to a motor exercise may interact with the networks related to motor learning processes recruited by the ongoing task. Neurophysiologic data (reduction of right cortical map of APB), functional test and piano performance parameters indicated a process of inter-hemispheric motor re-balance, possibly owing to a gain in cortical efficiency. Our single case-study confirms that neurorehabilitation, followed by combined, simultaneous association of hand motor training and rTMS, could improve hand motor performance and modulate cortical excitability. Placebo-controlled studies are needed to quantify the hypothetical synergic effect of rTMS and motor training.
A. Nuara, L. Straffi, F. Spagnolo, P. Rossi, G. Comi, M. Comola, L. Leocani (Milan, IT)
Introduction: Motor learning is a fundamental process of neurorehabilitation. One of its neurophysiological substrates -modulation cortex excitability- provides the rationale for non invasive brain stimulation techniques, such as repetitive transcranial stimulation (rTMS). Therefore, association of neuromotor rehabilitation and rTMS may be more effective than their use alone. The objective of this study was to assess the effectiveness of simultaneous rTMS and piano playing in improving hand dexterity and inducing changes in cortical excitability in a professional pianist affected by multiple sclerosis undergoing a 3-week period intensive neurorehabilitation.
Methods: A 39 y.o. pianist affected by multiple sclerosis with a bimanual (L>R) sensory-motor impairment due to 3 cervical relapses in the previous 3-12 months underwent 3-weeks neurorehabilitation sessions (twice a day, 5 days a week) together with treatment sessions of H-coil rTMS (10 Hz, bilateral fronto-parietal cortex) simultaneously to piano exercises performed during waiting times. Before (T0) and at the end (T1) of the study, functional (Nine-Hole-Peg-Test, Pinch, Jamar, MIDI sequencing) and neurophysiological tests (focal cortical mapping at 115% MT) were performed. Nine hole peg test and MIDI sequencing were also collected before and after each rTMS-piano session.
Results: At T1, the patient improved at NHPT in both hands (Right: 27.1'' vs 15.45'' ; Left 49.5'' vs 36.4'') and in piano performance. We found a decrease of cortical map motor area in both hemispheres (R>L). Improvement of these parameters occurring within single sessions was more evident in the first week of treatment.
Discussion and Conclusion: Improvement of hand dexterity and changes in cortical excitability can be explained through several mechanisms: rTMS applied simultaneously to a motor exercise may interact with the networks related to motor learning processes recruited by the ongoing task. Neurophysiologic data (reduction of right cortical map of APB), functional test and piano performance parameters indicated a process of inter-hemispheric motor re-balance, possibly owing to a gain in cortical efficiency. Our single case-study confirms that neurorehabilitation, followed by combined, simultaneous association of hand motor training and rTMS, could improve hand motor performance and modulate cortical excitability. Placebo-controlled studies are needed to quantify the hypothetical synergic effect of rTMS and motor training.