Role of 1 and 3 Hz repetitive transcranial magnetic stimulation on motor function recovery after acute ischaemic stroke E. M. Khedr a , M. R. Abdel-Fadeil b , A. Farghali b and M. Qaid b a Department of Neurology, Assiut University Hospital, Assiut, Egypt; and b Clinical Neurophysiology, Assiut University Hospital, Assiut, Egypt Keywords: cortical excitability, neuroplasticity, Repetitive transcranial magnetic stimulation, Stroke Received 17 April 2009 Accepted 5 June 2009 Background and purpose: The purpose of this study was to compare the long-term effect of five daily sessions of 1 vs. 3 Hz repetitive transcranial magnetic stimulation (rTMS) on motor recovery in acute stroke. Methods: A total of 36 patients with acute ischaemic stroke participated in the study. The patients were randomly assigned into one of three groups; the first and second groups received real rTMS; 1 and 3 Hz and third group received sham stimulation, daily for 5 days. Motor disability was assessed before and after the last session, and then after first, second and third month. Cortical excitability was assessed before and after the second and fifth session. The outcome measure was clinical disability at 3 months post-rTMS. Results: No significant differences were found in basal rating scales between the three groups. At the 3-month time point, both of the real rTMS groups had improved significantly more in different rating scales than the sham group; in addition, the 1 Hz group performed better than the 3 Hz group. Measures of cortical excitability immediately after the last session showed that the 1 Hz group had reduced excitability of the non-stroke hemisphere and increased excitability of the stroke hemisphere, whereas the 3 Hz group only showed increased excitability of the stroke hemisphere. Conclusion: These results confirm that five daily sessions of rTMS over motor cortex using either 1 Hz over the unaffected hemisphere or 3 Hz over the affected hemisphere can enhance recovery. At 3 months, the improvement was more pronounced in 1 Hz group. Introduction Stroke is a major cause of prolonged neurological dis- ability in adults [1,2]. Stroke burden is likely to increase as a result of ageing and population growth if action is not taken now to remove or reduce the well-established determinants of stroke [3]. Fortunately, the brain is ÔplasticÕ and able to reor- ganize itself up to a certain degree of damage. Many studies have documented the changes in cortical orga- nization that occur after motor stroke, particularly on the side of the lesion [4]. In addition, there is a balance of function between the two hemispheres that is con- trolled by interhemispheric inhibition. The stroke- affected hemisphere can be doubly disabled, by the stroke itself and by an imbalanced inhibition from the non-stroke hemisphere. In this model, increased activity in the affected hemisphere will promote recovery of the paretic limbs, as well as decreased inhibition from the non-stroke hemisphere [5]. Repetitive transcranial magnetic stimulation (rTMS) been identified as a mean of altering excitability in the motor cortex. Based on this ability to change excitability, rTMS has been pro- posed as a potential treatment for various disorders with putatively altered level of activity in cortical cir- cuits including stroke [6]. The development of rTMS allowed the imbalance of activity between hemispheres to be modulated for enhancing stroke recovery. For instance, post-stroke motor performance improved after inhibiting the unaffected hemisphere by low- frequency rTMS [7,8] or exciting the affected hemi- sphere by high-frequency rTMS [9–11], but which is more effective and beneficial for stroke recovery is still an area of uncertainty. Recently, Khedr et al., [12] recorded that rTMS has a useful therapeutic effect for dysphagia after stroke. We have previously extended Correspondence: Eman M. Khedr (MD), Professor of Neurology, Department of Neurology, Assiut University Hospital, Assiut 71511, Egypt, (tel.: 02 088 2333355; fax: 02 088 2333327; e-mail: emankhedr99@yahoo.com). Ó 2009 The Author(s) Journal compilation Ó 2009 EFNS 1323 European Journal of Neurology 2009, 16: 1323–1330 doi:10.1111/j.1468-1331.2009.02746.x