Niche Trial: Navigated Inhibitory rTMS to Contralesional Hemisphere Trial

Exclusion Criteria

• •Implanted metallic parts of implanted electronic devices, including pacemakers, defibrillators, or implant medication pump;
• •Pregnant or trying to become pregnant; Lack of pregnancy established in females of child-bearing potential by a negative urine pregnancy test at screening.
• •Active alcohol abuse, illicit drug use or drug abuse or significant mental illness
• •Patients suffering from depression as measured by a score of \>10 on the Patient Health Questionnaire (PHQ9). For clarity, patients diagnosed with depression which is controlled with stable anti-depressive medication and in whom PHQ9 is \<10 are eligible to participate in the trial.
• •History of epilepsy, defined as at least two unprovoked seizures occurring greater than 24 hours apart or diagnosis of an epilepsy syndrome, OR a seizure within the last 12 months.
• •Any condition that would prevent the subject from giving voluntary informed consent;
• •An implanted brain stimulator;
• •Any metal in head with the exception of dental work or any ferromagnetic metal elsewhere in the body;
• •Enrolled or plans to enroll in an interventional trial during this study;
• •Scalp wounds or infections;
• •Claustrophobia precluding MRI;
• •A fixed contraction deformity in the affected limb that would prevent normal dexterity if patient were neurologically intact;
• •Excessive spasticity as indicated by the Modified Ashworth Spasticity (MAS) Scale \>2/4 in either elbow flexors, wrist flexors or finger flexors of the affected limb;i
• •previous stroke with residual deficits (TIAs not a reason for exclusion);
• •premorbid (retrospective) modified Rankin Scale (mRS) score ≥2 of any aetiology;
• •a concurrent progressive neurologic disorder, acute coronary syndrome, severe heart disease (NYHA Classification \> 3), or other major medical condition,
• •confirmed or suspected lower-limb fracture preventing mobilization,
• •patients requiring palliative care
• •patients planning to undergo any other occupational therapy during the 6 week active treatment period of the trial (see section 5.2 for study schedule) than what is provided in the study
• •A recent injection of botulinium toxin to the affected upper limb in the last 3 months, or the need of an injection of botulinum toxin anytime during the study period and follow up.
• •A recent injection of phenol to the affected upper limb in the last 6 months, or the need of an injection of phenol anytime during the study period and follow up.
• •Ataxia as measured by a score \> 1 on item 7 (limb ataxia) of the NIH stroke scale.
• •Severe sensory deficits as measured by a score of 2 on item 8 of the NIH stroke scale.
• •Severe aphasia as measured by a score of \> 2 on item 9 (best language) of the NIH stroke scale.
• •Severe neglect as measured by a score of 2 on item 11 (extinction and inattention) of the NIH stroke scale.
• •Patients unable to comprehend or follow verbal commands
• •Based on PI's or local physician's assessment patient unable to tolerate the trial procedure due to medical condition
• •A Mini mental status exam (MMSE) \<25.