Purpose: To evaluate activity changes associated with the intervention of low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) after stroke using functional magnetic resonance (fMRI). Methods: Seventy stroke patients were scanned while performing finger tapping tasks twice, before and 12 days after the intervention. Recovery of motor functions assessed using Fugl–Meyer Assessment (FMA) and Wolf Motor Function Test-Functional Ability Scale (WMFT-FAS) for upper extremity at each time point. An fMRI analysis was performed, and a region of interest (ROI) analysis was conducted using percentage signal changes (% SC) to determine the magnitude of activation. Results: FMA and WMFT-FAS were significantly increased from pre-intervention to post-intervention. Intervention related activations were seen in the ipsilesional premotor cortex (PMC) and primary motor cortex (M1), thalamo-cortico regions with the paretic hand movements. With the unaffected hand movements, significant clusters in the contralesional primary somatosensory cortex (S1), superior parietal cortex, and bilateral cerebellum were observed. The ROI-based analysis revealed that ipsilesional M1, contralesional PMC, and supplementary motor area (SMA) showed significantly higher results with the paretic hand movements, a trend toward a significant decrease in the contralesional S1 with the unaffected hand movements from the pre-intervention to post-intervention. Conclusions: Our findings suggest that gains in motor functions produced by the intervention of rTMS and intensive OT in hemiparesis stroke patients may be associated with the ipsilesional hemisphere and contralesional hemisphere as well. Identifying rTMS and OT intervention based on cortical patterns may help to implement rTMS in motor rehabilitation after stroke. Supplementary data for this article is available online at https://doi.org/10.1080/00207454.2021.1968858.
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