The use of repetitive transcranial magnetic stimulation (rTMS) for the treatment of spasticity

Brain stimulation for patients with multiple sclerosis: an umbrella review of therapeutic efficacy

Multiple sclerosis patients often experience various symptoms that can greatly impact their quality of life. There are various brain stimulation techniques that have been evaluated for their ability to reduce the symptoms of multiple sclerosis. However, there is inconsistency in the specific stimulation methods used and the symptoms targeted in the existing research. This umbrella review conducted in order to evaluate the effectiveness of brain stimulation and identify limitations and gaps for further research. In this umbrella review, we conducted a searched on Web of Knowledge, PubMed, and Scopus database. We specifically looked for reviews, with or without meta-analyses, that have investigated the effects of brain stimulation methods on symptoms of multiple sclerosis. All articles were examined by AMSTAR 2 (A Measure Tool to Assess Systematic Review 2). We identified 155 articles, of which 14 were eligible for inclusion. Of those, five were qualitative studies and nine were meta-analyses. Among the included studies, four examined the use of deep brain stimulation, while ten investigated the therapeutic potential of noninvasive brain stimulation. Considering the heterogeneity of studies, the current evidence suggests that repetitive transcranial magnetic stimulation may be effective in treating pain and improving motor function, while transcranial direct current stimulation may be useful in alleviating fatigue and enhancing certain aspects of cognitive performance. Deep brain stimulation, on the other hand, appears to be effective in reducing tremors. However, further research is warranted to validate these findings and address the existing limitations in the field.

Testing spasticity mechanisms in chronic stroke before and after intervention with contralesional motor cortex 1 Hz rTMS and physiotherapy

BACKGROUND

Previous studies showed that repetitive transcranial magnetic stimulation (rTMS) reduces spasticity after stroke. However, clinical assessments like the modified Ashworth scale, cannot discriminate stretch reflex-mediated stiffness (spasticity) from passive stiffness components of resistance to muscle stretch. The mechanisms through which rTMS might influence spasticity are also not understood.

METHODS

We measured the effects of contralesional motor cortex 1 Hz rTMS (1200 pulses + 50 min physiotherapy: 3×/week, for 4-6 weeks) on spasticity of the wrist flexor muscles in 54 chronic stroke patients using a hand-held dynamometer for objective quantification of the stretch reflex response. In addition, we measured the excitability of three spinal mechanisms thought to be related to post-stroke spasticity: post-activation depression, presynaptic inhibition and reciprocal inhibition before and after the intervention. Effects on motor impairment and function were also assessed using standardized stroke-specific clinical scales.

RESULTS

The stretch reflex-mediated torque in the wrist flexors was significantly reduced after the intervention, while no change was detected in the passive stiffness. Additionally, there was a significant improvement in the clinical tests of motor impairment and function. There were no significant changes in the excitability of any of the measured spinal mechanisms.

CONCLUSIONS

We demonstrated that contralesional motor cortex 1 Hz rTMS and physiotherapy can reduce the stretch reflex-mediated component of resistance to muscle stretch without affecting passive stiffness in chronic stroke. The specific physiological mechanisms driving this spasticity reduction remain unresolved, as no changes were observed in the excitability of the investigated spinal mechanisms.

Treatment effects of low-frequency repetitive transcranial magnetic stimulation combined with motor relearning procedure on spasticity and limb motor function in stroke patients

Objective

Limb paralysis, which is a sequela of stroke, limits patients' activities of daily living and lowers their quality of life. The purpose of this study was to investigate the effects of repetitive transcranial magnetic stimulation (rTMS) combined with a motor relearning procedure (MRP) on motor function and limb spasticity in stroke patients.

Methods

Stroke patients were randomly divided into a combined treatment group (rTMS + MRP) and a control group (MRP) (n = 30 per group). The control group was given MRP in addition to conventional rehabilitation, and the combined treatment group was given 1 Hz rTMS combined with MRP. The treatment efficacy was assessed by the modified Ashworth scale (MAS), Fugl-Meyer motor function scale, and motor evoked potential (MEP) testing.

Results

After 4 weeks of treatment, the Brunnstrom score, Fugl-Meyer lower extremity motor function, and Fugl-Meyer balance function were significantly higher in the combination treatment group compared to the control group, while the MAS score was lower in the combination treatment group compared to the control group. The MEP extraction rate was higher in the combined treatment group compared to the control group, while the threshold and central motor conduction time (CMCT) were lower in the combined treatment group compared to the control group.

Conclusion

Low-frequency rTMS combined with MRP had better efficacy on spasticity and motor function in stroke patients with hemiparesis than MRP alone.

Case report: High-frequency repetitive transcranial magnetic stimulation for treatment of hereditary spastic paraplegia type 11

Hereditary spastic paraplegia (HSP) is a heterogeneous group of inherited neurodegenerative disorders that currently have no cure. HSP type 11 (SPG11-HSP) is a complex form carrying mutations in the SPG11 gene. Neuropathological studies demonstrate that motor deficits in these patients are mainly attributed to axonal degeneration of the corticospinal tract (CST). Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive technique that can induce central nervous system plasticity and promote neurological recovery by modulating the excitability of cortical neuronal cells. Although rTMS is expected to be a therapeutic tool for neurodegenerative diseases, no previous studies have applied rTMS to treat motor symptoms in SPG11-HSP. Here, we report a case of SPG11-HSP with lower extremity spasticity and gait instability, which were improved by applying high-frequency rTMS (HF-rTMS) at the primary motor cortex (M1). Clinical and physiological features were measured throughout the treatment, including the Modified Ashworth Scale (MAS), Berg Balance Scale (BBS), the timed up and go (TUG) test and the 10-meter walk test time (10 MWT). The structure and excitability of the CST were assessed by diffusion tensor imaging (DTI) and transcranial magnetic stimulation (TMS), respectively. After treatment, the patient gained 17 points of BBS, along with a gradual decrease in MAS scores of the bilateral lower extremity. In addition, the TUG test and 10 MWT improved to varying degrees. TMS assessment showed increased motor evoked potential (MEP) amplitude, decreased resting motor threshold (RMT), decreased central motor conduction time (CMCT), and decreased difference in the cortical silent period (CSP) between bilateral hemispheres. Using the DTI technique, we observed increased fractional anisotropy (FA) values and decreased mean diffusivity (MD) and radial diffusivity (RD) values in the CST. It suggests that applying HF-rTMS over the bilateral leg area of M1 (M1-LEG) is beneficial for SPG11-HSP. In this study, we demonstrate the potential of rTMS to promote neurological recovery from both functional and structural perspectives. It may provide a clinical rationale for using rTMS in the rehabilitation of HSP patients.

A Randomized Controlled Trial of the Effect of Repetitive Transcranial Magnetic Stimulation of the Motor Cortex on Lower Extremity Spasticity in Hereditary Spastic Paraplegia

INTRODUCTION

Hereditary spastic paraplegia refers to a group of conditions characterized by a slow progression of spasticity in lower limbs resulting in gait abnormalities. Current treatment options have proven to be insufficient in terms of symptom alleviation. In this study, we tested the effectiveness of repetitive transcranial magnetic stimulation (rTMS) on lower limb spasticity in patients with hereditary spastic paraplegia.

METHODS

Eight patients were randomly assigned to receive either five sessions of active 5 Hz-rTMS ( n = 4) or sham rTMS ( n = 4). The primary outcome was a change in spasticity assessed by the modified Ashworth scale. Secondary outcomes were change in 10 m walking test, Fugl-Meyer assessment of lower extremity motor function, and quality-of-life short-form survey scores. Assessment of the outcomes was done before, upon completion, and 1 month after the intervention. We analyzed the data using repeated-measure analysis of variance.

RESULTS

Mean age of the participants was 38.5 (SD = 5.4) years, and 50% were women. Compared with sham rTMS, real rTMS was effective in decreasing modified Ashworth scale (rTMS × time: F [df = 2] = 7.44; P = 0.008). Real rTMS group had lower modified Ashworth scale scores at the end of rTMS sessions (estimate = -0.938; SE = 0.295; P = 0.019) and at the end of follow-up (estimate = -0.688; SE = 0.277; P = 0.048) compared with the sham rTMS group. Real and sham rTMS groups were not different in the secondary outcomes.

CONCLUSIONS

Repetitive transcranial magnetic stimulation is an effective method in reducing lower limb spasticity of patients with hereditary spastic paraplegia.

Transcranial Magnetic Stimulation and its Imaging Features in Patients With Depression, Post-traumatic Stress Disorder, and Traumatic Brain Injury

Transcranial magnetic stimulation (TMS) is a type of noninvasive neurostimulation used increasingly often in clinical medicine. While most studies to date have focused on TMS's ability to treat major depressive disorder, it has shown promise in several other conditions including post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). As different treatment protocols are often used across studies, the ability to predict patient outcomes and evaluate immediate and long-term changes using imaging becomes increasingly important. Several imaging features, such as thickness, connectedness, and baseline activity of a variety of cortical and subcortical areas, have been found to be correlated with a greater response to TMS therapy. Intrastimulation imaging can reveal in real time how TMS applied to superficial areas activates or inhibits activity in deeper brain regions. Functional imaging performed weeks to months after treatment can offer an understanding of how long-term effects on brain activity relate to clinical improvement. Further work should be done to expand our knowledge of imaging features relevant to TMS therapy and how they vary across patients with different neurological and psychiatric conditions.

Non-invasive brain stimulation therapy on neurological symptoms in patients with multiple sclerosis: A network meta analysis

OBJECTIVE

The aim of the study was to evaluate non-invasive brain stimulation (NIBS) [including transcranial magnetic stimulation (TMS) and transcranial electrical stimulation (tES)] on neurological symptoms in patients with multiple sclerosis (PwMS).

METHOD

We searched PubMed, Embase, Cochrane Library, Web of Science and Ovid MEDLINE until February 2022. And we evaluated the included studies for methodological quality by the Cochrane bias risk assessment tool and assessed the studies' certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We performed network meta analysis (NMA) by using Stata 15 and ranked the results of the NMA by using the surface under the cumulative ranking curve (SUCRA) ranking chart.

RESULT

Twenty seven clinical trials were finally included (N = 596, 66.4% women). For the immediate effects, rTMS over M1 yielded the most optimal scheme for fatigue reduction among all the interventions compared to the sham stimulation groups [MD = -0.85, 95% CI (-1.57, -0.14)] (SUCRA = 82.6%). iTBS over M1 yielded the most signifcant reduced pain level than the sham groups did [MD = -1.26, 95% CI (-2.40, -0.11)] (SUCRA = 98.4%). tDCS over F3 was the best protocol of NIBS to improve quality of life (QOL) [MD = 1.41, 95% CI = (0.45,2.36)] (SUCRA = 76.7%), and iTBS over M1 may significantly reduce spasticity compared to sham stimulation [MD = -1.20, 95% CI = (-1.99, -0.41)] (SUCRA = 90.3%). Furthermore, rTMS, tRNS, and tDCS on certain areas may improve PwMS accuracy, response time, manual dexterity, pain relief and QOL, but does not show statistically significant differences. The evidence assessed using GRADE is very low.

CONCLUSION

Based on the NMA and SUCRA ranking, we can conclude that symptoms including fatigue, pain, spasticity, and QOL can be improved by following NIBS protocol after treatment. Nonetheless, most of the included studies lack a good methodology, and more high-quality randomized clinical trials are needed.

Transcranial direct current stimulation for spasticity in patients with multiple sclerosis: Exploring novel routes

BACKGROUND

Patients with Multiple sclerosis (MS) usually suffer from severe neurological disabilities. Spasticity is one of the most bothering and disabling manifestations that MS patients suffer from. Owing to being a chronic inflammatory demyelinating disorder; finding new modalities to alleviate some of the disabilities related to MS became a desired objective. Transcranial direct current stimulation (tDCS), a relatively new tool for modulating cortical excitability has been recently considered as a tool to provide symptomatic treatment for many neurologic and psychiatric diseases. In our study, we used tDCS to assess its effect on spasticity in MS patients.

METHODS

5 consecutive daily sessions of 20 minutes duration of active anodal tDCS over the ipsilesional motor cortex were given to 10 relapsing remitting MS (RRMS) patients with at least 1 spastic lower limb (active group) who were compared with other matched10 RRMS patients who received sham stimulation (sham group). The outcome was to measure the effect on spasticity both clinically using the Modified Ashworth Scale (MAS) and through neurophysiological assessment (H reflex latency and H/M amplitude ratio).

RESULTS

Patients who received active anodal tDCS showed significant improvement (p< 0.05) in the H/M amplitude ratio as compared to the sham group. However, there was no significant difference between the two groups in the MAS. H latency showed significant stability in active group when compared to the sham group.

CONCLUSION

Anodal direct current stimulation of the ipsilesional motor cortex in patients with MS, resulted in reduced spasticity as per neurophysiological assessment.

Effects of Non-Invasive Brain Stimulation on Post-Stroke Spasticity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

In recent years, the potential of non-invasive brain stimulation (NIBS) for the therapeutic effect of post-stroke spasticity has been explored. There are various NIBS methods depending on the stimulation modality, site and parameters. The purpose of this study is to evaluate the efficacy of NIBS on spasticity in patients after stroke. This systematic review and meta-analysis was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. PUBMED (MEDLINE), Web of Science, Cochrane Library and Excerpta Medica Database (EMBASE) were searched for all randomized controlled trials (RCTs) published before December 2021. Two independent researchers screened relevant articles and extracted data. This meta-analysis included 14 articles, and all included articles included 18 RCT datasets. The results showed that repetitive transcranial magnetic stimulation (rTMS) (MD = −0.40, [95% CI]: −0.56 to −0.25, p < 0.01) had a significant effect on improving spasticity, in which low-frequency rTMS (LF-rTMS) (MD = −0.51, [95% CI]: −0.78 to −0.24, p < 0.01) and stimulation of the unaffected hemisphere (MD = −0.58, [95% CI]: −0.80 to −0.36, p < 0.01) were beneficial on Modified Ashworth Scale (MAS) in patients with post-stroke spasticity. Transcranial direct current stimulation (tDCS) (MD = −0.65, [95% CI]: −1.07 to −0.22, p < 0.01) also had a significant impact on post-stroke rehabilitation, with anodal stimulation (MD = −0.74, [95% CI]: −1.35 to −0.13, p < 0.05) being more effective in improving spasticity in patients. This meta-analysis revealed moderate evidence that NIBS reduces spasticity after stroke and may promote recovery in stroke survivors. Future studies investigating the mechanisms of NIBS in addressing spasticity are warranted to further support the clinical application of NIBS in post-stroke spasticity.

Evidence of treating spasticity before it develops: a systematic review of spasticity outcomes in acute spinal cord injury interventional trials

Introduction: Spasticity is a common consequence of spinal cord injury (SCI), estimated to affect up to 93% of people living with SCI in the community. Problematic spasticity affects around 35% people with SCI spasticity. The early period after injury is believed to be the most opportune time for neural plasticity after SCI. We hypothesize that clinical interventions in the early period could reduce the incidence of spasticity. To address this, we evaluated the spasticity outcomes of clinical trials with interventions early after SCI.Methods: We performed a systematic review of the literature between January 2000 and May 2021 to identify control trials, in humans and animals, that were performed early after SCI that included measures of spasticity in accordance with PRISMA guidelines.Results: Our search yielded 1,463 records of which we reviewed 852 abstracts and included 8 human trial peer-reviewed publications and 9 animal studies. The 9 animal trials largely supported the hypothesis that early intervention can reduce spasticity, including evidence from electrophysiological, behavioral, and histologic measures. Of the 8 human trials, only one study measured spasticity as a primary outcome with a sample size sufficient to test the hypothesis. In this study, neuromodulation of the spinal cord using electric stimulation of the common peroneal nerve reduced spasticity in the lower extremities compared to controls.Conclusion: Given the prevalence of problematic spasticity, there is surprisingly little research being performed in the early period of SCI that includes spasticity measures, and even fewer studies that directly address spasticity. More research on the potential for early interventions to mitigate spasticity is needed.

Effects of non-invasive brain stimulation in multiple sclerosis: systematic review and meta-analysis

Objective:

The objective of this meta-analysis was to summarize evidence on the therapeutic effects of non-invasive brain stimulation (NIBS) on core symptoms of multiple sclerosis (MS). Specifically, findings from studies deploying transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) protocols were summarized in this review.

Methods:

We systematically searched articles published in four databases, until 31 May 2021, which compared the effects of active tDCS or rTMS with sham intervention in MS patients. We used a random-effects model for this meta-analysis. Meta-regression and subgroup meta-analysis were used to examine the effects of stimulation dose and different stimulation protocols, respectively.

Results:

Twenty-five randomized controlled trials (RCTs) were included in this review, consisting of 19 tDCS and 6 rTMS studies. tDCS led to a significant and immediate reduction of fatigue with a large effect size (Hedges’s g = −0.870, 95% confidence intervals (CI) = [−1.225 to −0.458], number needed to treat (NNT) = 2). Particularly, a subgroup analysis showed that applying tDCS over the left DLPFC and bilateral S1 led to fatigue reductions compared to sham stimulation. Furthermore, tDCS had favorable effects on fatigue in MS patients with low physical disability but not those with high physical disability, and additionally improved cognitive function. Finally, whereas rTMS was observed to reduce muscle spasticity, these NIBS protocols showed no further effect on MS-associated pain and mood symptoms.

Conclusion:

tDCS in MS alleviates fatigue and improves cognitive function whereas rTMS reduces muscle spasticity. More high-quality studies are needed to substantiate the therapeutic effects of different NIBS protocols in MS.

Cortical, Spinal, Sacral, and Peripheral Neuromodulations as Therapeutic Approaches for the Treatment of Lower Urinary Tract Symptoms in Multiple Sclerosis Patients: A Review

INTRODUCTION

Multiple sclerosis (MS) is often associated with urological disorders, mainly urinary incontinence and retention, the management of which being necessary to improve patient's quality of life (QOL) and to reduce potential urological complications. Besides the classical treatments based mainly on anticholinergics and/or self-catheterization, several neuromodulation techniques have been tried in recent years to improve these urinary disorders. By this review, we aim at providing an overview of neuromodulation and electrostimulation approaches to manage urinary symptoms in MS patients.

MATERIALS AND METHODS

A literature search using MEDLINE was performed. Only papers in English, and describing the effects of neuromodulation in MS patients, were considered.

RESULTS

A total of 18 studies met inclusion criteria and were reviewed. Of them, four related to sacral neuromodulation (SNM), seven to percutaneous tibial nerve stimulation (PTNS), six to spinal cord stimulation (SCS), and one to transcranial magnetic stimulation (TMS).

DISCUSSION

PTNS and SNM seem to be effective and safe therapeutic options for treating lower urinary tract symptoms in MS patients principally in case of overactive bladder (OAB) symptoms. Similarly, also SCS and TMS have been shown to be effective, despite the very limited number of patients and the small number of studies found in the literature. Interestingly, these techniques are effective even in patients who do not respond well to conservative therapies, such as anticholinergics. Furthermore, given their safety and efficacy, stimulations such as PTNS could be considered as a first-line treatment for OAB in MS patients, also considering that they are often preferred by patients to other commonly used treatments.

Neuromodulatory effects of repetitive transcranial magnetic stimulation on neural plasticity and motor functions in rats with an incomplete spinal cord injury: A preliminary study

We investigated the effects of intermittent theta-burst stimulation (iTBS) on locomotor function, motor plasticity, and axonal regeneration in an animal model of incomplete spinal cord injury (SCI). Aneurysm clips with different compression forces were applied extradurally around the spinal cord at T10. Motor plasticity was evaluated by examining the motor evoked potentials (MEPs). Long-term iTBS treatment was given at the post-SCI 5th week and continued for 2 weeks (5 consecutive days/week). Time-course changes in locomotor function and the axonal regeneration level were measured by the Basso Beattie Bresnahan (BBB) scale, and growth-associated protein (GAP)-43 expression was detected in brain and spinal cord tissues. iTBS-induced potentiation was reduced at post-1-week SCI lesion and had recovered by 4 weeks post-SCI lesion, except in the severe group. Multiple sessions of iTBS treatment enhanced the motor plasticity in all SCI rats. The locomotor function revealed no significant changes between pre- and post-iTBS treatment in SCI rats. The GAP-43 expression level in the spinal cord increased following 2 weeks of iTBS treatment compared to the sham-treatment group. This preclinical model may provide a translational platform to further investigate therapeutic mechanisms of transcranial magnetic stimulation and enhance the possibility of the potential use of TMS with the iTBS scheme for treating SCIs.

Quantifying Altered Neural Connectivity of the Stretch Reflex in Chronic Hemiparetic Stroke

Post-stroke flexion synergy limits arm/hand function and is also linked to hyperactive stretch reflexes or spasticity. It is implicated in the increased role of indirect motor pathways following damage to direct corticospinal projections. We hypothesized that this maladaptive neuroplasticity also affects stretch reflexes. Specifically, multi-synaptic interactions in indirect motor pathways may increase nonlinear neural connectivity and time lag between stretch and reflex muscle response. Continuous position perturbations were applied to the elbow joint when eleven participants with stroke generated two levels of shoulder abduction (SABD) torques with their paretic arm to induce synergy-related spasticity. Likewise, the perturbations were applied to eleven control subjects while performing SABD and elbow flexion levels matching the synergy torques in stroke. We quantified linear and non-linear connectivity and the corresponding time lags between perturbations and muscle activity. Enhanced nonlinear connectivity with a prolonged time lag was found in stroke as compared to controls. Non-linear connectivity and time lag also increased with the expression of the flexion synergy, as induced by greater SABD load levels, in stroke. This study provides new evidence of changes in neural connectivity and long-latency time lag in the stretch reflex response post-stroke. The results suggest the contribution of indirect motor pathways to synergy-related spasticity.

The Impact of Repetitive Transcranial Magnetic Stimulation on Affected and Unaffected Sides of a Child with Hemiplegic Cerebral Palsy

The purpose of this study was to investigate the therapeutic effects of neuro-navigated repetitive transcranial magnetic stimulation (rTMS) combined with occupational therapy (OT) on gait impairment of a child (male, age: 13.2) with spastic hemiplegic cerebral palsy (CP). The treatment included 4 days a week of rTMS sessions for 3 weeks and 4 days of rTMS and OT sessions per week for 3 weeks. Transcranial magnetic stimulation (TMS) was used to evaluate corticospinal tract (CST) activities and H-reflex test was used to assess reflex hyper-excitability. Common clinical tests demonstrate the clinical status of the patient. Evaluations were performed in 4 time steps: baseline, 3 weeks after the beginning of the treatment, at the end of the treatment, and 1 month after the end of the treatment. The patient did not receive any specific treatment after the end of the treatment up to the follow up evaluations. The tests' results were compared between the affected and unaffected legs of the patient. Four parameters of the TMS test were calculated (motor evoked potential (MEP) latency, MEP peak-to-peak amplitude, cortical silent period (cSP), and stimulation intensity). These parameters were all improved for the affected side and cSP improved for the unaffected side, but MEP p-p amplitude and intensity got worse slightly for the unaffected side. Recruitment curves of H response and M-wave of the H-reflex test for both sides were obtained. Improvements could be seen after the treatment for both sides. Max H response on max M-wave (H/M) and H response latency got better after the treatment for both sides. Walking speed for self and fast velocity, timed up and go, and walking endurance improved during and after the treatment. All the improvements persisted after one month of the end of the treatment in the follow up evaluations. These findings indicate that rTMS combined with OT can have effective and long-lasting impact on neuromuscular impairments in spastic CP children.

The Effect of Repetitive Transcranial Magnetic Stimulation on Spasticity in Patients with Multiple Sclerosis

Background and Purpose

This randomized controlled study examined the effect of repetitive transcranial magnetic stimulation (rTMS) on spasticity in patients with multiple sclerosis (MS).

Methods

This study included 16 patients with a history of MS and spasticity in the adductor hip muscles according to the Modified Ashworth Scale (MAS). The participants were randomized into the active group (n=10) and control group (n=6), in which active rTMS and sham rTMS were applied in 10 sessions, respectively. A physical therapy and rehabilitation program was applied along with rTMS sessions in both groups. The evaluation parameters were assessed at baseline and then 1 week and 1 month after applying rTMS.

Results

Statistical analyses with post-hoc correction revealed statistically significant improvements in the active group compared to the control group in the bilateral MAS score, Penn Spasm Frequency Scale score, patient satisfaction, amount of urine leakage, actual health status, perceived health status, energy and fatigue, role limitations due to physical problems, social function, overall quality of life, cognitive functioning, physical health composite score, mental health composite score, and total score on the Multiple Sclerosis Quality of Life-54 (MSQOL-54) (p<0.05). Statistically significant changes were detected in the MSQOL-54 social function and physical health composite scores of patients in the control group (p<0.05).

Conclusions

Active rTMS combined with a physical therapy program reduced spasticity in MS patients compared to the control group that received only physical therapy. Further comprehensive and more advanced studies are needed to confirm the present findings.

Repetitive Transcranial Magnetic Stimulation, Cognition, and Multiple Sclerosis: An Overview

Multiple sclerosis (MS) affects cognition in the majority of patients. A major aspect of the disease is brain volume loss (BVL), present in all phases and types (relapsing and progressive) of the disease and linked to both motor and cognitive disabilities. Due to the lack of effective pharmacological treatments for cognition, cognitive rehabilitation and other nonpharmacological interventions such as repetitive transcranial magnetic stimulation (rTMS) have recently emerged and their potential role in functional connectivity is studied. With recently developed advanced neuroimaging and neurophysiological techniques, changes related to alterations of the brain's functional connectivity can be detected. In this overview, we focus on the brain's functional reorganization in MS, theoretical and practical aspects of rTMS utilization in humans, and its potential therapeutic role in treating cognitively impaired MS patients.

Effects of repetitive transcranial magnetic stimulation on lower extremity spasticity and motor function in stroke patients

PURPOSE

To investigate the effect of low-frequency repetitive transcranial magnetic stimulation (rTMS) on lower extremity (LE) spasticity, motor function and motor neurone excitability in chronic stroke patients.

METHOD

This study was a randomised sham-controlled cross-over trial with 1-week follow-up. A total of 20 post-stroke patients were randomised to receive active (n = 10) or sham (n = 10) rTMS. Fourteen of them (7 in each group) crossed over to the sham or active rTMS after a washout period of 1 month. Interventions consist of five consecutive daily sessions of active or sham rTMS to the unaffected lower extremity motor area (1000 pulses; 1 Hz; 90% of the tibialis anterior motor threshold). Outcome measures were modified modified ashworth scale (MMAS), the H-reflex, lower extremity section of Fugl-Mayer assessment (LE-FMA) and timed UP and GO (TUG) test. All outcomes were measured at three levels in each intervention period: pre- and post-intervention and 1-week follow-up.

RESULTS

Friedman's test revealed significant improvement in MMAS score only after active rTMS. This improvement lasted for one week after the active rTMS. Repeated measure analysis of variance (ANOVA) showed significant time*intervention interaction for LE-FMA. There are no differences between groups for the MMAS and LE-FMA. No significant change in Hmax/Mmax ratio and TUG test was noted.

CONCLUSION

Low-frequency rTMS over the LE motor area can improve clinical measures of muscle spasticity and motor function. More studies are needed to clarify the changes underlying this improvement in spasticity. Implications for Rehabilitation Spasticity is a common disorder and one of the causes of long-term disability after stroke. Physical therapy modalities, oral medications, focal intervention and surgical procedures have been used for spasticity reduction. Beneficial effect of the repetitive transcranial magnetic stimulation (rTMS) for post-stroke upper extremity spasticity reduction and motor function improvement was demonstrated in previous studies. This study shows amelioration of lower extremity spasticity and motor function improvement after five daily sessions of inhibitory rTMS to the unaffected brain hemisphere which lasted for at least 1 week following the intervention.

Effects of intermittent theta burst stimulation on spasticity after stroke

Spasticity is a common cause of long-term disability in poststroke hemiplegic patients. We investigated whether intermittent theta burst stimulation (iTBS) could reduce upper-limb spasticity after a stroke. Fifteen hemiplegic stroke patients were recruited for a double-blind sham-controlled cross-over design study. A single session of iTBS or sham stimulation was delivered on the motor hotspot of the affected flexor carpi radialis muscle in a random and counterbalanced order with a 1-week interval. Modified Ashworth scale (MAS), modified Tardieu scale (MTS), H-wave/M-wave amplitude ratio, peak torque (PT), peak torque angle (PTA), work of affected wrist flexor, and rectified integrated electromyographic activity of the flexor carpi radialis muscle were measured before, immediately after, 30 min after, and 1 week after iTBS or sham stimulation. Repeated-measures analysis of variance showed a significant interaction between time and intervention for the MAS, MTS, PT, PTA, and rectified integrated electromyographic activity (P<0.05), indicating that these parameters were significantly improved by iTBS compared with sham stimulation. However, the H-wave/M-wave amplitude ratio and work were not affected. MAS and MTS significantly improved for at least 30 min after iTBS, but the other parameters only improved immediately after iTBS (P<0.05). In conclusion, iTBS on the affected hemisphere may help to reduce poststroke spasticity transiently.

A pilot study on the effects of low frequency repetitive transcranial magnetic stimulation on lower extremity spasticity and motor neuron excitability in patients after stroke

PURPOSE

To evaluate the effect of low frequency, repetitive transcranial magnetic stimulation (rTMS) on the lower extremity spasticity and motor neuron excitability in patients after stroke.

METHODS

Seven patients after stroke aged 42-78 years were included in this pretest-posttest clinical trial. The rTMS at 1 Hz and duration of 20 min was applied to the intact leg motor cortex for five consecutive sessions. Primary outcome measures were the Modified Modified Ashwoth Scale (MMAS) and the H(max)/M(max) ratio. Measurements were taken at baseline (T0), after the last treatment (5th) session (T1), and at 1 week follow up (T2).

RESULTS

Clinically assessed ankle plantar flexor spasticity (p = 0.05) improved significantly after treatment at T1. Knee extensor spasticity scored 0 after treatment at T1 and T2. The H(max)/M(max) ratio showed no statistically significant improvement after treatment.

CONCLUSION

The pilot data indicate that the inhibitory rTMS of the intact leg motor cortex in patients after stroke may improve the lower extremity spasticity.

Mechanism of GABA receptors involved in spasticity inhibition induced by transcranial magnetic stimulation following spinal cord injury

The effect of high-frequency repetitive transcranial magnetic stimulation (rTMS) on spasticity following spinal cord injury (SCI) and the action mechanism were investigated. SCI models were established in Sprague-Dawley rats. Five groups were set up: normal control group, SCI-7 day (7D) model group, SCI-14D model group, SCI-7D rTMS group and SCI-14D rTMS group (n=10 each). The rats in SCI rTMS groups were treated with 10 Hz rTMS at 8th day and 15th day after SCI respectively. Motor recovery and spasticity alleviation were evaluated by BBB scale once a week till the end of treatment. Finally, different parts of tissues were dissected out for detection of GABA receptors using Western blotting and polymerase chain reaction (PCR) technique. The results showed that the BBB scores after treatment were significantly higher in SCI-7D rTMS group than in SCI-14D rTMS group (P<0.05). The GABA receptors were down-regulated more significantly in SCI-14D model group than in SCI-7D model group (P<0.05). At different time points, rTMS treatment could affect the up-regulation of GABA receptors: The up-regulation of GABA receptors was more obvious in SCI-7D rTMS group than in SCI-14D rTMS treatment group (P<0.05). It was concluded that 10-Hz rTMS could alleviate spasticity following SCI and promote the motor recovery in rats, which might be attributed to the up-regulation of GABA receptors. It was also suggested that early high-frequency rTMS treatment after SCI may achieve more satisfactory curative effectiveness.

Sativex in the management of multiple sclerosis-related spasticity: role of the corticospinal modulation

Sativex is an emergent treatment option for spasticity in patients affected by multiple sclerosis (MS). This oromucosal spray, acting as a partial agonist at cannabinoid receptors, may modulate the balance between excitatory and inhibitory neurotransmitters, leading to muscle relaxation that is in turn responsible for spasticity improvement. Nevertheless, since the clinical assessment may not be sensitive enough to detect spasticity changes, other more objective tools should be tested to better define the real drug effect. The aim of our study was to investigate the role of Sativex in improving spasticity and related symptomatology in MS patients by means of an extensive neurophysiological assessment of sensory-motor circuits. To this end, 30 MS patients underwent a complete clinical and neurophysiological examination, including the following electrophysiological parameters: motor threshold, motor evoked potentials amplitude, intracortical excitability, sensory-motor integration, and H_max/M_max ratio. The same assessment was applied before and after one month of continuous treatment. Our data showed an increase of intracortical inhibition, a significant reduction of spinal excitability, and an improvement in spasticity and associated symptoms. Thus, we can speculate that Sativex could be effective in reducing spasticity by means of a double effect on intracortical and spinal excitability.

Non-Invasive Brain Stimulation for the Treatment of Symptoms Following Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) is a common cause of physical, psychological, and cognitive impairment, but many current treatments for TBI are ineffective or produce adverse side effects. Non-invasive methods of brain stimulation could help ameliorate some common trauma-induced symptoms.

OBJECTIVE

This review summarizes instances in which repetitive Transcranial Magnetic Stimulation (rTMS) and transcranial Direct Current Stimulation (tDCS) have been used to treat symptoms following a TBI. A subsequent discussion attempts to determine the value of these methods in light of their potential risks.

METHODS

The research databases of PubMed/MEDLINE and PsycINFO were electronically searched using terms relevant to the use of rTMS and tDCS as a tool to decrease symptoms in the context of rehabilitation post-TBI.

RESULTS

Eight case-studies and four multi-subject reports using rTMS and six multi--subject studies using tDCS were found. Two instances of seizure are discussed.

CONCLUSION

There is evidence that rTMS can be an effective treatment option for some post-TBI symptoms, such as depression, tinnitus, and neglect. Although the safety of this method remains uncertain, the use of rTMS in cases of mild TBI without obvious structural damage may be justified. Evidence on the effectiveness of tDCS is mixed, highlighting the need for additional investigations.

Effect of repetitive transcranial magnetic stimulation on reducing spasticity in patients suffering from HTLV-1-associated myelopathy

PURPOSE

Human T-lymphotropic virus type 1 has been implicated in human T-lymphotropic virus type 1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). Regarding its endemicity in Iran and the role of repetitive transcranial magnetic stimulation in reducing spasticity, we decided to evaluate the efficacy of repetitive transcranial magnetic stimulation in reducing spasticity (as primary outcome) and pain, muscle power, and quality of life (as secondary outcomes) in patients suffering from HAM/TSP.

METHODS

In this pretest-posttest study, nine definite patients with HAM/TSP (according to WHO guidelines) were recruited. All patients underwent five consecutive daily sessions of active repetitive transcranial magnetic stimulation (each session consisting of 20 trains of 10 pulses at 5 Hz and an intensity of 90% of resting motor threshold for the biceps brachii muscle). Main outcome measures including spasticity (by modified Ashworth scale), pain (by visual analog scale), muscle power, and quality of life (by SF 36) were measured before the study and days 5, 7, 30 after the termination of the sessions.

RESULTS

Seven (77.8%) females and 2 (22.2%) males were recruited with the mean age of 52 ± 12.67 years, and the mean duration of the disease was 5 ± 3.94. Comparison of the repeated measures showed a statistically significant decrease in pain and spasticity in lower limbs. The decrement in spasticity was persistent even 30 days after the intervention; however, the pain reduction was seen only 5 days after the procedure. No change in quality of life, and muscle power was detected.

CONCLUSIONS

It seems that repetitive transcranial magnetic stimulation could decrease spasticity and pain in patients with HAM/TSP, and this effect could persistently continue by 1 month, but it did not influence patients' muscle power and quality of life, and it could be used as an adjuvant therapy in patients suffering from human T-lymphotropic virus type 1-associated HAM/TSP.

Outcomes in spasticity after repetitive transcranial magnetic and transcranial direct current stimulations

Non-invasive brain stimulations mainly consist of repetitive transcranial magnetic stimulation and transcranial direct current stimulation. Repetitive transcranial magnetic stimulation exhibits satisfactory outcomes in improving multiple sclerosis, stroke, spinal cord injury and cerebral palsy-induced spasticity. By contrast, transcranial direct current stimulation has only been studied in post-stroke spasticity. To better validate the efficacy of non-invasive brain stimulations in improving the spasticity post-stroke, more prospective cohort studies involving large sample sizes are needed.

Effects of repetitive transcranial magnetic stimulation on recovery of function after spinal cord injury

A major goal of rehabilitation strategies after spinal cord injury (SCI) is to enhance the recovery of function. One possible avenue to achieve this goal is to strengthen the efficacy of the residual neuronal pathways. Noninvasive repetitive transcranial magnetic stimulation (rTMS) has been used in patients with motor disorders as a tool to modulate activity of corticospinal, cortical, and subcortical pathways to promote functional recovery. This article reviews a series of studies published during the last decade that used rTMS in the acute and chronic stages of paraplegia and tetraplegia in humans with complete and incomplete SCI. In the studies, rTMS has been applied over the arm and leg representations of the primary motor cortex to target 3 main consequences of SCI: sensory and motor function impairments, spasticity, and neuropathic pain. Although some studies demonstrated that consecutive sessions of rTMS improve aspects of particular functions, other studies did not show similar effects. We discuss how rTMS parameters and postinjury reorganization in the corticospinal tract, motor cortical, and spinal cord circuits might be critical factors in understanding the advantages and disadvantages of using rTMS in patients with SCI. The available data highlight the limited information on the use of rTMS after SCI and the need to further understand the pathophysiology of neuronal structures affected by rTMS to maximize the potential beneficial effects of this technique in humans with SCI.

Advances in rehabilitation medicine

Rehabilitation medicine is the medical specialty that integrates rehabilitation as its core therapeutic modality in disability management. More than a billion people worldwide are disabled, and the World Health Organization has developed the International Classification of Functioning, Disability and Health as a framework through which disability is addressed. Herein, we explore paradigm shifts in neurorehabilitation, with a focus on restoration, and provide overviews on developments in neuropharmacology, rehabilitation robotics, virtual reality, constraint-induced therapy and brain stimulation. We also discuss important issues in rehabilitation systems of care, including integrated care pathways, very early rehabilitation, early supported discharge and telerehabilitation. Finally, we highlight major new fields of rehabilitation such as spasticity management, frailty and geriatric rehabilitation, intensive care and cancer rehabilitation.

Effect of combined treadmill training and magnetic stimulation on spasticity and gait impairments after cervical spinal cord injury

Spasticity and gait impairments are two common disabilities after cervical spinal cord injury (C-SCI). In this study, we tested the therapeutic effects of early treadmill locomotor training (Tm) initiated at postoperative (PO) day 8 and continued for 6 weeks with injury site transcranial magnetic stimulation (TMSsc) on spasticity and gait impairments after low C6/7 moderate contusion C-SCI in a rat model. The combined treatment group (Tm+TMSsc) showed the most robust decreases in velocity-dependent ankle torques and triceps surae electromyography burst amplitudes that were time locked to the initial phase of lengthening, as well as the most improvement in limb coordination quantitated using three-dimensional kinematics and CatWalk gait analyses, compared to the control or single-treatment groups. These significant treatment-associated decreases in measures of spasticity and gait impairment were also accompanied by marked treatment-associated up-regulation of dopamine beta-hydroxylase, glutamic acid decarboxylase 67, gamma-aminobutyric acid B receptor, and brain-derived neurotrophic factor in the lumbar spinal cord (SC) segments of the treatment groups, compared to tissues from the C-SCI nontreated animals. We propose that the treatment-induced up-regulation of these systems enhanced the adaptive plasticity in the SC, in part through enhanced expression of pre- and postsynaptic reflex regulatory processes. Further, we propose that locomotor exercise in the setting of C-SCI may decrease aspects of the spontaneous maladaptive segmental and descending plasticity. Accordingly, TMSsc treatment is characterized as an adjuvant stimulation that may further enhance this capacity. These data are the first to suggest that a combination of Tm and TMSsc across the injury site can be an effective treatment modality for C-SCI-induced spasticity and gait impairments and provided a pre-clinical demonstration for feasibility and efficacy of early TMSsc intervention after C-SCI.

Restoring walking after spinal cord injury: operant conditioning of spinal reflexes can help

People with incomplete spinal cord injury (SCI) frequently suffer motor disabilities due to spasticity and poor muscle control, even after conventional therapy. Abnormal spinal reflex activity often contributes to these problems. Operant conditioning of spinal reflexes, which can target plasticity to specific reflex pathways, can enhance recovery. In rats in which a right lateral column lesion had weakened right stance and produced an asymmetrical gait, up-conditioning of the right soleus H-reflex, which increased muscle spindle afferent excitation of soleus, strengthened right stance and eliminated the asymmetry. In people with hyperreflexia due to incomplete SCI, down-conditioning of the soleus H-reflex improved walking speed and symmetry. Furthermore, modulation of electromyographic activity during walking improved bilaterally, indicating that a protocol that targets plasticity to a specific pathway can trigger widespread plasticity that improves recovery far beyond that attributable to the change in the targeted pathway. These improvements were apparent to people in their daily lives. They reported walking faster and farther, and noted less spasticity and better balance. Operant conditioning protocols could be developed to modify other spinal reflexes or corticospinal connections; and could be combined with other therapies to enhance recovery in people with SCI or other neuromuscular disorders.

Effect of single-session repetitive transcranial magnetic stimulation applied over the hand versus leg motor area on pain after spinal cord injury

BACKGROUND

Neuropathic pain often follows spinal cord injury (SCI).

OBJECTIVE

To compare the effect of repetitive transcranial magnetic stimulation (rTMS) applied over different motor cortex targets (hand vs leg area) versus sham stimulation on neuropathic pain and local neurophysiological changes in patients with SCI.

METHODS

A total of 16 patients with complete or incomplete motor SCI and chronic neuropathic pain participated in a double-blind, cross-over randomized study. Three single sessions of sham or active rTMS (10 Hz, total of 2000 stimuli) were applied in random order over the hand or leg area with a minimal 2-week interval. THE MAIN OUTCOME MEASURES: were the numeric rating scale for pain sensation and parameters derived from motor mapping of the first dorsal interosseous muscle, including maximal amplitude of evoked response as well as map area, volume, and location.

RESULTS

rTMS applied to either the hand or the leg area, but not sham stimulation, induced a significant but equivalent reduction in pain for the first 48 hours postintervention (P < .05). Participants with an incomplete lesion showed greater analgesia than those with a complete lesion (21% vs. 3%, respectively; P < .05). The main change observed for motor map measurements was an increase in corticospinal excitability after stimulation of the hand area (P = .04) but not for the other conditions.

CONCLUSION

rTMS applied over the hand or leg motor cortex decreased neuropathic pain regardless of any change in cortical excitability, suggesting that the analgesic effect is not associated with local changes at the motor cortex level itself.

The effect of extracorporeal shock wave therapy on lower limb spasticity in subacute stroke patients

Objective

To evaluate the effect of extracorporeal shock wave therapy (ESWT) on lower limb spasticity in subacute stroke patients.

Methods

We studied thirty hemiplegic subacute stroke patients with ankle plantar flexor spasticity. ESWT was applied for 1 session/week, with a total of 3 sessions at the musculotendinous junction of medial and lateral gastrocnemius muscles. Patients were evaluated both clinically and biomechanically at baseline, after sham stimulation, and at immediately 1 week and 4 weeks after ESWT. For clinical assessment, Modified Ashworth Scale (MAS), clonus score, passive range of motion of ankle, and Fugl-Myer Assessment for the lower extremity were used. A biomechanical assessment of spasticity was conducted by an isokinetic dynamometer. Two parameters, peak eccentric torque (PET) and torque threshold angle (TTA), were analyzed at the velocities of 60°/sec, 180°/sec, and 240°/sec.

Results

After sham stimulation, there were no significant changes between each assessment. MAS and PET (180°/sec and 240°/sec) were significantly improved immediately and 1 week after ESWT. However, these changes were not significant at 4 weeks after ESWT. PET (60°/sec) and TTA (60°/sec, 180°/sec, and 240°/sec) were significantly improved immediately after ESWT. Yet, these changes were not significant at 1 week and 4 weeks after ESWT as well.

Conclusion

Lower limb spasticity in subacute stroke patients was significantly improved immediately after ESWT. Although the therapeutic effect of ESWT reduced with time and therefore was not significant at 4 weeks after ESWT, the degree of spasticity was lower than that of the baseline. Future studies with a larger sample of patients are warranted in order to verify the protocols which can optimize the effect of ESWT on spasticity.

The effect of a hand-stretching device during the management of spasticity in chronic hemiparetic stroke patients

Objective

To describe a hand-stretching device that was developed for the management of hand spasticity in chronic hemiparetic stroke patients, and the effects of this device on hand spasticity.

Methods

Fifteen chronic hemiparetic stroke patients with finger flexor spasticity were recruited and randomly assigned to an intervention group (8 patients) or a control group (7 patients). The stretching device consists of a resting hand splint, a finger and thumb stretcher, and a frame. In use, the stretched state was maintained for 10 minutes per exercise session, and the exercise was performed twice daily for 4 weeks. Spasticity of finger flexor muscles in the two groups was assessed 3 times, 4 weeks apart, using the Modified Ashworth Scale (MAS). Patients in the intervention group were assessed twice (pre-1 and pre-2) before and once (post-1) after starting the stretching program.

Results

Mean MAS (mMAS) scores at initial evaluations were not significantly different at pre-1 in the intervention group and at 1st assessment in the control group (p>0.05). In addition, no significant differences were observed between mMAS scores at pre-1 and pre-2 in the intervention group (p>0.05). However, mMAS scores at post-1 were significantly lower than that at pre-2 in the intervention group (p<0.05). Within the control group, no significant changes in mMAS scores were observed between 1st, 2nd, and 3rd assessments (p>0.05). In addition, mMAS scores at post-1 in the intervention group were significantly decreased compared with those at the 3rd assessment in the control group (p<0.05).

Conclusion

The devised stretching device was found to relieve hand spasticity effectively in chronic hemiparetic stroke patients.

Effects of a dynamic progressive orthotic intervention for chronic hemiplegia: a case series

STUDY DESIGN

Case series design on a single subgroup of participants.

INTRODUCTION

Management of hypertonicity and resistance to passive movement (RTPM) in the upper extremity is an intractable problem for persons with stroke and the therapists who provide their care. Therapists have limited options for assessment and treatment of this condition which can profoundly limit functional performance and quality of life.

PURPOSE OF THE STUDY

To evaluate the effect of a 12-week dynamic progressive orthotic intervention in persons with chronic stroke exhibiting wrist flexion contracture who are residents of a long-term skilled nursing facility.

METHODS

A custom-fitted dynamic progressive wrist extension orthotic was applied to 6 residents with chronic stroke. The orthotic was worn for 4 h daily, 4×/week for 12 weeks. Wrist passive range of motion (PROM) and RTPM were measured weekly and after discontinuation of the orthotics using the Modified Ashworth Scale and the Tardieu Scale of Spasticity. Signal analysis of electromyographical (EMG) flexor response to extensor stretching was also measured before and after orthotic intervention using maximal root mean square (RMS) values and EMG burst onset time.

RESULTS

A moderate effect was found for changes in PROM with the orthotic intervention. Progress made diminished following discontinuation. Moderate effects were also seen in EMG measures which indicated increases in amount of resistive-free movement following intervention.

CONCLUSION

A dynamic progressive orthotic intervention can be an effective option for increasing wrist PROM and reducing RTPM in persons with chronic stroke.

LEVEL OF EVIDENCE

4.

Noninvasive brain stimulation in traumatic brain injury

OBJECTIVE

To review novel techniques of noninvasive brain stimulation (NBS), which may have value in assessment and treatment of traumatic brain injury (TBI).

METHODS

Review of the following techniques: transcranial magnetic stimulation, transcranial direct current stimulation, low-level laser therapy, and transcranial Doppler sonography. Furthermore, we provide a brief overview of TMS studies to date.

MAIN FINDINGS

We describe the rationale for the use of these techniques in TBI, discuss their possible mechanisms of action, and raise a number of considerations relevant to translation of these methods to clinical use. Depending on the stimulation parameters, NBS may enable suppression of the acute glutamatergic hyperexcitability following TBI and/or counter the excessive GABAergic effects in the subacute stage. In the chronic stage, brain stimulation coupled to rehabilitation may enhance behavioral recovery, learning of new skills, and cortical plasticity. Correlative animal models and comprehensive safety trials seem critical to establish the use of these modalities in TBI.

CONCLUSIONS

Different forms of NBS techniques harbor the promise of diagnostic and therapeutic utility, particularly to guide processes of cortical reorganization and enable functional restoration in TBI. Future lines of safety research and well-designed clinical trials in TBI are warranted to determine the capability of NBS to promote recovery and minimize disability.

F-wave suppression induced by suprathreshold high-frequency repetitive trascranial magnetic stimulation in poststroke patients with increased spasticity

OBJECTIVE

High-intensity and high-frequency repetitive transcranial magnetic stimulation (rTMS) of the primary motor cortex was carried out in poststroke patients with increased spasticity, and the changes in F-wave parameters in comparison with M-wave parameters induced by rTMS were examined.

METHODS

Ten-hertz rTMS pulses were delivered to the primary motor cortex of the lesion side at 110% intensity of the resting motor threshold, and F-waves were obtained from the first dorsal interosseous muscle. F-waves were recorded before (pre-stim) and immediately after the end of rTMS (post-stim) in poststroke patients.

RESULTS

F-wave persistence and F/M Amp.Ratio increased significantly in patients with lesions in upper motor tract as compared with healthy subjects (Wilcoxon rank sum test, p = 0.00023 and p = 0.0073, respectively). After the rTMS application, both F-wave persistence and F/M Amp.Ratio decreased significantly (paired t-test, p = 0.0095 and p = 0.037, respectively). However, the F-wave amplitude did not show a statistically significant variance in poststroke patients.

CONCLUSIONS

High-frequency suprathreshold rTMS may suppress the F-waves by enhancing the inhibitory effect on spinal excitability through the corticospinal tract, and F-wave persistence and F/M Amp.Ratio can be used to determine the effect of rTMS on patients with increased spasticity.

Effects of afferent stimulation rate on inhibitory spinal pathways in hemiplegic spastic patients

OBJECTIVE

It has recently been demonstrated in the cat and in healthy subjects that the effects of repetitive afferent fibre stimulation depends on the target spinal neurones. The purpose of this series of experiments was therefore to determine whether central nervous system lesions modify the behaviour of the inhibitory spinal pathways in response to repetitive activation of afferent fibres.

METHODS

The H-reflex technique was used to study the effect of increasing the conditioning stimulus rate from 0.16 to 1 Hz on disynaptic inhibition and on presynaptic Ia inhibition on the affected side of 36 hemiplegic patients.

RESULTS

The major finding was that, similar to results previously obtained in healthy subjects, increasing the conditioning stimulus rate in hemiplegic patients leads to an increase in the synaptic efficiency of inhibitory spinal circuits. Furthermore, a significant correlation was found between the severity of flexor carpi radialis muscle spasticity and the amount of disynaptic inhibition.

CONCLUSIONS

The reinforcement of inhibitory spinal networks induced by repetitive stimulation of afferent fibres is preserved in spastic patients, whereas the mechanisms underlying this phenomena might be altered.

SIGNIFICANCE

The results of these experiments open up a number of possibilities for novel spasticity therapies based on non-invasive techniques.