Therapeutic Effect of Ipsilesional High-Frequency Repetitive Transcranial Magnetic Stimulation Following Local Botulinum Toxin Injection in Post-Stroke Upper Limb Spasticity

Background: One of the most prominently apparent stroke consequences is spasticity. By preventing acetylcholine release at the neuromuscular junction, intramuscular injection of botulinum toxin can reduce post-stroke stiffness. Additionally, repetitive transcranial magnetic stimulation (rTMS), a type of noninvasive brain stimulation (NIBS), is well recognised to impact neuroplastic changes and control the healing of injured brain areas. Objective: The aim of the current study was to evaluate the combined effect of local botulinum toxin injection and ipsilesional high- frequency rTMS (HF-rTMS) on spastic UL in post-stroke patients, and if this effect could add together to the other treatment modalities available to these patients. Patients and Methods: 45 patients with post-stroke spastic upper limb (UL) were injected with botulinum toxin type-A (BoNT-A), then randomly designated to treatment with 20 Hz rTMS (Real rTMS group), N= 22 and SHAM rTMS group, N=23, applied over the ipsilesional cortex over 4 weeks. Spasticity was assessed with Modified Ashworth scale (MAS), the motor function of the affected upper limb was evaluated serially by Wolf Motor Function Tests (WMFT) and motor power was assessed by Medical Research Council (MRC) just before administration, 1.5 months and 3 months after administration of BoNT-A. Results: The real rTMS group showed significant improvement of spastic muscles as evident by reduction of their MAS score with significant improvement of motor function and motor power as shown by WMFT and MRC.  Conclusion: These findings suggested that, the application of HF-rTMS over the ipsilesional cortex following local BoNT-A injection contributes in reduction of spasticity and improves motor power and function in post-stroke patients.