High‐frequency repetitive transcranial magnetic stimulation and intermittent theta‐burst stimulation for spasticity management in secondary progressive multiple sclerosis

Abstract

Background and purpose The spasticity phenomenon is a significant factor in the development of disability. Repetitive transcranial magnetic stimulation (rTMS) is a promising treatment method for this disorder. Our aim was to compare the effects of two protocols of rTMS – the high‐frequency (HF) rTMS (20 Hz) and the intermittent theta‐burst stimulation (iTBS) – on the level of spasticity and concomitant symptoms in patients with secondary progressive multiple sclerosis with an analysis of the duration of the effects up to 12 weeks after the stimulation course. Methods Thirty‐four patients with secondary progressive multiple sclerosis and lower spastic paraparesis were randomized into three groups: (i) HF‐rTMS (20 Hz); (ii) iTBS; (iii) sham stimulation. Spasticity and spasticity‐associated symptoms were assessed by the Modified Ashworth Scale, the Subjective Evaluating Spasticity Scale (SESS), the numerical analog scale, the Modified Fatigue Impact Scale and the pain level scale. Results The Modified Ashworth Scale was significantly reduced after the stimulation course in the HF‐rTMS and iTBS groups. The SESS was reduced post‐intervention and at the two follow‐ups in the iTBS group, whilst HF‐rTMS produced an SESS reduction only at the 2‐week follow‐up, with no effects in the sham group. Conversely, reduction in pain and fatigue was found in the HF‐rTMS group. Conclusions The results show that HF‐rTMS and iTBS significantly reduce spasticity measured by the Modified Ashworth Scale, in contrast to sham stimulation. Some evidence was found in favor of a longer‐lasting effect of iTBS on the SESS and of a reduction in pain and fatigue after HF‐rTMS.

How to Design Optimal Accelerated rTMS Protocols Capable of Promoting Therapeutically Beneficial Metaplasticity

“…iTBS is increasingly being used as a treatment in a range of clinical applications such as rehabilitation, as well as neurological and psychiatric disorders. For example, to promote motor recovery after stroke ( 51 ), for managing spasticity associated with Multiple Sclerosis (MS) ( 52 ), and decreasing obsessive symptomatology associated with Obsessive Compulsive Disorder (OCD) ( 53 ), just to name a few. These protocols all must adhere to the established safety guidelines ( 54 ), and recommendations for clinical TMS use ( 55 , 56 ).…”

The Potential Role of Neurophysiology in the Management of Multiple Sclerosis-Related Fatigue

“…Regarding MS-related fatigue, three sham-controlled studies using TMS showed promising results (117)(118)(119). Two of these studies used TMS in combination with physical therapy and enrolled patients affected by spasticity (118,119).…”

“…Regarding MS-related fatigue, three sham-controlled studies using TMS showed promising results (117)(118)(119). Two of these studies used TMS in combination with physical therapy and enrolled patients affected by spasticity (118,119). Different TMS protocols were used: intermittent theta-burst stimulation (iTBS) applied to the M1 leg area (119), deep TMS, delivered with specific H-coils to the left prefrontal cortex and to bilateral M1 (117), and 20-Hz repetitive TMS and iTBS applied to bilateral M1 (118).…”

“…Two of these studies used TMS in combination with physical therapy and enrolled patients affected by spasticity (118,119). Different TMS protocols were used: intermittent theta-burst stimulation (iTBS) applied to the M1 leg area (119), deep TMS, delivered with specific H-coils to the left prefrontal cortex and to bilateral M1 (117), and 20-Hz repetitive TMS and iTBS applied to bilateral M1 (118). Preliminary evidence of efficacy was described for all the protocols excepted for iTBS on bilateral M1 (118).…”

Augmented Efficacy of Intermittent Theta Burst Stimulation on the Virtual Reality-based Cycling Training for Upper Limb Function in Patients With Stroke

“…The postulated pathophysiology of spasticity is that lesions of upper motor neuron impair the supraspinal inhibitory inputs, leading to an increased excitability of α and γ motor neurons, and of the interneurons at the spinal level, ultimately causing spasticity [34,35]. Therefore, facilitatory rTMS and iTBS had been applied to lower spasticity in patients with a number of neurologic disorders [20,33,[36][37][38][39][40][41] by modulating the excitability of cortical motor neurons. In addition, it is increasingly accepted that iTBS may modulate cortical excitability by inducing the long-term potential-like (LTP-like) plasticity changes [10,42,43], and the persistently increasing neural activity may project to inhibitory corticospinal synapses.…”