Lasting Effects of Low-Frequency Repetitive Transcranial Magnetic Stimulation in Writer’s Cramp: A Case Report

Abstract

The treatment of writer’s cramp (W’sC) is essentially based on the use of botulinum toxin. However, additional treatments are sometime required to prolong the effects of the toxin, compensate for its progressive loss of efficacy in some subjects, and re-educate handwriting (e.g., rehabilitation strategies). Low-frequency repetitive transcranial magnetic stimulation (rTMS) has been employed to improve W’sC, but with short-lasting and controversial outcomes. We report on the effects of a long-lasting low-frequency rTMS paradigm on W’sC symptoms. A 25-year-old male with a diagnosis of simple W’sC was enrolled in the study. He underwent an objective assessment using the Writer’s Cramp Rating Scale (WCRS) and the 1-min writing test. Further, we recorded muscle activation of the upper limb during handwriting using an EMG wireless system. The patient was provided with 1,200 biphasic magnetic pulses delivered at 1 Hz over the left premotor cortex (PMC), 15 times scheduled every 2 days, thus covering a period of 5 weeks, followed by 10 days of rest. This block of stimulations was practiced other four times, for a period of 6 months. The patient showed a gradual clinical improvement with the progression of the treatments. W’sC symptoms totally disappeared and all the clinical scores showed a significant improvement after rTMS completion. Such improvement lasted up to 1 year after the end of the treatment. Moreover, we detected a long-lasting improvement in sensorimotor plasticity as measured by a paired associative stimulation protocol. Our case suggests that the long-lasting application of 1 Hz rTMS to PMC is a safe and potentially valuable tool to improve W’sC symptoms enduringly, probably by reverting maladaptive plasticity mechanisms within the sensory-motor areas of the hemisphere contralateral to the dystonic hand.

Effects of non-invasive brain stimulation in dystonia: a systematic review and meta-analysis

“…Overall, 19 of the 20 studies reported some reduction in dystonia symptoms after the application of NIBS, however many did not report whether this was statistically significant. Two studies 72, 73 applied rTMS to patients with lower limb dystonia, and one study applied rTMS in a patient with left side multifocal dystonia, which affected the upper and lower limbs 77 .The average number of stimulation sessions was 10 ( SD = 15.1), with a maximum of 75 sessions 69 .…”

Neurosurgical versus neuromodulation treatment in writer’s cramps: a narrative review

“…There was case series in which WC has been improved with the low-frequency repetitive transcranial magnetic stimulation (rTMS), but the results were short-lived and contentious [21]. The effects of a long-term low-frequency rTMS paradigm on WC symptoms are described in a study done in Italy [21]. The study included a 25-year-old man who had been diagnosed with uncomplicated WC [21].…”

“…The effects of a long-term low-frequency rTMS paradigm on WC symptoms are described in a study done in Italy [21]. The study included a 25-year-old man who had been diagnosed with uncomplicated WC [21]. The WC Rating Scale (WCRS) and a 1-minute writing test were used to assess him objectively [21].…”

“…The study included a 25-year-old man who had been diagnosed with uncomplicated WC [21]. The WC Rating Scale (WCRS) and a 1-minute writing test were used to assess him objectively [21]. They also used EMG wireless equipment to record muscle activation in the upper limb while writing [21].…”

A Case of Psychogenic Myoclonus Responding to a Novel Transcranial Magnetic Stimulation Approach: Rationale, Feasibility, and Possible Neurophysiological Basis

“…Furthermore, antidepressants and muscle relaxants may also be beneficial (Espay et al, 2009 ; Gelauff et al, 2014 ; Ricciardi and Edwards, 2014 ). When these approaches are unsuccessful or not tolerated by the patient, non-invasive brain stimulation has been proposed as a useful add-on to improve a person’s functioning (Nicholson and Voon, 2016 ; Naro et al, 2019a , b ). Specifically, a few studies proposed repetitive TMS (rTMS) as a clinically valuable tool to improve PMDs.…”