Functional outcome of repetitive transcranial magnetic stimulation in spastic paretic upper limb after ultrasonography-guided botulinum toxin injection in patients with stroke

Abstract Background Spasticity is one of the most disabling stroke consequences, post-stroke spasticity (PSS). By acting via preventing acetylcholine release at the neuromuscular junction, intra-muscular injection of botulinum toxin A (BoNT-A) can reduce PSS. In addition, noninvasive brain stimulation (NIBS) specifically repetitive transcranial magnetic stimulation (rTMS), is well-defined to impact neuro-plastic changes and control the healing of injured brain areas. Objectives The current study aimed to evaluate the combined effect of ultrasonography (US)-guided local BoNT-A injection (for better accuracy and safety) and ipsilesional high-frequency rTMS (HF-rTMS) on spastic UL in chronic post-stroke patients. Patients and methods 80 patients with post-stroke spastic upper limb (UL) were under US guidance injected with BoNT-A, then randomly allocated to treatment with 20 Hz rTMS (HF-rTMS group, group 1), N = 40 or SHAM group (group 2), N = 40, applied over the ipsilesional cortex over 4 weeks. The motor function of the affected UL was evaluated serially by Wolf motor function tests (WMFT) just before BoNT-A administration, 1.5 months and 3 months after administration. Results The high-frequency rTMS group showed significant improvement of spastic muscles function as evident by WMFT. Conclusions These findings suggested that, the application of HF-rTMS over the ipsilesional cerebral cortex following local US-guided BoNT-A injection contributes in improving motor function of upper limb in chronic post-stroke patients.