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Repetitive Transcranial Magnetic Stimulation

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Repetitive transcranial magnetic stimulation (rTMS) has been widely explored as a tool for treating a variety of disorders, including depression (Martin et al., 2003; Couturier et al., 2005), pain (Lima & Fregni, 2008), and motor disorders following Parkinson’s disease (Elahi et al., 2009) and stroke (Corti et al., 2011). Experimental studies in humans have shown that low frequency rTMS (<1 Hz) can reduce the excitability of the motor cortex whereas high frequency rTMS (>1 Hz) causes an increase in motor cortical excitability (Kobayashi & Pascual-Leone, 2003). Given the ability for rTMS to modulate cortical excitability, there has been much interest in exploring its potential to facilitate supraspinal connectivity or restore the balance of interhemispheric inhibition (in stroke) as a means to promote motor recovery and function.

The recovery of functional ambulation following motor-incomplete SCI has been shown to be associated with enhanced excitability of motor cortical areas (Winchester et al., 2005) and corticospinal connectivity to the lower limb (Thomas & Gorassini, 2005). Recently, Kumru et al. (2013) explored the potential efficacy of combining rTMS with locomotor training on gait outcomes in people with sub-acute (<12 months) motor-incomplete SCI (ASIA D).  Seventeen participants were randomized to either a control group with sham stimulation, or the rTMS group. Stimulation (sham or rTMS) was delivered while participants lay supine, 5 times/week for 3 weeks. All participants also received daily overground gait training for 1 hour for 3 weeks. The gait training session was performed within 30 minutes of the stimulation session. There was an additional 2 weeks of overground gait training only as a follow-up.

Table 20: RCT Study Using Repetitive Transcranial Magnetic Stimulation

Discussion

Few studies have investigated the effects of rTMS on gait-related outcomes (Kumru et al., 2013; Benito et al., 2012). The authors report significant improvements in LEMS and 10MWT in the rTMS group, but not the sham stimulation group.

Effect Size Forest Plots of RCTs with Available Data
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Effect size SMD forest plot for Kumru et al. 2013, repetitive transcranial magnetic stimulation (rTMS)

Conclusion

There is level 1b evidence from one RCT (Kumru et al. 2013) that rTMS combined with overground locomotor training may not afford further benefits over overground locomotor training alone (with sham stimulation).

  • rTMS combined with overground locomotor training may not afford further benefits over overground locomotor training alone.