Mixed effectiveness of rTMS and retraining in the treatment of focal hand dystonia

Teresa J Kimberley, Rebekah L S Schmidt, Mo Chen, Dennis D Dykstra, Cathrin M Buetefisch, Teresa J Kimberley, Rebekah L S Schmidt, Mo Chen, Dennis D Dykstra, Cathrin M Buetefisch

Abstract

Though the pathophysiology of dystonia remains uncertain, two primary factors implicated in the development of dystonic symptoms are excessive cortical excitability and impaired sensorimotor processing. The aim of this study was to determine the functional efficacy of an intervention combining repetitive transcranial magnetic stimulation (rTMS) and sensorimotor retraining. A randomized, single-subject, multiple baseline design with crossover was used to examine participants with focal hand dystonia (FHD) (n = 9).

Intervention: 5 days rTMS + sensorimotor retraining (SMR) vs. Five days rTMS + control therapy (CTL) (which included stretching and massage). The rTMS was applied to the premotor cortex at 1 Hz at 80% resting motor threshold for 1200 pulses. For sensorimotor retraining, a subset of the Learning-based Sensorimotor Training program was followed. Each session in both groups consisted of rTMS followed immediately by 30 min of the therapy intervention (SMR or CTL). Contrary to our hypothesis, group analyses revealed no additional benefit from the SMR training vs. CTL. When analyzed across group however, there was significant improvement from the first baseline assessment in several measures, including tests of sensory ability and self-rated changes. The patient rated improvements were accompanied by a moderate effect size suggesting clinical meaningfulness. These results provide encouragement for further investigation of rTMS in FHD with a need to optimize a secondary intervention and determine likely responders vs. non-responders.

Keywords: human; neuromodulation; rehabilitation; sensory; transcranial magnetic stimulation; writer's cramp.

Figures

Figure 1
Figure 1
Consort diagram of screened and enrolled participants. Participants were randomly assigned to either the rTMS + SMR or rTMS + CTL intervention first and then crossed over to receive the other intervention after 1-month washout. (SMR, sensorimotor retraining intervention; CTL, control intervention; rTMS, repetitive transcranial magnetic stimulation).
Figure 2
Figure 2
Global rating of change (GROC) scores from first baseline to all subsequent assessments. This graph demonstrates mean change (±SE) over time, excluding one participant (#7) who appeared to misunderstand the rating (see text). Note, all individuals received both interventions. CTL-SMR (light gray) received the rTMS + CTL first and then the rTMS + SMR in Phase 2. The SMR-CTL (dark gray) group received rTMS + SMR first and then rTMS + CTL in Phase 2. GROC was assessed at one baseline, post-test and follow up for each phase. (SMR, sensorimotor retraining; rTMS, repetitive transcranial magnetic stimulation; CTL, control).
Figure 3
Figure 3
Arm Dystonia Disability Scale (ADDS) in first phase of treatment (CTLn= 4 in dark gray, SMRn= 5 in light gray). Regardless of intervention, all subjects reported improvement in self-perceived function. Mean (±SE). ADDS was tested at one baseline, post-test and follow up for each phase. (SMR, sensorimotor retraining, rTMS, repetitive transcranial magnetic stimulation, CTL, control).
Figure 4
Figure 4
Single subject analysis. Raw data presented across both phases. Lines represent mean (solid) and two SD (dashed) of baseline; dark gray, SMR; light gray, CTL. Cortical silent period (CSP) duration, average handwriting pressure while drawing loops, Global rating of change (GROC) scores (0, change; 1, almost the same). Improved handwriting quality after both interventions was observed while pressure remained stable. CSP suggests a decrease in excitability at both post-tests and at SMR follow-up.

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