Combined effects of botulinum toxin type A and repetitive transcranial magnetic stimulation with intensive motor training immediately after injection in a patient with chronic stroke: A case report.

Single case report. A previous study clarified that spasticity and motor function were improved by combined treatment with botulinum toxin type A (BTX) injection and 1-Hz repetitive transcranial magnetic stimulation (rTMS) with intensive motor training at 4 weeks after injection. However, it is not clear whether 1-Hz rTMS with intensive motor training immediately after BTX injection also improves spasticity and motor function in stroke patients. The purpose of this case report is to test the short- and long-term effects of BTX injection and rTMS with intensive motor training on the spasticity, motor function, and usefulness of the paretic hand in a stroke patient. A 64-year-old male, who suffered from a right cerebral hemorrhage 53 months previously, participated in the present study. BTX was injected into the spastic muscles of the affected upper limb. He then received the new protocol for a total of 24 sessions. The Modified Ashworth Scale (MAS), Fugl-Meyer Assessment (FMA), and Motor Activity Log, consisting of the amount of use and quality of movement scales, were assessed before and immediately after BTX injection, at discharge, and monthly for up to 5 months after discharge. For the short-term effects of the therapy, the MAS scores of the elbow and wrist, FMA score, and quality of movement score improved. For the long-term effects of the therapy, the MAS score of the fingers, FMA score, and amount of use score improved for up to 5 months after discharge. The present case report showed the improvement of all assessments performed in the short and/or long term and suggest the possibility of shortening the intervention period of combined therapy of BTX and rTMS with intensive motor training.

Hirakawa Y ，Koyama S ，Tanabe S ，Takeda K ，Ueda T ，Motoya I ，Sakurai H ，Kanada Y ，Kawamura N ，Kawamura M ，Nagata J ，Kanno T ... -  《-》

Combined therapeutic application of botulinum toxin type A, low-frequency rTMS, and intensive occupational therapy for post-stroke spastic upper limb hemiparesis.

Kakuda W ，Abo M ，Momosaki R ，Yokoi A ，Fukuda A ，Ito H ，Tominaga A ，Umemori T ，Kameda Y ... -  《-》

Local muscle injection of botulinum toxin type a synergistically improves the beneficial effects of repetitive transcranial magnetic stimulation and intensive occupational therapy in post-stroke patients with spastic upper limb hemiparesis.

The purpose of this study was to determine whether local injection of botulinum toxin type A (BoNT-A) into the spastic muscles has any added benefits to repetitive transcranial magnetic stimulation (RTMS)/occupational therapy (OT) in patients with spastic upper limb hemiparesis. The study subjects of 80 post-stroke patients with spastic upper limb hemiparesis (age: 60.2 ± 13.0 years, time after stroke: 55.3 ± 43.0 months), were divided into the BoNT-A plus RTMS/OT group and RTMS/OT group. BoNT-A was injected into the spastic muscles (total dose: 240 units) before RTMS/OT. The latter included 12 sessions of 40 min RTMS over the non-lesional hemisphere and 240-min intensive OT daily over 15 days. Spasticity was evaluated by the modified Ashworth scale (MAS) and the motor function of the affected upper limb was evaluated serially with Fugl-Meyer Assessment and Wolf Motor Function Tests. Both groups showed significant improvements in spasticity and motor function. The addition of BoNT-A resulted in better improvement in FMA score and MAS of finger flexor muscles (p < 0.05). The triple-element protocol of local injection of BoNT-A into spastic finger muscles, RTMS and intensive OT, is a promising therapeutic program for post-stroke spastic upper limb hemiparesis, although its significance should be confirmed in randomized, placebo-controlled trials.

Yamada N ，Kakuda W ，Kondo T ，Mitani S ，Shimizu M ，Abo M ... -  《-》

Comparison of the effects of modified constraint-induced movement therapy and intensive conventional therapy with a botulinum-a toxin injection on upper limb motor function recovery in patients with stroke.

Nasb M ，Li Z ，S A Youssef A ，Dayoub L ，Chen H ... -  《-》

Efficacy of coupling repetitive transcranial magnetic stimulation and physical therapy to reduce upper-limb spasticity in patients with stroke: a randomized controlled trial.

To assess the efficacy of inhibitory repetitive transcranial magnetic stimulation (rTMS) for decreasing upper-limb muscle tone after chronic stroke. A randomized sham-controlled trial with a 4-week follow-up. Research hospital. Patients with stroke (N=20) with poststroke upper limb spasticity. The experimental group received rTMS to the primary motor cortex of the unaffected side (1500 pulses; 1Hz; 90% of resting motor threshold for the first dorsal interosseous muscle) in 10 sessions, 3d/wk, and physical therapy (PT). The control group received sham stimulation and PT. Modified Ashworth scale (MAS), upper-extremity Fugl-Meyer assessment, FIM, range of motion, and stroke-specific quality-of-life scale. All outcomes were measured at baseline, after treatment (postintervention), and at a 4-week follow-up. A clinically important difference was defined as a reduction of ≥1 in the MAS score. Friedman test revealed that PT is efficient for significantly reducing the upper limb spasticity of patients only when it is associated with rTMS. In the experimental group, 90% of the patients at postintervention and 55.5% at follow-up showed a decrease of ≥1 in the MAS score, representing clinically important differences. In the control group, 30% of the patients at postintervention and 22.2% at follow-up experienced clinically meaningful changes. There were no differences between the groups at any time for any of the other outcome measures, indicating that both groups demonstrated similar behaviors over time for all variables. rTMS associated with PT can be beneficial in reducing poststroke spasticity. However, more studies are needed to clarify the clinical changes underlying the reduction in spasticity induced by noninvasive brain stimulations.

Barros Galvão SC ，Borba Costa dos Santos R ，Borba dos Santos P ，Cabral ME ，Monte-Silva K ... -  《-》