Long Term Effects of 5-Hz rTMS over M1 Cortex in Spastic Cerebral Palsy: A Pilot Randomized Controlled Trial


  • Suttipong Tipchatyotin Faculty of Medicine, Prince of Songkla university
  • Somrot Phonglamai
  • Atchara Boonmeeprakob


cerebral palsy, spasticity, repetitive transcranial magnetic stimulation


Objectives: To determine long term effect of repetitive transcranial magnetic stimulation (rTMS) on muscle tone reduction and mobility in children with spastic cerebral palsy (CP).

Study design: A pilot randomized controlled trial.

Setting: Southern Rehabilitation Center, Songklanagarind Hospital.

Subjects: Spastic CP aged 5-18 years old with modified Ashworth Scale (MAS) of extremities graded 1 to 3.

Methods: Participants were randomized into 2 groups, rTMS and sham groups. The rTMS group received 1500 stimuli of 5-Hz stimulation, 90% resting motor threshold stimulation over the primary motor cortex for 10 consecutive working days. The sham group received 10% resting motor threshold intensity over the same area and duration of stimulation. Both groups received a standard rehabilitation program during experimental periods. Outcome measurements included MAS of extremity muscles and joint range of motion (ROM) at angle of catch (Tardieu’s R1) for muscle tone and the Gross Motor Function Classification System - expanded and revised (GMFCS-ER) Thai version for mobility, were assessed before intervention, immediately after intervention, and follow up at 1, 2, 4 and 8 weeks after the last treatment session.

Results: Eighteen children were recruited, mean age (SD) was 95.9 (31.7) months in the rTMS group and 93.8 (20.4) months in the sham group. Their GMFCS-ER was classified as level 3 to 5. After completion of 10 sessions, there were no significant changes in MAS. ROMs at angle of catch tended to increase post intervention and during follow up period in the rTMS group. Mobility levels according to GMFCS-ER were constant within group and no difference between groups. No serious adverse event was reported entire this study.

Conclusion: 5-Hz rTMS over the primary motor cortex for 10 days had no additive effects of spasticity or muscle tone reduction or functional improvement in children with spastic cerebral palsy.

Keywords: cerebral palsy, spasticity, repetitive transcranial magnetic stimulation


Download data is not yet available.


Dabney KW, Lipton GE, Miller F. Cerebral palsy. Curr Opin Pediatr. 1997;9:81-8.

Reid SM, Carlin JB, Reddihough DS. Classification of topographical pattern of spasticity in cerebral palsy: a registry perspective. Res Dev Disabil. 2011;32:2909-15.

Ngamthanawat P, Chavasiri S. Epidemiology of pediatric patients at Department of Rehabilitation Medicine, Siriraj Hospital. J Thai Rehabil Med. 2016;26:31-8.

Katz RT, Rymer WZ. Spastic hypertonia: mechanisms and measurement. Arch Phys Med Rehabil. 1989;70:144-55.

Trompetto C, Marinelli L, Mori L, Pelosin E, Currà A, Molfetta L, Abbruzzese G. Pathophysiology of spasticity: implications for neurorehabilitation. Biomed Res Int. 2014;2014:354906. doi: 10.1155/2014/354906.

Nahm NJ, Graham HK, Gormley ME Jr, Georgiadis AG. Management of hypertonia in cerebral palsy. Curr Opin Pediatr. 2018;30: 57-64.

Rajapakse T, Kirton A. Non-invasive brain stimulation in children: applications and future directions. Transl Neurosci. 2013;4: 10.2478/s13380-013-0116-3. doi:10.2478/s13380-013-0116-3.

Zewdie E, Ciechanski P, Kuo HC, Giuffre A, Kahl C, King R, et al. Safety and tolerability of transcranial magnetic and direct current stimulation in children: prospective single center evidence from 3.5 million stimulations. Brain Stimul. 2020;13:565-75.

Allen CH, Kluger BM, Buard I. Safety of transcranial magnetic stimulation in children: a systematic review of the literature. Pediatr Neurol. 2017;68:3-17.

Korzhova J, Sinitsyn D, Chervyakov A, Poydasheva A, Zakharova M, Suponeva N, et al. Transcranial and spinal cord magnetic stimulation in treatment of spasticity: a literature review and meta-analysis. Eur J Phys Rehabil Med. 2018;54:75-84.

Gunduz A, Kumru H, Pascual-Leone A. Outcomes in spasticity after repetitive transcranial magnetic and transcranial direct current stimulations. Neural Regen Res. 2014;9:712-8.

Gupta M, Lal Rajak B, Bhatia D, Mukherjee A. Effect of r-TMS over standard therapy in decreasing muscle tone of spastic cerebral palsy patients. J Med Eng Technol. 2016;40:210-6.

Rossi S, Hallett M, Rossini PM, Pascual-Leone A; Safety of TMS Consensus Group. Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clin Neurophysiol. 2009;120:2008-39.

Valle AC, Dionisio K, Pitskel NB, Pascual-Leone A, Orsati F, Ferreira MJ, et al. Low and high frequency repetitive transcranial magnetic stimulation for the treatment of spasticity. Dev Med Child Neurol. 2007;49:534-8.

Gillick BT, Gordon AM, Feyma T, Krach LE, Carmel J, Rich TL, et al. Non-Invasive brain stimulation in children with unilateral cerebral palsy: a protocol and risk mitigation guide. Front Pediatr. 2018;6:56. doi:10.3389/fped.2018.00056.

Paulis WD, Horemans HL, Brouwer BS, Stam HJ. Excellent test-retest and inter-rater reliability for Tardieu Scale measurements with inertial sensors in elbow flexors of stroke patients. Gait Posture. 2011;33:185-9.

Liabsirinon S, Tantilipikorn P, Mahasup N. Interrater reliability of Thai version of Gross Motor Function Classification System (GMFCS) in Thai children with cerebral palsy. Thai J Phys Ther. 2008;30:26-36.

Rajak BL, Gupta M, Bhatia D, Mukherjee A. Effect of repetitive transcranial magnetic stimulation on hand function of spastic cerebral palsy children. J Neurol Disord. 2017;5:329. doi: 10.4172/2329-6895.1000329.

Shaw L, Rodgers H, Price C, van Wijck F, Shackley P, Steen N, et al. BoTULS: a multicentre randomised controlled trial to evaluate the clinical effectiveness and cost-effectiveness of treating upper limb spasticity due to stroke with botulinum toxin type A. Health Technol Assess. 2010;14:1-113,iii-iv.

Bar-On L, Molenaers G, Aertbeliën E, Van Campenhout A, Feys H, Nuttin B, et al. Spasticity and its contribution to hypertonia in cerebral palsy. Biomed Res Int. 2015;2015:317047. doi: 10.1155/2015/317047

Li S, Chen YT, Francisco GE, Zhou P, Rymer WZ. A unifying pathophysiological account for post-stroke spasticity and disordered motor control. Front Neurol. 2019;10:468. doi: 10.3389/fneur.2019.00468.

Carr LJ, Harrison LM, Evans AL, Stephens JA. Patterns of central motor reorganization in hemiplegic cerebral palsy. Brain. 1993; 116:1223-47.

Maegaki Y, Maeoka Y, Ishii S, Shiota M, Takeuchi A, Yoshino K, et al. Mechanisms of central motor reorganization in pediatric hemiplegic patients. Neuropediatrics. 1997;28:168-74.

Kirton A, Chen R, Friefeld S, Gunraj C, Pontigon AM, Deveber G. Contralesional repetitive transcranial magnetic stimulation for chronic hemiparesis in subcortical paediatric stroke: a randomised trial. Lancet Neurol. 2008;7:507-13.

Koponen LM, Nieminen JO, Ilmoniemi RJ. Multi-locus transcranial magnetic stimulation-theory and implementation. Brain Stimul 2018;11:849–55.






Original Article