The effect of the combined application of repetitive transcranial magnetic stimulation and local injection of botulinum neurotoxin versus their individual use in children with spastic diplegic cerebral palsy.

Background: Botulinum neurotoxin (BoNT) is frequently utilized for localized spasticity in patients with spastic diplegic cerebral palsy (CP), while repetitive transcranial magnetic stimulation (rTMS) offers a potential therapeutic option.

Objective: To assess and compare BoNT and rTMS effects among children with spastic diplegic CP on spasticity and motor function. Additionally, investigate the potential advantages of combining these therapeutic modalities.

Methods: Seventy five children (aged 4-8 years) with moderate spastic diplegia, were allocated to one of three groups (25 children in each group): the rTMS group (received 10 hz rTMS, 1500 pulses, two sessions per week for 3 months), the BoNT group (received single BoNT injection), and the combined BoNT-rTMS group. All groups underwent a 3-month physical therapy program. Baseline and post-3-month assessments included the motor function by using Gross Motor Function Classification System (GMFCS), and spasticity by using Modified Ashworth Scale (MAS), and electromyography (i.e. the ratio between the amplitude of both Hoffman response to muscle response (H/M ratio)).

Results: There were a statistically significant difference between groups regarding H/M ratio and GMFCS where values were (<0.001 and 0.009) respectively. Multivariate regression analysis favored combination therapy over BoNT alone, showing lower odds ratios for MAS (OR = 0.47, = .04), GMFCS (OR = 0.171,  < .001), and a negative beta coefficient for H/M ratio (Beta = -0.137,  < .001).

Conclusion: BoNT and rTMS reduce CP-related spasticity and improve motor function, however the combined therapy of these modalities demonstrates an additive effect.