Table 1.
Review of the effects of rTMS and PAS on sensorimotor function and spasticity in spinal cord injury.
| Study | Number in study | AIS and level | Trial protocol | TMS intensity | Freq. of TMS (Hz) | Total pulses | Target | Outcome timing | Outcomes |
|---|---|---|---|---|---|---|---|---|---|
| Sensorimotor function | |||||||||
| Belci et al. (2004) rTMS | 4 | AIS D, C5 | Placebo, random., X-over SB | 90% RMT | 10 + 0.1 Hz, doublets | 360 doublets × 5 (days) | UL | Week of treatment | ↑PP, ↑U&LEMS, ↓EPT, ↓Peg board time, ↓Cortical Inhibition |
| Follow-up 3 weeks | ↑PP, ↑U&LEMS, ↓EPT, ↓Peg board time persisted | ||||||||
| Kuppuswamy et al. (2011), rTMS | 15 | AIS A–D, C2–C8 | Placebo, random., X-over SB | 80% AMT | 5 Hz | 900 × 5 (days) | UL | 1, 72, and 120 h post rTMS | ASIA no change, ↑ARAT at 1h, ↑AMT at 72 and120 h, ↓EPT persisted (2 weeks) in two subjects |
| Benito et al. (2012), rTMS | 17 | AIS D, C4–T12 | Placebo, random, X-over. DB | 90% RMT | 20 Hz | 1600 × 15 (days) | LL | Post rTMS | ↑ LEMS = WISCI-II, ↑10MWT, ↑cadence (↑step length and ↓TUG no difference to sham) |
| Follow-up 2 weeks | ↑10MWT sustained over sham | ||||||||
| Kumru et al. (2013)†, rTMS | 10 | AIS D, C4–T12 | Placebo, random, X-over. SB | 90% RMT, (UL muscle) | 20 Hz | 1600 × 15 (days) | LL | Post rTMS | ↑LEMS, ↑10MWT = WISCI-II = TUG |
| Follow-up 2 weeks | ↑10MWT sustained over sham | ||||||||
| Bunday and Perez (2012) ††, PAS | 19 | AIS A–D, C4–C8 | X-over. SB | 100% MSO | 0.1 Hz | ~100 | UL | 0–30 min post PAS | ↑MEP, ↑cMEP, ↑voluntary force, ↓9HPT = F-waves |
| 1–2 h | ↑MEP | ||||||||
| Spasticity | |||||||||
| Kumru et al. (2010), rTMS | 14 | AIS C–D, C4–T12 | Placebo, random., X-over. DB | 90%RMT, (Biceps brachii) | 20 Hz | 1600 × 5 (days) | LL | During and post rTMS sessions | Less spasticity, ↓MAS, SCAT & MPSFS = Hmax/Mmax, = T reflex = withdrawal reflex |
| Follow-up 1 week | Reduction in spasticity persisted | ||||||||
| Benito et al. (2012), rTMS | 17 | AIS D, C4–C12 | Placebo, random., X-over. DB | 90% RMT | 20 Hz | 1600 × 15 (days) | LL | Post rTMS | Less spasticity, ↓MAS |
| Kumru et al. (2013)†, rTMS | 10 | AIS D, C4–T12 | Placebo, random., X-over. SB | 90%RMT, (UL muscle) | 20 Hz | 1600 × 15 (days) | LL | Post rTMS | Less spasticity (↓MAS) |
AIS, American Spinal Injuries Association (ASIA) Impairment Scale; AMT, active motor threshold to TMS; DB, double blinded; Hmax/Mmax, ratio of maximum H reflex to maximum M wave; LL, lower limb; MAS, Modified Ashworth Scale; MPSFS, Modified Penn Spasm Frequency Scale; MSO, maximal stimulator output; PAS, paired associative stimulation; PP, ASIA pin prick score; Random, randomised; RMT, resting motor threshold to TMS; rTMS, repetitive transcranial magnetic stimulation; SB, single blinded; SCAT, Spinal Cord Assessment Tool for Spasticity; T reflex, tendon reflex; TUG, timed up and go test; UL, upper limb; U&LEMS, upper and lower extremity motor scores; WISCI-II, Walking Index for SCI Scale; X-over, cross-over trial; 9HPT, nine-hole peg-board test. 10MWT, 10 min walking test; =, no change; ↑, increase; ↓, decrease; †Study combined rTMS with gait rehabilitation therapy; †† PAS study consisted of paired cortical TMS (100% MSO) and supramaximal peripheral nerve stimulation.