Objective: To investigate whether repetitive transcranial magnetic stimulation (rTMS) immediately followed by lidocaine injection (rTMS-LI) exerts disease-modifying or curative effects in dystonia.

Background: We previously reported acute effects of rTMS (0.2 Hz over the premotor cortex, 250 stimuli per session) in writer’s cramp (Murase N et al., 2005). This method was accessed as insufficient evidence in evidence-based medicine (EBM) because of the limited number of papers (Lefaucheure J.-P., 2020). On the other hand, lidocaine injection with dehydrated ethanol was reported to be effective in writer’s cramp (Kaji R et al., 1995), through blocking of sensory afferent fibers, referred to as muscle afferent block (MAB). Because the effects of rTMS lasted longer in patients previously treated with MAB than in treatment-naïve patients in our preliminary trials, we initiated the combination therapy of rTMS-LI, expecting the long-term effect. A RCT comparing six month-repeated treatment with rTMS-LI, botulinum neurotoxin (BoNT) and MAB, demonstrated that the long-term effect of rTMS-LI was compatible with BoNT and superior to MAB (n = 109; in preparation). Then we followed patients who received repeated rTMS-LI therapy for more than four years.

Method: Six patients with dystonia who showed a long-term response to rTMS-LI were enrolled: one with upper limb dystonia, three with writer’s cramp, one with musician’s cramp, and one with Meige syndrome. The mean age was 34.2 (SD 7.6) years and the mean disease duration was 4.5 (2.29) years. rTMS-LI was administered monthly and the modified BFM scale was used for evaluation. The mean follow-up period was 10.0 (6.3) years, ranging from 4 to 21 years. This was an open-label study without controls.

Results: All but one patients showed stable therapeutic effects and the modified BFM scale improved from 5.5 ± 3.1 at baseline to 2.2 ± 0.7 at maximum improvement. However, complete remission was not achieved in any patient. One male patient showed marked worsening associated with work-related stress. He then achieved complete remission by ablation surgery.

Conclusion: Monthly rTMS-LI therapy has disease-modifying, but not curative effects in dystonia.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/long-term-therapeutic-effects-of-repetitive-transcranial-magnetic-stimulation-combined-with-lidocaine-injection-rtms-li-in-dystonia/