The Effectiveness of Repetitive Transcranial Magnetic Stimulation for the Treatment of Spastic Diplegia Cerebral Palsy Based on the Gross Motor Function in School-aged Children: a Randomized Controlled Trial

Cerebral palsy describes a group of permanent disorders of the development of movement and posture, causing activity limitation that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain.

The reported worldwide prevalence rates of CP are approximately between 2 and 3 per 1000 live births. In Spain, it is estimated that between 2 and 2.5 per thousand born has cerebral palsy, that is, 1 per in 500 live births. In other words, in Spain there are 120,000 people with cerebral palsy.

The Spastic Diplegia form is the most common form with around 65-70 % of the CP children. It is characterized by gross motor difficulties, marked in the lower limb and partially affection noticeable in the upper limb.

Spasticity is defined as "disordered sensori-motor control, resulting from an upper motoneuron lesion, presenting as intermittent or sustained involuntary activation of muscles". Spasticity is a velocity-dependent motor disorder, characterized by an increased stretch reflex, resulting in immoderate muscle activation that causes a muscle hypertonia. The pathophysiology of spasticity is characterized, in general, by a deregulation of the motor pathways (mainly the corticospinal, reticulospinal, and the vestibulospinal tracts) running from the cerebral cortex, and brain stem to the spinal cord. In children who suffer from an early brain abnormality, spasticity is affected by the reorganization of supraspinal input and impaired motor maturation, causing a loss in descending inhibitory inputs and an increase of the excitability of gamma and alpha neurons.

NICE clinical guidance recommends the use of physiotherapy, as it provides an approach centred on how the current functional problems impact on the participation at home, school life and community. Nowadays, CP is not fully curable, and physiotherapy should be used in conjunction with other interventions such as oral drugs, botulinum toxin type A, continuous pump-administered intrathecal baclofen, orthopaedic surgery and selective dorsal rhizotomy. However, a recent Cochrane Systematic Review (CSR) concludes that there is low evidence that BoNT-A is more effective than placebo or a non-placebo control in children with CP. Another recent CSR determines that there is short-term evidence of the Intrathecal Baclofen therapy. Furthermore, there is not a CSR for orthopaedic surgery and selective dorsal rhizotomy.