Theta-burst Transcranial Magnetic Stimulation for the Treatment of Childhood Dystonia and Spasticity

Testing will occur at three identical visits, with escalating stimulation intensity at each visit. Initial screening will be performed by telephone or in clinic and final screening will be performed and informed consent will be signed at the start of the first study visit. Initial set-up and calibration of the magnetic stimulation device will require 10-20 minutes. Theta-burst stimulation requires 40 seconds. Hand and arm function will be tested immediately before and during the one hour following the TBS. Therefore, each visit should occupy 90-120 minutes. Each visit will be at least 2 days after the previous visit and a telephone call will be placed one week after the third visit.

Testing of limb function will be performed according to standard clinical rating scales, including the modified Ashworth spasticity scale and the Barry-Albright Dystonia rating scale. Electrophysiological testing of hand function will involve moving finger muscles against resistance while surface electromyographic signals (EMG) are monitored for the ability to activate one finger at a time while minimizing muscle co-contraction and overflow. Testing of arm function will involve measurement of the ability to relax the biceps and triceps and the resistance of the elbow to passive movement by the examiner.

Testing of cortical function will occur both before and after theta-burst stimulation, and will involve a standard protocol using suprathreshold single and paired-pulse magnetic stimulation with measurement of the induced motor evoked potential (MEP) in the hand and arm muscles. The resting MEP threshold and input-output curve will be measured for the first dorsal interosseus muscle. Paired-pulse inhibition of the MEP will be tested using a subthreshold pulse (80% of resting motor threshold) followed by a suprathreshold pulse at 2.5msec interval. Paired-pulse facilitation will be tested using a 12msec interval. Silent period duration in response to a pulse at 120% of resting motor threshold will be measured.

Theta-burst stimulation will be performed according to the standard protocols developed by Rothwell and co-workers with NIH and European consortium safety guidelines stringently enforced. Active motor threshold and resting motor threshold will be determined by single-pulse stimulation while monitoring electromyographic (EMG) activity at the first dorsal interosseus (FDI) muscle according to standard published protocols using commercially available surface EMG electrodes (DelSys Inc.). Stimulation will be performed using the commercially-available Magstim Rapid 2 (Magstim, Inc., Wales UK) with a standard figure-eight coil held by a member of the research team. Biphasic stimulation pulses will be given according to the standard included driver software. Single pulse, paired pulse, and theta-burst rapid stimulation protocols are directly available through standard user options on this device.

Threshold determination and stimulation location will be performed using each subject's most affected hand, or the non-dominant hand if both hands are affected. The location of lowest threshold for stimulation of the FDI will be determined by gradual movement of the stimulation coil over the surface of the contralateral scalp, in the region of the standard "C3" or "C4" electrode position (determined by international 10-20 EEG electrode placement convention). The handle of the stimulation coil will be pointed backward and 45 degrees from the sagittal plane so as to be approximately perpendicular to the rolandic fissure. The location of minimum threshold will be marked with a washable non-permanent marker on the subject's scalp in order to ensure consistency of stimulation.