TMS AND BOTULINUM TOXIN IN POST-STROKE UPPER LIMB SPASTICITY

As part of the study, patients who received botulinum toxin type A (BTX-A) injections for upper extremity spasticity following stroke were evaluated using different TMS protocols. All patients received a standard conventional physical therapy program. TMS sessions were conducted using an inhibitory protocol, with a total of 10 sessions administered to the contralateral hemisphere at least 3 days per week. Clinical evaluations were performed at baseline, at 1 month, and at 3 months. Thus, the early and long-term clinical outcomes of treatment were investigated. Spasticity was assessed using the Modified Ashworth Scale (MAS), motor improvement using the Brunnstrom staging system, upper extremity motor function using the Fugl-Meyer Assessment, and upper extremity use in activities of daily living using the Motor Activity Log-28 (MAL-28). Additionally, patients' anxiety and depression levels were measured using the Hospital Anxiety and Depression Scale (HADS).

Inclusion criteria

• Diagnosis of stroke (ischemic or hemorrhagic)
• Time since stroke onset between 3 and 24 months
• Age between 18 and 80 years
• Upper extremity motor recovery at Brunnstrom Stages 3-5
• Spasticity in the elbow, wrist, or finger flexor muscle groups of the upper extremity with a Modified Ashworth Scale (MAS) score between +1 and 3
• Receipt of botulinum toxin-A injection to the affected upper extremity within the previous week

Exclusion criteria

• History of epileptic seizures, epileptiform EEG findings, increased seizure risk, or use of antiepileptic medication
• Presence of implanted metallic or electronic devices (e.g., cardiac pacemaker, intrathecal baclofen pump)
• Pregnancy or lactation
• Presence of neurological disorders other than stroke
• History of cranial surgery
• Orthopedic conditions or previous orthopedic surgery limiting upper extremity movement
• Severe upper extremity spasticity (MAS >3) or presence of contracture
• Uncontrolled hypertension, advanced heart failure (NYHA Class III-IV), chronic obstructive pulmonary disease (COPD), active infection, severe hepatic failure, or severe renal failure
• History of malignancy
• Severe cognitive impairment (Mini-Mental State Examination score <24)
• Severe aphasia or communication disorder that would interfere with participation in the study
• Botulinum toxin injection administered to the upper extremity in a separate treatment session within the previous 3 months
• Any change in medication type or dosage within the previous month for oral medications used in the management of spasticity