Objective: To determine whether repetitive transcranial magnetic stimulation (rTMS) of anterior cingulate cortex (ACC) when added to botulinum toxin (BoNT) therapy improves benign essential blepharospasm (BEB) symptoms.

Background: BEB is a disabling focal dystonia commonly treated with BoNT therapy. However BoNT outcomes are suboptimal in many patients and may wear off earlier than the expected time frame of 12 weeks. Previous research found modulation of ACC excitability with rTMS therapy alleviated BEB symptoms.

Methods: Twelve patients with BEB participated in a randomized, sham-controlled study with blinded clinical assessments (six in each arm). These patients received 0.2 Hz rTMS over the ACC using a double cone TMS coil. rTMS was initiated about four to six weeks-after BoNT injections (BoNT_peak benefits) and delivered for two weeks. The primary outcome was physician-rated videos and patient-rated BEB frequency and severity score on Jankovic rating scale (JRS) and craniocervical dystonia quality-of-life (QOL) questionnaire. The secondary outcome was the change in blink reflex recovery (BRR) curve. These were measured before rTMS therapy (T0), two weeks-after (T1) and prior to the next BoNT injections (T2, BoNT_trough). Age and gender matched healthy controls were enrolled for normative BRR data.

Results: All patients tolerated the therapy well. There were three males and nine females in the study (mean age ± standard deviation 69.1 ± 7.1; age range 57-79 years). In the patient-rated outcomes, there were significant improvements in the real arm at T1 when compared to T0. The JRS frequency improved by 48% (p = 0.04), BEB severity by 46% (p = 0.02) and QOL by 46% (p = 0.002). In the physician-rated videos, only the forced blinks improved by 56% (p = 0.04) at T1. However none of the rTMS related benefits remained sustained at T2. The BRR revealed an increased excitability in the BEB group compared to healthy controls. rTMS therapy did not induce any significant change in the BRR curve.

Conclusions: rTMS has a potential to be used as an add-on treatment in BEB to enhance benefits related to BoNT therapy. A larger follow-up study is required for further confirmation.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/combined-effects-of-rtms-and-botulinum-toxin-therapy-in-benign-essential-blepharospasm/