Does a second course of low-frequency repetitive transcranial magnetic stimulation enhance neuroplasticity and motor function in children with hemiplegic cerebral palsy? Results of a prospective study

Background: Repetitive transcranial magnetic stimulation (rTMS) has emerged as a promising neuromodulation technique for enhancing motor recovery in children with hemiplegic cerebral palsy. However, long-term effects of repeated rTMS courses remain unclear, as existing studies have focused primarily on short-term outcomes following a single treatment course, with limited data on whether benefits decline, persist, or can be restored by a second course. Objective: To investigate the immediate and sustained neurophysiological and functional effects of two courses of low-frequency rTMS applied to the contralesional motor cortex in children with hemiplegic CP. Methods: Fifteen children (mean age 9.5 ± 2.8 years; GMFCS I-II, MACS I-II) received two courses of 1 Hz rTMS separated by 3 months. Each course consisted of 10 daily sessions at 90% resting motor threshold, targeting the contralesional motor cortex. Assessments at six time points included neurophysiological parameters (motor threshold MT; motor evoked potentials (MEP) latency and amplitude; cortical silent period, CSP) and functional tests (Finger Tapping, FT; Box and Blocks, BB; Melbourne Assessment, MA; Timed Up and Go, TUG; 1-Minute Walk Test, Berg Balance Scale, BBS). Results: < 0.001). Functional improvements consisted of 12% increase in FT and 8.5% in BB, 16% faster TUG, 16% greater 1-min walking distance, and 6.5% improved balance in BBS (all p < 0.001). During 3-month follow-up, effects gradually declined but remained significantly better than baseline. The second rTMS course produced similar magnitude improvements, restoring parameters to first-course post-treatment levels. No significant difference was found between neurophysiological and functional parameters 1 month after the first and 1 month after the second course, with the exception of progressive prolongation CSP. Conclusion: Repeated courses of low-frequency rTMS were associated with reproducible within-subject improvement in neurophysiological and functional measures in children with hemiplegic cerebral palsy. These effects appeared to partially decline over 3 months, and a second course was associated with restoration of treatment benefits without generating further major cumulative gains.