Identification of Optimal Stimulation Site for Cervical Dystonia Symptoms: An Exploratory Study

We propose using repetitive transcranial magnetic stimulation (rTMS) over distinct premotor
areas in patients with cervical dystonia (CD) with the goal of improving symptoms and
reducing unwanted side effects. The knowledge gained in this proposed research will
identify a specific premotor area to be targeted with rTMS that is expected to result in a
novel intervention that could enhance or replace current treatments for CD. rTMS could be
included as an adjunct treatment to botulinum toxin that could sustain treatment effect and
decrease the frequency of re-injection, potentially resulting in cost savings without a
decrease in symptom control. In addition to medical cost reduction, improved quality of life
could be expected with the successful development of therapies that extend dystonia symptom
control. rTMs has been FDA-approved for the treatment of depression and our proposal uses an
even lower stimulation rate, suggesting continued use within clearly safe parameters.
Successful completion of this research could lead to rapid adoption of this therapeutic
modality.

We will test the hypothesis that rTMS of a distinct premotor site will provide more
effective treatment of CD than non-specific activation of the entire premotor region. This
will be done by performing a randomized, observer-blinded exploratory pilot study to
determine the optimal site of rTMS over various sites of the premotor and motor cortex to
improve the symptoms of cervical dystonia. Completion of this aim should lead to
development of targeted TMS therapy for CD.

Inclusion Criteria:

- Clinical diagnosis of idiopathic cervical dystonia

- Age 18 years or older

- Normal findings in the medical history, physical and neurological examination, except
for dystonia

- Last treatment with botulinum toxin more than two months ago

Exclusion Criteria:

- History of seizure disorder

- Pregnancy- a pregnancy test will be performed for women of childbearing potential

- History of any other neurological disorders or conditions requiring the use of
anti-depressants that are known to increase seizure threshold, neuroleptic
medication, anticholinergic drugs and muscle relaxants

- History of neuroleptic medications/ prior use of neuroleptics