Transcranial magnetic stimulation as a primer for rapid improvement in functional neurological disorder: a case series.

Background: Functional weakness is common, and the prognosis can be poor without treatment. Transcranial magnetic stimulation (TMS) and specialist physiotherapy have each been trialled separately as interventions for functional weakness. We tested a novel approach for treating functional weakness and gait disorder using TMS as a primer before specialist physiotherapy. Methods: Single-pulse TMS, therapeutic education and limb pressure feedback were used as a primer for immediate specialist physiotherapy. TMS-primed physiotherapy was used for the first time in three consecutive patients with functional limb weakness and immobility. Results: Two women and one man (aged 30-55 years) with severe functional limb weakness such that they were unable to stand or walk independently, with symptom duration between 3 weeks and 7 years, were studied. All three had a rapid return of voluntary limb movement and achieved unassisted walking within a few hours of a single TMS-primed physiotherapy session. Treatment was well-tolerated, and outcomes were sustained at follow-up. Conclusions: These cases provide preliminary evidence supporting the efficacy of this approach, which may be further developed with future research. They also illustrate a practical approach for treating a clinically challenging population with severe functional weakness.