Cerebral palsy¹ (CP) is one of the most common disabling disorders in children and is a group of persistent syndromes caused by non-progressive brain damage in developing fetuses and infants, including central dyskinesia, abnormal posture, and limited mobility. Currently, there are approximately 17 million children worldwide affected by cerebral palsy², with over 5 million cases in China. Among various forms of cerebral palsy, spastic cerebral palsy (SCP) accounts for roughly 80%³. Children with SCP suffer from brain damage resulting in muscle spasms, diminished sensory function, impaired muscle coordination, and decreased balance capabilities, all of which hinder independent walking and daily activities. Current rehabilitation measures for enhancing gross motor function in children with SCP encompass activities such as core stability training⁴, task-oriented training⁵, constraint-induced movement therapy⁶, and mirror visual feedback therapy⁷. These measures can improve clinical symptoms of children by regulating and reshaping the central nervous system from bottom to top by improving the functions of peripheral organs.

Transcranial magnetic stimulation (TMS)⁸^,⁹ is a painless, non-invasive, and safe therapeutic method. rTMS refers to the continuous release of stimuli at equal intervals after a single command, which is one of the regular repetitive stimulation patterns. Based on the principle of electromagnetic induction and electromagnetic conversion, it applies transient currents through stimulation coils to form a pulsed magnetic field to penetrate the skull, generate induction current to stimulate neurons and trigger a series of physiological and biochemical responses. rTMS has been applied to the monitoring, evaluation, and treatment of neurological diseases, providing a novel approach to exploring the structure and function of the brain¹⁰. Existing studies¹¹^,¹² have shown that rTMS has varying therapeutic effects on limb spasms and motor function in children with CP. Moreover, the effect of rTMS treatment combined with other rehabilitation techniques is more noticeable.

AOT is a rehabilitation method that utilizes the Mirror Neuron System (MNS) to establish motor learning and memory¹³^,¹⁴. The essence of AOT is to make the observer carefully observe actions in the video and subsequently try their best to imitate what they observed. The observing process might trigger activation in the neural network known as MNS, akin to the activation that occurs when one is personally engaged in executing those actions¹⁵, which provides a neurophysiological basis for AOT. AOT has shown success in improving motor skills in patients with movement disorders, yielding positive outcomes in stroke recovery and rehabilitation of upper limb motor function in cerebral palsy patients¹⁶^,¹⁷.

Our previous studies have found that AOT based on the mirror neuron system could effectively improve the balance and walking ability of children with cerebral palsy¹⁸. In addition, studies¹⁹ have shown that rTMS can improve muscle spasticity, movement, and gait in children with SCP, but treatment standards of rTMS applied to children with cerebral palsy have not been unified, and it is an urgent problem to explore the influence of different parameters of rTMS on children with CP, to provide a personalized and precise treatment standard. We believe that combining rTMS with AOT has the potential to develop into a valuable physical therapy strategy for the neurological rehabilitation of cerebral palsy. Both rTMS and AOT stimulated the cerebral cortex in children with SCP²⁰, thereby aiding gross motor function development. This study aimed to find out whether the combination of rTMS and AOT could achieve a greater synergistic effect than conventional treatment or rTMS or AOT alone.

Repeated Transcranial Magnetic Stimulation with Action Observation Training for Rehabilitation of Children with Spastic Cerebral Palsy