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Brys M, Fox MD, Agarwal S, Biagioni M, Dacpano G, Kumar P, Pirraglia E, Chen R, Wu A, Fernandez H, Wagle Shukla A, Lou JS, Gray Z, Simon DK, Di Rocco A, Pascual-Leone A. Multifocal repetitive TMS for motor and mood symptoms of Parkinson disease: A randomized trial. Neurology 2016; 87:1907-1915. [PMID: 27708129 DOI: 10.1212/wnl.0000000000003279] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 07/14/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess whether multifocal, high-frequency repetitive transcranial magnetic stimulation (rTMS) of motor and prefrontal cortex benefits motor and mood symptoms in patients with Parkinson disease (PD). METHODS Patients with PD and depression were enrolled in this multicenter, double-blind, sham-controlled, parallel-group study of real or realistic (electric) sham rTMS. Patients were randomized to 1 of 4 groups: bilateral M1 ( + sham dorsolateral prefrontal cortex [DLPFC]), DLPFC ( + sham M1), M1 + DLPFC, or double sham. The TMS course consisted of 10 daily sessions of 2,000 stimuli for the left DLPFC and 1,000 stimuli for each M1 (50 × 4-second trains of 40 stimuli at 10 Hz). Patients were evaluated at baseline, at 1 week, and at 1, 3, and 6 months after treatment. Primary endpoints were changes in motor function assessed with the Unified Parkinson's Disease Rating Scale-III and in mood with the Hamilton Depression Rating Scale at 1 month. RESULTS Of the 160 patients planned for recruitment, 85 were screened, 61 were randomized, and 50 completed all study visits. Real M1 rTMS resulted in greater improvement in motor function than sham at the primary endpoint (p < 0.05). There was no improvement in mood in the DLPFC group compared to the double-sham group, as well as no benefit to combining M1 and DLPFC stimulation for either motor or mood symptoms. CONCLUSIONS In patients with PD with depression, M1 rTMS is an effective treatment of motor symptoms, while mood benefit after 2 weeks of DLPFC rTMS is not better than sham. Targeting both M1 and DLPFC in each rTMS session showed no evidence of synergistic effects. CLINICALTRIALSGOV IDENTIFIER NCT01080794. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that in patients with PD with depression, M1 rTMS leads to improvement in motor function while DLPFC rTMS does not lead to improvement in depression compared to sham rTMS.
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Affiliation(s)
- Miroslaw Brys
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Michael D Fox
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Shashank Agarwal
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Milton Biagioni
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Geraldine Dacpano
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Pawan Kumar
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Elizabeth Pirraglia
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Robert Chen
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Allan Wu
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Hubert Fernandez
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Aparna Wagle Shukla
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Jau-Shin Lou
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Zachary Gray
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - David K Simon
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Alessandro Di Rocco
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY
| | - Alvaro Pascual-Leone
- From the New York University School of Medicine (M.B., S.A., M.B., G.D., P.K., A.D.R.), Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, New York; Berenson-Allen Center for Noninvasive Brain Stimulation (M.D.F., Z.G., A.P.-L.), Division of Cognitive Neurology, and Parkinson's Disease and Movement Disorders Center (D.K.S., A.P.-L.), Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA; Department of Neurology (A.W.) and Ahmanson-Lovelace Brain Mapping Center (A.W.), University of California School of Medicine, Los Angeles; Cleveland Clinic (H.F.), Department of Neurology, OH; Toronto Western Research Institute (R.C.), University of Toronto, Ontario, Canada; University of Florida (A.W.S.), Department of Neurology, Gainesville; University of North Dakota School of Medicine (J.-S.L.), Department of Neurology, Grand Forks; and Center for Brain Health (E.P.), NYU School of Medicine, New York, NY.
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