Dual-target, High-dose TMS for PD Patients With FOG

Dual-target, High-dose, Transcranial Magnetic Stimulation for Parkinson's Disease With Freezing of Gait

The aim of the current study was to verify whether high-dose TMS treatment of the motor and cognitive cortices is more effective in alleviating FOG than conventional-dose TMS of the motor cortex only. Specifically, investigator hypothesized that the effect of dual-target TMS on FOG is better than traditional stimulation of the motor cortex only, and the effect of high-dose TMS is better than conventional doses.

Study Overview

• Status: Terminated
• Conditions: Transcranial Magnetic Stimulation; Freezing of Gait
• Intervention / Treatment: Device: transcranial magnetic stimulation

Detailed Description

This was an open-label, randomized controlled study. Participants were randomized in a 1:1:1 fashion to receive dual-target, high-dose TMS (DHT), dual-target, conventional-dose TMS (DCT), and single-target, conventional-dose TMS (SCT). SCT was designated as the control group with protocol reference to evidence-based guidelines, while DHT and DCT served as the experimental groups.

DHT refers to the left primary motor cortex of the lower leg (M1) and dorsolateral prefrontal cortex (DLPFC) receiving 9000 pulses/day of intermittent TBS (iTBS) for 5 consecutive days. DCT refers to the left M1 and DLPFC receiving 1800 pulses/day of iTBS for 5 consecutive days. The order of stimulation for the two targets was randomized across participants and the order of stimulation within participants remained unchanged throughout the session. SCT refers to the left M1 receiving 1800 pulses/day of iTBS treatment for 5 consecutive days.

Motor and cognitive measures were performed ("on medication" state) 1 day before TMS (baseline), 1 day after completion of TMS (post), and 1 month after completion of TMS (follow-up). The primary outcome of this study was the change in FOGQ scores from baseline to follow-up. Secondary outcomes included changes in the Unified Parkinson's Disease Rating Scale Part III (UPDRS III), 5 m Timed Up-and-Go test (TUG), FOG-provoking test (Standing-Start 180° Turn Test, SS-180), Stroop color-naming (SCN), Stroop word-reading (SWR), Stroop color-word (SCW), and Color Trails Test interference index (CTTII) from baseline to follow-up.

Evaluate the patient's brain function and structural changes by collecting Rest-EEG，transcranial magnetic stimulation-EEG, near-infrared functional brain imaging (fNIRS）and fMRI.

TMS was performed using a Magstim Rapid2 transcranial magnetic stimulator (Magstim Company, Whitland, UK) with a 70-mm air-cooled figure-of-eight coil. All stimulations were guided by the participant's anatomical image (1 × 1 × 1 mm3) and a frameless neuronavigation system (Brainsight; Rogue Research, Montreal, QC, Canada).

Stimulation intensity: Because each participant had different sensitivity to TMS, the individual Resting Motor Threshold (RMT) was measured before intervention. Specifically, surface electrodes (Ag/AgCl) were attached to both ends of the right abductor pollicis muscle (the ground wire was connected to the ulnar styloid process) and the left finger motor cortex was stimulated one time. The motor-evoked potentials were recorded from the hand muscles. The RMT was considered when the evoked potential > 50 μV occurred in > 5 of 10 consecutive stimulations. The stimulation intensity during intervention was 80% of the RMT in the current study.

Stimulation sequence: Each iTBS sequence in the high-dose stimulation sequence released 900 pulses at a time with a pulse cluster repeated every 200 ms at a frequency of 5 Hz. Each pulse cluster contained three pulses with a frequency of 50 Hz, stimulation time of 2 s, and interval of 8 s. A total of 10 iTBS sessions was performed each day with an interval of 40 min and the daily stimulation dose was 9000 pulses. Each iTBS sequence in the conventional-dose stimulation sequence released 600 pulses at a time with a pulse cluster repeated every 200 ms at a frequency of 5 Hz. Each pulse cluster contained three pulses with a frequency of 50 Hz, stimulation time of 2 s, and interval of 8 s. A total of three iTBS sessions were performed each day with an interval of 40 min and the daily stimulation dose was 1800 pulses.

Stimulation targets: There were two stimulation targets in this study that were used to intervene in the motor and cognitive cortices. The stimulation target of the motor cortex is located in the lower leg of the left primary motor cortex in the Montreal Neurological Institute space (coordinates: -10, -24, 75 [https:/ /afni.nimh.nih.gov/MNI_Atlas]) based on structural MRI. The stimulation target of the cognitive cortex was the left dorsolateral prefrontal cortex, which has the strongest functional connectivity with the executive control network (see Supplementary materials), based on fMRI. Finally, targets were transformed into the native space for each participant by applying an inverse matrix produced during brain structure and function segmentation using SPM12 (www.fil.ion.ucl.ac.uk/spm) and TMStarget software.

• Study Type: Interventional
• Enrollment (Actual): 64
• Phase: Not Applicable

Contacts and Locations

Study Locations

• China
  • Anhui
    • Hefei, Anhui, China, 230032
      • Cognitive Neuropsychology Lab Anhui Medical University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 40 years to 85 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. diagnosis of FOG with expertise in movement disorders.
2. the score of item 3 of the FOG questionnaire ≥1.
3. ongoing treatment with a stable dose of any medication for 2 months.
4. 40 years of age or older.

Exclusion Criteria:

1. a history of addiction, psychiatric disorders, or neurological diseases other than PD.
2. focal brain lesions on T1-/T2-weighted fluid-attenuated inversion recovery images.
3. anti-PD medication adjustments during rTMS treatment.
4. history of substance abuse within the past 6 months.
5. nonremovable metal objects in or around the head.
6. previously received rTMS treatment.
7. prior history of seizure or history in first-degree relatives.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Dual-target high-dose TMS (DHT); DHT refers to the left primary motor cortex of the lower leg (M1) and dorsolateral prefrontal cortex (DLPFC) receiving 9000 pulses/day of intermittent TBS (iTBS) for 5 consecutive days. Each iTBS sequence in the high-dose stimulation sequence released 900 pulses at a time with a pulse cluster repeated every 200 ms at a frequency of 5 Hz. Each pulse cluster contained three pulses with a frequency of 50 Hz, stimulation time of 2 s, and interval of 8 s. A total of 10 iTBS sessions was performed each day with an interval of 40 min and the daily stimulation dose was 9000 pulses. The order of stimulation for the two targets was randomized across participants and the order of stimulation within participants remained unchanged throughout the session.	Device: transcranial magnetic stimulation; TMS was performed using a Magstim Rapid2 transcranial magnetic stimulator (Magstim Company, Whitland, UK) with a 70-mm air-cooled figure-of-eight coil. All stimulations were guided by a frameless neuronavigation system (Brainsight; Rogue Research, Montreal, QC, Canada).
Experimental: Dual-target conventional-dose TMS (DCT); DCT refers to the left M1 and DLPFC receiving 1800 pulses/day of iTBS for 5 consecutive days. Each iTBS sequence in the conventional-dose stimulation sequence released 600 pulses at a time with a pulse cluster repeated every 200 ms at a frequency of 5 Hz. Each pulse cluster contained three pulses with a frequency of 50 Hz, stimulation time of 2 s, and interval of 8 s. A total of three iTBS sessions were performed each day with an interval of 40 min and the daily stimulation dose was 1800 pulses.The order of stimulation for the two targets was randomized across participants and the order of stimulation within participants remained unchanged throughout the session.	Device: transcranial magnetic stimulation; TMS was performed using a Magstim Rapid2 transcranial magnetic stimulator (Magstim Company, Whitland, UK) with a 70-mm air-cooled figure-of-eight coil. All stimulations were guided by a frameless neuronavigation system (Brainsight; Rogue Research, Montreal, QC, Canada).
Active Comparator: Single-target conventional-dose TMS (SCT); SCT refers to the left M1 receiving 1800 pulses/day of iTBS treatment for 5 consecutive days. Each iTBS sequence in the conventional-dose stimulation sequence released 600 pulses at a time with a pulse cluster repeated every 200 ms at a frequency of 5 Hz. Each pulse cluster contained three pulses with a frequency of 50 Hz, stimulation time of 2 s, and interval of 8 s. A total of three iTBS sessions were performed each day with an interval of 40 min and the daily stimulation dose was 1800 pulses.	Device: transcranial magnetic stimulation; TMS was performed using a Magstim Rapid2 transcranial magnetic stimulator (Magstim Company, Whitland, UK) with a 70-mm air-cooled figure-of-eight coil. All stimulations were guided by a frameless neuronavigation system (Brainsight; Rogue Research, Montreal, QC, Canada).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The Freezing of Gait Questionnaire (FOGQ) scores	This is an very common clinical motor estimating scale for evaluating FOG. 6 items and each item scored between 0 and 4 points (24 scores in total). Higher scores mean a worse outcome	the changes in FOGQ scores from baseline to 1 month after completion of TMS (follow-up).

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The timed up and go test (TUG)	The participants walk for a distance of five meters from a sitting position and come back to the chair after turning 180° around a traffic cone in a 0.7 m × 0.7 m target box .The time during the whole course are measured. The time is recorded in seconds, and the longer the time, the more severe the symptoms.The longer it takes, the worse it gets	changes from baseline to 1 month after completion of TMS (follow-up).
Unified Parkinson's Disease Rating Scale III (UPDRSIII) scores	This is an very common clinical motor estimating scale, 14 items and 108' in total. Higher scores indicate worse symptoms. Higher scores mean a worse outcome.	changes from baseline to 1 month after completion of TMS (follow-up).
Stroop test	stroop color word test is generally divided into three parts: (1) Quick naming of color dot plots (SCN); (2) Recite the nouns representing the color names quickly (SWR); (3) Present a set of cards, in which the nouns representing the color names are written on the cards in different colors, and check the ability of the subjects to distinguish between the color names and the actual colors, as well as the ability to recite the nouns representing the color names quickly (SCW). The degree to which subjects were influenced by font color as an indicator (SCW) of their cognitive control. The longer it takes, the worse it gets.	changes (SCN, SWR, SCW) from baseline to 1 month after completion of TMS (follow-up).
Color Trails Test interference index (CTTII)	The number color connection test was divided into two parts, A and B. Part A asked the subjects to connect 25 numbers on the paper in order. In Part B, numbers and letters were replaced by numbers of two different colors to eliminate the influence of culture on the test. When the subjects were asked to connect numbers in order, the two graphs were arranged alternately. The measurement index was time, and the longer the time, the more obvious the decline in prompt ability. CTTII=CTT(part B)-CTT(part A). The longer it takes, the worse it gets.	changes rom baseline to 1 month after completion of TMS (follow-up).
The Standing-Start 180° Turn Test (SS-180)	The participants walk for a distance of five meters from a sitting position and come back to the chair after turning 180° around a traffic cone in a 0.7 m × 0.7 m target box.The time during the 180° turn (SS180) are measured. The time is recorded in seconds, and the longer the time, the more severe the symptoms. The longer it takes, the worse it gets.	changes from baseline to 1 month after completion of TMS (follow-up).

Collaborators and Investigators

• Sponsor: Anhui Medical University
• Investigators: Principal Investigator: Kai Wang, Ph.D., Anhui Medical University

Study record dates

Study Major Dates

• Study Start (Actual): December 22, 2022
• Primary Completion (Actual): February 25, 2024
• Study Completion (Actual): March 31, 2024

Study Registration Dates

• First Submitted: June 29, 2022
• First Submitted That Met QC Criteria: November 14, 2022
• First Posted (Actual): November 22, 2022

Study Record Updates

• Last Update Posted (Estimated): November 19, 2025
• Last Update Submitted That Met QC Criteria: November 17, 2025
• Last Verified: April 1, 2024

More Information

Terms related to this study

• Keywords: Transcranial Magnetic Stimulation; Freezing of Gait
• Additional Relevant MeSH Terms: Therapeutics; Magnetic Field Therapy; Transcranial Magnetic Stimulation
• Other Study ID Numbers: AHMU-TMS-FOG-twotargets

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No