Brys Miroslaw, Fox Michael D, Agarwal Shashank, Biagioni Milton, Dacpano Geraldine, Kumar Pawan, Pirraglia Elizabeth, Chen Robert, Wu Allan, Fernandez Hubert, Wagle Shukla Aparna, Lou Jau-Shin, Gray Zachary, Simon David K, Di Rocco Alessandro, Pascual-Leone Alvaro
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.
Neurology. 2016 Nov 1;87(18):1907-1915. doi: 10.1212/WNL.0000000000003279. Epub 2016 Oct 5.
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).
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.
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.
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.
NCT01080794.
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.
评估对运动皮层和前额叶皮层进行多焦点、高频重复经颅磁刺激（rTMS）是否有益于帕金森病（PD）患者的运动和情绪症状。
患有PD和抑郁症的患者参与了这项多中心、双盲、假刺激对照、平行组的真实或逼真（电）假刺激rTMS研究。患者被随机分为4组中的1组：双侧M1（+假刺激背外侧前额叶皮层[DLPFC]）、DLPFC（+假刺激M1）、M1+DLPFC或双假刺激。TMS疗程包括每天对左侧DLPFC进行10次，每次2000次刺激，对每个M1进行1000次刺激（以10Hz的频率进行50次4秒的40次刺激序列）。在基线、1周时以及治疗后第1、3和6个月对患者进行评估。主要终点是在1个月时用统一帕金森病评定量表-III评估的运动功能变化以及用汉密尔顿抑郁评定量表评估的情绪变化。
在计划招募的160名患者中，85名接受了筛查，61名被随机分组，50名完成了所有研究访视。在主要终点时，真实的M1 rTMS比假刺激在运动功能改善方面效果更显著（p<0.05）。与双假刺激组相比，DLPFC组的情绪没有改善；同时，联合M1和DLPFC刺激对运动或情绪症状均无益处。
在患有抑郁症的PD患者中，M1 rTMS是治疗运动症状的有效方法，而DLPFC rTMS治疗2周后的情绪改善并不优于假刺激。在每次rTMS治疗中同时针对M1和DLPFC未显示出协同作用的证据。
NCT01080794。
本研究提供了I级证据，即在患有抑郁症的PD患者中，与假刺激rTMS相比，M1 rTMS可改善运动功能，而DLPFC rTMS不能改善抑郁症状。
