Effects of rTSMS Associated With Treadmill Training in Patients With Parkinson's Disease

NCT05938673 | Completed

• 1 other identifier: 57119022.4.1001.0068
• Study Type: interventional
• Target: 76
• Locations: 1 country
• Sites: 1

Brief Summary

Gait changes appear and become the main cause of disability, loss of independence, falls, fractures and reduced quality of life for patients with Parkinson Disease. Optimal gait management is complex and challenging. Some characteristics, such as gait variability, postural instability, and postural changes, continue to worsen over time despite optimal dopaminergic treatment, suggesting that additional interventions are needed. Given the physiology of gait and postural control in humans, spinal cord stimulation is a potential target for neuromodulatory approaches to gait and postural disorders. Repetitive transspinal magnetic stimulation ( rTSMS) has attracted a lot of attention, due to the possibility of modulating motor and sensory networks in a non-invasive way, activating directly the dorsal ascending pathways and projecting to the thalamic nuclei, cerebral cortex, and brainstem nuclei, thus stimulating descending motor tracts and interrupting aberrant oscillatory activity in corticobasal nuclei circuits. The combination of non-invasive neuromodulation with other therapies can enhance the effectiveness of rehabilitation, increasing plasticity and clinical efficacy, offering a greater and more sustained effect than either therapy alone.It's recommended that patients with PD perform a specific exercise for walking, such as treadmill training (tt), that imposes an external rhythm and concentration of attention on gait, acting as an external cue or marker, promoting a more stable gait, reducing gait variability and decreasing risk of falls. It is proposed, in this study, to develop a new treatment model through the integration of two promising and complementary approaches to improve gait disorders in PD: rTSMS and tt. Thus, the investigators idealized the realization of the first randomized, double-blind, placebo-controlled, parallel, phase III clinical trial that will evaluate the efficacy of tt associated with rTSMS in patients with PD.

Conditions

Parkinson Disease; Gait Disorders, Neurologic

Keywords

Non-invasive brain stimulation; Parkinson's disease; Spinal cord stimulation; gait

Outcome Measures

Primary Outcomes (1)

• 10 meter walk test- Fast walking speed

  Comparison of the change in fast gait speed between active stimulation and sham stimulation during Baseline, right after the end of the 10th session and follow-up (1 month and 3 months post-intervention). Longer time to complete the test results in slower gait speed and worse performance

  4 months

Secondary Outcomes (16)

• 10 meter walk test- Confortable walking speed

  4 months

• Unified Parkinson's Disease Rating Scale (MDS-UPDRS) - Part II and III

  4 months

• Freezing of Gait Score- (FOG- SCORE)

  4 months

• 2 Minute Walk Test

  4 months

• Timed up and Go (TUG)

  4 months

Study Arms (2)

Sham repetitive transpinal magnetic stimulation

SHAM COMPARATOR

In the Sham group a coil will be positioned in the T2-T3 thoracic region disconnected to the stimulation device and the active coil will be positioned about 15 cm behind the patient, away from his field of vision, to provide sound stimulus.

Other: Sham stimulation

Active repetitive transpinal magnetic stimulation

ACTIVE COMPARATOR

In the Active group, the patient will receive intermittent theta burst stimulation (iTBS) in the T2-T3 region while seated using a circular magnetic coil positioned at 90º, handle facing to the right, connected to a magnetic stimulator.

Other: Active stimulation- intermittent theta-burst (iTBS) stimulation

Interventions

Active stimulation- intermittent theta-burst (iTBS) stimulation OTHER

During active stimulation, patients will receive intermittent theta-burst (iTBS) stimulation in T2-T3 toracic region while seated using a circular magnetic coil positioned at 90º, handle facing to the right, connected to a magnetic stimulator.Each participant will receive a total of 1,200 rTsMS pulses at 120% of resting motor threshold, determined by abdominal muscle contractions. In 3 minutes and 58 seconds, 20 trains with 20 bursts and each burst with 3 pulses at 50 Hz repeated at 5Hz with an intertrain interval of 8 seconds will be applied.Immediately after, participants will proceed with 30 minutes of treadmill training, starting at 80% of the comfortable walking speed. Progressive speed increments of 0.2 km/h will be performed every 5 minutes as tolerated. The intensity of the exercise will be adjusted to the patient's tolerance and maintained between light to moderate intensity.

Active repetitive transpinal magnetic stimulation

Sham stimulation OTHER

During sham stimulation, a circular magnetic coil will be positioned in the T2-T3 toracic region disconnected to the stimulation device and the active coil will be positioned about 15 cm behind the patient, away from his field of vision, to provide sound stimulus. To create a sensation of muscle contraction and impression of active stimulation, the group will be submitted to the sensory effect of transcutaneous electrical neurostimulation (TENS) for 5 minutes, with surface electrodes placed in parallel at the T2-T3, with the parameters (80Hz,150ms, 60 mA).Immediately after, participants will proceed with 30 minutes of treadmill training, starting at 80% of the comfortable walking speed. Progressive speed increments of 0.2 km/h will be performed every 5 minutes as tolerated. The intensity of the exercise will be adjusted to the patient's tolerance and maintained between light to moderate intensity.

Sham repetitive transpinal magnetic stimulation

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Men and women over the age of 18;
• Participants with PD at Hoehn Yahr stages between 2 and 4 (moderate disease) while on-medication (i.e., at the time when their usual dopaminergic medication is clinically effective), whose primary symptom includes gait disturbance (score equal to or greater than 1 in subitem 2.12 of the MSD-UPDRS scale). Patients will be evaluated for the presence of freezing gait (freezing) through the Freezing of Gait Score (FOG-SCORE).
• While on on-medication, be able to walk independently for 30 meters or with a unilateral assistive device.
• Mini Mental State Examination (MMSE) score greater than or equal to 23.
• Sign the informed consent form.

You may not qualify if:

• Patients with unstabilized psychiatric comorbidities;
• Individuals who have other neurological disorders, musculoskeletal, orthopedic, cardiovascular and respiratory disorders that may affect the ability to walk on the treadmill will be excluded.
• Individuals with labyrinthine problems, using medication that may interfere with balance and performance in tests and treadmill training will be excluded.
• Individuals who have undergone deep brain stimulation surgery or epidural spinal cord stimulation will be excluded.
• Patients with uncontrolled infection or other uncontrolled pre-existing medical conditions (eg uncontrolled diabetes, high blood pressure, symptomatic lung or heart disease);
• Concomitant treatment with other experimental drugs;
• Pregnant or breastfeeding women.
• Presence of chronic low back and lower limb pain.
• Patients who cannot walk without assistance (cane, crutch, walker) or help from another person.
• Patients with metal implants and a cardiac pacemaker.
• Patient with a history of neurosurgery.

Sponsors & Collaborators

• University of Sao Paulo General Hospital: lead

Study Sites (1)

Hospital das Clínicas da Faculdade de Medicina da USP

São Paulo, São Paulo, 05403000, Brazil

Location

Related Publications (15)

• Arii Y, Sawada Y, Kawamura K, Miyake S, Taichi Y, Izumi Y, Kuroda Y, Inui T, Kaji R, Mitsui T. Immediate effect of spinal magnetic stimulation on camptocormia in Parkinson's disease. J Neurol Neurosurg Psychiatry. 2014 Nov;85(11):1221-6. doi: 10.1136/jnnp-2014-307651. Epub 2014 Apr 29.

  PMID: 24780955 BACKGROUND

• Chung CL, Mak MK, Hallett M. Transcranial Magnetic Stimulation Promotes Gait Training in Parkinson Disease. Ann Neurol. 2020 Nov;88(5):933-945. doi: 10.1002/ana.25881. Epub 2020 Sep 8.

  PMID: 32827221 BACKGROUND

• de Andrade EM, Ghilardi MG, Cury RG, Barbosa ER, Fuentes R, Teixeira MJ, Fonoff ET. Spinal cord stimulation for Parkinson's disease: a systematic review. Neurosurg Rev. 2016 Jan;39(1):27-35; discussion 35. doi: 10.1007/s10143-015-0651-1. Epub 2015 Jul 30.

  PMID: 26219854 BACKGROUND

• Fuentes R, Petersson P, Siesser WB, Caron MG, Nicolelis MA. Spinal cord stimulation restores locomotion in animal models of Parkinson's disease. Science. 2009 Mar 20;323(5921):1578-82. doi: 10.1126/science.1164901.

  PMID: 19299613 BACKGROUND

• Reis Menezes J, Bernhart Carra R, Aline Nunes G, da Silva Simoes J, Jacobsen Teixeira M, Paiva Duarte K, Ciampi de Andrade D, Barbosa ER, Antonio Marcolin M, Cury RG. Transcutaneous magnetic spinal cord stimulation for freezing of gait in Parkinson's disease. J Clin Neurosci. 2020 Nov;81:306-309. doi: 10.1016/j.jocn.2020.10.001. Epub 2020 Oct 20.

  PMID: 33222935 BACKGROUND

• Takakusaki K. Neurophysiology of gait: from the spinal cord to the frontal lobe. Mov Disord. 2013 Sep 15;28(11):1483-91. doi: 10.1002/mds.25669.

  PMID: 24132836 BACKGROUND

• Yadav AP, Nicolelis MAL. Electrical stimulation of the dorsal columns of the spinal cord for Parkinson's disease. Mov Disord. 2017 Jun;32(6):820-832. doi: 10.1002/mds.27033. Epub 2017 May 12.

  PMID: 28497877 BACKGROUND

• Yang YR, Tseng CY, Chiou SY, Liao KK, Cheng SJ, Lai KL, Wang RY. Combination of rTMS and treadmill training modulates corticomotor inhibition and improves walking in Parkinson disease: a randomized trial. Neurorehabil Neural Repair. 2013 Jan;27(1):79-86. doi: 10.1177/1545968312451915. Epub 2012 Jul 10.

  PMID: 22785003 BACKGROUND

• Agari T, Date I. Spinal cord stimulation for the treatment of abnormal posture and gait disorder in patients with Parkinson's disease. Neurol Med Chir (Tokyo). 2012;52(7):470-4. doi: 10.2176/nmc.52.470.

  PMID: 22850494 BACKGROUND

• Fenelon G, Goujon C, Gurruchaga JM, Cesaro P, Jarraya B, Palfi S, Lefaucheur JP. Spinal cord stimulation for chronic pain improved motor function in a patient with Parkinson's disease. Parkinsonism Relat Disord. 2012 Feb;18(2):213-4. doi: 10.1016/j.parkreldis.2011.07.015. Epub 2011 Aug 23. No abstract available.

  PMID: 21865071 BACKGROUND

• Santana MB, Halje P, Simplicio H, Richter U, Freire MAM, Petersson P, Fuentes R, Nicolelis MAL. Spinal cord stimulation alleviates motor deficits in a primate model of Parkinson disease. Neuron. 2014 Nov 19;84(4):716-722. doi: 10.1016/j.neuron.2014.08.061. Epub 2014 Oct 30.

  PMID: 25447740 BACKGROUND

• Pinto de Souza C, Hamani C, Oliveira Souza C, Lopez Contreras WO, Dos Santos Ghilardi MG, Cury RG, Reis Barbosa E, Jacobsen Teixeira M, Talamoni Fonoff E. Spinal cord stimulation improves gait in patients with Parkinson's disease previously treated with deep brain stimulation. Mov Disord. 2017 Feb;32(2):278-282. doi: 10.1002/mds.26850. Epub 2016 Nov 10.

  PMID: 27862267 BACKGROUND

• Samotus O, Parrent A, Jog M. Spinal Cord Stimulation Therapy for Gait Dysfunction in Advanced Parkinson's Disease Patients. Mov Disord. 2018 May;33(5):783-792. doi: 10.1002/mds.27299. Epub 2018 Feb 14.

  PMID: 29442369 BACKGROUND

• de Lima-Pardini AC, Coelho DB, Souza CP, Souza CO, Ghilardi MGDS, Garcia T, Voos M, Milosevic M, Hamani C, Teixeira LA, Fonoff ET. Effects of spinal cord stimulation on postural control in Parkinson's disease patients with freezing of gait. Elife. 2018 Aug 2;7:e37727. doi: 10.7554/eLife.37727.

  PMID: 30070204 BACKGROUND

• Mitsui T, Arii Y, Taniguchi K, Tsutsumi S, Takahara M, Mabuchi M, Sumitomo N, Matsuura M, Kuroda Y. Efficacy of Repetitive Trans-spinal Magnetic Stimulation for Patients with Parkinson's Disease: a Randomised Controlled Trial. Neurotherapeutics. 2022 Jul;19(4):1273-1282. doi: 10.1007/s13311-022-01213-y. Epub 2022 Jun 27.

  PMID: 35759108 BACKGROUND

MeSH Terms

Conditions

Parkinson Disease; Gait Disorders, Neurologic

Condition Hierarchy (Ancestors)

Parkinsonian Disorders; Basal Ganglia Diseases; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Movement Disorders; Synucleinopathies; Neurodegenerative Diseases; Neurologic Manifestations; Signs and Symptoms; Pathological Conditions, Signs and Symptoms

Study Officials

• Rubens G Cury, MD PHD

  Hospital das Clínicas da Faculdade de Medicina da USP

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: DOUBLE
• Who Masked: PARTICIPANT, OUTCOMES ASSESSOR
• Masking Details: Patients and examiners will be blinded to stimulation status
• Purpose: TREATMENT
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Model Details: randomized, double-blind, placebo-controlled, parallel, phase III clinical trial.

Study Record Dates

• First Submitted: June 2, 2023
• First Posted: July 10, 2023
• Study Start: June 1, 2023
• Primary Completion: June 1, 2023
• Study Completion: January 1, 2025
• Last Updated: March 2, 2026

Record last verified: 2023-05

Data Sharing

• IPD Sharing: Will not share

Locations

BR (1)