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Meta-Analysis
. 2018 Nov;8(11):e01132.
doi: 10.1002/brb3.1132. Epub 2018 Sep 28.

Repetitive transcranial magnetic stimulation therapy for motor recovery in Parkinson's disease: A Meta-analysis

Changxia Yang  1   2 , Zhiwei Guo  1 , Haitao Peng  1 , Guoqiang Xing  1   3 , Huaping Chen  1 , Morgan A McClure  1 , Bin He  1 , Lin He  1 , Fei Du  4 , Liangwen Xiong  5 , Qiwen Mu  1   6
Affiliations
Meta-Analysis

Repetitive transcranial magnetic stimulation therapy for motor recovery in Parkinson's disease: A Meta-analysis

Changxia Yang et al. Brain Behav. 2018 Nov.

Abstract

Introduction: Therapeutic effects of repetitive transcranial magnetic stimulation (rTMS) on motor recovery of Parkinson's disease (PD) have been reported; however, the protocols of these studies varied greatly. The aim of this meta-analysis was to evaluate the optimal rTMS parameters for motor recovery of PD.

Methods: Electronic databases were searched for studies investigating the therapeutic effects of rTMS on motor function in patients with PD. The section III of the Unified Parkinson's Disease Rating Scale (UPDRS) was extracted as the primary outcome, and the standardized mean difference (SMD) with 95% confidence interval (CI) was calculated.

Results: Twenty-three studies with a total of 646 participants were included. The pooled estimates of rTMS revealed significant short-term (SMD, 0.37; p < 0.00001) and long-term (SMD, 0.39; p = 0.005) effects on motor function improvement of PD. Subgroup analysis observed that high-frequency rTMS (HF-rTMS) was significant in improving motor function (SMD, 0.48; p < 0.00001), but low-frequency rTMS (LF-rTMS) was not. In particular, when HF-rTMS targeted over the primary motor cortex (M1), in which the bilateral M1 revealed a larger effect size than unilateral M1. Compared to single-session, multi-session of HF-rTMS over the M1 showed significant effect size. In addition, HF-rTMS over the M1 with a total of 18,000-20,000 stimulation pulses yielded more significant effects (SMD, 0.97; p = 0.01) than other dosages.

Conclusions: In conclusion, multi-session of HF-rTMS over the M1 (especially bilateral M1) with a total of 18,000-20,000 pulses appears to be the optimal parameters for motor improvement of PD.

Keywords: Parkinson's disease; meta-analysis; motor function; repetitive transcranial magnetic stimulation.

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Figures

Figure 1
Figure 1
Flow diagram of literature search
Figure 2
Figure 2
Forest plot from the meta‐analysis of rTMS on UPDRS‐III scores at short‐term showing estimates of mean effect size with 95% confidence interval (95% CI). Studies denoted as “on” or “off” distinguish those with assessment done both in “on” and “off” medication state
Figure 3
Figure 3
Forest plot of rTMS on UPDRS‐III scores measured during “on” and “off” medication state showing estimates of mean effect size with 95% confidence interval (95% CI). Studies denoted as “on” or “off” distinguish those with assessment done both in “on” and “off” medication state
Figure 4
Figure 4
Forest plots of rTMS on UPDRS‐III scores for studies comparing high‐frequency and low‐frequency rTMS protocol showing estimates of mean effect size with 95% confidence interval (95% CI). Studies denoted as “on” or “off” distinguish those with assessment done both in “on” and “off” medication state
Figure 5
Figure 5
Forest plots of rTMS on UPDRS‐III scores for studies comparing the stimulation site of primary motor cortex (M1), supplementary motor area (SMA), dorsal lateral prefrontal cortex (DLPFC), the other regions and complex region (M1 +  DLPFC) showing estimates of mean effect size with 95% confidence interval (95% CI). Studies denoted as “on” or “off” distinguish those with assessment done both in “on” and “off” medication state
Figure 6
Figure 6
The interaction between high‐frequency rTMS and stimulation site of rTMS on UPDRS‐III scores showing estimates of mean effect size with 95% confidence interval (95% CI). Studies denoted as “on” or “off” distinguish those with assessment done both in “on” and “off” medication state
Figure 7
Figure 7
Forest plots of HF‐rTMS over M1 on UPDRS‐III scores for studies comparing the bilateral vs unilateral stimulation of rTMS protocol showing estimates of mean effect size with 95% confidence interval (95% CI). Studies denoted as “on” or “off” distinguish those with assessment done both in “on” and “off” medication state
Figure 8
Figure 8
Forest plots of HF‐rTMS over M1 on UPDRS‐III scores for studies comparing the single‐ and multi‐session of rTMS protocol showing estimates of mean effect size with 95% confidence interval (95% CI). Studies denoted as “on” or “off” distinguish those with assessment done both in “on” and “off” medication state
Figure 9
Figure 9
Forest plots of HF‐rTMS over M1 on UPDRS‐III scores for studies comparing the different total pulses of rTMS protocol showing estimates of mean effect size with 95% confidence interval (95% CI). Studies denoted as “on” or “off” distinguish those with assessment done both in “on” and “off” medication state
Figure 10
Figure 10
Forest plot from the meta‐analysis of rTMS on UPDRS‐III scores at long‐term estimates of mean effect size with 95% confidence interval (95% CI). Studies denoted as “on” or “off” distinguish those with assessment done both in “on” and “off” medication state
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