The Effect of 20 Hz versus 1 Hz Repetitive Transcranial Magnetic Stimulation on Motor Dysfunction in Parkinson's Disease: Which Is More Beneficial?

BACKGROUND: There is evidence that both high and low frequency rTMS may have therapeutic effects on motor performance of Parkinson's disease. OBJECTIVE: The aim of the study was to conduct the first direct comparison of the two approaches. METHODS: 52 PD patients were randomly classified into two groups. The first group received 20 Hz and the 2nd group received 1 Hz rTMS with a total of 2000 pulses over M1of each hemisphere for ten days. Effects were assessed with the Unified Parkinson's Disease Rating Scale part III (UPDRS), Instrumental Activity of Daily Living (IADL), and a self-assessment score (SA) before, after the last session, and one month later. Cortical excitability was measured before and after the end of sessions. RESULTS: There was a significant improvement on all rating scales after either 1 Hz or 20 Hz rTMS, but the effect persisted for longer after 20 Hz (treatment X time interaction for UPDRS and IADL (P = 0.075 and 0.04, respectively). Neither treatment affected motor thresholds, but 20 Hz rTMS increased MEP amplitude and the duration of transcallosal inhibition. In an exploratory analysis, each group was subdivided into akinetic-rigid and tremor dominant subgroups and the effects of 1 Hz and 20 Hz treatment recalculated. There was weak evidence that patients with an akinetic-rigid presentation may respond better than those with predominant tremor. CONCLUSION: Both 20 Hz and 1 Hz rTMS improve motor function in PD, but 20 Hz rTMS is more effective.

Repetitive transcranial magnetic stimulation for treatment of tardive syndromes: double randomized clinical trial.

Tardive syndromes (TDS) typically manifest 3 months or later after exposure to antipsychotic drugs, and unfortunately have no satisfactory medical treatment. We explored the possibility of using therapeutic repetitive transcranial magnetic stimulation (rTMS). Twenty-six patients were allocated to receive real or sham rTMS over the hand/arm area of motor cortex (M1). Each received a daily total of 2000 rTMS pulses (20 Hz at 100% rMT: 1000 stimuli per hemisphere) for 10 consecutive days. Outcome was assessed using the Abnormal Involuntary Movement Scale (AIMS) and TMS measures of M1 excitability. Three patients in the sham group failed to complete the study. At baseline, there was no significant difference between the groups in age, sex distribution, duration of illness, AIMS score and drug treatment. rTMS improved symptoms in both groups. However, there was a greater reduction in the AIMS score of the real rTMS group compared with the sham group (real, 8.3 ± 1.7 points; sham 1.2 ± 3.3; repeated measure analysis ANOVA Time X Group interaction P = 0.001). The same trends were observed in the clinical subscales. Following treatment, MEP amplitudes at higher intensities (140, and 150%) increased more in the real treatment group than in the sham group. This is the first clinical trial study of bilateral hemispheric rTMS in patients with TDS and suggests that 20 Hz rTMS might be a feasible treatment option in patients unresponsive to "first-line" treatment.Clinical trial registration ClinicalTrials.gov Identifier: NCT03145311.

Changes in recruitment of motor cortex excitation and inhibition in patients with drug-induced tardive syndromes.

OBJECTIVES: It has recently been suggested that drug-induced tardive syndromes (TS) might be due to maladaptive plasticity, which increases motor excitability in cerebral cortex and basal ganglia. In order to test this hypothesis, we performed the first measurements of cortical excitability in TS. METHODS: Motor cortex excitability was examined using transcranial magnetic stimulation (TMS) in 22 TS patients and compared with that in 20 age and sex-matched healthy individuals. Resting and active motor threshold (RMT, AMT) and input-output curves (I/O curves) assessed corticospinal excitability. The duration of the contralateral silent period (cSP) at a range of stimulation intensities and ipsilateral silent period (iSP) were used as measures of inhibition. RESULTS: There were no significant differences in RMT and AMT between patients and controls, although the input-output curves were significantly steeper in patients. The cSP (at different stimulus intensities) and iSP were both longer in the patients compared to the control group. However, most of this difference could be accounted for by increased recruitment of motor evoked potentials (MEPs) in patients. CONCLUSION: TS is characterized by hyperexcitability of corticospinal output that might contribute to the lack of selectivity in muscle recruitment and contribute to excess involuntary movement. The findings are opposite to those in naturally-occurring hyperkinesia such as Sydenham's and Huntington's chorea, suggesting a fundamental difference in the pathophysiology.

Epidemiology of nonfatal stroke and transient ischemic attack in Al-Kharga District, New Valley, Egypt.

BACKGROUND: Stroke is a medical emergency. Nonfatal stroke may cause permanent neurologic damage, complications, and disability. The aim of this study was to determine the epidemiology of nonfatal stroke in Al-Kharga District, New Valley, Egypt. METHODS: The total population (62,583) was screened via a door-to-door study by three neurology specialists and 15 female social workers for demographic data collection. All subjects with probable stroke were subjected to a full clinical examination, neuroimaging (computed tomography and/or magnetic resonance imaging of the brain), and laboratory investigations including blood sugar, lipid profile, serum uric acid, a complete blood count, blood urea, and serum creatinine. Stroke severity and outcome were assessed using the Scandinavian Stroke Scale and Barthel Index. Carotid Doppler, echocardiography, and thyroid function tests were done in selected cases. RESULTS: During the study period (June 1, 2005 to May 31, 2008), 351 subjects were diagnosed as having suffered a cerebrovascular stroke at some point during their lives, yielding a total lifetime prevalence of 5.6 per 1,000 population. Of these, 156 subjects were identified as having suffered a stroke during the year from January 1 to December 31, 2007, with an incidence rate of 2.5 per 1,000. Both prevalence and incidence rates were higher in urban (5.8 per 1,000 and 2.6 per 1,000, respectively) than rural communities (5.2 per 1,000 and 2.3 per 1,000), and were higher in males (6.1 per 1,000 and 2.7 per 1,000, respectively) than in females (5.1 per 1,000 and 2.3 per 1,000). Thrombotic stroke had the highest prevalence and incidence rates (4.2 per 1,000 and 1.7 per 1,000, respectively), whereas subarachnoid hemorrhage had the lowest prevalence and incidence rates (0.03 per 1,000 and 0.02 per 1,000). CONCLUSION: The prevalence of cerebrovascular accident in Al-Kharga lies in the lower range of that in developing countries, and is similar to that in industrialized countries.

Epidemiology of major neurological disorders project in Al Kharga district, New Valley, Egypt.

BACKGROUND/METHODS: A door-to-door ('every door') study was carried out to assess the incidence and prevalence rates of epilepsy, stroke, Bell's palsy and cerebral palsy, as well as the prevalence of dementia, extrapyramidal syndromes, muscle and neuromuscular disorders, cerebellar ataxia and primary nocturnal enuresis among the urban and rural populations of Al Kharga district, New Valley, Egypt. The study was carried out in 3 stages from June 1, 2005 to May 31, 2009. A door-to-door screening including every door was carried out using a standardized questionnaire, which was administered by 3 neurologists to all inhabitants (62,583) of Al Kharga district. The study was designed to assess the prevalence, incidence and risk factors of major neurological disorders in Al Kharga district and aimed to reduce the burden of these neurological disorders in the entire region. RESULTS/CONCLUSIONS: This study clarified that dementia, primary nocturnal enuresis, epilepsy, stroke and cerebral palsy are the most common neurological disorders. On the other hand, Bell's palsy, extrapyramidal syndromes, cerebellar ataxia, muscle dystrophies and myasthenia gravis are less common neurological disorders in Al Kharga district.

Door-to-door survey of major neurological disorders in Al Kharga District, New Valley, Egypt: methodological aspects.

Epidemiology of neurological disorders is still lacking in Egypt. The door-to-door method is the most suitable one to screen neurological disorders in our country. Over a 4-year period (June 1, 2005 to May 31, 2009), screening and examination had been carried out to ascertain the incidence and prevalence rate of epilepsy, stroke, cerebral palsy and Bell's palsy, as well as the prevalence of dementia, extrapyramidal syndromes, muscle and neuromuscular disorders, cerebellar ataxia and primary nocturnal enuresis among the urban and rural population of Al Kharga District, New Valley, Egypt. A total of 62,583 people were screened by 3 neurologists in a door-to-door manner, including every door, using a standardized Arabic questionnaire to detect any patient with a neurological disorder. This was a project study of neurological disorders including 3 stages: first stage (June 1, 2005 to May 31, 2006) for data collection, designing a standardized questionnaire and screening; second stage (June 1, 2006 to May 31, 2008) for case ascertainment, classification of neurological disorders and investigations, and third stage (June 1, 2007 to May 31, 2009) for data entry and statistical analysis. The results of this study revealed that the total prevalence rate of neurological disorders in Al Kharga District, New Valley was 2.4/100 with no significant difference among both sexes. The highest prevalence rate was recorded among elderly people (60+ years; 9.25%) and among children (≤18 years; 2.9%).