Release time ：2024-08-13
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Clinical Support Department of Shenzhen Yingchi Technology Co.,Ltd.
Treatment methods, techniques, and concepts for Parkinson's Disease (PD) are continuously evolving. These include medication, surgical treatments, neuromodulation, botulinum toxin therapy, physical therapy, psychological intervention, and caregiving. Among these, repetitive transcranial magnetic stimulation (rTMS) has been proven to improve both motor and non-motor symptoms of PD patients and enhance their quality of life, making it an important non-drug treatment option for PD. As a newer research and treatment approach, rTMS offers advantages such as being painless, non-invasive, simple to operate, and reliable, and it has been widely used in the clinical treatment of drug-resistant depression, sleep disorders, and other conditions. Currently, numerous clinical studies on rTMS for PD have been conducted both domestically and internationally, but there is a lack of consensus on its indications, parameters, targets, and efficacy.
To better standardize the indications, treatment parameters, and targets for rTMS in PD in China, the Neurology Branch of the Chinese Medical Association, in collaboration with the Parkinson's Disease and Movement Disorders Group of the Neurology Branch of the Chinese Medical Association, has developed treatment guidelines for rTMS in PD. These guidelines were published on December 22, 2021, in the Chinese Journal of Neurology and Psychiatry.
The following are the main contents of the treatment guidelines:
This guideline summarizes the clinical practices of existing rTMS treatments for various symptoms of PD based on relevant domestic and international research, meta-analyses, and other literature. Under the guidance of evidence-based medicine principles, the evidence levels and recommendation strength standards are referenced from international guidelines, commonly used standards, and the evidence grading and recommendation strength system of the Oxford Centre for Evidence-Based Medicine, while also considering China's national conditions and feasibility.
| Levels of Evidence for Treatment Measures: |
| Level 1: Systematic reviews of multiple homogeneous randomized controlled trials; single randomized controlled trial (with a narrow 95% confidence interval); all-or-none case studies. |
| Level 2: Systematic reviews of multiple homogeneous cohort studies, or well-designed non-randomized controlled trials; single cohort study with poor quality or randomized controlled trials with poor quality (e.g., follow-up rate less than 80%); outcome studies or ecological studies. |
| Level 3: Systematic reviews of multiple homogeneous case-control studies; single case-control study. |
| Level 4: Case series studies, poor quality cohort studies, and case-control studies. |
| Level 5: Expert opinion based on theoretical principles or physiological studies without explicit discussion. |
| Grades of Recommendation for Treatment Measures: |
| Grade A: Based on consistent Level 1 evidence. |
| Grade B: Based on consistent Level 2 or Level 3 evidence, or Level 1 evidence under certain conditions. |
| Grade C: Based on Level 4 evidence, or Level 2 or Level 3 evidence under certain conditions. |
| Grade D: Based on Level 5 evidence, or inconsistent or inconclusive evidence of any level. |
Recommendations:
①rTMS (repetitive Transcranial Magnetic Stimulation) can effectively improve motor symptoms of Parkinson's disease (Grade B recommendation). High-frequency stimulation (10 Hz/5 Hz) of the M1 region can help alleviate motor slowing symptoms (Grade B recommendation), but improvements in PD tremors are not significant (Grade C recommendation).
②Low-frequency stimulation (1 Hz) of the SMA (Supplementary Motor Area) can improve postural and gait disorders in PD patients (Grade C recommendation), and this effect is independent of the use of anti-PD medications (Grade B recommendation).
③rTMS can be used to treat freezing of gait in Parkinson's disease, with short-term efficacy (Grade B recommendation). High-frequency stimulation of the M1 region or SMA may be effective (Grade C recommendation), but long-term efficacy, stimulation targets, and parameters require further research.
| Non-Motor Symptoms | Recommendations |
| Depression | rTMS can effectively improve depressive symptoms in PD patients (Grade B recommendation). High-frequency stimulation (5 Hz) of the left DLPFC (dorsolateral prefrontal cortex) is recommended for improving depressive symptoms in PD (Grade B recommendation). High-frequency (5 Hz) stimulation of the bilateral M1 regions may also help alleviate PD-related depression (Grade C recommendation), but precise efficacy needs further validation through large-scale, high-quality clinical studies. |
| Anxiety | rTMS may improve anxiety symptoms in PD. High-frequency stimulation (5 Hz/10 Hz) of the bilateral DLPFC may help with anxiety symptoms in PD (Grade C recommendation), but the exact efficacy requires further clinical research. |
| Cognitive Dysfunction | The effect of rTMS on overall cognitive dysfunction in PD is not yet clear (Grade B recommendation). Treatment targets and parameters are inconsistent and need further clinical research.①High-frequency (25 Hz) rTMS stimulation of the right DLPFC may help improve executive function in PD patients (Grade B recommendation).②High-frequency (25 Hz) rTMS stimulation of the inferior frontal gyrus may help improve frontal lobe cognitive function in PD patients (Grade C recommendation).③High-frequency (5 Hz) rTMS stimulation of the right parietal cortex may help enhance learning abilities in PD patients (Grade C recommendation).④Intermittent pulse rTMS stimulation of the DLPFC may benefit cognitive function in PD, but large-scale clinical studies are needed to confirm this (Grade C recommendation). |
| Sleep Disorders | ①High-frequency rTMS can improve sleep quality in PD patients (Grade B recommendation), with stimulation targets including the DLPFC or parietal regions.②The use of rTMS to treat obstructive sleep apnea syndrome, restless legs syndrome, and excessive daytime sleepiness in PD requires further research. |
| Apathy | High-frequency (10 Hz) rTMS stimulation of the bilateral DLPFC may help reduce apathy in PD (Grade D recommendation), but further high-quality clinical studies are needed for validation. |
| Autonomic Nervous System Dysfunction | The potential of rTMS to improve autonomic nervous system symptoms in PD is not yet clear (Grade D recommendation), and high-quality clinical research is needed to validate its effects. |
| Other Symptoms | Recommendations |
| Dystonia | Low-frequency rTMS stimulation of the M1 and SMA regions may improve dystonia in PD (Grade C recommendation), but the exact efficacy requires further research. |
| Swallowing Dysfunction | High-frequency (20 Hz) rTMS stimulation of the bilateral M1 regions may help improve swallowing dysfunction in PD (Grade C recommendation), though high-quality clinical studies are needed for further validation. |
| Impulse Control Disorders | Low-frequency rTMS stimulation of the DLPFC may aid in improving impulse control disorders in PD (Grade D recommendation), but high-quality clinical research is needed to confirm this. |
The main adverse reactions to rTMS treatment include mild headaches, discomfort at the stimulation site, decreased hearing, tinnitus, and seizures. Among these, headaches and discomfort at the stimulation site are the most common adverse reactions, but they are usually mild and transient, resolving on their own. Seizures are the most serious adverse reaction, with an occurrence rate ranging from 0.01% to 0.1%.
Most experts believe that the risk of seizures induced by rTMS is mainly related to parameters such as stimulation intensity, frequency, duration, and inter-stimulation intervals. Additionally, factors like antidepressant medications, antipsychotic drugs, sleep deprivation, brain injury, and a history of severe seizures can increase the risk of seizures.
In 2021, the International Federation of Clinical Neurophysiology (IFCN) published the third edition of safety guidelines for repetitive transcranial magnetic stimulation (rTMS). The guidelines indicate that the adverse reactions to TMS for treating neuropsychiatric disorders are very low. The probability of seizures is extremely low in the absence of risk factors. However, the likelihood of inducing seizures increases with higher stimulation frequencies. Low-frequency TMS has a lower risk of inducing seizures, possibly due to its inhibitory effects. Even among patients taking central nervous system medications, the risk of seizures from rTMS remains very low, though it is still important to prevent potential seizures.
Additionally, improving the accuracy of target localization helps reduce the occurrence of side effects, thereby enhancing the safety of rTMS. Therefore, it is recommended to use high-resolution structural MRI-guided neuronavigation technology for target localization to improve patient outcomes.
1. This content has been organized by the Clinical Support Department of Shenzhen Yingchi Technology Co.,Ltd. Feedback and corrections are welcome. Please indicate the source when?copying.
2. For more information on guidelines and consensus, you can leave a message for the Clinical Support Department of Shenzhen Yingchi Technology Co.,Ltd.
3. Reference: 王麗娟,聶坤,高玉元,等. 中國帕金森病重復經顱磁刺激治療指南.中國神經精神疾病雜志, 2021, 47(10): 577-585Wang L J, Nie K, Gao Y Y, et al. Chin J Nerv Ment Dis, 2021, 47(10): 577-585.
