Parkinson's disease (PD) is commonly associated with impaired motor learning and reduced motivation, both of which can negatively influence rehabilitation outcomes. Prior cross-sectional evidence suggests that providing individuals with PD self-controlled access to training parameters enhances motor learning, increases motivation, and facilitates cognitive processing. However, the effects of self-controlled practice implemented across repeated training sessions remain underexplored. Moreover, given that dysfunction of fronto-striatal circuits in PD may limit the neuroplastic response to motor training alone, adjunctive neuromodulatory priming approaches such as repetitive transcranial magnetic stimulation (rTMS) may be required to optimize therapeutic efficacy. To date, it remains unclear whether rTMS priming combined with self-controlled motor training yields superior clinical benefits, and whether stimulation of different cortical targets produces differential effects. In particular, the dorsolateral prefrontal cortex (DLPFC), a key region involved in cognitive control and motivation, may offer distinct therapeutic effects compared with stimulation of the primary motor cortex (M1). This study aims to investigate the effects of rTMS priming over the DLPFC or M1, followed by self-controlled motor training, in individuals with PD, and to compare these effects with a sham stimulation condition. This single-blinded, randomized control trial will recruit 90 individuals with PD, who will be matched into 45 pairs and randomly assigned to one of three stimulation conditions: DLPFC, M1, or sham. Within each pair, one participant will be allocated to a self-controlled practice condition, and the other to a yoked (paired-control) condition that receives identical training content determined by their matched counterpart. Each participant will undergo 12 intervention sessions. In each session, rTMS will be applied first as a priming intervention, followed immediately by 45 minutes of standardized physical therapy-based motor training. For the DLPFC group, stimulation will target the left DLPFC; for the M1 group, stimulation will be applied over the M1 contralateral to the more affected limb; and for the sham condition, the coil will be rotated 90 degrees to mimic stimulation without effective cortical activation. During the training phase, participants in the self-controlled condition will be allowed to select aspects of their practice content, whereas yoked participants will follow the corresponding selections made by their matched partner. The primary outcome measure is the Unified Parkinson's Disease Rating Scale (UPDRS). Secondary outcomes include assessments of cognitive function, apathy, non-motor symptoms, gait performance, balance, functional mobility, falls efficacy, and quality of life. Neurophysiological outcomes will be assessed using single- and paired-pulse TMS to evaluate corticospinal excitability and cortico-cortical connectivity, particularly between DLPFC and M1 networks. All assessments will be conducted in the medication-on state by blinded evaluators at baseline, immediately post-intervention, and at one-month follow-up. Data will be analyzed using mixed-effects repeated-measures ANOVA to examine group-by-time interactions and intervention effects. This study seeks to determine whether rTMS priming over cognitive-control versus motor networks differentially enhances the efficacy of self-controlled motor training, and whether such combined interventions can induce sustained improvements in motor and non-motor outcomes in PD.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
SINGLE
Enrollment
90
The iTBS paradigm will be used to prime the neuronal excitability of the DLPFC or M1 based on the group allocation. The patterns of iTBS are triplets of stimuli at 50Hz frequency repeated in 5Hz bursts with a 2 second train repeated every 10 seconds for a total of 190 seconds, which will result in 600 stimulation pulses. The intensity will be set at 80%-120% of motor threshold of the tibialis anterior (TA) or first dorsal interosseous (FDI) muscle of the more affected limb. As for the sham rTMS groups, the coil will be placed over the M1 hotspot but turned 90 degrees away so that the surface of the coil will be 90 degrees perpendicular to the scalp.
After the iTBS priming procedure, the participants will receive 45 minutes of one-on-one physical therapy training targeting whole body and lower extremity function. Each training session will involve flexibility exercise, gait training, balance training, resistance exercise, or cognitive-motor dual task training.
School and Graduate Institute of Physical Therapy
Taipei, Zhongzheng Dist., Taiwan
RECRUITINGMovement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS)
The MDS-UPDRS is currently the gold-standard scale used in the clinics as well as research to determine the disease severity of PD. The MDS-UPDRS contains four parts: (1) non-motor aspects of experiences of daily living, (2) motor aspects of experiences of daily living, (3) motor examination, and (4) motor complications. Each item is scored from 0 (no symptom) to 4 (most severe symptom), and the total score range for the MDS-UPDRS is from 0 to 260 with a higher score indicates greater disease severity.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
Montreal cognitive assessment (MoCA)
The MoCA will be used to assess general cognitive function of the participants. It examines various cognitive functions, including set-shifting, visuospatial processing, abstract thinking, short-term memory, attention, verbal fluency, calculation, orientation, and digit span abilities. The total score of MoCA is 30 with a higher score suggests better cognitive function, and a score below 26 would suggest an increased risk of cognitive decline.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
Short-form Lille apathy rating scale (LARS)
The LARS scale has 12 items categorized into 7 domains: everyday productivity, interests, take the initiative, novelty seeking, motivation-voluntary actions, emotional responses, and social life. Each item is scored on a 5-point Likert scale or a binary yes/no scale. The score ranges from -15 to 15 with a higher score suggests more apathetic symptoms. It has been established that a short-form LARS score ≥ -7 points is the cut-off score for identifying apathy in PD.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
Non-motor symptoms scale for Parkinson's disease (NMSS)
The NMSS is a specifically designed 30-item scale to assess various non-motor symptoms of PD. It evaluates severity (score 0-3) and frequency (score 1-4) across nine non-motor domains: cardiovascular including falls, sleep/fatigue, mood /cognition, perceptual problems/hallucinations, attention/ memory, gastrointestinal tract, urinary, sexual function, and miscellaneous.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
Gait performances
To measure walking ability, the participants will be asked to walk along a 10-meter hallway with their comfortable walking speed and fastest walking speed in single- and dual-task conditions. The Physilog®5 system (Gait Up, Renens, Switzerland) including two inertial sensors with built-in 3D accelerometers and gyroscopes will be fixated to the shoelaces area of both feet to record the walking data. The data will be sampled at a rate of 128Hz and will then be analysed by the Gait Up© gait analysis package (Gait Up SA, Switzerland). Gait parameters of interest include velocity, step length, cadence, foot-strike angle, and foot clearance.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
New freezing of gait questionnaire (NFOG-Q)
The NFOG-Q is a self-reported questionnaire to determine the presence and severity of freezing of gait in people with PD. It contains 9 questions with the first question asking the participants whether they have experienced freezing episodes in the past 1 month. If an individual answers 'no' to this question, he/she will be classified as non-freezer and will not need to answer the following questions. One the other hand, if a person answers 'yes' to the first question, he/she will be asked to further complete the rest of the questions regarding the severity and duration of the freezing episodes.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
5-time sit to stand test (5TSTS)
The 5TSTS will be used to evaluate the lower extremity muscle strength and endurance. Using a standardized chair, the participants will be requested to stand up and then sit down as quickly as possible for 5 times, and the time to complete the test will be recorded.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
Timed up and go (TUG) test
The TUG is a gold standard to measure dynamic balance and gait ability. The participant will first sit on a standardized chair with back supported. After a GO signal, he/she will stand up, walk 3 meters, turn 180°, walk back and then sit down. The participants will be instructed to walk with their preferred and fastest walking speeds.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
Mini balance evaluation systems test (Mini-BESTest)
The Mini-BESTest assesses 4 aspects of balance ability, including anticipatory postural adjustments, reactive postural control, sensory orientation, and dynamic gait. It contains 14 items, and each item is scored on a 0-2 ordinal scale, with a total score of 28 points. A higher score indicates better balance control.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
Activities-Specific Balance Confidence (ABC) scale
The ABC scale will be utilized to assess an individual's confidence level of not falling when performing daily activities at home and in the community. Sixteen indoor and outdoor activities are involved in the scale, and the participants will rate their confidence level of not falling from 0 (no confidence at all) to 100 (very confident) when performing the activities. An average score of these questions will then be calculated with a higher score suggests greater confidence of not falling.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
Parkinson's Disease Questionnaire-39 (PDQ-39)
The PDQ-39 is a specifically designed self-report questionnaire to determine quality of life in individuals with PD. The questionnaire contains 39 health-related items, and the participants will answer these questions based on their own experience in the past one month. Each item is score on a 5-point Likert scale with a lower score suggests less difficulty performing the task. As a result, a lower total score will indicate better quality of life.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
Motivation questionnaire
The motivational questionnaire will be used to determine their motivation level after each training session. It consists of perceived competence, task interest/enjoyment, and autonomy. The questions for perceived competence and task interest/enjoyment are directly taken from Intrinsic Motivation Inventory (IMI), which originally consists of 22 items with 4 subscales including interest/enjoyment, perceived competence, perceived choice, and pressure/tension (McAuley et al., 1989). As for autonomy, the questions are referenced from the autonomy subscale used in a study by Carter and Ste-Marie (Carter \& Ste-Marie, 2017b). The motivational questionnaire used in this study consists of 21 items scored with a 7-point Likert scale with a higher score indicates better in perceived competence, task interest/enjoyment, and autonomy.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
Corticomotor excitability
Transcranial magnetic stimulation (TMS) device (The Magstim Company Ltd, Whitland, UK) will be used to determine the neurophysiology of corticomotor excitability.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
Cortico-cortical connectivity
Transcranial magnetic stimulation (TMS) device (The Magstim Company Ltd, Whitland, UK) will be used to determine the neurophysiology of corticocortical connectivity.
Time frame: Three time points: pre-test (before intervention, 0 week), post-test (after all intervention sessions, up to 4 weeks), follow-up test (one month after intervention, up to 8 weeks)
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