rTMS to Improve Cognition in Parkinson's

Study Overview
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Brief Summary
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The purpose of this study is to examine safety, feasibility, and the behavioral and brain effects of a non-invasive treatment, repetitive transcranial magnetic stimulation (rTMS), for Veterans with Parkinson's disease and mild impairments in their thinking. The hypothesis is that rTMS can improve thinking for people with Parkinson's disease who are experiencing mild problems with their thinking ability.

Detailed Description
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Repetitive transcranial magnetic stimulation (rTMS) shows promise as an effective cognitive neurorehabilitation treatment. To date, no rTMS studies have assessed the effect of rTMS on cognitive function in PD-MCI. Nor has there been PD neurophysiological studies using rTMS to examine neural plasticity in cognitive neural networks. This study seeks to fill this gap by conducting a small scaled pilot randomized controlled trial (RCT) designed to assess the safety and therapeutic effects of rTMS on cognitive outcomes as well as on brain connectivity in Veterans with PD-MCI. PD-MCI participants will be randomized to either active rTMS or sham rTMS. Participants will complete a standardized neurocognitive battery assessment at baseline, endpoint and at a one month follow-up. The primary outcome is change in executive function. Secondary outcomes include performance on other cognitive domain tasks and a proximal measure of real-life function that captures relevant functional changes related to cognitive impairment in PD. Multi-modal neuroimaging, in a subsample of participants, will be used to study neural connectivity changes induced by rTMS. Changes in resting state functional connectivity, grey matter volume via voxel-based morphometry and white matter integrity via diffusion tensor imaging will be assessed at baseline and endpoint. To inform how to optimize rTMS treatment in PD-MCI, these changes will be correlated with changes in cognitive performance.

Official Title
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rTMS as a Cognitive Rehabilitation Approach in Veterans With Parkinson'sDisease

Conditions
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Parkinson's Disease, Mild Cognitive Impairment

Intervention / Treatment
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* Device: MagVenture MagProX100 stimulator (MagVenture, Falun, Denmark)
* Device: MagVenture MagProX100 stimulator (MagVenture, Falun, Denmark)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Veterans who seek services at Hines VA Hospital or Jesse Brown VA Medical Center Diagnosis of PD as determined by the UK Parkinson's Disease Society Brain Bank Diagnostic Criteria Meet criteria for having mild cognitive impairment Receiving stable (i.e., no changes in medication and medication dose) medication and who are expected to remain on stable medication for the duration of the RCT Speak and read English 50 years or older Exclusion Criteria: Dementia Failure to demonstrate decision making capacity History of deep brain stimulation surgery Severe depression Resting head tremor Dyskinesia that will interfere with collecting imaging data Has congestive heart failure Implanted cardiac pacemaker or defibrillator Cochlear implant, nerve stimulator, or intracranial metal clips Implanted medical pump Increased intracranial pressure History of claustrophobia Metal in eyes/face, shrapnel/bullet remnants in brain Participants at potential increased risk of seizure including those who have the following: history (or family history) of seizure or epilepsy history of stroke, head injury, or unexplained seizures presence of other neurological disease that may be associated with an altered seizure threshold such as CVA, cerebral aneurysm, dementia, increased intracranial pressure Concurrent medication use such as tricyclic antidepressants, neuroleptic medications, any other drug known to lower seizure threshold Secondary conditions that may significantly alter electrolyte balance or lower seizure threshold No quantifiable motor threshold such that rTMS dosage cannot be accurately deter-mined

Ages Eligible for Study
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Minimum Age: 50 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: randomized control trial. Participants will receive either active or sham rTMS
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: active rTMS<br>For active rTMS, a butterfly coil and MagVenture MagProX100 stimulator (MagVenture, Falun, Denmark) will be used. One rTMS session will consist of 40 trains of 5sec each at 110% of resting motor threshold and 15Hz will be provided at the left DLPFC. | Device: MagVenture MagProX100 stimulator (MagVenture, Falun, Denmark)<br>* The coil will be held tangentially to the skull at approximately 45º from the midline. One rTMS session will consist of 40 trains of 5sec each at 110% of resting motor threshold and 15Hz will be provided at the left DLPFC.<br>|
| Sham Comparator: sham rTMS<br>For sham rTMS, the procedure will be carried out at the left DLPFC but a sham coil will be used. The MagVenture coil has an active side and a placebo side allowing a double-blind study to be conducted. The sham system looks, sounds and feels like active rTMS. | Device: MagVenture MagProX100 stimulator (MagVenture, Falun, Denmark)<br>* The coil will be held tangentially to the skull at approximately 45º from the midline. The sham coil will not release any stimulation, but it will look, feel and sound like the real rTMS<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| change in NIH sponsored Executive Abilities: Measures and Instruments for neurobehavioral evaluation and re-search (NIH-EXAMINER) executive composite score | The NIH-EXAMINER has an established 3-factor model defined by (1) cognitive control, (2) working memory (3) fluency. A confirmatory factor analysis indicates these 3-factors load on to 1-factor: executive composite score. Seven tests in the NIH-EXAMINER will be used to compute the composite score | baseline, 8 weeks, 12 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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rTMS, Parkinson's disease, mild cognitive impairment, executive function, neuromodulation, functional connectivity