Parkinson’s disease (PD) is a neurodegenerative pathology that mainly affects the part of the brain that regulates fine-tuning and co-ordination of limb movements. It commonly appears in older age but, however, there is an entity called young onset PD which starts at the age of 40s. PD is manifested by tremors, slowness of movement (bradykinesia), stiffness, lack of expressibility, low voice, small stepped hesitant gait etc. Gait disorder leads to a tendency to fall which further impair quality of life.  In addition to movement disorder, it is also associated with psychiatric symptoms like hallucination, emotional lability, and sleep disorders. Medications are the primary treatment of PD but it is limited by adverse effects and decreases effectiveness as disease progresses.

Transcranial magnetic stimulation is a non-invasive painless FDA approved novel method that has shown promising results in recent studies in psychiatric conditions. It is a painless, noninvasive method that modulates cortical excitability.

• These all patients are potential candidates for TMS:
  • PD patients have short stepped hesitant gait and stooped posture. These lead to functional decline and tendency to fall.
  • Stiffness and slowing of movement may progress to such an extent that patients may become dependent for their daily needs. This dependable state may lead to depression in PD patients.
  • Patients with advanced PD symptoms are likely to experience increased impairment in daily functioning and a poor quality of life. They are also likely to have poor mental health, increased social isolation and high chances of suffering from depression, anxiety and low mood.
• Even patients with pregnancy, hypertension, diabetes, thyroid disorders, kidney diseases, heart diseases etc. can take part in this treatment
• Medical devices which are commonly used now-a-days like stents, pacemakers, coils, orthopedic implants etc. are usually MRI compatible so they usually do not interfere with the TMS

TMS has been researched around the world since about the 1980s. Lots of literature has been published so far in peer-reviewed journals on TMS with positive outcomes and negligible adverse effects.

A study was conducted wherein 27 PD patients took part in 12 Deep TMS sessions along with medication, with stimulations in both the motor and prefrontal cortical regions. Improvement in gait, motor rigidity, tremors and slowness of movement was observed.

Another European randomized controlled study was conducted including 60 patients.  Results showed significant improvement of UPDRS III in patients who were given real TMS compared to the control group. Improvement was significant in motor scales.

Another study was conducted wherein real-world data collected from a hospital in Germany was retrospectively analyzed. Results showed that Parkinson’s symptoms that were non-responsive to medication reduced significantly post the deep TMS sessions. Additionally, an improvement in depression and mood levels was observed as well. Greater improvement was noticed in the older population.

A randomized control trial was conducted in Hong Kong with fifty participants to know the effects of TMS on Gait. It was interpreted that TMS can augment the benefits of treadmill training and lead to long-term motor improvement up to 3 months post intervention.

Method

• TMS is a non-invasive way of Neuromodulation.
• It involves low energy magnetic stimulation of the particular site of the brain through the skull
• This is delivered through a specially designed coil, incorporated in a helmet.
• When the patient comes in, the nurse will take a detailed history and update the doctor. The doctor will thereafter discuss the most suitable protocol with the patient, which will include the duration of each sitting, the frequency of sittings/week and the total no. of sittings.
• Once all is confirmed, this will be fed to the computer.
• Following this, necessary evaluation is done to determine the MT (Motor threshold) by imparting stimulation through the helmet.
• Based on the predesigned protocols, TMS will be administered to the patient.
• For PD, the patient will require about 12 sessions over the period of 4 weeks. Each session will be approximately 30-40 minutes long.
• The procedure does not require any sedation or anesthesia. Patient is not required to keep fasting before the procedure.

The Jaslok Hospital & Research Centre is one of the oldest tertiary care, multi-specialty Trust hospitals in the country. Jaslok Hospital has research activities ongoing in various fields in collaboration with other institutions in India & abroad. The hospital has a dedicated “Restorative and Regenerative Medicine” department including consultants in various fields with more than 20 years of experience.

The department has procured the state-of-art technology and equipment from internationally reputed and trusted “Brainsway” company. It contains the advanced technology of  H1-7 coils instead of conventional coils, that can deliver noninvasive deep TMS in precise manner to get maximum result. It has FDA and CE clearance for treatment of various neurological and psychiatric conditions. The conventional TMS can only deliver specific target sites, limiting their use and capabilities. Deep TMS can reach the following target sites; insula, cingulate gyrus, etc.