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Gait disorders are symptoms that significantly compromise the quality of life and functionality of patients with Parkinson's disease (PD). When they are not responsive to drug dopaminergic therapy and deep brain stimulation (DBS), the management of these symptoms is a challenge in clinical practice. Although deep brain stimulation is useful in the motor symptoms of Parkinson's disease, gait symptoms remains a challenge in patients undergoing this therapy. This is because, in addition to adjustments in the DBS programming not adding evident benefit in some patients with gait disorders, motor symptoms tend to progress over the years. In this context, spinal cord invasive electrical stimulation was proposed as a potential and effective therapy in a group of patients with PD who presented with gait impairment. More recently, the application of transcutaneous magnetic stimulation of the spinal cord has emerged as a possible therapeutic option, as it could stimulate neural elements in a non-invasive way. The general objective will be to study the effect of transcutaneous magnetic stimulation of the spinal cord on gait in PD patients with deep brain stimulation refractory to dopaminergic therapy. The method of the present study will be a randomized, double-blind, placebo-controlled, parallel, phase II clinical trial that will evaluate the efficacy of transcutaneous magnetic stimulation of the spinal cord in patients with PD and deep brain stimulation who present gait disorders refractory to dopaminergic therapy. The primary outcome will be the change in gait speed between pre-stimulation and post-stimulation conditions between the two groups (active and placebo) assessed using the Timed Up and Go Test (TUG). Secondary outcomes will be the effects of stimulation on other gait measures (speed, step length, stride length, cadence, step width, sway time, support time and the presence of blocks), other motor symptoms (Unified Parkinson's Disease Rating Scale), cognitive alterations, quality of life and side effects. Statistical analysis will be performed using ANOVA for repeated measures and 38 patients will be included. The expected results are supported by transcutaneous magnetic stimulation of the spinal cord, which may improve gait disorders in participants with PD and DBS.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| ACTIVE | Active Comparator | Magnetic transcutaneous spinal cord stimulation |
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| PLACEBO | Sham Comparator |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Magnetic transcutaneous spinal cord stimulation | Device | In the active group, non-invasive spinal cord stimulation will be applied by placing a circular magnetic coil (Magventure®️ MagPro®️ R20) on the skin, in the upper thoracic region (thoracic level T2-T3). The intensity of stimulation will represent 100% of the motor threshold, which is determined by abdominal muscle contractions, found from single pulses, gradually applied every 10 seconds until the onset of contractions. The intermittent theta burst stimulation protocol will consist of 20 stimulation trains, with an interval of 8 seconds between trains, each train will have 20 bursts, and each burst will have 3 pulses at 50 Hertz repeated at 5 Hertz. In total 1200 pulses will be applied for 3 minutes and 58 seconds. |
| Measure | Description | Time Frame |
|---|---|---|
| Timed Up and Go - Test 5 Meters (TUG-Test 5M) | The primary outcome will be the change in gait speed between pre-stimulation and post-stimulation conditions between the two groups (active and placebo) assessed using the 5-meter total Timed Up and Go Test (TUG). Mixel model ANOVA, with TUG as the dependent variable, and time and group as independent variables - "group" would have two levels ("active" and "placebo"). Our alternative hypotesis is that "the time vs. group" interaction effect is significant. Then we should use post hoc statistical tests to explore our data further and to compare the effects of active versus placebo at different time levels. | Baseline, immediately after the fifth day of stimulation, seven days after the stimulation, twenty-eight days after stimulation |
| Measure | Description | Time Frame |
|---|---|---|
| Freezing of gait score (FOG SCORE) | Change in FOG SCORE between pre-stimulation and post-stimulation conditions.Minimum value 0 and maximum value 36. Higher value is worse. | Baseline, immediately after the fifth day of stimulation, seven days after the stimulation, twenty-eight days after stimulation. |
| Percentage of freezing by video analysis of Timed Up and Go - Test |
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Inclusion Criteria:
Exclusion Criteria:
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| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| University of Sao Paulo | São Paulo | São Paulo | 01246-000 | Brazil |
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| Transcutaneous electrical nerve stimulation | Device | To create a sensation of muscle contraction and impression of active stimulation, both the placebo and active groups will be subjected to the sensory effect of transcutaneous electrical neurostimulation (TENS). The surface electrodes of TENS (model Neurodyn®️, Ibramed®️) will be placed in parallel at the height of the thoracic level T2-T3, with the following parameters: 80Hertz, 150ms, approximately at 60 miliampère. In the placebo group, a coil will be allocated in the thoracic region T2-T3, however this coil will not be connected to the stimulation device, and another active coil will be positioned about 15cm behind, away from its field of view, to provide the idea from the sound stimulus that it is being stimulated. |
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Change in percentage between pre-stimulation and post-stimulation conditions |
| Baseline, immediately after the fifth day of stimulation, seven days after the stimulation, twenty-eight days after stimulation. |
| Unified Parkinson's Disease Rating Scale (MDS-UPDRS) - Part III | Change in UPDRS PART III between pre-stimulation and post-stimulation conditions. Minimum value 0 and maximum value 132. Higher value is worse. | Baseline, immediately after the fifth day of stimulation, seven days after the stimulation, twenty-eight days after stimulation. |
| Timed Up and Go - Test 5 Meters (TUG-Test 5M) Dual Task | Change in gait speed between pre-stimulation and post-stimulation conditions | Baseline, immediately after the fifth day of stimulation, seven days after the stimulation, twenty-eight days after stimulation. |
| Mini Balance Evaluation Systems Test (Mini-BESTest) | Change in balance between pre-stimulation and post-stimulation conditions. Minimum value 0 and maximum value 108. Higher value is better. | Baseline, immediately after the fifth day of stimulation, seven days after the stimulation, twenty-eight days after stimulation. |
| New Freezing of Gait Questionnaire (NFOG-Q) | Change in NFOG-Q between pre-stimulation and post-stimulation conditions. Minimum 0 Maximum 28. Higher value is worse. | Baseline, immediately after the fifth day of stimulation, seven days after the stimulation, fourteen days after the stimulation, twenty-one days after the stimulation, twenty-eight, thirty-five and forty-two days after the stimulation. |
| Subitems 2.12 and 2.13 of Unified Parkinson's Disease Rating Scale (MDS-UPDRS) | Change between pre-stimulation and post-stimulation conditions | Baseline, immediately after the fifth day of stimulation, seven days after the stimulation, fourteen days after the stimulation, twenty-one days after the stimulation, twenty-eight, thirty-five and forty-two days after the stimulation |
| Parkinson's Disease Questionnaire 39 (PDQ-39); | Change in PDQ-39 between pre-stimulation and post-stimulation conditions. Minimum value 0% and maximum value 100%. Higher value is worse. | Baseline, seven days after the stimulation, twenty-eight days after stimulation. |
| Falls Efficacy Scale (FES-I) | Change in FES-I between pre-stimulation and post-stimulation conditions. Minimum value 16 and maximum value 64. Higher value is worse. | Baseline, seven days after the stimulation, twenty-eight days after stimulation. |
| Activities-specific Balance Confidence (ABC) Scale | Change in ABC scale between pre-stimulation and post-stimulation conditions. Minimum value 0 and maximum value 100%. Higher value is better. | Baseline, seven days after the stimulation, twenty-eight days after stimulation. |
| Visual analog scale (VAS) | Change in pain between pre-stimulation and post-stimulation conditions. Minimum value 0 and maximum value 10. Higher value is worse. | Baseline, immediately after the fifth day of stimulation, seven days after the stimulation, twenty-eight days after stimulation. |
| Patient Global Impression of Change (PGIC) | Impression of change post-stimulation conditions | Baseline, immediately after the fifth day of stimulation, seven days after the stimulation, fourteen days after the stimulation, twenty-one days after the stimulation, twenty-eight, thirty-five and forty-two days after the stimulation |
| Frontal assessment battery (FAB); | Change in executive function between pre-stimulation and post-stimulation conditions. Minimum value 0 and maximum value 18. Higher value is better. | Baseline, immediately after the fifth day of stimulation, seven days after the stimulation, twenty-eight days after stimulation. |
| ID | Term |
|---|---|
| D010300 | Parkinson Disease |
| ID | Term |
|---|---|
| D020734 | Parkinsonian Disorders |
| D001480 | Basal Ganglia Diseases |
| D001927 | Brain Diseases |
| D002493 | Central Nervous System Diseases |
| D009422 | Nervous System Diseases |
| D009069 | Movement Disorders |
| D000080874 | Synucleinopathies |
| D019636 | Neurodegenerative Diseases |
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| ID | Term |
|---|---|
| D004561 | Transcutaneous Electric Nerve Stimulation |
| ID | Term |
|---|---|
| D004599 | Electric Stimulation Therapy |
| D013812 | Therapeutics |
| D026741 | Physical Therapy Modalities |
| D012046 | Rehabilitation |
| D000698 | Analgesia |
| D000760 | Anesthesia and Analgesia |
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