• Ying-hui Chou, Patrick T Hickey, Mark Sundman, Allen W Song, and Nan-kuei Chen.
• Brain Imaging and Analysis Center, Duke University Medical Center, Durham, North Carolina2Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.
• JAMA Neurol. 2015 Apr 1;72(4):432-40.

ImportanceRepetitive transcranial magnetic stimulation (rTMS) is a noninvasive neuromodulation technique that has been closely examined as a possible treatment for Parkinson disease (PD). However, results evaluating the effectiveness of rTMS in PD are mixed, mostly owing to low statistical power or variety in individual rTMS protocols.ObjectivesTo determine the rTMS effects on motor dysfunction in patients with PD and to examine potential factors that modulate the rTMS effects.Data SourcesDatabases searched included PubMed, EMBASE, Web of Knowledge, Scopus, and the Cochrane Library from inception to June 30, 2014.Study SelectionEligible studies included sham-controlled, randomized clinical trials of rTMS intervention for motor dysfunction in patients with PD.Data Extraction And SynthesisRelevant measures were extracted independently by 2 investigators. Standardized mean differences (SMDs) were calculated with random-effects models.Main Outcomes And MeasuresMotor examination of the Unified Parkinson's Disease Rating Scale.ResultsTwenty studies with a total of 470 patients were included. Random-effects analysis revealed a pooled SMD of 0.46 (95% CI, 0.29-0.64), indicating an overall medium effect size favoring active rTMS over sham rTMS in the reduction of motor symptoms (P<.001). Subgroup analysis showed that the effect sizes estimated from high-frequency rTMS targeting the primary motor cortex (SMD, 0.77; 95% CI, 0.46-1.08; P<.001) and low-frequency rTMS applied over other frontal regions (SMD, 0.50; 95% CI, 0.13-0.87; P=.008) were significant. The effect sizes obtained from the other 2 combinations of rTMS frequency and rTMS site (ie, high-frequency rTMS at other frontal regions: SMD, 0.23; 95% CI, -0.02 to 0.48, and low primary motor cortex: SMD, 0.28; 95% CI, -0.23 to 0.78) were not significant. Meta-regression revealed that a greater number of pulses per session or across sessions is associated with larger rTMS effects. Using the Grading of Recommendations, Assessment, Development, and Evaluation criteria, we characterized the quality of evidence presented in this meta-analysis as moderate quality.Conclusions And RelevanceThe pooled evidence suggests that rTMS improves motor symptoms for patients with PD. Combinations of rTMS site and frequency as well as the number of rTMS pulses are key modulators of rTMS effects. The findings of our meta-analysis may guide treatment decisions and inform future research.

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