Paired inhibitory stimulation and gait training modulates supplemental motor area connectivity in freezing of gait

• Published in: Parkinsonism & related disorders Vol. 88; pp. 28 - 33
• Main Authors: Lench, Daniel H., DeVries, Will, Kearney-Ramos, Tonisha E., Chesnutt, Alyssa, Monsch, Eric D., Embry, Aaron E., Doolittle, Jade D., Kautz, Steven A., Hanlon, Colleen A., Revuelta, Gonzalo J.
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.07.2021
• Subjects: Aged; Cerebellum - diagnostic imaging; Cerebellum - physiopathology; Combined Modality Therapy; Connectivity; Connectome; Exercise Therapy; Female; Freezing; Gait; Gait Disorders, Neurologic - etiology; Gait Disorders, Neurologic - physiopathology; Gait Disorders, Neurologic - therapy; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Motor Cortex - diagnostic imaging; Motor Cortex - physiopathology; Neurological Rehabilitation; Parkinson Disease - complications; Parkinson Disease - physiopathology; Parkinson Disease - therapy; Parkinson's disease; Transcranial Magnetic Stimulation; Connectivity; Parkinson's disease; Transcranial magnetic stimulation; Gait; Freezing
• ISSN: 1353-8020; 1873-5126
• DOI: 10.1016/j.parkreldis.2021.05.028

Freezing of gait (FOG) is a debilitating feature of Parkinson's disease (PD). Evidence suggests patients with FOG have increased cortical control of gait. The supplementary motor area (SMA) may be a key structure due to its connectivity with locomotor and cognitive networks. The objectives of this study were to determine (1) if SMA connectivity is disrupted in patients with FOG and (2) if “inhibitory” repetitive transcranial magnetic stimulation can decrease maladaptive SMA connectivity. Two experiments were performed. In experiment 1 resting-state (T2* BOLD imaging) was compared between 38 PD freezers and 17 PD controls. In experiment 2, twenty PD patients with FOG were randomized to either 10 sessions of real or sham rTMS to the SMA (1 Hz, 110% motor threshold, 1200 pulses/session) combined with daily gait training. (Experiment 1) Freezers had increased connectivity between the left SMA and the vermis of the cerebellum and decreased connectivity between the SMA and the orbitofrontal cortex (pFDR-corr <0.05). (Experiment 2) 10 sessions of active TMS reduced SMA connectivity with the anterior cingulate, angular gyrus and the medial temporal cortex, whereas sham TMS did not reduce SMA connectivity. From a behavioral perspective, both groups showed nFOG-Q improvements (F(4, 25.7) = 3.87, p = 0.014). The SMA in freezers is hyper-connected to the cerebellum, a key locomotor region which may represent maladaptive compensation. In this preliminary study, 1 Hz rTMS reduced SMA connectivity however, this was not specific to the locomotor regions. Intervention outcomes may be improved with subject specific targeting of SMA. •Unknown if supplementary motor area is adaptive or maladaptive for freezing of gait.•The supplemental motor area is hyperconnected to the cerebellum in freezers.•Low frequency stimulation of the supplemental motor area and gait training reduces connectivity.•Low frequency stimulation and gait training has variable effects on freezing outcomes.