{"title":"Effect of Different Cortical Targets of Transcranial Magnetic Stimulation on Freezing of Gait in Parkinsonism: A Systematic Review.","authors":"Magdy Adel, Rawda Zayed, Aya Mohamed, Nada Abdelnaby, Nada Hatim, Yasmin Abdelhamed, Eman Abdelwahab, Nada Araby, Mariam Hany, Doaa Abdelhaleem, Aliaa Elabd","doi":"10.1002/pri.70360","DOIUrl":null,"url":null,"abstract":"<p><strong>Background and purpose: </strong>Freezing of gait (FOG) is a disabling and episodic gait disturbance in patients with Parkinson's, with varying responses to noninvasive brain stimulation. Transcranial magnetic stimulation (TMS) has been explored as a therapeutic option; however, the optimal cortical target for reducing FOG remains unclear. This systematic review synthesizes and critically evaluates the available evidence regarding the effects of TMS applied to different cortical targets on FOG-related outcomes, with emphasis on the indirect nature of comparisons between targets.</p><p><strong>Methods: </strong>A systematic search was conducted in four electronic databases (PubMed, Cochrane Library, Web of Science, and Scopus) from inception to December 2025, followed by an updated search conducted through July 21, 2026. Randomized and crossover randomized controlled trials investigating the effects of TMS on FOG in parkinsonism were included. Studies have used TMS with a variety of protocols to target different cortical regions. They evaluated FOG-related outcomes by using validated questionnaires or objective tasks. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Because of heterogeneity in stimulation protocols and outcome measures, a narrative synthesis was performed.</p><p><strong>Results: </strong>The updated search identified additional records; however, no new eligible studies were identified after screening. Therefore, ten studies met the inclusion criteria. Favorable FOG-related findings were reported in some studies targeting the primary motor cortex, including reductions in Freezing of Gait Questionnaire scores and improvements in gait performance, with effects persisting for several weeks in some studies. Findings regarding stimulation of the supplementary motor area were variable, ranging from reported reductions in FOG-related outcomes to limited effects and, in one study, worsening of gait performance. Evidence regarding other targets, including the cerebellum and premotor cortex, was limited and did not demonstrate consistent improvements in FOG-related outcomes. Overall, the included studies reported predominantly mild and transient adverse effects associated with TMS. However, because comparisons between cortical targets were indirect and the included studies demonstrated substantial clinical and methodological heterogeneity, the available evidence does not permit identification of an optimal cortical target for improving FOG.</p><p><strong>Discussion: </strong>The available randomized evidence suggests that TMS may influence FOG-related outcomes; however, the effects cannot be reliably attributed to the cortical target alone. Because no direct head-to-head comparisons between cortical targets were available and the included studies were small and clinically and methodologically heterogeneous, the current evidence is insufficient to identify an optimal or preferred cortical target. Future adequately powered randomized trials directly comparing cortical targets are required.</p><p><strong>Trial registration: </strong>PROSPERO; registration number CRD420261280646.</p>","PeriodicalId":47243,"journal":{"name":"Physiotherapy Research International","volume":"31 4","pages":"e70360"},"PeriodicalIF":1.7000,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Physiotherapy Research International","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.1002/pri.70360","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"REHABILITATION","Score":null,"Total":0}
引用次数: 0
Abstract
Background and purpose: Freezing of gait (FOG) is a disabling and episodic gait disturbance in patients with Parkinson's, with varying responses to noninvasive brain stimulation. Transcranial magnetic stimulation (TMS) has been explored as a therapeutic option; however, the optimal cortical target for reducing FOG remains unclear. This systematic review synthesizes and critically evaluates the available evidence regarding the effects of TMS applied to different cortical targets on FOG-related outcomes, with emphasis on the indirect nature of comparisons between targets.
Methods: A systematic search was conducted in four electronic databases (PubMed, Cochrane Library, Web of Science, and Scopus) from inception to December 2025, followed by an updated search conducted through July 21, 2026. Randomized and crossover randomized controlled trials investigating the effects of TMS on FOG in parkinsonism were included. Studies have used TMS with a variety of protocols to target different cortical regions. They evaluated FOG-related outcomes by using validated questionnaires or objective tasks. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Because of heterogeneity in stimulation protocols and outcome measures, a narrative synthesis was performed.
Results: The updated search identified additional records; however, no new eligible studies were identified after screening. Therefore, ten studies met the inclusion criteria. Favorable FOG-related findings were reported in some studies targeting the primary motor cortex, including reductions in Freezing of Gait Questionnaire scores and improvements in gait performance, with effects persisting for several weeks in some studies. Findings regarding stimulation of the supplementary motor area were variable, ranging from reported reductions in FOG-related outcomes to limited effects and, in one study, worsening of gait performance. Evidence regarding other targets, including the cerebellum and premotor cortex, was limited and did not demonstrate consistent improvements in FOG-related outcomes. Overall, the included studies reported predominantly mild and transient adverse effects associated with TMS. However, because comparisons between cortical targets were indirect and the included studies demonstrated substantial clinical and methodological heterogeneity, the available evidence does not permit identification of an optimal cortical target for improving FOG.
Discussion: The available randomized evidence suggests that TMS may influence FOG-related outcomes; however, the effects cannot be reliably attributed to the cortical target alone. Because no direct head-to-head comparisons between cortical targets were available and the included studies were small and clinically and methodologically heterogeneous, the current evidence is insufficient to identify an optimal or preferred cortical target. Future adequately powered randomized trials directly comparing cortical targets are required.
Trial registration: PROSPERO; registration number CRD420261280646.
背景和目的：步态冻结（FOG）是帕金森患者致残和发作性步态障碍，对非侵入性脑刺激有不同的反应。经颅磁刺激（TMS）已被探索作为一种治疗选择；然而，减少FOG的最佳皮质靶点仍不清楚。本系统综述综合并批判性地评估了应用于不同皮层靶点的经颅磁刺激对fog相关结果影响的现有证据，并强调了靶点之间比较的间接性。方法：系统检索4个电子数据库（PubMed、Cochrane Library、Web of Science和Scopus），检索时间为成立至2025年12月，更新检索时间为2026年7月21日。研究经颅磁刺激对帕金森病FOG影响的随机和交叉随机对照试验被纳入。研究使用不同方案的经颅磁刺激来针对不同的皮层区域。他们通过使用有效的问卷或客观任务来评估fog相关的结果。使用Cochrane Risk of bias 2工具评估偏倚风险。由于刺激方案和结果测量的异质性，我们进行了叙事综合。结果：更新后的搜索发现了额外的记录；然而，筛选后没有发现新的符合条件的研究。因此，有10项研究符合纳入标准。一些针对初级运动皮层的研究报告了有利的fogg相关发现，包括步态冻结问卷得分的降低和步态表现的改善，在一些研究中效果持续数周。关于辅助运动区刺激的结果是不同的，从报道的fogg相关结果的减少到有限的效果，在一项研究中，步态表现恶化。关于其他靶点的证据，包括小脑和运动前皮层，是有限的，并且没有显示出fogg相关结果的持续改善。总的来说，纳入的研究主要报告了与经颅磁刺激相关的轻微和短暂的不良反应。然而，由于皮质靶点之间的比较是间接的，而且纳入的研究显示了大量的临床和方法学上的异质性，现有的证据不允许确定改善FOG的最佳皮质靶点。讨论：现有的随机证据表明经颅磁刺激可能影响fogg相关的结果；然而，这种效果不能可靠地单独归因于皮质靶点。由于在皮质靶点之间没有直接的头对头比较，而且纳入的研究规模小，临床和方法上都不一致，目前的证据不足以确定最佳或首选的皮质靶点。未来需要足够有力的随机试验直接比较皮层靶点。试验注册：PROSPERO；注册号CRD420261280646。
期刊介绍：
Physiotherapy Research International is an international peer reviewed journal dedicated to the exchange of knowledge that is directly relevant to specialist areas of physiotherapy theory, practice, and research. Our aim is to promote a high level of scholarship and build on the current evidence base to inform the advancement of the physiotherapy profession. We publish original research on a wide range of topics e.g. Primary research testing new physiotherapy treatments; methodological research; measurement and outcome research and qualitative research of interest to researchers, clinicians and educators. Further, we aim to publish high quality papers that represent the range of cultures and settings where physiotherapy services are delivered. We attract a wide readership from physiotherapists and others working in diverse clinical and academic settings. We aim to promote an international debate amongst the profession about current best evidence based practice. Papers are directed primarily towards the physiotherapy profession, but can be relevant to a wide range of professional groups. The growth of interdisciplinary research is also key to our aims and scope, and we encourage relevant submissions from other professional groups. The journal actively encourages submissions which utilise a breadth of different methodologies and research designs to facilitate addressing key questions related to the physiotherapy practice. PRI seeks to encourage good quality topical debates on a range of relevant issues and promote critical reflection on decision making and implementation of physiotherapy interventions.
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