Purpose: Freezing of gait (FOG) affects mobility and balance seriously. Few reports have investigated the effects of repetitive transcranial magnetic stimulation (rTMS) on FOG in Parkinson’s disease (PD). We investigated the efficacy of high-frequency rTMS for the treatment of FOG in PD. Methods: Seventeen patients diagnosed with PD were recruited in a randomized, double-blinded, cross-over study. We applied high frequency rTMS (90% of resting motor threshold, 10 Hz, 1,000 pulses) over the lower leg primary motor cortex of the dominant hemisphere (M1-LL) for five sessions in a week. We also administered alternative sham stimulation with a two-week wash out period. The primary outcomes were measured before, immediately after, and one week after the intervention using the Standing Start 180° Turn Test (SS-180) with video analysis and the Freezing of Gait Questionnaire (FOG-Q). The secondary outcome measurements consisted of Timed Up and Go (TUG) tasks and the Unified Parkinson’s Disease Rating Scale part III (UPDRS-III). Motor cortical excitability was also evaluated. Results: There were significant improvements in the step required to complete the SS-180 and FOG-Q in the rTMS condition compared to the sham condition, and the effects continued for a week. The TUG and UPDRS-III also showed significant ameliorations over time in the rTMS condition. The MEP amplitude at 120% resting motor threshold and intracortical facilitation also increased after real rTMS condition. Conclusions: High frequency rTMS over the M1-LL may serve as an add-on therapy for improving FOG in PD.

Background: The COVID-19 pandemic restricted usual healthcare management for movement-disorders patients, with a consequent upsurge in telemedicine to bridge the gap. Objective: To assess global telemedicine usage in the context of the pandemic. Methods: The Movement Disorder Society (MDS) Telemedicine Study Group surveyed telemedicine experts from 40 countries across all continents in March-April 2020. Four domains of telemedicine were assessed: legal regulations, reimbursement, clinical use, and barriers; comparing emerging responses to the pandemic versus the baseline scenario. Results: All forms of telemedicine for movement disorders increased globally, irrespective of country income categorization, as an immediate response to the pandemic. This was aided by widespread availability of technology and updated government regulations. However, privacy concerns, lack of reimbursement, limited access, and lack of telemedicine training were barriers highlighted worldwide. Conclusions: Questions remain about the longevity and extent of changes in regulations and reimbursement regarding telemedicine in the aftermath of the pandemic.

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Introduction The coronavirus disease 2019 (COVID-19) pandemic has disrupted everyday life of Parkinson's disease (PD) patients, but its clinical impact has not been illustrated. In this study, we investigated the change in physical activity and subsequently clinical symptoms of PD during the COVID-19 pandemic. Methods We enrolled PD patients who were able to ambulate independently and had visited our clinic at Samsung Medical Centre from December 2019 to January 2020 (baseline) and in May 2020 (follow-up during the COVID-19 crisis), and divided them into either ‘the sustained exercise group’ or ‘the reduced exercise group’. Then, we assessed the change in the exercise and clinical features between these two groups over the study period. Results A total of 100 subjects were recruited. During the COVID-19 pandemic, the amount, duration and frequency of exercise were reduced. There was decrease in number of patients who do indoor-solo exercise and increase in that of patients who do not exercise. One third reported subjective worsening of both motor and non-motor features, although Unified PD Rating Scale (UPDRS) part 3 score was similar. Additionally, the reduced exercise group reported more motor and non-motor aggravation than the sustained exercise group, despite lack of significant difference in the UPDRS part 3 score. Conclusion The COVID-19 pandemic had a clear impact on exercise and subjective symptoms in PD patients, with reduced exercise being related to a subjective increase in both motor and non-motor symptoms of PD. Maintaining exercise should therefore be emphasized even in situations like the COVID-19 pandemic.

Background/Aims: Parkinson’s disease (PD) is a common neurodegenerative disease with a chronic disease course. The increase in life expectancy of humans worldwide is expected to increase the prevalence and duration of PD; therefore, it is important to determine factors that contribute to the caregiver burden for both clinical and social reasons. Methods: We surveyed 91 main caregivers of patients, and compared factors contributing to caregiver burden between 50 spouses and 41 offspring of patients. We determined Burden Interview, Depression Scale, Health-Related Quality of Life, and Obligation Scale scores, as well as the degree of functional social support of caregivers. Results: Interestingly, the burden scores of the two groups were not significantly different. Correlation analysis revealed that depression, health-related quality of life, social support, subdivided parts of the Unified Parkinson’s Disease Rating Scale (UPDRS), Hoehn and Yahr Scale, score of Mini-Mental State Examination, and Barthel index were correlated with burden in both spouses and offspring. However, in multiple regression, depression score and part 1 of the UPDRS were more significant predictors of burden in the spousal group, whereas social support of community and part 3 of the UPDRS were more important correlated factors in the offspring group. Conclusions: The caregiver burden of spousal and offspring caregivers of PD patients was not significantly different. However, different factors contributed to caregiver burden according to the caregiver’s relationship with the patient.

13Purpose: The aim of this study was to investigate the site-specific effects of repetitive transcranial magnetic stimulation (rTMS) on freezing of gait (FOG) in patients with parkinsonism. 14 15 Methods: Twenty patients with parkinsonism and FOG were included. A single session of 10 Hz rTMS was applied over three different cortical regions of the dominant hemisphere: the primary motor cortex of the lower leg (M1-LL), the supplementary motor area (SMA), and the dorsolateral prefrontal cortex (DLPFC). We also performed sham stimulation as a control. The Timed Up and Go (TUG) test, Turn Steps and Turn Time in 180 • turning, Unified Parkinson's Disease Rating Scale (UPDRS) part III, FOG Questionnaire (FOG-Q), and motor evoked potential (MEP) studies were performed before and after each intervention. 16 17 18 19 20Results: There were significant improvements in TUG test times after rTMS over the M1-LL and the DLPFC. Improvement was significantly greater after the M1-LL stimulation than sham condition. The M1-LL and DLPFC stimulation also resulted in significant improvements in both the number of Turn Steps and Turn Time. UPDRS-III scores were significantly decreased after the M1-LL and DLPFC stimulation. 21 22 23 24 Conclusions: Use of 10 Hz rTMS on the M1-LL and DLPFC is therapeutically effective for FOG in patients with parkinsonism.25

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Background/Aims: Previous studies indicate that patients with the parkinsonian subtype of multiple system atrophy (MSA-P) experience cognitive impairment. This study aimed to identify the existence of cognitive impairments and the different topographic patterns of morphological changes in MSA-P by means of imaging analysis, and also whether these morphological changes could be associated with cognitive dysfunctions in MSA-P. Methods: We recruited 15 nondemented probable MSA-P patients and 32 normal controls (NC) for neuropsychological testing and MRI. We analyzed morphological changes using cortical thickness analysis, voxel-based morphometry (VBM) and cerebellar volumetry. Multiple linear regression analysis was performed to evaluate the correlation of each cognitive score with the mean thickness of significant cortical-thinning clusters, mean gray-matter density of VBM clusters and cerebellar volume. Results: The scores on the Digit Span Test, the Seoul Verbal Learning Test (immediate and delayed), the phonemic Controlled Oral Word Association Test and the Stroop color test were significantly lower in the MSA-P group than in the NC group. We found two clusters exhibiting significant cortical thinning in the right paracentral lobule and parahippocampal gyrus. VBM analysis revealed significant gray-matter atrophy in the MSA-P group in the bilateral basal ganglia, cerebellum and temporal and frontal cortical areas. Multiple linear regression analysis demonstrated that cognitive dysfunction correlated significantly with thinning in the neocortex, cerebellum and striatum. Conclusions: Our data demonstrate that cortical and cerebellar atrophy and striatal degeneration are associated with cognitive impairment in patients with MSA-P.