Integration of Virtual Reality into Transcranial Magnetic Stimulation Improves Cognitive Function in Patients with Parkinson’s Disease with Cognitive Impairment: A Proof-of-Concept Study

Article type: Research Article

Authors: Cheng, Tsai-Chin^a | Huang, Shih-Fong^b | Wu, Shang-Yu^a | Lin, Fu-Gong^c | Lin, Wang-Sheng^d | Tsai, Po-Yi^{a; e; *}

Affiliations: [a] Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan | [b] Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan | [c] Department of Optometry, University of Kang Ning, Taipei, Taiwan | [d] Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Yuan-Shan Branch, Yilan, Taiwan | [e] National Yang-Ming Chiao-Tung University, School of Medicine, Taipei, Taiwan

Correspondence: [*] Correspondence to: Po-Yi Tsai, MD, Department of Physical Medicine and Rehabilitation, Taipei Veterans General, Hospital, Taipei, Taiwan; National Yang-Ming Chiao-Tung University, School of Medicine, No. 201, Shih-Pai Rd, Sec. 2, Taipei, 11217 Taiwan. Tel.: +886 2 28757364 586, +886 9 38591978; Fax: +886 2 2875 7359; E-mail: pytsai@vghtpe.gov.tw.

Abstract: Background:Emerging evidence has indicated the positive effects of repetitive transcranial magnetic stimulation (rTMS) on patients with Parkinson’s disease (PD) for the treatment of mild cognitive impairment (MCI). Objective:Investigating whether combining virtual reality (VR) training with rTMS can further enhance cognitive improvement induced by rTMS treatment. Methods:We randomly assigned 40 patients with PD and MCI into three groups, namely the rTMS-VR group (n = 13), rTMS group (n = 11), and sham rTMS group (n = 16). rTMS was administered as 10 consecutive sessions of intermittent theta burst stimulation (iTBS) over the left dorsolateral prefrontal cortex. In the rTMS-VR group, VR training was administered immediately after each rTMS session. Cognitive function was measured using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and Montreal Cognitive Assessment (MoCA) at baseline, immediately after intervention, and at 3-month follow-up. Results:Compared with the rTMS group, the rTMS-VR group exhibited significantly more improvements in total and delayed memory scores of the RBANS and the visuospatial/executive function score of the MoCA after intervention (p = 0.000∼0.046) and the delayed memory score of the RBANS at 3-month follow-up (p = 0.028). Conclusion:The integrated rTMS-VR protocol achieved a superior outcome in global cognitive function, more effectively enhancing working memory and visuospatial executive function than did the rTMS protocol alone. The combination of VR and rTMS can be an effective regimen for improving the cognitive function of patients with PD.

Keywords: Cognitive dysfunction, Parkinson’s disease, transcranial magnetic stimulation, virtual reality

DOI: 10.3233/JPD-212978

Journal: Journal of Parkinson's Disease, vol. 12, no. 2, pp. 723-736, 2022