An interventional study of transcranial magnetic stimulation in Parkinson Disease, Autonomic Dysfunction and Depression, sponsored by University of North Carolina, Chapel Hill. Completed at 1 site in United States. Open to participants aged 50 Years to 90 Years. Per ClinicalTrials.gov, last updated 2025-05-21.
Sponsored by University of North Carolina, Chapel Hill · Not applicable, Interventional, and Basic science
This is a randomized, single-blinded, triple crossover study focused on determining the feasibility of using transcranial magnetic stimulation (TMS) for treatment of Parkinson's disease related autonomic dysfunction and depression. Participants will undergo TMS to three brain regions: medial prefrontal cortex (mPFC) (experimental site), dorsolateral prefrontal cortex (DLPFC) (alternative experimental site), or primary sensory cortex (S1) (control site) in a triple crossover design. Participants will complete symptom questionnaires, neurologic examination and cognitive assessments, and orthostatic vital signs recording before and after each brain stimulation session.
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Participants first undergo transcranial magnetic stimulation to the medial prefrontal cortex. After a 3 week washout period, participants then undergo transcranial magnetic stimulation to the control site. After a 3 week washout period, participants undergo transcranial magnetic stimulation to the dorsolateral prefrontal cortex.
Device: transcranial magnetic stimulation
Participants first undergo transcranial magnetic stimulation to the medial prefrontal cortex. After a 3 week washout period, participants then undergo transcranial magnetic stimulation to the dorsolateral prefrontal cortex. After a 3 week washout period, participants undergo transcranial magnetic stimulation to the control site.
Device: transcranial magnetic stimulation
Participants first undergo transcranial magnetic stimulation to the dorsolateral prefrontal cortex. After a 3 week washout period, participants then undergo transcranial magnetic stimulation to the medial prefrontal cortex. After a 3 week washout period, participants undergo transcranial magnetic stimulation to the control site.
Device: transcranial magnetic stimulation
Participants first undergo transcranial magnetic stimulation to the dorsolateral prefrontal cortex. After a 3 week washout period, participants then undergo transcranial magnetic stimulation to the control site. After a 3 week washout period, participants undergo transcranial magnetic stimulation to the medial prefrontal cortex.
Device: transcranial magnetic stimulation
Participants first undergo transcranial magnetic stimulation to the control site. After a 3 week washout period, participants then undergo transcranial magnetic stimulation to the medial prefrontal cortex. After a 3 week washout period, participants undergo transcranial magnetic stimulation to the dorsolateral prefrontal cortex.
Device: transcranial magnetic stimulation
Participants first undergo transcranial magnetic stimulation to the control site. After a 3 week washout period, participants then undergo transcranial magnetic stimulation to the dorsolateral prefrontal cortex. After a 3 week washout period, participants undergo transcranial magnetic stimulation to the medial prefrontal cortex.
Device: transcranial magnetic stimulation
Transcranial magnetic stimulation (or TMS) is a non-invasive form of brain stimulation in which a magnetic pulse is applied directly to the scalp. This device is FDA approved for treatment of depression and other neuropsychiatric disorders, and is regularly used in neurologic and psychiatric research. iTBS is a particular TMS protocol which delivers the magnetic field in triplet bursts (three stimulations very close together at a frequency of 50 Hz very quickly). The triplet bursts are repeated at a rate of 5 Hz for 2 seconds (30 pulses), followed by 8 seconds rest, repeated 20 times for a total of 600 pulses. Each treatments lasts approximately 3 minutes.
Also known as: intermittent theta-burst stimulation (iTBS)
Change in Frontal Midline Theta EEG Power After Brain Stimulation
Degree of change of frontal midline theta (FMT) power on electroencephalography (EEG) after brain stimulation at each site (medial prefrontal cortex, dorsolateral prefrontal cortex, control site).
Time frame: At least 30 minutes before initial iTBS, and 30 minutes after each iTBS treatment
Correlation Between the Scales for Outcomes in Parkinson's Disease - Autonomic (SCOPA-AUT) Total Score and EEG
Degree of correlation between the Scales for Outcomes in Parkinson's disease - Autonomic (SCOPA-AUT) total score and frontal midline theta EEG power extracted from Baseline pre-stimulation initial visit EEG and SCOPA-AUT questionnaire. The SCOPA-AUT is a validated autonomic symptom survey for people with Parkinson's disease. It contains 6 domains (gastrointestinal, urinary, cardiovascular, thermoregulatory, pupillary, and sexual). The investigators will use the total composite score including all domains. The score range is 0-69, with a total of 23 questions. 0 means no symptoms, 69 is highest burden of symptoms. The FMT and SCOPA-AUT were assessed at baseline. FMT power and SCOPA-AUT were correlated using the Spearman Correlation Coefficient calculation. A positive correlation coefficient indicates a positive relationship between the assessments; higher FMT power correlates with higher symptom burden.
Time frame: At least 30 minutes before initial iTBS
Correlation Between the Orthostatic Hypotension Questionnaire (OHQ) and EEG
Degree of correlation between the Orthostatic Hypotension Questionnaire (OHQ) composite score and frontal midline theta EEG power extracted from Baseline pre-stimulation initial visit EEG and OHQ questionnaire. The OHQ consists of two sections: 1-orthostatic hypotension symptom assessment, which includes 6 questions with a score range of 0-66 (0 is no symptoms, 66 is most severe symptoms); and 2-the orthostatic hypotension daily activity scale, which rates interference of symptoms on activities of daily living. This part consists of four questions, and score range is 0-44 (0 is no interference, 44 is most severe interference). The composite OHQ score is the average score between these two subsections. FMT power and OHQ were correlated using the Spearman Correlation Coefficient calculation. A positive correlation coefficient indicates a positive relationship between the assessments; higher FMT power correlates with higher symptom burden.
Time frame: At least 30 minutes before initial iTBS
Correlation Between Degree of Orthostatic Hypotension and EEG
Degree of correlation between degree of orthostatic hypotension and frontal midline theta EEG power will be measured extracted from Baseline pre-stimulation visit EEG and blood pressure measures. Orthostatic vital signs will be measured at least 30 minutes before initial iTBS as follows: blood pressure will be measured after at least 3 minutes of rest in the supine position. Blood pressure will again be measured after 3 minutes of standing. Blood pressure reduction is expressed as the magnitude of reduction, thus a positive number reflects a greater reduction. Lack of blood pressure reduction was coded as '0'. A positive correlation coefficient indicates a positive relationship between the assessments; higher FMT power correlates with higher more severe orthostatic hypotension.
Time frame: At least 30 minutes before initial iTBS
SCOPA-AUT Response to Brain Stimulation
Change in the SCales for Outcomes in Parkinson's disease - Autonomic (SCOPA-AUT) from 30 minutes before stimulation to 1 day after stimulation and 4 days after stimulation. The SCOPA-AUT is a validated autonomic symptom survey for people with Parkinson's disease. It contains 6 domains (gastrointestinal, urinary, cardiovascular, thermoregulatory, pupillary, and sexual). The investigators will use the total composite score including all domains. The score range is 0-69, with a total of 23 questions. 0 means no symptoms, 69 is highest burden of symptoms
Time frame: 30 minutes pre-iTBS, and 1 day and 4 days after each iTBS treatment
OHQ Response to Brain Stimulation
Change in the Orthostatic Hypotension Questionnaire (OHQ) from before to after iTBS. The OHQ will be administered at least 30 minutes before stimulation, and again 1 day and 4 days after stimulation. The OHQ is an orthostatic hypotension symptom survey and consists of two sections. The first is the orthostatic hypotension symptom assessment, which includes 6 questions with a score range of 0-66 (0 is no symptoms, 66 is most severe symptoms). The second part is the orthostatic hypotension daily activity scale, which rates interference of symptoms on activities of daily living. This part consists of four questions, and score range is 0-44 (0 is no interference, 44 is most severe interference). The investigators will calculate the composite OHQ score, which is the average score between these two subsections.
Time frame: At least 30 minutes pre-iTBS, and day 1 and day 4 after each iTBS treatment
Response of Orthostatic Blood Pressure Changes to Brain Stimulation
Change in the orthostatic blood pressure change from before to after iTBS. Orthostatic vital signs will be measured as follows: blood pressure will be measured after at least 3 minutes of rest in the supine position. Blood pressure will again be measured after 3 minutes of standing. This will be measured at least 30 minutes before brain stimulation, and again 30 minutes after brain stimulation.
Time frame: At least 30 minutes before each iTBS treatment, and 30 minutes after each iTBS treatment
Depression Symptom Response to Brain Stimulation
Change in the Beck Depression Inventory II (BDI-II) from before to after iTBS. Participants will complete the BDI-II at least 30 minutes before brain stimulation. The questionnaire will be repeated 1 day and 4 days after stimulation. The BDI-II is a validated depression symptom survey. This survey contains 21 questions, with a score range of 0-63, where 0 means no depression symptoms and 63 indicates severe depression symptoms.
Time frame: At least 30 minutes before each iTBS treatment, and day 1 and day 4 after each iTBS treatment
| Milestone | Medial Prefrontal Cortex - Control Site - Dorsolateral Prefrontal Cortex | Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Control Site - Medial Prefrontal Cortex | Control Site - Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex | Control Site - Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex |
|---|---|---|---|---|---|---|
| Started | 5 | 4 | 5 | 3 | 7 | 6 |
| Completed | 5 | 4 | 5 | 3 | 7 | 6 |
| Not completed | 0 | 0 | 0 | 0 | 0 | 0 |
| Milestone | Medial Prefrontal Cortex - Control Site - Dorsolateral Prefrontal Cortex | Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Control Site - Medial Prefrontal Cortex | Control Site - Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex | Control Site - Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex |
|---|---|---|---|---|---|---|
| Started | 5 | 3 | 5 | 3 | 7 | 5 |
| Completed | 5 | 2 | 5 | 2 | 6 | 5 |
| Not completed | 0 | 1 | 0 | 1 | 1 | 0 |
| Milestone | Medial Prefrontal Cortex - Control Site - Dorsolateral Prefrontal Cortex | Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Control Site - Medial Prefrontal Cortex | Control Site - Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex | Control Site - Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex |
|---|---|---|---|---|---|---|
| Started | 5 | 2 | 5 | 2 | 6 | 5 |
| Completed | 5 | 2 | 4 | 2 | 6 | 5 |
| Not completed | 0 | 0 | 1 | 0 | 0 | 0 |
| Milestone | Medial Prefrontal Cortex - Control Site - Dorsolateral Prefrontal Cortex | Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Control Site - Medial Prefrontal Cortex | Control Site - Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex | Control Site - Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex |
|---|---|---|---|---|---|---|
| Started | 5 | 2 | 4 | 2 | 6 | 5 |
| Completed | 5 | 2 | 4 | 2 | 6 | 5 |
| Not completed | 0 | 0 | 0 | 0 | 0 | 0 |
| Milestone | Medial Prefrontal Cortex - Control Site - Dorsolateral Prefrontal Cortex | Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Control Site - Medial Prefrontal Cortex | Control Site - Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex | Control Site - Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex |
|---|---|---|---|---|---|---|
| Started | 5 | 2 | 4 | 2 | 6 | 5 |
| Completed | 5 | 2 | 4 | 2 | 6 | 5 |
| Not completed | 0 | 0 | 0 | 0 | 0 | 0 |
| Milestone | Medial Prefrontal Cortex - Control Site - Dorsolateral Prefrontal Cortex | Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Control Site - Medial Prefrontal Cortex | Control Site - Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex | Control Site - Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex |
|---|---|---|---|---|---|---|
| Started | 5 | 2 | 4 | 2 | 6 | 5 |
| Completed | 5 | 2 | 4 | 2 | 6 | 5 |
| Not completed | 0 | 0 | 0 | 0 | 0 | 0 |
Degree of change of frontal midline theta (FMT) power on electroencephalography (EEG) after brain stimulation at each site (medial prefrontal cortex, dorsolateral prefrontal cortex, control site).
| microvolts^2/Hz | Medial Prefrontal Cortex Stimulation | Dorsolateral Prefrontal Cortex Stimulation | Control Site Stimulation |
|---|---|---|---|
| Change in Frontal Midline Theta EEG Power After Brain Stimulation | 1.03 ± 2.41 | 0.44 ± 2.55 | 1.01 ± 2.13 |
Degree of correlation between the Scales for Outcomes in Parkinson's disease - Autonomic (SCOPA-AUT) total score and frontal midline theta EEG power extracted from Baseline pre-stimulation initial visit EEG and SCOPA-AUT questionnaire. The SCOPA-AUT is a validated autonomic symptom survey for people with Parkinson's disease. It contains 6 domains (gastrointestinal, urinary, cardiovascular, thermoregulatory, pupillary, and sexual). The investigators will use the total composite score including all domains. The score range is 0-69, with a total of 23 questions. 0 means no symptoms, 69 is highest burden of symptoms. The FMT and SCOPA-AUT were assessed at baseline. FMT power and SCOPA-AUT were correlated using the Spearman Correlation Coefficient calculation. A positive correlation coefficient indicates a positive relationship between the assessments; higher FMT power correlates with higher symptom burden.
| Spearman Correlation coefficient | Stimulation Naiive |
|---|---|
| Correlation Between the Scales for Outcomes in Parkinson's Disease - Autonomic (SCOPA-AUT) Total Score and EEG | 0.255 |
Degree of correlation between the Orthostatic Hypotension Questionnaire (OHQ) composite score and frontal midline theta EEG power extracted from Baseline pre-stimulation initial visit EEG and OHQ questionnaire. The OHQ consists of two sections: 1-orthostatic hypotension symptom assessment, which includes 6 questions with a score range of 0-66 (0 is no symptoms, 66 is most severe symptoms); and 2-the orthostatic hypotension daily activity scale, which rates interference of symptoms on activities of daily living. This part consists of four questions, and score range is 0-44 (0 is no interference, 44 is most severe interference). The composite OHQ score is the average score between these two subsections. FMT power and OHQ were correlated using the Spearman Correlation Coefficient calculation. A positive correlation coefficient indicates a positive relationship between the assessments; higher FMT power correlates with higher symptom burden.
| Spearman Correlation coefficient | Stimulation Naiive |
|---|---|
| Correlation Between the Orthostatic Hypotension Questionnaire (OHQ) and EEG | 0.261 |
Degree of correlation between degree of orthostatic hypotension and frontal midline theta EEG power will be measured extracted from Baseline pre-stimulation visit EEG and blood pressure measures. Orthostatic vital signs will be measured at least 30 minutes before initial iTBS as follows: blood pressure will be measured after at least 3 minutes of rest in the supine position. Blood pressure will again be measured after 3 minutes of standing. Blood pressure reduction is expressed as the magnitude of reduction, thus a positive number reflects a greater reduction. Lack of blood pressure reduction was coded as '0'. A positive correlation coefficient indicates a positive relationship between the assessments; higher FMT power correlates with higher more severe orthostatic hypotension.
| Spearman Correlation coefficient | Stimulation Naiive |
|---|---|
| Correlation Between Degree of Orthostatic Hypotension and EEG | 0.429 |
Change in the SCales for Outcomes in Parkinson's disease - Autonomic (SCOPA-AUT) from 30 minutes before stimulation to 1 day after stimulation and 4 days after stimulation. The SCOPA-AUT is a validated autonomic symptom survey for people with Parkinson's disease. It contains 6 domains (gastrointestinal, urinary, cardiovascular, thermoregulatory, pupillary, and sexual). The investigators will use the total composite score including all domains. The score range is 0-69, with a total of 23 questions. 0 means no symptoms, 69 is highest burden of symptoms
Results for this outcome have not been posted.
Change in the Orthostatic Hypotension Questionnaire (OHQ) from before to after iTBS. The OHQ will be administered at least 30 minutes before stimulation, and again 1 day and 4 days after stimulation. The OHQ is an orthostatic hypotension symptom survey and consists of two sections. The first is the orthostatic hypotension symptom assessment, which includes 6 questions with a score range of 0-66 (0 is no symptoms, 66 is most severe symptoms). The second part is the orthostatic hypotension daily activity scale, which rates interference of symptoms on activities of daily living. This part consists of four questions, and score range is 0-44 (0 is no interference, 44 is most severe interference). The investigators will calculate the composite OHQ score, which is the average score between these two subsections.
Results for this outcome have not been posted.
Change in the orthostatic blood pressure change from before to after iTBS. Orthostatic vital signs will be measured as follows: blood pressure will be measured after at least 3 minutes of rest in the supine position. Blood pressure will again be measured after 3 minutes of standing. This will be measured at least 30 minutes before brain stimulation, and again 30 minutes after brain stimulation.
Results for this outcome have not been posted.
Change in the Beck Depression Inventory II (BDI-II) from before to after iTBS. Participants will complete the BDI-II at least 30 minutes before brain stimulation. The questionnaire will be repeated 1 day and 4 days after stimulation. The BDI-II is a validated depression symptom survey. This survey contains 21 questions, with a score range of 0-63, where 0 means no depression symptoms and 63 indicates severe depression symptoms.
Results for this outcome have not been posted.
Collected over From the time of signing informed consent through 1-3 days following completion of the 3rd intervention, approximately 6-7 weeks total depending upon optional consolidation of screening and Visit 1 as per protocol.. Non-serious events are listed at a 0% frequency threshold.
| Group | Deaths | Serious | Other |
|---|---|---|---|
| Medial Prefrontal Cortex Stimulation | 0/25 (0%) | 0/25 (0%) | 1/25 (4%) |
| Dorsolateral Prefrontal Cortex Stimulation | 0/26 (0%) | 0/26 (0%) | 1/26 (3.8%) |
| Control Site Stimulation | 0/25 (0%) | 0/25 (0%) | 0/25 (0%) |
| Event | Medial Prefrontal Cortex Stimulation | Dorsolateral Prefrontal Cortex Stimulation | Control Site Stimulation |
|---|---|---|---|
| Exacerbation of Muscle SpasmsMusculoskeletal and connective tissue disorders | 1/25 | 0/26 | 0/25 |
| Hair LossSkin and subcutaneous tissue disorders | 0/25 | 1/26 | 0/25 |
| Age, Continuous(years) | Medial Prefrontal Cortex - Control Site - Dorsolateral Prefrontal Cortex | Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Control Site - Medial Prefrontal Cortex | Control Site - Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex | Control Site - Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex | Total |
|---|---|---|---|---|---|---|---|
| Mean | 65.8 ± 7.36 | 68.5 ± 7.50 | 69.5 ± 3.77 | 74.0 ± 1.00 | 67.0 ± 9.27 | 67.2 ± 8.73 | 67.92 ± 7.78 |
| Sex: Female, Male(Participants) | Medial Prefrontal Cortex - Control Site - Dorsolateral Prefrontal Cortex | Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Control Site - Medial Prefrontal Cortex | Control Site - Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex | Control Site - Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex | Total |
|---|---|---|---|---|---|---|---|
| Female | 2 | 2 | 1 | 2 | 1 | 2 | 10 |
| Male | 3 | 0 | 3 | 0 | 5 | 3 | 14 |
| Race and Ethnicity Not Collected(Participants) | Medial Prefrontal Cortex - Control Site - Dorsolateral Prefrontal Cortex | Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Control Site - Medial Prefrontal Cortex | Control Site - Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex | Control Site - Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex | Total |
|---|---|---|---|---|---|---|---|
| Count of participants | — | — | — | — | — | — | 0 |
| Region of Enrollment(participants) | Medial Prefrontal Cortex - Control Site - Dorsolateral Prefrontal Cortex | Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex - Control Site | Dorsolateral Prefrontal Cortex - Control Site - Medial Prefrontal Cortex | Control Site - Medial Prefrontal Cortex - Dorsolateral Prefrontal Cortex | Control Site - Dorsolateral Prefrontal Cortex - Medial Prefrontal Cortex | Total |
|---|---|---|---|---|---|---|---|
| United States | 5 | 2 | 4 | 2 | 6 | 5 | 24 |
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Plan to share: Yes — Deidentified individual data that supports the results will be shared beginning 9 to 36 months following publication provided the investigator who proposes to use the data has approval from an Institutional Review Board (IRB), Independent Ethics Committee (IEC), or Research Ethics Board (REB), as applicable, and executes a data use/sharing agreement with UNC.
Supporting information: Study protocol
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University of North Carolina, Chapel Hill