May, 8, 2013

DynaMed EBM Journal Volume 8, Issue 19

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: May 8, 2013

Expiration Date: May 8, 2014

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company

James McLellan, PhD - Senior Medical Writer, DynaMed, Ipswich, Massachusetts, USA


Dr. Ehrlich, Dr. Fleming, Dr. McLellan, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 8, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 6, 2013. Term of approval is for one year from this date with the option of yearly renewal. Each weekly updated is approved for 0.25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1304158A


Last week 461 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 207 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article of significant interest was selected by the DynaMed Editorial Team.

Low-Frequency Repetitive Transcranial Magnetic Stimulation of Supplementary Motor Area Improves Motor Function in Patients with Parkinson Disease
Reference: Neurology 2013 Apr 9;80(15):1400, (level 1 [likely reliable] evidence)

Repetitive transcranial magnetic stimulation (rTMS) has shown efficacy for a wide variety of conditions ranging from stroke to depression to tobacco craving. Its use has been explored for control of motor symptoms in Parkinson disease, but the optimal location and frequency of stimulation are unclear. In previous studies in Parkinson disease, rTMS has generally targeted the primary motor cortex or prefrontal cortex, and high-frequency stimulation has shown greater efficacy than low-frequency stimulation (Mov Disord. 2009 Feb 15;24(3):357). A recent randomized trial evaluated rTMS of the supplementary motor area, comparing 2 different frequencies of stimulation and sham stimulation in 106 patients with Parkinson disease.

Patients (mean age 68 years) with Hoehn-Yahr stage 2-4 Parkinson disease were randomized to low-frequency rTMS (1 Hz) vs. high-frequency rTMS (10 Hz) vs. realistic sham simulation once weekly for 8 weeks and followed for 12 additional weeks. Focal stimulation was applied with a handheld device over the supplementary motor area (3 cm anterior to the leg motor area along the midline). Stimulation sessions lasted 17-20 minutes. All patients continued on their current medications. The primary outcome was change in motor function as measured by the Unified Parkinson's Disease Rating Scale (UPDRS) part III score. This score includes assessment of speech, tremor, rigidity, posture, gait, and other motor functions, with reduced scores indicating improvement. A change in score of 2.3 points is considered minimal clinically important difference, and a change of 4.5-7 points moderately important.

At the end of follow-up, the mean reductions in motor scores were 6.84 points with rTMS at 1 Hz, 0.71 points with rTMS at 10 Hz, and 2.15 points with sham (p < 0.022, pairwise comparisons not reported). Only the rTMS 1 Hz group showed a significant reduction from baseline. In post hoc analyses, rTMS 1 Hz was associated with significant improvement in posture and gait, and borderline improvement in rigidity and bradykinesia compared to the other groups. There were no significant differences in tremor or speech among groups. There were also no significant differences in depression, apathy scores, or nonmotor symptoms scores among groups. No adverse events were reported in any group.

Repetitive transcranial magnetic stimulation was approved by the FDA in 2008 for treatment of major depression and is widely available for that indication. Its use for other psychiatric and neurologic conditions is still considered investigational.

For more information, see the Parkinson disease topic in DynaMed.

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For more information on this educational activity, see the CME sidebar.

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