A Double Blind Sham-controled Study to Evaluate the Influence of Low Frequency Repetitive Transcranial Stimulation (r-TMS) on Motor and Cognitive Measurements in Patients With Asymmetric Parkinson's Disease

• Decrease in Unified Parkinson's Disease Rating Scale (UPDRS) score [ Time Frame: 3 months ] [ Designated as safety issue: No ]
  A decrease in the total UPDRS score in general and in the Motor UPDRS (part 3) score.
  
  

• CGIS [ Time Frame: 3 months ] [ Designated as safety issue: No ]
  Rater and patient's opinion on the change in thier PD due to the TMS treatment
  
  
• Decrease in time in Pegboard test [ Time Frame: 3 months ] [ Designated as safety issue: No ]
  
• Increase in Tapping test [ Time Frame: 3 months ] [ Designated as safety issue: No ]
  
• Decrease in Time Up&Go test [ Time Frame: 3 months ] [ Designated as safety issue: No ]
  Patient has to get up from a chair, walk 3 meters, turn around and return to sit on the chair.
  
  
• Increase in Word fluency [ Time Frame: 3 months ] [ Designated as safety issue: No ]
  Number of words the patient can think of that start with a certian letter or belong to a certian catagory, in one minute.
  
  
• Increase in Digits Forward & Backwards test [ Time Frame: 3 months ] [ Designated as safety issue: No ]
  
• Number of Participants with Adverse Events as a Measure of Safety and Tolerability [ Time Frame: 3 months ] [ Designated as safety issue: Yes ]
  

PD patients with asymmetric disease aged 40 years or older, diagnosed as idiopathic PD according to the UK Brain Bank criteria, with Hoehn & Yahr stages II - IV while "off" will be recruited. Participants on antidepressants should be at least 2 months on stable therapy.

Patient will be excluded if:

1. Patients who have concomitant epilepsy, a history of seizure or heat convulsion or history of epilepsy in first degree relative.
2. Patients on neuroleptics.
3. Patients with unstable medical disorder.
4. History or current unstable hypertension.
5. History of head injury or neurosurgical interventions.
6. History of any metal in the head (outside the mouth).
7. Known history of any metallic particles in the eye, implanted cardiac pacemaker, implanted neurostimulators, surgical clips (above the shoulder line) or any medical pumps.
8. History of migraine or frequent or severe headaches.
9. Current hearing loss.
10. The presence of cochlear implants
11. Current drug abuse or alcoholism.
12. Pregnancy or not using a reliable method of birth control.
13. Participation in current clinical study or clinical study within 30 days prior to this study.

Patients will be to randomized to an active rTMS arm or to a sham stimulation arm. Each patient will be given 12 stimulation sessions, over a period of 4 weeks, and then a maintenance phase consisting of 8 stimulation sessions for the first 4 weeks and additional 4 stimulation sessions during the following 4 weeks.

Active treatment with the H-coil will include stimulation over the motor cortex (1 Hz stimulation 110% of the motor threshold for 15 minutes) and over the prefrontal cortex (10Hz stimulation 100% of the motor threshold, 2 seconds each train, 20 seconds between trains, for 15 minutes). The control arm group will receive sham stimulations in identical treatment and maintenance schedules. Patients from the sham group who will complete the study will be given the opportunity to receive 12 sessions of real r-TMS treatment over 4 weeks as the treatment group.

The following outcome measures will be taken prior to the treatment (screening visit), and at day 1, 10, 30, 60 and 90. Evaluation will be while subjects are both at "on" and "off".

Motor:

1. Unified Parkinson's Disease Rating Scale (UPDRS )
2. Clinical Global Impression of Severity (CGIS)
3. Pegboard test.
4. Tapping test
5. Up & Go test
6. Abnormal Involuntary Movement Scale (AIMS) Mood and affect

1. Beck Depression Inventory (BDI) Cognition

1. Mini mental State examination (MMSE)
2. Digit forward and backward tests.
3. Word fluency.
4. Frontal Assessment Battery (FAB)

Side effects will be closely monitored by the researchers and will be promptly reported to the IRB.