الفهرس 
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Abstract
Parkinsonism is a braod definition means a collection of 4 main manifestations which are ” bradykinesia, rigidity, tremors and postural instability”.
It’s divided into many types, the most important of them is Parkinson’s disease (PD) as it’s the fisrt to be described and the most common among population.
Cinical picture of PD can be classified into : Motor and non motor symptoms.
Motor symptopms ,which include the main features, are:
bradykinesia which means slowness of movement, rigidity that means stiffness and increase of muscle tone , tremors that have special characters in PD patients ,they are resting distal pill rolling in character, disappear during sleep, and postural instability makes the patients easily to fall forward (propulsion) or backward (retropulsion).
They also include: gait disturbances (festination or freezing of gait), hypomimia and micrographia.
As regard the non motor symptoms: they include Hyposomia, psychiatric symptoms, cognitive imapirment, genitourinary symptoms and others.
Etiology of PD can be concluded up till now in the neurodegenerative process that affect more than one site in CNS such as substantia nigra, noradrenaline (NA)-producing cells in the locus coeruleus (LC) of the dorsal pon and in the reticular formation of the medulla oblongata, raphe nucleus, olfactory bulb and others. prescribed in ” Braak staging ”.
Plus, genetic and environmental factors.
PD can be treated by more than one line, the first of them is the medical treatment which includes:
1. Leveodopa : the most effective among all medications.
2. Dopamine agonist: Non ergot derivatives (like ropinirole and pramipexole|) and ergot derivatives (bromocriptine).
3. Catechol-O-methyltransferase (COMT) Inhibitors: Entacapone, telecapone.
4. Monoamine Oxidase (MAO) Inhibitors: siligiline, rasagiline.
5. Amantadine and anticholinergic.
Each of these medications has some side effects that some of them can be tolerable and others can not such as dyskinesia that occur with levodopa which consider the best drug.
Another line: is the surgical line that include thalamotomy and deep brain stimulation (DBS), the surgical consider the last line being invasive and has significant side effects in addition to the idea of fear of surgery present among our population.
Transcranial magnetic stimulation (TMS) is a non-invasive maneuver aiming to stimulate specific parts in the brain to improve their functions using the low of Faraday.
It has many types : repetitive transcranial magnetic stimulation is considered the most significant and it’s used in many neurological and psychiatric diseases such as stroke, tinnitus, depression and others.
Many studies and research cared about using rTMS in parkinsonian disorders and they resulted in promising results & our study is one of them.
Methodology of the study:
Our study is done on 35 patients (24 males & 11 females), they were chosen according to inclusion criteria (Adults aged 18 years and more, both males and females, diagnosed Parkinsonism, with no change in antiparkinsonian medications for 3 weeks.
Some patients were excluded according to exclusion criteria (Metal implants, personal or family history of seizures, brain tumors or injury, history of receiving TMS sessions, unstable any medical illness and pregnancy).
All patients were evaluated by Unified Parkinson’s Disease Rating scale (UPDRS) than divided into 2 groups :
A group received sham TMS (16) and the other received real TMS (19).
Our protocol:
Double blinded 10 sessions of high frequency rTMS on bilateral M1 (primary motor area of hand and legs) in 10 successive days.
(120% RMT stimulation intensity; 5 Hz frequency; 10 sec on and 1sec off; 2000 pulses per session; total duration 25 min per session).
Then reevaluation of all patients was done after the 10th session using the same scale.
Results:
35 patients were included in the study both males & females, some of them have some chronic diseases while others don’t.
Their duration of illness is between 1 & 16 years all on levodopa (antiparkinsonian drug) except for 5 of them, evaluated before the 1st session by the first parts of UPDRS , the score of the scale was almost equal between the 2 groups and the reevaluation was done after the 10th session.