Abstract
This study investigates the effect of Repetitive Transcranial Magnetic Stimulation (rTMS) on persistent post-concussion syndrome (PCS). The study design was a randomized (coin toss), placebo controlled, and double-blind study. Thirty-seven participants with PCS were assessed for eligibility; 22 were randomised and 18 completed the study requirements. Half the participants with PCS were given an Active rTMS intervention and the other half given Sham rTMS over 3 weeks. Follow ups were at the end of treatment and at 30 and 60 days. The primary outcome measure was the Rivermead Post-Concussion Symptoms Questionnaire (RPQ3 & RPQ13). The results indicate participants with more recent injuries (<12 month), who received Active rTMS, showed significant improvements compared to those of: 1) the same subgroup who received Sham, and 2) those with a longer duration of injury (>14 months) who received Active rTMS. This improvement predominantly manifested in RPQ13 in the follow up periods 1 and 2 months after the intervention (RPQ13 change (mean ± SD): at 1 month, Active = −21.8 ± 6.6, Sham = −2.2 ± 9.8; at 2 months, Active = −21.2 ± 5.3, Sham = −5.4 ± 13.7). No improvement was found in the subgroup with longer duration injuries. The results support rTMS as a tolerable and potentially effective treatment option for individuals with a recent (<1 year) concussion.
Highlights
Given that PCS imposes substantial medical and socio-economic burdens on patients and the healthcare system[11,12,13], there is an urgent need to develop an effective treatment strategy as well as quantitative methods to monitor PCS recovery
As PCS signs or symptoms can often last for a year, we believe that injured nerves and their connectivity can typically go through a recovery period which can last for one year suggestive that the application of repetitive Transcranial Magnetic Stimulation (rTMS) within this recovery period is likely more beneficial than for periods longer than one year
There was a significant difference between the long-term PCS (LPCS) Active and Sham subgroups (Table 3) that is in part linked to their quite different baseline values
Summary
Given that PCS imposes substantial medical and socio-economic burdens on patients and the healthcare system[11,12,13], there is an urgent need to develop an effective treatment strategy as well as quantitative methods to monitor PCS recovery. RTMS treatment involves the repetitive application of a quickly changing magnetic field pulse to the brain[22]. A recent small (n = 15) open-label study of high-frequency rTMS applied to mTBI participants support the tolerability of rTMS treatment in a PCS population and show a significant improvement in PCS Symptom Scale score[18]. The dorso-lateral pre-frontal cortex (DLPFC) is a common site for application of rTMS This site is near the surface of the brain and reachable using a typical figure-8 coil. There is evidence that stimulation of DLPFC area can be an effective treatment for depression[32] and Alzheimer’s33 and PCS18 In this randomized and double-blind pilot study, we evaluated rTMS treatment efficacy using the Rivermead Post Concussion Symptoms Questionnaire (RPQ)[34,35] as the primary outcome measure. The secondary outcome measures were the Montgomery–Åsberg Depression Rating Scale (MADRS) for investigating the confounding effects of depression and a novel feature (the average field potential area, see methods) derived from Electrovestibulography (EVestG)[36] recordings
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