Abstract
While repetitive transcranial magnetic stimulation (rTMS) has been applied in treatment of patients with disorders of consciousness (DOC), a standardized stimulation protocol has not been proposed, and its therapeutic effects are inconsistently documented. To assess the efficacy of rTMS in improving consciousness in patients with persistent minimally conscious state (MCS) or unresponsive wakefulness syndrome (UWS), previously known as vegetative state (VS). A prospective single-blinded study, with selected subjects, was carried out. In total, 16 patients (5 MCS and 11 VS/UWS) with chronic DOC were included. All patients received active 10 Hz rTMS at the left dorsolateral prefrontal cortex (DLPFC), at one session per day, for 20 consecutive days. A single daily session of stimulation consisted of 1,000 pulses (10 s of 10 Hz trains; repeated 10 times with an inter-train interval of 60 s; and 11 min and 40 s for total session). The main outcome measures were changes in the total score on the JFK Coma Recovery Scale-Revised (CRS-R) scale. Additional measures were the impressions of caregivers after the conclusion of the interventions, which were assessed using the Clinical Global Impression-Improvement (CGI-I) scale. The CRS-R scores were increased in all 5 MCS patients and 4 of 11 VS/UWS patients, while a significant enhancement of CRS-R scores was observed compared to the baseline in all participants (p = 0.007). However, the improvement was more notable in MCS patients (p = 0.042) than their VS/UWS counterparts (p = 0.066). Based on the CGI-I scores, two patients improved considerably, two improved, six minimally improved, six experienced no change, and none deteriorated. Good concordance was seen between the CGI-I result and the increases in CRS-R scores. Treatment of 10 Hz multisession rTMS applied to the left DLPFC is promising for the rehabilitation of DOC patients, especially those in MCS. Further validation with a cohort of a larger sample size is required.
Highlights
Severe chronic disorders of consciousness (DOC) after acute coma, which typically resolves within 2 weeks, mainly consist of two subgroups: unresponsive wakefulness syndrome (UWS), previously known as vegetative state (VS), and minimally conscious state (MCS) [1]
We proposed a new stimulation protocol consisting of 10 Hz L-dorsolateral prefrontal cortex (DLPFC) repetitive transcranial magnetic stimulation (rTMS) and applied it in patients with VS/UWS or MCS
All patients enrolled in this study had been of DOC status for more than 3 months according to the JFK Coma Recovery Scale-Revised (CRS-R) scores, which are widely used to define the level of consciousness and to monitor neurobehavioral recovery in patients
Summary
Severe chronic disorders of consciousness (DOC) after acute coma, which typically resolves within 2 weeks, mainly consist of two subgroups: unresponsive wakefulness syndrome (UWS), previously known as vegetative state (VS), and minimally conscious state (MCS) [1]. MCS− is characterized by noncommunicative responses to meaningful stimuli, whereas MCS+ is characterized by command following This definition is based on the various levels of consciousness retained in different entities and implicates that specific treatment is needed and various prognoses can be expected [5, 6]. There are still no evidence-based guidelines regarding the treatment of DOC [7], while neurostimulation techniques have been seen as potential experimental approaches to DOC treatment [8,9,10] As these invasive methods, including deep brain stimulation and spinal cord stimulation, have ethical and procedural limitations [11], extensive developments have recently been made in approaches that deploy non-invasive brain stimulation (NIBS). While repetitive transcranial magnetic stimulation (rTMS) has been applied in treatment of patients with disorders of consciousness (DOC), a standardized stimulation protocol has not been proposed, and its therapeutic effects are inconsistently documented
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