Benefit Of rTMS Research Articles

A topical reappreasal on use of repetitive Transcranial Magnetic Stimulation in elderly patients with postischemic stroke statuses - a systematic literature review

Abstract: Introduction: Stroke is a cerebrovascular disease with an impressive potential of disabil-ity, (multi)morbidity, and mortality among elderly patients. After stroke, a series of seque-lae represents a dynamic challenge for rehabilitation, especially for improving motor, cognitive and depressive disorders (1,2). Repetitive Transcranial Magnetic Stimulation (rTMS) is a non-invasive, painless, neuromodulations and neurostimulation method, which uses electromagnetic induction to administer repeated trains of pulses, with thera-peutic, diagnostic and research purposes (3–5). Method: We performed a systematic literature review of the related literature using a widely international accepted method - Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)(6), by searching, filtering, and selecting profile documen-tary material. Combinations/syntaxes of keywords were searched in the following interna-tional databases: Elsevier(7), PubMed(8), PMC(9), PEDro(10), in ISI indexed journals by Web of Knowledge/Science(11) during 1/01/2019-31/12/2021. Besides the 9 articles selected to enhance our related knowledge base we have also used some works freely identified in the literature. Results and discussions: 9 articles satisfied all the previous filtering criteria/ PRISMA steps and were selected for qualitative and detailed analysis. The benefits of rTMS, aiming to bring further insight into the responsiveness of motor deficit, depression, and cognitive impairment of the treatment, and through the favorable dynamic progress of the scores of the quantification scales used: HAMD-17/ HDRS, Hamilton Depression Scale; MMSE, Mini-Mental State Examination; MoCA, Montreal Cognitive Assesment; SCWT, Stroop Color-Word Interference Test; WAIS, Wechsler Adult Intelligence Scale; NIHSS, National Institutes of Health Stroke Scale; Barthel Index Score; ADL, Activities of Daily Living; mRS, modified Rankin Scale; FIM, Functional Independence Measures. Conclusions: Through this systematic review, we wish to present the perspective of the successful use of rTMS among elderly patients. We also intend for this work to be the start-ing point in the development of a doctoral study, which will include post-stroke sequelae, such as motor deficits, depressive and cognitive disorders, and through which we will strengthen scientific confidence in the tolerability and effectiveness of this type of stimula-tion for this segment of age.

The Effects of Repetitive Transcranial Magnetic Stimulation on Standing Balance and Walking in Older Adults with Age-related Neurological Disorders: A Systematic Review and Meta-analysis.

Considerable evidence showed that repetitive transcranial magnetic stimulation (rTMS) can improve standing balance and walking performance in older adults with age-related neurological disorders. We here thus completed a systematic review and meta-analysis to quantitatively examine such benefits of rTMS. A search strategy based on the PICOS principle was used to obtain the literature in 4 databases. The screening and assessments of quality and risk of bias in the included studies were independently completed by 2 researchers. Outcomes included scales related to standing balance, Timed Up and Go (TUG) time, and walking speed/time/distance. Twenty-three studies consisting of 532 participants were included, and the meta-analysis was completed on 21 of these studies. The study quality was good. Compared to control, rTMS induced both short-term (≤3days after last intervention session) and long-term (≥1month following last intervention session) significant improvements in balance scales (eg, Berg Balance Scale), TUG time, and walking speed/time/distance (short-term: standardized mean difference [SMD] = 0.26-0.34, 95% confidence interval [CI] = 0.05-0.62; long-term: SMD = 0.40-0.47, 95% CI = 0.04-0.79) for both PD and stroke cohorts. Subgroup analyses suggested that greater than 9 sessions of high-frequency rTMS targeting primary motor cortex with greater than 3000 pulses/wk can maximize such benefits. Only a few mild-to-moderate adverse events/side effects were reported, which were similar between rTMS and control group. The results suggest that rTMS holds promise to improve balance and walking performance in older adults with age-related neurological disorders. Future studies with more rigorous design are needed to confirm the observations in this work.

Cost-effectiveness modeling of repetitive transcranial magnetic stimulation compared to electroconvulsive therapy for treatment-resistant depression in Singapore

Background Compared to electroconvulsive therapy (ECT), the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) in the management of treatment-resistant depression (TRD) remains unclear. Objective/hypothesis This study evaluated the cost-effectiveness of rTMS vs. ECT for TRD from Singapore societal perspective. Methods We constructed a Markov model to project the cost and benefit of rTMS compared with ECT over one year in patients with TRD. The relative treatment effects between rTMS and ECT were obtained from meta-analyses of published trials. The effectiveness and quality of life data for patients using ECT, resource use for TRD and their associated costs were derived from the national tertiary mental institution in Singapore. Results At one year, rTMS was cost-effective relative to ECT. The incremental cost-effectiveness ratio (ICER) associated with ECT was Singapore dollars (SGD) 311,024 per quality-adjusted life-year (QALY) gained. This exceeded the willingness-to-pay threshold of SGD 70,000 per QALY gained. A similar trend was observed for ICER per remission achieved (i.e., SGD 143,811 per remission achieved with ECT). In the subgroup analysis, rTMS was found to be less costly and more effective than ECT in nonpsychotic depressive patients. In the scenario analysis, ECT employed as an ambulatory service yielded a much smaller ICER (i.e., SGD 78,819 per QALY gained) compared to the standard inpatient setting. Conclusions rTMS was a cost-effective treatment compared to ECT in TRD over one year. The cost-effectiveness of rTMS was attenuated when ECT was used in the outpatient setting.

Treatment of refractory auditory hallucinations in schizophrenia by rTMS: Positive impact of negative double blind controlled study

Background: Several studies reported on the effectiveness of 1 Hz repeated transcranial magnetic stimulation (rTMS) over the temporoparietal cortex (TPC) on refractory auditory hallucinations (AH) in schizophrenia but little is known about the long-term therapeutic effect of this tool. Aim: The aim of this study was to evaluate rTMS’ impact on auditory hallucinations (AH) and cognitive functions in patients with schizophrenia with a three-month follow-up. Methods: In a randomized double blind sham controlled study, 26 patients with refractory schizophrenia received 1 Hz rTMS applied on TPC for four weeks. rTMS was given to patients over one month with five rTMS sessions each week. Patients were evaluated via AHRS (Auditory Hallucination Rating Scale, Hoffman et al.), PANSS (Positive and Negative Syndrome Scale, Kay et al. 1988), and CGI (Clinical Global Impression) before treatment by rTMS every week during the first month, and every month until the third month. Results: Neither clinical nor cognitive differences were found between rTMS and placebo. Conclusion: 1 Hz rTMS using parameters mentioned above has no statistically significant effect on AH; although evidences about the potential benefit of rTMS in the treatment of AH negative results suggest the need for further studies in this area.

RTMS in the management of auditory hallucinations in patients with schizophrenia.

rTMS in the management of auditory hallucinations in patients with schizophrenia.

The relationship between brain oscillatory activity and therapeutic effectiveness of transcranial magnetic stimulation in the treatment of major depressive disorder

Major depressive disorder (MDD) is marked by disturbances in brain functional connectivity. This connectivity is modulated by rhythmic oscillations of brain electrical activity, which enable coordinated functions across brain regions. Oscillatory activity plays a central role in regulating thinking and memory, mood, cerebral blood flow, and neurotransmitter levels, and restoration of normal oscillatory patterns is associated with effective treatment of MDD. Repetitive transcranial magnetic stimulation (rTMS) is a robust treatment for MDD, but the mechanism of action (MOA) of its benefits for mood disorders remains incompletely understood. Benefits of rTMS have been tied to enhanced neuroplasticity in specific brain pathways. We summarize here the evidence that rTMS entrains and resets thalamocortical oscillators, normalizes regulation and facilitates reemergence of intrinsic cerebral rhythms, and through this mechanism restores normal brain function. This entrainment and resetting may be a critical step in engendering neuroplastic changes and the antidepressant effects of rTMS. It may be possible to modify the method of rTMS administration to enhance this MOA and achieve better antidepressant effectiveness. We propose that rTMS can be administered: (1) synchronized to a patient's individual alpha frequency (IAF), or synchronized rTMS (sTMS); (2) as a low magnetic field strength sinusoidal waveform; and, (3) broadly to multiple brain areas simultaneously. We present here the theory and evidence indicating that these modifications could enhance the therapeutic effectiveness of rTMS for the treatment of MDD.

P-1378 - Brain stimulation techniques: non-invasive treatments for depression

Nowadays there is an increasing interest on brain stimulation techniques as therapeutic tools in psychiatric disorders. One of the most promising results has been obtained in depression treatment. In fact, some countries have approved the use of transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) as treatments for depression (European Union, Canada, Australia, New Zealand, Unites States and Israel). It is well known that both high frequency repetitive TMS (rTMS) and anodal tDCS over the left dorsolateral pre-frontal cortex (DLPF), are effective in decreasing depressive symptoms and they have lasting beneficial effects. First evidence of benefits of rTMS on depression was published by Pascual-Leone and co-workers in 1996 (Pascual-Leone et al. , 1996). These results have been supported by others, both using rTMS (e.g. Anderson et al., 2009; George et al., 2010) and tDCS (e.g. Boggio et al., 2008; Rigonatti et al., 2008). On the other hand, later studies showed that low frequency rTMS over right PFDL cortex is also effective in depression improvement (Kauffmann, Cheema y Miller, 2004). In addition, both techniques have reported good results as treatment of secondary depression associated with Parkinson, epilepsy and brain damage (Fregni et al., 2004; Fregni et al., 2005; Jorge et al., 2004). Recent revisions and meta-analysis corroborates TMS and tDCS efficacy (e.g.: Slotema et al., 2010), always considering that their efficacy depends on several factors, such as the length of the current depression episode, age of patient, length of the treatment, stimulation intensity or number of pulses per session.

Intérêt de la TMS au long cours au sein d’une population de patients âgés déprimés résistants

Repetitive transcranial magnetic stimulation treatment (rTMS) in elderly depressed subjects (>60 years) should be assessed in view of the absence of severe side effects. But most of the results in the literature were negative probably due to too short a duration of TMS treatment in this particular population. In this article, the authors report the results of an open study over a 6-month period: 1 month of curative treatment followed by an average of 5 months of maintenance sessions. Twelve refractory elderly depressed patients were included (five men and seven women, nine unipolar and three bipolar according to the DMS-IV criteria), aged between 60 and 78 years (70 ± 6.24) and no responders to at least two different antidepressants over 6 weeks. The average duration of depressive disease was 10.88 years (10.13) with an average of 3.82 (3.28) number of hospitalizations. All patients provided informed consent. During the first period, patients received a daily session of rTMS, 5 days a week for the first and second week then three sessions a week for the third and fourth week. The stimulation was performed on the left dorsolateral prefrontal cortex (10 Hz, 80 % of the motor threshold, 26 trains of 6 s with an interval of 30 s). In the second period, patients received one weekly session during the second month (M2), then one rTMS session each fortnight the following months. The Hamilton depression rating scale (17 items) was used to assess the intensity of depressive symptoms. Clinical ratings were assessed at baseline, each week during the first month and monthly for 5 months (M6). The authors used a 50 % reduction criteria in Hamilton Depression Rating Scale (HDRS) scores following treatment compared to baseline for responders, and HDRS <8 for patients in remission. The results show a significant drop in HDRS scores after 1 month of rTMS: at baseline 22.50 ± 2.84 versus at M1 10.25 ± 4.18, p < 0.001. Two no responders received only 1 month of rTMS treatment. The other responder patients ( n = 10) had the possibility of receiving the treatment by rTMS maintenance for 5 months. The HDRS score showed no difference between the mean HDRS score at M1 and M6 ( p > 0.05). We noted a high score in compliance to the TMS treatment in this sample: 75 % ( n = 9) at M6 with only three drop-outs. No side effect was reported, except headache. The absence of cognitive effects is a strong argument in favor of TMS use in this population. Nevertheless, new double blind studies are needed to confirm this therapeutic tool and the benefits of rTMS in the treatment of elderly resistant depressed people.