Repetitive transcranial magnetic stimulation for treatment of tardive syndromes: double randomized clinical trial

Tardive Syndromes: A Challenging Multitude of Maladies

"Tardive syndrome" is an umbrella term for a group of drug-induced movement disorders associated with the prolonged use of mainly dopamine receptor blockers and also other medications. Early recognition followed by gradual withdrawal of the incriminating drug may lead to reversal, although not in all patients. Tardive syndromes are usually mixed movement disorders, with specific phenotypes, which may lead to severe disability. The pathophysiology remains incompletely understood. Treatment ranges from medical options, particularly dopamine-depleting agents and chemodenervation (botulinum toxin), to surgical options (deep brain stimulation and lesioning surgeries). Most studies that focused on treatment are limited by small patient numbers. Unfortunately, tardive syndromes often remain under-recognized in clinical practice. This article reviews the historical aspects, epidemiology and risk factors, pathophysiology, diagnostic criteria, clinical phenotypes, and management of tardive syndromes.

Therapeutic Efficacy of Reward Circuit‐Targeted Transcranial Magnetic Stimulation (TMS) on Suicidal Ideation in Depressed Patients: A Sham‐Controlled Trial of Two TMS Protocols

Background: Suicide is one of the leading causes of premature death, and dysfunctional reward processing may serve as a potential mechanism. However, effective treatment targeting reward circuits is rarely reported.

Objective: The present study investigated the therapeutic efficacy of two individualized protocols, repetitive transcranial magnetic stimulation (rTMS) and intermittent theta burst stimulation (iTBS), targeting the left dorsolateral prefrontal cortex (lDLPFC)–nucleus accumbens (NAcc) circuit on suicidal ideation among patients with major depressive disorder (MDD).

Methods: Here, 40 healthy controls (HCs) and 70 MDD patients (MDDs) were recruited for this double‐blinded, sham‐controlled clinical trial. The reward learning process during the Iowa gambling task (IGT) was initially measured at the baseline. Further, 62 MDDs were assigned to receive 15 daily sessions of individualized rTMS (n = 25), iTBS (n = 15), or sham treatment (n = 22) to the site of strongest lDLPFC–NAcc connectivity.

Results: We found MDDs demonstrated abnormalities in both IGT performance and reward‐associated event‐related potential (ERP) components compared to HCs. MDDs in the rTMS and iTBS groups showed significant improvements in suicidal ideation and anhedonia symptoms compared to the sham group. The rTMS group also exhibited a more negative‐going N170 and feedback‐related negativity (FRN) after treatment, and the increase in N170 absolute amplitude posttreatment showed a trend of correlation with improved Temporal Experience Pleasure Scales (TEPSs) and TEPS‐anticipatory (TEPS‐ant) scores.

Conclusion: The current study indicates that reward circuit‐based rTMS and iTBS showed comparable antisuicidal effects in depressive patients, suggesting that the lDLPFC–NAcc pathway may serve as a potential treatment target.

Trial Registration: ClinicalTrials.gov identifier: NCT03991572

Clinical neurophysiology in the treatment of movement disorders: IFCN handbook chapter

In this review, different aspects of the use of clinical neurophysiology techniques for the treatment of movement disorders are addressed. First of all, these techniques can be used to guide neuromodulation techniques or to perform therapeutic neuromodulation as such. Neuromodulation includes invasive techniques based on the surgical implantation of electrodes and a pulse generator, such as deep brain stimulation (DBS) or spinal cord stimulation (SCS) on the one hand, and non-invasive techniques aimed at modulating or even lesioning neural structures by transcranial application. Movement disorders are one of the main areas of indication for the various neuromodulation techniques. This review focuses on the following techniques: DBS, repetitive transcranial magnetic stimulation (rTMS), low-intensity transcranial electrical stimulation, including transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS), and focused ultrasound (FUS), including high-intensity magnetic resonance-guided FUS (MRgFUS), and pulsed mode low-intensity transcranial FUS stimulation (TUS). The main clinical conditions in which neuromodulation has proven its efficacy are Parkinson's disease, dystonia, and essential tremor, mainly using DBS or MRgFUS. There is also some evidence for Tourette syndrome (DBS), Huntington's disease (DBS), cerebellar ataxia (tDCS), and axial signs (SCS) and depression (rTMS) in PD. The development of non-invasive transcranial neuromodulation techniques is limited by the short-term clinical impact of these techniques, especially rTMS, in the context of very chronic diseases. However, at-home use (tDCS) or current advances in the design of closed-loop stimulation (tACS) may open new perspectives for the application of these techniques in patients, favored by their easier use and lower rate of adverse effects compared to invasive or lesioning methods. Finally, this review summarizes the evidence for keeping the use of electromyography to optimize the identification of muscles to be treated with botulinum toxin injection, which is indicated and widely performed for the treatment of various movement disorders.

The effect of repetitive transcranial magnetic stimulation on cognitive impairment in Parkinson's disease with dementia: Pilot study

BACKGROUND

The exact mechanism of cognitive impairment in PD is not known. Repetitive transcranial magnetic stimulation (rTMS) has been proposed as a possible treatment for cognitive impairment and to treat the motor symptoms in Parkinson's disease (PD) where its effects seem additive to those of dopaminergic medications.

OBJECTIVE

In this pilot study we investigated whether repeated sessions of rTMS have an effect on measures of cognitive impairment in patients with PD dementia.

METHODS

33 patients with PD dementia were randomly assigned sham or real rTMS (2000 pulses; 20 Hz; 90% RMT; 10 trains of 10 s with 25 s between each train) over the hand area of each motor cortex (5 min between hemispheres) for 10 days (5 days/week) followed by 5 booster sessions every month for 3 months. Assessments included the Unified Parkinson's Disease Rating Scale part III (UPDRS), Montreal Cognitive Assessment (MoCA); Mini Mental State Examination (MMSE), Clinical Dementia Rating Scale (CDR); Memory and Executive Screening (MES) and Instrumental activity of Daily Living (IADL). Event related potentials (P300) and cortical excitability were measured before treatment and after the last session.

RESULTS

There were no significant differences in the effects of rTMS between groups. Although rTMS improved motor function in the active group it had only a minor effect on two of the dementia rating scores (the MMSE and MoCA) but not the others (CDR and MES). There was also a reduction in the latency of the P300 in the active group.

CONCLUSIONS

rTMS over M1 is useful for motor function and may have a small positive effect on cognition. However, better approaches for the latter are necessary, may be require multisite rTMS to target both motor and frontal cortical region.

Tardive Dyskinesia: Spotlight on Current Approaches to Treatment

Tardive dyskinesia (TD) is a debilitating, iatrogenic, and potentially severe movement disorder characterized by involuntary, repetitive, purposeless movements that are present throughout the body. The authors present a review of studies of past, current, and possible future treatment approaches to the management of TD; consider the phenomenology, assessment, and putative pathophysiological mechanisms of TD, early pharmacological trials, a focus on the newer vesicular monoamine transporter 2 inhibitors, and other evidence-based approaches, such as clozapine; and present preliminary evidence for newer approaches, such as deep brain stimulation and repetitive transcranial magnetic stimulation. On the basis of the evidence presented here, the authors highlight the importance of early recognition and assessment of TD, as well as how to best approach management of these often incapacitating symptoms.

A double-blind randomized clinical trial of high frequency rTMS over the DLPFC on nicotine dependence, anxiety and depression

High frequency repetitive transcranial magnetic stimulation (HF-rTMS) over the left dorsolateral prefrontal cortex (L-DLPFC) is a widely applied treatment protocol for chronic smoking and major depressive disorder. However, no previous study has measured the effects of rTMS on both nicotine consumption and anxiety/depression in the same volunteers despite the relationship between them. The aim of this work was to evaluate the efficacy of 10 daily sessions of HF-rTMS over the L-DLPFC in chronic cigarette smokers' addiction and investigate the possible beneficial effects of this treatment procedure on symptoms of depression and anxiety in the same subjects. The study included 40 treatment-seeking nicotine-dependent cigarette smokers. Onset/duration of smoking, number of cigarettes/day, Fagerstrom Test of Nicotine Dependence (FTND), Tobacco Craving Questionnaire-Short Form (TCQ-SF), Hamilton depression and anxiety scales (HAM-D and HAM-A) were recorded. Participants were randomly assigned to the active or the sham treatment group. Those in the active group received 10 trains of 20 Hz stimulation, at 80% of the resting motor threshold (rMT) for 10 consecutive working days over L-DLPFC. Participants were reassessed immediately after treatment, and then 3 months later using all rating scales. There were no differences between active and sham groups at baseline. The cigarette consumption/day, and scores on FTND, and TCQ decreased significantly in both groups (p = 0.0001 for each) immediately after treatment. However, improvement persisted to 3 months in the active group but not in the sham group. Moreover, there was a significant reduction in HAM-D and HAM-A scores immediately after treatment in the active but not the sham group. Subjects with a longer history of smoking had a lower percent improvement in FTND (p = 0.005). Our findings revealed that HF-rTMS over L-DLPCF for 10 days reduced cigarette consumption, craving, dependence, and improved associated symptoms of anxiety and depression.ClinicalTrials.gov Identifier: NCT03264755 registered at 29/08/2017.