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Sakib MN, Saragadam A, Santagata MC, Jolicoeur-Becotte M, Kozyr L, Burhan AM, Hall PA. rTMS for post-covid-19 condition: A sham-controlled case series involving iTBS-300 and iTBS-600. Brain Behav Immun Health 2024; 36:100736. [PMID: 38371381 PMCID: PMC10869745 DOI: 10.1016/j.bbih.2024.100736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/03/2024] [Accepted: 02/04/2024] [Indexed: 02/20/2024] Open
Abstract
Post-Covid-19 Condition (PCC) is a syndrome comprised of symptoms persisting 3 months or more beyond SARS-CoV-2 primary infection. It is typically characterized by fatigue, cognitive problems and psychiatric symptoms, as well as cardiac symptoms that contribute to exercise intolerance in many. Despite the high prevalence of PCC among those with a prior SARS-CoV-2 infection, there is currently no widely accepted rehabilitation strategy, and many conventional modalities are movement-based. Non-invasive brain stimulation methods such as repetitive transcranial magnetic stimulation (rTMS) may have some potential to alleviate the cognitive and affective symptoms of PCC without reliance on exercise. The purpose of the present study was to explore the feasibility and tolerability of using rTMS to treat symptoms of "brain fog" and affective disturbance among those living with PCC, using a case series design. We enrolled four individuals with PCC following a confirmed SARS-CoV-2 infection, at least 3 months after the resolution of the primary infection. Participants were randomized to 4 sessions of active and 2 sessions of sham intermittent theta-burst stimulation (iTBS); two intensities of iTBS were evaluated: iTBS-300 and iTBS-600. No adverse events occurred in active or sham stimulation; 2 participants reported tingling sensation on the scalp but no other tolerability issues. Trends in symptoms suggested improvements in cognitive interference, quality of life, and anxiety in the majority of participants. In summary, in this case series iTBS was well tolerated among 4 individuals with PCC; active stimulation was associated with positive trends in some primary symptom clusters as compared with sham stimulation. Future studies should examine the effects of iTBS on PCC symptoms in the context of experimental studies and randomized controlled trials.
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Affiliation(s)
- Mohammad Nazmus Sakib
- School of Public Health Sciences, Faculty of Health, University of Waterloo, Waterloo, Ontario, Canada
| | - Ashish Saragadam
- School of Public Health Sciences, Faculty of Health, University of Waterloo, Waterloo, Ontario, Canada
| | - Mariella C. Santagata
- School of Public Health Sciences, Faculty of Health, University of Waterloo, Waterloo, Ontario, Canada
| | - Marie Jolicoeur-Becotte
- School of Public Health Sciences, Faculty of Health, University of Waterloo, Waterloo, Ontario, Canada
| | - Lena Kozyr
- School of Public Health Sciences, Faculty of Health, University of Waterloo, Waterloo, Ontario, Canada
| | - Amer M. Burhan
- Ontario Shores Centre for Mental Health Sciences, Whitby, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Peter A. Hall
- School of Public Health Sciences, Faculty of Health, University of Waterloo, Waterloo, Ontario, Canada
- Centre for Bioengineering and Biotechnology, University of Waterloo, Waterloo, Ontario, Canada
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Herrero Babiloni A, Bouferguene Y, Exposto FG, Beauregard R, Lavigne GJ, Moana-Filho EJ, Arbour C. The prevalence of persistent post-traumatic headache in adult civilian traumatic brain injury: a systematic review and meta-analysis on the past 14 years. Pain 2023; 164:2627-2641. [PMID: 37390366 DOI: 10.1097/j.pain.0000000000002949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/23/2023] [Indexed: 07/02/2023]
Abstract
ABSTRACT The most recent prevalence estimate of post-traumatic headache (PTH) after traumatic brain injury (TBI) in veterans and civilians dates back to 2008. The prevalence was found to be 57.8%, with surprising higher rates (75.3%) in mild TBI when compared with those with moderate/severe TBI (32.1%). However, the revision of mild TBI diagnostic criteria and an historic peak of TBI in the elderly individuals attributed to the ageing population may lead to different results. Thus, we conducted a systematic review and meta-analysis to assess the updated prevalence of PTH during the past 14 years only in civilians. A literature search was conducted following PRISMA guidelines guided by a librarian. Screening, full-text assessment, data extraction, and risk of bias assessment were performed blindly by 2 raters. Meta-analysis of proportions using the Freeman and Tukey double arcsine method of transformation was conducted. Heterogeneity, sensitivity analysis, and meta-regressions were performed with the predictors: year of publication, mean age, sex, TBI severity, and study design. Sixteen studies were selected for the qualitative analysis and 10 for the meta-analysis. The overall prevalence estimate of PTH was 47.1%, (confidence interval = 34.6, 59.8, prediction intervals = 10.8, 85.4), being similar at different time points (3, 6, 12, and 36+ months). Heterogeneity was high, and none of the meta-regressions were significant. The overall prevalence of PTH after TBI over the past 14 years remains high even if assessed only in civilians. However, the prevalence rates attributed to mild and moderate/severe TBI were similar, differing significantly from previous reports. Efforts are needed to improve TBI outcomes.
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Affiliation(s)
- Alberto Herrero Babiloni
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
- Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, QC, Canada
| | - Yasmine Bouferguene
- Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, QC, Canada
| | - Fernando G Exposto
- Section of Orofacial Pain and Jaw Function, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
- Scandinavian Center for Orofacial Neurosciences (SCON), Aarhus, Denmark
| | - Roxanne Beauregard
- Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, QC, Canada
| | - Gilles J Lavigne
- Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, QC, Canada
- Faculty of Dental Medicine, Université de Montréal, QC, Canada
| | - Estephan J Moana-Filho
- Division of TMD and Orofacial Pain, School of Dentistry, University of Minnesota, Minneapolis, MN, United States
| | - Caroline Arbour
- Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, QC, Canada
- Faculty of Nursing, Université de Montréal, QC, Canada
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Makale MT, Nybo C, Keifer J, Blum K, Dennen CA, Baron D, Sunder K, Elman I, Makale MR, Thanos PK, Murphy KT. Preliminary Observations of Personalized Repetitive Magnetic Stimulation (PrTMS) Guided by EEG Spectra for Concussion. Brain Sci 2023; 13:1179. [PMID: 37626535 PMCID: PMC10452199 DOI: 10.3390/brainsci13081179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/02/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
There are no FDA-approved treatments for the chronic sequelae of concussion. Repetitive magnetic transcranial stimulation (rTMS) has been explored as a therapy but outcomes have been inconsistent. To address this we developed a personalized rTMS (PrTMS) protocol involving continual rTMS stimulus frequency adjustment and progressive activation of multiple cortical sites, guided by spectral electroencephalogram (EEG)-based analyses and psychological questionnaires. We acquired pilot clinical data for 185 symptomatic brain concussion patients who underwent the PrTMS protocol over an approximate 6 week period. The PrTMS protocol used a proprietary EEG spectral frequency algorithm to define an initial stimulation frequency based on an anteriorly graded projection of the measured occipital alpha center peak, which was then used to interpolate and adjust regional stimulation frequency according to weekly EEG spectral acquisitions. PrTMS improved concussion indices and normalized the cortical alpha band center frequency and peak EEG amplitude. This potentially reflected changed neurotransmitter, cognitive, and perceptual status. PrTMS may be a promising treatment choice for patients with persistent concussion symptoms. This clinical observational study was limited in that there was no control group and a number of variables were not recorded, such as time since injury and levels of depression. While the present observations are indeed preliminary and cursory, they may suggest further prospective research on PrTMS in concussion, and exploration of the spectral EEG as a concussion biomarker, with the ultimate goals of confirmation and determining optimal PrTMS treatment parameters.
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Affiliation(s)
- Milan T. Makale
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA 92093, USA
| | - Chad Nybo
- CrossTx Inc., Bozeman, MT 59715, USA
| | | | - Kenneth Blum
- Department of Clinical Psychology and Addiction, Institute of Psychology, Faculty of Education and Psychology, Eötvös Loránd University, 1075 Budapest, Hungary
- Department of Psychiatry, Wright University, Boonshoft School of Medicine, Dayton, OH 45324, USA
- Department of Molecular Biology and Adelson School of Medicine, Ariel University, Ariel 40700, Israel
- Division of Addiction Research & Education, Center for Sports, Exercise & Global Mental Health, Western University Health Sciences, Pomona, CA 91766, USA
| | - Catherine A. Dennen
- Department of Family Medicine, Jefferson Health NE, Philadelphia, PA 19107, USA
| | - David Baron
- Division of Addiction Research & Education, Center for Sports, Exercise & Global Mental Health, Western University Health Sciences, Pomona, CA 91766, USA
| | - Keerthy Sunder
- School of Medicine, University of California Riverside, Riverside, CA 92521, USA
| | - Igor Elman
- Cambridge Health Alliance, Harvard Medical School, Cambridge, MA 02143, USA
| | - Miles R. Makale
- Department of Psychology, University of California San Diego, La Jolla, CA 92093, USA
| | - Panayotis K. Thanos
- Behavioral Neuropharmacology and Neuroimaging Laboratory on Addictions, Clinical Research Institute on Addictions, Department of Pharmacology and Toxicology, Jacobs School of Medicine and Biosciences, State University of New York at Buffalo, Buffalo, NY 14203, USA
- Department of Psychology, State University of New York at Buffalo, Buffalo, NY 14203, USA
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Mavroudis I, Ciobica A, Luca AC, Balmus IM. Post-Traumatic Headache: A Review of Prevalence, Clinical Features, Risk Factors, and Treatment Strategies. J Clin Med 2023; 12:4233. [PMID: 37445267 DOI: 10.3390/jcm12134233] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/23/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Post-traumatic headache (PTH) is a common and debilitating consequence of mild traumatic brain injury (mTBI) that can occur over one year after the head impact event. Thus, better understanding of the underlying pathophysiology and risk factors could facilitate early identification and management of PTH. There are several factors that could influence the reporting of PTH prevalence, including the definition of concussion and PTH. The main risk factors for PTHs include a history of migraines or headaches, female gender, younger age, greater severity of the head injury, and co-occurring psychological symptoms, such as anxiety and depression. PTH clinical profiles vary based on onset, duration, and severity: tension-type headache, migraine headaches, cervicogenic headache, occipital neuralgia, and new daily persistent headache. Pharmacological treatments often consist of analgesics and non-steroidal anti-inflammatory drugs, tricyclic antidepressants, or antiepileptic medication. Cognitive behavioral therapy, relaxation techniques, biofeedback, and physical therapy could also be used for PTH treatment. Our work highlighted the need for more rigorous studies to better describe the importance of identifying risk factors and patient-centered treatments and to evaluate the effectiveness of the existing treatment options. Clinicians should consider a multidisciplinary approach to managing PTH, including pharmacotherapy, cognitive behavioral therapy, and lifestyle changes.
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Affiliation(s)
- Ioannis Mavroudis
- Department of Neuroscience, Leeds Teaching Hospitals, NHS Trust, Leeds LS2 9JT, UK
- Faculty of Medicine, Leeds University, Leeds LS2 9JT, UK
| | - Alin Ciobica
- Department of Biology, Faculty of Biology, Alexandru Ioan Cuza University, 700506 Iasi, Romania
- Centre of Biomedical Research, Romanian Academy, B dul Carol I, No. 8, 700506 Iasi, Romania
- Academy of Romanian Scientists, Splaiul Independentei nr. 54, Sector 5, 050094 Bucuresti, Romania
| | - Alina Costina Luca
- Department of Mother and Child, Medicine-Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 16, Universitatii Street, 700115 Iasi, Romania
| | - Ioana-Miruna Balmus
- Department of Exact Sciences and Natural Sciences, Institute of Interdisciplinary Research, "Alexandru Ioan Cuza" University of Iasi, 700057 Iasi, Romania
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Philip NS, Ramanathan D, Gamboa B, Brennan MC, Kozel FA, Lazzeroni L, Madore MR. Repetitive Transcranial Magnetic Stimulation for Depression and Posttraumatic Stress Disorder in Veterans With Mild Traumatic Brain Injury. Neuromodulation 2023; 26:878-884. [PMID: 36737300 PMCID: PMC10765323 DOI: 10.1016/j.neurom.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 11/18/2022] [Accepted: 11/25/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Mild traumatic brain injury (mTBI) is a signature injury of military conflicts and is prevalent in veterans with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). Although therapeutic transcranial magnetic stimulation (TMS) can reduce symptoms of depression and PTSD, whether traumatic brain injury (TBI) affects TMS responsiveness is not yet known. We hypothesized mTBI would be associated with higher pretreatment symptom burden and poorer TMS response. MATERIALS AND METHODS We investigated a registry of veterans (N = 770) who received TMS for depression across the US Veterans Affairs system. Of these, 665 (86.4%) had data on TBI and lifetime number of head injuries while 658 had complete data related to depression outcomes. Depression symptoms were assessed using the nine-item Patient Health Questionnaire and PTSD symptoms using the PTSD Checklist for DSM-5. Linear mixed effects models and t-tests evaluated whether head injuries predicted symptom severity before treatment, and how TBI status affected clinical TMS outcomes. RESULTS Of the 658 veterans included, 337 (50.7%) reported previous mTBI, with a mean of three head injuries (range 1-20). TBI status did not predict depressive symptom severity or TMS-associated changes in depression (all p's > 0.1). TBI status was associated with a modest attenuation of TMS-associated improvement in PTSD (in patients with PTSD Checklist for DSM-5 scores > 33). There was no correlation between the number of head injuries and TMS response (p > 0.1). CONCLUSIONS Contrary to our hypothesis, presence of mTBI did not meaningfully change TMS outcomes. Veterans with mTBI had greater PTSD symptoms, yet neither TBI status nor cumulative head injuries reduced TMS effectiveness. Limitations include those inherent to retrospective registry studies and self-reporting. Although these findings are contrary to our hypotheses, they support the safety and effectiveness of TMS for MDD and PTSD in patients who have comorbid mTBI.
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Affiliation(s)
- Noah S Philip
- Veterans Affairs Rehabilitation Research & Development Center for Neurorestoration and Neurotechnology, Providence Veterans Affairs Healthcare System, Providence, RI, USA; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Dhakshin Ramanathan
- Center of Excellence for Stress and Mental Health, Veterans Affairs San Diego Healthcare System, San Diego, CA, USA; Department of Psychiatry, University of California, San Diego, San Diego, CA, USA
| | - Bruno Gamboa
- Mental Illness Research, Education, and Clinical Center, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - McKenna C Brennan
- Veterans Affairs Rehabilitation Research & Development Center for Neurorestoration and Neurotechnology, Providence Veterans Affairs Healthcare System, Providence, RI, USA; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Frank Andrew Kozel
- Department of Behavioral Sciences and Social Medicine, Florida State University, Tallahassee, FL, USA
| | - Laura Lazzeroni
- Mental Illness Research, Education, and Clinical Center, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Michelle R Madore
- Mental Illness Research, Education, and Clinical Center, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.
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Surendrakumar S, Rabelo TK, Campos ACP, Mollica A, Abrahao A, Lipsman N, Burke MJ, Hamani C. Neuromodulation Therapies in Pre-Clinical Models of Traumatic Brain Injury: Systematic Review and Translational Applications. J Neurotrauma 2023; 40:435-448. [PMID: 35983592 DOI: 10.1089/neu.2022.0286] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury (TBI) has been associated with several lasting impairments that affect quality of life. Pre-clinical models of TBI have been studied to further our understanding of the underlying short-term and long-term symptomatology. Neuromodulation techniques have become of great interest in recent years as potential rehabilitative therapies after injury because of their capacity to alter neuronal activity and neural circuits in targeted brain regions. This systematic review aims to provide an overlook of the behavioral and neurochemical effects of transcranial direct current stimulation (tDCS), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS) in pre-clinical TBI models. After screening 629 abstracts, 30 articles were pooled for review. These studies showed that tDCS, TMS, DBS, or VNS delivered to rodents restored TBI-induced deficits in coordination, balance, locomotor activity and improved cognitive impairments in memory, learning, and impulsivity. Potential mechanisms for these effects included neuroprotection, a decrease in apoptosis, neuroplasticity, and the restoration of neural circuit abnormalities. The translational value, potential applicability, and the interpretation of these findings in light of outcome data from clinical trials in patients with TBI are discussed.
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Affiliation(s)
- Shanan Surendrakumar
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Thallita Kelly Rabelo
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ana Carolina P Campos
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Adriano Mollica
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Neuropsychiatry Program, Department of Psychiatry, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Agessandro Abrahao
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nir Lipsman
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Matthew J Burke
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Neuropsychiatry Program, Department of Psychiatry, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Clement Hamani
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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A Systematic Review of Treatments of Post-Concussion Symptoms. J Clin Med 2022; 11:jcm11206224. [PMID: 36294545 PMCID: PMC9604759 DOI: 10.3390/jcm11206224] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/01/2022] [Accepted: 10/12/2022] [Indexed: 11/11/2022] Open
Abstract
Approximately 10−20% of patients who have sustained a mild Traumatic Brain Injury (mTBI) show persistent post-concussion symptoms (PCS). This review aims to summarize the level of evidence concerning interventions for PCS. Following the PRISMA guidelines, we conducted a systematic review regarding interventions for PCS post-mTBI until August 2021 using the Medline, Cochrane, and Embase databases. Inclusion criteria were the following: (1) intervention focusing on PCS after mTBI, (2) presence of a control group, and (3) adult patients (≥18 y.o). Quality assessment was determined using the Incog recommendation level, and the risk of bias was assessed using the revised Cochrane risk-of-bias tool. We first selected 104 full-text articles. Finally, 55 studies were retained, including 35 that obtained the highest level of evidence. The risk of bias was high in 22 out of 55 studies. Cognitive training, psycho-education, cognitive behavioral therapy, and graded return to physical activity demonstrated some effectiveness on persistent PCS. However, there is limited evidence of the beneficial effect of Methylphenidate. Oculomotor rehabilitation, light therapy, and headache management using repetitive transcranial magnetic stimulation seem effective regarding somatic complaints and sleep disorders. The preventive effect of early (<3 months) interventions remains up for debate. Despite its limitations, the results of the present review should encourage clinicians to propose a tailored treatment to patients according to the type and severity of PCS and could encourage further research with larger groups.
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Krese KA, Donnelly KZ, Etingen B, Bender Pape TL, Chaudhuri S, Aaronson AL, Shah RP, Bhaumik DK, Billups A, Bedo S, Wanicek-Squeo MT, Bobra S, Herrold AA. Feasibility of a Combined Neuromodulation and Yoga Intervention for Mild Traumatic Brain Injury and Chronic Pain: Protocol for an Open-label Pilot Trial. JMIR Res Protoc 2022; 11:e37836. [PMID: 35704372 PMCID: PMC9244651 DOI: 10.2196/37836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/16/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Mild traumatic brain injury (mTBI) and chronic pain often co-occur and worsen rehabilitation outcomes. There is a need for improved multimodal nonpharmacologic treatments that could improve outcomes for both conditions. Yoga is a promising activity-based intervention for mTBI and chronic pain, and neuromodulation through transcranial magnetic stimulation is a promising noninvasive, nonpharmacological treatment for mTBI and chronic pain. Intermittent theta burst stimulation (iTBS) is a type of patterned, excitatory transcranial magnetic stimulation. iTBS can induce a window of neuroplasticity, making it ideally suited to boost the effects of treatments provided after it. Thus, iTBS may magnify the impacts of subsequently delivered interventions as compared to delivering those interventions alone and accordingly boost their impact on outcomes. OBJECTIVE The aim of this study is to (1) develop a combined iTBS+yoga intervention for mTBI and chronic pain, (2) assess the intervention's feasibility and acceptability, and (3) gather preliminary clinical outcome data on quality of life, function, and pain that will guide future studies. METHODS This is a mixed methods, pilot, open-labeled, within-subject intervention study. We will enroll 20 US military veteran participants. The combined iTBS+yoga intervention will be provided in small group settings once a week for 6 weeks. The yoga intervention will follow the LoveYourBrain yoga protocol-specifically developed for individuals with TBI. iTBS will be administered immediately prior to the LoveYourBrain yoga session. We will collect preliminary quantitative outcome data before and after the intervention related to quality of life (TBI-quality of life), function (Mayo-Portland Adaptability Index), and pain (Brief Pain Inventory) to inform larger studies. We will collect qualitative data via semistructured interviews focused on intervention acceptability after completion of the intervention. RESULTS This study protocol was approved by Edward Hines Jr Veterans Administration Hospital Institutional Review Board (Hines IRB 1573116-4) and was prospectively registered on ClinicalTrials.gov (NCT04517604). This study includes a Food and Drug Administration Investigational Device Exemption (IDE: G200195). A 2-year research plan timeline was developed. As of March 2022, a total of 6 veterans have enrolled in the study. Data collection is ongoing and will be completed by November 2022. We expect the results of this study to be available by October 2024. CONCLUSIONS We will be able to provide preliminary evidence of safety, feasibility, and acceptability of a novel combined iTBS and yoga intervention for mTBI and chronic pain-conditions with unmet treatment needs. TRIAL REGISTRATION ClinicalTrials.gov NCT04517604; https://www.clinicaltrials.gov/ct2/show/NCT04517604. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/37836.
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Affiliation(s)
- Kelly A Krese
- Brain Innovation Center, Shirley Ryan AbilityLab, Chicago, IL, United States
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | | | - Bella Etingen
- Center for Innovation in Complex Chronic Healthcare & Research Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Theresa L Bender Pape
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Center for Innovation in Complex Chronic Healthcare & Research Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Sarmistha Chaudhuri
- Department of Physical Medicine and Rehabilitation, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Alexandra L Aaronson
- Mental Health Service Line, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Psychiatry, Feinberg School of Medicine, Northwestern University, Hines, IL, United States
| | - Rachana P Shah
- Department of Physical Medicine and Rehabilitation, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Dulal K Bhaumik
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Psychiatry, University of Illinois Chicago, Chicago, IL, United States
| | - Andrea Billups
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Sabrina Bedo
- Department of Physical Medicine and Rehabilitation, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Recreation Therapy, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Mary Terese Wanicek-Squeo
- Recreation Therapy, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
| | - Sonia Bobra
- Department of Radiology, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Radiology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
| | - Amy A Herrold
- Research and Development Service, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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9
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Guideline of clinical neurorestorative treatment for brain trauma (2022 China version). JOURNAL OF NEURORESTORATOLOGY 2022. [DOI: 10.1016/j.jnrt.2022.100005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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10
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Detection of Chronic Blast-Related Mild Traumatic Brain Injury with Diffusion Tensor Imaging and Support Vector Machines. Diagnostics (Basel) 2022; 12:diagnostics12040987. [PMID: 35454035 PMCID: PMC9030428 DOI: 10.3390/diagnostics12040987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 01/13/2023] Open
Abstract
Blast-related mild traumatic brain injury (bmTBI) often leads to long-term sequalae, but diagnostic approaches are lacking due to insufficient knowledge about the predominant pathophysiology. This study aimed to build a diagnostic model for future verification by applying machine-learning based support vector machine (SVM) modeling to diffusion tensor imaging (DTI) datasets to elucidate white-matter features that distinguish bmTBI from healthy controls (HC). Twenty subacute/chronic bmTBI and 19 HC combat-deployed personnel underwent DTI. Clinically relevant features for modeling were selected using tract-based analyses that identified group differences throughout white-matter tracts in five DTI metrics to elucidate the pathogenesis of injury. These features were then analyzed using SVM modeling with cross validation. Tract-based analyses revealed abnormally decreased radial diffusivity (RD), increased fractional anisotropy (FA) and axial/radial diffusivity ratio (AD/RD) in the bmTBI group, mostly in anterior tracts (29 features). SVM models showed that FA of the anterior/superior corona radiata and AD/RD of the corpus callosum and anterior limbs of the internal capsule (5 features) best distinguished bmTBI from HCs with 89% accuracy. This is the first application of SVM to identify prominent features of bmTBI solely based on DTI metrics in well-defined tracts, which if successfully validated could promote targeted treatment interventions.
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Neuromodulation Treatments for Mild Traumatic Brain Injury and Post-concussive Symptoms. Curr Neurol Neurosci Rep 2022; 22:171-181. [PMID: 35175543 DOI: 10.1007/s11910-022-01183-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Mild traumatic brain injury (mTBI) can result in prolonged post-concussive symptoms (e.g., depression, headaches, cognitive impairment) that are debilitating and difficult to treat. This article reviews recent research on neuromodulation for mTBI. RECENT FINDINGS Transcranial magnetic stimulation (TMS) is the most studied neuromodulation approach for mTBI (four studies for depression, four for headache, one for cognitive impairment, and two for global post-concussive symptoms) with promising results for post-concussive depression and headache. Transcranial direct current stimulation (tDCS) has also been evaluated (one study for post-traumatic headache, and three for cognitive impairment), with more mixed results overall. TMS appears to be a potentially promising neuromodulation treatment strategy for post-concussive symptoms; however, integration into clinical practice will require larger sham-controlled randomized trials with longer and more consistent follow-up periods. Future studies should also explore new stimulation protocols, personalized approaches, and the role of placebo effects.
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Mollica A, Dey A, Cairncross M, Silverberg N, Burke MJ. Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches. Semin Neurol 2022; 42:168-181. [PMID: 35114694 DOI: 10.1055/s-0041-1742143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Postconcussive symptoms following mild traumatic brain injury (mTBI)/concussion are common, disabling, and challenging to manage. Patients can experience a range of symptoms (e.g., mood disturbance, headaches, insomnia, vestibular symptoms, and cognitive dysfunction), and neuropsychiatric management relies heavily on nonpharmacological and multidisciplinary approaches. This article presents an overview of current nonpharmacological strategies for postconcussive symptoms including psychoeducation; psychotherapy; vestibular, visual, and physical therapies; cognitive rehabilitation; as well as more novel approaches, such as neuromodulation. Ultimately, treatment and management of mTBI should begin early with appropriate psychoeducation/counseling, and be tailored based on core symptoms and individual goals.
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Affiliation(s)
- Adriano Mollica
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ayan Dey
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Molly Cairncross
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada.,Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Noah Silverberg
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada.,Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Matthew J Burke
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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du Plessis S, Oni IK, Lapointe AP, Campbell C, Dunn JF, Debert CT. Treatment of Persistent Post-Concussion Syndrome with Repetitive Transcranial Magnetic Stimulation Using Functional Near-Infrared Spectroscopy as a Biomarker of Response: A Randomized Sham-Controlled Clinical Trial Protocol (Preprint). JMIR Res Protoc 2021; 11:e31308. [PMID: 35315783 PMCID: PMC8984821 DOI: 10.2196/31308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/29/2021] [Accepted: 01/25/2022] [Indexed: 01/13/2023] Open
Abstract
Background Approximately one-third of all concussions lead to persistent postconcussion syndrome (PPCS). Repetitive transcranial magnetic stimulation (rTMS) is a form of noninvasive brain stimulation that has been extensively used to treat refractory major depressive disorder and has a strong potential to be used as a treatment for patients with PPCS. Functional near-infrared spectroscopy (fNIRS) has already been used as a tool to assess patients with PPCS and may provide insight into the pathophysiology of rTMS treatment in patients with PPCS. Objective The primary objective of this research is to determine whether rTMS treatment improves symptom burden in patients with PPCS compared to sham treatment using the Rivermead postconcussion symptom questionnaire. The secondary objective is to explore the neuropathophysiological changes that occur following rTMS in participants with PPCS using fNIRS. Exploratory objectives include determining whether rTMS treatment in participants with PPCS will also improve quality of life, anxiety, depressive symptoms, cognition, posttraumatic stress, and function secondary to headaches. Methods A total of 44 adults (18-65 years old) with PPCS (>3 months to 5 years) will participate in a double-blind, sham-controlled, concealed allocation, randomized clinical trial. The participants will engage in either a 4-week rTMS treatment protocol or sham rTMS protocol (20 treatments). The left dorsolateral prefrontal cortex will be located through Montreal Neurologic Institute coordinates. The intensity of the rTMS treatment over the left dorsolateral prefrontal cortex will be 120% of resting motor threshold, with a frequency of 10 Hz, 10 trains of 60 pulses per train (total of 600 pulses), and intertrain interval of 45 seconds. Prior to starting the rTMS treatment, participant and injury characteristics, questionnaires (symptom burden, quality of life, depression, anxiety, cognition, and headache), and fNIRS assessment will be collected. Repeat questionnaires and fNIRS will occur immediately after rTMS treatment and at 1 month and 3 months post rTMS. Outcome parameters will be analyzed by a 2-way (treatment × time) mixed analysis of variance. Results As of May 6, 2021, 5 participants have been recruited for the study, and 3 have completed the rTMS protocol. The estimated completion date of the trial is May 2022. Conclusions This trial will expand our knowledge of how rTMS can be used as a treatment option of PPCS and will explore the neuropathophysiological response of rTMS through fNIRS analysis. Trial Registration ClinicalTrials.gov NCT04568369; https://clinicaltrials.gov/ct2/show/NCT04568369 International Registered Report Identifier (IRRID) DERR1-10.2196/31308
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Affiliation(s)
- Sané du Plessis
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada
| | - Ibukunoluwa K Oni
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew P Lapointe
- Hotchkiss Brain Institute, Calgary, AB, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christina Campbell
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jeff F Dunn
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Chantel T Debert
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada
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