Transcranial magnetic stimulation: potential treatment for co-occurring alcohol, traumatic brain injury and posttraumatic stress disorders

Managing substance use in patients receiving therapeutic repetitive transcranial magnetic stimulation: A scoping review

Repetitive Transcranial Magnetic Stimulation (rTMS) is an invaluable treatment option for neuropsychiatric disorders. Co-occurring recreational and nonmedical substance use can be common in those presenting for rTMS treatment, and it is unknown how it may affect the safety and efficacy of rTMS for the treatment of currently approved neuropsychiatric indications. This scoping review aimed to map the literature on humans receiving rTMS and had a history of any type of substance use. The search identified 274 articles providing information on inclusion/exclusion criteria, withdrawal criteria, safety protocols, type of rTMS and treatment parameters, adverse events and effect on primary outcomes that related to substance use. There are neurophysiological effects of substance use on cortical excitability, although the relevance to clinical rTMS practice is unknown. The current literature supports the safety and feasibility of delivering rTMS to those who have co-occurring neuropsychiatric disorder and substance use. However, specific details on how varying degrees of substance use alters the safety, efficacy, and mechanisms of rTMS remains poorly described.

The Rehabilitation Potential of Neurostimulation for Mild Traumatic Brain Injury in Animal and Human Studies

Neurostimulation carries high therapeutic potential, accompanied by an excellent safety profile. In this review, we argue that an arena in which these tools could provide breakthrough benefits is traumatic brain injury (TBI). TBI is a major health problem worldwide, with the majority of cases identified as mild TBI (mTBI). MTBI is of concern because it is a modifiable risk factor for dementia. A major challenge in studying mTBI is its inherent heterogeneity across a large feature space (e.g., etiology, age of injury, sex, treatment, initial health status, etc.). Parallel lines of research in human and rodent mTBI can be collated to take advantage of the full suite of neuroscience tools, from neuroimaging (electroencephalography: EEG; functional magnetic resonance imaging: fMRI; diffusion tensor imaging: DTI) to biochemical assays. Despite these attractive components and the need for effective treatments, there are at least two major challenges to implementation. First, there is insufficient understanding of how neurostimulation alters neural mechanisms. Second, there is insufficient understanding of how mTBI alters neural function. The goal of this review is to assemble interrelated but disparate areas of research to identify important gaps in knowledge impeding the implementation of neurostimulation.

rTMS/iTBS and Cognitive Rehabilitation for Deficits Associated With TBI and PTSD: A Theoretical Framework and Review

Rehabilitation of cognitive and psychosocial deficits resulting from traumatic brain injury (TBI) continues to be an area of concern in health care. Commonly co-occurring psychiatric disorders, such as major depressive disorder and posttraumatic stress disorder, create additional hurdles when attempting to remediate cognitive sequelae. There is increased need for procedures that will yield consistent gains indicative of recovery of function. Intermittent theta-burst stimulation (iTBS), a form of repetitive transcranial magnetic stimulation, has potential as an instrument that can be tailored to aid cognitive processes and support functional gains. The use of iTBS enables direct stimulation of desired neural systems. iTBS, performed in conjunction with behavioral interventions (e.g., cognitive rehabilitation, psychotherapy), may result in additive success in facilitating cognitive restoration and adaptation. The purpose of this theoretical review is to illustrate how the technical and physiological aspects of iTBS may enhance other forms of neurorehabilitation for individuals with TBI. Future research on combinatorial iTBS interventions has the potential to translate to other complex neuropsychiatric conditions.

Clinical application of repetitive transcranial magnetic stimulation for post-traumatic stress disorder: A literature review

The efficacy of traditional treatment for post-traumatic stress disorder (PTSD) is still unsatisfactory. Repetitive transcranial magnetic stimulation (rTMS) has been widely used in the treatment of various types of mental disorders, including PTSD. Although rTMS has been demonstrated to be effective in many cases, there are still arguments regarding its mechanism and protocol. This review aims to summarize the origin, development, principle, and future direction of rTMS and introduce this neuro-stimulation therapy to relevant clinicians.

Customizing TMS Applications in Traumatic Brain Injury Using Neuroimaging

Optimizing transcranial magnetic stimulation (TMS) treatments in traumatic brain injury (TBI) and co-occurring conditions may benefit from neuroimaging-based customization.

PARTICIPANTS

Our total sample (N = 97) included 58 individuals with TBI (49 mild, 8 moderate, and 1 severe in a state of disordered consciousness), of which 24 had co-occurring conditions (depression in 14 and alcohol use disorder in 10). Of those without TBI, 6 individuals had alcohol use disorder and 33 were healthy controls. Of our total sample, 54 were veterans and 43 were civilians.

DESIGN

Proof-of-concept study incorporating data from 5 analyses/studies that used multimodal approaches to integrate neuroimaging with TMS.

MAIN MEASURES

Multimodal neuroimaging methods including structural magnetic resonance imaging (MRI), MRI-guided TMS navigation, functional MRI, diffusion MRI, and TMS-induced electric fields. Outcomes included symptom scales, neuropsychological tests, and physiological measures.

RESULTS

It is feasible to use multimodal neuroimaging data to customize TMS targets and understand brain-based changes in targeted networks among people with TBI.

CONCLUSIONS

TBI is an anatomically heterogeneous disorder. Preliminary evidence from the 5 studies suggests that using multimodal neuroimaging approaches to customize TMS treatment is feasible. To test whether this will lead to increased clinical efficacy, studies that integrate neuroimaging and TMS targeting data with outcomes are needed.

The use of repetitive transcranial magnetic stimulation (rTMS) following traumatic brain injury (TBI): A scoping review

There is continued interest in developing effective and innovative treatment approaches to manage and improve outcomes after traumatic brain injury (TBI). Included in this, is the potential use of repetitive transcranial magnetic stimulation (rTMS), a neuromodulatory tool currently recommended by the National Institute for Health and Care Excellence as a treatment for depression. This review considers the application of rTMS after TBI, focussing on its therapeutic efficacy for a broad range of sequalae, whether an optimal and safe rTMS protocol can be determined, and recommendations for future clinical and research work. Five research databases (MEDLINE, CINAHL, PsychINFO, SCOPUS, and Web of Science) were electronically searched, identifying 30 empirical studies (single and multiple subject case reports; randomized controlled trials) for the full review. Evidence suggests that rTMS has the potential to be an efficacious therapeutic intervention for multiple symptoms after TBI, including depression, dizziness, central pain, and visual neglect. However, the picture is less encouraging for prolonged disorders of consciousness and mixed for cognitive outcomes. Overall, rTMS was well-tolerated by patients, although some incidents of side effects and seizures have been reported. Recommendations are made for more comprehensive guidelines and sufficient reporting of rTMS parameters and procedures.

Relationships and Evidence-Based Theoretical Perspectives on Persisting Symptoms and Functional Impairment Among Mild Traumatic Brain Injury and Behavioral Health Conditions

The purpose of this study is to characterize and describe the relationships between symptoms and functional impairment following mild traumatic brain injury (mTBI) and behavioral health conditions (BHCs) in order to inform evidence-based theories on why symptoms and functional impairments persist in some individuals but not others. This is a retrospective, multi-site, cross-sectional study utilizing data collected from a total of 289 Operation Iraqi Freedom/Operation Enduring Freedom Veterans who were classified into diagnostic groups using the symptom attribution and classification algorithm and the VA clinical reminder and comprehensive traumatic brain injury evaluation. The Neurobehavioral Symptom Inventory was used to assess mTBI symptom number and severity. The World Health Organization Disability Assessment Schedule 2.0 was used to assess functional impairment. Symptom profiles differed between diagnostic groups irrespective of symptom attribution method used. Veterans with both mTBI and BHCs and those with BHCs alone had consistently greater number of symptoms and more severe symptoms relative to no symptom and symptoms resolved groups. Symptom number and severity were significantly associated with functional impairment. Both symptom number and functional impairment were significantly associated with the number of mTBI exposures. Together, these results informed evidence-based theories on understanding why symptoms and functional impairment persist among some OEF/OIF Veterans.

Repetitive transcranial magnetic stimulation in trauma-related conditions

Some of trauma-exposed individuals develop posttraumatic stress disorder (PTSD), an incapacitating psychiatric disorder that is characterized by intrusion, avoidance, negative changes in mood and cognition, and hyperarousal. A number of other trauma-related conditions are very frequently found in individuals with PTSD. Traumatic brain injury (TBI) is one of the most frequently observed trauma-related conditions that trauma-exposed individuals with PTSD may experience. TBI refers to transient or permanent brain dysfunction that results in a wide range of neurological, cognitive, and psychiatric symptoms. These trauma-related conditions significantly affect one's quality of life, leading to substantial disability and socioeconomic burden. As the prevalence of PTSD with comorbid TBI is increasing in the general population along with the rates of crimes and accidents, effective prevention and intervention strategies are necessitated. However, a definitive treatment for PTSD with comorbid TBI is still lacking, resulting in high rates of treatment resistance and chronicity. It is essential to investigate the neurobiological mechanisms and potential therapeutics of PTSD with comorbid TBI. Yet, a few repetitive transcranial magnetic stimulation (rTMS) studies have recently investigated therapeutic efficacy in treatment-resistant patients with PTSD and/or TBI. Thus, this article reviews rTMS studies in trauma-related conditions, mainly focusing on PTSD and PTSD with TBI as one of the comorbidities. The review focuses on the applications of rTMS in reducing PTSD symptoms with and without comorbidities based on differential parameters and effects of rTMS as well as concomitant clinical conditions. The section on PTSD with comorbidities focuses on TBI with neurological, cognitive, and psychiatric symptoms. Although there were some inconsistencies in the clinical outcomes and optimized parameters of rTMS applied in PTSD and TBI, low frequency stimulation over the hyperactive frontal regions and/or high frequency stimulation over the hypoactive frontal regions generally improved the clinical symptoms of PTSD and TBI. Lastly, the limitations of the rTMS studies in PTSD and TBI as well as potential directions for future research are discussed.

Minute Pulsed Electromagnetic Neurostimulation for Mixed Trauma Syndromes

Research regarding noninvasive brain stimulation technologies for the treatment of mild traumatic brain injury (mTBI), posttraumatic stress disorder (PTSD), and mixed (mTBI/PTSD) trauma syndromes has been increasing exponentially. Technologies with the greatest potential thus far include repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), and cranial electrotherapy stimulation (CES). The nature and some of the controversies distinguishing mTBI, PTSD, and mTBI/PTSD are reviewed along with evidence for shared underlying mechanisms. An overview of treatment applications for rTMS, tDCS, and CES are also reviewed. A novel variant of a minute pulsed electromagnetic stimulation technology linked to ongoing electroencephalograph monitoring known as the Flexyx Neurotherapy System is introduced with an overview of the technology and technique, as well as a summary of supportive data to date that explores potential applications for amelioration of these syndromes.

Study of intracranial pressure in human brain during transcranial magnetic stimulation

This paper presents the results of cranial force in human brain due to electromagnetic pulse during transcranial magnetic stimulation. To model the force in a realistic brain, we used three dimensional magnetic resonance image of the 26 years old female subject. Simulation results show that during TMS procedure, there is a small force generated within the cranial tissue layers along with a torque value in different layers of brain tissues. The force depends on the magnitude of the magnetic field generated by the TMS coil.

Non-Invasive Brain Stimulation for the Treatment of Symptoms Following Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) is a common cause of physical, psychological, and cognitive impairment, but many current treatments for TBI are ineffective or produce adverse side effects. Non-invasive methods of brain stimulation could help ameliorate some common trauma-induced symptoms.

OBJECTIVE

This review summarizes instances in which repetitive Transcranial Magnetic Stimulation (rTMS) and transcranial Direct Current Stimulation (tDCS) have been used to treat symptoms following a TBI. A subsequent discussion attempts to determine the value of these methods in light of their potential risks.

METHODS

The research databases of PubMed/MEDLINE and PsycINFO were electronically searched using terms relevant to the use of rTMS and tDCS as a tool to decrease symptoms in the context of rehabilitation post-TBI.

RESULTS

Eight case-studies and four multi-subject reports using rTMS and six multi--subject studies using tDCS were found. Two instances of seizure are discussed.

CONCLUSION

There is evidence that rTMS can be an effective treatment option for some post-TBI symptoms, such as depression, tinnitus, and neglect. Although the safety of this method remains uncertain, the use of rTMS in cases of mild TBI without obvious structural damage may be justified. Evidence on the effectiveness of tDCS is mixed, highlighting the need for additional investigations.