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Stilling J, Paxman E, Mercier L, Gan LS, Wang M, Amoozegar F, Dukelow SP, Monchi O, Debert C. Treatment of Persistent Post-Traumatic Headache and Post-Concussion Symptoms Using Repetitive Transcranial Magnetic Stimulation: A Pilot, Double-Blind, Randomized Controlled Trial. J Neurotrauma 2019; 37:312-323. [PMID: 31530227 DOI: 10.1089/neu.2019.6692] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Persistent post-traumatic headache (PTH) after mild traumatic brain injury is one of the most prominent and highly reported persistent post-concussion symptoms (PPCS). Non-pharmacological treatments, including non-invasive neurostimulation technologies, have been proposed for use. Our objective was to evaluate headache characteristics at 1 month after repetitive transcranial magnetic stimulation (rTMS) treatment in participants with PTH and PPCS. A double-blind, randomized, sham-controlled, pilot clinical trial was performed on 20 participants (18-65 years) with persistent PTH (International Classification of Headache Disorders, 3rd edition) and PPCS (International Classification of Diseases, Tenth Revision). Ten sessions of rTMS therapy (10 Hz, 600 pulses, 70% resting motor threshold amplitude) were delivered to the left dorsolateral pre-frontal cortex. The primary outcome was a change in headache frequency or severity at 1 month post-rTMS. Two-week-long daily headache diaries and clinical questionnaires assessing function, PPCS, cognition, quality of life, and mood were completed at baseline, post-treatment, and at 1, 3, and 6 months post-rTMS. A two-way (treatment × time) mixed analyisis of variance indicated a significant overall time effect for average headache severity (F(3,54) = 3.214; p = 0.03) and a reduction in headache frequency at 1 month post-treatment (#/2 weeks, REAL -5.2 [standard deviation {SD} = 5.8]; SHAM, -3.3 [SD = 7.7]). Secondary outcomes revealed an overall time interaction for headache impact, depression, post-concussion symptoms, and quality of life. There was a significant reduction in depression rating in the REAL group between baseline and 1 month post-treatment, with no change in the SHAM group (Personal Health Questionnaire-9; REAL, -4.3 [SD = 3.7[ p = 0.020]; SHAM, -0.7 [SD = 4.7; p = 1.0]; Bonferroni corrected). In the REAL group, 60% returned to work whereas only 10% returned in the SHAM group (p = 0.027). This pilot study demonstrates an overall time effect on headache severity, functional impact, depression, PPCS, and quality of life after rTMS treatment in participants with persistent PTH; however, findings were below clinical significance thresholds. There was a 100% response rate, no dropouts, and minimal adverse effects, warranting a larger phase II study. Clinicaltrials.gov: NCT03691272.
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Affiliation(s)
- Joan Stilling
- University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Eric Paxman
- University of Calgary, Calgary, Alberta, Canada.,University of Alberta, Department of Medicine, Edmonton, Alberta, Canada
| | - Leah Mercier
- University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Liu Shi Gan
- University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Meng Wang
- University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Farnaz Amoozegar
- University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Sean P Dukelow
- University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Oury Monchi
- University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Chantel Debert
- University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, Calgary, Alberta, Canada
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Stilling JM, Duszynski CC, Oni I, Paxman E, Dunn JF, Debert CT. Using Functional Near-Infrared Spectroscopy to Study the Effect of Repetitive Transcranial Magnetic Stimulation in Concussion: A Two-Patient Case Study. Front Neurol 2019; 10:476. [PMID: 31139136 PMCID: PMC6518445 DOI: 10.3389/fneur.2019.00476] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 04/23/2019] [Indexed: 12/13/2022] Open
Abstract
Background: Approximately 25% of concussion patients experience persistent post-concussion symptoms (PPCS). Repetitive transcranial magnetic stimulation (rTMS) has been explored as a treatment, and functional near-infrared spectroscopy (fNIRS) may be a cost-effective method for assessing response. Objectives: Evaluate rTMS for the treatment of PPCS and introduce fNIRS as a method of assessing treatment response. Methods:Design: Two-patient case study. Setting: Calgary Brain Injury Program. Participants: 47 and 49 years. male, with PPCS for 1–2 years (headache, cognitive difficulties, nausea, visual difficulties, irritability, anxiety, poor mood, sleep, and fatigue). Intervention: 10 sessions of rTMS therapy to the left dorsolateral prefrontal cortex (DLPFC), at 10 Hz (600 pulses) and 70% of resting motor threshold amplitude. Participants completed an 8-week headache diary and a battery of clinical questionnaires prior to each fNIRS session. fNIRS: Hemodynamic changes were recorded over the frontoparietal cortex during rest, finger tapping, and a graded working memory test. fNIRS was completed pre-rTMS, following rTMS (day 14), and at 1-month post-rTMS (day 45). For comparison, two healthy, sex-matched controls were scanned with fNIRS once daily for five consecutive days. Results: Clinical scores improved (headache severity, MoCA, HIT-6, PHQ-9, GAD-7, QOLIBRI, RPSQ, BCPSI) or remained stable (PCL-5, headache frequency) post-rTMS, for both participants. Participant 1 reported moderate symptom burden, and a fNIRS task-evoked hemodynamic response showing increased oxyhemoglobin was observed following a working memory task, as expected. Participant 2 exhibited a high symptom burden pre-treatment, with abnormal fNIRS hemodynamic response where oxyhemoglobin declined, in response to task. One month following rTMS treatment, participant 2 had a normal fNIRS hemodynamic response to task, corresponding to significant improvements in clinical outcomes. Conclusion: This case study suggests fNIRS may be sensitive to physiological changes that accompany rTMS treatment. Further studies exploring fNIRS as a cost-effective technology for monitoring rTMS response in patients with PPCS are suggested.
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Affiliation(s)
- Joan M Stilling
- Hotchkiss Brain Institute, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Chris C Duszynski
- Hotchkiss Brain Institute, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ibukunoluwa Oni
- Hotchkiss Brain Institute, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eric Paxman
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jeff F Dunn
- Hotchkiss Brain Institute, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Chantel T Debert
- Hotchkiss Brain Institute, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Paxman E, Stilling J, Mercier L, Debert C. Repetitive Transcranial Magnetic Stimulation (rTMS) as an Effective Intervention for Chronic Dizziness Following Mild Traumatic Brain Injury: A Case Study. Brain Stimul 2019. [DOI: 10.1016/j.brs.2018.12.937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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McCreary JK, Erickson ZT, Paxman E, Kiss D, Montina T, Olson DM, Metz GAS. The rat cumulative allostatic load measure (rCALM): a new translational assessment of the burden of stress. Environ Epigenet 2019; 5:dvz005. [PMID: 31065381 PMCID: PMC6500369 DOI: 10.1093/eep/dvz005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/25/2019] [Indexed: 06/09/2023]
Abstract
Determinants of lifetime health are complex and emphasize the need for robust predictors of disease risk. Allostatic load (AL) has become a clinical framework to estimate the cumulative biological burden associated with chronic stress. To assist knowledge translation in the developmental origins of health and disease field, clinically valid methods for reliable AL assessment in experimental models are urgently needed. Here, we introduce the rat cumulative allostatic load measure (rCALM), as a new preclinical knowledge translation tool to assess the burden of chronic stress. First, we identified an array of stress-associated physiological markers that are particularly sensitive to hypothalamic-pituitary-adrenal axis dysregulation by ancestral prenatal stress. Second, we determined which of these markers are susceptible to an intervention by environmental enrichment (EE) to mitigate AL. The markers most responsive to stress and EE therapy were assembled to become operationalized in the rCALM. Third, the new rCALM was validated for the ability to indicate future disease risks. The results show that the rCALM estimates the burden of chronic stress and serves as a proxy to estimate stress resilience and vulnerability to disease. Using the rCALM we showed that enrichment therapy can offset the adverse health outcomes linked to a high AL. Thus, the rCALM provides a model for the development of new test strategies that facilitate knowledge translation in preclinical animal models.
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Affiliation(s)
- J Keiko McCreary
- Department of Neuroscience, Canadian Centre for Behavioural Neuroscience, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Zachary T Erickson
- Department of Neuroscience, Canadian Centre for Behavioural Neuroscience, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Eric Paxman
- Department of Neuroscience, Canadian Centre for Behavioural Neuroscience, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Douglas Kiss
- Department of Neuroscience, Canadian Centre for Behavioural Neuroscience, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Tony Montina
- Department of Chemistry and Biochemistry, University of Lethbridge, Lethbridge, Alberta, Canada
| | - David M Olson
- Department of Neuroscience, Canadian Centre for Behavioural Neuroscience, University of Lethbridge, Lethbridge, Alberta, Canada
- Departments of Obstetrics and Gynecology, Pediatrics and Physiology, University of Alberta, Edmonton, Alberta, Canada
| | - Gerlinde A S Metz
- Department of Neuroscience, Canadian Centre for Behavioural Neuroscience, University of Lethbridge, Lethbridge, Alberta, Canada
- Departments of Obstetrics and Gynecology, Pediatrics and Physiology, University of Alberta, Edmonton, Alberta, Canada
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Paxman E, Stilling J, Mercier L, Debert CT. Repetitive transcranial magnetic stimulation (rTMS) as a treatment for chronic dizziness following mild traumatic brain injury. BMJ Case Rep 2018; 2018:bcr-2018-226698. [PMID: 30396889 PMCID: PMC6229180 DOI: 10.1136/bcr-2018-226698] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2018] [Indexed: 11/04/2022] Open
Abstract
A 61-year-old man sustained a mild traumatic brain injury (mTBI) following a pedestrian versus vehicle traffic accident. Post injury, he began to experience symptoms including light-headedness, spatial disorientation, nausea, fatigue and prominent dizziness brought on by postural change, physical activity or eye movements. Symptoms of dizziness persisted for over 5 years, despite numerous extensive and rigorous vestibular and vision therapy regimens. All investigations suggested normal peripheral and central vestibular functioning. The patient underwent 10 sessions of repetitive transcranial magnetic stimulation (rTMS) treatment, with stimulation of the left dorsolateral prefrontal cortex at 70% of resting motor threshold and a frequency of 10 Hz. Dizziness symptom severity and frequency were reduced by greater than 50% at 3 months post treatment, with a clinically significant reduction of dizziness disability from 40 to 21 points on the Dizziness Handicap Inventory. We propose rTMS as a safe, effective and cost-effective treatment option for patients who experience persistent post-traumatic dizziness secondary to mTBI.
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Affiliation(s)
- Eric Paxman
- Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation, University of Calgary, Calgary, Alberta, Canada
| | - Joan Stilling
- Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation, University of Calgary, Calgary, Alberta, Canada
| | - Leah Mercier
- Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation, University of Calgary, Calgary, Alberta, Canada
| | - Chantel T Debert
- Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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