Fri, 11/06/2020 - 11:41
By Debra J. Stultz M.D.
The show must go on…… Despite the cancellation of our annual meeting due to COVID 19, fifty-eight of the posters that were to be presented at the meeting are now available in a virtual format at the following link:
https://ctmss2020postersession.ipostersessions.com/Default.aspx?s=visitor_login
Up to a max of 14.5 hours of CME may also be earned for reviewing the posters! They provide exciting data on a multitude of topics in a colorful and informative format. I highly suggest taking the time to review the hard work our colleagues have prepared to enhance our body of TMS research.
In this article, I will attempt to supply a brief review of the topics covered. I have tried to group the posters into like topics, but please keep in mind some posters could belong to various topic headings, and this article is only descriptive and not an exhaustive review of each poster/research available. Differing protocols, TMS use with therapy, gender issues, pediatric use, TMS in the elderly, durability/remission/response topics, safety issues, and the use of TMS in disorders such as Alzheimer's, anhedonia, generalized anxiety, OCD, PTSD, bipolar, Gulf War Illness, insomnia, pain, headaches, Parkinson's, smoking, and suicidal ideation were all area covered in this year's posters. TMS use with Ketamine, with comorbid personality disorders, and with patients having concussions were also presented.
Protocols
Theta Burst
Several of the posters focused on using Theta Burst stimulation, and descriptions of various treatment protocols were presented. Chandrashekar et al. studied 65 patients using iTBS for 36 sessions over the LDPFC at 120% while following the PHQ-9 and the Quick Inventory of Depression Symptomology Clinician Rating Scale. They found 48 responded with 31 having remission. Hess et al. did a retrospective review of 114 patients comparing theta-burst vs. rTMS. Forty patients had Theta Burst and 74 rTMS. Using the BDI, MADRS, Hamilton Anxiety Rating Scale, and the ADHD scale part A and B, they found TBS comparable to rTMS. There was no clinical response difference, and decreased psychiatric symptoms were observed with all measures suggesting TMS may help with more than just depression.
Trautner et al. conducted a naturalistic study of 786 patients, with 87 patients receiving iTBS to the LDLPFC while measuring the PHQ-9 and MADRS. Seventy-Eight patients initially started TMS and then switched to iTBS, with 62 patients having combined R-DLPFC iTBS - for bilateral treatment ranging from 80 – 120%. Theta Burst Treatment was used when there was intolerance of TMS, lack of response of TMS, activation, or anxiety with TMS, and when there were concerns of inducing mania. Remission rates with both full response and partial response of TMS vs. iTBS were essentially equivalent at 81% and 79%, respectively. TMS was superior to iTBS in the rate of remission, it was equivalent in the rate of those with full response, but TMS was inferior to iTBS in the partial response rate. There was a lower rate of non-response in TMS but a higher rate of withdrawal from TMS. Voight et al. reported on a significant response with TBS vs Sham, a non-significant difference in remission with TBS and TMS, and no significant difference in adverse effects of TBS and TMS.
Accelerated TMS
Phillips et al. described the SAINT-TRD (Stanford Accelerated Intelligent Neuromodulation Therapy protocol) of using iTBS, accelerated daily delivery, and a high pulse-dose on 29 patients with personalized L-DLPFC to the subgenual anterior cingulate cortex by using functional connectivity MRI. They reported a 90% remission rate after five days, iTBS was superior to Sham, and fatigue was the most common side effect along with increased headaches.
Muir et al. discussed a chart review of accelerated and non-accelerated dTMS protocols with the H1 coil over the left DLPFC at 80% MT iTBS of 600-1800 pulses at an interval of 50 minutes. While studying the PHQ-9 and BDI, dTMS decreased depression in those who did and did not participate in the accelerated protocol with no significant difference.
Sarkhel et al. reported on 23 patients receiving multiple rTMS treatments per day of 10 Hz 120% MT and 3000 pulses to the left DLPFC over 2 -3 days with a maximum of 3 treatments per day with at least 30 minutes between the treatments. After 30 sessions, the average HAM-D decreased from 23.8 to 7.9. Fifty-two percent of patients had mild transient side effects of tiredness, headache, lightheadedness, site discomfort, and increased thirst. They summarized that multiple treatments per day was feasible, tolerable, and effective.
DASH protocol
West et al. described the "DASH" Neurostar protocol of 19 minutes in a naturalistic study compared with the standard 38-minute protocol in 7759 patients at 103 practice sites. They found no efficacy differences with either protocol, supporting the use of the quicker protocol. On the PHQ-9, there were no meaningful differences in outcomes, but on the CGI-S outcomes, there was a 5-8% greater response with the DASH protocol.
Bilateral Stimulation
Allen et al. completed a retrospective chart review of clients having depression with and without anxiety in 361 patients with 190 patients receiving unilateral rTMS only, 72 receiving bilateral stimulation only, and 72 having mixed stimulation. The unilateral rTMS patients had a more significant improvement in PHQ-9 results than the bilateral group. There was no significant difference in GAD-7 between unilateral versus bilateral stimulation. Patients switching from unilateral to bilateral treatment mid-course had overall poorer outcomes. Bilateral treatment was also described by Garland et al. in treating mild TBI and PTSD, and various other studies described in greater detail below.
TMS less than 5 days per week
Pardell and Pardell compared the effectiveness of both three and five treatment sessions per week, with 22 patients having 3 per week and 108 having 5 per week. They found no significant difference in the efficacy in 3 vs. 5 days per week of treatment. The patients receiving 3/week had decreased financial cost and on average higher daily pulses. Having a lower number of treatment sessions per week predicted a slightly longer time to response and remission. Kokdere et al. also reported no statistically meaningful impact of TMS treatment schedule density on overall final depression in a naturalistic study.
Extended TMS Treatments
Monira et al. reported on extending rTMS 15 additional treatments in MDD or Bipolar disorder in those who failed to achieve or maintain remission for two consecutive weeks after rTMS using the PHQ-9, GAD-7, CHRT, QIDS, and the Zung self-rater scales. Forty-six percent of patients had improvement after session 36, with 63% of those obtaining remission with the extended protocol. They suggested an individualized number of rTMS treatments are needed to reach maximum benefit.
Malta protocol for suicidal ideation
Xuereb et al. reported on the 'Malta' Protocol using iTBS to decrease suicidal ideation and hospital admissions using 7 sessions daily, each lasting 3 minutes on day 1 and day 3 with a two-minute interval between treatments for a total of 31 minutes daily or 62 minutes for the whole treatment. Using 120% MT of 50 Hz on 2 seconds and then off for 8 seconds, they measured Beck's Suicide Intent Scale and documented a 56% decrease in the patients' BSI scores, which persisted through day 7 in 44 patients.
Ketamine and TMS
Amato reported on IV ketamine with TMS in 10 patients who had suboptimal results after 36 treatments of TMS alone. Using the PHQ-9, five of the ten patients had a significant response after six treatments. Best et al. used a combo of TMS and Ketamine infusions of 0.5 – 5 mg/kg for 20 – 30 minutes during TMS in 28 patients with treatment-resistant depression using 1 Hz stimulation for 40 minutes at 130% MT. Brain Spect Imaging revealed improved regional brain perfusion in all cortical and subcortical structures. While using the Clinical Global Impression Severity scale, they documented that statistical significance was sustained for two years. They suggested the higher intensities of TMS were achievable due to the moderate anesthesia from the Ketamine.
TMS Basics
Gender
Gender issues were described in two posters. Maniam et al. completed a retrospective analysis of 22 patients (16 females and 6 males) using the Beck Depression Inventory-II and found no significant difference with respect to response between males or females. Also, in the female population, they found no significant difference in premenopausal and post-menopausal. Stultz et al. compared 14 males vs. 14 female patients and found that females had increased severity of depression overall and required an increased number of TMS treatments. Studying the Beck Depression Inventory, PHQ-9, Insomnia Severity Index (ISI), and the Pittsburgh Sleep Quality Index (PSQI), the females had greater improvement in the BDI scales, with males having a more significant response in the PHQ-9, ISI, and PSQI. Males showed more improvement on the insomnia scales than the females with split results on two different depression scales.
Pediatrics
Muir et al described pediatric use. with H1 use in youth ages 10 – 21 over the LDLPFC using high-frequency iTBS. While following the PHQ-9 and the BDI, they found no correlation with age, indicating improvement was not age-related. Pediatric use was also described in a case report with OCD described elsewhere in this article by Parmar.
Young Adults
Viner et al. 's poster compared pre and post-TMS treatment of quantitative EEG indices of absolute power in the left prefrontal cortex and anterior cingulate cortex in 18 patients aged 19 – 29 years old having complex depression and found benefit in these younger adults.
Elderly
Two posters discussed TMS use in the elderly. Manu and Park used low frequency (1 Hz) dTMS over the right DLPFC for late-life treatment-resistant depression in a 76-year-old with comorbid anxiety. The patient received 44 dTMS treatments with additional maintenance sessions for 56 dTMS treatments, benefiting both depression and anxiety. Stultz et al. reported on 15 patients greater than 65 years of age with an average age of 70, receiving an average of 30.5 treatments over the left DLPFC while studying the PHQ-9, BDI, ISI, and PSQI. Over six months, patients demonstrated improvement on the PHQ-9 and BDI, but not on either sleep scales. Three of the 15 patients required booster sessions as their symptoms increased during the six months.
Durability, Remission, Response
Gersner et al. presented durability issues using dTMS., reporting durability after one year in 64 of 100 patients, after two years in 44 of 100 patients, and after three years in 33 of 100. The number of lifetime failed medications tended to correlate with durability negatively. Age, gender, race, and the number of treatments did not correlate with durability. They described an average durability of 860 days and median durability of 561 days.
Nassan et al. discussed remission and response rates with TMS in those with psychiatric co-morbidities of borderline personality disorder, generalized anxiety, and persistent depressive disorder using 10 Hz left DLPFC at 3000 pulses and 120% MT. Their retrospective review from 2009 – 2019 found co-morbidities did not influence response rates.
Muir et al. studied 107 patients with comorbid depression using dTMS of high frequency or iTBS while studying the PHQ-9 and BDI and found an equal response with or without co-morbidities. Eighteen of those patients had borderline or narcissistic personality disorder.
Harvey et al. reviewed post-marketing analysis of 1040 patients using dTMS at 29 sites and based on CGI-S, HDRS-21, MARS, PHQ-9, BDI, and HDRS reported improvement before the 20th session in the majority and that non-responders may need a longer treatment course.
Safety Issues
Safety issues were described in three posters. Singh and Neil reviewed 115 patients ages 18 – 85 and found the three most common side effects were headache, fatigue, and scalp discomfort. Increased side effects were seen with high Hz groups except for nausea, lightheadedness, and tooth pain. Sokolich et al. reported on safety use up to 140% MT in a multi-site retrospective analysis of 10 Hz left DLPFC stimulation. In 26,786 treatments over 120% MT with 20, 135 of 140%, they reported no seizures. Heart et al., in post-marketing surveillance of Neurostar treatments, found the seizure rate with this system was .001%. They indicated unsafe stimulation parameters, individual seizure threshold lowering factors, and stimulation location may contribute to a seizure during TMS.
Predictors of Response
Predictors of TMS response were described in two posters. Vaishnavi and Brammer reported reaction time to negative facial expression may be faster in MDD using the Perception of Emotions Test and CNS Vital Signs in 15 patients with rTMS at 120% over the left DLPFC with five sessions for six weeks. Reaction time to negative facial expressions before TMS treatment was predictive of improvement in depression after TMS treatment. The faster the baseline reaction time to negative faces, the greater the response to TMS.
Menolascino et al. reported on EEG use and TMS patients. Among 50 patients, they stated the majority had EEG phenotypes associated with an inadequate antidepressant response, difficulty with cognitive functioning, and environmental hypersensitivity. The indicated EEG's findings have helped them guide treatment choices in their practice.
Individual Disorders/Symptoms and TMS
Alzheimer' s/Cognition
Tsui et al. used TMS in an asymptomatic 31-year-old male with a family history of early-onset Alzheimer's. Using both left and right DLPFC, he was given two cycles of rTMS. The patient's cognitive domain scores improved with TMS compared to training in memory, attention, and flexibility.
Monira et al. used THINC-it, a 10-minute cognitive screener in 212 patients having rTMS, and found improvement in executive functioning, working memory, processing speed, and attention with no detrimental cognitive effects after treatment.
Jagtap et al. reviewed randomized/sham-controlled trials on TMS for cognitive impairment, with 9/21 having statistical significance, and found improvements across various disorders. Twelve of the 21 studies did not show statistical significance. High-frequency rTMS (10 Hz) yielded positive results, with ultra-HF (20 – 30 Hz) also having some benefit.
Anhedonia
Fukuda et al. reported that 70% of MDD patients have anhedonia associated with an inadequate response to psychotherapy and pharmacology. Their naturalistic study of 169 patients using the Snaith-Hamilton Pleasure Scale and Inventory of Depressive Symptomatology-Self Report indicated anhedonia's symptoms respond to TMS and baseline anhedonia did not predict clinical outcome.
Anxiety Disorders:
Generalized Anxiety
Engelbertson and Morris treated generalized anxiety 5 days per week for 30 treatments and then used a three-week taper of 3,2,1 with left hemisphere either high-frequency rTMS or Continuous Theta Burst along with right hemisphere at low-frequency rTMS or Continuous Theta Burst. They discovered similar remission rates for GAD and MDD (43.78% vs. 40.05%), and those for depression were similar to those found in the current literature.
OCD
Multiple studies were presented this year on OCD and TMS. Grammer et al. reported dTMS and OCD in data from 192 patients at 22 different sites using the H-7 coil while measuring the Yale-Brown Obsessive-Compulsive Scale. First and sustained response rates were 73.2% and 62.2% respectively; first response was achieved after an average of 18 sessions or 28 days; and sustained response was achieved after 19 sessions or 30 days. Extending the treatment course beyond 29 sessions resulted in continued improvement. Parmar presented a case report on a 14-year-old boy demonstrating an improvement on his YBOCS from 24 to 12 using two 19 minutes 1 Hz right-sided sessions 4 times per week at 55% MT to the right lateral orbital frontal cortex. Tendler et al. revealed that the overall durability of dTMS for OCD was 426 days, and the median durability was 201 days after studying 38 responders. Vidrine et al. used dTMS in 38 patients over the DMPFC, reporting 45% responded with 30% or more improvement in their YBOCS. 60% met the partial-response criteria of at least 20% improvement. The average improvement in the YBOCS was 7 points.
PTSD
Hashimoto et al. described a 49-year-old male having PTSD associated with major depression, social anxiety, and dissociation receiving TMS with symptom provocation using right DLPFC for 40 treatments at 80% MT. The patient had decreased flashbacks, nightmares, self-blame, avoidance, and hypervigilance.
Garland et al. reported on rTMS in 28 patients with mild TBI and PTSD receiving 30 sessions over five weeks, then a 3,2,1 taper of 3500 pulses to the left DLPFC at 10 Hz and then 1500 pulses to the right DLPFC at 1 Hz over approximately 70 minutes.
Bipolar
Gama-Chonlon et al. completed a retrospective chart review of 291 unipolar depression and 36 bipolar depressed patients using the PHQ-9 and GAD-7 scales. The most significant PHQ-9 change was seen in bipolar depressed patients treated with unilateral high-frequency LDLPFC rTMS. Bipolar patients had a more rapid response in PHQ-9 and a more remarkable change by the end of treatment. No significant group changes were seen with GAD scales.
Gulf War Illness In Veterans
Leung et al. completed a study of 40 veterans, 19 with active treatment, and 21 using sham treatments, including those with at least 3 out of 6 symptoms of pain, fatigue, neurological symptoms (headaches), GI issues, and respiratory problems or dermatological findings. Neuronavigation directed TMS to the left side at 10 Hz, 2000 pulses, and 80% MT patients were followed at one week, one month, and two months after treatment with positive results.
Insomnia
Raghunandan and Elmaadawi, in a case series of 5 participants, described a paradoxical TMS response of increased insomnia during the 1st month of treatment by 41%, which resolved after treatment. Stultz et al., in their gender study, reported more significant improvement in insomnia scales with males treated with TMS and a lack of response for insomnia in their elderly study.
Pain:
Neuropathic Pain
Kuluva and Bermudes treated 47 patients with Depression-Pain Syndrome and Depression-Pain Dyad at 90% MT, 5 Hz, for 1000 pulses over M1 followed by high frequency left DLPFC at 120%, 10 Hz, and 3000 pulses while following the Measured Visual Analogue Scales (VAS) and weekly PHQ-9. They reported a 44% reduction in the VAS after 25 sessions and a 56% decrease after 36 sessions. Their patients also had a >50% decrease in their PHQ-9. In another study, Bermudes et al. compared drug therapy cost in patients with Neuropathic Pain alone, Neuropathic Pain and depression, and Neuropathic Pain with Treatment-Resistant Depression. In all three categories, the cost of TMS was lower than that of drug therapy costs.
Leung et al., consisting of a 30 member multi-national multi-disciplinary panel under the leadership of both the International Neuromodulation Society and the North American Neuromodulation Society, developed the consensus reporting Extremely Recommendable and Strongly Recommended implications for neuronavigation guided high frequency (>5 Hz) rTMS for neuropathic pain such as post-stroke central pain and trigeminal neuralgia, with the more peripheral origin's such as post-traumatic peripheral neuropathic pain responding less favorably.
Post Traumatic Headache
Leung et al. in the Post-Traumatic Brain Injury Headache Task Group found the level and scope of evidence for rTMS in managing Post-Traumatic Brain Injury Headaches is High, and the treatment is Strongly Recommendable with either left MC or left DLPFC. Initial recommendations were five induction sessions at 10 – 20 Hz 2000 – 3000 pulses per session at a MT of 80 – 90%. With comorbid depression and MTBI-HA they recommended using at least ten sessions at 10 – 20 Hz 2000- 3000 Hz pulses of 80 – 90% MT over the left DLPFC.
Vaninetti et al. studied 14 Real vs. 12 Sham mild traumatic brain injury-related headache patients with rTMS of 2000 pulses at 10 Hz and 80% MT over the LDLPFC. The REAL group of patients had decreased average daily headache intensity, debilitating headache exacerbation frequency, composite scores, and decreased persistent headache at one week following treatment. At one month out, the REAL group had significant decreases in daily headache intensity. Correlated fMRI studies in the REAL group showed an increase in evoked heat pain activity and resting functional connectivity at the LPFC after rTMS, which was not found in the sham group.
Migraines
Melgar et al. did a case report on three adult patients having migraines using rTMS three times per week for five weeks over the LDLPFC at 2000 pulses and 10 Hz at 80% MT. They reported a decrease between 35 – 50 % of intensity, duration, and migraines frequency with a 4 point decrease quantified by pain scales and migraine diaries.
Parkinson's
Marcolin et al. presented info on the freezing of gait with Parkinson's in 5 patients using iTBS of 3 sessions daily at 50/5 Hz at 90% MT over the thoracic level (T5). Sessions were 2 minutes with 40-minute intervals in between. Their study noted a 22% improvement in freezing of gait, improved timed up, and go by 48%, and the patient global impression of change was "much improved."
Smoking
Bellini et al. used dTMS treatment of 15 daily sessions, then three weekly sessions, followed by three sessions every 15 days in 45 patients comparing dTMS vs. Sham. Forty-five eligible patients were randomized to dTMS vs. Sham. Thirty patients concluded the 21 sessions. This study conducted on people who smoked more than ten cigarettes per day over one year with no interruption of smoking for > 3 months. Patients had an average age of 46, with a range of 22 – 70. Twenty-two patients did not stop smoking. Fourteen patients dropped out, and one was excluded. They had eight successful patients. None had weight gain.
TMS with Therapy
Cognitive Therapy
Vaishnavi and Brammer using BrainHQ with 120% MT over the left DLPFC, found cognitive training during TMS did not improve depression outcomes. In the TMS + CT group, 56% remitted, and in the TMS only group 68% remitted.
Web-Based CBT
Evans et al., using a web-based intervention for CBT entitled "Train Your Brain: Your Record of Care with TMS" (which uses CBT and behavioral activation) found outcomes were higher than naturalistic data and similar to those of TMS and psychotherapy.
Hypnosis
Musher et al. studied 34 patients with comorbid anxiety and depression, with 17 receiving hypnotic suggestions by a recording. Using 10 Hz left DLPFC stimulation and following the Beck Anxiety Inventory and Hamilton Anxiety Rating scale, they suggested hypnosis and rTMS might work better than TMS alone.
Mindfulness
Cavallero et al. used Mindfulness-Based Cognitive Therapy audio-tracts focusing on breathing, working with difficulty, body scan, and formal meditation with 17 patients and suggested Mindfulness-Based Cognitive Therapy is a promising tool in the treatment of recurrent depression.
Music and rTMS
Mania and Kaur used personally inspiring music based on patient preference while following the HAM-D with rTMS to the left DLPFC. Music was played online before or after TMS. Nine patients had response and remission rates of 89% and 56%, respectively.
Therapy, Sleep Modifications, and Exercise
Narwal and Hervey studied 43 patients with left DLPFC stimulation for 36 treatments, receiving CBT, Dialectal Behavioral Therapy and group therapy. Using the PHQ-9, they demonstrated a 90.7% response rate and a 69.8% remission rate over six months. Thirty-nine of the patients had increased total sleep time. The patients also were able to increase their physical activity.
SUMMARY
In summary, the 2020 Clinical TMS Society poster session has provided us with an enormous amount of useful clinical data to add to our ever-growing research in the field of Transcranial Magnetic Stimulation. I strongly suggest a more in-depth review of these posters!
HOW TO ACCESS AND VIEW THE POSTERS
To access and view the 58 posters, please visit the following link and enter in the email address you used to register for the Virtual Poster Session: https://ctmss2020postersession.ipostersessions.com/Default.aspx?s=visitor_login
HOW TO GET YOUR CERTIFICATE
- Go to http://workshop-evaluator.herokuapp.com/evaluation/7533
- Select the Posters you viewed.
- Evaluate Posters.
- Print all pages of your certificate for your records.
Disclaimer: This article represents the individual opinion and work of the author not the CTMSS.