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Speech

INHIBITORY RIGHT-BRAIN TMS IMPROVES LANGUAGE AFTER STROKE

Sue Hughes-Medscape(July 11, 2013)

Use of inhibitory transcranial magnetic stimulation (TMS) over the speech area in the right side of the brain significantly improved language recovery in patients with stroke, new research shows.

“The dominant language center is normally in the left hemisphere of the brain. After a stroke, when this area is damaged, similar regions in the right hemisphere take over, but this is not as effective as if the left side recovers. Brain imaging studies show that stroke patients with right hemisphere activation generally do worse. So we used TMS treatment to inhibit the right hemisphere area, so the left hemisphere area has to function,” lead investigator Alexander Thiel, MD, McGill University, Montreal, Quebec, Canada, told Medscape Medical News.

First Proof-of-Concept Study

Dr. Thiel compared the strategy with treating someone who has paralysis on 1 side of their body.

“If someone has paralysis of one arm, if you immobilize the good arm, the patient is forced to use the paralyzed arm, which helps it recover.”

The inhibitory TMS is carried out by positioning a hand-held electromagnetic coil over the appropriate part of the brain. The fluctuating magnetic field induces an electrical current that blocks normal function.

Dr. Thiel noted that a few single case reports and case series of this treatment have been published previously, but this is the first randomized proof-of-concept study.

The study involved 24 patients (all right-handed) with subacute post-stroke aphasia from the rehabilitation hospital RehaNova in Cologne, Germany. They were randomly assigned to a 10-day protocol of 20-minute inhibitory 1-Hz TMS over the right triangular part of the posterior inferior frontal gyrus or sham stimulation, followed by 45 minutes of speech and language therapy.

Activity in language networks was measured with O-15-water positron emission tomography before and after treatment, and language performance was assessed by using the Aachen Aphasia Test (AAT) battery.

Results showed that language performance was significantly improved in the TMS group. The largest improvements were seen in the subtest of naming objects, but comprehension, token test, and writing also all improved.

Imaging results showed that patients in the TMS group also activated proportionally more voxels in the left hemisphere language center after treatment than before (difference in activation volume index) compared with sham-treated patients. There was a moderate but significant linear relationship between activation volume index change and global AAT score change.

“We found that patients who underwent the real TMS treatment had 2-3 times better recovery of their aphasia than patients who were given the sham treatment. The principal improvement was in the ability to name objects. This is very important — you cannot communicate if you can’t name things,” said Dr. Thiel.

Pronounced Effect

“This study is telling us that this therapy seems to work the way we think it should. We are very excited by these results. We were a little surprised by the magnitude of the effect. We didn’t expect it to be so pronounced. But the fact that the imaging results showed a shift in brain activity from the right to the left, corresponding with the improvement in aphasia, is reassuring and supports that this model is pathophysiologically valid.”

He noted that the effect was measured immediately after the treatment. “How long it will last we don’t know. Some previous studies suggest it does last long-term, but we need to study this further.”

The next step is to try reproducing these results in a larger study. Such a study — NORTHSTAR — is now planned to start in October. Funded by the Canadian Institutes of Health Research, it will involve 100 patients from Canada and Germany. Patients will be assessed at day 10, as in the current study, but also longer term — about a month after treatment stops.

In the current study, patients were treated within 3 months after stroke. In the next study they will be treated within 1 month.

“We think the earlier we perform this treatment the more likely it is to be effective, as we believe there is a window of a few weeks after stroke when the right side of the brain becomes very active.

“We have seen this in imaging studies. Eventually it shifts back to the left. But the more the left brain takes over again the better the recovery. This treatment is just trying to accelerate this naturally occurring pattern,” said Dr. Thiel.

Asked about risks, Dr. Thiel reported that aphasia did not deteriorate with the treatment.

The main adverse effect is headaches because TMS can cause the scalp muscles to contract, but these are benign and respond to normal headache treatments, he said.

BRAIN STIMULATION IMPROVES LANGUAGE RECOVERY POST-STROKE

FRIDAY, June 28 (HealthDay News) — Along with speech therapy, use of repetitive transcranial magnetic stimulation (rTMS) may improve language recovery following subacute ischemic stroke, according to a small study published online June 27 in Stroke.

Alexander Thiel, M.D., from McGill University in Montreal, and colleagues randomized 24 patients with subacute post-stroke aphasia to either a 10-day protocol of 20-minute inhibitory 1 Hz rTMS over the right triangular part of the posterior inferior frontal gyrus or sham stimulation, followed by 45 minutes of speech and language therapy. O-15-water positron emission tomography was used during verb generation to assess activity in language networks before and after treatment. The Aachen Aphasia Test battery was used to measure language performance.

The researchers found that global Aachen Aphasia Test score change was significantly higher in the rTMS group. Subtest naming had the largest increases (P = 0.002) and tended to be higher for comprehension, token test, and writing (P < 0.1). Compared to sham-treated patients, proportionally more voxels were activated in the left hemisphere of patients in the rTMS group after treatment than before (difference in activation volume index). Activation volume index change was significantly associated with global Aachen Aphasia Test score change.

“Ten sessions of inhibitory rTMS over the right posterior inferior frontal gyrus, in combination with speech and language therapy, significantly improve language recovery in subacute ischemic stroke and favor recruitment of left-hemispheric language networks,” the authors write.

TRANSCRANIAL STIMULATION IMPROVES SYMPTOMS OF TOURETTE’S

By Helen Albert, Senior medwireNews Reporter-A month of daily transcranial magnetic stimulation targeting the supplemental motor area (SMA) results in lasting improvements in symptoms of Tourette syndrome, show study findings.

Repetitive transcranial magnetic stimulation (rTMS)… involves repetitive generation of a brief, powerful magnetic field by a small coil positioned over the scalp that induces an electric current in the brain,” explain Nong Xiao (Chongqing Medical University, Yuzhong district, China) and colleagues.

The technique is designed as a noninvasive treatment for a range of neurological and psychiatric disorders including migraine, stroke, and Parkinson’s disease.

In this study, the researchers tested the capacity of low-frequency 1 Hz rTMS applied at 20 daily sessions (Monday-Friday) over 4 weeks for treatment of the motor and speech neurological tics displayed by patients with Tourette syndrome, on the basis that low-frequency rTMS (≤1 Hz) inhibits and high-frequency rTMS (>5 Hz) promotes cortical excitability.

In total, 25 children under 16 years took part in the study. After 4 weeks of treatment, the team observed no improvements in tic symptoms in six children, but significant improvements in these symptoms that lasted until 3 months in 19 children, and until 6 months in 17 children (68%).

On average, significant reductions were seen in the scores obtained on various tests by the children at 4 weeks compared with baseline. These included the Yale Global Tic Severity Scale; Clinical Global Impression Scale; Swanson, Nolan and Pelham Rating Scale, version IV for attention-deficit hyperactivity disorder (SNAP-IV); Children’s Depression Inventory; Spence Children’s Anxiety Scale; and a novel Attention Test.

Overall scores for all these tests were lower at 6 months than at baseline, but only the SNAP-IV and Attention test scores were significantly lower at 6 months than at 4 weeks.

“Low-frequency (1 Hz) rTMS to the SMA significantly improved Tourette syndrome symptoms, suggesting that it is effective on tics, hyperactivity, attention deficit, depression and anxiety in children with Tourette syndrome,” write Xiao and co-workers in the Journal of Clinical Neuroscience.

“These collective results suggest the need for further studies using rTMS as a research and clinical therapeutic tool in psychiatric and neurological diseases, with particular attention to patients with Tourette syndrome.”

http://www.southshoretms.com/blog/

Transcranial stimulation improves symptoms of Tourette’s

Helen Albert, Senior medwireNews Reporter (Dec. 18, 2012)-A month of daily transcranial magnetic stimulation targeting the supplemental motor area (SMA) results in lasting improvements in symptoms of Tourette syndrome, show study findings.

“Repetitive transcranial magnetic stimulation (rTMS)… involves repetitive generation of a brief, powerful magnetic field by a small coil positioned over the scalp that induces an electric current in the brain,” explain Nong Xiao (Chongqing Medical University, Yuzhong district, China) and colleagues.

The technique is designed as a noninvasive treatment for a range of neurological and psychiatric disorders including migraine, stroke, and Parkinson’s disease.

In this study, the researchers tested the capacity of low-frequency 1 Hz rTMS applied at 20 daily sessions (Monday-Friday) over 4 weeks for treatment of the motor and speech neurological tics displayed by patients with Tourette syndrome, on the basis that low-frequency rTMS (≤1 Hz) inhibits and high-frequency rTMS (>5 Hz) promotes cortical excitability.

In total, 25 children under 16 years took part in the study. After 4 weeks of treatment, the team observed no improvements in tic symptoms in six children, but significant improvements in these symptoms that lasted until 3 months in 19 children, and until 6 months in 17 children (68%).

On average, significant reductions were seen in the scores obtained on various tests by the children at 4 weeks compared with baseline. These included the Yale Global Tic Severity Scale; Clinical Global Impression Scale; Swanson, Nolan and Pelham Rating Scale, version IV for attention-defict hyperactivity disorder (SNAP-IV); Children’s Depression Inventory; Spence Children’s Anxiety Scale; and a novel Attention Test.

Overall scores for all these tests were lower at 6 months than at baseline, but only the SNAP-IV and Attention test scores were significantly lower at 6 months than at 4 weeks.

“Low-frequency (1 Hz) rTMS to the SMA significantly improved Tourette syndrome symptoms, suggesting that it is effective on tics, hyperactivity, attention deficit, depression and anxiety in children with Tourette syndrome,” write Xiao and co-workers in the Journal of Clinical Neuroscience.

“These collective results suggest the need for further studies using rTMS as a research and clinical therapeutic tool in psychiatric and neurological diseases, with particular attention to patients with Tourette syndrome.”