Edward Fruitman, MD
1451 Broadway
Hewlett, NY 11557
(516) 295-4867

Category

Stroke

TMS Could Help Treat Chronic Dizziness

Researchers from the Johns Hopkins University School of Medicine believe that they have located a specific site in the human brain that could be one of the sources of dizziness and spatial disorientation.

While dizziness can also be linked to damage to the inner ear, or to other senses such as vision, neurology instructor Dr. Amir Kheradmand and his colleagues report that they have discovered a region of the brain that plays a vital role in our subconscious awareness of which way is up and which way is down.

Their study, which appears online in the journal Cerebral Cortex, found that some causes of dizziness, unsteadiness and “floating” could be linked to that region in the parietal cortex.

The study authors opted to focus their analysis on the right parietal cortex, as research on stroke victims with balance problems has suggested that damage to that region of the brain was directly involved with upright perception.

They recruited eight healthy subjects, placing each in a dark room and showing them lines that were illuminated on a screen. Dr. Kheradmand’s team then had the study participants report the orientation of each line by rotating a dial to the left, the right, or straight ahead.

The subjects then received (TMS) – an FDA-approved treatment for depression and which “painlessly and noninvasively delivers electromagnetic currents to precise locations in the brain.”

Each individual had a TMS coil placed behind the ear and against the scalp across the right parietal lobe. The subjects received 600 electromagnetic pulses over the course of 40 seconds, and at the end of each session, they were asked a second time to show the researchers which way the illuminated line was positioned. At the end of the study, all of the subjects reported that his or her sense of being upright had been altered in the same way after TMS was administered in the same location in the parietal cortex.

According to Kheradmand, his team’s findings suggest that this form of stimulation could be used to treat chronic dizziness. “If we can disrupt upright perception in healthy people using TMS, it might also be possible to use TMS to fix dysfunction in the same location in people with dizziness and spatial disorientation,” he said.

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.

TMS MAY TREAT POST STROKE PAIN

May 14, 2013 (dailyRx News) Days or even weeks after a stroke, some patients experience intense pain. Medications and magnetic or electrical stimulation can help, but doctors often fail to correctly diagnose the condition.

Nearly 1 in 10 individuals who have had a stroke suffer from central post-stroke pain syndrome (CPSP). The condition causes a chronic sharp, stabbing or burning sensation.

When correctly identified, CPSP can be treated. However, many physicians often do not accurately identify the syndrome, according to a recent report.

“Tell your doctor if you’re experiencing pain after a stroke.”

Murray Flaster, MD, associate professor in the departments of Neurology and Neurological Surgery at Loyola University Chicago Stritch School of Medicine and medical director of the Loyola outpatient neurology clinic, co-authored the article with other scientists from Loyola University.

In reviewing previous research, Dr. Flaster and his colleagues found that about 8 percent of stroke patients experience CPSP, but it can range from 1 percent to 12 percent, depending on the study.

One investigation found that 63 percent of patients were affected within one month, 18 percent within six months and the remaining 18 percent after six months.

The affliction is a type of neuropathic pain caused by damage or dysfunction within the central nervous system.

For individuals with CPSP, the sensations can be extreme. They can experience hyperpathia (abnormally painful reaction to a painful stimulus) or allodynia (pain in response to a light touch or contact with clothing or bed sheets, air currents, etc.) Allodynia has been reported in two-thirds of CPSP patients.

Post-stroke patients may also deal with many other types of pain. These may include headache and musculoskeletal pain, especially pain related to abnormal shoulder movement.

“It is crucial to recognize CPSP and differentiate it from musculoskeletal pain or spasticity-associated pain,” wrote the authors. Spasticity refers to feelings of stiffness and a wide range of involuntary muscle spasms.

The researchers found descriptions of CPSP dating back to a medical journal in 1906. More than a century later, however, they say that CPSP is frequently misdiagnosed, and getting patients the relief they need requires correct recognition of the syndrome.

Standard first-line treatments for CPSP include amitriptyline (an antidepressant) and lamotrigine (an anticonvulsant, brand name Lamictal). If patients don’t respond to those medications, physicians may try the anticonvulsant gabapentin (brand names Neurontin and Gabarone).

If medications fail to work, a non-invasive therapy called transcranial magnetic stimulation (TMS) should be considered, according to the investigators. TMS sends short pulses of magnetic fields to the brain.

HAND USE IMPROVED AFTER SPINAL CORD INJURY WITH NONINVASIVE STIMULATION

ScienceCodex- By using noninvasive stimulation, researchers were able to temporarily improve the ability of people with spinal cord injuries to use their hands. The findings, reported on November 29th in Current Biology, a Cell Press publication, hold promise in treating thousands of people in the United States alone who are partially paralyzed due to spinal cord injury.

“This approach builds on earlier work and highlights the importance of the corticospinal tract—which conducts impulses from the brain’s motor cortex to the spinal cord and is a major pathway contributing to voluntary movement—as an important target for intervention after spinal cord injury,” said Monica Perez of the University of Pittsburgh.

The researchers tested the new method in 19 people with chronic cervical spinal cord injury and 14 uninjured people. The treatment was customized to each individual and paired transcranial magnetic stimulation delivered to a specific part of the motor cortex with electrical stimulation to peripheral nerves found in the wrist.

One hundred paired pulses were delivered every 10 seconds for a period of around 20 minutes to produce volleys of neural activity. The timing of arrival of those volleys in the spinal cord was absolutely essential to the treatment’s success, the report shows.

“This short, noninvasive stimulation protocol has the potential to be used within a clinic setting as part of a rehabilitation technique,” said study coauthor Karen Bunday, also of the University of Pittsburgh. “When pulses from the motor cortex were precisely timed to arrive at the spinal cord one or two milliseconds before pulses from the peripheral nerve, we observed an increase in spinal cord transmission and voluntary motor output for up to 80 minutes.”

After the noninvasive treatment, the majority of the participants in the study could exert more force with their hand muscles. Those effects translated into greater manual dexterity when participants were asked to grasp and manipulate small pegs with their index fingers and thumbs.

More prolonged use of the technique or its combination with other rehabilitation strategies may well improve its therapeutic benefits, the researchers say. The protocol might also be used in the treatment of other kinds of motor disorders involving damage to the corticospinal tract.

“Human electrophysiology can be a powerful tool for developing therapies,” Perez concluded. “We need to explore new targets to improve rehabilitation strategies by taking advantage of our knowledge in human physiology and their mechanisms.”

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.”