AIM Neuromodulation: Future of Mental Health and Neurological Treatments

Exploring Transcranial Direct Current Stimulation (tDCS): An Effective Depression Treatment available from AIM neuromodulation

Tue, 02 Jul 2024 06:00:15 GMT

Discover how transcranial direct current stimulation (tDCS) offers a non-invasive, at-home treatment for depression. Learn about its benefits and availability through AIM neuromodulation to patients living in Southwest England. Transcranial Direct Current Stimulation (tDCS) is an innovative neuromodulation treatment gaining traction for its effectiveness in treating depression. This non-invasive method, available through AIM neuromodulations in collaboration with Flow neuroscience, offers a convenient at-home solution for those in Southwest England, including Bristol, North Somerset, Somerset, and Weston-Super-Mare. Let's dive into how tDCS works, its benefits, and how you can access this cutting-edge treatment.

Transcranial Direct Current Stimulation (tDCS): An Overview

Transcranial Direct Current Stimulation (tDCS) is a groundbreaking neuromodulation treatment using low electrical currents to stimulate specific brain areas. This non-invasive method is delivered via electrodes placed on the scalp, making it a safe and effective option for various neurological and psychiatric conditions. In collaboration with Flow neuroscience, AIM neuromodulation offers this treatment, providing an accessible solution for those seeking relief from depression in Southwest England.

How tDCS Works

DCS targets specific brain regions with mild electrical currents. The Flow tDCS device delivers around 2 mA of electrical current to the brain, gently stimulating neurons to reach their action potential. This increased neuronal activity can enhance brain function over time, particularly in areas linked to mood regulation.

Unlike other neuromodulation techniques like Transcranial Magnetic Stimulation (TMS) or Electroconvulsive Therapy (ECT), tDCS provides sub-threshold stimulation, making it safe for home use with minimal side effects.

How The Flow tDCS Device Works

The Flow tDCS device focuses on alleviating depressive symptoms by stimulating the dorsolateral prefrontal cortex (DLPFC), a brain region associated with mood regulation, sleep, and motivation. This gentle electrical stimulation restores activity in this area, reducing depression. Typically, the headset is used 3-5 times a week, with each session lasting 30 minutes. Flow's software allows clinicians to monitor adherence and track symptom changes over time, providing behavioural therapy alongside tDCS treatment.

Benefits of Flow tDCS Treatment

Non-invasive treatment alternative to medication: Combines tDCS and behavioural therapy with clinical monitoring and supervision by consultant psychiatrists through AIM neuromodulation.

2. Enhanced response: Clinical improvement can be seen within three weeks. tDCS can augment other depression treatments, including medication and talking therapies, for patients with a partial response to these treatments. tDCS can also be used with rTMS to optimise treatment response and maintain improvements.

3. At-home convenience: Flow neuroscience’s tDCS device is approved for at-home use in the UK and EU, offering access to a neuromodulation treatment previously only available in clinics.

Evidence Supporting tDCS

Several high-quality randomized control trials (RCTs) show a definite effect of tDCS in improving depression. A 2023 RCT by the University of East London and King's College demonstrated that 57% of participants using the Flow tDCS device achieved remission within ten weeks with no serious side effects. Additionally, Flow neuroscience reports that data from their tDCS device app of 4,000 users showed that 46% of users went into remission by week 10.

Safety and Side Effects

Flow's tDCS device is recognised for its safety and efficacy. It is a CE-marked Class IIa medical device approved for use in the EU and UK and has received FDA Breakthrough Device Designation for innovative at-home depression treatment.

Side effects from tDCS are minimal, with serious side effects being extremely rare. Flow reports that less than 5% of its users experience side effects, including headaches, skin irritation, and tinnitus.

Cautions

Patients with the following conditions should consult their doctor before using tDCS:

Pregnancy
Suicidal thoughts
Skull not intact
Cranial or intracranial implants
Epilepsy or seizures
Chronic skin conditions on the forehead
Bipolar disorder

Using The Flow tDCS Device

Flow neuroscience has made tDCS treatment available at home, improving access and reducing costs. The device and app are well-designed and easy to use, combining tDCS with behavioural therapy courses available via the app.

Steps to Start Treatment

Initial consultation with a Consultant Psychiatrist
Purchase or rent a Flow tDCS device through AIM neuromodulation, which includes setup assistance and monitoring by a Consultant Psychiatrist.
Start Treatment

Initial Phase

Weeks 1-3: 5 sessions per week, each lasting 30 minutes.

Maintenance Phase

Weeks 4+: 1-2 sessions per week, each lasting 30 minutes.

Long-term

Continue for 6-12 months if effective after ten weeks.

AIM neuromodulation clinicians can monitor adherence and symptom changes through Flow’s clinical software, providing further guidance and adjusting tDCS settings as treatment progresses.

Pricing

An initial no-obligation discussion with a Consultant Psychiatrist is free – book now
Flow tDCS machine rental: £79/month – Includes Flow tDCS device and app, setup assistance, plus monthly supervision, and monitoring with a Consultant Psychiatrist.
Flow tDCS machine purchase: £399 – Includes Flow tDCS device and app, setup assistance, plus two months of supervision and monitoring with a Consultant Psychiatrist.
Ongoing supervision and monitoring of tDCS treatment - variable cost, please discuss further with Consultant Psychiatrist

Frequently Asked Questions

What Does Using the Flow tDCS Device Feel Like?

There is often a mild tingling, itching, or stinging sensation on the forehead during the first few minutes of a session. These sensations usually diminish over time.

Duration of Use?

The initial treatment lasts ten weeks. If beneficial, it is recommended to continue for an additional 6-12 months to maintain progress and prevent relapse.

Using tDCS with Antidepressants?

tDCS is safe to use alongside antidepressants.

Patients with Other Medical Conditions?

Patients with conditions such as epilepsy, cranial implants, or skin conditions on the forehead should consult their doctor before using tDCS.

Potential Side Effects?

Less than 5% of users report side effects, including headaches, skin irritation, and mild skin burns. Serious side effects are extremely rare.

Cautions?

Patients with the following conditions should use tDCS with caution and consult their doctor:

Pregnancy
Suicidal thoughts
Cranial or intracranial implants
Epilepsy or seizures
Chronic skin conditions on the forehead
Bipolar disorder

Learn More

Transcranial Direct Current Stimulation (tDCS) offers a promising, non-invasive treatment for depression. With Flow's at-home tDCS device available through AIM neuromodulation patients in Southwest England can access a convenient and effective solution bringing hope and relief from depressive symptoms right to their doorsteps.

Please book a free, initial, no-obligation consultation with a Consultant Psychiatrist - BOOK NOW

AIM neuromodulation, founded by three experienced Consultant Psychiatrists, offers innovative treatments for depression, addiction, and migraine using Transcranial Magnetic Stimulation (TMS) and Direct Current Stimulation (DCS). AIM neuromodulation is dedicated to advancing neuromodulation use and improving accessibility to these treatments in the UK.

Transcranial Magnetic Stimulation (TMS): Revolutionizing Mental Health Treatments in Southwest UK

Wed, 12 Jun 2024 11:37:15 GMT

Transcranial Magnetic Stimulation (TMS) and its variant, Repetitive Transcranial Magnetic Stimulation (rTMS), are making waves in the field of mental health. These non-invasive treatments use magnetic pulses to stimulate or inhibit specific brain areas, offering hope for those who haven't found relief through traditional therapies. Let's dive into what TMS and rTMS are, how they work, and the benefits they bring, especially for residents in Bristol, North Somerset, Somerset and Weston-Super-Mare.

What is Transcranial Magnetic Stimulation (TMS)?

TMS utilises targeted magnetic pulses to stimulate or inhibit areas of the brain linked with certain psychiatric and neurological conditions. This non-invasive technique has garnered approval from major health organisations due to its proven safety and effectiveness.

What is Repetitive Transcranial Magnetic Stimulation (rTMS)?

rTMS is a specific form of TMS where multiple pulses are delivered in a repetitive manner. Unlike TMS, which may involve single or a few pulses, rTMS delivers a series of pulses at regular intervals. This method is approved by the National Institute for Health and Care Excellence (NICE) in the UK and the Food and Drug Administration (FDA) in the USA to treat depression, among other conditions.

How Do TMS and rTMS Treatments Work?

In various psychiatric and neurological conditions, certain brain parts function abnormally. rTMS offers targeted therapy to these areas. A magnetic pulse, generated from an electrical coil placed over the scalp, passes through the skull into the brain, inducing brief activity in the underlying brain cells. This alters brain activity, aiming to correct dysfunctional brain regions.

High-frequency rTMS promotes neuroplasticity, the brain's ability to mend and build connections between nerve cells. This helps restore normal brain function. Conversely, low-frequency rTMS reduces activity in overactive brain regions. Over repeated sessions, these changes help normalise brain activity.

Conditions Treated by TMS and rTMS

TMS and rTMS are effective for a variety of conditions, including:

Addiction
Depression
Migraine
Obsessive-Compulsive Disorder (OCD)

Benefits of TMS and rTMS Treatments

Choosing TMS and rTMS over other treatments comes with several advantages:

Non-Invasive: No need for surgery or sedation.
Effective for Treatment-Resistant Conditions: Ideal for patients who haven't responded to traditional treatments.
Fewer Side Effects: Minimal side effects compared to medications.
Personalised Treatment: Tailored protocols and target areas based on individual needs.
Adjunctive Potential: Can be combined with other treatments for enhanced efficacy.

rTMS Treatment Process

A typical rTMS session lasts between 30 to 60 minutes, depending on the treatment parameters. The total number of sessions varies based on the condition and individual response, averaging around 30 sessions given over several weeks. Most people can resume their usual activities immediately after each session.

Who is a Candidate for TMS and rTMS?

TMS and rTMS are suitable for patients who:

Haven't responded adequately to standard treatments like medications or psychotherapy.
Can't tolerate medication side effects.
Seek a non-invasive treatment option.
Don't have contraindications for TMS, such as non-removable metal in or around the head, a history of epilepsy, recent strokes, or active substance abuse.

Side Effects and Risks of TMS and rTMS

TMS is generally well-tolerated with few side effects, including:

Scalp irritation
Mild headache
Temporary hearing changes
Rare instances of fainting or dizziness
Low risk of seizure

Frequently Asked Questions

Who administers TMS treatment? TMS is prescribed by a Consultant Psychiatrist and administered by a trained TMS technician under supervision.
Who can't have TMS? TMS is unsuitable for individuals with non-removable metal in the head, a history of seizures, recent strokes, active substance use, or pregnancy.
What happens at the first appointment? The first session includes an assessment, consent form signing, baseline questionnaires, and treatment explanation.
Are there special preparations for TMS treatment? Remove any jewellery, hair accessories, and hearing aids. Ensure you eat and drink before the appointment.

Conclusion

Transcranial Magnetic Stimulation (TMS) and Repetitive Transcranial Magnetic Stimulation (rTMS) represent promising treatments for various psychiatric and neurological conditions. Their non-invasive nature, minimal side effects, and effectiveness for treatment-resistant cases make them appealing options. For residents of Southwest UK, including Bristol, North Somerset, Somerset and Weston-Super-Mare, accessing these innovative treatments is a step towards better mental health.

Feel free to contact AIM neuromodulation for more information and to schedule an initial no-obligation consultation with a Consultant Psychiatrist.

Navigating the Future of Healthcare with AIM Neuromodulation

Mon, 13 May 2024 12:10:12 GMT

In the ever-evolving landscape of healthcare, AIM Neuromodulation stands out as a beacon of hope and innovation in the Southwest UK. By merging the expertise of leading Consultant Psychiatrists with groundbreaking neuromodulation therapies like Transcranial Magnetic Stimulation (TMS) and Direct Current Stimulation (DCS), AIM Neuromodulation offers personalised and effective care for mental health and neurological disorders. Let’s delve into how this revolutionary approach is transforming lives and providing new avenues of treatment for conditions such as depression, addiction, and migraine for patients in Briston, North Somerset and Weston-Super-Mare..

A Groundbreaking Collaboration in the Southwest UK

AIM Neuromodulation, founded in 2022, represents a unique collaboration between three Consultant Psychiatrists—Dr. Nathan Maynard, Dr. Radu Iosub, and Dr. Nick Airey—and Broadway Lodge, a leading recovery treatment centre in the UK. Based in Weston-Super-Mare, this partnership leverages Broadway Lodge's long-standing expertise in addiction recovery with AIM's advanced neuromodulation techniques, particularly in treating addiction.

Innovative Treatments for Mental Health and Neurological Disorders

AIM Neuromodulation specialises in TMS and DCS, both of which are non-invasive, non-pharmacological treatments showing significant promise, especially for patients who have not responded to traditional therapies.

Transcranial Magnetic Stimulation (TMS)

TMS utilises magnetic fields to stimulate nerve cells in the brain, recognised and approved by NICE since 2015, TMS has shown remarkable efficacy in alleviating symptoms in patients where medication and psychological therapies have not worked.

Direct Current Stimulation (DCS)

DCS, involves applying a low-intensity electrical current to targeted brain areas enhancing neuroplasticity and provides a safe and effective alternative to conventional treatments in treating depression.

The Patient Journey: From Initial Consultation to Recovery

At AIM Neuromodulation, the patient journey is designed to ensure comprehensive care and support at every step:

Initial Consultation: Patients start with a thorough assessment by a Consultant Psychiatrist, focusing on their medical history, symptoms, and treatment goals.

Personalised Treatment Plan: Based on the assessment, a tailored treatment plan is developed to address specific conditions.

Treatment Sessions: Patients undergo prescribed neuromodulation treatments, with each session typically lasting 20-40 minutes.

Monitoring and Adjustments: Progress is closely monitored, with regular follow-up appointments to assess effectiveness and make necessary adjustments.

Follow-Up Care: Post-treatment, patients have a review to assess effectiveness and provide additional recommendations for sustaining improvement.

Pioneering Research and Innovation

AIM Neuromodulation is not just about treatment; it's also deeply committed to advancing research and innovation in neuromodulation therapies. The organisation actively explores new applications for neuromodulation therapies from treating Obsessive Compulsive Disorder (OCD) to chronic pain. AIM has a specific interest in migraine treatment with rTMS which is backed by a growing evidence base, and are happy to discuss neuromodulation treatments for other conditions on a case-by-case basis.

Their focus on research ensures that patients benefit from the latest scientific advancements, positioning AIM Neuromodulation at the forefront of mental health and neurological treatment innovation.

Understanding Neuromodulation and Neuroplasticity

What is Neuromodulation?

Neuromodulation refers to therapeutic approaches that modulate nerve activity by delivering electrical or chemical agents to targeted areas. Techniques include electromagnetic stimulation (like deep brain stimulation or TMS) and pharmacological interventions targeting neural circuits.

What is Neuroplasticity?

Neuroplasticity is the brain's remarkable ability to form new neural connections. This capability allows the brain to recover from injury, adapt to new situations, and facilitate learning and memory formation. Neuromodulation therapies leverage neuroplasticity to enhance treatment outcomes for mental health and neurological conditions.

Meet the Expert Team

AIM Neuromodulation's strength lies in its expert team, each member bringing unique skills and extensive experience:

Dr. Nick Airey: With over 20 years in the NHS, Dr. Airey specialises in mental health and addiction treatment and has been a visiting clinician at Broadway Lodge.

Dr. Radu Iosub: Specialising in General Adult Psychiatry and Addictions, Dr. Iosub has a summa cum laude PhD and extensive training in Bristol.

Dr. Nathan Maynard: Leading the rTMS service at Somerset NHS Foundation Trust, Dr. Maynard is an honorary lecturer and psychiatry clerkship lead at Bristol University, Somerset Academy.

Conclusion: A New Era in Mental Health Care in the Southwest UK

AIM Neuromodulation is at the forefront of transforming mental health and neurological care. By combining innovative TMS Treatments and DCS with personalised care, AIM offers new hope to patients struggling with conditions resistant to conventional therapies. With a strong focus on research and innovation, AIM Neuromodulation ensures patients receive the most effective and cutting-edge treatments available.

Transcranial Magnetic Stimulation: A Promising New Frontier in Addiction Treatment

Mon, 29 Apr 2024 08:57:00 GMT

The Burden of Addiction

Addiction is a complex condition, a brain disorder that is manifested by compulsive substance use despite harmful consequences. Millions of people worldwide suffer from various forms of addiction, including alcohol, drugs, and behavioural addictions, leading to significant personal, social, and economic costs. Traditional treatments have been only partially successful, with high rates of relapse being a major challenge. Recent advancements in neuromodulation, particularly repetitive Transcranial Magnetic Stimulation (rTMS), offer new hope. rTMS is a non-invasive treatment method and in the recent years it has shown promise in effectively targeting the neurobiological roots of addiction.

Understanding Addiction and Its Current Treatments

At its core, addiction is a neurobiological disease. It hijacks the brain's reward system, leading to altered thinking, behaviour, and body functions. Drugs and addictive behaviours stimulate this system, producing temporary feelings of pleasure (‘the reward’) but at a high long-term cost, including the potential for developing tolerance and dependence. Current treatments focus on managing withdrawal symptoms and preventing relapse through a combination of pharmacotherapy, behavioural therapy, and support groups. However, these interventions often fall short in fully addressing the neurobiological alterations, leading to a cycle of recovery and relapse. The limitations of these treatments highlight the need for approaches that can directly target the modified brain neurobiology in patients suffering from addictions and rTMS is a new, promising and non-invasive treatment avenue.

The Neurobiology of Addiction and the Reward Circuit

Research led by Dr. Nora Volkow and colleagues suggests that addiction profoundly alters the functional architecture of the brain's reward circuit. These findings are summarised in a review article published by Volkow et al in The Journal of clinical investigation: “The addicted human brain: insights from imaging studies”. Utilizing functional MRI (fMRI) studies, has been pivotal in demonstrating how addiction leads to these neurobiological changes. One significant finding is the key role played by the prefrontal cortex, a region critical for decision-making, impulse control, and self-regulation. Functional imaging studies have shown that during drug intoxication, or during craving, these frontal regions become activated as part of a complex pattern that includes brain circuits involved with reward (nucleus accumbens), motivation (orbitofrontal cortex), memory (amygdala and hippocampus), and cognitive control (prefrontal cortex and cingulate gyrus). Volkow's research highlights that this dysregulation in the reward circuit is not just a matter of one region but involves the complex interplay between various parts of the brain. For instance, while there's reduced activity in the prefrontal cortex, there's often enhanced activity in areas of the brain associated with emotional processing and memory, which can trigger strong cravings when exposed to cues associated with the addictive substance or behaviour.

How rTMS Works to Address Addiction

Repetitive Transcranial Magnetic Stimulation (rTMS) offers a promising approach to restoring balance within these disrupted neurocircuits. rTMS uses magnetic fields to stimulate specific regions of the brain. In the context of addiction treatment, rTMS is primarily targeted at the prefrontal cortex to modulate its activity. The goal is to increase the activity of the dorsolateral pre-frontal cortex (DLPFC), thereby enhancing its regulatory control over the reward circuit and reducing the compulsive behaviour characteristic of addiction.

The mechanism by which rTMS exerts its effects is believed to involve the induction of long-term potentiation (LTP) or long-term depression (LTD) in the neurons of the targeted area. These processes can lead to lasting changes in brain activity, essentially helping to "reset" the reward circuit's dysregulated state. By directly modulating the activity of the prefrontal cortex and potentially other regions involved in the reward circuit, rTMS is believed to mitigate the altered reward sensitivity and impaired impulse control that underpin addiction.

Current Evidence and Research on rTMS for Addiction

A growing body of research supports the use of rTMS in treating various forms of addiction. Studies have investigated the effects of rTMS on craving reduction, treatment duration, side effects, and overall outcomes. For instance, clinical trials have shown that rTMS, particularly when applied to the dorsolateral prefrontal cortex (DLPFC), can significantly reduce cravings in individuals with substance use disorders. These effects have been observed across various substances, including nicotine, alcohol, and cocaine.

The typical duration of rTMS treatment for addiction varies but often involves daily sessions over a period of 3 to 6 weeks. Side effects are generally mild and may include headache or discomfort at the stimulation site. Importantly, the effectiveness of rTMS in reducing cravings and potentially preventing relapse offers a promising adjunct to traditional treatments, addressing the neurobiological alterations at the heart of addiction.

Looking to the published literature, there are now many studies concerning rTMS and the treatment of Substance Use Disorders (SUDs). One of the most compelling pieces of evidence for the efficacy of rTMS in the treatment of craving comes from a 2023 paper published in the Lancet by Kan et al: "Effects of repetitive transcranial magnetic stimulation of the left dorsolateral prefrontal cortex on symptom domains in neuropsychiatric disorders: a systematic review and cross-diagnostic meta-analysis". The authors refined over 9000 studies down to 174 that met their inclusion criteria, these with 7905 patients. These patients were treated for a variety of diagnoses and were clustered by symptom domain. The active rTMS treatment was compared against sham (or placebo) treatment. The largest effect size for a positive outcome from the rTMS treatment was for craving, with depression having a medium effect size. Difficulties such as anxiety, pain and cognitive issues yielded a small effect size. The paper has a particularly good graphic representation of effect size v symptom type.

From the beginning of 2024, we have another systematic review and meta-analysis, this time focussing on addiction, and published in Neuropsychopharmacology by Mehta et al: "A systematic review and meta-analysis of neuromodulation therapies for substance use disorders". In this study, the authors looked at rTMS, but also other therapies, namely Transcranial Direct Current stimulation (tDCS) and Deep Brain Stimulation (DBS). The authors found 94 suitable studies, of which 51 concerned rTMS, these featuring 2406 participants. 16 studies investigated the effects of rTMS on alcohol use disorder, another 16 concerned tobacco, with 8 for methamphetamine, 6 for cocaine, 4 for opioids and 2 for cannabis. The authors found a positive impact for rTMS with effect sizes being "clinically relevant" but with the usual problem inherent in the research base. This they refer to as the "heterogeneity of the published literature". That is, that the studies included patients treated with just 1 active TMS session, through to a more normal 10 to 20 treatment sessions, with one paper having 40 sessions. In addition, the number of magnetic pulses in each treatment session is not specified. The stimulus intensity varied between 90 and 110% and the frequency varied from the typical 10 or 20 Hz to some low frequency usage (1 and 5 Hz) and two papers using 50Hz. In the majority of papers, the Left Dorsolateral Prefrontal Cortex (DLPFC) was stimulated, but in some they treated the Right DLPFC (or both sides) and with a few studies stimulating other brain areas.

For the interested reader, there is a consensus paper from 2019, looking at the detail of research into transcranial magnetic (and electrical) stimulation in addiction medicine. The group responsible for the paper being INTAM (International Network of tES/TMS Trials for Addiction Medicine). Published in Neuroscience and Biobehavioural Reviews by Ekhtiari and approaching eighty collaborators: "Transcranial electrical and magnetic stimulation (tES and TMS) for addiction medicine: A consensus paper on the present state of science and the road ahead". The paper looks at some of the technical specifications involved in the treatments and ways of administering sham treatment. There is also a summary of the various brain areas targeted in TMS and international comparisons. Endpoints are considered, such as craving tools and biochemical markers. Another factor, well described, is the timing of the TMS treatment, for example as a pre-treatment intervention, an intervention during detoxification or an intervention during long-term recovery. Also considered is how TMS may combine with other treatments, particularly psychosocial interventions.

Research is ongoing to optimize rTMS protocols, including determining the most effective stimulation sites, frequencies, and durations of treatment for different forms of addiction. As this body of evidence grows, rTMS stands out as a valuable tool in the addiction treatment arsenal, offering hope for more effective management of this challenging condition.

References

1. Volkow, Nora D et al. “The addicted human brain: insights from imaging studies.” The Journal of clinical investigation vol. 111,10 (2003): 1444-51. doi:10.1172/JCI18533 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC155054/pdf/JCI0318533.pdf

2. Effects of repetitive transcranial magnetic stimulation of the left dorsolateral prefrontal cortex on symptom domains in neuropsychiatric disorders: systematic review and cross-diagnostic meta-analysis. Kan LD et al. Lancet Psychiatry 2023; 10: 252-59 https://doi.org/10.1016/S2215-0366(23)00026-3

3. A systematic review and meta-analysis of neuromodulation therapies for substance use disorders. Mehta DD et al. Neuropsychopharmacology 2024; 49: 649-680 (published online 12 December 2023) https://doi.org/10.1038/s41386-023-01776-0

4. Transcranial electrical and magnetic stimulation (tES and TMS) for addiction medicine: A consensus paper on the present state of the science and the road ahead. Ekhtiari h et al. Neuroscience and Biobehavioral Reviews 2019; 104: 118-140. https://doi.org/10.1016/j.neurobiorev.2019.06.007

Exploring the Potential of Repetitive Transcranial Magnetic Stimulation (rTMS) in Treating Alzheimer’s Disease

Sat, 24 Feb 2024 14:33:56 GMT

The Rising Interest in rTMS for Alzheimer's Treatment: An Overview

While TMS has become well established, and its clinical use ratified in various jurisdictions, particularly for the treatment of depression, there is also increasing interest in its use in the treatment of Alzheimer’s disease. This is not surprising as Alzheimer’s probably accounts for three quarters of all dementia cases and, with an ageing world population, the cost of treating it is said to be likely to rise across the world from the current many billions to two trillion dollars by 2030. Alzheimer’s disease is a neurodegenerative brain disease characterised by progressive changes in behavioural and cognitive functions, and many of those suffering from the condition also experience neuropsychiatric symptoms. The incidence of the condition is positively correlated with age, doubling every five years from the age of 65. WHO data estimates that Alzheimer’s disease affects approximately 50 million patients worldwide. Some medications do exist, particularly so-called acetylcholinesterase inhibitors, but these are not curative, and indeed may often show limited efficacy, and themselves can come with not inconsiderable side-effect burden. As rTMS is regarded as a safe treatment, with few side-effects, is not surprising that its use is being considered for the treatment of dementia.

Key Research Findings: A Deep Dive into Recent Studies

Three research papers are perhaps worth considering. The first of these being “Efficacy of non-invasive brain stimulation on global cognition and neuropsychiatric symptoms in Alzheimer’s disease and mild cognitive impairment: a meta-analysis and systemic review” by Teselink et al from Toronto and published in Ageing Research Reviews in 2021. They undertook a literature search for non-invasive brain stimulation (NIBS) and found around 1900 possible papers and ended up with 19 papers which they could use. They required research that used sham (that is placebo) treatment as well as active treatment. They looked at two types of NIBS, that is both rTMS and tDCS (transcranial direct current stimulation). They found that both types of treatment improved global cognition and neuropsychiatric symptoms (NPS), and this particularly so with the rTMS. They speculate that the improved global cognition in Alzheimer’s disease may have been a consequence of the improvement in the NPS, that is presumably a lifting of mood. The authors, comment on the greater efficacy of rTMS...

Comparative Analysis: rTMS Versus Drug Therapy in Alzheimer's Disease

Then, there is the first of two papers from China, with Wei et al. from departments of neurosurgery and geriatrics, published in CNS Neuroscience Therapy in 2023, “Repetitive transcranial magnetic stimulation may be superior to drug therapy in the treatment of Alzheimer’s disease: a systematic review and Bayesian network meta-analysis”. From over 21,000 papers, they managed to include 57 randomised clinical trials involving over 15,000 patients. rTMS was compared to drug treatments which were the now standard acetylcholinesterase inhibitors together with NMDA, anti-amyloid-beta and what were described as being some “new targeted therapeutic drugs”. The rTMS yielded better cognitive function improvement and significantly fewer adverse offence when compared to the medication treatment. They concede that while the rTMS appears effective, larger sample sizes are needed together with long-term follow-up studies to determine the best technology, and to check on the long-term effectiveness of our rTMS in Alzheimer’s disease. This is a drawback of much research, particularly with medication, where patients are followed up often for limited periods of time and almost certainly less than a year. The authors used a statistical tool called SUCRA probability, and this found that rTMS was the best intervention for increasing MMSE scores. MMSE is a widely used cognitive function test (mini mental state examination). It scores out of 30 and has questions relating to orientation, registration, attention and calculation, recall, language and copying). It is regarded as not being a terribly sophisticated measure, although it is easy to apply, use and score.

Evaluating High-Frequency rTMS in Alzheimer's: A Comprehensive Review

The third paper, also published in 2023, this time in Neurological Sciences by Xiu et al. from Fujian University “High-frequency repetitive transcranial magnetic stimulation (HF-rTMS) on global cognitive function of elderly in mild to moderate Alzheimer’s disease: a systematic review and meta-analysis”. These researchers found over 3000 relevant papers, which then reduced to 17 usable papers, these involving 1161 patients with mild to moderate Alzheimer’s disease. As with the other papers, they required a placebo, or sham, control to try and eradicate a placebo effect, which can understandably be very potent with rTMS. The study participants were measured with the use of a variety of cognitive function tools (including MMSE, but also more comprehensive ones) and showed significant improvements. The typical side effects, seen in rTMS clinics treating those with depression were noted e.g. headache and tinnitus. One study, however, reported a number of patients with significant adverse events, though it is difficult to see how some of these could be causally related as, for example, one case was reported as having an inflamed gallbladder! The authors offer a suggestion as to why rTMS may help in Alzheimer’s disease. They note that one of the brain changes in Alzheimer’s disease, is an accumulation of abnormal amyloid protein. They refer to another paper which demonstrated that rTMS can reverse abnormal levels of this protein in rats with memory impairment. They also speculate that rTMS can induce changes in excitability of neural circuits and effects can propagate between brain areas. They also refer to functional imaging studies that show that brain glucose metabolism is impaired in Alzheimer’s disease and the increase in excitability of cerebral cortex, stimulated by rTMS, may increase local metabolic activity in the brain.

Concluding Thoughts: The Future of rTMS in Alzheimer’s Disease Treatment

In conclusion, the three research papers do appear to demonstrate that rTMS may help individuals with the cognitive impairment of Alzheimer’s disease. One caveat is that while patients may show an improvement of a few points on a rating scale, this may not necessarily translate into much by way of a day-to-day improvement in a functional state. Also, as noted, there are no long-term studies to see whether any improvements in cognitive functioning are sustained. Equally, it is not wholly clear what type of treatment protocol works best, and whether patients will be required to have ongoing treatment in order to support any clinical improvement. On the other hand, it is well known that the majority of medications currently used to try and help those with dementia (the acetylcholine esterase inhibitors in particular) come with an unacceptable side-effect burden, and have only a moderate impact. It may be too soon to recommend TMS treatment for people with dementia, but given that it is typically very well tolerated and has minimal side effects, it may be that as the treatment becomes better known, there develops pressure from patients and their carers to try the treatment. This on the basis that (apart from the financial cost) there are few drawbacks and some potential benefits.

References:

1.Teselink et al. on Brain Stimulation in Alzheimer’s Disease

Johannes Teselink, Kritleen K. Bawa, Grace KY Koo, Krushnaa Sankhe, Celina S. Liu, Mark Rapoport, Paul Oh, Susan Marzolini, Damien Gallagher, Walter Swardfager, Nathan Herrmann, Krista L. Lanctôt, Efficacy of non-invasive brain stimulation on global cognition and neuropsychiatric symptoms in Alzheimer’s disease and mild cognitive impairment: a meta-analysis and systemic review, Ageing Research Reviews 72 (2021) 101499. https://www.sciencedirect.com/science/article/pii/S1568163721002464

2. Wei et al. on rTMS vs Drug Therapy in Alzheimer’s Treatment

Wei N, Liu H, Ye W, Xu S, Lu C, Dai A, Hou T, Zeng X, Wu J, Chen J. Repetitive transcranial magnetic stimulation may be superior to drug therapy in the treatment of Alzheimer's disease: A systematic review and Bayesian network meta-analysis. CNS Neurosci Ther. 2023 Oct;29(10):2912-2924. https://onlinelibrary.wiley.com/doi/10.1111/cns.14228

3. Xiu et al. HF-rTMS on Alzheimer's Disease

Xiu, H., Liu, F., Hou, Y. et al. High-frequency repetitive transcranial magnetic stimulation (HF-rTMS) on global cognitive function of elderly in mild to moderate Alzheimer’s disease: a systematic review and meta-analysis. Neurol Sci 45, 13–25 (2024). https://doi.org/10.1007/s10072-023-07072-5

Exploring the Efficacy of rTMS in Migraine Management: A Review

Fri, 23 Feb 2024 12:21:57 GMT

Understanding Migraine: A Global Health Burden

Migraine is a neurovascular disorder that is said to affect more than 1 billion people across the world. It can be an extremely debilitating condition with significant impairments of health, daily living, and quality of life. According to the global burden of disease study, migraine is in the top 10 causes of years lived with disability, in the general population and the second cause of disability in both males and females younger than 50 years. The World Health Organisation (WHO) currently reports that migraine affects 15 to 20% of the population and is three times more prevalent in women than in men in the United States and Europe. Medication treatments are often effective in the treatment of migraine, but there are large individual differences, and many medications do come with a significant side-effect burden. Also, there can be significant issues following medication cessation. For example, headache may worsen following suspension of anti-CGRP monoclonal antibody therapy.

rTMS: A Potential Migraine Treatment

rTMS has been used, at least in trial work, for many years now as a treatment for migraine. In the UK, NICE (National Institute for Health and Care Excellence) issued a so-called Interventional Procedures Guidance back in 2014. They concluded that while the procedure appeared safe, there was a lack of information concerning long-term effects, and while there was some positive research concerning efficacy, they could not approve use within the NHS on the then available evidence.

NICE's Stance on rTMS for Migraine Treatment

In their recommendations, they highlight the difficulty when trying to interpret migraine research as TMS has been evaluated in a number of settings e.g. : (1) for use during the aura before a migraine episode or (2) at the start of migraine episode or (3) with the intention of stopping or reducing the severity of an episode or (4) at planned intervals with the intention of reducing the frequency or severity of migraine episodes. So, TMS might be used as a treatment or for prevention.

The Mechanisms Behind rTMS in Migraine Relief

The mechanism behind rTMS potentially helping in migraine patients is discussed in a paper by Zhong et al. in 2022 “Non-invasive brain stimulation (NiBS) technology has been regarded as an important innovation in neuropsychiatric diseases and chronic pain (including migraine) in recent years and is widely used in clinical settings. Transcranial magnetic stimulation, which applies a magnetic field to the surface of the scalp, and induces current in this subjacent cortex is an effective and safe approach that has been approved by the FDA for migraine treatment. As a NiBS method, TMS can excite or de-polarise neurones by fast alternating magnetic field, and electrical changes in the brain are believed to regulate neurotransmitters in the brain. TMS may reduce pain by modulating the excitability level, as patients with migraine tend to show hyper excitability of the neurones.” And “Chronic migraine patients may also suffer a higher level of central excitability. So the long lasting effect of rTMS could be appropriate for chronic migraine sufferers”. (Note that the FDA approved treatment referred to, is actually not rTMS, but use of a single pulse TMS machine).

Comparative Studies: rTMS vs. Other Non-Invasive Brain Stimulations

Further complicating matters, when looking at the impact of non-invasive brain stimulation (NiBS) is that different types of stimulation have been tried (e.g. repetitive or single pulse TMS) to treat migraine, while different coil types are used and different brain regions stimulated. As well as rTMS, transcranial direct current stimulation (tDCS) has also been trialled. One recent paper out of Iran “The efficacy of repetitive transcranial magnetic stimulation (rTMS) versus transcranial direct current stimulation (tDCS) on migraine headaches: a randomised clinical trial” by Naji et al in Advanced Biomedical Research (2024) highlights this. Here, they studied 72 patients with migraine headaches. The TMS patients received stimulation over the left dorsolateral prefrontal cortex (DLPFC). They refer to significant improvements in both groups for anxiety, with rTMS also showing significant improvement in depression. The report, however, concluded that there was no improvements in pain intensity or the impact of headaches of daily life. The issue here, is that targeting the DLPFC is the standard practice for the treatment of depression, craving and other such disorders. Evidence is emerging, however, that for rTMS to have a positive impact on migraine, it may be necessary to not just target one specific brain area (e.g. the DLPFC) but rather a number of brain areas.

Advances in rTMS Treatment Protocols for Migraine

A differing form of rTMS treatment is described in a paper from authors Leahu et al in Germany and Romania, this from 2021 in Brain Stimulation: “Increased migraine-free intervals with multifocal repetitive transcranial magnetic stimulation”. They describe a double-blind randomised control study, with 65 patients, with episodic migraine with or without aura, randomly selected to receive either real or sham rTMS. The protocol involved six sessions of treatment over two weeks, using a MagVenture machine with a circular coil rather than standard figure-of-eight coil (as used to treat depression for example, and as used in the study described in the previous paragraph). Another difference to the “usual” rTMS treatment, e.g. as used in depression treatment, is that a much higher frequency was used. In the Naji paper, the researchers stimulated at 10 Hz, but Leahu stimulated at 67 Hz. The coil was not left in a fixed position, but was moved across the surface of the head in a number of sweeps from front to back (fronto-occipital) and side to side (temporal-temporal). Then, there were a number of “spot burst stimulations”, again at high frequency, these over 11 specific areas. They found positive results, over the 12 week study period, in the active treatment group, with a reduction in mean migraine days from 7.6 to 4.3 days per month and with a reduction from 6.2 to 4.3 days in the “sham” group. While the sham, ie placebo, group therefore also showed an improvement, the reduction in the real group was statistically significant (p< 0.05). They also found over the study period that there was a reduction migraine attack frequency of 42% in the real group compared to 33% in the sham group (again p<0.05). Of importance, they reported that no serious adverse events were observed and the adverse events that were observed (headache, auditory discomfort, dizziness and local discomfort) were little different in the real as opposed to the sham treatment group. They also noted some limitations to their study e.g. a relatively small number of subjects and the fact that their treatment population had few patients with aura. Also, the study only looked at patients during three months of follow-up. They conclude that their “experimental multifocal r TMS paradigms” did reduce the number and intensity of migraine attacks and this from a “safe and well tolerated protocol”.

Systematic Reviews and Meta-Analyses: Assessing the Evidence

This research builds on another paper out of Germany, back in 2013, from Milnik et al published in Neurophysiology Laboratory. This was a non-blinded trial, again using a relatively high frequency stimulation (71 Hz) and again moving across the surface of the skull. They again used six treatment episodes i.e. two per week over three weeks, this repeated at intervals of three months or after a migraine attack. They concluded that the treatment could be used both as preventive treatment or an acute therapy for migraine with and without aura, and could “significantly alleviate the symptoms and significantly extend the migraine free interval”. The researchers again used a MagVenture machine with a “convex parabolic coil”.

Next to an overview of systematic reviews from 2023 in the Journal of Pain Research. A paper of Shen et al. “Transcranial magnetic stimulation as a therapy for migraine: an overview of systematic reviews”. Having found 103 systemic systematic reviews, the number reduced to just 7 as being of sufficient quality to meet their inclusion criteria. The authors concluded “TMS may have a beneficial effect on the severity and frequency of migraine episodes and has a good safety profile, but the evidence is limited and inconclusive due to the methodological flaws and heterogeneity of the existing studies. Some of the major limitations include small sample size, lack of blinding, heterogeneity of intervention parameters, variability of outcome measures, and risk of bias and publication bias in the included studies. Therefore, future studies should address these issues by carefully selecting patients, standardising use of TMS and rTMS, assessing side effects, and comparing with other treatments. This would provide more reliable and consistent evidence of the efficacy and safety of TMS in migraine management, as well as inform clinical decision-making and guideline development”.

Another review of papers, from Zhong et al published in Frontiers in Neurology in 2022: “Efficacy of repetitive transcranial magnetic stimulation on chronic migraine: a meta-analysis”. Here they found 585 papers which then shrink down only 8 which were felt to have sufficient quality. We come up against a problem highlighted before, this being that three of the research papers solely stimulated the LDLPFC, four stimulated the primary motor cortex and one stimulated both of these areas. None of these reviewed studies adopted the “German/Romanian” technique, ie using the specific type of coil, at a high frequency and stimulating a number of sites across the brain.

The Future of rTMS in Migraine Treatment: A Call for Updated Guidelines

In conclusion, it is to be hoped that NICE revisit their Interventional Procedures Guidance published 10 years ago, in the light of all the evidence that has emerged during the past decade. This evidence does show the potential for rTMS to be positive in the treatment of migraine. Given the fact that many of the existing pharmacological treatments are ineffective, or poorly tolerated, it is likely that there would be many patients in the UK who are suffering with a major health burden, who wish to try this treatment.

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References:

1. NICE Guidelines on rTMS for Migraine Treatment

• National Institute for Health and Care Excellence (NICE). Interventional Procedures Guidance [IPG477]. Available at: www.nice.org.uk/guidance/ipg477

2. Zhong et al. on rTMS in Migraine

• Zhong J, Lan W, Feng Y, Yu L, Xiao R, Shen Y, Zou Z, Hou X. Efficacy of repetitive transcranial magnetic stimulation on chronic migraine: A meta-analysis. Front Neurol. 2022 Nov 24;13:1050090. https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2022.1050090/full

3. Naji et al. on rTMS vs. tDCS in Migraine

• Naji, Fatemeh1; Sharbafchi, Mohammad Reza1; Khorvash, Fariborz2; Maracy, Mohammad R.1,3; Ghasemi Mobarak Abadi, Niloofar1,3. The Efficacy of Repetitive Transcranial Magnetic Stimulation (rTMS) versus Transcranial Direct-Current Stimulation (tDCS) on Migraine Headaches: A Randomized Clinical Trial. Advanced Biomedical Research 13():7, January 2024. | DOI: 10.4103/abr.abr_142_23 https://journals.lww.com/adbm/fulltext/2024/01300/the_efficacy_of_repetitive_transcranial_magnetic.3.asp

4. Leahu on Multifocal rTMS Treatment

• Leahu P, Bange M, Ciolac D, Scheiter S, Matei A, Gonzalez-Escamilla G, Chirumamilla VC, Groppa SA, Muthuraman M, Groppa S. Increased migraine-free intervals with multifocal repetitive transcranial magnetic stimulation. Brain Stimul. 2021 Nov-Dec;14(6):1544-1552. doi: 10.1016/j.brs.2021.10.383. Epub 2021 Oct 18. PMID: 34673259.. Available at: https://doi.org/10.1016/j.brs.2021.10.383.

5. Milnik on High Frequency rTMS in Migraine

• V. Milnik, D. Waibler, M. Kienle, Repetitive transkranielle Magnestimulation bei akuten Migräneattacken mit und ohne Aura, Das Neurophysiologie-Labor, Volume 35, Issue 1,2013,Pages 41-46,ISSN 1439-4847, https://doi.org/10.1016/j.neulab.2012.10.002 (https://www.sciencedirect.com/science/article/pii/S1439484712000373)

6. Shen's Overview of Systematic Reviews

• Shen M, Li C, Wei X, Zhang L, Li Y, Wu H, Zhang X, Dong Z, Gao S, Ma Y, Ma Y. Transcranial Magnetic Stimulation as a Therapy for Migraine: An Overview of Systematic Reviews. J Pain Res. 2023 Sep 13;16:3133-3144. doi: 10.2147/JPR.S416993. PMID: 37724171; PMCID: PMC10505396. https://www.dovepress.com/transcranial-magnetic-stimulation-as-a-therapy-for-migraine-an-overvie-peer-reviewed-fulltext-article-JPR