Brain Stimulation | 2021
Utilizing Repetitive Transcranial Magnetic Stimulation (rTMS) to Relieve Pain Associated with Complex Regional Pain Syndrome (CRPS) Type II: A Case Report
Abstract
s Brain Stimulation 14 (2021) 1404e1417 Background: Annually, 20% of US adults will suffer chronic pain(CP) for more than six months, 8% to a degree that limits their life and work activities. CP results from a combination of biological, psychological and social factors and requires a multifactorial approach to manage. The evaluation and management of CP syndromes follows the biopsychosocial approach, attempting to identify the cause and type of pain syndrome. Treatment begins with patient education, which includes setting patient expectations and initiating non-pharmacological interventions. The 2019 guidelines for the therapeutic use of rTMS scored high-frequency motor cortex(MC) stimulation to the contralateral MC for neuropathic pain as level A, for fibromyalgia level B, and for CRPS I level C. Several small Deep TMS studies demonstrate the analgesic effect of somatotopic MC stimulation. Here, we report on real world utilization of Deep-TMS for CP, to aid in patient expectations. Methods: The database of a psychiatry clinic was reviewed for patients who received deep-TMS for CP syndromes. The stimulation parameters were 20 Hz, 2.5 sec train, 20 sec inter-train interval, 30 trains, 1500 total pulses, at 100% of motor threshold of area in pain, treated over that area on MC. The primary endpoint was the change in the comparative pain scale(CPS) from baseline to endpoint. Results: Thirteen patients with a variety of CPS were treated, including two with CRPS. Eleven improved at endpoint. First treatment analgesia (-1.8±0.4, p1⁄40.0005) was predictive of treatment success (r1⁄40.59, p1⁄40.003), and further decreased at endpoint (-3.3±0.7, p1⁄40.0003). CPS reduction was independent of psychiatric comorbidity response. Conclusions: Somatotopic MC Deep-TMS offers meaningful non-pharmacologic analgesia to CPS and CRPS patients. Controlled dosing and maintenance studies are warranted. Funding: None. Disclosures: Aron Tendler has a financial interest in BrainsWay as well as a commercial/research TMS center. Tal Harmelech is an employee of BrainsWay. UTILIZING REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (RTMS) TO RELIEVE PAIN ASSOCIATED WITH COMPLEX REGIONAL PAIN SYNDROME (CRPS) TYPE II: A CASE REPORT C.R. Rizzuto , J.S. Garland , C.J. Kim , G.M. Kim , O.A. GbadeAlabi , J. Yuan , P.F. Pasquina . Uniformed Services University of the Health Sciences, Bethesda, MD; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD; Walter Reed National Military Medical Center, Bethesda, MD * Corresponding author. 8901 Wisconsin Ave. Building 19, Bethesda MD, 20889 E-mail address: [email protected] (C.R. Rizzuto). Background: Complex Regional Pain Syndrome (CRPS) is a poorly understood phenomenon, frequently presenting as pain out of proportion to an underlying injury, and often refractory to treatment. Although CRPS is typically limited to a single limb, it has been reported to spread to other regions of the body. Emerging reports advocate the use of repetitive transcranial magnetic stimulation (rTMS) in treatment of pain conditions, including neuropathic pain. We report the case of a 33-year-old military member who developed refractory widespread CRPS after a severe ankle sprain. Methods: After failing multiple interventions, including oral medications, ketamine infusions, sympathetic nerve blocks, and physical and occupational therapy, the patient consented to a trial of rTMS. He subsequently received twenty rTMS sessions over three weeks. Each session included 20 minutes of stimulation to his left (contralateral) motor cortex (M1) at 10 Hz and 80% of his motor threshold (MT). Patient-reported outcomes including the Defense and Veterans Pain Rating Scale (DVPRS), rTMS tolerability, Health Related Quality of Life-14, and side effect profiles. Results: At one month, the patient reported a 30% reduction in total pain and increased overall quality of life, functional mobility, and independence. Average DVPRS pain scores decreased from 5.93 to 3.75/10 in the feet and from 5.26 to 3.3/10 in the hands. At one-month post treatment, the patient continued to report a 10% pain reductionwith a DVPRS score of 4/10. Tolerability was high with no significant side effects. 1406 Conclusions: rTMS may be a safe, tolerable, and effective treatment for individuals with refractory and widespread CRPS. Conflicts of Interest: The views expressed in this abstract are those of the author(s) and do not necessarily reflect the official policy of the Department of Defense or the U.S. Government. Funding Source: Center for Rehabilitation Sciences Research A RETROSPECTIVE REVIEW OF PATIENTS WITH POST-TRAUMATIC STRESS SYNDROME (PTSD) TREATED BY PERSONALIZED REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (PRTMS®) Chad J. Parks , Sherry Abbasi , Milan T. Makale , Kevin T. Murphy . 1 PeakLogic Inc, Del Mar, California, USA; University of Portland, Electrical Engineering Department, Oregon, USA; University of California San Diego, Radiation Medicine and Applied Sciences, California, USA Background: Post-traumatic stress syndrome (PTSD) is an often debilitating neuropsychiatric disorder that can be permanent despite intensive standard therapy involving pharmacological and psychotherapeutic interventions. Clinical data acquired by us and by others suggest that matching rTMS stimulation frequency to each patient’s inherent EEG frequency may be effective in refractory psychopathologies. Hence our objective was to determine whether patient frequency matched rTMS, termed Personalized rTMS (PrTMS®) could improve PTSD status. Methods: Male and female adult patients (N 1⁄4 299) eligible for PrTMS® and with Post-traumatic Stress Disorder Checklist (PCL-5) test scores indicative of PTSD ( 31) were treated with PrTMS® daily for 5 days aweek for up to 60 treatment sessions. All patients were instructed to remain on their standard PTSD therapy throughout their PrTMS® treatment course. PCL-5 scores before and after PrTMS® were compared statistically, and PrTMS® associated EEG changes were compared to baseline values. Results: PCL-5 scores dropped by one week of PrTMS® and continued to decline until 30-50 treatments (6-9 weeks). 84% of patients responded, and their mean PCL-5 score reduction was 23 (range1⁄41-71, SD1⁄415.3, SEM1⁄4 ± 0.96). Concomitantly, the EEG power spectrum peaks typically migrated by up to 1 Hz towards each patient’s personal alpha peak frequency. Conclusions: These findings indicate that PrTMS® significantly improved the symptoms of PTSD as reflected by a mean PCL-5 score drop of 23 points. Conflicts of Interests: Kevin T. Murphy, MD, is the founder and CEO of PeakLogic, Inc. Funding: PeakLogic, Inc, funded this study. REPEAT TRANSCRANIAL MAGNETIC STIMULATION (TMS) TREATMENT CYCLES IN AN ELDERLY PATIENT WITH RECURRENT RESISTANT DEPRESSION AND A HISTORY OF SEIZURES: A CALL FOR MAINTENANCE THERAPY Debra J. Stultz, Savanna Osburn, Tyler Burns, Robin Walton, Amy Cope, Sylvia Pawlowska-Wajswol. * Corresponding author. Stultz Sleep & Behavioral Health, 6171 Childers Road, Barboursville, WV, 25504 304-7335380 E-mail address: [email protected] (D.J. Stultz). Background This case study presents a 70-year-old female with a history of recurrent resistant depression and partial seizures, having three generalized seizures in her lifetime. She has failed multiple psychotropic medications, light therapy, the Fisher Wallace Stimulator, Synthroid augmentation and has participated in psychotherapy. Design/Methods She was treated with the Brainsway device at 120% MT and 18 Hz over the left DLPFC while following the Beck Depression Inventory (BDI) and the Patient Health Questionnaire-9 (PHQ-9). Results Abstracts Brain Stimulation 14 (2021) 1404e1417s Brain Stimulation 14 (2021) 1404e1417 The patient has completed three cycles of dTMSwith benefit each time but with a recurrence of symptoms. Her first cycle in May 2019 consisted of 31 treatments with improvement on her BDI of 33 to 9 and improved PHQ-9 of 23 to 6. Cycle #2 was in November 2019 and consisted of 32 treatments with an improvement on her BDI from 54 to 7 and PHQ-9 from 25 to 4. Cycle #3 occurred in October 2020. It consisted of 35 treatments with an improvement on her BDI from 46 to 21 and her PHQ-9 from 23 to 13. Insurance concerns have prevented maintenance treatment, and she has now started her 4th TMS cycle in less than two years. Conclusions This case demonstrates 1) the benefit of TMS in an elderly patient, 2) no seizure in>100 TMS treatments in a patient with a known seizure disorder, and 3) the possibility that maintenance TMS may have proven a better treatment alternative due to the recurrent nature and severity of her resistant depression. Conflict of Interest The authors have no conflicts of interest to report, and no funding was provided for this research. TRANSCRANIAL MAGNETIC STIMULATION (TMS) IMPROVEMENT IN DEPRESSION, INSOMNIA, AND FATIGUE ASSOCIATED WITH MULTIPLE SCLEROSIS (MS) Debra J. Stultz , Savanna Osburn, Tyler Burns, Robin Walton, Amy Cope, Sylvia Pawlowska-Wajswol. * Corresponding author. Stultz Sleep & Behavioral Health 6171 Childers Road, Barboursville, WV, 25504 304-733-5380 E-mail address: [email protected] (D.J. Stultz). Background This case presents a 60-year-old white female with a 30-year history of Secondary Progressive Multiple Sclerosis, a long history of depression, and frequent suicidal ideation. She had previously tried citalopram, venlafaxine, paroxetine, desvenlafaxine, fluoxetine, bupropion, and at the time of treatment initiation, she was on vilazodone. She had been on modafinil and methylphenidate for fatigue. The patient had complaints of chronic insomnia. Design/Methods Using the Brainsway dTMS system to the left dorsolateral prefrontal cortex (LDPFC) at 120% motor threshold and 18 Hz, the patient received 29 treatments while following the Beck Depression Inventory (BDI), the Patient Health Questionnaire-9 (PHQ-9), the Insom