Postpartum Depression cured with TMS

The St. Louis Post-Dispatch had an article (Link) this morning about a trial going on at Washington University using rTMS for postpartum depression. Only four patients have been treated at this point, but all four had resolution of their symptoms.

Within a few days after receiving her first treatment in February with the device, Meinert said she began to feel better. After two weeks, her symptoms were gone.

"It honestly was incredible. I was shocked to be feeling that well after two weeks," Meinert said. "I was feeling like my old self, and I still feel great today."

One of the points that this article makes is that standard antidepressants take up to four weeks to work. And in reality they may take longer... In addition there are a number of less than savory side effects that are fairly common with these drugs including " diarrhea, dry mouth, lethargy, nervousness, a bad taste in the mouth and loss of libido...". The author is obliquely getting at a point that I have mentioned before: maybe rTMS is a better starting point than the typical antidepressants that we currently reach for. Fewer side effects, potentially less cost, fewer interactions with other medications, the list could go on.
Another interesting point brought up is that the TMS unit used in this study was made by Neuronetics, the outfit that is working on getting an FDA indication for TMS and depression. This will be the first FDA indication for the transcranial application of TMS (currently it is my understanding that it is only approved for peripheral nerve stimulation). The word on the street is that Neuronetics should be getting this indication relatively soon, but that has been the word for several years.
All of the politics of the FDA and their approval process aside, it is my opinion (and just like every opinion out there, you can take it with a grain of salt..) that this is a major step forward in our options to clinically induce neuroplasticity and make a positive difference in the quality of someone's life.

Fibromyalgia pain reduced by rTMS

A report from a group in France, published in the journal Brain, describes the effects of repetitive transcranial magnetic stimulation (rTMS) on self-reported average pain intensity recorded at baseline (before treatments), during 10 days of daily stimulation and then at 15, 30 and 60 days after the finish of treatments.
Thirty patients were divided up in a double blind fashion with one group getting sham treatment while the other got rTMS. Outcomes that were measured, meaning what effects were monitored during the study based on the researchers hypotheses, included depression monitoring scales, quality of life scales, scales that monitor how much pain interferes with the patient's functioning as well as the amount of pain a predetermined amount of pressure caused.
Twenty six of the original thirty, 13 in each group, were monitored through day 60 and the group that received the real rTMS had a significant reduction in pain , fatigue, morning tiredness, general activity and sleep at least two weeks after the last session was completed. The affective pain reduction was more long lasting than the sensory effects.
There were no significant side effects that occurred, as is the case with almost all of the studies that have been published in the last few years that adhere to published guidelines.
This group concluded that rTMS "...induces a long-lasting decrease in chronic widespread pain and may therefore constitute an effective alternative analgesic treatment for fibromyalgia."
Once again it seems that inducing neuroplasticity can help rebalance the maladaptive patterns that chronic pain syndromes have created. Is it the magic bullet we all hope for? Or is it snake oil? Or maybe something somewhere in between the two? Could this be another step in the right direction, opening the huge black box that is our brain just a little bit more?

rTMS for Bipolar Disorder

An article about Brainsway and their trials on using rTMS for Bipolar disorder.

Brainsway Ltd. (TASE:BRIN) reports positive
interim results in the clinical trial of its Deep TMS transcranial magnetic
stimulation device for the treatment of bipolar disorder on patients who did not
respond to any medications.
The findings are based on the interim report by
the chief researcher on the nine patients in the study at the Shalvata
Psychiatric Hospital in Israel. The effect of Deep TMS on the patients was
measured using different methods for measuring depression, such as the Hamilton
Depression Rating Scale (HDRS), and self questionnaires.
The study found that all the patients
responded positively to the treatment, compared with previous treatments using
antidepressants. There were no complaints or side effects, except for slight
headaches that some patients felt after the treatment and which quickly passed.
The chief researcher at Shalvata said that the study was the first evidence
that Deep TMS was an effective treatment for bipolar disorder, with the caveat
that this was only the beginning.
Brainsway also reported the results of a
study on the effectiveness and safety of the use of Deep TMS for the treatment
of major depression in cases where patients did not respond to medications.
These findings are based on a preliminary report by the chief researcher on 54
patients participating in the trial at Shalvata.
Published by Globes Israel business news - www.globes.co.il - on August 8, 2007

Recent paper on rTMS and pain

The Journal of Pain just published a review article on the effects of rTMS on experimentally induced and chronic neuropathic pain. They looked at a seven studies that used rTMS to modulate experimentally induced acute pain brought on by ischemic muscle pain, cold immersion, capsaicin or laser stimulation. Those last tow really get to me, I am still recovering from a traumatic expericence as a child at a Mexican restaurant in California. I must have been about four and I grabbed a chip-full of homemade salsa that must have been served to the devil himself it was so hot. All I remember after being stunned by the growing four alarm fire in my mouth was the busboy grabbing a glass of milk and pouring it down my gullet. And anything involving lasers requires the obligatory reference to Dr. Evil's "sharks with lasers.."
It seems the findings in the acute pain papers were mixed. The authors conclude that "The varied effects of rTMS on acute pain may have been influenced by the type of experimentally induced pain, the stimulation frequencies used, and the cortical sites of rTMS stimulation." They noted some of the findings from this group of papers included that ability of single session rTMS to alter pain thresholds.
There were 16 chronic neuropathic pain papers that were included in this group that included approximately 250 patients with a wide variety of conditions including thalamic stroke, trigeminal neuralgia, CRPS, peripheral neuropathy, spinal cord injury, brahcial plexus injury, back pain, thalamotomy pain and osteomyelitis. The papers included used varying protocols including single session and multiple sessions.
In eight of the studies there was a "significant decrease in post-TMS VAS (visual analog scale, usually a 0-10 scale of pain) means as compared with pretreatment means...". To confuse issues there were some studies that reported a decreased in studies that used sham TMS to control for the placebo effect. However, the post-TMS VAS scores were significantly lower than the sham scores.
Some of the numbers that the authors present caught my eye: 62% of patients acheived at least 30% reduction in pain based on their VAS scores after TMS and almost 30% of those patients had at least a 50% drop in their pain score.
They then go on to make some generalizations about TMS protocols including the type of coil used, fast vs slow, the number of pulses used and the location of stimulation. None of the studies reported any adverse affects.
Once again, this presents some thought provoking information and causes me to continue to consider therapeutic neuromodulation with TMS may be in our future.
At what point does someone take the plunge and start offering this to patients with refractory neuropathic pain. I have seen these patients and they are miserable. Their pain is their life, and if you could offer someone a 30-50% reduction in their pain, even if it involved ongoing treatment, I have to wonder if this would be potentially life-altering. Just a thought....

Slow-Frequency rTMS and Fibromyalgia Pain

This was the first article I read that introduced me to the concept of transcranial magnetic stimulation. I had just seen a patient the day before in a Rheumatology clinic I was visiting and had a long chat with the Rheumatologist I was working with about the etiology of Fibromyalgia and what sorts of treatments were available. Needless to say, he was fairly pessimistic about what was possible. I ran across this article in Rehab in Review, it piqued my interest and I pulled the article.
Some thoughts about the article: an n of four is always concerning, so it needs to be considered a limited case series. But if you examine the response of the patients to repetitive transcranial stimulation (rTMS), it was pretty amazing. A baseline pain of 8.2(ranging from 7-9.5 on a scale of 0-10) that was dropped to 1.5 (0-3.5) is not only statistically significant, but if you consider the functional ramifications it is amazing. These subjects received rTMS five days per week for four weeks, one of the patients received sham rTMS prior to the four weeks and one got an additional twelve treatments because she (they were all women) had remission of depressive symptoms. All had been diagnosed by board certified Rheumatologists and all had been evaluated by Psychiatrists.
The results showed one patient had resolution of depression and two of the four had resolution of their pain. Pain was improved, defined as not increasing more than 1.5 points on the 0-10 scale, for 15-27 weeks.
This was a real eye-opener for me even when taken with a large grain of salt. Just something to think about.
PubMed Citation