Intermittent tetraburst stimulation combined with transcranial direct current stimulation once weekly for treatment-resistant depression: a case report.

BACKGROUND: Single-time non-invasive brain stimulation was carried out using the two-technique approach on a patient suffering from treatment-resistant depression. Five treatment sessions given at weekly intervals resulted in a significant improvement in the Patient Health Questionnaire-9 score for up to 6 weeks. The findings of this study could pave the way for a more efficient less resource-intensive time- and budget-saving technique of employing non-invasive brain stimulation for patients with treatment-resistant depression by minimizing the number of stimulation sessions. CASE PRESENTATION: A 67-year-old married non-Latino white American woman suffering from treatment-resistant depression received intermittent tetraburst stimulation in combination with transcranial direct current stimulation weekly for 5 consecutive weeks. Diagnostic transcranial magnetic stimulation showed an observable electrophysiological change. The patient reported a drastic improvement in Patient Health Questionnaire-9 score up until 6-week follow-up and expressed satisfaction with the treatment. CONCLUSIONS: This case study suggests that a streamlined protocol for using non-invasive brain stimulation could prove more effective for patients and healthcare providers in terms of safety in comparison to the present guidelines.

Normal parameters for diagnostic transcranial magnetic stimulation using a parabolic coil with biphasic pulse stimulation.

BACKGROUND: TMS is being used to aid in the diagnosis of central nervous system (CNS) illnesses. It is useful in planning rehabilitation programs and setting appropriate goals for patients. We used a parabolic coil with biphasic pulse stimulation to find normal values for diagnostic TMS parameters. OBJECTIVES: 1. To determine the normal motor threshold (MT), motor evoked potentials (MEP), central motor conduction time (CMCT), intracortical facilitation (ICF), short-interval intracortical inhibition (SICI), and silent period (SP) values. 2. To measure the MEP latencies of abductor pollicis brevis (APB) and extensor digitorum brevis (EDB) at various ages, heights, and arm and leg lengths. STUDY DESIGN: Descriptive Study. SETTING: Department of Rehabilitation Medicine, Chiang Mai University, Thailand. SUBJECTS: Forty-eight healthy participants volunteered for the study. METHODS: All participants received a single diagnostic TMS using a parabolic coil with biphasic pulse stimulation on the left primary motor cortex (M1). All parameters: MT, MEP, CMCT, ICF, SICI, and SP were recorded through surface EMGs at the right APB and EDB. Outcome parameters were reported by the mean and standard deviation (SD) or median and interquartile range (IQR), according to data distribution. MEP latencies of APB and EDB were also measured at various ages, heights, and arm and leg lengths. RESULTS: APB-MEP latencies at 120% and 140% MT were 21.77 ± 1.47 and 21.17 ± 1.44 ms. APB-CMCT at 120% and 140% MT were 7.81 ± 1.32 and 7.19 ± 1.21 ms. APB-MEP amplitudes at 120% and 140% MT were 1.04 (0.80-1.68) and 2.24 (1.47-3.52) mV. EDB-MEP latencies at 120% and 140% MT were 37.14 ± 2.85 and 36.46 ± 2.53 ms. EDB-CMCT at 120% and 140% MT were 14.33 ± 2.50 and 13.63 ± 2.57 ms. EDB-MEP amplitudes at 120% and 140% MT were 0.60 (0.38-0.98) and 0.95 (0.69-1.55) mV. ICF amplitudes of APB and EDB were 2.26 (1.61-3.49) and 1.26 (0.88-1.98) mV. SICI amplitudes of APB and EDB were 0.21 (0.13-0.51) and 0.18 (0.09-0.29) mV. MEP latencies of APB at 120% and 140% MT were different between heights < 160 cm and ≥ 160 cm (p < 0.001 and p < 0.001) and different between arm lengths < 65 and ≥ 65 cm (p = 0.022 and p = 0.002). CONCLUSION: We established diagnostic TMS measurements using a parabolic coil with a biphasic pulse configuration. EDB has a higher MT than APB. The 140/120 MEP ratio of APB and EDB is two-fold. The optimal MEP recording for APB is 120%, whereas EDB is 140% of MT. CMCT by the F-wave is more convenient and tolerable for patients. ICF provides a twofold increase in MEP amplitude. SICI provides a »-fold of MEP amplitude. SP from APB and EDB are 121.58 ± 21.50 and 181.01 ± 40.99 ms, respectively. Height and MEP latencies have a modest relationship, whereas height and arm length share a strong positive correlation.

Effects of combining two techniques of non-invasive brain stimulation in subacute stroke patients: a pilot study.

BACKGROUND: Strokes have recently become a leading cause of disability among Thai people. Non-invasive brain stimulation (NIBS) seems to give promising results in stroke recovery when combined with standard rehabilitation programs. OBJECTIVE: To evaluate the combined effect of low-frequency repetitive transcranial magnetic stimulation (rTMS) and cathodal transcranial direct current stimulation (tDCS) over the non-lesional primary motor cortex on upper limb motor recovery in patients with subacute stroke. No reports of a combination of these two techniques of NIBS were found in the relevant literature. METHODS: This pilot study was a double-blinded, randomized controlled trial of ten patients with subacute stroke admitted to the Rehabilitation Medicine Inpatient Unit, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University. They were randomized into two groups: five in an active and five in a sham intervention group. Fugl-Meyer's upper extremity motor score (FMA-UE) and Wolf Motor Function Test (WMFT) were used to assess motor recovery at baseline, immediately, and 1 week after stimulation. RESULTS: A two-way repeated ANOVA (mixed design) showed a significant improvement in FMA-UE scores in the active intervention group both immediately and 1 week after stimulation in comparison to the baseline, [time, F (2, 16) = 27.44, p < 0.001, time x group interaction, F (2, 16) = 13.29, p < 0.001]. Despite no statistical significance, a trend toward higher WMFT scores was shown in the active intervention group. CONCLUSIONS: A single session of low-frequency rTMS and cathodal tDCS over the non-lesional primary motor cortex may enhance upper limb motor recovery in patients with subacute stroke.

The Effectiveness and Safety of Commonly Used Injectates for Ultrasound-Guided Hydrodissection Treatment of Peripheral Nerve Entrapment Syndromes: A Systematic Review.

Background: Peripheral nerve entrapment syndromes commonly result in pain, discomfort, and ensuing sensory and motor impairment. Many conservative measures have been proposed as treatment, local injection being one of those measures. Now with high-resolution ultrasound, anatomical details can be visualized allowing diagnosis and more accurate injection treatment. Ultrasound-guided injection technique using a range of injectates to mechanically release and decompress the entrapped nerves has therefore developed called hydrodissection or perineural injection therapy. Several different injectates from normal saline, local anesthetics, corticosteroids, 5% dextrose in water (D5W), and platelet-rich plasma (PRP) are available and present clinical challenges when selecting agents regarding effectiveness and safety. Aims: To systematically search and summarize the clinical evidence and mechanism of different commonly used injectates for ultrasound-guided hydrodissection entrapment neuropathy treatment. Methods: Four databases, including PubMed, EMBASE, Scopus, and Cochrane were systematically searched from the inception of the database up to August 22, 2020. Studies evaluating the effectiveness and safety of different commonly used injectates for ultrasound-guided hydrodissection entrapment neuropathy treatment were included. Injectate efficacy presents clinical effects on pain intensity, clinical symptoms/function, and physical performance, electrodiagnostic findings, and nerve cross-sectional areas. Safety outcomes and mechanism of action of each injectate were also described. Results: From ten ultrasound-guided hydrodissection studies, nine studies were conducted in carpal tunnel syndrome and one study was performed in ulnar neuropathy at the elbow. All studies compared different interventions with different comparisons. Injectates included normal saline, D5W, corticosteroids, local anesthetics, hyaluronidase, and PRP. Five studies investigated PRP or PRP plus splinting comparisons. Both D5W and PRP showed a consistently favorable outcome than those in the control group or corticosteroids. The improved outcomes were also observed in comparison groups using injections with normal saline, local anesthetics, or corticosteroids, or splinting. No serious adverse events were reported. Local steroid injection side effects were reported in only one study. Conclusion: Ultrasound-guided hydrodissection is a safe and effective treatment for peripheral nerve entrapment. Injectate selection should be considered based on the injectate mechanism, effectiveness, and safety profile.