Posts Tagged Transcranial magnetic stimulation

[WEB] Neuroimaging technology used to study how brain stimulation works for treatment of depression

Reviewed by Emily Henderson, B.Sc. May 4 2021

Repetitive transcranial magnetic stimulation, or rTMS, was FDA approved in 2008 as a safe and effective noninvasive treatment for severe depression resistant to antidepressant medications. A small coil positioned near the scalp generates repetitive, pulsed magnetic waves that pass through the skull and stimulate brain cells to relieve symptoms of depression. The procedure has few side effects and is typically prescribed as an alternative or supplemental therapy when multiple antidepressant medications and/or psychotherapy do not work.

Despite increased use of rTMS in psychiatry, the rates at which patients respond to therapy and experience remission of often-disabling symptoms have been modest at best.

Now, for the first time, a team of University of South Florida psychiatrists and biomedical engineers applied an emerging functional neuroimaging technology, known as diffuse optical tomography (DOT), to better understand how rTMS works so they can begin to improve the technique’s effectiveness in treating depression. DOT uses near-infrared light waves and sophisticated algorithms (computer instructions) to produce three-dimensional images of soft tissue, including brain tissue.

Comparing depressed and healthy individuals, the USF researchers demonstrated that this newer optical imaging technique can safely and reliably measure changes in brain activity induced during rTMS in a targeted region of the brain implicated in mood regulation. Their findings were published April 1 in the Nature journal Scientific Reports.

This study is a good example of how collaboration between disciplines can advance our overall understanding of how a treatment like TMS works. We want to use what we learned from the application of the diffuse optical tomography device to optimize TMS, so that the treatments become more personalized and lead to more remission of depression.”

Shixie Jiang, MD, study lead author, third-year psychiatry resident, USF Health Morsani College of Medicine

DOT has been used clinically for imaging epilepsy, breast cancer, and osteoarthritis and to visualize activation of cortical brain regions, but the USF team is the first to introduce the technology to psychiatry to study brain stimulation with TMS.

“Diffuse optical tomography is really the only modality that can image brain function at the same time that TMS is administered,” said study principal investigator Huabei Jiang, PhD, a professor in the Department of Medical Engineering and father of Shixie Jiang. The DOT imaging system used for USF’s collaborative study was custom built in his laboratory at the USF College of Engineering.

The researchers point to three main reasons why TMS likely has not lived up to its full potential in treating major depression: nonoptimized brain stimulation targeting; unclear treatment parameters (i.e., rTMS dose, magnetic pulse patterns and frequencies, rest periods between stimulation intervals), and incomplete knowledge of how nerve cells in the brain respond physiologically to the procedure.

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Portable, less expensive, and less confining than some other neuroimaging equipment like MRIs, DOT still renders relatively high-resolution, localized 3D images. More importantly, Dr. Huabei Jiang said, DOT can be used during TMS without interfering with treatment’s magnetic pulses and without compromising the images and other data generated.

DOT relies on the fact that higher levels of oxygenated blood correlate with more brain activity and increased cerebral blood flow, and lower levels indicate less activity and blood flow. Certain neuroimaging studies have also revealed that depressed people display abnormally low brain activity in the prefrontal cortex, a brain region associated with emotional responses and mood regulation.

By measuring changes in near-infrared light, DOT detects changes in brain activity and, secondarily, changes in blood volume (flow) that might be triggering activation in the prefrontal cortex. In particular, the device can monitor altered levels of oxygenated, deoxygenated, and total hemoglobin, a protein in red blood cells carrying oxygen to tissues.

The USF study analyzed data collected from 13 adults (7 depressed and 6 healthy controls) who underwent DOT imaging simultaneously with rTMS at the USF Health outpatient psychiatry clinic. Applying the standard rTMS protocol, the treatment was aimed at the brain’s left dorsolateral prefrontal cortex – the region most targeted for depression.

The researchers found that the depressed patients had significantly less brain activation in response to rTMS than the healthy study participants. Furthermore, peak brain activation took longer to reach in the depressed group, compared to the healthy control group.

This delayed, less robust activation suggests that rTMS as currently administered under FDA guidelines may not be adequate for some patients with severe depression, Dr. Shixie Jiang said. The dose and timing of treatment may need to be adjusted for patients who exhibit weakened responses to brain stimulation at baseline (initial treatment), he added.

Larger clinical trials are needed to validate the USF preliminary study results, as well as to develop ideal treatment parameters and identify other dysfunctional regions in the depression-affected brain that may benefit from targeted stimulation.

“More work is needed,” Dr. Shixie Jiang said, “but advances in neuroimaging with new approaches like diffuse optical tomography hold great promise for helping us improve rTMS and depression outcomes.”

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[ARTICLE] Evidence of neuroplasticity with robotic hand exoskeleton for post-stroke rehabilitation: a randomized controlled trial – Full Text

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Fig. 2 Whole set-up of exoskeleton with performance biofeedback, voluntary cue and PCB in the black control box which also works as user interface [28]

Abstract

Background

A novel electromechanical robotic-exoskeleton was designed in-house for the rehabilitation of wrist joint and Metacarpophalangeal (MCP) joint.

Objective

The objective was to compare the rehabilitation effectiveness (clinical-scales and neurophysiological-measures) of robotic-therapy training sessions with dose-matched conventional therapy in patients with stroke.

Methods

A pilot prospective parallel randomized controlled study at clinical settings was designed for patients with stroke within 2 years of chronicity. Patients were randomly assigned to receive an intervention of 20 sessions of 45 min each, five days a week for four weeks, in Robotic-therapy Group (RG) (n = 12) and conventional upper-limb rehabilitation in Control-Group (CG) (n = 11). We intended to evaluate the effects of a novel exoskeleton based therapy on the functional rehabilitation outcomes of upper-limb and cortical-excitability in patients with stroke as compared to the conventional-rehabilitation. Clinical-scales– Modified Ashworth Scale, Active Range of Motion, Barthel-Index, Brunnstrom-stage and Fugl-Meyer (FM) scale and neurophysiological measures of cortical-excitability (using Transcranial Magnetic Stimulation) –Motor Evoked Potential and Resting Motor threshold, were acquired pre- and post-therapy.

Results

No side effects were noticed in any of the patients. Both RG and CG showed significant (p < 0.05) improvement in all clinical motor-outcomes except Modified Ashworth Scale in CG. RG showed significantly (p < 0.05) higher improvement over CG in Modified Ashworth Scale, Active Range of Motion and Fugl-Meyer scale and FM Wrist-/Hand component. An increase in cortical-excitability in ipsilesional-hemisphere was found to be statistically significant (p < 0.05) in RG over CG, as indexed by a decrease in Resting Motor Threshold and increase in the amplitude of Motor Evoked Potential. No significant changes were shown by the contralesional-hemisphere. Interhemispheric RMT-asymmetry evidenced significant (p < 0.05) changes in RG over CG indicating increased cortical-excitability in ipsilesional-hemisphere along with interhemispheric changes.

Conclusion

Robotic-exoskeleton training showed improvement in motor outcomes and cortical-excitability in patients with stroke. Neurophysiological changes in RG could most likely be a consequence of plastic reorganization and use-dependent plasticity.

Trial registry number: ISRCTN95291802

Introduction

Stroke is one of the leading causes of mortality and morbidity worldwide [1]. Flexor hypertonia of the wrist is one of its common presentations. Post-stroke, the ability to actively initiate extension movement at the wrist and fingers is one of the indicators of the motor recovery [23]. Regaining hand function and Activities of daily living (ADL) is particularly impervious to therapy owing to fine motor control needed for the distal-joints [4]. Conventional rehabilitation therapy is time taking, labor-intensive and subjective. Therapists usually have a high clinical load and a lack of evidence-based technologies to support them, resulting in therapist burnout and a healthcare system that cannot provide appropriate or effective rehabilitation services [5].

Although rehabilitation with neuro-rehabilitation robots has shown encouraging clinical results [5,6,7,8,9,10,11,12,13,14,15,16,17,18], it is currently limited to a very few hospitals and not widely used because of the associated high-cost and an infrastructural-requirement to station these large and complex devices with a high set-up time and limited usability [19,20,21]. Rehabilitation strategies need to take into account the multifaceted nature of the disability, which is self-changing (progressing or improving), i.e. itself changes with time and requires a multimodal approach. Hence, the assistive device needs to be flexible and adaptive enough to accommodate the needs of a large patient population.

An effective rehabilitation device for the upper-limb should be able to facilitate a specific pattern of coordinated movements of joints, especially for a hand. However, this particular coordination is currently not integrated with any of the commercially available devices, where they mostly focus on movements of the specific individual joint in isolation [22]. For a healthy subject, extending the wrist naturally leads to flexion of the fingers. Semi-extension of the wrist with grasped fingers contributes to ADL movements; which is also commonly disrupted in patients with stroke due to flexor hypertonia. These complex movement patterns have been disintegrated during conventional physiotherapy into few simpler tasks, for example, holding a glass of water consists of sub-tasks like grasping the glass with the fingers in the motion of flexion while wrist in 30–40 degree semi-extended position, and releasing it with fingers being in extension and wrist coming back to the neutral position with flexion as elaborated in [23]. Hence, a device that can simulate the movement pattern of wrist extension along with finger flexion (such as in ADL), maintaining inter-joint coordination with the limited number of actuators making the device less complex, is the need of the hour. Only two devices, Hand Mentor and HWARD, allow hand and wrist synchronization [24]. The Hand Mentor Pro rotates wrist with Metacarpophalengeal (MCP) placed at a constant angle with respect to the wrist, but lacks flexion (grasp) and extension (release) of MCP, also it can’t accommodate patient-centric ROM and speed. Though HWARD synchronized wrist and MCP and provided seminal evidence of reorganization of the brain through robotic-therapy sessions, it had few other challenges such as limited range of motion, no patient-centric muscle-specific training, finger opening requirement, manual adjustment of force at pneumatic cylinders and device having ~ 25 kg of weight. Hence, the challenges remained to simplify the complex design and therapy protocols into simple, lightweight, user-friendly devices that are convenient with a potential to use even in home-settings. Moreover, the device must show efficacy for a broader community while being cost-effective for low and middle-income countries with limited research on rehabilitation [25,26,27]. Our device attempt to address the key limitations which other commercial devices faced.

In our previous work, we have designed a robotic hand exoskeleton for rehabilitation of the wrist and MCP joint, to synchronize wrist extension with finger-flexion and wrist-flexion with finger extension [28]. It is a prototype device with the potential of being simple and easy to operate exoskeleton rehabilitation device for low-resource settings in the future. The exoskeleton targets spasticity through a synergy-based rehabilitation approach while also maintaining patient-initiated therapy through residual muscle activity for maximizing voluntary effort. The lightweight and portable device indicated an improvement in quantitative motor clinical outcomes in patients with chronic stroke [28].

The aim of the present study was twofold. The first objective was to assess the clinical effectiveness of the novel robotic-exoskeleton device [28] and the second is a comparison of its clinical effectiveness with conventional upper-limb rehabilitation. There is a considerable amount of literature documented for neurorehabilitation robots that takes into account the specific, repetitive, and timed movement goals [29] with maximizing voluntary residual muscle activity, real-time visual performance biofeedback, and proprioceptive feedback for sensorimotor integration. These features might give the robotic-therapy a notch over dose-matched conventional therapy [3031]. As the exoskeleton device also has these features [28], thus, we hypothesized that exoskeleton-based rehabilitation therapy might also encourage clinically relevant neuroplasticity with expected better clinical outcomes for distal joints in patients with stroke than the dose-matched conventional rehabilitation.[…]

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[Abstract] Evidence for a Window of Enhanced Plasticity in the Human Motor Cortex Following Ischemic Stroke

Abstract

Background

In preclinical models, behavioral training early after stroke produces larger gains compared with delayed training. The effects are thought to be mediated by increased and widespread reorganization of synaptic connections in the brain. It is viewed as a period of spontaneous biological recovery during which synaptic plasticity is increased.

Objective

To look for evidence of a similar change in synaptic plasticity in the human brain in the weeks and months after ischemic stroke.

Methods

We used continuous theta burst stimulation (cTBS) to activate synapses repeatedly in the motor cortex. This initiates early stages of synaptic plasticity that temporarily reduces cortical excitability and motor-evoked potential amplitude. Thus, the greater the effect of cTBS on the motor-evoked potential, the greater the inferred level of synaptic plasticity. Data were collected from separate cohorts (Australia and UK). In each cohort, serial measurements were made in the weeks to months following stroke. Data were obtained for the ipsilesional motor cortex in 31 stroke survivors (Australia, 66.6 ± 17.8 years) over 12 months and the contralesional motor cortex in 29 stroke survivors (UK, 68.2 ± 9.8 years) over 6 months.

Results

Depression of cortical excitability by cTBS was most prominent shortly after stroke in the contralesional hemisphere and diminished over subsequent sessions (P = .030). cTBS response did not differ across the 12-month follow-up period in the ipsilesional hemisphere (P = .903).

Conclusions

Our results provide the first neurophysiological evidence consistent with a period of enhanced synaptic plasticity in the human brain after stroke. Behavioral training given during this period may be especially effective in supporting poststroke recovery.

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[ARTICLE] A novel glasses-free virtual reality rehabilitation system on improving upper limb motor function among patients with stroke: a feasibility pilot study – Full Text

Abstract

Background

Virtual reality (VR) technology is increasingly used in stroke rehabilitation. This study aimed to investigate the effectiveness of using the glasses-free VR training to improve motor function of upper limb in patients with stroke.

Methods

Twelve patients with stroke were recruited to participate in the intervention of 3 weeks. At the baseline and post intervention, two times of evaluation including Fugl-Meyer upper-extremity scale (FMS-UE), transcranial magnetic stimulation (TMS) measurement and motion evaluation were performed.

Results

No significant difference was observed between two groups at baseline evaluation. After the intervention, the FMS-UE scores presented a greater improvement in the VR group compared with the control group. TMS measurement showed that there was significant difference in cortex latency and central motor conduction time between two groups after the intervention, but no significant difference in the amplitude of motor event potential was observed. In addition, there was a significant correlation between game scores and FMS-UE scores.

Conclusions

The novel glasses-free VR training was at least as effective as conventional occupational therapy in upper limb motor function, improving nerve conduction time and corticospinal excitability in patient with stroke.

1. Introduction

Stroke is among the leading cause of long-term disability with up to 85% of patients with stroke experience upper limb motor deficits [1]. Motor function of upper limb, in particular the hand function, occupies more than 60% of the physical function for an individual [2]. However, the recovery of upper limb motor function post stroke is clinical challenging, and the outcomes of upper limb rehabilitation remains unsatisfactory [1]. The loss of control input from the brain is believed to be a contributor to muscle spasm and flaccid paresis, leading to the difficulty in performing daily activities and reduced quality of life among patients with stroke [3]. Additionally, early literature also suggested that there was a significant descending information flow which potentially reflected the recruitment of motor neurons from the supplementary motor area [4]. Thus, the recovery of the corticospinal pathway is likely to be a precondition of motor function improvement for patients with stroke [4,5].

Virtual reality (VR) technology has emerged as a promising intervention to facilitate functional recovery among patients with stroke [6]. VR intervention provides interactive tasks within a computer-generated virtual environment which incorporates auditory and visual feedback [7]. It has the advantage to increase users’ motivation by providing the high intensity repetitive tasks [8]. A previous review demonstrated the potential benefits of VR to improve upper limb function and activities of daily living (ADL) function in patients with stroke [9]. However, the clinical effectiveness of VR systems in the recovery of hand function remains unsatisfied [9]. The high complexity of the hand represents a challenge to accurately capture and simulate the movements of the hands and fingers [6,10,11].Thus, stroke patients could not obtain precise and timely feedback from the VR system, which contribute to poor clinical outcome [9,12]. Although gloves or other wearable devices with built-in motion sensors are often adopted in some VR systems to capture hand movements, these wearable items place extraneous load on the users which reduce motion velocity and increases the difficulty of training for patients with stroke [13,14]. Leap Motion© Controller (LMC) is a device designed to capture the fine motions of hands and fingers [6]. Compared with other devices, LMC has the benefits of low-cost and easiness to use [15]. To date, three studies were found that had trialed the LMC as part of a VR training system to capture hand movements in patients with stroke, and reported improvements in Wolf motor function test (WMFT) scores and performance time [6], higher hand abilities and grasp force [16], and increased Fugl-Meyer scale (FMS) scores and Box-and-Blocks Test scores [17]. These studies demonstrated the feasibility and potential benefits of LMC-based VR training in improving upper limb motor function among stroke patients. It should be noted that only a two-dimension (2D) display was used in those studies, which would not provide a stereoscopic virtual environment for patients with stroke.

The neurological mechanism of VR training to improve upper limb motor function in patients with stroke mainly involved two aspects, cortical reorganization [6] and the recovery of corticospinal tract [18]. Wang et al. [6] observed an increase in activation intensity from functional magnetic resonance imaging (fMRI) of the lesioned hemisphere in sub-acute stroke patients after four weeks of Leap Motion-based VR training. This finding provided support that Leap Motion-based VR intervention promote neuroplasticity which contribute to functional improvement [6,19].

The integrity of the corticospinal tract was demonstrated to be associated with motor function recovery in chronic stroke patients [2021]. A previous study suggested the positive relationship between the integrity of corticospinal tract and upper limb motor recovery in patients with cerebrovascular accidents [18]. Another research reported an improvement in the functional integrity of ipsilateral corticospinal tract and upper limb motor function after two weeks of VR training in patients with subacute stroke [22]. The author stated that stroke patients with higher motor evoked potentials (MEPs) had a significantly greater FMS and WMFT scores than those with MEP absence. It suggested that functional recovery of upper limb post stroke may be related to the ipsilesional corticospinal tract [2223]. However, there is still a lack of evidence whether neural conduction time would change after the VR training among stroke patients, and more research is needed.

Our institute has recently developed a novel glasses-free VR rehabilitation system that addressed the issues of external sensors to capture hands and finger motion of the existence VR system discussed above. This study was aimed to investigate whether the novel VR rehabilitation system was able to facilitate the recovery of upper limb motor function, as well as the corticospinal tract in patients with stroke. We hypothesized that after the glasses-free VR training, there would be an improvement in upper limb motor function and the function of corticospinal tract among patients with stroke.[…]

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Figure 2
Figure 2. The glasses-free VR rehabilitation system. (A) A participant with stroke was using the glasses-free VR rehabilitation system to do VR training; (B) HSTDB projected 3D effect to a viewer; (C) Schematic diagram of the glasses-free VR rehabilitation system; (D) Leap Motion Controller.

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[Abstract] Effects of Robotic Therapy Associated With Noninvasive Brain Stimulation on Upper-Limb Rehabilitation After Stroke: Systematic Review and Meta-analysis of Randomized Clinical Trials

Abstract

Background

Robot-assisted therapy and noninvasive brain stimulation (NIBS) are promising strategies for stroke rehabilitation.

Objective

This systematic review and meta-analysis aims to evaluate the evidence of NIBS as an add-on intervention to robotic therapy in order to improve outcomes of upper-limb motor impairment or activity in individuals with stroke.

Methods

This study was performed according to the PRISMA Protocol and was previously registered on the PROSPERO Platform (CRD42017054563). Seven databases and gray literature were systematically searched by 2 reviewers, and 1176 registers were accessed. Eight randomized clinical trials with upper-limb body structure/function or activity limitation outcome measures were included. Subgroup analyses were performed according to phase poststroke, device characteristics (ie, arm support, joints involved, unimanual or bimanual training), NIBS paradigm, timing of stimulation, and number of sessions. The Grade-Pro Software was used to assess quality of the evidence.

Results

A nonsignificant homogeneous summary effect size was found both for body structure function domain (mean difference [MD] = 0.15; 95% CI = −3.10 to 3.40; P = 0.93; I2 = 0%) and activity limitation domain (standard MD = 0.03; 95% CI = −0.28 to 0.33; P = 0.87; I2 = 0%).

Conclusions

According to this systematic review and meta-analysis, at the moment, there are not enough data about the benefits of NIBS as an add-on intervention to robot-assisted therapy on upper-limb motor function or activity in individuals with stroke.

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[Slideshow] Depression Overview: Emotional Symptoms, Physical Signs, and More

Δημιουργήθηκε απόσπασμα από: https://www.webmd.com/depression/ss/slideshow-depression-overview

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Depression: What Is It?

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It’s natural to feel down sometimes, but if that low mood lingers day after day, it could signal depression. Major depression is an episode of sadness or apathy along with other symptoms that lasts at least two consecutive weeks and is severe enough to interrupt daily activities. Depression is not a sign of weakness or a negative personality. It is a major public health problem and a treatable medical condition.

Shown here are PET scans of the brain showing different activity levels in a person with depression, compared to a person without depression.

Depression Symptoms: Emotional

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The primary symptoms of depression are a sad mood and/or loss of interest in life. Activities that were once pleasurable lose their appeal. Patients may also be haunted by a sense of guilt or worthlessness, lack of hope, and recurring thoughts of death or suicide.

Depression Symptoms: Physical

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Depression is sometimes linked to physical symptoms. These include:

  • Fatigue and decreased energy
  • Insomnia, especially early-morning waking
  • Excessive sleep
  • Persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment

Depression can make other health problems feel worse, particularly chronic pain. Key brain chemicals influence both mood and pain. Treating depression has been shown to improve co-existing illnesses.

Depression Symptom: Appetite

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Changes in appetite or weight are another hallmark of depression. Some patients develop increased appetite, while others lose their appetite altogether. Depressed people may experience serious weight loss or weight gain.

Impact on Daily Life

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Without treatment, the physical and emotional turmoil brought on by depression can derail careers, hobbies, and relationships. People with depression often find it difficult to concentrate and make decisions. They turn away from previously enjoyable activities, including sex. In severe cases, depression can become life-threatening.

Suicide Warning Signs

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People who are depressed are more likely to attempt suicide. Warning signs include talking about death or suicide, threatening to hurt people, or engaging in aggressive or risky behavior. Anyone who appears suicidal should be taken very seriously. Do not hesitate to call one of the suicide hotlines: 800-SUICIDE (800-784-2433) and 800-273-TALK (800-273-8255). If you have a plan to commit suicide, go to the emergency room for immediate treatment.

Depression: Who’s at Risk?

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Anyone can become depressed, but many experts believe genetics play a role. Having a parent or sibling with depression increases your risk of developing the disorder. Women are twice as likely as men to become depressed.

Causes of Depression

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Doctors aren’t sure what causes depression, but a prominent theory is altered brain structure and chemical function. Brain circuits that regulate mood may work less efficiently during depression. Drugs that treat depression are believed to improve communication between nerve cells, making them run more normally. Experts also think that while stress — such as losing a loved one — can trigger depression, one must first be biologically prone to develop the disorder. Other triggers could include certain medications, alcohol or substance abuse, hormonal changes, or even the season.

Illustrated here are neurons (nerve cells) in the brain communicating via neurotransmitters.

Seasonal Depression

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If your mood matches the season — sunny in the summer, gloomy in the winter — you may have a form of depression called seasonal affective disorder (SAD). The onset of SAD usually occurs in the late fall and early winter, as the daylight hours grow shorter. Experts say SAD affects from 3% to 20% of all people, depending upon where they live.

Postpartum Depression

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The “baby blues” strikes as many as three out of four new mothers. But nearly 12% develop a more intense dark mood that lingers even as their baby thrives. This is known as postpartum depression, and the symptoms are the same as those of major depression. An important difference is that the baby’s well-being is also at stake. A depressed mother may have trouble enjoying and bonding with their infant.

  

Depression in Children

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In the United States, depression affects 2% of grade school kids and about one in 10 teenagers. It interferes with the ability to play, make friends, and complete schoolwork. Symptoms are similar to depression in adults, but some children may appear angry or engage in risky behavior, called “acting out.” Depression can be difficult to diagnose in children.
  

Diagnosing Depression

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As of yet, there is no lab test for depression. To make an accurate diagnosis, doctors rely on a patient’s description of the symptoms. You’ll be asked about your medical history and medication use since these may contribute to symptoms of depression. Discussing moods, behaviors, and daily activities can help reveal the severity and type of depression. This is a critical step in determining the most effective treatment.

Talk Therapy for Depression

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Studies suggest different types of talk therapy can fight mild to moderate depression. Cognitive behavioral therapy aims to change thoughts and behaviors that contribute to depression. Interpersonal therapy identifies how your relationships impact your mood. Psychodynamic psychotherapy helps people understand how their behavior and mood are affected by unresolved issues and unconscious feelings. Some patients find a few months of therapy are all they need, while others continue long term.

Medications for Depression

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Antidepressants affect the levels of brain chemicals, such as serotonin and norepinephrine. There are many options. Give antidepressants a few weeks of use to take effect. Good follow-up with your doctor is important to evaluate their effectiveness and make dosage adjustments. If the first medication tried doesn’t help, there’s a good chance another will. The combination of talk therapy and medication appears particularly effective.

Exercise for Depression

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Research suggests exercise is a potent weapon against mild to moderate depression. Physical activity releases endorphins that can help boost mood. Regular exercise is also linked to higher self-esteem, better sleep, less stress, and more energy. Any type of moderate activity, from swimming to housework, can help. Choose something you enjoy and aim for 20 to 30 minutes four or five times a week.

Light Therapy (Phototherapy)

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Light therapy has shown promise as an effective treatment not only for SAD but for some other types of depression as well. It involves sitting in front of a specially designed light box that provides either a bright or dim light for a prescribed amount of time each day. Light therapy may be used in conjunction with other treatments. Talk to your doctor about getting a light box and the recommended length of time for its use.

St. John’s Wort for Depression

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St. John’s wort is an herbal supplement that has been the subject of extensive debate. There is some evidence that it can fight mild depression, but two large studies have shown it is ineffective against moderately severe major depression. St. John’s wort can interact with other medications you may be taking for medical conditions or birth control. Talk to your doctor before taking this or any other supplement.  

Pets for Depression

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A playful puppy or wise-mouthed parrot is no substitute for medication or talk therapy. But researchers say pets can ease the symptoms of mild to moderate depression in many people. Pets provide unconditional love, relieve loneliness, and give patients a sense of purpose. Studies have found pet owners have less trouble sleeping and better overall health.

The Role of Social Support

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Because loneliness goes hand-in-hand with depression, developing a social support network can be an important part of treatment. This may include joining a support group, finding an online support community, or making a genuine effort to see friends and family more often. Even joining a book club or taking classes at your gym can help you connect with people on a regular basis.

Vagus Nerve Stimulation (VNS)

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Vagus nerve stimulation (VNS) may help patients with treatment-resistant depression that does not improve with medication. VNS is like a pacemaker for the brain. The surgically implanted device sends electrical pulses to the brain through the vagus nerve in the neck. These pulses are believed to ease depression by affecting mood areas of the brain.
  

Electroconvulsive Therapy (ECT)

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Another option for patients with treatment-resistant or severe melancholic depression is electroconvulsive therapy (ECT). This treatment uses electric charges to create a controlled seizure. Patients are not conscious for the procedure. ECT helps 80% to 90% of patients who receive it, giving new hope to those who don’t improve with medication.

Transcranial Magnetic Stimulation

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A newer option for people with stubborn depression is repetitive transcranial magnetic stimulation (rTMS). This treatment aims electromagnetic pulses at the skull. It stimulates a tiny electrical current in a part of the brain linked to depression. rTMS does not cause a seizure and appears to have few side effects. But doctors are still fine-tuning this treatment.

Good Outlook

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In the midst of major depression, you may feel hopeless and helpless. But the fact is, this condition is highly treatable. More than 80% of people get better with medication, talk therapy, or a combination of the two. Even when these therapies fail to help, there are cutting-edge treatments that pick up the slack.

Sources Reviewed by Melinda Ratini, DO, MS on August 06, 2020

IMAGES PROVIDED BY:

(1)    Science Source / Photo Researchers, Inc.

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(6)    Nikolaevich / Photonica

(7)    Jetta Productions, Inc / Iconica

(8)    3D4Medical.com

(9)    Megan Wyeth / Aurora

(10)  Charles Gullung / Photonica

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(13)  Mauro Fermariello / Photo Researchers, Inc.

(14)  Mauro Fermariello / Photo Researchers, Inc.

(15)  Katzer / Mauritius

(16)  Christopher Furlong / Getty Images

(17)  Dr. Jeremy Burgess / Photo Researchers, Inc.

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(20)  David J. Phillip / AP

(21)  Will McIntyre / Photo Researchers, Inc.

(22)  Universal Images Group / Getty

(23)  Frank Gaglione / Riser

SOURCES:
 Barkham, M. British Medical Bulletin, 2001.

 Gjerdinjen, D. Journal of the American Board of Family Medicine, 2007.

 Harvard Health Publications: “Exercise and Depression.”

 Johns Hopkins Health Alerts: “The Many Benefits of Pets.”

 Johns Hopkins Medicine: “Seasonal Affective Disorder.”

 Mental Health America: “Co-occuring Disorders and Depression.”

 National Institute of Mental Health, National Institutes of Health: “How is depression diagnosed and treated?” “What causes depression?” “What are the signs and symptoms of depression?” “What illnesses often co-exist with depression?” “Magnetic Stimulation Scores Modest Success as Antidepressant,” “Major Depressive Disorder in Children.”

 The Merck Manual: “Depression.”

This tool does not provide medical advice. See additional information.

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[Abstract + References] Canadian Platform for Trials in Noninvasive Brain Stimulation (CanStim) Consensus Recommendations for Repetitive Transcranial Magnetic Stimulation in Upper Extremity Motor Stroke Rehabilitation Trials

Abstract

Objective. To develop consensus recommendations for the use of repetitive transcranial magnetic stimulation (rTMS) as an adjunct intervention for upper extremity motor recovery in stroke rehabilitation clinical trials. 

Participants. The Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim) convened a multidisciplinary team of clinicians and researchers from institutions across Canada to form the CanStim Consensus Expert Working Group. 

Consensus Process. Four consensus themes were identified: (1) patient population, (2) rehabilitation interventions, (3) outcome measures, and (4) stimulation parameters. Theme leaders conducted comprehensive evidence reviews for each theme, and during a 2-day Consensus Meeting, the Expert Working Group used a weighted dot-voting consensus procedure to achieve consensus on recommendations for the use of rTMS as an adjunct intervention in motor stroke recovery rehabilitation clinical trials. 

Results. Based on best available evidence, consensus was achieved for recommendations identifying the target poststroke population, rehabilitation intervention, objective and subjective outcomes, and specific rTMS parameters for rehabilitation trials evaluating the efficacy of rTMS as an adjunct therapy for upper extremity motor stroke recovery. 

Conclusions. The establishment of the CanStim platform and development of these consensus recommendations is a first step toward the translation of noninvasive brain stimulation technologies from the laboratory to clinic to enhance stroke recovery.

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[ARTICLE] Novel TMS for Stroke and Depression (NoTSAD): Accelerated Repetitive Transcranial Magnetic Stimulation as a Safe and Effective Treatment for Post-stroke Depression – Full Text

Background: Post-stroke depression (PSD) affects up to 50% of stroke survivors, reducing quality of life, and increasing adverse outcomes. Conventional therapies to treat PSD may not be effective for some patients. Repetitive transcranial magnetic stimulation (rTMS) is well-established as an effective treatment for Major Depressive Disorder (MDD) and some small trials have shown that rTMS may be effective for chronic PSD; however, no trials have evaluated an accelerated rTMS protocol in a subacute stroke population. We hypothesized that an accelerated rTMS protocol will be a safe and viable option to treat PSD symptoms.

Methods: Patients (N = 6) with radiographic evidence of ischemic stroke within the last 2 weeks to 6 months with Hamilton Depression Rating Scale (HAMD-17) scores >7 were recruited for an open label study using an accelerated rTMS protocol as follows: High-frequency (20-Hz) rTMS at 110% resting motor threshold (RMT) was applied to the left dorsolateral prefrontal cortex (DLPFC) during five sessions per day over four consecutive days for a total of 20 sessions. Safety assessment and adverse events were documented based on the patients’ responses following each day of stimulation. Before and after the 4-days neurostimulation protocol, outcome measures were obtained for the HAMD, modified Rankin Scale (mRS), functional independence measures (FIM), and National Institutes of Health Stroke Scales (NIHSS). These same measures were obtained at 3-months follow up.

Results: HAMD significantly decreased (Wilcoxon p = 0.03) from M = 15.5 (2.81)−4.17 (0.98) following rTMS, a difference which persisted at the 3-months follow-up (p = 0.03). No statistically significant difference in FIM, mRS, or NIHSS were observed. No significant adverse events related to the treatment were observed and patients tolerated the stimulation protocol well overall.

Conclusions: This pilot study indicates that an accelerated rTMS protocol is a safe and viable option, and may be an effective alternative or adjunctive therapy for patients suffering from PSD. Future randomized, controlled studies are needed to confirm these preliminary findings.

Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04093843.

Introduction

The interplay between depression and cerebrovascular disease is complex and clinically important. Post-stroke depression (PSD) is the most common neuropsychological complication of stroke, with a prevalence of ~33% (1) in stroke survivors. PSD adversely influences outcomes by reducing quality of life, increasing caregiver burden, and increasing early mortality as much as ten-fold (24). As acute stroke interventions continue to improve, stroke survivorship and associated morbidity will also increase, making the need to explore innovative treatments for PSD even more urgent.

Despite the significant clinical burden of PSD, there are limited treatment options to prevent or reduce its severity. Psychotherapy and pharmacotherapy are well-established as treatments of choice in major depression, however a subset of patients do not respond to either of these first-line therapies (5). Selective Serotonin Reuptake Inhibitor (SSRI) use has been associated with increased risk of hemorrhagic complications as well as increased risk of falls in the elderly, while other studies have shown that SSRIs are actually associated with increased risk for stroke, myocardial infarction, and all-cause mortality (6). A recent meta-analysis for stroke patients concluded that antidepressants did not significantly improve patients’ general recovery, achieved varied response rates, and were not tolerated due to adverse effects (7). Compliance, communication problems, and lack of access to psychiatric care are further challenges to treating PSD.

Repetitive transcranial magnetic stimulation (rTMS) may represent an effective treatment option that mitigates the issues associated with the standard PSD interventions. The FDA approved rTMS for patients with Major Depressive Disorder (MDD) in 2008 (8). The typical rTMS protocol that has been used effectively for major depression is 5 days per week for 4–6 weeks. Conventional rTMS paradigms have been studied in the PSD population, and many studies including a meta-analysis have shown that conventional rTMS is likely effective for chronic, refractory PSD (910). However, these conventional paradigms may be inconvenient for patients with limited transportation access and may limit compliancy of patients. Therefore, an accelerated protocol which minimizes the number of days needed to complete the full treatment may be more accessible to patients and may increase compliancy. While there have been some accelerated rTMS paradigms that have been designed to treat conditions such as alcohol withdrawal and treatment-resistant depression (1114), similar accelerated protocols have not been studied in patients suffering from PSD. Applying accelerated rTMS to the PSD population comes with unique and complex factors. For example, the theoretical risk of seizure using an accelerated protocol may be higher, and this risk may increase even further in patients in the acute to subacute stroke period. Therefore, it is important to study the safety of an accelerated protocol in this population. In addition, the period immediately following cerebrovascular ischemia potentially represents a biologically unique phase amenable to intervention given that both neuroplasticity as well as recurrent stroke risk are highest during this time (1516).

There is a clear medical need to further address the impact of rTMS for PSD and to optimize stimulation parameters. We hypothesized that an accelerated 4-days rTMS protocol would be a safe and viable method for treating PSD and would help ameliorate depressive symptoms.[…]

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[ARTICLE] Virtual reality and non-invasive brain stimulation for rehabilitation applications: a systematic review – Full Text

Abstract

The present article reports the results of a systematic review on the potential benefits of the combined use of virtual reality (VR) and non-invasive brain stimulation (NIBS) as a novel approach for rehabilitation. VR and NIBS are two rehabilitation techniques that have been consistently explored by health professionals, and in recent years there is strong evidence of the therapeutic benefits of their combined use. In this work, we reviewed research articles that report the combined use of VR and two common NIBS techniques, namely transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS). Relevant queries to six major bibliographic databases were performed to retrieve original research articles that reported the use of the combination VR-NIBS for rehabilitation applications. A total of 16 articles were identified and reviewed. The reviewed studies have significant differences in the goals, materials, methods, and outcomes. These differences are likely caused by the lack of guidelines and best practices on how to combine VR and NIBS techniques. Five therapeutic applications were identified: stroke, neuropathic pain, cerebral palsy, phobia and post-traumatic stress disorder, and multiple sclerosis rehabilitation. The majority of the reviewed studies reported positive effects of the use of VR-NIBS. However, further research is still needed to validate existing results on larger sample sizes and across different clinical conditions. For these reasons, in this review recommendations for future studies exploring the combined use of VR and NIBS are presented to facilitate the comparison among works.

Background

Virtual reality (VR) is a medium that is typically composed of an interactive computer simulation which detects the actions and position of the subject, additionally, it replaces or augments the feedback (e.g., visual, auditory, haptic) to the user, providing a sensation of presence in the simulation [1,2,3]. The last decade has witnessed a drastic improvement in computer graphics and computational power, which in turn, have paved the road to more realistic virtual- and augmented-reality systems and experiences, with applications in entertainment, gaming, e-commerce, architecture, interior design, manufacture, education, health and medicine [4]. Regarding rehabilitation, there is strong evidence supporting the use of VR therapy [5,6,7] in the treatment of pain, phobias, post-traumatic stress disorder (PTSD) [5], eating disorders [8], mental disorders, such as anxiety, schizophrenia and autism [9], and chemical abuse [10]. Moreover, VR has proven to be an important tool for exposure therapy [11]. Interestingly, a recent review on the medical literature has revealed that no reports of photosensitive epilepsy evoked by the use of VR headset [12].

Non-invasive brain stimulation (NIBS) techniques, in turn, have been consistently studied in the treatment of neuropsychiatric diseases as methods to modify or modulate the cortical excitability [13], and plasticity in the cerebral cortex [1314]. The two most common techniques used for NIBS are transcranial magnetic stimulation (TMS) and transcranial electrical stimulation (tES). As the name suggests, TMS uses magnetic fields, more specifically, their rapid change to induce a short pulse of electric current on the cortex, which in turn generates action potentials with a depth up to 5 cm. The application of the magnetic fields is carried out by a magnetic coil that is placed near the scalp over the cortical region of interest. TMS can be used in different ways, as single-pulse, repetitive TMS pulses (rTMS) [1516], or intermittent theta burst stimulation (iTBS) when magnetic pulses are intermittently applied in a specific burst [17]. NIBS with TMS have been used for the treatment of depression and schizophrenia [1819], pain [18], obsessive–compulsive disorder, Parkinson’s disease, epilepsy, task-related dystonia, and tic disorders [19]. On the other hand, tES relies on the passage of a weak electric current between electrodes placed on the scalp, thus stimulating the brain tissues between the electrodes. Depending on the type of electric current that is used, tES can be further divided into transcranial direct current stimulation (tDCS), alternating current stimulation (tACS), and random noise stimulation (tRNS) [20]; with tDCS being the most common type [14]. As tDCS possesses polarity, it can be anodal or cathodal, thus depolarizing or hyperpolarizing the resting membrane potential, respectively. This is reflected as an increase or decrease on the cortical excitability, respectively [2021]. Reported therapeutic applications of tDCS include treatment of pain, Parkinson’s disease, Alzheimer’s disease, motor disorders, stroke, aphasia, multiple sclerosis, epilepsy, depression, schizophrenia, and substance abuse [13]. In studies using TMS and tES, a “sham” (placebo) condition is often used as control. For tES, the sham condition consists in administering real tES to the subject during only few seconds at the beginning of the experiment to mimic the perception and experience of real stimulation. In TMS, there are two approaches for the sham condition: in one approach a TMS coil is placed in a position and orientation that evokes the somatosensory effects of real TMS but brain stimulation is absent; on the other approach, a sham TMS coil that resembles a regular TMS coil but is equipped with a magnetic shield that attenuates the magnetic field, additionally, electrical stimulation can be used to replicate the somatosensory effects of real TMS [22].

Recently, evidence has emerged showing promising therapeutic applications for the combined use of VR and tES (more specifically tDCS) [23,24,25,26], as well as VR and TMS [27,28,29], with outcomes not achievable by using either technique individually. Despite the reported promising results, the literature still lacks a systematic review covering the reported methods, outcomes, and potential therapeutic applications in neurological rehabilitation, on the combination of VR and NIBS techniques. This review aims to fill this gap, by reporting, comparing, and discussing studies that used VR-NIBS therapy for rehabilitation applications. Moreover, this review provides recommendations for future studies in the field to facilitate their development and comparison.[…]

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Fig. 1
Example of a stationary VR system where the user actions are mapped to the virtual tennis player through a controller. Different viewpoints for the same VE are presented: a 1PP, b 1PP-mirror and c 3PP

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[ARTICLE] Prediction of Motor Recovery in the Upper Extremity for Repetitive Transcranial Magnetic Stimulation and Occupational Therapy Goal Setting in Patients With Chronic Stroke: A Retrospective Analysis of Prospectively Collected Data – Full Text

Recovery from motor paralysis is facilitated by affected patients’ recognition of the need for and practice of their own exercise goals. Neurorehabilitation has been proposed and used for the treatment of motor paralysis in stroke, and its effect has been verified. If an expected score for the neurorehabilitation effect can be calculated using the Fugl-Meyer Motor Assessment (FMA), a global assessment index, before neurorehabilitation, such a score will be useful for optimizing the treatment application criteria and for setting a goal to enhance the treatment effect. Therefore, this study verified whether the responsiveness to a treatment method, the NovEl intervention using repetitive transcranial magnetic stimulation and occupational therapy (NEURO), in patients with post-stroke upper extremity (UE) motor paralysis could be predicted by the pretreatment FMA score. No control group was established in this study for NEURO treatment. To analyze the recovery of the motor function in the UE, delta-FMA was calculated from the pre- and post-FMA scores obtained during NEURO treatment. The probability of three levels of treatment responsiveness was evaluated in association with delta-FMA score (<5, 5 ≤ delta-FMA <10, and ≥10 as non-responders; responders; and hyper-responders, respectively) according to the reported minimal clinically important difference (MCID). The association of the initial FMA scores with post-FMA scores, from the status of the treatment responsiveness, was determined by multinomial logistic regression analysis. Finally, 1,254 patients with stroke, stratified by FMA scores were analyzed. About 45% of the patients who had FMA scores ranging from 30 to 40 before treatment showed improvement over the MCID by NEURO treatment (odds ratio = 0.93, 95% CI = 0.92–0.95). Furthermore, more than 25% of the patients with more severe initial values, ranging from 26 to 30, improved beyond the MCID calculated in the acute phase (odds ratio = 0.87, 95% CI = 0.85–0.89). These results suggest that the evaluated motor function score of the UE before NEURO treatment can be used to estimate the possibility of a patient recovering beyond MCID in the chronic phase. This study provided clinical data to estimate the effect of NEURO treatment by the pretreatment FMA-UE score.

Introduction

Motor paralysis due to the aftereffects of stroke impairs the activities of daily living (ADL) and quality of life (QOL) of patients; it also affects their individual or social activities (12). In particular, motor paralysis of the upper extremity has a large impact on ADL (3). Recovery from motor paralysis is facilitated by patients recognizing the need for and practicing their own exercise goals (4). The type of goals that patients set are related to their goal satisfaction scores, with impairment-based goals being rated significantly higher than activity-based and participation-based goals (5). It is known that patients’ level of knowledge of their rehabilitation goals leads to effective treatment results (6). Thus, clinicians and patients are active partners in setting goals within stroke rehabilitation (5). In previous studies, some prognosis prediction systems were developed for motor paralysis (79), and they have been used to set goals for rehabilitation in patients with stroke.

Neurorehabilitation has been proposed and used for the treatment of motor paralysis in stroke, and its effect has been verified (1014). One of the treatment methods, the NovEl intervention Using Repetitive transcranial magnetic stimulation and Occupational therapy (NEURO), facilitates peripheral muscle movement by controlling the excitability of the motor cortices by repetitive transcranial magnetic stimulation (rTMS). It also promotes peripheral muscle exercise and practice, for the active use of the paralyzed upper extremity (1516). NEURO’s efficacy has been proved in a randomized controlled study (17). To date, many patients have been treated by using NEURO; however, the prediction regarding whether patients’ recovery from motor paralysis after treatments can be predicted before treatment, has not been verified. If the Fugl-Meyer Motor Assessment (FMA) score before treatment can be used to predict NEURO treatment response, the score can be used as an effective goal for rehabilitation, by patients and therapists.

The minimal clinically important difference (MCID) of motor paralysis in the upper extremity has been investigated (1820). If the expected value of an effect exceeding MCID can be calculated using FMA score measured before NEURO treatment, such a value will be useful for optimizing the treatment application criteria and setting a goal to enhance the treatment effect. For that purpose, it is sufficient to retroactively analyze the band of the FMA score before NEURO for a patient who is significantly improved. Therefore, this study verified whether the responsiveness of NEURO treatment for patients with post-stroke upper extremity motor paralysis could be predicted by the pre-treatment FMA score.[…]

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