Repetitive transcranial magnetic stimulation in trauma-related conditions

Figures & data

Figure 1 Schematic representation of the target brain regions according to frequency of rTMS among trauma-exposed individuals in the review: (A) PTSD patients and (B) TBI patients.

Notes: The size of the nodes is proportional to the number of rTMS studies allocated to each target brain region. The color of the nodes reflects the frequency of rTMS applied to each target region: high frequency stimulation (>1 Hz) (red color) and low frequency stimulation (≤1 Hz) (blue color).
Abbreviations: DLPFC, dorsolateral prefrontal cortex; HF, high frequency; L, left; LF, low frequency; PMC, primary motor cortex; PTSD, posttraumatic stress disorder; R, right; rTMS, repetitive transcranial magnetic stimulation; TBI, traumatic brain injury.

Table 1 rTMS studies in patients with PTSD

rTMS for the treatment of PTSD
Study	PTSD (n)	Group (n)	Methodology	rTMS parameters					Outcomes
				Site	Frequency (Hz)	Intensity (% MT)	Total sessions	Total pulses	Post rTMS – pre rTMS
Nam et al^Citation28	16	(A) active (7) (B) sham (9)	RCT 90° off sham	R DLPFC	1	100	15	18,000	[CAPS] ↓ total PTSD severity (A)>(B) – ↓ re-experiencing (A)>(B)
Kozel et al^Citation29	103	(A) active + CPT (54) (B) sham + CPT (49)	RCT sham coil	R DLPFC	1	110	12–15	21,600–27,000	[CAPS] ↓ PTSD symptoms (A)>(B)
Osuch et al^Citation30	9	(A) active + imaginal ET (9) (B) sham + imaginal ET (9)	RCT sham- controlled 45° off sham cross-over	R DLPFC	1	100	20	36,000	[CAPS/IES] – ↓ hyperarousal (A)>(B) [↑ 24-hour urinary NE, ↑ T4, ↓ serum prolactin] (A)>(B)
Isserles et al^Citation31	26	(A) active DTMS + traumatic SI + ET (9) (B) active DTMS + non-traumatic SI + ET (8) (C) sham DTMS + traumatic SI + ET (9)	RCT sham coil	R & L mPFC	20	120	12	20,160	[CAPS] ↓ PTSD severity (A)>(B)>(C) – ↓ intrusion (A)>(B)>(C) [HR] ↓ response to traumatic script (A)>(B)>(C)
Boggio et al^Citation32	26	(A) active, R DLPFC (9) (B) active, L DLPFC (9) (C) sham (8)	RCT double-blind sham coil	(A) R DLPFC (B) L DLPFC	20	80	10	16,000	[PCL/TOP] ↓ core PTSD symptoms (A)>(B)>(C) – ↓ avoidance (A)>(B) – re-experiencing (A)=(B) – ↓ hyperarousal (A)<(B) [HDRS] ↓ mood (B)>(A) [HARS] ↓ anxiety (A)>(B)
Cohen et al^Citation33	24	(A) active, 1 Hz, R DLPFC (8) (B) active, 10 Hz, R DLPFC (10) (C) sham, R DLPFC (6)	RCT double-blind 90° off sham	R DLPFC	(A) 1 (B) 10	80	10	(A) 1,000 (B) 4,000	[PCL/TOP/CAPS] ↓ core PTSD symptoms (A)=(B)>(C) – ↓ re-experiencing (A)=(B)>(C) – ↓ avoidance (A)=(B)>(C) [HARS] ↓ anxiety (B)>(A)>(C)
George et al^Citation34	+ mTBI (41)	(A) active (20) (B) sham (21)	RCT double-blind sham coil	L DLPFC	10	120	9	54,000	[SIS] ↓ suicidal ideation Day 1 (A)>(B) Day 2, 3 (A)=(B)
Watts et al^Citation35	+ PD/OCD (20)	(A) active (10) (B) sham (10)	RCT double-blind sham coil	R DLPFC	1	90	10	4,000	[PCL] ↓ core PTSD symptoms, (A)>(B) – re-experiencing=avoidance=hyperarousal [BDI] ↓ depression symptoms, (A)>(B) [STAI] ↓ anxiety symptoms, (A)>(B) [BNCE] cognitive improvement, (A)=(B)

Note: The ↑ and ↓ symbols indicate an increase and a decrease, respectively.

Abbreviations: BDI, Beck Depression Inventory; BNCE, Brief Neuropsychological Cognitive Examination; CAPS, Clinician-Administered Posttraumatic Stress Disorder Scale; CPT, cognitive processing therapy; DLPFC, dorsolateral prefrontal cortex; DTMS, deep transcranial magnetic stimulation; ET, exposure therapy; HARS, Hamilton Anxiety Rating Scale; HDRS, Hamilton Depression Rating Scale; HR, heart rate; IES, Impact of Event Scale; L, left; MT, motor threshold; NE, norepinephrine; OCD, obsessive compulsive disorder; PCL, Posttraumatic Stress Disorder Checklist; PD, panic disorder; mPFC, medial prefrontal cortex; PTSD, posttraumatic stress disorder; R, right; RCT, randomized-controlled trial; SI, script-driven imagery; STAI, State-Trait Anxiety Inventory; SIS, Suicide Intention Scale; T4, thyroxine; TOP, Treatment Outcome Posttraumatic Stress Disorder Scale; mTBI, mild traumatic brain injury; rTMS, repetitive transcranial magnetic stimulation.

Table 2 rTMS studies in patients with TBI

Study	TBI (n)	Methodology	rTMS parameters					Outcomes
			Site	Frequency (Hz)	Intensity (% MT)	Total sessions	Total pulses	Post rTMS – pre rTMS
rTMS for the treatment of TBI-related neurological symptoms
Leung et al^Citation42	Post mTBI (6)	Case study	L PMC L DLPFC	10	80	4	8,000	[NPRS] ↓ headache
Leung et al^Citation43	Post mTBI (active: 15 sham: 16)	RCT 180° off sham neuronavigation	L PMC	10	80	3	6,000	[NPRS] ↓ headache
Leung et al^Citation44	Post mTBI (active: 14 sham: 15)	RCT 180° off sham neuronavigation	L DLPFC	10	80	4	8,000	[NPRS] ↓ headache
Koski et al^Citation45	6 mo post mTBI (15)	Open label	L DLPFC	10	110	20	–	[PCSS] ↓ Post-concussion symptoms (headache, sleep deprivation)(BR/)[task fMRI]: ↑ NP task-related activation peaks in the DLPFC and ↑ deactivation in the ACC
Choi et al^Citation46	Headache post mTBI (active: 6 sham: 6)	RCT 90° off sham	PMC	10	90	10	10,000	[NPRS] ↓ central pain
Manganotti et al^Citation47	Post severe TBI (A) VS: 3 (B) MCS: 3	Open label	L PMC R PMC	20	120	1	–	[DRS/JFK CRS] coma/consciousness 1 patient (MCS) ↑, 5 patients: pre = post [MEP]: ↑ motor excitability [EEG]: no altered consciousness or slightly ↑
rTMS for the treatment of TBI-related cognitive symptoms
Leung et al^Citation43	Post mTBI (active: 15 sham: 16)	RCT 180° off sham neuronavigation	L PMC	10	80	3	6,000	[CPT] (=) attention
Leung et al^Citation44	Post mTBI (active: 14 sham: 15)	RCT 180° off sham neuronavigation	L DLPFC	10	80	4	8,000	[CPT] (=) attention, concentration, working memory
Koski et al^Citation45	6 mo post mTBI (15)	Open label	L DLPFC	10	110	20	–	[NP battery] ↑ attention, processing speed, executive function, memory [task-fMRI]: ↑ NP task-related activation peaks in the DLPFC & ↑ deactivation in the ACC
Neville et al^Citation48	Post severe TBI (active: 18 sham: 18)	RCT double-blind sham coil	L DLPFC	10	110	10	20,000	[NP battery] ↑ executive function, attention, memory
rTMS for the treatment of TBI-related psychiatric symptoms
George et al^Citation34	(A) active (20) (B) sham (21)	RCT double-blind sham coil	L DLPFC	10	120	9	54,000	[SIS] suicidal ideation (A) = (B)
Leung et al^Citation43	Post mTBI (active: 15 sham: 16)	RCT 180° off sham neuronavigation	L PMC	10	80	3	6,000	[HDRS] (=) depression
Leung et al^Citation44	Post mTBI (active: 14 sham: 15)	RCT 180° off sham neuronavigation	L DLPFC	10	80	4	8,000	[HDRS] ↓ depression

Note: The ↑ and ↓ symbols indicate an increase and a decrease, respectively.

Abbreviations: ACC, anterior cingulate cortex; JFK CRS, JFK Coma Recovery Scale; CPT, Conner’s Continuous Performance Test; DLPFC, dorsolateral prefrontal cortex; DRS, Disability Rating Scale; EEG, electroencephalography; fMRI, functional magnetic resonance imaging; HDRS, Hamilton Depression Rating Scale; L, left; MCS, minimally conscious state; MEP, motor evoked potentials; mo, months; MT, motor threshold; NP, neuropsychological test; NPRS, Numeric Pain Rating Scale; PCSS, Post-Concussion Symptom Scale; PMC, primary motor cortex; R, right; RCT, randomized-controlled trial; SIS, Suicide Intention Scale; TBI, traumatic brain injury; mTBI, mild traumatic brain injury; rTMS, repetitive transcranial magnetic stimulation; VS, vegetative state.

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