The report is a product of the VA/HSR&D Evidence Synthesis Program.
Evidence Brief: Transcranial Magnetic Stimulation (TMS) for Chronic Pain, PTSD, TBI, Opioid Addiction, and Sexual Trauma
Transcranial Magnetic Stimulation (TMS) is a non-invasive therapy that uses magnetic pulses to induce electrical currents in various parts of the brain. Repetitive TMS (rTMS) delivers magnetic pulses to the brain rapidly at regular intervals and is the most widely studied and commonly used type of TMS. Transcranial Magnetic Stimulation has been used in a variety of applications, including intraoperative neurologic monitoring, investigating nerve conduction, diagnosing neurologic conditions, and for treating certain psychiatric and neurologic conditions. TMS therapy in VA is offered through the National Clinical rTMS Program. There are currently 35 VA rTMS clinics across the country, with additional clinics under development. Currently, rTMS is most frequently used within VA for treating depression. There is interest in expanding the use of TMS to treat other conditions, but fewer studies have examined the efficacy of TMS for other conditions, and there remain open questions about the generalizability of existing evidence, the reliability of treatment effects, and the optimal treatment protocol for each condition.
The exact biological mechanism of TMS is unknown, but it is hypothesized that as magnetic pulses pass through the skull, electrical activity is induced in nerve cells, activating underlying areas of the brain cortex. Biological studies have shown changes in neural activity with TMS treatment, such as increased blood flow and dopamine transmission in areas of the brain targeted by TMS.
This systematic review was done in response to a request from VA’s Center for Compassionate Care Innovation for an evidence brief on the use of TMS for the treatment of mental and physical health diagnoses (not including major depressive disorder). Findings will be used to inform a VA pilot program to provide access to TMS for Veterans suffering from chronic pain, PTSD, traumatic brain injury (TBI), opioid addiction, or sexual trauma. Investigators with VA’s Evidence Synthesis Program (ESP) Center in Portland, OR searched the literature, including MEDLINE, Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials from January 2012 to August 2020. After reviewing 1,729 citations, they included 1 systematic review, 39 controlled trials, and 15 case series in their review.
Summary of Findings
Findings of this review suggest that rTMS therapy may reduce symptoms in people with chronic pain, post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), and opiate addiction and could be a treatment option for patients who have exhausted all other available options. Strength of evidence was limited by considerable variation in patient populations (i.e., demographics, disease or symptom characteristics), TMS protocols (i.e., TMS coil type and position, stimulation parameters), and study methodology (i.e., sample size, outcomes and number of timepoints assessed) among included studies. This variation may have contributed to inconsistency in the observed effects of TMS therapy. Moreover, the generally small sample sizes of included studies could have limited statistical power to detect differences between TMS and control conditions. Finally, no studies were found that examined the use of TMS specifically for sexual trauma, or that directly compared rTMS to other forms of TMS.
Implications for VA
Practical aspects of more widely implementing TMS in a healthcare system need further consideration, particularly as they relate to patient and provider burden, cost, and accessibility. Generally, TMS therapy consists of daily therapy, usually for a period of 4 to 6 weeks, and patients must travel daily to a designated clinic where TMS is offered. Limitations in transportation or clinic access for patients, staff availability, training requirements, and the need for a designated clinic site with TMS technology may be barriers in expanding use of TMS. Pairing these considerations with the findings that suggest potential effectiveness and high patient safety and acceptability, it is reasonable to conclude that TMS therapy, in particular rTMS, could be considered a treatment option for patients who have exhausted other available options for treatment of chronic pain, PTSD, TBI, or opiate addiction. With this approach, a limited expansion of rTMS could be conducted that would provide additional information about implementation feasibility and would allow for more rigorous trials.
Research Gaps/Future Research
Future research should use larger samples, robust methodology (i.e., appropriate randomization and matching procedures), and standardized TMS parameters (i.e., following various TMS guidance for specific patient populations, if available) to provide more conclusive evidence on the use of TMS for chronic pain, PTSD, TBI, opioid addiction, and sexual trauma.
Anderson J, Parr NJ, Vela K. Evidence Brief: Transcranial Magnetic Stimulation (TMS) for Chronic Pain, PTSD, TBI, Opioid Addiction, and Sexual Trauma. VA ESP Project #09-009; 2020.
To view the full report, go to www.hsrd.research.va.gov/publications/esp/tms-mh.cfm
ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
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