Long Term Transcranial Pulse Stimulation (TPS) on Older Adults With Mild Neurocognitive Disorder (NCD)

Mild Neurocognitive Disorder Clinical Trial

Official title:

Efficacy of a 24-week Long Term Transcranial Pulse Stimulation (TPS) on Cognition and Brain Structure in Older Adults With Mild Neurocognitive Disorder (NCD)

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT05602467
• Other study ID #: UW22-642
• Status: Recruiting
• Phase: N/A
• Start date: November 25, 2022
• Est. completion date: August 2024

Study information

• Verified date: July 2023
• Source: The University of Hong Kong
• Contact: Calvin PW Cheng, MBBS (HKU)
• Phone: +852-22554486
• Email: chengpsy[@]hku.hk
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Background: Dementia, now known as major neurocognitive disorder (NCD), is a great health burden in Hong Kong and worldwide. In principle, to achieve its optimal benefits, intervention for dementia should begin at the earliest preclinical stage, which is defined as mild cognitive impairment (MCI). However, no evidence has been found to support a pharmacological approach to the prevention or postponement of cognitive decline during the stage of mild NCD. Non-invasive brain stimulation (NIBS) is increasingly recognized as a potential alternative to tackle this problem. The typical examples of NIBS are transcranial direct current stimulation (DCS) and transcranial magnetic stimulation (MS). Besides these, there is a new NIBS named transcranial pulse stimulation (TPS), which recently obtained CE marking in 2018 for the treatment of the central nervous system (CNS) in patients with mild to moderate Alzheimer's disease (AD). TPS is using repetitive single ultrashort pulses in the ultrasound frequency range to stimulate the brain. With a neuro-navigation device, TPS can achieve this in a highly focal and precisely targeted manner. TPS differs from DCS and TMS using direct or induced electric current. Instead, TPS provides good spatial precision and resolution to noninvasively modulate subcortical areas, despite the problem of skull attenuation. Using lower ultrasound frequencies TPS can successfully improve skull penetration in humans. TPS has shown its neuroprotective effects through inducing long term neuroplastic changes, supported by neuropsychological tests and neuroimaging investigations both in animal and human studies. Mild NCD is a golden period for intervention to avoid further progression to dementia. Although TPS has great potential as a new treatment option due to its neuroprotective effects, there is no TPS study done on mild CD subjects according to our knowledge. To determine the effectiveness of TPS in mild NCD, an open-label pilot study was conducted by our team from Dec 2020 to Dec 2021. The preliminary result was presented in the 2021 Brain Stimulation Conference and published in abstract format. We recruited 16 older adults who had mild CD. They received 6 sessions of TPS over 2 weeks. Assessments were done at the 3 time points. No subjects dropped out during the study. Statistically significant improvement was found in the primary outcome, HK-MoCA, from 18.06 to 20.25. The improvement was maintained till 12 weeks after the TPS intervention. No adverse effect was observed. The result suggested that TPS is likely to have an immediate effect on global cognition in mild CD, and the improvements were sustainable. However, a 2-week treatment duration may not be long enough to induce a significant change in neurodegenerative disease in long term. Up to date, there is no long-term NIBS treatment done on NCD. Therefore, we plan to conduct a pilot case-controlled trial to evaluate the efficacy of long-term TPS on cognition and brain structure in patients with mild ND based on the results of our pilot study. Objective: This study is to determine the efficacy of a 24-week program (32 sessions) of TPS in older adults with mild NCD. We hypothesized that TPS group is significantly more effective than control group in maintain or improve the global cognitive function measured by Hong Kong Chinese version of Montreal Cognitive Assessment (HK-MoCA) in patients with mild NCD. Design: This case-controlled trial will assess the efficacy of a 24-week TPS program on cognition and brain structure in subjects with mild NCD. All eligible participants will receive an intervention trial of TPS. They would receive 2 sets of stimulation programs, each set lasting 12-weeks. Participants would receive 3 sessions/week in the first 2 weeks and then 1 session/week in the subsequent 10 weeks. A total of 32 sessions (2 sets of 16 sessions) ofTPS will be delivered, with each session lasting 30 minutes. Data Analysis: The primary and secondary outcomes will be assessed at baseline, immediately after the 1st set of stimulation program (12th week), 2nd set of stimulation program (24th week), and 12 weeks after the intervention (36th week). The primary outcome will be the change of the Hong Kong Chinese version of the Montreal Cognitive Assessment (HK-MoCA). The secondary outcome includes specific cognitive domains, daily functioning, mood, and apathy. The intention-to-treat analysis would be carried out. Pre and post-intervention brain MRI scans will be used during the intervention to evaluate the changes in brain structure. A checklist of potential adverse effects associated with TPS administration will be generated from the available literature. Blood pressure and heart rate will be recorded at the beginning and at the end of the TPS intervention course.

Description:

Background: Dementia, now known as major neurocognitive disorder (NCD), is a great health burden in Hong Kong and worldwide. Interventions that aim to ameliorate cognitive decline or prevent dementia offer a compelling alternative paradigm for reducing the impact of the disease. In principle, to achieve its optimal benefits, intervention for dementia should begin at the earliest preclinical stage, which is defined as mild cognitive impairment (MCI) or mild NCD defined by the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, no evidence has been found to support a pharmacological approach to the prevention or postponement of cognitive decline during the stage of mild NCD or MCI (1, 2). Non-invasive brain stimulation (NIBS) is increasingly recognized as a potential alternative to tackle this problem. The introduction of TPS: The typical examples of NIBS are transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS). Besides these, there is a new NIBS named transcranial pulse stimulation (TPS), which recently obtained CE marking in 2018 for the treatment of the central nervous system (CNS) in patients with mild to moderate Alzheimer's disease (AD). TPS is using repetitive single ultrashort pulses in the ultrasound frequency range to stimulate the brain. With a neuro-navigation device, TPS can achieve this in a highly focal and precisely targeted manner (3). TPS differs from tDCS and TMS using direct or induced electric current. Using electric current to stimulate the brain may be limited by the problem of conductivity (4) and failure to reach deep brain regions (5). Instead, TPS provides good spatial precision and resolution to noninvasively modulate subcortical areas, despite the problem of skull attenuation (6). Using lower ultrasound frequencies TPS can successfully improve skull penetration in humans (3). Biological mechanism of TPS: The basic mechanism of TPS is mechanotransduction. It is a biological pathway through which the cells convert the mechanical TPS stimulus into biochemical responses, thus influencing some fundamental cell functions such as migration, proliferation, differentiation, and apoptosis (7, 8). The ultrashort ultrasound pulse could enhance cell proliferation and differentiation in cultured neural stem cells, which plays an important role in the repair of brain function in CNS diseases (9). The TPS probably affects neurons and induces neuroplastic effects through several pathways including increasing cell permeability (9), stimulation of mechanosensitive ion channels (7), the release of nitric oxide resulting in vasodilation, increased metabolic activity and angiogenesis (10), stimulation of vascular growth factors (VEGF) (11) and stimulation of brain-derived neurotrophic factor (BDNF) (12). Another animal study showed that ultrasound stimulation immediately after ischemic brain injury is neuroprotective through the increase of cerebral blood flow and activation of the synthesis of nitric oxide (13). Previous clinical experience of TPS and its safety issue: TPS demonstrated neuromodulation effects in the human brain. There are a few advantages of TPS techniques. First, the ultrashort TPS pulses avoid brain heating and secondary stimulation maxima. Second, TPS can modulate the amplitude of somatosensory evoked potentials (SEPs) at both the cortical regions (3) and even the deep structure such as the thalamus (6). Third, TPS may alter human brain morphology (14). For clinical use, long-term TPS was shown to bring significant improvement in patients with unresponsive wakefulness syndrome. (15). In another clinical study, TPS was applied to elderly with AD. Significant improvement in cognition was demonstrated (immediately as well as 1 and 3 months after stimulation. fMRI also showed significantly increased connectivity within the memory network (3). During the subsequent follow-up in the same study, TPS has been shown reduced cortical atrophy within the default mode network, which is associated with neuropsychological improvement (14). Another TPS study done on the human brain found that the active TPS increased the functional and structural coupling within the stimulated area and adjacent areas up to one week after the last stimulation compared with the sham TPS control. It suggested that TPS could induce neuroplastic changes with long-term effects in humans (16). In summary, TPS has shown its neuroprotective effects by inducing long-term neuroplastic changes, supported by neuropsychological tests and neuroimaging investigations both in animal and human studies. Concerning the safety issue, in vivo animal TPS study did not cause any tissue damage despite using 6-7-fold higher energy levels compared with those in human studies. Furthermore, the intervention did not cause any serious adverse effects such as intracranial bleeding, oedema or other intracranial pathology in human, as confirmed with MRI in a previous AD study. No serious adverse effects except headache (4%), pain or pressure (1%) and mood deterioration (3%) was reported (3). The CE marked TPS system has proven to be safe in >1500 treatments. Knowledge gap and results from our pilot study: Mild NCD is a golden period for intervention to avoid further progression to dementia. Although TPS has great potential as a new treatment option due to its neuroprotective effects, there is no TPS study done on mild NCD subjects according to our knowledge. To determine the effectiveness of TPS in mild NCD, an open-label pilot study was conducted by our team from Dec 2020 to Dec 2021. (Appendix 1) The preliminary result was presented at 2021 Brain Stimulation Conference and published in abstract format (17). We recruited 16 older adults who had mild NCD. They received 6 sessions of TPS over 2 weeks. Assessments were done at the 3 time points. No subjects dropped out during the study. Statistically significant improvement was found in the primary outcome, HK-MoCA, from 18.06 to 20.25. The improvement was maintained till 12 weeks after the TPS intervention. No adverse effect was observed. The result suggested that TPS is likely to have an immediate effect on global cognition in mild NCD, and the improvements were sustainable. However, a 2-week treatment duration may not be long enough to induce a significant change in neurodegenerative disease in long term. Previous research showed that long-term deep brain stimulation may reverse hippocampal atrophy and influence the natural course of brain atrophy in Alzheimer's disease (AD) (18). Up to date, there is no long-term NIBS treatment done on NCD. Therefore, we plan to conduct a pilot case-controlled trial to evaluate the efficacy of long-term TPS on cognition and brain structure in patients with mild NCD based on the results of our pilot study.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 22
• Est. completion date: August 2024
• Est. primary completion date: August 2024
• Accepts healthy volunteers: No
• Gender: All
• Age group: 60 Years and older

Eligibility

Inclusion Criteria:

1. 60 years of age or above

2. Chinese ethnicity

3. Fulfil the criteria of mild neurocognitive disorder (NCD), defined by the DSM-5

4. Stable dosage/frequency of anti-dementia therapy or other treatments for mild NCD in recent 8 weeks

5. Valid informed written consent

Exclusion Criteria:

1. HK-MoCA score below the second percentile according to the subject's age and education level (to exclude subjects with existing major NCD/dementia)

2. Alcohol or substance dependence

3. Concomitant unstable major medical conditions or major neurological conditions such as brain tumour, recent stroke

4. Haemophilia or other blood clotting disorders or thrombosis

5. Significant communicative impairments

6. Participants with any metal implant in brain or treated area of the head

Related Conditions & MeSH terms

• Cognitive Dysfunction
• Mild Neurocognitive Disorder
• Neurocognitive Disorders

Intervention

Device:
• Transcranial Pulse Stimulation (TPS)
A global brain stimulation approach, which homogenously distributes the total energy of 6000 TPS pulses per session over all accessible brain areas. Prefrontal, Temporal and Occipital brain areas were stimulated by ultrashort (3µs) ultrasound pulses with typical energy levels of 0.2-0.25 mJ/mm2 and pulse frequencies of 4-5 Hz (pulses per second).

Other:
• Treatment as usual (TAU)
Treatment-as-usual (TAU) in the Hong Kong outpatient clinic without TPS intervention was given. They would receive the standard care for mild NCD including counselling, lifestyle modification, cognitive training and antidementia medications occasionally depending on the case doctor's judgement.

Locations

Country	Name	City	State
Hong Kong	The Hong Kong Jockey Club Building for Interdisciplinary Research	Hong Kong

Sponsors (2)

Lead Sponsor	Collaborator
The University of Hong Kong	Storz Medical AG

Country where clinical trial is conducted

Hong Kong, 

References & Publications (21)

Beisteiner R, Matt E, Fan C, Baldysiak H, Schonfeld M, Philippi Novak T, Amini A, Aslan T, Reinecke R, Lehrner J, Weber A, Reime U, Goldenstedt C, Marlinghaus E, Hallett M, Lohse-Busch H. Transcranial Pulse Stimulation with Ultrasound in Alzheimer's Disease-A New Navigated Focal Brain Therapy. Adv Sci (Weinh). 2019 Dec 23;7(3):1902583. doi: 10.1002/advs.201902583. eCollection 2020 Feb. — View Citation

Chu LW, Chiu KC, Hui SL, Yu GK, Tsui WJ, Lee PW. The reliability and validity of the Alzheimer's Disease Assessment Scale Cognitive Subscale (ADAS-Cog) among the elderly Chinese in Hong Kong. Ann Acad Med Singap. 2000 Jul;29(4):474-85. — View Citation

Cooper C, Li R, Lyketsos C, Livingston G. Treatment for mild cognitive impairment: systematic review. Br J Psychiatry. 2013 Sep;203(3):255-64. doi: 10.1192/bjp.bp.113.127811. Erratum In: Br J Psychiatry. 2014 Jan;204(1):81. — View Citation

d'Agostino MC, Craig K, Tibalt E, Respizzi S. Shock wave as biological therapeutic tool: From mechanical stimulation to recovery and healing, through mechanotransduction. Int J Surg. 2015 Dec;24(Pt B):147-53. doi: 10.1016/j.ijsu.2015.11.030. Epub 2015 Nov 28. — View Citation

Farrer LA, Cupples LA, Haines JL, Hyman B, Kukull WA, Mayeux R, Myers RH, Pericak-Vance MA, Risch N, van Duijn CM. Effects of age, sex, and ethnicity on the association between apolipoprotein E genotype and Alzheimer disease. A meta-analysis. APOE and Alzheimer Disease Meta Analysis Consortium. JAMA. 1997 Oct 22-29;278(16):1349-56. — View Citation

Guo T, Li H, Lv Y, Lu H, Niu J, Sun J, Yang GY, Ren C, Tong S. Pulsed Transcranial Ultrasound Stimulation Immediately After The Ischemic Brain Injury is Neuroprotective. IEEE Trans Biomed Eng. 2015 Oct;62(10):2352-7. doi: 10.1109/TBME.2015.2427339. Epub 2015 Apr 28. — View Citation

Hatanaka K, Ito K, Shindo T, Kagaya Y, Ogata T, Eguchi K, Kurosawa R, Shimokawa H. Molecular mechanisms of the angiogenic effects of low-energy shock wave therapy: roles of mechanotransduction. Am J Physiol Cell Physiol. 2016 Sep 1;311(3):C378-85. doi: 10.1152/ajpcell.00152.2016. Epub 2016 Jul 13. — View Citation

Ingber DE. Cellular mechanotransduction: putting all the pieces together again. FASEB J. 2006 May;20(7):811-27. doi: 10.1096/fj.05-5424rev. — View Citation

Kasper S, Bancher C, Eckert A, Forstl H, Frolich L, Hort J, Korczyn AD, Kressig RW, Levin O, Palomo MSM. Management of mild cognitive impairment (MCI): The need for national and international guidelines. World J Biol Psychiatry. 2020 Oct;21(8):579-594. doi: 10.1080/15622975.2019.1696473. Epub 2020 Feb 5. — View Citation

Lam LC, Tam CW, Lui VW, Chan WC, Chan SS, Chiu HF, Leung T, Tham MK, Ho KS, Chan WM. Screening of mild cognitive impairment in Chinese older adults--a multistage validation of the Chinese abbreviated mild cognitive impairment test. Neuroepidemiology. 2008;30(1):6-12. doi: 10.1159/000113300. Epub 2008 Jan 17. — View Citation

Legon W, Ai L, Bansal P, Mueller JK. Neuromodulation with single-element transcranial focused ultrasound in human thalamus. Hum Brain Mapp. 2018 May;39(5):1995-2006. doi: 10.1002/hbm.23981. Epub 2018 Jan 29. — View Citation

Lohse-Busch H, Reime U, Falland R. Symptomatic treatment of unresponsive wakefulness syndrome with transcranially focused extracorporeal shock waves. NeuroRehabilitation. 2014 Jan 1;35(2):235-44. doi: 10.3233/NRE-141115. — View Citation

Mariotto S, Cavalieri E, Amelio E, Ciampa AR, de Prati AC, Marlinghaus E, Russo S, Suzuki H. Extracorporeal shock waves: from lithotripsy to anti-inflammatory action by NO production. Nitric Oxide. 2005 Mar;12(2):89-96. doi: 10.1016/j.niox.2004.12.005. — View Citation

Matt E, Kaindl L, Tenk S, Egger A, Kolarova T, Karahasanovic N, Amini A, Arslan A, Saricicek K, Weber A, Beisteiner R. First evidence of long-term effects of transcranial pulse stimulation (TPS) on the human brain. J Transl Med. 2022 Jan 15;20(1):26. doi: 10.1186/s12967-021-03222-5. — View Citation

Minjoli S, Saturnino GB, Blicher JU, Stagg CJ, Siebner HR, Antunes A, Thielscher A. The impact of large structural brain changes in chronic stroke patients on the electric field caused by transcranial brain stimulation. Neuroimage Clin. 2017 Apr 18;15:106-117. doi: 10.1016/j.nicl.2017.04.014. eCollection 2017. — View Citation

Sankar T, Chakravarty MM, Bescos A, Lara M, Obuchi T, Laxton AW, McAndrews MP, Tang-Wai DF, Workman CI, Smith GS, Lozano AM. Deep Brain Stimulation Influences Brain Structure in Alzheimer's Disease. Brain Stimul. 2015 May-Jun;8(3):645-54. doi: 10.1016/j.brs.2014.11.020. Epub 2014 Dec 3. — View Citation

Spagnolo PA, Wang H, Srivanitchapoom P, Schwandt M, Heilig M, Hallett M. Lack of Target Engagement Following Low-Frequency Deep Transcranial Magnetic Stimulation of the Anterior Insula. Neuromodulation. 2019 Dec;22(8):877-883. doi: 10.1111/ner.12875. Epub 2018 Oct 29. — View Citation

Wang B, Ning H, Reed-Maldonado AB, Zhou J, Ruan Y, Zhou T, Wang HS, Oh BS, Banie L, Lin G, Lue TF. Low-Intensity Extracorporeal Shock Wave Therapy Enhances Brain-Derived Neurotrophic Factor Expression through PERK/ATF4 Signaling Pathway. Int J Mol Sci. 2017 Feb 16;18(2):433. doi: 10.3390/ijms18020433. — View Citation

Yeung PY, Wong LL, Chan CC, Leung JL, Yung CY. A validation study of the Hong Kong version of Montreal Cognitive Assessment (HK-MoCA) in Chinese older adults in Hong Kong. Hong Kong Med J. 2014 Dec;20(6):504-10. doi: 10.12809/hkmj144219. Epub 2014 Aug 15. — View Citation

Zhang J, Kang N, Yu X, Ma Y, Pang X. Radial Extracorporeal Shock Wave Therapy Enhances the Proliferation and Differentiation of Neural Stem Cells by Notch, PI3K/AKT, and Wnt/beta-catenin Signaling. Sci Rep. 2017 Nov 10;7(1):15321. doi: 10.1038/s41598-017-15662-5. — View Citation

Zheng YP, Zhao JP, Phillips M, Liu JB, Cai MF, Sun SQ, Huang MF. Validity and reliability of the Chinese Hamilton Depression Rating Scale. Br J Psychiatry. 1988 May;152:660-4. doi: 10.1192/bjp.152.5.660. — View Citation

* Note: There are 21 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Change in Global Cognition	Global cognitive function measured by the Hong Kong Chinese version of the Montreal Cognitive Assessment (HK-MoCA) ranges from 0 to 30, with higher scores indicating better cognition.	Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
Secondary	Change in Memory	Measured by Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) - Chinese version	Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
Secondary	Change in Executive Function	Measured by Stroop test.	Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
Secondary	Change in Attention/Working Memory	Measured by Trail Making Test Parts A and B	Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
Secondary	Change in Brain Structure	Structural MRI will be performed using a 3T scanner at HKU. Pre and post intervention brain MRI scan will be used during intervention and evaluate the changes in brain structure. The participants' brain images will be loaded into the TPS machine before the session start. Those participants with abnormal brain scan result such as brain tumour and recent stroke will be excluded. Images processing and analysis will be performed using software packages including FSL and SPM8 to assess the voxel-based morphometry (VBM) in hippocampus and other relevant regions.	Baseline, 12-week Follow-up
Secondary	Change in Daily Functioning	Measured by Hong Kong Chinese version of the Lawton Instrumental Activities of Daily Living Scale.	Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
Secondary	Change in Mood	Measured by the Depression Rating Scale (HAMD-17)	Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up

External Links

•   Cheng PWC, Fong KHT. Efficacy and safety of transcranial pulse stimulation (TPS) in older adults with mild neurocognitive disorder-an open-label trial. Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation. 2021;14(6):1636.