Toiminnallisten liikehäiriöiden työryhmä avuksi ongelmatapauksiin

TYKS:ssa on vuodesta 2016 lähtien järjestetty kuukausittain toiminnallisia liikehäiriöitä käsitteleviä työryhmätapaamisia. Ne ovat parantaneet hoidon laatua, vähentäneet turhia tutkimuksia ja antaneet hoitaville lääkäreille mahdollisuuden vaihtaa ajatuksia ongelmatapauksista

Sarjamagneettistimulaatio kivun ja neurologisten sairauksien hoidossa

• Aivojen sarjamagneettistimulaatio (rTMS) on kajoamaton neuromodulaatiohoito, jolla ei ole turvasuosituksia noudatettaessa vakavia haittavaikutuksia.• Eurooppalaisessa näytönastekatsauksessa rTMS on arvioitu varmasti tehokkaaksi hermoperäiseen kipuun ja alle 6 kuukautta kestäneen aivohalvauksen kuntoutukseen (näytönaste A).• Sarjamagneettistimulaatio on todennäköisesti tehokasta Parkinsonin taudin liikehäiriöihin, MS-potilaiden alaraajojen spastisuuteen, tinnitukseen ja fibromyalgiaan.• Se saattaa olla tehokasta hoitoresistentin epilepsian, monimuotoisen alueellisen kiputilan (CRPS) ja neglect-oireiston hoidossa.</p

Sarjamagneettistimulaation mahdollisuudet psykiatriassa ja tulevaisuuden näkymät

Eurooppalaisessa näytönastekatsauksessa sarjamagneettistimulaatio (rTMS) on arvioitu varmasti tehokkaaksi masennuksen hoitomuodoksi (näytönaste A). Teho sijoittunee lääkehoidon ja sähköhoidon välille.rTMS on todennäköisesti tehokasta (näytönaste B) kaksisuuntaisen mielialahäiriön masennusjaksoissa, traumaperäisessä stressihäiriössä ja skitsofrenian negatiivissa oireissa.Menetelmän tekninen kehitys on nopeaa, ja lähitulevaisuudessa hoito todennäköisesti nopeutuu, tehostuu ja sen vaikuttavuus paranee edelleen.</p

Successful suppression of musical hallucinations with low-frequency rTMS of the left temporo-parietal junction: A case report

Background: Inhibitory low frequency repetitive transcranial magnetic stimulation (rTMS) of the temporo-parietal area has been applied to treat both auditory verbal hallucinations as well as tinnitus.Objective: We hypothesized that 1 Hz rTMS to the left temporoparietal junction (TPJ) may be beneficial in alleviating musical hallucinations (MH), another condition with auditory experiences in the absence of an external source.Methods: Here we describe a patient with almost insufferable life-long MH with comorbid depression, who received inhibitory rTMS to the left TPJ as well as the right dorsolateral prefrontal cortex (DLPFC).Results: The intrusiveness and frequency of her MH as well as her depressive symptoms alleviated quickly and substantially, and once-a-week maintenance therapy with rTMS seemed to preserve this amelioration. Future studies will hopefully reveal whether this is a viable treatment approach for other patients suffering from MH with or without comorbid depression.(c) 2021 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).</p

Aivojen tasavirtastimulaation teho masennuksen hoidossa

• Aivojen tasavirtastimulaatio (tDCS) on uusimpien meta-analyysien perusteella masennuksen hoidossa lumetta tehokkaampaa vaikutuksen koolla 0,3–0,7 (Hedgesin g). Teho lienee samaa luokkaa kuin ­lääkehoidon.• Tasavirtastimulaation tehoa masennuksessa, jossa on liitännäissairauksia, on tutkittu vähän. Aivohaverin jälkeiseen masennukseen se näyttää olevan lumetta tehokkaampi. On viitteitä siitä, että hoitotulos on parempi potilailla, joilla masennuksen yhteydessä esiintyy ahdistuneisuusoireita.• Tasavirtastimulaatio ei näytä soveltuvan hoitoresistentin masennuksen hoitoon.• Hoito voidaan toteuttaa potilaan kotona.</p

Bentsodiatsepiinien pitkäaikaiskäyttö on vähentynyt

VertaisarvioituLähtökohdat Rekisteritutkimuksessa selvitettiin bentsodiatsepiinien pitkäaikaiskäytön yleisyyttä lääkeaineittain, ikäryhmittäin ja sukupuolittain koko väestössä. Menetelmät Kelan reseptitiedostosta tarkasteltiin sairausvakuutuksesta korvattuja bentsodiatsepiinien lääkeostoja vuosina 2006–2014. Pitkäaikaiskäytöksi määriteltiin vähintään 180 vuorokausiannoksen lääkeosto kalenterivuoden aikana. Tulokset Bentsodiatsepiinien pitkäaikaiskäyttö väheni kaikissa ikäryhmissä merkittävästi. Eniten se väheni75 vuotta täyttäneillä, mutta silti heistä 9,7 % oli pitkäaikaiskäyttäjiä vuonna 2014. Unilääkkeiden pitkäaikaiskäyttö oli yleisintä vanhimmissa ikäryhmissä ja rauhoittavien lääkkeiden 50–64-vuotiailla. Tsopikloni oli käytetyin lääkeaine ja myös sen pitkäaikaiskäyttö oli yleisintä. Tsolpideemin pitkäaikaiskäyttö lisääntyi kaikissa ja klonatsepaamin muissa paitsi 75 vuotta täyttäneiden ikäryhmässä. Päätelmät Vaikka bentsodiatsepiinien pitkäaikaiskäyttö on kokonaisuutena vähentynyt, käytön pitkittymiseen tulee edelleen kiinnittää huomiota.Peer reviewe

The analgesic effect of therapeutic rTMS is not mediated or predicted by comorbid psychiatric or sleep disorders

Background: Mechanisms underlying alleviation of neuropathic pain by repetitive transcranial magnetic stimulation (rTMS) of primary motor cortex (M1) and right secondary somatosensory cortex (S2) are only partly known. Patients with chronic neuropathic pain often have comorbidities like depression and sleep problems. Through functional connectivity, rTMS of M1 and S2 may activate dorsolateral prefrontal cortex, the target for treating depression with rTMS. Thus, the analgesic effect of rTMS could be mediated indirectly via improvement of psychiatric comorbidities or sleep. We examined whether rTMS has an independent analgesic effect or whether its clinical benefits depend on effects on mood or sleep. We also evaluated if comorbid psychiatric or sleep disorders predict the treatment outcome. Methods: Sixteen patients with chronic drug-resistant neuropathic orofacial pain participated in this randomized controlled crossover rTMS study. Patients' psychiatric history was evaluated by a specialist in psychiatry. Intensity and interference of pain, mood, and the quality of sleep and life were evaluated at baseline and after 2 active (primary somatosensory cortex [S1]/M1 and S2) and placebo rTMS treatments. A logistic regression analysis was done to investigate predictors of treatment outcome. Results: The analgesic effect of the right S2 stimulation was not associated with improvement of psychiatric conditions or sleep, whereas S1 /M1 stimulation improved sleep without significant analgesic effect (P=0.013-0.0/16 in sleep scores). Psychiatric and sleep disorders were more common in patients than in the general population (P=0.000-0.001 in sleep scores), but these comorbidities did not predict the rTMS treatment outcome. Conclusion: We conclude that rTMS to the right S2 does not exert its beneficial analgesic effects in chronic neuropathic orofacial pain via indirect improvement of comorbid psychiatric or sleep disorders.Peer reviewe

Incidence of and Characteristics Associated With Long-term Benzodiazepine Use in Finland

Importance The proportion of patients who develop long-term benzodiazepine use remains controversial, as do the length of time before long-term use develops and the factors associated with long-term use. Objective To investigate the incidence of long-term benzodiazepine and related drug (BZDR) use and factors associated with the development of long-term use implementing a follow-up design with new BZDR users. Design, Setting, and Participants This population-based cohort study used a nationwide cohort of 129x202f;732 new BZDR users in Finland. New users of BZDRs aged 18 years or older were identified from the prescription register maintained by the Social Insurance Institution of Finland as individuals who initiated BZDR use during 2006 and had not used BZDRs from 2004 to 2005. The follow-up continued until death, long-term hospitalization, a gap of 2 years in BZDR use, or December 31, 2015. The population was analyzed according to age at treatment initiation, categorized into younger (= 65 years) subcohorts. Analyses were conducted from May 2019 to February 2020. Exposures Use of BZDRs, modeled from register-based data using the PRE2DUP (from prescriptions to drug use periods) method. Main Outcomes and Measures Long-term BZDR use, defined as continuous use of 180 days or longer, and factors associated with long-term vs short-term use, compared using Cox proportional hazards models. Results Among the 129 732 incident BZDR users, the mean (SD) age was 52.6 (17.7) years, and 78x202f;017 (60.1%) individuals were women. During the follow-up period, 51 099 BZDR users (39.4%) became long-term users. Long-term treatment was more common in the older subcohort (19 103 individuals [54.5%]) than the younger subcohort (31 996 individuals [33.8%]). At 6 months, 28 586 individuals (22.0%) had become long-term users: 11 805 (33.7%) in the older subcohort and 16 781 (17.7%) in the younger subcohort. The largest proportions of initiators who became long-term users were those persons who initiated treatment with nitrazepam (76.4%; 95% CI, 73.6%-79.1%), temazepam (63.9%; 95% CI, 62.9%-65.0%), lorazepam (62.4%; 95% CI, 59.7%-65.1%), or clonazepam (57.5%; 95% CI, 55.9%-59.2%). Factors associated with the development of long-term use included male sex, older age, receipt of social benefits, psychiatric comorbidities, and substance abuse. Conclusions and Relevance The findings of this population-based cohort study conducted in Finland suggest that the incidence of subsequent long-term BZDR use in individuals who initiate use of BZDRs is high, especially among older persons, and that the specific BZDR used initially is associated with the development of long-term BZDR use and should be carefully considered when prescribing BZDRs. The observed factors that appear to be associated with development of long-term BZDR use also should be considered in clinical decision-making when starting and monitoring BZDR treatment.</div

Neuronavigated Versus Non-navigated Repetitive Transcranial Magnetic Stimulation for Chronic Tinnitus: A Randomized Study

Repetitive transcranial magnetic stimulation (rTMS) has shown variable effect on tinnitus. A prospective, randomized 6-month follow-up study on parallel groups was conducted to compare the effects of neuronavigated rTMS to non-navigated rTMS in chronic tinnitus. Forty patients (20 men, 20 women), mean age of 52.9 years (standard deviation [SD] = 11.7), with a mean tinnitus duration of 5.8 years (SD = 3.2) and a mean tinnitus intensity of 62.2/100 (SD = 12.8) on Visual Analog Scale (VAS 0–100) participated. Patients received 10 sessions of 1-Hz rTMS to the left temporal area overlying auditory cortex with or without neuronavigation. The main outcome measures were VAS scores for tinnitus intensity, annoyance, and distress, and Tinnitus Handicap Inventory (THI) immediately and at 1, 3, and 6 months after treatment. The mean tinnitus intensity (hierarchical linear mixed model: F3 = 7.34, p = .0006), annoyance (F3 = 4.45, p = .0093), distress (F3 = 5.04, p = .0051), and THI scores (F4 = 17.30, p F3 = 2.96, p = .0451) favoring the non-navigated rTMS. Reduction in THI scores persisted for up to 6 months in both groups. Cohen’s d for tinnitus intensity ranged between 0.33 and 0.47 in navigated rTMS and between 0.55 and 1.07 in non-navigated rTMS. The responder rates for VAS or THI ranged between 35% and 85% with no differences between groups (p = .054–1.0). In conclusion, rTMS was effective for chronic tinnitus, but the method of coil localization was not a critical factor for the treatment outcome.</p