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

July 25, 2023 updated by: Dr. Cheng Pak Wing, Calvin, The University of Hong Kong

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

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.

Study Overview

Status

Recruiting

Conditions

Intervention / Treatment

Detailed 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.

Study Type

Interventional

Enrollment (Estimated)

22

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

  • Name: Calvin PW Cheng, MBBS (HKU)
  • Phone Number: +852-22554486
  • Email: chengpsy@hku.hk

Study Contact Backup

Study Locations

  • Hong Kong
      • Hong Kong, Hong Kong
        • Recruiting
        • The Hong Kong Jockey Club Building for Interdisciplinary Research

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

58 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Description

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

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Non-Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: Treatment Group
A total of 32 sessions (2 sets of 16 sessions) of TPS will be delivered, each lasting 30 minutes. Each set includes 3 sessions per week in the first 2 weeks and then 1 session per week in the subsequent 10 weeks.
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).
Placebo Comparator: Control Group
The control group will be recruited with the same recruitment criteria. They would receive treatment-as-usual (TAU) in the outpatient clinic without TPS intervention given.
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.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in Global Cognition
Time Frame: Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
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 Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in Memory
Time Frame: Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
Measured by Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) - Chinese version
Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
Change in Executive Function
Time Frame: Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
Measured by Stroop test.
Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
Change in Attention/Working Memory
Time Frame: Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
Measured by Trail Making Test Parts A and B
Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
Change in Brain Structure
Time Frame: Baseline, 12-week Follow-up
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
Change in Daily Functioning
Time Frame: Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
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
Change in Mood
Time Frame: Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up
Measured by the Depression Rating Scale (HAMD-17)
Baseline, at 12 weeks, at 24 weeks, 12-week Follow-up

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

The University of Hong Kong

Collaborators

Storz Medical AG

Investigators

  • Principal Investigator: Calvin PW Cheng, MBBS (HKU), The University of Hong Kong

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Helpful Links

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

November 25, 2022

Primary Completion (Estimated)

August 1, 2024

Study Completion (Estimated)

August 1, 2024

Study Registration Dates

First Submitted

October 24, 2022

First Submitted That Met QC Criteria

November 1, 2022

First Posted (Actual)

November 2, 2022

Study Record Updates

Last Update Posted (Actual)

July 27, 2023

Last Update Submitted That Met QC Criteria

July 25, 2023

Last Verified

July 1, 2023

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • UW22-642

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

IPD Plan Description

Since the study involves sensitive and private medical history from recruited or self-enrolled subjects, individual data will not be available to other researchers.

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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