Enhancing the Attention Domain in Neurological Rehabilitation with a Novel Combination Therapy in a Patient with Mild TBI: Pairing iTBS/rTMS with Cognitive Training - A Case Review

Case Diagnosis: The patient is a 37-year-old female with two mild traumatic brain injuries (TBIs), post-traumatic stress disorder, generalized anxiety disorder, and borderline personality disorder who underwent neuromodulation therapy plus attention processing training (APT) and demonstrated improvement in her composite attention scores.

Case Description or Program Description: The patient participated in an ongoing multi-site partially-blinded sham-controlled clinical trial evaluating neuromodulation using repetitive transcranial magnetic stimulation (rTMS) plus cognitive training in patients suffering mild TBI. A type of rTMS, intermittent theta-burst stimulation (iTBS), was utilized. Compared to traditional rTMS, iTBS uses higher frequencies, patterned pulses, and aperiodic pauses, known to increase neuronal excitability. Of note, iTBS targets a personalized location within the attention system, the functional intersection within the right dorsolateral prefrontal cortex. Specifically, this neurological rehabilitation therapy combined iTBS with APT, a cognitively-based intervention.

The study divided participants into three groups based on neuromodulation combined with cognitive training: iTBS+APT, iTBS with sham training, and sham iTBS with sham training. The patient was initially randomized to sham+sham, but then elected for iTBS+APT therapy after completing the sham branch. To measure cognitive effects of intervention, baseline, midpoint, endpoint, and follow-up cognitive composite testing scores included the WAIS-IV Digit Span and Conners Performance Test.

Setting: Clinical research lab at a quaternary care hospital.

Assessment/Results: At four-week follow up after sham intervention, her composite attention standard score increased by 7 points reflecting a placebo or practice effect. After iTBS+APT, however, her composite attention standard score at follow up increased again, but by 12 points.

Discussion (relevance): Given the patient’s placebo gains in attention with borderline personality disorder relative to almost twice the attention gains after iTBS+APT, in absence of meaningful changes in executive function and processing speed, the results suggest improvement in attention skills targeted for remediation.

Conclusions: Combining iTBS neuromodulation with APT demonstrates promise in improving persisting attention challenges experienced by persons with mild TBI.