Transcranial Magnetic Stimulation (TMS)

What is Transcranial Magnetic Stimulation?

Transcranial Magnetic Stimulation (TMS) therapy is a system that creates a magnetic field and activates the brain’s natural electricity without direct electricity to the brain. This article contains many details and process of TMS.

Memory Center, Repetitive Transcranial Magnetic Stimulation (RTM is – repetitive Transcranial Magnetic Stimulation) Therapy, the purpose implements one of the first psychiatric health institutions in Turkey. Repetitive Transcranial Magnetic Stimulation (rTMS – repetitive Transcranial Magnetic Stimulation) Therapy is still successfully applied in our hospitals and polyclinics with the experience we have gained from the past. Our hospital is considered as a reference in this field as one of the first institutions to apply TMS treatment.

Technological advances in the last 15 years have led to the development of some devices for measuring and modifying cellular electrical current in the brain. One of these devices is the TRANSCRANIAL MAGNETIC EXCITATION (TME) system.

Details About Transcranial Magnetic Stimulation

In Transcranial Magnetic Stimulation application, brain activity is changed by creating a strong but short magnetic field from the outside and the treatment effect occurs. Transcranial magnetic stimulation (TMS) is a noninvasive method that stimulates neurons in the brain. Through rapidly changing magnetic fields (electromagnetic induction), weak electric currents induced in tissues lead to excitation. In this way, brain activity can be triggered or modulated without the need for surgery or external electrodes. TMS method, which maps the functioning of the brain, is a powerful tool for diagnosis and research in orology.

Repetitive, transcranial magnetic stimulation (rTMS) shows promise in the treatment of a number of disorders such as depression and anxiety disorder. As a result, it is a good alternative to ECT with its current situation.

In which diseases is Transcranial Magnetic Stimulation effective?

Transcranial Magnetic Stimulation is not recommended as a first-line treatment. The application of Transcranial Magnetic Stimulation (TMS) is recommended as an option in the treatment of depression that has not responded to a drug application in the 2010 ‘guideline’ approved by the FDA in 2008 and published by the APA. Typically, it is used only in patients with depression who did not improve with standard therapies, or in patients who may consider electroconvulsive therapy but want to try another alternative. Patients with prolonged depression or those who do not improve with standard treatments may be candidates for this procedure. rTMS is an important option in treatment-resistant psychiatric cases. For patients who do not achieve sufficient improvement with standard treatments; It deserves attention as a promising treatment for negatively manifested schizophrenia, hallucinatory conditions, addiction, OCD and other refractory psychiatric disorders. The important thing is that by listening to the voice of the clinician in the physician, the patient can make a decision to move one more step towards remission.

Responsibility for treatment is not only about the treatments given, it also covers the potential treatments available as options. On the other hand, determining the rtms protocol and considering the security screen are important issues that the physician should pay attention to. In the 2010 ‘guideline’ approved by the FDA in 2008 and published by the APA, TMS application is recommended as an option in the treatment of depression that has not responded to a drug administration. Typically, it is used only in patients with depression who did not improve with standard therapies, or in patients who may consider electroconvulsive therapy but want to try another alternative.

Transcranial Magnetic Stimulation can also be used in cases where drug use is restricted, for example; It can be used easily in pregnancy, breastfeeding mothers and heart patients and in this respect, it provides great convenience to the patient and the physician.

What is Deep Transcranial Magnetic Stimulation?

Source: @russ_nikov

Deep Transcranial Magnetic Stimulation: It is the TMS application that can affect the deep structures of the brain. Thanks to the features of the head used, stimulation can be given to different brain regions in different diseases. There are studies showing that it is effective in Obsessive-Compulsive Disorder, Adult Attention Deficit Hyperactivity Disorder, and some other psychiatric diseases, and its use is increasingly common.

In which situations is Deep Transcranial Magnetic Stimulation applied?

The use of Deep Transcranial Magnetic Stimulation application in Depression and Bipolar disorder is FDA and CE approved, and it is widely used in the treatment of depression in America, Canada, Australia, Germany, Belgium, Italy and other European and South American countries.

Deep Transcranial Magnetic Stimulation application also;

  • Alcohol use disorder
  • Alzheimer’s Disease
  • Cocaine addiction
  • Multiple sclerosis-relieving fatigue,
  • Neuropathic pain,
  • Obsessive compulsive disorder,
  • Increasing autism-communication skills,
  • Parkinson’s disease,
  • Smoking addiction
  • CE approval is also available for resistant neuro / psychiatric disorders such as schizophrenia-negative symptoms, and the results of clinical studies are positive, and its use in treatment is increasing.

What is neuronavigation Transcranial Magnetic Stimulation?

Neuronavigation is an application that enables the treatment to be applied exactly to the desired point in the brain and thus increases the effectiveness of the treatment.

  •  Brain MRIs of the patients are taken first and the images taken are transferred to the na¬vigation device.
  • • The point in the patient’s brain to be treated is determined by a specialist.
  • • The neuronavigation device ensures that brain stimulation (transcranial magne¬tic stimulation) is given to this exact point.
  • • There is a neuronavigation device in our institution.

Does Transcranial Magnetic Stimulation / rTMS have an effect on the brain?

With TMS, the electrical conduction of the cells in the brain is intervened. Considering that the brain works with electrical and chemical messages, this intervention has the effect of activating the natural processes of the brain that are not functioning adequately. The treatment effect is created by creating a strong but short magnetic field, without giving any electrical current from outside. Thus, a change called “neuronal depolarization” occurs in the targeted area of ​​the brain.

What is the difference between Transcranial Magnetic Stimulation / rTMS and Electroconvulsive therapy (ECT)?

ECT is applied by direct electrical current to the brain. It should be done in a hospital environment and under general anesthesia. TMS treatment can be applied on an outpatient basis and does not require anesthesia or analgesic. In most cases, the patient does not feel any negative effects other than a mild headache and a slight discomfort at the stimulation site.

How long is the Transcranial Magnetic Stimulation / Rtms session?

Session duration is determined according to the individual needs of the patient. Thermal application of the specified frequency and intensity is performed for 5 to 30 minutes.

In which diseases is Transcranial Magnetic Stimulation / rTMS effective?

Currently primarily recommended treatment areas; Treatment Resistant Depression, Schizophrenia and Obsessive Compulsive Disorder and Schizophrenia are mental disorders. It is noted that it can be used in pregnancy, breastfeeding mothers and cardiac patients and has superiority over drug therapy. (Arch. Gec – Psychiatry. 1999; 56: 300-311)

In which situations is Transcranial Magnetic Stimulation used in neurology?

It is currently used for experimental purposes in speech disorders, epilepsy, Parkinson’s and some strokes. Research is ongoing.

How is Transcranial Magnetic Stimulation / rTMS used in children?

Scientific studies on use in autism and hyperactivity are ongoing.

How is Transcranial Magnetic Stimulation / rTMS applied?

After psychiatric evaluation and then imaging of the brain with functional MRI or Quantitative EEG, it is recommended to determine the appropriate area according to the diagnosis considered and apply it to that region. In depression, a coil is usually placed in the left anterior forehead area. Rhythmic warnings are given. It is applied in sessions of 10 to 30 minutes, not less than 20 sessions. There is no need for any preliminary preparation other than clean hair.

What are the benefits of (TMS / rTMS)?

• Based on highly effective clinical research results, the success rate of tTMS treatment is higher than pharmacotherapy and less than electro convulsive therapy.

• It has few or no side effects. The most severe side effect is a mild headache.

• Quick onset therapeutic effect (typically within 1 week).

• There is no direct intervention on the body. So it does not require an invasive procedure.

• It does not require anesthesia.

• The patient is treated on an outpatient basis.

• It has superior targeting power for specific neuron circuits.

• It only requires 2 to 4 weeks of treatment.

• Provides therapeutic benefit for people resistant to treatment.

• Patients do not need to stop using medication for rtms application.

• A reduction in depression symptoms is typically achieved for those who do not respond to treatment.

• Equally effective in treating patients with major depressive disorder and bipolar disorder.

• Treatment parameters are determined individually for each patient.

• Protocols are based on the specific diagnosis of each individual patient and allow the most effective course of treatment.

• Patients are informed of the progress made on the depression and anxiety rating scales throughout the treatment course.

• The treatment parameters applied in our hospital and the results obtained from all rtms procedures were followed using a specially developed software program. This allows the medical staff to track each patient’s progress in treatment and provide feedback on results on an individual basis.

           • As with an effective treatment modality, the degree of improvement varies from person to                person. Pre-procedure initial consultation with a medical doctor at our hospital helps determine the possible outcome range based on the individual’s depression intensity, medical history, and expectations.

When does Transcranial Magnetic Stimulation treatment respond?

  • Typically, improvement is seen within one to two weeks of starting treatment.
    • Most patients tend to notice therapeutic benefit within the second week of treatment.
    • Late responders may need additional sessions on the third week to achieve significant reductions in depression symptoms.
    • On average, patients enter maintenance therapy after about 8-12 months. This time frame varies for each patient.
    • On average, maintenance therapy involves half the number of rtms sessions completed initially.
    • We strongly request that patients who feel their depression symptoms recur should contact us immediately. You will be contacted as soon as possible.

What are the immediate and short-term risks of TMS?

Seizures

The primary safety problem experienced in TMS is the risk of causing a seizure. Although this risk is primarily associated with rtms, single-pulse stimulation has been reported to cause seizures in patients with large cerebral infarctions, contusions, or other structural brain lesions. It can be said that the occurrence of seizure activity is highly improbable if the conditions are in accordance with established safety guidelines (Wassermann 1998).

Cardiovascular effects

No significant changes in blood pressure and heart rate were reported during and after rtms administration (Foerster et al. 1997).

Auditory function

In a study involving 12 depressed subjects who received tTMS for four weeks, no significant change in hearing threshold was observed for four weeks after the study (Loo et al. 2001).

Headache

TMS application can cause local pain caused by direct stimulation of the muscles under the coil and the stimulation of the nerves in the face and scalp. The procedure is usually more painful with higher intensity and frequency. Approximately 5% to 20% of subjects experience tension headaches after rTMS sessions (George et al. 1999).

What are the side effects of TMU / tTMS (TMS / rTMS)

Compared with other brain stimulation methods, it can be considered that rTMS is relatively safe because it is non-invasive. Major problems; Involuntary induced seizures are local pain during the application, changes in auditory performance due to the noise generated by the coil due to the passage of electrical current, ligament pain, and potential changes in cognitive function.

Most of these side effects are sudden and short-lived. Results of animal studies did not reveal any long-term neuron damage findings attributable to tTMS. In a safety study, it was revealed that rTMS has no significant effect on sleep EEG in therapeutic parameters (Graf et al. 2001).

Can TMS be used in the treatment of depression in the elderly?

Late-life depression is an important issue in treatment resistance. Treatment-refractory depression is more common in the elderly, and combination or augmentation treatments carry greater risks of drug interactions. There are a limited number of TMS studies in this patient group. In the only study conducted on the use of TMS in the treatment of depression in the elderly in our country, an average of 18 sessions of TMS in the left DLPFC area was administered simultaneously with antidepressant therapy in 65 elderly patients with treatment-resistant depression with an average age of 66.6. As a result of the treatment, 38 of 65 patients had partial recovery and 19 had full recovery. In this study, no cases with worsening depression symptoms were found, and no serious side effects or cognitive worsening were reported. (Hız Sayar et al. 2013).

rTMS Procedure Description

  • • rTMS treatment is applied to brain regions that are thought to be affected by depression and other mood disorders.
  • • Thanks to rTMS, it is possible to selectively modulate or change the activity in some parts of the brain.
  • RTMS produces a number of positive effects on the brain that have been shown to be effective in the treatment of various conditions and diseases as well as depression (e.g. stimulant or suppressive effects).
  • • The treatment affects the electrical activity in the brain through the pulsed magnetic field. A magnetic field is created by giving short pulses of current through an eight-shaped metal coil, (see picture below) • The metal coil covered with plastic is kept close to the scalp so that the magnetic field is focused on specific areas of the cortex or brain surface.
  • • The magnetic field generated in rTMS penetrates the skull and scalp painlessly and safely and induces a current in specific neurons (brain cells).
  • • Because magnetic stimulation is transmitted at regular intervals, it is called repeating TMS or rTMS.
  • • Stimulation parameters, such as the number of alerts, alert strength and duration, and the length of the alert interval, can vary completely. Its ability to change parameters while directly targeting specific brain cells suggests that rTMS has a very valuable therapeutic potential. It is also possible to adapt the treatment to the needs of each patient.
  • • The validity of rTMS treatment has been tested in multiple ways in clinical trials and medical research studies. It has been approved for use in Canada since 2002.
  • • In peer-reviewed articles in various medical journals, it has been stated that rTMS treatment shows promise in the treatment of Parkinson’s disease, Auditory Hallucination, Schizophrenia, Obsessive Compulsive Disorder, Tinnitus, Eating Disorders, Migraine-type headaches, Pain Management and other mood disorders.
  • • In peer-reviewed articles in various medical journals, it has been stated that rTMS treatment shows promise in the treatment of Parkinson’s disease, Auditory Hallucination, Schizophrenia, Obsessive Compulsive Disorder, Tinnitus, Eating Disorders, Migraine-type headaches, Pain Management and other mood disorders.

Response rate of patients receiving rTMS therapy (CANADA Mind Care Centers table)

 • MindCare Centers applied rTMS therapy to more than 300 patients on a clinical basis.

• Clinical data revealed that more than two-thirds of the patients responded significantly to rTMS treatment.

Typically, a reduction of at least 75% in the depression symptoms of “responders” was achieved.

• Response statistics of MindCare Centers

• Those who did not respond 32.6%

• 62.4% of respondents

• Unknown 5.1%

•Determined through the Beck Depression Inventory, Hamilton-7 Index, Hamilton-Anxiety Scale, and Patient Feedback.  

Benefit Period

• Typically, improvement is seen within one to two weeks of starting treatment.

• Most patients tend to notice therapeutic benefit within the second week of treatment.

• Late responders may need additional sessions on the third week to achieve significant reductions in depression symptoms.

• On average, patients enter maintenance therapy after about 8-12 months. This time frame varies for each patient.

• On average, maintenance therapy involves half the number of rTMS sessions completed initially.

We ask patients who feel their depression symptoms recur to contact us immediately. NPİSTANBUL employees will make the necessary effort to get an appointment as soon as possible.

In NPİSTANBUL Brain Hospital, this treatment has been considered to be applied to people with the following disease states in treatment-resistant cases.

NOTE: It can be used as the first choice in patients who are not resistant to treatment in CANADA. However, in NPISTANBUL, rTMS treatment is applied with approval in cases resistant to other treatments.

Last Updated on December 24, 2020 by Lucas Berg

William Lindberg
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