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About Brain Stimulation


What is TMS and rTMS?

TMS stands for transcranial magnetic stimulation. It is a technique where magnetic pulses are emitted and can pass noninvasively and nearly painlessly through the scalp and into the cortex. There the magnetic pulses induce an electric field, which in turn can influence neural activity. Strictly speaking, the name TMS is used for single pulse applications, for instance in the diagnosis of nerve damage.

rTMS stands for repetitive transcranial magnetic stimulation, and describes a technique where magnetic pulses are emitted at a high rate (e.g. 5, 10 or 20 pulses per second). Repeating rTMS session over several days has shown to have an effect on neural plasticity, allowing the user to either inhibit or facilitate specific brain regions. This technique can be used in therapies for the treatment of depression, tinnitus or schizophrenia, among others. 

When is rTMS applied? And what are the advantages of rTMS compared to conventional drug treatments?

Conventional drug treatments are and until rTMS has been studied more sufficiently probably should stay the state-of-the-art for the initial treatment. rTMS is currently applied as an alternative form of therapy after one or two therapies with psychotropic drugs have proven unsuccessful. Additionally rTMS can be administered together with conventional drugs in a combinatorial  therapy. Depending on specific cases rTMS might also be reasonable as a primary treatment option, for instance when patients cannot or will not tolerate drugs.

rTMS has several distinct advantages compared to psychotropic drugs. Mainly, the side effects are fewer, of which psychotropic drugs can have a very large range. Additionally, rTMS is noninvasive and nearly painless, so that is very tolerable.


Are TMS and rTMS safe? What about the risk of seizures?

TMS and rTMS can have several side effects, the most common of which are temporary mild headaches and temporary discomfort during or after treatment sessions. The risk of evoking a seizure is extremely low if certain safety guidelines are abided. Rossi et al. published a well-known and worth reading study on the safety and application guidelines for TMS and rTMS (Rossi et al, Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research). The study sets safety guidelines for stimulation parameters, e.g. how long stimulation trains can be at certain intensities so that they may be considered save. The probability of evoking a seizure within these safety limits is extremely low. Still, patients with a family history of epilepsy, patients taking pro-epileptogenic medications or patients with lesions near stimulated brain areas must be treated under increased observation (or possibly emitted from TMS / rTMS therapy).


What is a 3D neuronavigation and when is it used?

Neuronavigation allows the user to see exactly where he is stimulating on a 3D reconstruction of his patient’s brain. The software takes slices from MRT or fMRT scans and reconstructs them into a three dimensional model. Additionally, a camera system tracks both the position of the patient’s head as well as the coil, which emits the magnetic pulses. Now a user can see live on screen where the focal point of the coil is while traveling across the patient’s skull. The user can either aim for functionally or anatomically defined regions, but also set his own navigation points, hence guaranteeing reproducibility, as previously saved navigation points can be reloaded in later sessions. This way a user can ensure that he is always stimulating the exact same spot, for instance Brocca’s speech area during an Aphasia treatment.


Who may administer TMS and rTMS?

Theoretically any trained medical staff person may apply TMS and rTMS. This includes doctors, MTAs or nurses. It is important that they are sufficiently trained in the field of TMS in general and fully understand how to handle the stimulator and coil. Additionally, a doctor must be available within a range where he can quickly be present in case of an emergency.


Which psychiatric and neurological disorders can be treated with rTMS?

A very wide range of disorders can be treated with rTMS. Some applications have been studied to a point where they are proven to be sufficiently safe and efficacious and have been recommended by responsible entities (such as the FDA), while others are still being studied towards improving stimulation parameters and hence efficacy.

Lefaucheur et al published an excellent summary with guidelines as to which disorders may treated with TMS (Lefaucher et al, Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). ), classifying recommendations on rTMS efficacy into Levels A (Definite Effect), B (Probable Effect) and C (Possible Effect).

The following presents an excerpt on some of the recommendations from this study (exact treatment parameters for each disorder are emitted):

Level A: Depression ; Neuropathic pain; …

Level B: Motor Stroke; Negative symptom of schizophrenia; …

Level C: Tinnitus; Anxiety disorders; Parkinson’s disease; …





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