TMS & rTMS
Repetitive Transcranial Magnetic Stimulation
Transcranial Magnetic Stimulation (TMS) is a non-invasive neurophysiological technique that uses electromagnetic fields to induce a current capable of altering brain activity. This technique belongs to the new treatment methods of neuromodulation or neurostimulation. It is currently applied in the treatment of depression, anxiety, attention-deficit disorder, autism, asperger, addictions, stroke and other neuropsychiatric disorders that acts by directly stimulating the brain.
When does Transcranial Magnetic Stimulation start?
TMS was introduced in 1985 by Barker as a neurological technique to non-invasively induce motor movements by means of magnetic stimulation of the cerebral motor cortex, measuring its connectivity and excitability. It is based on the principle of mutual induction (stated by Michael Faraday in 1831), according to which electrical energy can be converted into magnetic fields, and magnetic fields can be transformed into electrical energy.
How does Transcranial Magnetic Stimulation (rTMS) work?
rTMS activates certain parts of the brain by using electromagnetic energy passed through a coil-shaped paddle to create a powerful magnetic field. This energy is transferred to the brain during a treatment session. Magnetic energy easily passes through the skin and skull, brain activation is; without pain and without the need for surgery or sedation. TMS is applied to areas of the brain associated with mood regulation, such as the prefrontal cortex by acting on altered brain functions and neurochemical activity.
The diagnoses that rTMS is being used today are:
Major depression, bipolar depressive disorder, obsessive-compulsive disorder, autism, multiple sclerosis, Parkinson's disease, Alzheimer's, post-traumatic disorder, schizophrenia, psychosis, chronic pain, migraine, stroke, cerebral palsy, substance abuse, and anxiety.
Repetitive Transcranial Magnetic Stimulation (rTMS) is a non-invasive technique approved by the Food Drug Administration (FDA) since 2008. It is one of the new neuromodulation or neurostimulation techniques for the treatment of neuropsychiatric disorders such as:
Post-traumatic stress disorder
Schizophrenia with negative symptoms and schizophrenia with hallucinations
Attention deficit disorder
Other neuropsychiatric disorders that works by directly stimulating the brain.
When is repetitive Transcranial Magnetic Stimulation (TMS) (rTMS) used?
TMS uses magnetic stimulators with multiple capacitors, which generate very fast pulses of up to 60 Hz. There are two types: simple TMS and repetitive TMS (rTMS) depending on whether single stimuli or regularly repeated stimuli are applied to the same area of the cerebral cortex, respectively. In cases where pharmacological treatments or therapies do not work, rTMS (r=repetitive) is used, even to increase the effectiveness of medications. Patients who cannot tolerate the drugs are likely candidates. There are disorders, that drugs are the first-line treatments and rTMS serves as support. In other words, rTMS can be part of a combined treatment with medications or in some cases it can be used as monotherapy.
For example, in Autism Spectrum Disorder and Asperger's it is considered a first-line therapy. In another example of resistant depression, rTMS can be combined with psychoactive drugs.
What does a repetitive Transcranial Magnetic Stimulation procedure consist of?
In each rTMS session, you will sit in a specially designed, reclining treatment chair. You will be fully awake and alert and able to talk and relax during treatment.
Repetitive Transcranial Magnetic Stimulation (rTMS) uses magnetic pulses, before starting a treatment, you are asked to remove any sensitive magnetic objects (such as jewelry, earrings, credit cards, cell phones, glasses). A cap and earplugs are fitted for your comfort and hearing protection as the rTMS produces a clicking noise with each pulse, much like an MRI machine. Music may be played during treatment to minimize the sound of the equipment. During the first rTMS session, several measurements are taken to ensure that the TMS coil, ie the paddle, is positioned correctly on the patient's head. This consists in that the magnetic coil rests on the appropriate area of the scalp and thus the adjustments (dose parameters) are determined before starting the session. Once this is done, the TMS coil is suspended over the patient's scalp.
The physician or technician then measures the patient's motor threshold by administering several short pulses. This motor threshold is the minimum amount of energy required to cause the patient's thumb to contract slightly, and this varies from individual to individual. Motor threshold measurement helps the psychiatrist customize treatment settings and determines the amount of energy needed to stimulate brain regions.
Once the motor threshold is determined, the coil is then brought forward so that it rests on top of the frontal region of the patient's brain. Treatment starts next.
During treatment, you may hear a series of clicks and feel a tapping sensation under the treatment coil. Subsequent treatment sessions do not require the motor threshold to be determined again, unless otherwise indicated, for example, when medication changes are made during the course of treatment.
Do I have to be hospitalized for a repetitive Transcranial Magnetic Stimulation treatment?
Repetitive Transcranial Magnetic Stimulation (rTMS) does not require sedation or anesthesia. Patients are fully awake and conscious during treatment. There is no “recovery time”, so patients can go home immediately and even return to their usual activities.
Who prescribes and administers repetitive Transcranial Magnetic Stimulation (rTMS)?
Repetitive Transcranial Magnetic Stimulation (rTMS) is always prescribed by a psychiatrist or a neurologist after evaluating the patient and determining if it is a patient with the appropriate diagnosis to receive rTMS therapy, in addition to the care and follow-up of the disease.
How long does a repetitive Transcranial Magnetic Stimulation (rTMS) procedure take?
Repetitive Transcranial Magnetic Stimulation (rTMS) therapy involves a series of treatment sessions. Treatment sessions are approximately 30 – 60 minutes each, and are administered 5 days a week for a period of 2-4 weeks depending on each patient. The most widely used protocol is theta burst stimulation, composed of series of high-frequency impulses (three pulses at 50Hz) repeated at 200-millisecond intervals (5Hz in the theta rhythm of the electroencephalogram [EEG]), which can be applied in continuous trains (uninterrupted theta burst pulses in a short time) or intermittent (2s theta burst trains repeated every 10s). Being the duration of 3 to 6 minutes with this wave.
However, this may vary depending on the response to treatment. Often there is no noticeable change in psychiatric symptoms during the first few sessions.
Does Transcranial Magnetic Stimulation disrupt other areas of brain function or change my personality?
No. One of the benefits of TMS, in relation to other treatments, is the precision that is achieved, allowing the stimulus to be directed to very specific parts of the brain.
Transcranial Magnetic Stimulation does not lead to memory problems or other disturbances in thinking. It does not change a person's personality, however, when patients experience relief from the symptoms of depression and other psychiatric manifestations, their ability to think and function normally improves, impacting on the improvement of the quality of life of the patient and their family members.
It has been observed that patients report an improvement in their cognitive area, improving memory.
In some cases of severe neuropsychiatric symptoms (schizophrenia, bipolar disorder) there may be a "rebound" of symptoms in the first few weeks, before improvement is evident. Especially on the fourth day of application, which is corrected by adjusting the medications.
What are the side effects of repetitive Transcranial Magnetic Stimulation?
Repetitive Transcranial Magnetic Stimulation (rTMS) is well tolerated. The most common side effect is headache. These are mild and usually subside with the course of treatment. Regular pain relievers can be used, either before or after TMS sessions to treat these headaches.
Approximately one third of patients may experience a tapping sensation on the scalp which tends to decrease over the course of treatment. The most serious risk of rTMS) is seizures. However, the risk is very low.
Who can not receive therapy with Transcranial Magnetic Stimulation?
Patients with any type of non-removable metal in the head (with the exception of braces or dental fillings). Failure to follow this rule may cause the object to heat up, move, and malfunction causing serious injury.
The following list are metallic implants that may prevent a patient from receiving repetitive Transcranial Magnetic Stimulation (rTMS):
• Aneurysm clips at brain level.
• Stents in the neck or in the brain.
• Stimulators implanted at the brain level such as those used in Parkinson's disease.
• Cardiac pacemakers or implantable cardioverting defibrillators.
• Electrodes to monitor brain activity.
• Metallic implants in ears and eyes.
• Bullet fragments in or near the head.
• Facial tattoos with metal objects or objects sensitive to magnetism.
• Other metallic devices or objects implanted in or near the head.
Who will benefit most from repetitive Transcranial Magnetic Stimulation (rTMS) therapy?
There is scientific evidence that rTMS is useful in a wide variety of neuropsychiatric and neurodevelopmental conditions.
Dr. Rose Nina, Ph.D.
Dr. Rose Nina, Ph.D., a psychiatrist, psychogeriatrist with a doctorate in neurosciences of Puerto Rican origin, decided to start this type of Repetitive Transcranial Magnetic Stimulation treatment in her private practice, for the care of a number of psychiatric disorders and neurological. This treatment has been available since November 20, 2018, here in Santo Domingo, Dominican Republic. Dr. Nina expresses the following: "I have always been concerned about maintaining a high scientific level, which is why I have decided to study and train myself more and more and my last training has been with this new therapeutic modality in psychiatry, to assist my patients. It is very important to remember that both psychiatric and neurological patients need quality of life and this is a new therapeutic option that could reduce the use of drugs or a speedy recovery without drugs."