What is rTMS
“Brainsway Ltd. has reported results of the trial of its Deep TMS device in the treatment of manic depressive
patients at the Shalvata psychiatric hospital who did not respond to other treatments. …80% of the patients
responded to treatment, with more than 50% reporting a significant improvement.” (Globes Online, June 11/08)
“‘I’m excited because I think it’s a real major advance in our ability to treat depression,’ said Dr. Philip Janicak,
psychiatrist, Rush University Medical Center… After four to six weeks, those who received TMS were twice as
likely to report improvement in their mental state compared to those who had the sham procedure.”
(ABC 7 News, May 15/08)
“A British team is to test a home ‘brain stimulation’ method to short-circuit migraines before they become
disabling. Migraine pain is the most common neurological condition in the developed world. It affects over 15%
of the UK population… a team at Ohio State University showed that zapping the brain with a magnetic field,
using transcranial magnetic stimulation, TMS, can abort attacks as they start to develop.”
(Telegraph UK, May 16/08)
“‘rTMS is probably the most promising advance in neuro-psychiatry so far,’ says psychiatrist Sanjay
Chugh, who has recently brought the treatment to India… Neuropsychiatric illnesses are often associated with
changes in neurotransmitter and neuroendocrine systems, both of which rTMS can alter. The ability of rTMS
therapy to alter brain functioning provides a limitless potential to work as an effective therapy option for any
disorder involving dysfunctional behaviour in the neural circuits.”
(Times of India, June 15/08)
“Twelve patients with comorbid post traumatic stress disorder (PTSD) and major depression underwent repetitive Transcranial Magnetic Stimulation (rTMS) to left frontal cortex as an open-label adjunct to current antidepressant medications.Seventy-five percent of the patients had a clinically significant antidepressant response after rTMS, and 50% had sustained response at 2-month follow-up. Comparable improvements were seen in anxiety, hostility, and insomnia…”
[Rosenberg et al., 2001]
rTMS in AIIMS Hospital New Delhi
What is repetitive Transcranial Magnet-ic Stimulation?
Repetitive Transcranial Magnetic Stimulation (rTMS) is a procedure that uses a pulsed magnetic field to influence electrical activity in the brain. In this a brief current pulses is passed through a coil or wire that is shaped like a Figure 8 creates the magnetic field. To allow the magnetic field to focus on certain areas of the brain, the coil of wire is enclosed in plastic and held close to brain. This magnetic field is capable of penetrating the skull safely and painlessly to induce a current in certain brain cells. The stimulation is called repetitive because it is delivered of regular intervals.
In which countries is rTMS being used clinically?
rTMS was approved as a treatment for medication resistant depression is Canada in 2002. Since then, the treatment has been offered to patients of various other psychiatric and neurological disorders in USA, the FDA currently allows rTMS to be used off-label by doctors. In UK, the first clinical rTMS service was established in 2003 by the 5 Boroughs Partnership NHS Trust. It is widely used in private hospitals in Australia.
When was rTMS developed?
Repetitive Transcranial Magnetic Stimulation was designed in the mid 1980’s as a neurodiagnostic tool. It was also used to study nerve fibres and create a function map of the brain in clinical neurophysiology. Through technical developments in the devices used to administer the magnetic stimulation, it become possible to apply more and faster stimuli to specific areas of the brain. By the early 1990’s rTMS was beginning to be used to treat depression. Numeous clinical trials were conducted in the 199’s and research has been ongoing around the world for over ten years.
What illnesses has rTMS been successful in treating?
rTMS is currently being used as a potential treatment for many Psychiatric and Neurological disorders. The psychiatric indications include Depression, Schizophrenia, Monia, Posttraumotic Stress Disorder, Obsessive- compulsive Disorder, Phobias, Panic Disorder, attention Delicit Hyperoctivity Disorder (ADH), Eating disorder and Addictions. The neurological conditions where rTMS has proved to be useful one Stroke, Pakinson’s Disease, Migroine, Multiple Sclerosis, Autism, Epilepsy, Fibromyalgia and Chronic Paint.
Can rTMS help in Bipolar Disorder?
Yes rTMS is useful in trading the Monic plase in Bipolor Disorder, in addition to its antidepressant effects.
Is rTMS useful in Multiple Sclerosis? The use of rTMS in MS has been associated with decreased spasticity in the limbs, improved hand dexterity and empowerment in union not related problems.
Does rTMS have a role to play in Migraine?
Yes, it has been used for its role in preventing the Migraine attacks from locking place and can reduce the frequently and severely of the Migoine headache.
What are the results of rTMS in Schizo-phrenia?
Many patients with schizophrenia experience auditory hallucinations. Following rTMS, a majority of patients experience a significant reduction in these voices. Patients of chronic Schizophrenia often exhibit negative symptoms such as lack of motivation, lack of interest or pleasure, lack of energy, social withdrawal, decreased speech etc. Use of rTMS has enabled patients to experience a significant decrease in the severity of the negative symptoms.
Does rTMS help in OCD?
Yes. rTMS has been shown to not only bring about significant improvement in the Obsessive thoughts and compulsive urges but it also helps to improve the mood of the individual.
Can rTMS help in decreasing Anxiety?
Yes. Where anxiety is present as a part of a Depressive illness, the treatment for the depression will help to decrease t he symptoms of anxiety. However, rTMS will also teat Anxiety disorders such as Panic Disorder, Post Traumatic Stress Disorder and Phobias in addition to OCD (discussed above).
Can rTMS help in ADHD?
Yes. When used in the inhibitory mode, rTMS can bring down the Hyperactivity in a child who has ADHD. This could result in significantly low dose of medication being required to manage the problem in addition to improving the results with other interventions.
Does rTMS help with Tic Disorder or Tourette’s Disease?
Yes. There is a reduction in tics following a course of rTMS.
What about rTMS in Eating Disorders?
Studies have shown that rTMS can help some people with Eating Disorders such as Anorexia Nervosa and Bulimia Nervosa. We are recommending that a trial of rTMS should be given in these conditions.
Is there only role for rTMS in Addictions?
Craving is seen to go down following application of rTMS. So, it would be a worthwhile modality to try as a part of overall treatment for Chemical Dependence.
What is the role of rTMS in Parkinson’s disease?
Following a course of rTMS, there is a decrease in rigidity and slowing (Bradykinesia), improvement in the abnormal movements (Dyskinesias) and on improvement in walking as well. Improvement in speech is also noted.
Can rTMS help in recovery after a brain stroke?
Yes. A course of rTMS has been shown to improve spasticity, decrease weakness or paresis and induce movements in paralysed limbs. These improvements have been induced even several years after the Stroke happened.
Is rTMS useful in Autism?
After a course of rTMS, children with Autism showed fewer symptoms of hyperactivity, sensory overload and repetitive behaviours. The results show a great deal of promise in reducing the severity of the distressing symptoms of Autism and, as a result, helping in better communication and social interaction. The treatment does not adversely affect areas of “giftedness” in the treated children.
Is rTMS a guaranteed treatment for various disorders?
No, it is not. rTMS is a treatment option and like all other treatments for any other illness, it too has its limitation. It will not help every one who receives it. There will be some who benefit less than the others. But it is a very effective and extremely safe treatment alternative, both in treatment resistant cases and also as fist line treatment.
Why is rTMS used for depression?
Repetitive Transcranial Magnetic Stimulation can larget area of the brain that are believed to be target areas of depression. In addition, it has the potential to selectively modulate or change activity in the areas of the brain that affect depression and are involving with the determination of mood. One of the determining factors in depression is a decrease in the levels of activity in the prefrontal cortex (DLPFC) located just a few inches above the temple and beneath the skull is the area that is stimulated for treating depression. Repetitive Transcranial Magnetic Stimulation treats depression by inducing a current into the DLPFC with stimulation by a magnetic field. According to several studies, rTMS down regulates beta adrenoreceptors and increases the levels of dopamine and serotonin. Additionally rTMS can alter activity in other remote areas of the brain structure even through they are not directly accessible to the rTMS coil. A process of focal cortial stimulation does this, and some of these remote brain structures and also believe to be linked to depression.
Have Tinnitus which has not responded to any treatment. Will rTMS help?
Yes. Low frequency rTMS over the hyperactive auditory cortex has repeatedly been shown to reduce the sensation of ringing in the ears.
What is the role of rTMS in Fibromyalgia & management?
Patients report a measurable reduction in pain after rTMS. It has a selective effect by increasing pain tolerance and altering pain processing, thereby providing long lasting pain relief.
Can rTMS help is Lazy Eye (Ambklyopia)?
Yes. Amblyopia is the most prevalent cause of visual impairment in a single eye, affecting millions of people in India. If not detected early enough – before seven to twelve years of age – the condition has been considered untreatable. Recent studies show that rTMS therapy improved contrast sensitivity in patients’ amblyopic eyes.
Is rTMS safe? What problems do patients commonly report?
Yes. rTMS is a very safe treatment modality. It is generally considered to be free from side effects when proper procedures are followed. Over the years since its introduction, safety guidelines have been developed which minimize risks. The main complaint from a small percentage of patients is discomfort in the scalp or a headache during and immediately following the stimulation session. This can be prevented or treated with usual pain medications such as aspirin or ibuprofen.
Are any investigations required before treatment commences or during the course of treatment?
Before treatment starts, on MRI on the head is advisable. This helps in an accurate determinatikon of different sites of stimulation during the course of treatment. The MRI has to be done at a centre recommended by us so that correct location of areas of the brain can be done.
How long is the course of treatment?
20 to 30 sessions, each lasting 20 to 30 minutes, are required. These are done at a frequency of either once or twice a day. When 2 sessions are done in a day, there is a gap of 45 to 60 minutes between sessions.
How soon does rTMS start to work?
Typically, results are achieved within one or two weeks of beginning treatment.
What about long term of maintenance therapy?
All chronic illness may need maintenance therapy. Usually, this would be done with medication. However, in certain cases, it may be advisable or even desirable to have follow up rTMS sessions 6 to 12 months after the initial phase of treatment is over. This can be discussed with your treating doctor.
Can rTMS be used for other illnesses?
According to current research, rTMS has a valuable therapeutic potential to treat other illnesses and disorders other than depression. Because of its capacity to selectively increase or decrease the excitability of neurons in certain areas of the brain, it mail hold promise in the treatment of other illnesses. Recent studies have shown that rTMS shows promise in the treatment of Parkinson’s disease, Schizophrenia, Bipolar Disorders and some other mood disorders. Further research is still being conducted to determine the overall effectiveness in treating these conditions. Only the future will show how far and to what degree rTMS will be beneficial in treating other mood-altering disorders, but for now, we can only accept that research and case studies are still in the process.