Transcranial magnetic stimulation

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Depiction of how the magnetic field from the coil creates the electric current in the brain.

List of Transcranial magnetic stimulation devices:

Transcranial magnetic stimulation, or TMS, is a non-invasive method of brain stimulation. During the procedure, a magnetic coil is placed over the scalp of the person receiving the treatment. The magnetic field penetrates the skull and the electric stimulus activates the neurons in the target area. This can be used for exploring how the brain works by disrupting its normal behaviour with the stimulation, or, in the case of repetitive stimulation, for modulationg the brain activity for therapeutic purposes.[1][2] TMS has been used in the treatment of anorexia nervosa with modest results.[3]

Magnetic stimulation is used for mapping the human brain, mainly the primary motor cortex because the reaction of the body to the stimulus is easily observable. This is how the location of brain functions of the brain were localized, first for the motor functions, by measuring the motor evoked potentials in the muscles, and now it is possible to localize cognitive and sensory processes with TMS as well.[4]

It is also used as a treatment for major depression. Two TMS devices, NeuroStar TMS Therapy system from Neuronetics,[5] Inc., and Brainsway Deep TMS system[6] have been approved by the U.S. Food and Drug Administration for the treatment of depression[1] One session usually lasts 30 to 60 minutes.[7] for which TMS is a cost-effective alternative as opposed to antidepressants.[8][4] It has also been found effective in treating migraine.[9]

Main characteristics

A simplified circuit diagram of a single-pulse magnetic stimulator. (V = voltage source, s = switch, C = capacitator, D = diode, R = resistor, T = thyristor)

The magnetic field created by the the coil produces electrical current in the brain of the subject due to the electromagnetic induction effect. This produces secondary ionic current which activates the near-surface neuronal axons in the target area. However, TMS, especially in higher intensities, may activate any neuron along the way.[2] The magnetic field can reach up to 2 T and usually lasts for about 100 µs.[4]

TMS system is composed of two parts. A high-voltage charge-discharge component that produces the required current waveform. This is a RLC circuit modified so it produces the waveform with the lowest amount of heat generated. The second components is the current carrying coil that servers as the emitter of the magnetic field. Although the design of the coils vary, the most used are two circular coil in parallel so as they resemble the number eight, or butterfly, shape. The coils are made of copper wiring and enclosed in a plastic chassis, with the diameter ranging from 4 to 9 centimetres.[10][11]

Purpose

Transcranial magnetic stimulation was traditionally used for brain mapping, especially of the motor cortex. However, it has been demonstrated that it can be used as a therapeutic tool also. It can remedy patients suffering from major depression and help in post-stroke rehabilitation. Other conditions which have been treated by TMS are: migraine, tinnitus, epilepsy, schizophrenia, Obsessive-compulsive disorder, or Alzheimer's disease.

It can also be used to enhance cognitive abilities (memory, motor reaction speed, verbal fluency) in healthy individuals, although the efficacy of these effects are disputed in the literature.

Historical overview

Reza Jalinous, Ian Freeston and Anthony Barker with the first stimulator that achieved TMS. (February 1985)

The physical principles behind magnetic field induction generating electrical current in nearby conductors were discovered by Michael Faraday in 1881. The experimentation with the effects of electricity on the human body begun in the 18th century and continued until the beginning of the 20th century. In 1937, electroconvulsive therapy (ECT) was developed by the Italians Cerletti and Bini. The procedure was originally used to treat schizophrenia but became so popular it was used in virtually every psychological treatment. This resulted in a series of unwanted side-effects and the public stop tolerating the use of the technique. In 1976, the U.S. Food and Drug Administration assumed regulatory control over these types of devices.[12]

Late 1970s saw the creation of the Transcranial direct-current stimulation that was, together with TMS, beginning to be considered for diagnostic and therapeutic purposes among physicians. In years 1984 - 1985 Anthony Barker and his colleagues manufactured first TMS stimulator.[12] One of the first papers to utilize TSM was published in 1991.[13] The authors used repetitive TMS (rTMS) to induce speech difficulties in patients while counting. Other study claimed that TMS can be successfully used in the treatment of depression in 1995.[14] The late 1990s meant wide adoption of TMS into practice, although the treatment was, and in general still is, used as a form of last resort after more established techniques fail.[15] A consensus conference in Italy in 2008 re-evaluated the guidelines for TMS from 1998. In October 2008, the U.S. Food and Drug Administration (FDA) approved the NeuroStar TMS Therapy system from Neuronetics, Inc. to be used in the industry-sponsored clinical trial of the treatment of medication-refractory depression (FDA approval K061053) through TMS.[16] In 2013, Cerena device was approved by FDA as a treatment of pain associated with migraine headache with aura. This device use single-pulse TMS (sTMS).[17]

http://www.brainefit.net/history-of-tms.html

http://www.scholarpedia.org/article/Transcranial_magnetic_stimulation

Important Dates

  • 1831 - Michael Faraday discovered electromagnetic induction on which TMS is based.
  • 1937 - The ECT was presented by Cerletti and Bini.
  • 1984/1985 - The first TMS stimulator was manufactured by Anthony Barker and his colleagues.[12]
  • 1991 - The publication of one of the first papers, which describes research, which utilized rTMS.[13]
  • 1995 - The publication of the study, which focuses on the treatment of depression by TMS.[14]
  • 1998 - TMS risk and safety guidelines were published by Eric M. Wassermann and Sarah H Lisanby.[15]
  • 2008 - The consensus conference which review the guideline published 10 years ago took place in Italy.[12]
  • October 2008 - NeuroStar TMS system was approved by FDA as a treatment of medication-refractory depression.[16]
  • 13th December 2013 - Cerena was classified into class II. devices and approved for the treatment of pain associated with migraine headache with aura.[17]


Enhancement/Therapy/Treatment

Enhancement - There is a growing evidence that TMS can enhance cognitive functions in some healthy subjects. This is however investigated only marginally in the literature.

Depression

Depression is an umbrella term for common mood disorders. They affected severely daily activities of the patients.[18] In 1950 were developed anti-depressant drugs, but the disorder of approximately 15-30% patients cannot be controlled by medications. Therefore, researchers were interested in new forms of treatment, TMS is one of them.[19]

TMS effect on drug-resistant depression was proved for the first time by Pascual-Leone and his colleagues in 1996. Each patient was stimulated in one of three centres: verex, right dorsolateral prefrontal cortex or left dorsolateral prefrontal cortex. The researchers used the frequency 10Hz.[20][21] In the "Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation", Jean-Pascal Lefaucheur and his colleagues claim that there are two ways of TMS, which are prevalent in the current research: the low frequency stimulation of right dorsolateral prefrontal cortex and the high frequency stimulation of left dorsolateral prefrontal cortex. While the former stimulation leads to inhibition of areas which are hyperactive during depression, the latter stimulation increase the activity in the areas which are hypoactive during depression. The combination of both methods could be also used. They also point out that TMS treatment of depression is the most efficient if it is applied in young patients, whose disorder is in an acute state and who possess a limited level of treatment resistance.[22]

Migraine

Migraine is a neurological disorder which is one of the most common causes of disability.[23] The patients suffering from migraine report symptoms as headache, nausea, vomiting, sound and light sensitivity. The migraine could be with or without aura. Certain patients have also migraine without headache but with aura. There is no treatment which could cure migraine, but several treatments handle with its symptoms. There are drugs as painkillers, triptans or anti-emetics which could deal with certain symptoms of migraine.[24]

For the treatment of migraine's symptoms, Cerena was approved by FDA in 2013 as the first device. The stimulation is based on single-pulse TMS (sTMS).[25] However, the results show that TMS is more efficient in the case of patients suffering from the migraine with aura. The migraine with aura is accompanied with cortical spreading depression, which give a rise of migraine pain. TMS could disturb these condition, which leads to the reduction of headache. However, the migraine without aura could be also positively affected by TMS. The results are not as significant as in the case of migraine with aura.[9] There are several possible TMS, which could affect migraine. The treatment provided by devices manufactured by eNeura (Cerena, SpringTMS) consists in sTMS. It is stimulated the area below the occipital bone.[26]


Although TMS is currently approved only for the treatment of depression and migraine with aura, its benefits were also examined on the treatment of other diseases and disorders as Alzheimer's disease,[27] tinnitus,[28] obsessive-compulsive disorder,[29] autism spectrum disorder,[30] schizophrenia,[31] or post-stroke recovery.[32]

Ethical & Health Issues

Transcriptional magnetic stimulation does not have a community of enthusiasts as large as the tDCS does. However, the recent approvals from the FDA mean that these devices are soon to be considered safe for treatment of more patients and that means the technology will move closer to the regular consumer. Excluding ethical issues perhaps more relevant to the clinical use of the TMS, i.e. issues such as the need of informed consent of the patient, pre-treatment observations, and long-term effects research, there are other potential ethical concerns TMS, or rather any other brain stimulation technique may pose.[12][33]

This technology can introduce unwanted, although short-lasting, mood changes. It can be used to alter cognition, and in this regard it an be abused by healthy subjects to do so. This may lead to unexpected side-effects, addiction or, in the worst cases, to serious health issues (discussed below). Because brain stimulation replaces the effect of pharmaceuticals, it can be abused as a form cheating or doping while being undetectable by chemical tests (see tDCS entry for more).

While non-invasive, transcranial magnetic stimulation is not without unwanted side-effects. The ability to easily influence the human brain and subsequently the entire body and thus health of the patients raises great concerns about safety and procedure protocol of the technique. The adverse effects of TMS can include but are not limited to inducing seizure, headache, syncope, phosphenes, dysphoria, uncontrollable laughter, speech arrest, scotoma, or skin burns from electrodes (if used).[34] Other minor health concern is the procedure itself. The coil produces a high-intensity 'click' sound when a TMS is turned on, with enough sound pressure to damage hearing.

Contraindication and health risks. https://www.fda.gov/RegulatoryInformation/Guidances/ucm265269.htm

Public & Media Impact and Presentation

Public Policy

https://www.google.com/patents/US9561384

"Nevertheless, rTMS is an accepted, evidence-based treatment option by the American Psychiatric Association (APA), the Canadian Network for Mood and Anxiety Treatments (CANMAT), and the World Federation of Societies of Biological Psychiatry (WFSBP)." For the treatment of depression.[22]

Related Technologies, Projects or Scientific Research

http://www.eneura.com/

References

  1. ↑ 1.0 1.1 ELDAIEF, Mark C., PRESS, Daniel Z. and PASCUAL-LEONE, Alvaro, 2013, Transcranial magnetic stimulation in neurology A review of established and prospective applications. Neurology: Clinical Practice. 2013. Vol. 3, no. 6, p. 519–526. DOI 10.1212/01.CPJ.0000436213.11132.8e.
  2. ↑ 2.0 2.1 RIDDING, Michael C and ROTHWELL, John C, 2007, Is there a future for therapeutic use of transcranial magnetic stimulation? Nature reviews. Neuroscience. 2007. Vol. 8, no. 7, p. 559–567. DOI 10.1038/nrn2169.
  3. ↑ MCCLELLAND, Jessica, KEKIC, Maria, BOZHILOVA, Natali, NESTLER, Steffen, DEW, Tracy, VAN DEN EYNDE, Frederique, DAVID, Anthony S., RUBIA, Katya, CAMPBELL, Iain C. and SCHMIDT, Ulrike, 2016, A Randomised Controlled Trial of Neuronavigated Repetitive Transcranial Magnetic Stimulation (rTMS) in Anorexia Nervosa. Plos One [online]. 2016. Vol. 11, no. 3, p. e0148606. DOI 10.1371/journal.pone.0148606. Available from: http://dx.plos.org/10.1371/journal.pone.0148606
  4. ↑ 4.0 4.1 4.2 HALLETT, Mark, 2007, Transcranial Magnetic Stimulation: A Primer. Neuron. 2007. Vol. 55, no. 2, p. 187–199. DOI 10.1016/j.neuron.2007.06.026.
  5. ↑ https://neurostar.com/
  6. ↑ http://www.brainsway.com/about-brainsway
  7. ↑ http://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml
  8. ↑ NGUYEN, Kim-Huong and GORDON, Louisa G, 2015, Cost-Effectiveness of Repetitive Transcranial Magnetic Stimulation versus Antidepressant Therapy for Treatment-Resistant Depression. Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research [online]. 2015. Vol. 18, no. 5, p. 597–604. DOI 10.1016/j.jval.2015.04.004. Available from: http://www.sciencedirect.com/science/article/pii/S1098301515019270
  9. ↑ 9.0 9.1 LIPTON, Richard B. et al. Single-pulse transcranial magnetic stimulation for acute treatment of migraine with aura: a randomised, double-blind, parallel-group, sham-controlled trial. The Lancet: Neurology. 2010, Apr. 9(4), 373–380 Doi: 10.1016/S1474-4422(10)70054-5 Available online at: http://www.sciencedirect.com/science/article/pii/S1474442210700545 (Retrieved 2nd May, 2017).
  10. ↑ WAGNER, Timothy, VALERO-CABRE, Antoni and PASCUAL-LEONE, Alvaro, 2007, Noninvasive human brain stimulation. Annual Review of Biomedical Engineering [online]. 2007. Vol. 9, no. 1, p. 527–565. DOI 10.1146/annurev.bioeng.9.061206.133100. Available from: http://dx.doi.org/10.1146/annurev.bioeng.9.061206.133100\nfiles/392/Wagner et al. - 2007 - Noninvasive Human Brain Stimulation.pdf
  11. ↑ KOBAYASHI, Masahito and PASCUAL-LEONE, Alvaro, 2003, Basic principles of magnetic stimulation. The Lancet. 2003. Vol. 2, p. 145–156. DOI 10.1016/S1474-4422(03)00321-1.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 HORVATH, J. C., et al. Transcranial magnetic stimulation: a historical evaluation and future prognosis of therapeutically relevant ethical concerns. Journal of medical ethics. 2011, 37(3), 137–43. Doi: 10.1136/jme.2010.039966 Available online at: https://www.ncbi.nlm.nih.gov/pubmed/21106996 (Retrieved 26th April, 2017).
  13. ↑ 13.0 13.1 PASCUAL‐LEONE, Alvaro; GATES, John R.; DHUNA, Anil. Induction of speech arrest and counting errors with rapid‐rate transcranial magnetic stimulation. Neurology, 1991, 41.5: 697-702.
  14. ↑ 14.0 14.1 KOLBINGER, H. M. et al. Transcranial Magnetic Stimulation (TMS) in the Treatment of Major Depression - a Pilot-Study. Human Psychopharmacology-Clinical and Experimental [online]. 1995. 10(4), 305–310. Doi: 10.1002/Hup.470100408 Available online at: http://onlinelibrary.wiley.com/doi/10.1002/hup.470100408/abstract (Retrieved 26th April, 2017).
  15. ↑ 15.0 15.1 WASSERMANN, E. M. and LISANBY, S. H. Therapeutic application of repetitive transcranial magnetic stimulation: a review. Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology [online]. 2001, 112(8), 1367–77. Doi: 10.1016/S1388-2457(01)00585-5. Available online at: http://www.sciencedirect.com/science/article/pii/S1388245701005855 (Retrieved 26th April, 2017).
  16. ↑ 16.0 16.1 O’REARDON, John P. et al. Efficacy and Safety of Transcranial Magnetic Stimulation in the Acute Treatment of Major Depression: A Multisite Randomized Controlled Trial. Biological Psychiatry. 2007. 62(11), 1208–1216. Doi: 10.1016/j.biopsych.2007.01.018.
  17. ↑ 17.0 17.1 FOY, Jonette. Cerena Transcranial Magnetic Stimulator: Evaluation of Automatic Class III Designation – De Novo Request. U.S. Food and Drug Administration [online]. 2013, Dec 13. Available online at: https://www.accessdata.fda.gov/cdrh_docs/pdf13/K130556.pdf (Retrieved 2nd May, 2017).
  18. ↑ The National Institute of Mental Health. Depression. The National Institute of Mental Health [online]. Available online at: https://www.nimh.nih.gov/health/topics/depression/index.shtml (Retrieved 2nd May, 2017).
  19. ↑ HERWIG, U. et al. Antidepressant effects of augmentative transcranial magnetic stimulation. British Journal of Psychiatry. 2007, 191(5), 441-448. Doi: 10.1192/bjp.bp.106.034371 Available online at: http://bjp.rcpsych.org/content/bjprcpsych/191/5/441.full.pdf (Retrieved 2nd May, 2017).
  20. ↑ PASCUAL-LEONE, Alvaro et al. Rapid-rate transcranial magnetic stimulation of left dorsolateral prefrontal cortex in drug-resistant depression. The Lancet [online]. 1996, Jul 27. 348(9022), 233–237. Doi: https://doi.org/10.1016/S0140-6736(96)01219-6 Available online at: http://www.sciencedirect.com/science/article/pii/S0140673696012196 (Retrieved 2nd May, 2017).
  21. ↑ ZIEMANN, Ulf. Thirty years of transcranial magnetic stimulation: where do we stand? Experimental Brain Research. 2017, 235(4), 973–984. Doi: 10.1007/s00221-016-4865-4 Available online at: http://link.springer.com/article/10.1007%2Fs00221-016-4865-4 (Retrieved 2nd May, 2017).
  22. ↑ 22.0 22.1 LEFAUCHEUR, Jean-Pascal et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clinical Neurophysiology. 2014, Nov. 125(11), 2150–2206. Doi: 10.1016/j.clinph.2014.05.021 Available online at: http://www.sciencedirect.com/science/article/pii/S138824571400296X (Retrieved 2nd May, 2017).
  23. ↑ ANDREOU, Anna P. et al. Transcranial magnetic stimulation and potential cortical and trigeminothalamic mechanisms in migraine. Brain. 2016, May 30. 139(7), 2002-2014. Doi: https://doi.org/10.1093/brain/aww118 Available online at: https://academic.oup.com/brain/article-lookup/doi/10.1093/brain/aww118 (Retrieved 2nd May, 2017).
  24. ↑ NHS Choices. Migraine. NHS Choices [online]. Available online at: http://www.nhs.uk/Conditions/Migraine/Pages/Introduction.aspx (Retrieved 2nd May, 2017).
  25. ↑ eNeura, Inc. eNeura, Inc. Receives FDA Clearance for SpringTMS® Migraine Treatment Device. PR Newswire [online]. 2014, May 23. Available online at: http://www.prnewswire.com/news-releases/eneura-inc-receives-fda-clearance-for-springtms-migraine-treatment-device-260398971.html (Retrieved 2nd May, 2017).
  26. ↑ BARKER, Anthony T. and SHIELDS, Kevin. Transcranial Magnetic Stimulation: Basic Principles and Clinical Applications in Migraine. Headache. 2016, Dec 28. 57(3), 517-524. DOI: 10.1111/head.13002 Available online at: https://www.ncbi.nlm.nih.gov/labs/articles/28028801/ (Retrieved 2nd May, 2017).
  27. ↑ RABEY, Jose M. et al. Repetitive transcranial magnetic stimulation combined with cognitive training is a safe and effective modality for the treatment of Alzheimer’s disease: a randomized, double-blind study. Journal of Neural Transmission. 2013, May. 120(5), 813–819. Doi: 10.1007/s00702-012-0902-z Available online at: http://link.springer.com/article/10.1007/s00702-012-0902-z/fulltext.html (Retrieved 3rd May, 2017).
  28. ↑ LEFAUCHEUR, Jean-Pascal et al. Navigated rTMS for the treatment of tinnitus: A pilot study with assessment by fMRI and AEPs. Neurophysiologie Clinique/Clinical Neurophysiology. 2012, Apr. 42(3), 95–109. Doi: 10.1016/j.neucli.2011.12.001 Available online at: http://www.sciencedirect.com/science/article/pii/S0987705311002358 (Retrieved 3rd May, 2017).
  29. ↑ ZHOU, Dong-Dong et al. An updated meta-analysis: Short-term therapeutic effects of repeated transcranial magnetic stimulation in treating obsessive-compulsive disorder. Journal of Affective Disorders, 2017, Jun. 215, 187–196. Doi: 10.1016/j.jad.2017.03.033 Available online at: http://www.sciencedirect.com/science/article/pii/S0165032716317967 (Retrieved 3rd May, 2017).
  30. ↑ OBERMAN, Lindsay M. et al. Transcranial magnetic stimulation in autism spectrum disorder: Challenges, promise, and roadmap for future research. Autism Research. 2016, Feb. 9(2), 184–203 Doi: 10.1002/aur.1567 Available online at: http://onlinelibrary.wiley.com/doi/10.1002/aur.1567/abstract (Retrieved 3rd May, 2017).
  31. ↑ DOUGALL N. et al. Transcranial magnetic stimulation (TMS) for schizophrenia. Cochrane Database of Systematic Reviews. 2015, 8. Art. No.: CD006081. DOI: 10.1002/14651858 Available online at: http://www.cochrane.org/CD006081/SCHIZ_transcranial-magnetic-stimulation-tms-treatment-schizophrenia (Retrieved 3rd May, 2017).
  32. ↑ HUMMEL F. C. et al. Controversy: noninvasive and invasive cortical stimulation show efficacy in treating stroke patients. Brain Stimulation. 2008, Oct. 1(4), 370–82. Doi: 10.1016/j.brs.2008.09.003 Available online at: http://www.sciencedirect.com/science/article/pii/S1935861X08003367 (Retrieved 3rd May, 2017).
  33. ↑ ROSSI, Simone et al., Ulf, 2009, Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clinical Neurophysiology [online]. 2009. Vol. 120, no. 12, p. 2008–2039. DOI 10.1016/j.clinph.2009.08.016. Available from: http://dx.doi.org/10.1016/j.clinph.2009.08.016
  34. ↑ WASSERMANN, Eric M., 1998, Risk and safety of repetitive transcranial magnetic stimulation. Electroencephalography and Clinical Neurophysiology [online]. 1998. Vol. 108, no. 1, p. 1–16. DOI 10.1016/S0168-5597(97)00096-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9474057
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