Transcranial Magnetic Stimulation (TMS)

What is Transcranial Magnetic Stimulation (TMS)?

Transcranial magnetic stimulation (TMS) is a non-invasive, non-pharmacologic neuromodulation technique that uses the magnetic field to stimulate or inhibit specific areas of the brain. TMS was developed in the 1980s as a diagnostic technique to study brain function, but today it is used as a treatment method for a range of neurological and psychiatric disorders, such as Resistant Depression and Obsessive-Compulsive Disorder.

Principles of action

Transcranial magnetic stimulation (TMS) is based on the principle of electromagnetic induction, which makes it possible to stimulate or inhibit the neuronal activity of specific brain areas, thereby succeeding in restoring the proper functioning of brain cells that are impaired by the disorder's presence. More specifically, starting with an electrical stimulus passing through the machine's coil, a magnetic pulse is generated that can painlessly penetrate the treated person's skull and reach the cerebral cortex, inducing a stimulatory current capable of modulating the activity of neuron cells.

Depending on the chosen parameters for stimulation, the effect on the brain can be of two types:

1. Activation - induction/increase in the electrical activity of an otherwise inactive or hypoactive area;

2. Inhibition - reduction of the ongoing electrical activity in a given hyperactive area.

Several laboratory studies suggest that the modulation action of neuronal activity achieved by TMS is accomplished through enhancement and potentiation of Brain Derived Neurotrofic Factor (BDNF; an important factor involved in neuronal cell plasticity) activity through an action on its TrkB receptors, thus suggesting that the benefits obtained through this neuromodulation technique can be attributed to an improvement in brain plasticity.

Types of TMS

There are different types of TMS, which can be applied in a customized manner to effectively achieve the specific therapeutic goal set for each individual patient:

• Repetitive Transcranial Magnetic Stimulation (rTMS): rTMS represents the most widely used type of Transcranial Magnetic Stimulation in the clinical setting due to its high flexibility that allows its use for the treatment of many disorders. It is a neuromodulation technique that makes use of short, repeated magnetic pulses spaced at programmable time intervals to achieve the desired therapeutic effect. The great advantage of rTMS is that it enables to stimulate or inhibit specific brain areas of interest in an absolutely personalized manner depending on the symptomatology presented by the individual patient, thus allowing a high degree of adaptation to the specific needs of each patient and, for this reason, constituting an ideal method of treatment for precision care.

• Theta Burst Stimulation (TBS): TBS is a very promising brain stimulation method characterized by the administration of rapid repetitions of high-frequency (50 Hz) magnetic stimuli divided into consecutive triplets of stimuli. Through this kind of TMS it is possible to provide two different types of protocols that are capable of achieving opposite effects on brain cells: continuous TBS (capable of reducing brain activity of brain cortical regions of interest) and intermittent TBS (capable of increasing brain activity of brain cortical regions of interest). The main advantage of TBS is its efficiency and efficacy: due to its high stimulation intensity, TBS is shown to induce rapid changes in brain plasticity that are sometimes maintained longer than those obtained with standard TMS, thus allowing greater accessibility and lower cost for the patient.

• Theta-Burst Multi Session Treatment (SNT): SNT is an innovative high-frequency, high-intensity Magnetic Stimulation protocol characterized by multiple daily sessions. Due to its high efficacy in treating Treatment-Resistant Depression, this protocol is considered a real game changer in the treatment of severe forms of depression. Although the TBS described above has been approved by the FDA for the treatment of Resistant Depression, it still generally takes about 6 weeks of treatment to achieve the desired effects. Thanks to the repetition of multiple daily sessions, the SNT protocol has been specifically structured to achieve accelerated effects on depressive symptoms and has been associated with a remission rate of about 90% after only 5 days of treatment. For this reason, it proves to be a particularly promising treatment when dealing with very severe forms of depression that require rapid improvement of symptoms. To demonstrate its effectiveness, Dr. Pallanti published a study conducted on 24 patients with Severe Depression resistant to any treatment who responded in more than 80% of cases to this protocol. In addition to being surprisingly effective, the treatment protocol was also shown to be extremely well tolerated. The result on treatment-resistant severe depressive symptoms is so positive that the FDA is considering making it an affordable and even reimbursable treatment in the United States.

• Deep Transcranial Magnetic Stimulation (Deep TMS): Deep TMS is an innovative technique in the field of Neuroscience in that, unlike other neuromodulation modalities, it is shown to noninvasively reach deep brain regions underneath the cerebral cortex up to 6cm deep. This makes it possible to reach deep brain areas that have been shown to underlie several psychiatric disorders, otherwise unreachable through other, more superficial types of stimulation. This technique has been approved by the FDA for the treatment of Depression, Obsessive-Compulsive Disorder, Nicotine Dependence, and is currently under approval for Post-Traumatic Stress Disorder (PTSD).

At Dr. Pallanti's Istituto di Neuroscienze we operate on the full range of TMS for the treatment of psychiatric disorders. In addition, we are the only facility in Italy that makes use of Neuronavigation to localize the target of stimulation, thus succeeding in greatly increasing the precision of treatment.

How does rTMS work?

Before starting the treatment with rTMS, we use the novel system of Neuronavigation, which enables us to reconstruct the anatomical structure of the patient's brain in real time and in a three-dimensional manner, allowing us to precisely identify the brain area to be stimulated with excitatory or inhibitory pulses.

During an rTMS session, the patient is comfortably seated in a reclining chair, and the operator or physician places a coil on the patient's head. Using a stimulator, the coil generates a magnetic field that can painlessly and noninvasively penetrate through the patient's scalp and reach the underlying specific brain structures of interest, thereby modifying their electrical activity, plastic properties, and improving communication between various brain areas, thereby facilitating the reduction of treated symptoms.

The magnetic stimuli emitted by the device produce a recordable response, which manifests as a noise similar to a series of "clicks." During rTMS sessions, NO pain is experienced. At most, some people may experience a slight and transient tingling sensation in the scalp area where magnetic stimulation is applied or small muscle contractions. In addition, rTMS is a highly safe procedure and causes NO notable side effects. In certain cases, some patients may experience a mild, transient muscle-tension headache.

For which disorders is TMS recommended?

Different types of TMS can be used to effectively and safely treat several disorders. In 2008, TMS gained Food and Drug Administration (FDA) approval for the treatment of Resistant Depression and in 2018 for the treatment of Obsessive-Compulsive Disorder. In addition to these two disorders, TMS is also an effective treatment option for other conditions, including Pathological Addictions and Post-Traumatic Stress Disorder (PTSD).

TMS appears to be particularly suitable for those who have not benefited from other treatments, such as pharmacological treatment. However, in recent years, numerous clinical trials have been put in place within different scientific disciplines to evaluate its effectiveness in numerous conditions. For this reason, there is an increasing amount of clinical evidence demonstrating the effectiveness of Neuromodulation Therapies in a wide variety of medical fields.

Neuromodulation Therapies offered by the Istituto di Neuroscienze can be safely and effectively applied in a broad spectrum of therapeutic areas and on different types of patients of all ages. Everyone can benefit from Neuromodulation therapies, with the exception of the following cases:

• Presence of previous or current seizures (Epilepsy);

• Presence of Pacemakers;

• Presence of cochlear implants.

* For many of the areas mentioned above, Neuromodulation Therapies are administered as scientifically validated "Off-Label" treatments.

TMS in our treatment plans

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OCD and Obsessive-Compulsive Spectrum Disorders

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How does the treatment work in practice?

The individual sessions

The duration of a TMS session varies depending on the type of treatment and the symptoms presented by the patient. Typically, a TMS session lasts 20 to 30 minutes, but the duration of an individual treatment can vary widely depending on the specific therapy and, therefore, last from a few minutes to just under an hour.

During therapy sessions, it is necessary to remain awake: reading or talking are permitted. During the course of the stimulation session, the practitioner/physician will ask the patient a few simple questions in order to track the daily progress of the person and the therapy. These questions concern:

• Activities performed during the day;

• Rest degree and quality of sleep;

• Nutrition;

• Sebjective mood and the progress of symptoms;

• Pharmacotherapy, in order to monitor any changes or modifications;

• Alcohol and/or substances intake: substances such as alcohol, marijuana and cocaine may interfere with therapy and produce a change in pacing parameters.

Treatment duration and therapeutic procedures

The number of sessions required to achieve the best results depends on the disorder being treated and the patient's subjective response to therapy. In general, the minimum and ideal duration of therapy should be longer than 30 consecutive sessions given daily for one or more times a day. In any case, keep in mind that typically the rule applies that the more sessions, the greater the benefits obtained. In the United States, the first course of treatment lasts no less than 40 to 50 sessions.

Sessions take place on an outpatient basis under constant supervision. In fact, the goal is to stimulate the patient to adopt an active attitude so that he or she makes available to himself or herself every useful resource for change, the cornerstone of any therapy.

The beneficial effects of Neuromodulation Therapy may not be immediate. The time frame within which the first improvements occur depends from person to person. For this reason, at the end of the initial cycle of treatment it may be useful to consider whether the therapy can be extended further. If the beneficial effects of symptom improvement become apparent toward the end of the first agreed cycle, it is certainly advisable to extend the treatment period beyond the first 30 sessions in order to consolidate the effect.

Follow-up and recall visits

At the end of the initial course of treatment, reevaluation and recall visits to be made at regular time intervals are determined together with the patient in order to maintain and consolidate the effects achieved and reduce the risk of future relapse.

It is crucial to keep in mind that the mere disappearance or decrease of symptoms does not necessarily coincide with the disappearance of the disease.

In fact, even after the symptoms remission, the pathology concerning the brain circuits that initially originated to the symptomatology may remain. In such cases, if one completely stops the therapies carried out without performing the reevaluation and recall visits, the treated symptoms may reappear sometimes even in a different form from the initial ones ― experiencing the so-called "relapse." In these situations, it may be more difficult, complex, and may take longer to return to feeling better.

In order to minimize the possibility of incurring relapse, it is essential to regularly schedule booster treatment sessions, which are generally carried out shortly after the end of the first course of therapy and consist of the administration of a few treatment sessions spread over one or more consecutive days. It is not possible to establish in advance the duration of the reevaluation and recall visits, because this depends on many factors, including the type and severity of symptoms presented by the individual patient, the effects achieved through the first course of treatment, and the presence of any symptoms and disorders in comorbidity that may make the clinical picture more complex by increasing the incidence rate of relapse. It will be our Specialist Team's concern to assess, on a case-by-case basis, the number and duration of follow-up and recall visits.

At follow-up and recall visits, the stimulation protocol and type of Neuromodulation Therapy carried out-as well as any other therapies in place-may undergo modifications in order to best adapt the treatment to changes in each patient's clinical and metabolic condition over time.

The treatments are valid for 2 months. After this time frame has passed, they must necessarily be reevaluated in order to provide the person with the best possible treatment tailored to his or her specific condition.

Guidelines for accessing treatments

In order to facilitate proper conduct of treatments, we kindly ask you to follow the following directions:

• Arrive at the Neuroscience Institute at least 15 minutes before your appointment so that paperwork can be completed before the treatment session begins.

• Show up on time at the agreed-upon time for the start of treatment so that you can take advantage of the full scheduled program for the day.

• Consider that no recoveries or refunds are made for treatments not taken advantage of due to causes outside the responsibility of the Istituto di Neuroscienze.

Testimonies on TMS and in-depth resources

Testimonials from our patients

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Depression

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Watch and listen to Dr. Stefano Pallanti's interviews and speeches on the topic and to the contribution of some of our patients who provided their testimony regarding their treatment experience at our Institute.

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Addictions

This video collection on Substance and Behavioral Addictions explores the main features of these disorders and the most effective and innovative intervention methodologies for their management.

Watch and listen to Dr. Stefano Pallanti's interviews and speeches on the topic and to the contribution of some of our patients who provided their testimony regarding their treatment experience at our Institute.

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Firenze Neuroscienze #4 (Italian)

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