About TMS: How does TMS work?

‘TMS’ stands for Transcranial Magnetic Stimulation. It is a non-invasive treatment that uses magnets to stimulate specific brain areas in its field. 

A non-invasive magnetic device is placed near the head during treatment, which induces an electrical current in the underlying brain areas. This stimulates the brain to “reset” its activity in this area. Research has shown that TMS has an effect on neuroendocrinological processes, neurotransmitter systems, and neurotrophic factors (Pogarell 2006, 2007 and Baeken 2010) and connectivity between different brain areas (Paus, 2001 and Shajahan, 2002). It’s thought that imbalances in neurotransmitters are the cause of a number of mental health conditions.

Depression

  • Is often a relapsing and remitting disorder, which means that many people may suffer more than one episode. 
  • Is a mental health disorder that can affect any combination of a person’s mood, sleep/appetite/sexual drive, ability to concentrate, zest for life, but usually involving their mood. 
  • When severe, it can lead to suicidal thoughts and attempts.

Recent research has shown that 1 in 7 Australians will suffer from depression in their lifetime. 1 in 14 females is currently suffering from depression , compared to 1 in 19 men. 

In the perinatal population (people who have had a baby in the past year), the rates of depression are even higher, with 1 in 5 Australian mums suffering from depression and 1 in 10 dads!

Depression is a serious illness that affects whole families and communities, as it affects people’s relationships, work performance, physical health and participation in society. 

We are pleased that the Australian government has recognised the importance of treating depression, and has included rTMS on the Medicare list of treatments for depression. 

Human-Health-Clinics-TMS Melbourne

Why did Human Health Clinics choose NexstimTM?

Two reasons: accuracy and best-in-class

NexstimTM allows for accurate and precise targeting of specific brain areas for stimulation, based on individual brain anatomy. Historically, neurosurgeons use NexstimTM to map the motor and speech areas of the brain before surgery to avoid damaging these critical areas. This indicates a higher level of precision is possible. Accurate targeting contributes to a more effective assessment of cortical excitability, which means that each session is individually-tailored for patients.

Nexstim is a paradigm changer: As doctors and patients ourselves, the founders of HHC had read the literature regarding neuronavigation TMS vs cap-based targeting (eg Caulfield et al, 2022 “Cap targeting was significantly more off-target each distance and angle measure vs. neuronavigation (p < 0.0001).”). Some of us had experienced or observed side-effects from inaccurate placement with cap-based targeting, and so we sought the next generation of nTMS despite it being a significant investment in contrast to non-navigated TMS systems.

Pieramico et al (2023) showed that with better navigation, a more nuanced understanding of orientation for the coil could be achieved – and as a result, “stimulation orientation is a crucial determinant of the modulation of brain functional connectivity”. Ie if the efficacy of TMS is predicated on the ability to modulate brain functional connectivity, a responsible thing for practitioners to do is to gain more specificity on the location of the target and the orientation of the coil respective to that target.

About Nextstim’s neuronavigation

Nexstim TMS machines have been produced for over 20 years and are used for a variety of purposes, including research and neurosurgery. 

Nexstim is the only company in the world to have their TMS machines FDA and CE approved for motor mapping (2009) and speech mapping (2012) which are important aspects of neurosurgical planning. This shows how anatomically accurate Nextstim is, which we hope will translate to more effective clinical effectiveness for our patients.

In recent data using Nexstim; Of the first 403 patients completing treatment at clinical sites in the U.S., 200 (49.6%) had achieved clinical remission and 307 (76.2%) had obtained a clinical response at end of treatment based on Beck’s Depression Inventory (BDI) and Patient Health Questionnaire – 9 (PHQ-9) scores. These are higher than what is consistently reported for non-navigated TMS.

What are the potential benefits of neuronavigated TMS with NexstimTM?

Neuronavigated #TMS with NexstimTM has been shown to be an effective treatment for depression. It is registered in Australia with the TGA for treatment of major depressive disorder (MDD). For a list of the whitepapers, please see the References below.

How is neuronavigated TMS performed?

Neuronavigated TMS with NexstimTM involves the use of a brain map which is created by an MRI (Magnetic Resonance Imaging). It is then uploaded into the computer to create a 3D map of the patient’s brain, which is then used to guide the placement of the magnetic coil to the specific area of the brain that needs stimulation.

Are there any risks or side effects associated with neuronavigated #TMS with NexstimTM?

TMS is generally considered safe and well-tolerated. Neuronavigated #TMS with NexstimTM has more specific targeting and theoretically less spread into facial muscles and other tissue structures. Some patients may still experience mild side effects such as headaches, dizziness, or tingling sensations during or after the treatment. These side effects are usually temporary and resolve quickly.

How long does a neuronavigated TMS with NexstimTM system session last?

The length of a neuronavigated #TMS with NexstimTM can vary depending on the individual and the specific treatment being performed. Generally, a single session (non-Theta Burst) lasts between 30-60 minutes. It is possible to do a Theta Burst session using Nexstim and this will reduce the duration of the treatment significantly.

References

Pogarell O, Koch W, Popperl G, Tatsch K, Jakob F, Zwanzger P, et al. Striatal dopamine release after prefrontal repetitive transcranial magnetic stimulation in major depression: preliminary results of a dynamic [123I] IBZM SPECT study. J Psychiatr Res. 2006; 40(4): 307-314. doi: http://dx.doi.org/10.1016/j.jpsychires.2005.09.001 [PubMed] [Google Scholar]

Pogarell O, Koch W, Popperl G, Tatsch K, Jakob F, Mulert C, et al. Acute prefrontal rTMS increases striatal dopamine to a similar degree as D-amphetamine. Psychiatry Res. 2007; 156(3): 251-255. doi: http://dx.doi.org/10.1016/j.pscychresns.2007.05.002

Baeken C, De Raedt R. Neurobiological mechanisms of repetitive transcranial magnetic stimulation on the underlying neurocircuitry in unipolar depression. Dialogues Clin Neurosci. 2011;13(1):139-45. doi: 10.31887/DCNS.2011.13.1/cbaeken. PMID: 21485753; PMCID: PMC3181968.

Caulfield, K. A., Fleischmann, H. H., Cox, C. E., Wolf, J. P., George, M. S., & McTeague, L. M. (2022). Neuronavigation maximizes accuracy and precision in TMS positioning: Evidence from 11,230 distance, angle, and electric field modeling measurements. Brain Stimulation, 15(5), 1192-1205. https://doi.org/10.1016/j.brs.2022.08.013

Chail A, Saini RK, Bhat PS, Srivastava K, Chauhan V. Transcranial magnetic stimulation: A review of its evolution and current applications. Ind Psychiatry J. 2018 Jul-Dec;27(2):172-180. doi: 10.4103/ipj.ipj_88_18. PMID: 31359968; PMCID: PMC6592198.

Kricheldorff J, Göke K, Kiebs M, Kasten FH, Herrmann CS, Witt K, Hurlemann R. Evidence of Neuroplastic Changes after Transcranial Magnetic, Electric, and Deep Brain Stimulation. Brain Sci. 2022 Jul 15;12(7):929. doi: 10.3390/brainsci12070929. PMID: 35884734; PMCID: PMC9313265.

Paus T, Sipila PK, Strafella AP. Synchronization of neuronal activity in the human primary motor cortex by transcranial magnetic stimulation: an EEG study. J Neurophysiol. 2001 Oct;86(4):1983-90. doi: 10.1152/jn.2001.86.4.1983. PMID: 11600655.

Shajahan PM, Glabus MF, Steele JD, Doris AB, Anderson K, Jenkins JA et al (2002). Left dorso-lateral repetitive transcranial magnetic stimulation affects cortical excitability and functional connectivity, but does not impair cognition in major depression. Prog Neuropsychopharmacol Biol Psychiatry 26: 945–954.

List of Nexstim whitepapers: https://www.nexstim.com/research/white-papers

Nexstim’s own research paper: https://www.nexstim.com/fileadmin/Downloads/Case_reports/2022-10-11_MDD_Registry_Results_Report_11_October_2022.pdf

Pieramico, G., Guidotti, R., Nieminen, A.E., D’Andrea, A., Basti, A., Souza, V.H., Nieminen, J.O., Lioumis, P., Ilmoniemi, R.J., Romani, G.L., Pizzella, V., & Marzetti, L. (2023). TMS-Induced Modulation of EEG Functional Connectivity Is Affected by the E-Field Orientation. Brain Sciences, 13(3), 418. https://doi.org/10.3390/brainsci13030418

Romero, M.C., Davare, M., Armendariz, M. et al. Neural effects of transcranial magnetic stimulation at the single-cell level. Nat Commun 10, 2642 (2019). https://doi.org/10.1038/s41467-019-10638-7