What is the research that supports neuronavigated TMS?

For major depressive disorder (MDD): in order of year of publication –

Carpenter, L.L., Janicak, P.G., Aaronson, S.T., Boyadjis, T., Brock, D.G., Cook, I.A., Dunner, D.L., Lanocha, K., Solvason, H.B., Demitrack, M.A., et al. Transcranial Magnetic Stimulation (TMS) for Major Depression: A Multisite, Naturalistic, Observational Study of Acute Treatment Outcomes in Clinical Practice. Depress. Anxiety 2012, 29, 587–596. https://doi.org/10.1002/da.21969.

Rizvi, S. and Khan, A.M., 2019. Use of Transcranial Magnetic Stimulation for Depression. Cureus, 11(5), p.e4736. https://doi.org/10.7759/cureus.4736.

Voigt, J., Carpenter, L. & Leuchter, A. A systematic literature review of the clinical efficacy of repetitive transcranial magnetic stimulation (rTMS) in non-treatment resistant patients with major depressive disorder. BMC Psychiatry 19, 13 (2019). https://doi.org/10.1186/s12888-018-1989-z.

Yanan C, Haijian F, Cui B, Wanyue G, Fengqiong Y, Xiaoming L. Efficacy of Transcranial Magnetic Stimulation for Reducing Suicidal Ideation in Depression: A Meta-Analysis. Front Psychiatry. 2022;12:764183. https://www.frontiersin.org/articles/10.3389/fpsyt.2021.764183/full.

There are a number of Australian and world-wide publications that support TMS’s use for other conditions, but in Australia, only MDD is on the MBS.

Why did Human Health Clinics choose to standardise on 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.

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.

References

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

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

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

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