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Treatments

Treatments

What is rTMS? How does it work?

In rTMS the individual’s brain is stimulated non-invasively, through a handheld device (electromagnet). This coil creates a magnetic field around the target area on the brain, causing weak electric currents to flow in the brain. Depending on the needs of the individual, one can regulate his/her brain activity by increasing/decreasing neuronal activity with this device. Approved in Canada in 2002, rTMS has successfully helped in relieving symptoms of various psychiatric and neurological disorders like Depression, Schizophrenia, Mania, PTSD, OCD, Phobias, Panic Disorders, ADHD, Eating Disorders, Parkinson’s Disease, Autism, Cerebral Palsy, MS – to name a few.

It is widely used in hospitals in UK, Australia, Israel, Brazil, Egypt, Costa Rica, etc. A safe method of treatment, rTMS has been reported to cause little to no side effects in recipients compared to ECT and other such treatments.

Latest Treatment for Psychiatric & Neurological Disorders

Introduction:

After undergoing rigorous training in rTMS at Harvard Medical School and at Medical University of South Carolina, Dr Sanjay Chugh, a renowned Delhi based Neuro-psychiatrist, pioneered the treatment of rTMS in India in 2007. After successfully treating hundreds of cases at his clinic in New Delhi, Dr. Chugh partnered Dr. Anjali Chhabria to set up an rTMS clinic at Mindtemple in January 2011. A large number of people have already benefited from this treatment at Mindtemple.

What does rTMS stand for?

rTMS is the abbreviated from of Repetitive Transcranial Magnetic Stimulation. The term refers to the fact that a magnetic field comprising multiple magnetic pulses per second passes non-invasively through the skull or cranium and no surgery is required. It is this magnetic field which is the basics for the therapeutic change within the brain cells.


How does rTMS work?

The rTMS device allows a trained person to use an electromagnet to stimulate the brain of a patient non-invasively. A hand –held magnetic coil creates a rapidly changing magnetic field, which causes weak electric currents inside the brain through electromagnetic induction. By stimulating different areas of the brain, it is possible to elicit a therapeutic response in different disease states. rTMS targets sites within a few millimeters in the brain. This eliminates the various side effects as would be seen by a non-specific treatment such as Electric Shock Therapy (ECT).


In which countries is rTMS being used clinically?

rTMS was approved as a treatment for medication-resistant depression in Canada in 2002. Since then, the treatment has been offered to patients of various other psychiatric and neurological disorders. In USA, the FDA approved the use of rTMS in 2008. It is now widely used in hospitals in UK, Australia, Israel, Brazil, Egypt, Costa Rica etc.


What illnesses has rTMS been successful in treating?

rTMS is currently being used as a potential treatment for many Psychiatric & Neurological disorders. The psychiatric indications include Depression, Schizophrenia, Mania, Posttraumatic Stress Disorder, Obsessive – Compulsive Disorder, Phobias, Panic Disorder, Attention Deficit Hyperactivity Disorder (ADHD), Eating Disorders & Addictions. The neurological conditions where rTMS has proved to be useful are Stroke, Parkinson’s Disease, Migraine, Multiple Sclerosis, Autism, Epilepsy, Fibromyalgia and Chronic Pain. Details of the utility of rTMS in these conditions are given below. There are other disorders as well, where rTMS is currently being tested.


Can rTMS be given if the patient is already on medicine?

Yes. rTMS will not interfere adversely with medication. Rather, both will have a complimentary effect on the underlying disease process.


Is rTMS a guaranteed treatment for various disorders?

No, it is not. Like all other treatments for any other illness, this treatment too has its limitations. It may not help everyone who receives it. There will be some who benefit less then the others. But it is an effective and extremely safe treatment alternative, both in treatment resistant cases and also as first line treatment.


How effective is rTMS in Depression?

The efficacy of rTMS in treating Depression has been clearly established. It is useful both in treatment-resistant Depression as well as a first line treatment modality for this illness. Our experience and scientific studies show that its benefits may exceed those seen with anti-depressants. When given in combination with medication, relief from symptoms and recovery occurs more quickly. The required dosage of medication goes down, reducing the adverse effects associated with continued intake of higher doses of medication.

Overall, rTMS has been considered a ‘life saver’ in Depression.


What are the results of rTMS in Schizophrenia?

Many patients with schizophrenia experience auditory hallucinations. Following rTMS, a majority of patients experience 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. Anxiety which is associated with Depression decreases when the individual is treated with rTMS for depression. However, rTMS is also used in treatment of Anxiety disorders such as Panic Disorder, Post Traumatic Stress Disorder & Phobias, in addition to OCD (discussed above).


Can rTMS help in Bipolar Disorder?

Yes. rTMS is useful in treating the Manic phase in Bipolar Disorder, in addition to its antidepressant effects.


Can rTMS help in ADHD?

Yes. rTMS can bring down the Hyperactivity in a child who has ADHD. This could result in a significantly low does 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 & Bulimia Nervosa. We recommend that a trial of rTMS be given in these conditions.


Is there any 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 & slowing (Bradykinesia), improvement in the abnormal movements (Dyskinesias) and an 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 paralysis limbs. These improvements have been induced even several years after the Stroke happened.


Is rTMS useful in Multiple Sclerosis?

The use of rTMS in MS has been associated with decreased spasticity in the limbs, improved hand dexterity & improvement in urinary tract related problems.


Does rTMS have a role to play in Migraine?

Yes. It has been used to prevent Migraine attacks and can also reduce the frequency & severity of the Migraine headache.


Is rTMS useful in Autism?

After a course of rTMS, children with Autism showed fewer symptoms of hyperactivity, sensory overload and repetitive behaviours. Promising results such as reduces severity of distressing symptoms of Autism, better communication & social interaction have been observed with the help of this treatment. The treatment does not adversely affect areas of “giftedness” in the treated children.


I 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 & Pain management?

Patients report a measurable reduction in pain after rTMS. It helps increase the threshold for pain tolerance & alters pain processing, thereby providing long-lasting pain relief.


Can rTMS help in Lazy Eye (Amblyopia)?

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 how 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. When correct procedures are followed, the treatment is considered to be relatively free of side effects. 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 trated with usual pain medications such as aspirin or ibuprofen. Another problem may be ringing in the ears caused by the noise of the stimulating coil, so earplugs are typically worn during the procedure which cut the sound by up to 30 Decibels.

Seizures are the only major possible risk associated with rTMS. rTMS safety guidelines were established in 1993 and revised in 1996. When these have been followed, no seizures have been reported. These guidelines are strictly followed at our clinic.

It is also relevant to point out that the risk for seizures with rTMS is considerably less than the risk for seizures with medication.


What is the sensation like during rTMS treatment?

Patients can hear a clicking noise when the magnetic pulse is applied, so earplugs are normally worn to avoid discomfort. There is also a tingling sensation which can be felt in the scalp to a greater or lesser degree by patients. It is rarely uncomfortable and usually stops being a disturbance after the first 3 – 4 sessions. Some patients even report that they become so accustomed to the feeling that they can tell when the physician is stimulating the correct spot.


How does rTMS compare with medication?

Medicines will always remain the mainstay for treatment of various disorders. However, there are studies available now which report that the therapeutic effects of rTMS in Depression match those produced by medicines. Currently, our understanding & experience show that if rTMS is started in a patient on medication and is effective, there would be a quicker onset of recovery, a decrease in the does of the required medicine, a decrease in the adverse effects produced by medicines and better compliance.

Where medicines have not helped in recovery or remission, rTMS has the potential to become the Number 1 alternative treatment in such drug-resistant cases.


How does rTMS compare with ECT (Electroconvulsive therapy or Shock Therapy)?

ECT is a highly effective but invasive treatment for Major Depression which stimulates the entire brain with a large amount of electricity in a non-focussed way, thereby causing brief unconsciousness, lot of cognitive side effects & memory disturbances. rTMS is a non-invasive method stimulating the brain through the use of focussed magnetic fields in a variety of Psychiatric & Neurological disorders. rTMS has not been shown to cause memory loss or loss of consciousness. It does not require anaesthesia, unlike ECT.ECT is undoubtedly more effective as an anti-depressant in Major Depression but rTMS has a superior side effect profile to ECT, apart from the much larger spectrum of disorders where it is effective.


Are there any long term risks associated with rTMS?

Currently available data from repeated application of high intensity, time-varying magnetic fields to humans, as in magnetic resonance imaging, do not suggest that the long-term risks of rTMS are significant.


Are any investigations required before treatment commences or during the course of treatment?

Before treatment starts, an MRI of the head is advisable. This helps in an accurate determination 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 localization of the areas of the brain required to be targeted during the treatment can be done.


How long is the course of treatment?

Different disorders require different protocols for rTMS. Usually, 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, positive results are achieved within one or two weeks of beginning the treatment. Most patients tend to become aware of therapeutic benefit only in the second week of treatment. Late-responders may require sessions going into the third week to achieve significant reduction in symptoms.


What about long term or maintenance therapy?

All chronic illnesses 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 in the months following the initial phase of treatment. This would result in better outcome and lower doses of medication.


What does rTMS treatment cost?

Different disorders have different protocols for rTMS. Costs of different packages are available upon request.


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