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Transcranial magnetic stimulation (TMS) – A new vision for chronic depression

SC WW blogpost - late night thoughtsSavantCare has started providing FDA cleared Transcranial Magnetic Stimulation (TMS) for the treatment of major depressive disorder and obsessive compulsive disorder (OCD). TMS improves mood and anxiety symptoms by stimulating nerve cells with MRI strength magnetic fields. This process has no side effects.

TMS is usually used when medications and psychotherapy have failed to bring any significant improvements in adult patients suffering from depression or OCD.

Here’s how the process works.


This is a video demonstrating how to use the magneto TMS therapy system the magneto TMS therapy is indicated for the treatment of major depressive disorder in adult patients who have failed to receive satisfactory improvement from prior antidepressant medication in the current episode.

System Description


The magnetic TMS therapy system consists of a magnetic stimulator type R30 or X 100. The stimulator is an all-in-one standalone solution with a built-in display for the easy user interface.

The simulator is mounted on a trolley along with the systems isolation transformer, vacuum pump, and cooler unit.

The isolation transformer provides power for all components in the system including the stimulator, chair, cooler, and pump. The treatment chair is a fully adjustable chair designed for the comfort of the patient in combination with the vacuum pillow it ensures stable positioning of the patient’s head during the treatment.

Mounted to the trolley or chair is an articulated stainless-steel arm for easy and flexible positioning of the stimulation coil. The three articulations are released and fixed by a single central control knob, allowing the user to fix the coil in place by tightening a single mechanism.

The user also has the option to mount the arm on the backrest of the treatment chair or to a table or wall using a special mounting kit.

The system comes with two different coils one for the motor threshold determination and one for the actual repetitive transcranial magnetic stimulation procedure.

Connect the cooling hoses if these have been unplugged, and check that the cooler is turned on the place the handle of the cool B65 coil in the hold around the Flex arm tighten the knob to hold the coil securely.

SAFETY


Please be aware of the contraindications for mag Vita TMS therapy.
Contraindications include implanted electronic devices and/or conductive objects in or near the head and nonremovable metallic objects within 12 inches corresponding to 30 centimeters of the coil.

Patients having implanted devices that are activated or controlled in any way by physiological signals and or ferromagnetic or other magnetic sensitive metals implanted in their head must not receive mag vita TMS therapy.

Examples are :

  • Cochlear implants
  • Implanted Electrodes/Stimulators
  • Aneurysm clips or coils
  • Stents and bullet fragments

Failure to follow these restrictions could result in serious injury or death. To identify if a patient has one or more of the above-listed contraindications, or if any, of the other precautions listed in the user guide apply a standard questionnaire is recommended.

Please see the safety information in the user guide for an example.
Please read the user guide for a comprehensive explanation of the safety guidelines.

Getting Started


Before the initiation of any TMS treatment, the correct stimulation intensity for the procedure needs to be established.

The stimulation intensity of the therapeutic procedure is based on each patient’s individual sensitivity, also known as the patient’s motor threshold, with the Mag vita TMS therapy system, the MT is measured by observance of a visible muscle twitch of the right thumb after stimulation of the motor hotspot for the intrinsic hand muscles in the motor area on the left hemisphere in five out of ten simulations.

The lowest possible stimulation intensity needed to get a visible twitch of the thumb represents the patient’s motor threshold value. Because the motor threshold in any given individual has been shown to be state-dependent and variable.

The mag vita TMS therapy protocol specifies that the motor treshold value must be determined every two weeks during the six-week course of treatment.

Defining Motor Threshold


In order to begin a motor threshold determination procedure, turn on the mag Pro and attach the CB 60 coil, ensure that the marking plate is attached, for the motor threshold determination procedure, one will need a treatment cap for the patient earplugs, a marking pen, and measuring tape, for patients who are anxious about the procedure applying a few stimulations to the forearm may be helpful to get the patient familiar with the stimulation.

To start, write the patient’s ID on the cap and place it on the patient’s head with the central seam aligned to the midline, be sure the cap fits the patient’s head snugly. To find the area of the scalp above the motor cortex first identify the location of nasion and inion. The nasion is the intersection of the frontal bone and to nasal bones of the skull, it is the deepest depression on the midline between the nose, and forehead. Write the distance from the nasion to the edge of the cap on the cap.

The Inion is the most prominent projection of the occipital bone at the lower rear part of the skull measure the distance between the nasion and inion along the midline of the head, locate the halfway point between these two landmarks and market on the cap.

Next measure the distance between the tragus of each year be careful to have the imaginary line joining the truggy passed through the halfway point between the nasion and the inion.

Find the halfway point between the trachy and mark this as the vertex the motor cortex for the right thumb is located to the left and front of the vertex, make a mark at the point on the left side of the patient’s head, five centimeters lateral to the vertex, along the imaginary line joining the truggy of the ears, make a mark at the point along the midline five centimeter anterior to the vertex, draw a dotted line between the two points, along this line the motor threshold spot for the right thumb is located, the optimal coil orientation for finding the motor threshold is achieved by keeping the coil at an angle of 45 degrees to the midline, with the center of the coil in contact with the scalp such that the plane of the surface of the coil is tangential to the curvature of the head.

This orientation is obtained by keeping the straight edge of the marking plate parallel to the cap midline place the center of the coil, at the midpoint of the dotted line and start searching for the motor threshold spot by delivering single stimulations while moving the coil in small increments along the line while continuously observing the thumb for a twitch.

Start the stimulation and an intensity of 40 to 50%, if no response gradually increase the intensity until a response is observed, a random interval between the single stimulations of between six to nine seconds is recommended, once the location of the most robust response is found incrementally lower the intensity to find the lowest possible value where at which is still observed in five out of ten stimulations.

The stimulation intensity value is the individual patient’s motor threshold while holding the coil firmly in place at this location trace the contour along the front edge of the marking plate under the treatment cap, this is to indicate where the treatment coil is to be placed, record the motor threshold intensity shown on the mag pro in the patients treatment records, or, on the side of the cap.

Getting Ready For Treatment


Once the optimal motor threshold location and intensity are found, and the position for learning the treatment coil has been marked on the cap the motor threshold coils should be disconnected from the stimulator and replaced by the cool p65 treatment coil.

Remember to also connect the small limo connector before the actual treatment starts it is important to make sure the patient is comfortably seated with his or her head stabilized in a fixed position, use the remote control connected to the chair to adjust the footrest the seat and backrest to recline the patient into a comfortable position.

Make sure the vacuum pump is on and place the footswitch close to your foot, make sure the valve is open fit the vacuum pillow around the patient’s neck to give the most support possible, when the pillow is in a good position depress the footswitch to elevate the air in the pillow stiffening it in the chosen position, close, the valve.

Place the Treatment Coil


Before starting check that the cap is still in its correct position by checking that the distance from the nasion on to the edge of the cap hasn’t changed also check that the midline is still centered on the head, unlock the grip on the center joint of the Flex arm, to freely move the coil to the treatment spot, it is a good idea to make sure the arm in the lowest joint is placed in a vertical position which eases the operation of the coil, align the coil, on the treatment location by using the contoured line drawn on the cap, the center of the coil should be in good contact with the scalp, make sure the coil is placed tangentially to the head.

Set and Start the Treatment Protocol


Once the patient is positioned and the treatment coil is placed in the correct location, the operator can start the rTMS treatment protocol, meg Vita rTMS therapy systems come loaded with FDA and CEO proved our rTMS protocols as the default setting upon boot up the stimulator loads the default protocol automatically.

The user should double-check thesettings to confirm that the default protocol has been loaded correctly, after verification the operator navigates the software interface to the timing menu enables the stimulator sets the correct intensity the intensity corresponding to 120% of motor threshold and depresses the start button.

Once the our rTMS treatment session has been initiated the graphic display in the lower left part of the timing menu is populated with information about the protocol.

The total time and number of pulses in the protocol is shown as well as a progress bar that indicates how much of the protocol has been delivered and how much remains before the protocol reaches completion.

During the treatment it is possible to pause the protocol and resume from the point of pause using the pause button.

Set or Recall Protocol


If the stimulator does not boot up with a default protocol loaded, one can either recall it or define, it again to recall a protocol that has previously been defined and stored from the main menu used the pol scale to select the protocol to recall, depress the recall soft key.

The recalled protocol is now loaded and information about the protocol is displayed in the setup View window to the left of the display, to define a protocol manually confirm that the mode current direction and waveform are set to the correct values for the approved our TMS depression protocol.

The stimulator should operate in standard mode with a normal current direction and with a biphasic waveform, navigate to the turning page by depressing the timing button, on the timing page, set the actual protocol, use the arrow buttons to navigate through the various data fields, and use the pulse wheel to select the appropriate values.

The timing control should be set to sequence, and rest of the protocol settings are defined according to the user guide, once the correct settings have been selected one can enable the stimulator set the correct intensity which is 120% of the motor threshold value, and initiate a treatment session by depressing the start button.

To save a protocol first to find the mode waveform and current direction on the main page set the protocol parameters on the timing page then navigate to the configure menu using the configure button navigate to the uppermost data field in the configure menu and use the pulse field to choose one of the predefined headers for the protocol depress the save button.

The protocol is then saved under the chosen header and can be recalled from the main page by using the pulse field to select a protocol header from the different saved setups in the setup data field recall the protocol by depressing the recall button the setup is thus loaded and the information for the protocol is populated in the protocol setup menu in the left side of the display.

End of the Protocol


When the protocol has reached completion remove the coil from the patient’s head by loosening the joints on the articulated flex arm and moving the coil away from the patient, release the vacuum from the pillow by disconnecting the tube connecting it to its pump and opening the valve readjust the chair to allow the patient to get off of it without difficulty.

Second and Subsequent Treatment Sessions

When the patient returns for the subsequent sessions make sure to accurately reposition the cap in the same position it was during the initial session making sure that the distance from the nasin end to the edge of the cap is same as noted down from the first session.

Make sure the cap is properly aligned with the midline once the cap is positioned correctly prepare the patient for the treatment session.

Place the treatment coil on the treat location by using the contoured line marked on the cap just as was done during the first session, ensure the proper protocol is loaded navigate to the timing menu enable a stimulator, set the intensity to 120% of the patient’s motor threshold value and initiate rTMS session by pressing start.

Thank you for watching for further information please turn to the user guide or contact Meg venture you.




Published by SavantCare, On Jan 9, 2020