Often likened to a lazy boy chair, the TMS chair is cushioned and reclines such that the patient rests comfortably with his or her head supported by a headrest. The doctor, nurse or TMS technician may ask the patient to remove any metallic jewelry such as earrings, large necklaces, headwear or bracelets prior to starting. This is because, while pulsing, the magnetic coil can interact with metallic devices within 1 foot away, which may cause the metal to heat up and become slightly uncomfortable during treatment. Once the patient is seated, a small cushion is placed against the right temple to hold the head in place. During treatment, the patient is not constricted or held down in the chair in any way.
Brain mapping is a procedure used to determine treatment location and energy level of TMS pulses required for optimum effect. Treatment location and energy level are tailored to individual patients, depending on size and shape of the head. Brain mapping takes place only one time, prior to the first treatment session, and it takes about 20-30 minutes to complete.
Though different TMS manufacturers have developed their own methods, the most commonly used brain mapping protocol is the one developed by Neuronetics Inc., which uses the NeuroStar TMS device. With this protocol, the patient is asked to hold up his or her right hand in a relaxed hitchhiker position while the elbow rests against a cushion. The attending physician gently places a magnetic coil against the middle left side of the patient’s head. Patients may hear and feel a light tap against the head—this is a single pulse emanating from the coil. This pulse is, in fact, electrically stimulating a portion of the motor cortex, or a group of neurons in the center top portion of the brain responsible for producing muscle contraction, that corresponds to hand and arm movement. When the pulse goes off, the patient will experience an involuntary twitch of the right hand, which will indicate to the doctor the region of the motor cortex that is being stimulated.
During brain mapping, the doctor and TMS technician or nurse together will observe hand movement corresponding to taps at various locations of the motor cortex. Once treatment location and energy levels are determined, the patient will proceed to the first TMS treatment session.
The standard treatment protocol for major depressive disorder (MDD) has the magnetic coil placed against the left dorsolateral prefrontal cortex (DLPFC), an area implicated in mood regulation, working memory, and cognitive control. The left DLPFC is also found to be underactive in patients with MDD. The patient will feel the coil against the top-left side of the head, just above the temple. When the patient is ready to begin treatment, the coil will deliver a rapid train of pulses: 10 Hz (or 10 pulses per second) over 4 consecutive seconds, with 26-second break before the next train of pulses. Though the patient may feel a tapping sensation against the head during the pulses, there is actually nothing physically tapping against the head. The sensation is merely due to nerves of the scalp that are being stimulated by the magnetic pulses.The mild tapping sensation may feel slightly uncomfortable for the first few sessions until the nerves in the scalp accommodate. Passing headache or mild tenderness in treatment area afterwards is common during the first week. Treatment does not cause drowsiness, though some patients reports feeling tired following initial sessions.During treatment, the patient is awake, as there is no use of anesthesia. Each session lasts about 37 minutes; treatment time may be shorter or longer depending on the specific protocol determined between doctor and patient. To pass the time, patients may watch television, read books or Kindle, listen to music, or chat with the TMS technician or nurse, who will stay throughout the session to ensure patient’s comfort and safety. Earplugs are provided for hearing protection, though patients are also allowed to use earphones.
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