Transcranial magnetic stimulation
||The lead section of this article may need to be rewritten. (May 2014)|
|Transcranial magnetic stimulation|
Transcranial magnetic stimulation (schematic diagram)
Transcranial magnetic stimulation (TMS) is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain. TMS uses electromagnetic induction to induce weak electric currents using a rapidly changing magnetic field; this can cause activity in specific or general parts of the brain with little discomfort, allowing for study of the brain's functioning and interconnections. According to the United States National Institute of Mental Health, TMS "uses a magnet instead of an electrical current to activate the brain. An electromagnetic coil is held against the forehead and short electromagnetic pulses are administered through the coil. The magnetic pulse easily passes through the skull, and causes small electrical currents that stimulate nerve cells in the targeted brain region. Because this type of pulse generally does not reach further than two inches into the brain, scientists can select which parts of the brain will be affected and which will not be. The magnetic field is about the same strength as that of a magnetic resonance imaging (MRI) scan." A variant of TMS, repetitive transcranial magnetic stimulation (rTMS), has been tested as a treatment tool for various neurological and psychiatric disorders including migraine, stroke, Parkinson's disease, dystonia, tinnitus and depression.
Early attempts at stimulation of the brain using a magnetic field included those, in 1910, of Silvanus P. Thompson in London. The principle of inductive brain stimulation with eddy currents has been noted since the 20th century. The first successful TMS study was performed in 1985 by Anthony Barker and his colleagues at the Royal Hallamshire Hospital in Sheffield, England. Its earliest application demonstrated conduction of nerve impulses from the motor cortex to the spinal cord, stimulating muscle contractions in the hand. As compared to the previous method of transcranial stimulation proposed by Merton and Morton in 1980 in which direct electrical current was applied to the scalp, the use of electromagnets greatly reduced the discomfort of the procedure, and allowed mapping of the cerebral cortex and its connections.
- 1 Medical uses
- 2 Risks
- 3 Mechanism of action
- 4 FDA actions
- 5 Health insurance considerations
- 6 Technical information
- 7 Research
- 8 See also
- 9 References
- 10 Further reading
- 11 External links
The uses of TMS and rTMS can be divided into diagnostic and therapeutic uses.
TMS can be used clinically to measure activity and function of specific brain circuits in humans. The most robust and widely accepted use is in measuring the connection between the primary motor cortex and a muscle to evaluate damage from stroke, multiple sclerosis, amyotrophic lateral sclerosis, movement disorders, motor neuron disease and injuries and other disorders affecting the facial and other cranial nerves and the spinal cord. TMS has been suggested as a means of assessing short-interval intracortical inhibition (SICI) which measures the internal pathways of the motor cortex but this use has not yet been validated.
Studies of the use of TMS and rTMS to treat many neurological and psychiatric conditions have generally shown only modest effects with little confirmation of results. However, reviews have stated that rTMS appeared to be effective in the treatment of certain types of major depression under certain specific conditions.
A meta-analysis of 34 studies comparing rTMS to sham treatment for the acute treatment of depression found that rTMS was effective with an effect size of 0.55. This is comparable to commonly reported effect of medications for treatment of depression in the range of 0.17-0.46. However, this meta-analysis found that rTMS was worse than electroconvulsive therapy (ECT), although there were significantly fewer adverse effects with rTMS. An analysis of one of the studies included in the meta-analysis found that one extra remission from depression occurred for every 3 people given electroconvulsive therapy rather than rTMS.
One trial of rTMS in depression used an active "sham" placebo treatment that appeared to mimic the sound and scalp stimulation. A review of the trial's report has questioned the adequacy of the placebo, noting that treaters were able to guess whether patients were receiving treatment with active or sham TMS, better than chance.
A comprehensive safety study of rTMS in the treatment of major depression looked at three separate groups totalling over 300 patients. It found that rTMS was associated with a low incidence of side effects, most of which were mild to moderate. Additionally, only 4.5% of patients discontinued their participation during acute treatment because of adverse events. Although TMS is generally regarded as safe, the greatest acute risk is the rare occurrence of induced seizures and syncope (fainting). There have been 16 reports of TMS-related seizures (as of 2009), with seven reported before the publication of safety guidelines in 1998, and nine reported afterwards. The seizures are primarily associated with rTMS, although they have been reported following single-pulse TMS. Reports have stated that, in at least some cases, predisposing factors (medication, brain lesions or genetic susceptibility) may have contributed to the seizure. A review of nine seizures associated with rTMS that had been reported after 1998 stated that four seizures were within the safety parameters, four were outside of those parameters, and one had occurred in a healthy volunteer with no predisposing factors. A 2009 international consensus statement on TMS that contained this review concluded that based on the number of studies, subjects, and patients involved with TMS research, the risk of seizure with rTMS is considered very low.
Other adverse effects of TMS are:
- Discomfort or pain from the stimulation of the scalp and associated nerves and muscles on the overlying skin; this is more common with rTMS than single pulse TMS.
- Minor cognitive changes, and psychiatric symptoms (particularly a low risk of mania in depressed patients).
- Rapid deformation of the TMS coil produces a loud clicking sound that increases with the stimulation intensity and can affect hearing with sufficient exposure, which is particularly relevant for rTMS (hearing protection may be used to prevent this).
- rTMS in the presence of EEG-incompatible electrodes can result in electrode heating and, in severe cases, skin burns. Non-metallic electrodes are used if concurrent EEG data is required.
- Other side effects may be associated with TMS, such as alterations to the endocrine system, altered neurotransmitter, and immune system activity, but these side effects are considered lacking substantive proof.
Mechanism of action
From the Biot–Savart law
it has been shown that a current through a wire generates a magnetic field around that wire. Transcranial magnetic stimulation is achieved by quickly discharging current from a large capacitor into a coil to produce pulsed magnetic fields of 1-10 mT. By directing the magnetic field pulse at a targeted area of the brain, one can either depolarize or hyperpolarize neurons in the brain. The magnetic flux density pulse generated by the current pulse through the coil causes an electric field as explained by the Maxwell-Faraday equation,
The exact details of how TMS functions are still being explored. The effects of TMS can be divided into two types depending on the mode of stimulation:
- Single or paired pulse TMS causes neurons in the neocortex under the site of stimulation to depolarize and discharge an action potential. If used in the primary motor cortex, it produces muscle activity referred to as a motor evoked potential (MEP) which can be recorded on electromyography. If used on the occipital cortex, 'phosphenes' (flashes of light) might be perceived by the subject. In most other areas of the cortex, the participant does not consciously experience any effect, but his or her behaviour may be slightly altered (e.g., slower reaction time on a cognitive task), or changes in brain activity may be detected using sensing equipment.
- Repetitive TMS produces longer-lasting effects which persist past the initial period of stimulation. rTMS can increase or decrease the excitability of the corticospinal tract depending on the intensity of stimulation, coil orientation, and frequency. The mechanism of these effects is not clear, though it is widely believed to reflect changes in synaptic efficacy akin to long-term potentiation (LTP) and long-term depression (LTD).
MRI images, recorded during TMS of the motor cortex of the brain, have been found to match very closely with PET produced by voluntary movements of the hand muscles innervated by TMS, to 5–22 mm of accuracy. The localisation of motor areas with TMS has also been seen to correlate closely to MEG and also fMRI.
In January 2007, an advisory panel of the United States Food and Drug Administration (FDA) did not recommend clearance for marketing of an rTMS device, stating that the device appeared to be reasonably safe but had failed to demonstrate efficacy in a study of people with major depression who had not benefitted from prior adequate treatment with oral antidepressants during their current major depressive episode. The panel agreed that "unblinding was greater in the active group, and considering the magnitude of the effect size, it may have influenced the study results." However, the FDA determined in December 2008 that the rTMS device was sufficiently similar to existing devices that did not require a premarket approval application and allowed the device to be marketed in accordance with Section 510(k) of the Federal Food, Drug, and Cosmetic Act In March 2014, the FDA cleared this device "for the treatment of Major Depressive Disorder in adult patients who have failed to achieve satisfactory improvement from prior antidepressant medication in the current episode".
In July 2011, the FDA published a final rule in the Federal Register that classified the rTMS system into Class II (special controls) "in order to provide a reasonable assurance of safety and effectiveness of these devices". The rule identified the rTMS system as "an external device that delivers transcranial pulsed magnetic fields of sufficient magnitude to induce neural action potentials in the prefrontal cortex to treat the symptoms of major depressive disorder without inducing seizure in patients who have failed at least one antidepressant medication and are currently not on any antidepressant therapy". An FDA guidance document issued in conjunction with the final rule describes the special controls that support the classification of the rTMS system into Class II.
Soon after the FDA initially cleared the device, several members of Public Citizen stated in a letter to the editor of the medical journal Neuropsychopharmacology that the FDA seemed to have based its decision on a post-hoc analysis that did not establish the effectiveness of rTMS for the treatment of depression. The writers of the letter expressed their concern that patients would be diverted from therapies such as antidepressant medications that have an established history of effectiveness.
In December 2013, in a decision that was partially based on a post hoc analysis for the primary end point for effectiveness, the FDA permitted the marketing in the United States of a TMS device intended for the treatment of migraine headache. The FDA classified the device into Class II (special controls). The FDA defined this type of device as being one that "delivers brief duration, rapidly alternating, or pulsed, magnetic fields that are externally directed at spatially discrete regions of the brain to induce electric currents for the treatment of migraine headache".
Health insurance considerations
Commercial health insurance
In July 2011, the Technology Evaluation Center (TEC) of the Blue Cross Blue Shield Association, in cooperation with the Kaiser Foundation Health Plan and the Southern California Permanente Medical Group, determined that TMS for the treatment of depression did not meet the TEC's criteria, which assess whether a technology improves health outcomes such as length of life, quality of life and functional ability. The TEC's report stated that "the meta-analyses and recent clinical trials of TMS generally show statistically significant effects on depression outcomes at the end of the TMS treatment period. However, there is a lack of rigorous evaluation beyond the treatment period", which was, with a few exceptions, one to four weeks. The Blue Cross Blue Shield Association's medical advisory panel concluded that "the available evidence does not permit conclusions regarding the effect of TMS on health outcomes or compared with alternatives."
In 2013, several commercial health insurance plans in the United States, including Anthem, Health Net, and Blue Cross Blue Shield of Nebraska and of Rhode Island, covered TMS for the treatment of depression. In contrast, UnitedHealthcare issued a medical policy for TMS in 2013 that stated there is insufficient evidence that the procedure is beneficial for health outcomes in patients with depression. UnitedHealthcare noted that methodological concerns raised about the scientific evidence studying TMS for depression include small sample size, lack of a validated sham comparison in randomized controlled studies, and variable uses of outcome measures. Other commercial insurance plans whose 2013 medical coverage policies stated that the role of TMS in the treatment of depression and other disorders had not been clearly established or remained investigational included Aetna, Cigna and Regence.
There is no national policy for Medicare coverage of TMS in the United States. Policies vary according to local coverage determinations (LCDs) that Medicare administrative contractors (MACs) for the Centers for Medicare and Medicaid Services (CMS) make for geographical areas over which they have jurisdiction. CMS presently has ten to fifteen MAC jurisdictions that each cover several U.S. states.
LCDs for individual MAC jurisdictions can change over time. For example:
- In early 2012, the efforts of TMS treatment advocates resulted in the establishment by a MAC with jurisdiction over New England of the first Medicare coverage policy for TMS in the United States. However, a new MAC for the same jurisdiction subsequently determined that Medicare would not cover services for TMS performed in New England on or after October 25, 2013.
- In August 2012, the MAC whose jurisdiction covered Arkansas, Louisiana, Mississippi, Colorado, Texas, Oklahoma and New Mexico determined that, based on limitations in the published literature,
... the evidence is insufficient to determine rTMS improves health outcomes in the Medicare or general population. ... The contractor considers repetitive transcranial magnetic stimulation (rTMS) not medically necessary when used for its FDA-approved indication and for all off-label uses.
- However, the same MAC subsequently determined that Medicare would cover TMS for the treatment of depression for services performed within the MAC's jurisdiction on or after December 5, 2013,
- In December 2012, Medicare began covering TMS for the treatment of depression in Tennessee, Alabama and Georgia.
CMS maintains a searchable database that enables users to find current Medicare LCDs for TMS for individual U.S. states.
National Health Service
The United Kingdom's National Institute for Health and Care Excellence (NICE) issues guidance to the National Health Service (NHS) in England, Wales, Scotland and Northern Ireland. NICE guidance does not cover whether or not the NHS should fund a procedure. Local NHS bodies (primary care trusts and hospital trusts) make decisions about funding after considering the clinical effectiveness of the procedure and whether the procedure represents value for money for the NHS.
The NICE has issued guidance to the NHS for TMS for the following two indications:
- Treatment of severe depression (IPG 242)
- Treating and preventing migraine (IPG 477)
1. TMS for treatment of severe depression
The NICE evaluated TMS for severe depression (IPG 242) in 2007. The Institute subsequently considered TMS for reassessment in January 2011 but did not change its evaluation. The Institute's recommendation states:
Current evidence suggests that there are no major safety concerns associated with transcranial magnetic stimulation (TMS) for severe depression. There is uncertainty about the procedure's clinical efficacy, which may depend on higher intensity, greater frequency, bilateral application and/or longer treatment durations than have appeared in the evidence to date. TMS should therefore be performed only in research studies designed to investigate these factors.
2. TMS for treating and preventing migraine
In January 2014, the NICE reported the results of an evaluation of TMS for treating and preventing migraine (IPG 477). The Institute's recommendation states:
Evidence on the efficacy of TMS for the treatment of migraine is limited in quantity and for the prevention of migraine is limited in both quality and quantity. Evidence on its safety in the short and medium term is adequate but there is uncertainty about the safety of long-term or frequent use of TMS. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit or research. ....
TMS uses electromagnetic induction to generate an electric current across the scalp and skull without physical contact. A plastic-enclosed coil of wire is held next to the skull and when activated, produces a magnetic field oriented orthogonal to the plane of the coil. The magnetic field passes unimpeded through the skin and skull, inducing an oppositely directed current in the brain that activates nearby nerve cells in much the same way as currents applied directly to the cortical surface.
The path of this current is difficult to model because the brain is irregularly shaped and electricity and magnetism are not conducted uniformly throughout its tissues. The magnetic field is about the same strength as an MRI, and the pulse generally reaches no more than 5 centimeters into the brain unless using the deep transcranial magnetic stimulation variant of TMS. Deep TMS can reach up to 6 cm into the brain to stimulate deeper layers of the motor cortex, such as that which controls leg motion.
The design of transcranial magnetic stimulation coils used in either treatment or diagnostic/experimental studies may differ in a variety of ways. These differences should be considered in the interpretation of any study result, and the type of coil used should be specified in the study methods for any published reports.
The most important considerations include:
- the type of material used to construct the core of the coil
- the geometry of the coil configuration
- the biophysical characteristics of the pulse produced by the coil.
With regard to coil composition, the core material may be either a magnetically inert substrate (i.e., the so-called ‘air-core’ coil design), or possess a solid, ferromagnetically active material (i.e., the so-called ‘solid-core’ design). Solid core coil design result in a more efficient transfer of electrical energy into a magnetic field, with a substantially reduced amount of energy dissipated as heat, and so can be operated under more aggressive duty cycles often mandated in therapeutic protocols, without treatment interruption due to heat accumulation, or the use of an accessory method of cooling the coil during operation. Varying the geometric shape of the coil itself may also result in variations in the focality, shape, and depth of cortical penetration of the magnetic field. Differences in the coil substance as well as the electronic operation of the power supply to the coil may also result in variations in the biophysical characteristics of the resulting magnetic pulse (e.g., width or duration of the magnetic field pulse). All of these features should be considered when comparing results obtained from different studies, with respect to both safety and efficacy.
A number of different types of coils exist, each of which produce different magnetic field patterns. Some examples:
- round coil: the original type of TMS coil
- figure-eight coil (i.e., butterfly coil): results in a more focal pattern of activation
- double-cone coil: conforms to shape of head, useful for deeper stimulation
- four-leaf coil: for focal stimulation of peripheral nerves
- H-coil: for deep transcranial magnetic stimulation
Design variations in the shape of the TMS coils allow much deeper penetration of the brain than the standard depth of 1.5-2.5 cm. Circular crown coils, Hesed (or H-core) coils, double cone coils, and other experimental variations can induce excitation or inhibition of neurons deeper in the brain including activation of motor neurons for the cerebellum, legs and pelvic floor. Though able to penetrate deeper in the brain, they are less able to produce a focused, localized response and are relatively non-focal.
Devices available for transcranial magnetic stimulation include:
- Coils: This is the main component of a TMS system and the part applied directly to the head. A coil can be of different types.
- Stimulators: The stimulator is the machine delivering high intensity pulses of electrical current in the coil to produce electromagnetic induction in the brain. It allows setting all important stimulation parameters and defining complex patterns of pulses to be delivered to the brain. In case of rTMS, the stimulator often contains a cooling system to evacuate the heat produced by repetitive pulses of current.
- Neuronavigation systems: Neuronavigation is a technique originally used in neurosurgery. It makes uses of a software system able to load MRI and possibly fMRI data to localize stimulation spots directly in a 3D reconstruction of the brain. Combined with optical motion tracking systems focusing on the head, neuro-navigation provides computer-assisted TMS allowing for personalized stimulations. In traditional TMS indeed, the coil is positioned based on anatomical landmarks on the skull (including, but not limited to, the inion or the nasion), thereby deriving the location of stimulation spots from the anatomical position of the brain in the head.
- Coil positioning systems: positioning systems help to keep the coil in place for the whole duration of a TMS session. Such systems can be simple static coil holders or computer-controlled robotic arms. Static holders need to be manually adjusted at the stimulation site. Robotic arms are controlled by neuronavigation to adjust the coil position automatically.
Areas of research include the rehabilitation of aphasia and motor disability after stroke, tinnitus, anxiety disorders, obsessive-compulsive disorder, amyotrophic lateral sclerosis, multiple sclerosis, epilepsy, Alzheimer's disease, Parkinson's disease,schizophrenia, substance abuse, addiction, and posttraumatic stress disorder (PTSD).
It is difficult to establish a convincing form of "sham" TMS to test for placebo effects during controlled trials in conscious individuals, due to the neck pain, headache and twitching in the scalp or upper face associated with the intervention. "Sham" TMS manipulations can affect cerebral glucose metabolism and MEPs, which may confound results. This problem is exacerbated when using subjective measures of improvement. Placebo responses in trials of rTMS in major depression are negatively associated with refractoriness to treatment, vary among studies and can influence results. Depending on the research question asked and the experimental design, matching the discomfort of rTMS to distinguish true effects from placebo can be an important and challenging issue.
- Cranial electrotherapy stimulation
- Electrical brain stimulation
- Transcranial direct current stimulation
- Electroconvulsive therapy
- Cortical stimulation mapping
- National Institute of Mental Health (2009). "Brain Stimulation Therapies". nimh.nih.gov. Retrieved 12 December 2013.
- Anthony T. Barker and Ian Freeston (2007). "Transcranial magnetic stimulation". scholarpedia.org. Retrieved 28 June 2013.
- Barker, AT; Jalinous, R; Freeston, IL (1985). "Non-Invasive Magnetic Stimulation of Human Motor Cortex". The Lancet 325 (8437): 1106–1107. doi:10.1016/S0140-6736(85)92413-4. PMID 2860322.
- Merton, PA; Morton, HB (1980). "Stimulation of the cerebral cortex in the intact human subject". Nature 285 (5762): 227. doi:10.1038/285227a0. PMID 7374773.
- Groppa, S.; Oliviero, A.; Eisen, A.; Quartarone, A.; Cohen, L. G.; Mall, V.; Kaelin-Lang, A.; Mima, T.; Rossi, S.; Thickbroom, G. W.; Rossini, P. M.; Ziemann, U.; Valls-Solé, J.; Siebner, H. R. (2012). "A practical guide to diagnostic transcranial magnetic stimulation: Report of an IFCN committee". Clinical Neurophysiology 123 (5): 858–882. doi:10.1016/j.clinph.2012.01.010. PMID 22349304.
- Rossini, P; Rossi, S (2007). "Transcranial magnetic stimulation: diagnostic, therapeutic, and research potential". Neurology 68 (7): 484–488. doi:10.1212/01.wnl.0000250268.13789.b2. PMID 17296913.
- Dimyan, MA; Cohen, LG (2009). "Contribution of Transcranial Magnetic Stimulation to the Understanding of Functional Recovery Mechanisms After Stroke". Neurorehabilitation and Neural Repair 24 (2): 125–135. doi:10.1177/1545968309345270. PMC 2945387. PMID 19767591.
- Nowak, D; Bösl, K; Podubeckà, J; Carey, J (2010). "Noninvasive brain stimulation and motor recovery after stroke". Restorative Neurology and Neuroscience 28 (4): 531–544. doi:10.3233/RNN-2010-0552. PMID 20714076.
- Kujirai, T.; Caramia, M. D.; Rothwell, J. C.; Day, B. L.; Thompson, P. D.; Ferbert, A.; Wroe, S.; Asselman, P.; Marsden, C. D. (1993). "Corticocortical inhibition in human motor cortex". The Journal of physiology 471: 501–519. PMC 1143973. PMID 8120818.
- Slotema, C. W.; Blom, J. D.; Hoek, H. W.; Sommer, I. E. C. (2010). "Should We Expand the Toolbox of Psychiatric Treatment Methods to Include Repetitive Transcranial Magnetic Stimulation (rTMS)?". The Journal of Clinical Psychiatry 71 (7): 873–884. doi:10.4088/JCP.08m04872gre. PMID 20361902.
- (1) Martin, JL; Barbanoj, MJ; Schlaepfer, TE; Thompson, E; Pérez, V; Kulisevsky, J (2003). "Repetitive transcranial magnetic stimulation for the treatment of depression. Systematic review and meta-analysis". The British journal of psychiatry : the journal of mental science 182: 480–491. PMID 12777338.
(2) Bersani, FS; Minichino, FS; Capra, E; Bonanno, R; Pannese, C; Salviati, M; Chiaie, D; Biondi, M (2012). "ECT, rTMS, and deepTMS in pharmacoresistant drug-free patients with unipolar depression: A comparative review". Neuropsychiatric Disease and Treatment 8: 55–64. doi:10.2147/NDT.S27025. PMC 3280107. PMID 22347797.
- Lefaucheur, JP; André-Obadia, N; Antal, A; Ayache, SS; Baeken, C; Benninger, DH; Cantello, RM; Cincotta M; de Carvalho, M; De Ridder, D; Devanne, H; Di Lazzaro, V; Filipović, SR; Hummel, FC; Jääskeläinen, SK; Kimiskidis, VK; Koch, G; Langguth, B; Nyffeler, T; Oliviero, A; Padberg, F; Poulet, E; Rossi, S; Rossini, PM; Rothwell, JC; Schönfeldt-Lecuona, C; Siebner, HR; Slotema, CW, Stagg, CJ, Valls-Sole, J; Ziemann, U; Paulus, W; Garcia-Larrea, L (2014). "Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS)". Clinical Neurophysiology. doi:10.1016/j.clinph.2014.05.021. PMID 25034472.
- Marangell, LB; Martinez, M; Jurdi, RA; Zboyan, H (2007). "Neurostimulation therapies in depression: a review of new modalities". Acta Psychiatrica Scandinavica 116 (3): 174–181. doi:10.1111/j.1600-0447.2007.01033.x. PMID 17655558.
- (1) Medical Advisory Secretariat (2004). "Repetitive transcranial magnetic stimulation for the treatment of major depressive disorder: an evidence-based analysis" (pdf). Ontario Health Technology Assessment Series 4 (7). Archived from the original on 2012-11-28. Retrieved 2012-11-28.
(2) Schutter, D (2008). "Antidepressant efficacy of high-frequency transcranial magnetic stimulation over the left dorsolateral prefrontal cortex in double-blind sham-controlled designs: a meta-analysis". Psychological Medicine 39 (1): 65–75. doi:10.1017/S0033291708003462. PMID 18447962.
(3) Lam, RW; Chan, P; Wilkins-Ho, M; Yatham, LN (2008). "Repetitive transcranial magnetic stimulation for treatment-resistant depression: A systematic review and metaanalysis". Canadian journal of psychiatry. Revue canadienne de psychiatrie 53 (9): 621–631. PMID 18801225.
(4) Dell'Osso, B; Camuri, G; Castellano, F; Vecchi, V; Benedetti, M; Bortolussi, S; Altamura, AC (2011). "Meta-Review of Metanalytic Studies with Repetitive Transcranial Magnetic Stimulation (rTMS) for the Treatment of Major Depression". Clinical Practice & Epidemiology in Mental Health 7: 167–177. doi:10.2174/1745017901107010167. PMC 3227860. PMID 22135698.
(5) George, MS; Post, RM (2011). "Daily Left Prefrontal Repetitive Transcranial Magnetic Stimulation for Acute Treatment of Medication-Resistant Depression". American Journal of Psychiatry 168 (4): 356–364. doi:10.1176/appi.ajp.2010.10060864. PMID 21474597.
(6) Gaynes BN, Lux L, Lloyd S, Hansen RA, Gartlehner G, Thieda P, Brode S, Swinson Evans T, Jonas D, Crotty K, Viswanathan M, Lohr KN, Research Triangle Park, North Carolina (September 2011). "Nonpharmacologic Interventions for Treatment-Resistant Depression in Adults. Comparative Effectiveness Review Number 33. (Prepared by RTI International-University of North Carolina (RTI-UNC) Evidence-based Practice Center)". AHRQ Publication No. 11-EHC056-EF. Rockville, Maryland: Agency for Healthcare Research and Quality. p. 36. Archived from the original on 2012-10-11. Retrieved 2011-10-11.
(7) Dirmaier, J; Steinmann, M; Krattenmacher, T; Watzke, B; Barghaan, D; Koch, U; Schulz, H (2012). "Non-pharmacological treatment of depressive disorders: A review of evidence-based treatment options". Reviews on recent clinical trials 7 (2): 141–149. doi:10.2174/157488712800100233. PMID 22353197.
(8) Bersani, FS; Minichino, A; Enticott, PG; Mazzarini, L; Khan, N; Antonacci, G; Raccah, RN; Salviati, M; Delle Chiaie, R; Bersani, G; Fitzgerald, PB; Biondi, M (2013). "Deep transcranial magnetic stimulation as a treatment for psychiatric disorders: A comprehensive review". European Psychiatry 28 (1): 30–39. doi:10.1016/j.eurpsy.2012.02.006. PMID 22559998.
(9) Fitzgerald, PB; Daskalakis, ZJ (2013). Repetitive Transcranial Magnetic Stimulation for Depressive Disorders. Berlin Heidelberg: Springer-Verlag. doi:10.1007/978-3-642-36467-9. ISBN 978-3-642-36466-2. At Google Books.
(10) Hovington, CL; McGirr, A; Lepage, M; Berlim, MT (2013). "Repetitive transcranial magnetic stimulation (rTMS) for treating major depression and schizophrenia: a systematic review of recent meta-analyses". Annals of Medicine 45 (4): 308–321. doi:10.3109/07853890.2013.783993. PMID 23687987.
(11) Berlim, MT; van den Eynde, F; Tovar-Perdomo, S; Daskalakis, ZJ (2014). "Response, remission and drop-out rates following high-frequency repetitive transcranial magnetic stimulation (rTMS) for treating major depression: a systematic review and meta-analysis of randomized, double-blind and sham-controlled trials". Psychological Medicine 44 (2): 225–239. doi:10.1017/S0033291713000512. PMID 23507264.
- Eranti, S.; Mogg, A.; Pluck, G.; Landau, S.; Purvis, R.; Brown, R. G.; Howard, R.; Knapp, M.; Philpot, M.; Rabe-Hesketh, S.; Romeo, R.; Rothwell, J.; Edwards, D.; McLoughlin, D. M. (2007). "A Randomized, Controlled Trial with 6-Month Follow-Up of Repetitive Transcranial Magnetic Stimulation and Electroconvulsive Therapy for Severe Depression". American Journal of Psychiatry 164 (1): 73–81. doi:10.1176/appi.ajp.164.1.73. PMID 17202547.
- Lapitska, N; Gosseries, O; Delvaux, V; Overgaard, M; Nielsen, F; Maertens De Noordhout, A; Moonen, G; Laureys, S (2009). "Transcranial magnetic stimulation in disorders of consciousness". Reviews in the neurosciences 20 (3-4): 235–50. PMID 20157993.
- Li, H; Wang, J; Li, C; Xiao, Z (Sep 17, 2014). "Repetitive transcranial magnetic stimulation (rTMS) for panic disorder in adults.". The Cochrane database of systematic reviews 9: CD009083. PMID 25230088.
- Mattes, Jeffrey A (2010-06-29). "TMS: Does it Really Work". Archives of General Psychiatry (American Medical Association). Archived from the original on 2011-01-16. Retrieved 2012-08-01.
- Janicak, PG; O'Reardon, JP; Sampson, SM; Husain, MM; Lisanby, SH; Rado, JT; Heart, KL; Demitrack, MA (2008). "Transcranial magnetic stimulation in the treatment of major depressive disorder: a comprehensive summary of safety experience from acute exposure, extended exposure, and during reintroduction treatment". The Journal of clinical psychiatry 69 (2): 222–32. doi:10.4088/jcp.v69n0208. PMID 18232722.
- Rossi, S; Hallett, M; Rossini, PM; Pascual-Leone, A; Safety of TMS Consensus Group (2009). "Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research". Clinical Neurophysiology 120 (12): 2008–2039. doi:10.1016/j.clinph.2009.08.016. PMC 3260536. PMID 19833552.
- Fitzgerald, PB; Daskalakis, ZJ (2013). "7. rTMS-Associated Adverse Events". Repetitive Transcranial Magnetic Stimulation for Depressive Disorders. Berlin Heidelberg: Springer-Verlag. pp. 81–90. doi:10.1007/978-3-642-36467-9. ISBN 978-3-642-36466-2. At Google Books.
- Wassermann, EM (1998). "Risk and safety of repetitive transcranial magnetic stimulation: Report and suggested guidelines from the International Workshop on the Safety of Repetitive Transcranial Magnetic Stimulation, June 5–7, 1996". Electroencephalography and Clinical Neurophysiology/Evoked Potentials Section 108: 1–9. doi:10.1016/S0168-5597(97)00096-8. PMID 9474057.
- "Transcranial Magnetic Stimulation (TMS)". National Alliance on Mental Illness. Retrieved 2008-12-15.
- Roth, BJ; Pascual-Leone, A; Cohen, LG; Hallett, M (1992). "The heating of metal electrodes during rapid-rate magnetic stimulation: A possible safety hazard". Electroencephalography and Clinical Neurophysiology/Evoked Potentials Section 85 (2): 116. doi:10.1016/0168-5597(92)90077-O. PMID 1373364.
- V. Walsh and A. Pascual-Leone, "Transcranial Magnetic Stimulation: A Neurochronometrics of Mind." Cambridge, Massachusetts: MIT Press, 2003.
- Pascual-Leone A; Davey N; Rothwell J; Wassermann EM; Puri BK (2002). Handbook of Transcranial Magnetic Stimulation. London: Edward Arnold. ISBN 0-340-72009-3.
- Fitzgerald, P; Fountain, S; Daskalakis, Z (2006). "A comprehensive review of the effects of rTMS on motor cortical excitability and inhibition". Clinical Neurophysiology 117 (12): 2584–2596. doi:10.1016/j.clinph.2006.06.712. PMID 16890483.
- Wassermann, EM; Wang, B; Zeffiro, TA; Sadato, N; Pascual-Leone, A; Toro, C; Hallett, M (1996). "Locating the Motor Cortex on the MRI with Transcranial Magnetic Stimulation and PET". NeuroImage 3 (1): 1–9. doi:10.1006/nimg.1996.0001. PMID 9345470.
- T. Morioka, T. Yamamoto, A. Mizushima, S. Tombimatsu, H. Shigeto, K. Hasuo, S. Nishio, K. Fujii and M. Fukui. Comparison of magnetoencephalography, functional MRI, and motor evoked potentials in the localization of the sensory-motor cortex. Neurol. Res., vol. 17, no. 5, pp. 361-367. 1995
- Terao, Y; Ugawa, Y; Sakai, K; Miyauchi, S; Fukuda, H; Sasaki, Y; Takino, R; Hanajima, R; Furubayashi, T; püTz, B; Kanazawa, I (1998). "Localizing the site of magnetic brain stimulation by functional MRI". Experimental Brain Research 121 (2): 145. doi:10.1007/s002210050446.
- Scudiero, JL (2007-01-26). "Brief Summary From the Neurological Devices Panel Meeting - January 26, 2007". FDA. Retrieved 2010-07-14. "The Panel's consensus was that the efficacy was not established; some stated that the device's effectiveness was "small," "borderline," "marginal" and "of questionable clinical significance.""
- Melkerson, MN (2008-12-16). "Special Premarket 510(k) Notification for NeuroStar® TMS Therapy System for Major Depressive Disorder" (pdf). Food and Drug Administration. Retrieved 2010-07-16.
- "K133408: 510(k) Summary: Neuronetics NeuroStar® TMS Therapy System" (pdf). U.S. Department of Health and Human Services: Food and Drug Administration: Center for Devices and Radiological Health. 2014-03-28. p. 2. Archived from the original on 2014-07-23. Retrieved 2014-07-23.
- Stade, NK, Deputy Director for Policy, Center for Devices and Radiological Health, Food and Drug Administration, United States Department of Health and Human Services (2011-07-26). "Medical Devices; Neurological Devices; Classification of Repetitive Transcranial Magnetic Stimulation System: Final rule". Federal Register (United States Government Printing Office) 76 (143): 44489–44491. Retrieved 2011-08-11.
- U.S. Department of Health and Human Services: Food and Drug Administration: Center for Devices and Radiological Health: Office of Device Evaluation: Division of Ophthalmic, Neurological and Ear, Nose and Throat Devices: Neurodiagnostic and Neurotherapeutic Devices Branch (2011-07-26). "Guidance for Industry and FDA Staff - Class II Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems". U.S. Food and Drug Administration. Retrieved 2011-08-10.
- Hines, JZ; Lurie, P; Wolfe SM, Sidney M (2009). "Reply to Lisanby et al.: Post hoc analysis does not establish effectiveness of rTMS for depression" (pdf). Neuropsychopharmacology 34 (8): 2053–2054. doi:10.1038/npp.2009.22. PMID 19528946.
- (1) "Decision Summary: DE NOVO CLASSIFICATION REQUEST FOR CERENA TRANSCRANIAL MAGNETIC STIMULATOR (TMS) DEVICE". 510(k) premarket notification number K130556: NEURALIEVE CERENA TRANSCRANIAL MAGNETIC STIMULATOR. Silver Spring, Maryland: United States Food and Drug Administration. Retrieved 2014-02-16. "With a post-hoc analysis of these 113 subjects, the primary endpoint (proportion of subjects who were free of pain 2 hours after treatment) analysis demonstrated a statistically significant 21.07% difference in favor of the device over the sham device (37.74% for Cerena and 16.67% for sham, p=0.0181)."
(2) Foy, Jonette, Deputy Director for Engineering and Science Review, Office of Device Evaluation Center for Devices and Radiological Health, United States Food and Drug Administration (2013-12-13). "Letter to eNeura Therapeutics LLC re. Cerena Transcranial Magnetic Stimulator: Evaluation of Automatic Class III Designation – De Novo Request". 510(k) premarket notification number K130556: NEURALIEVE CERENA TRANSCRANIAL MAGNETIC STIMULATOR. Silver Spring, Maryland: United States Food and Drug Administration. Retrieved 2014-02-16.
- "Product Classification: Transcranial Magnetic Stimulator For The Treatment Of Migraine Headache". Silver Spring, Maryland: United States Food and Drug Administration. 2014-02-10. Retrieved 2014-02-16.
- "Technology Evaluation Center Criteria". Technology Evaluation Center (TEC)]. Blue Cross Blue Shield Association. Retrieved 2013-12-11.
- "Transcranial Magnetic Stimulation for Depression". TEC Assessment Program (Blue Cross Blue Shield Association) 26 (3). July 2011. Archived from the original on 2012-10-12. Retrieved 2012-10-12.
- (1) Anthem (2013-04-16). "Medical Policy: Transcranial Magnetic Stimulation for Depression and Other Neuropsychiatric Disorders". Policy No. BEH.00002. Anthem. Archived from the original on 2013-12-11. Retrieved 2013-12-11.
(2) Health Net (March 2012). "National Medical Policy: Transcranial Magnetic Stimulation". Policy Number NMP 508. Health Net. Archived from the original on 2012-10-11. Retrieved 2012-09-05.
(3) Blue Cross Blue Shield of Nebraska (2011-05-2011). "Medical Policy Manual". Section IV.67. Blue Cross Blue Shield of Nebraska. Archived from the original on 2012-10-11. Check date values in:
(4) Blue Cross Blue Shield of Rhode Island (2012-05-15). "Medical Coverage Policy: Transcranial Magnetic Stimulation for Treatment of Depression and Other Psychiatric/Neurologic Disorders". Blue Cross Blue Shield of Rhode Island. Archived from the original on 2012-10-11. Retrieved 2012-09-05.
- UnitedHealthcare (2013-12-01). "Transcranial Magnetic Stimulation". UnitedHealthCare. p. 2. Archived from the original on 2013-12-11. Retrieved 2013-12-11.
- (1) Aetna (2013-10-11). "Clinical Policy Bulletin: Transcranial Magnetic Stimulation and Cranial Electrical Stimulation". Number 0469. Aetna. Archived from the original on 2013-12-11. Retrieved 2013-12-11.
(2) Cigna (2013-01-15). "Cigna Medical Coverage Policy: Transcranial Magnetic Stimulation". Coverage Policy Number 0383. Cigna. Archived from the original on 2013-12-11. Retrieved 2013-12-11.
(3) Regence (2013-06-01). "Medical Policy: Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders". Policy No. 17. Regence. Archived from the original on 2013-12-11. Retrieved 2013-12-11.
- (1) "Medicare Administrative Contractors". Centers for Medicare and Medicaid Services. 2013-07-10. Archived from the original on 2014-02-17. Retrieved 2014-02-14.
(2) "MAC Jurisdictions". Medicare Administrative Contractors. Centers for Medicare and Medicaid Services. 2014-02-14. Archived from the original on 2014-02-17. Retrieved 2014-02-17.
- (1) NHIC, Corp. (2013-10-24). "Local Coverage Determination (LCD) for Repetitive Transcranial Magnetic Stimulation (rTMS) (L32228)". Centers for Medicare and Medicaid Services. Retrieved 2014-02-17.
(2) "Important Treatment Option for Depression Receives Medicare Coverage". Press Release. PBN.com: Providence Business News. 2012-03-30. Archived from the original on 2012-10-11. Retrieved 2012-10-11.
(3) The Institute for Clinical and Economic Review (June 2012). "Coverage Policy Analysis: Repetitive Transcranial Magnetic Stimulation (rTMS)". The New England Comparative Effectiveness Public Advisory Council (CEPAC). Archived from the original on 2013-12-11. Retrieved 2013-12-11.
(4) "Transcranial Magnetic Stimulation Cites Influence of New England Comparative Effectiveness Public Advisory Council (CEPAC)". Berlin, Vermont: Central Vermont Medical Center. 2012-02-06. Archived from the original on 2012-10-12. Retrieved 2012-10-12.
- National Government Services, Inc. (2013-10-25). "Local Coverage Determination (LCD): Transcranial Magnetic Stimulation (L32038)". Centers for Medicare and Medicaid Services. Retrieved 2014-02-17.
- Novitas Solutions, Inc. (2013-12-04). "LCD L32752 - Transcranial Magnetic Stimulation for Depression". Contractor's Determination Number L32752. Centers for Medicare and Medicaid Services. Retrieved 2014-02-17.
- Novitas Solutions, Inc. (2013-12-05). "LCD L33660 - Transcranial Magnetic Stimulation (TMS) for the Treatment of Depression". Contractor's Determination Number L33660. Centers for Medicare and Medicaid Services. Retrieved 2014-02-17.
- (1) Cahaba Government Benefit Administrators®, LLC (2012-12-01). "Local Coverage Determination (LCD): Medicine: Repetitive Transcranial Magnetic Stimulation (rTMS) for Resistant Depression (L32834)". Retrieved 2014-02-17.
(2)Nannie, Phillip (2012-10-31). "Medicare agrees to cover TMS treatment for depression in TN, GA, AL". NashvillePost.com. Nashville, Tennessee: SouthComm Communications, Inc. Archived from the original on 2013-12-11. Retrieved 2013-11-13.
- "Advanced Search: Transcranial Magnetic Stimulation". Centers for Medicare and Medicaid Services. Retrieved 2014-02-17.
- "Transcranial magnetic stimulation for severe depression (IPG 242)" (pdf). London, England: National Institute for Health and Clinical Excellence. November 2007. ISBN 1-84629-556-4. Archived from the original on 2014-02-19. Retrieved 2014-02-18.
- "Interventional Procedures Programme: Interventional procedure overview of transcranial magnetic stimulation for severe depression (IP346)" (pdf). November 2006. Archived from the original on 2014-02-19. Retrieved 2014-02-18.
- "Transcranial magnetic stimulation for severe depression (IPG242)". London, England: National Institute for Health and Clinical Excellence. 2011-03-04. Archived from the original on 2012-11-27. Retrieved 2012-11-27.
- (1) "Transcranial magnetic stimulation for treating and preventing migraine" (pdf). NICE interventional procedure guidance 477. London, England: National Institute for Health and Clinical Excellence. January 2014. Archived from the original on 2014-02-19. Retrieved 2014-02-18.
(2) "Interventional Procedures Programme: Interventional procedure overview of transcranial magnetic stimulation for treating and preventing migraine (IP 866)" (pdf). London, England: National Institute for Health and Clinical Excellence. March 2013. Archived from the original on 2014-02-18. Retrieved 2014-02-18.
- Cacioppo, JT; Tassinary, LG; Berntson, GG., ed. (2007). Handbook of psychophysiology (3rd ed.). New York: Cambridge Univ. Press. p. 121. ISBN 0-521-84471-1.
- "Brain Stimulation Therapies". National Institute of Mental Health. 2009-11-17. Retrieved 2010-07-14.
- (1) Zangen, A.; Roth, Y.; Voller, B.; Hallett, M. (2005). "Transcranial magnetic stimulation of deep brain regions: Evidence for efficacy of the H-Coil". Clinical Neurophysiology 116 (4): 775–779. doi:10.1016/j.clinph.2004.11.008. PMID 15792886.
(2) Huang, YZ; Sommer, M; Thickbroom, G; Hamada, M; Pascual-Leonne, A; Paulus, W; Classen, J; Peterchev, AV; Zangen, A; Ugawa, Y (2009). "Consensus: New methodologies for brain stimulation". Brain Stimulation 2 (1): 2–13. doi:10.1016/j.brs.2008.09.007. PMID 20633398.
- Riehl M (2008). "TMS Stimulator Design". In Wassermann EM, Epstein CM, Ziemann U, Walsh V, Paus T, Lisanby SH. Oxford Handbook of Transcranial Stimulation. Oxford: Oxford University Press. pp. 13–23, 25–32. ISBN 0-19-856892-4.
- Roth, BJ; MacCabee, PJ; Eberle, LP; Amassian, VE; Hallett, M; Cadwell, J; Anselmi, GD; Tatarian, GT (1994). "In vitro evaluation of a 4-leaf coil design for magnetic stimulation of peripheral nerve". Electroencephalography and Clinical Neurophysiology/Evoked Potentials Section 93: 68. doi:10.1016/0168-5597(94)90093-0. PMID 7511524.
- Fitzgerald, PB; Hoy, K; McQueen, S; Maller, JJ; Herring, S; Segrave, R; Bailey first7=M; Been, G; Kulkarni, J; Daskalakis, ZJ (April 2009). "A randomized trial of rTMS targeted with MRI based neuro-navigation in treatment-resistant depression". Neuropsychopharmacology 34 (5). doi:10.1038/npp.2008.233. PMID 19145228.
- Nauczyciel, C; Hellier, P; Morandi, X; Blestel, S; Drapier, D; Ferre, JC; Barillot, C; Millet, B (30 April 2011). "Assessment of standard coil positioning in transcranial magnetic stimulation in depression". Psychiatry Research 186 (2-3). doi:10.1016/j.psychres.2010.06.012. PMID 20692709.
- Zorn, L; Renaud, P; Bayle, B; Goffin, L (March 2012). "Design and Evaluation of a Robotic System for Transcranial Magnetic Stimulation". IEEE Transactions on Biomedical Engineering (pdfdoi:10.1109/TBME.2011.2179938. PMID 22186930.) 59 (3): 805–815.
- Richter Lars (2013). Robotized Transcranial Magnetic Stimulation. New York: Springer. ISBN 978-1-4614-7359-6.
- (1) Martin, PI; Naeser, MA; Ho, M; Treglia, E; Kaplan, E; Baker, EH; Pascual-Leone, A (2009). "Research with Transcranial Magnetic Stimulation in the Treatment of Aphasia". Current Neurology and Neuroscience Reports 9 (6): 451–458. doi:10.1007/s11910-009-0067-9. PMC 2887285. PMID 19818232.
(2) Corti, M; Patten, C; Triggs, W (2012). "Repetitive Transcranial Magnetic Stimulation of Motor Cortex after Stroke". American Journal of Physical Medicine & Rehabilitation 91 (3): 254–270. doi:10.1097/PHM.0b013e318228bf0c. PMID 22042336.
- Kleinjung, T; Vielsmeier, V; Landgrebe, M; Hajak, G; Langguth, B (2008). "Transcranial magnetic stimulation: a new diagnostic and therapeutic tool for tinnitus patients". The international tinnitus journal 14 (2): 112–8. PMID 19205161.
- Lefaucheur, JP (2009). "Treatment of Parkinson’s disease by cortical stimulation". Expert Review of Neurotherapeutics 9 (12): 1755–1771. doi:10.1586/ern.09.132. PMID 19951135.
(2) Arias-Carrión, O (2008). "Basic mechanisms of rTMS: Implications in Parkinson's disease". International Archives of Medicine 1 (1): 2. doi:10.1186/1755-7682-1-2. PMC 2375865. PMID 18471317.
- Nizard J; Lefaucher J-P; Helbert M; de Chauvigny E; Nguyen J-P (2012). "Non-invasive stimulation therapies for the treatment of chronic pain". Discovery Medicine 14 (74): 21–31. ISSN 1539-6509. PMID 22846200. Archived from the original on 2014-02-21.
- (1) Osuch, EA; Benson, BE; Luckenbaugh, DA; Geraci, M; Post, RM; McCann, U (2009). "Repetitive TMS combined with exposure therapy for PTSD: A preliminary study". Journal of Anxiety Disorders 23 (1): 54–59. doi:10.1016/j.janxdis.2008.03.015. PMC 2693184. PMID 18455908.
(2) Watts, BV; Landon, B; Groft, A; Young-Xu, Y (2012). "A sham controlled study of repetitive transcranial magnetic stimulation for posttraumatic stress disorder". Brain Stimulation 5 (1): 38–43. doi:10.1016/j.brs.2011.02.002. PMID 22264669.
- Brunoni, A. R.; Lopes, M.; Kaptchuk, T. J.; Fregni, F. (2009). Hashimoto, Kenji, ed. "Placebo Response of Non-Pharmacological and Pharmacological Trials in Major Depression: A Systematic Review and Meta-Analysis". PLoS ONE 4 (3): e4824. doi:10.1371/journal.pone.0004824. PMC 2653635. PMID 19293925.
- Wassermann, EM; Epstein, CM; Ziemann, U; Walsh, V; Paus, T; Lisanby, SH (2008). Oxford Handbook of Transcranial Stimulation (Oxford Handbooks). Oxford University Press, USA. ISBN 0-19-856892-4.
- Freeston, I; Barker, A (2007). "Transcranial magnetic stimulation". Scholarpedia 2 (10): 2936. doi:10.4249/scholarpedia.2936.
|Wikimedia Commons has media related to Transcranial magnetic stimulation.|
- Stuttering Triggered by Transcranial Magnetic Stimulation (video)
- More on the diagnostic utility of Transcranial Magnetic Stimulation
- coil manufacturers: Brainsway, Neuronetics, Magstim, MagVenture, Mag&More.
- stimulators: most coil manufacturers also produce stimulators.
- neuronavigation systems: Rogue Research, Nexstim, ANT Neuro, LOCALITE, BrainInnovation, Syneika.
- coil holders: most coil manufacturers also provide static coil holders. Manufacturers of robotic holders include ANT Neuro, Axilum Robotics.