Transcranial Magnetic Stimulation (TMS) at PYONG Rehabilitation Penthouse

TMS (Transcranial Magnetic Stimulation) is the technology of stimulating the brain with a magnetic field through a special coil head, in order to induce a low electric current in the target area of the brain. This technique is a procedure that does not depend on surgery, needs no general anaesthetic, and does not take long per session. It suits those who want to restore the capacity of the brain and the nervous system, such as patients facing the state after stroke, Parkinson's, or cognitive impairment, and also those wanting therapy for mood and sleep. In our care, every step is carried out by a specialist physician in rehabilitation medicine and a multidisciplinary team, in order to fix the position of stimulation, the frequency, and the plan of treatment appropriately according to each individual's symptoms.

PYONG Rehabilitation Penthouse is located at Gaysorn Tower, floor 11 (BTS Chidlom), convenient to reach, in the heart of Bangkok, with comprehensive technology in rehabilitation medicine.

What is TMS

TMS is a technology using a short and repetitive magnetic field (repetitive TMS; rTMS) to rebalance the working of the neural circuits in the parts of the brain involved in movement, the control of muscle, mood, and thinking. Stimulation with TMS can be designed to increase (facilitation) or reduce (inhibition) the activity of the brain in the target area, depending on the frequency and the protocol used.

What stands out about TMS is that it is a procedure that needs no surgery and no general anaesthetic. The side effects often met are irritation of the scalp or slight headache, which can usually be relieved with ordinary painkillers. The safety standards of TMS have been set out by international experts, and it is used widely in clinics of brain and behavioural therapy, and in clinics of rehabilitation medicine, to support the recovery of neural networks in conditions of the nervous system of many causes.

Why have TMS at PYONG Rehabilitation

• TMS at PYONG Rehabilitation is a model of TMS meeting international standards, supported by the FDA of the United States and the European Union, with as many as three modes of treatment: 1) Biphasic pulse, the traditional mode, 2) Theta Burst Stimulation (TBS), to hasten the result of treatment, and
  3) Pair stimulation, to stimulate both sides of the brain (compared with ordinary TMS, which has only Biphasic pulse)
• TMS at PYONG Rehabilitation has a magnetic strength as high as 3 tesla, reaching deeper structures of the brain than ordinary TMS, and its frequency can be adjusted over a wide range of 0.1–100 Hz, suited to planning treatment for the individual for the highest effectiveness
• The rehabilitation physician is the main carer: the specialist physician in rehabilitation medicine will assess, set the goal of treatment, and set the plan of treatment to match the condition of the nervous system to be treated
• A comprehensive programme of treatment: combining TMS with physiotherapy/occupational therapy, a speech therapist, a clinical psychologist, and nutrition, for a result that is complete on every side
• Comprehensive technology: with examination rooms and modern equipment that are complete, together with safety guidance of international standard
• A convenient location in the heart of the city: Gaysorn Tower, 11th Floor (BTS Chidlom), suited to patients and carers
• A plan for the individual: with follow-up at intervals and adjustment of the plan of treatment/frequency according to the response of the person receiving treatment

How TMS works

The principle of TMS is the release of a magnetic field through a coil head placed on the head. The magnetic field is converted into a low-level electric current entering the cortex, which makes the nerve cells undergo "learning anew" (neuroplasticity) and adjusts the strength of the connection between brain cells (synaptic plasticity).

The steps in summary

1. Assessment by the doctor: taking the history, examining the nervous system, testing readiness, identifying contraindications/points to be careful of, and choosing the target area of the brain
2. Setting the values: measuring the Motor Threshold to find the suitable level of energy, and setting the frequency/number of pulses/number of rounds
3. During the procedure: the person receiving the service sits comfortably while receiving treatment, and may feel slight tightness around the scalp. It takes about 20–40 minutes
4. Follow-up: assessing the symptoms; the doctor will adjust the plan of treatment weekly according to the response of the person receiving the service
   The person receiving the service needs no recovery time and can carry on with their routine as normal

The symptoms/conditions suited to TMS

• Restoring movement in the state after stroke
• Reducing tightness/rebalancing the motor network in Parkinson's
• Supporting cognitive working in cognitive impairment/Alzheimer's
• Conditions of mood, such as depression (certified in several countries)
• Some groups of anxiety
• Some kinds of problem of sleep
• Chronic pain/pain from the nervous system
• The state after traumatic brain injury (TBI) in the context of rehabilitation medicine
• Older adults wanting to reinforce the capacity of the brain and balance together with an intensive rehabilitation programme
• Specialist cases where the doctor sees that the brain network should be treated with neuromodulation

The academic evidence on TMS

• Safety and standards: international guidance by experts (IFCN) has produced recommendations on safety, protocols, and training, so that the use of TMS in patients is responsible and the risk is reduced, such as screening patients with a seizure condition and with implanted devices before the procedure. (PubMed (opens in a new tab), ScienceDirect (opens in a new tab))
• Stroke/movement: several meta-analyses report that rTMS may help improve the working of the arm and hand and motor function overall, when the position and the frequency are chosen suitably, with a tendency to bring about a good result during the period of recovery if used together with physiotherapy training. (PubMed (opens in a new tab), BioMed Central (opens in a new tab))
• Parkinson's: the latest meta-analysis indicates that the use of TMS releasing a magnetic field of high frequency over the SMA has the potential to help motor symptoms/gait in part, although the quality of the evidence still varies. (Lippincott Journals (opens in a new tab), Nature (opens in a new tab), PMC (opens in a new tab))
• Alzheimer's/cognition: research indicates that the use of rTMS together with occupational therapy and cognitive training may help improve some aspects of cognition. (PubMed (opens in a new tab), Frontiers (opens in a new tab))
• Mood/anxiety: TMS has been permitted for marketing for the treatment of major depressive disorder (MDD) in several countries, and for the treatment of OCD in the United States; (U.S. Food and Drug Administration (opens in a new tab), PMC (opens in a new tab), Oxford Academic (opens in a new tab))

Note: the result differs according to the diagnosis, the point stimulated, the frequency, the number of sessions, and whether it is done together with other rehabilitation programmes.

How often should TMS be done

The frequency depends on the purpose and the condition being treated. In general the plan of treatment is 2–5 times a week, continuing for 2–6 weeks, and then the result is assessed, in order to adjust the protocol for the next round. For example:

• Neurological rehabilitation (Stroke/Parkinson's): usually planned alongside physiotherapy/occupational therapy, to reinforce the training of real skills in daily life
• Mood/anxiety/sleep: a moderate fixed frequency may be set in the first period, and adjusting the frequency considered according to the response
  At PYONG Rehabilitation every case begins with assessment by a rehabilitation physician, in order to set the number of pulses, the frequency, the target position, and how it is combined with other rehabilitation programmes to suit each individual patient

When to expect a result

Some people receiving the service may feel a slight change, such as in the quality of sleep/the tightness of muscle/better focus, within the first 1–2 weeks, while reaching the goal of improving movement or cognition usually depends on repeating it continuously over several weeks together with rehabilitation training (such as physiotherapy/occupational therapy), so that the learning of the brain (neuroplasticity) is lasting.

After the first round ends, the doctor will assess the result and plan the next round as necessary. The result differs from one individual to another, depending on age, the time since the condition arose, its severity, complications, and the participation of the family/carers.

Contraindications and points to be careful of in the procedure

TMS is considered safe when done according to standard guidance by a team of experienced specialists. The side effect met most often is headache/temporary tightness of the scalp. The risk of bringing on a seizure is very small in those with no risk factor, and can be reduced by suitable screening. The important contraindications to the procedure include:

• Those with a pacemaker, a brain/nerve stimulator, a cochlear implant, or metal/a device implanted in the skull near the area of stimulation
• Epilepsy that is not controlled, pregnancy (considered case by case), acute infection/fever, high blood pressure that is still not controlled
  Before beginning every case, we carry out history-taking and safety screening according to international guidance, and watch closely for side effects during and after the procedure. (PubMed (opens in a new tab), PMC (opens in a new tab))

The cost

The service charge for TMS is 6,000–8,000 baht per session (THB), depending on the package chosen. Where the person receiving the service joins an intensive rehabilitation programme, TMS may be combined with training with the multidisciplinary team in the programme. The actual price, however, depends on the assessment by the rehabilitation physician and the goal of treatment for the individual.

Frequently asked questions (FAQ) — 5 questions

1) Is TMS painful?

Most will feel tightness/a start at the scalp, or the loud sound of the pulse rhythm. No general anaesthetic is needed. A slight headache can be eased with ordinary painkillers.

2) How many sessions before a result is seen?

Overall 2–5 times a week, continuing for 2–6 weeks, and then the result is assessed. The answer depends on the condition and the response of the individual.

3) How safe is it? Is there a chance of a seizure?

There is clear guidance on screening to reduce the risk. The risk of a seizure is very low in those with no risk factor, and the medical team will follow up closely. (PubMed (opens in a new tab))

4) Can TMS be used for depression/obsessive-compulsive disorder?

In several countries TMS is permitted for depression (MDD), and in the United States it is permitted for OCD under specific indications. (U.S. Food and Drug Administration (opens in a new tab))

5) Can it be used together with other rehabilitation?

It is advised to do it together with physiotherapy/occupational therapy, cognitive training, and care of the mind, in order to reinforce the learning of the brain and a lasting result.

Choosing a place to treat pain and conditions of the brain from a clinic cared for by a team of specialist physicians with expertise, such as PYONG Rehabilitation Clinic and PYONG Rehabilitation Penthouse, helps the patient receive effective and safe care, with modern technology, so that the patient has the chance to recover and return to a better quality of life quickly.