Repetitive Transcranial Magnetic Stimulation (rTMS) in India

Dr. Sanjay Chugh pioneered the use of the treatment modality known as Repetitive Transcranial Magnetic Stimulation (rTMS) in Clinical Practice in India. Before he began using this treatment clinically, Dr. Chugh had received advanced training in rTMS at both Harvard Medical School and the Medical University of South Carolina.

What does rTMS stand for?

rTMS is the abbreviated form of Repetitive Transcranial Magnetic Stimulation. Dr. Sanjay Chugh pioneered the use of this treatment in Clinical Practice in India. 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 basis for the therapeutic change within the brain cells.

How does rTMS work?

The rTMS device allows a trained person to use an electromagnet to non-invasively stimulate the brain of a patient. A rapidly changing magnetic field created by a hand-held magnetic coil causes weak electric currents in the brain through electromagnetic induction. By stimulating different areas of the brain, it is possible to elicit a therapeutic response in different disease states. This treatment can currently target sites in the brain to within a few millimeters and 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 with various other psychiatric and neurological disorders. In the USA, the FDA currently allows rTMS to be used off-label by doctors. In the UK, the first clinical rTMS service was established in 2003. It is widely used in private hospitals in Australia. Other countries where this treatment is available for clinical use are Israel, Brazil, Costa Rica etc.

What illnesses has rTMS been successful in treating?

This treatment 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 this modality is currently being tried.

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

Yes.This treatment 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. It is a treatment option and like all other treatments for any other illness, it too has its limitations. It will not help everyone who receives it. There will be some who benefit less than the others. But it is a very effective and extremely safe treatment alternative, both intreatment-resistantt cases and also as first line treatment.

How effective is rTMS in Depression?

The efficacy of this treatment in treating Depression has been clearly established. It is useful both in treatment resistant Depression and also as a first line treatment modality. There are studies which have shown that its benefits equal those seen with the use of anti-depressants. When given in combination with medication, relief from symptoms and recovery can be anticipated quicker, the dose requirement of medication goes down and the adverse effects associated with continued intake of higher doses of medicine would also decrease. 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 this treatment, a majority of patients experience a 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.

Can rTMS help in ADHD?

Yes. When used in the inhibitory mode, this treatment can bring down the Hyperactivity in a child who has ADHD. This could result a significantly low dose 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 this treatment.

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 are recommending that a trial of rTMS should 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 paralysed 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 for its role in preventing the Migraine attacks from taking place and can 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. The results show a great deal of promise in reducing the severity of the distressing symptoms of Autism and, as a result, helping in better communication & social interaction. 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 has a selective effect by increasing pain tolerance & altering pain processing, thereby providing long-lasting pain relief.

Is rTMS useful in Autism?

After a course of rTMS, children with Autism showed fewer symptoms of hyperactivity, sensory overload and repetitive behaviours. The results show a great deal of promise in reducing the severity of the distressing symptoms of Autism and, as a result, helping in better communication & social interaction. 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.

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 show 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. It is generally considered to be free from side effects when proper procedures are followed. 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 treated 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 major possible risk associated with rTMS, although they have only been reported in less than 20 patients thus far out of the tens of thousands of sessions that have been given worldwide. rTMS safety guidelines were established in 1993 and revised in 1996 and when these have been followed, no seizures have been reported. These guidelines are strictly followed at our clinic.

What is the sensation like during rTMS treatment?

Patients can hear a loud 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 dose 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 #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, a lot of cognitive side effects & memory disturbances. rTMS is a non-invasive method of 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 rTMS 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 localisation of areas of the brain can be done.

How long is the course of treatment with rTMS?

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, results are achieved within one or two weeks of beginning treatment. Most patients tend to be 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 with rTMS?

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 sessions 6 to 12 months after the initial phase of treatment is over. This can be discussed with your treating doctor.

What does rTMS treatment cost?

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