Dr.

AGUS SOLICHIEN,SpS,MARS

Treatment

Diagnostic

Trans cranial Magnetic Stimulation/Peripheral Magnetic Stimulation Found by Anthony Barker 1985 Diagnostic tool Therapeutic tool (rTMS)

Magnetic field product by Neuro MS Intensities up to 2.5 tesla Magnetic field was given to the head (cranial) and body (peripheral)

 Capacitor is charged to high voltage (0-3,000 V) Capacitor is discharged into stimulating coil (current 0-8,000 A) Magnetic field is induced around stimulating coil (0-2.5 T)

Controller Electric outlet

Discharge switch

Stimulating coil

Capacitor charger

Energystorage capacitor

Magnetic field

Induced currents

[Neuronetics]

Magnetic field

++ +++ + Current pulse in Neuro MS coil induces + +++ Axon magnetic field - ---- - - - - - - -- Magnetic field pulse induces electrical - - - -currents in brain +++ + + Principle of electromagnetic induction, + + also used in electrical transformers
[Ruohonen & Ilmoniemi, 2005]

Electric field

Magnetic field has to change rapidly; Putting fridge magnets on your head wont do

Induced currents depolarize axons and make them fire

 Coil current (a) induces magnetic field (b) Changing magnetic field (c) induces electric field (d) in brain Electric field (d) induces electric current (e) in brain tissue Induced currents (e) depolarize neuronal membranes (f) Neuronal depolarization (f) modulates neuronal firing, resulting in behavioral effects (g)
Neuronal Membrane Potential
f g 8

[Walsh & Pascual-Leone, 2003]

Continues stimulation may change nerves polarity. Clinical improvement Effect magnetic to ferum made oxygenation circulation improve.

Sherrington dan Cajal : Proses belajar perubahan disynap LTP Hebbian Synap: synap yang meningkat efektifnya di pre dan post synap oleh kerena aktivitas yang terus menerus. LTP : jika satu atau lebih akson yang terhubung dengan beberapa dendrit dilakukan stimulasi secara serial dan singkat menggunakan frekuensi yang tinggi maka akan terjadi ledakan stimulasi yang menimbulkan synap menjadi lebih respon terhadap rangsang baru yang sejenis untuk beberapa menit, hari, bahkan minggu.

1.

2.

LTP : menunjukan tiga basis seluler dalam belajar dan memori: Spesifisity Jika beberapa synap yang masuk kedalam sel sangat aktif sedangkan yang lain tidak, maka yang aktif yang akan menjadi kuat. Cooperativity Jika stimulasi dilakukan pada lebih dari satu akson maka akan menghasilkan efek LTP yang lebih kuat dibandingkan bila satu akson saja.

Ex: akson A dan B :aktif ,B dan C :tidak, A dan B akan lebih kuat sebaliknya B dan C akan tetap sama atau melemah ( Sejnowski, Chattarji, n Stanton)

3. Asosiativity jika input berpasangan antara yg lemah dgn yang kuat akan memperkuat input yg lemah. Synap yg ke LTP akan seperti Hebian synap, kecuali LTP membutuhkan depolarisasi di denrit yg tidak perlu potensial aksi.

LTD berkebalikan dgn LTP stimulasi dengan low frekuensi.

Monophasic Magnetic Field

Biphasic

Neuronal Membrane Potential

Electric Field More selective stimulation Single-pulse devices

Less selective stimulation Rapid-rate devices

15

magnetic flux

double cone

Circular (round) coil Non-focal

Figure-of-8 (double) coil Focal

Medium efficiency
Fast field falloff

Low efficiency
Fast field falloff
16

 Figure-of-eight coil stimulates focally under intersection of two loops Circular equally stimulates all structures under the loop If tilted, circular coil becomes more focal

[Ruohonen & Ilmoniemi, 2005]

17

Small coil: focal, small depth

Fundamental physics constraints: Larger coils can stimulate deeper brain structures, but are less focal Smaller coils stimulate the cortex more focally, but cannot stimulate deeper structures

Large coil: diffuse, larger depth

18

Brain: ( Neurology) Stroke therapy Parkinson Epilepsy Tinnitus Suppression Vertigo Cognitive Studies Sleep research ADHD Smoking cessation Inducing Dyscalculia

Brain: (Psychiatry) Schizophrenia Depression OCD Manic Depression

Peripheral : Pain Management Arthritis Bone healing Muscle soreness Chronic Low Back Pain Aid Diaphragm Contraction Fibromyalgia

Systemic Neurological Psychiatric

Gastrointestinal: nausea Cardiovascular: theoretical, but none reported Musculoskeletal: back pain, muscle pain, muscle twitch, arthralgias Hormonal: incr TSH (George 1996); incr prolactin (1 patient, George, unpubl); neg results for ACTH, PRL, TSH, LH, FSH Immunologic: CD8+ T-cell (+/-) Skin: erythema, burn (e-shield)

Pain:

Treatment site: scalp muscle Treatment site: superficial nerves/branches Headache

Paresthesias General:
Fatigue Malaise Dizziness

Mostly generalized TC; at least one partial Single pulse vs repetitive Frequency Intertrain interval Structural brain lesions--cortical Concomitant medications Epilepsy or seizure history, family history

As of 2000, 6 seizures in normal controls, 2 in patients with depression Site of stimulation: primary motor cortex No long-term sequelae (except 1 patient with structural lesion-->epilepsy) Short-term mild recall deficits (24h) Normal EEG (Loo 1999)

Inefficacy Anxiety Acute dysphoria/crying Laughing (speech arrest study) Suicidal ideation Switch to mania

Metal implants Pacemakers, implanted medication pumps Unstable CV disease Increased intracranial pressure Pregnancy Children

Stroke Patients ( 12 orang) Stimulasi Frekuensi 1HZ, Train 50 X, Pause 5,Sesion 10 Serial 5hari ,Power 80%-100% Perbaikan motorik Perbaikan cognitive Perbaikan pola tidur

Parkinson syndrome: (4 orang) Frekuensi 1HZ ,Train 50X, Pause 5,Sesion 10 Power 80% Frekuensi 5HZ,Train 50X,Pause 5,Sesion 5 Power 100% Perbaikan gerakan Tremor berkurang Perbaikan pola tidur

From Journal Watch Physician-authored summaries and commentary from the publishers of the New England Journal of Medicine Journal Watch Neurology August 21, 2003 Repetitive Transcranial Magnetic Stimulation to Treat Parkinson Disease Posted 10/06/2003 Summary Repetitive transcranial magnetic stimulation (rTMS) of the brain is a noninvasive, welltolerated technique that can modify cerebral cortex excitability both locally and at remote, but functionally connected, areas (Lancet Neurology 2003; 2:145). Initial research on rTMS for motor function in Parkinson disease (PD) showed promising results (Neurology 1994; 44:892), but later research failed to confirm initial findings (e.g., Neurology 1999; 52:768) and has yielded mostly conflicting results. Now, two groups of researchers report results with further variations on rTMS in PD.

Pasien post CKS dengan gangguan memory ,disfasia Frekuensi 1HZ,Train 50X,Pause 5 Sesion 10 Power 80% Frekuensi 2,5HZ,Train50X,Pause 5,Sesion 5 Power 80% Perbaikan dramatis memory dan disfasia Perbaikan pola tidur

Pasien Ischialgia dan Cronic LBP (30 orang) Frekuensi 2,5 HZ, Train 50X,Pause 5Sesion 5 Power 40% Frekuensi 5HZ,Train 50X,Pause 5,Sesion 5 Power 50% Hasil : Perbaikan Nyeri Perbaikan ADL

Pasien Bells Palsy (3 orang) Celah mata 3mm,sudut nasolabialis Frekuensi 2,5 HZ, Train 50X,Pause 5Sesion 5 Power 40% Frekuensi 5HZ,Train 50X,Pause 5,Sesion 5 Power 50% Hasil : Perbaikan muka simetris setelah 4X stimulasi

Pasien gangguan memory (2 orang) Frekuensi 2,5 HZ, Train 50X,Pause 5Sesion 5 Power 40% Frekuensi 5HZ,Train 50X,Pause 5,Sesion 5 Power 50% Hasil : Perbaikan fungsi memory

Pasien Hiperventilation Syndrome (10 orang) Frekuensi 2,5 HZ, Train 50X,Pause 5Sesion 5 Power 40% Frekuensi 5HZ,Train 50X,Pause 5,Sesion 5 Power 50% Hasil : Perbaikan symptomatik

Pasien Vertigo, Dizziness, Tinitus (7 orang) Frekuensi 2,5 HZ, Train 50X,Pause 5Sesion 5 Power 40% Frekuensi 5HZ,Train 50X,Pause 5,Sesion 5 Power 50% Hasil : Perbaikan fungsi memory

Pasien ADHD, Autis, Down Syndrome,Dyscalculi (4 orang) Perbaikan klinis.

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