Setting up a TMS Treatment Program Alvaro Pascual-Leone, M.D., - - PowerPoint PPT Presentation
Setting up a TMS Treatment Program Alvaro Pascual-Leone, M.D., Ph.D. Daniel Cohen, M.D., M.M.Sc. Professor in Neurology Instructor in Neurology Harvard Medical School Harvard Medical School Beth Israel Deaconess Medical Center Beth Israel
Daniel Cohen, M.D., M.M.Sc. Instructor in Neurology Harvard Medical School Beth Israel Deaconess Medical Center Alvaro Pascual-Leone, M.D., Ph.D. Professor in Neurology Harvard Medical School Beth Israel Deaconess Medical Center
Safety and training of personnel Equipment Certification Evaluation and Consent Treatment Protocol Assessment Maintenance Cost/Billing Future Developments
Starting program Managing patients Long term plans
Clinicians (Neurology / Psychiatry) Administrative support
Scheduling Providing information to prospective patients Data collection
Technicians
TMS trained Basic Life Support Patient interaction
Patient selection
Family history of epilepsy Personal history of seizure/spells, head trauma, focal findings Epileptogenic medications/combinations Increased ICP, unstable cardiac disease Metallic implants, aneurism clips, med pumps
TMS protocol- 10-20hz vs. 1hz
Seizure Response Protocol
Staff training in acute seizure response Physician notification Emergency medical services/code team
Equipment
Crash cart with benzodiazepines Acetaminophen (headaches/neck pain) Ear plugs
Air cooled coil to prevent overheating FDA-Approved Device (stimulator and coil) Peripheral Stimulation – Magstim, MagVentures, etc. Depression – Neuronetics (only one that can be advertised now)
Referral from treating psychiatrist Neurology
Contraindications Effect of medication on TMS
Psychiatry
Caution if: Psychotic depression, bipolar, personality
disorders
At least one adequate trial of antidepressant medication
Local ethical/safety committee (not IRB!) Discussion of on-label* vs. off-label treatment
treatment of Major Depressive Disorder in adult patients who have failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode.
Explanation of side-effects
Seizure Headache Neck pain Scalp pain Tinnitus/hearing Cognitive side effects (theoretical)
Site Hemisphere Frequency Duration Waiting time Repetitions DLPFC Left 20 Hz 2 seconds 28 seconds 40 DLPFC Right 1 Hz 1600 seconds N/A 1
Both protocols give a total of 1600 pulses, Intensity is 110% of MT
Neuronetics trial protocol: Left DLPFC 10 Hz, 4sec duration, 26 sec inter-train, total pulses: 3,000 per session 4-6 weeks
Treatments daily (excluding weekends) Mood assessed weekly Duration:
Beck, Hamilton, Analogue scale Target symptoms Clinician evaluation of patient Other sources of information (e.g. family, referring
Side effects questionnaire Weekly meeting of all staff to discuss progress
Minimal evidence (absence of evidence, not evidence of
absence)
Relapse prevention
Start with weekly treatment Gradually space out sessions
“Watchful Waiting”
Patient presents when feeling worse
Insurance does not necessarily pay $300/session magstim, $350 neuronetics Additional fee for assessments Helping with billing, talking with payers
Currently its approved rarely on case-by-case
With FDA approval, carriers will be developing
Widespread acceptance and coverage still in
Targeting (use of structural MRI’s and fMRI’s
More than one session/day Interaction of rTMS with medications Predictors of response Monitoring response biologically Other indications (pain, seizures, stroke