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| {{Other uses|TMS (disambiguation)}}
| | If your home has traditional burglarized, that one awful feeling you find yourself the pit of your stomach. You are feeling violated that an intruder has visit your home and undergone your personal space.<br><br> |
| {{Interventions infobox |
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| Name = Transcranial magnetic stimulation |
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| Image = File:Transcranial magnetic stimulation.jpg|
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| Caption = Transcranial magnetic stimulation (schematic diagram)|
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| MeshID = D050781 |
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| '''Transcranial magnetic stimulation''' ('''TMS''') is a noninvasive method to cause [[depolarization]] or [[Hyperpolarization (biology)|hyperpolarization]] in the [[neuron]]s of the [[brain]]. TMS uses [[electromagnetic induction]] to induce weak [[electric current]]s 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. A variant of TMS, '''repetitive transcranial magnetic stimulation''' ('''rTMS'''). According to the National Institute of Mental Health, it “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. And 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.”<ref>{{cite web |url=http://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml |title=Brain Stimulation Therapies |author=National Institute of Mental Health |publisher=nimh.nih.gov |year=2009 |accessdate=12 December 2013}}</ref> Repetitive transcranial magnetic stimulation has been tested as a treatment tool for various [[neurological disorder|neurological]] and [[mental disorder|psychiatric]] disorders including [[migraine]], [[stroke]], [[Parkinson's disease]], [[dystonia]], [[tinnitus]] and [[major depressive disorder|depression]].
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| ==Background==
| | Generally speaking, most walls are made of brick or block with stucco together with. Although this can be costly it does look pleasant when might be completed. You might want to hire one who builds walls for a living to be sure that it created correctly. Most walls like this require cleaning now after that.<br><br><br><br>If house looks gorgeous in spring, you can have trouble conveying this towards buyer ultimately dead of winter. Through the time you use the home, you should take pictures of the outer of the property during different seasons. Show these photos to alleviate uncertainty ultimately buyer's head.<br><br>Trim your hedges and mow your lawn prior to going on retreat. If you're in order to be away for longer time, consider having someone come and gaze after your lawn care.<br><br>Put up some new trim and art to update a bath room. Wallpaper trim is not expensive, and the wide range of designs can complement any decor that it's possible to imagine. It's also simple set up. Add some simple, inexpensive artwork, and your bath room can be completely revised.<br><br>Your lawn can utilized care of once 7 days with a landscaper. You can hire the do a plethora of different designs in your front turf. Cross mowing, checkering, lines or even plain mowing the lawn are many different designs you get to pick generating your grass look in top create. A landscaper will rake all of the chopped grass for you so your roots don't die.<br><br>Spring is the best time to analyse the soil in your paddock. A lack of nutrients or infection planet soil will affect the growth and health of your grassland. The final results of your soil analysis will aid successful paddock management mainly because will allow you to make changes to your routine enhance the grassland for your animals.<br><br>Nudism has impacted my life in tons of paths and both of which are positive. I'm hoping that as the years go by, much more more men and women will try keep in mind this! And if you are in florida and 'd like to visit a nude beach then make sure you you should visit Haulover.<br><br>If you loved this short article and you would such as to obtain even more information concerning [http://www.hopesgrovenurseries.co.uk/ hedging plants] kindly visit the web site. |
| Early attempts at stimulation of the brain using a magnetic field included those, in 1910, of [[Silvanus P. Thompson]] in London.<ref>{{cite web |url=http://www.scholarpedia.org/article/Transcranial_magnetic_stimulation |title=Transcranial magnetic stimulation |author=Anthony T. Barker and Ian Freeston |publisher=scholarpedia.org |year=2007 |accessdate=28 June 2013}}</ref> The principle of inductive brain stimulation with [[eddy current]]s 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.<ref name=Barker>{{cite doi|10.1016/S0140-6736(85)92413-4}}</ref> 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<ref name=Merton>{{cite doi|10.1038/285227a0}}</ref> in which direct electrical current was applied to the scalp, the use of [[electromagnet]]s greatly reduced the discomfort of the procedure, and allowed mapping of the [[cerebral cortex]] and its connections.
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| ==Theory==
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| From the [[Biot-Savart Law]]
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| <center><math> \mathbf B = \frac{\mu_0}{4\pi} I \int_C \frac{d\mathbf l \times \mathbf{\hat r}}{r^2}</math> </center>
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| 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.<ref name=Walsh>V. Walsh and A. Pascual-Leone, "Transcranial Magnetic Stimulation: A Neurochronometrics of Mind." Cambridge, MA: MIT Press, 2003.</ref> 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 due to the [[Electromagnetic induction#Maxwell–Faraday equation|Maxwell-Faraday equation]],
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| <center><math>\nabla \times \mathbf{E} = -\frac{\partial \mathbf{B}} {\partial t}</math> .</center>
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| This electric field causes a change in the transmembrane current of the neuron, which leads to the depolarization or hyperpolarization of the neuron and the firing of an action potential.<ref name=Walsh/>
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| ==Effects on the brain==
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| 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:
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| *Single or paired pulse TMS causes neurons in the neocortex under the site of stimulation to [[Depolarization|depolarize]] and discharge an [[action potential]]. If used in the [[primary motor cortex]], it produces muscle activity referred to as a [[Evoked potential#Motor evoked potentials|motor evoked potential]] (MEP) which can be recorded on [[electromyography]]. If used on the [[occipital cortex]], '[[phosphene]]s' (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.<ref name="Handbook of Transcranial Magnetic Stimulation">{{cite book | author = [[Alvaro Pascual-Leone|Pascual-Leone A]]; Davey N; Rothwell J; Wassermann EM; Puri BK | year = 2002 | title = Handbook of Transcranial Magnetic Stimulation | publisher = [[Edward Arnold (publisher)|Arnold]]|location=[[London]] | isbn = 0-340-72009-3 }}</ref>
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| *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).<ref name=Fitzgerald>{{cite doi|10.1016/j.clinph.2006.06.712}}</ref>
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| ==Use in localisation of sensorimotor cortex==
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| MRI images, recorded during TMS of the motor cortex of the brain, have been found to match very closely with [[Positron emission tomography|PET]] produced by during voluntary movements of the hand muscles innervated by TMS, to 5–22 mm of accuracy.<ref name=Wassermann1996>{{cite doi|10.1006/nimg.1996.0001}}</ref>
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| The localisation of motor areas with TMS has also been seen to correlate closely to [[Magnetoencephalography|MEG]]<ref name=Morioka>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</ref> and also [[Functional magnetic resonance imaging|fMRI]].<ref name=Terao>{{cite doi|10.1007/s002210050446}}</ref>
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| ==Risks==
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| 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.<ref name = Janicak>{{cite pmid|18232722}}</ref> Although TMS is generally regarded as safe, the greatest acute risk is the rare occurrence of induced [[epileptic seizure|seizures]] and [[syncope (medicine)|syncope (fainting)]].<ref name = Rossi>{{cite doi| 10.1016/j.clinph.2009.08.016}}</ref><ref name=Fitzgerald2>{{cite book|last=Fitzgerald|first=PB|last2=Daskalakis|first2=ZJ|url=http://books.google.com/books?id=2VFEAAAAQBAJ&printsec=frontcover&f=false#v=onepage&q&f=false|title=Repetitive Transcranial Magnetic Stimulation for Depressive Disorders|chapter=7. rTMS-Associated Adverse Events|pages=81–90|location=Berlin Heidelberg|publisher=Springer-Verlag|year=2013|doi=10.1007/978-3-642-36467-9|isbn=978-3-642-36466-2}} ''At'' [[Google Books]].</ref> There have been 16 reports of TMS-related seizures (as of 2009), with seven reported before the publication of safety guidelines in 1998,<ref name=Wassermann1998 /> 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.<ref name = Rossi/>
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| Other adverse effects of TMS are:
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| * Discomfort or pain from the stimulation of the scalp and associated [[nerves]] and [[muscle]]s on the overlying skin;<ref name=nami>{{cite web | url=http://www.nami.org/Content/ContentGroups/Helpline1/Transcranial_Magnetic_Stimulation_(rTMS).htm | title=Transcranial Magnetic Stimulation (TMS) | publisher=[[National Alliance on Mental Illness]] | accessdate=2008-12-15}}</ref> this is more common with rTMS than single pulse TMS.<ref name=Wassermann1998>{{cite doi|10.1016/S0168-5597(97)00096-8}}</ref>
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| * Minor cognitive changes, and psychiatric symptoms (particularly a low risk of [[mania]] in [[Depression (mood)|depressed]] patients).<ref name = Rossi/><ref name=Fitzgerald2/>
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| * 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).<ref name=Wassermann1998/>
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| * rTMS in the presence of EEG-incompatible electrodes can result in electrode heating and, in severe cases, skin burns.<ref name=roth>{{cite doi|10.1016/0168-5597(92)90077-O}}</ref> Non-metallic electrodes are used if concurrent EEG data is required.
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| * 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.<ref name = Rossi/>
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| ==Clinical uses==
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| The uses of TMS and rTMS can be divided into diagnostic and therapeutic uses.
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| ===Diagnostic use===
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| TMS can be used clinically to measure activity and function of specific brain circuits in humans.<ref name=diagnostic1>{{cite doi|10.1016.2Fj.clinph.2012.01.010}}</ref> 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 disorder]]s, [[motor neuron disease]] and injuries and other disorders affecting the [[facial nerve|facial]] and other [[cranial nerve]]s and the [[spinal cord]].<ref name=diagnostic1/><ref>{{cite doi|10.1212.2F01.wnl.0000250268.13789.b2}}</ref><ref name="Dimyan">{{cite doi|10.1177/1545968309345270}}</ref><ref name="Nowak">{{cite doi|10.3233/RNN-2010-0552}}</ref> 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.<ref name=Kujirai>{{cite pmid|8120818}}</ref>
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| ===Therapeutic use===
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| 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.<ref name=Slotema>{{cite pmid|20361902}}</ref><ref>{{cite pmid|22347797}}</ref> However, publications reporting the results of reviews and statistical [[meta-analysis|meta-analyses]] of earlier investigations have stated that rTMS appeared to be effective in the treatment of certain types of [[Major depressive disorder|major depression]] under certain specific conditions.<ref name=Slotema/><ref name="pmid17655558">{{cite doi|10.1111.2Fj.1600-0447.2007.01033.x}}</ref><ref>(1) {{cite journal|author=Medical Advisory Secretariat|archiveurl=http://www.webcitation.org/6CWM44LTG|archivedate=2012-11-28|url=http://www.health.gov.on.ca/english/providers/program/mas/tech/reviews/pdf/rev_rtms_060104.pdf|title=Repetitive transcranial magnetic stimulation for the treatment of major depressive disorder: an evidence-based analysis|journal=Ontario Health Technology Assessment Series|format=pdf|year=2004|volume=4|accessdate=2012-11-28|issue=7}}<br>(2) {{cite doi|10.1111.2Fj.1600-0447.2007.01033.x}}<br>(3) {{cite doi|10.1017.2FS0033291708003462}}<br>(4) {{cite pmid|18801225}}<br>(5) {{cite doi|10.2174.2F1745017901107010167}}<br>(6) {{cite doi|10.1176/appi.ajp.2010.10060864}}<br>(7) {{cite web|author=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]]|archiveurl=http://www.webcitation.org/6BLBRlpyk|archivedate=2012-10-11|url=http://www.effectivehealthcare.ahrq.gov/ehc/products/76/792/TRD_CER33_20111110.pdf|title=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)|work=AHRQ Publication No. 11-EHC056-EF|page=36|location=[[Rockville, Maryland]]|publisher=[[Agency for Healthcare Research and Quality]]|date=September 2011|accessdate=2011-10-11}}<br>(8) {{cite pmid|22353197}}<br>(9) {{cite pmid|22559998}}<br>(10) {{cite book|last=Fitzgerald|first=PB|last2=Daskalakis|first2=ZJ|url=http://books.google.com/books?id=2VFEAAAAQBAJ&printsec=frontcover&f=false#v=onepage&q&f=false|title=Repetitive Transcranial Magnetic Stimulation for Depressive Disorders|location=Berlin Heidelberg|publisher=Springer-Verlag|year=2013|doi=10.1007/978-3-642-36467-9|isbn=978-3-642-36466-2}} ''At'' [[Google Books]].</ref> rTMS devices are marketed for the treatment of such disorders in Canada, Australia, New Zealand, the European Union, Israel and the United States.<ref name="pmid17655558" /><ref name="Melkerson">{{cite web | url = http://www.accessdata.fda.gov/cdrh_docs/pdf8/K083538.pdf|format= pdf|date=2008-12-16|accessdate=2010-07-16|publisher=[[Food and Drug Administration]]|last=Melkerson|first=MN|title=Special Premarket 510(k) Notification for NeuroStar TMS Therapy System for Major Depressive Disorder}}</ref>
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| 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 (p<.001).<ref name=Slotema/> This is comparable to commonly reported effect sizes of pharmacotherapeutic strategies for treatment of depression in the range of 0.17-0.46.<ref name=Slotema/> However, this meta-analysis found that rTMS was significantly worse than [[electroconvulsive therapy]] (ECT) (effect size = -0.47), 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 occured for every 3 patients given electroconvulsive therapy rather than rTMS (number needed to treat 2.36).<ref>{{cite doi|10.1176.2Fappi.ajp.164.1.73}}</ref> rTMS has been found to temporarily reduce chronic pain and change pain-related brain and nerve activity, and to predict the success of surgically implanted electrical brain stimulation for the treatment of pain.<ref>{{cite doi|10.1016/j.brs.2011.02.002}}</ref>
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| Other areas of research include the rehabilitation of [[aphasia]] and motor disability after stroke,<ref name=Rossi /><ref name="Dimyan" /><ref name="Nowak" /><ref>(1) {{cite pmid|19818232}}<br>(2) {{cite doi|10.1097.2FPHM.0b013e318228bf0c}}</ref> [[tinnitus]],<ref>{{cite pmid |19205161}}</ref> [[Parkinson's disease]],<ref>{{cite doi|10.1586.2Fern.09.132}}<br>(2) {{cite doi|10.1186.2F1755-7682-1-2}}</ref> [[tic]] disorders,<ref>{{cite pmid|22398000}}</ref> and [[posttraumatic stress disorder]] (PTSD).<ref>(1) {{cite doi|10.1016/j.janxdis.2008.03.015}}<br>(2) {{cite doi|10.1016/j.brs.2011.02.002}}</ref> TMS has failed to show effectiveness for the treatment of [[brain death]], [[coma]], and other [[persistent vegetative state]]s.<ref>{{cite pmid | 20157993 }}</ref>
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| It is difficult to establish a convincing form of "sham" TMS to test for [[placebo]] effects during [[Scientific control|controlled]] [[Clinical trial|trials]] in [[conscious]] individuals, due to the neck pain, headache and twitching in the scalp or upper face associated with the intervention.<ref name = Rossi/> "Sham" TMS manipulations can affect [[cerebrum|cerebral]] [[Glycolysis|glucose metabolism]] and MEPs, which may confound results.<ref name="pmid17655558" /> This problem is exacerbated when using [[Subjectivity|subjective]] measures of improvement.<ref name = Rossi/> Placebo responses in trials of rTMS in major depression are [[Negative relationship|negatively associated]] with refractoriness to treatment, vary among studies and can influence results.<ref>{{pmid|19293925}}</ref> Depending on the research question asked and the [[design of experiments|experimental design]], matching the discomfort of rTMS to distinguish true effects from placebo can be an important and challenging issue.<ref name = Rossi/>
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| One [[multicenter trial]] of rTMS in depression used an active "sham" placebo treatment that appeared to mimic the sound and scalp stimulation associated with active TMS treatment. The investigators reported that the patients and clinical raters were unable to guess the treatment better than chance, suggesting that the sham placebo adequately [[Blind experiment|blinded]] these people to treatment.<ref name=sham/> The investigators concluded: "Although the treatment effect was statistically significant on a clinically meaningful variable (remission), the overall number of remitters and responders was less than one would like with a treatment that requires daily intervention for 3 weeks or more, even with a benign adverse effect profile".<ref name=sham>{{cite doi|10.1001.2Farchgenpsychiatry.2010.46}}</ref> However, 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.<ref>{{cite journal|last=Mattes|first=Jeffrey A|archiveurl=http://web.archive.org/web/20110116075558/http://archpsyc.ama-assn.org/cgi/eletters/67/5/507|archivedate=2011-01-16|url=http://archpsyc.ama-assn.org/cgi/eletters/67/5/507#13743|title=TMS: Does it Really Work|journal=[[Archives of General Psychiatry]]|publisher=[[American Medical Association]]|date=2010-06-29|accessdate=2012-08-01}}</ref> In this regard, the trial's report stated that the confidence ratings for the treaters' guesses were low.<ref name=sham/>
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| In 2013 in the United Kingdom, the [[National Institute for Health and Care Excellence]] recommended the use of transcranial magnetic stimulators in the treatment of migraine. In clinical trials, 39 per cent of patients treated with the device were found to be pain free after two hours and 30 per cent were still without pain after 24 hours. In a separate study, three-quarters of patients with migraine who were treated repeatedly with the device had a reduction in headache frequency.<ref>{{cite web |url=http://www.telegraph.co.uk/health/healthnews/10588318/Magentic-pulse-can-stop-migraine.html |title=Magentic pulse can stop migraine |author=Sarah Knapton| publisher=telegraph.co.uk |date=22 January 2014 |accessdate= 22 January 2014}}</ref>
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| ==FDA actions==
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| 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.<ref name="Scudiero">{{cite web | publisher = [[Food and Drug Administration|FDA]] | last = Scudiero | first = JL | url = http://www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/NeurologicalDevicesPanel/ucm124779.htm | title = Brief Summary From the Neurological Devices Panel Meeting - January 26, 2007| accessdate = 2010-07-14 | date = 2007-01-26 | quote=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.” }}</ref> 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."<ref name="Scudiero" /> 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 [[Federal Food, Drug, and Cosmetic Act#Section 510(k) and the device approval process|Section 510(k)]] of the [[Federal Food, Drug, and Cosmetic Act]] for "the 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".<ref name="Melkerson"/> The user manual for the device warns that effectiveness has not been established in patients with major depressive disorder who have failed to achieve satisfactory improvement from zero and from two or more antidepressant medications in the current episode and that the device has not been studied in patients who have had no prior antidepressant medication.<ref>{{cite book|url=http://www.neuronetics.com/pdf/Prescribing%20Information.pdf|title=NeuroStar TMS Therapy System User Manual|volume=1|pages=1–5|publisher=[[Neuronetics|Neuronetics, Inc.]]|accessdate=2010-09-13}}</ref>
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| In July 2011, the FDA published a final rule in the [[Federal Register]] that classified the rTMS system into [[Medical device#Class II: General controls with special controls|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".<ref>{{cite journal|last=Stade|first=NK, Deputy Director for Policy, Center for Devices and Radiological Health, Food and Drug Administration, [[United States Department of Health and Human Services]]|url=http://www.gpo.gov/fdsys/pkg/FR-2011-07-26/pdf/2011-18806.pdf|title=Medical Devices; Neurological Devices; Classification of Repetitive Transcranial Magnetic Stimulation System: Final rule|journal=[[Federal Register]]|volume=76|pages=44489–44491|publisher=[[United States Government Printing Office]]|date=2011-07-26|accessdate=2011-08-11|issue=143}}</ref> 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.<ref>{{cite web|author=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|url=http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm265269.htm|title=Guidance for Industry and FDA Staff - Class II Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems|publisher=U.S. Food and Drug Administration|date=2011-07-26|accessdate=2011-08-10}}</ref>
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| ===Response to FDA decision===
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| Soon after the FDA cleared the device, several members of [[Public Citizen]] stated in a [[letter to the editor]] of the medical journal ''[[Neuropsychopharmacology (journal)|Neuropsychopharmacology]]'' that the FDA seemed to have based its decision on a [[post-hoc analysis|''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.<ref>{{cite journal|last=Hines |first=JZ |last2=Lurie |first2=P |last3=Wolfe SM|first3=Sidney M|url=http://www.nature.com/npp/journal/v34/n8/pdf/npp200922a.pdf|title=Reply to Lisanby et al.: ''Post hoc'' analysis does not establish effectiveness of rTMS for depression|journal=[[Neuropsychopharmacology (journal)|Neuropsychopharmacology]]| year = 2009| volume=34 |issue=8 |pages=2053–2054 |pmid=19528946 |doi=10.1038/npp.2009.22 | format = pdf |authorlink3= Sidney M. Wolfe }}</ref>
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| ==Health insurance considerations==
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| ===United States===
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| ====Commercial health insurance====
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| In July 2011, the Technology Evaluation Center (TEC) of the [[Blue Cross Blue Shield Association]], in cooperation with the [[Kaiser Permanente|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.<ref>{{cite web|url=http://www.bcbs.com/blueresources/tec/|title=Technology Evaluation Center Criteria|work=Technology Evaluation Center (TEC)]|publisher=[[Blue Cross Blue Shield Association]]|accessdate=2013-12-11}}</ref><ref name=TEC1>{{cite journal|archiveurl=http://www.webcitation.org/6BMxPPs8X|archivedate=2012-10-12|url=http://www.elsevierbi.com/~/media/Images/Publications/Archive/The%20Gray%20Sheet/37/35/01110829008/082911_bcbs_tms_august11.pdf|title=Transcranial Magnetic Stimulation for Depression|journal=[http://www.bcbs.com/blueresources/tec/ TEC Assessment Program]|volume=26|date=July 2011|publisher=[[Blue Cross Blue Shield Association]]|accessdate=2012-10-12|issue=3}}</ref> 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.<ref name=TEC1 /> 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.”<ref name=TEC1 />
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| In 2013, several commercial health insurance plans in the United States, including [[Anthem (insurance)|Anthem]], [[Health Net]], and [[Blue Cross Blue Shield Association|Blue Cross Blue Shield]] of [[Nebraska]] and of [[Rhode Island]], covered TMS for the treatment of depression.<ref>(1) {{cite web|author=Anthem|archiveurl=http://www.webcitation.org/6LnDHQcJA|archivedate=2013-12-11|url=http://www.anthem.com/ca/medicalpolicies/policies/mp_pw_a047769.htm|title=Medical Policy: Transcranial Magnetic Stimulation for Depression and Other Neuropsychiatric Disorders|work=Policy No. BEH.00002|publisher=Anthem |date=2013-04-16|accessdate=2013-12-11}}<br>(2) {{cite web|author=Health Net|archiveurl=http://www.webcitation.org/6BLNdUZpk|archivedate=2012-10-11|url=https://www.healthnet.com/static/general/unprotected/pdfs/national/policies/Transcranial_Magnetic_Stimulation_Mar_12.pdf|title=National Medical Policy: Transcranial Magnetic Stimulation|work=Policy Number NMP 508|publisher=Health Net|date=March 2012|accessdate=2012-09-05}}<br> (3) {{cite web|author=Blue Cross Blue Shield of Nebraska|archiveurl=http://www.webcitation.org/6BLN4D8mx|archivedate=2012-10-11|work=Section IV.67|title=Medical Policy Manual|date=2011-05-2011|publisher= Blue Cross Blue Shield of Nebraska |year=2012|url=https://www.nebraskablue.com/~/media/pdf/Provider/Policy%20Procedure%20Manuals/MedicalPolicies.pdf}}<br>(4) {{cite web|author=Blue Cross Blue Shield of Rhode Island|archiveurl=http://www.webcitation.org/6BLNAY6l7|archivedate=2012-10-11|url=https://www.bcbsri.com/sites/default/files/polices/TranscranialMagneticStimulationasaTreatmentofDepressionandOtherPsychiatricNeurologicDisorders_0.pdf|title=Medical Coverage Policy: Transcranial Magnetic Stimulation for Treatment of Depression and Other Psychiatric/Neurologic Disorders|publisher= Blue Cross Blue Shield of Rhode Island |date=2012-05-15|accessdate=2012-09-05}}</ref> In contrast, [[UnitedHealth Group|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.<ref>{{cite web|author=[[UnitedHealthcare]]|archiveurl=http://www.webcitation.org/6Ln87XaDU|archivedate=2013-12-11|url=https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Transcranial_Magnetic_Stimulation.pdf|title=Transcranial Magnetic Stimulation|date=2013-12-01|publisher=UnitedHealthCare|page=2|accessdate=2013-12-11}}</ref> 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 [[The Regence Group|Regence]].<ref>(1) {{cite web|author=[[Aetna]]|archiveurl=http://www.webcitation.org/6Ln95sNWy|archivedate=2013-12-11|url=http://www.aetna.com/cpb/medical/data/400_499/0469.html|title=Clinical Policy Bulletin: Transcranial Magnetic Stimulation and Cranial Electrical Stimulation|date=2013-10-11|work=Number 0469|publisher=Aetna|accessdate=2013-12-11}}<br>(2) {{cite web|author=[[Cigna]]|archiveurl=http://www.webcitation.org/6LnADO1zQ|archivedate=2013-12-11|url=http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0383_coveragepositioncriteria_transcranial_magnetic_stimulation.pdf|title=Cigna Medical Coverage Policy: Transcranial Magnetic Stimulation|date=2013-01-15|work=Coverage Policy Number 0383|publisher=Cigna|accessdate=2013-12-11}}<br>(3) {{cite web|archiveurl=http://www.webcitation.org/6LnArSxDn|archivedate=2013-12-11|author=[[The Regence Group|Regence]]|url=http://blue.regence.com/trgmedpol/medicine/med148.pdf|title=Medical Policy: Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders|work=Policy No. 17|date=2013-06-01|publisher=Regence|accessdate=2013-12-11}}</ref>
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| ====Medicare====
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| In early 2012, the efforts of TMS treatment advocates resulted in the approval for the [[New England]] region of the first [[Medicare (United States)|Medicare]] coverage policy for TMS in the United States.<ref>(1) {{cite web|author=[[Centers for Medicare and Medicaid Services]] |url=http://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=207#ResultsAnchor|title= Repetitive Transcranial Magnetic Stimulation (rTMS) |publisher= [[United States Department of Health and Human Services]]|year=2012|accessdate=2012-09-05}}<br>(2) {{cite web|url=http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=32228&ContrId=208&ver=3&ContrVer=1&CntrctrSelected=208*1&Cntrctr=208&name=NHIC%2c+Corp.+(14202%2c+MAC+-+Part+B)&DocStatus=Future&s=24&bc=AggAAAIAQAAA&|title=Local Coverage Determination (LCD) for Repetitive Transcranial Magnetic Stimulation (rTMS) (L32228)|author=[[Centers for Medicare and Medicaid Services]]|publisher=[[United States Department of Health and Human Services]]|date=2012-01-27|accessdate=2012-10-12}}<br>(3) {{cite web|archiveurl=http://www.webcitation.org/6BLOZQP6W|archivedate=2012-10-11|accessdate=2012-10-11|url=http://www.pbn.com/Important-Treatment-Option-for-Depression-Receives-Medicare-Coverage,66462|title=Important Treatment Option for Depression Receives Medicare Coverage|work=Press Release|date=2012-03-30|publisher=[http://www.pbn.com/ PBN.com: Providence Business News]}}<br>(4) {{cite web|author=The Institute for Clinical and Economic Review|date=June 2012|archiveurl=http://www.webcitation.org/6LnIhPFhU|archivedate=2013-12-11|url=http://cepac.icer-review.org/wp-content/uploads/2012/07/rTMS-Coverage-Policy-Analysis.pdf|title=Coverage Policy Analysis: Repetitive Transcranial Magnetic Stimulation (rTMS)|publisher=[http://cepac.icer-review.org/?page_id=18 The New England Comparative Effectiveness Public Advisory Council (CEPAC)]|accessdate=2013-12-11}}<br>(5) {{cite web|archiveurl=http://www.webcitation.org/6BN4UpUXK|archivedate=2012-10-12|url=http://www.cvmc.org/news/2012-theresa-fama-cepac|title=Transcranial Magnetic Stimulation Cites Influence of New England Comparative Effectiveness Public Advisory Council (CEPAC)|date=2012-02-06|location=[[Berlin, Vermont]]|publisher=[[Central Vermont Medical Center]]|accessdate=2012-10-12}}</ref> In December 2012, Medicare began covering TMS for the treatment of depression in [[Tennessee]], [[Alabama]] and [[Georgia (U.S. state)|Georgia]].<ref>{{cite web|first=Phillip|last=Nannie|url=http://nashvillepost.com/blogs/postbusiness/2012/10/31/medicare_agrees_to_cover_tms_treatment_for_depression_in_tn_ga_al|archiveurl=http://www.webcitation.org/6LnGKnmZw|archivedate=2013-12-11|title=Medicare agrees to cover TMS treatment for depression in TN, GA, AL|work=[[NashvillePost.com]]|publisher=[http://www.southcomm.com/ SouthComm Communications, Inc.]|location=Nashville, Tennessee|date=2012-10-31|accessdate=2013-11-13}}</ref> In contrast, in August 2012, the Medicare administrative contractor for the [[Centers for Medicare and Medicaid Services]] jurisdiction covering [[Arkansas]], [[Louisiana]], [[Mississippi]], [[Colorado]], [[Texas]], [[Oklahoma]] and [[New Mexico]] determined that, based on limitations in the published literature, <blockquote>... 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 use]]s.<ref>{{cite web|url=https://www.novitas-solutions.com/policy/jh/l32752-r1.html|title=LCD L32752 - Transcranial Magnetic Stimulation for Depression|author=Novitas Solutions, Inc.|work=Contractor's Determination Number L32752|publisher=[https://www.novitas-solutions.com/ Novitas Solutions]|date=2012-08-20|accessdate=2012-10-12}}</ref></blockquote>
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| ===United Kingdom===
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| ====National Health Service====
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| The [[United Kingdom]]'s [[National Institute for Health and Clinical Excellence]] 2007 guidance to the [[National Health Service]] in [[England]], [[Wales]], [[Scotland]] and [[Northern Ireland]] on transcranial magnetic stimulation for severe depression (IPG242), considered for reassessment in January 2011, states:
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| <blockquote>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.<ref>(1) {{cite web|archiveurl=http://www.webcitation.org/6CUsaPbmy|archivedate=2012-11-27|url=http://publications.nice.org.uk/transcranial-magnetic-stimulation-for-severe-depression-ipg242|title=Guidance: Transcranial magnetic stimulation for severe depression (IPG242)|work=NICE interventional procedure guidance, issued November 2007|publisher=[[National Institute for Health and Clinical Excellence]]|accessdate=2012-11-27}}<br>(2) {{cite web|archiveurl=http://www.webcitation.org/6CUrsKLDq|archivedate=2012-11-27|url=http://www.nice.org.uk/guidance/IPG242|title=Transcranial magnetic stimulation for severe depression (IPG242)|publisher=[[National Institute for Health and Clinical Excellence]]|date=2011-03-04|accessdate=2012-11-27}}</ref></blockquote>
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| ==American Medical Association category codes==
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| In 2011, the [[American Medical Association]] established three Category I CPT® Codes to be used for the reporting and billing of therapeutic repetitive transcranial magnetic stimulation treatment services.<ref>{{cite web|author=American Medical Association|url=https://ocm.ama-assn.org/OCM/CPTRelativeValueSearch.do|title=Current Procedural Terminology|publisher=American Medical Association|year=2012|accessdate=2012-02-02}}</ref> The three codes effective January 1, 2012 are:
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| * 90867 – Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management
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| * 90868 – Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session
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| * 90869 – Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management
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| ==Technical information==
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| [[Image:TMS focal field .png|right|150px]]
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| [[Image:TMS Butterfly Coil HEAD .png|right|thumb|240px|TMS - Butterfly Coils]]
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| TMS uses [[electromagnetic induction]] to generate an electric current across the [[scalp]] and [[Human skull|skull]] without physical contact. A plastic-enclosed coil of wire is held next to the skull and when activated, produces a [[magnetic field]] oriented [[Orthogonality|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.<ref>{{cite book |title=Handbook of psychophysiology |year=2007 |publisher=Cambridge Univ. Press |location=New York, NY |isbn=0-521-84471-1 |edition=3rd |editor=Cacioppo, JT; Tassinary, LG; Berntson, GG.|page=121}}</ref>
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| The path of this current is difficult to model because the brain is irregularly shaped and electricity and magnetism are not [[Electrical conduction|conducted]] uniformly throughout its tissues. The magnetic field is about the same strength as an [[Magnetic resonance imaging|MRI]], and the pulse generally reaches no more than 5 centimeters into the brain unless using the [[deep transcranial magnetic stimulation]] variant of TMS.<ref>{{cite web | url = http://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml | title = Brain Stimulation Therapies | accessdate = 2010-07-14 | date = 2009-11-17 | publisher = [[National Institute of Mental Health]] }}</ref> 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.<ref>(1) {{cite doi|10.1016/j.clinph.2004.11.008}}<br>(2) {{cite pmid|20633398}}</ref>
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| === Coil types ===
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| 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.
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| The most important considerations include:
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| * the type of material used to construct the core of the coil
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| * the geometry of the coil configuration
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| * the biophysical characteristics of the pulse produced by the coil.
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| 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.<ref>{{cite book |title=Oxford Handbook of Transcranial Stimulation |editor=Wassermann EM, Epstein CM, Ziemann U, Walsh V, Paus T, Lisanby SH |chapter=TMS Stimulator Design |author=Riehl M |year=2008 |publisher=Oxford University Press |location=Oxford |isbn=0-19-856892-4 |pages=[http://books.google.com/books?id=YeKleGrKwC4C&pg=PA13#v=onepage&q&f=false 13–23], [http://books.google.com/books?id=YeKleGrKwC4C&pg=PA25#v=onepage&q&f=false 25–32] }}</ref>
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| [[File:H-coil helmet.jpg|right|thumb|120px|H-coil helmet]]
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| A number of different types of coils exist, each of which produce different magnetic field patterns. Some examples:
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| * round coil: the original type of TMS coil
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| * figure-eight coil (i.e., butterfly coil): results in a more focal pattern of activation
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| * double-cone coil: conforms to shape of head, useful for deeper stimulation
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| * four-leaf coil: for focal stimulation of peripheral nerves<ref name=roth2>{{cite doi|10.1016/0168-5597(94)90093-0}}</ref>
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| * H-coil: for deep transcranial magnetic stimulation
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| 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 produced a focused, localized response and are relatively non-focal.<ref name = Rossi/>
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| === Devices used in transcranial magnetic stimulation ===
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| Devices available for transcranial magnetic stimulation include:
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| * 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.
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| * 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 to set all important stimulation parameters and to define 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.
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| * Neuronavigation systems: [[Neuronavigation]] is a technique originally used in [[neurosurgery]]. It makes uses of a software system able to load [[Magnetic resonance imaging|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.<ref>{{cite journal|last=Fitzgerald |first=PB | last2=Hoy |first2=K |last3=McQueen |first3=S |last4=Maller |first4=JJ |last5=Herring |first5=S |last6=Segrave |first6=R |last7=Bailey first7=M |last8=Been |first8=G |last9=Kulkarni |first9=J |last10=Daskalakis |first10=ZJ |title=A randomized trial of rTMS targeted with MRI based neuro-navigation in treatment-resistant depression|journal=Neuropsychopharmacology|date=April 2009 |volume=34|issue=5 |pmid=19145228 |doi=10.1038/npp.2008.233 }}</ref><ref>{{cite journal|last=Nauczyciel |first=C |last2=Hellier |first2=P |last3=Morandi |first3=X |last4=Blestel |first4=S |last5=Drapier |first5=D |last6=Ferre |first6=JC |last7=Barillot |first7=C |last8=Millet |first8=B |title=Assessment of standard coil positioning in transcranial magnetic stimulation in depression | journal=Psychiatry Research| date=30 April 2011 |volume=186|issue=2-3 |pmid= 20692709 |doi=10.1016/j.psychres.2010.06.012 }}</ref>
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| * 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 arm]]s. Static holders need to be manually adjusted at the stimulation site. [[Robotic arm]]s are controlled by neuronavigation to adjust the coil position automatically.<ref>{{cite journal|last=Zorn |first=L |last2=Renaud |first2=P |last3=Bayle |first3=B |last4=Goffin |first4=L |title=Design and Evaluation of a Robotic System for Transcranial Magnetic Stimulation|journal=IEEE Transactions on Biomedical Engineering|date=March 2012 |volume=59 |issue=3 |pages=805–815 |pmid=22186930 |doi=10.1109/TBME.2011.2179938 | format = pdf }}</ref><ref name="Robotized Transcranial Magnetic Stimulation">{{cite book | author = Richter Lars | year = 2013| title = Robotized Transcranial Magnetic Stimulation | publisher = Springer | location=[[New York]] | isbn = 978-1-4614-7359-6 }}</ref>
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| ==See also==
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| * [[Cranial electrotherapy stimulation]]
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| * [[Electrical brain stimulation]]
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| * [[Transcranial direct current stimulation]]
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| * [[Electroconvulsive therapy]]
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| * [[Cortical stimulation mapping]]
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| ==References==
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| {{reflist|2}}
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| ==Further reading==
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| * {{cite book |last=Wassermann|first=EM|last2=Epstein|first2=CM|last3=Ziemann|first3=U|last4=Walsh|first4=V|last5=Paus|first5=T|last6=Lisanby|first6=SH|title=Oxford Handbook of Transcranial Stimulation (Oxford Handbooks) |publisher=[[Oxford University Press]], USA |location= |year=2008 |pages= |isbn=0-19-856892-4 |oclc= |doi= |accessdate= | url = http://books.google.com/?id=YeKleGrKwC4C&printsec=frontcover#v=onepage&q}}
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| * {{cite doi|10.4249/scholarpedia.2936}}
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| ==External links==
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| {{Commons category}}
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| * [http://www.overstream.net/view.php?oid=n7aomgtia5ul Stuttering Triggered by Transcranial Magnetic Stimulation (video)]
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| * [http://www.magneticstimulation.gr/index.php/information-for-the-neurophysiology-tests/ More on the diagnostic utility of Transcranial Magnetic Stimulation]
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| * coil manufacturers: [http://www.brainsway.com/ Brainsway], [http://neuronetics.com/ Neuronetics], [http://www.magstim.com/ Magstim], [http://www.magventure.com/ MagVenture], [http://www.magandmore.com/ Mag&More].
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| * stimulators: most coil manufacturers also produce stimulators.
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| * neuronavigation systems: [http://www.rogue-research.com/ Rogue Research], [http://www.nexstim.com/ Nexstim], [http://www.ant-neuro.com ANT Neuro], [http://www.localite.de LOCALITE], [http://www.brainvoyager.com/ BrainInnovation], [http://www.syneika.com/uk/home Syneika].
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| * coil holders: most coil manufacturers also provide static coil holders. Manufacturers of robotic holders include [http://www.ant-neuro.com ANT Neuro], [http://www.axilumrobotics.com/ Axilum Robotics].
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| {{DEFAULTSORT:Transcranial Magnetic Stimulation}}
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| [[Category:Neurophysiology]]
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| [[Category:Neuropsychology]]
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| [[Category:Neurotechnology]]
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| [[Category:Magnetic devices]]
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| [[Category:Electrotherapy]]
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| [[Category:Treatment of bipolar disorder]]
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| [[Category:Physical psychiatric treatments]]
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