Frequently Asked Questions
TMS is a focal brain stimulation treatment that passes small electromagnetic currents through parts of the brain. Different regions of the brain can be targeted by holding a specially designed coil near the patient's scalp. Energy is then applied which stimulates nerve cells in that particular brain region.
TMS therapy doesn’t use a drug; it directly stimulates relevant areas of the brain. As a result, there are no foreign compounds introduced to the body in TMS, and it does not have the side effects typically associated with drug therapy.
TMS therapy usually involves several repetitive sessions; this is referred to as repetitive Transcranial Magnetic Stimulation (rTMS)
There are various models for TMS treatment. We select the model most appropriate to the patient’s condition, the nature of their problems, concurrent therapies, and progress.
Usually, TMS requires a course of acute treatment – consecutive, daily (5 days a week) treatments – until remission (sustained improvement) of symptoms is reached. Some patients may require future, intermittent, less intense treatments – referred to as “maintenance TMS” – which can help sustain the initial benefits for a longer period. The intensity and frequency of such maintenance treatments, if required, will be recommended to the individual patient by the treating team.
rTMS has been established since 1985 as an effective alternative to some antidepressants. It has been increasingly used to treat depression, obsessive-compulsive disorders (OCD), some symptoms of psychoses (auditory hallucinations) and PTSD, among other conditions.
Research also suggests that targeting the stimulation more precisely within the area of the dorsal prefrontal cortex can improve symptoms of depression. This region of the brain is responsible for “executive functions”, such as selecting appropriate memories and inhibiting inappropriate responses.
Other psychiatric symptoms, such as OCD, require specific modification to the stimulation regions. To this end, Modalis follows well researched and published protocols.
If you suffer from depression and have not seen significant improvement from traditional antidepressant medications like SSRIs, SNRIs, TCAs, and MAOIs, our TMS therapy may be an excellent solution for you.
rTMS is effective via several complex pathways. One mechanism, in particular, appears to involve opioids, which are the body’s natural pain-relieving chemicals. When rTMS stimulates the brain area involved in pain, there is a significant release of opioids. In conjunction with several other brain chemical systems, this provides substantial pain relief beyond the time of stimulation.
To manage pain, an area of the brain called the primary motor cortex (M1) is typically targeted. A range of other, different regions of the brain could be stimulated for other forms of pain such as neuropathic pain, fibromyalgia, and migraines. rTMS can also be used to treat tinnitus (ringing in the ears).
rTMS is a well-tolerated treatment. It has been used to treat thousands of people, and only a small percentage discontinue treatment because of its side effects:
- Headache: this is the most common side effect and occurs in about half of patients treated with rTMS. These headaches are usually minor and generally resolve throughout the treatment. Simple over the counter pain medication (e.g. paracetamol) is typically enough to address these headaches, but they are often self-resolving.
- Scalp discomfort: this is usually minor and occurs in about a third of patients. This happens where the coil is placed over the scalp and often resolves by the third treatment. Adjustments can be made to the coil position and stimulation settings to reduce discomfort.
- Seizures: This is an infrequent side effect and typically occurs in people at an independent risk of seizures. These seizures tend to be short and self-limiting. Patients are screened before treatment to ensure they do not fall into this at-risk category. Importantly, the chance of having a seizure during an rTMS treatment is lower than that while taking an antidepressant or analgesic drug.
It is important to note that all patients are monitored during each treatment session by specially trained medical and nursing staff. Any side effects will be managed and are reversible once the rTMS treatment stops. As rTMS is a relatively new treatment, there may be unforeseeable risks that are not currently recognized
A medical practitioner who has expertise in rTMS treatment will complete a thorough assessment before treatment to ensure its safety and suitability for the patient. In general, patients who have a history of epileptic seizures or those who have metal in their heads should not receive rTMS. Below is a list of examples, which is not exhaustive:
- Metal stents in the neck or brain
- Deep brain stimulators
- Aneurysm clips or coils
- Metallic implants in your head, ears, eyes or neck
- Facial tattoos with metallic ink
- Other metal objects around your head
TMS treatment is generally safe for patients with non-epileptic seizures.
Positive treatment responses to rTMS vary between patients. A bettering of symptoms is just one measure of success. Others include improvements in productivity, increased psychological and emotional wellbeing, improvement in sleep and in quality of life, and a reduction in the need for pharmacological treatment.
The duration of benefits can also vary between patients and conditions. For example:
- In chronic pain, benefits can last up to 2 months, but usually require “top-up” sessions to maintain the improvement. How often a patient receives a top-up session can also vary. Patients can expect to receive one treatment every month to consider rTMS a worthwhile treatment.
For depression and other psychiatric conditions, the response rates and remissions also vary from patient to patient. TMS treatment should be a part of broader clinical interventions and should not be seen in isolation to other forms of treatment, including counselling and practical support.
About the TMS process
Before a patient’s first session, the severity of their symptoms will be scored so progress can be better measured.
On the first session, their Resting Motor Threshold will be determined. This is the initial “dose” of stimulation. This dose will be increased according to protocol.
Acute treatment - as determined by the administering TMS specialist. This phase will vary from patient to patient depending on the indication and other elements of the treatment.
After the acute treatment discharge report is provided to the referrer, the next stage of the patient’s treatment will be discussed. The acute treatment could be concluded at this point, or they may progress to the maintenance part of the treatment (see below for further information).
Before treatment commences, patients complete a thorough assessment with a specialist physician. This includes an MRI brain scan. This helps to ensure correct targeting of the brain.
During each treatment, patients are asked to remove any magnetic objects (e.g. jewellery, mobile phones) as these can interfere with the TMS machine. Patients may be required to wear earplugs during the treatment for their comfort as the TMS machine can produce a loud clicking sound. This sound is similar to that of an MRI machine, but usually quieter.
For each session, patients are comfortably seated in a cushioned chair, with the stimulation applied with a specific coil. There are different types of coils required for various forms of stimulation. The machine generates an electrical impulse, which results in intense but brief magnetic fields. These fields briefly stimulate the targeted area of the brain.
The first TMS session is a dosing treatment. Several measures are taken to ensure the TMS coil is correctly placed and that the right level of stimulation is applied. This involves using the TMS coil over the scalp. Several brief pulses are applied to establish the “motor threshold”. The motor threshold is the minimum amount of energy needed to elicit a twitch in the thumb muscles of the patient. It varies between individuals. Knowing the motor threshold helps to ensure the right amount of energy is used to stimulate the brain cells. The motor threshold is not checked at every treatment but may be reassessed if there is a concern this has changed.
Patients will have regular observations taken from the nursing staff, and can stop a treatment at any time by asking one of the staff members present.
The TMS treatment will be initiated by a specialist physician who is trained in the use of TMS. On the first session, this specialist will determine the parameters of the treatment: precise location and stimulus strength.
An experienced nursing technician then administers the treatment itself under the supervision of the treating specialist physician. The TMS nurse and a physician is always present to monitor the patient throughout the treatment.
The exact length of rTMS treatment for pain varies between patients. Some patients can notice benefits after five treatments, whereas others may need to go up to 25. The length of individual treatment sessions can also vary. A typical treatment lasts around 20-25 minutes. Patients receive rTMS treatment five days per week: Monday through to Friday.
We offer a considerable capacity to customise each patient’s treatment, which can be discussed with their doctor at the time of consent for treatment and during the regular reviews. We can space sessions out more if a patient is not able to come into the office every weekday
No; rTMS is conducted in an outpatient setting. No sedation or anaesthesia is required, and the patient is fully awake and aware during the treatment. There is no specific recovery time, so patients can drive home after their treatment and resume their day.
The MRI brain images are uploaded to the rTMS program and are used to guide the patient’s individual treatment. This process is known as Neural Navigation. Such navigation techniques refine and improve the accuracy of the treatment. Precise targeting of the underlying brain structures, the right angle of the TMS coil and the depth of the stimulation has been demonstrated to increase the effectiveness of treatment and significantly shorten essential titration of the stimulus.
About treatment access & costs
TMS is a medical treatment that requires an assessment by a trained medical practitioner. Modalis has several specialist physicians (general psychiatrists, pain specialists, a child psychiatrist and associated neurologist) who can assist with a treatment plan. Patients need to obtain a referral to Modalis from their GP or another medical practitioner, who will then arrange an assessment session. These referrals can be directed to the individual specialist, or they will be allocated to the most appropriate specialist.
The treatment can be prescribed by any medical practitioners familiar with TMS techniques and its clinical indications. When the team of TMS specialists at Modalis receives the referral, its further progress of this referral will be decided based on the patient’s specific requirements and clinical presentation.
Patients may be offered an initial clinical review by the TMS specialist at Modalis to determine if TMS is their best clinical option. Some referrals could progress without such a review, in which case the first meeting with the staff of Modalis will occur at the time of the proposed first treatment.
Before any medical procedures, every patient is comprehensively informed about the treatment and has the opportunity to ask any questions about the process: indications, course and potential benefits as well as its side effects. Modalis strictly follows all the relevant clinical, ethical and medico-legal guidelines relating to such consent processes.
All patients are encouraged to review all the information on this website about TMS. The TMS process will also be discussed in your initial meeting with our TMS specialist. Modalis encourages other people involved in your life to participate in this process.
When satisfied with the information received, a formal consent form is then signed and witnessed before the treatment takes place. This consent relates to the specific course of TMS treatment but can be withdrawn at any stage of the process.
rTMS as an outpatient is not currently funded by Medicare or any of the private health funds. There is the possibility that if you are a DVA patient or covered by a third-party insurance claim, that the treatment will be covered.
If you are responsible for the treatment, then you can expect to pay $220 for the initial session and $180 for each subsequent treatment.
Please note: We are pleased to inform you that the Commonwealth Government has approved ongoing Medicare funding for TMS (for treatment-resistant depression). It is a much needed and welcomed decision, which will substantially enhance the range of clinical options for many of our patients who have been dealing with their chronic, treatment-resistant condition. This decision will be implemented by the relevant Government Departments in the next few months. Most likely, medical rebates will be available after 1 November 2021. For the time being, Modalis will be offering MRI-guided rTMS under the current funding options.
In most cases, you will not need any specific preparation before the treatment. Your doctor will have assessed you and have organized an MRI brain scan.
Like more information
or have a question?
If you have any further queries, please do not hesitate to contact one of our friendly receptionists. Our reception is open Monday to Friday between 9:00am and 4:30pm or you can contact us using one of the options below.
We look forward to assisting you.