The New Inovation

7/29/2019 The New Inovation

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Dr.AGUS SOLICHIEN,SpS,MARS


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Treatment Diagnostic


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Trans cranial Magnetic Stimulation/PeripheralMagnetic Stimulation

Found by Anthony Barker 1985

Diagnostic tool

Therapeutic tool (rTMS)


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Magnetic field product by Neuro MS

Intensities up to 2.5 tesla

Magnetic field was given to the head (cranial)

and body (peripheral)


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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)

Dischargeswitch

Energy-storage

capacitor

Capacitorcharger

Stimulatingcoil

Electricoutlet

Controller

Magneticfield

Inducedcurrents

[Neuronetics]


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Current pulse in Neuro MS coil inducesmagnetic field

Magnetic field pulse induces electricalcurrents in brain

Principle of electromagnetic induction,also used in electrical transformers

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

+- --

-

--

--

-

- ---

--

-

++++

+

+ ++ +

+++++

+

- --

---

+ +

--

Magneticfield

Electric field

Axon

Induced currents depolarizeaxons and make them fire

[Ruohonen & Ilmoniemi, 2005]


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[Walsh & Pascual-Leone, 2003]

Neuronal Membrane Potential

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)

f

g


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Continues stimulation may change nervespolarity.

Clinical improvement

Effect magnetic to ferum made oxygenationcirculation improve.


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Sherrington dan Cajal : Proses belajarperubahandisynap LTP

Hebbian Synap: synap yang meningkat efektifnyadi pre dan post synap oleh kerena aktivitas yangterus menerus.

LTP : jika satu atau lebih akson yang terhubungdengan beberapa dendrit dilakukan stimulasisecara serial dan singkat menggunakan frekuensi

yang tinggi maka akan terjadi ledakan stimulasiyang menimbulkan synap menjadi lebih responterhadap rangsang baru yang sejenis untukbeberapa menit, hari, bahkan minggu.


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LTP : menunjukan tiga basis seluler dalambelajar dan memori:

1. Spesifisity Jika beberapa synap yang masuk

kedalam sel sangat aktif sedangkan yang laintidak, maka yang aktif yang akan menjadi kuat.

2. Cooperativity Jika stimulasi dilakukan padalebih dari satu akson maka akan menghasilkanefek LTP yang lebih kuat dibandingkan bilasatu akson saja.


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Ex: akson A dan B :aktif,B dan C :tidak, A dan B

akan lebih kuat sebaliknya B dan C akan tetap samaatau melemah ( Sejnowski, Chattarji, n Stanton)

3. Asosiativityjika input berpasangan antara yg

lemah dgn yang kuat akan memperkuat input yglemah. Synap yg ke LTP akan seperti Hebiansynap, kecuali LTP membutuhkan depolarisasi didenrit yg tidak perlu potensial aksi.

LTD berkebalikan dgn LTP stimulasi dengan lowfrekuensi.


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Monophasic Biphasic

Magnetic

Field

NeuronalMembrane

Potential

Electric

Field

More selective stimulation

Single-pulse devices

Less selective stimulation

Rapid-rate devices


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double cone

Circular (round) coil

Non-focal

Medium efficiency

Fast field falloff

Figure-of-8 (double) coil

Focal

Low efficiency

Fast field falloff

magnetic flux


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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]


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Small coil: focal, small depth

Large coil: diffuse, larger depth

Fundamental physics constraints:

Larger coils can stimulate deeperbrain structures, but are less focal

Smaller coils stimulate the cortexmore focally, but cannot stimulate

deeper structures


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


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Brain: (Psychiatry)

Schizophrenia

Depression

OCD

Manic Depression


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Peripheral :

Pain Management

Arthritis

Bone healing

Muscle soreness

Chronic Low Back Pain

Aid Diaphragm Contraction Fibromyalgia


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Systemic

Neurological

Psychiatric


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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); negresults for ACTH, PRL, TSH, LH, FSH

Immunologic: CD8+ T-cell (+/-) Skin: erythema, burn (e-shield)


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Pain: Treatment site: scalp muscle

Treatment site: superficial nerves/branches

Headache

Paresthesias

General:

Fatigue

Malaise

Dizziness


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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


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As of 2000, 6 seizures in normal controls, 2 inpatients with depression

Site of stimulation: primary motor cortex

No long-term sequelae (except 1 patient withstructural lesion-->epilepsy)

Short-term mild recall deficits (24h)

Normal EEG (Loo 1999)


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Inefficacy

Anxiety

Acute dysphoria/crying

Laughing (speech arrest study)

Suicidal ideation

Switch to mania


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Metal implants

Pacemakers, implanted medication pumps

Unstable CV disease

Increased intracranial pressure

Pregnancy

Children


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Stroke Patients ( 12 orang)

Stimulasi Frekuensi 1HZ, Train 50 X, Pause5,Sesion 10 Serial 5hari ,Power 80%-100%

Perbaikan motorik Perbaikan cognitive

Perbaikan pola tidur


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Parkinson syndrome: (4 orang)

Frekuensi 1HZ ,Train 50X, Pause 5,Sesion 10

Power 80%

Frekuensi 5HZ,Train 50X,Pause 5,Sesion 5Power 100%

Perbaikan gerakan

Tremor berkurang Perbaikan pola tidur


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FromJournal WatchPhysician-authored summaries and commentaryfrom the publishers of the New Engl and Journalof MedicineJournal Watch NeurologyAugust 21, 2003Repetitive Transcranial Magnetic Stimulation to Treat Parkinson DiseasePosted 10/06/2003SummaryRepetitive transcranial magnetic stimulation (rTMS) of the brain is a noninvasive, well-tolerated technique that can modify cerebral cortex excitability both locally and at remote,but functionally connected, areas (Lancet Neurology 2003; 2:145). Initial research on rTMSfor motor function in Parkinson disease (PD) showed promising results (Neurology 1994;44:892), but later research failed to confirm initial find ings (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.
http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664http://www.medscape.com/viewpublication/664


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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


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Pasien Ischialgia dan Cronic LBP (30 orang)

Frekuensi 2,5 HZ, Train 50X,Pause 5Sesion 5

Power 40%


Hasil : Perbaikan Nyeri

Perbaikan ADL


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Pasien Bells Palsy (3 orang)

Celah mata 3mm,sudut nasolabialis -


Power 40% Frekuensi 5HZ,Train 50X,Pause 5,Sesion 5

Power 50%

Hasil : Perbaikan muka simetris setelah 4Xstimulasi


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Pasien gangguan memory (2 orang)


Power 40%


Hasil : Perbaikan fungsi memory


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Pasien Hiperventilation Syndrome (10 orang)


Power 40%


Hasil : Perbaikan symptomatik


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Pasien Vertigo, Dizziness, Tinitus (7 orang)


Power 40%


Hasil : Perbaikan fungsi memory


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Pasien ADHD, Autis, DownSyndrome,Dyscalculi (4 orang)

Perbaikan klinis.


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Hari Ke 3


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The New Inovation