—Precise TMS Diagnosis and Treatment
With the accelerated pace of work and the increasing pressure of life, the incidence of mental and neurological diseases has continued to rise. In order to effectively ameliorate these mental and neurological diseases, many attempts have been made—drug therapy, psychotherapy, behavior therapy, etc. Among them, drug treatment has a rapid onset, but there are still many patients who do not respond to it well. The onset of psychotherapy is slow, and the effect of behavioral therapy is also limited. As a new type of physical therapy, transcranial magnetic stimulation is gradually accepted by the public due to its advantages of non-invasiveness, painless, effectiveness, and less adverse effects.
TMS mainly excites or inhibits local cerebral cortex functions by changing the stimulation frequency, and treats diseases by bidirectionally regulating the balance between brain excitation and inhibition functions. Mainly used in the field of mental, neurological, rehabilitation and pediatrics.
1. Psychiatry
Depression, anxiety, obsessive-compulsive disorder, schizophrenia, bipolar disorder and post-traumatic disorder of consciousness.
2. Neurology
Parkinson's disease, Alzheimer's disease, disturbance of consciousness, epilepsy, multiple sclerosis (lower extremity spasticity), etc.
3. Rehabilitation
Post-stroke dyskinesia, post-stroke aphasia, dysphagia, neglect, fibromyalgia, spinal cord injury, etc.
4. Pediatrics
Autism spectrum disorder, cerebral palsy, attention deficit hyperactivity disorder, Tourette's syndrome, etc.
At present, in the process of diagnosing mental and neurological diseases, clinical methods include scales, EEG, near-infrared, etc. The use of scales is subjective to a certain extent, which cannot objectively and truly reflect the therapeutic effect before and after intervention. The use of EEG and near-infrared can more intuitively observe the state of the human brain, which is more reliable than scales. In the process of treatment, common methods include drug therapy, psychotherapy, behavior therapy and other rehabilitation therapy as well as physical therapy, etc. Although drug therapy works quickly, it does not respond to some drug-resistant patients. Psychotherapy has a slow onset, and behavioral therapy as well as other rehabilitation treatments only offers limited effects. As a brain neuromodulation technology, transcranial magnetic stimulation can non-invasively and accurately stimulate damaged target areas of the brain and modulate neural excitability. It is an advanced treatment for mental and neurological diseases.
YINGCHI Technology is fully equipped with TMS detection, evaluation and rehabilitation system, which can provide comprehensive diagnosis and treatment of diseases in the field of mental, neurological, rehabilitation and pediatrics.
It mainly includes electroencephalogram (EEG), event-related potential (ERP) analyzer, functional near-infrared imaging technology, cognitive function testing and training system, etc. Through these objective examinations, patients are examined before treatment to determine the TMS treatment prescription, and the above-mentioned tests are used to evaluate the therapeutic effect of TMS treatment, which is more convincing than subjective evaluations such as scales.
(1) EEG/ERP
EEG is a neurophysiological measurement tool that traces electrical activity in the brain through electrodes placed on the scalp, subdural, or within the cerebral cortex (in special cases). The resulting traces are called electroencephalography(EEG), representing the total amount of postsynaptic potential from a large number of neurons. EEG dynamically reflects the state of brain function by recording electrical signals in the cerebral cortex. It plays an irreplaceable and important role in the diagnosis and localization of epilepsy. It is used in brain function monitoring and prognosis evaluation in various brain diseases, intensive care and neonatal fields. It also has a wide range of applications and is also an important method for brain research.
Event-related potentials (ERPs) are specific electrophysiological responses in the brain elicited by internal or external stimuli, in other words the result of thinking processes in the brain. More and more scholars are devoted to various event-related potential (ERP) studies that are sensitive to cognitive function detection. ERP can usually detect abnormal brain function before clinical detection of abnormality, where P stands for positive wave, N stands for negative wave. Defined by the time that occurs after stimulus presentation in the task-related EEG, it can be divided into early (P100, P200, N200, ERN/Ne) and late (P300, Pe) components, reflecting the time course of task-related neural information processing. ERP provides a unique window for us to observe the brain. The amplitude and latency of each component are the main clinical observation indicators, which are not limited by the tester's culture and language, with low requirements for cooperation, objective data, and high temporal resolution. Changes in brain activity provide a guarantee for immediate evaluation of brain functional status, and it is expected to become a potential indicator for early diagnosis of cognitive impairment. The widely studied ERP components include N200, P300, Mismatch Negativity (MMN) and so on. Among them, the event-related potential P300 can reflect the emotional cognitive function of patients with major depression while MMN can reflect the social cognitive function of those patients.
The combined application of TMS and EEG is being actively promoted, which can measure the stimulation site and stimulation conduction of TMS in real time to understand its effect. Simultaneous recording of TMS-EEG can take advantage of the high temporal resolution of EEG to track transient changes in neurons induced by TMS.
(2) fNIRS
Near-infrared spectroscopy (NIRS) estimates hemoglobin (Hb) concentration changes by measuring reflected light based on the difference in absorption spectra between oxyhemoglobin (oxy-Hb) and deoxyhemoglobin (deoxy-Hb). Combining NIR and TMS allows direct investigation of brain region activity and connectivity. Repeated TMS measurements in different brain regions cannot be reflected by behavioral changes, but can be directly observed by near-infrared. Near-infrared is an optical signal, and no artifacts and collisions of near-infrared data are generated when TMS is performed. Therefore, the TMS coil can be placed directly on the NIRS detector to directly measure hemodynamic changes at the stimulated site.
(3) Computerized Cognitive Testing and Training System
The computerized cognitive testing and training system can be used for neuropsychological evaluation and training in hospitals, focusing on attention, execution objective assessment can be made in multiple dimensions such as function, learning and memory, reaction behavior, visual motor coordination ability, etc. Patients with cognitive deficits can be trained with difficulty adaptive cognitive training to help patients recover sooner.
Each test contains instruction, practice, and formal test stages. The test results are automatically calculated, and the test time accuracy reaches the millisecond level. Compared with the traditional paper-and-pencil test, the computerized cognitive test and training system has standardized test administration, which is not easily affected by patients, and have the advantages of being objective, accurate, and efficient. Cognitive training programs are designed based on daily life scenarios, interactive training with 3D games, patients are highly motivated to participate, and the training results can be better transferred to daily life. The intelligent interactive design can stably determine the patient's ability level and automatically adjust the training difficulty according to its level, thereby ensuring the patient's motivation, compliance and training effect.
(4) EMG Evoked Potential
The EMG evoked potential analysis system is a device for evaluating and diagnosing the functional status of the peripheral and central nervous muscle systems and suspicious lesions. The detection function of the system includes three categories: EMG, nerve conduction velocity, and evoked potential. It is mainly used for positioning and differential diagnosis of various nerves and muscles, detecting sub-clinical lesions, and accurately locating lesions. It can effectively assist in the differential diagnosis of peripheral nerve diseases, myelopathy, demyelinating diseases, cervical spondylosis, diabetes, various nerve injuries, etc., and provides an objective basis for the evaluation of sensory and motor function.
The TMS treatment and rehabilitation system mainly includes a transcranial magnetic stimulator, deep transcranial magnetic stimulation system, transcranial magnetic stimulation 3D navigation system and TMS-PRO-ROB intelligent navigation robot, which can provide comprehensive treatment for different indications.
(1) Transcranial Magnetic Stimulation Therapy
The specific treatment protocols are shown in Table 1.
Table 1 TMS TherapeuticGuidelines (The Latest European Guidelines in 2019)
| Level A(Definite Efficacy) | Neuropathic Pain | HF-rTMS of M1 contralateral to pain side |
| Depression | HF-rTMS of the left DLPFC | |
| Motor Stroke (Postacute) | LF-rTMS of contralesional M1 in hand motor recovery | |
| Level B(Probable Efficacy) | Fibromyalgia | HF-rTMS stimulation of left M1 or DLPFC for improving quality of life or pain, respectively |
| Parkinson’s Disease(Motor Dysfunction & Depression ) | HF-rTMS of bilateral M1 area and left DLPFC for dyskinesia and depression, respectively | |
| Motor Stroke (Postacute) | HF-rTMS of ipsilesional M1 in hand motor recovery | |
| Multiple Sclerosis( Lower Limb Spasticity) | iTBS of the leg area of M1 contralateral to the most affected limb (or both M1) | |
| Post-traumatic Stress Disorder | HF-rTMS of the right DLPFC | |
| Post-stroke Aphasia | LF-rTMS of right IFG | |
| Depression | LF-rTMS of right DLPFC combined with HF-rTMS of left DLPFC; or cTBS of right DLPFC combined with iTBS of left DLPFC; or LF-rTMS of right DLPFC alone | |
| Level C(Possible Efficacy) | CRPS Type I | HF-rTMS of M1 contralateral to pain side |
| Obsessive Compulsive Disorder | LF-rTMS of the right DLPFC | |
| Addiction and Craving | HF-rTMS of the left DLPFC | |
| Alzheimer’s Disease(Mild/Early Stage) | Multisite rTMS-COG to improve cognitive function, memory and language level of AD patients | |
| Tinnitus | LF rTMS of the auditory cortex of the left hemisphere (or contralateral to the affected ear) | |
| Epilepsy | LF-rTMS of the epileptic focus | |
| Hemispatial Neglect | cTBS of the contralesional left parietal | |
| Schizophrenia(Auditory Hallucinations;Negative Symptoms) | LF-rTMS of left temporoparietal (TPC) for auditory hallucination symptoms;HF-rTMS of left DLPFC for negative symptoms | |
| Motor Stroke (Chronic) | LF-rTMS of contralesional M1 in hand motor recovery |
*Lefaucheur, J. P. , Aleman, A. , Baeken, C. , Benninger, D. H. , & Ziemann, U. . (2020). Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rtms): an update (2014–2018). Clinical Neurophysiology, 131(2).
(2) TMS 3D Navigation System
YINGCHI TMS 3D Navigation System adopts high-precision infrared optical capture technology, which can track and locate the TMS coil with millimeter-level accuracy, visualize the stimulation focus magnetic field on the anatomical image of the personalized brain, and locate the navigation system. Intuitive and easy to use, it can assist operators to quickly complete TMS target location, thereby greatly improving the effect and efficiency of diagnosis and treatment.
(3) TMS-PRO-ROB (Intelligent Navigation Robot )
Accurately locate individualized TMS targets according to individual differences in the connectivity of patients' brain functional areas;
The integrated near-infrared binocular vision positioning technology and the intelligent follow-up system of the collaborative robot ensure that each pulse is stimulated to the same target, and achieve accurate rTMS.
After completing the TMS treatment, the above-mentioned detection and evaluation system was used to re-evaluate the patient to observe the changes of the patient's brain function. At the same time, the efficacy of the treatment plan was determined based on the changes of the patient's behavioral performance.
