Daily Pre-TMS Treatment Checklist
Each day before beginning the TMS procedure, you will be asked to remove any metal or magnetic sensitive objects (e.g., jewelry, keys, watch, credit cards); remember the device generates a magnetic field strength which is similar in strength an MRI device. To be safe, no metal should be within 30 centimeters of the coil; we encourage very expensive watches and electronics and potentially reactive jewelry or glasses to be set far outside the magnetic field; a table across the room from the TMS device is sufficient. Daily, you will also be asked specific questions concerning: medication adherence, sleep, alcohol or other drug intake, nutrition and exercise. This is a daily pre-treatment checklist. These questions are important because changes to sleep, alcohol and other substance ingestion, and changes in some types of medications can affect your brain’s activity level and can affect your TMS treatment and could increase risks of seizure during TMS. You should answer the daily pre-treatment questions and have your TMS technician review before you begin your TMS session daily. You will see the daily pre-treatment checklist on your <strong><em>Daily Treatment Log</em></strong> which you will review in-depth tomorrow. Your treatment team can complete the log for today for you.
It is important for your TMS technician and your clinician to monitor your sleep patterns. You will be asked about your sleep before each TMS session. Your team needs to know about your sleep the night prior to your TMS treatments. You will be asked if you had trouble falling asleep, how many hours you slept, if the sleep was interrupted, and if you felt rested from your sleep. You will note that the daily log has a spot to record sleep quality and quantity. You and your TMS technician may wish to review this form each day. Your team will understand if you did not sleep as well as usual the first night before starting TMS, as most patients experience some level of excitement/anxiety the night before the first TMS treatment; this is normal. During TMS treatment, if you get less sleep and do not feel tired, or if you sleep much worse than usual, or not at all, tell your treatment team so that they can address this with you; the clinician may ask you to skip a treatment that day. We use four hours as our conservative number of hours of total sleep as a requisite for receiving TMS in our clinics. Sometimes if four hours is achieved but it was broken into multiple pieces, we still might skip a treatment. Ask your clinician and technicians what their sleep policy is during TMS treatments. Getting less sleep can be caused by multiple factors, and not sleeping makes the brain more vulnerable to side effects like a seizure. Sleep disruptions can be a sign of being over-stimulated. Other signs include racing thoughts, irritability, or an inability to focus; in rare cases this could lead to anxiety, hypomania or even mania.
You will also be asked if you drank alcohol or used any substances like marijuana, cocaine, or other brain altering substances for the two days prior to your treatment. Your clinician needs to know if you consume alcohol, or other substances, which can affect your brain and your mood. Besides being depressants to the brain, drugs can alter your brain’s reactivity to the magnetic field used in TMS; changing the substances you take into your body can increase the likelihood of experiencing a seizure during a TMS treatment. In fact, in the rare case when seizures have happened to patients receiving TMS, many have been associated with alcohol use the night prior to TMS. It is wise, not to use alcohol or other brain altering substances during TMS. We recognize alcohol and other substances are used socially to celebrate, and if a celebration is scheduled during the treatments with TMS, we advise that you consume no more than 1-2 alcoholic beverages per week (and not on an evening when TMS is scheduled the next day).
You will be asked about current medication, so your team can be aware of any changes you have made, accidentally, or on purpose. Please inform your team if you take any medications as needed, or if you have taken any medications inconsistently or differently as prescribed. Make sure you think about all medications from all prescribers. It is recommended you keep a daily medication log during your treatment; a log is included in the manual each day for you to improve your consistency and adherence to the plan to get well. A final note about medications: to stay consistent with medications you will want to pay close attention to your medication refills so that if you need refills during your TMS Sessions you can make your clinician aware; you may want to calculate this in the first couple of days of TMS so that you will not have to do it again throughout TMS.
The first TMS session is all about giving education, determining the strength and the location of the coil, and administering the first TMS treatment. Your clinician and TMS technician will do as much as possible to make you comfortable and will explain a lot to you today. Don’t worry if you don’t remember everything as it can be repeated later. During TMS treatments you will likely sit in a reclined position. If, during the first session, you become uncomfortable please speak up! Today is the best, but not only, time to adjust your settings for comfort. If, over the next few weeks, the treatment position becomes uncomfortable please inform your TMS technician and clinician. There is no need for this treatment to be very uncomfortable.
During the initial session two of the most important aspects of your treatment will be established:
- The strength of the magnetic pulse needed to stimulate your brain (motor threshold), and
- The treatment location.
To determine the motor threshold (MT), which is the strength needed for the electro-magnet to stimulate your brain, your clinician will conduct single pulses over your motor strip. The motor strip is an area on each side of the brain, which controls the motion for the opposite side of your body. When determining the MT for TMS, most Clinicians want to get the right hand, fingers, or thumb to move when they deliver the magnetic pulse over your motor strip.
Your clinician and TMS technician will also locate the treatment area today. There are multiple techniques which can be used. Your clinician and TMS technician will complete a method to determine the location and strength where your TMS will be given daily. The standard of care as of early 2018 is to use F3 or modified F3 to find the DLPFC when treating depression in the US; in Canada, positive results have been found using a similar method to find the DMPFC. Research is continuing daily attempting to determine the best location for particular patients, however, a suitable algorithm has not yet been determined. For now, as of early 2018, most doctors use one of these two determinations. Ask your clinician why they use the particular placement method which they have selected for you, and how the location of your treatment is determined soo that you understand the rationale.
Once the treatment location and strength are determined, your first TMS treatment will begin. The first several stimulations may be uncomfortable, but your clinician and TMS technician can do several things to improve the tolerability of the treatment. They might keep the strength of the magnetic pulses lower for the first several sessions or they may apply topical gels or reduce the intensity of the treatment to relieve initial discomfort. Most patients do tolerate the treatments with little to no discomfort by the end of the first few TMS treatments. Remember to tell the clinician or TMS technician if you are uncomfortable.
If your treatment location is too uncomfortable, you may need minor adjustments on device placement or strength of the treatment for the first few sessions. If you experience pain in your eye, radiation of pain down your face, or feel uncomfortable sensations with the stimulations, your prescribing clinician can adjust the position or strength of the device for comfort. If any adjustments to your treatment location occurred, those adjustments will be recorded in this workbook. Please ask your clinician to tell you what the final settings are so you will know exactly where you were treated.
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