TMS and tDCS

[anon-medic]

TMS and tDCS are emerging therapies in a number of neurologic and psychiatric disease areas. Publications are building up in support of their use e.g. : http://stm.sciencemag.org/content/8/330/330re1

Until now, there hasn't been much clinical use. If research continues to be promising, I'm assuming this will change.

Who do you think will take responsibility for administering these therapies? Will it be subspecialist neurologists dealing with TMS and tDCS (perhaps alongside DBS, or alongside EMG/NCS)? Will it be neurologists focusing on each specific area administering their own protocols? Will it be neuroradiology, and if so, diagnostic or interventional?

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[neglect]

TMS and tDCS are emerging therapies in a number of neurologic and psychiatric disease areas. Publications are building up in support of their use e.g. : http://stm.sciencemag.org/content/8/330/330re1

Until now, there hasn't been much clinical use. If research continues to be promising, I'm assuming this will change.

Who do you think will take responsibility for administering these therapies? Will it be subspecialist neurologists dealing with TMS and tDCS (perhaps alongside DBS, or alongside EMG/NCS)? Will it be neurologists focusing on each specific area administering their own protocols? Will it be neuroradiology, and if so, diagnostic or interventional?

TMS is a natural outgrowth of neurophysiology. If paid for and effective, it will be used. Psychiatry is already using it as an ECT-like intervention, but I have not seen this.

Both TMS and DCS will also be used by rehab. Location. They see them, so these fall under their jurisdiction. Of course, the entire MO of rehab is no diagnosis, no hard and dirty work (after we tell a stroke person they just went from normal to Rankin 3, they get to tell them that with effort, they could be a Rankin 1-2), just steal the lucrative procedures from specialties: injections from ortho/rheum, pain injections, botox and NCV from neuro. They might not do them well and they run into walls (good for CTS, bad for ALS), but that doesn't stop insurers from paying them. So they will also do TMS.

Anyway, we are going to need more studies that demonstrate benefit.

 

[Hank Rearden]

I'm not optimistic that TMS and tDCS are going to emerge as significant therapies for neurologic disease. All of the studies to date (including the one linked above) are small and there is probably significant publication bias. There is currently an industry sponsored multicenter trial of rTMS for stroke underway and I understand a similar trial of tDCS has been proposed. Until I see a positive multicenter trial I'll remain quite skeptical. rTMS to dorsolateral prefrontal cortex definitely works for depression, though not nearly as efficacious as ECT.

TMS has it's place as a neurophysiologic tool and can teach us a great deal about human cognition in health and disease, I just don't see it becoming a major therapy.