Ablauf der Anwendung und Grundlagen der Wirkung

Basics of Application and physiology

Geschichte der transkraniellen Magnetstimulation (TMS)

Geschichte der transkraníellen Gleichstromstimulation (tDCS)   

 Geschichte TMS  Geschichte tDCS

 


rTMS - repetitive transkranielle Magnetstimulation

Ablauf der Anwendung

In einer ärztlichen Voruntersuchung wird abgeklärt, ob bei Ihnen eine Erkrankung vorliegt, für die in wissenschaftlichen Studien eine Wirkung einer rTMS-Anwendung gezeigt wurde. Außerhalb von Studien sollte rTMS als Heilversuch nur dann eingesetzt werden, wenn bewährte Therapien nicht ausreichend wirksam waren, oder nicht vertragen wurden. Bedenken Sie bitte, dass die rTMS-Anwendung die genaue ärztliche Diagnostik und die bei Ihrer Erkrankung übliche Therapie nicht ersetzen kann.

 

Die Therapie mit rTMS ist weitgehend schmerzfrei und nebenwirkungsarm. Zu Beginn werden mehere Sitzungen täglich oder im Abstand von wenigen Tagen durchgeführt. Zur Fortsetzung der Therapie werden einzelne Sitzungen im Abstand von Wochen bis Monaten angewendet. Sitzungsanzahl und das individuelle Stimulationsprotokoll legt Ihr behandelnder Arzt im Vorgespräch fest. Die rTMS-Neuromodulation wird in komfortabler Sitzposition mit einer Magnetspule am Kopf durchgeführt, wobei das Magnetfeld bis zu einer Tiefe von 2-3 cm einwirkt.

Mit kurzen Impulsen wird eine Feldstärke von ca. 1-2 Tesla erreicht, vergleichbar mit der Intensität einer Kernspintomographie, aber die rTMS-Therapie wird ohne enge „Röhre" durchgeführt. Wegen der lauten Geräusche werden Ohrstöpsel verwendet. Uhren und Karten mit Magnetstreifen müssen in 1 Meter Entfernung abgelegt werden. Die Weltgesundheits-Organisation hat statische Magnetfelder bis zu 2 Tesla für unbedenklich erklärt. In der Regel liegt die Magnetfeldstärke bei rTMS deutlich darunter.

 

Magnetstimulation mit rTMS - moderner Einsatz in der Medizin

Die transkranielle Magnetstimulation (TMS) wurde 1985 eingeführt und ist heute ein Standardinstrument in der Diagnostik zentraler Nervenbahnen. Dabei wird ein Stromimpuls von etwa 5000 Ampere für etwa 200-400 Mikrosekunden durch eine gut isolierte Spule geleitet und erzeugt damit kurzfristig ein sehr starkes Magnetfeld. Der Magnetpuls reizt Nervenzellen und führt zu deren Entladung im Zielbereich mit Weiterleitung in die vernetzen Hirnzentren. Seit 1994 werden Serien derartiger Magnetpulse auch für therapeutische Zwecke eingesetzt. Durch repetitive transkranielle Magnetstimulation (rTMS) wird dabei eine Wirkung auf die Nervenzellen der Hirnrinde erreicht, die die Stimulation überdauert. Der Zielpunkt für die rTMS-Therapie richtet sich nach der zu behandelnden Erkrankung und wurde in wissenschaftlichen Studien ermittelt. Bei der Anwendung am Kopf wird meistens eine sogenannte Achterspule eingesetzt, bei der das Magnetfeld gebündelt wird und genau auf den Zielpunkt ausgerichtet werden kann. Neben einem Kribbeln der Kopfhaut können leichte Kopfschmerzen auftreten. Andere Nebenwirkungen sind sehr selten und die Behandlung wird sehr gut vertragen. Bei der rTMS-Neuromodulation orientieren wir uns an Protokollen und Indikationen, für die in wissenschaftlichen Studien ein Therapieeffekt gezeigt wurde. Diese neue Therapiemethode kann bei Patienten als therapeutischer Heilversuch eingesetzt werden, wenn die Standardtherapie nicht ausreichend wirksam ist, oder nicht vertragen wurde.

 

Sicherheit der rTMS-Anwendung beim Menschen

Für die rTMS-Anwendung wurden wissenschaftliche Sicherheitsrichtlinen veröffentlicht. Diese Richtlinen setzen voraus, dass zuerst die individuelle Stärke des Magnetpulses bestimmt wird, bei der eine Muskelaktion der Hand ausgelöst wird, die als Motorschwelle / motor threshold bezeichnet wird. Bezogen auf die Motorschwelle wird dann in den Sicherheitsrichtlinen eine Obergrenze der anzuwendenden Frequenz der rTMS definiert. Die im Netzwerk Neuromodulation genannten Behandlungseinrichtungen haben sich zur Einhaltung der Sicherheitsrichtlinien verpflichtet. Wenn Sie eine hier nicht genannte rTMS-Behandlungseinrichtung konsultieren sollten, empfehlen wir eine Nachfrage, ob die Sicherheitsrichtlinien mit Bestimmung der individuell verschiedenen Motorschwelle eingehalten werden.

 

tDCS - transcranial direct current stimulation - transkranielle Gleichstromstimulation

Bei der nichtinvasiven Hirnstimulation durch tDCS fließt über zwei an der Kopfhaut angebrachte Elektroden ein kontinuierlicher Gleichstrom, der meistens für 10 bis 20 Minuten angwendet wird. Es kommt zu einer Auslenkung des Ruhemembranpotentials von Nervenzellen des Gehirns. Dabei kommt es bei der anodalen (anregenden) Stimulation zu einer Anhebung, bei der kathodalen (hemmenden) Stimulation zu einer Absenkung des Membranpotentials. Dadurch lassen sich Signale im Gehirn (Aktionspotentiale) entweder leichter (anodal) oder schwerer (kathodal) auslösen. Weiter verändert die tDCS die glutamaterge N-methyl-D-aspartat (NMDA)-Rezeptor-abhängige Übertragung im Gehirn und kann so Lernvorgänge erleichtern.

 

Interessierte können sich in der sehr umfangreichen Literatur zu den Grundlagen (Physiologie) der nichtinvasiven Hirnstimulation informieren.

Literatur - references

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  • On the role of the ventral premotor cortex and anterior intraparietal area for predictive and reactive scaling of grip force. Dafotakis 2008.
  • One-Hertz TMS over the frontal eye field induces lasting inhibition of saccade triggering. Nyffeler 2006.
  • Opposite effects of 1 Hz and 20 Hz over left DLPFC on PET. Speer 2000.
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  • Paroxetine pretreatment does not change the effects induced in the rat cortical beta-adrenergic receptor system by rTMS and electroconvulsive shock. Vetulani 2009.
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  • Pharmacologic Influences on TMS Effects. Boroojerdi 2002.
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  • Preconditioning with tDCS sensitizes the motor cortex to rapid-rate TMS and controls the direction of after-effects. Lang 2004.
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  • Priming theta-burst rPMS with low- and high-frequency stimulation. Todd 2009.
  • Prospective memory and working memory - Asymmetrical effects during frontal lobe TMS stimulation. Basso 2010.
  • Protective effects of rTMS in a rat model of transient cerebral ischaemia - a microPET study. Gao 2010.
  • Reduced motor cortex plasticity following inhibitory rTMS in older adults. Todd 2010.
  • Regional modulation of BOLD MRI responses to human sensorimotor activation by tDCS. Baudewig 2001.
  • Repetitive paired-pulse TMS affects corticospinal excitability and finger tapping in Parkinson's disease. Sommer 2002.
  • Repetitive stimulation of premotor cortex affects primary motor cortex excitability and movement preparation. Stinear 2009.
  • Repetitive TMS over the human oculomotor cortex - Comparison of 1-Hz and theta burst stimulation. Nyffeler 2006.
  • Responses to rapid-rate TMS of the human motor cortex. Pascual-Leone 1994.
  • Reversal of a Virtual Lesion in Human Pharyngeal Motor Cortex by High Frequency Contralesional Brain Stimulation. Jefferson 2009.
  • rTMS activates PVT circadian rythm in rat brain Ji. 1998.
  • rTMS Affects behavior by Biasing Endogenous Cortical Oscillations. Hamadi 2009.
  • rTMS induces active coping strategies and attenuates the neuroendocrine stress response in rats. Keck 2000.
  • rTMS of the human prefrontal cortex induces dopamine release in the caudate nucleus. Strafella 2001.
  • rTMS of the left dorsolateral prefrontal cortex modulates dopamine release in the ipsilateral anterior cingulate cortex and orbitofrontal cortex. Cho 2009.
  • rTMS of the SMA degrades bimanual movement control in humans. Serrien 2002.
  • rTMS on activation in quadriceps weakness Urbach. 2005.
  • rTMS over the right dorsolateral prefrontal cortex affects strategic decision-making. Van't Wout 2005.
  • rTMS reveals abnormal plastic response to premotor cortex stimulation in schizophrenia. Oxley 2004.
  • rTMS to the primary motor cortex interferes with motor learning by observing. Brown 2009.
  • Modulatoy effects of low- and high-frequency rTMS of visual cortex of healthy subjects undergoing light deprivation. Fierro 2005.
  • rTMS-induced Changes in Sensorimotor Coupling Parallel Improvements of Somatosensation in Humans. Pleger 2006.
  • Sensitivity of Neurons to Weak Electric Fields. Francis 2003.
  • Serotonin Affects Transcranial Direct Current-Induced Neuroplasticity in Humans. Nitsche 2009.
  • Shaping the Effects of tDCS of the Human Motor Cortex. Nitsche 2007.
  • Shaping the excitability of human MC with premotor rTMS. Rizzo 2004.
  • Short and long duration tDCS (tDCS) over the human hand motor area. Furubayashi 2008.
  • Short-duration transcranial random noise stimulation induces blood oxygenation level dependent response attenuation in the human motor cortex. Chaieb 2009.
  • Short-term modulation of regional excitability and blood flow in human motor cortex by rTMS. Takano 2004.
  • Simply longer is not better - reversal of theta burst after-effect with prolonged stimulation. Gamboa 2010.
  • Slow rTMS increases somatosensory high-frequency oscillations in humans. Ogawa 2004.
  • Slow TMS Long-Term Depotentiation, and Brain Hyperexcitability Disorders. Hoffman 2002.
  • Slowing fastest finger movements of the dominant hand with low-frequency rTMS of the hand area of the primary motor cortex. Jancke 2004.
  • State-Dependent Variability of Neuronal Responses to TMS of the Visual Cortex. Pasley 2009.
  • Stimulation-induced within-representation and across-representation plasticity in human motor cortex. Ziemann 2002.
  • Stimulus intensity and coil characteristics influence the efficacy of rTMS to suppress cortical excitability. Lang 2006.
  • Study and Modulation of Human Cortical Excitability With TMS. Pascual-Leone 1998.
  • Subthreshold high-frequency TMS of human premotor cortex modulates interconnected frontal motor areas as detected by interleaved fMRI-TMS. Bestmann 2003.
  • Suppressing the surface field during TMS. Davey 2006.
  • Sustained excitability elevations induced by transcranial DC motor cortex stimulation in humans. Nitsche 2001.
  • Switching skills on by turning off part of the brain. Young 2004.
  • Task-dependent modulation of inputs to proximal upper limb following tDCS of primary motor cortex. Bradnan 2010.
  • TBS over the human primary motor cortex modulates neural processes involved in movement preparation. Ortu 2009.
  • tDCS - a tool for double-blind sham-controlled clinical studies in brain stimulation. Gandiga 2006.
  • tDCS applied over the somatosensory cortex - differential effect on low and high frequency SEPs. Dieckhöfer 2007.
  • tDCS of the primary motor cortex affects cortical drive to human musculature as assessed by intermuscular coherence. Power 2006.
  • tDCS over V5 enhances visuomotor coordination by improving motion perception in humans. Antal 2004.
  • Testing for causality with tDCS pitch memory and the left supramarginal gyrus. Vines 2006.
  • The effect of TMS and peripheral nerve stimulation on corticomuscular coherence in humans. Hansen 2004.
  • The effects of externally applied transcephalic weak direct currents on lateralization in choice reaction tasks. Jaeger 1987.
  • The effects of motor cortex rTMS on corticospinal descending activity. Di Lazzaro 2010.
  • The Effect of rTMS on Gamma Oscillatory Activity in Schizophrenia. Barr 2011. 
  • The facilitatory effects of intermittent theta burst stimulation on corticospinal excitability are enhanced by nicotine. Swayne 2009.
  • The influence of coil-skull distance on TMS motor-evoked responses. Cukic 2009.
  • The influence of current direction on phosphene thresholds evoked by TMS. Kammer 2001.
  • The influence of low-level transcortical DC-currents on response speed in humans. Elbert 1981.
  • The influence of low-level, event-related DC-currents during time estimation in humans. Elbert 1981.
  • The Neurochemical Effects of Theta Burst Stimulation as assessed by Magnetic Resonance Spectroscopy. Stagg 2009.
  • The physiological basis of the effects of intermittent theta burst stimulation of the human motor cortex. Di Lazzaro 2008.
  • The Truth about Lying - Inhibition of the Anterior Prefrontal Cortex Improves Deceptive Behavior. Karim 2010.
  • Therapeutic Window for theta burst rTMS. Paulus 2005.
  • Theta burst and conventional low-frequency rTMS differentially affect GABAergic neurotransmission in the rat cortex. Trippe 2009.
  • Theta Burst Stimulation of the Prefrontal Cortex - Safety and Impact on Cognition Mood and Resting EEG. Grossheinrich 2009.
  • Theta burst stimulation of the human motor cortex. Huang 2005.
  • Theta burst stimulation over the primary motor cortex does not induce cortical plasticity in Parkinson's disease. Eggers 2010. 
  • Theta Burst suppresses excitatory circuits. Di Lazzaro 2005.
  • Time course of the state-dependent effect of TMS in the TMS-adaptation paradigm. Cattaneo 2008.
  • Time-course of "off-line" prefrontal rTMS effects - a PET study. Eisenegger 2008.
  • Timing-Dependent Modulation of Associative Plasticity by General Network Excitability in the Human Motor Cortex. Nitsche 2007.
  • TMS - studying the brain-behaviour relationship by induction of virtual lesions. Pascual-Leone 1999.
  • TMS of posterior parietal cortex affects decisions of hand choice. Oliveira 2010.
  • TMS in controlled treatment studies - are some sham forms active? Loo 2000.
  • TMS in heterogeneous brain tissue - Clinical impact on focality reproducibility and true sham stimulation. Toschi 2009.
  • TMS induced plasticity in human cortex. Ziemann 2004.
  • TMS of deep brain regions - evidence for efficacy of the H-coil. Zangen 2005.
  • TMS of the primary motor cortex modulates response interference in a flanker task. Soto 2009.
  • TMS Over Human Dorsal-Lateral Posterior Parietal Cortex Disrupts Integration of Hand Position Signals Into the Reach Plan. Vesia 2008.
  • TMS synaptic plasticity and network oscillations. Huerta 2009.
  • Transcutaneous magnetic stimulation of the Quadriceps via the femoral nerve. Kremenic 2004.
  • T-type calcium channels mediate rebound firing in intact deep cerebellar neurons. Alvina 2009.
  • Two different reorganization patterns after rehabilitative therapy - An exploratory study with fMRI and TMS. Hamzei 2006.
  • Visual evoked potentials modulation during direct current cortical polarization. Accornero 2007.
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  • Es sind nur die Erstautoren aufgelistet und nur in Pubmed zitierte Arbeiten werden in die Liste aufgenommen. Only first authors are listed and citation in Pubmed is usually required for inclusion in this list.
  • Abkürzungen - abbreviations:
  • TMS - transkranielle Magnetstimulation - transcranial magnetic stimulation.
  • rTMS - repetitive transkranielle Magnetstimulation - repetitive transcranial magnetic stimulation.
  • tDCS - transkranielle Gleichstromstimulation - transcranial direct current stimulation.
  • TBS - thetaburst stimulation - burst TMS.
  • DC - Gleichstrom -  direct current 

Startseite

repetitive transkranielle
Magnetstimulation (rTMS)


repetitive transcranial
magnetic stimulation

repetitive periphere
Magnetstimulation (rPMS)


repetitive peripheral
magnetic stimulation

transkranielle Gleich-
stromstimulation (tDCS)


transcranial direct
current stimulation

Thetaburst Stimulation (TBS)


theta burst stimulation