TMS Flashcards
How deep does the electric field penetrate the heads surface?
2-4 cm
What does the train represent?
The number of repetitive pulses in a quick succession.
Why do we get the motor threshold?
It is used to determine the goal treatment intensity and we base it on the level of tolerability
What is the goal of mapping?
To locate the motor cortex and the motor threshold so that we can use the motor threshold to determine the intensity of the treatment.
What is the nasion and inion?
Nasion is the point where the nasal and frontal bone connect
Inion is the projecting part of the occipital bone at the base of the skull.
What should the measurements for the nasion to cap be between
Between 1 to 2.5 cm. No greater than 2.5 cm.
What does c3 and f3 represent
C3 is left side motor cortex for right hand
F3 is left dorsolateral prefrontal cortex
Why is the motor cortex important?
It helps us find the dlpfc!
The goal is to move the index finger (but any finger moment is sufficient)
What are the steps involved in the BEAM method?
Measure the distance from nasion to onion and Tragus to tragus (making sure it is going through the cz/vertex)
Then take 20% of the tragus to tragus and measure laterally from the vertex and that gives you c3
In the 5 cm rule, where do you place your marks on the diagonal line
4.5 cm, 5 cm, and 5.5 cm
What amplitude do you start at when testing for motor threshold?
40% or 50%
Keep going until you see a response and then
Where do you usually start treatment intensity at?
80% of MT
If the patients MT is between 20 and 40 what should your treatment intensity goal range be?
100 to 120%
If the patient motor threshold is between 40 to 50, the treatment intensity goal should be?
100 to 110% of the motor threshold 
How much time do you want to take to increase to the goal Treatment intensity
Do you want to slowly increase over the course of 3 to 5 days
If having difficulty finding the motor threshold, what amplitude should you not go over?
60 
What are the two most important things when it comes to TMS treatment?
Making sure the patient can tolerate the treatment and making sure that we can get the patient the most pulses throughout the course of their treatment 
On the brains way device, what amplitude do you not want to exceeded?
40, patients typically tolerate 25 to 35 
At what point should you do remapping
Close to the 15th treatment
At what point should you do remapping
Close to the 15th treatment
How much of a gap should there be when the coil is placed on the head?
It should not go beyond your distal, interphalangeal point 
When doing rem mapping, which side should you start on?
You should start on the right side and complete the birth and then complete the left side. 
During re-mapping, if the motor threshold is 35 or lower what percentage can you go up to?
Can go higher than 120 if tolerated 
During remapping if the motocross hold is 35 or higher, what goal percentage should you shoot for?
Do not go over 110% unless as a psychiatrist, you see that they can tolerate it and will benefit from a higher intensity 
What is the machine average for a mag venture?
40
What is the machine average for brains way?
About 30
At remapping, if depression symptoms have not improved. What can you do?
You can double down by adding left sided theta. 
How many sessions are included in a TMS treatment?
36 sessions typically done over six weeks and the patient should show up about five days out of the week 
What should you do if you have double down on the left side to help with depression treatment and there is still no improvement?
You can either consider changing devices or a violate for other aspects that may be contributing to their poor progress (bio, psycho,social, spiritual)
Went to consider brains way
When the patient has OCD, patient with personality disorders, patients who are doing a second round of TMS and they responded well but the effects were not long lasting from magventure 
What to do when giving treatment and depression is improving but anxiety has gotten worse
You can add the default 10 Hz protocol to the right side
If there is time constraints- then you can switch theta bursts to the left and 10hz to the right but only if depression has improved 
What to do if depression and anxiety has gotten worse at remapping?
Consider adding left sided theta and right sided 10 hz
Or if they already have 10hz on the right side- then consider adding left sided theta burst or a device change
What is the ideal improvement we want to see in MDD
50% decrease in phq9 or at least 5 point reduction in depressive scale
Typically will see improvement in sleep
When to consider the 1 Hz protocol?
When anxiety is the main concern.
There is a 10 min option for less severe anxiety and a 20 min option (double the pulses but more of a time commitment)
Ideal improvement for anxiety ?
50 % decrease on GAD7
How would you add the 1 hz protocol?
You would do the default bilateral protocol and then add 1 Hz protocol to the right side.
What can you do if the primary concern is ptsd/trauma?
Do the standard and add 10Hz to the right side (addds 15 minutes)
Time required for each part of the protocol
10hz- 15 minutes
Theta burst- 3 minutes
1 hz - 10-20 minutes
