Edward Fruitman, MD
1451 Broadway
Hewlett, NY 11557
(516) 295-4867

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tms therapy

TMS Can Help Treat Root Causes of Depression & Anxiety

Dr. Edward Fruitman, Medical Director of South Shore Neuropsychiatric Center offers innovative genetically based treatment options for Depression and Anxiety. At South Shore Neuropsychiatric Center we offer a simple test that gives insight into our patients’ specific genetic profile which enables Dr. Fruitman to optimize medication regimen and/or offer alternative treatment options.

Recent studies suggest that early life experiences in combination with genetic predispositions are major contributors to treatment resistant anxiety and depression.  The amygdala is a region of the brain responsible for emotion regulation while the prefrontal cortex (PFC) is responsible for emotion processing. Fear inducing cues increase amygdala activity and cause the physiological responses to anxiety. The PFC regulates the amygdala effect by inhibiting autonomic and endocrine responses to stressors. In essence, the PFC controls the extent of an emotional response. Individuals that experience heightened anxiety and depressive symptoms are shown to have an inability to control and habituate responses to stressors.  Studies suggest that genetic factors may contribute to this effect. Researchers found that in “subjects carrying a substituted methionine in the BDNF gene, fear doesn’t extinguish as readily in response to repeated nonthreatening cues; in those with a valine, it extinguishes more easily. Using neuroimaging, the authors showed that polymorphism carriers exhibited more amygdala and less PFC activity with subsequent cue presentations.”  In these individuals the PFC is dormant and individuals may not respond to psychotherapy or medication.

Transcranial Magnetic Stimulation Therapy (TMS) is a noninvasive treatment option for individuals suffering from treatment resistant anxiety and depression.  TMS stimulates the PFC using noninvasive magnetic energy, which over time provides relief to depression and anxiety symptoms. Dr. Edward Fruitman is the pioneer provider of Transcranial Magnetic Stimulation (TMS) Therapy in the Five Towns area. Dr. Fruitman has successfully treated patients suffering from anxiety and depression with TMS since 2010.

PROBLEM: ADDED COST FOR MEDICAL PATIENTS WITH TREATMENT RESISTANT MAJOR DEPRESSION SOLUTION: TRANSCRANIAL MAGNETIC STIMULATION?

Behavioral Healthcare/ December 4, 2013

By Alison Knopf

neurostar-infoTranscranial Magnetic Stimulation (TMS) may be the best way to help patients with treatment-resistant major depression (TRMD) – people who have tried antidepressants at least once for the appropriate amount of time on the appropriate dose, according to Pete Mumma, Administrative Director of the Behavioral Health Service Line in the Department of Psychiatry at Lancaster General Health in Lancaster, Pennsylvania. But that doesn’t mean it’s easy to “sell” the TMS device to financial people in your institution.

Here’s how Mumma did it: 9.1 percent of the population has depression, and .05 percent has TRMD. These people are “superutilizers,” who consume 18 percent of a health system’s uncompensated or undercompensated spending. “It’s unsustainable,” he said. “We expect people who have extreme needs to be treated in pathway models that don’t meet their needs – what will we do with these patients, not just from a mental health perspective, but from a total medical perspective?”

For example, an individual with TRMD who also has cardiac disease or cancer is going to be very complicated to treat. “Any medical provider who is helping patients with TRMD is going to bump up against some or all of their issues,” said Mumma. Symptoms such as lack of energy, lack of concentration, and sleep problems create further distractions for the patient, he said. The recommendations of the cardiologist or oncologist won’t go as far as they would if the patient didn’t have depression.

The impact of mental health problems on physical treatment is more relevant now than it was in the past because of the way health systems are being reimbursed, said Mumma, citing in particular the penalty for readmissions within 30 days. If a patient fails cardiac treatment – perhaps because he didn’t exercise, something that is notably difficult for people with depression – and needs to be readmitted, that’s a ding to the hospital’s bottom line. “So cardiologists and every other doctor wants to make sure they eliminate barriers to good outcomes,” he said. Mental problems that make it difficult to follow through with physician recommendations are suddenly seen as very important – a good thing for both patients and the health care system.

“We can spend a little money up front to treat the depression, and the patient’s cardiac care goes farther, faster,” said Mumma.

The treatment

Typically, patients start with a daily course of treatment, which takes about 37 minutes. This would go on for four to six weeks. The treatment is painless and requires no sedation. Once the initial course is done, some patients may come back for a maintenance treatment. The treating provider will determine the exact treatment protocol and any maintenance needed.

Medications

The first line of treatment for depression is medication, but people with TRMD are patients for whom medication isn’t working. On the system side, the clinical benefit is important, but on the patient side, it’s crucial. “The tragic thing is these patients aren’t getting better,” said Mumma of TRMD.

Doing depression care differently – what Mumma is suggesting is avoiding the “shotgun approach” that most depression patients who have tried one medication after another have experienced. At Lancaster, before selecting a medication, the psychiatry department does “pharmacogenetic” testing via a cheek swab to at least narrow down the type of medication to try in the first place. “But many patients get agent after agent, and have had no other options over their lifetime.” Now, at least patients who have failed one course of medication with an appropriate dose and duration have another option.

“Through medications, we’re trying to light up some parts of the brain and quiet others,” said Mumma. That’s the same thing that TMS does – the magnet near the head “reaches deep into the amygdala, which scientists think is responsible for mood,” he said. “Instead of washing the brain with chemicals, this seems to isolate the problem.” Many patients continue to take medications while getting TMS but find they can reduce their medications over time, he added.

Another issue is the cost of medications. Abilify, the medication used for treatment-resistant major depression, is very expensive, said Mumma. “The health plan might be paying more than $1,000 per month” for Abilify, he said. “Add to that the costs of Celexa or other medications, plus the medication management.”

Tracking medical costs

Mumma also has scrutinized the literature, finding that one study showed that the most costly expense to employers was depression, at a cost of more than $350,000 per thousand employees. That isn’t only medical costs, of course, but aggregated costs of medical treatment, pharmacy, absenteeism, and “presenteeism” – in which employees are still at work but unable to function. “If we were to do depression care differently, that’s a huge savings,” said Mumma.

Patients paying

In clinical trials, suicidality was four times higher in the placebo group than the TMS group, said Mumma. (In the clinical trials, TMS was compared to sham TMS, not compared to medication.)

Major depression is a devastating disease for people who don’t get better, and 40 percent of the patients experience remission, said Mumma, who is not compensated by Neuronetics.

The big question is whether TMS is going to be as effective as electroconvulsive therapy (ECT), said Mumma. Clearly TMS is much more appealing to patients. “ECT is scary as hell, and it has ugly side effects like memory loss,” he said. ECT is effective, but many studies are showing comparable results for people with TMS, said Mumma.

“Nobody’s using the word, ‘cure,’” said Mumma. But TMS is different from medications, he said. TMS is non-medication based treatment, so there are no drug-drug interactions. “It’s difficult to get off of antidepressants once you get on, and antidepressants are basically a band-aid for a problem – just symptom improvement, not managing the illness.”  TMS does allow patients to return to functionality with fewer side effects than medication, said Mumma.

TMS Could Help Treat Chronic Dizziness

Researchers from the Johns Hopkins University School of Medicine believe that they have located a specific site in the human brain that could be one of the sources of dizziness and spatial disorientation.

While dizziness can also be linked to damage to the inner ear, or to other senses such as vision, neurology instructor Dr. Amir Kheradmand and his colleagues report that they have discovered a region of the brain that plays a vital role in our subconscious awareness of which way is up and which way is down.

Their study, which appears online in the journal Cerebral Cortex, found that some causes of dizziness, unsteadiness and “floating” could be linked to that region in the parietal cortex.

The study authors opted to focus their analysis on the right parietal cortex, as research on stroke victims with balance problems has suggested that damage to that region of the brain was directly involved with upright perception.

They recruited eight healthy subjects, placing each in a dark room and showing them lines that were illuminated on a screen. Dr. Kheradmand’s team then had the study participants report the orientation of each line by rotating a dial to the left, the right, or straight ahead.

The subjects then received (TMS) – an FDA-approved treatment for depression and which “painlessly and noninvasively delivers electromagnetic currents to precise locations in the brain.”

Each individual had a TMS coil placed behind the ear and against the scalp across the right parietal lobe. The subjects received 600 electromagnetic pulses over the course of 40 seconds, and at the end of each session, they were asked a second time to show the researchers which way the illuminated line was positioned. At the end of the study, all of the subjects reported that his or her sense of being upright had been altered in the same way after TMS was administered in the same location in the parietal cortex.

According to Kheradmand, his team’s findings suggest that this form of stimulation could be used to treat chronic dizziness. “If we can disrupt upright perception in healthy people using TMS, it might also be possible to use TMS to fix dysfunction in the same location in people with dizziness and spatial disorientation,” he said.

FDA approves TMS device to relieve migraine pain

FoxNews.com

694940094001_1409784734001_640-brain.jpgThose who suffer from debilitating migraines may soon be able receive an outpatient procedure that can help alleviate their pain, as reported by Nature World News.

The U.S. Food and Drug Administration (FDA) recently approved a TMS device for people who suffer from migraines that are preceded by an aura – characterized by a tingling sensation in the extremities and flashes of light or blind spots in a person’s vision. The device uses magnetic energy to stimulate the occipital cortex – an area of the brain involved in visual processing – in order to alleviate migraine pain.

In a trial conducted by the FDA, 201 migraine sufferers tested the device when they experienced head pain. Overall, 38 percent of patients using the device experienced relief from migraine pain within two hours, compared to just 17 percent of people who were given a fake version of the device.

While the TMS has not been proven to completely eliminate all migraine symptoms, it does help relieve migraine pain. The FDA noted that the device doesn’t provide relief for other symptoms of migraines, including  sensitivity to light, sensitivity to sound and nausea.

Data Published in CNS Spectrums Indicate Acute Transcranial Magnetic Stimulation (TMS) with NeuroStar TMS Therapy® Improves Quality of Life in Patients with Depression

MALVERN, Pa., Sept. 16, 2013 /PRNewswire/ — Neuronetics, Inc., today announced that results of a naturalistic, observational study from 42 clinical trial sites in the United States, which examined the efficacy of acute treatment with NeuroStar TMS Therapy® in patients with Major Depressive Disorder (MDD), were published in the July 2013 issue of CNS Spectrums. In the study, patients who experienced persistent symptoms of MDD without benefit from concurrent antidepressant pharmacotherapy reported statistically and clinically meaningful improvement in quality of life (QOL) symptoms and functional status following acute treatment with NeuroStar TMS Therapy.  Acute efficacy results of this trial were previously reported, showing statistically significant improvement from baseline in depression symptoms including 58% response and 37% remission rates as rated by the clinician using the CGI-Severity of Illness scale under conditions of general clinical use (Carpenter, et al, 2012).

MDD is a debilitating condition in which nearly two-thirds of patients do not benefit adequately from antidepressant medications, and continue to experience life-altering symptoms and functional impairment.

“The publication of these findings is an important validation that NeuroStar TMS Therapy is effective in improving quality of life measures during acute treatment of MDD, particularly in patients with greater disease severity who have not benefitted from treatment with oral antidepressant medication,” said Philip Janicak, M.D., first author, Professor of Psychiatry at Rush UniversityMedical Center. “Patients reported improvement in QOL outcomes after just six weeks of treatment with NeuroStar TMS, which is faster than results we typically see with pharmacotherapy. These data offer hope to people living with MDD and reinforce TMS as a viable treatment option that induces symptom relief and improves overall well-being.”

The published observational study, entitled “Transcranial Magnetic Stimulation (TMS) for Major Depression: A Multisite, Naturalistic, Observational Study of Quality of Life Outcome Measures in Clinical Practice”, involved 307 outpatients across 42 clinical TMS practice sites in the United States with a primary diagnosis of MDD who had failed to benefit from  antidepressant medication. A recurrent course of illness was reported in 93 percent of patients and 44 percent had previously been hospitalized for depression. A significant level of treatment resistance was present.

At the end of the acute phase of NeuroStar TMS treatment, statistically significant improvements across physical health and mental health components variables were observed, as measured by the Short Form 36-Item Questionnaire (SF-36). Severely depressed patients experienced the most robust improvement in a relatively short time frame (six weeks). The largest treatment effects were observed on those subscale scores associated with improvements in mental health and social functioning. In addition, 37 percent (N=114) of study patients achieved remission during acute NeuroStar treatment and experienced a superior improvement in QOL compared with non-remitters. Patients with moderately severe to severe depression had the most robust improvement in QOL.

The vitality, social functioning, role-emotional, and mental health perceptions subscales of SF-36 showed a statistically significant improvement of 12-14.8 points or 1.2-1.5 standard deviations (SDs) in the normed score. The mean mental component summary (MCS) score improved by 16.8 points to 33.5 (+/- 15.06), which is comparable to previous studies showing an improvement in the MCS scores following nine months of treatment with paroxetine (15.8), fluoxetine (15.1), or sertraline (17.4). The subpopulation of remitters showed a much more robust improvement of 27.4 to 30.9 points, reaching scores that are close to the general population norms and are only 0.13 to 0.55 SDs lower.

While the Factors Influencing Depression Endpoints Research (FINDER) Study, a European, prospective, observational trial in 3,468 patients, reported that severely depressed patients had significantly worse SF-36 MCS outcomes, the CNS Spectrums’published study demonstrated that acute NeuroStar TMS treatment produced a pronounced QOL improvement in moderately severely- and severely-ill patients compared with the mildly- and moderately-ill groups.

About NeuroStar TMS Therapy®
Neuronetics’ NeuroStar TMS Therapy System was cleared by the FDA in October 2008 for the treatment of Major Depressive Disorder (MDD). NeuroStar TMS Therapy is indicated for the treatment of MDD in adult patients who have failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode. NeuroStar TMS Therapy is a non-systemic (does not circulate in the bloodstream throughout the body) and non-invasive (does not involve surgery) form of neuromodulation. It stimulates nerve cells in an area of the brain that has been linked to depression by delivering highly-focused MRI-strength magnetic field pulses.

In a controlled trial, patients treated with active NeuroStar TMS Therapy received greater than 3 times the improvement in depressive symptoms compared to placebo at four weeks (MADRS, -7.1 vs -2.1, P=0.0006).  The treatment is available by prescription and typically administered daily for 4-6 weeks.

About Depression
Depression is a serious illness that affects about 20 million Americans annually. People with depression may experience a range of physically and emotionally debilitating symptoms, including anxiousness, sadness, irritability, fatigue, changes in sleep patterns, loss of interest in previously enjoyable activities and digestive problems. It is estimated that about four million patients do not benefit from standard treatments for depression, even after repeated treatment attempts.

About the Study
Forty-two clinical TMS practice sites across the United States treated 307 outpatients with a primary diagnosis of MDD and persistent symptoms despite adequate antidepressant pharmacotherapy. Treatment parameters were based on individual clinical considerations and followed the labeled procedures for use of the NeuroStar TMS Therapy System. Functional status was ascertained using the Medical Outcome Study Short-Form Health Survey (SF-36), comprised of eight subscales that measure physical and role functioning: bodily pain, general health, vitality, social and role functioning, and mental health. The physical component summary (PCS) score and a mental component summary (MCS) score integrate information from all eight of the subscales. Patient-reported QOL was also characterized using the EuroQol 5-Dimension Questionnaire (EQ-5D), which contains five dimensions measuring the degree of impairment in the domains of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.

Patient-reported outcome measures of functional status and QOL were obtained at baseline prior to the initial TMS treatment, and again at the end of acute treatment.

Magnetic fields help to combat depression

Aisha Dow (Syndey Morning Herald)

A pioneering medical treatment using intense magnetic fields is achieving dramatic results for patients with drug-resistant chronic depression.

After living with depression her entire life, Jan Steele, 57, said undergoing magnetic stimulation had been like winning the lottery. This weekend she is driving to Canberra for a weekend away with her husband. Before her treatment, she would often spend Saturday and Sunday in bed.

“The enjoyment I get out of life is outstanding now, even if it’s just staying home and watching TV,” she said.

Targeted at the approximately 30 per cent of people who have treatment-resistant depression, TMS involves the use of an extremely focused magnetic field.

As the patient sits awake in an armchair, a wand containing a plastic-coated coil is placed close to their scalp – creating a magnetic field that stimulates activity in the brain. The treatment takes about four to six weeks and involves about 20 or 30 daily sessions lasting 45 minutes, although researchers have been successfully trialling a six-day treatment.

Centre deputy director Paul Fitzgerald said they believed TMS increased activity between areas of the brain involved in control of mood and emotion.

He said patients could remain depression-free for several months or even several years before they had to return for further sessions. “If they get better the first time, more than 90 per cent of people will respond again if you treat them,” Professor Fitzgerald said.

Chair of Psychiatry at Deakin University Michael Berk said TMS was one of the safest treatments available in the field of psychiatry. But like other depression treatments, including lithium and electroconvulsive therapy, he said researchers do not fully understand how it works, and why it works only in some people.

“There’s no [depression] treatment that works for everybody and we don’t have ways of predicting who will benefit from what treatment,” he said.

Experts at the Monash Alfred Psychiatry Research Centre are studying these unanswered questions and also the possibility TMS may treat other conditions, including schizophrenia and autism.

Until then, Jan Steele remains in remission. Depression, she said, was like carrying a wet blanket on your shoulders – and that weight has been lifted.

REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION OFFERS RELIEF FROM DEPRESSION

Umesh Isalkar, TNN Jul 28, 2013

Rakesh used to feel low. Soon he lost interest in his job. He took to alcohol to feel better and things kept going downhill after his wife walked out. When he approached doctor for treatment of depression, he had already spent two years in depression.

Today, Rakesh has almost recovered and leading a normal and productive life. Thanks to a new treatment modality called repetitive transcranial magnetic stimulation (rTMS). Rakesh is just one of many suffering from depression and one of the few who have had his depression treated with rTMS Therapy.

According to WHO ( World Health Organization) report depression is going to be second leading cause for disability. The problem however is not the illness but lack of awareness and stigma attached to it.

“Depression if not treated can last for more than a year. Treatment is necessary as depression can lead to professional, family, financial, and physical health related complications including suicide,” said psychiatrist Swapnil Deshmukh of Shreeyash Hospital who has treated Rakesh with rTMS.

Various types of treatment modalities are available depending on severity of illness including cognitive behavioural therapy (CBT), medicine, electro convulsive therapy (ECT), and latest – rTMS ( re-petitive Transcranial magnetic stimulation). All these are standard, well proved and accepted worldwide -FDA approved treatment modalities.

“Around 20% of cases are mild and can be treated with CBT itself but remaining requires medications in addition to counselling. Around 30 to 40% of depression cases can be severe, resistant to treatment.

“rTMS is a recent treatment modality in depression and other psychiatric illness in which magnetic waves can directly stimulate affected- less functioning brain areas non-invasively. It is considered to be safest, non-medicine dependent, cost effective treatment modality getting very popular in west. Combination of both rTMS and medication and therapy work best,” Deshmukh said.

For more information about our TMS services please contact us at South Shore Neuropsychiatric Center (516)295-4867

NeuroStar Patient Experience Video

NeuroStar Patient Experience Video

For more information on TMS Therapy or to schedule your free initial consultation with Dr. Fruitman, please contact us at South Shore Neuropsychiatric Center, (516)295-4867.

New Studies Show Promising Support for Long-term Efficacy of TMS Therapy

Dr. Edward Fruitman, Board Certified Psychiatrist and Medical Director of South Shore Neuropsychiatric Center, is pleased to support the long-term efficacy of Transcranial Magnetic Stimulation (TMS) in the treatment of chronic, treatment-resistant Depression.

 

Dr. Edward Fruitman, a renowned expert in psychopharmacology and the treatment of mood disorders, has been offering TMS therapy at South Shore Neuropsychiatric Center, Hewlett, NY for over three years. TMS uses concentrated electromagnetic pulses emitted to the area of the brain linked to be responsible for controlling mood. New studies show that TMS may change the foundational neurological circuitry seen in depression, possibly ensuring a more stable and enduring remission.

 

As a safe, non-invasive, and visibly effective treatment for depression, TMS is an innovative therapy option for patients who have not experienced benefits of prior antidepressant treatment. In a year-long study performed with over 250 clinically depressed individuals, TMS therapy was shown to incite a significant reduction of depressive symptoms, which was maintained by 68% of patients at 52 weeks post treatment. Similarly, Dr. Fruitman’s comprehensive approach of TMS, counseling, and medication management shows a nearly 100% success rate in reduction of depressive symptoms among his patients who completed TMS therapy.

 

Dr. Fruitman was the first psychiatrist to introduce TMS therapy to the Five Towns area of Long Island and promotes the use of this ground-breaking treatment as an important tool for the treatment of Major Depression. Individuals interested in learning more about the benefits of TMS therapy, especially those who have had difficulty controlling their depression with medication, should feel free to contact South Shore Neuropsychiatric Clinic to speak with a TMS Specialist and schedule a complementary consultation with Dr. Fruitman.

 

South Shore Neuropsychiatric Center

1451 Broadway

Hewlett, NY 11557

516-295-4867

www.southshoretms.com

INHIBITORY RIGHT-BRAIN TMS IMPROVES LANGUAGE AFTER STROKE

Sue Hughes-Medscape(July 11, 2013)

Use of inhibitory transcranial magnetic stimulation (TMS) over the speech area in the right side of the brain significantly improved language recovery in patients with stroke, new research shows.

“The dominant language center is normally in the left hemisphere of the brain. After a stroke, when this area is damaged, similar regions in the right hemisphere take over, but this is not as effective as if the left side recovers. Brain imaging studies show that stroke patients with right hemisphere activation generally do worse. So we used TMS treatment to inhibit the right hemisphere area, so the left hemisphere area has to function,” lead investigator Alexander Thiel, MD, McGill University, Montreal, Quebec, Canada, told Medscape Medical News.

First Proof-of-Concept Study

Dr. Thiel compared the strategy with treating someone who has paralysis on 1 side of their body.

“If someone has paralysis of one arm, if you immobilize the good arm, the patient is forced to use the paralyzed arm, which helps it recover.”

The inhibitory TMS is carried out by positioning a hand-held electromagnetic coil over the appropriate part of the brain. The fluctuating magnetic field induces an electrical current that blocks normal function.

Dr. Thiel noted that a few single case reports and case series of this treatment have been published previously, but this is the first randomized proof-of-concept study.

The study involved 24 patients (all right-handed) with subacute post-stroke aphasia from the rehabilitation hospital RehaNova in Cologne, Germany. They were randomly assigned to a 10-day protocol of 20-minute inhibitory 1-Hz TMS over the right triangular part of the posterior inferior frontal gyrus or sham stimulation, followed by 45 minutes of speech and language therapy.

Activity in language networks was measured with O-15-water positron emission tomography before and after treatment, and language performance was assessed by using the Aachen Aphasia Test (AAT) battery.

Results showed that language performance was significantly improved in the TMS group. The largest improvements were seen in the subtest of naming objects, but comprehension, token test, and writing also all improved.

Imaging results showed that patients in the TMS group also activated proportionally more voxels in the left hemisphere language center after treatment than before (difference in activation volume index) compared with sham-treated patients. There was a moderate but significant linear relationship between activation volume index change and global AAT score change.

“We found that patients who underwent the real TMS treatment had 2-3 times better recovery of their aphasia than patients who were given the sham treatment. The principal improvement was in the ability to name objects. This is very important — you cannot communicate if you can’t name things,” said Dr. Thiel.

Pronounced Effect

“This study is telling us that this therapy seems to work the way we think it should. We are very excited by these results. We were a little surprised by the magnitude of the effect. We didn’t expect it to be so pronounced. But the fact that the imaging results showed a shift in brain activity from the right to the left, corresponding with the improvement in aphasia, is reassuring and supports that this model is pathophysiologically valid.”

He noted that the effect was measured immediately after the treatment. “How long it will last we don’t know. Some previous studies suggest it does last long-term, but we need to study this further.”

The next step is to try reproducing these results in a larger study. Such a study — NORTHSTAR — is now planned to start in October. Funded by the Canadian Institutes of Health Research, it will involve 100 patients from Canada and Germany. Patients will be assessed at day 10, as in the current study, but also longer term — about a month after treatment stops.

In the current study, patients were treated within 3 months after stroke. In the next study they will be treated within 1 month.

“We think the earlier we perform this treatment the more likely it is to be effective, as we believe there is a window of a few weeks after stroke when the right side of the brain becomes very active.

“We have seen this in imaging studies. Eventually it shifts back to the left. But the more the left brain takes over again the better the recovery. This treatment is just trying to accelerate this naturally occurring pattern,” said Dr. Thiel.

Asked about risks, Dr. Thiel reported that aphasia did not deteriorate with the treatment.

The main adverse effect is headaches because TMS can cause the scalp muscles to contract, but these are benign and respond to normal headache treatments, he said.

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