11/28/2010
Dr. Satya Hanura, SpS
What is Neuro Magnetic Stimulation Devices which can provide the magnetic field Use to stimulate : CNS (Central Nerve System) PNS (Peripheral Nerve System)
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Neuro Magnetic Stimulation Technology Overview Capacitor is charged to high voltage (0-3,000 V) Capacitor is discharged into stimulating coil (current 0-8,000 A) Magnetic field is induced around stimulating coil (0-2.5 T)
Controller
Discharge switch
Stimulating coil
Electric outlet
Capacitor charger
Energystorage capacitor
Magnetic field
Induced currents
[Neuronetics]
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Neuro MS Works Via Electromagnetic Induction
Magnetic field
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Electric field ++ +++ + Current pulse in Neuro MS coil induces + +++ Axon magnetic field - ---- - - - Magnetic field pulse induces electrical - - --- - currents in brain + + + + +- - - Principle of electromagnetic induction, + + also used in electrical transformers [Ruohonen & Ilmoniemi, 2005]
Magnetic field has to change rapidly; Putting fridge magnets on your head won’t do
Induced currents depolarize axons and make them fire
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Schematic of the RPMS Application
Mechanism of Action Magnetic field may induce electric field Eddy Current / Foucault currents adalah arus yang terinduksi pada konduktor (neuron akibat terekspose dengan medan magnit yang berubah-ubah karena pergerakan relative medan magnit sumber dan konduktor; atau di sebabkan karena variasi medan magnit terhadap waktu. Hal ini akan menyebabkan arus elektron yang sirkular didalam konduktor . Penetrasi medan magnit dapat dalam.
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Application of Magnetic Stimulation TENS VS MAGNETIC STIMULATION Pain Management Frequency Intensities Train Intertrain Pulses
Pain diagram
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Technical Application High frequency low intensity Based on gate control theory of Wall and Melzack
Activation A beta fiber Stimulation of sensory nerve with wide diameter suppress small diameter which carry out the pain stimulus. Moderate and acute pain Damage tissues
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Technical application Low Frequency (below 10 Hz) and High Intensity Activation A-delta fibers, stimulation of some C fibers, generation of B- endorphin in pituitary Effective in neuropathy related pain Local circuit in spinal cord for secretes opioid analgesic substance by activating descendent and inhibitory pathway. Chronic pain and Radiculopathy
Technical Application Low frequency (3-5 Hz) Brief Maximal Intensity Stimulation of C fibers cause nociceptive reflex Slight increase in damage The method has not been systemized.
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Method for pain cause by Neuromuscular Stimulation in Root Nerve Stimulation in Peripheral Nerve Mechanism: Opioid release Tissue regeneration Hardened band of muscles
Effect of Peripheral rMS on muscle pain Pujo et all 1998 sham controlled study performed in 30 patients with musculoskeletal pain supported the efficacy of rMS at 20 HZ directly to tender body region for 40 sec Smania et all 2003 (40 trains of 5 s at 20HZ with 25s pauses) over 2 weeks in 9 patients relief of myofasial pain .
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Cont’ Smania et all 2005 rMS more effective than TENS at long term 3 month after stimulation in myofasial pain.
Others Method to relieve pain TMS: Transcranial Magnetic Stimulation Site of stimulation : M1, S1 Frequency 10HZ Low frequency was not effective to relieve pain (lefaucher et all 2001, Andrea-Obadia et al 2006)
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rTMS pada focal chronic pain syndrome (Fibromyalgia) A Passard et al. 2007 rTMS pada korteks motorik (M1) menginduksi efek analgesik pada sindrom nyeri kronik yang fokal, kemungkinan melalui modifikasi sistem nyeri sentral Randomly assigned, double blind. rTMS diberikan pada korteks motorik primer sisi kiri (M1 2 cm anterior & 2 cm lateral dari vertex) pada 10 session dalam 2 minggu ( 5 session per minggu).
Primary outcome: laporan derajat nyeri dalam 24 jam dengan VAS (Visual Analogue Scale = 11 skala numerik; dimana 0 = tidak ada nyer dan 10 = nyeri terhebat yang dapat dibayangkan)
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Pengukur outcome lainnya: the Mc Gill pain Questionnaire skor nyeri sensorik dan affektif. Brief Pain Inventory and the Fibromyalgia Impact Questionnaire Quality of life Hamilton Depression Rating Scale; Beck Depression Inventory and Hospital Anziety and Depression Scale Mood and anxiety
Session: 25 series of 8 s pulses, interval 52 s Frequency 10 Hz, intensity 80% resting MT Total: 2000 pulses per session (diberikan dalam 25 menit). Motor Threshold: Intensitas terkecil yang mampu membangkitkan motor evoked potential pada 50% percobaan yang berturutan.
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Hasil Active rTMS: secara bermakna mengurangi rasa nyeri dan memperbaiki beberapa aspek dari QOL (fatigue, keletihan di pagi hari, aktivitas umum, berjalan dan tidur) Efek analgesik didapatkan setelah stimulasi kelima dan seterusnya dan tidak berhubungan dengan perubahan mood maupun anxietas.
Hasil, cont’ Efek rTMS lebih long-lasting untuk nyeri afektif dibandingkan dengan nyeri sensorik. Selama periode stimulasi dilaporkan adanya efek samping yang ringan dan transien (nyeri kepala ringan dan mual) rTMS pada satu sisi korteks motorik (kiri) menginduksi penurunan nyeri kronik yang longlasting.
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rTMS pada LBP H. Tsao et. Al. 2008 Pasien dengan LBP yang berulang gangguan kontrol
postur tubuh pada otot-otot punggung menyebabkan episode nyeri kambuhan. Korteks motorik mengatur penyesuaian postural kontrol. Centre of Gravity dari otot abdominal dalam (transversus abdominis) pada: Populasi Normal healthy : 2 cm anterior dan lateral dari
vertex LBP: lebih posterior dan lateral dar i vertex NB: MT sisi ipsilateral lebih rendah pada LBP, tapi hanya pada hemisfer yang less excitable.
Kesimpulan Pada Pain Management dapat dilakukan: Repetitif Transcranial Magnetic Stimulation Repetitif Peripheral Magnetic stimulation kedua metoda dapat digunakan secara simultan hasil lebih maksimal.
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