Brief Answer:
Detailed description provided.

Detailed Answer:
Hi XXXXXXX

Welcome to Healthcare Magic!

Repetitive Transcranial Magnetic Stimulation (rTMS) is a relatively new treatment that has been tried in depressive and anxiety disorders. It is a non-invasive method which means that it is applied externally. It stimulates the brain through electromagnetic induction using an insulated coil placed over the scalp, which is focused on certain areas of the brain. The coil generates brief magnetic pulses, which pass easily and painlessly through the skull and into the brain. The pulses generated are of the same type and strength as those generated by magnetic resonance imaging (MRI) machines. When these pulses are administered in rapid succession, it is referred to as “repetitive TMS “ or “rTMS”, which can produce longer lasting changes in brain activity.

rTMS exerts its effects by producing changes in neuronal activity in certain regions of the brain. As each magnetic pulse passes through the skull and into the brain, this induces brief activity of brain cells underlying the treatment coil. Patients who have failed to achieve an adequate response from antidepressants, or who are unable to tolerate medications, might consider rTMS therapy.

This was an overview of what rTMS is and how it works. Let us come to the procedure that is usually followed in most centers. For each rTMS session, the patient sits in a specially designed treatment chair, similar to a dentist's chair. Because rTMS uses magnetic pulses, before beginning a treatment, patients are asked to remove any magnetic-sensitive objects (such as jewelry, credit cards). Patients are required to wear earplugs during treatment for their comfort and hearing protection, as rTMS produces a loud clicking sound with each pulse, much like an MRI machine.

During the first rTMS session, several measurements are made to ensure that the TMS coil will be properly positioned over the patient’s head. Once this is done, the TMS coil is suspended over the patient’s scalp. The TMS physician then measures the patient’s motor threshold, by administering several brief pulses. The motor threshold is the minimum amount of power necessary to make the patient’s thumb twitch, and varies from individual to individual. Measuring the motor threshold helps the physician personalize the treatment settings and determine the amount of energy required to stimulate brain cells.

Once the motor threshold is determined, the coil is then brought forward so that it rests above the front region of the patient’s brain. Treatment is then commenced. During the treatment, patients will hear a series of clicking sounds and will feel a tapping sensation under the treatment coil.

Succeeding treatment sessions do not require that the motor threshold be determined again, unless indicated otherwise, such as when changes in medications are made during the course of the treatment.

rTMS doesn't require any sedation or general anesthesia, so patient is fully awake and aware during the treatment. There is no recovery time, so you can drive home afterwards and return to your usual activities. There are no other major "dos and don'ts" apart from these.

Duration of treatment: A typical course of rTMS is 4 to 6 weeks. Treatment sessions are approximately 40 minutes each, and administered 5 days a week. The exact duration of treatment would depend on your response to treatment.

Side effects: rTMS is well-tolerated and associated with few side-effects and only a small percentage of patients discontinue treatment because of these. The most common side-effect, which is reported in about half of patients treated with rTMS, is headaches. These are mild and generally diminish over the course of the treatment. Over-the-counter pain medication can be used to treat these headaches.

About one third of patients may experience painful scalp sensations or facial twitching with rTMS pulses. These too tend to diminish over the course of treatment although adjustments can be made immediately in coil positioning and stimulation settings to reduce discomfort.

The rTMS machine produces a loud noise and because of this earplugs are given to the patient to use during the treatment. However, some patients may still complain of hearing problems immediately following treatment. No evidence suggests these effects are permanent if earplugs are worn during the treatment.

rTMS has not been associated with many of the side-effects caused by antidepressant medications, such as gastrointestinal upset, dry mouth, sexual dysfunction, weight gain, or sedation.

The most serious risk of rTMS is seizures. However, the risk of a seizure is exceedingly low. rTMS will not cause slowing of your brain, brain damage or tumors.

As far as I know, you will not be taken up for rTMS if you have any metallic implants or pacemakers in your body.

I hope this detailed description answers all your concerns. But please feel free to ask if you need any other clarifications.

Best wishes.

Dr Preeti Parakh
MD Psychiatry

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Brief Answer:
Yoga will benefit you.

Detailed Answer:
Hi XXXXXXX

I cannot really help you with the holter abnormalities, but for the bloating and gaseous distension, I have some good suggestions for you.

1) When you eat, take small bites and chew your food slowly. This is to prevent ingestion of air with food which adds to the bloating and makes you burp.
2) Try finding out which foods provoke this. In my experience, if you can cut down fats from the food, you will see that this problem reduces. Try avoiding different foods one at a time so that you can finally arrive at a diet which is easy on the tummy.
3) If you can join yoga classes, these will benefit both in bloating and anxiety. If this not feasible, check the internet for instructions and do pranayam, especially "anulom vilom" and "kapal bhati". Also practice "pavanmuktasan" which is targeted at removing the air from the digestive tract.

I hope these steps will benefit you.

Best wishes.

Dr Preeti Parakh
MD Psychiatry

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