Aula sobre avanço no tratamento da dor crônica com o uso de Estimulação Magnética Transcraniana (EMT) ministrada por Dr. Rafael Higashi, médico neurologista, no departamento de tratamento da dor do Centro Médico da Universidade de Nova York, NYU, EUA. www.estimulacaoneurologica.com.br

1. TMS - TranscranialMagnetic Stimulation for Chronic Pain Rafael Higashi, MD Department of Neurology- Clínica Higashi Rio de Janeiro - Brazil www.estimulacaoneurologica.com.br

2. Department of Neurology Marcilio Dias Navy Hospital – Rio de Janeiro - Brazil

3. Transcranial Magnetic Stimulation Laboratory

4. Aldini. Frankenstein, Mary Wollstonecraft Shelley (1797-1851) Luigi Rolando (1773-1831), pioneered in cerebral electrical stimulation (1809) in vivo animals Rolando or central fissure Experiments: stimulation of nerves and muscles by Luigi Galvani in 1786 - voltaic

5. Basic Principles I(t)/Imax Tempo-ms Voltage until 3kV Currents (discharge of capacitor)- 4-8kA Energy reserve 500J 500 J /100 S Magnetic field Eletrical current in the cerebral cortex eletrical current Main Unit Bobbin

6. Basic Principles Magnetic field generate Current induction TMS bobbin

8. Intensity

10. EMT Local effect, distant effect or both?

11. Behavior and Motor Effects in Distant Areas TMS Motor improvement stimulating contralateral motor area A Sham-Controlled Trial of a 5-Day Course of Repetitive Transcranial Magnetic Stimulation of the Unaffected Hemisphere in Stroke Patients Felipe Fregni et al. Stroke. 2006;37:2115-2122. Harvard Center for Non-Invasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston University of Sao Paulo, Sao Paulo, Brazil

12. rTMSSpecific points How to localize this point? PFMC – (depression) motor point threshold (pain chronic) 5 cm

13. rTMSSpecific points PFMC (depression) motor point threshold (Chronic Pain)

15. hearing loss (earplugs)

16. Mild headache ( 28% of subjects experienced headache x 16% sham )

17. Psychiatric complications: hypomanic (transient)International Journal of Neuropsychopharmacology (2008), 11, 131–147. Colleen K. Loo et al. School of Psychiatry, University of New South Wales, Sydney, Australia

18. Mechanism of Action Neurotransmittor release Long-term potentiation – increasing receptors Genetic induction Effects (long term): Synaptic Connection Improvement Ions induction and others substances locally rTMS immediate effect Cerebral cortex Cerebral cortex

19. Use of Repetitive Transcranial Magnetic Stimulation in chronic pain relief MCS with surgically implanted epidural in the early 1990s with significant analgesic effects Tsubokawa et al. Act neurochir.,52, 137-139 (1991). In the later 1990s rTMS was introduced for clinical research. Lefauchaer at all. Eletroencefalogr. Clin. Neurophysiol. 107, 92(1998). At present, 20 studies (case reports, open or controlled trials have assessed the efficacy of rTMS. Lefaucher et al. Expert Rev. Neurotherapeutics 8 (5), 799-808 (2008).

20. Postoperative coronal cranial radiograph showing the 4-pole epidural electrode over the convexity of the right motor cortex. Using PET , regional changes in cerebral blood flow in 10 patients undergoing motor cortex stimulation for pain control Showing regions with significant CBF increases during motor cortex stimulation. Note the absence of any significant CBF change in the right motor or somatosensory cortices directly underlying the stimulator G. Larreat al, Pain 83 (1999) 259±273. Functional Neurology Unit, Claude Bernard University, Lyon, France

21. Five patients underwent MCS in which functional imaging guidance was used. Trial periods of stimulation successfully reduced pain in three of the five patients who then underwent permanent internal placement of the system. At a mean 6-month follow up, these patients reported an average reduction in pain of 55% on a visual analog scale. Left: Photograph showing the permanent electrode sutured to the dura. Right: Lateral radiograph demonstrating the craniotomy and final electrode placement. ALON Y. MOGILNER at all. Neurosurg Focus 11 (3):Article 4, 2001. Department of Neurosurgery, New York Medical College, Valhalla, end Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio

22. Postoperative Left Prefrontal rTMS Reduces Patient controlled Analgesia Use Jeffrey J. Borckardt at all Anesthesiology 2006; 105:557–62. Medical University of South Carolina Photo of TMS motor threshold assessment in the postanesthesia care unit. Dr. Weinstein (left) supports the patient’s right wrist to allow free movement of thumb and fingers. Dr. Borckardt (middle) positions the coil over the motor cortex and locates the area corresponding with abductor pollicisbrevis (APB). Neil Shelly (right) runs the Parameter Estimation by Sequential Testing and adjusts the TMS machine output to the specified levels until the amount of TMS output is determined that is necessary to cause visible thumb movement 50% of the time

23. Postoperative Left Prefrontal rTMS Reduces Patient controlled Analgesia Use Jeffrey J. Borckardt et all. Anesthesiology 2006; 105:557–62. Department of Psychiatry andBehavioral Sciences, Medical University of South Carolina Methods: Twenty gastric bypass surgery patients were randomly assigned to receive 20 min of either active or sham immediately after surgery. PCA pump use was tracked Results: Active rTMS was associated with a 40% reduction in total morphine use compared with sham during the 44 h after surgery. The effect seemed to be most prominent during the first 24 h after cortical stimulation delivery. No effects were observed for r TMS on mood ratings Conclusions: A single session of postoperative prefrontal rTMS was associated with a reduction in PCA pump use in gastric bypass surgery patients. This is important because the risks associated with postoperative morphine use are high, especially among obese patients who frequently have obstructive sleep apnea, right ventricular dysfunction, and pulmonary hypertension. These preliminary findings suggest a potential new noninvasive method for managing postoperative morphine use.

24. Motor cortex rTMS restores defective intracortical inhibition in chronic neuropathic pain. J.P. Lefaucheur et al. NEUROLOGY 2006;67:1568–1574. Departments of Physiology and Neurosurgery , Hopital Henri Mondor, Assistance Publique - Hopitaux de Paris, Faculte de Médecine de Créteil, France. Effects of unilateral repetitive transcranial magnetic stimulation of the motor cortex on chronic widespread pain in fibromyalgia. A. Passard et al. Brain (2007), 130, 2661-2670. Universite Versailles-Saint-Quentin, Versailles, France Somatotopic organization of the analgesic effects of motor cortex rTMS in neuropathic pain. J.P. Lefaucheur at al. NEUROLOGY 2006;67:1998–2004. Departments of Physiology and Neurosurgery , Hopital Henri Mondor, Assistance Publique - Hopitaux de Paris, Faculte de Médecine de Créteil, France

26. optimistic that, in the future, rTMS might become new therapeutic options for patients with chronic pain.

28. Repeated daily rTMS prolong the effects

29. More efficient when applied in an area adjacent to the cortical representation of the painful zone

32. TENS may be better than placebo (level C) although worse than electroacupuncture (level B)

33. rTMS has transient efficacy in central and peripheral neuropathic pains (level B)

34. MCS is efficacious in central post-stroke and facial pain(level C)

35. Evidence for implanted peripheral stimulations is inadequate

36. r-TMS are non-invasive and suitable as preliminary or add-on therapies

38. Rio de Janeiro, Brazil (night)

39. www.estimulacaoneurologica.com.br