What are neuromodulation therapies?
Although the name Neuromodulation Therapies is not yet widely used in the general population, they represent a set of diagnostic and therapeutic techniques that utilize different stimulation modalities that can pass through the scalp and skull of the person receiving them by promoting processes of neuronal plasticity, thus promoting the replication of new neurons and the creation of new connections (synapses) between them.
Brain stimulation using magnetic pulses represents a method already widely in use since the 1980s within hospitals and outpatient facilities for diagnostic purposes. The first to introduce it in these settings was Anthony Barker (University of Sheffield, UK), who in 1985 introduced this technique as a non-invasive tool for clinical use (Barker et al., 1985). Since these years, the use of this method of stimulation has become increasingly widespread within the fields of neurology, clinical neurophysiology, and psychiatry for both research and clinical purposes (George and Bellmaker, 2000).
Among the various neuromodulation therapies, the undoubtedly best known technique is Transcranial Magnetic Stimulation (TMS), which has been used by the Istituto di Neuroscienze since 2005 along with Transcranial Direct Current Stimulation (tDCS).
Neuromodulation therapies since 2005
Dr. Stefano Pallanti has been using Neuromodulation Therapies (particularly TMS and tDCS) since 2005. In the last 15 years, numerous clinical follow-up studies have demonstrated their efficacy, as published in PubMed: a search engine for biomedical scientific literature, produced by the National Center for Biotechnology Information (NCBI) at the National Library of Medicine (NLM) of the U.S. National Institutes of Health (NIH) since 1949.
In Italy, only a few years ago the first clinical centers for the use of TMS in the treatment of neuropsychiatric disorders were launched.
In 2008, TMS received Food and Drug Administration approval in the US for the treatment of Treatment-Resistant Depression, and in 2018 for the treatment of Obsessive-Compulsive Disorder (OCD). Large clinical trials are being conducted within different disciplines and in different conditions; therefore, there is increasing clinical evidence regarding the effectiveness of Neuromodulation Therapies, even off-label.
Neuroplasticity: the science behind Neuromodulation Therapies
Rita Levi Montalcini, Nobel Prize winner in 1986 for the discovery of the Nerve Growth Factor, pioneered studies on the possibility for nerve cells to differentiate and replicate, introducing the concept of Neuroplasticity.
In 2000 Eric Kandel, Arvid Carlsson and Paul Greengard were awarded the Nobel Prize in Physiology and Medicine for their studies on synaptic plasticity; thus, it becomes clearer that the brain exists as an extremely plastic organ and therefore is in a state of continuous remodeling.
Neuroplasticity means the ability of our brain to change its structure and functioning permanently, allowing the evolution of stem cells into neurons and the creation of new neuronal synapses throughout the person’s entire life span.
Therefore, according to this discovery, many diseases of the nervous system are the result of a decompensation between stressful agents, mainly inflammatory, which attack certain structures (on the basis of individual vulnerability based on genetic predisposition) and neuroplasticity factors.
What does the treatment consist of practically?
Neuromodulation therapies use physical, magnetic, electrical and light stimuli that act by promoting Neurogenesis, or the process of formation of new nerve cells (neurons), increasing the neuronal plasticity and the creation of new connections (synapses) between them. In some cases, they also promote the anti-inflammatory and anti-scarring reaction of the supporting glial cells.
These therapies represent an advantageous alternative to medical treatment; TMS is, in fact, indicated by international guidelines, including those of the American Psychiatric Association (APA) as a treatment in cases of unsatisfactory response to pharmacological treatments.
Different Neuromodulation Techniques can be combined with each other and applied to further medical and psychological therapies.
Types of Neuromodulation Therapies
At our Institute, we are able to offer multiple types of Neuromodulation Therapies, applied in a personalized manner within multiple treatment plans:
― Repetitive Transcranial Magnetic Stimulation (rTMS);
― Transcranial Magnetic Stimulation Theta-Burst (TBS);
― Deep Transcranial Magnetic Stimulation (Deep TMS);
― Transcranial Direct Current Stimulation (tDCS);
― Photo-Bio-Modulation (PBM);
― Vagus Nerve Stimulation (VNS);
― Light Therapy;
― Pulsating Electrostatic Field Therapy (PESF).
Transcranial Magnetic Stimulation (TMS)
Transcranial Magnetic Stimulation (TMS)
The different types of Transcranial Magnetic Stimulation (TMS) represent non-invasive and non-pharmacological therapies that use magnetic field to stimulate or inhibit specific brain areas, proving to be highly effective for the treatment of many disorders, including Resistant Depression and Obsessive-Compulsive Disorder (OCD).
Neuromodulation Therapies by Professor Stefano Pallanti, and Beyond
In 2005, Dr. Pallanti began to use Neuromodulation Therapies, using the methods of Transcranial Magnetic Stimulation, rTMS and Transcranial Continuous Direct Current Stimulation (tDCS), additionally to Light Therapy and Pulsating Electrostatic Field Therapy (PESF).
At that time there were few centers in the world where these therapies were being operated, despite the fact that there was already very convincing research and studies.
Just think that Stanford University in California ― which is one of the world's major centers dedicated to medicine along with Harvard University ― only began using TMS in 2016, 11 years after Dr. Pallanti. It was precisely his expertise regarding TMS that led Dr. Pallanti to be requested at Stanford University where he was given a position as Full Professor and "TMS consultant" to train their physicians. He is, in fact, considered a world expert on transcranial magnetic stimulation (TMS) and other Neuromodulation Treatments: he is the founding member and has served as a member of the Board of Directors of the Clinical TMS Society in 2013 – 2017; furthermore, he holds a Chair of the European Network for Neuromodulation at the European College of Neuropsychopharmacology (ECNP).
While others in Italy and around the world are only now starting to use TMS, the Istituto di Neuroscienze goes even further, starting in 2019 to offer other cutting-edge therapies: Photo-Bio-Modulation (PBM) and non-invasive Vagus Nerve Stimulation (VNS), which is used both alone and in combination with other therapies with excellent results.
The Istituto di Neuroscienze is a center that attracts patients from different parts of the world, including Germany, England, the U.S., Switzerland, Lebanon, Russia, the United Arab Emirates, Australia. More and more people are arriving who have literally traveled the world in search of the best treatments.
Dr. Pallanti is now already at work on another innovation: Precision Psychiatry, that is, the application of genetics to treatment. When we talk about Precision Medicine, we refer to any personalized therapy that refers to the individual characteristics of a given subject; primarily genetic and metabolic characteristics. This leads to the most important target circuit of stimulation, the most effective drug, the metabolism system that interferes in enabling the effective dose of cure.
On these aspects we recommend browsing the journal Firenze Neuroscienze No. 4 available on our Website.
Neuromodulation Therapies offered by the Istituto di Neuroscienze can be applied effectively ― as off-label but scientifically validated therapies ― in a broad spectrum of neuropsychiatric areas and on different types of patients:
― Drug-Resistant patients;
― Patients with residual symptoms;
― Patients with cognitive symptoms;
― ECT candidates or ECT resistant patients;
― Patients with Mood Disorders (Depression, Bipolar Disorder);
― Reproductive Psychiatry patients (pregnant women);
― Post-partum Depression;
― Patients undergoing assisted fertilization;
― Depression associated with metabolic disorders;
― Depression for cases where medications should be avoided (liver / kidney failure);
― Seasonal Depression;
― Autism - reduction of repetitive behaviors and improvement of communication;
― Psychosis - reduction of hallucinations, reduction of negative symptoms;
― Obsessive Compulsive Disorder and OCD Spectrum Disorders (Trichotillomania, Tics);
― Behavioral addictions (Gambling, Internet, Pornography);
― Substance Use Disorders (Cocaine, Alcohol, THC);
― Cognitive rehabilitation;
― Post-stroke rehabilitation or head trauma;
― Pain, including headaches and fibromyalgia;
― Parkinson's Disease;
― Tinnitus (Tinnitus).
In Weight and Nutrition Disorders:
― Carbohydrate Craving;
― Obesity and Binge Eating;
― Eating Disorders.
How the sessions are conducted
The duration of individual treatment can vary depending on the specific therapy and can range from a few minutes to just under an hour.
It is necessary to remain awake during stimulation and it is possible to read and talk.
The practitioner/physician will ask a few simple questions about daily progress regarding:
― Activities performed during the day, rest, nutrition;
― Subjective mood and progress of symptoms;
― Pharmacotherapy, in order to monitor any changes or modifications;
― Alcohol and/or substance intake: substances such as alcohol, marijuana and cocaine can interfere with therapy and produce a change in pacing parameters.
Therapeutic sessions are given on a daily basis for one or more sessions per day, unless specifically indicated. The minimum duration of therapy should be longer than 20 sessions, but as a rule the more sessions the better. In the US, the first course of treatment lasts no less than 40-50 sessions.
Sessions are conducted on an outpatient basis under constant supervision. In fact, the goal is to stimulate the patient to adopt an active attitude so that he or she makes available to himself or herself every useful resource for change, the cornerstone of any therapy.
The beneficial effects may not be immediate: this depends from person to person.
At the end of the initial cycle, the usefulness of extending treatment further is evaluated. If the beneficial effects become evident toward the end of the agreed cycle, surely it is advisable to prolong the treatment period to consolidate the effect.
Reevaluation and recall visits should be established: essential to consolidate the effects obtained during the first cycle and reduce the risk of future relapse.
Follow-up and recall visits
The mere disappearance/decrease of the symptom does not coincide with the disappearance of the disease.
Even after the symptom disappears or diminishes, the brain circuit disorder may remain. If one stops therapies, pharmacological or Neuromodulation, the symptom reappears perhaps in a different form from the first one (relapse). At that point it will be more difficult and take longer to return to feeling better.
In order to avoid relapse, it is important to schedule regular booster treatment sessions, which are generally done shortly after the end of the first cycle and consist of a few consecutive days of treatment.
The duration of the reevaluation visits cannot be established a priori but depends on the patient's symptomatology, the effects achieved in the first course of treatment, and any comorbidities that may make the clinical picture more complex, consequently increasing the incidence rate of relapse.
The protocol as well as the type of Neuromodulation therapy (as well as other current therapies) may undergo modifications in order to best adapt to changes in each individual's clinical and metabolic condition. That is why the treatments are valid for 2 months, after which, they must be reevaluated: one cannot go on with the same treatments beyond two months, unless otherwise directed by the doctor.