María Alicia Lage, licensed psychologist and clinical neuropsychologist, Dr. Alejandro Fuertes-Saiz, psychiatrist, and Carla Castro, teacher with a mention in special and curricular education, discuss in this article transcranial magnetic stimulation (TMS) and neuropsychological rehabilitation.
The importance of assessment and diagnosis for the design of an intervention program
Migraine is a neurological disease that affects approximately 12% of the world’s population. Typical symptoms include throbbing headaches, nausea, and sensitivity to light and sound.
In addition to these symptoms, migraine can also affect alternating attention and episodic memory. Alternating attention is the ability to shift the focus of attention from one task to another. On the other hand, episodic memory is the ability to recall specific events and details about those events.
It is crucial in a migraine patient to perform a neuropsychological evaluation to quantify this possible cognitive impairment and develop a comprehensive intervention plan that encompasses these areas as well.
Neuropsychological rehabilitation with transcranial magnetic stimulation
It is a broader concept than cognitive stimulation; it involves reducing the impact of conditions that are disabling for the client and allowing him/her to reach an optimal level of social integration (WHO, 2001). Therefore, it includes different types of intervention, which can be framed in four major groups: cognitive rehabilitation, behavior modification, intervention with families and social, educational or professional readaptation.
Rehabilitation in terms of the approach:
- Compensation, consists in the reorganization of functions to minimize or save the functional limitations of the individual. Its goal is to improve functionality in daily life. The resources are external aids and environmental adaptations.
- Restoration/Rehabilitation consists in the direct training of lost, damaged or impaired function. Its objective is to improve cognitive function through repetitive exercises and tasks of increasing complexity. It involves “bottom-up” mechanisms, with low-level processes leading to the recovery of high-level processes.
- Substitution is the development of a new method of response that replaces the damage produced. Its objective is the search for new ways to solve the problem. Resources are the optimization of the preserved systems.
What neuropsychological processes do we work on through the NeuronUP platform?
Memory is not a unitary system, but rather there are different memory systems, with differentiated contents and related to distinctive brain structures distributed throughout the cerebral cortex. They are systems with an organized brain structure, whose results are translated into mental processes and behavior, being at the service of cognitive and behavioral functions.
Tirapu and Grandi, publish in 2017, in Cuadernos de Neuropsicología, the article “On working memory and declarative memory: proposal for a conceptual clarification”.
Understanding that, episodic memory is the organization of information contents subject to spatio-temporal parameters.
Episodic and semantic memory, although they represent two declarative memory systems, are anatomically and functionally different. And in turn, taking into account the temporal gradient, we can distinguish retrospective episodic memory (past events) or prospective episodic memory (future events).
Thanks to our lived experiences, we can organize and plan our future in an adaptive way, examples of our daily life that demonstrate this are, remembering to return a book to a friend, taking medication or buying milk at the supermarket.
The most widely used theoretical model when dealing with attention is the clinical model of Sholberg and Mateer, in which five hierarchically ordered levels are established, with alternating attention being the fourth level.
This means that in order to be able to adequately carry out an activity that requires alternating attention, it is a requirement that the three previous levels, i.e., focused, sustained and selective attention, function well.
Alternating attention is the ability to shift our focus of attention from one task or internal norm to another in a smooth way. For this, the pace at which our brain performs the task is extremely important, i.e., our processing speed.
What is non-invasive brain stimulation?
Non-invasive brain neuromodulation techniques are a set of therapeutic tools that seek to modify the electrical activity of certain areas of the brain to treat various neurological and psychiatric disorders.
These techniques are based on electrical or magnetic stimulation of the brain, and have become an increasingly popular option due to their efficacy, safety and lack of serious side effects.
Among the most prominent techniques are transcranial magnetic stimulation and transcranial direct current stimulation. Both are painless techniques, with few side effects and growing therapeutic applications in the field of neuropsychiatry (depression, OCD, anxiety, addictions, migraines, post-stroke rehabilitation, etc.).
Transcranial magnetic stimulation
How does TMS work?
Transcranial magnetic stimulation works by applying magnetic pulses through the scalp (on a cortical target) which induce electrical currents in nearby neurons. These electrical currents can modify neuronal activity in the stimulated area, either increasing or decreasing it.
The effect of stimulation on brain activity depends on several factors, such as the intensity and frequency of the magnetic pulses, the location of the stimulation and the duration of the treatment.
In general, it is believed that transcranial magnetic stimulation can increase the activity of neurons in the stimulated area and in the connected areas, therefore, it has a global effect on the set of brain neurocircuits and not only on the one directly stimulated by the technique.
It has been proven that transcranial magnetic stimulation can increase activity in the dorsolateral prefrontal cortex, a region involved in cognitive and emotional control.
This has led to the exploration of magnetic stimulation as a treatment for depression, anxiety, migraines, and other neuropsychiatric disorders involving prefrontal cortex dysfunction.
In summary, transcranial magnetic stimulation is a noninvasive brain neuromodulation technique that works by applying magnetic pulses to modify neuronal activity in specific areas of the brain, which can have therapeutic effects in a variety of neurological and psychiatric disorders.
Advantages of transcranial magnetic stimulation
- No hospitalization is required.
- The patient can immediately resume his daily activities.
- Does not require anesthesia.
- It is not incompatible with other pharmacological or physical treatments.
- It does not produce systemic or serious side effects.
- It does not require prior preparation.
Contraindications for TMS
- This technique is not suitable for patients with implanted or non-removable metallic devices in the head (metallic plates, cerebrospinal fluid shunt valves, aneurysm clips or coils).
- TMS treatment also cannot be used in patients with controlled physiological signal implants such as pacemakers, implantable defibrillators, vagus nerve stimulators, spinal cord stimulators or drug infusion pumps.
- Application in patients with epilepsy or a history of seizures should be considered.
Transcranial magnetic stimulation side effects
These are usually mild to moderate and improve shortly after the session and tend to improve with the course of the sessions. They may include some of the following:
- Discomfort in the area of scalp stimulation.
- Tingling sensation, spasms or twitching of the facial muscles.
- 0.003% risk of inducing a seizure.
Currently, transcranial magnetic stimulation is not only used in the approved indications (depression and OCD) but there are numerous promising studies on its application in different pathologies, such as fibromyalgia, spasticity, post-traumatic stress, auditory hallucinations, negative symptomatology of schizophrenia or stroke rehabilitation.
It should be emphasized that it should always be used in properly selected cases and when other less expensive lines of treatment have failed. The use of transcranial magnetic stimulation as a therapeutic tool in patients with brain damage, whether supervening or degenerative, has increased exponentially in recent years.
Thus, we can find recent research that studies the use of transcranial magnetic stimulation as a therapeutic approach in patients with Parkinson’s disease, Alzheimer’s type dementia, cranioencephalic trauma, cerebrovascular accidents and other types of neurological, neuropsychological, psychological and psychiatric disorders with cognitive impairment such as migraines.
Research to date has shown promising results and has demonstrated that transcranial magnetic stimulation is capable of enhancing and inducing neuroplasticity and long-term changes in the brain, both structurally and functionally.
Grandi, Fabrissio & Tirapu, Javier. (2017). Sobre la memoria de trabajo y la memoria declarativa: propuesta de una clarificación conceptual. Cuadernos de neuropsicología Panamerican Journal of Neuropsychology. 10. 13-31. 10.7714/CNPS/10.3.201.
Ibiricu, M.A. & Morales, G. (2009). Estimulación magnética transcraneal. Anales del Sistema Sanitario de Navarra, 32 (supl.3). Pamplona.
López-Ibor, J.J.; Pastrana, J.I.; Cisneros, S. & López-Ibor, M.I. (2010). Eficacia de la estimulación magnética transcraneal en depresión. Estudio naturalístico. Actas Esp. Psiquiatría, 38 (2): 87-93.
Mauro García-Toro, Margalida Gili, Miguel Roca, Capítulo 7 – Estimulación magnética transcraneal en psiquiatría, Editor(s): Isaac Túnez Fiñana, Álvaro Pascual Leone, Estimulación magnética transcraneal y neuromodulación, Elsevier, 2014, Pages 79-86,
ISBN 9788490224977, https://doi.org/10.1016/B978-84-9022-497-7.00007-3. (https://www.sciencedirect.com/science/article/pii/B9788490224977000073)
Pascual-Leone, A. y Tormos-Muñoz, J.M. (2008). Estimulación magnética transcraneal: fundamentos y potencial de la modulación de redes neurales específicas. Rev. Neurol., 46 (Supl 1): S3- S10.