ZOOM TMS 101 – HOW TO START & BUILD A SUCCESSFUL TMS PRACTICE Learn more

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How to run the CloudTMS device using a laptop

Now let me tell you how we can operate CloudTMS directly from the laptop. In other words, if you have a patient, you can set up all the session protocols, treatment protocols on the laptop and each time the patient comes back the second o third time, the laptop will take over and know exactly where it left the last time and start a new session, and I will show you how we can program the laptop to do this.

The laptop now is connected through a USB cable to the machine. Now that the laptop is open, I click on the ‘Neuro-MS.net’ and that’s the program that actually runs the CloudTMS machine. Here I go and I click on this man here (clicks on the pop up on the laptop screen) and I can see ‘treatments’, ‘hardware’, ‘report’, ‘view’ and ‘setup’. So I can select a new patient from ‘treatment’ or I can select a new treatment from here. When I open this, it’s going to open a new patient file and I can say ‘test patient’, like so (types out ‘test patient’ into laptop), and I will say it’s a male, and I will say the date of birth month is 5 and the day is 10 and it’s 1982, and here you are going to see immediately the FDA approved protocol pop up and you can tell what department the patient was in. If you press on this (clicks on ‘standard diagnosis’), you are going to see the standard ICD-10 diagnosis if you want to do that and of course, you can put the name of the doctor and the assistant. Once I’m happy with that, I’m going to press on the green check mark right here (clicks on green check mark) and as soon as you do that, the machine comes on and you can hear the machine.

The first thing that you’re going to come across is the ‘treatment protocol’ right here (pushes the ‘treatment protocol’ button). The FDA approved treatment protocols which is right here, ‘FDA approved’ and click this green check sign here. The treatment protocol tells you that it’s a depression, 10 Hertz, 120 percent of the motor threshold. That’s the level at which you’re going to stimulate the patient – ‘sessions 1 out of 30, depression, 10 Hertz, 120 percent’ and the stimulation is 120 percent, 40 pulses, 10 Hertz for 4 seconds, and I’ll show you what that means in a minute – 75 of those. As soon as I press on this right here (the stimulation just mentioned), you will see that the patient will be stimulated at 50. Amplitude is 120 percent of the motor threshold again and the motor threshold is what you calculate whenever you put the coil over the hotspot of the head. The pulses frequency is 10 Hertz and the train has 40 pulses, so 10 Hertz for 4 seconds is 40 pulses. 1 Hertz is 1 per second, so you do 10 per second for 4 seconds essentially, so if you do 10 Hertz for 4 seconds, that’s 40 pulses. The number of 40 pulses is going to be 75, so there would be 75 trains of 4 seconds each and between each train, there’s a 26-second break for the patient. That was the FDA approved protocol. If you remember, that’s how I set the machine up when I was operating it independently.

I like this very much, it shows you a 120 percent of the threshold, 26 seconds rest, 40 pulses at 10 Hertz, 75 hours, so you’ve given the patient 3000 pulses. As soon as I’m done with that, I need to determine the motor threshold and it essentially tells me at what level I am stimulating over the hotspot that I get a movement of the patient’s thumb. Now bear in mind that in the brain, everything is crossed, so if you stimulate the left side of the brain, the right side of the body is what moves and vice versa. So, basically, here I’m stimulating the left side of the brain over the hotspot and I’m using 40 percent amplitude from here, and I can make 42 or 44. I’m trying to find out the lowest possible level that I can stimulate the patient on the left side of the brain to see a thumb movement. That’s how you calculate the motor threshold, and when you say 120 percent of the motor threshold, you do 120 percent of that.

Now, imagine that I’m doing the motor threshold and I found that the patient’s motor threshold is roughly at 50, I can increase it from the machine or I can increase it from the laptop. As soon as I increase it to this, and I start stimulating the patient over the left side of the head because that’s what controls the right thumb. So bear in mind, in the brain, the left controls the right side. Now I start seeing a movement of the right thumb, I can say, well this is the motor threshold and as soon as I press on this (clicks on the icon labeled ‘Fix MT’), notice that this will turn from red to green (box underneath ‘MT. %’). Right here is set at 50 so now I’m going to go for this stimulation mode and you see this says session 1 of 30, it’s stimulating over the dorsolateral prefrontal cortex, 3000 pulses, duration 36:56, it’s about 37 and a half minutes. Now I’m going to say, okay, we’re going to start stimulating the patient, which I do when I press this here play button. That means I want to start the stimulation. Now bear in mind, the patient is sitting in a chair and this coil is over their head but I’m just showing the operation of the machine now. Here it’s going to say, ‘place the coil on the stimulation site’, and if I say yes, I already placed that, press ‘OK’.

So here’s what’s going to happen next, as soon as I do this, it starts stimulating. Now the laptop is telling the machine what to do, it stimulates at 40, so 40 pulses, and between pulses, it’s going to rest. You can see here that the timing is going down. So basically it’s going to break for 26 seconds and then it’s going to start again as soon as the 26 seconds are over. The laptop is going to start the stimulation over again, it’s going to deliver another 40 pulses and then it’s going to take another 26-second break. It’s going to do this for the entire 37 and a half minutes protocol and here’s what it’s doing. That was the second stimulation of 10 Hertz at 4 seconds, 40 pulses, then I wait for another 26 seconds and it gives me that. As soon as I’m done with that, I can say that this has been executed and the laptop will take care of that and next time the patient comes and you open their file, it’s going to start at the second session or third session.

Now, I want to show you something else that you can do. Let’s say that the patient moved their head while you’re doing that, what I can do is, I pause, reposition the patient, make sure that the coil is in the right position and then I do that again (press pause) and it starts over again. So now, let’s say I’m done, I’m going to press on here, stop, and it says, ‘mark intervention as executed’ and I say ‘yes’, it’s executed, so basically, as soon as I do that, it’s executed. Now it’s going to (say) ‘session 1 is complete’ and I say ‘OK’. To close this treatment and ‘save the treatment?’, ‘yes’. Now, when the patient comes back the next day, if I open this, it already says ‘session 2 of 30’ and again, the same thing here if I press (the play button), everything is set up the same way. I can show you here (clicks on treatment protocol), treatment protocol the same way, the motor threshold is the same thing so the computer remembered all of these and now, I can start stimulation again and make sure it’s positioned in the right place, and now it’s stimulating. As soon as it stops, it’s done 40. Let’s say I’m done with session 2 here and I say ‘yes’ and save, ‘session 2 is complete’ and I’m going to show you real quick here that after I close this and I save the patient, next time I open this patient, it’s going to say it’s session 3 out of 30.

Setting up the 19-minutes protocol

So the FDA approves different protocols from time to time. The latest approved protocol is the 19-minutes protocol, so it cuts down the treatment time from 37 and a half minutes to 19 minutes, and I’m going to show you how you can actually build a 19-minutes protocol on this laptop. In order to change protocols, I go to ‘set up’, I go to ‘treatment protocols’ and I choose ‘treatment courses’, right here and it says, you might not be doing an FDA (approved). Any time it’s FDA approved, you can change treatment courses, but it’s warning you here. Here, what I do is, I click on ‘depression’ and you see here it has ‘FDA approved’ and it has ‘120%’. There’s another ‘80%’ that’s not FDA approved, but let’s say that I want to build a 19 minutes protocol.

So basically, I want to modify that from 37 and a half minutes to 19 minutes and here’s how I do that. Click on this (Depression 10Hz (120%) – FDA approved) and I would copy it and paste it and now I have a copy of this protocol and I can change this copy. So basically, let’s do this here and I can call this 19 minutes. And really, the only thing that has changed in this 19 minutes protocol is the break period between the stimulations, so instead of having a 26 seconds break period, we’re now going to have an 11 seconds break period and that’s where you’re cutting on that. So basically, you can still deliver 3000 pulses and now you can see that this here says there’s an 11 seconds rest, everything else staying the same. So by cutting down on the rest period, you’re going to be able to execute that protocol in 19 minutes. If I like that, I click on this (the green check mark) and now the 19 minutes protocol is saved.

So let’s say I’m going to bring in a new patient in here, a new treatment, I click on this (‘new treatment’) and then I say ‘test 19 minutes’ (in ‘Name’ box) and I say it’s a female and I’m going to say ’06-10-1988′ (under ‘birth date’) and I can feel out the rest as I want, but notice here it says the FDA approved protocol and that’s not the one I want right now. I want to choose the 19 minutes protocol, right here (in the drop-down list under ‘treatment protocol’), and I say ‘Ok’. And now I click the check mark here, and again, ‘treatment protocol’. You’re going to adjust the motor threshold and let’s say that I can get a stimulation at 40, I fix the motor threshold, it turns green here, and now I say ‘repetitive mode’.

So here’s what happened, now it’s showing you 120 percent, 40 pulses, 10 Hertz, 3000 pulses but the rest is 11 seconds and that’s session 1. And like I did before, I press on this (play button) and I’m going to say ‘OK’, and now it starts stimulating and it’s going to go to 40, but notice that it will not wait 26 seconds to get to the next stimulation. It’s going to just wait 11 seconds, so that’s how you cut down the time. Immediately as the 11 seconds are over, it starts again, 80 (pulses). It’s going to break for 11 seconds and start again and it’s going to do that 75 times. And now I can stop that and session 1 is completed and the next time the patient comes back in, I’m going to close that and let’s say I’m saving that treatment and let’s say the patient came back in the next day and you see it says ‘session 2’ and again, it’s going to still do the 19 minutes protocol, so I say this (play button) and I say ‘yes’ I’ve placed it. Now it’s going to do it again, it’s going to stop for 11 seconds and as soon as those 11 seconds are over, and it’s timing, by the way, see it says 18 and 17 now. As soon as these 11 seconds are over, it’s going to start stimulating again and that’s how you get the 19-minutes protocol.