TMS training manual and safety guidelines

Please also review the TMS Standard Operating Procedures and TMS Safety Screening Form (see attachments).

Requirements for performing TMS

1. Basic Life Support Certification
2. If a student, they must be directly mentored by one of the PIs or have received written permission from one of the PIs
3. Access to SMNP + Falcon Lab Scheduler
4. Must pass equipment and participant check test. 
   1. Must be able to setup equipment in 20 minutes (Brainsight, EMG, Stimulator, etc.)
   2. Must be able to setup participant in 20 minutes (Registration, Brainsight, EMG leads, etc.)
5. Passing grade (+3% or lower MSO relative to Mike or Sara) on TMS threshold test
6. Passing grade on TMS Safety Quiz (Talk to Mike about this).

Equipment needed to perform TMS properly

1. Deymed TMS device
2. Deymed TMS coil (one of three, depending on experimental procedures)
   1. Active air-cooled coil
   2. Active non-cooled coil
   3. Sham air cooled coil
3. EMG electrodes and alcohol wipes (if delivering TMS to the motor cortex)
4. Earplugs
5. Neuronavigation computer and camera stand
6. Individual subject T1-weighted structural MRI (if performing image-guided TMS)
7. Mobile telephone (lab telephone is cosmetic).
8. Motor Threshold Assessment Tool (TMS MTAT)
9. Pregnancy test, urine specimen cup, nitrile gloves (if performing rTMS > 1 Hz)
10. Printed copy of TMS Safety Screening form

Risks of TMS

1. Headache / scalp discomfort.
   1. This usually goes away with time and nonprescription medication. However, we do not provide over the counter / nonprescription medications to our participants. Instead, we can recommend that they take some on their own.
2. Hearing damage 
   1. This is mitigated by always using earplugs.
3.  Seizure
   1. This is a very unlikely but serious risk. Seizure is more likely to occur in individuals who have personal or family history of epilepsy/seizures or brain damage.
   2. All participants should be screened using the questions posted in the laboratory (546F).
4. Interference with metal / electronic devices in the body 
   1. Participants with electronic / metal devices in their head, neck, or arms should not undergo TMS.
   2. Welders or people working with metal may have metal in their body without them knowing. 
5.  Risks to a developing fetus are unknown.
   1. This is mitigated by requiring a negative pregnancy test within 24 hours of any rTMS session (> 1 Hz). Negative pregnancy tests are not required for TMS procedures ≤ 1 Hz.

Safety precautions

1. All participants must have provided their written informed consent prior to receiving any TMS procedures.
2. All participants must undergo verbal TMS Safety Screening by the person who obtained informed consent.
3. Ear plugs must be worn whenever TMS is being delivered. Earplugs MUST be placed by research personnel and NOT the subject.
4. A mobile telephone must be available (and charged) in case of medical emergency.
5. Two individuals who are trained in TMS procedures must be present. One of these will physically perform TMS. The other will monitor the participant for any signs of discomfort.
   1. One person must be FULLY trained.
   2. The other person must have passed the equipment and participant test described above. 
6. The PI must be notified that you are performing TMS procedures. This can be accomplished by adding session information to the SMNP + Falcon Lab Scheduler.
7. After TMS procedures, the research team must ask the participant how they are feeling. If the participant indicates that they are not feeling well, they should remain in the lab for a few minutes. At this point, please call the PI for information on how to proceed.
   1. Using the following scale is a good way to standardize participants' responses and should be used when collecting data.
      1. 0 = TMS was tolerable with no discomfort.
      2. 1 = TMS was tolerable with some discomfort.
      3. 2 = TMS was intolerable.

Emergency procedures

1. If a participant exhibits any signs of a seizure or loss of consciousness, call 911 immediately.
2. One person will remain with the participant to ensure their safety.
3. The other person will describe the medical event to the 911 operator and indicate the location of the laboratory (546F Bellmont Hall, UT Austin main campus at 2109 San Jacinto Dr, Austin TX).
4. The person communicating with the 911 operator will go outside to meet emergency personnel and guide them to the laboratory.
5. Once emergency personnel have arrived and the situation under control, the PI should be contacted immediately. The PI will provide additional guidance.

Guidelines, tips, and tricks

1. When testing a participant who has never experienced TMS before, first show the participant how TMS feels on their forearm. Then, if they are comfortable with that, you can show them how a single pulse feels on their head. Afterwards, ask them if they are comfortable proceeding.
2. TMS often makes participants sleepy. However, sleep involves brain states that are vastly different than those present during wake. Because of this, we should not allow participants to sleep or close their eyes during TMS procedures. If this occurs, simply tap the participant and remind them to try and stay awake.
3. Do not be afraid to stabilize a participants head to improve coil stability and the consistency of coil placement. The head is most stable when the neck rest is positioned to fit between their upper back and head.
4. Participants should remain as relaxed as possible during TMS procedures.
5. When delivering TMS to the motor cortex, the coil should be held tangential to the head, and 45 degrees away from the mid-sagittal line. The handle should be pointing backwards on an angle. There should be substantial contact between the coil and the head, but do not push downwards on the participants head. This can be uncomfortable for the participant.
6. TMS delivered to prefrontal regions can be very uncomfortable if not painful. Please perform this procure cautiously. If using rTMS, introduce the sensation with a single-pulse and a short train or rTMS to the area where stimulation is to be delivered.

Equipment maintenance

1. The TMS coil that you are using should be calibrated in BrainSight before each session. If you switch coils in the middle of a session, the spheres move, you should recalibrate. 
2. When a TMS coil is not in use, it should be removed from the coil holder. This prevents the coil from accidentally falling off of the holder and being damaged.
3. All equipment should be TURNED OFF and UNPLUGGED after every use.
4. Neither the TMS device nor the neuronavigation device should be plugged into surge protectors.
5. When using the reflective spheres for neuronavigation, do your best not to touch these. Skin oils reduce their reflective capacity.
6. Electrodes, goggles, headbands, and the TMS chair should be cleaned using alcohol pads or Lysol wipes after each participant.
7. If you have questions on how to use BrainSight or the Deymed TMS unit, consult the manuals.

Consumable supplies

1. If you are not a member of the SMNP or Falcon lab, you are responsible for obtaining your own EMG electrodes for your studies. These should be clearly labeled as such to avoid confusion.
2. If you are a member of the SMNP or Falcon lab, please keep track of consumable supplies in the lab. This includes electrodes, alcohol wipes, Lysol wipes, and masks. These can be found in the cabinets by the sink. This will help ensure that you do not run out of supplies immediately before a participant arrives for testing.
3. When supplies are running low, please notify the PI so that she/he can order more as needed.

Contact information

• Sara Hussain: 847-309-5189
• Michael Freedberg: 718-290-6729
• In case of emergency, if Sara does not answer, call Mike. If Mike does not answer, call Sara.