INFORMATION PACKAGE -PATIENT– 10.03.24

RTMS THERAPY

INFORMATION

REVIEW

MindCare Centres Headquarters [Vancouver] Toll-free: 1.888.706.RTMS (7867)

Email: info@mindcarecentres.com

Website: www.mindcarecentres.com

Toronto > Local: 647.344. RTMS [7867] / Toll Free: 1.888.726.MIND [6463] Ottawa > Local: 613.569.RTMS [7867] / Toll Free: 1.888.726.RTMS [7867]

Montreal > Local: 514.481.RTMS [7867] / Toll Free: 1.866.331.3431

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TABLE OF CONTENTS

MindCare Centres ............................................................................................................. - 1 - Background Information on rTMS Therapy .................................................................... - 2 -

What is rTMS? ......................................................................................................................... - 2 - When was rTMS developed? ................................................................................................... - 3 -

Disease States and rTMS ................................................................................................. - 4 - Depression............................................................................................................................... - 4 - Anxiety and Post Traumatic Stress Disorder ............................................................................ - 5 - Auditory Hallucination Schizophrenia ....................................................................................... - 5 - Obsessive Compulsive Disorder (OCD) ................................................................................... - 6 - Parkinson’s Disease................................................................................................................. - 6 - Eating Disorders – Bulimia ....................................................................................................... - 6 - Migraines ................................................................................................................................. - 7 - Tinnitus .................................................................................................................................... - 7 - Fibromyalgia and Pain Management ........................................................................................ - 7 -

How is Response to rTMS assessed?............................................................................. - 8 - rTMS Responder Rate at MindCare Centres................................................................... - 9 - Advantages of rTMS ......................................................................................................... - 9 - How long will the benefits last?....................................................................................... - 9 - The Procedure................................................................................................................... - 9 -

How is rTMS administered? ................................................................................................... - 10 - Who will be involved in my treatment? ................................................................................... - 10 - How long will the initial medical consultation take?................................................................. - 10 - How often will I receive rTMS therapy? .................................................................................. - 10 - How long is each rTMS treatment session? ........................................................................... - 11 - What are the risks? ................................................................................................................ - 11 - Am I a Candidate? ................................................................................................................. - 11 -

Cost.................................................................................................................................. - 11 - Post-rTMS Therapy......................................................................................................... - 12 - Why MindCare Centres?................................................................................................. - 13 -

Quality patient care ................................................................................................................ - 13 - Our clinics .............................................................................................................................. - 13 - Our staff ................................................................................................................................. - 13 - Letters from MindCare Centres’ Patients................................................................................ - 13 - Scientific Board of Advisors.................................................................................................... - 13 - Outcome tracking ................................................................................................................... - 14 -

Read more about rTMS Therapy online ........................................................................ - 14 - MindCare Centres Locations ......................................................................................... - 15 - MindCare Centres Literature Review ............................................................................ - 16 - MindCare Centres Treatment Process .......................................................................... - 27 - Patient Testimonials ....................................................................................................... - 29 - Prepayment / Cancellation Policy.................................................................................. - 32 -

MINDCARE CENTRES

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We specialize in delivering a safe and effective treatment called repetitive Transcranial Magnetic Stimulation, also known as rTMS. rTMS therapy has been extensively validated in clinical trials and medical research studies and was approved for use in Canada in 2002. With rTMS, electrical activity in the patient’s brain is influenced by a targeted, pulsed magnetic field. It is a painless, non-invasive procedure that does not require anesthesia. Depending on the disorder being treated, rTMS therapy involves approximately 10 to 30 treatment sessions, each lasting approximately half an hour. Treatment occurs over a period of two to three consecutive weeks (weekends off). Our goals:

� Improve your quality of life. � Provide you with the information you need to make informed decisions. � Provide a supportive and comfortable treatment environment. � Offer best possible care and follow recommended guidelines from the ISTS (International Society for

Transcranial Stimulation) and reviewed by the MindCare Scientific Advisory Board. � Customize each patient’s treatment, track results using our custom Electronic Medical Record system,

and follow-up on treatment success using a secure outcome tracking system.

To date, MindCare Centres has administered rTMS therapy to over 600 patients. We offer a specific rTMS treatment protocol for a variety of disease states:

• Depression

• Anxiety and Post Traumatic Stress Disorder (PTSD) • Auditory Hallucination Schizophrenia

• Eating Disorders - Bulimia • Parkinson’s Disease

• Migraines • Obsessive Compulsive Disorder (OCD)

• Tinnitus • Fibromyalgia and Pain Management

BACKGROUND INFORMATION ON RTMS THERAPY

What is rTMS? Repetitive Transcranial Magnetic Stimulation, or rTMS, is a procedure in which electrical activity in the brain is influenced by a pulsed magnetic field. The magnetic field is generated by passing brief current pulses through a figure 8 coil of wire. This coil of wire is encased in plastic and is held directly on the scalp so that the magnetic field can be focused onto specific areas of the cortex, or surface, of the brain. The magnetic field that is generated in rTMS can penetrate the scalp and skull safely and painlessly to induce a current in specific neurons (brain cells). Because the magnetic stimulation is delivered at regular intervals, it is termed repetitive TMS, or rTMS. The area of the brain targeted with rTMS for the various disease states are explained below. Many aspects of rTMS, referred to as stimulation parameters, can be changed. The ability to change parameters while directly targeting specific brain cells suggests that rTMS therapy has an extremely valuable therapeutic potential. The stimulation parameters are:

• The number of stimuli

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• The strength of the stimuli

• The duration of the stimuli

• The length of the interval between stimuli

• Targeted area of the brain

This means that the delivery of rTMS therapy may be customized for each patient. It also suggests that rTMS may be used to elicit certain desired effects in the brain (i.e., excitatory or inhibitory effects) that have shown promise for treating various other conditions or illnesses.

When was rTMS developed? 1831 • Faraday discovers the principle of mutual induction. Faraday’s law quantifies the

conversion of electrical energy into magnetic fields and magnetic fields into electrical energy.

1896 • D’arsonval places a subject’s head inside a power magnetic coil. Subjects recorded seeing “magneto phosphenes” (sparks) and experiencing vertigo and syncope.

1902 • Researchers in Vienna, Australia treat a patient for depression by using an electromagnetic coil placed over the skull to pass vibrations into the cranium.

• These early innovations represent the historical structures that have shaped today’s modern version of rTMS but they did not permit high intensity or frequency usage.

1965 • The first magnetic stimulation of human nerves is conducted by Bickford and Fremming.

Mid 1980’s

• Anthony Barker at the University of Sheffield, England, built the first effective, modern Transcranial Magnetic Stimulation (TMS) device. It was designed as a neuro-diagnostic tool. Researchers could now induce movement in the finger and foot by placing the coil over a specific region of the brain. It was also used to study nerve fibers and create a functional map of the brain. The procedure’s non-invasive and painless nature allowed early researchers to utilize the TMS devices to map and study regions of the brain that were involved in memory, vision and muscle control.

1990’s

• The first open trials of using TMS for depression began. Hoflich et al. suggested that TMS, which was applied over the vertex (i.e., top of the skull), has antidepressant effects. The first clinical utilization of the early TMS devices involved diagnostics for multiple sclerosis and motor neuron disease.

2002 • rTMS therapy was approved by Health Canada for clinical delivery in Canada.

Present • rTMS research has now been ongoing for over 20 years around the world. • More recently, rTMS has been used to investigate sensory and cognitive aspects of

cortical processing. • Current research suggests that rTMS has valuable therapeutic potential for many

other illness and disorders, besides depression, because of its unique capacity to selectively increase or decrease the excitability of neurons in discrete brain regions. This emerging technology represents the most significant innovation in neuropsychiatry in the last 50 years.

Frequency: Wave forms

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DISEASE STATES AND RTMS

Depression • In treating depression, rTMS therapy targets the area just a few inches above

the temple and beneath the skull. This area is called the left dorsolateral prefrontal cortex (LDLPFC, see photo). The DLPFC is readily accessible to the magnetic field and is highly interconnected with limbic structures, which play a dominant role in mood modulation and major depression.

• rTMS is used to treat depression by inducing a current in the DLPFC with stimulation by a magnetic field. The stimulations are short but intense, lasting less than a millisecond. The penetration itself holds little energy. Several studies have suggested that rTMS regulates beta adreno-receptors and increases dopamine and serotonin levels.

• Some of the remote brain structures are also believed to be linked to

depression. rTMS can alter activity in these structures that are not directly accessible to the rTMS coil by focal cortical stimulation. The indirect stimulation occurs via trans-synaptic effects. This means that the accessible areas of the brain, such as the DLPFC described above, are first directly stimulated by the magnetic field. This direct stimulation will in turn cause the inaccessible areas of the brain to be stimulated.

• The human brain is an electrical organ that functions through transmitting electrical signals from one nerve cell to another. Brain imaging techniques demonstrate that individuals suffering from depression often portray insufficient levels of glucose metabolism, lower blood flow in the DLPFC and increased activity in the limbic system. rTMS plays on this process by regulating the flow of interactions between neurons that will appropriately increase or decrease the activity in the desired regions to relieve the depression.

• Acute treatment for depression consists of 20-30 rTMS sessions, over 2-3 consecutive weeks

(weekends off).

• “Repeated rTMS applications have demonstrated a reproducible antidepressant effect in patients with refractory depression who initially showed a clinically significant benefit…..benefits were sustained for a mean of nearly 5 months.” (Demirtas-Tatlidede et al., 2008, Journal of Clinical Psychiatry).

• “…young age and additional rTMS sessions – were

associated with a long duration of remissions time…” (Cohen et al., 2009, Wiley-Liss, Inc.).

• “High-frequency rTMS of the left dorsolateral prefrontal cortex is effective in treatment-resistant depression.” (Kito et al., 2008, The Journal of Neuropsychiatry and Clinical Neurosciences)

• “Over the 3 weeks, the active rTMS treatment was superior to sham TMS… which indicates not only a statistically but also a clinically significant effect.” (Bretlau et al., 2008, Pharmacopsychiatry)

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Anxiety and Post Traumatic Stress Disorder • Patients suffering from depression who also have anxiety components can receive a large reduction in

anxiety levels, simply as a result of the treatment protocol used in the treatment for depression. However, in some cases, the desired therapeutic benefit is not fully achieved from depression treatment protocols alone. In this case, with the analysis of anxiety assessment scales, verbal feedback from patients and advisement from MindCare Centres medical staff, supplementary right-sided treatment for anxiety can be provided.

• For patients primarily seeking relief from anxiety, rTMS can be administered twice a day for 2-3 weeks, totaling 20-30 treatments.

• When added as supplementary treatment, anxiety/PTSD treatment consists of 10-20 rTMS sessions on the right dorso-lateral prefrontal cortex (RDLPFC, see photo below) administered once per day.

• “Stimulation of the right dorsolateral prefrontal cortex, especially at high frequencies, has been reported to reduce anxiety symptoms in posttraumatic stress disorder and panic disorder…” (Pallanti et al., 2009, International Clinical Psychopharmacology).

• “A clinically significant and sustained improvement of panic symptoms was observed in more than 80% of patients…” Mantovani et al., 2007, Journal of Affective Disorders).

• “High frequency rTMS over the right dorso-lateral prefrontal cortex alleviated anxiety symptoms of PTSD patients.” (Cohen et al., 2004, American Journal of Psychiatry)

• RDLPFC treatments decreased anxiety symptoms by 78% and panic symptoms by 59%, with benefits remaining at one month follow up. (Zwanzger et al., 2002, American Journal of Psychiatry)

Auditory Hallucination Schizophrenia • MindCare Centres has been successful at reducing the number and duration of auditory

hallucinations in patients.

• Treatment for AH schizophrenia consists of a minimum of 15-30 rTMS sessions over a period of 1-3 weeks (weekends off).

• Treatment for AH schizophrenia is a highly targeted treatment and patients are required to wear a marking-cap on which brain mapping takes place.

• “The patient’s auditory hallucinations were greatly improved by 80%... more than 1 year later, [the patient] is not receiving any antipsychotic medication, and her Auditory Hallucination Rating Scale and SAPS scores remain at 0.” (Poulet et al., 2008, American Journal of Psychiatry)

• “The inhibitory effects of 1 Hz rTMS have demonstrated efficacy in reducing intensity of and attentional salience of refractory AH in some studies.” (Standford et al., 2008, International Journal of Neuropsychopharmacology).

• “Compared to sham, active rTMS significantly improved negative symptoms [in schizophrenia], irrespective of change in depressive symptoms.” (Goyal et al., 2007, The Journal of Neuropsychiatry and Clinical Neurosciences)

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Obsessive Compulsive Disorder (OCD) • Neuroimaging studies on OCD patients indicate hyperactivity in a

circuit involving the orbitofrontal cortex and basal ganglia.

• 20-30 slow-frequency rTMS sessions administered over the supplementary motor cortex (SMC) has shown a statistically significant reduction in OCD symptoms.

• “At the second week of treatment, statistically significant reductions were seen…symptom improvement was stable at 3 months follow-up. Slow rTMS [to the SMC] resulted in a significant clinical improvement.” (Mantovani et al., 2005, International Journal of Neuropsychopharmacology)

Parkinson’s Disease • At MindCare Centres, rTMS for Parkinson’s disease has been effective in improving walking, speech and

coordination.

• There are three locations requiring rTMS stimulation: 1) Primary motor areas, associated with left and right hand movement,

are identified by applying single TMS pulses until observing movement in the fingers.

2) The primary area of the motor cortex, associated with lower limb movement, is identified by visually observing movement in the toes.

3) Each treatment consists of rTMS applied for eight minutes to each of the locations.

• Acute treatment for Parkinson’s disease consists of a minimum of 15-40 rTMS sessions administered twice per day, over 2-4 weeks (weekends off). Maintenance treatments will be required on an ongoing basis (typically, 5 treatments every 1-2 months) depending on individual response rate.

• “There was significant improvement in Unified Parkinson's Disease Rating Scale compared with the baseline. Serum dopamine level also was significantly elevated over the same interval. There was a significant correlation between UPDRS and serum dopamine level before and after [rTMS] treatment.” (Khedr et al., 2007, Movement Disorders)

Eating Disorders – Bulimia • For patients suffering from bulimia, rTMS has proven effectiveness in reducing the number of purging

sessions per day in a small sample of patients.

• Treatment for bulimia consists of a minimum of 20-30 rTMS sessions administered to the left Dorso-Lateral Prefrontal Cortex (DLPFC) twice per day, for 2-3 weeks (weekends off).

• “rTMS may represent an alternative strategy for the treatment of eating disorders…rTMS can change feeding behaviors and central neurotransmitters related to the regulation of eating behaviors.” (Tsai, 2005, Medical Hypotheses)

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Migraines • MindCare Centres has been successful at reducing the frequency and duration of migraines in a

small sample of patients.

• For these patients, relief from migraines was accomplished as an additional feature to the treatment protocols for depression.

• Treatment for migraines consists of 10-20 high-frequency rTMS sessions administered over the left

dorso-lateral prefrontal cortex (DLPFC) twice per day, over 1-2 weeks (weekends off).

• “rTMS can change cortical excitability and habituation patterns may be useful in treating migraines.” (Fumal et al., 2006, Cephalalgia)

Tinnitus • Low-frequency rTMS on the left primary auditory cortex is used to treat this hyperexcitability disorder and

reduce or relieve the ringing in the ears. • 15-30 rTMS sessions (2 treatments per day, for 8-15 days) is the minimal requirement to see benefits.

• Treatment for tinnitus is a highly targeted treatment and patients are required to wear a swim-cap on which specific brain mapping takes place.

• “Some patients show a lasting benefit at 1 year after 10 days of rTMS treatment.” (Khedr, 2009, European Journal of Neurology).

• “A significant reduction in tinnitus complaints occurred after rTMS. In the questionnaire, 40% of the

patients improved by five points or more.” (Kleinjung et al., 2007, Otolaryngology-Head and Neck Surgery)

Fibromyalgia and Pain Management

• Treatments for both fibromyalgia and pain management consist of 15-20 slow-frequency rTMS sessions administered over the right dorso-lateral prefrontal cortex, twice per day, for 2 weeks (weekends off).

• “Active rTMS significantly reduced pain and improved several aspects of quality of life (including fatigue, morning tiredness, general activity, walking and sleep)…unilateral rTMS of the motor cortex induces a long-lasting decrease in chronic widespread pain and may therefore constitute an effective alternative analgesic treatment for fibromyalgia.” (Passard et al., 2007, Brain)

• “A significant decrease in temperature for cold detection and pain thresholds and a significant

increase in temperature for heat pain thresholds were evident following a single session of rTMS.” (Johnson et al, 2006, Pain)

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Beck Depression Inventory Scale

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HOW IS RESPONSE TO RTMS ASSESSED?

The standard assessment scales used among the research community for assessing depression and anxiety symptoms are employed at MindCare Centres:

• Hamilton Depression Scale (HAM-D), also referred to as the Hamilton Depression Rating Scale (HDRS)

• Beck Depression Inventory (BDI)

• Hamilton Anxiety Scale (HAM-A) These scales are recognized throughout the medical community as valid and reliable measurement assessments for patients with depression and have been used in numerous studies published on rTMS and depression (e.g., Januel et al., 2005, Zanardini et al., 2006, Garcia-Toro, 2004, Avery et al., 2005, Rossini et al., 2005, Shultz-Rauschenbach, 2005). MindCare Centres also utilizes the following scales when applicable:

• Auditory Hallucinations Rating Scale

• Brief Pain Inventory

• Eating Disorders Checklist

• Parkinson's Disease Quality of Life Questionnaire

• Post Traumatic Stress Disorder Checklist

• Tinnitus Handicap Inventory

• Tinnitus Severity Index

• Yale-Brown Obsessive-Compulsive Scale MindCare Centres' patients complete the applicable assessment scales on the first day of treatment, after 10 treatment sessions, at the beginning and end of each week, including the last day of treatment. The HAM-D interview is conducted on the first day of rTMS treatment, as well as upon completion of treatment. These tools, together with personal feedback from patients, are utilized to assess each patient’s progress throughout the treatment process. ‘Responder’ to rTMS treatment = A patient’s score on the BDI and HAM-D must decrease by at least 50% over the course of treatment (Rossini et al., 2005).

Graph A: A Typical Responder’s Decrease in Scores on the Beck Depression Inventory over the course of rTMS

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N/A

3.1%Non-

Responders

28.7%

Responders(68.2%)

Non-Responders(28.7%)

N/A(3.1%)

Responders*

68.2%

*Response indicated by a decrease of at least 50% in symptoms

RTMS RESPONDER RATE AT MINDCARE CENTRES

ADVANTAGES OF RTMS

• Highly effective (based on results of clinical research) • Few or no side effects • Quick onset of therapeutic effect (typically within 1.5 weeks) • Painless procedure • Non-invasive

• No anesthesia required • Outpatient therapy • You may NOT need to stop taking medication to receive rTMS therapy.

HOW LONG WILL THE BENEFITS LAST?

Acute Therapy

• Typically, results may be achieved within two weeks of beginning rTMS treatment.

• Most patients tend to be aware of therapeutic benefit into the second week of treatment (after 14-20 sessions).

• Late-responders may require additional sessions into a third week to achieve significant reductions in symptoms. The third week of rTMS therapy may extend the period of therapeutic benefit and lengthen the time before maintenance therapy is required.

• During and following your acute therapy, your results will be continuously assessed. Patients will be informed of their progress on the various psychological assessment scales.

Maintenance Therapy

• Patients tend to return for maintenance therapy after approximately 5-12 months. This time frame varies between each patient.

• On average, patients return for maintenance after 9 months to 1 year.

• Maintenance entails half the number of rTMS sessions that were originally completed (typically 1 week of therapy = 10 treatment sessions).

• We encourage patients to contact us immediately if they sense their symptoms are returning. MindCare Centres staff does its best to promptly accommodate needed appointments.

THE PROCEDURE

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How is rTMS administered? Welcome

• From the moment you walk into the clinic, our friendly and highly trained staff will be there for you so that you feel comfortable.

• Your first visit will consist of an initial intake consultation with a MindCare medical physician/psychiatrist who will discuss and confirm that this procedure is right for you.

• We will explain the entire procedure to you, do our best to answer your questions and provide you with a comfortable treatment environment.

rTMS Therapy • rTMS is an outpatient procedure = no hospitalization, no anesthetics (painless) and non-invasive. • rTMS therapy may therefore be administered in a clinical setting by a trained technician under the

supervision of a medical doctor.

• During your treatment session, you will be fully conscious and be able to read a newspaper or magazine.

• The magnetic stimulation is delivered by a figure 8 coil of conducting wire that is encased in plastic and is held directly on the scalp.

• The intensity of the stimulus that will be delivered is determined by inducing a motor-evoked potential (i.e. causing a movement or twitch to occur) in the abductor pollici brevis, or the thumb muscle.

• You may feel a tingling or tapping sensation on your head, or your scalp muscles may feel a little tense, during and a bit after your procedure. This is normal and may result in a minor headache. Most patients describe this as a “mild tapping sensation.”

• You will also be asked to wear earplugs to reduce the noise from the sound of the machine.

Who will be involved in my treatment? A medical practitioner will be involved throughout your rTMS therapy procedure. He/she will complete the pre-procedure consultation, be available during administration of rTMS therapy and be available for questions during treatment. In addition, an rTMS technician will administer rTMS sessions. All doctors and medical technicians working at MindCare Centres have been educated in all aspects of rTMS therapy. While our doctors and rTMS technicians are highly qualified and well-trained, the outcome of your rTMS therapy also depends upon individual factors and how you respond to the treatment. We will work closely with you and your doctor to provide you with a high level of quality care and comprehensive results. We recommend you also consult your own doctor or psychiatrist, who is familiar with your illness, your medical history and will continue to care for you after your treatment. Please note: Patients who are actively suicidal must be accompanied by a trusted family member / friend for the duration of therapy.

How long will the initial medical consultation take? During your initial consultation, a doctor will review your medical and psychiatric history, including discussion of any previous treatments completed and medication history. The initial consultation acts as a second screening device, in addition to the referral form, to ensure that you are a suitable candidate for rTMS therapy. Any patient questions or concerns can be raised at this time. Your initial consultation will take about one hour.

How often will I receive rTMS therapy? Generally, rTMS therapy will consist of two stages of treatment:

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1) Acute therapy involves 20-30 consecutive treatment sessions over a two to three week period. 2) Maintenance therapy may be required once every 5-12 months, depending on your results. A trained medical staff member will discuss this with you and will determine your need for maintenance therapy following your first set of acute treatment sessions.

How long is each rTMS treatment session? A trained MindCare rTMS technician will administer each treatment session. On your first day of treatment, a technician will explain the procedure in detail and inform you of what to expect during your first session. Each rTMS treatment session will last approximately half an hour. During each session, you will be able to discuss your treatment experience and ask questions. A 45-minute break is placed in between each treatment session.

What are the risks? While there are some risks associated with having rTMS therapy, these risks are minimal in most cases. The chance of experiencing a complication or side effect during or after the procedure has been documented to be minimal in a number of clinical studies. A potential side effect of rTMS therapy is a mild headache, resulting from muscle stimulation on the scalp. This is experienced by only 1 in 10 patients. Typically, the headache will pass with a few hours or with a dose of Tylenol. The ear plugs you are asked to wear will minimize the noise during the procedure. These and other risks of the therapy are discussed fully with you prior to the procedure. Proper pre-procedural screening ensures that we proceed with the therapy only when it is medically advisable. Post-procedural follow-up helps to identify and address any potential side effects or complications, as well.

Am I a Candidate?

The best way for you to determine if rTMS is right for you is by discussing with your family doctor, psychiatrist, or another qualified health care professional.

In order to ensure patient safety, the following general requirements will need to be met prior to receiving rTMS therapy: � Currently have a diagnosis by a psychiatrist or physician* (NOTE: a completed MindCare referral form* will be required to be eligible for treatment) � No implanted ferromagnetic items (i.e., pacemaker) � No previous history of epilepsy � No foreign metal cranial bodies or metallic/magnetic implants

Also, in the initial consultation with a MindCare Centres doctor, we will confirm that you are a good candidate, explain the procedure and answer any persisting questions. Proper pre-procedural screening ensures that we proceed with the therapy only when it is medically advisable. Please note: rTMS is not suitable for the treatment of personality disorder / psychosis.

COST

rTMS Treatment Process:

Doctor completes MindCare rTMS referral form for patient

Patient is assessed by MindCare medical doctor/psychiatrist

Patient completes 2 to 3 weeks of rTMS

Patient returns to doctor’s care for ongoing medical advice. Assess

need for maintenance rTMS

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MindCare Centres believes in providing quality patient care and affordability for our patients is important. Although there has been significant research on the use of rTMS as a treatment for depression and the equipment is considered a medical device by Health Canada, this is still a new treatment in the medical community. rTMS is not covered under the provincially insured services. The majority of our treatment protocols cost $250 per session ($5000 for 20 sessions, $7500 for 30 sessions). Secondary treatments are discounted at $100 per session. A course of treatment is estimated at $5,000 to $7,500. Currently the majority of the largest extended insurance providers in Canada will cover this treatment cost on a case-by-case basis (Great West Life, Manulife, Sunlife, Desjardins Financial, etc). As awareness of rTMS among medical providers and medical researchers' increases, MindCare Centres is confident that more insurance providers and Employee Assistance Providers will see this as a cost-effective treatment.

• MindCare Centres is pleased to work with you to apply for extended insurance coverage.

• Financing for rTMS therapy may also be available through: o Medicard: http://medicard.com o Credit Medical Corporation: www.creditmedical.com

Treatment

Primary Treatment Cost Per Session

Min. Sessions Required

Max. Sessions Required

*Secondary Treatment Cost Per Session

Min. Sessions Required

Max. Sessions Required

Auditory Hallucinations $200.00 15 30 $100.00 10 20

Anxiety/PTSD $250.00 20 40 $100.00 5 20

Bulimia Nervosa $200.00 20 30 $100.00 10 20

Depression $250.00 20 40 $100.00 10 20

Fibromyalgia $200.00 15 20 $100.00 10 20

Memory And Cognition $150.00 15 20 $100.00 10 20

Migraines $150.00 10 20 $100.00 10 20

Neuralgia $200.00 20 30 $100.00 10 20

Obsessive Compulsive $200.00 20 30 $100.00 10 20

Pain Management $200.00 20 30 $100.00 10 20

Parkinson's Disease $150.00 15 40 $100.00 10 20

Tinnitus $200.00 15 30 $100.00 10 20

* For patients completing the min-max number of treatment sessions for a primary disease state at standard pricing and a secondary treatment for an alternate disease state, the secondary treatment will be discounted to $100.00/session.

POST-RTMS THERAPY

Shortly after concluding treatment, your referring doctor will receive a comprehensive Physician Report, and you will be provided with a Patient Report. This report will provide:

• A detailed summary of the treatment administered

• Summary of the initial psychiatric consultation conducted at MindCare Centres

• Graphs illustrating changes in assessment scale scores (BDI, HAM-D, etc)

• Patient feedback on treatment process

• rTMS technician notes

• Results to date

You will also be provided with a Patient Take-Home Package, consisting of a Patient Satisfaction Survey and applicable assessment scales. It will be requested that these forms be completed and mailed back to MindCare Centres two weeks following the final treatment.

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Communication with MindCare staff post-treatment is encouraged. Our follow-up procedure will begin two weeks following the last day of rTMS treatment. We encourage you and your doctor to contact us in the interim with any questions or concerns.

WHY MINDCARE CENTRES?

Quality patient care Providing quality patient care is not only our priority but is incorporated into everything we do. From the moment you contact us and during your initial consultation, we will provide you with the information you need to make an informed decision about rTMS therapy. Our doctors and staff are knowledgeable, caring, and enjoy working with you to provide the best possible care. Our quality patient care program also incorporates a sophisticated outcome tracking system so that we may foster an ongoing relationship with you and see your progress from your treatment sessions. Please feel free to contact us and ask questions to learn more about rTMS therapy. Providing patient care on a personalized basis is important, and we enjoy talking to you so that you may become informed about rTMS and the expected outcomes associated with the treatment.

Our clinics We understand that living with mood disorders and receiving treatment may be difficult and this is why we strive to provide you with a pleasant and comfortable treatment environment. The location and layout of our clinics have all been designed with you, our patient, in mind. Our clinics are centrally located so that they are accessible by personal and public transport. The design, layout, and features of our clinic have been specially tailored so that you will feel comfortable and have a pleasant treatment experience.

Our staff Our network of caring and highly trained staff and doctors are dedicated to helping you improve your quality of life and receive a pleasant treatment experience. We feel that the treatment experience is just as important as the treatment itself. Our staff and physicians are approachable, friendly and committed to quality patient care. That is why our Team is one of our most important resources. Our staff will help you plan accommodations near the clinic, assist with transportation routes and offer activities and exercise options to engage in when not in treatment.

Letters from MindCare Centres’ Patients - “Thank you so much for making this whole process so pleasant. Right from the start, I’ve felt welcomed

and comfortable. The professionalism, thoughtfulness, and good humor in this office are amazing. You make a difference!” F.K.

- “I don’t quite know how to thank all of you. Your kindness and patience will always be appreciated. I came here with no hope of life becoming better and you not only provided a service that changed that, but you did it with grace and care. I am forever grateful to you.” K.D.

- “I want to tell you how much I appreciate the kindness, care, and concern that you gave me while I was there. You made me feel so at home that it was hard to leave.” B.N.

- “In all the years of dealing with healthcare staff I have never met such a kind, genuinely caring group. You all went above and beyond so many times to help – I am touched deeply by you all.” L.M.

Scientific Board of Advisors We have also been working closely with our own Scientific Board of Advisors, consisting of leading rTMS researchers and doctors in the world. The advisors on our board keep us informed of the latest findings, developments, treatment practices and techniques regarding rTMS. They also ensure that we employ the best possible treatment practices and provide you with a high level of quality care.

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Currently, our advisors include academics at Harvard Medical School (Boston, MA), The University of British Columbia (Vancouver, BC), and a number of top researchers across North America.

Outcome tracking Your progress and results are important to us and following up with you is an integral part of providing quality patient care. We have employed a sophisticated outcome tracking system using specialized and custom-developed software. This not only allows us to track your results, but it also allows us to optimize your treatment, provide reports and predict your need for maintenance treatment sessions. We ensure patient and record confidentiality throughout the entire process by employing a high-level security software system. The success of rTMS depends largely on how the treatment is administered. We share the same vision of improving your quality of life for each of our patients. Using this outcome tracking system allows us to see how we have measured up to these goals, and it also helps us ensure that you are receiving the best possible care.

READ MORE ABOUT RTMS THERAPY ONLINE

MindCare Centres Visit our website for information and links on depression and repetitive transcranial magnetic stimulation. http://www.mindcarecentres.com National Institute of Mental Health (NIMH) http://patientinfo.nimh.nih.gov

Pubmed.com A service of the U.S. National Library of Medicine that includes over 17 million citations from MEDLINE and other life science journals for biomedical articles back to the 1950s. PubMed includes links to full text articles and other related resources. www.pubmed.com

** Subscribe to the MindCare Alert feature from www.mindcarecentres.com to receive updates and newly released journal/media articles on rTMS therapy directly to your inbox.

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CONTACT US Should you have any further questions about rTMS or MindCare Centres that are not included in this package, please contact us:

MINDCARE CENTRES LOCATIONS

We will be pleased to accommodate you at our various Canadian locations:

MindCare Centre Vancouver, BC Fairmont Medical Building 750 West Broadway, Suite 1116 Vancouver, BC V5Z 1J1 Phone: 604-739-7867 (RTMS) Fax: 604-739-7884 Toll-Free: 1-888-706-7867 (RTMS) MindCare Centre Ottawa Royal Ottawa Mental Health Centre 1145 Carling Avenue, Suite 6451 Ottawa, Ontario K1Z 7K4 Phone: 613-569-7867 (RTMS) Fax: 613-715-5833 Toll-Free: 1-888-726-7867 (RTMS) MindCare Centre Toronto 340 College Street, Suite 405-A Toronto, Ontario M5T 3A9 Phone: 647-344-7867 (RTMS) Fax: 647-259-7869 Toll-Free: 1-888-726-6463 (MIND)

MindCare Centre Montreal 2100 Marlowe Ave, Suite 350 Montreal, Quebec H4A 3L5 Phone: 514-481-7867 (RTMS) Fax: 514-933-6318 Toll-Free: 1-866-3310-3431

**MindCare Centre Waterloo opening in Spring 2010!

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7%

55%

0%

10%

20%

30%

40%

50%

60%

Resp

on

ders

(%

)

Sham Active

Anderson, 2007: Fast rTMS in Depression

Sham

Active

N = 29 Participants

Patients had 3 rTMS treatments a week (4-6 wks)

MINDCARE CENTRES LITERATURE REVIEW

Depression: Title: Daily Left Prefrontal Repetitive Transcranial Magnetic Stimulation in the Acute

Treatment of Major Depression: Clinical Predictors of Outcome in a Multisite, Randomized Controlled Clinical Trial

Author(s): Lisbany SH, Husain MM, Rosenquist PB, Maixner D, Guitierre R, Krystal A, Gilmer W, Marangell LB, Aaron S, Daskalakis ZJ, Canterbury R, Richelson E, Sackeim HA, George MS

Source: Neuropsychopharmacology (2009) 34, 522–534

Results:

-9

-8

-7

-6

-5

-4

-3

-2

-1

0

Change fro

m B

ase

line S

core

Basel ine Week 2 Week4 Week 6

Lisbany, 2009: Fast rTMS in Major Depression

Active TMS

Sham TMS

N = 164 Participants; 1 rTMS tx a day over 4-6 weeks

“Patients described as having one adequate antidepressant treatment trial and a median of four treatment attempts in current episode showed significant reductions in the MADRS at weeks 2, 4, and 6 (p<0.0018, 0.0006, and 0.0063, respectively)”

Title: Adjunctive fast repetitive transcranial magnetic stimulation in depression

Author(s): Anderson IM, Delvai NA, Ashim B, Ashim S, Lewin C, Singh V, Sturman D, and Strickland PL.

Source: British Journal of Psychiatry (2007) 190:533-534

Results: “The procedure was generally well tolerated and more effective than sham treatment (7 vs. 55% responding, P <0.05), with improvement maintained up to 12 weeks.”

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0%

10%

20%

30%

40%

50%

60%

Responders

(%

)

Active Sham Active Sham Active Sham

HAMD24 HAMD17 MADRS

O'Reardon, 2007: rTMS in Major

Depression

N = 301 Participants; 1 rTMS tx a day over 4-6 weeks

0%

10%

20%

30%

40%

50%

60%

Decre

ase in S

core

s (%

)

Panic and

Agoraphobia

Scale

Acute Pain

Inventory

Panic

Symptom

Scale

Zwanzger, 2002: TMS for Panic

10 rTMS treatment over 2 weeks

Title: Efficacy and Safety of Transcranial Magnetic Stimulation in the Acute Treatment of

Major Depression: A Multisite Randomized Controlled Trial

Author(s): O’Reardon JP, Solvason HB, Janicak PG, Sampson S, Isenberg KE, Nahas Z, McDonald WM, Avery D, Fitzgerald PB, Loo C, Demitrack MA, George MS, and Sackeim HA.

Source: Biological Psychiatry (2007) 62:1208–1216

Results: “Response rates were significantly higher with active transcranial magnetic stimulation on all three scales. TMS was effective in treating major depression with minimal side effects reported.”

Anxiety:

Title: Transcranial Magnetic Stimulation for Panic

Author(s): Zwanzger P, Minov C, Ella R, Schüle C, Baghai T, Möller H-J, Rupprecht R, and Padberg F.

Source: American Psychiatric Association (2002) 159:315-316

Results: “After 2 weeks of rTMS, Ms. A reported a marked improvement in her anxiety. At the 4-week follow-up examination, Ms. A’s condition was stable, so she did not require further pharmaco-therapy.”

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10Hz Sham 10Hz Sham 10Hz Sham 10Hz Sham

Ham-D Ham-A PTSD

Scale

PTSD

Checklist

-10%

0%

10%

20%

30%

40%

50%

De

cre

as

e i

n S

co

res

(%

)

10Hz Sham 10Hz Sham 10Hz Sham 10Hz Sham

Ham-D Ham-A PTSD

Scale

PTSD

Checklist

Cohen, 2004: rTMS in Posttraumatic Stress Disorder

N=6 for sham and N=10 for 10Hz tx ; 10 treatments/day for 2 weeks

0

10

20

30

40

Decr

ease

in

Sca

le S

core

s

Baseline After rTMS

Bagati, 2009: rTMS in the treatment of auditory

hallunication schizophrenia

rTMS

Control

N=20 for rTMS treatment and N=20 for control

Post-Traumatic Stress Disorder

Title: Repetitive Transcranial Magnetic Stimulation of the Right Dorsolateral Prefrontal Cortex in Posttraumatic Stress Disorder: A Double-Blind, Placebo-Controlled Study

Author(s): Cohen H, Kaplan Z, Kotler M, Kouperman I, Moisa R, and Grisaru N.

Source: American Journal of Psychiatry (2004) 161:515-524

Results: “This double-blind, controlled trial suggests that in PTSD patients, rTMS over the right dorsolateral prefrontal cortex has greater therapeutic effects than slow-frequency or sham stimulation. PTSD core symptoms (re-experiencing, avoidance) markedly improved with this treatment.”

Auditory Hallucinations Schizophrenia

Title: Effect of augmentatory repetitive transcranial magnetic stimulation on auditory hallucinations in schizophrenia: randomized controlled

Author(s): Bagati D, Nizamie SH, and Prakash R

Source: Australian and New Zealand Journal of Psychiatry (2009) 43(4), 386 - 392

Results: ”There was a significant effect for treatment group in the Auditory Hallucination Rating Scale scores. While there was minimal difference in the control group from baseline, active rTMS corresponded to an 80% improvement of on AHRS scores.”

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0%

10%

20%

30%

40%

50%D

ecre

ase in

Sco

res (

%)

rTMS Sham rTMS Sham

PANSS negative

symptom subscale

Scales for assessment

of negative symptoms

Prikryl, 2007: Treatment of schizophrenia using rTMS

N=11 for rTMS treatment and N=11 for sham

Title: Treatment of negative symptoms of schizophrenia using repetitive transcranial

magnetic stimulation in a double-blind, randomized controlled study

Author(s): Prikryl R, Kasparek T, Skotakova S, Ustohal L, Kucerova H, and Ceskova E.

Source: Schizophrenia Research (2007) 95(1-3):151-157

Results: “During real rTMS treatment a statistic-cally significant decrease of negative symptoms was found. No adverse events occurred during therapy except for mild headaches. Mutual comparison revealed a greater decrease of negative symptoms in favor of real rTMS in contrast to sham rTMS.”

Title: Slow Transcranial Magnetic Stimulation Can Rapidly Reduce Resistant Auditory Hallucinations in Schizophrenia

Author(s): Poulet E, Brunelin J, Bediou B, Bation R, Forgeard L, Dalery J, d’Amato T, and Saoud M.

Source: Biological Psychiatry (2005) 57:188-191

Results: “A [decrease] in the Auditory Hallucination Rating Scale scores after active rTMS was observed with no difference after the sham block. There was a significant effect of rTMS treatment corresponding to a mean improvement of 56% on AHRS scores.”

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0

5

10

15

20

25

30

35

40

Scale

Sco

re

Baseline Week 2 of rTMS

Yale-Brown Obsessive Compulsive Scale

Mantovani, 2005: rTMS in treatment of Obessive

Compulsive Disorder and Tourette's syndrome

N = 7 (5 OCD and 2 OCD/TS patients)

40.0

50.0

60.0

70.0

Resti

ng

Mo

tor

Th

resh

old

Right RMT Left RMT Right RMT Left RMT

Baseline Week 2 of rTMS

Mantovani, 2005: rTMS in treatment of Obessive

Compulsive Disorder and Tourette's syndrome

N = 7 (5 OCD and 2 OCD/TS patients)

Obsessive Compulsive Disorder Title: Repetitive transcranial magnetic stimulation (rTMS) in the treatment of obsessive-

compulsive disorder (OCD) and Tourette's syndrome (TS)

Author(s): Mantovani A, Lisanby SH, Pieraccini F, Ulivelli M, Castrogiovanni P, Rossi S.

Source: International Journal of Neuropsychopharmacology (2006) 9(1):95-100

Results: “Suggestions of clinical improvement were apparent as early as the first-week of rTMS. At the second week of treatment, statistically significant reductions were seen in the Yale-Brown Obsessive-Compulsive Scale (YBOCS). Symptoms improvement was stable at 3 months follow-up.”

“Symptoms improvement was correlated with a significant increase of the right resting motor threshold. Slow rTMS resulted in…a normalization of the right hemisphere hyperexcitability, thereby restoring hemispheric symmetry in motor threshold.”

- 21 -

-14

-12

-10

-8

-6

-4

-2

0

2

Chan

ge in

Sco

res

(%)

Dyskinesia Scores Dystonia Subscores

Filipovic, 2009: rTMS for Dyskinesias treatment in Parkinson's

Disease

rTMS

Sham

Parkinson’s Disease

Title: Repetitive transcranial magnetic stimulation for levodopa-induced dyskinesias in Parkinson’s disease.

Author(s): Filipović SR, Rothwell JC, van de Warrenburg BP, Bhatia K.

Source: Otolaryngology – Head and Neck Surgery (2008) 138: 497-501

Results: ”Comparison with baseline showed a small but significant reduction in dyskinesia severity and dystonia subscores following real rTMS but not sham…the results suggest the existence of residual beneficial clinical aftereffects of consecutive daily applications of low-frequency rTMS on dyskinesias in PD”

Title: Effect of daily repetitive transcranial magnetic stimulation on motor performance in Parkinson's disease

Author(s): Khedr EM, Rothwell JC, Shawky OA, Ahmed MA, Hamdy A.

Source: Movement Disorders (2007) 22(7): 1046-1051

Results:

0

10

20

30

40

Scale

Sco

re

Before After rTMS

Unified Parkinson's Disease

Rating Scale (UPDRS)

Khedr, 2007: rTMS in Parkinson's

Disease

N=20 participants

0

0.1

0.2

0.3

0.4

0.5

0.6

Seru

m level (n

g)

Before After rTMS

Dopamine

Khedr, 2007: rTMS in Parkinson's

Disease

N=20 participants

“There was significant improvement in UPDRS compared with the baseline. Serum dopamine level also was significantly elevated. There was a significant correlation between them before and after treatment. Improved motor performance in PD after… rTMS may be related to an elevation of serum dopamine concentration.”

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Title: Placebo-controlled study of rTMS for the treatment of Parkinson’s Disease

Author(s): Source:

Lomarev MP, Kanchana S, Bara-Jimenez W, Iyer M, Wassermann EM, and Hallett M. Movement Disorders (2006) 21(3): 325-331

Results:

“During the 4 weeks, times for executing walking and complex hand movement tests gradually decreased. rTMS appears to have a cumulative benefit for improving gait, as well as reducing upper limb bradykinesia in PD patients.”

Migraines

Title: Induction of long-lasting changes of visual cortex excitability by five daily sessions of repetitive transcranial magnetic stimulation (rTMS) in healthy volunteers and migraine patients

Author(s): Fumal A, Coppola G, Bohotin V, Gerardy PY, Seidel L, Donneau AF, Vandenheede M, Maertens de Noordhout A, and Schoenen J.

Source: Cephalalgia (2006) 26(2):143-149

Results: “Daily rTMS can induce long-lasting changes in cortical excitability and habituation pattern. If the habitua-tion deficit plays a role in migraine patho-genesis, one might expect that its total or partial alleviation by high-frequency rTMS could have a preventative effect on attacks.”

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Title: Facilitatory effects of 1 Hz rTMS in motor cortex of patients affected by migraine with aura.

Author(s): Brighina F, Piazza A, Vitello G, Akiusui A, Palermo A, Daniele O, and Fierro B.

Source: Journal of the Neurological Sciences (2004) 227: 67– 71

Results:

0

5

10

15

20

25N

um

be

r o

f A

tta

ck

s

Before During

rTMS

After rTMS

Brighina, 2004: rTMS in the treatment of

chronic migraine

Placebo

rTMS

0

5

10

15

20

25

30

35

40

Ab

ort

ive

Me

dic

ine

Before During

rTMS

After rTMS

Brighina, 2004: rTMS in the treatment of

chronic migraine

Placebo

rTMS

“Subjects treated by rTMS (n =6) showed a significant reduction of the outcome measures: attack frequency, number of abortive medications, and headache index (graph not shown here). High-frequency rTMS over left DLPFC was able to ameliorate chronic migraine.”

Eating Disorders – Bulimia

Title: Repetitive transcranial magnetic stimulation: a possible novel therapeutic approach to eating disorders.

Author(s): Tsai SJ.

Source: Med Hypotheses (2005) 65(6):1176-1178

Abstract: The two most common eating disorders, anorexia nervosa and bulimia nervosa, are characterized by aberrant eating patterns and disturbances in body image. Treatment involves combining individual, behavioural, group, and family therapies, possibly with medications. Studies have found that medication, chiefly antidepressants, could be of help in bulimia nervosa but the evidence is weaker for use in anorexia nervosa. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive technique that briefly stimulates or depresses cortical areas within the brain. It has been used in the treatment of various psychiatric disorders, especially major depression, which is a condition that patients with eating disorders often experience as a significant comorbidity. Given that both disorders may share a common pathogenesis, this report proposes that rTMS may represent an alternative strategy for the treatment of eating disorders. Other evidence that supports this notion comes from animal studies that show that rTMS can change feeding behaviours and central neurotransmitters related to the regulation of eating behaviours. Further investigation into the dose, duration and type of rTMS stimulus is needed to verify the efficacy of this intervention in eating disorders.

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0

20

40

60

80

100

Annoya

nce

(%

aw

ake)

Pre 4 mnths 1 year

Khedr, 2009: effect of rTMS on patient's

Tinnitus annoyance

1 Hz rTMS

10 Hz rTMS

25 Hz rTMS

Sham

N = 66 Participant; 10 days of treatment

-15

-10

-5

0

5

Dif

fere

nce

Sco

res

2 weeks 3 months

Kleinburg, 2008: rTMS treatment for Tinnitus

Standard rTMS

Combined rTMS

N = 32 Participants; 10 days of treatment

Tinnitus Title: One-year follow up of patients with chronic tinnitus treated with left temporoparietal

rTMS

Author(s): Khedr EM, Rothwell JC, and El-Atar A.

Source: European Journal of Neurology (2009) 16: 404-408

Results:

0

10

20

30

40

50

60

Scal

e S

core

(/1

00)

Pre 4 mnths 1 year

Khedr, 2009: rTMS effects on Tinnitus over 1

year

1 Hz rTMS

10 Hz rTMS

25 Hz rTMS

Sham

N = 66 Participants; 10 days of treatment

“While sham rTMS had little effect on any parameter, all forms of real rTMS improved tinnitus, and this persisted for the year of follow up…. After 1 year, the tinnitus was absent in one or both ears of 10 patients who had received real rTMS”

Title: Combined temporal and prefrontal transcranial magnetic stimulation for tinnitus

treatment: a pilot study

Author(s): Kleinburg T, Eichhammer P, Landgrebe M, Sand P, Hajak G, Steffens T, Strutz J, and Langguth B.

Source: Otolaryngology – Head and Neck Surgery (2008) 138: 497-501

Results: ” After therapy there was an improvement on Tinnitus Questionnaire scores for both groups, but no differences between groups [low frequency temporal rTMS (standard) or a combination of high-frequency prefrontal and low-frequency temporal rTMS (combined)]…an evaluation after 3 months revealed a continued improvement from the use of combined prefrontal and temporal rTMS tx”.

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0%

10%

20%

30%

40%

50%

60%

70%

Resp

on

ders

(%

)

1 Hz rTMS 10 Hz rTMS

Londero, 2006: Magnetic Stimluation

for Disability Tinnitus

1 Hz rTMS

10 Hz rTMS

N = 13 Participants

0%

10%

20%

30%

40%

50%

60%

70%R

es

po

nd

ers

(%

)

1 Hz rTMS Sham

Rossi, 2007: rTMS on Chronic Tinnitus

1 Hz rTMS

Sham

N = 16 Participants

Title: Effects of repetitive transcranial magnetic stimulation on chronic tinnitus. A randomised, cross over, double blind, placebo-controlled study

Author(s): Rossi S, De Capua A, Ulivelli M, Bartalini S, Falzarano V, Filippone G, and Passero S.

Source: Journal of Neurology, Neurosurgery & Psychiatry (2007) 78(8): 857-63

Results: "Active rTMS induced an overall significant… improvement (35%) of the basal score of subjective tinnitus perception that was independent of either tinnitus laterality or mood or anxiety changes. There were 8 out of 14 (60%) responders.”

Title: Magnetic stimulation of the auditory cortex for disabling tinnitus: preliminary results

Author(s): Londero A, Lefaucheur JP, Malinvaud D, Brugieres P, Peignard P, Nguyen JP, Avan P, Bonfils P.

Source: Presse Med (2006) 35:200-206

Results: “Prolonged low frequency (1 Hz) stimulation was effective in 62.5% of patients… rTMS may be a new non-invasive technique…for patients with disabling tinnitus resistant to all treatment.”

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0

1

2

3

4

5

6

7

8

9

10

Sc

ale

Sc

ore

s (

0 =

no

pa

in)

Start End Start End Start End Start End

A B C D

Subjects

Sampson, 2006: rTMS Reduces Fibromyalgia Pain

N = 4; End = after 4-week rTMS treatment

Fibromyalgia & Pain Management Title: Effects of unilateral repetitive transcranial magnetic stimulation of the motor cortex on

chronic widespread pain in fibromyalgia

Author(s): Passard A, Attal N, Benadhira R, Brasseur L, Saba G, Sichere P, Perrot S, Januel D, and Bouhassira D.

Source: Brain (2007) 130:2661-70

Results:

“Active rTMS significantly reduced pain and improved several aspects of quality of life (including fatigue, morning tiredness, general activity, walking and sleep, P < 0.05) for up to 2 weeks after treatment had ended.”

Title: Slow-frequency rTMS reduces fibromyalgia pain

Author(s): Sampson SM, Rome JD, and Rummans TA.

Source: Pain Medicine (2006) 7(2): 115-118

Abstract: “Pretreatment pain averaged 8.2 (7–9.5) and reduced to 1.5 (0–3.5) after treatment (P<0.009). All had improvement in pain, and two had complete resolution of pain.”

3.0

4.0

5.0

6.0

7.0

8.0

Scale

Score

s (/1

0)

rTMS Sham rTMS Sham rTMSSham rTMS Sham rTMSSham

General

activity

Walking Sleep Faigue

subscale

Rest

subscale

Brief Pian Inventory Fibromyalgia Impact

Questionnaire

Passard, 2007: rTMS on Chronic Pain in Fibromyalgia

N=15 for active rTMS and N=15 sham

Fatigue

subscale

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MINDCARE CENTRES TREATMENT PROCESS

PRE-ARRIVAL: • Submit completed referral form

• Book consultation and appointment times

• Provide $1000 deposit to secure rTMS therapy start date Extended Insurance Claims (CDN Patients): The most effective method to receive coverage is for a patient’s medical doctor or psychiatrist to write a letter to the Insurance provider. If appropriate, this letter should state the mandatory need of rTMS therapy for this patient’s health and must be addressed to the Rehabilitation Department of the Insurance provider. MindCare Centres can provide an official letter confirming the patient’s treatment schedule and costs, answer questions via email or phone and offer a description of rTMS therapy. Extended Insurance Claims (US Patients): Please check with your insurance provider if you have overseas coverage for medical treatment. This differs from travelers insurance as it is for planned medical treatment outside of the USA. If this coverage is part of your plan MindCare can work with your insurance company to deliever any necessary information once your referral form has been received and approved.

STEP ONE: a) First Day of Treatment:

• Tour of the facility

• Complete a Patient Information Questionnaire (contact details, medication history, and emergency contact)

• Review and sign consent forms

• Complete standard assessment scales (Beck’s Depression Index and Hamilton Depression / Anxiety Scales and/or other applicable scales)

b) Pre-treatment Interview: An in-take interview with a MindCare Centre supervising physician to review medical and psychiatric history, including discussion of any previous treatments and medication history.

c) Second Day of Treatment: Patients will be asked to pay the remaining balance towards the cost of treatment.

STEP TWO: Treatment: rTMS treatment sessions will begin on the same day following the physician consult. Treatment is administered by a trained rTMS technician and overseen by a medical doctor.

• The technician will familiarize the patient with the equipment and treatment procedure prior to commencing the first session

• Patients will be provided with a set of earplugs. These will be used to protect against ear sensitivity due to the slightly noisy machine sound

• During treatment, patients are fully conscious and able to read or converse with the technician or traveling acquaintance

- 28 -

STEP THREE: Duration:

• MindCare Centres’ treatment protocol consists of approximately 20-30 rTMS sessions (depends on the disorder being treated)

• We will typically administer 2 sessions per day, Monday to Friday for 10-15 days

• Each session is ~30 minutes in length, with a 45-minute break in between treatments

• Applicable assessment scales are completed at the beginning and end of each week of treatment

• In some cases, 10 extra rTMS sessions is recommended for late responders. This need will be assessed on an individual basis by trained medical staff. We strongly encourage patients to keep a third week free for additional treatment sessions.

STEP FOUR: Communication: Patients can discuss freely any concerns and ask questions as they arise. We encourage patients to keep us informed as to how we can help make the treatment experience as comfortable as possible. We are pleased to speak with a patient’s referring doctor throughout the process.

STEP FIVE: Last Day of Treatment: Patients will complete the standard assessment scales. They will be provided with:

• Patient Take-Home Package, consisting of a Patient Satisfaction Survey, Mood Tracker, and applicable assessment scales. We request that these forms be completed and mailed back to MindCare Centres 2 weeks following the final treatment.

• Patient Report. This report will provide a detailed summary of the treatment received, assessment scale scores and results to date. This will be mailed to the patient’s home shortly after treatment concludes. A detailed Physician Report will also be mailed to the patient’s referring doctor.

STEP SIX: Follow-up: The MindCare Centres Team cares about our patients’ progress following treatment. It is our priority to keep in contact with patients and we encourage them to do the same. Regular follow-up via telephone and/or email will be maintained. Patients can expect to hear from us at 2 weeks, 1 month, 3 months, 6 months and 1 year following the final rTMS treatment.

STEP SEVEN: Maintenance: Maintenance treatment will typically consist of half the number of treatments received for acute therapy. On average, patients return for maintenance therapy after 9-12 months. This will vary from patient to patient. If a patient feels as though he/she are “slipping” and require maintenance sessions, we encourage him/her to contact us immediately.

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PATIENT TESTIMONIALS

Depression

“I lived in black and white for ten years with bipolar depression. rTMS has changed my mind, body, and spirit and I now see in color. My life has just started.” NQ, Vancouver “My rTMS treatment at the MindCare Centre was very successful. The depression is gone. My tests also indicate that I’m in remission from depression. I feel MUCH better. The rTMS treatment worked MUCH better than any medication I have ever tried. The staff at the Centre is superb and very supportive. I would not hesitate to send a family member or a friend to the MindCare Centre.” EO, California “Since November 2000 I have suffered from severe depression. I took all different kinds of medicine for several years (Paxil, Celexa, Lexapro, Effexor XR, to name a few), but nothing worked very well. I was frequently suicidal and twice voluntarily committed myself to institutions. That was not successful either. I decided to try rTMS as my options were getting pretty narrow. I was definitely skeptical about this option. Mid-second week of treatment, however, my perspective changed. My mood started lifting. Over the next few days I had ups and downs, but by the end of the second week I felt a lot better. I have had no memory loss, seizures, or anything of the sort. I can wholeheartedly recommend the procedure for anyone who feels hopeless and is suffering from severe depression. Yes, it really works.” AB, Costa Rica “I have a 25 year history of depression. I became refractory to medication 5 years ago and my life began to slide out of control. My physician heard of rTMS and suggested that I try it. I did not qualify for a local research study so I went to MindCare Centres in Vancouver: I felt an improvement within two weeks. I have my life, my business and my family back.” CH, Washington “After receiving just 2 weeks of rTMS therapy from MindCare Centres, my mood continues to be more stable than any other time I can remember, post June 1987. I am pleased every morning to awaken with the same sense of well being that I had when I went to sleep.” DY, Nova Scotia “My experience with the MindCare Centre in Canada was a very positive experience indeed. I was born with a severe depressive state, in other words with a chemical imbalance which propelled me into a depressive state lasting anywhere from a few hours to several months at a time. At 18, and in my first Ph.D. studies in Columbia, my depressive state was lasting 7 months at a time. In my late 40’s, and in my second Ph.D. study at Walden, my depressive state was lasting 18 to 25 months at a time. All this time I was seeing a series of psychiatrists, whom suggested anywhere from environmental change to radical lobotomy. Many of the doctors I have seen have suggested a regimented form of medication. The variety of medications prescribed was somewhat able to control my depression to a state where I could start enjoying life and experiencing some of the things normal people do. Though this did come with a price tag which ranged anywhere from $1,200 to $1,840 a month, not including the physician’s monthly fee of $180.00 a month. My doctor said he had heard many good things about coming out of Vancouver, and had read several articles written by a noted researcher and respected psychiatrist, who heads up the research facility there. I was indeed very impressed with the facilities in Canada, and my first consultation with the psychiatrist, who assured me the procedure would be painless. He said the treatment was a bit noisy at first, yet the end result would be beneficial. He went on to say “In

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rTMS, a magnetic coil is placed on the scalp to create fields that induce mild electric currents in the brain. Much as a defibrillator shocks a heart into beating regularly, the magnetic pulses may jolt nerve cells into functioning more regularly. In clinical trials, many patients who failed to respond to several other treatments improved within a week of rTMS treatment, and the vast majority were significantly better after two weeks of daily 20-minute sessions. Repetitive transcranial magnetic stimulation (rTMS) has been found to exert modest to substantial antidepressant effects in the majority of clinical studies. After about three sessions, I began to notice significant changes in my mood, outlook in life and had a positive feeling about my future, which is something I hadn’t experienced in all my years (52). MindCare Centres’ staff consists of professionals in the field of rTMS, most with advanced degrees and all with the willingness to help or make ones stay in Canada as comfortable as possible. My stay was three weeks, and as a busy professional senior scientist, I didn’t think I would stay the duration, though I am very happy I did. And indeed, after a few weeks of my treatment, I was DEPRESSION FREE! I had never experienced a day without depression, until I visited MindCare Centres. Depression free and medication free for the first time since I was young, all I can say is with all the money I had spent in the past for depression, the small amount of money I did spend for my treatment and stay in Canada, was well worth my time – my only question is why didn’t someone didn’t invent rTMS sooner?” NH, Washington, June 19, 2008

Anxiety

“I suffered from anxiety for years. I found myself worrying about little day to day events to such an extent that I was unable to face the larger challenges. After doing an extensive review of the academic literature, I decided to try rTMS. I am now better able to deal with the small scale events that present themselves on a daily basis, which allows me to work through some of the larger challenges in my life. My illness no longer controls me – I control it.” KJ, Florida

Parkinson’s Disease

“I was way over the maximum dosage of my medication for Parkinson’s disease and my doctor had run out of ideas. After one treatment of rTMS I felt my muscles were more relaxed, my mobility increased, and my speech improved. I am committed to continue with treatments to maintain these positive effects.” SS, Seattle

Auditory Hallucination Schizophrenia

“I completed 15 rTMS treatments for Auditory Hallucination Schizophrenia over a three week period. It has now been two and a half months since completing the treatments and I am almost totally rid of my auditory hallucinations.” FS, Victoria

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Obsessive-Compulsive Disorder

“After trying a number of different medications and attending therapy for almost three years, I decided to try another treatment option for my obsessive-compulsive disorder. I completed 2 rTMS treatments a day, for two weeks and it significantly reduced my obsessions. I am now much better able to cope with my compulsions and feel like I have more control over my illness.” AP, Illinois

Chronic Migraines

“I suffered from debilitating migraines for many years. I exhausted all medical options. On the fourth day of the two-week rTMS treatment I noticed a decrease in my migraine frequency. Now it has been two months since I received treatment and I am still migraine-free! I wholeheartedly recommend this treatment to anyone suffering from migraines.” TD, Vancouver “I suffered from depression, as well as severe migraines for years. Although I started rTMS treatments as a treatment modality for my depression, early on in treatment, I noticed that my migraines were becoming more like headaches. On the four day of treatment, I didn’t even have a headache. This pattern persisted, and now I rarely take the ‘as needed’ medication that I used to be very reliant on.” LJ, California

Tinnitus

“Working in construction, I was readily exposed to loud machinery. I developed Tinnitus as a result of this. I had difficulty falling asleep nightly because of the ringing in my ears and was often unable to concentrate due to this sound. Now it has been 6 months since rTMS, and I am able to sleep through the night and maintain my concentration a lot better.” PJ, Boston

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PREPAYMENT / CANCELLATION POLICY

Thank you for choosing rTMS therapy as your treatment modality. Upon booking treatments, via phone or in person, a credit card payment for the deposit will be collected. As a precaution to cancellations without notice, we request a deposit of $1000.00 in advance, for a minimum booking of 20-sessions of rTMS therapy. The full $1000.00 deposit will go towards the remaining cost of treatment. This deposit will only be refundable if appointments are cancelled with at least one week’s notice (5 business days), or due to extenuating circumstances at the discretion of our clinic. Should you cancel the treatment or miss an appointment without one week’s notice (5 business days) for any reason, a portion of the deposit will be forfeited. The forfeited amount of deposit will be $500.00 for a late cancellation or missed appointment, due to non-refundable physician fees and appointment slots. By the second day of treatments, each patient’s tolerance of rTMS therapy will be known; therefore, any cancellations beyond this second day of treatment must be due to extenuating circumstances as determined by MindCare staff. This process allows us to secure your appointments and avoid any scheduling problems that may interfere with your treatment plans. Prior to commencing rTMS treatment, each patient has a one hour consultation with the in-house psychiatrist/ medical doctor. The cost of this consultation is $250.00. This consultation fee is included in your $1000.00 deposit. If you have the consultation and then you decide to not pursue rTMS treatment, $500.00 of the deposit is forfeited. If the doctor completing the consultation determines treatment should not be pursued the deposit, minus the consultation fee, will be refunded. In extenuating circumstances, as determined by MindCare Centres, the treatment start date may be postponed without penalty. MindCare Centres will hold the deposit for up to six months from the original treatment or rTMS consultation start date. Once this time has passed, the deposit has expired and MindCare Centres will not provide any refund from the deposit. We are happy to discuss this further with you to address any questions. Your opinions and comments are valuable to us. Sincerely, MindCare Centres

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PATIENT REFERRAL □ Psychiatric Assessment □ rTMS Therapy □ Disease State(s):

PATIENT SCREENING INFORMATION (In order to avoid time delays, please ensure the following questions have been completed with the patient).

YES NO □ □ 1. Has the patient ever been a grinder, metal worker or welder? □ □ 2. Has the patient EVER had a metal foreign body in their eye?

If yes, please provide an orbital x-ray report prior to appt. □ □ 3. Is there a chance the patient may be pregnant? Indicate date of last menstrual period .

4. Does the patient have any of the following? □ □ Cardiac pacemaker □ □ Aneurysm clip □ □ Neurostimulator □ □ Coclear implants □ □ Other implanted device(s) or metallic objects in body □ □ 5. Does the patient or any first degree relative have idiopathic epilepsy? □ □ 6. Does the patient suffer from significant cardiac disease? □ □ 7. Is there any history of either alcohol or drug abuse? □ □ 8. Has the patient made any suicide attempts or is patient currently suicidal? If yes, please indicate when and provide any notes available. □ □ 9. Does the patient have any infectious diseases? □ □ 10. Does the patient have a personality disorder? If the patient has answered YES to any of these questions, the doctor’s office should call MindCare Centres before submitting this requisition. Thank you

MindCare Centre Headquarters □ Vancouver Fax: 604.739.7884 Healthy Minds. Better Lives. ™

750 West Broadway, Suite 1116 □ Toronto Fax: 647.259.7869

Vancouver, BC V5Z 1J1 □ Ottawa Fax: 613.715.5833

Phone: 604.739.RTMS (7867) □ Montreal Fax: 514.933.6318 Toll Free: 1.888.706. RTMS (7867) Web: www.mindcarecentres.com

CLINICAL HISTORY

MEDICATION/DOSAGE □ tricyclics □ buproprion

ALLERGIES

Signature Date

Patient Name Care Taker Address City Prov/State Postal/Zip Country Tel ( ) DOB Sex YYYY/MM/DD

Doctor Name Address City Prov/State Postal/Zip Country Tel ( ) Fax ( ) Email