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Transcranial Magnetic Stimulation for Autism

by Steven Novella, Jul 01 2013

A clinic known as the Brain Treatment Center (BTC) is offering what they call Magnetic Resonance Therapy, or MRT™, as a treatment for autism and other disorders, including sleep disorders, schizophrenia, Alzheimer’s disease, emotional disorders, anxiety, addiction, and for athletic performance.

MRT (always be suspicious of a medical treatment that is trademarked) consists of transcranial magnetic stimulation along with other modalities:

…EEG, brain stimulation, Neurofeedback, EKG and other biometric techniques to provide a highly customized treatment personalized to how a patient’s brain takes in, processes, and communicates information.

I will discuss both the use of transcranial magnetic stimulation (TMS) for autism, and the specific claims made by BTC, starting with the latter.

BTC

The website for BTC has many signs of a dubious clinic, and offers an excellent example of the red flags that any prospective patient should watch out for when seeking treatment. I have already mentioned one – trademarking the name of a therapy, which they claim is unique to their clinic.

This is similar to the issue of patenting a medical use or technique. Medical use patents are generally considered unethical and counterproductive in the medical community, and are illegal in many countries, although still legal in the US.

Medical knowledge and treatments are, or at least should be, “open source” (as with scientific knowledge generally). The attempt to present a clinic’s or practitioner’s treatment as unique or special is a marketing ploy, but betrays a misunderstanding of the nature of medical knowledge. Advances in medicine need to be peer reviewed, examined by the community, and replicated. By definition there is no such thing as a “unique” and simultaneously legitimate treatment.

They actually write: “With our unique knowledge of neuroscience.” How did they manage to come by this unique knowledge? The very concept is anathema to science.

The BTC website also declares:

The Brain Treatment Center offers a unique science-based approach to the treatment of autism spectrum disorder (ASD). This therapy addresses core underlying issues that contribute to behavioral and cognitive symptoms pervasive to autism spectrum disorder (ASD). It is our belief that every patient should receive personalized attention with all therapies and procedures. With our unique knowledge of neuroscience, Brain Treatment Center integrates an array of therapies and technologies to pioneer a new treatment to autism.

I don’t think they use the term “science-based” the same way that we at science-based medicine do. In addition to calling their treatment unique, there are some other red flags in the above paragraph. They claim to address underlying causes, as if that is somehow also unique to them. That is a common claim of so-called “alternative medicine” proponents – combining the unfair claim that mainstream medicine does not address underlying causes when possible with the claim that their special treatment does.

Another red flag is the claim that their treatment is “personalized.” This is another huge marketing ploy common in fringe clinics. Mainstream medicine already does personalize treatment, as much as possible, when our knowledge and the evidence supports specific personalizing factors. The question is – is BTC “personalizing” their treatments in an evidence-based fashion, or is this just marketing? Is there personalization superficial and for show, or does it actually improve outcomes? There is no evidence on their site, references to such evidence, or anything published I can find to support these claims.

Finally, they promote their treatment with video testimonials. The use of testimonials (rather than published evidence) to promote the efficacy of treatments I consider to be dubious and unethical. Testimonials are by definition anecdotal evidence. They tend to be misleading, because they are not controlled and systematic. A legitimate clinic should use published rigorous studies to support their treatments, not testimonials.

It’s OK to use testimonials to promote the quality of service provided by a doctor or clinic – our staff are friendly, we have convenient parking, short wait times, etc. – but not the treatments themselves.

The BTC website has this disclaimer on their testimonials page:

The opinions and views represented in these videos are not necessarily those of Brain Treatment Center.

This betrays one of the reason for using testimonials – they allow a person or clinic to imply medical claims without making the claims directly themselves. The disclaimer is the cherry on top – we don’t necessarily stand by these claims, but here they are. This is similar to, “results not typical,” or “your mileage may vary.”

TMS for Autism

Transcranial magnetic stimulation is a legitimate, cutting edge treatment modality. Is uses low-powered magnetic fields to alter the firing of neurons in one part of the brain, and can be tuned to a specific brain region and to either increase or decrease activity. It is very useful in research for identifying the neuroanatomical correlates of brain function. As a treatment modality, however, it is very new and existing research is therefore scant.

The best researched indication for TMS is depression. Other brain stimulation treatments, like electroconvulsive therapy, are well established. TMS is new, and the research so far shows promise but is insufficient to conclude that it definitely works. Existing research shows a statistically significant positive effect, but is limited by small effect size and lack or rigorous methodology – and this is the best current case for therapeutic use of TMS.

There are many other possible indications being investigated: migraine, Parkinson’s disease, insomnia, tinnitus, and others. However, none have been adequately researched to establish TMS as clearly effective.

The same is true of autism – there are some preliminary reports, but nothing compelling. In an interview for NOVA, TMS expert Mark George gave this summary:

There have been only a few small studies with TMS in autism, with inconclusive results. We really do not know which part of the brain is not working in autism, or how it is not working. We do not have the roadmap yet to know how to even think about using TMS to treat it. More research is needed, and maybe someday…

Not only is there insufficient evidence to conclude that TMS works for autism, we haven’t even done enough basic research to design an adequate treatment. TMS is not one treatment – it is a treatment approach. You need to know what frequencies to use on which part of the brain in order to apply the treatment effectively.

How does BTC deal with this lack of knowledge? They appear to just make it up. They give low level “subthreshold” TMS to the whole brain. They are not even properly using TMS.

Conclusion

TMS is an exciting research tool, and a potential new treatment modality for a variety of neurological conditions. However, a great deal of research needs to be done before it can be established as an accepted safe and effective treatment. So far there is only one indication for which TMS is close to being an accepted treatment, depression, and that is controversial.

TMS is not a scientifically established treatment for autism. This is a possible future application, but much more research needs to be done.

There is a tendency, however, for some dubious clinics to latch onto emerging therapies and then offer them to their patients for a long list of indications, supported only by preliminary evidence and testimonials. They can easily make themselves sound scientific, and cloak their clinic in the trappings of cutting edge science, but this is ultimately a deception – little more than clever marketing.

This is harmful on many levels, not least of which it may taint with pseudoscience a potential emerging therapy.

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7 Responses to “Transcranial Magnetic Stimulation for Autism”

  1. Stephen H says:

    As someone who was diagnosed several years ago (well and truly as an adult) with Asperger’s*, the very idea of “treatment” horrifies me. Manage some of the more difficult aspects of it, sure. I have drugs to help me manage anxiety, and I need to speak to someone about ADHD, but “treating” it? Asperger’s is part of who I am. While there are some problems associated with it (I am vaguely aware of the concept of “friends”, and more aware of my lack thereof), there are also some benefits. And changing who I am by “treating” me would terrify me.

    Caveat: there are other autism sufferers who have more problems than I: nevertheless, autistic spectrum disorders (with the emphasis on spectrum) have benefits as well as costs, and the patient needs to be involved in any decisions about “treatment”.

    *Oops, I forgot – Asperger’s no longer exists, as the contributors to DSM IV couldn’t figure out how to separate it from “normal” autism.

  2. Michael Forbes Wilcox says:

    Excellent caveats. I have participated, as a subject, in many research studies that have used TMS. I am happy to lend my autistic brain to science.

    I am convinced that TMS is a very useful research tool, and I’ve learned a lot about brain functioning in my conversations with the researchers. I believe TMS has a lot more promise as a possible diagnostic tool than as a treatment, although I wouldn’t rule that out.

    In particular, TMS seems to be an excellent way to measure brain plasticity, and extreme plasticity may prove to be one of the more quantifiable measures of autism. I (and several other subjects) have experienced startling (temporary) changes in the functioning of Broca’s area. The researchers were able to measure this change, but to me the more interesting part of the experiment was the subjective experience of the subjects.

    Getting some insight into what is possible (e.g. clearly seeing emotional content in written sentences or short video clips, where what was detected before was done with great difficulty and imprecision) gives one the ability to figure out how to reproduce that, using CBT or other mindfulness techniques.

    But I’m very doubtful that TMS alone could produce permanent changes of the magnitude we experienced. Nor would that necessarily be desirable. Autism, after all, is not something that needs to be “treated” — it is a different way of being in the world. Sometimes that is an advantage, sometimes not, but my goal is not to become someone I am not. Rather, I would like to figure out how to acquire skills that do not come easily, and make other adjustments in my behavior and perceptions that I find beneficial.

    So, yes, I think TMS could play a role in a therapeutic setting, but it will never be part of a “cure” — nor is that (whatever that means) an outcome that I would want. Nor do most autistic people I know. We’re just fine, thanks very much for asking.

  3. Michael Forbes Wilcox says:

    After leaving the above comment, I wrote this post:

    http://www.mfw.us/blog/2013/07/02/caveat-emptor-tms-as-snake-oil/

  4. Cari says:

    Great article. It is important for parents of children with autism to look beyond the marketing and studies completed by the developers of the ‘treatment’ and look for therapies/ treatments that have had studies done by their peers with positive results.

    http://www.NationalAutismNetwork.com has provided many resources on various treatments and therapies for autism spectrum disorder and which are shown to be effective vs. ineffective.

  5. Phea says:

    Thank you for a very informative dissection and explanation of the slick techniques savvy conmen use to snare the many gullible, and often desperate people out there. The more a deception is debunked and exposed, the less likely people will be sucked in and “wooed” by it. I linked this article to the skeptic subreddit on reddit. You do a great job of explaining things without talking way over the head of a layperson, while not talking down to them either. You have a real knack for hitting that middle ground. Thanks again, Dr Novella.

  6. Gustav says:

    Thank you for this excellent article. I have passed on the link for my nephew and his wife who are desperately seeking a cure for their son with Aspergers.

    I have also passed on the link to Michael Forbes Wilcox’s blog so they can learn that Asperger’s [or whatever they are going to call it from now on] is not a handicap — it is a different way of being in the world.

    Thank you both

  7. Bill L. said says:

    http://www.ncbi.nlm.nih.gov/pubmed/22311204

    Prefrontal neuromodulation using rTMS improves error monitoring and correction function in autism.
    Sokhadze EM, Baruth JM, Sears L, Sokhadze GE, El-Baz AS, Casanova MF.
    Source
    Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, KY 40202, USA. tato.sokhadze@louisville.edu
    Abstract
    One important executive function known to be compromised in autism spectrum disorder (ASD) is related to response error monitoring and post-error response correction. Several reports indicate that children with ASD show reduced error processing and deficient behavioral correction after an error is committed. Error sensitivity can be readily examined by measuring event-related potentials (ERP) associated with responses to errors, the fronto-central error-related negativity (ERN), and the error-related positivity (Pe). The goal of our study was to investigate whether reaction time (RT), error rate, post-error RT change, ERN, and Pe will show positive changes following 12-week long slow frequency repetitive TMS (rTMS) over dorsolateral prefrontal cortex (DLPFC) in high functioning children with ASD. We hypothesized that 12 sessions of 1 Hz rTMS bilaterally applied over the DLPFC will result in improvements reflected in both behavioral and ERP measures. Participants were randomly assigned to either active rTMS treatment or wait-list (WTL) groups. Baseline and post-TMS/or WTL EEG was collected using 128 channel EEG system. The task involved the recognition of a specific illusory shape, in this case a square or triangle, created by three or four inducer disks. ERN in TMS treatment group became significantly more negative. The number of omission errors decreased post-TMS. The RT did not change, but post-error RT became slower. There were no changes in RT, error rate, post-error RT slowing, nor in ERN/Pe measures in the wait-list group. Our results show significant post-TMS differences in the response-locked ERP such as ERN, as well as behavioral response monitoring measures indicative of improved error monitoring and correction function. The ERN and Pe, along with behavioral performance measures, can be used as functional outcome measures to assess the effectiveness of neuromodulation (e.g., rTMS) in children with autism and thus may have important practical implications.

    I am a scientist who believes in oversight, generating statistically significant peer reviewed data.  My advise when you hear someone bashing someones hard work, you might want to google National Institutes of Health web site.  This is not run by profiteers and naysayers, it’s peer reviewed studies conducting under FDA guidelines.  

    As far as I have seen TMS not only work to reverse depression, it also sadistically significant learning and social abilities of Autistic children.  Neuro-modulation is not a new idea, but the technology is, the problem is there are only a few clinicians who have detailed enough information to effectively use it in a clinical setting.  The power uses, the pulse cycling, the duration and number of treatment cycles.  When a new treatment is introduced, there are natural fans and detractors. For me that’s just fine, it’s the way good science is conducted.  But this person said there were dubious claims, well this and about 29 other independent study gives us a clear non-opinion, non-sales-hype data to make adult choices.  

    I recommend that anyone looking for a new treatments go to NIH web site called NCBI, search the potential new treatment. Enroll in clinical trails listed in the site or parallel site.  Don’t let people take away your hope, only believe in peer reviewed scientifically validated data.  When I called BTC for addiction treatment, they were honest with me.  Said 73% of patients were drug free 30 days, but only 20% were 10 years after treatment.  Since there has been no data on maintenance treatment, they did not offer it.  I also understand they just purchased 16 new TMS instruments to vastly increase treatment offering.  I am a scientist and a parent, I don’t listed to white noise on either side.