The US military is honing a crack team of super humans by turbo boosting their brains with neuro-stimulation technology.

Somewhere in covert quarters, behind ‘restricted access’ signs, a cognitive enhancement programme is said to be underway.

Volunteers, including Navy Seals, are reportedly being tested in various ways to extend peak performance of key tasks from minutes to 20 hours.

Like the rise of drugs which supposedly propel creativity and thinking speed, cognitive enhancement technology has red sci-fi imaginings into the real world.

At the heart of the revolution is Transcranial Magnetic Stimulation (TMS). The field is not new but its development has accelerated at break neck pace in recent years.

As a result, it promises a new dawn of treatments for stroke and brain and spinal injury patients.

“I honestly feel the potential of TMS is absolutely limitless,” says Faraz Jeddi, a neuro-rehab consultant at the Royal Berkshire Hospital.

“Although it’s been around for years, amazing possibilities have just started arising.”

Jeddi is more than a keen observer of this new age of TMS.

Having acquired TMS equipment, he is looking to build teams to further investigate links between the technology and functional recovery after stroke and severe injuries.

Currently TMS is grounded in depression and chronic pain treatment, while also used in diagnostics. The exciting potential that enthuses Jeddi is in the recovery of specific motor functions, to the “ultimate goal” of restoring the ability to walk after paralysis.

“Scientists around the world are asking where
the limit is. Trials of TMS to restore functions of limbs are already happening. The implications for stroke and brain injury could be massive.”

TMS is a non-invasive procedure, using magnets held against the scalp to induce electric fields inside the brain, effectively switching on neurones.

It is usually delivered by a contraption akin to a dentist’s chair, although work to develop smaller, less cumbersome devices is progressing. Its value as a treatment for depression is well evidenced, and is becoming increasingly established within healthcare.

In June this year, doctors at the Semel Institute for Neuroscience and Human Behavior at UCLA, spoke out about the underselling of TMS as an alternative for depression in cases where medication hadn’t worked.

The number of people with reported depression has increased by 18 per cent since 2005, the World Health Organisation says.

Meanwhile, US authorities believe antidepressants work in only 60 to 70 per cent of people who take them. TMS could therefore help fill a gap.

“There are new TMS devices recently approved by the FDA that will allow patients to achieve the benefits of the treatment in a much shorter period of time,” said UCLA’s Andrew Leuchter after the installation of new TMS technology
at the world-renowned hospital.

“For some patients, we will have the ability to decrease the length of a treatment session from 37.5 minutes down to three minutes, and to complete a whole course of TMS in two weeks.”

In the UK, a handful of private providers offer TMS for depression, while some NHS trusts are considering introducing it; with Northampton reported to be its only adopter so far.

Jeddi says: “I don’t know why TMS is not being used to treat depression in the NHS more widely. In the private sector, they are using it for a whole range of conditions, including tinnitus and general pain management.”

According to Dr Alex O’Neill-Kerr from the
 Royal College of Psychiatrists, around 30 per cent of depressed patients who have TMS treatment face no symptoms of depression afterwards, while others say depressive symptoms are significantly reduced.

Several research studies also show that repetitive TMS can control neuropathic pain and fibromyalgia (a condition characterised by pain throughout the body).

One study by neuroscientists at the US university of Stanford found that pain was reduced by as much as 50 per cent after a daily dose of TMS for four weeks.

TMS in action in the US

TMS in action in the US

Further studies report 30 to 40 per cent reductions. As yet, however, official guidelines supporting TMS are limited. NICE says TMS for depression shows no major safety concerns, while the evidence on its efficacy in the short term is adequate, although the clinical response is variable.

“Repetitive TMS for depression may be
used with normal arrangements for clinical governance and audit,” it states.

The Food and Drug Administration (FDA) has issued similar guidelines in the US, where TMS usage is significantly more widespread than in the UK.
Healthcare body Cochrane – which scrutinises the case for treatments and therapies – reflects these conclusions in various papers.

Its report suggest there is insufficient evidence for TMS as a treatment for motor neurone disease (2013) and epileptic seizure reduction (2016).

Its 2002 review into TMS and depression said there was no strong evidence but also that small sample sizes did not exclude the possibility of benefit. Given developments in the years since, a new review is likely to be published soon.

Jeddi says: “I don’t see anything holding back TMS in the UK except a lack of research. Unlike anywhere else, practice follows evidence from absolutely robust research.

“It’s going to take time for that to mature but once it does I’m convinced the UK will lead the way with this technology. More and more people are getting involved and I even know of a few psychiatrists who have left their profession to focus solely on TMS.

“It is gathering pace and there are people here who are extremely motivated to prove what it can do.”

In terms of stroke treatment, TMS offers lots of potential but more research is also needed here.

One theory, currently being investigated by the University of Cincinnati, involves using TMS to reduce activity on a stroke patient’s non-injured side of the brain to give the injured side a better chance of recovery.

TMS also seems to be a promising intervention to reduce spasticity in patients with MS, stroke, cerebral palsy and spinal cord injury.

As noted in a 2014 report (Gunduz, Kumru and Pascual-Leone), clinical applicability needs to be confirmed in well-designed trials with bigger sample size and longer-term follow-up.

Even with more evidence from such research, the price of implementing TMS might also be a stumbling block to widespread usage in the NHS.

TMS systems currently cost £120,000 to £150,000, with further investment required in training or taking on specialist personnel to operate it.
In these stringent times, few NHS trusts are likely to have even this relatively modest amount spare on the budget sheet.

Yet the potential value in reducing the amount of care provision, drugs and equipment needed by patients could vastly outweigh upfront overheads, Jeddi believes.

“If you enable a person to go back to working life or to walk again and do things independently, there is no match to the value of that. We may see TMS increasingly replacing drug use, in depression for example, but I expect that TMS could be used complementarily with medication.”

The ancestry of TMS can be traced back to the 1700s when experiments by Volta and Galvani revealed that nerves were electrical conductors rather than water pipes, as previously thought.

Michael Faraday kicked things on in 1831 when he enlightened the world on the possibilities of electromagnetic induction.

Then came the technology’s modern architect, Yorkshire physicist Anthony Barker, whose lengthy research led to the 1985 demonstration of a twitching hand through TMS.

The therapy was applied to the motor cortex in the opposite hemisphere that controls movement of particular hand muscles.

This proved that precise parts of the brain could be targeted without painful electrical stimulation. It was all the more impressive given that it had been carried out in awake, human volunteers.

After that, TMS gradually became
widely used as a brain mapping tool by neurosurgeons. Its rise as a therapeutic tool began around a decade ago.

As the technology continues to develop, lingering questions remain unanswered. One area of concern is the safety of TMS
for certain patients.

“There are limitations to patient selection,” says Jeddi. “If you su er from uncontrollable epileptic seizures, or have a pacemaker, TMS machines may not be suitable.

“But the stimulus of TMS is very mild compared to an MRI magnet and the incidence of seizures
is very low. Safety will increase as the technology improves.

“We are already using seventh generation machines and improvements have continually been made. It has evolved at a phenomenal rate in the last five years and could well be standard practice very soon.”

Questions must also be answered about
the threat of any long-term effects, and the longevity of positive results.

TMS also has an identity problem, in that in some sceptical minds, it incites images of electric shock treatment, perhaps in some 1960s asylum. This will dissipate as research grows, says Jeddi.

“We are trained to always go for the evidence and that is in the making, so it’s only a matter of time before these views change.”

As well as doctors like Jeddi, who are passionate champions of TMS, equipment makers will also have a big hand to play in spreading its usage.

The neuromodulation devices market –
of which TMS systems are a major part – is on track to almost double in value from 2015 to 2020 to £4.8bn.

Rising geriatric populations around the world and increased prevalence of neurological diseases are cited as key growth drivers.

A lack of trained staff is listed as a hindering factor.

If TMS can live up to expectations, reducing drug dependence, transforming lives and slashing required care resources, there will be no shortage of neuro-rehab professionals keen to get trained up on the technology, however.