An email from Michelle Pearson at the NIH (because I had signed up for the online version of the workshop) alerted me today to a trove of TES (Transcranial Electric Stimulation) info being made available to us. Presenter slides (in PDF form) from the workshop were available for download. Because the download process was pretty wonky, involving many clicks and declined logins to Dropbox I thought to make them available here as well.
We developed a cellular brain stimulation device as part of our ELEC5622 Sensors, Signals & Health assessment at the University of Sydney. The technique, known as transcranial direct current stimulation (tDCS), uses weak electrical currents to modulate ongoing brain activity, and is a promising treatment for a range of neurological and psychiatric diseases. As the feasibility of administering tDCS at home has recently become an emerging area of research, there is a substantial need for a tDCS device which send data to the clinician in real time.
[Update 11/7/16 The video mentioned has been deleted.]
Lynne Malcolm: Colleen Loo says that this transcranial direct current stimulation treatment is best used for people with clinical depression who haven’t responded to other treatments. There are very few, if any, side-effects and some participants have even noticed benefits beyond changing their moods.
Colleen Loo: Yes, and this was very exciting. So when we did our first depression trial we were measuring things like memory and thinking…you know, it was just to be safe, to check these things. And one of the things we measured was we asked people to do a test which really showed you how quickly the brain was working. And as people went through the trial they were saying things like, ‘Gee, I don’t know what kind of stimulation I’m having, but it’s almost like my brain clears and I can concentrate and think so much more clearly after the stimulation.’
So we were very excited when we got the end of the study and we formally analysed the results of the formal test, that it showed exactly what people were saying to us, that after the act of stimulation the actual thinking speed was faster, and that has led our team to develop a whole parallel line of research of using TDCS to improve memory and thinking. So our main line of research is in treating depression, but I also have a very promising young researcher who is a clinical neuropsychologist, Dr Donel Martin, who is heading a whole program of research into using this to improve memory and thinking. For example, in people who are older and who are just starting to notice some changes in their memory and thinking.
Marom Bikson is CEO of Soterix Medical and Associate Professor at City College of New York in the Department of Biomedical Engineering. Marom is a distinguished tDCS scientist and prominent in the development of HD-tDCS. Download the interviewhere (zipped mp3). (Firefox users- there is an audio player here, but it’s displaying intermittently. Trying to track down the issue. In the meantime you can download the episode or open the page in another browser).
Marom Bikson
(We got a good forty minutes of interview in before the Skype gremlins caught up with us. I had to cobble an ending together.)
Customizing technologies to match needs of particular clinical situations.
Soterix developed software designed for clinicians.
HDTargeting
HDExplore
Modeling current flow through the head.
Perhaps depression studies are closest to FDA qualification for tDCS?
(Prediction is very hard, especially about the future – Yogi Berra.)
A device (NorDoc Smartstim) that can go to 4mA is being used in a smoking cessation trial? (Trial info indicates 2mA current dose.)
FDA tDCS approval would be device-specific at first. But would open the door to ‘me too’ mechanism, FDA 510(k)
HD tDCS can have multiple cathodes and or multiple anodes. An array of 4 small anodes splitting 2mA, for example (.5 mA each electrode), can function as an anodal ‘virtual pad’. Assumes cathode somewhere else on the body).
Image By Richard McKinley USAF
Tolerability is how tolerable in terms of side effects a medication is.
A Theory of tDCS (“Gross oversimplification”) As positive current flows into the cortex it passes neurons.
Because of the nature of neurons, this positive current depolarizes somas (cell’s body), increasing excitability, thereby increasing the functionality & plasticity of that region (hypothesis… “We really don’t know.”). Under the cathode, somas (cells) are being hyper-polarized – excitabilty decreases.
A synapse is a structure that permits a neuron (or nerve cell) to pass an electrical or chemical signal to another cell. Pyramidal neuron
Titration, also known as titrimetry, is a common laboratory method of quantitative chemical analysis that is used to determine the unknown concentration of an identified analyte.
TES Transcranial Electric Stimulation
“transcranial electrical stimulation” Merton and Morton 1980
“Priming the network in conjunction with applying tDCS makes a lot of sense, as a way to make the tDCS to do what you want.” (Co-priming – The idea that one would initiate an activity first, and THEN add tDCS.)
[Apologies for audio quality. It won’t happen again.]
Dr. Jim Fugedy runs the Brain Stimulation Clinic, in Atlanta, GA, and has been treating patients using tDCS since 2007. Download the interviewhere (zipped mp3).
Dr. Jim Fugedy
The Brain Stimulation Clinic in Atlanta is the destination for memory and learning enhancement and treatment-resistant patients who suffer from chronic pain, fibromyalgia, migraine headaches, CRPS, depression and tinnitus. Transcranial direct current stimulation (tDCS) therapy is provided in a pleasant, relaxing environment. Instruction, training and supervision for home use is also available for select patients.
Show Notes:
Jim is an anesthesiologist.
The study Jim refers to regarding Felipe Fregni & fibromyalgia: A randomized, sham-controlled, proof of principle study of transcranial direct current stimulation for the treatment of pain in fibromyalgia (full pdf)
tDCS for treatment of fibromyalgia is not certified – it’s ‘off label’
Device is certified, but not for tDCS = no insurance code, can’t be billed to insurance
20 minute treatment for 5 days.
For fibromyalgia – reduces pain, improves issues – fatigue, compromised mental function
2″ electrodes
(ActivaDose ii Update 3/16 now available as complete tDCS kit through Caputron Medical, use voucher code ‘diytdcs’ for generous discount.)
Most benefit… chronic depression, treatment protocol based on Colleen Loo, Black Dog Institute 6 weeks, follow up maintenance. Up to 8 weeks of treatment + 1-2 treatments follow up maintenance. Daily 20 minute sessions
Can be treated at the clinic for 1-2 weeks. Or home treatment package.
“To treat depression, I place the anode over the left dlpfc (left dorsolateral prefrontal cortex) and the cathode over the contralateral supraorbital area. I have tried positioning the cathode over the contralateral dlpfc and extracephalically (opposite shoulder or upper arm), but the contralateral supraorbital locations provides the most robust effect.” (Correspondence)
Pain montage 2mA, anode M1 & cathode contralateral supra-orbital area
For chronic pain, the M1 is the most used area and that’s almost always my first choice. But you can use the cathode over the somatosensory (S1) cortex, to down-regulate the patient’s perception of pain.
And you can also stimulate the Dorsalateral prefrontal cortex which is involved in the emotional component of pain.
Looking at stimulating right dorsalateral prefrontal cortex to attenuate anxiety.
… it may be a location
for the non-pharmaceutical treatment for ADD.
Office visit $150.
Home use treatment package $2400 includes in-office evaluation and training, ActivaDose ii device, electrodes, and unlimited follow-up via visit, phone, skype…
Only side effect Jim has seen is skin burn (but easily avoided with sponge electrodes).
(Patient with skin burns who’d been treated by a doctor using electroencephalogram (EEG) electrodes.)
Tinnitus responds well, though temporarily, to tDCS
Anode, right dorsalateral prefrontal cortex, cortex opposite supra-orbital Harvard one day course on how to treat with tDCS. Taught 3-4 times a year.
Contrast with approved Electromagnetic treatment for depression (I think he’s referring to TMS transcranial magnetic stimulation here) A 6 week 30 treatment protocol costs between $10-15,000. Affects last about 6 months. And even though it’s certified, it’s not covered by insurance.
…”in the 12 years that it’s been used there have been no side effects reported other than skin (irritations).
“You know we hear stories about Canadians having to wait for surgery. But in the United States, if you don’t have the money and you don’t have insurance, you don’t have to worry about waiting, you won’t get the surgery.”
You can reach Jim at: doctorfugedy [theAtSignHere] transcranialbrainstimulation.com
Thanks Jim!
“We think it probably works by re-setting the activity levels of those nerve cells which tend to be reduced when you’re depressed.” Colleen Loo
From Black Dog Institute, Sydney, Australia
We are looking for:
People aged over 18
People who have been experiencing feelings of depression for at least 4 weeks prior to study
People able to commit to the trial for at least 4 weeks with the option of additional further treatment, attending usually for 40 minutes every weekday.
Peter Simpson-Young 
