Transcranial direct current stimulation (tDCS) is the most exciting innovation I’ve experienced in 30 years of practicing medicine.
I first used tDCS to treat fibromyalgia five years ago. Subsequently, I’ve used tDCS for migraine, complex regional pain syndrome, treatment-resistant depression, temporomandibular joint disorder (TMJ), chronic daily headaches, bipolar disorder and stroke rehabilitation – all with good results.
tDCS sends a weak direct electrical current to selected portions of the brain using sponge electrodes on the surface of the scalp. First used to treat depression over a hundred years ago, tDCS should not be confused with electroconvulsive or shock therapy (ECT), which sends a much stronger electric current to the entire brain. tDCS uses an imperceptible 1-2 milliamps of electricity, producing benefit with no pain or side effects.
In 2000, the the seminal paper by Nitsche and Paulus heralded the rediscovery of tDCS for non-invasive neurostimulation. Clinical application over the last 12 years has demonstrated benefit for the treatment of chronic pain, mental illness and stroke rehabilitation. Recent studies have also confirmed the ability of tDCS to enhance learning, improve cognitive function and expand intellect.
Patients Benefit From tDCS
It is especially rewarding to help someone resistant to conventional treatment. I frequently get calls from patients after the tDCS. A 70-year-old woman I treated last month said that her whole family can tell the difference. Her pain is less, her thinking is clearer, her affect is brighter, she’s more active and she “feels like she’s 60 again.”
A 25-year-old patient treated with tDCS, who was unable to work for six months because of depression, now has two jobs and a new girlfriend.
My most satisfying experience, however, is with a determined and inspirational individual who I’m treating for complex regional pain syndrome. She initially had a week’s treatment of tDCS in New York. After three months, the pain returned. Because of the severity of the pain and the compromised quality of life, she and I collaborated on an extended protocol. After six months, her pain has decreased, she is able to leave her house, go out to dinner and yesterday she was outside planting flowers.
More Studies Needed
The tDCS procedure itself is simple, but protocols have evolved and results have improved. The numerous but small studies done thus far indicate, but do not yet conclusively prove benefit. Large multi-center studies need to be done to verify outcomes. Still, there is enough evidence at this time to justify clinical use for the treatment-resistant patient, particularly when you consider that there are no negative side effects with tDCS.
Early studies used single intervals of tDCS and the effects were short-lived. Increasing the duration of stimulation and the number of sessions can result in longer lasting and more profound results. Five daily treatments, increased to ten and now 6-week treatment protocols are being utilized and resulting in greater improvement. Also, it is now appreciated that delayed benefit can occur even up to a month after the completion of treatment.
The extended protocols create logistical problems, however. Daily clinic visits, particularly for out of town patients, become inconvenient, aggravating and expensive. A viable alternative is home use which can be performed for select, capable and motivated patients. To ensure safety, rigid protocols, effective training and rigorous supervision is mandatory.
Three years ago a Harvard study estimated the yearly expenditure for tDCS at the clinic to be $11,000. Home use can be done for a fraction of the cost. Programmable stimulators are under development and these should further facilitate safe individual use.
The two areas of the brain most stimulated with tDCS are the motor cortex and dorsolateral prefrontal cortex. Based on studies utilizing deep brain and cortical stimulation, the motor cortex is targeted for the relief of chronic pain syndromes and rehabilitation of muscle function. Stimulation of the left dorsolateral prefrontal cortex effects executive function, memory, planning, abstract thinking, social judgment and provides relief for depression and the emotional component of pain.
Recently, temporal and parietal lobe targeting demonstrates the ability to improve insight and learning, generating a sudden popular interest for tDCS. A bizarre sideline to this interest resulted in a proposal to produce tDCS kits for amateur researchers. Uncontrolled and undisciplined use by individuals securing and constructing stimulation devices has already been reported and is a serious concern. As with any beneficial technology, there is always the risk for misuse and abuse.
In summary, after 12 years of development, tDCS is a safe, inexpensive, easy-to-do medical procedure for the neuromodulation of chronic pain with demonstrated benefit for the treatment of patients who don’t show improvement from other therapies.
Dr. James Fugedy is an Atlanta anesthesiologist who has treated patients in pain for over 30 years. More information about tDCS and treatment options can be found at his website.
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