This document summarizes Transcranial Direct Current Stimulation (tDCS). It discusses the history of tDCS, how it works, applications in therapeutic and enhancement contexts, physiological effects and basis, safety considerations, and the future of research. tDCS involves applying a weak electrical current to the brain via electrodes to modulate cortical excitability. It has therapeutic potential for conditions like depression, motor rehabilitation, and is being studied for cognitive enhancement. Research suggests its effects are mediated by changes in neuronal membrane potentials and synaptic plasticity.
Disentangling the origin of chemical differences using GHOST
tDCS Effects and Physiology
1. Transcranial Direct Current
Stimulation (tDCS)
Daniel C. Stevenson
daniel.cortez.stevenson@gmail.com
https://www.linkedin.com/in/daniel-c-stevenson/
Presented in Fall, 2015
1
2. Agenda
1. History, tDCS vs. TMS, applications, & efficacy
2. Physiological effects of tDCS
3. Physiological basis of tDCS
4. Safety, DIY, and the FDA
5. Future Directions
2
11. Parkinson’s: Dose-dependent effects
11
Boggio et al. (2006). Journal of Neurological Sciences,
249(1): 31-38.
N=18
Duration=20min
3-Back Working Memory Test during last
5min of stimulation
12. Depression: Combination
Therapy
12Brunoni et al. (2013). JAMA Psychiatry 70(4): 383-91
Dorsolateral Prefrontal Cortex (DLPFC)
Located at F3,F4
N=120
Strength=2mA
Duration=30min
Frequency=1/day for 10 days; 4wks; 6wks
13. Enhancement Application
• Motor learning
• Language learning
• Visual perception
• Working memory
• Attention
• Problem-solving
• Moral judgment
13
14. Target Detection: Task x tDCS effects
14
Clark et al. (2010). NeuroImage, 59(1): 117-128.
RIF=right inferior frontal
Anodal Stimulation
Duration=30min
15. 15
Target Detection: Task x tDCS effects
Clark et al. (2010). NeuroImage, 59(1): 117-128.
N2.0mA=26
N0.1mA=36
17. Is there really an effect?
• Horvath, J. C., Forte, J. D., & Carter, O. (2015). Quantitative
review finds no evidence of cognitive effects in healthy
populations from single-session transcranial direct current
stimulation (tDCS). Brain Stimulation, 8(3): 535-550.
• Price, A. R., & Hamilton, R. H. (2015). A re-evaluation of the
cognitive effects from single-session transcranial direct
current stimulation. Brain Stimulation 8(3): 663-665.
• Horvath, J. C. (2015). New quantitative analysis following
Price & Hamilton’s critique do not change original findings
of Horvath et al. Brain Stimulation 8(3): 665-666.
• Nitsche, M. A., Bikson, M., & Bestmann, S. (2015). On the
use of meta-analysis in neuromodulatory non-invasive brain
stimulation. Brain Stimulation 8(3): 666-667.
17
19. Methodology
Abductor digiti minimi muscle
of the hand (ADM)
Tendon
Belly
Surface EMG Recordings of TMS
induced Motor Evoked Potentials
(MEPs)
Ag-AgCl
electrodes are
placed in a
“belly-tendon
montage”
19
21. Pyrimidal Tract Neurons:
Corticospinal-Upper motor neurons originating
in layer 5 of the cortex terminate in spinal cord and
innervate lower motor neuron
Corticobulbular-terminate in brainstem
21
32. Current modifies elicited neuron firing
(in rats)
32
Anodal Stimulation Cathodal Stimulation
Bindman et al. (1964) J Physiol 172: 369-382
*b,d are control traces
33. Current modifies tonic neuron firing
(in rats)
33
Control
Cathodal
Anodal
Bindman et al. (1964) J Physiol 172: 369-382
34. Na+ Voltage Gated
Channels
Nitsche et al. (2003). J Physiology 533.1: 293-301
CBZ = carbamazepine (600mg);
Na+ channel blocker
* Indicates significant difference
from the respective PLC/Drug
condition
NI=12
N0=12
NI=10
N0=10
No ∆
34
During tDCS
35. Conclusions: During tDCS Effects
• Resting membrane potential is modulated by
the electrical current
• Anodal effects are abolished by blocking Na+
channels
• These effects are necessary for longer-term
effects to occur
35
36. Long-term potentiation/depression
(LTP/LTD)
• Modulation of synaptic strength
• Occurs within the horizontal connections of
the primary motor cortex (during motor
learning and rehabilitation)
– Glutamatergic interneurons
• NMDA receptors
• AMPA receptors
36
37. Early LTP is Ca2+ dependent
37
Lynch, M. A. (2004). Long-term potentiation and memory.
Physiological Reviews 84(1): 87-136.
41. Conclusions: NMDAR/Ca2+
• NMDAR-mediated LTP is integral to long-term
tDCS effect
– NMDA antagonism eliminates both cathodal and
anodal long-term effects
– NMDA agonism enhances anodal tDCS
• Ca2+ channels mediate short-term tDCS effect
• Ca2+ channels necessary for longer-term
effects
– NMDAR interaction
41
42. Conclusions: Physiological Basis
1. Short-term effects are mediated by sub-
threshold alterations in neuron resting
membrane potential
2. Long-term effects are mediated by LTP
involving NMDA receptors
42
43. Safety: Adverse Effects
• 63% of studies report 1 mild ‘adverse effect’
– Itching, tingling, headache, burning sensation,
discomfort
• However:
– Active tDCS Rate = Sham Rate
– Except:
• Skin reddening (Tx w/ Ketoprofen)
43
Fregni et al. (2014). Clinical Research and Regulatory Affairs, [Early
Online]: 1-14.
44. Safety: Serious Adverse Effects
• Review: No “serious adverse events” since
1998 in >10,000 subjects
• 1964 study: “respiratory and motor paralysis”
– Bifrontal anodal electrodes with leg cathode
– 10x intended current strength (likely ~3mA)
– DIY-tDCS concerns
44
Fregni et al. (2014). Clinical Research and Regulatory Affairs, [Early
Online]: 1-14.
Lippold O. C. J., & Redfearn, J. W. T. (1964). Mental changes resulting
from the passage of small direct currents through the human brain.
110(469): 768-772
45. Safety: Physiological Evidence
• No pathological changes in:
– Serum enolase (marker of neuronal damage)
– HRV
– EEG
• 100x the charge density used in humans is
required to cause brain damage in rats
– Discomfort in humans starts at 2-3x
45
Fregni et al. (2014). Clinical Research and Regulatory Affairs, [Early
Online]: 1-14.
47. Safety: Standard Parameters
• Current strength <2.5mA
• Duration <60min
• ≤2 sessions per day
• This does not imply going beyond these
parameters is not safe!
47
Fregni et al. (2014). Clinical Research and Regulatory Affairs, [Early
Online]: 1-14.
48. Safety: Unknowns
• Long-term usage
• Need for more studies on safety
48
Fregni et al. (2014). Clinical Research and Regulatory Affairs, [Early
Online]: 1-14.
49. FDA Regulations
• “Medical device”
– Most stimulators are Class II
• “Investigational Device Exception” approval
– “non-significant risk” exception “expedited IDE”
– NSR overwhelmingly applied
• “Minimal Risk”
• Not cleared for any medical indication
49
50. tDCS Research is Accelerating
• 2008: Review of 122 tDCS studies since 1998a
– physiological effects of tDCS
– pharmacological modulation of tDCS
– establishing application protocols
• 2008-2010: ~100 new tDCS studiesb
– enhancing the efficacy of protocols
– defining safety parameters
– broadening the range of application
50
a Nitsche et al. (2008). Brain Stimulation, 1: 206-233.
b Nitsche, M. A., & Paulus, W. (2011). Restorative Neurology and Neuroscience, 29:463-492.
51. tDCS Research is Accelerating
51
0
100
200
300
400
500
#ofPublications
Year
PubMed publications on the subject
"transcranial direct current stimulation" since 1998
http://dan.corlan.net/medline-trend.html
52. Future Research Should Explore…
• effects of tDCS on cortical areas outside of M1
– neurotransmitters, receptors, neurons, and
networks are heterogeneous
• interaction of of [Stimulation x Task]
• timing and duration of stimulation (before,
during or after a task)
• multi-electrode stimulation of functional
networks
52
Shin, Y.-I., Foerster, A., & Nitsche, M. A. (2015).
Neuropsychologia, 69: 154-175
53. Overview: tDCS…
• is an exciting and novel electrical stimulation
device with a long history
• has a wide variety of applications
• modifies the resting membrane potential of
cells, and can induce lasting changes in
neuronal plasticity
• is of minimal risk, yet still awaits FDA approval
• tDCS research is booming, but has a long way
to go
53
Scribonius Largus
Sudden, transient stupor with pain relief
Relief due to numbness, torpor, and narcotic effect from electric fish
Alos Pliny the Elder and Greek physician Claudius Glaen (131-401 AD)
Ibn-Sidah
Muslin physician
Placed on frontal bone
Alessandro Volta
Electrical stimuli of varying du7ration can evoke different physiological effects
Discusions with Galvani started the electrical century
Many different applications of electricity (including medicine)
DC current = Galvanic Current = Voltaic Current
Giovanni Aldini (Galvani’s nephew)
Facial muscle contractions in guillotined cadavers
On himself: induced insomnia for a few days and ‘unpleasant sensation’
Augistin and Grapengiesser
DC currents as stimulating or sedative treatment
Bishoff
Successful Tx in a case of depression
1938: Cerletti treats 1st patient with ECT
Priori 2003 Clinical Neurophysiology
Kuo, Paulus, & Nitsche (2014) NeuroImage
Fregni et al, Clinical Research and Regulatory Affairs (2014)
Tinnitus
Anodal tDCS reduces intensisty of symptoms
Stroke
Daily sessions of tDCS improve upper limb function, increase activities of daily living (ADLs) scores
Various Montages, w/ or w/out Physical Therapy improve motor function in mild to moderate stoke patients
Anodal tDCS over perilesional areas improves language function, persists over time when coupled with language training
Stability of improvement over clinically significant intervals remains to be assessed.
Alzheimer’s
May improve memory performance
rtDCS creates effects lasting >4 weeks
Addiction
Effective in reducing cravings for food, smoking, concaine and alcohol.
As effective as rTMS in reducing cravings in substant dependent people and cravings for palatable food
DLPFC
Post-Polio Syndrome
Anodal tDCS over pre-motor areas improves sleep and fatigue symptoms
Brunoni et al. (2013). The Sertraline vs Electrical Current Therapy for Treating Depression Clinical StudyResults From a Factorial, Randomized, Controlled Trial. JAMA Psychiatry 70(4): 383-391
Nitsche, M. A., & Paulus, W. (2011). Transcranial direct current stimulation – update 2011. Restorative Neurology and Neuroscience, 29:463-492.
Clark et al. (2010). TDCS guided using fMRI significantly accelerates learning to identify concealed objects. NeuroImage, 59(1): 117-128.
Subjects with 2.0mA stimulation were also better than sham at both post-tests
right frontal and parietal cortex are involved in learning to identify concealed objects in naturalistic surroundings. Furthermore, they suggest that the application of anodal tDCS over these regions can greatly increase learning, resulting in one of the largest effects on learning yet reported.
Effects also found for Right Parietal
Karim, A. A., Schneider, M., Lotze, M., Veit, R., Sauseng, P., Braun, C., & Birbaumer, N. (2010). The truth about lying: Inhibitioin of the anterioir prefrontal cortex improves deceptive behavior. Cerebral Cortex, 20: 205-213.
In this arrangement, active electrode (known as G1) is placed on the belly of the muscle and reference electrode (known as G2) on the tendon. The ground electrode is usually placed between the stimulating and recording electrodes. (http://neurologysimplified.blogspot.com/2008/09/recording-electrodes-for-motor-studies.html)
\
Image from :
Acute Changes in Motor Cortical Excitability During Slow Oscillatory and Constant Anodal Transcranial Direct Current Stimulation
Til Ole Bergmann, Sergiu Groppa, Markus Seeger, Matthias Mölle, Lisa Marshall, Hartwig Roman Siebner
Journal of Neurophysiology Published 1 October 2009 Vol. 102 no. 4, 2303-2311 DOI: 10.1152/jn.00437.2009
"Blausen 0103 Brain Sensory&Motor" by BruceBlaus. When using this image in external sources it can be cited as:Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. - Own work. Licensed under CC BY 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Blausen_0103_Brain_Sensory%26Motor.png#/media/File:Blausen_0103_Brain_Sensory%26Motor.png
"Human motor map" by Michael Graziano - emailed peresonally. Licensed under CC BY-SA 1.0 via Wikipedia - https://en.wikipedia.org/wiki/File:Human_motor_map.jpg#/media/File:Human_motor_map.jpg
"Spinal cord tracts - English" by Polarlys and Mikael Häggström - File:Medulla spinalis - tracts - English.svg by Polarlys (translation by Selket).. Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Spinal_cord_tracts_-_English.svg#/media/File:Spinal_cord_tracts_-_English.svg
Nitsche & Paulus J Physiology (2000)
Boxes indicate 25th and 75th percentiles
Error Bars indicate 10th and 90th percentiles
MEPs recorded in Abductor Digiti minimi (ADM) muscle
Ag/AgCl electrodes in a belly tendon arrangement
Neuroscan system (Neuroscan Inc., Herndon, VA, USA)
Time indicates last significant timepoint at indicated stimulus duration
35cm^2 electrodes
Fig. 1. After-effects of cathodal tDCS. Time course of changes in MEP amplitude evoked by a standard TMS pulse following termination of 5 – 9 min
polarisation with a 1 mA DC current.
Error bars are SEM
35 cm^2 electrodes
No effect for cathodal!
This is in accordance with tDCS-generated hyperpolarization
of the neuron leading to inactivation of the relevant
voltage-gated channels and therefore negation of any
drug effect.
Cathodal tDCS hyperpolarization inactivation of Ca2+/Na+ voltage gated channels no drug effect
Lynch, M. A. (2004). Long-term potentiation and memory. Physiological Reviews 84(1): 87-136.
Ca activations Calcium dependent kinases which control AMPA and NMDA receptor trafficking
This is in accordance with tDCS-generated hyperpolarization
of the neuron leading to inactivation of the relevant
voltage-gated channels and therefore negation of any
drug effect.
tDCShyperpolarizationinactivation of Na+/Ca2+ voltage gated channelsno drug effect
Error bars are SEM
35 cm^2
Binds at glycine binding site
100mg dosage of CYC beneificicial for Alzheimer’s disease
Fregni et al. (2014). Regulatory considerations for the clinical and research use of transcranial direct current stimulation (tDCS): Review and recommendations from an expert panel. Clinical Research and Regulatory Affairs, [Early Online]: 1-14.
Fregni et al, Clinical Research and Regulatory Affairs (2014)
“Out of 172 articles, 56% mentioned adverse effects and 63%
reported at least one adverse effect”
“when they were systematically assessed, the rates of common adverse
effects did not differ between the active arms of the studies and the sham arms.”
Most studies did not systematically assess
Erythema = skin reddening
“Due to an increase in blood flow of dermal vessels accompanying the current application”
Might be ameliorated by pre-treatment topical Ketoprofen (NSAID w/ analgesic and antipyretic effects, inhibits production of prostaglandin)
Rare skin burns resulting from incorrect application (prep of skin, humidifcation of sponges, limit of voltage)
Serious Adverse events
“According to the FDA, and similarly to other international
regulatory agencies, serious adverse events are those in which
the outcome is (i) death, (ii) life-threatening, (iii) hospitalization,
(iv) disability/permanent damage, (v) congenital
anomaly/birth defect, (vi) required intervention to prevent
permanent impairment or damage (for implantable devices),
(vii) and other serious events—e.g. refractory seizures,
cardiorespiratory arrest, anaphylactic reaction etc.”
Fregni et al, Clinical Research and Regulatory Affairs (2014)
Fregni et al, Clinical Research and Regulatory Affairs (2014)
“non-invasive procedure in the
standard medical usage of this term, meaning that it does not
involve penetrating the skin or a body cavity”
Fregni et al, Clinical Research and Regulatory Affairs (2014)
This does not imply going beyond these parameters is not safe, but we can not say for sure.
Fregni et al, Clinical Research and Regulatory Affairs (2014)
The safety and efficacy of daily to twice-daily, domiciliary,
30-min, 1–3-mA tDCS sessions across nearly 3 years was
reported in a patient with schizophrenia
Medical Device
“According to the US
Food and Drug Administration (FDA) (27), a medical device is
defined as: ‘‘An instrument, apparatus, implement, machine,
contrivance, implant, in vitro reagent, or other similar or
related article, including a component part, or accessory’’ that
is recognized for the use in diagnosis, prevention, and
treatment in humans without using chemical pathways.”
REGARDLESS OF USAGE INDICATION
“nearly all noninvasive or cutaneously administered electrical stimulationdevices have been deemed Class II medical devices by the FDA”
Investigational Device Exception (IDE) Approval
“allows for human research pending controls, documentation, and monitoring by both the manufacturer and investigator.”
Every clinical trial with tDCS requires an IDE approval from FDA
EXCEPT those clinical trials that receive a NSR exception from their IRB, resulting in an expedited IDE by FDA
NSR designation overwhelmingly applied by both IRBs and FDA (when asked)
NeuroConn and Soterix Medical have IDE for tDCS
Minimal risk
“Minimal risk means there have been no
serious adverse events, that common adverse effects such as
reddening of the skin are mild and short-lived, and that
reasonable efforts at assessment have determined there is no
evidence of brain damage.”
DEVICE x PROTOCOL designation
If it were significant-risk
May still be approved if “benefits offset risk and/or appropriate measures are taken to control risk”
Clearance
Absence of manufacturer application
Fregni et al, Clinical Research and Regulatory Affairs (2014)
Nitsche, M. A., & Paulus, W. (2011). Transcranial direct current stimulation – update 2011. Restorative Neurology and Neuroscience, 29:463-492.