151
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Noninvasive cortical modulation of experimental pain. Pain 2012; 153:1350-1363. [DOI: 10.1016/j.pain.2012.04.009] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 04/05/2012] [Accepted: 04/09/2012] [Indexed: 01/09/2023]
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152
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Transcranial Direct Current Stimulation for the Reduction of Clinical and Experimentally Induced Pain. Clin J Pain 2012; 28:452-61. [DOI: 10.1097/ajp.0b013e31823853e3] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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153
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Vanneste S, De Ridder D. Noninvasive and Invasive Neuromodulation for the Treatment of Tinnitus: An Overview. Neuromodulation 2012; 15:350-60. [DOI: 10.1111/j.1525-1403.2012.00447.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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154
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Plow EB, Pascual-Leone A, Machado A. Brain stimulation in the treatment of chronic neuropathic and non-cancerous pain. THE JOURNAL OF PAIN 2012; 13:411-24. [PMID: 22484179 DOI: 10.1016/j.jpain.2012.02.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 12/27/2011] [Accepted: 02/02/2012] [Indexed: 01/16/2023]
Abstract
UNLABELLED Chronic neuropathic pain is one of the most prevalent and debilitating disorders. Conventional medical management, however, remains frustrating for both patients and clinicians owing to poor specificity of pharmacotherapy, delayed onset of analgesia and extensive side effects. Neuromodulation presents as a promising alternative, or at least an adjunct, as it is more specific in inducing analgesia without associated risks of pharmacotherapy. Here, we discuss common clinical and investigational methods of neuromodulation. Compared to clinical spinal cord stimulation (SCS), investigational techniques of cerebral neuromodulation, both invasive (deep brain stimulation [DBS] and motor cortical stimulation [MCS]) and noninvasive (repetitive transcranial magnetic stimulation [rTMS] and transcranial direct current stimulation [tDCS]), may be more advantageous. By adaptively targeting the multidimensional experience of pain, subtended by integrative pain circuitry in the brain, including somatosensory and thalamocortical, limbic and cognitive, cerebral methods may modulate the sensory-discriminative, affective-emotional and evaluative-cognitive spheres of the pain neuromatrix. Despite promise, the current state of results alludes to the possibility that cerebral neuromodulation has thus far not been effective in producing analgesia as intended in patients with chronic pain disorders. These techniques, thus, remain investigational and off-label. We discuss issues implicated in inadequate efficacy, variability of responsiveness, and poor retention of benefit, while recommending design and conceptual refinements for future trials of cerebral neuromodulation in management of chronic neuropathic pain. PERSPECTIVE This critical review focuses on factors contributing to poor therapeutic utility of invasive and noninvasive brain stimulation in the treatment of chronic neuropathic and pain of noncancerous origin. Through key clinical trial design and conceptual refinements, retention and consistency of response may be improved, potentially facilitating the widespread clinical applicability of such approaches.
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Affiliation(s)
- Ela B Plow
- Department of Biomedical Engineering, Lerner Research Institute, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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155
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Volz MS, Mendonca M, Pinheiro FS, Cui H, Santana M, Fregni F. Dissociation of motor task-induced cortical excitability and pain perception changes in healthy volunteers. PLoS One 2012; 7:e34273. [PMID: 22470548 PMCID: PMC3314609 DOI: 10.1371/journal.pone.0034273] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 02/27/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND There is evidence that interventions aiming at modulation of the motor cortex activity lead to pain reduction. In order to understand further the role of the motor cortex on pain modulation, we aimed to compare the behavioral (pressure pain threshold) and neurophysiological effects (transcranial magnetic stimulation (TMS) induced cortical excitability) across three different motor tasks. METHODOLOGY/PRINCIPAL FINDINGS Fifteen healthy male subjects were enrolled in this randomized, controlled, blinded, cross-over designed study. Three different tasks were tested including motor learning with and without visual feedback, and simple hand movements. Cortical excitability was assessed using single and paired-pulse TMS measures such as resting motor threshold (RMT), motor-evoked potential (MEP), intracortical facilitation (ICF), short intracortical inhibition (SICI), and cortical silent period (CSP). All tasks showed significant reduction in pain perception represented by an increase in pressure pain threshold compared to the control condition (untrained hand). ANOVA indicated a difference among the three tasks regarding motor cortex excitability change. There was a significant increase in motor cortex excitability (as indexed by MEP increase and CSP shortening) for the simple hand movements. CONCLUSIONS/SIGNIFICANCE Although different motor tasks involving motor learning with and without visual feedback and simple hand movements appear to change pain perception similarly, it is likely that the neural mechanisms might not be the same as evidenced by differential effects in motor cortex excitability induced by these tasks. In addition, TMS-indexed motor excitability measures are not likely good markers to index the effects of motor-based tasks on pain perception in healthy subjects as other neural networks besides primary motor cortex might be involved with pain modulation during motor training.
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Affiliation(s)
- Magdalena S. Volz
- Laboratory of Neuromodulation, Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Charité Center for Neurology, Neurosurgery and Psychiatry, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Mariana Mendonca
- Laboratory of Neuromodulation, Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Fernando S. Pinheiro
- Laboratory of Neuromodulation, Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Huashun Cui
- Laboratory of Neuromodulation, Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Marcus Santana
- Laboratory of Neuromodulation, Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Felipe Fregni
- Laboratory of Neuromodulation, Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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156
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Kim KY, Sim KC, Kim HS, Choi WS, Kim GD. Analgesic Effects of Transcranial Direct Current Stimulation on Central Neuropathic Pain in Spinal Cord Contusive Rat Model. INTERNATIONAL JOURNAL OF CONTENTS 2012. [DOI: 10.5392/ijoc.2012.8.1.074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Taylor JJ, Borckardt JJ, George MS. Endogenous opioids mediate left dorsolateral prefrontal cortex rTMS-induced analgesia. Pain 2012; 153:1219-1225. [PMID: 22444187 DOI: 10.1016/j.pain.2012.02.030] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 12/11/2011] [Accepted: 02/24/2012] [Indexed: 01/20/2023]
Abstract
The concurrent rise of undertreated pain and opiate abuse poses a unique challenge to physicians and researchers alike. A focal, noninvasive form of brain stimulation called repetitive transcranial magnetic stimulation (rTMS) has been shown to produce acute and chronic analgesic effects when applied to dorsolateral prefrontal cortex (DLPFC), but the anatomical and pharmacological mechanisms by which prefrontal rTMS induces analgesia remain unclear. Data suggest that DLPFC mediates top-down analgesia via gain modulation of the supraspinal opioidergic circuit. This potential pathway might explain how prefrontal rTMS reduces pain. The purpose of this sham-controlled, double-blind, crossover study was to determine whether left DLPFC rTMS-induced analgesia was sensitive to μ-opioid blockade. Twenty-four healthy volunteers were randomized to receive real or sham TMS after either intravenous saline or naloxone pretreatment. Acute hot and cold pain via quantitative sensory testing and hot allodynia via block testing on capsaicin-treated skin were assessed at baseline and at 0, 20, and 40 minutes after TMS treatment. When compared to sham, real rTMS reduced hot pain and hot allodynia. Naloxone pretreatment significantly reduced the analgesic effects of real rTMS. These results demonstrate that left DLPFC rTMS-induced analgesia requires opioid activity and suggest that rTMS drives endogenous opioidergic pain relief in the human brain. Further studies with chronic dosing regimens of drugs that block or augment the actions of opiates are needed to determine whether TMS can augment opiates in chronic or postoperative pain management.
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Affiliation(s)
- Joseph J Taylor
- Brain Stimulation Laboratory, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA Ralph H. Johnson VA Medical Center, Charleston, SC, USA
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158
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Jürgens T, Schulte A, Klein T, May A. Transcranial direct current stimulation does neither modulate results of a quantitative sensory testing protocol nor ratings of suprathreshold heat stimuli in healthy volunteers. Eur J Pain 2012; 16:1251-63. [DOI: 10.1002/j.1532-2149.2012.00135.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2012] [Indexed: 11/08/2022]
Affiliation(s)
- T.P. Jürgens
- Department of Systems Neuroscience; University Medical Centre Hamburg-Eppendorf; Hamburg; Germany
| | - A. Schulte
- Department of Systems Neuroscience; University Medical Centre Hamburg-Eppendorf; Hamburg; Germany
| | - T. Klein
- Department of Neurophysiology; Centre for Biomedicine and Medical Technology Mannheim (CBTM); University of Heidelberg; Mannheim; Germany
| | - A. May
- Department of Systems Neuroscience; University Medical Centre Hamburg-Eppendorf; Hamburg; Germany
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159
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A Pilot Study of the Tolerability and Effects of High-Definition Transcranial Direct Current Stimulation (HD-tDCS) on Pain Perception. THE JOURNAL OF PAIN 2012; 13:112-20. [DOI: 10.1016/j.jpain.2011.07.001] [Citation(s) in RCA: 181] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Revised: 04/18/2011] [Accepted: 07/12/2011] [Indexed: 11/17/2022]
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160
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Mylius V, Jung M, Menzler K, Haag A, Khader P, Oertel W, Rosenow F, Lefaucheur JP. Effects of transcranial direct current stimulation on pain perception and working memory. Eur J Pain 2012; 16:974-82. [DOI: 10.1002/j.1532-2149.2011.00105.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2011] [Indexed: 11/11/2022]
Affiliation(s)
| | - M. Jung
- Department of Neurology; Philipps University Marburg; Germany
| | - K. Menzler
- Department of Neurology; Philipps University Marburg; Germany
| | - A. Haag
- Department of Neurology; Philipps University Marburg; Germany
| | - P.H. Khader
- Department of Psychology; Philipps University Marburg; Germany
| | - W.H. Oertel
- Department of Neurology; Philipps University Marburg; Germany
| | - F. Rosenow
- Department of Neurology; Philipps University Marburg; Germany
| | - J.-P. Lefaucheur
- EA 4391; Service de Physiologie; Hôpital Henri-Mondor; Université Paris Est Créteil; France
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161
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Faber M, Vanneste S, Fregni F, De Ridder D. Top down prefrontal affective modulation of tinnitus with multiple sessions of tDCS of dorsolateral prefrontal cortex. Brain Stimul 2011; 5:492-8. [PMID: 22019079 DOI: 10.1016/j.brs.2011.09.003] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Revised: 09/09/2011] [Accepted: 09/10/2011] [Indexed: 10/17/2022] Open
Abstract
Most forms of tinnitus are attributable to reorganization and hyperactivity in the auditory central nervous system with coactivation of nonauditory brain structures. One such nonauditory brain area is the dorsolateral prefrontal cortex (DLPFC), which is important for the integration of sensory and emotional aspects of tinnitus. Based on extensive evidence that transcranial direct current stimulation can induce significant effects on DLPFC-related cognitive function, we aimed to investigate whether left or right anodal DLFPC tDCS is associated with modulation of tinnitus. We conducted a double-blind, placebo-controlled cross-over study in which 15 subjects with tinnitus were randomly assigned to receive active and sham anodal tDCS over left (n = 8) or right DLPFC (n = 7) for six sessions in a counterbalanced order; the cathode electrode was placed in the contralateral DLPFC. The results demonstrate that both active conditions-irrespective of the anodal position-can decrease tinnitus annoyance but it is not associated with improvements in tinnitus intensity when comparing pre-tDCS versus post-tDCS as well as comparing sham-tDCS versus real tDCS. Also, we show that the anode electrode placed over the left DLPFC modulates depression when comparing pre-tDCS versus post-tDCS as well as comparing sham-tDCS versus real tDCS. In addition, we also show that the anode electrode placed over the right DLPFC modulates anxiety when comparing pre-tDCS versus post-tDCS. This latter effect does not remain when we compare sham-tDCS versus real tDCS. This study further supports the involvement of the prefrontal cortex in the neural network associated with tinnitus, and also provides initial evidence for a potential brain stimulation site for tinnitus treatment in association with other treatments that can reduce tinnitus intensity.
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Affiliation(s)
- Margriet Faber
- Tinnitus Research Initiative Clinic Antwerp and Department of Neurosurgery, University Hospital Antwerp, Antwerp, Belgium
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162
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Vallar G, Bolognini N. Behavioural facilitation following brain stimulation: Implications for neurorehabilitation. Neuropsychol Rehabil 2011; 21:618-49. [DOI: 10.1080/09602011.2011.574050] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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163
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Polanía R, Paulus W, Nitsche MA. Modulating cortico-striatal and thalamo-cortical functional connectivity with transcranial direct current stimulation. Hum Brain Mapp 2011; 33:2499-508. [PMID: 21922602 DOI: 10.1002/hbm.21380] [Citation(s) in RCA: 287] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 04/19/2011] [Accepted: 05/18/2011] [Indexed: 11/08/2022] Open
Abstract
Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that has been shown to alter cortical excitability and activity via application of weak direct currents. Beyond intracortical effects, functional imaging as well as behavioral studies are suggesting additional tDCS-driven alterations of subcortical areas, however, direct evidence for such effects is scarce. We aimed to investigate the impact of tDCS on cortico-subcortical functional networks by seed functional connectivity analysis of different striatal and thalamic regions to prove tDCS-induced alterations of the cortico-striato-thalamic circuit. fMRI resting state data sets were acquired immediately before and after 10 min of bipolar tDCS during rest, with the anode/cathode placed over the left primary motor cortex (M1) and the cathode/anode over the contralateral frontopolar cortex. To control for possible placebo effects, an additional sham stimulation session was carried out. Functional coupling between the left thalamus and the ipsilateral primary motor cortex (M1) significantly increased following anodal stimulation over M1. Additionally, functional connectivity between the left caudate nucleus and parietal association cortices was significantly strengthened. In contrast, cathodal tDCS over M1 decreased functional coupling between left M1 and contralateral putamen. In summary, in this study, we show for the first time that tDCS modulates functional connectivity of cortico-striatal and thalamo-cortical circuits. Here we highlight that anodal tDCS over M1 is capable of modulating elements of the cortico-striato-thalamo-cortical functional motor circuit.
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Affiliation(s)
- Rafael Polanía
- Department of Clinical Neurophysiology, Georg-August University of Göttingen, 37075 Göttingen, Germany.
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164
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Montenegro RA, Farinatti PDTV, Fontes EB, Soares PPDS, Cunha FAD, Gurgel JL, Porto F, Cyrino ES, Okano AH. Transcranial direct current stimulation influences the cardiac autonomic nervous control. Neurosci Lett 2011; 497:32-6. [DOI: 10.1016/j.neulet.2011.04.019] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Revised: 04/06/2011] [Accepted: 04/08/2011] [Indexed: 12/12/2022]
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165
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Borckardt JJ, Romagnuolo J, Reeves ST, Madan A, Frohman H, Beam W, George MS. Feasibility, safety, and effectiveness of transcranial direct current stimulation for decreasing post-ERCP pain: a randomized, sham-controlled, pilot study. Gastrointest Endosc 2011; 73:1158-64. [PMID: 21470608 DOI: 10.1016/j.gie.2011.01.050] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 01/24/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Emerging evidence shows that transcranial direct current stimulation (tDCS), a minimally invasive brain stimulation technique, has analgesic effects in chronic pain patients and in healthy volunteers with experimental pain. No studies have examined the analgesic effects of tDCS immediately after surgical/endoscopic procedures. Endoscopy investigating abdominal pain, especially ERCP, can cause significant postprocedural pain. OBJECTIVE To test the feasibility, efficacy, and safety of tDCS on post-ERCP pain and analgesia use. DESIGN Randomized, sham-controlled, pilot study. SETTING Tertiary-care medical center. PATIENTS This study involved 21 patients who were hospitalized overnight for ERCP for unexplained right upper quadrant pain. INTERVENTION Twenty minutes of real 2.0 mA tDCS or sham (anode over left prefrontal cortex; cathode over gut-representation of right sensory cortex) immediately after ERCP. MAIN OUTCOME MEASUREMENTS Pain (visual analogue scale, McGill pain questionnaire, brief pain inventory), patient-controlled analgesia use, adverse events. RESULTS Real tDCS was associated with 22% less total hydromorphone use, versus sham. The slope of the cumulative patient-controlled analgesia usage curve was significantly steeper in the sham tDCS group (F [2,13] = 15.96; P = .0003). Real tDCS patients reported significantly less pain interference with sleep (t [17] = 3.70; P = .002) and less throbbing pain (t [16] = 2.37; P = .03). Visual analogue scale pain and mood scores (4 hours post-ERCP) suggested a nonsignificant advantage for real tDCS, despite less hydromorphone use. Side effects of tDCS were limited to mild, self-limited tingling, itching, and stinging under electrodes. LIMITATIONS Small sample size, variability in chronic pain, and chronic opioid use. CONCLUSION In this pilot study, tDCS appears to be safe, has minimal side effects, and may reduce postprocedural analgesia requirements and subjective pain ratings. Future studies appear warranted.
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Affiliation(s)
- Jeffrey J Borckardt
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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166
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Cognitive, mood, and electroencephalographic effects of noninvasive cortical stimulation with weak electrical currents. J ECT 2011; 27:134-40. [PMID: 20938352 DOI: 10.1097/yct.0b013e3181e631a8] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES : The use of noninvasive cortical electrical stimulation with weak currents has significantly increased in basic and clinical human studies. Initial, preliminary studies with this technique have shown encouraging results; however, the safety and tolerability of this method of brain stimulation have not been sufficiently explored yet. The purpose of our study was to assess the effects of direct current (DC) and alternating current (AC) stimulation at different intensities in order to measure their effects on cognition, mood, and electroencephalogram. METHODS : Eighty-two healthy, right-handed subjects received active and sham stimulation in a randomized order. We conducted 164 ninety-minute sessions of electrical stimulation in 4 different protocols to assess safety of (1) anodal DC of the dorsolateral prefrontal cortex (DLPFC); (2) cathodal DC of the DLPFC; (3) intermittent anodal DC of the DLPFC and; (4) AC on the zygomatic process. We used weak currents of 1 to 2 mA (for DC experiments) or 0.1 to 0.2 mA (for AC experiment). RESULTS : We found no significant changes in electroencephalogram, cognition, mood, and pain between groups and a low prevalence of mild adverse effects (0.11% and 0.08% in the active and sham stimulation groups, respectively), mainly, sleepiness and mild headache that were equally distributed between groups. CONCLUSIONS : Here, we show no neurophysiological or behavioral signs that transcranial DC stimulation or AC stimulation with weak currents induce deleterious changes when comparing active and sham groups. This study provides therefore additional information for researchers and ethics committees, adding important results to the safety pool of studies assessing the effects of cortical stimulation using weak electrical currents. Further studies in patients with neuropsychiatric disorders are warranted.
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167
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DaSilva AF, Volz MS, Bikson M, Fregni F. Electrode positioning and montage in transcranial direct current stimulation. J Vis Exp 2011:2744. [PMID: 21654618 PMCID: PMC3339846 DOI: 10.3791/2744] [Citation(s) in RCA: 163] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Transcranial direct current stimulation (tDCS) is a technique that has been intensively investigated in the past decade as this method offers a non-invasive and safe alternative to change cortical excitability2. The effects of one session of tDCS can last for several minutes, and its effects depend on polarity of stimulation, such as that cathodal stimulation induces a decrease in cortical excitability, and anodal stimulation induces an increase in cortical excitability that may last beyond the duration of stimulation6. These effects have been explored in cognitive neuroscience and also clinically in a variety of neuropsychiatric disorders – especially when applied over several consecutive sessions4. One area that has been attracting attention of neuroscientists and clinicians is the use of tDCS for modulation of pain-related neural networks3,5. Modulation of two main cortical areas in pain research has been explored: primary motor cortex and dorsolateral prefrontal cortex7. Due to the critical role of electrode montage, in this article, we show different alternatives for electrode placement for tDCS clinical trials on pain; discussing advantages and disadvantages of each method of stimulation.
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Affiliation(s)
- Alexandre F DaSilva
- Headache & Orofacial Pain Effort, Biologic & Material Sciences, School of Dentistry, University of Michigan, USA.
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168
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Mendonca ME, Santana MB, Baptista AF, Datta A, Bikson M, Fregni F, Araujo CP. Transcranial DC Stimulation in Fibromyalgia: Optimized Cortical Target Supported by High-Resolution Computational Models. THE JOURNAL OF PAIN 2011; 12:610-7. [DOI: 10.1016/j.jpain.2010.12.015] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2010] [Revised: 12/19/2010] [Accepted: 12/31/2010] [Indexed: 11/24/2022]
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169
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Different resting state brain activity and functional connectivity in patients who respond and not respond to bifrontal tDCS for tinnitus suppression. Exp Brain Res 2011; 210:217-27. [DOI: 10.1007/s00221-011-2617-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 02/26/2011] [Indexed: 10/18/2022]
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170
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Prefrontal direct current stimulation modulates resting EEG and event-related potentials in healthy subjects: A standardized low resolution tomography (sLORETA) study. Neuroimage 2011; 55:644-57. [DOI: 10.1016/j.neuroimage.2010.12.004] [Citation(s) in RCA: 212] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Revised: 11/03/2010] [Accepted: 12/02/2010] [Indexed: 11/17/2022] Open
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171
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Brighina F, De Tommaso M, Giglia F, Scalia S, Cosentino G, Puma A, Panetta M, Giglia G, Fierro B. Modulation of pain perception by transcranial magnetic stimulation of left prefrontal cortex. J Headache Pain 2011; 12:185-91. [PMID: 21350791 PMCID: PMC3072504 DOI: 10.1007/s10194-011-0322-8] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Accepted: 11/30/2010] [Indexed: 02/08/2023] Open
Abstract
Evidence by functional imaging studies suggests the role of left dorsolateral prefrontal cortex (DLPFC) in the inhibitory control of nociceptive transmission system. Repetitive transcranial magnetic stimulation (rTMS) is able to modulate pain response to capsaicin. In the present study, we evaluated the effect of DLPFC activation (through rTMS) on nociceptive control in a model of capsaicin-induced pain. The study was performed on healthy subjects that underwent capsaicin application on right or left hand. Subjects judged the pain induced by capsaicin through a 0–100 VAS scale before and after 5 Hz rTMS over left and right DLPFC at 10 or 20 min after capsaicin application in two separate groups (8 subjects each). Left DLPFC-rTMS delivered either at 10 and 20 min after capsaicin application significantly decreased spontaneous pain in both hands. Right DLPFC rTMS showed no significant effect on pain measures. According to these results, stimulation of left DLPFC seems able to exert a bilateral control on pain system, supporting the critical antinociceptive role of such area. This could open new perspectives to non-invasive brain stimulation protocols of alternative target area for pain treatment.
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Affiliation(s)
- Filippo Brighina
- Dip di Biomedicine Sperimentali e Neuroscienze Cliniche (BioNeC), University of Palermo, Via G. La Loggia, 1, 90129 Palermo, Italy
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172
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Ahmed Z. Trans-spinal direct current stimulation modulates motor cortex-induced muscle contraction in mice. J Appl Physiol (1985) 2011; 110:1414-24. [PMID: 21350028 DOI: 10.1152/japplphysiol.01390.2010] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The present study investigated the effect of trans-spinal direct current (tsDC) on the firing rate, pattern, and amplitude of spontaneous activity of the tibial nerve and on the magnitude of cortically elicited triceps surae (TS) muscle contractions. The effect of combined tsDC and repetitive cortical electrical stimulation (rCES) on the amplitude of cortically elicited TS twitches was also investigated. Stimulation was applied by two disk electrodes (0.79 cm(2)): one was located subcutaneously over the vertebral column (T(10)-L(1)) and was used to deliver anodal DC (a-tsDC) or cathodal DC (c-tsDC) (density range: ± 0.64 to ± 38.2 A/m(2)), whereas the other was located subcutaneously on the lateral aspect of the abdomen and served as a reference. While the application of a-tsDC significantly increased the spike frequency and amplitude of spontaneous discharges compared with c-tsDC, c-tsDC made the spontaneous discharges more rhythmic. Cortically elicited TS twitches were depressed during a-tsDC and potentiated after termination. Conversely, cortically elicited TS twitches were enhanced during c-tsDC and depressed after termination. While combined a-tsDC and rCES produced similar effects as a-tsDC alone, combined c-tsDC and rCES showed the greatest increase in cortically elicited TS twitches. tsDC appears to be a powerful neurostimulation tool that can differentially modulate spinal cord excitability and corticospinal transmission.
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Affiliation(s)
- Zaghloul Ahmed
- Department of Physical Therapy and Neuroscience Program, The College of Staten Island/City University of New York, Staten Island, NY, USA.
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173
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Bagnato F, Centonze D, Galgani S, Grasso MG, Haggiag S, Strano S. Painful and involuntary multiple sclerosis. Expert Opin Pharmacother 2011; 12:763-77. [PMID: 21323633 DOI: 10.1517/14656566.2011.540239] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Pain, dysphagia, respiratory problems, sexual and cardiovascular dysfunctions may occur in patients with MS. AREAS COVERED In the present review, we attempt to summarize the current knowledge on the impact pain, dysphagia, respiratory problems, sexual and cardiovascular dysfunctions have in patients with MS. EXPERT OPINION To effectively manage MS, it is essential that these symptoms are recognized as early as possible and treated by a rehabilitative multidisciplinary approach, based on proven scientific evidence.
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Affiliation(s)
- Francesca Bagnato
- Vanderbilt University Institute of Imaging Science 1161 21st Ave. S. AA1105 MCN Radiology Department, Nashville, TN 37232, USA.
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174
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Hansen N, Obermann M, Poitz F, Holle D, Diener HC, Antal A, Paulus W, Katsarava Z. Modulation of human trigeminal and extracranial nociceptive processing by transcranial direct current stimulation of the motor cortex. Cephalalgia 2011; 31:661-70. [DOI: 10.1177/0333102410390394] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective: The study was conducted to investigate the after-effect of transcranial direct current stimulation (tDCS) applied over the human primary motor cortex (M1) on trigeminal and extracranial nociceptive processing. Basic procedures: Nineteen healthy volunteers were stimulated using cathodal, anodal (both 1 mA) or sham tDCS for 20 minutes. Pain processing was assessed by recording trigeminal and extracranial pain-related evoked potentials (PREPs) following electrical stimulation of the contralateral forehead and hand at baseline, 0, 20 and 50 minutes post-tDCS. Main findings: Cathodal tDCS resulted in decreased peak-to-peak amplitudes (PPAs) by 18% while anodal tDCS lead to increased PPAs of PREPs by 35% ( p < .05). Principal conclusions: The decreased PPAs suggest an inhibition and the increased PPAs of PREPs suggest an excitation of trigeminal and extracranial pain processing induced by tDCS of the M1. These results may provide evidence for the effectiveness of tDCS as a therapeutic instrument in treating headache disorders.
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Affiliation(s)
- Niels Hansen
- University Duisburg-Essen, Germany
- Julius-Maximilians-University, Germany
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175
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Boggio PS, Zaghi S, Villani AB, Fecteau S, Pascual-Leone A, Fregni F. Modulation of risk-taking in marijuana users by transcranial direct current stimulation (tDCS) of the dorsolateral prefrontal cortex (DLPFC). Drug Alcohol Depend 2010; 112:220-5. [PMID: 20729009 DOI: 10.1016/j.drugalcdep.2010.06.019] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Revised: 06/14/2010] [Accepted: 06/18/2010] [Indexed: 01/12/2023]
Abstract
Cognitive deficits that are reported in heavy marijuana users (attention, memory, affect perception, decision-making) appear to be completely reversible after a prolonged abstinence period of about 28 days. However, it remains unclear whether the reversibility of these cognitive deficits indicates that (1) chronic marijuana use is not associated with long-lasting changes in cortical networks or (2) that such changes occur but the brain adapts to and compensates for the drug-induced changes. Therefore, we examined whether chronic marijuana smokers would demonstrate a differential pattern of response in comparison to healthy volunteers on a decision-making paradigm (Risk Task) while undergoing sham or active transcranial direct current stimulation (tDCS) of the dorsolateral prefrontal cortex (DLPFC). Twenty-five chronic marijuana users who were abstinent for at least 24h were randomly assigned to receive left anodal/right cathodal tDCS of DLPFC (n=8), right anodal/left cathodal tDCS of DLPFC (n=9), or sham stimulation (n=8); results on Risk Task during sham/active tDCS were compared to healthy volunteers from a previously published dataset. Chronic marijuana users demonstrated more conservative (i.e. less risky) decision-making during sham stimulation. While right anodal stimulation of the DLPFC enhanced conservative decision-making in healthy volunteers, both right anodal and left anodal DLPFC stimulation increased the propensity for risk-taking in marijuana users. These findings reveal alterations in the decision-making neural networks among chronic marijuana users. Finally, we also assessed the effects of tDCS on marijuana craving and observed that right anodal/left cathodal tDCS of DLPFC is significantly associated with a diminished craving for marijuana.
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Affiliation(s)
- Paulo S Boggio
- Cognitive Neuroscience Laboratory and Developmental Disorders Program, Center for Health and Biological Sciences, Mackenzie Presbyterian University, Rua Piaui, 181, 10 Andar, Sao Paulo, SP 01241-001, Brazil.
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176
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Utz KS, Dimova V, Oppenländer K, Kerkhoff G. Electrified minds: Transcranial direct current stimulation (tDCS) and Galvanic Vestibular Stimulation (GVS) as methods of non-invasive brain stimulation in neuropsychology—A review of current data and future implications. Neuropsychologia 2010; 48:2789-810. [DOI: 10.1016/j.neuropsychologia.2010.06.002] [Citation(s) in RCA: 284] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Revised: 04/15/2010] [Accepted: 06/03/2010] [Indexed: 10/19/2022]
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177
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The analgesic and antihyperalgesic effects of transcranial electrostimulation with combined direct and alternating current in healthy volunteers. Anesth Analg 2010; 111:1301-7. [PMID: 20530614 DOI: 10.1213/ane.0b013e3181e3697e] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Transcranial electrostimulation (TES) has been reported to produce clinically significant analgesia, but randomized and double-blind studies are lacking. We investigated the analgesic and antihyperalgesic effects of TES in validated human experimental pain models. METHODS In 20 healthy male subjects we evaluated the analgesic and antihyperalgesic effects of TES(60Hz) and TES(100Hz) to heat and mechanical pain in experimentally induced ultraviolet B skin sunburns and in normal skin. Previous animal studies in our laboratory predicted that TES(60Hz) would provide significant analgesia, and TES(100Hz) was a suitable active control. The study was conducted in a double-blind, randomized, 2-way cross-over fashion. TES was administered for 35 minutes. Quantitative sensory testing evaluating heat and mechanical pain thresholds was conducted before TES, during TES, and 45 minutes after TES. RESULTS TES (TES(60Hz) > TES(100Hz)) evoked rapidly developing, significant thermal and mechanical antihyperalgesic effects in the ultraviolet B lesion, and attenuated thermal pain in unimpaired skin. No long-lasting analgesic and antihyperalgesic effects of a single TES treatment were demonstrated in this study. CONCLUSIONS TES produces significant, frequency-dependent antihyperalgesic and analgesic effects in humans. The characteristics of the TES effects indicate a high likelihood of its ability to modulate both peripheral sensitization of nociceptors and central hyperexcitability.
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178
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Mori F, Codecà C, Kusayanagi H, Monteleone F, Buttari F, Fiore S, Bernardi G, Koch G, Centonze D. Effects of Anodal Transcranial Direct Current Stimulation on Chronic Neuropathic Pain in Patients With Multiple Sclerosis. THE JOURNAL OF PAIN 2010; 11:436-42. [DOI: 10.1016/j.jpain.2009.08.011] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2009] [Revised: 07/29/2009] [Accepted: 08/26/2009] [Indexed: 10/20/2022]
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179
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Basu A, Graziadio S, Smith M, Clowry GJ, Cioni G, Eyre JA. Developmental plasticity connects visual cortex to motoneurons after stroke. Ann Neurol 2010; 67:132-6. [PMID: 20186850 DOI: 10.1002/ana.21827] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
We report motor cortical function in the left occipital cortex of a subject who suffered a left middle cerebral artery stroke early in development. Transcranial magnetic stimulation of the left occipital cortex evoked contraction of right hand muscles. Electroencephalogram recorded over the left occipital cortex showed: 1) coherence with electromyogram from a right hand muscle; 2) a typical sensorimotor Mu rhythm at rest that was suppressed during contraction of right hand muscles. This is the first evidence that cortical plasticity extends beyond reshaping of primary sensory cortical fields to respecification of the cortical origin of subcortically projecting pathways.
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Affiliation(s)
- Anna Basu
- Developmental Neuroscience, Institute of Neuroscience, Newcastle University, Newcastle Upon Tyne, UK
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180
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Edelmuth RCL, Nitsche MA, Battistella L, Fregni F. Why do some promising brain-stimulation devices fail the next steps of clinical development? Expert Rev Med Devices 2010; 7:67-97. [PMID: 20021241 DOI: 10.1586/erd.09.64] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Interest in techniques of noninvasive brain stimulation (NIBS) has been growing exponentially in the last decade. Recent studies have shown that some of these techniques induce significant neurophysiological and clinical effects. Although recent results are promising, there are several techniques that have been abandoned despite positive initial results. In this study, we performed a systematic review to identify NIBS methods with promising preliminary clinical results that were not fully developed and adopted into clinical practice, and discuss its clinical, research and device characteristics. We identified five devices (transmeatal cochlear laser stimulation, transcranial micropolarization, transcranial electrostimulation, cranial electric stimulation and stimulation with weak electromagnetic fields) and compared them with two established NIBS devices (transcranial magnetic stimulation and transcranial direct current stimulation) and with well-known drugs used in neuropsychiatry (pramipexole and escitalopram) in order to understand the reasons why they failed to reach clinical practice and further steps of research development. Finally, we also discuss novel NIBS devices that have recently showed promising results: brain ultrasound and transcranial high-frequency random noise stimulation. Our results show that some of the reasons for the failure of NIBS devices with promising clinical findings are the difficulty to disseminate results, lack of controlled studies, duration of research development, mixed results and lack of standardization.
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Affiliation(s)
- Rodrigo C L Edelmuth
- Laboratory of Neuromodulation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
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181
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Vanneste S, Plazier M, Ost J, van der Loo E, Van de Heyning P, De Ridder D. Bilateral dorsolateral prefrontal cortex modulation for tinnitus by transcranial direct current stimulation: a preliminary clinical study. Exp Brain Res 2010; 202:779-85. [PMID: 20186404 DOI: 10.1007/s00221-010-2183-9] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2009] [Accepted: 01/28/2010] [Indexed: 10/19/2022]
Abstract
Tinnitus is considered as an auditory phantom percept. Preliminary evidence indicates that transcranial direct current stimulation (tDCS) of the temporo-parietal area might reduce tinnitus. tDCS studies of the prefrontal cortex have been successful in reducing depression, impulsiveness and pain. Recently, it was shown that the prefrontal cortex is important for the integration of sensory and emotional aspects of tinnitus. As such, frontal tDCS might suppress tinnitus as well. In an open label study, a total of 478 tinnitus patients received bilateral tDCS on dorsolateral prefrontal cortex (448 patients anode right, cathode left and 30 anode left, cathode right) for 20 min. Treatment effects were assessed with visual analogue scale for tinnitus intensity and distress. No tinnitus-suppressing effect was found for tDCS with left anode and right cathode. Analyses show that tDCS with right anode and left cathode modulates tinnitus perception in 29.9% of the tinnitus patients. For these responders a significant reduction was found for both tinnitus-related distress and tinnitus intensity. In addition, the amount of suppression for tinnitus-related distress is moderated by an interaction between tinnitus type and tinnitus laterality. This was, however, not the case for tinnitus intensity. Our study supports the involvement of the prefrontal cortex in the pathophysiology of tinnitus.
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Affiliation(s)
- Sven Vanneste
- Brai2n, TRI, Department of Neurosurgery, University Hospital Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium.
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182
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Merzagora A, Foffani G, Panyavin I, Mordillo-Mateos L, Aguilar J, Onaral B, Oliviero A. Prefrontal hemodynamic changes produced by anodal direct current stimulation. Neuroimage 2010; 49:2304-10. [DOI: 10.1016/j.neuroimage.2009.10.044] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 09/23/2009] [Accepted: 10/14/2009] [Indexed: 11/26/2022] Open
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183
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Cogiamanian F, Brunoni A, Boggio P, Fregni F, Ciocca M, Priori A. Non-invasive brain stimulation for the management of arterial hypertension. Med Hypotheses 2010; 74:332-6. [DOI: 10.1016/j.mehy.2009.08.037] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Accepted: 08/23/2009] [Indexed: 11/15/2022]
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184
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Hecht D. Transcranial direct current stimulation in the treatment of anorexia. Med Hypotheses 2010; 74:1044-7. [PMID: 20096507 DOI: 10.1016/j.mehy.2009.12.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 12/27/2009] [Indexed: 11/29/2022]
Abstract
Transcranial direct current stimulation (tDCS) is a non-invasive technique for brain stimulation and it increasingly being used in the treatments of some neurological/psychiatric conditions (e.g. chronic pain, epilepsy, depression, motor rehabilitation after stroke and Parkinson's disease). With tDCS, cortical neurons excitability increases in the vicinity of the anodal electrode and suppressed near the cathodal electrode. There is evidence that anorexia is associated with hyperactivity in right-hemisphere frontal regions. tDCS, therefore has a promising potential in facilitating inter-hemispheric balance. A tDCS protocol is proposed: the anode electrode placed over the left prefrontal cortex and the cathode electrode located, either on the right homotopic region for non-SSRI-medicated anorexics, or on a non-cephalic site for SSRI-medicated anorexics. Together with nutritional supplements, psychotherapy and other treatments, tDCS have a good potential, as a complementary tool, in the treatment of anorexia.
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Affiliation(s)
- David Hecht
- Institute of Cognitive Neuroscience, University College London, London WC1N 3AR, UK.
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185
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Zaghi S, Acar M, Hultgren B, Boggio PS, Fregni F. Noninvasive brain stimulation with low-intensity electrical currents: putative mechanisms of action for direct and alternating current stimulation. Neuroscientist 2009; 16:285-307. [PMID: 20040569 DOI: 10.1177/1073858409336227] [Citation(s) in RCA: 227] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Transcranial stimulation with weak direct current (DC) has been valuable in exploring the effect of cortical modulation on various neural networks. Less attention has been given, however, to cranial stimulation with low-intensity alternating current (AC). Reviewing and discussing these methods simultaneously with special attention to what is known about their mechanisms of action may provide new insights for the field of noninvasive brain stimulation. Direct current appears to modulate spontaneous neuronal activity in a polarity-dependent fashion with site-specific effects that are perpetuated throughout the brain via networks of interneuronal circuits, inducing significant effects on high-order cortical processes implicated in decision making, language, memory, sensory perception, and pain. AC stimulation has also been associated with a significant behavioral and clinical impact, but the mechanism of AC stimulation has been underinvestigated in comparison with DC stimulation. Even so, preliminary studies show that although AC stimulation has only modest effects on cortical excitability, it has been shown to induce synchronous changes in brain activity as measured by EEG activity. Thus, cranial AC stimulation may render its effects not by polarizing brain tissue, but rather via rhythmic stimulation that synchronizes and enhances the efficacy of endogenous neurophysiologic activity. Alternatively, secondary nonspecific central and peripheral effects may explain the clinical outcomes of DC or AC stimulation. Here the authors review what is known about DC and AC stimulation, and they discuss features that remain to be investigated.
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Affiliation(s)
- Soroush Zaghi
- Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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186
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Arul-Anandam AP, Loo C, Martin D, Mitchell PB. Chronic neuropathic pain alleviation after transcranial direct current stimulation to the dorsolateral prefrontal cortex. Brain Stimul 2009; 2:149-51. [DOI: 10.1016/j.brs.2008.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 12/19/2008] [Accepted: 12/19/2008] [Indexed: 11/26/2022] Open
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187
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The use of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) to relieve pain. Brain Stimul 2008; 1:337-44. [DOI: 10.1016/j.brs.2008.07.003] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2008] [Revised: 07/22/2008] [Accepted: 07/23/2008] [Indexed: 12/17/2022] Open
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