Transracial direct current stimulation (tDCS) is a non-invasive form of brain stimulation that delivers low currents of electricity to modulate neuronal activity. It has been studied as a treatment for conditions such as depression, stroke rehabilitation and cognitive impairment. While generally safe with minor side effects like skin irritation and fatigue, more research is still needed on its efficacy and long term effects before it can be recommended in clinical practice. tDCS holds promise as a treatment to induce neuroplasticity but requires further evaluation in controlled trials.
Intro to Transcranial Direct Curent Stimulation (tDCS)Daniel Stevenson
A comprehensive introduction to tDCS with a main focus on research utilizing motor-evoked potentials (MEPs) to uncover the physiological mechanism of therapeutic and enhancing effects of tDCS application. Regulation and FDA guidelines are also thoroughly covered. Provides a good source of relevant academic citations (on each slide).
Trans-cranial Direct Current Stimulation (tDCS) has been found effective and easy way in Stroke Rehabilitation. This is a literature review of few articles that reported the results of clinical trials of such DC stimulation in patients with stroke during their rehabilitation.
Late response are the most helpful findings in some of the diseases affecting the peripheral nerves, (e.g GBS, Radiculopathies, ). How to assess these responses while performing Nerve Conduction Studies, is the most technical and theoretical consideration.... Here we go with the same things in the stated slides
Intro to Transcranial Direct Curent Stimulation (tDCS)Daniel Stevenson
A comprehensive introduction to tDCS with a main focus on research utilizing motor-evoked potentials (MEPs) to uncover the physiological mechanism of therapeutic and enhancing effects of tDCS application. Regulation and FDA guidelines are also thoroughly covered. Provides a good source of relevant academic citations (on each slide).
Trans-cranial Direct Current Stimulation (tDCS) has been found effective and easy way in Stroke Rehabilitation. This is a literature review of few articles that reported the results of clinical trials of such DC stimulation in patients with stroke during their rehabilitation.
Late response are the most helpful findings in some of the diseases affecting the peripheral nerves, (e.g GBS, Radiculopathies, ). How to assess these responses while performing Nerve Conduction Studies, is the most technical and theoretical consideration.... Here we go with the same things in the stated slides
Event Related Potentials, Cognitive Evoked Potentials. These are stimulus unrelated potentials, which depend on the patient's ability to differentiate between a rare stimulus and a common stimulus.
biofeedback is a modality of behavioral therapy that helps patients to gain control over their physical subliminal functions by increasing their awareness of bodily responses to physical, emotional and psychological stress
Transcranial magnetic stimulation (TMS) is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain.
This video explains the physics of this method and how it can be used in daily practice.
More about magnetic simulators: http://www.neurosoft.ru/eng/product/neuro-msd/index.aspx
Event Related Potentials, Cognitive Evoked Potentials. These are stimulus unrelated potentials, which depend on the patient's ability to differentiate between a rare stimulus and a common stimulus.
biofeedback is a modality of behavioral therapy that helps patients to gain control over their physical subliminal functions by increasing their awareness of bodily responses to physical, emotional and psychological stress
Transcranial magnetic stimulation (TMS) is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain.
This video explains the physics of this method and how it can be used in daily practice.
More about magnetic simulators: http://www.neurosoft.ru/eng/product/neuro-msd/index.aspx
Marom Bikson speaks at the BrainSTIM2015 - Targeting transcranial Electrical Stimulation (tES) using EEG. Includes how to use EEG to inform transcranial Direct Current Stimulation (tDCS) montages. And critical pitfalls in concurrent recording. Stay tuned for our upcoming paper on reciprocity.
The complete video can be found here: https://www.youtube.com/watch?v=yYmDQB7qSCE
The first publication on the topic can be found here http://neuralengr.com/wp-content/uploads/2016/05/2016-Cancelli-A-simple-method.pdf
Related technology can be found here http://soterixmedical.com/research/monitoring/eeg
Repetitive Transcranial Magnetic Stimulation at Southeastern Psychiatric Asso...Miriam Isreb
Repetitive Transcranial Magnetic Stimulation is a noninvasive treatment that uses a magnetic field to stimulate nerve cells in the dorsolateral prefrontal cortex, to relieve symptoms of depression. For more information, please review the e-brochure.
If you have any questions or are interested in receiving this treatment, please email sepa.tms@gmail.com
Magnets - Not Drugs: TMS IMMH San Antonio 2014Louis Cady, MD
In this talk, Dr. Cady covers a remarkable new treatment for depression: transcranial magnetic stimulation. The historical roots of this treatment are traced, followed by a review of the literature in terms of the proven efficacy of this treatment. A comparison with ECT shows that TMS has a very favorable profile, with remarkably fewer side effects and incredibly better tolerated side effects compared to ECT. Given that this was a "CME" talk, off-label uses of TMS were reviewed, including stepping stones for future avenues to explore
Physiology of Neuromodulation and neuromodulators. Difference between neuromodulation and synapse. Recent advances in neuromodulation, clinical application of neuromodulation.
This presentation gives an over view: of the depression, its symptoms, prevalence, and patho-physiology. It then reviews various treatment options for depression, first starting with medication, and then moving to neuro-modulation. Focus is then on the similarities and differences of ECT and TMS. And finally information is provided about PineWood TMS.
Deep brain stimulation (DBS)/Brain pacemaker has evolved as an important and established treatment modality for variety of advanced movement disorders and also for some psychiatry disorders.1Chronic DBS stimulation provides a non destructive and reversible means of disturbing the abnormal function of basal ganglia circuit. It can be adjusted as disease progresses or adverse event occur. Bilateral stimulation can be performed without a significant increase inadverse effects.Adverse events related to unintended stimulation of adjacent structures are readily reversible by altering the stimulus parameters.
Micro-Neuro-Sensor Recording of STN Neurons of the Human Brainijcoa
What cause to the neurons of the human brain cells when they are damaged. They become inactive. So damage to subthalamiuc nucleus (STN) neurons of the human brain causing larger involuntary movements and thereby attacking the Parkinson’s disease (PD). Deep brain stimulation (DBS) of bilateral sub thalamic nuclei (STN) is an efficient method of rehabilitation technique in subjects with advanced idiopathic Parkinson’s (or Parkinson) disease. Accurate targeting of STN neurons and placement of microelectrodes/ (neurosensors) are paramount importance for optimal results after STN-DBS method.In this paper, microminiaturized electrode recordings (MER) of STN neurons were detected in a mean of 3.5 ±1.1 channels on right hemisphere and 3.6 ±1.04 on left hemisphere.Final channel selected were most commonly central seen in 42.3% followed by anterior in 33.7%. When a high current is delivered to STN or GPi neurons of basal ganglia (a component of human brain), causing their inhibition and improved indication of symptoms. It is now known that there is a significant change in the firing pattern and a reorganization of the entire basal ganglia circuit with DBS. The MER of STN neurons has identified a specific high frequency irregular larger amplitude firing patterns seen only in disease states and hence used to detect the neurons of ST nucleus during functional surgery. Microelectrode recording is so useful to confirm the right path but has to be taken in consideration with effects on macro stimulation.
Similar to Transcranial direct current stimulation (20)
Diagnosis and Treatment of Psychosomatic Disorder (Educational Slides)Andri Andri
This is a standard presentation for teaching medical students and colleagues about psychosomatic disorder, its diagnosis and therapy. We hope by reading this slides, you will understand the nature of psychosomatic disorder and its current approach in therapy
Psychogenic Pain : Psychosomatic Point of ViewAndri Andri
This presentation was presented in "Medical Approach in Holistic Management to Relieve Pain" 13 Des 2015 at The Sunan Hotel, SOLO.
Since Pain is always subjective, Psychogenic pain is very related to psychiatric problems and very often it does not recognized by physicians in their practice.
Relationship between sleep disorder and gastrointestinal problemAndri Andri
Presentasi tentang hubungan gangguan tidur dengan gangguan lambung/gastrointestinal. Slides ini dipresentasikan pada Konas Psikiatri Biologi dan Psikofarmakologi di Makassar 30 Juli 2015
This presentation is talking about the relationship between sleep disorder and gastrointestinal disorder. Presented in National Conference of Psychiatry Biology in Makassar, Indonesia July 30th,2015
Pandangan Ilmu Kedokteran Jiwa pada KESURUPAN Andri Andri
Kasus Kesurupan di Indonesia banyak dikaitkan dengan budaya. Presentasi ini mencoba melihat masalah kesurupan lebih kepada sudut pandang ilmiah. Presentasi ini disampaikan di Fakultas Psikologi Univ Mercubuana pada tanggal 23 Mei 2015
Developing Leadership Skills: Lessons Learned from Our TeachersAndri Andri
Developing Leadership Skills: Lessons Learned from Our Teachers
Maryland Pao, MD, FAPM
Clinical Director and Deputy Scientific Director, National Institute of Mental Health, National Institutes of Health, DHHS, Bethesda, Maryland
Donald L. Rosenstein, MD, FAPM
Director, Comprehensive Cancer Support Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Karen Johnson, MD, FAPM
Associate Chair, Department of Psychiatry; Director, Consult Liaison Services, Medstar Washington Hospital Center, Professor of Psychiatry Georgetown University School of Medicine, Washington, District of Columbia
Theodore Stern, MD, FAPM
Chief, Avery D. Weisman Psychiatry Consultation Service, Massachusetts General Hospital, Ned H. Cassem Professor of Psychiatry in the field of Psychosomatic Medicine/Consultation, Harvard Medical School, Boston, Massachusetts
As early career psychiatrists advance and reach the next level in their careers, they are called upon to lead programs and their respective academic fields. But what makes an effective leader? Are leaders born? Are leaders a product of the times? Can leadership be taught? Leaders in Psychosomatic Medicine will review the available evidence base and share their own experiences.
Dr. Maryland Pao will introduce evolving ideas of leadership from the business literature from Dale Carnegie's "How to win friends and influence people" to Jim Collins' "Good to Great" to Sheryl Sandberg's "Lean In". Dr. Donald Rosenstein will discuss the often neglected topic of unsung heroes, "Deputy Leadership". Dr. Karen Johnson will provide considerations regarding academic advancement in "Negotiating Institutions: Models for Promotion". Dr. Pao will talk about choices we make to lead or not in "Lean In, Lean Out: How do we choose?" Finally, Dr. Theodore Stern will talk on "What makes a leader an effective leader?" The panel will encourage audience participation and allow time for discussion.
Learning Objectives:
To describe at least 3 ideas used by business leaders in the last few decades and understand how they might apply to leadership in the field of Psychosomatic Medicine
To understand how emotional intelligence can facilitate effective leadership
To appreciate the critical role of deputy leadership in health care organizations
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
3. OUTLINE
What CL Psychiatrists Need to Know
Complications of tDCS
Efficacy of tDCS
Indications/Contraindications for tDCS
Mechanism of Action of tDCS
What is tDCS?
Brief History of Electrical Stimulation
5. EARLY BRAIN STIMULATION
Ancient civilizations applied the
electric torpedo fish to the head
to treat illness (Kellaway 1946)
Kellaway P. The part played by electric fish in the early history of
bioelectricity and electrotherapy. Bull Hist Med 1946; 20(2): 112-137.
6. 18-19TH CENTURIES
Giovanni Aldini in 1803 used
voltaic devices to stimulate
patients and corpses (Aldini 1803)
Rudolph Arndt in 1870 applied
electrotherapy to the scalp to treat
mental illness (Steinberg 2013)
Stagg CJ, Nitsche MA. Physiological basis of tDCS. Neuroscientist 2012. Steinberg H. A pioneer work on electric brain stimulation in psychotic patients: Rudolph Gottfried Arndt
and his 1870s studies. Brain Stim 2013; 6: 477-481.
7. 20TH CENTURY
“Electrosleep
Therapy” (1950s)
• Russian experiments
“Brain Polarization”
(1970s)
• British, US experiments
“tDCS” (2000)
• Nitsche, Paulus Clark VP, Parasuraman R. Neuroenhancement: enhancing brain and
mind in health and disease. Neuroimage 2014; 85: 889-894.
9. WHAT IS TDCS?
A form of brain stimulation:
• Non-invasive
• Non-focal
• Non-convulsive
Delivers low currents of electricity
• Patient is conscious
• Minimal discomfort
Modulates spontaneous neuronal activity
• Neurons become more or less likely to fire
• Does not trigger action potentials
• More charge over time ~ longer lasting effect
10. DIRECT CURRENT
The electrode placement and
direction of current flow has
specific effects (George 2010)
Anodal current = depolarizing
Cathodal current = hyperpolarizing
George MS, Aston-Jones G. Noninvasive techniques for probing neurocircuitry and treating illness: VNS, TMS, and tDCS. Neuropsychopharmacology 2010; 35: 301-316. Saote C,
Turi Z, Paulus W, Antal A. Combining functional magnetic resonance imaging with tDCS. Front Hum Neurosci 2013; 7 (435): 1-7.
12. CONSTANT CURRENT
tDCS is not pulsatile, so there
is no pulsewidth variable.
Voltage varies to maintain
current constant (V = IR)
Current strength is varied
depending on desired intensity
of stimulation.
Current duration is varied
depending on desired total
charge.
Nitsche MA et al. TDCS: state of the art 2008. Brain Stimulation 2008;
1: 206-223.
14. ANIMAL STUDIES
Applied cortical direct currents
resulted in long-lasting
changes in firing rates (Bindman
1963)
Changes in firing rates
dependent on protein
synthesis, calcium handling,
cAMP accumulation (Gartside
1968, Nitsche 2008)
Bindman LJ, LIppold OCJ, Redfearn JWT. Long-lasting changes in the level of the electrical activity of the cerebral cortex produced by polarizing currents. Nature 1962; 4854: 584-
585. Gartside IB. Mechanisms of sustained increases of firing rate of neurones in the rat cerebral cortex after polarization: role of protein synthesis. Nature 1968; 220: 383-384.
15. POLARIZING CURRENT
Electric fields penetrate the
scalp and cause polarization of
neurons, increasing or
decreasing their excitability (de
Berker 2013)
de Berker AO, Bikson M, Bestmann S. Prediciting the behavioral impact of transcranial direct current stimulation: issues and limitations. Front Hum Neurosci 2013; 7(613): 1-6.
Miranda PC, Lomarev M, Hallett M. Modeling the current distribution during tDCS. Clin Neurophys 2006; 117: 1623-1629. de. Pazzarini M, Fiocchi S, Rossi E, Paglialonga A,
Ravazzani P. tDCS: estimation of the electric field and of the current density in an anatomical human head model. IEEE transactions on biomedical engineering 2011; 58(6): 1773-
1780.
16. TDCS MODULATES CORTICAL
EXCITABILITY
Priori A. Brain polarization in humans: a reappraisal of an old tool for prolonged non-
invasive modulation of brain excitability. Clin Neurophys 2003; 114: 589-595.
Wassermann EM, Grafman J. Recharging cognition with DC brain polarization.
Trends Cog Sci 2005; 9(11): 503-505. Nitsche MA, Paulus W. Excitability changes
induced in the human motor cortex by weak transcranial direct current stimulation. J
Physiol 2000; 527(3): 633-639.
Motor evoked potentials are
facilitated by anodal tDCS and
inhibited by cathodal (Nitsche 2000)
17. TDCS INDUCES LTP-LIKE
NEUROPLASTICITY
LTP is a persistent increase in
neuronal transmission after
synchronous stimulation.
tDCS-induced changes in
neuronal firing are dependent
on NMDA, Ca++, and BDNF like
LTP
Monte-Silva K, Kuo MF, Hessenthaler S, Fresnoza S, Liebetanz D, Paulus W, Nitsche MA. Induction of late LTP-like plasticity in the human motor cortex by repeated non-
invasive brain stimulation. Brain Stim 2013; 6: 424-432. Fritsch B, Reis J, Martinowich K, Schambra HM, Ji YY, Cohen LG, Lu B. Direct current stimulation promotes BDNF-
dependent synaptic plasticity: potential implications for motor learning. Neuron 2010; 66: 198-204.
18. TDCS FOCAL EFFECTS
N-acetyl aspartate increased
focally under the electrode (Clark
2011)
Cerebral blood flow increases
under the electrode (Lang 2005)
Clark VP, Coffman BA, Trumbo MC, Gasparovic C. TDCS produces localized and specific alterations in
neurochemistry: a 1H MRS study. Neurosci Lett 2011500: 67-71. Lang N, Siebner HR, Ward NS, Lee L, Nitsche MA,
Paulus W, Rothwell JC, Lemon RN, Frackowiak RS. How does TDCS of the primary motor cortex alter regional
neuronal activity in the human brain? Eur J Neurosci 2005; 22: 495-504. Jang SH, Ahn SH, Byun WM, Kim CS, Lee
MY, Kwon YH. The effect of TDCS on the cortical activation by motor task in the human brain: an fMRI study.
Neurosci Lett 2009; 460: 117-120.
19. TDCS NONFOCAL
tDCS effects are diffuse
and spread over
multiple regions and
networks. (Lang 2005)
Lang N, Siebner HR, Ward NS, Lee L, Nitsche MA, Paulus W, Rothwell JC, Lemon RN, Frackowiak RS. How does tDCS of the primary motor cortex alter regional
neuronal activity in the human brain? Eur J Neurosci 2005; 22: 495-504. Pena-Gomez C, Sala-Lonch R, Junque C, Clemente IC, Vidal D, Bargallo N, Falcon C, Valls-
Sole J, Pascual-Leone A, Bartres-Faz D. Modulation of large-scale brain networks by tdcs evidenced by resting-state fMRI. Brain Stim 2012; 5: 52-63.
21. DC STIMULATORS
Not FDA Approved for use
in Psychiatric Disorders
• Certain devices are FDA
approved for iontophoresis
Studied in:
• Stroke rehabilitation
• Memory/Alzheimers
• Depression/Emotion
• Learning/Perception
• Pain/Fibromyalgia
• Addiction/Impulsivity
• Tinnitus
• Epilepsy
Exclusions from
studies:
• Metal implant
• Pregnancy
• Seizure disorder
• Ongoing substance use
23. TDCS FOR STROKE
Hummel F, Celnick P, Giraux P, Floel A, Wu WH, Gerloff C, Cohen LG. Effects of non-invasive cortical stimulation on
skilled motor function in chronic stroke. Brain 2005; 128: 490-499.Adeyemo BO, Simis M, Macea DD, Fregni F.
Systematic review of parameters of stimulation, clinical trial design characteristics, and motor coutcomes in non-
invasive brain stimulation in stroke. Front Psychiatry 2012; 3 (88): 1-27.
24. DEPRESSION
120 mod-severe nonpsychotic
MDD pts received sertraline 50
mg daily (60) or placebo (60)
(Brunoni 2013)
60: 12 tx tDCS: 2 mA DLPFC (L
anodal/R cathodal) x 30min
60: sham tDCS
Brunoni AR, Valiengo L, Baccaro A, Tamires AZ, Oliveira JF, Goulart A, Boggio PS, Lotufo PA, Bensenor IM, Fregni F. The sertraline versus electrical current therapy for treating
depression study clinical study. JAMA Psychiatry 2013; 70(4): 383-391.
25. LEARNING
fMRI of detection task in 96 pts
revealed R Frontal and Parietal
foci of activation (Clark 2012)
Anodal 2 mA tDCS x 30 min to
these areas led to faster
learning
Clark VP, Coffman BA, Mayer AR, Weisend MP, Lane TDR, Calhoun VD, Raybourn EM, Garcia C, Wasserman EM. tDCS guided using fMRI significantly accelerates learning to identify
concealed objects. Neuroimage 2012; 59: 117-128.
26. LEARNING
Clark VP, Coffman BA, Mayer AR, Weisend MP, Lane TDR, Calhoun VD, Raybourn EM, Garcia C, Wasserman EM. tDCS guided using fMRI significantly accelerates learning to
identify concealed objects. Neuroimage 2012; 59: 117-128.
27. TDCS FOR MMTBI
US: 1.7 million TBIs annually
NM 2nd among 34 states in TBI deaths
Suicide by firearm (38%)
Motor vehicle accident (22%)
Falls (17%)
Homicide (12%)
NM Brain Injury Advisory Council, www.nmbiac.com.
Traumatic Brain Injury in the United States,
www.cdc.gov/TraumaticBrainInjury Yeo RA, personal correspondence
29. SIDE EFFECTS
Hypomania/Insomnia
Drowsiness/Fatigue
Skin Itching/Burning
Nausea/Headache
NO seizures
NO autonomic/CV effects
NO lasting cognitive changes
**Both utilized Neuroconn devices
Palm U, Keeser D, Schiller C, Fintescu Z, Reisinger E, Nitsche M, Padberg
F. Skin lesions after treatment with tDCS. Brain Stim 2008; 1: 386-387.
Frank Em Wilfurth S, Landgrebe M, Eichhammer P, Hajak G, Langguth B.
Anodal skin lesions after treatment with tDCS. Brain Stim 2010; 3: 58-59.
Arul-Anandam AP, Loo C, Mitchell P. Induction of hypomanic episode with
tDCS. J ECT 2010; 26)7): 68-69. Vandermeeren Y, Jamart J, Ossemann M.
Effect of tDCS with an extracephalic reference electrode on cardio-
respiratory and autonomic functions. BMC Neurosci 2010; 11: 38. Poreisz C,
Boros K, Antal A, Paulus W. Safety aspects of TDCS concerning healthy
subjects and patients. Brain Res Bull 2007; 72: 208-214.
31. NEED TO KNOW
TDCS is:
• Extremely safe
• Induces neuroplasticity and
modulates neuronal activity both
focally and nonfocally
• Not FDA approved for use on the
brain
• Potentially synergistic with
medications
• Likely to cause mild side effects
• Most likely to affect your current
practice—when video gamer comes
into the ED with scalp burns from
DIY TDCS
• A potential therapy for many
psychosomatic medicine disorders
http://smartdrugsmarts.com/do-it-yourself-transcranial-direct-current-
stimulation/
32. THANKS
UNM Center for Brain
Recovery and Repair
Bill Shuttleworth
Ronald Yeo
Richard
Campbell
UNM Psychology
Clinical
Neuroscience Center
Vince Clark
Brian Coffman
UNM Department of
Psychiatry
Mauricio Tohen
Chris Abbott
Alya Reeve
Brant Hager
MIND Research
Network
Andrew Mayer
Stefan Klimaj
33. Murat Altinay, MD |
Fellow in Mood Disorders and Neurosciences
Cleveland Clinic Foundation
Department of Psychiatry
36. Major depressive disorder (MDD):
Common
Recurrent
Chronic
Leading contributor to disability
Current treatments fall short (~20 to 40% failing to
respond to AD trials)
Psychotropic medications,
Psychotherapy,
ECT
STAR-D highlighted these limitations.
Failure of depression to respond to currently available
treatment options-- major treatment challenge.
37.
38. VNS is an implantable neuromodulation device which
has established efficacy in pharmaco-resistant
epilepsy.
July 2005:
FDA approval as an adjunctive treatment of severe,
recurrent unipolar and bipolar depression.
Other disorders (under investigation):
Anxiety,
Migraines
Alzheimer’s disease.
39. Innervation
- larynx,
- esophagus,
- trachea,
- heart,
- aorta, and GI
The right
vagus:
HR regulation
SA node
(pace maker
of the heart)
The left
vagus:
AV node (less-
no influence in
HR)
41. The VNS device:
generator electrodes
low-frequency, chronic
intermittent-pulsed electrical
signals left cervical vagus
nerve.
Separate incision in the neck
stimulating electrodes
wrapped around the left
cervical vagus nerve.
Subcuteanous tunelling
procedure
Electrodes are connected to
the implanted generator.
42.
43. VNS was approved for pharmaco-resistant epilepsy in
Europe in 1994 and in the US in 1997.
Anecdotal clinical observations of mood improvement
in epilepsy patients after VNS implantation.
Role for VNS therapy in depression??
July 2005:
FDA approval as an adjunctive treatment of severe,
recurrent unipolar and bipolar depression.
44. Epilepsy Studies
Harden et al. (2000)
A pilot prospective study
VNS effects on mood in epilepsy patients
VNS device vs. anti-epileptic drugs
Significant mood improvement in the VNS group at 3 months.
(HAMD, HAMA, BDI, CDRS)
Elger et al. (2000)
11 epilepsy pts w/ mild MDD.
Baseline
9 /11 subjects had significant depressive symptoms
Only 2/10 at 6-months follow up.
Only 2/11 subjects in the trial could be classified as responders in terms of
seizure reduction over the 6-months
These findings suggested that VNS has a separate and distinct
effect on depressive symptoms not related to outcomes on
seizures
45.
46. Open label Studies
• 30 pts with chronic uni/bipolar depression
who had failed ≥ 2 AD trials.
• Implantation 2 week recovery (no
stim) 10 weeks of stim + existing fixed
med.
• Results: Response rate of 40% and a
remission rate of 17%.
Rush et al
(2000)
• 30 TRD unipolar and bipolar patients for a
total sample size of 60.
• 12 weeks (2 week post-surgery w/o stim
10 weeks of VNS) to determine the acute
response to VNS.
• Response rate: 30% (HAM-D-28). 37%
CGI-I and 34% on the MADRS.
• Remission (HAM-D score <10) : 15%.
O’Reardon
et al
47. Randomized Controlled studies
Rush et al. (2005)
A negative trial.
Multi-center trial of VNS (n=225)
Active vs. sham VNS
10-weeks of active stimulation the response rate on HAM-D24
was 15% (n=112) and the sham/placebo response rate was 10%
(n=110), which did not differ from each other (p=0.238).
BUT– well tolerated + better response rate on self report
measure IDS-SR-30.
48. The first pilot study (Rush et al. 2000) followed patients
over 12 months:
Response rates increase over time (HAMD24 response rate was
27.2% ; remission rate (HRSD(24) < or = 9) 15.8% )
10-week trials of VNS might underestimate its potential
to treat TRD patients.
Marangell et al. (2002)
Additional 9-months of VNS (1 year total)
Response rate slightly increased from 40 46%
Remission rate increased 17% (3 months) to 29% at 1
year
49. 2 years
Results remained similar:
- response rate of 42% and
a - remission rate of 22%
- Overall response
rate : 40-45% long
term
- 81% of patients
who elect to keep
their device active
at 2-years.
Additional 25% of patients
(separate from the 42%),
improvement in symptoms of
25 -49%, which is short of
responder status
meaningful in the context of
severe, unremitting MDD?
51. Manufacturer FDA
• One-year outcomes from its
pivotal trial.
One-year outcome:
• VNS+ TAU (n=205)vs TAU
(n=124) compared.
Adjunctive VNS
• Better outcomes compared to
TAU only.
• HAM-D the response rate with
VNS was 30% vs. 13% with TAU
• CGI-I the margin of superiority
was greater, 37% versus 12%
response rate.
• IDS-SR-30, the response rate
with VNS was 22% versus 12% for
TAU
Longer term, adjunctive
VNS:
• Increased response rate in TRD
by 2-3 fold,
• Fairly low absolute response
rates,
• Indicates impressive adjunctive
benefit from VNS in this severely
ill patient group
52. The FDA approved the VNS implant for patients with
chronic or recurrent depression, (uni/bipolar) with a
history of failure of their depression to respond to at
least 4 antidepressant interventions.
ECT failure is not a requirement to be eligible for VNS
53.
54. Indication
TRD patients with bipolar and unipolar depressive
episodes as a long term adjunctive treatment option
Failure to respond to ECT is not a prerequisite for VNS
eligibility,
It may be appropriate to use ECT as an acute treatment
for severe depression to be followed by VNS as a long
term maintenance intervention.
55. Relative
Contraindications
Not approved for psychotic
MDD or the depressed
phase of SAD.
Paranoid ideation
Unstable axis II disorders
Borderline personality
disorder or other
disorders,
Not studied in pregnancy-
non-systemic treatment
potential effects on fetus should
be limited
Limitations in post-surgery MRI
MRIs spine/joints prohibited.
MRI brain possible w/ special
send-receive coils. (otherwise a CT scan
would need to substitute for an MRI)
Dissatisfied?
Could be switched off (the implant left
in place)
Pulse generator could be
explanted.
The electrode is left in situ--
adhesions around the vagus nerve
itself might increase risk of injury
during removal .
Precautions with MRI remain in
place indefinitely
Special Precautions
56. Dosing
4 principal settings
1. current charge (mA),
2. pulse width (microseconds),
3. frequency (Hz),
4. duty cycle (on time relative to off time - in seconds and
expressed as a percentage).
Start at 0.25 mA, increase gradually in 0.25 mA increments
until a comfortable tolerance level is reached.
Maximum tolerable level has been exceeded pain/ bouts
of coughing.
The stimulating device is then reset to the highest
‘comfortable’ setting.
57. Surgery
post 2 wks
•0.25 mA titrations in
current so that a
target dose of 1.0 mA
might be achieved at
the end of the first
month.
Weekly for
1 month
Q 2weeks for
1 month
Month 3
•Monthly visits if effective
•amplitude 1.0-1.5 mA range
and no improvement
increase the duty cycle at
the juncture by adjusting
the on-off schedule.
Significant proportion of
responders to VNS only
emerge in the second 6
months of stimulation and
a full VNS trial may require
at least 12 months
61. VNS device can remain functioning for up to 8 years.
Patients are unable to adjust the treatment settings
independently.
In the one year pivotal study (Rush et al. 2005)
Continuation rate at 1 year was 90%.
3% discontinued secondary to adverse events
implant related infection,
hoarseness,
lightheadedness,
postoperative pain
chest and arm pain.
7% -- lack of efficacy or other reasons.
At 2 years (Nahas et al 2005)
>80% of patients had device in place and functioning
Most subjects electing to discontinue VNS because of lack of efficacy
rather than side effects.
62. Safe and effective treatment in TRD
FDA approved.
Better results when used long term (12
weeks-1 year)
Better results when combined with
meds. (can be combined with any meds
including MAOIs).
Safe with ECT but it needs to be turned
off.
No cognitive side effects.
Can be used both for unipolar and
bipolar depression
Dosing can be done in an outpatient
setting.
Cautions
Surgical risks
Current and future MRI safety
Side effects
http://www.utsouthwestern.edu/newsroom/news-releases/year-2005/vns-therapy-
for-treatment-resistant-depression-proves-effective-for-some-patients.html
Vagal Nerve Stimulation for Seizures. Textbook of Stereotactic and Functional
Neurosurgery. pp 2801-2822
63. Safe and efficient neuromodulation modality in TRD.
Over the longer term at one and at two years the
results observed with VNS appear reasonable in terms
of realistic expectations for this population.
A controlled post marketing study as suggested by the
FDA is being conducted by the device manufacturer.
Significant promise to treat TRD as a long term
treatment.
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