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Methods and Technologies for Low-Intensity Transcranial Electrical Stimulation: Waveforms, 2 Terminology, and Historical Notes

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Methods and Technologies for Low-Intensity Transcranial Electrical Stimulation: Waveforms, 2 Terminology, and Historical Notes Methods and Technologies for Low-Intensity Transcranial Electrical Stimulation: Waveforms, 2 Terminology, and Historical Notes Berkan Guleyupoglu, Pedro Schestatsky, Felipe Fregni, and Marom Bikson Scope and Approach 2. Electroanesthesia (EA) went through several periods of waning interest and resurgence when new waveform Transcranial electrical stimulation (tES) encompasses all variations were proposed, including transcutaneous forms of research and clinical applications of electrical cranial electrical stimulation (TCES), Limoge, and inter- currents to the brain noninvasively using (at least one) ferential stimulation (IS). electrodes on the head. The dose of tES is defined by the 3. Polarizing or direct current stimulation includes recent electrode montage and the stimulation waveform applied to transcranial direct current stimulation, transcranial the electrode [1]. There has been a resurgence of interest micropolarization, high-definition transcranial direct cur- since 2000, but “modern” tES developed incrementally over rent stimulation (HD-tDCS), and galvanic vestibular a century. This review provides the first comprehensive stimulation (GVS). organization of approaches and doses used in modern tES 4. Electroconvulsive therapy (ECT), initially called electro- since 1900. shock therapy, evolved in technique and dose, such as This process involves defining the litany of terminology focal electrically administered seizure therapy (FEAST). that has developed and evolved around tES. We make no 5. Finally, we categorize “contemporary” approaches that attempt to re-define or qualify any approaches used, but have been explored intensely over the last decade, such explain the terminology as used contemporarily by as transcranial alternating current stimulation (tACS), researchers. Particular attention is paid to historically linked transcranial sinusoidal direct current stimulation categories of tES, “streams,” of which we identify four that (tSDCS), and transcranial random noise stimulation span decades plus “contemporary” approaches (Fig. 2.1). (tRNS). Though analogues to these contemporary 1. Cranial electrical stimulation (CES) descended from approaches can be identified in earlier literature, contem- electrosleep (ES) through cranial electro-stimulation porary approaches contain dose features that motivate us therapy (CET), transcerebral electrotherapy (TCET), to consider them novel. Contemporary approaches to and neuroelectric therapy (NET). some extent reflect a “re-boot” of the tES approach, typically employing basic, well-documented, and well- defined waveforms (e.g., one sinusoid [1] in contrast to B. Guleyupoglu (*) the increasingly complex waveforms developed [though Department of Biomedical Engineering, The City College of New not always justified] over decades in some streams. York, 160 Convent Avenue, 463 Steinman Hall, New York, NY 10031, USA As our technical focus is on dose clarification and clas- e-mail: [email protected] sification, we minimize comments on the clinical efficacy P. Schestatsky or safety of any approaches except in special cases where Department of Internal Medicine, Universidade Federal do Rio Grande findings resulted in historically notable and sudden changes do Sul, Capes, Brazil in dose or terminology. We note specific conferences and F. Fregni regulatory agencies that helped identify and shape the field Department of Physical Medicine and Rehabilitation, Harvard Medical of tES including establishing terminology. Commercial School, Berenson-Allen Center for Noninvasive Brain Stimulation, (brand) names of devices are noted ad hoc for context and Boston, MA, USA linked to dose terms where appropriate. We do not com- M. Bikson ment directly on mechanisms but emphasize that dose Neural Engineering Laboratory, Department of Biomedical Engineering, The City College of New York of CUNY, New York, determines electric field in the brain [2] which, in turn, NY, USA gives rise to neurophysiological responses [3]; thus H. Knotkova and D. Rasche (eds.), Textbook of Neuromodulation, 7 DOI 10.1007/978-1-4939-1408-1_2, # Springer Science+Business Media, LLC 2015 8 B. Guleyupoglu et al. Fig. 2.1 A general timeline of 1902 Electrosleep (ES) ES/EA noting key points in the 1903 Electroanesthesia (EA) history from 1902 until 2011 as Successful use of EA claimed 1914 First claim of Electrosleep well as their relation to DC for treatment of insomnia in major human surgery stimulation. A brief history of DC stimulation is also presented in 1933 Electroconvulsive Therapy Resurgence of EA this table. Other cranial therapies 1940 are mentioned for a complete 1942 Iontophoresis cranial stimulation history and 1953 Clinical Use of Electrosleep in Europe noncranial therapies are 1956 Preliminaries of chemical anesthesia used with EA DC Bias mentioned for their connection to 1957 Unusual use of DC bias in an Electrosleep study Classifications 1958 First Book on Electrosleep Electrosleep/CES ES/EA. Arrows are used to 1959 Optic nerve irritation reported in Electroanesthesia/TCES connect historically related points case of DC bias use in Electrosleep DC Stimulation 1960 Resurgence of EA while the horizontal purple lines Electroconvulsive Therapy 1962 Transcutaneous Cranial Electrical Stimulation DC Bias are used to point out DC use in Contemporary Approaches Clinical Use of Limoge Current historically pulsed applications 1963 Electrosleep in USA Pulsating currents claimed to be 1964 more effective than DC currents Polarizing current 1965 Interference Technique Used Other Categories First Symposium on ES/EA ES renamed to Cranial Electro- Major Conferences 1966 stimulation Therapy(CET) Other Cranial Stimulation 1967 Non-Cranial Stimulation 1968 Neurotone 101 Fading in EA studied First FDA Approved CES Device Transcerebral Electrotherapy Second Symposium on ES/EA 1969 EA requirement using (TCET) proposed as new DC Use name for ES DC-only found to be 40mA 1972 NeuroElectric Therapy (NET) Third Symposium on ES/EA 1974 Transcutaneous Electrical Nerve Stimulation 1975 Fourth Symposium on ES/EA 1976 FDA gets control of medical devices 1977 Electrosleep goes under FDA review Electrosleep renamed to Cranial Neurotone 101 1978 Electrotherapy Stimulation(CES) called before FDA Fifth Symposium on ES/EA FDA approves CES for anxiety, depression & insomnia 1980 “Transcranial Electrical Stimulation” 1984 Microcurrent Electrical Therapy 1989 FDA requires all previous medical devices to get premarket approval 1990 1998 First Conference on TMS/tDCS Short duration tDCS used 2000 transcranial Direct Current Stimulation (tDCS) 2003 Second Conference on TMS/tDCS 2005 TCES investigated for effects on required levels of post-operative analgesics 2006 transcranial Alternating Current Stimulation 2007 Third Conference on TMS/tDCS transcranial Random Noise Stimulation 2008 transcranial Sinusoidal Direct Current Stimulation 2009 High Definition transcranial Direct Current Stimulation (HD-tDCS) 2011 Fourth Conference on TMS/tDCS 2012 Transcranial Pulsed Current Stimulation (tPCS) understanding the dose is a prerequisite to understanding associated with that terminology; when these papers provide mechanisms. sufficient dose details, these deviations are noted. Our sum- We do not address magnetic stimulation approaches or mary aims to reflect the most typical doses used across the electrical stimulation approaches not targeting the brain, or majority of studies (Figs. 2.2, 2.3, and 2.4). In addition, to nonelectrical therapies, except in specific cases to indicate promote a more comprehensive and systematic dose classi- the terminology used in these other approaches for the pur- fication, we propose new categories for those waveforms pose of overall clarity of nomenclature. We did not attempt using pulsed stimulation in Fig. 2.5 (transcranial pulsed to perform an exhaustive cataloging of tES publications. current stimulation [tPCS]). Though we do not comment on efficacy, the nominal It is important to emphasize that the specifics of tES dose indications for tES use (intended clinical outcomes) are (electrode montage and waveform) determine brain modula- noted when contextually relevant, especially for many his- tion—evidently the given therapy name is incidental and torical streams (defined above). There are instances in which often reflects a historical bias and varying intended use. In researchers used terminology to describe a dose in a manner this sense, a strict approach would involve ignoring all potentially inconsistent with typical historical norms of dose historical nomenclature and consideration of specific dose. 2 Methods and Technologies for Low-Intensity Transcranial Electrical... 9 Fig. 2.2 Electrosleep and Electroanesthesia Dosage. These Form of Transcranial Electrode Placement Waveform are a mixture of low- and high- SƟmulaƟon (Electrode count) (3): Placed on top of the eyes 20-25 mA monophasic square intensity stimulation waveforms. Electrosleep (ES)- 1902 and mastoid. wave pulses at 100 cps lasƟng 0.3- The year at which the form of 0.5 ms. 20-60 minutes stimulation came about is written Cranial with the stimulation method. ElectrosƟmulaƟon 0.1-0.5 mA. Pulse frequency of 30- Therapy (CET)- 1966 100Hz and pulse width of 1-2 ms. Each method is connected to an (3): Placed above the eyes and over the mastoid. 10-20V supply. Monophasic and electrode placement as well as a Transcerebral Biphasic. Electrotherapy (TCET)- waveform used 1969 0.5Hz-100Hz sƟmulaƟon over (2): ~2cm2 Placed in the ears. 20minutes to an hour. 0-600μA. NeuroElectric Therapy Biphasic (NET)-
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