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Bikson M, Paneri B, Mourdoukoutas A, Esmaeilpour Z, Badran BW, Azzam R, Adair D, Datta A, Fang XH, Wingeier B, Chao D, Alonso-Alonso M, Lee K, Knotkova H, Woods AJ, Hagedorn D, Jeffery D, Giordano J, Tyler WJ. Limited output transcranial electrical stimulation (LOTES-2017): Engineering principles, regulatory statutes, and industry standards for wellness, over-the-counter, or prescription devices with low risk. Brain Stimul 2017; 11:134-157. [PMID: 29122535 DOI: 10.1016/j.brs.2017.10.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 09/16/2017] [Accepted: 10/15/2017] [Indexed: 01/17/2023] Open
Abstract
We present device standards for low-power non-invasive electrical brain stimulation devices classified as limited output transcranial electrical stimulation (tES). Emerging applications of limited output tES to modulate brain function span techniques to stimulate brain or nerve structures, including transcranial direct current stimulation (tDCS), transcranial alternating current stimulation (tACS), and transcranial pulsed current stimulation (tPCS), have engendered discussion on how access to technology should be regulated. In regards to legal regulations and manufacturing standards for comparable technologies, a comprehensive framework already exists, including quality systems (QS), risk management, and (inter)national electrotechnical standards (IEC). In Part 1, relevant statutes are described for medical and wellness application. While agencies overseeing medical devices have broad jurisdiction, enforcement typically focuses on those devices with medical claims or posing significant risk. Consumer protections regarding responsible marketing and manufacture apply regardless. In Part 2 of this paper, we classify the electrical output performance of devices cleared by the United States Food and Drug Administration (FDA) including over-the-counter (OTC) and prescription electrostimulation devices, devices available for therapeutic or cosmetic purposes, and devices indicated for stimulation of the body or head. Examples include iontophoresis devices, powered muscle stimulators (PMS), cranial electrotherapy stimulation (CES), and transcutaneous electrical nerve stimulation (TENS) devices. Spanning over 13 FDA product codes, more than 1200 electrical stimulators have been cleared for marketing since 1977. The output characteristics of conventional tDCS, tACS, and tPCS techniques are well below those of most FDA cleared devices, including devices that are available OTC and those intended for stimulation on the head. This engineering analysis demonstrates that with regard to output performance and standing regulation, the availability of tDCS, tACS, or tPCS to the public would not introduce risk, provided such devices are responsibly manufactured and legally marketed. In Part 3, we develop voluntary manufacturer guidance for limited output tES that is aligned with current regulatory standards. Based on established medical engineering and scientific principles, we outline a robust and transparent technical framework for ensuring limited output tES devices are designed to minimize risks, while also supporting access and innovation. Alongside applicable medical and government activities, this voluntary industry standard (LOTES-2017) further serves an important role in supporting informed decisions by the public.
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Li X, Sahlem GL, Badran BW, McTeague LM, Hanlon CA, Hartwell KJ, Henderson S, George MS. Transcranial magnetic stimulation of the dorsal lateral prefrontal cortex inhibits medial orbitofrontal activity in smokers. Am J Addict 2017; 26:788-794. [PMID: 28898485 DOI: 10.1111/ajad.12621] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 08/14/2017] [Accepted: 08/17/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Several studies have shown that repetitive transcranial magnetic stimulation (rTMS), applied to the dorsolateral prefrontal cortex (DLPFC), can reduce cue-elicited craving in smokers. Currently, the mechanism of this effect is unknown. We used functional magnetic resonance imaging (fMRI) to explore the effect of a single treatment of rTMS on cortical and sub-cortical neural activity in non-treatment seeking nicotine-dependent participants. METHODS We conducted a randomized, counterbalanced, crossover trial in which participants attended two experimental visits separated by at least 1 week. On the first visit, participants received either active, or sham rTMS (10 Hz, 5 s-on, 10 s-off, 100% motor threshold, 3,000 pulses) over the left DLPFC, and on the second visit they received the opposite condition (active or sham). Cue craving fMRI scans were completed before and after each rTMS session. RESULTS A total of 11 non-treatment seeking nicotine-dependent cigarette smokers were enrolled in the study [six female, average age 39.7 ± 13.2, average cigarettes per day 17.3 ± 5.9]. Active rTMS decreased activity in the contralateral medial orbitofrontal cortex (mOFC) and ipsilateral nucleus accumbens (NAc) compared to sham rTMS. CONCLUSIONS This preliminary data suggests that one session of rTMS applied to the DLPFC decreases brain activity in the NAc and mOFC in smokers. SCIENTIFIC SIGNIFICANCE rTMS may exert its anti-craving effect by decreasing activity in the NAc and mOFC in smokers. Despite a small sample size, these findings warrant future rTMS/fMRI studies in addictions. (Am J Addict 2017;26:788-794).
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Badran BW, Austelle CW, Smith NR, Glusman CE, Froeliger B, Garland EL, Borckardt JJ, George MS, Short B. E-meditation: A novel paradigm using tDCS to enhance mindfulness meditation. Brain Stimul 2017. [DOI: 10.1016/j.brs.2017.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Li X, Du L, Sahlem GL, Badran BW, Henderson S, George MS. Repetitive transcranial magnetic stimulation (rTMS) of the dorsolateral prefrontal cortex reduces resting-state insula activity and modulates functional connectivity of the orbitofrontal cortex in cigarette smokers. Drug Alcohol Depend 2017; 174:98-105. [PMID: 28319755 PMCID: PMC5400684 DOI: 10.1016/j.drugalcdep.2017.02.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 12/01/2016] [Accepted: 02/21/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Previous studies reported that repetitive transcranial magnetic stimulation (rTMS) can reduce cue-elicited craving and decrease cigarette consumption in smokers. The mechanism of this effect however, remains unclear. We used resting-state functional magnetic resonance imaging (rsfMRI) to test the effect of rTMS in non-treatment seeking smokers. METHODS We used a single blinded, sham-controlled, randomized counterbalanced crossover design where participants underwent two visits separated by at least 1 week. Participants received active rTMS over the left dorsolateral prefrontal cortex (DLPFC) during one of their visits, and sham rTMS during their other visit. They had two rsFMRI scans before and after each rTMS session. We used the same rTMS stimulation parameters as in a previous study (10Hz, 5s-on, 10s-off, 100% resting motor threshold, 3000 pulses). RESULTS Ten non-treatment-seeking, nicotine-dependent, cigarette smokers (6 women, an average age of 39.72 and an average cigarette per day of 17.30) finished the study. rsFMRI results demonstrate that as compared to a single session of sham rTMS, a single session of active rTMS inhibits brain activity in the right insula and thalamus in fractional amplitude of low frequency fluctuation (fALFF). For intrinsic brain connectivity comparisons, active TMS resulted in significantly decreased connectivity from the site of rTMS to the left orbitomedial prefrontal cortex. CONCLUSIONS This data suggests that one session of rTMS can reduce activity in the right insula and right thalamus as measured by fALFF. The data also demonstrates that rTMS can reduce rsFC between the left DLPFC and the medial orbitofrontal cortex.
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Bentzley BS, Pannu J, Badran BW, Halpern CH, Williams NR. It takes time to tune. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:171. [PMID: 28480207 PMCID: PMC5401673 DOI: 10.21037/atm.2017.03.49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 02/06/2017] [Indexed: 11/06/2022]
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Sahlem GL, Badran BW, Peyton E, Reeves MT, Leslie K, Halford JJ, Bachman D, Uhde TW, Borckardt JJ, George MS. A Randomized Controlled Pilot Trial Suggesting That Cathodal Bi-Frontal Transcranial Direct Current Stimulation (tDCS) May Shorten Sleep Onset Latency, and Increase Sleep Efficiency When Applied Before An Afternoon Nap. Brain Stimul 2017. [DOI: 10.1016/j.brs.2016.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Sahlem GL, Badran BW, Halford JJ, Williams NR, Korte JE, Leslie K, Strachan M, Breedlove JL, Runion J, Bachman DL, Uhde TW, Borckardt JJ, George MS. Oscillating Square Wave Transcranial Direct Current Stimulation (tDCS) Delivered during Slow Wave Sleep Does Not Improve Declarative Memory More Than Sham: A Randomized Sham-Controlled Crossover Study. Brain Stimul 2017. [DOI: 10.1016/j.brs.2016.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Badran BW, Austelle CW, Smith NR, Glusman CE, Froeliger B, Garland EL, Borckardt JJ, George MS, Short B. A Double-Blind Study Exploring the Use of Transcranial Direct Current Stimulation (tDCS) to Potentially Enhance Mindfulness Meditation (E-Meditation). Brain Stimul 2017; 10:152-154. [DOI: 10.1016/j.brs.2016.09.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/16/2016] [Accepted: 09/09/2016] [Indexed: 10/20/2022] Open
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Badran BW, Glusman CE, Austelle CW, Jenkins S, DeVries WH, Galbraith V, Thomas T, Adams TG, George MS, Revuelta GJ. A Double-Blind, Sham-Controlled Pilot Trial of Pre-Supplementary Motor Area (Pre-SMA) 1 Hz rTMS to Treat Essential Tremor. Brain Stimul 2016; 9:945-947. [PMID: 27567469 DOI: 10.1016/j.brs.2016.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 07/28/2016] [Accepted: 08/03/2016] [Indexed: 11/25/2022] Open
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Umezaki Y, Badran BW, DeVries WH, Moss J, Gonzales T, George MS. The Efficacy of Daily Prefrontal Repetitive Transcranial Magnetic Stimulation (rTMS) for Burning Mouth Syndrome (BMS): A Randomized Controlled Single-blind Study. Brain Stimul 2016; 9:234-42. [DOI: 10.1016/j.brs.2015.10.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/01/2015] [Accepted: 10/20/2015] [Indexed: 02/07/2023] Open
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Rostami R, Badran BW, Kazemi R, Habibnezhad M, George MS. Long-lasting analgesic effect of transcranial direct current stimulation in treatment of chronic endometriosis pain. J Obstet Gynaecol Res 2015; 41:1998-2001. [DOI: 10.1111/jog.12817] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 06/22/2015] [Indexed: 11/27/2022]
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George MS, Baron Short E, Kerns SE, Li X, Hanlon C, Pelic C, Taylor JJ, Badran BW, Borckardt JJ, Williams N, Fox J. Therapeutic Applications of rTMS for Psychiatric and Neurological Conditions. Brain Stimul 2015. [DOI: 10.1002/9781118568323.ch12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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Sahlem GL, Badran BW, Halford JJ, Williams NR, Korte JE, Leslie K, Strachan M, Breedlove JL, Runion J, Bachman DL, Uhde TW, Borckardt JJ, George MS. Oscillating Square Wave Transcranial Direct Current Stimulation (tDCS) Delivered During Slow Wave Sleep Does Not Improve Declarative Memory More Than Sham: A Randomized Sham Controlled Crossover Study. Brain Stimul 2015; 8:528-34. [PMID: 25795621 PMCID: PMC4598642 DOI: 10.1016/j.brs.2015.01.414] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/29/2015] [Accepted: 01/30/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND A 2006 trial in healthy medical students found that anodal slow oscillating tDCS delivered bi-frontally during slow wave sleep had an enhancing effect in declarative, but not procedural memory. Although there have been supporting animal studies, and similar findings in pathological groups, this study has not been replicated, or refuted, in the intervening years. We therefore tested these earlier results for replication using similar methods with the exception of current waveform (square in our study, nearly sinusoidal in the original). OBJECTIVE/HYPOTHESIS Our objective was to test the findings of a 2006 trial suggesting bi-frontal anodal tDCS during slow wave sleep enhances declarative memory. METHODS Twelve students (mean age 25, 9 women) free of medical problems underwent two testing conditions (active, sham) in a randomized counterbalanced fashion. Active stimulation consisted of oscillating square wave tDCS delivered during early Non-Rapid Eye Movement (NREM) sleep. The sham condition consisted of setting-up the tDCS device and electrodes, but not turning it on during sleep. tDCS was delivered bi-frontally with anodes placed at F3/F4, and cathodes placed at mastoids. Current density was 0.517 mA/cm(2), and oscillated between zero and maximal current at a frequency of 0.75 Hz. Stimulation occurred during five-five minute blocks with 1-min inter-block intervals (25 min total stimulation). The primary outcomes were both declarative memory consolidation measured by a paired word association test (PWA), and non-declarative memory, measured by a non-dominant finger-tapping test (FTT). We also recorded and analyzed sleep EEG. RESULTS There was no difference in the number of paired word associations remembered before compared to after sleep [(active = 3.1 ± 3.0 SD more associations) (sham = 3.8 ± 3.1 SD more associations)]. Finger tapping improved, (non-significantly) following active stimulation [(3.6 ± 2.7 SD correctly typed sequences) compared to sham stimulation (2.3 ± 2.2 SD correctly typed sequences)]. CONCLUSION In this study, we failed to find improvements in declarative or performance memory and could not replicate an earlier study using nearly identical settings. Specifically we failed to find a beneficial effect on either overnight declarative or non-declarative memory consolidation via square-wave oscillating tDCS intervention applied bi-frontally during early NREM sleep. It is unclear if the morphology of the tDCS pulse is critical in any memory related improvements.
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Hanlon CA, Dowdle LT, Austelle CW, DeVries W, Mithoefer O, Badran BW, George MS. What goes up, can come down: Novel brain stimulation paradigms may attenuate craving and craving-related neural circuitry in substance dependent individuals. Brain Res 2015; 1628:199-209. [PMID: 25770818 DOI: 10.1016/j.brainres.2015.02.053] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 01/29/2015] [Accepted: 02/10/2015] [Indexed: 12/17/2022]
Abstract
Vulnerability to drug related cues is one of the leading causes for continued use and relapse among substance dependent individuals. Using drugs in the face of cues may be associated with dysfunction in at least two frontal-striatal neural circuits: (1) elevated activity in medial and ventral areas that govern limbic arousal (including the medial prefrontal cortex (MPFC) and ventral striatum) or (2) depressed activity in dorsal and lateral areas that govern cognitive control (including the dorsolateral prefrontal cortex (DLPFC) and dorsal striatum). Transcranial magnetic stimulation (TMS) is emerging as a promising new tool for the attenuation of craving among multiple substance dependent populations. To date however, nearly all repetitive TMS studies in addiction have focused on amplifying activity in frontal-striatal circuits that govern cognitive control. This manuscript reviews recent work using TMS as a tool to decrease craving for multiple substances and provides a theoretical model for how clinical researchers might approach target and frequency selection for TMS of addiction. To buttress this model, preliminary data from a single-blind, sham-controlled, crossover study of 11 cocaine-dependent individuals is also presented. These results suggest that attenuating MPFC activity through theta burst stimulation decreases activity in the striatum and anterior insula. It is also more likely to attenuate craving than sham TMS. Hence, while many TMS studies are focused on applying LTP-like stimulation to the DLPFC, the MPFC might be a new, efficacious, and treatable target for craving in cocaine dependent individuals.
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Badran BW, Taylor JJ, Devries W, Li X, Hanlon C, George MS. One Step Closer To Patient-Specific Brain Treatments: Interleaved Transcranial Magnetic Stimulation (TMS)/fMRI to Assess the fMRI BOLD Response Before and After High Frequency Repetitive TMS Treatment. Brain Stimul 2015. [DOI: 10.1016/j.brs.2015.01.300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Adams TG, Badran BW, George MS. Integration of cortical brain stimulation and exposure and response prevention for obsessive-compulsive disorder (OCD). Brain Stimul 2014; 7:764-5. [PMID: 25048526 DOI: 10.1016/j.brs.2014.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 06/18/2014] [Accepted: 06/20/2014] [Indexed: 10/25/2022] Open
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