Home Application of Non-invasive Neuromodulation: How does this work?

The appearance of new disruptive technology and the advent of telemedicine are bringing a new era to medical treatments. Telemedicine comes from the Greek prefix “tele” that means “distance “and the Latin verb “mederi” that means “to heal”. Therefore, the World Health Organization refers to telemedicine as “healing from a distance“. In contrast to traditional medical practices, telemedicine, and in particular home telemedicine applications, allows for remote exchange between the patient and their doctor, providing clinical services without requiring the patient to visit the doctor’s office. It may sound a bit odd, but one of the first telemedicine attempts in history actually took place in space. NASA’s efforts in telemedicine began in the early 1960s when humans began spaceflight. The sustained presence of humans in space through programs like the Shuttle-Mir or the International Space Station motivated scientists to go beyond biophysiological telemetry and develop new systems to remotely diagnose ill astronauts and provide them with appropriate treatment. As you will read in this blog post, modern home applications are not all that different to what was used in space.

One major benefit of telemedicine is accessibility to patients

While clinical settings provide great advantages, they also present logistical challenges, especially when patients need to travel. Telemedicine applications do not require patients to be physically present for medical consultation as care can potentially be delivered at home at any time. This is particularly relevant in rural areas and regions with limited medical access. Telemedicine can significantly reduce cancellations or no-shows, especially in treatments that require several interventions. Home applications also have the added advantage of reducing overall health-care costs, as a result of the fundamental restructuring of the way health care is delivered. Its main breakthrough, however, is the reduction of clinical costs in treatments that require multiple interventions. The world’s aging population and the transformation of acute illnesses into chronic diseases will increase the number of number of patients in the coming years, and consequently overall medical costs. Home care will without a doubt contribute to a more efficient and less costly way of treating patients in the near future.

In recent years, research in home applications has increased exponentially. Among them, telemedicine applications for noninvasive neuromodulation have gained enormous traction. Neuromodulation therapies aim for a gradual but lasting modification of a patient’s brain functionality. In general, this is accomplished through transcranial brain stimulation, either magnetic (TMS) or electrical (tES), that is capable of regulating neural activity. Neuromodulation therapies can be applied to a wide range of neural diseases such as Parkinson’s Disease, Attention Deficit Hyperactivity Disorder (ADHD), chronic pain, or epilepsy – to name a few. These therapies usually consist of a series of daily interventions in which a certain brain region’s activity is primed to either increase or decrease excitability. A typical treatment may consist of several weekly sessions of a one-hour duration. Neuromodulation therapies require long procedures to extend the duration of clinical benefits and can thus enormously benefit from telemedical home platforms that circumvent the need for numerous, lengthy visits to the clinic.

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Unlike TMS, tES is a portable technology that can be used at home because it is safe and simple enough for patient/family-use. Furthermore, there are specific types of tES with promising applications for the elderly, disabled, and other less mobile populations. One of these types is known as transcranial direct current stimulation, or tDCS. An example of these breakthrough applications is a paper published by Garcia-Larrea and colleagues from earlier this year (see references). Within the framework of the EU project Stiped, Neuroelectrics is currently building a personalized platform for the remote stimulation of children diagnosed of ADHD. Sandran concluded in her study on home-tES strategies and implementation that the “delivery of transcranial electrical stimulation within a person’s home offers many potential benefits and appears acceptable and safe provided appropriate preparation and monitoring is provided”.

Designing home neuromodulation systems is already possible, and Neuroelectrics is advancing this field. However, there are important challenges that need to be addressed in order to make these systems robust, reliable, and ultimately safe for the home. The first thing to consider is the threat of misuse. Although tES is considered a safe technique, telemedicine applications must avoid possible misuse while running therapies at home. Secondly, a good montage needs to be ensured, given that there is a risk of mild burns and skin irritation if the experiment is not designed or set up properly (e.g. use of gel between the scalp and electrode, proper amount of gel used, etc). Home systems therefore should continuously monitor stimulation electrodes impedances and automatically abort stimulation if any problem is detected. Thirdly, tDCS home systems need to provide limitations in terms of allotted sessions. The system should monitor previous uses and prevent additional uses beyond the number of sessions prescribed by the doctor. It is also crucial to ensure that a person other than the prescribed patient does not have access to tDCS stimulation. A final important aspect of a home system is the communication management with the doctor who prescribed the tDCS treatment. The doctor should be informed in a timely manner of the result of scheduled tDCS sessions, especially if the patient misses a session. It is crucial that the home system monitors all aspects of the remotely conducted stimulation session, allowing complete supervision by the doctor. Full remote supervision will allow doctors to make timely modifications in the patient’s planned therapy.

In the coming years, we will witness the progression of advanced telemedical applications that will radically change the way we interact with doctors and care-givers. Neuromodulation home solutions, for example, allow clinicians to prescribe and schedule tCS sessions via a web portal. Patients will benefit from this therapy safely at home and in a completely supervised fashion. Throughout sessions, doctors have the capability to monitor the therapy in real-time and immediately be warned of any adverse effects. In addition to medicine becoming more convenient and accessible to patients, treatments are easier to apply by the doctor. Travel for treatment will no longer be required, which is an enormous benefit for the elderly and populations with limited access to health treatment. We believe the Neuroelectrics Starstim home system is the most innovative and advanced system in the field of tES. Our home technology controls for concerns regarding potential misuse and cumbersome remote control. This gives you an opportunity to effectively study in the intended use environment, which opens up recruitment for previously excluded populations and saves researchers costs/time through controlled access and monitoring automation. The future of medicine is telemedicine, and tES home use has come to stay!

References:

Allen A, Allen D. Telemedicine programs: 2nd annual review reveals doubling of programs in a year. Telemedicine Today. 1995;3(1):10–4.

Flodgren, G., Rachas, A., Farmer, A. J., Inzitari, M., & Shepperd, S. (2015). Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, (9).

Kahn, J. M. (2015). Virtual visits—confronting the challenges of telemedicine. N Engl J Med372(18), 1684-1685.

Burke, B. L., & Hall, R. W. (2015). Telemedicine: pediatric applications. Pediatrics136(1), e293-e308.

Hailey, D., Roine, R., & Ohinmaa, A. (2002). Systematic review of evidence for the benefits of telemedicine. Journal of telemedicine and telecare8(1_suppl), 1-7.

Hjelm, N. M. (2005). Benefits and drawbacks of telemedicine. Journal of telemedicine and telecare11(2), 60-70.

P.S. Katz, R.J. Calin-Jageman, in Encyclopedia of Neuroscience, 2009

Garcia-Larrea, L., Perchet, C., Hagiwara, K., & André-Obadia, N. (2019). At-Home Cortical Stimulation for Neuropathic Pain: a Feasibility Study with Initial Clinical Results. Neurotherapeutics, 1-12.

Sandran, N., Hillier, S., & Hordacre, B. (2019). Strategies to implement and monitor in-home transcranial electrical stimulation in neurological and psychiatric patient populations: a systematic review. Journal of neuroengineering and rehabilitation16(1), 58.

A Brief History of NASA’s Contributions to Telemedicine

Strategies to implement and monitor in-home transcranial electrical stimulation in neurological and psychiatric patient populations: a systematic review

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