tDCS – negotiating the “rising tide” of hype.

By now most of you will have heard of transcranial direct current stimulation (tDCS). It’s been all over the media in recent years and original research has been flooding through the neuroscience and clinical journals. In a nutshell it involves the non-invasive delivery of low intensity direct current applied to the brain via electrodes that are secured to the scalp. This stimulation temporarily alters levels of cortical excitability and so it follows that it might affect many of the outputs of brain activity. We’ve discussed it before here.

Barely a week goes by without a new trial or study with an excitable press release claiming, for example, that tDCS (or in the technically unconcerned, veracity-free parlance of the press a “zap”, “shock”, “jump-start” , “mild jolt” or “electrical thinking cap”) improves academic performance, mathematic ability, craving, chronic pain, depression, anxiety, addiction, gambling ability. Indeed my recent favourite press-story is that the US military are interested in its capacity to create the apocryphal “super soldier” (lest anyone take that as a potentially convincing argument from authority in favour of tDCS, I direct you to Jon Ronson’s very funny book “The men who stare at goats” for some context). More worryingly perhaps, companies, unfettered by anything approaching meaningful regulation have started producing DIY brain stimulation kits, for example to improve your performance at “gaming”.

In recent months two short review papers have addressed the rising profile of tDCS in the public consciousness and the research field and both make related arguments that, in my view, need to be taken very seriously by anyone reading about tDCS in the press and more importantly, anyone engaged in tDCS research.

Veljko Dubljević and colleagues in this months “Neuron” show the surge over the last 7 years in both academic articles and media reports. Unsurprisingly they found a substantial mismatch between the media coverage and the original papers, with the former frequently containing what they describe as misleading statements such as “schoolchildren who struggle to grasp mathematics could benefit from having their brains roused with electricity”. They suggest that there is a need for researchers and professional societies to promote a more nuanced and cautious message about tDCS and to better reflect the uncertainty and limitations of our current knowledge, and that steps might need to be taken to regulate tDCS devices.

A few months ago Prof Vincent Walsh of University College London published a lively commentary in the journal Brain Stimulation touching on many of the same issues. Prof Walsh is also clearly concerned about hype and brain stimulation but lays the blame for this situation firmly at the feet of us researchers. He points out it is researchers who use phrases such as “brain boosting”, who hype our results, and “cross the line between what is scientifically interesting and clinically and recreationally possible”. He also highlights a few uncomfortable facts about tDCS that get a little less airplay. For example effects are usually short-lived, they are often very small, they are hard to replicate often and have a tendency to disappear in the noise of real life. Not characteristics that bode well for powerful real world applications. He suggests that we might more honestly say to people “Based on the best available studies, from reputable laboratories, we don’t really know where to put the electrodes, we don’t know how robust is the idea that the effects are excitatory or inhibitory, we don’t know what other behaviours are affected, we haven’t tested the methods with real-world tasks and therefore don’t know how they perform outside the lab, and we have no idea in healthy people if they continue to work after more than 2-3 repeated applications.” Now make me a sexy headline out of that.

Prof Walsh is less concerned with regulation of tDCS, pointing to the apparent safety of well-made devices. He argues that to regulate and “medicalise” tDCS seems unwarranted and that in the end market forces might find tDCS out; that the market won’t continue to invest in brain stimulation if it doesn’t actually work. On that point I personally disagree and would produce one word to counter this argument: Homeopathy. Wrong yet still going strong since 1796.

Both of these papers speak to a real problem that, as someone who has done some research with tDCS, I think we should be genuinely concerned about. Protocols for clinical trials of tDCS are on the rise. The scope of conditions it is being considered for is staggering and in some instances fairly surprising. The claims for the potential of these devices are racing ahead of the evidence and the evidence-base itself has problems. Studies are generally small, often underpowered, regularly poorly controlled, not uncommonly based on loose analyses. None of this means that tDCS does not have potential but the tDCS field needed a reality check and together these papers have attempted to deliver it.

So the next time you read a news story about cognitive enhancement with tDCS, brain boosting or the like, proceed with caution, because at this point nothing is a done deal.

Neil O’Connell

grey tDCS   negotiating the “rising tide” of hype.As well as writing for Body in Mind, Dr Neil O’Connell, (PhD, not MD) is a researcher in the Centre for Research in Rehabilitation, Brunel University, West London, UK. He divides his time between research and training new physiotherapists and previously worked extensively as a musculoskeletal physiotherapist.
He also tweets! @NeilOConnell
Neil’s main research interests are chronic low back pain and chronic pain more broadly with a focus on evidence based practice. He has conducted numerous systematic reviews including some for the Cochrane Collaboration. He also makes a mean Yorkshire pudding despite being a child of Essex.
Link to Neil’s published research here. Downloadable PDFs here.

References

Dubljević V, Saigle V, Racine E. The Rising Tide of tDCS in the Media and Academic Literature. Neuron. 2014 May 21;82(4):731-6. doi: 10.1016/j.neuron.2014.05.003.

Walsh VQ. Ethics and social risks in brain stimulation. Brain Stimul. 2013;6(5):715-7. doi: 10.1016/j.brs.2013.08.001.

Comments

  1. Please correct me if I am misunderstanding this technique or therapy, but in the USA some clinics are using what they call Calmare Therapy for CRPS and other chronic pain conditions. I think the Mayo Clinic was involved with some trials. Can you explain this? Thanks.

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  2. Humans love anything that can ostensibly shock, zap or otherwise electromagneticly stimulate the body. Really it is no surprise that clinical studies are weak. Rule for creating a new modality: get barely enough evidence to justify plausible clinical use then once the new tech is embedded in clinic health culture just keep pumping out low powered weak studies.

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  3. Neil O'Connell says:

    Hi Judy, it looks like Calmare therapy is something different to tDCS. tDCS aims to stimulate the brain directly whereas it appears Calmare therapy has more in common with TENS or interferential therapy which stimulate sensoryt nerves in the skin.

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  4. Neil O'Connell says:

    Hi Eric,

    Thanks for commenting, I recognsise that pattern of activity, and its not restrcited to zap-style therapies. Indeed for many therapies you can just have a bright idea (or not) and then role out the courses regardless of evidence. Colourful tape anyone?

    Cheers

    Neil

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  5. Whilst the Truth puts on its shoes the Lie is half way around the world…

    Doesn’t every area of medicine have this problem? Sexy science fantasy as a replacement for good journalism – see The Disconnect in The Edge question http://edge.org/response-detail/23711.

    The people still waiting for their personnal hover board or jet pack that they were promised in the ’50s have had a long wait. There are those of us that grew up with the cliche of ‘Tomorrow’s World’ “Scientists predict that by 1990 we will have (insert extrapolation of aspirational science themed BS here)” We know the difference.

    How do we address our directly professional disconnects between science reality and science fantasy? I don’t know if we can – getting proactively involved makes us look like spoilsports – I suspect standing nearby looking concerned and willing to explain when asked by interested parties is the best we can do. And the list of subjects we need to do it on is immense. But these ideas often become the Zombies of pop science and as you point out some can carry on with a semblance of living for hundreds of years.

    Brain stimulation is sadly a cultural meme entwining with all sorts of other brainstuff; brain washing, personality control, the tinkering with the interface between your perception of reality and what that then means when it is switched off – what was ever ‘real’. Maybe I read too much P K Dick as a kid.

    In short I suspect it is something to observe and be willing to comment on when asked and not lose too much sweat over.

    Kind thoughts,
    Steve

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  6. Jason Miller says:

    I think people like Prof Walsh should realise that not everyone is as sensible or smart as him. They may not see the nonsense, only the promise. And they are all desperate to be more clever.

    The cat is out of the bag and it doesn’t matter who is to blame. With the absence of regulation, self-proclaimed experts are suggesting the use of tdcs on children in classrooms with financial assistance offered to families that can’t afford it themselves. I don’t pretend to understand this, but your comparison to homeopathy makes this sound like something equally harmless. Is tdcs really harmless?

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  7. Neil O'Connell says:

    It is too far in my view to say tDCS is harmless. It presumes that all new devices are manufactured in a certain way with adequate safety features. It presumes that people will use them as per the guidelines and it presumes that our existing safety data are adequate. I suspect none of those things can be relied upon as true,

    My comparison to homeopathy is not to imply equal safety but simple to illustrate that inneffective treatments persist whether they work or not. But I dont think homeopathy is harmless – any intervention for which bold claims are made affects behaviour and often not for the better. Avoidance of effective treatments, avoidance of active self management etc.

    How risky is tDCS – we dont really know. Should we assume it is safe bcause there are few signs of serious adverse events to date? Not in my view.

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  8. Ah, okay. Thanks.

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  9. Neil,
    Thank you for this great review. I think European Society is publishing quite an interesting guidelines on this issue:

    Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS)
    Jean-Pascal Lefaucheur, Nathalie André-Obadia, Andrea Antal, et al.
    PII: S1388-2457(14)00296-X
    DOI: http://dx.doi.org/10.1016/j.clinph.2014.05.021
    Reference: CLINPH 2007118
    To appear in: Clinical Neurophysiology

    And speaking of brain stimulation, here is another interesting review on this topic.

    Supraspinal Stimulation for Treatment of Refractory
    Pain
    Author: V.K. Parmar L. Gee H. Smith J.G. Pilitsis
    PII: S0303-8467(14)00200-5
    DOI: http://dx.doi.org/doi:10.1016/j.clineuro.2014.05.026
    Reference: CLINEU 3736
    To appear in: Clinical Neurology and Neurosurgery

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  10. Dr.O’Connell:
    I thoroughly enjoyed your discussion of tDCS, and agree with your logical critique of the surrounding hype. However I disagree with your rebuttal of Dr. Walsh’s claim “that to regulate and “medicalise” tDCS seems unwarranted and that in the end market forces might find tDCS out; that the market won’t continue to invest in brain stimulation if it doesn’t actually work.” I especially find objectionable your “one word to counter this argument: Homeopathy”

    Is this an intuitively grounded opinion unproven by RCT’s. Not that I believe that homeopathy is scientifically based—it is not, in my own biased opinion. Nor have I personally used a Homeopath’s services, although as a standard allopathically trained physician I have seen many patients who have claimed benefit from seeing one.

    I deal regularly with chronic pelvic pain. I know that some allopath’s have delivered far more dangerous and ineffective treatments to my patients than any homeopath. I think we all need to practice a modicum of tolerance in an area where we are all ignorant. It might be that homeopaths are doing something right, even though it is not for the reasons they think.

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