At-Home Transcranial Direct Current Stimulation (tDCS) With Telehealth Support for Symptom Control in Chronically-Ill Patients With Multiple Symptoms.

Alexa Riggs,Helena Knotkova,Marom Bikson,Vaishali Patel,Russell K Portenoy,Bhaskar Paneri

doi:10.3389/fnbeh.2018.00093

Abstract

Transcranial direct current stimulation (tDCS) delivered in multiple sessions can reduce symptom burden, but access of chronically ill patients to tDCS studies is constrained by the burden of office-based tDCS administration. Expanded access to this therapy can be accomplished through the development of interventions that allow at-home tDCS applications.Objective: We describe the development and initial feasibility assessment of a novel intervention for the chronically ill that combines at-home tDCS with telehealth support.Methods: In the developmental phase, the tDCS procedure was adjusted for easy application by patients or their informal caregivers at home, and a tDCS protocol with specific elements for enhanced safety and remote adherence monitoring was created. Lay language instructional materials were written and revised based on expert feedback. The materials were loaded onto a tablet allowing for secure video-conferencing. The telehealth tablet was paired with an at-home tDCS device that allowed for remote dose control via electronic codes dispensed to patients prior to each session. tDCS was delivered in two phases: once daily on 10 consecutive days, followed by an as needed regimen for 20 days. Initial feasibility of this tDCS-telehealth system was evaluated in four patients with advanced chronic illness and multiple symptoms. Change in symptom burden and patient satisfaction were assessed with the Condensed Memorial Symptom Assessment Scale (CMSAS) and a tDCS user survey.Results: The telehealth-tDCS protocol includes one home visit and has seven patient-tailored elements and six elements enhancing safety monitoring. Replicable electrode placement at home without 10–20 EEG measurement is achieved via a headband that holds electrodes in a pre-determined position. There were no difficulties with patients’ training, protocol adherence, or tolerability. A total of 60 tDCS sessions were applied. No session required discontinuation, and there were no adverse events. Data collection was feasible and there were no missing data. Satisfaction with the tDCS-telehealth procedure was high and the patients were comfortable using the system.Conclusion: At-home tDCS with telehealth support appears to be a feasible approach for the management of symptom burden in patients with chronic illness. Further studies to evaluate and optimize the protocol effectiveness for symptom-control outcomes are warranted.

Highlights

In the United States, at least 175 million people are chronically ill (Centers for Medicare and Medicaid Services, 2012; Ortman et al, 2014)
Transcranial direct current stimulation is a noninvasive and non-pharmacological intervention that may address multiple symptoms of chronic illness (Nitsche and Paulus, 2000; Fregni et al, 2006a,b; Rigonatti et al, 2008; Valle et al, 2009; Loo et al, 2012; Knotkova et al, 2014a,b). tDCS is delivered via a battery-powered device with two or more electrodes that transfer electrical current of low intensity to the surface of the head
We have developed a novel intervention that combines athome tDCS and telehealth support; we have adapted the tDCS procedure and technology for easy home use by the chronically ill, and developed instructional materials, a comprehensive training plan, and a patient-tailored tDCS application protocol that allows for dose-control, and enhanced adherence and safety monitoring in remote

Summary

Introduction

In the United States, at least 175 million people are chronically ill (Centers for Medicare and Medicaid Services, 2012; Ortman et al, 2014). The scientific rationale for tDCS studies in symptom management builds on findings from neurophysiological and neuroimaging studies indicating that the development and maintenance of symptoms frequently occurring in various chronic illnesses are associated with changes in cerebral networks and altered functional connectivity (e.g., Apkarian et al, 2013; Hemington et al, 2016). Earlier studies suggest that reversal of these potentially maladaptive changes in brain function is possible and can be associated with an improvement of symptoms (Maihöfner et al, 2003, 2004; Napadow et al, 2012; and others) Neuromodulation techniques, such as tDCS, can induce enduring alterations of neural activity and connectivity, and can be used to attempt reversal the maladaptive neuroplastic changes occurring in chronic illness (Lefaucheur, 2016; Stock et al, 2016; Woods et al, 2016)

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Conclusion