Abstract
Neuromodulation devices are approved in the United States for the treatment of movement disorders, epilepsy, pain, and depression, and are used off-label for other neurologic indications. By 2035, advances in our understanding of neuroanatomical networks and in the mechanism of action of stimulation, coupled with developments in material science, miniaturization, energy storage, and delivery, will expand the use of neuromodulation devices. Neuromodulation approaches are flexible and modifiable. Stimulation can be targeted to a dysfunctional brain focus, region, or network, and can be delivered as a single treatment, continuously, according to a duty cycle, or in response to physiologic changes. Programming can be titrated and modified based on the clinical response or a physiologic biomarker. In addition to keeping pace with clinical and technological developments, neurologists in 2035 will need to navigate complex ethical and economic considerations to ensure access to neuromodulation technology for a rapidly expanding population of patients. This article provides an overview of systems in use today and those that are anticipated and highlights the opportunities and challenges for the future, some of which are technical, but most of which will be addressed by learning about brain networks, and from rapidly growing experience with neuromodulation devices.
Highlights
Neuromodulation devices are approved in the United States for the treatment of movement disorders, epilepsy, pain, and depression, and are used off-label for other neurologic indications
The proposed mechanism is that neural activity is promoted by the current flow under one electrode, and is inhibited under the second[18]; clinical applications are being explored in rehabilitation, neuropsychiatry, epilepsy, and memory enhancement.[19,20]
Key challenges to effective treatment are to define the targets for stimulation and the “dose,” recognizing there are multiple configurable stimulation measures, including stimulation pathways, frequency, pulse width, duration, current, and whether the stimulation is provided as a single treatment, continuously, on a duty cycle or responsively
Summary
The authors contributed to this work. From the Department of Engineering Science (T.D.), University of Oxford, UK; Department of Neurology and Neurological Sciences (M.J.M), Stanford University, CA; and NeuroPace (M.J.M), Mountain View, CA. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. The treatment of many disorders of the nervous system relies on chronic noncurative pharmacologic or biologic treatments or on creation of focal lesions. Neuromodulation therapies offer another approach: targeting and disrupting a dysfunctional brain focus, region, or network. We use the term neuromodulation broadly, to include direct stimulation of a neural substrate to drive action potentials and modulate distributed neural activity, as well as subthreshold stimulation to bias local activity
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