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Neurostimulation technology can improve the life quality of those who are severely paralyzed or suffering from profound losses
to various sense organs, as well as for permanent reduction of severe, chronic pain which would otherwise require constant
(around-the-clock), high-dose opioid therapy (such as neuropathic pain and spinal-cord injury). It serves as the key part of neural
prosthetics for hearing aids, artificial vision, artificial limbs, and brain-machine interfaces. In the case of neural stimulation,
mostly an electrical stimulation is utilized and charge-balanced biphasic constant current waveforms or capacitively coupled
charge injection approaches are adopted. Alternatively, transcranial magnetic stimulation and transcranial electric stimulation
have been proposed as non-invasive methods in which either a magnetic field or transcranially applied electric currents cause
neurostimulation.[1][2]
Contents
Brain stimulation
Deep brain stimulation
Non-invasive brain stimulation
Transcranial magnetic stimulation
Transcranial electrical stimulation
Spinal cord stimulation
Transcutaneous supraorbital nerve stimulation
Cochlear implants
Visual prosthesis
Cardiac electrostimulation devices
Stimulation microelectrode technologies
History
Research
See also
References
Brain stimulation
Brain stimulation has potentials to treat some disorders such as epilepsy. In this method, scheduled stimulation is applied to
specific cortical or subcortical targets. There are available commercial devices[3] that can deliver an electrical pulse at scheduled
time intervals. Scheduled stimulation is hypothesized to alter the intrinsic neurophysiologic properties of epileptic networks. The
most explored targets for scheduled stimulation are the anterior nucleus of the thalamus and the hippocampus. The anterior
nucleus of the thalamus has been studied, which has shown a significant seizure reduction with the stimulator on versus off during
several months after stimulator implantation.[4] Moreover, the cluster headache (CH) can be treated by using a temporary
stimulating electrode at sphenopalatine ganglion (SPG). Pain relief is reported within several minutes of stimulation in this
method.[5] To avoid use of implanted electrodes, researchers have engineered ways to inscribe a "window" made of zirconia that
has been modified to be transparent and implanted in mice skulls, to allow optical waves to penetrate more deeply, as in
optogenetics, to stimulate or inhibit individual neurons.[6]
A simple DBS system consists of two different parts. First, tiny microelectrodes are implanted in the brain to deliver stimulation
pulses to the tissue. Second, an electrical pulse generator (PG) generates stimulation pulses, which it sends to the electrodes
through microwires.
The application and effects of DBS, on both normal and diseased brains, involves many parameters. These include the
physiological properties of the brain tissue, which may change with disease state. Also important are the stimulation parameters,
such as amplitude and temporal characteristics, and the geometric configuration of the electrode and the tissue that surrounds it.
In spite of a huge number of studies on DBS, its mechanism of action is still not well understood. Developing DBS
microelectrodes is still challenging.[7]
Cochlear implants
Cochlear implants have provided partial hearing to more than 120,000 persons worldwide as of 2008. The electrical stimulation is
used in a cochlear implant to provide functional hearing in totally deafened persons. Cochlear implants include several subsystem
components from the external speech processor and radio frequency (RF) transmission link to the internal receiver, stimulator,
and electrode arrays. Modern cochlear implant research started in the 1960s and 1970s. In 1961, a crude single electrode device
was implanted in two deaf patients and useful hearing with electric stimulation was reported. The first FDA approved complete
single channel device was released in 1984.[14] In cochlear implants, the sound is picked up by a microphone and transmitted to
the behind-the-ear external processor to be converted to the digital data. The digitized data is then modulated on a radio frequency
signal and transmitted to an antenna inside a headpiece. The data and power carrier are transmitted through a pair of coupled coils
to the hermetically sealed internal unit. By extracting the power and demodulating the data, electric current commands are sent to
the cochlea to stimulate the auditory nerve through microelectrodes.[15] The key point is that the internal unit does not have a
battery and it should be able to extract the required energy. Also to reduce the infection, data is transmitted wirelessly along with
power. Inductively coupled coils are good candidates for power and data telemetry, although radio-frequency transmission could
provide better efficiency and data rates[16]. Parameters needed by the internal unit include the pulse amplitude, pulse duration,
pulse gap, active electrode, and return electrode that are used to define a biphasic pulse and the stimulation mode. An example of
the commercial devices include Nucleus 22 device that utilized a carrier
frequency of 2.5 MHz and later in the newer revision called Nucleus 24
device, the carrier frequency was increased to 5 MHz.[17] The internal unit
in the cochlear implants is an ASIC (application-specific integrated circuit)
chip that is responsible to ensure safe and reliable electric stimulation.
Inside the ASIC chip, there is a forward pathway, a backward pathway, and
control units. The forward pathway recovers digital information from the
RF signal which includes stimulation parameters and some handshaking
bits to reduce the communication error. The backward pathway usually
includes a back telemetry voltage sampler that reads the voltage over a
period of time on the recording electrode. The stimulator block is
responsible to deliver predetermined current by external unit to the
microelectrodes. This block includes a reference current and a digital to
analog converter to transform digital commands to an analog current.[18] Cochlear implant
Visual prosthesis
Theoretical and experimental clinical evidences suggest that direct electrical
stimulation of the retina might be able to provide some vision to subjects who
have lost the photoreceptive elements of their retina.[19] Therefore, visual
prostheses are developed to restore vision for the blind by using the stimulation.
Depending upon which visual pathway location is targeted for neural
stimulation, different approaches have been considered. Visual pathway consists
mainly of the eye, optic nerve, lateral geniculate nucleus (LGN), and visual
cortex. Therefore, retinal, optic nerve and visual cortex stimulation are the three
different methods used in visual prostheses.[20] Retinal degenerative diseases,
The Visual Cortical Implant
such as retinitis pigmentosa (RP) and age-related macular degeneration (AMD),
are two likely candidate diseases in which retinal stimulation may be helpful.
Three approaches called intraocular epiretinal, subretinal and extraocular transretinal stimulation are pursued in retinal devices
that stimulate remaining retinal neural cells to bypass lost photoreceptors and allow the visual signal to reach the brain via the
normal visual pathway. In epiretinal approach, electrodes are placed on the top side of the retina near ganglion cells,[21] whereas
the electrodes are placed under the retina in subretinal approaches.[22] Finally, the posterior scleral surface of the eye is the place
in which extraocular approach electrodes are positioned. Second Sight and the Humayun group at USC are the most active groups
in the design of intraocular retinal prostheses. The ArgusTM 16 retinal implant is an intraocular retinal prosthesis utilizing video
processing technologies. Regarding to the visual cortex stimulation, Brindley, and Dobelle were the first ones who did the
experiments and demonstrated that by stimulating the top side of the visual cortex most of the electrodes can produce visual
percept.[11] More recently Sawan built a complete implant for intracortical stimulation and validated the operation in rats[23]
LGN, which is located in the midbrain to relay signals from the retina to the visual cortex, is another potential area that can be
used for stimulation. But this area has limited access due to surgical difficulty. The recent success of deep brain stimulation
techniques targeting the midbrain has encouraged research to pursue the approach of LGN stimulation for a visual prosthesis.[24]
History
The primary findings about neurostimulation originated from the idea to stimulate nerves for therapeutic purposes. The 1st
recorded use of electrical stimulation for pain relief goes back to 46 AD, when Scribonius Largus used torpedo fish (electric ray)
for relieving headaches.[29] In the late 18th century, Luigi Galvani discovered that the muscles of dead frog legs twitched when
struck by direct current on the nervous system.[30] The modulation of the brain activity by electrical stimulation of the motor
cortex in dogs was shown in 1870 that resulted in limb movement.[31] From the late 18th century to today many milestones have
been developed. Nowadays, sensory prosthetic devices, such as visual implants, cochlear implants, auditory midbrain implants,
and spinal cord stimulators and also motor prosthetic devices, such as deep brain stimulators, Bion microstimulators, the brain
control and sensing interface, and cardiac electro-stimulation devices are widely used.[11]
In 2013 the British pharmaceutical company GlaxoSmithKline (GSK) coined the term "electroceutical" to broadly encompass
medical devices that use electrical, mechanical, or light stimulation to affect electrical signaling in relevant tissue types.[32][33]
Clinical neural implants such as cochlear implants to restore hearing, retinal implants to restore sight, spinal cord stimulators for
pain relief or cardiac pacemakers and implantable defibrillators are proposed examples of electroceuticals.[32] GSK formed a
venture fund and said it would host a conference in 2013 to lay out a research agenda for the field.[34] A 2016 review of research
on interactions between the nervous and immune systems in autoimmune disorders and mentioned "electroceuticals" in passing
and quotation marks, referring to neurostimulation devices in development for conditions like arthritis.[35]
Research
In addition to the enormous usage of neurostimulation for clinical applications, it is also used widely in laboratories started dates
back to 1920s by people like Delgado who used stimulation as an experimental manipulation to study basics of how the brain
works. The primary works were on the reward center of the brain in which stimulation of those structures led to pleasure that
requested more stimulation. Another most recent example is the electrical stimulation of the MT area of primary visual cortex to
bias perception. In particular, the directionality of motion is represented in a regular way in the MT area. They presented
monkeys with moving images on screen and monkey throughput was to determine what the direction is. They found that by
systematically introducing some errors to the monkey's responses, by stimulating the MT area which is responsible for perceiving
the motion in another direction, the monkey responded to somewhere in between the actual motion and the stimulated one. This
was an elegant use of stimulation to show that MT area is essential in the actual perception of motion. Within the memory field,
stimulation is used very frequently to test the strength of the connection between one bundle of cells to another by applying a
small current in one cell which results in the release of neurotransmitters and measuring the postsynaptic potential.
Generally, a short but high-frequency current in the range of 100 Hz helps strengthening the connection known as long-term
potentiation. However, longer but low-frequency current tends to weaken the connections known as long-term depression.[36]
See also
Non-invasive cerebellar stimulation
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