Editor’s Choice: Review ArticleNoninvasive Brain Stimulation to Modulate Neuroplasticity in Traumatic Brain Injury
Section snippets
INTRODUCTION
Traumatic brain injury (TBI) is a major health problem with devastating consequences and an enormous socioeconomic burden on individuals and their families. It has been estimated to affect around 1.5 million people in the USA each year, resulting in 290,000 hospitalizations and 51,000 deaths (1), and lifetime costs that may reach $2 million per patient (2). An estimated 5.3 million U.S. citizens live with long-term disabilities following TBI (3). Although cognitive and emotional derangements
ACUTE CHANGES FOLLOWING TBI
TBI has been divided into primary and secondary injury. The former involves the initial disruption of brain tissue by a cortical contusion, hemorrhage, or axonal injury (5), oftentimes causing irreversible damage to the central nervous system (CNS) (6). The secondary injury consists of a series of events that lead to impairment of cell functions, cell death (7), and consequent dissemination of damage (8), which will eventually determine the degree and magnitude of long-term deficits (9). From a
The Role of Brain Plasticity in TBI Recovery
Plasticity can be defined as an ongoing, intrinsic property of the nervous system, whereby changes in the afferent input or the efferent demands of a neural network lead to systemic reorganization that might be demonstrable from molecular and cellular to anatomical and behavioral levels (35). This dynamic process plays a crucial role in neural development and homeostasis (36), as well as in the response after damage to the peripheral or central nervous system. In the setting of brain injury,
Transcranial Magnetic Stimulation (TMS)
TMS, introduced in 1985 (103), is an NBS technique based on the principle of electromagnetic induction. By passing a very brief and large electric current though a coil held over the scalp, a rapidly changing magnetic field is created which then penetrates relatively unimpeded through the skull and secondarily induces electric currents in particular brain regions. When a single TMS pulse is applied, the resulting electric current can be of sufficient magnitude to depolarize cortical neurons,
TRANSCRANIAL DIRECT CURRENT STIMULATION (TDCS)
Modification of brain function by means of electrical currents was first described more than 200 years ago (129) and extensively studied in animal models in the 1950s and 1960s (130., 131., 132., 133., 134.). Based on these observations, tDCS was developed as an NBS technique that consists of placing two relatively large rubber electrodes (25–35 cm2) on the scalp, in order to allow a weak direct current to flow from anode to cathode. Although there is shunting of current in the overlying
NBS AS A THERAPEUTIC TOOL IN TBI
TBI may lead to a variety of neurobehavioral consequences that may appear in the first days after the insult and continue to show in the following months (2). These may include seizures (154,155), headache (156), movement disorders, motor impairment, language and visual deficits, sleep (157), memory (158,159), and attention disorders as well as concentration impairment (160). The course of recovery is complex and the time needed to recover from these sequelae may last months to years (2),
SAFETY CONSIDERATIONS
Due to specific characteristics of this group of patients, some particular safety considerations regarding the use of NBS in TBI should be noted. First, given their high incidence of LPTS, one of the potential issues that may arise relates to the likelihood of triggering seizures associated with the stimulation. The other involves the effects of NBS in individuals with skull defects and skull plates, two common findings among TBI survivors.
A large number of subjects and patients have undergone
CONCLUDING REMARKS
The complex pathophysiology underlying TBI, together with the diversity of phenomena that predominate at different time points and the unique characteristics of each patient, make it necessary to develop individualized therapeutic approaches. They would help enhance recovery and decrease the burden of disabling sequelae after the injury.
Plasticity, an innate property of the brain, is responsible for the changes occurring not only in the lesioned site but also in distant areas, and takes place
Acknowledgements
The authors wish to thank Ms. Laura Sherman for her editorial support during preparation of this manuscript, and the reviewers for their insightful feedback and comments.
Authorship Statements
Drs. Villamar and Santos Portilla conducted a review of the literature and prepared the manuscript, with important intellectual input provided by Drs. Zafonte and Fregni. All authors approved the final manuscript.
How to Cite this Article:
Villamar M.F., Santos Portilla A., Fregni F., Zafonte R. 2012. Noninvasive Brain Stimulation to Modulate
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