tDCS and Brain Exercises for Chronic Pain
What is tDCS?
tDCS stands for Transcranial Direct Current Stimulation.
tDCS is a non-invasive brain based treatment that delivers a very weak depolarising and/or hyperpolarising current to the brain (Filmer, 2014). Low current intensities of 1-2mA are used and determined dependent on age and other factors. A treatment session using the tDCS device is usually 10 – 20 minutes duration (Nitsche, 2015).
tDCS increases the excitability, plasticity and potential for positive change in the region of the brain targeted by the anode, and in turn decreases excitability in the area targeted by the cathode. The appropriateness of tDCS for individuals and the position of anode and cathode will be determined by your health professional, following a QEEG brain scan, at Perth Brain Centre (Hunter, 2013).
An extensive study was published this year verifying the efficacy and safety of tDCS. Bikson (2016) assures that of over 33,200 sessions included in their review of human studies there have been no serious adverse effects with use of tDCS. The most common harmless side effects may include – slight sensations perhaps itching, tingling, pins and needles, minimal discomfort under the electrode sites (Bikson, 2016).
Some conditions, medications and substances may also impact the efficacy of tDCS, and there are other special considerations that require an experienced approach (Nitsche, 2015). tDCS is a brain-based treatment that is best recommended and delivered by a health professional. Our team of healthcare professionals at The Perth Brain Centre are always happy to discuss treatment options with individuals.
Brain Exercises for Chronic Pain
When you commence your tDCS treatment for chronic pain you commit to a concurrent program to capitalise on the increased excitability and plasticity of the brain regions related to your pain experience. New learning and repetition are key to lasting brain change.
Evidence suggests the ‘window of opportunity’ following tDCS can last from 90 minutes to 24 hours. It is critically important to make the most of this time. Our Team at The Perth Brain Centre will encourage you to plan for actively engaging in carefully designed activities for at least 60 – 90 minutes after your tDCS treatment.
Your program will be developed with you to suit your needs, and may include:
- Graded Motor Imagery
- Moskowitz Exercises
- Guided Imagery for Pain
- Mindfulness Practice
- Physical Exercise
These exercises have some great names, and sound very exciting…but what are they? We have summarised key components of three of these exercises below. If these exercises become a part of your tDCS for Chronic Pain Program at The Perth Brain Centre, we will work with you and demonstrate and explain these exercises in great detail.
Graded Motor Imagery
The Graded Motor Imagery (often referred to as GMI) was developed by Professor Lorimer Moseley, David Butler and colleagues – founders of the Neuro Orthopaedic Institute (NOIgroup).
GMI exercises your brain in measured and monitored steps, it is a process of training and retraining your brain and its trillions of connections (Butler, 2003). GMI is based in over 15 years of neuroscience and clinical research (Moseley, 2017). It has been tested and proven to be effective. GMI is sometimes used as a “stand alone” therapy but at The Perth Brain Centre it often comprises part of a very comprehensive neuro-rehabilitation programme.
GMI programs are about building a ‘platform of knowledge’ on which to base treatment. There are three unique stages of treatment techniques, each exercising the brain in different ways. Our expert team at The Perth Brain Centre will teach and guide you through these stages:
STAGE ONE: Left/Right Discrimination
STAGE TWO: Explicit Motor Imagery
STAGE THREE: Mirror Therapy
STAGE ONE: Left/Right Discrimination
The ability to quickly and accurately recognise an image of a body area as either right or left is known as Left/Right Discrimination. This skill or process, which requires complex brain activity, has been shown to be reduced in many chronic pain states.
There are a collection of games that you can play that exercise this skill of left/right discrimination. The games are available on specifically developed apps that you can download your phone/computer or you can choose to use flash cards if this better suits you.
STAGE TWO: Explicit Motor Imagery or Imagined Movements
Athletes and performers of all kinds have long used their imaginations as a way to ‘practice’ and ‘rehearse’ complex and important movements and activities. When we vividly imagine a movement, our brains are active in many of the same areas as when we actually move. This allows a progressive brain activation compared to Stage 1 of GMI, and continues the treatment programme. There are a number of ways to approach these imagined movement exercises and these will be explored with you during your sessions at The Perth Brain Centre.
STAGE THREE: Mirror Therapy
The final stage of a Graded Motor Imagery programme uses a mirror to create an illusion that you are moving your problem body area using the reflection of your other hand, foot, elbow, knee etc. This can be powerful therapy, but it is important that you have undertaken the first two stages of GMI, to get the best results. Mirror Therapy is not appropriate for everyone with chronic pain. The team at The Perth Brain Centre will advise you if Mirror Therapy is indicated in your case.
The NOIgroup has a vast and informative collection of interventions and resources for the treatment of chronic pain: http://www.gradedmotorimagery.com/
Experience can be the best teacher, and indeed this is true in the case of Dr Moskowitz. He developed core components of his treatment program on himself, following a water-skiing accident that severely damaged his neck.
Dr Michael Moskowitz is a Psychiatrist who has dedicated his practice to the neuroplastic treatment of persistent (chronic) pain. His clinic operates under the name ‘Neuroplastix’ and is located on the west coast of the USA: www.neuroplastix.com
The Neuroplastix moto reads: Change the Brain; Relieve the Pain; Transform the Person.
If you would like to you can read more about Dr Moskowitz and his story ‘Physician Hurt, Then Heal Thyself’ in chapter one of Dr Norman Doidge’s book ‘The Brain’s Way of Healing’.
In his workbook ‘Neuroplastic Transformation – Your Brain On Pain’ Dr Moskowitz describes the following things happening when you have chronic pain: 16 places in your brain have been identified that activate, ‘fire’ or ‘light up’ when pain signals are received by the brain. 9 of these places are in the conscious part of your brain, the cerebral cortex. In these 9 places only around 5% of the nerve cells are normally assigned the job of processing pain, but in chronic pain this can expand to 15-25% of the cells. Pain effectively hijacks valuable brain territory, stealing these brain cells from other important functions. The brain ‘learns’ pain, and we need to teach it to ‘unlearn’ pain.
We can do this by making the most of what we know about neuroplasticity. What brain cells do is a competitive business. We need to make the other functions of these brain areas more important for the brain cells to do than pain. We need to offer LOTS of alternatives, lots and lots of counter stimulation. We need to pursue pleasure, instead of pursuing pain.
Practically this translates to dedicating lots of time to immersing yourself in exercises to ‘flood the brain to stop the pain’. At The Perth Brain Centre we have developed a detailed worksheet that explains many of the other functions of nine brain areas that are known to ‘light up’ to process pain in a chronic pain experience. We can see that there is a lot more for these brain areas to ‘do’ instead of pain. And these other things are exactly what we want you to do. At The Perth Brain Centre we will tailor these exercises to you, your pain experience and your interests. Together we will build a collection of practical and meaningful activities you can do to reclaim that valuable brain real-estate back from the clutches of pain.
Guided Imagery for Pain
Guided Imagery evokes thoughts of relaxation and stress reduction. Research into Guided Imagery has proven it to be effective in a number of ways for individuals with chronic pain. Guided Imagery can improve: pain and mobility (Baird & Sands, 2004); functional status and a sense of self efficacy for managing pain states (Menzies, 2006) and can reduce re-injury anxiety (Cupal & Brewer, 2001).
At The Perth Brain Centre we use a simple ten minute video entitled ‘Guided Imagery for Pain’ to introduce some of the concepts of guided imagery to individuals as an exercise to change their pain experience.
For more information about how brain-based therapies can help to relieve chronic pain, please contact The Perth Brain Centre on (08) 65003277 or www.perthbraincentre.com.au.