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TRANSCRANIAL ELECTRICAL STIMULATION AFTER INFECTION
Article written by: EDIS MUSTAFA, MD, Medical rehabilitation doctor
SARS-COV-2 is an extremely infectious virus that led to the current pandemic (COVID-19). Throughout the pandemic, understanding the nature and course of the COVID-19 disease has evolved together with its optimal management. Neuromodulation may have a potential role in treating symptoms related to COVID-19. This potential is theorized based on known mechanisms of biological action, demonstrated benefits in non-COVID-19 patients for various known sequelae of the disease, and recovery.
Most current investigative efforts regarding the use of non-invasive stimulation approaches in COVID-19 are focused on managing acute infection by modulating the immune response and restoring respiratory function through vagus nerve stimulation. VNS techniques include invasive and non-invasive manual or electrical (transcutaneous) stimulation, with therapeutically relevant effects for COVID-19 in clinical investigations.
This update provides a summary of current efforts in evaluating and applying non-invasive brain stimulation techniques as interventions in the context of COVID-19 recovery, focusing on transcranial electrical stimulation (tES) approaches, particularly transcranial direct and alternating current stimulation.
Transcranial electrical stimulation is increasingly gaining ground nowadays, being a therapy with very good results in many neurological conditions, as well as for improving sports performance or increasing intellectual capacity.
It can be used in neurological conditions as a first-line therapy or in combination with medication, and remains an alternative in cases where patients develop pharmacoresistance (drug resistance) or have not achieved favorable results after existing conventional treatments.
In an interview from a National Geographic documentary on transcranial stimulation, the brilliant physicist Stephen Hawking stated that “probably in the next 20 years, this type of therapy will be used by most people and will represent an important step in the evolution of the human species, as it will help in discovering brain functions that could accelerate healing and memory processes.”
Transcranial electrical stimulation (tES) is a simple, painless treatment method that uses an electric current intensity around 1mA and induces long-term positive brain changes.
The tES/TMS techniques are designed to modulate the activity of intracranial brain structures and neural circuits. These approaches induce different models of electric fields, with tES being less focused and more limited in reaching deep brain structures. While tES techniques sometimes involve stimulation of peripheral or auxiliary cranial nerves, this review refers only to direct non-invasive brain stimulation. There are several ways in which tES may address the immediate and long-term morbidity of COVID-19, but when subjected to direct experimental testing in infected patients, these connections remain indirect. There is a bidirectional influence between the brain and the immune response.
The deep regions of the brainstem and the frontal areas of the brain mediate the immune response throughout the body and may be potential targets for non-invasive neuromodulatory approaches. Although it is not practical to selectively activate deep regions using tES, they can certainly be stimulated by electric current. The cortical regions conventionally targeted by tES, such as the frontal and temporal regions, can be stimulated to influence the systemic immune response and prevent neuronal inflammation. In addition, tES may be investigated for applications in restoring respiratory and musculoskeletal functions during recovery.
Transcranial electrical stimulation has great potential to manage COVID-19 infection, its complications, and associated symptoms through four mechanisms:
1. Directly attenuates the infection by stimulating regions involved in regulating systemic anti-inflammatory responses, autonomic responses, preventing neuroinflammation, and aiding respiratory recovery.
2. Acts as an adjunct treatment to enhance cognitive and physical rehabilitation following critical illness, and to treat acute psychological reactions.
3. Manages persistent post-infectious symptoms such as fatigue and pain.
4. Treats pandemic-related distress, including neurological and psychiatric disorders exacerbated by surrounding psychosocial stressors.
Potential role in acute infections and other conditions
tES approaches aim to have direct effects on brain functions, which may include clearance mechanisms and immune response. From a theoretical perspective, tES may be applicable for preventing acute neuroinflammation or directly addressing the neurological manifestations of COVID-19 infection. In acute infection, COVID-19 typically presents with CNS symptoms such as headache, anosmia, ageusia, and dizziness. The virus may be neurotropic. Neuroinvasion, particularly involving the brainstem, may be directly linked to respiratory failure syndrome. In addition, systemic inflammation following COVID-19 has led to disorders of consciousness, delirium, encephalopathy, psychosis, cerebrovascular events, seizures, Guillain-Barré syndrome, and optic neuritis.
There is also a theoretical potential role for tDCS in the prevention and treatment of thrombosis through modulation of the autonomic nervous system. Patients treated in ICUs have an increased risk of microvascular, venous, or arterial thrombosis associated with higher mortality, demonstrating the importance of coagulation abnormalities in these patients. Anticoagulant treatment of thrombosis with low molecular weight heparin tends to have an improved prognosis in COVID-19 patients meeting sepsis-induced coagulopathy criteria or with significantly elevated D-dimers.
Heparins may be a potential approach in caring for COVID-19 patients, as they combat hypoxia and generalized organ failure with coagulopathies and can reduce cardiovascular arrhythmias and sudden deaths, both associated with COVID-19. Interestingly, increased sympathetic activity is linked to thrombosis development, and sympathetic blockade is also suggested as a potential treatment approach for thrombosis. Therefore, autonomic neuromodulation is used as a complementary therapeutic strategy for thrombosis.
Role in post-acute functional recovery
Neurological consequences often result from severe impairment following COVID-19 infection, for example after intubation. COVID-19 infection can cause severe damage to cranial and peripheral nerves, leading to muscle weakness, muscle injury, facial palsy, sensory ataxia, flaccid diplegia, or tetraplegia. Intubation during the acute phase of the disease may reduce neurological drive from the motor cortex to the diaphragm and hinder normal respiratory recovery. Furthermore, for patients living with neurological disorders, COVID-19 infection and its treatments may also exacerbate pre-existing conditions, such as worsening disease symptoms following acute systemic inflammation. A large and growing number of studies demonstrate the benefits of tES in neurorehabilitation. Additionally, tES applied as an adjunct cognitive or physical rehabilitation technique amplifies results, as widely demonstrated across several neurological conditions, including post-stroke recovery, multiple sclerosis, and Parkinson’s disease.
As a result of acute neurological events related to COVID-19 infection, patients who survived ICU hospitalization also report a high prevalence of cognitive-communication disorders. tDCS has been previously applied in conjunction with speech therapy for speech recovery in aphasia.
Role in managing persistent post-infectious symptoms - pain and fatigue
Over 87% of COVID-19 patients report at least one persistent symptom 60 days after initial recovery, the most common being fatigue, dyspnea, and pain. tES treatments have been established as an approach to reduce fatigue, for example in athletes and in neuroimmune conditions such as multiple sclerosis and post-polio syndrome, possibly by restoring autonomic imbalance. The effectiveness of tES in pain management has been observed in reducing musculoskeletal pain (e.g., in fibromyalgia and arthralgia). tDCS is also being investigated for the treatment of dyspnea.
Role in managing acute and chronic psychological states and mental health
The most direct application of tES in COVID-19 management is in mental health. To date, most evidence for tES efficacy comes from managing neuropsychiatric conditions such as anxiety, PTSD, and depression. For those with acute infection, and especially with a history of ICU hospitalization, there may be a “post-intensive care syndrome” combining acute psychological distress, such as post-traumatic stress disorder, acute anxiety, and/or short- and long-term depression. So far, there is a case report demonstrating that tDCS may be a potential adjuvant therapy for acute post-COVID-19 anxiety.
Furthermore, there are growing concerns about the consequences of the COVID-19 pandemic on mental health, resulting from both the disease and surrounding stress factors. This pandemic has caused an increase in addictive behaviors, both new and relapsing, including alcohol and/or drug abuse. Those with substance use disorders, in particular, exhibit changes in immune, respiratory, and pulmonary systems that may increase susceptibility to COVID-19 infection.
Among the available resources to assist patient recovery, tES and TMS have been used in an increasing number of studies for their therapeutic potential in treating substance use disorders (e.g., nicotine, alcohol, and cocaine). The general population, healthcare workers, and post-acute recovery patients report high rates of sleep disorders (e.g., acute insomnia) mainly related to changes in stress and anxiety levels.
In this context, recent studies have investigated the use of tDCS in emotion regulation with a positive mediating effect on sleep. tDCS has been developed for home use with remote supervision, providing an advantage in treatment access and ensuring its continuity.
tES techniques are considered safe and well tolerated. However, even though tDCS is considered safe, it still requires investigation for many potential applications in COVID-19. Studies on tES in patients with acute and/or severe disease should consult the relevant literature, including for those with conditions such as myocarditis or thrombotic stroke.
Conclusions
As with any medical intervention, the use of tES will depend on the informed decision of the therapy team, applied in relation to other treatments. Any use of tES is subject to regulatory factors and must comply with current research findings. This pandemic has created an urgent need for discovering and implementing new treatments. tES has a long history of safety and tolerability in completed clinical studies to date.
Dr. Edis Mustafa, a specialist in physical and rehabilitation medicine, is highly trained in tES therapy, having treated over 200 patients, none of whom have experienced any side effects. Dr. Mustafa completed his PhD in tES therapy and is the most experienced doctor in Romania in this field.
Transcranial electrical stimulation prices
Service | Rate (LEI) | Details |
Package of 10 transcranial electrical stimulation sessions | 1500 | Details |
Package of 20 transcranial electrical stimulation sessions | 2800 | Details |
Transcranial electrical stimulation sessions | 180 | Details |
You can find here a detailed list of transcranial electrical stimulation (tES) service prices. However, any proper recovery process is based on a mixed plan of therapies and procedures, personalized according to the condition, stage, patient profile, and other objective medical factors. Therefore, to configure a treatment plan, including the involved therapies, periods, and corresponding tariff, please make an appointment here for an initial consultation.
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