Our future: Everything in modulation

Our future: Everything in modulation

 
 Don't worry. Be happy☺.

  In a recent post, I documented the desperate -- even ruthless -- effort to gain acceptance of vagus nerve stimulation for the treatment of depression. The medical-device industry is investing millions in order to reap billions in the burgeoning field of neuromodulation. But if you're not depressed: "Don't worry. Be happy!" Before long, they'll be peddling something that may change your life, too. Your brain is their playground.
  If you have any of these conditions (among others), just be patient. The finest minds in science are at work as we speak: Anxiety, sleep apnea, depression, Alzheimer’s, epilepsy, stroke, Tourette's syndrome, addiction, "phantom pain," obsessive-compulsive disorder, Parkinson's and other movement disorders, obesity, tinnitus, incontinence, PTSD,  fibromyalgia, hearing loss, bladder dysfunction, migraine, IBS, asthma, eating disorders, chronic pain, heart disease, systemic inflammation, and autoimmune diseases, including rheumatoid arthritis. They will also perk up your memory and cognition. All you'll feel is a little tingle.
  But the more you know about the industry, the more uneasy you'll feel about them messing with your mind. 
 

         There are a few charmingly reckless people who are electrifying their own brains, just to see what happens, as I will describe below.
  What's even scarier, is that now the military is involved. The Defense Advanced Research Projects Agency, or DARPA, is launching a $70 million program to study how electrodes implanted in our troops' brains might improve their moods and their ability to tolerate traumatic events, and allay their anxiety about what they're doing. Does that sound like a good thing to you? 
   The new program will fund development of high-tech implanted devices able to both monitor and electrically stimulate specific brain circuits, according to a May 27, 2014 NPR story.
    Isn't this kind of like mind control? And DARPA is renowned for sharing its tax-funded findings with industry, which can then apply them to the population at large. Things just keep getting creepier.
    UPDATE July 17, 2014: There has been so much hype about attaching electrodes to one part of the skull or another and zapping the brain with electricity -- achieving literally mind-boggling results -- that I have actually fantasized about affixing my TENS unit pads to my temples and having a little "brainstorm" of my own. Now the New York Times reports that "You can devise your own battery-pack shocker from consumer goods at Radio Shack for about $20, according to Greg Miller at Wired. He details how DIYers have embraced the technology, spreading online advice, subreddits for trading information and how-to videos about delivering zaps at home." Dangerous anecdotal evidence, which is taking on the status of urban legend, indicates that these brave kids are getting a marvelous new clear-headedness, joy, peace and focus. But Marom Bikson, a biomedical engineer at City College of New York, says we don’t yet understand how the altered physiological state of the neurons can have therapeutic effects on the brain. The Times adds. "Mr. Bikson also took issue with the notion that different skills can be targeted by electrode placement — there is no 'math' or 'language' area of the brain to locate." (http://op-talk.blogs.nytimes.com/2014/07/17/this-procedure-may-improve-your-brain-and-uncover-the-real-you).

UPDATE AUGUST 24, 2014: Oh cool, marketers are using data about transcranial direct current stimulation (TDCS) -- which passes small electrical currents directly onto the scalp and theoretically stimulates the nerve cells in the brain -- to entice gamers, and everyone else they can think of, to buy their cute, futuristic-looking gadgets.

 
Your brain is not a plaything, you crazy, reckless young lady!

     Since they are not making medical claims (in their opinion, anyway), the are not subject to regulatory oversight. One of their ads exclaims:  "Can you learn 20-40 percent quicker, reduce pain, feel better, increase energy or reduce stress with tDCS? Research studies say, YES!" Studies also indicate you could mess up your mind, you fools! (http://www.bbc.com/news/health-27343047).

YOUR BRAIN IS THEIR 'FINAL FRONTIER' (AND FINAL SOLUTION?)
    My participation in Cyberonics' clinical trial for vagus nerve stimulation (VNS) gave me a rather too up-close-and-personal glimpse into how this frenetically competitive new industry is gearing up to be The Next Big Thing, in the health-care system and among profit-hungry investors (http://kronstantinople.blogspot.com/2013/09/what-happens-in-my-vagus-stays-in-my.html).
    Even so, I decided to write about neuromodulation because I had become intrigued by its extraordinary potential to improve the quality of life for people around the world. I felt hopeful.
    Silly me! I can't believe how readily I was taken in by the beautiful pictures and prose that the medical device industry is using to entice patients.They portray sleek, futuristic technologies that infuse our neurons with sparkly, radiant relief from our physical and mental dysfunctions.
    What began as a heartwarming tale of human genius laboring humbly for the betterment of mankind quickly devolved into the usual scenario: When money and ambition are involved, scandal ensues.

CREEPY CURIOSITY CREEPS INTO OUR MINDS
    To make matters worse, our neurological systems -- including our brains -- are the unfortunate raw material of this industry, which really doesn't know what it's doing. (In fact, in a Sept. 17, 2013 New York Times article, those who are deciding how to embark upon the new, $100 million "U.S. Brain Initiative," admitted that their first order of business is "determining how many different types of neurons there are, what they do, and how to study them.")
    Even though these remain open questions, researchers are plunging in, zapping whatever looks interesting amid the jumble, and hoping that nothing catastrophic occurs.
 

"Let's see: Which strand do you think triggers anxiety?"
    A June 6, 2014, New York Times article makes the case that we are way too ignorant to be mucking about inside people's craniums:  "The question is: How do you get from signal patterns to human consciousness? (This exhibition) reminds us very quickly just how far we are from knowing the answer. How is vision synthesized in the brain? How are conflicting sensory data reconciled in the anterior cingulate cortex? How do regions of the brain work together? 'We’re not sure,' is the recurring answer.

    The article continues: "In a 2010 exhibition, the American Museum of Natural History noted that the human brain is probably the most complicated object in the universe. Here, we learn that it contains some 86 billion neurons, each making connections with about 7,000 others in changing configurations and firing up to 100 times a second."
     UPDATE June 6, 2014: The National Institutes of Health has set an ambitious $4.5 billion price tag on its part of President Obama’s Brain Initiative, "which is developing and applying new technology to crack the toughest unsolved puzzles of how the brains of humans and animals function." The Defense department is seeking billions to probe our brains as well. (http://www.nytimes.com/2014/06/06/science/nih-seeks-4-5-billion-to-try-to-crack-the-code-of-how-brains-function.html?hpw&rref=health).
    Meanwhile, clueless researchers in the private sector have plunged in already, experimenting -- on human beings! for profit! -- with what happens when one site or another is electrically stimulated. Will they cure your incontinence (or make you incontinent?), make you fall down every five minutes, or cause you to acquire a British accent? Will they give you delusions of grandeur, or create amnesia? If they are attempting to normalize your appetite or elevate your mood, couldn't they electrocute your creativity or kill a skill? If they are trying to elicit your bonding instincts, could they accidentally unleash aggression or turn you into an alcoholic? Could they change your sex drive, or even your sexual orientation? In an effort to erase your traumatic memories, what else might they erase? Could all this experimental tinkering and mucking about in the delicate, mysterious realm of our neurological infrastructures leave us wondering who we truly are? Do we have a fundamental Self that the mad scientists can't take away from us -- or not? Fundamental ethical questions about this research have not been addressed.
    "We scientists are not only far from a comprehensive explanation of how the brain works; we’re also not even in agreement about the best way to study it, or what questions we should be asking," Gary Marcus wrote recently in "The Trouble with Brain Science."
    UPDATE: (http://www.nytimes.com/2014/05/25/magazine/can-the-nervous-system-be-hacked.html?nav). "(Neurosurgeon) Kevin Tracey’s efforts using vagus nerve stimulation have helped establish what is now the growing field of bioelectronics. He has grand hopes for it. “I think this is the industry that will replace the drug industry,” he told me. Today researchers are creating implants that can communicate directly with the nervous system in order to try to fight everything from cancer to the common cold. Conceptually, bioelectronics is straightforward: Get the nervous system to tell the body to heal itself.....(Unsurprisingly) in August, GlaxoSmithKline invested $5 million in SetPoint, and its bioelectronics R. & D. unit now has partnerships with 26 independent research groups in six countries. Glaxo has also established a $50 million fund to support the science of bioelectronics and is offering a prize of $1 million to the first team that can develop an implantable device that can, by recording and responding to an organ’s electrical signals, exert influence over its function. Instead of drugs, “the treatment is a pattern of electrical impulses,” Famm says. “The information is the treatment.” In addition to rheumatoid arthritis, Famm believes, bioelectronic medicine might someday treat hypertension, asthma, diabetes, epilepsy, infertility, obesity and cancer...These devices are indiscriminate, blasting electricity into billions of neurons and hoping for the best, critics. (And) if large numbers of patients someday choose bioelectronics over drugs, another issue awaits resolution: security. Bioelectronics devices will feature wireless connectivity so they can be fine-tuned and upgraded, “just like the software on your iPhone,” Famm says. And wireless means hackable, an unsettling fact that worries two experts on medical-device security."

    YET ANOTHER SCARY UPDATE: (http://www.nytimes.com/2014/07/09/health/probing-brains-depth-trying-to-aid-memory.html?hp&action=click&pgtype=Homepage&version=HpSumSmallMediaHigh&module=second-column-region&region=top-news&WT.nav=top-news&_r=0). "The Department of Defense on June 8 announced a $40 million investment in what has become the fastest-moving branch of neuroscience: direct brain recording. Scientists have found in preliminary studies that they can sharpen some kinds of memory by directly recording, and stimulating, circuits deep in the brain. Unlike brain imaging, direct brain recording allows scientists to conduct experiments while listening to the brain’s internal dialogue in real time. Experts worry about the possible side effects of directly tampering with memory. The frontier of the direct-recording approach is in implants that act something like thermostats, adjusting levels of simulation when signals in the brain become too faint or too noisy. Experts caution that some big practical and ethical questions remain. One is how closely stimulation truly mimics the brain’s internal language and whether such experiments may cause more harm than good. “We have to keep reminding ourselves that, no, we are not speaking the brain’s secret language — we’re doing some very crude stimulating,” said Dr. Anthony Ritaccio, the director of neurosurgery at Albany Hospital in New York. “When working with the brain, you have to keep slapping yourself in the face as a reality check; we still understand so little.”

JACKASSES GALORE
    (And wacko "Jackass"-inspired dudes are applying electrodes to their skulls to see what crazy things might happen. Crazy things do, at least when they're after lots of YouTube hits.) 
    UPDATE: A May 16, 2014 BBC story reports the latest Jackass shenanigans of "serious" scientists:

No, she's not curling her hair: She's having a mood readjustment.
     The "helmet," shown in the picture above, delivers mild electric impulses to the brain. It has shown "promise" in treating depression, the researchers claim.

    It was tested on 65 patients by the Department of Cellular and Molecular Medicine at Copenhagen University and the Psychiatric Centre at Hillerod in North Zealand. 
    The device contains seven coils that deliver a dose of Transcranial Pulsating Electro Magnetic Fields (T-PEMF) to brain tissues.
    "The pulses are so minute that the patient cannot detect any sensation, and the only side effect so far is occasional 'tiny' nausea that immediately disappears after treatment, according to the BBC.
    Prof. Steen Dissing, of Copenhagen's Faculty of Health Sciences is the helmet's principal architect. He said: "The device mimics electrical fields in the brain, and triggers the body's own healing mechanism."
    "The pulses activate capillaries in the brain, which form new blood vessels and secrete growth hormones."
    This explanation assumes that depression is an "injury" that requires greater oxygenation and repair activity, a theory that is simply laughable. Any psychiatrist or neurologist will tell you that clinical depression has little if anything to do with the circulatory system or growth hormones.
    Electricity is being poured into the brains of hapless clinical trial subjects with such wild abandon, with the hope that something positive will occur, that I have seriously considered putting my two TENS unit electrodes on my temples to see what might happen.
    "We’re dealing with things affecting thought, emotion, behaviour — what people hold valuable as the essence of the self," says James Giordano, chief of neuroethics studies at Georgetown University. The disturbing moral implications of this research are addressed in the August 2013 issue of Nature (http://www.nature.com/news/us-brain-project-puts-focus-on-ethics-1.13549).  
 

 

    For the time being, it's a crap shoot. And those who are in enough distress to serve as study subjects for unproven technologies are the crap.
    Billions of dollars are at stake. Patients are used, in some cases damaged or defrauded,  and then left to fend for themselves.
    And that's how a saga of hope and dreams turned into investigative reporting, with a side dish of disgust. Fasten your seatbelts.

THE ELECTRA COMPLEX 
    For generations, physicians have been "intrigued by the possibility of harvesting the power of electrical impulses in the human body for therapeutic benefit," according to the International Neuromodulation Society website. I was surprised to learn that the "modern" era of neuromodulation began (albeit in a rather primitive way) in the early 1960s, with the use of deep brain stimulation (DBS) to resolve chronic and intractable pain, and evolved to include spinal cord stimulation by the end of the decade. 
    Which begs the question: After all these years, why are they still screwing up so badly?

Electra emitted her own special sparks.

     A September 9, 2013 article in the New York Times substantiates what I have learned in my extensive coverage of the FDA (http://well.blogs.nytimes.com/2013/09/09/new-concerns-on-robotic-surgeries/?src=rechp&_r=0). Its approval process in general, and for medical devices in particular, is lax and ethically compromised. Its monitoring, via stern "warning letters," is regarded as a joke by the industry. Both doctors and device-makers fail to report the vast majority of malfunctions, injuries and deaths that are caused by approved products. And the FDA fails to act on the complaints it does receive, even when there are hundreds of them.
    "In health care, one fifth of the economy, we have this haphazard smattering of reports that relies on voluntary self-reporting with no oversight, no enforcement and no consequences," Dr. Martin A. Makary, an associate professor of surgery at Johns Hopkins, told the Times.
     (New FDA rules published on September 20, 2013, "after years of pressure," will enable federal health regulators to begin tracking millions of medical devices, using a new electronic tracking system meant to protect patients by catching problematic implants earlier." The tracking system follows years of highly publicized recalls of (medical devices) that have been plagued by design and manufacturing flaws," according to the New York Times http://www.nytimes.com/2013/09/21/business/fda-to-require-tracking-codes-in-medical-devices.html?src=rechp.) 
 

     In a post about the heart-device industry (pacemakers and defibrillators) I uncovered this regulatory failure in detail, and described the industry's unscrupulous marketing tactics, which it employs in its neuromodulatory sector as well (http://kronstantinople.blogspot.com/2012/07/heartless.html).  (Today – Oct. 17, 2013 --  the government shutdown has ended, and the medical-device industry, which waged an intense lobbying campaign, says it has garnered enough support to achieve a full repeal of the excise tax by early next year. Medical-device manufacturers allocate only a sliver of profits to research and development  The industry’s enormous profits are a result of anticompetitive practices. Exorbitant prices fuel enormous profits — profits that dwarf both the medical-device tax and the industry’s investments in research and development. The United States spends about 50 percent more on the top five medical devices, compared with Europe and Japan, leading to $26 billion annually in excess spending, according to Topher Spiro, vice president for health policy at the Center for American Progress. http://www.nytimes.com/2013/10/17/opinion/the-myth-of-the-medical-device-tax.html?hp&_r=0. )

    In a companion article, I will describe the financial, regulatory and ethical aspects of the wild and crazy industry of neuromodulation, which has potential applications for virtually every physical and psychological ailment, and is thus expected to see explosive growth -- 20 percent to 30 percent annually -- in coming decades. In this post, I'll examine some of its current and future products.   

BABY'S GOT BACK, BUT THE PAIN IS AN AFFRONT 
    One of the most highly touted and desperately needed neuromodulation therapies is spinal cord stimulation (SCS), a pacemaker-like device which inserts stimulating electrodes into the epidural area, between the vertebrae, to block pain signals from reaching the brain. I am one of the millions of Americans who suffers from chronic back and sciatic pain. Just looking at the pictures of this device, radiating its soothing pulses, makes me long to get one.
     UPDATE New York Times July 3, 2014: "A widely used method of treating a common cause of back and leg pain — epidural steroid injections for spinal stenosis — may provide little benefit for many patients, according to a new study that experts said should make doctors and patients think twice about the treatment. Hundreds of thousands of injections are given for stenosis each year in the United States, experts say, costing hundreds of millions of dollars.

    "But the study, the largest randomized trial evaluating the treatment, found that patients receiving a standard stenosis injection — which combine a steroid and a local anesthetic — had no less pain and virtually no greater function after six weeks than patients injected with anesthetic alone. The research, involving 400 patients at 16 sites, was published Wednesday in The New England Journal of Medicine."

 

Ahhh...I can almost feel the relief.
    These costly devices, which are marketed by several giants in the U.S. health-care industry, are being sold by the tens of thousands -- despite dismal success in clinical trials and a determination by a study done for Workmen's Compensation that they "are not cost-effective."
    Since the millions of people who suffer from chronic back pain rarely do the research required to access clinical-trial data, they are readily seduced by device-makers' ravishing sales pitches. I will review the sweeping claims made by these companies a bit farther down, but first I will share some patients' perspectives.
    There are several blogs maintained by people who have had spinal cord stimulators implanted, but remain tormented by pain. One of them writes: "My support group is a forum for people suffering from chronic pain, living with a spinal cord stimulator and who are  isolated and demoralized. It’s so difficult to express what it’s like to endure chronic pain every single day of my life. It’s difficult to explain how wonderful a spinal cord stimulator can be, yet in the same sentence explain how it is not a cure, that it doesn’t take away my pain.  I am often up with intense pain at 2:00 AM and feeling all alone or having issues with my spinal cord stimulator...why can't it do more? After those promises, why do I hurt so dang much?"

 

 
DISAPPOINTED PATIENTS HAVE EACH OTHERS' BACKS
    If you spend a bit of time perusing message boards, on which SCS patients discuss their experiences, your hope for a solution to your debilitating pain will be dimmed, if not dashed. These sites go on -- page after page after page -- of frantic and disheartened people who feel totally ripped off and powerless. They took
the expensive and risky step of having a stimulator implanted in their spines, and it backfired.
    The activists among them urge an uprising of SCS victims, instructing them to report their experiences to the FDA's MedWatch site, in the hope that approval will be revoked and others won't have to endure the disappointment and anguish that they have. 

FDA WEBSITE IS WORTHLESS TO PATIENTS
    I scrutinized this site but was unable to find any FDA web page that lists the complaints -- so that prospective implant patients could be informed about what kind of problems they might experience -- and there was no indication how many complaints had been received or whether/when any action would be taken. Knowing the FDA, I assume no one has even read the complaints, much less acted on them.

    This message board alone is enough to deter me from seeking an SCS solution to my back pain: http://www.healthcentral.com/chronic-pain/c/question/71294/76385
    As described on the message board, many if not most SCS patients have had extremely disappointing pain reduction, although there were some who were profusely grateful for the new lives that had been made possible by the device. 
    A number of them have had infections, rejection of the device by the body, and autoimmune reactions. Some have lost bladder control while adjusting the intensity of the stimulation or have had their legs give way as they were walking. One woman, who maintains a blog about her SCS journey, said she never expected to get more than a 30-40 percent reduction in pain relief, and that's as good as its gotten. She still takes medication and gets acupuncture treatments for her back pain. Some patients still have to use a morphine pain pump, even after SCS surgery. A registered nurse wrote, "I had the permanent spinal stimulator implant inserted in August of 2010. It has never worked right and I am now being scheduled to have it removed." She's not the only one: Many patients are seeking funds to have the device removed.
    "This has been my worst nightmare," one young man wrote. "I hoped I could return to athletics if my back got better, and now I can hardly even move my legs." 
 
His back still hurts, and now he can't walk.
    "Have had one for 5 yrs. never has worked, and good luck finding a doc that will remove it, I would advise NO ONE to have a nerve stimulator, do the trail, but yeah it was okay for 5 day's but not long term!!" another post says.
    "Just home from spending 68 days in hospital due to infection after having MEDTRONIC BACK STIMULATOR in back only 2 months. I contracted MRSA INFECTION which damaged the spine. They took out stimulator drained spine.the infection has caused right leg damage and neurgenic bladder and bowels," a former Marine complained.
     "I have had a nerve stimulator implanted in my back -- my advice DON'T DO IT!!!!!!!! It's uncomfortable, never worked, you can get the same results with a Tens unit. And the people that sell them, will promise u the world, mine cost over $60,000.  I am going to have mine removed, because after it was installed my legs started swelling up.  My Doctor has 3 other patients with the same problems!!!!"
     "Due to the horrible experience I have had with SCS, along with countless others, I can no way in good faith, endorse or recommend the spinal cord stimulator to anyone. There are simply too many problems with it, so many known and unknown nightmare side effects that make your health even worse," another post adds.
                                                                  by Jon Gemma
 
    "I am 65 yr's. old and had mine installed last Februray. I lost more tha 50 lbs. over the next 7 months because trying to eat made me sick, and I wasn't overweight to begin with. Now, they can't adjust it properly. I get stimulation under my left pectoral muscle and my butt but they can't get it in the lumbar area, which is where I need it. I have constant and severe muscle spasm in my left oblique area which is where the implant is located. Boston Scientific is the name of the unit. I think it is nothing more than a 'bonus check' for the doctor."
    A more detailed list of unintended effects appears at the bottom of this post. 
    The most common complaint is that SCS simply does not relieve lower back pain, despite the exhilarating promises that were made. People who had been so hopeful are devastated.
HEY JUDE: DON'T MAKE IT BAD 
   ("And anytime you feel the pain, hey Jude, refrain!) 

    St. Jude Medical claims that its Medical Neuromodulation Division has developed new technologies to manage chronic pain and other neurological disorders for more than 30 years. 

    "More than 75,000 patients in 40 countries have been implanted with St. Jude Medical neurostimulation systems," one of its press releases proclaims. "Neurostimulation therapy is a proven method of managing chronic pain."

      Given the saga of its ill-fated Eon Mini in 2008 -- among other disasters -- its use of the term "proven method" becomes worse than hyperbolic -- it's simply untrue.

 
The Eon Mini: Warnings were finally issued in 2011. Five models were recalled in 2012. Hundreds have been removed.

    "Even with its small size, the Eon Mini has the longest-lasting battery life of any rechargeable spinal cord stimulation (SCS) device in its class. It is the only small rechargeable neurostimulator to receive a 10-year battery longevity approval by the FDA. For patients this means the device should provide sustainable therapy and maintain a reasonable recharge interval for 10 years of use at high settings."
    Remember what all those message board people were saying about "sustainable therapy"?

    Just months before it announced two-year results in a post-market clinical study evaluating SCS for the management of chronic low-back pain at the 14th annual North American Neuromodulation Society (NANS) meeting in Las Vegas, it was hit with a scathing letter from the FDA. 

 FDA ANOINTS 'THE SAINT,' THEN CASTIGATES IT

    Following a routine overview of the production facility in 2009, the FDA wrote, "Inspection revealed that these devices are adulterated within the meaning of section 501 (h) of the Act, 21 U.S.C. § 351 (h), in that the methods used in, or the facilities or controls used for, their manufacture, packing, storage, or installation are not in conformity with the Current Good Manufacturing Practice (CGMP) requirements."

    The letter continued: "...we encourage your company to contact our Recall Coordinator. While initiating Corrective and Preventive Actions (CAPAs) to correct the various quality issues, these CAPAs did not address the gaps in your company's design and production controls that caused the quality problems. The Agency is not satisfied with your response."
    The letter goes on to demand that St. Jude address the violations, which it enumerates in detail.

     (Soon, St. Jude would also be coping with massive recalls of its new-and-improved, FDA sanctioned heart-device leads, which were burning through their insulation. And as recently as this year, it was still receiving FDA warning letters, stating, "Your firm should take prompt action to correct the violations addressed in this letter.  Failure to promptly correct these violations may result in regulatory action being initiated by the FDA without further notice.  These actions include, but are not limited to, seizure, injunction, and civil money penalties.")
    Regarding the spinal-stimulation debacle: As usual, St. Jude had set itself up with grandiose claims (pride goeth before the fall): "The Eon Mini design is based on the field-proven platform of the Eon® neurostimulator and almost three years of performance data and improvements to the device. It will be available in both the U.S. and Europe in the third quarter of 2008."

STERN MEMOS, WARNING LETTERS, RECALLS, LAWSUITS
    Before long, internal batteries were burning up, and leads were deteriorating.
    There were more stern FDA memos, which never seem to scare anyone very much. There were thousands of warning letters sent to patients. And then there were the recalls. And now there are the class-action lawsuits.
    Poor St. Jude. What is wrong with those people? I sent them a list of very polite questions, but they very politely referred me to their website. My questions, they said, "request details that we do not share publicly."
    (I simply asked about the evolution of the firm's products over 30 years, and which devices their 75,000 customers have implanted. How many of these patients are in the U.S.? I asked. Do your clinical trial data reflect the same weakness of other SCS devices in treating back pain? How much do your SCS systems cost? What is their reimbursement status?)
    These questions were too intrusive for a publicly traded multinational corporation to answer, which seems odd to me.   
    Now, after its purported 30 years in this field, St. Jude is eerily vague about spinal cord stimulation. It presents no actual  products, but tries to lure you with the amorphous concept of SCS to eradicate your pain. SCS sales still represent a significant sector of its profitability.
    It has created a special, separate web site, "Power over your pain," which provides extensive material on the promise of SCS, which it refers to as "the product." It does not picture or name a product.
    "If your doctor decides you are a candidate for neurostimulation, you will likely begin the process for getting a system. This process includes two main steps. During the first step, you will have a temporary evaluation of neurostimulation. If the evaluation is successful, you will proceed to the second step: getting a system implanted.
    The St. Jude official did tell me that the company "does sell spinal cord stimulation devices, including the Eon." I guess its brand name was so tainted by the FDA actions that it is no longer in the firm's interest to use it.
    Having no particular device of its own to market publicly,  this Giant in the Industry, "with some of the finest minds in science" on its payroll, came up with a clever "fix": Buy a company that knows (or seems to know) what it's doing. 
    In June of this year, St. Jude made a $40 million equity investment in Spinal Modulation, a company that has developed Axium, an "innovative neuromodulation therapy that provides a new pain management option for patients with chronic, intractable pain," a company press release revealed. (Ironically, Axium is funded in part by arch-rival Medtronic.) 
    "The agreement provides St. Jude Medical with an exclusive option to distribute the Axium™ Neurostimulator System, developed and manufactured by Spinal Modulation, in international markets where it is approved for sale. Additionally, St. Jude Medical will have the exclusive option to acquire the company for up to $300 million plus certain revenue-based milestones following U.S. commercialization."
    The Axium Neurostimulator System delivers a form of spinal cord stimulation (SCS) targeting the dorsal root ganglion (DRG)."

 
Look at that nice, broad swath of pain relief. I wonder if it works.

"BACK" TO THE FUTURE: ANOTHER THRILLING FLOP
     Medtronic, like the other major device makers, has had persistent problems with its products and with regulators. As I researched this article,  I submitted an inquiry to the company, asking for clarification on a number of issues, including its efforts to improve and expand the uses for its neurostimulation and deep brain stimulation systems. The company declined to provide any information.
     Since Medtronic developed neurostimulation therapy in partnership with physicians in the 1980s, nearly 250,000 people worldwide have received Medtronic neurostimulation therapy for the treatment of chronic, intractable pain, according to the company's promotional materials. No breakdown is provided on the type of therapy, the numbers by country, or the percentage of those who have continued to use these implanted devices, which prove to be ineffective in many patients and which lose effectiveness over time in others. Replacement costs, which are incurred every several years, can be prohibitive.
    When Medtronic received FDA approval for its RestoreUltra spinal stimulation system in 2008, its clinical trials had produced results that would seem surprisingly weak, if one were not familiar with the flawed (to put it kindly) FDA process.

 

    The Medtronic study compared SCS therapy plus conventional medical management to conventional medical management alone for treating chronic neuropathic back and leg pain. Investigators found that at six months, less than half of the 24 SCS patients  had gotten a 50 percent or better pain relief in their legs. Back pain was characterized as "improved," and as a secondary benefit, without further elaboration. 

BACK AND FORTH, GETTING NOWHERE
    This is a shocking outcome, which was ignored in the aggressive promotion of this product to doctors, and to patients whose primary complaint was chronic back pain. If this device significantly relieved back pain, that would have been reflected in the data.  
    The product's performance is so weak, it should not even have been approved to treat leg (sciatic) pain.
    (A study published in the November 2012 issue of Neuromodulation -- and funded by a competitor, Nevro Corp. -- refers to this defect. The authors, who are promoting a new SCS device, write: "Despite advances in SCS technology.... pain relief for patients with predominant chronic back pain has been elusive, and patients with predominantly neuropathic leg pain are still widely accepted to be the best candidates for SCS." )
    This observation is corroborated by numerous studies over the past decade at least, but SCS devices continue to be marketed as an effective treatment for chronic back pain, which is by far the larger market. As far as I'm concerned, this is fraud.
 

 

'PROVEN' DEVICES ARE PAINFULLY IMPERFECT
     To make matters worse,  27 Medtronic SCS test subjects (32 percent) experienced device-related complications at the 12 months follow-up, the authors noted. 
    Does this success rate (and device failure rate) merit FDA approval? It appears the therapy is not very safe and not very effective. But Medtronic qualified for reimbursement from Medicare and Medicaid when the approval was secured, ensuring a handsome cash flow as thousands flocked to obtain pain relief. 
    And when the company flooded the media with the announcement of its FDA approval, it did not include the unimpressive statistical data from the clinical trial, which I accessed by seeking out the journal article in Pain. Medtronic also failed to mention that the study enrolled those suffering from "failed back surgery syndrome." It portrayed its product as "a treatment for chronic, intractable pain of the trunk, limbs or both."
    Its web site reiterates the device's usefulness in providing "significant and sustained reduction in chronic pain," using the article above as footnoted documentation of this claim, when in fact the article does not corroborate that claim. The site also says the device is "proven safe and effective when used as directed," which is also contradicted by its own clinical trial.

 

     Medtronic therapy, like other SCS systems, uses a medical device placed under a patient’s skin to deliver mild electrical impulses to the spinal cord to block pain signals from going to the brain. 

    "Instead of pain, patients feel a tingling sensation from the neurostimulation in areas where they previously experienced pain," Medtronics says. This tingling or prickling sensation is referred to as
paresthesia in the clinical literature. Some patients find it uncomfortable or even intolerable.
    The benefits of Medtronic's system, if the company were accurate, would be substantial: 

      · Reversible therapy that can be turned off or surgically removed
     · Manual adjustability, giving patients the ability to adjust the therapy based on pain level
     · AdaptiveStim Diary available with Medtronic’s AdaptiveStim with RestoreSensor, which provides objective data regarding patient activity and enables clinicians to use this data to assess, evaluate, and optimize a patient’s neurostimulation experience.

TRYING IT ON FOR SIZE

    One very attractive aspect of this product is that, according to Medtronics, a screening test enables patients to try the therapy before committing to the permanent implant. During the screening test, which is conducted for three to seven days, an external neurostimulator worn around the waist helps patients to determine if the therapy might provide relief from their chronic pain. The external device delivers electrical impulses that interrupt the pain signals in a manner similar to an implanted neurostimulator. (St. Jude also offers a test period, but it requires minor surgery to implant electrodes subcutaneously up the spine.)
    Both St. Jude and Medtronic refused to disclose how well their "test" devices work relative to the implanted one, nor would they comment on why a patient who has responded to the test device fails to get relief from the implant. Medtronic refused to explain why it doesn't offer the external neurostimulator for sale.
   (The study by Menlo Park-based Nevro, cited above, was for an SCS device that delivers continuous, high-frequency (10,000 Hz) stimulation rather than the "mild electrical impulses" used in its competitors' devices. Its clinical trial data claim far superior relief for back pain, and the new device does not cause the paresthesia that other SCS systems do.
"What's the frequency, Kenneth?" Dan Rather was asked. With Nevro's Senza system, it's high.
     I had never heard of Nevro until I began reading through relevant articles in the journal Neuromodulation. According to the firm's web site, its SENZA SCS system, "inspired by work done at the Mayo Clinic,"  received CE Mark in 2010 (from the EU), TGA Approval (Australia) in 2011 and as a result is commercially available in Europe and Australia. The company says that in its clinical trial in Europe, "the Senza system provided significant and sustained relief for low back pain and leg pain in more than 70 percent of treated patients."
    In the United States, the SENZA system is for investigational use only. A clinical trial is currently in progress, which is intended compare SENZA's effectiveness with that of SCS devices currently on the market, and to collect data to secure FDA approval. The estimated primary completion date for this trial is March 2014, according to ClinicalTrials.gov. In March of this year, Nevro raised $48 million in a Series C financing round in support of SENZA research and commercialization.

    The Money Boys seem to be tripping over each other as they dash from the newest thing to the Newest New Thing.

BOSTON SCIENTIFIC PUTS THE 'BS' IN SCS
    Another of the Big Three players in the field of neuromodulation, Boston Scientific, announced in May of this year that it had received FDA approval for an even more complex device, the Precision Spectra Spinal Cord Stimulator (SCS) System, and was beginning a limited launch of the "World's First and Only System with Illumina 3D™ Software and 32 Contacts." It had obtained approval in Europe five months earlier.

 

Pain relief is just 32 electrical jolts away.
 

    According to the firm's web site, Boston Scientific in 2004 launched the world's first rechargeable SCS device, the Precision™ System, which was also the world's first 16-contact implantable SCS device.  
    Today, more than 60,000 patients worldwide have been treated using Boston Scientific SCS systems, the company says. 
    The new device uses "a proprietary computer model that takes into account 3D anatomical structures, including the conductivity of the spinal cord and surrounding tissue.  The physician simply selects a desired location on the spinal cord and the programming software creates a customized stimulation field to mask the patient’s pain," the company states.
    So far, so good.
    In a study cited to support the use of the technology, this conclusion was reached: "Precision SCS is a durable therapy and may provide pain relief for more than 50 percent of patients for a year or more."
    This kind of cautionary information is not readily available to patients who are considering this major surgical and financial commitment. Would you get this implant if you were informed of the odds?
   The study began with 65 patients and ended with four.
   That is not a valid study. 

 

    In another study, enrolling those who had failed back surgeries, the results were "lower levels of leg pain" and "no difference in back pain."
    Thousands of people with back pain have been sold on this device and had it implanted. Too bad for them.  
    Do our public servants who give the imprimatur of the federal government to these devices even read the journal articles about their performance?
    The study cited above is titled: "The Effects of Spinal Cord Stimulation in Neuropathic Pain Are Sustained: A 24-month Follow-up." The implication is clear that the study refers to back pain, even though back pain was not relieved.
    As if to add to the "Monty Python" ambiance of this process, the study acknowledged that 45 percent of patients experienced 34 device-related complications, and 31 percent required a device-related surgical revision. There was pain, and there was gain:

Is this all just a Monty Python skit called "No pain, no gain, in America"?

     Lacking this information, tens of thousands of patients continue to have SCS devices implanted.
   In yet another study, less than a third of SCS patients reduced their intake of addictive opiate pain-killers, even though some had the device turned on constantly. Many implant patients have noted that the implant itself has only added to their existing pain, and that such mundane acts as shifting in their chairs or rolling over in bed elicits bursts of discomfort and even electrical shocks.

SCS TECHNOLOGY: THE POSTURE OF DEFEAT
    The FDA has permitted the continued marketing, implantation and reimbursement for spinal cord stimulation devices, ignoring the overwhelming lack of evidence that they effectively treat chronic back pain in the vast majority of patients. 
    Despite the slick, handsomely designed and authoritatively worded promotional materials, the devices remain quite primitive. "The industry is still in its infancy," one researcher admitted.
    Why don't they just admit that, instead of luring you into violating your body with a foreign object of dubious value?
 

The leads are inserted in the epidural areas of the spinal cord.
 

    Millions of dollars have been paid to install SCS technology in tens of thousands of patients, whose pain has severely diminished their quality of life and ability to work. Many of them have had one or more surgeries prior to the implant, and are still dysfunctional. Clinical depression is a common effect of this condition.  Opioid usage of 250 mg. per day is typical among this population.
    Back pain is the leading cause of disability for those under 45, according to the National Centers for Health Statistics.
    So a lot of both well-established and little upstart medical device firms continue to tweak SCS technology in an attempt to corner the market.

GREATBATCH HATCHES ITS OWN SCS BABY
    Greatbatch Inc. is in a different category. It has, up to now, not been a device maker, but rather has been a highly successful and respected supplier of critical components to the largest medical device companies in the world.
    It just couldn't resist getting into the SCS game, though.
    It announced in March 2013 that Algostim, its "innovative, internally developed SCS system" is nearing completion. 
    No photos or design illustrations are available. My request to Greatbatch for details about how Algostim differs from products already on the market was ignored. 
    Device makers and market analysts were baffled that a firm which had already created a secure niche for itself would do an about-face and engage its customers in direct competition.

 

    "Ninety-five percent of all active implantable medical devices contain one or more of our proprietary component products – a core business that’s driving top line and bottom line performance," said CEO Thomas Hook. "In turn, this is propelling our evolution into a medical device company. 
    "Algostim is a highly differentiated, complete SCS system and platform with extensive offering of innovation, intellectual property, advanced safety features, and future generation capabilities to serve the fast growing $1.4 billion SCS market (which is growing at more than 10 percent a year," commented President Scott Drees. 
    Highly differentiated, how? One learns to look cynically at every bit of hype these people throw out there as bait to lure venture capital.

WANTED: A PARTNER WITH DEEP POCKETS
    The device is nearing completion of development, the firm says, and will be moving into the commercialization phase.  The company is looking for a partner to push the product into the end market, after Greatback has completed its design work, obtained FDA approval, and launched the manufacturing phase. 
    "We have many interested companies who would like to work with us to commercialize this," Hook told the Dallas Business Journal. "We are screening them for their ability to take a product like this and go into a market to paying physicians and sell it." 
    Was this a slip of the tongue, or a naive bit of honesty? Paying physicians to implant your device is not a new phenomenon, of course, but I have never seen a company admit it. It's illegal and unethical. There have been prosecutions and penalties.

CAN PERIPHERAL NERVES PUT SOME SPINE INTO SCS?

    The failure of SCS technology to relieve chronic back pain is addressed forcefully in the September 2012 issue of Neuromodulation by three physician/researchers in Italy. They address what American clinical trials have already discovered (but hidden from public view):  SCS has been highly unsatisfactory in relieving the most problematic back pain, which is in the lower, lumbar and sacral, regions.
    In a study comparing the effectiveness of SCS to a combination of SCS and peripheral nerve field stimulation (PNfS), the combination therapy was so superior that those on SCS were switched over, to put them out of their misery.
 

 

    PNfs involves an implant of electrical leads that are connected to a stimulator just under the skin (subcutaneous) of the lower back, rather than into the spine. 
    "Even with recent improvements (in American SCS devices) such as a self-regulating current, we found recruitment of the (difficult to reach) lumbar fibers still to be problematic," the authors found. "PNfS is an effective, simple way to recruit lumbar and sacral fibers directly from the painful region, by placing electrodes in the superficial subcutaneous layer to stimulate the nerve endings and dermal receptors."  

COMBINATION THERAPY HOLDS PROMISE
   "In the patients we treated with the combined SCS + PNfS system, there has been a drastic reduction in the lumbar pain compared with those treated with SCS only; this has led to a significant improvement in the quality of life, especially in the social activities (work, physical activity, and health), and to a reduction in drugs intake," the doctors reported.
     Many patients discontinued their use of opioids altogether. Average use dropped by more than 90 percent. 
    Even with this combined therapy, patients cannot resume strenuous physical exertion, the doctors acknowledged. In some patients, the effect recedes over time, and medication use may need to be increased. Others can find continued relief if their devices are recalibrated. 
    A 2011 article in the journal Pain Medicine explored the use of PNfS for a wide range of conditions by doing a survey of clinical literature. The success rate of PNfS in treating lower back pain was not impressive or well-substantiated. The implant did appear to be of significant value in treating migraines, but all of the studies cited had too few participants to be anything but suggestive.
    Even so -- ever-ready to run after a more promising revenue source -- Medtronic announced in April 2013 the first patient enrollments in a "pivotal" clinical trial to pursue FDA approval of a PNfS system for back pain. Christened SubQStim II, it involves an implant of electrical leads that are connected to a stimulator just under the skin of the lower back, as in the Italian study. 

 

    Industry media were skeptical. "Medical device company Medtronic continues to battle for its position in the market for neurostimulation systems by launching yet another study," Mass Device reported, a bit irritably. "The new study is the latest in a handful of neurostimulation trials launched by the medical device giant as it faces intense rivalry in the marketplace." 
    Medtronic posted a request at ClinicalTrials.gov for back patients  just last month to enable additional study of its SubQStim II system.

OFF LABEL BUT ON TARGET
    Dr. Eugene Lipov, a Chicago pain specialist and Director of Research, Alexian Brothers Hospital Network Pain Program, claims to have invented a hybrid neurostimulator  -- SCS plus PNfS -- to treat back, leg and neck pain many years before the Italian study was conducted.  

 

    "This is an exciting evolution of (conventional SCS), which has been in clinical use for the last 20 years," he says. "Where the previous stimulator was placed in the spinal canal right behind the spinal chord, this is placed at the site of pain, making it very effective for lower back pain and rendering it essentially free of complications."  
    Despite the assertion that this approach has been successfully used for many years, it is classified as "investigational," not FDA approved, "and as such use in this context is 'off label'." The procedure costs $60,000.
    He declined to answer questions about success rates, the number of patients treated, and complications.
    

Two eight-polar leads are implanted bilaterally above the gluteal region, over the painful site 

EVERYTHING IN MODERATION -- EXCEPT FOR THE EXCESSES
    The gross and ongoing flaws in the neuromodulation industry's products have  cost Medicare, Medicaid and private insurers hundreds of millions of dollars. Just as they have done with pacemakers and defibrillators, the companies emerge into the media spotlight time after time to announce extraordinary technological breakthroughs. Before long, all hell breaks loose as these "exhaustively tested and proven devices" fail.    
    And then there are the lawsuits: 
    The Meyerson law firm in San Antonio, Texas, is representing clients who have been harmed by SCS implants. Currently, the major players in the market include Medtronic, with a market share of 61 percent, followed by St. Jude Medical and Boston Scientific, with market shares of 15.1 percent and 23.8 percent respectively, according to the firm.
    Because of the doctrine of pre-emption (discussed earlier), which protects device makers from liability, the only active suit at this time is against St. Jude, because its products have been recalled. 

 

    Nevertheless, the law firm is compiling a database of SCS patients who have been harmed by the devices for possible action in the future.
    "The failure of a stimulator to operate correctly has had many effects on our clients." attorney Jeff Meyerson says.. "At a minimum, defective devices expose clients to the very pain the devices are supposed to relieve."
   In addition to increased pain, other symptoms clients have reported include:

  • Severe irritation and burning at the battery site
  • An inability to control the stimulator (resulting in unwelcome jolts, pain, or temporary paralysis)
  • Severe burns while recharging the battery
  • Premature battery depletion
  • Bladder problems
  • Increased numbness
  • Lead migration and broken anchors
  • Partial paralysis

   "In the push to develop attractive products, these companies have produced stimulators that may not only fail to operate as promised, but can put patients in physical danger," the law firm's web site says. "In a letter dated July 17, 2012, the FDA issued a warning letter related to Medtronic's process for handling complaints and stated that regulatory action might ensue should the manufacturer fail to address the agency's request to take action. The FDA also issued a warning letter to St. Jude Medical, resulting in the company's announcement that there were were failures present within the internal batteries of their units. Patients who may have been implanted with defective stimulators are being notified individually by St. Jude Medical. Since the problem surfaced in 2011, over 300 heat-related complaints have been filed on behalf of carriers of defective units, and several lawsuits have been filed."

GOING DEEP -- A THERAPEUTIC PLUNGE INTO THE BRAIN
    In my research on Alzheimer's disease, I have come across extraordinary accounts of deep brain stimulation (DBS) having the effect of uncovering long-lost memories. Electrodes placed in various spots on the brain elicit different memories. Variations in the intensity of the current can cause vivid details to be recalled by test subjects.

 

    "Scientists in Canada have raised a tantalising prospect - reversing Alzheimer's disease, using DBS," according to the BBC. Brain shrinkage, declining function and memory loss had been thought to be irreversible. In two patients, the brain's memory hub reversed its expected decline and actually grew by 8 percent. 
    "How big a deal is 8 percent? It is huge. We’ve never seen the hippocampus grow in Alzheimer’s under any circumstance. It was an amazing finding for us," lead researcher Andres Lozano told the BBC.

THE BANE OF PAIN IS MAINLY IN YOUR BRAIN    
 

     The Alzheimer's research is still preliminary, but American device makers have for years marketed DBS for other uses. 
    Despite an acknowledged lack of understanding about how depression affects the brain, and which sites should be stimulated to treat the disorder, Medtronic is running three clinical trials investigating various DBS devices for different depression targets in the brain, according to a September 2013 article in the Financial Times (http://www.ft.com/cms/s/2/3cfb9658-1665-11e3-a57d-00144feabdc0.html#axzz2e5y4RysX). St. Jude Medical also has three clinical trials. This is perilous territory. The firms are seeking "desperate" patients, but it's hard to imagine being desperate enough to entrust your brain to these amateurs.
    (UPDATE: The Pentagon's Defense Advanced Research Projects Agency (DARPA) announced Oct. 24, 2013 that it intends to spend more than $70 million over five years to jump to the next level of brain implants, either by improving deep brain stimulation or developing new technology. Taxpayers foot the bill. The device makers get even RICHER. http://www.nytimes.com/2013/10/25/science/pentagon-agency-to-spend-70-million-on-brain-research.html)

    Medtronic has developed a deep brain stimulation (DBS) system that "outsmarts your pain" and "embeds the capability of measuring brain disturbances into an implantable device," according to an August 28, 2013, article in Forbes magazine. Over 100,000 patients have been implanted with the Medronic DBS system, the company notes. 
    Who are these 100,000 people? What is their ailment? How satisfied are they? What complications have they experienced from the electrodes that are permanently implanted in their brains? Medtronic has no comment.

Eletrodes are on my mind, and I'm not sure I like it.
 

    "Medtronic developed and leads the field of neuromodulation, the targeted and regulated delivery of electrical pulses and pharmaceuticals to specific sites in the nervous system," the firm's web site states. "Our neuromodulation business includes implantable neurostimulation and targeted drug delivery systems for the management of chronic pain, common movement disorders, spasticity and urologic and gastrointestinal disorders."
     Who would have thought that such a fabulous system would be the subject of an "urgent" Class 1 recall by the FDA due to "potential lead damage"? According to Bloomberg News, this 2013 regulatory action means "there is a reasonable probability that the defect could cause serious health consequences or death."
    In an article regarding the recall in the Minneapolis Star-Tribune, Justin Ihle, a Medtronic spokesman, "would not say how many patients have been implanted with Medtronic deep brain stimulation devices. Nor would he provide sales figures."
    This kind of secrecy can only lead to more questions about Medtronic's integrity.

KNOWN UNKNOWNS AND UNKNOWN UNKNOWNS
    And since DBS has been marketed to so many patients for so many years, who would have thought that "the effect of the device on cognitive functions and its psychiatric side-effects are still controversial"? That is the characterization of a study funded by the German Federal Ministry of Education and Research.  
     An article in the Journal of the American Medical Association (JAMA) substantiates this observation. But how much is disclosed to patients who are considering this therapy for Parkinson's disease? 
    "Neurocognitive testing revealed decrements in some areas of information processing for patients receiving deep brain stimulation," the 2009 JAMA article reported.  "(Moreover), at least one serious adverse event occurred in each of 49 deep brain stimulation patients, including 39 adverse events related to the surgical procedure and 1 death secondary to cerebral hemorrhage."
      The  most common neurobehavioral adverse events included depression, confusional state, and anxiety, the researchers found. Some 41 percent of patients experienced cognitive problems and 8 percent experienced depression. There also were more falls in the deep brain stimulation group, often resulting in injuries (eg, fractures, dislocations, head trauma) requiring surgery or another intervention, the authors added.
 

 

    It remains to be explored, they said, "whether patients who undergo deep brain stimulation view (their substantial) improvement in motor function and quality of life as outweighing adverse events."
    Why does it remain to be explored? These devices have been implanted in tens of thousands of people with Parkinson's disease and other motor disorders, reaping huge profits. But the profiteers haven't seen fit to launch and publicize the results of studies about patient outcomes.
    A 2006 study, funded in part by Medtronic and published in Neuropsychopharmacology concluded that DBS has
"encouraging" therapeutic effects in treating obsessive-compulsive disorder (OCD), but "a more definitive test of the efficacy and tolerability of DBS will require a larger controlled trial."

    UPDATE December 4, 2013: Under a special FDA exemption, doctors are also now using an implanted electrical brain stimulator made by Medtronic to treat patients with severe obsessive-compulsive disorder who have not responded to drugs (http://www.nytimes.com/2013/12/04/business/rare-cancer-treatments-cleared-by-fda-but-not-subject-to-scrutiny.html?pagewanted=2&rref=science&hpw). But Dr. Joseph J. Fins, a professor at Weill Cornell Medical College in Manhattan, said the development represented an uncontrolled medical experiment because doctors were not collecting uniform data about what happens to patients. “People use it and it begins to become part of the medical environment,” said Dr. Fins, who has been critical of the F.D.A.’s decision to issue the Medtronic exemption. A spokesman for Medtronic said that the company was running a study in Europe to gain data about the treatment’s safety and effectiveness, according to the Times.

DISORDERED THINKING AMONG THE THINKERS
    It seems that "definitive" testing should be performed before such a product is widely marketed, or even approved.

    A planned study earlier this year -- to determine whether DBS can safely reduce symptoms of post-traumatic stress disorder (PTSD) in combat veterans was withdrawn after funding was denied by the Veterans Administration.   
    Recently, Medtronic announced the first human implants of a new DBS system, Activa PC+S. 

 

 

    "This system is the first to enable the sensing and recording of brain signals in some of the deepest areas in the brain while simultaneously providing targeted DBS therapy," according to Forbes contributing writer John Nosta.
    "This experimental 'closed loop' system has the potential to enhance the current ability of DBS to treat various physiological and psychological conditions," Nosta writes.
     Medtronics' system is FDA approved for movement disorders, such as Parkinson's disease. A Humanitarian Device Exemption been authorized for the treatment dystonia and severe, treatment-resistant obsessive-compulsive disorder, although DBS "has not been shown to be effective in the treatment of these disorders," the company's web site acknowledges.

 

UNPLANTING THE IMPLANTS
   But implantable devices may eventually become obsolete,  as tech firms work feverishly on external products that require no surgery or permanent commitment.
    In a November, 2013 article, "Jumper Cables for the Mind," New York Times reporter Dan Hurley undergoes  transcranial direct-current stimulation, or tDCS, an experimental technique for delivering extremely low dose electrical stimulation to the brain. (http://www.nytimes.com/2013/11/03/magazine/jumper-cables-for-the-mind.html?hpw).
    "Using less than 1 percent of the electrical energy necessary for electroconvulsive therapy, powered by an ordinary nine-volt battery, tDCS has been shown in hundreds of studies to enhance an astonishing, seemingly implausible variety of intellectual, emotional and movement-related brain functions," he writes. 

                    (Nigel Parry for The New York Times)
 

    J. León Morales-Quezada, senior research associate at Harvard’s Laboratory of Neuromodulation, is conducting experiments on the ability of this therapy to improve the speed and accuracy with which people perform attention-switching tasks. It is showing promise in several areas of brain function, and has the advantage of not requiring implantation.
     Cyberonics, whose invasive, problematic VNS system has undoubtedly deterred many potential customers -- has seen the light, and has developed an alliance with CerboMed, a private company based in Erlangen, Germany. Its NEMOS t-VNS system, which includes an earplug-like device, is designed to stimulate a branch of the vagus nerve in the outer ear by sending a pulse through the skin. 

Isn't this a bit nicer than having a wire wrapped deep inside your neck?

    CerboMed’s device has received clearance for marketing in Europe for patients with epilepsy, depression, and pain, but is not yet approved in the U.S. In September 2013, Cyberonics said it had made an initial investment of about $2.6 million in Cerbomed and gained an exclusive option to market the NEMOS device worldwide as an epilepsy treatment.
   In a clinical trial in Germany, "Five of the seven patients who applied t-VNS for nine months showed a reduction in seizure frequency." This information is obviously not adequate to enable a prospective patient to make an informed decision. How much reduction? How severe was the disease in those studied?
   The transcutaneous therapy is also being tested in migraine patients.
   Cyberonics’ VNS system already dominates the market in devices for epilepsy. Some 100,000 people worldwide have received its relatively primitive and permanent implant. Think how they must feel, knowing that the wire that is gripping a nerve deep in their necks is unnecessary? 

ANOTHER NONINVASIVE APPROACH FOR DEPRESSION, EPILEPSY
      Another intriguing, nonsurgical option: Los Angeles-based NeuroSigma received EU certification last year for an external trigeminal nerve stimulation (eTNS) system for the adjunctive treatment of epilepsy and major depressive disorder for adults and children aged nine years and older, according to Medscape.

 

    The device has been evaluated in clinical trials conducted at the University of California, Los Angeles (UCLA) and the University of Southern California. It consists of an external pulse generator and disposable electric patches placed on the forehead that are replaced daily and must be worn for 12 hours a day.
    But in the clinical trials, the improvement rates "did not achieve significance," according to a 2013 Medscape article. Only 30 percent of patients responded to the treatment.
    The study, the first randomized, active controlled trial of external trigeminal nerve stimulation in drug-resistant partial seizures, was published in the February 26 issue of Neurology. The lead investigator was the vice president of NeuroSigma.
    Commenting on the results for Medscape Medical News, Gregory Bergey, MD, from Johns Hopkins Epilepsy Center, said, "These things need more study."
    An accompaning editorial stated: "The beneficial effect demonstrated by DeGiorgio et al. was modest but is sufficient to encourage design of a more definitive study." 

 
No surgery required.
External trigeminal nerve stimulation.

    "As a non-invasive neuromodulation therapy, trigeminal nerve stimulation may represent a paradigm shift in the way we treat major depression and offers the potential to significantly improve the lives of millions of people without the side-effects common to medication treatment," said UCLA's Ian A. Cook, MD, who led clinical and human mechanism of action studies of the device in depression. 

A TREATMENT WITH REAL MAGNETISM
    Yet another contestant in this race to the pot of gold is Neuronetics' Neurostar mechanism, which uses a highly focused pulsed magnetic field, similar in type and strength to those produced by a magnetic resonance imaging (MRI) machine, to stimulate cortical neurons.

   Its pulsed, MRI-strength magnetic fields induce small electric currents in the prefrontal cortex of the brain, according to the company's website. Local neurons theoretically depolarize and release neurotransmitters.  Distant areas of the limbic system are activated via neuronal pathways. Blood flow and glucose metabolism rise in the stimulated regions, which is thought to result in improved mood.
    It sounds great! But they all do!
    The therapy, which won the FDA nod in 2008, according to MassDevice.com, is a rarity in the med-tech world: A device-based approach to a psychiatric disorder. 
    Treatment is administered five days a week, for approximately four to six weeks, the firm's web site explains. The therapy "stimulates key areas of the brain that are underactive in patients with depression."
    "The only other widely used device-based therapy in psychiatry is shock therapy, and that's been around since the 1930s," CEO Bruce Shook told MassDevice in 2011. "While the therapy is not a cure (there is still no known "cure" for depression), clinical tests show that patients treated with NeuroStar experience improvement in anxiety and other symptoms associated with depression, without side effects such as weight gain, sexual dysfunction and nausea often associated with drug therapy."
    The key word here is "improvement." 
    Upon further examination of the data, it was revealed that one half of patients "responded" to TMS. Half, obviously, didn't. But a "response" can mean anything from mild mood improvement to a joyful relief from gloom and anguish. NeuroStar
 
 

ELECTROCORE KEEPS YOU OUT OF THE OPERATING ROOM, TOO

    Another promising example of external neuromodulation comes from New Jersey-based ElectroCore, maker of the handheld gammaCore device. The firm conducted clinical trials on the use of vagus nerve stimulation to treat migraine headaches. The attractive little invention  also holds promise for such disparate conditions as coma, irritable bowel syndrome, asthma and obesity, according to Scientific American.

ElectroCore's device treats migraines and is being tested for tinnitus.
     
But wouldn't you rather take off your clothes and wear a migraine "tiara" by Cefaly?

     The results of ElectroCore's trial, which involved only 21 volunteers, were presented in July month at the International Headache Congress in Boston. Eighteen of the test subjects reported a reduction in the severity and frequency of their headaches, rating them, on average, 50 per cent less painful after using the device daily and whenever they felt a headache coming on.
    The device also appears to stimulate the release of inhibitory neurotransmitters, which counter the effects of glutamate, Scientific American added. This is a neurotransmitter, which is pertinent to the treatment of depression.
    The big question is whether a non-implantable device can really trigger changes in brain chemistry in humans, or whether people are simply experiencing a placebo effect. 
    "The vagus nerve is buried deep in the neck, and something that's delivering currents through the skin can only go so deep," says Mike Kilgard  of the University of Texas at Dallas. As you turn up the voltage, there's a risk of it activating muscle fibers that trigger painful cramps, he adds.

THE ALLURE OF VAGUS: AN INTERESTING NEW GAMBLE 
    Giant drugmaker GlaxoSmithKline and medical-device powerhouse Boston Scientific, among others, recently invested in $27 million SetPoint, which describes itself as “a biomedical technology company developing neuromodulation therapies for patients with inflammatory autoimmune diseases, such as rheumatoid arthritis and Crohn's Disease.” 
    The company’s particular spin on bioelectronics medicine uses stimulation of the vagus nerve to activate the inflammatory reflex, which, according to the company, “produces a potent systemic anti-inflammatory effect.” Inflammation is one of the most damaging bodily conditions, and creates or exacerbates numerous major health problems. However, it is also the body's potent response to harm or infection, so it is unclear what unwanted results might occur if it were suppressed effectively.
    

If this device works, it could improve the health of millions.

   

Collar keeps the SetPoint device charged.

      The collar pictured above also provides wireless communication with an iPad app, which monitors and adjusts the stimulator. 
    Now, with such high-profile backers lending weight to the technology, the company has reached "an inflection point" in its work to find an alternative to immunosuppressive drugs, CEO Anthony Arnold said.
     If its clinical development goes according to plan, neuromodulation could be a breakthrough treatment for inflammatory diseases, Arnold added.
   SetPoint Medical announced "positive" results from the first-ever human study using an implanted neuromodulation device to treat rheumatoid arthritis at the American College of Rheumatology Annual Meeting in November 2012.
    In this "proof of concept" trial, SetPoint's device reduced the severity of rheumatoid arthritis in six of eight patients who didn't respond to the RA drug methotrexate. In an August 2013 article, the company said its results "validate neuromodulation as a viable option for sufferers of inflammatory diseases including Crohn's, ulcerative colitis and psoriasis."
    If you dig up the actual documentation, you find that the study doesn't necessarily even validate the treatment for sufferers of arthritis, much less of the three other diseases. It was not double-blind, and there was no control group.
    The unpublished, non peer-reviewed study acknowledges that only two of the eight patients achieved remission, as measured on a self-reporting scale, and six of the eight had results similar to those typically achieved in larger studies with drugs currently used to treat RA.
     Many RA drugs are not well-tolerated, and one reason is that they suppress the immune system, just as SetPoint's system does. But drugs don't require a surgical implant, and they can be stopped or changed when they become problematic or ineffective, unlike a permanent appliance.
    According to a company press release, SetPoint is developing "a novel platform to treat a variety of inflammation-mediated autoimmune diseases. The company is planning larger clinical studies in several diseases this year."
    Autoimmune diseases -- like quite a few others -- have been described as "a new epidemic" in the media over the past few years. The notion of regulating the immune system is intriguing, but one has to wonder what undesirable and unanticipated effects could result. Our immune systems are extremely complex and not well understood. The same can be said for inflammation, which has only in recent years been measured, through the CRP test, and tied to a wide range of chronic health problems.
    It is interesting, albeit seemingly fraught with peril, to start messing around with these processes until medicine has a clearer understanding of their dynamics.

A SPUNKY, SAVVY FIRM JUMPS INTO THE FRAY   
    An overview of the neuromodulation industry that I cited above listed "the usual suspects" as the major players, and then named three up-and-coming young firms. One of them is MicroTransponder, a privately held, Dallas-based, medical device startup, which is a University of Texas at Dallas spin-off. I doubt I would have had the opportunity to learn about this small operation if its president hadn't written to me regarding my VNS article.
    Microtransponder  is sponsoring research, announced earlier this year, at the University of Glasgow, hoping to help victims of stroke to overcome physical disabilities by nudging their brains to "rewire" themselves. Like most aggressive little tech startups, MicroTransponder hopes to turn itself into a hot property and get gobbled up by one of the Big Guys, which is a good thing for everyone involved, I guess. Its current areas of research are stroke rehab, tinnitus and chronic pain.

    The firm has developed the Vivistim device for stroke patients, and has received National Institutes of Health funds to support its work. It has also raised more than $25 million, primarily from "angel investors." 
    Doctors and scientists from the Institute of Cardiovascular and Medical Sciences in Scotland, working under the auspices of MicroTransponder, will undertake the world’s first in-human trial of vagus nerve stimulation in stroke patients. "Stroke can result in the loss of brain tissue and negatively affect various bodily functions from speech to movement, depending on the location of the stroke," the firm's web site says.

 

    The study, which will be carried out at the Western Infirmary in Glasgow, will recruit 20 patients who suffered a stroke around six months ago and who have been left with poor arm function as a result.

 

A nice place to work.

 

    Federal tax dollars are being spent on this effort because obtaining regulatory approval is an expensive process, according MicroTransponder's president and COO Jason Curnes, and "a lot of VC money has dried up."
    The initial clinical trials are being conducted in the EU "due to the significant additional regulatory burdens and costs required to conduct the exact same trial in the U.S," Curnes explains in an email. "It is a common practice in the medical device industry to run trials in Europe first."
    These trials are involve only a handful of subjects, he told me,  because surgery is involved.  
    Half of the group will  receive an implanted Vivistim device, a vagus nerve stimulator, which connects to the vagus nerve in the neck. When test subjects are receiving physiotherapy to help improve their arm's mobility and coordination, the device will stimulate the nerve.
    Lead researcher Dr Jesse Dawson, a stroke specialist and Clinical Senior Lecturer in Medicine, said: "Evidence from animal studies suggests that vagus nerve stimulation could cause the release of neurotransmitters which help facilitate neural plasticity and help people re-learn how to use their arms after stroke; particularly if stimulation is paired with specific tasks.
    "It remains to be seen how much we can improve function, but if we can help people perform even small actions again, like being able to hold a cup of tea, it would greatly improve their quality of life."
    Would it? Greatly? Having been asked to consider VNS surgery myself, I certainly wouldn't accept the risks involved in order to hold a cup of tea. The benefits would have to be far, far greater than that for me to have a wire permanently wrapped around that big nerve in my neck, and to live forever with the side effects. 
    Curnes, who is an earnest and open young man, has a different perspective: "It is not just about holding a cup of tea. We have met with stroke patients who no longer can take care of themselves.  They cannot feed themselves, they cannot dress or bathe themselves, they cannot open a door.  The lack of upper limb use has stripped them of their basic human dignity to be able to care for themselves. These are the stories that provide constant motivation and incentive to keep pressing on to bring our therapy to those patients."

 

    Microtransponder is also exploring vagus nerve stimulation as a treatment for tinnitus, which is described by the Mayo Clinic as a common problem perceived as noise or ringing in the ears. "Tinnitus isn't a condition itself — it's a symptom of an underlying condition, such as age-related hearing loss, ear injury or a circulatory system disorder," Mayo explains.   
    Vagus nerve stimulation is an expensive, invasive procedure that is minimally effective for other conditions and has major risks associated with it. It seems like an extreme solution to pursue for tinnitus. 
    The Mayo Clinic, and other respected medical resources, list an array of relatively simple and inexpensive ways to treat tinnitus, including changing your medications (which are a common culprit), using white-noise machines (which actually seemed to cure my condition over time), tinnitus retraining, which involves a wearable device that delivers individually programmed tonal music to mask the specific frequencies of the tinnitus you experience. Over time, the patient becomes oblivious to the problem. Medications such as amitryptiline and alprazolam can also help. 
    But apparently there are people whose tinnitus is much more severe and requires a bolder approach. Some patients become acutely depressed, or even suicidal, Curnes told me.
    Microtransponder's web site refers to a survey, conducted by an unnamed source and consisting of an unspecified number and demographic of people, in which 85 percent said they were willing to have an invasive surgery with a permanent implant if it could reduce their tinnitus by one half. 
    When I sought documentation for this impressive statistic, I was provided with a study published in Neuromodulation in 2012. It was conducted by MicroTransponder principals and a doctor paid by the company, and it consisted of an Internet survey. Even this extremely suspect "investigational protocol" was inaccurately reported by MicroTransponder on its web site. The online survey indicated that "70 percent of those with very loud tinnitus would be willing to have a temporary implant, and about 60 percent would be willing to have a permanent implant." That's not the 85 percent touted on the web site --  and most of those who said they'd consider an implant were considering a temporary one, which is not what MicroTransponder is developing.
    Only about 60 percent of those who had signed up for an email list on tinnitus research responded to the survey. Fewer than 10 percent of veterans who were on a mailing list of the American Tinnitus Association responded. The defects in this sampling were not disclosed when MicroTransponder cited the study. The company's materials infer a very large market for their product, when in fact their corroboration is based upon a small subset of those severely afflicted.
     "If the therapy was able to completely eliminate the tinnitus, then a full 83 percent would be WILLING or ABSOLUTELY WILLING to pay $5,000," the company claims.
    The likelihood that VNS treatment can "completely eliminate" tinnitus is virtually zero, and in fact other company data suggest that a 50 percent reduction is a reasonable target.

    The company's promotional materials also neglected to mention that the published study included  "a few cautionary notes" about the survey's questions and methodology that made the whole project patently absurd: The authors admitted if they had provided survey respondents with the expected failure rate of the procedure, "our results may have been affected."

     "We did not have the respondents consider potential risks of treatments," the authors added, and, "It might very well be that the respondents did not have a clear picture ...or realistic understanding of (the invasive nature of ) what was involved."    
    Moreover, although the survey asked those with "very LOUD tinnitus" if they would implant a device, the study's misleading conclusion was: "The results of this survey indicate that VNS would be an acceptable therapeutic solution for individuals with moderate to severe tinnitus and should be developed for the market."
    This is not a legitimate study. It is an advertisement -- a self-serving bit of propaganda -- to attract investors, which MicroTransponder is trying aggressively to do. The company's characterization of study results is totally misleading. 
    This is yet another example of so-called peer-reviewed journals permitting articles that will be very influential in various aspects of health care to be ghost written; to be written by physicians and others who have been paid by the party who will benefit from the research; and to present the data in a misleading -- or entirely fabricated -- way. It has recently been reported several times that studies which reach conclusions that don't benefit the device- or drug-maker that sponsored them are withheld from publication, and it has been acknowledged  that "peer reviewed" -- which formerly was so valuable in establishing credibility -- means nothing anymore. "Peers" are too busy advancing their own careers to spend time reviewing your article. It's a thankless task, providing nothing to the "peer," except perhaps a sense of integrity and social responsibility. But that's not going to pay for the Escalade.

RINGY-DINGY: IMPLANT THAT THINGY     
    The American Tinnitus Association, which I don't regard as a particularly credible source either, estimates that as many as two million Americans currently suffer from "severe debilitating tinnitus that prevents them from functioning on a daily basis."
    I don't believe that.
    Tinnitus has become an especially common problem in soldiers returning from Iraq and Afghanistan with over 850,000 veterans currently having tinnitus, according to the association.  
    The medical device industry as a whole has been very effective in exploiting sympathy for our veterans to obtain funding from NIH and the VA, not just for tinnitus but for a mind-boggling array of conditions. War is such a windfall for everyone involved. The military-industrial complex has become the military-industrial-tech complex, with a major hunk of "independent contractor" thrown in. And the taxpayers are throwing money at all of them. Neuromodulators want their share!
   Last summer Microtransponder officials presented data from the initial 10-patient tinnitus clinical trial  at the Tinnitus Research Initiative conference in Belgium, according to a company press release.
    Patients with tinnitus were treated using "a novel paired vagus nerve stimulation therapy which pairs listening to tones with small bursts of stimulation to the vagus nerve in the neck."  The results for this initial trial were "positive," the company claims, and "many" of the patients "experienced a reduction in the severity and perception of tinnitus." No supportive data were provided.
    MicroTransponder recently reached another milestone, raising $2 million in angel funding to continue its development of the Serenity System™, a contraption designed to deliver the tinnitus therapy at the home of the patient, a company press release reported.

 

 
 
     As part of the therapy, the patient wears headphones, and every time he hears a tone, he receives a small burst of neurostimulation to the vagus nerve.

    The aim of the therapy is to "reverse this maladaptive plasticity by retraining the brain to 'shrink' the abnormal representation of the phantom sound. To do this, the researchers targeted the vagus nerve...(which) stimulates other brain structures to release neuromodulators such as acetylcholine and norepinephrine," company materials explain.

WHAT A PAIN: FAILURE AND MISUNDERESTIMATION
    In 2010, MicroTransponder received nearly $10 million -- $2.6 million of it from a National Institutes of Health grant -- to help it build and conduct clinical trials for a wireless neurotransmitter that would treat chronic pain. The Saint (Subcutaneous Arrangement of Implantable Neural Transponders) MicroStim System had already received about $5 million in funding, private investment and grants, including $1.38 million from Texas’ Emerging Technology Fund. 
    A patent, obtained the year before by Microtransponder, was characterized as "a major step to ensure that the Company maintains a competitive edge in our newly developed wireless stimulator technology," by Frank McEachern, CEO of the company. 

 

 

    The proposed device would involve having a microchip the size of two grains of rice injected where a patient feels pain, said MicroTransponder board chairman Will Rosellini. With the push of a button, patients could send electrical pulses to the microchip, and block pain in the affected area. The implant would be controlled with an external device that can be worn like an armband, according to an article at OneMedPlace. Patients would be able to hook the controller up to a laptop or PDA to alter the device settings to the patient’s specifications. The SAINT Microstim System concept is based on technology developed in a prosthetics program at the University of Texas in Dallas, OneMedPlace reports.
    Currently, the smallest neurotransmitter for pain on the market is 100 times larger, Rosellini said. 
    “Our solution is smaller and more elegant,” Curnes added. “It gets rid of all of those batteries and wires.”
    Rosellini said that for the five million to 10 million people whose chronic pain can’t be helped by pharmaceuticals, the Saint MicroStim System “would be a treatment of last resort.”
 

Frank McEachern, Will Rosellini and Jordan Curnes are MicroTransponder officers.

    The funding was intended to build the device, finance clinical trials, and obtain FDA approval, Curnes said. The firm announced that the device would be on the market by the end of 2011. 
    And that was the end of that. I could find no further information, anywhere, about what happened to this grand vision.
    What happened to this much-ballyhooded and well-funded project?
     In a September 6, 2013, email to me, Curnes admitted that Microsponder had been "far too optimistic" in its projections, but added that the firm is still working on the device. 
 

    "We found out that while we could create something that would work in the lab, it was much more technically difficult to create something that can be mass manufactured using existing technology and implanted in the body," he said, seemingly stating the obvious. "There are many different biocompatibility tests and material standards that makes this a difficult challenge for any commercial manufacturer.  Also, there is less of an incentive for them to spend tens of millions on customizing their machines for the manufacture of medical devices because the total numbers being sold are significantly less than other consumer products they produce.  The FDA has an extensive set of tests and material studies that must be completed prior to any approvals for a clinical trial and it is very expensive and time consuming."
 
 
    Exactly! Did any of this occur to the principals at MircoTransponder before soliciting funds based upon a fantasy timetable of R&D, testing, regulatory approval and marketing?

    How could the company have conducted clinical trials, if it hadn't even created the product? Entrepreneurs are eager people, vulnerable to a bit of delusion and expansiveness. 
    Being bipolar, I understand what a manic phase is like, and I sense some of the grandiosity associated with that condition in this industry.
    At MicroTransponder, they have the excuse of being relatively young and inexperienced. Their Big Shot competitors have no excuse. They are callous opportunists.
  
 

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Comments

Hostility

Alhough I can understand your hostility and scepticism to many of these treatments - in regards to VNS therapy it is undeniable that it is a successful treatment for epilepsy. You present potential dangers of these devices (obviously they are in their infancy) but many medications are equally as clouded in mystery - with little to know knowledge of how they work, and what the short and long term effects are.

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