CES for Mild Traumatic Brain Injury
Cranial electrotherapy stimulation (CES) is the generic term for a medical treatment that entered the USA from the USSR and Europe in the 1960s as “electrosleep.” It involves the passage of small levels of microcurrent stimulation in a specific waveform through the brain to normalize and bring back into homeostatic balance the brain’s electrochemistry which can be thrown into disarray by physical or psychological trauma. Once back into a pre-stress homeostasis, the brain can function normally again, carrying out its myriad systemic regulation duties.
CES treatment is generally administered for 20 minutes to one hour per day, at least once a week, but as often as daily in severe cases. Most symptoms improve significantly during a customary initial three week evaluation period, although patients are often provided a CES unit to have at home to use from time to time in order to prevent symptoms from returning.
This article reviews the promising available information on cranial electrotherapy stimulation (CES) for mild traumatic brain injury (mTBI) in the civilian sector but it is equally applicable to the military rehabilitation setting since mild traumatic brain injury (mTBI) is one of the signature injuries of the current wars in Iraq and Afghanistan.
Electroconvulsive Therapy, Electro- anesthesia, and CES
CES was advanced in Europe under the assumption that if the strong current used in electroconvulsive therapy (ECT) were turned down sufficiently, electroanesthesia could be produced so that surgery could be performed on an unconscious patient without the danger of concomitant seizure activity. Once electroanesthesia devices were available, physicians who had an interest in sleep therapy or who merely wanted to provide a non-drug way of assisting insomniacs, had the electroanesthesia current turned down another substantial notch to microcurrent levels and obtained a treatment originally called electrosleep, the forerunner of CES. The idea was to induce sleep, then turn off the CES device to allow the patient to complete a good nights rest.
Much research was done in American, Russian, and European medical schools and other research centers in the 1960s and early 1970s to learn what parameters—waveform, frequencies, current levels, etc.—were necessary to reliably induce sleep in their patients. These researchers were never able to find a set of electrical stimulation parameters that reliably induced sleep.1-5
A serendipitous discovery, however, was that the patients who were given even one treatment with CES reported general feelings of relaxation and a substantial reduction of anxiety.6-10 When treated daily over a few weeks to a month, even severe cases of anxiety and depression resolved.11-13
CES Research in the US: Stress, Rehabilitation, Cognitive Improvements
A major reorientation of CES studies and clinical use followed. Controlled scientific studies began on the substance abstinence syndrome—with its major symptoms of anxiety, insomnia and depression—of patients withdrawing from illicit drugs and/or pharmaceuticals, alcohol, or nicotine.14-19 Other studies looked at the stress of graduate students in a business management training program,20 incarcerated prisoners on a prison psychiatric ward,21 and of psychiatric patients in general.22-24
Because of its ability to treat stress under such a wide assortment of patient populations, CES soon became a major component of rehabilitation medicine. Patients in rehabilitation programs are well known to suffer from extreme stress, including anxiety and depression, as they and their therapists work to get their lives back to a semblance of normality.25,26 It found use in treating the stress-related symptoms in para- and quadriplegic patients and, in doing so, it was found to significantly reduce their muscle spasticity.2,27 CES also proved beneficial for cerebral palsy patients in gaining control of primitive reflexes and brought many of their other neuromuscular symptoms under control.28-30
Another serendipitous finding was that in every case where patients experienced an improvement in their stress level, they also experienced a dramatic improvement in cognitive function, with an average gain of 12 to 18 points on standardized IQ tests administered just previous to, and following, three weeks of daily CES treatment. It was in this manner that researchers found that so-called permanent brain damage in drug and alcoholic addicts was not permanent. While the cognitive abilities of most such patients would approach normal following two years of total abstinence, it could return to normal with just three weeks of CES treatment.31-33
“...in every case where patients experienced an improvement in their stress level, they also experienced a dramatic improvement in cognitive function, with an average gain of 12 to 18 points on standardized IQ tests administered just previous to and following three weeks of daily CES treatment.”
Research attention was then turned to patients with mild traumatic brain injuries (mTBI) incurred in various ways such as motor vehicle accidents or falls from high elevations on construction projects. That group drew special attention because the majority of them were known seizure patients and little was known of the effects of CES on seizure patients.
Confused and agitated TBI (or post-anoxic or post-stroke) patients may be classified as ‘Rancho Level IV’ from the Rancho Los Amigo I-VIII Scale and are described as follows:
“The patient is in a heightened state of activity with severely decreased ability to process information. He is detached from the present and responds primarily to his own internal confusion. Behavior is frequently bizarre and non-purposeful relative to his immediate environment. He may cry out or scream out of proportion to stimulus even after removal. He may show aggressive behavior and attempt to remove restraints or tubes.”
A 33-year-old male Rancho IV patient was given p.r.n. droperidol along with CES. The patient developed meningitis at age 14 which left him with a generalized tonic-clonic seizure disorder. Seizures were controlled until two years later when he suffered a significant concussion playing high school football. At that time he experienced up to seven generalized tonic-clonic seizures a day, uncontrollable by medication. In 1989, he underwent a right temporal lobectomy which resulted in a disappearance of the seizures for two years. In 1991, he experienced the acute onset of status epilepticus followed by a prolonged coma. He was diagnosed with viral encephalitis. On awakening, his behavior deteriorated into confusion, sexual inappropriateness, and dangerous aggression. MRI showed left temporal ishemia and atrophy with enlargement of the left temporal horn and atrium of the left temporal ventricle. Topographical EEG showed increased right temporal and frontal slowing. Brain stem auditory, middle latency, and 40 Hz evoked potentials were all abnormal. Haldol, Norpramin, Verapamil, lithium, sodium amytal, and lorazepam were all ineffective.