Neurostimulation for sleep disorders

Richard P Knudsen MD CNP (

Dr. Knudsen of the Pacific Sleep Tech in Aiea, Hawaii has no relevant financial relationships to disclose.

)
Antonio Culebras MD, editor. (

Dr. Culebras of SUNY Upstate Medical University at Syracuse received an honorarium from Jazz Pharmaceuticals for a speaking engagement.

)
Originally released June 10, 2018; expires June 10, 2021

Overview

Sleep disorders are prevalent and include, commonly, both obstructive and central sleep apnea. Positive airway pressure therapy, although widely used, has inherent drawbacks, clinically. Alternative treatment modalities have been approved and hold interest within certain spheres. The first-in-class, novel “electroceuticals” will be reviewed in this article. These “electroceuticals” rely on the pathway of neural signal modulation via products that regulate the firing of neural circuits, in contradistinction to prescription drugs or pharmaceuticals that harbor untoward, systemic, and generalized side effects.

Key points

 

• Neurostimulation is reaching respected heights within many realms of medicine, including sleep medicine.

 

• For certain cases of obstructive sleep apnea, hypoglossal nerve stimulation can alleviate suffering.

 

• For certain cases of central sleep apnea, phrenic nerve stimulation can prove efficacious.

Historical note and terminology

Origins include the use of electric fish in the management of perceived chronic pain. The electrogenic eel, given its ability to create an electric field, was applied to patients for various medical maladies. Since antiquity, practitioners have been intrigued with the possibility of harvesting the power of electrical impulses in the human body for therapeutic benefit.

The discipline gained scientific ground when both Luigi Galvani and Alessandro Volta, in the 18th century, explored the nature of “electrochemistry.” Volta, an Italian physicist and chemist, is credited as a pioneer of electricity and power. His rival, Galvani, an Italian physician and philosopher, discovered animal electricity and is considered the father of bioelectromagnetics. This era gave birth to what is now a rather advanced and sophisticated modality applied to many fields of clinical medicine, as will be explained in this article.

The modern era of neurostimulation began in the early 1960s with the use of deep brain stimulation. The first implantable neuromodulatory device (used for analgesic benefits) was the dorsal column stimulator, as installed by C N Shealy MD PhD, Neurosurgeon and Holistic Medicine specialist. He is also credited with the invention of the transcutaneous electric nerve stimulator (TENS) plus other major contributions to his specialties.

Another significant stride in the field stemmed from Rodríguez Delgado MD, inventor of the “stimoceiver.” He is famous for his research of mind control through electrical stimulation of the brain. The stimoceiver, when implanted, was used to elicit emotions and to control behavior. For example, when stimulating the caudate nucleus, a loss of aggressivity was elicited; when stimulating the septum of the limbic system, euphoria would result; when stimulating the motor cortex, motor activity was either facilitated or obliterated. Dr. Rodríguez Delgado published the controversial text: Physical Control of the Mind: Toward a Psychocivilized Society. The evoked response of pleasure and reward was further explored in the 1950s by Dr. James Olds, a founder of modern neuroscience.

Electroconvulsive therapy, another form of bioelectric medicine, was first conducted in 1938. This form of neurostimulation involved electrical induction of seizures in mentally challenged patients to provide relief from disorders such as depression, mania, catatonia, and suicidality. It was deemed especially efficacious for treatment-resistant major depressive disorder. Certain famous figures who were managed with electroconvulsive therapy include Ernest Hemingway, Nobel-prize winning American novelist and journalist, as well as Robert M Pirsig, author of Zen and the Art of Motorcycle Maintenance. Electroconvulsive therapy had been prominently utilized as a psychiatric tool until the acclaimed book, by Ken Kesey, and the renowned film One Flew Over the Cuckoo s Nest, which served to shed a darker light on that otherwise popularized modality.

Neurostimulation is a form of neuromodulation. Within this scientific realm, either electricity or magnetic energy can be employed. The approach can be either invasive or noninvasive. There is now a plethora of neuromodulation applications and related transformative technologies.

The electrical stimulation therapies, within neuromodulation therapies, include:

 

• Spinal cord stimulation
• Deep brain stimulation
• Motor cortex stimulation
• Sacral nerve stimulation
• Peripheral nerve stimulation
• Occipital nerve stimulation
• Pudendal nerve stimulation
Vagus nerve stimulation
• Responsive neurostimulation – closed loop
• Trigeminal nerve stimulation
• Retinal stimulation
• Cochlear implant
• Phrenic nerve stimulation (diaphragm pacing)
• Optogenetic neuromodulation
• Hypoglossal nerve stimulation (upper airway stimulation)

These approaches are employed in healthcare to manage such conditions as:

• Breathing disorders (eg, obstructive sleep apnea, central sleep apnea, obesity hypoventilation syndrome)

• Chronic pain (eg, cephalgia, migraine and cluster headache, peripheral neuropathy, ischemic pain, failed back surgery syndrome, trigeminal neuralgia, complex regional pain syndrome, spinal cord injury)

• Movement disorders (eg, Parkinsonism, tremor, spasticity, dystonia, Tourette syndrome, hemifacial spasm, Meige syndrome, epilepsy, camptocormia, brain injury)

• Cardiovascular disorders (eg, angina, heart failure, hypertension, stroke, peripheral vascular disease, critical limb ischemia)

• Gastrointestinal disorders (eg, incontinence or voiding dysfunction, painful bladder syndrome, interstitial cystitis)

• Functional restoration (eg, blindness, hearing impairment, tinnitus)

The Neuromodulation Society, in addressing these issues, holds meetings and publishes a leading journal.

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