On April 14th and 15th 2016, The 4th annual Neuromodulation Symposium was hosted in Commons Hotel by the University of Minnesota. The Symposium is a yearly event where the brightest neurologists, engineers, scientists, and researchers from all over the world gather together to share new findings on neuromodulation, neuroprosthetics and solutions to many neuropathologies like Parkinson disease, stroke, paralysis, major depression, tinnitus, and epilepsy. The Symposium consisted of honorary speakers, panel discussions, and a poster contest showcasing hundreds of selected entries in a rigorous triple round judging process.
Among the cookies, coffee and nearly record breaking 500 attendees, the most important discussion that takes place every year addresses the challenges that the field faces and how to move forward. It also is the perfect time to professionally vent about what problems and struggles we currently face with neuromodulation.
The State of Technology
In past years, the major issue with neuromodulation was simply determining the relative areas of the neural system to stimulate. Often considered as “dirty stimulation” since most of the equipment wasn’t very sophisticated for the task at hand, the goal was to find the structures to stimulate and create some positive outcome for the patient. Additionally, devices and software to visually and spatially image the brain were needed (better functional magnetic resonance imaging, fMRI, and functional near-infrared spectroscopy, fNIR). Today, the technology still isn’t at the level of detail that it needs to be, but has improved greatly.
Most of the products that are currently available are either for sensing or stimulation. In the case of Parkinson’s, the focus of stimulation is to increase motor control or rehabilitate motor function. However, the voltage stimulation required to elicit a motor reaction is at the detriment
of cognitive function. Cognitive function is not well studied and defined and more difficult to observe in comparison; the immediate consequences have yet to be analyzed. For most physicians, restoring physical ability is a major priority for patients with severe levels of disease.
The primary issue with neuromodulation now is increased accuracy of devices that can sense and stimulate simultaneously, rather than one or the other. This is arguably best done with non-invasive therapy and devices using Transcranial Magnetic Stimulation (TMS), Transcranial direct stimulation (tCDS), Electroencephalogram (EEG), and ultrasound. The goal is to be able to treat and offer patients safe, noninvasive, cost-effective therapies that they could do in the comfort of their homes at some point in the future. While these therapies are presumably safer in the sense that there are no lesions and bleeding, the accuracy is often compromised due to external artifacts and noise present in the data compared to more invasive therapies such as deep brain stimulation (DBS).
Generalized or Individualized medicine?
In addition to creating more accurate and easier to use tools, the field has moved towards more generalized medicine in hopes of serving a vast majority of patients. Trends are very helpful but they oversimplify the complexity of the issues at hand; these diseases are incredibly complex. No two patients are alike. Simply meeting one Parkinson’s patient means just that, you only know one Parkinson’s patient and have exposure to only one expression of Parkinson’s disease. Physicians can’t make such assumptions for the sake of a more streamlined treatment process, as that would risk misdiagnoses. One could argue the need for more individualized and personalized care despite the logistical difficulty of feasibly accommodating multitudes of patients.
Building radios with biology: Physiologists versus Engineering Mindsets
This might hae been the biggest frustration and schism in the group. Most of the attendees of the Neuromodulation Symposium fell into one of two general categories: biologist/physiologist or engineer. Despite both fields being in STEM, the approaches towards solutions are very different, and for some reason we all can’t be friends. Engineering embodies a very linear thought process, whereas biology is holistic in thinking. Both have their merit and are valid in their own respects. Take building a radio for example. If you ask a physiologist and engineer to build a radio, the engineer will start by looking at the design already made for them and put the parts together accordingly. They know the circuitry and placement because it's laid out. They even know why it works when it does work. The physiologist will poke around in the dark until they discover a circuit that functions with no means of explaining why. This is poetic metaphor for the human body as a puzzle.
Engineers think the body can be simplified and analyzed to its constituent parts. That all it takes to solve these diseases is adding more RAM or a better sensor, or creating a more detailed computer rendered model, but that’s not enough. Physiologists on the other hand, cherish the complexity of the body but have no idea how to read the data of the new devices to determine any conclusions to suit both themselves and their patients’ needs. Simply put, no one knows and understands what the other does or thinks. The lack of communication is problematic and frustrating.
Oddly enough, the biggest complaint throughout the Symposium was that we aren’t where we should be technologically despite decades of research. As much as many of us would love to live in a world that mirrors science fiction with all the answers written in the next chapter, it’s important to remember that complexity allows and calls for flexibility. There’s isn’t one solution based on one type of thinking to solve the human brain puzzle. The issue is multifaceted and interdisciplinary and needs solutions that mirror its complexity. But based on the siloed nature of university research institutions and industry, there aren’t spaces that foster interdisciplinary thought and practice. We don’t get the opportunity to share and learn outside of symposiums like this. Without these spaces and opportunity, we are being denied a more in-depth understanding of the brain and its function.
The need for science journalism and better public awareness
Despite the plethora of research done in the field of neuromodulation, only 3% of physicians will recommend it as a legitimate treatment option to their patients. It seems that there is an exclusive club for neuromodulation. If you know about you’re in, but everyone else isn’t allowed in on the secret. It’s easier as physician working in the academic setting at a top tier research institution where the latest research is at their fingertips. However, clinicians don’t necessarily have the same type of access to the research. Now it’s not entirely a problem of access per se, but that a good number of physicians are conservative towards new (experimental) therapies without enough evidence supporting the efficacy. Above all else, beneficial patient outcome is the highest priority. Increasing awareness and availability about the research going on with neuromodulation will better aid physicians in making more educated decisions toward possible treatment options for their patients.