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• W3136339758 abstract "Maas and colleagues reported a single case of sustained cutaneous lesion (burn) following 10 daily sessions of transcranial direct current stimulation (tDCS, 2 mA × 20 min using a neuroConn constant current stimulator) [[1]Maas R.P.P.W.M. van de Warrenburg B.P.C. Schutter D.J.L.G. Cathodal skin lesions in a tattoo following transcranial direct current stimulation.Brain Stimul Basic Transl Clin Res Neuromodul. 2021; 14: 284-286https://doi.org/10.1016/j.brs.2021.01.011Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar]. The skin lesion was reported under the cathode electrode which was placed on the right arm over the deltoid muscle (extracephalic position) using a large (7 × 5 cm) rubber electrode. The Ten20 conductive paste, manually applied, was used as a conductor between the skin and the electrode. The presence of a tattoo near the lesion was noted as a possible cause of skin burning. We have collectively had a high volume of experience in tDCS administration across numerous clinical trial protocols using both saline-soaked sponges and rubber electrodes with conductive paste. Through the NYU tDCS program, repeated tDCS sessions have been administered in 8609 applications in 370 patients. Through the program at the University of Florida, there have now been 6086 applications of tDCS in 383 participants. With this extensive volume of experience, there have been no serious adverse events or occurrence of any sustained cutaneous reactions, including repeated applications in our many participants older in age (e.g. up to 88 years old), and often with advanced neurological conditions. As one example, we have reported a case report using the same cerebellar montage for 60 tDCS applications, and using a higher electrical current intensity of 2.5 mA, without any skin lesion or burn [[2]Pilloni G. Shaw M. Feinberg C. et al.Long term at-home treatment with transcranial direct current stimulation (tDCS) improves symptoms of cerebellar ataxia: a case report.J NeuroEng Rehabil. 2019; 16: 41https://doi.org/10.1186/s12984-019-0514-zCrossref PubMed Scopus (21) Google Scholar]. Standard tDCS protocols typically use saline soaked sponges, where the sponge “pocket” serves to ensure the conductive rubber insert cannot contact directly with the skin [[3]Khadka N. Woods A.J. Bikson M. Transcranial direct current stimulation electrodes.in: Knotkova H. Nitsche M.A. Bikson M. Woods A.J. Practical guide to transcranial direct current stimulation: principles, procedures and applications. Springer International Publishing, 2019: 263-291https://doi.org/10.1007/978-3-319-95948-1_10Crossref Google Scholar]. In contrast, paste is used less frequently due to the risk of rubber contacting the skin. Sustained cutaneous lesion (including burns) would be unexpected, but may occur when there is uneven application of the conductive paste that allows for electrode to skin contact in an area with minimal coating [4Woods A.J. Antal A. Bikson M. et al.A technical guide to tDCS, and related non-invasive brain stimulation tools.Clin Neurophysiol. 2016; 127: 1031-1048https://doi.org/10.1016/j.clinph.2015.11.012Crossref PubMed Scopus (558) Google Scholar, 5Lu H. Lam L.C.W. Cathodal skin lesions induced by transcranial direct current stimulation (tDCS).Neuromodulation. 2019; 22: 989-991https://doi.org/10.1111/ner.12892Crossref PubMed Scopus (5) Google Scholar, 6Lagopoulos J. Degabriele R. Feeling the heat: the electrode–skin interface during DCS.Acta Neuropsychiatr. 2008; 20: 98-100https://doi.org/10.1111/j.1601-5215.2008.00274.xCrossref Scopus (25) Google Scholar]. Sudden and inadvertent skin contact, for instance if the rubber slides from its positioning, could cause change in the impedance between electrode and skin [[7]Loo C.K. Martin D.M. Alonzo A. Gandevia S. Mitchell P.B. Sachdev P. Avoiding skin burns with transcranial direct current stimulation: preliminary considerations.Int J Neuropsychopharmacol. 2011; 14: 425-426https://doi.org/10.1017/S1461145710001197Crossref PubMed Scopus (62) Google Scholar,[8]Khadka N. Rahman A. Sarantos C. Truong D.Q. Bikson M. Methods for specific electrode resistance measurement during transcranial direct current stimulation.Brain Stimul. 2015 Jan-Feb; 8: 150-159https://doi.org/10.1016/j.brs.2014.10.004Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. Therefore, the use of paste is often reserved for use in static situations, such as during an MRI protocol, with electrodes on the head while the participant remains immobile. At initial application, impedance level for Ten20 paste can be above 50 kΩ. After 20–30 minutes, impedance level for paste based application can commonly fall to <10 kΩ and remain stable for several hours. Therefore, the use of conductive paste requires additional time following its initial application for electrode impedance to decrease to an appropriate level for stimulation (e.g., <20 kΩ). Stimulation under unusually high impedance levels may also contribute to the potential for atypical and sustained cutaneous reactions including burn. In either type of application, ongoing participant report of any experience of pain or discomfort may also allow stimulation to be aborted in advance of sustained adverse reaction. In sum, based on the tDCS safety literature [[9]Bikson M. Grossman P. Thomas C. et al.Safety of transcranial direct current stimulation: evidence based update 2016.Brain Stimul. 2016; 9: 641-661https://doi.org/10.1016/j.brs.2016.06.004Abstract Full Text Full Text PDF PubMed Scopus (555) Google Scholar] and our extensive experience in delivering repeated tDCS applications, there is no known risk of burn when appropriate methodological rigor and monitoring protocols are in place. Single-use saline-soaked sponges with reliable headset for the placement of tDCS electrodes are preferred under most conditions. However, an electrolyte paste conductor is suitable for specialized laboratory applications of conventional tDCS (e.g. in MRI) [[10]Esmaeilpour Z. Shereen A.D. Ghobadi-Azbari P. et al.Methodology for tDCS integration with fMRI.Hum Brain Mapp. 2020; 41: 1950-1967https://doi.org/10.1002/hbm.24908Crossref PubMed Scopus (20) Google Scholar] or electrolyte gel with High-Definition tDCS electrodes [[11]Gbadeyan O. Steinhauser M. McMahon K. Meinzer M. Safety, tolerability, blinding efficacy and behavioural effects of a novel MRI-compatible, high-definition tDCS set-up.Brain Stimul. 2016 Jul-Aug; 9: 545-552https://doi.org/10.1016/j.brs.2016.03.018Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar]. This will avoid movement of the electrode during the stimulation and ensure consistent electric field distribution. The authors declare that there is no conflict of interest." @default.
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• W3136339758 title "No risk of skin lesion or burn with transcranial direct current stimulation (tDCS) using standardized protocols" @default.
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