Cranioelectrical stimulation or CES is a non-invasive brain stimulation technique that’s done at home or in the clinic during therapy sessions.
Principles of Treating the Brain
Three principles guide most techniques of neurostimulation or brain training. Most take time to see results. CES works within six minutes.
The first principle is to reboot, repair, or rewire the brain.
The second principle is to train the brain to the edge of its ability through intensity and frequency of training over time with rest breaks. When training begins to become easier, increase the difficulty so as to continue to train to the edge of ability. Reassess regularly through feedback and progress discussions with the client and by using the same objective tests at the end of the treatment cycle. Exhaustion is a given, and so build in rest in between brain training sessions. Research shows learning works best with breaks in between.
The third principle is to engage in desired activity during or immediately after neurostimulation in order to stimulate rewiring of the neural networks involved in that activity.
CES and the Principles
CES resets the brain and works without having to follow the second principle. By reducing anxiety and increasing neurotransmitter production in the brainstem — and because it’s portable — it allows the person to engage in desired activities while wearing it.
CES versus ECT and rTMS
As with tDCS, CES is powered by a 9V battery. CES stimulates at 1 to 3 milliamperes of alternating current. In contrast, ECT — the electroconvulsive therapy of movies and still used in hospitals — delivers 800 milliamperes of current.
ECT and rTMS or repetitive transcranial magnetic stimulation are both plugged into the electrical power grid as they require and deliver more current. ECT is meant to induce seizures and requires sedation. Memory loss happens from it. rTMS uses a magnetic coil to generate electrical current that then stimulates the brain. rTMS also has multiple side effects, such as permanent headache, arms raising up Frankenstein style during it, intense neck pain. (I know of these from listening to patients trade stories.) CES does not have any of these significant negative effects.
The magnetic coil of “TMS requires high currents [several thousand milliamperes] to be pulsed through the coil, which generates a loud acoustic impulse whose peak sound pressure level (SPL) can exceed 130 dB.” [rTMS is TMS applied over a specific region.]Lari Koponen, Stefan Goetz, Angel V Peterchev. Double-containment coil with enhanced winding mounting for transcranial magnetic stimulation with reduced acoustic noise. July 2020. Preprint.
TMS’s magnetic coil sizes typically span from 5 cm to 10 cm.
I theorized in my book Concussion Is Brain Injury: Treating the Neurons and Me that the brain will more likely respond to and not be damaged by electrical current in the same range as it creates. CES is effective with no side effects.
What Is CES?
CES is non-invasive brain stimulation that revives neurotransmitter production. A small current is applied through the earlobes across the cranium; the current crosses the brain stem primarily, but also crosses the temporal lobes which sit near the ears. It may produce mild brainwave entrainment. Although there are many applications for CES, the FDA has approved CES for treating anxiety, depression, and insomnia.
“Drs. Leduc and Rouxeau of France were first to experiment with low intensity electrical stimulation of the brain in 1902. Initially, this method was called electrosleep as it was thought to be able to induce sleep. Since then, it has been referred to by many other names, the most popular being transcranial electrotherapy (TCET) and neuroelectric therapy (NET). Research on using what is now known as cranial electrotherapy stimulation (CES) began in the Soviet Union during the 1950s.”Daniel L. Kirsch. CES: A Practical Protocol for theTreatment of Pain. Practical Pain Management.
Like audiovisual entrainment (AVE), it has frequency. CES reduces anxiety, increases neurotransmitter production, enhances AVE, encourages sleep at night, can re-energize during the day, and is part of my hypothalamus fix (see Concussion Is Brain Injury: Treating the Neurons and Me), It’s used as an adjunct during talk therapy. By reducing anxiety, the person can talk about difficult subjects. And it can reduce pain from musculoskeletal injuries.
The Current, A Brief Explanation
Unlike tDCS, which uses a fixed amount of amperage (current strength) in direct current, CES constitutes alternating current similar to an electrical outlet. CES is usually set to a mildly perceived sensation. It sends short pulses of current back and forth between the two earclips.
The pulse of current alternates between negative and positive in each earclip. So when, for example, the left is positive, the right is negative, then the current flows from the left ear to the right ear through the brain. As the pulse proceeds, both ears are either negative or positive at the same time, and current stops flowing. Then the left ear becomes negative, the right positive, and current flows from the right ear to the left. In that way, it creates a frequency, which in turn leads to symptom relief. For example, if the frequency created is sub-delta, 0.5 to 3 Hz, that leads to endorphin production and pain relief while 100 Hz is believed to increase serotonin.
A 9V battery, which is direct current, can give good stimulation. But when you pulse the current, as happens with CES, that changes whether or not the unit can provide stimulation. As pulse frequency increases — that is, the time between pulses decreases — the unit requires more voltage to push the current through our electrophysiology. The more milliseconds between pulses of current, the less voltage needs to push the amperage through. With CES, negative polarity between earclips is what does the work of pushing the current through. Most CES devices max out at 50V, and commonly, CES devices stimulate at 1 to 3 milliamps. To put that in perspective, the indicator lights on a CES device may use more power from the battery than the stimulation itself.
Acupuncture points are highly conductive.
So if you have a bad connection between earclip and earlobe, then all the current will go through the tiny acupuncture points, instead of through all the skin underneath the earclip. That’d be painful. That’s why you need a good connection.
CES is used sub-threshold in studies, that is, it works when you don’t feel it.
Another consideration to avoid your ears being stung is checking out what waveform the device uses. The simplest waveform is square. It goes on. It goes off. This waveform can sting the ears, so rounding the front end of the pulse to gradually turn it on reduces the sting without losing the pulse’s effectiveness. No one likes their ears feeling like bees are at them, and it’s not necessary.
Frequencies and Waveforms
Some CES manufacturers claim their effectiveness comes through the waveform and/or frequencies. To date, no study has compared various frequencies. And except for at least one manufacturer rounding the front end of the waveform to reduce or remove stinging on the earlobes, no study has analyzed various waveforms for comparative effectiveness.
One CES manufacturer uses long-pulse trains at 15 kHz, whereas all other CES devices use 100 Hz and under. Although a 1990s study experimented with the effect of various frequencies on drug addiction, no study has established any specific frequency having an advantage over any other specific frequency.
R.C. Kennerly in 2006 “showed that 0.5 Hz versus 100 Hz frequency differentially affected brainwave activity, with 0.5 Hz stimulation decreasing a wider range of delta brainwaves and 100 Hz decreasing a wider range of beta frequencies. This caused him to conclude that 0.5 Hz stimulated more endorphins, while 100 Hz stimulated more serotonin. However this was never confirmed with chemical analysis.”Dave Siever. CES Effects on Brain from .5 Hz – 15 kHz. Mind Alive Blog. 2021.
However, fMRI scans revealed that though both 100 Hz and 0.5 Hz activate the default mode network, they affect different areas of it. Since the default mode network often activates poorly in conditions that include PTSD, anxiety, and chronic pain, this finding is good news for people with brain injury.
In addition, Shealy in 1989 using the LISS Stimulator found dramatic changes in neurotransmitters in cerebrospinal fluid (CSF). The CSF bathes the brain, cushions it (somewhat) from impacts, and feeds the brain while removing waste.
Modulating The Brain
The negative or cathodic pulse stimulates the neurons by triggering an action potential in them, that is, an electrical signal down the long axon arm of the neuron. This signal then leads to release of neurotransmitters that talk to the next neurons and trigger an action potential in them and so on.
“We evaluated different electrode configurations of CES including in-ear and over-ear montages. Our results confirm that significant amounts of current pass the skull and reach cortical and subcortical structures. In addition, depending on the montage, induced currents at subcortical areas, such as midbrain, pons, thalamus and hypothalamus are of similar magnitude than that of cortical areas.”Abhishek Datta, Jacek P Dmochowski, Berkan Guleyupoglu, Marom Bikson, and Felipe Fregni. Cranial electrotherapy stimulation and transcranial pulsed current stimulation: a computer based high-resolution modeling study. Neuroimage 15;65:280-7. Jan 2013. doi: 10.1016/j.neuroimage.2012.09.062.
Kennerly in 2006 had also noted, “a whole brain response to the CES stimulus. The qEEG and LORETA findings revealed that a single 20-minute session of CES does have a significant effect on the cortical and subcortical activity of the human brain resulting in activity consistent with decreased anxiety and increased relaxation.”
CES primarily modulates the brain by producing neurotransmitters. The brainstem neurotransmitters that CES can increase are norepinephrine, dopamine, serotonin, and acetylcholine. That plus the current flowing through the posterior aspect of the hypothalamus is why CES is part of my hypothalamus fix.
CES comprises a hand-sized 9V-battery-powered unit with two earclip electrodes that plug into the unit via a wire at one end and clip onto your earlobes at the other. A drop of water or saline on each clip ensures good conductivity. Better units test for connection strength.
After clipping on and turning on the device, you can raise the intensity slowly. Everyone has different levels of sensitivity, with the earlobes feeling the current and with the effect in their brain. A prickling sensation means the seal between clips and earlobes is incomplete and needs to be redone. You increase the intensity to just below where you can feel it. Sub-threshold. The intensity should be enough to feel the relaxation effect without unpleasant electrical buzzing or prickles. In dry, wintry air, wet the earlobes well; otherwise, they dry up before you can seat the clips. Adjust the clips around earrings, although it’s better to take earrings out as they can pick up the current through inadvertent touching. Wearing glasses should not be a problem.
Once the clips are in place, press the “on” button, choose the desired session, start the session, and increase the intensity to the desired level. At home, sit back and relax or stuff the device in your pocket as you do the activity that anxiety, pain, or some brain injury symptoms may’ve been inhibiting.
Negative effects, if any, are mild and temporary.
CES works quicker than medication. It’s safer, too. The 100Hz session acts similar to a beta blocker in that it releases the feelings of stress. But it also increases serotonin, norepinephrine, and endorphins, which would require multiple medications with their commensurate side effects if going the chemical route. At the same time, it stabilizes the brain, and it creates clarity in thinking. It can also release a person from the freezing anxiety of PTSD, something that accompanies brain injury or develops after the injury.
CES is an option, along with AVE, for those with brain injury and/or PTSD who want effective relief from the anxiety and pain the injury brings on without medications’ side effects, addiction issues, and tolerance build-up. It is a failure of medicine that psychiatrists and psychologists don’t have this option in their session toolbox—for two reasons:
- CES facilitates talk therapy. Reducing anxiety during therapy makes it easier for the patient to talk about difficult things, people, and relationships. Recent research using propranolol demonstrated efficacy in reducing physiological response to traumatic memories through psychopharmacology during scripted therapy. CES has the benefit of having no side effects when used properly and similarly.
- CES is far easier for a patient to become comfortable with CES when their health care provider introduces them to it, oversees its use, and guides them on how to use it at home.
Although researchers have found differences between 0.5 Hz and 100 Hz, their studies generally show CES reduces depression, anxiety, pain, and insomnia — all symptoms of brain injury — in roughly the same way at any frequency between 0.5 Hz to 15 kHz with no differences between waveforms.
C. Shealy, R.K. Cady, R.G. Wilkie, R. Cox, S. Liss, & W. Clossen. Depression: a diagnostic, neurochemical profile and therapy with cranial electrical stimulation (CES). Journal of Neurological and Orthopaedic Medicine and Surgery, 10(4), 319-321. 1989.
Meg Patterson, Noel V. Flood, & Lorne Patterson. Neuroelectric Therapy (NET) In Addiction Detoxification. Subtle Energies, Volume 3, Number 3.
R.C. Kennerly. Changes in Quantitative EEG and Low Resolution Tomography Following Cranial Electrotherapy Stimulation. Dissertation for Doctor of Philosophy (Ph.D.). University of North Texas. 2006.
Christopher Fisher. Cranial Electrotherapy Stimulation For Mild Traumatic Brain Injury and Post-Concussion Syndrome. 24 Oct 2009.
Dave Siever. Two Earclips, Wires, a Little Box and Presto-the Wonderful World of Cranio-electro Stimulation. Paper on CES. 2014.
On ScienceDirect, Meta-analyses examined CES for the treatment of depression – 5 RCTs and 12 NRSIs incorporating 16 data sets:
CES now has a foundation of more than 50 years of research and clinical use in the USA from which proof of safety and effectiveness has been well established. The mechanisms of action of externally applied CES has been observed in the limbic system associated with emotional regulation and memory and the cingulate gyrus, insula and prefrontal cortex associated with the processing of pain (Jarzembski et al., 1970; Taylor et al., 2013). Early research into the use of CES as a treatment for insomnia subsequently revealed it was an effective treatment for mood-related symptoms as well, as determined using various psychological assessment scales of anxiety and depression (e.g., Hamilton Anxiety Scale, State/Trait Anxiety Inventory, Zung Depression Scale, Profile of Mood States, etc.) (Kirsch, 2002).Larry Price, Josh Briley, Steve Haltiwanger, Rita Hitching. A meta-analysis of cranial electrotherapy stimulation in the treatment of depression. Journal of Psychiatric Research Volume 135, Pages 119-134. March 2021. https://doi.org/10.1016/j.jpsychires.2020.12.043
*I’ve used Mind Alive Inc.’s products since 2005 when I was referred to them by my Clinical Psychologist. Previously, I’d used another company’s device in the clinical setting with another psychologist. I have not been compensated, provided special discounts, nor received any benefits by Mind Alive for writing about their products.