( NOTE: The retail packaging and pricing of the Go Flow has changed as of mid-March 2016. See http://www.foc.us for details. This is part 1 of my series on the Go Flow. Parts 2 and 3 are also available at http://www.speakwisdom.com )
(The Go Flow in white or gray – next to a foc.us V2)
Introduction
While preparing this blog post, I pondered what its title might be. Here are a few of my ideas:
The New Price of Freedom (from Depression, Chronic Pain, and more) $9.99
New foc.us Go Flow tDCS Device Raises the Bar, AGAIN!
tDCS* for Everyone! The New foc.us Go Flow
Hey Medical Community. No More Excuses, Time To Get On Board.
…well, you get the idea. Foc.us has done it again – bringing to the world a really cool, very capable, tDCS device at a price that will rock the marketplace, $9.99. That’s right, not $999 or $99.99, but less than $10! Add electrodes and wires and you can have a top-notch tDCS kit for less than $30!
For those suffering with depression, chronic pain, and learning disabilities, the miracle of tDCS just became VERY affordable. This same device can also be used to enhance memory, problem solving ability, creativity, athletic ability, etc. Ahh yes, tDCS is a wonderful thing.
And now, my oft repeated question for the medical and mental health community – when are you going to at least give tDCS a chance? You are more than happy to experiment on your patients with a variety of pharmaceuticals – frequently with poor results and nasty side-effects. Why not try something that provides great relief to some (honestly, not everyone) – without scary side-effects? Add up the annual cost to the patient of buying pharmaceuticals and follow-up care vs. the cost of a Go Flow, a few 9 volt batteries, and some oversight. Wow, are you beginning to get it?
If you are hearing about tDCS for the first time, please see my other related posts at www.speakwisdom.com or check out www.diytdcs.com for more of the basics on this great technology!
The foc.us Go Flow
The Go Flow tDCS device is a tiny module that snaps on to the top of a standard 9 volt battery. A pair of electrodes plug into the module using the same plug configuration that foc.us uses with their V2 product.
Some Key Features
- Current delivery from 0.5 to 2 mA in 0.125 mA increments
- Timed delivery from 5 to 35 minutes
- Ramped Current up / down
- Easy to use control switch and LED indicators
- Tiny, light, rugged. Uses a standard 9 volt battery
- Perfect for beginner, pro, home and travel use
Operation
Let’s say you want to treat depression with a Go Flow. What would a tDCS session with the Go Flow be like? Here are typical steps with some discussion along the way:
- Attach electrodes to the forehead area (anode on the high-left forehead, called F3, cathode on the right above the eyebrow, called FP2. See tdcsplacements.com for details.) You can use stick-on gel electrodes or wetted sponge electrodes. I discuss how to tell anode from cathode below.
- Plug electrode wire into the Go Flow unit
- Attach the Go Flow module to a 9 volt battery
- The Go Flow LEDs will light up in sequence as it powers up and leave you with one or more ORANGE LEDs lit, showing the amount of current for your session. The lowest LED represents 0.5 mA, the highest 2.0 mA. To change the current level slide the rocker switch UP for more current or DOWN for less. A typical tDCS session is 1, 1.5, or 2 mA.
(The Go Flow module showing LED display, electrode jack, and slide switch.) - Once you have the desired session current set you PRESS IN on the rocker switch to move to the time setting.
- Session time is shown with GREEN LEDs with each representing 5 minutes of time. Slide the rocker switch UP for more time or down for less. A typical tDCS session is 20 minutes.
- You are ready to begin your tDCS session! To START, PRESS IN on the rocker switch one more time.
- With a session in progress, the LED display will alternate between GREEN, showing time remaining, and ORANGE showing the actual delivered current level.
(The Go Flow connected to my “test head” using Amrex electrodes.)
Additional Notes:
- You can STOP your tDCS session anytime by pressing IN on the slide switch. Current will ramp down gently to zero
- You can adjust current level up or down during a session. Move the slide switch up or down as desired. Each movement will change the current 0.125 mA
- There is no ON/OFF switch on the Go Flow. When your session is complete, UNPLUG the 9 volt battery
(Wow how things have changed! Go Flow next to a DIY tDCS device I built a couple of years ago. Thank you foc.us!)
Technical Notes:
- I measured the current output of the two Go Flow units I have and found current to be spot on with my current selection.
- Maximum output voltage is 24 volts (needed to overcome electrode resistance, skin resistance, etc. This is much better than the 9 volt max of many DIY tDCS devices.
- Current drain on the battery is, according to my measurements, about 24 mA during a 2 mA tDCS session. It is about 13 mA for a 1 mA session. Current drain varies somewhat depending on how many indicator LEDs are lit.
- A Duracell CopperTop 9 volt battery goes from 9 volts to 8 volts in 25 hours with a 10 mA load. So one could expect at least 50 to 100 tDCS sessions per battery (highly dependent on session settings.)
(Inside the Go Flow. Image from foc.us.)
Electrode Choices with the Go Flow
- foc.us has a number of electrode choices available on their web site – and third party electrodes can be used with the Go Flow, too. Foc.us supplied electrodes and cable are marked to indicate anode and cathode. Some models have a big X stamped or printed on the anode and a Y on the cathode. With any electrodes, if you are not sure of polarity, check with a volt meter.
- The electrode connector in the Go Flow uses a 2.5 mm four conductor plug for its mate. From the tip of the plug (1) to base (4): 1-unused, 2-unused, 3-Y cathode, 4-X anode (which is the same as the default foc.us V2 setup.)
- foc.us has adapter cables and such on their web site. You can also easily build your own cables with parts from Radio-Shack, Parts Express, etc.
- I have a personal preference for wetted sponge-type electrodes as they can be used on skin and over hair and provide excellent conductivity.
Conclusion
The foc.us Go Flow represents a true shift in the brain stimulation and tDCS marketplace. Via this new product they provide all the capability a typical user will ever need – in a tiny, easy to use, convenient package. The Go Flow, sold along with a good instructional video could literally change the lives of millions for the better. I’d love to travel around providing instructional seminars for medical and mental health professional showing them the Go Flow and that tDCS really is a miracle! Anyone willing to fund that?
The Go Flow can be ordered now at http://www.foc.us . Watch for Part 2 of my review of the Go Flow coming soon.
Caveat
Anyone considering the use of tDCS or any brain stimulation technology should do their homework. It’s important to understand the technology, risks, and if you should be excluded based on seizure disorder or other complications. If you are unsure you should seek the advice of a doctor, preferably one using tDCS or similar technologies in their practice.
*tDCS is transcranial direct current stimulation
SpeakWisdom 
I have 3 Go-Flows with 2 kits on order for review. For whatever reason, Foc.us noted the Foc.us gamer headset apparently is incompatible with the Go Flow. I have no idea why.
I myself as a psychiatrist have patients use tDCS for depression and other conditions for which I have developed simple instructions.
I am excited with the high quality and low cost of Go Flow to make it affordable for even more patients to use – such as those at the community mental health level. It is so low cost, I may simply buy some and give it to patients.
But affordability is not the biggest hurdle for TDCS.
1. LACK OF FDA APPROVAL AND STANDARD OF CARE.
For the medical and psychiatric community: tDCS is an alternative treatment which is not FDA approved nor even FDA cleared. Despite some studies showing it helps reduce depression and may be equivalent to Zoloft, there simply is not enough data and replicated studies to prove TDCS effectiveness at the FDA level. tDCS manufacturers cannot claim at all that they treat any illness. They have no reps visiting doctors to convince them to try it out.
Some alternative treatments such as fish oil and melatonin are so commonly used, they have become part of the standard of care. But TDCS is NOT part of the standard of care. It certainly is in no major psychiatric textbook.
Doctors are conservative – rightly so because they are under the gun at all times from the Medical Board and malpractice lawyers. Many states have no malpractice award limits so doctors are even more at risk. To do tDCS as monotherapy without SIMULTANEOUSLY giving standard treatment for major depressive disorder may put you at high risk of losing your license.
If something goes wrong – e.g. patient attempts suicide or even they don’t improve – you can lose your license for malpractice. You have to always combine TDCS with a standard treatment and call it adjunctive treatment, or demonstrate that the patient has failed multiple standard treatments before using TDCS.
In contrast, Repetitive Transcranial Magnetic Stimulation has reps who visit doctors, who have experts give presentations at major medical conventions. They are able to sell or lease $90,000+ machines to doctors plus $4000 worth of supplies needed per patient per $9000-13,000 course of rTMS. Doctors have to ask you to get a loan to pay for it. But it is fully FDA approved and some insurance companies will pay for treatment. The manufacturers of rTMS machines have paid their millions for studies to prove it works to the FDA standard. No TDCS manufacturer has paid their dues.
2. PHYSICIAN RESISTANCE DUE TO COMPLEXITY OF TDCS.
The protocols for TDCS are NOT well described in the literature. The physician considering TDCS has to do a lot study to understand and perform TDCS. There is no textbook for doing TDCS. There are no step-by-step instructions they can provide to patients. Sure there are websites like Speakwisdom and DIYTDCS and Reddit – but they are absolutely not enough. And obviously, the manufacturers can supply NO instructions for TDCS’s medical uses. Their lips are legally sealed.
In practice, TDCS IS NOT THAT SIMPLE if you as the physician have to break down the steps of how to use it and describe that to patients.
Realize that family doctors only have 6 minutes on average to see a patient. If they spend more time, they go out of business. The overhead is simply too great. That is the reality of modern medical practice forced by managed care. This is a big reason most family doctors want to leave medicine. Family doctors don’t have the time to educate, explain and demonstrate TDCS to patients – particularly with so much of it being very DIY. Psychiatrists are in a better position. But the complexity of educating and demonstrating TDCS step by step to patients makes TDCS time consuming and too difficult to pursue.
3. PATIENT RESISTANCE TO COMPLEXITY OF TDCS.
As an example of patient resistance to complexity: Vitamin C comes as a pill or powdered drink called Emergen-C. But having to mix the Vitamin C in water is literally too much effort and complexity for a mentally ill patient to do for a long period of time. After the first month, most will give up and will gravitate to take the pill. Today I asked a 3rd grader who has difficulty swallowing the large Vitamin C pills if he would rather drink vitamin C in the powdered form called Emergen-C. He refused. He would rather take the choke-evoking large Vitamin C pills than to have to mix and drink the powdered Vitamin C EVERY single day.
It is the patients themselves who are the most resistant to tdcs because TDCS not that simple to do. It looks simple but the actual process is not. It requires multiple steps. And if using sponge electrodes, add the cleaning and care of the spone eletrodes to minimize corrosion deterioration.
It is not the cost that is the issue. Many of my patients literally spend thousands for the travel to see me – not including my fee. Most of my private practice patients have college degrees and are affluent. Many are in the tech industry so are tech saavy. Even then, there is resistance from them to using TDCS because it is much more complicated than you think it is in real life use.
For my practice, I had to go through several iterations of my own instructions for patients to make it so simple enough that patients will be motivated to try TDCS. Even college educated millionaire patients hesitate to use TDCS. Complexity is the biggest hurdle.
Mentally ill patients cannot think clearly. Patients with major depressive disorder do not have the motivation NOR energy to do something as complex as tDCS. Obviously, patients with ADHD have difficulty even with simplified instructions.
I have to work harder to educate and convince my patients to try tDCS than a lot of alternative medicine treatments. I have to give them simple step-by-step, illustrated instructions. I take the time to demonstrate its use. I have them do a session during the appointment. I have to have them repeatedly practice use of the device during an appointment. Even with printed and illustrated instructions, patients forget or give up. Such is the nature of mental illness. Realize that some patients need family or friends or an in-home service provider to help them perform TDCS because of their illness limits what they can accomplish alone.
Foc.us doesn’t make this process easier – even with the Go Flow.
The primary objection I have to the Go Flow is that the control button/slideris actually a COMPLEX control. IT IS NOT INTUITIVE TO USE. Patients will forget how to use it the moment they leave your office. Secondarily the indicators for time and current are NOT clearly demarcated. If you have major depressive disorder OR ADHD, this looks really complicated and intimidating.
I would have preferred an interface with 3 small buttons and a numeric OLED or LED display plus an indicator light LED for the interface. One button sets the duration, a second button sets the current, and a third button to start and stop the session. A small OLED or LED display shows the time and current. A small led light the session is running. Sure it may cost more, but it would be worth it to improve the ease of use and user interface – and ultimately the patient experience.
I strongly dislike Foc.us’s TENS-style pads. I believe they are primarily designed for lock-in rather than patient experience or ease of use. I would have preferred standard TENS button connectors or TENS-style prongs. The Foc.us cables should be off the bat compatible with regular TENS pads. Unfortunately, Foc.us’s best advice is to cut their cables and make your own TENS compatible cables. The final straw is that Foc.us’s pads are often OUT OF STOCK. This is unacceptable – particularly since patients have to special order them long-distance from England, instead of buying them from Amazon with next day delivery or immediate availability from their local medical suppy store or pharmacy. Refills for Foc.us TENS-style pads are not easy to obtain.
For patients to use the Foc.us device with regular TENS pads, they have to create their own cable – using a continuity tester to determine which is the anode and cathode – another complex task for a mentally ill patient to do. I wish Foc.us simply created such a cable like they created the adapter cable for sponge electrodes. For some patients, I have to create the cable myself and give it to them. How many other doctors want to do this? Very few if any. They want off the self simplicity.
Another complexity for TDCS is that patients have to set aside time to use TDCS. This is not that easy to do for many working or school-going patients. [This is one big reason I prefer TENS-style pads, not sponge electrodes. It is far easier to do TDCS anywhere such as during lunch, studying in the library, etc. And you don’t have to wash and dry the sponge every day or carry saline water with you. Sponge eletrodes are a huge hassle]. But setting aside time to do TDCS may end up being like the exercise machine or gym membership you buy but end up not using and stowing in a drawer or closet.
Patients with major depressive disorder lack motivation as a core symptom of their illness. This is why they won’t exercise even if it is proven to reduce depression. For TDCS, I have to repeatedly remind and encourage them to use TDCS otherwise patients will stop using TDCS. It is far easier to pop a pill than to do exercise or TDCS. That is the nature of the illness.
If Foc.us made TENS pad compatible cables, they would go a long way to making the Go Flow and Foc.us stimulator far easier and convenient for patients to use.
Note that I am a strong proponent of TDCS. I believe it can be very effective adjunctive treatment when used for the right patients as part of a comprehensive treatment plan with components targetting the actual pathology causing the illness. I say adjunctive because like rTMS and ECT and many antidepressants, TDCS often does not directly address the underlying cause of the mental illness – depression, ADHD, anxiety, etc. – but in the right patient it can get them started on the road to recovery. TDCS is a fantastic additiona to my toolkit.
Thank you for the great response. It speaks from experience and provides and important perspective on tDCS and the medical community. I appreciate that some MDs have stepped up to the plate and taken on the challenge of finding ways to use tDCS to the benefit of their patients. I know the secret of success with tDCS is persistence on the part of the user. I see great successes with it and sad failures, too – mostly related to whether or not a person had the discipline or coaching to keep doing the sessions.
I too would love to see foc.us make the use of standard electrodes easier – either by selling a complete cable for tens and sponge electrodes or using a more “common” connector on their devices.
But like you, I’m happy that this additional entry in now in the marketplace – and it will be interesting to see how competitors respond. Competition is a good thing!
Thank you again for your great response.