Pioneers Describe Establishment of the INS, 25 Years Later
Soon after the International Neuromodulation Society (INS) formed in 1989, Dr. Patrick Wall, who co- developed the Melzack & Wall Gate Theory that inspired neurostimulation, declared at the society’s first international congress in 1992 that, “Stimulation of identified specific groups of nerve cells will be a very large challenge, but we must face that challenge.”
Twenty-five years later, toward the end of 2014, founding and early members of the INS looked back at establishing that direction and the surprises and challenges they met along the way. Their views were solicited for a perspective newsletter article to mark the anniversary.
Mike DeJongste, MD, PhD, and Michiel Staal, MD, PhD recall that the INS had its origins in an interdisciplinary meeting about spinal cord stimulation in the Netherlands in 1989. The meeting was organized by a diverse group of Dutch medical specialists who had closely cooperated on spinal cord stimulation (SCS) for spasticity. Called “ICESS: International CONGRESS ON EPIDURAL SPINAL CORD STIMULATION," the meeting took place from June 1-3, 1989 in Groningen, the Netherlands and addressed movement (i.e. spasticity), pain and cardiovascular disorders.
A subsequent meeting in Paris on April 21, 1990 drew representatives of different disciplines from France, Belgium, the Netherlands, Germany, England, and Italy. They included Lars Eric Augustinsson, MD, a Swedish neurosurgeon; J. M. Gybels, MD, PhD; N. Lambooy, MD; Geert H. J. J. Spincemaille, MD, PhD; V. Rettori, MD; and F. Sellier, MD. The official name “International Neuromodulation Society” was selected, and the first board was elected: Lee S. Illis, MD, a British neurologist, chairman; J. C. Sier, MD, a Dutch vascular surgeon, secretary; and Dr. Staal, a Dutch neurosurgeon, treasurer; with board members J. U. Krainick, MD, a German neurosurgeon; Mario Meglio, MD, an Italian neurosurgeon; and Daniel Galley, MD, a French cardiologist.
First International Congress and Early Meetings
The First International Congress of the INS was convened by this board, in Rome, on June 3-6, 1992. Drs. Meglio and Illis write in the introduction to the published proceedings that the congress was intended to “define the state of the art and to outline the most promising research projects.” They add that the society was founded “to promote research, both experimental and clinical, in the field of electrical stimulation and pharmacological stimulation of the nervous system.”
Brian Simpson, MA, MD, FRCS, recalls, “At the first Annual General Meeting, in Amsterdam on Nov. 6
1993, apart from the board members only one ordinary member attended – me!” By 1995, he was on the board. Swedish neurosurgeon Bengt Linderoth, MD, PhD, joined the board by 1996 and recalls the society in early years as a very small group, a “ ‘family type of organization’ where we all knew each other.”
Dr. DeJongste said a “beginner’s mistake” might be that once the original board had organized a second congress in Rome in 1992 and their first term ended, the entire board decided to step down rather than looking for continuity by leaving at least one member on the new board. The new board was presided over by Giancarlo Barolat, MD. The fact that the entire first board left constituted one of the first surprises for Dr. Barolat, who noted that the founders faced hostility from existing European pain and neurosurgical societies, which viewed the INS as another potential competitor.
Dr. Barolat was surprised ”that the society actually survived, despite the attacks by other societies and the difficulty in finding its own identity and niche. There were many times, early on, that the existence of the society was questioned by the board itself,” he said, pointing out that, “as I was given the presidency of the society, all the existing board quit at once.” He believes it was, and remains, a challenge to involve a breadth of disciplines such as cardiology, urology, vascular surgery, neurology, and basic science.
Since 1990, Dr. Barolat had collaborated on modeling spinal cord stimulation with Jan Holsheimer, PhD, a Dutch electrophysiologist/biophysicist (and Honorary Lifetime Member of the INS since 2007). Dr. Barolat brought him onto the board in November 1993.
Prof. Holsheimer recalls there was a slow warming-up period for board members to continue to get to know each other and decide how large the membership should be – for instance, if it could just be board members and some invited friends. Before the structure became more formalized, he says, “to avoid stressful situations the initial board meetings were held without an agenda and minutes of the previous meeting. The board took its job seriously and did not make decisions before an issue had been discussed at three subsequent meetings.”
Caption: At a 1995 board meeting in Italy, starting from the left foreground and going back around the table toward the far wall, are Brian Simpson, MD; possibly Wolfhard Winkelmüller, MD (behind Dr. Simpson, in a white shirt); Robert Foreman, PhD; then-INS President Giancarlo Barolat, MD; then- Executive Director Sherri Kae Calkins; José Antonio de Vera Reyes, MD; Claus Naumann, MD; Lars Augustinsson, MD; Jan Holsheimer, PhD; and Mike DeJongste, MD, PhD. (Photo courtesy of Dr. Giancarlo Barolat)
Elliot Krames, MD, became involved after the second INS Congress in Goteborg, Sweden in 1994, which was organized by Dr. Augustinsson. “Cooking in my kitchen one night in 1994, I received a call from Giancarlo Barolat,” Dr. Krames recalls. “I knew Giancarlo only from his published works and was honored by his call and invitation. He asked if I would like to be on the board of the INS. Of course, I said I would.” Dr. Krames and Dr. Barolat had both already been asked to join the board of the just-formed U.S. society, which would soon change its name from the American Neuromodulation Society to the North American Neuromodulation Society (NANS), and not long after, become associated with INS.
Dr. Krames had heard that the INS held meetings in Europe and had wanted to be a part. He attended his first board meeting in Lucerne, Switzerland in 1997, which included a visit to a well-known rehabilitation center in Nottwil. Dr. Krames remembers a discussion there on how to increase INS membership – he believes there were only 10 dues-paying members at that time, and that not all board members were paid-up members.
The Journal is Conceived
When the discussion turned to a newsletter for the society, he drew his attention away from the window outside the schoolroom where the meeting was held, with sheep grazing in the meadow outside (“a very beautiful and peaceful scene”) and raised his hand to say that “if we are a scientific society, we should have a journal.” Some board members were not convinced that this proposal was a good idea, and raised objections. But when the proposal came to a vote several hours later, he was asked to create the journal. Dr. Krames states that he knew nothing of scientific journals or the process of how to even go about starting one.
“Well I did and am glad,” he says now. “I think that the journal led to the real birth of the society and has been a focal point to its growth” – with “thanks to Bob Levy in no small way.” Robert Levy, MD, PhD, has guided the journal through its growth as the second editor-in-chief since 2009.
In Dr. Simpson’s view, the INS owes Dr. Krames a huge debt for nurturing that vision and for investing more than a decade of very hard work in it, adding that after the journal “came of age”, Dr. Levy “has brilliantly taken forward the further development of this essential component of the INS.” Dr. Barolat considers the journal “the most credible vehicle for clinical and scientific information in the field.”
Dr. Krames adds, “Our funding industry partners wondered early on why ‘they’ needed another society. Today, our society is the only one representing the science, clinical access to the therapies, and education of healthcare providers about the benefits of neuromodulation. It was through the journal and our ever-increasingly successful meetings that they slowly came onboard.”
Early Challenges and Assistance in the Growth of the Society
Overall, Dr. Barolat has been pleasantly surprised the society has developed a clinical background and very strong scientific presence, which he mainly credits “to the relentless efforts of Drs. [Robert] Foreman, Linderoth and Krames.”
Getting there, Dr. Linderoth notes, was not without challenges. “One challenge was the merging of different professions into neuromodulators; functional neurosurgeons, anesthetists, pain clinicians, basic researchers, engineers, statisticians, epidemiologists, economists and people concerned with legal matters and compensation etc. Dr. Linderoth goes on to say that “One big problem with starting up a new journal, Neuromodulation, [in 1998] was that it was not accepted in any of the existing scientific databases. The impact factor thus was 0.0. It was of course difficult to advise PhD students to submit research articles to Neuromodulation since they would not be retrievable after publication. I am personally happy that one paper written together with Bob Foreman in 1999 was one of the most downloaded and cited of the articles. Due to the hard work of Elliot Krames and especially by Robert Levy, the journal is now attracting a high degree of attention, has an increasing impact and is listed in PubMed. The articles of high quality have increased and the rejection rate is also rising.”
Dr. Simpson counts as challenges growing the membership sufficiently to achieve and maintain viability, as well as striking the right balance in its structure. “There was always the risk of . . . not representing and promulgating the increasing breadth of the field of neuromodulation. Aiming for a broad church generated an initially less-than-welcoming attitude from the World Society for Stereotactic and Functional Neurosurgery, although, fortunately, relationships improved as the INS matured.”
However, the founders were not without help in the earliest days. Following the ICESS congress, notes Dr. Staal, “several grants enabled the researchers in the Netherlands to initiate clinical studies with neuromodulation for several indications, making several meetings possible in order to elaborate our plans for establishing the INS. Later specialists from other disciplines joined the Dutch ‘neuromodulation family’ (cardiologist Dr. DeJongste and several anesthesiologists).”
The Chosen Name and Its Significance
Even choosing the name “neuromodulation” was not a simple matter. There was discussion among the board members with terms bandied about such as neural prosthetics, neural augmentation, etc. Drs. Staal and DeJongste say the term neuromodulation was a “Dutch invention”. During a later discussion, Dr. Krames notes in a 2006 NANS newsletter article, “the term neuromodulation was proposed by Mario Meglio and accepted by the preliminary board of the society to include all neurodevices implanted to help and improve function in humankind.”
The term neuromodulation links the therapy to the underlying physiology and the unfolding quest to refine insight and interventions. “INS has always supported the research and knowledge about mechanisms of action in neuromodulation," comments Dr. Linderoth. "For a long time I thought that we were only a very, very small group doing this but now it is also rapidly expanding. A very important thing is that the INS has increased the cross-fertilization . . . Moreover, the INS has attracted much support from the neuromodulation manufacturing industry and actually driven the development of new treatment algorithms (which we now see just the start of . . .)” – as well as influencing industry in the development of new and more-refined devices, indications, and stimulation targets.
In the 2004 INS newsletter, Dr. Meglio, who had advocated for the society’s name to use the term
“neuromodulation,” wrote as then-president of the INS:
“We wanted to include all kinds of neuromodulation interventions in this field, not just electrical stimulation, realizing that the nervous system should be viewed not only as a complex electrical system of integrated circuits, but also as an intricate chemical laboratory. Pioneers in neuromodulation recognized early on that the result of modulating the function of the nervous system, either by electrical or chemical means, would indirectly affect other systems in the body, and that neuromodulation could treat conditions which do not directly involve the nervous system.
“The first objective of this Society was to create a stimulating environment and venue for scientists and clinicians with different backgrounds to unite and to study the effects of neuromodulation and its mechanisms of action. Progress in this field would not have been made and will not continue without utilizing a multidisciplinary approach in treating both the patient and the disease.”
Dr. Krames proposed adding to the journal title the phrase “Technology at the Neural Interface” in 2007 to distinguish between pharmacologic neuromodulation from systemic agents and device neuromodulation – and to attract submissions from all of applied neuroscience. He now relishes seeing newer branches of the field such as brain-computer interfaces, brain-machine interfaces, optogenetics and bioelectric medicine, saying, “Our field might just represent the future of medicine!”
“The most gratifying thing about the INS today,” he continues, “with the increasing interest amongst clinicians, scientists, and engineers, is the notion that we are all in this together.”
Chapter Formation
In the early years, Dr. Barolat had formulated, with Dr. Simpson, the idea of national and regional chapters as a way of expanding the reach of the society. When Dr. Krames brought this idea to the NANS board in the 1990s, he encountered some initial skepticism. However, he believes NANS joining the INS was a game-changer, since “the USA implanters were now part of a worldwide federation of implanters and the INS just doubled its growth.”
Dr. Barolat counts as the most tangible change of the INS “the number of members as well as member societies, which have skyrocketed in the recent years. INS has become, de facto, the champion society for neuromodulation all throughout the world. And that is an undisputed fact.”
Growing the membership sufficiently to achieve and maintain viability was very challenging, Dr. Simpson says. He made chapter development one of the priorities of his presidency in 2000 - 2003, with a resulting impact on the full board, since chapter presidents automatically have a seat there.
Both he and Dr. Krames credit Tia Sofatzis with providing needed continuity as a unifying force for the growth of the society, as well as being central to creation of the journal. (She has been managing editor of the journal since 1998 and became executive director of the INS in 2001.)
Room to Grow
Prof. Holsheimer sees a need for a big effort to have specialists in various disciplines communicate together and bring neuromodulation to a higher scientific and technological level, pointing out that strictly basic sciences and technology themselves play only a minor role in enabling interdisciplinary establishment of proven capabilities. He does believe founding the journal “determined further activities, primarily an urgent growth of the membership to make the journal a success.”
Among the many pluses of the society, Drs. Staal and DeJongste still note that despite the rapid growth of the society and development of professionalism, there have been relatively fewer contributions from younger colleagues, perhaps due to lack of interest from regional specialty societies (maybe because neuromodulation is not in the official curriculum), and some lag in widespread use of neuromodulation for the full range of indications, as well as unrealized potential to integrate different neuromodulation applications within one center.
All the same, Dr. Linderoth sees an upward curve with rapidly spreading, active interest in many facets of neuromodulation therapy. He predicts current strides will develop exponentially. For instance, he is part
of one research team constructing future nano-sized “electrobiological GABA interneurons” for implantation in the spinal cord and another research team that has implanted cell probes that secrete nerve growth factor into discrete brain targets of 10 Alzheimer’s patients. “This is to me the translation of neurostimulation to restorative neuromodulation/reparative neuromodulation – the pace here was slower and the difficulties we had to meet were larger – but we will master this too, in the end.”
(Note: For a brief historical run-down of milestones in the first 18 years of INS please see http://www.neuromodulation.com/history---ins)
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