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Naegel S, Biermann J, Theysohn N, Kleinschnitz C, Diener HC, Katsarava Z, Obermann M, Holle D. Polarity-specific modulation of pain processing by transcranial direct current stimulation - a blinded longitudinal fMRI study. J Headache Pain 2018; 19:99. [PMID: 30355321 PMCID: PMC6755563 DOI: 10.1186/s10194-018-0924-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 09/24/2018] [Indexed: 12/21/2022] Open
Abstract
Background To enrich the hitherto insufficient understanding regarding the mechanisms of action of transcranial direct current stimulation (tDCS) in pain disorders, we investigated its modulating effects on cerebral pain processing using functional magnetic resonance imaging (fMRI). Methods Thirteen right-handed healthy participants received 20 min of 1.5 mA tDCS applied over the primary motor cortex thrice and under three different stimulation pattern (1.anodal-tDCS, 2.cathodal-tDCS, and 3.sham-tDCS) in a blinded cross-over design. After tDCS neural response to electric trigeminal-nociceptive stimulation was investigated using a block designed fMRI. Results Pain stimulation showed a distinct activation pattern within well-established brain regions associated with pain processing. Following anodal tDCS increased activation was detected in the thalamus, basal ganglia, amygdala, cingulate, precentral, postcentral, and dorsolateral prefrontal cortex, while cathodal t-DCS showed decreased response in these areas (pFWE < 0.05). Interestingly the observed effect was reversed in both control conditions (visual- and motor-stimulation). Behavioral data remained unchanged irrespective of the tDCS stimulation mode. Conclusions This study demonstrates polarity-specific modulation of cerebral pain processing, in reconfirmation of previous electrophysiological data. Anodal tDCS leads to an activation of the central pain-network while cathodal tDCS does not. Results contribute to a network-based understanding of tDCS’s impact on cerebral pain-processing.
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Affiliation(s)
- Steffen Naegel
- Department of Neurology, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany.
| | - Josephine Biermann
- Department of Neurology, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Nina Theysohn
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Hans-Christoph Diener
- Department of Neurology, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Zaza Katsarava
- Department of Neurology, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany.,Department of Neurology, Evangelical Hospital Unna, Holbeinstr. 10, 59423, Unna, Germany.,EVEX Medical Corporation, 40 Vazha-Pshavela Avenue, Tbilisi, 0177, Georgia.,Sechenov University Moscow, 8-2 Trubetskaya str., Moscow, 119991, Russian Federation
| | - Mark Obermann
- Department of Neurology, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany.,Center for Neurology, Asklepios Hospitals Schildautal, Karl-Herold-Straße 1, 38723, Seesen, Germany
| | - Dagny Holle
- Department of Neurology, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45122, Essen, Germany
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Jiang N, Li G, Wei J, Wei B, Zhu FF, Hu Y. Transcranial direct current stimulation of the primary motor cortex on postoperative pain and spontaneous oscillatory electroencephalographic activity following lumbar spine surgery: A pilot study. Restor Neurol Neurosci 2018; 36:605-620. [DOI: 10.3233/rnn-180816] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Naifu Jiang
- CAS Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Guangsheng Li
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
- Spinal Division, Department of Orthopaedics, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Jinsong Wei
- Spinal Division, Department of Orthopaedics, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Bo Wei
- Spinal Division, Department of Orthopaedics, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Frank F. Zhu
- Faculty of Education, The University of Hong Kong, Hong Kong
| | - Yong Hu
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
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Abstract
Transcranial direct current stimulation (tDCS) modulates spontaneous neuronal activity that can generate long-term neuroplastic changes. It has been used in numerous therapeutic trials showing significant clinical effects especially when combined with other behavioral therapies. One area of intensive tDCS research is chronic pain. Since the initial tDCS trials for chronic pain treatment using current parameters of stimulation, more than 60 clinical trials have been published testing its effects in different pain syndromes. However, as the field moves in the direction of clinical application, several aspects need to be taken into consideration regarding tDCS effectiveness and parameters of stimulation. In this article, we reviewed the evidence of tDCS effects for the treatment of chronic pain and critically analyzed the literature pertaining its safety and efficacy, and how to optimize tDCS clinical effects in a therapeutic setting. We discuss optimization of tDCS effects in 3 different domains: (i) parameters of stimulation, (ii) combination therapies, and (iii) subject selection. This article aims to provide insights for the development of future tDCS clinical trials.
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Affiliation(s)
- Camila Bonin Pinto
- Laboratory of Neuromodulation & Center for Clinical Research Learning, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Beatriz Teixeira Costa
- Laboratory of Neuromodulation & Center for Clinical Research Learning, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Dante Duarte
- Laboratory of Neuromodulation & Center for Clinical Research Learning, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Felipe Fregni
- Laboratory of Neuromodulation & Center for Clinical Research Learning, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, USA
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Braulio G, Passos SC, Leite F, Schwertner A, Stefani LC, Palmer ACS, Torres ILS, Fregni F, Caumo W. Effects of Transcranial Direct Current Stimulation Block Remifentanil-Induced Hyperalgesia: A Randomized, Double-Blind Clinical Trial. Front Pharmacol 2018. [PMID: 29515438 PMCID: PMC5825908 DOI: 10.3389/fphar.2018.00094] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: Remifentanil-induced hyperalgesia (r-IH) involves an imbalance in the inhibitory and excitatory systems. As the transcranial Direct Current Stimulation (tDCS) modulates the thalamocortical synapses in a top-down manner, we hypothesized that the active (a)-t-DCS would be more effective than sham(s)-tDCS to prevent r-IH. We used an experimental paradigm to induce temporal summation of pain utilizing a repetitive cold test (rCOLDT) assessed by the Numerical Pain Score (NPS 0-10) and we evaluated the function of the descending pain modulatory system (DPMS) by the change on the NPS (0–10) during the conditioned pain modulation (CPM)-task (primary outcomes). We tested whether a-tDCS would be more effective than s-tDCS to improve pain perception assessed by the heat pain threshold (HPT) and the reaction time during the ice-water pain test (IPT) (secondary outcomes). Methods: This double-blinded, factorial randomized trial included 48 healthy males, ages ranging 19–40 years. They were randomized into four equal groups: a-tDCS/saline, s-tDCS/saline, a-tDCS/remifentanil and s-tDCS/remifentanil. tDCS was applied over the primary motor cortex, during 20 min at 2 mA, which was introduced 10 min after starting remifentanil infusion at 0.06 μg⋅kg-1⋅min-1 or saline. Results: An ANCOVA mixed model revealed that during the rCOLDT, there was a significant main effect on the NPS scores (F = 3.81; P = 0.01). The s-tDCS/remifentanil group presented larger pain scores during rCOLDT, [mean (SD) 5.49 (1.04)] and a-tDCS/remifentanil group had relative lower pain scores [4.15 (1.62)]; showing its blocking effect on r-IH. a-tDCS/saline and s-tDCS/saline groups showed lowest pain scores during rCOLDT, [3.11 (1.2)] and [3.15 (1.62)], respectively. The effect of sedation induced by remifentanil during the rCOLDT was not significant (F = 0.76; P = 0.38). Remifentanil groups showed positive scores in the NPS (0–10) during the CPM-task, that is, it produced a disengagement of the DPMS. Also, s-tDCS/Remifentanil compared to a-tDCS showed lower HPT and larger reaction-time during the IPT. Conclusion: These findings suggest that effects of a-tDCS prevent the summation response induced by r-IH during rCOLDT and the a-tDCS blocked the disengagement of DPMS. Thereby, tDCS could be considered as a new approach to contra-regulate paradoxical mechanisms involved in the r-IH. Clinical trials identification: NCT02432677. URL:https://clinicaltrials.gov/.
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Affiliation(s)
- Gilberto Braulio
- Post-graduate Program in Medical Sciences, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Pain and Palliative Care Service and Laboratory of Pain and Neuromodulation at HCPA, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Savio C Passos
- Pain and Palliative Care Service and Laboratory of Pain and Neuromodulation at HCPA, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Fabricio Leite
- Post-graduate Program in Medical Sciences, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Andre Schwertner
- Post-graduate Program in Medical Sciences, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Luciana C Stefani
- Post-graduate Program in Medical Sciences, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Department of Surgery Pain and Anesthesia, School of Medicine, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Ana C S Palmer
- Post-graduate Program in Pharmacology and Therapeutic, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Iraci L S Torres
- Post-graduate Program in Medical Sciences, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Post-graduate Program in Pharmacology and Therapeutic, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Department of Pharmacology, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Felipe Fregni
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States.,Department of Neurology, Harvard Medical School, Boston, MA, United States.,Berenson-Allen Center for Noninvasive Brain Stimulation, Boston, MA, United States.,Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Wolnei Caumo
- Post-graduate Program in Medical Sciences, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Pain and Palliative Care Service and Laboratory of Pain and Neuromodulation at HCPA, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Department of Surgery Pain and Anesthesia, School of Medicine, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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Luz-Santos C, Ribeiro Camatti J, Barbosa Paixão A, Nunes Sá K, Montoya P, Lee M, Fontes Baptista A. Additive effect of tDCS combined with Peripheral Electrical Stimulation to an exercise program in pain control in knee osteoarthritis: study protocol for a randomized controlled trial. Trials 2017; 18:609. [PMID: 29268764 PMCID: PMC5740917 DOI: 10.1186/s13063-017-2332-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 11/08/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Knee osteoarthritis (OA) has been linked to maladaptive plasticity in the brain, which may contribute to chronic pain. Neuromodulatory approaches, such as Transcranial Direct Current Stimulation (tDCS) and Peripheral Electrical Stimulation (PES), have been used therapeutically to counteract brain maladaptive plasticity. However, it is currently unclear whether these neuromodulatory techniques enhance the benefits of exercise when administered together. Therefore, this protocol aims to investigate whether the addition of tDCS combined or not with PES enhances the effects of a land-based strengthening exercise program in patients with knee OA. METHODS Patients with knee OA (n = 80) will undertake a structured exercise program for five consecutive days. In addition, they will be randomized into four subgroups receiving either active anodal tDCS and sham PES (group 1; n = 20), sham tDCS and active PES (group 2, n = 20), sham tDCS and PES (group 3, n = 20), or active tDCS and PES (group 4, n = 20) for 20 min/day for five consecutive days just prior to commencement of the exercise program. The primary outcomes will be subjective pain intensity (VAS) and related function (WOMAC). Secondary outcomes will include quality of life (SF-36), anxiety and depression symptoms (HAD), self-perception of improvement, pressure pain thresholds over the knee, quadriceps strength, and quadriceps electromyographic activity during maximum knee extension voluntary contraction. We will also investigate cortical excitability using transcranial magnetic stimulation. Outcome measures will be assessed at baseline, 1 month after, before any intervention, after 5 days of intervention, and at 1 month post exercise intervention. DISCUSSION The motor cortex becomes less responsive in knee OA because of poorly adapted plastic changes, which can impede exercise therapy benefits. Adding tDCS and/or PES may help to counteract those maladaptive plastic changes and improve the benefits of exercises, and the combination of both neuromodulatory techniques must have a higher magnitude of effect. TRIAL REGISTRATION Brazilian Registry on Clinical Trials (ReBEC) - Effects of electrical stimulation over the skull and tight together with exercises for knee OA; protocol number RBR-9D7C7B. TRIAL REGISTRATION ID: RBR-9D7C7B . Registered on 29 February 2016.
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Affiliation(s)
- Cleber Luz-Santos
- Functional Electrostimulation Laboratory, Health Sciences Institute, Federal University of Bahia, Salvador, Brazil
- Graduate Program in Medicine and Health, Faculty of Medicine, Federal University of Bahia, Salvador, Brazil
| | - Janine Ribeiro Camatti
- Functional Electrostimulation Laboratory, Health Sciences Institute, Federal University of Bahia, Salvador, Brazil
- Center for Mathematics, Computation and Cognition, Federal University of ABC, São Bernardo do Campo, São Paulo 09.080-045 Brazil
- Graduate Program in Neuroscience and Cognition, Federal University of ABC, São Bernardo do Campo, Brazil
| | - Alaí Barbosa Paixão
- Functional Electrostimulation Laboratory, Health Sciences Institute, Federal University of Bahia, Salvador, Brazil
- Graduate Program in Medicine and Health, Faculty of Medicine, Federal University of Bahia, Salvador, Brazil
| | - Katia Nunes Sá
- Functional Electrostimulation Laboratory, Health Sciences Institute, Federal University of Bahia, Salvador, Brazil
- Bahian School of Medicine and Public Health, Salvador, Brazil
| | - Pedro Montoya
- Research Institute on Health Sciences, University of Balearic Islands, Palma de Majorca, Spain
| | - Michael Lee
- Graduate School of Health, Discipline of Physiotherapy, University of Technology Sydney, Sydney, NSW Australia
| | - Abrahão Fontes Baptista
- Functional Electrostimulation Laboratory, Health Sciences Institute, Federal University of Bahia, Salvador, Brazil
- Graduate Program in Medicine and Health, Faculty of Medicine, Federal University of Bahia, Salvador, Brazil
- Center for Mathematics, Computation and Cognition, Federal University of ABC, São Bernardo do Campo, São Paulo 09.080-045 Brazil
- Graduate Program in Neuroscience and Cognition, Federal University of ABC, São Bernardo do Campo, Brazil
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56
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Oveisgharan S, Organji H, Ghorbani A. Enhancement of Motor Recovery through Left Dorsolateral Prefrontal Cortex Stimulation after Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 27:185-191. [PMID: 28893574 DOI: 10.1016/j.jstrokecerebrovasdis.2017.08.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/06/2017] [Accepted: 08/14/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Two previous studies, which investigated transcranial direct current stimulation (tDCS) use in motor recovery after acute ischemic stroke, did not show tDCS to be effective in this regard. We speculated that additional left dorsolateral prefrontal cortex (DLPFC) stimulation may enhance poststroke motor recovery. METHODS In the present randomized clinical trial, 20 acute ischemic stroke patients were recruited. Patients received real motor cortex (M1) stimulation in both arms of the trial. The 2 arms differed in terms of real versus sham stimulation over the left DLPFC. The motor component of the Fugl-Meyer upper extremity assessment (FM) and Action Research Arm Test (ARAT) scores were used to assess primary outcomes, and nonlinear mixed effects models were used for data analyses. RESULTS Primary outcome measures improved more and faster among the real stimulation group. During the first days of stimulations, the sham group's FM scores increased by 1.2 per day, while the real group's scores increased by 1.7 per day (P = .003). In the following days, FM improvement decelerated in both groups. Based on the derived models, a stroke patient with a baseline FM score of 15 improves to 32 in the sham stimulation group and to 41 in the real stimulation group within the first month after stroke. Models with ARAT scores yielded nearly similar results. No significant adverse effect was reported. CONCLUSION The current study results showed that left DLPFC stimulation in conjunction with M1 stimulation resulted in better motor recovery than M1 stimulation alone.
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Affiliation(s)
- Shahram Oveisgharan
- Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, Illinois.
| | - Hosein Organji
- Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Askar Ghorbani
- Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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57
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Transcranial direct current stimulation over the primary motor vs prefrontal cortex in refractory chronic migraine: A pilot randomized controlled trial. J Neurol Sci 2017; 378:225-232. [PMID: 28566169 DOI: 10.1016/j.jns.2017.05.007] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 04/04/2017] [Accepted: 05/02/2017] [Indexed: 12/21/2022]
Abstract
Although transcranial direct current stimulation (tDCS) represents a therapeutic option for the prophylaxis of chronic migraine, the target area for application of the electrical current to the cortex has not yet been well established. Here we sought to determine whether a treatment protocol involving 12 sessions of 2mA, 20min anodal stimulation of the left primary motor (M1) or dorsolateral prefrontal cortex (DLPFC) could offer clinical benefits in the management of pain from migraine. Thirteen participants were assessed before and after treatment, using the Headache Impact Test-6, Visual Analogue Scale and Medical Outcomes Study 36 - Item Short - Form Health Survey. After treatment, group DLPFC exhibited a better performance compared with groups M1 and sham. On intragroup comparison, groups DLPFC and M1 exhibited a greater reduction in headache impact and pain intensity and a higher quality of life after treatment. No significant change was found in group sham. The participants in group M1 exhibited more adverse effects, especially headache, heartburn, and sleepiness, than did those in the other two groups. Transcranial direct current stimulation is a safe and efficacious technique for treating chronic migraine. However, it should be kept in mind that the site of cortical stimulation might modulate the patient's response to treatment.
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58
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Sankarasubramanian V, Cunningham DA, Potter-Baker KA, Beall EB, Roelle SM, Varnerin NM, Machado AG, Jones SE, Lowe MJ, Plow EB. Transcranial Direct Current Stimulation Targeting Primary Motor Versus Dorsolateral Prefrontal Cortices: Proof-of-Concept Study Investigating Functional Connectivity of Thalamocortical Networks Specific to Sensory-Affective Information Processing. Brain Connect 2017; 7:182-196. [PMID: 28142257 DOI: 10.1089/brain.2016.0440] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The pain matrix is comprised of an extensive network of brain structures involved in sensory and/or affective information processing. The thalamus is a key structure constituting the pain matrix. The thalamus serves as a relay center receiving information from multiple ascending pathways and relating information to and from multiple cortical areas. However, it is unknown how thalamocortical networks specific to sensory-affective information processing are functionally integrated. Here, in a proof-of-concept study in healthy humans, we aimed to understand this connectivity using transcranial direct current stimulation (tDCS) targeting primary motor (M1) or dorsolateral prefrontal cortices (DLPFC). We compared changes in functional connectivity (FC) with DLPFC tDCS to changes in FC with M1 tDCS. FC changes were also compared to further investigate its relation with individual's baseline experience of pain. We hypothesized that resting-state FC would change based on tDCS location and would represent known thalamocortical networks. Ten right-handed individuals received a single application of anodal tDCS (1 mA, 20 min) to right M1 and DLPFC in a single-blind, sham-controlled crossover study. FC changes were studied between ventroposterolateral (VPL), the sensory nucleus of thalamus, and cortical areas involved in sensory information processing and between medial dorsal (MD), the affective nucleus, and cortical areas involved in affective information processing. Individual's perception of pain at baseline was assessed using cutaneous heat pain stimuli. We found that anodal M1 tDCS and anodal DLPFC tDCS both increased FC between VPL and sensorimotor cortices, although FC effects were greater with M1 tDCS. Similarly, anodal M1 tDCS and anodal DLPFC tDCS both increased FC between MD and motor cortices, but only DLPFC tDCS modulated FC between MD and affective cortices, like DLPFC. Our findings suggest that M1 stimulation primarily modulates FC of sensory networks, whereas DLPFC stimulation modulates FC of both sensory and affective networks. Our findings when replicated in a larger group of individuals could provide useful evidence that may inform future studies on pain to differentiate between effects of M1 and DLPFC stimulation. Notably, our finding that individuals with high baseline pain thresholds experience greater FC changes with DLPFC tDCS implies the role of DLPFC in pain modulation, particularly pain tolerance.
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Affiliation(s)
| | - David A Cunningham
- 1 Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation , Cleveland, Ohio.,2 School of Biomedical Sciences, Department of Neuroscience, Kent State University , Kent, Ohio
| | - Kelsey A Potter-Baker
- 1 Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation , Cleveland, Ohio
| | - Erik B Beall
- 3 Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic Foundation , Cleveland, Ohio
| | - Sarah M Roelle
- 1 Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation , Cleveland, Ohio
| | - Nicole M Varnerin
- 1 Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation , Cleveland, Ohio
| | - Andre G Machado
- 4 Center for Neurological Restoration, Neurosurgery, Neurological Institute, Cleveland Clinic Foundation , Cleveland, Ohio
| | - Stephen E Jones
- 3 Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic Foundation , Cleveland, Ohio
| | - Mark J Lowe
- 3 Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic Foundation , Cleveland, Ohio
| | - Ela B Plow
- 1 Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation , Cleveland, Ohio.,4 Center for Neurological Restoration, Neurosurgery, Neurological Institute, Cleveland Clinic Foundation , Cleveland, Ohio.,5 Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic Foundation , Cleveland, Ohio
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Hashemirad F, Fitzgerald PB, Zoghi M, Jaberzadeh S. Single-Session Anodal tDCS with Small-Size Stimulating Electrodes Over Frontoparietal Superficial Sites Does Not Affect Motor Sequence Learning. Front Hum Neurosci 2017; 11:153. [PMID: 28420970 PMCID: PMC5376552 DOI: 10.3389/fnhum.2017.00153] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 03/15/2017] [Indexed: 12/12/2022] Open
Abstract
Due to the potential of anodal transcranial direct current stimulation (a-tDCS) for enhancement of fine sequenced movements and increasing interest in achieving high level of fine movements in the trained and untrained hands especially at initial stage of learning, we designed this study to investigate whether the application of single-session a-tDCS with small-size stimulating electrodes over FPN sites, such as dorsolateral prefrontal cortex (DLPFC), primary motor cortex (M1) or posterior parietal cortex (PPC) could enhance sequence learning with the trained hand and these effects are transferred into the untrained hand or not. A total of 51 right-handed healthy participants were randomly assigned to one of the four stimulation groups: a-tDCS of left M1, DLPFC, PPC, or sham. Stimulation was applied for 20 min during a sequential visual isometric pinch task (SVIPT). Eight blocks of training using SVIPT were completed with the right hand during stimulation. Two blocks of sequence training with each hand were performed by participants as assessment blocks at three time points: baseline, 15 min and one day following the intervention. Behavioral outcomes including movement time, error rate and skill were assessed in all assessment blocks across three time points. We also measured corticospinal excitability, short-interval intracortical inhibition, and intracortical facilitation using single- and paired-pulse transcranial magnetic stimulation. The results indicated that the behavioral outcomes were significantly improved with the right trained hand, but this learning effect was not modulated by a-tDCS with small-size stimulating electrodes over the FPN. Transfer of learning into the untrained hand was observed in all four groups for movement time but not for the error rate or skill. Our results suggest that sequential learning in SVIPT and its transfer into the untrained hand were not sensitive to a single-session a-tDCS with small-size stimulating electrodes over left M1, DLPFC or PPC in young healthy participants.
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Affiliation(s)
- Fahimeh Hashemirad
- Department of Physiotherapy, School of Primary Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, MelbourneVIC, Australia
| | - Paul B Fitzgerald
- Monash Alfred Psychiatry Research Centre, the Alfred and Monash University Central Clinical School, MelbourneVIC, Australia
| | - Maryam Zoghi
- Department of Medicine at Royal Melbourne Hospital, the University of Melbourne, MelbourneVIC, Australia
| | - Shapour Jaberzadeh
- Department of Physiotherapy, School of Primary Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, MelbourneVIC, Australia
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Janice Jimenez-Torres G, Weinstein BL, Walker CR, Christopher Fowler J, Ashford P, Borckardt JJ, Madan A. A study protocol for a single-blind, randomized controlled trial of adjunctive transcranial direct current stimulation (tDCS) for chronic pain among patients receiving specialized, inpatient multimodal pain management. Contemp Clin Trials 2016; 54:36-47. [PMID: 28039022 DOI: 10.1016/j.cct.2016.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 12/23/2016] [Accepted: 12/24/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Available treatments for chronic pain (CP) are modestly effective or associated with iatrogenic harm. Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that may be an effective, adjunctive treatment to non-opioid therapies. In this randomized control trial (RCT), we compare adjunctive active versus sham tDCS among patients in a multimodal inpatient pain management program. The primary objectives of the RCT are to improve pain tolerance and subjective pain experience. METHODS AND DESIGN Patients admitted to the Pain Management Program at The Menninger Clinic in Houston, Texas are eligible for this trial. Eighty-four participants will be randomized (1:1) into a single-blind, 2×12 (group×time) controlled trial. A battery-powered direct and constant current stimulator (Soterix Medical Inc. 2014) delivers anodal stimulation over the left dorsolateral prefrontal cortex (DLPFC) and cathodal stimulation over the right DLPFC. Active tDCS is applied by supplying a 2mA current for 20min/session over 10 sessions. Participants complete self-report and performance-based assessments on a weekly basis just prior to brain stimulation. Self-report assessments are collected via Chronic Pain Tracker version 3.6, an iPad interfaced application. The performance-based pain tolerance task is completed through the cold presser task. DISCUSSION Interventions with cross-symptomatic therapeutic potential are absolutely essential in the context of CP, in which psychiatric comorbidity is the norm. Modalities that can be used in tandem with evidence-based, non-opioid therapies have the potential to have a synergistic effect, resulting in increased effectiveness of what have been modestly effective treatments to date.
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Affiliation(s)
- G Janice Jimenez-Torres
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Benjamin L Weinstein
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Cory R Walker
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - J Christopher Fowler
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | | | - Jeffrey J Borckardt
- Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, United States; Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States; Ralph H. Johnson Veterans' Affairs Medical Center, Charleston, SC, United States
| | - Alok Madan
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States.
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Filho PRM, Vercelino R, Cioato SG, Medeiros LF, de Oliveira C, Scarabelot VL, Souza A, Rozisky JR, Quevedo ADS, Adachi LNS, Sanches PRS, Fregni F, Caumo W, Torres ILS. Transcranial direct current stimulation (tDCS) reverts behavioral alterations and brainstem BDNF level increase induced by neuropathic pain model: Long-lasting effect. Prog Neuropsychopharmacol Biol Psychiatry 2016; 64:44-51. [PMID: 26160698 DOI: 10.1016/j.pnpbp.2015.06.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 06/24/2015] [Accepted: 06/30/2015] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Neuropathic pain (NP) is a chronic pain modality that usually results of damage in the somatosensory system. NP often shows insufficient response to classic analgesics and remains a challenge to medical treatment. The transcranial direct current stimulation (tDCS) is a non-invasive technique, which induces neuroplastic changes in central nervous system of animals and humans. The brain derived neurotrophic factor plays an important role in synaptic plasticity process. Behavior changes such as decreased locomotor and exploratory activities and anxiety disorders are common comorbidities associated with NP. OBJECTIVE Evaluate the effect of tDCS treatment on locomotor and exploratory activities, and anxiety-like behavior, and peripheral and central BDNF levels in rats submitted to neuropathic pain model. METHODS Rats were randomly divided: Ss, SsS, SsT, NP, NpS, and NpT. The neuropathic pain model was induced by partial sciatic nerve compression at 14 days after surgery; the tDCS treatment was initiated. The animals of treated groups were subjected to a 20 minute session of tDCS, for eight days. The Open Field and Elevated Pluz Maze tests were applied 24 h (phase I) and 7 days (phase II) after the end of tDCS treatment. The serum, spinal cord, brainstem and cerebral cortex BDNF levels were determined 48 h (phase I) and 8 days (phase II) after tDCS treatment by ELISA. RESULTS The chronic constriction injury (CCI) induces decrease in locomotor and exploratory activities, increases in the behavior-like anxiety, and increases in the brainstem BDNF levels, the last, in phase II (one-way ANOVA/SNK, P<0.05 for all). The tDCS treatment already reverted all these effects induced by CCI (one-way ANOVA/SNK, P<0.05 for all). Furthermore, the tDCS treatment decreased serum and cerebral cortex BDNF levels and it increased these levels in the spinal cord in phase II (one-way ANOVA/SNK, P<0.05). CONCLUSION tDCS reverts behavioral alterations associated to neuropathic pain, indicating possible analgesic and anxiolytic tDCS effects. tDCS treatment induces changes in the BDNF levels in different regions of the central nervous system (CNS), and this effect can be attributed to different cellular signaling activations.
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Affiliation(s)
- Paulo Ricardo Marques Filho
- Post-Graduate Program in Medicine: Medical Sciences - Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS 90035-003, Brazil; Pharmacology of Pain and Neuromodulation Laboratory: Pre-clinical Researches Department of Pharmacology, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil; Animal Experimentation Unit and Graduate Research Group, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS 90035-003, Brazil
| | - Rafael Vercelino
- Pharmacology of Pain and Neuromodulation Laboratory: Pre-clinical Researches Department of Pharmacology, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil; Animal Experimentation Unit and Graduate Research Group, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS 90035-003, Brazil; Post-Graduate Program in Biological Sciences - Physiology, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil
| | - Stefania Giotti Cioato
- Post-Graduate Program in Medicine: Medical Sciences - Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS 90035-003, Brazil; Pharmacology of Pain and Neuromodulation Laboratory: Pre-clinical Researches Department of Pharmacology, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil; Animal Experimentation Unit and Graduate Research Group, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS 90035-003, Brazil
| | - Liciane Fernandes Medeiros
- Pharmacology of Pain and Neuromodulation Laboratory: Pre-clinical Researches Department of Pharmacology, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil; Animal Experimentation Unit and Graduate Research Group, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS 90035-003, Brazil; Post-Graduate Program in Biological Sciences: Pharmacology and Experimental Therapeutic, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil
| | - Carla de Oliveira
- Post-Graduate Program in Medicine: Medical Sciences - Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS 90035-003, Brazil; Pharmacology of Pain and Neuromodulation Laboratory: Pre-clinical Researches Department of Pharmacology, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil; Animal Experimentation Unit and Graduate Research Group, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS 90035-003, Brazil
| | - Vanessa Leal Scarabelot
- Pharmacology of Pain and Neuromodulation Laboratory: Pre-clinical Researches Department of Pharmacology, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil; Animal Experimentation Unit and Graduate Research Group, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS 90035-003, Brazil; Post-Graduate Program in Biological Sciences - Physiology, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil
| | - Andressa Souza
- Pharmacology of Pain and Neuromodulation Laboratory: Pre-clinical Researches Department of Pharmacology, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil
| | - Joanna Ripoll Rozisky
- Post-Graduate Program in Medicine: Medical Sciences - Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS 90035-003, Brazil; Animal Experimentation Unit and Graduate Research Group, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS 90035-003, Brazil
| | - Alexandre da Silva Quevedo
- Pharmacology of Pain and Neuromodulation Laboratory: Pre-clinical Researches Department of Pharmacology, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil
| | - Lauren Naomi Spezia Adachi
- Post-Graduate Program in Medicine: Medical Sciences - Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS 90035-003, Brazil; Pharmacology of Pain and Neuromodulation Laboratory: Pre-clinical Researches Department of Pharmacology, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil; Animal Experimentation Unit and Graduate Research Group, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS 90035-003, Brazil
| | - Paulo Roberto S Sanches
- Biomedical Engineering of Hospital de Clínicas de Porto Alegre, Porto Alegre, RS 90035-003, Brazil
| | - Felipe Fregni
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Wolnei Caumo
- Post-Graduate Program in Medicine: Medical Sciences - Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS 90035-003, Brazil
| | - Iraci L S Torres
- Post-Graduate Program in Medicine: Medical Sciences - Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS 90035-003, Brazil; Pharmacology of Pain and Neuromodulation Laboratory: Pre-clinical Researches Department of Pharmacology, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil; Animal Experimentation Unit and Graduate Research Group, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS 90035-003, Brazil; Post-Graduate Program in Biological Sciences - Physiology, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil; Post-Graduate Program in Biological Sciences: Pharmacology and Experimental Therapeutic, Universidade Federal do Rio Grande do Sul, ICBS, Porto Alegre, RS 90050-170, Brazil.
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Vaseghi B, Zoghi M, Jaberzadeh S. The effects of anodal-tDCS on corticospinal excitability enhancement and its after-effects: conventional vs. unihemispheric concurrent dual-site stimulation. Front Hum Neurosci 2015; 9:533. [PMID: 27242498 PMCID: PMC4871166 DOI: 10.3389/fnhum.2015.00533] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 09/14/2015] [Indexed: 12/13/2022] Open
Abstract
Previous researchers have approved the ability of anodal transcranial direct current stimulation (a-tDCS) of the primary motor cortex (M1) to enhance corticospinal excitability (CSE). The primary aim of the current study was to investigate the effect of concurrent stimulation of M1 and a functionally connected cortical site of M1 on CSE modulation. This new technique is called unihemispheric concurrent dual-site a-tDCS (a-tDCSUHCDS). The secondary aim was to investigate the mechanisms underlying the efficacy of this new approach in healthy individuals. In a randomized crossover study, 12 healthy right-handed volunteers received a-tDCS under five conditions: a-tDCS of M1, a-tDCSUHCDS of M1-dorsolateral prefrontal cortex (DLPFC), a-tDCSUHCDS of M1-primary sensory cortex (S1), a-tDCSUHCDS of M1-primary visual cortex (V1), and sham a-tDCSUHCDS. Peak-to-peak amplitude of transcranial magnetic stimulation (TMS) induced MEPs, short-interval intracortical inhibition (SICI) and intracortical facilitation (ICF) were assessed before and four times after each condition. A-tDCSUHCDS conditions induced larger MEPs than conventional a-tDCS. The level of M1 CSE was significantly higher following a-tDCSUHCDS of M1-DLPFC than other a-tDCSUHCDS conditions (p < 0.001), and lasted for over 24 h. The paired-pulse TMS results after a-tDCS of M1-DLPFC showed significant facilitatory increase and inhibitory change. A-tDCSUHCDS of M1-DLPFC increases M1 CSE twofold that of conventional a-tDCS. A-tDCSUHCDS of M1-DLPFC enhances the activity of glutamergic mechanisms for at least 24 h. Such long-lasting M1 CSE enhancement induced by a-tDCSUHCDS of M1-DLPFC could be a valuable finding in clinical scenarios such as learning, motor performance, or pain management. The present study has been registered on the Australian New Zealand Clinical Trial at http://www.anzctr.org.au/ with registry number of ACTRN12614000817640.
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Affiliation(s)
- Bita Vaseghi
- Faculty of Medicine, Department of Physiotherapy, School of Primary Health Care, Nursing and Health Sciences, Monash University Melbourne, Australia
| | - Maryam Zoghi
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne Parkville, Australia
| | - Shapour Jaberzadeh
- Faculty of Medicine, Department of Physiotherapy, School of Primary Health Care, Nursing and Health Sciences, Monash University Melbourne, Australia
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Brandão Filho RA, Baptista AF, Brandão RDAFS, Meneses FM, Okeson J, de Sena EP. Analgesic effect of cathodal transcranial current stimulation over right dorsolateral prefrontal cortex in subjects with muscular temporomandibular disorders: study protocol for a randomized controlled trial. Trials 2015; 16:415. [PMID: 26381733 PMCID: PMC4574533 DOI: 10.1186/s13063-015-0938-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 09/02/2015] [Indexed: 02/03/2023] Open
Abstract
Background Temporomandibular disorders are a group of orofacial pain conditions that are commonly identified in the general population. Like many other chronic pain conditions, they can be associated with anxiety/depression, which can be related to changes in the activity of the dorsolateral prefrontal cortex. Some studies have demonstrated clinical improvement in subjects with chronic pain who are given therapeutic neuromodulation. Transcranial direct current stimulation is a noninvasive brain stimulation technique that allows the modulation of neuronal membranes. This therapy can enhance or inhibit action potential generation in cortical neurons. In some instances, medications acting in the central nervous system may be helpful despite their adverse side effects. It is important to determine if cathodal transcranial direct current stimulation over the dorsolateral prefrontal cortex, an area that modulates emotion and motor cortex excitability, has an analgesic effect on chronic temporomandibular disorders pain. Method/design The investigators will run a randomized, controlled crossover double blind study with 15 chronic muscular temporomandibular disorder subjects. Each subject will undergo active (1 mA and 2 mA) and sham transcranial direct current stimulation. Inclusion criteria will be determined by the Research Diagnostic Criteria for Temporomandibular Disorders questionnaire, with subjects who have a pain visual analogic scale score of greater than 4/10 and whose pain has been present for the previous 6 months, and with a State-Trait Anxiety Inventory score of more than 42. The influence of transcranial direct current stimulation will be assessed through a visual analogic scale, quantitative sensory testing, quantitative electroencephalogram, and the State-Trait Anxiety Inventory score. Discussion Some studies have demonstrated a strong association between anxiety/depression and chronic pain, where one may be the cause of the other. This is especially true in chronic temporomandibular disorders, and breaking this cycle may have an effect over the symptoms and associated dysfunction. We believe that by inhibiting activity of the dorsolateral prefrontal cortex though cathodal transcranial direct current stimulation, there may be a change in both anxiety/depression and pain level. Transcranial direct current stimulation may emerge as a new tool to be considered for managing these patients. We envision that the information obtained from this study will provide a better understanding of the management of chronic temporomandibular disorders. Trial registration This trial was registered at clinicaltrials.gov on 24 May 2014 (Identifier: NCT02152267).
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Affiliation(s)
- Rivail Almeida Brandão Filho
- Postgraduate Program of Interactive Processes of Organs and Systems, Health and Science Institute of Federal University of Bahia and University of State of Bahia, Avenida Reitor Miguel Calmon, S/N, Vale do Canela, Salvador, Bahia, CEP 40110-902, Brasil. .,University of the State of Bahia, Rua Silveira Martins, 2555, Cabula, Salvador, Bahia, CEP: 41.150-000, Brasil.
| | - Abrahão Fontes Baptista
- Functional Electrostimulation Laboratory, Department of Biomorphology, Health and Science Institute, Federal University of Bahia, Avenida Reitor Miguel Calmon, S/N, Vale do Canela, Salvador, Bahia, CEP 40110-902, Brasil.
| | - Renata de Assis Fonseca Santos Brandão
- Postgraduate Program of Interactive Processes of Organs and Systems, Health and Science Institute of Federal University of Bahia and University of State of Bahia, Avenida Reitor Miguel Calmon, S/N, Vale do Canela, Salvador, Bahia, CEP 40110-902, Brasil. .,University of the State of Bahia, Rua Silveira Martins, 2555, Cabula, Salvador, Bahia, CEP: 41.150-000, Brasil.
| | - Francisco Monteiro Meneses
- Functional Electrostimulation Laboratory, Department of Biomorphology, Health and Science Institute, Federal University of Bahia, Avenida Reitor Miguel Calmon, S/N, Vale do Canela, Salvador, Bahia, CEP 40110-902, Brasil.
| | - Jeffrey Okeson
- Department of Oral Health Science, University of Kentucky College of Dentistry, Lexington, KY, USA.
| | - Eduardo Pondé de Sena
- Department of Bioregulation, Health Sciences Institute, Federal University of Bahia, Avenida Reitor Miguel Calmon, S/N, Vale do Canela, Salvador, Bahia, CEP 40110-902, Brasil.
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