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Adams W, Idnani S, Kim J. Transcranial Direct Current Stimulation for Orthopedic Pain: A Systematic Review with Meta-Analysis. Brain Sci 2024; 14:66. [PMID: 38248281 PMCID: PMC10813248 DOI: 10.3390/brainsci14010066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/16/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024] Open
Abstract
(1) Background: Transcranial direct current stimulation (tDCS) appears to alleviate chronic pain via a brain-down mechanism. Although several review studies have examined the effects of tDCS on patients with chronic pain, no systematic review or meta-analysis has comprehensively analyzed the effects of tDCS on chronic orthopedic joint pain in one study. We aim to evaluate the effectiveness of tDCS for pain reduction in chronic orthopedic patients; (2) Methods: A comprehensive search of five electronic databases (Medline, Embase, Web of Science, CINAHL, and Cochrane) was performed. Only randomized controlled trials that compared tDCS with a control intervention were included. Eighteen studies met our inclusion criteria. We identified four categories of chronic orthopedic pain: knee (k = 8), lower back (k = 7), shoulder (k = 2), and orofacial pain (k = 1). Random effect models were utilized, and a sensitivity analysis was conducted in the presence of significant heterogeneity. Studies within each pain condition were further classified according to the number of treatment sessions: 1-5 sessions, 6-10 sessions, and >10 sessions.; (3) Results: Significant reductions in chronic orthopedic joint pain were observed following tDCS compared to controls for knee (g = 0.59, p = 0.005), lower back (g = 1.14, p = 0.005), and shoulder (g = 1.17, p = 0.020). Subgroup analyses showed pain reductions after 6-10 tDCS sessions for knee pain and after 1-5 and >10 sessions for lower back pain; (4) Conclusions: tDCS could be considered a potential stand-alone or supplemental therapy for chronic knee and lower back pain. The effectiveness of tDCS treatment varies depending on the number of treatment sessions. Our findings suggest the importance of implementing individualized treatment plans when considering tDCS for chronic pain conditions.
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Affiliation(s)
- William Adams
- Department of Kinesiology and Sport Sciences, University of Miami, Coral Gables, FL 33146, USA; (W.A.); (S.I.)
| | - Sherina Idnani
- Department of Kinesiology and Sport Sciences, University of Miami, Coral Gables, FL 33146, USA; (W.A.); (S.I.)
| | - Joosung Kim
- Department of Kinesiology and Sport Sciences, University of Miami, Coral Gables, FL 33146, USA; (W.A.); (S.I.)
- Department of Health and Human Performance, Texas State University, San Marcos, TX 78666, USA
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2
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Kong Q, Li T, Reddy S, Hodges S, Kong J. Brain stimulation targets for chronic pain: Insights from meta-analysis, functional connectivity and literature review. Neurotherapeutics 2024; 21:e00297. [PMID: 38237403 PMCID: PMC10903102 DOI: 10.1016/j.neurot.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/11/2023] [Indexed: 02/16/2024] Open
Abstract
Noninvasive brain stimulation (NIBS) techniques have demonstrated their potential for chronic pain management, yet their efficacy exhibits variability across studies. Refining stimulation targets and exploring additional targets offer a possible solution to this challenge. This study aimed to identify potential brain surface targets for NIBS in treating chronic pain disorders by integrating literature review, neuroimaging meta-analysis, and functional connectivity analysis on 90 chronic low back pain patients. Our results showed that the primary motor cortex (M1) (C3/C4, 10-20 EEG system) and prefrontal cortex (F3/F4/Fz) were the most used brain stimulation targets for chronic pain treatment according to the literature review. The bilateral precentral gyrus (M1), supplementary motor area, Rolandic operculum, and temporoparietal junction, were all identified as common potential NIBS targets through both a meta-analysis sourced from Neurosynth and functional connectivity analysis. This study presents a comprehensive summary of the current literature and refines the existing NIBS targets through a combination of imaging meta-analysis and functional connectivity analysis for chronic pain conditions. The derived coordinates (with integration of the international electroencephalography (EEG) 10/20 electrode placement system) within the above brain regions may further facilitate the localization of these targets for NIBS application. Our findings may have the potential to expand NIBS target selection beyond current clinical trials and improve chronic pain treatment.
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Affiliation(s)
- Qiao Kong
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA
| | - Tingting Li
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA
| | - Sveta Reddy
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA
| | - Sierra Hodges
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA
| | - Jian Kong
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA.
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da Silva AAC, Gomes SRA, do Nascimento RM, Fonseca AK, Pegado R, Souza CG, Macedo LDB. Effects of transcranial direct current stimulation combined with Pilates-based exercises in the treatment of chronic low back pain in outpatient rehabilitation service in Brazil: double-blind randomised controlled trial protocol. BMJ Open 2023; 13:e075373. [PMID: 38159941 PMCID: PMC10759071 DOI: 10.1136/bmjopen-2023-075373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 10/30/2023] [Indexed: 01/03/2024] Open
Abstract
INTRODUCTION Chronic low back pain may be associated with pathoanatomical, neurophysiological, physical, psychological and social factors; thus, treatments to reduce symptoms are important to improve the quality of life of this population. We aimed to evaluate the effects of transcranial direct current stimulation (tDCS) combined with Pilates-based exercises compared with sham stimulation on pain, quality of life and disability in patients with chronic non-specific low back pain. METHODS AND ANALYSIS This is a protocol for a double-blind randomised controlled trial with participants, outcome assessor and statistician blinded. We will include 36 individuals with a history of non-specific chronic low back pain for more than 12 weeks and minimum pain intensity of 3 points on the Numerical Pain Rating Scale. Individuals will be randomised into two groups: (1) active tDCS combined with Pilates-based exercises and (2) sham tDCS combined with Pilates-based exercises. Three weekly sessions of the protocol will be provided for 4 weeks, and individuals will be submitted to three assessments: the first (T0) will be performed before the intervention protocol, the second (T1) immediately after the intervention protocol and the third (T2) will be a follow-up 1 month after the end of the intervention. We will assess pain, disability, central sensitisation, quality of life, pressure pain threshold, global impression of change, adverse events and medication use. The Numerical Pain Rating Scale and the Roland-Morris Disability Questionnaire will be used at T1 to assess pain and disability, respectively, as primary outcome measures. ETHICS AND DISSEMINATION This trial was prospectively registered in ClinicalTrials.gov website and ethically approved by the Ethics and Research Committee of the Faculty of Health Sciences of Trairi (report number: 5.411.244) before data collection. We will publish the results in a peer-reviewed medical journal and on institution websites. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (NCT05467566).
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Affiliation(s)
| | | | | | | | - Rodrigo Pegado
- Graduate Program in Health Sciences. Graduate Program in Physical Therapy, UFRN, Natal, Brazil
| | - Clécio Gabriel Souza
- Faculty of Health Sciences of Trairi, Post Graduation Program in Rehabilitation Science, UFRN, Santa Cruz, Brazil
| | - Liane de Brito Macedo
- Faculty of Health Sciences of Trairi, Post Graduation Program in Rehabilitation Science, UFRN, Santa Cruz, Brazil
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Szymoniuk M, Chin JH, Domagalski Ł, Biszewski M, Jóźwik K, Kamieniak P. Brain stimulation for chronic pain management: a narrative review of analgesic mechanisms and clinical evidence. Neurosurg Rev 2023; 46:127. [PMID: 37247036 PMCID: PMC10227133 DOI: 10.1007/s10143-023-02032-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/01/2023] [Accepted: 05/10/2023] [Indexed: 05/30/2023]
Abstract
Chronic pain constitutes one of the most common chronic complaints that people experience. According to the International Association for the Study of Pain, chronic pain is defined as pain that persists or recurs longer than 3 months. Chronic pain has a significant impact on individuals' well-being and psychosocial health and the economy of healthcare systems as well. Despite the availability of numerous therapeutic modalities, treatment of chronic pain can be challenging. Only about 30% of individuals with non-cancer chronic pain achieve improvement from standard pharmacological treatment. Therefore, numerous therapeutic approaches were proposed as a potential treatment for chronic pain including non-opioid pharmacological agents, nerve blocks, acupuncture, cannabidiol, stem cells, exosomes, and neurostimulation techniques. Although some neurostimulation methods such as spinal cord stimulation were successfully introduced into clinical practice as a therapy for chronic pain, the current evidence for brain stimulation efficacy in the treatment of chronic pain remains unclear. Hence, this narrative literature review aimed to give an up-to-date overview of brain stimulation methods, including deep brain stimulation, motor cortex stimulation, transcranial direct current stimulation, repetitive transcranial magnetic stimulation, cranial electrotherapy stimulation, and reduced impedance non-invasive cortical electrostimulation as a potential treatment for chronic pain.
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Affiliation(s)
- Michał Szymoniuk
- Student Scientific Association at the Department of Neurosurgery, Medical University of Lublin, Lublin, Poland
| | - Jia-Hsuan Chin
- Student Scientific Association at the Department of Neurosurgery, Medical University of Lublin, Lublin, Poland
| | - Łukasz Domagalski
- Student Scientific Association at the Department of Neurosurgery, Medical University of Lublin, Lublin, Poland.
| | - Mateusz Biszewski
- Student Scientific Association at the Department of Neurosurgery, Medical University of Lublin, Lublin, Poland
| | - Katarzyna Jóźwik
- Student Scientific Association at the Department of Neurosurgery, Medical University of Lublin, Lublin, Poland
| | - Piotr Kamieniak
- Department of Neurosurgery, Medical University of Lublin, Lublin, Poland
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Nascimento RMD, Cavalcanti RL, Souza CG, Chaves G, Macedo LB. Transcranial direct current stimulation combined with peripheral stimulation in chronic pain: a systematic review and meta-analysis. Expert Rev Med Devices 2023; 20:121-140. [PMID: 35130800 DOI: 10.1080/17434440.2022.2039623] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The combination of Transcranial Direct Current Stimulation (tDCS) with peripheral stimulation may optimize their effects and bring positive results in treatment of people with chronic pain. AREAS COVERED A systematic review with meta-analysis of randomized and non-randomized trials was performed to investigate the combination of tDCS with peripheral stimulation in adults with chronic pain. The primary outcome was pain intensity. Six studies were included in this review (sample of 228 participants), which investigated the combination of tDCS and transcutaneous electrical nerve stimulation, peripheral electrical stimulation, breathing-controlled electrical stimulation and intramuscular electrical stimulation. The conditions studied were knee osteoarthritis, spinal cord injury, chronic low back pain, and neurogenic pain of the arms. Pain intensity, measured by visual analog scale or numerical rating scale, was reduced in all included studies when at least one of the interventions was active, regardless they were combined or alone, with or without tDCS. However, meta-analysis showed superiority of tDCS used in combination with peripheral stimulation. EXPERT OPINION This systematic review and meta-analysis suggests positive effects of tDCS combined with peripheral stimulation in chronic pain conditions. However, the evidence of the primary outcome was classified as low quality due to the limited number of studies.
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Affiliation(s)
| | | | - Clécio Gabriel Souza
- Faculty of Health Sciences of Trairí, Federal University of Rio Grande Do Norte, Santa Cruz, Brazil
| | - Gabriela Chaves
- Research and Development, Myant Inc. . Toronto, Ontario, Canada
| | - Liane Brito Macedo
- Faculty of Health Sciences of Trairí, Federal University of Rio Grande Do Norte, Santa Cruz, Brazil
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Agostinho M, Weissman Fogel I, Treister R. Time since onset might be of essence: A recommendation to assess the effects of combination of non-pharmacological neuromodulatory approaches at early stage since symptoms onset. Front Neurol 2023; 14:1115370. [PMID: 36793488 PMCID: PMC9923174 DOI: 10.3389/fneur.2023.1115370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/11/2023] [Indexed: 01/31/2023] Open
Abstract
In the past decade researchers began to assess the potential beneficial effects of non-invasive brain stimulation (NIBS) combined with a behavioral task as a treatment approach for various medical conditions. Transcranial direct current stimulation (tDCS) applied to the motor cortex combined with another treatment approach has been assessed as analgesic treatment in neuropathic and non-neuropathic pain conditions, and was found to exert only modest pain relief. Our group results show that combined tDCS and mirror therapy dramatically reduced acute phantom limb pain intensity with long-lasting effects, potentially preventing pain chronification. A review of the scientific literature indicates that our approach differs from that of others: We applied the intervention at the acute stage of the disease, whereas other studies applied the intervention in patients whose disease had already been established. We suggest that the timing of administration of the combined intervention is critical. Unlike in patients with chronic painful condition, in which the maladaptive plasticity associated with pain chronification and chronicity is well-consolidated, early treatment at the acute pain stage may be more successful in counterbalancing the not-yet consolidated maladaptive plasticity. We encourage the research community to test our hypothesis, both in the treatment of pain, and beyond.
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Affiliation(s)
- Mariana Agostinho
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel,Centre for Interdisciplinary Health Research, CIIS, Institute of Health Sciences, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Irit Weissman Fogel
- Physical Therapy Department, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Roi Treister
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel,*Correspondence: Roi Treister ✉
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Anodal-TDCS over Left-DLPFC Modulates Motor Cortex Excitability in Chronic Lower Back Pain. Brain Sci 2022; 12:brainsci12121654. [PMID: 36552115 PMCID: PMC9776085 DOI: 10.3390/brainsci12121654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 11/22/2022] [Accepted: 11/30/2022] [Indexed: 12/05/2022] Open
Abstract
Chronic pain is associated with abnormal cortical excitability and increased pain intensity. Research investigating the potential for transcranial direct current stimulation (tDCS) to modulate motor cortex excitability and reduce pain in individuals with chronic lower back pain (CLBP) yield mixed results. The present randomised, placebo-controlled study examined the impact of anodal-tDCS over left-dorsolateral prefrontal cortex (left-DLPFC) on motor cortex excitability and pain in those with CLBP. Nineteen participants with CLBP (Mage = 53.16 years, SDage = 14.80 years) received 20-min of sham or anodal tDCS, twice weekly, for 4 weeks. Short interval intracortical inhibition (SICI) and intracortical facilitation (ICF) were assessed using paired-pulse Transcranial Magnetic Stimulation prior to and immediately following the tDCS intervention. Linear Mixed Models revealed no significant effect of tDCS group or time, on SICI or ICF. The interactions between tDCS group and time on SICI and ICF only approached significance. Bayesian analyses revealed the anodal-tDCS group demonstrated higher ICF and SICI following the intervention compared to the sham-tDCS group. The anodal-tDCS group also demonstrated a reduction in pain intensity and self-reported disability compared to the sham-tDCS group. These findings provide preliminary support for anodal-tDCS over left-DLPFC to modulate cortical excitability and reduce pain in CLBP.
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Alcon CA, Wang-Price S. Non-invasive brain stimulation and pain neuroscience education in the cognitive-affective treatment of chronic low back pain: Evidence and future directions. FRONTIERS IN PAIN RESEARCH 2022; 3:959609. [PMID: 36438443 PMCID: PMC9686004 DOI: 10.3389/fpain.2022.959609] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/24/2022] [Indexed: 11/12/2022] Open
Abstract
Chronic low back pain (CLBP) is among the leading causes of disability worldwide. Beyond the physical and functional limitations, people's beliefs, cognitions, and perceptions of their pain can negatively influence their prognosis. Altered cognitive and affective behaviors, such as pain catastrophizing and kinesiophobia, are correlated with changes in the brain and share a dynamic and bidirectional relationship. Similarly, in the presence of persistent pain, attentional control mechanisms, which serve to organize relevant task information are impaired. These deficits demonstrate that pain may be a predominant focus of attentional resources, leaving limited reserve for other cognitively demanding tasks. Cognitive dysfunction may limit one's capacity to evaluate, interpret, and revise the maladaptive thoughts and behaviors associated with catastrophizing and fear. As such, interventions targeting the brain and resultant behaviors are compelling. Pain neuroscience education (PNE), a cognitive intervention used to reconceptualize a person's pain experiences, has been shown to reduce the effects of pain catastrophizing and kinesiophobia. However, cognitive deficits associated with chronic pain may impact the efficacy of such interventions. Non-invasive brain stimulation (NIBS), such as transcranial direct current stimulation (tDCS) or repetitive transcranial magnetic stimulation (rTMS) has been shown to be effective in the treatment of anxiety, depression, and pain. In addition, as with the treatment of most physical and psychological diagnoses, an active multimodal approach is considered to be optimal. Therefore, combining the neuromodulatory effects of NIBS with a cognitive intervention such as PNE could be promising. This review highlights the cognitive-affective deficits associated with CLBP while focusing on current evidence for cognition-based therapies and NIBS.
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Affiliation(s)
- Cory A. Alcon
- Department of Physical Therapy, High Point University, High Point, NC, United States
- School of Physical Therapy, Texas Woman’s University, Dallas, TX, United States
- Correspondence: Cory A. Alcon
| | - Sharon Wang-Price
- School of Physical Therapy, Texas Woman’s University, Dallas, TX, United States
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Chang TT, Chang YH, Du SH, Chen PJ, Wang XQ. Non-invasive brain neuromodulation techniques for chronic low back pain. Front Mol Neurosci 2022; 15:1032617. [PMID: 36340685 PMCID: PMC9627199 DOI: 10.3389/fnmol.2022.1032617] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/03/2022] [Indexed: 11/22/2022] Open
Abstract
Structural and functional changes of the brain occur in many chronic pain conditions, including chronic low back pain (CLBP), and these brain abnormalities can be reversed by effective treatment. Research on the clinical applications of non-invasive brain neuromodulation (NIBS) techniques for chronic pain is increasing. Unfortunately, little is known about the effectiveness of NIBS on CLBP, which limits its application in clinical pain management. Therefore, we summarized the effectiveness and limitations of NIBS techniques on CLBP management and described the effects and mechanisms of NIBS approaches on CLBP in this review. Overall, NIBS may be effective for the treatment of CLBP. And the analgesic mechanisms of NIBS for CLBP may involve the regulation of pain signal pathway, synaptic plasticity, neuroprotective effect, neuroinflammation modulation, and variations in cerebral blood flow and metabolism. Current NIBS studies for CLBP have limitations, such as small sample size, relative low quality of evidence, and lack of mechanistic studies. Further studies on the effect of NIBS are needed, especially randomized controlled trials with high quality and large sample size.
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Affiliation(s)
- Tian-Tian Chang
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
| | - Yu-Hao Chang
- Department of Luoyang Postgraduate Training, Henan University of Traditional Chinese Medicine, Luoyang, China
| | - Shu-Hao Du
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
| | - Pei-Jie Chen
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
- *Correspondence: Pei-Jie Chen,
| | - Xue-Qiang Wang
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
- Department of Rehabilitation Medicine, Shanghai Shangti Orthopaedic Hospital, Shanghai, China
- Shanghai Key Lab of Human Performance, Shanghai University of Sport, Shanghai, China
- Xue-Qiang Wang,
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Adhia DB, Mani R, Reynolds JN, Hall M, Vanneste S, De Ridder D. High-Definition Transcranial Infraslow Pink-Noise Stimulation Can Influence Functional and Effective Cortical Connectivity in Individuals With Chronic Low Back Pain: A Pilot Randomized Placebo-Controlled Study. Neuromodulation 2022:S1094-7159(22)01225-9. [DOI: 10.1016/j.neurom.2022.08.450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/02/2022] [Accepted: 08/15/2022] [Indexed: 11/06/2022]
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Adhia DB, Mani R, Reynolds JNJ, Vanneste S, De Ridder D. High-definition transcranial infraslow pink noise stimulation for chronic low back pain: protocol for a pilot, safety and feasibility randomised placebo-controlled trial. BMJ Open 2022; 12:e056842. [PMID: 35705354 PMCID: PMC9204463 DOI: 10.1136/bmjopen-2021-056842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Chronic low back pain (CLBP) is a common disabling health condition. Current treatments demonstrate modest effects, warranting newer therapies. Brain imaging demonstrates altered electrical activities in cortical areas responsible for pain modulation, emotional and sensory components of pain experience. Treatments targeting to change electrical activities of these key brain regions may produce clinical benefits. This pilot study aims to (1) evaluate feasibility, safety and acceptability of a novel neuromodulation technique, high-definition transcranial infraslow pink noise stimulation (HD-tIPNS), in people with CLBP, (2) explore the trend of effect of HD-tIPNS on pain and function, and (3) derive treatment estimates to support sample size calculation for a fully powered trial should trends of effectiveness be present. METHODS AND ANALYSIS A pilot, triple-blinded randomised two-arm placebo-controlled parallel trial. Participants (n=40) with CLBP will be randomised to either sham stimulation or HD-tIPNS (targeting somatosensory cortex and dorsal and pregenual anterior cingulate cortex). Primary outcomes include feasibility and safety measures, and clinical outcomes of pain (Brief Pain Inventory) and disability (Roland-Morris disability questionnaire). Secondary measures include clinical, psychological, quantitative sensory testing and electroencephalography collected at baseline, immediately postintervention, and at 1-week, 1-month and 3 months postintervention. All data will be analysed descriptively. A nested qualitative study will assess participants perceptions about acceptability of intervention and analysed thematically. ETHICS AND DISSEMINATION Ethical approval has been obtained from Health and Disability Ethics Committee (Ref:20/NTB/67). Findings will be reported to regulatory and funding bodies, presented at conferences, and published in a scientific journal. TRIAL REGISTRATION NUMBER ACTRN12620000505909p.
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Affiliation(s)
- Divya Bharatkumar Adhia
- Department of Surgical Sciences, and Pain@Otago Research Theme, University of Otago - Dunedin Campus, Dunedin, New Zealand
| | - Ramakrishnan Mani
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, and Pain@Otago Research Theme, University of Otago - Dunedin Campus, Dunedin, New Zealand
| | - John N J Reynolds
- Department of Anatomy and the Brain Health Research Centre, University of Otago - Dunedin Campus, Dunedin, New Zealand
| | - Sven Vanneste
- School of Psychology, Global Brain Health Institute, Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
| | - Dirk De Ridder
- Department of Surgical Sciences, and Pain@Otago Research Theme, University of Otago - Dunedin Campus, Dunedin, New Zealand
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12
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McPhee ME, Graven-Nielsen T. Medial Prefrontal High-Definition Transcranial Direct Current Stimulation to Improve Pain Modulation in Chronic Low Back Pain: A Pilot Randomized Double-blinded Placebo-Controlled Crossover Trial. THE JOURNAL OF PAIN 2021; 22:952-967. [PMID: 33676009 DOI: 10.1016/j.jpain.2021.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 02/09/2021] [Accepted: 02/19/2021] [Indexed: 06/12/2023]
Abstract
Chronic low back pain (CLBP) is highly disabling, but often without identifiable source. Focus has been on impaired anti-nociceptive mechanisms contributing to pain maintenance, though methods of targeting this impairment remain limited. This randomised-controlled cross-over pilot trial used active versus sham medial prefrontal cortex (mPFC) high-definition transcranial direct current stimulation (HD-tDCS) for 3-consecutive days to improve descending pain inhibitory function. Twelve CLBP patients were included with an average visual analogue scale (VAS) pain intensity of 3.0 ± 1.5 and pain duration of 5.3 ± 2.6 years. Pressure pain thresholds (PPTs), conditioned pain modulation (CPM), and temporal summation of pain (TSP) assessed by cuff algometry, as well as pain symptomatology (intensity, unpleasantness, quality, disability) and related psychological features (pain catastrophizing, anxiety, affect), were assessed on Day1 before 3 consecutive days of HD-tDCS sessions (each 20 minutes), at 24-hours (Day 4) and 2-weeks (Day 21) following final HD-tDCS. Blinding was successful. No significant differences in psychophysical (PPT, CPM, TSP), symptomatology or psychological outcomes were observed between active and sham HD-tDCS on Day4 and Day21. CPM-effects at Day 1 negatively correlated with change in CPM-effect at Day4 following active HD-tDCS (P = .002). Lack of efficacy was attributed to several factors, not least that patients did not display impaired CPM at baseline. TRIAL REGISTRATION: : ClinicalTrials.gov (NCT03864822). PERSPECTIVE: Medial prefrontal HD-tDCS did not alter pain, psychological nor psychophysical outcomes, though correlational analysis suggested response may depend on baseline pain inhibitory efficacy, with best potential effects in patients with severe impairments in descending pain inhibitory mechanisms. Future work should focus on appropriate patient selection and optimising stimulation targeting.
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Affiliation(s)
- Megan E McPhee
- Center for Neuroplasticity and Pain (CNAP), Aalborg University, Denmark
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13
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Patricio P, Roy JS, Rohel A, Gariépy C, Émond C, Hamel É, Massé-Alarie H. The Effect of Noninvasive Brain Stimulation to Reduce Nonspecific Low Back Pain: A Systematic Review and Meta-analysis. Clin J Pain 2021; 37:475-485. [PMID: 33949359 DOI: 10.1097/ajp.0000000000000934] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 03/03/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We conducted a systematic review/meta-analysis to evaluate noninvasive brain stimulation (NIBS) efficacy to alleviate pain and improve disability in low back pain (LBP). MATERIALS AND METHODS A systematic literature search was performed by a librarian in MEDLINE, Embase, EBM Reviews, CINAHL, and Web of Science databases (last search: January 14, 2021). Data were pooled by the number of sessions and follow-up periods. Independent reviewers performed screening, data extraction, and risk of bias. Pain reduction and disability were used as outcomes. RESULTS Twelve articles were included in the qualitative synthesis and 8 in the meta-analysis. A single session of NIBS reduced pain compared with sham (standardized mean difference: -0.47; P<0.001; very low-quality evidence). Repeated sessions of NIBS did not impact pain at short-term (mean difference [MD]: -0.31; P=0.23) or midterm (MD: -0.56; P=0.33; moderate quality evidence). Combining NIBS with cointerventions did not influence pain (MD: -0.31; P=0.30; moderate quality evidence). NIBS did not have a statistically significant impact on disability. DISCUSSION There is very low-quality evidence suggesting that a single NIBS session reduces LBP intensity. In contrast, there is moderate quality evidence that repeated NIBS sessions or combination with cointervention did not improve pain or disability. Thus, current results do not support NIBS use to treat chronic LBP. Considering that tDCS was tested in 8 of 12 studies with little success, studies focusing on different NIBS techniques or innovative parameters are required to determine their potential to improve pain and disability in chronic LBP.
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Affiliation(s)
- Philippe Patricio
- Department of Rehabilitation, Faculty of Medicine, Laval University
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec City, QC, Canada
| | - Jean-Sébastien Roy
- Department of Rehabilitation, Faculty of Medicine, Laval University
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec City, QC, Canada
| | - Antoine Rohel
- Department of Rehabilitation, Faculty of Medicine, Laval University
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec City, QC, Canada
| | - Cynthia Gariépy
- Department of Rehabilitation, Faculty of Medicine, Laval University
| | - Camille Émond
- Department of Rehabilitation, Faculty of Medicine, Laval University
| | - Élodie Hamel
- Department of Rehabilitation, Faculty of Medicine, Laval University
| | - Hugo Massé-Alarie
- Department of Rehabilitation, Faculty of Medicine, Laval University
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec City, QC, Canada
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Noninvasive Neuromodulation Techniques in Difficult Tracheostomy Weaning of Patients With Spinal Cord Injury: Report of Two Cases. Chest 2021; 159:e299-e302. [PMID: 33965152 DOI: 10.1016/j.chest.2020.11.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/15/2020] [Indexed: 11/21/2022] Open
Abstract
High spinal cord injured patients (SCI) are susceptible to respiratory muscle impairments. Transcranial direct current stimulation (tDCS) and peripheral electrical stimulation (PES) may influence the diaphragm's central control, but until now they are not described as a therapeutic resource for difficult weaning. We present two case reports of SCI patients (P1 and P2) with long-term tracheostomy (>40 days) and hospital stay (>50 days). In association with respiratory exercise, P1 received a combined application of anodal tDCS over the supplementary motor area plus sensory PES in the thoracic-abdominal muscles, and P2 received isolated excitatory PES in the abdominal muscles, applied daily except on weekends. Maximum inspiratory/expiratory pressure, peak cough flow, diaphragm excursion, and thickening fraction were measured in the first and last days of the protocol. Both patients had improvements, with clinical impact such as cough effectiveness, decannulated after 15 applications of stimulation. Augmentation of neural respiratory drive and corticospinal excitability is suggested.
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Liu Z, Dong S, Zhong S, Huang F, Zhang C, Zhou Y, Deng H. The effect of combined transcranial pulsed current stimulation and transcutaneous electrical nerve stimulation on lower limb spasticity in children with spastic cerebral palsy: a randomized and controlled clinical study. BMC Pediatr 2021; 21:141. [PMID: 33761932 PMCID: PMC7989146 DOI: 10.1186/s12887-021-02615-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 03/17/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND In the current study, we applied a combination of non-invasive neuromodulation modalities concurrently with multiple stimulating electrodes. Specifically, we used transcranial pulsed current stimulation (tPCS) and transcutaneous electrical nerve stimulation (TENS) as a novel strategy for improving lower limb spasticity in children with spastic cerebral palsy (SCP) categorized on levels III-V of the Gross Motor Function Classification System (GMFCS) with minimal side effects. METHODS Sixty-three SCP children aged 2-12 years, who were classified on levels III-V of the GMFCS were randomly assigned to one of two groups, resulting in 32 children in the experimental group and 31 children in the control group. The experimental group underwent a combination therapy of tPCS (400 Hz, 1 mA cerebello-cerebral stimulation) and TENS (400 Hz, max 10 mA) for 30 min, followed by 30 min of physiotherapy five times per week for 12 weeks. The control group underwent physiotherapy only 30 mins per day five times per week for 12 weeks. In total, all groups underwent 60 treatment sessions. The primary outcome measures were the Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS). Evaluations were performed 3 days before and after treatment. RESULTS We found a significant improvement in MAS and MTS scores of the lower limbs in the experimental group compared to the control group in the hip adductors (Left: p = 0.002; Right: p = 0.002), hamstrings (Left: p = 0.001; Right: p < 0.001, and gastrocnemius (Left: p = 0.001; Right: p = 0.000). Moreover, MTS scores of R1, R2 and R2-R1 in left and right hip adduction, knee joint, and ankle joint all showed significant improvements (p ≤ 0.05). Analysis of MAS and MTS scores compared to baseline scores showed significant improvements in the experimental group but declines in the control group. CONCLUSION These results are among the first to demonstrate that a combination of tPCS and TENS can significantly improve lower limb spasticity in SCP children classified on GMFCS levels III-V with minimal side effects, presenting a novel strategy for addressing spasticity challenges in children with severe SCP. TRIAL REGISTRATION ChiCTR.org, ChiCTR1800020283, Registration: 22 December 2018 (URL: http://www.chictr.org.cn/showproj.aspx?proj=33953 ).
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Affiliation(s)
- Zhenhuan Liu
- Department of Pediatric Rehabilitation, Nanhai Maternity and Children's Hospital Affiliated to Guangzhou University of Traditional Chinese Medicine, Foshan, Guangdong Province, China.
| | - Shangsheng Dong
- Department of Pediatric Rehabilitation, Jiangmen Maternity and Child Health Care Hospital, Jiangmen, Guangdong Province, China
| | - Sandra Zhong
- Guangzhou Yirui Charitable Foundation, Guangzhou, Guangdong Province, China
| | - Fang Huang
- Department of Pediatric Rehabilitation, Guangzhou City Social Welfare Institute Rehabilitation Hospital, Guangzhou, Guangdong Province, China
| | - Chuntao Zhang
- Department of Pediatric Rehabilitation, Nanhai Maternity and Children's Hospital Affiliated to Guangzhou University of Traditional Chinese Medicine, Foshan, Guangdong Province, China
| | - Yuan Zhou
- Department of Pediatric Rehabilitation, Nanhai Maternity and Children's Hospital Affiliated to Guangzhou University of Traditional Chinese Medicine, Foshan, Guangdong Province, China
| | - Haorong Deng
- Department of Pediatric Rehabilitation, Guangzhou City Social Welfare Institute Rehabilitation Hospital, Guangzhou, Guangdong Province, China
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Motor cortex transcranial direct current stimulation effects on knee osteoarthritis pain in elderly subjects with dysfunctional descending pain inhibitory system: A randomized controlled trial. Brain Stimul 2021; 14:477-487. [PMID: 33684598 DOI: 10.1016/j.brs.2021.02.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 02/19/2021] [Accepted: 02/24/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although evidence has indicated a positive effect of transcranial direct current stimulation (tDCS) on reducing pain, few studies have focused on the elderly population with knee osteoarthritis (KOA). OBJECTIVE To evaluate whether tDCS reduces KOA pain in elderly individuals with a dysfunctional descending pain inhibitory system (DPIS). METHODS In a double-blind trial, individuals ≥ 60 years with KOA pain and a dysfunctional DPIS, we randomly assigned patients to receive 15 daily sessions of 2 mA tDCS over the primary motor cortex (anode) and contralateral supraorbital area (cathode) (M1-SO) for 20 min or sham tDCS. Change in pain perception indexed by the Brief Pain Inventory (BPI) at the end of intervention was the primary outcome. Secondary outcomes included: disability, quantitative sensory testing, pain pressure threshold and conditioned pain modulation (CPM). Subjects were followed-up for 2 months. RESULTS Of the 104 enrolled subjects, with mean (SD) age of 73.9 (8.01) years and 88 (84.6%) female, 102 finished the trial. In the intention-to-treat analysis, the active tDCS group had a significantly greater reduction in BPI compared to the sham group (difference, 1.59; 95% CI, 0.95 to 2.23; P < 0.001; Cohen's d, 0.58); and, also a significantly greater improvement in CPM-pressure in the knee (P = 0.01) and CPM-pain in the hand (P = 0.01). These effects were not sustained at follow-up. The intervention was well tolerated, with no severe adverse effects. CONCLUSION M1-SO tDCS is associated with a moderate effect size in reducing pain in elderly patients with KOA after 15 daily sessions of stimulation. This intervention has also shown to modulate the DPIS.
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De Souza CG, Pegado R, Costa J, Morya E, Baptista AF, Unal G, Bikson M, Okano AH. Alternate sessions of transcranial direct current stimulation (tDCS) reduce chronic pain in women affected by chikungunya. A randomized clinical trial. Brain Stimul 2021; 14:541-548. [PMID: 33667699 DOI: 10.1016/j.brs.2021.02.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 10/28/2020] [Accepted: 02/21/2021] [Indexed: 12/27/2022] Open
Abstract
CONTEXT Thousands of people worldwide have been infected by the chikungunya virus (CHIKV), and the persistence of joint pain symptoms has been considered the main problem. Neuromodulation techniques such as transcranial direct current stimulation (tDCS) act on brain areas involved in the processing of chronic pain. It was previously demonstrated that tDCS for five consecutive days significantly reduced pain in the chronic phase of chikungunya (CHIK). OBJECTIVE To analyze the effect of alternate tDCS sessions on pain and functional capacity in individuals affected by CHIK. METHODS In a randomized clinical trial, 58 women in the chronic phase of CHIK were divided into two groups: active-tDCS (M1-S0, 2 mA, 20 min) and sham-tDCS. The Visual Analogue Scale (VAS) and the Brief Pain Inventory (BPI) were used to assess pain, while the Health Assessment Questionnaire (HAQ) assessed functional capacity. These scales were used before and after six sessions of tDCS in nonconsecutive days on the primary motor cortex, and at follow-up consultation 7 and 15 days after the last session. A repeated measures mixed-model ANOVA was used for comparison between groups (significant p-values < 0.05). RESULTS A significant pain reduction (Z [3, 171] = 14.303; p < 0.0001) was observed in the tDCS group compared to the sham group; no significant difference in functional capacity was observed (Z [1.57] = 2.797; p = 0.1). CONCLUSION Our results suggest that six nonconsecutive sessions of active tDCS on M1 reduce pain in chronic CHIKV arthralgia.
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Affiliation(s)
- Clecio Gabriel De Souza
- Federal University of Rio Grande Do Norte, Postgraduate Program in Rehabilitation Sciences, Santa Cruz, RN, Brazil; Graduate Program in Collective Health, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil.
| | - Rodrigo Pegado
- Federal University of Rio Grande Do Norte, Postgraduate Program in Rehabilitation Sciences, Santa Cruz, RN, Brazil; NAPeN Network (Rede de Núcleos de Assistência e Pesquisa em Neuromodulação), Brazil.
| | - Jardson Costa
- Faculty Estacio of Rio Grande Do Norte, Natal, RN, Brazil
| | - Edgard Morya
- Edmond and Lily Safra International Neuroscience Institute, Santos Dumont Institute, Macaíba, RN, Brazil; Brazilian Institute of Neuroscience and Neurotechnology (BRAINN/CEPID-FAPESP), University of Campinas, Campinas, São Paulo, Brazil; NAPeN Network (Rede de Núcleos de Assistência e Pesquisa em Neuromodulação), Brazil.
| | - Abrahão Fontes Baptista
- Universidade Federal do ABC, Center for Mathematics, Computing and Cognition, São Bernardo do Campo, SP, Brazil; Brazilian Institute of Neuroscience and Neurotechnology (BRAINN/CEPID-FAPESP), University of Campinas, Campinas, São Paulo, Brazil; NAPeN Network (Rede de Núcleos de Assistência e Pesquisa em Neuromodulação), Brazil
| | - Gozde Unal
- Department of Biomedical Engineering, The City College of New York, NY, USA
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York, NY, USA
| | - Alexandre Hideki Okano
- Universidade Federal do ABC, Center for Mathematics, Computing and Cognition, São Bernardo do Campo, SP, Brazil; Brazilian Institute of Neuroscience and Neurotechnology (BRAINN/CEPID-FAPESP), University of Campinas, Campinas, São Paulo, Brazil; NAPeN Network (Rede de Núcleos de Assistência e Pesquisa em Neuromodulação), Brazil.
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Lloyd DM, Wittkopf PG, Arendsen LJ, Jones AK. Is Transcranial Direct Current Stimulation (tDCS) Effective for the Treatment of Pain in Fibromyalgia? A Systematic Review and Meta-Analysis. THE JOURNAL OF PAIN 2020; 21:1085-1100. [DOI: 10.1016/j.jpain.2020.01.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/22/2019] [Accepted: 01/06/2020] [Indexed: 01/24/2023]
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Randomized clinical trial comparing of transcranial direct current stimulation (tDCS) and transcutaneous electrical nerve stimulation (TENS) in knee osteoarthritis. Neurophysiol Clin 2020; 50:367-374. [PMID: 32912627 DOI: 10.1016/j.neucli.2020.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Due to the limitations of pharmacological and surgical management of knee osteoarthritis (OA), several non-pharmacologic approaches including transcutaneous electrical nerve stimulation (TENS) and transcranial direct current stimulation (tDCS) have been introduced, with promising results. OBJECTIVE We aimed to investigate and compare the therapeutic effects of TENS and tDCS for the treatment of patients with knee OA. METHODS In this double-blinded randomized controlled trial, a total of 40 adult patients with knee OA were randomly allocated to either the TENS or the tDCS group. Patients in either group received 6 sessions of the TENS or tDCS for 2 weeks. Knee strengthening exercises were performed twice daily for the entire treatment period. Patients were evaluated using the visual analogue scale (VAS) and Western Ontario and McMaster Universities (WOMAC). RESULTS Significant improvement was observed in all outcomes in both TENS and tDCS groups at each follow up compared to baseline although the early improvement (first follow-up) in the WOMAC index was not significant in the TENS group. Based on the within-subject analysis, the behavior of two treatment groups did not differ regarding the changes in the course of the VAS, WOMAC score and its subscales, i.e. stiffness, pain and function (p = 0.263, 0.051, 0.198, 0.075, and 0.146, respectively). CONCLUSIONS Based on the results of this study, the effect of tDCS and TENS was not significantly different on pain and function of patients with knee OA.
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Cavalcante PGL, Baptista AF, Cardoso VS, Filgueiras MDC, Hasue RH, João SMA, Hazime FA. Transcranial Direct Current Stimulation Combined With Therapeutic Exercise in Chronic Low Back Pain: Protocol of a Randomized Controlled Trial. Phys Ther 2020; 100:1595-1602. [PMID: 32526017 DOI: 10.1093/ptj/pzaa105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 10/28/2019] [Accepted: 04/08/2020] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Although some studies have shown the clinical benefits of therapeutic exercise in chronic nonspecific low back pain, the effect sizes are generally small to moderate and recurrence rates are high. Transcranial direct current stimulation (tDCS) has been used to modulate pain-processing systems and motor outputs and has the potential to optimize the clinical benefits of therapeutic exercise. However, evidence for this combination is still lacking. The purpose of this protocol for a randomized clinical trial is to investigate whether the combination of tDCS and therapeutic exercise is more effective in relieving pain than therapeutic exercise alone. METHODS This 2-arm, randomized controlled clinical trial will take place at the Federal University of Piauí, Brazil. Sixty patients will be randomized into 2 groups to receive tDCS (real/sham) + exercise therapies for 12 sessions over a period of 4 weeks. Pain intensity, sensory and affective aspects of pain, physical functioning, kinesiophobia, and global perceived effect will be recorded before treatment and at 4 weeks, 3 months, and 6 months after randomization. Data will be collected by an examiner unaware of (blind to) the treatment allocation. IMPACT This trial can potentially provide important information and assist in clinical decision-making on the combined use of tDCS to optimize the clinical benefits of therapeutic exercise in patients with chronic nonspecific low back pain.
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Affiliation(s)
| | - Abrahão Fontes Baptista
- Center for Mathematics, Computation and Cognition, Universidade Federal do ABC, São Bernardo do Campo, SP - Brazil
| | - Vinícius Saura Cardoso
- Department of Physical Therapy, Biomedical Master Science Program, Universidade Federal do Piaui
| | | | - Renata Hydee Hasue
- Department of Physical Therapy, Communication Sciences and Disorders, and Occupational Therapy, Doctoral Programs in Rehabilitation Sciences, Faculdade de Medicina da Universidade de São Paulo - USP, São Paulo, SP - Brazil
| | - Silvia Maria Amado João
- Department of Physical Therapy, Communication Sciences and Disorders, and Occupational Therapy, Doctoral Programs in Rehabilitation Sciences, Faculdade de Medicina da Universidade de São Paulo
| | - Fuad Ahmad Hazime
- Department of Physical Therapy, Biomedical Master Science Program, Universidade Federal do Piaui, Parnaíba, Avenida São Sebastião, 2819, CEP: 64202-020 Parnaíba, PI - Brazil
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Arendsen LJ, Henshaw J, Brown CA, Sivan M, Taylor JR, Trujillo-Barreto NJ, Casson AJ, Jones AKP. Entraining Alpha Activity Using Visual Stimulation in Patients With Chronic Musculoskeletal Pain: A Feasibility Study. Front Neurosci 2020; 14:828. [PMID: 32973429 PMCID: PMC7468433 DOI: 10.3389/fnins.2020.00828] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/15/2020] [Indexed: 11/13/2022] Open
Abstract
Entraining alpha activity with rhythmic visual, auditory, and electrical stimulation can reduce experimentally induced pain. However, evidence for alpha entrainment and pain reduction in patients with chronic pain is limited. This feasibility study investigated whether visual alpha stimulation can increase alpha power in patients with chronic musculoskeletal pain and, secondarily, if chronic pain was reduced following stimulation. In a within-subject design, 20 patients underwent 4-min periods of stimulation at 10 Hz (alpha), 7 Hz (high-theta, control), and 1 Hz (control) in a pseudo-randomized order. Patients underwent stimulation both sitting and standing and verbally rated their pain before and after each stimulation block on a 0-10 numerical rating scale. Global alpha power was significantly higher during 10 Hz compared to 1 Hz stimulation when patients were standing (t = -6.08, p < 0.001). On a more regional level, a significant increase of alpha power was found for 10 Hz stimulation in the right-middle and left-posterior region when patients were sitting. With respect to our secondary aim, no significant reduction of pain intensity and unpleasantness was found. However, only the alpha stimulation resulted in a minimal clinically important difference in at least 50% of participants for pain intensity (50%) and unpleasantness ratings (65%) in the sitting condition. This study provides initial evidence for the potential of visual stimulation as a means to enhance alpha activity in patients with chronic musculoskeletal pain. The brief period of stimulation was insufficient to reduce chronic pain significantly. This study is the first to provide evidence that a brief period of visual stimulation at alpha frequency can significantly increase alpha power in patients with chronic musculoskeletal pain. A further larger study is warranted to investigate optimal dose and individual stimulation parameters to achieve pain relief in these patients.
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Affiliation(s)
- Laura J. Arendsen
- Division of Functional and Restorative Neurosurgery, Eberhart Karls University of Tübingen, Tübingen, Germany
| | - James Henshaw
- Human Pain Research Group, Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, United Kingdom
| | - Christopher A. Brown
- Human Pain Research Group, Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, United Kingdom
- Department of Psychological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Manoj Sivan
- Human Pain Research Group, Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, United Kingdom
- Leeds Institute of Rheumatology and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Jason R. Taylor
- Human Pain Research Group, Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, United Kingdom
| | - Nelson J. Trujillo-Barreto
- Human Pain Research Group, Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, United Kingdom
| | - Alexander J. Casson
- Department of Electrical and Electronic Engineering, University of Manchester, Manchester, United Kingdom
| | - Anthony K. P. Jones
- Human Pain Research Group, Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, United Kingdom
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Alwardat M, Pisani A, Etoom M, Carpenedo R, Chinè E, Dauri M, Leonardis F, Natoli S. Is transcranial direct current stimulation (tDCS) effective for chronic low back pain? A systematic review and meta-analysis. J Neural Transm (Vienna) 2020; 127:1257-1270. [DOI: 10.1007/s00702-020-02223-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/28/2020] [Indexed: 12/11/2022]
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The Analgesic Effect of Transcranial Direct Current Stimulation (tDCS) combined with Physical Therapy on Common Musculoskeletal Conditions: A Systematic Review and Meta-Analysis. ACTA ACUST UNITED AC 2020; 6:23-26. [PMID: 32766451 DOI: 10.21801/ppcrj.2020.61.5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The analgesic effects of transcranial Direct Current Stimulation (tDCS) combined with physical therapy remain unclear. OBJECTIVE To systematically review available evidence comparing tDCS with any physical therapy modality (PTM) to PTM alone or PTM with sham tDCS on pain relief on common musculoskeletal (MSK) conditions, namely knee osteoarthritis (KOA), chronic low back pain (CLBP), myofascial pain syndrome (MPS) and fibromyalgia. METHODS EMBASE and MEDLINE were searched from inception to April 2019 for randomized controlled trials. Reviewers independently assessed the studies quality and extracted data according to the PRISMA protocol. The GRADE approach was used to asses quality of evidence and a "Summary of Findings" table was created. The analyses used random-effects model. The primary outcome was pain reduction after treatment. RESULTS Eight articles were included. Only one study had low risk of bias. Quality of evidence was considered low or very low. Significant reduction in pain scores were found for fibromyalgia and KOA (Standardized mean difference (SMD) = -1.94 [95% CI: -3.37 to -0.49; I 2=76.4%] and SMD = -2.35 [95% CI: -3.63 to -1.06; I 2=69.7%] respectively). Subgroup analysis considering the type of PTM despite MSK condition revealed significant reduction in pain scores for exercise, SMD = -1.20 [95% CI: -1.683 to -0.717; I 2=10.8%]. CONCLUSIONS Large heterogeneity and low quality of evidence and limited number of studies were found. Results suggest a potential analgesic effect of tDCS in combination with a PTM for fibromyalgia and KOA. Subgroup analysis suggests a stronger effect of tDCS when combined with an exercise based PTM.
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Meeker TJ, Jupudi R, Lenz FA, Greenspan JD. New Developments in Non-invasive Brain Stimulation in Chronic Pain. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020; 8:280-292. [PMID: 33473332 DOI: 10.1007/s40141-020-00260-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose of Review The goal of this review is to present a summary of the recent literature of a non-invasive brain stimulation (NIBS) to alleviate pain in people with chronic pain syndromes. This article reviews the current evidence for the use of transcranial direct current (tDCS) and repetitive transcranial magnetic stimulation (rTMS) to improve outcomes in chronic pain. Finally, we introduce the reader to novel stimulation methods that may improve therapeutic outcomes in chronic pain. Recent Findings While tDCS is approved for treatment of fibromyalgia in Canada and the European Union, no NIBS method is currently approved for chronic pain in the United States. Increasing sample sizes in randomized clinical trials (RCTs) seems the most efficient way to increase confidence in initial promising results. Trends at funding agencies reveal increased interest and support for NIBS such as recent Requests for Application from the National Institutes of Health. NIBS in conjunction with cognitive behavioral therapy and physical therapy may enhance outcomes in chronic pain. Novel stimulation methods, such as transcranial ultrasound stimulation, await rigorous study in chronic pain.
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Affiliation(s)
- Timothy J Meeker
- Dept. of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.,Dept. of Neural and Pain Sciences, School of Dentistry, and Center to Advance Chronic Pain Research, Univ. of Maryland Baltimore, Baltimore, MD, USA
| | - Rithvic Jupudi
- Dept. of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Frederik A Lenz
- Dept. of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Joel D Greenspan
- Dept. of Neural and Pain Sciences, School of Dentistry, and Center to Advance Chronic Pain Research, Univ. of Maryland Baltimore, Baltimore, MD, USA
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Houde F, Harvey MP, Tremblay Labrecque PF, Lamarche F, Lefebvre A, Leonard G. Combining Transcranial Direct Current Stimulation and Transcutaneous Electrical Nerve Stimulation to Relieve Persistent Pain in a Patient Suffering from Complex Regional Pain Syndrome: A Case Report. J Pain Res 2020; 13:467-473. [PMID: 32184651 PMCID: PMC7060070 DOI: 10.2147/jpr.s226616] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 12/24/2019] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Complex regional pain syndrome (CRPS) is a rare neuropathic pain condition characterized by sensory, motor and autonomic alterations. Previous investigations have shown that transcranial direct current stimulation (tDCS) and transcutaneous electrical nerve stimulation (TENS) can alleviate pain in various populations, and that a combination of these treatments could provide greater hypoalgesic effects. In the present case report, we describe the effect of tDCS and TENS treatment on pain intensity and unpleasantness in a patient suffering from chronic CRPS. RESULTS The patient was a 37-year-old woman, suffering from left lower limb CRPS (type I) for more than 5 years. Despite medication (pregabalin, tapentadol, duloxetine), rehabilitation treatments (sensorimotor retraining, graded motor imagery) and spinal cord stimulation (SCS), the participant reported moderate to severe pain. Treatments of tDCS alone (performed with SCS turned off during tDCS application, 1 session/day, for 5 consecutive days) did not significantly decrease pain. Combining tDCS with TENS (SCS temporarily turned off during tDCS, 1 session/day, for 5 consecutive days) slightly reduced pain intensity and unpleasantness. DISCUSSION Our results suggest that combining tDCS and TENS could be a therapeutic strategy worth investigating further to relieve pain in chronic CRPS patients. Future studies should examine the efficacy of combined tDCS and TENS treatments in CRPS patients, and other chronic pain conditions, with special attention to the cumulative and long-term effects and its effect on function and quality of life.
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Affiliation(s)
- Francis Houde
- Research Center on Aging, CIUSSS de l'Estrie - CHUS, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Research Center of the Centre hospitalier universitaire de Sherbrooke (CHUS), CIUSSS de l'Estrie - CHUS, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Québec, Canada
| | - Marie-Philippe Harvey
- Research Center on Aging, CIUSSS de l'Estrie - CHUS, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Québec, Canada
| | - Pierre-François Tremblay Labrecque
- Research Center on Aging, CIUSSS de l'Estrie - CHUS, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Québec, Canada
| | - Francis Lamarche
- Research Center on Aging, CIUSSS de l'Estrie - CHUS, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Québec, Canada
| | - Alexandra Lefebvre
- Research Center on Aging, CIUSSS de l'Estrie - CHUS, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Québec, Canada
| | - Guillaume Leonard
- Research Center on Aging, CIUSSS de l'Estrie - CHUS, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Québec, Canada
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Morya E, Monte-Silva K, Bikson M, Esmaeilpour Z, Biazoli CE, Fonseca A, Bocci T, Farzan F, Chatterjee R, Hausdorff JM, da Silva Machado DG, Brunoni AR, Mezger E, Moscaleski LA, Pegado R, Sato JR, Caetano MS, Sá KN, Tanaka C, Li LM, Baptista AF, Okano AH. Beyond the target area: an integrative view of tDCS-induced motor cortex modulation in patients and athletes. J Neuroeng Rehabil 2019; 16:141. [PMID: 31730494 PMCID: PMC6858746 DOI: 10.1186/s12984-019-0581-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 08/19/2019] [Indexed: 02/07/2023] Open
Abstract
Transcranial Direct Current Stimulation (tDCS) is a non-invasive technique used to modulate neural tissue. Neuromodulation apparently improves cognitive functions in several neurologic diseases treatment and sports performance. In this study, we present a comprehensive, integrative review of tDCS for motor rehabilitation and motor learning in healthy individuals, athletes and multiple neurologic and neuropsychiatric conditions. We also report on neuromodulation mechanisms, main applications, current knowledge including areas such as language, embodied cognition, functional and social aspects, and future directions. We present the use and perspectives of new developments in tDCS technology, namely high-definition tDCS (HD-tDCS) which promises to overcome one of the main tDCS limitation (i.e., low focality) and its application for neurological disease, pain relief, and motor learning/rehabilitation. Finally, we provided information regarding the Transcutaneous Spinal Direct Current Stimulation (tsDCS) in clinical applications, Cerebellar tDCS (ctDCS) and its influence on motor learning, and TMS combined with electroencephalography (EEG) as a tool to evaluate tDCS effects on brain function.
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Affiliation(s)
- Edgard Morya
- Edmond and Lily Safra International Institute of Neuroscience, Santos Dumont Institute, Macaíba, Rio Grande do Norte Brazil
- Brazilian Institute of Neuroscience and Neurotechnology (BRAINN/CEPID-FAPESP), University of Campinas, Campinas, São Paulo, Brazil
| | - Kátia Monte-Silva
- Universidade Federal de Pernambuco, Recife, Pernambuco Brazil
- Núcleo de Assistência e Pesquisa em Neuromodulação (NAPeN), Universidade Federal do ABC (UFABC)/Universidade de São Paulo (USP)/Universidade Cidade de São Paulo (UNICID)/Universidade Federal de Pernambuco (UFPE), Escola Bahiana de Medicina e Saúde Pública (EBMSP), Santo André, Brazil
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York of CUNY, New York, NY USA
| | - Zeinab Esmaeilpour
- Department of Biomedical Engineering, The City College of New York of CUNY, New York, NY USA
| | - Claudinei Eduardo Biazoli
- Center of Mathematics, Computing and Cognition (CMCC), Universidade Federal do ABC (UFABC), Alameda da Universidade, 3 - Anchieta, Bloco Delta – Sala 257, São Bernardo do Campo, SP CEP 09606-070 Brazil
| | - Andre Fonseca
- Brazilian Institute of Neuroscience and Neurotechnology (BRAINN/CEPID-FAPESP), University of Campinas, Campinas, São Paulo, Brazil
- Center of Mathematics, Computing and Cognition (CMCC), Universidade Federal do ABC (UFABC), Alameda da Universidade, 3 - Anchieta, Bloco Delta – Sala 257, São Bernardo do Campo, SP CEP 09606-070 Brazil
| | - Tommaso Bocci
- Aldo Ravelli Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences, International Medical School, University of Milan, Milan, Italy
| | - Faranak Farzan
- School of Mechatronic Systems Engineering, Simon Fraser University, Surrey, British Columbia Canada
| | - Raaj Chatterjee
- School of Mechatronic Systems Engineering, Simon Fraser University, Surrey, British Columbia Canada
| | - Jeffrey M. Hausdorff
- Department of Physical Therapy, Sackler Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Eva Mezger
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Luciane Aparecida Moscaleski
- Brazilian Institute of Neuroscience and Neurotechnology (BRAINN/CEPID-FAPESP), University of Campinas, Campinas, São Paulo, Brazil
- Center of Mathematics, Computing and Cognition (CMCC), Universidade Federal do ABC (UFABC), Alameda da Universidade, 3 - Anchieta, Bloco Delta – Sala 257, São Bernardo do Campo, SP CEP 09606-070 Brazil
| | - Rodrigo Pegado
- Graduate Program in Rehabilitation Science, Universidade Federal do Rio Grande do Norte, Santa Cruz, Rio Grande do Norte Brazil
| | - João Ricardo Sato
- Center of Mathematics, Computing and Cognition (CMCC), Universidade Federal do ABC (UFABC), Alameda da Universidade, 3 - Anchieta, Bloco Delta – Sala 257, São Bernardo do Campo, SP CEP 09606-070 Brazil
| | - Marcelo Salvador Caetano
- Center of Mathematics, Computing and Cognition (CMCC), Universidade Federal do ABC (UFABC), Alameda da Universidade, 3 - Anchieta, Bloco Delta – Sala 257, São Bernardo do Campo, SP CEP 09606-070 Brazil
| | - Kátia Nunes Sá
- Núcleo de Assistência e Pesquisa em Neuromodulação (NAPeN), Universidade Federal do ABC (UFABC)/Universidade de São Paulo (USP)/Universidade Cidade de São Paulo (UNICID)/Universidade Federal de Pernambuco (UFPE), Escola Bahiana de Medicina e Saúde Pública (EBMSP), Santo André, Brazil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia Brazil
| | - Clarice Tanaka
- Núcleo de Assistência e Pesquisa em Neuromodulação (NAPeN), Universidade Federal do ABC (UFABC)/Universidade de São Paulo (USP)/Universidade Cidade de São Paulo (UNICID)/Universidade Federal de Pernambuco (UFPE), Escola Bahiana de Medicina e Saúde Pública (EBMSP), Santo André, Brazil
- Laboratório de Investigações Médicas-54, Universidade de São Paulo, São Paulo, São Paulo Brazil
| | - Li Min Li
- Brazilian Institute of Neuroscience and Neurotechnology (BRAINN/CEPID-FAPESP), University of Campinas, Campinas, São Paulo, Brazil
| | - Abrahão Fontes Baptista
- Brazilian Institute of Neuroscience and Neurotechnology (BRAINN/CEPID-FAPESP), University of Campinas, Campinas, São Paulo, Brazil
- Núcleo de Assistência e Pesquisa em Neuromodulação (NAPeN), Universidade Federal do ABC (UFABC)/Universidade de São Paulo (USP)/Universidade Cidade de São Paulo (UNICID)/Universidade Federal de Pernambuco (UFPE), Escola Bahiana de Medicina e Saúde Pública (EBMSP), Santo André, Brazil
- Center of Mathematics, Computing and Cognition (CMCC), Universidade Federal do ABC (UFABC), Alameda da Universidade, 3 - Anchieta, Bloco Delta – Sala 257, São Bernardo do Campo, SP CEP 09606-070 Brazil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia Brazil
- Laboratório de Investigações Médicas-54, Universidade de São Paulo, São Paulo, São Paulo Brazil
| | - Alexandre Hideki Okano
- Brazilian Institute of Neuroscience and Neurotechnology (BRAINN/CEPID-FAPESP), University of Campinas, Campinas, São Paulo, Brazil
- Núcleo de Assistência e Pesquisa em Neuromodulação (NAPeN), Universidade Federal do ABC (UFABC)/Universidade de São Paulo (USP)/Universidade Cidade de São Paulo (UNICID)/Universidade Federal de Pernambuco (UFPE), Escola Bahiana de Medicina e Saúde Pública (EBMSP), Santo André, Brazil
- Center of Mathematics, Computing and Cognition (CMCC), Universidade Federal do ABC (UFABC), Alameda da Universidade, 3 - Anchieta, Bloco Delta – Sala 257, São Bernardo do Campo, SP CEP 09606-070 Brazil
- Graduate Program in Physical Education. State University of Londrina, Londrina, Paraná, Brazil
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Castelo-Branco L, Uygur Kucukseymen E, Duarte D, El-Hagrassy MM, Bonin Pinto C, Gunduz ME, Cardenas-Rojas A, Pacheco-Barrios K, Yang Y, Gonzalez-Mego P, Estudillo-Guerra A, Candido-Santos L, Mesia-Toledo I, Rafferty H, Caumo W, Fregni F. Optimised transcranial direct current stimulation (tDCS) for fibromyalgia-targeting the endogenous pain control system: a randomised, double-blind, factorial clinical trial protocol. BMJ Open 2019; 9:e032710. [PMID: 31672712 PMCID: PMC6830717 DOI: 10.1136/bmjopen-2019-032710] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Fibromyalgia (FM) is a common debilitating condition with limited therapeutic options. Medications have low efficacy and are often associated with adverse effects. Given that FM is associated with a defective endogenous pain control system and central sensitisation, combining interventions such as transcranial direct current stimulation (tDCS) and aerobic exercise (AE) to modulate pain-processing circuits may enhance pain control. METHODS AND ANALYSIS A prospective, randomised (1:1:1:1), placebo-controlled, double-blind, factorial clinical trial will test the hypothesis that optimised tDCS (16 anodal tDCS sessions combined with AE) can restore of the pain endogenous control system. Participants with FM (n=148) will undergo a conditioning exercise period and be randomly allocated to one of four groups: (1) active tDCS and AE, (2) sham tDCS and AE, (3) active tDCS and non-aerobic exercise (nAE) or (4) sham tDCS and nAE. Pain inhibitory activity will be assessed using conditioned pain modulation (CPM) and temporal slow pain summation (TSPS)-primary outcomes. Secondary outcomes will include the following assessments: Transcranial magnetic stimulation and electroencephalography as cortical markers of pain inhibitory control and thalamocortical circuits; secondary clinical outcomes on pain, FM, quality of life, sleep and depression. Finally, the relationship between the two main mechanistic targets in this study-CPM and TSPS-and changes in secondary clinical outcomes will be tested. The change in the primary efficacy endpoint, CPM and TSPS, from baseline to week 4 of stimulation will be tested with a mixed linear model and adjusted for important demographic variables. ETHICS AND DISSEMINATION This study obeys the Declaration of Helsinki and was approved by the Institutional Review Board (IRB) of Partners Healthcare under the protocol number 2017P002524. Informed consent will be obtained from participants. Study findings will be reported in conferences and peer-reviewed journal publications. TRIAL REGISTRATION NUMBER NCT03371225.
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Affiliation(s)
- Luis Castelo-Branco
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elif Uygur Kucukseymen
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dante Duarte
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mirret M El-Hagrassy
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Camila Bonin Pinto
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Muhammed Enes Gunduz
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alejandra Cardenas-Rojas
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin Pacheco-Barrios
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yiling Yang
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paola Gonzalez-Mego
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anayali Estudillo-Guerra
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ludmilla Candido-Santos
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ines Mesia-Toledo
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Haley Rafferty
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wolnei Caumo
- Laboratory of Pain & Neuromodulation, Hospital de Clinicas de Porto Alegre da Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Felipe Fregni
- Neuromodulation Center/Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Elgueta-Cancino E, Massé-Alarie H, Schabrun SM, Hodges PW. Electrical Stimulation of Back Muscles Does Not Prime the Corticospinal Pathway. Neuromodulation 2019; 22:555-563. [PMID: 31232503 DOI: 10.1111/ner.12978] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 05/03/2019] [Accepted: 05/06/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To investigate whether peripheral electrical stimulation (PES) of back extensor muscles changes excitability of the corticospinal pathway of the stimulated muscle and synergist trunk muscles. METHODS In 12 volunteers with no history of low back pain (LBP), intramuscular fine-wire electrodes recorded electromyography (EMG) from the deep multifidus (DM) and longissimus muscles. Surface electrodes recorded general EMG from the erector spinae and abdominal muscles. Single- and paired-pulse transcranial magnetic stimulation (TMS) paradigms tested corticospinal excitability, short-interval intracortical inhibition (SICI-2 and 3 ms), and intracortical facilitation (ICF) optimized for recordings of DM. Active motor threshold (aMT) to evoke a motor-evoked potential (MEP) in DM was determined and stimulation was applied at 120% of this intensity. PES was provided via electrodes placed over the right multifidus. The effect of 20-min PES (ramped motor activation) was studied. RESULTS Mean aMT for DM was 42.7 ± 10% of the maximal stimulator output. No effects of PES were found on MEP amplitude (single-pulse TMS) for any trunk muscles examined. There was no evidence for changes in SICI or ICF; that is, conditioned MEP amplitude was not different between trials after PES. CONCLUSION Results indicate that, unlike previous reports that show increased corticospinal excitability of limb muscles, PES of back muscles does not modify the corticospinal excitability. This difference in response of the motor pathway of back muscles to PES might be explained by the lesser importance of voluntary cortical drive to these muscles and the greater role of postural networks. Whether PES influences back muscle training remains unclear, yet the present results suggest that potential effects are unlikely to be explained by the effects of PES at corticospinal level with the parameters used in this study.
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Affiliation(s)
- Edith Elgueta-Cancino
- Centre of Clinical Excellence Research in Spinal Pain Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Hugo Massé-Alarie
- Centre of Clinical Excellence Research in Spinal Pain Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Siobhan M Schabrun
- Brain Rehabilitation and Neuroplasticity Unit, School of Science and Health, Western Sydney University, Sydney, New South Wales, Australia
| | - Paul W Hodges
- Centre of Clinical Excellence Research in Spinal Pain Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
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Smith JS, Shaffrey CI, Ames CP, Lenke LG. Treatment of adult thoracolumbar spinal deformity: past, present, and future. J Neurosurg Spine 2019; 30:551-567. [PMID: 31042666 DOI: 10.3171/2019.1.spine181494] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 01/22/2019] [Indexed: 01/27/2023]
Abstract
Care of the patient with adult spinal deformity (ASD) has evolved from being primarily supportive to now having the ability to directly treat and correct the spinal pathology. The focus of this narrative literature review is to briefly summarize the history of ASD treatment, discuss the current state of the art of ASD care with focus on surgical treatment and current challenges, and conclude with a discussion of potential developments related to ASD surgery.In the past, care for ASD was primarily based on supportive measures, including braces and assistive devices, with few options for surgical treatments that were often deemed high risk and reserved for rare situations. Advances in anesthetic and critical care, surgical techniques, and instrumentation now enable almost routine surgery for many patients with ASD. Despite the advances, there are many remaining challenges currently impacting the care of ASD patients, including increasing numbers of elderly patients with greater comorbidities, high complication and reoperation rates, and high procedure cost without clearly demonstrated cost-effectiveness based on standard criteria. In addition, there remains considerable variability across multiple aspects of ASD surgery. For example, there is currently very limited ability to provide preoperative individualized counseling regarding optimal treatment approaches (e.g., operative vs nonoperative), complication risks with surgery, durability of surgery, and likelihood of achieving individualized patient goals and satisfaction. Despite the challenges associated with the current state-of-the-art ASD treatment, surgery continues to be a primary option, as multiple reports have demonstrated the potential for surgery to significantly improve pain and disability. The future of ASD care will likely include techniques and technologies to markedly reduce complication rates, including greater use of navigation and robotics, and a shift toward individualized medicine that enables improved counseling, preoperative planning, procedure safety, and patient satisfaction.Advances in the care of ASD patients have been remarkable over the past few decades. The current state of the art enables almost routine surgical treatment for many types of ASD that have the potential to significantly improve pain and disability. However, significant challenges remain, including high complication rates, lack of demonstrated cost-effectiveness, and limited ability to meaningfully counsel patients preoperatively on an individual basis. The future of ASD surgery will require continued improvement of predictability, safety, and sustainability.
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Affiliation(s)
- Justin S Smith
- 1Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Christopher I Shaffrey
- 2Departments of Neurosurgery and Orthopaedic Surgery, Duke Medical Center, Durham, North Carolina
| | - Christopher P Ames
- 3Department of Neurosurgery, University of California, San Francisco, California; and
| | - Lawrence G Lenke
- 4Department of Orthopaedic Surgery, Columbia University, New York, New York
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Latin American and Caribbean consensus on noninvasive central nervous system neuromodulation for chronic pain management (LAC 2-NIN-CP). Pain Rep 2019; 4:e692. [PMID: 30801041 PMCID: PMC6370142 DOI: 10.1097/pr9.0000000000000692] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 09/05/2018] [Indexed: 12/16/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Introduction: Chronic pain (CP) is highly prevalent and generally undertreated health condition. Noninvasive brain stimulation may contribute to decrease pain intensity and influence other aspects related to CP. Objective: To provide consensus-based recommendations for the use of noninvasive brain stimulation in clinical practice. Methods: Systematic review of the literature searching for randomized clinical trials followed by consensus panel. Recommendations also involved a cost-estimation study. Results: The systematic review wielded 24 transcranial direct current stimulation (tDCS) and 22 repetitive transcranial magnetic stimulation (rTMS) studies. The following recommendations were provided: (1) Level A for anodal tDCS over the primary motor cortex (M1) in fibromyalgia, and level B for peripheral neuropathic pain, abdominal pain, and migraine; bifrontal (F3/F4) tDCS and M1 high-definition (HD)-tDCS for fibromyalgia; Oz/Cz tDCS for migraine and for secondary benefits such as improvement in quality of life, decrease in anxiety, and increase in pressure pain threshold; (2) level A recommendation for high-frequency (HF) rTMS over M1 for fibromyalgia and neuropathic pain, and level B for myofascial or musculoskeletal pain, complex regional pain syndrome, and migraine; (3) level A recommendation against the use of anodal M1 tDCS for low back pain; and (4) level B recommendation against the use of HF rTMS over the left dorsolateral prefrontal cortex in the control of pain. Conclusion: Transcranial DCS and rTMS are recommended techniques to be used in the control of CP conditions, with low to moderate analgesic effects, and no severe adverse events. These recommendations are based on a systematic review of the literature and a consensus made by experts in the field. Readers should use it as part of the resources available to decision-making.
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da Graca-Tarragó M, Lech M, Angoleri LDM, Santos DS, Deitos A, Brietzke AP, Torres IL, Fregni F, Caumo W. Intramuscular electrical stimulus potentiates motor cortex modulation effects on pain and descending inhibitory systems in knee osteoarthritis: a randomized, factorial, sham-controlled study. J Pain Res 2019; 12:209-221. [PMID: 30655690 PMCID: PMC6322702 DOI: 10.2147/jpr.s181019] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Neuroplastic changes in nociceptive pathways contribute to severity of symptoms in knee osteoarthritis (KOA). A new look at neuroplastic changes management includes modulation of the primary motor cortex by transcranial direct current stimulation (tDCS). Objectives We investigated whether tDCS combined with intramuscular electrical stimulation (EIMS) would be more efficacious than a sham (s) intervention (s-tDCS/s-EIMS) or a single active(a)-tDCS/s-EIMS intervention and/or s-tDCS/a-EIMS in the following domains: pain measures (visual analog scale [VAS] score and descending pain modulatory system [DPMS], and outcomes, and analgesic use, disability, and pain pressure threshold (PPT) for secondary outcomes. Registration The trial is registered in Clinicaltrials.gov: NCT01747070. Methods Sixty women with KOA, aged 50–75 years old, randomly received five sessions of one of the four interventions (a-tDCS/a-EIMS, s-tDCS/s-EIMS, a-tDCS/s-EIMS, and s-tDCS/a-EIMS). tDCS was applied over the primary motor cortex (M1), for 30 minutes at 2 mA and the EIMS paraspinal of L1–S2. Results A generalized estimating equation model revealed the main effect of the a-tDCS/a-EIMS in the VAS pain scores at end treatment compared with the other three groups (P<0.0001). There existed a significant effect of time and a significant interaction between group and time (P<0.01 for both). The delta-(Δ) pain score on VAS in the a-tDCS/a-EIMS group was −3.59, 95% CI: −4.10 to −2.63. The (Δ) pain scores on VAS in the other three groups were: a-tDCS/s-EIMS=−2.13, 95% CI: −2.48 to −1.64; s-tDCS/a-EIMS=−2.25, 95% CI: −2.59 to −1.68; s-tDCS/s-EIMS MR =–1.77, 95% CI: −2.08 to −1.38. The a-tDCS/a-EIMS led to better effect in DPMS, PPT, analgesic use, and disability related to pain. Conclusion This study provides additional evidence regarding additive clinical effects to improve pain measures and descending pain inhibitory controls when the neuromodulation of the primary motor cortex with tDCS is combined with a bottom-up modulation with EIMS in KOA. Also, it improved the ability to walk due to reduced pain and reduced analgesic use.
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Affiliation(s)
- Maria da Graca-Tarragó
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, .,Laboratory of Pain and Neuromodulation, HCPA, Porto Alegre, Brazil,
| | - Mateus Lech
- Laboratory of Pain and Neuromodulation, HCPA, Porto Alegre, Brazil,
| | | | | | - Alícia Deitos
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, .,Laboratory of Pain and Neuromodulation, HCPA, Porto Alegre, Brazil,
| | - Aline Patrícia Brietzke
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, .,Laboratory of Pain and Neuromodulation, HCPA, Porto Alegre, Brazil,
| | - Iraci Ls Torres
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, .,Pharmacology Department, 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, USA
| | - Wolnei Caumo
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, .,Laboratory of Pain and Neuromodulation, HCPA, Porto Alegre, Brazil, .,Surgery Department, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, .,Pain and Palliative Care Service, HCPA, Porto Alegre, Brazil,
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Hughes S, Grimsey S, Strutton PH. Primary Motor Cortex Transcranial Direct Current Stimulation Modulates Temporal Summation of the Nociceptive Withdrawal Reflex in Healthy Subjects. PAIN MEDICINE 2018; 20:1156-1165. [DOI: 10.1093/pm/pny200] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Sam Hughes
- The Nick Davey Laboratory, Faculty of Medicine, Imperial College London, London, UK
| | - Sybil Grimsey
- The Nick Davey Laboratory, Faculty of Medicine, Imperial College London, London, UK
| | - Paul H Strutton
- The Nick Davey Laboratory, Faculty of Medicine, Imperial College London, London, UK
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Duarte D, Castelo-Branco LEC, Uygur Kucukseymen E, Fregni F. Developing an optimized strategy with transcranial direct current stimulation to enhance the endogenous pain control system in fibromyalgia. Expert Rev Med Devices 2018; 15:863-873. [PMID: 30501532 PMCID: PMC6644718 DOI: 10.1080/17434440.2018.1551129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/19/2018] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Fibromyalgia affects more than 5 million people in the United States and has a detrimental impact on individuals' quality of life. Current pharmacological treatments provide limited benefits to relieve the pain of fibromyalgia, along with a risk of adverse effects; a scenario that explains the increasing interest for multimodal approaches. A tailored strategy to focus on this dysfunctional endogenous pain inhibitory system is transcranial direct current stimulation (tDCS) of the primary motor cortex. By combining tDCS with aerobic exercise, the effects can be optimized. Areas covered: The relevant literature was reviewed and discussed the methodological issues for designing a mechanistic clinical trial to test this combined intervention. Also, we reviewed the neural control of different pathways that integrate the endogenous pain inhibitory system, as well as the effects of tDCS and aerobic exercise both alone and combined. In addition, potential neurophysiological assessments are addressed: conditioned pain modulation, temporal slow pain summation, transcranial magnetic stimulation, and electroencephalography in the context of fibromyalgia. Expert commentary: By understanding the neural mechanisms underlying pain processing and potential optimized interventions in fibromyalgia with higher accuracy, the field has an evident potential of advancement in the direction of new neuromarkers and tailored therapies.
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Affiliation(s)
- Dante Duarte
- a Laboratory of Neuromodulation & Center for Clinical Research Learning, Department of Physical Medicine and Rehabilitation , Spaulding Rehabilitation Hospital, Harvard Medical School , Boston , MA , USA
| | - Luis Eduardo Coutinho Castelo-Branco
- a Laboratory of Neuromodulation & Center for Clinical Research Learning, Department of Physical Medicine and Rehabilitation , Spaulding Rehabilitation Hospital, Harvard Medical School , Boston , MA , USA
| | - Elif Uygur Kucukseymen
- a Laboratory of Neuromodulation & Center for Clinical Research Learning, Department of Physical Medicine and Rehabilitation , Spaulding Rehabilitation Hospital, Harvard Medical School , Boston , MA , USA
| | - Felipe Fregni
- a Laboratory of Neuromodulation & Center for Clinical Research Learning, Department of Physical Medicine and Rehabilitation , Spaulding Rehabilitation Hospital, Harvard Medical School , Boston , MA , USA
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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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Sun R, Hong X, Guo J, Yin S, Feng P, Lan L, Lei D, Liu X, Suo X, Yin T, Zhang T, Huang L, Gao F, Gong Q, Liang F, Zeng F. The central mechanism of acupuncture treatment with a long-lasting effect for functional dyspepsia: study protocol for a randomized controlled trial. Trials 2018; 19:373. [PMID: 30001732 PMCID: PMC6043952 DOI: 10.1186/s13063-018-2742-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 06/13/2018] [Indexed: 02/05/2023] Open
Abstract
Background The mechanism of the long-lasting effect and the relationship between the long-lasting effect and the deqi sensation, which is the key of achieving the acupuncture effect, has not been well investigated. This trial focuses on investigating the possible central mechanism of the long-lasting effect influenced by the deqi sensation. Methods A randomized controlled functional brain imaging trial is currently being conducted in Sichuan, China. In total 105 functional dyspepsia (FD) patients will be allocated into three groups: an acupuncture with deqi group, an acupuncture without deqi group, and a wait-list group. This trial will include a 2-week baseline period, a 4-week treatment period, and a 4-week follow-up period. During the 4-week treatment, patients in two acupuncture groups will receive 20 sessions of acupuncture treatment with or without deqi. The Nepean Dyspepsia Index (NDI) and the short form Leeds Dyspepsia Questionnaire (SF-LDQ) will be used to evaluate the clinical efficacy of acupuncture treatment at baseline, the end of treatment, and the end of the follow-up. Functional magnetic resonance imaging (fMRI) scans will be performed to detect cerebral functional changes in 25 patients in each group at three time points mentioned above. The clinical data and fMRI data will be analyzed, respectively. Correlation analysis will be conducted to investigate the relationship between cerebral functional changes and symptom improvement. Discussion The results of this trial will allow us to compare the changes of acupuncture therapeutic effect at three time points (the baseline vs. the end of treatment vs. the end of follow-up), and investigate the potential central mechanism of the long-lasting effect influenced by acupuncture with deqi. This trial aims to re-identify the long-lasting effect of acupuncture and investigate its central mechanism, and to further explore the central influence of deqi sensation on the long-lasting effect. Trial registration Chinese Clinical Trial Registry, IDF: ChiCTR-IOR-15006523. Registered on 5 June 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2742-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ruirui Sun
- Acupuncture and Tuina School/The 3rd Teaching Hospital, Chengdu University of Traditional Chinese Medicine, 37# Shierqiao Road, Chengdu, 610075, Sichuan, China
| | - Xiaojuan Hong
- Acupuncture and Tuina School/The 3rd Teaching Hospital, Chengdu University of Traditional Chinese Medicine, 37# Shierqiao Road, Chengdu, 610075, Sichuan, China
| | - Jing Guo
- Acupuncture and Tuina School/The 3rd Teaching Hospital, Chengdu University of Traditional Chinese Medicine, 37# Shierqiao Road, Chengdu, 610075, Sichuan, China
| | - Shuai Yin
- First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, Henan Province, China
| | - Peiming Feng
- The 1st Teaching Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Lei Lan
- Acupuncture and Tuina School/The 3rd Teaching Hospital, Chengdu University of Traditional Chinese Medicine, 37# Shierqiao Road, Chengdu, 610075, Sichuan, China
| | - Du Lei
- Huaxi MR Research Center (HMRRC), Departments of Radiology, West China Hospital of Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Xiaoyan Liu
- Acupuncture and Tuina School/The 3rd Teaching Hospital, Chengdu University of Traditional Chinese Medicine, 37# Shierqiao Road, Chengdu, 610075, Sichuan, China
| | - Xueling Suo
- Huaxi MR Research Center (HMRRC), Departments of Radiology, West China Hospital of Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Tao Yin
- Acupuncture and Tuina School/The 3rd Teaching Hospital, Chengdu University of Traditional Chinese Medicine, 37# Shierqiao Road, Chengdu, 610075, Sichuan, China
| | - Tingting Zhang
- Acupuncture and Tuina School/The 3rd Teaching Hospital, Chengdu University of Traditional Chinese Medicine, 37# Shierqiao Road, Chengdu, 610075, Sichuan, China
| | - Liuyang Huang
- Acupuncture and Tuina School/The 3rd Teaching Hospital, Chengdu University of Traditional Chinese Medicine, 37# Shierqiao Road, Chengdu, 610075, Sichuan, China
| | - Feifei Gao
- Acupuncture and Tuina School/The 3rd Teaching Hospital, Chengdu University of Traditional Chinese Medicine, 37# Shierqiao Road, Chengdu, 610075, Sichuan, China
| | - Qiyong Gong
- Huaxi MR Research Center (HMRRC), Departments of Radiology, West China Hospital of Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
| | - Fanrong Liang
- Acupuncture and Tuina School/The 3rd Teaching Hospital, Chengdu University of Traditional Chinese Medicine, 37# Shierqiao Road, Chengdu, 610075, Sichuan, China.
| | - Fang Zeng
- Acupuncture and Tuina School/The 3rd Teaching Hospital, Chengdu University of Traditional Chinese Medicine, 37# Shierqiao Road, Chengdu, 610075, Sichuan, China.
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Anodal Transcranial Direct-Current Stimulation to Enhance Rehabilitation in Individuals With Rotator Cuff Tendinopathy: A Triple-Blind Randomized Controlled Trial. J Orthop Sports Phys Ther 2018; 48:541-551. [PMID: 29747540 DOI: 10.2519/jospt.2018.7871] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Anodal transcranial direct-current stimulation (a-tDCS) has been shown to enhance the effects of sensorimotor training in neurological populations. Sensorimotor training leads to reduced pain and increased function in the treatment of rotator cuff tendinopathy. The addition of a-tDCS during a rehabilitation program centered on sensorimotor training may improve treatment outcomes in individuals with rotator cuff tendinopathy. Objective To compare 2 groups of individuals with rotator cuff tendinopathy, one receiving a rehabilitation program centered on sensorimotor training with a-tDCS and the other receiving the same rehabilitation program with sham a-tDCS. Methods In this triple-blind, parallel-group randomized controlled trial, 40 adults with rotator cuff tendinopathy participated in a 6-week rehabilitation program (8 treatments with home exercises and including sensorimotor training, patient education, and strengthening). They were randomly assigned to 1 of 2 groups to receive either real a-tDCS (stimulation, 1.5 mA for 30 minutes) or sham a-tDCS during the first 5 treatments. Symptoms and functional limitations (Disabilities of the Arm, Shoulder and Hand questionnaire, Western Ontario Rotator Cuff index) of all participants were evaluated at baseline and at 3, 6, and 12 weeks. Acromiohumeral distances (ultrasonographic measurement at 0°, 45°, and 60° of arm elevation) were assessed at baseline and 6 weeks. Two-way or 3-way repeated-measures analyses of variance were used for statistical analyses. Results Both groups showed statistically significant improvement in Disabilities of the Arm, Shoulder and Hand questionnaire and Western Ontario Rotator Cuff index scores at 3, 6, and 12 weeks, and in acromiohumeral distance at 45° and 60° at 6 weeks (P<.05). No significant group-by-time interaction was observed for all outcomes (P>.43). Conclusion Results do not demonstrate any improved treatment outcomes from the addition of a-tDCS during a rehabilitation program for individuals with rotator cuff tendinopathy. Level of Evidence Therapy, level 1b. J Orthop Sports Phys Ther 2018;48(7):541-551. Epub 10 May 2018. doi:10.2519/jospt.2018.7871.
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Hughes SW, Ali M, Sharma P, Insan N, Strutton PH. Frequency-dependent top-down modulation of temporal summation by anodal transcranial direct-current stimulation of the primary motor cortex in healthy adults. Eur J Pain 2018; 22:1494-1501. [PMID: 29704875 DOI: 10.1002/ejp.1238] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2018] [Indexed: 02/28/2024]
Abstract
BACKGROUND Transcranial direct-current stimulation (tDCS) applied over the primary motor cortex has been shown to be effective in the treatment of a number of chronic pain conditions. However, there is a lack of understanding of the top-down analgesic mechanisms involved. METHOD In this study, we investigated the effects of tDCS on the facilitation of subjective sensory and pain scores using a transcutaneous electrically evoked measure of temporal summation. In this randomized, blinded, cross-over study healthy subjects received a single stimulus given at 0.9× pain threshold (pTh) over the L5 dermatome on the lateral aspect of the right leg, followed by a train of 5 stimuli given at 0.5, 1, 5 and 20 Hz before and after 20 min of sham or anodal tDCS (2 mA) applied over the primary motor cortex. Ratings of sensation and pain intensity were scored on a visual analogue scale (VAS). RESULTS Temporal summation leading to pain only occurred at higher frequencies (5 and 20 Hz). Sham or real tDCS had no effect over temporal summation evoked at 5 Hz; however, there was a significant analgesic effect at 20 Hz. Sham or real tDCS had no effect over acute, single stimuli-evoked responses. CONCLUSION These results indicate that anodal tDCS applied to the primary motor cortex preferentially modulates temporal summation induced by high-frequency electrical stimulation-induced pain. The inhibitory effects of tDCS appear to be dynamic and dependent on the degree of spinal cord excitability and may explain the higher analgesic efficacy in patients with moderate to severe chronic pain symptoms. SIGNIFICANCE The analgesic effects of tDCS are dependent on spinal cord excitability. This work provides insight into top-down modulation during acute pain and temporal summation. This knowledge may explain why tDCS has a higher analgesic efficacy in chronic pain patients.
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Affiliation(s)
- S W Hughes
- Faculty of Medicine, The Nick Davey Laboratory, Imperial College London, London, UK
| | - M Ali
- Faculty of Medicine, The Nick Davey Laboratory, Imperial College London, London, UK
| | - P Sharma
- Faculty of Medicine, The Nick Davey Laboratory, Imperial College London, London, UK
| | - N Insan
- Faculty of Medicine, The Nick Davey Laboratory, Imperial College London, London, UK
| | - P H Strutton
- Faculty of Medicine, The Nick Davey Laboratory, Imperial College London, London, UK
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Abstract
BACKGROUND This is an updated version of the original Cochrane Review published in 2010, Issue 9, and last updated in 2014, Issue 4. Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), transcranial direct current stimulation (tDCS), transcranial random noise stimulation (tRNS) and reduced impedance non-invasive cortical electrostimulation (RINCE). OBJECTIVES To evaluate the efficacy of non-invasive cortical stimulation techniques in the treatment of chronic pain. SEARCH METHODS For this update we searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, LILACS and clinical trials registers from July 2013 to October 2017. SELECTION CRITERIA Randomised and quasi-randomised studies of rTMS, CES, tDCS, RINCE and tRNS if they employed a sham stimulation control group, recruited patients over the age of 18 years with pain of three months' duration or more, and measured pain as an outcome. Outcomes of interest were pain intensity measured using visual analogue scales or numerical rating scales, disability, quality of life and adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and verified data. Where possible we entered data into meta-analyses, excluding studies judged as high risk of bias. We used the GRADE system to assess the quality of evidence for core comparisons, and created three 'Summary of findings' tables. MAIN RESULTS We included an additional 38 trials (involving 1225 randomised participants) in this update, making a total of 94 trials in the review (involving 2983 randomised participants). This update included a total of 42 rTMS studies, 11 CES, 36 tDCS, two RINCE and two tRNS. One study evaluated both rTMS and tDCS. We judged only four studies as low risk of bias across all key criteria. Using the GRADE criteria we judged the quality of evidence for each outcome, and for all comparisons as low or very low; in large part this was due to issues of blinding and of precision.rTMSMeta-analysis of rTMS studies versus sham for pain intensity at short-term follow-up (0 to < 1 week postintervention), (27 studies, involving 655 participants), demonstrated a small effect with heterogeneity (standardised mean difference (SMD) -0.22, 95% confidence interval (CI) -0.29 to -0.16, low-quality evidence). This equates to a 7% (95% CI 5% to 9%) reduction in pain, or a 0.40 (95% CI 0.53 to 0.32) point reduction on a 0 to 10 pain intensity scale, which does not meet the minimum clinically important difference threshold of 15% or greater. Pre-specified subgroup analyses did not find a difference between low-frequency stimulation (low-quality evidence) and rTMS applied to the prefrontal cortex compared to sham for reducing pain intensity at short-term follow-up (very low-quality evidence). High-frequency stimulation of the motor cortex in single-dose studies was associated with a small short-term reduction in pain intensity at short-term follow-up (low-quality evidence, pooled n = 249, SMD -0.38 95% CI -0.49 to -0.27). This equates to a 12% (95% CI 9% to 16%) reduction in pain, or a 0.77 (95% CI 0.55 to 0.99) point change on a 0 to 10 pain intensity scale, which does not achieve the minimum clinically important difference threshold of 15% or greater. The results from multiple-dose studies were heterogeneous and there was no evidence of an effect in this subgroup (very low-quality evidence). We did not find evidence that rTMS improved disability. Meta-analysis of studies of rTMS versus sham for quality of life (measured using the Fibromyalgia Impact Questionnaire (FIQ) at short-term follow-up demonstrated a positive effect (MD -10.80 95% CI -15.04 to -6.55, low-quality evidence).CESFor CES (five studies, 270 participants) we found no evidence of a difference between active stimulation and sham (SMD -0.24, 95% CI -0.48 to 0.01, low-quality evidence) for pain intensity. We found no evidence relating to the effectiveness of CES on disability. One study (36 participants) of CES versus sham for quality of life (measured using the FIQ) at short-term follow-up demonstrated a positive effect (MD -25.05 95% CI -37.82 to -12.28, very low-quality evidence).tDCSAnalysis of tDCS studies (27 studies, 747 participants) showed heterogeneity and a difference between active and sham stimulation (SMD -0.43 95% CI -0.63 to -0.22, very low-quality evidence) for pain intensity. This equates to a reduction of 0.82 (95% CI 0.42 to 1.2) points, or a percentage change of 17% (95% CI 9% to 25%) of the control group outcome. This point estimate meets our threshold for a minimum clinically important difference, though the lower confidence interval is substantially below that threshold. We found evidence of small study bias in the tDCS analyses. We did not find evidence that tDCS improved disability. Meta-analysis of studies of tDCS versus sham for quality of life (measured using different scales across studies) at short-term follow-up demonstrated a positive effect (SMD 0.66 95% CI 0.21 to 1.11, low-quality evidence).Adverse eventsAll forms of non-invasive brain stimulation and sham stimulation appear to be frequently associated with minor or transient side effects and there were two reported incidences of seizure, both related to the active rTMS intervention in the included studies. However many studies did not adequately report adverse events. AUTHORS' CONCLUSIONS There is very low-quality evidence that single doses of high-frequency rTMS of the motor cortex and tDCS may have short-term effects on chronic pain and quality of life but multiple sources of bias exist that may have influenced the observed effects. We did not find evidence that low-frequency rTMS, rTMS applied to the dorsolateral prefrontal cortex and CES are effective for reducing pain intensity in chronic pain. The broad conclusions of this review have not changed substantially for this update. There remains a need for substantially larger, rigorously designed studies, particularly of longer courses of stimulation. Future evidence may substantially impact upon the presented results.
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Affiliation(s)
- Neil E O'Connell
- Brunel University LondonHealth Economics Research Group, Institute of Environment, Health and Societies, Department of Clinical SciencesKingston LaneUxbridgeMiddlesexUKUB8 3PH
| | - Louise Marston
- University College LondonResearch Department of Primary Care & Population HealthRoyal Free Campus, Rowland HillLondonUKNW3 2PF
| | - Sally Spencer
- Edge Hill UniversityPostgraduate Medical InstituteSt Helens RoadOrmskirkLancashireUKL39 4QP
| | - Lorraine H DeSouza
- Brunel University LondonDepartment of Clinical Sciences/Health Ageing Research Group, Institute of Environment, Health and SocietiesKingston LaneUxbridgeMiddlesexUKUB8 3PH
| | - Benedict M Wand
- The University of Notre Dame Australia FremantleSchool of Physiotherapy19 Mouat Street (PO Box 1225)PerthWest AustraliaAustralia6959
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O'Connell NE, Marston L, Spencer S, DeSouza LH, Wand BM. Non-invasive brain stimulation techniques for chronic pain. Cochrane Database Syst Rev 2018; 3:CD008208. [PMID: 29547226 PMCID: PMC7039253 DOI: 10.1002/14651858.cd008208.pub4] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane Review published in 2010, Issue 9, and last updated in 2014, Issue 4. Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), transcranial direct current stimulation (tDCS), transcranial random noise stimulation (tRNS) and reduced impedance non-invasive cortical electrostimulation (RINCE). OBJECTIVES To evaluate the efficacy of non-invasive cortical stimulation techniques in the treatment of chronic pain. SEARCH METHODS For this update we searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, LILACS and clinical trials registers from July 2013 to October 2017. SELECTION CRITERIA Randomised and quasi-randomised studies of rTMS, CES, tDCS, RINCE and tRNS if they employed a sham stimulation control group, recruited patients over the age of 18 years with pain of three months' duration or more, and measured pain as an outcome. Outcomes of interest were pain intensity measured using visual analogue scales or numerical rating scales, disability, quality of life and adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and verified data. Where possible we entered data into meta-analyses, excluding studies judged as high risk of bias. We used the GRADE system to assess the quality of evidence for core comparisons, and created three 'Summary of findings' tables. MAIN RESULTS We included an additional 38 trials (involving 1225 randomised participants) in this update, making a total of 94 trials in the review (involving 2983 randomised participants). This update included a total of 42 rTMS studies, 11 CES, 36 tDCS, two RINCE and two tRNS. One study evaluated both rTMS and tDCS. We judged only four studies as low risk of bias across all key criteria. Using the GRADE criteria we judged the quality of evidence for each outcome, and for all comparisons as low or very low; in large part this was due to issues of blinding and of precision.rTMSMeta-analysis of rTMS studies versus sham for pain intensity at short-term follow-up (0 to < 1 week postintervention), (27 studies, involving 655 participants), demonstrated a small effect with heterogeneity (standardised mean difference (SMD) -0.22, 95% confidence interval (CI) -0.29 to -0.16, low-quality evidence). This equates to a 7% (95% CI 5% to 9%) reduction in pain, or a 0.40 (95% CI 0.53 to 0.32) point reduction on a 0 to 10 pain intensity scale, which does not meet the minimum clinically important difference threshold of 15% or greater. Pre-specified subgroup analyses did not find a difference between low-frequency stimulation (low-quality evidence) and rTMS applied to the prefrontal cortex compared to sham for reducing pain intensity at short-term follow-up (very low-quality evidence). High-frequency stimulation of the motor cortex in single-dose studies was associated with a small short-term reduction in pain intensity at short-term follow-up (low-quality evidence, pooled n = 249, SMD -0.38 95% CI -0.49 to -0.27). This equates to a 12% (95% CI 9% to 16%) reduction in pain, or a 0.77 (95% CI 0.55 to 0.99) point change on a 0 to 10 pain intensity scale, which does not achieve the minimum clinically important difference threshold of 15% or greater. The results from multiple-dose studies were heterogeneous and there was no evidence of an effect in this subgroup (very low-quality evidence). We did not find evidence that rTMS improved disability. Meta-analysis of studies of rTMS versus sham for quality of life (measured using the Fibromyalgia Impact Questionnaire (FIQ) at short-term follow-up demonstrated a positive effect (MD -10.80 95% CI -15.04 to -6.55, low-quality evidence).CESFor CES (five studies, 270 participants) we found no evidence of a difference between active stimulation and sham (SMD -0.24, 95% CI -0.48 to 0.01, low-quality evidence) for pain intensity. We found no evidence relating to the effectiveness of CES on disability. One study (36 participants) of CES versus sham for quality of life (measured using the FIQ) at short-term follow-up demonstrated a positive effect (MD -25.05 95% CI -37.82 to -12.28, very low-quality evidence).tDCSAnalysis of tDCS studies (27 studies, 747 participants) showed heterogeneity and a difference between active and sham stimulation (SMD -0.43 95% CI -0.63 to -0.22, very low-quality evidence) for pain intensity. This equates to a reduction of 0.82 (95% CI 0.42 to 1.2) points, or a percentage change of 17% (95% CI 9% to 25%) of the control group outcome. This point estimate meets our threshold for a minimum clinically important difference, though the lower confidence interval is substantially below that threshold. We found evidence of small study bias in the tDCS analyses. We did not find evidence that tDCS improved disability. Meta-analysis of studies of tDCS versus sham for quality of life (measured using different scales across studies) at short-term follow-up demonstrated a positive effect (SMD 0.66 95% CI 0.21 to 1.11, low-quality evidence).Adverse eventsAll forms of non-invasive brain stimulation and sham stimulation appear to be frequently associated with minor or transient side effects and there were two reported incidences of seizure, both related to the active rTMS intervention in the included studies. However many studies did not adequately report adverse events. AUTHORS' CONCLUSIONS There is very low-quality evidence that single doses of high-frequency rTMS of the motor cortex and tDCS may have short-term effects on chronic pain and quality of life but multiple sources of bias exist that may have influenced the observed effects. We did not find evidence that low-frequency rTMS, rTMS applied to the dorsolateral prefrontal cortex and CES are effective for reducing pain intensity in chronic pain. The broad conclusions of this review have not changed substantially for this update. There remains a need for substantially larger, rigorously designed studies, particularly of longer courses of stimulation. Future evidence may substantially impact upon the presented results.
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Affiliation(s)
- Neil E O'Connell
- Brunel UniversityDepartment of Clinical Sciences/Health Economics Research Group, Institute of Environment, Health and SocietiesKingston LaneUxbridgeUKUB8 3PH
| | - Louise Marston
- University College LondonResearch Department of Primary Care & Population HealthRoyal Free Campus, Rowland HillLondonUKNW3 2PF
| | - Sally Spencer
- Edge Hill UniversityPostgraduate Medical InstituteSt Helens RoadOrmskirkUKL39 4QP
| | - Lorraine H DeSouza
- Brunel University LondonDepartment of Clinical Sciences/Health Ageing Research Group, Institute of Environment, Health and SocietiesKingston LaneUxbridgeUKUB8 3PH
| | - Benedict M Wand
- The University of Notre Dame AustraliaSchool of Physiotherapy19 Mouat Street (PO Box 1225)FremantleAustralia6959
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Lopes TDS, Silva WDS, Ribeiro SB, Figueiredo CA, Campbell FQ, Daltro GDC, Valenzuela A, Montoya P, Lucena RDCS, Baptista AF. Does Transcranial Direct Current Stimulation Combined with Peripheral Electrical Stimulation Have an Additive Effect in the Control of Hip Joint Osteonecrosis Pain Associated with Sickle Cell Disease? A Protocol for a One-Session Double Blind, Block-Randomized Clinical Trial. Front Hum Neurosci 2017; 11:633. [PMID: 29326577 PMCID: PMC5742338 DOI: 10.3389/fnhum.2017.00633] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/11/2017] [Indexed: 12/29/2022] Open
Abstract
Chronic pain in Sickle Cell Disease (SCD) is probably related to maladaptive plasticity of brain areas involved in nociceptive processing. Transcranial Direct Current Stimulation (tDCS) and Peripheral Electrical Stimulation (PES) can modulate cortical excitability and help to control chronic pain. Studies have shown that combined use of tDCS and PES has additive effects. However, to date, no study investigated additive effects of these neuromodulatory techniques on chronic pain in patients with SCD. This protocol describes a study aiming to assess whether combined use of tDCS and PES more effectively alleviate pain in patients with SCD compared to single use of each technique. The study consists of a one-session double blind, block-randomized clinical trial (NCT02813629) in which 128 participants with SCD and femoral osteonecrosis will be enrolled. Stepwise procedures will occur on two independent days. On day 1, participants will be screened for eligibility criteria. On day 2, data collection will occur in four stages: sample characterization, baseline assessment, intervention, and post-intervention assessment. These procedures will last ~5 h. Participants will be divided into two groups according to homozygous for S allele (HbSS) (n = 64) and heterozygous for S and C alleles (HbSC) (n = 64) genotypes. Participants in each group will be randomly assigned, equally, to one of the following interventions: (1) active tDCS + active PES; (2) active tDCS + sham PES; (3) sham tDCS + active PES; and (4) sham tDCS + sham PES. Active tDCS intervention will consist of 20 min 2 mA anodic stimulation over the primary motor cortex contralateral to the most painful hip. Active PES intervention will consist of 30 min sensory electrical stimulation at 100 Hz over the most painful hip. The main study outcome will be pain intensity, measured by a Visual Analogue Scale. In addition, electroencephalographic power density, cortical maps of the gluteus maximus muscle elicited by Transcranial Magnetic Stimulation (TMS), serum levels of Brain-derived Neurotrophic Factor (BDNF), and Tumor Necrosis Factor (TNF) will be assessed as secondary outcomes. Data will be analyzed using ANOVA of repeated measures, controlling for confounding variables.
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Affiliation(s)
- Tiago da Silva Lopes
- Health and Functionality Study Group, Federal University of Bahia, Salvador, Brazil.,Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, Brazil
| | - Wellington Dos Santos Silva
- Health and Functionality Study Group, Federal University of Bahia, Salvador, Brazil.,Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, Brazil.,Health Section, Adventist Faculty of Bahia, Cachoeira, Brazil
| | - Sânzia B Ribeiro
- Health and Functionality Study Group, Federal University of Bahia, Salvador, Brazil.,Health Section, Adventist Faculty of Bahia, Cachoeira, Brazil
| | | | - Fernanda Q Campbell
- Health and Functionality Study Group, Federal University of Bahia, Salvador, Brazil
| | | | | | - Pedro Montoya
- Research Institute of Health Sciences (IUNICS), University of the Balearic Islands, Palma, Spain
| | - Rita de C S Lucena
- Health and Functionality Study Group, Federal University of Bahia, Salvador, Brazil.,Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, Brazil
| | - Abrahão F Baptista
- Health and Functionality Study Group, Federal University of Bahia, Salvador, Brazil.,Graduate Program in Medicine and Health, Federal University of Bahia, Salvador, Brazil.,Center for Mathematics, Computation and Cognition, Federal University of ABC, São Bernardo do Campo, Brazil
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Fitzgibbon BM, de Andrade DC, Schabrun SM. Combined cerebral and peripheral treatments for pain: A commentary on Hazime et al. Eur J Pain 2017; 21:1130-1131. [PMID: 28573676 DOI: 10.1002/ejp.1045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2017] [Indexed: 11/09/2022]
Affiliation(s)
- B M Fitzgibbon
- Monash Alfred Psychiatry Research Centre, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - D C de Andrade
- Pain Centre, Department of Neurology, University of São Paulo, Brazil
| | - S M Schabrun
- Brain Rehabilitation and Neuroplasticity Unit, School of Science and Health, Western Sydney University, Australia
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