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Lefaucheur JP, Moro E, Shirota Y, Ugawa Y, Grippe T, Chen R, Benninger DH, Jabbari B, Attaripour S, Hallett M, Paulus W. Clinical neurophysiology in the treatment of movement disorders: IFCN handbook chapter. Clin Neurophysiol 2024; 164:57-99. [PMID: 38852434 DOI: 10.1016/j.clinph.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 03/02/2024] [Accepted: 05/15/2024] [Indexed: 06/11/2024]
Abstract
In this review, different aspects of the use of clinical neurophysiology techniques for the treatment of movement disorders are addressed. First of all, these techniques can be used to guide neuromodulation techniques or to perform therapeutic neuromodulation as such. Neuromodulation includes invasive techniques based on the surgical implantation of electrodes and a pulse generator, such as deep brain stimulation (DBS) or spinal cord stimulation (SCS) on the one hand, and non-invasive techniques aimed at modulating or even lesioning neural structures by transcranial application. Movement disorders are one of the main areas of indication for the various neuromodulation techniques. This review focuses on the following techniques: DBS, repetitive transcranial magnetic stimulation (rTMS), low-intensity transcranial electrical stimulation, including transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS), and focused ultrasound (FUS), including high-intensity magnetic resonance-guided FUS (MRgFUS), and pulsed mode low-intensity transcranial FUS stimulation (TUS). The main clinical conditions in which neuromodulation has proven its efficacy are Parkinson's disease, dystonia, and essential tremor, mainly using DBS or MRgFUS. There is also some evidence for Tourette syndrome (DBS), Huntington's disease (DBS), cerebellar ataxia (tDCS), and axial signs (SCS) and depression (rTMS) in PD. The development of non-invasive transcranial neuromodulation techniques is limited by the short-term clinical impact of these techniques, especially rTMS, in the context of very chronic diseases. However, at-home use (tDCS) or current advances in the design of closed-loop stimulation (tACS) may open new perspectives for the application of these techniques in patients, favored by their easier use and lower rate of adverse effects compared to invasive or lesioning methods. Finally, this review summarizes the evidence for keeping the use of electromyography to optimize the identification of muscles to be treated with botulinum toxin injection, which is indicated and widely performed for the treatment of various movement disorders.
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Affiliation(s)
- Jean-Pascal Lefaucheur
- Clinical Neurophysiology Unit, Henri Mondor University Hospital, AP-HP, Créteil, France; EA 4391, ENT Team, Paris-Est Créteil University, Créteil, France.
| | - Elena Moro
- Grenoble Alpes University, Division of Neurology, CHU of Grenoble, Grenoble Institute of Neuroscience, Grenoble, France
| | - Yuichiro Shirota
- Department of Neurology, Division of Neuroscience, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshikazu Ugawa
- Department of Human Neurophysiology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Talyta Grippe
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Neuroscience Graduate Program, Federal University of Minas Gerais, Belo Horizonte, Brazil; Krembil Brain Institute, Toronto, Ontario, Canada
| | - Robert Chen
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Krembil Brain Institute, Toronto, Ontario, Canada
| | - David H Benninger
- Service of Neurology, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Bahman Jabbari
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Sanaz Attaripour
- Department of Neurology, University of California, Irvine, CA, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Walter Paulus
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
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Borutta MC, Koehn J, de Oliveira DS, Del Vecchio A, Engelhorn T, Schwab S, Buchfelder M, Kinfe TM. The Impact of Burst Motor Cortex Stimulation on Cardiovascular Autonomic Modulation in Chronic Pain: A Feasibility Study for a New Approach to Objectively Monitor Therapeutic Effects. Pain Ther 2023; 12:1235-1251. [PMID: 37532960 PMCID: PMC10444743 DOI: 10.1007/s40122-023-00541-x] [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: 05/25/2023] [Accepted: 07/07/2023] [Indexed: 08/04/2023] Open
Abstract
INTRODUCTION Chronic refractory pain of various origin occurs in 30-45% of pain patients, and a considerable proportion remains resistant to pharmacological and behavioral therapies, requiring adjunctive neurostimulation therapies. Chronic pain is known to stimulate sympathetic outflow, yet the impact of burst motor cortex stimulation (burstMCS) on objectifiable autonomic cardiovascular parameters in chronic pain remains largely unknown. METHODS In three patients with chronic pain (2 facial pain/1 post-stroke pain), we compared pain intensity using a visual analog scale (VAS 1-10) and parameters of autonomic cardiovascular modulation at supine rest, during parasympathetic challenge with six cycles per minute of metronomic deep breathing, and during sympathetic challenge (active standing) at baseline and after 4 months of burstMCS compared to age-/gender-matched healthy controls. RESULTS While two out of three patients were responsive after 4 months of adjunctive burstMCS (defined as pain reduction of > 30%), no differences were found in any of the three patients regarding the R-R intervals of adjacent QRS complexes (RRI, 642 vs. 676 ms) and blood pressure (BP, 139/88 vs. 141/90 mmHg). Under resting conditions, parameters of parasympathetic tone [normalized units of high-frequency oscillations of RRI (RRI-HFnu power) 0.24 vs. 0.38, root-mean-square differences of successive RRI (RRI-RMSSD) 7.7 vs. 14.7 ms], total autonomic cardiac modulation [RRI total power 129.3 vs. 406.2 ms2, standard deviation of RRI (RRI-SD) 11.6 vs. 18.5 ms, coefficient of variation of RRI (RRI-CV) 1.9 vs. 3.7%], and baroreceptor reflex sensitivity (BRS, 1.9 vs. 2.3 ms/mmHg) increased, and parameters of sympathetic tone [normalized units of low-frequency oscillations of RRI (RRI-LFnu power) 0.76 vs. 0.62] and sympatho-vagal balance [ratio of RR-LF to RRI-HF power (RRI-LF/HF ratio) 3.4 vs. 1.9] decreased after 4 months of burstMCS. Low-frequency oscillations of systolic blood pressure (SBP-LF power), a parameter of sympathetic cardiovascular modulation, increased slightly (17.6 vs. 20.4 mmHg2). During parasympathetic stimulation, the expiratory-inspiratory ratio (E/I ratio) increased slightly, while upon sympathetic stimulation, the ratio between the shortest RRI around the 15th heartbeat and the longest RRI around the 30th heartbeat after standing up (RRI 30/15 ratio) remained unchanged. CONCLUSION Four months of adjunctive burstMCS was associated with an increase in parameters reflecting both total and parasympathetic autonomic modulation and baroreceptor reflex sensitivity. In contrast, sympathetic tone declined in our three patients, suggesting stimulation-associated improvement not only in subjectively perceived VAS pain scores, but also in objectifiable parameters of autonomic cardiovascular modulation.
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Affiliation(s)
- Matthias C Borutta
- Department of Neurology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Julia Koehn
- Department of Neurology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Daniela Souza de Oliveira
- Department of Artificial Intelligence in Biomedical Engineering (AIBE), Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Alessandro Del Vecchio
- Department of Artificial Intelligence in Biomedical Engineering (AIBE), Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas M Kinfe
- Division of Functional Neurosurgery and Stereotaxy, Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Schwabach Anlage 6, 91054, Erlangen, Germany.
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Metzger CS, Hammond MB, Paz-Solis JF, Newton WJ, Thomson SJ, Pei Y, Jain R, Moffitt M, Annecchino L, Doan Q. A novel fast-acting sub-perception spinal cord stimulation therapy enables rapid onset of analgesia in patients with chronic pain. Expert Rev Med Devices 2021; 18:299-306. [PMID: 33656411 DOI: 10.1080/17434440.2021.1890580] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Treating chronic pain using sub-perception Spinal Cord Stimulation (SCS) does not elicit paresthesia but is associated with long analgesic 'wash-in' (i.e. duration until maximum pain relief) and prolonged assessment of therapy. We describe the attainment of clinically meaningful and rapid-onset analgesic outcomes using a novel sub-perception SCS approach.Methods: This observational case-series evaluated patients implanted with an SCS device for chronic pain, who underwent re-programming utilizing a new methodology in which paresthesia was used to guide sub-perception stimulation field targeting at specific parameters including charge-balanced symmetrical pulses at 90 Hz (termed Fast-Acting Sub-Perception Therapy, FAST). Pain scores (NRS) were collected as reported per standard-of-care from patient charts.Results: Mean overall pain score at baseline was 8.4 ± 0.2 (n = 41). After activation of FAST, a 7.1-point reduction in overall pain score was (1.3 ± 0.2, p < 0.0001) reported within 11.2 ± 1.9 minutes (n = 34). This decrease in pain score was sustained out to 3-month (1.6 ± 0.3, n = 26) and 6-month follow-up (1.7 ± 0.4, n = 18). At last follow up (mean = 223 ± 132 days), a pain score of 1.6 ± 0.3, n = 30 was determined.Conclusions: After FAST implementation, a profound analgesic response, requiring substantially less energy than conventional sub-perception methodologies, was observed. This rapid analgesic onset achieved with the novel FAST technique suggests the potential for an alternative mechanism of action(s) of sub-perception SCS.
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Affiliation(s)
| | | | - Jose F Paz-Solis
- Department of Neurosurgery , University Hospital La Paz, Madrid, Spain
| | | | - Simon J Thomson
- Pain Management and Neuromodulation (Basildon and Thurrock University Hospitals), NHS, Basildon, UK
| | - Yu Pei
- Division of Neuromodulation, Boston Scientific, Valencia, CA, USA
| | - Roshini Jain
- Division of Neuromodulation, Boston Scientific, Valencia, CA, USA
| | - Michael Moffitt
- Division of Neuromodulation, Boston Scientific, Valencia, CA, USA
| | - Luca Annecchino
- Division of Neuromodulation, Boston Scientific, Valencia, CA, USA
| | - Que Doan
- Division of Neuromodulation, Boston Scientific, Valencia, CA, USA
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Nüssel M, Hamperl M, Maslarova A, Chaudhry SR, Köhn J, Stadlbauer A, Buchfelder M, Kinfe T. Burst Motor Cortex Stimulation Evokes Sustained Suppression of Thalamic Stroke Pain: A Narrative Review and Single-Case Overview. Pain Ther 2020; 10:101-114. [PMID: 33325005 PMCID: PMC8119548 DOI: 10.1007/s40122-020-00221-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 11/16/2020] [Indexed: 02/07/2023] Open
Abstract
Chronic refractory central post-stroke pain (CPSP), one of the most disabling consequences of cerebral stroke, occurs in up to 10% of patients with CPSP. Because a considerable proportion of these patients with chronic pain remain resistant to pharmacological and behavioral therapies, adjunctive invasive and non-invasive brain stimulation therapies are needed. We performed a review of human studies applying burst and conventional motor cortex stimulation (burstMCS and cMCS, respectively) for chronic pain states, on the basis of data sources identified through searches of PubMed, MEDLINE/OVID, and SCOPUS, as well as manual searches of the bibliographies of known primary and review articles. Our aim was to review and discuss clinical data on the indications of burstMCS for various chronic pain states originating from central stroke (excluding trigeminal facial pain). In addition, we assessed the efficacy and safety of burst versus cMCS for central post-stroke pain with an extended follow-up of 5 years in a 60-year-old man. According to our review, uncontrolled observational human cohort studies and one RCT using cMCS waveforms have revealed a meaningful clinical response; however, these studies lacked placebo groups and extended observation periods. In our case report, we found that 3 months of adjunctive cMCS reduced pain levels [visual analog scale (VAS) pre: 9/10 versus VAS post 7/10], whereas the pain decreased further under burstMCS (VAS pre: 7/10 versus VAS post: 2/10); the study involved a follow-up of 5 years and the following parameters: burst rate 40 Hz (500 Hz), 1–1.75 mA, 1 ms, bipolar configuration. To date, only limited evidence exists for the efficacy and safety of burst motor cortex stimulation for the treatment of refractory chronic pain. BurstMCS resulted in significantly decreased post-stroke pain observed after 5 years of cMCS. The available literature suggests similar efficacy as that of conventional (tonic) motor cortex stimulation, although the results are preliminary. Mechanistically, the precise mechanism of action is not fully understood. However, burstMCS may interact with the nociceptive thalamic-cingulate and descending spinal pain networks. To determine the potential utility of this treatment, large-scale sham-controlled trials comparing cMCS and burstMCS are highly recommended.
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Affiliation(s)
- Martin Nüssel
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Melanie Hamperl
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Anna Maslarova
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Shafqat R Chaudhry
- College of Pharmaceutical Sciences, Shifa Tameer-E-Millat University, Islamabad, Pakistan
| | - Julia Köhn
- Department of Neurology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Andreas Stadlbauer
- Institute of Medical Radiology, University Clinic St. Pölten, Karl Landsteiner University of Health Sciences, St. Pölten, Austria
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Kinfe
- Division of Functional Neurosurgery and Stereotaxy, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany.
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De Ridder D, Vancamp T, Falowski SM, Vanneste S. All bursts are equal, but some are more equal (to burst firing): burstDR stimulation versus Boston burst stimulation. Expert Rev Med Devices 2020; 17:289-295. [PMID: 32129099 DOI: 10.1080/17434440.2020.1736560] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Since the introduction of burst spinal cord stimulation for neuropathic pain, several companies have developed their own version of burst stimulation, which is confusing the marketplace and clinicians of what burst stimulation truly is, the value and utilization of the therapy.Areas covered: We review those two burst stimulation designs and notice important differences. The original burstDRTM stimulation tries to mimic physiologic burst firing, which involves closely spaced high frequency sodium spikes nested on a calcium mediated plateau. This is realized by generating a train of 5 monophasic spikes of increasing amplitude with passive charge balance after the last spike, in contrast to the other burst designs which involve a version of cycling 4-5 spikes each being individually actively charge balanced spikes.Expert opinion: Based on the neurobiology of burst firing as well as abductive reasoning we like to clarify that burstDRTM is a true physiologic burst stimulation, and that other versions being called burst stimulation are essentially clustered tonic stimulation. This differentiating terminology will prevent confusion for healthcare providers, regulators, and the marketplace of what burst stimulation is.
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Affiliation(s)
- Dirk De Ridder
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Otago, New Zealand
| | | | | | - Sven Vanneste
- Global Brain Health Institute, Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland.,Lab for Clinical and Integrative Neuroscience, School for Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, TX, USA
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Russo M, Santarelli DM, Smith U. Cervical spinal cord stimulation for the treatment of essential tremor. BMJ Case Rep 2018; 2018:bcr-2018-224347. [PMID: 30068576 PMCID: PMC6078261 DOI: 10.1136/bcr-2018-224347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2018] [Indexed: 12/26/2022] Open
Abstract
A patient with refractory essential tremor of the hands and head/neck refused deep brain stimulation and requested consideration for spinal cord stimulation (SCS). Trial of a cervical SCS system using a basic tonic waveform produced positive outcomes in hand tremor, head-nodding and daily functioning. The patient proceeded to implant and received regular programming sessions. Outcomes were recorded at follow-ups (1, 3, 6, 12, 23 months postimplant) and included patient self-reported changes, clinical observations, handwriting assessments and The Essential Tremor Rating Assessment Scale scores. Trial of a paraesthesia-free burst waveform programme produced a small improvement in head-nodding, without uncomfortable paraesthesias. With continued programming, the patient reported further improvements to tremor and functionality, with minimal tremor remaining at 12-23 months. No major side effects were reported.
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Affiliation(s)
- Marc Russo
- Hunter Pain Clinic, Broadmeadow, New South Wales, Australia
| | | | - Ushtana Smith
- Boston Scientific Neuromodulation, Mascot, New South Wales, Australia
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