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Kaye AD, Plaisance TR, Smith SA, Ragland AR, Alfred MJ, Nguyen CG, Chami AA, Kataria S, Dufrene K, Shekoohi S, Robinson CL. Peripheral Nerve Stimulation in Postoperative Analgesia: A Narrative Review. Curr Pain Headache Rep 2024; 28:691-698. [PMID: 38642233 DOI: 10.1007/s11916-024-01257-z] [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] [Accepted: 04/08/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE OF REVIEW Recent research has shown the effectiveness of peripheral nerve stimulators (PNS) in managing chronic pain conditions. Ongoing studies aim to explore its potential application in treating acute postoperative pain states. The purpose of this systematic review is to assess the role of PNS in providing relief for postoperative pain. RECENT FINDINGS Clinical studies investigating the use of peripheral nerve stimulators (PNS) for analgesia following various surgeries, such as total knee arthroplasty, anterior cruciate ligament repair, ankle arthroplasty, rotator cuff repair, hallux valgus correction, and extremity amputation, have shown promising results. Lead placement locations include the brachial plexus, sciatic, femoral, tibial, genicular, perineal, sural, radial, median, and ulnar nerves. These studies consistently report clinically significant reductions in pain scores, and some even indicate a decrease in opioid consumption following PNS for postoperative pain. PNS involves the subcutaneous placement of electrode leads to target peripheral nerve(s) followed by delivery of an electric current via an external pulse generator. While the precise mechanism is not fully understood, the theory posits that PNS modulates electrical stimulation, hindering the signaling of nociceptive pain. PNS presents itself as an alternative to opioid therapy, holding promise to address the opioid epidemic by offering a nonpharmacologic approach for both acute and chronic pain states.
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Affiliation(s)
- Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
- Department of Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Taylor R Plaisance
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Summer A Smith
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Amanda R Ragland
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Michael J Alfred
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Catherine G Nguyen
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Azem A Chami
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Saurabh Kataria
- Department of Neurology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - Kylie Dufrene
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA.
| | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
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Goree JH, Grant SA, Dickerson DM, Ilfeld BM, Eshraghi Y, Vaid S, Valimahomed AK, Shah JR, Smith GL, Finneran JJ, Shah NN, Guirguis MN, Eckmann MS, Antony AB, Ohlendorf BJ, Gupta M, Gilbert JE, Wongsarnpigoon A, Boggs JW. Randomized Placebo-Controlled Trial of 60-Day Percutaneous Peripheral Nerve Stimulation Treatment Indicates Relief of Persistent Postoperative Pain, and Improved Function After Knee Replacement. Neuromodulation 2024; 27:847-861. [PMID: 38739062 DOI: 10.1016/j.neurom.2024.03.001] [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: 12/26/2023] [Revised: 02/22/2024] [Accepted: 03/06/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVES Total knee arthroplasty (TKA) is an effective surgery for end-stage knee osteoarthritis, but chronic postoperative pain and reduced function affect up to 20% of patients who undergo such surgery. There are limited treatment options, but percutaneous peripheral nerve stimulation (PNS) is a promising nonopioid treatment option for chronic, persistent postoperative pain. The objective of the present study was to evaluate the effect of a 60-day percutaneous PNS treatment in a multicenter, randomized, double-blind, placebo-controlled trial for treating persistent postoperative pain after TKA. MATERIALS AND METHODS Patients with postoperative pain after knee replacement were screened for this postmarket, institutional review board-approved, prospectively registered (NCT04341948) trial. Subjects were randomized to receive either active PNS or placebo (sham) stimulation. Subjects and a designated evaluator were blinded to group assignments. Subjects in both groups underwent ultrasound-guided placement of percutaneous fine-wire coiled leads targeting the femoral and sciatic nerves on the leg with postoperative pain. Leads were indwelling for eight weeks, and the primary efficacy outcome compared the proportion of subjects in each group reporting ≥50% reduction in average pain relative to baseline during weeks five to eight. Functional outcomes (6-minute walk test; 6MWT and Western Ontario and McMaster Universities Osteoarthritis Index) and quality of life (Patient Global Impression of Change) also were evaluated at end of treatment (EOT). RESULTS A greater proportion of subjects in the PNS groups (60%; 12/20) than in the placebo (sham) group (24%; 5/21) responded with ≥50% pain relief relative to baseline (p = 0.028) during the primary endpoint (weeks 5-8). Subjects in the PNS group also walked a significantly greater distance at EOT than did those in the placebo (sham) group (6MWT; +47% vs -9% change from baseline; p = 0.048, n = 18 vs n = 20 completed the test, respectively). Prospective follow-up to 12 months is ongoing. CONCLUSIONS This study provides evidence that percutaneous PNS decreases persistent pain, which leads to improved functional outcomes after TKA at EOT.
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Affiliation(s)
- Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Stuart A Grant
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David M Dickerson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL, USA; The University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Yashar Eshraghi
- Department of Anesthesiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Sandeep Vaid
- Better Health Clinical Research, Newnan, GA, USA
| | | | - Jarna R Shah
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - G Lawson Smith
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - John J Finneran
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Nirav N Shah
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL, USA; The University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Maged N Guirguis
- Department of Anesthesiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Maxim S Eckmann
- Department of Anesthesiology, University of Texas San Antonio, San Antonio, TX, USA
| | | | - Brian J Ohlendorf
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Mayank Gupta
- Neuroscience Research Center, Overland Park, KS, USA
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D'Souza RS, Barrington MJ, Sen A, Mascha EJ, Kelley GA. Systematic reviews and meta-analyses in regional anesthesia and pain medicine (Part II): guidelines for performing the systematic review. Reg Anesth Pain Med 2024; 49:403-422. [PMID: 37945064 DOI: 10.1136/rapm-2023-104802] [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: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 11/12/2023]
Abstract
In Part I of this series, we provide guidance for preparing a systematic review protocol. In this article, we highlight important steps and supplement with exemplars on conducting and reporting the results of a systematic review. We suggest how authors can manage protocol violations, multiplicity of outcomes and analyses, and heterogeneity. The quality (certainty) of the evidence and strength of recommendations should follow the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. It is our goal that Part II of this series provides valid guidance to authors and peer reviewers who conduct systematic reviews to adhere to important constructs of transparency, structure, reproducibility, and accountability. This will likely result in more rigorous systematic reviews being submitted for publication to the journals like Regional Anesthesia & Pain Medicine and Anesthesia & Analgesia.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, Minnesota, USA
| | - Michael J Barrington
- Department of Anesthesia and Perioperative Pain Medicine, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Ananda Sen
- Departments of Biostatistics and Family Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Edward J Mascha
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - George A Kelley
- Department of Epidemiology and Biostatistics, West Virginia University, Morgantown, West Virginia, USA
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Ruan QZ, Chang J, Pak D, Supra R, Yazdi C, Kollenburg L, Kurt E, Reece D, Fonseca ACG, Abd-Elsayed A, Robinson CL. Literature Review: Mechanism, Indications, and Clinical Efficacy of Peripheral Nerve Stimulators in Lower Extremity Pain. Curr Pain Headache Rep 2024; 28:469-479. [PMID: 38512600 DOI: 10.1007/s11916-024-01240-8] [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] [Accepted: 03/13/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE OF REVIEW Lower extremity pain is deemed by Center for Disease Control and Prevention (CDC) to be a significant source of chronic pain in adults. If not appropriately managed, patients are subjected to risks of prolonged musculoskeletal dysfunction, disruption to quality of life, and elevated healthcare expenditures. Peripheral nerve stimulation (PNS) has shown great potential in recent years demonstrating efficacy in multiple diagnoses ranging from acute post-surgical pain to complex regional pain syndrome (CRPS). This study seeks to delineate efficacy of peripheral neuromodulation in the context of chronic lower extremity pain. RECENT FINDINGS Prevailing clinical studies demonstrate evidence levels ranging from II to V (Oxford Centre of Level of Evidence) in lower limb PNS, attaining positive outcomes in pain scores, opioid use, and quality of life measures. Nerves most frequently targeted are the sciatic and femoral nerves with post-amputation pain and CRPS most commonly investigated for efficacy. PNS is a promising therapeutic modality demonstrated to be effective for a variety of nociceptive and neuropathic pain conditions in the lower extremity. PNS offers chronic pain physicians a powerful tool in the multi-modal management of lower limb chronic pain.
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Affiliation(s)
- Qing Zhao Ruan
- Department of Anesthesiology, Weill Cornell Medicine, 1300 York Ave, New York City, NY, 10021, USA.
| | - Jason Chang
- Department of Anesthesiology, Weill Cornell Medicine, 1300 York Ave, New York City, NY, 10021, USA
| | - Daniel Pak
- Department of Anesthesiology, Weill Cornell Medicine, 1300 York Ave, New York City, NY, 10021, USA
| | - Rajesh Supra
- Georgetown University School of Medicine, Washington, DC, USA
| | - Cyrus Yazdi
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School-Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Linda Kollenburg
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erkan Kurt
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David Reece
- Absolute Pain Management, Rockville, MD, USA
| | - Alexandra C G Fonseca
- Harvard Medical School, Brigham and Women's Hospital, Department of Anesthesiology, Perioperative, and Pain Medicine, Boston, MA, USA
| | - Alaa Abd-Elsayed
- Chronic Pain Medicine, Department of Anesthesiology, University of Wisconsin-Madison, Madison, USA
| | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School-Beth Israel Deaconess Medical Center, Boston, MA, USA
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D'Souza RS, Barrington MJ, Sen A, Mascha EJ, Kelley GA. Systematic Reviews and Meta-analyses in Regional Anesthesia and Pain Medicine (Part II): Guidelines for Performing the Systematic Review. Anesth Analg 2024; 138:395-419. [PMID: 37942964 DOI: 10.1213/ane.0000000000006607] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
In Part I of this series, we provide guidance for preparing a systematic review protocol. In this article, we highlight important steps and supplement with exemplars on conducting and reporting the results of a systematic review. We suggest how authors can manage protocol violations, multiplicity of outcomes and analyses, and heterogeneity. The quality (certainty) of the evidence and strength of recommendations should follow the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. It is our goal that Part II of this series provides valid guidance to authors and peer reviewers who conduct systematic reviews to adhere to important constructs of transparency, structure, reproducibility, and accountability. This will likely result in more rigorous systematic reviews being submitted for publication to the journals like Regional Anesthesia & Pain Medicine and Anesthesia & Analgesia .
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Affiliation(s)
- Ryan S D'Souza
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, Minnesota
| | - Michael J Barrington
- Department of Anesthesia and Perioperative Pain Medicine, Oregon Health & Sciences University, Portland, Oregon
| | - Ananda Sen
- Departments of Biostatistics and Family Medicine, University of Michigan, Ann Arbor, Michigan
| | - Edward J Mascha
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - George A Kelley
- Department of Epidemiology and Biostatistics, West Virginia University, Morgantown, West Virginia
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Liu Y, Wang L, Zhou C, Yuan Y, Fang B, Lu K, Xu F, Chen L, Huang L. MiR-31-5p regulates the neuroinflammatory response via TRAF6 in neuropathic pain. Biol Direct 2024; 19:10. [PMID: 38267979 PMCID: PMC10807213 DOI: 10.1186/s13062-023-00434-1] [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: 07/27/2023] [Accepted: 11/02/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Neuropathic pain is chronic pain and has few effective control strategies. Studies have demonstrated that microRNAs have functions in neuropathic pain. However, no study has been conducted to demonstrate the role and mechanism of microRNA (miR)-31-5p in neuropathic pain. Accordingly, this study sought to determine the pathological role of miR-31-5p in chronic constriction injury (CCI) -induced neuropathic pain mouse models. METHODS We used CCI surgery to establish mouse neuropathic pain model. Behavioral tests were performed to evaluate pain sensitivity of mice. Expressions of miR-31-5p and inflammatory cytokines in dorsal root ganglion (DRG) were examined by polymerase chain reaction. Animals or cells were received with/without miR-31-5p mimic or inhibitor to investigate its role in neuropathic pain. The mechanism of miR-31-5p was assayed using western blotting, immunofluorescence staining and dual-luciferase reporter assay. RESULTS We found that CCI led to a significant decrease in miR-31-5p levels. Knockout of miR-31-5p and administration of miPEP31 exacerbated pain in C57BL/6 mice. Meanwhile, miR-31-5p overexpression increased the paw withdrawal threshold and latency. TRAF6 is one of the target gene of miR-31-5p, which can trigger a complex inflammatory response. TRAF6 was associated with pain and that reducing the DRG expression of TRAF6 could alleviate pain. In addition, miR-31-5p overexpression inhibited the TRAF6 expression and reduced the neuroinflammatory response. CONCLUSIONS All the results reveal that miR-31-5p could potentially alleviate pain in CCI mouse models by inhibiting the TRAF6 mediated neuroinflammatory response. MiR-31-5p upregulation is highlighted here as new target for CCI treatment.
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Affiliation(s)
- Yuqi Liu
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 20080, China
| | - Lijuan Wang
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 20080, China
| | - Chengcheng Zhou
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 20080, China
| | - Yuan Yuan
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 20080, China
| | - Bin Fang
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 20080, China
| | - Kaimei Lu
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 20080, China
| | - Fangxia Xu
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 20080, China.
| | - Lianhua Chen
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 20080, China.
| | - Lina Huang
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 20080, China.
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Yeung AM, Huang J, Nguyen KT, Xu NY, Hughes LT, Agrawal BK, Ejskjaer N, Klonoff DC. Painful Diabetic Neuropathy: The Need for New Approaches. J Diabetes Sci Technol 2024; 18:159-167. [PMID: 36305521 PMCID: PMC10899841 DOI: 10.1177/19322968221132252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Painful diabetic neuropathy is a common vexing problem for people with diabetes and a costly problem for society. The pathophysiology is not well understood, and no safe and effective mechanistically-based treatment has been identified. Poor glycemic control is a risk factor for painful diabetic neuropathy. Excessive intraneuronal glucose in people with diabetes can be shunted away from physiological glycolysis into multiple pathological pathways associated with neuropathy and pain. The first three treatments that are traditionally offered consist of risk factor reduction, lifestyle modifications, and pharmacological therapy, which includes only three drugs that are approved for this indication by the United States Food and Drug Administration. All of these traditional treatments are often inadequate for relieving neuropathic pain, and thus, new approaches are needed. Modern devices based on neuromodulation technology, which act directly on the nervous system, have been recently cleared by the United States Food and Drug Administration for painful diabetic neuropathy and offer promise as next-in-line therapy when traditional therapies fail.
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Affiliation(s)
| | | | | | - Nicole Y. Xu
- Diabetes Technology Society, Burlingame, CA, USA
| | - Lorenzo T. Hughes
- Balance Health, San Francisco, CA, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | | | - Niels Ejskjaer
- Steno Diabetes Center North Denmark and Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - David C. Klonoff
- Diabetes Technology Society, Burlingame, CA, USA
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
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Pollina R, Betanzons G, Abd-Elsayed A. Peripheral Nerve Stimulation With a High-Frequency Electromagnetic Coupled Powered Implanted Receiver at the Posterior Tibial Nerve for the Treatment of Chronic Pain in the Foot. Neuromodulation 2024; 27:126-129. [PMID: 37245139 DOI: 10.1016/j.neurom.2023.04.469] [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: 01/28/2023] [Revised: 04/07/2023] [Accepted: 04/24/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Peripheral neuropathy has several causes, with diabetes being the most common. Conservative management may fail to control pain. Our study aimed at evaluating the use of peripheral nerve stimulation of the posterior tibial nerve for treating peripheral neuropathy. MATERIALS AND METHODS This was an observational study of 15 patients who received peripheral nerve stimulation at the posterior tibial nerve to treat peripheral neuropathy. Outcomes measured were improvement of pain scores and Patient Global Impression of Change (PGIC) at 12 months compared with before the implant. RESULTS Mean pain scores with the verbal rating scale were 3 ± 1.8 at >12 months compared with 8.6 ± 1.2 at baseline, a reduction of 65% (p < 0.001). Median satisfaction with the PGIC at >12 months was 7 of 7, with most subjects reporting a 6 (better) or a 7 (a great deal better). CONCLUSION Peripheral nerve stimulation of the posterior tibial nerve can be a safe and effective modality for treating chronic pain symptoms related to peripheral neuropathy of the foot.
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Affiliation(s)
- Ryan Pollina
- Great Lake Physiatrists, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Gabriela Betanzons
- Great Lake Physiatrists, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Abd-Elsayed A, Keith MK, Cao NN, Fiala KJ, Martens JM. Temporary Peripheral Nerve Stimulation as Treatment for Chronic Pain. Pain Ther 2023; 12:1415-1426. [PMID: 37737951 PMCID: PMC10616055 DOI: 10.1007/s40122-023-00557-3] [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: 07/09/2023] [Accepted: 09/04/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION Chronic pain is a growing problem across the world, and in the midst of an opioid epidemic, it is imperative that alternative treatment measures are identified to help alleviate the pain experienced by these patients. Chronic pain greatly affects ones quality of life and many patients do not experience adequate relief with conventional treatment measures. The purpose of this retrospective analysis is to assess the efficacy of peripheral nerve stimulation (PNS) therapy in adult patients suffering from chronic pain refractory to conventional treatment measures who underwent therapy on various anatomical locations. METHODS This retrospective analysis consisted of data collected from electronic health records for n = 89 patients who underwent PNS therapy. Data collected relates to patient age, sex, weight, height, body mass index (BMI), diagnosis, targeted nerves, follow-up encounters, pain scores from before and after PNS therapy, and duration of improvement. Statistical analysis used SPSS software, version 26 (IBM), using a paired t test to assess significance between pre and post PNS therapy pain scores. P values were significant if found to be ≤ 0.05. Further analysis assessed the correlation between age and BMI with visual analog scale (VAS) pain improvement and subjective percentage pain relief. RESULTS The mean pre-operative (pre-op) pain score before PNS therapy was 6.36 (standard deviation (SD) = 2.18, SEM = 0.23) and the mean post-operative (post-op) pain score after PNS therapy was 4.19 (SD = 2.70, SEM = 0.29). The mean patient-reported percent improvement in pain following PNS therapy was 49.04% (SD = 34.79). The improvement in pain scores between pre-op and post-op was statistically significant (M = 2.17, SD = 2.82, SEM = 0.30, t(88) = 7.26, p < .001), 95% confidence interval (CI) [1.57, 2.76]. The mean duration of improvement for patients was 123 days after therapy initiation (min = 6, max = 683, SD = 126). CONCLUSIONS This study demonstrated the potential role for PNS therapy in improving patient-reported pain levels for various neuropathies, targeting various nerves. With PNS therapy's use as a chronic pain treatment and available research being limited, further study needs to be done on the efficacy of PNS therapy for pain management and complications associated with PNS device placements at various locations.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology, Division of Chronic Pain Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA.
| | - Mitchell K Keith
- Department of Anesthesiology, Division of Chronic Pain Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA
| | - Nancy N Cao
- Department of Anesthesiology, Division of Chronic Pain Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA
| | - Kenneth J Fiala
- Department of Anesthesiology, Division of Chronic Pain Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA
| | - Joshua M Martens
- Department of Anesthesiology, Division of Chronic Pain Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA
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Kelly TD, Pazzol ML, Rahimi Darabad R. Peripheral Nerve Stimulation in Chronic Knee Pain: A Case Series. Cureus 2023; 15:e50127. [PMID: 38186428 PMCID: PMC10771261 DOI: 10.7759/cureus.50127] [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] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
Introduction Chronic knee pain is increasing in prevalence and is associated with substantial limitations in functional mobility. Peripheral nerve stimulation (PNS) has been increasingly used to treat various chronic pain conditions. However, there is a paucity of research exploring the potential therapeutic benefit of PNS for chronic knee pain. Methods This research is a retrospective case series of all patients who received PNS for the treatment of chronic knee pain performed at a single-center academic medical institution between March 2021 and June 2022. The primary outcome was percent pain reduction six months after implantation. Outcome data was obtained via chart review and phone calls to patients. Secondary outcomes included percent pain reduction two weeks and two months after implantation and adverse medical events related to the procedure and nerve stimulation. Results Fourteen individual patients received PNS for chronic knee pain during the study period. Three of these patients received bilateral PNS for a total of 17 cases. The mean percent pain reduction six months after implantation was 52% (SD=28.2) (N=12). A total of 75.0% of participants (9/12) reported ≥50% reductions in pain six months after implantation. No adverse events were reported relating to the implantation procedure and/or nerve stimulation. Conclusion PNS is a safe and efficacious treatment modality for chronic knee pain with demonstrated long-term benefit. Further research should clarify patient factors associated with improved treatment response.
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Affiliation(s)
- Timothy D Kelly
- Department of Emergency Medicine Residency, Indiana University School of Medicine, Indianapolis, USA
| | - Michael L Pazzol
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, USA
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Tieppo Francio V, Westerhaus BD, Carayannopoulos AG, Sayed D. Multifidus dysfunction and restorative neurostimulation: a scoping review. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1341-1354. [PMID: 37439698 PMCID: PMC10690869 DOI: 10.1093/pm/pnad098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/14/2023] [Accepted: 07/10/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE Chronic low back pain (CLBP) is multifactorial in nature, with recent research highlighting the role of multifidus dysfunction in a subset of nonspecific CLBP. This review aimed to provide a foundational reference that elucidates the pathophysiological cascade of multifidus dysfunction, how it contrasts with other CLBP etiologies and the role of restorative neurostimulation. METHODS A scoping review of the literature. RESULTS In total, 194 articles were included, and findings were presented to highlight emerging principles related to multifidus dysfunction and restorative neurostimulation. Multifidus dysfunction is diagnosed by a history of mechanical, axial, nociceptive CLBP and exam demonstrating functional lumbar instability, which differs from other structural etiologies. Diagnostic images may be used to grade multifidus atrophy and assess other structural pathologies. While various treatments exist for CLBP, restorative neurostimulation distinguishes itself from traditional neurostimulation in a way that treats a different etiology, targets a different anatomical site, and has a distinctive mechanism of action. CONCLUSIONS Multifidus dysfunction has been proposed to result from loss of neuromuscular control, which may manifest clinically as muscle inhibition resulting in altered movement patterns. Over time, this cycle may result in potential atrophy, degeneration and CLBP. Restorative neurostimulation, a novel implantable neurostimulator system, stimulates the efferent lumbar medial branch nerve to elicit repetitive multifidus contractions. This intervention aims to interrupt the cycle of dysfunction and normalize multifidus activity incrementally, potentially restoring neuromuscular control. Restorative neurostimulation has been shown to reduce pain and disability in CLBP, improve quality of life and reduce health care expenditures.
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Affiliation(s)
- Vinicius Tieppo Francio
- Department of Physical Medicine & Rehabilitation, The University of Kansas Medical Center, Kansas City, KS 66160, United States
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, United States
| | - Benjamin D Westerhaus
- Cantor Spine Institute at the Paley Orthopedic & Spine Institute, West Palm Beach, FL 33407, United States
| | - Alexios G Carayannopoulos
- Department of Neurosurgery and Neurology, Warren Alpert Medical School of Brown University, Providence, RI 02903, United States
| | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, United States
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12
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Shlobin NA, Wu C. Current Neurostimulation Therapies for Chronic Pain Conditions. Curr Pain Headache Rep 2023; 27:719-728. [PMID: 37728863 DOI: 10.1007/s11916-023-01168-5] [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] [Accepted: 08/09/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE OF REVIEW Neurostimulation treatment options have become more commonly used for chronic pain conditions refractory to these options. In this review, we characterize current neurostimulation therapies for chronic pain conditions and provide an analysis of their effectiveness and clinical adoption. This manuscript will inform clinicians of treatment options for chronic pain. RECENT FINDINGS Non-invasive neurostimulation includes transcranial direct current stimulation and repetitive transcranial magnetic stimulation, while more invasive options include spinal cord stimulation (SCS), peripheral nerve stimulation (PNS), dorsal root ganglion stimulation, motor cortex stimulation, and deep brain stimulation. Developments in transcranial direct current stimulation, repetitive transcranial magnetic stimulation, spinal cord stimulation, and peripheral nerve stimulation render these modalities most promising for the alleviating chronic pain. Neurostimulation for chronic pain involves non-invasive and invasive modalities with varying efficacy. Well-designed randomized controlled trials are required to delineate the outcomes of neurostimulatory modalities more precisely.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, 909 Walnut Street, Floor 2, Philadelphia, PA, 19107, USA.
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13
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Abd-Elsayed A, Attanti S, Anderson M, Dunn T, Maloney J, Strand N. Mechanism of Action of Temporary Peripheral Nerve Stimulation. Curr Pain Headache Rep 2023:10.1007/s11916-023-01184-5. [PMID: 37889467 DOI: 10.1007/s11916-023-01184-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE OF REVIEW Peripheral nerve stimulation (PNS) refers to the technique of utilizing electrical stimulation of peripheral nerves to inhibit the transmission of pain signals. PNS is used to treat chronic intractable pain and post-surgical or post-traumatic pain alongside a variety of other pain conditions, including headaches, facial pain, pelvic and urogenital pain, chest wall pain, residual limb or phantom limb pain, and back pain. RECENT FINDINGS More recently, PNS has been used temporarily for periods of time less than 60 days to treat acute post-surgical pain. Peripheral nerve stimulation is believed to be effective due to its effects on both central and peripheral pathways. Centrally, it is proposed that the electrical pulses of PNS inhibit alpha-delta and C fibers, which decreases pain signaling in the higher centers of the central nervous system. Peripherally, gate theory is applied as it is theorized that PNS downregulates inflammatory mediators, endorphins, and neurotransmitters associated with pain signaling to decrease the transmission of efferent nociception and reduce pain sensations.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology and Pain Management, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sumedha Attanti
- Mayo Clinic Alix School of Medicine, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Meredith Anderson
- Mayo Clinic Alix School of Medicine, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Tyler Dunn
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Jillian Maloney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Natalie Strand
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA.
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14
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Chow RM, Lee RY, Rajput K. Peripheral Nerve Stimulation for Pain Management: A Review. Curr Pain Headache Rep 2023; 27:321-327. [PMID: 37523121 DOI: 10.1007/s11916-023-01143-0] [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] [Accepted: 06/26/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE OF REVIEW Peripheral nerve stimulation has seen a recent upsurge in utilization for various chronic pain conditions, specifically from a neuropathic etiology, where a single peripheral nerve can be pinpointed as a culprit for pain. RECENT FINDINGS There is conflicting evidence about the efficacy and long-term outcomes of peripheral nerve stimulation for chronic pain, with most studies being small sized. The focus of this article is to review available evidence for the utilization of peripheral nerve stimulation for chronic pain syndromes as well as upcoming evidence in the immediate postoperative realm. The indications for the use of PNS have expanded from neuropathic pain such as occipital neuralgia and post-amputation pain, to more widespread disease processes such as chronic low back pain. Percutaneous PNS delivered over a 60-day period may provide significant carry-over effects including pain relief, potentially avoiding the need for a permanently implanted system while enabling improved function in patients with chronic pain.
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Affiliation(s)
- Robert M Chow
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar St, New Haven, CT, TMP306510, USA
| | - Ryan Yesung Lee
- Medical Student-3, Yale University School of Medicine, New Haven, USA
| | - Kanishka Rajput
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar St, New Haven, CT, TMP306510, USA.
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15
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Fisher LE, Lempka SF. Neurotechnology for Pain. Annu Rev Biomed Eng 2023; 25:387-412. [PMID: 37068766 DOI: 10.1146/annurev-bioeng-111022-121637] [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] [Indexed: 04/19/2023]
Abstract
Neurotechnologies for treating pain rely on electrical stimulation of the central or peripheral nervous system to disrupt or block pain signaling and have been commercialized to treat a variety of pain conditions. While their adoption is accelerating, neurotechnologies are still frequently viewed as a last resort, after many other treatment options have been explored. We review the pain conditions commonly treated with electrical stimulation, as well as the specific neurotechnologies used for treating those conditions. We identify barriers to adoption, including a limited understanding of mechanisms of action, inconsistent efficacy across patients, and challenges related to selectivity of stimulation and off-target side effects. We describe design improvements that have recently been implemented, as well as some cutting-edge technologies that may address the limitations of existing neurotechnologies. Addressing these challenges will accelerate adoption and change neurotechnologies from last-line to first-line treatments for people living with chronic pain.
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Affiliation(s)
- Lee E Fisher
- Rehab Neural Engineering Labs, Department of Physical Medicine and Rehabilitation, and Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA;
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Scott F Lempka
- Department of Biomedical Engineering, Biointerfaces Institute, and Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA;
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16
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Tsui BCH, Gupta RK. Role of neuromodulation in acute pain settings. Reg Anesth Pain Med 2023; 48:338-342. [PMID: 37080583 DOI: 10.1136/rapm-2022-103837] [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: 06/01/2022] [Accepted: 11/15/2022] [Indexed: 04/22/2023]
Abstract
Peripheral nerve stimulation (PNS), a type of neuromodulatory technique, is increasingly used to treat chronic pain syndromes. PNS has also recently gained popularity as a viable adjunct analgesic modality in acute pain settings, where the practice primarily relies on using boluses or infusion of local anesthetics for nerve blockade, followed by stimulation to extend the analgesia. There is some early promise in PNS for perioperative analgesic control, but considerable obstacles must be addressed before it can be implemented into standard practice. In this daring discourse, we explore the possibilities and constraints of using the PNS paradigm in acute pain.
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Affiliation(s)
- Ban C H Tsui
- Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA
| | - Rajnish K Gupta
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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17
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Li AHY, Bhatia A, Gulati A, Ottestad E. Role of peripheral nerve stimulation in treating chronic neuropathic pain: an international focused survey of pain medicine experts. Reg Anesth Pain Med 2023; 48:312-318. [PMID: 37080584 DOI: 10.1136/rapm-2022-104073] [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: 09/15/2022] [Accepted: 12/02/2022] [Indexed: 04/22/2023]
Abstract
Interventional pain management (IPM) options for refractory neuropathic pain (NP) have recently increased with availability of peripheral nerve stimulation (PNS) equipment and expertise. Given a lack of high-quality evidence and guidelines on this topic, we sought to understand the perception of physicians with expertise in treating NP regarding IPM and the role of PNS. We emailed a survey in March 2022 to international NP experts including pain medicine physicians, researchers, and leaders of 11 professional pain societies. No representatives from vendors of PNS systems were included in the design of the survey nor as respondents. Among 24 respondents (67% of those contacted), the distal common peroneal, tibial, and sural nerves were most frequently targeted (60%) with PNS. Persistent postsurgical pain of more than 3 months was the most common indication for PNS (84%). The aggregate NP treatment algorithm in order of median rank was non-opioid medications as first line, IPM including epidural/perineural steroid injections tied with transcutaneous electrical nerve stimulation as second line, pulsed radiofrequency (RF) tied with RF ablation/denervation as third line, temporary then permanent PNS as fourth line, followed by spinal cord stimulation, opioids, cryoablation, botulinum, peripheral nerve field stimulation, intrathecal targeted drug delivery, and others. Before offering PNS, 12 respondents (50%) indicated their preference for trialing non-neuromodulation treatments for 1-3 months. Twenty-two respondents (92%) agreed PNS should be offered early in the treatment of neuropathic pain. The most common barriers to PNS use were cost, lack of high-quality evidence in support of its use, lack of exposure to PNS in training programs, and lack of familiarity with the use of ultrasound guidance. PNS appears to have an increasing role in the treatment of NP but more research is needed on the outcomes of PNS to elucidate its role.
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Affiliation(s)
- Alice Huai-Yu Li
- Department of Anesthesia, Stanford University, Stanford, California, USA
| | - Anuj Bhatia
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amit Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Einar Ottestad
- Anesthesiology and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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18
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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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19
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Tate Q, Pagan-Rosado R, Hallo-Carrasco A, Hurdle MFB. Peripheral Nerve Stimulation for Chronic Intractable Neuropathic Pain Following a Brachial Plexus Avulsion Injury: A Case Report. A A Pract 2023; 17:e01681. [PMID: 37146225 DOI: 10.1213/xaa.0000000000001681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Brachial plexus avulsion injuries result in permanent motor and sensory deficits, leading to debilitating symptoms. We report the case of a 25-year-old man with chronic pain following right-sided C5-T1 nerve root avulsion without evidence of peripheral nerve injury. His pain was recalcitrant to medical and neurosurgical interventions. However, he experienced substantial (>70%) pain relief with peripheral nerve stimulation targeting the median nerve. These results agree with data suggesting collateral sprouting of sensory nerves occurs following a brachial plexus injury. Further study is needed if we are to understand the mechanisms of the peripheral nerve stimulator as a treatment option.
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Affiliation(s)
- Quinn Tate
- From the Department of Physical Medicine and Rehabilitation, Penn Medicine, Philadelphia, Pennsylvania
- Department of Pain Medicine, Mayo Clinic, Jacksonville, Florida
| | - Robert Pagan-Rosado
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota
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20
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Luckey AM, Adcock K, Vanneste S. Peripheral nerve stimulation: A neuromodulation-based approach. Neurosci Biobehav Rev 2023; 149:105180. [PMID: 37059406 DOI: 10.1016/j.neubiorev.2023.105180] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 03/23/2023] [Accepted: 04/11/2023] [Indexed: 04/16/2023]
Abstract
Recent technological improvements have positioned us at the threshold of innovative discoveries that will assist in new perspectives and avenues of research. Increased attention has been directed towards peripheral nerve stimulation, particularly of the vagus, trigeminal, or greater occipital nerve, due to their unique pathway that engages neural circuits within networks involved in higher cognitive processes. Here, we question whether the effects of transcutaneous electrical stimulation are mediated by synergistic interactions of multiple neuromodulatory networks, considering this pathway is shared by more than one neuromodulatory system. By spotlighting this attractive transcutaneous pathway, this opinion piece aims to acknowledge the contributions of four vital neuromodulators and prompt researchers to consider them in future investigations or explanations.
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Affiliation(s)
- Alison M Luckey
- Lab for Clinical & Integrative Neuroscience, School of Psychology, Trinity College Dublin, Dublin, Ireland; Trinity College Institute for Neuroscience, Trinity College Dublin, Dublin, Ireland
| | - Katherine Adcock
- Lab for Clinical & Integrative Neuroscience, School of Psychology, Trinity College Dublin, Dublin, Ireland; Trinity College Institute for Neuroscience, Trinity College Dublin, Dublin, Ireland
| | - Sven Vanneste
- Lab for Clinical & Integrative Neuroscience, School of Psychology, Trinity College Dublin, Dublin, Ireland; Trinity College Institute for Neuroscience, Trinity College Dublin, Dublin, Ireland; Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland.
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21
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Abd-Elsayed A, Gyorfi M, Fischman M, Odonkor C, Siff B, Cyr K. Reduced Pain and Improved Function Following Short-Term Use of Noninvasive BioWave High Frequency Peripheral Nerve Stimulation for Pain Management. Pain Ther 2023; 12:553-562. [PMID: 36807084 PMCID: PMC10036714 DOI: 10.1007/s40122-023-00480-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/25/2023] [Indexed: 02/23/2023] Open
Abstract
INTRODUCTION The peripheral nervous system is an increasingly popular target for chronic pain treatment modalities. Noninvasive neuromodulation has shown promise at providing significant chronic pain relief with a much safer side effect profile. This retrospective pilot study is shaped around a noninvasive neuromodulation system over a 2-week treatment timeline. METHODS Open-label survey of chronic pain patients recruited from Veteran Affairs, orthopedic, and pain health systems. If a noninvasive neuromodulation system was prescribed the patients were then offered a 2-week follow-up survey. This voluntary survey did not affect their therapy duration or quality. This survey was designed to address similar metrics as smaller noninvasive neuromodulation studies to allow a quality comparison while giving more power with a large population size of 1511 patients. Overall pain scores (including before and after scores), satisfaction level, desire to continue therapy, medication use, effect on functional metrics (mood, sleep, sit, stand, walk, and lift), and activities of daily living (ADL) scores were assessed. RESULTS The results demonstrated an overall pain reduction of 46%. All functional metrics were improved throughout with the largest improvements reported in mood and sleep at over 47%. Medication use was reported as decreased or eliminated in 42% of patients. There were no adverse reactions or complications reported over the 1511 patients. CONCLUSION This survey is amongst the largest population sizes every studied for noninvasive neuromodulation. Within just 2 weeks patients can see a reduction in overall pain and medication needs. Although survey studies have inherent limitations such as duration and compliance biases with such an overwhelming benefit in every category we believe that noninvasive neuromodulation therapy is a promising, safe, and cost-effective therapy. Future studies should focus on long-term follow-ups and post-therapy pain scores with a placebo group.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA.
| | - Michael Gyorfi
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA
| | | | - Charles Odonkor
- Department of Orthopedics and Rehabilitation, Division of Physiatry, Interventional Pain Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | | | - Kevin Cyr
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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22
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Beauchene C, Zurn CA, Ehrens D, Duff I, Duan W, Caterina M, Guan Y, Sarma SV. Steering Toward Normative Wide-Dynamic-Range Neuron Activity in Nerve-Injured Rats With Closed-Loop Peripheral Nerve Stimulation. Neuromodulation 2023; 26:552-562. [PMID: 36402658 PMCID: PMC10081946 DOI: 10.1016/j.neurom.2022.09.011] [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: 07/02/2022] [Revised: 09/08/2022] [Accepted: 09/30/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Chronic pain is primarily treated with pharmaceuticals, but the effects remain unsatisfactory. A promising alternative therapy is peripheral nerve stimulation (PNS), but it has been associated with suboptimal efficacy because its modulation mechanisms are not clear and the current therapies are primarily open loop (ie, manually adjusting the stimulation parameters). In this study, we developed a proof-of-concept computational modeling as the first step toward implementing closed-loop PNS in future biological studies. When developing new pain therapies, a useful pain biomarker is the wide-dynamic-range (WDR) neuron activity in the dorsal horn. In healthy animals, the WDR neuron activity occurs in a stereotyped manner; however, this response profile can vary widely after nerve injury to create a chronic pain condition. We hypothesized that if injury-induced changes of neuronal response can be normalized to resemble those of a healthy condition, the pathological aspects of pain may be treated while maintaining protective physiological nociception. MATERIALS AND METHODS Using an in vivo electrophysiology data set of WDR neuron recordings obtained in nerve-injured rats and naïve rats, we constructed sets of linear phenomenologic models of WDR firing rate during windup stimulation for both conditions. Then, we applied robust control systems techniques to identify a closed-loop PNS controller, which can drive the dynamics of WDR neuron response in neuropathic pain model into ranges associated with normal physiological pain. RESULTS The sets of identified linear models can accurately predict, in silico, nonlinear neural responses to electrical stimulation of the peripheral nerve. In addition, we showed that continuous closed-loop control of PNS can be used to normalize WDR neuron firing responses in three injured cases. CONCLUSIONS In this proof-of-concept study, we show how tractable, linear mathematical models of pain-related neurotransmission can be used to inform the development of closed-loop PNS. This new application of robust control to neurotechnology may also be expanded and applied across other neuromodulation applications.
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Affiliation(s)
- Christine Beauchene
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Claire A Zurn
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel Ehrens
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Irina Duff
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wanru Duan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael Caterina
- Department of Neurosurgery, Neurosurgery Pain Research Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Biological Chemistry, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurosurgery, Neurosurgery Pain Research Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sridevi V Sarma
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA.
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Aggarwal AK, Ottestad E, Pfaff KE, Huai-Yu Li A, Xu L, Derby R, Hecht D, Hah J, Pritzlaff S, Prabhakar N, Krane E, D’Souza G, Hoydonckx Y. Review of Ultrasound-Guided Procedures in the Management of Chronic Pain. Anesthesiol Clin 2023; 41:395-470. [DOI: 10.1016/j.anclin.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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24
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Hiendlmeier L, Zurita F, Vogel J, Del Duca F, Al Boustani G, Peng H, Kopic I, Nikić M, F Teshima T, Wolfrum B. 4D-Printed Soft and Stretchable Self-Folding Cuff Electrodes for Small-Nerve Interfacing. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2023; 35:e2210206. [PMID: 36594106 DOI: 10.1002/adma.202210206] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/19/2022] [Indexed: 06/17/2023]
Abstract
Peripheral nerve interfacing (PNI) has a high clinical potential for treating various diseases, such as obesity or diabetes. However, currently existing electrodes present challenges to the interfacing procedure, which limit their clinical application, in particular, when targeting small peripheral nerves (<200 µm). To improve the electrode handling and implantation, a nerve interface that can fold itself to a cuff around a small nerve, triggered by the body moisture during insertion, is fabricated. This folding is achieved by printing a bilayer of a flexible polyurethane printing resin and a highly swelling sodium acrylate hydrogel using photopolymerization. When immersed in an aqueous liquid, the hydrogel swells and folds the electrode softly around the nerve. Furthermore, the electrodes are robust, can be stretched (>20%), and bent to facilitate the implantation due to the use of soft and stretchable printing resins as substrates and a microcracked gold film as conductive layer. The straightforward implantation and extraction of the electrode as well as stimulation and recording capabilities on a small peripheral nerve in vivo are demonstrated. It is believed that such simple and robust to use self-folding electrodes will pave the way for bringing PNI to a broader clinical application.
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Affiliation(s)
- Lukas Hiendlmeier
- Neuroelectronics, Munich Institute of Biomedical Engineering, School of Computation, Informatics and Technology, Technical University of Munich, Hans-Piloty-Str. 1, 85748, Garching, Germany
- Medical & Health Informatics Laboratories, NTT Research Incorporated, 940 Stewart Dr, Sunnyvale, CA, 94085, USA
| | - Francisco Zurita
- Neuroelectronics, Munich Institute of Biomedical Engineering, School of Computation, Informatics and Technology, Technical University of Munich, Hans-Piloty-Str. 1, 85748, Garching, Germany
- Medical & Health Informatics Laboratories, NTT Research Incorporated, 940 Stewart Dr, Sunnyvale, CA, 94085, USA
| | - Jonas Vogel
- Neuroelectronics, Munich Institute of Biomedical Engineering, School of Computation, Informatics and Technology, Technical University of Munich, Hans-Piloty-Str. 1, 85748, Garching, Germany
| | - Fulvia Del Duca
- Neuroelectronics, Munich Institute of Biomedical Engineering, School of Computation, Informatics and Technology, Technical University of Munich, Hans-Piloty-Str. 1, 85748, Garching, Germany
- Medical & Health Informatics Laboratories, NTT Research Incorporated, 940 Stewart Dr, Sunnyvale, CA, 94085, USA
| | - George Al Boustani
- Neuroelectronics, Munich Institute of Biomedical Engineering, School of Computation, Informatics and Technology, Technical University of Munich, Hans-Piloty-Str. 1, 85748, Garching, Germany
- Medical & Health Informatics Laboratories, NTT Research Incorporated, 940 Stewart Dr, Sunnyvale, CA, 94085, USA
| | - Hu Peng
- Neuroelectronics, Munich Institute of Biomedical Engineering, School of Computation, Informatics and Technology, Technical University of Munich, Hans-Piloty-Str. 1, 85748, Garching, Germany
| | - Inola Kopic
- Neuroelectronics, Munich Institute of Biomedical Engineering, School of Computation, Informatics and Technology, Technical University of Munich, Hans-Piloty-Str. 1, 85748, Garching, Germany
| | - Marta Nikić
- Neuroelectronics, Munich Institute of Biomedical Engineering, School of Computation, Informatics and Technology, Technical University of Munich, Hans-Piloty-Str. 1, 85748, Garching, Germany
| | - Tetsuhiko F Teshima
- Neuroelectronics, Munich Institute of Biomedical Engineering, School of Computation, Informatics and Technology, Technical University of Munich, Hans-Piloty-Str. 1, 85748, Garching, Germany
- Medical & Health Informatics Laboratories, NTT Research Incorporated, 940 Stewart Dr, Sunnyvale, CA, 94085, USA
| | - Bernhard Wolfrum
- Neuroelectronics, Munich Institute of Biomedical Engineering, School of Computation, Informatics and Technology, Technical University of Munich, Hans-Piloty-Str. 1, 85748, Garching, Germany
- Medical & Health Informatics Laboratories, NTT Research Incorporated, 940 Stewart Dr, Sunnyvale, CA, 94085, USA
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25
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Ong Sio LC, Hom B, Garg S, Abd-Elsayed A. Mechanism of Action of Peripheral Nerve Stimulation for Chronic Pain: A Narrative Review. Int J Mol Sci 2023; 24:ijms24054540. [PMID: 36901970 PMCID: PMC10003676 DOI: 10.3390/ijms24054540] [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: 01/12/2023] [Revised: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
The use of stimulation of peripheral nerves to test or treat various medical disorders has been prevalent for a long time. Over the last few years, there has been growing evidence for the use of peripheral nerve stimulation (PNS) for treating a myriad of chronic pain conditions such as limb mononeuropathies, nerve entrapments, peripheral nerve injuries, phantom limb pain, complex regional pain syndrome, back pain, and even fibromyalgia. The ease of placement of a minimally invasive electrode via percutaneous approach in the close vicinity of the nerve and the ability to target various nerves have led to its widespread use and compliance. While most of the mechanism behind its role in neuromodulation is largely unknown, the gate control theory proposed by Melzack and Wall in the 1960s has been the mainstay for understanding its mechanism of action. In this review article, the authors performed a literature review to discuss the mechanism of action of PNS and discuss its safety and usefulness in treating chronic pain. The authors also discuss current PNS devices available in the market today.
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Affiliation(s)
- Lady Christine Ong Sio
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Brian Hom
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Shuchita Garg
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, USA
- Correspondence: ; Tel.: +1-608-263-8100; Fax: +1-608-263-0575
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Abd-Elsayed A, Moghim R. Efficacy of Peripheral Nerve Stimulation with a High Frequency Electromagnetic Coupled (HF-EMC) Powered Implanted Receiver in Treating Different Pain Targets/Neuralgias. J Pain Res 2023; 16:589-596. [PMID: 36861112 PMCID: PMC9969801 DOI: 10.2147/jpr.s399532] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/17/2023] [Indexed: 02/25/2023] Open
Abstract
Introduction Chronic pain is a significant global public health problem. Peripheral nerve stimulation (PNS) has been gaining popularity in recent years as it is effective, safe and less invasive than surgery for the treatment of chronic pain. The authors aimed to document and share a collection of patient-reported pain scores before and after implanting a percutaneous PNS lead/s with an external wireless generator at various target nerves. Methods The authors designed a retrospective study, reviewing electronic medical records. Statistical analysis was performed using SPSS 26; p-value ≤ 0.05 was considered significant. Results The mean baseline pain scores of 57 patients have reduced significantly after the procedure at different follow-up durations. Target nerves included genicular nerves, superior cluneal nerves, posterior tibial nerve ± sural nerve, middle cluneal nerves, radial and ulnar nerves and right common peroneal nerve. In the one-month follow-up group, mean pain score was reduced from 7.44 ± 1.48 pre-procedure to 1.6 ± 1.49, from 7.42 ± 1.5 pre-procedure to 1.6 ± 1.5 7.42 at 3 months, from 7.52 ± 1.5 to 1.72 ± 1.57 at 6 months, from 7.41 ± 1.53 to 1.7 ± 1.55 at 9 months, from 7.41 ± 1.58 to 1.76 ± 1.63 at 12 months, from 7.38 ± 1.59 to 1.69 ± 1.56 at 15 months and from 7.5 ± 1.7 to 1.45 ± 1.57 at 24 months (p ≤ 0.001). Patients also reported significant reduction in morphine milliequivalent, pre-procedure MME 47.75 ± 452.5 to 37.92 ± 43.51 at 6 months (p = 0.002, N = 57), pre-procedure MME 42.72 ± 43.19 to 30.38 ± 41.62 at 12 months (p = 0.003, N = 42), and pre-procedure MME 41.2 ± 46.12 to 21.19 ± 40.88 at 24 months (p ≤ 0.001, N = 27). The only complications occurred post procedure with 2 patients receiving an explant and 1 patient receiving a lead migration. Conclusion PNS has been shown to be safe and effective in treating chronic pain at different sites with sustained pain relief for up to 24 months. This study is unique in providing long-term follow-up data.
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Affiliation(s)
- Alaa Abd-Elsayed
- Anesthesiology Department, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA,Correspondence: Alaa Abd-Elsayed, Department of Anesthesiology and Pain Management, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792-3272, USA, Email
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Application of Repetitive Transcranial Magnetic Stimulation in Neuropathic Pain: A Narrative Review. Life (Basel) 2023; 13:life13020258. [PMID: 36836613 PMCID: PMC9962564 DOI: 10.3390/life13020258] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/08/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Neuropathic pain, affecting 6.9-10% of the general population, has a negative impact on patients' quality of life and potentially leads to functional impairment and disability. Repetitive transcranial magnetic stimulation (rTMS)-a safe, indirect and non-invasive technique-has been increasingly applied for treating neuropathic pain. The mechanism underlying rTMS is not yet well understood, and the analgesic effects of rTMS have been inconsistent with respect to different settings/parameters, causing insufficient evidence to determine its efficacy in patients with neuropathic pain. This narrative review aimed to provide an up-to-date overview of rTMS for treating neuropathic pain as well as to summarize the treatment protocols and related adverse effects from existing clinical trials. Current evidence supports the use of 10 Hz HF-rTMS of the primary motor cortex to reduce neuropathic pain, especially in patients with spinal cord injury, diabetic neuropathy and post-herpetic neuralgia. However, the lack of standardized protocols impedes the universal use of rTMS for neuropathic pain. rTMS was hypothesized to achieve analgesic effects by upregulating the pain threshold, inhibiting pain impulse, modulating the brain cortex, altering imbalanced functional connectivity, regulating neurotrophin and increasing endogenous opioid and anti-inflammatory cytokines. Further studies are warranted to explore the differences in the parameters/settings of rTMS for treating neuropathic pain due to different disease types.
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28
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Javed S, Perry K, Mach S, Huh B. Case report: Use of peripheral nerve stimulation for treatment of pain from vertebral plana fracture. FRONTIERS IN PAIN RESEARCH (LAUSANNE, SWITZERLAND) 2023; 3:1088097. [PMID: 36713642 PMCID: PMC9878588 DOI: 10.3389/fpain.2022.1088097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/16/2022] [Indexed: 01/13/2023]
Abstract
Vertebral plana fractures are a severe form of compression fractures that can cause significant morbidity due to incapacitating pain. Due to the flattening of the vertebrae in a plana fracture, accessing the vertebral body transpedicularly can be difficult, making traditional vertebral augmentation treatment dangerous. These injuries also typically occur in elderly patients with contraindications to invasive procedures. Peripheral nerve stimulation is a relatively new and minimally invasive treatment that uses electrical stimulation to inhibit pain signals from reaching the somatosensory cortex. Our case describes an 80 Year old female with multiple comorbidities and refractory pain due to a vertebral planar fracture successfully treated with a 60 day course of peripheral nerve stimulation as evidenced by over 50% reduction in symptoms and discontinuation of opioid pain medication use.
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Affiliation(s)
- Saba Javed
- Department of Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, United States
| | - Kenneth Perry
- Department of Anesthesiology, Critical Care and Pain Medicine, University of Texas Health Science Center at Houston, Houston, United States,Correspondence: Kenneth Perry
| | - Steven Mach
- Department of Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, United States
| | - Billy Huh
- Department of Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, United States
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29
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Nikitin AS, Kudryavtseva EV, Kamchatnov PR. [Post-traumatic pain mononeuropathies]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:14-23. [PMID: 37084360 DOI: 10.17116/jnevro202312304114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
Neuropathic pain syndrome (NPS) caused by peripheral nerve (PN) injury is a serious clinical problem due to its prevalence, complexity of pathogenesis, significant impact on the quality of life of patients. The issues of epidemiology, pathogenesis and treatment of patients with NBS with PN injury are considered. Modern possibilities of invasive treatment of such patients are discussed.
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Affiliation(s)
- A S Nikitin
- Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - E V Kudryavtseva
- Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - P R Kamchatnov
- Pirogov National Research Medical University, Moscow, Russia
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Yaccarino V, Jin MY, Abd-Elsayed A, Kraemer JM, Sehgal N. Peripheral Nerve Stimulation in Painful Conditions of the Upper Extremity-An Overview. Biomedicines 2022; 10:2776. [PMID: 36359295 PMCID: PMC9687108 DOI: 10.3390/biomedicines10112776] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 10/27/2022] [Accepted: 10/30/2022] [Indexed: 08/01/2023] Open
Abstract
Our objective is to present a brief history of the evolution of peripheral nerve stimulation, the current understanding of peripheral nerve stimulation mechanisms in chronic pain, peripheral nerve stimulation applications in upper extremity chronic pain conditions, and complications of peripheral nerve stimulation. The evolution of peripheral nerve stimulation from the early ages to the current status has been facilitated by discoveries in neurobehavioral mechanisms of pain, advances in technology and percutaneous lead development, and the availability of high-quality portable ultrasound units. Peripheral nerve stimulation application in managing upper extremity pain of amputated limbs, post-stroke shoulder pain, complex regional pain syndrome (CRPS), and median, ulnar, and radial neuropathies are discussed. Finally, we describe complications of peripheral nerve stimulation. The availability of ultrasound-guided peripheral nerve stimulation techniques and superior peripheral nerve stimulation technology have opened up new and minimally invasive treatment options for chronic intractable neuropathic pain of the upper extremity. Additionally, the ability to place peripheral nerve stimulation leads percutaneously without open peripheral nerve surgery expands the pool of implanting physicians, while simultaneously decreasing the risks and complications that are associated with open surgery.
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Affiliation(s)
- Vincent Yaccarino
- Department of Orthopedics & Rehabilitation, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, USA
| | - Max Y. Jin
- Department of Anesthesiology, University of Wisconsin, Madison, WI 53792, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI 53792, USA
| | | | - Nalini Sehgal
- Department of Orthopedics & Rehabilitation, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, USA
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Pirvulescu I, Biskis A, Candido KD, Knezevic NN. Overcoming clinical challenges of refractory neuropathic pain. Expert Rev Neurother 2022; 22:595-622. [PMID: 35866187 DOI: 10.1080/14737175.2022.2105206] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Refractory neuropathic pain (ReNP), and its definition, is widely disputed amongst clinicians due in part to unclear categorical diagnosing guidelines, overall time duration of neuropathic pain, and the exhaustiveness of treatment options. Usually ReNP is defined as chronic, intractable, and unresponsive neuropathic pain that have otherwise been untreatable. AREAS COVERED : In this narrative review, we discuss and summarize the effectiveness of prospective ReNP research conducted over the past 10 years. This research looks at pharmacological and interventional therapies in clinical trial settings. The pharmacological therapies discussed include the use of adjuvant treatments to improve the safety and efficacy of conventional approaches. Different modalities of administration, such as injection therapy and intrathecal drug delivery systems, provide targeted drug delivery. Interventional therapies such as neuromodulation, pulse radiofrequency, and nerve lesioning are more invasive, however, they are increasingly utilized in the field, as reflected in ongoing clinical trials. EXPERT OPINION : Based on the current data from RCTs and systematic reviews, it is clear that single drug therapy cannot be effective and has significant limitations. Transitioning to interventional modalities that showed more promising results sooner rather than later may be even more cost-efficient than attempting different conservative treatments with a high failure rate.
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Affiliation(s)
- Iulia Pirvulescu
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Alexandras Biskis
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.,Advocate Aurora Research Institute, Chicago, IL, USA.,College of Aviation, Science and Technology, Lewis University, Romeoville, IL, USA
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.,Department of Anesthesiology, University of Illinois, Chicago, IL, USA.,Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.,Department of Anesthesiology, University of Illinois, Chicago, IL, USA.,Department of Surgery, University of Illinois, Chicago, IL, USA
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Pascual-Valdunciel A, Rajagopal A, Pons JL, Delp S. Non-invasive electrical stimulation of peripheral nerves for the management of tremor. J Neurol Sci 2022; 435:120195. [PMID: 35220113 PMCID: PMC9590374 DOI: 10.1016/j.jns.2022.120195] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/06/2021] [Accepted: 02/17/2022] [Indexed: 12/22/2022]
Abstract
Pathological tremor in patients with essential tremor and Parkinsons disease is typically treated using medication or neurosurgical interventions. There is a widely recognized need for new treatments that avoid the side effects of current medications and do not carry the risks of surgical interventions. Building on decades of research and engineering development, non-invasive electrical stimulation of peripheral nerves has emerged as a safe and effective strategy for reducing pathologic tremor in essential tremor. This review surveys the peripheral electrical stimulation (PES) literature and summarizes effectiveness, safety, clinical translatability, and hypothesized tremor-reduction mechanisms of various PES approaches. The review also proposes guidelines for assessing tremor in the context of evaluating new therapies that combine the strengths of clinician assessments, patient evaluations, and novel motion sensing technology. The review concludes with a summary of future directions for PES, including expanding clinical access for patients with Parkinson's disease and leveraging large, at-home datasets to learn more about tremor physiology and treatment effect that will better characterize the state of tremor management and accelerate discovery of new therapies. Growing evidence suggests that non-invasive electrical stimulation of afferent neural pathways provides a viable new option for management of pathological tremor, with one specific PES therapy cleared for prescription and home use, suggesting that PES be considered along with medication and neurosurgical interventions for treatment of tremor. This article is part of the Special Issue "Tremor" edited by Daniel D. Truong, Mark Hallett, and Aasef Shaikh.
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Affiliation(s)
- Alejandro Pascual-Valdunciel
- Northwestern University, Evanston, IL, USA; E.T.S. Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, Spain
| | | | - Jose L Pons
- Northwestern University, Evanston, IL, USA; Shirley Ryan AbilityLab, Chicago, IL, USA.
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Stewart CM, Qadri MYJ, Daly CA. Upper-Extremity Peripheral Nerve Stimulators. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 5:121-125. [PMID: 36704375 PMCID: PMC9870788 DOI: 10.1016/j.jhsg.2021.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/15/2021] [Indexed: 01/29/2023] Open
Abstract
Chronic pain conditions are some of the most challenging problems upper-extremity surgeons face and often require a multimodal approach including neuromodulation. Peripheral nerve stimulation (PNS) is one of these modalities, delivering electrical stimulation to peripheral axons to modulate the spinal cord and block out nociceptive signals from the extremity. This blockade leads to long-lasting effects in both the peripheral and central nervous systems. Not only does PNS decrease peripheral pain signals but it also decreases the peripheral inflammatory response and assists with central nervous system plasticity for long-term pain control. Although PNS was initially developed in the 1960s, it has been underrepresented in the literature largely due to the advent of spinal cord stimulation and the lack of Food and Drug Administration-approved hardware for PNS. However, for upper-extremity pain, PNS provides notable benefits over spinal cord stimulation devices, as PNS allows for safer, more specific, and often more effective pain control. As clinicians attempt to limit narcotic use, therapies such as PNS have been revisited and are gaining popularity. We present a narrative review of PNS; discuss its mechanism of action, indications, and surgical technique; and provide a summary of the available literature for the upper-extremity surgeon. Peripheral nerve stimulation offers a solution for chronic, debilitating pain recalcitrant to other treatment modalities.
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Affiliation(s)
| | | | - Charles A. Daly
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA,Corresponding author: Charles A. Daly, MD, Department of Orthopaedic Surgery, Emory University, 21 Ortho Lane, Atlanta, GA 30324.
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Lubejko ST, Graham RD, Livrizzi G, Schaefer R, Banghart MR, Creed MC. The role of endogenous opioid neuropeptides in neurostimulation-driven analgesia. Front Syst Neurosci 2022; 16:1044686. [PMID: 36591324 PMCID: PMC9794630 DOI: 10.3389/fnsys.2022.1044686] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/18/2022] [Indexed: 12/15/2022] Open
Abstract
Due to the prevalence of chronic pain worldwide, there is an urgent need to improve pain management strategies. While opioid drugs have long been used to treat chronic pain, their use is severely limited by adverse effects and abuse liability. Neurostimulation techniques have emerged as a promising option for chronic pain that is refractory to other treatments. While different neurostimulation strategies have been applied to many neural structures implicated in pain processing, there is variability in efficacy between patients, underscoring the need to optimize neurostimulation techniques for use in pain management. This optimization requires a deeper understanding of the mechanisms underlying neurostimulation-induced pain relief. Here, we discuss the most commonly used neurostimulation techniques for treating chronic pain. We present evidence that neurostimulation-induced analgesia is in part driven by the release of endogenous opioids and that this endogenous opioid release is a common endpoint between different methods of neurostimulation. Finally, we introduce technological and clinical innovations that are being explored to optimize neurostimulation techniques for the treatment of pain, including multidisciplinary efforts between neuroscience research and clinical treatment that may refine the efficacy of neurostimulation based on its underlying mechanisms.
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Affiliation(s)
- Susan T. Lubejko
- Department of Neurobiology, School of Biological Sciences, University of California, San Diego, La Jolla, CA, United States
| | - Robert D. Graham
- Department of Anesthesiology, Pain Center, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Giulia Livrizzi
- Department of Neurobiology, School of Biological Sciences, University of California, San Diego, La Jolla, CA, United States
| | - Robert Schaefer
- Department of Anesthesiology, Pain Center, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Matthew R. Banghart
- Department of Neurobiology, School of Biological Sciences, University of California, San Diego, La Jolla, CA, United States
- *Correspondence: Matthew R. Banghart,
| | - Meaghan C. Creed
- Department of Anesthesiology, Pain Center, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
- Department of Neuroscience, Washington University in St. Louis, St. Louis, MO, United States
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States
- Meaghan C. Creed,
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