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Barboza VR, Kubota GT, da Silva VA, Barbosa LM, Arnaut D, Rodrigues ALDL, Galhardoni R, Barbosa ER, Brunoni AR, Teixeira MJ, Cury RG, de Andrade DC. Posterior insula repetitive transcranial magnetic stimulation for chronic pain in patients with Parkinson disease - pain type matters: A double-blinded randomized sham-controlled trial. Neurophysiol Clin 2024; 54:102994. [PMID: 39024845 DOI: 10.1016/j.neucli.2024.102994] [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: 04/24/2024] [Revised: 06/01/2024] [Accepted: 06/01/2024] [Indexed: 07/20/2024] Open
Abstract
OBJECTIVES Altered somatosensory processing in the posterior insula may play a role in chronic pain development and contribute to Parkinson disease (PD)-related pain. Posterior-superior insula (PSI) repetitive transcranial magnetic stimulation (rTMS) has been demonstrated to have analgesic effects among patients with some chronic pain conditions. This study aimed at assessing the efficacy of PSI-rTMS for treating PD-related pain. METHODS This was a double-blinded, randomized, sham-controlled, parallel-arm trial (NCT03504748). People with PD (PwP)-related chronic pain underwent five daily PSI-rTMS sessions for a week, followed by once weekly maintenance stimulations for seven weeks. rTMS was delivered at 10 Hz and 80% of the resting motor threshold. The primary outcome was a ≥ 30% pain intensity reduction at 8 weeks compared to baseline. Functionality, mood, cognitive, motor status, and somatosensory thresholds were also assessed. RESULTS Twenty-five patients were enrolled. Mean age was 55.2 ± 9.5 years-old, and 56% were female. Nociceptive pain accounted for 60%, and neuropathic and nociplastic for 20% each. No significant difference was found for 30% pain reduction response rates between active (42.7%) and sham groups (14.6%, p = 0.26). Secondary clinical outcomes and sensory thresholds also did not differ significantly. In a post hoc analysis, PwP with nociceptive pain sub-type experienced more pain relief after active (85.7%) compared to sham PSI-rTMS (25%, p = 0.032). CONCLUSION Our preliminary results suggest that different types of PD-related pain may respond differently to treatment, and therefore people with PD may benefit from having PD-related pain well characterized in research trials and in clinical practice.
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Affiliation(s)
| | | | | | | | - Debora Arnaut
- Pain Center, Department of Neurology, University of São Paulo, São Paulo, Brazil
| | | | - Ricardo Galhardoni
- Pain Center, Department of Neurology, University of São Paulo, São Paulo, Brazil
| | - Egberto Reis Barbosa
- Movement Disorders Group, Department of Neurology, University of São Paulo., Av. Dr. Enéas Carvalho de Aguiar, 255 - Cerqueira Cesar, Sao Paulo, Sao Paulo 05403-000, Brazil
| | - Andre Russowsky Brunoni
- Laboratory of Neuroscience and National Institute of Biomarkers in Psychiatry, Department and Institute of Psychiatry, Center for Clinical and Epidemiological Research & Interdisciplinary Center for Applied Neuromodulation, University Hospital, University of São Paulo, R. Dr. Ovídio Pires de Campos, 785 - Cerqueira Cesar, Sao Paulo, Sao Paulo 05403-903, Brazil
| | - Manoel Jacobsen Teixeira
- Pain Center, Department of Neurology, University of São Paulo, São Paulo, Brazil; Movement Disorders Group, Department of Neurology, University of São Paulo., Av. Dr. Enéas Carvalho de Aguiar, 255 - Cerqueira Cesar, Sao Paulo, Sao Paulo 05403-000, Brazil
| | - Rubens Gisbert Cury
- Movement Disorders Group, Department of Neurology, University of São Paulo., Av. Dr. Enéas Carvalho de Aguiar, 255 - Cerqueira Cesar, Sao Paulo, Sao Paulo 05403-000, Brazil
| | - Daniel Ciampi de Andrade
- Pain Center, Department of Neurology, University of São Paulo, São Paulo, Brazil; Center for Neuroplasticity and Pain, Department of Health Sciences and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
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Ayache SS, Chalah MA, Mylius V. Effects of high frequency rTMS on nociceptive pain in Parkinson's disease - Towards a personalized mechanism-based therapeutic approach. Neurophysiol Clin 2024; 54:103008. [PMID: 39181088 DOI: 10.1016/j.neucli.2024.103008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Revised: 07/29/2024] [Accepted: 07/29/2024] [Indexed: 08/27/2024] Open
Affiliation(s)
- Samar S Ayache
- Institut de la Colonne Vertébrale et des Neurosciences (ICVNS), Centre Médico Chirurgical Bizet, 75116 Paris, France; Department of Neurology, Gilbert and Rose-Marie Chagoury School of Medicine, Byblos, Lebanon; EA 4391, Excitabilité Nerveuse et Thérapeutique, Faculté de Santé, Université Paris Est, 94010 Créteil, France; Service de Physiologie-Explorations Fonctionnelles, DMU FIxIT, Hôpital Henri Mondor, 94010 Créteil, France.
| | - Moussa A Chalah
- Institut de la Colonne Vertébrale et des Neurosciences (ICVNS), Centre Médico Chirurgical Bizet, 75116 Paris, France; Department of Neurology, Gilbert and Rose-Marie Chagoury School of Medicine, Byblos, Lebanon; Institut de Neuromodulation, Pôle Hospitalo-Universitaire Psychiatrie Paris 15, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, 75014 Paris, France
| | - Veit Mylius
- Center for Neurorehabilitation, Valens, Switzerland; Department of Neurology, Philipps University, Marburg, Germany
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Liang D, Labrakakis C. Multiple Posterior Insula Projections to the Brainstem Descending Pain Modulatory System. Int J Mol Sci 2024; 25:9185. [PMID: 39273133 PMCID: PMC11395413 DOI: 10.3390/ijms25179185] [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: 07/01/2024] [Revised: 07/30/2024] [Accepted: 08/22/2024] [Indexed: 09/15/2024] Open
Abstract
The insular cortex is an important hub for sensory and emotional integration. It is one of the areas consistently found activated during pain. While the insular's connections to the limbic system might play a role in the aversive and emotional component of pain, its connections to the descending pain system might be involved in pain intensity coding. Here, we used anterograde tracing with viral expression of mCherry fluorescent protein, to examine the connectivity of insular axons to different brainstem nuclei involved in the descending modulation of pain in detail. We found extensive connections to the main areas of descending pain control, namely, the periaqueductal gray (PAG) and the raphe magnus (RMg). In addition, we also identified an extensive insular connection to the parabrachial nucleus (PBN). Although not as extensive, we found a consistent axonal input from the insula to different noradrenergic nuclei, the locus coeruleus (LC), the subcoereuleus (SubCD) and the A5 nucleus. These connections emphasize a prominent relation of the insula with the descending pain modulatory system, which reveals an important role of the insula in pain processing through descending pathways.
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Affiliation(s)
- Despoina Liang
- Department of Biological Applications and Technology, University of Ioannina, 45110 Ioannina, Greece
| | - Charalampos Labrakakis
- Department of Biological Applications and Technology, University of Ioannina, 45110 Ioannina, Greece
- Institute of Biosciences, University Research Center of Ioannina, 45110 Ioannina, Greece
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da Cunha PHM, de Andrade DC. The deep and the deeper: Spinal cord and deep brain stimulation for neuropathic pain. Presse Med 2024; 53:104231. [PMID: 38636785 DOI: 10.1016/j.lpm.2024.104231] [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] [Received: 10/17/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024] Open
Abstract
Neuropathic pain occurs in people experiencing lesion or disease affecting the somatosensorial system. It is present in 7 % of the general population and may not fully respond to first- and second-line treatments in up to 40 % of cases. Neuromodulation approaches are often proposed for those not tolerating or not responding to usual pharmacological management. These approaches can be delivered surgically (invasively) or non-invasively. Invasive neuromodulation techniques were the first to be employed in neuropathic pain. Among them is spinal cord stimulation (SCS), which consists of the implantation of epidural electrodes over the spinal cord. It is recommended in some guidelines for peripheral neuropathic pain. While recent studies have called into question its efficacy, others have provided promising data, driven by advances in techniques, battery capabilities, programming algorithms and software developments. Deep brain stimulation (DBS) is another well-stablished neuromodulation therapy routinely used for movement disorders; however, its role in pain management remains limited to specific research centers. This is not only due to variable results in the literature contesting its efficacy, but also because several different brain targets have been explored in small trials, compromising comparisons between these studies. Structures such as the periaqueductal grey, posterior thalamus, anterior cingulate cortex, ventral striatum/anterior limb of the internal capsule and the insula are the main targets described to date in literature. SCS and DBS present diverse rationales for use, mechanistic backgrounds, and varying levels of support from experimental studies. The present review aims to present their methodological details, main mechanisms of action for analgesia and their place in the current body of evidence in the management of patients with neuropathic pain, as well their particularities, effectiveness, safety and limitations.
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Affiliation(s)
| | - Daniel Ciampi de Andrade
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
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De Martino E, Casali A, Casarotto S, Hassan G, Couto BA, Rosanova M, Graven‐Nielsen T, de Andrade DC. Evoked oscillatory cortical activity during acute pain: Probing brain in pain by transcranial magnetic stimulation combined with electroencephalogram. Hum Brain Mapp 2024; 45:e26679. [PMID: 38647038 PMCID: PMC11034005 DOI: 10.1002/hbm.26679] [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: 09/28/2023] [Revised: 02/26/2024] [Accepted: 03/26/2024] [Indexed: 04/25/2024] Open
Abstract
Temporal dynamics of local cortical rhythms during acute pain remain largely unknown. The current study used a novel approach based on transcranial magnetic stimulation combined with electroencephalogram (TMS-EEG) to investigate evoked-oscillatory cortical activity during acute pain. Motor (M1) and dorsolateral prefrontal cortex (DLPFC) were probed by TMS, respectively, to record oscillatory power (event-related spectral perturbation and relative spectral power) and phase synchronization (inter-trial coherence) by 63 EEG channels during experimentally induced acute heat pain in 24 healthy participants. TMS-EEG was recorded before, during, and after noxious heat (acute pain condition) and non-noxious warm (Control condition), delivered in a randomized sequence. The main frequency bands (α, β1, and β2) of TMS-evoked potentials after M1 and DLPFC stimulation were recorded close to the TMS coil and remotely. Cold and heat pain thresholds were measured before TMS-EEG. Over M1, acute pain decreased α-band oscillatory power locally and α-band phase synchronization remotely in parietal-occipital clusters compared with non-noxious warm (all p < .05). The remote (parietal-occipital) decrease in α-band phase synchronization during acute pain correlated with the cold (p = .001) and heat pain thresholds (p = .023) and to local (M1) α-band oscillatory power decrease (p = .024). Over DLPFC, acute pain only decreased β1-band power locally compared with non-noxious warm (p = .015). Thus, evoked-oscillatory cortical activity to M1 stimulation is reduced by acute pain in central and parietal-occipital regions and correlated with pain sensitivity, in contrast to DLPFC, which had only local effects. This finding expands the significance of α and β band oscillations and may have relevance for pain therapies.
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Affiliation(s)
- Enrico De Martino
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of MedicineAalborg UniversityAalborgDenmark
| | - Adenauer Casali
- Institute of Science and TechnologyFederal University of São PauloSão PauloBrazil
| | - Silvia Casarotto
- Department of Biomedical and Clinical SciencesUniversity of MilanMilanItaly
- IRCCS Fondazione Don Carlo GnocchiMilanItaly
| | - Gabriel Hassan
- Department of Biomedical and Clinical SciencesUniversity of MilanMilanItaly
| | - Bruno Andry Couto
- Institute of Science and TechnologyFederal University of São PauloSão PauloBrazil
| | - Mario Rosanova
- Department of Biomedical and Clinical SciencesUniversity of MilanMilanItaly
| | - Thomas Graven‐Nielsen
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of MedicineAalborg UniversityAalborgDenmark
| | - Daniel Ciampi de Andrade
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of MedicineAalborg UniversityAalborgDenmark
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McBenedict B, Petrus D, Pires MP, Pogodina A, Arrey Agbor DB, Ahmed YA, Castro Ceron JI, Balaji A, Abrahão A, Lima Pessôa B. The Role of the Insula in Chronic Pain and Associated Structural Changes: An Integrative Review. Cureus 2024; 16:e58511. [PMID: 38770492 PMCID: PMC11103916 DOI: 10.7759/cureus.58511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/17/2024] [Indexed: 05/22/2024] Open
Abstract
Chronic pain affects a substantial portion of the global population, significantly impacting quality of life and well-being. This condition involves complex mechanisms, including dysfunction of the autonomic nervous system, which plays a crucial role in pain perception. The insula, a key brain region involved in pain processing, plays a critical role in pain perception and modulation. Lesions in the insula can result in pain asymbolia, where pain perception remains intact but emotional responses are inappropriate. The insula is anatomically and functionally divided into anterior and posterior regions, with the posterior insula processing nociceptive input based on intensity and location before relaying it to the anterior insula for emotional mediation. Understanding the insula's intricate role in pain processing is crucial, as it is involved in encoding prediction errors and mediating emotional dimensions of pain perception. The focus of this review was on synthesizing existing literature on the role of the insula in chronic pain and associated structural changes. The goal was to integrate findings from various sources to provide a comprehensive overview of the topic. The search strategy included a combination of Medical Subject Headings (MeSH) and relevant keywords related to insula and chronic pain. The following databases were surveyed: PubMed, Embase, Scopus, and Web of Science. We identified a total of 2515 articles, and after following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline based on eligibility criteria, 46 articles were used to synthesize this review. Our study highlights the pivotal role of the insula in chronic pain processing and associated structural changes, integrating findings from diverse studies and neuroimaging investigations. Beyond mere pain sensation, the insula contributes to emotional awareness, attention, and salience detection within the pain network. Various chronic pain conditions reveal alterations in insular activity and connectivity, accompanied by changes in gray matter volume and neurochemical profiles. Interventions targeting the insula show promise in alleviating chronic pain symptoms. However, further research is needed to understand underlying mechanisms, which can aid in developing more effective therapeutic interventions for pain.
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Affiliation(s)
| | - Dulci Petrus
- Family Health, Directorate of Special Programs, Ministry of Health and Social Services, Windhoek, NAM
| | | | - Anna Pogodina
- Medicine and Surgery, University of Buckingham, Buckingham, GBR
| | | | - Yusuf A Ahmed
- Faculty of Medicine, Mansoura University, Mansoura, EGY
| | - Jose Ittay Castro Ceron
- Academic Medicine, Institute of Health Sciences, Autonomous University of the State of Hidalgo, Pachuca, MEX
| | - Aishwariya Balaji
- General Practice, Government Kilpauk Medical College and Hospital, Chennai, IND
| | - Ana Abrahão
- Public Health, Fluminense Federal University, Niterói, BRA
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7
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Quesada C, Fauchon C, Pommier B, Bergandi F, Peyron R, Mertens P, Garcia-Larrea L. Field recordings of transcranial magnetic stimulation in human brain postmortem models. Pain Rep 2024; 9:e1134. [PMID: 38375090 PMCID: PMC10876241 DOI: 10.1097/pr9.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/16/2023] [Accepted: 10/24/2023] [Indexed: 02/21/2024] Open
Abstract
Introduction The ability of repetitive transcranial magnetic stimulation (rTMS) to deliver a magnetic field (MF) in deep brain targets is debated and poorly documented. Objective To quantify the decay of MF in the human brain. Methods Magnetic field was generated by single pulses of TMS delivered at maximum intensity using a flat or angulated coil. Magnetic field was recorded by a 3D-magnetic probe. Decay was measured in the air using both coils and in the head of 10 postmortem human heads with the flat coil being positioned tangential to the scalp. Magnetic field decay was interpreted as a function of distance to the coil for 6 potential brain targets of noninvasive brain stimulation: the primary motor cortex (M1, mean depth: 28.5 mm), dorsolateral prefrontal cortex (DLPFC: 28 mm), secondary somatosensory cortex (S2: 35.5 mm), posterior and anterior insulae (PI: 38.5 mm; AI: 43.5 mm), and midcingulate cortex (MCC: 57.5 mm). Results In air, the maximal MF intensities at coil center were 0.88 and 0.77 T for the flat and angulated coils, respectively. The maximal intracranial MF intensity in the cadaver model was 0.34 T, with a ∼50% decay at 15 mm and a ∼75% MF decay at 30 mm. The decay of the MF in air was similar for the flat coil and significantly less attenuated with the angulated coil (a ∼50% decay at 20 mm and a ∼75% MF decay at 45 mm). Conclusions Transcranial magnetic stimulation coil MFs decay in brain structures similarly as in air, attenuation with distance being significantly lower with angulated coils. Reaching brain targets deeper than 20 mm such as the insula or Antérior Cingulate Cortex seems feasible only when using angulated coils. The abacus of MF attenuation provided here can be used to adjust modalities of deep brain stimulation with rTMS in future research protocols.
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Affiliation(s)
- Charles Quesada
- NeuroPain Team, Centre de Recherche en Neurosciences de Lyon (CRNL), Inserm U1028, CNRS UMR5292, UJM & UCBL, Lyon, France
- Physiotherapy Department, Sciences of Rehabilitation Institute (ISTR), University Claude Bernard Lyon 1, Lyon, France
| | - Camille Fauchon
- NeuroPain Team, Centre de Recherche en Neurosciences de Lyon (CRNL), Inserm U1028, CNRS UMR5292, UJM & UCBL, Lyon, France
| | - Benjamin Pommier
- NeuroPain Team, Centre de Recherche en Neurosciences de Lyon (CRNL), Inserm U1028, CNRS UMR5292, UJM & UCBL, Lyon, France
| | - Florian Bergandi
- University of Medecine Jacques Lisfranc, Anatomy Laboratory, UJM, Saint-Etienne, France
| | - Roland Peyron
- NeuroPain Team, Centre de Recherche en Neurosciences de Lyon (CRNL), Inserm U1028, CNRS UMR5292, UJM & UCBL, Lyon, France
- Neurological Department & CETD, University Hospital, CHU Saint-Etienne, Saint-Etienne, France
| | - Patrick Mertens
- NeuroPain Team, Centre de Recherche en Neurosciences de Lyon (CRNL), Inserm U1028, CNRS UMR5292, UJM & UCBL, Lyon, France
- Laboratory of Anatomy, Faculté de Médecine Lyon-est, Université Claude Bernard Lyon 1, Saint-Etienne and Lyon, France
- CETD Neurological Hospital Lyon, Hospices Civils de Lyon, Lyon, France
| | - Luis Garcia-Larrea
- NeuroPain Team, Centre de Recherche en Neurosciences de Lyon (CRNL), Inserm U1028, CNRS UMR5292, UJM & UCBL, Lyon, France
- CETD Neurological Hospital Lyon, Hospices Civils de Lyon, Lyon, France
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Ju P, Zhao D, Ma L, Chen J. Biomarker development perspective: Exploring comorbid chronic pain in depression through deep transcranial magnetic stimulation. J Transl Int Med 2024; 12:123-128. [PMID: 38779118 PMCID: PMC11107179 DOI: 10.2478/jtim-2023-0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Affiliation(s)
- Peijun Ju
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Institute of Traditional Chinese Medicine for Mental Health, Shanghai, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai, China
| | - Di Zhao
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Le Ma
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinghong Chen
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Institute of Traditional Chinese Medicine for Mental Health, Shanghai, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai, China
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9
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Lefaucheur JP. It is time to personalize rTMS targeting for the treatment of pain. Neurophysiol Clin 2024; 54:102950. [PMID: 38382139 DOI: 10.1016/j.neucli.2024.102950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 01/30/2024] [Indexed: 02/23/2024] Open
Affiliation(s)
- Jean-Pascal Lefaucheur
- Unité de Neurophysiologie Clinique, Hôpital Henri Mondor, AP-HP, Créteil, France; UR ENT (EA4391), Faculté de Santé, Université Paris Est Créteil, Créteil, France.
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Duong A, Quabs J, Kucyi A, Lusk Z, Buch V, Caspers S, Parvizi J. Subjective states induced by intracranial electrical stimulation matches the cytoarchitectonic organization of the human insula. Brain Stimul 2023; 16:1653-1665. [PMID: 37949296 PMCID: PMC10893903 DOI: 10.1016/j.brs.2023.11.001] [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: 09/13/2023] [Revised: 10/23/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023] Open
Abstract
Functions of the human insula have been explored extensively with neuroimaging methods and intracranial electrical stimulation studies that have highlighted a functional segregation across its subregions. A recently developed cytoarchitectonic map of the human insula has also segregated this brain region into various areas. Our knowledge of the functional organization of this brain region at the level of these fine-parceled microstructural areas remains only partially understood. We address this gap of knowledge by applying a multimodal approach linking direct electrical stimulation and task-evoked intracranial EEG recordings with microstructural subdivisions of the human insular cortex. In 17 neurosurgical patients with 142 implanted electrodes, stimulation of 40 % of the sites induced a reportable change in the conscious experience of the subjects in visceral/autonomic, anxiety, taste/olfactory, pain/temperature as well as somatosensory domains. These subjective responses showed a topographical allocation to microstructural areas defined by probabilistic cytoarchitectonic parcellation maps of the human insula. We found the pain and thermal responses to be located in areas lg2/ld2, while non-painful/non-thermal somatosensory responses corresponded to area ld3 and visceroceptive responses to area Id6. Lastly, the stimulation of area Id7 in the dorsal anterior insula, failed to induce reportable changes to subjective experience even though intracranial EEG recordings from this region captured significant time-locked high-frequency activity (HFA). Our results provide a multimodal map of functional subdivisions within the human insular cortex at the individual brain basis and characterize their anatomical association with fine-grained cytoarchitectonic parcellations of this brain structure.
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Affiliation(s)
- Anna Duong
- Laboratory of Behavioral and Cognitive Neuroscience, Human Intracranial Cognitive Electrophysiology Program, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Julian Quabs
- Institute for Anatomy I, Medical Faculty & University Hospital, Heinrich Heine University, Düsseldorf, Germany; Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, Germany
| | - Aaron Kucyi
- Department of Psychological and Brain Sciences, Drexel University, Philadelphia, Pennsylvania, USA
| | - Zoe Lusk
- Laboratory of Behavioral and Cognitive Neuroscience, Human Intracranial Cognitive Electrophysiology Program, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Vivek Buch
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Svenja Caspers
- Institute for Anatomy I, Medical Faculty & University Hospital, Heinrich Heine University, Düsseldorf, Germany; Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, Germany
| | - Josef Parvizi
- Laboratory of Behavioral and Cognitive Neuroscience, Human Intracranial Cognitive Electrophysiology Program, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA; Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
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11
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de Andrade DC, García-Larrea L. Beyond trial-and-error: Individualizing therapeutic transcranial neuromodulation for chronic pain. Eur J Pain 2023; 27:1065-1083. [PMID: 37596980 PMCID: PMC7616049 DOI: 10.1002/ejp.2164] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND AND OBJECTIVE Repetitive transcranial magnetic stimulation (rTMS) applied to the motor cortex provides supplementary relief for some individuals with chronic pain who are refractory to pharmacological treatment. As rTMS slowly enters treatment guidelines for pain relief, its starts to be confronted with challenges long known to pharmacological approaches: efficacy at the group-level does not grant pain relief for a particular patient. In this review, we present and discuss a series of ongoing attempts to overcome this therapeutic challenge in a personalized medicine framework. DATABASES AND DATA TREATMENT Relevant scientific publications published in main databases such as PubMed and EMBASE from inception until March 2023 were systematically assessed, as well as a wide number of studies dedicated to the exploration of the mechanistic grounds of rTMS analgesic effects in humans, primates and rodents. RESULTS The main strategies reported to personalize cortical neuromodulation are: (i) the use of rTMS to predict individual response to implanted motor cortex stimulation; (ii) modifications of motor cortex stimulation patterns; (iii) stimulation of extra-motor targets; (iv) assessment of individual cortical networks and rhythms to personalize treatment; (v) deep sensory phenotyping; (vi) personalization of location, precision and intensity of motor rTMS. All approaches except (i) have so far low or moderate levels of evidence. CONCLUSIONS Although current evidence for most strategies under study remains at best moderate, the multiple mechanisms set up by cortical stimulation are an advantage over single-target 'clean' drugs, as they can influence multiple pathophysiologic paths and offer multiple possibilities of individualization. SIGNIFICANCE Non-invasive neuromodulation is on the verge of personalised medicine. Strategies ranging from integration of detailed clinical phenotyping into treatment design to advanced patient neurophysiological characterisation are being actively explored and creating a framework for actual individualisation of care.
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Affiliation(s)
- Daniel Ciampi de Andrade
- Department of Health Science and Technology, Faculty of Medicine, Center for Neuroplasticity and Pain (CNAP), Aalborg University, Aalborg, Denmark
| | - Luís García-Larrea
- University Hospital Pain Center (CETD), Neurological Hospital P. Wertheimer, Hospices Civils de Lyon, Lyon, France
- NeuroPain Lab, INSERM U1028, UMR5292, Lyon Neuroscience Research Center, CNRS, University Claude Bernard Lyon 1, Lyon, France
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12
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Garcia-Larrea L. Non-invasive cortical stimulation for drug-resistant pain. Curr Opin Support Palliat Care 2023; 17:142-149. [PMID: 37339516 DOI: 10.1097/spc.0000000000000654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
PURPOSE OF REVIEW Neuromodulation techniques are being increasingly used to alleviate pain and enhance quality of life. Non-invasive cortical stimulation was originally intended to predict the efficacy of invasive (neurosurgical) techniques, but has now gained a place as an analgesic procedure in its own right. RECENT FINDINGS Repetitive transcranial magnetic stimulation (rTMS): Evidence from 14 randomised, placebo-controlled trials (~750 patients) supports a significant analgesic effect of high-frequency motor cortex rTMS in neuropathic pain. Dorsolateral frontal stimulation has not proven efficacious so far. The posterior operculo-insular cortex is an attractive target but evidence remains insufficient. Short-term efficacy can be achieved with NNT (numbers needed to treat) ~2-3, but long-lasting efficacy remains a challenge.Like rTMS, transcranial direct-current stimulation (tDCS) induces activity changes in distributed brain networks and can influence various aspects of pain. Lower cost relative to rTMS, few safety issues and availability of home-based protocols are practical advantages. The limited quality of many published reports lowers the level of evidence, which will remain uncertain until more prospective controlled studies are available. SUMMARY Both rTMS and tDCS act preferentially upon abnormal hyperexcitable states of pain, rather than acute or experimental pain. For both techniques, M1 appears to be the best target for chronic pain relief, and repeated sessions over relatively long periods of time may be required to obtain clinically significant benefits. Patients responsive to tDCS may differ from those improved by rTMS.
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Affiliation(s)
- Luis Garcia-Larrea
- Central Integration of Pain (NeuroPain) Lab, Lyon Centre for Neuroscience (CRNL), INSERM U1028, University Claude Bernard Lyon 1, Villeurbanne
- University Hospital Pain Centre (CETD), Neurological Hospital, Hospices Civils de Lyon, Lyon, France
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13
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Marinelli S, Coccurello R. From the Gender Gap to Neuroactive Steroids: Exploring Multiple Cases to Further Understand Neuropathic Pain. Int J Mol Sci 2023; 24:ijms24108577. [PMID: 37239924 DOI: 10.3390/ijms24108577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Neuropathic pain (NeuP) is still an intractable form of highly debilitating chronic pain, resulting from a lesion or disease of the somatosensory nervous system [...].
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Affiliation(s)
- Sara Marinelli
- National Council of Research (CNR), Institute of Biochemistry and Cell Biology, 00015 Monterotondo, Italy
| | - Roberto Coccurello
- Institute for Complex Systems (ISC), National Council of Research (CNR), 00185 Rome, Italy
- European Center for Brain Research/Santa Lucia Foundation IRCCS, 00143 Rome, Italy
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14
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Labrakakis C. The Role of the Insular Cortex in Pain. Int J Mol Sci 2023; 24:ijms24065736. [PMID: 36982807 PMCID: PMC10056254 DOI: 10.3390/ijms24065736] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/09/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
The transition from normal to chronic pain is believed to involve alterations in several brain areas that participate in the perception of pain. These plastic changes are then responsible for aberrant pain perception and comorbidities. The insular cortex is consistently found activated in pain studies of normal and chronic pain patients. Functional changes in the insula contribute to chronic pain; however, the complex mechanisms by which the insula is involved in pain perception under normal and pathological conditions are still not clear. In this review, an overview of the insular function is provided and findings on its role in pain from human studies are summarized. Recent progress on the role of the insula in pain from preclinical experimental models is reviewed, and the connectivity of the insula with other brain regions is examined to shed new light on the neuronal mechanisms of the insular cortex’s contribution to normal and pathological pain sensation. This review underlines the need for further studies on the mechanisms underlying the involvement of the insula in the chronicity of pain and the expression of comorbid disorders.
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Affiliation(s)
- Charalampos Labrakakis
- Department of Biological Applications and Technology, University of Ioannina, 45110 Ioannina, Greece;
- Institute of Biosciences, University Research Center of Ioannina (URCI), 45110 Ioannina, Greece
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15
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Lapa JDDS, da Cunha PHM, Teixeira MJ, Brito Medeiros VM, Fernandes AM, Silva de Morais AD, Graven-Nielsen T, Cury RG, Ciampi de Andrade D. Burst Transspinal Magnetic Stimulation Alleviates Nociceptive Pain in Parkinson Disease—A Pilot Phase II Double-Blind, Randomized Study. Neuromodulation 2022:S1094-7159(22)01331-9. [DOI: 10.1016/j.neurom.2022.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/14/2022] [Accepted: 10/03/2022] [Indexed: 11/19/2022]
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16
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da Cunha PHM, Tanaka H, Lapa JDDS, Dongyang L, Boa Sorte AA, Pereira TMR, Soares FHC, Fernandes AM, Aparecida da Silva V, Graven-Nielsen T, Teixeira MJ, de Andrade DC. The fast-posterior superior insula (Fast-PSI): A neuronavigation-free targeting method for non-invasive neuromodulation. Brain Stimul 2022; 15:1178-1180. [PMID: 35987328 DOI: 10.1016/j.brs.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/02/2022] [Accepted: 08/11/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - Harki Tanaka
- Center of Engineering Modeling and Applied Social Science (CECS), Federal University of ABC (UFABC), Alameda da Universidade s/n, CEP 09606-045, São Bernardo do Campo, SP, Brazil
| | | | - Liu Dongyang
- LIM-62, Pain Center, Department of Neurology, University of São Paulo, São Paulo, Brazil
| | | | | | | | - Ana Mércia Fernandes
- LIM-62, Pain Center, Department of Neurology, University of São Paulo, São Paulo, Brazil
| | | | - Thomas Graven-Nielsen
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | | | - Daniel Ciampi de Andrade
- LIM-62, Pain Center, Department of Neurology, University of São Paulo, São Paulo, Brazil; Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
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17
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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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18
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Mussigmann T, Bardel B, Lefaucheur JP. Resting-state electroencephalography (EEG) biomarkers of chronic neuropathic pain. A systematic review. Neuroimage 2022; 258:119351. [PMID: 35659993 DOI: 10.1016/j.neuroimage.2022.119351] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/09/2022] [Accepted: 05/31/2022] [Indexed: 10/18/2022] Open
Abstract
Diagnosis and management of chronic neuropathic pain are challenging, leading to current efforts to characterize 'objective' biomarkers of pain using imaging or neurophysiological techniques, such as electroencephalography (EEG). A systematic literature review was conducted in PubMed-Medline and Web-of-Science until October 2021 to identify EEG biomarkers of chronic neuropathic pain in humans. The risk of bias was assessed by the Newcastle-Ottawa-Scale. Experimental, provoked, or chronic non-neuropathic pain studies were excluded. We identified 14 studies, in which resting-state EEG spectral analysis was compared between patients with pain related to a neurological disease and patients with the same disease but without pain or healthy controls. From these heterogeneous exploratory studies, some conclusions can be drawn, even if they must be weighted by the fact that confounding factors, such as medication and association with anxio-depressive disorders, are generally not taken into account. Overall, EEG signal power was increased in the θ band (4-7Hz) and possibly in the high-β band (20-30Hz), but decreased in the high-α-low-β band (10-20Hz) in the presence of ongoing neuropathic pain, while increased γ band oscillations were not evidenced, unlike in experimental pain. Consequently, the dominant peak frequency was decreased in the θ-α band and increased in the whole-β band in neuropathic pain patients. Disappointingly, pain intensity correlated with various EEG changes across studies, with no consistent trend. This review also discusses the location of regional pain-related EEG changes in the pain connectome, as the perspectives offered by advanced techniques of EEG signal analysis (source location, connectivity, or classification methods based on artificial intelligence). The biomarkers provided by resting-state EEG are of particular interest for optimizing the treatment of chronic neuropathic pain by neuromodulation techniques, such as transcranial alternating current stimulation or neurofeedback procedures.
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Affiliation(s)
- Thibaut Mussigmann
- Univ Paris Est Creteil, EA4391, ENT, Créteil, France; Clinical Neurophysiology Unit, Henri Mondor Hospital, AP-HP, Créteil, France
| | - Benjamin Bardel
- Univ Paris Est Creteil, EA4391, ENT, Créteil, France; Clinical Neurophysiology Unit, Henri Mondor Hospital, AP-HP, Créteil, France
| | - Jean-Pascal Lefaucheur
- Univ Paris Est Creteil, EA4391, ENT, Créteil, France; Clinical Neurophysiology Unit, Henri Mondor Hospital, AP-HP, Créteil, France.
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19
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New updates on transcranial magnetic stimulation in chronic pain. Curr Opin Support Palliat Care 2022; 16:65-70. [DOI: 10.1097/spc.0000000000000591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Barbosa LM, da Silva VA, de Lima Rodrigues AL, Mendes Fernandes DTR, de Oliveira RAA, Galhardoni R, Yeng LT, Junior JR, Conforto AB, Lucato LT, Lemos MD, Peyron R, Garcia-Larrea L, Teixeira MJ, Ciampi de Andrade D. Dissecting central post-stroke pain: a controlled symptom-psychophysical characterization. Brain Commun 2022; 4:fcac090. [PMID: 35528229 PMCID: PMC9070496 DOI: 10.1093/braincomms/fcac090] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/21/2021] [Accepted: 03/31/2022] [Indexed: 11/14/2022] Open
Abstract
Central post-stroke pain affects up to 12% of stroke survivors and is notoriously refractory to treatment. However, stroke patients often suffer from other types of pain of non-neuropathic nature (musculoskeletal, inflammatory, complex regional) and no head-to-head comparison of their respective clinical and somatosensory profiles has been performed so far. We compared 39 patients with definite central neuropathic post-stroke pain with two matched control groups: 32 patients with exclusively non-neuropathic pain developed after stroke and 31 stroke patients not complaining of pain. Patients underwent deep phenotyping via a comprehensive assessment including clinical exam, questionnaires and quantitative sensory testing to dissect central post-stroke pain from chronic pain in general and stroke. While central post-stroke pain was mostly located in the face and limbs, non-neuropathic pain was predominantly axial and located in neck, shoulders and knees (P < 0.05). Neuropathic Pain Symptom Inventory clusters burning (82.1%, n = 32, P < 0.001), tingling (66.7%, n = 26, P < 0.001) and evoked by cold (64.1%, n = 25, P < 0.001) occurred more frequently in central post-stroke pain. Hyperpathia, thermal and mechanical allodynia also occurred more commonly in this group (P < 0.001), which also presented higher levels of deafferentation (P < 0.012) with more asymmetric cold and warm detection thresholds compared with controls. In particular, cold hypoesthesia (considered when the threshold of the affected side was <41% of the contralateral threshold) odds ratio (OR) was 12 (95% CI: 3.8-41.6) for neuropathic pain. Additionally, cold detection threshold/warm detection threshold ratio correlated with the presence of neuropathic pain (ρ = -0.4, P < 0.001). Correlations were found between specific neuropathic pain symptom clusters and quantitative sensory testing: paroxysmal pain with cold (ρ = -0.4; P = 0.008) and heat pain thresholds (ρ = 0.5; P = 0.003), burning pain with mechanical detection (ρ = -0.4; P = 0.015) and mechanical pain thresholds (ρ = -0.4, P < 0.013), evoked pain with mechanical pain threshold (ρ = -0.3; P = 0.047). Logistic regression showed that the combination of cold hypoesthesia on quantitative sensory testing, the Neuropathic Pain Symptom Inventory, and the allodynia intensity on bedside examination explained 77% of the occurrence of neuropathic pain. These findings provide insights into the clinical-psychophysics relationships in central post-stroke pain and may assist more precise distinction of neuropathic from non-neuropathic post-stroke pain in clinical practice and in future trials.
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Affiliation(s)
- Luciana Mendonça Barbosa
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Ricardo Galhardoni
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, São Paulo, Brazil
| | - Lin Tchia Yeng
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, São Paulo, Brazil
| | - Jefferson Rosi Junior
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, São Paulo, Brazil
| | | | | | - Marcelo Delboni Lemos
- Department of Radiology, LIM-44, University of São Paulo, 05403-900 São Paulo, Brazil
| | - Roland Peyron
- NeuroPain Team, Lyon Neuroscience Research Center (CRNL), Inserm U1028, CNRS UMR5292, UCBL1, UJM, F-6900 Lyon, France
| | - Luis Garcia-Larrea
- NeuroPain Team, Lyon Neuroscience Research Center (CRNL), Inserm U1028, CNRS UMR5292, UCBL1, UJM, F-6900 Lyon, France
| | - Manoel Jacobsen Teixeira
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, São Paulo, Brazil
- Department of Neurology, LIM-62, University of São Paulo, 05403-900 São Paulo, Brazil
| | - Daniel Ciampi de Andrade
- Pain Center, Discipline of Neurosurgery HC-FMUSP, LIM-62, University of São Paulo, São Paulo, Brazil
- Center for Neuroplasticity and Pain, Department of Health Sciences and Technology, Faculty of Medicine, Aalborg University, DK-9220 Aalborg, Denmark
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21
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Garcia-Larrea L, Quesada C. Cortical stimulation for chronic pain: from anecdote to evidence. Eur J Phys Rehabil Med 2022; 58:290-305. [PMID: 35343176 PMCID: PMC9980528 DOI: 10.23736/s1973-9087.22.07411-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Epidural stimulation of the motor cortex (eMCS) was devised in the 1990's, and has now largely supplanted thalamic stimulation for neuropathic pain relief. Its mechanisms of action involve activation of multiple cortico-subcortical areas initiated in the thalamus, with involvement of endogenous opioids and descending inhibition toward the spinal cord. Evidence for clinical efficacy is now supported by at least seven RCTs; benefits may persist up to 10 years, and can be reasonably predicted by preoperative use of non-invasive repetitive magnetic stimulation (rTMS). rTMS first developed as a means of predicting the efficacy of epidural procedures, then as an analgesic method on its own right. Reasonable evidence from at least six well-conducted RCTs favors a significant analgesic effect of high-frequency rTMS of the motor cortex in neuropathic pain (NP), and less consistently in widespread/fibromyalgic pain. Stimulation of the dorsolateral frontal cortex (DLPFC) has not proven efficacious for pain, so far. The posterior operculo-insular cortex is a new and attractive target but evidence remains inconsistent. Transcranial direct current stimulation (tDCS) is applied upon similar targets as rTMS and eMCS; it does not elicit action potentials but modulates the neuronal resting membrane state. tDCS presents practical advantages including low cost, few safety issues, and possibility of home-based protocols; however, the limited quality of most published reports entails a low level of evidence. Patients responsive to tDCS may differ from those improved by rTMS, and in both cases repeated sessions over a long time may be required to achieve clinically significant relief. Both invasive and non-invasive procedures exert their effects through multiple distributed brain networks influencing the sensory, affective and cognitive aspects of chronic pain. Their effects are mainly exerted upon abnormally sensitized pathways, rather than on acute physiological pain. Extending the duration of long-term benefits remains a challenge, for which different strategies are discussed in this review.
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Affiliation(s)
- Luis Garcia-Larrea
- Central Integration of Pain (NeuroPain) Lab, Lyon Center for Neuroscience (CRNL), INSERM U1028, University Claude Bernard Lyon 1, Villeurbanne, France - .,University Hospital Pain Center (CETD), Neurological Hospital, Hospices Civils de Lyon, Lyon, France -
| | - Charles Quesada
- Central Integration of Pain (NeuroPain) Lab, Lyon Center for Neuroscience (CRNL), INSERM U1028, University Claude Bernard Lyon 1, Villeurbanne, France.,Department of Physiotherapy, Sciences of Rehabilitation Institute (ISTR), University Claude Bernard Lyon 1, Villeurbanne, France
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22
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da Cunha PHM, Dongyang L, Fernandes AM, Thibes RB, Sato J, Tanaka H, Dale C, Lapa JDDS, de Morais ADS, Soares FHC, da Silva VA, Graven-Nielsen T, Teixeira MJ, de Andrade DC. Non-invasive insular stimulation for peripheral neuropathic pain: Influence of target or symptom? Neurophysiol Clin 2022; 52:109-116. [DOI: 10.1016/j.neucli.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 10/18/2022] Open
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