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De Martino E, Casali A, Casarotto S, Hassan G, Rosanova M, Graven-Nielsen T, Ciampi de Andrade D. Acute pain drives different effects on local and global cortical excitability in motor and prefrontal areas: insights into interregional and interpersonal differences in pain processing. Cereb Cortex 2023; 33:9986-9996. [PMID: 37522261 DOI: 10.1093/cercor/bhad259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 08/01/2023] Open
Abstract
Pain-related depression of corticomotor excitability has been explored using transcranial magnetic stimulation-elicited motor-evoked potentials. Transcranial magnetic stimulation-electroencephalography now enables non-motor area cortical excitability assessments, offering novel insights into cortical excitability changes during pain states. Here, pain-related cortical excitability changes were explored in the dorsolateral prefrontal cortex and primary motor cortex (M1). Cortical excitability was recorded in 24 healthy participants before (Baseline), during painful heat (Acute Pain), and non-noxious warm (Warm) stimulation at the right forearm in a randomized sequence, followed by a pain-free stimulation measurement. Local cortical excitability was assessed as the peak-to-peak amplitude of early transcranial magnetic stimulation evoked potential, whereas global-mean field power measured the global excitability. Relative to the Baseline, Acute Pain decreased the peak-to-peak amplitude in M1 and dorsolateral prefrontal cortex compared with Warm (both P < 0.05). A reduced global-mean field power was only found in M1 during Acute Pain compared with Warm (P = 0.003). Participants with the largest reduction in local cortical excitability under Acute Pain showed a negative correlation between dorsolateral prefrontal cortex and M1 local cortical excitability (P = 0.006). Acute experimental pain drove differential pain-related effects on local and global cortical excitability changes in motor and non-motor areas at a group level while also revealing different interindividual patterns of cortical excitability changes, which can be explored when designing personalized treatment plans.
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Affiliation(s)
- Enrico De Martino
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg 9220, Denmark
| | - Adenauer Casali
- Institute of Science and Technology, Federal University of São Paulo, São Paulo 04021-001, Brazil
| | - Silvia Casarotto
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Milan 50143, Italy
| | - Gabriel Hassan
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Mario Rosanova
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Thomas Graven-Nielsen
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg 9220, Denmark
| | - Daniel Ciampi de Andrade
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg 9220, Denmark
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2
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Forster A, Rodrigues J, Ziebell P, Sanguinetti JL, Allen JJ, Hewig J. Investigating the role of the right inferior frontal gyrus in control perception: A double-blind cross-over study using ultrasonic neuromodulation. Neuropsychologia 2023; 187:108589. [PMID: 37302753 DOI: 10.1016/j.neuropsychologia.2023.108589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 03/23/2023] [Accepted: 05/24/2023] [Indexed: 06/13/2023]
Abstract
Being able to control inner and environmental states is a basic need of living creatures. The perception of such control is based on the perceived ratio of outcome probabilities given the presence and the absence of agentic behavior. If an organism believes that options exist to change the probability of a given outcome, control perception (CP) may emerge. Nonetheless, regarding this model, not much is known about how the brain processes CP from this information. This study uses low-intensity transcranial focused ultrasound neuromodulation in a randomized-controlled double blind cross-over design to investigate the impact of the right inferior frontal gyrus of the lateral prefrontal cortex (lPFC) on this process. 39 healthy participants visited the laboratory twice (once in a sham, once in a neuromodulation condition) and rated their control perception regarding a classical control illusion task. EEG alpha and theta power density were analyzed in a hierarchical single trial-based mixed modeling approach. Results indicate that the litFUS neuromodulation changed the processing of stimulus probability without changing CP. Furthermore, neuromodulation of the right lPFC was found to modulate mid-frontal theta by altering its relationship with self-reported effort and worrying. While these data indicate lateral prefrontal sensitivity to stimulus probability, no evidence emerged for the dependency of CP on this processing.
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Affiliation(s)
- André Forster
- Julius Maximilians Univeristy of Würzburg, Marcusstraße 9-11, 97070, Würzburg, Germany.
| | - Johannes Rodrigues
- Julius Maximilians Univeristy of Würzburg, Marcusstraße 9-11, 97070, Würzburg, Germany.
| | - Philipp Ziebell
- Julius Maximilians Univeristy of Würzburg, Marcusstraße 9-11, 97070, Würzburg, Germany.
| | | | | | - Johannes Hewig
- Julius Maximilians Univeristy of Würzburg, Marcusstraße 9-11, 97070, Würzburg, Germany.
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3
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Mosch B, Hagena V, Herpertz S, Ruttorf M, Diers M. Neural correlates of control over pain in fibromyalgia patients. Neuroimage Clin 2023; 37:103355. [PMID: 36848728 PMCID: PMC9982683 DOI: 10.1016/j.nicl.2023.103355] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/13/2023] [Accepted: 02/19/2023] [Indexed: 02/24/2023]
Abstract
The perceived lack of control over the experience of pain is arguably-one major cause of agony and impaired life quality in patients with chronic pain disorders as fibromyalgia (FM). The way perceived control affects subjective pain as well as the underlying neural mechanisms have so far not been investigated in chronic pain. We used functional magnetic resonance imaging (fMRI) to examine the neural correlates of self-controlled compared to computer-controlled heat pain in healthy controls (HC, n = 21) and FM patients (n = 23). Contrary to HC, FM failed to activate brain areas usually involved in pain modulation as well as reappraisal processes (right ventrolateral (VLPFC), dorsolateral prefrontal cortex (DLPFC) and dorsal anterior cingulate cortex (dACC)). Computer-controlled (compared to self-controlled) heat revealed significant activations of the orbitofrontal cortex (OFC) in HC, whereas FM activated structures that are typically involved in neural emotion processing (amygdala, parahippocampal gyrus). Additionally, FM displayed disrupted functional connectivity (FC) of the VLPFC, DLPFC and dACC with somatosensory and pain (inhibition)-related areas during self-controlled heat stimulation as well as significantly decreased gray matter (GM) volumes compared to HC in DLPFC and dACC. The described functional and structural changes provide evidence for far-reaching impairments concerning pain-modulatory processes in FM. Our investigation represents a first demonstration of dysfunctional neural pain modulation through experienced control in FM according to the extensive functional and structural changes in relevant sensory, limbic and associative brain areas. These areas may be targeted in clinical pain therapeutic methods involving TMS, neurofeedback or cognitive behavioral trainings.
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Affiliation(s)
- Benjamin Mosch
- Department of Psychosomatic Medicine and Psychotherapy, LWL University Hospital, Ruhr University Bochum, Bochum 44791, Germany
| | - Verena Hagena
- Department of Psychosomatic Medicine and Psychotherapy, LWL University Hospital, Ruhr University Bochum, Bochum 44791, Germany
| | - Stephan Herpertz
- Department of Psychosomatic Medicine and Psychotherapy, LWL University Hospital, Ruhr University Bochum, Bochum 44791, Germany
| | - Michaela Ruttorf
- Computer Assisted Clinical Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim 68167, Germany; Mannheim Institute for Intelligent Systems in Medicine, Heidelberg University, Mannheim 68167, Germany
| | - Martin Diers
- Department of Psychosomatic Medicine and Psychotherapy, LWL University Hospital, Ruhr University Bochum, Bochum 44791, Germany.
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Wolf TG, Faerber KA, Rummel C, Halsband U, Campus G. Functional Changes in Brain Activity Using Hypnosis: A Systematic Review. Brain Sci 2022; 12:brainsci12010108. [PMID: 35053851 PMCID: PMC8773773 DOI: 10.3390/brainsci12010108] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/04/2022] [Accepted: 01/11/2022] [Indexed: 02/05/2023] Open
Abstract
Hypnosis has proven a powerful method in indications such as pain control and anxiety reduction. As recently discussed, it has been yielding increased attention from medical/dental perspectives. This systematic review (PROSPERO-registration-ID-CRD42021259187) aimed to critically evaluate and discuss functional changes in brain activity using hypnosis by means of different imaging techniques. Randomized controlled trials, cohort, comparative, cross-sectional, evaluation and validation studies from three databases—Cochrane, Embase and Medline via PubMed from January 1979 to August 2021—were reviewed using an ad hoc prepared search string and following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. A total of 10,404 articles were identified, 1194 duplicates were removed and 9190 papers were discarded after consulting article titles/abstracts. Ultimately, 20 papers were assessed for eligibility, and 20 papers were included after a hand search (ntotal = 40). Despite a broad heterogenicity of included studies, evidence of functional changes in brain activity using hypnosis was identified. Electromyography (EMG) startle amplitudes result in greater activity in the frontal brain area; amplitudes using Somatosensory Event-Related Potentials (SERPs) showed similar results. Electroencephalography (EEG) oscillations of θ activity are positively associated with response to hypnosis. EEG results showed greater amplitudes for highly hypnotizable subjects over the left hemisphere. Less activity during hypnosis was observed in the insula and anterior cingulate cortex (ACC).
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Affiliation(s)
- Thomas Gerhard Wolf
- Department of Restorative, Preventive and Pediatric Dentistry, School of Dental Medicine, University of Bern, CH-3010 Bern, Switzerland; (K.A.F.); (G.C.)
- Department of Periodontology and Operative Dentistry, University Medical Center of the Johannes Gutenberg University Mainz, D-55131 Mainz, Germany
- Correspondence: ; Tel.: +41-31-632-2580
| | - Karin Anna Faerber
- Department of Restorative, Preventive and Pediatric Dentistry, School of Dental Medicine, University of Bern, CH-3010 Bern, Switzerland; (K.A.F.); (G.C.)
| | - Christian Rummel
- Support Center for Advanced Neuroimaging (SCAN), University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital (Inselspital), University of Bern, CH-3010 Bern, Switzerland;
| | - Ulrike Halsband
- Department of Psychology, Neuropsychology, University of Freiburg, D-79085 Freiburg im Breisgau, Germany;
| | - Guglielmo Campus
- Department of Restorative, Preventive and Pediatric Dentistry, School of Dental Medicine, University of Bern, CH-3010 Bern, Switzerland; (K.A.F.); (G.C.)
- Department of Surgery, Microsurgery and Medicine Sciences, School of Dentistry, University of Sassari, I-07100 Sassari, Italy
- Department of Pediatric, Preventive Dentistry and Orthodontics, School of Dentistry, Sechenov First Moscow State Medical University, 119991 Moscow, Russia
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Pagé MG, Dassieu L, Develay E, Roy M, Vachon-Presseau E, Lupien S, Rainville PhD P. The Stressful Characteristics of Pain That Drive You NUTS: A Qualitative Exploration of a Stress Model to Understand the Chronic Pain Experience. PAIN MEDICINE 2021; 22:1095-1108. [PMID: 33319901 DOI: 10.1093/pm/pnaa370] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Despite decades of research on the identification of specific characteristics of situations that trigger a physiological stress response (novelty, unpredictability, threat to the ego, and sense of low control [NUTS]), no integrative research has examined the validity of this framework applied to pain experiences. This study aimed to 1) explore the stressful characteristics of pain among individuals living with chronic pain and 2) examine whether the NUTS framework comprehensively captures the stressful nature of pain. SUBJECTS Participants were 41 adult participants living with chronic pain. METHODS Interviews in six focus groups were conducted in French using a semistructured interview guide. Participants first discussed how pain is stressful. Then, they were introduced to the NUTS framework and commented on the extent to which it captured their experience. The verbatim transcriptions of interviews were reviewed using reflexive thematic analysis. Analyses were conducted in French; quotes and themes were translated into English by a professional translator. RESULTS The pain-NUTS framework adequately captured participants' experiences. Multiple aspects of pain (pain intensity fluctuations, pain flare-up duration, pain quality and location, functional limitations, diagnosis and treatment) were associated with one or more stress-inducing characteristics. In addition, a second layer of meaning emerged in the context of chronic pain that provided contextual information regarding when, how, and why pain became more or less stressful. CONCLUSIONS The NUTS characteristics seem to offer a comprehensive framework to understand how pain and its context of chronicity can be a source of stress. This study provides preliminary support for the pain-NUTS framework to allow the formal integration of pain and stress research.
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Affiliation(s)
- M Gabrielle Pagé
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada.,Research Center of the Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada.,Department of Psychology, Faculty of Arts and Science, Université de Montréal, Montreal, QC, Canada
| | - Lise Dassieu
- Research Center of the Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada
| | - Elise Develay
- Research Center of the Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada
| | - Mathieu Roy
- Department of Psychology, Faculty of Science, McGill University, Montreal, QC, Canada.,Alan Edwards Centre for Research on Pain, McGill University Health Centre (MUHC), Montreal, QC, Canada
| | - Etienne Vachon-Presseau
- Department of Psychology, Faculty of Science, McGill University, Montreal, QC, Canada.,Alan Edwards Centre for Research on Pain, McGill University Health Centre (MUHC), Montreal, QC, Canada.,Faculty of Dentistry, McGill University, Montreal, QC, Canada.,Department of Anesthesia, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Sonia Lupien
- Department of Psychiatry, Centre for Studies on Human Stress, Montreal Mental Health University Institute, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Pierre Rainville PhD
- Department of Psychology, Faculty of Arts and Science, Université de Montréal, Montreal, QC, Canada.,Centre de recherche de l'Institut universitaire de gériatrie de Montréal, CIUSSS Centre-sud-de l'île de Montréal, Montreal, QC, Canada; ‡‡Department of Stomatology, Université de Montréal, Montreal, QC, Canada
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Becker S, Schakib-Ekbatan K, Wroblewski D, Schweiker M. Perception of repeated pain relief with controllable and uncontrollable pain. Eur J Pain 2021; 25:1702-1711. [PMID: 33829599 DOI: 10.1002/ejp.1775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The ultimate goal of pain research is to provide effective routes for pain relief. Nevertheless, the perception pain relief as a change in pain intensity and un-/pleasantness has only been rarely investigated. It has been demonstrated that pain relief has rewarding and reinforcing properties, but it remains unknown whether the perception of pain relief changes when pain reductions occur repeatedly. Further, it remains an open question whether the perception of pain relief depends on the controllability of the preceding pain. METHODS In this study, healthy volunteers (N = 38) received five cycles of painful heat stimulation and reduction of this stimulation to a non-painful warm stimulation once in a condition with control of the stimulation and once without control. Participants rated perceived intensity and un-/pleasantness on visual analogue scales during the heat stimulation and immediately after its reduction. RESULTS Results showed that perceived pain relief, estimated by the difference in ratings during ongoing heat stimulation and after its reduction, increased with repetitions. However, this increase levelled off after two to four repetitions. Further, perceived pain relief was larger in the condition without control compared to the condition with control. CONCLUSION The perception of pain relief can be modulated similar to the perception of pain by stimulus characteristics and psychological factors. Mechanistic knowledge about such modulating factors is important, because they can determine, e.g., the amount of requested pain killers in clinical settings and the efficacy of pain relief as a reinforcing stimulus. SIGNIFICANCE When in pain, pain relief can become an all-dominate goal. The perception of such pain relief can vary depending on external and internal characteristics and thus modulate, e.g., requests for pain killers in clinical settings. Here, we show that perceived intensity and pleasantness of pain relief changes with repetitions and whether the preceding pain is perceived as uncontrollable. Such mechanistic knowledge needs to be considered to maximize the effects of pain relief as a rewarding and reinforcing stimulus.
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Affiliation(s)
- Susanne Becker
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Integrative Spinal Research Group, Department of Chiropractic Medicine, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Karin Schakib-Ekbatan
- Heidelberg Academy of Sciences and Humanities, Heidelberg, Germany.,Building Science Group, Karlsruhe Institute of Technology, Karlsruhe, Germany.,Institute for Resource Efficiency and Energy Strategies, Karlsruhe, Germany
| | - Daniel Wroblewski
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marcel Schweiker
- Building Science Group, Karlsruhe Institute of Technology, Karlsruhe, Germany.,Institute for Occupational, Social and Environmental Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
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7
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Abdelkader AA, El Gohary AM, Mourad HS, El Salmawy DA. Repetitive TMS in treatment of resistant diabetic neuropathic pain. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0075-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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8
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The "virtual lesion" approach to transcranial magnetic stimulation: studying the brain-behavioral relationships in experimental pain. Pain Rep 2019; 4:e760. [PMID: 31579852 PMCID: PMC6728008 DOI: 10.1097/pr9.0000000000000760] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/24/2019] [Accepted: 04/27/2019] [Indexed: 12/11/2022] Open
Abstract
Transcranial magnetic stimulation (TMS) can be used to create a temporary “virtual lesion” (VL) of a target cortical area, disrupting its function and associated behavior. Transcranial magnetic stimulation can therefore test the functional role of specific brain areas. This scoping review aims at investigating the current literature of the “online” TMS-evoked VL approach to studying brain–behavioral relationships during experimental pain in healthy subjects. Ovid-Medline, Embase, and Web of Science electronic databases were searched. Included studies tested different TMS-based VLs of various pain brain areas during continuous experimental pain or when time-locked to a noxious stimulus. Outcome measures assessed different pain measurements. Initial screening resulted in a total of 403 studies, of which 17 studies were included in the review. The VLs were directed to the prefrontal, primary and secondary somatosensory, primary motor, and parietal cortices through single/double/triple/sequence of five-TMS pulses or through repeated TMS during mechanical, electrical contact, radiant heat, or capsaicin-evoked noxious stimulation. Despite a wide variability among the VL protocols, outcome measures, and study designs, a behavioral VL effect (decrease or increase in pain responses) was achieved in the majority of the studies. However, such findings on the relationships between the modified brain activity and the manifested pain characteristics were often mixed. To conclude, TMS–elicited VLs during experimental pain empower our understanding of brain–behavior relationships at specific time points during pain processing. The mixed findings of these relationships call for an obligatory standard of all pain-related TMS protocols for clearly determining the magnitude and direction of TMS-induced behavioral effects.
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Houghton DC, Uhde TW, Borckardt JJ, Cortese BM. Exploratory Investigation of a Brief Cognitive Behavioral Intervention and Transcranial Direct Current Stimulation on Odor Sensitivity. Psychosom Med 2019; 81:389-395. [PMID: 30762663 PMCID: PMC6961818 DOI: 10.1097/psy.0000000000000679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Enhanced odor sensitivity is a phenomenon that potentially underlies conditions such as multiple chemical sensitivity (MCS). Currently, there are no treatments that have been shown to effectively decrease odor sensitivity. Given similarities of odor hypersensitivity/MCS to pain sensitization disorders such as fibromyalgia, there may be a potential for interventions that improve pain tolerance to modulate odor sensitivity. METHODS This exploratory study randomized 72 healthy community adult volunteers to receive one of six treatments in between two assessments of thermal pain tolerance and odor threshold. Participants were randomized to receive either cathodal, anodal, or sham transcranial direct current stimulation (tDCS) aimed at dorsolateral prefrontal cortex. In addition, participants were provided a brief cognitive behavioral intervention (CBI) for pain consisting of task framing, cognitive restructuring, and distraction technique training, or a control intervention consisting of information about pain. RESULTS Persons who received a brief CBI showed significantly increased odor thresholds (reduced sensitivity) during intervention (F (1,62) = 7.29, p = .009, ηp = .11), whereas the control intervention was not associated with altered odor thresholds. Moreover, in those who received brief CBI, more severe anxiety associated with larger reductions in odor sensitivity (ρ = .364, p = .035). There was no effect of tDCS (F (2,62) = .11, p = .90) nor interaction between tDCS and CBI (F (2,62) = .32, p = .73). CONCLUSIONS Given the connection between anxiety and MCS, results suggest that CBT techniques for somatic processes may show promise in treating conditions characterized by increased sensitivity to odors (e.g., MCS).
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Affiliation(s)
- David C. Houghton
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
- Psychological and Brain Sciences Department, Texas A&M University, College Station, TX, USA
| | - Thomas W. Uhde
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jeffrey J. Borckardt
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Bernadette M. Cortese
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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10
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Powers A, Madan A, Hilbert M, Reeves ST, George M, Nash MR, Borckardt JJ. Effects of Combining a Brief Cognitive Intervention with Transcranial Direct Current Stimulation on Pain Tolerance: A Randomized Controlled Pilot Study. PAIN MEDICINE 2019; 19:677-685. [PMID: 28460127 DOI: 10.1093/pm/pnx098] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective Cognitive behavioral therapy has been shown to be effective for treating chronic pain, and a growing literature shows the potential analgesic effects of minimally invasive brain stimulation. However, few studies have systematically investigated the potential benefits associated with combining approaches. The goal of this pilot laboratory study was to investigate the combination of a brief cognitive restructuring intervention and transcranial direct current stimulation (tDCS) over the left dorsolateral prefrontal cortex in affecting pain tolerance. Design Randomized, double-blind, placebo-controlled laboratory pilot. Setting Medical University of South Carolina. Subjects A total of 79 healthy adult volunteers. Methods Subjects were randomized into one of six groups: 1) anodal tDCS plus a brief cognitive intervention (BCI); 2) anodal tDCS plus pain education; 3) cathodal tDCS plus BCI; 4) cathodal tDCS plus pain education; 5) sham tDCS plus BCI; and 6) sham tDCS plus pain education. Participants underwent thermal pain tolerance testing pre- and postintervention using the Method of Limits. Results A significant main effect for time (pre-post intervention) was found, as well as for baseline thermal pain tolerance (covariate) in the model. A significant time × group interaction effect was found on thermal pain tolerance. Each of the five groups that received at least one active intervention outperformed the group receiving sham tDCS and pain education only (i.e., control group), with the exception of the anodal tDCS + education-only group. Cathodal tDCS combined with the BCI produced the largest analgesic effect. Conclusions Combining cathodal tDCS with BCI yielded the largest analgesic effect of all the conditions tested. Future research might find stronger interactive effects of combined tDCS and a cognitive intervention with larger doses of each intervention. Because this controlled laboratory pilot employed an acute pain analogue and the cognitive intervention did not authentically represent cognitive behavioral therapy per se, the implications of the findings on chronic pain management remain unclear.
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Affiliation(s)
- Abigail Powers
- Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia
| | - Alok Madan
- The Menninger Clinic, Houston, Texas.,Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
| | | | | | - Mark George
- Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina.,Ralph Johnson VAMC, Charleston, South Carolina
| | - Michael R Nash
- University of Tennessee, Knoxville Department of Psychology
| | - Jeffrey J Borckardt
- Anesthesia and Perioperative Medicine.,Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina.,Ralph Johnson VAMC, Charleston, South Carolina
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11
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Costa B, Ferreira I, Trevizol A, Thibaut A, Fregni F. Emerging targets and uses of neuromodulation for pain. Expert Rev Neurother 2019; 19:109-118. [DOI: 10.1080/14737175.2019.1567332] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Beatriz Costa
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Center and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (MA), USA
| | - Isadora Ferreira
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Center and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (MA), USA
| | - Alisson Trevizol
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Center and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (MA), USA
| | - Aurore Thibaut
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Center and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (MA), USA
| | - Felipe Fregni
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Center and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (MA), USA
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Abstract
Supplemental Digital Content is Available in the Text. Introduction: Chronic pain and pain-related suffering are major health problems. The lack of controllability of experienced pain seems to greatly contribute to the extent of suffering. This study examined how controllability affects the perception of pain and pain-related suffering, and the modulation of this effect by beliefs and emotions such as locus of control of reinforcement, pain catastrophizing, and fear of pain. Methods: Twenty-six healthy subjects received painful electric stimulation in both controllable and uncontrollable conditions. Visual analogue scales and the “Pictorial Representation of Illness and Self Measure” were used to assess pain intensity, unpleasantness, pain-related suffering, and the level of perceived control. We also investigated nonverbal indicators of pain and suffering such as heart rate, skin conductance, and corrugator electromyogram. Results: Controllability selectively reduced the experience of pain-related suffering, but did not affect pain intensity or pain unpleasantness. This effect was modulated by chance locus of control but was unrelated to fear of pain or catastrophizing. Physiological responses were not affected by controllability. In a second sample of 25 participants, we varied the instruction. The effect of controllability on pain-related suffering was only present when instructions focused on the person being able to stop the pain. Discussion: Our data suggest that the additional measure of pain-related suffering may be important in the assessment of pain and may be more susceptible to the effects of perceived control than pain intensity and unpleasantness. We also show that this effect depends on personal involvement.
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13
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The vicious cycle of itch and anxiety. Neurosci Biobehav Rev 2018; 87:17-26. [PMID: 29374516 DOI: 10.1016/j.neubiorev.2018.01.009] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 12/28/2017] [Accepted: 01/21/2018] [Indexed: 12/21/2022]
Abstract
Chronic itch is associated with increased stress, anxiety, and other mood disorders. In turn, stress and anxiety exacerbate itch, leading to a vicious cycle that affects patient behavior (scratching) and worsens disease prognosis and quality of life. This cycle persists across chronic itch conditions of different etiologies and even to some extent in healthy individuals, suggesting that the final common pathway for itch processing (the central nervous system) plays a major role in the relationship between itch and anxiety. Pharmacological and nonpharmacological treatments that reduce anxiety have shown promising anti-itch effects. Further research is needed to establish specific central mechanisms of the itch-anxiety cycle and provide new targets for treatment.
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Different Brain Circuitries Mediating Controllable and Uncontrollable Pain. J Neurosci 2017; 36:5013-25. [PMID: 27147654 DOI: 10.1523/jneurosci.1954-15.2016] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 03/17/2016] [Indexed: 12/22/2022] Open
Abstract
UNLABELLED Uncontrollable, compared with controllable, painful stimulation can lead to increased pain perception and activation in pain-processing brain regions, but it is currently unknown which brain areas mediate this effect. When pain is controllable, the lateral prefrontal cortex (PFC) seems to inhibit pain processing, although it is unclear how this is achieved. Using fMRI in healthy volunteers, we examined brain activation during controllable and uncontrollable stimulation to answer these questions. In the controllable task, participants self-adjusted temperatures applied to their hand of pain or warm intensities to provoke a constant sensation. In the uncontrollable task, the temperature time courses of the controllable task were replayed (yoked control) and participants rated their sensation continuously. During controllable pain trials, participants significantly downregulated the temperature to keep their sensation constant. Despite receiving the identical nociceptive input, intensity ratings increased during the uncontrollable pain trials. This additional sensitization was mirrored in increased activation of pain-processing regions such as insula, anterior cingulate cortex, and thalamus. Further, increased connectivity between the anterior insula and medial PFC (mPFC) in the uncontrollable and increased negative connectivity between dorsolateral PFC (dlPFC) and insula in the controllable task were observed. This suggests a pain-facilitating role of the mPFC during uncontrollable pain and a pain-inhibiting role of the dlPFC during controllable pain, both exerting their respective effects via the anterior insula. These results elucidate neural mechanisms of context-dependent pain modulation and their relation to subjective perception. SIGNIFICANCE STATEMENT Pain control is of uttermost importance and stimulus controllability is an important way to achieve endogenous pain modulation. Here, we show differential effects of controllability and uncontrollability on pain perception and cerebral pain processing. When pain was controllable, the dorsolateral prefrontal cortex downregulated pain-evoked activation in important pain-processing regions. In contrast, sensitization during uncontrollable pain was mediated by increased connectivity of the medial prefrontal cortex with the anterior insula and other pain-processing regions. These novel insights into cerebral pain modulation by stimulus controllability have the potential to improve treatment approaches in pain patients.
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Janice Jimenez-Torres G, Weinstein BL, Walker CR, Christopher Fowler J, Ashford P, Borckardt JJ, Madan A. A study protocol for a single-blind, randomized controlled trial of adjunctive transcranial direct current stimulation (tDCS) for chronic pain among patients receiving specialized, inpatient multimodal pain management. Contemp Clin Trials 2016; 54:36-47. [PMID: 28039022 DOI: 10.1016/j.cct.2016.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 12/23/2016] [Accepted: 12/24/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Available treatments for chronic pain (CP) are modestly effective or associated with iatrogenic harm. Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that may be an effective, adjunctive treatment to non-opioid therapies. In this randomized control trial (RCT), we compare adjunctive active versus sham tDCS among patients in a multimodal inpatient pain management program. The primary objectives of the RCT are to improve pain tolerance and subjective pain experience. METHODS AND DESIGN Patients admitted to the Pain Management Program at The Menninger Clinic in Houston, Texas are eligible for this trial. Eighty-four participants will be randomized (1:1) into a single-blind, 2×12 (group×time) controlled trial. A battery-powered direct and constant current stimulator (Soterix Medical Inc. 2014) delivers anodal stimulation over the left dorsolateral prefrontal cortex (DLPFC) and cathodal stimulation over the right DLPFC. Active tDCS is applied by supplying a 2mA current for 20min/session over 10 sessions. Participants complete self-report and performance-based assessments on a weekly basis just prior to brain stimulation. Self-report assessments are collected via Chronic Pain Tracker version 3.6, an iPad interfaced application. The performance-based pain tolerance task is completed through the cold presser task. DISCUSSION Interventions with cross-symptomatic therapeutic potential are absolutely essential in the context of CP, in which psychiatric comorbidity is the norm. Modalities that can be used in tandem with evidence-based, non-opioid therapies have the potential to have a synergistic effect, resulting in increased effectiveness of what have been modestly effective treatments to date.
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Affiliation(s)
- G Janice Jimenez-Torres
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Benjamin L Weinstein
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Cory R Walker
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - J Christopher Fowler
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | | | - Jeffrey J Borckardt
- Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, United States; Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States; Ralph H. Johnson Veterans' Affairs Medical Center, Charleston, SC, United States
| | - Alok Madan
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States.
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Hu XS, Fisher CA, Munz SM, Toback RL, Nascimento TD, Bellile EL, Rozek L, Eisbruch A, Worden FP, Danciu TE, DaSilva AF. Feasibility of Non-invasive Brain Modulation for Management of Pain Related to Chemoradiotherapy in Patients with Advanced Head and Neck Cancer. Front Hum Neurosci 2016; 10:466. [PMID: 27729853 PMCID: PMC5037215 DOI: 10.3389/fnhum.2016.00466] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 09/05/2016] [Indexed: 11/18/2022] Open
Abstract
Patients with head and neck cancer often experience a significant decrease in their quality of life during chemoradiotherapy (CRT) due to treatment-related pain, which is frequently classified as severe. Transcranial direct current stimulation (tDCS) is a method of non-invasive brain stimulation that has been frequently used in experimental and clinical pain studies. In this pilot study, we investigated the clinical impact and central mechanisms of twenty primary motor cortex (M1) stimulation sessions with tDCS during 7 weeks of CRT for head and neck cancer. From 48 patients screened, seven met the inclusion criteria and were enrolled. Electroencephalography (EEG) data were recorded before and after tDCS stimulation as well as across the trial to monitor short and long-term impact on brain function. The compliance rate during the long trial was extremely high (98.4%), and patients mostly reported mild side effects in line with the literature (e.g., tingling). Compared to a large standard of care study from our institution, our initial results indicate that M1-tDCS stimulation has a pain relief effect during the CRT that resulted in a significant attenuation of weight reduction and dysphagia normally observed in these patients. These results translated to our patient cohort not needing feeding tubes or IV fluids. Power spectra analysis of EEG data indicated significant changes in α, β, and γ bands immediately after tDCS stimulation and, in addition, α, δ, and θ bands over the long term in the seventh stimulation week (p < 0.05). The independent component EEG clustering analysis showed estimated functional brain regions including precuneus and superior frontal gyrus (SFG) in the seventh week of tDCS stimulation. These areas colocalize with our previous positron emission tomography (PET) study where there was activation in the endogenous μ-opioid system during M1-tDCS. This study provides preliminary evidence demonstrating the feasibility and safety of M1-tDCS as a potential adjuvant neuromechanism-driven analgesic therapy for head and neck cancer patients receiving CRT, inducing immediate and long-term changes in the cortical activity and clinical measures, with minimal side-effects.
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Affiliation(s)
- Xiao-Su Hu
- Headache and Orofacial Pain Effort Lab, School of Dentistry, Department of Biologic and Materials Sciences, University of MichiganAnn Arbor, MI, USA
- Center for Human Growth and Development, University of MichiganAnn Arbor, MI, USA
| | - Clayton A. Fisher
- Headache and Orofacial Pain Effort Lab, School of Dentistry, Department of Biologic and Materials Sciences, University of MichiganAnn Arbor, MI, USA
- Division of Oral Pathology, Department of Periodontics and Oral Medicine, University of MichiganAnn Arbor, MI, USA
| | - Stephanie M. Munz
- Department of Oral and Maxillofacial Surgery/Hospital Dentistry, University of MichiganAnn Arbor, MI, USA
| | - Rebecca L. Toback
- Headache and Orofacial Pain Effort Lab, School of Dentistry, Department of Biologic and Materials Sciences, University of MichiganAnn Arbor, MI, USA
| | - Thiago D. Nascimento
- Headache and Orofacial Pain Effort Lab, School of Dentistry, Department of Biologic and Materials Sciences, University of MichiganAnn Arbor, MI, USA
| | - Emily L. Bellile
- Headache and Orofacial Pain Effort Lab, School of Dentistry, Department of Biologic and Materials Sciences, University of MichiganAnn Arbor, MI, USA
- Biostatistics Department, University of MichiganAnn Arbor, MI, USA
| | - Laura Rozek
- Biostatistics Department, University of MichiganAnn Arbor, MI, USA
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of MichiganAnn Arbor, MI, USA
| | - Francis P. Worden
- Department of Internal Medicine Oncology, University of MichiganAnn Arbor, MI, USA
| | - Theodora E. Danciu
- Division of Oral Pathology, Department of Periodontics and Oral Medicine, University of MichiganAnn Arbor, MI, USA
| | - Alexandre F. DaSilva
- Headache and Orofacial Pain Effort Lab, School of Dentistry, Department of Biologic and Materials Sciences, University of MichiganAnn Arbor, MI, USA
- Center for Human Growth and Development, University of MichiganAnn Arbor, MI, USA
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18
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Nardone R, Höller Y, Langthaler PB, Lochner P, Golaszewski S, Schwenker K, Brigo F, Trinka E. rTMS of the prefrontal cortex has analgesic effects on neuropathic pain in subjects with spinal cord injury. Spinal Cord 2016; 55:20-25. [DOI: 10.1038/sc.2016.87] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 11/26/2015] [Accepted: 11/30/2015] [Indexed: 01/24/2023]
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Lindholm P, Lamusuo S, Taiminen T, Pesonen U, Lahti A, Virtanen A, Forssell H, Hietala J, Hagelberg N, Pertovaara A, Parkkola R, Jääskeläinen S. Right secondary somatosensory cortex-a promising novel target for the treatment of drug-resistant neuropathic orofacial pain with repetitive transcranial magnetic stimulation. Pain 2015; 156:1276-1283. [PMID: 25830924 DOI: 10.1097/j.pain.0000000000000175] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
High-frequency repetitive transcranial magnetic stimulation (rTMS) of the motor cortex has analgesic effect; however, the efficacy of other cortical targets and the mode of action remain unclear. We examined the effects of rTMS in neuropathic orofacial pain, and compared 2 cortical targets against placebo. Furthermore, as dopaminergic mechanisms modulate pain responses, we assessed the influence of the functional DRD2 gene polymorphism (957C>T) and the catechol-O-methyltransferase (COMT) Val158Met polymorphism on the analgesic effect of rTMS. Sixteen patients with chronic drug-resistant neuropathic orofacial pain participated in this randomized, placebo-controlled, crossover study. Navigated high-frequency rTMS was given to the sensorimotor (S1/M1) and the right secondary somatosensory (S2) cortices. All subjects were genotyped for the DRD2 957C>T and COMT Val158Met polymorphisms. Pain, mood, and quality of life were monitored throughout the study. The numerical rating scale pain scores were significantly lower after the S2 stimulation than after the S1/M1 (P = 0.0071) or the sham (P = 0.0187) stimulations. The Brief Pain Inventory scores were also lower 3 to 5 days after the S2 stimulation than those at pretreatment baseline (P = 0.0127 for the intensity of pain and P = 0.0074 for the interference of pain) or after the S1/M1 (P = 0.001 and P = 0.0001) and sham (P = 0.0491 and P = 0.0359) stimulations. No correlations were found between the genetic polymorphisms and the analgesic effect in the present small clinical sample. The right S2 cortex is a promising new target for the treatment of neuropathic orofacial pain with high-frequency rTMS.
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Affiliation(s)
- Pauliina Lindholm
- Department of Neurology, Turku University Hospital, Salo Hospital, University of Turku, Turku, Finland Departments of Clinical Neurophysiology, and Psychiatry, Turku University Hospital, University of Turku, Turku, Finland Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland Department of Statistics, University of Turku, Turku, Finland Institute of Dentistry, University of Turku, Turku, Finland Pain Clinic, Turku University Hospital, University of Turku, Turku, Finland Department of Physiology, Institute of Biomedicine, University of Helsinki, Helsinki, Finland Department of Diagnostic Radiology, Turku University Hospital, University of Turku, Turku, Finland
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Wiech K, Edwards R, Moseley GL, Berna C, Ploner M, Tracey I. Dissociable neural mechanisms underlying the modulation of pain and anxiety? An FMRI pilot study. PLoS One 2014; 9:e110654. [PMID: 25502237 PMCID: PMC4266493 DOI: 10.1371/journal.pone.0110654] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 09/18/2014] [Indexed: 12/29/2022] Open
Abstract
The down-regulation of pain through beliefs is commonly discussed as a form of emotion regulation. In line with this interpretation, the analgesic effect has been shown to co-occur with reduced anxiety and increased activity in the ventrolateral prefrontal cortex (VLPFC), which is a key region of emotion regulation. This link between pain and anxiety modulation raises the question whether the two effects are rooted in the same neural mechanism. In this pilot fMRI study, we compared the neural basis of the analgesic and anxiolytic effect of two types of threat modulation: a “behavioral control” paradigm, which involves the ability to terminate a noxious stimulus, and a “safety signaling” paradigm, which involves visual cues that signal the threat (or absence of threat) that a subsequent noxious stimulus might be of unusually high intensity. Analgesia was paralleled by VLPFC activity during behavioral control. Safety signaling engaged elements of the descending pain control system, including the rostral anterior cingulate cortex that showed increased functional connectivity with the periaqueductal gray and VLPFC. Anxiety reduction, in contrast, scaled with dorsolateral prefrontal cortex activation during behavioral control but had no distinct neural signature during safety signaling. Our pilot data therefore suggest that analgesic and anxiolytic effects are instantiated in distinguishable neural mechanisms and differ between distinct stress- and pain-modulatory approaches, supporting the recent notion of multiple pathways subserving top-down modulation of the pain experience. Additional studies in larger cohorts are needed to follow up on these preliminary findings.
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Affiliation(s)
- Katja Wiech
- Nuffield Department of Clinical Neurosciences (Nuffield Division Anaesthetics), University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU, Oxford, United Kingdom
- Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU, Oxford, United Kingdom
- * E-mail:
| | - Robert Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Chestnut Hill, Massachusetts, United States of America
| | - Graham Lorimer Moseley
- Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU, Oxford, United Kingdom
- Sansom Institute for Health Research, University of South Australia, Adelaide 5000, Australia & Neuroscience Research Australia, Sydney, Australia
| | - Chantal Berna
- Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU, Oxford, United Kingdom
- Department of Psychiatry, University of Oxford, OX3 7JX, Oxford, United Kingdom
| | - Markus Ploner
- Department of Neurology, Technische Universität München, Munich, Germany
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences (Nuffield Division Anaesthetics), University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU, Oxford, United Kingdom
- Oxford Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU, Oxford, United Kingdom
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Repetitive Transcranial Magnetic Stimulation of the Left Premotor/Dorsolateral Prefrontal Cortex Does Not Have Analgesic Effect on Central Poststroke Pain. THE JOURNAL OF PAIN 2014; 15:1271-81. [DOI: 10.1016/j.jpain.2014.09.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 08/30/2014] [Accepted: 09/04/2014] [Indexed: 01/09/2023]
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Taylor JJ, Neitzke DJ, Khouri G, Borckardt JJ, Acierno R, Tuerk PW, Schmidt M, George MS. A pilot study to investigate the induction and manipulation of learned helplessness in healthy adults. Psychiatry Res 2014; 219:631-7. [PMID: 25023370 PMCID: PMC4186698 DOI: 10.1016/j.psychres.2014.05.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 05/13/2014] [Accepted: 05/22/2014] [Indexed: 10/25/2022]
Abstract
Eliminating the controllability of a noxious stimulus may induce a learned helplessness (LH) that resembles aspects of depression and post-traumatic stress disorder (PTSD). This study examined whether repetitive transcranial magnetic stimulation (rTMS) of the left dorsolateral prefrontal cortex (DLPFC) promotes resilience in an aversive stimulus model of LH. All 55 participants were told that an undisclosed sequence of button presses would terminate an aversive stimulus on their forearm. In truth, only half had control (+C). The other half had no control (-C). All participants received real (R) or sham (S) left DLPFC rTMS during the paradigm (+C/R, -C/S,+C/S,-C/R). We evaluated the cognitive effects of LH using an anagram task. The LH paradigm successfully reduced perceived control in the -C groups. As predicted, the +C/R and +C/S groups tended to give up less quickly and take less time to solve each anagram than did the -C/S group. Superior anagram performance in the -C/R group approached statistical significance. Our preliminary results suggest that manipulating the controllability of an aversive stimulus may induce an LH effect that manifests as impaired anagram performance. Further research is needed to refine this model and determine if DLPFC rTMS mitigates any LH effects.
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Affiliation(s)
| | | | - George Khouri
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Ron Acierno
- Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Peter W Tuerk
- Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | | | - Mark S George
- Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
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Abstract
The involvement of the primary motor cortex (M1) in chronic low back pain (LBP) is a relatively new concept. Decreased M1 excitability and an analgesic effect after M1 stimulation have been recently reported. However, the neurochemical changes underlying these functional M1 changes are unknown. The current study investigated whether neurochemicals specific to neurons and glial cells in both right and left M1 are altered. N-Acetylaspartate (NAA) and myo-inositol (mI) were measured with proton magnetic resonance spectroscopy in 19 subjects with chronic LBP and 14 healthy controls. We also examined correlations among neurochemicals within and between M1 and relationships between neurochemical concentrations and clinical features of pain. Right M1 NAA was lower in subjects with LBP compared to controls (p = 0.008). Left M1 NAA and mI were not significantly different between LBP and control groups. Correlations between neurochemical concentrations across M1s were different between groups (p = 0.008). There were no significant correlations between M1 neurochemicals and pain characteristics. These findings provide preliminary evidence of neuronal depression and altered neuronal-glial interactions across M1 in chronic LBP.
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24
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George MS, Raman R, Benedek DM, Pelic CG, Grammer GG, Stokes KT, Schmidt M, Spiegel C, Dealmeida N, Beaver KL, Borckardt JJ, Sun X, Jain S, Stein MB. A two-site pilot randomized 3 day trial of high dose left prefrontal repetitive transcranial magnetic stimulation (rTMS) for suicidal inpatients. Brain Stimul 2014; 7:421-31. [PMID: 24731434 DOI: 10.1016/j.brs.2014.03.006] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 03/07/2014] [Accepted: 03/11/2014] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Suicide attempts and completed suicides are common, yet there are no proven acute medication or device treatments for treating a suicidal crisis. Repeated daily left prefrontal repetitive transcranial magnetic stimulation (rTMS) for 4-6 weeks is a new FDA-approved treatment for acute depression. Some open-label rTMS studies have found rapid reductions in suicidality. DESIGN This study tests whether a high dose of rTMS to suicidal inpatients is feasible and safe, and also whether this higher dosing might rapidly improve suicidal thinking. This prospective, 2-site, randomized, active sham-controlled (1:1 randomization) design incorporated 9 sessions of rTMS over 3 days as adjunctive to usual inpatient suicidality treatment. The setting was two inpatient military hospital wards (one VA, the other DOD). PATIENTS Research staff screened approximately 377 inpatients, yielding 41 adults admitted for suicidal crisis. Because of the funding source, all patients also had either post-traumatic stress disorder, mild traumatic brain injury, or both. TMS METHODS Repetitive TMS (rTMS) was delivered to the left prefrontal cortex with a figure-eight solid core coil at 120% motor threshold, 10 Hertz (Hz), 5 second (s) train duration, 10 s intertrain interval for 30 minutes (6000 pulses) 3 times daily for 3 days (total 9 sessions; 54,000 stimuli). Sham rTMS used a similar coil that contained a metal insert blocking the magnetic field and utilized electrodes on the scalp, which delivered a matched somatosensory sensation. MAIN OUTCOME MEASURE Primary outcomes were the daily change in severity of suicidal thinking as measured by the Beck Scale of Suicidal Ideation (SSI) administered at baseline and then daily, as well as subjective visual analog scale measures before and after each TMS session. Mixed model repeated measures (MMRM) analysis was performed on modified intent to treat (mITT) and completer populations. RESULTS This intense schedule of rTMS with suicidal inpatients was feasible and safe. Minimal side effects occurred, none differing by arm, and the 3-day retention rate was 88%. No one died of suicide within the 6 month followup. From the mITT analyses, SSI scores declined rapidly over the 3 days for both groups (sham change -15.3 points, active change -15.4 points), with a trend for more rapid decline on the first day with active rTMS (sham change -6.4 points, active -10.7 points, P = 0.12). This decline was more pronounced in the completers subgroup [sham change -5.9 (95% CI: -10.1, -1.7), active -13 points (95% CI: -18.7, -7.4); P = 0.054]. Subjective ratings of 'being bothered by thoughts of suicide' declined non-significantly more with active rTMS than with sham at the end of 9 sessions of treatment in the mITT analysis [sham change -31.9 (95% CI: -41.7, -22.0), active change -42.5 (95% CI: -53.8, -31.2); P = 0.17]. There was a significant decrease in the completers sample [sham change -24.9 (95% CI: -34.4, -15.3), active change -43.8 (95% CI: -57.2, -30.3); P = 0.028]. CONCLUSIONS Delivering high doses of left prefrontal rTMS over three days (54,000 stimuli) to suicidal inpatients is possible and safe, with few side effects and no worsening of suicidal thinking. The suggestions of a rapid anti-suicide effect (day 1 SSI data, Visual Analogue Scale data over the 3 days) need to be tested for replication in a larger sample. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01212848, TMS for suicidal ideation.
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Affiliation(s)
- Mark S George
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA; Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA.
| | - Rema Raman
- Department of Psychiatry, University of California at San Diego (UCSD), USA
| | | | - Christopher G Pelic
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA; Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | | | - Karen T Stokes
- Department of Psychiatry, University of California at San Diego (UCSD), USA
| | - Matthew Schmidt
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA; Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - Chad Spiegel
- Walter Reed National Military Medical Center, USA
| | | | - Kathryn L Beaver
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA; Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - Jeffrey J Borckardt
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA; Brain Stimulation Division, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - Xiaoying Sun
- Department of Psychiatry, University of California at San Diego (UCSD), USA
| | - Sonia Jain
- Department of Psychiatry, University of California at San Diego (UCSD), USA
| | - Murray B Stein
- Department of Psychiatry, University of California at San Diego (UCSD), USA
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Müller MJ. Depressive attribution style and stressor uncontrollability increase perceived pain intensity after electric skin stimuli in healthy young men. Pain Res Manag 2013; 18:203-206. [PMID: 23717827 PMCID: PMC3812192 DOI: 10.1155/2013/263084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
BACKGROUND Depressive and pain symptoms often occur concurrently in patients with psychiatric disorders or somatic diseases, but the contribution of pre-existing dysfunctional cognitive schemata to pain perception remains unclear. OBJECTIVE To investigate the relationship between depression-related attribution styles and perceived pain intensity (PPI) after controllable versus uncontrollable electrical skin stimulation in healthy male individuals. METHODS Causal attributions for negative events were measured using the attribution style questionnaire (ASQ) on the dimensions internal versus external (INT), global versus specific (GLO) and stable versus unstable (STA) in 50 men (20 to 31 years of age). Additionally, symptoms of anxiety and depression (measured using the depression scale) as well as baseline helplessness were assessed. Participants were randomly assigned to receive self-administered (controllable) or experimenter-administered (uncontrollable) painful skin stimuli. PPI was assessed after stress exposure using a visual analogue scale (0 to 100). Relationships between PPI and depression-related cognitions were calculated using correlation and multiple regression analyses. RESULTS Correlation analyses revealed a moderate correlation between PPI and ASQ-INT scores (r=0.46). Following uncontrollable stress exposure, significantly higher PPI ratings (P=0.001) and a higher correlation between PPI and ASQ-INT (r=0.70) were observed. Multiple regression analysis showed an independent influence of stressor controllability (ß=0.39; P=0.003) and ASQ-INT (ß=0.36; P=0.006) on PPI. DISCUSSION These findings highlight the interaction of specific depression-related cognitions and stress controllability on pain intensity perception. CONCLUSIONS The results of the present study may facilitate understanding of the cognitive aspects of pain intensity perception and improve psychological pain therapies focusing on attributions and controllability.
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Affiliation(s)
- Matthias Johannes Müller
- Vistos Clinics for Psychiatry, Psychosomatic Medicine, and Psychotherapy Giessen and Masbuerg, Germany.
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Taylor JJ, Borckardt JJ, Canterberry M, Li X, Hanlon CA, Brown TR, George MS. Naloxone-reversible modulation of pain circuitry by left prefrontal rTMS. Neuropsychopharmacology 2013; 38:1189-97. [PMID: 23314221 PMCID: PMC3656361 DOI: 10.1038/npp.2013.13] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A 20-minute session of 10 Hz repetitive transcranial magnetic stimulation (rTMS) of Brodmann Area (BA) nine of the left dorsolateral prefrontal cortex (DLPFC) can produce analgesic effects on postoperative and laboratory-induced pain. This analgesia is blocked by pretreatment with naloxone, a μ-opioid antagonist. The purpose of this sham-controlled, double-blind, crossover study was to identify the neural circuitry that underlies the analgesic effects of left DLPFC rTMS, and to examine how the function of this circuit, including midbrain and medulla, changes during opioid blockade. Fourteen healthy volunteers were randomized to receive intravenous saline or naloxone immediately before sham and real left DLPFC rTMS on the same experimental visit. One week later, each participant received the novel pretreatment but the same stimulation paradigm. Using short sessions of heat on capsaicin-sensitized skin, hot allodynia was assessed during 3 Tesla functional magnetic resonance imaging (fMRI) scanning at baseline, post-sham rTMS, and post-real rTMS. Data were analyzed using whole-brain voxel-based analysis, as well as time series extractions from anatomically-defined regions of interest representing midbrain and medulla. Consistent with previous findings, real rTMS significantly reduced hot allodynia pain ratings. This analgesia was associated with elevated blood oxygenation-level dependent (BOLD) signal in BAs 9 and 10, and diminished BOLD signal in the anterior cingulate, thalamus, midbrain, and medulla during pain. Naloxone pretreatment largely abolished rTMS-induced analgesia, as well as rTMS-induced attenuation of BOLD signal response to painful stimuli throughout pain processing regions, including midbrain and medulla. These preliminary results suggest that left DLPFC rTMS drives top-down opioidergic analgesia.
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Affiliation(s)
- Joseph J Taylor
- Brain Stimulation Laboratory, Department of Psychiatry, Medical University of South Carolina, Charleston, SC 29414, USA.
| | - Jeffrey J Borckardt
- Brain Stimulation Laboratory, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - Melanie Canterberry
- Brain Stimulation Laboratory, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - Xingbao Li
- Brain Stimulation Laboratory, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - Colleen A Hanlon
- Brain Stimulation Laboratory, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - Truman R Brown
- Center for Biomedical Imaging, Department of Radiology, Medical University of South Carolina, Charleston, SC, USA
| | - Mark S George
- Brain Stimulation Laboratory, Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA,Ralph H. Johnson VA Medical Center, Charleston, SC, USA
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Uncertainty increases pain: evidence for a novel mechanism of pain modulation involving the periaqueductal gray. J Neurosci 2013; 33:5638-46. [PMID: 23536078 DOI: 10.1523/jneurosci.4984-12.2013] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Predictions about sensory input exert a dominant effect on what we perceive, and this is particularly true for the experience of pain. However, it remains unclear what component of prediction, from an information-theoretic perspective, controls this effect. We used a vicarious pain observation paradigm to study how the underlying statistics of predictive information modulate experience. Subjects observed judgments that a group of people made to a painful thermal stimulus, before receiving the same stimulus themselves. We show that the mean observed rating exerted a strong assimilative effect on subjective pain. In addition, we show that observed uncertainty had a specific and potent hyperalgesic effect. Using computational functional magnetic resonance imaging, we found that this effect correlated with activity in the periaqueductal gray. Our results provide evidence for a novel form of cognitive hyperalgesia relating to perceptual uncertainty, induced here by vicarious observation, with control mediated by the brainstem pain modulatory system.
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Barwood CHS, Murdoch BE. rTMS as a treatment for neurogenic communication and swallowing disorders. Acta Neurol Scand 2013; 127:77-91. [PMID: 22881826 DOI: 10.1111/j.1600-0404.2012.01710.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2012] [Indexed: 11/26/2022]
Abstract
Recent years have seen the introduction of non-invasive brain stimulation techniques (e.g. transcranial direct current stimulation and transcranial magnetic stimulation) utilized to target neural-based pathologies, for therapeutic gain. The direct manipulation of cortical brain activity by repetitive transcranial magnetic stimulation (rTMS) could potentially serve as an efficacious complimentary rehabilitatory treatment for speech, language and swallowing disorders of a neurological origin. The high prevalence of positive reports on communication and swallowing outcomes support these premises. Nonetheless, experimental evidence to date in some areas is considered rudimentary and is deficient in providing placebo-controlled substantiation of longitudinal neuroplastic change subsequent to stimulation. The most affirmative therapeutic responses have arisen from small placebo-controlled trials using low-frequency rTMS for patients with non-fluent aphasia and high-frequency rTMS applied to individuals with Parkinson's disease to improve motor speech performance and outcomes. Preliminary studies applying rTMS to ameliorate dysphagic symptoms post-stroke provide positive swallowing outcomes for patients. Further research into the optimization of rTMS protocols, including dosage, stimulation targets for maximal efficacy and placebo techniques, is critically needed to provide a fundamental basis for clinical interventions using this technique. rTMS represents a highly promising and clinically relevant technique, warranting the future development of clinical trials across a spectrum of communication and swallowing pathologies, to substantiate and expand on the methods outlined in published reports.
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Affiliation(s)
- C. H. S. Barwood
- Centre for Neurogenic Communication Disorders Research; School of Health and Rehabilitation Sciences; The University of Queensland; Brisbane; Queensland; Australia
| | - B. E. Murdoch
- Centre for Neurogenic Communication Disorders Research; School of Health and Rehabilitation Sciences; The University of Queensland; Brisbane; Queensland; Australia
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Noninvasive cortical modulation of experimental pain. Pain 2012; 153:1350-1363. [DOI: 10.1016/j.pain.2012.04.009] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 04/05/2012] [Accepted: 04/09/2012] [Indexed: 01/09/2023]
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Plow EB, Pascual-Leone A, Machado A. Brain stimulation in the treatment of chronic neuropathic and non-cancerous pain. THE JOURNAL OF PAIN 2012; 13:411-24. [PMID: 22484179 DOI: 10.1016/j.jpain.2012.02.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 12/27/2011] [Accepted: 02/02/2012] [Indexed: 01/16/2023]
Abstract
UNLABELLED Chronic neuropathic pain is one of the most prevalent and debilitating disorders. Conventional medical management, however, remains frustrating for both patients and clinicians owing to poor specificity of pharmacotherapy, delayed onset of analgesia and extensive side effects. Neuromodulation presents as a promising alternative, or at least an adjunct, as it is more specific in inducing analgesia without associated risks of pharmacotherapy. Here, we discuss common clinical and investigational methods of neuromodulation. Compared to clinical spinal cord stimulation (SCS), investigational techniques of cerebral neuromodulation, both invasive (deep brain stimulation [DBS] and motor cortical stimulation [MCS]) and noninvasive (repetitive transcranial magnetic stimulation [rTMS] and transcranial direct current stimulation [tDCS]), may be more advantageous. By adaptively targeting the multidimensional experience of pain, subtended by integrative pain circuitry in the brain, including somatosensory and thalamocortical, limbic and cognitive, cerebral methods may modulate the sensory-discriminative, affective-emotional and evaluative-cognitive spheres of the pain neuromatrix. Despite promise, the current state of results alludes to the possibility that cerebral neuromodulation has thus far not been effective in producing analgesia as intended in patients with chronic pain disorders. These techniques, thus, remain investigational and off-label. We discuss issues implicated in inadequate efficacy, variability of responsiveness, and poor retention of benefit, while recommending design and conceptual refinements for future trials of cerebral neuromodulation in management of chronic neuropathic pain. PERSPECTIVE This critical review focuses on factors contributing to poor therapeutic utility of invasive and noninvasive brain stimulation in the treatment of chronic neuropathic and pain of noncancerous origin. Through key clinical trial design and conceptual refinements, retention and consistency of response may be improved, potentially facilitating the widespread clinical applicability of such approaches.
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Affiliation(s)
- Ela B Plow
- Department of Biomedical Engineering, Lerner Research Institute, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Müller MJ. Helplessness and perceived pain intensity: relations to cortisol concentrations after electrocutaneous stimulation in healthy young men. Biopsychosoc Med 2011; 5:8. [PMID: 21718526 PMCID: PMC3141369 DOI: 10.1186/1751-0759-5-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Accepted: 06/30/2011] [Indexed: 01/24/2023] Open
Abstract
Background Uncontrollable aversive events are associated with feelings of helplessness and cortisol elevation and are suitable as a model of depression. The high comorbidity of depression and pain symptoms and the importance of controllability in both conditions are clinically well-known but empirical studies are scarce. The study investigated the relationship of pain experience, helplessness, and cortisol secretion after controllable vs. uncontrollable electric skin stimulation in healthy male individuals. Methods Sixty-four male volunteers were randomly assigned to receive 30 controllable (self-administered) or uncontrollable (experimenter-administered) painful electric skin stimuli. Perceived pain intensity (PPI), subjective helplessness ratings, and salivary cortisol concentrations were assessed. PPI was assessed after stress exposure. For salivary cortisol concentrations and subjective helplessness ratings, areas under the response curve (AUC) were calculated. Results After uncontrollable vs. controllable stress exposure significantly higher PPI ratings (P = 0.023), higher subjective helplessness AUC (P < 0.0005) and higher salivary cortisol AUC (P = 0.004, t-tests) were found. Correlation analyses revealed a significant correlation between subjective helplessness AUC and PPI (r = 0.500, P < 0.0005), subjective helplessness AUC and salivary cortisol AUC (r = 0.304, P = 0.015) and between PPI and salivary cortisol AUC (r = 0.298, P = 0.017). Conclusions The results confirm the impact of uncontrollability on stress responses in humans; the relationship of PPI with subjective helplessness and salivary cortisol suggests a cognitive-affective sensitization of pain perception, particularly under uncontrollable conditions.
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Affiliation(s)
- Matthias J Müller
- Vitos Clinical Centre Giessen-Marburg Clinic for Psychiatry, Psychosomatic Medicine and Psychotherapy Giessen Academic Hospital, University of Giessen, Licher Straße 106, 35394 Giessen, Germany.
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