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Shlobin NA, Rosenow JM. Ethical Considerations in the Implantation of Neuromodulatory Devices. Neuromodulation 2022; 25:222-231. [PMID: 35125141 DOI: 10.1111/ner.13357] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/26/2020] [Accepted: 12/21/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Neuromodulatory devices are increasingly used by neurosurgeons to manage a variety of chronic conditions. Given their potential benefits, it is imperative to create clear ethical guidelines for the use of these devices. We present a tiered ethical framework for neurosurgeon recommendations for the use of neuromodulatory devices. MATERIALS AND METHODS We conducted a literature review to identify factors neurosurgeons should consider when choosing to offer a neuromodulatory device to a patient. RESULTS Neurosurgeons must weigh reductions in debilitating symptoms, improved functionality, and preserved quality of life against risks for intraoperative complications and adverse events due to stimulation or the device itself. Neurosurgeons must also evaluate whether patients and families will maintain responsibility for the management of neuromodulatory devices. Consideration of these factors should occur on an axis of resource allocation, ranging from provision of neuromodulatory devices to those with greatest potential benefit in resource-limited settings to provision of neuromodulatory devices to all patients with indications in contexts without resource limitations. Neurosurgeons must also take action to promote device effectiveness throughout the duration of care. CONCLUSIONS Weighing risks and benefits of providing neuromodulatory devices and assessing ability to remain responsible for the devices on the level of the individual patient indicate which patients are most likely to achieve benefit from these devices. Consideration of these factors on an axis of resource allocation will allow for optimal provision of neuromodulatory devices to patients in settings of varied resources. Neurosurgeons play a primary role in promoting the effectiveness of these devices.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
| | - Joshua M Rosenow
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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Shlobin NA, Campbell JM, Rosenow JM, Rolston JD. Ethical considerations in the surgical and neuromodulatory treatment of epilepsy. Epilepsy Behav 2022; 127:108524. [PMID: 34998267 PMCID: PMC10184316 DOI: 10.1016/j.yebeh.2021.108524] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/19/2021] [Accepted: 12/19/2021] [Indexed: 02/08/2023]
Abstract
Surgical resection and neuromodulation are well-established treatments for those with medically refractory epilepsy. These treatments entail important ethical considerations beyond those which extend to the treatment of epilepsy generally. In this paper, the authors explore these unique considerations through a framework that relates foundational principles of bioethics to features of resective epilepsy surgery and neuromodulation. The authors conducted a literature review to identify ethical considerations for a variety of epilepsy surgery procedures and to examine how foundational principles in bioethics may inform treatment decisions. Healthcare providers should be cognizant of how an increased prevalence of somatic and psychiatric comorbidities, the dynamic nature of symptom burden over time, the individual and systemic barriers to treatment, and variable sociocultural contexts constitute important ethical considerations regarding the use of surgery or neuromodulation for the treatment of epilepsy. Moreover, careful attention should be paid to how resective epilepsy surgery and neuromodulation relate to notions of patient autonomy, safety and privacy, and the shared responsibility for device management and maintenance. A three-tiered approach-(1) gathering information and assessing the risks and benefits of different treatment options, (2) clear communication with patient or proxy with awareness of patient values and barriers to treatment, and (3) long-term decision maintenance through continued identification of gaps in understanding and provision of information-allows for optimal treatment of the individual person with epilepsy while minimizing disparities in epilepsy care.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Justin M Campbell
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA; Department of Neuroscience, University of Utah, Salt Lake City, UT, USA
| | - Joshua M Rosenow
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John D Rolston
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA; Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
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Jobst BM, Atasoy S, Ponce-Alvarez A, Sanjuán A, Roseman L, Kaelen M, Carhart-Harris R, Kringelbach ML, Deco G. Increased sensitivity to strong perturbations in a whole-brain model of LSD. Neuroimage 2021; 230:117809. [PMID: 33524579 PMCID: PMC8063176 DOI: 10.1016/j.neuroimage.2021.117809] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 01/02/2021] [Accepted: 01/25/2021] [Indexed: 02/09/2023] Open
Abstract
Novel offline perturbational method applied on functional magnetic resonance imaging (fMRI) data under the effect of lysergic acid diethylamide (LSD). Shift of brain's global working point to more complex dynamics after LSD intake. Consistently longer recovery time after model perturbation under LSD influence. Strongest effects in resting state networks relevant for psychedelic experience. Higher response diversity across brain regions under LSD influence after an external in silico perturbation.
Lysergic acid diethylamide (LSD) is a potent psychedelic drug, which has seen a revival in clinical and pharmacological research within recent years. Human neuroimaging studies have shown fundamental changes in brain-wide functional connectivity and an expansion of dynamical brain states, thus raising the question about a mechanistic explanation of the dynamics underlying these alterations. Here, we applied a novel perturbational approach based on a whole-brain computational model, which opens up the possibility to externally perturb different brain regions in silico and investigate differences in dynamical stability of different brain states, i.e. the dynamical response of a certain brain region to an external perturbation. After adjusting the whole-brain model parameters to reflect the dynamics of functional magnetic resonance imaging (fMRI) BOLD signals recorded under the influence of LSD or placebo, perturbations of different brain areas were simulated by either promoting or disrupting synchronization in the regarding brain region. After perturbation offset, we quantified the recovery characteristics of the brain area to its basal dynamical state with the Perturbational Integration Latency Index (PILI) and used this measure to distinguish between the two brain states. We found significant changes in dynamical complexity with consistently higher PILI values after LSD intake on a global level, which indicates a shift of the brain's global working point further away from a stable equilibrium as compared to normal conditions. On a local level, we found that the largest differences were measured within the limbic network, the visual network and the default mode network. Additionally, we found a higher variability of PILI values across different brain regions after LSD intake, indicating higher response diversity under LSD after an external perturbation. Our results provide important new insights into the brain-wide dynamical changes underlying the psychedelic state - here provoked by LSD intake - and underline possible future clinical applications of psychedelic drugs in particular psychiatric disorders.
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Affiliation(s)
- Beatrice M Jobst
- Center for Brain and Cognition, Computational Neuroscience Group, Universitat Pompeu Fabra, Calle Ramón Trias Fargas 25-27, 08005 Barcelona, Spain.
| | - Selen Atasoy
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom; Center of Music in the Brain (MIB), Clinical Medicine, Aarhus University, Denmark
| | - Adrián Ponce-Alvarez
- Center for Brain and Cognition, Computational Neuroscience Group, Universitat Pompeu Fabra, Calle Ramón Trias Fargas 25-27, 08005 Barcelona, Spain
| | - Ana Sanjuán
- Center for Brain and Cognition, Computational Neuroscience Group, Universitat Pompeu Fabra, Calle Ramón Trias Fargas 25-27, 08005 Barcelona, Spain
| | - Leor Roseman
- Centre for Psychedelic Research, Department of Brain Sciences, Imperial College London, United Kingdom
| | - Mendel Kaelen
- Centre for Psychedelic Research, Department of Brain Sciences, Imperial College London, United Kingdom
| | - Robin Carhart-Harris
- Centre for Psychedelic Research, Department of Brain Sciences, Imperial College London, United Kingdom
| | - Morten L Kringelbach
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom; Center of Music in the Brain (MIB), Clinical Medicine, Aarhus University, Denmark
| | - Gustavo Deco
- Center for Brain and Cognition, Computational Neuroscience Group, Universitat Pompeu Fabra, Calle Ramón Trias Fargas 25-27, 08005 Barcelona, Spain; Institució Catalana de la Recerca i Estudis Avançats (ICREA), Barcelona, Spain; Department of Neuropsychology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; School of Psychological Sciences, Monash University, Clayton, Melbourne, Australia
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Desmoulin-Canselier S. Patient's lived experience with DBS between medical research and care: some legal implications. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2019; 22:375-386. [PMID: 30074133 DOI: 10.1007/s11019-018-9859-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In the past 50 years, an ethical-legal boundary has been drawn between treatment and research. It is based on the reasoning that the two activities pursue different purposes. Treatment is aimed at achieving optimal therapeutic benefits for the individual patient, whereas the goal of scientific research is to increase knowledge, in the public interest. From this viewpoint, the patient's experience should be clearly distinguished from that of a participant in a clinical trial. On this premise, two parallel and mutually exclusive regimes have been established. Yet in the case of deep brain stimulation (DBS), this presentation is a poor fit, for both the patient's lived experience and medical practice and research. The frictions may be explained by the specificities of the treatment (including surgery and medical devices) and of the pathologies concerned (chronic and evolutive), and by the characteristics of the medical team implementing the treatment. These particularities challenge the dominant frame of reference in medical bioethics and cause difficulties for the current legal framework in fulfilling its dual role: to protect patients while supporting the development of innovative treatments. The dominant model is still the clinical trial for medication safety and legal requirements of drug market regulation. However, DBS forces us to reflect on a medical device that is permanently implanted in the brain by highly specialized multi-disciplinary neurosurgical teams, for the treatment of chronic evolutive diseases. These devices demand fine-tuning on a case-by-case basis and there is still a lot to discover about why DBS is effective (or not). As a result, the wall between treatment and research is osmotic: many discoveries are made incidentally, in the course of treatment. The following study begins with these observations, and suggests that we review legal provisions (especially in French and United States law) so that they are better adapted to the first-person needs and experience of the patient undergoing brain stimulation.
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Affiliation(s)
- Sonia Desmoulin-Canselier
- CNRS/Université de Nantes UMR 6297 Droit et Changement Social, Faculté de Droit et de sciences politiques, Université de Nantes, Chemin de la Censive du Tertre, Nantes, France.
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Chen X, Zhang C, Li Y, Huang P, Lv Q, Yu W, Chen S, Sun B, Wang Z. Functional Connectivity-Based Modelling Simulates Subject-Specific Network Spreading Effects of Focal Brain Stimulation. Neurosci Bull 2018; 34:921-938. [PMID: 30043099 PMCID: PMC6246850 DOI: 10.1007/s12264-018-0256-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 05/16/2018] [Indexed: 12/23/2022] Open
Abstract
Neurostimulation remarkably alleviates the symptoms in a variety of brain disorders by modulating the brain-wide network. However, how brain-wide effects on the direct and indirect pathways evoked by focal neurostimulation elicit therapeutic effects in an individual patient is unknown. Understanding this remains crucial for advancing neural circuit-based guidance to optimize candidate patient screening, pre-surgical target selection, and post-surgical parameter tuning. To address this issue, we propose a functional brain connectome-based modeling approach that simulates the spreading effects of stimulating different brain regions and quantifies the rectification of abnormal network topology in silico. We validated these analyses by pinpointing nuclei in the basal ganglia circuits as top-ranked targets for 43 local patients with Parkinson’s disease and 90 patients from a public database. Individual connectome-based analysis demonstrated that the globus pallidus was the best choice for 21.1% and the subthalamic nucleus for 19.5% of patients. Down-regulation of functional connectivity (up to 12%) at these prioritized targets optimally maximized the therapeutic effects. Notably, the priority rank of the subthalamic nucleus significantly correlated with motor symptom severity (Unified Parkinson’s Disease Rating Scale III) in the local cohort. These findings underscore the potential of neural network modeling for advancing personalized brain stimulation therapy, and warrant future experimental investigation to validate its clinical utility.
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Affiliation(s)
- Xiaoyu Chen
- Institute of Neuroscience, State Key Laboratory of Neuroscience, Chinese Academy of Sciences Center for Excellence in Brain Science and Intelligence Technology, Shanghai Institute for Biological Sciences, Chinese Academy of Sciences, Shanghai, 200031, China.,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Chencheng Zhang
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Yuxin Li
- Institute of Neuroscience, State Key Laboratory of Neuroscience, Chinese Academy of Sciences Center for Excellence in Brain Science and Intelligence Technology, Shanghai Institute for Biological Sciences, Chinese Academy of Sciences, Shanghai, 200031, China.,Department of Radiology, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Pei Huang
- Department of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Qian Lv
- Institute of Neuroscience, State Key Laboratory of Neuroscience, Chinese Academy of Sciences Center for Excellence in Brain Science and Intelligence Technology, Shanghai Institute for Biological Sciences, Chinese Academy of Sciences, Shanghai, 200031, China.,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Wenwen Yu
- Institute of Neuroscience, State Key Laboratory of Neuroscience, Chinese Academy of Sciences Center for Excellence in Brain Science and Intelligence Technology, Shanghai Institute for Biological Sciences, Chinese Academy of Sciences, Shanghai, 200031, China
| | - Shengdi Chen
- Department of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Bomin Sun
- University of Chinese Academy of Sciences, Beijing, 100049, China.
| | - Zheng Wang
- Institute of Neuroscience, State Key Laboratory of Neuroscience, Chinese Academy of Sciences Center for Excellence in Brain Science and Intelligence Technology, Shanghai Institute for Biological Sciences, Chinese Academy of Sciences, Shanghai, 200031, China.
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Perturbation of whole-brain dynamics in silico reveals mechanistic differences between brain states. Neuroimage 2018; 169:46-56. [DOI: 10.1016/j.neuroimage.2017.12.009] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 11/27/2017] [Accepted: 12/04/2017] [Indexed: 01/11/2023] Open
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Saenger VM, Kahan J, Foltynie T, Friston K, Aziz TZ, Green AL, van Hartevelt TJ, Cabral J, Stevner ABA, Fernandes HM, Mancini L, Thornton J, Yousry T, Limousin P, Zrinzo L, Hariz M, Marques P, Sousa N, Kringelbach ML, Deco G. Uncovering the underlying mechanisms and whole-brain dynamics of deep brain stimulation for Parkinson's disease. Sci Rep 2017; 7:9882. [PMID: 28851996 PMCID: PMC5574998 DOI: 10.1038/s41598-017-10003-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 06/28/2017] [Indexed: 12/01/2022] Open
Abstract
Deep brain stimulation (DBS) for Parkinson's disease is a highly effective treatment in controlling otherwise debilitating symptoms. Yet the underlying brain mechanisms are currently not well understood. Whole-brain computational modeling was used to disclose the effects of DBS during resting-state functional Magnetic Resonance Imaging in ten patients with Parkinson's disease. Specifically, we explored the local and global impact that DBS has in creating asynchronous, stable or critical oscillatory conditions using a supercritical bifurcation model. We found that DBS shifts global brain dynamics of patients towards a Healthy regime. This effect was more pronounced in very specific brain areas such as the thalamus, globus pallidus and orbitofrontal regions of the right hemisphere (with the left hemisphere not analyzed given artifacts arising from the electrode lead). Global aspects of integration and synchronization were also rebalanced. Empirically, we found higher communicability and coherence brain measures during DBS-ON compared to DBS-OFF. Finally, using our model as a framework, artificial in silico DBS was applied to find potential alternative target areas for stimulation and whole-brain rebalancing. These results offer important insights into the underlying large-scale effects of DBS as well as in finding novel stimulation targets, which may offer a route to more efficacious treatments.
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Affiliation(s)
- Victor M Saenger
- Center for Brain and Cognition, Computational Neuroscience Group, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, 08018, Spain
| | - Joshua Kahan
- Sobell Department of Motor Neuroscience & Movement Disorders, UCL Institute of Neurology, London, WC1N 3BG, United Kingdom
| | - Tom Foltynie
- Sobell Department of Motor Neuroscience & Movement Disorders, UCL Institute of Neurology, London, WC1N 3BG, United Kingdom
| | - Karl Friston
- Wellcome Trust Centre for Neuroimaging, Institute of Neurology, University College London, London, WC1N 3BG, United Kingdom
| | - Tipu Z Aziz
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, United Kingdom
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, OX3 9DU, United Kingdom
| | - Alexander L Green
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, United Kingdom
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, OX3 9DU, United Kingdom
| | - Tim J van Hartevelt
- Department of Psychiatry, University of Oxford, Oxford, OX3 7JX, United Kingdom
- Center for Music in the Brain, Aarhus University, Aarhus, 8000, Aarhus C, Denmark
| | - Joana Cabral
- Department of Psychiatry, University of Oxford, Oxford, OX3 7JX, United Kingdom
- Center for Music in the Brain, Aarhus University, Aarhus, 8000, Aarhus C, Denmark
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, 4710-057, Braga, Portugal
| | - Angus B A Stevner
- Department of Psychiatry, University of Oxford, Oxford, OX3 7JX, United Kingdom
- Center for Music in the Brain, Aarhus University, Aarhus, 8000, Aarhus C, Denmark
| | - Henrique M Fernandes
- Department of Psychiatry, University of Oxford, Oxford, OX3 7JX, United Kingdom
- Center for Music in the Brain, Aarhus University, Aarhus, 8000, Aarhus C, Denmark
| | - Laura Mancini
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London, WC1N 3BG, United Kingdom
| | - John Thornton
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London, WC1N 3BG, United Kingdom
| | - Tarek Yousry
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London, WC1N 3BG, United Kingdom
| | - Patricia Limousin
- Sobell Department of Motor Neuroscience & Movement Disorders, UCL Institute of Neurology, London, WC1N 3BG, United Kingdom
| | - Ludvic Zrinzo
- Sobell Department of Motor Neuroscience & Movement Disorders, UCL Institute of Neurology, London, WC1N 3BG, United Kingdom
| | - Marwan Hariz
- Sobell Department of Motor Neuroscience & Movement Disorders, UCL Institute of Neurology, London, WC1N 3BG, United Kingdom
| | - Paulo Marques
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, 4710-057, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, 4710-057, Braga, Portugal
- Clinical Academic Center, 4710-057, Braga, Portugal
| | - Nuno Sousa
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, 4710-057, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, 4710-057, Braga, Portugal
- Clinical Academic Center, 4710-057, Braga, Portugal
| | - Morten L Kringelbach
- Department of Psychiatry, University of Oxford, Oxford, OX3 7JX, United Kingdom.
- Center for Music in the Brain, Aarhus University, Aarhus, 8000, Aarhus C, Denmark.
| | - Gustavo Deco
- Center for Brain and Cognition, Computational Neuroscience Group, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, 08018, Spain
- Instituci Catalana de la Recerca i Estudis Avanats (ICREA), Universitat Pompeu Fabra, Barcelona, 08010, Spain
- Department of Neuropsychology, Max Planck Institute for Human Cognitive and Brain Sciences, 04103, Leipzig, Germany
- School of Psychological Sciences, Monash University, Clayton VIC, 3800, Melbourne, Australia
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Deco G, Tononi G, Boly M, Kringelbach ML. Rethinking segregation and integration: contributions of whole-brain modelling. Nat Rev Neurosci 2015; 16:430-9. [DOI: 10.1038/nrn3963] [Citation(s) in RCA: 369] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kringelbach ML. A Balanced Mind: A Network Perspective on Mood and Motivation Brain Pathways. Brain Stimul 2015. [DOI: 10.1002/9781118568323.ch2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Jiménez-Ponce F, García-Muñoz L, Carrillo-Ruiz J. The role of bioethics in the neurosurgical treatment of psychiatric disorders. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2015. [DOI: 10.1016/j.hgmx.2015.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Knotkova H, Cruciani RA, Tronnier VM, Rasche D. Current and future options for the management of phantom-limb pain. J Pain Res 2012; 5:39-49. [PMID: 22457600 PMCID: PMC3308715 DOI: 10.2147/jpr.s16733] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Phantom-limb pain (PLP) belongs among difficult-to-treat chronic pain syndromes. Treatment options for PLP are to a large degree implicated by the level of understanding the mechanisms and nature of PLP. Research and clinical findings acknowledge the neuropathic nature of PLP and also suggest that both peripheral as well as central mechanisms, including neuroplastic changes in central nervous system, can contribute to PLP. Neuroimaging studies in PLP have indicated a relation between PLP and the neuroplastic changes. Further, it has been shown that the pathological neuroplastic changes could be reverted, and there is a parallel between an improvement (reversal) of the neuroplastic changes in PLP and pain relief. These findings facilitated explorations of novel neuromodulatory treatment strategies, adding to the variety of treatment approaches in PLP. Overall, available treatment options in PLP include pharmacological treatment, supportive non-pharmacological non-invasive strategies (eg, neuromodulation using transcranial magnetic stimulation, visual feedback therapy, or motor imagery; peripheral transcutaneous electrical nerve stimulation, physical therapy, reflexology, or various psychotherapeutic approaches), and invasive treatment strategies (eg, surgical destructive procedures, nerve blocks, or invasive neuromodulation using deep brain stimulation, motor cortex stimulation, or spinal cord stimulation). Venues of further development in PLP management include a technological and methodological improvement of existing treatment methods, an implementation of new techniques and products, and a development of new treatment approaches.
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Affiliation(s)
- Helena Knotkova
- Department of Pain Medicine and Palliative Care, Research Division, Institute for Non-invasive Brain Stimulation, Beth Israel Medical Center, New York, NY, USA
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ricardo A Cruciani
- Department of Pain Medicine and Palliative Care, Research Division, Institute for Non-invasive Brain Stimulation, Beth Israel Medical Center, New York, NY, USA
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Anesthesiology, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Dirk Rasche
- Department of Neurosurgery, University of Lübeck, Germany
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