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Sohn R, Assar T, Kaufhold I, Brenneis M, Braun S, Junker M, Zaucke F, Pongratz G, Jenei-Lanzl Z. Osteoarthritis patients exhibit an autonomic dysfunction with indirect sympathetic dominance. J Transl Med 2024; 22:467. [PMID: 38755685 PMCID: PMC11100157 DOI: 10.1186/s12967-024-05258-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 04/29/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Osteoarthritis (OA) is a chronic degenerative joint disease causing limited mobility and pain, with no curative treatment available. Recent in vivo studies suggested autonomic alterations during OA progression in patients, yet clinical evidence is scarce. Therefore, autonomic tone was analyzed in OA patients via heart rate variability (HRV) measurements. METHODS Time-domain (SDRR, RMSSD, pRR50) and frequency-domain (LF, HF, LF/HF) HRV indices were determined to quantify sympathetic and parasympathetic activities. In addition, perceived stress, WOMAC pain as well as serum catecholamines, cortisol and dehydroepiandrosterone-sulphate (DHEA-S) were analyzed. The impact of the grade of disease (GoD) was evaluated by linear regression analysis and correlations with clinical data were performed. RESULTS GoD significantly impacted the autonomic tone in OA patients. All time-domain parameters reflected slightly decreased HRV in early OA patients and significantly reduced HRV in late OA patients. Moreover, frequency-domain analysis revealed decreased HF and LF power in all OA patients, reflecting diminished parasympathetic and sympathetic activities. However, LF/HF ratio was significantly higher in early OA patients compared to late OA patients and implied a clear sympathetic dominance. Furthermore, OA patients perceived significantly higher chronic stress and WOMAC pain levels compared to healthy controls. Serum cortisol and cortisol/DHEA-S ratio significantly increased with GoD and positively correlated with WOMAC pain. In contrast, serum catecholamines only trended to increase with GoD and pain level. CONCLUSIONS This prospective study provides compelling evidence of an autonomic dysfunction with indirect sympathetic dominance in early and late knee OA patients for the first time based on HRV analyses and further confirmed by serum stress hormone measurements. Increased sympathetic activity and chronic low-grade inflammation in OA as well as in its major comorbidities reinforce each other and might therefore create a vicious cycle. The observed autonomic alterations coupled with increased stress and pain levels highlight the potential of HRV as a prognostic marker. In addition, modulation of autonomic activity represents an attractive future therapeutic option.
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Affiliation(s)
- Rebecca Sohn
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt, University Hospital, Marienburgstr. 2, 60528, Frankfurt Am Main, Germany
- Faculty of Biological Sciences, Goethe University Frankfurt, 60438, Frankfurt, Germany
| | - Tina Assar
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt, University Hospital, Marienburgstr. 2, 60528, Frankfurt Am Main, Germany
| | - Isabelle Kaufhold
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt, University Hospital, Marienburgstr. 2, 60528, Frankfurt Am Main, Germany
| | - Marco Brenneis
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt, University Hospital, 60528, Frankfurt, Germany
| | - Sebastian Braun
- Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt, University Hospital, 60528, Frankfurt, Germany
| | - Marius Junker
- Department of Orthopedics, Tabea Hospital Hamburg, 22587, Hamburg, Germany
| | - Frank Zaucke
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt, University Hospital, Marienburgstr. 2, 60528, Frankfurt Am Main, Germany
| | - Georg Pongratz
- Division of Rheumatology and Clinical Immunology, St. John of God Hospital, Regensburg, Germany
- Medical Faculty, University of Regensburg, 93053, Regensburg, Germany
| | - Zsuzsa Jenei-Lanzl
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Trauma Surgery and Orthopedics, Goethe University Frankfurt, University Hospital, Marienburgstr. 2, 60528, Frankfurt Am Main, Germany.
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Bonaz B. A novel neuroimmune modulation system for the treatment of rheumatoid arthritis. Bioelectron Med 2024; 10:9. [PMID: 38566215 PMCID: PMC10988796 DOI: 10.1186/s42234-024-00142-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/08/2024] [Indexed: 04/04/2024] Open
Abstract
The vagus nerve has an anti-inflammatory effect through the inflammatory reflex, which inhibits the release of proinflammatory cytokines by macrophages. Recent pilot clinical trials, using implantable bioelectronic devices, have demonstrated the efficacy of vagus nerve stimulation in adult patients with rheumatoid arthritis and inflammatory bowel diseases as an alternative to drugs, which are not devoid of side effects and are costly. In this issue of Bioelectronic Medicine, Peterson et al. report the safety of novel implantable neuroimmune modulation device for treating rheumatoid arthritis (The RESET RA study), which I will discuss in this commentary.
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Affiliation(s)
- Bruno Bonaz
- Université Grenoble Alpes-Faculté de Médicine, Grenoble Institut Neurosciences (GIN, Inserm U1216), site Santé, Bâtiment Edmond J. Safra, 31 Chem. Fortuné Ferrini, 38700, La Tronche, France.
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Seifert O, Baerwald C. Stimulation of the vagus nerve as a therapeutic principle. Z Rheumatol 2024; 83:1-7. [PMID: 37597013 DOI: 10.1007/s00393-023-01398-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 08/21/2023]
Abstract
Modulation of the parasympathetic tone leads to extensive physiological reactions at several levels, including the decreased production of proinflammatory cytokines. Many studies have demonstrated that chronic inflammatory diseases are associated with reduced parasympathetic and increased sympathetic activities. Moreover, it was demonstrated that a low parasympathetic and a high sympathetic activity in patients with rheumatoid arthritis (RA) predicts a poor therapeutic response to anti-tumor necrosis factor (TNF) treatment compared to RA patients with a more balanced autonomic nervous system. The autonomic equilibrium could be restored by electrical stimulation of the vagus nerve. Considering the patients who do not sufficiently respond to the available drugs, patients for whom the effectiveness of the drugs wanes over time, or have drug-related adverse events, a nonpharmacological approach such as bioelectronics might be a useful supplement as an instrument in the successful extension of the therapeutic armamentarium for rheumatic diseases; however, there is a great need for further studies and the development of novel therapeutic strategies in the field of neuroimmunology.
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Affiliation(s)
- O Seifert
- MK II Rheumatologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| | - C Baerwald
- MK II Rheumatologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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Dutra AR, Salm DC, da Silva RH, Tanaka F, Lutdke DD, de Oliveira BH, Lampert R, Bittencourt EB, Bianco G, Gadotti VM, Reed WR, Mack JM, Bobinski F, Moré AOO, Martins DF. Electrical stimulation of the auricular branch of the vagus nerve potentiates analgesia induced by physical exercise in mice with peripheral inflammation. Front Integr Neurosci 2023; 17:1242278. [PMID: 37901799 PMCID: PMC10602751 DOI: 10.3389/fnint.2023.1242278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 09/04/2023] [Indexed: 10/31/2023] Open
Abstract
Objective This study evaluated the antihyperalgesic and anti-inflammatory effects of percutaneous vagus nerve electrical stimulation (pVNS) associated with physical exercise, i.e., swimming, in mice with peripheral inflammation. Methods The pain model was induced by intraplantar (i.pl.) injection of Freund's complete adjuvant (CFA). Sixty-four male Swiss mice (35-40 g) received an i.pl. of CFA and underwent behavioral tests, i.e., mechanical hyperalgesia, edema, and paw temperature tests. Additionally, cytokine levels, specifically interleukin-6 (IL-6) and interleukin-10 (IL-10), were determined by enzyme-linked immunosorbent assay. Mice were treated with swimming exercise for 30 min alone or associated with different time protocols (10, 20, or 30 min) of stimulation in the left ear with random frequency during four consecutive days. Results pVNS for 20 min prolonged the antihyperalgesic effect for up to 2 h, 24 h after CFA injection. pVNS for 30 min prolonged the antihyperalgesic effect for up to 7 h, 96 h after CFA injection. However, it did not alter the edema or temperature at both analyzed times (24 and 96 h). Furthermore, the combination of pVNS plus swimming exercise, but not swimming exercise alone, reduced IL-6 levels in the paw and spinal cord, as well as IL-10 levels in the spinal cord. Conclusion pVNS potentiates the analgesic effect induced by swimming, which may be, at least in part, mediated by the modulation of inflammatory cytokines in the periphery (paw) and central nervous system (spinal cord). Therefore, the combination of these therapies may serve as an important adjunctive treatment for persistent inflammatory pain.
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Affiliation(s)
- Aline Raulino Dutra
- Experimental Neuroscience Laboratory (LaNEx), Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça, SC, Brazil
| | - Daiana Cristina Salm
- Experimental Neuroscience Laboratory (LaNEx), Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça, SC, Brazil
| | - Rafaela Hardt da Silva
- Experimental Neuroscience Laboratory (LaNEx), Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça, SC, Brazil
| | - Fernanda Tanaka
- Experimental Neuroscience Laboratory (LaNEx), Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça, SC, Brazil
| | - Daniela Dero Lutdke
- Experimental Neuroscience Laboratory (LaNEx), Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça, SC, Brazil
| | - Bruna Hoffmann de Oliveira
- Experimental Neuroscience Laboratory (LaNEx), Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça, SC, Brazil
| | - Rose Lampert
- Experimental Neuroscience Laboratory (LaNEx), Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça, SC, Brazil
| | | | - Gianluca Bianco
- Research Laboratory of Posturology and Neuromodulation RELPON, Department of Human Neuroscience, Sapienza University and Istituto Di Formazione in Agopuntura E Neuromodulazione IFAN, Rome, Italy
| | - Vinícius M. Gadotti
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - William R. Reed
- Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL, United States
- Rehabilitation Science Program, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Josiel Mileno Mack
- Experimental Neuroscience Laboratory (LaNEx), Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça, SC, Brazil
| | - Franciane Bobinski
- Experimental Neuroscience Laboratory (LaNEx), Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça, SC, Brazil
| | - Ari O. O. Moré
- Integrative Medicine and Acupuncture Division, University Hospital, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
| | - Daniel Fernandes Martins
- Experimental Neuroscience Laboratory (LaNEx), Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça, SC, Brazil
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Seifert O, Baerwald C. [Stimulation of the vagus nerve as a therapeutic principle. German Version]. Z Rheumatol 2023:10.1007/s00393-023-01390-x. [PMID: 37490129 DOI: 10.1007/s00393-023-01390-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/26/2023]
Abstract
Modulation of the parasympathetic tone leads to extensive physiological reactions at several levels, including the decreased production of proinflammatory cytokines. Many studies have demonstrated that chronic inflammatory diseases are associated with reduced parasympathetic and increased sympathetic activities. Moreover, it was demonstrated that a low parasympathetic and a high sympathetic activity in patients with rheumatoid arthritis (RA) predicts a poor therapeutic response to anti-tumor necrosis factor (TNF) treatment compared to RA patients with a more balanced autonomic nervous system. The autonomic equilibrium could be restored by electrical stimulation of the vagus nerve. Considering the patients who do not sufficiently respond to the available drugs, patients for whom the effectiveness of the drugs wanes over time, or have drug-related adverse events, a nonpharmacological approach such as bioelectronics might be a useful supplement as an instrument in the successful extension of the therapeutic armamentarium for rheumatic diseases; however, there is a great need for further studies and the development of novel therapeutic strategies in the field of neuroimmunology.
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Affiliation(s)
- O Seifert
- MK II Rheumatologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - C Baerwald
- MK II Rheumatologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
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Jensen MK, Andersen SS, Andersen SS, Liboriussen CH, Kristensen S, Jochumsen M. Modulating Heart Rate Variability through Deep Breathing Exercises and Transcutaneous Auricular Vagus Nerve Stimulation: A Study in Healthy Participants and in Patients with Rheumatoid Arthritis or Systemic Lupus Erythematosus. SENSORS (BASEL, SWITZERLAND) 2022; 22:7884. [PMID: 36298234 PMCID: PMC9607552 DOI: 10.3390/s22207884] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 09/28/2022] [Accepted: 10/14/2022] [Indexed: 06/16/2023]
Abstract
Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are associated with an impaired autonomic nervous system and vagus nerve function. Electrical or physiological (deep breathing-DB) vagus nerve stimulation (VNS) could be a potential treatment approach, but no direct comparison has been made. In this study, the effect of transcutaneous auricular VNS (taVNS) and DB on vagal tone was compared in healthy participants and RA or SLE patients. The vagal tone was estimated using time-domain heart-rate variability (HRV) parameters. Forty-two healthy participants and 52 patients performed 30 min of DB and 30 min of taVNS on separate days. HRV was recorded before and immediately after each intervention. For the healthy participants, all HRV parameters increased after DB (SDNN + RMSSD: 21-46%), while one HRV parameter increased after taVNS (SDNN: 16%). For the patients, all HRV parameters increased after both DB (17-31%) and taVNS (18-25%), with no differences between the two types of VNS. DB was associated with the largest elevation of the HRV parameters in healthy participants, while both types of VNS led to elevated HRV parameters in the patients. The findings support a potential use of VNS as a new treatment approach, but the clinical effects need to be investigated in future studies.
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Affiliation(s)
| | | | | | | | - Salome Kristensen
- Department of Rheumatology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Mads Jochumsen
- Department of Health Science and Technology, Aalborg University, 9220 Aalborg, Denmark
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Zinglersen AH, Drange IL, Myhr KA, Fuchs A, Pfeiffer-Jensen M, Brock C, Jacobsen S. Vagus nerve stimulation as a novel treatment for systemic lupus erythematous: study protocol for a randomised, parallel-group, sham-controlled investigator-initiated clinical trial, the SLE-VNS study. BMJ Open 2022; 12:e064552. [PMID: 36127117 PMCID: PMC9490576 DOI: 10.1136/bmjopen-2022-064552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. SLE is treated with immunosuppressants with suboptimal efficacy and high risk of serious side effects. Patients with SLE have increased risk of mortality, organ damage and debilitating treatment-resistant fatigue. Autonomic nervous system dysfunction (AD) is present in approximately half of the patients and may promote autoimmunity by weakening the vagally mediated anti-inflammatory reflex. Recent studies suggest that transcutaneous vagus nerve stimulation (tVNS) has few side effects and beneficial effects on fatigue, pain, disease activity and organ function. This study investigates whether adjuvant tVNS improves measures of fatigue (primary end point), AD, clinical disease activity, inflammation, pain, organ function and quality of life.Hence, this study will contribute to the understanding of AD as a potentially important precursor of fatigue, disease activity, progression and complications in SLE, and how tVNS mechanistically may attenuate this. As adjuvant tVNS use may reduce the need for traditional immunosuppressive therapy, this trial may prompt a shift in the treatment of SLE and potentially other autoimmune disorders. METHODS AND ANALYSIS Eighty-four patients with SLE with fatigue and AD will be randomised 1:1 to active or sham tVNS in this double-blinded parallel-group study. In period 1 (1 week), participants will receive a 4 min tVNS 4 times daily and report on fatigue daily. After a 2-week pause, period 2 (8 weeks) will entail tVNS twice daily and participants will report on fatigue, pain and disease activity weekly. Secondary end points will be assessed before and after each period and after 1 week in period 2. ETHICS AND DISSEMINATION The study is approved by the Danish Medical Research Ethical Committees (case no: 2120231) and results will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05315739.
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Affiliation(s)
- Amanda Hempel Zinglersen
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases (COPEACT), Department of Rheumatology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Ida Lynghøj Drange
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases (COPEACT), Department of Rheumatology, Rigshospitalet, Copenhagen, Denmark
| | - Katrine Aagaard Myhr
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Andreas Fuchs
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Mogens Pfeiffer-Jensen
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Copenhagen Center for Arthritis Research (COPECARE), Department of Rheumatology, Rigshospitalet, Glostrup, Denmark
| | - Christina Brock
- Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University Faculty of Medicine, Aalborg, Denmark
| | - Søren Jacobsen
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases (COPEACT), Department of Rheumatology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
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The Effect of Transcutaneous Vagus Nerve Stimulation in Patients with Polymyalgia Rheumatica. Pharmaceuticals (Basel) 2021; 14:ph14111166. [PMID: 34832948 PMCID: PMC8621661 DOI: 10.3390/ph14111166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/24/2021] [Accepted: 10/28/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Polymyalgia rheumatica (PMR) is an inflammatory disease characterised by pain, morning stiffness, and reduced quality of life. Recently, vagus nerve stimulation (VNS) was shown to have anti-inflammatory effects. We aimed to examine the effect of transcutaneous VNS (t-VNS) on PMR. (2) Fifteen treatment-naïve PMR patients completed the study. Patients underwent a 5-day protocol, receiving 2 min of t-VNS stimulation bilaterally on the neck, three times daily. Cardiac vagal tone (CVT) measured on a linear vagal scale (LVS), blood pressure, heart rate, patient-reported outcome, and biochemical changes were assessed. (3) t-VNS induced a 22% increase in CVT at 20 min after initial stimulations compared with baseline (3.4 ± 2.2 LVS vs. 4.1 ± 2.9 LVS, p = 0.02) and was accompanied by a 4 BPM reduction in heart rate (73 ± 11 BPM vs. 69 ± 9, p < 0.01). No long-term effects were observed. Furthermore, t-VNS induced a 14% reduction in the VAS score for the hips at day 5 compared with the baseline (5.1 ± 2.8 vs. 4.4 ± 2.8, p = 0.04). No changes in CRP or proinflammatory analytes were observed. (4) t-VNS modulates the autonomic nervous system in patients with PMR, but further investigation of t-VNS in PMR patients is warranted.
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Rovsing C, Rovsing H, Liboriussen CH, Jensen MK, Andersen SS, Andersen SS, Kristensen S, Jochumsen M. Deep Breathing Increases Heart Rate Variability in Patients With Rheumatoid Arthritis and Systemic Lupus Erythematosus. J Clin Rheumatol 2021; 27:261-266. [PMID: 32195851 DOI: 10.1097/rhu.0000000000001300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/OBJECTIVE Autoimmune diseases such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) have been associated with an impaired function of the autonomic nervous system and reduced vagus nerve (VN) tone measured through lower heart rate variability (HRV). Targeting the VN through electrical stimulation has been proposed as a treatment strategy with promising results in patients with RA. Moreover, it has been suggested that the VN can be stimulated physiologically through deep breathing. In this study, the aim was to investigate if the VN can be stimulated through deep breathing in patients with RA and SLE, as measured by HRV. METHODS Fifty-seven patients with RA and SLE performed deep breathing exercises for 30 minutes in this explorative study. Before the breathing exercise, 2 electrocardiogram recordings were obtained to determine the patient's baseline HRV during rest. After the 30-minute breathing exercise, 5 minutes of electrocardiogram recordings were obtained to determine postintervention HRV and used as a measure of vagal activity. RESULTS No change was observed in the HRV between the 2 recordings prior the exercise, but the heart rate and HRV significantly decreased and increased, respectively, after the deep breathing exercise. CONCLUSIONS HRV can be modulated in patients with RA and SLE; this may have implications for future treatment with medications in conjunction with deep breathing. However, the biological and clinical effect of deep breathing must be investigated in future studies.
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Affiliation(s)
- Cecilie Rovsing
- From the SMI, Department of Health Science and Technology, Aalborg University
| | - Helene Rovsing
- From the SMI, Department of Health Science and Technology, Aalborg University
| | | | | | | | | | - Salome Kristensen
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
| | - Mads Jochumsen
- From the SMI, Department of Health Science and Technology, Aalborg University
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Vagal Nerve Stimulation-Modulation of the Anti-Inflammatory Response and Clinical Outcome in Psoriatic Arthritis or Ankylosing Spondylitis. Mediators Inflamm 2021; 2021:9933532. [PMID: 34135691 PMCID: PMC8175141 DOI: 10.1155/2021/9933532] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/03/2021] [Indexed: 02/08/2023] Open
Abstract
Objectives The vagal nerve exerts an essential pathway in controlling the cholinergic anti-inflammatory reflex. Thus, the study is aimed at investigating the acute effect of a noninvasive transcutaneous vagus nerve stimulation on clinical disease activity and systemic levels of inflammation in patients with psoriatic arthritis or ankylosing spondylitis. Methods Twenty patients with psoriatic arthritis (PsA) and 20 patients with ankylosing spondylitis (AS) were included and stimulated bilaterally with a handheld vagal nerve stimulator for 120 seconds 3 times a day for 5 consecutive days. All patients were in remission. Cardiac vagal tone, clinical scores, CRP, and cytokine levels were assessed. Results In PsA and AS, decreased heart rate was observed, confirming compliance. Furthermore, in PsA, a clear reduction of clinical disease activity associated with a 20% reduction in CRP was shown. In AS, a reduction in interferon-γ, interleukin- (IL-) 8, and 10 was shown. No side effects were described. Conclusion This open-label study provides support for an anti-inflammatory effect of transcutaneous vagus nerve stimulation in patients with psoriatic arthritis and ankylosing spondylitis. The modulated immune response and reduced disease activity and CRP-levels raise the fascinating possibility of using neuromodulation as an add-on to existing pharmacological treatments.
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Okdahl T, Bertoli D, Brock B, Krogh K, Knop FK, Brock C, Drewes AM. Study protocol for a multicentre, randomised, parallel group, sham-controlled clinical trial investigating the effect of transcutaneous vagal nerve stimulation on gastrointestinal symptoms in people with diabetes complicated with diabetic autonomic neuropathy: the DAN-VNS Study. BMJ Open 2021; 11:e038677. [PMID: 33408197 PMCID: PMC7789454 DOI: 10.1136/bmjopen-2020-038677] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 12/07/2020] [Accepted: 12/14/2020] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION A high proportion of people with diabetes experience gastrointestinal (GI) symptoms, which may be manifestations of diabetic autonomic neuropathy (DAN). The current treatment regime is ineffective and associated with major side effects. Transcutaneous vagal nerve stimulation (tVNS) is a new therapeutic option, which has been shown to increase GI motility and reduce inflammatory responses. As vagus is the main neuronal pathway for extrinsic coordination of GI secretion and motility, we hypothesise that tVNS will improve DAN-induced GI symptoms in subjects with diabetes. METHODS AND ANALYSIS The DAN-VNS study is a randomised multicentre clinical trial investigating the effect of short-term, high intensity as well as long-term, medium-intensity tVNS on GI symptom alleviation in 120 subjects with diabetes. The primary outcome consists of changes from baseline in subjective ratings of symptom severity. Secondary outcomes include changes in gastric motility and GI transit time measured by MRI and wireless motility capsule. Moreover, cardiovascular and sudomotor function, glycaemic control, brain sensory processing and presence of low-grade inflammation will be investigated as secondary outcome measures. Lastly, 15 responders of tVNS treatment will be included in an explorative, randomised, cross-over study, in which the acute endocrine and metabolic response to short-term tVNS will be investigated. ETHICS AND DISSEMINATION The study has been approved by the North Denmark Region Committee on Health Research Ethics (N-20190020). Results will be published in relevant international peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04143269.
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Affiliation(s)
- Tina Okdahl
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Davide Bertoli
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Birgitte Brock
- Steno Diabetes Center Copenhagen, The Capital Region of Denmark, Gentofte, Denmark
| | - Klaus Krogh
- Steno Diabetes Center Aarhus, Central Denmark Region, Aarhus, Denmark
| | - Filip Krag Knop
- Steno Diabetes Center Copenhagen, The Capital Region of Denmark, Gentofte, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
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Abstract
ZusammenfassungSchmerz als Hauptsymptom vieler chronisch-entzündlicher Erkrankungen stellt für den Patienten, aber auch für den behandelnden Arzt besonders in seiner chronifizierten Form eine große Herausforderung dar. Es gibt leider keine „Wunderpille“ mit der man Schmerzen für jeden gleich zuverlässig beseitigen kann. Es gibt aber viele Ansätze pharmakologischer als auch nicht-pharmakologischer Art und deren Kombination, um für den einzelnen Patienten wirksame Behandlungsstrategien zu finden. Um diese Strategien für jeden Patienten individuell optimal festzulegen, bedarf es zum einen eines fundamentierten Wissens über das Spektrum zur Verfügung stehender Mittel, zum anderen aber auch Erkenntnis darüber, wie diese sinnvoll nach Art der vorliegenden Schmerzformen einzusetzen sind. In dieser Übersicht wird beides behandelt, mit einem Fokus auf die medikamentöse Therapie von Schmerzen bei entzündlich-rheumatischen Erkrankungen. Dabei wird herausgearbeitet, dass es für die in diesem Zusammenhang relevantesten Formen des Schmerzes, akut-entzündlich nozizeptiv, neuropathisch und durch periphere und zentrale Sensibilisierung chronifizierte Schmerzen, jeweils andere wirksame Konzepte gibt.
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Affiliation(s)
- Georg Pongratz
- Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Universitätsklinikum Düsseldorf, Düsseldorf
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13
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Drewes AM, Brock C, Rasmussen SE, Møller HJ, Brock B, Deleuran BW, Farmer AD, Pfeiffer-Jensen M. Short-term transcutaneous non-invasive vagus nerve stimulation may reduce disease activity and pro-inflammatory cytokines in rheumatoid arthritis: results of a pilot study. Scand J Rheumatol 2020; 50:20-27. [PMID: 33047630 DOI: 10.1080/03009742.2020.1764617] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective: Rheumatoid arthritis (RA) is a chronic, autoimmune, inflammatory disease. Studies suggest that pro-inflammatory cytokines may be attenuated by the vagus nerve through the cholinergic anti-inflammatory pathway. We aimed to evaluate the anti-inflammatory effects of short-term transcutaneous non-invasive vagus nerve stimulation (n-VNS) applied to the cervical vagus nerve in patients with RA. Method: We conducted a single-centre, open-label, preliminary proof-of-concept study of n-VNS in two cohorts of participants with RA: one with high disease activity (n = 16) and one with low disease activity (n = 20). Disease Activity Score based on 28-joint count-C-reactive protein (DAS28-CRP), cardiac vagal tone, and pro-inflammatory cytokines were measured at baseline and after 1 and 4 days of n-VNS. Results: In the high disease activity group, n-VNS resulted in reductions in DAS28-CRP (4.1 to 3.8, p = 0.02), CRP (8.2 to 6 mg/mL, p = 0.01), and interferon-γ (29.8 to 22.5 pg/mL, p = 0.02). In the low disease activity group, there was no effect on DAS28-CRP, and n-VNS was associated with a decrease in cardiac vagal tone (p = 0.03) and a reduction in interleukin-10 (0.8 to 0.6 pg/mL, p = 0.02). Participants with high disease activity had lower baseline cardiac vagal tone than those with low disease activity (3.6 ± 2 vs 4.9 ± 3 linear vagal scale, p = 0.03). Cardiac vagal tone was negatively associated with DAS28-CRP (r = -0.37, p = 0.03). Overall, n-VNS was well tolerated. Conclusion: This study provides preliminary support for an anti-inflammatory effect of n-VNS in patients with RA. These findings warrant further investigation in larger placebo-controlled trials.
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Affiliation(s)
- A M Drewes
- Department of Rheumatology, Aarhus University Hospital , Aarhus, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital , Aalborg, Denmark
| | - S E Rasmussen
- Department of Rheumatology, Aarhus University Hospital , Aarhus, Denmark
| | - H J Møller
- Department of Clinical Biochemistry, Aarhus University Hospital , Aarhus, Denmark
| | - B Brock
- Steno Diabetes Center Copenhagen , Gentofte, Denmark
| | - B W Deleuran
- Department of Rheumatology, Aarhus University Hospital , Aarhus, Denmark
| | - A D Farmer
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital , Aalborg, Denmark.,Centre for Trauma and Neuroscience, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London , London, UK.,Institute of Applied Clinical Sciences, University of Keele , Stoke on Trent, UK
| | - M Pfeiffer-Jensen
- Department of Rheumatology, Aarhus University Hospital , Aarhus, Denmark
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14
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FM0807 decelerates experimental arthritis progression by inhibiting inflammatory responses and joint destruction via modulating NF-κB and MAPK pathways. Biosci Rep 2019; 39:BSR20182263. [PMID: 31431516 PMCID: PMC6722489 DOI: 10.1042/bsr20182263] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 07/07/2019] [Accepted: 08/19/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Rheumatoid arthritis (RA) is a chronic articular synovial inflammatory disease. The precise etiology underlying the pathogenesis of RA remains unknown. We aimed to investigate the inhibitory effect of curcumin analog FM0807 (curcumin salicylate monoester, 2-hydroxy-, 4-[(1E,6E)-7-(4-hydroxy-3-methoxyphenyl)-3,5-dioxo-1,6-heptadien-1-yl]-2-methoxyphenyl ester) on experimental RA and investigate its possible mechanisms of action. Method: Rats with Freund’s complete adjuvant (FCA)-induced arthritis (AIA) were administered aspirin (0.1 mmol.kg−1), curcumin (0.1 mmol.kg−1), FM0807 (0.1, 0.2 mmol.kg−1) and vehicle via gastric gavage, from days 7 to 21, once daily. The hind paw volume and arthritis index (AI) were measured, and radiographic and histological examinations were performed. Twenty-one days later, the animals were killed and left ankle joints were removed to measure protein expression of the elements of the nuclear factor κB (NF-κB) and mitogen-activated protein kinase (MAPK) pathway by Western blot analysis. The enzyme-linked immunosorbent assay (ELISA) was employed to measure synovial fluid levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-6, IL-1β and IL-10. Results: Compared with AIA group, FM0807 reduced the AI and swelling of the injected hind paw in a dose-dependent manner, and inhibited increases in inflammatory cell infiltration, pannus formation and cartilage destruction. FM0807 also potently attenuated the increase in the expression of inflammatory factors TNF-α, IL-6 and IL-1β in synovial fluid, while IL-10 levels were also elevated. FM0807 significantly suppressed phosphorylation of extracellular-signal-regulated kinase (ERK) 1/2 (ERK1/2), c-Jun-N-terminal kinase (JNK) 1/2 (JNK1/2), p38MAPK, inhibitor of NF-κB kinase (IKK), IκB and NF-κB p65 protein, (all P<0.05), which displayed more potential effects compared with those of the aspirin and curcumin groups. Conclusion: FM0807 exerts its therapeutic effects on RA by inhibiting cartilage degeneration. FM0807 treatment might be an effective therapeutic approach for RA.
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15
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Cellular Changes in Injured Rat Spinal Cord Following Electrical Brainstem Stimulation. Brain Sci 2019; 9:brainsci9060124. [PMID: 31142050 PMCID: PMC6628227 DOI: 10.3390/brainsci9060124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 05/23/2019] [Accepted: 05/27/2019] [Indexed: 01/06/2023] Open
Abstract
Spinal cord injury (SCI) is a major cause of disability and pain, but little progress has been made in its clinical management. Low-frequency electrical stimulation (LFS) of various anti-nociceptive targets improves outcomes after SCI, including motor recovery and mechanical allodynia. However, the mechanisms of these beneficial effects are incompletely delineated and probably multiple. Our aim was to explore near-term effects of LFS in the hindbrain's nucleus raphe magnus (NRM) on cellular proliferation in a rat SCI model. Starting 24 h after incomplete contusional SCI at C5, intermittent LFS at 8 Hz was delivered wirelessly to NRM. Controls were given inactive stimulators. At 48 h, 5-bromodeoxyuridine (BrdU) was administered and, at 72 h, spinal cords were extracted and immunostained for various immune and neuroglial progenitor markers and BrdU at the level of the lesion and proximally and distally. LFS altered cell marker counts predominantly at the dorsal injury site. BrdU cell counts were decreased. Individually and in combination with BrdU, there were reductions in CD68 (monocytes) and Sox2 (immature neural precursors) and increases in Blbp (radial glia) expression. CD68-positive cells showed increased co-staining with iNOS. No differences in the expression of GFAP (glia) and NG2 (oligodendrocytes) or in GFAP cell morphology were found. In conclusion, our work shows that LFS of NRM in subacute SCI influences the proliferation of cell types implicated in inflammation and repair, thus providing mechanistic insight into deep brain stimulation as a neuromodulatory treatment for this devastating pathology.
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16
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Hvas CL, Bendix M, Dige A, Dahlerup JF, Agnholt J. Current, experimental, and future treatments in inflammatory bowel disease: a clinical review. Immunopharmacol Immunotoxicol 2018; 40:446-460. [PMID: 29745777 DOI: 10.1080/08923973.2018.1469144] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel diseases (IBDs) may result from dysregulated mucosal immune responses directed toward the resident intestinal microbiota. This review describes the hallmark immunobiology of Crohn's disease and ulcerative colitis as well as therapeutic targets and mechanisms of action for current, experimental, and future treatments in IBD. Conventional therapies include 5-aminosalicylic acid, glucocorticosteroids, thiopurines, and methotrexate. Since 1997, monoclonal antibodies have gained widespread use. These consist of antibodies directed against pro-inflammatory cytokines such as tumor necrosis factor α, interleukin (IL)-12, and IL-23, or anti-homing antibodies directed against α4β7 integrin. Emerging oral therapies include modulators of intracellular signal transduction such as Janus kinase inhibitors. Vitamin D may help to regulate innate and adaptive immune responses. Modulation of the intestinal microbiota, using live microorganisms (probiotics), substrates for the colonic microbiota (prebiotics), or fecal microbiota transplantation (FMT), is in development. Dietary supplements are in widespread use, but providing evidence for their benefit is challenging. Stem cell treatment and nervous stimulation are promising future treatments.
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Affiliation(s)
- Christian L Hvas
- a Department of Hepatology and Gastroenterology , Aarhus University Hospital , Aarhus C , Denmark
| | - Mia Bendix
- a Department of Hepatology and Gastroenterology , Aarhus University Hospital , Aarhus C , Denmark.,b Medical Department, Randers Regional Hospital , Randers , Denmark
| | - Anders Dige
- a Department of Hepatology and Gastroenterology , Aarhus University Hospital , Aarhus C , Denmark
| | - Jens F Dahlerup
- a Department of Hepatology and Gastroenterology , Aarhus University Hospital , Aarhus C , Denmark
| | - Jørgen Agnholt
- a Department of Hepatology and Gastroenterology , Aarhus University Hospital , Aarhus C , Denmark
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17
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Kanashiro A, Shimizu Bassi G, de Queiróz Cunha F, Ulloa L. From neuroimunomodulation to bioelectronic treatment of rheumatoid arthritis. ACTA ACUST UNITED AC 2018; 1:151-165. [PMID: 30740246 DOI: 10.2217/bem-2018-0001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neuronal stimulation is an emerging field in modern medicine to control organ function and reestablish physiological homeostasis during illness. The nervous system innervates most of the peripheral organs and provides a fine tune to control the immune system. Most of these studies have focused on vagus nerve stimulation and the physiological, cellular and molecular mechanisms regulating the immune system. Here, we review the new results revealing afferent vagal signaling pathways, immunomodulatory brain structures, spinal cord-dependent circuits, neural and non-neural cholinergic/catecholaminergic signals and their respective receptors contributing to neuromodulation of inflammation in rheumatoid arthritis. These new neuromodulatory networks and structures will allow the design of innovative bioelectronic or pharmacological approaches for safer and low-cost treatment of arthritis and related inflammatory disorders.
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Affiliation(s)
- Alexandre Kanashiro
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.,Department of Physiological Sciences, Federal University of São Carlos (UFSCAR), São Carlos, SP, Brazil
| | - Gabriel Shimizu Bassi
- Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Fernando de Queiróz Cunha
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Luis Ulloa
- Department of Surgery, Center of Immunology & Inflammation, Rutgers-New Jersey Medical School, Rutgers University, Newark, NJ 07101, USA
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