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Shao P, Li H, Jiang J, Guan Y, Chen X, Wang Y. Role of Vagus Nerve Stimulation in the Treatment of Chronic Pain. Neuroimmunomodulation 2023; 30:167-183. [PMID: 37369181 PMCID: PMC10614462 DOI: 10.1159/000531626] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Vagus nerve stimulation (VNS) can modulate vagal activity and neuro-immune communication. Human and animal studies have provided growing evidence that VNS can produce analgesic effects in addition to alleviating refractory epilepsy and depression. The vagus nerve (VN) projects to many brain regions related to pain processing, which can be affected by VNS. In addition to neural regulation, the anti-inflammatory property of VNS may also contribute to its pain-inhibitory effects. To date, both invasive and noninvasive VNS devices have been developed, with noninvasive devices including transcutaneous stimulation of auricular VN or carotid VN that are undergoing many clinical trials for chronic pain treatment. This review aimed to provide an update on both preclinical and clinical studies of VNS in the management for chronic pain, including fibromyalgia, abdominal pain, and headaches. We further discuss potential underlying mechanisms for VNS to inhibit chronic pain.
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Affiliation(s)
- Peiqi Shao
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Huili Li
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jia Jiang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Xueming Chen
- Department of Orthopedics, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yun Wang
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Villar-Martinez MD, Goadsby PJ. Non-invasive neuromodulation of the cervical vagus nerve in rare primary headaches. FRONTIERS IN PAIN RESEARCH 2023; 4:1062892. [PMID: 36994091 PMCID: PMC10040883 DOI: 10.3389/fpain.2023.1062892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/02/2023] [Indexed: 03/14/2023] Open
Abstract
Primary headache disorders can be remarkably disabling and the therapeutic options available are usually limited to medication with a high rate of adverse events. Here, we discuss the mechanism of action of non-invasive vagal nerve stimulation, as well as the findings of the main studies involving patients with primary headaches other than migraine or cluster headache, such as hemicrania continua, paroxysmal hemicrania, cough headache, or short-lasting neuralgiform headache attacks (SUNCT/SUNA), in a narrative analysis. A bibliographical search of low-prevalence disorders such as rare primary headaches retrieves a moderate number of studies, usually underpowered. Headache intensity, severity, and duration showed a clinically significant reduction in the majority, especially those involving indomethacin-responsive headaches. The lack of response of some patients with a similar diagnosis could be due to a different stimulation pattern, technique, or total dose. The use of non-invasive vagal nerve stimulation for the treatment of primary headache disorders represents an excellent option for patients with these debilitating and otherwise refractory conditions, or that cannot tolerate several lines of preventive medication, and should always be considered before contemplating invasive, non-reversible stimulation techniques.
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Affiliation(s)
- Maria Dolores Villar-Martinez
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- NIHR King's Clinical Research Facility, SLaM Biomedical Research Centre, King's College Hospital, London, United Kingdom
| | - Peter J. Goadsby
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- NIHR King's Clinical Research Facility, SLaM Biomedical Research Centre, King's College Hospital, London, United Kingdom
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
- Correspondence: Peter J. Goadsby
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Dhondt E, Van Oosterwijck S, Van Branteghem T, Rhudy JL, Danneels L, Van Oosterwijck J. Modulation of the nociceptive flexion reflex by conservative therapy in patients and healthy people: a systematic review and meta-analysis. Pain 2022; 163:1446-1463. [PMID: 34813517 DOI: 10.1097/j.pain.0000000000002499] [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: 05/27/2021] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT The nociceptive flexion reflex (NFR) is a spinally mediated withdrawal response and is used as an electrophysiological marker of descending modulation of spinal nociception. Chemical and pharmacological modulation of nociceptive neurotransmission at the spinal level has been evidenced by direct effects of neurotransmitters and pharmacological agents on the NFR. Largely unexplored are, however, the effects of nonpharmacological noninvasive conservative interventions on the NFR. Therefore, a systematic review and meta-analysis was performed and reported following the PRISMA guidelines to determine whether and to what extent spinal nociception measured through the assessment of the NFR is modulated by conservative therapy in patients and healthy individuals. Five electronic databases were searched to identify relevant articles. Retrieved articles were screened on eligibility using the predefined inclusion criteria. Risk of bias was investigated according to Version 2 of the Cochrane risk-of-bias assessment tool for randomized trials. The evidence synthesis for this review was conducted in accordance with the Grading of Recommendations Assessment, Development and Evaluation. Thirty-six articles were included. Meta-analyses provided low-quality evidence showing that conservative therapy decreases NFR area and NFR magnitude and moderate-quality evidence for increases in NFR latency. This suggests that conservative interventions can exert immediate central effects by activating descending inhibitory pathways to reduce spinal nociception. Such interventions may help prevent and treat chronic pain characterized by enhanced spinal nociception. Furthermore, given the responsiveness of the NFR to conservative interventions, the NFR assessment seems to be an appropriate tool in empirical evaluations of treatment strategies.PROSPERO registration number: CRD42020164495.
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Affiliation(s)
- Evy Dhondt
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Pain in Motion International Research Group
| | - Sophie Van Oosterwijck
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Pain in Motion International Research Group
- Research Foundation-Flanders (FWO), Brussels, Belgium
| | - Thomas Van Branteghem
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jamie L Rhudy
- Department of Psychology, University of Tulsa, Tulsa, OK, United States
| | - Lieven Danneels
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jessica Van Oosterwijck
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Pain in Motion International Research Group
- Research Foundation-Flanders (FWO), Brussels, Belgium
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Non-invasive vagus nerve stimulation modulates trigeminal but not somatosensory perception: functional evidence for a trigemino-vagal system in humans. Pain 2022; 163:1978-1986. [PMID: 35082253 DOI: 10.1097/j.pain.0000000000002595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/07/2022] [Indexed: 11/26/2022]
Abstract
ABSTRACT Non-invasive vagus nerve stimulation (nVNS) is effective in several types of headache disorders. We sought to unravel the mechanism of how nVNS exhibits this efficacy. This study used a randomized, single-blind, sham-controlled, crossover-design, and comprised three projects with three independent cohorts of healthy participants. Project I (n=15) was explorative. Six quantitative sensory test (QST) parameters, including mechanical pain threshold (MPT), were measured over the left V1 dermatome and forearm, and compared before and after unilateral nVNS. Projects II (n=20) and III (n=21) were online pre-registered . QST parameters were compared over the left (Project II) or bilateral V1 and V3 dermatomes (Project III), respectively, in addition to the left forearm as a control. A secondary analysis of heart rate variability (HRV) using a historical control group was used to control for systemic effects of nVNS. Verum-nVNS induced trigeminal-specific modulation of pain threshold (i.e., MPT) over the left V1 in Project I, left V1 and V3 in Project II, and bilateral V1 and V3 in Project III. Data pooled from Project II and III demonstrated greater increase of MPT in the V1 vs. V3 dermatome. There were no differences associated with sham-nVNS in any projects. HRV parameters did not change after nVNS. Our results provide functional evidence of a long hypothesized functional trigemino-vagal system in humans and may explain why nVNS is effective in some headache but not in somatic pain disorders. Since unilateral nVNS modulated the trigeminal thresholds bilaterally, this effect is probably indirect through a central top-down mechanism.
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Patel AB, Weber V, Gourine AV, Ackland GL. The potential for autonomic neuromodulation to reduce perioperative complications and pain: a systematic review and meta-analysis. Br J Anaesth 2022; 128:135-149. [PMID: 34801224 PMCID: PMC8787777 DOI: 10.1016/j.bja.2021.08.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/09/2021] [Accepted: 08/25/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Autonomic dysfunction promotes organ injury after major surgery through numerous pathological mechanisms. Vagal withdrawal is a key feature of autonomic dysfunction, and it may increase the severity of pain. We systematically evaluated studies that examined whether vagal neuromodulation can reduce perioperative complications and pain. METHODS Two independent reviewers searched PubMed, EMBASE, and the Cochrane Register of Controlled Clinical Trials for studies of vagal neuromodulation in humans. Risk of bias was assessed; I2 index quantified heterogeneity. Primary outcomes were organ dysfunction (assessed by measures of cognition, cardiovascular function, and inflammation) and pain. Secondary outcomes were autonomic measures. Standardised mean difference (SMD) using the inverse variance random-effects model with 95% confidence interval (CI) summarised effect sizes for continuous outcomes. RESULTS From 1258 records, 166 full-text articles were retrieved, of which 31 studies involving patients (n=721) or volunteers (n=679) met the inclusion criteria. Six studies involved interventional cardiology or surgical patients. Indirect stimulation modalities (auricular [n=23] or cervical transcutaneous [n=5]) were most common. Vagal neuromodulation reduced pain (n=10 studies; SMD=2.29 [95% CI, 1.08-3.50]; P=0.0002; I2=97%) and inflammation (n=6 studies; SMD=1.31 [0.45-2.18]; P=0.003; I2=91%), and improved cognition (n=11 studies; SMD=1.74 [0.96-2.52]; P<0.0001; I2=94%) and cardiovascular function (n=6 studies; SMD=3.28 [1.96-4.59]; P<0.00001; I2=96%). Five of six studies demonstrated autonomic changes after vagal neuromodulation by measuring heart rate variability, muscle sympathetic nerve activity, or both. CONCLUSIONS Indirect vagal neuromodulation improves physiological measures associated with limiting organ dysfunction, although studies are of low quality, are susceptible to bias and lack specific focus on perioperative patients.
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Affiliation(s)
- Amour B.U. Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Valentin Weber
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Alexander V. Gourine
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology and Pharmacology, University College London, London, UK
| | - Gareth L. Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK,Corresponding author.
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Graeff P, Itter A, Wach K, Ruscheweyh R. Inter-Individual Differences Explain More Variance in Conditioned Pain Modulation Than Age, Sex and Conditioning Stimulus Intensity Combined. Brain Sci 2021; 11:brainsci11091186. [PMID: 34573207 PMCID: PMC8468738 DOI: 10.3390/brainsci11091186] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/03/2021] [Accepted: 09/06/2021] [Indexed: 11/21/2022] Open
Abstract
Conditioned pain modulation (CPM) describes the reduction in pain evoked by a test stimulus (TS) when presented together with a heterotopic painful conditioning stimulus (CS). CPM has been proposed to reflect inter-individual differences in endogenous pain modulation, which may predict susceptibility for acute and chronic pain. Here, we aimed to estimate the relative variance in CPM explained by inter-individual differences compared to age, sex, and CS physical and pain intensity. We constructed linear and mixed effect models on pooled data from 171 participants of several studies, of which 97 had repeated measures. Cross-sectional analyses showed no significant effect of age, sex or CS intensity. Repeated measures analyses revealed a significant effect of CS physical intensity (p = 0.002) but not CS pain intensity (p = 0.159). Variance decomposition showed that inter-individual differences accounted for 24% to 34% of the variance in CPM while age, sex, and CS intensity together explained <3% to 12%. In conclusion, the variance in CPM explained by inter-individual differences largely exceeds that of commonly considered factors such as age, sex and CS intensity. This may explain why predictive capability of these factors has had conflicting results and suggests that future models investigating them should account for inter-individual differences.
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Affiliation(s)
- Philipp Graeff
- Graduate School of Systemic Neuroscience, Ludwig-Maximilians-University Munich, 82152 Planegg, Germany;
- Research Training Group (RTG) 2175 Perception in Context and Its Neural Basis, Ludwig-Maximilians-University Munich, 82152 Planegg, Germany
- Correspondence:
| | - Alina Itter
- Department of Neurology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, 81377 Munich, Germany; (A.I.); (K.W.)
| | - Katharina Wach
- Department of Neurology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, 81377 Munich, Germany; (A.I.); (K.W.)
| | - Ruth Ruscheweyh
- Graduate School of Systemic Neuroscience, Ludwig-Maximilians-University Munich, 82152 Planegg, Germany;
- Research Training Group (RTG) 2175 Perception in Context and Its Neural Basis, Ludwig-Maximilians-University Munich, 82152 Planegg, Germany
- Department of Neurology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, 81377 Munich, Germany; (A.I.); (K.W.)
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