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Douven P, Tilborghs S, van de Borne S, van Koeveringe GA, de Wachter S. Burst Stimulation Evokes Increased Bladder and Urethral Pressure in Patients With Sacral Neuromodulation, Indicating Potential Activation of the Autonomic Nervous System: A Pilot Study. Neuromodulation 2024:S1094-7159(24)00647-0. [PMID: 39093261 DOI: 10.1016/j.neurom.2024.06.502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/28/2024] [Accepted: 06/06/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES Currently, sacral neuromodulation (SNM) outcomes are often suboptimal, and changing stimulation parameters might improve SNM efficacy. Burst stimulation mimics physiological burst firing of the nervous system and might therefore benefit patients treated with SNM. The purpose of the present pilot study was to evaluate the effect of various Burst SNM paradigms on bladder and urethral pressure in patients with overactive bladder (OAB) or nonobstructive urinary retention (NOUR). MATERIALS AND METHODS The bladder was filled to 50% of its capacity under general anesthesia in six patients with an implanted sacral lead for SNM purposes. Bladder pressure, and mid- and proximal urethral pressure were measured using conventional (Con-) SNM and various Burst SNM paradigms (10-20-40 Hz interburst frequency) with increasing amplitudes up to 5 mA for Con-SNM and 4 mA for Burst SNM. RESULTS Burst SNM caused a substantial increase in both bladder and urethral pressure. In contrast, Con-SNM caused a milder increase in urethral pressure, and only one patient showed a modest increase in bladder pressure. Furthermore, the pressure increase was higher in the proximal urethra than in the midurethra using Burst-SNM, whereas Con-SNM caused comparable increases in proximal and midurethra pressure. CONCLUSIONS Burst SNM induces bladder contraction compared with Con-SNM and induces higher pressure increases in bladder and proximal urethra than does Con-SNM in patients with OAB or NOUR, indicating a higher degree of autonomic nervous system stimulation. The observed responses could not be fully explained by the total charge of the Burst SNM paradigms, which suggests the importance of individual Burst SNM parameters, such as frequency and amplitude. Future studies should assess the feasibility and efficacy of Burst SNM in awake patients.
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Affiliation(s)
- Perla Douven
- Department of Urology, Maastricht University Medical Center, The Netherlands; Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNS), Maastricht University, The Netherlands
| | - Sam Tilborghs
- Department of Urology, Antwerp University Hospital, Edegem, Belgium; Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Anatomy, University of Antwerp, Belgium
| | - Sigrid van de Borne
- Department of Urology, Antwerp University Hospital, Edegem, Belgium; Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Anatomy, University of Antwerp, Belgium
| | - Gommert A van Koeveringe
- Department of Urology, Maastricht University Medical Center, The Netherlands; Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNS), Maastricht University, The Netherlands
| | - Stefan de Wachter
- Department of Urology, Antwerp University Hospital, Edegem, Belgium; Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Anatomy, University of Antwerp, Belgium.
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2
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da Cunha PHM, de Andrade DC. The deep and the deeper: Spinal cord and deep brain stimulation for neuropathic pain. Presse Med 2024; 53:104231. [PMID: 38636785 DOI: 10.1016/j.lpm.2024.104231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024] Open
Abstract
Neuropathic pain occurs in people experiencing lesion or disease affecting the somatosensorial system. It is present in 7 % of the general population and may not fully respond to first- and second-line treatments in up to 40 % of cases. Neuromodulation approaches are often proposed for those not tolerating or not responding to usual pharmacological management. These approaches can be delivered surgically (invasively) or non-invasively. Invasive neuromodulation techniques were the first to be employed in neuropathic pain. Among them is spinal cord stimulation (SCS), which consists of the implantation of epidural electrodes over the spinal cord. It is recommended in some guidelines for peripheral neuropathic pain. While recent studies have called into question its efficacy, others have provided promising data, driven by advances in techniques, battery capabilities, programming algorithms and software developments. Deep brain stimulation (DBS) is another well-stablished neuromodulation therapy routinely used for movement disorders; however, its role in pain management remains limited to specific research centers. This is not only due to variable results in the literature contesting its efficacy, but also because several different brain targets have been explored in small trials, compromising comparisons between these studies. Structures such as the periaqueductal grey, posterior thalamus, anterior cingulate cortex, ventral striatum/anterior limb of the internal capsule and the insula are the main targets described to date in literature. SCS and DBS present diverse rationales for use, mechanistic backgrounds, and varying levels of support from experimental studies. The present review aims to present their methodological details, main mechanisms of action for analgesia and their place in the current body of evidence in the management of patients with neuropathic pain, as well their particularities, effectiveness, safety and limitations.
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Affiliation(s)
| | - Daniel Ciampi de Andrade
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
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Rahimibarghani S, Morgan R, Diaz JJ. Neuromodulation Techniques in Chronic Refractory Coccydynia: A Narrative Review. Pain Ther 2024; 13:53-67. [PMID: 38175492 PMCID: PMC10796902 DOI: 10.1007/s40122-023-00572-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024] Open
Abstract
Refractory coccydynia is a condition characterized by severe coccygeal pain and poses a challenging management dilemma for clinicians. Advancements in neuromodulation (NM) technology have provided benefits to people experiencing chronic pain that is resistant to standard treatments. This review aims to summarize the spectrum of current NM techniques employed in the treatment of refractory coccydynia along with their effectiveness. A review of studies in the scientific literature from 2012 to 2023 was conducted, revealing a limited number of case reports. Although the available evidence at this time suggests significant pain relief with the utilization of NM techniques, the limited scope and nature of the studies reviewed emphasize the need for large-scale, rigorous, high-level research in this domain in order to establish a comprehensive understanding of the role of NM and its effectiveness in the management of intractable coccydynia.
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Affiliation(s)
- Sarvenaz Rahimibarghani
- Physical Medicine and Rehabilitation Department, Tehran University of Medical Sciences, Tehran, Iran.
| | - Richard Morgan
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Jose Juan Diaz
- Physical Medicine and Rehabilitation Department, Larkin Community Hospital, South Miami Campus, South Miami, FL, USA
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Rigoard P, Ounajim A, Moens M, Goudman L, Roulaud M, Lorgeoux B, Baron S, Nivole K, Many M, Lampert L, David R, Billot M. Should we Oppose or Combine Waveforms for Spinal Cord Stimulation in PSPS-T2 Patients? A Prospective Randomized Crossover Trial (MULTIWAVE Study). THE JOURNAL OF PAIN 2023; 24:2319-2339. [PMID: 37473903 DOI: 10.1016/j.jpain.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/16/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
Refractory persistent spinal pain syndrome after surgery (PSPS-T2) can be successfully addressed by spinal cord stimulation (SCS). While conventional stimulation generates paresthesia, recent systems enable the delivery of paresthesia-free stimulation. Studies have claimed non-inferiority/superiority of selected paresthesia-free stimulation compared with paresthesia-based stimulation, but the comparative efficacy between different waveforms still needs to be determined in a given patient. We designed a randomized controlled 3-month crossover trial to compare pain relief of paresthesia-based stimulation versus high frequency versus burst in 28 PSPS-T2 patients implanted with multiwave SCS systems. Our secondary objectives were to determine the efficacy of these 3 waveforms on pain surface, quality of life, functional capacity, psychological distress, and validated composite multidimensional clinical response index to provide holistic comparisons at 3-, 6-, 9-, and 15-month post-randomization. The preferred stimulation modality was documented during the follow-up periods. No difference between the waveforms was observed in this study (P = .08). SCS led to significant pain relief, quality of life improvement, improvement of multidimensional clinical response index, and of all other clinical outcomes at all follow-up visits. Forty-four percent of the patients chose to keep the paresthesia-based stimulation modality after the 15-month follow-up period. By giving the possibility to switch and/or to combine several waveforms, the overall rate of SCS responders further increased with 25%. In this study, high frequency or burst do not appear superior to paresthesia-based stimulation, wherefore paresthesia-based stimulation should still be considered as a valid option. However, combining paresthesia-based stimulation with paresthesia-free stimulation, through personalized multiwave therapy, might significantly improve SCS responses. PERSPECTIVE: This article assesses clinical SCS efficacy on pain relief, by comparing paresthesia-based stimulation and paresthesia-free stimulation (including high frequency and burst) modalities in patient presenting with PSPS-T2. Switching and/or combining waveforms contribute to increasing the global SCS responders rate.
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Affiliation(s)
- Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France; Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, Poitiers, France; Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, Chasseneuil-du-Poitou, France
| | - Amine Ounajim
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation-Flanders (FWO), Brussels, Belgium
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Bertille Lorgeoux
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Sandrine Baron
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Kévin Nivole
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Mathilde Many
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Lucie Lampert
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Romain David
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France; Department of Physical and Rehabilitation Medicine Unit, Poitiers University Hospital, University of Poitiers, Poitiers, France
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
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Rogers ER, Mirzakhalili E, Lempka SF. Model-based analysis of subthreshold mechanisms of spinal cord stimulation for pain. J Neural Eng 2023; 20:066003. [PMID: 37906966 PMCID: PMC10632558 DOI: 10.1088/1741-2552/ad0858] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/11/2023] [Accepted: 10/31/2023] [Indexed: 11/02/2023]
Abstract
Objective.Spinal cord stimulation (SCS) is a common treatment for chronic pain. For decades, SCS maximized overlap between stimulation-induced paresthesias and the patient's painful areas. Recently developed SCS paradigms relieve pain at sub-perceptible amplitudes, yet little is known about the neural response to these new waveforms or their analgesic mechanisms of action. Therefore, in this study, we investigated the neural response to multiple forms of paresthesia-free SCS.Approach.We used computational modeling to investigate the neurophysiological effects and the plausibility of commonly proposed mechanisms of three paresthesia-free SCS paradigms: burst, 1 kHz, and 10 kHz SCS. Specifically, in C- and Aβ-fibers, we investigated the effects of different SCS waveforms on spike timing and activation thresholds, as well as how stochastic ion channel gating affects the response of dorsal column axons. Finally, we characterized membrane polarization of superficial dorsal horn neurons.Main results.We found that none of the SCS waveforms activate nor modulate spike timing in C-fibers. Spike timing was modulated in Aβ-fibers only at suprathreshold amplitudes. Ion channel stochasticity had little effect on Aβ-fiber activation thresholds but produced heterogeneous spike timings at suprathreshold amplitudes. Finally, local cells were preferentially polarized in their axon terminals, and the magnitude of this polarization was dependent on cellular morphology and position relative to the stimulation electrodes.Significance.Overall, the mechanisms of action of subparesthetic SCS remain unclear. Our results suggest that no SCS waveforms directly activate C-fibers, and modulation of spike timing is unlikely at subthreshold amplitudes. We conclude that potential subthreshold neuromodulatory effects of SCS on local cells are likely to be presynaptic in nature, as axons are preferentially depolarized during SCS.
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Affiliation(s)
- Evan R Rogers
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States of America
- Biointerfaces Institute, University of Michigan, Ann Arbor, MI, United States of America
| | - Ehsan Mirzakhalili
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States of America
- Biointerfaces Institute, University of Michigan, Ann Arbor, MI, United States of America
| | - Scott F Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States of America
- Biointerfaces Institute, University of Michigan, Ann Arbor, MI, United States of America
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States of America
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Goudman L, Vets N, Jansen J, De Smedt A, Moens M. The Association Between Bodily Functions and Cognitive/Emotional Factors in Patients With Chronic Pain Treated With Neuromodulation: A Systematic Review and Meta-Analyses. Neuromodulation 2023; 26:3-24. [PMID: 35088738 DOI: 10.1016/j.neurom.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/15/2021] [Accepted: 10/26/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To date, pain relief in general continues to be the most prominent outcome measurement in daily routine care and clinical research. Nevertheless, the awareness of a shift toward more functional outcomes and/or emotional and cognitive outcomes has been raised. The interplay between bodily functions (such as pain intensity) and emotional or cognitive factors, however, has not yet been fully elucidated. The aim of this study was to systematically review the evidence for associations between bodily functions and cognitive and emotional factors in patients with chronic pain who are treated with neuromodulation. MATERIALS AND METHODS Four data bases were consulted for this systematic literature review: PubMed, Web of Science, Scopus, and Embase. The Downs and Black Checklist (modified) was used to assess the risk of bias. The study protocol was prospectively registered at the International prospective register of systematic reviews (PROSPERO, CRD42021226803). If two or more studies reported correlation coefficients for a specific association, a meta-analysis based on correlation coefficients was performed for that specific association. RESULTS The initial data base search identified a total of 1432 studies, of which 19 studies were eventually included in the systematic review. Evidence was found for two associations: 1) a positive correlation between pain intensity and anxiety (r = 0.42; 95% CI, 0.34 to 0.50) and 2) a positive correlation between pain intensity and depression (r = 0.32; 95% CI, 0.10 to 0.51). The association between pain intensity and catastrophizing was not statistically significant (r = 0.23; 95% CI, -0.36 to 0.69). CONCLUSIONS On the basis of the associations between pain intensity and anxiety/depression, a biopsychosocial approach might be the most suitable in clinical practice to properly address all aspects of the International Classification of Functioning, Disability, and Health framework in patients who are treated with neuromodulation.
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Affiliation(s)
- Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium; Pain in Motion (PAIN) Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation-Flanders (FWO), Brussels, Belgium.
| | - Nieke Vets
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium
| | - Julie Jansen
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium
| | - Ann De Smedt
- STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium; Department of Physical Medicine and Rehabilitation, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium; Pain in Motion (PAIN) Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
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Hewitt D, Byrne A, Henderson J, Wilford K, Chawla R, Sharma ML, Frank B, Fallon N, Brown C, Stancak A. Pulse Intensity Effects of Burst and Tonic Spinal Cord Stimulation on Neural Responses to Brushing in Patients With Neuropathic Pain. Neuromodulation 2022:S1094-7159(22)01349-6. [DOI: 10.1016/j.neurom.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/21/2022] [Accepted: 11/01/2022] [Indexed: 12/04/2022]
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Using evoked compound action potentials to quantify differential neural activation with burst and conventional, 40 Hz spinal cord stimulation in ovines. Pain Rep 2022; 7:e1047. [DOI: 10.1097/pr9.0000000000001047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/22/2022] [Accepted: 09/14/2022] [Indexed: 11/13/2022] Open
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Huang J, Zhang Y, Zhang Q, Wei L, Zhang X, Jin C, Yang J, Li Z, Liang S. The current status and trend of the functional magnetic resonance combined with stimulation in animals. Front Neurosci 2022; 16:963175. [PMID: 36213733 PMCID: PMC9540855 DOI: 10.3389/fnins.2022.963175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022] Open
Abstract
As a non-radiative, non-invasive imaging technique, functional magnetic resonance imaging (fMRI) has excellent effects on studying the activation of blood oxygen levels and functional connectivity of the brain in human and animal models. Compared with resting-state fMRI, fMRI combined with stimulation could be used to assess the activation of specific brain regions and the connectivity of specific pathways and achieve better signal capture with a clear purpose and more significant results. Various fMRI methods and specific stimulation paradigms have been proposed to investigate brain activation in a specific state, such as electrical, mechanical, visual, olfactory, and direct brain stimulation. In this review, the studies on animal brain activation using fMRI combined with different stimulation methods were retrieved. The instruments, experimental parameters, anesthesia, and animal models in different stimulation conditions were summarized. The findings would provide a reference for studies on estimating specific brain activation using fMRI combined with stimulation.
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Mons MR, Edelbroek C, Zuidema X, Bürger K, Elzinga L, de Vries J, van Kuijk S, Joosten EA, Kallewaard JW. Study protocol: Effects of active versus passive recharge burst spinal cord stimulation on pain experience in persistent spinal pain syndrome type 2: a multicentre randomized trial (BURST-RAP study). Trials 2022; 23:749. [PMID: 36064598 PMCID: PMC9446827 DOI: 10.1186/s13063-022-06637-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 08/05/2022] [Indexed: 11/17/2022] Open
Abstract
Background Spinal cord stimulation (SCS) has shown to be an effective treatment for patients with persistent spinal pain syndrome type 2 (PSPS Type 2). The method used to deliver electrical charge in SCS is important. One such method is burst stimulation. Within burst stimulation, a recharge pattern is used to prevent buildup of charge in stimulated tissues. Two variations of burst waveforms are currently in use: one that employs active recharge and one that uses passive recharge. It has been suggested that differences exist between active and passive recharge paradigms related to both efficacy of pain relief and their underlying mechanism of action. Active recharge has been shown to activate both the medial spinal pathway, engaging cortical sensorimotor areas involved in location and intensity of pain, and lateral pathway, reaching brain areas involved with cognitive-emotional aspects of pain. Passive recharge has been suggested to act via modulation of thalamic neurons, which fire in a similar electrical pattern, and thereby modulate activity in various cortical areas including those related to motivational and emotional aspects of pain. The objective of this randomized clinical trial is to assess and compare the effect of active versus passive recharge Burst SCS on a wide spectrum of pain in PSPS Type 2 patients. Methods This multicentre randomized clinical trial will take place in 6 Dutch hospitals. PSPS Type 2 patients (n=94) will be randomized into a group receiving either active or passive recharge burst. Following a successful trial period, patients are permanently implanted. Patients complete the Pain Catastrophizing Scale (PCS) (primary outcome at 6 months), Numeric Pain Rating Scale (NRS), Patient Vigilance and Awareness Questionnaire (PVAQ), Hospital Anxiety and Depression Scale (HADS), Quality of Life (EQ-5D), Oswestery Disability Index (ODI), Patient Global Impression of Change (PGIC) and painDETECT questionnaires (secondary outcomes) at baseline, after trial, 1, 3, 6 and 12 months following implantation. Discussion The BURST-RAP trial protocol will shed light on possible clinical differences and effectivity of pain relief, including emotional-motivational aspects between active and passive burst SCS in PSPS Type 2 patients. Trial registration ClinicalTrials.gov registration: NCT05421273. Registered on 16 June 2022. Netherlands Trial Register NL9194. Registered on 23 January 2021.
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Affiliation(s)
- Martijn R Mons
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht (UPCM) Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands. .,Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNS), University of Maastricht, Maastricht, the Netherlands.
| | - Caro Edelbroek
- Department of Anesthesiology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands
| | - Xander Zuidema
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht (UPCM) Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands.,Department of Anesthesiology, Diakonessen Hospital Utrecht, Utrecht, the Netherlands
| | - Katja Bürger
- Department of Anesthesiology, Alrijne Hospital Leiderdorp, Leiderdorp, the Netherlands
| | - Lars Elzinga
- Department of Anesthesiology, Bravis Hospital Roosendaal, Roosendaal, the Netherlands
| | - Jessica de Vries
- Department of Anesthesiology, Elizabeth TweeSteden Hospital Tilburg, Tilburg, the Netherlands
| | - Sander van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht UMC+, Maastricht, the Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht (UPCM) Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands.,Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNS), University of Maastricht, Maastricht, the Netherlands
| | - Jan-Willem Kallewaard
- Department of Anesthesiology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands.,Departement of Anesthesiology, Amsterdam Universitair Medisch Centrum, Amsterdam, the Netherlands
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Novel Therapies for the Treatment of Neuropathic Pain: Potential and Pitfalls. J Clin Med 2022; 11:jcm11113002. [PMID: 35683390 PMCID: PMC9181614 DOI: 10.3390/jcm11113002] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 12/15/2022] Open
Abstract
Neuropathic pain affects more than one million people across the globe. The quality of life of people suffering from neuropathic pain has been considerably declining due to the unavailability of appropriate therapeutics. Currently, available treatment options can only treat patients symptomatically, but they are associated with severe adverse side effects and the development of tolerance over prolonged use. In the past decade, researchers were able to gain a better understanding of the mechanisms involved in neuropathic pain; thus, continuous efforts are evident, aiming to develop novel interventions with better efficacy instead of symptomatic treatment. The current review discusses the latest interventional strategies used in the treatment and management of neuropathic pain. This review also provides insights into the present scenario of pain research, particularly various interventional techniques such as spinal cord stimulation, steroid injection, neural blockade, transcranial/epidural stimulation, deep brain stimulation, percutaneous electrical nerve stimulation, neuroablative procedures, opto/chemogenetics, gene therapy, etc. In a nutshell, most of the above techniques are at preclinical stage and facing difficulty in translation to clinical studies due to the non-availability of appropriate methodologies. Therefore, continuing research on these interventional strategies may help in the development of promising novel therapies that can improve the quality of life of patients suffering from neuropathic pain.
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Graham RD, Sankarasubramanian V, Lempka SF. Dorsal Root Ganglion Stimulation for Chronic Pain: Hypothesized Mechanisms of Action. THE JOURNAL OF PAIN 2022; 23:196-211. [PMID: 34425252 PMCID: PMC8943693 DOI: 10.1016/j.jpain.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/28/2021] [Accepted: 07/20/2021] [Indexed: 02/03/2023]
Abstract
Dorsal root ganglion stimulation (DRGS) is a neuromodulation therapy for chronic pain that is refractory to conventional medical management. Currently, the mechanisms of action of DRGS-induced pain relief are unknown, precluding both our understanding of why DRGS fails to provide pain relief to some patients and the design of neurostimulation technologies that directly target these mechanisms to maximize pain relief in all patients. Due to the heterogeneity of sensory neurons in the dorsal root ganglion (DRG), the analgesic mechanisms could be attributed to the modulation of one or many cell types within the DRG and the numerous brain regions that process sensory information. Here, we summarize the leading hypotheses of the mechanisms of DRGS-induced analgesia, and propose areas of future study that will be vital to improving the clinical implementation of DRGS. PERSPECTIVE: This article synthesizes the evidence supporting the current hypotheses of the mechanisms of action of DRGS for chronic pain and suggests avenues for future interdisciplinary research which will be critical to fully elucidate the analgesic mechanisms of the therapy.
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Affiliation(s)
- Robert D. Graham
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States
| | - Vishwanath Sankarasubramanian
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States
| | - Scott F. Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States,Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48109, United States,Corresponding author: Scott F. Lempka, PhD, Department of Biomedical Engineering, University of Michigan, 2800 Plymouth Road, NCRC 14-184, Ann Arbor, MI 48109-2800,
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13
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Spinal Cord Stimulation and Treatment of Peripheral or Central Neuropathic Pain: Mechanisms and Clinical Application. Neural Plast 2021; 2021:5607898. [PMID: 34721569 PMCID: PMC8553441 DOI: 10.1155/2021/5607898] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 09/11/2021] [Accepted: 10/05/2021] [Indexed: 12/13/2022] Open
Abstract
Spinal cord stimulation (SCS) as an evidence-based interventional treatment has been used and approved for clinical use in a variety of pathological states including peripheral neuropathic pain; however, until now, it has not been used for the treatment of spinal cord injury- (SCI-) induced central neuropathic pain. This paper reviews the underlying mechanisms of SCS-induced analgesia and its clinical application in the management of peripheral and central neuropathic pain. Evidence from recent research publications indicates that nociceptive processing at peripheral and central sensory systems is thought to be modulated by SCS through (i) inhibition of the ascending nociceptive transmission by the release of analgesic neurotransmitters such as GABA and endocannabinoids at the spinal dorsal horn; (ii) facilitation of the descending inhibition by release of noradrenalin, dopamine, and serotonin acting on their receptors in the spinal cord; and (iii) activation of a variety of supraspinal brain areas related to pain perception and emotion. These insights into the mechanisms have resulted in the clinically approved use of SCS in peripheral neuropathic pain states like Complex Regional Pain Syndrome (CRPS) and Failed Back Surgery Syndrome (FBSS). However, the mechanisms underlying SCS-induced pain relief in central neuropathic pain are only partly understood, and more research is needed before this therapy can be implemented in SCI patients with central neuropathic pain.
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14
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Exploration of the Supraspinal Hypotheses about Spinal Cord Stimulation and Dorsal Root Ganglion Stimulation: A Systematic Review. J Clin Med 2021; 10:jcm10132766. [PMID: 34201877 PMCID: PMC8268298 DOI: 10.3390/jcm10132766] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/19/2021] [Accepted: 06/20/2021] [Indexed: 12/27/2022] Open
Abstract
Despite the established efficacy and effectiveness of Spinal Cord Stimulation (SCS), there is still no consensus on the supraspinal mechanisms of action of this therapy. The purpose of this study was to systematically review previously raised hypotheses concerning supraspinal mechanisms of action of SCS based on human, animal and computational studies. Searches were conducted using four electronic databases (PubMed, EMBASE, SCOPUS and Web of Science), backward reference searching and consultation with experts. The study protocol was registered prior to initiation of the review process (PROSPERO CRD42020161531). A total of 54 publications were included, 21 of which were animal studies, and 33 were human studies. The supraspinal hypotheses (n = 69) identified from the included studies could be categorized into six groups concerning the proposed supraspinal hypothesis, namely descending pathways (n = 24); ascending medial pathway (n = 13); ascending lateral pathway (n = 10); affective/motivational influences (n = 8); spinal–cerebral (thalamic)-loop (n = 3) and miscellaneous (n = 11). Scientific support is provided for the hypotheses identified. Modulation of the descending nociceptive inhibitory pathways, medial and lateral pathways were the most frequently reported hypotheses about the supraspinal mechanisms of action of SCS. These hypotheses were mainly supported by studies with a high or moderate confidence in the body of evidence.
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15
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Differential Modulation of Dorsal Horn Neurons by Various Spinal Cord Stimulation Strategies. Biomedicines 2021; 9:biomedicines9050568. [PMID: 34070113 PMCID: PMC8158340 DOI: 10.3390/biomedicines9050568] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/10/2021] [Accepted: 05/13/2021] [Indexed: 12/18/2022] Open
Abstract
New strategies for spinal cord stimulation (SCS) for chronic pain have emerged in recent years, which may work better via different analgesic mechanisms than traditional low-frequency (e.g., 50 Hz) paresthesia-based SCS. To determine if 10 kHz and burst SCS waveforms might have a similar mechanistic basis, we examined whether these SCS strategies at intensities ostensibly below sensory thresholds would modulate spinal dorsal horn (DH) neuronal function in a neuron type-dependent manner. By using an in vivo electrophysiological approach in rodents, we found that low-intensity 10 kHz SCS, but not burst SCS, selectively activates inhibitory interneurons in the spinal DH. This study suggests that low-intensity 10 kHz SCS may inhibit pain-sensory processing in the spinal DH by activating inhibitory interneurons without activating DC fibers, resulting in paresthesia-free pain relief, whereas burst SCS likely operates via other mechanisms.
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16
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Canna A, Lehto LJ, Wu L, Sang S, Laakso H, Ma J, Filip P, Zhang Y, Gröhn O, Esposito F, Chen CC, Lavrov I, Michaeli S, Mangia S. Brain fMRI during orientation selective epidural spinal cord stimulation. Sci Rep 2021; 11:5504. [PMID: 33750822 PMCID: PMC7943775 DOI: 10.1038/s41598-021-84873-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 02/17/2021] [Indexed: 11/18/2022] Open
Abstract
Epidural spinal cord stimulation (ESCS) is widely used for chronic pain treatment, and is also a promising tool for restoring motor function after spinal cord injury. Despite significant positive impact of ESCS, currently available protocols provide limited specificity and efficiency partially due to the limited number of contacts of the leads and to the limited flexibility to vary the spatial distribution of the stimulation field in respect to the spinal cord. Recently, we introduced Orientation Selective (OS) stimulation strategies for deep brain stimulation, and demonstrated their selectivity in rats using functional MRI (fMRI). The method achieves orientation selectivity by controlling the main direction of the electric field gradients using individually driven channels. Here, we introduced a similar OS approach for ESCS, and demonstrated orientation dependent brain activations as detected by brain fMRI. The fMRI activation patterns during spinal cord stimulation demonstrated the complexity of brain networks stimulated by OS-ESCS paradigms, involving brain areas responsible for the transmission of the motor and sensory information. The OS approach may allow targeting ESCS to spinal fibers of different orientations, ultimately making stimulation less dependent on the precision of the electrode implantation.
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Affiliation(s)
- Antonietta Canna
- Center for Magnetic Resonance Research (CMRR), Department of Radiology, University of Minnesota, 2021 6th St. SE, Minneapolis, MN, 55455, USA.,Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Lauri J Lehto
- Center for Magnetic Resonance Research (CMRR), Department of Radiology, University of Minnesota, 2021 6th St. SE, Minneapolis, MN, 55455, USA
| | - Lin Wu
- Center for Magnetic Resonance Research (CMRR), Department of Radiology, University of Minnesota, 2021 6th St. SE, Minneapolis, MN, 55455, USA
| | - Sheng Sang
- Center for Magnetic Resonance Research (CMRR), Department of Radiology, University of Minnesota, 2021 6th St. SE, Minneapolis, MN, 55455, USA
| | - Hanne Laakso
- Center for Magnetic Resonance Research (CMRR), Department of Radiology, University of Minnesota, 2021 6th St. SE, Minneapolis, MN, 55455, USA.,A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jun Ma
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Pavel Filip
- Center for Magnetic Resonance Research (CMRR), Department of Radiology, University of Minnesota, 2021 6th St. SE, Minneapolis, MN, 55455, USA.,Department of Neurology, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Yuan Zhang
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Olli Gröhn
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Fabrizio Esposito
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Igor Lavrov
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA.,Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Shalom Michaeli
- Center for Magnetic Resonance Research (CMRR), Department of Radiology, University of Minnesota, 2021 6th St. SE, Minneapolis, MN, 55455, USA
| | - Silvia Mangia
- Center for Magnetic Resonance Research (CMRR), Department of Radiology, University of Minnesota, 2021 6th St. SE, Minneapolis, MN, 55455, USA.
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17
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Heijmans L, Mons MR, Joosten EA. A systematic review on descending serotonergic projections and modulation of spinal nociception in chronic neuropathic pain and after spinal cord stimulation. Mol Pain 2021; 17:17448069211043965. [PMID: 34662215 PMCID: PMC8527581 DOI: 10.1177/17448069211043965] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/01/2021] [Accepted: 08/16/2021] [Indexed: 12/11/2022] Open
Abstract
Chronic neuropathic pain is a debilitating ordeal for patients worldwide and pharmacological treatment efficacy is still limited. As many pharmacological interventions for neuropathic pain often fail, insights into the underlying mechanism and role of identified receptors is of utmost importance. An important target for improving treatment of neuropathic pain is the descending serotonergic system as these projections modulate nociceptive signaling in the dorsal horn. Also with use of last resort treatments like spinal cord stimulation (SCS), the descending serotonergic projections are known to be involved in the pain relieving effect. This systematic review summarizes the involvement of the serotonergic system on nociceptive modulation in the healthy adult rodent and the chronic neuropathic rodent and summarizes all available literature on the serotonergic system in the SCS-treated neuropathic rodent. Medline, Embase and Pubmed databases were used in the search for articles. Descending serotonergic modulation of nociceptive signaling in spinal dorsal horn in normal adult rat is mainly inhibitory and mediated by 5-HT1a, 5-HT1b, 5-HT2c, 5-HT3 and 5-HT4 receptors. Upon injury and in the neuropathic rat, this descending serotonergic modulation becomes facilitatory via activation of the 5-HT2a, 5-HT2b and 5-HT3 receptors. Analgesia due to neuromodulatory intervention like SCS restores the inhibitory function of the descending serotonergic system and involves 5-HT2, 5-HT3 and 5-HT4 receptors. The results of this systematic review provide insights and suggestions for further pharmacological and or neuromodulatory treatment of neuropathic pain based on targeting selected serotonergic receptors related to descending modulation of nociceptive signaling in spinal dorsal horn. With the novel developed SCS paradigms, the descending serotonergic system will be an important target for mechanism-based stimulation induced analgesia.
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Affiliation(s)
- Lonne Heijmans
- Department of Anesthesiology and Pain Management, Maastricht
University Medical Centre, the Netherlands
- Department of Translational Neuroscience, School of Mental
Health and Neuroscience, Maastricht University, the Netherlands
| | - Martijn R Mons
- Department of Anesthesiology and Pain Management, Maastricht
University Medical Centre, the Netherlands
- Department of Translational Neuroscience, School of Mental
Health and Neuroscience, Maastricht University, the Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, Maastricht
University Medical Centre, the Netherlands
- Department of Translational Neuroscience, School of Mental
Health and Neuroscience, Maastricht University, the Netherlands
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18
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Heijmans L, Joosten EA. Mechanisms and mode of action of spinal cord stimulation in chronic neuropathic pain. Postgrad Med 2020; 132:17-21. [PMID: 32403963 DOI: 10.1080/00325481.2020.1769393] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Tonic spinal cord stimulation (SCS) has been used as a treatment for chronic neuropathic pain ever since its discovery in late 1960s. Despite its clinical successes in a subset of chronic neuropathic pain syndromes, several limitations such as insufficient pain relief and uncomfortable paresthesias have led to the development of new targets, the dorsal root ganglion, and new stimulation waveforms, such as burst and high frequency. The aim of this review is to provide a brief overview of the main mechanisms behind the mode of action of the different SCS paradigms. Tonic SCS mainly acts via a segmental spinal mechanism where it induces GABA-release from inhibitory interneurons in the spinal dorsal horn. Tonic SCS concurrently initiates neuropathic pain modulation through a supraspinal-spinal feedback loop and serotonergic descending fibers. Mechanisms of stimulation of the DRG as well as those related to new SCS paradigms are now under investigation, where it seems that burst SCS not only stimulates sensory, discriminative aspects of pain (like Tonic SCS) but also emotional, affective, and motivational aspects of pain. Initial long-term study results on closed-loop SCS systems hold promise for improvement of future SCS treatment.
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Affiliation(s)
- Lonne Heijmans
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre , Maastricht, the Netherlands.,Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University , Maastricht, the Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre , Maastricht, the Netherlands.,Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University , Maastricht, the Netherlands
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