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Morin M, Morin A, Gougeon V, Marchand S, Waddell G, Bureau YA, Girard I, Brassard A, Benoit-Piau J, Léonard G. Transcranial direct current stimulation for provoked vestibulodynia: What roles do psychosexual factors play in treatment response? J Clin Neurosci 2021; 93:54-60. [PMID: 34656261 DOI: 10.1016/j.jocn.2021.08.003] [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: 08/24/2020] [Revised: 07/16/2021] [Accepted: 08/01/2021] [Indexed: 11/29/2022]
Abstract
There is growing evidence that provoked vestibulodynia (PVD), a frequent and debilitating condition, is characterized by central sensitization. This study aimed to examine predictive factors of transcranial direct current stimulation (tDCS) efficacy in this chronic pain population. Exploratory analysis derived from a randomized controlled trial was performed to assess predictors of pain reduction among 39 women with PVD who received 10 daily sessions of either active or sham tDCS. Clinical characteristics (e.g. pain intensity, duration and pain sensitivity) and psychosexual factors (e.g. pain catastrophizing, pain-related fear, anxiety, depressive symptoms and vaginal penetration cognitions) were assessed at baseline and used to predict tDCS response at 3-month follow-up. Analysis revealed that higher depressive symptoms and lower negative self-image cognitions were significant predictors of pain reduction at follow-up and accounted for 62.3% of the variance in the active tDCS group. Higher genital incompatibility cognitions were related to poorer response, regardless of treatment group. These findings suggest that women with PVD presenting higher depressive symptoms and lower levels of negative self-image cognitions could derive greater benefits from tDCS. These results suggest that tDCS could be effective in a subgroup of women with PVD - a possibility worth exploring with future prospective larger studies.
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Affiliation(s)
- Mélanie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Annie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Véronique Gougeon
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Serge Marchand
- Department of Surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Guy Waddell
- Department of Obstetrics Gynecology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Yves-André Bureau
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Isabelle Girard
- Department of Obstetrics Gynecology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Audrey Brassard
- Department of Psychology, Faculty of Arts and Social Sciences, 2500 blvd Université, Sherbrooke, Québec J1K 2Rl, Canada
| | - Justine Benoit-Piau
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Guillaume Léonard
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada.
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Gupta A, Woodworth DC, Ellingson BM, Rapkin AJ, Naliboff B, Kilpatrick LA, Stains J, Masghati S, Tillisch K, Mayer EA, Labus JS. Disease-Related Microstructural Differences in the Brain in Women With Provoked Vestibulodynia. THE JOURNAL OF PAIN 2018; 19:528.e1-528.e15. [PMID: 29391213 DOI: 10.1016/j.jpain.2017.12.269] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 11/06/2017] [Accepted: 12/17/2017] [Indexed: 12/13/2022]
Abstract
Provoked vestibulodynia (PVD) is a chronic pelvic pain disorder affecting 16% of the female population. Neuroimaging studies have highlighted central abnormalities in PVD, similar to other chronic pelvic pain disorders, including brain regions involved in sensory processing and modulation of pain. The aim of the study was to determine alterations in the subvoxel, microstructural organization within tissues in PVD compared with healthy control participants (HCs) and a disease control group (irritable bowel syndrome [IBS]). Diffusion tensor imaging magnetic resonance imaging was conducted in 87 age-matched premenopausal women (29 PVD, 29 HCs, 29 IBS). Statistical parameter mapping of fractional anisotropy (FA) and mean diffusivity (MD) maps were used to identify microstructural difference in the brain specific to PVD or shared with IBS. PVD alterations in microstructural organization of the brain were predominantly observed in fibers associated with sensorimotor integration and pain processing that relay information between the thalamus, basal ganglia, sensorimotor, and insular cortex. PVD, compared with HCs, showed extensive increases in the FA of somatosensory and basal ganglia regions. In contrast, PVD and IBS subjects did not show any FA-related group differences. PVD subjects showed greater MD in the basal ganglia compared with HCs (higher MD in the internal capsule and pallidum) and IBS (higher MD in the putamen and pallidum). Increases in MD were associated with increased vaginal muscle tenderness and vulvar pain. The current findings highlight possible shared mechanisms between 2 different pelvic pain disorders, but also highlight the widespread alterations observed specifically in PVD compared with HCs. PERSPECTIVE Alterations in microstructure in PVD were observed in fibers associated with sensorimotor integration and pain processing, which were also associated with increased vaginal muscle tenderness and vulvar pain. These alterations may be contributing to increased pain sensitivity and tenderness, highlighting the need for new therapies targeting the central nervous system.
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Affiliation(s)
- Arpana Gupta
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Davis C Woodworth
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Benjamin M Ellingson
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Department of Radiology at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Andrea J Rapkin
- Department of Obstetrics and Gynecology at UCLA, Los Angeles, California
| | - Bruce Naliboff
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Lisa A Kilpatrick
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jean Stains
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California
| | - Salome Masghati
- Department of Obstetrics and Gynecology at UCLA, Los Angeles, California
| | - Kirsten Tillisch
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Emeran A Mayer
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jennifer S Labus
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California.
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Morin A, Léonard G, Gougeon V, Cyr MP, Waddell G, Bureau YA, Girard I, Morin M. Efficacy of transcranial direct-current stimulation in women with provoked vestibulodynia. Am J Obstet Gynecol 2017; 216:584.e1-584.e11. [PMID: 28302387 DOI: 10.1016/j.ajog.2017.02.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/29/2017] [Accepted: 02/25/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Provoked vestibulodynia is a highly prevalent condition characterized by acute recurrent pain located at the vaginal entrance in response to pressure application or attempted vaginal penetration. Despite a wide variety of treatments offered to women with provoked vestibulodynia, a high proportion of women are refractory to conventional treatment. Transcranial direct-current stimulation is a noninvasive brain stimulation technique that has been shown effective for improving various chronic pain conditions. Growing evidence suggests that the central nervous system could play a key role in provoked vestibulodynia. Targeting the central nervous system could therefore be a promising treatment for women with provoked vestibulodynia. OBJECTIVE The purpose of this study was to evaluate and compare the efficacy of active and sham transcranial direct-current stimulation in reducing pain intensity during intercourse in patients with provoked vestibulodynia. STUDY DESIGN We conducted a triple-blind, parallel-group, randomized controlled trial. Women aged 17-45 years diagnosed with provoked vestibulodynia by a gynecologist using a validated protocol were randomized to 10 sessions of either active transcranial direct-current stimulation (intensity = 2 mA) or 10 sessions of sham transcranial direct-current stimulation, over a 2-week period. Both active and sham transcranial direct-current stimulation were applied for 20 minutes, with the anode positioned over the primary motor cortex, and the cathode over the contralateral supraorbital area. Outcome measures were collected at baseline, 2 weeks after treatment, and at 3-month follow-up by an evaluator blinded to group assignment. The primary objective was to assess pain intensity during intercourse, using a numerical rating scale. Secondary outcomes focused on sexual function and distress, vestibular sensitivity, psychological distress, treatment satisfaction, and patient impression of change. Statistical analyses were conducted on the intention-to-treat basis, and treatment effects were evaluated using a mixed linear model for repeated measures. RESULTS A total of 40 patients were randomly assigned to receive either active (n = 20) or sham (n = 20) transcranial direct-current stimulation treatments from November 2014 through February 2016. Baseline characteristics were similar between the active and sham transcranial direct-current stimulation groups. In full compliance with the study protocol, every participant followed all courses of the study treatment, including assessments at 2-week and 3-month follow-up. Pain during sexual intercourse was not significantly different between active and sham treatment groups 2 weeks after treatment (P = .84) and at follow-up (P = .09). Mean baseline and 2-week assessment pain intensity were, respectively, 6.8 (95% confidence interval, 5.9-7.7) and 5.6 (95% confidence interval, 4.7-6.5) for active transcranial direct-current stimulation (P = .03) vs 7.5 (95% confidence interval, 6.6-8.4) and 5.7 (95% confidence interval, 4.8-6.6) for sham transcranial direct-current stimulation (P = .001). Nonsignificant differences between the 2 groups were also found in their sexual function and distress after treatment (P > .20) and at follow-up (P > .10). Overall, at 2-week assessment 68% assigned to active transcranial direct-current stimulation reported being very much, much, or slightly improved compared to 65% assigned to sham transcranial direct-current stimulation (P = .82), and still comparable at follow-up: 42% vs 65%, respectively (P = .15). CONCLUSION Findings suggest that active transcranial direct-current stimulation is not more effective than sham transcranial direct-current stimulation for reducing pain in women with provoked vestibulodynia. Likewise, no significant effects were found on sexual function, vestibular sensitivity, or psychological distress.
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Morin M, Carroll MS, Bergeron S. Systematic Review of the Effectiveness of Physical Therapy Modalities in Women With Provoked Vestibulodynia. Sex Med Rev 2017; 5:295-322. [PMID: 28363763 DOI: 10.1016/j.sxmr.2017.02.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/24/2017] [Accepted: 02/25/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Pelvic floor muscle physical therapy is recommended in clinical guidelines for women with provoked vestibulodynia (PVD). Including isolated or combined treatment modalities, physical therapy is viewed as an effective first-line intervention, yet no systematic review concerning the effectiveness of physical therapy has been conducted. AIM To systematically appraise the current literature on the effectiveness of physical therapy modalities for decreasing pain during intercourse and improving sexual function in women with PVD. METHODS A systematic literature search using PubMed, Scopus, CINHAL, and PEDro was conducted until October 2016. Moreover, a manual search from reference lists of included articles was performed. Ongoing trials also were reviewed using clinicaltrial.gov and ISRCTNregistry. Randomized controlled trials, prospective and retrospective cohorts, and case reports evaluating the effect of isolated or combined physical therapy modalities in women with PVD were included in the review. MAIN OUTCOME MEASURES Main outcome measures were pain during intercourse, sexual function, and patient's perceived improvement. RESULTS The literature search resulted in 43 eligible studies including 7 randomized controlled trials, 20 prospective studies, 5 retrospective studies, 6 case reports, and 6 study protocols. Most studies had a high risk of bias mainly associated with the lack of a comparison group. Another common bias was related to insufficient sample size, non-validated outcomes, non-standardized intervention, and use of other ongoing treatment. The vast majority of studies showed that physical therapy modalities such as biofeedback, dilators, electrical stimulation, education, multimodal physical therapy, and multidisciplinary approaches were effective for decreasing pain during intercourse and improving sexual function. CONCLUSION The positive findings for the effectiveness of physical therapy modalities in women with PVD should be investigated further in robust and well-designed randomized controlled trials. Morin M, Carroll M-S, Bergeron S. Systematic Review of the Effectiveness of Physical Therapy Modalities in Women With Provoked Vestibulodynia. Sex Med Rev 2017;5:295-322.
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Affiliation(s)
- Mélanie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke; Research Center, Centre hospitalier universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada.
| | - Marie-Soleil Carroll
- Faculty of Medicine and Health Sciences, Université de Sherbrooke; Research Center, Centre hospitalier universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada
| | - Sophie Bergeron
- Department of Psychology, Université de Montréal, Montréal, QC, Canada
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Janice Jimenez-Torres G, Weinstein BL, Walker CR, Christopher Fowler J, Ashford P, Borckardt JJ, Madan A. A study protocol for a single-blind, randomized controlled trial of adjunctive transcranial direct current stimulation (tDCS) for chronic pain among patients receiving specialized, inpatient multimodal pain management. Contemp Clin Trials 2016; 54:36-47. [PMID: 28039022 DOI: 10.1016/j.cct.2016.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 12/23/2016] [Accepted: 12/24/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Available treatments for chronic pain (CP) are modestly effective or associated with iatrogenic harm. Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that may be an effective, adjunctive treatment to non-opioid therapies. In this randomized control trial (RCT), we compare adjunctive active versus sham tDCS among patients in a multimodal inpatient pain management program. The primary objectives of the RCT are to improve pain tolerance and subjective pain experience. METHODS AND DESIGN Patients admitted to the Pain Management Program at The Menninger Clinic in Houston, Texas are eligible for this trial. Eighty-four participants will be randomized (1:1) into a single-blind, 2×12 (group×time) controlled trial. A battery-powered direct and constant current stimulator (Soterix Medical Inc. 2014) delivers anodal stimulation over the left dorsolateral prefrontal cortex (DLPFC) and cathodal stimulation over the right DLPFC. Active tDCS is applied by supplying a 2mA current for 20min/session over 10 sessions. Participants complete self-report and performance-based assessments on a weekly basis just prior to brain stimulation. Self-report assessments are collected via Chronic Pain Tracker version 3.6, an iPad interfaced application. The performance-based pain tolerance task is completed through the cold presser task. DISCUSSION Interventions with cross-symptomatic therapeutic potential are absolutely essential in the context of CP, in which psychiatric comorbidity is the norm. Modalities that can be used in tandem with evidence-based, non-opioid therapies have the potential to have a synergistic effect, resulting in increased effectiveness of what have been modestly effective treatments to date.
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Affiliation(s)
- G Janice Jimenez-Torres
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Benjamin L Weinstein
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Cory R Walker
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - J Christopher Fowler
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | | | - Jeffrey J Borckardt
- Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, United States; Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States; Ralph H. Johnson Veterans' Affairs Medical Center, Charleston, SC, United States
| | - Alok Madan
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States.
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