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Hvingelby VS, Carra RB, Terkelsen MH, Hamani C, Capato T, Košutzká Z, Krauss JK, Moro E, Pavese N, Cury RG. A Pragmatic Review on Spinal Cord Stimulation Therapy for Parkinson's Disease Gait Related Disorders: Gaps and Controversies. Mov Disord Clin Pract 2024; 11:927-947. [PMID: 38899557 PMCID: PMC11329578 DOI: 10.1002/mdc3.14143] [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] [Received: 08/01/2023] [Revised: 05/30/2024] [Accepted: 06/01/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Parkinson's Disease (PD) is a progressive neurological disorder that results in potentially debilitating mobility deficits. Recently, spinal cord stimulation (SCS) has been proposed as a novel therapy for PD gait disorders. The highest levels of evidence remain limited for SCS. OBJECTIVES In this systematic review and narrative synthesis, the literature was searched using combinations of key phrases indicating spinal cord stimulation and PD. METHODS We included pre-clinical studies and all published clinical trials, case reports, conference abstracts as well as protocols for ongoing clinical trials. Additionally, we included trials of SCS applied to atypical parkinsonism. RESULTS A total of 45 human studies and trials met the inclusion criteria. Based on the narrative synthesis, a number of knowledge gaps and future avenues of potential research were identified. This review demonstrated that evidence for SCS is currently not sufficient to recommend it as an evidence-based therapy for PD related gait disorders. There remain challenges and significant barriers to widespread implementation, including issues regarding patient selection, effective outcome selection, stimulation location and mode, and in programming parameter optimization. Results of early randomized controlled trials are currently pending. SCS is prone to placebo, lessebo and nocebo as well as blinding effects which may impact interpretation of outcomes, particularly when studies are underpowered. CONCLUSION Therapies such as SCS may build on current evidence and be shown to improve specific gait features in PD. Early negative trials should be interpreted with caution, as more evidence will be required to develop effective methodologies in order to drive clinical outcomes.
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Affiliation(s)
- Victor S. Hvingelby
- Department of Clinical Medicine – Nuclear Medicine and PET CenterAarhus UniversityAarhusDenmark
| | - Rafael B. Carra
- Department of Neurology, School of MedicineUniversity of São PauloSão PauloBrazil
| | - Miriam H. Terkelsen
- Department of Clinical Medicine – Nuclear Medicine and PET CenterAarhus UniversityAarhusDenmark
| | - Clement Hamani
- Division of Neurosurgery, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Tamine Capato
- Department of Neurology, School of MedicineUniversity of São PauloSão PauloBrazil
| | - Zuzana Košutzká
- Second Department of NeurologyComenius University BratislavaBratislavaSlovakia
| | - Joachim K. Krauss
- Department of Neurosurgery, Hannover Medical SchoolHannoverGermany
- Center for Systems NeuroscienceHannoverGermany
| | - Elena Moro
- Grenoble Alpes University, Division of Neurology, CHU of Grenoble, Grenoble Institute of NeurosciencesGrenobleFrance
| | - Nicola Pavese
- Clinical Ageing Research Unit Newcastle UniversityNewcastle upon TyneUK
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Guzzi G, Della Torre A, Bruni A, Lavano A, Bosco V, Garofalo E, La Torre D, Longhini F. Anatomo-physiological basis and applied techniques of electrical neuromodulation in chronic pain. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:29. [PMID: 38698460 PMCID: PMC11064427 DOI: 10.1186/s44158-024-00167-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Abstract
Chronic pain, a complex and debilitating condition, poses a significant challenge to both patients and healthcare providers worldwide. Conventional pharmacological interventions often prove inadequate in delivering satisfactory relief while carrying the risks of addiction and adverse reactions. In recent years, electric neuromodulation emerged as a promising alternative in chronic pain management. This method entails the precise administration of electrical stimulation to specific nerves or regions within the central nervous system to regulate pain signals. Through mechanisms that include the alteration of neural activity and the release of endogenous pain-relieving substances, electric neuromodulation can effectively alleviate pain and improve patients' quality of life. Several modalities of electric neuromodulation, with a different grade of invasiveness, provide tailored strategies to tackle various forms and origins of chronic pain. Through an exploration of the anatomical and physiological pathways of chronic pain, encompassing neurotransmitter involvement, this narrative review offers insights into electrical therapies' mechanisms of action, clinical utility, and future perspectives in chronic pain management.
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Affiliation(s)
- Giusy Guzzi
- Neurosurgery Department, "R. Dulbecco" Hospital, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Attilio Della Torre
- Neurosurgery Department, "R. Dulbecco" Hospital, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care Unit, "R. Dulbecco" Univesity Hospital, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, Catanzaro, 88100, Italy
| | - Angelo Lavano
- Neurosurgery Department, "R. Dulbecco" Hospital, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Vincenzo Bosco
- Anesthesia and Intensive Care Unit, "R. Dulbecco" Univesity Hospital, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, Catanzaro, 88100, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care Unit, "R. Dulbecco" Univesity Hospital, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, Catanzaro, 88100, Italy
| | - Domenico La Torre
- Neurosurgery Department, "R. Dulbecco" Hospital, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care Unit, "R. Dulbecco" Univesity Hospital, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, Catanzaro, 88100, Italy.
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González-Zamorano Y, José Sánchez-Cuesta F, Moreno-Verdú M, Arroyo-Ferrer A, Fernández-Carnero J, Chaudhuri KR, Fieldwalker A, Romero JP. TDCS for parkinson's disease disease-related pain: A randomized trial. Clin Neurophysiol 2024; 161:133-146. [PMID: 38479239 DOI: 10.1016/j.clinph.2024.01.011] [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] [Received: 09/25/2023] [Revised: 12/05/2023] [Accepted: 01/04/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVE To evaluate the effects of transcranial direct current stimulation (tDCS) on Parkinson's disease (PD)-related pain. METHODS This triple-blind randomized controlled trial included twenty-two patients (age range 38-85, 10 male) with PD-related pain. Eleven subjects received ten sessions of 20 minutes tDCS over the primary motor cortex contralateral to pain at 2 mA intensity. Eleven subjects received sham stimulation. Outcome measures included changes in the Kinǵs Parkinsońs Pain Scale (KPPS), Brief Pain Inventory (BPI), widespread mechanical hyperalgesia (WMH), temporal summation of pain (TS), and conditioned pain modulation (CPM). RESULTS Significant differences were found in KPPS between groups favoring the active-tDCS group compared to the sham-tDCS group at 15-days follow-up (p = 0.014) but not at 2 days post-intervention (p = 0.059). The active-group showed significant improvements over the sham-group after 15 days (p = 0.017). Significant changes were found in CPM between groups in favor of active-tDCS group at 2 days post-intervention (p = 0.002) and at 15 days (p = 0.017). No meaningful differences were observed in BPI or TS. CONCLUSIONS tDCS of the primary motor cortex alleviates perceived PD-related pain, reduces pain sensitization, and enhances descending pain inhibition. SIGNIFICANCE This is the first study to test and demonstrate the use of tDCS for improving PD-related pain.
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Affiliation(s)
- Yeray González-Zamorano
- International Doctorate School, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28933 Alcorcón, Spain; Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Rey Juan Carlos University, 28933 Alcorcón, Spain; Cognitive Neuroscience, Pain and Rehabilitation Research Group (NECODOR), Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain; Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain.
| | - Francisco José Sánchez-Cuesta
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain; Faculty of Experimental Sciences, Francisco de Vitoria University, 28223 Pozuelo de Alarcón, Spain.
| | - Marcos Moreno-Verdú
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain; Faculty of Experimental Sciences, Francisco de Vitoria University, 28223 Pozuelo de Alarcón, Spain
| | - Aida Arroyo-Ferrer
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain; Faculty of Experimental Sciences, Francisco de Vitoria University, 28223 Pozuelo de Alarcón, Spain.
| | - Josué Fernández-Carnero
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Rey Juan Carlos University, 28933 Alcorcón, Spain; Cognitive Neuroscience, Pain and Rehabilitation Research Group (NECODOR), Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain.
| | - K Ray Chaudhuri
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; Parkinson's Foundation Centre of Excellence, King's College Hospital, London, United Kingdom.
| | - Anna Fieldwalker
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
| | - Juan Pablo Romero
- Cognitive Neuroscience, Pain and Rehabilitation Research Group (NECODOR), Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain; Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain; Faculty of Experimental Sciences, Francisco de Vitoria University, 28223 Pozuelo de Alarcón, Spain; Brain Damage Unit, Beata María Ana Hospital, 28007 Madrid, Spain.
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Rosenkjær S, Hvingelby VS, Johnsen EL, Møller M, Carlino E, Jensen TS, Vase L. Effects of deep brain stimulation and verbal suggestions on pain in Parkinson's disease. Scand J Pain 2024; 24:sjpain-2023-0126. [PMID: 38485660 DOI: 10.1515/sjpain-2023-0126] [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] [Received: 11/07/2023] [Accepted: 02/15/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND AND OBJECTIVES In Parkinson's disease (PD) patients, verbal suggestions have been shown to modulate motor and clinical outcomes in treatment with subthalamic deep brain stimulation (DBS). Furthermore, DBS may alleviate pain in PD. However, it is unknown if verbal suggestions influence DBS' effects on pain. METHODS Twenty-four people with PD and DBS had stimulation downregulated (80-60 to 20%) and upregulated (from 20-60 to 80%) in a blinded manner on randomized test days: (1) with negative and positive suggestions of pain for down- and upregulation, respectively, and (2) with no suggestions to effect (control). Effects of DBS and verbal suggestions were assessed on ongoing and evoked pain (hypertonic saline injections) via 0-10 numerical rating scales along with motor symptoms, expectations, and blinding. RESULTS Stimulation did not influence ongoing and evoked pain but influenced motor symptoms in the expected direction. Baseline and experimental pain measures showed no patterns in degree of pain. There was a trend toward negative suggestions increasing pain and positive suggestions decreasing pain. Results show significant differences in identical stimulation with negative vs positive suggestions (60% conditions AUC 38.75 vs 23.32, t(13) = 3.10, p < 0.001). Expectations to pain had small to moderate effects on evoked pain. Patients estimated stimulation level correctly within 10 points. CONCLUSION Stimulation does not seem to influence ongoing and evoked pain, but verbal suggestions may influence pain levels. Patients appear to be unblinded to stimulation level which is an important consideration for future studies testing DBS in an attempted blind fashion.
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Affiliation(s)
- Sophie Rosenkjær
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | | | - Erik Lisbjerg Johnsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Mette Møller
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Elisa Carlino
- Department of Neuroscience, University of Turin, Turin, Italy
| | - Troels Staehelin Jensen
- Department of Clinical Medicine, Danish Pain Research Centre, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
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de Andrade DC, Mylius V, Perez-Lloret S, Cury RG, Bannister K, Moisset X, Taricani Kubota G, Finnerup NB, Bouhassira D, Chaudhuri KR, Graven-Nielsen T, Treede RD. Pain in Parkinson disease: mechanistic substrates, main classification systems, and how to make sense out of them. Pain 2023; 164:2425-2434. [PMID: 37318012 DOI: 10.1097/j.pain.0000000000002968] [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: 01/25/2023] [Accepted: 05/02/2023] [Indexed: 06/16/2023]
Abstract
ABSTRACT Parkinson disease (PD) affects up to 2% of the general population older than 65 years and is a major cause of functional loss. Chronic pain is a common nonmotor symptom that affects up to 80% of patients with (Pw) PD both in prodromal phases and during the subsequent stages of the disease, negatively affecting patient's quality of life and function. Pain in PwPD is rather heterogeneous and may occur because of different mechanisms. Targeting motor symptoms by dopamine replacement or with neuromodulatory approaches may only partially control PD-related pain. Pain in general has been classified in PwPD according to the motor signs, pain dimensions, or pain subtypes. Recently, a new classification framework focusing on chronic pain was introduced to group different types of PD pains according to mechanistic descriptors: nociceptive, neuropathic, or neither nociceptive nor neuropathic. This is also in line with the International Classification of Disease-11 , which acknowledges the possibility of chronic secondary musculoskeletal or nociceptive pain due to disease of the CNS. In this narrative review and opinion article, a group of basic and clinical scientists revise the mechanism of pain in PD and the challenges faced when classifying it as a stepping stone to discuss an integrative view of the current classification approaches and how clinical practice can be influenced by them. Knowledge gaps to be tackled by coming classification and therapeutic efforts are presented, as well as a potential framework to address them in a patient-oriented manner.
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Affiliation(s)
- Daniel Ciampi de Andrade
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Veit Mylius
- Department of Neurology, Centre for Neurorehabilitation, Valens, Switzerland
- Department of Neurology, Philipps University, Marburg, Germany
- Department of Neurology, Kantonsspital, St. Gallen, Switzerland
| | - Santiago Perez-Lloret
- Observatorio de Salud Pública, Universidad Católica Argentina, Consejo de Investigaciones Científicas y Técnicas (UCA-CONICET), Buenos Aires, Argentina
- Facultad de Medicina, Pontificia Universidad Católica Argentina, Buenos Aires, Argentina
- Departamento de Fisiología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Rubens G Cury
- Movement Disorders Center, Department of Neurology, University of Sao Paulo, Sao Paulo, Brazil
| | - Kirsty Bannister
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Xavier Moisset
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Inserm, Neuro-Dol, Clermont-Ferrand, France
| | - Gabriel Taricani Kubota
- Department of Neurology, Centre for Neurorehabilitation, Valens, Switzerland
- Pain Center, University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
- Center for Pain Treatment, Institute of Cancer of the State of Sao Paulo, University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Didier Bouhassira
- Inserm U987, APHP, UVSQ, Paris-Saclay University, Ambroise Pare Hospital, Boulogne-Billancourt, France
| | - Kallol Ray Chaudhuri
- Division of Neuroscience, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- Parkinson Foundation Centre of Excellence in Care and Research, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Thomas Graven-Nielsen
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Rolf-Detlef Treede
- Department of Neurophysiology, Mannheim Center for Translational Neurosciences, Heidelberg University, Mannheim, Germany
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de Andrade DC, García-Larrea L. Beyond trial-and-error: Individualizing therapeutic transcranial neuromodulation for chronic pain. Eur J Pain 2023; 27:1065-1083. [PMID: 37596980 PMCID: PMC7616049 DOI: 10.1002/ejp.2164] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND AND OBJECTIVE Repetitive transcranial magnetic stimulation (rTMS) applied to the motor cortex provides supplementary relief for some individuals with chronic pain who are refractory to pharmacological treatment. As rTMS slowly enters treatment guidelines for pain relief, its starts to be confronted with challenges long known to pharmacological approaches: efficacy at the group-level does not grant pain relief for a particular patient. In this review, we present and discuss a series of ongoing attempts to overcome this therapeutic challenge in a personalized medicine framework. DATABASES AND DATA TREATMENT Relevant scientific publications published in main databases such as PubMed and EMBASE from inception until March 2023 were systematically assessed, as well as a wide number of studies dedicated to the exploration of the mechanistic grounds of rTMS analgesic effects in humans, primates and rodents. RESULTS The main strategies reported to personalize cortical neuromodulation are: (i) the use of rTMS to predict individual response to implanted motor cortex stimulation; (ii) modifications of motor cortex stimulation patterns; (iii) stimulation of extra-motor targets; (iv) assessment of individual cortical networks and rhythms to personalize treatment; (v) deep sensory phenotyping; (vi) personalization of location, precision and intensity of motor rTMS. All approaches except (i) have so far low or moderate levels of evidence. CONCLUSIONS Although current evidence for most strategies under study remains at best moderate, the multiple mechanisms set up by cortical stimulation are an advantage over single-target 'clean' drugs, as they can influence multiple pathophysiologic paths and offer multiple possibilities of individualization. SIGNIFICANCE Non-invasive neuromodulation is on the verge of personalised medicine. Strategies ranging from integration of detailed clinical phenotyping into treatment design to advanced patient neurophysiological characterisation are being actively explored and creating a framework for actual individualisation of care.
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Affiliation(s)
- Daniel Ciampi de Andrade
- Department of Health Science and Technology, Faculty of Medicine, Center for Neuroplasticity and Pain (CNAP), Aalborg University, Aalborg, Denmark
| | - Luís García-Larrea
- University Hospital Pain Center (CETD), Neurological Hospital P. Wertheimer, Hospices Civils de Lyon, Lyon, France
- NeuroPain Lab, INSERM U1028, UMR5292, Lyon Neuroscience Research Center, CNRS, University Claude Bernard Lyon 1, Lyon, France
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Flouty O, Yamamoto K, Germann J, Harmsen IE, Jung HH, Cheyuo C, Zemmar A, Milano V, Sarica C, Lozano AM. Idiopathic Parkinson's disease and chronic pain in the era of deep brain stimulation: a systematic review and meta-analysis. J Neurosurg 2022; 137:1821-1830. [PMID: 35535836 DOI: 10.3171/2022.2.jns212561] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pain is the most common nonmotor symptom of Parkinson's disease (PD) and is often undertreated. Deep brain stimulation (DBS) effectively mitigates the motor symptoms of this multisystem neurodegenerative disease; however, its therapeutic effect on nonmotor symptoms, especially pain, remains inconclusive. While there is a critical need to help this large PD patient population, guidelines for managing this significant disease burden are absent. Herein, the authors systematically reviewed the literature and conducted a meta-analysis to study the influence of traditional (subthalamic nucleus [STN] and globus pallidus internus [GPi]) DBS on chronic pain in patients with PD. METHODS The authors performed a systematic review of the literature and a meta-analysis following PRISMA guidelines. Risk of bias was assessed using the levels of evidence established by the Oxford Centre for Evidence-Based Medicine. Inclusion criteria were articles written in English, published in a peer-reviewed scholarly journal, and about studies conducting an intervention for PD-related pain in no fewer than 5 subjects. RESULTS Twenty-six studies were identified and included in this meta-analysis. Significant interstudy heterogeneity was detected (Cochran's Q test p < 0.05), supporting the use of the random-effects model. The random-effects model estimated the effect size of DBS for the treatment of idiopathic pain as 1.31 (95% CI 0.84-1.79). The DBS-on intervention improved pain scores by 40% as compared to the control state (preoperative baseline or DBS off). CONCLUSIONS The results indicated that traditional STN and GPi DBS can have a favorable impact on pain control and improve pain scores by 40% from baseline in PD patients experiencing chronic pain. Further trials are needed to identify the subtype of PD patients whose pain benefits from DBS and to identify the mechanisms by which DBS improves pain in PD patients.
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Affiliation(s)
- Oliver Flouty
- 1Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Kazuaki Yamamoto
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jurgen Germann
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Irene E Harmsen
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Hyun Ho Jung
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,3Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Cletus Cheyuo
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ajmal Zemmar
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,4Department of Neurosurgery, University of Louisville, School of Medicine, Louisville, Kentucky; and.,5Department of Neurosurgery, Henan Provincial People's Hospital, Henan University People's Hospital, Henan University School of Medicine, Zhengzhou, China
| | - Vanessa Milano
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Can Sarica
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- 2Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Hollunder B, Rajamani N, Siddiqi SH, Finke C, Kühn AA, Mayberg HS, Fox MD, Neudorfer C, Horn A. Toward personalized medicine in connectomic deep brain stimulation. Prog Neurobiol 2022; 210:102211. [PMID: 34958874 DOI: 10.1016/j.pneurobio.2021.102211] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 02/08/2023]
Abstract
At the group-level, deep brain stimulation leads to significant therapeutic benefit in a multitude of neurological and neuropsychiatric disorders. At the single-patient level, however, symptoms may sometimes persist despite "optimal" electrode placement at established treatment coordinates. This may be partly explained by limitations of disease-centric strategies that are unable to account for heterogeneous phenotypes and comorbidities observed in clinical practice. Instead, tailoring electrode placement and programming to individual patients' symptom profiles may increase the fraction of top-responding patients. Here, we propose a three-step, circuit-based framework with the aim of developing patient-specific treatment targets that address the unique symptom constellation prevalent in each patient. First, we describe how a symptom network target library could be established by mapping beneficial or undesirable DBS effects to distinct circuits based on (retrospective) group-level data. Second, we suggest ways of matching the resulting symptom networks to circuits defined in the individual patient (template matching). Third, we introduce network blending as a strategy to calculate optimal stimulation targets and parameters by selecting and weighting a set of symptom-specific networks based on the symptom profile and subjective priorities of the individual patient. We integrate the approach with published literature and conclude by discussing limitations and future challenges.
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Affiliation(s)
- Barbara Hollunder
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Nanditha Rajamani
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Shan H Siddiqi
- Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Carsten Finke
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andrea A Kühn
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany; NeuroCure Cluster of Excellence, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Helen S Mayberg
- Nash Family Center for Advanced Circuit Therapeutics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael D Fox
- Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA
| | - Clemens Neudorfer
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andreas Horn
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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9
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Mylius V, Möller JC, Bohlhalter S, Ciampi de Andrade D, Perez Lloret S. Diagnosis and Management of Pain in Parkinson's Disease: A New Approach. Drugs Aging 2021; 38:559-577. [PMID: 34224103 DOI: 10.1007/s40266-021-00867-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 12/27/2022]
Abstract
Pain is a frequent and disabling non-motor feature of Parkinson's disease (PD). The recently proposed PD Pain Classification System (PD-PCS) allows for an association of pain with PD to be determined before being allocated to the main pain mechanism (i.e. nociceptive, neuropathic, and nociplastic). In this article, previous studies on treatments for pain in PD are summarized according to the pain mechanisms. A mechanistic approach to treatment is discussed. We suggest that the first step should be optimizing dopaminergic therapy before other therapy is started. When these treatments remain unsuccessful, further causes of pain must be considered. The role of drugs, invasive treatments, and physiotherapeutic interventions are discussed with a focus on older PD patients and considering polypharmacy, altered pharmacokinetics, and comorbidities.
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Affiliation(s)
- Veit Mylius
- Department of Neurology, Center for Neurorehabilitation, 7317, Valens, Switzerland. .,Department of Neurology, Philipps University, Marburg, Germany. .,Department of Neurology, Kantonsspital, St. Gallen, Switzerland.
| | - Jens Carsten Möller
- Department of Neurology, Philipps University, Marburg, Germany.,Parkinson Center, Center for Neurological Rehabilitation, Zihlschlacht, Switzerland
| | - Stephan Bohlhalter
- Neurocenter, Luzerner Kantonsspital, Lucerne, Switzerland.,Department of Neurology, University of Zurich, Zurich, Switzerland
| | - Daniel Ciampi de Andrade
- Centro de Dor, Departamento de Neurologia da Faculdade de Medicina da, Universidade de Sao Paulo, Sao Paulo, Brazil.,Instituto do Cancer de Sao Paulo, Octavio Frias de Oliveira, Sao Paulo, Brazil.,Hospital das Clinicas, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Santiago Perez Lloret
- LIM 62, Biomedical Research Center (CAECIHS-UAI), National Research Council (CONICET), Buenos Aires, Argentina.,Facultad de Ciencias Médicas, Pontificia Universidad Católica Argentina, Buenos Aires, Argentina.,Departamento de Fisiología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
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10
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Diao Y, Bai Y, Hu T, Yin Z, Liu H, Meng F, Yang A, Zhang J. A Meta-Analysis of the Effect of Subthalamic Nucleus-Deep Brain Stimulation in Parkinson's Disease-Related Pain. Front Hum Neurosci 2021; 15:688818. [PMID: 34276330 PMCID: PMC8281028 DOI: 10.3389/fnhum.2021.688818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/31/2021] [Indexed: 11/18/2022] Open
Abstract
Pain from Parkinson's disease (PD) is a non-motor symptom affecting the quality of life and has prevalence of 20–80%. However, it is unclear whether subthalamic nucleus deep brain stimulation (STN–DBS), a well-established treatment for PD, is effective forPD-related pain. Thus, the objective of this meta-analysis was to investigate the efficacy of STN-DBS on PD-related pain and explore how its duration affects the efficacy of STN-DBS. A systematic search was performed using PubMed, Embase, and the Cochrane Library. Nine studies included numerical rating scale (NRS), visual analog scale (VAS), or non-motor symptom scale (NMSS) scores at baseline and at the last follow-up visit and therefore met the inclusion criteria of the authors. These studies exhibited moderate- to high-quality evidence. Two reviewers conducted assessments for study eligibility, risk of bias, data extraction, and quality of evidence rating. Random effect meta-analysis revealed a significant change in PD-related pain as assessed by NMSS, NRS, and VAS (P <0.01). Analysis of the short and long follow-up subgroups indicated delayed improvement in PD-related pain. These findings (a) show the efficacy of STN-DBS on PD-related pain and provide higher-level evidence, and (b) implicate delayed improvement in PD-related pain, which may help programming doctors with supplement selecting target and programming. Systematic Review Registration: This study is registered in Open Science Framework (DOI: 10.17605/OSF.IO/DNM6K).
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Affiliation(s)
- Yu Diao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yutong Bai
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tianqi Hu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Yin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huangguang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fangang Meng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
| | - Anchao Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianguo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
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11
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Rukavina K, Cummins TM, Chaudhuri KR, Bannister K. Pain in Parkinson's disease: Mechanism-based treatment strategies. Curr Opin Support Palliat Care 2021; 15:108-115. [PMID: 33782333 DOI: 10.1097/spc.0000000000000546] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Chronic pain, highly prevalent throughout the course of Parkinson's disease (PD), has been ranked as one of the top ten most bothersome symptoms people with Parkinson's (PwP) are experiencing. Yet, robust evidence-based treatment strategies are lacking. This unmet need is partly attributable to the multifaceted nature of PD-related pain, which results in part from a complex and poorly understood interplay involving a range of neurotransmitter pathways. Degeneration of nigrostriatal dopaminergic pathways and alterations of central nervous system extra-striatal dopaminergic, noradrenergic, serotoninergic, glutamatergic, opioidergic and endocannabinoid circuits may all promote a heightened experience of pain in PwP. Thus, the potential targets for mechanism-based pain-relieving strategies in PwP are several. These targets are discussed herein. RECENT FINDINGS An increasing number of clinical trials and experimental studies in animal models of PD are being designed with the aim of addressing the pathophysiological mechanism(s) underlying PD-related pain. Overall, recent research findings highlight the analgesic effects of dopaminergic and opioidergic medication for certain subtypes of pain in PwP, whereas proposing novel strategies that involve targeting other neurotransmitter pathways. SUMMARY The origin of pain in PwP remains under investigation. Although our understanding of the mechanisms underpinning persistent pain in PD has improved in recent years, this has not yet translated to clinical alleviation of this most troublesome nonmotor symptom. Patient stratification linked with evidence-based personalized pain-treatment plans for optimal analgesic relief will rely on advances in our understanding of the dopaminergic and nondopaminergic targets outlined in this review.
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Affiliation(s)
- Katarina Rukavina
- Department of Basic and Clinical Neuroscience, The Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
- Parkinson Foundation Centre of Excellence, King's College Hospital, London, UK
| | - Tatum M Cummins
- Central Modulation of Pain, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - K Ray Chaudhuri
- Department of Basic and Clinical Neuroscience, The Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
- Parkinson Foundation Centre of Excellence, King's College Hospital, London, UK
| | - Kirsty Bannister
- Central Modulation of Pain, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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12
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Horn A, Fox MD. Opportunities of connectomic neuromodulation. Neuroimage 2020; 221:117180. [PMID: 32702488 PMCID: PMC7847552 DOI: 10.1016/j.neuroimage.2020.117180] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 06/12/2020] [Accepted: 07/16/2020] [Indexed: 12/14/2022] Open
Abstract
The process of altering neural activity - neuromodulation - has long been used to treat patients with brain disorders and answer scientific questions. Deep brain stimulation in particular has provided clinical benefit to over 150,000 patients. However, our understanding of how neuromodulation impacts the brain is evolving. Instead of focusing on the local impact at the stimulation site itself, we are considering the remote impact on brain regions connected to the stimulation site. Brain connectivity information derived from advanced magnetic resonance imaging data can be used to identify these connections and better understand clinical and behavioral effects of neuromodulation. In this article, we review studies combining neuromodulation and brain connectomics, highlighting opportunities where this approach may prove particularly valuable. We focus on deep brain stimulation, but show that the same principles can be applied to other forms of neuromodulation, such as transcranial magnetic stimulation and MRI-guided focused ultrasound. We outline future perspectives and provide testable hypotheses for future work.
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Affiliation(s)
- Andreas Horn
- Neurology Department, Movement Disorders and Neuromodulation Sectio Charité - University Medicine Berlin,, Charitéplatz 1, D-10117 Berlin, Germany.
| | - Michael D Fox
- Berenson-Allen Center for Non-invasive Brain Stimulation, Department of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, United States; Martinos Center for Biomedical Imaging, Departments of Neurology and Radiology, Harvard Medical School and Massachusetts General Hospital, United States; Center for Brain Circuit Therapeutics, Departments of Neurology, Psychiatry, and Radiology, Harvard Medical School and Brigham and Women's Hospital, United States.
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