tDCS Task-Oriented Approach Improves Function in Individuals With Fibromyalgia Pain. A Pilot Study

Fibromyalgia (FM) is a complex pain syndrome accompanied by physical disability and loss of daily life activities. Evidences suggest that modulation of the primary motor cortex (M1) by transcranial direct current stimulation (tDCS) improves functional physical capacity in chronic pain conditions. However, the gain on physical function in people living with FM receiving tDCS is still unclear. This study aimed to evaluate whether the tDCS task-oriented approach improves function and reduces pain in a single cohort of 10 FM. A total of 10 women with FM (60.4 ± 15.37 years old) were enrolled in an intervention including anodal tDCS delivered on M1 (2 mA from a constant stimulator for 20 min); simultaneously they performed a functional task. The anode was placed on the contralateral hemisphere of the dominant hand. Outcome assessments were done before the stimulation, immediately after stimulation and 30 min after the end of tDCS. The same protocol was applied in subsequent sessions. A total of five consecutive days of tDCS were completed. The main outcomes were the number of repetitions achieved and time in active practice to evaluate functional physical task performance such as intensity of the pain (visual analog scale) and level of fatigue (Borg scale). After 5 days of tDCS, the number of repetitions achieved significantly increased by 49% (p = 0.012). No change was observed in active practice time. No increase in pain was observed despite the mobility of the painful parts of the body. These results are encouraging since an increase in pain due to the mobilization of painful body parts could have been observed at the end of the 5th day of the experiment. These results support the use of tDCS in task-based rehabilitation.

Vitamin D deficiency, functional status, and balance in older adults with osteoarthritis

BACKGROUND

Low vitamin D levels are associated with a more severe case of knee osteoarthritis (OA). However, there are few published reports concerning an association between vitamin D deficiency and functional status of individuals with OA and no reports about postural balance in this population.

AIM

To analyze the relationship between vitamin D deficiency and severity, functional status, and balance in elderly patients with OA.

METHODS

In this cross-sectional study, 105 elderly patients with hip and knee OA were included. The severity was assessed by the Kellgren-Lawrence criteria. The functional status was assessed with the Lequesne index. Postural balance was assessed using a force platform, and center-of-pressure parameters (velocity at anteroposterior and mediolateral axis) were used as the balance outcomes. Serum 25(OH) vitamin D levels were measured using a chemiluminescence method.

RESULTS

Most of the patients (mean age: 70.6 ± 6.5 years) were female (n = 78, 74.3%). In the group with vitamin D deficiency, 43 patients (56.6%) had severe OA, while 33 patients (43.4%) had mild or moderate OA (χ² test, P = 0.04). Patients with vitamin D deficiency showed a higher Lequesne index score (Mann-Whitney test, P = 0.04), indicating a worse functional impairment when compared to individuals with normal vitamin D levels. Additionally, patients with vitamin D deficiency had worse postural balance according to the Mann-Whitney test (P = 0.03).

CONCLUSION

Vitamin D deficiency is associated with worse severity, functional status, and postural balance in patients with OA.

Reliability of pressure pain threshold to discriminate individuals with neck and low back pain

BACKGROUND

Pressure pain threshold (PPT) is decreased in several musculoskeletal disorders, giving indirect evidence regarding pain status. Despite the fact that PPT has been already proven to be reliable in patients with acute conditions, there is great variability of methods and results observed within studies, and only a few evidences confirming its reliability in chronic conditions.

OBJECTIVE

The objective of this study was to determine the test-retest reliability of PPT in the neck and low back regions to discriminate individuals with neck or low back pain from healthy individuals. Additionally, one secondary aim was to establish the minimum detectable change (MDC) and the standard error of measurement for future clinical studies and interventions.

METHODS

In this reliability study, 74 individuals (15 individuals from the neck pain and 17 from the neck control group; 21 individuals from the low back pain and 21 from the low back control group). PPT was measured in the neck region (suboccipital, trapezius and supraspinal muscles) and in the lower back region (paraspinal muscles in the levels of L1, L3 and L5). Intrarater reliability was assessed using intraclass correlation coeficient and Bland-Altman.

RESULTS

Excellent intra-rater reliability was observed for both (ICC of 0.874 for the neck pain versus ICC of 0.895 in neck control group; ICC of 0.932 for the low back pain group versus ICC of 0.839 for the control group). A small bias was observed for all groups (-0.08 for the neck pain group versus 0.10 in the control group; and 0.32 in low back pain group versus 0.44 in the control group). Minimum detectable change of 0.63 kgf of neck pain and 1.21 kgf of low back pain was calculated. It was found difference in PPT between pain and control groups (p< 0.05).

CONCLUSION

It may be suggested that the protocol with PPT is reliable and able to discriminate individuals with and without neck and low back pain with a minor measurement error. Therefore, this method may be used to detect possible progress after interventions in patients with neck or low back pain.

People with chronic low back pain have poorer balance than controls in challenging tasks

PURPOSE

To compare the balance of individuals with and without chronic low back pain during five tasks.

METHOD

The participants were 20 volunteers, 10 with and 10 without nonspecific chronic low back pain, mean age 34 years, 50% females. The participants completed the following balance tasks on a force platform in random order: (1) two-legged stance with eyes open, (2) two-legged stance with eyes closed, (3) semi-tandem with eyes open, (4) semi-tandem with eyes closed and (5) one-legged stance with eyes open. The participants completed three 60-s trials of tasks 1-4, and three 30-s trials of task 5 with 30-s rests between trials. The center of pressure area, velocity and frequency in the antero-posterior and medio-lateral directions were computed during each task, and compared between groups and tasks.

RESULTS

Participants with chronic low back pain presented significantly larger center of pressure area and higher velocity than the healthy controls (p < 0.001). There were significant differences among tasks for all center of pressure variables (p < 0.001). Semi-tandem (tasks 3 and 4) and one-leg stance (task 5) were more sensitive to identify balance impairments in the chronic low back pain group than two-legged stance tasks 1 and 2 (effect size >1.37 vs. effect size <0.64). There were no significant interactions between groups and tasks.

CONCLUSIONS

Individuals with chronic low back pain presented poorer postural control using center of pressure measurements than the healthy controls, mainly during more challenging balance tasks such as semi-tandem and one-legged stance conditions. Implications for Rehabilitation People with chronic low back had poorer balance than those without it. Balance tasks need to be sensitive to capture impairments. Balance assessments during semi-tandem and one-legged stance were the most sensitive tasks to determine postural control deficit in people with chronic low back. Balance assessment should be included during rehabilitation programs for individuals with chronic low back pain for better clinical decision making related to balance re-training as necessary.

Angiotensin-II blockage, muscle strength, and exercise capacity in physically independent older adults

[Purpose] This study aimed to assess the exercise capacity and muscle strength in elderly people using drugs for angiotensin-II blockage. [Subjects and Methods] Four hundred and seven older adults were recruited for this study. Data about comorbidities and medication use were recorded and the individuals were divided into three groups: control group- elderly people with normal exercise capacity (n=235); angiotensin-converting enzyme inhibitor group - individuals using angiotensin-converting enzyme inhibitors (n=140); and angiotensin-II receptor blocker group- patients using angiotensin-II receptor blockers (n= 32). Exercise capacity was evaluated by a 6-minute walking test and muscle strength was measured using a handgrip dynamometer. [Results] Patients from the angiotensin-converting enzyme inhibitor group (mean: 99 ± 12%) and the angiotensin-II receptor blocker group (mean: 101 ± 14%) showed higher predicted values in the 6-minute walking test than the control group patients (mean: 96 ± 10%). Patients from the angiotensin-converting enzyme inhibitor group (mean: 105 ± 19%) and the angiotensin-II receptor blocker group (mean: 105.1 ± 18.73%) showed higher predicted values of muscle strength than control group patients (mean: 98.15 ± 18.77%). [Conclusion] Older adults using angiotensin-converting enzyme inhibitors or angiotensin-II receptor blockers have better functional exercise capacity and muscle strength.

Anti-inflammatory and analgesic effects of low-level laser therapy on the postoperative healing process

[Purpose] This study aimed to evaluate the anti-inflammatory and analgesic effects of intraoral application of low-level laser therapy (660 nm) to control pain, swelling and interincisal opening following the extraction of mandibular third molars. [Subjects and Methods] Ten patients underwent removal of lower third molars using the same surgical protocol and pharmacological approach. In the postoperative period, all patients received four consecutive daily sessions of low-level laser therapy, beginning 24 hours after the surgery. Intraoral applications using the diode laser with 660 nm wavelength in the continuous scan mode were performed covering the entire surgical area, which was divided into four quadrants, each of 1 cm² area at a distance of 1 cm. The energy applied at each point was 5 J/cm² during 8 seconds. [Results] The swelling and interincisal opening returned to normal 24 hours after the first low-level laser therapy application (Friedman test). Moreover, the pain intensity was reduced on the third postoperative day, according to the Friedman test. [Conclusion] Low-level laser therapy (660 nm), at the dosimetry used in this study, was effective in reducing postoperative pain and swelling following oral surgery.

Cariogenic microorganisms and oral conditions in asthmatic children

This study evaluated the caries risk of asthmatic patients on the basis of mutans streptococci (MS) and lactobacilli levels in saliva samples as well as the index of oral hygiene and dental caries (DMFT index). The study population was composed of 80 asthmatic children, aged 3-15 years, who use specific medication, and 80 matched, healthy control children. The parents were interviewed about oral health-related factors. The World Health Organization criteria were used for dental examinations. The Köhler and Bratthal methodology was used to detect salivary MS levels and dilutions of saliva were done for lactobacilli counting. No differences between asthma and control groups were observed for caries prevalence in children aged 3-6 and 7-10 years, except in severe cases in the younger group. However, higher caries prevalence for permanent dentition was observed in 11- to 15-year-old asthmatic children. An increased dental biofilm was observed in the asthma group, as well as salivary levels of MS. No differences were observed in levels of lactobacilli. No statistical correlations were found between medication, frequency of treatment, method of consumption and caries experience, dental biofilm and salivary levels of MS or lactobacilli. However, there was a correlation between MS levels and treatment duration. The logistic regression revealed that MS level is an important risk factor for increased caries experience. Asthma should be evaluated as a risk factor for caries experience because it can increase the levels of MS and the dental biofilm.

The lateral septal area is involved in the pressor pathway activated by microinjection of norepinephrine into the rat brain cingulate cortex

The cingulate cortex (CC) is involved in cardiovascular regulation. Microinjection of norepinephrine (NE) into the Cg3 area of the CC caused vasopressin release and pressor responses in unanesthetized rats. Microinjection of acetylcholine (ACh) into the lateral septal area (LSA) of unanesthetized rats caused similar vasopressin-related pressor responses. The LSA is anatomically connected to the CC and the paraventricular nucleus (PVN) of the hypothalamus, an important nucleus involved in vasopressin synthesis. Therefore, we attempted to verify if the cholinergic neurotransmission within the LSA is involved in the mediation of the pressor response to the microinjection of NE into the Cg3. Local pretreatment with lidocaine, muscimol, atropine or hemicholinium-3 microinjected into the LSA blocked the pressor response to the microinjection of NE injection into the Cg3. Conversely, pretreatment with physostigmine microinjected into the LSA potentiated the pressor response to NE injection into the Cg3. The present results indicate that the synapses in the LSA are part of the pressor pathway originating at the CC and that cholinergic neurotransmission within the LSA is involved in the mediation of the cardiovascular responses to the microinjection of NE into the Cg3.

α-Adrenergic and muscarinic cholinergic receptors are not involved in the modulation of the parasympathetic baroreflex by the medial prefrontal cortex in rats

The medial prefrontal cortex (MPFC) is involved in cardiovascular control and baroreflex modulation. Recent studies indicated that stimulation of MPFC muscarinic receptors causes hypotensive responses whereas stimulation of alpha1- but not of alpha2-adrenoceptors causes pressor responses in unanesthetized rats. It has also been shown that the MPFC is involved in the modulation of the parasympathetic component of the baroreflex in rats. We report that bilateral injections of CoCl2 in the ventral portion of the MPFC (vMPFC) reduced the parasympathetic component of the baroreflex, thus confirming the involvement of local synapses. We further evaluated the effect of the pharmacologic block of vMPFC alpha1- or alpha2-adrenoceptors and muscarinic receptors on the vMPFC-related modulation of the parasympathetic component of the baroreflex in unanesthetized rats. Bilateral microinjections of 10 nmol of the selective alpha1-adrenoceptor antagonist WB4101 or 10 nmol of the selective alpha2-adrenoceptors antagonist RX821002 into the MPFC did not affect the baroreflex. Bilateral microinjections of 9 nmol of the muscarinic antagonist atropine also did not affect baroreflex activity. The present results indicate that although vMPFC alpha-adrenergic and muscarinic receptors are involved in cardiovascular regulation, they do not mediate the vMPFC-related modulation of the parasympathetic component of the baroreflex.

Neural Connections Between Prosencephalic Structures Involved in Vasopressin Release

1. The diagonal band (DB) and the lateral septal area (LSA) are two prosencephalic structures, which were implicated in vasopressin release. 2. The present experiment was designed to investigate neural connections between the DB and the LSA and from these nuclei to the paraventricular (PVN) and supraoptic (SON) nuclei, which could be related to vasopressin release. 3. For the above purpose the bidirectional neuronal tracer biotinylated dextran amine (BDA) was injected into the DB or the LSA of male Wistar rats. Five days later the animals were sacrificed and brain slices were processed and analyzed to determine neuronal projections efferent from as well as afferent to these structures. 4. Neuronal staining was more prominent in regions ipsilateral to the BDA injection site. 5. After BDA injections into the DB, efferent projections from the DB were observed at the LSA, the PVN, the prefrontal cortex, the mediodorsal thalamic nucleus, and throughout the anterior hypothalamus, but not at the SON. At the PVN, labeled varicose fibers were observed at the magnocellular portion. The DB was found to receive a massive input from the LSA. More discrete projections to the DB were originated at the prefrontal cortex and from hypothalamic neurons outside the PVN and the SON. 6. After BDA injections into the ventral portion of the LSA, efferent projections from the LSA were intense at the DB and throughout the hypothalamus. Labeled fibers were observed at the structures surrounding the SON or the PVN but not within those nuclei. 7. The results indicate a massive neural output from the LSA to the DB and the existence of a direct neural connection from the DB to the PVN. No direct connections were observed between the LSA and the magnocellular nuclei (PVN and SON) or between the DB and the SON.

Medial prefrontal cortex modulation of the baroreflex parasympathetic component in the rat

The ventral portion of the medial prefrontal cortex (vMPFC) that comprises the prelimbic and infralimbic cortex is involved in arterial blood pressure and heart rate control. In the present study, we attempted to verify the effect of an acute and reversible blockade of vMPFC activity by local bilateral microinjections of either lidocaine (a local anesthetic) or CoCl2 (a nonselective synapse blocker) on the baroreflex response of unanesthetized rats. Bilateral microinjection of lidocaine into the vMPFC did not affect the tachycardiac response to mean arterial pressure (MAP) decreases caused by i.v. infusion of sodium nitroprusside or the baroreflex gain in unanesthetized rats. However, lidocaine caused a reversible shift of the reflex threshold pressure toward higher (MAP) increases in response to i.v. infusion of phenylephrine, thus indicating an action on the parasympathetic component of the baroreflex. The effects of the blockade of local synapses in the vMPFC by CoCl2 were similar to those observed after the acute ablation of that area caused by lidocaine. Bilateral microinjection of CoCl2 into the vMPFC also caused a shift of the reflex threshold pressure bradycardiac responses to MAP increases toward higher MAP values, without affecting the baroreflex gain. In conclusion, our data indicate that the vMPFC is involved in baroreflex control, and more specifically in the modulation of the parasympathetic baroreflex component. The temporary ablation of this area by local microinjections of lidocaine caused a shift of the reflex threshold pressure toward higher MAP values, which is compatible with the idea that the vMPFC has a modulatory action on the baroreflex. The observation that CoCl2 and lidocaine microinjections had similar effects on the baroreflex also suggests that this modulation involves local synaptic neurotransmission within the vMPFC.

Mechanisms involved in the pressor response to noradrenaline injection into the cingulate cortex of unanesthetized rats

The cingulate cortex (CC) is involved in cardiovascular modulation. CC electrical or chemical stimulation may evoke either pressor or depressor responses, depending on the stimulated site and experimental conditions such as anesthesia. Noradrenaline (NA) is involved in cardiovascular regulation and it is present throughout the cortex. However, there is no report on the cardiovascular effects of intracortical injections of NA. We attempted to verify the effect of NA injection into the CC and to identify possible receptor and peripheral mechanisms involved. NA injection caused pressor responses accompanied by bradycardia, in unanesthetized rats. These responses were markedly reduced under urethane anesthesia. The pressor response was blocked by intracortical pretreatment with phenoxybenzamine or the selective alpha(1)-antagonist WB4101, and it was not affected by pretreatment with the selective alpha(2)-antagonist RX821002, suggesting that alpha(1)-adrenoceptors mediate the response. The pressor response was potentiated by pretreatment with the ganglion blocker mecamylamine and it was abolished by pretreatment with the vasopressin antagonist, dTyr(CH(2)) (5)(Me)AVP or by hypophysectomy. Circulating vasopressin levels were increased after NA injection into the CC. The present results indicate that the pressor response to local injection of NA within the CC is independent of sympathetic nerve activation and is mediated by vasopressin release.