Efficacy of transcranial direct-current stimulation in women with provoked vestibulodynia

Effectiveness of nonpharmacological conservative therapies for chronic pelvic pain in women: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of nonpharmacological conservative therapies for women with CPP.

DATA SOURCES

A systematic search of electronic databases (Amed, CINAHL, PsycINFO, SportDiscuss, Medline, PubMed, Embase, and Cochrane Central Register of Controlled Trials) was performed in January 2023, and updated in December 2023.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials comparing a nonpharmacological conservative therapy to inert (eg, placebo, usual care) or nonconservative (eg, surgical, pharmacological) treatment were included. Conservative therapies of interest to this review were: multimodal physical therapy, predominantly psychological approaches, acupuncture, and other tissue-based monotherapies (eg, electrophysical agents, manual stretching).

STUDY APPRAISAL AND SYNTHESIS METHODS

All study data were aggregated, and analyses of the included studies were performed. Effects on pain; sexual measures; psychological and physical function; health-related quality of life; symptom severity/bother; pelvic floor muscle function and morphometry; perceived improvement; and adverse events were analyzed. Meta-analyses (random effects model) were conducted using postintervention scores for data that included similar interventions and outcomes. Standardized mean differences were calculated. A narrative summary of findings that could not be included in the meta-analysis is provided. The quality of the evidence was assessed with the Physiotherapy Evidence Database scale and the certainty of evidence with Grading of Recommendations, Assessment, Development, and Evaluations criteria.

RESULTS

Of 5776 retrieved studies, 38 randomized controlled trials including 2168 women (mean age 35.1±8.6) were included. Meta-analyses revealed that multimodal physical therapy resulted in lower pain intensity compared to inert or nonconservative treatments in both the short (standardized mean difference -1.69, 95% confidence interval -2.54, -0.85; high certainty) and intermediate-terms (standardized mean difference -1.82, 95% confidence interval -3.13, -0.52; moderate certainty), while predominantly psychological approaches resulted in no difference in pain intensity (standardized mean difference -0.18, 95% confidence interval -0.56, 0.20; moderate certainty) and a slight difference in sexual function (standardized mean difference -0.28, 95% confidence interval -0.52, -0.04; moderate certainty). The level of evidence regarding the meta-analysis of the effects of acupuncture on pain intensity (standardized mean difference 1.08, 95% confidence interval -1.38, 3.54, nonstatistically significant results in favor of control treatment) precluded any statement of certainty. A limited number of trials investigated individual tissue-based monotherapies, providing a restricted body of evidence.

CONCLUSION

This systematic review with meta-analysis revealed that multimodal physical therapy is effective in women with chronic pelvic pain with a high certainty of evidence.

Effect of different electric stimulation modalities on pain and functionality of patients with pelvic pain: Systematic review with META-analysis

INTRODUCTION

Pelvic pain is located in the anterior abdominal wall, below the umbilical scar. Its treatment includes pharmacological therapy, which can cause adverse effects and is not always sufficient to control symptoms. Thus, the use of adjunct therapies such as electric stimulation has been suggested. Therefore, this review intends to appraise the literature on the effectiveness of electrostimulation in the treatment of pelvic pain.

METHODS

The search for studies was conducted until April 2024 in PubMed, Cochrane Library, ScienceDirect, SciELO, PEDro, CINAHL, BVS, Web of Science, Scopus, and Google Scholar databases using a combination of Mesh terms "Electric Stimulation" and "Pelvic Pain." Risk of bias assessment and meta-analysis were performed with The Cochrane Collaboration tool (RevMan 5.4). Quality of the evidence was assessed with GRADE tool.

RESULTS

From the 3247 studies found, 19 were included. In the qualitative analysis, seven studies showed TENS, electroacupuncture, PTNS, and tDCS reduced pain intensity, one study on PTNS showed increased quality of life, and one on tDCS showed improved functional performance. However, in the meta-analysis, only TENS showed efficacy for the reduction of acute pelvic pain and primary dysmenorrhea.

CONCLUSION

Our results indicate that there is moderate-quality evidence for TENS to reduce pain intensity in primary dysmenorrhea and low-quality evidence for the same outcome in acute pelvic pain. Randomized controlled clinical trials with larger sample size and with better methodological quality are needed to establish the effectiveness of other forms of electrical stimulation in pelvic pain.

Acute Effect of Transcranial Direct Current Stimulation in Pelvic Floor Muscle Function in Young Healthy Women: Initial Findings of a Randomized Controlled Trial

INTRODUCTION AND HYPOTHESIS

Transcranial direct current stimulation (tDCS) can enhance muscle function in healthy individuals. However, it is unknown if tDCS associated with pelvic floor muscle training (PFMT) can improve pelvic floor muscle function (PFMF) in healthy women. The aim of this study was to investigate the acute effect of a single session of tDCS in PFMF compared with sham-tDCS in healthy women.

METHODS

A double-blind, cross-over, randomized clinical trial was conducted with healthy, nulliparous and sexually active women. PFMF was assessed by bidigital palpation (PERFECT scale) and intravaginal pressure by a manometer (Peritron™). Participants randomly underwent two tDCS sessions (active and sham) 7 days apart. The electrode was positioned equal for both protocols, the anode electrode in the supplementary motor area (M1) and the cathode electrode in the right supraorbital frontal cortex (Fp2). The current was applied for 20 min at 2 mA in active stimulation and for 30 s in sham-tDCS. The tDCS applications were associated with verbal instructions to PFMT in a seated position. After each tDCS session PFMF was reevaluated.

RESULTS

Twenty young healthy women (aged 23.4 ± 1.7 years; body mass index 21.7 ± 2.2 kg/m2) were included. No difference was observed in power, endurance, and intravaginal pressure of PFMF (p > 0.05). The number of sustained contractions improved from 3.0 (2.0-3.5) to 4.0 (3.0-5.0) after active-tDCS (p = 0.0004) and was superior to sham-tDCS (p = 0.01).

CONCLUSION

The number of sustained contractions of PFM improved immediately after a single active-tDCS session, with a difference compared with the post-intervention result of sham-tDCS in healthy young women.

Efficacy of Rehabilitative Techniques on Pain Relief in Patients With Vulvodynia: A Systematic Review and Meta-Analysis

OBJECTIVE

Vulvodynia is a chronic clinical condition characterized by provoked or non-provoked vulvar pain for at least 3 months of unknown etiology. The onset of vulvodynia involves a complex interplay of peripheral and central pain mechanisms, such as pelvic floor muscle and autonomic dysfunction, and interpersonal factors. A stepwise approach of pelvic floor physical therapy as medical management is suggested. In this scenario, by this meta-analysis of randomized controlled trials, we aimed to evaluate the efficacy of rehabilitation interventions in patients with vulvodynia.

METHODS

On October 13, 2022, PubMed, Scopus, and Web of Science were systematically searched for randomized controlled trials that assessed the efficacy of the rehabilitative approach to pain during intercourse in patients with vulvodynia. The quality assessment was performed with the Cochrane risk-of-bias tool for randomized trials. The trial registration number is CRD42021257449. At the end of the search, 9 studies were included for a total of 332 patients. A pairwise meta-analysis was performed to highlight the efficacy of rehabilitative approaches for reducing pain during intercourse, as measured with a visual analog scale or a numerical rating scale.

RESULTS

Meta-analysis showed that all these rehabilitative approaches had an overall effect size of -1.43 (95% CI = -2.69 to -0.17) in decreasing vulvodynia pain in terms of the visual analog scale. In the subgroup analysis, a significant effect size in acupuncture (effect size = -2.36; 95% CI = -3.83 to -0.89) and extracorporeal shockwave therapy (effect size = -2.94; 95% CI = -4.31 to -1.57; I2 = 58%) was observed. According to the Cochrane risk-of-bias tool, a low risk of bias for outcome selection in 89% of studies.

CONCLUSION

Findings from this meta-analysis suggested that the physical agent modalities and complementary medicine techniques in people with vulvodynia appear to be more effective than placebo, sham, or waiting list. Further evidence on physical agent modalities and complementary therapies are warranted in the future.

IMPACT

This was the first systematic review and meta-analysis of randomized controlled trials to provide evidence on the efficacy of rehabilitation interventions in patients with vulvodynia.

Physical Modalities for the Treatment of Localized Provoked Vulvodynia: A Scoping Review of the Literature from 2010 to 2023

Introduction

Localized provoked vulvodynia (LPV) is a prevalent sexual health condition with significant negative impacts on quality of life. There is a lack of consensus regarding effective management.

Methods

We used Arksey and O'Malley's five-step method to identify, collate, and evaluate literature published between 2010 and 2023. The scoping review investigated the efficacy or effectiveness of interventions in the management of LPV. The aim of this paper is to map the literature on the efficacy or effectiveness of physical interventions.

Results

The review produced 19 primary studies of physical interventions for LPV. These include acupuncture, laser therapy, physiotherapy, transcutaneous electrical nerve stimulation, low-intensity shockwave therapy, transcranial direct current stimulation, and vestibulectomy.

Conclusion

Published studies that investigated a range of physical treatments for LPV showed some positive effects, except for transcranial direct-current stimulation. The remaining modalities demonstrated improved sexual pain and treatment satisfaction, when measured. Findings were mixed for non-sexual pain. There was insufficient evidence to draw conclusions regarding other outcomes. Researchers are encouraged to conduct larger, high-quality studies that sample more diverse patient populations and use patient-oriented outcomes to assess effectiveness of physical modalities.

Individualized multidisciplinary therapy for vulvodynia

OBJECTIVE

The main objective of this review was to develop strategies for individualizing multidisciplinary therapy for vulvodynia.

METHODS

We conducted two literature searches; the first one focused on clinical trials assessing vulvodynia treatments published after the recommendations of the expert committee of the Fourth International Consultation on Sexual Medicine. The second search targeted studies identifying predictive factors and mediators of vulvodynia treatments, published from the earliest date to October 2022.

RESULTS

Based on data from 55 relevant studies, we developed models of individualized multidisciplinary therapy targeting groups of women less responsive to multidisciplinary therapy (characterized by women with higher vulvar pain intensity, impaired sexual functioning, and vulvodynia secondary subtype) and to physical therapy, as an isolated treatment (characterized by women with increased pelvic floor muscle tone and vulvodynia primary subtype). Each individualized multidisciplinary therapy model comprises three components: psychotherapy, medical care, and physical therapy. These components provide distinct therapeutic modalities for distinct subgroups of women with vulvodynia; the women subgroups were identified according to the characteristics of women, the disease, partners, and relationships. Additionally, for women with provoked vestibulodynia who exhibit less benefits from vestibulectomy (such as those with higher levels of erotophobia, greater vulvar pain intensity, and the primary subtype) and encounter resistance to individualized multidisciplinary therapy, we suggest additional conservative treatments before performing vestibulectomy.

CONCLUSION

Our study is a pioneer in the development of models that allow the individualization of multidisciplinary therapy for vulvodynia and represents a significant advance in the clinical practice of gynecologists, physiotherapists, and psychologists.

Efficacy of Physiotherapy for Treating Vulvodynia: A Systematic Review

OBJECTIVES

We set out to assess the efficacy of physiotherapy for vulvodynia.

MATERIALS AND METHODS

PubMed, Embase, Scopus, Web of Science, SciELO, PEDro, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched in February 2023. Two authors selected and extracted the data independently. The risk of bias was assessed using the Cochrane Risk of Bias tool (Rob 2). Because of the high heterogeneity presented between the studies, it was not possible to carry out qualitative analysis. The results were presented narratively. This systematic review was registered with the PROSPERO database.

RESULTS

A total of 2,274 articles were retrieved. Seven studies met the criteria and were included in a systematic review, which included a total of 477 patients. The interventions included were electromyography biofeedback ( n = 2), transcutaneous electrical nerve stimulation ( n = 1), transcranial direct current stimulation ( n = 1), low-intensity shockwave ( n = 1), physiotherapy treatment ( n = 1), and pelvic floor exercise with behavioral modification ( n = 1). All studies evaluated pain reduction, 5 evaluated sexual function, and 2 evaluated quality of life. All interventions were effective for the main outcomes; only the transcranial direct current stimulation intervention showed no significant difference when compared with the placebo or sham group. Three studies presented a high risk of bias due to the lack of blinding.

CONCLUSIONS

The studied interventions (electromyography biofeedback, transcutaneous electrical nerve stimulation, shockwave, physiotherapy, and pelvic floor exercise) seem to improve pain, sexual function, and quality of life. However, the heterogeneity of the studies prevented meta-analysis. In addition, well-designed trials are needed to improve the certainty of this evidence.

Vulvodynia: A practical guide in treatment strategies

Vulvodynia is a debilitating condition characterized by chronic vulvar pain, with a detrimental impact on the patient's overall quality of life. Its etiology is multifactorial, but still in the process of being clearly outlined. Vulvodynia is not a single entity. It is a heterogeneous condition characterized by multiple triggers, making it challenging to define a reference standard for its treatment. In this manuscript we selected all articles including the following key criteria: "vulvodynia". The primary outcomes observed included the resolution of chronic pelvic pain, dyspareunia and sexual satisfaction, psychological well-being, and overall quality of life. Most pharmacologic treatments require further evidence to be recommended. On the other hand, non-pharmacologic approaches such as psychotherapy, physical therapy, and surgery have received stronger support. This review summarizes pros and cons of adopting available treatments. Multimodal approaches should be introduced to improve patient outcomes. Further investigations are warranted to improve patients' quality of life.

Neuroelectric Correlates of Human Sexuality: A Review and Meta-Analysis

Many reviews on sexual arousal in humans focus on different brain imaging methods and behavioral observations. Although neurotransmission in the brain is mainly performed through electrochemical signals, there are no systematic reviews of the electrophysiological correlates of sexual arousal. We performed a systematic search on this subject and reviewed 255 studies including various electrophysiological methods. Our results show how neuroelectric signals have been used to investigate genital somatotopy as well as basic genital physiology during sexual arousal and how cortical electric signals have been recorded during orgasm. Moreover, experiments on the interactions of cognition and sexual arousal in healthy subjects and in individuals with abnormal sexual preferences were analyzed as well as case studies on sexual disturbances associated with diseases of the nervous system. In addition, 25 studies focusing on brain potentials during the interaction of cognition and sexual arousal were eligible for meta-analysis. The results showed significant effect sizes for specific brain potentials during sexual stimulation (P3: Cohen's d = 1.82, N = 300, LPP: Cohen's d = 2.30, N = 510) with high heterogeneity between the combined studies. Taken together, our review shows how neuroelectric methods can consistently differentiate sexual arousal from other emotional states.

Non-pharmacological therapies for treating chronic pelvic pain in women: A review

Chronic pelvic pain (CPP) is an intricate condition with multiple etiologies that lead to indefinite pain mechanisms. Physicians and researchers are challenged in its treatment, and the combined therapy of pharmacologic and non-pharmacologic treatment has been recognized as a multidisciplinary approach cited by guidelines and adopted in clinical practice. As an alternative therapy for CPP, non-pharmacologic therapies benefit patients and deserve further study. This study reviews the literature published from January 1991 to April 2022 on non-pharmacologic therapies for CPP in adult women. Based on a survey, this review found that the most commonly used non-pharmacological therapies for CPP include pelvic floor physical therapy, psychotherapy, acupuncture, neuromodulation, and dietary therapy. By evaluating the efficacy and safety of each therapy, this study concluded that non-pharmacological therapies should be included in the initial treatment plan because of their high degree of safety and low rate of side effects. To fill the lack of data on non-pharmacologic therapies for CPP, this study provides evidence that may guide treatment and pain management.

Is transcranial direct current stimulation beneficial for treating pain, depression, and anxiety symptoms in patients with chronic pain? A systematic review and meta-analysis

Background

Chronic pain is often accompanied by emotional dysfunction. Transcranial direct current stimulation (tDCS) has been used for reducing pain, depressive and anxiety symptoms in chronic pain patients, but its therapeutic effect remains unknown.

Objectives

To ascertain the treatment effect of tDCS on pain, depression, and anxiety symptoms of patients suffering from chronic pain, and potential factors that modulate the effectiveness of tDCS.

Methods

Literature search was performed on PubMed, Embase, Web of Science, and Cochrane Library from inception to July 2022. Randomized controlled trials that reported the effects of tDCS on pain and depression and anxiety symptoms in patients with chronic pain were included.

Results

Twenty-two studies were included in this review. Overall pooled results indicated that the use of tDCS can effectively alleviate short-term pain intensity [standard mean difference (SMD): -0.43, 95% confidence interval (CI): -0.75 to -0.12, P = 0.007] and depressive symptoms (SMD: -0.31, 95% CI, -0.47 to -0.14, P < 0.001), middle-term depressive symptoms (SMD: -0.35, 95% CI: -0.58 to -0.11, P = 0.004), long-term depressive symptoms (ES: -0.38, 95% CI: -0.64 to -0.13, P = 0.003) and anxiety symptoms (SMD: -0.26, 95% CI: -0.51 to -0.02, P = 0.03) compared with the control group.

Conclusion

tDCS may be an effective short-term treatment for the improvement of pain intensity and concomitant depression and anxiety symptoms in chronic pain patients. Stimulation site, stimulation frequency, and type of chronic pain were significant influence factors for the therapeutic effect of tDCS.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=297693, identifier: CRD42022297693.

Treatment of Provoked Vulvodynia: A Systematic Review

BACKGROUND

Treatment recommendations for provoked vulvodynia (PVD) are based on clinical experiences and there is a need for systematically summarizing the controlled trials in this field.

AIM

To provide an overview of randomized controlled trials and non-randomized studies of intervention for PVD, and to assess the certainty of the scientific evidence, in order to advance treatment guidelines.

DATA SOURCES

The search was conducted in CINAHL (EBSCO), Cochrane Library, Embase (Embase.com), Ovid MEDLINE, PsycINFO (EBSCO) and Scopus. Databases were searched from January 1, 1990 to January 29, 2021.

STUDY ELIGIBILITY CRITERIA

Population: Premenopausal women with PVD.

INTERVENTIONS

Pharmacological, surgical, psychosocial and physiotherapy, either alone or as combined/team-based interventions.

CONTROL

No treatment, waiting-list, placebo or other defined treatment.

OUTCOMES

Pain during intercourse, pain upon pressure or touch of the vaginal opening, sexual function/satisfaction, quality of life, psychological distress, adverse events and complications.

STUDY DESIGN

Randomized controlled trials and non-randomized studies of interventions with a control group.

STUDY APPRAISAL AND SYNTHESIS METHODS

2 reviewers independently screened citations for eligibility and assessed relevant studies for risk of bias using established tools. The results from each intervention were summarized. Studies were synthesized using a narrative approach, as meta-analyses were not considered appropriate. For each outcome, we assessed the certainty of evidence using grading of recommendations assessment, development, and evaluation (GRADE).

RESULTS

Most results of the evaluated studies in this systematic review were found to have very low certainty of evidence, which means that we are unable to draw any conclusions about effects of the interventions. Multimodal physiotherapy compared with lidocaine treatment was the only intervention with some evidential support (low certainty of evidence for significant treatment effects favoring physiotherapy). It was not possible to perform meta-analyses due to a heterogeneity in interventions and comparisons. In addition, there was a heterogeneity in outcome measures, which underlines the need to establish joint core outcome sets.

CLINICAL IMPLICATIONS

Our result underscores the need of stringent trials and defined core outcome sets for PVD.

STRENGTH AND LIMITATIONS

Standard procedures for systematic reviews and the Population Intervention Comparison Outcome model for clinical questions were used. The strict eligibility criteria resulted in limited number of studies which might have resulted in a loss of important information.

CONCLUSION

This systematic review underlines the need for more methodologically stringent trials on interventions for PVD, particularly for multimodal treatments approaches. For future research, there is a demand for joint core outcome sets. Bohm-Starke N, Ramsay KW, Lytsy P, et al. Treatment of Provoked Vulvodynia: A Systematic Review. J Sex Med 2022;19:789-808.

Transcranial direct current stimulation for provoked vestibulodynia: What roles do psychosexual factors play in treatment response?

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.

Treatment of Vulvodynia: Pharmacological and Non-Pharmacological Approaches

Vulvodynia is a common, recurrent, vulvar pain condition with debilitating consequences for affected women's health and quality of life. The heterogeneity of women suffering from vulvodynia as well as its uncertain and likely multifactorial etiology pose a significant challenge to identifying any kind of "gold standard" treatment. Thus, treatment providers must be well versed in the various options and the evidence for each. In this review, we begin with pharmacological treatments, followed by non-pharmacological treatments, surgery, and finally multimodal treatments. For each approach, we briefly discuss the method, mechanism of action, and empirical support for the treatment. In sum, pharmacological treatments that may be beneficial but require further research include antinociceptive agents (lidocaine, capsaicin), anti-inflammatory agents (corticosteroids, interferon), neuromodulating medications (anticonvulsants and antidepressants), hormonal agents, and muscle relaxants (e.g., botulinum toxin). There is strong evidence to support and recommend non-pharmacological interventions including psychological therapy, pelvic floor physical therapy, as well as surgery (i.e., vestibulectomy for provoked vestibulodynia) for the treatment of vulvodynia. We conclude this review with a discussion of issues that may have hindered progress of treatment efficacy and effectiveness, and recommendations for moving the field forward.

Transcranial Direct Current Stimulation to Improve the Dysfunction of Descending Pain Modulatory System Related to Opioids in Chronic Non-cancer Pain: An Integrative Review of Neurobiology and Meta-Analysis

Background: Opioid long-term therapy can produce tolerance, opioid-induced hyperalgesia (OIH), and it induces dysfunction in pain descending pain inhibitory system (DPIS). Objectives: This integrative review with meta-analysis aimed: (i) To discuss the potential mechanisms involved in analgesic tolerance and opioid-induced hyperalgesia (OIH). (ii) To examine how the opioid can affect the function of DPIS. (ii) To show evidence about the tDCS as an approach to treat acute and chronic pain. (iii) To discuss the effect of tDCS on DPIS and how it can counter-regulate the OIH. (iv) To draw perspectives for the future about the tDCS effects as an approach to improve the dysfunction in the DPIS in chronic non-cancer pain. Methods: Relevant published randomized clinical trials (RCT) comparing active (irrespective of the stimulation protocol) to sham tDCS for treating chronic non-cancer pain were identified, and risk of bias was assessed. We searched trials in PubMed, EMBASE and Cochrane trials databases. tDCS protocols accepted were application in areas of the primary motor cortex (M1), dorsolateral prefrontal cortex (DLPFC), or occipital area. Results: Fifty-nine studies were fully reviewed, and 24 with moderate to the high-quality methodology were included. tDCS improved chronic pain with a moderate effect size [pooled standardized mean difference; -0.66; 95% confidence interval (CI) -0.91 to -0.41]. On average, active protocols led to 27.26% less pain at the end of treatment compared to sham [95% CI; 15.89-32.90%]. Protocol varied in terms of anodal or cathodal stimulation, areas of stimulation (M1 and DLPFC the most common), number of sessions (from 5 to 20) and current intensity (from 1 to 2 mA). The time of application was 20 min in 92% of protocols. Conclusion: In comparison with sham stimulation, tDCS demonstrated a superior effect in reducing chronic pain conditions. They give perspectives that the top-down neuromodulator effects of tDCS are a promising approach to improve management in refractory chronic not-cancer related pain and to enhance dysfunctional neuronal circuitries involved in the DPIS and other pain dimensions and improve pain control with a therapeutic opioid-free. However, further studies are needed to determine individualized protocols according to a biopsychosocial perspective.

Systematic review and meta-analysis of the effects of treatment modalities for vestibulodynia in women

Objective: To quantify the effects of available treatments of vestibulodynia. Methods: Systematic review of randomised controlled trials (RCTs) in six search engines until December 2018, comparing any intervention vs. placebo or sham in women with vestibulodynia. Primary outcome was dyspareunia assessed with visual analogue (VAS) or numeric rating (NRS) scales. Secondary outcomes were daily vestibular symptoms (DVS), McGill Pain Questionnaire (MPQ) and Index of Sexual Satisfaction (ISS). Effects were described as mean differences (MDs) with their 95% confidence intervals (CIs). Traditional and frequentist network meta-analyses (NMA) were performed using random effect models. Results: Four RCTs (n = 275) were included evaluating vaginal cream of conjugated oestrogens, oral desipramine with or without topical lidocaine, topical lidocaine, laser therapy and transcranial direct current. In traditional MA, interventions did not reduce dyspareunia (MD = 0.08; 95%CI = -0.49 to 0.64), DVS (MD = -0.04; 95%CI = -0.31 to 0.24; 4 interventions), or MPQ (MD = -0.17; 95%CI = -2.16 to 1.81; 4 interventions). ISS was significantly improved (MD = -5.14; 95%CI = -9.52 to -0.75). In NMA, oral desipramine with or without lidocaine significantly improved ISS vs. other treatments. Conclusions: Several existing interventions were not associated with improvements in vestibulodynia. There only was improvement of sexual function with oral desipramine with or without lidocaine.

[Interest of transcranial stimulation in pelvic and perineal disorders]

OBJECTIVE

The aim of this article was to describe the diagnostic and therapeutic value of transcranial stimulation in pelvic and perineal disorders.

METHODS

A literature review (Medline database and Google scholar) with no time limit was performed using keywords: "transcranial direct stimulation", "transcranial magnetic stimulation", "neurogenic bladder", "urinary incontinence", "Parkinson disease", "multiple sclerosis", "stroke", "muscle spasticity", "pelvic pain", "visceral pain".

RESULTS

Twelve articles have been selected. Transcranial magnetic or electrical stimulation is a noninvasive neuromodulation technique widely used to establish brain maps to highlight causal relationships between brain and function. Regarding pelvic-perineal disorders, repeated transcranial stimulation has shown significant effects for the treatment of overactive bladder in Parkinson's disease (P<0.05) and multiple sclerosis, but also for the treatment of refractory chronic pelvic pain (P=0.026). Finally, therapeutic effects have also been demonstrated in irritable bowel syndrome. No evidence of efficacy was found on genito-sexual disorders.

CONCLUSION

Data from the literature suggest that transcranial stimulation is a noninvasive treatment that may have a role in the management of pelvic and perineal disorders. Its promising field of action would require prospective and randomized studies on a larger scale.

Latin American and Caribbean consensus on noninvasive central nervous system neuromodulation for chronic pain management (LAC2-NIN-CP)

Supplemental Digital Content is Available in the Text.

Introduction:

Chronic pain (CP) is highly prevalent and generally undertreated health condition. Noninvasive brain stimulation may contribute to decrease pain intensity and influence other aspects related to CP.

Objective:

To provide consensus-based recommendations for the use of noninvasive brain stimulation in clinical practice.

Methods:

Systematic review of the literature searching for randomized clinical trials followed by consensus panel. Recommendations also involved a cost-estimation study.

Results:

The systematic review wielded 24 transcranial direct current stimulation (tDCS) and 22 repetitive transcranial magnetic stimulation (rTMS) studies. The following recommendations were provided: (1) Level A for anodal tDCS over the primary motor cortex (M1) in fibromyalgia, and level B for peripheral neuropathic pain, abdominal pain, and migraine; bifrontal (F3/F4) tDCS and M1 high-definition (HD)-tDCS for fibromyalgia; Oz/Cz tDCS for migraine and for secondary benefits such as improvement in quality of life, decrease in anxiety, and increase in pressure pain threshold; (2) level A recommendation for high-frequency (HF) rTMS over M1 for fibromyalgia and neuropathic pain, and level B for myofascial or musculoskeletal pain, complex regional pain syndrome, and migraine; (3) level A recommendation against the use of anodal M1 tDCS for low back pain; and (4) level B recommendation against the use of HF rTMS over the left dorsolateral prefrontal cortex in the control of pain.

Conclusion:

Transcranial DCS and rTMS are recommended techniques to be used in the control of CP conditions, with low to moderate analgesic effects, and no severe adverse events. These recommendations are based on a systematic review of the literature and a consensus made by experts in the field. Readers should use it as part of the resources available to decision-making.

The role of nonpharmacologic therapies in management of chronic pelvic pain: what to do when surgery fails

PURPOSE OF REVIEW

To provide an update on nonsurgical and nonpharmacologic strategies for the management of chronic pelvic pain (CPP).

RECENT FINDINGS

Effective treatment of patients with CPP requires a multifaceted approach, with thoughtful consideration of surgical, pharmacologic, and nonpharmacologic strategies. Evidence for physical therapy and trigger point injections for treatment of myofascial components of CPP is increasing. Neuromodulation techniques, such as percutaneous tibial nerve stimulation and transcutaneous electrical stimulation, have limited but favorable preliminary data in patients with CPP. Behavioral strategies, such as exercise, cognitive behavioral therapy, and mindfulness, have demonstrated significant improvements in pain, function and quality of life in patients with a variety of chronic pain conditions and are promising avenues for future research in CPP.

SUMMARY

Nonpharmacologic therapies are important adjuncts to surgical and pharmacologic treatment for CPP and should be considered integral to a comprehensive treatment approach.

Non-invasive brain stimulation techniques for chronic pain

BACKGROUND

This is an updated version of the original Cochrane Review published in 2010, Issue 9, and last updated in 2014, Issue 4. Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), transcranial direct current stimulation (tDCS), transcranial random noise stimulation (tRNS) and reduced impedance non-invasive cortical electrostimulation (RINCE).

OBJECTIVES

To evaluate the efficacy of non-invasive cortical stimulation techniques in the treatment of chronic pain.

SEARCH METHODS

For this update we searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, LILACS and clinical trials registers from July 2013 to October 2017.

SELECTION CRITERIA

Randomised and quasi-randomised studies of rTMS, CES, tDCS, RINCE and tRNS if they employed a sham stimulation control group, recruited patients over the age of 18 years with pain of three months' duration or more, and measured pain as an outcome. Outcomes of interest were pain intensity measured using visual analogue scales or numerical rating scales, disability, quality of life and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted and verified data. Where possible we entered data into meta-analyses, excluding studies judged as high risk of bias. We used the GRADE system to assess the quality of evidence for core comparisons, and created three 'Summary of findings' tables.

MAIN RESULTS

We included an additional 38 trials (involving 1225 randomised participants) in this update, making a total of 94 trials in the review (involving 2983 randomised participants). This update included a total of 42 rTMS studies, 11 CES, 36 tDCS, two RINCE and two tRNS. One study evaluated both rTMS and tDCS. We judged only four studies as low risk of bias across all key criteria. Using the GRADE criteria we judged the quality of evidence for each outcome, and for all comparisons as low or very low; in large part this was due to issues of blinding and of precision.rTMSMeta-analysis of rTMS studies versus sham for pain intensity at short-term follow-up (0 to < 1 week postintervention), (27 studies, involving 655 participants), demonstrated a small effect with heterogeneity (standardised mean difference (SMD) -0.22, 95% confidence interval (CI) -0.29 to -0.16, low-quality evidence). This equates to a 7% (95% CI 5% to 9%) reduction in pain, or a 0.40 (95% CI 0.53 to 0.32) point reduction on a 0 to 10 pain intensity scale, which does not meet the minimum clinically important difference threshold of 15% or greater. Pre-specified subgroup analyses did not find a difference between low-frequency stimulation (low-quality evidence) and rTMS applied to the prefrontal cortex compared to sham for reducing pain intensity at short-term follow-up (very low-quality evidence). High-frequency stimulation of the motor cortex in single-dose studies was associated with a small short-term reduction in pain intensity at short-term follow-up (low-quality evidence, pooled n = 249, SMD -0.38 95% CI -0.49 to -0.27). This equates to a 12% (95% CI 9% to 16%) reduction in pain, or a 0.77 (95% CI 0.55 to 0.99) point change on a 0 to 10 pain intensity scale, which does not achieve the minimum clinically important difference threshold of 15% or greater. The results from multiple-dose studies were heterogeneous and there was no evidence of an effect in this subgroup (very low-quality evidence). We did not find evidence that rTMS improved disability. Meta-analysis of studies of rTMS versus sham for quality of life (measured using the Fibromyalgia Impact Questionnaire (FIQ) at short-term follow-up demonstrated a positive effect (MD -10.80 95% CI -15.04 to -6.55, low-quality evidence).CESFor CES (five studies, 270 participants) we found no evidence of a difference between active stimulation and sham (SMD -0.24, 95% CI -0.48 to 0.01, low-quality evidence) for pain intensity. We found no evidence relating to the effectiveness of CES on disability. One study (36 participants) of CES versus sham for quality of life (measured using the FIQ) at short-term follow-up demonstrated a positive effect (MD -25.05 95% CI -37.82 to -12.28, very low-quality evidence).tDCSAnalysis of tDCS studies (27 studies, 747 participants) showed heterogeneity and a difference between active and sham stimulation (SMD -0.43 95% CI -0.63 to -0.22, very low-quality evidence) for pain intensity. This equates to a reduction of 0.82 (95% CI 0.42 to 1.2) points, or a percentage change of 17% (95% CI 9% to 25%) of the control group outcome. This point estimate meets our threshold for a minimum clinically important difference, though the lower confidence interval is substantially below that threshold. We found evidence of small study bias in the tDCS analyses. We did not find evidence that tDCS improved disability. Meta-analysis of studies of tDCS versus sham for quality of life (measured using different scales across studies) at short-term follow-up demonstrated a positive effect (SMD 0.66 95% CI 0.21 to 1.11, low-quality evidence).Adverse eventsAll forms of non-invasive brain stimulation and sham stimulation appear to be frequently associated with minor or transient side effects and there were two reported incidences of seizure, both related to the active rTMS intervention in the included studies. However many studies did not adequately report adverse events.

AUTHORS' CONCLUSIONS

There is very low-quality evidence that single doses of high-frequency rTMS of the motor cortex and tDCS may have short-term effects on chronic pain and quality of life but multiple sources of bias exist that may have influenced the observed effects. We did not find evidence that low-frequency rTMS, rTMS applied to the dorsolateral prefrontal cortex and CES are effective for reducing pain intensity in chronic pain. The broad conclusions of this review have not changed substantially for this update. There remains a need for substantially larger, rigorously designed studies, particularly of longer courses of stimulation. Future evidence may substantially impact upon the presented results.

Non-invasive brain stimulation techniques for chronic pain

BACKGROUND

This is an updated version of the original Cochrane Review published in 2010, Issue 9, and last updated in 2014, Issue 4. Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), transcranial direct current stimulation (tDCS), transcranial random noise stimulation (tRNS) and reduced impedance non-invasive cortical electrostimulation (RINCE).

OBJECTIVES

To evaluate the efficacy of non-invasive cortical stimulation techniques in the treatment of chronic pain.

SEARCH METHODS

For this update we searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, LILACS and clinical trials registers from July 2013 to October 2017.

SELECTION CRITERIA

Randomised and quasi-randomised studies of rTMS, CES, tDCS, RINCE and tRNS if they employed a sham stimulation control group, recruited patients over the age of 18 years with pain of three months' duration or more, and measured pain as an outcome. Outcomes of interest were pain intensity measured using visual analogue scales or numerical rating scales, disability, quality of life and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted and verified data. Where possible we entered data into meta-analyses, excluding studies judged as high risk of bias. We used the GRADE system to assess the quality of evidence for core comparisons, and created three 'Summary of findings' tables.

MAIN RESULTS

We included an additional 38 trials (involving 1225 randomised participants) in this update, making a total of 94 trials in the review (involving 2983 randomised participants). This update included a total of 42 rTMS studies, 11 CES, 36 tDCS, two RINCE and two tRNS. One study evaluated both rTMS and tDCS. We judged only four studies as low risk of bias across all key criteria. Using the GRADE criteria we judged the quality of evidence for each outcome, and for all comparisons as low or very low; in large part this was due to issues of blinding and of precision.rTMSMeta-analysis of rTMS studies versus sham for pain intensity at short-term follow-up (0 to < 1 week postintervention), (27 studies, involving 655 participants), demonstrated a small effect with heterogeneity (standardised mean difference (SMD) -0.22, 95% confidence interval (CI) -0.29 to -0.16, low-quality evidence). This equates to a 7% (95% CI 5% to 9%) reduction in pain, or a 0.40 (95% CI 0.53 to 0.32) point reduction on a 0 to 10 pain intensity scale, which does not meet the minimum clinically important difference threshold of 15% or greater. Pre-specified subgroup analyses did not find a difference between low-frequency stimulation (low-quality evidence) and rTMS applied to the prefrontal cortex compared to sham for reducing pain intensity at short-term follow-up (very low-quality evidence). High-frequency stimulation of the motor cortex in single-dose studies was associated with a small short-term reduction in pain intensity at short-term follow-up (low-quality evidence, pooled n = 249, SMD -0.38 95% CI -0.49 to -0.27). This equates to a 12% (95% CI 9% to 16%) reduction in pain, or a 0.77 (95% CI 0.55 to 0.99) point change on a 0 to 10 pain intensity scale, which does not achieve the minimum clinically important difference threshold of 15% or greater. The results from multiple-dose studies were heterogeneous and there was no evidence of an effect in this subgroup (very low-quality evidence). We did not find evidence that rTMS improved disability. Meta-analysis of studies of rTMS versus sham for quality of life (measured using the Fibromyalgia Impact Questionnaire (FIQ) at short-term follow-up demonstrated a positive effect (MD -10.80 95% CI -15.04 to -6.55, low-quality evidence).CESFor CES (five studies, 270 participants) we found no evidence of a difference between active stimulation and sham (SMD -0.24, 95% CI -0.48 to 0.01, low-quality evidence) for pain intensity. We found no evidence relating to the effectiveness of CES on disability. One study (36 participants) of CES versus sham for quality of life (measured using the FIQ) at short-term follow-up demonstrated a positive effect (MD -25.05 95% CI -37.82 to -12.28, very low-quality evidence).tDCSAnalysis of tDCS studies (27 studies, 747 participants) showed heterogeneity and a difference between active and sham stimulation (SMD -0.43 95% CI -0.63 to -0.22, very low-quality evidence) for pain intensity. This equates to a reduction of 0.82 (95% CI 0.42 to 1.2) points, or a percentage change of 17% (95% CI 9% to 25%) of the control group outcome. This point estimate meets our threshold for a minimum clinically important difference, though the lower confidence interval is substantially below that threshold. We found evidence of small study bias in the tDCS analyses. We did not find evidence that tDCS improved disability. Meta-analysis of studies of tDCS versus sham for quality of life (measured using different scales across studies) at short-term follow-up demonstrated a positive effect (SMD 0.66 95% CI 0.21 to 1.11, low-quality evidence).Adverse eventsAll forms of non-invasive brain stimulation and sham stimulation appear to be frequently associated with minor or transient side effects and there were two reported incidences of seizure, both related to the active rTMS intervention in the included studies. However many studies did not adequately report adverse events.

AUTHORS' CONCLUSIONS

There is very low-quality evidence that single doses of high-frequency rTMS of the motor cortex and tDCS may have short-term effects on chronic pain and quality of life but multiple sources of bias exist that may have influenced the observed effects. We did not find evidence that low-frequency rTMS, rTMS applied to the dorsolateral prefrontal cortex and CES are effective for reducing pain intensity in chronic pain. The broad conclusions of this review have not changed substantially for this update. There remains a need for substantially larger, rigorously designed studies, particularly of longer courses of stimulation. Future evidence may substantially impact upon the presented results.