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Deer TR, Russo M, Grider JS, Sayed D, Lamer TJ, Dickerson DM, Hagedorn JM, Petersen EA, Fishman MA, FitzGerald J, Baranidharan G, De Ridder D, Chakravarthy KV, Al-Kaisy A, Hunter CW, Buchser E, Chapman K, Gilligan C, Hayek SM, Thomson S, Strand N, Jameson J, Simopoulos TT, Yang A, De Coster O, Cremaschi F, Christo PJ, Varshney V, Bojanic S, Levy RM. The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for Spinal Cord Stimulation Long-Term Outcome Optimization and Salvage Therapy. Neuromodulation 2024; 27:951-976. [PMID: 38904643 DOI: 10.1016/j.neurom.2024.04.006] [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: 02/19/2024] [Revised: 04/02/2024] [Accepted: 04/22/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION The International Neuromodulation Society (INS) has recognized a need to establish best practices for optimizing implantable devices and salvage when ideal outcomes are not realized. This group has established the Neurostimulation Appropriateness Consensus Committee (NACC)® to offer guidance on matters needed for both our members and the broader community of those affected by neuromodulation devices. MATERIALS AND METHODS The executive committee of the INS nominated faculty for this NACC® publication on the basis of expertise, publications, and career work on the issue. In addition, the faculty was chosen in consideration of diversity and inclusion of different career paths and demographic categories. Once chosen, the faculty was asked to grade current evidence and along with expert opinion create consensus recommendations to address the lapses in information on this topic. RESULTS The NACC® group established informative and authoritative recommendations on the salvage and optimization of care for those with indwelling devices. The recommendations are based on evidence and expert opinion and will be expected to evolve as new data are generated for each topic. CONCLUSIONS NACC® guidance should be considered for any patient with less-than-optimal outcomes with a stimulation device implanted for treating chronic pain. Consideration should be given to these consensus points to salvage a potentially failed device before explant.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA.
| | - Marc Russo
- Hunter Pain Specialists, Newcastle, Australia
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Dawood Sayed
- The University of Kansas Health System, Kansas City, KS, USA
| | | | | | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Erika A Petersen
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Ganesan Baranidharan
- Leeds Teaching Hospital National Health Service (NHS) Trust, University of Leeds, Leeds, UK
| | - Dirk De Ridder
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | | | - Adnan Al-Kaisy
- Guy's and St Thomas NHS Foundation Trust, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Corey W Hunter
- Ainsworth Institute, Ichan School of Medicine, Mt Sinai Hospital, New York, NY, USA
| | | | | | - Chris Gilligan
- Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Salim M Hayek
- Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Simon Thomson
- Pain & Neuromodulation Consulting Ltd, Nuffield Health Brentwood and The London Clinic, Brentwood, UK; Pain & Neuromodulation Centre, Mid & South Essex University NHS Hospitals, Basildon, UK
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | - Thomas T Simopoulos
- Arnold Warfield Pain Management Center, Harvard Medical School, Boston, MA, USA
| | - Ajax Yang
- Spine and Pain Consultant, PLLC, Staten Island, NY, USA
| | | | - Fabián Cremaschi
- Department of Neurosciences, National University of Cuyo, Mendoza, Argentina
| | - Paul J Christo
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vishal Varshney
- Providence Healthcare, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stana Bojanic
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
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Huang Y, Sadeghzadeh S, Li AHY, Schonfeld E, Ramayya AG, Buch VP. Rates and Predictors of Pain Reduction With Intracranial Stimulation for Intractable Pain Disorders. Neurosurgery 2024:00006123-990000000-01186. [PMID: 38836613 DOI: 10.1227/neu.0000000000003006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/01/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intracranial modulation paradigms, namely deep brain stimulation (DBS) and motor cortex stimulation (MCS), have been used to treat intractable pain disorders. However, treatment efficacy remains heterogeneous, and factors associated with pain reduction are not completely understood. METHODS We performed an individual patient review of pain outcomes (visual analog scale, quality-of-life measures, complications, pulse generator implant rate, cessation of stimulation) after implantation of DBS or MCS devices. We evaluated 663 patients from 36 study groups and stratified outcomes by pain etiology and implantation targets. RESULTS Included studies comprised primarily retrospective cohort studies. MCS patients had a similar externalized trial success rate compared with DBS patients (86% vs 81%; P = .16), whereas patients with peripheral pain had a higher trial success rate compared with patients with central pain (88% vs 79%; P = .004). Complication rates were similar for MCS and DBS patients (12% vs 15%; P = .79). Patients with peripheral pain had lower likelihood of device cessation compared with those with central pain (5.7% vs 10%; P = .03). Of all implanted patients, mean pain reduction at last follow-up was 45.8% (95% CI: 40.3-51.2) with a 31.2% (95% CI: 12.4-50.1) improvement in quality of life. No difference was seen between MCS patients (43.8%; 95% CI: 36.7-58.2) and DBS patients (48.6%; 95% CI: 39.2-58) or central (41.5%; 95% CI: 34.8-48.2) and peripheral (46.7%; 95% CI: 38.9-54.5) etiologies. Multivariate analysis identified the anterior cingulate cortex target to be associated with worse pain reduction, while postherpetic neuralgia was a positive prognostic factor. CONCLUSION Both DBS and MCS have similar efficacy and complication rates in the treatment of intractable pain. Patients with central pain disorders tended to have lower trial success and higher rates of device cessation. Additional prognostic factors include anterior cingulate cortex targeting and postherpetic neuralgia diagnosis. These findings underscore intracranial neurostimulation as an important modality for treatment of intractable pain disorders.
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Affiliation(s)
- Yuhao Huang
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sina Sadeghzadeh
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Alice Huai-Yu Li
- Department of Anesthesia, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ethan Schonfeld
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ashwin G Ramayya
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Vivek P Buch
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
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Wang D, Lu Y, Han Y, Zhang X, Dong S, Zhang H, Wang G, Wang G, Wang JJ. The Influence of Etiology and Stimulation Target on the Outcome of Deep Brain Stimulation for Chronic Neuropathic Pain: A Systematic Review and Meta-Analysis. Neuromodulation 2024; 27:83-94. [PMID: 36697341 DOI: 10.1016/j.neurom.2022.12.002] [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: 06/27/2022] [Revised: 11/12/2022] [Accepted: 12/01/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Deep brain stimulation (DBS) to treat chronic neuropathic pain has shown variable outcomes. Variations in pain etiologies and DBS targets are considered the main contributing factors, which are, however, underexplored owing to a paucity of patient data in individual studies. An updated meta-analysis to quantitatively assess the influence of these factors on the outcome of DBS for chronic neuropathic pain is warranted, especially considering that the anterior cingulate cortex (ACC) has emerged recently as a new DBS target. MATERIALS AND METHODS A comprehensive literature review was performed in PubMed, Embase, and Cochrane data bases to identify studies reporting quantitative outcomes of DBS for chronic neuropathic pain. Pain and quality of life (QoL) outcomes, grouped by etiology and DBS target, were extracted and analyzed (α = 0.05). RESULTS Twenty-five studies were included for analysis. Patients with peripheral neuropathic pain (PNP) had a significantly greater initial stimulation success rate than did patients with central neuropathic pain (CNP). Both patients with CNP and patients with PNP with definitive implant, regardless of targets, gained significant follow-up pain reduction. Patients with PNP had greater long-term pain relief than did patients with CNP. Patients with CNP with ACC DBS gained less long-term pain relief than did those with conventional targets. Significant short-term QoL improvement was reported in selected patients with CNP after ACC DBS. However, selective reporting bias was expected, and the improvement decreased in the long term. CONCLUSIONS Although DBS to treat chronic neuropathic pain is generally effective, patients with PNP are the preferred population over patients with CNP. Current data suggest that ACC DBS deserves further investigation as a potential way to treat the affective component of chronic neuropathic pain.
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Affiliation(s)
- Dengyu Wang
- School of Medicine, Tsinghua University, Beijing, China; Institute for Precision Medicine, Tsinghua University, Beijing, China
| | - Yang Lu
- Institute for Precision Medicine, Tsinghua University, Beijing, China; Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yan Han
- School of Medicine, Tsinghua University, Beijing, China; Institute for Precision Medicine, Tsinghua University, Beijing, China
| | - Xiaolei Zhang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Sheng Dong
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Huifang Zhang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Guoqin Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Guihuai Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - James Jin Wang
- Institute for Precision Medicine, Tsinghua University, Beijing, China; Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
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Shaheen N, Shaheen A, Elgendy A, Bezchlibnyk YB, Zesiewicz T, Dalm B, Jain J, Green AL, Aziz TZ, Flouty O. Deep brain stimulation for chronic pain: a systematic review and meta-analysis. Front Hum Neurosci 2023; 17:1297894. [PMID: 38098761 PMCID: PMC10719838 DOI: 10.3389/fnhum.2023.1297894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/30/2023] [Indexed: 12/17/2023] Open
Abstract
Background Deep brain stimulation (DBS) has shown promise in effectively treating chronic pain. This study aimed to assess the efficacy of DBS in this context. Methods We conducted a systematic literature search using PubMed, Scopus, and Web of Science, following the PRISMA guidelines. A well-constructed search strategy was utilized. Our literature search identified two groups of subjects: one group underwent DBS specifically for chronic pain treatment (DBS-P), while the second group received DBS for other indications (DBS-O), such as Parkinson's disease or dystonia, with pain perception investigated as a secondary outcome in this population. Meta-analysis was performed using R version 4.2.3 software. Heterogeneity was assessed using the tau^2 and I^2 indices, and Cochran's Q-test was conducted. Results The analysis included 966 patients in 43 original research studies with chronic pain who underwent DBS (340 for DBS-P and 625 for DBS-O). Subgroup analysis revealed that DBS-P exhibited a significant effect on chronic pain relief, with a standardized mean difference (SMD) of 1.65 and a 95% confidence interval (CI) of [1.31; 2.00]. Significant heterogeneity was observed among the studies, with an I^2 value of 85.8%. However, no significant difference was found between DBS-P and DBS-O subgroups. Subgroup analyses based on study design, age, pain diseases, and brain targets demonstrated varying levels of evidence for the effectiveness of DBS across different subgroups. Additionally, meta-regression analyses showed no significant relationship between age or pain duration and DBS effectiveness for chronic pain. Conclusion These findings significantly contribute to the expanding body of knowledge regarding the utility of DBS in the management of chronic pain. The study underscores the importance of conducting further research to enhance treatment outcomes and elucidate patient-specific factors that are associated with treatment response. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=428442, identifier CRD42023428442.
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Affiliation(s)
- Nour Shaheen
- Alexandria Faculty of Medicine, Alexandria, Egypt
| | | | | | - Yarema B. Bezchlibnyk
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, United States
| | - Theresa Zesiewicz
- Department of Neurology, University of South Florida, Tampa, FL, United States
| | - Brian Dalm
- Department of Neurosurgery, The Ohio State University, Columbus, OH, United States
| | - Jennifer Jain
- Department of Neurology, University of South Florida, Tampa, FL, United States
| | - Alexander L. Green
- Oxford Functional Neurosurgery, Department of Neurosurgery, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Tipu Z. Aziz
- Oxford Functional Neurosurgery, Department of Neurosurgery, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Oliver Flouty
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, United States
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Motzkin JC, Kanungo I, D’Esposito M, Shirvalkar P. Network targets for therapeutic brain stimulation: towards personalized therapy for pain. FRONTIERS IN PAIN RESEARCH 2023; 4:1156108. [PMID: 37363755 PMCID: PMC10286871 DOI: 10.3389/fpain.2023.1156108] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
Precision neuromodulation of central brain circuits is a promising emerging therapeutic modality for a variety of neuropsychiatric disorders. Reliably identifying in whom, where, and in what context to provide brain stimulation for optimal pain relief are fundamental challenges limiting the widespread implementation of central neuromodulation treatments for chronic pain. Current approaches to brain stimulation target empirically derived regions of interest to the disorder or targets with strong connections to these regions. However, complex, multidimensional experiences like chronic pain are more closely linked to patterns of coordinated activity across distributed large-scale functional networks. Recent advances in precision network neuroscience indicate that these networks are highly variable in their neuroanatomical organization across individuals. Here we review accumulating evidence that variable central representations of pain will likely pose a major barrier to implementation of population-derived analgesic brain stimulation targets. We propose network-level estimates as a more valid, robust, and reliable way to stratify personalized candidate regions. Finally, we review key background, methods, and implications for developing network topology-informed brain stimulation targets for chronic pain.
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Affiliation(s)
- Julian C. Motzkin
- Departments of Neurology and Anesthesia and Perioperative Care (Pain Management), University of California, San Francisco, San Francisco, CA, United States
| | - Ishan Kanungo
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Mark D’Esposito
- Department of Psychology, University of California, Berkeley, Berkeley, CA, United States
| | - Prasad Shirvalkar
- Departments of Neurology and Anesthesia and Perioperative Care (Pain Management), University of California, San Francisco, San Francisco, CA, United States
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
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Pang D, Ashkan K. Deep brain stimulation for phantom limb pain. Eur J Paediatr Neurol 2022; 39:96-102. [PMID: 35728428 DOI: 10.1016/j.ejpn.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 03/25/2022] [Accepted: 05/23/2022] [Indexed: 11/29/2022]
Abstract
Phantom limb pain is a rare cause of chronic pain in children but it is associated with extremely refractory pain and disability. The reason for limb amputation is often due to treatment for cancer or trauma and it has a lower incidence compared to adults. The mechanism of why phantom pain exists remains uncertain and may be a result of cortical reorganisation as well as ectopic peripheral input. Treatment is aimed at reducing both symptoms as well as managing pain related disability and functional restoration. Neuromodulatory approaches using deep brain stimulation for phantom limb pain is reserved for only the most refractory cases. The targets for brain stimulation include the thalamic nuclei and motor cortex. Novel targets such as the anterior cingulate cortex remain experimental as cases of serious adverse effects such as seziures have limited their widespread uptake. A multidisciplinary approach is crucial to successful rehabilitation using a biopsychosocial pain management approach.
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Affiliation(s)
- David Pang
- Consultant in Pain Management, Pain Management Centre, INPUT St Thomas Hospital, London, SE1 7EH, UK.
| | - Keyoumars Ashkan
- Department of Neurosurgery, Kins's College Hospital NHS Foundation Trust, London, UK
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Deep Brain Stimulation for Chronic Pain. Neurosurg Clin N Am 2022; 33:311-321. [DOI: 10.1016/j.nec.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Management of Phantom Limb Pain through Thalamotomy of the Centro-Median Nucleus. Neurol Int 2021; 13:587-593. [PMID: 34842785 PMCID: PMC8628935 DOI: 10.3390/neurolint13040058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/18/2021] [Accepted: 10/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Phantom limb syndrome is defined as the perception of intense pain or other sensations that are secondary to a neural lesion in a limb that does not exist. It can be treated using pharmacological and surgical interventions. Most medications are prescribed to improve patients’ lives; however, the response rate is low. In this case report, we present a case of phantom limb syndrome in a 42-year-old female with a history of transradial amputation of the left thoracic limb due to an accidental compression one year before. The patient underwent placement of a deep brain stimulator at the ventral posteromedial nucleus (VPM) on the right side and removal secondary to loss of battery. The patient continued to have a burning pain throughout the limb with a sensation of still having the limb, which was subsequently diagnosed as phantom limb syndrome. After a thorough discussion with the patient, a right stereotactic centro-median thalamotomy was offered. An immediate response was reported with a reduction in pain severity on the visual analogue scale (VAS) from a value of 9–10 preoperative to a value of 2 postoperative, with no postoperative complications. Although phantom limb pain is one of the most difficult to treat conditions, centro-median thalamotomy may provide an effective stereotactic treatment procedure with adequate outcomes.
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Pacheco-Barrios K, Meng X, Fregni F. Neuromodulation Techniques in Phantom Limb Pain: A Systematic Review and Meta-analysis. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:2310-2322. [PMID: 32176286 PMCID: PMC7593798 DOI: 10.1093/pm/pnaa039] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the effects of neuromodulation techniques in adults with phantom limb pain (PLP). METHODS A systematic search was performed, comprising randomized controlled trials (RCTs) and quasi-experimental (QE) studies that were published from database inception to February 2019 and that measured the effects of neuromodulation in adults with PLP. Hedge's g effect size (ES) and 95% confidence intervals were calculated, and random-effects meta-analyses were performed. RESULTS Fourteen studies (nine RCTs and five QE noncontrolled studies) were included. The meta-analysis of RCTs showed significant effects for i) excitatory primary motor cortex (M1) stimulation in reducing pain after stimulation (ES = -1.36, 95% confidence interval [CI] = -2.26 to -0.45); ii) anodal M1 transcranial direct current stimulation (tDCS) in lowering pain after stimulation (ES = -1.50, 95% CI = -2.05 to 0.95), and one-week follow-up (ES = -1.04, 95% CI = -1.64 to 0.45). The meta-analysis of noncontrolled QE studies demonstrated a high rate of pain reduction after stimulation with transcutaneous electrical nerve stimulation (rate = 67%, 95% CI = 60% to 73%) and at one-year follow-up with deep brain stimulation (rate = 73%, 95% CI = 63% to 82%). CONCLUSIONS The evidence from RCTs suggests that excitatory M1 stimulation-specifically, anodal M1 tDCS-has a significant short-term effect in reducing pain scale scores in PLP. Various neuromodulation techniques appear to have a significant and positive impact on PLP, but due to the limited amount of data, it is not possible to draw more definite conclusions.
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Affiliation(s)
- Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru
| | - Xianguo Meng
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Shandong First Medical University & Shandong Academy of Medical Sciences, College of Sport Medicine and Rehabilitation, Jinan, Shandong Province, P.R. China
| | - Felipe Fregni
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
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Frizon LA, Yamamoto EA, Nagel SJ, Simonson MT, Hogue O, Machado AG. Deep Brain Stimulation for Pain in the Modern Era: A Systematic Review. Neurosurgery 2020; 86:191-202. [PMID: 30799493 DOI: 10.1093/neuros/nyy552] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 01/25/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) has been considered for patients with intractable pain syndromes since the 1950s. Although there is substantial experience reported in the literature, the indications are contested, especially in the United States where it remains off-label. Historically, the sensory-discriminative pain pathways were targeted. More recently, modulation of the affective sphere of pain has emerged as a plausible alternative. OBJECTIVE To systematically review the literature from studies that used contemporary DBS technology. Our aim is to summarize the current evidence of this therapy. METHODS A systematic search was conducted in the MEDLINE, EMBASE, and Cochrane libraries through July 2017 to review all studies using the current DBS technology primarily for pain treatment. Study characteristics including patient demographics, surgical technique, outcomes, and complications were collected. RESULTS Twenty-two articles were included in this review. In total, 228 patients were implanted with a definitive DBS system for pain. The most common targets used were periaqueductal/periventricular gray matter region, ventral posterior lateral/posterior medial thalamus, or both. Poststroke pain, phantom limb pain, and brachial plexus injury were the most common specific indications for DBS. Outcomes varied between studies and across chronic pain diagnoses. Two different groups of investigators targeting the affective sphere of pain have demonstrated improvements in quality of life measures without significant reductions in pain scores. CONCLUSION DBS outcomes for chronic pain are heterogeneous thus far. Future studies may focus on specific pain diagnosis rather than multiple syndromes and consider randomized placebo-controlled designs. DBS targeting the affective sphere of pain seems promising and deserves further investigation.
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Affiliation(s)
- Leonardo A Frizon
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Post-graduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Erin A Yamamoto
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Sean J Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Olivia Hogue
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Andre G Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Chappell AG, Jordan SW, Dumanian GA. Targeted Muscle Reinnervation for Treatment of Neuropathic Pain. Clin Plast Surg 2020; 47:285-293. [DOI: 10.1016/j.cps.2020.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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12
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Knezevic NN, Aijaz T, Candido KD, Kovaleva S, Lissounov A, Knezevic I. The Effect of Once-Daily Gabapentin Extended Release Formulation in Patients With Postamputation Pain. Front Pharmacol 2019; 10:504. [PMID: 31156433 PMCID: PMC6529536 DOI: 10.3389/fphar.2019.00504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 04/23/2019] [Indexed: 12/31/2022] Open
Abstract
Objectives To compare gabapentin extended-release, a gastro-retentive formulation, in relieving postamputation pain among gabapentin-experienced and gabapentin-naïve patients. Design Open-labeled pilot study. Subjects Sixteen patients with postamputation pain (8 patients in the gabapentin-experienced and 8 patients in the gabapentin-naïve groups). Methods Patients were started on gabapentin extended-release and were followed up for 8 weeks. Patients reported their pain severity during rest and movement using a numeric rating scale (NRS), interference of pain with daily activities using the modified brief pain inventory (MBPI) questionnaire, and treatment satisfaction using the treatment satisfaction questionnaire for medication (TSQM). Results Patients from both gabapentin-experienced and gabapentin-naïve groups achieved a significant and sustainable pain relief over the course of therapy. The pain scores at rest decreased in both gabapentin-experienced and gabapentin-naïve groups from 5.88 ± 1.36 and 4.88 ± 2.95 to 1.88 ± 0.99 and 1.38 ± 1.51, respectively. An average percent of pain relief with gabapentin extended-release was noted to be significant (p < 0.01) after 8 weeks of therapy among gabapentin-experienced (81.25 ± 16.42%) and gabapentin-naïve groups (85 ± 17.73%) when compared to baseline for gabapentin-experienced (31.25 ± 29%) and gabapentin-naïve groups (36.25 ± 34.2%), respectively. Gabapentin-experienced and gabapentin-naïve groups had no significant difference in global satisfaction from treatment (79.14 ± 10.47 and 83.3 ± 20.82), convenience of treatment (73.78 ± 19.04 and 90.44 ± 11.66), effectiveness of treatment (72.6 ± 10.1 and 79.73 ± 11.6). The only statistically significant difference among gabapentin-experienced and gabapentin-naïve groups was found in adverse event tolerability (65.78 ± 10.36 and 85.8 ± 10.14, p < 0.01). Conclusion Once-daily dosing of gabapentin-extended release showed significant improvement in pain severity and functional status, with no difference found between gabapentin-experienced versus gabapentin-naïve patients.
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Affiliation(s)
- Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States.,Department of Anesthesiology, The University of Illinois at Chicago, Chicago, IL, United States.,Department of Surgery, The University of Illinois at Chicago, Chicago, IL, United States
| | - Tabish Aijaz
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States.,Department of Anesthesiology, The University of Illinois at Chicago, Chicago, IL, United States.,Department of Surgery, The University of Illinois at Chicago, Chicago, IL, United States
| | - Svetlana Kovaleva
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Alexei Lissounov
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Ivana Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
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13
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Abstract
Phantom limb pain is a chronic neuropathic pain that develops in 45-85% of patients who undergo major amputations of the upper and lower extremities and appears predominantly during two time frames following an amputation: the first month and later about 1 year. Although in most patients the frequency and intensity of pain diminish over time, severe pain persists in about 5-10%. It has been proposed that factors in both the peripheral and central nervous systems play major roles in triggering the development and maintenance of pain associated with extremity amputations. Chronic pain is physically and mentally debilitating, affecting an individual's capacity for self-care, but also diminishing an individual's daily capacity for personal and economic independence. In addition, the pain may lead to depression and feelings of hopelessness. A National Center for Biotechnology Information study found that in the USA alone, the annual cost of dealing with neuropathic pain is more than $600 billion, with an estimated 20 million people in the USA suffering from this condition. Although the pain can be reduced by antiepileptic drugs and analgesics, they are frequently ineffective or their side effects preclude their use. The optimal approach for eliminating neuropathic pain and improving individuals' quality of life is the development of novel techniques that permanently prevent the development and maintenance of neuropathic pain, or that eliminate the pain once it has developed. What is still required is understanding when and where an effective novel technique must be applied, such as onto the nerve stump of the transected peripheral axons, dorsal root ganglion neurons, spinal cord, or cortex to induce the desired influences. This review, the second of two in this journal volume, examines the techniques that may be capable of reducing or eliminating chronic neuropathic pain once it has developed. Such an understanding will improve amputees' quality of life by blocking the mechanisms that trigger and/or maintain PLP and chronic neuropathic pain.
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Affiliation(s)
- Damien P Kuffler
- Institute of Neurobiology, University of Puerto Rico, Medical Science Campus, 201 Blvd. del Valle, San Juan, PR, 00901, Puerto Rico.
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14
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Corbett M, South E, Harden M, Eldabe S, Pereira E, Sedki I, Hall N, Woolacott N. Brain and spinal stimulation therapies for phantom limb pain: a systematic review. Health Technol Assess 2019; 22:1-94. [PMID: 30407905 DOI: 10.3310/hta22620] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although many treatments exist for phantom limb pain (PLP), the evidence supporting them is limited and there are no guidelines for PLP management. Brain and spinal cord neurostimulation therapies are targeted at patients with chronic PLP but have yet to be systematically reviewed. OBJECTIVE To determine which types of brain and spinal stimulation therapy appear to be the best for treating chronic PLP. DESIGN Systematic reviews of effectiveness and epidemiology studies, and a survey of NHS practice. POPULATION All patients with PLP. INTERVENTIONS Invasive interventions - deep brain stimulation (DBS), motor cortex stimulation (MCS), spinal cord stimulation (SCS) and dorsal root ganglion (DRG) stimulation. Non-invasive interventions - repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS). MAIN OUTCOME MEASURES Phantom limb pain and quality of life. DATA SOURCES Twelve databases (including MEDLINE and EMBASE) and clinical trial registries were searched in May 2017, with no date limits applied. REVIEW METHODS Two reviewers screened titles and abstracts and full texts. Data extraction and quality assessments were undertaken by one reviewer and checked by another. A questionnaire was distributed to clinicians via established e-mail lists of two relevant clinical societies. All results were presented narratively with accompanying tables. RESULTS Seven randomised controlled trials (RCTs), 30 non-comparative group studies, 18 case reports and 21 epidemiology studies were included. Results from a good-quality RCT suggested short-term benefits of rTMS in reducing PLP, but not in reducing anxiety or depression. Small randomised trials of tDCS suggested the possibility of modest, short-term reductions in PLP. No RCTs of invasive therapies were identified. Results from small, non-comparative group studies suggested that, although many patients benefited from short-term pain reduction, far fewer maintained their benefits. Most studies had important methodological or reporting limitations and few studies reported quality-of-life data. The evidence on prognostic factors for the development of chronic PLP from the longitudinal studies also had important limitations. The results from these studies suggested that pre-amputation pain and early PLP intensity are good predictors of chronic PLP. Results from the cross-sectional studies suggested that the proportion of patients with severe chronic PLP is between around 30% and 40% of the chronic PLP population, and that around one-quarter of chronic PLP patients find their PLP to be either moderately or severely limiting or bothersome. There were 37 responses to the questionnaire distributed to clinicians. SCS and DRG stimulation are frequently used in the NHS but the prevalence of use of DBS and MCS was low. Most responders considered SCS and DRG stimulation to be at least sometimes effective. Neurosurgeons had mixed views on DBS, but most considered MCS to rarely be effective. Most clinicians thought that a randomised trial design could be successfully used to study neurostimulation therapies. LIMITATION There was a lack of robust research studies. CONCLUSIONS Currently available studies of the efficacy, effectiveness and safety of neurostimulation treatments do not provide robust, reliable results. Therefore, it is uncertain which treatments are best for chronic PLP. FUTURE WORK Randomised crossover trials, randomised N-of-1 trials and prospective registry trials are viable study designs for future research. STUDY REGISTRATION The study is registered as PROSPERO CRD42017065387. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Mark Corbett
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Emily South
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Melissa Harden
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Sam Eldabe
- James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Erlick Pereira
- Academic Neurosurgery Unit, St George's, University of London, London, UK
| | - Imad Sedki
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - Neil Hall
- James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Nerys Woolacott
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
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15
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Kohler M, Strauss S, Horn U, Langner I, Usichenko T, Neumann N, Lotze M. Differences in Neuronal Representation of Mental Rotation in Patients With Complex Regional Pain Syndrome and Healthy Controls. THE JOURNAL OF PAIN 2019; 20:898-907. [PMID: 30710707 DOI: 10.1016/j.jpain.2019.01.330] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/16/2019] [Accepted: 01/28/2019] [Indexed: 12/12/2022]
Abstract
Spatial integration of parts of the body is impaired in patients with complex regional pain syndrome (CRPS). Because the training of mental rotation (MR) has been shown to be among the effective therapy strategies for CRPS, impairment of MR is also important for the pathophysiological understanding of CRPS. The aim of this study was to evaluate whether differences in the neural representation of MR occur between patients with CRPS and healthy controls (HC). Therefore, we included 15 patients with chronic CRPS and 15 age- and gender-matched HC. We assessed behavioral (accuracy and reaction time for MR of both hands), clinical (Disabilities of Arm, Shoulder and Hand questionnaire) and magnetic resonance imaging (T1-weighted, function magnetic resonance imaging during MR) data. Reaction times in the patient group were delayed compared with HC without a lateralization effect for the affected hand side. Although both groups showed an activation pattern typical for MR, only HC showed a highly significant contrast for the rotated versus unrotated hands in the right intraparietal sulcus. Patients with CRPS showed a reduction of functional magnetic resonance imaging activation in areas including the subthalamic nucleus, nucleus accumbens, and putamen. Regression analysis for the CRPS group emphasized the importance of putamen and nucleus accumbens activation for MR performance. This study highlights the reduced access of patients with CRPS for mental resources modulating arousal, emotional response, and subcortical sensorimotor integration. PERSPECTIVE: This study localized the underlying neural responses for impaired mental rotation in patients with complex regional pain syndrome as a decrease in basal ganglia (putamen) and nucleus accumbens activation.
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Affiliation(s)
| | - Sebastian Strauss
- Functional Imaging Unit, Center for Diagnostic Radiology, and; Department of Neurology, University of Greifswald, Germany
| | - Ulrike Horn
- Functional Imaging Unit, Center for Diagnostic Radiology, and
| | - Inga Langner
- Division of Hand Surgery and Functional Microsurgery, Department of Trauma and Reconstructive Surgery, and
| | - Taras Usichenko
- Department of Anesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Nicola Neumann
- Functional Imaging Unit, Center for Diagnostic Radiology, and
| | - Martin Lotze
- Functional Imaging Unit, Center for Diagnostic Radiology, and.
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16
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Petersen BA, Nanivadekar AC, Chandrasekaran S, Fisher LE. Phantom limb pain: peripheral neuromodulatory and neuroprosthetic approaches to treatment. Muscle Nerve 2018; 59:154-167. [DOI: 10.1002/mus.26294] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Bailey A. Petersen
- Department of Bioengineering; University of Pittsburgh; 3520 Fifth Avenue, Pittsburgh Pennsylvania 15213 USA
| | - Ameya C. Nanivadekar
- Department of Bioengineering; University of Pittsburgh; 3520 Fifth Avenue, Pittsburgh Pennsylvania 15213 USA
| | - Santosh Chandrasekaran
- Department of Physical Medicine and Rehabilitation; University of Pittsburgh; Pittsburgh Pennsylvania USA
| | - Lee E. Fisher
- Department of Bioengineering; University of Pittsburgh; 3520 Fifth Avenue, Pittsburgh Pennsylvania 15213 USA
- Department of Physical Medicine and Rehabilitation; University of Pittsburgh; Pittsburgh Pennsylvania USA
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17
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Abstract
OBJECTIVE To review the literature related to different treatment strategies for the general population of individuals with amputation, spinal cord injury, and cerebral palsy, as well as how this may impact pain management in a correlated athlete population. DATA SOURCES A comprehensive literature search was performed linking pain with terms related to different impairment types. MAIN RESULTS There is a paucity in the literature relating to treatment of pain in athletes with impairment; however, it is possible that the treatment strategies used in the general population of individuals with impairment may be translated to the athlete population. There are a wide variety of treatment options including both pharmacological and nonpharmacological treatments which may be applicable in the athlete. CONCLUSIONS It is the role of the physician to determine which strategy of the possible treatment options will best facilitate the management of pain in the individual athlete in a sport-specific setting.
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18
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Basha D, Dostrovsky JO, Kalia SK, Hodaie M, Lozano AM, Hutchison WD. Gamma oscillations in the somatosensory thalamus of a patient with a phantom limb: case report. J Neurosurg 2017; 129:1048-1055. [PMID: 29125416 DOI: 10.3171/2017.5.jns17170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The amputation of an extremity is commonly followed by phantom sensations that are perceived to originate from the missing limb. The mechanism underlying the generation of these sensations is still not clear although the development of abnormal oscillatory bursting in thalamic neurons may be involved. The theory of thalamocortical dysrhythmia implicates gamma oscillations in phantom pathophysiology although this rhythm has not been previously observed in the phantom limb thalamus. In this study, the authors report the novel observation of widespread 38-Hz gamma oscillatory activity in spike and local field potential recordings obtained from the ventral caudal somatosensory nucleus of the thalamus (Vc) of a phantom limb patient undergoing deep brain stimulation (DBS) surgery. Interestingly, microstimulation near tonically firing cells in the Vc resulted in high-frequency, gamma oscillatory discharges coincident with phantom sensations reported by the patient. Recordings from the somatosensory thalamus of comparator groups (essential tremor and pain) did not reveal the presence of gamma oscillatory activity.
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Affiliation(s)
- Diellor Basha
- Departments of1Physiology and.,4Krembil Western Research Institute, Toronto, Ontario, Canada
| | - Jonathan O Dostrovsky
- Departments of1Physiology and.,3Division of Neurosurgery, Toronto Western Hospital; and.,4Krembil Western Research Institute, Toronto, Ontario, Canada
| | - Suneil K Kalia
- 2Surgery, University of Toronto.,4Krembil Western Research Institute, Toronto, Ontario, Canada
| | - Mojgan Hodaie
- 2Surgery, University of Toronto.,4Krembil Western Research Institute, Toronto, Ontario, Canada
| | - Andres M Lozano
- 2Surgery, University of Toronto.,4Krembil Western Research Institute, Toronto, Ontario, Canada
| | - William D Hutchison
- Departments of1Physiology and.,3Division of Neurosurgery, Toronto Western Hospital; and.,4Krembil Western Research Institute, Toronto, Ontario, Canada
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19
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Chen SC, Chu PY, Hsieh TH, Li YT, Peng CW. Feasibility of deep brain stimulation for controlling the lower urinary tract functions: An animal study. Clin Neurophysiol 2017; 128:2438-2449. [PMID: 29096218 DOI: 10.1016/j.clinph.2017.09.102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 08/17/2017] [Accepted: 09/16/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the feasibility of deep brain stimulation (DBS) and compare the potential of four DBS targets in rats for regulating bladder activity: the periaqueductal gray (PAG), locus coeruleus (LC), rostral pontine reticular nucleus (PnO), and pedunculopontine tegmental nucleus (PPTg). METHODS A bipolar stimulating electrode was implanted. The effects of DBS on the inhibition and activation of micturition reflexes were investigated by using isovolumetric intravesical pressure recordings. RESULTS PAG DBS at 2-2.5 V, PnO DBS at 2-2.5 V, and PPTg DBS at 1.75-2.5 V nearly completely inhibited reflexive isovolumetric bladder contractions. By contrast, LC DBS at 1.75 and 2 V slightly augmented reflexive isovolumetric bladder contractions in rats. DBSs on PnO and PPTg at higher intensities (2.5-5 V) demonstrated a higher success rate and larger contraction area evocation in activating bladder contractions in a partially filled bladder. DBS targeting the PPTg was most efficient in suppressing reflexive isovolumetric bladder contractions. CONCLUSION PPTg DBS demonstrated stable results and high potency for controlling bladder contractions. PPTg might be a promising DBS target for developing new neuromodulatory approaches for the treatment of bladder dysfunctions. SIGNIFICANCE DBS could be a potential approach to manage bladder function under various conditions.
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Affiliation(s)
- Shih-Ching Chen
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan
| | - Pei-Yi Chu
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
| | - Tsung-Hsun Hsieh
- Department of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Neuroscience Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; Graduate Institute of Neural Regenerative Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Ting Li
- Instrument Technology Research Center, National Applied Research Laboratories, Hsinchu, Taiwan
| | - Chih-Wei Peng
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan; School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan; International Ph.D. Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan.
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20
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Ramadugu S, Nagabushnam SC, Katuwal N, Chatterjee K. Intervention for phantom limb pain: A randomized single crossover study of mirror therapy. Indian J Psychiatry 2017; 59:457-464. [PMID: 29497188 PMCID: PMC5806325 DOI: 10.4103/psychiatry.indianjpsychiatry_259_16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Mirror therapy suggested to help relieve phantom limb pain (PLP) by resolving the visual- proprioceptive dissociation in the brain, but studies so far either had shorter follow-up or smaller sample size. MATERIALS AND METHODS In this randomized single crossover trial, 64 amputees with PLP in the age group of 15-75 years of age were distributed into test and control groups by simple randomization method. Of these 28 in control and 32 in test groups, respectively, completed the 4 weeks of mirror therapy and 12 weeks of follow-up assessments. A standardized set of exercises for 15 min/day for 4 and 8 weeks in test and control groups (in the first 4 weeks, the mirror was covered), respectively, was administered under supervision of one of the authors. All were assessed using the visual analog scale and Short-Form McGill Pain Questionnaire on day 0 and at 4, 8, and 12 weeks after therapy. In control group for the initial 4 weeks, the mirror was covered. The assessing author was blinded to the group to which the participants belonged. RESULTS Significant reduction in PLP was noted in the test group at 4 weeks compared to the control group (P < 0.0001). Significant reduction was seen in control group also after the switchover and sustained for 12 weeks in both. No harm was reported. CONCLUSION Mirror therapy is effective in relieving the intensity, duration, frequency, and overall PLP, and improvement is maintained up to 12 weeks' posttherapy.
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Affiliation(s)
- Shashikumar Ramadugu
- Department of Psychiatry, Deccan College of Medical Sciences, Hyderabad, Telangana, India
| | | | - Nagendra Katuwal
- Department of Psychiatry, Nepal Army Institute of Health Sciences, Kathmandu, Nepal
| | - Kaushik Chatterjee
- Department of Prosthetic Surgery, Armed Forces Medical College, Pune, Maharashtra, India
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21
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Richardson C, Kulkarni J. A review of the management of phantom limb pain: challenges and solutions. J Pain Res 2017; 10:1861-1870. [PMID: 28860841 PMCID: PMC5558877 DOI: 10.2147/jpr.s124664] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Phantom limb pain (PLP) occurs in 50% and 80% of amputees. Although it is often classified as a neuropathic pain, few of the large-scale trials of treatments for neuropathic pain included sufficient numbers of PLP sufferers to have confidence that they are effective in this condition. Many therapies have been administered to amputees with PLP over the years; however, as of yet, there appears to be no first-line treatment. OBJECTIVES To comprehensively review the literature on treatment modalities for PLP and to identify the challenges currently faced by clinicians dealing with this pain. METHOD MEDLINE, EMBASE, CINAHL, British Nursing Index, Cochrane and psycINFO databases were searched using "Phantom limb" initially as a MeSH term to identify treatments that had been tried. Then, a secondary search combining phantom limb with each treatment was performed to find papers specific to each therapy. Each paper was assessed for its research strength using the GRADE system. RESULTS Thirty-eight therapies were identified. Overall, the quality of evidence was low. There was one high-quality study which used repetitive transcutaneous magnetic stimulation and found a statistical reduction in pain at day 15 but no difference at day 30. Significant results from single studies of moderate level quality were available for gabapentin, ketamine and morphine; however, there was a risk of bias in these papers. Mirror therapy and associated techniques were assessed through two systematic reviews, which conclude that there is insufficient evidence to support their use. CONCLUSION No decisions can be made for the first-line management of PLP, as the level of evidence is too low. Robust studies on homogeneous populations, an understanding of what amputees consider a meaningful reduction in PLP and agreement of whether pain intensity is the legitimate therapeutic target are urgently required.
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Affiliation(s)
- Cliff Richardson
- University of Manchester, Division of Nursing Midwifery and Social Work, Manchester, UK
| | - Jai Kulkarni
- Specialized Ability Centre (Manchester), University Hospitals of South Manchester NHS Foundation Trust, Manchester, UK
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22
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Sclocco R, Beissner F, Bianciardi M, Polimeni JR, Napadow V. Challenges and opportunities for brainstem neuroimaging with ultrahigh field MRI. Neuroimage 2017; 168:412-426. [PMID: 28232189 DOI: 10.1016/j.neuroimage.2017.02.052] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/30/2017] [Accepted: 02/19/2017] [Indexed: 12/19/2022] Open
Abstract
The human brainstem plays a central role in connecting the cerebrum, the cerebellum and the spinal cord to one another, hosting relay nuclei for afferent and efferent signaling, and providing source nuclei for several neuromodulatory systems that impact central nervous system function. While the investigation of the brainstem with functional or structural magnetic resonance imaging has been hampered for years due to this brain structure's physiological and anatomical characteristics, the field has seen significant advances in recent years thanks to the broader adoption of ultrahigh-field (UHF) MRI scanning. In the present review, we focus on the advantages offered by UHF in the context of brainstem imaging, as well as the challenges posed by the investigation of this complex brain structure in terms of data acquisition and analysis. We also illustrate how UHF MRI can shed new light on the neuroanatomy and neurophysiology underlying different brainstem-based circuitries, such as the central autonomic network and neurotransmitter/neuromodulator systems, discuss existing and foreseeable clinical applications to better understand diseases such as chronic pain and Parkinson's disease, and explore promising future directions for further improvements in brainstem imaging using UHF MRI techniques.
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Affiliation(s)
- Roberta Sclocco
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, CNY 149-2301, 13th St. Charlestown, Boston, MA 02129, USA; Department of Radiology, Logan University, Chesterfield, MO, USA.
| | - Florian Beissner
- Somatosensory and Autonomic Therapy Research, Institute for Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Marta Bianciardi
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, CNY 149-2301, 13th St. Charlestown, Boston, MA 02129, USA
| | - Jonathan R Polimeni
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, CNY 149-2301, 13th St. Charlestown, Boston, MA 02129, USA; Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Vitaly Napadow
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, CNY 149-2301, 13th St. Charlestown, Boston, MA 02129, USA; Department of Radiology, Logan University, Chesterfield, MO, USA
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23
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Sims-Williams H, Matthews JC, Talbot PS, Love-Jones S, Brooks JC, Patel NK, Pickering AE. Deep brain stimulation of the periaqueductal gray releases endogenous opioids in humans. Neuroimage 2016; 146:833-842. [PMID: 27554530 PMCID: PMC5312788 DOI: 10.1016/j.neuroimage.2016.08.038] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/25/2016] [Accepted: 08/18/2016] [Indexed: 12/11/2022] Open
Abstract
Deep brain stimulation (DBS) of the periaqueductal gray (PAG) is used in the treatment of severe refractory neuropathic pain. We tested the hypothesis that DBS releases endogenous opioids to exert its analgesic effect using [11C]diprenorphine (DPN) positron emission tomography (PET). Patients with de-afferentation pain (phantom limb pain or Anaesthesia Dolorosa (n=5)) who obtained long-lasting analgesic benefit from DBS were recruited. [11C]DPN and [15O]water PET scanning was performed in consecutive sessions; first without, and then with PAG stimulation. The regional cerebral tracer distribution and kinetics were quantified for the whole brain and brainstem. Analysis was performed on a voxel-wise basis using statistical parametric mapping (SPM) and also within brainstem regions of interest and correlated to the DBS-induced improvement in pain score and mood. Brain-wide analysis identified a single cluster of reduced [11C]DPN binding (15.5% reduction) in the caudal, dorsal PAG following DBS from effective electrodes located in rostral dorsal/lateral PAG. There was no evidence for an accompanying focal change in blood flow within the PAG. No correlation was found between the change in PAG [11C]DPN binding and the analgesic effect or the effect on mood (POMSSV) of DBS. The analgesic effect of DBS in these subjects was not altered by systemic administration of the opioid antagonist naloxone (400 ug). These findings indicate that DBS of the PAG does indeed release endogenous opioid peptides focally within the midbrain of these neuropathic pain patients but we are unable to further resolve the question of whether this release is responsible for the observed analgesic benefit. Sequential opioid-PET imaging study of deafferentation pain patients. All obtained analgesic benefit from deep brain stimulators (DBS) in periaqueductal grey (PAG). PET imaging with diprenorphine showed DBS reduced binding of the radioligand in the PAG. Change in binding consistent with DBS-evoked release of endogenous opioids.
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Affiliation(s)
- Hugh Sims-Williams
- School of Physiology, Pharmacology & Neuroscience, Medical Sciences Building, University of Bristol, Bristol BS8 1TD, United Kingdom; Department of Neurosurgery & Pain Medicine, North Bristol NHS Trust, Bristol BS10 5NB, United Kingdom
| | - Julian C Matthews
- Imaging Sciences, MAHSC, University of Manchester, M20 3LJ, United Kingdom
| | - Peter S Talbot
- Imaging Sciences, MAHSC, University of Manchester, M20 3LJ, United Kingdom
| | - Sarah Love-Jones
- Department of Neurosurgery & Pain Medicine, North Bristol NHS Trust, Bristol BS10 5NB, United Kingdom
| | - Jonathan Cw Brooks
- Clinical Research Imaging Centre (CRiCBristol), University of Bristol, Bristol BS2 8DZ, United Kingdom
| | - Nikunj K Patel
- Department of Neurosurgery & Pain Medicine, North Bristol NHS Trust, Bristol BS10 5NB, United Kingdom
| | - Anthony E Pickering
- School of Physiology, Pharmacology & Neuroscience, Medical Sciences Building, University of Bristol, Bristol BS8 1TD, United Kingdom; Department of Anaesthesia, University Hospitals Bristol, Bristol BS2 8HW, United Kingdom.
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24
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Abstract
The aim of this study was to determine the efficacy of deep brain stimulation (DBS) in the treatment of various types of intractable head and facial pains. Seven patients underwent the insertion of DBS electrodes into the periventricular/periaqueductal grey region and/or the ventroposteromedial nucleus of the thalamus. We have shown statistically significant improvement in pain scores (visual analogue and McGill's) as well as health-related quality of life (SF-36v2) following surgery. There is wide variability in patient outcomes but, overall, DBS can be an effective treatment. Our results are compared with the published literature and electrode position for effective analgesia is discussed.
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Affiliation(s)
- A L Green
- Department of Neurosurgery, Radcliffe Infirmary, and University of Oxford, Department of Physiology, UK.
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25
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Sims-Williams HP, Javed S, Pickering AE, Patel NK. Characterising the Analgesic Effect of Different Targets for Deep Brain Stimulation in Trigeminal Anaesthesia Dolorosa. Stereotact Funct Neurosurg 2016; 94:174-81. [PMID: 27322524 PMCID: PMC5079070 DOI: 10.1159/000446608] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 05/04/2016] [Indexed: 12/03/2022]
Abstract
Background Several deep brain stimulation (DBS) targets have been explored for the alleviation of trigeminal anaesthesia dolorosa. We aimed to characterise the analgesia produced from the periaqueductal grey (PAG) and centromedian-parafascicular (CmPf) nucleus using a within-subject design. Method We report a case series of 3 subjects implanted with PAG and CmPf DBS systems for the treatment of anaesthesia dolorosa. At follow-up, testing of onset and offset times, magnitude, and thermal and mechanical sensitivity was performed. Results The mean pain score of the cohort was acutely reduced by 56% (p < 0.05) with PAG and 67% (p < 0.01) with CmPf stimulation at mean time intervals of 38 and 16 min, respectively. The onset time was 12.5 min (p < 0.05) for PAG stimulation and 2.5 min (p < 0.01) for CmPf. The offset time was 2.5 min (p < 0.05) for PAG and 12.5 min (p < 0.01) for CmPf. The two targets were effective at different stimulation frequencies and were not antagonistic in effect. Conclusion The mechanisms by which stimulation at these two targets produces analgesia are likely to be different. Certain pain qualities may respond more favourably to specific targets. Knowledge of onset and offset times for the targets can guide optimisation of stimulation settings. The use of more than one stimulation target may be beneficial and should be considered in anaesthesia dolorosa patients.
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Jagid J, Madhavan K, Bregy A, Desai M, Ruiz A, Quencer R, Landy HJ. Deep brain stimulation complicated by bilateral large cystic cavitation around the leads in a patient with Parkinson's disease. BMJ Case Rep 2015; 2015:bcr-2015-211470. [PMID: 26475878 DOI: 10.1136/bcr-2015-211470] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Deep brain stimulation (DBS) is an approved and effective therapy for patients suffering from advanced Parkinson's disease (PD). Several clinical trials have indicated significant motor function improvement in patients undergoing subthalamic nucleus stimulation. This therapy is, rarely, associated with complications, mostly related to infections, seizures or stimulation-induced side effects. We report a case of a 71-year-old man with a 10-year history of PD who underwent bilateral placement of subthalamic nucleus DBS. As a complication, the patient showed subjective postoperative cognitive decline, and subsequent MRI showed peri-lead oedema, which progressed to large cystic cavitation around the leads without indication of infection. The patient received steroid therapy and the cavitations regressed without surgical intervention.
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Affiliation(s)
- Jonathan Jagid
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Karthik Madhavan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Amade Bregy
- Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mehul Desai
- Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Armando Ruiz
- Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Robert Quencer
- Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Howard J Landy
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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27
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Abstract
Deep brain stimulation (DBS) is a commonly performed procedure and has been used for the treatment of chronic pain since the early 1970s. A review of the literature was performed utilizing the PubMed database evaluating the use of DBS in the treatment of various pain syndromes. Literature over the last 30 years was included with a focus on those articles in the last 10 years dealing with pain conditions with the highest success as well as the targets utilized for treatment. DBS carries favorable results for the treatment of chronic pain, especially when other methods have not been successful such as medications, conservative measures, and extracranial procedures. Various chronic pain conditions reported in the literature respond to DBS including failed back surgery syndrome (FBSS), phantom limb pain, and peripheral neuropathic pain with a higher response rate for those with nociceptive pain compared to neuropathic pain. Cephaligias have promising results, with cluster headaches carrying the best success rates. DBS plays a role in the treatment of chronic pain conditions. Although considered investigational in the USA, it carries promising success rates in a recalcitrant patient population.
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Keifer OP, Riley JP, Boulis NM. Deep brain stimulation for chronic pain: intracranial targets, clinical outcomes, and trial design considerations. Neurosurg Clin N Am 2015; 25:671-92. [PMID: 25240656 DOI: 10.1016/j.nec.2014.07.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
For over half a century, neurosurgeons have attempted to treat pain from a diversity of causes using acute and chronic intracranial stimulation. Targets of stimulation have included the sensory thalamus, periventricular and periaqueductal gray, the septum, the internal capsule, the motor cortex, posterior hypothalamus, and more recently, the anterior cingulate cortex. The current work focuses on presenting and evaluating the evidence for the efficacy of these targets in a historical context while also highlighting the major challenges to having a double-blind placebo-controlled clinical trial. Considerations for pain research in general and use of intracranial targets specifically are included.
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Affiliation(s)
- Orion Paul Keifer
- MD/PhD Program, School of Medicine, Emory University, Suite 375-B, 1648 Pierce Drive, Atlanta, GA 30322, USA
| | - Jonathan P Riley
- Department of Neurosurgery, Emory University, 1365-B Clifton Road Northeast, Suite 2200, Atlanta, GA 30322, USA
| | - Nicholas M Boulis
- Department of Neurosurgery, Emory University, 1365-B Clifton Road Northeast, Suite 2200, Atlanta, GA 30322, USA.
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Deer TR, Mekhail N, Petersen E, Krames E, Staats P, Pope J, Saweris Y, Lad SP, Diwan S, Falowski S, Feler C, Slavin K, Narouze S, Merabet L, Buvanendran A, Fregni F, Wellington J, Levy RM. The appropriate use of neurostimulation: stimulation of the intracranial and extracranial space and head for chronic pain. Neuromodulation Appropriateness Consensus Committee. Neuromodulation 2015; 17:551-70; discussion 570. [PMID: 25112890 DOI: 10.1111/ner.12215] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 04/17/2014] [Accepted: 05/13/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The International Neuromodulation Society (INS) has identified a need for evaluation and analysis of the practice of neurostimulation of the brain and extracranial nerves of the head to treat chronic pain. METHODS The INS board of directors chose an expert panel, the Neuromodulation Appropriateness Consensus Committee (NACC), to evaluate the peer-reviewed literature, current research, and clinical experience and to give guidance for the appropriate use of these methods. The literature searches involved key word searches in PubMed, EMBASE, and Google Scholar dated 1970-2013, which were graded and evaluated by the authors. RESULTS The NACC found that evidence supports extracranial stimulation for facial pain, migraine, and scalp pain but is limited for intracranial neuromodulation. High cervical spinal cord stimulation is an evolving option for facial pain. Intracranial neurostimulation may be an excellent option to treat diseases of the nervous system, such as tremor and Parkinson's disease, and in the future, potentially Alzheimer's disease and traumatic brain injury, but current use of intracranial stimulation for pain should be seen as investigational. CONCLUSIONS The NACC concludes that extracranial nerve stimulation should be considered in the algorithmic treatment of migraine and other disorders of the head. We should strive to perfect targets outside the cranium when treating pain, if at all possible.
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Abstract
Chronic pain impairs the quality of life for millions of individuals and therefore presents a serious ongoing challenge to clinicians and researchers. Debilitating chronic pain syndromes cost the US economy more than $600 billion per year. This article provides an overview of the epidemiology, clinical presentation, and treatment outcomes for craniofacial, spinal, and peripheral neurologic pain syndromes. Although the authors recognize that the diagnosis and treatment of the chronic forms of neuropathic pain syndromes represent a clinical challenge, there is an urgent need for standardized classification systems, improved epidemiologic data, and reliable treatment outcomes data.
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31
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Tian S, Nick S, Wu H. Phantom limb pain: A review of evidence-based treatment options. World J Anesthesiol 2014; 3:146-153. [DOI: 10.5313/wja.v3.i2.146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 01/11/2014] [Accepted: 03/12/2014] [Indexed: 02/06/2023] Open
Abstract
Phantom limb pain (PLP) is not uncommon after amputation. PLP is described as a painful sensation perceived in the missing limb. Despite of its complicated pathophysiology, high prevalence of PLP has been associated with poor health-related quality of life, low daily activity and short walking distances. A prompt and effective management of PLP is essential in caring for the amputee population. Current treatments including physical therapy, psychotherapy, medications, and interventions have been used with limited success. In this review, we provided an updated and evidence-based review of treatment options for PLP.
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De Ridder D, Vanneste S, Freeman W. The Bayesian brain: Phantom percepts resolve sensory uncertainty. Neurosci Biobehav Rev 2014; 44:4-15. [PMID: 22516669 DOI: 10.1016/j.neubiorev.2012.04.001] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 03/13/2012] [Accepted: 04/01/2012] [Indexed: 12/23/2022]
Affiliation(s)
- Dirk De Ridder
- Brai(2)n, TRI & Department of Neurosurgery, University Hospital Antwerp, Belgium.
| | - Sven Vanneste
- Brai(2)n, TRI & Department of Neurosurgery, University Hospital Antwerp, Belgium; Department of Translational Neuroscience, Faculty of Medicine, University of Antwerp, Belgium
| | - Walter Freeman
- Department of Molecular & Cell Biology, University of California at Berkeley, USA
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33
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Abstract
Deep brain stimulation (DBS) is a neurosurgical intervention the efficacy, safety, and utility of which are established in the treatment of Parkinson's disease. For the treatment of chronic, neuropathic pain refractory to medical therapies, many prospective case series have been reported, but few have published findings from patients treated with current standards of neuroimaging and stimulator technology over the last decade . We summarize the history, science, selection, assessment, surgery, programming, and personal clinical experience of DBS of the ventral posterior thalamus, periventricular/periaqueductal gray matter, and latterly rostral anterior cingulate cortex (Cg24) in 113 patients treated at 2 centers (John Radcliffe, Oxford, UK, and Hospital de São João, Porto, Portugal) over 13 years. Several experienced centers continue DBS for chronic pain, with success in selected patients, in particular those with pain after amputation, brachial plexus injury, stroke, and cephalalgias including anesthesia dolorosa. Other successes include pain after multiple sclerosis and spine injury. Somatotopic coverage during awake surgery is important in our technique, with cingulate DBS under general anesthesia considered for whole or hemibody pain, or after unsuccessful DBS of other targets. Findings discussed from neuroimaging modalities, invasive neurophysiological insights from local field potential recording, and autonomic assessments may translate into improved patient selection and enhanced efficacy, encouraging larger clinical trials.
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Affiliation(s)
- Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Department of Neurological Surgery and Nuffield Department of Surgical Sciences, Oxford University, John Radcliffe Hospital, Oxford, OX3 9DU, UK,
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34
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Griffin SC, Tsao JW. A mechanism-based classification of phantom limb pain. Pain 2014; 155:2236-2242. [PMID: 24857794 DOI: 10.1016/j.pain.2014.05.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 04/18/2014] [Accepted: 05/15/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Sarah C Griffin
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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35
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Pereira EAC, Boccard SG, Linhares P, Chamadoira C, Rosas MJ, Abreu P, Rebelo V, Vaz R, Aziz TZ. Thalamic deep brain stimulation for neuropathic pain after amputation or brachial plexus avulsion. Neurosurg Focus 2014; 35:E7. [PMID: 23991820 DOI: 10.3171/2013.7.focus1346] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Fifteen hundred patients have received deep brain stimulation (DBS) to treat neuropathic pain refractory to pharmacotherapy over the last half-century, but few during the last decade. Deep brain stimulation for neuropathic pain has shown variable outcomes and gained consensus approval in Europe but not the US. This study prospectively evaluated the efficacy at 1 year of DBS for phantom limb pain after amputation, and deafferentation pain after brachial plexus avulsion (BPA), in a single-center case series. METHODS Patient-reported outcome measures were collated before and after surgery, using a visual analog scale (VAS) score, 36-Item Short-Form Health Survey (SF-36), Brief Pain Inventory (BPI), and University of Washington Neuropathic Pain Score (UWNPS). RESULTS Twelve patients were treated over 29 months, receiving contralateral, ventroposterolateral sensory thalamic DBS. Five patients were amputees and 7 had BPAs, all from traumas. A postoperative trial of externalized DBS failed in 1 patient with BPA. Eleven patients proceeded to implantation and gained improvement in pain scores at 12 months. No surgical complications or stimulation side effects were noted. In the amputation group, after 12 months the mean VAS score improved by 90.0% ± 10.0% (p = 0.001), SF-36 by 57.5% ± 97.9% (p = 0.127), UWNPS by 80.4% ± 12.7% (p < 0.001), and BPI by 79.9% ± 14.7% (p < 0.001). In the BPA group, after 12 months the mean VAS score improved by 52.7% ± 30.2% (p < 0.001), SF-36 by 15.6% ± 30.5% (p = 1.000), UWNPS by 26.2% ± 40.8% (p = 0.399), and BPI by 38.4% ± 41.7% (p = 0.018). Mean DBS parameters were 2.5 V, 213 microseconds, and 25 Hz. CONCLUSIONS Deep brain stimulation demonstrated efficacy at 1 year for chronic neuropathic pain after traumatic amputation and BPA. Clinical trials that retain patients in long-term follow-up are desirable to confirm findings from prospectively assessed case series.
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Affiliation(s)
- Erlick A C Pereira
- Department of Neurosurgery and Nuffield Department of Surgery, Oxford University Hospitals, Oxford, United Kingdom.
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36
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Roldan CJ, Lesnick JS. Phantom organ pain syndrome, a ghostly visitor to the ED. Am J Emerg Med 2014; 32:1152.e1-2. [PMID: 24680011 DOI: 10.1016/j.ajem.2014.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022] Open
Affiliation(s)
- Carlos J Roldan
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Joseph S Lesnick
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA.
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37
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Pereira EAC, Green AL, Nandi D, Aziz TZ. Deep brain stimulation: indications and evidence. Expert Rev Med Devices 2014; 4:591-603. [PMID: 17850194 DOI: 10.1586/17434440.4.5.591] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Deep brain stimulation is a minimally invasive targeted neurosurgical intervention that enables structures deep in the brain to be stimulated electrically by an implanted pacemaker. It has become the treatment of choice for Parkinson's disease, refractory to, or complicated by, drug therapy. Its efficacy has been demonstrated robustly by randomized, controlled clinical trials, with multiple novel brain targets having been discovered in the last 20 years. Multifarious clinical indications for deep brain stimulation now exist, including dystonia and tremor in movement disorders; depression, obsessive-compulsive disorder and Tourette's syndrome in psychiatry; epilepsy, cluster headache and chronic pain, including pain from stroke, amputation, trigeminal neuralgia and multiple sclerosis. Current research argues for novel indications, including hypertension and orthostatic hypotension. The development, principles, indications and effectiveness of the technique are reviewed here. While deep brain stimulation is a standard and widely accepted treatment for Parkinson's disease after 20 years of experience, in chronic pain it remains restricted to a handful of experienced, specialist centers willing to publish outcomes despite its use for over 50 years. Reasons are reviewed and novel approaches to appraising clinical evidence in functional neurosurgery are suggested.
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Affiliation(s)
- Erlick A C Pereira
- Oxford Functional Neurosurgery, Nuffield Department of Surgery and Department of Neurological Surgery, The West Wing, The John Radcliffe Hospital, Oxford, OX3 9DU, UK.
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38
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Gray AM, Pounds-Cornish E, Eccles FJR, Aziz TZ, Green AL, Scott RB. Deep brain stimulation as a treatment for neuropathic pain: a longitudinal study addressing neuropsychological outcomes. THE JOURNAL OF PAIN 2013; 15:283-92. [PMID: 24333399 DOI: 10.1016/j.jpain.2013.11.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 10/21/2013] [Accepted: 11/14/2013] [Indexed: 11/30/2022]
Abstract
UNLABELLED Deep brain stimulation (DBS) of the periventricular/periaqueductal gray area and sensory thalamus can reduce pain intensity in patients with neuropathic pain. However, little is known about its impact on quality of life, emotional well-being, and cognition. This study followed up 18 patients who had received DBS for neuropathic pain. Each participant had previously undergone psychometric evaluation of each of the above areas as part of a routine presurgical neuropsychological assessment. Commensurate measures were employed at a follow-up assessment at least 6 months postsurgery. DBS significantly improved mood, anxiety, and aspects of quality of life. Improvements correlated with reduced pain severity. However, the sample continued to show impairments in most areas when compared against normative data published on nonclinical samples. There was little change in general cognitive functioning, aside from deterioration in spatial working memory. However, improvements in pain severity were associated with less improvement (and even deterioration) on measures of executive cognitive functioning. Improvements in emotional well-being also were correlated with changes in cognition. These results suggest that DBS of the periventricular/periaqueductal gray and/or sensory thalamus improves quality of life and emotional well-being in sufferers, although there is some indication of executive dysfunction, particularly among those reporting greatest pain alleviation. PERSPECTIVE This article examines the neuropsychological outcomes of DBS surgery as a treatment for neuropathic pain. This intervention was found to improve pain severity, emotional well-being, and quality of life, although such benefits may be accompanied by reduced ability on tasks measuring executive functioning.
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Affiliation(s)
- Alan M Gray
- Headwise Ltd, Birmingham, England, United Kingdom; Clinical Psychology Unit, University of Sheffield, Sheffield, England, United Kingdom.
| | - Elizabeth Pounds-Cornish
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, Buckinghamshire, England
| | - Fiona J R Eccles
- Division of Health Research, Lancaster University, Lancaster, England, United Kingdom
| | - Tipu Z Aziz
- Oxford Functional Neurosurgery and Experimental Neurology, John Radcliffe Hospital, Oxford, England, United Kingdom
| | - Alexander L Green
- Oxford Functional Neurosurgery and Experimental Neurology, John Radcliffe Hospital, Oxford, England, United Kingdom
| | - Richard B Scott
- Oxford Functional Neurosurgery and Experimental Neurology, John Radcliffe Hospital, Oxford, England, United Kingdom
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Boccard SGJ, Pereira EAC, Moir L, Aziz TZ, Green AL. Long-term outcomes of deep brain stimulation for neuropathic pain. Neurosurgery 2013; 72:221-30; discussion 231. [PMID: 23149975 DOI: 10.1227/neu.0b013e31827b97d6] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) to treat neuropathic pain refractory to pharmacotherapy has reported variable outcomes and has gained United Kingdom but not USA regulatory approval. OBJECTIVE To prospectively assess long-term efficacy of DBS for chronic neuropathic pain in a single-center case series. METHODS Patient reported outcome measures were collated before and after surgery, using a visual analog score, short-form 36-question quality-of-life survey, McGill pain questionnaire, and EuroQol-5D questionnaires (EQ-5D and health state). RESULTS One hundred ninety-seven patients were referred over 12 years, of whom 85 received DBS for various etiologies: 9 amputees, 7 brachial plexus injuries, 31 after stroke, 13 with spinal pathology, 15 with head and face pain, and 10 miscellaneous. Mean age at surgery was 52 years, and mean follow-up was 19.6 months. Contralateral DBS targeted the periventricular gray area (n = 33), the ventral posterior nuclei of the thalamus (n = 15), or both targets (n = 37). Almost 70% (69.4%) of patients retained implants 6 months after surgery. Thirty-nine of 59 (66%) of those implanted gained benefit and efficacy varied by etiology, improving outcomes in 89% after amputation and 70% after stroke. In this cohort, >30% improvements sustained in visual analog score, McGill pain questionnaire, short-form 36-question quality-of-life survey, and EuroQol-5D questionnaire were observed in 15 patients with >42 months of follow-up, with several outcome measures improving from those assessed at 1 year. CONCLUSION DBS for pain has long-term efficacy for select etiologies. Clinical trials retaining patients in long-term follow-up are desirable to confirm findings from prospectively assessed case series.
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Affiliation(s)
- Sandra G J Boccard
- Department of Physiology, Anatomy and Genetics, University of Oxford, United Kingdom.
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40
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Kim J, Eun Lee S, Sik Min K, Jung HH, Lee JE, Kim SJ, Chang JW. Ventral posterolateral deep brain stimulation treatment for neuropathic pain shortens pain response after cold stimuli. J Neurosci Res 2013; 91:997-1004. [PMID: 23606542 DOI: 10.1002/jnr.23222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Revised: 11/26/2013] [Accepted: 02/22/2013] [Indexed: 11/07/2022]
Abstract
Neuropathic pain is often severe. Deep brain stimulation (DBS) is a treatment method for neuropathic pain, but its mechanism of action remains unclear. Patients with neuropathic pain are affected by various stimulations, such as mechanical and cold stimuli, but studies of cold allodynia showed the associated pain to be less than that caused by mechanical stimuli. This study focused on the effects of DBS on cold allodynia in rats. To observe the effects of DBS, we established three groups: a normal group (normal), a neuropathic pain group (pain), and a DBS with neuropathic pain group (DBS). The stimulation target was the ventral posterolateral nucleus (VPL). We observed differences in the degree of cold allodynia elicited between a conventional method that measured the number of pain responses and our altered novel method that measured the duration of pain responses. Cold allodynia after DBS did not differ when conventional analysis was applied, but the pain response duration was decreased. We suggest that VPL DBS was partially effective in cold allodynia, implicating complex pathways of pain signaling.
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Affiliation(s)
- Jinhyung Kim
- Brain Korea 21 Project for Medical Science and Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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41
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Abstract
Postamputation pain (PAP) is highly prevalent after limb amputation but remains an extremely challenging pain condition to treat. A large part of its intractability stems from the myriad pathophysiological mechanisms. A state-of-art understanding of the pathophysiologic basis underlying postamputation phenomena can be broadly categorized in terms of supraspinal, spinal, and peripheral mechanisms. Supraspinal mechanisms involve somatosensory cortical reorganization of the area representing the deafferentated limb and are predominant in phantom limb pain and phantom sensations. Spinal reorganization in the dorsal horn occurs after deafferentataion from a peripheral nerve injury. Peripherally, axonal nerve damage initiates inflammation, regenerative sprouting, and increased "ectopic" afferent input which is thought by many to be the predominant mechanism involved in residual limb pain or neuroma pain, but may also contribute to phantom phenomena. To optimize treatment outcomes, therapy should be individually tailored and mechanism based. Treatment modalities include injection therapy, pharmacotherapy, complementary and alternative therapy, surgical therapy, and interventions aimed at prevention. Unfortunately, there is a lack of high quality clinical trials to support most of these treatments. Most of the randomized controlled trials in PAP have evaluated medications, with a trend for short-term Efficacy noted for ketamine and opioids. Evidence for peripheral injection therapy with botulinum toxin and pulsed radiofrequency for residual limb pain is limited to very small trials and case series. Mirror therapy is a safe and cost-effective alternative treatment modality for PAP. Neuromodulation using implanted motor cortex stimulation has shown a trend toward effectiveness for refractory phantom limb pain, though the evidence is largely anecdotal. Studies that aim to prevent PA P using epidural and perineural catheters have yielded inconsistent results, though there may be some benefit for epidural prevention when the infusions are started more than 24 hours preoperatively and compared with nonoptimized alternatives. Further investigation into the mechanisms responsible for and the factors associated with the development of PAP is needed to provide an evidence-based foundation to guide current and future treatment approaches.
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Affiliation(s)
- Eugene Hsu
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Steven P Cohen
- Johns Hopkins School of Medicine and Uniformed Services, University of the Health Sciences, Bethesda, MD, USA
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42
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Mannix SM, O'Sullivan C, Kelly GA. Acupuncture for Managing Phantom-Limb Syndrome: A Systematic Review. Med Acupunct 2013. [DOI: 10.1089/acu.2012.0928] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Sharon M. Mannix
- Health Sciences Centre, University College Dublin, Belfield, Dublin, Ireland
| | - Cliona O'Sullivan
- Health Sciences Centre, University College Dublin, Belfield, Dublin, Ireland
| | - Gráinne A. Kelly
- Health Sciences Centre, University College Dublin, Belfield, Dublin, Ireland
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43
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Abstract
Deep brain stimulation (DBS) is a neurosurgical intervention whose efficacy, safety, and utility have been shown in the treatment of movement disorders. For the treatment of chronic pain refractory to medical therapies, many prospective case series have been reported, but few have published findings from patients treated during the past decade using current standards of neuroimaging and stimulator technology. We summarize the history, science, selection, assessment, surgery, and personal clinical experience of DBS of the ventral posterior thalamus, periventricular/periaqueductal gray matter, and, latterly, the rostral anterior cingulate cortex (Cg24) in 100 patients treated now at two centers (John Radcliffe Hospital, Oxford, UK, and Hospital de São João, Porto, Portugal) over 12 years. Several experienced centers continue DBS for chronic pain with success in selected patients, in particular those with pain after amputation, brachial plexus injury, stroke, and cephalalgias including anesthesia dolorosa. Other successes include pain after multiple sclerosis and spine injury. Somatotopic coverage during awake surgery is important in our technique, with cingulate DBS considered for whole-body pain or after unsuccessful DBS of other targets. Findings discussed from neuroimaging modalities, invasive neurophysiological insights from local field potential recording, and autonomic assessments may translate into improved patient selection and enhanced efficacy, encouraging larger clinical trials.
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Affiliation(s)
- Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Department of Neurological Surgery and Nuffield Department of Surgical Sciences, Oxford University, John Radcliffe Hospital, Oxford, UK
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44
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Use of Yamamoto New Scalp Acupuncture for Treatment of Chronic, Severe Phantom Leg Pain. Med Acupunct 2012. [DOI: 10.1089/acu.2011.0854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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45
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Plow EB, Pascual-Leone A, Machado A. Brain stimulation in the treatment of chronic neuropathic and non-cancerous pain. THE JOURNAL OF PAIN 2012; 13:411-24. [PMID: 22484179 DOI: 10.1016/j.jpain.2012.02.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 12/27/2011] [Accepted: 02/02/2012] [Indexed: 01/16/2023]
Abstract
UNLABELLED Chronic neuropathic pain is one of the most prevalent and debilitating disorders. Conventional medical management, however, remains frustrating for both patients and clinicians owing to poor specificity of pharmacotherapy, delayed onset of analgesia and extensive side effects. Neuromodulation presents as a promising alternative, or at least an adjunct, as it is more specific in inducing analgesia without associated risks of pharmacotherapy. Here, we discuss common clinical and investigational methods of neuromodulation. Compared to clinical spinal cord stimulation (SCS), investigational techniques of cerebral neuromodulation, both invasive (deep brain stimulation [DBS] and motor cortical stimulation [MCS]) and noninvasive (repetitive transcranial magnetic stimulation [rTMS] and transcranial direct current stimulation [tDCS]), may be more advantageous. By adaptively targeting the multidimensional experience of pain, subtended by integrative pain circuitry in the brain, including somatosensory and thalamocortical, limbic and cognitive, cerebral methods may modulate the sensory-discriminative, affective-emotional and evaluative-cognitive spheres of the pain neuromatrix. Despite promise, the current state of results alludes to the possibility that cerebral neuromodulation has thus far not been effective in producing analgesia as intended in patients with chronic pain disorders. These techniques, thus, remain investigational and off-label. We discuss issues implicated in inadequate efficacy, variability of responsiveness, and poor retention of benefit, while recommending design and conceptual refinements for future trials of cerebral neuromodulation in management of chronic neuropathic pain. PERSPECTIVE This critical review focuses on factors contributing to poor therapeutic utility of invasive and noninvasive brain stimulation in the treatment of chronic neuropathic and pain of noncancerous origin. Through key clinical trial design and conceptual refinements, retention and consistency of response may be improved, potentially facilitating the widespread clinical applicability of such approaches.
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Affiliation(s)
- Ela B Plow
- Department of Biomedical Engineering, Lerner Research Institute, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Bókkon I, Till A, Grass F, Erdöfi Szabó A. Phantom pain reduction by low-frequency and low-intensity electromagnetic fields. Electromagn Biol Med 2012; 30:115-27. [PMID: 21861690 DOI: 10.3109/15368378.2011.596246] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Although various treatments have been presented for phantom pain, there is little proof supporting the benefits of pharmacological treatments, surgery or interventional techniques, electroconvulsive therapy, electrical nerve stimulation, far infrared ray therapy, psychological therapies, etc. Here, we report the preliminary results for phantom pain reduction by low-frequency and intensity electromagnetic fields under clinical circumstances. Our method is called as Electromagnetic-Own-Signal-Treatment (EMOST). Fifteen people with phantom limb pain participated. The patients were treated using a pre-programmed, six sessions. Pain intensity was quantified upon admission using a 0-10 verbal numerical rating scale. Most of the patients (n = 10) reported a marked reduction in the intensity of phantom limb pain. Several patients also reported about improvement in their sleep and mood quality, or a reduction in the frequency of phantom pain after the treatments. No improvements in the reduction of phantom limb pain or sleep and mood improvement were reported in the control group (n = 5). Our nonlinear electromagnetic EMOST method may be a possible therapeutic application in the reduction of phantom limb pain. Here, we also suggest that some of the possible effects of the EMOST may be achieved via the redox balance of the body and redox-related neural plasticity.
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Affiliation(s)
- István Bókkon
- Doctoral School of Pharmaceutical and Pharmacological Sciences, Semmelweis University , Budapest , Hungary.
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Nguyen JP, Nizard J, Keravel Y, Lefaucheur JP. Invasive brain stimulation for the treatment of neuropathic pain. Nat Rev Neurol 2011; 7:699-709. [DOI: 10.1038/nrneurol.2011.138] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Subedi B, Grossberg GT. Phantom limb pain: mechanisms and treatment approaches. PAIN RESEARCH AND TREATMENT 2011; 2011:864605. [PMID: 22110933 PMCID: PMC3198614 DOI: 10.1155/2011/864605] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 07/01/2011] [Indexed: 12/31/2022]
Abstract
The vast amount of research over the past decades has significantly added to our knowledge of phantom limb pain. Multiple factors including site of amputation or presence of preamputation pain have been found to have a positive correlation with the development of phantom limb pain. The paradigms of proposed mechanisms have shifted over the past years from the psychogenic theory to peripheral and central neural changes involving cortical reorganization. More recently, the role of mirror neurons in the brain has been proposed in the generation of phantom pain. A wide variety of treatment approaches have been employed, but mechanism-based specific treatment guidelines are yet to evolve. Phantom limb pain is considered a neuropathic pain, and most treatment recommendations are based on recommendations for neuropathic pain syndromes. Mirror therapy, a relatively recently proposed therapy for phantom limb pain, has mixed results in randomized controlled trials. Most successful treatment outcomes include multidisciplinary measures. This paper attempts to review and summarize recent research relative to the proposed mechanisms of and treatments for phantom limb pain.
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Affiliation(s)
- Bishnu Subedi
- Department of Neurology & Psychiatry, Saint Louis University School of Medicine, St. Louis, MO 63104, USA
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Abstract
Deep brain stimulation (DBS) is an important treatment option for neuropathic pain. DBS has a considerable history, and it can be used successfully for a wide number of pain syndromes. Epidural motor cortex stimulation (MCS) also is a treatment option for neuropathic pain. Less invasive than DBS, MCS has been rapidly adopted and studied since first described in 1991. A growing body of literature supports the use of MCS for facial pain, though further study to better define the mechanism of action and the most appropriate patient populations is ongoing.
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