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Dorrian RM, Leonard AV, Lauto A. Millimetric devices for nerve stimulation: a promising path towards miniaturization. Neural Regen Res 2024; 19:1702-1706. [PMID: 38103235 PMCID: PMC10960286 DOI: 10.4103/1673-5374.389627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/21/2023] [Accepted: 10/19/2023] [Indexed: 12/18/2023] Open
Abstract
Nerve stimulation is a rapidly developing field, demonstrating positive outcomes across several conditions. Despite potential benefits, current nerve stimulation devices are large, complicated, and are powered via implanted pulse generators. These factors necessitate invasive surgical implantation and limit potential applications. Reducing nerve stimulation devices to millimetric sizes would make these interventions less invasive and facilitate broader therapeutic applications. However, device miniaturization presents a serious engineering challenge. This review presents significant advancements from several groups that have overcome this challenge and developed millimetric-sized nerve stimulation devices. These are based on antennas, mini-coils, magneto-electric and opto-electronic materials, or receive ultrasound power. We highlight key design elements, findings from pilot studies, and present several considerations for future applications of these devices.
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Affiliation(s)
- Ryan M. Dorrian
- Spinal Cord Injury Research Group, School of Biomedicine, The University of Adelaide, Adelaide, SA, Australia
| | - Anna V. Leonard
- Spinal Cord Injury Research Group, School of Biomedicine, The University of Adelaide, Adelaide, SA, Australia
| | - Antonio Lauto
- School of Science, Western Sydney University, Penrith, NSW, Australia
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Kelly TD, Pazzol ML, Rahimi Darabad R. Peripheral Nerve Stimulation in Chronic Knee Pain: A Case Series. Cureus 2023; 15:e50127. [PMID: 38186428 PMCID: PMC10771261 DOI: 10.7759/cureus.50127] [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] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
Introduction Chronic knee pain is increasing in prevalence and is associated with substantial limitations in functional mobility. Peripheral nerve stimulation (PNS) has been increasingly used to treat various chronic pain conditions. However, there is a paucity of research exploring the potential therapeutic benefit of PNS for chronic knee pain. Methods This research is a retrospective case series of all patients who received PNS for the treatment of chronic knee pain performed at a single-center academic medical institution between March 2021 and June 2022. The primary outcome was percent pain reduction six months after implantation. Outcome data was obtained via chart review and phone calls to patients. Secondary outcomes included percent pain reduction two weeks and two months after implantation and adverse medical events related to the procedure and nerve stimulation. Results Fourteen individual patients received PNS for chronic knee pain during the study period. Three of these patients received bilateral PNS for a total of 17 cases. The mean percent pain reduction six months after implantation was 52% (SD=28.2) (N=12). A total of 75.0% of participants (9/12) reported ≥50% reductions in pain six months after implantation. No adverse events were reported relating to the implantation procedure and/or nerve stimulation. Conclusion PNS is a safe and efficacious treatment modality for chronic knee pain with demonstrated long-term benefit. Further research should clarify patient factors associated with improved treatment response.
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Affiliation(s)
- Timothy D Kelly
- Department of Emergency Medicine Residency, Indiana University School of Medicine, Indianapolis, USA
| | - Michael L Pazzol
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, USA
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Allen CB, Williamson TK, Norwood SM, Gupta A. Do Electrical Stimulation Devices Reduce Pain and Improve Function?-A Comparative Review. Pain Ther 2023; 12:1339-1354. [PMID: 37751060 PMCID: PMC10616008 DOI: 10.1007/s40122-023-00554-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 08/30/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Multiple forms of electrical stimulation (ES) potentially offer widely varying clinical benefits. Diminished function commonly associated with acute and chronic pain lessens productivity and increases medical costs. This review aims to compare the relative effects of various forms of ES on functional and pain outcomes. METHODS A comprehensive literature search focused on studies of commonly marketed forms of ES used for treatment of pain and improvement of function. Peer-reviewed manuscripts were categorized as "Important" (systematic review or meta-analysis, randomized controlled trial, observational cohort study) and "Minor" (retrospective case series, case report, opinion review) for each identified form of ES. RESULTS AND DISCUSSION Varying forms of ES have markedly different technical parameters, applications, and indications, based on clinically meaningful impact on pain perception, function improvement, and medication reduction. Despite being around for decades, there is limited quality evidence for most forms of ES, although there are several notable exceptions for treatment of specific indications. Neuromuscular electrical stimulation (NMES) has well-demonstrated beneficial effects for rehabilitation of selective spinal cord injured (SCI), post-stroke, and debilitated inpatients. Functional electrical stimulation (FES) has similarly shown effectiveness in rehabilitation of some stroke, SCI, and foot drop outpatients. H-Wave® device stimulation (HWDS) has moderate supportive evidence for treatment of acute and refractory chronic pain, consistently demonstrating improvements in function and pain measures across diverse populations. Interestingly, transcutaneous electrical nerve stimulation (TENS), the most widely used form of ES, demonstrated insignificant or very low levels of pain and functional improvement. CONCLUSION Ten of 13 reviewed forms of ES have only limited quality evidence for clinically significant reduction of pain or improvement of function across different patient populations. NMES and FES have reasonably demonstrated effectiveness, albeit for specific clinical rehabilitation indications. HWDS was associated with the most clinically significant outcomes, in terms of functional improvement combined with reduction of pain and medication use. More rigorous long-term clinical trials are needed to further validate appropriate use and specific indications for most forms of ES. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Christian B Allen
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX, 78235, USA
| | - Tyler K Williamson
- Department of Orthopaedic Surgery, University of Texas Health San Antonio, San Antonio, TX, 78229, USA
| | | | - Ashim Gupta
- Future Biologics, Lawrenceville, GA, 30043, USA.
- Regenerative Orthopaedics, Noida, Uttar Pradesh, 201301, India.
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Lee MT, Mackie K, Chiou LC. Alternative pain management via endocannabinoids in the time of the opioid epidemic: Peripheral neuromodulation and pharmacological interventions. Br J Pharmacol 2023; 180:894-909. [PMID: 34877650 PMCID: PMC9170838 DOI: 10.1111/bph.15771] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 11/23/2021] [Accepted: 11/27/2021] [Indexed: 01/18/2023] Open
Abstract
The use of opioids in pain management is hampered by the emergence of analgesic tolerance, which leads to increased dosing and side effects, both of which have contributed to the opioid epidemic. One promising potential approach to limit opioid analgesic tolerance is activating the endocannabinoid system in the CNS, via activation of CB1 receptors in the descending pain inhibitory pathway. In this review, we first discuss preclinical and clinical evidence revealing the potential of pharmacological activation of CB1 receptors in modulating opioid tolerance, including activation by phytocannabinoids, synthetic CB1 receptor agonists, endocannabinoid degradation enzyme inhibitors, and recently discovered positive allosteric modulators of CB1 receptors. On the other hand, as non-pharmacological pain relief is advocated by the US-NIH to combat the opioid epidemic, we also discuss contributions of peripheral neuromodulation, involving the electrostimulation of peripheral nerves, in addressing chronic pain and opioid tolerance. The involvement of supraspinal endocannabinoid systems in peripheral neuromodulation-induced analgesia is also discussed. LINKED ARTICLES: This article is part of a themed issue on Advances in Opioid Pharmacology at the Time of the Opioid Epidemic. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v180.7/issuetoc.
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Grants
- MOST 108-2321-B-002-005 Ministry of Science and Technology, Taiwan
- MOST 107-2811-B-002-008 Ministry of Science and Technology, Taiwan
- R01 DA041229 NIDA NIH HHS
- MOST 107-2321-B-002-010 Ministry of Science and Technology, Taiwan
- R01 DA047858 NIDA NIH HHS
- 107M4022-3 Ministry of Education, Taiwan
- MOST 106-2321-B-002-019 Ministry of Science and Technology, Taiwan
- NHRI-EX111-11114NI National Health Research Institutes, Taiwan
- FRGS/1/2021/WAB13/UCSI/02/1 Ministry of Higher Education, Malaysia
- R21 DA042584 NIDA NIH HHS
- REIG-FPS-2020/065 UCSI University Research Excellence and Innovation Grant, Malaysia
- NHRI-EX109-10733NI National Health Research Institutes, Taiwan
- MOST 104-2745-B-002-004 Ministry of Science and Technology, Taiwan
- MOST 109-2320-B-002-042-MY3 Ministry of Science and Technology, Taiwan
- MOST 107-2811-B-002 -008 Ministry of Science and Technology, Taiwan
- MOST 108-2320-B-002-029-MY3 Ministry of Science and Technology, Taiwan
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Affiliation(s)
- Ming Tatt Lee
- Department of Pharmacology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan
- Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur 56000, Malaysia
| | - Ken Mackie
- Gill Center for Biomolecular Research, Indiana University, Bloomington, Indiana 47405, USA
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana 47405, USA
| | - Lih-Chu Chiou
- Department of Pharmacology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan
- Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei 10051, Taiwan
- Graduate Institute of Acupuncture Science, China Medical University, Taichung 40402, Taiwan
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Sciatic nerve stimulation alleviates acute neuropathic pain via modulation of neuroinflammation and descending pain inhibition in a rodent model. J Neuroinflammation 2022; 19:153. [PMID: 35706025 PMCID: PMC9199305 DOI: 10.1186/s12974-022-02513-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 06/01/2022] [Indexed: 11/12/2022] Open
Abstract
Background Neuropathic pain (NP) is characterized by abnormal activation of pain conducting pathways and manifests as mechanical allodynia and thermal hypersensitivity. Peripheral nerve stimulation is used for treatment of medically refractory chronic NP and has been shown to reduce neuroinflammation. However, whether sciatic nerve stimulation (SNS) is of therapeutic benefit to NP remains unclear. Moreover, the optimal frequency for SNS is unknown. To address this research gap, we investigated the effect of SNS in an acute NP rodent model. Methods Rats with right L5 nerve root ligation (NRL) or Sham surgery were used. Ipsilateral SNS was performed at 2 Hz, 20 Hz, and 60 Hz frequencies. Behavioral tests were performed to assess pain and thermal hypersensitivity before and after NRL and SNS. Expression of inflammatory proteins in the L5 spinal cord and the immunohistochemical alterations of spinal cord astrocytes and microglia were examined on post-injury day 7 (PID7) following NRL and SNS. The involvement of the descending pain modulatory pathway was also investigated. Results Following NRL, the rats showed a decreased pain threshold and latency on the von Frey and Hargreaves tests. The immunofluorescence results indicated hyperactivation of superficial spinal cord dorsal horn (SCDH) neurons. Both 2-Hz and 20-Hz SNS alleviated pain behavior and hyperactivation of SCDH neurons. On PID7, NRL resulted in elevated expression of spinal cord inflammatory proteins including NF-κB, TNF-α, IL-1β, and IL-6, which was mitigated by 2-Hz and 20-Hz SNS. Furthermore, 2-Hz and 20-Hz SNS suppressed the activation of spinal cord astrocytes and microglia following NRL on PID7. Activity of the descending serotoninergic pain modulation pathway showed an increase early on PID1 following 2-Hz and 20-Hz SNS. Conclusions Our results support that both 2-Hz and 20-Hz SNS can alleviate NP behaviors and hyperactivation of pain conducting pathways. We showed that SNS regulates neuroinflammation and reduces inflammatory protein expression, astrocytic gliosis, and microglia activation. During the early post-injury period, SNS also facilitates the descending pain modulatory pathway. Taken together, these findings support the therapeutic potential of SNS for acute NP. Supplementary Information The online version contains supplementary material available at 10.1186/s12974-022-02513-y.
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Peripheral Nerve Stimulation: A Review of Techniques and Clinical Efficacy. Pain Ther 2021; 10:961-972. [PMID: 34331668 PMCID: PMC8586305 DOI: 10.1007/s40122-021-00298-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/19/2021] [Indexed: 12/21/2022] Open
Abstract
Chronic pain is a common source of morbidity in many patient populations worldwide. There are growing concerns about the potential side effects of currently prescribed medications and a continued need for effective treatment. Related to these concerns, peripheral nerve stimulation has been regaining popularity as a potential treatment modality. Peripheral nerve stimulation components include helically coiled electrical leads, which direct an applied current to afferent neurons providing sensory innervation to the painful area. In theory, the applied current to the peripheral nerve will alter the large-diameter myelinated afferent nerve fibers, which interfere with the central processing of pain signals through small-diameter afferent fibers at the level of the spinal cord. Multiple studies have shown success in the use of peripheral nerve stimulation for acute post-surgical pain for orthopedic surgery, including post total knee arthroplasty and anterior cruciate ligament surgery, and chronic knee pain. Many studies have investigated the utility of peripheral nerve stimulation for the management of chronic shoulder pain. Peripheral nerve stimulation also serves as one of the potential non-pharmacologic therapies to treat back pain along with physical therapy, application of transcutaneous electrical neurostimulation unit, radiofrequency ablation, epidural steroid injections, permanently implanted neurostimulators, and surgery. Studies regarding back pain treatment have shown that peripheral nerve stimulation led to significant improvement in all pain and quality-of-life measures and a reduction in the use of opioids. Further studies are needed as the long-term risks and benefits of peripheral nerve stimulation have not been well studied as most information available on the effectiveness of peripheral nerve stimulation is based on shorter-term improvements in chronic pain.
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Vanzant DR, Mukhdomi JJ, Bolash R. Peripheral Nerve Stimulation Yields an Unexpected Motor Response in a Patient with Chronic Shoulder Pain: A Case Report. PAIN MEDICINE 2021; 23:1338-1341. [PMID: 34791443 DOI: 10.1093/pm/pnab328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/31/2021] [Accepted: 11/08/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Daniel R Vanzant
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Junaid J Mukhdomi
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Robert Bolash
- Department of Pain Management, Cleveland Clinic, Cleveland, OH
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Ye Y, Gabriel RA, Mariano ER. The expanding role of chronic pain interventions in multimodal perioperative pain management: a narrative review. Postgrad Med 2021; 134:449-457. [PMID: 34033737 DOI: 10.1080/00325481.2021.1935281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Surgery is a risk factor for chronic pain and long-term opioid use. As perioperative pain management continues to evolve, treatment modalities traditionally used for chronic pain therapy may provide additional benefit to patients undergoing surgery. Interventions such as radiofrequency ablation, cryoneurolysis, and neuromodulation may potentially be used in conjunction with acute pain procedures such as nerve blocks and multimodal analgesia. Pharmacological agents associated with chronic pain medicine, including gabapentinoids, ketamine, and selective serotonin reuptake inhibitors, may be useful adjuncts in perioperative pain management when indicated. There may also be a role for acupuncture, music therapy, and other integrative medicine therapies. A transitional pain service can help coordinate outpatient care with inpatient perioperative pain management and promote a more personalized and comprehensive approach that can improve postoperative outcomes.
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Affiliation(s)
- Ying Ye
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System; Palo Alto, California, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine; Stanford, California, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia, University of California, San Diego; California, USA.,Department of Medicine, Division of Biomedical Informatics, University of California, San Diego; California, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System; Palo Alto, California, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine; Stanford, California, USA
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Börner C, Urban G, Beaulieu LD, Sollmann N, Krieg SM, Straube A, Renner T, Schandelmaier P, Lang M, Lechner M, Vill K, Gerstl L, Heinen F, Landgraf MN, Bonfert MV. The bottom-up approach: Non-invasive peripheral neurostimulation methods to treat migraine: A scoping review from the child neurologist's perspective. Eur J Paediatr Neurol 2021; 32:16-28. [PMID: 33743386 DOI: 10.1016/j.ejpn.2021.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/07/2021] [Accepted: 02/23/2021] [Indexed: 12/14/2022]
Abstract
Migraine is a common and invalidating disorder worldwide. Patients of all ages experience the disorder as very impairing regarding their personal and occupational lives. The current approach in migraine therapy is multimodal including lifestyle management, psychoeducation and, if available, psychotherapeutic interventions, and pharmacotherapy. The lack of non-pharmacological and non-invasive treatment options call for new and innovative therapeutic approaches. Peripheral neurostimulation is a relatively new method in migraine management offering a painless and non-pharmacological way of targeting specific mechanisms involved in migraine. This review summarizes 15 recent randomized clinical trials to provide an overview of non-invasive peripheral neurostimulation methods currently available for the treatment of migraine. Efficacy, tolerability, and safety of the different interventions and their feasibility in the pediatric setting are evaluated. Vagal nerve stimulation (VNS), remote electrical neuromodulation (REN) and supraorbital nerve stimulation (SNS) are considered effective in treating acute migraine attacks, the latter being more pronounced in migraine without aura. Regarding migraine prevention, occipital nerve stimulation (ONS) and supraorbital nerve stimulation (SNS) demonstrated efficacy, whereas repetitive neuromuscular magnetic stimulation (rNMS) may represent a further effective option in episodic migraine. REN and rNMS were found to be well-accepted with fewer patients discontinuing treatment than those receiving direct cranial nerve stimulation. In summary, peripheral neurostimulation represents a promising option to complement the multimodal therapy concept for pediatric migraine. In particular, rNMS opens a new field for research and treatment fitting the requirements of "non-invasiveness" for children. Given the reported efficacy, safety, and feasibility, the therapy decision should be made on an individual level.
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Affiliation(s)
- Corinna Börner
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Giada Urban
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Louis-David Beaulieu
- Biomechanical and Neurophysiological Research Lab in neuro-musculo-skelettal Rehabilitation (BioNR Lab), Université du Québec à Chicoutimi, Chicoutimi, Canada
| | - Nico Sollmann
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Tabea Renner
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Paul Schandelmaier
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Magdalena Lang
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Matthias Lechner
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Katharina Vill
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Lucia Gerstl
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Florian Heinen
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Mirjam N Landgraf
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany
| | - Michaela V Bonfert
- LMU Hospital, Dr. von Hauner Children's Hospital, Division of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Munich, Germany.
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Chmiela MA, Hendrickson M, Hale J, Liang C, Telefus P, Sagir A, Stanton-Hicks M. Direct Peripheral Nerve Stimulation for the Treatment of Complex Regional Pain Syndrome: A 30-Year Review. Neuromodulation 2020; 24:971-982. [PMID: 33098229 DOI: 10.1111/ner.13295] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/24/2020] [Accepted: 09/28/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy (RSD), is a difficult to treat condition characterized by debilitating pain and limitations in functional ability. Neuromodulation, in the form of spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS), have been traditionally used as a treatment for CRPS with variable success. OBJECTIVE This chart review describes the use of implantable PNS systems in the treatment of CRPS of the upper and lower extremities spanning nearly three decades. MATERIALS AND METHODS A retrospective chart review was performed on 240 patients with PNS implanted between 1990 and 2017 at our institution. Of these, 165 patients were identified who had PNS systems implanted for a diagnosis of CRPS. Patient profile, including baseline characteristics, comorbidities, past/current interventions/medications and targeted nerves, was descriptively summarized through standard summary statistics. Patients' pain scores and opioid consumptions at baseline (preimplant), 1 month, 6 months, and 12 months were collected and compared. Device revisions and explants were summarized, and patient functional outcomes were described. RESULTS Pain scores at baseline and at 12-month follow-up were decreased from a mean of 7.4 ± 1.6 to 5.5 ± 2.4 and estimated to be 1.87 (95% CI: [1.29, 2.46], paired t-test p-value <0.001) lower at 12 months. At baseline, 62% of patients were on chronic opioid therapy, compared with 41% at 12 months. Of 126 patients who reported changes in functional status, 64 (51%) reported improvement, 27 (21%) reported worsening, and 35 (28%) did not report any meaningful change. Excluding end-of-life battery replacements, surgical revision occurred in 56 (34%) of patients. Thirteen patients (8%) underwent implantation of a second PNS because of symptomatic expansion outside of the original painful region. Device explant was performed in 32 (19%) of patients. Median length of follow-up was 74 [14, 147] months. Of the 36 patients who continue to follow-up at our institution, 29 (81%) continue to use their PNS. CONCLUSIONS We can conclude that PNS is a useful modality to improve function and reduce long-term pain in selected patients suffering from CRPS type I and type II.
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Affiliation(s)
- Mark A Chmiela
- Department of Pain Management, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mark Hendrickson
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jason Hale
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Chen Liang
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Phillip Telefus
- Department of Pain Management, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Afrin Sagir
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Lee MT, Chen YH, Mackie K, Chiou LC. Median Nerve Stimulation as a Nonpharmacological Approach to Bypass Analgesic Tolerance to Morphine: A Proof-of-Concept Study in Mice. THE JOURNAL OF PAIN 2020; 22:300-312. [PMID: 33069869 DOI: 10.1016/j.jpain.2020.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023]
Abstract
Analgesic tolerance to opioids contributes to the opioid crisis by increasing the quantity of opioids prescribed and consumed. Thus, there is a need to develop non-opioid-based pain-relieving regimens as well as strategies to circumvent opioid tolerance. Previously, we revealed a non-opioid analgesic mechanism induced by median nerve electrostimulation at the overlaying PC6 (Neiguan) acupoint (MNS-PC6). Here, we further examined the efficacy of MNS-PC6 in morphine-tolerant mice with neuropathic pain induced by chronic constriction injury (CCI) of the sciatic nerve. Daily treatments of MNS-PC6 (2 Hz, 2 mA), but not electrostimulation at a nonmedian nerve-innervated location, for a week post-CCI induction significantly suppressed established mechanical allodynia in CCI-mice in an orexin-1 (OX1) and cannabinoid-1 (CB1) receptor-dependent fashion. This antiallodynic effect induced by repeated MNS-PC6 was comparable to that induced by repeated gabapentin (50 mg/kg, i.p.) or single morphine (10 mg/kg, i.p.) treatments, but without tolerance, unlike repeated morphine-induced analgesia. Furthermore, single and repeated MNS-PC6 treatments remained fully effective in morphine-tolerant CCI-mice, also in an OX1 and CB1 receptor-dependent fashion. In CCI-mice receiving escalating doses of morphine for 21 days (10, 20 and 50 mg/kg), single and repeated MNS-PC6 treatments remained fully effective. Therefore, repeated MNS-PC6 treatments induce analgesia without tolerance, and retain efficacy in opioid-tolerant mice via a mechanism that involves OX1 and CB1 receptors. This study suggests that MNS-PC6 is an alternative pain management strategy that maybe useful for combatting the opioid epidemic, and opioid-tolerant patients receiving palliative care. PERSPECTIVE: Median nerve stimulation relieves neuropathic pain in mice without tolerance and retains efficacy even in mice with analgesic tolerance to escalating doses of morphine, via an opioid-independent, orexin-endocannabinoid-mediated mechanism. This study provides a proof of concept for utilizing peripheral nerve stimulating devices for pain management in opioid-tolerant patients.
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Affiliation(s)
- Ming Tatt Lee
- Graduate Institute of Pharmacology, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei, Taiwan; Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur, Malaysia
| | - Yi-Hung Chen
- Graduate Institute of Acupuncture Science, China Medical University, Taichung, Taiwan; Chinese Medicine Research Center, China Medical University, Taichung, Taiwan
| | - Ken Mackie
- Gill Center for Biomolecular Research, Indiana University, Bloomington, Indiana; Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - Lih-Chu Chiou
- Graduate Institute of Pharmacology, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Acupuncture Science, China Medical University, Taichung, Taiwan.
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