Brain Modulation by Electric Currents in Fibromyalgia: A Structured Review on Non-invasive Approach With Transcranial Electrical Stimulation

Efficacy of neuromodulation on the treatment of fibromyalgia: A network meta-analysis

OBJECTIVE

Several types of neuromodulation have been investigated for the treatment of fibromyalgia, but they show varied efficacy on pain, functioning, comorbid depression and comorbid anxiety. Whether some types of neuromodulation or some factors are associated with a better response also awaits clarification.

METHODS

We conducted a systematic review and network meta-analysis of randomized controlled trials to evaluate the efficacy of neuromodulation in patients with fibromyalgia. We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials and PsycINFO before March 2022. We employed a frequentist random-effects network meta-analysis.

RESULTS

Forty trials involving 1541 participants were included. Compared with sham control interventions, several types of transcranial direct current stimulation (tDCS), transcranial random noise stimulation (tRNS), and high-frequency repetitive transcranial magnetic stimulation (rTMS) were associated with significant reduction of pain, depression, anxiety, and improvement in functioning. Many significantly effective treatment options involve stimulation of the primary motor cortex or dorsolateral prefrontal cortex.

CONCLUSION

We concluded that several types of rTMS, tDCS and tRNS may have the potential to be applied for clinical purposes.

Effect of neuronavigated repetitive Transcranial Magnetic Stimulation on pain, cognition and cortical excitability in fibromyalgia syndrome

BACKGROUND

Fibromyalgia syndrome is a widespread chronic pain condition identified by body-wide pain, fatigue, cognitive fogginess, and sleep issues. In the past decade, repetitive transcranial magnetic stimulation has emerged as a potential management tool.. In the present study, we enquired whether repetitive transcranial magnetic stimulation could modify pain, corticomotor excitability, cognition, and sleep.

METHODS

Study is a randomized, sham-controlled, double-blind, clinical trial; wherein after randomizing thirty-four fibromyalgia patients into active or sham therapy (n = 17 each), each participant received repetitive transcranial magnetic stimulation therapy. In active therapy was given at 1 Hz for 20 sessions were delivered on dorsolateral prefrontal cortex (1200 pulses, 150 pulses per train for 8 trains); while in sham therapy coil was placed at right angle to the scalp with same frequency. Functional magnetic resonance imaging was used to identify the therapeutic site. Pain intensity, corticomotor excitability, cognition, and sleep were examined before and after therapy.

RESULTS

Baseline demographic and clinical parameters for both active and sham groups were comparable. In comparison to sham, active repetitive transcranial magnetic stimulation showed significant difference in pain intensity (P < 0.001, effect size = 0.29, large effect) after intervention. Other parameters of pain perception, cognition, and sleep quality also showed a significant improvement after the therapy in active therapy group only, as compared to sham.

CONCLUSIONS

Findings suggest that repetitive transcranial magnetic stimulation intervention is effective in managing pain alongside cognition and sleep disturbances in patients of fibromyalgia. It may prove to be an important tool in relieving fibromyalgia-associated morbidity.

Transcranial direct current stimulation in physical therapy treatment for adults after stroke: A systematic review

BACKGROUND

Stroke is a clinical syndrome that can cause neurological disorders due to a reduction or interruption in the blood flow at the brain level. Transcranial direct current stimulation (TDCS) is a non-invasive electrotherapy technique with the ability to modulate the function of nervous tissue.

OBJECTIVE

The aim of this review is to analyze the effects derived from the application of the TDCS for post-stroke patients on functionality and mobility.

METHODS

The data search was conducted in PubMed, PEDro, Cochrane Library, Web of Science and Scopus between July and August 2023. The search focused on randomized clinical trials conducted in the period of 2019-2023, and according to the selection criteria, seven studies were obtained.

RESULTS

The results found are mainly focused on the analysis of the scales Fugl-Meyer Assessment for Upper Extremity and Wolf Motor Function Test.

CONCLUSION

The application of TDCS presents benefits in post-stroke individuals on functionality, mobility and other secondary studied variables.

Efficacy of Transcranial Direct Current Stimulation on Pain Level and Disability of Patients with Fibromyalgia: A Systematic Review of Randomized Controlled Trials with Parallel-Group Design

Transcranial direct current stimulation (tDCS) has been increasingly applied in fibromyalgia (FM) to reduce pain and fatigue. While results are promising, observed effects are variable, and there are questions about optimal stimulation parameters such as target region (e.g., motor vs. prefrontal cortices). This systematic review aimed to provide the latest update on published randomized controlled trials with a parallel-group design to examine the specific effects of active tDCS in reducing pain and disability in FM patients. Using the PRISMA approach, a literature search identified 14 randomized controlled trials investigating the effects of tDCS on pain and fatigue in patients with FM. Assessment of biases shows an overall low-to-moderate risk of bias. tDCS was found effective in all included studies conducted in patients with FM, except one study, in which the improving effects of tDCS were due to placebo. We recommended tDCS over the motor and prefrontal cortices as "effective" and "probably effective" respectively, and also safe for reducing pain perception and fatigue in patients with FM, according to evidence-based guidelines. Stimulation polarity was anodal in all studies, and one single-session study also examined cathodal polarity. The stimulation intensity ranged from 1-mA (7.14% of studies) to 1.5-mA (7.14% of studies) and 2-mA (85.7% of studies). In all of the included studies, a significant improvement in at least one outcome variable (pain or fatigue reduction) was observed. Moreover, 92.8% (13 of 14) applied multi-session tDCS protocols in FM treatment and reported significant improvement in their outcome variables. While tDCS is therapeutically effective for FM, titration studies that systematically evaluate different stimulation intensities, durations, and electrode placement are needed.

The effects of transcranial direct-current stimulation (tDCS) on pain intensity of patients with fibromyalgia: a systematic review and meta-analysis

INTRODUCTION

Fibromyalgia (FM) is a chronic pain condition that affects millions of people worldwide. Transcranial Direct Current Stimulation (tDCS) is a non-invasive brain stimulation technique that has shown promise as a potential treatment for FM by modulating pain perception and reducing symptoms, such as fatigue and depression. We aimed to systematically review studies that assess the effect of tDCS on pain reduction in FM patients.

METHODS

Seven electronic databases (PubMed, Scopus, Embase, PsycINFO, Web of Science, Cochrane, and CINAHL Complete) were searched for records in English. Studies that measured the effect of tDCS on pain intensity in FM patients were included. The Cochrane Collaboration's tool was used to assess the quality of the included studies. A random-effect model was preferred, and statistical analysis was performed by Stata software version 17.

RESULTS

Twenty studies were included for qualitative, and eleven for quantitative analysis. Out of 664 patients included in the study, 443 were in the stimulation group. The left M1 area was the most common stimulation target (n = 12), and 2 mA was the most common stimulation amplitude (n = 19). The analysis showed that active tDCS significantly reduced pain intensity in FM patients in comparison to the sham group (SMD= -1.55; 95% CI -2.10, -0.99); also, no publication bias was noted.

CONCLUSION

Our systematic review highlights the potential effect of tDCS on the reduction of pain intensity in FM patients. Additionally, this current evidence could suggest that tDCS applied at an intensity of 2mA to the left M1 is the most effective strategy.

Non-invasive cortical stimulation for drug-resistant pain

PURPOSE OF REVIEW

Neuromodulation techniques are being increasingly used to alleviate pain and enhance quality of life. Non-invasive cortical stimulation was originally intended to predict the efficacy of invasive (neurosurgical) techniques, but has now gained a place as an analgesic procedure in its own right.

RECENT FINDINGS

Repetitive transcranial magnetic stimulation (rTMS): Evidence from 14 randomised, placebo-controlled trials (~750 patients) supports a significant analgesic effect of high-frequency motor cortex rTMS in neuropathic pain. Dorsolateral frontal stimulation has not proven efficacious so far. The posterior operculo-insular cortex is an attractive target but evidence remains insufficient. Short-term efficacy can be achieved with NNT (numbers needed to treat) ~2-3, but long-lasting efficacy remains a challenge.Like rTMS, transcranial direct-current stimulation (tDCS) induces activity changes in distributed brain networks and can influence various aspects of pain. Lower cost relative to rTMS, few safety issues and availability of home-based protocols are practical advantages. The limited quality of many published reports lowers the level of evidence, which will remain uncertain until more prospective controlled studies are available.

SUMMARY

Both rTMS and tDCS act preferentially upon abnormal hyperexcitable states of pain, rather than acute or experimental pain. For both techniques, M1 appears to be the best target for chronic pain relief, and repeated sessions over relatively long periods of time may be required to obtain clinically significant benefits. Patients responsive to tDCS may differ from those improved by rTMS.

Effects of Repetitive-Transcranial Magnetic Stimulation (rTMS) in Fibromyalgia Syndrome: An Umbrella and Mapping Review

BACKGROUND

The main aim of this study was to assess the effects of repetitive-transcranial magnetic stimulation (rTMS) in patients with fibromyalgia (FMS).

METHODS

We systematically searched PubMed, PEDro, EMBASE, and CINAHL. Methodological quality was analyzed using the AMSTAR and ROBIS scales, and the strength of evidence was established according to the guidelines advisory committee grading criteria. A total of 11 systematic reviews were included. The assessed variables were pain intensity, depressive symptoms, anxiety, and general health.

RESULTS

Regarding pain intensity, it seems that high-frequency rTMS significantly reduces pain intensity at a 1-month follow-up when the primary motor cortex (M1) is stimulated. However, we cannot robustly conclude the same for low-frequency protocols. When we look at the combination of high and low-frequency rTMS, there seems to be a significant effect on pain intensity up to 1-week post-intervention, but after that point of follow-up, the results are controversial. Regarding depressive symptoms and anxiety, results showed that the effects of rTMS are almost non-existent. Finally, in regard to general health, results showed that rTMS caused significant post-intervention effects in a robust way. However, the results of the follow-ups are contradictory.

CONCLUSIONS

The results obtained showed that high-frequency rTMS applied on the M1 showed some effect on the variable of pain intensity with a limited quality of evidence. Overall, rTMS was shown to be effective in improving general health with moderate quality of evidence. Finally, rTMS was not shown to be effective in managing depressive symptoms and anxiety with a limited to moderate quality of evidence. PROSPERO number: This review was previously registered in PROSPERO (CRD42023391032).

Non-Invasive Electric and Magnetic Brain Stimulation for the Treatment of Fibromyalgia

Although fibromyalgia is defined by its core muscular nociceptive component, it also includes multiple dysfunctions that involve the musculoskeletal, gastrointestinal, immune, endocrine, as well as the central and peripheral nervous systems, amongst others. The pathogenic involvement of the nervous system and the numerous neurological and neuroinflammatory symptoms of this disease may benefit from neuromodulatory stimulation techniques that have been shown to be effective and safe in diverse nervous system pathologies. In this systematic review, we outline current evidence showing the potential of non-invasive brain stimulation techniques, such as therapeutic strategies in fibromyalgia. In addition, we evaluate the contribution of these tools to the exploration of the neurophysiological characteristics of fibromyalgia. Considering that the pathogenesis of this disease is unknown, these approaches do not aim to causally treat this syndrome, but to significantly reduce a range of key symptoms and thus improve the quality of life of the patients.

Effects of Anodal Transcranial Direct Current Stimulation on the Primary Motor Cortex in Women With Fibromyalgia: A Randomized, Triple-Blind Clinical Trial

OBJECTIVES

The aim of this study was to analyze the effects of ten sessions of active transcranial direct current stimulation transcranial direct current stimulation (tDCS) (2 mA) with 13:20:13 stimulation at M1 in women with fibromyalgia (FM). To the best of our knowledge, this is the first article that uses this protocol in patients with FM. The main hypothesis is that the protocol would be effective in decreasing pain and that the results would last for up to 90 days.

MATERIALS AND METHODS

This study was a randomized clinical trial with 35 women with FM divided into two groups, active tDCS group and sham tDCS group. A conventional tDCS device was used to deliver 2 mA for 13 minutes, with a 20-minute break followed by a further 13 minutes of stimulation for ten sessions. The anodal stimulus was in the left primary motor cortex M1 region. The primary outcome was a change in the visual analog scale and the Survey of Pain Attitudes pain score at the end of treatment, after 30 days, and 90 days after the end of treatment. Secondary outcomes included changes in the Fibromyalgia Impact Questionnaire, Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale, World Health Organization's Quality of Life Questionnaire, and Fatigue Assessment Scale. The Research Ethics Committee of the Centro Universitário da Grande Dourados under registration number Certificado de Apresentação de Apreciação Ética approved this research: 36444920.5.0000.5159. The study was registered in The Brazilian Registry of Clinical Trials with the identifier RBR-8wc8rjq.

RESULTS

The active tDCS group showed improvement in pain after ten sessions (p < 0.001), after 30 days (p < 0.01), and after 90 days (p < 0.001) compared with sham tDCS. In addition, improvement in quality of life (QoL) and fatigue was observed in the active tDCS group.

CONCLUSION

The results of this study suggest that active tDCS with an intensity of 2 mA for ten sessions was effective in decreasing pain and fatigue and improving QoL in patients with FM.

Effect of Single Session of Anodal M1 Transcranial Direct Current Stimulation—TDCS—On Cortical Hemodynamic Activity: A Pilot Study in Fibromyalgia

Transcranial direct current stimulation (TDCS) on the primary motor cortex (M1) has been reported to be effective in fibromyalgia (FM). Our previous works have shown hypometabolism of motor networks in FM using Functional Near Infrared Spectroscopy (fNIRS), which could contribute to pain symptoms. To investigate if a single Transcranial Direct Current Stimulation (TDCS) session can restore the reduced metabolism expected in FM patients, we compared metabolic activity in FM patients and controls during a finger-tapping task in basal condition, sham condition, and under anodal TDCS on M1. During the finger tapping task, a continuous wave 20 channel fNIRS system was placed across the bilateral central-frontal areas in 22 healthy controls and 54 FM patients. Subjects were randomly assigned to real TDCS or sham stimulation. The finger-tapping slowness did not change after real and sham stimulation. After real TDCS stimulation, FM patients showed an increased activation of cortical motor regions (t-statistic = −2.5246, p-value = 0.0125 for the stimulated hemisphere and t-statistic = −4.6638, p-value = 0.0001 for the non-stimulated hemisphere). The basal differences between FM and controls reverted after real TDCS, while this effect was not observed for sham stimulation. A single TDCS session of the cortical motor network seemed able to restore basic cortical hypometabolism in FM patients. Further studies could clarify the long-term effect of M1 stimulation on cortical metabolism, and its relevance in pain processing and clinical features.

Sound-Induced Flash Illusions Support Cortex Hyperexcitability in Fibromyalgia

Objectives

Fibromyalgia (FM) is characterized by spontaneous chronic widespread pain in combination with hyperalgesia to pressure stimuli. Sound-induced flash illusions (SIFIs) reflect cross-modal interactions between senses allowing to assess a visual cortical hoerexcitability (VCH) by evaluating the fission and fusion illusions disruption. The aims of the present study were to explore whether SIFIs are perceived differently in patients with fibromyalgia as compared to healthy controls (HCs) and how migraine affects fission and fusion illusions in fibromyalgia.

Methods

A single flash (F) accompanied by 0 to 4 beeps (B) was presented to induce the fission illusion while multiple flash (i.e., 2 to 4) accompanied by 0 or 1 beep was presented to induce fusion illusion. The mean number of perceived flashes in fission and fusion illusion trials was compared between the groups (i.e., FM, FM with migraine, and HCs) using repeated-measures analysis of variance. Medication history was recorded along with the administration of Fibromyalgia Impact Questionnaire and Hospital Anxiety and Depression scales.

Results

Twenty-four patients with FM (mean age 51, 2 ± 10, 6 years; 22 females), seventeen patients with FM and migraine without aura (mean age 47.8 ± 11.4 years; 16 females; 13 chronic, 4 episodic migraine), and forty-one age- and sex-matched HCs (mean age 47.3 ± 6.9 years; 34 females) participated in the study. Fission and fusion illusory effects were detected in all the participants. However, in FM patients, the fission illusion was reduced and almost abolished as compared to HCs (1F1B, p = 0.02; 1F2B, p < 0.0001; 1F3B, p < 0.0001; 1F4B, p = 0.0001), while there were no differences between groups in fusion trials. Migraine did not affect the fission and the fusion illusions.

Conclusion

Results from this study confirm that patients with FM have a VCH suggesting that the pathological changes in cortical excitability might have important roles in the pathophysiology of FM. SIFI represents a noninvasive behavioral tool for the exploration of cross-sensory functional interplay.

Active and sham transcranial direct current stimulation (tDCS) improved quality of life in female patients with fibromyalgia

PURPOSE

Fibromyalgia (FM) is a chronic pain syndrome with a strong impact on quality of life (QoL). Treatment of this condition remains a challenge, due to the scarce evidence for the effectiveness of the therapeutic approaches available. Current attention is focused on transcranial direct current stimulation (tDCS), which has yielded promising results for pain treatment. Rather than focusing only on pain relief, in this study, we aimed to determine how active or sham tDCS (over three cortical targets -the primary motor cortex, the dorsolateral prefrontal cortex and the operculo-insular cortex-) affect QoL in patients with FM.

METHODS

Using a double-blind, placebo-controlled design, we applied fifteen tDCS sessions of 20' to initial 130 participants (randomized to any of the four treatment groups). We evaluated the QoL (assessed by SF-36) and the symptoms' impact (assessed by FIQ-R) in baseline, after treatment and at 6 months follow-up.

RESULTS

All groups were comparable as regards age, medication pattern and severity of symptoms before the treatment. We found that QoL and symptoms' impact improved in all treatment groups (including the sham) and this improvement lasted for up to 6 months. However, we did not observe any group effect nor group*treatment interaction.

CONCLUSIONS

After the intervention, we observed a non-specific effect that may be due to placebo, favoured by the expectations of tDCS efficacy and psychosocial variables inherent to the intervention (daily relationship with therapists and other patients in the clinic). Therefore, active tDCS is not superior to sham stimulation in improving QoL in FM.

Transcranial direct current stimulation of 3 cortical targets is no more effective than placebo as treatment for fibromyalgia: a double-blind sham-controlled clinical trial

ABSTRACT

Transcranial direct current stimulation (tDCS) over the primary motor cortex (M1) and the dorsolateral prefrontal cortex seem to improve pain and other symptoms of fibromyalgia (FM), although the evidence on the effectiveness of tDCS and the optimal stimulation target is not robust enough. Our main objective was to establish the optimal area of stimulation, comparing the 2 classical targets and a novel pain-related area, the operculo-insular cortex, in a sham-controlled trial. Using a double-blind design, we randomly assigned 130 women with FM to 4 treatment groups (M1, dorsolateral prefrontal cortex, operculo-insular cortex, and sham), each receiving fifteen 20-minute sessions of 2 mA anodal tDCS over the left hemisphere. Our primary outcome was pain intensity. The secondary outcomes were the other core symptoms of FM (fatigue, mood, cognitive and sleep disorders, and hyperalgesia measured by the pressure pain threshold). We performed the assessment at 3 time points (before, immediately after treatment, and at 6 months follow-up). The linear mixed-model analysis of variances showed significant treatment effects across time for clinical pain and for fatigue, cognitive and sleep disturbances, and experimental pain, irrespective of the group. In mood, the 3 active tDCS groups showed a significantly larger improvement in anxiety and depression than sham. Our findings provide evidence of a placebo effect, support the use of tDCS for the treatment of affective symptoms, and challenge the effectiveness of tDCS as treatment of FM.

A Randomized, Double-Blind, Sham-Controlled Trial of Transcranial Direct Current Stimulation for the Treatment of Persistent Postural-Perceptual Dizziness (PPPD)

Background

Persistent postural-perceptual dizziness (PPPD) is a functional vestibular disorder that causes chronic dizziness interfering with daily activities. Transcranial direct current stimulation (tDCS) has reportedly improved dizziness in patients with phobic postural vertigo in an open-label trial. However, no randomized, double-blind, sham-controlled study has been conducted on its therapeutic efficacy in PPPD.

Objective

This study was conducted to investigate the efficacy and safety of tDCS as an add-on treatment to pharmacotherapy in patients with PPPD. In addition, functional neuroimaging was used to identify the neural mechanisms underlying the effects of tDCS.

Materials and Methods

In a randomized, double-blind, sham-controlled trial, 24 patients diagnosed with PPPD were randomized to receive active (2 mA, 20 min) or sham tDCS to the left dorsolateral prefrontal cortex (DLPFC), administered in 15 sessions over 3 weeks. The clinical measures that assess the severity of dizziness, depression, and anxiety were collected at baseline, immediate follow-up, 1-month follow-up, and 3-month follow-up. Adverse events were also observed. The effect of tDCS on regional cerebral blood flow (rCBF) was evaluated with single photon emission tomography before and after tDCS sessions.

Results

For the primary outcome measure of the Dizziness Handicap Inventory (DHI) score, a significant main effect of time was found, but neither the treatment-by-time interaction effect nor the main effect of treatment was significant. For the Hamilton Depression Rating Scale (HDRS) score, there was a statistical significance for the treatment-by-time interaction effect and the main effect of time, but not for the main effect of treatment. However, the treatment-by-time interaction effect and the main effect of time on HDRS score appear to be due to one data point, an increase in depressive symptoms reported by the sham group at the 3-month follow-up. For the Activities-specific Balance Confidence (ABC) Scale and the Hamilton Anxiety Rating Scale scores, there were no significant main effects of time, treatment, and treatment-by-time interaction. In a comparison with the changes in rCBF between the groups, a significant treatment-by-time interaction effect was found in the right superior temporal and left hippocampus, controlling for age and sex.

Conclusion

Active tDCS was not found to be significantly more efficacious than sham tDCS on dizziness symptoms in patients with PPPD. It is conceivable that tDCS targeting the DLPFC may not be an optimal treatment option for reducing dizziness symptoms in PPPD. Our findings encourage further investigation on the effects of tDCS in PPPD, which considers different stimulation protocols in terms of stimulation site or the number of sessions.

Clinical Trial Registration

cris.nih.go.kr, identifier: KCT0005068.

The efficacy of non-invasive, non-convulsive electrical neuromodulation on depression, anxiety and sleep disturbance: a systematic review and meta-analysis

The effects of non-invasive, non-convulsive electrical neuromodulation (NINCEN) on depression, anxiety and sleep disturbance are inconsistent in different studies. Previous meta-analyses on transcranial direct current stimulation (tDCS) and cerebral electrotherapy stimulation (CES) suggested that these methods are effective on depression. However, not all types of NINECN were included; results on anxiety and sleep disturbance were lacking and the influence of different populations and treatment parameters was not completely analyzed. We searched PubMed, Embase, PsycInfo, PsycArticles and CINAHL before March 2021 and included published randomized clinical trials of all types of NINCEN for symptoms of depression, anxiety and sleep in clinical and non-clinical populations. Data were pooled using a random-effects model. The main outcome was change in the severity of depressive symptoms after NINCEN treatment. A total of 58 studies on NINCEN were included in the meta-analysis. Active tDCS showed a significant effect on depressive symptoms (Hedges' g = 0.544), anxiety (Hedges' g = 0.667) and response rate (odds ratio = 1.9594) compared to sham control. CES also had a significant effect on depression (Hedges' g = 0.654) and anxiety (Hedges' g = 0.711). For all types of NINCEN, active stimulation was significantly effective on depression, anxiety, sleep efficiency, sleep latency, total sleep time, etc. Our results showed that tDCS has significant effects on both depression and anxiety and that these effects are robust for different populations and treatment parameters. The rational expectation of the tDCS effect is 'response' rather than 'remission'. CES also is effective for depression and anxiety, especially in patients with disorders of low severity.

Cortical stimulation for chronic pain: from anecdote to evidence

Epidural stimulation of the motor cortex (eMCS) was devised in the 1990's, and has now largely supplanted thalamic stimulation for neuropathic pain relief. Its mechanisms of action involve activation of multiple cortico-subcortical areas initiated in the thalamus, with involvement of endogenous opioids and descending inhibition toward the spinal cord. Evidence for clinical efficacy is now supported by at least seven RCTs; benefits may persist up to 10 years, and can be reasonably predicted by preoperative use of non-invasive repetitive magnetic stimulation (rTMS). rTMS first developed as a means of predicting the efficacy of epidural procedures, then as an analgesic method on its own right. Reasonable evidence from at least six well-conducted RCTs favors a significant analgesic effect of high-frequency rTMS of the motor cortex in neuropathic pain (NP), and less consistently in widespread/fibromyalgic pain. Stimulation of the dorsolateral frontal cortex (DLPFC) has not proven efficacious for pain, so far. The posterior operculo-insular cortex is a new and attractive target but evidence remains inconsistent. Transcranial direct current stimulation (tDCS) is applied upon similar targets as rTMS and eMCS; it does not elicit action potentials but modulates the neuronal resting membrane state. tDCS presents practical advantages including low cost, few safety issues, and possibility of home-based protocols; however, the limited quality of most published reports entails a low level of evidence. Patients responsive to tDCS may differ from those improved by rTMS, and in both cases repeated sessions over a long time may be required to achieve clinically significant relief. Both invasive and non-invasive procedures exert their effects through multiple distributed brain networks influencing the sensory, affective and cognitive aspects of chronic pain. Their effects are mainly exerted upon abnormally sensitized pathways, rather than on acute physiological pain. Extending the duration of long-term benefits remains a challenge, for which different strategies are discussed in this review.

Movement observation activates motor cortex in fibromyalgia patients: a fNIRS study

Scientific evidence points to a shared neural representation between performing and observing an action. The action observation notoriously determines a modulation of the observer’s sensorimotor system, a phenomenon called Motor Resonance (MR). Fibromyalgia (FM) patients suffer from a condition characterized by generalized musculoskeletal pain in which even simple movement can exacerbate their symptoms. Maladaptive functioning of the primary motor cortex is a common finding in patients with chronic pain. Activation of the motor cortex is known to induce an analgesic effect in patients with chronic pain. In this exploratory study, we intend to verify if the mere observation of a movement could elicit activation of the motor cortical areas in patients with FM. Therefore, the purpose of this study was to examine the presence of MR in patients affected by fibromyalgia. We adopted a behavioral paradigm known for detecting the presence of MR and a neurophysiological experiment. Participants watched videos showing gripping movements towards a graspable or an ungraspable object, respectively, and were asked to press a button the instant the agent touched the object (Time-to-contact detection session). In a different experimental session, participants were only requested to observe and pay attention to the videos (Observation-only session). During each experimental session, the participants’ cerebral hemodynamic activity was recorded using the functional Near-Infrared Spectroscopy method. The behavioral task analysis revealed the presence of MR in both FM patients and healthy controls. Moreover, neurophysiological findings suggested that the observation of movement during the Observation-only session provoked activation and modulation of the cortical motor networks of FM patients. These results could represent evidence of the possible beneficial effects of movement observation in restarting motor activation, notoriously reduced, in FM patients.

Effectiveness of Repetitive Transcranial Magnetic Stimulation on Managing Fibromyalgia: A Systematic Meta-Analysis

OBJECTIVE

In fibromyalgia, central sensitization is a key mechanism, and repetitive transcranial magnetic stimulation (rTMS) has been reported to potentially manage symptoms of fibromyalgia. In this meta-analysis, we evaluated the therapeutic effect of rTMS in patients with fibromyalgia according to stimulation locations and follow-up time points.

METHODS

We searched the MEDLINE, Cochrane, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Web of Science databases for articles published from January 1, 1990 to August 26, 2021, including randomized controlled studies investigating the effectiveness of rTMS on managing fibromyalgia.

RESULTS

In total, 10 papers and 299 participants were included. The high-frequency rTMS on the left primary motor cortex (Lt. M1) had a significant effect on pain reduction immediately and 1-4 weeks after the end of the session but had no significant effect after 5-12 weeks. Additionally, after high-frequency rTMS sessions on the Lt. M1, the effect on patients' quality of life (QoL) appeared late at 5-12 weeks of follow-up. In contrast, high-frequency rTMS on the left dorsolateral prefrontal cortex (Lt. DLPFC) did not reduce pain from fibromyalgia. The effect on controlling the affective problem was not observed after rTMS treatment on both the Lt. M1 and Lt. DLPFC.

CONCLUSIONS

High-frequency rTMS had a positive pain-reducing effect immediately and at 1-4 weeks after completing the rTMS sessions, and the patients' QoL improved after 5-12 weeks. However, Lt. DLPFC stimulation was not effective in controlling fibromyalgia symptoms.

Offset analgesia is associated with opposing modulation of medial versus dorsolateral prefrontal cortex activations: A functional near-infrared spectroscopy study

Offset analgesia is defined by a dramatic drop in perceived pain intensity with a relatively small decrease in noxious input. Although functional magnetic resonance imaging studies implicate subcortical descending inhibitory circuits during offset analgesia, the role of cortical areas remains unclear. The current study identifies cortical correlates of offset analgesia using functional near infrared spectroscopy (fNIRS). Twenty-four healthy volunteers underwent fNIRS scanning during offset (OS) and control (Con) heat stimuli applied to the forearm. After controlling for non-neural hemodynamic responses in superficial tissues, widespread increases in cortical oxygenated hemoglobin concentration were observed, reflecting cortical activation during heat pain. OS-Con contrasts revealed deactivations in bilateral medial prefrontal cortex (mPFC) and bilateral somatosensory cortex (SSC) associated with offset analgesia. Right dorsolateral prefrontal cortex (dlPFC) showed activation only during OS. These data demonstrate opposing cortical activation patterns during offset analgesia and support a model in which right dlPFC underlies ongoing evaluation of pain intensity change. With predictions of decreasing pain intensity, right dlPFC activation likely inhibits ascending noxious input via subcortical pathways resulting in SSC and mPFC deactivation. This study identifies cortical circuitry underlying offset analgesia and introduces the use of fNIRS to study pain modulation in an outpatient clinical environment.

Pathophysiology and Clinical Implications of Cognitive Dysfunction in Fibromyalgia

Cognitive dysfunction is a complaint of many patients diagnosed with fibromyalgia. Although the main symptoms of the disease are fatigue, widespread musculoskeletal pain, poor sleep quality, and tenderness points, the cognitive symptoms can be more distressing than the pain itself, and negatively affect their lives; however, many healthcare professionals underestimate these cognitive complaints and it is still one of the least researched topics. Proper management of these symptoms at an early stage may have a great impact to improve the mental health, physical function, and overall health of these patients. Hence, this traditional review aimed to look at the previous body of literature in PubMed in the past five years to address the pathophysiology of the cognitive dysfunction in fibromyalgia patients, to find the risk factors of cognitive dysfunction in these patients, to discover the recent modalities for treatment, and to figure out the clinical implications and recent recommendations by researchers on screening, diagnosis, and management of fibromyalgia and its cognitive dysfunction symptoms.

This review has shown the various mechanisms of cognitive dysfunction. Some mechanisms are related to disease symptomologies, such as excessive pain perception, and others are related to hormonal and metabolite changes in the brain. Tobacco smoking and high body mass index showed an inverse impact on cognitive dysfunction and quality of life in fibromyalgia. Other risk factors and clinical implications were discussed in detail.

Diagnostic Challenges and Management of Fibromyalgia

The World Health Organization regards chronic pain to be a public health concern. In clinical medicine, fibromyalgia (FM) is the most prevalent chronic widespread pain disease. In terms of impairment, consumption of health and social resources, and impact on primary and speciality care systems, it has reached worrisome proportions. This disease is frequently managed by primary care providers. Because of its intricacy, fibromyalgia diagnosis and treatment can be difficult. Fibromyalgia is a controversial condition. It might appear ill-defined in comparison to other pain conditions, with no clear knowledge of pathophysiology and hence no particular targeted therapy. This invariably sparks debates and challenges. There is no obvious cut-off point that distinguishes FM from non-FM. The diagnosis of fibromyalgia has been complicated by several factors, including patients' health-seeking behaviour, symptom identification, and physician labelling of the disease. Fibromyalgia is currently considered a centralized pain condition, according to research that has improved our understanding of its etiopathology. A multidisciplinary strategy combining pharmacological and non-pharmacological therapies based on a biopsychosocial paradigm can result in effective therapy. Cultural and psychosocial variables appear to be a recent development in fibromyalgia, and they appear to have a larger influence on physician diagnosis than severe symptom levels in FM patients. Although physicians rely on FM criteria as the only way to classify FM patients in research and clinical settings, some crucial elements of the diagnostic challenge of fibromyalgia remain unsolved - invalidation, psychosocial variables, and diverse illness manifestation are some examples. Beyond the existing constructional scores, physicians' judgment gained in real communicative contexts with patients, appears to be the only dependable route for a more accurate diagnosis for fibromyalgia. We have performed an exhaustive review of the literature using the keywords "Fibromyalgia", "challenges" and "diagnosis" in PubMed and Google Scholar indexes up to September 2021. This article aims to examine the causes, diagnosis, and current treatment protocols of FM, as well as discuss some continuing debates and diagnostic challenges which physicians face in accurately diagnosing fibromyalgia.

Transcranial Direct Current Stimulation Associated With Functional Exercise Program for Treating Fibromyalgia: A Randomized Controlled Trial

OBJECTIVE

To investigate the effects of transcranial direct current stimulation (tDCS) associated with functional exercise on pain, functional performance, psychological symptoms, and quality of life of patients with fibromyalgia (FM).

DESIGN

Randomized controlled trial. Participants were randomized by blocks into 2 groups: tDCS associated with functional exercise (n=17) and sham-tDCS associated with functional exercise (n=14).

SETTING

Laboratory of neuromuscular performance in the department of physical therapy.

PARTICIPANTS

Women with FM (N=31) according to American College of Rheumatology-2010 criteria.

INTERVENTIONS

Anodal tDCS or sham-tDCS was applied over the left motor cortex for 5 consecutive days during the first week of intervention (2 mA; 20min). All volunteers also engaged in 8 weeks of functional exercises 3 times per week.

MAIN OUTCOME MEASURES

Pain intensity, functional performance, psychological symptoms, and quality of life were assessed pre-exercise and immediately after the first, fourth, and eighth weeks of intervention.

RESULTS

Pain intensity, functional performance, psychological symptoms, and quality of life increased significantly in both groups (P<.05); however, no significant differences between groups were found in all outcomes (P>.05).

CONCLUSION

tDCS associated with functional exercises did not enhance the effects of physical exercise on pain, functional performance, psychological symptoms, and quality of life of patients with FM.

Deep Brain Stimulation of the Posterior Insula in Chronic Pain: A Theoretical Framework

INTRODUCTION

To date, clinical trials of deep brain stimulation (DBS) for refractory chronic pain have yielded unsatisfying results. Recent evidence suggests that the posterior insula may represent a promising DBS target for this indication.

METHODS

We present a narrative review highlighting the theoretical basis of posterior insula DBS in patients with chronic pain.

RESULTS

Neuroanatomical studies identified the posterior insula as an important cortical relay center for pain and interoception. Intracranial neuronal recordings showed that the earliest response to painful laser stimulation occurs in the posterior insula. The posterior insula is one of the only regions in the brain whose low-frequency electrical stimulation can elicit painful sensations. Most chronic pain syndromes, such as fibromyalgia, had abnormal functional connectivity of the posterior insula on functional imaging. Finally, preliminary results indicated that high-frequency electrical stimulation of the posterior insula can acutely increase pain thresholds.

CONCLUSION

In light of the converging evidence from neuroanatomical, brain lesion, neuroimaging, and intracranial recording and stimulation as well as non-invasive stimulation studies, it appears that the insula is a critical hub for central integration and processing of painful stimuli, whose high-frequency electrical stimulation has the potential to relieve patients from the sensory and affective burden of chronic pain.

Transcranial Alternating Current Stimulation (tACS) Does Not Affect Sports People's Explosive Power: A Pilot Study

Purpose: This study is aimed to preliminary investigate whether transcranial alternating current stimulation (tACS) could affect explosive power considering genetic background in sport subjects. Methods: Seventeen healthy sports volunteers with at least 3 years of sports activities participated in the experiment. After 2 weeks of familiarization performed without any stimulation, each participant received either 50 Hz-tACS or sham-tACS. Before and after stimulation, subjects performed the following tests: (1) the squat jump with the hands on the hips (SJ); (2) countermovement jump with the hands on the hips (CMJ); (3) countermovement jump with arm swing (CMJ-AS); (4) 15-s Bosco's test; (5) seated backward overhead medicine ball throw (SBOMBT); (6) seated chest pass throw (SCPT) with a 3-kg rubber medicine ball; and (7) hand-grip test. Additionally, saliva samples were collected from each participant. Genotyping analysis was carried out by polymerase chain reaction (PCR). Results: No significant differences were found in sport performance of subjects after 50 Hz-tACS. Additionally, we did not find any influence of genetic background on tACS-related effect on physical performance. These results suggest that tACS at gamma frequency is not able to induce an after-effect modulating sport performance. Further investigations with larger sample size are needed in order to understand the potential role of non-invasive brain stimulation techniques (NIBS) in motor performances. Conclusions: Gamma-tACS applied before the physical performance fails to improve explosive power in sport subjects.

Repetitive transcranial magnetic stimulation (rTMS) versus transcranial direct current stimulation (tDCS) in the management of patients with fibromyalgia: A randomized controlled trial

OBJECTIVES

The aim of this study was to compare the effects of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) on pain and quality of life in patients with fibromyalgia.

METHODS

Thirty participants were randomized into two groups of 15 patients, to receive 3 sessions of either high-frequency (10 Hz) rTMS or 2 mA, 20 min anodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex (DLPFC) over 1 week. Pain was assessed using a Visual Analog Scale (VAS) before treatment, immediately after treatment, 6 and 12 weeks later. Quality of life was evaluated using the Revised Fibromyalgia Impact Questionnaire (FIQR) and psychiatric symptoms were measured using the Depression Anxiety Stress Scale-21 Item (DASS-21) before treatment, and 6 and 12 weeks after treatment.

RESULTS

For the VAS there was a significant time-group interaction, showing that the behavior of two groups differed regarding changes of VAS in favor of the RTMS group (df = 1.73, F = 4.80, p = <0.016). Time-group interaction effect on DASS-21 and FIQR was not significant. 66.6% of patients in rTMS group and 26.6% of patients in tDCS group experienced at least a 30% reduction of VAS from baseline to last follow-up (p = 0.028).

DISCUSSION

With the methodology used in this study, both rTMS and tDCS were safe modalities and three sessions of rTMS over DLPFC had greater and longer lasting analgesic effects compared to tDCS in patients with FM. However, considering the limitations of this study, further studies are needed to explore the most effective modality.

Augmentation of EMDR with multifocal transcranial current stimulation (MtCS) in the treatment of fibromyalgia: study protocol of a double-blind randomized controlled exploratory and pragmatic trial

BACKGROUND

Fibromyalgia (FM) is a generalized, widespread chronic pain disorder affecting 2.7% of the general population. In recent years, different studies have observed a strong association between FM and psychological trauma. Therefore, a trauma-focused psychotherapy, such as eye movement desensitization and reprocessing (EMDR), combined with a non-invasive brain stimulation technique, such as multifocal transcranial current stimulation (MtCS), could be an innovative adjunctive treatment option. This double-blind randomized controlled trial (RCT) analyzes if EMDR therapy is effective in the reduction of pain symptoms in FM patients and if its potential is boosted with the addition of MtCS.

METHODS

Forty-five patients with FM and a history of traumatic events will be randomly allocated to Waiting List, EMDR + active-MtCS, or EMDR + sham-MtCS. Therapists and patients will be kept blind to MtCS conditions, and raters will be kept blind to both EMDR and MtCS. All patients will be evaluated at baseline, post-treatment, and follow-up at 6 months after post-treatment. Evaluations will assess the following variables: sociodemographic data, pain, psychological trauma, sleep disturbance, anxiety and affective symptoms, and wellbeing.

DISCUSSION

This study will provide evidence of whether EMDR therapy is effective in reducing pain symptoms in FM patients, and whether the effect of EMDR can be enhanced by MtCS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04084795 . Registered on 2 August 2019.

Beyond physiotherapy and pharmacological treatment for fibromyalgia syndrome: tailored tACS as a new therapeutic tool

Fibromyalgia syndrome (FMS) is a complex pain disorder, characterized by diffuse pain and cognitive disturbances. Abnormal cortical oscillatory activity may be a promising biomarker, encouraging non-invasive neurostimulation techniques as a treatment. We aimed to modulate abnormal slow cortical oscillations by delivering transcranial alternating current stimulation (tACS) and physiotherapy to reduce pain and cognitive symptoms. This was a double-blinded, randomized, crossover trial conducted between February and September 2018 at the Rehabilitation Unit of a teaching Hospital (NCT03221413). Participants were randomly assigned to tACS or random noise stimulation (RNS), 5 days/week for 2 weeks followed by ad hoc physiotherapy. Clinical and cognitive assessments were performed at T₀ (baseline), T₁ (after stimulation), T₂ (1 month after stimulation). Electroencephalogram (EEG) spectral topographies recorded from 15 participants confirmed slow-rhythm prevalence and provided tACS tailored stimulation parameters and electrode sites. Following tACS, EEG alpha1 ([8-10] Hz) activity increased at T₁ (p = 0.024) compared to RNS, pain symptoms assessed by Visual Analog Scale decreased at T₁ (T₁ vs T₀ p = 0.010), self-reported cognitive skills and neuropsychological scores improved both at T₁ and T₂ (Patient-Reported Outcomes in Cognitive Impairment, T₀-T₂, p = 0.024; Everyday memory questionnaire, T₁ compared to RNS, p = 0.012; Montréal Cognitive Assessment, T₀ vs T₁, p = 0.048 and T₀ vs T₂, p = 0.009; Trail Making Test B T₀-T₂, p = 0.034). Psychopathological scales and other neuropsychological scores (Trail Making Test-A; Total Phonemic Fluency; Hopkins Verbal Learning Test-Revised; Rey-Osterrieth Complex Figure) improved both after tACS and RNS but earlier improvements (T₁) were registered only after tACS. These results support tACS coupled with physiotherapy in treating FMS cognitive symptoms, pain and subclinical psychopathology.

Fibromyalgia: Recent Advances in Diagnosis, Classification, Pharmacotherapy and Alternative Remedies

Fibromyalgia (FM) is a syndrome that does not present a well-defined underlying organic disease. FM is a condition which has been associated with diseases such as infections, diabetes, psychiatric or neurological disorders, rheumatic pathologies, and is a disorder that rather than diagnosis of exclusion requires positive diagnosis. A multidimensional approach is required for the management of FM, including pain management, pharmacological therapies, behavioral therapy, patient education, and exercise. The purpose of this review is to summarize the recent advances in classification criteria and diagnostic criteria for FM as well as to explore pharmacotherapy and the use of alternative therapies including the use of plant bioactive molecules.

Methods and strategies of tDCS for the treatment of pain: current status and future directions

INTRODUCTION

Transcranial direct current stimulation (tDCS) is a noninvasive neuromodulation technique that has been widely studied for the treatment of chronic pain. It is considered a promising and safe alternative pain therapy. Different targets have been tested, each having their own particular mechanisms for modulating pain perception.

AREAS COVERED

We discuss the current state of the art of tDCS to manage pain and future strategies to optimize tDCS' effects. Current strategies include primary motor cortex tDCS, prefrontal tDCS and tDCS combined with behavioral interventions while future strategies, on the other hand, include high-intensity tDCS, transcutaneous spinal direct current stimulation, cerebellar tDCS, home-based tDCS, and tDCS with extended number of sessions.

EXPERT COMMENTARY

It has been shown that the stimulation of the prefrontal and primary motor cortex is efficient for pain reduction while a few other new strategies, such as high-intensity tDCS and network-based tDCS, are believed to induce strong neuroplastic effects, although the underlying neural mechanisms still need to be fully uncovered. Hence, conventional tDCS approaches demonstrated promising effects to manage pain and new strategies are under development to enhance tDCS effects and make this approach more easily available by using, for instance, home-based devices.

Open-tES: An open-source stimulator for transcranial electrical stimulation designed for rodent research

Non-invasive neuromodulatory techniques, including transcranial direct current stimulation (tDCS), have been shown to modulate neuronal function and are used both in cognitive neuroscience and to treat neuropsychiatric conditions. In this context, animal models provide a powerful tool to identify the neurobiological mechanisms of action of tDCS. However, finding a current generator that is easily usable and which allows a wide range of stimulation parameters can be difficult and/or expensive. Here, we introduce the Open-tES device, a project under a Creative Commons License (CC BY, SA 4.0) shared on the collaborative platform Git-Hub. This current generator allows tDCS (and other kinds of stimulations) to be realized, is suitable for rodents, is easy to use, and is low-cost. Characterization has been performed to measure the precision and accuracy of the current delivered. We also aimed to compare its effects with a commercial stimulator used in clinical trials (DC-Stimulator Plus, NeuroConn, Germany). To achieve this, a behavioral study was conducted to evaluate its efficacy for decreasing depression related-behavior in mice. The stimulator precision and accuracy were better than 250 nA and 25 nA, respectively. The behavioral evaluation performed in mice in the present study did not reveal any significant differences between the commercial stimulator used in clinical trials and the Open-tES device. Accuracy and precision of the stimulator ensure high repeatability of the stimulations. This current generator constitutes a reliable and inexpensive tool that is useful for preclinical studies in the field of non-invasive electrical brain stimulation.

The effectiveness and safety of electrotherapy in the management of fibromyalgia

Treating fibromyalgia is a challenging task for physicians. With its multifaceted features, fibromyalgia requires a comprehensive management strategy focusing on both the pharmacological and non-pharmacological treatment options. During the last decades, there has been growing evidence regarding the role of electrotherapy in fibromyalgia treatment. In this regard, the present article aimed to review the recent literature on the effectiveness and safety of the electrotherapy in the treatment of fibromyalgia. A literature search was conducted through PubMed/MEDLINE and Scopus databases. Transcutaneous electrical nerve stimulation (TENS), non-invasive brain stimulation (transcranial direct current/magnetic stimulation), and light amplification by stimulated emission of radiation (LASER) emerged as the most commonly examined electrotherapy techniques in fibromyalgia. Currently, there is growing data regarding the effectiveness of electrotherapy in the management of fibromyalgia-related pain. Besides, non-invasive electrotherapy techniques are related to no/minor side effects. Further studies are warranted to identify the optimal treatment protocols for each electrotherapy modality.

Supervised transcranial direct current stimulation (tDCS) at home: A guide for clinical research and practice

BACKGROUND

Transcranial direct current stimulation (tDCS) is a method of noninvasive neuromodulation and potential therapeutic tool to improve functioning and relieve symptoms across a range of central and peripheral nervous system conditions. Evidence suggests that the effects of tDCS are cumulative with consecutive daily applications needed to achieve clinically meaningful effects. Therefore, there is growing interest in delivering tDCS away from the clinic or research facility, usually at home.

OBJECTIVE

To provide a comprehensive guide to operationalize safe and responsible use of tDCS in home settings for both investigative and clinical use.

METHODS

Providing treatment at home can improve access and compliance by decreasing the burden of time and travel for patients and their caregivers, as well as to reach those in remote locations and/or living with more advanced disabilities.

RESULTS

To date, methodological approaches for at-home tDCS delivery have varied. After implementing the first basic guidelines for at-home tDCS in clinical trials, this work describes a comprehensive guide for facilitating safe and responsible use of tDCS in home settings enabling access for repeated administration over time.

CONCLUSION

These guidelines provide a reference and standard for practice when employing the use of tDCS outside of the clinic setting.

Mutual interaction between motor cortex activation and pain in fibromyalgia: EEG-fNIRS study

BACKGROUND

Experimental and clinical studies suggested an analgesic effect on chronic pain by motor cortex activation. The present study explored the complex mechanisms of interaction between motor and pain during performing the slow and fast finger tapping task alone and in concomitant with nociceptive laser stimulation.

METHOD

The participants were 38 patients with fibromyalgia (FM) and 21 healthy subjects. We used a simultaneous multimodal method of laser-evoked potentials and functional near-infrared spectroscopy to investigate metabolic and electrical changes during the finger tapping task and concomitant noxious laser stimulation. Functional near-infrared spectroscopy is a portable and optical method to detect cortical metabolic changes. Laser-evoked potentials are a suitable tool to study the nociceptive pathways function.

RESULTS

We found a reduced tone of cortical motor areas in patients with FM compared to controls, especially during the fast finger tapping task. FM patients presented a slow motor performance in all the experimental conditions, requesting rapid movements. The amplitude of laser evoked potentials was different between patients and controls, in each experimental condition, as patients showed smaller evoked responses compared to controls. Concurrent phasic pain stimulation had a low effect on motor cortex metabolism in both groups nor motor activity changed laser evoked responses in a relevant way. There were no correlations between Functional Near-Infrared Spectroscopy (FNIRS) and clinical features in FM patients.

CONCLUSION

Our findings indicated that a low tone of motor cortex activation could be an intrinsic feature in FM and generate a scarce modulation on pain condition. A simple and repetitive movement such as that of the finger tapping task seems inefficacious in modulating cortical responses to pain both in patients and controls. The complex mechanisms of interaction between networks involved in pain control and motor function require further studies for the important role they play in structuring rehabilitation strategies.

Computed tomography-guided navigated transcranial magnetic stimulation for preoperative brain motor mapping in brain lesion resection: A case report

Background:

Navigated transcranial magnetic stimulation (nTMS) is a well establish a noninvasive method for preoperative brain motor mapping. We commonly use magnetic resonance imaging (MRI) to supply the nTMS system. In some cases, MRI is not possible or available, and the use of computed tomography (CT) is necessary. We present the first report describing the association of CT and nTMS motor mapping for brain lesion resection.

Case Description:

CT imaging of a 59-year-old man suffering from acquired immune deficiency syndrome for 17 years, presenting with seizure and right hemiparesis, revealed a small single hypodense ring-enhancing lesion in the left central sulci suggesting cerebral toxoplasmosis. After 3 weeks of neurotoxoplasmosis treatment, due to four consecutive tonic-clonic seizures, a new CT scan was performed and showed no lesion changes. MRI was in maintenance at that time. Infectious diseases department suggested a brain lesion biopsy. Due to lesion’s location, we decided to perform a presurgical nTMS motor mapping. After a small craniotomy, we could precisely locate and safely totally remove the lesion. The pathology report revealed a high suspicious toxoplasmosis pattern. The patient was discharged after 2 days and continued toxoplasmosis treatment. After 6 months follow-up, he showed no signs of any procedure-related deficits or radiological recurrence.

Conclusion:

We report the feasibility and applicability of nTMS motor mapping using CT scan as an image source. It gives neurosurgeons another possibility to perform motor mapping for brain lesion removal, especially when MRI is not available or feasible.