Long-Term Analgesic Effects of Transcranial Direct Current Stimulation of the Motor Cortex on Phantom Limb and Stump Pain: A Case Report (original) (raw)
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Mediterranean Journal of Clinical Psychology, 2020
Phantom limb phenomena are often reported by patients after the amputation or deafferentation of limbs. The most debilitating condition is named phantom limb pain and, to present, an efficacious treatment is not been identify, yet. However, alternative non-invasive treatments such as transcranial direct current stimulation could be a valid approach in order to modulate pain. Based on the studies considered, tDCS might represent a potential novel tool able to reduce phantom limb symptoms. Due to the limited number of investigations, the positive outcomes summarized in this letter to editor need to be interpreted with caution.
Cephalalgia, 2011
Objective: The study was conducted to investigate the after-effect of transcranial direct current stimulation (tDCS) applied over the human primary motor cortex (M1) on trigeminal and extracranial nociceptive processing. Basic procedures: Nineteen healthy volunteers were stimulated using cathodal, anodal (both 1 mA) or sham tDCS for 20 minutes. Pain processing was assessed by recording trigeminal and extracranial pain-related evoked potentials (PREPs) following electrical stimulation of the contralateral forehead and hand at baseline, 0, 20 and 50 minutes post-tDCS. Main findings: Cathodal tDCS resulted in decreased peak-to-peak amplitudes (PPAs) by 18% while anodal tDCS lead to increased PPAs of PREPs by 35% (p < .05). Principal conclusions: The decreased PPAs suggest an inhibition and the increased PPAs of PREPs suggest an excitation of trigeminal and extracranial pain processing induced by tDCS of the M1. These results may provide evidence for the effectiveness of tDCS as a therapeutic instrument in treating headache disorders.
Chronic subdural cortical stimulation for phantom limb pain: report of a series of two cases
Acta Neurochirurgica, 2019
Phantom limb pain is a complex, incompletely understood pain syndrome that is characterized by chronic painful paresthesias in a previous amputated body part. Limited treatment modalities exist that provide meaningful relief, including pharmacological treatments and spinal cord stimulation that are rarely successful for refractory cases. Here, we describe our two-patient cohort with recalcitrant upper extremity phantom limb pain treated with chronic subdural cortical stimulation. The patient with evidence of cortical reorganization and almost 60 years of debilitating phantom limb pain experienced sustained analgesic relief at a follow-up period of 6 months. The second patient became tolerant to the stimulation and his pain returned to baseline at a 1-month follow-up. Our unique case series report adds to the growing body of literature suggesting critical appraisal before widespread implementation of cortical stimulation for phantom limb pain can be considered.
Motor Cortex Stimulation in Patients with Chronic Central Pain
Advances in Clinical and Experimental Medicine, 2015
Background. Motor cortex stimulation is one of the neuromodulation methods of treating refractory central neurogenic pain. Objectives. The aim of this study was to retrospectively evaluate the effects of motor cortex stimulation. Material and Methods. The study group consisted of 14 consecutive patients with thalamic pain, atypical facial pain, post-brachial plexus avulsion injury pain, phantom pain and pain in syringomyelia who were treated with motor cortex stimulation at the Department of Neurosurgery of the Military Research Hospital in Bydgoszcz, Poland, from 2005 to 2013. The procedures were conducted with the use of neurosurgical navigation and intraoperative neurophysiological monitoring. The outcomes were assessed in terms of visual analog scale scores. The long-term follow-up ranged from one to six years. Results. A statistically significant reduction in the intensity of pain was noted in patients treated with motor cortex stimulation (pre-surgery median visual analog scale = 9, short-term result median visual analog scale = 3, p = 0.0009; long-term result median visual analog scale = 5, p = 0.0036). Over the long term, with follow-ups ranging from one to six years, the results were excellent (over 80% reduction in pain) in 31% of the patients and satisfactory (50-80% reduction in pain) in 23% of the patients. Unsatisfactory pain control (less than 50%) was noted in 31% of the patients and no improvement was noted in 15%. Significantly better relief of pain was observed in the early postoperative period. In this series of patients, the highest efficacy of motor cortex stimulation was observed in post-stroke or post-hemorrhagic thalamic pain (5/7 patients-71%). Long-term outcomes were not related to the age or sex of the patient, the preoperative duration of the pain, or to the position or number of implanted electrodes. Conclusions. MCS significantly reduces the intensity of neurogenic pain. The best long-term results in the present study were achieved in patients with thalamic syndrome. No significant predictors were found for a successful final outcome. The authors consider appropriate selection of patients, accurate placement of the electrodes and frequent adjusting of the stimulation parameters to be important factors increasing the efficacy of MCS (Adv Clin Exp Med 2015, 24, 2, 289-296).
Chronic Motor Cortex Stimulation for Phantom Limb Pain
Neurosurgery, 2008
OBJECTIVE AND IMPORTANCE: Chronic motor cortex stimulation has provided satisfactory control of pain in patients with central or neuropathic trigeminal pain. We used this technique in a patient who experienced phantom limb pain. Functional magnetic resonance imaging (fMRI) was used to guide electrode placement and to assist in understanding the control mechanisms involved in phantom limb pain. CLINICAL PRESENTATION: A 45-year-old man whose right arm had been amputated 2 years previously experienced phantom limb pain and phantom limb phenomena, described as the apparent possibility of moving the amputated hand voluntarily. He was treated with chronic motor cortex stimulation. INTERVENTION: Data from fMRI were used pre-and postoperatively to detect shoulder and stump cortical activated areas and the "virtual" amputated hand cortical area. These sites of preoperative fMRI activation were integrated in an infrared-based frameless stereotactic device for surgical planning. Phantom limb virtual finger movement caused contralateral primary motor cortex activation. Satisfactory pain control was obtained; a 70% reduction in the phantom limb pain was achieved on a visual analog scale. Postoperatively and under chronic stimulation, inhibiting effects on the primary sensorimotor cortex as well as on the contralateral primary motor and sensitive cortices were detected by fMRI studies. CONCLUSION: Chronic motor cortex stimulation can be used to relieve phantom limb pain and phantom limb phenomena. Integrated by an infrared-based frameless stereotactic device, fMRI data are useful in assisting the neurosurgeon in electrode placement for this indication. Pain control mechanisms and cortical reorganization phenomena can be studied by the use of fMRI.
Motor and parietal cortex stimulation for phantom limb pain and sensations
PAIN, 2013
Limb amputation may lead to chronic painful sensations referred to the absent limb, ie phantom limb pain (PLP), which is likely subtended by maladaptive plasticity. The present study investigated whether transcranial direct current stimulation (tDCS), a noninvasive technique of brain stimulation that can modulate neuroplasticity, can reduce PLP. In 2 double-blind, sham-controlled experiments in subjects with unilateral lower or upper limb amputation, we measured the effects of a single session of tDCS (2 mA, 15 min) of the primary motor cortex (M1) and of the posterior parietal cortex (PPC) on PLP, stump pain, nonpainful phantom limb sensations and telescoping. Anodal tDCS of M1 induced a selective shortlasting decrease of PLP, whereas cathodal tDCS of PPC induced a selective short-lasting decrease of nonpainful phantom sensations; stump pain and telescoping were not affected by parietal or by motor tDCS. These findings demonstrate that painful and nonpainful phantom limb sensations are dissociable phenomena. PLP is associated primarily with cortical excitability shifts in the sensorimotor network; increasing excitability in this system by anodal tDCS has an antalgic effect on PLP. Conversely, nonpainful phantom sensations are associated to a hyperexcitation of PPC that can be normalized by cathodal tDCS. This evidence highlights the relationship between the level of excitability of different cortical areas, which underpins maladaptive plasticity following limb amputation and the phenomenology of phantom limb, and it opens up new opportunities for the use of tDCS in the treatment of PLP.
Transcranial Direct Current Stimulation in Neuropathic Pain
Journal of pain & relief, 2013
Neuropathic pain (NP) is one of the most common problems contributing to suffering and disability worldwide. Unfortunately, NP is also largely refractory to treatments, with a large number of patients continuing to report significant pain even when they are receiving recommended medications and physical therapy. Thus, there remains an urgent need for additional effective treatments. In recent years, nonpharmacologic brain stimulation techniques have emerged as potential therapeutic options. Many of these techniques and procedures - such as transcranial magnetic stimulation, spinal cord stimulation, deep brain stimulation, and motor cortical stimulation - have very limited availability, particularly in developing countries. Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation procedure that has shown promise for effectively treating NP, and also has the potential to be widely available. This review describes tDCS and the tDCS procedures and principles tha...
Case reports in medicine, 2011
Phantom limb pain is very common after limb amputation and is often difficult to treat. The motor cortex stimulation is a valid treatment for deafferentation pain that does not respond to conventional pain treatment, with relief for 50% to 70% of patients. This treatment is invasive as it uses implanted epidural electrodes. Cortical stimulation can be performed noninvasively by repetitive transcranial magnetic stimulation (rTMS). The stimulation of the hemisphere that isn't involved in phantom limb (unaffected hemisphere), remains unexplored. We report a case of phantom limb pain treated with 1 Hz rTMS stimulation over motor cortex in unaffected hemisphere. This stimulation produces a relevant clinical improvement of phantom limb pain; however, further studies are necessary to determine the efficacy of the method and the stimulation parameters.
Clinical Neurophysiology, 2006
Objective: To assess, using a double-blind procedure, the pain-relieving effects of rTMS against placebo, and their predictive value regarding the efficacy of implanted motor cortex stimulation (MCS). Methods: Three randomised, double-blinded, 25 min sessions of focal rTMS (1 Hz, 20 Hz and sham) were performed in 12 patients, at 2 weeks intervals. Effects on pain were estimated from daily scores across 5 days before, and 6 days after each session. Analgesic effects were correlated with those of subsequent implanted motor cortex stimulation (MCS). Results: Immediately after the stimulating session, pain scores were similarly decreased by all rTMS modalities. Conversely, during the following week, 1 Hz stimulation provided significantly less analgesia than 20 Hz and placebo, and was pro-algesic in some patients. Placebo and 20 Hz rTMS were effective on different patients, and only 20 Hz rTMS predicted the efficacy of subsequent MCS, with no false positives. Conclusions: While 1 Hz rTMS should not be used with analgesic purposes, high-frequency rTMS may become useful to select candidates for MCS. Placebo effects are powerful and should be controlled for. Immediate results after a single rTMS session are misleading. Significance: Defining rTMS parameters is a crucial step before proposing rTMS as predictive test of SCM efficacy in clinical practice.
Brain Stimulation, 2008
Chronic pain resulting from injury of the peripheral or central nervous system may be associated with a significant dysfunction of extensive neural networks. Noninvasive stimulation techniques, such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) may be suitable to treat chronic pain as they can act on these networks by modulating neural activities not only in the stimulated area, but also in remote regions that are interconnected to the site of stimulation. Motor cortex was the first cortical target that was proved to be efficacious in chronic pain treatment. At present, significant analgesic effects were also shown to occur after the stimulation of other cortical targets (including prefrontal and parietal areas) in acute provoked pain, chronic neuropathic pain, fibromyalgia, or visceral pain. Therapeutic applications of rTMS in pain syndromes are limited by the short duration of the induced effects, but prolonged pain relief can be obtained by repeating rTMS sessions every day for several weeks. Recent tDCS studies also showed some effects on various types of chronic pain. We review the evidence to date of these two techniques of noninvasive brain stimulation for the treatment of pain.