Long-Term Analgesic Effects of Transcranial Direct Current Stimulation of the Motor Cortex on Phantom Limb and Stump Pain: A Case Report (original) (raw)
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.
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...
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.
Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology, 2015
Transcranial direct current stimulation (tDCS) has demonstrated efficacy for reducing neuropathic pain, but the respective mechanisms remain largely unknown. The current study tested the hypothesis that pain reduction with tDCS is associated with an increase in the peak frequency spectrum density in the theta-alpha range. Twenty patients with spinal cord injury and bilateral neuropathic pain received single sessions of both sham and anodal tDCS (2mA) over the left primary motor area (M1) for 20min. Treatment order was randomly assigned. Pre- to post-procedure changes in pain intensity and peak frequency of electroencephalogram spectral analysis were compared between treatment conditions. The active treatment condition (anodal tDCS over M1) but not sham treatment resulted in significant decreases in pain intensity. In addition, consistent with the study hypothesis, peak theta-alpha frequency (PTAF) assessed from an electrode placed over the site of stimulation increased more from pre...
Noninvasive transcranial brain stimulation and pain
Current Pain and Headache Reports, 2009
Transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) are two noninvasive brain stimulation techniques that can modulate activity in specific regions of the cortex. At this point, their use in brain stimulation is primarily investigational; however, there is clear evidence that these tools can reduce pain and modify neurophysiologic correlates of the pain experience. TMS has also been used to predict response to surgically implanted stimulation for the treatment of chronic pain. Furthermore, TMS and tDCS can be applied with other techniques, such as event-related potentials and pharmacologic manipulation, to illuminate the underlying physiologic mechanisms of normal and pathological pain. This review presents a description and overview of the uses of two major brain stimulation techniques and a listing of useful references for further study.
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.
Noninvasive Brain Stimulation, Maladaptive Plasticity, and Bayesian Analysis in Phantom Limb Pain
Medical Acupuncture, 2017
Introduction: Phantom limb pain (PLP) is a common and poorly understood pathology of difficult medical control that progressively takes place after amputation occurs. Objective: This article discusses the multifactorial bases of PLP. These bases involve local changes at the stump level, spinal modifications of excitability, deafferentation, and central sensitization, leading to the development of maladaptive plasticity, and consequentially, defective processing of sensory information by associative neural networks. These changes can be traced by neurophysiology and imaging topographical studies, indicating a degree of cortical reorganization that perpetuates pain and discomfort. Intervention: Noninvasive brain stimulation can be an alternative way to manage PLP. This article discusses two techniques-transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS)-that have shown promising results for controlling PLP. The modulation that both techniques rely on is based on synaptic mechanisms linked to long-term potentiation and long-term depression phenomena. By applying tDCS or rTMS, clinicians can target processes associated with central sensitization and maladaptive plasticity, while promoting adequate sensory information processing by integrative cognitive behavioral techniques in a comprehensive rehabilitation program. Conclusions: Understanding PLP from a dynamic neurocomputational perspective will help to develop better treatments. Furthermore, Bayesian analysis of sensory information can help guide and monitor therapeutic interventions directed toward PLP resolution.
Motor cortex stimulation for chronic neuropathic pain: a preliminary study of 10 cases
Pain, 2000
There is growing evidence to support the use of motor cortex stimulation (MCS) in the management of patients with chronic neuropathic pain. A prospective audit of ten patients using a modi®ed staged technique for motor cortex implantation provides further evidence for the analgesic effectiveness of this technique. Ten patients suffering from phantom limb pain (n 3), post stroke pain (n 5), post traumatic neuralgia secondary to gunshot injury to the brain stem (n 1) and brachyalgia secondary to neuro-®bromatosis (n 1) were treated between November 1995 and February 1998. All ten patients had failed to respond to previous multiple pain therapies. Patients were evaluated pre and post-operatively by an independent pain specialist. The overall response rate was 50%, with 5/10 patients reporting short term relief (. 50% pain relief) and long-term bene®t in 4/5 of patients who initially responded to intermittent cortical stimulation (longest follow up 31 months after implantation). Of those patients who bene®ted two had post stroke pain, two phantom limb pain and one posttraumatic neuralgia. We conclude that motor cortex stimulation is an effective analgesic intervention in some patients with chronic neuropathic pain, but it is dif®cult if not impossible to predict those patients who may respond to treatment prior to implantation. Randomised controlled trials are now urgently needed to test the effectiveness of motor cortex stimulation under double-blind conditions. q 2000 International Association for the Study of Pain. Published by Elsevier Science B.V.
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).
Pain, 2006
Past evidence has shown that motor cortical stimulation with invasive and non-invasive brain stimulation is effective to relieve central pain. Here we aimed to study the effects of another, very safe technique of non-invasive brain stimulation -transcranial direct current stimulation (tDCS) -on pain control in patients with central pain due to traumatic spinal cord injury. Patients were randomized to receive sham or active motor tDCS (2 mA, 20 min for 5 consecutive days). A blinded evaluator rated the pain using the visual analogue scale for pain, Clinician Global Impression and Patient Global Assessment. Safety was assessed with a neuropsychological battery and confounders with the evaluation of depression and anxiety changes. There was a significant pain improvement after active anodal stimulation of the motor cortex, but not after sham stimulation. These results were not confounded by depression or anxiety changes. Furthermore, cognitive performance was not significantly changed throughout the trial in both treatment groups. The results of our study suggest that this new approach of cortical stimulation can be effective to control pain in patients with spinal cord lesion. We discuss potential mechanisms for pain amelioration after tDCS, such as a secondary modulation of thalamic nuclei activity. Ó