Modulating pain in crps with tdcs
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Modulating pain in CRPS with tDCS. Giridhar Gundu , M.D. PGY III Dept. of PM&R University of Kentucky 5/22/2012. Complex regional pain syndrome. CRPS is a highly painful, limb-confined condition , which arises usually after trauma.

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Modulating pain in CRPS with tDCS

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Modulating pain in crps with tdcs

Modulating pain in CRPS with tDCS

GiridharGundu, M.D.

PGY III

Dept. of PM&R

University of Kentucky

5/22/2012


Complex regional pain syndrome

Complex regional pain syndrome

  • CRPS is a highly painful, limb-confined condition, which arises usually after trauma.

  • Associated with a particularly poor quality of life, and large health-care and societal costs.

  • Crossroads of interests of several disciplines including rheumatology, pain medicine, neurology, physiatry.


Clinical presentation of crps

Clinical presentation of CRPS

Early CRPS of the right hand:

Clearly visible signs include swelling, red color and a shiny skin.

As the disease progresses some of these visible signs can partially or completely disappear while pain may persist unabated.


Patients with crps can present in many different ways

Patients with CRPS can present in many different ways…….

  • Limbs can be hot or cold, shiny, swollen or thin, red or blue with scaling or clammy skin.

  • Some patients cannot tolerate slight air movement on their skin, while others have completely lost the ability to feel any stimulus to the limb (with normal nerve conduction studies).

  • Blister formation, skin ulcerations, severe atrophy, joint ankylosis, dystonia and myoclonus may also be present.

  • Joints usually feel stiff with reduced range and weakness; often limb parts cannot be moved at all, and there is a fine tremor.


Causes of crps

Causes of CRPS

UNKNOWN???????


Modulating pain in crps with tdcs

There are currently eight major concepts about CRPS etiology.

  • Inflammatory process

  • Sympathetically mediated disorder

  • Autoimmune condition

  • Limb ischemia/ischemia reperfusion injury

  • Cortical reorganization

  • Nerve damage

  • Neurogenic inflammation

  • Alternative concepts


Modulating pain in crps with tdcs

  • The IASP has proposed dividing CRPS into two types based on the presence of nerve lesion following the injury:

  • CRPS type I (reflex sympathetic dystrophy). Minor injuries or fracture of a limb precede the onset of symptoms.

  • CRPS type II (causalgia) develops after injury to a major peripheral nerve.


Modulating pain in crps with tdcs

  • CRPS diagnosis is based upon clinical criteria and that there is so far no gold standard nor any objective diagnostic tool.

  • It is a diagnosis of exclusion.

  • Budapest Criteria used for diagnosis


Modulating pain in crps with tdcs

4. No other diagnosis can better explain the signs and symptoms.


Diagnostic tests which may aid the diagnosis of crps

Diagnostic tests which may aid the diagnosis of CRPS

  • X-ray

  • 3-phase bone scan

  • Quantitative sensory testing (QST)

  • Autonomic testing

  • Thermography


Modulating pain in crps with tdcs

http://www.medscape.com/viewarticle/430537_7


Treatment

Treatment


Treatment1

Treatment

  • Pharmacological (Gabapentin, corticosteroids,antidepressants, anticonvulsants, opioids capsaicin, lidocaine, clonazepam, ketamine, bisphosphonates)

  • Interventional

  • Neurostimulatory

  • Psychological/CBT

  • Physical and vocational rehabilitation

  • Patient education

    There is a desperate need for further research into the treatment of CRPS


Transcranial direct current stimulation tdcs

Transcranialdirect current stimulation (tDCS)

  • Uses weak electrical currents (1-2mA) to modulate the activity of neurons in the brain

  • In tDCS, the anodal electrode placed over the cortical target results in increased cortical excitability, whereas cathodal stimulation decreases local cortical excitability.


Modulating pain in crps with tdcs

  • The primary action of tDCS for pain reduction is direct modulation of activity in certain areas of the brain that are involved in pain processing, such as the thalamus and inhibitory corticospinal mechanisms.

  • tDCSis used in other pain syndromes, such as fibromyalgia, phantom pain and central pain in traumatic spinal cord injury.


Objectives

Objectives

Our proposed study has 2 specific aims:

  • Determine the effect of tDCS on pain and quality of life associated with CRPS.

  • Determine the specificity of tDCS site for modulation of pain and quality of life associated with CRPS.


Study design

Study Design

  • Double-blind, randomized, placebo-controlled study

  • Subjects stratified based on pain intensity and duration of CRPS.

  • Subjects then randomly assigned to 1of the following 3 groups:

  • Group 1: anodal tDCS over DLPFC

  • Group 2: anodal tDCS over M1

  • Group 3: sham tDCSover DLPFC


Modulating pain in crps with tdcs

4 evaluation sessions and 10 treatment sessions with each subject

1 week

1 week

1 week

1 week

T0

T1

Begin

treatment

T3

T4


Study population

Study Population

  • Inclusion criteria:

    Subjects must be at least 18 years of age with diagnosed CRPS following the recently updated Budapest criteria

  • Exclusion criteria:

  • Within 1 month of recruitment, addition or change in the dosage of drugs known to interfere with pain

  • Untreated depression

  • History of head injury with loss of consciousness, severe alcohol or drug abuse, or psychiatric illness, Seizure disorder

  • Pregnancy

  • Presence of ferromagnetic material in the cranium except in the mouth, including metal fragments from occupational exposure, and surgical clips in or near the brain.


Intervention

Intervention

  • One 35 cm2saline-soaked sponge electrodes placed over the scalp sites overlying the relevant cortex and reference electrode placed supraorbitally.

  • Battery-operated direct current stimulator for delivery of stimulation (Magstim Ltd., Wales, UK).

  • With the exception of the control group, each subject will receive 20 minutes of tDCS at an intensity of 1.4mA. (These values result in a current density of 0.04mA/cm2 and a charge density of 480 Coulombs/M2)

  • For the control condition, stimulation intensity will be ramped up then ramped down over a 30-second window.


Assessment

Assessment

  • Short-Form McGill Pain Questionnaire, which will serve as the primary behavioral outcome for this study.

  • The SF-36 Health Survey will be used to measure changes in quality of life.


References

References

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  • Perez RS, Kwakkel G, Zuurmond WW, de Lange JJ. Treatment of reflex sympathetic dystrophy (crps type 1): A research synthesis of 21 randomized clinical trials. J Pain Symptom Manage. 2001;21:511-526

  • PicarelliH, Teixeira MJ, de Andrade DC, Myczkowski ML, Luvisotto TB, Yeng LT, Fonoff ET, Pridmore S, Marcolin MA. Repetitive transcranial magnetic stimulation is efficacious as an add-on to pharmacological therapy in complex regional pain syndrome (crps) type i. J Pain. 2010;11:1203-1210

  • PlegerB, Janssen F, Schwenkreis P, Volker B, Maier C, Tegenthoff M. Repetitive transcranial magnetic stimulation of the motor cortex attenuates pain perception in complex regional pain syndrome type i. NeurosciLett. 2004;356:87-90

  • Goebel A. Complex regional pain syndrome in adults. Rheumatology (Oxford). 2011;50:1739-1750

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  • Grachev ID, Thomas PS, Ramachandran TS. Decreased levels of n-acetylaspartate in dorsolateral prefrontal cortex in a case of intractable severe sympathetically mediated chronic pain (complex regional pain syndrome, type i). Brain Cogn. 2002;49:102-113

  • Seminowicz DA, Wideman TH, Naso L, Hatami-Khoroushahi Z, Fallatah S, Ware MA, Jarzem P, Bushnell MC, Shir Y, Ouellet JA, Stone LS. Effective treatment of chronic low back pain in humans reverses abnormal brain anatomy and function. J Neurosci. 2011;31:7540-7550


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References2

References

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References3

References

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Modulating pain in crps with tdcs

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