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INTRODUCTION: Chronic pain (CP) is highly prevalent and generally undertreated health condition. Noninvasive brain stimulation may contribute to decrease pain intensity and influence other aspects related to CP. OBJECTIVE: To provide consensus-based recommendations for the use of noninvasive brain stimulation in clinical practice. METHODS: Systematic review of the literature searching for randomized clinical trials followed by consensus panel. Recommendations also involved a cost-estimation study. RESULTS: The systematic review wielded 24 transcranial direct current stimulation (tDCS) and 22 repetitive transcranial magnetic stimulation (rTMS) studies. The following recommendations were provided: (1) Level A for anodal tDCS over the primary motor cortex (M1) in fibromyalgia, and level B for peripheral neuropathic pain, abdominal pain, and migraine; bifrontal (F3/F4) tDCS and M1 high-definition (HD)-tDCS for fibromyalgia; Oz/Cz tDCS for migraine and for secondary benefits such as improvement in quality of life, decrease in anxiety, and increase in pressure pain threshold; (2) level A recommendation for high-frequency (HF) rTMS over M1 for fibromyalgia and neuropathic pain, and level B for myofascial or musculoskeletal pain, complex regional pain syndrome, and migraine; (3) level A recommendation against the use of anodal M1 tDCS for low back pain; and (4) level B recommendation against the use of HF rTMS over the left dorsolateral prefrontal cortex in the control of pain. CONCLUSION: Transcranial DCS and rTMS are recommended techniques to be used in the control of CP conditions, with low to moderate analgesic effects, and no severe adverse events. These recommendations are based on a systematic review of the literature and a consensus made by experts in the field. Readers should use it as part of the resources available to decision-making.
RESUMO
INTRODUÇÃO: A osteoartrite do joelho (OA) está associada à dor crônica, comprometimento da função e perda da qualidade de vida. A plasticidade mal-adaptativa do cérebro pode estar envolvida, impedindo efeitos benéficos de exercícios e outras intervenções. A neuromodulação com estimulação elétrica periférica guiada pelo mapeamento da TMS pode influenciar especificamente as modificações mal-adaptativas. OBJETIVO: Comparar a organização cortical e excitabilidade de três músculos (reto femuris, vasto lateral e vasto medial) em um sujeito com OA joelho. MÉTODOS: Este estudo de caso único envolveu uma mulher de 66 anos com OA de joelho que estava considerando se submeter a uma artroplastia. Ela foi avaliada para dor (VAS), função (WOMAC e ICOAP) e força do quadríceps uma vez por semana, durante 10 semanas - ABA (A - avaliação de quatro semanas; B - avaliação de duas semanas e intervenção; A - avaliação de quatro semanas). O mapeamento de TMS foi realizado no início do estudo, após o período de intervenção de duas semanas e no final do estudo. Esse exame inicialmente revelou uma diminuição proeminente no volume da porção do músculo quadríceps do vasto medial sobre o córtex motor primário (M1), que determinou um protocolo de estimulação elétrica periférica projetado especificamente para aumentar a excitabilidade desse músculo. Durante o período de intervenção, o participante também realizou exercícios específicos diariamente. RESULTADOS: Os escores do WOMAC e a força do quadríceps não foram alterados durante o período do estudo. Melhoras foram observadas nas três subescalas do ICOAP após a intervenção. Esta alteração clínica foi associada a um aumento do vasto medial e também do vasto lateral, e uma diminuição nos volumes do mapa da TMS do músculo reto femoral, que foram mantidos até a última avaliação. CONCLUSÃO: O mapeamento do TMS pode guiar intervenções específicas para contrabalançar a plasticidade mal-adaptativa do córtex motor e influenciar positivamente a dor e a função na OA do joelho. [AU]
BACKGROUND: Knee osteoarthritis (OA) is associated with chronic pain, impaired function and loss of quality of life. Brain maladaptive plasticity may be involved and prevent beneficial effects of exercises and other interventions. Neuromodulation with peripheral electrical stimulation guided by TMS mapping may specifically influence those maladaptive modifications. OBJECTIVE: To compare the cortical organization and excitability of three muscles (straight femuris, vastus lateralis and vastus medialis) in a subject with OA knee. METHODS: This single case ABA study involved a 66 yo woman with knee OA that was considering an arthroplasty. She was assessed for pain (VAS), function (WOMAC, ICOAP), and quadriceps strength one time a week, for 10 weeks (A four weeks assessment; B two weeks assessment and intervention; A four weeks assessment). TMS mapping was performed at baseline, after the two-week intervention period and at the end of the study. This examination initially revealed a prominent decrease in the volume of vastus medialis portion of the quadriceps muscle over the primary motor cortex (M1), which determined a peripheral electrical stimulation protocol specifically designed to increase this muscle's excitability. During the intervention period the participant also carried over specific exercises daily. RESULTS: WOMAC scores, and quadriceps strength were not changed during the study period. Improvements were seen in the three subscales of the ICOAP following the intervention. This clinical change was associated with an increase in vastus medialis and also Vastus lateralis, and a decrease in rectus femuris TMS map volumes, which were maintained until the last evaluation. CONCLUSION: TMS mapping may guide specific interventions to counteract motor cortex maladaptive plasticity and positively influence pain and function in knee OA. [AU]