Sports Medicine Research: In the Lab & In the Field: Combining Central and Peripheral Neurostimulation to Reduce Pain (Sports Med Res)


Friday, July 7, 2017

Combining Central and Peripheral Neurostimulation to Reduce Pain

Treating low back pain with combined cerebral and peripheral electrical stimulation: A randomized, double-blind, factorial clinical trial

Hazime FA, Baptista AF, de Freitas DG, Monteiro RL, Maretto RL, Hasue RH, João SMA. Eur J Pain. 2017 Apr 25. doi: 10.1002/ejp.1037. [Epub ahead of print]

Take Home Message: While Transcranial Direct-current stimulation (tDCS) and peripheral electrical stimulation (PES) alone may not provide extended pain relief, combining the two treatments provided immediate and short-term pain relief for people with chronic low back pain.

Despite many people having chronic low back pain there is no gold standard treatment. A possible therapeutic target may be the underlying changes in the brain related to the onset of chronic pain (for example, grey matter degradation in pain sensitizations regions). A potential method to target these changes is transcranial direct-current stimulation (tDCS), which provides a continuous, low current stimulation to the primary motor cortex to increase excitability and modulate pain. Efficacy of tDCS is controversial but combining it with other techniques such as peripheral electrical stimulus (PES) has shown promise. In contrast to tDCS, PES reduces excitability within the primary sensory and motor cortices and stimulates other neural sensitization pathways. Combining both therapies may be more efficacious than isolated tDCS or PES; however, randomized-control trials have yet to be conducted for back pain. Therefore, investigators conducted a randomized control, double blind, clinical trial to determine whether combination therapy of tDCS and PES mitigate chronic low back pain symptoms. Researchers recruited 92 adults with nonspecific chronic low back pain (>3 months) between 18-60 years old at a rehabilitation center and local university. Participants were randomized into four groups that included combination therapy (tDCS + PES), monotherapy of tDCS or PES, or a sham control for tDCS and PES. The participants received 12 electrical stimulation sessions over 4 weeks. The researchers assessed pain intensity with an 11-point numerical rating scale at short-term (4 weeks), medium term (3 months) and long term (6 months) after treatment. Secondary outcomes included disability and global perception. Immediately after treatment, all 3 treatment groups had greater pain relief than the group with a sham treatment. However, there were no differences between treatments. The concurrent therapy of tDCS and PES was the only technique that maintained analgesic effects after 3 months (compared with those who received the sham treatment). The analgesic effects and global perception improvements were lost after 6 months. No treatment impacted disability or other symptoms at any time point.

This study is important because it highlights that isolated treatments of tCDS or PES exhibits some effect for immediate nonspecific chronic low back pain relief but only combination therapy of both techniques provided pain reduction for medium-term (3 months) relief. The extended pain relief after using both modalities concurrently may imply a synergistic effect. While synergistic mechanism is still not understood, the author suggests complementary effects via concurrent activation of opioid receptors and the release of opioids. While a passive intervention such as tDCS and PES may fail to provide functional recovery, the pain-relieving effects they offer may be implemented with other active therapies. While tDCS and PES are not recommended as primary treatment, they do seem to provide some effectiveness as adjunct therapy for pain. 

Questions for Discussion: Do you think concurrent therapy of tDCS and PES has potential to become a mainstream treatment for chronic pain management for athletes?

Written by: Cody Criss & Dustin Grooms
Reviewed by: Jeffrey Driban

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Dana said...

I think it will be at least a few years before these modalities could be considered a mainstream treatment for chronic pain management. More research combining the two modalities to treat pain is necessary in addition to its performance against current treatment interventions. The results are promising yet I would also want to know how it does when combined with active therapies too.

Cody Criss said...

These are great points Dana. What sort of active therapies do you think would be best suited for these modalities?

Dana said...

Hi Cody,

Well to be honest I'm not entirely sure. I would like to see this therapy utilized while progressing a patient to a status where they can be functional without relying only on the respective stimulation interventions [assuming it will be common practice to use this modality combination]. Let it be a starting point to manage pain while incorporating exercises for strength as well as implementing strategies for faulty mechanics at work or with activities of daily living. Any active therapy that can help the patient achieve sustainable pain management beyond the limited timeline these neural stimulations can offer.

Cody Criss said...

Hello Dana,

I completely agree. While these modalities may not be fully effective as primary treatment, they could be a potential adjunct to other therapies. Perhaps, further research may give light to the efficacy of these modalities with exercise and active therapy.

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