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      Combining Transcranial Direct Current Stimulation and Transcutaneous Electrical Nerve Stimulation to Relieve Persistent Pain in a Patient Suffering from Complex Regional Pain Syndrome: A Case Report

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          Abstract

          Purpose

          Complex regional pain syndrome (CRPS) is a rare neuropathic pain condition characterized by sensory, motor and autonomic alterations. Previous investigations have shown that transcranial direct current stimulation (tDCS) and transcutaneous electrical nerve stimulation (TENS) can alleviate pain in various populations, and that a combination of these treatments could provide greater hypoalgesic effects. In the present case report, we describe the effect of tDCS and TENS treatment on pain intensity and unpleasantness in a patient suffering from chronic CRPS.

          Results

          The patient was a 37-year-old woman, suffering from left lower limb CRPS (type I) for more than 5 years. Despite medication (pregabalin, tapentadol, duloxetine), rehabilitation treatments (sensorimotor retraining, graded motor imagery) and spinal cord stimulation (SCS), the participant reported moderate to severe pain. Treatments of tDCS alone (performed with SCS turned off during tDCS application, 1 session/day, for 5 consecutive days) did not significantly decrease pain. Combining tDCS with TENS (SCS temporarily turned off during tDCS, 1 session/day, for 5 consecutive days) slightly reduced pain intensity and unpleasantness.

          Discussion

          Our results suggest that combining tDCS and TENS could be a therapeutic strategy worth investigating further to relieve pain in chronic CRPS patients. Future studies should examine the efficacy of combined tDCS and TENS treatments in CRPS patients, and other chronic pain conditions, with special attention to the cumulative and long-term effects and its effect on function and quality of life.

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          Most cited references 39

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          Graded motor imagery for pathologic pain: a randomized controlled trial.

           G. L. Moseley (2006)
          Phantom limb and complex regional pain syndrome type 1 (CRPS1) are characterized by changes in cortical processing and organization, perceptual disturbances, and poor response to conventional treatments. Graded motor imagery is effective for a small subset of patients with CRPS1. To investigate whether graded motor imagery would reduce pain and disability for a more general CRPS1 population and for people with phantom limb pain. Fifty-one patients with phantom limb pain or CRPS1 were randomly allocated to motor imagery, consisting of 2 weeks each of limb laterality recognition, imagined movements, and mirror movements, or to physical therapy and ongoing medical care. There was a main statistical effect of treatment group, but not diagnostic group, on pain and function. The mean (95% CI) decrease in pain between pre- and post-treatment (100 mm visual analogue scale) was 23.4 mm (16.2 to 30.4 mm) for the motor imagery group and 10.5 mm (1.9 to 19.2 mm) for the control group. Improvement in function was similar and gains were maintained at 6-month follow-up. Motor imagery reduced pain and disability in these patients with complex regional pain syndrome type I or phantom limb pain, but the mechanism, or mechanisms, of the effect are not clear.
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            Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition.

            This is the fourth edition of diagnostic and treatment guidelines for complex regional pain syndrome (CRPS; aka reflex sympathetic dystrophy).
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              Effects of anodal transcranial direct current stimulation on chronic neuropathic pain in patients with multiple sclerosis.

              Neuropathic pain in patients with MS is frequent and is associated with a great interference with daily life activities. In the present study, we investigated whether anodal transcranial direct current stimulation (tDCS) may be effective in reducing central chronic pain in MS patients. Patients received sham tDCS or real tDCS in a 5-day period of treatment in a randomized, double blind, sham-controlled study. Pain was measured using visual analog scale (VAS) for pain and the short form McGill questionnaire (SF-MPQ). Quality of life was measured using the Multiple Sclerosis Quality of Life-54 scale (MSQoL-54). Depressive symptoms and anxiety were also evaluated as confounding factors using the Beck Depression Inventory (BDI) and VAS for anxiety. Evaluations were performed at baseline, immediately after the end of treatment, and once a week during a 3-week follow-up period. Following anodal but not sham tDCS over the motor cortex, there was a significant pain improvement as assessed by VAS for pain and McGill questionnaire, and of overall quality of life. No depression or anxiety changes were observed. Our results show that anodal tDCS is able to reduce pain-scale scores in MS patients with central chronic pain and that this effect outlasts the period of stimulation, leading to long-lasting clinical effects. This article presents a new, noninvasive therapeutic approach to chronic, central neuropathic pain in multiple sclerosis, poorly responsive to current conventional medications. tDCS is known to cause long-lasting changes of neuronal excitability at the site of stimulation and in the connected areas in healthy subjects. This led us to hypothesize that pain decrease may be the result of functional plastic changes in brain structures involved in the pathogenesis of chronic neuropathic pain. Copyright 2010 American Pain Society. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                JPR
                jpainres
                Journal of Pain Research
                Dove
                1178-7090
                02 March 2020
                2020
                : 13
                : 467-473
                Affiliations
                [1 ]Research Center on Aging, CIUSSS de l’Estrie - CHUS, Université de Sherbrooke , Sherbrooke, Québec, Canada
                [2 ]Research Center of the Centre hospitalier universitaire de Sherbrooke (CHUS), CIUSSS de l’Estrie – CHUS, Université de Sherbrooke , Sherbrooke, Québec, Canada
                [3 ]Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke , Québec, Canada
                Author notes
                Correspondence: Guillaume Leonard Centre de recherche sur le vieillissement, CIUSSS de l’Estrie - CHUS , 1036, rue Belvédère Sud, Sherbrooke, QuébecJ1H 4C4, CanadaTel +1 (819) 829-7131 ext. 45246Fax +1 (819) 820-6864 Email guillaume.leonard2@usherbrooke.ca
                Article
                226616
                10.2147/JPR.S226616
                7060070
                © 2020 Houde et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 2, References: 50, Pages: 7
                Funding
                GL is supported by the Fonds de recherche du Québec-Santé (FRQ-S).
                Categories
                Case Report

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