Transcutaneous Electrical Nerve Stimulation (TENS) for neuropathic pain in adults (Protocol)

This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the analgesic effectiveness of TENS versus placebo (sham) TENS, TENS versus usual care, TENS versus no treatment and TENS in addition to usual care versus usual care alone in the management of neuropathic pain in adults

Tactile thresholds are preserved yet complex sensory function is impaired over the lumbar spine of chronic non-specific low back pain patients: A preliminary investigation

Evidence indicates that chronic non-specific low back pain (CNSLBP) is associated with alteration in the brain’s cortical representation of the back, resulting in body perception disturbance and contributing to the condition [1,2]. This study investigated perception via ‘cortical’ sensory tests, in this case two-point discrimination and graphaesthesia—whose results partly depend on the integrity of cortical representation [2]. The hypothesis was dysfunction in these higher-order tasks, with simple tactile thresholds remaining unchanged. Furthermore a relationship between cortical sensation and severity of the condition was predicted

Non-invasive brain stimulation techniques for chronic pain (review)

Background This is an updated version of the original Cochrane review published in 2010, Issue 9. Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), transcranial direct current stimulation (tDCS) and reduced impedance non-invasive cortical electrostimulation (RINCE). Objectives To evaluate the efficacy of non-invasive brain stimulation techniques in chronic pain. Search methods We searched CENTRAL (2013, Issue 6), MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS and clinical trials registers. The original search for the review was run in November 2009 and searched all databases from their inception. To identify studies for inclusion in this update we searched from 2009 to July 2013. Selection criteria Randomised and quasi-randomised studies of rTMS, CES, tDCS or RINCE if they employed a sham stimulation control group, recruited patients over the age of 18 with pain of three months duration or more and measured pain as a primary outcome. Data collection and analysis Two authors independently extracted and verified data. Where possible we entered data into meta-analyses. We excluded studies judged as being at high risk of bias from the analysis. We used the GRADE system to summarise the quality of evidence for core comparisons. Main results We included an additional 23 trials (involving 773 participants randomised) in this update, making a total of 56 trials in the review (involving 1710 participants randomised). This update included a total of 30 rTMS studies, 11 CES, 14 tDCS and one study of RINCE(the original review included 19 rTMS, eight CES and six tDCS studies). We judged only three studies as being at low risk of bias across all criteria. Meta-analysis of studies of rTMS (involving 528 participants) demonstrated significant heterogeneity. Pre-specified subgroup analyses suggest that low-frequency stimulation is ineffective (low-quality evidence) and that rTMS applied to the dorsolateral prefrontal cortex is ineffective (very low-quality evidence). We found a short-term effect on pain of active high-frequency stimulation of the motor cortex in single-dose studies (low-quality evidence, standardised mean difference (SMD) 0.39 (95% confidence interval (CI) -0.27 to -0.51 P \u3c 0.01)). This equates to a 12% (95% CI 8% to 15%) reduction in pain, which does not exceed the pre-established criteria for a minimal clinically important difference (≥ 15%). Evidence for multiple-dose studies was heterogenous but did not demonstrate a significant effect (very low-quality evidence). For CES (six studies, 270 participants) no statistically significant difference was found between active stimulation and sham (low-quality evidence). Analysis of tDCS studies (11 studies, 193 people) demonstrated significant heterogeneity and did not find a significant difference between active and sham stimulation (very low-quality evidence). Pre-specified subgroup analysis of tDCS applied to the motor cortex (n = 183) did not demonstrate a statistically significant effect and this lack of effect was consistent for subgroups of single or multiple-dose studies. One small study (n = 91) at unclear risk of bias suggested a positive effect of RINCE over sham stimulation on pain (very low-quality evidence). Non-invasive brain stimulation appears to be frequently associated with minor and transient side effects, though there were two reported incidences of seizure related to active rTMS in the included studies. Authors\u27 conclusions Single doses of high-frequency rTMS of the motor cortex may have small short-term effects on chronic pain. It is likely that multiple sources of bias may exaggerate this observed effect. The effects do not meet the predetermined threshold of minimal clinical significance and multiple-dose studies do not consistently demonstrate effectiveness. The available evidence suggests that low-frequency rTMS, rTMS applied to the pre-frontal cortex, CES and tDCS are not effective in the treatment of chronic pain. While the broad conclusions for rTMS and CES have not changed substantially, the addition of this new evidence and the application of the GRADE system has modified some of our interpretation and the conclusion regarding the effectiveness of tDCS has changed. We recommend that previous readers should re-read this update. There is a need for larger, rigorously designed studies, particularly of longer courses of stimulation. It is likely that future evidence may substantially impact upon the presented results

Non-invasive brain stimulation techniques for chronic pain

Stimulating the brain without surgery in the management of chronic pain in adults Bottom line: There is a lack of high-quality evidence to support or refute the effectiveness of non-invasive brain stimulation techniques for chronic pain. Background: Electrical stimulation of the brain has been used to address a variety of painful conditions. Various devices are available that can electrically stimulate the brain without the need for surgery or any invasive treatment. There are five main treatment types: repetitive transcranial magnetic stimulation (rTMS) in which the brain is stimulated by a coil applied to the scalp, cranial electrotherapy stimulation (CES) in which electrodes are clipped to the ears or applied to the scalp, transcranial direct current stimulation (tDCS), reduced impedance non-invasive cortical electrostimulation (RINCE) and transcranial random noise stimulation (tRNS) in which electrodes are applied to the scalp. These have been used to try to reduce pain by aiming to alter the activity of the brain. How effective they are is uncertain. Study characteristics: This review update included 94 randomised controlled studies: 42 of rTMS, 11 of CES, 36 of tDCS two of RINCE, two of tRNS and one study which evaluated both tDCS and rTMS. Key findings: rTMS applied to the motor cortex may lead to small, short-term reductions in pain but these effects are not likely to be clinically important. tDCS may reduce pain when compared with sham but for rTMS and tDCS our estimates of benefit are likely to be exaggerated by the small number of participants in each of the studies and limitations in the way the studies were conducted. Low- or very low-quality evidence suggests that low-frequency rTMS and rTMS that is applied to prefrontal areas of the brain are not effective. Low-quality evidence does not suggest that CES is an effective treatment for chronic pain. For all forms of stimulation the evidence is not conclusive and there is substantial uncertainty about the possible benefits and harms of the treatment. Of the studies that clearly reported side effects, short-lived and minor side effects such as headache, nausea and skin irritation were usually reported both with real and sham stimulation. Two cases of seizure were reported following real rTMS. Our conclusions for rTMS, CES, tDCS, and RINCE have not changed substantially in this update. Quality of the evidence: We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low-quality evidence means that we are very uncertain about the results. High-quality evidence means that we are very confident in the results. We considered all of the evidence to be of low or very low quality, mainly because of bias in the studies that can lead to unreliable results and the small size of the studies, which makes them imprecise

Moving in an environment of induced sensory-motor incongruence does not influence pain sensitivity in healthy volunteers: A randomised within-subject cross-over experiment

A mismatch between the brain\u27s motor control and sensory systems has been suggested as one mechanism whereby maladaptive neuroplastic changes contribute to the experience of chronic pain. Several studies have investigated this hypothesis by artificially inducing a state of sensory-motor incongruence using mirrors. The data to date appear to suggest that creating an environment of sensori-motor incongruence induces various sensory changes and feeling of peculiarity, however the effect on pain is less clear. The aim of this study was to test the hypothesis that healthy participants would demonstrate reduced pain thresholds and report greater intensity of pain in a condition of induced sensory motor incongruence compared to conditions that did not promote incongruence

Non-invasive brain stimulation techniques for chronic pain. A Cochrane systematic review and meta-analysis

Poster Presentation Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES) and transcranial direct current stimulation (tDCS). These approaches to pain treatment are relatively novel. It is important to assess the existing literature robustly to ascertain the current level of supporting evidence and to inform future research and potential clinical use

Transcranial direct current stimulation of the motor cortex in the treatment of chronic non-specific low back pain. A randomised, double-blind exploratory study

This exploratory study aimed to test the proof of principle that active anodal transcranial direct current stimulation (tDCS) applied to the motor cortex reduces pain significantly more than sham stimulation in a group of participants with chronic non-specific low back pain

Paracetamol, NSAIDS and opioid analgesics for chronic low back pain: A network meta-analysis (Protocol)

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To answer the clinical question: ‘what analgesic medicine shall I prescribe this patient with chronic low back pain to reduce their pain?’. The objectives are to determine the analgesic effects, safety, effect on function, and relative rank according to analgesic effect, safety and effect on function of a single course of opioid analgesics, NSAIDs or paracetamol or combinations of these medicines

The RESOLVE Trial for people with chronic low back pain: Statistical analysis plan

Background: Statistical analysis plans describe the planned data management and analysis for clinical trials. This supports transparent reporting and interpretation of clinical trial results. This paper reports the statistical analysis plan for the RESOLVE clinical trial. The RESOLVE trial assigned participants with chronic low back pain to graded sensory-motor precision training or sham-control. Results: We report the planned data management and analysis for the primary and secondary outcomes. The primary outcome is pain intensity at 18-weeks post randomization. We will use mixed-effects models to analyze the primary and secondary outcomes by intention-to-treat. We will report adverse effects in full. We also describe analyses if there is non-adherence to the interventions, data management procedures, and our planned reporting of results. Conclusion: This statistical analysis plan will minimize the potential for bias in the analysis and reporting of results from the RESOLVE trial. Trial registration: ACTRN12615000610538 (https://www.anzctr.org.au/Trial/Registration/ TrialReview.aspx?id=368619). © 2020 Associac¸ao˜ Brasileira de Pesquisa e Pos-Graduac ´ ¸ao˜ em Fisioterapia. Published by Elsevier Editora Ltda. All rights reserved