Central Neuromodulation for Chronic Pain: Invasive and Noninvasive Techniques

Ricardo Cruciani, MD, PhD

Vice-Chairman and Director of the Research Division
Department of Pain Medicine and Palliative Care
Beth Israel Medical Center
New York, New York

Neurostimulatory manipulation of cortical signaling is being explored as a potential treatment strategy for chronic pain. Pain treatment has traditionally been based on pharmacologic agents that target various peripheral and central neural pathways related to nociceptive signaling. On the other hand, cortical neurostimulation directly targets specific areas of the sensory cortex. One early study of amputees with phantom limb pain showed that cortical stimulation altered neural representations of the amputated limbs, providing evidence for changes neural excitability and plasticity in adult patients. Clinical research then began to examine noninvasive brain stimulation techniques, such as transcranial magnetic stimulation and transcortical direct current stimulation, to modulate cortical excitability in individuals with chronic pain. While the clinical use of these techniques is still evolving, studies have demonstrated their ability to reduce pain and modify neurophysiologic correlates of the pain experience. Here, Dr. Cruciani discusses the analgesic mechanisms, data for safety and efficacy, and practical applications of these modalities for a variety of pain conditions.

References

Knotkova H, Cruciani RA. Non-invasive transcranial direct current stimulation for the study and treatment of neuropathic pain. Methods Mol Biol. 2010;617:505-515.
Zaghi S, Heine N, Fregni F. Brain stimulation for the treatment of pain: A review of costs, clinical effects, and mechanisms of treatment for three different central neuromodulatory approaches. J Pain Manag. 2009;2:339-352.
Flor H. The modification of cortical reorganization and chronic pain by sensory feedback. Appl Psychophysiol Biofeedback. 2002;27:215-227.
Lefaucheur JP, Antal A, Ahdab R, et al. The use of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) to relieve pain. Brain Stimul. 2008;1:337-344.

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