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Non-invasive brain stimulation techniques for chronic pain. A report of a Cochrane systematic review and meta-analysis.
Eur J Phys Rehabil Med. 2011 Jun; 47(2):309-26.EJ

Abstract

BACKGROUND

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).

AIM

To evaluate the efficacy of non-invasive brain stimulation techniques in chronic pain.

DESIGN

A Cochrane systematic review with meta-analyses.

METHODS

We employed a comprehensive search strategy. Randomised and quasi-randomised studies of rTMS, CES or tDCS were included 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. Where possible we entered data into meta-analyses.

RESULTS

We included 33 trials in the review (19 rTMS, eight CES and six tDCS). Only one study was judged as being at low risk of bias. Studies of rTMS demonstrated significant heterogeneity. Pre-specified subgroup analyses suggest that low-frequency stimulation is ineffective. A short-term effect on pain of active high-frequency stimulation of the motor cortex in single-dose studies was suggested (standardised mean difference (SMD) -0.40, 95% confidence interval (CI) -0.26 to -0.54, P < 0.00001). This equates to a 15% (95% CI 10% to 20%) reduction in pain which does not clearly exceed the pre-established criteria for a minimally clinically important difference (> 15%). For CES (four studies, 133 participants) no statistically significant difference was found between active stimulation and sham. Analysis of tDCS studies (five studies, 83 people) demonstrated significant heterogeneity and did not find a significant difference between active and sham stimulation. Pre-specified subgroup analysis of tDCS applied to the motor cortex suggested superiority of active stimulation over sham (SMD -0.59, 95% CI -1.10 to -0.08). Non-invasive brain stimulation appears to be associated with minor and transient side effects.

CONCLUSION

Single doses of high-frequency rTMS of the motor cortex may have small short-term effects on chronic pain. The effects do not clearly exceed the predetermined threshold of minimal clinical significance. Low-frequency rTMS is not effective in the treatment of chronic pain. There is insufficient evidence from which to draw firm conclusions regarding the efficacy of CES or tDCS. The available evidence suggests that tDCS applied to the motor cortex may have short-term effects on chronic pain and that CES may be ineffective. There is a need for further, rigorously designed studies of all types of stimulation.

Authors+Show Affiliations

Centre for Research in Rehabilitation, School of Health Sciences and Social Care, Brunel University, Uxbridge, UK. neil.oconnell@brunel.ac.ukNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis
Review
Systematic Review

Language

eng

PubMed ID

21494222

Citation

O'Connell, N E., et al. "Non-invasive Brain Stimulation Techniques for Chronic Pain. a Report of a Cochrane Systematic Review and Meta-analysis." European Journal of Physical and Rehabilitation Medicine, vol. 47, no. 2, 2011, pp. 309-26.
O'Connell NE, Wand BM, Marston L, et al. Non-invasive brain stimulation techniques for chronic pain. A report of a Cochrane systematic review and meta-analysis. Eur J Phys Rehabil Med. 2011;47(2):309-26.
O'Connell, N. E., Wand, B. M., Marston, L., Spencer, S., & Desouza, L. H. (2011). Non-invasive brain stimulation techniques for chronic pain. A report of a Cochrane systematic review and meta-analysis. European Journal of Physical and Rehabilitation Medicine, 47(2), 309-26.
O'Connell NE, et al. Non-invasive Brain Stimulation Techniques for Chronic Pain. a Report of a Cochrane Systematic Review and Meta-analysis. Eur J Phys Rehabil Med. 2011;47(2):309-26. PubMed PMID: 21494222.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Non-invasive brain stimulation techniques for chronic pain. A report of a Cochrane systematic review and meta-analysis. AU - O'Connell,N E, AU - Wand,B M, AU - Marston,L, AU - Spencer,S, AU - Desouza,L H, Y1 - 2011/04/14/ PY - 2011/4/16/entrez PY - 2011/4/16/pubmed PY - 2011/10/1/medline SP - 309 EP - 26 JF - European journal of physical and rehabilitation medicine JO - Eur J Phys Rehabil Med VL - 47 IS - 2 N2 - BACKGROUND: 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). AIM: To evaluate the efficacy of non-invasive brain stimulation techniques in chronic pain. DESIGN: A Cochrane systematic review with meta-analyses. METHODS: We employed a comprehensive search strategy. Randomised and quasi-randomised studies of rTMS, CES or tDCS were included 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. Where possible we entered data into meta-analyses. RESULTS: We included 33 trials in the review (19 rTMS, eight CES and six tDCS). Only one study was judged as being at low risk of bias. Studies of rTMS demonstrated significant heterogeneity. Pre-specified subgroup analyses suggest that low-frequency stimulation is ineffective. A short-term effect on pain of active high-frequency stimulation of the motor cortex in single-dose studies was suggested (standardised mean difference (SMD) -0.40, 95% confidence interval (CI) -0.26 to -0.54, P < 0.00001). This equates to a 15% (95% CI 10% to 20%) reduction in pain which does not clearly exceed the pre-established criteria for a minimally clinically important difference (> 15%). For CES (four studies, 133 participants) no statistically significant difference was found between active stimulation and sham. Analysis of tDCS studies (five studies, 83 people) demonstrated significant heterogeneity and did not find a significant difference between active and sham stimulation. Pre-specified subgroup analysis of tDCS applied to the motor cortex suggested superiority of active stimulation over sham (SMD -0.59, 95% CI -1.10 to -0.08). Non-invasive brain stimulation appears to be associated with minor and transient side effects. CONCLUSION: Single doses of high-frequency rTMS of the motor cortex may have small short-term effects on chronic pain. The effects do not clearly exceed the predetermined threshold of minimal clinical significance. Low-frequency rTMS is not effective in the treatment of chronic pain. There is insufficient evidence from which to draw firm conclusions regarding the efficacy of CES or tDCS. The available evidence suggests that tDCS applied to the motor cortex may have short-term effects on chronic pain and that CES may be ineffective. There is a need for further, rigorously designed studies of all types of stimulation. SN - 1973-9095 UR - https://www.unboundmedicine.com/medline/citation/21494222/Non_invasive_brain_stimulation_techniques_for_chronic_pain__A_report_of_a_Cochrane_systematic_review_and_meta_analysis_ L2 - https://ClinicalTrials.gov/search/term=21494222 [PUBMED-IDS] DB - PRIME DP - Unbound Medicine ER -