Optimizing Rehabilitation for Phantom Limb Pain Using Mirror Therapy and tDCS

使用镜像疗法和 tDCS 优化幻肢痛康复

• 批准号: 9979731
• 负责人: Felipe Fregni
• 金额: $ 30.81万
• 依托单位: SPAULDING REHABILITATION HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-08-01 至 2022-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9979731
• 关键词: Accounting; Affect; Aftercare; Amputees; Analgesics; Anodes; Area; Behavior Therapy; Boston; Brain; Caring; Chronic; Clinical; Complex; Coupling; Dimensions; Functional Magnetic Resonance Imaging; Goals; Hospitals; Intervention; Lead; Limb structure; Measures; Medical; Membrane; Methods; Modeling; Motor Cortex; Movement; Neurons; Operative Surgical Procedures; Pain; Pain management; Patients; Phantom Limb Pain; Pharmacology; Physiologic pulse; Quality of life; Randomized; Randomized Controlled Trials; Rehabilitation Centers; Rehabilitation therapy; Reporting; Research; Resistance; Sensory; Severities; Side; Somatosensory Cortex; Spinal cord injury; Structure; Syndrome; Techniques; Transcranial magnetic stimulation; Visual; analog; base; biopsychosocial; blood oxygen level dependent; chronic pain; chronic pain patient; cortex mapping; design; disability; exhaust; experience; follow-up; functional restoration; indexing; interdisciplinary approach; multimodality; neural correlate; neural network; neurological rehabilitation; neuromechanism; neuroregulation; novel; pain patient; pain perception; pain reduction; pain rehabilitation; painful neuropathy; post-amputation pain; primary endpoint; programs; response; tool; treatment planning

 DESCRIPTION (provided by applicant): Rehabilitation for chronic pain involves a structured treatment plan targeting all dimensions of the pain experience, and should include a comprehensive interdisciplinary approach that allows patients to receive the most benefit according to their needs. As in other chronic pain syndromes, chronic Phantom limb pain (PLP) is often difficult to treat, showing to be resistant to classical pharmacological and surgical treatment approaches. This lack of efficacy in treatment of PLP is because current rehabilitative measures do not take into account the complex underlying neural mechanisms related to this pain. In fact, extensive evidence indicates that chronic PLP is a phenomenon related to a significant reorganization of the somatosensory and motor cortex. Analgesic drugs do not counteract the mechanisms that lead to maladaptive plasticity of these areas, and therefore is not the most efficacious treatment. In this context, we hypothesize that novel treatments of PLP need to target specific neural networks associated with this maladaptive plasticity. Transcranial direct current stimulation (tDCS) is a powerful and non-invasive technique of brain stimulation that is known to significantly modulate plasticity and alleviate chronic pain in various syndromes. Recently, we showed that anodal tDCS can induce a selective short-lasting relief from PLP, and repeated applications of anodal tDCS induces long- lasting analgesic effects. These preliminary results show that tDCS may be a promising rehabilitative tool for the management of chronic PLP. Given tDCS underlying neural mechanisms, it is critical to use a multimodal approach to treatment - using both tDCS and behavioral therapy simultaneously. In this case, an ideal therapy is mirror therapy (MT). This neurorehabilitation technique is commonly used in PLP, and is designed to modulate cortical mechanisms of pain by performing movements using the unaffected limb in front of a mirror. We propose to carry out a mechanistic, factorial, randomized controlled trial to evaluate a novel rehabilitation approach combining tDCS and MT in PLP patients. We aim to compare the brain changes before and after treatment in order to study the mechanisms underlying PLP. Aim 1 will evaluate the efficacy of tDCS and MT as rehabilitative tools. Patients will be assigned to one of four groups: active tDCS/MT; sham tDCS/MT; active tDCS/sham MT (covered MT); and sham tDCS/sham MT (covered MT). Aim 2 will examine the mechanisms underlying PLP. We will use single and paired-pulse transcranial magnetic stimulation (TMS) to assess cortical mapping and cortical excitability changes associated with cortical reorganization. We will also use functional magnetic resonance imaging (fMRI) to assess brain responses in the sensory-motor cortex associated with this treatment. This proposal has a great significance as it will help to understand and develop a novel intervention for PLP. Spaulding Rehabilitation Hospital - where this proposal is being developed - is a major center for rehabilitation of amputees including most of the amputees from the Boston Marathon Bombing. RELEVANCE: Chronic phantom limb pain (PLP) is recognized as very difficult to treat as it is often resistant to classical pharmacological and surgical treatment approaches. It is a major cause of disability and a main contributor to the quality of life. Extensive evidence indicates tha PLP is a phenomenon related to significant maladaptive brain changes. In this study we propose to investigate a novel rehabilitation approach combining a behavioral therapy- mirror therapy- with a method of brain modulation (tDCS) to treat and investigate the mechanisms of PLP.

 描述（应用程序提供）：慢性疼痛的康复涉及针对疼痛体验的所有维度的结构化治疗计划，并应包括一种全面的跨学科方法，使患者可以根据自己的需求获得最大的好处。与其他慢性疼痛综合征一样，慢性幻影肢体疼痛（PLP）通常很难治疗，表明对经典的药物和手术治疗方法具有抵抗力。缺乏PLP治疗的效率是因为目前的康复措施没有考虑到与这种疼痛有关的复杂基础神经机制。实际上，大量证据表明，慢性PLP是与体感和运动皮层的显着重组有关的现象。镇痛药不能抵消导致这些区域不良适应可塑性的机制，因此不是最有效的治疗方法。在这种情况下，我们假设PLP的新型治疗方法需要针对与这种不良适应性可塑性相关的特定神经元网络。经颅直流刺激（TDC）是一种强大而无创的脑刺激技术，已知可显着调节可塑性并减轻各种综合症的慢性疼痛。 最近，我们表明，阳极TDC可以诱导PLP的选择性短暂的浮雕，并且反复使用阳极TDC会影响长期的镇痛作用。这些初步结果表明，TDC可能是用于管理慢性PLP的有希望的康复工具。给定TDC的基本神经机制，使用多模式方法进行治疗至关重要 - 简单地使用TDC和行为疗法。在这种情况下，理想的疗法是镜像疗法（MT）。这种神经居住技术通常在PLP中使用，旨在通过使用镜子前的未受影响的肢体执行运动来调节疼痛的皮质机制。我们建议进行一项机械，阶乘随机对照试验，以评估一种新型的康复方法，该方法结合了PLP患者的TDC和MT。我们旨在比较治疗前后的大脑变化，以研究PLP的基础机制。 AIM 1将评估TDC和MT作为康复工具的效率。患者将分为四组之一：主动TDC/mt；假tdcs/mt;主动TDC/假MT（覆盖MT）；和假tdcs/sham MT（覆盖MT）。 AIM 2将检查PLP的基础机制。我们将使用单个和配对的脉冲trancranial磁刺激（TMS）来评估与皮质重组相关的皮质映射和皮质兴奋性变化。我们还将使用功能磁共振成像（fMRI）来评估与该处理相关的感觉运动皮层中的大脑反应。该建议具有重要意义，因为它将有助于了解和开发PLP的新颖干预措施。 Spaulding Rehabilitation Hospital（该提案正在开发）是恢复截肢者的主要中心，包括来自波士顿马拉松爆炸案的大多数截肢者。 相关性：慢性幻影肢体疼痛（PLP）被认为很难治疗，因为它通常对经典的药物和手术治疗方法有抵抗力。这是残疾的主要原因，也是导致生活质量的主要贡献者。广泛的证据表明，THA PLP是与严重不良适应性大脑变化有关的现象。在这项研究中，我们建议研究一种新型的康复方法，该方法将行为疗法 - 镜像治疗与脑部调节方法（TDCS）结合在一起，以治疗和研究PLP的机制。