Tag Archives: Pain

Transcranial Magnetic Stimulation (TMS) for Knee pain osteoarthritis and other great things

Transcranial Direct Current Stimulation Effective for Knee OA Pain

Transcranial direct current stimulation (tDCS) can effectively alleviate osteoarthritis (OA)-related knee pain, according to results from a double-blind, randomized and sham-controlled pilot clinical study presented at the American Pain Society’s 36th Annual Scientific Meeting in Pittsburgh, Pennsylvania. Upon session completion, participants in the tDCS group showed improved analgesia compared with patients in the sham tDCS group, as indicated by reported pain ratings (on a 0 to 100 numeric scale: 18.50 ± 3.60 vs 6.45 ± 2.26; mean difference 12.05 [P =.007]).

Efficacy of Transcranial Direct Current Stimulation on Clinical Pain Severity in Older Adults with Knee Osteoarthritis Pain A Double-Blind, Randomized, Sham-Controlled Pilot Clinical S

The knee joint is the most affected one in individuals with OA, the most prevalent type of arthritis and itself a major cause of disability in individuals aged ≥45 years. Although OA pain is commonly managed pharmacologically, these treatments (eg, tapentadol, corticosteroids) are often associated with adverse effects.2,3Neuromodulation of central pain pathways therefore represents an attractive alternative for the treatment of chronic pain, including knee OA-related pain. tDCS, a noninvasive technique increasingly used for the treatment of several conditions that include chronic pain, as well as motor and psychiatric disorders, exerts its effects by depolarizing (anodal tDCS) or hyperpolarizing (cathodal tDCS) cortical neurons.4,5

The current study aimed to evaluate the efficacy of tDCS in alleviating knee OA pain. Study participants (n = 40; mean age, 59 years; ages 50 to 70 years; 53% women) were randomly assigned to receive tDCS (2 mA) or sham tDCS for 20 minutes daily over a 5-day period. tDCS electrodes were placed on the primary motor cortex of the side contralateral to the painful knee (anode) and on the supraorbital region ipsilaterally (cathode).

Story from clinical pain adviser.


Evidence-based guidelines on the therapeutic use of transcranial direct current stimulation (tDCS).


A group of European experts was commissioned by the European Chapter of the International Federation of Clinical Neurophysiology to gather knowledge about the state of the art of the therapeutic use of transcranial direct current stimulation (tDCS) from studies published up until September 2016, regarding pain, Parkinson’s disease, other movement disorders, motor stroke, poststroke aphasia, multiple sclerosis, epilepsy, consciousness disorders, Alzheimer’s disease, tinnitus, depression, schizophrenia, and craving/addiction. The evidence-based analysis included only studies based on repeated tDCS sessions with sham tDCS control procedure; 25 patients or more having received active treatment was required for Class I, while a lower number of 10-24 patients was accepted for Class II studies. Current evidence does not allow making any recommendation of Level A (definite efficacy) for any indication. Level B recommendation (probable efficacy) is proposed for: (i) anodal tDCS of the left primary motor cortex (M1) (with right orbitofrontal cathode) in fibromyalgia; (ii) anodal tDCS of the left dorsolateral prefrontal cortex (DLPFC) (with right orbitofrontal cathode) in major depressive episode without drug resistance; (iii) anodal tDCS of the right DLPFC (with left DLPFC cathode) in addiction/craving. Level C recommendation (possible efficacy) is proposed for anodal tDCS of the left M1 (or contralateral to pain side, with right orbitofrontal cathode) in chronic lower limb neuropathic pain secondary to spinal cord lesion. Conversely, Level B recommendation (probable inefficacy) is conferred on the absence of clinical effects of: (i) anodal tDCS of the left temporal cortex (with right orbitofrontal cathode) in tinnitus; (ii) anodal tDCS of the left DLPFC (with right orbitofrontal cathode) in drug-resistant major depressive episode. It remains to be clarified whether the probable or possible therapeutic effects of tDCS are clinically meaningful and how to optimally perform tDCS in a therapeutic setting. In addition, the easy management and low cost of tDCS devices allow at home use by the patient, but this might raise ethical and legal concerns with regard to potential misuse or overuse. We must be careful to avoid inappropriate applications of this technique by ensuring rigorous training of the professionals and education of the patients.

Efficacy of transcranial direct current stimulation and repetitive transcranial magnetic stimulation for treating fibromyalgia syndrome a systematic review.

 To systematically review the literature to date applying repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) for patients with fibromyalgia syndrome (FMS).


 Electronic bibliography databases screened included PubMed, Ovid MEDLINE, PsychINFO, CINAHL, and Cochrane Library. The keyword “fibromyalgia” was combined with (“transcranial” and “stimulation”) or “TMS” or “tDCS” or “transcranial magnetic stimulation” or “transcranial direct current stimulation”.


 Nine of 23 studies were included; brain stimulation sites comprised either the primary motor cortex (M1) or the dorsolateral prefrontal cortex (DLPFC). Five studies used rTMS (high-frequency-M1: 2, low-frequency-DLPFC: 2, high-frequency-DLPFC: 1), while 4 applied tDCS (anodal-M1: 1, anodal-M1/DLPFC: 3). Eight were double-blinded, randomized controlled trials. Most (80%) rTMS studies that measured pain reported significant decreases, while all (100%) tDCS studies with pain measures reported significant decreases. Greater longevity of significant pain reductions was observed for excitatory M1 rTMS/tDCS.


 Studies involving excitatory rTMS/tDCS at M1 showed analogous pain reductions as well as considerably fewer side effects compared to FDA apaproved FMS pharmaceuticals. The most commonly reported side effects were mild, including transient headaches and scalp discomforts at the stimulation site. Yearly use of rTMS/tDCS regimens appears costly ($11,740 to 14,507/year); however, analyses to apapropriately weigh these costs against clinical and quality of life benefits for patients with FMS are lacking. Consequently, rTMS/tDCS should be considered when treating patients with FMS, particularly those who are unable to find adequate symptom relief with other therapies. Further work into optimal stimulation parameters and standardized outcome measures is needed to clarify associated efficacy and effectiveness.

Transcranial Magnetic Stimulation-Mediated Analgesia is Independent of Improvements in Depression

Repetitive transcranial magnetic stimulation of the right secondary somatosensory motor cortex (S2) produces pain relief in patients with chronic neuropathic orofacial pain, an effect that was shown to be direct, and not a result of improvements in psychiatric or sleep disorder comorbidities. These findings were published in November in Medicine

The study participants had been diagnosed by a neurologist and an orofacial pain physician as follows: 7 had trigeminal neuropathic pain, 4 had atypical facial pain, and 5 had burning mouth syndrome. All patients displayed dysfunction of the trigeminal small- (and also large-, in some) fiber system, as well as a score ≥4 on the 0 to 10 numerical rating scale (NRS) for chronic daily neuropathic orofacial pain (daily average, 5.7; mean duration, 10.4 years).

Each study participant received 3 rTMS treatments (one of which was a placebo session), administered 4 weeks apart in a single-blind/within-subject manner. Stimulations (50 pulses at 90% of the resting motor threshold, every 10 s) targeted the facial area within the somatotopic representation of the primary sensorimotor cortex (S1/M1) and S2 in a random order.

Patients were assessed for psychiatric disorders based on the structured clinical interview for axis I disorders.3 Pain, mood, sleep and quality of life were assessed by study participants using the NRS to rate both pain and sleep and collected in study diaries for 4 weeks prior to and following treatment.

In addition, total hours of sleep, intensity, and interference of pain (measured using the Brief Pain Inventory),4 and sleep characteristics (assessed using the Basic Nordic Sleep Questionnaire),5 were all reported.

A more thorough assessment of sleep quality, measuring the 6 dimensions of sleep (ie, sleep disturbance , snoring, awakening with shortness of breath or headache, sleep adequacy, daytime somnolence, and quantity of sleep) was achieved through the Medical Outcomes Study (MOS) Sleep Measure, prior to and 1 month following each rTMS session.6

The authors found that neither sleep nor psychiatric disorders or medications (eg, opioids) had predictive value for rTMS treatment efficacy in study participants. The treatments had no detectable impact on either mood (assessed with the Beck Depression Inventory),7 or sleep quality.

Pain scores specific to neuropathic pain — but not to general pain — were reduced following S2 stimulation, as indicated by lower scores on the Neuropathic Pain Impact on Quality-of-Life questionnaire8 in treated vs sham-stimulated patients (P=.0031).

Six (38%) and 10 (63%) of the patients had a current or lifetime psychiatric disorder (depression or anxiety), respectively.

The authors concluded that “the present results show that the analgesic effect of rTMS given to the right S2 cortex as previously reported is most likely due to a direct action on specific top-down pain modulation networks rather than a result of an indirect action via improvement of comorbid psychiatric or sleep disturbances.”

They also added that “S2 stimulation had no effect on depressive symptoms, sleep diary measures, or the MOS sleep scale index scores, and that “comorbidities such as depression, anxiety disorders, and sleep problems did not predict the rTMS treatment outcome.”

The analgesic effect of therapeutic rTMS is not mediated or predicted by comorbid psychiatric or sleep disorders

Lindholm P, Lamusuo S, Taiminen T, et al. The analgesic effect of therapeutic rTMS is not mediated or predicted by comorbid psychiatric or sleep disorders. Medicine (Baltimore). 2016;95(44)

Lindholm P, Lamusuo S, Taiminen T, et al. Right secondary somatosensory cortex-a promising novel target for the treatment of drug-resistant neuropathic orofacial pain with repetitive transcranial magnetic stimulation. Pain. 2015;156(7):1276-1283

Right secondary somatosensory cortex-a promising novel target for the treatment of drug-resistant neuropathic orofacial pain with repetitive transcranial magnetic stimulation

Transcranial Direct Current Stimulation in Epilepsy

Results: We analyzed 9 articles with different methodologies (3 animals/6 humans) with a total of 174 stimulated individuals; 109 animals and 65 humans. In vivo and in vitro animal studies showed that direct current stimulation can successfully induce suppression of epileptiform activity without neurological injury and 4/6 (67%) clinical studies showed an effective decrease in epileptic seizures and 5/6 (83%) reduction of inter-ictal epileptiform activity. All patients tolerated tDCS well. Conclusions: tDCS trials have demonstrated preliminary safety and efficacy in animals and patients with epilepsy. Further larger studies are needed to define the best stimulation protocols and long-term follow-up.

Beck AT, Rial WY, Rickels K. Short form of depression inventory: crossvalidation. Psychol Rep. 1974;34:1184–1186




Insane Medicine – Arthritis pain and what to do:

Arthritis Pain:


Arthritis affects millions of individuals, reducing quality of life.  There are multiple facets that can be addressed regarding arthritis pain and what to do, but I will address several points:

  • Exercise added to the daily routine is the best way to help combat arthritis. Unused joint cause increased pain. What type of exercise? Flexibility Exercises, strength training, and aerobic exercises all help combat joint pain. They also help an individual lose weight as well, which increases mobility.
  • Range of motion exercises can help with stiffness and can improve mobility. Flexibility  exercises allow one to do this. Tai chi and yoga are examples.
  • Preserve your muscle mass with strength training at least three times a week. This also allows one to lose weight and helps maintain mobility. Muscle training helps support the joint structure and function, such as the knees. This decreases joint stress.
  • Aerobic exercises also add a lot to overall health and diminish joint pain. Swimming is low impact. Walking is another option.

Options to help arthritis pain:

  • Heat application: Relaxes the muscles and increases blood flow to affected areas, helping provide nutrients and oxygen. This is useful in multiple areas such as knee, neck, and back pain.
  • Cold Applications: Cold packs can be used acutely after exercise to decrease inflammation, muscle spasms, and pain, especially in the first 72 hours, after which, use heat.
  • Emotional support: Remember that a large challenge to arthritis is the emotional impact. Cognitive behavioral therapy is an option to help one cope with the pain of arthritis. Remember to keep busy and keep moving. Meditation can help overcome the negative emotions that can actually increase your pain. Pain can increase your anxiety and depression. Insomnia can result from arthritis pain, so the emotional impact is huge as arthritis affects so many facets in one’s life.
  • Acupuncture: This may be an option in some individuals. Consider going online to find a certified acupuncture specialist near you.
  • Spinal Manipulation Therapy (SMT): Look at the entire body and evaluate the triggers that aggravate arthritis. SMT can reduce stiffness and help with joint movement.  These changes in joint mobility have a local effect on the chemical factors that cause inflammation and pain. The joint may be the culprit in causing stiffness or the muscles surrounding the joint may be inflamed or spastic, resulting in lower mobility and pain.
  • Physical Therapy: Consult your physician for a PT referral., which can help you find ways to promote strength and flexibility.
  • Quit Smoking: Smoking lowers bone density.

Remember that muscles support your bones, and it is important to increase your muscle mass as it provides numerous benefits in addition to supporting your joints and your back. The back, in particular, with it’s discs and small facets, is affected over time by pressure, which can be unloaded by stretching and strengthening the spinal muscles through basic exercises like:

  1. Pelvic tilt exercises:

    Pelvic tilt
    Pelvic tilt
  2. One -legged wind releasing

    one legged wind releasing
    one legged wind releasing
  3. trunk lift
    trunk lift
    trunk lift

    You need core muscle strength and flexibility to help preserve your back. The hip muscles need to have flexibility maintained as well for better back health. Consider doing this through the 4.hammerstring stretch:

    hammerstring stretch
    hammerstring stretch


  4. hamstring-stretch-seated

    http://wellbalancedwoman.com/blog/< link to stretching blog – and alternative therapies.


Insane Medicine – Passion fruit peel has some efficacy for arthritis pain.

Insane Medicine - Passion fruit for arthritis pain
Passion fruit for arthritis pain.
  • Passiflora edulis has shown to reduce joint pain and stiffness by close to 20% when the passion fruit peel (150 mg a day) was taken for two months.
  • Passion fruit has flavonoids with anti-oxidant and anti-inflammatory ability. It may also be helpful in reducing blood pressure and asthma.
  • You can add this fruit to your well-rounded diet. It comes in many forms including puree, concentrate, or as the fresh fruit itself.
  • In addition to passion fruit for your pains, incorporate other avenues of treatment including appropriate exercise and stretching exercises. Increase your vegetable intake for the anti-inflammatory component, as well as spices such as tumeric and ginger, for their inflammation-fighting abilities. Don’t forget the omega-3 fatty acids found in fish and walnuts, which can help reduce your pain as well!


Insane Medicine – Chronic pain and it’s emotional component

  • Chronic pain affects both cognitive and emotional circuits in the brain as both mood and cognition are affected. Basically, an injury causes changes in the body’s chemistry and function which results in a change in the brain’s circuitry on how we perceive pain. Normal emotional processing is damaged.
  • Initially, acute pain is perceived in brain regions involved with pain reception, but as it transitions to chronic pain, it is perceived in centers of the brain that are involved with the mediation of emotions. Chronic pain involves abnormal stress responses, in which patients with chronic pain have higher cortisol stress hormone released to a painful stimulus. They also have smaller hippocampus areas of the brain that are involved in memory, learning, and emotions, This area of the brain begins to process pain signals poorly while areas of the brain that are involved in anticipatory anxiety and associative learning have over activity. There appears to be connectivity problems between brain areas involved in mood and cognitive function. This results not on ly in the sensation of pain, but also mood disorders such as anxiety and problems with decision-making.
  • Significant factors leading to chronic pain include non-restorative sleep, anxiety, memory impairment, and poor quality of life.
  • Things that help: Get regular exercise at least 30 minutes a day for 5 days a week. Ensure healthful sleep with good sleep hygiene. Be certain to sleep in a quiet, comfortable environment and avoid caffeine and strenuous activities before bedtime. Become more active in Lifesocialize more and get involved with hobby or helping others.
  • Other options for treatment include vagal-nerve stimulation to interfere with pain perception and transcranial magnetic stimulation, in which a magnet is used to alter nerve circuits in the brain that are involved with pain. Cognitive behavioral therapy, acupuncture, and meditation are also means of combating chronic pain.