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: 9116238
• 负责人: Felipe Fregni
• 金额: $ 33.9万
• 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 2020-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9116238
• 关键词: Accounting; Affect; Aftercare; Amputees; Analgesics; Area; Behavior Therapy; Biological Neural Networks; Boston; Brain; Caring; Chronic; Clinical; Complex; Couples Therapy; Dimensions; Functional Magnetic Resonance Imaging; Goals; Hospitals; Intervention; Lead; Limb structure; Measures; Medical; Membrane; Methods; Modeling; Motor Cortex; Movement; Neurons; Neurorehabilitation; Operative Surgical Procedures; Pain; Pain management; Patients; Perception; Phantom Limb Pain; 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; control trial; cortex mapping; design; disability; exhaust; experience; follow-up; functional restoration; indexing; interdisciplinary approach; neural correlate; neuromechanism; neuroregulation; novel; pain rehabilitation; painful neuropathy; post-amputation pain; 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（由申请人提供）：慢性疼痛的康复涉及针对疼痛经历的所有方面的结构化治疗计划，并应包括全面的跨学科方法，使患者能够根据自己的需求获得最大的益处。与其他慢性疼痛综合征一样，慢性幻肢痛（PLP）通常难以治疗，对经典的药理学和手术治疗方法具有抵抗力。PLP治疗缺乏疗效是因为目前的康复措施没有考虑到与这种疼痛相关的复杂的潜在神经机制。事实上，大量证据表明，慢性PLP是一种与躯体感觉和运动皮层的显著重组相关的现象。镇痛药物不能抵消导致这些区域适应不良可塑性的机制，因此不是最有效的治疗方法。在这种情况下，我们假设PLP的新治疗方法需要针对与这种适应不良可塑性相关的特定神经网络。经颅直流电刺激（tDCS）是一种功能强大的非侵入性脑刺激技术，已知可显著调节可塑性并缓解各种综合征中的慢性疼痛。 最近，我们表明阳极tDCS可以诱导PLP的选择性短期缓解，并且重复应用阳极tDCS诱导长期镇痛作用。这些初步结果表明，tDCS可能是一个有前途的康复工具，用于管理慢性PLP。鉴于tDCS的神经机制，使用多模式治疗方法至关重要-同时使用tDCS和行为治疗。在这种情况下，理想的治疗方法是镜像治疗（MT）。这种神经康复技术通常用于PLP，旨在通过在镜子前使用未受影响的肢体进行运动来调节疼痛的皮质机制。我们建议进行一项机制，析因，随机对照试验，以评估一种新的康复方法相结合的tDCS和MT PLP患者。我们的目的是比较治疗前后的大脑变化，以研究PLP的机制。目的1将评估tDCS和MT作为康复工具的有效性。患者将被分配到四个组之一：活性tDCS/MT;假tDCS/MT;活性tDCS/假MT（覆盖MT）;和假tDCS/假MT（覆盖MT）。目标2将研究PLP的潜在机制。我们将使用单脉冲和双脉冲经颅磁刺激（TMS）来评估与皮质重组相关的皮质映射和皮质兴奋性变化。我们还将使用功能性磁共振成像（fMRI）来评估与这种治疗相关的感觉运动皮层的大脑反应。这一建议具有重要意义，因为它将有助于了解和开发一种新的干预PLP。斯波尔丁康复医院--这一建议正在制定中--是一个主要的截肢者康复中心，包括波士顿马拉松爆炸案中的大多数截肢者。 相关性：慢性幻肢痛（PLP）被认为是非常难以治疗的，因为它通常对经典的药理学和手术治疗方法有抵抗力。它是造成残疾的主要原因，也是影响生活质量的主要因素。大量证据表明PLP是一种与显著的适应不良脑变化相关的现象。在这项研究中，我们提出了一种新的康复方法相结合的行为疗法-镜像治疗-与脑调制（tDCS）的方法来治疗和研究PLP的机制。