Long-term maintenance of the analgesic effects of transcranial magnetic stimulation in fibromyalgia

We assessed for the first time the long-term maintenance of repetitive transcranial magnetic stimulation (rTMS)-induced analgesia in patients with chronic widespread pain due to fibromyalgia. Forty consecutive patients were randomly assigned, in a double-blind fashion, to 2 groups: one receiving active rTMS (n = 20) and the other, sham stimulation (n = 20), applied to the left primary motor cortex. The stimulation protocol consisted of 14 sessions: an “induction phase” of 5 daily sessions followed by a “maintenance phase” of 3 sessions a week apart, 3 sessions a fortnight apart, and 3 sessions a month apart. The primary outcome was average pain intensity over the last 24 hours, measured before each stimulation from day 1 to week 21 and at week 25 (1 month after the last stimulation). Other outcomes measured included quality of life, mood and anxiety, and several parameters of motor cortical excitability. Thirty patients completed the study (14 in the sham stimulation group and 16 in the active stimulation group). Active rTMS significantly reduced pain intensity from day 5 to week 25. These analgesic effects were associated with a long-term improvement in items related to quality of life (including fatigue, morning tiredness, general activity, walking, and sleep) and were directly correlated with changes in intracortical inhibition. In conclusion, these results suggest that TMS may be a valuable and safe new therapeutic option in patients with fibromyalgia.     

Effects of spinal cord stimulation on cortical excitability in patients with chronic neuropathic pain: A pilot study

BackgroundDespite a broad clinical use, the mechanism of action of SCS is poorly understood. Current information suggests that the effects of SCS are mediated by a complex set of interactions at several levels of the nervous system including spinal and supraspinal mechanisms.AimsThe study was undertaken to investigate the influence of SCS on distinct parameters of cortical excitability using single- and paired-pulse transcranial magnetic stimulation (TMS).MethodsFive patients with chronic neuropathic pain were examined with the SCS stimulator on and off by means of TMS. Pain was assessed using a visual-analogue scale. Electrophysiological and pain parameters of patients during this procedure were compared by means of a linear mixed effect model.ResultsSCS induced a significant modulation of cortical excitability, especially by influencing the parameter “intracortical facilitation” (t = −2.657; df = 8; p = 0.029). A significant relationship between this parameter and “perceived pain” could be obtained (t = −4.798; df = 8; p = 0.002).ConclusionsThese results suggest that SCS is able to influence neurobiological processes at the supraspinal level and that clinical effects of SCS may be at least in part of cortical origin.     

1H-MRS在脑胶质瘤肿瘤周围组织的临床应用研究

目的分析脑胶质瘤肿瘤周围组织的1H-MRS表现,探讨脑胶质瘤肿瘤周围组织的1H-MRS特点与肿瘤侵袭性的相关性。方法收集经临床手术、病理证实的脑胶质瘤36例,按照MRI检查结果分成两组:肿瘤周围区域有水肿组、肿瘤周围区域无水肿组。所有患者在术前行1H-MRS检查,均在MR非增强成像的基础上获得。使用1.5T超导磁共振、多体素扫描、点分辨表面线圈法,检测不同区域代谢物变化。结果脑胶质瘤肿瘤周围组织的1H-MRS表现:Cr轻度下降,NAA下降,Cho增高。肿瘤周围水肿组织和肿瘤组织、对侧正常脑组织的NAA/Cr、Cho/Cr、NAA/Cho比值存在显著性差异(P<0.05)。脑胶质瘤肿瘤周围无水肿组织和肿瘤组织的NAA/Cr、Cho/Cr、NAA/Cho比值存在显著性差异(P<0.05);肿瘤周围无水肿组织和对侧正常脑组织的NAA/Cr、NAA/Cho比值存在显著性差异(P<0.05),但Cho/Cr比值无显著性差异(P>0.05)。20例肿瘤周围水肿组与16例肿瘤周围无水肿组的肿瘤组织、肿瘤周围组织的NAA/Cho比值均存在显著性差异(P<0.05),但NAA/Cr、Cho/Cr比值无显著性差异(P>0.05)。结论1H-MRS可评价肿瘤周围组织(水肿区或无水肿区)肿瘤细胞浸润情况,反映肿瘤生长潜能,为制定治疗方案提供帮助。     

Fibromyalgia pain and its modulation by hypnotic and non‐hypnotic suggestion: An fMRI analysis

The neuropsychological status of pain conditions such as fibromyalgia, commonly categorized as ‘psychosomatic’ or ‘functional’ disorders, remains controversial. Activation of brain structures dependent upon subjective alterations of fibromyalgia pain experience could provide an insight into the underlying neuropsychological processes. Suggestion following a hypnotic induction can readily modulate the subjective experience of pain. It is unclear whether suggestion without hypnosis is equally effective. To explore these and related questions, suggestions following a hypnotic induction and the same suggestions without a hypnotic induction were used during functional magnetic resonance imaging to increase and decrease the subjective experience of fibromyalgia pain. Suggestion in both conditions resulted in significant changes in reported pain experience, although patients claimed significantly more control over their pain and reported greater pain reduction when hypnotised. Activation of the midbrain, cerebellum, thalamus, and midcingulate, primary and secondary sensory, inferior parietal, insula and prefrontal cortices correlated with reported changes in pain with hypnotic and non‐hypnotic suggestion. These activations were of greater magnitude, however, when suggestions followed a hypnotic induction in the cerebellum, anterior midcingulate cortex, anterior and posterior insula and the inferior parietal cortex. Our results thus provide evidence for the greater efficacy of suggestion following a hypnotic induction. They also indicate direct involvement of a network of areas widely associated with the pain ‘neuromatrix’ in fibromyalgia pain experience. These findings extend beyond the general proposal of a neural network for pain by providing direct evidence that regions involved in pain experience are actively involved in the generation of fibromyalgia pain.     

不同频率的高频重复经颅磁刺激对大鼠神经病理性疼痛的影响

目的观察高频重复经颅磁刺激(rTMS)对神经病理性疼痛模型大鼠的影响,并比较3种不同频率的rTMS对神经病理性疼痛的治疗效果,探索最佳治疗频率。方法选取健康成年雄性SD大鼠100只,随机分为假手术组、模型组、rTMS组、假刺激组,rTMS组又分为5 Hz组、10 Hz组、20 Hz组。于造模成功后第3天开始进行为期5 d或10 d的rTMS治疗。分别于术前、术后不同时间点对各组大鼠进行疼痛行为学评分,包括热痛敏缩足潜伏时(PWTL)、机械痛敏缩足阈值(PWMT)。结果治疗后各rTMS组的PWTL和PWMT值均较模型组不同程度增加,且10 Hz组、20 Hz组的PWTL、PWMT值增加较5 Hz组更明显,10 Hz和20 Hz组间的PWTL和PWMT值比较,差异无统计学意义(P>0.05)。结论不同频率rTMS治疗神经病理性疼痛的疗效不同,10 Hz和20 Hz的疗效优于5 Hz。     

DWI和1H-MRS鉴别诊断结核性与细菌性脑脓肿

目的 探讨DWI、¹H-MRS鉴别诊断结核性脑脓肿与细菌性脑脓肿的价值。 方法 对7例结核性脑脓肿、20例细菌性脑脓肿患者,治疗前行常规MRI、DWI和¹H-MRS检查。DWI采用单次激发SE-EPI序列,扩散敏感系数(b值)为0及1000 s/mm²。¹H-MRS采用点分辨选择波谱(PRESS),扫描参数为TR 1000 ms、TE 144 ms。观察两类病变坏死区的常规MRI、DWI及¹H-MRS表现特点,分析其ADC值有无差异。采用ROC曲线评价DWI、¹H-MRS对结核性与细菌性脑脓肿的鉴别诊断价值。 结果 7例结核性脑脓肿共19个病灶,20例细菌性脑脓肿共23个病灶。结核性脑脓肿病灶坏死区DWI表现为低信号2个,等信号6个,高信号11个;23个细菌性脑脓肿病灶脓腔均呈明显高于脑白质的高信号。结核性和细菌性脑脓肿坏死区平均最小ADC值分别为(1.02±0.11)×10^-3mm²/s和(0.55±0.21)×10^-3mm²/s,差异有统计学意义(P<0.01)。¹H-MRS于7例结核性脑脓肿的8个病灶内坏死区均测到脂质(Lip)峰,未见氨基酸峰;20个细菌性脑脓肿有8个脓腔存在Lip或乳酸(Lac)峰,12个分布各异的多种氨基酸峰。ADC值、¹H-MRS鉴别诊断结核性脑脓肿与细菌性脑脓肿的ROC曲线下面积分别为0.94、0.80,敏感度分别为82.41%、100%,特异度分别为94.43%、60.00%。 结论 结合常规MRI,DWI及¹H-MRS对鉴别诊断结核性与细菌性脑脓肿有重要临床应用价值。     

Neural mechanisms mediating positive and negative treatment expectations in visceral pain: A functional magnetic resonance imaging study on placebo and nocebo effects in healthy volunteers

To elucidate placebo and nocebo effects in visceral pain, we conducted a functional magnetic resonance imaging (fMRI) study to analyze effects of positive and negative treatment expectations in a rectal pain model. In 36 healthy volunteers, painful rectal distensions were delivered after intravenous application of an inert substance combined with either positive instructions of pain relief (placebo group) or negative instructions of pain increase (nocebo group), each compared to neutral instructions. Neural activation during cued-pain anticipation and pain was analyzed along with expected and perceived pain intensity. Expected and perceived pain intensity were significantly increased in the nocebo group and significantly decreased in the placebo group. In the placebo group, positive expectations significantly reduced activation of the somatosensory cortex during anticipation and of the insula, somatosensory cortex, and amygdala during pain delivery when compared to neutral expectations. Within the nocebo group, negative expectations led to significantly increased insula activation during painful stimulation. Direct group contrasts during expectation modulation revealed significantly increased distension-induced activation within the somatosensory cortex in the nocebo group. In conclusion, the experience and neural processing of visceral pain can be increased or decreased by drug-specific expectations. This first brain imaging study on nocebo effects in visceral pain has implications for the pathophysiology and treatment of patients with chronic abdominal complaints such as irritable bowel syndrome.     

慢性疼痛的功能MRI研究进展

慢性疼痛是一种关乎人体生理和心理的疾病,近年来学者应用功能MRI技术(functional magnetic resonance imaging,fMRI)对慢性疼痛进行了大量研究,作者从慢性疼痛的特点、静息态fMRI对慢性疼痛的研究方法、实验和分析等方面对慢性疼痛的静息态fMRI研究进展进行综述。     

Anatomical connections between brain areas activated during rectal distension in healthy volunteers: A visceral pain network

Diffusion Tensor Imaging (DTI) is a promising new imaging method allowing in vivo mapping of anatomical connections in the living human brain. We combined DTI with functional magnetic resonance imaging (fMRI) to investigate the anatomical relationships between areas involved in visceral sensations in humans. Non‐painful and moderately painful rectal distensions were performed in 11 healthy women (38.4 ± 3.1 years). fMRI was used to analyse the changes in brain activity during both types of distension. Then, DTI was applied for tracking fibers between the main activated regions. Non‐painful distension bilaterally activated the PreFrontal Cortex (PFC), the Anterior Cingulate Cortex (ACC) and the right insula. Painful distension bilaterally activated the primary (S1) and secondary (S2) somatosensory cortices, the motor cortex, the frontal inferior gyrus, the thalamus, the insula, the striatum and the cerebellum. DTI revealed direct connections between insula, and the four areas more frequently activated in this study, i.e. ACC, thalamus, S1, S2 and PFC. The combined use of fMRI and DTI in healthy subjects during rectal distension revealed a neural network of visceral sensory perception involving the insula, thalamus, somatosensory cortices, ACC and PFC.     

Referral practices in patients suffering from non‐malignant chronic pain

This paper presents the results of a prospective observational cohort study investigating referral practices to six specialized pain centres (SPCs) in 303 patients with headache (HD), low back pain (LBP), and neuropathic pain (NP). The study was divided into three parts. Part 1: The pain health care history (contacts with general practitioners and specialists, further referrals, time spans, therapies) before first contact with the SPC. Part 2: Reality of pain therapy and management in the SPC (patients’ attrition, interdisciplinarity of therapy and novel therapeutic strategies instigated). Part 3: Follow‐up and assessment of pain levels (NRS, SES), disability scores (PDI), QoL scores (SF 12), and anxiety and depression scores (HADS) at 0, 6 and 12 months. Using an ordinal linear regression model, factors predicting a good treatment outcome were identified. On average it took 3 years of pain symptoms before first consultation with GP. The median time period from the first pain sensations until the appointment in the SPC was 12 years. Nearly half of the referrals to specialists or SPCs were initiated by a non‐professional. In the SPC the medication was changed in 71% of cases. Care was interdisciplinary in only 32%. At 6 and 12 months after the first contact with the SPC, only 20% of the patients had improved with respect to levels of pain and psychometric data. A high degree of chronicity, a history of pain‐associated surgeries and low social support were negative predictors for treatment outcome.     

MRS及DWI在糖尿病酮症酸中毒脑损伤中的初步应用

目的 探讨MRS及DWI在糖尿病酮症酸中毒(DKA)脑损伤中的应用价值.方法 收集17例临床确诊的DKA患者,于发病早期(初始治疗后0～12 h)和恢复以后(治疗开始72 h后或更长时间)行脑部MR检查.分别测量发病早期和恢复以后的右侧基底节区和半卵圆中心的ADC值,比较发病早期和恢复以后ADC值;在右侧基底节区、双侧枕叶灰质和中脑导水管周围灰质检测N-乙酰天门冬氨酸(NAA)、胆碱(Cho)、肌酸(Cr),比较以上3个ROI发病早期和恢复以后的NAA/Cr和Cho/Cr及发病早期的NAA/Cr.结果 DKA早期与恢复以后右侧基底节区和半卵圆中心ADC值差异无统计学意义(t=-0.94、0.77,P均＞0.05);DKA发病早期NAA/Cr降低,经治疗恢复以后NAA/Cr升高;右侧基底节区、双侧枕叶灰质和中脑导水管周围灰质NAA/Cr差异有统计学意义(t=-7.01、-2.88、-2.41,P均＜0.05).发病早期右侧基底节区、枕叶灰质和中脑导水管周围灰质NAA/Cr差异有统计学意义(F=8.40,P＜0.01).发病早期和恢复以后Cho/Cr差异无统计学意义(右侧基底节区:t=1.03,P ＞0.05;双侧枕叶灰质:t=-0.12,P＞0.05;中脑导水管周围灰质:t=0.86,P＞0.05).结论 DKA发病早期脑部神经元活性或功能减低,恢复以后神经元活性或功能自所恢复.DKA发病期间存在代谢性脑损伤.MRS可用于评价DKA患者发病期间脑损伤及其预后.     

慢性腰背痛患者的脑静息态功能磁共振成像

目的 观察慢性腰背痛患者静息状态下的脑功能活动特点。方法 对15例慢性腰背痛患者及16名健康对照组受试者进行静息态脑功能磁共振成像,应用局部一致性(ReHo)方法处理fMRI数据,观察脑功能成像的差异。 结果 与健康对照组相比,慢性腰背痛患者双侧额叶、右侧枕叶、双侧前扣带回等脑区的ReHo值升高;中脑导水管周围灰质、臂旁核、脑桥、左侧顶叶后部、双侧扣带回后部及邻近楔前叶的ReHo值减低。结论 静息状态下慢性腰背痛患者多个脑区的功能活动存在异常,可能与机体对持续疼痛刺激的适应性增加、内源性镇痛系统活动减低等有关。     

磁共振多技术联合应用对脑原发性淋巴瘤的诊断价值

目的 探讨磁共振多技术联合应用对脑原发性淋巴瘤的诊断价值.方法 收集2005～2011年经手术或穿刺检查病理证实的12例脑原发性淋巴瘤患者MRI表现,并进行回顾性分析.结果 12例中共发现病灶25个,多发8例,单发4例.MRI表现为脑内多发团块状等、低T1,等、高T2异常信号,弥散加权成像(DWI)呈高或略高信号,周围水肿较轻.其中20个病灶位于脑深部中线旁,5个病灶位于幕下.增强扫描21个病灶呈团块状强化,4个病灶呈不规则厚环状强化.其中8个病灶可见脑室周围增强征、6个镜像征,4个缺口征.6例行磁共振氢波谱(1H-MRS)检查,均表现为N-乙酰天门冬氨酸(NAA)、肌酸(Cr)峰降低,胆碱(CHO)峰升高,见乳酸(Lac)峰和高大脂肪(Lip)峰.结论 磁共振是诊断脑原发性淋巴瘤的重要手段;脑室周围增强征、镜像征及缺口征是脑原发性淋巴瘤的特征性MRI表现;磁共振多技术的联合应用能提高脑原发性淋巴瘤的诊断与鉴别诊断水平.     

重复经颅磁刺激联合针刺治疗脊髓损伤后神经病理性疼痛的临床研究

目的：观察重复经颅磁刺激（rTMS）联合针刺治疗脊髓损伤（SCI）后神经病理性疼痛（NP）的临床疗效。方法：按随机数字表法将99例SCI后NP患者分成对照组、针刺组和联合组,各33例。对照组进行常规基础治疗,针刺组在对照组基础上进行针刺治疗,联合组在针刺组基础上进行rTMS治疗。分别于治疗前及治疗6周后对3组患者进行视觉模拟量表（VAS）、汉密顿抑郁量表（HAMD）、汉密顿焦虑量表(HAMA)及生活质量SF-36量表评估。结果：治疗6周后,3组患者VAS、HAMD和HAMA评分较治疗前均明显降低（P＜0.05）,SF-36量表各项评分较治疗前均明显升高（P＜0.05）;针刺组VAS、HAMD和HAMA评分较对照组均有降低（P＜0.05）,SF-36量表各项评分较对照组均有升高（P＜0.05）;联合组VAS、HAMD和HAMA评分较针刺组和对照组均有降低（P＜0.05）,SF-36量表各项评分较针刺组和对照组均有升高（P＜0.05）。结论：rTMS联合针刺治疗SCI后NP患者,有助于改善患者临床疼痛现象,且在改善患者情绪和生活质量方面疗效显著。     

慢性疼痛静息态脑功能连接研究的Meta分析

目的用Meta分析方法系统地描绘慢性疼痛患者静息态脑功能连接的变化特点。材料与方法数据库检索Pubmed、EMBASE、Web Science、Science Direct、Springerlink、brainmap自建库至2016年9月符合纳入标准的所有f MRI研究。利用Icbm2tal软件将Talairach坐标统一转换为MNI坐标,依据ALE手册中数据录入方法将坐标数据分组录入,使用Ginger-ALE 2.3软件进行Meta分析并计算脑区ALE分布图。结果纳入20篇文献,共389名慢性疼痛患者。Meta分析结果表明,慢性疼痛会导致默认网络的功能连接出现异常。选取岛叶作为种子点,研究发现:岛叶和楔前叶;岛叶和前扣带回;岛叶和后扣带回;岛叶和顶下小叶;岛叶和内侧前额叶的功能连接均出现异常。结论静息态下慢性疼痛患者的岛叶与默认网络的功能连接异常,反映出疼痛脑加工与感知觉辨认、认知和情绪相关脑区活动有关,为慢性疼痛下的神经认知模型提供了实证基础,有助于进一步探索疼痛与脑之间的联系。     

功能MRI揭示抑郁症脑结构及功能变化的应用及展望

抑郁症是由多种因素导致的心境障碍性疾病,主要表现为情绪低落,悲观,严重者甚至会有自杀倾向。有研究发现抑郁症与脑部某些神经联系减低及神经递质减少有关。随着功能MRI的发展,越来越多的人将功能MRI用于抑郁症的研究,以期阐明其发病机制。与传统的成像方式相比,它能反应脑白质微结构的变化并将相应脑区的功能状态影像化,有利于更加直观地分析研究脑结构与功能之间的关系。     

Psychosocial predictors and correlates for chronic post‐surgical pain (CPSP) – A systematic review

Chronic post‐surgical pain (CPSP) is a serious problem. Incidence as high as 50% has been reported, depending on type of surgery undergone. Because the etiology of chronic pain is grounded in the bio‐psychosocial model, physical, psychological, and social factors are implicated in the development of CPSP. Biomedical factors such as pre‐operative pain, severe acute post‐operative pain, modes of anesthesia, and surgical approaches have been extensively examined, therefore this systematic review focuses on psychosocial elements. A systematic search was performed using the PubMed, PsychINFO, Embase, and Cochrane Databases. Fifty relevant publications were selected from this search, in which psychosocial predictors for and correlates to CPSP were identified. The level of evidence was assessed for each study, and corresponding score points were awarded for ease of comparison. The grade of association with CPSP for each predictor/correlate was then determined. Depression, psychological vulnerability, stress, and late return to work showed likely correlation with CPSP (grade of association=1). Other factors were determined to have either unlikely (grade of association=3) or inconclusive (grade of association=2) correlations. In addition, results were examined in light of the type of surgery undergone. This review is intended as a first step to develop an instrument for identifying patients at high risk for CPSP, to optimize clinical pain management.     

Multimodal therapeutic assessment of peripheral nerve stimulation in neuropathic pain: Five case reports with a 20‐year follow‐up

Neuropathic pain following peripheral nerve lesion is highly resistant to conventional pain treatments but may respond well to direct electrical peripheral nerve stimulation (PNS). In the 1980 s, we treated a series of 11 peripheral neuropathic pain patients with PNS. A first outcome assessment, conducted after a 52‐month follow‐up, revealed that the majority of the patients were significantly improved. Here, we present the results of a second and more comprehensive follow‐up, conducted after more than 20 years of PNS usage. Of the six patients still using PNS, five participated in a multimodality assessment of the long‐term efficacy of PNS. Home evaluations showed reduced pain ratings and improved quality‐of‐life during active periods of stimulation. Quantitative sensory testing confirmed the neuropathic character of the pain complaints. PNS had no significant overall effect on tactile detection, cool, warmth, cold pain and heat pain thresholds. Laser‐evoked potentials showed an enlarged N2–P2 complex during active PNS. Positron Emission Tomography revealed that PNS decreased activation in the pain matrix at rest and during thermal stimulation. PNS led to increased blood flow not only in primary somatosensory cortex, but also in anterior cingulate and insular cortices, suggesting that besides activation of the dorsal column lemniscal system, other mechanisms may play a role in its analgesic effects. These data show that PNS can provide truly long‐term pain relief in carefully selected patients and they provide some objective quantitative data in support of this. They encourage the planning of future prospective studies in a larger cohort of patients.     

2型糖尿病血糖水平致慢性脑损害脑区差异的磁共振波谱研究

目的 采用多体素氢质子磁共振波谱(1H-MRS)定量技术探讨2型糖尿病(T2DM)患者不同脑区代谢物变化与糖化血红蛋白(HbAlc)水平的关系.方法 T2DM患者45例(HbAlc<6.5％组15例、HbAlc 6.5％～7.5％组15例、HbAlc>7.5％组15例)与正常对照34例行多体素1H-MRS扫描后用SAG...     

Chronic pelvic pain: gynaecological and non‐gynaecological causes and considerations for nursing care

Chronic pelvic pain (CPP) is one of the most difficult problems encountered by health professionals, and it is a very common gynaecological complaint in women of reproductive age. Any structure in the abdomen and/or pelvis could have a role in aetiology of CPP. The aetiology, however, is often unclear and the origin seems can be multifactorial. A multidisciplinary team can offer simultaneous assessment and management of somatic, behavioural and psychosocial components of the pain, and the nurse as an integral member of the healthcare team has an important role to play in ensuring effective care provision. The purpose of this review is to present comprehensive and contemporary information about the gynaecological and non‐gynaecological causes of CPP alongside an examination of the role of the nurse in caring for women who experience this problem.