Featured Journal Club Article

Brain Stimulation in the Treatment of Chronic Neuropathic and Non-Cancerous Pain

Factors contributing to poor therapeutic utility of invasive and noninvasive brain stimulation in the treatment of chronic neuropathic and pain of non-cancerous origin are examined in this critical review. Through key clinical trial design and conceptual refinements, retention and consistency of response may be improved, potentially facilitating the widespread clinical applicability of such approaches.

Use the following questions to start a discussion about this article at your next journal club meeting.

1. Melzack’s theory of the pain neuromatrix has revolutionized our understanding of the mechanisms underlying the experience of pain. Discuss and compare how the response of the neuromatrix may differ or overlap for pain originating from peripheral nervous system lesions, such as trigeminal neuralgia, or that resulting from damage to the central nervous system, such as in case of thalamic stroke.
2. The field of invasive cerebral neuromodulation over decades has studied efficacy of several deep brain targets and the motor cortices in modulating the experience of chronic neuropathic pain. Unequivocally, however, the benefit for patients with lesions of the central nervous system remains limited. Cite the potential mechanistic reasons and issues related to clinical trial design that may explain the lack of adequate response.
3. What are the mechanisms that are historically believed to underlie effects of brain stem, thalamic and motor cortical targeting in cerebral neuromodulation in the treatment of chronic neuropathic pain?
4. Cite evidence that challenges the traditionally-accepted beliefs about distinctive mechanisms of targeting cerebral structures in the treatment of chronic neuropathic pain.
5. Noninvasive brain stimulation, including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), have become popular experimental techniques in the study of modulation of chronic neuropathic pain. Discuss the evidence for efficacy in regards to response and maintenance and illustrate factors that affect existing evidence.
6. Indications for both invasive and noninvasive methods of cerebral neuromodulation in chronic neuropathic pain remain off-label. In revaluating the existing evidence in the field, discuss refinements, both theoretical and experimental, that could introduce a paradigm shift in the study of cerebral neuromodulation in chronic neuropathic pain.

See previous Journal Club Articles here.