NEUROMODULAÇÃO TRANSCRANIANA COM ESTIMULAÇÃO ELÉTRICA

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compreensão do controle homeostático máximo quando são usadas intervenções combinadas. Também demostramos que a ETCC no tratamento da dor, pode contrarregular a disfunção nos sistemas neuromoduladores descendentes da dor induzida por opioides. Alem disso desenvolvemos um equipamento de ETCC para uso em domicílio. A contribuição nesta área de conhecimento tem permitido oferecer novas opções de tratamento da dor refratária aos analgésicos convencionais, sobretudo por apresentarem potencial de modificar as disfunções neuroplásticas que compreendem o mecanismo fisiopatológico da dor crônica.

NEUROMODULAÇÃO TRANSCRANIANA COM ESTIMULAÇÃO ELÉTRICA

Um método não invasivo para modular as conexões neuronais por meio da eletricidade.

JPain.2014 Aug;15(8):845-55. doi: 10.1016/j.jpain.2014.05.001. Epub 2014 May 24. Repetitive transcranial magnetic stimulation increases the corticospinal inhibition and the brain-derived neurotrophic factor in chronic myofascial pain syndrome: an explanatory double-blinded, randomized, sham-controlled trial.

Dall’Agnol L1,Medeiros LF2,Torres IL3,Deitos A1,Brietzke A1,Laste G4,de Souza A5,Vieira JL6,Fregni F7,Caumo W8.

Chronicmyofascial pain syndromehas been related to defective descending inhibitory systems. Twenty-four females aged 19 to 65 years withchronicmyofascial pain syndromewere randomized to receive 10 sessions of repetitive transcranial magnetic stimulation (rTMS) (n = 12) at 10 Hz or a sham intervention (n = 12). We tested ifpain(quantitative sensory testing), descending inhibitory systems (conditionedpain modulation [quantitative sensory testing + conditionedpainmodulation]), cortical excitability (TMS parameters), and the brain-derived neurotrophic factor (BDNF) would be modified. There was a significant interaction (time vs group) regarding the main outcomes of thepain scores as indexed by the visual analog scale onpain(analysis of variance, P < .01). Post hoc analysis showed that compared with placebo-sham, the treatment reduced dailypainscores by -30.21% (95% confidence interval = -39.23 to -21.20) and analgesic use by -44.56 (-57.46 to -31.67). Compared to sham, rTMS enhanced the corticospinal inhibitory system (41.74% reduction in quantitative sensory testing + conditionedpainmodulation, P < .05), reduced the intracortical facilitation in 23.94% (P = .03), increased the motor evoked potential in 52.02% (P = .02), and presented 12.38 ng/ mL higher serum BDNF (95% confidence interval = 2.32-22.38). No adverse events were observed. rTMS analgesic effects inchronicmyofascial pain syndromewere mediated by top-down regulation mechanisms, enhancing the corticospinal inhibitory system possibly via BDNF secretion modulation. PERSPECTIVE: High-frequency rTMS analgesic effects were mediated by top-down regulation mechanisms enhancing the corticospinal inhibitory, and this effect involved an increase in BDNF secretion. No: 32 FI: 5.42 Citações: 49

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Clin Res Regul Aff.2015 Mar 1;32(1):22-35.

Regulatory Considerations for the Clinical and Research Use of Transcranial Direct Current Stimulation (tDCS): review and recommendations from an expert panel.

Fregni F1,Nitsche MA2,Loo CK3,Brunoni AR4,Marangolo P5,Leite J6,Carvalho S6,Bolognini N7,Caumo W8,Paik NJ9,Simis M4,Ueda K10,Ekhitari H11,Luu P12,Tucker DM12,Tyler WJ13,Brunelin J14,Datta A15,Juan CH16,Venkatasubramanian G17,Boggio PS18,Bikson M15.

The field of transcranial electrical stimulation (tES) has experienced significant growth in thepast15years.Oneof thetEStechniques leading this increased interest is transcranial direct current stimulation (tDCS). Significant research efforts have been devoted to determining the clinical potential oftDCSin humans. Despite the promising results obtained withtDCSin basic and clinical neuroscience, further progress has been impeded by a lack of clarity on international regulatory pathways. We therefore convened a group of research and clinician experts ontDCSto review the research and clinical use oftDCS. In this report, we review the regulatory status oftDCS, and we summarize the results according to research, offlabel and compassionate use oftDCSin the following countries: Australia, Brazil, France, Germany, India, Iran, Italy, Portugal, South Korea, Taiwan and United States. Research use, off label treatment and compassionate use oftDCSare employed in most of the countries reviewed in this study. It is critical that a global or local effort is organized to pursue definite evidence to either approve and regulate or restrict the use oftDCSin clinical practice on the basis of adequate randomized controlled treatment trials. No: 33 FI: 0.88 Citações: 162

Front Neurosci.2016 Jan 11;9:498. doi: 10.3389/fnins.2015.00498. eCollection 2015. Neuroplastic Effects of Transcranial Direct Current Stimulation on Painful Symptoms Reduction in Chronic Hepatitis C: A Phase II Randomized, Double Blind, Sham Controlled Trial.

Brietzke AP1,Rozisky JR1,Dussan-Sarria JA1,Deitos A1,Laste G1,Hoppe PF1,Muller S1,Torres IL1,Alvaresda-Silva MR2,de Amorim RF3,Fregni F3,Caumo W1.

INTRODUCTION: Pegylated Interferon Alpha (Peg-IFN) in combination with other drugs is thestandardtreatmentforchronic hepatitis C Infection(HCV) and isrelatedtoseverepainfulsymptoms. The aim of this study was access the efficacy of transcranial direct current stimulation (tDCS) in controlling thepainfulsymptomsrelatedtoPeg-IFNside effects. MATERIALS AND METHODS: In this phase II double-blind trial, twenty eight (n = 28)HCVsubjects were randomized to receive either 5 consecutive days of active tDCS (n = 14) or sham (n = 14) during 5 consecutive days with anodal stimulation over the primary motor cortex region using 2 mA for 20 min. The primary outcomes were visual analogue scale (VAS)painand brain-derived neurotrophic factor (BDNF) serum levels. Secondary outcomes were the pressure-painthreshold (PPT), the Brazilian Profile of ChronicPain: Screen (B-PCP:S), anddruganalgesics use. RESULTS: tDCS reduced the VAS scores (P < 0.003), with a meanpaindrop of 56% (p < 0.001). Furthermore, tDCS was able to enhance BDNF levels (p < 0.01). The mean increase was 37.48% in the active group. Finally, tDCS raised PPT (p < 0.001) and reduced the B-PCP:S scores and analgesic use (p < 0.05). CONCLUSIONS: Five sessions of tDCS were effective in reducing thepainfulsymptoms inHCVpatients

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undergoingPeg-IFNtreatment. These findings support the efficacy of tDCS as a promising therapeutic tool to improve the tolerance of the side effectsrelatedto the use ofPeg-IFN. Future larger studies (phase III and IV trials) are needed to confirm the clinical use of the therapeutic effects of tDCS in such condition. TRIAL REGISTRATION: Brazilian Human Health Regulator for Research with the approval number CAAE 07802012.0.0000.5327. No: 34 FI: 3.87 Citações: 22

PainPract.2016 Mar;16(3):294-304. doi: 10.1111/papr.12276. Epub 2015 Jan 12. Repetitive Transcranial Magnetic Stimulation for Fibromyalgia: Systematic Review and Meta-Analysis.

Knijnik LM1,2,Dussán-Sarria JA1,3,4,Rozisky JR1,Torres IL3,5,Brunoni AR6,Fregni F7,Caumo W1,4,8.

BACKGROUND: Fibromyalgia(FM) is aprevalentchronic painsyndrome with few effective therapeutic options available. Repetitive transcranial magnetic stimulation (rTMS) is an emerging therapeutic alternative for this condition; however, results have been mixed. OBJECTIVES: To evaluate the efficacy of rTMS onFM, a comprehensive systematic review and meta-analysis were performed. METHODS: Relevant published, English and Portuguese language, randomized clinical trials (RCT) comparing rTMS (irrespective of the stimulation protocol) to sham stimulation for treatingFMpainintensity, depression, and/or quality of life (QoL) were identified, considering only those with low risk for bias. Trials available until April 2014 were searched through MEDLINE, EMBASE, the Cochrane Library Databases, and other 26 relevant medical databases covering from every continent. The outcomes forpain, depression, and QoL assessed closest to the 30th day after rTMS treatment were extracted, and changes from baseline were calculated to compare the effects of rTMS vs. placebo. RESULTS: One hundred and sixty-three articles were screened, and five with moderate to high quality were included. rTMS improved QoL with a moderate effect size (Pooled SMD = -0.472 95%CI = -0.80 to -0.14); it showed a trend toward reducingpainintensity (SMD = -0.64 95%CI = -0.31 to 0.017), but did not change depressive symptoms. CONCLUSION: In comparison with sham stimulation, rTMS demonstrated superior effect on the QoL of patients withFM1 month after starting therapy. However, further studies are needed to determine optimal treatment protocols and to elucidate the mechanisms involved with this effect, which does not seem to be mediated by changes in depression, but that may involvepainmodulation. Level of evidence 1b. No: 35 FI: 2.18 Citações: 34

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PLoS One.2017 Nov 30;12(11):e0187013. doi: 10.1371/journal.pone.0187013. eCollection 2017. Preoperative transcranial direct current stimulation: Exploration of novel strategy to enhance neuroplasticity before surgery to control postoperative pain. A randomized sham-controlled study.

Ribeiro H1,2, Sesterhenn RB2, Souza A1, Souza AC1, ILDS1,4,Stefani LC1,5,Fregni F6,Caumo W1,5,7. Alves M2, Machado JC3, Burger NB2, Torres

BACKGROUND: An imbalance in the excitatory/inhibitory systems in thepainnetworks may explain the persistent chronicpainafter hallux valgussurgery. Thus, to contra-regulate this dysfunction, the use of transcranial directcurrent stimulation (tDCS) becomes attractive. OBJECTIVE: We tested the hypothesis that twopreoperativeactive(a)-tDCS sessions compared with sham(s)- tDCS could improve thepostoperativepain[as indexed by Visual Analogue Scale (VAS) at rest and during walking (primary outcomes)]. To assess their effect on the change in the NumericalPainScale (NPS0-10) during ConditionedPainModulation (CPM-task), disability related topain(DRP) and analgesic consumption (secondary outcomes). Also, we assessed if the brain derived neurotrophic factor (BDNF) in the cerebral spinal fluid (CSF) after tDCS could predict the intervention’s effect on the DRP. METHODS: It is a prospective, double blind,sham-controlled,randomizedsingle center, 40 women (18-70 years-old) who had undergone hallux valgus surgery were randomized to receive two sessions (20 minutes each) of anodal a-tDCS or s-tDCS on the primary motor cortex at night and in the morning before thesurgery. To assess the DRP was used the Brazilian Profile of ChronicPain: Screen (B-PCP:S).RESULTS: A-tDCS group showed lower scores on VAS at rest and during walking (P<0.001). At rest, the difference between groups was 2.13cm (95%CI = 1.59 to 2.68) while during walking was 1.67cm (95%CI = 1.05 to 2.28). A-tDCS, when compared to s-tDCS reduced analgesic doses in 73.25% (P<0.001), produced a greater reduction in B-PCP:S (mean difference of 9.41 points, 95%CI = 0.63 to 18.21) and higher function of descendingpainmodulatory system (DPMS) during CPM-task. CONCLUSION: A-tDCS improvespostoperativepain, the DRP and the function of DPMS. Also, the CSF BDNF after a-tDCS predicted the improvement in the DRP. In overall, these findings suggest that a-tDCS effects may be mediated by top-down regulatory mechanisms associated with the inhibitory corticalcontrol. No: 36 FI: 2.78 Citações: 7

Menopause.2017 Oct;24(10):1122-1128. doi: 10.1097/GME.0000000000000905. Transcranial direct current stimulation effects on menopausal vasomotor symptoms.

Bianchi MS1,Ferreira CF,Fregni F,Schestatsky P,Caumo W,Wender MCO.

OBJECTIVE: To assess theeffectsoftranscranialdirectcurrentstimulation(tDCS) compared with tDCS-sham onvasomotorsymptomsof postmenopausal women. METHODS: Postmenopausal women (N = 30), aged between 45 and 68 years, with at least four episodes ofvasomotorsymptomsper day, were recruited from a specialized outpatient clinic at a tertiary hospital in the south of Brazil and through a media call after inclusion and exclusion criteria were ensured. Active and tDCS-sham were administered over the motor cortex position (anode electrode) and contralateral supraorbital region (cathode electrode) for 10 consecutive days, except weekends. The number and intensity

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records of hot flashes were evaluated for 7 days before and along 30 days after the intervention. The Women’s Health Questionnaire and the Hamilton Depression Rating Scale were applied to assess the quality of life and the depressivesymptoms, respectively. RESULTS: The frequencies of hot flashes per day happened in a similar way in both groups, with a reduction in the first 3 weeks after the intervention. There was a return in hot flash frequencies to baseline in the fourth week (week 0: 79.0 ± 6.2 and 75.8 ± 6.0, week 1: 61.6 ± 9.6 and 57.0 ± 7.8, week 2: 56.8 ± 8.9 and 55.9 ± 7.1, week 3: 56.8 ± 8.9 and 54.2 ± 7.2, week 4: 64.9 ± 10.7, 70.1 ± 8.9; tDCS-sham and tDCS groups, respectively). In the tDCS group, a trend towards a conversion of intensive hot flashes into mild ones was observed. CONCLUSIONS: Our results suggest that the tDCS technique showed small trends on postmenopausal vasomotor symptoms, justifying searches for more effective methods by which tDCS could reduce hot flashes. No: 37 FI: 2.67 Citações: 2

Sci Rep.2017 Mar 9;7(1):135. doi: 10.1038/s41598-017-00185-w. Anodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex modulates attention and pain in fibromyalgia: randomized clinical trial.

Silva AF1,Zortea M1,2,Carvalho S3,4,Leite J3,4,Torres IL1,5,Fregni F3,Caumo W6,7,8,9,10.

Cognitive dysfunction in fibromyalgia patients has been reported, especially when increased attentional demands are required. Transcranial direct current stimulation (tDCS) over the dorsolateral prefrontal cortex (DLPFC) has been effective in modulatingattention. We tested the effects of a single session of tDCS coupled with a Go/No-go task in modulating three distinct attentional networks: alertness, orienting and executive control. Secondarily, the effect on pain measures was evaluated. Forty females with fibromyalgia were randomized to receive active or sham tDCS. Anodal stimulation (1 mA, 20 min) was applied over the DLPFC.Attentionindices were assessed using theAttentionNetwork Test (ANT). Heat pain threshold (HPTh) and tolerance (HPTo) were measured. Active compared to sham tDCS led to increased performance in the orienting (mean difference [MD] = 14.63) and executive (MD = 21.00)attentionnetworks. There was no effect on alertness. Active tDCS increased HPTh as compared to sham (MD = 1.93) and HPTo (MD = 1.52). Regression analysis showed the effect on executiveattentionis mostly independent of the effect on pain. DLPFC may be an important target for neurostimulation therapies in addition to the primary motor cortex for patients who do not respond adequately to neurostimulation therapies. No: 38 FI: 4.12 Citações: 15

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Front Pharmacol.2018 Feb 19;9:94. doi: 10.3389/fphar.2018.00094. eCollection 2018. Effects of Transcranial Direct Current Stimulation Block Remifentanil-Induced Hyperalgesia: A Randomized, Double-Blind Clinical Trial.

Braulio G1,2,

Passos SC2, F6,7,8,9,Caumo W1 Leite F1, Schwertner A1, Stefani LC1,3, Palmer ACS4, Torres ILS1,4,5, Fregni

Background: Remifentanil-induced hyperalgesia

(r-IH) involves an imbalance in the inhibitory and excitatory systems. As thetranscranial Direct Current Stimulation (tDCS) modulates the thalamocortical synapses in a top-down manner, we hypothesized that the active (a)-t-DCS would be more effective than sham(s)-tDCS to prevent r-IH. We used an experimental paradigm to induce temporal summation of pain utilizing a repetitive cold test (rCOLDT) assessed by the Numerical Pain Score (NPS 0-10) and we evaluated the function of the descending pain modulatory system (DPMS) by the change on the NPS (0-10) during the conditioned pain modulation (CPM)-task (primary outcomes). We tested whether a-tDCS would be more effective than s-tDCS to improve pain perception assessed by the heat pain threshold (HPT) and the reaction time during the ice-water pain test (IPT) (secondary outcomes).Methods:This double-blinded, factorialrandomizedtrial included 48 healthy males, ages ranging 19-40 years. They wererandomizedinto four equal groups: a-tDCS/saline, s-tDCS/saline, a-tDCS/remifentanil and s-tDCS/remifentanil. tDCS was applied over the primary motor cortex, during 20 min at 2 mA, which was introduced 10 min after starting remifentanil infusion at 0.06 μg⋅kg-1⋅min-1or saline.Results:An ANCOVA mixed model revealed that during the rCOLDT, there was a significant maineffecton the NPS scores (F= 3.81;P= 0.01). The s-tDCS/remifentanil group presented larger pain scores during rCOLDT, [mean (SD) 5.49 (1.04)] and a-tDCS/ remifentanil group had relative lower pain scores [4.15 (1.62)]; showing its blockingeffecton r-IH. a-tDCS/ saline and s-tDCS/saline groups showed lowest pain scores during rCOLDT, [3.11 (1.2)] and [3.15 (1.62)], respectively. Theeffectof sedation induced by remifentanil during the rCOLDT was not significant (F= 0.76;P= 0.38). Remifentanil groups showed positive scores in the NPS (0-10) during the CPM-task, that is, it produced a disengagement of the DPMS. Also, s-tDCS/Remifentanil compared to a-tDCS showed lower HPT and larger reaction-time during the IPT.Conclusion:These findings suggest thateffectsof a-tDCS prevent the summation response induced by r-IH during rCOLDT and the a-tDCS blocked the disengagement of DPMS. Thereby, tDCS could be considered as a new approach to contra-regulate paradoxical mechanisms involved in the r-IH.Clinicaltrialsidentification:NCT02432677. RL:https://clinicaltrials.gov/ No: 39 FI: 3.83 Citações: 3

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Neuromodulation.2015 Jun;18(4):261-5. doi: 10.1111/ner.12230. Epub 2014 Sep 11. Reducing transcranial direct current stimulation-induced erythema with skin pretreatment: considerations for sham-controlled clinical trials.

Guarienti F1,2,Caumo W2,Shiozawa P1,3,Cordeiro Q3,Boggio PS4,Benseñor IM1,Lotufo PA1,Bikson M5,Brunoni AR1.

OBJECTIVES: Transcranial direct current stimulation (tDCS)-induced erythema (skin reddening) has beendescribedas anadverseeffect that can harm blinding integrityinsham-controlleddesigns. To tackle this issue, we investigated whether the use of topical pretreatments could decreaseerythemaand other adverse effects associated with tDCS. MATERIALS AND METHODS: Thirty healthy volunteers were recruited, and four interventions were applied 30 min prior to tDCS in a Latin square design: placebo, ketoprofen 2%, hydroxyzine 1%, and lidocaine 5%.TDCSwas applied for 30 min (2 mA, anode and cathode over F3 and F4, respectively) in two active sessions with a minimum 1-week interval. The Draizeerythemascoring system scale was used to assesserythemaintensity; atDCSquestionnaire was used to assess otheradverseeffects(e.g., tingling, itching, burning sensation, and pain). RESULTS: We found that ketoprofen (but not hydroxyzine or lidocaine) significantly attenuated tDCSinduced erythema regarding intensity and duration, with a medium effect compared with placebo.Erythemawas overall mild, short-lived (lasting 18-24 min aftertDCSending), and more intense under the anode. Subjects with darkerskincolor also tended to present less intensetDCS-inducederythema. The prevalence of otheradverseeffectswas low and did not differ between dermatological groups. CONCLUSIONS: Ketoprofen 2% topical pretreatment might be an interesting strategy to reduce tDCSinducederythemaand might be useful forblindingimprovement in furthersham-controlledtDCStrials. No: 40 FI: 2.77 Citações: 40

J Pain Res.2019 Jan 3;12:209-221. doi: 10.2147/JPR.S181019. eCollection 2019. Intramuscular electrical stimulus potentiates motor cortex modulation effects on pain and descending inhibitory systems in knee osteoarthritis: a randomized, factorial, shamcontrolled study.

da Graca-Tarragó M1,2,Lech M2,Angoleri LDM2,Santos DS2,Deitos A1,2,Brietzke AP1,2,Torres IL1,3,Fregni F4,Caumo W1,2,5,6

BACKGROUND: Neuroplastic changes in nociceptive pathways contribute to severity of symptoms in knee osteoarthritis (KOA). A new look at neuroplastic changes management includes modulation of the primary motor cortex by transcranial direct current stimulation (tDCS). OBJECTIVES: We investigated whether tDCS combined with intramuscular electrical stimulation (EIMS) would be more efficacious than a sham (s) intervention (s-tDCS/s-EIMS) or a single active(a)-tDCS/s-EIMS intervention and/or s-tDCS/a-EIMS in the following domains: pain measures (visual analog scale [VAS] score and descending pain modulatory system [DPMS], and outcomes, and analgesic use, disability, and pain pressure threshold (PPT) for secondary outcomes. REGISTRATION: The trial is registered in Clinicaltrials.gov:NCT01747070.

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METHODS: Sixty women with KOA, aged 50-75 years old, randomly received five sessions of one of the four interventions (a-tDCS/a-EIMS, s-tDCS/s-EIMS, a-tDCS/s-EIMS, and s-tDCS/a-EIMS). tDCS was applied over the primary motor cortex (M1), for 30 minutes at 2 mA and the EIMS paraspinal of L1-S2. RESULTS: A generalized estimating equation model revealed the main effect of the a-tDCS/a-EIMS in the VAS pain scores at end treatment compared with the other three groups (P<0.0001). There existed a significant effect of time and a significant interaction between group and time (P<0.01 for both). The delta-(Δ) pain score on VAS in the a-tDCS/a-EIMS group was -3.59, 95% CI: -4.10 to -2.63. The (Δ) pain scores on VAS in the other three groups were: a-tDCS/s-EIMS=-2.13, 95% CI: -2.48 to -1.64; s-tDCS/a-EIMS=-2.25, 95% CI: -2.59 to -1.68; s-tDCS/s-EIMS MR =-1.77, 95% CI: -2.08 to -1.38. The a-tDCS/a-EIMS led to better effect in DPMS, PPT, analgesic use, and disability related to pain. CONCLUSION: This study provides additional evidence regarding additive clinical effects to improve pain measures and descending pain inhibitory controls when the neuromodulation of the primary motor cortex with tDCS is combined with a bottom-up modulation with EIMS in KOA. Also, it improved the ability to walk due to reduced pain and reduced analgesic use. No: 41 FI: 2.65 Citações: 2

Pain Rep.2019 Jan 9;4(1):e692. doi: 10.1097/PR9.0000000000000692. eCollection 2019 Jan-Feb. Latin American and Caribbean consensus on noninvasive central nervous system neuromodulation for chronic pain management (LAC2-NIN-CP).

Baptista AF1,2,3,4,Fernandes AMBL5,Sá KN2,Okano AH1,Brunoni AR6,7,Lara-Solares A8,Jreige Iskandar A9,Guerrero C10,Amescua-García C11,Kraychete DC3,Caparelli-Daquer E12,Atencio E13,Piedimonte F14,Colimon F15,Hazime FA16,Garcia JBS17,Hernández-Castro JJ18,Cantisani JAF19,Karina do Monte-Silva K20,Lemos Correia LC2,21,Gallegos MS22,Marcolin MA5,Ricco MA23,Cook MB24,Bonilla P25,Schestatsky P26, Galhardoni R5,6,7,27, Silva V5, Delgado Barrera W28, Caumo W26, Bouhassira D29, Chipchase LS30,Lefaucheur JP31,Teixeira MJ5,de Andrade DC5,6,7,32,33.

INTRODUCTION: Chronic pain (CP) is highly prevalent and generally undertreated health condition. Noninvasive brain stimulation may contribute to decrease pain intensity and influence other aspects related to CP. OBJECTIVE: To provide consensus-based recommendations for the use of noninvasive brain stimulation in clinical practice. METHODS: Systematic review of the literature searching for randomized clinical trials followed by consensus panel. Recommendations also involved a cost-estimation study. RESULTS: The systematic review wielded 24 transcranial direct current stimulation (tDCS) and 22 repetitive transcranial magnetic stimulation (rTMS) studies. The following recommendations were provided: (1) Level A for anodal tDCS over the primary motor cortex (M1) in fibromyalgia, and level B for peripheral neuropathic pain, abdominal pain, and migraine; bifrontal (F3/F4) tDCS and M1 high-definition (HD)-tDCS for fibromyalgia; Oz/Cz tDCS for migraine and for secondary benefits such as improvement in quality of life, decrease in anxiety, and increase in pressure pain threshold; (2) level A recommendation for high-frequency (HF) rTMS over M1 for fibromyalgia and neuropathic pain, and level B for myofascial or musculoskeletal pain, complex regional pain syndrome, and migraine; (3) level A recommendation against the use of anodal M1 tDCS for low back pain; and (4) level B recommendation against the use of HF rTMS over the left dorsolateral prefrontal cortex in the control of pain.

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CONCLUSION: Transcranial DCS and rTMS are recommended techniques to be used in the control of CP conditions, with low to moderate analgesic effects, and no severe adverse events. These recommendations are based on a systematic review of the literature and a consensus made by experts in the field. Readers should use it as part of the resources available to decision-making. No: 42 FI: 0 Citações: 4

NEUROMODULAÇÃO PERIFÉRICA – ACUPUNTURA MÉDICA NEUROFUNCIONAL

Uma técnica milenar aplicada à medicina ocidental com base no conhecimento da neurofisiologia.

A acupuntura originou-se na China, no período pré-histórico, e as teorias dos meridianos e do fluxo de energia evoluíram por meio de observações junto ao ambiente da filosofia chinesa. A teoria tradicional e os conceitos filosóficos são imensamente encantadores, no entanto as indicações e o diagnóstico

feito por meio do pulso são baseadas apenas na experiência e carecem de evidências científicas. A acupuntura deve muito de sua respeitabilidade à descoberta de que a inserção de agulhas libera peptídeos opioides e outros neurotransmissores tais como a noradrenalina nas vias inibitórias da dor. A acupuntura com agulhas secas pode ser realizada com a inserção das agulhas de várias maneiras, que variam desde o número de agulhas, a profundidade da inserção e o método pode incluir estimulação manual ou elétrica.

O estudo do efeito da Acupuntura Neurofuncional como técnica terapêutica pelo Grupo de Dor e Neuromodulação iniciou com o treinamento sobre o uso da acupuntura medical neurofuncional na Universidade de McMaster no ano de 2008. Foi um curso de treinamento intensivo durante dez dias com o professor Alexandre Claraco. Trata-se de uma técnica que usa agulhas de acupuntura. No entanto, neurofuncional (ACNF) baseia a escolha dos melhores locais

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de estimulação na anatomia e neurofisiologia. Uma de suas premissas é estimular perifericamente músculos, articulações e nervos com eletricidade. Outro termo que pode ser utilizado como sinônimo de ACNF é neuromodulação periférica percutânea (NMPP), que, por sua vez, tem como premissa a estimulação elétrica do tecido-alvo com agulhas com a finalidade de produzir neuromodulação por contrarregular a desinibição do sistema modulador descendente.

Em 2009 com a dissertação do mestrado do aluno Claudio Couto sobre a eficácia da estimulação intramuscular no tratamento da dor miofascial crônica em 2009 teve origem um artigo publicado no Clin J Pain. 2014 Mar;30(3):214-23. doi: 10.1097/ AJP.0b013e3182934b8d, intitulado

Paraspinal stimulation combined with trigger point needling and needle rotation for the treatment of myofascial pain: a

randomized sham-controlled clinical trial. Este estudo destacou a maior eficácia da estimulação intramuscular paraespinhal em relação ao placebo-sham e injeção de lidocaína e indicou que ambos os tratamentos ativos são mais eficazes do que placebo-sham para o tratamento da síndrome dolorosa miofascial.

As agulhas podem permanecer inseridas por 20-30 minutos, ou por mais tempo, como também podem ser retiradas imediatamente, dentro de 1 ou 2 segundos. As agulhas podem permanecer inseridas sem serem tocadas, podem ser manipuladas de várias formas e estimuladas eletricamente. Por último, há a questão de onde as agulhas devem ser inseridas, o que depende do tipo de acupuntura que está sendo exercida (tradicional, moderna, neoclássica ou neurofuncional). Na tradicional, as agulhas são inseridas de acordo com a estrutura teórica da Medicina Tradicional Chinesa: polaridade yin-yang, qi, canais (meridianos), pontos e assim por diante. Nesse sistema, os sintomas são

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diagnosticados de acordo com as categorias tradicionais, usando os pulsos e a aparência da língua. Essa técnica prima pela localização precisa dos pontos. A neoclássica refere-se a uma variedade de métodos que surgiram durante as últimas décadas e guardam alguma relação com o sistema tradicional, como, por exemplo, a auriculoterapia e o sistema ryodoraku. São sistemas difíceis de explicar, mas a maioria utiliza os conceitos de “equilíbrio da energia” e pode utilizar métodos diagnósticos elétricos. A acupuntura baseada nos pontos-gatilho baseia a escolha dos locais de inserção das agulhas em pontos localizados por meio da sensibilidade local, da dor irradiada e do sobressalto. A acupuntura periostal consiste em agulhar o periósteo. O procedimento produz dor peculiar e muito desagradável.

A acupuntura neurofuncional (ACNF) baseia a escolha dos melhores locais de estimulação na anatomia e neurofisiologia. Uma de suas premissas é estimular perifericamente músculos, articulações e nervos com eletricidade. Outro termo que pode ser utilizado como sinônimo de ACNF é neuromodulação periférica percutânea (NMPP), que, por sua vez, tem como premissa a estimulação elétrica do tecido-alvo com agulhas com a finalidade de produzir neuromodulação por contrarregular a desinibição do sistema modulador descendente. Quando a ACNF é realizada dentro do tecido muscular, é denominada estimulação intramuscular ou estimulação elétrica intramuscular (EEIM). Foi criada para o tratamento da dor miofascial com componente neuropático. Na teoria de Chun Gunn, a dor miofascial crônica é decorrente de radiculopatia associada à contratura da musculatura paravertebral e/ou de doença degenerativa da coluna. Gunn postulou com base na “Lei de Canon da supersensibilidade após denervação”, na qual, quando uma parte de uma cadeia de unidades nervosas é lesada, a sensibilidade dos seus receptores se torna anormalmente aumentada. Essa supersensibilidade seria expressa na unidade nervosa lesada junto à musculatura esquelética, provocando o “encurtamento muscular”, a formação de pontos-gatilho e da banda tensa que, ao serem estimulados, podem produzir dor referida, e o conjunto constituir a síndrome dolorosa miofascial. Na EEIM, o sítio de estimulação é determinado por meio do diagnóstico clínico funcional considerando seus respectivos dermátomos, miótomos e esclerótomos. O agulhamento pode ser realizado nos pontos-gatilho, pontos motores ou troncos nervosos, além da musculatura paravertebral do segmento de origem da raiz nervosa envolvida na disfunção. Essa técnica tem seu efeito mediado pelos sistemas opioidérgico, gabaérgico, noradrenérgico e serotonérgico. Sobretudo modula a regulação autonômica e a via modulatória descendente. O efeito duradouro das técnicas neuromodulatórias (eletroacupuntura, ETCC, EMT) são mediados pelo aumento do input pré-