da Graca-Tarragó Maria, Lech Mateus, Angoleri Letícia Dal Moro, Santos Daniela Silva, Deitos Alícia, Brietzke Aline Patrícia, Torres Iraci Ls, Fregni Felipe, Caumo Wolnei
Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil,
Laboratory of Pain and Neuromodulation, HCPA, Porto Alegre, Brazil,
J Pain Res. 2019 Jan 3;12:209-221. doi: 10.2147/JPR.S181019. eCollection 2019.
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).
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.
The trial is registered in Clinicaltrials.gov: NCT01747070.
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.
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 (<0.0001). There existed a significant effect of time and a significant interaction between group and time (<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.
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.
伤害性感受通路中的神经可塑性变化会导致膝关节骨关节炎（KOA）症状的严重程度增加。对神经可塑性变化管理的新认识包括通过经颅直流电刺激（tDCS）调节初级运动皮层。
我们研究了tDCS联合肌内电刺激（EIMS）在以下方面是否比假干预（s-tDCS/s-EIMS）或单一主动（a）-tDCS/s-EIMS干预和/或s-tDCS/a-EIMS更有效：疼痛测量（视觉模拟量表[VAS]评分和下行疼痛调节系统[DPMS]）、结局、镇痛药物使用、残疾情况以及作为次要结局的疼痛压力阈值（PPT）。
该试验已在Clinicaltrials.gov注册：NCT01747070。
60名年龄在50 - 75岁的KOA女性随机接受四种干预之一（a-tDCS/a-EIMS、s-tDCS/s-EIMS、a-tDCS/s-EIMS和s-tDCS/a-EIMS）的五个疗程。tDCS应用于初级运动皮层（M1），2 mA，持续30分钟，EIMS应用于L1 - S2的椎旁肌。
广义估计方程模型显示，与其他三组相比，a-tDCS/a-EIMS在治疗结束时的VAS疼痛评分方面有主要效应（<0.0001）。存在时间的显著效应以及组与时间之间的显著交互作用（两者均<0.01）。a-tDCS/a-EIMS组VAS上的疼痛评分差值（Δ）为-3.59，95%可信区间：-4.10至-2.63。其他三组VAS上的（Δ）疼痛评分分别为：a-tDCS/s-EIMS = -2.13，95%可信区间：-2.48至-1.64；s-tDCS/a-EIMS = -2.25，95%可信区间：-2.59至-1.68；s-tDCS/s-EIMS = -1.77，95%可信区间：-2.08至-1.38。a-tDCS/a-EIMS在DPMS、PPT、镇痛药物使用以及与疼痛相关的残疾方面产生了更好的效果。
本研究提供了额外证据，表明在KOA中，当用tDCS对初级运动皮层进行神经调节与用EIMS进行自下而上的调节相结合时，在改善疼痛测量指标和下行疼痛抑制控制方面具有累加临床效果。此外，由于疼痛减轻和镇痛药物使用减少，其还改善了行走能力。
