Non-invasive Neuromodulation as a Pain Management Method in a Combined Therapy of Chronic Lower Back Pain

Aim: To describe the Russian and foreign experience in the use of non-invasive neuromodulation for pain management in patients with chronic lower back pain (LBP); to present various neuromodulation techniques and other rehabilitation methods which can be used in combination with neuromodulation in patients with LBP; to describe neuromodulation parameters and programs for an optimal analgesic effect.

Key points. LBP is a common (affecting 7.5 % of the world population) and socially significant condition (one of the leading causes of disability worldwide). The efficiency of drug pain management in chronic LBP is approximately 40 %, therefore, non-drug treatment options are required.

The neuropathic component of chronic LBP is associated with reorganization in cortex brain structures Hence, neural stimulation is a most promising approach to chronic LBP management, while transcranial direct current electrotherapy stimulation (TEdC) and rhythmic transcranial magnetic stimulation (rTMS) are the most efficient and safest neural stimulation methods. rTMS is an efficient and safe approach to the management both of nociceptive and neuropathic pain, which is a common component of chronic conditions, in particular of LBP. The main area of exposure is motor cortex areas (М1). As compared to TEdC, rTMS is better tolerated by patients and demonstrates better pain management results.

Conclusion. Pain syndrome is a significant limitation to rehabilitation in patients with LBP, and drug pain management is inefficient. We suggest that anaesthetic neuromodulation be included into a complex therapy of such patients. The most widely used and efficient neuromodulation techniques are TEdC and rTMS.

1. Fullen B., Morlion B., Linton S.J., Roomes D. et al. Management of chronic low back pain and the impact on patients’ personal and professional lives: results from an international patient survey. Pain Pract. 2022;22(4):463–77. DOI: 10.1111/papr.13103

2. Isaykin A.I., Akarachkova E.S., Isaykina O.Yu., Kondrashov A.A. et al. Back pain: Clinical guidelines. St. Petersburg: Skifiaprint; M.: Profmedpress; 2021. 80 p. (in Russian)

3. Abd-Elsayed A., Tang T., Karri J., Hughes M. et al. Neuromodulation for pain management in the inpatient setting: a narrative review. Cureus. 2021;13(3):e13892. DOI: 10.7759/cureus.13892

4. Baptista A.F., Fernandes A.M.B.L., Sá K.N., Okano A.H. et al. Latin American and Caribbean consensus on noninvasive central nervous system neuromodulation for chronic pain management (LAC2-NIN-CP). Pain Rep. 2019;4(1):e692. DOI: 10.1097/PR9.0000000000000692

5. Xiong H.-Y., Zheng J.-J., Wang X.-Q. Non-invasive brain stimulation for chronic pain: state of the art and future directions. Front. Mol. Neurosci. 2022;15:888716. DOI: 10.3389/fnmol.2022.888716

6. O'Connell N.E., Marston L., Spencer S., DeSouza L.H. Non-invasive brain stimulation techniques for chronic pain. Cochrane Database Syst. Rev. 2018;4(4):CD008208. DOI: 10.1002/14651858

7. Cecchi F. Are non-invasive brain stimulation techniques effective in the treatment of chronic pain? A Cochrane Review Summary with commentary. J. Rehabil. Med. 2020;52(4):jrm00039. DOI: 10.2340/16501977-2663

8. Cheng C.-M., Wang S.-J., Su T.-P., Chen M.-H. et al. Analgesic effects of repetitive transcranial magnetic stimulation on modified 2010 criteria-diagnosed fibromyalgia: Pilot study. Psychiatry Clin. Neurosci. 2019;73(4):187–93. DOI: 10.1111/pcn.12812

9. Gatzinsky K., Bergh C., Liljegren A., Silander H. et al. Repetitive transcranial magnetic stimulation of the primary motor cortex in management of chronic neuropathic pain: a systematic review. Scand. J. Pain. 2020;21(1):8–21. DOI: 10.1515/sjpain-2020-0054

10. Hamid P., Malik B.H., Hussain M.L. Noninvasive transcranial magnetic stimulation (TMS) in chronic refractory pain: a systematic review. Cureus. 2019;11(10):e6019. DOI: 10.7759/cureus.6019

11. Lim Y.-H., Song J.M., Choi E.-H., Lee J.W. Effects of repetitive peripheral magnetic stimulation on patients with acute low back pain: A pilot study. Ann. Rehabil. Med. 2018;42(2):229–38. DOI: 10.5535/arm.2018.42.2.229

12. Li C., Sun M., Tian S. Research hotspots and effectiveness of transcranial magnetic stimulation in pain: a bibliometric analysis. Front. Hum. Neurosci. 2022;16:887246. DOI: 10.3389/fnhum.2022.887246

13. Yang Q.-H., Zhang Y.-H., Du S.-H., Wang Y.-C. et al. Non-invasive brain stimulation for central neuropathic pain. Front. Mol. Neurosci. 2022;15:879909. DOI: 10.3389/fnmol.2022.879909

14. Shinu P., Morsy M.A., Nair A.B., Mouslem A.K.A. et al. Novel therapies for the treatment of neuropathic pain: potential and pitfalls. J. Clin. Med. 2022;11(11):3002. DOI: 10.3390/jcm11113002

15. Ngernyam N., Jensen M.P., Auvichayapat N., Punjaruk W. et al. Transcranial direct current stimulation in neuropathic pain. J. Pain Relief. 2013(suppl.3):001. DOI: 10.4172/2167-0846.S3-001

16. Zhang K.-L., Yuan H., Wu F.-F., Pu X.-Y. et al. Analgesic effect of noninvasive brain stimulation for neuropathic pain patients: a systematic review. Pain Ther. 2021;10(1):315–32. DOI: 10.1007/s40122-021-00252-1

17. Prasad A., Teh D.B.L., Blasiak A., Chai C. et al. Static magnetic field stimulation enhances oligodendrocyte differentiation and secretion of neurotrophic factors. Sci. Rep. 2017;7(1):6743. DOI: 10.1038/s41598-017-06331-8

18. Papuć E., Rejdak K. The role of neurostimulation in the treatment of neuropathic pain. Ann. Agric. Environ. Med. 2013;Spec.no.1:14–7.

19. Rossini P.M., Burke D., Chen R., Соhen L.G. et al. Non-invasive electrical and magnetic stimulation of the brain, spinal cord, roots and peripheral nerves: basic principles and procedures for routine clinical and research application. An updated report from an I.F.C.N. Committee. Clin. Neurophysiol. 2015;126(6):1071–107. DOI: 10.1016/j.clinph.2015.02.001

20. Deng Z.-D., Lisanby S.H., Peterchev A.V. Electric field depth-focality tradeoff in transcranial magnetic stimulation: simulation comparison of 50 coil designs. Brain Stimul. 2013;6(1):1–13. DOI: 10.1016/j.brs.2012.02.005

21. Klein M.M., Treister R., Raij T., Pascual-Leone A. et al. Transcranial magnetic stimulation of the brain: Guidelines for pain treatment research. Pain. 2015;156(9):1601–14. DOI: 10.1097/j.pain.0000000000000210

22. Treister R., Lang M., Klein M.M., Oaklander A.L. Non-invasive transcranial magnetic stimulation (TMS) of the motor cortex for neuropathic pain — at the tipping point? Rambam Maimonides Med. J. 2013;4(4):e0023. DOI: 10.5041/RMMJ.10130

23. Patricio P., Roy J.-S., Macedo L., Roy M. et al. Repetitive transcranial magnetic stimulation alone and in combination with motor control exercise for the treatment of individuals with chronic non-specific low back pain (ExTraStim trial): Study protocol for a randomised controlled trial. BMJ Open. 2021;11(3):e045504. DOI: 10.1136/bmjopen-2020-045504

24. Jin Y., Xing G., Li G., Wang A. et al. High frequency repetitive transcranial magnetic stimulation therapy for chronic neuropathic pain: a meta-analysis. Pain Physician. 2015;18(6):E1029–46.

25. Lefaucheur J.-P., Aleman A., Baeken C., Benninger D.H. et al. Evidencebased guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): An update (2014–2018). Clin. Neurophysiol. 2020;131(2):474–528. DOI: 10.1016/j.clinph.2019.11.002

26. Paolucci T., Pezzi L., Centra A.M., Giannandrea N. et al. Electromagnetic field therapy: a rehabilitative perspective in the management of musculoskeletal pain — a systematic review. J. Pain Res. 2020;13:1385–400. DOI: 10.2147/JPR.S231778

27. Cassani R., Novak G.S., Falk T.H., Oliveira A.A. Virtual reality and non-invasive brain stimulation for rehabilitation applications: a systematic review. J. Neuroeng. Rehabil. 2020;17(1):147. DOI: 10.1186/s12984-020-00780-5

28. Tolmacheva A., Mäkelä J.P., Shulga A. Increasing the frequency of peripheral component in paired associative stimulation strengthens its efficacy. Sci. Rep. 2019;9(1):3849. DOI: 10.1038/s41598-019-40474-0

29. Andrade R., Duarte H., Pereira R., Lopes I. et al. Pulsed electromagnetic field therapy effectiveness in low back pain: A systematic review of randomized controlled trials. Porto Biomed. J. 2016;1(5):156–63. DOI: 10.1016/j.pbj.2016.09.001

30. Maestú C., Blanco M., Nevado A., Romero J. et al. Reduction of pain thresholds in fibromyalgia after very low-intensity magnetic stimulation: A double-blinded, randomized placebo-controlled clinical trial. Pain Res. Manag. 2013;18(6):e101- 6. DOI: 10.1155/2013/270183

31. Woldańska-Okońska M., Koszela K. Chronic-exposure low-frequency magnetic fields (magnetotherapy and magnetic stimulation) influence serum serotonin concentrations in patients with low back pain — clinical observation study. Int. J. Environ. Res. Public Health. 2022;19(15):9743. DOI: 10.3390/ijerph19159743