DIEGO TOLEDO REIS MENDES FERNANDES
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LIM/62 - Laboratório de Fisiopatologia Cirúrgica, Hospital das Clínicas, Faculdade de Medicina
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- Insular and anterior cingulate cortex deep stimulation for central neuropathic pain Disassembling the percept of pain(2019) GALHARDONI, Ricardo Geront; SILVA, Valquiria Aparecida da; GARCIA-LARREA, Luis; DALE, Camila; BAPTISTA, Abrahao F.; BARBOSA, Luciana Mendonca; MENEZES, Luciana Mendes Bahia; SIQUEIRA, Silvia R. D. T. de; VALERIO, Fernanda; ROSI JR., Jefferson; RODRIGUES, Antonia Lilian de Lima; FERNANDES, Diego Toledo Reis Mendes; SELINGARDI, Priscila Mara Lorencini; MARCOLIN, Marco Antonio; DURAN, Fabio Luis de Souza; ONO, Carla Rachel; LUCATO, Leandro Tavares; FERNANDES, Ana Mercia B. L.; SILVA, Fabio E. F. da; YENG, Lin T.; BRUNONI, Andre R.; BUCHPIGUEL, Carlos A.; TEIXEIRA, Manoel J.; ANDRADE, Daniel Ciampi deObjective To compare the analgesic effects of stimulation of the anterior cingulate cortex (ACC) or the posterior superior insula (PSI) against sham deep (d) repetitive (r) transcranial magnetic stimulation (TMS) in patients with central neuropathic pain (CNP) after stroke or spinal cord injury in a randomized, double-blinded, sham-controlled, 3-arm parallel study. Methods Participants were randomly allocated into the active PSI-rTMS, ACC-rTMS, sham-PSI-rTMS, or sham-ACC-rTMS arms. Stimulations were performed for 12 weeks, and a comprehensive clinical and pain assessment, psychophysics, and cortical excitability measurements were performed at baseline and during treatment. The main outcome of the study was pain intensity (numeric rating scale [NRS]) after the last stimulation session. Results Ninety-eight patients (age 55.02 +/- 12.13 years) completed the study. NRS score was not significantly different between groups at the end of the study. Active rTMS treatments had no significant effects on pain interference with daily activities, pain dimensions, neuropathic pain symptoms, mood, medication use, cortical excitability measurements, or quality of life. Heat pain threshold was significantly increased after treatment in the PSI-dTMS group from baseline (1.58, 95% confidence interval [CI] 0.09-3.06]) compared to sham-dTMS (-1.02, 95% CI -2.10 to 0.04, p = 0.014), and ACC-dTMS caused a significant decrease in anxiety scores (-2.96, 95% CI -4.1 to -1.7]) compared to sham-dTMS (-0.78, 95% CI -1.9 to 0.3; p = 0.018). Conclusions ACC- and PSI-dTMS were not different from sham-dTMS for pain relief in CNP despite a significant antinociceptive effect after insular stimulation and anxiolytic effects of ACC-dTMS. These results showed that the different dimensions of pain can be modulated in humans noninvasively by directly stimulating deeper SNC cortical structures without necessarily affecting clinical pain per se.
bookPart Cervicalgias(2019) YENG, Lin Tchia; TEIXEIRA, Manoel Jacobsen; TEIXEIRA, William Gemio Jacobsen; TOLEDO, Diego- Repetitive Transcranial Magnetic Stimulation in Chronic Pain: A Review of the Literature(2015) GALHARDONI, Ricardo; CORREIA, Guilherme S.; ARAUJO, Haniel; YENG, Lin T.; FERNANDES, Diego T.; KAZIYAMA, Helena H.; MARCOLIN, Marco A.; BOUHASSIRA, Didier; TEIXEIRA, Manoel Jacobsen; ANDRADE, Daniel Ciampi deObjective: To review the literature on the analgesic effects of repetitive transcranial magnetic stimulation (rTMS) in chronic pain according to different pain syndromes and stimulation parameters. Data Sources: Publications on rTMS and chronic pain were searched in PubMed and Google Scholar using the following key words: chronic pain, analgesia, transcranial magnetic stimulation, neuropathic pain, fibromyalgia, and complex regional pain syndrome. Study Selection: This review only included double-blind, controlled studies with >10 participants in each arm that were published from 1996 to 2014 and written in English. Studies with relevant information for the understanding of the effects of rTMS were also cited. Data Extraction: The following data were retained: type of pain syndrome, type of study, coil type, target, stimulation intensity, frequency, number of pulses, orientation of induced current, number of session, and a brief summary of intervention outcomes. Data Synthesis: A total of 33 randomized trials were found. Many studies reported significant pain relief by rTMS, especially high-frequency stimulation over the primary motor cortex performed in consecutive treatment sessions. Pain relief was frequently >30% compared with control treatment. Neuropathic pain, fibromyalgia, and complex regional pain syndrome were the pain syndromes more frequently studied. However, among all published studies, only a few performed repetitive sessions of rTMS. Conclusions: rTMS has potential utility in the management of chronic pain; however, studies using maintenance sessions of rTMS and assessing the effects of rTMS on the different aspects of chronic pain are needed to provide a more solid basis for its clinical application for pain relief. (C) 2015 by the American Congress of Rehabilitation Medicine
- Author response: Insular and anterior cingulate cortex deep stimulation for central neuropathic pain: Disassembling the percept of pain(2020) ANDRADE, Daniel Ciampi de; GALHARDONI, Ricardo; SILVA, Valquiria Aparecida da; GARCIA-LARREA, Luis; DALE, Camila; BAPTISTA, Abrahao F.; BARBOSA, Luciana Mendonca; MENEZES, Luciana Mendes Bahia; SIQUEIRA, Silvia R. D. T. de; VALERIO, Fernanda; ROSI, Jefferson; RODRIGUES, Antonia Lilian de Lima; FERNANDES, Diego Toledo Reis Mendes; SELINGARDI, Priscila Mara Lorencini; MARCOLIN, Marco Antonio; DURAN, Fabio Luis de Souza; ONO, Carla Rachel; LUCATO, Leandro Tavares; FERNANDES, Ana Mercia B. L.; SILVA, Fabio E. F. da; YENG, Lin T.; BRUNONI, Andre R.; BUCHPIGUEL, Carlos A.; TEIXEIRA, Manoel J.
- Long-term deep-TMS does not negatively affect cognitive functions in stroke and spinal cord injury patients with central neuropathic pain(2019) SELINGARDI, Priscila Mara Lorencini; RODRIGUES, Antonia Lilian de Lima; SILVA, Valquiria Aparecida da; FERNANDES, Diego Toledo Reis Mendes; ROSI JR., Jefferson; MARCOLIN, Marco Antonio; YENG, Lin T.; BRUNONI, Andre R.; TEIXEIRA, Manoel J.; GALHARDONI, Ricardo; ANDRADE, Daniel Ciampi de
- Neuropathic pain after brachial plexus avulsion - central and peripheral mechanisms(2015) TEIXEIRA, Manoel Jacobsen; PAZ, Matheus Gomes da S. da; BINA, Mauro Tupiniquim; SANTOS, Scheila Nogueira; RAICHER, Irina; GALHARDONI, Ricardo; FERNANDES, Diego Toledo; YENG, Lin T.; BAPTISTA, Abrahao F.; ANDRADE, Daniel Ciampi DeReview: The pain that commonly occurs after brachial plexus avulsion poses an additional burden on the quality of life of patients already impaired by motor, sensory and autonomic deficits. Evidence-based treatments for the pain associated with brachial plexus avulsion are scarce, thus frequently leaving the condition refractory to treatment with the standard methods used to manage neuropathic pain. Unfortunately, little is known about the pathophysiology of brachial plexus avulsion. Available evidence indicates that besides primary nerve root injury, central lesions related to the abrupt disconnection of nerve roots from the spinal cord may play an important role in the genesis of neuropathic pain in these patients and may explain in part its refractoriness to treatment. Conclusions: The understanding of both central and peripheral mechanisms that contribute to the development of pain is of major importance in order to propose more effective treatments for brachial plexus avulsion-related pain. This review focuses on the current understanding about the occurrence of neuropathic pain in these patients and the role played by peripheral and central mechanisms that provides insights into its treatment. Summary: Pain after brachial plexus avulsion involves both peripheral and central components; thereby it is characterized as a mixed (central and peripheral) neuropathic pain syndrome.
bookPart Dor em Avulsão de Raízes Plexulares(2019) TEIXEIRA, Manoel Jacobsen; YENG, Lin Tchia; PORTNOI, Andréa G.; TOLEDO, Diego- Dissecting central post-stroke pain: a controlled symptom-psychophysical characterization(2022) BARBOSA, Luciana Mendonca; SILVA, Valquiria Aparecida da; RODRIGUES, Antonia Lilian de Lima; FERNANDES, Diego Toledo Reis Mendes; OLIVEIRA, Rogerio Adas Ayres de; GALHARDONI, Ricardo; YENG, Lin Tchia; ROSI JUNIOR, Jefferson; CONFORTO, Adriana Bastos; LUCATO, Leandro Tavares; LEMOS, Marcelo Delboni; PEYRON, Roland; GARCIA-LARREA, Luis; TEIXEIRA, Manoel Jacobsen; ANDRADE, Daniel Ciampi deDissection of distinct post-stroke pain syndromes evidenced that the neuropathic pain inventory, the presence of cold thermal deficit and the finding of allodynia on bedside examination, explained 77% of the occurrence of neuropathic central post-stroke pain, a new finding that has clear diagnostic potential. Central post-stroke pain affects up to 12% of stroke survivors and is notoriously refractory to treatment. However, stroke patients often suffer from other types of pain of non-neuropathic nature (musculoskeletal, inflammatory, complex regional) and no head-to-head comparison of their respective clinical and somatosensory profiles has been performed so far. We compared 39 patients with definite central neuropathic post-stroke pain with two matched control groups: 32 patients with exclusively non-neuropathic pain developed after stroke and 31 stroke patients not complaining of pain. Patients underwent deep phenotyping via a comprehensive assessment including clinical exam, questionnaires and quantitative sensory testing to dissect central post-stroke pain from chronic pain in general and stroke. While central post-stroke pain was mostly located in the face and limbs, non-neuropathic pain was predominantly axial and located in neck, shoulders and knees (P < 0.05). Neuropathic Pain Symptom Inventory clusters burning (82.1%, n = 32, P < 0.001), tingling (66.7%, n = 26, P < 0.001) and evoked by cold (64.1%, n = 25, P < 0.001) occurred more frequently in central post-stroke pain. Hyperpathia, thermal and mechanical allodynia also occurred more commonly in this group (P < 0.001), which also presented higher levels of deafferentation (P < 0.012) with more asymmetric cold and warm detection thresholds compared with controls. In particular, cold hypoesthesia (considered when the threshold of the affected side was <41% of the contralateral threshold) odds ratio (OR) was 12 (95% CI: 3.8-41.6) for neuropathic pain. Additionally, cold detection threshold/warm detection threshold ratio correlated with the presence of neuropathic pain (rho = -0.4, P < 0.001). Correlations were found between specific neuropathic pain symptom clusters and quantitative sensory testing: paroxysmal pain with cold (rho = -0.4; P = 0.008) and heat pain thresholds (rho = 0.5; P = 0.003), burning pain with mechanical detection (rho = -0.4; P = 0.015) and mechanical pain thresholds (rho = -0.4, P < 0.013), evoked pain with mechanical pain threshold (rho = -0.3; P = 0.047). Logistic regression showed that the combination of cold hypoesthesia on quantitative sensory testing, the Neuropathic Pain Symptom Inventory, and the allodynia intensity on bedside examination explained 77% of the occurrence of neuropathic pain. These findings provide insights into the clinical-psychophysics relationships in central post-stroke pain and may assist more precise distinction of neuropathic from non-neuropathic post-stroke pain in clinical practice and in future trials.
bookPart Bases da Reabilitaçãp em Dor(2015) YENG, Lin Tchia; FERNANDES, Diego Toledo Reis Mendes; KAZIYAMA, Helena H. SeguchibookPart Dor nos Membros Superiores(2019) TOLEDO, Diego; YENG, Lin Tchia; TEIXEIRA, Manoel Jacobsen; KOBAYASHI, Carolina Besser Cozac; BARBOZA, Victor Rossetto; KOBAYASHI, Ricardo