Tratamentos alternativos mas baseados em evidência para o tratamento da Dor Neuropática.

Transcrição

1 Tratamentos alternativos mas baseados em evidência para o tratamento da Dor Neuropática Pedro Schestatsky MD, PhD Prof. Adjunto - Departamento de Medicina Interna / UFRGS Coordenador DC de Dor Academia Brasileira de Neurologia (ABN)

2 Conclusões Existe certa evidência da boa eficácia de alguns tratamentos alternativos para Dor Neuropática A maioria destas práticas é plausível, acessível, segura e barata (PASB); Neurologistas devem sempre considerar o seu uso, seja em monoterapia ou em combinação, especialmente naqueles pacientes refratários ou intolerantes às práticas convencionais

3 Estes são os tratamentos usuais para DN! Number Needed to Treat Finnerup et al., 2005

4 Tratamentos alternativos

5 Mas por que precisamos de alternativas? Number Needed to Treat Finnerup et al., 2005

6 3 motivos

7 1) ~60% dos tratamentos convencionais são ineficazes!

8 2) Fisiopatologia variada!

9 3) Efeitos adversos dos ttos convencionais!

10 Existem 2 tipos de tratamento para qualquer doença CIAC versus PASB (Hurt et al., 2011) Complexo Inacessível Arriscado Caro Plausível Acessível Seguro Barato Exigência: Quantidade E qualidade De artigos Quantidade de artigos

11 Tratamentos alternativos PASB para DN Acupuncture PENS Capsaicin patch Clonidine patch Botulinum toxin Lipoic Acid Cannabis Hypnosis Biofeedback Motor Imagery rtms tdcs Schestatsky et al., 2014 (Arquivos de Neuro-Psiquiatria, in press)

12 Ant Cingulate Cortex hypothalamus + PAG PAG, periaqueductal gray matter The pain inhibitory system Ascending pathway (modified from Wall & Melzack, Textbook of pain, 1999) Painful stimulus Dorsal horn Primary afferent

13 Acupuncture can activate the PAG and induces analgesia via descending pain inhibition. Liu X, Zhu B, Zhang SX. Relationship between acupuncture analgesia and descending pain inhibitory mechanism of nucleus raphe magnus and PAG. Pain. 1986;24:

14 NO NEUROPATHIC PAIN PATIENTS!

15 Positive results in Neuropathic Pain: Abuaisha BB, Costanzi JB, Boulton AJ. Acupuncture for the treatment of chronic painful peripheral diabetic neuropathy: A longterm study. Diabetes Res Clin Pract 1998;39: Tong Y, Guo H, Han B. Fifteen-day acupuncture treatment relieves diabetic peripheral neuropathy. J Acupunct Meridian Stud 2010;3:

16 However...

17 The Gate Control Theory Melzack and Wall, 1965 Closed gate for pain inputs! Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150:971-9.

18 No significant differences in comparison to placebo

19

20

21 PENS SHAM SHAM PENS Decrease the number of pills/day

22 Other skin treatments

23

24 Trader Joe s Market. Boston, 2012

25 Ziegler D, Ametov A, Barinov A, Dyck PJ, Gurieva I, Low P, Munzel U, Yakhno N, Raz I, Novosadova M, Maus J, Samigullin R 181 patients 5 weeks 12 discontinued (N/V) TSS = summation of main symptoms: lancinating, stabbing, burning pain, paresthesia and numbness

26 5-week treatment in 66 patients Oromucosal spray

27 Placebo CBM

28 ADVERSE EFFECTS AND THC CONCENTRATION

29

30 PLEASANT FEELING UNPLEASANT FEELING

31 Biofeedback is information about your biological functions. It works by detecting changes in your body and providing you with visual information of these changes. When you see this information, you can then go through a "trial and error" strategy where you learn to control your biological response. Reference:

32 Jensen MP, Barber J, Romano JM, Hanley MA, Raichle KA, Molton IR, Engel JM, Osborne TL, Stoelb BL, Cardenas DD, Patterson 29 subjects; Daily treatment for 10 days Stanford Hypnotic Clinical Scale to measure global hypnotizability. Duration of effect = 3 months

33 Guttmann O, Wykes V. Images in clinical medicine. Complex regional pain syndrome-i N Engl J Med. 2008;359:508.

34 Neurology. 2003;61: Controle CRPS I

35

36 Easy!!!! From Google

37

38 Methods: Results:

39 Nature Clin Pract Neurol. 2007;3: Estimulação magnética transcraniana - Repetitiva - Estimulação elétrica transcraniana - Contínua - NEURO - ESTIMULAÇÃO NEURO - MODULAÇÃO NEURO - MODULAÇÃO

40 Circular Tipo de estímulo repetitivo: Oito INIBITÓRIO Baixa frequencia: < 1Hz EXCITATÓRIO Alta frequencia: 5 a 20 Hz Long term inhibition Long term Potentiation Kobaiashi e Pascual-Leone, 2007

41 rtms for NP according to topography Nerve root Peripheral nerve Spinal cord Post Stroke Trigeminal neuralgia

42 SHAM rtms

43 MONTAGEM: ESTÍMULO ANODAL EXCITATÓRIO Long term Potentiation CATODAL INIBITÓRIO Long term inhibition CATHODE tdcs ANODE CATHODE tdcs

44 Spaulding Rehabilitation Hospital, Harvard University Boston MA

45 1: Soler MD, Kumru H, Pelayo R, Vidal J, Tormos JM, Fregni F, Navarro X, Pascual-Leone A. Effectiveness of transcranial direct current stimulation and visual illusion on neuropathic pain in spinal cord injury. Brain Sep;133(9): : Antal A, Terney D, Kühnl S, Paulus W. Anodal transcranial direct current stimulation of the motor cortex ameliorates chronic pain and reduces short intracortical inhibition. J Pain Symptom Manage May; 39(5): : Mori F, Codecà C, Kusayanagi H, Monteleone F, Buttari F, Fiore S, Bernardi G, Koch G, Centonze D. Effects of anodal transcranial direct current stimulation on chronic neuropathic pain in patients with multiple sclerosis. J Pain May;11(5): : Fregni F, Boggio PS, Lima MC, Ferreira MJ, Wagner T, Rigonatti SP, Castro AW, Souza DR, Riberto M, Freedman SD, Nitsche MA, Pascual-Leone A. A sham-controlled, phase II trial of transcranial direct current stimulation for the treatment of central pain in traumatic spinal cord injury. Pain May;122(1-2):

46 39 patients were randomized into four groups 2 weeks of treatment and follow-up after 12 weeks

47

48 Dor associada à disfunção do SNA Migraine (Shechter et al., 2002) Parkinsonian pain (Iodice et al., 2011) Complex regional pain syndrome (Marinus et al., 2011)

49 A systematic review of autonomic nervous system alterations induced by non-invasive brain stimulation Pedro Schestatsky Marcel Simis Roy Freeman Alvaro Pascual-Leone Felipe Fregni Beth Israel (Boston, 2012)

50 EEG EEG EEG EEG Anode EEG EEG Reference Journal of Visualized Experiments (accepted) Simultaneous EEG monitoring during tdcs Pedro Schestatsky 1,2, Leon Morales-Quezada 2,3, Felipe Fregni

51 Arquivos de Neuro-Psiquiatria, 2014 (in press)

52 Conclusões Existe certa evidência da boa eficácia de alguns tratamentos alternativos para Dor Neuropática A maioria destas práticas é plausível, acessível, segura e barata (PASB); Neurologistas devem sempre considerar o seu uso, seja em monoterapia ou em combinação, especialmente naqueles pacientes refratários ou intolerantes às práticas convencionais

53 Obrigado! View from Neuromodulation Lab - Boston