New Stories: Translating Findings From Nonpharmacological Interventions into Practice: Neuromodulation

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Contributors

Didier Bouhassira, MD, PhD

Dr. Didier Bouhassira, MD, PhD, was been trained in neurology and neurophysiology in Paris, France. He has been involved in both basic and clinical research on pain and is currently Director of Research at the National Institute for Health and Medical Research (INSERM). He is associate attending neurologist in the Pain Clinic at Ambroise Paré hospital in Boulogne-Billancourt and director of the laboratory of "Pathophysiology and Clinical Pharmacology of Pain" (INSERM U-987). Didier is the immediate past president of the French Pain Society and an active member of several international associations or societies. He is field editor for the European Journal of Pain and associate editor for several scientific journals, including Pain. He has co-authored over 190 articles in peer-reviewed journals and has written a number of book chapters devoted to the pharmacology and pathophysiology of pain.

DISCLOSURE: Nothing to disclose.
Sulayman Dib-Hajj, PhD

Dr. Dib-Hajj is a Senior Research Scientist in the Yale School of Medicine and Graduate School, and Deputy Director of the Center for Restoration of Nervous System Function at the Veterans Administration Medical Center in West Haven, Connecticut. He received his undergraduate education from the American University of Beirut, Lebanon, and his PhD from the Ohio State University, Columbus, OH. His research for the past 2 decades at Yale and the VA has centered on the molecular basis of excitability disorders in humans including pain, with a focus on the role of voltage-gated sodium channels in the pathophysiology of these disorders, and as targets for new therapeutics. He has served on the Scientific Advisory Board of the Paralyzed Veterans of America Educational Foundation, and is currently serving on the Board of Directors of the National Disease Research Interchange. He serves on the editorial boards of several journals, and as a permanent member merit award panel at the VA BLRD service, and as ad hoc reviewer for the NIH and international funding organizations. He has published more than 200 primary papers and reviews, and has established national and international collaborations with academic and pharmaceutical groups.

DISCLOSURE: Nothing to disclose.

Neuromodulation techniques are widely and long-establishedly used in the treatment of chronic pain. The classical techniques include: transcutaneous electrical stimulation (TENS), electrical stimulation of the dorsal columns of the spinal cord, epidural stimulation of the motor cortex. More recently new non-invasive electrical (TENS) or magnetic (rTMS) cortical stimulation, vagal stimulation, or occipital stimulation have been developed.

The general principle underlying the use of these different approaches is to act on the systems that modulate the transmission of pain signals from the periphery to the brain. These treatments are based directly on experimental works that analysed these mechanisms in animals as early as the 1960s.

Pain modulation systems have been the subject of a considerable amount of experimental works since the 1960s, starting with the identification of the segmental modulatory controls organized in the spinal cord, which formed the basis of the famous and classical "gate control" theory. During the 1970s and 1980s, experimental studies lead to the discovery and characterization of descending modulatory systems, originating, in particular, in the brainstem, and which exert a powerful control (inhibitory or facilitatory) on the activities of nociceptive neurons of the spinal dorsal horn. Other electrophysiological studies showed the modulatory role of motor cortex stimulation in the early 1990s.

This is a very nice example of the success of translational research insofar as the clinical applications of these experimental discoveries have had an immediate impact in the clinic. It should be remembered that TENS techniques and spinal cord stimulation were used in humans less than 5 years after the publication of the experimental work that led to the proposal of the "gate control" theory. Similarly, brain stimulation techniques aimed at acting on the modulation systems organised at the supraspinal level were also very rapid. The first epidural stimulations of the motor cortex was performed as soon as the experimental results were published. It is on the basis of these results that, only a few years later, non-invasive stimulation techniques such as rTMS, which are currently undergoing strong clinical development, were subsequently used. Interestingly, new experimental works based on these clinical data are now investgating further the mechanisms of action of these non invasive brain stimulation techniques. Thus, this is an example of the bidirectional nature of translational research.

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Description

Contributors

Didier Bouhassira, MD, PhD

Sulayman Dib-Hajj, PhD