Parameters and results of non-invasive neuromodulation in the management of chronic pelvic pain: integrative literature review

Barbosa, Pâmela Maria Massaro; Capello, Maria Gabriela Maziero; Generoso, Laura Pereira; Cardoso, Edvaldo José Rodrigues; Silva, Marcelo Lourenço da; Silva, Josie Resende Torres da

doi:10.5935/2595-0118.20230071-en

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REVIEW ARTICLE • BrJP 6 (3) • Jul-Sep 2023 • https://doi.org/10.5935/2595-0118.20230071-en copy

Parameters and results of non-invasive neuromodulation in the management of chronic pelvic pain: integrative literature review

Authorship SCIMAGO INSTITUTIONS RANKINGS

HIGHLIGHTS

There is a need for standardization and consensus on the parameters of neuromodulation techniques for chronic pelvic pain.
The stimulation area includes the motor cortex and the dorsolateral prefrontal cortex.
Neuromodulation techniques, such as Transcranial Magnetic Stimulation and Transcranial Direct Current Stimulation, have shown potential in addressing not only pain but also other aspects such as sleep, cognitive complaints, fatigue, catastrophizing, depression, and mood in patients with chronic pelvic pain.

ABSTRACT

BACKGROUND AND OBJECTIVES:

Chronic Pelvic Pain (CPP) is characterized by persistent pain in the pelvic region for more than six months, affecting both men and women and causing significant impairment in quality of life (QoL). Two of the main non-invasive approaches are Transcranial Magnetic Stimulation (TMS) and Transcranial Direct Current Stimulation (tDCS). These techniques aim to modulate neural activity and promote pain relief. In this context, this research conducted an integrative literature review to summarize the results of relevant studies, aiming to identify the key parameters used in TMS and tDCS for CPP treatment. The objective was to assess the effect and efficacy of non-invasive neuromodulation as a therapeutic intervention for CPP.

For this integrative review, electronic searches were conducted in Pubmed, Scielo, PEDro, Medline, Cochrane, and Scopus databases, examining studies in Portuguese, English, or Spanish. The keywords “pelvic pain,” “transcranial direct current stimulation,” and “transcranial magnetic stimulation” and their derivatives were searched in the three languages in studies from 2013 to 2023. Seven studies were included for analysis. Both techniques showed positive effects in managing CPP, improving pain levels and quality of life to a relevant extent. However, there is still no consensus on the parameters applied in TMS and tDCS techniques for CPP.

CONCLUSION:

Non-invasive neuromodulation improves pain levels and quality of life in patients with CPP. Further studies are needed to establish more reliable parameter relationships, and the limited number of studies restricts definitive conclusions on the subject.

Keywords
Chronic pain; Non-invasive neuromodulation; Pelvic pain; Transcranial magnetic stimulation; Transcranial direct current stimulation

Authors	Type of Study	Sample	Stimulated Area	Parameters (Amplitude, Electrode Size, Number of Sessions, and Duration)	Primary Outcome	Secondary Outcome	Conclusion
Divandari et al.¹1 Divandari N, Manshadi FD, Shokouhi N, Vakili M, Jaberzadeh S. Effect of one session of tDCS on the severity of pain in women with chronic pelvic pain. J Bodyw Mov Ther. 2019;23(3):678-82.	RCT	16 women between the ages of 20 and 50 who were diagnosed with CPP and were not in the postmenopausal period	Left M1 and DLPFC	Amplitude: 0.3mA Electrode Size: 1.5 x 2cm (0.1mA/cm²) Number of Sessions: 2 Duration: 20 minutes Reference Electrodes: Two reference electrodes (2 x 6 cm) were positioned in the supraorbital area	tDCS was found to be effective in reducing pain levels.	Real tDCS showed improvement in quality of life and disability but did not demonstrate an effect on depression.	Real tDCS treatment was effective in reducing CPP and improving quality of life.
Simis et al.²⁷27 Simis M, Reidler JS, Duarte Macea D, Moreno Duarte I, Wang X, Lenkinski R, Petrozza JC, Fregni F. Investigation of central nervous system dysfunction in chronic pelvic pain using magnetic resonance spectroscopy and noninvasive brain stimulation. Pain Pract. 2015;15(5):423-32.	RCT	11 male and female patients, aged between 18 and 24 years, who were diagnosed with CPP and reported a minimum pain level of 3 on the visual analog scale (VAS).	Anode: Left M1 (contralateral to the more painful side or where the symptoms started). Cathode: Contralateral supraorbital area.	2mA; electrode size: 35cm²; 10 consecutive sessions; 20 minutes each.	Significant increases were found in sensory and pain thresholds after 2 weeks of active ETCC compared to sham.	Biochemical changes in neural circuits related to pain are associated with the pain levels measured by quantitative pain tests.	A significant increase in pain thresholds was observed after active tDCS compared to sham conditions, but further testing of neuromodulatory interventions for DPC is needed.
Harvey et al.²⁸28 Harvey MP, Watier A, Dufort Rouleau É, Léonard G. Non-invasive stimulation techniques to relieve abdominal/pelvic pain: Is more always better? World J Gastroenterol. 2017;23(20):3758-60.	RCT	9 male and female patients who were diagnosed with CPP.	tDCS: Anode: Contralateral M1 to the more painful side; Cathode: Contralateral supraorbital area. TENS: Lower abdominal and/or lumbar region + Tibial region.	TENS: Frequency of 3Hz, pulse duration of 400ms, intensity at the pain threshold, and duration of 30 minutes. TENS+tDCS: tDCS applied with an intensity of 2 mA, electrode size of 5 x 7cm, and duration of 30 minutes.	There was a slight decrease in pain during the treatment, but it was not clinically significant in both groups.	One session of TENS, either alone or in combination with ETCC, can slightly reduce pain in patients with CPP.	The combination of TENS and tDCS did not provide additional benefits in patients with CPP (based on the analysis of one session).

Authors	Type of Study	Sample	Stimulated Area	Parameters (Amplitude, Electrode Size, Number of Sessions, and Duration)	Primary Outcome	Secondary Outcome	Conclusion
Pinot- Monange et. al.²⁴24 Pinot-Monange A, Moisset X, Chauvet P, Gremeau AS, Comptour A, Canis M, Pereira B, Bourdel N. Repetitive transcranial magnetic stimulation therapy (rTMS) for endometriosis patients with refractory pelvic chronic pain: a pilot study. J Clin Med. 2019;8(4):508.	Pilot Study	12 women with Endometriosis and CPP	left M1	80% of the resting motor threshold (LMR); 8-shaped coil; 10-second pulses every 50 seconds, 10Hz up to 1500 pulses per session; 5 sessions; not reported.	Pain improvement.	9 women reported pain improvement and a reduction in its interference with their quality of life.	TMS appeared to be an interesting alternative for patients with endometriosis and CPP.
Nikkola et al.²⁶26 Nikkola J, Holm A, Seppänen M, Joutsi T, Rauhala E, Kaipia A. Repetitive transcranial magnetic stimulation for chronic prostatitis/chronic pelvic pain syndrome: a prospective pilot study. Int Neurourol J. 2020;24(2):144-9.	Pilot Study	11 patients (both male and female) with CPP	Left and right M1 in the corresponding locations to the pelvic area.	110% do LMR; B8; pulsos de 5s a cada 26s até 1500 pulsos/sessão; 5 sessões; 20min.	Reduction in pain levels was observed after treatment and at the first and eighth week.	NIBS patients reported an overall improvement in pain levels, and six patients were able to reduce their medications.	rTMS appeared to be a safe and well-tolerated therapy for prostatic pain and CPP. It may be an alternative for pain that is resistant to other conventional therapies.
Louppe et. al.³⁰30 Louppe JM, Nguyen JP, Robert R, Buffenoir K, de Chauvigny E, Riant T, Péréon Y, Labat JJ, Nizard J. Motor cortex stimulation in refractory pelvic and perineal pain: report of two successful cases. Neurourol Urodyn. 2013;32(1):53-7.	Case study	2 women with CPP	M1	Patient 1: 1 session, 20 minutes, 2 electrodes stimulating M1r, 20 trains of 10 seconds, 10 Hz, 80% of the resting motor threshold (LMR), interval between trains of 50 seconds (2,000 stimuli). Amplitude 2.5 V, pulse width 60 ms, frequency 40 Hz. Patient 2: 3 sessions, 1 placebo session, except for the Amplitude (2V), all parameters remained the same.	Conventional neuromodulation techniques previously performed failed in the mentioned cases, making rTMS a promising treatment for them.	Conventional neuromodulation techniques previously performed failed in the mentioned cases, making rTMS a promising treatment for them.	Motor Cortex stimulation via rTMS was an effective technique in the treatment of refractory chronic pelvic/perineal pain. However, further comprehensive studies in this field are needed.
Zakka et al.²⁵25 Zakka TRM, Yeng LT, Teixeira MJ, Rosi Júnior J. Dor pélvica crônica não visceral: tratamento multidisciplinar. Relato de caso. Rev Dor. 2013;14(3):231-3.	Cross-sectional observational	20 females with CPP	M1	80% of RMT; Coil position B8; 10 Hz; 10-second pulses every 20 seconds up to 3,000 pulses per session; 2 sessions; 15 minutes.	Reduction in the mean scores of all items on the Brief Pain Inventory was observed in patients initially treated with rTMS.	rTMS induced analgesic effects independent of improvements in quality of life or mood in the included patients.	rTMS is feasible and constitutes a safe procedure and a good therapeutic alternative for CPP.

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[1] Conflict of interests: none - Sponsoring sources: CAPES (Finance code 001).

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Parameters and results of non-invasive neuromodulation in the management of chronic pelvic pain: integrative literature review

HIGHLIGHTS

ABSTRACT

BACKGROUND AND OBJECTIVES:

CONTENTS:

CONCLUSION: