Neuromodulation for pain and measuring treatment efficacy

Neuromodulation for pain and measuring treatment efficacy

Pain protects. In the presence of acute pain, we rarely think of its beneficial functions in the human body. Pain allows us to recognize problems in our body at the right time, such as bone fractures. However, for some patients, pain becomes a long-lasting companion, that is, pain becomes a chronic condition.

I think of pain as a neurological disease because ultimately, it is the brain that interprets and understands pain. Chronic pain is accompanied by psychological and social phenomena reflected by a reduction in work and functional capacity as well as by altered relationships between couples and people in general. In addition, chronic pain is also an economic issue: the associated societal cost results from sick days, early disability pension, and various treatments.

How to treat pain?

The greatest challenge in treating pain is that pain cannot be measured objectively. Pain cannot be imaged, and its existence cannot be verified by blood tests. The diagnosis and the intensity of the pain are based on the patient’s own reporting. For the same reasons, it is difficult to scientifically determine the effectiveness of treatment of pain.

The treatment of chronic pain requires a multidisciplinary approach that includes physiotherapy, medication, and psychological support. If the above-mentioned treatments are not effective, they can be supplemented with “invasive” therapies, such as nerve root blocks and peripheral nerve blocks. If the pain is not sufficiently relieved by these measures, the patient can be referred to a multidisciplinary study that evaluates the possibility of neuromodulation therapy. Neuromodulation can only treat neuropathic pain, wherein the site of the pain does not have any physical issue; rather, the problem is in the nervous system that transmits the pain signals.

In neuromodulation therapy, pain is alleviated by using a targeted electrical current or drug infusion into the central nervous system. The most commonly used method is spinal cord stimulation. The treatment costs around EUR 20 000, and previous studies have shown that about half of the patients benefit from the treatment.

Research studies have demonstrated that spinal cord stimulation works, although its precise mechanism of action remains unknown. In spinal cord stimulation, an electrode is permanently mounted on the dural membrane in the epidural space. The surgery does not involve any major risks of injury, although the risk of infection always exists. Such stimulation is a palliative treatment and does not cure nerve damage. However, at its best, it can improve the patient’s ability to function so that the patient can, for example, start exercising, which may have been impossible for years because of chronic pain.

Framework for Neuromodulation Management at Kuopio University Central Hospital

Data sources
The greatest challenge in pain management is the systematic collection of information and its application in research. We have resolved this issue at the Kuopio University Hospital (KYS) by setting up a neuromodulation register, which functions not only as a register for patient care quality and follow-up but also as a research database.

In the neuromodulation register, information is systematically collected through eight different questionnaires. These questionnaires evaluate the intensity of the pain and the degree of neuropathy; further, we also evaluate the patient’s psychological stress, functional capacity, quality of sexual health and function, and the overall impact of neuropathic pain on the quality of life.

Finland is unique in the world in that we can collect objective data on how people are coping and how they use health services. The Finnish social security institution Kela’s databases record each separate drug purchase. After the electrode for spinal stimulation has been implanted and the treatment is started, we can map the subsequent usage of strong analgesics by the patient: has treatment relieved pain and have the purchases of pain-relieving drugs reduced?

Another objective source of data collection is sick leave and retirement: how does a patient cope with working life? Has the patient’s number of sick days increased or decreased, and did the patient have to retire from work due to pain?

First contact with the neuromodulation therapistAlthough chronic pain is now a commonly recognized and recognized problem, access to treatment can be slow. In addition, healthcare professionals across the board need more training in order to identify and treat pain.

In Kuopio University Central Hospital, the process has been formulated such that patients suffering from chronic pain can easily access the neuromodulation therapist who specializes in pain relief, and if necessary, instructs the doctor.

The hospital’s pain working group, a multidisciplinary team of professionals including a psychiatrist, meets twice a month. Chronic pain itself is a traumatic experience and is associated with mental health problems. In addition, research has shown that trauma experienced in childhood has a predisposing effect on the chronicization of pain in later life.
The psychiatrist is involved in evaluating the need for psychological support for the patient prior to the initiation of the stimulation treatment as well as during the trial phase of the three-week stimulation treatment.

Need for pain research

The exact mechanism of action of spinal cord stimulation remains unknown. It is important to identify and clarify the mechanisms of pain via multidisciplinary research. Currently, the neural pathways for pain are fairly well known. Could functional brain imaging methods identify those areas of the brain that are activated during spinal cord stimulation? It is clear that pain research in neuroscience needs more research funding.

Few pharmaceutical companies have ongoing product development for drugs aimed at neuropathic pain: interestingly, the demand for such drugs is certainly there, with up to 40% of Europeans suffering from pain at some point in their lives. It is also important for medical device developers to carry out high-quality studies in order to objectively assess the efficiency and effectiveness of new devices entering the market.

However, the key need in pain research is that systematic collection of information and research is carried out in every hospital and treatment unit where pain patients are treated. Such collective and collaborative data collection will enable a better understanding of individual pain management in the future.