Effect of low-frequency dorsal root ganglion stimulation in the treatment of chronic pain.

BACKGROUND: The role of stimulation parameters, especially stimulation frequency is not well understood in dorsal root ganglion stimulation. Previous studies documented higher effectiveness for frequencies as low as 20 Hz, but there is evidence that even lower values could lead to better outcomes. In this study, we investigate the influence of low-frequency DRG-S. METHOD: This is a randomized double-blind clinical trial with a crossover design. Patients with an already implanted DRG-S system were included and randomly tested with 4 Hz, 20 Hz, 60 Hz, and sham stimulation. Amplitude was adjusted to subthreshold values for each frequency. Each frequency was tested for 5 days, followed by a 2-day washout period. Patients were assessed using VAS, McGill Pain Questionnaire, EQ-5D-5L, and Beck Depression Inventory. RESULTS: Seventeen patients were in included. Time between inclusion in this study and primary implant was 32.8 months. Baseline stimulation frequency was 20 Hz in all patients. Mean baseline pain intensity was VAS 3.2 (SD 2.2). With 4-Hz stimulation, VAS was 3.8 (SD 1.9), with 20 Hz VAS 4.2 (SD 2.0) and with 60 Hz VAS 4.6 (SD 2.7). Worst pain control was seen with sham stimulation with a VAS of 5.3 (SD 3.0). Stimulation with 4 Hz achieved lower VAS scores, but this was only statistically significant when compared to sham (p = 0.001). A similar trend favoring 4-Hz stimulation was seen using the Beck Depression Inventory, but in this case no statistical significance was found. Outcomes of McGill Pain Questionnaire and EQ-5D-5L favored 20 Hz stimulation, but again without statistical significance. CONCLUSIONS: Low-frequency stimulation was not significantly better than classic 20-Hz stimulation in relieving pain intensity; the study might however be underpowered. Longer washout and observational periods might also be necessary to show clear differences in frequency response.

Frequency dependency of therapeutic efficacy in dorsal root ganglion stimulation for neuropathic pain.

BACKGROUND: The influence of the stimulation frequency on the outcomes of dorsal root ganglion stimulation (DRG-S) to treat pain is not well understood. It is assumed that specific neural components dedicated to different tasks in the DRG can be preferably influenced at specific frequencies. The identification of frequencies designed for the type of pain and the ratio of neuropathic versus nociceptive pain might improve overall pain control and open new indications in DRG-S. METHOD: We report on a randomized double-blind clinical trial with a crossover design. Patients with a permanent DRG-S system underwent phases of stimulation with 20 Hz, 40 Hz, 60 Hz, 80 Hz, and sham in a randomized order. Each phase lasted for 4 days and was followed by a 2-day washout period. Pain intensity and quality of life were assessed with visual analog scale (VAS), McGill Pain Questionnaire (MPQ), EQ-5D, and Beck Depression Inventory (BDI). Analgesics intake was assessed. RESULTS: Overall 19 patients were included in the study. CRPS was the most frequent pain etiology (7). Five patients had a PainDetect score of 12 or lower at baseline. The mean VAS before the system was implanted was 8.6 and 3.9 at the baseline. Pain intensity was reduced to 3.7 by the stimulation with 20 Hz but increased with higher frequencies reaching 5.8 at 80 Hz. A significant difference among the groups was shown over all variables examined (VAS, MPQ, EQ-5D, BDI). The best results were seen at 20 Hz for all variables, including the smallest increase in pain medication consumption. CONCLUSIONS: The choice of the stimulation frequency shows a clear influence on pain reduction and quality of life. Lower stimulation frequencies seem to be most effective in neuropathic pain. Further studies are required to determine whether specific frequencies should be preferred based on the condition treated.

Route navigating without place recognition: what is recognised in recognition-triggered responses?

The use of landmark information in a route-navigation task has been investigated in a virtual environment. After learning a route, subjects were released at intermediate points along the route and asked to indicate the next movement direction required to continue the route. At each decision point, three landmarks were present, one of which was viewed centrally and two which appeared in the periphery of the visual field when approaching the decision point. In the test phase, landmarks could be replaced either within or across places. If all landmarks combined into a new place had been associated with the same movement direction during training, subjects performed as in the control condition. This indicates that they did not need to recognise places as configurations of landmarks. If, however, landmarks that had been associated with conflicting movement directions during training were combined, subjects' performance was reduced. We conclude that local views and objects are recognised individually and that the associated directions are combined in a voting scheme. No evidence was found for a recognition of places as panoramic views or configurations of objects.

Navigation and acquisition of spatial knowledge in a virtual maze.

Spatial behavior in humans and animals includes a wide variety of behavioral competences and makes use of a large number of sensory cues. Here we studied the ability of human subjects to search locations, to find shortcuts and novel paths, to estimate distances between remembered places, and to draw sketch maps of the explored environment; these competences are related to goal-independent memory of space, or cognitive maps. Information on spatial relations was restricted to two types: a visual motion sequence generated by simulated movements in a virtual maze and the subject's own movement decisions defining the path through the maze. Visual information was local (i.e., no global landmarks or compass information was provided). Other position and movement information (vestibular or proprioceptive) was excluded. The amount of visual information provided was varied over four experimental conditions. The results indicate that human subjects are able to learn a virtual maze from sequences of local views and movements. The information acquired is local, consisting of recognized positions and movement decisions associated to them. Although simple associations of this type can be shown to be present in some subjects, more complete configurational knowledge is acquired as well. The results are discussed in a view-based framework of navigation and the representation of spatial knowledge by means of a view graph.

Is correspondence search in human stereo vision a coarse-to-fine process?

One possible strategy for the solution of the correspondence problem of stereo matching is the coarse-to-fine mechanism: The matching process starts with a lowpass-filtered version of the stereogram where only a few, high-contrast image features can be extracted and the probability of false matches is therefore low. In subsequent stages, information from higher spatial frequencies is used gradually to improve the correspondence data obtained on the coarser scales. Coarse-to-fine strategies predict that information from coarse scale is used to disambiguate matching information on finer scales. We have tested this prediction by means of the wallpaper illusion using periodic intensity-profiles with different matching ambiguities on different spatial scale. Our psychophysical experiments show (i) that unambiguous information at coarse scale is not always used to disambiguate finer scale information, (ii) that unambiguous fine-scale information can be used to disambiguate coarse-scale information and (iii) that low spatial frequency is more efficient for disambiguation than higher frequency. We conclude that the human stereo vision system does not always proceed from coarse to fine. As an alternative scheme for scale-space integration, we discuss more symmetric schemes such as maximum likelihood combinations of data from different channels.