Pain is a significant public health problem that costs society at least $560-$635 billion annually. Rheumatoid arthritis (RA) is a disease associated with considerable chronic pain, disability and dysfunction. RA is related to increased mortality, and the expected survival of RA patients is likely to be decreased by 3-10 years. The dominant treatment paradigms today to manage chronic pain involve systemic medications and surgical interventions. Cognitive Behavioral Therapy (CBT) is also a widely-accepted and efficacious treatment for chronic pain and is an important adjunctive treatment for pain management, but by itself, does not provide substantial relief for some patients. While several novel brain stimulatio technologies such as transcranial direct current stimulation (tDCS) have reliably demonstrated promise in the management of chronic pain, the analgesic benefit tends to be somewhat short-lived (lasting only 2-4 weeks), and optimal stimulation strategies are still unclear. More and more data is emerging that suggests endogenous brain state and brain activity when an exogenous electric stimulus is applied is hugely important in determining a patient's response and the therapeutic potential of tDCS. Despite several preliminary trials suggesting that tDCS may have analgesic effects on its own, tDCS may actually be more useful at facilitating endogenous neuro-cognitive analgesic processes like those engendered via CBT. If the brain is engaged in pain-inhibitory activity (such as CBT- guided cognitive reappraisal of a pain stimulus), application of tDCS over responsible brain areas might enhance, prolong and facilitate the endogenous analgesic effects. While this concept has been accepted and widely implemented in stroke rehabilitation research where it is common practice to use tDCS to facilitate and enhance the benefits of rehabilitative and occupational therapies, it has not been employed in such a manner with CBT and pain. Preliminary pilot data presented in this application suggest that anodal tDCS over the left dorsolateral prefrontal cortex (DLPFC) appears to enhance the analgesic benefits of a cognitive intervention for pain. The present proposal will use a well-controlled laboratory paradigm to closely examine and characterize the potential analgesic benefits of a series of cognitive-behavioral therapy interventions paired with anodal, cathodal or sham tDCS. This work may help determine the potential benefit of beginning a more refined and sophisticated line of brain stimulation research geared toward enhancing our knowledge about pain processing in the brain, treatment optimization and the synergistic value of combining treatment strategies. A parallel clinical pilot trial in patients with RA will also be conducted to determine whether laboratory findings correspond and generalize to a clinical cohort. Findings from the proposed study might lead to new paradigms of thought and experimentation in the development of novel, technology-savvy interventions for chronic pain.
Pain is a significant public health problem that costs society at least $560-$635 billion annually. The present proposal will use a well-controlled laboratory paradigm and a preliminary clinical pilot design to closely examine and characterize the potential analgesic benefits of combining cognitive-behavioral therapy interventions and tDCS for the management of pain.