Fibromyalgia
Conditions
Keywords
Pain, Fibromyalgia, Magnetic Resonance Imaging, Cranial Electrical Stimulation, Myofascial Pain Syndromes, Veterans
Brief summary
Given recent increasing opioid-related deaths and evidence showing against the use of opioids for non-malignant chronic pain, there is growing need for non-narcotic pain management. Fibromyalgia is a difficult to treat chronic pain condition that is often treated with opioids despite existing evidence. The prevalence of fibromyalgia is increased among Veterans returning from the gulf war and is already a significant burden in senior Veterans who may have suffered with chronic pain for decades already. Many treatment options for fibromyalgia carry intolerable side effects. CES (Cranial Electrical Stimulation) is a FDA-approved, non-pharmacologic therapy that is currently utilized within the military and VA system, but sufficient evidence regarding its outcomes and neural mechanisms have not been adequately investigated. An understanding of its neural underpinnings and analgesic effects could lead to 1) improvements in pain management and quality of life, 2) cost-savings and 3) development of new techniques to address pain.
Detailed description
RESEARCH PLAN: In the setting of the opioid epidemic, it is crucial to develop non-pharmacologic treatments for pain and biomarkers to accurately assess pain treatment outcomes. In the present investigation, the investigators assess a novel non-pharmacologic approach to chronic pain treatment in patients suffering from fibromyalgia (a notoriously difficult to treat pain syndrome), utilizing neuroimaging as a biomarker. Resting state functional connectivity MRI (rs-fcMRI), a specific neuroimaging technique, has emerged as a reliable research tool to objectively assess, understand, and predict clinical pain in syndromes such as fibromyalgia. Preliminary results reveal a trend towards improved pain and function with a FDA-approved, non-pharmacologic therapy - auricular Cranial Electrical Stimulation (CES) - over standard therapy control, correlating to altered network connectivity on rs-fcMRI. CES-related improvements continued through 12 weeks following the completion of treatment and correlated to changes in cross-network connectivity, which differed between groups. OBJECTIVE: The proposed CDA-2, a randomized, sham-controlled trial of auricular CES, evaluates 1) the clinical utility of CES for fibromyalgia as compared to sham placebo control, 2) short- and long-term CES-related neural changes visualized on rs-fcMRI and 3) the ability of rs-fcMRI to predict CES treatment response. HYPOTHESIS: True CES results in non-placebo-related short- and long-term pain and functional improvements that can be correlated with altered connectivity and predicted by baseline rs-fcMRI. METHODS: Fifty total subjects (male and female Veterans, age 20-60 years old) will be randomized to either sham (n=25) or true (n=25) auricular CES. Neuroimaging data, self-reported pain, and function will be assessed at baseline and at 1 and 12 weeks post-treatment to evaluate neural correlates of CES-related treatment. Subjects who meet study criteria will receive baseline assessments including rs-fcMRI, Defense and Veterans Pain Rating Scale (DVPRS) measures, PROMIS measures, arm curl, 30-s chair stand, handgrip strength tests, and baseline analgesic consumption. Subjects will be block-randomized, stratified based on gender, to either true or sham CES (series of 4, weekly) treatments and assessed for rs-fcMRI and functional changes at 1 and 12 weeks post-treatment. This study addresses the critical need to identify and understand neural correlates of pain and non-opioid pain management.
Interventions
DEVICEAlpha-stim
The device for both groups is the Alpha-stim, a FDA-approved device similar to the Military Field Stimulator (MFS/Neuro-Stim System), a cranial electrical stimulation (CES) device.
Sponsors
VA Office of Research and Development
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Masking description
Double-blind, sham placebo-controlled
Intervention model description
Cranial electrical stimulation (CES) using a FDA-approved device that uses earclip electrodes to deliver current through the earlobe. The stimulator is meant to stimulate branches of the cranial nerves via the external ear.
Eligibility
Sex/Gender
ALL
Age
20 Years to 60 Years
Healthy volunteers
No
Inclusion criteria
* Subjects must be male and female Veterans age 20-60 with a diagnosis of fibromyalgia as diagnosed by a clinician, by chart review, and by the most recent American College of Rheumatology 2010 criteria for the diagnosis of fibromyalgia. * Subjects must self-report consistent, daily pain (greater than 5 on the VAS) \>90 days. * Subjects must have intact skin free of infection at the site of electrode placement. * Subjects must be willing to participate and understand the consent. * Subjects must be right-handed in order to provide consistency in brain structure and function.
Exclusion criteria
* Subjects must not be currently pregnant, since effects of fMRI and electrical current on the developing fetus are not well-known. * Subjects must not have an implanted electrical device such as a vagal stimulator, pacemaker, or spinal pain pump, which are not compatible with MRI. * Subjects must not have a history of seizures or neurologic condition that may alter the structure of the brain. * Subjects must not have a history of drug abuse or severe, uncontrolled psychiatric illness such as schizophrenia or major depressive disorder with suicidal ideation. * Subjects must not have psoriasis vulgaris or other skin conditions that may increase the risk of infection at the implantation site. * Subjects must not have severe anxiety, claustrophobia, or other conditions that may prevent their ability to lie at rest in an MRI scanner. This will be determined after discussion with the patient regarding their own perceived ability to lie at rest in an MRI scanner without the use of additional sedating medications. * Subjects must not introduce new medications or treatments for fibromyalgia symptoms during the course of the study to prevent confounding results.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Clinical Pain Change | baseline, 6 weeks into treatment, and 12 weeks post treatment | For subjects with fibromyalgia, clinical pain was assessed in both groups using the Defense Veterans Pain Rating Scale (DVPRS), a validated measurement tool for pain, as well as analgesic consumption. Clinical pain was measured at baseline, 6 weeks following treatment, and 12 weeks following treatment completion in both groups. Mean differences were measured between the baseline score and the 12-week score. The DVPRS is a combination of several different pain scales including the VAS, verbal rating scale, FACES scale, and numerical rating scale. Measurements will be graded on a scale of 0-10 with 0 being "no pain" and 10 being "severe" or "worst pain." |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in Rs-fcMRI Connectivity Effect Size | baseline, 6 weeks into treatment, and 12 weeks post treatment (change from baseline to 12 weeks post reported) | The region of interest (ROI) was the right Cerebellar 7b seed, and a 2x2 mixed ANOVA interaction was conducted with Family -Wise Error (FWE) constraints to control for multiple comparisons. Voxel threshold was set to p\<0.005 uncorrected, cluster threshold of p\<0.05 FWE corrected. A Fisher-transform z-score represents the mean connectivity values for each covariate in the model (i.e. groups) for each significant cluster. A z-score value of 0 indicates no difference in functional connectivity. Positive z-scores denote stronger, and negative z-scores weaker, connectivity with the ROI; further research is needed to determine their clinical implications and whether these changes denote a positive or negative outcome. |
| Sit-to-stand | baseline, 6 weeks into treatment, and 12 weeks post treatment | Tests of function (sit-to-stand, bicep curl, handgrip strength) was performed in both groups at baseline, 6 weeks, and 12 weeks following treatment. Mean difference was measured between baseline and 12 weeks. The sit-to-stand test tests how many full sit-to-stands a subject can perform within a 30 second interval. |
| Bicep-curl | baseline, 6 weeks into treatment, and 12 weeks post treatment | Tests of function (sit-to-stand, bicep curl, handgrip strength) was performed in both groups at baseline, 6 weeks, and 12 weeks following treatment. Mean difference was measured between baseline and 12 weeks. The bicep curl tests how many full bicep curls with gender specific weights (8 pounds for male, 5 pounds for female) a subject can perform within a 30 second interval. Both arms were tested. |
| Handgrip Strength | baseline, 6 weeks into treatment, and 12 weeks post treatment | Tests of function (sit-to-stand, bicep curl, handgrip strength) was performed in both groups at baseline, 6 weeks, and 12 weeks following treatment. Mean difference was measured between baseline and 12 weeks. The handgrip strength test uses a dynamometer to gauge the pressure that a subject can apply with their handgrip. Both hands were tested. |
| PROMIS Change | baseline visit and 12 weeks post treatment | NIH Patient-Reported Outcomes Measurement Information System (PROMIS) measures were assessed using a validated survey created from independently validated NIH survey questions in both groups. Mean differences in T-scores were measured between the baseline visit and the 12-week visit. PROMIS measures included: PROMIS Item Bank v1.0 - Fatigue - Short Form 6a, PROMIS Item Bank v1.0 - Emotional Distress-Depression - Short Form 4a, PROMIS Item Bank v.1.0 - Emotional Distress - Anxiety- Short Form 7a. For each measure, a lower T-score represents a better clinical outcome. All of the PROMIS measures reported (Fatigue, Depression, and Anxiety) have been standardized to have a mean of 50 and an SD of 10. This standardization means that a score of 50 is the average level in the population, and any 10-point change in either direction (greater or lesser) represents one SD difference. |
Countries
United States
Contacts
PRINCIPAL_INVESTIGATORAnna Woodbury, MD
Atlanta VA Medical and Rehab Center, Decatur, GA
Participant flow
Recruitment details
Veterans were recruited through direct referrals from Atlanta VA Healthcare System physicians, and through letters and phone calls inviting them to participate following a data access request through the VA corporate data warehouse based on a diagnosis of fibromyalgia and other characteristics matching inclusion criteria for the study.
Pre-assignment details
A total of 50 participants were consented for this study. Two of these participants could not begin the study due to MRI-incompatible medical device/metal implants. These two individuals were excluded from the study after initial consent and prior to randomization. A total of 48 participants were randomly allocated to treatment groups.
Baseline characteristics
| Characteristic | — |
|---|---|
| Age, Continuous | 49.4 Years |
| Defense & Veterans Pain Rating Scale (DVPRS) | 6.7 Score on scale |
| Ethnicity (NIH/OMB) Hispanic or Latino | 0 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 24 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants |
| Race (NIH/OMB) Black or African American | 17 Participants |
| Race (NIH/OMB) More than one race | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 1 Participants |
| Race (NIH/OMB) White | 15 Participants |
| Sex: Female, Male Female | 33 Participants |
| Sex: Female, Male Male | 5 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 25 | 0 / 23 |
| other Total, other adverse events | 0 / 25 | 0 / 23 |
| serious Total, serious adverse events | 0 / 25 | 0 / 23 |
Outcome results
None listed