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For the first time, guidelines for neuromodulation – recommendations for good practice – have been published in the UK. Andrew Atkinson considers what this means in practice.What is neuromodulation?
Neuromodulation is a type of technology acting directly on our nerves. I have previously written about two forms of neuromodulation for CRPS: spinal cord stimulation (SCS) and dorsal root ganglion stimulation, a more targeted technology.
SCS was first developed back in the 1960s as a novel treatment for chronic pain. Nowadays, the procedure involves the surgical implantation of a pacemaker-like device (the SCS). Electrodes from the SCS are implanted into the epidural space close to the spinal cord. Similar procedures target the dorsal root, peripheral nerves, and occipital nerve, depending on the source of the pain. All variations produce a mild electric current that interrupts pain signals en route to the brain, reducing pain intensity – or that’s what should happen.
Psychological and social factors
For many years, it has been suggested that various psychological and social factors can impact outcomes from neuromodulation. Following studies in the 1990s, evidence of any of the following could exclude a patient from the procedure:
- personality disorders;
- unusual pain ratings;
- a history of alcohol or drug abuse;
- suicidal ideation;
- dysfunctional personality traits;
- unrealistic expectations;
- misconception of pain or pain treatment;
- inadequate social support, and
- an inability to understand or manage the implantable device.
Subsequently, there’s been a shift towards identifying any factors that might be amenable to treatment or support instead of using them as a basis for excluding treatment.
Approaching the issue from a different direction, another study sought to identify positive indicators for a successful outcome in neuromodulation. Among the characteristics suggested were:
- ‘general psychological stability’;
- ‘moderate levels’ of self-confidence and self-efficacy;
- realistic concerns regarding illness and proposed therapy;
- mild depression appropriate to the level of impairment; and
- general optimism regarding outcome could be associated with better outcomes from surgery.
NICE recommends a psychological assessment as part of the pre-surgery multidisciplinary assessment. Despite that, the available evidence for the role of psychological and social factors in successful outcomes remains limited. In addition, until now, there have been no guidelines to inform these assessments.
Guidelines for neuromodulation
Psychologists in Pain Neuromodulation (PiPN) is a network of clinical psychologists working within neuromodulation services in the UK. In light of the absence of formal guidelines, PiPN has published “Good practice guidelines for psychological assessment and intervention for pain neuromodulation services”. It means that for the first time, clinical psychologists in this sector have:
- recommendations for good practice;
- guidance on planning pre- or post-surgical psychological interventions; and
- information on some of the professional challenges faced in neuromodulation services.