Augmentation of EMDR With tDCS in the Treatment of Fibromyalgia

Overview

Fibromyalgia (FM) is a generalized, widespread chronic pain disorder and has an estimated prevalence of 2%-4% in the general population. Current pharmacological and psychological interventions frequently produce limited benefits in FM patients. Due to FM's strong association with psychological trauma causing neurobiological alterations in stress response, a trauma-focused psychotherapy is an innovative alternative treatment option. Eye Movement Desensitization and Reprocessing (EMDR) has been recognized by the World Health Organization as a first-line therapeutic tool for post-traumatic stress disorder and first evidence suggests that it is also beneficial for patients with FM. Given the complex etiology of FM, a combination of psychotherapy with other treatment options can maximize a potential therapeutic success. A possible candidate herby is transcranial Direct Current Stimulation (tDCS), a non-invasive stimulation technique, which can modify neural activities related to pain and which has shown short-term positive effects on chronic pain and quality of life in FM patients. The patient sample will consist of 45 female patients meeting 2016 American College of Rheumatology criteria for FM based on a clinical interview. They will be randomized to 20 sessions of EMDR plus tDCS or EMDR plus sham-tDCS, or Treatment as Usual (TAU). Therapists, raters, and patients will be kept blind to tDCS treatment conditions. Evaluations will be at baseline, post treatment at 6 months, and follow-up at 12 months. Hypotheses are that EMDR improves pain intensity and clinical symptoms at short and long-term, and that tDCS enhances this effect, which will be superior to tDCS-sham.

Full Title of Study: “Augmentation of EMDR With Transcranial Direct Current Stimulation in the Treatment of Fibromyalgia: a Randomized Controlled Trial”

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Parallel Assignment
    • Primary Purpose: Treatment
    • Masking: Triple (Participant, Care Provider, Investigator)
  • Study Primary Completion Date: May 31, 2022

Detailed Description

Fibromyalgia (FM) affects 2-4% of the general population with typical symptoms such as generalized and widespread pain, sleep disturbances, problems in memory and attention, anxiety and depression. Pharmacological treatment and psychotherapeutic interventions have produced limited effects so far. Interestingly, lifetime psychosocial adversities are substantially elevated in FM but no interventions are currently offered. Given the complex etiology of FM, combining a psychotherapy with other treatment options can maximize the potential benefit of this intervention. The investigators will test in a marginalized catchment area in Barcelona, whether a trauma-oriented therapy, Eye Movement Desensitization Reprocessing (EMDR), in combination with a non-invasive brain stimulation technique, transcranial Direct Current Stimulation (tDCS), can improve typical FM symptoms.

Outcomes

Primary outcomes:

1. To test whether EMDR plus tDCS or EMDR plus sham-tDCS in comparison to TAU group, improve pain intensity, depressive and anxious symptoms and trauma associated symptoms after therapy and follow-up.

2. To test whether an improvement in pain intensity, depressive and anxious symptoms and trauma associated symptoms can be augmented by simultaneous tDCS comparing EMDR plus tDCS with EMDR plus sham-tDCS after the intervention and whether this is maintained at the follow-up visit.

Secondary outcomes:

3. To test whether the EMDR plus tDCS or EMDR plus sham-tDCS incomparison to TAU group, improves more in subjective wellbeing after the treatment, and whether this is maintained at the follow-up visit.

Indicators to monitor clinical changes will be performed via various standard self- and hetero-applied scales by blind-to-treatment raters and information provided by patients and the medical chart IT system of our catchment area at baseline (visit 1), post treatment at 6 months (visit 2), and follow-up evaluation at 12 months (visit 3).

This multicenter collaborative project will involve the participation of the Psychiatric Department of the Parc de Salut Mar responsible for coordinating the study, the Rheumatologist Department of the Parc de Salut Mar responsible for patient recruitment, the Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) responsible for randomization and data base management, and the Cognitive Neuro-Lab responsible for the tDCS stimulation.

Design

Within a double-blind randomized controlled design, patients will be randomized to one of the following three treatment arms:

EMDR with tDCS (20 sessions) vs EMDR with sham-tDCS (20 sessions) vs TAU. Psychotherapists, raters, and patients will be kept blind for tDCS treatment conditions until the end of the trial.

Participants

The patient sample will consist of 45 females fulfilling the 2016 American College of Rheumatology criteria for FM based on clinical interview (Wolfe et al, 2010).

Interventions

- EMDR therapy

- Transcranial Direct Current Stimulation (tDCS)

- Treatment as Usual

Randomizations

The main analysis will be the comparison between patients assigned to EMDR vs not assigned to EMDR, and the secondary analysis will be, among patients assign to EMDR, the comparison between patients with FM assigned to active tDCS vs patients with FM assigned to sham tDCS. Therefore, the investigators will not randomly assign the individuals to one of the three arms but, rather, will randomize patients meeting the inclusion criteria twice: they will first randomize them to EMDR vs non-EMDR, and then will randomize those in the EMDR group to active tDCS or sham tDCS. For the sake of brevity, the investigators describe here only the randomization to EMDR vs non-EMDR, because the randomization to active tDCS vs. sham tDCS is identical. The first two patients will be randomly allocated to EMDR with p=2/3. For each subsequent patient, the following biased coin algorithm will be applied. If a group includes at least two more patients than it would have to have to maintain the ratio 2 EMDR / 1 control, the patient will be randomly assigned to the other group with p=0.6. Otherwise, the researchers will simulate that the new patient is allocated to EMDR and calculate the between-group standardized difference in pain intensity variable, will then simulate that the new patient is allocated to non-EMDR and recalculate the difference, and finally randomly allocate the patient to the group associated to the smallest difference with p=0.6. This strategy decreases prognostic imbalances between groups because it decreases differences in potential confounders but it still includes randomization.

Computation of sample size

The main tests of the study will consist in assessing whether patients assigned to EMDR show different levels of pain intensity variable using standard formula, the total sample size required to detect large to very large effect size differences (Cohen's d ≥ 1) between two groups with a significance level of 0.05 is 13 and 26. Assuming 15% dropouts, the researchers will aim to randomize 45 patients, i.e. 15 and 30 per arm.

Statistical Analysis

The distribution of socio-demographic and clinical characteristics between groups at baseline will be summarized using descriptive statistics. The change in clinical and functional variables from the baseline evaluation to post intervention will be analyzed using linear model t-tests, including as regressors of no interest the potential confounders (age, pain score, anxiety and depression severity, and number of years in education). The statistical software used for the analysis will be the latest available version of R. The investigators will conduct an intention to treat (ITT) analysis, and will use the "Last Observation Carried Forward" (LOCF) method for losses at follow-up.

Interventions

  • Behavioral: Eye Movement Desensitization and Reprocessing therapy
    • EMDR is a psychotherapeutic approach using a standardized 8-phase protocol to alleviate the distress associated with traumatic memories, facilitating the access to and processing of traumatic memories. Patients will receive 20 individual EMDR sessions of 60 minutes each using the standard protocol, as well as a specific pain protocol and the fibromyalgia protocol. EMDR is an integrative psychotherapy that uses standardized protocols and elements of cognitive-behavioral, interpersonal, and body-centered therapies, as well as dual stimulation (e.g., side-to-side eye movements). The current standard protocol includes eight phases: Patient history. Patient preparation. Patient assessment. Memory desensitization. Installing the positive cognition. Body scan. Closure. Reevaluation.
  • Other: Transcranial Direct Current Stimulation
    • tDCS represents a promising intervention option, given its capacity to modulate cerebral excitability in a simple, safe manner. We will use a multifocal transcranial direct current stimulation (MtDCS) montage (AF3 anodal, Fp1, AF7, F5, F3, F1, AFz return), intended to target the right dlPFC. Half of the patients will receive active stimulation and the other half sham stimulation. Active stimulation will consist of 1mA MtDCS for 20 minutes applied immediately before EMDR sessions. The same protocol and montage will be used for sham stimulation.

Arms, Groups and Cohorts

  • Active Comparator: EMDR plus tDCS
    • tDCS stimulation will consist of 1mA MtDCS for 20 minutes applied immediately before EMDR sessions.
  • Placebo Comparator: EMDR plus sham-tDCS
    • Sham stimulation will consist of inactive MtDCS for 20 minutes applied immediately before EMDR sessions
  • No Intervention: Treatment as Usual
    • Patients in this condition will not receive EMDR nor tDCS sessions, and will continue to attend their regular visits with rheumatology and psychiatry. The patients from the TAU group will have the choice to attend 10 sessions of EMDR group therapy when the research project finishes.

Clinical Trial Outcome Measures

Primary Measures

  • Change in pain assessed with the Visual Analogic Scale Questionnaire.
    • Time Frame: Change from baseline to visits at 6 and 12 months
    • Severity and changes in pain intensity will be assessed with the Visual Analogic Scale (rated in a continuum from 0 to 10).
  • Change in pain assessed with the Pain Dissability Index.
    • Time Frame: Change from baseline to visits at 6 and 12 months
    • Severity and changes in pain intensity will be assessed with the Pain Disability Index (7 items rated from 0 to 10, making a total score from 0 to 70).
  • Change in pain assessed with the Fibromyalgia Impact Questionnaire.
    • Time Frame: Change from baseline to visits at 6 and 12 months
    • Severity and changes in pain intensity will be assessed with the Fibromyalgia Impact Questionnaire (the first items is rated from 0 to 4, the second from 0 to 7 and the third from 0 to 5; whereas the other 7 items are rated from 0 to 10, with a cut-off score of 50).
  • Change in depressive symptoms assessed by with the Hospital Anxiety and Depression Scale
    • Time Frame: Change from baseline to visits at 6 and 12 months
    • Severity and changes in depressive symptoms will be evaluated with the Hospital Anxiety and Depression Scale. Items are rated on a 4-point Likert scale from 0 and 3, yielding a total score ranging from 0 to 21 and a cut-off score of 8 indicating probable clinical symptoms.
  • Change in anxious symptoms evaluated with the Hospital Anxiety and Depression Scale.
    • Time Frame: Change from baseline to visits at 6 and 12 months
    • Severity and changes in anxious symptoms will be evaluated with the Hospital Anxiety and Depression Scale. Items are rated on a 4-point Likert scale from 0 and 3, yielding a total score ranging from 0 to 21 and a cut-off score of 8 indicating probable clinical symptoms.
  • Change in trauma associated symptoms assessed with the Impact of Events Scale-Revised.
    • Time Frame: Change from baseline to visits at 6 and 12 months
    • Psychological trauma will be evaluated using the Impact of Events Scale-Revised. This scale consists in 22-item to determine frequency and impact of posttraumatic symptoms experienced, with subscales of intrusion, avoidance and hyperarousal, each scored on a 5-point Likert scale, yielding a score for each subscale and a total score. This scale has a scoring range of 0 to 88. On this test, scores that exceed 24 can be quite meaningful. High scores have the following associations: 24 or more PTSD is a clinical concern. Those with scores this high who do not have full PTSD will have partial PTSD or at least some of the symptoms; 33 and above represents the best cutoff for a probable diagnosis of PTSD; 37 or more this is high enough to suppress your immune system’s functioning (even 10 years after an impact event).

Secondary Measures

  • Change in subjective wellbeing measured with the Satisfaction With Life Scale.
    • Time Frame: Change from baseline to visits at 6 and 12 months
    • The improvement of subjective wellbeing will be evaluated using the Satisfaction With Life Scale. This scale is completed by 5 items rated from 1 (totally agree) to 5 (totally disagree), with a maximum score of 25.
  • Change in insomnia symptoms assessed with the Athens Insomnia Scale.
    • Time Frame: Change from baseline to visits at 6 and 12 months
    • The improvement of insomnia symptoms will be evaluated using the Athens Insomnia Scale. This scale is completed by 8 items rated from 0 to 3, with a maximum score of 24.

Participating in This Clinical Trial

Inclusion Criteria

  • Age between 18 and 70 years old
  • Mean pain score of at least 4 on the visual analog scale (VAS) in the two weeks preceding the clinical trial
  • Presence of one or more traumatic events causing current trauma-related symptoms
  • Current clinical symptoms of depression and/or anxiety
  • 2 weeks of stable medication

Exclusion Criteria

  • Comorbid autoimmune or chronic inflammatory disease
  • Neurological or serious medical diseases
  • Bipolar disorder, schizoaffective disorder and schizophrenia
  • Suicidal ideation
  • Previous EMDR therapy
  • Substance abuse/dependency within 1 month prior to participation (except for nicotine abuse/dependency),
  • Pending FM-related litigation or disability
  • Metallic implants in the head
  • Positive test for pregnancy

Gender Eligibility: Female

The relevance of the current proposal is underscored by a recent review (Borchers & Gershwin, 2015) on FM, where the authors highlight that it is a frequent disorder with mainly women of low educational level and socio-economic status affected.

Minimum Age: 18 Years

Maximum Age: 70 Years

Are Healthy Volunteers Accepted: No

Investigator Details

  • Lead Sponsor
    • Parc de Salut Mar
  • Collaborator
    • Universitat Oberta de Catalunya
  • Provider of Information About this Clinical Study
    • Sponsor
  • Overall Official(s)
    • Benedikt L. Amann, M.D., Principal Investigator, Parc de Salut Mar
  • Overall Contact(s)
    • Ana Moreno-Alcázar, Ph.D., (0034)933268500, amoreno1@imim.es

References

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Bernardy K, Klose P, Busch AJ, Choy EH, Häuser W. Cognitive behavioural therapies for fibromyalgia. Cochrane Database Syst Rev. 2013 Sep 10;(9):CD009796. doi: 10.1002/14651858.CD009796.pub2. Review.

Borchers AT, Gershwin ME. Fibromyalgia: A Critical and Comprehensive Review. Clin Rev Allergy Immunol. 2015 Oct;49(2):100-51. doi: 10.1007/s12016-015-8509-4. Review.

Burke NN, Finn DP, McGuire BE, Roche M. Psychological stress in early life as a predisposing factor for the development of chronic pain: Clinical and preclinical evidence and neurobiological mechanisms. J Neurosci Res. 2017 Jun;95(6):1257-1270. doi: 10.1002/jnr.23802. Epub 2016 Jul 12. Review.

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Hampstead BM, Briceño EM, Mascaro N, Mourdoukoutas A, Bikson M. Current Status of Transcranial Direct Current Stimulation in Posttraumatic Stress and Other Anxiety Disorders. Curr Behav Neurosci Rep. 2016 Jun;3(2):95-101. doi: 10.1007/s40473-016-0070-9. Epub 2016 Mar 28.

Lumley MA, Schubiner H, Lockhart NA, Kidwell KM, Harte SE, Clauw DJ, Williams DA. Emotional awareness and expression therapy, cognitive behavioral therapy, and education for fibromyalgia: a cluster-randomized controlled trial. Pain. 2017 Dec;158(12):2354-2363. doi: 10.1097/j.pain.0000000000001036.

O'Connell NE, Marston L, Spencer S, DeSouza LH, Wand BM. Non-invasive brain stimulation techniques for chronic pain. Cochrane Database Syst Rev. 2018 Mar 16;3:CD008208. doi: 10.1002/14651858.CD008208.pub4. Review. Update in: Cochrane Database Syst Rev. 2018 Apr 13;4:CD008208.

Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB, Yunus MB. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010 May;62(5):600-10. doi: 10.1002/acr.20140.

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