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Psihološka perspektiva

Nevrobiološki pristopi

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Nova nevroznanstvena dognanja, ki potrjujejo bolj individualizirano in biopsihosocialno formulacijo FNM, so privedla do večjega razumevanja sprememb v aktivnosti in funkcionalni povezljivosti več možganskih omrežij pri pacientih s funkcionalno nevrološko motnjo.

Tako lahko učinkovito terapevtsko možnost za paciente s FNM, predstavljajo tudi neinvazivne tehnike stimulacije možganov (Gonsalvez idr., 2021; Perez idr., 2021). Nevroznanstvene študije so namreč potrdile, da se funkcionalni nevrološki simptomi povezujejo z nenormalnostjo v aktivnosti in funkcionalni povezljivosti motorično-limbičnega možganskega omrežja (npr. amigdala, insula, suplementarno motorično področje), kot tudi desnega tempoparietalnega spoja (rTPJ; Perez idr., 2021). 

Transkranialna magnetna stimulacija (TMS) in Transkranialna stimulacija z enosmernim tokom (tDCS) predstavljata neinvazivni tehniki, ki ne zahtevata splošne anestezije, hkrati pa imata manj stranskih učinkov kot druge tehnike stimulacije možganov. Prav tako so študije ugotovile učinkovito modulacijo možganskih domen in pridruženih motenj ter simptomov, ki so značilni tudi za FNM (Gonsalvez idr., 2021).  

Transkranialna magnetna stimulacija (TMS)

Transkranialna magnetna stimulacija je neinvazivna tehnika, ki z uporabo elektromagnetne tuljave ustvarja električno aktivnost v ciljnih možganskih regijah, preko rabe magnetnih impulzov. Magnetna tuljava, ki je nameščena na lasišče, dovaja magnetni pulz, ki lahko preide skozi lobanjsko kost in ob vstopu ustvarja električno polje. Jakost induciranega električnega toka je dovolj velika za ustvarjanje akcijskih potencialov in nebolečo ter varno aktivacijo možganskih omrežij. Vendar lahko s to tehniko dosežemo zgolj površinski del možganov (Lefaucheur, 2019). 

V znanstveni literaturi se je TMS, med drugim, izkazala za učinkovito pri zdravljenju naslednjih motenj:

  • depresija (Gershon idr., 2003; McNamara idr., 2001; O’Reardon idr., 2007),

  • bipolarna motnja motnje (Dolberg idr., 2002; McGirr idr., 2016),

  • obsesivno-kompulzivna motnja (Carmi idr., 2019; Lusicic idr., 2018),

  • shizofrenija (Dlabač-de Lange idr., 2010; Haraldsson idr., 2004),

  • posttravmatska stresna motnja (Cirillo idr., 2019; Karsen idr., 2014),

  • Parkinsonova bolezen (Cantello idr., 2002, Chou idr., 2015),

  • distonija (Latorre idr., 2019; Mauroudakis idr., 1994),

  • tiki (Hsu idr., 2018; Steeves idr., 2012)

  • epilepsija (Bae idr., 2007; Chen idr., 2016; Tassinari idr., 2003)

  • bolečinski sindromi (Galhardoni idr., 2015; Nardone idr., 2018; Marlow idr., 2013; Yang in Chang, 2020).

Varnost TMS

Najpogostejši stranski učinki repetetativne TMS (rTMS) so :

  • lokalna bolečina na mestu stimulacije (najverjetneje zaradi stimulacije površinskih živcev in/ali obraznih mišic)

  • bolečina v vratu (zaradi dolgotrajne neugodne pozicije)

  • glavobol (najverjetneje zaradi spremembe v lokalnem toku cerebralne krvi; Loo idr., 2008).

Omenjeni stranski učinki so sicer pogosti, vendar niso resni v intenziteti in sčasoma izzvenijo.

Poleg omenjenih stranskih učinkov Loo idr., (2008) poročajo tudi o resnejših stranskih učinkih, ki so sicer zelo redki in se običajno povezujejo z intenzivnejšimi protokoli TMS:

  • napadi (izvajalci rTMS so sicer usposobljeni za prvo pomoč pri napadih, prav tako morajo slediti varnostnim protokolom),

  • okvara sluha (pacienti morajo nositi slušno zaščito, zaradi glasnih zvokov, ki se proizvajajo ob vsaki TMS),

  • psihoza (pomembna posebna pazljivost pri bipolarni motnji).

Transkranialna stimulacija z enosmernim tokom (tDCS)

Transkranialna stimulacija z enosmernim tokom (tDCS) je neinvazivna tehnika, ki uporablja šibek enosmeren električni tok, ki je doveden do nevronskega tkiva, z namenom povzročanja sprememb v kortikalni aktivnosti še nekaj ur po stimulaciji (Brunoni idr., 2011). Prednosti omenjene tehnike so predvsem v njeni ekonomski učinkovitosti, enostavni prenosljivosti ter zmožnosti induciranja fizioloških učinkov preko funkcionalnih povezljivih območjih, pri čemer učinki trajajo tudi dlje kot zgolj v obdobju stimulacije (Jamil in Nitsche, 2017). 

tDCS se je med drugim izkazala za učinkovito pri zdravljenju:

  • motoričnih in kognitivnih domen (delovni in dolgotrajni spomin, učenje; Jacobson idr., 2012; Schroeder in Plewnia, 2017).

  • depresije (Meron idr., 2015; Palm idr., 2016),

  • možganske kapi (Marquez idr., 2015; Schlaug in Nair, 2008),

  • bolečine (DaSilva idr., 2012; Lefaucheur idr., 2008; Pacheco-Barrios idr., 2020)

  • emocionalne regulacije (Feeser idr., 2014)

  • anksioznosti (Stein idr., 2020).

Varnost tDCS

tDCS predstavlja varno tehniko stimulacije možganov. Redki stranski učinki poročani v študijah:

  • opekline pod elektrodami (posledica pomanjkljive izvedbe; Palm idr., 2008)

  • manija /hipermanija (zgolj pri pacientih s unipolarno ali bipolarno motnjo; Palm idr., 2015).

Gonsalvez idr., (2021) so naredili sistematični pregled 21 študij, ki so preučevale učinkovitost rTMS in tDCS pri zdravljenju FNM. Interpretacija rezultatov je omejena zaradi:

  • majhnih vzorcev,

  • preiskovanja na različnih podtipih FNM,

  • variabilnosti v dizajnu in izvedbi rTMS in tDCS,

  • merjenih izidih

Učinkovitost omenjenih tehnik je tako potrebno še preučiti, upoštevajoč heterogenost pacientov s FNM, pridružene nevro(psihiatrične motnje), optimalnost parametrov stimulacije in potrebe po najdbi specifične subpopulacije pacientov s FNM, za katere bi bili omenjeni tehniki najbolj učinkoviti.

Nenivazivne tehnike stimulacije možganov in FNM

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    • Gonsalvez, I., Spagnolo, P., Dworetzky, B., in Baslet, G. (2021). Neurostimulation for the treatment of functional neurological disorder: A systematic review. Epilepsy & Behavior Reports, 16, 10050

    • Haraldsson, H. M., Ferrarelli, F., Kalin, N. H., in Tononi, G. (2004). Transcranial Magnetic Stimulation in the investigation and treatment of schizophrenia: a review. Schizophrenia research, 71(1), 1-16.

    • Hsu, C. W., Wang, L. J., in Lin, P. Y. (2018). Efficacy of repetitive transcranial magnetic stimulation for Tourette syndrome: a systematic review and meta-analysis. Brain Stimulation, 11(5), 1110-1118.

    • Jacobson, L., Koslowsky, M., in Lavidor, M. (2012). tDCS polarity effects in motor and cognitive domains: a meta-analytical review. Experimental brain research, 216, 1-10.

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    • Karsen, E. F., Watts, B. V., in Holtzheimer, P. E. (2014). Review of the effectiveness of transcranial magnetic stimulation for post-traumatic stress disorder. Brain stimulation, 7(2), 151-157.

    • Latorre, A., Rocchi, L., Berardelli, A., Bhatia, K. P., in Rothwell, J. C. (2019). The use of transcranial magnetic stimulation as a treatment for movement disorders: a critical review. Movement Disorders, 34(6), 769-782.

    • Lusicic, A., Schruers, K. R., Pallanti, S., in Castle, D. J. (2018). Transcranial magnetic stimulation in the treatment of obsessive–compulsive disorder: current perspectives. Neuropsychiatric disease and treatment, 1721-1736.

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    • Marquez, J., van Vliet, P., McElduff, P., Lagopoulos, J., in Parsons, M. (2015). Transcranial direct current stimulation (tDCS): does it have merit in stroke rehabilitation? A systematic review. International Journal of Stroke, 10(3), 306-316.

    • Marlow, N. M., Bonilha, H. S., in Short, E. B. (2013). Efficacy of transcranial direct current stimulation and repetitive transcranial magnetic stimulation for treating fibromyalgia syndrome: a systematic review. Pain Practice, 13(2), 131-145.

    • McGirr, A., Karmani, S., Arsappa, R., Berlim, M. T., Thirthalli, J., Muralidharan, K., in Yatham, L. N. (2016). Clinical efficacy and safety of repetitive transcranial magnetic stimulation in acute bipolar depression. World Psychiatry, 15(1), 85.

    • McNamara, B., Ray, J. L., Arthurs, O. J., in Boniface, S. (2001). Transcranial magnetic stimulation for depression and other psychiatric disorders. Psychological medicine, 31(7), 1141-1146.

    • Meron, D., Hedger, N., Garner, M., in Baldwin, D. S. (2015). Transcranial direct current stimulation (tDCS) in the treatment of depression: systematic review and meta-analysis of efficacy and tolerability. Neuroscience & Biobehavioral Reviews, 57, 46-62.

    • Nardone, R., Brigo, F., Höller, Y., Sebastianelli, L., Versace, V., Saltuari, L., ... in Trinka, E. (2018). Transcranial magnetic stimulation studies in complex regional pain syndrome type I: a review. Acta Neurologica Scandinavica, 137(2), 158-164.

    • O’Reardon, J. P., Solvason, H. B., Janicak, P. G., Sampson, S., Isenberg, K. E., Nahas, Z., ... in Sackeim, H. A. (2007). Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biological psychiatry, 62(11), 1208-1216.

    • Pacheco-Barrios, K., Cardenas-Rojas, A., Thibaut, A., Costa, B., Ferreira, I., Caumo, W., in Fregni, F. (2020). Methods and strategies of tDCS for the treatment of pain: current status and future directions. Expert review of medical devices, 17(9), 879-898.

    • Palm, U., Hasan, A., Strube, W., in Padberg, F. (2016). tDCS for the treatment of depression: a comprehensive review. European archives of psychiatry and clinical neuroscience, 266, 681-694.

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    • Palm U, Keeser D, Schiller C, Fintescu Z, Nitsche MA, Reis inger E… (2008) Skin lesions after treatment with transcranial direct current stimulation (tDCS). Brain Stimul 1:386–387

    • Palm U, Leitner B, Strube W, Hasan A in Padberg F (2015) Safety of repeated twice-daily 30 minutes of 2 mA tDCS in depressed patients. Int Neuropsychiatr Dis J 4:168–171

    • Schlaug, G., Renga, V., in Nair, D. (2008). Transcranial direct current stimulation in stroke recovery. Archives of neurology, 65(12), 1571-1576.

    • Schroeder, P. A., in Plewnia, C. (2017). Beneficial effects of cathodal transcranial direct current stimulation (tDCS) on cognitive performance. Journal of Cognitive Enhancement, 1, 5-9.

    • Stein, D. J., Fernandes Medeiros, L., Caumo, W., & Torres, I. L. (2020). Transcranial direct current stimulation in patients with anxiety: current perspectives. Neuropsychiatric Disease and Treatment, 161-169.

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    • Tassinari, C. A., Cincotta, M., Zaccara, G., in Michelucci, R. (2003). Transcranial magnetic stimulation and epilepsy. Clinical neurophysiology, 114(5), 777-798.

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