Neuromodulation of Pain

Many of my patients have expressed interest in procedures for Neuromodulation of Pain – spinal cord stimulators, peripheral nerve stimulators and transcranial magnetic stimulation (TMS) – for treatment of pain.

What is Neuromodulation?

Neuromodulation is a field of science that encompasses implantable and non-implantable technologies, magnetic and electrical techniques that improves life for humanity.  Neuromodulation is a technology that impacts upon the neural interface to change pain perception by the brain.

How does it apply to treatment of chronic pain?

The electrical neuromodulation technique employed to effectively treat pain includes implantable peripheral nerve stimulators and spinal cord stimulators.

The spinal cord stimulators are increasingly being used to treat low back and neck pain (especially pain that persists after surgery), pelvic/sacral pain, incontinence and gastric pain (irritable bowel syndrome).

Peripheral nerve stimulators are being used to treat peripheral nerve pain like occipital neuralgia and sacroilitis.

The nerve stimulators work on the “Gate Theory.”  This theory implies that if you stimulate the nerves carrying the vibration sensation to the brain then it will block or decrease the activity of the nerves carrying the pain sensation to the brain.

Transcranial magnetic stimulation (TMS) is the latest revolutionary non-invasive and non-systemic (no medications involved) technology using the same principles as an MRI to stimulate brain cells back into a healthy state.  It is FDA approved for treating depression in United States.  It has many off label uses including treating many chronic pain conditions including migraine headaches and fibromyalgia.

TMJ/Temporomandibular Joint Dysfunction (TMD)

Many of my patients with headaches and face pain have questioned me about the role and treatment for TMD (temporomandibular joint dysfunction).  Here is a brief outline of classification of head and face pain due to TMJ disorders and its treatment.

When a patient presents with facial pain, the first challenge is to make a diagnosis. It is crucial to determine if the patient’s pain is due to TMD, or if they show signs of a non-TMD problem such as migraine, neuralgia, intracranial lesion, neoplasm, radiculopathy, tooth pulpalgia, third molar pericornitis, etc.  Once we have determined that the patient has TMD (which might be contributing to headaches), the next question is whether the patient has a primary TMJ or a muscle problem, or both? Treatment depends on making the correct diagnosis.

Below are the DIAGNOSTIC CRITERIA established by the American Academy of Orofacial Pain for joint disorders and muscle disorders.

Diagnostic Criteria for Joint Disorders

1. Congenital or developmental disorders (rarely cause TMD)

2. Disk displacement

3. Dislocation (also known as open lock or subluxation)

4. Inflammatory disorders

5. Osteoarthritis

6. Ankylosis

Diagnostic Criteria for Masticatory Muscle Disorders

1. Myofascial pain

2. Myositis

3. Myospasm

4. Local myalgia

5. Myofibrotic contracture


We have success in managing the majority of persons suffering from TMD by using noninvasive, conservative treatment regimen involving self-care, physical therapy (PT), behavioral therapy (BT), injections, etc.  But there are still a significant number of patients (5%–20%) that are refractive to treatment and require more invasive therapies.  We refer these patients to dentists for occlusal devices and surgery as last resort if conservative therapy fails.