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38 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 2. 13. 14. Melzack R, Wall P. Pain Mechanisms: A New Theory. Science. 1965; 150:971-9. Mogilner A. Neuromodulation and Neuronal Plasticity (1a Edição). Neuromodulation. 2009. Krames E, Peckham PH, Rezai A. What is Neuromodulation? (1a Edição). Neuromodulation. 2009. Ellrich J, Lamp S. Peripheral Nerve Stimulation Inhibits Nociceptive Processing: An Electrophysiological Study in Healthy Volunteers. Neuromodulation. 2005;8(4):225-32. Ristic D, Spangenberg P, Ellrich J. Analagesic and antinociceptive effects of peripheral nerve stimulation in an advanced human exper- imental model. European Journal of Pain 2008;12:480-90. Mathary M, Bartsch T, Ward N, Trackowiak RS, Weiner R, Goadsby PJ. Central Neuromodulation in Chronic Migraine Patients with Sub- occipital Stimulators: a PET study. Brain. 2004;127:220-30. Sweet WH, Wepsic JG: Treatment of Chronic Pain by Stimulation of Fibers of Primary Afferent Neuron. Trans Am Neurol Assoc. 1968;93:103-7. Slavin KV. History of Peripheral Nerve Stimulation. Prog Neurol Surg. 2011;24:1-15. Bendinger T, Plunkett N, Poole D, Turnbull D. Psychological Factors as Outcome Predictors for Spinal Cord Stimulation. Neuromodula- tion. 2015;18:465-71. Campbell C, Jamison R, Edwards R. Psychological Screening/Phe- notyping as Predictors for Spinal Cord Stimulation. Curr Pain Head- ache Rep. 2013;17(1):307. Celestin J, Edwards RR, Jamison RN. Pretreatment Psychosocial Variables as Predictors of Outcomes Following Lumbar Surgery and Spinal Cord Stimulation: A Systematic Review and Literature Synthe- sis. Pain Med. 2009;10(4):639-53. Al-Jehani H, Jacques L. Peripheral Nerve Stimulation for Chronic Neurogenic Pain. Prog Neurol Surg. 2011;24:27-40. Slavin K. Peripheral Nerve Stimulation for Neuropathic Pain. US Neurology. 2011;7(2):144-8. Slavin K, Colpan E, Munawar N, Wess C, Nersesyan H. Trigeminal and Occipital Peripheral Nerve Stimulation for Craniofacial Pain: a Dor (2018) 26 pé diabético, foi avaliada a utilização de TENS de alta intensidade e constatou-se uma eficácia significativa na melhoria da dor severa em ca- sos onde a analgesia farmacológica foi insufi- ciente89. Complicações e limitações Como contraindicações definidas pelos fabri- cantes estão os pacemakers cardíacos, a gravi- dez e a epilepsia. A administração de TENS também não deve ser feita na proximidade de sistemas transdérmicos de libertação de fárma- cos. Quanto aos efeitos adversos, poderá ocor- rer irritação cutânea e dermatite de contacto nos locais de colocação dos elétrodos e estão des- critos raros casos de náusea e lipotimia90. Na dor crónica, a eficácia analgésica da utili- zação do TENS pode ser limitada pelo desen- volvimento de tolerância, principalmente se for aplicado diariamente com a mesma intensidade e frequência, isto é, a mesma dose. Estratégias para prolongar a analgesia nestes casos pode- rão passar pela alteração dos parâmetros. Tam- bém está descrito a existência de tolerância cruzada em doentes que já tenham desenvolvi- do tolerância a opioides91. Outra limitação da utilização do TENS no tra- tamento da dor crónica consiste na falta de evi- dência de alta qualidade que demonstre o seu benefício. A maioria das revisões sistemáticas realizadas sobre esta temática encontram uma fraca qualidade metodológica nos estudos que avaliam esta modalidade analgésica, nunca se conseguindo constatar um efeito claro92. Bibliografia Single-institution Experience and Review of the Literature. Neurosurg Focus. 2006:21(6):E6. 15. Kapural L, Mekhail N, Hayek SM, Stanton-Hicks M, Malak O. Oc- cipital nerve electrical stimulation via the midline approach and subcutaneous surgical leads for treatment of severe occipital neu- ralgia: a pilot study. Anesth Analg. 2005;101:171-4. 16. Huntoon MA, Burgher AH. 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Miller S, Watkins L, Matharu MS Treatment of intractable hemicrania continua by occipital nerve stimulation. J Neurol Neurosurg Psychi- atry. 2017;88:805-6. 24. Liu AJ, Ji HJ, Jiao YC, Zhang ZW. Peripheral Nerve Stimulation of Occipital Neuralgia. Chin Med J. 2015;128:2553-4. 25. Eldrige J, Obray J, Pringree M, Hoelzer B. Occipital Neuromodula- tion: Ultrasound Guidance for Peripheral Nerve Stimulator Implanta- tion. Pain Practice. 2010;10(6):580-5. 26. Johnstone CS, Sunderaj R. Occipital Nerve Stimulation for the Treat- ment of Occipital Neuralgia- Eight Case Studies. Neuromodulation. 2006;9:41-7. 27. Abhinav K, Park N, Prakash S, Love-Jones S, Patel N. Novel Use of Narrow Paddle Electrodes for Occipital Nerve Stimulation. Neuro- modulation. 2013;16:607-9. 28. Rodrigo-Royo MD, Azcona JM, Quero J, Lorente MC, Acín P, Azco- na J. Peripheral Neurostimulation in the Management of Cervicogen- ic Headaches: Four Case Reports. Neuromodulation. 2005; 8:241-8. 29. 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