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Transcranial direct current stimulation as a tool for postoperative pain

management : a review of the current clinical evidence

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 (Acta Anaesth. Belg., 2019, 70, 173-181)

Transcranial direct current stimulation as a tool for postoperative

pain management : a review of the current clinical evidence

A. Steyaert (*,**), C. Lenoir (*,***), P. Lavand’homme (*,**), A. Mouraux (*)

Abstract : Adequate control of acute postoperative pain is defined as pain that develops after a surgical
remains a challenge, and many patients still experience procedure and persists at least three months, when
moderate to severe pain. Surgery is also a major cause all other causes of pain (e.g. infection, recurring
of chronic pain, which cannot reliably be prevented with malignancy, …), as well as pain from a pre-existing
available interventions. Current analgesic regimens are pain problem have been excluded (8). CPSP affects
also associated with severe side-effects. Consequently,
up to 50% of patients after common surgical
we are in need of new techniques to better manage pain
in the perioperative period. Transcranial direct current
procedures, worsening quality of life and increasing
stimulation (tDCS) – a non-invasive neuromodulation health care use  (9). Chronic pain is hard to treat,
technique – affects pain perception in human volunteers. but the programmed nature of the surgical trauma
Its ease of use, relatively low cost and absence of serious could offer a window of opportunity for primary
side effects make it an ideal candidate for clinical preventive measures (10). Unfortunately, a recent
practice and a recent review concluded that it reduces review of the available perioperative interventions
pain intensity and improves quality of life of chronic pain for CPSP prevention concluded that, currently, none
patients. This article aims to review the clinical evidence reliably prevent its development (11).
for its use as a tool for postoperative pain management. The non-invasive application of electrical
In summary, seven randomized controlled trials have currents to the brain and the spinal cord has been used
included over 310 patients and report encouraging results, in research and clinical practice since the beginning
most notably a considerable reduction in postoperative
of the 20th century  (12). Among the various forms
opioid use. More studies are needed to better establish
the place of tDCS in this setting and to determine the
of non-invasive brain stimulation techniques, tDCS
optimal stimulation protocols. has several characteristics, which make it an ideal
candidate for clinical use : low risk, non-invasive
Keywords : Postoperative pain ; transcranial direct cur- and painless, lack of serious side effects, ease of
rent stimulation ; analgesia administration and relatively low cost (13). Because
participants only feel a light tingling sensation
during the first minutes of stimulation, regardless of
Introduction stimulation duration, adequate patient blinding can
be obtained in clinical trials by delivering a very short
Despite currently used analgesic techniques,
adequate control of acute postoperative pain
remains a challenge, and many patients still Arnaud Steyaert MD, Cédric Lenoir PT, PhD, Patricia
experience moderate to severe pain after their Lavand’homme MD, PhD, André Mouraux MD, PhD
surgery  (1). Unrelieved pain is associated with (*) Institute of Neurosciences, Université Catholique de
Louvain, Belgium
increased morbidity, functional and quality-of-life (**) Department of Anesthesiology, Cliniques Universitaires
impairment, delayed recovery, higher health care Saint-Luc, Belgium
costs, and prolonged opioid use (2). Moreover, (***) Department of Neuroscience, Physiology and
Pharmacology, University College London, UK.
current postoperative analgesic regimens are Corresponding author : Arnaud Steyaert, MD, Department
associated with severe side effects, including long- of Anesthesiology, Cliniques Universitaires Saint-Luc, av.
term opioid use, misuse, and addiction (3). Recent Hippocrate 10, 1200 Woluwé-St-Lambert, Belgium.
E-mail  : arnaud.steyaert@uclouvain.be
studies have also raised security concerns with other
analgesic drugs, e.g. an increased risk of respiratory Paper submitted on Jul 07, 2019 and accepted on Nov 20, 2019.
depression when gabapentin (4) or pregabalin  (5) Conflict of interest : Arnaud Steyaert is supported by research
are combined with opioids. grants of the Society of Anesthesia and Resuscitation
of Belgium and of the Fonds de Recherche Clinique.
Surgery is also a frequent cause of persistent Cédric Lenoir is supported by the Wellcome Trust (COLL
pain (6, 7). Chronic postsurgical pain (CPSP) JLARAXR).

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 174 a. steyaert et al.
et al. (19) showed that one 10-minute session of
anodal HD-tDCS over M1 significantly increases
pain pressure thresholds as well as the magnitude
of conditioned pain modulation (CPM). Earlier,
Borckardt et al. (20) demonstrated that a single
session of anodal HD-tDCS over M1 significantly
reduces the slope of temporal summation of thermal
pain in healthy volunteers. Anodal tDCS over M1
also reduces the intensity and extent of mechanical
secondary hyperalgesia induced by capsaicin-
heat application, possibly through the activation
of descending pain modulation pathways (21).
Fig. 1 — Left: anatomical location of areas commonly targeted Moreover, a recent Cochrane review concluded
with tDCS for pain control: dorsolateral prefrontal cortex
that there is evidence – albeit of low-quality – that
(DLPFC) and primary motor cortex (M1) ; middle: wide-
spread electrical field generated by a traditional tDCS montage, tDCS of M1 or DLPFC reduces pain intensity and
using two sponge electrodes ; right: more focalized electrical improves quality of life in chronic pain patients (22).
field generated by an optimized HD-tDCS montage, using 8 In the present article, we aim to review the
electrodes (adapted with permission from (58)). current clinical evidence for the use of tDCS in the
management of acute postoperative pain.
stimulation mimicking the initial experienced scalp
sensations at the beginning of real stimulation (13). Methods
During tDCS, a weak direct electrical current
is delivered through two or more electrodes placed We performed a PubMed search (up to
on the subject’s scalp. The resulting physiological December 2018) with the following terms : ‘post-
effects depend on several parameters  (13). First, operative pain’ OR ‘postsurgical pain’ AND ‘trans-
the targeted brain structures (Figure 1, left) are cranial direct current stimulation’ OR ‘tDCS’,
of importance. For pain relief, these are most focusing on adult randomized, controlled trials. We
commonly the primary motor cortex (M1)  (14) or excluded studies not available in English or French
the dorsolateral prefrontal cortex (DLPFC)  (15). language. All titles and abstracts were examined to
Second, the type and configuration of electrodes exclude irrelevant studies.
have an influence. Originally, two large sponge We extracted data about participants (number
electrodes were used, resulting in a rather widespread of patients, gender), intervention (tDCS montage,
electric field (Figure 1, middle). More recently, number, timing, and duration of sessions, current
the use of several smaller electrodes, referred to intensity, polarity, electrodes’ size, current density),
as high-definition tDCS (HD-tDCS)  with at least control condition (sham stimulation), adverse
one ‘active’ electrode surrounded by four or more events, and outcomes (opioid use, pain scores).
‘return’ electrodes, has demonstrated improved
focus of the stimulation (Figure 1, right) (13,16). Results
Third, the polarity of the active electrode located
over the target makes a difference. It is commonly Our literature search retrieved seven rando-
reported that the anodal electrode over the target mized controlled trials investigating the use of
region increases its excitability, while the cathodal tDCS as a postoperative pain management tool. We
electrode decreases it (17). Fourth, the current dose present the characteristics of each study in Tables 1
is thought to determine the effectiveness of the to 3 and summarize their findings in the text below.
neuromodulation. It is determined by the intensity In 2013, Dubois et al. randomized 59 patients
and duration of the stimulation, commonly set to 1 scheduled for lumbar spine surgery to receive
or 2 mA and 20 minutes, respectively (13). a single session of anodal, cathodal or sham
Several studies have demonstrated that tDCS tDCS over the left DLPFC (23). Anesthesia and
alters pain perception in humans. A recent meta- postoperative analgesia were standardized. Patients
analysis concluded that anodal tDCS of M1 but not underwent stimulation in the recovery room.
of the primary somatosensory cortex (S1) increases Outcomes – morphine consumption and pain levels
sensory detection and pain thresholds in healthy over the two first postoperative days – were similar
volunteers and decreases pain levels in chronic in both groups. No serious adverse events were
pain patients (18). In a study on healthy men, Flood noted. About half of the patients described some

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 tdcs and postoperative pain 175

mild itching under the electrodes and one patient in (Leeds Assessment of Neuropathic Symptoms and
the cathodal group experienced a visual flash at the Signs questionnaire and pain scores) were similar.
start of the stimulation. Adverse events were not reported.
Borckardt et al. randomly assigned 40 patients Ribeiro et al. conducted a double blinded,
scheduled for unilateral total knee arthroplasty sham-controlled, randomized trial, where patients
(TKA) to receive four 20-minute sessions of real (n scheduled for hallux valgus surgery were assigned
= 20) or sham tDCS (n = 20) (24). The anode was to receive two preoperative 20-minute sessions of
positioned over M1 – contralateral to the operated either anodal or sham tDCS over M1 (28). The first
knee – and the cathode over the right DLPFC. session was planned the night before surgery, and the
Patients received two sessions on the day of surgery second in the morning before the procedure. Patients
and two sessions on the first post-operative day. in the real tDCS group reported significantly lower
Patients who had received real tDCS consumed pain scores and needed less opioids than patients
significantly less opioids up to 48 hours after assigned to the sham group. Adverse events were
surgery, without reporting higher pain. Adverse not reported.
events were not reported. In 2018, Jiang et al. reported the findings of
In a follow-up study, Borckardt et al. enrolled a single-blind, randomized, sham-controlled trial
61 patients undergoing TKA and randomly assigned including 32 patients having underwent lumbar
them to one of four groups : (A) anode : M1, spine surgery (29). On postoperative day one, half
cathode : right DLPFC ; (B) anode : left DLPFC, of the patients received one 20-minutes session of
cathode  : primary somatosensory cortex  ; (C) anodal tDCS over M1, while the other half received
anode : left temporal-occipital junction, cathode : sham tDCS. Patients in the real tDCS group
medial anterior pre-motor area (active-control con- saw their pain intensity significantly decreased
dition) ; (D) sham tDCS, with electrode placement immediately after the intervention, while no effect
similar to group A or B (randomly selected) (25). was seen in the sham group. Interestingly, changes
The timing of the sessions was the same as in in pain intensity were correlated with changes in
their previous study. Anodal stimulation over alpha and beta bands of the spectral power of the
the DLPFC decreased opioid consumption as EEG in frontal regions. Some patients complained
compared to anodal stimulation over M1 and to about mild discomfort during the first minutes of
sham. Surprisingly, anodal tDCS over M1 increased stimulation, which did not require its interruption.
opioid consumption. Pain scores were similar in all
groups and no serious adverse events were reported. Discussion
Glazer et al. included lumbar spine surgery
patients in a randomized, double-blind, sham- In summary, seven randomized clinical trials
controlled clinical trial (26). Twenty-seven patients (310 patients) have investigated the effect of tDCS
received four 20-minute sessions of either active on postoperative opioid consumption and pain
or sham tDCS, with the anode positioned over M1 scores, with encouraging results. Most studies
and the cathode over the right DLPFC. Patients found a significant opioid-sparing effect (between
received two sessions on the day of surgery and two 23 and 76%), but little difference in perceived pain
sessions on the first post-operative day. Average intensity  (24-28). In one trial, two preoperative
hydromorphone consumption was significantly tDCS sessions reduced pain intensity and opioid
reduced in the real tDCS group as compared to the consumption during the first 48  hours after hallux
sham group (12.6 ± 9.9 mg and 16.5 ± 12.7 mg, valgus surgery  (28). Furthermore, tDCS appears
respectively). Pain intensity levels were similar safe, as no study reported any serious adverse
in both groups. The authors reported no serious events.
adverse events.
In 2017, Khedr et al. published the results of a What are the optimal tDCS parameters?
randomized, sham-controlled trial where 50 patients
undergoing unilateral TKA randomly received Nearly all studies (6 out of 7) have positioned
one daily session during four postoperative days the anode over M1 and all but one (25) reported
of either real or sham tDCS (27). The anode was positive results (24,26-29). Position of the return
placed over M1, while the cathode was positioned electrode was more variable : contralateral arm (27),
on the contralateral arm. Opioid consumption was supraorbital (28, 29) or DLPFC region (24-26). Two
significantly reduced in the tDCS group as compared trials targeted the DLPFC : one negative (anodal
to the sham group. Secondary outcome measures and cathodal) (23) and one positive (anodal)  (28).

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 176 a. steyaert et al.
All studies, except one (29), used large conventional bining tDCS with systemic or locoregional analgesic
sponge electrodes (23-28). These montages are techniques found that it could contribute to achieve
expected to induce broad current flows extending two of the goals of multimodal analgesia, namely
beyond the targeted area (30). HD-tDCS has been reduce opioid consumption and improve pain scores
developed to increase the stimulation focus of (24, 25, 27, 28). An additional goal of multimodal
superficial cortical regions such as M1  (20)  or analgesia is the reduction of opioid-related adverse
DLPFC (26), however it has not been tested yet in events, but none of the studies included this in their
the field of postoperative pain management. outcomes. Therefore, we suggest that future trials
Multiple sessions seem necessary to observe not only assess opioid consumption, but also opioid-
long lasting after-effects. Indeed, a single tDCS related adverse effects.
session did not seem to reduce pain and morphine On the other hand, the combination of two
consumption after surgery (23). Similarly, all posi- interventions can also result in antagonism. Studies
tive studies applied a current intensity of 2 mA, in on healthy volunteers have demonstrated that high
contrast to 1 mA for the aforementioned negative doses of dextromethorphan – an NMDA antagonist
trial (23). The timing of sessions could also be – suppressed the excitability enhancement usually
important. While the vast majority of trials only observed after anodal tDCS of M1 and assessed
applied tDCS postoperatively (23-27, 29), the only by motor evoked potentials  (34). Aside from the
study which found a significant decrease in pain stimulation parameters discussed above, the absence
intensity used two preoperative sessions (28). The of effect observed in the study conducted by Dubois
only common setting in all trials was the duration et al. (23) could also result from the fact that all
of the stimulation sessions, namely 20 minutes (23- patients received two potent NMDA-blockers, keta-
29). mine and magnesium sulfate, potentially blocking
In conclusion, as there is great heterogeneity the effects of the stimulation. Further studies are
in the targeted brain regions, dose, and timing needed to clarify the impact of certain components
of sessions, it is difficult to reach a definitive of multimodal analgesia regimen on the efficacy
recommendation on the best stimulation protocol. of tDCS. Moreover, it is critical that future studies
Tentatively, we would propose a protocol with report on the specific anesthesia and analgesia
multiple 20-minute anodal tDCS sessions at 2 mA, techniques received by the patients. Two of the
starting preoperatively, targeting either M1 or the reviewed studies, for instance, only indicated that
DLPFC. patients underwent general anesthesia, without
additional information (26, 29).
After which types of surgery could tDCS be effective? Besides pharmacological interventions, tDCS
could conceivably also be combined with other
The available studies have included patients non-invasive neuromodulation techniques, such
undergoing various orthopedic procedures : knee as transcutaneous spinal direct current stimulation
arthroplasty, lumbar spine and hallux valgus (tsDCS) or peripheral transcutaneous electrical
surgery. Consequently, the effects of tDCS in nerve stimulation (TENS).
different surgical models – e.g. abdominal surgery Similar to tDCS – but at the level of the spinal
– remain to be investigated. Encouragingly, tDCS cord – tsDCS delivers direct currents through the
has been shown to relieve pain in patients with skin (35). In healthy volunteers, there is evidence
chronic abdominal pain (31) and repeated sessions that anodal tsDCS could alter the spinal transmission
of transcranial magnetic stimulation – another and/or processing of nociceptive inputs. Modulation
non-invasive brain modulation technique – was of nociceptive laser-evoked brain potentials (36),
suggested to reduce pain and opioid consumption increased pain tolerance (36), reduction of mecha-
after gastric bypass surgery (32). nical pain sensitivity (37) and reduction of temporal
pain summation (38) have been reported. However,
Could the effects of tDCS be enhanced – or reduced anodal or cathodal tsDCS does not appear to
– by other analgesic techniques? significantly affect hyperalgesia induced by high-
frequency electrical stimulation (39). Very recently,
Current recommendations for the management Lenoir et al. (40) showed a selective and segmental
of postoperative pain advocate the use of multimodal effect of tsDCS on nociceptive processing. Speci-
regimens, including both pharmacological and non- fically, they found that low thoracic (but not
pharmacological modalities  (33). The majority of cervical) tsDCS selectively altered nociceptive
trials investigating a multimodal approach com- responses originating from the feet, suggesting

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 tdcs and postoperative pain 177

Table 1
Demographic and clinical characteristics of patients in the selected studies
Study Number of Postoperative
Reference Blinding Surgery type Anesthesia
design patients analgesia

Dubois et al. RCT Double blind Lumbar spine 63 GA (propofol, sufentanil, sevoflurane, Paracetamol
(2013) surgery ketamine, MgSO4) Morphine PCA

Borckardt et RCT Single blind TKA 40 GA (propofol, fentanyl, sevoflurane) + femo- Femoral catheter
al. (2013) ral catheter + sciatic nerve bloc Hydromorphone PCA

Glaser et al. RCT Double blind Lumbar spine 27 GA (not detailed) Hydromorphone PCA
(2016) surgery

Khedr et al. RCT Double blind TKA 50 Spinal anesthesia (bupivacaine, fentanyl) Ketorolac
(2017) Paracetamol
Nalbuphine
Borckardt et RCT Double blind TKA 58 GA (propofol, fentanyl, sevoflurane) + femo- Femoral catheter
al. (2017) ral catheter + sciatic nerve bloc Hydromorphone PCA

Ribeiro et RCT Double blind Hallux valgus 40 Spinal anesthesia (bupivacaine, morphine) + Paracetamol
al. (2017) surgery sedation (propofol, fentanyl, midazolam) Tramadol
Morphine
Jiang et al. RCT Single blind Lumbar spine 32 GA (not detailed) Dezocine
(2018) surgery

GA: general anesthesia; MgSO4: magnesium sulfate; PCA: patient-controlled analgesia; RCT: randomized controlled trial; TKA: total knee arthro-
plasty.

Table 2
Details of tDCS interventions in the selected studies
Number (duration)
Reference Type of electrode Intensity Anode Cathode Control group
and timing of sessions
Dubois et al. 1 session (20 min Sponge 35 cm2 1 mA A Left DLPFC (F3) Right ear Sham tDCS
(2013) Recovery room C Right ear left DLPFC (F3)
Borckardt et al. 4 sessions (20 min) Sponge 16 cm2 2 mA M1 knee area (C1–C2) Right DLPFC (F4) Sham tDCS
(2013) D0 (+30 min, + 4h)
D1 (morning, + 4h)
Glaser et al. 4 sessions (20 min) Not detailed 2 mA Superior motor cortex (Cz) Right DLPFC (F4) Sham tDCS
(2016) D0 (+30 min, + 4h)
D1 (morning, + 4h)
Khedr et al. 4 sessions (20 min) Sponge 24 cm2 2 mA M1 knee area (C1–C2) Contro-lateral arm Sham tDCS
(2017) D1–D4
Borckardt et al. 4 sessions (20 min) Sponge 16 cm2 2 mA A left DLPFC (F3) S1 knee area (CPz) Sham tDCS, electro-
(2017) D0 (+30 min, + 4h) B M1 knee area (C1–C2) right DLPFC (F4) des similar to group
D1 (morning, + 4h) A or B (randomly
C left temporo-occipital medial anterior pre-
selected)
junction (P3) motor (FCz)
Ribeiro et al. 2 sessions (20 min) Sponge 35 cm2 2 mA Left M1 Right supra-orbital Sham tDCS
(2017) D–1 (4–8 PM) region (FP2)
D0 (8–10 AM)
Jiang et al. 1 session (20 min) “Dry electrode”, 2 mA Left M1 (C3) Right supra-orbital Sham tDCS
(2018) D1 in the morning anode : 2,5 cm2; region (FP2)
cathode : 12,5 cm2
D–1: day before surgery; D0: day of surgery; D1–4: postoperative day one to four; mA: milliamperes; DLPFC: dorsolateral prefrontal cortex; M1:
primary motor cortex; tDCS: transcranial direct current stimulation; F3–4, C1–3, Cz, CPz, FCz, FP2: standardized scalp positions in the international
10–20 EEG system.

that tsDCS could act by modulating the synaptic the feasibility and safety of this approach in chronic
transmission and/or local processing of nociceptive pain (41). Nine patients suffering from chronic
input at spinal segmental level. As tDCS and tsDCS headache received one daily application for five
modulate nociceptive processing at different levels, consecutive days (20 minutes of tDCS followed
their combined application could produce additive by 20 minutes of tsDCS), without serious side
or synergistic effects. A recent pilot trial confirmed effects (41).

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 178 a. steyaert et al.
Table 3
Outcomes and results of the selected studies
Reference Primary outcome Results Secondary outcomes Results
Dubois et al. Opioid consumption No statistically significant dif- VAS at rest D1–D2 No statistically significant dif-
(2013) D1–D2 ference between the groups. VAS at movement D1–D2 ference between the groups.
Depression 48h.
Borckardt et Not defined, probably Decreased opioid consumption VAS and mood, before and after No difference in VAS or mood.
al. (2013) cumulative opioid con- (46%) in the real tDCS group. each tDCS session.
sumption over 48h
Glaser et al. Cumulative opioid con- Decreased opioid use (23%) in BPI least pain No difference in BPI scores.
(2016) sumption the tDCS group. BPI worst pain
BPI pain on average.
Khedr et al. Opioid consumption Decreased opioid use (59 vs. VAS D1–D4 Decreased LANSS score in tDCS
(2017) D1–D4 33% decrease between D1 and LANSS D1–D4. group. No difference in VAS
D4) in the tDCS group. between the groups.
Borckardt et Not defined, probably Decreased opioid consumption VAS and mood, before and after No difference in VAS or mood.
al. (2017) cumulative opioid con- in group A (DLPFC) but in- each tDCS session.
sumption over 72h. creased opioid consumption in
group B (M1).
Ribeiro et al. VAS 48h at rest and Reduced VAS 48h in the tDCS Opioid consumption Decreased analgesic use (73%) in
(2017) during walking. group (3.1 vs. 5.5). Score variation during CPM-task the tDCS group. Improvement in
BPCP score CPM efficiency in the tDCS group.
BDNF (blood and spinal). No difference in BDNF.
Jiang et al. NRS immediately after Reduced NRS in the tDCS Resting EEG in prefrontal cortex Change in spectral power (alpha 2
(2018) tDCS. group. and beta 1 band) in Fp1, correlated
with the decrease in NRS.
BDNF: brain-derived neutrophic factor; BPCP score: Brazilian Profile of Chronic Pain score; BPI: Brief Pain Inventory; CPM: conditioned pain modu-
lation; D1–4: postoperative day one to four; DLPFC: dorsolateral prefrontal cortex; LANNS: Leeds Assessment Neuropathic Symptoms and Signs
questionnaire; M1: primary motor cortex; NRS: numerical rating scale; tDCS: transcranial direct current stimulation; VAS: visual analog scale; Fp1:
standardized scalp position in the international 10–20 EEG system.

TENS is a peripheral neuromodulation tech- condition (48). This concept has been validated in
nique which is currently recommended for post- the perioperative setting. Patients with enhanced
operative pain management (33, 42). Several clini- TSP report higher acute pain scores after thoracic
cal studies have demonstrated the superiority of surgery (49) and are more prone to develop
combining TENS and tDCS over either technique persistent pain after knee (50,51) and hip (52)
applied alone for managing chronic neuropathic arthroplasty. On the other hand, patients with
(43) and low back pain  (44, 45) patients. To our inefficient CPM are more at risk for CPSP after knee
knowledge, no studies have tested any of these arthroplasty (51), thoracotomy (53) and abdominal
combinations in a postoperative setting. surgery  (33). As tDCS can significantly reduce
TSP  (20) and strengthen CPM  (19), it is possible
Could subgroups of patients benefit more from that the preoperative pain modulating profile of
tDCS? each patient could predict the analgesic effects
of the technique. Interestingly, it has been shown
Patients have been included in the clinical that low back pain patients with diffuse reduced
trials based only on the type of surgery they were pressure pain thresholds, which could be interpreted
about to undergo, without taking account of their as a sign of altered pain processing, responded
individual risk for intense acute post-surgical better to combined tDCS and peripheral electrical
pain and CPSP  (46). Preoperatively, the balance stimulation than patients with high pain pressure
between inhibitory and facilitating mechanisms of thresholds (44).
pain modulation could be assessed by measuring Another group deserving special attention
the magnitude of conditioned pain modulation is those patients receiving chronic opioid therapy
(CPM) and temporal summation of pain (TSP) before their surgery. They are often less easy to
protocols (47). Based on individual pain modulation manage in the postoperative period : they report
profiles, patients would be expected to express a higher pain scores, need more analgesics and
higher (or lower) clinical pain phenotype and be resolve their pain more slowly than opioid-naïve
more (or less) at risk of developing a chronic pain patients (54). These poor outcomes could be a

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 tdcs and postoperative pain 179

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