Method for treatment of neuropathic pain and phantom pain syndrome in traumatic amputation

Abstract

FIELD: physiotherapy.SUBSTANCE: used to treat phantom pain syndrome (PPS) and neuropathic pain (NP) following traumatic amputation. The degree and nature of pain syndrome are determined using the diagnostic questionnaires of neuropathic pain DN4 and PainDETECT (PD). If the total score on the DN4 questionnaire is less than 4 and at the same time on the PD questionnaire in the range of 13–18 points, 10 sessions of TDCS are performed in bipolar mode once a day with a current strength of 2–3 mA with a session duration of 20–40 minutes. If the total score on the DN4 questionnaire is more than 4 and at the same time on the PD questionnaire more than 18 points, TDCS is carried out twice a day, namely from 8 a.m. to 12 p.m. the first procedure is carried out in a monopolar mode lasting 20-40 minutes with a current of 1.5–3 mA, and in the period from 3 p.m. to 7 p.m. the second procedure is carried out in a bipolar mode lasting 20-40 minutes with a current of 2–4 mA. During the course of treatment, 20 procedures are carried out over 10 days, 2 procedures daily.EFFECT: reliable and safe relief of neuropathic pain and phantom pain syndrome following traumatic amputation.2 cl, 1 tbl, 4 ex

Description

[0001] The invention relates to physiotherapy and can be used for the treatment of phantom pain syndrome (PPS) and the treatment of neuropathic pain (NPP) in civilian and military medicine during traumatic amputation of limbs.

[0002] Various methods of diagnosis and treatment of neuropathic pain, including phantom pain, are known. In particular, in clinical guidelines for the diagnosis and treatment of phantom pain (O.S. Davydov, N.N. Yakhno, M.L. Kukushkin et al. Neuropathic pain: clinical guidelines for diagnosis and treatment of the Russian Society for the Study of Pain [electronic resource]. URL: www.painrussia.ru. No. 4, 2018, pp. 5-41) it is indicated that despite the existence of a large number of different pain scales and questionnaires, only two scales have been tested and validated in Russia: the DN4 neuropathic pain diagnostic questionnaire and the PainDETECT (PD) questionnaire. According to the DN4 questionnaire, NPB is diagnosed if the patient's score is above 4. According to the PD questionnaire, with a score of 0-12, NPB is absent, with a score of 13-18, the result is considered indeterminate, and with a score of 19 or more, the presence of NPB is diagnosed.A visual analog scale (VAS) with scores from 1 to 10 is used to determine pain intensity, with 10 representing the most severe and intolerable pain. According to this source, treatment for PNS includes pharmacotherapy with anticonvulsants, antidepressants, opioid analgesics (gabapentin, pregabalin, tramadol, morphine, etc.), as well as non-pharmacological methods such as transcranial magnetic stimulation (TMS), exercise therapy, mirror therapy, reflexology, and others.

[0003] According to the official document of the Ministry of Defense of the Russian Federation (“Diagnostics and treatment of chronic post-amputation pain: methodological recommendations / / Ministry of Defense of the Russian Federation, 2025”), treatment of FBS is also carried out using similar pharmacotherapy and TMS.

[0004] A known method for treating phantom pain in the lower limb involves identifying the sciatic nerve using ultrasound scanning with a linear transducer operating at a frequency of 4-12 MHz above the damaged area. The skin is then anesthetized, after which two electrodes are successively used to deliver sensory and motor test stimulation by applying a pulse at a frequency of 50 Hz and a pulse at a frequency of 2 Hz, respectively. If both test results are positive, bipolar pulsed radiofrequency (PRF) ablation of the nerve is performed using two electrodes heated to 42°C, with an electric current of 45 V and a pulse frequency of 2 Hz, for 4 minutes. After PRF, 4 ml of 1% lidocaine solution and 4 mg of dexamethasone are administered perineurally, the electrodes are removed, and an antiseptic dressing is applied.The method, according to the authors, ensures the elimination of FB and a reduction in the need for opioid analgesics (patent RU 2817812 C1, A61N 1 / 00 ​​et al., 2023).

[0005] A known method for treating phantom pain involves acupuncture in microacupuncture zones of the hand and foot, selected according to F.B. Kandarov. For phantom pain in the upper limb stump, the projection zone of the hand on the foot on the side of the upper limb stump is pricked with 5-6 needles using the excitation method. After 5-7 minutes, after removing these needles, the projection zone of the hand on the contralateral foot is pricked with 5-6 needles using the deceleration method. For phantom pain in the lower limb stump, the projection zone of the leg on the hand on the side of the lower limb stump is pricked with 5-6 needles using the excitation method. After 5-7 minutes, after removing these needles, the projection zone of the leg on the contralateral hand is pricked with 5-6 needles using the deceleration method. The method simplifies the treatment of phantom pain while being highly effective (patent RU 2281749 C1, A61N 39 / 08, 2005).

[0006] A known method for treating polyneuropathy during combination therapy for cancer patients involves applying infrared laser radiation and a constant magnetic field with a magnetic induction intensity of 25-30 mT, a pulsed infrared laser repetition rate of 80 Hz, and a power of 0.5-1 W, labilely for 1-2 minutes to the nerve exit zone of the upper or lower extremity. Then, the E36, RP2, and VC8 points of the lower extremity or the GI4, MS3, MC6, and TR5 points of the upper extremity are sequentially stimulated for 1-2 seconds per session. The total course of treatment consists of 10-12 sessions performed daily. The method makes it possible to reduce the severity of complications after chemotherapy courses, shorten the time it takes to restore the function of the upper and lower extremities, and improve the quality of life of cancer patients through a combination of techniques of the claimed invention (patent RU 2776235 C1, A61N, 2 / 06, 2021).

[0007] As practice shows, the effectiveness of all the methods described above, including those used in combination, is not always sufficient to completely relieve pain. According to literature, treatment success rates do not exceed 30-40%. This is because with extensive injuries such as traumatic amputation, when virtually all types of limb tissue—bone, muscle, nerve, vascular, lymphatic, and others—are damaged, the control of this part of the body is completely disrupted. As a result, it is necessary not only to ensure the healing of the stump but also to reconfigure its blood supply, lymph, signaling systems, and motor control. And, of course, to create a new "image" of the limb in the injured person's brain to ensure adequate processing of afferent signals coming from the stump.To address these issues, in addition to pain relief, increased production of growth hormone (GH), which largely ensures the restoration of all types of tissue and the generation of new tissue, is required. Serotonin (ST), which reduces pain sensitivity and anxiety, is also essential. The role of GH and ST is discussed in more detail below. The methods described above are primarily focused on pain relief and eliminating the psychological component after amputation, rather than addressing the many other issues described above, hence their low effectiveness.

[0008] A method for transcranial electrical stimulation of the endorphin mechanisms of the brain has been defined as a prototype, including contact action on the forehead and mammillary processes of the patient with an electric current, characterized in that the electrical stimulation is carried out with a current of 0.2 - 5 mA in the form of a sequence of monopolar rectangular pulses with a front and tail duration of no more than 20 μs, following with a period of 12.9 ± 0.4 ms with a duty cycle of 3.2 - 3.7 or a sequence of the same pulses with a filtered constant component of the spectrum (bipolar pulses), while the impact is carried out in sessions lasting 15-40 minutes once a day in one of these two modes (patent RU 2159639, A61N 1 / 34, 2000). This method is used to stimulate endorphin and serotonin mechanisms in the brain, which, among other things, helps relieve pain of various origins and locations. Furthermore, the method accelerates healing, has an anti-stress effect, and more.In practical medicine, this method is called TES therapy.

[0009] The disadvantages of this method include the lack of individualization, i.e., differences in the application of the two TES therapy modes, monopolar and bipolar, depending on the severity of neuropathic pain and phantom pain syndrome, as well as indications of the preferred time for performing procedures, which can reduce not only the effectiveness but also safety, since the production of somatotropic hormone and serotonin have clearly defined circadian rhythms.

[0010] The technical problem that the invention is aimed at solving is the creation of an effective method for treating neuropathic pain and phantom pain syndrome in traumatic amputation.

[0011] The technical result is to increase the efficiency and safety of therapeutic intervention, with the aim of eliminating neuropathic pain and phantom pain syndrome during traumatic amputation.

[0012] The problem is solved and the technical result is achieved by preliminarily determining the degree and nature of pain syndrome in patients using the diagnostic questionnaires for neuropathic pain DN4 and PainDETECT (PD). If the total score on the DN4 questionnaire is less than 4 and simultaneously on the PD questionnaire it is in the range of 13-18 points, a course of treatment is carried out consisting of 10 sessions of TES therapy in bipolar mode once a day with a current strength of 2-3 mA with a session duration of 20-40 minutes, and if the total score on the DN4 questionnaire is more than 4 and simultaneously on the PD questionnaire it is more than 18 points, TES therapy is carried out twice a day: from 8 am to 12 pm, the first procedure is carried out in monopolar mode with a duration of 20-40 minutes with a current strength of 1.5-3 mA, and from 3 pm to 7 pm, the second procedure is carried out in bipolar mode with a duration of 20-40 minutes with a current strength of 2-4 mA, while during the course of treatment, 20 procedures are carried out over 10 days, 2 procedures daily.

[0013] This method can also be carried out against the background of or after standard pharmacotherapy with anticonvulsants, antidepressants, opioid analgesics, as well as in conjunction with non-pharmacological methods: psychotherapy, exercise therapy, mirror therapy and others, excluding the simultaneous use of transcranial magnetic stimulation, pressure chambers, cryosaunas and other methods of systemic influence.

[0014] TES therapy has proven itself in medical practice as a highly effective means of pain relief and healing. However, to enhance its effectiveness in the treatment of neuropathic pain, phantom limb pain, and pain syndromes associated with traumatic amputations, a more intensified approach is necessary, as these pain syndromes cause suffering for patients and prevent, for example, prosthetic replacement. This effect is achieved by influencing the production of growth hormone (GH) and serotonin (ST), which are involved in eliminating the causes of pain syndromes, during periods of daily minimum levels.

[0015] Somatotropic hormone (STH) promotes protein synthesis and stimulates the transport of amino acids into cells, which improves reparative and regenerative processes, accelerating tissue healing after injury or trauma. It also plays a key role in strengthening the body's immune system. It stimulates the development and activity of lymphocytes—the cells responsible for protecting the body from infection and disease. STH levels can be particularly low during times of stress or illness, so it is important to ensure adequate levels to maintain a healthy immune system. STH also stimulates lipolysis—the breakdown of fat cells—leading to an increase in free fatty acids in the blood. This increases the use of fat as an energy source, which is especially important when blood glucose levels are low. Therefore, STH helps reduce body fat and improve physical endurance.

[0016] Serotonin (ST) reduces pain sensitivity and is involved in the inhibition of pain signals sent to the brain. ST influences mood and mental health, suppresses negative emotions, and prevents depression. It also plays a major role in regulating anxiety. Serotonin, released by platelets, influences blood clotting, causing vasoconstriction and promoting thrombus formation. ST is a precursor to melatonin, a hormone that regulates the sleep-wake cycle. A lack of serotonin can disrupt melatonin production, leading to insomnia.

[0017] Numerous studies have shown that using TES therapy with monopolar stimulation significantly increases STH production by 5-7 times. However, natural STH production follows a circadian rhythm, with production significantly reduced in the morning and gradually increasing only in the evening. Thus, the body spends a significant portion of the day with a STH deficiency, which slows the recovery of all types of damaged tissue. Therefore, TES therapy should be administered in a monopolar mode (i.e., using monopolar impulses) in the morning. However, monopolar TES therapy in the evening does not increase STH production, as the body's capacity is limited by natural limits (the rate of STH synthesis). Instead, it is perceived as an additional burden and weakens (depletes) protective functions.

[0018] Research has also shown that TES therapy using bipolar stimulation significantly increases serotonin (ST) production. The circadian rhythm of natural ST production is such that its level is highest in the morning, gradually declining towards evening. Therefore, the bipolar stimulation should be used in the afternoon, when the body experiences a ST deficiency. Considering that serotonin is also a biochemical precursor to the sleep hormone melatonin, it is important to follow this recommendation, as the most intensive recovery processes occur during sleep (healthy sleep is the best medicine). As with STH, performing bipolar stimulation in the morning, when ST concentration is highest, will not lead to an increase in its production, as it is at its lowest during this period.

[0019] Therefore, in the post-traumatic amputation period, when neuropathic pain and subsequently phantom limb pain almost always occur in the amputated limb (i.e., DN4 and PD scores greater than 4 and greater than 18, respectively), to improve the effectiveness and safety of treatment, it is essential to strictly adhere to the sequence of TES therapy procedures: monopolar mode in the morning, bipolar mode in the evening. The treatment course should consist of at least 20 procedures, two per day.

[0020] If the neuropathic pain level is less than 4 and 12-18 on the DN4 and PD scales, respectively, it is concluded that the body is generally coping with the recovery process and there is no need for additional STH stimulation, but pain persists. In this case, TES therapy sessions in bipolar mode are sufficient, providing pain relief and comfortable recovery. The treatment course is 10 days, one session per day.

[0021] It should be noted that the simultaneous administration of transcranial magnetic stimulation (TMS), hyperbaric chambers, cryosaunas, and other systemic physiotherapy procedures on the same day as TES therapy can lead to systemic overload, manifesting as headaches, discomfort, weakness, and fatigue, ultimately leading to a delay in the healing process. Therefore, their simultaneous use should be avoided, at least on the same day.

[0022] As a result of applying the said method, the following results were achieved, reflected in the examples of using the invention.

[0023] Example 1.

[0024] Patient B., 35, complained of severe phantom pain syndrome (PPS) in the stumps of both lower limbs amputated due to a mine blast injury (MBI). The acute pain was felt as a drilling sensation, like an electric shock in the area of ​​the missing toes and heels, and a sensation of the amputated limbs as if they were still there. The pain was constant and significantly worsened at night.

[0025] Considered himself ill for 2 weeks, after traumatic amputation of the right lower limb at the level of the lower third of the thigh and the left limb at the level of the upper third of the leg.

[0026] Objectively: the patient is emotionally mobile. For 2 weeks, he received medication for FBS: pregabalin 150 mg, twice daily, per os; amitriptyline 12.5 mg, three times daily per os, without a significant positive effect. Due to the presence of pain syndrome, the patient experienced persistent sleep disturbances (with periods of wakefulness at night and superficial sleep during the day, which was one of the causes of the patient's asthenia). Melatonin 3 mg, once daily, at night, per os, was prescribed, followed by normalization of sleep and wakefulness periods.

[0027] As a result of a comprehensive assessment of the pain level using specific diagnostic questionnaires: DN4 (DouleurNeuropathiqueen 4 questions) - 6 points, PainDETECT - 32 points, a neuropathic component of the pain syndrome was identified, manifested to a pronounced degree.

[0028] Despite conservative pharmacotherapy for pain, the patient continued to have FBS. A course of combined transcranial electrical stimulation (TES) was administered. TES therapy was performed using the Transair-04 device (St. Petersburg, Russia) with a pulse repetition rate of 77±0.5 Hz and a pulse duration of 3.75±0.25 ms. Stimulation utilized frontomastoid electrode placement in accordance with the operating instructions. The combined TES therapy course lasted 10 days (20 sessions), twice daily (morning and evening) for 20 minutes.

[0029] Morning TES therapy sessions were conducted in monopolar mode, with the current gradually increasing to 2.5 mA. Evening sessions were conducted in bipolar mode, with the current gradually increasing to 3.0 mA. As a result of combined TES therapy, the patient noted a decrease in lower limb FBS: from 32 to 7 points on the painDETECT questionnaire and from 6 to 1 point on the DN4 scale. Sleep was normalized, emotional stress was reduced, and overall well-being improved.

[0030] At present, 4 months after receiving a severe injury, the patient notes the absence of significant pain in the limbs and has received prosthetics.

[0031] Example 2.

[0032] Patient K., 27, presented with complaints of prolonged, intense phantom pain syndrome in his right upper limb, in the forearm and wrist area, following a traumatic amputation of his right hand. He described the pain as attacks of burning, twisting, and tingling in the fingers of his missing hand; there was no irradiation. The pain was continuous, with periodic attacks of shooting pain in the thumb and index finger of his missing right hand.

[0033] Considered myself ill for 2 months, the first signs of neuropathic pain appeared 4 weeks after the injury.

[0034] Two weeks after the injury, surgery was performed: an epineural suture of the median nerve was performed. One month after the surgery, a control ultrasound (US) examination of the upper limb nerves was performed: US signs of a competent reconstruction of the right median nerve, without signs of neuroma formation; US signs of pathological changes in the right ulnar and radial nerves were not detected (no evidence of nerve entrapment, rupture, or swelling). Neurological examination revealed no organic pathology.

[0035] As a result of a comprehensive assessment of the pain level using specific diagnostic questionnaires: DN4 (DouleurNeuropathiqueen 4 questions) - 5 points, PainDETECT - 28 points, a neuropathic component of the pain syndrome was identified, manifested to a pronounced degree.

[0036] During the observation period, patient K. received analgesics: Ketoprofen 30 mg, 3 times a day, orally; Tramadol 2.0 ml, intramuscularly, for severe pain. Three weeks after the injury, Gabapentin 300 mg, 3 times a day, orally was prescribed.

[0037] Due to the lack of significant positive dynamics during standard drug therapy, a decision was made to conduct combined TES therapy, that is, a course of treatment of 20 procedures, 2 daily, in the morning - in a monopolar mode, in the evening - in a bipolar mode.

[0038] Combined TES therapy was performed using the Transair-04 device (Russia, St. Petersburg) with a pulse repetition rate of 77±0.5 Hz and a pulse duration of 3.75±0.25 ms. Stimulation was performed using the frontomastoid application of electrodes in accordance with the operating manual. The combined TES therapy course lasted 10 days (20 sessions), twice a day (morning and evening) for 20 minutes. Morning TES therapy sessions were conducted in a monopolar mode, with the current gradually increasing to 2.8 mA, while evening sessions were conducted in a bipolar mode, with the current gradually increasing to 3.3 mA.

[0039] At the end of the course of combination TES therapy, the patient noted a reduction in pain severity. Pain scores on the DN4 scales decreased from 5 to 1 point, and on the PainDETECT scale, from 28 to 9 points. Improvements in sleep quality and overall well-being were also noted. Additionally, the gabapentin dosage was reduced to 300 mg orally once daily. Ten days after completing the course of combination TES therapy, the patient discontinued gabapentin therapy. Treatment was monitored for three months, and the positive effect of combination TES therapy was sustained.

[0040] Example 3.

[0041] Patient S., 46, presented with complaints of persistent, severe pain in the stump of his amputated left lower limb at the level of the lower third of the thigh, resulting from a MVT. He described the pain as aching, pressing, with periodic sharp, "electric-like" twitching sensations. He also experienced phantom sensations and pain, which he perceived as attacks of pressure on the missing foot. The pain intensified in the evening and at night. He reported sleep disturbances, primarily due to the pain.

[0042] Considered myself ill for 2.5 months after traumatic amputation of the left lower limb at the level of the upper third of the leg.

[0043] Objectively: the patient is emotionally stable, critical of the condition and disease.

[0044] History: long-term use of narcotic analgesics: tramadol, promedol (about 2 months), according to the patient, the pain syndrome was relieved for a short period of time; NSAID analgesics - without effect.

[0045] Therapy for FBS was prescribed: pregabalin 75 mg, 3 times a day, per os; amitriptyline 25 mg, 1 time per day, per os.

[0046] Considering that the patient had been using narcotic analgesics for a long time to relieve pain, the development of drug-induced pain syndrome could not be ruled out.

[0047] As a result of a comprehensive assessment of the pain level using specific diagnostic questionnaires: DN4 (DouleurNeuropathiqueen 4 questions) - 6 points, PainDETECT - 31 points, a neuropathic component of the pain syndrome was identified, manifested to a pronounced degree.

[0048] Due to the lack of significant positive dynamics during standard drug therapy, and also in order to reduce the dose of narcotic analgesics, a decision was made to conduct combined TES therapy, that is, a course of treatment of 20 procedures, 2 daily, in the morning - in a monopolar mode, in the evening - in a bipolar mode.

[0049] Combined TES therapy was performed using Transair-04 devices (Russia, St. Petersburg) with a pulse repetition rate of 77±0.5 Hz and a pulse duration of 3.75±0.25 ms. Stimulation was performed using frontomastoid electrode placement. The duration of TES therapy was 10 days (20 sessions), twice a day (morning and evening) for 20 minutes. Morning TES therapy sessions were conducted in monopolar mode with a current of up to 2.5 mA, evening sessions - in bipolar mode with a current of up to 3.5 mA.

[0050] As a result of combined TES therapy, it was possible to achieve complete discontinuation of narcotic analgesics, as well as a reduction in the dose of drugs: pregabalin to 75 mg once a day for a month, followed by discontinuation of the drug.

[0051] Treatment follow-up for 2 months: the patient has no FBS, the positive effect of combined TES therapy is stable.

[0052] Example 4.

[0053] Patient Ts., 21, complained of phantom pain syndrome (PPS) in the area of ​​a wound on his right lower extremity sustained as a result of a mine blast injury (MBI). The pain was experienced as bouts of burning, tingling, periodic bouts of numbness, and a sensation of the amputated fingers still being present. The pain was continuous, with intermittent attacks.

[0054] Considered himself ill for a month, after traumatic amputation of the right lower limb at the level of the middle third of the foot.

[0055] Objectively: the patient is critical of his own condition and the disease. For a month, he received medication for FBS: pregabalin 150 mg, twice daily, per os; amitriptyline 12.5 mg, three times daily per os; non-narcotic analgesics as needed, without significant positive effect.

[0056] As a result of a comprehensive assessment of the pain level using specific diagnostic questionnaires: DN4 (DouleurNeuropathiqueen 4 questions) - 4 points, PainDETECT - 18 points, a neuropathic component of the pain syndrome was identified, manifested in an indefinite (borderline) degree.

[0057] Despite conservative pharmacotherapy for pain, the patient continued to have FBS. A course of transcranial electrical stimulation (TES) was administered. TES therapy was performed using the Transair-04 device (Russia, St. Petersburg) with a pulse repetition rate of 77±0.5 Hz and a pulse duration of 3.75±0.25 ms, using bipolar pulses. Stimulation utilized frontomastoid placement of electrodes in accordance with the operating manual. The course of TES therapy lasted 10 days (10 sessions), administered once daily for 30 minutes.

[0058] TES therapy sessions were conducted with a current intensity determined based on patient tolerance, starting with 2.0 mA and gradually increasing to 3.0 mA. As a result of TES therapy, the patient noted a decrease in lower limb FBS: from 4 to 1 point on the DN4 scale and from 18 to 8 points on the painDETECT questionnaire. Sleep was normalized, emotional stress was reduced, and overall well-being improved.

[0059] Currently, 6 months after the injury, the patient notes the absence of FBS in the limb.

[0060] The average results of the application of the developed method of treatment of NPB and FBS are shown in Table 1.

[0061] Table 1.

[0062] Degree of NPB / FBS DN4 points PD points ST level, μg / l STH level mcg / l To After To After To After To After Expressed 6,5±1,5 2,2±0,6 31,1±6 7,3±2,1 10,5±4,0 60,8±8,1 2,0±0,5 12,2±3,0 Uncertain 4,0 1,0 18,0 8,0 16,0 70,0 -- --

[0063] Thus, the treatment provided provides significant or complete relief of neuropathic pain and phantom pain syndrome in the post-traumatic amputation period, without any complications. The effect is sustained for at least several months without additional interventions. Furthermore, the need for narcotic and other strong analgesics has been significantly reduced, eliminating the risk of addiction and thus improving safety.

Claims

1. A method for the relief of neuropathic pain and phantom pain syndrome following traumatic amputation, including transcranial electrical stimulation (TES), characterized in that a preliminary determination of the degree and nature of the pain syndrome is carried out using the DN4 and PainDETECT (PD) diagnostic neuropathic pain questionnaires, followed by TES therapy with a pulse repetition rate of 77±0.5 Hz and a pulse duration of 3.75±0.25 ms using frontomastoid electrode placement, wherein if the total score on the DN4 questionnaire is less than 4 and simultaneously on the PD questionnaire in the range of 13-18 points, 10 sessions of TES therapy are carried out in a bipolar mode once a day with a current strength of 2-3 mA with a session duration of 20-40 minutes, and if the total score on the DN4 questionnaire is more than 4 and simultaneously on the PD questionnaire more than 18 TES therapy is performed twice a day,namely, from 8 a.m. to 12 p.m., the first procedure is carried out in a monopolar mode lasting 20-40 minutes with a current of 1.5-3 mA, and in the period from 3 p.m. to 7 p.m., the second procedure is carried out in a bipolar mode lasting 20-40 minutes with a current of 2-4 mA, while during the course of treatment, 20 procedures are carried out over 10 days, 2 procedures daily.

2. The method according to paragraph 1, characterized in that TES therapy is carried out against the background of or after pharmacotherapy with anticonvulsants, antidepressants, and opioid analgesics.