The effects of repetitive transcranial magnetic stimulation (rTMS) over the motor cortex on complex regional pain syndrome patients

Abstract

Objective: There are many evidences that repetitive transcranial magnetic stimulation (rTMS) of the motor cortex is effective in relief of chronic pain. The aim of this study was to evaluate the analgesic effects of rTMS in patients with refractory complex regional pain syndrome (CRPS). Methods: Twenty-three patients presenting with CRPS of the hand were randomly selected and treated with conventional treatment (analgesics, adjuvant medications and physical therapy) plus sham-TMS or rTMS to the motor cortex opposite the affected limb: 100% MT, 10 hz, 10 s trains, 25 trains daily, 10 daily sessions. The Visual Analogical Scale of Pain (VAS), McGill Questionnaire, Pain Impact Questionnaire (PIQ-6), Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), Hamilton Depression and Anxiety Rating Scales and SF-36 Questionnaire were the instruments used for the evaluation. The groups were comparable with regards to socio-demographics, mood and pain intensity. Evaluations were performed before, during TMS treatment and up to three months the end of the treatment. Results: There was a significant reduction in VAS scores favoring the rTMS group up to the seventh follow-up day (p<0.05). The mean reduction in the rTMS group was of 4.65 cm (fall of 50.9%) against 2.18 cm (fall of 24.7%) in sham group during treatment. Improvement in VAS scores was independent of other variables, except for improvement in emotional aspects in the SF-36. Conclusions: During rTMS sessions, there was significant and positive improvement in pain experience of CRPS patients regardless of mood, function or quality of life effects.

Non-invasive brain stimulation techniques for chronic pain

“…In total 43 studies investigated rTMS (Ahmed 2011; André‐Obadia 2006; André‐Obadia 2008; André‐Obadia 2011; Avery 2013; Borckardt 2009; Boyer 2014, Carretero 2009; Dall'Agnol 2014; Defrin 2007; de Oliveira 2014; Fregni 2005; Fregni 2011; Hirayama 2006; Hosomi 2013; Irlbacher 2006; Jetté 2013, Kang 2009; Khedr 2005; Lee 2012; Lefaucheur 2001a; Lefaucheur 2001b; Lefaucheur 2004; Lefaucheur 2006; Lefaucheur 2008; Malavera 2013; Medeiros 2016; Mhalla 2011; Nardone 2017; Nurmikko 2016; Onesti 2013; Passard 2007; Picarelli 2010; Pleger 2004; Rollnik 2002; Saitoh 2007; Short 2011; Tekin 2014; Tzabazis 2013; Umezaki 2016; Yagci 2014; Yilmaz 2014). Eleven studies investigated CES (Capel 2003; Cork 2004; Gabis 2003; Gabis 2009; Katsnelson 2004; Lichtbroun 2001; Rintala 2010; Tan 2000; Tan 2006; Tan 2011; Taylor 2013), 36 studies investigated tDCS (Ahn 2017; Antal 2010; Ayache 2016; Bae 2014; Boggio 2009; Brietzke 2016; Chang 2017; …”

“…One study included a mix of participants with central and facial neuropathic pain (Lefaucheur 2001a), six rTMS studies included only participants with central neuropathic pain (Defrin 2007; de Oliveira 2014; Jetté 2013; Kang 2009; Nardone 2017, Yilmaz 2014 ), one included only participants with peripheral neuropathic pain (Borckardt 2009), and one study included participants with burning mouth syndrome (Umezaki 2016). Sixteen studies included non‐neuropathic chronic pain including fibromyalgia (Boyer 2014; Carretero 2009; Lee 2012; Mhalla 2011; Passard 2007; Short 2011; Tekin 2014; Tzabazis 2013; Yagci 2014), chronic widespread pain (Avery 2013), chronic pancreatitis pain (Fregni 2005; Fregni 2011), chronic myofascial pain (Dall'Agnol 2014; Medeiros 2016) and complex regional pain syndrome type I (CRPSI) (Picarelli 2010; Pleger 2004). Two studies included only phantom limb pain (Ahmed 2011; Malavera 2013).…”

“…Finally one study included a mix of peripheral neuropathic and non‐neuropathic chronic pain (Rollnik 2002), including one participant with phantom limb pain and one with osteomyelitis. The majority (21) of rTMS studies specified chronic pain that was refractory to current medical management (André‐Obadia 2006; André‐Obadia 2008, André‐Obadia 2011; Defrin 2007; Hirayama 2006; Hosomi 2013; Kang 2009; Khedr 2005; Lefaucheur 2001a; Lefaucheur 2001b; Lefaucheur 2004; Lefaucheur 2006; Lefaucheur 2008; Nardone 2017; Nurmikko 2016; Onesti 2013; Picarelli 2010; Rollnik 2002; Saitoh 2007; Yagci 2014; Yilmaz 2014). This inclusion criterion was varyingly described as intractable, resistant to medical intervention or resistant to drug management.…”

“…All studies assessed pain at the short‐term (< 1 week post‐treatment) follow‐up stage. Thirty‐seven studies reported medium‐term outcome data (1 to 6 weeks post‐treatment) (Ahmed 2011; Ahn 2017André‐Obadia 2008; Antal 2010; Ayache 2016; Bae 2014; Borckardt 2009; Carretero 2009; Defrin 2007; de Oliveira 2014; Fagerlund 2015; Fenton 2009; Fregni 2006a; Fregni 2006b; Fregni 2011; Gabis 2009; Kang 2009; Khedr 2005; Khedr 2017; Kim 2013; Lee 2012; Lefaucheur 2001a; Luedtke 2015; Mendonca 2016; Mori 2010; Nardone 2017; Nurmikko 2016; Passard 2007; Picarelli 2010; Short 2011; Soler 2010; Thibaut 2017; Tzabazis 2013; Valle 2009; Volz 2016; Wrigley 2014; Yagci 2014). Eight studies collected outcome data at long‐term (> 6 weeks post‐treatment) follow‐up (Avery 2013; Hazime 2017; Kang 2009; Luedtke 2015; Mendonca 2016; Passard 2007; Thibaut 2017; Yagci 2014).…”

“…Sixteen studies used measures of disability (Ahn 2017; Attal 2016; Avery 2013; Chang 2017; Cork 2004; Hazime 2017; Kang 2009; Lagueux 2017; Luedtke 2015; Mhalla 2011; Passard 2007; Short 2011; Soler 2010; Tan 2000; Tan 2006; Umezaki 2016), and 27 studies collected measures of quality of life (Avery 2013; Boyer 2014; Curatolo 2017; de Oliveira 2014; Fregni 2006b; Jales Junior 2015; Lagueux 2017; Lee 2012; Lichtbroun 2001; Mendonca 2016; Mhalla 2011; Mori 2010; Oliveira 2015; Passard 2007; Picarelli 2010; Riberto 2011;Sakrajai 2014; Short 2011; Tan 2011; Taylor 2013; Tekin 2014; Thibaut 2017; Tzabazis 2013; Valle 2009; Villamar 2013; Volz 2016; Yagci 2014).…”