Archives of Physical Medicine and Rehabilitation
Review article (Meta-analysis)Repetitive Transcranial Magnetic Stimulation in Chronic Pain: A Review of the Literature
Section snippets
Literature search strategy
A search of literature on the analgesic effect of rTMS in chronic pain published from 1996 to 2014 was conducted using databases (Google Scholar and PubMed). Keywords included the following: chronic pain, analgesia, transcranial magnetic stimulation, neuropathic pain, fibromyalgia, and complex regional pain syndrome.
Study selection
The review included double-blind, sham-controlled, or direct comparative studies with >10 participants in each arm and were written in English. Studies with relevant information to
Results
We found 33 randomized trials on the analgesic effect of rTMS. Many studies reported significant relief by rTMS, especially high-frequency stimulation over the primary motor cortex (M1) performed in consecutive treatment sessions. The available studies included 843 patients; of these, 223 (26.4%) had central NeP, and 277 (26.9%) had peripheral NeP. Fibromyalgia was present in 166 (19.7%) patients, and complex regional pain syndrome (CRPS) was present in 35 (4.1%) patients. Other pain syndromes
Evidence for pain relief after rTMS in the different chronic pain syndromes
Most studies reported significant pain relief after rTMS, which was frequently >30% pain reduction compared with the control treatment, especially in studies where rTMS was performed at a high frequency (10Hz) over the M1 and the induced electric current was delivered in the posterior/anterior direction. The main characteristics of the studies, outcome measurements, and stimulation parameters are described in table 1. A critical review of the analgesic effects of rTMS in each of the main pain
Neuropathic pain
NeP affects 7% of the general population and can negatively impact quality of life. It is caused by lesions or disease affecting the peripheral or central nervous system. We found 21 randomized controlled trials that evaluated the analgesic effects of rTMS in approximately 500 patients with NeP. Sixteen studies showed significant pain reduction after rTMS compared with sham or 1Hz stimulation, whereas 5 studies were negative. In NeP treatment trials, 30% pain intensity reduction is frequently
Mechanisms of action of cortical stimulation in pain
Studies on the mechanisms of action of rTMS on pain in animals and patients are scarce, and most of the available data involve experimental pain studies in healthy volunteers.35, 36, 37, 63, 64, 65, 66 Another rich source of information comes from studies on implanted epidural precentral gyrus stimulation in patients and animals under experimental pain models. Implanted epidural stimulation is a different technique from rTMS. However, the available evidence suggests that both techniques may
Conclusions
Studies using maintenance sessions of rTMS and assessing the different aspects of chronic pain and its different symptom profiles are needed to provide a more solid basis for its clinical application in this patient population.
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Supported by Pain Center Research from the Department of Neurology, University of São Paulo, São Paulo, Brazil.
Disclosures: none.
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Galhardoni and Correia contributed equally to this work.