Transcranial Magnetic Stimulation (TMS) Induces Long-Term Pain Decrease as an Alternative Treatment for Fibromyalgia Patients at Dr. Gregory Marsella's South Florida Chrysalis TMS Institute

Transcranial magnetic stimulation (TMS) is increasingly being studied and found to be effective in pain reduction for Fibromyalgia and other conditions. The latest study of transcranial magnetic stimulation (TMS) comes from the journal Brain (2007 Sep 14) and details an experiment conducted by researchers in France. This study was based upon the premise that "non-invasive unilateral repetitive transcranial magnetic stimulation (rTMS) of the motor cortex induces analgesic effects in focal chronic pain syndromes, probably by modifying central pain modulatory systems." Because neuroimaging studies have shown that a large number of brain structures, including those involved in pain processing, are activated during rTMS, the researchers purported that this type of stimulation could induce "generalized analgesic effects." They conducted their study with the goal of determining the effects of unilateral motor cortex-focused rTMS on 30 patients with chronic widespread Fibromyalgia pain.

In this double-blind study, patients were randomly assigned to receive active rTMS or a placebo treatment, both applied to the left primary motor cortex once a day for ten days. Outcome was measured primarily through self-reported pain intensity over the last 24 hours, which was measured before the study, daily during the treatments, and then 15, 30 and 60 days after the treatment sessions began. They also used other assessment tools such as the McGill Pain Questionnaire, Fibromyalgia Impact Questionnaire, Hamilton Depression Rating Scale, the Beck Depression Inventory and the Hospital Anxiety and Depression Scale. In addition, they tested the pain threshold of specific tenderpoints using applied pressure after rTMS treatments.

The study found that

"[A]active rTMS significantly reduced pain and improved several aspects of quality of life (including fatigue, morning tiredness, general activity, walking and sleep) for up to 2 weeks after treatment had ended. The analgesic effects were observed from the fifth stimulation onwards and were not related to changes in mood or anxiety. The effects of rTMS were more long-lasting for affective than for sensory pain, suggesting differential effects on brain structures involved in pain perception."

They reported very few side effects and concluded that the data shows that unilateral rTMS of the motor cortex has potential as an effective analgesic treatment for Fibromyalgia due to its long-term reduction of chronic widespread pain.

Neurogenic pain relief by repetitive transcranial magnetic cortical stimulation (rTMS) depends on the origin and the site of pain

J-P Lefaucheur, X drouot, I Menard-Lefaucheur, F Zerah, B Bendib, P Cesaro, Y Kerave, J-P Nguyen

Abstract

Objective:

drug resistant neurogenic pain can be relieved by repetitive transcranial magnetic stimulation (rTMS) of the motor cortex. This study was designed to assess the influence of pain origin, pain site, and sensory loss on rTMS efficacy.

Patients and methods:

Sixty right handed patients were included, suffering from intractable pain secondary to one of the following types of lesion: thalamic stroke, brainstem stroke, spinal cord lesion, brachial plexus lesion, or trigeminal nerve lesion. The pain predominated unilaterally in the face, the upper limb, or the lower limb. The thermal sensory thresholds were measured within the painful zone and were found to be highly or moderately elevated. Finally, the pain level was scored on a visual analogue scale before and after a 20 minute session of "real" or "placebo" 10 Hz rTMS over the side of the motor cortex corresponding to the hand on the painful side, even if the pain was not experienced in the hand itself.

Results and discussion:

The percentage pain reduction was significantly greater following real than placebo rTMS (−22.9% v −7.8%, p = 0.0002), confirming that motor cortex rTMS was able to induce analgesic effects. These effects were significantly influenced by the origin and the site of pain. For pain origin, results were worse in patients with brainstem stroke, whatever the site of pain. This was consistent with a descending modulation within the brainstem, triggered by the motor corticothalamic output. For pain site, better results were obtained for facial pain, although stimulation was targeted on the hand cortical area. Thus, in contrast to implanted stimulation, the target for rTMS procedure in pain control may not be the area corresponding to the painful zone but an adjacent one. Across representation plasticity of cortical areas resulting from deafferentation could explain this discrepancy. Finally, the degree of sensory loss did not interfere with pain origin or pain site regarding rTMS effects.

Conclusion:

Motor cortex rTMS was found to result in a significant but transient relief of chronic pain, influenced by pain origin and pain site. These parameters should be taken into account in any further study of rTMS application in chronic pain control.

Discussion

In conclusion, even if only less than one third of patients in the whole series experienced good pain relief (reduction of VAS score by more than 30%) immediately after rTMS session, these results are encouraging for the development of rTMS studies on pain control. Firstly, analgesic effects obtained after a single session of real rTMS were significant compared with placebo in patients suffering from severe chronic pain resistant to all medication. Secondly, selected indications of rTMS according to pain distribution or type of lesion could increase the rate of clinical efficacy; for example, we found more than 60% of good results occurred in patients with facial pain. Thirdly, our results seem to indicate that the cortical target for rTMS procedure in pain control may not be the area corresponding to the painful zone, in contrast to the surgical procedure, and this observation has to be taken into consideration for the design of further pain studies using rTMS. Fourthly, considering that the optimal effect of rTMS on pain is delayed by 2–4 days, the immediate pain relief observed in this series could have resulted in more marked effects on the following days, as was experienced and related by some of our patients, but not systematically assessed in the present study. Fifthly, repeated daily sessions of rTMS are able to expand the effects of a single session, as shown in other clinical indications such as severe depression, and should be tried for the control of neurogenic pain for a longer period of time. All these observations open exciting perspectives for clinical application of rTMS in pain research, at least in selected patients suffering from chronic neurogenic pain

This study confirmed that a single session of 10 Hz rTMS over the motor cortex could reduce pain level in patients suffering from chronic, intractable neurogenic pain.

Slow-frequency rTMS reduces Fibromyalgia pain.

Sampson SM, Rome JD, Rummans TA.
Department of Psychiatry and Psychology, W11A, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA. sampson.shirlene@mayo.edu

Abstract

Objective:

Evidence suggests that Fibromyalgia (FM) is a centrally mediated pain disorder. Antidepressants, including electroconvulsive treatment, provide some symptomatic relief in FM and other pain disorders. Repetitive transcranial magnetic stimulation (rTMS) is a new antidepressant treatment, which may also be useful in treating chronic pain.

DESIGN:

As part of a larger study, four women with depression, FM, and borderline personality disorder received 1-Hz rTMS applied to the right dorsolateral prefrontal cortex. Subjects rated pain using an 11-point Likert scale.

Results

Pretreatment pain averaged 8.2 (7-9.5) and reduced to 1.5 (0-3.5) after treatment (P < 0.009). All had improvement in pain, and two had complete resolution of pain. Only one of the four subjects had an antidepressant response.

These preliminary findings suggest a possible role for rTMS in treating andibromyalgia