Continuous repetitive transcranial magnetic stimulation for intractable neuropathic pain
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Dec 7, 2012. Continuous Repetitive Transcranial Magnetic Stimulation for intractable Neuropathic Pain. Youichi Saitoh , M.D., Ph.D. Department of Neuromodulation and Neurosurgery Office for Univeristy -Industry Collaboration, Osaka University.

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Continuous Repetitive Transcranial Magnetic Stimulation for intractable Neuropathic Pain

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Continuous repetitive transcranial magnetic stimulation for intractable neuropathic pain

Dec 7, 2012

Continuous Repetitive Transcranial Magnetic Stimulation for intractable Neuropathic Pain

YouichiSaitoh, M.D., Ph.D.

Department of Neuromodulation and Neurosurgery

Office for Univeristy-Industry Collaboration,

Osaka University


Electrical motor cortex stimulation emcs

Electrical motor cortex stimulation; EMCS

EMCS expand to the world from Japan

Rasche et al., Pain, 2006

Saitoh et al. J Neurosurg 2000

Department of Neurosurgery, Osaka University Graduate School of Medicine


Efficacy of emcs on intractable neuropathic pain

Efficacy of EMCS on intractable neuropathic pain

Approximately half of the patients satisfy

No large double-blinded clinical trials

Saitoh and Yoshimine, ActaNeurochirSuppl, 2007

Saitoh Y et al, ActaNeurochir, 2007


Repetitive transcranial magnetic stimulation rtms

Repetitive transcranial magnetic stimulation(rTMS)

Eddy current

curent

Figure-8-coil is most popular


Cochrane review o connell ne et al 2010 non invasive brain stimulation techniques for chronic pain

Cochrane reviewO’Connell NE et al, 2010Non-invasive brain stimulation techniques for chronic pain

  • Single doses of high-frequency rTMS of motor cortex may have short-term effects on chronic pain.

  • Efficacies of cranial electrotherapy stimulation and transcranial direct current stimulation are uncertain.

VS


Multi centered randomized double blind sham controlled crossover study 2009 2011

Multi-centered, Randomized, double-blind, sham-controlled, crossover study2009 〜2011

This study was funded by the Japanese Ministry of Health,

Labourand Welfare with a Health and Labour Sciences Research Grant.


Randomized double blind sham controlled crossover study

Randomized, double-blind, sham-controlled, crossover study

  • Real (5Hz)and sham stimulations are randomized.

    • Double-blind Randomized Crossover Study

    • Specialist of biological statistics randomized the patients to two groups.

  • Validation of efficacy and safety of daily rTMS for 2 weeks.

    • Previous studies were mostly single session

    • Primary endpoint is VAS, secondary is SF-MPQ

  • Realistic shamis applied.

    • Synchronized cutaneous electrical stimulation is delivered.

    • Hamada M et al, MovDisord, 23:1524-31, 2008

  • 70 patients


Randomized double blind sham controlled crossover study1

Randomized, double-blind, sham-controlled, crossover study

  • Seven centers

    • Rehabilitation, Hokaido Univ.

    • Neurology, Fukushima

    • Neurosurgery, Nihon Univ.

    • Neurosurgery, Hamamatsu Univ.

    • Neurosurgery, Osaka Univ.

    • Neurology, Kinki Univ.

    • Neurology, Univ. of Occulational


Protocol of sham controlled crossover study

Protocol of sham-controlled crossover study


Trial profile

Trial profile

Sham first

Real first


Results of short term effect of vas primary endpoint

Results of short-term effect of VASPrimary endpoint


Results of short term effect of sf mpq secondary endpoint

Results of short-term effect ofSF-MPQ Secondary endpoint


Patient global impression of change pgic

Patient global impression of change (PGIC)

Intervention


Beck depression inventory bdi

Beck depression inventory (BDI)

Intervention


Continuous repetitive transcranial magnetic stimulation for intractable neuropathic pain

Forest Plot of subgroup analyses


Adverse effects

Adverse effects


Discussion

Discussion

  • This prospective study shows daily high-frequency rTMS is transiently effective for pain relief in intractable neuropathic pain patients (70 cases).

  • There has been no serious adverse effects.

  • The real rTMS, compared with the sham, showed significant short-term improvements in VAS and SF-MPQ scores without a carry-over effect. The result of PGIC suggested cumulative effect.

  • More than once a day or continuous rTMS treatment may improve the effect.

  • In this study, 81% of enrolled patients were post-stroke pain and 60.7 y.o. (mean) which is older than previous studies. Therefore, the effect was mild but significant.


Cerebral mechanism of pain relief emcs rtms

Cerebral mechanism of pain relief(EMCS, rTMS)

rTMS

M1

ACC

S2

Modulate pain recognition

PFC

Ins

Th

Pain relief

PAG

Modulate a pain threshold

Elicit plastic changes


Thank you for attention

Thank you for attention!!


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