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Repetitive transcranial magnetic stimulation of the prefrontal cortex for fibromyalgia syndrome: a randomised controlled trial with 6-months follow up


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Objectives: Fibromyalgia Syndrome (FMS), is a chronic pain disorder with poorly understood pathophysiology. In recent years, repetitive transcranial magnetic stimulation (rTMS) has been recommended for pain relief in various chronic pain disorders. The objective of the present research was to study the effect of low frequency rTMS over the right dorsolateral prefrontal cortex (DLPFC) on pain status in FMS. Methods: Ninety diagnosed cases of FMS were randomized into Sham-rTMS and Real-rTMS groups. Real rTMS (1 Hz/1200 pulses/8 trains/90% resting motor threshold) was delivered over the right DLPFC for 5 consecutive days/week for 4 weeks. Pain was assessed by subjective and objective methods along with oxidative stress markers. Patients were followed up for 6 months (post-rTMS;15 days, 3 months and 6 months). Results: In Real-rTMS group, average pain ratings and associated symptoms showed significant improvement post rTMS. The beneficial effects of rTMS lasted up to 6 months in the follow-up phase. In Sham-rTMS group, no significant change in pain ratings was observed. Conclusion: Right DLPFC rTMS can significantly reduce pain and associated symptoms of FMS probably through targeting spinal pain circuits and top-down pain modulation . Trial registration: Ref No: CTRI/2013/12/004228.
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R E S E A R C H Open Access
Repetitive transcranial magnetic stimulation
of the prefrontal cortex for fibromyalgia
syndrome: a randomised controlled trial
with 6-months follow up
Suman Tanwar
, Bhawna Mattoo
, Uma Kumar
and Renu Bhatia
Objectives: Fibromyalgia Syndrome (FMS), is a chronic pain disorder with poorly understood pathophysiology. In
recent years, repetitive transcranial magnetic stimulation (rTMS) has been recommended for pain relief in various
chronic pain disorders. The objective of the present research was to study the effect of low frequency rTMS over
the right dorsolateral prefrontal cortex (DLPFC) on pain status in FMS.
Methods: Ninety diagnosed cases of FMS were randomized into Sham-rTMS and Real-rTMS groups. Real rTMS (1Hz/
1200 pulses/8 trains/90% resting motor threshold) was delivered over the right DLPFC for 5 consecutive days/week
for 4 weeks. Pain was assessed by subjective and objective methods along with oxidative stress markers. Patients were
followed up for 6 months (post-rTMS;15 days, 3 months and 6 months).
Results: In Real-rTMS group, average pain ratings and associated symptoms showed significant improvement post
rTMS. The beneficial effects of rTMS lasted up to 6 months in the follow-up phase. In Sham-rTMS group, no significant
change in pain ratings was observed.
Conclusion: Right DLPFC rTMS can significantly reduce pain and associated symptoms of FMS probably through
targeting spinal pain circuits and top-down pain modulation .
Trial registration: Ref No: CTRI/2013/12/004228.
Keywords: Neuromodulation, Chronic pain, Dorsolateral prefrontal cortex, Non-invasive therapy, Nociceptive flexion
reflex, Oxidative stress
Fibromyalgia affects nearly 2.10% of the worlds popula-
tion [1]. The etiopathogenesis of FMS is largely un-
known, although tender points all over the body suggest
a peripheral pathology, but a considerable amount of
data also points towards the sensitization of central pain
processing pathways [2], dysfunctional pain inhibition
[3] and abnormal cortical excitability [4]. Keeping in
view the variable pathophysiology, the management
strategies recommended for FMS include; pharmaceuti-
cals, behavioral interventions, physical therapy, exercises
along with other complementary and alternativemedic-
inal approaches [5]. However, no single treatment mo-
dality has been able to alleviate the full range of FMS
symptoms. Hence, it is pertinent to search for effective
alternative methods of therapy.
Transcranial magnetic stimulation is a non-invasive
brain stimulation technique which is being used to man-
age psychiatric cases, several movement disorders and
chronic pain conditions including fibromyalgia [68].
Recent study has shown that rTMS of the DLPFC in-
duces changes in the activity of a network of structures
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* Correspondence:
Department of Physiology, AIIMS, New Delhi 110029, India
Full list of author information is available at the end of the article
Advances in Rheumatolo
Tanwar et al. Advances in Rheumatology (2020) 60:34
involved in the integration and modulation of pain sig-
nals, including the thalamus, brainstem, insular and cin-
gulate cortices [9]. A previous study by our group
observed beneficial effects of low frequency rTMS and
established the role of DLPFC modulation in chronic
tension type headache [10]. However, the substrates of
the analgesia and its longevity remains to be unravelled.
We hypothesized that TMS of the right DLPFC using
low-frequency rTMS could relieve pain and associated
symptoms of fibromyalgia. The objectives (primary and
secondary) of the study were to investigate the effect of
rTMS on FMS pain and related symptoms and explore
the mechanism of analgesia by recording the nocicep-
tive flexion reflex (NFR); an objective marker of pain.
Further, in order to understand the effect of right-
DLPFC rTMS on descending pain inhibitory pathways,
we assessed the diffuse noxious inhibitory controls
(DNIC) system. To further substantiate the literature
suggesting the role of oxidative stress markers in FMS
[11,12], we assessed the levels of thiobarbituric acid re-
active substances (TBARS) and F2-isoprostane in our
FMS patients before and after rTMS therapy.
Materials and methods
Ethical considerations and trial design
The study was conducted at the Pain Research and TMS
Laboratory, Department of Physiology, All India Institute
of Medical Sciences (AIIMS) New Delhi, India. Human
Ethics committee of the AIIMS, New Delhi (Ref No:
IESC/T-251/15.06.2013) approved the research protocol
in 2013. The study was also registered in ICMR-CTRI;
India (Ref No: CTRI/2013/12/004228). The study was a
randomized, parallel group, placebo controlled trial.
Randomization was performed through a computer gen-
erated random number table and concealment was done
with sequentially numbered, sealed, opaque envelopes.
Block randomization design used was to ensure equal
sample size between two groups over time. The patients
were blinded to the block size as well as to the treatment
allocations. Participants were free to withdraw from the
study at any stage. All the participants were enrolled
only after obtaining the ethical approval and a duly
signed informed consent form.
Study protocol
Participants were randomly assigned to either the Sham
or Real rTMS group. Subjective, objective assessment of
pain and estimation of oxidative stress markers were
done at baseline and post-Sham/Real rTMS. Immedi-
ately post-rTMS, the patients were followed up to a
period of 6 months, at the three time points; 15 days
Post-rTMS, 3-months and 6-months after the therapy.
During follow-up, subjective evaluation using specific
questionnaires was done for a period of 6 months while
NFR and DNIC were performed at post-rTMS and 15th-
day post-rTMS (Fig. S1).
Sample size calculation
According to a preliminary study on fibromyalgia [13],
NPRS ratings were 5·60 (1·85) at baseline which were re-
duced to 3·99 (1·90) after Real rTMS, while in Sham
group, baseline and post treatment values were 5·34 (1.82)
and 5·07 (1·89) respectively. Using this data, we required
41 cases per group to detect a significant difference
between sham and real rTMS treatment in a 5% two sided
t-test with 90% power. Assuming a 10% loss to the follow
up, we required 45 patients of FMS per group. Accord-
ingly a sample size of 90 patients (45 on sham treatment
and 45 on real rTMS treatment) was decided.
Recruitment of FMS patients
Female patients with FMS (age, 1850 years) having
regular menstrual cycle were recruited from the
Rheumatology Clinic, Department of Rheumatology,
AIIMS, New Delhi; after establishing the diagnosis by a
Rheumatologist. The diagnosis was based on the Ameri-
can College of Rheumatology criteria, 2010 for the clas-
sification of FMS [14]. Only those patients, who gave
written informed consent, were enrolled for the study.
The record of rescue analgesics was also maintained.
The details of medication used by patients (NSAIDs, an-
tidepressants and opioids, etc) before and after the treat-
ment with rTMS have been given Table 1. FMS patients
were excluded from the study, if they had following
conditions: i) unable to give written informed consent
form ii) History of seizures iii) History of seizures in
first-degree relatives iv) History of any illness involving
the brain v) Consumption of medications (like tramadol,
acetylcholinesterase inhibitors, anticholinergics, anti-
emetics, antihistamines, baclofen, ß-blockers, cephalo-
sporins, cyclosporine etc) known to lower the seizure
threshold vi) History of tinnitus vii) History of bipolar
disorder viii) having implants of defibrillators or neuro-
stimulators or cardiac pacemakers ix) pregnant or lactat-
ing x) having chronic systemic disease, inflammatory
joint diseases, secondary FM, history of trauma xi) with
a concomitant diagnosis of chronic fatigue syndrome
and/or any psychiatric disorder xii) currently undergoing
Protocol for real/sham rTMS
MagPro R100 (MagVenture, USA) transcranial magnetic
stimulator was used for repetitive magnetic stimulation
of the brain. Real rTMS was administered using a
butterfly coil (MCF-B70, MagVenture, USA). For selec-
tion of the optimal scalp area on the right motor cortex;
resting motor threshold (RMT) was determined using
single-pulse stimulation over the right primary motor
Tanwar et al. Advances in Rheumatology (2020) 60:34 Page 2 of 11
cortex (M1) and systematically moving and adjusting
until each pulse resulted in an isolated movement of the
right thumb at rest (abductor pollicis brevis muscle).
The machine output was adjusted to the lowest intensity
that reliably induced thumb movement [15]. The RMT
was defined as the lowest stimulus intensity could elicit
at least five twitches in abductor pollicis brevis muscle
(Motor Evoked Potentials) out of ten consecutive stimuli
given over the motor hot spotat M1.
During real and sham stimulations, the TMS coil
was aligned in a parasagittal line (stimulation coil was
held at a 45° angle off the midline, with the handle
pointing in the posterior direction) 5 cm (right
pollicis brevis muscle movement for resting motor
threshold testing [8](Fig. S2). Stimulation was given
at a pulse frequency of 1.0 Hz over the right DLPFC
at 90% of resting motor threshold. rTMS was given
in 8 trains of 150 pulses/train at inter train interval
of 1 min. Total of 1200 stimuli were given during
each session which lasted for 27 min. There were 5
sessions (Monday through Friday) per week and
rTMS therapy was given over 4 consecutive weeks
(20 sessions). During Sham (placebo/inactive) stimula-
tion, an inactive rTMS coil (MC-B70, MagVenture,
MagPro, Denmark) was used and placed over the
same area as the active coil. The sham coil produced
similar sound as the real coil but without active
stimulation of the brain.
Primary outcome
The primary outcome was defined as a reduction in pain
intensity. This was assessed with the help of Numerical
Pain Rating Scale (NPRS), an 11-point numerical scale
ranging from 0representing No painto 10repre-
senting Pain as bad as you can imagineor Worst pain
Secondary outcomes
We assessed Pain related depression, anxiety, impact of
pain and quality of life, as secondary outcomes using
McGill Pain Questionnaire (MPQ) [17]; Hamilton De-
pression Rating Scale (HDRS) [18]; Hamilton Anxiety
Rating Scale (HARS) [19] and WHOQOL-Quality of
Life-BREF (WHOQOL-BREF) questionnaire [20]. The
other secondary outcomes assessed were, the NFR, pain
modulation (effect of cold pressor test; CPT on NFR)
and estimation of oxidative stress markers.
In the present study, NFR was recorded according the
method described by Willer and colleagues [21]. Further
details of the NFR are mentioned in our research article
[22](Fig. S3). Pain modulation was assessed by observ-
ing the effect of cold pressor test (CPT) on NFR parame-
ters according to methods shown by Sandrini et al. [23]
(Fig. S4). For biochemical estimation, blood samples
were collected in heparinzed BD21q vacutainer collec-
tion tubes. The samples were centrifuged at 1500 rpm
for 15 min at 4°C. The plasma was separated and trans-
ferred to the microcentrifuge tube and stored at 80 °C
till further analysis. Urine samples were also collected
and stored at 80 °C until further analysis. Both, blood
and urine samples were collected at two time points i.e.
pre rTMS and immediately post rTMS. To assess the
oxidative stress, plasma levels of TBARS (Quanti-
ChromTM TBARS Assay Kit (DTBA-100), USA) and
urinary levels of F
-isoprostane (Elabscience Biotechnol-
ogy Co. Ltd. (Elabscience®, China) were estimated with
commercial kits.
Statistical analysis
All the analyses were performed using IBM SPSS Statis-
tics version 22.0 (IBM Statistics for Windows, Chicago,
IL, USA) and graphs were created using Graph Pad
Prism 5.01 for Windows, (GraphPad Software, San
Diego, California, USA). Baseline scores of the parame-
ters between FMS Sham-rTMS and FMS Real-rTMS
groups were compared using paired t test/ Wilcoxon
Signed Rank test. The difference between FMS-Sham
and FMS-rTMS was analyzed using unpaired t test/
Mann-Whitney U test. p< 0.05 was considered statisti-
cally significant. Analysis of follow- up data was done by
Table 1 General characteristics and medication details of FMS
Sham-rTMS and Real-rTMS group
Parameters FMS Sham-
(n= 41)
FMS Real-
(n= 45)
Age (year) 39.05 ± 7.12 41.54 ±
Height (cm) 158.13 ±
157.17 ±
Weight (kg) 61.80 ± 7.54 62.73 ±
Pain duration (Yrs) 7.63 ± 4.65 8.0 ± 5.11 0.73
Medication used
Analgesics % 7 9
Opiates % 4 5
Antidepressants % 3 4
Nonsteroidal anti-inflammatory
drugs (NSAIDs) %
24 22
Anxiolytic % 8 9
Sedatives % 4 4
Gastrointestinal % 12 21
Thyroid % 3 0
Multivitamins % 34 26
Data is expressed as Mean ± SD
Tanwar et al. Advances in Rheumatology (2020) 60:34 Page 3 of 11
paired t tests/ Wilcoxon Signed Rank test examining
follow-up scores relative to post-rTMS (immediate after
completion of therapy). Repeated Measures ANOVA
was applied to assess the statistical significance within
the group between two subsequent time points after
Bonferroni correction.
After Real/Sham rTMS, Follow-up (FU) was done at
three time points i.e. 15 days post-rTMS (FU-1), 3
months post-rTMS (FU-2) and 6 months post-rTMS
(FU-3). At the end of follow-up, 41 subjects in Sham-
rTMS while 45 subjects in Real-rTMS group were ana-
lysed (Fig. S5). The data is presented as Mean ± SD and/
or Median (25Q-75Q). Age, height, body weight and
other general body parameters were comparable be-
tween Sham and Real-rTMS group (Table 1).
Primary outcome
A decrease in NPRS ratings due to rTMS treatment was
observed in the Real-rTMS group immediately post-
rTMS (p= 0·001) which was sustained through 6 months
(Fig. 1). In the Sham-rTMS group no significant change
in pain ratings was observed.
Secondary outcomes
The ratings of affective-motivational components of pain
were reduced post-rTMS (p= 0·001) and were main-
tained even at 6 months when compared to its baseline
value (Table 2). The results of other components of
MPQ ratings have been presented in Table 2. The HDRS
and HARS ratings of Real-rTMS group decreased, post-
rTMS and the changes were maintained through 6
months of therapy (Figs. 2and 3). WHOQOL-BREF rat-
ings were significantly increased post-rTMS when
compared to baseline in Real-rTMS and through 6
months of therapy (Table 2).
In Real-rTMS group, the threshold (volts, V) of NFR
post-rTMS and 15 days post-rTMS was higher, com-
pared to the baseline (p= 0·001) as well as from the
Sham-rTMS group (Fig. 4). No significant change was
observed in other parameters of NFR (latency, duration
and amplitude) between Sham-rTMS and Real-rTMS
group (Table 3).
A sustained improvement in NFR thresholds (V) in re-
sponse to cold noxious stimulus (4-5 ºC) during DNIC
paradigm was observed in Real-rTMS group post-rTMS
which was maintained 15 days post-rTMS also compared
to the baseline (Table 3). NFR latency (ms), amplitude
(μV) and duration (ms) did not change significantly in
response to CPT (DNIC paradigm) in Real-rTMS or
Sham-rTMS group during post-rTMS and 15 days post-
rTMS. Plasma levels of TBARS were comparable in
Real-rTMS group at baseline and post-rTMS (Real) (p=
0·12). Urinary levels of F2-isoprostane levels, did not
vary significantly between groups at baseline and post-
rTMS (Table 3).
Side effects due to sham/real rTMS
During the entire study period no serious side effects of
rTMS were observed. However, two Real-rTMS allo-
cated patients complained of headache; two Sham-rTMS
allocated patients complained of neck pain while another
patient reported mild dizziness.
Selection of low frequency right DLPFC rTMS
In the present study, low-frequency rTMS (1 Hz) of right
dorsolateral prefrontal cortex was selected as low fre-
quency is safer and, previous studies targeting DLPFC
have shown its beneficial effects in relieving chronic pain
Fig. 1 :Effect of rTMS on subjective pain rating scores in FMS. Subjective pain assessed by numerical pain rating scale (NPRS) in Sham (n= 41)
and Real-rTMS (n= 45) group at each time points;pre, post and follow up (FU-1 = 15 days, FU-2 = 3 months and FU-3 = 6 months post-rTMS). Hash
(#) symbol indicates within group pvalue. Asterisk (*) symbol indicates pvalue between Sham-rTMS and Real-rTMSgroup. *por #p< 0.05; **por
##p< 0.01; ***por ###p< 0.001
Tanwar et al. Advances in Rheumatology (2020) 60:34 Page 4 of 11
and depression in fibromyalgia [8,25]. According to an
earlier research, chronic pain is known to be closely as-
sociated with depression and anxiety, in fact the disabil-
ity felt by the patient due to chronicity of pain and the
existing poor quality of life, could be a contributory cause
of depressive symptoms [26]. A reduction in both pain
and depression/anxiety has been observed by targeting
(reducing the activity) of DLPFC via transcranial direct
current stimulation [27]. Low frequency TMS causes
long-lasting inhibition of cellcell communications
or long term depression; whereas high-frequency TMS
can produce long term potentiation [28,29]. Neuro-
imaging studies have also affirmed that the DLPFC may
have a role in topdown mode of inhibition through de-
scending fibres from the prefrontal cortex (PFCx) which
may modulate pain perception [30,31]. The findings of
an fMRI research suggested that interhemispheric
DLPFC connectivity can affect pain tolerance by altering
interhemispheric inhibition [26]. Low frequency rTMS
stimulation of right DLPFC possibly causes the removal
of transcallosal inhibition, allowing an enhanced de-
scending inhibition from the left hemisphere [10].
Effect of rTMS on subjective pain assessment
We observed a significant decrease in the pain ratings
(NPRS) in Real-rTMS group compared to Sham-
rTMS group which was sustained till 6 months of fol-
low up period. Our findings are consistent with previ-
ous studies which reported reduced pain ratings after
rTMS therapy and showed that rTMS performed sub-
stantially better than placebo, in management of FMS
[25]. Pain related depression and anxiety ratings were
also reduced in Real-rTMS group, this is consistent
with the previous reports of right DLPFC TMS stud-
ies in chronic pain [8,25]. We also recorded an im-
provement in pain scores in the Sham-rTMS though
not statistically significant suggesting some placebo
effect may exist for such therapies. Similar results
have been reported with placebo type sham manoeu-
vres [32]. Our findings are supported by recent study
from our group which has assessed the effect of low
frequency rTMS on the right DLPFC in chronic ten-
sion type headache and reported a beneficial effect on
pain and related symptoms [10].
Effect of rTMS on objective pain measures and pain
Ours is amongst the first few studies to report the effect
of rTMS on threshold of NFR. NFR is a spinally medi-
ated withdrawal response that has been used to assess
pain objectively. NFR was recorded at baseline and post
rTMS to assess the pain objectively. In our FMS patients
NFR thresholds were significantly lower indicating an
exaggerated response to painful stimuli or hyperalgesia
[22]. However, at the end of real-rTMS treatment, there
was an increase in NFR threshold which was maintained
during follow-up i.e. 15 days post-rTMS. Considering
the intricacy of the procedure and time involved, NFR
was not recorded at the 3 and 6 months follow-up time
points. In contrast, a previous study which administered
a single rTMS session, observed no significant effect of
rTMS on threshold or recruitment curve of NFR in
healthy subjects [33]. The contrasting results may be
due to difference in study population and the rTMS
protocol (single session of rTMS). The mechanisms that
are thought to contribute to the pain-relieving effects of
rTMS in experimentally induced and chronic pain lie
within the medial or the lateral pain pathways and the
descending pain inhibitory systems, modulating the pain
perception [34].
In our study, descending pain inhibitory pathways
were assessed by recording the effect of CPT on NFR.
Fig. 2 : Effect of rTMS on pain related depression in FMS. Depression assessed by Hamilton depression rating scale (HRDS) in Sham (n= 41) and
Real-rTMS (n= 45) group at each time points;pre, post and follow up (FU-1 = 15 days, FU-2 = 3 months and FU-3 = 6 months post-rTMS). Hash (#)
symbol indicates within group pvalue. Asterisk (*) symbol indicates pvalue between Sham-rTMS and Real-rTMS group. *por #p< 0.05; **por
##p< 0.01; ***por ###p< 0.001
Tanwar et al. Advances in Rheumatology (2020) 60:34 Page 5 of 11
Table 2 Comparison of subjective pain measures in FMS Sham-rTMS and Real-rTMS group
Pre-rTMS Post-rTMS Follow-up
FU-1 (15-days) FU-2 (3-months) FU-3 (6-months)
MPQ: Sensory
Sham 23.0 (17.026.5) 20.0 (17.024.5) 22.0 (20.023.0) 22.0 (21.023.0) 22.0 (20.024.0)
Real 23.0 (21.026.0) 23.0 (18.326.8) 21.0 (18.026.0) 22.0 (18.025.5) 22.0 (18.028.0)
p* 0.40 0.29 0.89 0.72 0.74
MPQ: Affective-motivational
Sham 8.0 (4.59.0) 7.0 (4.08.0) 6.0 (4.08.0) 6.0 (4.08.0) 6.0 (5.07.5)
Real 7.0 (5.08.0) 3.0 (3.04.0)## 4.0 (3.04.5) 4.0 (3.05.0) 4.0 (3.05.0)
p* 0.10 0.001 0.001 0.001 0.001
MPQ: Evaluative
Sham 3.0 (3.03.5) 3.0 (2.03.5) 3.0 (2.03.5) 2.0 (1.03.5) 3.0 (2.04.0)
Real 3.0 (3.04.0) 2.0 (1.02.0)## 2.0 (1.02.0) 2.0 (1.02.0) 2.0 (1.02.0)
p* 0.33 0.001 0.001 0.004 0.001
MPQ: Miscellaneous
Sham 9.0 (4.2510.75) 7.0 (5.08.0) 7.0 (4.09.0) 7.0 (5.09.0) 7.0 (5.09.0)
Real 7.0 (4.09.0) 6.0 (4.09.0) 5.0 (3.09.0) 6.0 (3.59.0) 7.0 (4.010.0)
p* 0.34 0.33 0.51 0.45 0.95
MPQ: Total score
Sham 39.0 (36.044.0) 39.0 (33.045.0) 38.0 (34.041.5) 39.0 (34.541.0) 38.0 (32.541.0)
Real 39.0 (36.044.5) 20.0 (16.029.5) ## 20.0 (17.030.0) 20.0 (17.030.0) 21.0 (18.029.0)
p* 0.87 0.001 0.001 0.001 0.001
MPQ: Present pain intensity
Sham 3.0 (2.03.0) 2.0 (1.02.0) 2.0 (2.03.0) 2.0 (2.03.0) 2.0 (2.03.0)
Real 3.0 (2.04.0) 1.0 (1.02.0)## 2.0 (1.02.0) 2.0 (1.02.0) 2.0 (1.02.0)
p* 0.60 0.001 0.001 0.001 0.001
Sham 38.0 (38.044.0) 43.0 (38.050.0) 44.0 (38.047.0) 44.0 (38.050.0) 44.0 (38.047.0)
Real 38.0 (31.050.0) 44.0 (38.056.0) #47.0 (40.062.0) 44.0 (40.056.0) 44.0 (38.056.0)
p* 0.59 0.05 0.05 0.05 0.05
WHOQOL-BREF: Psychological
Sham 56.0 (38.069) 59.0 (38.075.0) 44.0 (44.069.0) 56.0 (38.069.0) 56.0 (44.075.0)
Real 56.0 (44.056.0) 69.0 (56.075.0) #69.0 (56.075.0) 58.0 (56.069.0) 69.0 (56.069.0)
p* 0.74 0.002 0.004 0.04 0.05
Sham 44.0 (44.056.0) 50.0 (44.056.0) 44.0 (44.056.0) 44.0 (43.056.0) 50.0 (44.056.0)
Real 50.0 (31.069.0) 56.0 (44.069.0) #56.0 (53.069.0) 56.0 (47.069.0) 56.0 (50.069.0)
p* 0.57 0.004 0.001 0.001 0.02
WHOQOL-BREF: Environmental
Sham 56.0 (44.069) 56.0 (47.069.0) 56.0 (44.072.0) 56.0 (44.069.0) 56.0 (44.069.0)
Real 69.0 (56.069.0) 56.0 (53.075.0) 56.0 (53.069.0) 49.0 (56.072.0) 56.0 (48.569.0)
p* 0.06 0.28 0.91 0.28 0.94
Sham (n= 41) and Real (n= 45); Data is presented as Median (25Q-75Q); MPQ: McGill Pain Questionnaire; WHOQOL-BREF: WHO-Quality of Life questionnaire.;
Asterisk (*) symbol indicates pvalue between Sham-rTMS and Real-rTMS group. Hash (#) symbol indicates pvalue within group. *por #p< 0.05; **por ##p< 0.01;
***por ###p< 0.001.
Tanwar et al. Advances in Rheumatology (2020) 60:34 Page 6 of 11
In our patients, pain tolerance time to noxious cold water
was lower indicating diffuse hyper-excitability and
sensitization of the nociceptive system which is also
shown by earlier reports on fibromyalgia [35]. After rTMS
therapy, we found an increase in threshold of NFR during
CPT and pain tolerance for CPT suggesting that rTMS
has alleviated the diffuse hyper-excitability and
sensitization of the nociceptive system associated with
FMS. Findings of this study are consistent with previous
research suggesting that low-frequency (1 Hz) rTMS of
the right DLPFC could increase cold pain tolerance [36].
Our results of pain modulation paradigm are also in ac-
cordance with a recent study on chronic myofascial pain
syndrome which found that rTMS enhanced the cortico-
spinal inhibitory system (41.74% reduction in quantitative
sensory testing and conditioned pain modulationand a de-
crease of 23.94% in the intracortical facilitation) [37].
rTMS and oxidative stress markers
Recently, oxidative stress has been implicated as an im-
portant factor in the pathogenesis of FMS [11]. Al-
though, we did not find any difference between levels of
oxidative stress markers (TBARS and F2-isoprostane)
before and after rTMS. To the best of our knowledge,
no published report is available on effect of rTMS on
TBARS and F2-isoprostane in FMS. The literature offers
limited information about oxidative stress in FMS. It has
been reported that malondialdehyde (MDA), which is an
indicator of lipid peroxidation, increased [11,12] and
vitamin E, which prevents lipid peroxidation, is de-
creased in FMS patients [11].
Proposed mechanism of action rTMS in fibromyalgia
The possible mechanism of relief in pain and associated
depression and anxiety after DLPFC stimulation could be
Fig. 3 :Effect of rTMS on pain related anxiety in FMS. Anxiety assessed by Hamilton anxiety rating scale (HARS) in Sham (n= 41) and Real-rTMS
(n= 45) group at each time points;pre, post and follow up (FU-1 = 15 days, FU-2 = 3 months and FU-3 = 6 months post-rTMS). Hash (#) symbol
indicates within group p value. Asterisk (*) symbol indicates pvalue between Sham-rTMS and Real-rTMSgroup. *por #p< 0.05; **por ##p< 0.01;
***por ###p< 0.001
Fig. 4 : Effect of rTMS on spinal nociception (NFR) in FMS. Central nociception assessed by nociceptive flexion reflex (NFR) thresholds in Sham
(n= 41) and Real-rTMS (n= 45) group at each time points;pre, post and follow up (FU-1 = 15 days, FU-2 = 3 months and FU-3 = 6months post-
rTMS). Hash (#) symbol indicates within group pvalue. Asterisk (*) symbol indicates pvalue between Sham-rTMS and Real-rTMS group. *por #p<
0.05; **por ##p< 0.01; ***por ###p< 0.001
Tanwar et al. Advances in Rheumatology (2020) 60:34 Page 7 of 11
through top-down modulation by rTMS. As DLPFC is as-
sociated with other brain areas such as rostral anterior cin-
gulate cortex (which has been known to play an important
role in pain processing [3] and bilateral amygdala and
contralateral anterior insula (where an increased neuronal
activity is observed in association with depressive symp-
toms) [38], it can potentially modulate this nexus. Recent
studies have also observed decrease in regional cerebral
blood flow (rCBF) in the bilateral medial prefrontal cortex,
bilateral premotor area, bilateral anterior insula, right anter-
ior and posterior insula, left anterior cingulate, right sub-
genual cingulate and right frontal cortex after right DLPFC
rTMS. These studies have also reported a correlation be-
tween therapeutic efficacy of rTMS and decreased rCBF in
bilateral frontal white matter [3942]. Another study re-
ported a significant decrease of activation in the bilateral
middle frontal gyrus with right DLPFC-rTMS in rTMS re-
sponders [43]. Therefore, improvement in depression and
anxiety after therapy suggests that rTMS of right DLPFC
positively influences the brain regions responsible for such
In our study, improvement in quality of life with rTMS
indicates that right DLPFC stimulation may also have
positive effect on the limbic system (right medial
temporal cortex, involved in modulation of the emo-
tional aspects of pain) [44] and superior temporal sulcus
(involved in the social cognition and perception under-
lying social functioning of quality of life) [4547], as
neural connections have been reported between these
areas and the limbic system [48].
The mechanisms that are thought to contribute to the
pain relieving effects of rTMS of the motor cortex in ex-
perimentally induced pain and in chronic pain are the
modulation of pain perception within the medial or the
lateral pain pathway and the modulation of the descending
inhibitory systems [34,49]. In the present study, increased
NFR threshold during CPT and the enhanced pain toler-
ance (during CPT) suggest that rTMS of DLPFC indirectly
modulates nociception through its association with the
cingulate cortex and medial thalamus which are known to
be involved in nociceptive modulation [5052]. The
DLPFC is a highly integrated area with the affective cir-
cuit[53] i.e. ventral and anterior division of the anterior
cingulate cortex including the hypothalamus, amyg-
dala, orbitofrontal cortex, nucleus accumbens, and
other limbic structures [54]. Therefore, the positive
effects of rTMS on pain and associated symptoms are
probably due to modulation of right DLPFC which
further modulates the brain areas related with this
affective circuit(Fig. 5).
To sum up, decrease in ratings of pain and related
symptoms, increased NFR threshold and the enhanced
pain tolerance during CPT suggests that rTMS of
DLPFC modulates nociception, associated with the
cingulate cortex and medial thalamus which are
known to be involved in such type of nociceptive
modulation [50,51].
Strengths and limitations of the study
There are many strengths of our study. Based on the
published literature on the effect of rTMS in FMS symp-
toms, this is the first study which shows long term bene-
ficial effects of rTMS (6 months follow-up). Most of the
previous rTMS studies have reported 12 weeks of
follow-up, and some have also followed their patients till
1 month or 3 months. Moreover, in earlier studies num-
ber of rTMS sessions were less as compared to our
rTMS protocol and continuity of the sessions was also
lacking in these studies [25,45].
Table 3 Comparison of objective pain measures and oxidative
stress markers between FMS Sham-rTMS and Real-rTMS group
Pre-rTMS Post-rTMS Follow-up
FU-1 (15-days)
NFR: Latency (ms)
Sham 105.0 (95.0124.4) 105.0 (90.0120.0) 102.0 (87.6104.0)
Real 110.0 (95.5137.8) 106.5 (97.6120.8) 105.0 (97.3120.0)
p* 0.41 0.06 0.05
NFR: Duration (ms)
Sham 42.5 (40.047.5) 42.5 (40.045.5) 45.0 (40.050.0)
Real 40.5 (38.345.25) 40.0 (38.6545.0) 42.3 (40.045.0)
p* 0.52 0.06 0.07
NFR: Amplitude ((μV)
Sham 294.0 (273.0312.0) 287.0 (263.3297.0) 284.5 (260.8298.5)
Real 281.6 (260.5 ± 314.3) 276.0 (234.5311.5) 276.0 (243.8295.2)
p* 0.42 0.28 0.35
DNIC: Threshold (V)
Sham 21.0 (18.524.5) 21.0 (20.024.0) 22.0 (19.025.0)
Real 22.0 (18.025.5) 27.0 (25.034.0) ## 29.0 (25.039.0)
p* 0.75 0.001 0.001
Thiobarbituric acid reactive substances; TBARS (ng/ml)
Sham 0.88 (0.112.3) 0.90 (0.222.11)
Real 0.97 (0.232.1) 0.78 (0.181.6)
p* 0.71 0.07
-isoprostanes (pg/ml)
Sham 209.8 (135.8317.4) 183.9 (123.6251.4)
Real 180.4 (78.35243.8) 181.9 (89.4315.3)
p* 0.14 0.19
Sham (n= 41) and Real (n= 45); Data is presented as Median (25Q-75Q); NFR:
Nociceptive flexion reflex. Asterisk (*) symbol indicates pvalue between Sham-
rTMS and Real-rTMS group. Hash (#) symbol indicates pvalue within group.
Hyphen-minus () symbol indicates that the data not recorded. *por #p<
0.05; **por ##p< 0.01; ***por ###p< 0.001
Tanwar et al. Advances in Rheumatology (2020) 60:34 Page 8 of 11
This is the first study which has tediously explored the
effect of low frequency right DLPFC rTMS on subjective
and objective pain parameters, descending pain modula-
tion and oxidative stress markers in FMS patients.
Although, we have extensively studied the role of rTMS
applied over DLPFC on pain status in FMS, yet there are
some limitations that need to be addressed. We identified
hotspot for rTMS therapy by using abductor muscle
twitch. This method of getting hotspot has limitations , as
far as targeting the actual area of stimulation is concerned.
Recent research has recommended MRI based neuro-
navigational techniques to localize the DLPFC thereby de-
creasing the inter-subject variability [55]. The exact mech-
anism of action of low frequency on pain modulation and
central neurotransmitters involved could not be ad-
dressed. This could be due to inter-subject variability. Our
study is a single blinded trial, although the participants
blinding was meticulous, yet the rTMS administrator bias
cannot be disregarded.
Future directions
Further studies should investigate the consistency of
structural and functional DLPFC abnormalities in
chronic pain conditions utilizing neuroimaging tech-
niques; compare low frequency right DLPFC rTMS with
other administration protocols or other novel paradigms
in FMS patients. Future research should also assess the
effect of rTMS on the levels of central neurotransmitters
which play predominant role in endogenous pain facili-
tatory and inhibitory pathways. For oxidative stress
markers, more studies may be designed with assessment
at multiple time points during progression and post
therapy, including follow-up period in FMS patients.
Fig. 5 : Putative mechanism for the effect of low frequency right DLPFC in fibromyalgia syndrome. Proposed mechanism for effect of Rt DLPFC
rTMS on pain and related symptoms of FMS. (rDLPFC = right dorsolateral prefrontal cortex; rVMPFC = right ventromedial prefrontal cortex; ACC =
anterior cingulate cortex; OFC = orbitofrontal cortex; rCBF = regional cerebral blood flow). Skull with TMS coilimage was adapted from Diana
et al., [24]
Tanwar et al. Advances in Rheumatology (2020) 60:34 Page 9 of 11
Findings of our 6-months follow-up study suggest that
right DLPFC rTMS can significantly reduce pain and as-
sociated symptoms of FMS and preferentially targets
spinal pain circuits and top-down pain modulation with
no effect on oxidative stress markers.
Supplementary information
Supplementary information accompanies this paper at
Additional file 1: Figure S1. Study protocol. Figure S2. Patient
receiving rTMS therapy. Figure S3. Nociceptive Flexion Reflex recording
set up. Figure S4. Set up for DNIC study (NFR recording during cold
pressor test; CPT). Figure S5. CONSORT flow diagram
Authors acknowledge FMS patients for participation and technical staff of
Pain Research and TMS laboratory, AIIMS, New Delhi, India.
Renu Bhatia takes responsibility for the integrity of the work as a whole, from
inception of idea to final manuscript. Suman Tanwar, Uma Kumar and Renu
Bhatia made primary contributions in study design, data acquisition, analysis
and interpretation of data and preparing of the final manuscript. Bhawna
Mattoo made notable contributions in data acquisition, analysis,
interpretation and preparing of the final manuscript along with its critical
revision. All authors have discussed the results and gave final approval of the
version to be submitted for publication.
Research work was supported by University Grant Commission (UGC), New
Delhi. SumanTanwar was awarded by UGC-Junior/Senior Research fellowship
grant for her doctoral research by UGC, New Delhi, India.
Availability of data and materials
The authors confirm that the data supporting the findings of this study are
available within the article and additional information can be provided if
Ethics approval and consent to participate
The study was conducted at the Pain Research and TMS Laboratory,
Department of Physiology, All India Institute of Medical Sciences (AIIMS) New
Delhi, India. Human Ethics committee of the AIIMS, New Delhi (Ref No: IESC/
T-251/15.06.2013) approved the research protocol in 2013. The study was
also registered in ICMR-CTRI; India (Ref No: CTRI/2013/12/004228). All proce-
dures performed during study involving human participants were in accord-
ance with the ethical standards of the Human Ethics committee of the
AIIMS, New Delhi. All the participants provided written informed consent. All
the participants were enrolled only after getting ethical approval.
Consent for publication
Consent to publish was also obtained from all the participants included in
the study.
Competing interests
Authors declare no competing interests concerning the work reported in
this manuscript.
Author details
Department of Physiology, AIIMS, New Delhi 110029, India.
Department of
Zoology, Govt. College for Girls, Sec-14, Gurugram, Haryana 122001, India.
Department of Rheumatology, All India Institute of Medical Sciences, AIIMS,
New Delhi 110029, India.
Received: 10 February 2020 Accepted: 28 May 2020
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Tanwar et al. Advances in Rheumatology (2020) 60:34 Page 11 of 11
... Increased body mass in the trunk and upper limbs associated with changes in the mechanoreceptors of the lower limbs, along with muscle weakness and/or fatigue, especially of the postural muscles, 29,30 may trigger an increase in postural sway and difficulties in standing. 19,25 A study with 41 female shift-workers demonstrated the decline of the postural control by 13.8% after the shift as result of fatigue, 31 and another study revealed worse shift-workers' postural performance due to muscle fatigue. 32 Therefore, it is possible to observe cognitive and motor deficits as a consequence of obesity, fatigue, and nocturnal sleep deprivation. ...
... The shift-working time induced postural instability in nurses worked three 12-hour shifts in a 4-day period. 31 In this sense, in several clinical studies, high BMI, sleep deprivation and sleepiness symptoms were related to a decline in postural performance. 3,7,25 In the present study, we observed an association between high BMI (27.4 AE 2.8 kg/m 2 ) and postural sway in the anteroposterior direction before and after the night shift. ...
... With this information, it is possible to suggest that female workers of this study may be predisposed to falls and, consequently, injuries in the work environment. 23,28,31 In agreement with our study, researchers showed that high BMIs interfere with postural stability, which may compromise the control of posture in obese and overweight individuals. 25,26,50 Hue et al. 25 reported that regardless of sensory inputs (with or without vision), CoP velocity increased linearly with increasing body mass, indicating a reduction in postural performance due to obesity. ...
Full-text available
Objectives To verify the relationships between sleep duration (Total Sleep Time – TST) and postural control of female night workers before and after shift. As well as, to verify if there is an influence of the body mass index (BMI) on the postural control of these female workers before and after shift. Methods A total of 14 female night workers (mean age: 35.0 ± 7.7 years) were evaluated. An actigraph was placed on the wrist to evaluate the sleep-wake cycle. The body mass and height were measured, and BMI was calculated. Postural control was evaluated by means of a force platform, with eyes opened and eyes closed before and after the 12-hour workday. Results There was an effect of the BMI on the velocity and the center of pressure path with eyes opened before ( t = 2.55, p = 0.02) and after ( t = 4.10, p < 0.01) night work. The BMI impaired the velocity and the center of pressure path with eyes closed before ( t = 3.05, p = 0.01; t = 3.04, p = 0.01) and after ( t = 2.95, p = 0.01; t = 2.94, p = 0.01) night work. Furthermore, high BMI is associated with female workers' postural sway ( p < 0.05). Conclusion Therefore, high BMI impairs the postural control of female night workers, indicating postural instability before and after night work.
... A variety of interventions can influence the peripheral and central nervous system and can promote targeted neuroplastic changes for each musculoskeletal disorder. 265,266 These techniques can influence different parts of the nervous system and contribute to electrophysiological and clinical changes. 262 Electrical currents can be used in central and peripheral regions of the body in order to promote plastic changes in the nervous system and clinical changes. ...
... Low frequency Dorsolateral Prefrontal córtex can significantly reduce pain and associated symptoms of Fibromyalgia and mechanisms are probably related to top-down pain modulation. 266 Peripheral neuromodulation techniques have also contributed to the treatment of musculoskeletal disorders. pPES promotes pain improvement and function in soft tissue injuries. ...
Full-text available
INTRODUCTION: Despite being considered least important for clinical practice in the pyramid of evidence for recommendations, sometimes scientists' expert opinions could help to better understand the summarization of updated publications. OBJECTIVE: To provide a major summarized update about brain imaging and stimulation of the nervous system in health and disease. METHODS: Comprehensive review developed by experts in each subarea of knowledge in neuroimaging and non-invasive stimulation of the nervous system. A team of researchers and clinic experts was invited to present an update on their area of expertise. RESULTS: In basics on brain imaging techniques, we approach general and quantitative electroencephalography, functional magnetic resonance imaging, functional near-infrared spectroscopy, and experimental paradigms in brain imaging studies. Were included associations between transcranial magnetic stimulation and electromyography, electroencephalography, and functional near-infrared stimulation to evaluate brain activity. Furthermore, we showed several actualized central and peripheral neuromodulation techniques. And finally, we presented different clinical and performance uses of non-invasive neuromodulation. CONCLUSION: To our knowledge, this is a major summarized and concentrated update about brain imaging and stimulation that can benefit neuroscience researchers and clinicians from different levels of experience.
... rTMS is also recommended by FDA for its use in treating patients with depression. Repetitive Transcranial Magnetic Stimulation (rTMS) for four weeks at dorsolateral prefrontal cortex was proved to improve pain and related symptoms of bromyalgia when targeted [54][55]. Transcranial Direct Current Stimulation (tDCS) can also result in signicant pain relief in FM patients and may be an effective complementary treatment strategy [56]. ...
... Considering the decrease in GABA-dependent inhibition occurring in chronic pain, we hypothesize that the increase in Lβ power possibly indicates a compensatory mechanism counteracting chronic pain-related GABAergic dysfunction. Interestingly, the PFC (in particular the dorsolateral PFC) constitutes a primary target for non-invasive brain therapies, such as the transcranial magnetic stimulation (TMS), including in FM [62]. Furthermore, TMS has been reported to have analgesic effects through GABAergic restauration [7]. ...
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Fibromyalgia (FM) is a major chronic pain disease with prominent affective disturbances, and pain-associated changes in neurotransmitters activity and in brain connectivity. However, correlates of affective pain dimension lack. The primary goal of this correlational cross-sectional case-control pilot study was to find electrophysiological correlates of the affective pain component in FM. We examined the resting-state EEG spectral power and imaginary coherence in the beta (β) band (supposedly indexing the GABAergic neurotransmission) in 16 female patients with FM and 11 age-adjusted female controls. FM patients displayed lower functional connectivity in the High β (Hβ, 20-30 Hz) sub-band than controls (p = 0.039) in the left basolateral complex of the amygdala (p = 0.039) within the left mesiotemporal area, in particular, in correlation with a higher affective pain component level (r = 0.50, p = 0.049). Patients showed higher Low β (Lβ, 13-20 Hz) relative power than controls in the left prefrontal cortex (p = 0.001), correlated with ongoing pain intensity (r = 0.54, p = 0.032). For the first time, GABA-related connectivity changes correlated with the affective pain component are shown in the amygdala, a region highly involved in the affective regulation of pain. The β power increase in the prefrontal cortex could be compensatory to pain-related GABAergic dysfunction.
... Treatment arms of all other studies were considered for the pre-post-intervention effects of active rTMS stimulation. Four studies [28,36,44,50] out of 52 could not be included for meta-analysis of efficacy as they did not report means and standard deviations. ...
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Unlabelled: Repetitive transcranial magnetic stimulation (rTMS) is potentially effective as an augmentation strategy in the treatment of many neuropsychiatric conditions. Several Indian studies have been conducted in this regard. We aimed to quantitatively synthesize evidence from Indian studies assessing efficacy and safety of rTMS across broad range of neuropsychiatric conditions. Fifty two studies- both randomized controlled and non-controlled studies were included for a series of random-effects meta-analyses. Pre-post intervention effects of rTMS efficacy were estimated in "active only" rTMS treatment arms/groups and "active vs sham" (sham-controlled) studies using pooled Standardized Mean Differences (SMDs). The outcomes were 'any depression', depression in unipolar/bipolar depressive disorder, depression in obsessive compulsive disorder (OCD), depression in schizophrenia, schizophrenia symptoms (positive, negative, total psychopathology, auditory hallucinations and cognitive deficits), obsessive compulsive symptoms of OCD, mania, craving/compulsion in substance use disorders (SUDs) and migraine (headache severity and frequency). Frequencies and odds ratios (OR) for adverse events were calculated. Methodological quality of included studies, publication bias and sensitivity assessment for each meta-analyses was conducted. Meta-analyses of "active only" studies suggested a significant effect of rTMS for all outcomes, with moderate to large effect sizes, at both end of treatment as well as at follow-up. However, except for migraine (headache severity and frequency) with large effect sizes at end of treatment only and craving in alcohol dependence where moderate effect size at follow-up only, rTMS was not found to be effective for any outcome in the series of "active vs sham" meta-analyses. Significant heterogeneity was seen. Serious adverse events were rare. Publication bias was common and the sham controlled positive results lost significance in sensitivity analysis. We conclude that rTMS is safe and shows positive results in 'only active' treatment groups for all the studied neuropsychiatric conditions. However, the sham-controlled evidence for efficacy is negative from India. Conclusion: rTMS is safe and shows positive results in "only active" treatment groups for all the studied neuropsychiatric conditions. However, the sham-controlled evidence for efficacy is negative from India.
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Purpose of Review Neurostimulation treatment options have become more commonly used for chronic pain conditions refractory to these options. In this review, we characterize current neurostimulation therapies for chronic pain conditions and provide an analysis of their effectiveness and clinical adoption. This manuscript will inform clinicians of treatment options for chronic pain. Recent Findings Non-invasive neurostimulation includes transcranial direct current stimulation and repetitive transcranial magnetic stimulation, while more invasive options include spinal cord stimulation (SCS), peripheral nerve stimulation (PNS), dorsal root ganglion stimulation, motor cortex stimulation, and deep brain stimulation. Developments in transcranial direct current stimulation, repetitive transcranial magnetic stimulation, spinal cord stimulation, and peripheral nerve stimulation render these modalities most promising for the alleviating chronic pain. Summary Neurostimulation for chronic pain involves non-invasive and invasive modalities with varying efficacy. Well-designed randomized controlled trials are required to delineate the outcomes of neurostimulatory modalities more precisely.
Objective: To examine the effectiveness of electrophysical agents in fibromyalgia. Data sources: CINAHL, Cochrane Library, Embase, Medline, PEDro, and Web of Science were searched from their inceptions to March 27, 2023. Methods: This study was registered in PROSPERO (CRD42022354326). Methodological quality of included trials was assessed using PEDro scale, and the quality of evidence was determined according to the Grading of Recommendations Assessment, Development, and Evaluation system. The primary outcomes were pain, functional status, and mood. Results: Fifty-four studies involving 3045 patients with fibromyalgia were eligible for qualitative synthesis and 47 (pain), 31 (functional status), and 26 (mood) for network meta-analysis. The network consistency model revealed that, when compared with true control, transcutaneous electrical nerve stimulation and microcurrent improved pain symptoms (P=0.006 and P=0.037, respectively); repetitive transcranial magnetic stimulation improved patient functional status (P=0.018); and microcurrent (P=0.001), repetitive transcranial magnetic stimulation (P =0.022), and no treatment (P=0.038) significantly improved mood after intervention. Surface under the cumulative ranking indicated that microcurrent was most likely to be the best for managing pain and mood (surface under the cumulative ranking: 70% and 100%, respectively); low-level laser therapy for pain and mood (80% and 70%, respectively); and repetitive transcranial magnetic stimulation for improving functional status and mood (80% and 70%, respectively). Conclusion: This review found low to moderate quality evidence that microcurrent, laser therapy, and repetitive transcranial magnetic stimulation are the most effective electrophysical agents for improving at least one outcome in fibromyalgia.
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Chronic low back pain (CLBP) is among the leading causes of disability worldwide. Beyond the physical and functional limitations, people's beliefs, cognitions, and perceptions of their pain can negatively influence their prognosis. Altered cognitive and affective behaviors, such as pain catastrophizing and kinesiophobia, are correlated with changes in the brain and share a dynamic and bidirectional relationship. Similarly, in the presence of persistent pain, attentional control mechanisms, which serve to organize relevant task information are impaired. These deficits demonstrate that pain may be a predominant focus of attentional resources, leaving limited reserve for other cognitively demanding tasks. Cognitive dysfunction may limit one's capacity to evaluate, interpret, and revise the maladaptive thoughts and behaviors associated with catastrophizing and fear. As such, interventions targeting the brain and resultant behaviors are compelling. Pain neuroscience education (PNE), a cognitive intervention used to reconceptualize a person's pain experiences, has been shown to reduce the effects of pain catastrophizing and kinesiophobia. However, cognitive deficits associated with chronic pain may impact the efficacy of such interventions. Non-invasive brain stimulation (NIBS), such as transcranial direct current stimulation (tDCS) or repetitive transcranial magnetic stimulation (rTMS) has been shown to be effective in the treatment of anxiety, depression, and pain. In addition, as with the treatment of most physical and psychological diagnoses, an active multimodal approach is considered to be optimal. Therefore, combining the neuromodulatory effects of NIBS with a cognitive intervention such as PNE could be promising. This review highlights the cognitive-affective deficits associated with CLBP while focusing on current evidence for cognition-based therapies and NIBS.
La stimulation épidurale du cortex moteur (eMCS) a été conçue dans les années 1990 et a maintenant largement supplanté la stimulation thalamique pour soulager la douleur neuropathique. Ses mécanismes d’action impliquent l’activation de multiples zones cortico-sous-corticales via une activation initiée dans le thalamus, avec implication des opioïdes endogènes et une inhibition descendante vers la moelle épinière. Les preuves de l’efficacité clinique sont maintenant étayées par au moins sept essais randomisés et les effets favorables peuvent persister jusqu’à dix ans, mais seul un candidat sur deux est significativement soulagé en l’absence de critère approprié de sélection. La stimulation magnétique répétitive non invasive (rTMS) s’est d’abord développée comme un moyen de prédire l’efficacité des procédures épidurales, avec une forte valeur prédictive positive, puis comme une méthode analgésique à part entière. Des preuves raisonnables provenant d’au moins six essais randomisés sont en faveur d’un effet analgésique significatif de la rTMS à haute fréquence sur le cortex moteur dans la douleur neuropathique, et de manière moins reproductible dans la fibromyalgie. La stimulation du cortex frontal dorsolatéral ne s’est pas avérée significativement efficace jusqu’à présent. Le cortex operculo-insulaire postérieur est une cible nouvelle et attrayante, mais l’évidence en sa faveur reste encore limitée. La stimulation transcrânienne à courant continu (tDCS) est appliquée sur des cibles similaires à celles de la rTMS ; elle ne provoque pas de potentiels d’action, mais module l’état de repos de la membrane neuronale. La tDCS présente des avantages pratiques, notamment un faible coût, peu de problèmes de sécurité et la possibilité de protocoles à domicile ; cependant, la qualité limitée de la plupart des rapports publiés lui confère actuellement un faible niveau de preuve. Les patients réagissant à la tDCS peuvent différer de ceux qui sont améliorés par la rTMS, et dans les deux cas des séances répétées sur une longue période peuvent être nécessaires pour obtenir un soulagement cliniquement significatif. Ces procédures exercent leurs effets par le biais de multiples réseaux cérébraux distribués qui influencent les aspects sensoriels, affectifs et cognitifs de la douleur chronique. Leurs effets s’exercent principalement sur les états hyperexcitables anormaux plutôt que sur la douleur aiguë expérimentale. L’extension de la durée des effets sur le long terme reste un défi, pour lequel différentes stratégies sont discutées dans cette revue.
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Background & objectives: Tension-type headache (TTH) is the most common type of primary headache disorder. Its chronic form is often the most ignored and challenging to treat. Transcranial magnetic stimulation (TMS) is a novel technique in the treatment of chronic pain. The aim of this pilot study was to explore the effect of low-frequency repetitive TMS (rTMS) on pain status in chronic TTH (CTTH) by subjective and objective pain assessment. Methods: Patients (n=30) diagnosed with CTTH were randomized into rTMS (n=15) and placebo (n=15) groups in this study. Pre-intervention detailed history of patients was taken. Numerical Rating Scale (NRS) for Pain and questionnaires [Headache Impact Test-6 (HIT-6), McGill Pain Questionnaire, Pain Beliefs Questionnaire, Coping Strategies Questionnaire, State-Trait Anxiety Inventory Test, Hamilton Rating Scale for Depression and WHO-Quality of Life Questionnaire-Brief version] were filled, and objective assessments such as nociceptive flexion reflex (NFR) and conditioned pain modulation were done. The tests were repeated after 20 sessions (5 days/week). In the rTMS group, 1200 pulses in eight trains of 150 pulses each were given at 1Hz over the right dorsolateral prefrontal cortex (RDLPFC). In the placebo group, the rTMS coil was placed such that magnetic stimulation did not reach the cortex. Results: The NRS score decreased significantly (P<0.001) and NFR thresholds increased significantly (P=0.011) in the rTMS group when compared to placebo group. Interpretation & conclusions: Subjective improvements in the NRS, HIT-6, McGill Present Pain Intensity, trait of anxiety and psychological pain beliefs were observed. The increase in the thresholds of NFR served as an objective marker for improvement in pain status. Further studies need to be done to confirm our preliminary findings.
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Substance use disorders (SUDs) are one of the leading causes of morbidity and mortality worldwide. In spite of considerable advances in understanding the neural underpinnings of SUDs, therapeutic options remain limited. Recent studies have highlighted the potential of transcranial magnetic stimulation (TMS) as an innovative, safe and cost-effective treatment for some SUDs. Repetitive TMS (rTMS) influences neural activity in the short and long term by mechanisms involving neuroplasticity both locally, under the stimulating coil, and at the network level, throughout the brain. The long-term neurophysiological changes induced by rTMS have the potential to affect behaviours relating to drug craving, intake and relapse. Here, we review TMS mechanisms and evidence that rTMS is opening new avenues in addiction treatments.
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Background: High frequency repetitive transcranial magnetic stimulation (rTMS) of the left dorsolateral prefrontal cortex (DLPFC) has shown significant efficiency in the treatment of resistant depression. However in healthy subjects, the effects of rTMS remain unclear. Objective: Our aim was to determine the impact of 10 sessions of rTMS applied to the DLPFC on mood and emotion recognition in healthy subjects. Design: In a randomised double-blind study, 20 subjects received 10 daily sessions of active (10 Hz frequency) or sham rTMS. The TMS coil was positioned on the left DLPFC through neuronavigation. Several dimensions of mood and emotion processing were assessed at baseline and after rTMS with clinical scales, visual analogue scales (VASs), and the Ekman 60 faces test. Results: The 10 rTMS sessions targeting the DLPFC were well tolerated. No significant difference was found between the active group and the control group for clinical scales and the Ekman 60 faces test. Compared to the control group, the active rTMS group presented a significant improvement in their adaptation to daily life, which was assessed through VAS. Conclusion: This study did not show any deleterious effect on mood and emotion recognition of 10 sessions of rTMS applied on the DLPFC in healthy subjects. This study also suggested a positive effect of rTMS on quality of life.
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Chronic neuropathic pain is estimated to affect 3%-4.5% of the worldwide population. It is associated with significant loss of productive time, withdrawal from the workforce, development of mood disorders such as depression and anxiety, and disruption of family and social life. Current medical therapeutics often fail to adequately treat chronic neuropathic pain. Deep brain stimulation (DBS) targeting subcortical structures such as the periaqueductal gray, the ventral posterior lateral and medial thalamic nuclei, and the internal capsule has been investigated for the relief of refractory neuropathic pain over the past 3 decades. Recent work has identified the dorsal anterior cingulate cortex (dACC) as a new potential neuromodulation target given its central role in cognitive and affective processing. In this review, the authors briefly discuss the history of DBS for chronic neuropathic pain in the United States and present evidence supporting dACC DBS for this indication. They review existent literature on dACC DBS and summarize important findings from imaging and neurophysiological studies supporting a central role for the dACC in the processing of chronic neuropathic pain. The available neurophysiological and empirical clinical evidence suggests that dACC DBS is a viable therapeutic option for the treatment of chronic neuropathic pain and warrants further investigation.
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The dorsolateral prefrontal cortex (DLPFC) is a common target for repetitive transcranial magnetic stimulation (rTMS) in major depression, but the conventional "5 cm rule" misses DLPFC in >1/3 cases. Another heuristic, BeamF3, locates the F3 EEG site from scalp measurements. MRI-guided neuronavigation is more onerous, but can target a specific DLPFC stereotaxic coordinate directly. The concordance between these two approaches has not previously been assessed. To quantify the discrepancy in scalp site between BeamF3 versus MRI-guided neuronavigation for left DLPFC. Using 100 pre-treatment MRIs from subjects undergoing left DLPFC-rTMS, we localized the scalp site at minimum Euclidean distance from a target MNI coordinate (X - 38 Y + 44 Z + 26) derived from our previous work. We performed nasion-inion, tragus-tragus, and head-circumference measurements on the same subjects' MRIs, and applied the BeamF3 heuristic. We then compared the distance between BeamF3 and MRI-guided scalp sites. BeamF3-to-MRI-guided discrepancies were <0.65 cm in 50% of subjects, <0.99 cm in 75% of subjects, and <1.36 cm in 95% of subjects. The angle from midline to the scalp site did not differ significantly using MRI-guided versus BeamF3 methods. However, the length of the radial arc from vertex to target site was slightly but significantly longer (mean 0.35 cm) with MRI-guidance versus BeamF3. The BeamF3 heuristic may provide a reasonable approximation to MRI-guided neuronavigation for locating left DLPFC in a majority of subjects. A minor optimization of the heuristic may yield additional concordance. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.
Fibromyalgia is an idiopathic chronic condition that causes widespread musculoskeletal pain, hyperalgesia and allodynia. This review aims to approach the general epidemiology of fibromyalgia according to the most recent published studies, identifying the general worldwide prevalence of the disease, its basic epidemiological profiles and its economic costs, with specific interest in the Spanish and Comunidad Valenciana cases. Fibromyalgia affects, on average, 2.10% of the world's population; 2.31% of the European population; 2.40% of the Spanish population; and 3.69% of the population in the Comunidad Valenciana. It supposes a painful loss of the quality of life of the people who suffer it and the economic costs are enormous: in Spain is has been estimated at more than 12,993 million euros annually.
The dorsolateral prefrontal cortex (DLPFC) is implicated in pain modulation via multiple psychological processes. Recent non-invasive brain stimulation studies suggest that interhemispheric DLPFC connectivity influence pain tolerance and discomfort by altering interhemispheric inhibition. The structure and role of interhemispheric DLPFC connectivity in pain processing has not been investigated. The present study used dynamic causal modeling (DCM) for fMRI to investigate transcallosal DLPFC connectivity during painful stimulation in healthy volunteers. DCM parameters were used to predict individual differences in sensitivity to noxious heat stimuli. Bayesian model selection results indicated that influences among the right and left DLPFC are modulated during painful stimuli. Regression analyses revealed that greater right DLPFC→left DLPFC couplings were associated with higher suprathreshold pain temperatures. These results highlight the role of interhemispheric connectivity in pain modulation and support the preferential role of the right hemisphere in pain processing. Knowledge of these mechanisms may improve understanding of abnormal pain modulation in chronic pain populations.
Unlabelled: Chronic myofascial pain syndrome has been related to defective descending inhibitory systems. Twenty-four females aged 19 to 65 years with chronic myofascial pain syndrome were randomized to receive 10 sessions of repetitive transcranial magnetic stimulation (rTMS) (n = 12) at 10 Hz or a sham intervention (n = 12). We tested if pain (quantitative sensory testing), descending inhibitory systems (conditioned pain modulation [quantitative sensory testing + conditioned pain modulation]), cortical excitability (TMS parameters), and the brain-derived neurotrophic factor (BDNF) would be modified. There was a significant interaction (time vs group) regarding the main outcomes of the pain scores as indexed by the visual analog scale on pain (analysis of variance, P < .01). Post hoc analysis showed that compared with placebo-sham, the treatment reduced daily pain scores by -30.21% (95% confidence interval = -39.23 to -21.20) and analgesic use by -44.56 (-57.46 to -31.67). Compared to sham, rTMS enhanced the corticospinal inhibitory system (41.74% reduction in quantitative sensory testing + conditioned pain modulation, P < .05), reduced the intracortical facilitation in 23.94% (P = .03), increased the motor evoked potential in 52.02% (P = .02), and presented 12.38 ng/mL higher serum BDNF (95% confidence interval = 2.32-22.38). No adverse events were observed. rTMS analgesic effects in chronic myofascial pain syndrome were mediated by top-down regulation mechanisms, enhancing the corticospinal inhibitory system possibly via BDNF secretion modulation. Perspective: High-frequency rTMS analgesic effects were mediated by top-down regulation mechanisms enhancing the corticospinal inhibitory, and this effect involved an increase in BDNF secretion.