Efficacy of Transcranial Magnetic Stimulation (TMS) in Chronic Idiopathic Pain Disorders

Efficacy of Repetitive Transcranial Magnetic Stimulation in the Treatment of Chronic Idiopathic Pain Syndromes : a Double Blind Sham Controlled Study

Objectives : To investigate the analgesic effects of repeated sessions of unilateral rTMS in patients with chronic pain syndrome due to fibromyalgia, IBS or burning mouth syndrome. Primary outcome will be numerical pain scores.

Methods : The study will be randomized and performed in parallel groups and double blind versus sham stimulation, and will include 90 patients (45 patients per treatment arm). The randomization will be computerized and performed for each aetiological group separately. The rTMS will be performed on the left motor cortex, 5 consecutive days , then once a week during 3 weeks then twice a month during 2 months, then once a month during 6 months. Clinical assessment will include an assessment of pain, quality of life, sleep, depression and anxiety, catastrophizing, and a neuropsychological evaluation.

Conclusion : this study should allow to determine for the first time the long term efficacy and safety of rTMS in the treatment of dysfunctional or idiopathic chronic pain syndromes which are often refractory to conventional treatments.

Study Overview

• Status: Completed
• Conditions: Irritable Bowel Syndrome; Fibromyalgia; Burning Mouth Syndrome
• Intervention / Treatment: Device: Repetitive transcranial magnetic stimulation

Detailed Description

Several lines of evidence suggest that fibromyalgia syndrome, Irritable Bowel syndrome (IBS) and burning mouth syndrome are chronic pain disorders affecting pain modulation. Repetitive transcranial magnetic stimulation (rTMS) is a recent, safe and non-invasive technique for stimulating the cerebral cortex, which has recently been reported to induce short term analgesic effects in patients with chronic focal pain. We have also recently shown in a double blind randomized trial, that rTMS could have short term analgesic effects in patients with fibromyalgia.

Objectives : Our aim is to investigate the long term analgesic effects of repeated sessions of unilateral rTMS in patients with chronic pain syndrome due to fibromyalgia, IBS or burning mouth syndrome. Primary outcome will be numerical pain scores on brief pain inventory at each visit.

Methods : This study will be randomized and performed in parallel groups and double blind versus sham stimulation. It will include at least 30 patients per pain disorder, ie 90 patients. Randomization will be computerized and performed for each of the aetiological groups separately (ie, there will be 3 distinct randomization procedures for fibromyalgia, IBS and stomatodynia);. Stimulation will be applied to the right motor area corresponding to the contralateral hand. The treatment will consist in a first period of 5 consecutive days of stimulation, followed by a stimulation once a week during 3 weeks then a stimulation twice a month during 2 months then stimulation once a month during 3 additional months. Clinical assessment will be performed at baseline, then at day 1, 5, weeks 3, 5, 7, 9, 13 and 25. It will include depending on the visits an assessment of pain intensity and characteristics, quality of life, sleep, depression and anxiety, catastrophizing, and a brief neuropsychological evaluation (focusing on memory, attention and vigilance). In patients with fibromyalgia, the evaluation will also include specifically the number of tender points. In patients with IBS, evaluation of bowel dysfunction will also be performed.

Conclusion : This study should allow to determine for the first time the long term efficacy and safety of rTMS in the treatment of dysfunctional or idiopathic chronic pain syndromes which are often refractory to conventional treatments.

• Study Type: Interventional
• Enrollment (Actual): 60
• Phase: Phase 3

Contacts and Locations

Study Locations

• France
  • Boulogne, France, 92100
    • Hopital Ambroise Pare

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 80 years (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Pain related to Fibromyalgia (ACR criteria) or IBS (Rome II criteria) or burning mouth syndrome (IHS criteria 2004)
• Chronic pain for at least 6 months
• Pain for at least 4 days a week
• Mean average pain score at inclusion and randomization ≥ 4/10 (numerical scale)
• Patients aged 18 years and less than 80 years
• Informed consent
• Stable antalgic treatment

Exclusion Criteria:

• Contraindications to TMS (electroconvulsive therapy, epilepsy, head trauma, intracranial hypertension, metallic clip, pace maker, pregnancy)
• Major depression (DSM IV criteria) or psychosis
• Disorder preventing an accurate understanding of the testing and protocol
• Intermittent pain
• Pain for less than 6 months
• Other pain more severe than the pain evaluated for the trial
• Alcohol/psychoactive drugs abuse

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: QUADRUPLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: transcranial magnetic stimulation; repetitive transcranial magnetic stimulation of the motor cortex	Device: Repetitive transcranial magnetic stimulation; Repetitive transcranial magnetic stimulation of the motor cortex (10 Hz) every day during 5 days then every week for 3 weeks then every two weeks for 2 months then every month for 3 additional months; Other Names: rTMS; placebo stimulation
SHAM_COMPARATOR: placebo stimulation; repetitive placebo stimulation of the motor cortex	Device: Repetitive transcranial magnetic stimulation; Repetitive transcranial magnetic stimulation of the motor cortex (10 Hz) every day during 5 days then every week for 3 weeks then every two weeks for 2 months then every month for 3 additional months; Other Names: rTMS; placebo stimulation

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Average pain over the last 24 hours at each visit -pain diary at baseline to see the stability of the measures	Brief Pain inventory	at each visit before the stimulation session

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Sensory and affective pain scores (McGill pain questionnaire)	Short form MPQ was used	at baseline, then day 1, 5, weeks 3, 9, and 25 after the induction phase
Quality of life (brief pain inventory)	Brief Pain inventory (Cleeland and Ryan 1992) interference items (7)	at baseline, days 1, 5,weeks 3, 9, and 25 after the induction phase
Disability ( FIQ)	FIQ only for fibromyalgia patients	at days 1, 5, weeks 3, 9 and 25 after the induction phase
Comorbidities (HAD)	21 item Hospital anxiety and depression scale	at week 3 7, 13, 25 after the induction phase
Catastrophizing (PCS)	Pain Catastrophizing Scale (Sullivan et al 1995)	at weeks 3, 7, 13 and 25 after the induction phase
Predictors of the response based on psychological factors and measures of cortical excitability		at inclusion
Safety including cognitive evaluation	Cognitive tests were performed by a neuropsychologists and included measures of attention and memory	at 6 months (cognitive evaluation) ; safety assessed every month for up to 12 months
Comparison of the efficacy of TMS between 3 different pain disorders	this can only be made when the two other groups of patients will have finished the enrollment - for now the study on fibromyalgia is finished and results analysed - the other groups are still being recruited (ie, IBS, burning mouth syndrome)	during the whole study period -ie, days 1, 5, then before each stimulation throughout the study
assessment of cortical excitability	determination of rest motor threshold, suprathreshold motor evoiked potentials (MEP), SICI and ICF, for the left hemisphere	day 1, 5, weeks 3, 9 and 21 after the induction phase

Collaborators and Investigators

• Sponsor: Hospital Ambroise Paré Paris
• Investigators: Principal Investigator: Nadine ATTAL, MD, PhD, INSERM U 987 and AP-HP

Study record dates

Study Major Dates

• Study Start: October 1, 2006
• Primary Completion (ACTUAL): March 1, 2012
• Study Completion (ACTUAL): April 1, 2012

Study Registration Dates

• First Submitted: September 8, 2006
• First Submitted That Met QC Criteria: September 8, 2006
• First Posted (ESTIMATE): September 11, 2006

Study Record Updates

• Last Update Posted (ESTIMATE): December 3, 2015
• Last Update Submitted That Met QC Criteria: December 2, 2015
• Last Verified: December 1, 2015

More Information

Terms related to this study

• Keywords: chronic pain; IBS; fibromyalgia; TMS; predictive factors; burning mouth syndrome
• Additional Relevant MeSH Terms: Digestive System Diseases; Pathologic Processes; Nervous System Diseases; Wounds and Injuries; Disease; Gastrointestinal Diseases; Musculoskeletal Diseases; Rheumatic Diseases; Muscular Diseases; Neuromuscular Diseases; Stomatognathic Diseases; Mouth Diseases; Colonic Diseases, Functional; Colonic Diseases; Intestinal Diseases; Syndrome; Burns; Irritable Bowel Syndrome; Fibromyalgia; Myofascial Pain Syndromes; Burning Mouth Syndrome
• Other Study ID Numbers: TMS-chronic pain 1