Pain, Postoperative Clinical Trial
Official title:
A Pilot Trial of Longitudinal Repetitive Transcranial Magnetic Stimulation (rTMS) for Chronic Neuropathic Pain
Chronic neuropathic pain is defined as pain caused by a lesion or disease of the somatosensory nervous system. It is highly prevalent, debilitating, and challenging to treat. Current available treatments have low efficacy, high side effect burden, and are prone to misuse and dependence. Emerging evidence suggests that the transition from acute to chronic neuropathic pain is associated with reorganization of central brain circuits involved in pain processing. Repetitive transcranial magnetic stimulation (rTMS) is a promising alternative treatment that uses focused magnetic pulses to non-invasively modulate brain activity, a strategy that can potentially circumvent the adverse effects of available treatments for pain. RTMS is FDA-approved for the treatment of major depressive disorder, obsessive-compulsive disorder, and migraine, and has been shown to reduce pain scores when applied to the contralateral motor cortex (M1). However, available studies of rTMS for chronic neuropathic pain typically show variable and often short-lived benefits, and many aspects of optimal treatment remain unknown, including ideal rTMS stimulation parameters, duration of treatment, and relationship to the underlying pain etiology. Here the investigators propose to evaluate the efficacy of high frequency rTMS to M1, the region with most evidence of benefit in chronic neuropathic pain, and to use functional magnetic resonance imaging (fMRI) to identify alternative rTMS targets for participants that do not respond to stimulation at M1. The central aim is to evaluate the pain relieving efficacy of multi-session high-frequency M1 TMS for pain. In secondary exploratory analyses, the investigator propose to investigate patient characteristic that are predictive of responsive to M1 rTMS and identify viable alternative stimulation targets in non-responders to M1 rTMS.
Status | Recruiting |
Enrollment | 20 |
Est. completion date | January 30, 2025 |
Est. primary completion date | December 30, 2024 |
Accepts healthy volunteers | No |
Gender | All |
Age group | 18 Years to 80 Years |
Eligibility | Inclusion Criteria: - Meets Criteria for Chronic Neuropathic Pain (NP): 1. "Pain caused by a lesion or disease of the somatosensory nervous system 2. Intractable pain longer than 6 months after pain onset 3. Baseline VAS score 30-94-mm 4. Currently prescribed pain medication for NP, history of prior medication trials without adequate pain control, or refused treatments for individual reasons 5. Continuous pain in face and/or extremities - Age 18-80 - Any gender and all ethnoracial categories - Stable on chronic pain medications for 4 weeks prior to the study and agreeable to continue throughout the study. These medications include: Tricyclic antidepressants (e.g., nortriptyline, amitriptyline), SNRIs (e.g., duloxetine, venlafaxine), gabapentinoids (e.g., gabapentin, pregabalin), antiepileptics (e.g., valproic acid, carbamazepine, lamotrigine), and daily anti-inflammatories (e.g., meloxicam), among others (as determined by study physician at the time of screening). Note: Medications that are known to increase cortical excitability (e.g., buproprion, maprotiline, tricyclic antidepressants, classical antipsychotics) or to have an inhibitory effect on brain excitability (e.g., antiepileptics, benzodiazepines, and atypical antipsychotics), or any other medications with relative hazard for use in TMS will be allowed upon review of medications and/or motor threshold determination by TMS specialist. - Participants may continue to take as-needed pain medications and record daily usage throughout the experiment - Capacity to provide informed consent - Ability to tolerate study procedures - Successfully complete the screening forms without contraindications Exclusion Criteria: - Neurologic: Dementia, Severe neurocognitive disorder (MoCA < 22), Severe aphasia, Seizure disorder, certain structural brain lesions (e.g., intracranial mass lesions, hydrocephalus, sequelae of meningitis), or complete paralysis at target site - Psychiatric: DSM Axis I disorder, Suicidal thoughts, prior psychosurgery, prior ECT - Procedural: prior rTMS within 1 year of consent, enrollment in other clinical trial in the past 6 months - TMS contraindications: implanted device; presence of metal in the head, including eyes and ears (excluding dental implants); certain tics; medications or systemic illness that predispose seizure risk - Participants with an unstable physical, systemic, or metabolic disorder (e.g., unstable hypertension, cardiac disease) - Females who are pregnant or nursing - Inability to complete the research study |
Country | Name | City | State |
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United States | UCSF Medical Center | San Francisco | California |
Lead Sponsor | Collaborator |
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University of California, San Francisco |
United States,
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Type | Measure | Description | Time frame | Safety issue |
---|---|---|---|---|
Other | Change in NIH PROMIS Toolbox Scores | The NIH PROMIS toolbox contains a host of survey questions tailored to measurement of specific disease states such as pain, global health and function.
The patient impression evaluates patient self-evaluation and physician evaluation of the patient's general health ranging form 0 to 7 with 7 being the worst general health. |
Baseline and 6 months | |
Other | Change in WHO Disability Assessment Schedule (WHODAS) Scores | Assessment of functional disability from the WHO to track level of function throughout the trial. The total score for WHODAS ranges from 0-100. A high score indicates major living limitations. | Baseline and 6 months | |
Other | Pain Catastrophizing Scale (PCS) | Validated scale measuring emotional responses to pain to track pain-related symptoms during the trial. It is a 13-item scale, with a total range of 0 to 52. Higher scores are associated with higher amounts of pain catastrophizing. | Baseline and 6 months | |
Other | Change in Pain Anxiety Symptom Scale (PASS) Scores | Validated scale measuring pain-related anxiety. It is a 20 item scale with a total range of 0-100. Higher scores indicate higher pain-related anxiety symptoms. | Baseline and 6 months | |
Other | Patient Global Impression of Change (PGIC) | Standardized assessment to assess subject's overall impression of improvement. Scores range from 1 to 7, with 1 representing "no change" and 7 representing "a great deal better" | 6 months | |
Other | Change Pittsburgh Sleep Quality Index (PSQI) Scores | Validated insomnia and sleep symptom scale. PSQI ranges from 0-21. Higher scores indicate worse sleep quality. | Baseline and 6 months | |
Other | Brain Network Assessment | T1-weighted high-resolution anatomical image will be acquired to facilitate neuronavigation for TMS treatment. A variety of other sequences including T2 FLAIR and diffusion tensor imaging (DTI) anatomical scans, as well as functional MRI scans (at rest and during ratings of spontaneous pain) will be acquired for research aims. Network features after TMS will be compared with baseline network features. | Baseline and 2 weeks | |
Other | Change in Heart Rate Variability | Single estimate of heart rate variability to assess change in autonomic physiology after TMS relative to baseline. | Baseline and 2 weeks | |
Other | Change in Skin Conductance Level | Single estimate of galvanic skin conductance to assess change in autonomic physiology after TMS relative to baseline. | Baseline and 2 weeks | |
Primary | Change in Pain Intensity Over 2 weeks | Change in visual analog scores (VAS) of pain intensity on 0-100 mm scale. 0 indicates no pain, 100 indicates most pain imaginable. | Baseline and 2 weeks | |
Secondary | Change in Pain Intensity Over 6 months | Change in visual analog scores (VAS) of pain intensity on 0-100 mm scale. 0 indicates no pain, 100 indicates most pain imaginable. | Baseline and 6 months | |
Secondary | Change in Pain Unpleasantness Over 2 weeks | Change in visual analog scores (VAS) of pain unpleasantness on 0-100 mm scale. 0 indicates not bothersome at all, 100 indicates most bothersome pain imaginable. | Baseline and 2 weeks | |
Secondary | Change in Pain Unpleasantness Over 6 months | Change in visual analog scores (VAS) of pain unpleasantness on 0-100 mm scale. 0 indicates not bothersome at all, 100 indicates most bothersome pain imaginable. | Baseline and 6 months | |
Secondary | Percent Responders | Proportion of patients in each group with >50% reduction in pain intensity VAS | Baseline and 2 weeks | |
Secondary | Percent Responders | Proportion of patients in each group with >50% reduction in pain intensity VAS | Baseline and 6 months | |
Secondary | Change in medication use | Change in daily as-needed medication use from baseline, in number of doses per day. | Baseline and 2 weeks | |
Secondary | Change in medication use | Change in daily as-needed medication use from baseline, in number of doses per day. | Baseline and 6 months | |
Secondary | Change in McGill Pain Questionnaire (MPQ) Pain scores | The McGill Pain Questionnaire is a validated measure of multiple domains of pain processing, including sensory and affective pain processing as well as nociceptive and neuropathic pain. Scores range from 0-45 with 0 indicating low pain and 45 indicating high pain. | Baseline and 6 months | |
Secondary | Change in Beck Depression Inventory (BDI-II) Scores | Validated measure of clinical depression symptoms to quantify and track mood over time. Scores index depression severity and range from 0-63: 0-13 is considered minimal range, 14-19 is mild, 20-28 is moderate, and 29-63 is severe. | Baseline and 6 months |
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