背景:幻肢疼痛(PLP)在60-80%的截肢患者中是一种普遍且令人痛苦的现象。最近的研究强调了适应不良皮质可塑性在PLP发生中的意义,强调针对皮质区域进行治疗干预的重要性。重复经颅磁刺激(rTMS),一种非侵入性的皮质刺激工具,证明了治疗神经性起源的各种慢性疼痛病症的有效性。然而,目前研究rTMS作为治疗干预的应用,专门用于管理PLP.值得注意的是,背外侧前额叶皮质(DLPFC)在中枢疼痛处理中起着至关重要的作用,提示其作为PLP治疗关键治疗靶点的潜力。缺乏关于DLPFC靶向rTMS在减轻PLP患者所经历的疼痛中的有效性的充分数据。
目的:在本研究中,我们的目的是研究10次DLPFC靶向rTMS对PLP患者疼痛状态的影响.
方法:随机对照试验。
方法:创伤截肢者向三级护理中心报告PLP。
方法:该研究获得了研究所伦理委员会(IECPG-299/27.04.2022)的批准,并在印度临床试验注册中心(CTRI/2022/07/043938)注册。招募了19名患有PLP的患者,并将其随机分为真实或假rTMS组。在真正的rTMS组中,患者在截肢部位对侧的DLPFC接受了10次rTMS治疗.rTMS,以90%的静息运动阈值(RMT)进行管理,以1Hz的速率和60秒的列车间间隔,作为每个列车150个脉冲的8个列车递送。每个疗程的脉冲总数为1,200。假手术组通过在DLPFC上垂直放置rTMS线圈接受10次假rTMS。这些会话持续相同的持续时间,并包括与真实组相同的声音,但不涉及主动刺激。在基线时使用视觉模拟量表(VAS)评估患者的疼痛状态,在每一次真实或虚假的rTMS结束时,在15日,30日,以及完成真实或虚假治疗后的第60天。
结果:在10次针对DLPFC的真实rTMS后,VAS评分显着下降,与假rTMS组相反。在随访期间,真实rTMS组的VAS评分降低也持续存在。
结论:由于身体限制和经济限制,一些患者不得不退出。因此,只有少数个体能够成功完成研究方案.
结论:10次DLPFC的真实rTMS方案与PLP患者的疼痛缓解有关,效果持续2个月。因此,本研究表明,DLPFC的rTMS有可能作为PLP患者持续缓解疼痛的有效治疗干预措施.
BACKGROUND: Phantom limb pain (PLP) is a prevalent and distressing occurrence in 60-80% of individuals who have undergone amputations. Recent research underscores the significance of maladaptive cortical plasticity in the genesis of PLP, emphasizing the importance of targeting cortical areas for therapeutic interventions. Repetitive transcranial magnetic stimulation (rTMS), a noninvasive tool for cortical stimulation, demonstrates effectiveness in treating various chronic pain conditions of neuropathic origin. Nevertheless, there exists a limited body of research investigating the application of rTMS as a therapeutic intervention specifically for managing PLP. Notably, the dorsolateral prefrontal cortex (DLPFC) plays a crucial role in central pain processing, suggesting its potential as a key therapeutic target in PLP treatment. There is a lack of adequate data regarding the effectiveness of DLPFC-targeting rTMS in alleviating the pain experienced by PLP patients.
OBJECTIVE: In this study, our aim was to investigate the impact of 10 sessions of DLPFC-targeting rTMS on the pain status of individuals experiencing PLP.
METHODS: Randomized controlled trial.
METHODS: Traumatic amputees reporting to the tertiary care center with PLP.
METHODS: The study was approved by the Institute Ethics Committee (IECPG-299/27.04.2022) and registered in the Clinical Trials Registry of India (CTRI/2022/07/043938). Nineteen patients suffering from PLP were recruited and randomized into real or sham rTMS groups. In the real rTMS group, patients received 10 sessions of rTMS at the DLPFC contralateral to the amputation site. The rTMS, administered at 90% of the resting motor threshold (RMT), was delivered as 8 trains of 150 pulses per train at the rate of one Hz and an inter-train interval of 60 seconds. The total number of pulses per session was 1,200. The sham group received 10 sessions of sham rTMS through the perpendicular placement of an rTMS coil over the DLPFC. These sessions lasted for the same duration and included the same sounds as the real group but involved no active stimulation. The patients\' pain status was evaluated using the Visual Analog Scale (VAS) at baseline, at the end of each session of real or sham rTMS and at the 15th, 30th, and 60th day after the the completion of real or sham therapy.
RESULTS: A significant decrease in VAS scores was noted after 10 sessions of real rTMS that targeted the DLPFC, in contrast to the sham rTMS group. The real rTMS group\'s reduction in VAS scores also persisted during the follow-up.
CONCLUSIONS: A few patients had to drop out due to physical restrictions and financial constraints. Consequently, only a small number of individuals were able to complete the study protocol successfully.
CONCLUSIONS: A regimen of 10 sessions of real rTMS of the DLPFC was associated with significant pain relief in patients with PLP, and the effects were sustained for 2 months. Therefore, the present study shows that rTMS of the DLPFC has potential as an effective therapeutic intervention for sustained pain relief in PLP patients.