Abstract
Neuropathic pain after brachial plexus injury (NPBPI) is a highly disabling clinical condition and is increasingly prevalent due to increased motorcycle accidents. Currently, no randomized controlled trials have evaluated the effectiveness of non-invasive brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct-current stimulation (tDCS) in patients suffering from NPBPI. In this study, we directly compare the efficacy of 10-Hz rTMS and anodal 2 mA tDCS techniques applied over the motor cortex (5 daily consecutive sessions) in 20 patients with NPBPI, allocated into 2 parallel groups (active or sham). The order of the sessions was randomised for each of these treatment groups according to a crossover design and separated by a 30-day interval. Scores for “continuous” and “paroxysmal” pain (primary outcome) were tabulated after the last stimulation day and 30 days after. Secondary outcomes included the improvement in multidimensional aspects of pain, anxiety state and quality of life from a qualitative and quantitative approach. Active rTMS and tDCS were both superior to sham in reducing continuous (p < 0.001) and paroxysmal (p = 0.002; p = 0.02) pain as well as in multidimensional aspects of pain (p = 0.001; p = 0.002) and anxiety state (p = < 0.001; p = 0.005). Our results suggest rTMS and tDCS are able to treat NPBPI with little distinction in pain and anxiety state, which may promote the use of tDCS in brachial plexus injury pain management, as it constitutes an easier and more available technique.Clinical Trial Registration: http://www.ensaiosclinicos.gov.br/, RBR-5xnjbc – Sep 3, 2018.
Highlights
Neuropathic pain after brachial plexus injury (NPBPI) is a highly disabling clinical condition and is increasingly prevalent due to increased motorcycle accidents
Recent neurophysiological support and previous neuroimaging studies for this possibility comes from reports that repetitive transcranial magnetic stimulation (rTMS) and transcranial direct-current stimulation (tDCS) over functionally connected regions of the distributed motor network leads to greater enhancements in pain relief, especially given the evidence to modulate the activity of an extensive neuronal network[13], which includes thalamic nuclei, the limbic system, brain stem nuclei, and spinal medulla[15,16,17,18]
Currently, a direct comparison approach about rTMS and tDCS techniques has not been explored in relation to neuropathic pain (NP) located in the upper limb[12,14,18]
Summary
Neuropathic pain after brachial plexus injury (NPBPI) is a highly disabling clinical condition and is increasingly prevalent due to increased motorcycle accidents. Our results suggest rTMS and tDCS are able to treat NPBPI with little distinction in pain and anxiety state, which may promote the use of tDCS in brachial plexus injury pain management, as it constitutes an easier and more available technique. Since chronic pain results from inadequate plastic changes in the central and peripheral nervous s ystem[12], non-invasive brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct-current stimulation (tDCS) have been reported as a therapeutic option[12,13,14]. In the current crossover study, we focused on comparing changes in pain intensity and multidimensional aspects of patients with NPBPI, from sensory, affective and evaluative components of pain aspects using a qualitative and quantitative approach. As a secondary analysis, we explored the effects of stimulation over the anxiety and quality of life in this population, which constitute two important nodes within the management of chronic p ain[21,22,23]
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