Study of rTMS Analgesic Effect in Chronic Neuropathic Pain,

Study Overview
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Brief Summary
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The purpose of this study is to compare the analgesic effectiveness of three modes of repetitive Transcranial Magnetic Stimulation (rTMS) in chronic neuropathic pain: Classical rTMS stimulation Deeper rTMS stimulation Sham rTMS stimulation

Detailed Description
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Conduct of study: Entry into the study: After informed consent, patients will be randomised. The physician responsible for conducting neurostimulation sessions will make the randomization via an interactive web response system (IWRS). Only this physician will have the knowledge of the group allocated to the patient. Baseline : Patients, will record on a diary form, a daily Visual Numeric Scale(VNS) of Pain Intensity for 1 week. Treatment sessions: after the baseline, sessions of neurostimulation will begin for seven weeks. After the end of neurostimulation sessions, patients will be followed for 2 weeks. Throughout their participation in the study, patients will plot on a diary form their daily VNS.

Official Title
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Randomized Double-blind Study of rTMS Analgesic Effect in Chronic Neuropathic Pain. Comparison Between Three Groups: Motor Cortex Stimulation by the Classic Coil B65, Deeper Stimulation by the Coil B70 and Placebo Stimulation. Analysis of Long-term rTMS-induced Brain Changes Using fMRI.

Conditions
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Chronic Neuropathic Pain

Intervention / Treatment
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* Device: RepetitiveTranscranial Magnetic Stimulation (rTMS)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patient's written consent Affiliated with social security system Male or female, suffering for more than a year from unilateral refractory neuropathic pain: hemi-body, upper limb, lower limb and facial chronic pain. Patient whose analgesic treatment, is stable for at least 1 month. Patient not responding to conventional treatments Prescreening EVN >3 Exclusion Criteria: History of drug addiction, epilepsy, cranial trauma History of psychiatric disorder Patients previously treated with rTMS Patient with intracranial ferromagnetic material or implanted stimulator New treatment for less than one month Pregnant or Breastfeeding woman Patient who does not understand the study protocol Persons who are protected under the act.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Classic rTMS Stimulation using the B65 Coil<br> | Device: RepetitiveTranscranial Magnetic Stimulation (rTMS)<br>* The rTMS protocol consist of one session per day for five days during the first week, then three sessions the second week and then one session the third week, followed by two monthly sessions.<br>|
| Experimental: Deeper rTMS Stimulation using the B70 Coil<br> | Device: RepetitiveTranscranial Magnetic Stimulation (rTMS)<br>* The rTMS protocol consist of one session per day for five days during the first week, then three sessions the second week and then one session the third week, followed by two monthly sessions.<br>|
| Sham Comparator: control group with a sham stimulation using a sham coil<br> | Device: RepetitiveTranscranial Magnetic Stimulation (rTMS)<br>* The rTMS protocol consist of one session per day for five days during the first week, then three sessions the second week and then one session the third week, followed by two monthly sessions.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Evolution of Pain. | Comparison between the 3 groups of the evolution of the weekly value of the Visual Numeric Scale (VNS): The patient will raise his pain level on a follow-up diary each day. The VNS average will be calculated for each week. The NSV is a 10-point scale, ranging from 0 (worse) to 10 (better). | Pain progression will be assessed from week 1 (before treatment) to week 7 (end of treatment) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Assesment of Potential Changes in Sensory-motor Cortical Maps Induced by rTMS | Comparison between the 3 groups of changes in sensory-motor cortical maps using Functional magnetic resonance imaging (FMRI). | Day 60 from the beginning of rTMS treatment compared to baseline. | 
| Rate of Responding Patients. | Comparison between the 3 groups of the rate of responding patients. Responding patients is defined by a 30% reduction in pain intensity assessed with VNS. | week 7 compared with baseline | 
| Assessment of Overall Patient Improvement. | Comparison between the 3 groups of the overall patient improvement using the Clinical Global Impression of Change scale (CGI).The CGI is a 7-point scale, ranging from 1 (better) to 7 (worse). | Day 30 and day 60 from the beginning of rTMS treatment compared to baseline | 
| Quality of Life Improvement. | Comparison between the 3 groups of the improvement of quality of life using the SF12 (Short Form 12) questionnaire.SF12 includes a mental and social score ranging from 5.89 to 71.97 and a physical score ranging from 9.95 to 70. a high score indicates a better quality of life. | Day 30 and day 60 from the beginning of rTMS treatment compared to baseline | 
| Evolution of Anxiety and Depressive Traits. | Comparison between the 3 groups of the improvement of anxiety and depressive traits using the HADS questionnaire (Hospital Anxiety and Depression Scale).the HADS score varies between 0 and 42. zero corresponding to the best score. | Day 30 and day 60 from the beginning of rTMS treatment compared to baseline | 
| Evolution of Symptomatological Profiles of Neuropathic Pain. | Comparison between the 3 groups of symptomatological profiles of neuropathic pain using NPSI questionnaire (Neuropathic Pain Symptom Inventory). | Day 30 and day 60 from the beginning of rTMS treatment compared to baseline. | 
| Sympathetic Autonomic System Injury and Small Fiber Neuropathy. | Comparison between the 3 groups of sympathetic autonomic system injury and small fiber neuropathy using the Sudoscan® device. | Day 60 from the beginning of rTMS treatment compared to baseline. | 
| Autonomous System Assessement. | Comparison between the 3 groups of changes in skin tension and conductance during fMRI examination. | Day 60 from the beginning of rTMS treatment compared to baseline. | 
| Evolution of the use of analgesic treatments. | Comparison between the 3 groups of the evolution of the use of analgesic treatments reported on the diary. | From baseline to day 60. | 
| Analgesic Response Analysis | Comparison between the 3 groups of the evolution of the weekly EVN average according to the clinical profile of patients | From baseline to day 60. | 
| Improvement of pain triggered by a stimulus (allodynia). | Comparison between the 3 groups of allodynia improvement. | Day 30 and day 60 from the beginning of rTMS treatment compared to baseline. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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rTMS, Chronic neuropathic pain, Repetitive Transcranial Magnetic Stimulation