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Dong-Ha Kang1*, Yu Hui Won1,2, Sung-Hee Park1,2, Myoung-Hwan Ko1,2, Jeong-Hwan Seo1,2, Gi-Wook Kim1,2† |
The mechanism and treatment of the mild Traumatic Brain Injury(TBI) with central pain has been studied, but it has not been clarified yet. The aim of this study was to investigate the therapeutic effect of repeated transcranial magnetic stimulation therapy(rTMS) in mild TBI with central pain and the changes in the objective evaluations of central pain before and after rTMS.
Subjects of this study are the patients with mild TBI who complained of pain but had no specific findings on neurological examination and brain magnetic resonance(MR) – fluid attenuated inversion recoveryimaging.
We have attempted to perform various objective evaluations related to central pain on subjects such as physical examination(perception of pain, temperature, crude touch, and pressure sensation), Visual Analogue Scale(VAS), Quantitative Sensory Test(QST), Sympathetic Skin Response(SSR) and Fractional Anisotropy(FA) test of spinothalamic tract using brain diffusion tensor MRI.
Patients who were included in this study were in car traffic accidents, all of which were side-impacts resulting in vehicle rotation.The pain that patients complained is whole body pain below neck area, with more severe symptoms on either the left or right side than another side. And there is difference in perception of temperature sensation compared one side with another.We applied rTMS to patients for treatment using 8-shaped coil and we determined the cortical site at which single pulse TMS evoked a contralateral motor evoked potential of maximal amplitude in a hand muscle. The study comprised two separate rTMS sessions. Each sessionincluded five rTMS per week for three weeks, total 15 treatments.In first session, we applied rTMS on M1 cortex area contralateral to painful side and subjects received 10 consecutive trains of 200 stimuli pulses at a frequency of 20Hz. And in second session, rTMS was applied to the contralateral side. Physical examination, VAS, QST, SSR, and brain diffusion tensor MRI were performed again after treatment. All treatments and pre- and post-treatment evaluations according to the plan described above were only completed in three patients.
All three patients showed improvement in physical examination and VAS and there is decreased amplitude of SSR after rTMS. And two patients showed improvement in FA value of spinothalamic tract on brain diffusion tensor MRI.The QST did not show any significant difference between the right and left side beforerTMS, and there was no change before and after rTMS.
In this study, we found that the pain patterns of three TBI patients with central pain changed from neurogenic pain to musculoskeletal pain after rTMS.And we were able to identify the evaluation showing changes of assessment of central pain before and after rTMS.In the future, further studies involving more patients will be needed to establish an objective evaluation and treatment system for mild TBI patients with central pain.
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