| BackgroundNeuropathic pain(NP)is one of the most common types of pain in clinical practice.Its clinical manifestations are complex,and patients will have pain of different degrees,mainly characterized by spontaneous pain,allodynia,hyperalgesia and abnormal pain sensation.Because the pathogenesis of neuropathic pain is not well understood,the treatment of neuropathic pain in clinical practice is not yet able to achieve the desired analgesic effect,and patients often suffer from prolonged illness,which not only seriously affects their quality of life,but also brings a heavy burden to their families and society.Research has shown that pain experience is a soma-psychological compound product,and pain and emotional response often appear together and interact with each other in clinical.In recent years,repetitive transcranial magnetic stimulation(rTMS),a noninvasive neuromodulation therapy,has become a popular method for clinical analgesia.The latest international guidelines include high frequency rTMS applied to the M1 region as one of the central nerve stimulation treatments for NP(Level A evidence).In addition,by stimulating the left DLPFC region of patients with depression,rTMS intervention can effectively reduce the utilization rate of antidepressants and improve the clinical symptoms of depression.Therefore,international guidelines suggested that high frequency rTMS acting on the left DLPFC region has clear efficacy in the treatment of depression(Level A evidence).rTMS also plays an important role in improving the negative emotional state of anxiety,alleviating the cognition of bipolar disorder and reducing addiction,etc.Therefore,rTMS is expected to become one of the common non-drug treatment methods for mood disorders.However,the study on whether rTMS will cause changes in the emotional state of patients with neuropathic pain accompanied by anxiety/depression in clinical practice is insufficient,and its optimal effect needs to be further research.MethodsPart I: This part of the study was a retrospective study.79 hospitalized patients with spinal cord injury and NP who were admitted to the Department of Rehabilitation Medicine of the First Affiliated Hospital of Air Force Medical University from January 2018 to December 2019 were selected as the research objects,and the general data of the patients were statistically analyzed.The pain symptoms of the patients were quantified using the Numerical Rating Scale(NRS)and the Short-form Mc Gill Pain Questionnaire-2(SFMPQ2).The two dimensions of pain/emotion in the SF-MPQ2 scale were further selected to analyze the correlation between neuropathic pain symptoms and emotional state of the subjects.It provides a new way of prevention and treatment for patients with neuropathic pain complicated with anxiety / depression.Part II: This study was a prospective,single-center,randomized controlled trial,in which 39 patients with spinal cord injury and NP with anxiety / depression treated and diagnosed at the Department of Rehabilitation Medicine,First Affiliated Hospital of the Air Force Medical University from June 2019 to October 2021 were selected as subjects and randomly divided into the rTMS group and the control group(sham stimulation group),with the addition of high frequency rTMS stimulation to the conventional treatment of patients.High frequency(10 Hz)rTMS was added to stimulate the M1 area of patients for analgesia treatment,and scale-based pain and emotional state assessment was performed before stimulation treatment,on the 3rd day after treatment,and at the 1st,2nd,3rd and 4th week respectively.The scales used in this study include the Numerical rating Scale(NRS),Shortform Mc Gill Pain Questionnaire 2(SF-MPQ2),Hamilton Anxiety Scale(HAMA)and Hamilton Depression Scale(HAMD).The purpose of this study is to explore the effect of rTMS on patients with NP accompanied by depression / anxiety,so as to provide an experimental basis for the clinical application of rTMS treatment and the optimization of clinical treatment protocols.ResultsPart I:The pain symptoms of patients with spinal cord injury and NP were correlated with emotional symptoms,especially in moderate and severe patients.Therefore,for the diagnosis and treatment of clinical pain patients,especially those with severe pain symptoms,attention should be paid to the changes in their emotional states.Part II:1.Baseline data analysis showed that there were no statistically significant differences in demographic data,pain and emotional state between the two groups.2.After treatment,the NRS scores of both groups were lower than before treatment and the difference was statistically significant(control group: P = 0.0005,rTMS group: P <0.0001),indicating that both the basic treatment and the combination of high frequency rTMS stimulation on top of it could improve the pain symptoms of the patients.The NRS scores of patients in the rTMS group were lower than those of patients in the control group from 1 w after treatment and continued until the end of treatment,and showed a statistical difference(P < 0.05),suggesting that the combination of rTMS treatment on top of the basic treatment could better relieve the patients’ pain symptoms.3.There was no statistical difference in the SF-MPQ2 scores between the two groups before treatment,while the rTMS group scored significantly lower than the control group after treatment(P = 0.0005),indicating that patients in the rTMS group had better analgesia.Further analysis of the SF-MPQ2 data on the sensory(S)and affective(A)dimensions of pain showed that the rTMS group showed a statistically significant reduction in both dimensions before and after treatment(P < 0.05),suggesting that patients in the rTMS group experienced pain relief along with an improvement in their emotional state.The difference was statistically significant.4.The results showed that there was no statistically significant difference in the pretreatment scores between the two groups and that the HAMA scores of patients in both groups decreased after treatment(control group: P = 0.0069,rTMS group: P = 0.0001),suggesting an improvement in anxiety symptoms in both groups.In addition,patients in the control group did not have a significant reduction in HAMD scores after treatment compared to before treatment(P = 0.9791),whereas patients in the rTMS group had a significant reduction in HAMD scores after a 4 w treatment period(P = 0.0003)and a significant difference compared to the control group(P = 0.0001),suggesting that the rTMS intervention also had a beneficial effect on the patients’ depressive symptoms.5.Results of the efficacy of the two groups of observation indicators showed that the overall pain relief effect was better in the rTMS treatment group than in the control group and there was a statistical difference(P = 0.0396).There was no significant difference between the two groups in terms of anxiety relief(P > 0.9999).In addition,rTMS played a better role in alleviating patients’ depression than the control group(P = 0.0351)6.There was no statistical difference in the incidence of adverse reactions between the two groups(P = 0.6050).7.Patients in the rTMS group showed a positive correlation between reduced NRS values and improved mood state before and after treatment,that is,the more significant relief of pain symptoms,the better improvement in mood state of the patients in the rTMS group.The correlation of HAMD was stronger than HAMA(HAMA,r = 0.4714;HAMD,r = 0.7432),indicating that patients’ depressed emotional state is more closely associated with pain.Conclusions1.The pain symptoms of patients with spinal cord injury and NP are correlated with emotional symptoms.2.Stimulation of primary motor cortex(M1)with rTMS can effectively relieve the pain symptoms of patients with spinal cord injury and NP.3.For patients with spinal cord injury and NP accompanied by anxiety / depression,rTMS of M1 not only alleviates their pain symptoms,but also improves their emotional state to some extent. |
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