rTMS (repetitive transcranial magnetic stimulation) for the management of pain from rheumatological causes

rTMS (repetitive transcranial magnetic stimulation) is a novel, non-invasive treatment method that works to reduce (chronic) pain through the modulation of pain processing mechanisms in the brain. The other symptoms of fibromyalgia; brain fog, sleep disturbance and exhaustion are also relieved by the technique.

Top Doctors spoke to Dr Stephanie Kaye-Barrett, one of London’s renowned consultant rheumatologists and the founder of rTMS London at The London Clinic, about the functionality, the effectiveness and the different uses of rTMS.

What is rTMS?

rTMS (repetitive transcranial magnetic stimulation) is a safe and non-invasive neuromodulation (brain stimulation) technique that involves the use of a magnetic coil to deliver a series of rapid magnetic pulses to a specific area of the brain.

rTMS has already been approved by NICE and the FDA for the treatment of depression and obsessive-compulsive disorder (OCD). In the context of chronic pain, rTMS has shown to be effective in reducing pain intensity and improving quality of life for patients who have fibromyalgia, neuropathic pain, and other severe pain syndromes that have not responded to medication or physiotherapy.

The mechanism of rTMS

The magnetic pulses delivered by the rTMS coil alter the activity of neurons in the brain, leading to changes in the way that pain signals are processed and perceived. The magnetic fields produced by rTMS penetrate the scalp and skull to reach the brain, where they induce small electric currents in the specific target areas of the brain that are involved in pain processing. These include the primary sensory cortex, the secondary somatosensory cortex, the dorsal anterior cingulate cortex, and the insula.

By applying repetitive magnetic pulses to these areas, rTMS can modulate the activity of neurons and alter the function of neural networks involved in pain perception and modulation. These normalise abnormal pain processing, reduce pain sensitivity, and enhance the brain’s natural inhibitory processes. In addition, the brain also increases its neuroplasticity, becoming more able to adapt to build healthy, non-chronic, amplified pain pathways.

Moreover, rTMS is able to modulate the release of neurotransmitters such as endogenous opioids, which can have analgesic effects.

rTMS case studies

I started to use rTMS years ago in collaboration with an rTMS psychiatric centre in London for patients who had chronic/central pain amplification and mild depression.

With rTMS, patients’ pain improved dramatically after 20 sessions of low frequency stimulation to the right dorsolateral pre-frontal cortex. For the first time in their lives, patients who had suffered widespread body pain for years had a means to switch off their daily pain using a non-drug, non-invasive, and safe tool.

I then set up the rTMS and PMS (peripheral magnetic stimulation) treatment centre (rTMS London) at 116 Harley Street, alongside and integrated with my general rheumatology clinic. I have treated and evaluated more than 22 patients who received 20 sessions of rTMS with remarkable breakthrough results. These included 4 lawyers who were signed off as ‘long-term sick’ who were able to return to full-time work after treatment with rTMS. Mothers and grandmothers were also able to go back to looking after their children, having been unable to do so due to severe pain and fibromyalgia.

Several studies have also assessed the use of rTMS for chronic pain, including neuropathic pain.

A study in the Journal of Pain in 2012 found that rTMS in neuropathic patients led to changes in brain activity in regions involved in pain processing, such as the primary somatosensory cortex and the anterior cingulate cortex.

Another study published in NeuroImage: Clinical in 2018, used fMRI to investigate changes in brain activity in patients with fibromyalgia who underwent rTMS treatment. The study found that rTMS led to changes in brain activity in regions involved in pain processing, such as the thalamus and the anterior cingulate cortex.

Notably, in 2020, Tanwar et al evaluated 90 patients who had severe fibromyalgia, randomising them into sham and real rTMS groups. There was a significant improvement in the real rTMS group, with pain relief lasting at least six months.

Besides the relief from pain, the other benefit of rTMS is relief from exhaustion, sleep disturbance and brain fog.

Peripheral magnetic stimulation (PMS)

PMS (peripheral magnetic stimulation) is another non-invasive neuromodulation technique, similar to rTMS, that delivers magnetic pulses to damaged peripheral nerves (the nerves outside the brain and spinal cord) and the muscles/soft tissue that they connect to. Damage to the peripheral nerves leads to peripheral neuropathy, a condition that causes numbness, muscle weakness and burning pain.

A study published in Pain in 2015 used fMRI to investigate changes in brain activity in patients with chronic pain who underwent PMS treatment. The study found that PMS led to changes in brain activity in regions involved in pain processing, such as the thalamus and the insula.

A second study published in the European Journal of Pain in 2019 used PET-CT scans to investigate changes in brain activity in patients with peripheral neuropathy who underwent PMS treatment. The study found that PMS led to changes in brain activity in regions involved in pain processing, such as the thalamus and the insula.

Overall, the exact mechanism by which PMS works to relieve pain in peripheral neuropathy is not fully understood. However, it is thought that the electrical impulses produced by the PMS device can interfere with the transmission of pain signals along the affected nerves, thereby reducing the sensation of pain. PMS may also modulate the activity of certain regions in the brain involved in pain processing, such as the thalamus and the primary somatosensory cortex. By modulating the activity of these regions, PMS can reduce the perception of pain.

Dr Stephanie Kaye-Barrett is a leading rheumatologist with over 20 years’ consultant-level experience.

If you are considering rTMS or PMS for the management of pain symptoms and you would like to consult your options with an expert, don’t hesitate to reach out to Dr Kaye-Barrett via her Top Doctors profile today.