Repetitive transcranial magnetic stimulation in central post-stroke pain: a meta-analysis and systematic review of randomized controlled trials

 Right now what is your doctor EXACTLY doing to cure your central post-stroke pain? ANYTHING AT ALL? The keyword there is cure!

Repetitive transcranial magnetic stimulation in central post-stroke pain: a meta-analysis and systematic review of randomized controlled trials

Ying Liu^1†Runqing Miao^2†Hui Zou¹Qian Hu³Shao Yin⁴Fengya Zhu^5*

• ¹Department of Acupuncture and Rehabilitation, Traditional Chinese Medicine Hospital of Renshou County, Meishan, China
• ²Department of Preventive Treatment, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
• ³Department of Hematology, Meishan City People's Hospital, Meishan, China
• ⁴School of Clinical Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
• ⁵Traditional Chinese Medicine Department, Zigong First People's Hospital, Zigong, China

Background: The rehabilitation of central post-stroke pain (CPSP) is a complex clinical challenge, and repetitive transcranial magnetic stimulation (rTMS) has been widely applied in the research of neurofunctional recovery following stroke. However, there is currently no reliable evidence-based medicine supporting the efficacy of rTMS in central post-stroke pain. This review aims to evaluate the effects of rTMS on central post-stroke pain.

Methods: Following the PRISMA guidelines, we conducted searches on PubMed, Cochrane Library, Embase, Web of Science, CNKI, and Wan Fang Data Knowledge Service Platform. We searched for randomized controlled trials (RCTs) investigating the use of rTMS in treating central post-stroke pain, and conducted screening based on inclusion and exclusion criteria. Characteristics of the included RCTs were extracted. The heterogeneity of the trials was assessed using the I2 statistic. Meta-analysis was performed using Stata 17 software. Bias risk and methodological quality were evaluated using the Cochrane RoB 2 tool and the Pedro scale.

Results: A total of six randomized controlled trials involving 288 patients met our inclusion criteria. In our analysis, rTMS was more effective in treating patients with CPSP compared to the placebo group (SMD=-1.15, 95% CI: −1.69, −0.61, P < 0.001). Furthermore, results from subgroup analysis indicated no statistically significant difference in the improvement of pain for durations exceeding 6 months when comparing rTMS to conventional treatment (SMD=-0.80, 95% CI: −1.63, 0.03, P = 0.059).

Conclusion: TMS can alleviate pain in CPSP patients and improve their motor function, but its effects on depression, anxiety, and MEP-latency are not significant.

Systematic review registration: https://www.crd.york.ac.uk/prospero/, CRD42024497530.

1 Introduction

Stroke is one of the diseases with high global incidence, disability rates, and mortality rates (Zhang et al., 2020). Despite comprehensive rehabilitation treatments, most stroke patients experience varying degrees of recovery in motor and sensory functions. However, some patients still suffer from persistent pain on the affected side of the body after a stroke. This pain, occurring after a stroke and associated with the damaged area while excluding other causes, is referred to as CPSP (Radiansyah and Hadi, 2023). Although the onset time of CPSP may be related to the severity and progression of the condition, more than half of the cases manifest within the initial months following a stroke (Klit et al., 2009; Osama et al., 2018; Vukojevic et al., 2018). The incidence rate ranges from 1% to 35% (Dub and Mercier, 2011; Hansen et al., 2012). Many patients may experience various forms of pain concurrently with sensory abnormalities, such as searing, pressing, pulsating, or freezing sensations, numbness, and decreased sensation (Kumar, 2009; Klit et al., 2011). CPSP significantly impacts the sleep, emotions, and overall quality of life for stroke patients, hindering the implementation of effective rehabilitation treatments. The pathogenesis of CPSP is not fully understood, and its treatment remains challenging. Currently, the primary approach involves medications for neuropathic pain. Existing evidence suggests that even with the use of high-dose medications, pain relief is often difficult to achieve for the majority of CPSP patients (Scuteri et al., 2020; Singh et al., 2020; Choi et al., 2021; Mohanan et al., 2023). Additionally, these medications are associated with various side effects (Banerjee et al., 2013; Kim, 2014) and may lead to drug dependence (Kumar and Soni, 2009).

rTMS provides a non-invasive, painless method for studying and treating neuropathic pain states (Lefaucheur, 2016). By applying a magnetic field to the cerebral cortex, it induces electric currents, influencing neural electrical activity. This, in turn, regulates cerebral blood flow and neurotransmitter expression to alleviate pain. Currently, it is recommended by relevant treatment guidelines for various pain conditions (Winstein et al., 2016; Lefaucheur et al., 2020). In addition to its impact on the target area, the synaptic effects produced by rTMS contribute to its distal therapeutic effects (Hallett et al., 2017), but there is no uniform standard for therapeutic parameters in the treatment of CPSP using rTMS. Diverse treatment parameters, including stimulation frequency, target site, and duration of therapy, yield varying analgesic effects. Traditionally, low-frequency (LF) rTMS, defined as stimulation below 1 Hz, has been shown to reduce cortical excitability, whereas high-frequency (HF) rTMS, with frequencies above 1 Hz, exerts the opposite effect (Cruccu et al., 2007; Bai et al., 2022). Previous studies investigating the analgesic effects of rTMS on PSP have discovered that HF-rTMS (5–20 Hz) can effectively alleviate PSP-related pain (Pazzaglia et al., 2018). Compared to single and short-term interventions, multiple sessions and longer durations of intervention have been found to produce superior analgesic outcomes (Hosomi et al., 2013; Ramger et al., 2019).

The meta-analytic review conducted by McDonnell and Stinear (2017) indicated that, in stroke patients, the M1 of the non-affected hemisphere did not exhibit heightened activation during both active muscle contraction and rest, as evidenced by the absence of significant disparities in the parameters of aMT (active motor threshold), rMT (resting motor threshold), and MEPs (motor evoked potentials) when compared to those of healthy controls. This finding suggests that directly enhancing the excitability of the affected M1 may confer greater therapeutic benefits than indirectly suppressing the excitability of the unaffected M1 in facilitating motor recovery following stroke. Numerous previous studies have also discovered that LF-rTMS and continuous theta-burst stimulation (cTBS) not only suppress the amplitude of MEPs in the stimulated M1, but also enhance the MEP amplitude in the non-stimulated M1 (Di Lazzaro et al., 2011; Boddington and Reynolds, 2017). The increased cortical excitability within the unstimulated M1 may be associated with an elevated intrinsic excitability of excitatory interneurons responsible for glutamatergic non-NMDA receptor activity (Heide et al., 2006).

In studies utilizing a rat model of thalamic pain, it has been observed that neuronal structural damage occurs in the lesion area following cerebral hemorrhage or infarction, leading to increased neural excitability. Such alterations may precipitate a range of clinical manifestations, including limb pain and motor functional impairments (An et al., 2019). Other animal experiments have also demonstrated that CPSP reduces the functional connectivity between the VPL and S1/S2 (primary and secondary somatosensory cortices), responsible for perceiving pain location, intensity, and duration, while enhancing connectivity between the thalamus (involved in attention, cognitive abilities) and amygdala (associated with emotional aspects of pain assessment) (Sweet et al., 1971), rTMS can alleviate this abnormal connectivity (Gruart and Delgado-García, 1994).

In recent years, some reviews have summarized the impact of rTMS on pain (Pan et al., 2022; Cheng et al., 2023; Mohanan et al., 2023; Radiansyah and Hadi, 2023), suggesting that rTMS may have a beneficial effect in alleviating pain. However, some reviews primarily focus on exploring the mechanisms and concentrate on conditions such as fibromyalgia, postherpetic neuralgia, malignant neuropathic pain. There is limited analysis in these reviews regarding the clinical evidence of rTMS in treating CPSP. The effectiveness of rTMS for CPSP has not yet received sufficient support from evidence-based medicine. Therefore, to establish the relationship between rTMS and the relief of CPSP, we conducted a systematic review and meta-analysis of published randomized controlled trials. This meta-analysis aims to provide the latest evidence for the use of transcranial magnetic stimulation in the treatment of CPSP.

More at link.

Treatment of post-stroke aphasia: A narrative review for stroke neurologists

 Immediately notice the useless word; 'management', NOT RECOVERY OR CURE OR RESULTS. Do you really think survivors want their disability managed? Your tyranny of low expectations is that fucking low?

Treatment of post-stroke aphasia: A narrative review for stroke neurologists

Emilia Vitti, Argye E Hillis

First Published June 6, 2021 Review Article Find in PubMed 

https://doi.org/10.1177/17474930211017807

Article information

Abstract

This review is intended to help physicians guide patients to optimal management of post-stroke aphasia. We review literature on post-stroke aphasia treatment, focusing on: (1) when and for whom language therapy is most effective, (2) the variety of approaches that can be effective for different individuals, and (3) the extent to which behavioral therapy might be augmented by non-invasive brain stimulation and/or medications.

Keywords

Ischaemic stroke, neurology, rehabilitation, stroke, therapy, treatment

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Unravelling perceived fatigue and activity pacing in maintaining a physically active lifestyle after stroke rehabilitation: a longitudinal cohort study

YOU FUCKING BLITHERING IDIOTS. 'Perceived'. Talk to survivors sometime, there is nothing perceived about post stroke fatigue. THIS is why we need survivors in charge, we wouldn't allow stupid assumptions like this to be researched.

 Unravelling perceived fatigue and activity pacing in maintaining a physically active lifestyle after stroke rehabilitation: a longitudinal cohort study

 

Abstract

To identify fatigue trajectories during/after stroke rehabilitation, to determine characteristics associated with trajectory membership before discharge and to investigate how these trajectories and activity pacing are associated with sustained physical activity after rehabilitation.People after stroke (n = 206) were followed from 3–6 weeks before discharge (T0) to 14 (T1), 33 (T2) and 52 (T3) weeks after discharge from rehabilitation in the ReSpAct study. Latent Class analysis was used to identify trajectories of perceived fatigue. Binomial multivariable logistic regression analyses were performed to determine characteristics associated with trajectory membership (T0). Multilevel regression analyses were used to investigate how perceived fatigue and activity pacing were associated with self-reported physical activity (T0–T3).

Three fatigue trajectories were identified: high (n = 163), low (n = 41) and recovery (n = 2). Compared with the high fatigue trajectory, people in the low fatigue trajectory were more likely to report higher levels of health-related quality of life (HR-QoL) (OR = 3.07, 95%CI = 1.51–6.26) and physical activity (OR = 1.93, 95%CI = 1.07–3.47). Sustained high levels of physical activity after rehabilitation were significantly associated with low perceived fatigue and high perceived risk of overactivity.

Three fatigue trajectories after stroke rehabilitation were identified. High levels of HR-QoL and physical activity before discharge identified people in the low fatigue trajectory. A physically active lifestyle after rehabilitation was associated with low perceived fatigue and perceived risk of overactivity.

• IMPLICATIONS FOR REHABILITATION

• Since almost 80% of people after stroke in this study perceived severe fatigue up to 1 year after stroke rehabilitation, activities focusing on the management of fatigue symptoms should be integrated in general stroke rehabilitation.

• In clinical practice, low levels of health-related quality of life and low levels of self-reported physical activity before discharge from stroke rehabilitation should be considered by rehabilitation professionals (e.g., physicians, physiotherapists, and physical activity counsellors) since these characteristics can predict chronic perceived fatigue up to 1 year after stroke rehabilitation.

• A physical activity counselling programme delivered during and after stroke rehabilitation may be improved by incorporating tailored advice regarding the management of fatigue.(NOT CURE!)
  

Chemodenervation and Nerve Blocks in the Diagnosis and Management of Spasticity and Muscle Overactivity

I see nothing out there that in the 11 years since that any protocol exists for spasticity.  You can read the 6 pages on your own.  And what is even worse is this is management of spasticity NOT curing spasticity. The tyranny of low expectations in full display.  YOU get to be the recipient of such incompetence.

Chemodenervation and Nerve Blocks in the Diagnosis and Management of Spasticity and Muscle Overactivity

 2009, PM&R

Elie P. Elovic, MD, 

Alberto Esquenazi, MD, 

Katharine E. Alter, MD, 

John L. Lin, MD,

Abraham Alfaro, PhD, DO, 

Darryl L. Kaelin, MD
This article will discuss many of the key concepts regarding chemodenervation and neurolysis in the management of spasticity. Topics that will be discussed include techniques for localization, strengths and limitations of various agents (botulinum toxin, phenol, and alcohol), the value of combination therapies, and the role of nerve blocks (diagnostic and therapeutic). With advancing technology have come newer methods to improve accuracy of localization for the performance of chemodenervation and neurolysis such as electro-myographic guidance, electrical stimulation, and ultrasound guidance. During the last 2 decades, the addition of botulinum toxin chemodenervation as an adjunct to traditional neurolysis, medication, and therapy modalities has expanded the field of treatment of intramuscular hyperactivity in upper motor neuron syndrome. The technique of diagnostic blocks as predictors of response and the therapeutic value of nerve blocks will be discussed.
INTRODUCTION
Numerous factors must be taken into account when deciding on the treatment approach for an individual with spasticity. Etiology, chronicity, prognosis, distribution, location, severity, and medical comorbidities are all important factors. In addition, clinicians must take into account the patient’s and caregiver’s goals to effectively plan a course of action that is realistic, meaningful, and maximizes the potential for success. The classic model of delivering spasticity treatment using a linear hierarchical approach has been supplantd by a more modern approach of choosing singular  or multiple interventions that are based on the factors previously listed. Spasticity and the upper motor neuron syndrome (UMNS) differ greatly in their presentations and response. A critical factor in the treatment algorithm is the distribution of the spasticity. It can be focal, affecting a single joint or functional group of joints such as the hand; more widespread, affecting most of a limb; or multisegmental as in spastic hemipares is when it affects many areas simultaneously. Because chemodenervation affects a limited area, it is important to have realistic outcome expectations. Examples of appropriate goals include improved range of motion, reduction of co-contraction, and improved local function. (Fuck you and your tyranny of low expectations! When you have a stroke will you be ok with this crapola?)As the severity of spasticity increases, there is greater emphasis on aggressive management so as to lessen suffering and prevent secondary complications such as contracture and skin breakdown. Diagnostic nerve blocks are minimal risk procedures that may be helpful in determining the presence of contractures and the risk of excessive weakness, as well as estimating potential functional gains after chemodenervation. Often these individuals have other medical conditions that affect decision making, such as altered cognition,diabetes, venous thrombosis, and anticoagulation. When dealing with spasticity in complex neurologic patients, physicians should be holistic in their approach.(Meaningless)

911 STROKE CARE: Lancet study confirms need for speed in treatment; a patient speaks out

I'll focus on one statement in this article, which is totally false! 

911 STROKE CARE: Lancet study confirms need for speed in treatment; a patient speaks out

 When you do act fast, stroke is completely curable.
This assumes almost complete perfection and is obviously not attainable very often. This focus needs to change to pointing out that under normal circumstances tPA is a failure. 
It's efficacy is only 12% and does nothing to stop the neuronal cascade of death.
Assuming you can reach perfection consistently in any endeavor is guaranteed to be a failure. Why do our doctors insist upon staying with the failure option?