L'effet antalgique de stimulations corticales non invasives par stimulation magnétique transcrânienne répétée (rTMS). : Confirmation de l'intérêt antalgique de la stimulation du cortex moteur primaire et exploration du potentiel d'une nouvelle cible corticale : le cortex somatosensoriel secondaire

Abstract : Central neuropathic pain is a common sequelae after central nervous system injury. Its negative consequences on the quality of life and the moderate efficacy (40% of responders) of first-line treatments make the search for alternative therapies a major clinical challenge. For several years, the technique of repeated transcranial magnetic stimulation (rTMS) is presented as an interesting tool to relieve this sort of pain even though its clinical efficacy has not been clearly demonstrated. The aim of this thesis was to investigate the effectiveness of rTMS to relieve central neuropathic pain.We first demonstrated, in an observational study, that a minimum of 4-5 sessions over two months of rTMS at 20HZ on the primary motor cortex (M1) produces pain relief that can be maintained even after a year of stimulation. In order to rule out a possible placebo effect, we objectified the analgesic efficacy by replicating this protocol in a randomized, controlled, cross-over clinical study. The results obtained confirm those of the observational study since the analgesic effect of the active rTMS was significantly greater than the placebo stimulation for the main criterion (% of pain relief, +33%) or pain intensity (VAS, -19%), with 47% of responders. For patients who did not respond to M1 stimulation, we also tested the efficacy of an alternative target in a randomized study: the secondary somatosensory cortex (S2). None of the patients were relieved by this stimulation, but the small size of this study does not allow us to definitively conclude that there is no analgesic effect. Finally, given the increasing use of new deeper cortical targets in rTMS for pain treatment, we have from the recording of the magnetic field produced by the rTMS in different media (air and ex-vivo model), proposed a magnetic-field distribution model according to the depth of the target and the type of stimulation coils used.To conclude, this work objectify the analgesic effect of 4 rTMS sessions at 20 Hz of M1 to relieve central neuropathic pain, validating its use when first-line treatments have failed. The results obtained by S2 stimulation as well as magnetic field modeling should allow future studies to explore new cortical targets for patients who are still failing treatment
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Charles Quesada. L'effet antalgique de stimulations corticales non invasives par stimulation magnétique transcrânienne répétée (rTMS). : Confirmation de l'intérêt antalgique de la stimulation du cortex moteur primaire et exploration du potentiel d'une nouvelle cible corticale : le cortex somatosensoriel secondaire. Médecine humaine et pathologie. Université de Lyon, 2018. Français. ⟨NNT : 2018LYSES056⟩. ⟨tel-02181722⟩

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