Is Repetitive Transcranial Magnetic Stimulation Effective in Reducing Endometriosis-associated Pain

NCT06333353 | Recruiting

• 1 other identifier: H-06-23-9278
• Study Type: interventional
• Target: 152
• Locations: 1 country
• Sites: 1

Brief Summary

The goal of this research is to improve pain outcomes for the over 500K Canadian women, girls and gender-diverse individuals who are newly diagnosed with endometriosis each year. Chronic pain that persists after interventions for endometriosis is a huge problem. There is some evidence that endometriosis-associated pain (EAP) is, at least to some extent, associated with changes in pain physiology, particularly central sensitization of pain. There is currently no effective evidence-informed intervention that addresses EAP. Yet a recent feasibility trial on a repetitive transcranial magnetic stimulation (rTMS) intervention demonstrated promising results compared to a sham intervention for reducing pain in a sample with EAP. The objectives of this trial are:

1. 1.to evaluate the effectiveness of an rTMS intervention for pain reduction among those with recalcitrant post-operative EAP,
2. 2.to inform on the utility of a long (10 session) vs short (5 session) protocol for pain reduction among those with recalcitrant post-operative EAP
3. 3.to determine if any improvements in pain observed 30 days after an rTMS intervention are retained 6 months later
4. 4.to identify physical and psychosocial mediators that impact the successful reduction of pain among patients with EAP treated using rTMS.
5. 5.to describe patients' perceptions of and satisfaction with rTMS as an intervention for EAP.

Conditions

Endometriosis; Pain

Keywords

Repetitive Transcranial Magnetic Stimulation; intervention; endometriosis; pain

Outcome Measures

Primary Outcomes (5)

• Numeric rating scale (NRS) used to record daily pain over 30 days

  Pain intensity, using a numeric rating scale (NRS), will be recorded daily for 30 days prior to trial entry to provide a suitable baseline, It will measure the average and worst overall pain intensity, menstrual and sexual activity related pain (if applicable). The questions will be applied as described below: Please rate any pain you experienced today (over the past 24 hours) that you attribute to your endometriosis using a scale from 0 (no pain) to 10 (worst pain imaginable). Is today your first day of menstrual cycle? Did you attempt any sexual activity or tampon insertion in the last 24hs? Please rate the pain associated with this activity on a scale from 0 (no pain) to 10 (worst pain imaginable),for sexual activity and/or tampon insertion (if applicable).

  Baseline -30 days after enrolment and before allocation

• Numeric rating scale(NRS) used to record daily pain over 30 days

  Pain intensity, using a numeric rating scale (NRS), will be recorded daily after the intervention period for 30 days. It will measure the average and worst overall pain intensity, menstrual and sexual activity related pain (if applicable). The questions will be applied as described below: Please rate any pain you experienced today (over the past 24 hours) that you attribute to your endometriosis using a scale from 0 (no pain) to 10 (worst pain imaginable). Is today your first day of menstrual cycle? Did you attempt any sexual activity or tampon insertion in the last 24hs? Please rate the pain associated with this activity on a scale from 0 (no pain) to 10 (worst pain imaginable), for sexual activity and/or tampon insertion (if applicable).

  30 days following intervention

• Patient Global Impression of Change (PGIC) in pain

  PGIC is a single question through which participants provide a ordinal rating based on their overall perception of change in their pain attributed to the intervention: Very Much Better, Much Better, Somewhat better, About the same, somewhat worse, much worse, very much worse

  After the Intervention on the final intervention day

• Patient Global Impression of Change (PGIC) in pain

  PGIC is a single question through which participants provide a ordinal rating based on their overall perception of change in their pain attributed to the intervention: Very Much Better, Much Better, Somewhat better, About the same, somewhat worse, much worse, very much worse

  30 days after completing the intervention

• Patient Global Impression of Change (PGIC) in pain

  PGIC is a single question through which participants provide a ordinal rating based on their overall perception of change in their pain attributed to the intervention: Very Much Better, Much Better, Somewhat better, About the same, somewhat worse, much worse, very much worse

  6 months after the intervention

Secondary Outcomes (29)

• The Beck Depression Inventory (BDI-II)

  Baseline

• The Beck Depression Inventory (BDI-II)

  30 days following the intervention

• The Beck Depression Inventory (BDI-II)

  6 months following the intervention

• The State-Trait Anxiety Inventory (STAI)

  Baseline

• The Pain Catastrophizing Scale

  Baseline

Study Arms (4)

Real RepetitiveTranscranial Magnetic Stimulation (rTMS) 5 sessions

EXPERIMENTAL

The real rTMS intervention will be delivered to the primary motor cortex (M1) on the left side, over the hand representation, using high frequency (HF) rTMS applied by way of a Magstim Rapid² system. The coil position and orientation will be standardized between treatment visits through using a Brainsight neuronavigation system (Rogue Research, Canada). Each of 5 rTMS sessions will consist of a total of 1500 pulses: 15 sets of pulses delivered at 10Hz for 10s at 80% resting motor threshold (RMT), separated by 50s intervals. The real rTMS intervention will be delivered daily over 5 consecutive days.

Device: Real RepetitiveTranscranial Magnetic Stimulation 5 sessions

Sham RepetitiveTranscranial Magnetic Stimulation (rTMS) 5 sessions

SHAM COMPARATOR

The sham rTMS intervention will be delivered to the primary motor cortex (M1) on the left side, over the hand representation, using high frequency (HF) rTMS applied by way of a Magstim Rapid² system interfaced with a placebo coil, whose position and orientation will standardized between treatment visits using a Brainsight neuronavigation system (Rogue Research, Canada) The sham stimulation target will be individually defined at baseline as the site eliciting the highest averaged motor evoked potential (MEP) peak-to-peak amplitude in the first dorsal interosseous (FDI) muscle. Each of 5 sham rTMS sessions will consist of a total of 1500 sham pulses: 15 sets of sham pulses (0% output) delivered at 10Hz for 10s, separated by 50s intervals. The sham intervention will be delivered daily over 5 consecutive days.

Device: Sham RepetitiveTranscranial Magnetic Stimulation 5 sessions

Real RepetitiveTranscranial Magnetic Stimulation (rTMS) 10 sessions

EXPERIMENTAL

The real 10-session rTMS intervention will be the same as that delivered for the real 5-session rTMS intervention, but delivered as 5 daily sessions, a two day break, and 5 more daily sessions.

Device: Real RepetitiveTranscranial Magnetic Stimulation 10 sessions

Sham RepetitiveTranscranial Magnetic Stimulation (rTMS) 10 sessions

SHAM COMPARATOR

The sham 10 session rTMS intervention will be delivered identically to the sham 5 session intervention, but delivered as 5 daily sessions, a two day break, and 5 more daily sessions.

Device: Sham RepetitiveTranscranial Magnetic Stimulation 10 sessions

Interventions

Real RepetitiveTranscranial Magnetic Stimulation 5 sessions DEVICE

5 consecutive treatment sessions will be provided using a protocol based on the updated guideline (Lefaucheur, 2014) and on Pinot-Monange et al. (2019). Each treatment session will last approximately 30 minutes. Acceptability, adverse events and side effects will be recorded after each session, while the researchers will also record the total treatment time, difficulties encountered during implementation, and any modifications to the intervention.

Real RepetitiveTranscranial Magnetic Stimulation (rTMS) 5 sessions

Sham RepetitiveTranscranial Magnetic Stimulation 5 sessions DEVICE

5 consecutive sham treatment sessions will be provided using a protocol based on the updated guideline (Lefaucheur, 2014) and on Pinot-Monange et al. (2019). Each treatment session will last approximately 30 minutes. Acceptability, adverse events and side effects will be recorded after each session, while the researchers will also record the total treatment time, difficulties encountered during implementation, and any modifications to the intervention

Sham RepetitiveTranscranial Magnetic Stimulation (rTMS) 5 sessions

Real RepetitiveTranscranial Magnetic Stimulation 10 sessions DEVICE

10 consective treatment sessions will be provided using a protocol based on the updated guideline (Lefaucheur, 2014) and on Pinot-Monange et al. (2019). Each treatment session will last approximatly 30 minutes. Acceptability, adverse events and side effects will be recorded after each session, while the researchers will also record the total treatment time, difficulties encountered during implementation, and any modifications to the intervention.

Real RepetitiveTranscranial Magnetic Stimulation (rTMS) 10 sessions

Sham RepetitiveTranscranial Magnetic Stimulation 10 sessions DEVICE

10 consective sham treatment sessions will be provided using a protocol based on the updated guideline (Lefaucheur, 2014) and on Pinot-Monange et al. (2019). Each treatment session will last approximatly 30 minutes. Acceptability, adverse events and side effects will be recorded after each session, while the researchers will also record the total treatment time, difficulties encountered during implementation, and any modifications to the intervention.

Sham RepetitiveTranscranial Magnetic Stimulation (rTMS) 10 sessions

Eligibility Criteria

• Age: 18 Years - 60 Years
• Sex: female
• Healthy Volunteers: No
• Age Groups: Adult (18-64)

You may qualify if:

• self-reported endometriosis-associated pain (\> 3 in the numeric rating scale, 0-10) that has persisted following medical or surgical intervention,

You may not qualify if:

• Contra-indications to rTMS (e.g., metal/implants around the head/neck, pacemaker), history of epilepsy (history of seizures) in the family
• Pain symptoms initiated by other known causes (e.g., infections, thyroid disease, autoimmune diseases, gastrointestinal disease)
• Experience a more severe, extra-pelvic pain than that associated with endometriosis
• Pregnancy

Sponsors & Collaborators

• University of Ottawa: lead

Study Sites (1)

McLean Function Measurement Lab

Ottawa, Ontario, K1S1S2, Canada

RECRUITING

Related Publications (25)

• Bajaj P, Bajaj P, Madsen H, Arendt-Nielsen L. Endometriosis is associated with central sensitization: a psychophysical controlled study. J Pain. 2003 Sep;4(7):372-80. doi: 10.1016/s1526-5900(03)00720-x.

  PMID: 14622679 BACKGROUND

• Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007 Jul;133(4):581-624. doi: 10.1037/0033-2909.133.4.581.

  PMID: 17592957 BACKGROUND

• Kennedy DL, Kemp HI, Ridout D, Yarnitsky D, Rice ASC. Reliability of conditioned pain modulation: a systematic review. Pain. 2016 Nov;157(11):2410-2419. doi: 10.1097/j.pain.0000000000000689.

  PMID: 27559835 BACKGROUND

• O'Connell NE, Marston L, Spencer S, DeSouza LH, Wand BM. Non-invasive brain stimulation techniques for chronic pain. Cochrane Database Syst Rev. 2018 Mar 16;3(3):CD008208. doi: 10.1002/14651858.CD008208.pub4.

  PMID: 29547226 BACKGROUND

• Singh S, Soliman AM, Rahal Y, Robert C, Defoy I, Nisbet P, Leyland N. Prevalence, Symptomatic Burden, and Diagnosis of Endometriosis in Canada: Cross-Sectional Survey of 30 000 Women. J Obstet Gynaecol Can. 2020 Jul;42(7):829-838. doi: 10.1016/j.jogc.2019.10.038. Epub 2020 Jan 27.

  PMID: 32001176 BACKGROUND

• McNamara HC, Frawley HC, Donoghue JF, Readman E, Healey M, Ellett L, Reddington C, Hicks LJ, Harlow K, Rogers PAW, Cheng C. Peripheral, Central, and Cross Sensitization in Endometriosis-Associated Pain and Comorbid Pain Syndromes. Front Reprod Health. 2021 Sep 1;3:729642. doi: 10.3389/frph.2021.729642. eCollection 2021.

  PMID: 36303969 BACKGROUND

• Carey ET, Martin CE, Siedhoff MT, Bair ED, As-Sanie S. Biopsychosocial correlates of persistent postsurgical pain in women with endometriosis. Int J Gynaecol Obstet. 2014 Feb;124(2):169-73. doi: 10.1016/j.ijgo.2013.07.033. Epub 2013 Oct 31.

  PMID: 24290537 BACKGROUND

• Coccia ME, Rizzello F, Palagiano A, Scarselli G. Long-term follow-up after laparoscopic treatment for endometriosis: multivariate analysis of predictive factors for recurrence of endometriotic lesions and pain. Eur J Obstet Gynecol Reprod Biol. 2011 Jul;157(1):78-83. doi: 10.1016/j.ejogrb.2011.02.008. Epub 2011 Apr 9.

  PMID: 21481523 BACKGROUND

• Pagano RL, Fonoff ET, Dale CS, Ballester G, Teixeira MJ, Britto LRG. Motor cortex stimulation inhibits thalamic sensory neurons and enhances activity of PAG neurons: possible pathways for antinociception. Pain. 2012 Dec;153(12):2359-2369. doi: 10.1016/j.pain.2012.08.002. Epub 2012 Sep 25.

  PMID: 23017297 BACKGROUND

• Leung A, Donohue M, Xu R, Lee R, Lefaucheur JP, Khedr EM, Saitoh Y, Andre-Obadia N, Rollnik J, Wallace M, Chen R. rTMS for suppressing neuropathic pain: a meta-analysis. J Pain. 2009 Dec;10(12):1205-16. doi: 10.1016/j.jpain.2009.03.010. Epub 2009 May 23.

  PMID: 19464959 BACKGROUND

• Pinot-Monange A, Moisset X, Chauvet P, Gremeau AS, Comptour A, Canis M, Pereira B, Bourdel N. Repetitive Transcranial Magnetic Stimulation Therapy (rTMS) for Endometriosis Patients with Refractory Pelvic Chronic Pain: A Pilot Study. J Clin Med. 2019 Apr 13;8(4):508. doi: 10.3390/jcm8040508.

  PMID: 31013910 BACKGROUND

• Turk DC, Dworkin RH, Burke LB, Gershon R, Rothman M, Scott J, Allen RR, Atkinson HJ, Chandler J, Cleeland C, Cowan P, Dimitrova R, Dionne R, Farrar JT, Haythornthwaite JA, Hertz S, Jadad AR, Jensen MP, Kellstein D, Kerns RD, Manning DC, Martin S, Max MB, McDermott MP, McGrath P, Moulin DE, Nurmikko T, Quessy S, Raja S, Rappaport BA, Rauschkolb C, Robinson JP, Royal MA, Simon L, Stauffer JW, Stucki G, Tollett J, von Stein T, Wallace MS, Wernicke J, White RE, Williams AC, Witter J, Wyrwich KW. Developing patient-reported outcome measures for pain clinical trials: IMMPACT recommendations. Pain. 2006 Dec 5;125(3):208-215. doi: 10.1016/j.pain.2006.09.028. Epub 2006 Oct 25. No abstract available.

  PMID: 17069973 BACKGROUND

• Neelakantan D, Omojole F, Clark TJ, Gupta JK, Khan KS. Quality of life instruments in studies of chronic pelvic pain: a systematic review. J Obstet Gynaecol. 2004 Nov;24(8):851-8. doi: 10.1080/01443610400019138.

  PMID: 16147635 BACKGROUND

• Jones G, Kennedy S, Barnard A, Wong J, Jenkinson C. Development of an endometriosis quality-of-life instrument: The Endometriosis Health Profile-30. Obstet Gynecol. 2001 Aug;98(2):258-64. doi: 10.1016/s0029-7844(01)01433-8.

  PMID: 11506842 BACKGROUND

• Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singap. 1994 Mar;23(2):129-38.

  PMID: 8080219 BACKGROUND

• Bourdel N, Alves J, Pickering G, Ramilo I, Roman H, Canis M. Systematic review of endometriosis pain assessment: how to choose a scale? Hum Reprod Update. 2015 Jan-Feb;21(1):136-52. doi: 10.1093/humupd/dmu046. Epub 2014 Sep 1.

  PMID: 25180023 BACKGROUND

• Mayer TG, Neblett R, Cohen H, Howard KJ, Choi YH, Williams MJ, Perez Y, Gatchel RJ. The development and psychometric validation of the central sensitization inventory. Pain Pract. 2012 Apr;12(4):276-85. doi: 10.1111/j.1533-2500.2011.00493.x. Epub 2011 Sep 27.

  PMID: 21951710 BACKGROUND

• Neblett R, Cohen H, Choi Y, Hartzell MM, Williams M, Mayer TG, Gatchel RJ. The Central Sensitization Inventory (CSI): establishing clinically significant values for identifying central sensitivity syndromes in an outpatient chronic pain sample. J Pain. 2013 May;14(5):438-45. doi: 10.1016/j.jpain.2012.11.012. Epub 2013 Mar 13.

  PMID: 23490634 BACKGROUND

• Orr NL, Wahl KJ, Lisonek M, Joannou A, Noga H, Albert A, Bedaiwy MA, Williams C, Allaire C, Yong PJ. Central sensitization inventory in endometriosis. Pain. 2022 Feb 1;163(2):e234-e245. doi: 10.1097/j.pain.0000000000002351.

  PMID: 34030173 BACKGROUND

• Sepulcri Rde P, do Amaral VF. Depressive symptoms, anxiety, and quality of life in women with pelvic endometriosis. Eur J Obstet Gynecol Reprod Biol. 2009 Jan;142(1):53-6. doi: 10.1016/j.ejogrb.2008.09.003. Epub 2008 Nov 17.

  PMID: 19010584 BACKGROUND

• Morin M, Morin A, Gougeon V, Marchand S, Waddell G, Bureau YA, Girard I, Brassard A, Benoit-Piau J, Leonard G. Transcranial direct current stimulation for provoked vestibulodynia: What roles do psychosexual factors play in treatment response? J Clin Neurosci. 2021 Nov;93:54-60. doi: 10.1016/j.jocn.2021.08.003. Epub 2021 Sep 11.

  PMID: 34656261 BACKGROUND

• Stratton P, Khachikyan I, Sinaii N, Ortiz R, Shah J. Association of chronic pelvic pain and endometriosis with signs of sensitization and myofascial pain. Obstet Gynecol. 2015 Mar;125(3):719-728. doi: 10.1097/AOG.0000000000000663.

  PMID: 25730237 BACKGROUND

• McLean L, Charette M, Varette K, Brooks K, Harvey MA, Robert M, Baker K, Day A, Della Zazzera V, Sauerbrei E, Brison R. Pelvic floor muscle training as an adjunct to a midurethral sling: a single-blind randomised controlled trial. Int Urogynecol J. 2022 Apr;33(4):809-819. doi: 10.1007/s00192-020-04668-9. Epub 2021 Mar 3.

  PMID: 33660001 BACKGROUND

• Lefaucheur JP, Aleman A, Baeken C, Benninger DH, Brunelin J, Di Lazzaro V, Filipovic SR, Grefkes C, Hasan A, Hummel FC, Jaaskelainen SK, Langguth B, Leocani L, Londero A, Nardone R, Nguyen JP, Nyffeler T, Oliveira-Maia AJ, Oliviero A, Padberg F, Palm U, Paulus W, Poulet E, Quartarone A, Rachid F, Rektorova I, Rossi S, Sahlsten H, Schecklmann M, Szekely D, Ziemann U. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS): An update (2014-2018). Clin Neurophysiol. 2020 Feb;131(2):474-528. doi: 10.1016/j.clinph.2019.11.002. Epub 2020 Jan 1.

  PMID: 31901449 BACKGROUND

• Oldfield RC. The assessment and analysis of handedness: the Edinburgh inventory. Neuropsychologia. 1971 Mar;9(1):97-113. doi: 10.1016/0028-3932(71)90067-4. No abstract available.

  PMID: 5146491 BACKGROUND

MeSH Terms

Conditions

Endometriosis; Pain

Condition Hierarchy (Ancestors)

Genital Diseases, Female; Female Urogenital Diseases; Female Urogenital Diseases and Pregnancy Complications; Urogenital Diseases; Genital Diseases; Neurologic Manifestations; Signs and Symptoms; Pathological Conditions, Signs and Symptoms

Study Officials

• Linda McLean, PhD

  University of Ottawa

  PRINCIPAL INVESTIGATOR

Central Study Contacts

Anne-Marie MacDonald, MSc

CONTACT

613-562-5800; alake@uottawa.ca

Flavia Ignacio Antonio, PhD

CONTACT

8193181627; fignacio@uottawa.ca

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: QUADRUPLE
• Who Masked: PARTICIPANT, CARE PROVIDER, INVESTIGATOR, OUTCOMES ASSESSOR
• Masking Details: All participants, care providers, investigators and outcome assessors will remain blinded to real/sham intervention. The outcomes assessor and the investigator will remain blinded to intervention duration.
• Purpose: TREATMENT
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Professor in the School of Rehabilitation Sciences at University Of Ottawa

Model Details: Parallel Assignment

Study Record Dates

• First Submitted: March 20, 2024
• First Posted: March 27, 2024
• Study Start: April 12, 2024
• Primary Completion (Estimated): May 20, 2027
• Study Completion (Estimated): June 20, 2027
• Last Updated: April 15, 2024

Record last verified: 2024-04

Data Sharing

• IPD Sharing: Will share
• Shared Documents: STUDY PROTOCOL, SAP, ICF
• Time Frame: Data will be available for 10 years after the publication of the study results
• Access Criteria: Planned use of data for systematic review or meta-analysis.

Locations

CA (1)