Highlights
- •Active theta burst stimulation (TBS) reduces hamstring mechanical sensitivity compared to sham.
- •TBS did not influence corticomotor organisation.
- •Pain intensity and function did not change following TBS, contrasting reports in the upper limb.
Abstract
Theta burst stimulation (TBS) over the primary motor cortex (M1) is an emerging technique
that may have utility in the treatment of musculoskeletal pain. However, previous
work exploring the analgesic effects of noninvasive brain stimulation has been limited
largely to the arm or hand, despite 80% of acute musculoskeletal injuries occurring
in the lower limb. This is a pertinent point, given the functional and neurophysiological
differences between upper and lower limb musculature, as well as evidence suggesting
that reorganization of corticomotor pathways is region-specific. This study investigated
the effect of excitatory TBS on pain, function, and corticomotor organization during
experimentally induced lower limb pain. Twenty-eight healthy participants attended
2 experimental sessions. On Day 0, participants completed 10 sets of 10 maximal eccentric
contractions of the right hamstring muscles to induce delayed onset muscle soreness.
Four consecutive blocks of either active or sham TBS were delivered on Day 2. Measures
of mechanical sensitivity, pain (muscle soreness, pain intensity, pain area) function
(single-leg hop distance, maximum voluntary isometric contraction, lower extremity
functional scale), and corticomotor organization were recorded before and after TBS
on Day 2. Pain and function were also assessed daily from Days 2 to 10. Active TBS
reduced mechanical sensitivity compared to sham stimulation (P = .01). Corticomotor organization did not differ between groups, suggesting that
improvements in mechanical sensitivity were not mediated by changes in M1. Subjective
reports of pain intensity and function did not change following active TBS, contrasting
previous reports in studies of the upper limb.
Perspective: M1 TBS reduces mechanical sensitivity associated with experimentally
induced hamstring pain. Though further work is needed, these findings may hold important
implications for those seeking to expedite recovery or reduce muscle sensitivity following
hamstring injury.
Key Words
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References
- Somatotopic effects of rTMS in neuropathic pain? A comparison between stimulation over hand and face motor areas.Eur J Pain. 2018; 22: 707-715
- Somatotopic effects of rTMS in neuropathic pain? A comparison between stimulation over hand and face motor areas.Eur J Pain. 2018; 22: 707-715
- A new hamstring test to complement the common clinical examination before return to sport after injury.Knee Surg Sports Traumatol Arthrosc. 2010; 18: 1798-1803https://doi.org/10.1007/s00167-010-1265-3
- Non-invasive brain stimulation in chronic orofacial pain: A systematic review.J Pain Res. 2018; 11: 1445-1457
- Is one trial sufficient to obtain excellent pressure pain threshold reliability in the low back of asymptomatic individuals? A test-retest study.PLoS One. 2016; 11e0160866
- Functional MRI of the immediate impact of transcranial magnetic stimulation on cortical and subcortical motor circuits.Eur J Neurosci. 2004; 19: 1950-1962https://doi.org/10.1111/j.1460-9568.2004.03277.x
- The lower extremity functional scale (lefs): Scale development, measurement properties, and clinical application.Phys Ther. 1999; 79: 371-383
- Validation of the new zealand physical activity questionnaire (nzpaq-lf) and the international physical activity questionnaire (ipaq-lf) with accelerometry.Br J Sports Med. 2010; 44: 741-746https://doi.org/10.1136/bjsm.2008.052167
- Mechanisms and applications of theta-burst rTMS on the human motor cortex.Brain Topogr. 2010; 22: 294-306
- Evaluation of the revised physical activity readiness questionnaire in older adults.Med Sci Sports Exerc. 1996; 28: 468-472https://doi.org/10.1097/00005768-199604000-00011
- The relationship between corticomotor reorganization and acute pain severity: A randomized, controlled study using rapid transcranial magnetic stimulation mapping.Pain Med. 2021; 22: 1312-1323
- Repetitive transcranial magnetic stimulation of the primary motor cortex expedites recovery in the transition from acute to sustained experimental pain: A randomised, controlled study.Pain. 2019; 160: 2624https://doi.org/10.1097/j.pain.0000000000001656
- Repetitive transcranial magnetic stimulation of the primary motor cortex expedites recovery in the transition from acute to sustained experimental pain: A randomised, controlled study.Pain. 2019; 160: 2624-2633
- The number of stimuli required to reliably assess corticomotor excitability and primary motor cortical representations using transcranial magnetic stimulation (TMS): A systematic review and meta-analysis.Syst Rev. 2017; 6: 1-11
- The reliability and validity of rapid transcranial magnetic stimulation mapping.Brain Stimulation. 2018; 11: 1291-1295https://doi.org/10.1016/j.brs.2018.07.043
- Theta-burst stimulation: A new form of TMS treatment for depression?.Depress Anxiety. 2015; 32: 182-192
- Treatment of complex regional pain syndrome in adults: A systematic review of randomized controlled trials published from june 2000 to february 2012.Eur J Pain. 2013; 17: 158-173
- Hamstring muscle strain recurrence and strength performance disorders.Am J Sports Med. 2002; 30: 199-203https://doi.org/10.1177/03635465020300020901
- Using transcranial magnetic stimulation to map the cortical representation of lower-limb muscles.Clin Neurophysiol Pract. 2020; 5: 87-99https://doi.org/10.1016/j.cnp.2020.04.001
- Neuropharmacological basis of rTMS-induced analgesia: The role of endogenous opioids.Pain. 2011; 152: 320-326
- Sessions of prolonged continuous theta burst stimulation or high-frequency 10 Hz stimulation to left dorsolateral prefrontal cortex for 3 days decreased pain sensitivity by modulation of the efficacy of conditioned pain modulation.J Pain. 2019; 20: 1459-1469https://doi.org/10.1016/j.jpain.2019.05.010
- Cortical somatosensory excitability is modulated in response to several days of muscle soreness.J Pain. 2018; 19: 1296-1307https://doi.org/10.1016/j.jpain.2018.05.004
- Unilateral eccentric exercise of the knee flexors affects muscle activation during gait.Gait Posture. 2012; 36: 73-77https://doi.org/10.1016/j.gaitpost.2012.01.009
- Hamstring injuries have increased by 4% annually in men's professional football, since 2001: A 13-year longitudinal analysis of the uefa elite club injury study.Br J Sports Med. 2016; 50: 731-737
- Footedness is a better predictor than is handedness of emotional lateralization.Neuropsychologia. 1998; 36: 37-43https://doi.org/10.1016/s0028-3932(97)00107-3
- TMS and TMS-EEG techniques in the study of the excitability, connectivity, and plasticity of the human motor cortex.Rev Neurosci. 2013; 24: 431-442
- The pain threshold of high-threshold mechanosensitive receptors subsequent to maximal eccentric exercise is a potential marker in the prediction of doms associated impairment.PLoS One. 2017; 12e0185463
- New developments in the understanding and management of persistent pain.Curr Opin Psychiatry. 2012; 25: 109-113
- Lower extremity injuries in the skeletally immature athlete.J Am Acad Orthop Surg. 2007; 15: 356-366https://doi.org/10.5435/00124635-200706000-00005
- Electrical stimulation of motor cortex for pain control: A combined PET-scan and electrophysiological study.Pain. 1999; 83: 259-273https://doi.org/10.1016/S0304-3959(99)00114-1
- Delayed onset muscle soreness at tendon–bone junction and muscle tissue is associated with facilitated referred pain.Exp Brain Res. 2006; 174: 351-360https://doi.org/10.1007/s00221-006-0466-y
- Increased pain from muscle fascia following eccentric exercise: Animal and human findings.Exp Brain Res. 2009; 194: 299-308
- Realistic sham TMS.Brain Stimulation. 2019; 12: 418https://doi.org/10.1016/j.brs.2018.12.353
- A practical guide to diagnostic transcranial magnetic stimulation: Report of an IFCN committee.Clin Neurophysiol. 2012; 123: 858-882
- Measures of adult pain: Visual analog scale for pain (vas pain), numeric rating scale for pain (nrs pain), mcgill pain questionnaire (mpq), short-form mcgill pain questionnaire (sf-mpq), chronic pain grade scale (cpgs), short form-36 bodily pain scale (sf-36 bps), and measure of intermittent and constant osteoarthritis pain (icoap).Arthritis Care Res (2010). 2011; 63: S240-S252https://doi.org/10.1002/acr.20543
- Hamstring strain injuries: Recommendations for diagnosis, rehabilitation, and injury prevention.J Orthop Sports Phys Ther. 2010; 40: 67-81https://doi.org/10.2519/jospt.2010.3047
- The financial cost of hamstring strain injuries in the Australian football league.Br J Sports Med. 2013; 48: 729-730https://doi.org/10.1136/bjsports-2013-092884
- Pain-free versus pain-threshold rehabilitation following acute hamstring strain injury: A randomized controlled trial.J Orthop Sports Phys Ther. 2020; 50: 91-103https://doi.org/10.2519/jospt.2020.8895
- Moving differently in pain: A new theory to explain the adaptation to pain.Pain. 2011; 152: S90-S98
- The clinical utility of repetitive transcranial magnetic stimulation in reducing the risks of transitioning from acute to chronic pain in traumatically injured patients.Prog Neuropsychopharmacol Bio Psychiatry. 2018; 87: 322-331
- The effects of preexercise stretching on muscular soreness, tenderness and force loss following heavy eccentric exercise.Scand J Med Sci Sports. 2007; 9: 219-225https://doi.org/10.1111/j.1600-0838.1999.tb00237.x
- Test-retest reliability of pressure pain threshold measurements of the upper limb and torso in young healthy women.J Pain. 2007; 8: 650-656
- Repetitive transcranial magnetic stimulation for fibromyalgia: Systematic review and meta-analysis.Pain Pract. 2016; 16: 294-304
- Theta burst stimulation in the treatment of chronic orofacial pain: A randomized controlled trial.Physiol Res. 2017; 66: 1041-1047
- Motor cortical measures of use-dependent plasticity are graded from distal to proximal in the human upper limb.J Neurophysiol. 2007; 98: 3230-3241
- Thalamic projections from the precentral motor cortex in macaca fascicularis.Brain Res. 1976; 105: 253-267
- Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS).Clin Neurophysiol. 2014; 125: 2150-2206
- Motor cortex rTMS reduces acute pain provoked by laser stimulation in patients with chronic neuropathic pain.Clin Neurophysiol. 2010; 121: 895-901
- The use of repetitive transcranial magnetic stimulation (rTMS) in chronic neuropathic pain.Neurophysiol Clin/Clin Neurophysiol. 2006; 36: 117-124
- Afferent and efferent connections of the dorsolateral precentral gyrus (area 4, hand/arm region) in the macaque monkey, with comparisons to area 8.J Comp Neurol. 1986; 254: 460-492
- Repetitive transcranial magnetic stimulation (rTMS) in experimentally induced and chronic neuropathic pain: A review.J Pain. 2007; 8: 453-459
- rTMS for suppressing neuropathic pain: A meta-analysis.J Pain. 2009; 10: 1205-1216
- An introduction to multiplicity issues in clinical trials: The what, why, when and how.Int J Epidemiol. 2017, 746-755; 46
- Motor cortex stimulation reduces hyperalgesia in an animal model of central pain.Pain. 2011; 152: 1398-1407
- Efficacy of transcranial direct current stimulation and repetitive transcranial magnetic stimulation for treating fibromyalgia syndrome: A systematic review.Pain Pract. 2013; 13: 131-145
- Theta burst stimulation does not reliably depress all regions of the human motor cortex.Clin Neurophysiol. 2006; 117: 2684-2690
- Alteration of cortical excitability in patients with fibromyalgia.Pain. 2010; 49: 495-500
- From pulses to pain relief: An update on the mechanisms of rTMS-induced analgesic effects.Eur J Pain. 2016; 20: 689-700
- Risk factors for lower extremity injury: A review of the literature.Br J Sports Med. 2003; 37: 13-29
- Non-invasive brain stimulation techniques for chronic pain.Cochrane Database Syst Rev. 2018; 3: 1-284
- Factor structure, reliability, and validity of the pain catastrophizing scale.J Behav Med. 1997; 20: 589-605https://doi.org/10.1023/a:1025570508954
- The depression anxiety stress scales-21 (dass-21): Further examination of dimensions, scale reliability, and correlates.J Clin Psychol. 2012; 68: 1322-1338https://doi.org/10.1002/jclp.21908
- Corticospinal projections to upper limb motoneurones in humans.J Physiol. 1992; 448: 397-412
- Repetitive transcranial magnetic stimulation of the motor cortex attenuates pain perception in complex regional pain syndrome type i.Neurosci Lett. 2004; 356: 87-90
- Optimal coil orientation for transcranial magnetic stimulation.PLoS One. 2013; 8: e60358
- Interferential therapy effect on mechanical pain threshold and isometric torque after delayed onset muscle soreness induction in human hamstrings.J Sports Sci. 2012; 30: 733-742https://doi.org/10.1080/02640414.2012.672025
- Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert guidelines.Clin Neurophysiol. 2020; https://doi.org/10.1016/j.clinph.2020.10.003
- Motor cortical dysfunction disclosed by single and double magnetic stimulation in patients with fibromyalgia.Clin Neurophysiol. 2000; 111: 994-1001
- Smudging of the motor cortex is related to the severity of low back pain.Spine. 2017; 42: 1172-1178
- Novel adaptations in motor cortical maps: The relationship to persistent elbow pain.Med Sci Sports Exerc. 2014; 5: 1-34https://doi.org/10.1249/mss.0000000000000469
- Mapping tenderness to palpation predicts return to play following acute hamstring strain.Int J Sports Phys Ther. 2020; 15: 421
- Corticomotor depression is associated with higher pain severity in the transition to sustained pain: A longitudinal exploratory study of individual differences.J Pain. 2019; 20: 1498-1506
- Self-reported and performance-based functional outcomes after surgical repair of proximal hamstring avulsions.Am J Sports Med. 2013; 41: 2577-2584https://doi.org/10.1177/0363546513499518
- Experimental deep tissue pain in wrist extensors—A model of lateral epicondylalgia.Eur J Pain. 2003; 7: 277-288
- Corticospinal excitability in patients with chronic low back pain.Clin Spine Surg. 2005; 18: 420-424
- The pain catastrophizing scale: Development and validation.Psychol Assess. 1995; 7: 524
- Correlation of single leg vertical jump, single leg hop for distance, and single leg hop for time.Phys Ther Sport. 2011; 12: 194-198https://doi.org/10.1016/j.ptsp.2011.06.001
- Effects of 1-Hz repetitive transcranial magnetic stimulation on acute pain induced by capsaicin.Pain. 2004; 107: 107-115https://doi.org/10.1016/j.pain.2003.10.011
- Primary motor cortex organization is altered in persistent patellofemoral pain.Pain Med. 2017; 18: 2224-2234
- Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain.Brain. 2008; 131: 2161-2171
- TMS brain mapping in less than two minutes.Brain Stimul. 2015; 8: 231-239
- Leg kinematics and kinetics in landing from a single-leg hop for distance. A comparison between dominant and non-dominant leg.Clin Biomech. 2007; 22: 674-680https://doi.org/10.1016/j.clinbiomech.2007.02.007
- Projections of precentral and premotor cortex to the red nucleus and other midbrain areas in macaca fascicularis.Exp Brain Res. 1979; 34: 91-105
- Reliability of pressure pain threshold testing in healthy pain free young adults.Scand J Pain. 2015; 9: 38-41
- Clinical pressure pain threshold testing in neck pain: Comparing protocols, responsiveness, and association with psychological variables.Phys Ther. 2014; 94: 827-837
- Noninvasive mapping of muscle representations in human motor cortex.Electroencephalogr Clin Neurophysiol/Evoked Potentials Section. 1992; 85: 1-8
- The football association medical research programme: An audit of injuries in professional football-analysis of preseason injuries.Br J Sports Med. 2002; 36: 436https://doi.org/10.1136/bjsm.36.6.436
- A new self-diagnostic test for biceps femoris muscle strains.Clin J Sport Med. 2006; 16: 166-169https://doi.org/10.1097/00042752-200603000-00014
Article info
Publication history
Published online: December 01, 2022
Accepted:
November 26,
2022
Received in revised form:
November 2,
2022
Received:
July 8,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2022 by United States Association for the Study of Pain, Inc.
