Maintenance TMS Following ECT in MDD: A Case Report

Background: Phantom limb pain (PLP), a neuropathic pain type, can be disabling after amputation; severe episodes occur in ~10-15%.In this anonymized case, an adult with work-related traumatic upper-limb amputation reported PLP for ~1 year, described as pressure/burning with focal mechanical triggers radiating into the phantom hand and worsening across the day, limiting prosthesis use and activity.Methods: Single-patient case study.Task-based fMRI with alternating rest and guided imagery identified sensorimotor targets in motor cortex.Neuronavigated rTMS was delivered to three serial motor-cortex targets selected from activation peaks and updated pain topography.A 10-Hz Nexstim pain protocol (2000 pulses; 80-100% RMT) was delivered 3 days/week and later accelerated to 3 sessions/day, 3 days/week, with planned breaks, over a period of 27 weeks.Outcomes included six-times-daily pain diaries plus daily function and mood ratings.Results: Target 1 reduced phantom hand pain while finger pain persisted; benefits were maintained during a 2-week "treatment holiday".Subsequent targets shifted toward finger representations, with patient-rated pain maps showing recession of palm burning/ tingling and later reduced tingling across digits.Mean daily pain decreased 49% at end-of-treatment and 51% at 6-months-post; bedtime pain decreased 56% at end-of-treatment and 61% at 6months-post.Self-rated impact of pain decreased for activity (54%), stress (52%), mood (33%), and sleep (100%).Prosthesis tolerance increased from <1 hour/day to 5-10 hours/day, 7 days/week.Discussion: Neuronavigated rTMS fMRI pain target treatment was feasible and associated with usefully improved pain and function in upper-limb PLP.Prospective studies are needed to optimize protocols and evaluate durability.