Ipsilateral inhibitory rTMS restores interhemispheric motor cortex balance and reduces phantom limb pain: an exploratory longitudinal nTMS mapping study.

Only two participants, so there is no statistical generalisability and no way to separate a true treatment effect from spontaneous fluctuation. No sham-stimulation control, so the cortical and pain changes cannot be definitively attributed to the rTMS rather than to repeated testing, expectation, or natural history. P1 stopped pregabalin entirely before the baseline phase and P2 reduced his dose, so medication withdrawal is a plausible contributor to the pain reduction that the design cannot rule out. P1 received two sessions and P2 received five, and the stopping rule was based on the same pain outcome being measured, which limits any comparison between the two. Follow-up was five weeks; nothing is known about whether the effect lasts months or years. The callosal disinhibition mechanism is inferred from single-pulse mapping data; the authors explicitly note they did not measure interhemispheric inhibition with paired-pulse TMS, so the mechanistic claim is hypothesis-generating, not confirmed. The 50 µV threshold used to define cortical area was not subjected to a sensitivity analysis, so the reported area figures depend on an arbitrary cut-off.

Funded by Technische Universität München (a university). No industry sponsor, no author conflicts of interest declared.

Do not read the 66% and 33% pain reductions as evidence that ipsilateral rTMS is an effective treatment for phantom limb pain. The study had two participants, no sham control, one participant had stopped his pain medication before the baseline phase, and the authors themselves label the callosal-disinhibition interpretation as hypothesis-generating rather than confirmatory. A single case report from 2011 is the only other published example of this approach, and the authors position their work as a methodological foundation for future sham-controlled trials, not as a treatment recommendation.