Nurmikko 2016

Methods	Cross‐over RCT
Participants	Country of study: UK Setting: laboratory Condition: mixed refractory neuropathic pain Prior management details: no benefit from medication or other stimulation approaches n = 40 (27 after loss to follow‐up) Age, range: 27‐79 years Duration of symptoms: not reported Gender distribution: 23 M, 17 F
Interventions	Stimulation type: rTMS Stimulation parameters: frequency 10 Hz; coil orientation AP direction, 90% RMT, number of trains 20; duration of trains 10 s; ITI 1 min; total number of pulses 2000 Stimulation location: Site A: M1 hotspot, Site B M1 reorganised area, Site C (sham) occipital fissure Number of treatments: 3‐5 sessions per week for 5 sessions Control type: sham active stimulation of occipital fissure
Outcomes	Primary: pain NRS anchors 0 = no pain 10 = worst pain imagined When taken: postintervention, 3 weeks postintervention Secondary: none relevant AEs
Notes	Funding source: research funded by the National Institute for Health Research (NIHR) under Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB‐PG‐0110‐20321). COI: Prof. Nurmikko has received travel sponsorship from Nexstim Ltd. None of the other authors report any COI.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: “Patients were randomly allocated to receive three cycles of rTMS in 5 sessions at sites A, B, and SHAM. Randomization order was computer generated."
Adequate blinding of participants?	Low risk	Comment: sham was active stimulation of a non target brain area‐ likely indistinguishable from active stimulation
Adequate blinding of assessors?	Low risk	Comment: outcomes self‐reported via pain diaries
Incomplete outcome data (attrition bias) All outcomes	High risk	Comment: 40 randomised, 38 received rTMS, 27 included in per‐protocol analysis (33% attrition). Responder analysis n = 33 (17% dropout) Reasons for dropout not reported
Selective reporting (reporting bias)	Low risk	Comment: outcomes reported adequately
Free from carry‐over effects?	Low risk	Comment: 3 weeks washout period observed. Baseline pain levels for each condition appear equivalent
Study Size	High risk	Comment: n = 40, 27 after loss to follow‐up
Study duration	Unclear risk	Comment: 3 week follow‐up
Other bias	Low risk	Comment: no other bias detected