ArticleLiterature Review

A Meta-Analysis of Transcutaneous Electrical Nerve Stimulation for Chronic Low Back Pain

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Abstract

Objective: Transcutaneous electrical nerve stimulation (TENS) may provide a safe alternative to current side-effect-heavy narcotics and anti-inflammatories utilized in chronic low back pain. Therefore, we performed a meta-analysis to evaluate the efficacy of TENS for the treatment of chronic low back pain. Materials and methods: We included randomized controlled trials (RCTs), cohort studies, and randomized crossover studies on TENS for the management of low back pain. We utilized a visual analogue scale (VAS) for pain as our primary outcome. Effectiveness of treatment was quantified using improvement in outcome scores for each study. Of the studies that met the criteria, 13 allowed for calculation of weighted mean differences in pain reduction. We used a random model effect to evaluate changes in pain produced by the intervention. Results: Included were nine level I and four level II, encompassing 267 patients (39% male) who had a mean follow-up of seven weeks (range; 2 to 24 weeks). The mean duration of treatment was six weeks (range; 2 to 24 weeks). The standardized mean difference in pain from pre- to post-treatment for TENS was 0.844, which demonstrated significant improvement of TENS on pain reduction. When subdividing treatment duration, patients that were treated for < 5 weeks had significant effects on pain, while those treated for > 5 weeks did not. Conclusion: Treatment of chronic low back pain with TENS demonstrated significant pain reduction. The application of TENS may lead to less pain medication usage and should be incorporated into the treatment armamentarium for chronic low back pain.

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... Systematic reviews similarly conclude that TENS is ineffective or inconclusive for a variety of painful conditions (Khadilkar et al., 2008;Nnoaham and Kumbang, 2008;Dowswell et al., 2009;Kroeling et al., 2009;Rutjes et al., 2009;Walsh et al., 2009;Hurlow et al., 2012). On the other hand, Jauregui et al. (2016) concluded in their systematic review that the treatment of chronic low back pain with TENS demonstrated significant pain reduction in patients who were treated for less than 5 weeks. Prior studies, however, have not considered important aspects of TENS treatment, namely intensity of stimulation and timing of assessment. ...
... TENS is a nonpharmacological modality widely used to manage pain; however, its effectiveness for patients with CLBP has been questioned (Brosseau et al., 2002;Khadilkar et al., 2008;van Middelkoop et al., 2011;Buchmuller et al., 2012). The current analysis showed that TENS/IFC intervention was superior to placebo/control for reducing pain intensity in those with non-specific low back pain during treatment, in concordance with prior systematic reviews and meta-analyses (Machado et al., 2009;Jauregui et al., 2016). However, caution should be used with interpretation of effectiveness as the studies used in the current review and the prior review are very heterogenous (I 2 = 80%-82%) (Jauregui et al., 2016). ...
... The current analysis showed that TENS/IFC intervention was superior to placebo/control for reducing pain intensity in those with non-specific low back pain during treatment, in concordance with prior systematic reviews and meta-analyses (Machado et al., 2009;Jauregui et al., 2016). However, caution should be used with interpretation of effectiveness as the studies used in the current review and the prior review are very heterogenous (I 2 = 80%-82%) (Jauregui et al., 2016). Further, NICE guidelines and the Centers for Medicare and Medicaid Services recommend clinicians do not offer transcutaneous electrical nerve simulation (TENS) for managing low back pain (Bernstein et al., 2017;CMS.gov). ...
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We conducted a systematic review and meta‐analysis analysing the existing data on transcutaneous electrical nerve stimulation (TENS) or interferential current (IFC) for chronic low back pain (CLBP) and/or neck pain (CNP) taking into account intensity and timing of stimulation, examining pain, function and disability. Seven electronic databases were searched for TENS or IFC treatment in non‐specific CLBP or CNP. Four reviewers independently selected randomized controlled trials (RCTs) of TENS or IFC intervention in adult individuals with non‐specific CLBP or CNP. Primary outcomes were for self‐reported pain intensity and back‐specific disability. Two reviewers performed quality assessment, and two reviewers extracted data using a standardized form. Nine RCTs were selected (eight CLBP; one CNP), and seven studies with complete data sets were included for meta‐analysis (655 participants). For CLBP, meta‐analysis shows TENS/IFC intervention, independent of time of assessment, was significantly different from placebo/control (p < 0.02). TENS/IFC intervention was better than placebo/control, during therapy (p = 0.02), but not immediately after therapy (p = 0.08), or 1–3 months after therapy (p = 0.99). Analysis for adequate stimulation parameters was not significantly different, and there was no effect on disability. This systematic review provides inconclusive evidence of TENS benefits in low back pain patients because the quality of the studies was low, and adequate parameters and timing of assessment were not uniformly used or reported. Without additional high‐quality clinical trials using sufficient sample sizes and adequate parameters and outcome assessments, the outcomes of this review are likely to remain unchanged. Significance These data highlight the need for additional high‐quality RCTs to examine the effects of TENS in CLBP. Trials should consider intensity of stimulation, timing of outcome assessment and assessment of pain, disability and function.
... One of the most developed branches of physical therapy is electrotherapy, which by using a current with specific parameters, helps to effectively fight both acute and chronic pain. The group of most important electrotherapy procedures is transcutaneous electrical nerve stimulation − TENS, which in recent years, has become a widely used and accepted therapeutic method [9][10][11][12][13][14][15] . The use of TENS in people with musculoskeletal system pain allows for reduction or complete relief of pain. ...
... Acupunctural-like TENS is based on low frequencies (50 Hz and below), most commonly in the 1-30 Hz, 1-20 Hz, 1-5 Hz ranges. Analgesia, achieved with this type of current, is usually delayed but long-lasting, which results from stimulation of descending systems and release of endorphins [12][13][14][15][16] . ...
... Adequate conservative treatment, including physiotherapy, can significantly reduce symptoms and delay disease progression. Complementarity of activities supplements the use of phys-ical therapy, as it has a scientifically confirmed position in the prevention and treatment of degenerative changes of the spine [8][9][10][12][13][14][15] . ...
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Introduction: Chronic low back pain impairs routinely performed activities and decreases quality of life. It may be caused bydifferent conditions, however, the most frequent is osteoarthritis. Electrotherapy is a modality essentially applied in the treatment of chronic pain syndromes because of high efficacy and absence of side effects. Study aim: Comparison of the analgesic effect of Transcutaneous Electrical Nerve Stimulation and High Tone Power Therapy in patients with chronic low back pain caused by osteoarthritis. Material and methods: The study included 50 people, 22 males and 28 females, of mean age 46.2±10 years with chronic low back pain caused by osteoarthritis. The study protocol included treatment with Transcutaneous Electrical Nerve Stimulation or High Tone Power Therapy. Each participant was exposed to the particular modality 10 times. Participants were randomly divided into two groups: treated with High Tone Power Therapy (Group I) and with Transcutaneous Electrical Nerve Stimulation (Group II). Before and after treatment, the threshold of pain and pain intensity were measured with PainMatcher and a numeric rating scale. Results: The application of Transcutaneous Electrical Nerve Stimulation or High Tone Power Therapy resulted in a decrease of the subjectively assessed pain intensity. A decrease was also observed in objective measurements. Conclusions: The demonstrated analgesic effectiveness of the applied therapies encourages their further use in the treatment of low back pain syndrome. These modalities seem to be an effective method of increasing the pain threshold, and thus reducing pain.
... Studies have reported that TENS can reduce acute and chronic pain of different etiologies, (2,(6)(7)(8)(9)(10) however, the optimal parameters in CLBP treatment are still unknown. (5) When TENS is applied with high frequency, such as in the conventional mode, the physiological intention is to produce Aβ fiber depolarization effect, capable of inhibit transmission of nociceptive information for spinal cord. ...
... Hence, no evidence on the appropriate parameters and stimulation modes was found. Jauregui et al., (9) conducted a meta-analysis and concluded that treatment using TENS resulted in not only reduced pain, but also reduced drug intake among patients with CLBP treated for less than 5 months. ...
... All systematic reviews (8)(9)(10) pointed to studies comparing a single TENS parameter with PG or with other therapies. Of the studies cited in these reviews, only one (12) compared three types of TENS (conventional TENS, acupuncture TENS, biphasic TENS and PG), and during one month of treatment no differences were found between groups. ...
Article
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Objective: To compare and assess the immediate analgesic effects of conventional and burst transcutaneous electrical nerve stimulation in patients with chronic low back pain. Methods: We conducted a three-arm single-blinded randomized controlled trial. A total of 105 patients with non-specific chronic low back pain aged between 18 and 85 years were randomly assigned into the following groups: Placebo Group (sham electrical stimulation), Conventional TENS Group (continuous stimulation at 100Hz for 100µs with sensory intensity), and Burst TENS Group (stimulation at 100Hz modulated at 2Hz for 100µs with motor-level intensity). All groups received a single application of transcutaneous electrical nerve stimulation for 30 minutes. The outcomes, namely, pain intensity, quality of pain, and pressure pain threshold were measured by the visual analog scale, McGill pain questionnaire, and algometry, respectively. The patients were evaluated before and immediately after the transcutaneous electrical nerve stimulation application. Results: Pain intensity (visual analog scale score) and quality of pain (McGill pain questionnaire score) significantly decreased (p<0.05) in Intervention Groups (Conventional TENS Group and Burst TENS Group). A positive effect was observed in the interventions compared to the Placebo Group in all domains of the McGill pain questionnaire (p<0.05), excepting for the pain intensity. Pressure pain threshold significantly increased (p<0.05) immediately after the transcutaneous electrical nerve stimulation application in both Intervention Groups, but not in the Placebo Group. For significant difference was found during assessment when comparing both Intervetion Group. Conclusion: Both transcutaneous electrical nerve stimulation modes were effective for pain modulation. Moreover, there was an increase in the pressure pain threshold. No significant results were found to indicate the best mode for the treatment of chronic low back pain.Clinical Trial Registration: RBR-59YGRB.
... Low reimbursement by third-party providers also adds to the underutilization of these therapies. Specific studies have demonstrated that using electroanalgesia or laser therapy combined with conventional pharmacological approaches improve treatment outcomes (psychological well-being, ability to return to work, sleep quality, activity level) in select patient populations [1,15,[32][33][34][35]. ...
... Several studies have shown them to be viable non-pharmacologic options in pain management. Despite certain research limitations, like small sample sizes, the presence of some biases, the lack of appropriate placebo controls, and other methodological issues [34,35], most studies suggest that electroanalgesia and laser therapy are useful interventional modalities in pain management. Other studies have questioned the efficacy of these alternative approaches [10]; ...
Article
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Acute and chronic pain management is demanding for many healthcare professionals and their patients. Patients need relief. However, physicians must balance the therapeutic benefits of such therapy with the potential or actual adverse effects, including drug dependence, overdose and unintended death. The opioid crisis has reached epidemic proportions, resulting in considerable and unnecessary loss of life. This crisis and other adverse effects of pain medications necessitates applying an individualized, multimodal, and multidisciplinary approach to pain management. Effective non-pharmacological options should be considered and utilized to a greater extent-than they currently are-for more efficacious results for the patient and stem the tidal wave tide of drug dependence and addiction. Electricity has been used for pain relief since ancient times and is becoming more widely used today. Many healthcare providers have heard about electroanalgesia but may know little about how electroanalgesia works (its mechanisms of action), its indications and contraindications, what devices are available, and how to integrate electroanalgesia and electrotherapy into their practices for the benefit of specific, acute and chronic pain patients. This review aims to bridge this knowledge and know-how gap regarding electroanalgesia and electrotherapy by providing an overview of five types of electroanalgesia currently used clinically and how to integrate such therapies into practice; these five types being electroacupuncture (EA), ultrasound-guided acupotomy, transcutaneous electrical nerve stimulation (TENS), percutaneous electrical nerve stimulation (PENS) and peripheral nerve stimulation (PNS).
... Used since 1970 as an adjunct therapy to control acute and chronic pain in a lot of medical and surgical conditions, transcutaneous electrical nerve stimulation (TENS) is a noninvasive physiotherapeutic resource that acts to block pain through the central nervous system [1][2][3][4][5]. ...
... Regarding studies with TENS and pain reduction [1][2][3][4][5], the results evidence that there is a reduction in pain intensity when compared to control groups in a variety of diseases. When evaluating studies related to pain intensity, it is observed that less intense pain also has fewer cytokines [7,9,10]. ...
Article
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Background: Transcutaneous electrical nerve stimulation (TENS) has been used as analgesic therapy in many diseases. It is already known that studies that have observed the relationship between pain and cytokines have found that patients who report less severe pain have less production of proinflammatory cytokines. However, one another accepted mechanism is that decreasing proinflammatory cytokines results in decreased pain intensity. Analyzing the literature, the authors describe that, in addition to the analgesic effect, TENS has shown systemic effects, and clinically, the reduction of proinflammatory cytokines could be a protective factor against inflammation. To test the inflammatory effect of TENS, we researched the literature for clinical conditions that suggest that proinflammatory cytokines are one of the main mediators of the disease process. Chronic inflammation is one of the risk factors mentioned for the development of a new cancer; at the same time, it is indicated as an indicator of the worst prognosis. Studies also suggest that the worst prognosis of breast cancer, one of the types with the highest incidence in the world, may be related to increased inflammatory activity. Considering that inflammation is increased in breast cancer and that TENS can reduce proinflammatory cytokines even without blocking the pain pathway, our hypothesis is that the anti-inflammatory effect of TENS can bring benefits to these patients. The aim of this study will be to evaluate the effect of TENS on blood reduction of proinflammatory cytokines in breast cancer patients. Methods: This study will evaluate at least 59 patients, over 18 years of age, diagnosed with breast cancer, but who have not yet started any treatment. All patients will be submitted to TENS intervention (Ibramed, Model Neurodyn III, parameters: VIF-turn on, frequency-2-247 Hz, pulse size-50-500 μs, and intensity (mA)-maximum tolerated by the patient), and the data will be analyzed in the pre- and postintervention of each patient. The application has a total duration of 30 minutes, and 8 ml of blood will be collected before and after the intervention. Proinflammatory (IL-1, IL-2, IL-6, IL-7, and TNF-α) and anti-inflammatory (IL-4, IL-10, IL-13, and FTCβ) cytokines will be analyzed. As a primary endpoint, we will analyze the reduction in blood concentration of proinflammatory cytokines, and as secondary endpoints, we will analyze the size of the effect according to each type of proinflammatory cytokine, describe the effect size of the reduction according to the breast cancer immunohistochemistry, and analyze the effect of TENS on anti-inflammatory cytokines. This study is approved by the Research Ethics Committee (Centro Universitário FMABC, Brazil) and registered in the Brazilian Clinical Trials (Search text: RBR-10jbwh47).
... Thermal stimulus generated by hot packs decreases muscle tone and spasm by increasing the elasticity of the collagenous tissue and decreasing the activity of muscle spindles [19,20]. Analgesic currents, such as TENS, are commonly used for pain inhibition in NSLBP because they inhibit afferent sensory neurons at the dorsal horn of the spinal cord and close the pain gate, leading to pain relief [21]. ...
... For these reasons, one of the goals of treatment is to increase mobility. Improvement in pain and disability by PT in LBP has been shown inprevious studies [5,20,21,24]; however, there are limited data about its effects on spinal mobility. Although a few studies have investigated the effects of PT on spinal mobility, it may be considered that there will also be a positive influence on mobility, as well as pain and disability, by improving pain and functional status and enhancing soft tissue elasticity. ...
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Objective: To investigate the effects of physical therapy (PT) on pain, functional status, sagittal spinal alignment, and spinal mobility in chronic non-specific low back pain (NSLBP). Materials and methods: The study population consisted of 100 patients with chronic NSLBP. The study group comprised 60 patients to whom a PT program including superficial heat, transcutaneous electrical nerve stimulation, and ultrasound for 10 sessions was assigned. The control group was composed of 40 patients who received no PT. Home exercise programs were applied to both groups. Pain severity was determined using a Visual Analog Scale (VAS), and functional status was evaluated using the Oswestry Disability Index (ODI). Spinal sagittal alignment in regard to lumbosacral, lumbar lordosis, and thoracic kyphosis angles and spinal mobility regarding lumbar and thoracic flexion and extension degrees were assessed using a digital inclinometer. Lumbar flexion was also assessed using the modified lumbar Schober test (mLST). Evaluations were performed at baseline and after completing the therapy sessions. Results: There were significant decreases in VAS scores in each group upon therapy completion. However, significant improvements in ODI, mLST, and all inclinometric evaluations in terms of sagittal spinal alignment and spinal mobility were noted only in the study group compared with baseline values (p<0.05). Conclusion: Despite the short course of treatment, PT was found to have significant positive effects on pain severity, functional status, sagittal spinal alignment, and spinal mobility. PT was determined to be an effective treatment option for chronic NSLBP.
... Standardised mean differences are shown in Table 2. One of the SMDs did not include a comparator (i.e., pre-post TENS estimate for chronic back pain [52]). Visual inspection of the 19 SMD estimates versus a comparator revealed one idiosyncratic SMD estimate by Brosseau et al. [62] who reported an unusually high SMD relative to baseline for chronic low back pain (i.e., SMD = −4.32 ...
... We included 21 systematic reviews of TENS for non-specific back pain and 2 hybrid reviews ( [51]. Jauregui et al. [52] suggested that their meta-analysis provided evidence that TENS reduced pain and medication; Wu et al. [14] that TENS improved functional disability but not lower back pain; and Resende et al. [51] that evidence was inconclusive based on large heterogeneity between studies. Their meta-analysis of 290 participants found that pain intensity was lower during TENS or interferential current therapy compared with placebo/control with an overall standardised mean difference of −0.92 (95% CI −1.73, −0.12; p < 0.02). ...
Article
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Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors’ conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with ‘sufficient data’ demonstrating benefit. There were no examples of meta-analyses with ‘sufficient data’ demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with ‘insufficient data’ and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.
... In a nationwide database review, Pivec et al. concluded that TENS usage for chronic low back pain is correlated with fewer hospital, clinic, and physical therapy visits compared to controls not using TENS therapy [39]. However, the benefit of chronic back pain treatment with a TENS unit is controversial, and several past studies have suggested equivocal and contradictory findings [40][41][42]. ...
... However, this only held true for patients who received the therapy for \ 5 weeks. After 5 weeks, statistical difference in chronic lower back pain severity between the control and TENS unit treatment groups disappeared, suggesting the benefit of TENS therapy may be most significant during short-term use [41]. ...
Article
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Purpose of the review: Chronic low back pain (CLBP) is a major contributor to societal disease burden and years lived with disability. Nonspecific low back pain (LBP) is attributed to physical and psychosocial factors, including lifestyle factors, obesity, and depression. Mechanical low back pain occurs related to repeated trauma to or overuse of the spine, intervertebral disks, and surrounding tissues. This causes disc herniation, vertebral compression fractures, lumbar spondylosis, spondylolisthesis, and lumbosacral muscle strain. Recent findings: A systematic review of relevant literature was conducted. CENTRAL, MEDLINE, EMBASE, PubMed, and two clinical trials registry databases up to 24 June 2015 were included in this review. Search terms included: low back pain, over the counter, non-steroidal anti-inflammatory (NSAID), CLBP, ibuprofen, naproxen, acetaminophen, disk herniation, lumbar spondylosis, vertebral compression fractures, spondylolisthesis, and lumbosacral muscle strain. Over-the-counter analgesics are the most frequently used first-line medication for LBP, and current guidelines indicate that over-the-counter medications should be the first prescribed treatment for non-specific LBP. Current literature suggests that NSAIDs and acetaminophen as well as antidepressants, muscle relaxants, and opioids are effective treatments for CLBP. Recent randomized controlled trials also evaluate the benefit of buprenorphine, tramadol, and strong opioids such as oxycodone. This systematic review discusses current evidence pertaining to non-prescription treatment options for chronic low back pain.
... This combination may improve the symptoms associated with osteoarthritis and restore the knee function of patients. 3,4 The main goal of this study was to further explore the immediate clinical efficacy of platelet rich plasma in combination with celecoxib on the pain and knee function of patients with osteoarthritis. ...
Article
Objectives: To analyze the immediate effect of platelet rich plasma, combined with celecoxib, on knee function and pain in patients with knee osteoarthritis. Methods: The clinical data of 86 patients with knee osteoarthritis, treated in our hospital from January 2019 to January 2021, were analyzed retrospectively. According to the treatment records, patients were divided into a control group (n = 43, celecoxib) and a treatment group (n = 43, platelet rich plasma + celecoxib). The knee function, pain and clinical effect in the two groups were compared and analyzed using the Hospital for Special Surgery (HSS) knee score and the visual analog scale (VAS). Results: The treatment group had a higher HSS score, and a lower VAS score compared to the control group (P<0.05). The clinical efficacy in the treatment group was higher than that in the control group (95.35% and 72.09% respectively, P<0.05). Conclusions: Platelet rich plasma combined with celecoxib can promote the recovery of knee function and reduce pain in patients with knee osteoarthritis. This treatment combination also has a high immediate clinical effectiveness but needs further evaluation to find out the long term effects.
... 2,3 Conventional TENS is a useful component of a chronic pain-treatment plan. 2,[4][5][6][7][8][9] However, there are questions about the effectiveness and optimal applications of TENS. 10,11 It is likely that TENS efficacy in both clinical trials and real-world use has been adversely impacted by underdosing and poor adherence. ...
Article
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Background: Transcutaneous electrical nerve stimulation (TENS) is a safe, noninvasive treatment for chronic pain that can be self-administered. Conventional TENS involves stimulation of peripheral sensory nerves at a strong, non-painful level. Following the original gate-control theory of pain, stimulation is typically near the target pain. As another option, remote stimulation may also be effective and offers potential advantages. Objective: This narrative review examines mechanisms underlying the remote analgesic effects of conventional TENS and appraises the clinical evidence. Methods: A literature search for English-language articles was performed on PubMed. Keywords included terms related to the location of TENS . Citations from primary references and textbooks were examined for additional articles. Results: Over 30 studies reported remote analgesic effects of conventional TENS. The evidence included studies using animal models of pain, experimental pain in humans, and clinical studies in subjects with chronic pain. Three types of remote analgesia were identified: at the contralateral homologous site, at sites distant from stimulation but innervated by overlapping spinal segments, and at unrelated extrasegmental sites. Conclusion: There is scientific and clinical evidence that conventional TENS has remote analgesic effects. This may occur through modulation of pain processing at the level of the dorsal horn, in brainstem centers mediating descending inhibition, and within the pain matrix. A broadening of perspectives on how conventional TENS produces analgesia may encourage researchers, clinicians, and medical-device manufacturers to develop novel ways of using this safe, cost-effective neuromodulation technique for chronic pain.
... J. Jauregui и соавт. [65] провели метаанализ 13 РКИ (n=267, длительность от 2 до 12 нед), оценивающих результаты применения ЧЭНС при хронической НБС. Было показано, что, в сравнении с исходным уровнем, этот метод позволял достичь значимого уменьшения боли (РСЗ 0,844). ...
Article
Medical rehabilitation is a set of non-drug methods aimed at reducing pain and functional disorders, restoring working ability, social activity, and mental stability in patients. This is a necessary part of treatment in patients with rheumatic diseases, which is as important as pharmacotherapy in many cases (for example, osteoarthritis, chronic nonspecific back pain, and spondyloarthritis). Unfortunately, many Russian physicians underestimate the possibilities of nondrug approaches, referring to the fact that the effectiveness of medical rehabilitation and physiotherapy methods have not been evaluated during clinical trials and their therapeutic significance has passed no serious test in the context of evidence-based medicine. This is not entirely true. This review presents data from a large number of clinical trials and related meta-analyses of studies evaluating the efficiency of the most commonly used medical rehabilitation techniques: cryotherapy, laser therapy, magnetotherapy, ultrasound therapy, percutaneous electroneuromyostimulation, acupuncture, manual therapy, massage, and therapeutic exercises.
... Transcutaneous electrical nerve stimulation may provide an alternative/complement to medication in patients with FBSS. Its effectiveness in chronic low back pain is, however, still controversial [50,51]. Other nonpharmacological complementary therapies, such as acupuncture, manual therapy, functional restoration, and cognitive behavioral therapy, may also be utilized, although the level of evidence supporting most of these therapies in the management of chronic back pain is moderate at best [52,53]. ...
Article
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Failed back surgery syndrome (FBSS) is a major, worldwide health problem that generates considerable expense for healthcare systems. A number of controversial issues concerning the management of FBSS are regularly debated, but no clear consensus has been reached. This pitfall is the result of lack of a standardized care pathway due to insufficient characterization of underlying pathophysiological mechanisms, which are essential to identify in order to offer appropriate treatment, and the paucity of evidence of treatment outcomes. In an attempt to address the challenges and barriers in the clinical management of FBSS, an international panel of physicians with a special interest in FBSS established the Chronic Back and Leg Pain (CBLP) Network with the primary intention to provide recommendations through consensus on how to optimize outcomes. In the first of a series of two papers, a definition of FBSS was delineated with specification of criteria for patient assessment and identification of appropriate evaluation tools in order to choose the right treatment options. In this second paper, we present a proposal of a standardized care pathway aiming to guide clinicians in their decision-making on how to optimize their management of FBSS patients. The utilization of a multidisciplinary approach is emphasized to ensure that care is provided in a uniform manner to reduce variation in practice and improve patient outcomes.
... Furthermore, epidemiological data show an excessive rate of patients suffering from chronic pain [15,16]. Accordingly, there exist a considerable number of patients who have undergone permanent PM or ICD implantation and are afterwards confronted with the opportunity to benefit from EST for treatment of the pain condition [17]. In cases of electrical interference between EST and cardiac device therapy different effects on PM function might be observed: If the applied current is classified as "noise" by the PM device due to interference with the sensing function a switch to a V00 safety back-up pacing mode commonly occurs, which is of minor clinical relevance in PM-dependent patients; however, in patients with an intrinsic cardiac activity at higher rates than V00 safety back-up pacing (70-90 bpm for most devices), there is the theoretical risk for the induction of ventricular arrhythmia or even ventricular fibrillation. ...
Article
Background Electrical stimulation therapy (EST) and transcutaneous electrical neuromuscular stimulation (TENS), a modality of EST, have become widely applied, accepted and effective methods for the treatment of musculoskeletal and other pain conditions. According to the rising number of permanent pacemaker (PM) wearers the number of potential candidates for EST with concomitant device implantation is growing. Contradictory recommendations exist regarding the application of EST or TENS on PM wearers. Aim The study was carried out to evaluate the impact of EST on PM function. Methods A full size model mimicking the electrical characteristics of the human body was used to evaluate the application of EST on permanent PM devices. Various configurations with respect to energy modality, position of the stimulation electrodes and PM device models were evaluated. Intracardiac PM electrogram tracings (iEGM) were analyzed for the interference of EST with PM function. Results Unilateral EST application did not cause interference with PM function in any of the configurations (0%; n = 700). On the contrary, bilateral stimulation (350 configurations in total) caused either ventricular inhibition or switch to V00 back-up pacing due to electrical interference in 165 cases (47.1%) depending on the applied stimulation parameters. Conclusion The use of EST potentially interferes with PM therapy, especially if the electrodes are positioned bilaterally; however, unilateral EST application appeared to be safe in all tested configurations.
... The Routledge Handbook of Philosophy of Pain; edited by Jennifer Corns Format: Royal (174 × 246 mm); Style: Handbook_1; Font: Bembo; Dir: //integrafs5/kcg/2-Pagination/TandF/RHPP_RAPS/ApplicationFiles/ 9781138823181_text.3d; Created: 13/12/2016 @ 17:43:40 than five weeks (Jauregui et al. 2016), while a comprehensive, but older, Cochrane review reported inconsistent evidence for any benefit (Khadilkar et al. 2005). ...
... The resulting stimulation of large diameter, deep tissue afferents [10], produces pain relief by decreasing central excitability and increasing central inhibition [11,12]. TENS provides pain relief or improves function in multiple types of chronic pain [11,[12][13][14][15][16][17][18][19]. ...
... Somatosensory stimulation treatments are nonpharmacological treatments that apply stimulation (electrical, heat, or manual) to sensory system; they are beneficial for pain management. [15][16][17][18] These treatments include acupuncture-related techniques, transcutaneous electrical nerve stimulation (TENS), moxibustion (heat stimulation), and cupping (mechanic stimulation). These treatments have the advantages of lower adverse events, and they were reported to be effective in the management of postoperative pain after hemorrhoidectomy. ...
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Background: Pain after hemorrhoidal surgery bothers both clinicians and patients. Somatosensory stimulation treatments have shown promising effect on the pain after hemorrhoidal surgery, but the comparative effectiveness between them has not been studied. We aim to determine the relative effectiveness among these treatments on pain relief after hemorrhoidal surgery by using network meta-analysis. Method: We will search the following electronic databases: MEDLINE, EMBASE, the Cochrane library, Chinese Biomedicine database (CBM), China National Knowledge Infrastructure (CNKI). We will include randomized controlled trials (RCTs) that examine the effect of somatosensory stimulation treatments on pain after hemorrhoidal surgery. The primary outcome will be the responder rate after treatment. The secondary outcomes will include the assessments with pain intensity scales (visual analog scale, numeric rating scale, or other scales) on day 1 to 7 after surgery. Two independent reviewers will extract needed information from eligible trials using standardized electronic forms. Network meta-analysis will be performed using a frequentist framework based on electrical network theory. The relative effectiveness of the treatments will be ranked by using P score, which is the mean probability of a treatment ranking the best in all treatments. Meta-regression will be performed to assess the impact of surgery type, anesthesia methods, and funding source on the treatment ranking. The quality of the eligible RCTs will be evaluated by the Cochrane risk of bias tool. Ethics and dissemination: The result of this network meta-analysis will clarify which is the relatively best somatosensory-stimulation treatment in relieving postoperative pain caused by hemorrhoidal surgery, and the review will, therefore, guide the management of postoperative pain after hemorrhoidal surgery for clinicians and patients. This review does not require ethical approval and will be reported in a peer-reviewed journal. Trial registration number: PROSPERO CRD42018115558.
... The study reports a significant but transient improvement in LBP, but the effect is not evident after the 5th week of treatment. [18] Gladwell et al [9] described the problems with TENS use reported by experienced TENS users as follows: connectivity (pad adhesion, wires), fitting the TENS device (reaching to fit the pads and clothing), availability (portability and accessibility), sensation and settings (sensation of TENS and the controls), and visibility (device or wires visible to other people). A TEP, i.e., pain resource nurse consultations, could enhance any potential benefits of TENS or at least minimize any obstacles to its use. ...
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Background: Transcutaneous electrical nerve stimulation (TENS) is often used for the treatment of low-back pain (LBP). However, its effectiveness is controversial. Objective: To determine the efficacy of TENS in the treatment LBP when associated to a therapeutic education program (TEP). Design: Open randomized monocentric study. Setting: University hospital between 2010 and 2014. Patients: A total of 97 patients suffering from LBP. Interventions: Routine care (TENS group) or routine care plus a therapeutic education program (TENS-TEP group) based on consultation support by a pain resource nurse. Main outcome measures: EIFEL and Dallas Pain Questionnaire scores. Results: Twenty-two patients (44%) were still assessable at the end-of-study visit, whereas 33 (70%) were assessable at the same time point in the TENS-TEP group (P = .013). The EIFEL score and the Dallas score had a similar evolution over time between groups (P = .18 and P = .50 respectively). Similarly, there were no significant differences between the groups with respect to resting pain scores (P = .94 for back pain and P = .16 for leg pain) and movement pain scores (P = .52 for back pain and P = .56 for leg pain). At Month 6, there was no significant difference between the groups (P = .85) with regard to analgesics and social impact. Two patients presented a serious adverse event during the study (one in each group) but non-attributable to the treatment studied. Conclusion: This study does not support the use of TENS in the treatment of patients with chronic LBP even though patients benefited from a therapeutic education program by a pain resource nurse. However, the higher number of premature withdrawals in the TENS group may be due to early withdrawal of patients who did not experience improvement of their symptoms.
... These therapy modality options include acupuncture, moxibustion, yoga, exercise, physical therapy, Qigong, transcutaneous electrical nerve stimulation, and neuromuscular electrical stimulation (NMES). [12][13][14][15][16][17][18][19][20] However, no guidance of such kind of therapies is available for the treatment of CLBP, especially for the NMES. Additionally, there is significant disparity in the technique device, and treatment standardization. ...
Article
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This retrospective study investigated the effectiveness and safety of neuromuscular electrical stimulation (NMES) for patients with chronic low back pain (CLBP).A total of 72 patients with CLBP were included in this retrospective study. All patients received usual care, and were assigned to a NMES group (n = 36) and a control group (n = 36). In addition, patients in the NMES group also received NMES for a total of 4 weeks. The primary outcome was pain intensity, measured by numerical rating scale (NRS). The secondary outcome was disability, assessed by the Roland-Morris Disability Questionnaire (RMDQ), and the Quebec Back Pain Disability Scale (QBPDS). The outcomes were evaluated before and after 4-week treatment.After 4-week treatment, the patients in the NMES group did not show better effectiveness in pain intensity relief, as measured by NRS (P = .11); and disability improvement, as evaluated by the RMDQ (P = .14), and QBPDS (P = .33), when compared with the patients in the control group. Additionally, no adverse events related to the NNES were recorded.The results of this study did not show promising effectiveness of NMES for patients with CLBP after 4-week treatment.
... Testing whether fewer stimuli are more effective over the long term may also be advisable. Clinical and animal research has noted that too much stimulation can lead to desensitization or produce tolerance to further analgesic effect (Chandran & Sluka, 2003;Jauregui et al., 2016). Perhaps this is related to the observations in the current study in which singlesession training produced a more persistent habituation memory compared to multi-session training. ...
Article
Repetitive activation of non-nociceptive afferents is known to attenuate nociceptive signaling. However, the functional details of how this modulatory process operates are not understood and this has been a barrier in using such stimuli to effectively treat chronic pain. The present study tests the hypothesis that the ability of repeated non-nociceptive stimuli to reduce nociception is a form of generalized habituation from the non-nociceptive stimulus-response pathway to the nociceptive pathway. Habituation training, using non-nociceptive mechanosensory stimuli, did reduce responses to nociceptive thermal stimulation. This generalization of habituation to nociceptive stimuli required endocannabinoid-mediated neuromodulation, although disrupting of endocannabinoid signaling did not affect "direct" habituation of to the non-nociceptive stimulus. Surprisingly, the reduced response to nociceptive stimuli following habituation training was very long-lasting (3-8 days). This long-term habituation required endocannabinoid signaling during the training/acquisition phase, but endocannabinoids were not required for post-training retention phase. The implications of these results are that applying principles of habituation learning could potentially improve anti-nociceptive therapies utilizing repeated non-nociceptive stimulation such as transcutaneous nerve stimulation (TENS), spinal cord stimulation (SCS), or electro-acupuncture.
... Regarding analgesia, studies [1][2][3][4][5] show a reduction in pain intensity when compared to control groups in a variety of diseases. However, the evidence on the best parameters for application and their dose-response relationships in diseaserelated outcomes (e.g., in low back pain, osteoarthritis, and cancer) are not yet definitive, mainly due to the different clinical protocols performed. ...
Article
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The mechanism of pain reduction involves bidirectional processes of pain blocking (nociception) and reductions in the levels of proinflammatory cytokines in the blood. Does transcutaneous electrical nerve stimulation (TENS) reduce blood levels of proinflammatory cytokines? For this systematic review, we searched in six databases to identify randomized controlled trials with the criteria: humans older than 18 years (adults), use of TENS in the experimental group, and having at least one pre- and postintervention blood level of at least one proinflammatory cytokine. The risk of bias and the level of evidence were assessed. Five studies were included involving 240 participants. The heterogeneity of the studies was high ( I² : 85%); therefore, we used a random-effects meta-analysis. It was observed through the meta-analysis synthesis measures that there were statistically significant differences following the use of TENS to reduce the general group of cytokines. When grouped by chronic disease, by postoperative settings, or by individual studies in the case of IL-6, it was observed that the significant reduction of cytokines related to the use of TENS was maintained. The use of TENS reduced the blood levels of proinflammatory cytokines (we observed a protective factor of TENS in relation to inflammation). The protocol of the systematic review was registered in PROSPERO, CRD42017060379.
... Therapeutic exercises and transcutaneous electrical nerve stimulation (TENS), two modalities frequently used by physical therapists, that have been proposed as treatment options for chronic pain [6][7][8][9][10][11]. TENS, perhaps the lesser known of these two interventions, consists in applying electrical stimulation through skin electrodes to depolarize peripheral nerve fibers and induce hypoalgesia [12]. ...
Article
Purpose: Chronic pain is a highly prevalent and debilitating condition, and there is a pressing need to find safe, effective and affordable treatments to tackle this public health issue. This pilot study aimed to assess whether therapeutic exercises supplemented by transcutaneous electrical nerve stimulation induces a greater hypoalgesic effect than therapeutic exercises supplemented by sham transcutaneous electrical nerve stimulation, in an elderly population suffering from chronic pain. Materials and methods: Eighteen elderly participants suffering from chronic pain completed a therapeutic exercise program consisting of 45-min group sessions administered twice a week for 4 weeks. Half of the participants received real transcutaneous electrical nerve stimulation during the exercise sessions, while the others received sham transcutaneous electrical nerve stimulation. Participants completed pain questionnaires (McGill Pain Questionnaire, Brief Pain Inventory, Beck Depression Index) before and after the intervention, and recorded their pain levels on an 11-point numerical rating scale before and after each session (Clinical Trial.Gov ID: NCT02445677). Results and conclusion: Our results suggest that supplementing exercise sessions with transcutaneous electrical nerve stimulation does not improve the long-term outcomes of elderly patients suffering from chronic pain, but does induce short-term hypoalgesia during exercise sessions. Our study also offers valuable guidelines for the implementation of a future and adequately powered study looking at this research question. • Implications for rehabilitation • The application of transcutaneous electrical nerve stimulation during exercises is well tolerated by elderly individuals suffering from chronic pain. • Supplementing exercises with transcutaneous electrical nerve stimulation does not seem to improve general outcome in elderly suffering from chronic pain. • Notwithstanding, the addition of transcutaneous electrical nerve stimulation tends to produce a marked hypoalgesic effect during the exercise sessions, an effect that could prompt indirect benefits for pain patients.
... Хотя не все методики немедикаментозной терапии обладают доказанной эффективностью с позиций доказательной медицины, их применение оправдывает безопасность, позитивное влияние на качество жизни, физическую и социальную активность пациентов. Серия методических обзоров и метаанализов, опубликованных в последние годы, подтверждает положительное влияние на боль и функциональные нарушения при ХНБС таких методов, как чрескожная электронейростимуляция [98,99], акупунктура [100], остеопатия (хиропрактика, мануальная терапия) [101], массаж [102] и лечебная физкультура [103]. ...
Article
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Chronic nonspecific low back pain (CNSLBP) is a serious health and social problem and one of the major causes of disability and significantly lower quality of life of persons in the present-day population. The development of effective methods for treating CNSLBP requires the joint efforts of the representatives of various medical specialties: therapists, rheumatologists, neurologists, neurosurgeons, and rehabilitation therapists. Osteoarthritis of the facet and sacroiliac joints should be considered as one of the common causes of CNSLBP. The autors consider the pathogenesis and clinical manifestations, diagnostic problems of this pathology, as well as various approaches to its treatment. Based on their own experience and analysis of the data available in the literature, the authors defined a number of provisions that can later be used to formulate recommendations for the treatment and rehabilitation of patients with CNSLBP.
... The research evidence, TENS reduces hyperalgesia through both peripheral and central mechanisms, reducing the need for medication in these patients. 24,25 However, the different systematic reviews have examined the e cacy of TENS for low back pain with con icting results. [26][27][28][29][30][31][32][33] The contradiction is due often a lack of homogeneity in the studies, for example, with respect to location of TENS electrodes, frequency, intensity and duration of TENS stimulation, and the combination of TENS stimulation with another intervention. ...
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Background: Most patients who experience chronic low back pain are managed in primary care services, the international clinical guidelines endorse like first line of treatment the self-management and recommendations for the management of their ailment. The treatment of low back pain an individual self-maintenance program through a web application could mean maintaining of the symptoms, reducing costs in terms of medical care and time work absence. There is little evidence on the reliability of the via Internet-based rehabilitation systems to treat low back pain, the implementation of a clinical and efficient self-maintenance web program is a key priority for the health service in Andalusia. Methods: This protocol describes a double-blind, randomized controlled feasibility trial of a telemedicine program (e-Health intervention) developed to support the self-management of people with chronic low back pain in primary care physiotherapy. Three Hospital with primary care for outpatients will be the units of randomisation, in each Hospital the participants will be randomized to one of two groups, a pragmatic control group receiving either the usual home program based on electrostimulation and McKenzie Therapy and e-Health intervention. Patients are followed up at 2 and 6 months. The primary outcomes are (1) acceptability and demand of the intervention by general practitioners, physiotherapists and patients and (2) feasibility and optimal study design/ methods for a definitive trial. Secondary outcomes will include exploratory analysis and variation in clinical outcomes of pain, disability, fear of movement, quality of life, isometric resistance of the trunk flexors, lumbar mobility in flexion and lumbar segmental range of motion; and the effect of the intervention. Discussion: Through the specific e-Health programs at home, could increase adherence to treatment, patients could learn to control and self-manage the evolution of their low back pain, preventing its evolution to stages of greater pain and disability. If the painful symptomatology improves could be cost-effective healthcare tool that can reach a large number of people living in rural or remote areas. Trial Registration: PC-0185-2017/ NCT04283370. Registered 20 February 2020, https://clinicaltrials.gov/ct2/show/NCT04283370. Recruiting.
... Stimulation électrique nerveuse transcutanée :Elle consiste en l'application d'un courant électrique continu biphasique de faible intensité aux fibres nerveuses cutanées sans implication musculaire. Elle est utilisée dans le traitement des douleurs aiguë et chronique(168). Il existe deux types de courant antalgique : la stimulation à haute fréquence (80-100 Hz) ou à basse fréquence (2 à 10 Hz). La durée d'impulsion utilisée lors de la stimulation électrique nerveuse transcutanée est relativement courte (≤ 200 µs). ...
Thesis
La réhabilitation respiratoire (RR) est recommandée dans la prise en soin des patients atteints d’un handicap ventilatoire afin d’améliorer leur qualité de vie. Malgré une efficacité clairement établie, très peu de patients en bénéficient et les modalités optimales d’entrainement restent à définir. L’utilisation des outils existants et des nouveaux outils pour optimiser l’accès au programme et ses effets représentent des développements majeurs qui méritent d’être évalués. Dans le cadre de cette thèse, nous avons cherché à aborder ces deux problématiques (1) en tentant de proposer un modèle de RR délocalisée hors des centres tout en évaluant les freins à ce modèle et (2) en explorant la place de différents adjuvants à la RR afin d’en optimiser les bénéfices. Dans la première partie, nous avons montré, à travers plusieurs études rétrospectives et une contribution originale prospective multicentrique, que le test stepper de six minutes peut être utilisé pour prescrire l’entrainement en endurance, particulièrement pour les patients présentant une forme légère à modérée de bronchopneumopathie chronique obstructive (BPCO), mais pas pour prescrire le renforcement musculaire. Par ailleurs, nous avons montré dans une population de 105 patients adressés en RR que l’utilisation d’un dispositif de telemonitoring était faisable, valide et largement accepté. Enfin, nous avons exploré la prévalence des dysfonctions cognitives, autre conséquence systémique de la BPCO qui pourrait compromettre la délocalisation du programme, et avons montré que cette prévalence était très élevée (environ 75% des patients) mais que ces troubles cognitifs pouvaient s’améliorer après la RR et ne semblaient pas influencer l’utilisation d’un dispositif de telemonitoring. Dans la seconde partie, nous avons évalué la place de différents adjuvants à la RR utilisés pour en potentialiser les bénéfices. Dans une étude en cross-over menée chez 21 patients atteints de BPCO, nous avons montré que la ventilation non invasive ne permettait pas d’améliorer la capacité à l’exercice en endurance en raison d’une limitation technologique du ventilateur. A travers une étude contrôlée randomisée multicentrique menée chez 73 patients atteints de BPCO sévère à très sévère, nous avons montré que la stimulation électrique excito-motrice à domicile, réalisée en plus d’un programme de RR, n’apportait pas davantage de bénéfices sur la qualité de vie ou la capacité à l’exercice. Enfin, à travers une étude randomisée en cross-over et en double aveugle menée chez 10 patients, nous n’avons pas pu montrer l’intérêt de la stimulation électrique nerveuse transcutanée pour améliorer leur capacité à l’exercice en endurance. Enfin, dans la dernière partie, nous avons présenté les recherches actuellement menées au sein de notre laboratoire, faisant suite aux contributions originales décrites au cours de cette thèse, ainsi que de nouvelles pistes de recherche afin de poursuivre les thématiques explorées. Ainsi, deux revues de littérature et méta-analyses (l’une d’elle portant sur le haut débit nasal et l’autre sur l’utilisation des technologies de santé avancées pour réaliser la RR respiratoire à domicile) serviront de base pour de futurs travaux.
... 21 Transcutaneous electrical nerve stimulation (TENS), alone or in combination with other interventions, is one of the most common techniques for pain relief in chronic LBP. [22][23][24][25][26] Some studies have shown that TENS can lead to decreased use of pain medications and should be incorporated into the treatment arsenal for chronic LBP. 22 In spite of this, there is some controversy in the clinical evidence about its use as the only treatment in chronic LBP. ...
Article
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Introduction Chronic lower back pain is a highly prevalent medical condition in Western countries, which that incurs a considerable social and economic burden. Although prescription exercise at home for chronic pain has become a widely used alternative to reduce healthcare costs, the evidence regarding patient adherence and decreased in costs in European countries is scarce and inconclusive. The objective of this study is to examine the cost–utility and cost-effectiveness in patients with chronic lower back pain treated with the McKenzie Method and electroanalgesia via a telemedicine programme versus a face-to-face programme. Methods and analysis This study reports the protocol for a randomised, two-arm, multicentre, parallel controlled trial. A total of 540 patients with chronic lower back pain (onset time ≥3 months, Roland Morris Disability Questionnaire ≥4) will be recruited in three hospitals in Andalusia. Participants will be assigned to one of two groups (n=270, respectively) to receive electroanalgesia and Mckenzie method exercises through a telemedicine or a face-to-face programme. A total of 24 sessions will be administered three times a week for 8 weeks. Since the study design does not allow participant blinding, the outcome assessor and the statistician will be blinded. Use of helth care resources and costs due to work absenteeism will be captured and analysed. In addition, pain, intensity, fear of movement, quality of life and strength of the core muscle and anteflexion lumbar will be recorded at 2 and 6 months after the start of treatment. Ethics and dissemination Human Research and Local Ethics Committee of the ‘Hospital Complex Torrecárdenas of Almeria, University Hospital of Granada and Virgen Macarena de Sevilla Hospital—Andalusian Health Service’. Study findings will be released to the research, clinical and health service through publication in international journals and conferences. Trial registration number NCT04266366 .
... Conventional conservative treatment for CLBP focuses on electrotherapy, exercise therapy, and manual therapy [18]. Treatment of CLBP with Transcutaneous Electrical Nerve Stimulation (TENS) results in significant pain reduction [19]. Sayilir and Yildizgoren (2017) showed that using TENS for patients with CLBP could reduce pain and improved physical functions; hence, they suggested using TENS as part of the rehabilitation CLBP [20]. ...
Article
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It is unknown how diaphragm training combined with electrical stimulation affects pain, function, static stability, and balance in athletes with chronic low back pain (CLBP). This study aimed to explore the effects of combining diaphragm training with electrical stimulation on pain, function, static stability, and dynamic balance in athletes with nonspecific CLBP. The design was a randomized clinical trial. A total of 24 amateur athletes (12 women, 12 men, mean age: 35.2 ± 9.8) with nonspecific CLBP were randomly allocated into two groups. The experimental group (n = 12) received diaphragm training plus Transcutaneous Electrical Nerve Stimulation (TENS), while the control group (n = 12) received TENS alone. Both groups underwent 12 sessions over a four-week period. Static stability, dynamic balance, pain, and function were measured pre- and post-intervention. Analysis of variance 2 × 2 revealed greater improvements in pain (p < 0.001), static stability (p < 0.001), and dynamic balance (p < 0.01) in the experimental group compared to the control group. Function was improved in both groups following the interventions (p < 0.001), and there was a trend of a larger improvement in the experimental group than the control group (p = 0.09). Fisher’s exact test showed that the experimental group reported ≥50% improvement only in the pain score, not function, compared to the group that received TENS alone (p = 0.005). Pain, function, static stability, and dynamic balance were improved in both groups following 12 intervention sessions. However, pain, static stability, and dynamic balance were improved to a greater extent in diaphragm training plus TENS than TENS alone in amateur athletes with CLBP. Therefore, it seems beneficial to add diaphragm training to the rehabilitation program for athletes with nonspecific CLBP. The trial was retrospectively registered in the Iranian Registry of Clinical Trials (www.irct.ir) on September 10, 2020 as IRCT20090228001719N8.
... Therapeutic radiation CIED should be evaluated prior to radiation and a patient-specific treatment plan (including radiation dose estimation or measurement) should be outlined by CIED specialists and radiation oncologists prior to initiation of treatment CIED interrogation and ECG monitoring should be performed according to risk stratification during radiation therapy and after completion of the last fraction of treatment CIED-trained personnel readily available or on call is encouraged during radiation fractions for all CIED patients Relocation of a CIED for radiotherapy is not indicated, unless the device interferes with adequate tumour treatment Transcutaneous electrical nerve stimulation, electrical muscle stimulation, spinal cord stimulation Incidence and risk factors Electrical stimulation therapy (EST) such as transcutaneous electrical nerve stimulation (TENS), electrical muscle stimulation (EMS), or spinal cord stimulation (SCS) have been used for decades for the treatment of various pain conditions and other neuromuscular disorders including stroke, spinal cord injury, and refractory angina pectoris. [89][90][91][92][93][94] In TENS and EMS, different modalities of electrical current are applied using temporarily attached stimulation patches, whereas SCS requires surgical implantation of stimulation electrodes. In general, asymmetric biphasic impulses are delivered continuously with a frequency of 2-80 Hz. ...
... The subjective evaluation through NPRS has shown significant improvements in the use of TENS (Sayilir and Yildizg€ oren, 2017;Ebadi et al., 2018;Safdar et al., 2017;Jauregui et al., 2106). In addition, the metaanalysis performed by Jauregui et al. (2016) concludes that the use of TENS significantly reduced pain in cases of CLBP. However, despite the positive results, further randomized clinical trials are needed to seek the best parameters for the application of TENS. ...
Article
Objective To compare the immediate analgesic effect of transcutaneous nerve stimulation (TENS) and interferential current (IFC), with different combinations of parameters, in individuals with chronic low back pain (CLBP). Methodology 280 individuals with CLBP were included in the study, both genders, randomized in 8 groups: GI2KHz/100Hz, GI2KHz/2Hz, GI4KHz/100Hz, GI4KHz/2Hz, placebo interferential group (GIP), GT100Hz, GT2Hz, and placebo TENS group (GTP). All individuals underwent a single application of TENS or IFC for 30min. The assessments were carried out prior to the intervention, as well as immediately after, with the following outcomes: pain intensity (Numeric Pain Rating Scale-NPRS), qualitative pain characteristics (McGill Pain Questionnaire-MPQ), and pressure pain threshold (PPT) by pressure algometry (PA) in 4 points of the low back region. Results In the intergroup comparison of NPRS, all intervention groups showed greater pain reduction compared to GTP (p<0.05). In the total MPQ score, the groups that obtained significant results (p<0.05) when compared to GTP were GT100Hz and GT2Hz, while the groups GT100Hz and GI4KHz/100Hz were significant when compared to GIP. In the PA, GI4KHz/100Hz showed an increase in the PPT in all points compared to GTP and GI2KHz/100Hz. Conclusion Both TENS and IFC presented immediate analgesic effect in CLBP, with emphasis on the interferential current of 4KHz modulated at 100Hz.
... [5][6][7] Therapeutic exercise and physical therapy modalities can relieve pain intensity and alleviate back disability for patients with low back pain. [8][9][10][11][12] Transcutaneous electrical nerve stimulation and infrared ray thermal therapy are common modalities that are frequently used for treatment of chronic low back pain. 13,14 Among the numerous therapeutic exercises available, therapeutic aquatic exercise is often prescribed by physicians for chronic low back pain, and it is becoming increasingly popular for treatment of chronic low back pain. ...
Article
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Importance Therapeutic aquatic exercise is frequently offered to patients with chronic low back pain, but its long-term benefits are unclear. Objective To assess the long-term effects of therapeutic aquatic exercise on people with chronic low back pain. Design, Setting, and Participants This 3-month, single-blind randomized clinical trial with a 12-month follow-up period was performed from September 10, 2018, to March 12, 2019, and the trial follow-up was completed March 17, 2020. A total of 113 people with chronic low back pain were included in the experiment. Interventions Participants were randomized to either the therapeutic aquatic exercise or the physical therapy modalities group. The therapeutic aquatic exercise group received aquatic exercise, whereas the physical therapy modalities group received transcutaneous electrical nerve stimulation and infrared ray thermal therapy. Both interventions were performed for 60 minutes twice a week for 3 months. Main Outcomes and Measures The primary outcome was disability level, which was measured using the Roland-Morris Disability Questionnaire; scores range from 0 to 24, with higher scores indicating more severe disability. Secondary outcomes included pain intensity, quality of life, sleep quality, recommendation of intervention, and minimal clinically important difference. Intention-to-treat and per-protocol analyses were performed. Results Of the 113 participants, 59 were women (52.2%) (mean [SD] age, 31.0 [11.5] years). Participants were randomly allocated into the therapeutic aquatic exercise group (n = 56) or the physical therapy modalities group (n = 57), and 98 patients (86.7%) completed the 12-month follow-up. Compared with the physical therapy modalities group, the therapeutic aquatic exercise group showed greater alleviation of disability, with adjusted mean group differences of −1.77 (95% CI, −3.02 to −0.51; P = .006) after the 3-month intervention, −2.42 (95% CI, −4.13 to −0.70; P = .006) at the 6-month follow-up, and −3.61 (95% CI, −5.63 to −1.58; P = .001) at the 12-month follow-up (P < .001 for overall group × time interaction). At the 12-month follow-up point, improvements were significantly greater in the therapeutic aquatic exercise group vs the physical therapy modalities group in the number of participants who met the minimal clinically important difference in pain (at least a 2-point improvement on the numeric rating scale) (most severe pain, 30 [53.57%] vs 12 [21.05%]; average pain, 14 [25%] vs 11 [19.30%]; and current pain, 22 [39.29%] vs 10 [17.54%]) and disability (at least a 5-point improvement on the Roland-Morris Disability Questionnaire) (26 [46.43%] vs 4 [7.02%]). One of the 56 participants (1.8%) in the therapeutic aquatic exercise group vs 2 of the 57 participants (3.5%) in the physical therapy modalities group experienced low back pain and other pains related to the intervention. Conclusions and Relevance The therapeutic aquatic exercise program led to greater alleviation in patients with chronic low back pain than physical therapy modalities and had a long-term effect up to 12 months. This finding may prompt clinicians to recommend therapeutic aquatic exercise to patients with chronic low back pain as part of treatment to improve their health through active exercise rather than relying on passive relaxation. Trial Registration Chinese Clinical Trial Registry: ChiCTR1800016396
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Back pain is a common disease and although it can be located in any of its cervical, thoracic and lumbosacral sections, however the vast majority of patients complain of lumbosacral pain. Back pain syndromes has become a challenge for modern rehabilitation, both in the issue of the prevention as well as therapy. A major problem for people with back pain is progressive disability, and thus a deterioration in the quality of life. Despite many treatment methods and health care resources devoted to back pain, disability and burden are increasing. An important place in the therapy of back pain syndromes is occupied by physical methods and health resort treatment. The work presents the use of balneotherapy and physiotherapy in the most common back pain syndromes, i.e. in chronic diseases of the intervertebral discs and degenerative changes of the lumbosacral spine.
Article
Background: There is little evidence on the reliability of the web application-based rehabilitation systems to treat chronic low back pain (CLBP). Methods: This protocol describes a double-blind, randomized controlled feasibility trial of an e-Health intervention developed to support the self-management of people with CLBP in primary care physiotherapy. Three Hospitals with primary care for outpatients will be the units of randomisation, in each Hospital the participants will be randomized to one of two groups, a pragmatic control group receiving either the usual home program based on electrostimulation and McKenzie Therapy and e-Health intervention. Patients are followed up at 2 and 6 months. The primary outcomes are (1) acceptability and demand of the intervention by GPs, physiotherapists and patients and (2) feasibility and optimal study design/methods for a definitive trial. Secondary outcomes will include analysis in the clinical outcomes of pain, disability, fear of movement, quality of life, isometric resistance of the trunk flexors, lumbar anteflexion and lumbar segmental range of motion. Discussion: The specific e-Health programs to home could increase adherence to treatment, prevent stages of greater pain and disability, and improve the painful symptomatology. Conclusions: The e-Health programs could be an effective healthcare tool that can reach a large number of people living in rural or remote areas.
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The use of opioid analgesics for postoperative pain management has contributed to the global opioid epidemic. It was recently reported that prescription opioid analgesic use often continued after major joint replacement surgery even though patients were no longer experiencing joint pain. The use of epidural local analgesia for perioperative pain management was not found to be protective against persistent opioid use in a large cohort of opioid-naïve patients undergoing abdominal surgery. In a retrospective study involving over 390,000 outpatients more than 66 years of age who underwent minor ambulatory surgery procedures, patients receiving a prescription opioid analgesic within 7 days of discharge were 44% more likely to continue using opioids 1 year after surgery. In a review of 11 million patients undergoing elective surgery from 2002 to 2011, both opioid overdoses and opioid dependence were found to be increasing over time. Opioid-dependent surgical patients were more likely to experience postoperative pulmonary complications, require longer hospital stays, and increase costs to the health-care system. The Centers for Disease Control and Prevention emphasized the importance of finding alternatives to opioid medication for treating pain. In the new clinical practice guidelines for back pain, the authors endorsed the use of non-pharmacologic therapies. However, one of the more widely used non-pharmacologic treatments for chronic pain (namely radiofrequency ablation therapy) was recently reported to have no clinical benefit. Therefore, this clinical commentary will review evidence in the peer-reviewed literature supporting the use of electroanalgesia and laser therapies for treating acute pain, cervical (neck) pain, low back pain, persistent post-surgical pain after spine surgery (“failed back syndrome”), major joint replacements, and abdominal surgery as well as other common chronic pain syndromes (for example, myofascial pain, peripheral neuropathic pain, fibromyalgia, degenerative joint disease/osteoarthritis, and migraine headaches).
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Background Perception is the process or result of the process arising from the mental interpretation of the phenomena occurring, therefore it depends not only on physiology, but is also psychologically and socially conditioned. The aim of this study was to assess if there is a difference in the sensory sensitivity to an electrical stimulus in women suffering from depression and what the hedonic rating is of the lived experience of transcutaneous electrical nerve stimulation. Methods The depression group: 44 women, who were inpatients treated for depression at the Psychiatric Ward in the Clinical Hospital, and the control group: 41 women, matched by the age, height and weight, with no mental illness. Measures: threshold for sensing current, type of sensation evoked, hedonic rating. Results Median sensing threshold of electric current (depression vs. control: 7.75 mA vs. 8.35 mA; no significant), type of sensation evoked (depression vs. control: tingling 90.9% vs. 92.7%, no significant), hedonic rating (depression vs. control: unpleasant 11.4% vs. 2.4%; p = 0.003), hedonic rating (mildly ill vs. moderately ill vs. markedly ill: unpleasant 5.3% vs. 6.3% vs. 33.3%; p = 0.066). Conclusions Women suffering from depression exhibit a similar threshold of sensitivity to an electrical stimulus as mentally healthy women, however the hedonic rating of the stimulus acting on the skin in the group of clinically depressed women was more negative than in the mentally healthy subjects. The stimulus was described as ‘unpleasant’ for many of the mentally unhealthy women. The most negative sensations related to the electrical stimulus were experienced by women with the highest severity of mental illness according to The Clinical Global Impression - Severity Scale.
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Background and objectives: This study is a meta-analysis of randomized controlled trials comparing the efficacy of transcutaneous electrical nerve stimulation (TENS) to a control and to other nerve stimulation therapies (NSTs) for the treatment of chronic back pain. Methods: Citations were identified in MEDLINE, the Cochrane Library, Google Scholar, and ClinicalTrials.gov through June 2014 using the following keywords: nerve stimulation therapy, transcutaneous electrical nerve stimulation, back pain, chronic pain. Control treatments included sham, placebo, or medication only. Other NSTs included electroacupuncture, percutaneous electrical nerve stimulation, and percutaneous neuromodulation therapy. Results: Twelve randomized controlled trials including 700 patients were included in the analysis. The efficacy of TENS was similar to that of control treatment for providing pain relief (standardized difference in means [SDM] = -0.20; 95% confidence interval [CI], -0.58 to 0.18; P = 0.293). Other types of NSTs were more effective than TENS in providing pain relief (SDM = 0.86; 95% CI, 0.15-1.57; P = 0.017). Transcutaneous electrical nerve stimulation was more effective than control treatment in improving functional disability only in patients with follow-up of less than 6 weeks (SDM = -1.24; 95% CI, -1.83 to -0.65; P < 0.001). There was no difference in functional disability outcomes between TENS and other NSTs. Conclusions: These results suggest that TENS does not improve symptoms of lower back pain, but may offer short-term improvement of functional disability.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
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Physical modalities are tools that can be used to complement a patient's rehabilitation treatment plan through the use of thermal, sound, electrical, and light energy. They can be used to address pain, swelling, soft tissue restrictions, joint range of motion (ROM) limitations, and muscle weakness, as well as to promote tissue healing, thereby improving a patient's ability to participate in other aspects of rehabilitation therapy (e.g., therapeutic exercise, functional mobility retraining, etc.). A general overview of the physical modalities most commonly used in canine rehabilitation is presented, with a goal of assisting the therapist in determining if and when their use may improve treatment outcome. The modalities discussed are cryotherapy and superficial heating (superficial thermal agents), therapeutic ultrasound (TUS), neuromuscular electrical stimulation (NMES) and transcutaneous electrical nerve stimulation (TENS) (electrical stimulation modalities), low-level laser therapy (LLLT)/photobiomodulation, and extracorporeal shock wave therapy (ESWT). Patients affected by orthopedic and neurological injuries, working and sporting dogs, and the geriatric population can all benefit from use of physical modalities at some point during their rehabilitation program.
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This study focuses on the acute influence of non-thermal alternating current (AC) electromagnetic field (EMF) exposure (50 Hz, peak magnetic flux density Bmax180 mT, 15-min duration of exposure) on blood flow velocity in healthy human subjects. Healthy subjects (11 males, age range 21-56 years) participated after signing an informed consent form approved by the university's institutional review board. The values of the blood flow velocity in an ulnar artery in a biceps brachii were measured and compared with two different exposures, i.e., the sham control (CTL) exposure and the EMF exposure. The EMF exposure was randomly applied to either forearm or neck. In a randomized, double-blind, and counterbalanced manner, the CTL exposure and the EMF exposure were carried out. The values of the blood flow velocity in the CTL exposure were significantly decreased compared with the baseline value (indicated as 100%), probably due to immobility stress-induced ischemic conditions by preventing the arm from moving. In forearm exposure, the values of the blood flow velocity were significantly increased by the EMF exposure during and after exposure periods compared with the CTL exposure. In neck exposure, the values of the blood flow velocity were not significantly changed by the EMF exposure, but there were significant differences between the control and EMF groups. When considering the physiological significance of the non-thermal EMF effects, these results imply that the physiological role of the EMF-enhanced blood circulation might help eliminate the metabolic waste products and endogenous pain producing substances inducing muscle stiffness and pain.
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Background: Transcutaneous electrical nerve stimulation (TENS) is a promising non-pharmacological modality for the management ofchronic low back pain (CLBP), but its efficacy and mode of action have not been clearly established. Objective: To evaluate the responses of plasma beta-endorphin (βE), met-enkephalin (ME), and pain intensity (PI) among patients with CLBP exposed to TENS or sham-TENS. Methods: This double-blind trial involved 62 participants (aged 53.29 ± 5.07 years) randomised into TENS group (frequency 100 Hz, burst-rate 2 Hz, burst-width 150 μs, intensity 40 mA, duration 30 min), and sham-TENS group. The PI and plasma concentrations of βE and ME were measured at baseline, immediately (0 hr), 1 hr, 24 hrs, and 48 hrs post-intervention. Data were analysed using general linear model repeated measures, ordinal regression, one-way analysis of variance, Kruskal-Wallis test, independent and paired t-tests, Mann-Whitney U test, Wilcoxon signed-rank test, and Kendall's tau coefficient. Results: There was a significant temporal difference in PI between groups, F (1, 58) = 18.83, p< 0.001; the TENS group had better pain relief. The relative analgesic effect of TENS started immediately after the intervention (median difference [M⁢D] =-3, p< 0.001), peaked at 1 hr (M⁢D=-4, p< 0.001), and worn out by 24 hrs (M⁢D=-1, p= 0.029). However, there was no significant difference in βE and ME between the groups from 0 hr to 24 hrs post interventions, and no significant correlation between the PI, and βE, or ME. Conclusion: TENS significantly reduced PI up to 24 hrs after treatment.
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The Knowledge Alliance Prevent4Work for Preventing Work-Related Musculoskeletal Disorders aims at establishing a collaborative network between higher education and research world, work health-related institutions, technology enterprises, and companies from different activity sectors to develop innovative educational programs, high quality evidence-based material and actions that could be implemented in the European Union to improve the prevention and management of Work-Related Musculoskeletal Disorders. The present work compiles the proceedings of the Third P4Work Symposium – Work & Pain. The virtual symposium was organized by Universidad San Jorge and INP Formation in collaboration with the other partners of the "Prevent 4 Work" project and was held on 20 October 2021 via Zoom.
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Background The objectives of this study were to evaluate the effects of an ultrasound (US)‐guided percutaneous neuromodulation (PNM) intervention on the sciatic nerve, regarding pain, hip range of motion (ROM), balance, and functionality in patients with chronic low back pain (LBP); and to determine the optimal anatomical location of sciatic nerve stimulation to obtain therapeutic benefits in such patients. Materials and Methods Thirty patients with chronic LBP were recruited and divided randomly into three groups. All patients received a single percutaneous electrical stimulation intervention on the sciatic nerve, with a different anatomical application location for each group (proximal, middle, and distal). Level of pain, hip passive ROM, dynamic balance, and Oswestry disability index were analyzed. All variables were calculated before the intervention, immediately postintervention, 48 hours and one week after the intervention, except the LBP questionnaire (before, and 48 hours and one week after the intervention). Results All interventions decreased the level of pain and increased the ROM, balance, and functionality. Besides, these therapeutic effects were maintained during one week, regardless of the anatomical location of application. Conclusions The choice of an anatomical location of application of the US‐guided PNM on the sciatic nerve by the physiotherapist does not influence the improvement of pain, ROM, balance, and function in patients with chronic LBP.
Article
This article highlights the role that lifestyle medicine plays in managing lower back pain as a cost-effective intervention strategy. It is suggested that lifestyle medicine strategies, such as incorporating whole foods and a plant-based diet, sustainable physical activity and mind-body exercises, restorative sleep, stress resiliency, awareness and mitigation of substance abuse and addiction, and establishing meaningful social networks and self-care strategies, be a part of managing chronic lower back pain.
Article
Objective Transcutaneous electrical nerve stimulation (TENS) and peripheral nerve field stimulation (PNFS) may be proposed to patients with chronic lumbar pain refractory to conventional treatment. Aim of this study was to assess the importance of preoperatively treatment with TENS as a predictive value for later successful PNFS and impact of PNFS in follow‐up of 12 months. Methods Between 2012 and 2016, a retrospective analysis of 25 patients with chronic lumbar pain and implantation of a PNFS‐system was performed. Pain intensity (NRS), health‐related quality of life (EQ‐5D‐5L), Oswestry disability index (ODI), actual mood state scale (ASTS), and treatment satisfaction (CSQ‐8) were assessed pre/postoperatively, after 6 and 12 months. TENS use before surgery was assessed. Results The cohort consisted of 25 patients with a median age of 56 years (IQR25‐75 51–63). In a subgroup analysis, 18 patients used TENS before surgery, 7 did not use TENS and were excluded. No pain relief was observed in 14 patients. Ten of these patients showed later positive effect in PNFS trial stimulation. In four patients, pain relief with TENS was seen. One patient later on had no benefit after PNFS trial, three had sufficient pain relief. In the whole cohort, five patients had no benefit after PNFS trial, in 20 patients a neurostimulator was implanted. NRS, EQ‐5D‐5L, and ODI measures showed significant improvement in the whole follow‐up after PNFS implantation. ASTS scale showed an increase of values for positive mood and a reduction in values for sorrow, fatigue, and anger. In 55%, a sustained reduction in demand for analgesics was seen after 6 months, 50% after 12 months, respectively. Conclusion In this retrospective analysis, TENS has no predictive value in the selection of patients with low back pain for the PFNS treatment. PNFS is effective and safe to relieve significantly symptoms of chronic low back pain.
Article
Background and Purpose: This study aimed to investigate the effect of intermittent diet and/or physical therapy in patients with chronic low back pain. Materials and Methods: Sixty sedentary volunteers with chronic low back pain participated in the study. Body weight and body mass index (BMI) were measured. Pain severity was assessed using Visual Analogue Scale (VAS) and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), while assessment of disability was done using Barthel Index (BI). Results: The weight and BMI were reduced after treatment with diet only and diet plus physical therapy (p < 0.001). The pain severity was reduced in all the treated groups (p < 0.001), while BI was increased in the group treated with only physical therapy (p < 0.001). Conclusion: The present study indicated that intermittent diet and/or physical therapy are beneficial to patients with chronic low back pain in terms of pain sensation and daily activities.
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Objective: The purpose of this study was to determine if transcutaneous electrical nerve stimulation (TENS) improves sleep in chronic low back pain (CLBP). Background: There is uncertainty over the effectiveness of TENS in CLBP. In most studies, pain intensity has been the primary outcome measure. Although sleep abnormalities are common in CLBP, sleep outcomes have not been evaluated in most studies of TENS effectiveness. Subjective and objective sleep measures are often inconsistent in CLBP, suggesting that perception of sleep and actual sleep may differ. Methods: This retrospective cohort study evaluated TENS for CLBP over 10 weeks. The source database included demographics, pain characteristics, pain intensity and interference on an 11-point numerical rating scale, adherence and actigraphic sleep data from real-world TENS users. Key inclusion criteria were CLBP with self-reported history of back injury and baseline pain interference with sleep ≥4. Study participants were stratified into improved and unimproved groups based on changes in pain interference with sleep (improved ≥1-point decrease). Actigraphic sleep metrics were compared between the two groups for weeks 1-2 and weeks 9-10. Results: The inclusion criteria were met by 554 TENS users. There were 282 (50.9%) participants in the improved group and 272 (49.1%) in the unimproved group. The two groups had similar baseline characteristics and high TENS adherence. At the weeks 1-2 assessment, there were no differences among actigraphic sleep. At the weeks 9-10 assessment, there was a difference in total sleep time, with the improved group sleeping 29 minutes longer. In addition, the periodic leg movement (PLM) index was lower in the improved group. Conclusion: Regular TENS improved self-reported and objective sleep measures in individuals with CLBP. When compared to the unimproved group, the improved group had longer total sleep time and fewer PLMs. Sleep may be an important outcome for TENS effectiveness in CLBP.
Article
Background and aims There has been no comprehensive evaluation of the efficacy of transcutaneous electric nerve stimulation (TENS) for acute low back pain (LBP). The aim of this systematic review was to investigate the efficacy and safety of TENS for acute LBP. Methods We searched MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL and PsycINFO (inception to May 2018) for randomised placebo controlled trials. The primary outcome measure was pain relief in the immediate term (within 2-weeks of administration) assessed using the 100 mm visual analogue scale. A mean difference of at least 10 points on the 100-point pain scale was considered clinically significant. Methodological quality of the eligible studies was assessed using the PEDro scale and overall quality assessment rating was assessed using GRADE. Results Three placebo controlled studies ( n = 192) were included. One low quality trial ( n = 63) provides low quality evidence that ~30 min treatment with TENS in an emergency-care setting provides clinically worthwhile pain relief for moderate to severe acute LBP in the immediate term compared with sham TENS [Mean Difference (MD) – 28.0 (95% CI – 32.7, −23.3)]. Two other studies which administered a course of TENS over 4–5 weeks, in more usual settings provide inconclusive evidence; MD −2.75 (95% CI −11.63, 6.13). There was limited data on adverse events or long term follow-up. Conclusions The current evidence is insufficient to support or dismiss the use of TENS for acute LBP. Implications There is insufficient evidence to guide the use of TENS for acute LBP. There is low quality evidence of moderate improvements in pain with a short course of TENS (~30 min) during emergency transport of patients to the hospital. Future research should evaluate whether TENS has an opioid sparing role in the management of acute LBP.
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Purpose: This prospective, randomized and single-blinded study assesses the influence of radial extracorporeal shock wave therapy (rESWT) in patients with low back pain (LBP). Methods: A total of 52 patients with LBP were enrolled in the study, out of which a homogeneous group of 40 patients with mean age of 53.45±4.9 years was included. Patients were randomized into group A (n=20) treated with rESWT (2000 pulses; 2.5 bars; 5 Hz, 7 mins) performed twice a week for five weeks (10 sessions) and stabilization training, as well as group B (n=20) treated with sham rESWT and stabilization training. To analyze the therapeutic progress, the following tests were performed (before and after therapy; 1 and 3 months follow-up) to assess pain and functional efficiency: (1) Visual Analog Scale (VAS), (2) Laitinen Pain Scale (LPS), and (3) Oswestry Disability Index (ODI). Results: The control group had a statistically significant advantage over the rESWT group (4.4 vs. 3.1 points on the VAS; p=0.039). However, in long-term observations, group A gradually experienced more pain relief than group B (2.7 vs. 3.5 points, p>0.05, at one month and 2.0 vs. 4.4 points at three months after treatment; p<0.0001). Similar findings can be seen in the analysis of changes in pain sensations measured with the LPS. The functional state (ODI) was better in rESWT group, especially in follow-up observation (9.3 vs. 14.6 points, p=0.033, at one month and 9.3 vs. 17.8 points, p=0.004, at three months after treatment). Conclusion: The rESWT combined with stabilization training is particularly effective in the long-term and achieves a stable beneficial effect for patients with LBP. The use of rESWT has a significant long-term influence on the reduction of pain and the improvement of the general functional state in relation to the conventional motor improvement program.
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Background Non-specific low back pain (LBP) is the leading cause of disability worldwide. The primary physiotherapeutic treatment for LBP is physical exercise, but evidence suggesting a specific exercise as most appropriate for any given case is limited. Objective To determine if specific stabilization exercise (SSE) is more effective than traditional trunk exercise (TTE) in reducing levels of pain, disability and inflammation in women with non-specific low back pain (LBP). Design A pilot randomized controlled trial was conducted in Rovira i Virgili University, Catalonia. Methods Thirty-nine females experiencing non-specific LBP were included in two groups: the TTE program and SSE program, both were conducted by a physiotherapist during twenty sessions. The primary outcome was pain intensity (10-cm Visual Analogue Scale). Secondary outcomes were disability (Roland Morris Disability Questionnaire), and inflammation (IL-6 and TNF- α plasma levels). Measurements were taken at baseline, at half intervention, at post-intervention, and a month later. Results Mean group differences in change from baseline to post-intervention for TTE were: −4.5 points (CI 3.3 to 5.6) for pain, −5.1 points (CI 3.0 to 7.3) for disability, 0.19 pg/mL (95% CI [−1.6–1.2]) for IL-6 levels, and 46.2 pg/mL (CI 13.0 to 85.3) for TNF- α levels. For SSE, differences were: −4.3 points (CI 3.1 to 5.6) for pain, −6.1 points (CI 3.7 to 8.6) for disability, 1.1 pg/mL (CI 0.0 to 2.1) for IL-6 levels , and 12.8 pg/mL (95% CI [−42.3–16.7]) for TNF- α levels. There were an insignificant effect size and no statistically significant overall mean differences between both groups. Conclusion This study suggests that both interventions (traditional trunk and specific stabilization exercises) are effective in reducing pain and disability in non-specific LBP patients, but the two programs produce different degrees of inflammation change. Clinical trial registration number NCT02103036.
Article
Introduction: Humans have always experienced pain. Pain is defined as an unpleasant sensory and emotional experience which affects the quality of life and disturbs individuals’ day-to-day functioning. The instruments of measuring pain that are available nowadays include numeric, visual, analogue visual methods as well as the algometry-based method. Proper pain treatment plans and techniques can only be administered if accurate and correct diagnosis and measurements of pain are made. M aterial and Methods: There were 240 low back pain patients involved in the study. They were divided into two groups: 120 of them were treated on an outpatient basis, and the other 120 underwent health resort treatment. Pain measurements were made prior to and after the treatment with the use of the VAS and algometry. Results: In the study we found that the condition of the patients who received health resort treatment got much better compared to the condition of the patients who received outpatient treatment. As far the use of the measuring instruments is concerned, no differences were found between the VAS and algometry. There is no statistically significant correlation between the VAS measurements and measuring pain thresholds with the use of algometry.
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In most patients after lumbar discoectomy, despite the elimination of root compression, the manifestations of chronic radiculopathy continue. Pain syndrome persists in 85.8% of patients, numbness in 74.1%, and paresthesia in 44.7%. Objective:to study the efficacy of transcutaneous electroneurostimulation (TENS) of the peroneal and tibial nerves in the treatment of patients with neurological deficit after undergoing discoectomy at the L4–S1 level. Materials and methods. After a course of pharmacotherapy, 15 patients underwent a course of direct stimulation of the peroneal and tibial nerves using transcutaneous electroneurostimulation, and 15 patients underwent a course of sham stimulation. Conclusion. Direct labile stimulation of the peroneal and tibial nerves using a monopolar current with a frequency of 1Hz, a duration of 200 μs and an amplitude that induces a painless motor response is a highly effective method of treating patients with residual clinical neurological manifestations after undergoing discoectomy at the L4–S1 level. Against the background of this method, the symptoms of tension, motor deficit, gait disturbance, impaired аchilles reflex and pain syndrome in the sensory and affective aspects are reliably regressed.
Article
Objective Peripheral nerve field stimulation (PNFS) is an effective alternative treatment for patients with chronic low back pain. Transcutaneous electrical nerve stimulation (TENS) is frequently used in pain therapy. Aim of this prospective study was to examine the predictive value of TENS for later PNFS treatment. Materials and Methods Between 2014 and 2019, a prospective cohort study of 41 patients with chronic lumbar pain was conducted. Pain intensity (NRS) was assessed before and after TENS use, preoperatively/postoperatively and in the follow‐up after three and six months, SF12v2 questionnaires with physical (PCS) and mental component summary (MCS) scores, and Oswestry disability index (ODI) questionnaire at baseline as well as three and six months after PNFS implantation. Implantation of the PNFS‐system with two percutaneous leads was performed after four to seven days of positive testing. Statistical analysis was performed using depending t ‐test, ANOVA, and Spearman correlation. Results The cohort consisted of 41 patients (19 females, 22 males) with a median age of 60.5 years (IQR25‐75 52–67). Two patients were lost to follow‐up. After positive PNFS testing a pulse generator (IPG) was implanted in 15 patients with positive TENS effect and 15 patients without TENS effect. Leads were explanted in nine patients after negative PNFS trial phase. TENS positive patients showed significant correlation to a positive effect in the PNFS trial phase in NRS reduction (p = 0.042) indicating that TENS responders will also respond to PNFS (94% patients). After three and six months follow‐up median NRS and SF12v2 (PCS) improved significantly in both cohorts, SF12v2 (MCS) and ODI only in the TENS positive cohort, respectively. Conclusion TENS can be predictive for patient selection in PNFS, as TENS positive patients showed significant correlation with a positive PNFS trial period. Therefore, TENS positive patients might be justifiable to be directly implanted with leads and IPG. TENS positive patients further tend to show a better improvement in the follow‐up.
Article
Background Musculoskeletal pain is often caused by self-enforcing cycles on physical, psychological and social level, leading to an escalation through feedback. Treatment objective The goal is to bring the disturbed control system towards the optimum mean value, to dampen the self-enforcing symptom—adjustment disruption—symptom feedback, to activate the resilience mechanism through therapeutic interventions and to achieve a permanent stable condition. Furthermore, insufficient treatment or a delay in treatment initiation can lead to chronicity of the complaints. Methods Physical combination therapy comprises thermotherapy (e.g. moor, mud, paraffin, cataplasm, shortwave, decametric wave, microwave, hot air or red light), electrotherapy (e.g galvanisation; impulse galvanisation; iontophoresis; pulsed-current, interferential or exponential current therapy; four-chambered galvanic baths), mechanotherapy (e.g. curative massage, ultrasound, hydrotherapy). For pronounced chronic forms of back pain, multidisciplinary treatments including psychological interventions, high-intensity occupational back training (>5 h/day), and exercise and functional therapy are indicated. In multimodal therapy, non-medical treatments have priority, e.g., behavioral therapy, mindfulness-based stress reduction or yoga. Results There are numerous studies proving the efficiency of physical combination therapy. In the state of chronicity (pain disorder), structural multimodal programs are required.
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To estimate the global burden of low back pain (LBP). LBP was defined as pain in the area on the posterior aspect of the body from the lower margin of the twelfth ribs to the lower glutaeal folds with or without pain referred into one or both lower limbs that lasts for at least one day. Systematic reviews were performed of the prevalence, incidence, remission, duration, and mortality risk of LBP. Four levels of severity were identified for LBP with and without leg pain, each with their own disability weights. The disability weights were applied to prevalence values to derive the overall disability of LBP expressed as years lived with disability (YLDs). As there is no mortality from LBP, YLDs are the same as disability-adjusted life years (DALYs). Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, LBP ranked highest in terms of disability (YLDs), and sixth in terms of overall burden (DALYs). The global point prevalence of LBP was 9.4% (95% CI 9.0 to 9.8). DALYs increased from 58.2 million (M) (95% CI 39.9M to 78.1M) in 1990 to 83.0M (95% CI 56.6M to 111.9M) in 2010. Prevalence and burden increased with age. LBP causes more global disability than any other condition. With the ageing population, there is an urgent need for further research to better understand LBP across different settings.
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This study evaluated patients who were given transcutaneous electrical nerve stimulation (TENS) compared with a matched group without TENS prior to intervention and at 1-year follow-up. Patients who were treated with TENS had significantly fewer hospital and clinic visits, used less diagnostic imaging (31 vs 46 events per 100 patients), had fewer physical therapy visits (94 vs 107), and required less back surgery (7.5 vs 9.2 surgeries) than patients receiving other treatment modalities. Total annual costs for chronic low back pain patients without neurological involvement were lower in TENS patients ($17,957 vs $17,986 for non-TENS), even when the cost of the device was taken into account.
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Transcutaneous electrical nerve stimulation (TENS) and interferential current are the most used electrotherapy methods, although there is little scientific evidence to support their use. The aim of this study was to compare the effects of TENS and interferential current among patients with nonspecific chronic low back pain. Single-blind randomized controlled trial in the Department of Physiotherapy, Centro Universitário de Maringá. One hundred and fifty patients were randomly divided into three groups: TENS (group 1), interferential current (group 2) and controls (group 3). The patients designated for electrotherapy received ten 30-minute sessions, while the control group remained untreated. All patients and controls were evaluated before and after treatment using a visual analog scale and the McGill Pain and Roland Morris questionnaires, and regarding their use of additional medications. There was a mean reduction on the visual analog scale of 39.18 mm with TENS, 44.86 mm with interferential current and 8.53 mm among the controls. In the Roland Morris questionnaire, group 1 had a mean reduction of 6.59; group 2, 7.20; and group 3, 0.70 points. In group 1, 84% of the patients stopped using medications after the treatment; in group 2, 75%; and in group 3, 34%. There was no statistically significant difference between the TENS and interferential current groups (P > 0.05); a difference was only found between these groups and the controls (P < 0.0001). There was no difference between TENS and interferential current for chronic low back pain treatment. NCT01017913.
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To report chronic opioid therapy discontinuation rates after five years and identify factors associated with discontinuation. Medical and pharmacy claims records from January 2000 through December 2005 from a national private health network (HealthCore), and Arkansas (AR) Medicaid were used to identify ambulatory adult enrollees who had 90 days of opioids supplied. Recipients were followed until they discontinued opioid prescription fills or disenrolled. Kaplan Meier survival models and Cox proportional hazards models were estimated to identify factors associated with time until opioid discontinuation. There were 23,419 and 6,848 chronic opioid recipients followed for a mean of 1.9 and 2.3 years in the HealthCore and AR Medicaid samples. Over a maximum follow up of 4.8 years, 67.0% of HealthCore and 64.9% AR Medicaid recipients remained on opioids. Recipients on high daily opioid dose (greater than 120 milligrams morphine equivalent (MED)) were less likely to discontinue than recipients taking lower doses: HealthCore hazard ratio (HR) = 0.66 (95%CI: 0.57-0.76), AR Medicaid HR = 0.66 (95%CI: 0.50-0.82). Recipients with possible opioid misuse were also less likely to discontinue: HealthCore HR = 0.83 (95%CI: 0.78-0.89), AR Medicaid HR = 0.78 (95%CI: 0.67-0.90). Over half of persons receiving 90 days of continuous opioid therapy remain on opioids years later. Factors most strongly associated with continuation were intermittent prior opioid exposure, daily opioid dose ≥ 120 mg MED, and possible opioid misuse. Since high dose and opioid misuse have been shown to increase the risk of adverse outcomes special caution is warranted when prescribing more than 90 days of opioid therapy in these patients.
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To estimate the prevalence of and risk factors for opioid abuse/dependence in long-term users of opioids for chronic pain, including risk factors for opioid abuse/dependence that can potentially be modified to decrease the likelihood of opioid abuse/dependence, and non-modifiable risk factors for opioid abuse/dependence that may be useful for risk stratification when considering prescribing opioids. We used claims data from two disparate populations, one national, commercially insured population (HealthCore) and one state-based, publicly insured (Arkansas Medicaid). Among users of chronic opioid therapy, we regressed claims-based diagnoses of opioid abuse/dependence on patient characteristics, including physical health, mental health and substance abuse diagnoses, sociodemographic factors, and pharmacological risk factors. Among users of chronic opioid therapy, 3% of both the HealthCore and Arkansas Medicaid samples had a claims-based opioid abuse/dependence diagnosis. There was a strong inverse relationship between age and a diagnosis of opioid abuse/dependence. Mental health and substance use disorders were associated with an increased risk of opioid abuse/dependence. Effects of substance use disorders were especially strong, although mental health disorders were more common. Concerning opioid exposure; lower days supply, lower average doses, and use of Schedule III-IV opioids only, were all associated with lower likelihood of a diagnosis of opioid abuse/dependence. Opioid abuse and dependence are diagnosed in a small minority of patients receiving chronic opioid therapy, but this may under-estimate actual misuse. Characteristics of the patients and of the opioid therapy itself are associated with the risk of abuse and dependence.
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A number of treatments are widely prescribed for chronic back pain, but few have been rigorously evaluated. We examined the effectiveness of transcutaneous electrical nerve stimulation (TENS), a program of stretching exercises, or a combination of both for low back pain. Patients with chronic low back pain (median duration, 4.1 years) were randomly assigned to receive daily treatment with TENS (n = 36), sham TENS (n = 36), TENS plus a program of exercises (n = 37), or sham TENS plus exercises (n = 36). After one month no clinically or statistically significant treatment effect of TENS was found on any of 11 indicators of outcome measuring pain, function, and back flexion; there was no interactive effect of TENS with exercise. Overall improvement in pain indicators was 47 percent with TENS and 42 percent with sham TENS (P not significant). The 95 percent confidence intervals for group differences excluded a major clinical benefit of TENS for most outcomes. By contrast, after one month patients in the exercise groups had significant improvement in self-rated pain scores, reduction in the frequency of pain, and greater levels of activity as compared with patients in the groups that did not exercise. The mean reported improvement in pain scores was 52 percent in the exercise groups and 37 percent in the nonexercise groups (P = 0.02). Two months after the active intervention, however, most patients had discontinued the exercises, and the initial improvements were gone. We conclude that for patients with chronic low back pain, treatment with TENS is no more effective than treatment with a placebo, and TENS adds no apparent benefit to that of exercise alone.
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Although high-frequency low-intensity transcutaneous electric nerve stimulation (TENS) has been extensively used to relieve low back pain, experimental studies of its effectiveness have yielded contradictory findings mainly due to methodological problems in pain evaluation and placebo control. In the present study, separate visual analog scales (VAS) were used to measure the sensory-discriminative and motivational-affective components of low back pain. Forty-two subjects were randomly assigned to 1 of 3 groups: TENS, placebo-TENS, and no treatment (control). In order to measure the short-term effect of TENS, VAS pain ratings were taken before and after each treatment session. Also, to measure long-term effects, patients rated their pain at home every 2 h throughout a 3-day period before and 1 week, 3 months and 6 months after the treatment sessions. In comparing the pain evaluations made immediately before and after each treatment session, TENS and placebo-TENS significantly reduced both the intensity and unpleasantness of chronic low back pain. TENS was significantly more efficient than placebo-TENS in reducing pain intensity but not pain unpleasantness. TENS also produced a significant additive effect over repetitive treatment sessions for pain intensity and relative pain unpleasantness. This additive effect was not found for placebo-TENS. When evaluated at home, pain intensity was significantly reduced more by TENS than placebo-TENS 1 week after the end of treatment, but not 3 months and 6 months later. At home evaluation of pain unpleasantness in the TENS group was never different from the placebo-TENS group.(ABSTRACT TRUNCATED AT 250 WORDS)
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Musculoskeletal conditions are a major burden on individuals, health systems, and social care systems, with indirect costs being predominant. This burden has been recognized by the United Nations and WHO, by endorsing the Bone and Joint Decade 2000-2010. This paper describes the burden of four major musculoskeletal conditions: osteoarthritis, rheumatoid arthritis, osteoporosis, and low back pain. Osteoarthritis, which is characterized by loss of joint cartilage that leads to pain and loss of function primarily in the knees and hips, affects 9.6% of men and 18% of women aged > 60 years. Increases in life expectancy and ageing populations are expected to make osteoarthritis the fourth leading cause of disability by the year 2020. Joint replacement surgery, where available, provides effective relief. Rheumatoid arthritis is an inflammatory condition that usually affects multiple joints. It affects 0.3-1.0% of the general population and is more prevalent among women and in developed countries. Persistent inflammation leads to joint destruction, but the disease can be controlled with drugs. The incidence may be on the decline, but the increase in the number of older people in some regions makes it difficult to estimate future prevalence. Osteoporosis, which is characterized by low bone mass and microarchitectural deterioration, is a major risk factor for fractures of the hip, vertebrae, and distal forearm. Hip fracture is the most detrimental fracture, being associated with 20% mortality and 50% permanent loss in function. Low back pain is the most prevalent of musculoskeletal conditions; it affects nearly everyone at some point in time and about 4-33% of the population at any given point. Cultural factors greatly influence the prevalence and prognosis of low back pain.
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The causes of chronic low back pain (CLBP) remain obscure and effective treatment of symptoms remains elusive. A mechanism of relieving chronic pain based on the consequences of conflicting unpleasant sensory inputs to the central nervous system has been hypothesised. As a result a device was generated to deliver sensory discrimination training (FairMed), and this randomised controlled trial compared therapeutic effects with a comparable treatment modality, TENS. 60 patients with CLBP were recruited from physiotherapy referrals to a single-blinded, randomised controlled, non-inferiority trial. They were randomised to receive either FairMed or TENS and asked to use the allocated device for 30 minutes, twice a day, for 3 weeks. The primary outcome variable measured at 0 and 3 weeks was pain intensity measured using a visual analogue scale averaged over 7 days. Secondary outcome measures were Oswestry Disability Index, 3 timed physical tests, 4 questionnaires assessing different aspects of emotional coping and a global measure of patient rating of change. Data were analysed for the difference in change of scores between groups using one-way ANOVA. Baseline characteristics of the two groups were comparable. The primary outcome, change in pain intensity (VAS) at 3 weeks showed a mean difference between groups of -0.1, (non significant p = 0.82). The mean difference in change in ODI scores was 0.4; (non significant p = 0.85). Differences in change of physical functioning showed that no significant difference in change of scores for any of these test (p = 0.58 - 0.90). Changes in scores of aspects of emotional coping also demonstrated no significant difference in change scores between the groups (p = 0.14 - 0.94). FairMed was not inferior to TENS treatment. The findings have implications for further research on current chronic pain theories and treatments. Further work to explore these mechanisms is important to expand our understanding of chronic pain and the role of neuro-modulation.
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The objective of this study was to compare conventional transcutaneous electrical nerve stimulation [TENS] with sham therapy using a randomized double blind crossover design. The subjects of the study were patients with chronic low back pain without sciatica seen in an outpatient clinic. Patients were randomized to receive either conventional TENS, or sham TENS, which was then followed by two treatments of the other modality. The physician, patient, and treating therapist were blinded to the order of treatment. Pain tolerance was measured with a visual analog scale rating from no pain to worst pain. Physical measurements included flexion, extension, straight leg raising, isolift score, back extensions, sit-ups, oblique sit-ups, and side flexion. There was a significant improvement for the conventional TENS in both the objective outcomes and functional measurements. The conclusion is that TENS therapy significantly reduces pain and improves performance on the majority of standardized tests of physical capacity. Transcutaneous electrical nerve stimulation should be considered in the situation where short-term pain relief is desired.
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To evaluate the efficacy of transcutaneous electrical neurostimulation (TENS) in patients with chronic low back pain (LBP). Design: Prospective, randomized, multicentre, single-blind study. Setting: Twenty-one French pain centres. Participants: Two hundred thirty-six consecutive adult patients consulting for chronic LBP, with or without radicular pain (mean age ± standard deviation: 53 ± 13 years; range: 28-86 years). Intervention: Patients were randomly assigned to receive either active (n = 117) or sham (n = 119) TENS in four 1-h daily treatment sessions for 3 months. Main outcome measures: The primary outcome measured was improvement of functional status at 6 weeks (Roland-Morris Disability Questionnaire). Secondary outcome measures were improvement of functional status at 3 months, pain relief (weekly visual analogue scale assessments), positive functional repercussions of pain levels on quality of life, a diminution of the use of analgesic and anti-inflammatory medication, satisfaction with the overall treatment strategy and compliance. Functional status did not differ between the groups, whether at 6 weeks or 3 months (p = 0.351 at 6 weeks). A significant improvement between the first and last visual analogue scale assessments was observed in patients with either lumbar pain alone or lumbar and radicular pain treated with active TENS. Other outcome measures did not differ significantly between the two groups. There was no functional benefit of TENS in the treatment of patients with chronic LBP.
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Back pain has multi-factorial etiology and is modified by environmental influences, character of work, and individual predispositions. The aim of this study was to compare the efficiency of analgesic DD current therapy and TENS in low back discopathy. Eighty patients (age, 45-60 years) with diagnosed low back pain syndrome due to discopathy were subjected to therapy. In the first group (DD) of 40 people, DD current therapy was applied. In the second group (TENS) of 40 people, TENS was applied. The third group of 40 people was a control group in which a functional fitness test was performed for comparison purposes. The control group was in this case an equivalent to a norm. Before the beginning and on the completion of therapy in all patients, a pain level measurement and functional fitness test were performed. On the basis of research conducted it was stated that both therapies reduce pain level effectively. Obtained analyzed results conclude that both therapies applied have an analgesic effect. DD current and TENS therapies in low back discopathy have an analgesic impact and improve functional fitness. The applied therapies have a comparable impact on researched parameters.
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Although opioids are increasingly used for chronic noncancer pain (CNCP), we know little about opioid dosing patterns among individuals with CNCP in usual care settings, and how these are changing over time. To investigate the distribution of mean daily dose and mean days supply among patients with CNCP in two disparate populations, one national and commercially insured population (HealthCore) and one state based and publicly insured (Arkansas Medicaid), for years 2000 and 2005. For individuals with any opioid use, we calculated the distribution of mean daily dose (in milligram morphine equivalents), mean days supply in a year, mean annual dose, and patient characteristics associated with heavy utilizers of opioids. Between 2000 and 2005, across all percentiles, there was little change in the mean daily opioid dose. In HealthCore, mean days supply increased most rapidly at the top end of the days supply distribution, whereas in Arkansas Medicaid, the greatest increases were near the median of days supply. In HealthCore, the top 5% of users accounted for 70% of total use (measured in milligram morphine equivalents), and the top 5% of Arkansas Medicaid users accounted for 48% of total use. The likelihood of heavy opioid utilization was increased among individuals with multiple pain conditions, and in HealthCore, among those with mental health and substance use disorders. Opioid use is heavily concentrated among a small percent of patients. The characteristics of these high utilizers need to be further established, and the benefits and risks of their treatment evaluated.
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The use of chronic opioid therapy (COT) for chronic non-cancer pain (CNCP) has increased dramatically in the past two decades. There has also been a marked increase in the abuse of prescribed opioids and in accidental opioid overdose. Misuse of prescribed opioids may link these trends, but has thus far only been studied in small clinical samples. We therefore sought to validate an administrative indicator of opioid misuse among large samples of recipients of COT and determine the demographic, clinical, and pharmacological risks associated with possible and probable opioid misuse. A total of 21,685 enrollees in commercial insurance plans and 10,159 in Arkansas Medicaid who had at least 90 days of continuous opioid use 2000-2005 were studied for one year. Criteria were developed for possible and probable opioid misuse using administrative claims data concerning excess days supplied of short-acting and long-acting opioids, opioid prescribers and opioid pharmacies. We estimated possible misuse at 24% of COT recipients in the commercially insured sample and 20% in the Medicaid sample and probable misuse at 6% in commercially insured and at 3% in Medicaid. Among non-modifiable factors, younger age, back pain, multiple pain complaints and substance abuse disorders identify patients at high risk for misuse. Among modifiable factors, treatment with high daily dose opioids (especially >120 mg MED per day) and short-acting Schedule II opioids appears to increase the risk of misuse. The consistency of the findings across diverse patient populations and the varying levels of misuse suggest that these results will generalize broadly, but await confirmation in other studies.
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Low back pain is prevalent, and both debilitating for the patient and costly for society if it becomes a chronic condition. The initial prognosis at the onset of low back pain is positive, however the rate of recurrence is high and about 20% of patients seeking care develop a chronic problem that may or may not lead to disability. The main message, based on the best evidence, is that keeping active despite low back pain is "healthy". A large portion of patients seeking care can manage their short term and even longer term incapacity. However, for those who cannot manage their pain, significant relief can be found in a variety of conservative treatments. Passive treatment should be kept to a minimum as evidence shows that active treatments are more effective for improving function and return to work. There is evidence that identifying psychosocial symptoms and barriers, and referral to appropriate interventions improves outcomes. There are currently no clear indications for surgery in nonspecific low back pain.
Article
Use of prescription opioids for chronic pain is increasing, as is abuse of these medications, though the nature of the link between these trends is unclear. These increases may be most marked in patients with mental health (MH) and substance use disorders (SUDs). We analyzed trends between 2000 and 2005 in opioid prescribing among individuals with noncancer pain conditions (NCPC), with and without MH and SUDs. Secondary data analysis of longitudinal administrative data from 2 dissimilar populations: a national, commercially insured population and Arkansas Medicaid enrollees. We examined these opioid outcomes: (1) rates of any prescription opioid use in the past year, (2) rates of chronic use of prescription opioids (greater than 90 d in the past year), (3) mean days supply of opioids, (4) mean daily opioid dose in morphine equivalents, and (5) percentage of total opioid dose that was Schedule II opioids. In 2000, among individuals with NCPC, chronic opioid use was more common among those with a MH or SUD than among those without in commercially insured (8% vs. 3%, P<0.001) and Arkansas Medicaid (20% vs. 13%, P<0.001) populations. Between 2000 and 2005, in commercially insured, rates of chronic opioid use increased by 34.9% among individuals with an MH or SUD and 27.8% among individuals without these disorders. In Arkansas Medicaid chronic, opioid use increased by 55.4% among individuals with an MH or SUD and 39.8% among those without. Chronic use of prescription opioids for NCPC is much higher and growing faster in patients with MH and SUDs than in those without these diagnoses. Clinicians should monitor the use of prescription opioids in these vulnerable groups to determine whether opioids are substituting for or interfering with appropriate MH and substance abuse treatment.
Article
The present study tests whether a combined treatment of acupuncture and transcutaneous electrical nerve stimulation (TENS) is more effective than acupuncture or TENS alone for treating chronic low back pain (LBP). Thirty-two patients with chronic LBP were randomly allocated to four groups. The acupuncture group (ACP) received only acupuncture treatment at selected acupoints for low back pain; the TENS group (TENS) received only TENS treatment at pain areas; the acupuncture and TENS group (A&T) received both acupuncture and TENS treatments; the control group (CT) received topical poultice (only when necessary). Each group received specific weekly treatment five times during the study. Outcome measures were pain intensity in terms of visual analogue scale (VAS) and QOL of low back in terms of Roland-Morris Disability Questionnaire (RDQ). The ACP, TENS and A&T groups all reported lower VAS and RDQ scores. Significant reduction in pain intensity (P<0.008) and significant improvement in QOL (P<0.008) were shown in the A&T group. Combined acupuncture and TENS treatment is effective in pain relief and QOL of low back improvement for the sampled patients suffering from chronic LBP.
Article
Background: Transcutaneous electrical nerve stimulation (TENS) was introduced more than 30 years ago as a therapeutic adjunct to the pharmacological management of pain. However, despite widespread use, its effectiveness in chronic low-back pain (LBP) is still controversial. Objectives: To determine whether TENS is more effective than placebo for the management of chronic LBP. Search strategy: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PEDro and CINAHL were searched up to July 19, 2007. Selection criteria: Only randomized controlled clinical trials (RCTs) comparing TENS to placebo in patients with chronic LBP were included. Data collection and analysis: Two review authors independently selected the trials, assessed their methodological quality and extracted relevant data. If quantitative meta-analysis was not possible, a qualitative synthesis was performed, taking into consideration 5 levels of evidence as recommended by the Cochrane Collaboration Back Review Group. Main results: Four high-quality RCTs (585 patients) met the selection criteria. Clinical heterogeneity prevented the use of meta-analysis. Therefore, a qualitative synthesis was completed. There was conflicting evidence about whether TENS was beneficial in reducing back pain intensity and consistent evidence in two trials (410 patients) that it did not improve back-specific functional status. There was moderate evidence that work status and the use of medical services did not change with treatment. Conflicting results were obtained from two studies regarding generic health status, with one study showing no improvement on the modified Sickness Impact Profile and another study showing significant improvements on several, but not all subsections of the SF-36 questionnaire. Multiple physical outcome measures lacked statistically significant improvement relative to placebo. In general, patients treated with acupuncture-like TENS responded similarly to those treated with conventional TENS. However, in two of the trials, an inadequate stimulation intensity was used for acupuncture-like TENS, given that muscle twitching was not induced. Optimal treatment schedules could not be reliably determined based on the available data. Adverse effects included minor skin irritation at the site of electrode placement. Authors' conclusions: At this time, the evidence from the small number of placebo-controlled trials does not support the use of TENS in the routine management of chronic LBP. Further research is encouraged.
Article
Fifty-four patients treated in a 3-week inpatient rehabilitation program were randomly assigned to and accepted treatment with electroacupuncture (n = 17), TENS (low intensity transcutaneous nerve stimulation, n = 18), and TENS dead-battery (placebo, n = 18). Outcome measures included estimates of pain (on a Visual Analogue Scale) and disability by both physician and patient, physical measures of trunk strength and spine range of motion, as well as the patient's perceptions of the relative contribution of the education, exercise training, and the electrical stimulation. Analyses of variance were utilized to determine effects of treatment (electroacupuncture, TENS, placebo) across time (admission, discharge, and return) for the outcome measures. There were no significant differences between treatment groups with respect to their overall rehabilitation. All 3 treatment groups ranked the contribution of the education as being greater than the electrical stimulation. However, the electroacupuncture group consistently demonstrated greater improvement on the outcome measures than the other treatment groups. For the visual analogue scale measure of average pain, there was a statistical trend at the return visit suggesting that the acupuncture group was experiencing less pain.
Article
A preliminary examination of NMES and combined NMES/TENS for the management of chronic back pain. Double-blind, placebo-controlled, randomized repeated measures. Consecutive sample of 24 chronic back pain patients (16 women and 8 men) attending an outpatient pain clinic (mean age 51.67 years, mean pain duration 3.83 years). All treatments were administered at home. Subjects self-administered NMES, combined NMES/TENS, TENS, and placebo treatments. Each treatment had a duration of 5 consecutive hours per day over 2 consecutive days, with a 2-day hiatus between treatments to minimize carryover effects. Pain reduction was assessed through pretreatment to posttreatment differences on the Present Pain Intensity (PPI) scale, and a visual analogue scale of Pain Intensity (VAS-I). Posttreatment pain relief was assessed using a visual analogue scale of Pain Relief (VAS-R). Combined treatment, NMES, and TENS each produced significant pretreatment to posttreatment reductions in pain intensity as measured by both the PPI and VAS-I (p < .05). Combined treatment was superior to placebo on pain reduction (p = .001, p = .016) as well as pain relief (p < .001). Combined treatment was also superior to both TENS and NMES for pain reduction and pain relief (p < .01). NMES and TENS were superior only to placebo for pain relief (p < .001). Combined NMES/TENS treatment consistently produced greater pain reduction and pain relief than placebo, TENS, or NMES. NMES alone, although less effective, did produce as much pain relief as TENS. Although preliminary, this pattern of results suggests that combined NMES/TENS may be a valuable adjunct in the management of chronic back pain. Further research investigating the effectiveness of both NMES and combined NMES/TENS seems warranted.
Article
To investigate to what extent a single 60-minute session of transcutaneous electrical nerve stimulation (TENS) would modify chronic clinical pain, acute experimental pain, and the flexion reflex evoked in chronic low back pain patients. Thirty young subjects with chronic low back pain were randomly allocated to two groups, receiving either TENS or placebo stimulation to the lumbosacral region for 60 minutes. The flexion reflex was elicited by an electrical stimulation applied to the subject's right sole and recorded electromyographically from the biceps femoris and the tibialis anterior muscles. Subjective sensation of low back pain and the electrically induced pain were measured by two separate visual analog scales, termed VAS(LBP) and VAS(FR), respectively. Data obtained before, during, and 60 minutes after TENS and placebo stimulations were analyzed using repeated measures ANOVA. The VAS(LBP) score was significantly reduced to 63.1% of the prestimulation value after TENS (p<.001), but the reduction was negligible after placebo stimulation (to 96.7%, p = .786). In contrast, no significant change was found in the VASFR score (p = .666) and the flexion reflex area (p = .062) during and after stimulation within each group and between the two groups (p = .133 for VASFR and p = .215 for flexion reflex area). The same TENS protocol had different degrees of antinociceptive influence on chronic and acute pain in chronic low back pain patients.
Article
Low back pain is one of the most significant medical and socioeconomic problems in modern society. International guidelines call for evidence-based management for the pain and disability associated with musculoskeletal disorders. The purpose of this randomized controlled trial is to address the question of efficacy and appropriateness of vertebral axial decompression (VAX-D) therapy, a new technology that has been shown in clinical research to create negative intradiscal pressures, and has been shown to be effective in treating patients presenting with chronic low back pain (> 3 months duration) with associated leg pain. Successful outcome was defined as a 50% reduction in pain utilizing a 10 cm Visual Analog Pain Scale and an improvement in the level of functioning as measured by patient-nominated disability ratings. Patients were randomly assigned to VAX-D or to TENS which was used as a control treatment or placebo. The TENS treatment demonstrated a success rate of 0%, while VAX-D demonstrated a success rate of 68.4% (p < 0.001). A statistically significant reduction in pain and improvement in functional outcome was obtained in patients with chronic low back pain treated with VAX-D.
Article
Unlabelled: The long-term effect of percutaneous electrical nerve stimulation (PENS) on chronic low back pain (LBP) is unclear. We evaluated the number of sessions for which PENS should be performed to alleviate chronic LBP and how long analgesia is sustained. Patients underwent treatment on a twice-weekly schedule for 8 wk. Group A (n = 18) received PENS for 8 wk, group B (n = 17) received PENS for the first 4 wk and transcutaneous electrical nerve stimulation (TENS) for the second 4 wk, and group C (n = 18) received TENS for 8 wk. Pain level, degree of physical impairment, and the daily intake of nonsteroidal antiinflammatory drugs (NSAIDs) were assessed before the first treatment, 3 days after Week 2, Week 4, and Week 8 treatments, and at 1 and 2 mo after the sessions. During PENS therapy, the pain level decreased significantly from Week 2 in Groups A and B (P < 0.05 or 0.01), and physical impairment and required NSAIDs decreased significantly from Week 4 (P < 0.05 or 0.01) in Group A but only at Week 4 in Group B (P < 0.05 or 0.01). These effects were sustained until 1-mo follow-up (P < 0.01) in Group A but not in Group B; these effects were not observed at 2-mo follow-up even in Group A. In Group C, pain level decreased significantly only at Week 8 (P < 0.05). Our results indicate that repeated PENS is more effective than TENS for chronic LBP but must be continued to sustain the analgesic effect. Implications: A cumulative analgesic effect was observed in patients with chronic low back pain (LBP) after repeated percutaneous electrical nerve stimulation (PENS), but this effect gradually faded after the treatment was terminated. Results indicate that although PENS is effective for chronic LBP, treatments need to be continued to sustain analgesia.
Article
Musculoskeletal diseases are one of the major causes of disability around the world and have been a significant reason for the development of the Bone and Joint Decade. Rheumatoid arthritis, osteoarthritis and back pain are important causes of disability-adjusted-life years in both the developed and developing world. COPCORD studies in over 17 countries around the world have identified back and knee pain as common in the community and are likely to increase with the ageing population. Musculoskeletal conditions are an enormous cost to the community in economic terms, and these figures emphasise how governments need to invest in the future and look at ways of reducing the burden of musculoskeletal diseases by encouraging exercise and obesity prevention campaigns.
Article
Chronic low back pain (CLBP) is one of the most common, poorly understood, and potentially disabling chronic pain conditions from which older adults suffer. Many older adults remain quite functional despite CLBP, and because age-related comorbidities often exist independently of pain (e.g., medical illnesses, sleep disturbance, mobility difficulty), the unique impact of CLBP is unknown. We conducted this research to identify the multidimensional factors that distinguish independent community dwelling older adults with CLBP from those that are pain-free. Three hundred twenty cognitively intact participants (162 with moderate pain for 3 months, and 158 pain-free) underwent comprehensive assessment of pain severity, medical comorbidity (illnesses, body mass index, medications), severity of degenerative disc and facet disease, lumbar flexion, psychological constructs (self-efficacy, mood, overall mental health), and self-reported as well as performance-based physical function. Significant differences were ascertained for all 22 measures. Discriminant function analysis revealed that eight measures uniquely maximized the separation between the two groups (self-reported function with the Functional Status Index and the SF-36, performance-based function with repetitive trunk rotation and functional reach, mood with the Geriatric Depression Scale, comorbidity with the Cumulative Illness Rating Scale and BMI, and severity of degenerative disc disease). These results should help to guide investigators that perform studies of CLBP in older adults and practitioners that want an easily adaptable battery for use in clinical settings.