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Transcutaneous Electrical Nerve Stimulation (TENS) in Patients with Pregnancy-Induced Low Back Pain and/or Pelvic Girdle Pain
Abstract
Purpose: Low back and/or pelvic girdle pain is common during pregnancy and may persist after delivery. Therapeutic methods to alleviate pain, with no side effects for mother and child, are of high clinical importance. The consensus statement expresses the position of the Working Group on Evidence-Based Medicine in Physical and Rehabilitation Medicine, the Austrian Society of Physical Medicine and Rehabilitation and the Austrian Pain Society, for the treatment of low back and/or pelvic girdle pain by transcutaneous electrical nerve stimulation (TENS) during pregnancy.
Materials and Methods: The literature was reviewed followed by a subsequent interdisciplinary discussion.
Results: Diagnostic investigations, therapeutic options, mode of application as well as efficacy and side effects of the method are presented.
Conclusion: TENS is a safe therapy for low back and/or pelvic girdle pain in the last trimester of pregnancy with no side effects, low costs and the possibility of home application.
... [58][59][60] In addition to physical therapy and exercise, other treatments that may be helpful for PGP include the use of supportive devices such as pelvic belts or crutches, hot or cold therapy, and transcutaneous electrical nerve stimulation (TENS). 12,61 In some cases, a combination of treatments may be required to effectively manage PGP symptoms. ...
Background
Pregnancy-related Pelvic Girdle Pain (PPGP) is a prevalent condition characterized by various physiological and pathological processes in the female body. The objective of this study is to offer a comprehensive understanding of the current research landscape, key areas of interest, and potential future directions in the field of PPGP.
Methods
Using Web of Science, we explored PPGP literature from 2002 to 2022. VOSviewer and CiteSpace facilitated a quantitative analysis, revealing co-authorship patterns, co-occurring themes, citations, and co-citations.
Results
We identified, peaking at 99 publications in 2021. The United States led with 138 publications and the highest citation count (3160). The Karolinska Institute boasted the highest tally of publications (n = 21). Regarding the volume of publications, the esteemed journal of BMC Pregnancy and Childbirth attained the foremost position. Notably, Gutke, Annelie emerged as the most prolific and highly cited author. The analysis of keyword co-occurrence and co-citation clustering unveiled an intricate tapestry of PPGP studies, spanning various domains including risk factors, mechanistic intricacies, diagnostic benchmark, treatment modalities, and far-reaching ramifications on one’s quality of life.
Conclusion
Research endeavors exploring PPGP have unveiled an enduring trajectory of growth in contemporary times. The existing body of research primarily focuses on delving into the intricate interplay of epidemiological factors and the profound implications of interventions encompassing physical therapy, exercise protocols, and diverse modes of pain management within the domain of PPGP. Multidisciplinary integration encapsulates a prevailing trajectory of progress within this domain, while the focal point of future inquiries into PPGP may revolve around subjects pertaining to standardized outcome reporting.
... 43 U jednom istraživanju uspoređivali su se učinci mobilizacijskih tehnika sakroilijakalnog zgloba u odnosu na učinke terapije TENS-om, te je utvrđeno da su oba načina vrlo učinkovita u smanjenju zdjeličnih bolova uzrokovanih trudnoćom, ali je ipak tehnika mobilizacije sakroilijakalnog zgloba nadmašila učinke TENS-a u smislu poboljšanja stanja trudnica. 44 Zbog lakoće primjene niskih troškova korištenja i jednostavnosti, TENS se smatra vrlo efikasnim elektroterapijskim modalitetom u liječenju bolnosti kod trudnica s bolovima u lumbalnom dijelu kralježnice, što je u skladu s prethodno navedenim i uspoređenim rezultatima istraživanja. 45 Osim za navedene tegobe, u ranijim stadijima trudnoće javljaju se mučnine, vrtoglavice i povraćanje, pri čemu akupunkturni TENS može biti efikasna fizioterapijska metoda za redukciju povraćanja i smirivanje mučnine. ...
Uvod: Trudnoća donosi mnogobrojne promjene na organizam žene, te se intenzitet promjena mijenja ovisno o razdoblju trudnoće u kojem se žena nalazi. Upravo fizioterapeut svojim intervencijama utječe na poboljšanje funkcije i olakšavanje tih promjena. Postupci: Prikupljeni su podaci iz medicinske literature, odnosno knjiga u tiskanom i elektronskom izdanju, te iz znanstveno-medicinskih baza podataka Scopus, PubMed/Medline na engleskom jeziku, te CROSBI i Hrčak za časopise na hrvatskom jeziku. Prikaz teme: Trudnoća utječe na promjenu respiratornog, kardiovaskularnog i mišićno-koštanog sustava, što može dovesti do pojave boli, pogoršanja funkcije, anksioznosti i depresije trudnice. Fizioterapeut pravilnom procjenom i fizioterapijskom intervencijom utječe na poboljšani ishod i tijek poroda primjenom individualizirane tjelovježbe, čime se utječe na tjelesnu težinu majke i postiže pozitivan učinak na kliničku sliku djeteta pri rođenju, te se sprječavaju neke moguće komplikacije u zdravlju djeteta. Zaključak: Za zdravlje majke i djeteta u trudnoći i pri porodu bitno je pravilnim fizioterapijskim intervencijama koje uključuju tjelesno vježbanje, procjenu muskulature i dijastaze, pravilnu prehranu i edukaciju, utjecati na kompletno psihofizičko zdravlje trudnice.
... Werden physikalische Therapien angewendet, gilt TENS Elektrotherapie (Transkutane elektrische Nervenstimulation) als sicher [27]. Dabei handelt es sich um eine nebenwirkungsfreie Therapie bei Schmerzen im thorakolumbalen Übergang, die mehrmals pro Woche als Heimtherapie durchgeführt werden kann. ...
Zusammenfassung
Hintergrund
Schwangerschaft und Schmerzen unterschiedlicher Herkunft sind eine ungünstige Kombination, die alle BehandlerInnen vor besondere Herausforderungen stellt. Schmerzen beeinflussen die Homöostase des Menschen negativ. Compliance der Patientin und fundiertes Wissen über Fetotoxizität und Teratogenität von Analgetika sind nötig, um die Balance zwischen Therapie der Mutter und Sicherheit des Ungeborenen zu wahren.
Ziel der Arbeit
ExpertInnen verschiedener Disziplinen, die mit der Betreuung von schwangeren Schmerzpatientinnen betraut sind, haben sich zusammengeschlossen, um medikamentöse und nichtmedikamentöse Therapiekonzepte zu erstellen, mit dem Ziel, eine suffiziente Analgesie von schwangeren Schmerzpatientinnen zu ermöglichen.
Material und Methode
Relevante Fragestellungen wurden durch ExpertInnen formuliert und einer Literatursuche unterzogen. Kombiniert mit weiteren nationalen und internationalen Empfehlungen wurden Behandlungskonzepte entwickelt, interdisziplinär diskutiert und im Anschluss Kernaussagen erstellt, die mit Empfehlungsgraden abgestuft wurden.
Ergebnisse
Abhängig vom Trimenon können bei Schmerzen Paracetamol, Ibuprofen, Diclofenac, Metamizol und Opioide wohlüberlegt verabreicht werden, besondere Vorsicht ist bei nichtsteroidalen Antirheumatika (NSAR) im letzten Trimenon geboten. COX-2-Hemmer werden nicht empfohlen. Bei neuropathischen Schmerzen gelten Amitriptylin, Duloxetin, Venlafaxin als sicher. Bei starker Migräne kann Sumatriptan zum Einsatz kommen. Nichtmedikamentöse Therapien wie transkutane elektrische Nervenstimulation (TENS-Therapie), Kinesio-Tapes und Akupunktur gelten als sicher. Lymphdrainagen werden bei Ödemen empfohlen, sofern sie nicht durch eine Präeklampsie bedingt sind.
Schlussfolgerung
Die Therapie sollte mit einer nichtmedikamentösen Behandlung beginnen und eskalierend in einer Kombination aus medikamentösen und nichtmedikamentösen Konzepten enden.
Pain and its management hold a central place in health care. The pain associated with pregnancy and giving birth is unique in that it is a normal, physiologic phenomenon that is affected by cultural mores, personal experience, and internalized sensations. There are numerous nonpharmacologic tools available to treat discomfort during pregnancy and childbirth. Some methods of nonpharmacologic relief are underutilized, due to the lack of knowledge of the evidence. Childbirth educators, doulas, nurses, and midwives are a prime source of knowledge for birthing families to learn a variety of comfort techniques during pregnancy and labor. The purpose of this article is to discuss the use of transcutaneous electrical nerve stimulation (TENS) as a nonpharmacologic comfort technique.
TENS ist die Abkürzung für transkutane elektrische Nervenstimulation. Es handelt sich um ein Verfahren der niederfrequenten Reizstrombehandlung. TENS wird zur Schmerzlinderung eingesetzt. Zudem hat TENS auch eine durchblutungsfördernde und muskelrelaxierende Wirkung. Eines der weiteren Anwendungsgebiete ist die Triggerpunktbehandlung.
Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological treatment for control of pain. It has come under much scrutiny lately with the Center for Medicare Services rendering a recent decision stating that "TENS is not reasonable and necessary for the treatment of CLBP [chronic low back pain]".When reading and analyzing the existing literature for which systematic reviews show that TENS is inconclusive or ineffective, it is clear that a number of variables related to TENS application have not been considered. While many of the trials were designed with the highest of standards, recent evidence suggests that factors related to TENS application need to be considered in an assessment of efficacy. These factors include, dosing of TENS, negative interactions with long-term opioid use, the population and outcome assessed, timing of outcome measurement and comparison groups. The purpose of this perspective is to highlight and interpret recent evidence to help improve the design of clinical trials and the efficacy of TENS in the clinical setting.
To study the efficacy of uterine electrical stimulation (ES) with various parameters in delaying delivery in term- and preterm-laboring animals.
Catheters and electrodes, as well as ES electrodes, were sutured onto the uterine horn in day-15 pregnant rats. ES with various durations/frequencies (five sets of parameters) was tested from gestation day 21 to determine its effects on uterine contractility. The best set of ES parameters was applied in term (day 21) and preterm (day 18-labor induced) animals to determine the effects of ES on delivery.
(1) Significant reduction in uterine contractions (0.54+/-0.11 vs. 0.86+/-0.08 contractions per minute, P<0.001) was noted with ES of only one of the five sets of parameters (set #5 with pulse train of 10s on and 10s off, 28ms pulse width, frequency of 30Hz and amplitude of 4mA); (2) ES with parameter set 5 delayed delivery by 12.5h (P=0.01) and reduced area under the curve of intrauterine pressure in mmHgs (311+/-147.21 vs. 848.75+/-350.38, P<0.05) and AUC-electromyographic activity is area under rectified (i.e. absolute value) uterine EMG trace in mVs (145.25+/-93.1 vs. 410+/-182.46, P<0.05) in the term rats; and (3) similar effects were noted with ES in preterm rats with a delay in delivery by 28h (P<0.001), and a decrease in IUP-AUC (intrauterine pressure-area under curve) (101.5+/-55.45 vs. 551+/-269.06, P=0.017) and EMG-AUC (64.25+/-43.63 vs. 172.5+/-62.91, P=0.03).
ES of the uterus with appropriate parameters inhibits uterine contractions and delays delivery in both term and preterm rats.
Pain in the pelvic joints and lower back, a major problem for pregnant women, has proved resistant to precise measurement and quantification. To develop a classification system, the clinical tests used must be able to separate pelvic from low back pain; they must also have a high inter-examiner reliability, sensitivity and specificity, and preferably be easy to perform. The aim of this study was to describe a standardised way of performing tests for examining the pelvis, and to evaluate inter-examiner reliability, and establish the sensitivity and specificity of 15 clinical tests. It was designed as a longitudinal, prospective, epidemiological cohort study. First, 34 pregnant women were examined by blinded examiners to establish inter-examiner reliability. Second, a cohort of 2269 consecutive pregnant women, each responded to a questionnaire and underwent a thorough and highly standardised physical examination (15 tests with 48 possible responses) of the pelvic joints and surrounding areas. The 535 women who reported daily pain from the pelvic joints and had objective findings from the joints were divided, according to symptoms, into four classification groups and one miscellaneous group. The results of the study showed inter-examiner agreement of the tests was high, calculated in percentage terms, at between 88 and 100%. Using the Kappa coefficient, most tests kept the high agreement: six tests had an inter-examiner agreement of between 0.81 and 1.00, three between 0.61 and 0.80, and two between 0.60 and 0.41. Five tests showed superior sensitivity. The specificity of the tests was between 0.98 and 1.00, except the value for pelvic topography, which was 0.79. These results show that it is possible to standardise examination and interpretation of clinical tests of the pelvic joints, resulting in a high degree of sensitivity, specificity and inter-examiner reliability.
Low back pain affects a large proportion of the population. Transcutaneous electrical nerve stimulation (TENS) was introduced more than 30 years ago as an alternative therapy to pharmacologic treatments for chronic pain. However, despite its widespread use, the efficacy of TENS is still controversial.
The aim of this meta-analysis was to determine the efficacy of TENS in the treatment of chronic low back pain.
The authors searched MEDLINE, EMBASE, PEDro, and the Cochrane Controlled Trials Register up to June 1, 2000. Only randomized controlled clinical trials of TENS for the treatment of patients with a clinical diagnosis of chronic low back pain were included. Abstracts were excluded unless further data could be obtained from the authors. Two reviewers independently selected trials and extracted data using predetermined forms.
Heterogeneity was tested with Cochrane's Q test. A fixed effects model was used throughout for continuous variables, except where heterogeneity existed, in which case, a random effects model was used. Results are presented as weighted mean differences with 95% confidence intervals, where the difference between the treated and control groups was weighted by the inverse of the variance. Standardized mean differences were calculated by dividing the difference between the treated and control by the baseline variance. Standardized mean differences were used when different scales were integrated to measure the same concept. Dichotomous outcomes were analyzed with odds ratios.
Five trials were included, with 170 subjects randomized to the placebo group receiving sham TENS and 251 subjects receiving active TENS (153 for conventional mode, 98 for acupuncture-like TENS). The schedule of treatments varied greatly between studies ranging from one treatment/day for 2 consecutive days, to three treatments/day for 4 weeks. There were no statistically significant differences between the active TENS group compared with the placebo TENS group for any outcome measures. Subgroup analysis performed on TENS application and methodologic quality did not demonstrate a significant statistical difference (P > 0.05). Remaining preplanned subgroup analysis was not conducted because of the small number of included trials and the variety of outcome measures reported.
The results of the meta-analysis present no evidence to support the use or nonuse of TENS alone in the treatment of chronic low back pain. Considering the small number of studies responding to the criteria to be included in this meta-analysis, it is clear that more appropriately designed studies are needed before a final conclusion. Clinicians and researchers should consistently report the characteristics of the TENS device and the application techniques used. New trials on TENS should make use of standardized outcome measures. This meta-analysis lacked data on how TENS efficacy is affected by four important factors: type of applications, site of application, treatment duration of TENS, and optimal frequencies and intensities.
Pregnancy-related lumbopelvic pain has puzzled medicine for a long time. The present systematic review focuses on terminology, clinical presentation, and prevalence. Numerous terms are used, as if they indicated one and the same entity. We propose "pregnancy-related pelvic girdle pain (PPP)", and "pregnancy-related low back pain (PLBP)", present evidence that the two add up to "lumbopelvic pain", and show that they are distinct entities (although underlying mechanisms may be similar). Average pain intensity during pregnancy is 50 mm on a visual analogue scale; postpartum, pain is less. During pregnancy, serious pain occurs in about 25%, and severe disability in about 8% of patients. After pregnancy, problems are serious in about 7%. The mechanisms behind disabilities remain unclear, and constitute an important research priority. Changes in muscle activity, unusual perceptions of the leg when moving it, and altered motor coordination were observed but remain poorly understood. Published prevalence for PPP and/or PLBP varies widely. Quantitative analysis was used to explain the differences. Overall, about 45% of all pregnant women and 25% of all women postpartum suffer from PPP and/or PLBP. These values decrease by about 20% if one excludes mild complaints. Strenuous work, previous low back pain, and previous PPP and/or PLBP are risk factors, and the inclusion/exclusion of high-risk subgroups influences prevalence. Of all patients, about one-half have PPP, one-third PLBP, and one-sixth both conditions combined. Overall, the literature reveals that PPP deserves serious attention from the clinical and research communities, at all times and in all countries.
Previous studies and meta-analyses of the efficacy of electrical nerve stimulation (ENS) for the treatment of chronic pain of multiple etiologies have produced mixed results. The objective of the present study was to determine whether ENS is an effective treatment for chronic musculoskeletal pain by using statistical techniques that permit accumulation of a sample size with adequate power. Randomized, controlled trials published between January 1976 and November 2006 were obtained from the National Libraries of Medicine, EMBASE, and the Cochrane Library. Prospective, placebo-controlled studies using any modality of ENS to treat chronic musculoskeletal pain in any anatomical location were included. The main outcome measure was pain at rest. The use of statistical methods to enhance data extraction and a random-effects meta-analysis to accommodate heterogeneity of ENS therapies permitted an adequate number of well designed trials of ENS to be included in the meta-analysis. A total of 38 studies in 29 papers, which included 335 placebo, 474 ENS, and 418 cross-over (both placebo and at least one ENS treatment) patients, met the selection criteria. The overall results showed a significant decrease in pain with ENS therapy using a random-effects model (p<0.0005). These results indicate that ENS is an effective treatment modality for chronic musculoskeletal pain and that previous, equivocal results may have been due to underpowered studies.
Numerous randomized trials have been published investigating the effectiveness of treatments for non-specific low-back pain (LBP) either by trials comparing interventions with a no-treatment group or comparing different interventions. In trials comparing two interventions, often no differences are found and it raises questions about the basic benefit of each treatment. To estimate the effect sizes of treatments for non-specific LBP compared to no-treatment comparison groups, we searched for randomized controlled trials from systematic reviews of treatment of non-specific LBP in the latest issue of the Cochrane Library, issue 2, 2005 and available databases until December 2005. Extracted data were effect sizes estimated as Standardized Mean Differences (SMD) and Relative Risk (RR) or data enabling calculation of effect sizes. For acute LBP, the effect size of non-steroidal anti-inflammatory drugs (NSAIDs) and manipulation were only modest (ES: 0.51 and 0.40, respectively) and there was no effect of exercise (ES: 0.07). For chronic LBP, acupuncture, behavioral therapy, exercise therapy, and NSAIDs had the largest effect sizes (SMD: 0.61, 0.57, and 0.52, and RR: 0.61, respectively), all with only a modest effect. Transcutaneous electric nerve stimulation and manipulation had small effect sizes (SMD: 0.22 and 0.35, respectively). As a conclusion, the effect of treatments for LBP is only small to moderate. Therefore, there is a dire need for developing more effective interventions.
A guideline on pelvic girdle pain (PGP) was developed by "Working Group 4" within the framework of the COST ACTION B13 "Low back pain: guidelines for its management", issued by the European Commission, Research Directorate-General, Department of Policy, Coordination and Strategy. To ensure an evidence-based approach, three subgroups were formed to explore: (a) basic information, (b) diagnostics and epidemiology, and (c) therapeutical interventions. The progress of the subgroups was discussed at each meeting and the final report is based on group consensus. A grading system was used to denote the strength of the evidence, based on the AHCPR Guidelines (1994) and levels of evidence recommended in the method guidelines of the Cochrane Back Review group. It is concluded that PGP is a specific form of low back pain (LBP) that can occur separately or in conjunction with LBP. PGP generally arises in relation to pregnancy, trauma, arthritis and/or osteoarthritis. Uniform definitions are proposed for PGP as well as for joint stability. The point prevalence of pregnant women suffering from PGP is about 20%. Risk factors for developing PGP during pregnancy are most probably a history of previous LBP, and previous trauma to the pelvis. There is agreement that non risk factors are: contraceptive pills, time interval since last pregnancy, height, weight, smoking, and most probably age. PGP can be diagnosed by pain provocation tests (P4/thigh thrust, Patrick's Faber, Gaenslen's test, and modified Trendelenburg's test) and pain palpation tests (long dorsal ligament test and palpation of the symphysis). As a functional test, the active straight leg raise (ASLR) test is recommended. Mobility (palpation) tests, X-rays, CT, scintigraphy, diagnostic injections and diagnostic external pelvic fixation are not recommended. MRI may be used to exclude ankylosing spondylitis and in the case of positive red flags. The recommended treatment includes adequate information and reassurance of the patient, individualized exercises for pregnant women and an individualized multifactorial treatment program for other patients. We recommend medication (excluding pregnant women), if necessary, for pain relief. Recommendations are made for future research on PGP.
To investigate the association of muscle function and subgroups of low back pain (no low back pain, pelvic girdle pain, lumbar pain and combined pelvic girdle pain and lumbar pain) in relation to pregnancy.
Prospective cohort study.
Consecutively enrolled pregnant women seen in gestational weeks 12-18 (n = 301) and 3 months postpartum (n = 262).
Classification into subgroups by means of mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history and a pain drawing. Trunk muscle endurance, hip muscle strength (dynamometer) and gait speed were investigated.
In pregnancy 116 women had no low back pain, 33% (n = 99) had pelvic girdle pain, 11% (n = 32) had lumbar pain and 18% (n = 54) had combined pelvic girdle pain and lumbar pain. The prevalence of pelvic girdle pain/combined pelvic girdle pain and lumbar pain decreased postpartum, whereas the prevalence of lumbar pain remained stable. Women with pelvic girdle pain and/or combined pelvic girdle pain and lumbar pain had lower values for trunk muscle endurance, hip extension and gait speed as compared to women without low back pain in pregnancy and postpartum (p < 0.001-0.04). Women with pelvic girdle pain throughout the study had lower values of back flexor endurance compared with women without low back pain.
Muscle dysfunction was associated with pelvic girdle pain, which should be taken into consideration when developing treatment strategies and preventive measures.
Objective
To evaluate the effects of application of transcutaneous electrical nerve stimulation (TENS) at low and high frequencies to the abdomens of Swiss mice throughout pregnancy.
Design
Experimental animal study.
Setting
Research laboratory.
Participants Thirty Swiss mice received TENS throughout pregnancy. They were divided into three groups (n = 10): placebo, low-frequency TENS (LF group) and high-frequency TENS (HF group).
Interventions In the placebo group, the electrodes were applied to the abdominal region without any electrical current. In the LF group, the frequency was 10 Hz, pulse duration was 200 μs and intensity started at 2 mA. In the HF group, the same parameters were applied and the frequency was 150 Hz. All stimulation protocols were applied for 20 min/day from Day 0 until Day 20.
Main outcome measures The pregnant mice were weighed on Days 0, 7, 14 and 20 to verify weekly weight gain by two-way analysis of variance. The numbers of fetuses, placentas, implantations, resorptions and major external fetal malformations on Day 20 were analysed using the Kruskal–Wallis test.
Results
No significant differences were found between the placebo and TENS groups (P > 0.05).
Conclusion
Application of low- and high-frequency TENS to the abdomens of pregnant mice did not cause any deleterious or major teratogenic effects.
More than two-thirds of pregnant women experience low-back pain (LBP) and almost one-fifth experience pelvic pain. Pain increases with advancing pregnancy and interferes with work, daily activities and sleep.
To assess the effects of interventions for preventing and treating pelvic and back pain in pregnancy.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 July 2012), identified related studies and reviews from the Cochrane Back Review Group search strategy to July 2012, and checked reference lists from identified reviews and studies.
Randomised controlled trials (RCTs) of any treatment to prevent or reduce the incidence or severity of pelvic or back pain in pregnancy.
Two review authors independently assessed risk of bias and extracted data. Quality of the evidence for outcomes was assessed using the five criteria outlined by the GRADE Working Group.
We included 26 randomised trials examining 4093 pregnant women in this updated review. Eleven trials examined LBP (N = 1312), four examined pelvic pain (N = 661), and 11 trials examined lumbo-pelvic (LBP and pelvic) pain (N = 2120). Diagnoses ranged from self-reported symptoms to the results of specific tests. All interventions were added to usual prenatal care and unless noted, were compared to usual prenatal care. For LBP, there was low-quality evidence that in general, the addition of exercise significantly reduced pain (standardised mean difference (SMD) -0.80; 95% confidence interval (CI) -1.07 to -0.53; six RCTs, N = 543), and disability (SMD -0.56; 95% CI -0.89 to -0.23; two RCTs, N = 146); and water-based exercise significantly reduced LBP-related sick leave (risk ratio (RR) 0.40; 95% CI 0.17 to 0.92; one RCT, N = 241). Low-quality evidence from single trials suggested no significant difference in pain or function between two types of pelvic support belt, between osteopathic manipulation (OMT) and usual care or sham ultrasound (sham US). Very low-quality evidence suggested that a specially-designed pillow may relieve night pain better than a regular pillow. For pelvic pain, there was moderate-quality evidence that acupuncture significantly reduced evening pain better than exercise; both were better than usual care. Low-quality evidence from single trials suggested that adding a rigid belt to exercise improved average pain but not function; acupuncture was significantly better than sham acupuncture for improving evening pain and function, but not average pain; and evening pain relief was the same following either deep or superficial acupuncture. For lumbo-pelvic pain, there was moderate-quality evidence that an eight- to 20-week exercise program reduced the risk of women reporting lumbo-pelvic pain (RR 0.85; 95% CI 0.73 to 1.00; four RCTs, N = 1344); but a 16- to 20-week training program was no more successful than usual care at preventing pelvic pain (one RCT, N = 257). Low-quality evidence suggested that exercise significantly reduced lumbo-pelvic-related sick leave (RR 0.76; 95% CI 0.62 to 0.94, two RCTs, N = 1062), and improved function. Low-quality evidence from single trials suggested that OMT significantly reduced pain and improved function; either a multi-modal intervention that included manual therapy, exercise and education (MOM) or usual care significantly reduced disability, but only MOM improved pain and physical function; acupuncture improved pain and function more than usual care or physiotherapy; pain and function improved more when acupuncture was started at 26- rather than 20- weeks' gestation; and auricular (ear) acupuncture significantly improved these outcomes more than sham acupuncture.When reported, adverse events were minor and transient.
Moderate-quality evidence suggested that acupuncture or exercise, tailored to the stage of pregnancy, significantly reduced evening pelvic pain or lumbo-pelvic pain more than usual care alone, acupuncture was significantly more effective than exercise for reducing evening pelvic pain, and a 16- to 20-week training program was no more successful than usual prenatal care at preventing pelvic or LBP. Low-quality evidence suggested that exercise significantly reduced pain and disability from LBP.There was low-quality evidence from single trials for other outcomes because of high risk of bias and sparse data; clinical heterogeneity precluded pooling. Publication bias and selective reporting cannot be ruled out.Physiotherapy, OMT, acupuncture, a multi-modal intervention, or the addition of a rigid pelvic belt to exercise seemed to relieve pelvic or back pain more than usual care alone. Acupuncture was more effective than physiotherapy at relieving evening lumbo-pelvic pain and disability and improving pain and function when it was started at 26- rather than 20-weeks' gestation, although the effects were small.There was no significant difference in LBP and function for different support belts, exercise, neuro emotional technique or spinal manipulation (SMT), or in evening pelvic pain between deep and superficial acupuncture.Very low-quality evidence suggested a specially-designed pillow may reduce night-time LBP.Further research is very likely to have an important impact on our confidence in the estimates of effect and is likely to change the estimates. Future research would benefit from the introduction of an agreed classification system that can be used to categorise women according to presenting symptoms.
To compare the efficiency of transcutaneous electrical nerve stimulation (TENS) with those of exercise and acetaminophen for the treatment of pregnancy-related low back pain (LBP) during the third trimester of pregnancy.
This prospective study included 79 subjects (≥32 gestational weeks) with visual analog scale (VAS) pain scores ≥5. Participants were divided randomly into a control group (n = 21) and three treatment groups [exercise (n = 19); acetaminophen (n = 19); TENS (n = 20)]. The VAS and the Roland-Morris disability questionnaire (RMDQ) were completed before and 3 weeks after treatment to assess the impact of pain on daily activities.
During the study period, pain intensity increased in 57% of participants in the control group, whereas pain decreased in 95% of participants in the exercise group and in all participants in the acetaminophen and TENS groups. Post-treatment VAS and RMDQ values were significantly lower in the treatment groups (p < 0.001). VAS and RMDQ scores indicated a significantly greater degree of pain relief in the TENS group than in the exercise and acetaminophen groups (p < 0.001). No adverse effect of TENS application on pregnant women was observed during the study.
TENS is an effective and safe treatment modality for LBP during pregnancy. TENS improved LBP more effectively than did exercise and acetaminophen.
Pregnancy-related pelvic girdle pain (PGP) and pregnancy-related low back pain (PLBP) are common problems with significant physical, psychological, and socioeconomic implications. There are several management options that are underutilized because of lack of comprehensive knowledge by health-care professionals and fear of harmful effects of treatment on the developing fetus. Interventions such as patient education, the use of pelvic belts, acupuncture, and aquatic and tailored postpartum exercises can be of some benefit to these patients. This article will focus on the diagnosis and management of PGP and PLBP, with discussion of terminology, epidemiology, risk factors, pathophysiology, and prognosis.
Background:
Transcutaneous nerve stimulation (TENS) has been proposed as a means of reducing pain in labour. The TENS unit emits low-voltage electrical impulses which vary in frequency and intensity. During labour, TENS electrodes are generally placed on the lower back, although TENS may be used to stimulate acupuncture points or other parts of the body. The physiological mechanisms whereby TENS relieves pain are uncertain. The TENS unit is frequently operated by women, which may increase sense of control in labour.
Objectives:
To assess the effects of TENS on pain in labour.
Search strategy:
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2008).
Selection criteria:
Randomised controlled trials comparing women receiving TENS for pain relief in labour versus routine care, alternative pharmacological methods of pain relief, or placebo devices. We included all types of TENS machines.
Data collection and analysis:
Two review authors assessed for inclusion all trials identified by the search strategy, carried out data extraction and assessed risk of bias. We have recorded reasons for excluding studies.
Main results:
The search identified 25 studies; we excluded six and included 19 studies including 1671 women. Fifteen examined TENS applied to the back, two to acupuncture points and two to the cranium. Overall, there was little difference in pain ratings between TENS and control groups, although women receiving TENS to acupuncture points were less likely to report severe pain (risk ratio 0.41, 95% confidence interval 0.32 to 0.55). The majority of women using TENS said they would be willing to use it again in a future labour. Where TENS was used as an adjunct to epidural analgesia there was no evidence that it reduced pain. There was no consistent evidence that TENS had any impact on interventions and outcomes in labour. There was little information on outcomes for mothers and babies. No adverse events were reported.
Authors' conclusions:
There is only limited evidence that TENS reduces pain in labour and it does not seem to have any impact (either positive or negative) on other outcomes for mothers or babies. The use of TENS at home in early labour has not been evaluated. TENS is widely available in hospital settings and women should have the choice of using it in labour.
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.
A report about 12. gravid patients with a diminished uteroplacental flow is given. To increase their placental perfusion a transcutaneus lumbo-sacral electric nerve stimulation was performed. In all 12 cases a distinet increase war measured by the method of radioisotope placenta-perfusion. The mean values showed a high significant difference (p less than 0,001). The reasons for this results and the possibilities of this findings for the therapy of funcitonal placental insufficiency are discussed.
Serum relaxin immunoreactivity was measured by means of a porcine relaxin radioimmunoassay in 35 patients with severe pelvic pain and pelvic joint instability during late pregnancy. Results were compared with a control group of 368 samples obtained throughout pregnancy from normal singleton pregnancies. Most of the relaxin concentrations in the study group were above the 95% confidence limits of the median for the corresponding gestational age in the control group. The difference in relaxin levels between the study and control groups in the third trimester was highly significant. Relaxin levels in patients with pelvic pain were close to normal non-pregnant levels by the third postnatal day. The highest relaxin levels during pregnancy were found in the patients who were the most incapacitated clinically. The results suggest that there may be an association between high serum relaxin levels and pelvic pain and joint laxity during late pregnancy.
A report is given on 37 patients with a diminished utero-placental perfusion. 12 patients underwent only once, 25 patients daily over 2 to 3 weeks a transcutaneous lumbo-sacral electric nerve stimulation. Both, the 12 patients stimulated only once and the 25 patients with daily stimulation, showed a significant increase of utero-placental perfusion measured by the method of radioisotope placental perfusion. Transcutaneous nerve stimulation (TNS) therefore could be used for therapeutic purpose in cases of placental dysfunction.
Backache is a common symptom in women of childbearing age. With as many as half of women reporting back pain at some stage during pregnancy,1 2 3 it is perhaps not surprising that many of their carers dismiss it as unimportant. But backache in pregnancy is a substantial problem. Many women are helped by understanding the likely cause of the pain and by advice on prevention and management.
There seems to be little difference in the prevalence of backache between pregnant and non-pregnant women.3 4 Of Swedish women questioned between the ages of 38 and 64, two thirds reported experiencing back pain at some time, and only a minority said that it had started in pregnancy.3 4 However, backache experienced during pregnancy is more severe and disabling and present for a greater proportion of the time.1 About 10% of women may be prevented by it from working,2 and over a third report that it interferes with daily life.3
Though non-specific low back pain (radiating classically to buttocks and thighs) is experienced by both pregnant and non-pregnant women, more severe pain arising from sacroiliac dysfunction is particular to pregnancy. It increases in prevalence with gestation concentrations and is often associated with symphyseal pain.2 3 Relaxin, a polypeptide hormone that regulates collagen, softens the ligaments in preparation for parturition. …
Electrical stimulation has been considered a contraindication in pregnant women with various voiding dysfunctions, because of the potential to cause teratogenicity or abortion. However, it is not known whether electrical stimulation can cause fetal malformation or abortion. The purpose of this study is to evaluate whether electrical stimulation has any adverse effect on pregnant rats and fetuses.
Twenty Sprague-Dawley pregnant rats were divided into two groups: electrical stimulation group (n = 10) and sham controls (n = 10). Rats in the stimulation group were stimulated 7 hours every day from Day 4 to Day 20 of gestation. All pregnant rats were sacrificed and fetuses were examined at near term (Day 20 of gestation). The number of fetuses, resorptions, fetal liability, body weight and gross appearance were recorded. Viscera and skeleton stained with Alizarin Red S were examined under stereoscope.
All pregnant rats were healthy during the gestation period and no abortions were noted. Fetal body weight in the stimulation group (2.27 +/- 0.51 gm.) was not significantly different from sham group (2.13 +/- 0.51 gm.; p = 0.91). No significant difference was found in the number of resorptions between both groups. All fetuses were alive at the time of cesarean section. No fetal malformation was observed in gross appearance, viscera and skeleton of all rats.
Electrical stimulation did not have any adverse effect on pregnant rats and their fetuses. Termination of pregnancy is not advised for prospective mothers when electrical stimulation has been performed inadvertently in early pregnancy.
Transcutaneous electrostimulation is thought to be able to improve blood flow and so it has been suggested that it may help to promote fetal growth.
The objective was to assess the effects of transcutaneous electrostimulation in suspected placental insufficiency on the promotion of fetal growth.
We searched the Cochrane Pregnancy and Childbirth trials register and the Cochrane Controlled Trials Register. Date of last search: December 1999.
Acceptably controlled trials of transcutaneous electrostimulation compared with placebo or no treatment in women with suspected impaired fetal growth or placental insufficiency.
Trial quality was assessed.
No studies were included.
There is not enough evidence to evaluate the use of transcutaneous electrostimulation in the management of women with suspected placental insufficiency.
To determine the prevalence of low back pain during pregnancy (LBPP) in an Australian population.
A representative population-based survey of women aged 15 years and older.
Four thousand four hundred randomly selected South Australian households were visited by trained surveyors who interviewed 1531 women (69.7% response rate) using pre-tested questions.
The South Australian Health Omnibus survey was utilised.
Demographic data were collected along with details of previous pregnancies, and degree of back pain during pregnancy treatment regimens, and persistence of back pain.
Thirty-five and a half per cent of women recall having at least moderately severe back pain during pregnancy. Women who reported such back pain were younger, were more likely to report ill health and be unemployed. Increasing parity was not associated with current back pain. The most commonly used treatments were bed rest, pain killing medication, physiotherapy, and chiropractic treatment. Half of those with symptoms were untreated. Sixty-eight per cent of women who experienced moderate or worse low back pain during pregnancy continued to experience recurring low back pain with a self reported reduction in their health.
Chronic low back pain is commonly associated with an onset in pregnancy subjectively contributing to long-term morbidity The high prevalence may be an underestimate in view of the potential for recall bias in older women.
To estimate the severity of the low back pain (LBP) during pregnancy, including prevalence, risk factors, impact on daily living, and health provider management.
An anonymous survey consisting of 36 questions was distributed to pregnant women participating in various prenatal care clinics and educational classes in New Haven County, Connecticut. A total of 950 surveys was returned from May 2002 through October 2003. At each site, a researcher was available each week to answer questions and gather surveys.
Six hundred forty-five (68.5%; 95% confidence interval [CI] 65-72%) respondents reported experiencing LBP during their current pregnancy. The prevalence was not affected by gestational age (P =.56). Low back pain during the current pregnancy was predicted by age (younger women were more likely to develop it; P =.004), history of LBP without pregnancy (P =.002), during menstruation (P =.01), and during a previous pregnancy (P =.002). The majority of respondents reported that LBP during pregnancy caused sleep disturbances (58%; 95% CI 54-62%) and impaired daily living (57%; 95% CI 53-62%). Average pain was moderate in severity. Nearly 30% of respondents stopped performing at least one daily activity because of pain and reported that pain also impaired the performance of other routine tasks. Only 32% (95% CI 28-36%) of the respondents with LBP during pregnancy informed their prenatal care providers of this problem, and only 25% (95% CI 21-28%) of prenatal care providers recommended a treatment.
Low back pain during pregnancy is a common problem that causes hardship in this population. Further studies are indicated in the areas of prevention and treatment.
Sex-specific care of musculoskeletal impairments is an increasingly important topic in women's health. This is clinically relevant and of paramount importance as it pertains to diagnosis and treatment of musculoskeletal and peripheral neurologic disorders of pregnancy and the puerperium. It is estimated that virtually all women experience some degree of musculoskeletal discomfort during pregnancy, and 25% have at least temporarily disabling symptoms. This review provides information on common pregnancy-related musculoskeletal conditions, including a discussion of anatomy and physiology, diagnosis, prognosis, and treatment of these disorders.
Chronic low-back pain (LBP) affects a significant proportion of the population. Transcutaneous electrical nerve stimulation (TENS) was introduced more than 30 years ago as an adjunct to the pharmacological management of pain. However, despite its widespread use, the usefulness of TENS in chronic LBP is still controversial.
The aim of this systematic review was to determine the effectiveness of TENS in the management of chronic LBP.
We searched the Cochrane Central Register of Controlled Trials (Issue 2, 2005), MEDLINE, EMBASE and PEDro up to April 1, 2005.
Only randomized controlled clinical trials (RCTs) evaluating the effect of TENS on chronic LBP were included. Abstracts were excluded unless further data could be obtained from the authors.
Two reviewers independently selected trials and extracted data using predetermined forms. Heterogeneity was tested with Cochrane's Q test. A fixed effect model was used throughout for calculating continuous variables, except where heterogeneity existed, in which case, a random effects model was used. Results are presented as weighted mean differences (WMD) with 95% confidence intervals (95% CI), where the difference between the treated and control groups was weighted by the inverse of the variance. Standardized mean differences (SMD) were calculated by dividing the difference between the treated and control by the baseline variance. SMD were used when different scales were used to measure the same concept. Dichotomous outcomes were analyzed with odds ratios.
The only two RCTs (175 patients) meeting eligibility criteria differed in study design, methodological quality, inclusion and exclusion criteria, type and method of TENS application, treatment schedule, co-interventions and final outcomes. In one RCT, TENS produced significantly greater pain relief than the placebo control. However, in the other RCT, no statistically significant differences between treatment and control groups were shown for multiple outcome measures. Pre-planned subgroup analyses, intended to examine the impact of different stimulation parameters, sites of TENS application, treatment durations and baseline patient characteristics were not possible due to the small number of included trials.
There is inconsistent evidence to support the use of TENS as a single treatment in the management of chronic LBP. Larger, multi-center, randomized controlled trials are needed to better assess the true effectiveness of TENS. Special attention should be given to the risks and benefits of long-term use, which more appropriately addresses the realities of managing chronic low-back pain.
A cross-sectional study in pregnancy.
To differentiate between pregnancy related pelvic girdle pain (PGP) and low back pain (LBP) in Iranian women, and investigate the prevalence of each syndrome.
Most of the information about PGP and LBP has been obtained in Western countries. There are few studies to investigate pregnancy related lumbopelvic pain, and, especially, differentiate between PGP and LBP in non-Western countries, particularly in the Middle East.
This study included 325 pregnant women, ranging in age from 16 to 42 years. All pregnant women were interviewed using a questionnaire. Two trained physical therapists performed the posterior pelvic pain provocation test on all women with lumbopelvic pain.
A total of 161 pregnant women (49.5%) had reported lumbopelvic pain at the time of the examination. Based on the posterior pelvic pain provocation test, 91 women (28%) had PGP, 43 (13.2%) had LBP, and 27 (8.3%) had both PGP and LBP simultaneously. The intensity of pain in women with lumbopelvic pain using the visual analog scale was 5.6 (standard deviation 2.0; range 2-10).
About 1 in every 2 pregnant women studied experienced lumbopelvic pain at the time of the examination. In this study, PGP was almost 2 times more common than LBP. The high prevalence of PGP suggests that this symptom is a significant health problem in Iranian pregnant women, and needs more attention by Iranian health professionals and researchers.
Evidence and consensus based Austrian guidelines for management of acute and chronic nonspecific backache
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