10/9/2017. Electrotherapy for Chronic Pain: Combining Active and Passive Modalities. Electrotherapy for Chronic Pain

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1 10/9/2017 Electrotherapy for Chronic Pain: Combining Active and Passive Modalities Rose L. Smith PT, DPT, SCS, ATC Amy Banks PT, DPT, NCS Electrotherapy for Chronic Pain TENS Parameters High Frequency TENS Pulse rate: above 50 ppsusually greater (80-100) Pulse width: lower ( usec) Intensity: strongnonpainful Chesterton 2003 Low Frequency TENS Pulse rate: 2-10 pps Pulse width: higher ( usec) Intensity: muscle contraction or strong nonpainful Mechanism of TENS reduction on analgesia Peripheral mechanisms Rokugo 2002 HF reduces substance P LF blockade of peripheral opioid receptors LF with muscle contraction has increased blood flow: peripheral adrenergic receptors Nam 2001 Central mechanisms HF and LF reduce dorsal horn activity Ma 2001 HF reduces central neuron sensitization Strength duration curves Frequency Elements that effect analgesic effect of TENS Interaction with pharmacological agents Leonard 2010 High frequency TENS Analgesia by activating endogenous inhibitory mechanisms in CNS Opioids Clonidine (Catapres, Kapvay, Nexiclon)» Treat high blood pressure Low frequency TENS Uses classic descending inhibitory pathways activating opioid receptors Seretonin to produce analgesic effects» Does not produce analgesia in opioid and muscarinic tolerant clients Uptake inhibitors improve effectiveness (SSRIs) (Lexapro, Zoloft, Prozac) 1

2 10/9/2017 Elements that effect analgesic effect of TENS Caffeine consumption Marchand1995 Block the analgesic effect of high frequency TENS Half life of caffeine 4-6 hours; delay TENS usage Electrode placement Sluka 2003 Adapted individually based on location Entire area addressed with high frequency Spinal originated site Referred site Tolerance to repeated TENS DeSantana2008 Accommodation Intensity of TENS Leonard 2010 Lower intensities ineffective Pain intensity Benedetti 1997 Less positive response if pain rated severe Integrating Exercise Education provided on Biomedical Model vs Biopsychosocial Model within an interprofessionalpain team consisting of a PT, Chiropractor, Psychologist and Pharmacist TENS unit provided as part of larger pain flare kit to encourage self management Veterans seen individually by pain physical therapist are given pedometer and log sheet for daily step count tracking 2

3 Electrotherapy for Chronic Pain High Frequency TENS Electrotherapy for Chronic Pain: Combining Active and Passive Modalities Rose L. Smith PT, DPT, SCS, ATC Amy Banks PT, DPT, NCS Pulse rate: above 50 pps usually greater (80-100) Pulse width: lower ( usec) Intensity: strong nonpainful Chesterton 2003 Low Frequency TENS Pulse rate: 2-10 pps Pulse width: higher ( usec) Intensity: muscle contraction or strong nonpainful Mechanism of TENS reduction on analgesia Peripheral mechanisms Rokugo 2002 HF reduces substance P LF blockade of peripheral opioid receptors LF with muscle contraction has increased blood flow: peripheral adrenergic receptors Nam 2001 Central mechanisms HF and LF reduce dorsal horn activity Ma 2001 HF reduces central neuron sensitization Elements that effect analgesic effect of TENS Interaction with pharmacological agents Leonard 2010 High frequency TENS Analgesia by activating endogenous inhibitory mechanisms in CNS Opioids Clonidine (Catapres, Kapvay, Nexiclon)

4 Low frequency TENS Treat high blood pressure Uses classic descending inhibitory pathways activating opioid receptors Seretonin to produce analgesic effects Does not produce analgesia in opioid and muscarinic tolerant clients Uptake inhibitors improve effectiveness (SSRIs) (Lexapro, Zoloft, Prozac) Caffeine consumption Marchand 1995 Block the analgesic effect of high frequency TENS Half life of caffeine 4-6 hours; delay TENS usage Electrode placement Sluka 2003 Adapted individually based on location Entire area addressed with high frequency Spinal originated site Referred site Tolerance to repeated TENS DeSantana 2008 Accommodation Intensity of TENS Leonard 2010 Lower intensities ineffective Pain intensity Benedetti 1997 Integrating Exercise Less positive response if pain rated severe Education provided on Biomedical Model vs Biopsychosocial Model within an interprofessional pain team consisting of a PT, Chiropractor, Psychologist and Pharmacist TENS unit provided as part of larger pain flare kit to encourage self management Veterans seen individually by pain physical therapist are given pedometer and log sheet for daily step count tracking

5 Mr. H is a 63 year old Vietnam Veteran with a 12 year history of chronic low back pain. No red flags. Referred to the chronic pain clinic where he was evaluated by the interprofessional pain team which included the PT, Psychologist, Pharmacist, and Chiropractor. The team recommended the Veteran engage in the 7 week outpatient PSME program (Pain Self Management and Education) which includes the ACT model of psychoeducation and individualized pain rehab physical therapy. Outpatient Medications Status ========================================================================= 1) ACETAMINOPHEN 500MG CAP/TAB TAKE 1 OR 2 TABLETS BY ACTIVE MOUTH TWICE A DAY FOR PAIN (MAX 3000MG/DAY ACETAMINOPHEN FROM ALL SOURCES) 2) ARIPIPRAZOLE 10MG TAB TAKE ONE TABLET BY MOUTH AT ACTIVE BEDTIME **NOTE STRENGTH & DIRECTIONS** 3) CHOLECALCIFEROL 1000UNT TAB TAKE TWO TABLETS BY MOUTH ACTIVE ONCE DAILY - BEGIN WHEN ERGOCALCIFEROL IS COMPLETED 4) CYCLOBENZAPRINE HCL 10MG TAB TAKE ONE TABLET BY MOUTH ACTIVE THREE TIMES A DAY AS NEEDED FOR MUSCLE SPASMS 5) DICLOFENAC NA 75MG EC TAB TAKE ONE TABLET BY MOUTH ACTIVE TWICE A DAY WITH FOOD FOR PAIN OR INFLAMMATION. REPLACES NAPROXEN 6) GABAPENTIN 300MG CAP TAKE TWO CAPSULES BY MOUTH EVERY ACTIVE MORNING AND TAKE THREE CAPSULES EVERY AFTERNOON AND TAKE THREE CAPSULES AT BEDTIME 7) HYDROXYZINE PAMOATE 50MG CAP TAKE ONE CAPSULE BY ACTIVE MOUTH TWICE A DAY AS NEEDED FOR ANXIETY OR SLEEP 8) OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE BY MOUTH ONCE ACTIVE DAILY TO TWICE A DAY -- START TAKING ONE CAPSULE ONCE DAILY - MAY INCREASE TO TAKE ONE CAPSULE TWICE A DAY IF NEEDED 9) SIMVASTATIN 40MG TAB TAKE ONE-HALF TABLET BY MOUTH AT ACTIVE BEDTIME FOR CHOLESTEROL 10) TOPIRAMATE 25MG TAB TAKE ONE TABLET BY MOUTH TWICE A ACTIVE DAY 11) TRAZODONE HCL 100MG TAB TAKE ONE TABLET BY MOUTH AT ACTIVE BEDTIME FOR SLEEP 12) ZOLPIDEM TARTRATE 10MG TAB TAKE ONE TABLET BY MOUTH ACTIVE AT BEDTIME FOR SLEEP -Sleep: Reported 3-4 hours per night, as he has difficulty getting to sleep and staying asleep. -Substances: Nicotine: Smokes 2 cigars per day Alcohol: Veteran reported being clean from alcohol and other drugs for last 10 years (8 of which were in prison). Illicit drugs: Denied any current use. Prior to his incarceration, Veteran reported frequent use of many substances, including cocaine, heroin, and methamphetamines. He stated, "The only thing I haven't abused is prescription medications." Caffeine: Veteran reported drinking about 5 cups (60 oz.) of coffee each morning and 2-3 Monster energy drinks per day. PMH: Depressive disorder, Mood disorder, Degeneration of lumbar intervertebral disc, Insomnia, Chronic back pain, Tobacco dependence 30 second chair rise: 6/14 Patient goals: "Hoping to find a way to make the pain tolerable." Functional goal: return to social activities such as bowling Physical Therapy Plan: Pt engaged in the PSME program with individual pain rehab PT where he was issued a TENS unit, pedometer with log sheet, given a home program and encouraged to wean from lumbar brace

6 References Benedetti, F., Amanzio, M., Casadio, C., Cavallo, A., Cianci, R., Giobbe, R., et al. (1997). Control of postoperative pain by transcutaneous electrical nerve stimulation after thoracic operations. The Annals of Thoracic Surgery, 63(3), Chandran, P., & Sluka, K. A. (2003). Development of opioid tolerance with repeated transcutaneous electrical nerve stimulation administration. Pain, 102(1-2), Chesterton, L. S., Foster, N. E., Wright, C. C., Baxter, G. D., & Barlas, P. (2003). Effects of TENS frequency, intensity and stimulation site parameter manipulation on pressure pain thresholds in healthy human subjects.pain, 106(1-2), Dailey, D. L., Rakel, B. A., Vance, C. G., Liebano, R. E., Amrit, A. S., Bush, H. M., et al. (2013). Transcutaneous electrical nerve stimulation reduces pain, fatigue and hyperalgesia while restoring central inhibition in primary fibromyalgia. Pain, 154(11), Desantana, J. M., Santana-Filho, V. J., & Sluka, K. A. (2008). Modulation between high- and lowfrequency transcutaneous electric nerve stimulation delays the development of analgesic tolerance in arthritic rats.archives of Physical Medicine and Rehabilitation, 89(4), DeSantana, J. M., Walsh, D. M., Vance, C., Rakel, B. A., & Sluka, K. A. (2008). Effectiveness of transcutaneous electrical nerve stimulation for treatment of hyperalgesia and pain. Current Rheumatology Reports, 10(6), Gemmell, H., & Hilland, A. (2011). Immediate effect of electric point stimulation (TENS) in treating latent upper trapezius trigger points: A double blind randomised placebo-controlled trial. Journal of Bodywork and Movement Therapies, 15(3),

7 Leonard, G., Cloutier, C., & Marchand, S. (2011). Reduced analgesic effect of acupuncture-like TENS but not conventional TENS in opioid-treated patients. The Journal of Pain: Official Journal of the American Pain Society, 12(2), Leonard, G., Goffaux, P., & Marchand, S. (2010). Deciphering the role of endogenous opioids in highfrequency TENS using low and high doses of naloxone. Pain, 151(1), Ma, Y. T., & Sluka, K. A. (2001). Reduction in inflammation-induced sensitization of dorsal horn neurons by transcutaneous electrical nerve stimulation in anesthetized rats. Experimental Brain Research, 137(1), Marchand, S., Li, J., & Charest, J. (1995). Effects of caffeine on analgesia from transcutaneous electrical nerve stimulation. The New England Journal of Medicine, 333(5), Mutlu, B., Paker, N., Bugdayci, D., Tekdos, D., & Kesiktas, N. (2013). Efficacy of supervised exercise combined with transcutaneous electrical nerve stimulation in women with fibromyalgia: A prospective controlled study. Rheumatology International, 33(3), Nam, T. S., Choi, Y., Yeon, D. S., Leem, J. W., & Paik, K. S. (2001). Differential antinociceptive effect of transcutaneous electrical stimulation on pain behavior sensitive or insensitive to phentolamine in neuropathic rats. Neuroscience Letters, 301(1), Noehren, B., Dailey, D. L., Rakel, B. A., Vance, C. G., Zimmerman, M. B., Crofford, L. J., et al. (2015). Effect of transcutaneous electrical nerve stimulation on pain, function, and quality of life in fibromyalgia: A double-blind randomized clinical trial. Physical Therapy, 95(1), Palmer, S., Domaille, M., Cramp, F., Walsh, N., Pollock, J., Kirwan, J., et al. (2014). Transcutaneous electrical nerve stimulation as an adjunct to education and exercise for knee osteoarthritis: A randomized controlled trial. Arthritis Care & Research, 66(3),

8 Rokugo, T., Takeuchi, T., & Ito, H. (2002). A histochemical study of substance P in the rat spinal cord: Effect of transcutaneous electrical nerve stimulation. Journal of Nippon Medical School = Nippon Ika Daigaku Zasshi, 69(5), Sluka, K. A., & Walsh, D. (2003). Transcutaneous electrical nerve stimulation: Basic science mechanisms and clinical effectiveness. The Journal of Pain : Official Journal of the American Pain Society, 4(3), Vance, C. G., Dailey, D. L., Rakel, B. A., & Sluka, K. A. (2014). Using TENS for pain control: The state of the evidence. Pain Management, 4(3), Vance, C. G., Rakel, B. A., Dailey, D. L., & Sluka, K. A. (2015). Skin impedance is not a factor in transcutaneous electrical nerve stimulation effectiveness. Journal of Pain Research, 8,