TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION IN OSTEOPOROSIS RELATED PAIN Sanjay Kalra, Bharti Kalra,...
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Transcript of TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION IN OSTEOPOROSIS RELATED PAIN Sanjay Kalra, Bharti Kalra,...
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION IN OSTEOPOROSIS RELATED PAIN
Sanjay Kalra, Bharti Kalra,Bharti Hospital, Karnal [email protected]
BACKGROUND
Pain is a common comorbid feature of osteoporosis.
Many drugs are available to manage pain, but all have
limited success.
Adverse effects, drug interactions and geriatric nature
of most patients limit the use of drugs
There is a need for non pharmacological means of
symptom management.
The first uses of electroanalgesia were recorded by Aristotle, Plinyand Plutarch, who reported application of electrical fish to pain sites.
TENS
Transcutaneous electrical nerve stimulation (TENS) is
an electrical modality of pain relief
(Chabel et al; 1997, Shealy 2003) .
Considered gold standard amongst non
pharmacological modalities of pain relief (Mc Quay et al;1997).
PRESENT STATUS
No reports are available, however, on the
use of TENS in osteoporosis
No reports are available on effect of TENS
on varying symptoms such as burning,
lancinating pain, deep pain, crawling
sensation and allodynia.
TENS
TENS devices consist of electronic stimulus generator
which transmits pulses to electrodes on skin for pain
management .
Electrical pulses may block transmission of pain fibres
( large diameter myelinated A vs non
myelinated slow C fibres) or may stimulate release of
endogenous opioids.
STUDY DESIGN
Single blind, randomized, prospective, single centre
study at Bharti Hospital, Karnal.
To assess efficacy of TENS, compared with diclofenac,
in subjects with osteoporosis and pain.
To assess efficacy of TENS in different symptoms of
pain.
PATIENT POPULATION
30 patients in group I:
• Diclofenac 50 mg b.d. x 3 weeks.
• Five o d/ EOD sittings of 15 min using sham electrodes
with no stimulation.
30 patients in group II
• 5 o d/ EOD sittings of TENS.( Life Care, Ghaziabad, India)
Duration, intensity of TENS decided on daily basis by physiotherapist
(FREQUENCY ; hold: relax ratio modulation)
STUDY DESIGN
Osteoporosis management as routine
No opioids, TCAs, SSRIs etc. given to TENS group.
Supportive management as needed.
Pain severity assessed by visual analog scale 0 - 10. Validated English language questionnaires used to
assess physician communication, time spent in stretching/strengthening exercise, social/role activities limitation, cognitive symptom management, health distress score and energy/fatigue levels.
TENS PARAMETERS
WAVE FORMS
Biphasic (containing both + ve and –ve waveforms).
may be –
Square
Rectangular
Sinusoidal
Triangular /spiked
Selection depends on patient’s comfort.
TENS PARAMETERS
FREQUENCY OF DOSING
EOD to q6h (od or EOD)
DURATION OF SITTING
15 mins to 1 hour (15 mins)
FREQUENCY
• 80-150 Hz / 2-10 Hz
• PULSE WIDTH / DURATION
50 -400 µs (100-200 µs)
TENS PARAMETERS
CURRENT
0 – 60 mA ; treatment based on patients
sensation (12 – 30 mA).
CONSTANT CURRENT VS VOLTAGE
constant voltage.
HOLD TIME
10:1 to 1:1 ratio (6 to 9” hold 4 to 3” rest ratio)
TENS PARAMETERS
PLACEMENT OF ELECTRODES
Associated nerve roots and dermatomes.
Point of pain
Acupuncture point proximal/distal to point of pain.
Trans artheral placements ( knee & foot).
Contra lateral placements in inaccessible areas due
to amputations, dressings, open wounds & casts.
MODULATION IN TENS
Frequency modulation
Pulse width modulation
Current modulation
May vary about 10% periodically.
(e.g 12 to 15 to 12 to 15 mA etc.)
Hold: relax ratio modulation
frequency modulation
BASELINE CHARACTERISTICSGroup Diclofenac + TENS
Age (years) 47.60 ± 22.40 46.11 ± 23.88
Gender (female/male)
22/8 19/11
Durn of pain(years) 1.86 ± 1.12 1.86 ± 1.21
Tingling 7 8
Burning3
3
Deep pain 17
15
Restless legs 3
5
Symptom TENS GROUPmean
improvement (pain score)
DICLOFENAC mean
improvement (pain score)
burning** 3.28 ± 0.64 1.12 ± 0.33
tingling 2.62 ± 0.35 1.68 ± 0.72
restless legs* 2.16 ± 0.56 0.91 ± 0.12
DEEP PAIN** 3.00 ± 0.00 2.00± 0.15
* P<0.05; **P<0.01
DOSE
The dose of TENS used varied from 5.5 to 9.0 Hz on the initial day to 3.5 to 5.5 Hz on the last sitting. The dose varied insignificantly for different symptoms
This difference was maintained after 3 weeks, even though the TENS sittings had stopped
Improvement in Physician communication score :1.43 ± 1.19 to
3.93 ± 0.86 over one month of therapy in all subjects.
Time spent in stretching/strengthening exercise: 0.0 ± 0.0 to 15.0 ± 0.0 min/week.
social/role activities limitation : 2.25 ± 0.63 to 1.08 ± 0.39.
Cognitive symptom management : 1.30 ± 0.63 to 2.00 ± 0.67.
health distress score:3.20 ± 0.82 to 1.35 ± 0.47 Energy/fatigue score: 2.25 ± 0.51 to 3.30 ± 0.50
0
0.5
1
1.5
2
2.5
3
3.5
4
PCS TSE SAL CSM HDS EFS
Baseline
Four Weeks
PCS= Physician communication score ,TSE= Time spent in stretching/strengthening exercise,SAL= social/role activities ,CSM= Cognitive symptom management, HDS=health distress score,EFS= Energy/fatigue score
Conclusion
Till date no study has tried to assess effect of TENS in
osteoporosis-related pain.
This study demonstrates the increased efficacy of TENS
in osteoporosis with pain-related symptoms.
The efficacy and efficiency of TENS as a therapeutic
modality in persons with osteoporosis and pain is worthy
of more extensive study.
ACKNOWLEDGEMENTS
STAFF AND PATIENTSof
BHARTI HOSPITALKARNAL
INDIAN SOCIETY FOR BONE AND MINERAL RESEARCH
Thank you