TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION IN OSTEOPOROSIS RELATED PAIN

Sanjay Kalra, Bharti Kalra,Bharti Hospital, Karnal INDIAbhartihospital@rediffmail.com

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