Choosept: Electrotherapy, Effective Alternative for Opioid Reduction?

9/25/2018

Disclosures #ChoosePT: Electrotherapy, Effective Alternative for  We have relevant financial associations with some of the modalities Opioid Reduction? discussed in this presentation as we are employees of Accelerated Care Plus Inc. (ACP), Reno, NV.

KELLY CONTRERAS, PT, GCS, CEEAA SEEMA GURNANI, DPT, GCS, CEEAA  ACP manufactures biophysical agents and provides education, training, and clinical support services to its customers. NORTH CAROLINA PHYSICAL THERAPY ASSOCIATION, OCTOBER 20, 2018, GREENSBORO, NC

Objectives Agenda

 Opioid epidemic statistics and current response to date  Examine the mechanisms of Transcutaneous Electrical Nerve Stimulation (TENS) as a nonpharmacological intervention for pain management  Mechanisms of TENS for pain management  Optimizing TENS stimulation parameters for efficacious results

 TENS as an adjunct for opioid reduction  Examine the evidence regarding TENS efficacy and utilize this to select appropriate stimulation parameters  Acute Pain (Pregnancy/Labor, Post-Operative)  Chronic Pain (Diabetic Neuropathy, Knee Osteoarthritis, Low Back Pain)

 Preliminary results from clinical implementation  Summarize the research with regards to using TENS as an adjunct for pain  Promising avenues for TENS application models management and opioid reduction on acute and chronic pain conditions.  Addiction Recovery  Prehospital Setting

 Q & A

Road to Crisis

 1990’s – Pain as 5th Vital Sign

The Opioid Epidemic  Campaign touting the alleged under treatment of pain

 Liberalization of laws governing prescription of opioids

 Aggressive marketing by pharmaceutical companies

 Increase awareness and education on the inherent right of pain relief

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Road to Crisis - Timeline Map of Crisis

AUGUST 2017: MARCH 2016: SEPTEMBER 2016: CDC Guidelines for President JUNE 2016: National Opioid and declares opioid Prescribing Opioids Heroin Epidemic for Chronic Pain #ChoosePT crisis a national Awareness Week emergency

FEBRUARY 2017: JUNE 2016: AUGUST 2016: American College of FDA announces Surgeon General Physicians recommends non- immediate-release Turn the Tide Rx pharmacological opioids will carry Campaign ‘black box’ Warning approaches first-line tx for LBP

Prevalence/Consequences - Deaths

Since 1999, the # of overdose deaths involving opioids has increased by 46 QUINTUPLED >6/10 drug overdose deaths involve an opioid

Prevalence/Consequences – Other Risks Prevalence/Consequences – Other Risks

 With an initial 10-day supply of opioids, 1 in 5 people become long-term users  1 out of 4 people who get prescription opioids long term for non- cancer pain in primary care settings struggles with opioid use  The National Institute on Drug Abuse defines tolerance as: “A state in which an organism no disorder (addiction) longer responds to a drug. A higher dose is required to achieve the same effect.”  Adult patients who are opioid tolerant are those receiving, for one week or longer, at least:

 1 out of every 550 patients started on opioid therapy, died of opioid-related causes a median of 2.6 yrs after their first opioid prescription

 2010 study showed 40% of Medicaid enrollees with prescriptions for pain relievers had at least one indicator of potentially inappropriate use or prescribing

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Prevalence/Consequences – Other Risks

 2016: Washington Post-Kaiser Family Foundation Survey

 65% - doctor talked with them about possibility of addiction

 61% - no discussion about a plan for getting off the painkillers when the doctor first prescribed them

 62% - received education from their physician about other ways to manage pain

 68% - pain relief provided by opioids outweighs the risk of addiction

 31% - had not tried managing pain with “treatments such as physical therapy, acupuncture, or meditation”

Prescription

 The amount of opioids prescribed in the United States peaked in 2010 and has decreased each year since

 Despite reductions, the amount of opioids prescribed remains approximately three times as high as in 1999

 91% of people who survive an opioid overdose are prescribed more opioids 2015 per capita prescription Nearly 1 in 3 on Medicare opioid rates are enough for 60% of adults received prescription for “every American to be prescribed opioids opioids in 2016 medicated around the clock for 3 weeks” have leftover pills

Pain Pathway

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Nerve Fibers involved in Pain Transmission Pain Modulation

 Release of endogenous opioids activates A Fibers C Fibers PAG the descending inhibitory pathway. The PAG sends projections to the RVM, which then sends projections to the spinal dorsal horn A Beta Fibers A Delta Fibers • Small and unmyelinated • Very slow conducting  Stimulation of the PAG or RVM produces • Large • Small • Respond to all types of inhibition of the dorsal horn nucleus • Myelinated • Lightly myelinated noxious stimuli RVM • Fast conducting • Slow conducting • Transmit prolonged dull • Low stimulating • Respond to heat, pain ***The net effect of opioids on the nerves threshold pressure, cooling, • Require high intensity is inhibition of pain transmission to the • Respond to light chemicals stimuli to trigger a touch • Sharp sensation of brain, and a decrease in the perception pain response and experience of pain by the patient. • ACUTE pain • CHRONIC pain

Pain Modulation

 Endogenous opioids are peptides that are naturally occurring in the body and help modulate the pain experience Mu

 3 representative opioid peptides: Kappa B-endorphins, Metenkephalins, Dynorphins Delta

 There are various receptor types on which opioids have been found to work: Mu, Delta and Kappa

Pain Modulation Types

 Endogenous Opioids: stimulation of opioid receptors produces analgesia by inhibiting Ca++ and K+ channels, which prevents release of pain neurotransmitters Evidence Based Practice: Electrotherapy  Exogenous Opioids: act on same receptor sites as endogenous opioids

Endogenous opioids Mu, Block release of PAIN Delta, pain MODULATION Kappa neurotransmitters Exogenous opioids

**side effects! (addiction, respiratory depression, nausea/vomiting, constipation, tolerance, pruritus, dry mouth, headaches, etc)

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Evidence Based Practice Transcutaneous Electrical Nerve Stimulation Biophysical Agents (TENS)

 Evidence Based Practice (EBP) supports the use of biophysical agents as part of a complete and effective alternative, or at least adjunct to opioid prescription  Definition of TENS [transcutaneous electrical nerve stimulation]: electrical stimulation of the  Electroanalgesia: primary goal is to provide degree of symptomatic pain relief by skin to relieve pain by interfering with the neural transmission of signals from activating natural physiological mechanisms underlying pain receptors (Merriam Webster)

TENS TENS Mechanisms of Action Mechanisms of Action

 Neurotransmitters/receptors that mediate TENS analgesia:  Reduction in central excitability:  Animal models – with peripheral inflammation or neuropathic pain, increased dorsal horn activity to  High Frequency (HF) and Low Frequency (LF) TENS increases concentration of B-endorphins (bloodstream, CSF), noxious or innocuous stimuli is reduced Metenkephalins (CSF), and Dynorphin A (CSF)  There is a reduction in pressure pain thresholds at the stimulation site, as well as at sites outside the area of application, which suggests decreased central excitability (in patients with fibromyalgia and osteoarthritis)  HF TENS produces analgesia by activating endogenous inhibitory mechanisms in the central nervous system involving opioid, GABA, and muscarinic receptors  TENS reduces the release of excitatory neurotransmitters, neuron excitation and resulting sensitization in the spinal cord  HF and LF TENS reduce primary and secondary hyperalgesia  LF TENS does not produce analgesia in opioid tolerant people and animals, but HF TENS does  Peripheral mechanisms:  TENS may modify the excitability of peripheral sensory receptors of painful stimuli to reduce afferent input to the CNS  LF TENS uses descending inhibitory pathways the PAG-RVM, involving opioid, GABA, serotonin and muscarinic receptors ***TENS can re-boot the pain sensory pathways and return them to their normal pain signal inhibitory levels Vance, et al, Pain Manag, 2014 Vance, et al, Pain Manag, 2014

TENS TENS Mechanism of Action – Clinical Implications Key Elements for Efficacy

Opioids primarily inhibit C-fiber nerve conduction. However, painful stimuli from the large, myelinated sensory receptors are poorly controlled by opioids

What makes Using TENS for E-stim stimulates A-delta (motor) and A-beta (sensory) fibers and decreases the TENS work? pain control: activity of noxiously evoked dorsal horn cells located in the spinal cord Making sense of the state of the the mixed results evidence in the clinical E-stim reduces hyperalgesia in damaged tissues thereby decreasing the literature (Sluka, (Vance, Pain amount and intensity of pain signals and increasing patient pain thresholds PTJ, 2013): Manag, 2014)

Some Clinical Practice Guidelines advise properly-administered pain medications and adjunctive, properly-dosed electrical stimulation for optimal pain management

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TENS TENS – Key Elements for Efficacy Waveform Frequency

 Waveform Frequency (Hz) Low Frequency TENS High Frequency TENS

 1-10 Hz  50-150 Hz  Electrode Placement  Adelta fibers activated  Abeta fibers activated  Intensity  Endogenous Opioid released:  Endogenous Opioid released: endorphins, endomorphins dynorphins  Frequency of Application ***Modulation between low and high frequencies provides collective mechanisms for pain relief

TENS TENS Waveform Frequency Electrode Placement

 Preferentially, place the electrodes around the local, E-STIM PROTOCOL DURATION OF PAIN RELIEF painful area to provide other benefits (i.e., facilitate tissue healing and promote increase circulation/ edema reduction)

OPIOID ANALGESIC High-Frequency ½ to 2 hrs minimum  Other electrode placement options include:  Over acupoints and trigger points  Segmental: 1.5 or 3 body inches lateral to the Weaning from Mixed Frequency 2 to 8 hrs minimum spinous process(es) of the involved segmental OPIOID ANALGESIC (modulation between low/high) level(s) and/or  Over the nerve(s) innervating the painful area

TENS TENS Intensity Frequency of Application

 Intensity of TENS is crucial to obtain analgesic response  Research suggests that repeated TENS applications decreases sensitivity of sensory  TENS delivered at or below sensory threshold is ineffective fibers and neurons, centrally and peripherally

 TENS delivered at strong but comfortable intensity provides significant analgesic effect  With repeated TENS stimulation, sensory neurons show reduced spontaneous firing, less response to noxious and non-noxious stimuli • High Frequency TENS (Increase intensity to just below pain threshold at sensory level)

• Low Frequency TENS (Increase intensity to produce motor contractions)  Frequency of application may vary according to chronicity of pain. More frequent applications for acute conditions (e.g., QD) and less frequent for chronic  Research shows that there is a greater analgesic effect when TENS intensity was conditions (e.g., 2x/week). increased during treatments in response to subject accommodation to the stimulation

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TENS – Summary of Key Elements Review of The Evidence Opioids and low-frequency TENS activate same Mu Waveform Frequency (Hz) receptor, therefore consider high-frequency TENS for patients on opioids regularly to activate alternate pain mechanisms. Modulating between low and high frequencies delays opioid tolerance ACUTE PAIN

Electrode Placement Electrode Placement options include surrounding local area of pain, acupoints/trigger points, segmental level or nerve(s) innervating painful area

Intensity Strong, but comfortable intensity; increase intensity during treatment to prevent analgesic tolerance

Frequency of Application More frequent applications for acute conditions, less frequent for chronic conditions

ACUTE PAIN TENS vs. Placebo TENS TENS vs. No Treatment

Cochrane Review (19 Randomized Controlled Trials, N=1346)

 PURPOSE: To assess the analgesic effectiveness of TENS, as a sole treatment, for acute pain in adults.

 CONCLUSION: The analysis provides tentative evidence that TENS reduces pain intensity over and above that seen with placebo (no current) TENS when administered as a stand-alone treatment for acute pain in adults.

Johnson et al, Cochrane Database, 2015 Johnson et al, Cochrane Database, 2015

ACUTE PAIN: Labor

ACUTE PAIN: Labor and Post-Partum Randomized Controlled Trial (N=90)

 PURPOSE: Investigate the effect of transcutaneous electrical nerve stimulation on labor pain among nulliparous women

 METHOD: Participates randomly divided into control (CG), experimental (EG), or placebo (PG)

 EG: TENS electrodes placed between T10-L1 and S2-S4, frequency not listed, intensity increased until mother expressed feeling minor tingles in the area. Intensity then fixed at that Acute Pain level  Pain measured in all 3 groups at 4 cm dilation (pre TENS for EG), within every hour until the 1st stage of labor and in the second stage of labor. Pain recorded 4 hours after delivery

Roonak, Comp Therapies in Clinical Practice, 2017

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RESULTS Severity of pain during 1st and 2nd stage of labor was reported to be less for EG compared to ACUTE PAIN: Labor placebo and control group

Duration of 1st stage of labor less in EG compared to placebo and control group (158’ vs. Randomized Controlled Trial (N=100) 262’ vs. 257’)

Statistically significant difference in recorded severity of pain 4 hours after delivery for EG  PURPOSE: To assess the effectiveness of transcutaneous electric nerve stimulation (TENS) compared to placebo and control group (6.7% vs. 43.3% vs. 60%) in controlling labor pain

No negative consequences to mothers or newborn  METHOD: Random assignment to two groups: Group A used TENS and Group B (control) received pethidine

 Group A: one electrode at level of T10-L1 and the other at level of S2-S4 CONCLUSION: TENS assists with the delivery progress through relieving pain in the first stage of labor, and diminishes duration of 1st stage. Considered a safe pain relief method during • Mixed-Frequency TENS waveform childbirth • Group B: 50-100 mg pethidine , IM into gluteal region every 4 h or more if needed Roonak, Comp Therapies in Clinical Practice, 2017 Shaban, Evid Based Women Health J, 2013

RESULTS Need for oxytocin augmentation during labor was less in Group A (TENS) ACUTE PAIN: Post Partum

Difference in pain scores among TENS and Control group statistically non-significant Prospective Randomized Controlled Trial (N=200)

Neonatal outcomes- no difference in Apgar scores at 1’, but statistical difference between both groups in the 5’ Apgar  PURPOSE: Determine efficacy and reliability of TENS in management of pain related to 100% neonates in Group A had Apgar of 7 or higher. Only 30% neonates in Group B with childbirth Apgar of 7 or higher

No adverse effects encountered in Group A (TENS) and high willingness to use TENS again in  METHOD: A 100 healthy women s/p cesarean section under general anesthesia were subsequent deliveries, Group B (control, pethidine) experienced nausea, vomiting, and randomly assignment to the placebo (group 1) or the TENS group (group 2), while 100 sedation women who delivered by vaginal route without episiotomy were randomized into the placebo group (group 3) or the TENS group (group 4) CONCLUSION: TENS is as effective as conventional methods for labor pain relief, but with greater satisfaction reported by women and no side effects

Shaban, Evid Based Women Health J 2013 Kayman-Kose et al, J Matern Fetal Neonatal Med, 2014

RESULTS Pain related to uterine contraction decreased after vaginal delivery in those who received ACUTE PAIN: Post Partum TENS

Post- op pain at incision and with uterine contraction significantly decreased post C-section Randomized Controlled Trial (N=42) in those who received TENS.

 PURPOSE: Examine effectiveness and overall opiate consumption between TENS combined with 20% less need for opioid analgesics after 8 hours in women who received TENs after patient-controlled analgesia with morphine and patient-controlled analgesia with morphine C-section alone following scheduled caesarean birth

 METHOD: Participants randomized and connected to patient controlled analgesia with morphine alone (PCA-m) or in combination with TENS (PCA-TENS) CONCLUSION: TENS is an effective, reliable, practical, and easily available modality of treatment for postpartum pain  TENS, high frequency (>50 hz), intensity increased until patient felt a comfortable tingling sensation without motor contraction

 PCA pump filled with like dosage of morphine, rate of infusion each time button pressed set to be equal in both groups Kayman-Kose et al, J Matern Fetal Neonatal Med, 2014 Binder et al, Midwifery, 2011

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RESULTS Pain assessment did not differ between groups initially, overall moderate levels of post-op pain, which decreased over time through observation period

Women in the PCA-TENS group consumed nearly 50% less of the morphine dosage of ACUTE PAIN: Post-Operative women in the group using PCA-m alone (p<.001)

PCA-m mothers reported feeling more sedated over time during 3 to 12 hours post partum

CONCLUSION: High frequency TENS in combination with morphine reduces the overall amount of opioid analgesic required to achieve pain relief Acute Pain

Binder et al, Midwifery, 2011

ACUTE PAIN: Total Knee Arthroplasty (TKA) ACUTE PAIN: Total Knee Arthroplasty (TKA)

Meta-analysis (39 RCTs published between 1946 to 2016, N=2391patients) Meta-analysis (5 RCTs published between 2004 to 2017, N=472 patients)

 PURPOSE: To systematically review and meta-analyze evidence of nonpharmacological  PURPOSE: Evaluate the efficiency and safety of TENS for pain control after TKA interventions for postoperative pain management after TKA

 CONCLUSION:  CONCLUSION:  TENS groups (experimental) showed significant improvements in VAS scores and  Clinical trials included commonly performed interventions of continuous passive opioid consumption at 12, 24, and 48 hours after TKA, compared to ‘sham/placebo’ motion, preoperative exercise, cryotherapy, electrotherapy, and acupuncture TENS groups (control)  Electrotherapy and Acupuncture after total knee arthroplasty were associated with  TENS groups showed reduced risk of vomiting and nausea compared to reduced or delayed opioid consumption ‘sham/placebo’ TENS groups groups

Tedesco, JAMA, 2017 Li and Song, Medicine, 2017

ACUTE PAIN: TKA

Systematic Review (5 RCTs published between 1990 to 2011 , N=347 patients)

Favors experimental Favors control  PURPOSE: Evaluate the clinical efficacy of TENS in the treatment of post-operative pain for patients with knee arthroplasty and relate this to the stimulation parameters used 24 hours 48 hours

 CONCLUSION:

 The quality of TENS interventions that were used showed multiple areas of concern that may Reduced Opioid 12 hours underestimate the effects of TENS Consumption  Majority of the included studies point out that TENS has no analgesic effect in patients with knee following TKA arthroplasty. All studies showed poor methodological quality.

 ***The 2 studies that used TENS intensities in accordance with the latest guidelines (“strong but comfortable”) did report positive effect on analgesic consumption or subjective pain measure Li and Song, Medicine, 2017 Beckwee et al, SAGE Open Medicine, 2014

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RESULTS ACUTE PAIN: Total Hip Arthroplasty (THA) No difference on pain intensity between groups at 8hr, 24hr and 48hr post-operatively at rest and during movement

Fentanyl use was significantly LOWER in Group Acu Randomized Controlled Trial (N=68 patients) than Group Sham at 24hrs (by 37%) and 48hrs (by 31%) after surgery

 PURPOSE: Investigate whether TENS on acupoints can provide complementary analgesia to Nausea, vomiting and dizziness were significantly LOWER in Group Acu (16.7%, 10%, 6.7%) reduce the requirement of fentanyl PCA and its related side effects after THA in elderly patients than Group Sham (46.7%, 32.2%, 26.7%)

Frequency of rescue medication was significantly LOWER in Group Acu (13.3%)  METHOD: Randomly allocated to Group Acu (PCA + TENS on acupoints) or Group Sham (PCA + sham TENS) than Group Sham (36.7%)

 Group Acu = alternately stimulating at 2Hz and 100Hz every 3 seconds, high intensity at 9- 20mA CONCLUSION: TENS is a non-invasive, non-pharmacological technique for use in postoperative analgesia and is associated with reductions in opioid-related side effects  Group Sham = intensity at 0mA

Lan et al, Minerva Anestesiologica, 2012 Lan et al, Minerva Anestesiologica, 2012

Use of Opioids

ACUTE PAIN: Cardiac Surgery

Systematic Review and Meta-Analysis (7 RCTs published between 2001 to 2016, N=321 patients)

 PURPOSE: Evaluate the efficacy of electroacupuncture in addition to general anesthesia in patients undergoing cardiac surgery

 CONCLUSION:

 Electroacupuncture groups demonstrated a lower dosage trend for opioids (fentanyl and morphine), however no statistical significance  Electroacupuncture groups demonstrated reduced dosage of intraoperative anesthetic Favors Control Favors TENS drugs, leading to shorter mechanical ventilation time, shorter ICU stay, and reduced (Electroacupuncture) postoperative dose of vasoactive drugs

Asmussen et al, Journal of Intensive Care Medicine, 2017 Asmussen et al, Journal of Intensive Care Medicine, 2017

ACUTE PAIN: Thoracotomy RESULTS

TENS Group showed significantly LOWER pain levels compared to Control Group at Post-Op Day 0, 1, 2 Prospective Randomized Controlled Trial (N=87)

No statistically significant differences between groups  PURPOSE: Assess the effects of TENS on pain, vital signs, early post-operative in mean arterial blood pressure and heart rate complications, and length of hospital stay

 METHOD: Randomly allocated to Group T (TENS) or Group C (placebo TENS) CONCLUSION: TENS appears to be an effective method of aiding a patient to breathe more  Group T = stimulating at 100Hz effectively after thoracic surgery, and is a safe and effective adjunctive therapy for acute  Group C = placebo TENS with inoperative machine postthoracotomy pain control. TENS does not affect the duration of hospitalization or early pulmonary complications.

Sezen et al, Asian Cardiovascular & Thoracic Annals, 2017 Sezen et al, Asian Cardiovascular & Thoracic Annals, 2017

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RESULTS

ACUTE PAIN: Thoracotomy Group EA showed significantly LOWER pain levels than Group Sham at 2hr, 24hr, 48hr, 72hr after surgery

Randomized Controlled Trial (N=92) Total Sauteralgyl (synthetic narcotic) supplemental use was 20% LOWER in Group EA than Group Sham  PURPOSE: Determine whether ElectroAcupuncture (EA) can reduce postoperative analgesic requirement and incidence of opioid-related side effects in the first 72hrs after surgery Nausea was significantly LOWER in Group EA (21.7%) than Group Sham (47.8%), No statistically significant difference in vomiting between both groups  METHOD: Randomly allocated to Group EA (TENS over acupoints) or Group Sham (placebo TENS over acupoints)

 Group EA = stimulating at 2Hz, intensity of 3-5mA

 Group Sham = placebo TENS over same acupoints without use of electrical current CONCLUSION: Postoperative EA is advantageous in reducing acute postoperative pain, analgesic consumption, and incidence of nausea in the first 72 hours post-operatively.

Chen et al, Evidence-Based Complementary and Alternative Medicine, 2016 Chen et al, Evidence-Based Complementary and Alternative Medicine, 2016

Review of The Evidence Chronic Pain: Diabetic Neuropathy CHRONIC PAIN

Acute Pain

CHRONIC PAIN: Diabetic Neuropathy CHRONIC PAIN: Diabetic Neuropathy

Critical analysis (3 systematic reviews, 1 RCT, 1 observational study between 2009-2014) Systematic Review (12 RCTs)

 PURPOSE: Critical analysis of the available evidence on the application of TENS for the  PURPOSE: Evaluate the effects of treatment with electrical stimulation and clinical treatment of painful diabetic peripheral neuropathy patients electromagnetic fields on pain and sensitivity in patients with painful diabetic neuropathy compared with placebo or another intervention

 Conclusion: The majority of the evidence recommends the use of TENS therapy for the management of painful diabetic peripheral neuropathy. However, it is limited with short  CONCLUSION: Transcutaneous electric nerve stimulation may be an effective and safe duration of trial period and lack of standardization of TENS therapy for the condition strategy for the treatment of symptomatic diabetic neuropathy

Merghani, Journal of Dental and Medical Sciences, 2015 Stein et al, Braz J Phys Ther, 2013

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Pain Relief TENS vs. Placebo

Chronic Pain: Knee Osteoarthritis

Acute Pain

Favors TENSFavors Placebo Stein et al, Braz J Phys Ther, 2013

CHRONIC PAIN: Knee Osteoarthritis CHRONIC PAIN: Knee Osteoarthritis

Systematic Review (30 randomized controlled trials, 7 specific to TENS) Pain pre- to post treatment TENS-Pain Literature • Cheing et al 2002: n=16 TENS (80Hz, 60 mins)  PURPOSE: Evaluate the effects of various non-operative modalities of treatment (TENS, • Cheing et al 2003: n=10 TENS (100 Hz, 40 mins) NMES, insoles, bracing) on pain of OA of knee • Itoh et al 2008: n=6 TENS (122 Hz, 15 mins) • Cetin et al 2008: n= 20 TENS (60 to 100 Hz) + heat  CONCLUSION: Overall, all four non-operative modalities of treatment were found to & exercise have a significant effect on the reduction of pain in OA of the knee • Atamaz et al 2012: n=29 TENS (80 Hz, approx 3 hrs of wearable brace)

• Cherian et al 2014: n=13 (80 HZ) Favors TENS • Law and Cheing 2004: n=13 TENS (2 Hz, 40 mins) Cherian et al, Bone Joint J, 2016 Cherian et al, Bone Joint J, 2016

RESULTS CHRONIC PAIN: Knee Osteoarthritis Patients who received TENS showed significant improvement in mean pain scores from the initial appointment to the 3-month follow-up compared with the control group

Randomized Controlled Trial (N=40) Patients who received TENS had a significantly greater improvement in objective Knee Society Scores from the initial visit to the 3-month follow-up compared with patients Subjective functional outcomes and quality of life also improved  PURPOSE: The purpose of this study was to evaluate the efficacy of transcutaneous electrical nerve stimulation compared with those of other standard non-operative modalities for the treatment of osteoarthritis of the knee On evaluation of patients who eventually progressed to total knee arthroplasty, fewer patients in the TENS group than in the control group underwent the procedure (11% vs 6%)

 METHOD: Patients were blindly randomized to receive either a TENS device or standard treatment only (physical therapy-3x week/6 weeks or intra articular corticosteroid CONCLUSION: Patients had significant relief of pain when receiving TENS vs. standard injection, and self-directed exercise) treatment. In addition, TENS significantly reduced the progression of loss of strength in the quadriceps muscle. The use of TENS may be a viable adjunct to current standard treatment for pain associated with OA of the knee Jeffrey et al, Orthopedics, 2016 Jeffrey et al, Orthopedics, 2016

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CHRONIC PAIN: Low Back Pain

Chronic Pain: Low Back Pain Randomized Controlled Trial (N=127)  PURPOSE: Assess the influence of individual electrotherapeutic treatments on reduction of pain, improvement of range of movement in lower section of the spine, and improvement of motor functions and mobility for people suffering from L5-S1 discopathy, chronic radiating pain and pseudo radicular syndrome.

 METHOD: Randomly allocated to Group A (Conventional TENS + Exercise), Group B (Acupuncture-like TENS + Exercise), and Control Group F (Exercise)

 Group A = stimulating at 100Hz, intensity to ‘distinctive sensation of current flow’, increased during Acute Pain treatment to maintain sensation

 Group B = stimulating at 10Hz, intensity to ‘distinctive muscle contraction’, increased during treatment to maintain sensation

 Group F = motor improvement exercises only Rajfur et al, Med Sci Monit, 2017

F RESULTS u Groups A and B showed significantly LOWER pain levels on VAS scale and Laitinen Questionnaire n than Control Group F c t i Groups A and B showed statistically significant HIGHER scores in Oswestry Questionnaire than Control o Group F. Although both groups also showed higher scores on the Roland-Morris Questionnaire, they n M P were not statistically significant. Both questionnaires assess improvement in functional ability. a o a L b i i n M L Groups A and B showed statistically significant HIGHER hip and lumbosacral spinal mobility than o i Control Goup F, on both the Lasegue and Schober tests b t i y L CONCLUSION: Both types of TENS applications are helpful in treatment of discopathy of the i lower region of the spine (Interferential current led to greater remission of symptoms). t y Rajfur et al, Med Sci Monit, 2017

RESULTS CHRONIC PAIN: Low Back Pain Opioid usage was significantly LOWER in the TENS group (57.7%) than the non-TENS group (60.3%)

Observational Retrospective Analysis (N=45,826) LOWER average per-patient opioid costs in the TENS group ($169 per patient) than the non-TENS group ($192 per patient), and LOWER per-patient pharmacy-related costs in the TENS group ($2,955 per patient) than the non-TENS group ($3,104), however the results were not statistically significant  PURPOSE: Evaluate patients who were given TENS for chronic low back pain (CLBP) compared to a matched group without TENS at one-year follow-up, to determine differences between opioid consumption. Significantly LOWER opioid event rates in the TENS group (3.8) compared to the non-TENS group (4.1) and FEWER prescription claims in the TENS group (31.6) than the non-TENS group (32.3)

 METHOD: Opioid utilization and costs in patients who did and did not receive TENS were Significantly LOWER average per-opioid event costs in TENS group ($44) than the non-TENS group ($49) extracted from a Medicare supplemental administrative claims database.

 Patients were selected if they had at least two ICD-9-CM coded claims for low back pain in a three-month period CONCLUSION: Treatment of CLBP with TENS (which is both non-invasive and a non-narcotic)  Propensity score matching at a 1:1 ratio to identify similar baseline demographic and clinical demonstrated significantly fewer patients requiring opioids, fewer events where a patient characteristics (22,913 people in each group) required an opioid prescription, and lower per-patient costs. Pivec et al, Orthopedic Surgery, 2015 Pivec et al, Orthopedic Surgery, 2015

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• Low number of trials • Larger Sample Sizes

• Incomplete reporting of study designs • Longer Duration

• Poor methodological rigor • Optimal daily treatment duration, methods of blinding unclear or not described, electrode site application, long-term lack of ‘control’ or ‘sham’ groups, patient groups use were heterogeneous, small sample size, short Limitations of duration Study TENS tolerance Areas of Further • Current • Parameters not fully described Research • Include more outcome measures Research • Lack of consistency with key elements of efficacy • Additional patient populations and waveform frequency, intensity, electrode subgroups examined placement, frequency of application • Head to head comparison of TENS vs. • Follow-up times were different pharmacological (opioid-based) interventions for pain management • Inconsistent outcome measures

CLINICAL RESULTS - #1 CLINICAL RESULTS - #2

• 9 facilities, N = 173 • 1 facility, N = 19 Average Pain Pain Rating- Change in Days on Rating- Program D/C Pain Rating Average Pain Pain Change in Caseload Program Days on Rating- Rating- Pain Rating • Diagnoses ranged from acute • Diagnoses: Acute post-op Start postop to chronic Caseload Program Program lower extremity orthopedic Start D/C population 4.76 2.57 46% • Combination short stay vs. long stay 21.3 7.30 3.44 53% • Short stay only TUG TUG Change in TUG Program Start Program D/C Score (sec)

• All received electrotherapy • All received electrotherapy as adjunct to treatment as adjunct to treatment 71.1 20.3 71%

Addiction Recovery Promising Avenues Randomized Controlled Trial (N=63)

 PURPOSE: To assess the therapeutic effect of transcutaneous electric acupoint Addiction Recovery and stimulation (TEAS) for the treatment of withdrawal syndrome in heroin addicts Pre-Hospital Setting  METHOD: Random distribution into two groups  TENS EA group (N=31) received 30 minutes/session for 10 consecutive days . Frequencies alternated between 2 and 100 Hz (LI4, PC-8 on one hand, PC-6, SJ-5 on opposite forearm)  Control Group (N=32) similar procedure as TENS EA group, but with leads disconnected

Da, Pain Med, 2015

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RESULTS Symptoms of anxiety and agitation were 60% and 71% lower in the TEA group Pre-Hospital Setting

The median of musculoskeletal pain of the TEAS group during 10 days was 59% lower than Systematic Review and Meta-Analysis (4 RCTs published between inception to 2012, N=261 patients) the control group

The severity of insomnia and symptoms of sleepiness/yawn were 74% and 70% lower in the  PURPOSE: Investigate the effectiveness of TENS, compared with ‘Sham’ TENS for relieving pain and TEA group anxiety when performed by medics in the prehospital setting.

Withdrawal syndrome in the TEA group was 60% lower than that of control group. Dosage of  CONCLUSION: Buprenorphine significantly less in TEA group  Each study found significant difference in the average final pain scores favoring TENS compared to Sham treatment (pooled analysis showed difference = 33mm).

 Each study found significant difference in the average final anxiety scores favoring TENS compared CONCLUSION: TEAS of 2/100 Hz for 10 days in abrupt abstinence of the heroin addicts resulted to Sham treatment (pooled analysis showed difference = 26mm). in a marked reduction of the withdrawal syndrome as well as a reduced requirement for  When compared to Sham treatments, TENS could be an effective prehospital analgesic modality rescue opioids. Results from this study strongly suggest that the treatment seems to be safe that leads to clinical meaningful reductions in acute pain for patients with moderate-to-severe pain and effective of musculoskeletal and visceral etiology. Simpson et al, Eur J Emerg Med, 2014 Da, Pain Med, 2015

Average Final Pain Score between TENS and Sham

CONCLUSION

√ The opioid epidemic is a monumental health crisis, with far-reaching and devastating Average Reduction in Anxiety Score implications

√ Opioids and TENS use similar mechanisms of action to modulate the pain pathway

√ Efficacy of TENS is dependent on mindful and skilled application incorporating the key elements discussed (waveform frequency, electrode placement, intensity and frequency of application)

***TENS should be considered as an adjunct or alternative Favors TENS Favors Control to pharmacological intervention in acute and chronic painful conditions Simpson et al, Eur J Emerg Med, 2014

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