#ChoosePT: Electrotherapy,

Effective Alternative for

Opioid Reduction?
KELLY CONTRERAS, PT, GCS, CEEAA SEEMA GURNANI, DPT, GCS, CEEAA

COMBINED SECTIONS MEETING, FEBRUARY 21-24, NEW ORLEANS, LA

 Disclosures

We have relevant financial associations with some of the modalities

discussed in this presentation as we are employees of Accelerated
Care Plus Inc. (ACP), Reno, NV.

ACP manufactures biophysical agents and provides education,

training, and clinical support services to its customers.
 Objectives

Examine the mechanisms of Transcutaneous Electrical Nerve Stimulation

(TENS) as a nonpharmacological intervention for pain management

Examine the evidence regarding TENS efficacy and utilize this to select
appropriate stimulation parameters

Summarize the research with regards to using TENS as an adjunct for pain
management and opioid reduction on acute and chronic pain
conditions.
 Agenda

Opioid epidemic statistics and current response to date

Mechanisms of TENS for pain management

Optimizing TENS stimulation parameters for efficacious results

TENS as an adjunct for opioid reduction

Acute Pain (Pregnancy/Labor, Post-Operative)

Chronic Pain (Diabetic Neuropathy, Knee Osteoarthritis, Low Back Pain)

Preliminary results from clinical implementation

Promising avenues for TENS application models

Addiction Recovery

Prehospital Setting

Q&A
The Opioid Epidemic
VIDEO
 Road to Crisis

1990’s – Pain as 5th Vital Sign

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

 Road to Crisis - Timeline

MARCH 2016: AUGUST 2017:

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

JUNE 2016: FEBRUARY 2017:

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

>6/10 drug overdose

deaths involve an
opioid

Since 1999, the # of

overdose deaths
involving opioids
QUADRUPLED
 Prevalence/Consequences – Other Risks

1 out of 4 people who get prescription opioids long term for non-
cancer pain in primary care settings struggles with opioid use
disorder (addiction)

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
 Prevalence/Consequences – Other Risks

With an initial 10-day supply of opioids, 1 in 5 people become long-term users

The National Institute on Drug Abuse defines tolerance as: “A state in which an organism no
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:
 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 then
decreased each year through 2015

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
opioid rates are enough for Nearly 1 in 3 on Medicare
60% of adults “every American to be received prescription for
prescribed opioids medicated around the opioids in 2015
have leftover pills clock for 3 weeks”
Pain Pathway
 Nerve Fibers involved in Pain Transmission

A Fibers C Fibers

A Beta Fibers A Delta Fibers • Small and unmyelinated

• Very slow conducting
• Large • Small • Respond to all types of
• Myelinated • Lightly myelinated noxious stimuli
• Fast conducting Slow conducting
• • Transmit prolonged dull
• Low stimulating • Respond to heat,
pain
threshold pressure, cooling,
• Respond to light
• Require high intensity
chemicals
touch • Sharp sensation of
stimuli to trigger a
pain response
• ACUTE pain • CHRONIC pain
Pain Modulation

Release of endogenous opioids activates

PAG the descending inhibitory pathway. The
PAG sends projections to the RVM, which
then sends projections to the spinal dorsal
horn

Stimulation of the PAG or RVM produces

inhibition of the dorsal horn nucleus
RVM
***The net effect of opioids on the nerves
is inhibition of pain transmission to the
brain, and a decrease in the perception
and experience of pain by the patient.
Pain Modulation

Endogenous opioids are peptides

that are naturally occurring in the
body and help modulate the pain
experience

3 representative opioid peptides:

B-endorphins, Metenkephalins,
Dynorphins

There are various receptor types on

which opioids have been found to work:
Mu, Delta and Kappa
 Mu

Kappa

Delta
 Pain Modulation Types

Endogenous Opioids: stimulation of opioid receptors produces analgesia by inhibiting

Ca++ and K+ channels, which prevents release of pain neurotransmitters

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)
Evidence Based Practice:
Electrotherapy
 Evidence Based Practice
Biophysical Agents

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

Electroanalgesia: primary goal is to provide degree of symptomatic pain relief by

activating natural physiological mechanisms
Transcutaneous Electrical Nerve Stimulation
(TENS)

Definition of TENS
[transcutaneous electrical nerve stimulation]: electrical stimulation of the
skin to relieve pain by interfering with the neural transmission of signals from
underlying pain receptors
(Merriam Webster)
 TENS
Mechanisms of Action

Neurotransmitters/receptors that mediate TENS analgesia:

High Frequency (HF) and Low Frequency (LF) TENS increases concentration of B-endorphins (bloodstream, CSF),
Metenkephalins (CSF), and Dynorphin A (CSF)

HF TENS produces analgesia by activating endogenous inhibitory mechanisms in the central nervous system
involving opioid, GABA, and muscarinic receptors

LF TENS does not produce analgesia in opioid tolerant people and animals, but HF TENS does

LF TENS uses descending inhibitory pathways the PAG-RVM, involving opioid, GABA, serotonin and muscarinic
receptors

Vance, et al, Pain Manag, 2014

 TENS
Mechanisms of Action

Reduction in central excitability:

Animal models – with peripheral inflammation or neuropathic pain, increased dorsal horn activity to
noxious or innocuous stimuli is reduced

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)

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

Peripheral mechanisms:

TENS may modify the excitability of peripheral sensory receptors of painful stimuli to reduce afferent input
to the CNS

***TENS can re-boot the pain sensory pathways and return them to their normal pain signal inhibitory
levels
Vance, et al, Pain Manag, 2014
TENS
Mechanism of Action – Clinical Implications
Opioids primarily inhibit C-fiber nerve conduction. However, painful stimuli from
the large, myelinated sensory receptors are poorly controlled by opioids

E-stim stimulates A-delta (motor) and A-beta (sensory) fibers and decreases the
activity of noxiously evoked dorsal horn cells located in the spinal cord

E-stim reduces hyperalgesia in damaged tissues thereby decreasing the

amount and intensity of pain signals and increasing patient pain thresholds

Some Clinical Practice Guidelines advise properly-administered pain

medications and adjunctive, properly-dosed electrical stimulation for optimal
pain management
 TENS
Key Elements for Efficacy

What makes Using TENS for

TENS work? pain control:
Making sense of the state of the
the mixed results evidence
in the clinical
literature (Sluka, (Vance, Pain
PTJ, 2013): Manag, 2014)
TENS – Key Elements for Efficacy

 Waveform Frequency (Hz)

 Electrode Placement

 Intensity

 Frequency of Application
 TENS
Waveform Frequency

Low Frequency TENS High Frequency TENS

1-10 Hz
50-150 Hz

Adelta fibers activated
Abeta fibers activated

Endogenous Opioid released:
Endogenous Opioid released:

endorphins, endomorphins dynorphins

***Modulation between low and high frequencies provides collective mechanisms for pain relief
 TENS
Waveform Frequency

E-STIM PROTOCOL DURATION OF PAIN RELIEF

OPIOID ANALGESIC High-Frequency ½ to 2 hrs minimum

Weaning from Mixed Frequency 2 to 8 hrs minimum

OPIOID ANALGESIC (modulation between low/high)

34
 TENS
Electrode Placement

Preferentially, place the electrodes around the local,

painful area to provide other benefits (i.e., facilitate
tissue healing and promote increase circulation/
edema reduction)

Other electrode placement options include:

Over acupoints and trigger points

Segmental: 1.5 or 3 body inches lateral to the
spinous process(es) of the involved segmental
level(s) and/or

Over the nerve(s) innervating the painful area
 TENS
Intensity

Intensity of TENS is crucial to obtain analgesic response

TENS delivered at or below sensory threshold is ineffective

TENS delivered at strong but comfortable intensity provides significant analgesic effect
• High Frequency TENS (Increase intensity to just below pain threshold at sensory level)
• Low Frequency TENS (Increase intensity to produce motor contractions)

Research shows that there is a greater analgesic effect when TENS intensity was
increased during treatments in response to subject accommodation to the
stimulation
 TENS
Frequency of Application

Research suggests that repeated TENS applications decreases sensitivity of sensory

fibers and neurons, centrally and peripherally

With repeated TENS stimulation, sensory neurons show reduced spontaneous firing, less
response to noxious and non-noxious stimuli

Frequency of application may vary according to chronicity of pain. More frequent

applications for acute conditions (e.g., QD) and less frequent for chronic
conditions (e.g., 2x/week).
 TENS – Summary of Key Elements

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

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
VIDEO
Review of The Evidence
ACUTE PAIN
 ACUTE PAIN

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

TENS vs. Placebo TENS TENS vs. No Treatment

Johnson et al, Cochrane Database, 2015

ACUTE PAIN: Labor and Post-Partum

Acute Pain
 ACUTE PAIN: Labor

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
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

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

Duration of 1st stage of labor less in EG compared to placebo and control group (158’ vs.
262’ vs. 257’)

Statistically significant difference in recorded severity of pain 4 hours after delivery for EG
compared to placebo and control group (6.7% vs. 43.3% vs. 60%)

No negative consequences to mothers or newborn

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
childbirth
Roonak, Comp Therapies in Clinical Practice, 2017
 ACUTE PAIN: Labor

Randomized Controlled Trial (N=180)

PURPOSE: Evaluate the effects of non-pharmacologic electro-acupuncture method at

different acupoints on labor pain management.

METHOD:

Random allocation into two experimental groups (EX-B2, SP6) and one control group (CG)
by lottery
• TENS electrodes placed bilaterally to EX-B2 acupoints
• TENS electrodes placed bilaterally to SP6 acupoints
• CG: routine intrapartum care

Frequency of 100Hz, current intensity set at 15 mA at the starting point of active phase of
labor, adjusted to higher intensity upon patient request
Dong et al, Arch Gynecol Obstet, 2015
 RESULTS
Significant analgesic effects noted during active phase of labor (33%, 21.7% vs. 1.7%
decrease from starting point to after 120’ intervention)

After 30’ 60’ and 120’ intervention EX-B2 and SP6 group Visual Analog Scores (VAS)
significantly decreased compared to CG

Significant difference in duration of active phase of labor between both experimental

groups and the control group (151’, 163’ vs. 185’)

CONCLUSION: Electro-acupuncture can be used as a non-pharmacologic method to reduce

labor pain and shorten the active phase of labor. EA is safe, less expensive than traditional
pharmacological intervention. No adverse effects to mother or child. Further RCT with larger
sample size recommended.
Dong et al, Arch Gynecol Obstet, 2015
 ACUTE PAIN: Labor

Randomized Controlled Trial (N=100)

PURPOSE: To assess the effectiveness of transcutaneous electric nerve stimulation (TENS)

in controlling labor pain

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
• Mixed-Frequency TENS waveform
• Group B: 50-100 mg pethidine , IM into gluteal region every 4 h or more if needed
Shaban, Evid Based Women Health J, 2013
 RESULTS
Need for oxytocin augmentation during labor was less in Group A (TENS)

Difference in pain scores among TENS and Control group statistically non-significant

Neonatal outcomes- no difference in Apgar scores at 1’, but statistical difference

between both groups in the 5’ Apgar
100% neonates in Group A had Apgar of 7 or higher. Only 30% neonates in Group B with
Apgar of 7 or higher

No adverse effects encountered in Group A (TENS) and high willingness to use TENS again in
subsequent deliveries, Group B (control, pethidine) experienced nausea, vomiting, and
sedation
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

 ACUTE PAIN: Labor

Overview of systematic reviews (15 Cochrane systematic reviews 2009-2012, 3 non-Cochrane reviews)

PURPOSE: To summarize the evidence from Cochrane systematic reviews on the efficacy
and safety of non-pharmacological and pharmacological interventions to manage pain
in labor

CONCLUSION: There is insufficient evidence to make judgments on whether or not TENS is

more effective than placebo or other interventions for pain management in labor.
Efficacy of TENS is unclear due to limited high quality evidence

Jones et al, Cochrane Library, 2012

 ACUTE PAIN: Post Partum

Prospective Randomized Controlled Trial (N=200)

PURPOSE: Determine efficacy and reliability of TENS in management of pain related to

childbirth

METHOD: A 100 healthy women s/p cesarean section under general anesthesia were
randomly assignment to the placebo (group 1) or the TENS group (group 2), while 100
women who delivered by vaginal route without episiotomy were randomized into the
placebo group (group 3) or the TENS group (group 4)

Kayman-Kose et al, J Matern Fetal Neonatal Med, 2014

 RESULTS
Pain related to uterine contraction decreased after vaginal delivery in those who received
TENS

Post- op pain at incision and with uterine contraction significantly decreased post C-section
in those who received TENS.

20% less need for opioid analgesics after 8 hours in women who received TENs after
C-section

CONCLUSION: TENS is an effective, reliable, practical, and easily available modality of

treatment for postpartum pain

Kayman-Kose et al, J Matern Fetal Neonatal Med, 2014

 ACUTE PAIN: Post Partum

Randomized Controlled Trial (N=32, multiparous vaginal birth)

PURPOSE: Evaluate TENS to relieve uterine contraction pain during breast feeding in
multiparous women.

METHOD: Participants randomized into an experimental (EG) and a control group (CG)

EG: TENS electrodes placed between T10-L1 and S2-S4, with a frequency of 100Hz,
pulse duration of 75 us, intensity adjusted to produce strong and tolerable sensation x
40’

EG participants instructed to adjust intensity to keep strong and tolerable without
muscle contraction
deSousa et al, J Obstec and Gynecol Research , 2014
 RESULTS Pain Scores

Clinically relevant pain relief for participants in EG

100% participants in EG reported to very satisfied or satisfied

with the treatment

100% of women in EG stated they would use the technique

of TENS for uterine contraction relief in future births

CONCLUSION: Data obtained supports the use of TENS in reducing uterine contraction pain
during breastfeeding in multiparous women

deSousa et al, J Obstec and Gynecol Research , 2014

 ACUTE PAIN: Post Partum

Randomized Controlled Trial (N=42)

PURPOSE: Examine effectiveness and overall opiate consumption between TENS combined with
patient-controlled analgesia with morphine and patient-controlled analgesia with morphine
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)

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
Binder et al, Midwifery, 2011
 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
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

Binder et al, Midwifery, 2011

ACUTE PAIN: Post-Operative

Acute Pain
 ACUTE PAIN: Total Knee Arthroplasty (TKA)

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

PURPOSE: Evaluate the efficiency and safety of TENS for pain control after TKA

CONCLUSION:

TENS groups (experimental) showed significant improvements in VAS scores and
opioid consumption at 12, 24, and 48 hours after TKA, compared to ‘sham/placebo’
TENS groups (control)

TENS groups showed reduced risk of vomiting and nausea compared to
‘sham/placebo’ TENS groups groups

Li and Song, Medicine, 2017

Favors experimental Favors control

24 hours 48 hours

Reduced Opioid
12 hours
Consumption
following TKA

Li and Song, Medicine, 2017

 ACUTE PAIN: TKA

Systematic Review and Meta-Analysis (6 RCTs published between 2003 to 2014, N=529 patients)

PURPOSE: Explore the effect of TENS on patients with TKA

CONCLUSION:

Compared with control groups, TENS intervention was associated with significantly reduced
VAS scores and total postoperative morphine dose at 24 hours post-surgery

TENS did not influence VAS scores at 2 weeks post-surgery

TENS intervention significantly improved active range of motion at knee

***TENS intervention showed an important ability to reduce immediate pain after TKA and
facilitated the recover of knee function
Zhu et al, Journal of Rehabilitation Medicine, 2017
 ACUTE PAIN: TKA

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

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

CONCLUSION:

The quality of TENS interventions that were used showed multiple areas of concern that may
underestimate the effects of TENS

Majority of the included studies point out that TENS has no analgesic effect in patients with knee
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
Beckwee et al, SAGE Open Medicine, 2014
 ACUTE PAIN: Total Hip Arthroplasty (THA)

Randomized Controlled Trial (N=68 patients)

PURPOSE: Investigate whether TENS on acupoints can provide complementary analgesia to

reduce the requirement of fentanyl PCA and its related side effects after THA in elderly patients

METHOD: Randomly allocated to Group Acu (PCA + TENS on acupoints) or Group Sham (PCA +
sham TENS)

Group Acu = alternately stimulating at 2Hz and 100Hz every 3 seconds, high intensity at 9-
20mA

Group Sham = intensity at 0mA

Lan et al, Minerva Anestesiologica, 2012

 RESULTS
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

than Group Sham at 24hrs (by 37%) and 48hrs (by 31%) after surgery

Nausea, vomiting and dizziness were significantly LOWER in Group Acu (16.7%, 10%, 6.7%)
than Group Sham (46.7%, 32.2%, 26.7%)

Frequency of rescue medication was significantly LOWER in Group Acu (13.3%)

than Group Sham (36.7%)

CONCLUSION: TENS is a non-invasive, non-pharmacological technique for use in

postoperative analgesia and is associated with reductions in opioid-related side effects

Lan et al, Minerva Anestesiologica, 2012

 ACUTE PAIN: Spinal Surgery

Prospective Randomized Single-Blinded Trial (N=54 patients)

PURPOSE: Assess TENS application performed after spinal surgery (open lumbar discectomy) on
the effect of pain, analgesic consumption, functionality, and depression

METHOD: Randomly allocated to Experimental Group (PCA + TENS) or Control Group (PCA)

Experimental Group = alternately stimulating at 50Hz and 100Hz, high intensity of strong
paresthesia without muscle contraction, up to 30mA

PCA therapy discontinued when patient no longer required IV analgesic therapy, TENS
discontinued when patient able to control pain with oral analgesic medication (NSAIDs)

Kara et al, Turkish Neurology, 2011

 RESULTS
TENS Group showed significantly LOWER pain levels with activity
than Control Group at Post-Op Day 1 (morning/afternoon) and Post-Op Day 2 (morning)

Meperidine use of TENS Group was significantly LOWER at 24h after surgery and total
consumption than Control Group.

No statistically significant differences between groups on Timed-Up-and-Go (TUG) test

TENS Group had less depressive symptoms on Back Depression Inventory (BDI) than Control
Group from pre-operative to post-operative discharge day, however not statistically significant

CONCLUSION: TENS applications after spinal surgery reduced analgesic consumption, and
perception of low back pain in the early post-operative period.

Kara et al, Turkish Neurology, 2011

 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
drugs, leading to shorter mechanical ventilation time, shorter ICU stay, and reduced
postoperative dose of vasoactive drugs

Asmussen et al, Journal of Intensive Care Medicine, 2017

 Use of Opioids

Favors Control Favors TENS

(Electroacupuncture)

Asmussen et al, Journal of Intensive Care Medicine, 2017

 ACUTE PAIN: Cardiac Surgery

Randomized Controlled Trial (N=120)

PURPOSE: Compare the efficacy of TENS and parasternal block with local anesthetic
filtration in relieving pain during the first 24 hr period following median sternotomy

METHOD: Randomly allocated to TENS Group (TENS + PCA), Parasternal Block Group
(parasternal block + PCA), Control Group (PCA alone)

TENS Group = stimulating at 100Hz, intensity at strong but comfortable sensation

Parasternal Block Group = placebo TENS

Ozturk et al, Pain Research and Management, 2016

 RESULTS
Both TENS and Parasternal Block Groups showed LOWER morphine requirements than Control Group

TENS Group showed LOWER pain levels through mean VAS scores compared to Control Group at
most time intervals (4h, 5h, 6h, 7h, 8h), however the differences were NOT significant
No statistical differences between groups on extubation time, rescue analgesics, length of ICU stay

CONCLUSION: Both treatment groups reduced pain scores better than control for the first 4h
to 8h after median sternotomy for CABG (Parasternal block > Intermittent TENS). Both
treatment groups decreased postoperative opioid requirements than control (Parasternal
block > Intermittent TENS).
Ozturk et al, Pain Research and Management, 2016
 ACUTE PAIN: Thoracotomy

Prospective Randomized Controlled Trial (N=87)

PURPOSE: Assess the effects of TENS on pain, vital signs, early post-operative
complications, and length of hospital stay

METHOD: Randomly allocated to Group T (TENS) or Group C (placebo TENS)

Group T = stimulating at 100Hz

Group C = placebo TENS with inoperative machine

Sezen et al, Asian Cardiovascular & Thoracic Annals, 2017

 RESULTS
TENS Group showed significantly LOWER pain levels
compared to Control Group at Post-Op Day 0, 1, 2

No statistically significant differences between groups

in mean arterial blood pressure and heart rate

CONCLUSION: TENS appears to be an effective method of aiding a patient to breathe more

effectively after thoracic surgery, and is a safe and effective adjunctive therapy for acute
postthoracotomy pain control. TENS does not affect the duration of hospitalization or early
pulmonary complications.

Sezen et al, Asian Cardiovascular & Thoracic Annals, 2017

 ACUTE PAIN: Thoracotomy

Randomized Controlled Trial (N=92)

PURPOSE: Determine whether ElectroAcupuncture (EA) can reduce postoperative analgesic

requirement and incidence of opioid-related side effects in the first 72hrs after surgery

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

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

 RESULTS
Group EA showed significantly LOWER pain levels
than Group Sham at 2hr, 24hr, 48hr, 72hr after surgery

Total Sauteralgyl (synthetic narcotic) supplemental use

was 20% LOWER in Group EA
than Group Sham

Nausea was significantly LOWER in Group EA (21.7%)

than Group Sham (47.8%), No statistically significant
difference in vomiting between both groups

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
 ACUTE PAIN: Thoracotomy and Sternotomy

Systematic Review and Meta-Analysis (11 RCTs published between inception to 2011, N=570 patients)

PURPOSE: Evaluate the effects of TENS on pain and pulmonary function in the postoperative period of
thoracic surgery (5 studies for posterolateral thoracotomy and 6 studies for median sternotomy)

CONCLUSION:

TENS associated with pharmacological analgesia provides greater pain relief compared to
placebo TENS in patients after thoracic surgery, for both approaches

TENS combined with pharmacological analgesia was more effective at pain relief than
pharmacological analgesia alone, specifically for sternotomy approach

No conclusive evidence about the effective of TENS on pulmonary function (forced vital capacity)
after sternotomy
Sbruzzi et al, Brazilian Journal of Cardiovascular Surgery, 2012
Posterolateral thoracotomy

Median Sternotomy

Favors TENS Favors Control

Sbruzzi et al, Brazilian Journal of Cardiovascular Surgery, 2012

VIDEO
Review of The Evidence
CHRONIC PAIN
Chronic Pain: Diabetic Neuropathy

Acute Pain
 CHRONIC PAIN: Diabetic Neuropathy

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

PURPOSE: Critical analysis of the available evidence on the application of TENS for the
clinical treatment of painful diabetic peripheral neuropathy patients

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
duration of trial period and lack of standardization of TENS therapy for the condition

Merghani, Journal of Dental and Medical Sciences, 2015

 CHRONIC PAIN: Diabetic Neuropathy

Systematic Review (8 RCTs)

PURPOSE: Evaluate the use of electrical stimulation to treat diabetic neuropathy

CONCLUSION: Electrical stimulation provided improvement in symptoms of painful

neuropathy (six studies) and sensory neuropathy (one study) in persons with diabetes.
Electrical stimulation may be an effective alternative and adjunctive therapy to current
interventions for diabetic peripheral neuropathy

Thakral, J Diabetes Sci Technol, 2013

 CHRONIC PAIN: Diabetic Neuropathy

Systematic Review (12 RCTs)

PURPOSE: Evaluate the effects of treatment with electrical stimulation and

electromagnetic fields on pain and sensitivity in patients with painful diabetic
neuropathy compared with placebo or another intervention

CONCLUSION: Transcutaneous electric nerve stimulation may be an effective and safe

strategy for the treatment of symptomatic diabetic neuropathy

Stein et al, Braz J Phys Ther, 2013

Pain Relief
TENS vs.
Placebo

Favors TENS Favors Placebo

Stein et al, Braz J Phys Ther, 2013
Chronic Pain: Knee Osteoarthritis

Acute Pain
 CHRONIC PAIN: Knee Osteoarthritis

Systematic Review (30 randomized controlled trials, 7 specific to TENS)

PURPOSE: Evaluate the effects of various non-operative modalities of treatment (TENS,

NMES, insoles, bracing) on pain of OA of knee

CONCLUSION: Overall, all four non-operative modalities of treatment were found to

have a significant effect on the reduction of pain in OA of the knee

Cherian et al, Bone Joint J, 2016

 CHRONIC PAIN: Knee Osteoarthritis

Pain pre- to post treatment

TENS-Pain Literature
• Cheing et al 2002: n=16 TENS (80Hz, 60 mins)
• Cheing et al 2003: n=10 TENS (100 Hz, 40 mins)
• Itoh et al 2008: n=6 TENS (122 Hz, 15 mins)
• Cetin et al 2008: n= 20 TENS (60 to 100 Hz) + heat
& exercise
• 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
 CHRONIC PAIN: Knee Osteoarthritis

Randomized Controlled Trial (N=40)

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

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
injection, and self-directed exercise)

Jeffrey et al, Orthopedics, 2016

 RESULTS
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

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

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%)

CONCLUSION: Patients had significant relief of pain when receiving TENS vs. standard
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
 CHRONIC PAIN: Knee Osteoarthritis

Double-blind, randomized controlled trial (N=75)

PURPOSE: The purpose of this study was to determine the effects of high frequency TENS
(HF-TENS) and low-frequency TENS (LF-TENS) on several outcome measures (pain at rest,
movement-evoked pain, and pain sensitivity) in people with knee osteoarthritis

METHODS: Participants were randomly assigned to receive HF-TENS (100 Hz) (n25), LF-
TENS (4 Hz) (n25), or placebo TENS (n25) (pulse duration 100 microseconds; intensity10%
below motor threshold)

Vance et al, Phys Ther, 2012

 RESULTS
Pain at rest decreased significantly in all 3 groups for HF-TENS, LF-TENS, and placebo TENS,
respectively. However, there were no significant differences between groups

Low-frequency TENS significantly increased pressure pain threshold (PPT) at the affected
knee. Placebo TENS did not significantly change PPT

High-frequency TENS increased PPT at the affected knee and over the anterior tibialis
muscle of the affected leg compared with pre-TENS values.

The time to perform the TUG did not change significantly in any of the groups

CONCLUSION: Both HF and LF-TENS increased PPT in people with knee OA. Subjective pain
ratings at rest and during movement were similarly reduced by active and placebo TENS,
suggesting a strong placebo component of the effect of TENS

Vance et al, Phys Ther, 2012

Chronic Pain: Low Back Pain

Acute 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
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
u
n
c
t
i
o
n M
P a o
a L b
i i
n M L
o i
b t
i y
L
i
t
y
 RESULTS
Groups A and B showed significantly LOWER pain levels on VAS scale and Laitinen Questionnaire
than Control Group F

Groups A and B showed statistically significant HIGHER scores in Oswestry Questionnaire than Control
Group F. Although both groups also showed higher scores on the Roland-Morris Questionnaire, they
were not statistically significant. Both questionnaires assess improvement in functional ability.

Groups A and B showed statistically significant HIGHER hip and lumbosacral spinal mobility than
Control Goup F, on both the Lasegue and Schober tests

CONCLUSION: Both types of TENS applications are helpful in treatment of discopathy of the
lower region of the spine (Interferential current led to greater remission of symptoms).

Rajfur et al, Med Sci Monit, 2017

 CHRONIC PAIN: Low Back Pain

Observational Retrospective Analysis (N=45,826)

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.

METHOD: Opioid utilization and costs in patients who did and did not receive TENS were
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

Propensity score matching at a 1:1 ratio to identify similar baseline demographic and clinical
characteristics (22,913 people in each group)
Pivec et al, Orthopedic Surgery, 2015
 RESULTS

Opioid usage was significantly LOWER in the TENS group (57.7%) than the non-TENS group (60.3%)

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

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)

Significantly LOWER average per-opioid event costs in TENS group ($44) than the non-TENS group ($49)

CONCLUSION: Treatment of CLBP with TENS (which is both non-invasive and a non-narcotic)
demonstrated significantly fewer patients requiring opioids, fewer events where a patient
required an opioid prescription, and lower per-patient costs.
Pivec et al, Orthopedic Surgery, 2015
 CHRONIC PAIN: Low Back Pain

Single-Blind Randomized Controlled Trial (N=150)

PURPOSE: Compare the analgesic effects of TENS and IFC among patients with nonspecific
chronic low back pain

METHOD: Randomly allocated to Group 1 (TENS), Group 2 (IFC), and Control Group 3 (untreated)
Group A = stimulating at 100Hz

Groups 1 and 2 = TENS at 20Hz frequency, and IFC at 20Hz modulated frequency range, both at ‘strong,
but comfortable’ intensity, guidance folder on vertebral column care

Group 3 = guidance folder on vertebral column care only

Facci et al, Sao Paolo Med J, 2011

 RESULTS
Significantly LOWER average pain intensity on VAS scale in TENS group (3.91cm drop ) than the Control
group (0.85cm drop), 84% of TENS group had pain reduction compared to 56% in Control group

TENS group demonstrated significant improvement on pain evaluation using McGill Pain Questionnaire
compared to the Control group

Average duration of analgesia from TENS showed increasing trend over course of sessions, with peak
at 10th session

TENS group showed significantly improved disability scores using the Roland-Morris Disability
Questionnaire compared to Control group
84% of patients in TENS group stopped using medications (NSAIDs or analgesics) compared to 34% of
patients in the Control group

CONCLUSION: Both TENS and IFC demonstrated significant effects with pain reduction,
disability improvement and less medication used.
Facci et al, Sao Paolo Med J, 2011
Facci et al, Sao Paolo Med J, 2011
 • Low number of trials

• Incomplete reporting of study designs

• Poor methodological rigor

methods of blinding unclear or not described,
lack of ‘control’ or ‘sham’ groups, patient groups
were heterogeneous, small sample size, short
Limitations of duration

Current • Parameters not fully described

Research • Lack of consistency with key elements

of efficacy
waveform frequency, intensity, electrode
placement, frequency of application

• Follow-up times were different

• Inconsistent outcome measures

 • Larger Sample Sizes

• Longer Duration

• Optimal daily treatment duration,

electrode site application, long-term
use

• Study TENS tolerance

Areas of Further
• Include more outcome measures
Research
• Additional patient populations and
subgroups examined

• Head to head comparison of TENS vs.

pharmacological (opioid-based)
interventions for pain management
 CLINICAL RESULTS - #1

• 9 facilities, N = 173
Average Pain Pain Change in
• Diagnoses ranged from acute Days on Rating- Rating- Pain Rating
postop to chronic Caseload Program Program
Start D/C
• Combination short stay vs.
long stay
21.3 7.30 3.44 53%
• All received electrotherapy
as adjunct to treatment
 CLINICAL RESULTS - #2

• 1 facility, N = 19 Average Pain Pain Rating- Change in

Days on Rating- Program D/C Pain Rating
Caseload Program
• Diagnoses: Acute post-op
lower extremity orthopedic
Start
population
4.76 2.57 46%
• Short stay only TUG TUG Change in TUG
Program Start Program D/C Score (sec)
• All received electrotherapy
as adjunct to treatment
71.1 20.3 71%
VIDEO
Promising Avenues
Addiction Recovery and
Pre-Hospital Setting
 Addiction Recovery

Randomized Controlled Trial (N=63)

PURPOSE: To assess the therapeutic effect of transcutaneous electric acupoint

stimulation (TEAS) for the treatment of withdrawal syndrome in heroin addicts

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

 RESULTS
Symptoms of anxiety and agitation were 60% and 71% lower in the TEA group

The median of musculoskeletal pain of the TEAS group during 10 days was 59% lower than
the control group
The severity of insomnia and symptoms of sleepiness/yawn were 74% and 70% lower in the
TEA group

Withdrawal syndrome in the TEA group was 60% lower than that of control group. Dosage of
Buprenorphine significantly less in TEA group

CONCLUSION: TEAS of 2/100 Hz for 10 days in abrupt abstinence of the heroin addicts resulted
in a marked reduction of the withdrawal syndrome as well as a reduced requirement for
rescue opioids. Results from this study strongly suggest that the treatment seems to be safe
and effective
Da, Pain Med, 2015
 Pre-Hospital Setting

Systematic Review and Meta-Analysis (4 RCTs published between inception to 2012, N=261 patients)

PURPOSE: Investigate the effectiveness of TENS, compared with ‘Sham’ TENS for relieving pain and
anxiety when performed by medics in the prehospital setting.

CONCLUSION:

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
to Sham treatment (pooled analysis showed difference = 26mm).

When compared to Sham treatments, TENS could be an effective prehospital analgesic modality
that leads to clinical meaningful reductions in acute pain for patients with moderate-to-severe pain
of musculoskeletal and visceral etiology.
Simpson et al, Eur J Emerg Med, 2014
Average Final Pain Score between TENS and Sham

Average Reduction in Anxiety Score

Favors TENS Favors Control

Simpson et al, Eur J Emerg Med, 2014
VIDEO
 CONCLUSION

√ The opioid epidemic is a monumental health crisis, with far-reaching and devastating
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

to pharmacological intervention in acute and chronic painful conditions
QUESTIONS?
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Kelly Contreras, PT, GCS, CEEAA Seema Gurnani, PT, DPT, GCS, CEEAA
Combined Sections Meeting, February 21-24, New Orleans, LA