ESTIM for Pain

 

Problem:

Your patient is a 48 yo female s/p MVA * 8 weeks with complaints of headaches and neck pain. She notes increased frequency and intensity of her headaches with deep palpation of her right trapezius.

 

Justification:

A randomized control trial performed by Frahani et al investigated the efficacy of Transcutaneous Electrical Nerve Stimulation (TENS) against Neurofeedback Behavioral Therapy (NFB).  The study included 45 subjects with primary headaches who were divided into TENS, NFB, and control groups. The study concluded that therapeutic TENS interventions were effecting in treating headaches in that the frequency, severity, and duration of headaches were significantly reduced as compared to the control group.  Maayah and Al-Jarrah performed an evaluation on the efficacy of TENS for neck pain due to musculoskeletal disorder and concluded that TENS is an effective method for pain relief in the neck due to musculoskeletal disorders, reporting a significantly greater reduction in cervical pain when using TENS as compared to the placebo control group. It was theorized that the success of the TENS treatment could be attributed to the utilization of the gate control theory by stimulating large-diameter afferent fibers to reduce the pain signals transmitted by smaller nociceptive afferent fibers.  Sjaastad et al examined two patient cases, one of which was a patient with cervicogenic headaches as a result of whiplash sustained in an MVA. In this case, Sjaastad et al found electrical stimulation of the dorsal column at the C1/2 transition to be successful in completely eliminating some symptoms related to neck pain and post-traumatic headache while markedly diminishing others. While this was an invasive electrical stimulation procedure, it would stand to reason that electrodes placed over the bilateral regions of the sub occipital triangles could produce a similar result.

 

Procedure:

The more specific guidelines established by Maayah and Al-Jarrah will be utilized for the TENS intervention for pain control. Two karaya pad electrodes will be attached to the TENS machine via a two cord lead. The area of maximum tenderness will be marked and the electrodes will be placed at the site of local acupuncture points around the neck that are associated with the areas of greatest tenderness. The placement of the electrodes can vary as the pain pattern changes from session to session.2 With the frequency set at 4-8 Hz, the intensity would be adjusted to a comfortable level tolerable to the patient.1,2 The patient will be informed that the sensation should produce a tingling sensation that should not be painful. Treatment will last for a duration of one-hour with intensity setting adjusted to maintain stimulation at a tolerable level throughout.2

 

Outcomes:

With the goal of the treatment being to reduce pain, outcomes will predominately lie in self-reporting of the patient through self-assessment forms addressing weekly pain, sleep disturbances and the immediate response to the treatment.2 The patient will also be asked to keep a record of the daily drug intake and daily pain level as this form of self reporting has been sound to significantly correlate with global ratings of pain and disability.1 To quantify muscle strength, a Myometer machine will be used2. A myometer will allow for an objective measure to determine if pain is an inhibiting factor to strength. The Myometer will be used before, during, and immediately after treatment and one week after treatment to determine the effects of the TENS intervention on volitional strength.2  

 

References:

 

1. Frahani D, Tavallaie S, Ahmadi K, Ashtiani A. Comparison of Neurofeedback and Transcutaneous Electrical Nerve Stimulation on Treatment of Primary Headaches: A Randomized Controlled Clinical Trial. Iran Red Crescent Med J. 2014; 16(8): e17799

2. Maayah M, Al-Jarrah M. Evaluation of Transcutaneous Electrical Nerve Stimulation as a Treatment of Neck Pain due to Musculoskeletal Disorders. J Clin Med Res. 2010; 2(3):127-36

3. Sjaastad O, Fredriksen T, Jorgensen J. Electrical stimulation in headache treatment. For separate headache(s) or for headache generally? Funct Neurol. 2009; 24(1):53-9