Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain

The effect of EMS, IFC, and TENS on patient-reported outcome measures for chronic low back pain: a systematic review and meta-analysis

Introduction

Chronic low back pain (CLBP) is the leading cause of years lived with disability worldwide. Transcutaneous electrotherapies have been widely used to treat CLBP but, with the partial exception of transcutaneous electrical nerve stimulation (TENS), their effect on pain, disability, quality-of-life, and psychosocial outcomes have not been systematically reviewed. The purpose of this systematic review and meta-analysis was to clarify the overall effect of transcutaneous electrotherapies on patient-reported outcome measures (PROMs) in CLBP patients.

Methods

Four databases and two study registries were searched for studies that utilized transcutaneous electrotherapies as a primary intervention for CLBP, compared against active or passive controls. Two reviewers independently extracted study data and assessed risk of bias. Studies were grouped by intervention vs. comparison, and by time of follow-up. Meta-analyses were conducted where appropriate.

Results

A total of 89 full-text were assessed for eligibility; 14 studies were included, with 6 in the meta-analyses (all TENS or mixed TENS). Pain: meta-analyses revealed no significant difference for TENS vs. active control, TENS vs. passive control, or mixed TENS vs. active control at post-intervention, nor for mixed TENS vs. active control at 1-month post-intervention. Interferential current (IFC) was more effective than active control (2 studies), while electromyostimulation (EMS) was generally superior to passive, but not active, controls (6 studies).

Disability

Meta-analyses revealed no significant difference for TENS vs. active control at post-intervention, mixed TENS vs. active control at post-intervention, or mixed TENS vs. active control at 1-month post-intervention. IFC was more effective than active control (2 studies), while the EMS results were mixed (6 studies). We were unable to perform meta-analyses for quality-of-life or psychosocial outcomes.

Conclusion

There is moderate evidence that TENS is similar to all controls for improving pain and disability. There is limited evidence that IFC is superior to active controls for improving pain and disability. There is limited evidence that EMS is superior to passive but not active controls for improving pain, and similar to all controls for improving disability.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=452851, Identifier (CRD42023452851).

The effect of transcutaneous electrical nerve stimulation on pain and electrical stimulation muscle thickness in patients with non-specific chronic low back pain-based ultrasonographic evaluation

Aim: The existing mechanisms of transcutaneous electrical nerve stimulation (TENS) focuses more on the effect of neural tissue. This study investigated the effect of TENS on the thickness of the erector spinae muscles and reducing pain. Patients & methods: 56 individuals with low back pain participated in this single-blind, pre/post-test study. For 2 weeks, participants underwent ten sessions of TENS. The ultrasound evaluations examined the thickness of the erector spinae muscle, and the visual analog scale measured the severity of low back pain. Results: There was a decrease in pain score and muscle thickness after the interventions (p ≤ 0.004). There was also a strong correlation between reducing pain and decreasing muscle thickness (R = 0.709; p = 0.000). Conclusion: Following TENS in the lumbar, in addition to reducing pain, the thickness of the erector spinae muscles also decreased. Clinical Trial Registration: IRCT20200423047173N1 (ClinicalTrials.gov).

Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses

Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors' conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with 'sufficient data' demonstrating benefit. There were no examples of meta-analyses with 'sufficient data' demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with 'insufficient data' and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.

Does transcutaneous electrical nerve stimulation affect pain, neuropathic pain, and sympathetic skin responses in the treatment of chronic low back pain? A randomized, placebo-controlled study

Background

The purpose of this study was to assess the effectiveness of transcutaneous electrical nerve stimulation (TENS) in chronic low back pain and neuropathic pain.

Methods

Seventy-four patients aged 18-65 with chronic low back pain were included in the study. Baseline measurements were performed, and patients were randomized into three groups. The first group received burst TENS (bTENS), the second group conventional TENS (cTENS), and the third group placebo TENS (pTENS), all over 15 sessions. Patients' visual analogue scale (VAS) scores were evaluated before treatment (preT), immediately after treatment (postT), and in the third month after treatment (postT3). Douleur Neuropathique 4 Questions (DN4), the Modified Oswestry Low Back Pain Disability Questionnaire (MOS), the Beck Depression Inventory (BDI), and sympathetic skin response (SSR) values were also evaluated preT and postT3.

Results

A statistically significant improvement was observed in mean VAS scores postT compared to preT in all three groups. Intergroup comparison revealed a significant difference between preT and postT values, that difference being assessed in favor of bTENS at multiple comparison analysis. Although significant improvement was determined in neuropathic pain DN4 scores measured at postT3 compared to preT in all groups, there was no significant difference between the groups. No statistically significant difference was also observed between the groups in terms of MOS, BDI, or SSR values at postT3 (P > 0.05).

Conclusions

bTENS therapy in patients with low back pain is an effective and safe method that can be employed in short-term pain control.

Adding connective tissue manipulation to physiotherapy for chronic low back pain improves pain, mobility, and well-being: a randomized controlled trial

This study aimed to evaluate the effectiveness of connective tissue manipulation (CTM) for improving pain, mobility, and well-being in chronic low back pain (CLBP). Sixty-six patients with CLBP were randomized to three groups: CTM, sham massage (SM) and control groups. The groups got standardized physiotherapy and the related applications 5 days/wk, 3 weeks. Pain intensity, mobility, and well-being (Hospital Anxiety and Depression Scale [HADS], Oswestry Disability Index [ODI], and Short Form-36 [SF-36]) were assessed before and after the applications. Pain, mobility, and disability improved in all groups (P<0.05). There were differences in resting pain, HADS, and SF-36 scores in CTM, resting pain in SM, and SF-36 scores in controls (P<0.05). Activity pain, HADS scores decreased, mobility and physical component of the SF-36 in-creased in CTM compared to SM (P<0.05). Pain, ODI, and HADS scores decreased, mobility and SF-36 increased in CTM, and ODI scores decreased in SM compared to controls (P<0.05). In conclusion, pain intensity during activity and at night and disability decreased, and spinal mobility increased in all groups. However, CTM showed superiority in improving pain, mobility, and well-being in patients with CLBP.

Literature Review and Meta-Analysis of Transcutaneous Electrical Nerve Stimulation in Treating Chronic Back Pain

Supplemental digital content is available in the text.

Background and Objectives

This study is a meta-analysis of randomized controlled trials comparing the efficacy of transcutaneous electrical nerve stimulation (TENS) to a control and to other nerve stimulation therapies (NSTs) for the treatment of chronic back pain.

Methods

Citations were identified in MEDLINE, the Cochrane Library, Google Scholar, and ClinicalTrials.gov through June 2014 using the following keywords: nerve stimulation therapy, transcutaneous electrical nerve stimulation, back pain, chronic pain. Control treatments included sham, placebo, or medication only. Other NSTs included electroacupuncture, percutaneous electrical nerve stimulation, and percutaneous neuromodulation therapy.

Results

Twelve randomized controlled trials including 700 patients were included in the analysis. The efficacy of TENS was similar to that of control treatment for providing pain relief (standardized difference in means [SDM] = −0.20; 95% confidence interval [CI], −0.58 to 0.18; P = 0.293). Other types of NSTs were more effective than TENS in providing pain relief (SDM = 0.86; 95% CI, 0.15–1.57; P = 0.017). Transcutaneous electrical nerve stimulation was more effective than control treatment in improving functional disability only in patients with follow-up of less than 6 weeks (SDM = −1.24; 95% CI, −1.83 to −0.65; P < 0.001). There was no difference in functional disability outcomes between TENS and other NSTs.

Conclusions

These results suggest that TENS does not improve symptoms of lower back pain, but may offer short-term improvement of functional disability.

Effects of transcutaneous electrical nerve stimulation and visuotactile synchrony on the embodiment of an artificial hand

The rubber hand illusion (RHI) is an experimental paradigm known to produce a bodily illusion. Transcutaneous electrical nerve stimulation (TENS) combined with the RHI induces a stronger illusion than the RHI alone. Visuotactile stimulus synchrony is an important aspect of the RHI. However, the effect of TENS and visuotactile stimulus synchrony in TENS combined with the RHI remains unknown. The purpose of this study was to investigate the effects of TENS and visuotactile stimulus synchrony on the embodiment of an artificial hand when using TENS combined with the RHI. The participants underwent four experimental conditions in random order: TENS/noTENS × Synchronous/Asynchronous. TENS was set at an intensity such that it generated a feeling of electrical paresthesia in the radial nerve area of the hand but did not cause pain, i.e., 100-Hz pulse frequency, 80-µs pulse duration, and a constant pulse pattern. A visuotactile stimulus, either temporally synchronous or asynchronous, was generated using paintbrush strokes. To evaluate the outcome measures, the participants completed a questionnaire report and proprioceptive drift assessments (motor response and perceptual response). There were significant main effects of TENS and visuotactile synchrony, but no interaction between these factors, on the results of the questionnaire and the perceptual response. In contrast, there was no significant effect on the result of the motor response. These findings indicate that TENS and visuotactile synchrony might affect differently the embodiment of an artificial hand when using TENS combined with the RHI.

What Evidence Exists for Work-Related Injury Prevention and Management? Analysis of an Occupational Therapy Evidence Database (OTseeker)

This study aimed to summarise the quantity and quality of research contained in an online evidence database (OTseeker) in one practice area, work-related injury prevention and management, to highlight the available evidence.

In May 2004, the systematic reviews and randomised controlled trials (RCTs) contained in OTseeker were analysed. The number and proportion of systematic reviews and RCTs and the number and proportion of RCTs meeting each of the 10 criteria on the PEDro scale (partitioned) were calculated and the topics and conclusions of the systematic reviews were summarised.

Of the 2330 records contained in OTseeker, 346 (14.8%) related to work-related injury prevention and management (86 systematic reviews and 260 RCTs). Of the 260 RCTs, the majority (n = 140, 53.8%) scored between 3/8 and 5/8 for internal validity on the PEDro scale (partitioned); a few scored 6/8 or more (n = 13, 5.0%). The majority of the RCTs scored 2/2 for the reporting of results (n = 217, 83.5%). Evidence was identified, mostly for the treatment of low back pain, to support the use of multidisciplinary biopsychosocial rehabilitation including workplace visits, back schools, workplace exercise, and advice to stay active and/or return to normal activities.

OTseeker contains a substantial body of research on the effectiveness of work-related injury prevention and management, although this research is of varying methodological quality.

Electrical stimulation for chronic non-specific low back pain in a working-age population: a 12-week double blinded randomized controlled trial

Background

Non-invasive electrotherapy is commonly used for treatment of chronic low back pain. Evidence for efficacy of most electrotherapy modalities is weak or lacking. This study aims to execute a high-quality, double-blinded randomized controlled clinical trial comparing 1) H-Wave® Device stimulation plus usual care with 2) transcutaneous electrical nerve stimulation (TENS) plus usual care, and 3) Sham electrotherapy plus usual care to determine comparative efficacy for treatment of chronic non-specific low back pain patients.

Methods/Design

Patients- Chronic non-specific low back pain patients between ages of 18–65 years, with pain of at least 3 months duration and minimal current 5/10 VAS pain. Patients will have no significant signs or symptoms of lumbosacral nerve impingement, malignancy, spinal stenosis, or mood disorders.

Study design- Double blind RCT with 3 arms and 38 subjects per arm. Randomization by permuted blocks of random length, stratified by Workers Compensation claim (yes vs. no), and use of opioids. The null hypothesis of this study is that there are no statistically significant differences in functional improvement between treatment types during and at the end of a 12-week week treatment period.

Data collection- Subjective data will be collected using Filemaker Pro™ database management collection tools. Objective data will be obtained through functional assessments. Data will be collected at enrollment and at 1, 4, 8, and 12 weeks for each participant by a blinded assessor.

Interventions- H-Wave® device stimulation (Intervention A) plus usual care, transcutaneous electrical nerve stimulation (TENS) (Intervention B) plus usual care, and sham electrotherapy plus usual care (control). Each treatment arm will have identical numbers of visits (4) and researcher contact time (approximately 15 hours).

Outcomes- Primary outcome measure: Oswestry Disability Index. Secondary measures include: Rowland Morris Instrument, VAS pain score, functional evaluation including strength when pushing and pulling, pain free range of motion in flexion and extension. Outcome measures assessed at baseline, 1, 4, 8, and 12 weeks. Treatment failure will be defined if patient terminates assigned treatment arm for non-efficacy or undergoes invasive procedure or other excluded cointerventions. Data will be analyzed using intention-to-treat analysis and adjusted for covariates related to LBP (e.g. age) as needed.

Discussion

Study strengths include complex randomization, treatment group allocation concealment, double blinding, controlling for co-interventions, rigorous inclusion criteria, assessment of compliance, plans for limiting dropout, identical assessment methods and timing for each treatment arm, and planned intention-to-treat analyses.

Evaluation of Transcutaneous Electrical Nerve Stimulation as a Treatment of Neck Pain due to Musculoskeletal Disorders

BACKGROUND

This study was designed to evaluate transcutaneous electrical nerve stimulation (TENS) as a treatment for neck pain due to musculoskeletal disorders within the context of a physiotherapy treatment.

METHODS

Thirty subjects with neck pain were randomly allocated to two groups, treated with either TENS (n = 15) or placebo (n = 15). Each subject received one session for one hour. All subjects were evaluated before, during treatment, after switch off and again a week after by using Myometer machine. All subjects completed the follow-up assessment. Subjects referred for out-subjects' physiotherapy department, fulfilling the inclusion and exclusion criteria, took part in the study.

RESULTS

The assessments were compared and used to measure outcome treatment. Improvement in their condition was measured in terms of a reduction in the individual's level of pain during the week after the end of the first session. At the end of the first session, the study showed that 11 subjects (73%) in the treatment and 7 subjects (43%) in the control groups had gained marked improvement. These results are statistically highly significant, (P = 0.01) at the end of the follow-up assessment.

CONCLUSIONS

A conclusion could be drawn that a single intense TENS treatment is an effective treatment for neck pain due to musculoskeletal disorders. On the other hand, TENS showed an effective pain relief with subjects who have a mild neck pain rather than those with severe symptoms.

KEYWORDS

Musculoskeletal disorders; Transcutaneous electrical nerve stimulation; Neck pain.

Effective treatments for pain in the older patient

By 2050, the number of older persons across the globe will exceed the number of younger people for the first time in history. Chronic conditions, especially pain, will rise in prevalence as the population ages. Controlling pain in this unique subset of the population demands careful attention to pharmacokinetic and pharmacodynamic factors and their specific impact on pharmacotherapies, relevant complementary and alternative medicine therapies, and interventional strategies.

Lumbar spondylosis: clinical presentation and treatment approaches

Low back pain (LBP) affects approximately 60-85% of adults during some point in their lives. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15-45% of the population. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable. Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine. Back pain has been termed as "an illness in search of a disease." Indeed, once "red flag" diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative. We will elaborate on these degenerative processes and their clinical implications. We will further discuss diagnostic approaches and the efficacy of existing treatment options.

Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS) was introduced more than 30 years ago as a therapeutic adjunct to the pharmacological management of pain. However, despite widespread use, its effectiveness in chronic low-back pain (LBP) is still controversial.

OBJECTIVES

To determine whether TENS is more effective than placebo for the management of chronic LBP.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PEDro and CINAHL were searched up to July 19, 2007.

SELECTION CRITERIA

Only randomized controlled clinical trials (RCTs) comparing TENS to placebo in patients with chronic LBP were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials, assessed their methodological quality and extracted relevant data. If quantitative meta-analysis was not possible, a qualitative synthesis was performed, taking into consideration 5 levels of evidence as recommended by the Cochrane Collaboration Back Review Group.

MAIN RESULTS

Four high-quality RCTs (585 patients) met the selection criteria. Clinical heterogeneity prevented the use of meta-analysis. Therefore, a qualitative synthesis was completed. There was conflicting evidence about whether TENS was beneficial in reducing back pain intensity and consistent evidence in two trials (410 patients) that it did not improve back-specific functional status. There was moderate evidence that work status and the use of medical services did not change with treatment. Conflicting results were obtained from two studies regarding generic health status, with one study showing no improvement on the modified Sickness Impact Profile and another study showing significant improvements on several, but not all subsections of the SF-36 questionnaire. Multiple physical outcome measures lacked statistically significant improvement relative to placebo. In general, patients treated with acupuncture-like TENS responded similarly to those treated with conventional TENS. However, in two of the trials, an inadequate stimulation intensity was used for acupuncture-like TENS, given that muscle twitching was not induced. Optimal treatment schedules could not be reliably determined based on the available data. Adverse effects included minor skin irritation at the site of electrode placement.

AUTHORS' CONCLUSIONS

At this time, the evidence from the small number of placebo-controlled trials does not support the use of TENS in the routine management of chronic LBP. Further research is encouraged.

A New Analgesic Method, Two-minute Sciatic Nerve Press, for Immediate Pain Relief: A Randomized Trial

BACKGROUND

Current analgesics have drawbacks such as delays in acquisition, lag-times for effect, and side effects. We recently presented a preliminary report of a new analgesic method involving a two-minute sciatic nerve press, which resulted in immediate short-term relief of pain associated with dental and renal diseases. The present study investigated whether this technique was effective for pain associated with other disease types, and whether the relief was effective for up to one hour.

METHODS

This randomized, placebo-controlled, parallel-group trial was conducted in four hospitals in Anhui Province, China. Patients with pain were sequentially recruited by participating physicians during clinic visits, and 135 patients aged 15 - 80 years were enrolled. Dental disease patients included those with acute pulpitis and periapical abscesses. Renal disease patients included those with kidney infections and/or stones. Tumor patients included those with nose, breast, stomach and liver cancers, while Emergency Room patients had various pathologies. Patients were randomly assigned to receive a "sciatic nerve press" in which pressure was applied simultaneously to the sciatic nerves at the back of both thighs, or a "placebo press" in which pressure was applied to a parallel region on the front of the thighs. Each fist applied a pressure of 11 - 20 kg for 2 minutes. Patients rated their level of pain before and after the procedure.

RESULTS

The "sciatic nerve press" produced immediate relief of pain in all patient groups. Emergency patients reported a 43.5% reduction in pain (p < 0.001). Significant pain relief for dental, renal and tumor patients lasted for 60 minutes (p < 0.001). The peak pain relief occurred at the 10 - 20th minutes, and the relief decreased 47% by the 60th minutes.

CONCLUSION

Two minutes of pressure on both sciatic nerves produced immediate significant short-term conduction analgesia. This technique is a convenient, safe and powerful method for the short-term treatment of clinical pain associated with a diverse range of pathologies.

TRIAL REGISTRATION

Current Controlled Trials ACTRN012606000439549.

Immediate and short-term pain relief by acute sciatic nerve press: a randomized controlled trial

BACKGROUND

Despite much research, an immediately available, instantly effective and harmless pain relief technique has not been discovered. This study describes a new manipulation: a "2-minute sciatic nerve press", for rapid short-term relief of pain brought on by various dental and renal diseases.

METHODS

This randomized, single-blind, placebo-controlled trial ran in three hospitals in Anhui Province, China, with an enrollment of 66 out of 111 solicited patients aged 16 to 74 years. Patients were recruited sequentially, by specific participating physicians at their clinic visits to three independent hospitals. The diseases in enrolled dental patients included dental caries, periodontal diseases and dental trauma. Renal diseases in recruits included kidney infections, stones and some other conditions. Patients were randomly assigned to receive the "2-minute sciatic nerve press" or the "placebo press". For the "2-minute sciatic nerve press", pressure was applied simultaneously to the sciatic nerves at the back of the thighs, using the fists while patients lay prone. For the "placebo press", pressure was applied simultaneously to a parallel spot on the front of the thighs, using the fists while patients lay supine. Each fist applied a pressure of 11 to 20 kg for 2 minutes, after which, patients arose to rate pain.

RESULTS

The "2-minute sciatic nerve press" produced greater pain relief than the "placebo press". Within the first 10 minutes after sciatic pressure, immediate pain relief ratings averaged 66.4% (p < 0.001) for the dental patients, versus pain relief of 20% for the placebo press, and, 52.2% (p < 0.01) for the renal patients, versus relief of 14% for the placebo press, in median. The method worked excellently for dental caries and periodontal diseases, but poorly for dental trauma. Forty percent of renal patients with renal colic did not report any pain relief after the treatment.

CONCLUSION

Two minutes of pressure on both sciatic nerves can produce immediate significant conduction analgesia, providing a convenient, safe and powerful way to overcome clinical pain brought on by dental diseases and renal diseases for short term purposes.

TRIAL REGISTRATION

ACTR 12606000439549.

Spinal 5-HT(2) and 5-HT(3) receptors mediate low, but not high, frequency TENS-induced antihyperalgesia in rats

Transcutaneous electrical nerve stimulation (TENS) is a form of non-pharmacological treatment for pain. Involvement of descending inhibitory systems is implicated in TENS-induced analgesia. In the present study, the roles of spinal 5-HT and alpha(2)-adrenoceptors in TENS analgesia were investigated in rats. Hyperalgesia was induced by inflaming the knee joint with 3% kaolin-carrageenan mixture and assessed by measuring paw withdrawal latency (PWL) to heat before and 4 h after injection. The (1). alpha(2)-adrenergic antagonist yohimbine (30 microg), (2). 5-HT antagonist methysergide (5-HT(1). and 5-HT(2). 30 microg), one of the 5-HT receptor subtype antagonists, (3). NAN-190 (5-HT(1A), 15 microg), (4). ketanserin (5-HT(2A), 30 microg), (5). MDL-72222 (5-HT(3), 12 microg), or (6). vehicle was administered intrathecally prior to TENS treatment. Low (4 Hz) or high (100 Hz) frequency TENS at sensory intensity was then applied to the inflamed knee for 20 min and PWL was determined. Selectivity of the antagonists used was confirmed using respective agonists administered intrathecally. Yohimbine had no effect on the antihyperalgesia produced by low or high frequency TENS. Methysergide and MDL-72222 prevented the antihyperalgesia produced by low, but not high, frequency TENS. Ketanserin attenuated the antihyperalgesic effects of low frequency TENS whereas NAN-190 had no effect. The results from the present study show that spinal 5-HT receptors mediate low, but not high, frequency TENS-induced antihyperalgesia through activation of 5-HT(2A) and 5-HT(3) receptors in rats. Furthermore, spinal noradrenergic receptors are not involved in either low or high frequency TENS antihyperalgesia.

Efficacy of rehabilitative therapy in regional musculoskeletal conditions

This chapter reviews the best evidence for the rehabilitation of regional musculoskeletal conditions. Evidence-based efficacy of different modalities for treatment of musculoskeletal pain is presented, and the value of the patient's active participation in the rehabilitation programme is emphasized. The following modalities are commonly included in the holistic approach to patient-centred care and are reviewed: exercise therapy, thermotherapy, transcutaneous electrical nerve stimulation (TENS), and alternative therapies such as acupuncture, massage and yoga. A review of cognitive-behavioural strategies in pain management to prevent or treat fear-avoidance behaviour is also presented. Furthermore, the application of biomechanics in treating and preventing musculoskeletal disorders is illustrated. Moreover, the evidence for pain self-management to improve symptoms, health status and decrease the utilization of health care resources and cost is outlined. Finally, an overview will be presented, concerning the application of the evidence for treatment modalities to patient care, with focus on patient-centred, holistic treatment in a supportive setting. The following key questions/issues are addressed. What are the relevant therapeutic modalities for musculoskeletal pain disorders? What is the evidence of efficacy of these modalities in regional musculoskeletal conditions? What is the importance of understanding biomechanics? What is the importance of understanding fear-avoidance beliefs? What is the evidence for 'alternative' therapies such as acupuncture, massage or yoga? What is the evidence for 'pain self-management?' How does one apply the evidence for rehabilitation in regional musculoskeletal conditions into clinical practice?