Transcutaneous electrical nerve stimulation for the treatment of chronic low back pain: a systematic review

Effectiveness of interferential current in patients with chronic non-specific low back pain: a systematic review with meta-analysis

BACKGROUND

There is no systematic review assessing the effectiveness of interferential current (IC) in patients with low back pain.

OBJECTIVE

To investigate the effectiveness of IC in patients with chronic non-specific low back pain.

METHODS

The databases PUBMED, EMBASE, PEDro, Cochrane Library, CINAHL, and SCIELO were searched. Randomized controlled trials reporting pain intensity and disability in patients with chronic non-specific low back pain, in which IC was applied were included. Methodological quality was assessed using the PEDro scale. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to evaluate the quality of evidence.

RESULTS

Thirteen RCTs were considered eligible for this systematic review (pooled n = 1367). Main results showed moderate-quality evidence and moderate effect sizes that IC probably reduces pain intensity and disability compared to placebo immediately post-treatment (Pain: MD = -1.57 points; 95% CI -2.17, -0.98; Disability: MD = -1.51 points; 95% CI -2.57, -0.46), but not at intermediate-term follow-up. Low-quality evidence with small effect size showed that IC may reduce pain intensity (SMD = -0.32; 95% CI -0.61, -0.03, p = 0.03) compared to TENS immediately post-treatment, but not for disability. There is very low-quality evidence that IC combined with other interventions (massage or exercises) may not further reduce pain intensity and disability compared to the other interventions provided in isolation immediately post-treatment.

CONCLUSION

Moderate-quality evidence shows that IC is probably better than placebo for reducing pain intensity and disability immediately post-treatment in patients with chronic non-specific low back pain.

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).

Electrical dry needling versus conventional physiotherapy in the treatment of active and latent myofascial trigger points in patients with nonspecific chronic low back pain

Background

Chronic low back pain is considered to be one of the main causes of absenteeism from work and primary and specialized consultations. The symptoms of nonspecific chronic low back pain may be accompanied by the activation of myofascial trigger points in the muscles, together with local and/or referred pain. Electrical dry needling is increasingly used in the treatment of lumbar myofascial pain. Conventional physiotherapy, however, is a popular approach to chronic pathologies, and there is evidence of different modalities of physiotherapy being used in the treatment of chronic low back pain. The aim of this study has been to determine the effectiveness of electrical dry needling versus conventional physiotherapy when applied to active and latent myofascial trigger points in patients with nonspecific chronic low back pain.

Methods

This is a controlled, randomized, two-arm, double-blind study. A total of 92 patients with chronic low back pain (time to onset ≥ 3 months, Roland Morris Disability Questionnaire score ≥ 4) will be recruited from the University of Almería. Participants will be divided into two study groups (n = 40) to receive treatment of low back pain with electrical dry needling and conventional physiotherapy (ischaemic compression, analytic stretching and postural education training dossier). A total of 6 sessions will be administered once a week for 6 weeks. Pain intensity, disability, fear of movement, quality of life, quality of sleep, anxiety and depression, pressure pain threshold, abdominal strength and lumbar mobility will be recorded at 6 weeks (post-immediate) and 2 months after the end of treatment.

Discussion

We believe that an approach including electrical dry needling to chronic low back pain dysfunction will be more effective in these patients. The results of this study will inform clinicians on which type of treatment is more beneficial for patients with chronic low back pain.

Trial registration

ClinicalTrials.gov NCT04804228. Registered on 14 January 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06179-y.

Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition

BACKGROUND

The latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine.

METHODS

The Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, "body of evidence" and "benefit and harm balance" were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members.

RESULTS

Nine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature.

CONCLUSIONS

The 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.

The Added Value of Subcutaneous Peripheral Nerve Field Stimulation Combined with SCS, as Salvage Therapy, for Refractory Low Back Pain Component in Persistent Spinal Pain Syndrome Implanted Patients: A Randomized Controlled Study (CUMPNS Study) Based on 3D-Mapping Composite Pain Assessment

While Spinal Cord Stimulation (SCS) provides satisfaction to almost 2/3 of Persistent Spinal Pain Syndrome-Type 2 (PSPS-T2) patients implanted for refractory chronic back and/or leg pain, when not adequately addressed the back pain component, leaves patients in a therapeutic cul-de-sac. Peripheral Nerve field Stimulation (PNfS) has shown interesting results addressing back pain in the same population. Far from placing these two techniques in opposition, we suggest that these approaches could be combined to better treat PSPS-T2 patients. We designed a RCT (CUMPNS), with a 12-month follow-up, to assess the potential added value of PNfS, as a salvage therapy, in PSPS-T2 patients experiencing a "Failed SCS Syndrome" in the back pain component. Fourteen patients were included in this study and randomized into 2 groups ("SCS + PNfS" group/n = 6 vs. "SCS only" group/n = 8). The primary objective of the study was to compare the percentage of back pain surface decrease after 3 months, using a computerized interface to obtain quantitative pain mappings, combined with multi-dimensional SCS outcomes. Back pain surface decreased significantly greater for the "SCS + PNfS" group (80.2% ± 21.3%) compared to the "SCS only" group (13.2% ± 94.8%) (p = 0.012), highlighting the clinical interest of SCS + PNfS, in cases where SCS fails to address back pain.

Low Back Pain: A Comprehensive Review on the Diagnosis, Treatment Options, and the Role of Other Contributing Factors

BACKGROUND: In recent years, low back pain (LBP) is a growing major health issue around the world and mostly addressed in primary healthcare settings. This may be due to changing work environment including the nature of long sitting work hours, especially in the booming information and technology (IT) and Business Process Outsourcing (BPO) industry. LBP is normally considered as a combination of various types of pain and its related conditions, which eventually lead to disabilities. AIM: In this article, the aim is to discuss the current and future perspectives of LBP mainly on diagnosis and therapeutic front of LBP. METHODS: A search was performed using electronic databases, which include PubMed Central and Google Scholar, using the related key words “back pain and low back pain.” All related peer reviewed published articles were included regardless of the language, region, or the publication date. RESULTS: Although the management of LBP both in terms of diagnosis as well as in the therapeutic options has witnessed considerable progress but challenges are still exist not only within countries but also in the regions and continents among various medical professionals. However, in the past few years, a huge array of coordinated but randomized multi-center clinical studies were performed and various detailed insight investigations have been done, and substantial clinical guidelines have become available. Hence, a new view on evidence-based management approach for LBP has significantly improved recently and discussed here. CONCLUSION: Based on the available evidence and literature, this comprehensive review discusses the present and future perspectives of LBP mainly on diagnosis and therapeutic front for LBP. In addition, current intervention and prevention plans have failed to lessen the considerable burden of LBP and hence several areas which require more details, which deserves additional discussion to augment us through an understanding of this very important topic on improvements of multi tasked outcomes to benefit the affected patients.

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.

Parameterization of physical properties of layered body structure into equivalent circuit model

Background

This study presents a novel technique to develop an equivalent circuit model (ECM) for analyzing the responses of the layered body structure to transcutaneous electrical nerve stimulation (TENS) by parameterizing electrical and geometrical properties.Many classical ECMs are non-parametric because of the difficulty in projecting intrapersonal variability in the physical properties into ECM. However, not considering the intrapersonal variability hampers patient-specifically analyzing the body response to TENS and personal optimization of TENS parameter design. To overcome this limitation, we propose a tissue property-based (TPB) approach for the direct parameterization of the physical properties in the layered body structure and thus enable to quantify the effects of intrapersonal variability.

Results

The proposed method was first validated through in vitro phantom studies and then was applied in-vivo to analyze the TENS on the forearm. The TPB-ECM calculated the impedance network in the forearm and corresponding responses to TENS. In addition, the modelled impedance was in good agreement with well-known impedance properties that have been achieved empirically.

Conclusions

The TPB approach uses the parameterized circuit components compared to non-parametric conventional ECMs, thus overcoming the intrapersonal variability problem of the conventional ECMs. Therefore, the TPB-ECM has a potential for widely-applicable TENS analysis and could provide impactful guidance in the TENS parameter design.

Supplementary Information

The online version contains supplementary material available at (10.1186/s42490-021-00054-8).

Review article: Paramedic pain management of femur fractures in the prehospital setting: A systematic review

Femur shaft and neck of femur (NOF) fractures are often undertreated in the prehospital setting. These injuries can present unique clinical and logistical concerns in the prehospital setting. This systematic review aimed to investigate paramedic prehospital pain management of patients who had suffered NOF or femur fractures, and to investigate which interventions are effective. A systematic review was conducted in line with Preferred Reporting Item for Systematic Reviews and Meta-Analyses guidelines. Four databases were searched from inception date 23 March 2020. Articles were independently reviewed by two authors and conflicts resolved by a third author, followed by a hand search of the included reference lists. References were included if they addressed paramedic interventions for NOF or femur shaft fractures. Outcomes of interest were the effectiveness and complications of different modalities administered by paramedics. The search yielded 6868 articles, of which 19 met the final inclusion criteria. Studies investigated a variety of interventions including traction splints, intravenous (IV) analgesia and alternative analgesic options. Traction splinting and IV analgesia were consistently reported as underutilised. Alternative analgesics such as auricular acupressure, transcutaneous electrical nerve stimulation (TENS) and fascia iliaca compartment block were found to be effective techniques that could be safely and competently employed by paramedics, reducing pain for patients with limited adverse events. NOF and femur shaft fractures are an undertreated injury in the prehospital setting. Traction splinting and IV analgesia remain the traditional methodologies of treatment for these injuries; however, there are alternatives such as TENS, auricular acupressure and fascia iliaca compartment block that appear to be emerging as safe and effective options for the prehospital setting.

Effects of combining diaphragm training with electrical stimulation on pain, function, and balance in athletes with chronic low back pain: a randomized clinical trial

BACKGROUND

It is unknown how diaphragm training combined with electrical stimulation affects pain, function, static stability, and balance in athletes with chronic low back pain (CLBP). This study aimed to explore the effects of combining diaphragm training with electrical stimulation on pain, function, static stability, and dynamic balance in athletes with nonspecific CLBP.

METHODS

The design was a randomized clinical trial. A total of 24 amateur athletes (12 women, 12 men, mean age: 35.2 ± 9.8) with nonspecific CLBP were randomly allocated into two groups. The experimental group (n = 12) received diaphragm training plus Transcutaneous Electrical Nerve Stimulation (TENS), while the control group (n = 12) received TENS alone. Both groups underwent 12 sessions over a four-week period. Static stability, dynamic balance, pain, and function were measured pre- and post-intervention.

RESULTS

Analysis of variance 2 × 2 revealed greater improvements in pain (p < 0.001), static stability (p < 0.001), and dynamic balance (p < 0.01) in the experimental group compared to the control group. Function was improved in both groups following the interventions (p < 0.001), and there was a trend of a larger improvement in the experimental group than the control group (p = 0.09). Fisher's exact test showed that the experimental group reported ≥50% improvement only in the pain score, not function, compared to the group that received TENS alone (p = 0.005).

CONCLUSIONS

Pain, function, static stability, and dynamic balance were improved in both groups following 12 intervention sessions. However, pain, static stability, and dynamic balance were improved to a greater extent in diaphragm training plus TENS than TENS alone in amateur athletes with CLBP. Therefore, it seems beneficial to add diaphragm training to the rehabilitation program for athletes with nonspecific CLBP.

TRIAL REGISTRATION

The trial was retrospectively registered in the Iranian Registry of Clinical Trials ( www.irct.ir ) on September 10, 2020 as IRCT20090228001719N8 .

Transcutaneous electrical nerve stimulation and heat to reduce pain in a chronic low back pain population: a randomized controlled clinical trial

BACKGROUND

Low back pain is the leading cause of disability worldwide. The therapeutic management of patients with chronic LBP is challenging.

OBJECTIVES

The aim of this study is to evaluate the effects of heat and transcutaneous electrical nerve stimulation combined on pain relief in participants with chronic low back pain.

METHODS

Fifty participants with chronic (≥3 months) low back pain were randomly assigned to two groups: HeatTens (n=25) and control group (n=25). Primary outcome was pain. Secondary outcomes were pressure pain thresholds, temporal summation, conditioned pain modulation, fear-avoidance and beliefs questionnaire, central sensitization inventory, quality of life, and medication use. The control group received no treatment and continued usual care. After four weeks of treatment, all measurements were repeated.

RESULTS

Fifty individuals participated in this study. Significant higher pressure pain threshold measures after both 30min and 4 weeks for the lower back region and the second plantar toe were found only in the experimental group.

CONCLUSION

The combination of heat and transcutaneous electrical nerve stimulation does not reduce pain scores in patients with chronic low back pain. Pressure pain threshold values significantly improved, showing beneficial effects of the experimental treatment. ClinicalTrials.gov: NCT03643731 (https://clinicaltrials.gov/ct2/show/NCT03643731).

Study protocol randomised controlled trial comparison of cost-utility and cost-effectiveness of a face-to-face rehabilitation programme versus a telemedicine programme in the treatment of patients with chronic low back pain

INTRODUCTION

Chronic lower back pain is a highly prevalent medical condition in Western countries, which that incurs a considerable social and economic burden. Although prescription exercise at home for chronic pain has become a widely used alternative to reduce healthcare costs, the evidence regarding patient adherence and decreased in costs in European countries is scarce and inconclusive. The objective of this study is to examine the cost-utility and cost-effectiveness in patients with chronic lower back pain treated with the McKenzie Method and electroanalgesia via a telemedicine programme versus a face-to-face programme.

METHODS AND ANALYSIS

This study reports the protocol for a randomised, two-arm, multicentre, parallel controlled trial. A total of 540 patients with chronic lower back pain (onset time ≥3 months, Roland Morris Disability Questionnaire ≥4) will be recruited in three hospitals in Andalusia. Participants will be assigned to one of two groups (n=270, respectively) to receive electroanalgesia and Mckenzie method exercises through a telemedicine or a face-to-face programme. A total of 24 sessions will be administered three times a week for 8 weeks. Since the study design does not allow participant blinding, the outcome assessor and the statistician will be blinded. Use of helth care resources and costs due to work absenteeism will be captured and analysed. In addition, pain, intensity, fear of movement, quality of life and strength of the core muscle and anteflexion lumbar will be recorded at 2 and 6 months after the start of treatment.

ETHICS AND DISSEMINATION

Human Research and Local Ethics Committee of the 'Hospital Complex Torrecárdenas of Almeria, University Hospital of Granada and Virgen Macarena de Sevilla Hospital-Andalusian Health Service'. Study findings will be released to the research, clinical and health service through publication in international journals and conferences.

TRIAL REGISTRATION NUMBER

NCT04266366.

Effect of Psycho-Regulatory Massage Therapy on Pain and Depression in Women with Chronic and/or Somatoform Back Pain: A Randomized Controlled Trial

Chronic unspecific back pain (cBP) is often associated with depressive symptoms, negative body perception, and abnormal interoception. Given the general failure of surgery in cBP, treatment guidelines focus on conservative therapies. Neurophysiological evidence indicates that C-tactile fibers associated with the oxytonergic system can be activated by slow superficial stroking of the skin in the back, shoulder, neck, and dorsal limb areas. We hypothesize that, through recruitment of C-tactile fibers, psycho-regulatory massage therapy (PRMT) can reduce pain in patients with cBP. In our study, 66 patients were randomized to PRMT or CMT (classical massage therapy) over a 12-week period and tested by questionnaires regarding pain (HSAL= Hamburger Schmerz Adjektiv Liste; Hamburg Pain adjective list), depression (BDI-II = Beck depression inventory), and disability (ODI = Oswestry Disability Index). In all outcome measures, patients receiving PRMT improved significantly more than did those receiving CMT. The mean values of the HSAL sensory subscale decreased by -51.5% in the PRMT group compared to -6.7% in the CMT group. Depressive symptoms were reduced by -55.69% (PRMT) and -3.1% (CMT), respectively. The results suggest that the superiority of PRMT over CMT may rely on its ability to activate the C-tactile fibers of superficial skin layers, recruiting the oxytonergic system.

Explicit and Implicit Own's Body and Space Perception in Painful Musculoskeletal Disorders and Rheumatic Diseases: A Systematic Scoping Review

Background: Pain and body perception are essentially two subjective mutually influencing experiences. However, in the field of musculoskeletal disorders and rheumatic diseases we lack of a comprehensive knowledge about the relationship between body perception dysfunctions and pain or disability. We systematically mapped the literature published about the topics of: (a) somatoperception; (b) body ownership; and (c) perception of space, analysing the relationship with pain and disability. The results were organized around the two main topics of the assessment and treatment of perceptual dysfunctions.

Methods: This scoping review followed the six-stage methodology suggested by Arksey and O'Malley. Ten electronic databases and grey literature were systematically searched. The PRISMA Extension for Scoping Reviews was used for reporting results. Two reviewers with different background, independently performed study screening and selection, and one author performed data extraction, that was checked by a second reviewer.

Results: Thirty-seven studies fulfilled the eligibility criteria. The majority of studies (68%) concerned the assessment methodology, and the remaining 32% investigated the effects of therapeutic interventions. Research designs, methodologies adopted, and settings varied considerably across studies. Evidence of distorted body experience were found mainly for explicit somatoperception, especially in studies adopting self-administered questionnaire and subjective measures, highlighting in some cases the presence of sub-groups with different perceptual features. Almost half of the intervention studies (42%) provided therapeutic approaches combining more than one perceptual task, or sensory-motor tasks together with perceptual strategies, thus it was difficult to estimate the relative effectiveness of each single therapeutic component.

Conclusions: To our knowledge, this is the first attempt to systematically map and summarize this research area in the field of musculoskeletal disorders and rheumatic diseases. Although methodological limitations limit the validity of the evidence obtained, some strategies of assessment tested and therapeutic strategies proposed represent useful starting points for future research. This review highlights preliminary evidence, strengths, and limitations of the literature published about the research questions, identifying key points that remain opened to be addressed, and make suggestions for future research studies. Body representation, as well as pain perception and treatment, can be better understood if an enlarged perspective including body and space perception is considered.

Evidence-based pain medicine for primary care physicians

The last several decades have seen a marked increase in both the recognition and treatment of chronic pain. Unfortunately, patients frequently misunderstand both the nature of pain and the best practices for its treatment. Because primary care physicians treat the majority of chronic pain, they are ideally situated to provide evidence-based pain care. The majority of the medical evidence supports a biopsychosocial model of pain that integrates physical, emotional, social, and cultural variables. The goal of this primer is to assist primary care physicians in their understanding of pain, evaluation of the chronic pain patient, and ability to direct evidence-based care. This article will discuss the role of physical rehabilitation, pain psychology, pharmacotherapy, and procedural interventions in the treatment of chronic pain. Given the current epidemic of drug-related deaths, particular emphasis is placed on the alternatives to opioid therapy. Unfortunately, death is not the only significant complication from opioid therapy, and this article discusses many of the most common side effects. This article provides general guidelines on the most appropriate utilization of opioids with emphasis on the recent Centers for Disease Control and Prevention guidelines, risk stratification, and patient monitoring. Finally, the article concludes with the critical role that a pain medicine specialist can play in the management of patients with chronic pain.

Interfacing with the nervous system: a review of current bioelectric technologies

The aim of this study is to discuss the state of the art with regard to established or promising bioelectric therapies meant to alter or control neurologic function. We present recent reports on bioelectric technologies that interface with the nervous system at three potential sites-(1) the end organ, (2) the peripheral nervous system, and (3) the central nervous system-while exploring practical and clinical considerations. A literature search was executed on PubMed, IEEE, and Web of Science databases. A review of the current literature was conducted to examine functional and histomorphological effects of neuroprosthetic interfaces with a focus on end-organ, peripheral, and central nervous system interfaces. Innovations in bioelectric technologies are providing increasing selectivity in stimulating distinct nerve fiber populations in order to activate discrete muscles. Significant advances in electrode array design focus on increasing selectivity, stability, and functionality of implantable neuroprosthetics. The application of neuroprosthetics to paretic nerves or even directly stimulating or recording from the central nervous system holds great potential in advancing the field of nerve and tissue bioelectric engineering and contributing to clinical care. Although current physiotherapeutic and surgical treatments seek to restore function, structure, or comfort, they bear significant limitations in enabling cosmetic or functional recovery. Instead, the introduction of bioelectric technology may play a role in the restoration of function in patients with neurologic deficits.

The Role of Therapeutic Modalities in Surgical and Nonsurgical Management of Orthopaedic Injuries

Rehabilitation professionals often use therapeutic modalities as a component of the surgical and nonsurgical management of orthopaedic injuries. Myriad therapeutic modalities, including cryotherapy, thermotherapy, ultrasonography, electrical stimulation, iontophoresis, and laser therapy, are available. Knowledge of the scientific basis of each modality and the principles of implementation for specific injuries enables musculoskeletal treatment providers to prescribe these modalities effectively. The selection of specific therapeutic modalities is based on their efficacy during a particular phase of rehabilitation. Therapeutic modalities are an adjunct to standard exercise and manual therapy techniques and should not be used in isolation.

Electro-analgesia for sheep husbandry practices: a review

Several sheep-husbandry practices such as mulesing, castration, ear-tagging and tail-docking are currently performed with no, or little, anaesthesia or analgesia. The potential for using electrotherapies to provide analgesia during and after these operations is examined in this review. The most common electrotherapy is transcutaneous electrical nerve stimulation (TENS). TENS is the application of an electrical current from electrodes placed on the skin. Analysis of a large number of trials in humans and in animal models indicates that TENS provides effective relief from acute and chronic pain, including pain associated with surgery. There is strong evidence now that TENS analgesia operates at the levels of the periphery, the spinal cord and in the brain. The mechanisms involve the autonomic nervous system, the opioid pathways and neurotransmitters involved in descending inhibitory pathways from the brain. Centrally operating pathways mean the current does not have to be applied near the injured site and there is evidence of sustained pain relief lasting hours, days or even weeks post-treatment, particularly after very high-frequency, randomly variable current applications. Treatment of sheep during painful operations with such a current has the potential to provide immediate and possibly sustained pain relief. Combining such a treatment with electro-immobilisation of the animal would be advantageous for sheep-husbandry operations, but there is considerable evidence that high-intensity currents producing tetanic contractions are aversive and probably painful for sheep. Investigations of the application and efficacy of electrotherapies for painful sheep operations should be undertaken.

Management of Postherniorrhaphy Chronic Neuropathic Groin Pain: A Role for Dorsal Root Ganglion Stimulation

Chronic neuropathic groin pain is a sequela of hernia surgery that occurs at unacceptably high rates, causing widespread impacts on quality of life. Although the medical community is beginning to recognize the role of surgical technique in the initiation and maintenance of postherniorrhaphy neuropathic pain, little information exists regarding pain management strategies for this condition. This review presents a summary of the pain condition state, its treatment options, and treatment recommendations. Both literature review and clinical experience were used to develop a proposed a treatment algorithm for the treatment of postherniorrhaphy pain. The development of chronic pain may be prevented via a number of perioperative measures. For pain that is already established, some surgical approaches including inguinal neurectomy can be effective, in addition to standard pharmacological treatments and local infiltrations. An unmet need may still exist with these options, however, leaving a role for neuromodulation for the treatment of intractable cases. A pain management algorithm for iterative interventions including stimulation of the dorsal root ganglion (DRG) is described. It is expected that cross-disciplinary awareness of surgeons for nonsurgical pain management options in the treatment of chronic neuropathic postherniorrhaphy pain will contribute to better clinical outcomes.

The Evaluation of Curative Effect of Acupuncture

The present study attempts to critically evaluate previously published research articles on the efficiency of acupuncture in the treatment of diseases. First, 35 systematic reviews or meta-analysis were found in the Cochrane database. Second, 54 related articles were selected by searching important scientific databases. Based on the results obtained regarding the efficacy of acupuncture for the treatment of various diseases, the articles were divided into 3 groups. The first group of articles confirmed the efficacy of treatment by acupuncture. In the second group of articles, the therapeutic effect of acupuncture was shown; however, further research is required to verify the results. In the third group of articles there is no evidence regarding the therapeutic effect of acupuncture till now. There is an urgent need to design and conduct double-blinded randomized clinical trials with high-quality methodologies. This provides a more careful evaluation of acupuncture efficiency in relation to the treatment of a vast array of diseases, based on scientific evidence.

Physical agent modalities in physical therapy and rehabilitation of small animals

Physical agent modalities can be effective components of the overall rehabilitation of small animals. This article reviews the effects, indications, contraindications, and precautions of cold, superficial heat, therapeutic ultrasound, and electrical stimulation.

Rehabilitation and physical therapy for the neurologic veterinary patient

A comprehensive physiotherapy plan for neurology patients manages pain, prevents secondary complications, and supports the health and function of musculoskeletal tissues during recovery. Neurologically impaired patients range in ability from complete immobility (tetraplegia/paraplegia), partial mobility (tetraparesis/paraparesis), mild ataxia, to pain only. Important considerations for the design of a physiotherapy program include access to the patient, level of staff support, and safety of staff, patient, and client during treatments. A thorough overview of the treatment plan and expected outcome should be discussed with the client at the onset of therapy and should be reviewed frequently, particularly as the patient's status changes.

Role of rehabilitation medicine and physical agents in the treatment of cancer-associated pain

PURPOSE

To provide an overview of rehabilitation medicine- and physical modality-based approaches to cancer pain management, and to highlight the fact that these approaches are generally used in conjunction and that a majority are focused on minimizing pain during periods of mobility and the performance of activities of daily living.

METHODS

We performed a nonsystematic literature review and provide a description of the current standard of care.

RESULTS

Rehabilitative and physical modalities used to manage pain can be grouped into four categories: those that modulate nociception, stabilize or unload painful structures, influence physiological processes that indirectly influence nociception, or alleviate pain arising from the overloading of muscles and connective tissues that often occurs after surgery or with sarcopenia in late-stage cancer. Most modalities have been pragmatically refined over the years, and many have an evidence base, although few have been explicitly validated in the oncologic setting. With few exceptions, they are patient controlled and free of adverse effects.

CONCLUSION

Physical modalities and rehabilitation medicine offer a range of pain management approaches that may serve as beneficial adjuncts to the conventional systemic and interventional analgesic strategies used to control cancer-related pain. These approaches may be particularly beneficial to patients with movement-associated pain and those who are ambivalent regarding pharmacoanalgesia.

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.

Development and application of a newly designed massage instrument for deep cross-friction massage in chronic non-specific low back pain

Objective

To introduce a newly designed massage instrument, the Hand Grip T-bar (HT-bar) and use it to relieve chronic non-specific low back pain (nLBP) through deep cross-friction massage (roptrotherapy).

Method

22 subjects (9 males and 13 females, aged 51.6±6.7) with chronic nLBP were allocated randomly to a Roptrotherapy group (n=12) and a Transcutaneous Electrical Nerve Stimulation (TENS) group (n=10). The Roptrotherapy group received deep cross-friction massage with the HT-bar, which was made of metal and had a cylinder for increasing weight and grooves for an easy grip. It was applied across the middle and lower back for 20 minutes a day, 3 days a week for 2 weeks. The TENS group received TENS for 20 minutes a day, 5 days a week for 2 weeks. The outcome was measured on the pain numeric rating scale (PNRS), by the Oswestry disability index (ODI), and by the Roland & Morris Disability Questionnaire (RMDQ) at pre-treatment, at immediate post-treatment and 2 weeks later. The application of the HT-bar was assessed by a questionnaire to 19 therapists.

Results

At post-treatment, immediately and 2 weeks later, both groups showed significant improvement in PNRS, ODI and RMDQ. During the two weeks after post-treatment, however, the Roptrotherapy group improved in PNRS, ODI and RMDQ, but the TENS group did not. Over 80% of the therapists responded that the HT-bar was useful and comfortable.

Conclusion

This study suggests that deep cross-friction massage can be a beneficial therapeutic technique and that the HT-bar can be a useful instrument in deep cross-friction massage for chronic nLBP patients.

Avoidable costs of physical treatments for chronic back, neck and shoulder pain within the Spanish National Health Service: a cross-sectional study

BACKGROUND

Back, neck and shoulder pain are the most common causes of occupational disability. They reduce health-related quality of life and have a significant economic impact. Many different forms of physical treatment are routinely used. The objective of this study was to estimate the cost of physical treatments which, despite the absence of evidence supporting their effectiveness, were used between 2004 and 2007 for chronic and non-specific neck pain (NP), back pain (BP) and shoulder pain (SP), within the Spanish National Health Service in the Canary Islands (SNHSCI).

METHODS

Chronic patients referred from the SNHSCI to private physical therapy centres for NP, BP or SP, between 2004 and 2007, were identified. The cost of providing physical therapies to these patients was estimated. Systematic reviews (SRs) and clinical practice guidelines (CPGs) for NP, BP and SP available in the same period were searched for and rated according to the Oxman and AGREE criteria, respectively. Those rated positively for ≥70% of the criteria, were used to categorise physical therapies as Effective; Ineffective; Inconclusive; and Insufficiently Assessed. The main outcome was the cost of physical therapies included in each of these categories.

RESULTS

8,308 chronic cases of NP, 4,693 of BP and 5,035 of SP, were included in this study. Among prescribed treatments, 39.88% were considered Effective (physical exercise and manual therapy with mobilization); 23.06% Ineffective; 13.38% Inconclusive, and 23.66% Insufficiently Assessed. The total cost of treatments was € 5,107,720. Effective therapies accounted for € 2,069,932.

CONCLUSIONS

Sixty percent of the resources allocated by the SNHSCI to fund physical treatment for NP, BP and SP in private practices are spent on forms of treatment proven to be ineffective, or for which there is no evidence of effectiveness.

The efficacy, safety, effectiveness, and cost-effectiveness of ultrasound and shock wave therapies for low back pain: a systematic review

BACKGROUND CONTEXT

Shock wave and especially ultrasound are commonly used to treat low back pain (LBP) in routine practice.

PURPOSE

To assess the evidence on the efficacy, effectiveness, cost-effectiveness, and safety of ultrasound and shock wave to treat LBP.

STUDY DESIGN

Systematic review.

METHODS

An electronic search was performed in MEDLINE, EMBASE, and the Cochrane Library databases up to July 2009 to identify randomized controlled trials (RCTs) comparing vibrotherapy with placebo or with other treatments for LBP. No language restrictions were applied. Additional data were requested from the authors of the original studies. The risk of bias of each study was assessed following the criteria recommended by the Cochrane Back Review Group.

RESULTS

Thirteen studies were identified. The four RCTs complying with the inclusion criteria included 252 patients. Two of the three RCTs on ultrasound had a high risk of bias. For acute patients with LBP and leg pain attributed to disc herniation, ultrasound, traction, and low-power laser obtained similar results. For chronic LBP patients without leg pain, ultrasound was less effective than spinal manipulation, whereas a shock wave device and transcutaneous electrical nerve stimulation led to similar results. Results from the only study comparing ultrasound versus a sham procedure are unreliable because of the inappropriateness of the sham procedure, low sample size, and lack of adjustment for potential confounders. No study assessed cost-effectiveness. No adverse events were reported.

CONCLUSION

The available evidence does not support the effectiveness of ultrasound or shock wave for treating LBP. High-quality RCTs are needed to assess their efficacy versus appropriate sham procedures, and their effectiveness and cost-effectiveness versus other procedures shown to be effective for LBP. In the absence of such evidence, the clinical use of these forms of treatment is not justified and should be discouraged.

Safety of nerve conduction studies in patients with implantable cardioverter-defibrillators

OBJECTIVE

A patient with an implantable cardioverter-defibrillator (ICD) may suffer from neuromuscular disorders and may need to undergo a nerve conduction study (NCS). However, a NCS may be a source of electromagnetic interference (EMI). The aim of the present study was to investigate whether the interference from NCS used in a standardised test protocol affects ICD function.

METHODS

Twenty patients (19 males; mean age of 59.8±9.9 years) with implantable ICDs (eight with integrated and 12 with true bipolar leads), treated with amiodarone and with symptoms suggesting neuropathy were included. NCS were conducted using repetitive stimulation with frequency of 2 Hz and single, rectangular pulses of intensity up to 100 mA. Stimulation was performed in standard sites including proximal sites in the arm.

RESULTS

The impulses generated NCS were not detected by the ICD, irrespective of the site, rate or stimulus intensity.

CONCLUSIONS

Standardised test protocol for an NCS is safe in patients with an ICD regardless of the leads type.

SIGNIFICANCE

Current guidelines which limitate the NCS in patients with ICD may be the subject of revision.

Disc strain and resulting positive mRNA expression from application of a noninvasive treatment

STUDY DESIGN

Bovine caudal intervertebral discs were exposed to a noninvasive vibrating intervention for 10 minutes at amplitudes of 0 or 0.5 to 5 g and frequencies of 0, 16, 50 to 80, and a combined 16+50 to 80 Hz treatment. Expression of mRNA for aggrecan, collagen type I, collagen type II, biglycan, decorin, and versican were assayed.

OBJECTIVE

To determine if the intervention is effective in altering intervertebral disc gene expression.

SUMMARY OF BACKGROUND DATA

Studies have variously suggested either an increased risk of disc degeneration with vibrations, no effect, analgesic effect, or even positive effects within certain loading parameters. The KKT intervention is in clinical use for spinal ailment pain reduction.

METHODS

The intervention was applied in a clinic emulation set-up. Gene expression in the nucleus pulposus was assessed using real-time RT-PCR and SYBR Green chemistry.

RESULTS

Expression of mRNAs for aggrecan, collagen type II, and versican were significantly effected by the intervention. Collagen type I, biglycan, and decorin were uneffected.

CONCLUSION

Expression of the extracellular matrix genes were significantly up-regulated when vibrated with the intervention under specific loading patterns, indicating a potential therapeutic stimulus. Further studies on the protein-level and long-term effects are warranted. Previous studies have indicated a mixed effect of vibrations in the human spine. In this study, a clinical intervention using vibrations was applied to bovine intervertebral discs, and gene expression in the nucleus pulposus was measured. Several extracellular matrix genes were up-regulated, suggesting a potential therapeutic effect.

Physical therapy for chronic low back pain in North Carolina: overuse, underuse, or misuse?

BACKGROUND

There are limited population-based studies of determinants of physical therapy use for chronic low back pain (LBP) and of the types of treatments received by individuals who see a physical therapist.

OBJECTIVE

The purposes of this study were: (1) to identify determinants of physical therapy use for chronic LBP, (2) to describe physical therapy treatments for chronic LBP, and (3) to compare use of treatments with current best evidence on care for this condition.

DESIGN

This study was a cross-sectional, population-based telephone survey of North Carolinians.

METHODS

Five hundred eighty-eight individuals with chronic LBP who had sought care in the previous year were surveyed on their health and health care use. Bivariate and multivariable analyses were conducted to identify predisposing, enabling, and need characteristics associated with physical therapy use. Descriptive analyses were conducted to determine the use of physical treatments for individuals who saw a physical therapist. Use of treatments was compared with evidence from systematic reviews.

RESULTS

Of our sample, 29.7% had seen a physical therapist in the previous year, with a mean of 15.6 visits. In multivariable analyses, receiving workers' compensation, seeing physician specialists, and higher Medical Outcomes Study 12-Item Short-Form Health Survey questionnaire (SF-12) physical component scores were positively associated with physical therapy use. Having no health insurance was negatively associated with physical therapy use. Exercise was the most frequent treatment received (75% of sample), and traction was the least frequent treatment received (7%). Some effective treatments were underutilized, whereas some ineffective treatments were overutilized.

LIMITATIONS

Only one state was examined, and findings were based on patient report.

CONCLUSIONS

Fewer than one third of individuals with chronic LBP saw a physical therapist. Health-related and non-health-related factors were associated with physical therapy use. Individuals who saw a physical therapist did not always receive evidence-based treatments. There are potential opportunities for improving access to and quality of physical therapy for chronic LBP.

Maldynia: pathophysiology and management of neuropathic and maladaptive pain--a report of the AMA Council on Science and Public Health

BACKGROUND

Because of disparate taxonomic arrays for classification, the American Academy of Pain Medicine has proposed categorizing pain on a neurobiologic basis as eudynia (nociceptive pain), Greek for "good pain," or maldynia (maladaptive pain), Greek for "bad pain." The latter has been viewed as maladaptive because it may occur in the absence of ongoing noxious stimuli and does not promote healing and repair.

OBJECTIVE

To address recent findings on the pathogenesis of pain following neural injury and consider whether the development of maladaptive pain justifies its classification as a disease and to briefly discuss the scope of pharmacologic and non-pharmacologic approaches employed in patients with such pain.

METHODS

English language reports on studies using human subjects were selected from a PubMed search of the literature from 1995 to August 2010 and from the Cochrane Library. Further information was obtained from Internet sites of medical specialty and other societies devoted to pain management.

RESULTS

Neural damage to either the peripheral or central nervous system provokes multiple processes including peripheral and central sensitization, ectopic activity, neuronal cell death, disinhibition, altered gene expression, and abnormal sprouting and cellular connectivity. A series of neuro-immune interactions underlie many of these mechanisms. Imaging studies have shown that such damage is characterized by functional, structural, and chemical changes in the brain. Such pain is maladaptive in the sense that it occurs in the absence of ongoing noxious stimuli and does not promote healing and repair.

CONCLUSION

As defined, maldynia is a multidimensional process that may warrant consideration as a chronic disease not only affecting sensory and emotional processing but also producing an altered brain state based on both functional imaging and macroscopic measurements. However, the absolute clinical value of this definition is not established.

The H-Wave((R)) Device Induces NODependent Augmented Microcirculation and Angiogenesis, Providing Both Analgesia and Tissue Healing in Sports Injuries

The hypothesis that the H-Wave(R) device (Electronic Waveform Lab, Inc., Huntington Beach, CA), a small-diameter fiber stimulator, is a paradigm shift of electrotherapeutic treatment of pain associated with human neuropathies and sports injuries is based on a number of its properties. The primary effect of H-Wave(R) device stimulation (HWDS) is the stimulation of "red-slow-twitch" skeletal muscle fibers. The authors propose, based on the unique waveform, that the H-Wave(R) device specifically and directly stimulates the small smooth muscle fibers within the lymphatic vessels ultimately leading to fluid shifts and reduced edema. In unpublished rat studies, it has been observed that HWDS induces protein clearance. The H-Wave(R) device was designed to stimulate an ultra low frequency (1-2 Hz), low tension, nontetanizing, and nonfatiguing contraction, which closely mimics voluntary or natural muscle contractions. The H-Wave(R) device can stimulate small fibers due in part to its exponentially decaying waveform and constant current generator activity. The main advantage of these technologies over currently applied electrical stimulators (eg, transcutaneous electrical nerve stimulator [TENS], interferential [IF], neuromuscular electrical stimulation [NMES], high-volt galvanic, etc.) is that H-Wave\'s(R) small fiber contraction does not trigger an activation of the motor nerves of the large white muscle fibers or the sensory delta and C pain nerve fibers, thus eliminating the negative and painful effects of tetanizing fatigue, which reduces transcapillary fluid shifts. Another function of the H-Wave(R) device is an anesthetic effect on pain conditions, unlike a TENS unit which in the short term activates a hypersensory overload effect (gate theory) to stop pain signals from reaching the thalamic region of the brain. When the H-Wave(R) device is used at high frequency (60 Hz), it acts intrinsically on the nerve to deactivate the sodium pump within the nerve fiber, leading to a long-lasting anesthetic/analgesic effect due to an accumulative postsynaptic depression. Moreover, HWDS produces a nitric oxide (NO)-dependent enhancement of microcirculation and angiogenesis in rats. Thus, the authors hypothesize that because of these innate properties of the H-Wave(R) device, it may provide a paradigm shift for the treatment of both short- and long-term inflammatory conditions associated with pain due to sports injuries. A recent meta-analysis found a moderate-to-strong effect of the H-Wave(R) device in providing pain relief, reducing the requirement for pain medication, and increasing functionality. The most robust effect was observed for improved functionality, suggesting that the H-Wave(R) device may facilitate a quicker return to the field.

KEYWORDS

H-Wave(R) device; sportsmedicine, nitric oxide-dependent blood flow; analgesia; angiogenesis.

Using evidence in pain practice: Part II: Interpreting and applying systematic reviews and clinical practice guidelines

Systematic reviews and clinical practice guidelines are useful tools for bringing evidence into pain practice. However, even when their conclusions or recommendations appear valid, interpreting and applying systematic reviews and clinical practice guidelines in everyday practice is not always straightforward. Judging external validity or applicability of findings requires careful consideration of factors related to patient selection, clinical setting, feasibility, costs, and availability of interventions. Clinicians should also consider whether effects on clinically relevant outcomes are large enough to warrant use of the intervention in question. Other challenges to using systematic reviews and clinical practice guidelines in pain practice include the need to make decisions about pain interventions when evidence is weak or inconclusive, and the increasing and confusing presence of discordant systematic reviews and clinical practice guidelines. This article discusses how to evaluate applicability and clinical relevance of systematic reviews and clinical practice guidelines, and provides a framework for approaching clinical decisions when evidence is weak or conflicting.

Current management of pain associated with multiple sclerosis

While pain is a common problem in patients with multiple sclerosis (MS), it is not frequently mentioned by patients and a more direct approach is required in order to obtain information about pain from patients. Many patients with MS experience more than one pain syndrome; combinations of dysaesthesia, headaches and/or back or muscle and joint pain are frequent. For each pain syndrome a clear diagnosis and therapeutic concept needs to be established. Pain in MS can be classified into four diagnostically and therapeutically relevant categories: (i) neuropathic pain due to MS (pain directly related to MS); (ii) pain indirectly related to MS; (iii) MS treatment-related pain; and (iv) pain unrelated to MS. Painful paroxysmal symptoms such as trigeminal neuralgia (TN), or painful tonic spasms are treated with antiepileptics as first choice, e.g. carbamazepine, oxcarbazepine, lamotrigine, gabapentin, pregabalin, etc. Painful 'burning' dysaesthesias, the most frequent chronic pain syndrome, are treated with TCAs such as amitriptyline, or antiepileptics such as gabapentin, pregabalin, lamotrigine, etc. Combinations of drugs with different modes of action can be particularly useful for reducing adverse effects. While escalation therapy may require opioids, there are encouraging results from studies regarding cannabinoids, but their future role in the treatment of MS-related pain has still to be determined. Pain related to spasticity often improves with adequate physiotherapy. Drug treatment includes antispastic agents such as baclofen or tizanidine and in patients with phasic spasticity, gabapentin or levetiracetam are administered. In patients with severe spasticity, botulinum toxin injections or intrathecal baclofen merit consideration. While physiotherapy may ameliorate malposition-induced joint and muscle pain, additional drug treatment with paracetamol (acetaminophen) or NSAIDs may be useful. Moreover, painful pressure lesions should be avoided by using optimally adjusted aids. Treatment-related pain associated with MS can occur with subcutaneous injections of interferon-beta or glatiramer acetate, and may be reduced by optimizing the injection technique and by local cooling. Systemic (particularly 'flu-like') adverse effects of interferons, e.g. myalgias, can be reduced by administering paracetamol, ibuprofen or naproxen. A potential increase in the frequency of pre-existing headaches after starting treatment with interferons may require optimization of headache attack therapy or even prophylactic treatment. Pain unrelated to MS, such as back pain or headache, is common in patients with MS and may deteriorate as a result of the disease. In summary, a careful analysis of each pain syndrome will allow the design of the appropriate treatment plan using various medical and nonmedical options (multimodal therapy), and will thus help to improve the quality of life (QOL) of the patients.

Thermal rehabilitation and osteoarticular diseases of the elderly

Elderly people with osteoarticular disease (OAD) traditionally visit spas for cycles of treatment comprising mud therapy and balneotherapy. We believe that the thermal environment is a suitable place for providing rehabilitative and preventive treatment both in association with traditional spa therapy and as the sole means of treatment. The aim of this paper is to describe the advantages and possible developments of these integrated approaches to OAD in the elderly.

Sequentially allocated clinical trial of rhythmic stabilization exercises and TENS in women with chronic low back pain

Objective: To examine the effectiveness of rhythmic stabilization exercises and transcutaneous electrical nerve stimulation (TENS) and their combination in treating women with chronic low back pain.

Design: Sequentially allocated, single-blinded and controlled study, with a two-month follow-up.

Setting: The data were collected in a patient rehabilitation setting.

Subjects: A total of 92 women (34—46 years old) with chronic low back pain were studied.

Interventions: Sequential allocation was undertaken into four groups: `rhythmic stabilization' (n=23), `rhythmic stabilization — TENS' (n=23), TENS (n=23), and a placebo group (n = 23). Each programme lasted for four weeks. All outcome measures were assessed prior to, immediately after, four weeks and eight weeks post intervention.

Main measures: Data were obtained on functional disability, pain intensity, trunk extension range of motion, dynamic endurance of trunk flexion and static endurance of trunk extension.

Results: A total of 88 patients provided two-month follow-up data. The `rhythmic stabilization' and the `rhythmic stabilization — TENS' groups displayed statistically significant (P<0.05) improvements in functional disability and pain intensity (ranging from 21.2 to 42.8%), trunk extension range of motion (ranging from 6.5 to 25.5%), dynamic endurance of trunk flexion and static endurance of trunk extension (ranging from 13.5 to 74.3%) compared with the remaining groups.

Conclusions: The rhythmic stabilization programmes resulted in more gains in women with chronic low back pain regarding the present outcome variables compared with the other groups; therefore, its application in female chronic low back pain patients aged 34—46 years is recommended.

Effect sizes of non-surgical treatments of non-specific low-back pain

Numerous randomized trials have been published investigating the effectiveness of treatments for non-specific low-back pain (LBP) either by trials comparing interventions with a no-treatment group or comparing different interventions. In trials comparing two interventions, often no differences are found and it raises questions about the basic benefit of each treatment. To estimate the effect sizes of treatments for non-specific LBP compared to no-treatment comparison groups, we searched for randomized controlled trials from systematic reviews of treatment of non-specific LBP in the latest issue of the Cochrane Library, issue 2, 2005 and available databases until December 2005. Extracted data were effect sizes estimated as Standardized Mean Differences (SMD) and Relative Risk (RR) or data enabling calculation of effect sizes. For acute LBP, the effect size of non-steroidal anti-inflammatory drugs (NSAIDs) and manipulation were only modest (ES: 0.51 and 0.40, respectively) and there was no effect of exercise (ES: 0.07). For chronic LBP, acupuncture, behavioral therapy, exercise therapy, and NSAIDs had the largest effect sizes (SMD: 0.61, 0.57, and 0.52, and RR: 0.61, respectively), all with only a modest effect. Transcutaneous electric nerve stimulation and manipulation had small effect sizes (SMD: 0.22 and 0.35, respectively). As a conclusion, the effect of treatments for LBP is only small to moderate. Therefore, there is a dire need for developing more effective interventions.

Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: a meta-analysis of randomized controlled trials

Previous studies and meta-analyses of the efficacy of electrical nerve stimulation (ENS) for the treatment of chronic pain of multiple etiologies have produced mixed results. The objective of the present study was to determine whether ENS is an effective treatment for chronic musculoskeletal pain by using statistical techniques that permit accumulation of a sample size with adequate power. Randomized, controlled trials published between January 1976 and November 2006 were obtained from the National Libraries of Medicine, EMBASE, and the Cochrane Library. Prospective, placebo-controlled studies using any modality of ENS to treat chronic musculoskeletal pain in any anatomical location were included. The main outcome measure was pain at rest. The use of statistical methods to enhance data extraction and a random-effects meta-analysis to accommodate heterogeneity of ENS therapies permitted an adequate number of well designed trials of ENS to be included in the meta-analysis. A total of 38 studies in 29 papers, which included 335 placebo, 474 ENS, and 418 cross-over (both placebo and at least one ENS treatment) patients, met the selection criteria. The overall results showed a significant decrease in pain with ENS therapy using a random-effects model (p<0.0005). These results indicate that ENS is an effective treatment modality for chronic musculoskeletal pain and that previous, equivocal results may have been due to underpowered studies.

Management of musculoskeletal pain

Chronic musculoskeletal pain is a major public health problem affecting about one third of the adult population. Pain is often present without any specific findings in the musculoskeletal system and a strictly biomedical approach could be inadequate. A biopsychosocial model could give a better understanding of symptoms and new targets for management. Identification of risk factors for chronicity is important for prevention and early intervention. The cornerstones in management of chronic non-specific, and often widespread, musculoskeletal pain are non-pharmacological. Physical exercise and cognitive behavioral therapy, ideally in combination, are first line treatments in e.g. chronic low back pain and fibromyalgia. Analgesics are useful when there is a specific nociceptive component, but are often of limited usefulness in non-specific or chronic widespread pain (including fibromyalgia). Antidepressants and anticonvulsants could be of value in some patients but there is a need for more knowledge in order to give general recommendations.