Electrotherapy for neck disorders

Comparative effectiveness of electroacupuncture VS neuromuscular electrical stimulation in the treatment of chronic low back pain in active-duty personals: A single-center, randomized control study

Introduction

Low back pain (LBP) is the most prevalent form of chronic pain in active-duty military personnel worldwide. Electroacupuncture (EA) and neuromuscular electrical stimulation (NMES) are the two most widely used treatment methods in the military, while evidence for their benefits is lacking. The aim of this randomized clinical trial is to investigate the effectiveness of EA vs. NMES in reducing pain intensity among active-duty navy personals with chronic LBP.

Methods

The study is designed as a single-center, randomized controlled trial. The primary outcome is a positive categorical response for treatment success in the first-time follow-up, which is predesignated as a two-point or greater decrease in the NRS score and combined with a score > 3 on the treatment satisfaction scale. The secondary outcomes include pain intensity, rate of treatment success, and Oswestry Disability Index (ODI) fear-avoidance beliefs questionnaire (FABQ) score along with muscular performance. The first follow-up starts on the first day after completing the last treatment session, and then the 4-weeks and 12-weeks follow-up are applied via telephone visit.

Results

Eighty-five subjects complete the treatment diagram and are included in the analysis. For the primary outcome, no difference has been found between EA and NMES, with 65.1% (28 in 43) individuals reporting a positive response to EA treatment, while 53.5% (23 in 43) in NMES. However, for longer follow-ups, superiority in positive response of EA has been found in 4-weeks (26 in 39, 66.7% vs. 16 in 40, 40%; P = 0.018) and 12-weeks (24 in 36, 66.7% vs. 12 in 36, 33.3%; P = 0.005) follow-up. In the regression analysis, baseline pain intensity and FABQ score are identified to be highly associated with positive treatment outcomes. Finally, the subgroup analysis suggests that EA treatment is associated with better long-term outcomes in patients with LBP with a severe pain score (NRS score >4, Figure 4B) and stronger fear-avoidance beliefs.

Conclusion

Both the EA and NMES are associated with a positive response in treating military LBP, and the former offers lasting benefits in the later follow-ups. Thus, electroacupuncture is a more recommended treatment for military LBP. A lot of research is needed to verify an efficient and standardized treatment session, with more information and evidence about indications for these treatments.

Trial registration

ChiCTR, (ChiCTR2100043726); registered February 27, 2021.

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.

Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults

BACKGROUND

This is the first update of a Cochrane review published in Issue 5, 2010 on transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Pain may present in a body part that has been amputated (phantom pain) or at the site of amputation (stump pain), or both. Phantom pain and stump pain are complex and multidimensional and the underlying pathophysiology remains unclear. The condition remains a severe burden for those who are affected by it. The mainstay treatments are predominately pharmacological, with increasing acknowledgement of the need for non-drug interventions. TENS has been recommended as a treatment option but there has been no systematic review of available evidence. Hence, the effectiveness of TENS for phantom pain and stump pain is currently unknown.

OBJECTIVES

To assess the analgesic effectiveness of TENS for the treatment of phantom pain and stump pain following amputation in adults.

SEARCH METHODS

For the original version of the review we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, AMED, CINAHL, PEDRO and SPORTDiscus (February 2010). For this update, we searched the same databases for relevant randomised controlled trials (RCTs) from 2010 to 25 March 2015.

SELECTION CRITERIA

We only included RCTs investigating the use of TENS for the management of phantom pain and stump pain following an amputation in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We planned that where available and appropriate, data from outcome measures were to be pooled and presented as an overall estimate of the effectiveness of TENS.

MAIN RESULTS

In the original review there were no RCTs that examined the effectiveness of TENS for the treatment of phantom pain and stump pain in adults. For this update, we did not identify any additional RCTs for inclusion.

AUTHORS' CONCLUSIONS

There were no RCTs to judge the effectiveness of TENS for the management of phantom pain and stump pain. The published literature on TENS for phantom pain and stump pain lacks the methodological rigour and robust reporting needed to confidently assess its effectiveness. Further RCT evidence is required before an assessment can be made. Since publication of the original version of this review, we have found no new studies and our conclusions remain unchanged.

Therapy recommendation "act as usual" in patients with whiplash injuries QTF I°

Up to now no therapy study has used the classification system of the Quebec Task Force (QTF) to differentiate between patients with (QTF II°) and without functional disorders (QTF I°). This differentiation seems meaningful, as this difference may be relevant for the correct treatment planning. In this context the effect of the therapy recommendation “act as usual” has been evaluated in a homogeneous patient collective with whiplash injuries QTF I°.

470 patients with acute whiplash injuries had been catched in this study and classified according to the QTF. 359 patients (76.4%) with QTF I° injuries could be identified. Out of that 162 patients were enrolled to the study and received the therapy recommendation “act as usual” and the adapted pain treatment with non-steroidal anti-inflammatory drugs (NSAID). After six months the outcome was evaluated by phone.

After injury the median pain score assessed by a visual analogue scale (VAS) was 5.4 (min = 3.3; max = 8.5). After six months 5 of the 162 patients complained intermittent pain symptoms (VAS values < 2). This is consistent with a chronification rate of 3.1%. After injury, the median pain disability index (PDI) was 3.9 (min = 1.9; max = 7.7). After six months 3 of the 162 patients stated persisting disability during sporting and physical activities (VAS values < 1).

The therapy recommendation “act as usual” in combination with an adapted pain treatment is sufficient. Usually patients with whiplash injuries QTF I° do not need physical therapy. An escalation of therapy measures should be reserved to patients with complicated healing processes.

Factors affecting myofascial pain pattern recognition in musculoskeletal therapists: an exploratory study

Aims:

To evaluate the ability of experienced musculoskeletal physiotherapists to recall and identify myofascial trigger point (MTrP) pain referral patterns associated with the cervical spine, and to determine the factors affecting myofascial pain pattern recognition in experienced musculoskeletal physiotherapists.

Methodology:

A questionnaire-based descriptive survey using mixed methods was employed. A specially constructed questionnaire was used in the study. Responses were subjected to descriptive, statistical, and thematic analysis.

Results:

Twenty-five experienced musculoskeletal (MSK) physiotherapists (mean qualification period=10.3 years, mean specialist MSK experience=7.52 years) took part in the study. 100% completed the questionnaire. The MTrP pattern recognition rate was 23.33%. Thematic analysis of the qualitative data revealed a number of factors that may help to explain this low rate within the study sample.

Conclusions:

This exploratory study highlights deficiencies in the ability of experienced musculoskeletal physiotherapists to recall and identify MTrP pain referral patterns associated with the cervical spine. Several factors were identified that may have contributed to the observed deficiencies in this area including: lack of education, knowledge and experience, difficulty with clinical recall, and notions surrounding clinical relevance.

Repeated Applications of Thoracic Spine Thrust Manipulation do not Lead to Tolerance in Patients Presenting with Acute Mechanical Neck Pain: A Secondary Analysis

It has been demonstrated that patients receiving mobilization techniques do not exhibit tolerance to repeated applications. However, this phenomenon has not been investigated for thoracic manipulation. Our aim was to determine if patients receiving thoracic thrust manipulation exhibit tolerance to repeated applications in acute mechanical neck pain. Forty-five patients were randomly assigned to two groups. The control group received electro- and thermotherapy for 5 sessions, and the experimental group received the same program and also received a thoracic thrust manipulation once a week for 3 consecutive weeks. Outcome measures included neck pain and cervical mobility. Within-session change scores for pain and mobility during treatment sessions #1, 3, and 5 were examined with a one-way repeated measured ANOVA. A 2-way ANOVA with session as within-subject variable and group as between-subject variable was used to compare change scores for each visit between groups to ascertain if there were significant between-group differences in within-session changes for the experimental versus the control group. The ANOVA showed that for either group the 3 within-session change scores were not significantly different (P > 0.1). The 2-way ANOVA revealed significant differences between groups for both pain and neck mobility in within-session change scores (all, P < 0.001). Change scores in each session were superior in the experimental group as compared to those in the control group. The results suggest that patients receiving thoracic manipulation do not exhibit tolerance to repeated applications with regard to pain and mobility measures in acute mechanical neck pain. Further studies should investigate the dose-response relationship of thoracic thrust manipulation in this population.

Conservative treatment for neck pain: medications, physical therapy, and exercise

This article offers conservative treatment strategies for patients suffering from musculoskeletal causes of neck pain. Basic pharmacology is reviewed, including that of opioids, nonsteroidal anti-inflammatory drugs, adjuvants, and topical analgesics. Moreover, indications for therapeutic exercise, manual therapy, and modalities are reviewed, along with any supporting literature. Treatment considerations with each category of medication and physical therapy are discussed. This article is meant to serve as a resource for physicians to tailor conservative treatment options to their individual patients.

Prevalence, practice patterns, and evidence for chronic neck pain

OBJECTIVE

To estimate the prevalence of chronic neck pain in North Carolina, to describe health care use (providers, treatments, and diagnostic testing) for chronic neck pain, and to correlate health care use with the current best evidence.

METHODS

We used data from a cross-sectional telephone survey of a representative sample of North Carolina households in 2006. A total of 5,357 households were contacted in 2006 to identify 141 noninstitutionalized adults ages ≥21 years with chronic neck pain and no chronic low back pain. The subjects were interviewed about their health and health care use (i.e., provider, tests, and treatments). Patterns of health care use were compared with current systematic reviews.

RESULTS

The estimated prevalence of chronic neck pain in 2006 among noninstitutionalized individuals for the state of North Carolina was 2.2% (95% confidence interval [95% CI] 1.7-2.6). Individuals with chronic neck pain were middle-aged (mean age 48.9 years) and the majority of subjects were women (56%) and non-Hispanic white (81%). The subjects saw a mean of 5.21 (95% CI 4.8-5.6) provider types and had a mean of 21 visits. The types of treatments subjects reported varied, with treatments such as electrotherapy stimulation (30.3%), corsets or braces (20.9%), massage (28.1%), ultrasound (27.3%), heat (57.0%), and cold (47.4%) having unclear or little benefit based on the current best available reviews.

CONCLUSION

Based on the current evidence for best practice, our findings indicate overutilization of diagnostic testing, narcotics, and modalities, and underutilization of effective treatments such as therapeutic exercise.

Challenges and recommendations for placebo controls in randomized trials in physical and rehabilitation medicine: a report of the international placebo symposium working group

Compared with other specialties, the field of physical and rehabilitation medicine has not received the deserved recognition from clinicians and researchers in the scientific community. One of the reasons is the lack of sound evidence to support the traditional physical and rehabilitation medicine treatments. The best way to change this disadvantage is through a well conducted clinical research, such as standard placebo- or sham-controlled randomized clinical trials. Therefore, having placebo groups in clinical trials is essential to improve the level of evidence-based practice in physical and rehabilitation medicine that ultimately translates to better clinical care. To address the challenges for the use of placebo in physical and rehabilitation medicine and randomized clinical trials and to create useful recommendations, we convened a working group during the inaugural International Symposium in Placebo (February 2009, in Sao Paulo, Brazil) in which the following topics were discussed: (1) current status of randomized clinical trials in physical and rehabilitation medicine, (2) challenges for the use of placebo in physical and rehabilitation medicine, (3) bioethics, (4) use of placebo in acupuncture trials and for the treatment of low-back pain, (5) mechanisms of placebo, and (6) insights from other specialties. The current article represents the consensus report from the working group.

Associations between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practice

OBJECTIVE

To identify how treatment processes are related to functional outcomes for patients seeking treatment for musculoskeletal impairments while controlling for demographic and health characteristics at intake.

DESIGN

Prospective, observational cohort study. Treatment processes were not altered. Data were collected continuously from June 2005 to January 2008. Descriptive statistics were applied to compare patient characteristics, interventions, and outcomes between impairment categories. Ordinary least-squares multiple regressions were used to examine associations between patient characteristics at intake, treatment processes, and functional outcomes.

SETTING

Fifty-four community-based outpatient physical therapy clinics of Maccabi Healthcare Services, a public health plan in Israel.

PARTICIPANTS

A consecutive sample of 22,019 adult patients (mean age 51.2 y, standard deviation=15.7, range 18-96, 58% women) seeking treatment due to lumbar spine, knee, cervical spine, or shoulder impairments with functional measurements at intake and discharge.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Functional status at discharge.

RESULTS

Explanatory power ranged from 30% to 39%. Better outcomes were associated with patient compliance with self-exercise and therapy attendance, application of therapeutic exercise and manual therapy, and completion of 3 or more functional surveys during the episode of care. Worse outcomes were associated with women, electrotherapy for pain management, and therapeutic ultrasound for shoulder impairments. Mixed results were found for group exercise programs.

CONCLUSIONS

The study of associations between treatment processes, patient characteristics, and outcomes helps to describe practice and can be used to suggest ways to improve outcomes in outpatient physical therapy practice.

A cochrane systematic review of transcutaneous electrical nerve stimulation for cancer pain

Cancer-related pain is complex and multi-dimensional; yet, the mainstay of cancer pain management has been the biomedical approach. There is a need for nonpharmacological and innovative pain management strategies. Transcutaneous electrical nerve stimulation (TENS) may have a role. The aim of this systematic review was to determine the effectiveness of TENS for cancer-related pain in adults. The Cochrane Library, MEDLINE, EMBASE, CINAHL, PsychINFO, AMED, and PEDro databases were searched for randomized controlled trials (RCTs) investigating the use of TENS for the management of cancer-related pain in adults. Once relevant studies were identified, two pairs of reviewers assessed eligibility for inclusion in the review based on a study eligibility form and using the 5-point Oxford Quality Scale. Two RCTs met the study eligibility criteria (these involved 64 patients). These studies were heterogeneous with respect to study population, methodology, and outcome measures. This prevented meta-analysis. In one RCT, there were no significant differences between TENS and placebo in women with chronic pain secondary to breast cancer treatment. In the other RCT, there were no significant differences between acupuncture-like TENS (AL-TENS) and sham in palliative care patients; this study was significantly underpowered. There is insufficient available evidence to determine the effectiveness of TENS in treating cancer-related pain. Further research is needed to help guide clinical practice, and large multi-center RCTs are required to assess the value of TENS in the management of cancer-related pain in adults.

Research priorities for non-pharmacological therapies for common musculoskeletal problems: nationally and internationally agreed recommendations

BACKGROUND

Musculoskeletal problems such as low back pain, neck, knee and shoulder pain are leading causes of disability and activity limitation in adults and are most frequently managed within primary care. There is a clear trend towards large, high quality trials testing the effectiveness of common non-pharmacological interventions for these conditions showing, at best, small to moderate benefits. This paper summarises the main lessons learnt from recent trials of the effectiveness of non-pharmacological therapies for common musculoskeletal conditions in primary care and provides agreed research priorities for future clinical trials.

METHODS

Consensus development using nominal group techniques through national (UK) and international workshops. During a national Clinical Trials Thinktank workshop in April 2007 in the UK, a group of 30 senior researchers experienced in clinical trials for musculoskeletal conditions and 2 patient representatives debated the possible explanations for the findings of recent high quality trials of non-pharmacological interventions. Using the qualitative method of nominal group technique, these experts developed and ranked a set of priorities for future research, guided by the evidence from recent trials of treatments for common musculoskeletal problems. The recommendations from the national workshop were presented and further ranked at an international symposium (hosted in Canada) in June 2007.

RESULTS

22 recommended research priorities were developed, of which 12 reached consensus as priorities for future research from the UK workshop. The 12 recommendations were reduced to 7 agreed priorities at the international symposium. These were: to increase the focus on implementation (research into practice); to develop national musculoskeletal research networks in which large trials can be sited and smaller trials supported; to use more innovative trial designs such as those based on stepped care and subgrouping for targeted treatment models; to routinely incorporate health economic analysis into future trials; to include more patient-centred outcome measures; to develop a core set of outcomes for new trials of interventions for musculoskeletal problems; and to focus on studies that advance methodological approaches for clinical trials in this field.

CONCLUSION

A set of research priorities for future trials of non-pharmacological therapies for common musculoskeletal conditions has been developed and agreed through national (UK) and international consensus processes. These priorities provide useful direction for researchers and research funders alike and impetus for improvement in the quality and methodology of clinical trials in this field.

The effectiveness of ENAR for the treatment of chronic neck pain in Australian adults: a preliminary single-blind, randomised controlled trial

BACKGROUND

Current evidence on electrotherapies for the management of chronic neck pain is either lacking or conflicting. New therapeutic devices being introduced to the market should be investigated for their effectiveness and efficacy. The ENAR (Electro Neuro Adaptive Regulator) therapy device combines Western biofeedback with Eastern energy medicine.

METHODS

A small, preliminary randomised and controlled single-blinded trial was conducted on 24 participants (ten males, 14 females) between the ages of 18 to 50 years (median age of 40.5) Consent was obtained and participants were randomly allocated to one of three groups--ENAR, Transcutaneous Electrical Nerve Stimulation (TENS), or control therapy--to test the hypothesis that ENAR therapy would result in superior pain reduction/disability and improvements in neck function compared with TENS or control intervention. The treatment regimen included twelve 15-minute treatment sessions over a six week period, followed by two assessment periods. Visual Analogue Scale (VAS) pain scores, Neck Disability Index (NDI) scores, Patient Specific Functional Scale (PSFS) scores and Short Form 36v1 (SF-36) quality of life scores reported by participants were collected at each of the assessments points throughout the trial (0, 6, 12, 18 and 24 weeks).

RESULTS

Eligible participants (n = 30) were recruited and attended clinic visits for 6 months from the time of randomisation. Final trial sample (n = 24) comprised 9 within the ENAR group, 7 within the TENS group and 8 within the control group. With an overall study power of 0.92, the ENAR group showed a decrease in mean pain score from measurement at time zero (5.0 +/- 0.79 95%CI) to the first follow-up measurement at six weeks (1.4 +/- 0.83 95%CI). Improvement was maintained until week 24 (1.75 +/- 0.9 95%CI). The TENS and control groups showed consistent pain levels throughout the trial (3.4 +/- 0.96 95%CI and 4.1 +/- 0.9 95%CI respectively). Wald analysis for pain intensity was significant for the ENAR group (p = 0.01). Six month NDI scores showed the disability level of the ENAR group (11.3 +/- 4.5 95%CI) was approximately half that of either the TENS (22.9 +/- 4.8 95%CI) or the control (29.4 +/- 4.5 95%CI) groups. NDI analysis using the Wald method, indicated significant reductions in disability only for the ENAR group (p = 0.022). PSFS results also demonstrated significantly better performance of ENAR (p = 0.001) compared to both alternative interventions. Differential means analysis of the SF-36 results favoured ENAR for all of the subscales. Six of the initial 30 participants discontinued the trial protocol.

CONCLUSION

ENAR therapy participants reported a significant reduction in the intensity of neck pain (VAS) and disability (NDI), as well as a significant increased function (PSFS) and overall quality of life (SF-36) than TENS or control intervention participants. Due to the modest sample size and restricted cohort characteristics, future larger and more comprehensive trials are required to better evaluate the potential efficacy of the ENAR device in a more widely distributed sample population.

TRIAL REGISTRATION

This study has been registered with the Australian Clinical Trials Registry (ACTR): ACTRN012606000438550.

Strategies for prevention and management of musculoskeletal conditions. Neck pain

The aim of this article was to summarise the existing evidence concerning interventions for non-specific neck pain. Neck-and-shoulder pain is commonly experienced by both adolescents and adults. Although the prevalence appears to vary among different nations, the situation is essentially the same, at least in the industrialised nations. Explanations for the wide variation in incidence and prevalence include various methodological issues. Back and neck disorders represent one of the most common causes for both short- and long-term sick leave and disability pension. Evidenced risk factors for the onset and maintenance of non-specific neck and back pain include both individual and work-related psychosocial factors. Based on the existing evidence different forms of exercise can be strongly recommended for at-risk populations, as well as for the acute and chronic non-specific neck pain patient. Furthermore, for symptom relief this condition can be treated with transcutaneous electric nerve stimulation, low level laser therapy, pulse electromagnetic treatment or radiofrequency denervation.

Repetitive strain injury

Repetitive strain injury remains a controversial topic. The term repetitive strain injury includes specific disorders such as carpal tunnel syndrome, cubital tunnel syndrome, Guyon canal syndrome, lateral epicondylitis, and tendonitis of the wrist or hand. The diagnosis is usually made on the basis of history and clinical examination. Large high-quality studies using newer imaging techniques, such as MRI and ultrasonography are few. Consequently, the role of such imaging in diagnosis of upper limb disorders remains unclear. In many cases, no specific diagnosis can be established and complaints are labelled as non-specific. Little is known about the effectiveness of treatment options for upper limb disorders. Strong evidence for any intervention is scarce and the effect, if any, is mainly short-term pain relief. Exercise is beneficial for non-specific upper limb disorders. Immobilising hand braces and open carpal tunnel surgery release are beneficial for carpal tunnel syndrome, and topical and oral non-steroidal anti-inflammatory drugs, and corticosteroid injections are helpful for lateral epicondylitis. Exercise is probably beneficial for neck pain, as are corticosteroid injections and exercise for shoulder pain. Although upper limb disorders occur frequently in the working population, most trials have not exclusively included a working population or assessed effects on work-related outcomes. Further high-quality trials should aim to include sufficient sample sizes, working populations, and work-related outcomes.

The role of physiotherapy in the management of non-specific back pain and neck pain

This paper provides an overview of best practice for the role of physiotherapy in managing back pain and neck pain, based mainly on evidence-based guidelines and systematic reviews. More up-to-date relevant primary research is also highlighted. A stepped approach is recommended in which the physiotherapist initially takes a history and carries out a physical examination to exclude any potentially serious pathology and identify any particular functional deficits. Initially, advice providing simple messages of explanation and reassurance will form the basis of a patient education package. Self-management is emphasized throughout. A return to normal activities is encouraged. For the patient who is not recovering after a few weeks, a short course of physiotherapy may be offered. This should be based on an active management approach, such as exercise therapy. Manual therapy should also be considered. Any passive treatment should only be used if required to relieve pain and assist in helping patients get moving. Barriers to recovery need to be explored. Those few patients who have persistent pain and disability that interferes with their daily lives and work need more intensive treatment or a different approach. A multidisciplinary approach may then be optimal, although it is not widely available. Liaison with the workplace and/or social services may be important. Getting all players on side is crucial, especially at this stage.