Transcutaneous electrical nerve stimulation for the control of pain during rehabilitation after total knee arthroplasty: A randomized, blinded, placebo-controlled trial

Effect of Transcutaneous Electrical Nerve Stimulation on Patients with Total Knee Replacement: A Randomized Controlled Trial

PURPOSE

The aim of this study was to determine the effect of transcutaneous electrical nerve stimulation (TENS) on pain, functionality, quality of life, and analgesic consumption in patients undergoing TKR.

DESIGN

A single center, randomized controlled trial.

METHODS

A total of 52 participants were randomly assigned to the intervention (n = 26) and control (n = 26) groups. The intervention group was exposed to conventional TENS. Data were collected with a Patient Identification Form, the Visual Analogue Scale (VAS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Quality of Life Scale (SF-36), and the Analgesic Tracking Form.

RESULTS

VAS and WOMAC scores significantly decreased in the intervention group, over time, while they increased in the control group. SF-36 scores significantly increased in the intervention group over time. It was determined that analgesic consumption was significantly lower in the intervention group than in the control group.

CONCLUSIONS

TENS significantly reduced pain and increased functionality and quality of life. Our findings suggest that TENS may be an effective adjunctive analgesic therapy in patients receiving TKR; however, more testing is needed in larger and more heterogeneous populations.

CLINICAL IMPLICATIONS

Nurses can provide effective postoperative pain control in patients undergoing TKR, increase functionality, accelerate the healing process, and improve their quality of life by using TENS, a non-pharmacological treatment method, in the perioperative period.

Transcutaneous Electrical Nerve Stimulation Integrated into Pants for the Relief of Postoperative Pain in Hip Surgery Patients: A Randomized Trial

Background

The effect of transcutaneous electrical nerve stimulation (TENS) on pain and impression of change was assessed during a 2.5-hour intervention on the first postoperative days following hip surgery in a randomized, single-blinded, placebo-controlled trial involving 30 patients.

Methods

Mixed-frequency TENS (2 Hz/80 Hz) was administered using specially designed pants integrating modular textile electrodes to facilitate stimulation both at rest and during activity. The treatment outcome was assessed by self-reported pain Numerical Rating Scale (NRS) and Patient Global Impression of Change (PGIC) scores at four time points. The ability to perform a 3-meter walk test and the use of analgesics were also evaluated. Group comparison and repeated-measure analysis were carried out using nonparametric statistics.

Results

The active TENS group exhibited significantly higher PGIC scores after 30 minutes, which persisted throughout the intervention (all p ≤ 0.001). A reduction in NRS appeared after one hour of active TENS, persisting throughout the intervention (all p ≤ 0.05). The median group differences in pain ratings were greater than the minimum clinically important difference, and the analysis of pain trajectories confirmed clinical significance at the individual level. Moreover, patients in the active TENS group were more likely able to perform a 3-meter walk test by the end of the intervention (p = 0.04). Analysis of the opioid-sparing effect of TENS was inconclusive (p = 0.066). No postoperative surgical complications or TENS-related side effects were observed during the study.

Conclusion

Mixed-frequency TENS integrated in pants could potentially be an interesting addition to the arsenal of treatments for multimodal analgesia following hip surgery. This trial is registered with NCT05678101.

Efficacy and safety of tonic motor activation (TOMAC) for medication-refractory restless legs syndrome: a randomized clinical trial

STUDY OBJECTIVES

The purpose of this study was to evaluate the efficacy and safety/tolerability of bilateral high-frequency tonic motor activation (TOMAC) in patients with medication-refractory restless legs syndrome (RLS).

METHODS

RESTFUL was a multicenter, randomized, double-blind, sham-controlled trial in adults with medication-refractory moderate-to-severe primary RLS. Participants were randomized 1:1 to active or sham TOMAC for a double-blind, 4-week stage 1 and all received active TOMAC during open-label, 4-week stage 2. The primary endpoint was the Clinical Global Impressions-Improvement (CGI-I) responder rate at the end of stage 1. Key secondary endpoints included change to International RLS Study Group (IRLS) total score from study entry to the end of stage 1.

RESULTS

A total of 133 participants were enrolled. CGI-I responder rate at the end of stage 1 was significantly greater for the active versus sham group (45% vs. 16%; Difference = 28%; 95% CI 14% to 43%; p = .00011). At the end of stage 2, CGI-I responder rate further increased to 61% for the active group. IRLS change at the end of stage 1 improved for the active versus sham group (-7.2 vs. -3.8; difference = -3.4; 95% CI -1.4 to -5.4; p = .00093). There were no severe or serious device-related adverse events (AEs). The most common AEs were mild discomfort and mild administration site irritation which resolved rapidly and reduced in prevalence over time.

CONCLUSIONS

TOMAC was safe, well tolerated, and reduced symptoms of RLS in medication-refractory patients. TOMAC is a promising new treatment for this population.

CLINICAL TRIAL

Noninvasive Peripheral Nerve Stimulation for Medication-Refractory Primary RLS (The RESTFUL Study); clinicaltrials.gov/ct2/show/NCT04874155; Registered at ClinicalTrials.gov with the identifier number NCT04874155.

Improved Outcomes Following a Care Guideline Implementation: Part 1 of an Analysis of 12 355 Patients After Total Knee Arthroplasty

OBJECTIVE: To describe the application and examine the influence of a continuous quality improvement intervention, which had a goal of standardizing care to reduce the proportion of patients who do not have a meaningful improvement in patient-reported outcomes following total knee arthroplasty (TKA). DESIGN: Continuous quality improvement. METHODS: A physical therapy (PT) care guideline was initiated in 2013 for patients following TKA. The Knee Outcome Survey - Activities of Daily Living (KOS-ADL) was measured at every visit, and scores were extracted from a clinical outcomes database to calculate the proportion of patients who did not achieve a minimal clinically important difference. Based on logistic regression analysis, we compared the proportion of patients who did not progress on the KOS-ADL in a non-care guideline group (2008-2012) to a care guideline (CG) group (2014-2019). RESULTS: This study included 12 355 patients (aged 18-92 years) following TKA incurring at least 3 PT visits from 2008 to 2019. The percentage of patients who did not progress in the non-care guideline group was 25.8% and in the care guideline group 14.3% (P<0.001). The relationship between care guideline adherence and lack of progression on the KOS-ADL was statistically significant, X2 (df = 1) = 148.7, P<.001. CONCLUSION: The percentage of patients who did not achieve meaningful progress on the KOS-ADL declined significantly in the 6 years after implementing a TKA care guideline without an increase in the number of clinical visits. The standardized care guideline was associated with meaningful improvements for patients following TKA when applied in conjunction with PT access to outcome data, feedback through audits, performance goals, and financial incentives. J Orthop Sports Phys Ther 2023;53(3):143-150. Epub: 12 December 2022. doi:10.2519/jospt.2022.11369.

Optimizing and Accelerating the Development of Precision Pain Treatments for Chronic Pain: IMMPACT Review and Recommendations

Large variability in the individual response to even the most-efficacious pain treatments is observed clinically, which has led to calls for a more personalized, tailored approach to treating patients with pain (ie, "precision pain medicine"). Precision pain medicine, currently an aspirational goal, would consist of empirically based algorithms that determine the optimal treatments, or treatment combinations, for specific patients (ie, targeting the right treatment, in the right dose, to the right patient, at the right time). Answering this question of "what works for whom" will certainly improve the clinical care of patients with pain. It may also support the success of novel drug development in pain, making it easier to identify novel treatments that work for certain patients and more accurately identify the magnitude of the treatment effect for those subgroups. Significant preliminary work has been done in this area, and analgesic trials are beginning to utilize precision pain medicine approaches such as stratified allocation on the basis of prespecified patient phenotypes using assessment methodologies such as quantitative sensory testing. Current major challenges within the field include: 1) identifying optimal measurement approaches to assessing patient characteristics that are most robustly and consistently predictive of inter-patient variation in specific analgesic treatment outcomes, 2) designing clinical trials that can identify treatment-by-phenotype interactions, and 3) selecting the most promising therapeutics to be tested in this way. This review surveys the current state of precision pain medicine, with a focus on drug treatments (which have been most-studied in a precision pain medicine context). It further presents a set of evidence-based recommendations for accelerating the application of precision pain methods in chronic pain research. PERSPECTIVE: Given the considerable variability in treatment outcomes for chronic pain, progress in precision pain treatment is critical for the field. An array of phenotypes and mechanisms contribute to chronic pain; this review summarizes current knowledge regarding which treatments are most effective for patients with specific biopsychosocial characteristics.

Effectiveness of Physical Therapy in Orthognathic Surgery Patients: A Systematic Review of Randomized Controlled Trials

Orthognathic surgery (OS) can present many complications that affect patients' rehabilitation. However, there have been no systematic reviews that assessed the effectiveness of physiotherapy interventions in the postsurgical rehabilitation of OS patients. The aim of this systematic review was to analyze the effectiveness of physiotherapy after OS. The inclusion criteria were randomized clinical trials (RCTs) of patients who underwent OS and who received therapeutic interventions that included any physiotherapy modality. Temporomandibular joint disorders were excluded. After the filtering process, five RCTs were selected from the 1152 initially obtained (two had acceptable methodological quality; three had insufficient methodological quality). The results obtained showed that the effects of the physiotherapy interventions studied in this systematic review on the variables of range of motion, pain, edema and masticatory muscle strength were limited. Only laser therapy and LED showed a moderate level of evidence in the postoperative neurosensory rehabilitation of the inferior alveolar nerve compared with a placebo LED intervention.

Perioperative Management in the Collegiate Athlete: An Integrated Approach

Collegiate athletes face rigorous physical, academic, and emotional demands. While significant attention has been paid to injury prevention among young athletes in the past two decades, orthopedic injury rates remain high among collegiate athletes, and a significant number will undergo surgical management for injuries each year. In this narrative review, we describe techniques for perioperative management of pain and stress after surgery in collegiate athletes. In particular, we outline pharmacologic and non-pharmacologic management of surgical pain, with a goal of minimizing opiate consumption. We emphasize a multi-disciplinary approach to optimizing post-operative recovery in collegiate athletes help minimize reliance on opiate pain medication. Additionally, we recommend that institutional resources should be harnessed to support athletes in their well-being, from a nutritional, psychological and sleep standpoint. Critical to success in perioperative pain management is the communication among the athletic medicine team members and with the athlete and family to address pain and stress management and encourage timely, safe return to play.

Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience

Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from – unfortunately, there is no consensus on which treatments are “better” and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.

Perineural Methylprednisolone Depot Formulation Decreases Opioid Consumption After Total Knee Arthroplasty

Purpose

Opioid consumption after total knee arthroplasty (TKA) remains a challenge with single injection nerve blocks even with common local anesthetic adjuvants dexamethasone (DEX). This study aimed to investigate the effects of adding methylprednisolone acetate (MPA) to adductor canal blocks (ACB) and interspace between the popliteal artery and capsule of the posterior knee (iPACK) blocks on postoperative opioid consumption.

Methods

A retrospective analysis was conducted on 100 consecutive TKA patients equally assigned into two groups, with one group receiving DEX through ACB and iPACK block and the other group receiving DEX and methylprednisolone acetate (DEX/MPA) through the same nerve blocks. The primary outcome was cumulative opioid consumption (oral milligram morphine equivalent, OME) during hospitalization for up to three days. Secondary outcomes included daily opioid consumption, highest rest and active pain scores, prosthetic knee joint active range of motion (AROM), laboratory studies including fasting serum glucose (FSG) and white blood cell count (WBC) on each postoperative day (POD), and length of hospital stay.

Results

Cumulative opioid consumption was significantly lower in the DEX/MPA group vs DEX group (median difference (95% CI) = -45.3 (-80.5 to -10), P = 0.011). The highest rest and active pain scores were both significantly lower in the DEX/MPA group than in DEX group on POD 2 (least square mean difference (95% CI) = -1.3 (-2.3 to -0.4), P = 0.005 and -0.9 (-1.8 to -0.1), P = 0.031, respectively). Except on POD 1, FSG values were significantly lower in the DEX/MPA group (median difference (95% CI) = -22.5 (-36 to -8.9), P = 0.001). AROM, WBC, and length of stay were comparable between both groups.

Conclusion

Compared to perineural DEX alone, the addition of MPA further decreases postoperative opioid consumption without clinically significant changes on FSG and WBC.

Level of Evidence

III.

Characterising the Features of 381 Clinical Studies Evaluating Transcutaneous Electrical Nerve Stimulation (TENS) for Pain Relief: A Secondary Analysis of the Meta-TENS Study to Improve Future Research

Background and Objectives: Characterising the features of methodologies, clinical attributes and intervention protocols, of studies is valuable to advise directions for research and practice. This article reports the findings of a secondary analysis of the features from studies screened as part of a large systematic review of TENS (the meta-TENS study). Materials and Methods: A descriptive analysis was performed on information associated with methodology, sample populations and intervention protocols from 381 randomised controlled trials (24,532 participants) evaluating TENS delivered at a strong comfortable intensity at the painful site in adults with pain, irrespective of diagnosis. Results: Studies were conducted in 43 countries commonly using parallel group design (n = 334) and one comparator group (n = 231). Mean ± standard deviation (SD) study sample size (64.05 ± 58.29 participants) and TENS group size (27.67 ± 21.90 participants) were small, with only 13 of 381 studies having 100 participants or more in the TENS group. Most TENS interventions were ‘high frequency’ (>10 pps, n = 276) and using 100 Hz (109/353 reports that stated a pulse frequency value). Of 476 comparator groups, 54.2% were active treatments (i.e., analgesic medication(s), exercise, manual therapies and electrophysical agents). Of 202 placebo comparator groups, 155 used a TENS device that did not deliver currents. At least 216 of 383 study groups were able to access other treatments whilst receiving TENS. Only 136 out of 381 reports included a statement about adverse events. Conclusions: Clinical studies on TENS are dominated by small parallel group evaluations of high frequency TENS that are often contaminated by concurrent treatment(s). Study reports tended focus on physiological and clinical implications rather than the veracity of methodology and findings. Previously published criteria for designing and reporting TENS studies were neglected and this should be corrected in future research using insights gleaned from this analysis.

Transcutaneous Electric Nerve Stimulation Reduces Pathological Sensation of Mesh One Week after Open Inguinal Hernia Surgery: Follow-Up Results from a Randomized, Double Blind and Placebo-Controlled Trial

Background and Objectives: Quality of life (QoL) and chronic pain are important outcomes following hernia surgery. The long-term effects of Transcutaneous Electric Nerve Stimulation (TENS) on postoperative recovery are not well known. In this trial we investigated the role of TENS on QoL and on the incidence of chronic pain following inguinal hernia repair with mesh. Materials and Methods: A total of 80 male patients with elective primary unilateral hernia Lichtenstein repair were randomly allocated to receive TENS or a placebo-TENS procedure. The TENS group received conventional TENS twice a day on the first and second postoperative days. The intensity was set at 0–0.5 mA in the placebo-TENS group. General and hernia-specific QoL, as well as the incidence of chronic pain were assessed using SF-36v2 and the Carolinas comfort scale. Results: Less sensation of mesh was reported by the TENS group patients one week after surgery. At this time point, the mean sensation score was 6.07 ± 8.88 in the TENS group and 14.08 ± 16.67 in the placebo-TENS group (p = 0.029). Although at two days and one week postoperatively, TENS group patients tended to have less pain, less movement restrictions and better overall hernia-specific QoL, the differences were not statistically significant. At 6 months postoperatively, no incidence of chronic pain was found in either the placebo-TENS or TENS group. Conclusions: Conventional TENS applied in the early postoperative period following inguinal hernia repair with mesh was found to reduce mesh-related foreign body sensation one week after surgery. Promising results were also found for other QoL domains.

Profiles of Risk and Resilience in Chronic Pain: Loneliness, Social Support, Mindfulness, and Optimism Coming out of the First Pandemic Year

Objective

Individuals experience chronic pain differently, not only because of different clinical diagnoses, but also because of differing degrees of influence from biopsychosocial pain modulators. We aimed to cluster patients with chronic pain into distinct subgroups based on psychosocial characteristics and pain intensity, and we subsequently examined group differences in pain-related interference approximately 1 year later.

Methods

In this observational, longitudinal study, patients with chronic pain (n = 94) completed validated assessments of psychosocial characteristics and pain intensity at the beginning of COVID-19–related social distancing (April to June 2020). One year later (May to June 2021), patients completed a follow-up survey with assessments of pain interference, loneliness, social support, mindfulness, and optimism.

Results

A cluster analysis, using psychosocial factors and pain intensity, empirically produced three patient groups: 1) psychosocial predominant (PSP), characterized by high psychosocial distress and average pain intensity; 2) pain intensity predominant (PIP), characterized by average psychosocial distress and high pain intensity; and 3) less elevated symptoms (LES), characterized by low psychosocial distress and low pain intensity. At the 1-year follow-up, patients in the PSP and PIP clusters suffered greater pain interference than patients in the LES cluster, while patients in the PSP cluster also reported greater loneliness and lower mindfulness and optimism.

Conclusions

An empirical psychosocial-based clustering of patients identified three distinct groups that differed in pain interference. Patients with high psychosocial modulation of pain at the onset of social distancing (the PSP cluster) suffered not only greater pain interference but also greater loneliness and lower levels of mindfulness and optimism, which suggests some potential behavioral targets for this group in the future.

Effect of Early Electroacupuncture Combined with Enhanced Recovery after Surgery (ERAS) on Pain Perception and Dysfunction in Patients after Total Knee Arthroplasty (TKA)

Objective

A retrospective case-control study was performed to observe the effect and clinical significance of early electroacupuncture combined with enhanced recovery after surgery (ERAS) on pain perception and dysfunction after total knee arthroplasty (TKA).

Methods

About 100 patients who diagnosed with TKA from February 2019 to April 2021 were enrolled in our hospital. The patients were arbitrarily assigned into control group and study group. The former group was cured with electroacupuncture in the early stage, and the latter group was intervened on the basis of early electroacupuncture combined with the concept of ERAS. The curative effect, the time of getting out of bed for the first time after operation, the time of postoperative rehabilitation, postoperative rehabilitation cost, pain score and knee joint function score, range of motion (ROM) of knee joint, low shear of whole blood viscosity, plasma viscosity, fibrinogen level, and postoperative complications were compared.

Results

There exhibited no statistical difference in clinical data. In terms of the treatment effects, there were 27 cases of markedly effective, 22 cases of effective, and 1 case of ineffective in the study group, and the total effective rate was 98.00%; in the control group, 15 cases were markedly effective, 28 cases were effective, and 13 cases were ineffective, and the total effective rate was 86.00%. Compared to the control group, the total effective rate of the study group was higher (P < 0.05). And the first time to get out of bed and the postoperative rehabilitation time in the study group were lower. Compared to the control group (10113.42 ± 524.83) yuan, the postoperative rehabilitation cost in the study group (12401.71 ± 530.77) yuan was higher. In terms of the scores of VAS and HSS, there exhibited no remarkable difference before treatment (P > 0.05). After treatment, the VAS score lessened and the HSS score augmented the study group VAS score (1.76 ± 0.28); the score in the control group was lower compared to the control group (3.45 ± 0.36), and HSS scoring (83.48 ± 11.23) points higher compared to the control group (65.82 ± 10.44) points (P < 0.05). The ROM of knee joint augmented successively at the 1st, 2nd, 4th, and 8th week after treatment comparison between groups, the ROM of the knee joint in the study group at the 1st, 2nd, 4th, and 8th week was (49.47 ± 3.60)°, (64.38 ± 5.32)°, (86.93 ± 6.72)°, and (104.20 ± 9.11)°, is higher compared to the control group (46.53 ± 3.41)°, (61.52 ± 5.20)°, (78.42 ± 6.45)°, and (98.77 ± 8.67)° (P < 0.05). One day after operation, there exhibited no remarkable difference in whole blood viscosity low shear, plasma viscosity, and fibrinogen level (P > 0.05). However, there exhibited no remarkable difference in plasma viscosity and fibrinogen level at 1 day and 7 days after operation (P > 0.05). Seven days after operation, the whole blood viscosity, plasma viscosity, and fibrinogen in the study group were lower (P < 0.05). The probability of postoperative complications was compared. In the study group, there were 2 cases of limb swelling and pain, 1 case of joint stiffness, and no swelling and pain complicated with deep venous thrombosis, and the total incidence was 6.00%. In the control group, there were 5 cases of limb swelling and pain, 3 cases of joint stiffness, and 3 cases of swelling and pain complicated with deep venous thrombosis, with a total incidence of 22.00%. The incidence of adverse reactions in the study group was lower (χ 2 = 5.317 P < 0.05).

Conclusion

Early electroacupuncture combined with ERAS is of positive significance to the patients after TKA, which can reduce the pain, enhance the function of the knee joint, and promote the ROM of the knee joint, and can effectively shorten the first time out of bed and postoperative rehabilitation time and reduce whole blood viscosity low shear, plasma viscosity, and fibrinogen level, but the overall rehabilitation cost is high, and clinical application should be combined with the actual situation of patients.

Effects of transcutaneous electrical nerve stimulation (TENS) in people with knee osteoarthritis: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effects of Transcutaneous Electric Nerve Stimulation (TENS) on pain, function, walking ability and stiffness in people with Knee osteoarthritis (KOA).

DESIGN

Systematic review and meta-analysis of randomized controlled trials.

METHODS

We searched MEDLINE, EMBASE, PubMed, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database (PEDro), clinicaltrials.gov and Web of Science (last search November 2021) for randomized controlled trials. The Cochrane Risk of Bias Tool was used for the included studies, and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was used to interpret the certainty of results. Standardized Mean Differences (SMDs) and 95% confidence interval (CI) were calculated for meta-analysis.

RESULTS

Twenty-nine studies were found (1398 people, age range 54-85, 74% are female) and fourteen were included in this review. Intervention duration was divided as short term (immediately after intervention), medium term (<four weeks) and long term (≥ four weeks). Active TENS showed greater improvement in Visual Analogue Scale (VAS) than sham TENS.Combining TENS with other interventions produced superior outcomes compared with other interventions for VAS in all the terms. In the meanwhile, TENS combined with other interventions was superior to other interventions for the pain subgroup of Western Ontario and McMaster Universities Arthritis Index in the medium term and long term. TENS combined with other interventions was superior to other interventions for function in the medium term and long term.

CONCLUSION

TENS could significantly relieve pain, decrease dysfunction and improve walking ability in people with KOA, but it is not effective for stiffness.

Efficacy of Transcutaneous Electrical Nerve Stimulation for Postoperative Pain, Pulmonary Function, and Opioid Consumption Following Cardiothoracic Procedures: A Systematic Review

OBJECTIVE

Transcutaneous electrical nerve stimulation (TENS) is a minimally invasive method for treating pain. In the most recent review published in 2012, TENS was associated with increased pain relief following cardiothoracic surgery when compared to standard multimodal analgesia. The purpose of this systematic review and meta-analysis is to determine if adding TENS to current pain management practices decreases pain and analgesic use and improves pulmonary function for postcardiothoracic surgery patients.

MATERIALS AND METHODS

CINAHL, MEDLINE, Cochrane Database of Systematic Reviews, PubMed, and ClinicalTrials.gov were searched using specific keywords. Covidence was used to screen, select studies, and extract data by two independent reviewers. The Cochrane Risk of Bias tool assessed risk of bias. Visual analog scale (VAS) and pulmonary function data were exported for meta-analysis using a random effects model.

RESULTS

The search yielded 38 articles. Eight randomized controlled trials met inclusion criteria for the literature review. Five studies were included in the meta-analysis of pain at 24, 48, and 72 hours postoperatively. Data were analyzed using the standard mean difference (SMD). TENS had a significant impact on VAS at rest (-0.76 SMD [95% confidence interval, CI = -1.06 to -0.49], p < 0.00001) and with coughing (-1.11 SMD [95% CI = -1.64 to -0.56], p < 0.0001). FEV1 improved after 72 hours (1.00 SMD [95% CI = 0.66-1.35], p < 0.00001), as did forced vital capacity (1.16 SMD [95% CI = 0.23-2.10], p = 0.01).

CONCLUSION

The addition of TENS therapy to multimodal analgesia significantly decreases pain following cardiothoracic surgery, increases the recovery of pulmonary function, and decreases the use of analgesics.

Minimizing the Risk of Opioid Misuse and Abuse in the Surgical Setting

The misuse of opioids continues to be a public health problem. Acute post-surgical pain management requires a careful balance between the benefits and risks of opioids. Opioids should be part of a multimodal treatment plan, including the use of nonopioid and nonpharmacologic treatment options. Multimodal pain management allows for individualized treatment and improved patient satisfaction while limiting the risks inherent to opioids, including diversion. Surgeons should avoid overprescribing opioids and have a plan for decreasing the use of opioids in the postsurgical time frame. With careful consideration of the risks, opioids can be prescribed to treat acute postsurgical pain effectively. [Orthopedics. 2021;44(6):353-359.].

Reduction in movement-evoked pain and fatigue during initial 30-minute transcutaneous electrical nerve stimulation treatment predicts transcutaneous electrical nerve stimulation responders in women with fibromyalgia

ABSTRACT

We previously showed that 1 month of transcutaneous electrical nerve stimulation (TENS) reduces movement-evoked pain and fatigue in women with fibromyalgia (FM). Using data from this study (Fibromyalgia Activity Study with TENS [FAST]), we performed a responder analysis to identify predictors of clinical improvement in pain and fatigue with TENS, validated these models using receiver operator characteristic, and determined number needed to treat and number needed to harm. Participants were randomly assigned to active-TENS (2-125 Hz; highest-tolerable intensity), placebo-TENS, or no-TENS for 1 month. At the end of the randomized phase, placebo-TENS and no-TENS groups received active-TENS for 1 month. The predictor model was developed using data from the randomized phase for the active-TENS group (n = 103) and validated using data from placebo-TENS and no-TENS groups after active-TENS for 1 month (n = 155). Participant characteristics, initial response to TENS for pain and fatigue, sleep, psychological factors, and function were screened for association with changes in pain or fatigue using a logistic regression model. Predictors of clinical improvement in pain were initial response to pain and widespread pain index (area under the curve was 0.80; 95% confidence interval: 0.73-0.87). Predictors of clinical improvement in fatigue were marital status, sleep impairment, and initial response to TENS (area under the curve was 0.67; 95% confidence interval: 0.58-0.75). Number needed to treat for pain and fatigue ranged between 3.3 and 5.3. Number needed to harm ranged from 20 to 100 for minor TENS-related adverse events. The response to an initial 30-minute TENS treatment predicts who responds to longer-term TENS use in women with FM, making this a clinically useful procedure. Number needed to treat and number needed to harm suggest that TENS is effective and safe for managing pain and fatigue in FM.

Effect of transcutaneous electrical nerve stimulation on quality of recovery and pain after abdominal hysterectomy

Background and Aims:

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive complementary therapy for postoperative pain management. The effect of TENS on quality of recovery (QoR) and pain treatment in the early postoperative period is not well documented. The aim of this study was to evaluate the effect of TENS on postoperative QoR and pain in patients who had undergone a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH + BSO).

Material and Methods:

Fifty-two patients were randomized into two groups: control (sham TENS treatment) and TENS (TENS treatment). QoR, dynamic pain, and static pain were evaluated after surgery.

Results:

The QoR score was significantly higher in the TENS group as compared with that in the control group (P = 0.029). Pain scores during coughing (dynamic pain) were significantly less in TENS group compared to control group (P <0.001). However, there was no between-group difference in pain scores at rest (static pain) or total analgesic consumption (P = 0.63 or P = 0.83, respectively).

Conclusion:

TENS may be a valuable tool to improve patients' QoR and dynamic pain scores after TAH + BSO.

Total ankle arthroplasty: Strength, pain, and motion

BACKGROUND

While outcomes such as pain and ankle motion are well researched, information regarding the effect of total ankle arthroplasty on ankle plantarflexion strength is extraordinarily limited. The purpose of this study was to evaluate ankle plantarflexion strength before and after total ankle arthroplasty, and examine the interplay of pain, motion, and strength.

METHODS

This prospective case-control study included 19 patients with end-stage ankle arthritis who received a total ankle arthroplasty and 19 healthy control participants matched for age, sex, and body mass index. Pain was measured with a numeric pain rating scale. Passive sagittal plane ankle range of motion (°) and isokinetic ankle plantarflexion torque (Nm/kg) at 60 and 120°/s were measured with an instrumented dynamometer. t-tests or non-parametric tests were used to evaluate outcomes across time and between groups. Bivariate correlations were performed to evaluate the interplay of postoperative pain, motion, and torque.

FINDINGS

Patient pain and motion improved between the preoperative and six-month postoperative time points (d ≥ 0.7). Ankle plantarflexion torque was not different across time (d ≤ 0.5), but was lower than control group values postoperatively (d ≥ 1.4). Significant correlations between pain and motion (r = -0.48), but not torque (-0.11 ≤ r ≤ 0.13), were observed.

INTERPRETATION

Unchanged following surgery, impairments in muscle performance following total ankle arthroplasty do not appear to be changed by improved pain or motion. These findings provide impetus for postoperative strengthening interventions.

Multicenter, randomized, double-blind, controlled trial of transcutaneous electrical nerve stimulation for pancreatic cancer related pain

BACKGROUND

Up to 80% of patients with pancreatic cancer experience abdominal and back pain. Although pharmacologic medications provide some relief, many report inadequate analgesia and adverse effects. Transcutaneous electrical nerve stimulation (TENS) is a non-invasive physical modality and had been widely applied for pain relieving, yet no study has investigated the effectiveness of TENS for pain in pancreatic cancer.

METHODS

Eligible patients were randomly assigned in a 1:1 ratio to TENS group or control group. The primary outcome was percentage change of numerous rating scale (NRS) after treatment. Secondary outcomes included percentage change of analgesic medication consumption and effect on constipation and poor appetite.

RESULTS

One hundred seventy-one patients were recruited (84 to control group and 87 to TENS group). NRS in TENS group has been largely decreased 77.9% right after treatment and 27.1% in 2 hours, before applying any analgesic medication, while that in control group was slightly downregulated right after treatment but gave a trend to increase at 1, 2, and 3 hours. When comparing both groups, pain was significantly well controlled without analgesic medication supplement in TENS group at 0 hour (difference in mean percent change in NRS = 50.0 [95% CI, 50-51.4], P < .01) and 3 hours (difference in mean percent change in NRS = 134.0 [95% CI, 130.0-142.7], P < .01) after treatment, and this analgesic effect last to 3 weeks after treatment cycle (difference in mean percent change in NRS = 22.5 [95% CI, 17.6-27.3], P < .01) without increase of analgesic medication consumption.

CONCLUSIONS

TENS reduces pain without increase analgesic medication consumption in patients with pancreatic cancer pain. It provides an alternative therapy for pain in pancreatic cancer.

CLINICAL TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov, identifier NCT03331055.

A Scoping Review of Nursing's Contribution to the Management of Patients with Pain and Opioid Misuse

BACKGROUND

Nursing brings a unique lens to care of patients with pain and opioid misuse.

AIMS

This scoping review describes nursing's contribution to the literature on the management of patients with pain and opioid misuse, generating evidence to guide clinical care.

DESIGN

The scoping review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews guideline.

DATA SOURCES

Using combined key terms ("opioid misuse," "pain," "nursing") in systematic searches in PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases, snowball technique, and personal knowledge resulted in 108 relevant articles, reports, and websites.

ANALYSIS METHOD

Summative approach to content analysis was used to quantify and describe nursing's contribution to the literature.

RESULTS

Contributions of nurses emerged in the areas of research, clinical practice, policy, and education. The highest number of publications addressed research (50%, 54 of 108), whereas the fewest number of publications involved education (7%, 8 of 108).

CONCLUSION

Results provide a picture of the breadth of expertise and crucial leadership that nurses contribute to influence management of patients with pain and opioid misuse.

IMPLICATIONS FOR NURSING

This scoping review indicates the importance of continued support from key stakeholders, including training and interprofessional collaboration opportunities supported by the National Institutes of Health, to sustain nursing's contribution to quality care of patients with pain and opioid misuse. Ultimately, all health care professionals must collaborate to conduct rigorous research and construct evidence-based guidelines to inform policy initiatives and education strategies to solve the complex co-occurring epidemics of pain and opioid misuse.

Patient phenotyping in clinical trials of chronic pain treatments: IMMPACT recommendations

There is tremendous interpatient variability in the response to analgesic therapy (even for efficacious treatments), which can be the source of great frustration in clinical practice. This has led to calls for “precision medicine” or personalized pain therapeutics (ie, empirically based algorithms that determine the optimal treatments, or treatment combinations, for individual patients) that would presumably improve both the clinical care of patients with pain and the success rates for putative analgesic drugs in phase 2 and 3 clinical trials. However, before implementing this approach, the characteristics of individual patients or subgroups of patients that increase or decrease the response to a specific treatment need to be identified. The challenge is to identify the measurable phenotypic characteristics of patients that are most predictive of individual variation in analgesic treatment outcomes, and the measurement tools that are best suited to evaluate these characteristics. In this article, we present evidence on the most promising of these phenotypic characteristics for use in future research, including psychosocial factors, symptom characteristics, sleep patterns, responses to noxious stimulation, endogenous pain-modulatory processes, and response to pharmacologic challenge. We provide evidence-based recommendations for core phenotyping domains and recommend measures of each domain.

Effects of Nurse-Led Pain Management Interventions for Patients with Total Knee/Hip Replacement

BACKGROUND

A literature review was conducted to assess nurse-led nonpharmacologic pain management interventions intended for total knee/hip replacement patients.

DESIGN

This was a systematic review and meta-analysis.

DATA SOURCES

The PubMed, Embase, CINAHL, and Cochrane Library databases were searched to identify relevant studies.

REVIEW METHODS

The systematic review was conducted based on the Cochrane Handbook for Systematic Reviews of Interventions and all Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guidelines. Two reviewers independently selected the studies and appraised their quality. Thereafter, the effects of all described nurse-led nonpharmacologic pain management interventions were estimated regarding pain, anxiety, and satisfaction through a meta-analysis.

RESULTS

In total, 219 relevant studies were found through a search. Finally, 23 studies were selected for review, with 17 included in the meta-analysis. Nurse-led nonpharmacologic pain management was effective for pain relief (effect size, -0.22; 95% confidence interval [CI], -0.42 to -0.02), and educational interventions were especially effective (effect size, -0.36; 95% CI, -0.69 to -0.03). Although interventions reduced anxiety and improved satisfaction, these results were not statistically significant based on the analysis.

CONCLUSION

Our findings support that nurse-led nonpharmacologic pain management interventions could help reduce pain in patients with total knee/hip replacement by supplementing pharmacologic pain management.

IMPLICATIONS FOR NURSING

Nurse-led nonpharmacologic pain interventions should be considered to reduce patient pain with total knee/hip replacement.

Transcutaneous Electric Nerve Stimulation Reduces Acute Postoperative Pain and Analgesic Use After Open Inguinal Hernia Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial

In this randomized, double-blind, placebo-controlled trial, we evaluated the role of transcutaneous electrical nerve stimulation (TENS) in the multimodal treatment (nonopioid analgesics and kinesiotherapy) of postoperative pain following open inguinal hernia repair. In total, 80 males participants with elective primary unilateral hernia Lichtenstein repair were randomly allocated to receive TENS or a placebo-TENS procedure. The TENS group received local and segmental conventional TENS on the first and second postoperative days. In the placebo-TENS group, intensity was set at 0 to 0.5mA. Change of pain level at rest, when walking, when standing up from bed, pressure algometry parameters and additional analgesic use were the main outcomes. Reduction of VAS pain score and absolute and relative pain relief were observed in the TENS group following the procedures compared to the placebo-TENS group (P< .001). The pressure pain threshold and maximal tolerable pressure in the hernia side were equal before the TENS procedure in both groups (P= .84), but after the procedure, these were higher in TENS group (P< .001). Additional nonopioid analgesics requirements were lower in the TENS group on the first and second postoperative days (P< .001). TENS is a safe procedure that can reduce postoperative pain and analgesic use after open inguinal hernia repair. The study was registered in the database of clinicaltrials.gov (register number NCT03739060). PERSPECTIVE: This article presents TENS as a safe and effective nonpharmacologic intervention to reduce postoperative pain after open inguinal hernia repair. TENS could be used in daily practice as part of a multimodal postoperative pain treatment, especially for patients suffering from hyperalgesia.

One-day Acceptance and Commitment Therapy workshop for preventing persistent post-surgical pain and dysfunction in at-risk veterans: A randomized controlled trial protocol

OBJECTIVE

Persistent post-surgical pain is common among patients undergoing surgery, is detrimental to patients' quality of life, and can precipitate long-term opioid use. The purpose of this randomized controlled trial is to assess the effects of a behavioral intervention offered prior to surgery for patients at risk for poor post-surgical outcomes, including persistent pain and impaired functioning.

METHODS

Described herein is an ongoing randomized, patient- and assessor-blind, attention-controlled multisite clinical trial. Four hundred and thirty Veterans indicated for total knee arthroplasty (TKA) with distress and/or pain will be recruited for this study. Participants will be randomly assigned to a one-day (~5 h) Acceptance and Commitment Therapy workshop or one-day education and attention control workshop. Approximately two weeks following their TKA surgery, patients receive an individualized booster session via phone. Following their TKA, patients complete assessments at 1 week, 6 weeks, 3 months, and 6 months.

RESULTS

The primary outcomes are pain intensity and knee-specific functioning; secondary outcomes are symptoms of distress and coping skills. Mediation analyses will examine whether changes in symptoms of distress and coping skills have an impact on pain and functioning at 6 months in Veterans receiving ACT. This study is conducted mostly with older Veterans; therefore, results may not generalize to women and younger adults who are underrepresented in this veteran population.

CONCLUSIONS

The results of this study will provide the first evidence from a large-scale, patient- and assessor-blind controlled trial on the effectiveness of a brief behavioral intervention for the prevention of persistent post-surgical pain and dysfunction.

Effectiveness of transcutaneous electrical stimulation combined with artificial tears for the treatment of dry eye: A randomized controlled trial

There is currently no available cure or universally effective treatment for dry eye (DE). The aim of the present study was to investigate the clinical efficacy of transcutaneous electrical stimulation (TES) combined with artificial tears in treating DE. Patients diagnosed with DE were referred for therapy with TES combined with sodium hyaluronate (SH)-containing artificial tears. A total of 52 patients (104 eyes) with DE were enrolled in this randomized controlled trial. The patients were randomized 1:1 to the TES + SH or SH group. The patients in the TES + SH group were treated with 20 sessions (5 sessions per week for 4 weeks), and each session lasted for 20 min. The treatment was continued for 4 weeks in all cases. The Ocular Surface Disease Index (OSDI), tear film breakup time (BUT), Schirmer's I test and corneal fluorescein scores were used to assess treatment efficacy. A total of 90 eyes of 45 patients completed all aspects of the study: 22 patients (44 eyes) in the TES + SH group and 23 patients (46 eyes) in the SH group. There was no statistically significant difference in sex, age or course between the two groups. The mean OSDI scores, BUT, Schirmer's I test and corneal fluorescein scores exhibited a significant improvement in the TES + SH group compared with the SH group after treatment. No serious adverse events were recorded during TES treatment. In conclusion, TES combined with artificial tears appeared to be an effective treatment for DE. Therefore, TES may represent a new therapeutic option with promising potential applications.

Transcutaneous Electrical Stimulation Influences the Time-Frequency Map of Cortical Activity - A Pilot Study

Phantom limb pain (PLP) is pain felt in the missing limb in amputees. Somatosensory input delivered as high-frequency surface electrical stimulation may provoke a significant temporary decrease in PLP. Also, transcutaneous electrical nerve stimulation (TENS) is a somatosensory input that may activate descending inhibitory systems and thereby relieve pain. Our aim was to investigate changes in cortical activity following long-time sensory TENS. Time-frequency features were extracted from EEG signals of Cz and C4 channels (contralateral to the stimulation site) with or without TENS (2 subjects). We found that the TENS caused inhibition of the spectral activity of the somatosensory cortex following TENS, whereas no change was found when no stimulation was applied.Clinical Relevance- Although our preliminary results show a depression of the cortical activity following TENS, a future study with a larger population is needed to provide strong evidence to evaluate the effectiveness of sensory TENS on cortical activity. Our results may be useful for the design of TENS protocols for relief of PLP.

Ultrasound-Guided Percutaneous Neuromodulation in Patients with Unilateral Anterior Knee Pain: A Randomized Clinical Trial

The objective of this study was to evaluate the short-term and crossover effects of a percutaneous neuromodulation (PNM) intervention on the femoral nerve, regarding the pain, knee flexion motion (range of motion (ROM)), and functionality, in patients with unilateral anterior knee pain (AKP). Our study used a randomized clinical trial design. Thirty patients were divided into two groups: one asymptomatic knee group in which patients received stimulation in the femoral nerve corresponding to the nonsymptomatic knee; and one symptomatic knee group, in which patients received stimulation in the femoral nerve corresponding to the painful knee. Pain, knee flexion ROM, Victorian Institute of Sport Assessment-Patella (VISA-P) and Kujala questionnaires were evaluated. Twenty-eight patients completed the study. Compared to their baseline values, both groups showed an increase immediately at 24 h, and at 1 week for the knee flexion ROM variable. In addition, the symptomatic knee group showed an increase for the Kujala score and a decrease for the numeric rating scale (NRS) variable from baseline to 1 week. VISA-P score did not show statistically significant differences for the time-group interaction. After the intervention, there were no differences between the groups in any measured time. Conclusion: a single-shot ultrasound-guided PNM intervention per week in the femoral nerve may be an effective treatment for improving the pain, knee flexion ROM, and knee functionality. In addition, this technique produces crossover benefits in the nonintervention limb.

Preoperative pain catastrophisation may predict worse patient-reported outcomes after primary hip arthroplasty: A pilot study

AIM

to investigate the relationship between pain catastrophising and patient-reported clinical outcomes following primary total hip arthroplasty.

MATERIALS AND METHODS

prospective consecutive study of 103 patients who completed preoperative Pain Catastrophisation Score (PCS), preoperative and 12-month postoperative Oxford Hip Score (OHS). Correlation analysis was carried out between the improvement in OHS (mean difference between pre- and postoperative scores) and the mean preoperative PCS score using the Pearson's r rank test. Multiple linear regression was then performed using the postoperative OHS as the outcome variable against a number of predictor variables.

RESULTS

there were 37 males and 66 females with average age of 60.5 years (range 22-84). Mean preoperative PCS score was 16.3 (±13.6; range 0-49). Mean preoperative OHS was 16.5 (±3.5) which had improved at 12-months postoperatively to a mean 38.1 (±11.1). The difference was statistically significant (P < 0.0001). Preoperative PCS scores were correlated with the OHS improvement at 12-months which revealed a weak negative correlation Pearson's correlation coefficient r = - 0.248 (P = 0.0114). Preoperative PCS score, predictor variable, had statistically significant relationship with the postoperative OHS (P = 0.0207). The regression coefficient for the PCS was -0.25, therefore for each unit increase in the preoperative PCS score there was a 0.25 unit decrease in the postoperative OHS score.

CONCLUSION

pain catastrophising appear to predict poorer postoperative patient-reported outcome measures. Further research is needed to evaluate the value of early identification of high-risk patients and the role of preoperative involvement of pain specialists and its effects on postoperative outcomes.

Electrical Stimulation of Muscle: Electrophysiology and Rehabilitation

The generation of action potentials in intramuscular motor and sensory axons in response to an imposed external current source can evoke muscle contractions and elicit widespread responses throughout the nervous system that impact sensorimotor function. The benefits experienced by individuals exposed to several weeks of treatment with electrical stimulation of muscle suggest that the underlying adaptations involve several physiological systems, but little is known about the specific changes elicited by such interventions.

The Reciprocal Relationship of Pain and Movement in African American Older Adults With Multi-Joint Osteoarthritis

Pain with movement is a common issue for older adults with osteoarthritis; however, there has been insufficient attention within populations at increased risk for disabling pain, such as African American older adults. Accordingly, using a mixed methods approach, the purpose of the current study is to describe the nature of chronic joint pain and movement and its impact on physical function in African American older adults with symptomatic osteoarthritis. The authors accrued a sample of 110 African American older adults who completed cross-sectional surveys; from this sample, the authors interviewed 18 participants. Findings suggest that patterns of movement are uniquely influenced by pain. Specifically, three dynamic themes emerged: The Impact of Pain on Movement; The Importance and Impact of Movement on Pain; and The Adaptation of Personal Behaviors to Minimize Pain With Movement. Function-focused nursing care rests on addressing challenges and opportunities that African American older adults face in maintaining healthy movement when managing osteoarthritis pain. [Research in Gerontological Nursing, xx(x), xx-xx.].

Effects of genotype on TENS effectiveness in controlling knee pain in persons with mild to moderate osteoarthritis

BACKGROUND

This study examined the extent to which genetic variability modifies Transcutaneous Electrical Nerve Stimulation (TENS) effectiveness in osteoarthritic knee pain.

METHODS

Seventy-five participants with knee osteoarthritis were randomly assigned to either: (a) High-frequency TENS, (b) Low-frequency TENS or (c) Transient Placebo TENS. Pain measures were collected pre- and post-treatment. Participants were genotyped on genes implicated in central or peripheral pain pathways: NGFB, NTRK1, EDNRA, EDNRB, EDN1, OPRM1, TAC1, TACR1, BDNF, BDKRB1, 5HTT, COMT, ESR2, IL6 and IL1B. Genetic association using linear regression modelling was performed separately for the transient placebo TENS subjects, and within the High-frequency TENS + Low-frequency TENS participants, including TENS level as a covariate.

RESULTS

In the placebo group, SNPs rs165599 (COMT) was significantly associated with an increased heat pain threshold (β = -1.87; p = .003) and rs6827096 (EDNRA) with an increased resting pain (β = 2.68; p = .001). Within the treatment groups, TENS effectiveness was reduced by the SNP rs6537485 (EDNRA) minor allele in relationship to mechanical sensation (β = 184.13; p = 5.5E-9). Individuals with the COMT rs4680 minor allele reported lowered pain at rest after TENS (β = -42.30; p = .001), with a higher magnitude of pain reduction (28 unit difference) in the low-frequency TENS group compared to the high-frequency TENS group (β = 28.37; p = .0004).

CONCLUSIONS

EDNRA and COMT are implicated in osteoarthritic knee pain and provide a basis for tailoring TENS interventions according to individual characteristics.

SIGNIFICANCE

Findings from this study demonstrate that genetic variation within the COMT and EDNRA genes influences the effectiveness of TENS, a non-pharmacologic pain-reduction intervention, in the context of osteoarthritic knee pain. Evidence such as this may contribute to risk models that provide a clinically useful tool for personalizing TENS interventions according to individual characteristics in order to best control pain and maximize functional status.

Effects of transcutaneous electrical nerve stimulation (TENS) on acute postoperative pain intensity and mobility after hip fracture: A double-blinded, randomized trial

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive modality which may be used to reduce acute postoperative pain. Intense perioperative pain within the first few days after hip fracture surgery is common and is related to negative consequences such as restricted and delayed ambulation.

OBJECTIVE

The objective of the present study was to examine the effect of incorporating TENS treatment on pain intensity, and mobility, with standard rehabilitation care during the acute post-operative phase following Gamma-nail surgical fixation of extracapsular hip fractures.

MATERIALS AND METHODS

Forty-one patients were randomly assigned to a supplement of 30 mins of active TENS or sham TENS. The standard rehabilitation care included five daily 30 mins physical therapy treatments beginning 24 hrs after surgery. Outcome measures were: pain intensity at rest, at night and during ambulation (assessed with the Numeric Rating Scale; Functional Ambulation Classification instrument; time to complete five sit-to-stand tests; and two-minute walk test). Data were analyzed with Wilcoxon score rank tests. Significance was set at p≤0.05.

RESULTS

Significantly greater pain reduction during walking was noted in the active TENS group compared to sham TENS group (differences between the fifth and the second days: 2.55±1.37 vs 1.06± 1.11, respectively; p=0.0011). Additionally, advantage of active TENS was demonstrated in greater increase in walking distance on the fifth day and higher level of mobility compared to the sham TENS group. No additional effects of active TENS were noted on pain intensity at rest and at night and on five times sit-to-stand performance.

CONCLUSION

Addition of TENS to the standard care of elderly patients in the early days following Gamma nail surgical fixation of extracapsular hip fracture is recommended for pain management while walking and functional gait recovery. The effect of TENS on long-term functional outcomes should be explored in future studies.

TRIAL REGISTRATION

The trial was registered at the ISRCTN registry: ID ISRCTN32476360.

Opioid-Sparing Pain Management in Upper Extremity Surgery: Part 2: Surgeon as Prescriber

A multimodal pain management strategy combines complementary medications and techniques, targeting unique pathways, to improve overall analgesic effect and reduce opioid requirements. In this 2-part review, we examine the literature identifying nonopioid analgesic modalities and their targets in the pain pathway as well as anesthetic techniques found to be opioid sparing in the practice of upper extremity surgery. Part 1 focused on operative anesthesia and analgesia. In part 2, we discuss the nonopioid options available after surgery and explore areas for future investigation specific to upper extremity surgery.

Neurobiological mechanisms of TENS-induced analgesia

Pain inhibition by additional somatosensory input is the rationale for the widespread use of Transcutaneous Electrical Nerve Stimulation (TENS) to relieve pain. Two main types of TENS produce analgesia in animal models: high-frequency (∼50-100 Hz) and low-intensity 'conventional' TENS, and low-frequency (∼2-4 Hz) and high-intensity 'acupuncture-like' TENS. However, TENS efficacy in human participants is debated, raising the question of whether the analgesic mechanisms identified in animal models are valid in humans. Here, we used a sham-controlled experimental design to clarify the efficacy and the neurobiological effects of 'conventional' and 'acupuncture-like' TENS in 80 human volunteers. To test the analgesic effect of TENS we recorded the perceptual and brain responses elicited by radiant heat laser pulses that activate selectively Aδ and C cutaneous nociceptors. To test whether TENS has a long-lasting effect on brain state we recorded spontaneous electrocortical oscillations. The analgesic effect of 'conventional' TENS was maximal when nociceptive stimuli were delivered homotopically, to the same hand that received the TENS. In contrast, 'acupuncture-like' TENS produced a spatially-diffuse analgesic effect, coupled with long-lasting changes both in the state of the primary sensorimotor cortex (S1/M1) and in the functional connectivity between S1/M1 and the medial prefrontal cortex, a core region in the descending pain inhibitory system. These results demonstrate that 'conventional' and 'acupuncture-like' TENS have different analgesic effects, which are mediated by different neurobiological mechanisms.

Efficacy of different-frequency TEAS on acute pain after the total knee arthroplasty: a study protocol for a parallel group randomized trial

BACKGROUND

Total knee arthroplasty (TKA) is an optimal option for patients with middle-to-end-stage knee osteoarthritis. However, the management of postoperative acute pain remains inefficient. Transcutaneous electrical acupoint stimulation (TEAS) is a nonpharmacological method to manage postoperative acute pain. Different frequencies of TEAS have been tested using varying parameters, but the optimal analgesic frequency remains controversial. The aim of this study was to explore the optimal analgesic frequency of TEAS for treating acute pain after the primary unilateral TKA.

METHODS/DESIGN

This is a double-blind, randomized controlled trial. A total of 156 patients are randomly assigned to: G1, 5 Hz TEAS; G2, 100 Hz TEAS; G3, mixed TEAS (alternative use of daily 5 Hz and 100 Hz TEAS) and G4, placebo TEAS. In the G1, G2 and G3 groups, TEAS is conducted at acupoints SP9 and GB34 of the leg that was operated on (at a wave of continuous, balanced and asymmetrical biphasic square, with a pulse width of 200 μs, and a strong but comfortable current) for 30 min prior to a 30-min rehabilitation session per day for 2 weeks. In G4 group, TEAS is delivered at a strong but comfortable current for 30 s, then the current is gradually decreased to none over the next 15 s. The primary outcomes are measured before surgery, at baseline (POD 3, before TEAS intervention), week 1 and 2 after TEAS intervention with the Numeric Pain Rating Scale and The American Knee Society Score. The secondary outcomes include: (1) Active range of motion of the knee that was operated on; (2) Surface electromyography of both quadriceps; (3) Modified 30-s sit to stand test; (4) Additional usage of analgesia; and (5) SF-36. The additional outcomes include: (1) Patients' satisfaction rate; (2) Patient's expectation rate; and (3) Incidence of analgesia-related side effects. To test the blinding of participants and assessors, they are asked to guess whether the subjects received active or placebo TEAS within 5 min after the latest intervention. The safety and financial cost of TEAS are assessed.

DISCUSSION

Mixed TEAS has more favorable effect on acute pain control than the placebo or 5 Hz or 100 Hz TEAS.

TRIAL REGISTRATION

ChiCTR1800016347 . Date of registration was 26 May 2018. Retrospectively registered.

Coping with Phantom Limb Pain

Phantom limb pain is a chronic neuropathic pain that develops in 45-85% of patients who undergo major amputations of the upper and lower extremities and appears predominantly during two time frames following an amputation: the first month and later about 1 year. Although in most patients the frequency and intensity of pain diminish over time, severe pain persists in about 5-10%. It has been proposed that factors in both the peripheral and central nervous systems play major roles in triggering the development and maintenance of pain associated with extremity amputations. Chronic pain is physically and mentally debilitating, affecting an individual's capacity for self-care, but also diminishing an individual's daily capacity for personal and economic independence. In addition, the pain may lead to depression and feelings of hopelessness. A National Center for Biotechnology Information study found that in the USA alone, the annual cost of dealing with neuropathic pain is more than $600 billion, with an estimated 20 million people in the USA suffering from this condition. Although the pain can be reduced by antiepileptic drugs and analgesics, they are frequently ineffective or their side effects preclude their use. The optimal approach for eliminating neuropathic pain and improving individuals' quality of life is the development of novel techniques that permanently prevent the development and maintenance of neuropathic pain, or that eliminate the pain once it has developed. What is still required is understanding when and where an effective novel technique must be applied, such as onto the nerve stump of the transected peripheral axons, dorsal root ganglion neurons, spinal cord, or cortex to induce the desired influences. This review, the second of two in this journal volume, examines the techniques that may be capable of reducing or eliminating chronic neuropathic pain once it has developed. Such an understanding will improve amputees' quality of life by blocking the mechanisms that trigger and/or maintain PLP and chronic neuropathic pain.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Longitudinal Postoperative Course of Pain and Dysfunction Following Total Knee Arthroplasty

OBJECTIVES

Although the majority of patients undergoing total knee arthroplasty (TKA) report substantial improvement in pain and function, a significant subset experience persistent postsurgical pain and dysfunction. Better understanding of the longitudinal postoperative course is needed, including the association between patient status following physical rehabilitation at 6-weeks post-TKA, to 6-months outcomes. This study aims to described the postoperative course of TKA and examine variables associated with change in pain and functioning between 6-weeks and 6-months post-TKA.

METHODS

In this longitudinal study of 223 participants, assessments of analgesic intake, depression, anxiety, pain catastrophizing, dysfunction, resting and range of motion pain, and pain sensitivity were completed at 6-weeks post-TKA. Analgesic intake, pain ratings, and dysfunction data were also collected at 6-months post-TKA. Pain and dysfunction ratings were divided into none-mild and moderate-severe categories.

RESULTS

Between 6-weeks and 6-months post-TKA, 75% of the sample stayed in the same pain category, 20% improved, and 5% worsened. In terms of functional changes between 6 weeks and 6 months, 65% of the sample stayed in the same functional category, whereas 31% improved and 5% worsened.

DISCUSSION

These findings demonstrate that the majority of patients' pain and functioning remains stable between 6 weeks and 6 months post-TKA. However, a notable subset continues to improve or worsen in pain and functioning and the current study identifies variables associated with these changes.

Contralateral segmental transcutaneous electrical nerve stimulation inhibits nociceptive flexion reflex in healthy participants

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS) is a non-invasive treatment to relieve pain. Contralateral TENS (i.e. TENS administered to the contralateral side of a painful body part) is beneficial when TENS cannot be directly applied to pain site, such as in cases of trauma. Although TENS produces segmental analgesia in an ipsilateral limb, it has been unclear whether TENS produces higher analgesic effects in the contralateral segmental area. The aim of the present study was to investigate the analgesic effects of TENS in contralateral segmental or extra-segmental areas on physiological and subjective pain outcomes, using a nociceptive flexion reflex (NFR) method.

METHODS

We randomly allocated 60 healthy participants to three groups: contralateral segmental TENS (CS-TENS); contralateral extra-segmental TENS (CE-TENS); and contralateral placebo TENS (CP-TENS). CS-TENS was applied to right superficial sural nerve and CE-TENS was applied to the right superficial femoral nerve, each for 30 minutes. The magnitude of the NFR elicited by electrical stimulation of the left sural nerve was measured at baseline and at three subsequent 10-minute intervals. Subjective pain intensity was measured simultaneously with a visual analogue scale (VAS).

RESULTS

At 30 min, the NFR magnitude of CS-TENS group was significantly lower than that of the CP-TENS group (p = 0.021). There were no significant differences in VAS scores among the groups at any time point.

CONCLUSIONS

Our findings suggest that CS-TENS inhibited NFR. Although there was no significant between-group difference in subjective pain intensity, factors such as a placebo effect probably impacted it.

SIGNIFICANCE

Our findings provide support for the contralateral approach at stimulation sites when TENS cannot be directly administered to a pain site (e.g. due to disease or trauma).

Evaluating psychosocial contributions to chronic pain outcomes

The biopsychosocial model of pain dominates the scientific community's understanding of chronic pain. Indeed, the biopsychosocial approach describes pain and disability as a multidimensional, dynamic integration among physiological, psychological, and social factors that reciprocally influence one another. In this article, we review two categories of studies that evaluate the contributions of psychosocial factors to the experience of chronic pain. First, we consider general psychosocial variables including distress, trauma, and interpersonal factors. Additionally, we discuss pain-specific psychosocial variables including catastrophizing, expectations, and pain-related coping. Together, we present a diverse array of psychological, social, and contextual factors and highlight the need to consider their roles in the development, maintenance, and treatment of chronic pain conditions.

Development of a method to maximize the transcutaneous electrical nerve stimulation intensity in women with fibromyalgia

Introduction

Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological intervention clinically used for pain relief. The importance of utilizing the adequate stimulation intensity is well documented; however, clinical methods to achieve the highest possible intensity are not established.

Objectives

Our primary aim was to determine if exposure to the full range of clinical levels of stimulation, from sensory threshold to noxious, would result in higher final stimulation intensities. A secondary aim explored the association of pain, disease severity, and psychological variables with the ability to achieve higher final stimulation intensity.

Methods

Women with fibromyalgia (N=143) were recruited for a dual-site randomized controlled trial - Fibromyalgia Activity Study with TENS (FAST). TENS electrodes and stimulation were applied to the lumbar area, and intensity was increased to sensory threshold (ST), then to "strong but comfortable" (SC1), then to "noxious" (N). This was followed by a reduction to the final stimulation intensity of "strong but comfortable" (SC2). We called this the Setting of Intensity of TENS (SIT) test.

Results

There was a significant increase from SC1 (37.5 mA IQR: 35.6-39.0) to SC2 (39.2 mA IQR: 37.1-45.3) (p<0.0001) with a mean increase of 1.7 mA (95% CI: 1.5, 2.2). Linear regression analysis showed that those with the largest increase between SC1 and N had the largest increase in SC2-SC1. Further, those with older age and higher anxiety were able to achieve greater increases in intensity (SC2-SC1) using the SIT test.

Conclusion

The SC2-SC1 increase was significantly associated with age and anxiety, with greater mean increases associated with older age and higher anxiety. Thus, although all patients may benefit from this protocol, older women and women with elevated anxiety receive the greatest benefit.

Opioid use prior to knee arthroplasty in patients who catastrophize about their pain: preoperative data from a multisite randomized clinical trial

Background

Opioid use rates prior to knee arthroplasty (KA) among people who catastrophize about their pain are unknown. We determined prevalence of opioid use and compared patterns of preoperative opioid use and oral morphine equivalent (OME), a measure of daily opioid dose, across varied geographic sites. We also determined which baseline variables were associated with opioid use and OME.

Patients and methods

Preoperative opioid use data described type of opioid, dosage, and frequency among 397 patients scheduled for KA. Demographic, knee-related pain, and psychological distress dimensions were examined to identify variables associated with opioid use and opioid dose (OME). Opioid use prevalence and OME were compared across the four sites. A three-level censored regression determined variables associated with opioid use and OME.

Results

The overall opioid use prevalence was 31.7% (95% confidence interval [CI] = 27.0, 36.3) and varied across sites from 15.9% (95% CI = 9.0, 22.8) to 51.2% (95% CI = 40.5, 61.9). After adjustment, patients using opioids were more likely to be younger, African American, and have higher self-efficacy and comorbidity scores (P < 0.05). The only variable independently associated with OME was lower depressive symptoms (P < 0.05).

Conclusion

People who catastrophized prior to KA did not demonstrate increased preoperative opioid use based on current evidence, but variation in the prevalence of opioid use across study sites was substantial. Variables associated with opioid use were non-modifiable demographic and comorbidity variables.

A Feasibility Study of Percutaneous Peripheral Nerve Stimulation for the Treatment of Postoperative Pain Following Total Knee Arthroplasty

INTRODUCTION

The objective of the present feasibility study was to investigate the use of a new treatment modality-percutaneous peripheral nerve stimulation (PNS)-in controlling the often severe and long-lasting pain following total knee arthroplasty (TKA).

METHODS

For patients undergoing a primary, unilateral TKA, both femoral and sciatic open-coil percutaneous leads (SPR Therapeutics, Cleveland, OH) were placed up to seven days prior to surgery using ultrasound guidance. The leads were connected to external stimulators and used both at home and in the hospital for up to six weeks total.

RESULTS

In six of seven subjects (86%), the average of daily pain scores across the first two weeks was <4 on the 0-10 Numeric Rating Scale for pain. A majority of subjects (four out of seven; 57%) had ceased opioid use within the first week (median time to opioid cessation for all subjects was six days). Gross sensory/motor function was maintained during stimulation, enabling stimulation during physical therapy and activities of daily living. At 12 weeks following surgery, six of seven subjects had improved by >10% on the Six-Minute Walk Test compared to preoperative levels, and WOMAC scores improved by an average of 85% compared to before surgery. No falls, motor block, or lead infections were reported.

CONCLUSIONS

This feasibility study suggests that for TKA, ultrasound-guided percutaneous PNS is feasible in the immediate perioperative period and may provide analgesia without the undesirable systemic effects of opioids or quadriceps weakness induced by local anesthetics-based peripheral nerve blocks.

Systematic Review of Three Electrical Stimulation Techniques for Rehabilitation After Total Knee Arthroplasty

BACKGROUND

The comparative effectiveness of neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and electroacupuncture (EA) for improving patient rehabilitation following total knee arthroplasty (TKA) is controversial. Therefore we conducted this systematic review to assess the available evidence.

METHODS

The PubMed, OVID, and ScienceDirect databases were comprehensively searched and studies were selected and analyzed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Data were extracted and qualitatively synthesized for several outcomes.

RESULTS

Data were analyzed from 17 randomized controlled trials involving 1285 procedures: 8 NMES studies (608 procedures), 7 TENS studies (560 procedures), and 2 EA studies (117 procedures). Qualitative analysis suggested that NMES was associated with higher quadriceps strength and functional recovery after TKA. Recovery benefits were maximal when the stimulation was performed once or twice a day for 4-6 weeks at an intensity of 100-120 mA and frequency of 30-100 Hz. The electrode should be sufficiently large (100-200 cm²) to reduce discomfort. TENS at an intensity of 15-40 mA and frequency of 70-150 Hz provided effective analgesia after TKA. EA at an intensity of 2 mA and frequency of 2 Hz may also provide postoperative analgesia of TKA.

CONCLUSION

As adjunct modalities, NMES and TENS can effectively improve rehabilitation after TKA without triggering significant intolerance, and maximal benefits depend on optimized parameters and intervention protocols. EA may be an effective adjunct modality for analgesia after TKA.