Current concepts in electrotherapy

Pain management in hemophilia: expert recommendations

INTRODUCTION

As a typical consequence of bleeding into muscles and joints, patients with severe hemophilia suffer from acute and chronic pain. In spite of its high prevalence, pain in this patient group is not always sufficiently considered or treated in an effective manner.

AIM

The recommendations presented in this paper address possible improvements in pain management in hemophilia patients and particularities that have to be taken into account in this patient group.

METHOD

The manifold aspects of pain management in hemophilia patients were discussed within the framework of an expert meeting. Based on the available literature and the experts' clinical experience, the participants developed a set of recommendations presented in this paper.

RESULTS

Pain management in patients with hemophilia is often insufficient, a fact that not only influences the patients' quality of life but also implies the risk of difficult to manage chronic pain. Both the prevalent polypharmacy (due to comorbidities) as well as the underlying disease itself present special challenges to pain therapy in this patient group. The present review and recommendations are intended to support medical professionals in recognising the risks of pain chronicity, applying basic principles of multimodal pain therapy, including the options of psychological intervention and modalities of physical medicine in therapy concepts, and reaching a comprehensive understanding of the range of analgesic options available.

[Pain therapy for children and adolescents with hemophilia : Recommendations by an expert panel]

BACKGROUND

Children and adolescents with severe hemophilia commonly suffer from acute and chronic pain as a consequence of hemophilia-related bleeding. Intervention-related pain also plays a major role. Despite its high prevalence in this patient group, hemophilia-related pain is not always adequately addressed and sufficiently treated.

OBJECTIVES

This paper discusses how to improve pain management for children and adolescents (0-18 years) with hemophilia and which specific features in this population should influence decisions in pain management.

MATERIALS AND METHODS

An expert panel discussed challenges in pain treatment in children and adolescents with hemophilia. Recommendations are based on evidence and clinical experience.

RESULT

Pain management in children with hemophilia needs improvement. Children with hemophilia are at risk of developing chronic pain and of suffering traumatization due to insufficient pain management. Pain therapy can be challenging in these children as both their age and the underlying disease limit the options in particular in pain medication. The expert panel developed recommendations to improve pain management in children with hemophilia.

Immediate Effects of Simultaneous Application of Transcutaneous Electrical Nerve Stimulation and Ultrasound Phonophoresis on Active Myofascial Trigger Points: A Randomized Controlled Trial

OBJECTIVE

The aim of the study was to investigate the efficacy of phonophoresis with combined therapy on active myofascial trigger points.

PARTICIPANTS

One hundred participants with acute mechanical neck pain and at least one active myofascial trigger point in the upper trapezius were randomly assigned into four equal groups.

INTERVENTION

Groups consisted of diclofenac phonophoresis with combined therapy, diclofenac phonophoresis, ultrasound (US) with coupling gel, and sham US and applied for 10 mins over myofascial trigger points.

MEASUREMENTS

Measurements included pressure pain threshold and active cervical lateral flexion.

RESULTS

There were statistically significant improvements in postintervention pressure pain threshold and range of motion values in treatment groups (P < 0.0001). As for the sham US, no significant difference was found between the preintervention and postintervention values (P > 0.05). Bonferroni correction test revealed that there was a significant difference between all the four groups in pressure pain threshold values (P < 0.0001); however, it was nonsignificant (P > 0.05) for range of motion.

CONCLUSIONS

Diclofenac phonophoresis with combined therapy, phonophoresis, and US were all effective in increasing pressure pain threshold values and range of motion. In addition, phonophoresis with combined therapy was shown to be superior over phonophoresis, and phonophoresis was superior over US in terms of reducing pain sensitivity. However, none of the treatment groups were found to be superior over the other in increasing range of motion.

Electroacupuncture for the treatment of supraspinatus calcific tendonitis

BACKGROUND

Conservative treatment of calcific tendonitis includes rest, medications, and physical therapy. Several physiotherapy interventions such as shockwave therapy are commonly used. The aim of this study was to investigate the efficacy of an electrotherapy method called electroacupuncture, in the treatment of calcific tendonitis.

METHODS

40 patients with calcific tendonitis were randomly divided to receive either a combination of medications and electroacupuncture, or just a course of medications. Evaluated outcomes included pain using the visual analog scale, shoulder range of motion with the use of goniometer, and quality of life along with functional status using the Instrumental Activities of Daily Living Scale (IAOLDS) and the Beck Depression Inventory (BDI). Radiological evaluation for the progression of the calcific deposits was also performed. All these evaluations were performed before and at the end of treatment. A final interview with the patients regarding any recurrent episodes was performed 18-24 months after the end of treatment.

RESULTS

The intervention group showed greater improvement in pain intensity (2.8 points), range of motion (forward flexion, +30; abduction +29) when compared with the control group (for all, P < .05) while there was no statistically significant difference regarding the quality of life (IOLDS +0.2; BDI 0). Radiological evaluation demonstrated total or nearly total absorption of calcific deposits in 15 patients of the intervention group and in 8 patients of the control group.

CONCLUSION

The successful clinical results of electroacupuncture and the regression of calcific depositions after treatment showed that electroacupuncture may have a role as a treatment modality in calcific tendonitis.

Comparison of treatment effects on lateral epicondylitis between acupuncture and extracorporeal shockwave therapy

Background

Lateral epicondylitis is one of the most common overuse injuries, and has been reported to reduce function and affect daily activities. There is no standard therapy for lateral epicondylitis. In Hong Kong, acupuncture and extracorporeal shockwave therapy (ESWT) have been popular in treating lateral epicondylitis in recent years.

Objective

This study is to compare the treatment effects of acupuncture and ESWT on lateral epicondylitis.

Methods

In this study, we evaluated 34 patients (34 elbows) with lateral epicondylitis. Seventeen patients were treated by 3-week ESWT, one session per week. Another 17 were treated by 3-week acupuncture therapy, two sessions per week. The outcome measures included pain score by visual analogue scale, maximum grip strength by Jamar dynamometer, and level of functional impairment by disability of arms, shoulders, and hands questionnaire. Participants were assessed at three time points: baseline; after treatment; and 2-week follow-up.

Results

The two treatments showed no significant difference at any assessment time-point. Both treatment groups had significant improvement in pain score in longitudinal comparisons. No significant difference was found in maximum grip strength and functional impairment in either treatment group, but a trend of improvement could be observed. In addition, improvement in pain relief stopped when treatment ended for either groups.

Conclusions

The treatment effects of acupuncture and ESWT on lateral epicondylitis were similar. The pain relief persisted for at least two weeks after treatment.

Preconditioning with mono and polyunsaturated fatty acids and low-intensity electrical stimulation. Effects on skin repair in rats

PURPOSE

To evaluate the effects of preconditioning with oils mixes containing ω3/ω6/ω9 associated with micro-currents on skin repair in rats.

METHODS

One-hundred and eight Wistar rats randomized into G-1, G-2 and G-3 groups were treated with saline (0.9%), mix 1 (corn+soybean oils) and mix 2 (olive+canola+flaxseed oils), respectively, in a single dose (0.01ml/g) by gavage. Next, each group was subdivided into sham and stimulated subgroups. Pulsed-wave microcurrents (0.5 µA, 0.5 Hz) were applied to stimulated subgroups for 20 min. One hour later anesthetized rats were subjected to surgery. A dorsal incision (6 cm long) was carried out and closed with interrupted nylon sutures. Samples (1 cm2) were harvested from the mid-portion of the incision on the 7, 14, 21 post-operative (P.O.) days. Variables were analyzed using Mann-Whitney/Dunn tests Significance level was set to 5 % (p<0.05).

RESULTS

Micro-currents promoted increase of exudate and reduction of epithelialization on day 7 in G1 rats. Mixes 1/2 reduced vascularization on 7/14th days P.O. Both 1/2 mixes reduced fibrosis on day 14. Preconditioning with mix 1 led to increased expression of NF-kB on the 7th day.

CONCLUSION

Preconditioning with microcurrents has pro-inflammatory effects while oil mixes 1 and 2 decrease fibrosis and vascularization in the proliferative phase of cicatrization.

Analgesic effects of transcutaneous electrical nerve stimulation and interferential current on experimental ischemic pain models: frequencies of 50 hz and 100 hz

[Purpose] This study compared the analgesic effects of transcutaneous electrical nerve stimulation (TENS) and interferential currents (IFC) on induced ischemic pain in healthy volunteers. [Subjects] The subjects were 36 volunteers (18 male, 18 female) without known pathology that could cause pain. Their mean age was 24.5±2.2 years. [Methods] A single-blind and parallel-group method was used. Subjects were randomly allocated to receive each 50 Hz TENS, 50 Hz IFC, 100 Hz TENS, and 100 Hz IFC. This study experimentally induced ischemic pain in otherwise pain-free subjects using a modified version of the submaximal effort tourniquet technique. Subjects completed twelve cycles of the ischemic-induced pain test. The primary outcome measure was the change in self-reported of pain intensity during one of four possible treatments. [Results] There were significant effects for Time, which were attributed to a significant reduction in pain intensity for all groups. There were no significant effects for groups or group-time interaction. The 50 Hz IFC treatment was more comfortable than the other treatments in the present study, and it is likely to be better accepted and tolerated by patients. [Conclusion] We conclude that there were no differences in the analgesic effects of the four treatments under the present experimental conditions. The 50 Hz IFC treatment is more comfortable than the other treatments.

Effects of microcurrent application alone or in combination with topical Hypericum perforatum L. and Arnica montana L. on surgically induced wound healing in Wistar rats

OBJECTIVES

This study evaluated the wound healing activity of microcurrent application alone or in combination with topical Hypericum perforatum L. and Arnica montana L. on skin surgical incision surgically induced on the back of Wistar rats.

DESIGN

The animals were randomly divided into six groups: (1) no intervention (control group); (2) microcurrent application (10 μA/2 min); (3) topical application of gel containing H. perforatum; (4) topical application of H. perforatum gel and microcurrent (10 μA/2 min); (5) topical application of gel containing A. montana; (6) topical application of A. montana gel and microcurrent (10 μA/2 min). Tissue samples were obtained on the 2nd, 6th and 10th days after injury and submitted to structural and morphometric analysis.

RESULTS AND CONCLUSION

Differences in wound healing were observed between treatments when compared to the control group. Microcurrent application alone or combined with H. perforatum gel or A. montana gel exerted significant effects on wound healing in this experimental model in all of the study parameters (P<0.05) when compared to the control group with positive effects seen regarding newly formed tissue, number of newly formed blood vessels and percentage of mature collagen fibers. The morphometric data confirmed the structural findings. In conclusion, application of H. perforatum or A. montana was effective on experimental wound healing when compared to control, but significant differences in the parameters studied were only observed when these treatments were combined with microcurrent application.

Comparison between pulsed ultrasound and low level laser therapy on experimental haemarthrosis

The use of pulsed ultrasound (PUS) and low level laser therapy (LLLT) in patients with haemophilia has been recommended for supportive treatment of acute and chronic phases of haemarthrosis but its role has not been supported by experimental evidence. The purpose of the present study was to evaluate the effect of these modalities on joint swelling, friction and biomechanical parameters of articular cartilage. An experimental rabbit knee haemarthrosis model was used to test the hypothesis that LLLT and PUS favourably impacted on the biotribological and biomechanical properties of cartilage after joint bleeding. To test this, 35 male albino rabbits weighing 1.5-2 kg were used. The left knee of 30 rabbits was injected with 1 mL of fresh autologous blood two times per week for four consecutive weeks to simulate recurrent haemarthrosis; five rabbits served as non-bleeding controls. Ten rabbits were treated with PUS and 10 with LLLT and the remaining 10 were not treated. The treatments were started after 2 days and the treatment duration was planned for 5 days (sessions) in ultrasound and laser groups. A low level Ga-Al-As laser was applied with an 810 nm wavelength, 25 mW power, and 1 J cm(-2) dosage for 200 s duration. The PUS treatment was applied with a duty cycle of 1/9, frequency of 1 MHz, and power of 0.4 W cm(-2) for 150 s. Joint perimeter was measured before the procedure at the beginning of therapies and after cessation of the procedure. Friction and biomechanical parameters were measured immediately after the killing of the animals. The results demonstrate that PUS was more effective in reducing knee joint swelling than LLLT. Moreover, PUS had the unique ability of reducing the joint friction below normal values. However, it was not successful in returning the articular cartilage force and stiffness to normal state. LLLT was more effective in increasing equilibrium force of the articular cartilage than PUS, however, neither therapy normalized this parameter. From these data, we conclude that PUS is more effective than LLLT in reducing joint swelling and articular joint friction after experimental haemarthrosis.

Influence of heat on fatigue and electromyographic activity of the biceps brachii muscle

Electromyography enables registering muscle activity during contraction and can identify muscle fatigue. In the present study, 30 volunteers between 18 and 30 years of age were submitted to an exertion 1 min of maximal voluntary isometric contraction. The electromyographic signal of the biceps brachii muscle and the strength of the flexor muscles of the elbow were determined before and after the administration of microwave diathermy in order to analyze the influence of heat over the strength of the elbow flexor muscles and fatigue of the biceps brachii. The results demonstrate that the strength of the elbow flexor muscles diminished significantly following the application of heat (p<0.05). Heat also led to a significant reduction in the electrical activity of the muscle studied. The present study demonstrates that microwave diathermy on the biceps brachii muscle reduces the flexion strength of the elbow as well as signs of muscle fatigue in the biceps.

Penetration and spread of interferential current in cutaneous, subcutaneous and muscle tissues

OBJECTIVES

To investigate the penetration depth of interferential current (IFC) through soft tissue and the area over which it spreads during clinical application.

DESIGN

A laboratory-based study of healthy participants.

SETTING

A university research laboratory.

PARTICIPANTS

Twelve healthy subjects.

INTERVENTIONS

Premodulated IFC at 90 Hz and 'true' IFC at frequencies of 4, 40 and 90 Hz were applied via four electrodes, in a quadrant setting, to the distal medial thigh of each participant on separate occasions.

MAIN OUTCOME MEASURE

Voltage induced by tested currents was measured at three locations (middle of the four electrodes, in line with one circuit and outside the four electrodes) and three depths (skin, subcutaneous and muscle tissues) using three Teflon-coated needle electrodes connected to a Cambridge Electronic Design data acquisition system.

RESULTS

All voltages were greater at all depths and locations compared with baseline (P<0.001): premodulated IFC [mean difference 0.112, 95% confidence interval (CI) 0.065 to 0.160], 4 Hz (mean difference 0.168, 95% CI 0.106 to 0.229), 40 Hz (mean difference 0.165, 95% CI 0.107 to 0.223) and 90 Hz (mean difference 0.162, 95% CI 0.102 to 0.221). Voltages decreased with depth. Lower voltages of all currents were recorded in the middle of the four electrodes, with the highest voltage for 'true' IFC being recorded outside the four electrodes (mean difference 0.04, 95% CI 0.01 to 0.029; P=0.011). The premodulated IFC had the highest voltage in line with one circuit.

CONCLUSIONS

IFC passed through soft tissues, with the highest voltages recorded in superficial tissue and the lowest voltages recorded in muscle. For 'true' IFC, the current spread outside the electrodes at higher voltages compared with the intersection of the four electrodes. The premodulated IFC had the highest voltage in line with one circuit. In terms of higher recorded voltages, 'true' IFCs were more efficient than the premodulated IFC when targeting deeper tissues. However, further studies with larger samples are required to confirm the results of this study.

Mechanical stimulation improves survival in random-pattern skin flaps in rats

This was a study on the effects of 3-MHz ultrasound at 16- and 100-Hz pulse repetition frequencies on angiogenesis and viability of random-pattern skin flaps in rats. A cranially-based dorsal skin flap was raised in 60 EPM-Wistar rats, which were randomly divided into four groups: control, sham, 16-Hz and 100-Hz groups. The mean percentage of necrosis was as follows: control, 42% ± 13%; sham, 18% ± 13%; 16-Hz group, 13% ± 10%; and 100-Hz group, 15% ± 7%, with significant differences between the control and the other groups (p < 0.001). The mean vascular density was as follows: control, 5% ± 2%; sham, 7% ± 2%; 16-Hz group, 21% ± 4%; and 100-Hz group, 24% ± 10%, with significant differences between control and ultrasound groups, and between the sham and ultrasound groups (p < 0.001). Both ultrasound treatments (16- and 100-Hz PRFs) induced angiogenesis, and sham and ultrasound treatments improved viability of random-pattern skin flaps in rats.

Ultrasound in contemporary physiotherapy practice

The use of therapeutic ultrasound as an element of physiotherapy practice is well established, but the nature of that practice has changed significantly over the last 20 years. This paper aims to review the rationale and range of applications for which this modality is employed in current practice. Whereas in the past, its primary use was as a thermal modality, it is argued that currently, it is the 'non-thermal' aspects of the intervention that are most commonly employed. The predominant use of therapeutic ultrasound is in relation to tissue repair and soft tissue lesion management, where the evidence would support its application in the inflammatory, proliferative and remodelling phases. The clinical outcomes appear to be dose dependent, and whilst this paper does not detail dose related clinical decision making, the broad issues are considered. The future possibilities for the use of the modality are reviewed, and although outside the immediate remit of this paper, the use of therapeutic ultrasound in fracture management is briefly considered.

Modern management of haemophilic arthropathy

Currently available factor concentrates for treatment of patients with haemophilia are virally inactivated or are made by recombinant technology and their broad use in developed nations has resulted in the dramatic elimination of the treatment-related viral illnesses that decimated the haemophilia community in the late 20th century. The major morbidity experienced by patients with haemophilia today is joint disease, a result of repeated bleeding episodes into joint spaces. Although administration of factor concentrates to prevent bleeding has been demonstrated to prevent haemophilic joint disease when applied assiduously, repeated bleeding episodes induce synovitis that is irreversible and may progress despite subsequent prophylaxis. Surgical and nuclear medicine interventions are available to reduce the pain of haemophilic arthropathy and to reduce further bleeding episodes. Patients with high titre inhibitors are at great risk for the development of joint disease and present the greatest therapeutic challenges when joint surgery is needed.