PAIN FACTS 6

Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip.Diab. DCA, Dip. Software statistics PhD (physio)Mahatma Gandhi medical college and research institute , puducherry – India

USUALLY WE DO BY

NONPHARMACOLOGICAL METHODS

SOME METHODS

TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

acupuncture Others ultrasound heat and cold laser

WHAT IS TENS

TENS is the process of applying low-voltage electrical impulses to the skin to affect conduction in the underlying nerves

No drugs

But use our own neurobiology to relieve pain

GATE CONTROL THEORY

WORKS BY GATE CONTROL THEORY

Underlying mechanism explaining the efficacy of

TENS is based on the gate-control theory. It is

felt that stimulating the larger A-β fibers by

selective application of electricity may inhibit

nociceptive conduction by the smaller A-δ

and C fibers.

TYPES

Conventional TENS High frequency (40- 150 Hz) low

intensity 10-30 mA ----- gate control theory

Acupuncture like TENS Low frequency bursts (1-2 Hz) high

intensity (20 -50 mA) – endorphin release

OTHER MODES

Intense mode – high freq, high amplitude

Modulating ( rise is in steps)

Conventional and acu – alternate

APPLICATION

Three parts Stimulator On/off switch, pulse width, amperage ,

frequency Leads Electrodes Carbon rubber, self adhesive

COMMERCIALLY AVAILABLE TENS UNIT

USE OF EQUIPMENT

Position the electrodes In pairs Minimum 1 cm apart even jelly (TENS jelly) ECG more saline , more skin irritation Skin clean and dry Maximum 24 hours – change electrodes Dual sometimes

STIMULATOR

comfortable paresthesia What is shock ?? Demonstrate usually

70 Hz Comfortable No muscle spasm (conventional) TENS trial 1 hour, familiarize, no side effects,

acceptance Start for a treatment plan

INCREASED AMPLITUDE

INDICATIONS – ACUTE AND CHRONIC Acute Labour Arthritis Dysmenorhoea Post op pain

No side effects of opioids or NSAIDs

EXAMPLES

INNUMERABLE STUDIES FOR TENS IN POST OP ANALGESIA

Superficial pain and deep pain SHAM TENS – less effective All types of surgeries Peak pain Total narcotics Side effects , lung function TFA – all are favourable

OTHER PAINFUL CONDITIONS

PHN ICN Facial pain Tic Angina Itch Peripheral vascular insufficiency Central pain states, psychogenic ??

OUTCOMES

Region, stimulator type,patient type – no changes

VAS reduction by 50 % in 47 % individuals Onset – 30 minutes in 75 % one hour in 95 %

Some may need 9 hours a day Not useful as a single therapy in severe

pain

COMPLICATIONS

Skin irritation Possibly one third in patients – more

than 7 hours

Dry skin and proper electrode gelly with changing the place atleast every 24 hours

COMPLICATIONS

Allergy Possibly around 1% Gelly, pads, can be changed

Skin burn Think of TENS only when there is

normal sensation in the area applied

COMPLICATIONS

Equipment failure Battery exhaustion, wire fracture

especially in the junctions

Tolerance Stop , Change mode Use other methods

CONTRAINDICATIONS

1. don’t -- anterior neck Fear of carotid sinus stimulation , fear

of laryngeal spasm 2. don’t stimulate on the pregnant

uterus

3. pacemaker patients beware 4. implantable drug delivery and SCS

SUMMARY

TENS – expansion What is it? Types Parts Uses Side effects Contraindications

JOACP 2001 DR. S.PARTHASARATHY

ACUPUNCTURE

It is estimated that acupuncture was first used in China 4000 to 5000 years ago.

Preliminary evidence suggests that acupuncture may modulate the hypothalamus–limbic system and subcortical gray structures of the human brain.

EA to modulate expression of the c-fos gene in the central nervous system.

CLINICAL USES

acupuncture can alleviate dental pain and

postoperative nausea

EA can decrease the postoperative opioid

requirement.

used in other types of surgical procedures such

as craniotomy, tonsillectomy, thyroidectomy, and

labour-related procedures as analgesia

As a sole anaesthetic ??

CHRONIC PAIN – USES

chronic neck pain Headache LBA, OA PA Tennis elbow CRPS

ACUTE PAIN – USES

labour pain Post op pain Trauma Angina

IJA 2001 . DR.S.PARTHASARATHY

PROBLEMS – NOT MUCH

Needle injuries Infection Bleeding

THERAPEUTIC HEAT

As old as human being

Pain, spasm, RSD, thrombophlebitis, FMS, bursitis, hematoma resolution

Superficial and deep heating modalities

PROBLEMS

Gonads, Malgnancies Haemorrhagic disease Foetus

SUPERFICIAL

Water heating pads Chemical pads Paraffin baths Hydrotherapy

DEEP MODALITIES - CONVERSION OF PHYSICAL ENERGY TO HEAT

Ultrasound 1 MHz Direct and indirect - ?metal

prostheses ,more deep Amputation neuroma Short wave diathermy 25 MHz Electromagnetic radio waves , no metals no

jewels , Cu T , superficial poor water Microwave diathermy 1000 MHz High water content , less energy leak and

more efficient Edema sweat, cataract ??

THERAPEUTIC COLD

Pain, injury spasm,tendinitis etc

No in raynauds, cold intolerance and decreased sensation.

Packs, whirlpools, evaporative cool sprays, and chemical ice packs

Massaging in acu points – effective Alternating heat and cold - CRPS

LABOUR PAIN

J Midwifery Womens Health. 2003 Sep-

Oct;48(5):317-21.

Ice massage for the reduction of

labor pain.

Waters BL, Raisler J.

LASERS

Neo dymium , Helion neon laser

Various indications with variable results

BIOFEEDBACK – ADJUNCT

Presentation to the individual a sensory signal (audio or visual ) that changes in proportion to the biological process.

All pain syndromes Thermistor Skin temperature monitors

and blood flow Electromyographic device Galvanic skin response Heart rate monitors

THANK YOU ALL