Leica S. Claydon

Effects of simultaneous dual-site TENS stimulation on experimental pain

Transcutaneous electrical nerve stimulation (TENS) is commonly used for pain relief. However, little robust research exists regarding the combination of parameters required to provide effective doses. This study investigated the hypoalgesic effects of different parameter combinations, applied simultaneously at two sites (segmental and extrasegmental), on pressure pain threshold (PPT) in pain‐free humans. Two‐hundred and eight volunteers (median age 22 years, range 20–26) were randomized to eight groups: six active TENS groups, placebo and control. Parameter combinations were such that frequency always differed at each site (110Hz or 4Hz), but intensity could be either the same or different levels: high (to tolerance without pain) or low (strong but comfortable). TENS was administered to the forearm over the radial nerve and the ipsilateral leg below the fibular head for 30min with monitoring for 30 further minutes. PPT measurements were taken bilaterally from the mid‐point of first dorsal interosseous muscle, by an independent blinded rater, at baseline and at six subsequent 10‐min intervals. Log‐transformed data were analysed using repeated‐measures analysis of covariance (baseline values and gender as covariates). Those groups using high‐intensity stimulation at the segmental stimulation sites showed significantly greater hypoalgesia than placebo (p<0.025 in each case). The largest hypoalgesic effect was for simultaneous high‐intensity stimulation at segmental and extrasegmental sites, using different frequencies. These results reaffirm that high‐intensity stimulation (regardless of frequency) is of fundamental importance in effective dosage.

Dose-specific effects of transcutaneous electrical nerve stimulation (TENS) on experimental pain: a systematic review.

ObjectiveTo determine the hypoalgesic effects of transcutaneous electrical nerve stimulation (TENS) parameter combinations on experimental models in healthy humans. MethodsSearches were performed using the electronic databases Ovid MEDLINE, CINAHL, AMED, and Web of Science (from inception to December 2009). Manual searches of journals and reference lists of retrieved trials were also performed. Randomized controlled trials (RCTs) were included in the review if they compared the hypoalgesic effect of TENS relative with placebo and control, using an experimental pain model in healthy human participants. Two reviewers independently selected the trials, assessed their methodologic quality and extracted data. ResultsForty-three RCTs were eligible for inclusion. A best evidence synthesis revealed: Overall “conflicting” (inconsistent findings in multiple RCTs) evidence of TENS efficacy on experimental pain irrespective of TENS parameters used. Overall intense TENS has “moderate” evidence of efficacy (1 high-quality and 2 low-quality trials). Conventional TENS has overall conflicting evidence of efficacy, this is derived from “strong” evidence of efficacy (generally consistent findings in multiple high-quality RCTs) on pressure pain but strong evidence of inefficacy on other pain models. “Limited” evidence (positive findings from 1 RCT) of hypoalgesia exists for some novel parameters. Low-intensity, low-frequency, local TENS has strong evidence of inefficacy. Inappropriate TENS (using “barely perceptible” intensities) has moderate evidence of inefficacy. DiscussionThe level of hypoalgesic efficacy of TENS is clearly dependent on TENS parameter combination selection (defined in terms of intensity, frequency, and stimulation site) and experimental pain model. Future clinical RCTs may consider these TENS dose responses.

A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation

The aim of this systematic review of systematic reviews was to critically appraise systematic reviews on Anterior Cruciate Ligament (ACL) reconstruction rehabilitation to determine which interventions are supported by the highest quality evidence. Electronic searches were undertaken, of MEDLINE, AMED, EMBASE, EBM reviews, PEDro, Scopus, and Web of Science to identify systematic reviews of ACL rehabilitation. Two reviewers independently selected the studies, extracted data, and applied quality criteria. Study quality was assessed using PRISMA and a best evidence synthesis was performed. Five systematic reviews were included assessing eight rehabilitation components. There was strong evidence (consistent evidence from multiple high quality randomised controlled trials (RCTs)) of no added benefit of bracing (0-6 weeks post-surgery) compared to standard treatment in the short term. Moderate evidence (consistent evidence from multiple low quality RCTs and/or one high quality RCT) supported no added benefit of continuous passive motion to standard treatment for increasing range of motion. There was moderate evidence of equal effectiveness of closed versus open kinetic chain exercise and home versus clinic based rehabilitation, on a range of short term outcomes. There was inconsistent or limited evidence for some interventions. Recommendations for clinical practice are made at specific time points for specific outcomes.

The effects of spinal mobilizations on the sympathetic nervous system: A systematic review

The activity of the sympathetic nervous system is of importance to manual therapists, since the experience of pain is associated with sympathetic activity. There has been little exploration into the effects of mobilizing vertebral segments below the cervical spine. In addition to this, a synthesis of the evidence for changes in sympathetic outcome measures has not been completed. The primary aim of this review was to investigate the effects of spinal mobilizations compared to a control or placebo on sympathetic outcome measures. The secondary aim was to establish the level of change, either excitatory or inhibitory, in sympathetic outcome measures. Five electronic databases (Ovid Medline, Embase, AMED, PEDro, and the Cochrane library; from database inception to May 2012) were searched for randomized controlled trials. Two independent raters applied inclusion criteria and rated studies for methodological quality. Seven studies met the inclusion criteria. All studies demonstrated a consistent increase in sympathetic outcome measures, indicative of sympathetic excitation, irrespective of the segments mobilized. Synthesis of the results established strong evidence (multiple high-quality randomised controlled trials (RCTs) for a positive change in skin conductance, respiratory rate, blood pressure, and heart rate among the healthy population. As only one study investigated changes in a symptomatic population, there was limited evidence (one RCT) for an increase in skin conductance and decrease in skin temperature. Evidence from this systematic review supports a sympatho-excitatory response to spinal mobilizations irrespective of the segment mobilized.

The effect of dry needling for myofascial trigger points in the neck and shoulders: A systematic review and meta-analysis

BACKGROUND and purpose: The aim of this systematic review with meta-analysis is to determine the effect of dry needling in the treatment of MTrPs. METHODS Searches were performed using the electronic databases AMED, EBM reviews, Embase, and Ovid MEDLINE (all from database inception-February 2012). STUDY SELECTION Randomized controlled trials (RCTs) were included if they compared dry needling with another form of treatment or placebo and included pain intensity as an outcome. DATA EXTRACTION Two blinded reviewers independently screened the articles, scored their methodological quality and extracted data. QUALITY ASSESSMENT Physiotherapy Evidence Database (PEDro) quality scale and the Cochrane risk of bias tool were used. RESULTS Four RCTs compared dry needling to lidocaine and one RCT compared dry needling to placebo. Meta-analyses of dry needling revealed no significant difference between dry needling and lidocaine immediately after treatment standardized mean difference (SMD) 0.41 (95%CI -0.15 to 0.97), at one month (SMD -1.46; 95% CI -2.04 to 4.96) and three to six months (SMD -0.28; 95% CI -0.63 to 0.07). DISCUSSION Although not significant in the meta-analyses, there were interesting patterns favoring lidocaine immediately after treatment and dry needling at three to six months.

Some physiotherapy treatments may relieve menstrual pain in women with primary dysmenorrhea: a systematic review

QUESTION In women with primary dysmenorrhoea, what is the effect of physiotherapeutic interventions compared to control (either no treatment or placebo/sham) on pain and quality of life? DESIGN Systematic review of randomised trials with meta-analysis. PARTICIPANTS Women with primary dysmenorrhea. INTERVENTION Any form of physiotherapy treatment. OUTCOME MEASURES The primary outcome was menstrual pain intensity and the secondary outcome was quality of life. RESULTS The search yielded 222 citations. Of these, 11 were eligible randomised trials and were included in the review. Meta-analysis revealed statistically significant reductions in pain severity on a 0-10 scale from acupuncture (weighted mean difference 2.3, 95% CI 1.6 to 2.9) and acupressure (weighted mean difference 1.4, 95% CI 0.8 to 1.9), when compared to a control group receiving no treatment. However, these are likely to be placebo effects because when the control groups in acupuncture/acupressure trials received a sham instead of no treatment, pain severity did not significantly differ between the groups. Significant reductions in pain intensity on a 0-10 scale were noted in individual trials of heat (by 1.8, 95% CI 0.9 to 2.7), transcutaneous electrical nerve stimulation (2.3, 95% CI 0.03 to 4.2), and yoga (3.2, 95% CI 2.2 to 4.2). Meta-analysis of two trials of spinal manipulation showed no significant reduction in pain. None of the included studies measured quality of life. CONCLUSION Physiotherapists could consider using heat, transcutaneous electrical nerve stimulation, and yoga in the management of primary dysmenorrhea. While benefits were also identified for acupuncture and acupressure in no-treatment controlled trials, the absence of significant effects in sham-controlled trials suggests these effects are mainly attributable to placebo effects.

Alternating-frequency TENS effects on experimental pain in healthy human participants: a randomized placebo-controlled trial.

Background:Transcutaneous electrical nerve stimulation (TENS) is a modality commonly used in pain management. Objectives:This study investigated the hypoalgesic effects of alternating-frequency TENS (4 Hz for 3 s/110 Hz for 3 s) on pressure pain threshold (PPT). Methods:Two-hundred and eight healthy, pain-free volunteers (19 to 59 y old; 104 males, 104 females) were randomized to 8 groups: 6 active TENS groups, placebo, and control (n=26 per group). Parameter combinations were such that alternating-frequency TENS was combined with different levels of intensity “low” (strong but comfortable) or “high” (strong and uncomfortable but not painful). TENS was administered either at the forearm (segmental stimulation), at the ipsilateral leg (extrasegmental stimulation), or at both sites (dual-site stimulation) for 30 minutes and monitored for 30 further minutes. PPT measurements were taken bilaterally from the mid-point of first dorsal interosseous muscle, by an independent blinded rater, at baseline and at 6 subsequent 10-minute intervals. Square-root transformed data were analyzed using repeated measures analysis of covariance (baseline values and sex as covariates). Results:Alternating-frequency TENS groups did not achieve significant hypoalgesic effects compared with placebo or control (P>0.05). The largest increase in PPT (from baseline) was 76.6 kPa with low-intensity segmental alternating frequency TENS at the 20-minute stimulation time point. This change from baseline is below a difference of 100 kPa that is considered to be a clinically meaningful change in hypoalgesia. Discussion:The alternating-frequency setting does not result in large hypoalgesic effects such as those previously reported using fixed-frequency TENS.

Systematic review of the psychometric properties of balance measures for cerebellar ataxia

Objective: To review systematically the psychometric properties of balance measures for use in people with cerebellar ataxia. Data sources: Medline, AMED, CINAHL, Web of Science and EMBASE were searched between 1946 and April 2014. Review methods: Two reviewers independently searched data sources. Cerebellar-specific and generic measures of balance were considered. Included studies tested psychometric properties of balance measures in people with cerebellar ataxia of any cause. Quality of reported studies was rated using the Consensus Based Standards for the selection of health status Measurement INstruments (COSMIN) checklist. Results: Twenty-one articles across which 16 measures had been tested were included for review. Using the COSMIN, quality of methodology in studies investigating psychometric properties of generic balance measures (n=10) was rated predominantly as ‘poor’. Furthermore, responsiveness has not been tested for any generic measures in this population. The quality of studies investigating psychometric properties of balance sub-components of the cerebellar-specific measures (n=6) ranged from ‘poor’ to ‘excellent’; however, Minimally Clinically Important Difference has not been determined for these cerebellar-specific measures. Conclusion: The Posture and Gait (PG) sub-component of the International Cooperative Ataxia Rating Scale (ICARS) demonstrates the most robust psychometric properties with acceptable clinical utility.

Injuries and falls among adults with intellectual disability: A prospective New Zealand cohort study

Abstract Background Falls and fall-related injuries are a problem for many adults with intellectual disability. Most previous studies have collected falls data retrospectively, using organisational incident reports. We developed tools to specifically collect fall-related data and potential fall risk data. This paper reports on the development of these tools and the fall-related data collected in 3 prospective studies. Method Consultations with 33 stakeholders representing 29 organisations and 5 focus group discussions were used to develop 2 tools for gathering information. Studies in 3 cities applied the tools to explore their acceptability, utility, and cultural appropriateness. Results Two simple tick box forms were developed; both were easy and quick to complete. In the studies, 135 individuals participated (70 males, 65 females, aged 45 [SD = 11] years), of whom 27% experienced a fall; 39% of these resulted in an injury. Injuries were mostly bruises (30%) and grazes (28%), particularly to the facial area (42%). The 6-month period prevalence of falls was 0.76%. Most falls occurred indoors and during the daytime. Individuals appeared more likely to experience a fall if they had had previous falls and/or fractures, epilepsy, orthopaedic-related conditions, and problems with gait and balance. Conclusion A robust process ensured the acceptability, utility, face and content validity, and cultural safety of our data collection tools. Falling is a serious problem for many people with intellectual disability, but the reasons for falling appear multifaceted and complex, complicating the development of fall prevention programs.

Pain and Physical Functioning in Neuropathic Pain: A Systematic Review of Psychometric Properties of Various Outcome Measures.

A range of outcome measures across various domains are used to evaluate change following an intervention in clinical trials on chronic neuropathic pain (NeP). However, to capture a real change in the variable of interest, the psychometric properties of a particular measure should demonstrate appropriate methodological quality. Various outcome measures in the domains of pain and physical functioning have been used in the literature for NeP, for which individual properties (eg, reliability/validity) have been reported. To date, there is no definitive synthesis of evidence on the psychometric properties of those outcome measures; thus, the aim of this systematic review was to evaluate the methodological quality [COnsensus‐based Standards for the selection of health status Measurement INstruments (COSMIN) guidelines] of studies that evaluated psychometric properties of pain and physical functioning outcome measures used for NeP.