1. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION IN OSTEOPOROSIS RELATED PAIN
Sanjay Kalra, Bharti Kalra,
Bharti Hospital, Karnal
INDIA

2. BACKGROUND Pain is a common comorbid feature of osteoporosis.
Many drugs are available to manage pain, but all have limited success.
Adverse effects, drug interactions and geriatric nature of most patients limit the use of drugs
There is a need for non pharmacological means of symptom management.

3. The first uses of electroanalgesia were recorded by Aristotle, Pliny and Plutarch, who reported application of electrical fish to pain sites.

5. TENS
Transcutaneous electrical nerve stimulation (TENS) is an electrical modality of pain relief (Chabel et al; 1997, Shealy 2003) .
Considered gold standard amongst non pharmacological modalities of pain relief (Mc Quay et al;1997).

6. No reports are available, however, on the use of TENS in osteoporosis
PRESENT STATUS
No reports are available, however, on the use of TENS in osteoporosis
No reports are available on effect of TENS on varying symptoms such as burning, lancinating pain, deep pain, crawling sensation and allodynia.

7. TENS
TENS devices consist of electronic stimulus generator which transmits pulses to electrodes on skin for pain management .
Electrical pulses may block transmission of pain fibres ( large diameter myelinated A vs non myelinated slow C fibres) or may stimulate release of endogenous opioids.

8. STUDY DESIGN
Single blind, randomized, prospective, single centre study at Bharti Hospital, Karnal.
To assess efficacy of TENS, compared with diclofenac, in subjects with osteoporosis and pain.
To assess efficacy of TENS in different symptoms of pain.

9. PATIENT POPULATION Diclofenac 50 mg b.d. x 3 weeks.
30 patients in group I:
Diclofenac 50 mg b.d. x 3 weeks.
Five o d/ EOD sittings of 15 min using sham electrodes with no stimulation.
30 patients in group II
5 o d/ EOD sittings of TENS.( Life Care, Ghaziabad, India)
Duration, intensity of TENS decided on daily basis by physiotherapist (FREQUENCY ; hold: relax ratio modulation)

10. STUDY DESIGN Osteoporosis management as routine
No opioids, TCAs, SSRIs etc. given to TENS group.
Supportive management as needed.
Pain severity assessed by visual analog scale
Validated English language questionnaires used to assess physician communication, time spent in stretching/strengthening exercise, social/role activities limitation, cognitive symptom management, health distress score and energy/fatigue levels.

12. TENS PARAMETERS Square Rectangular Sinusoidal Triangular /spiked
WAVE FORMS
Biphasic (containing both + ve and –ve waveforms).
may be –
Square
Rectangular
Sinusoidal
Triangular /spiked
Selection depends on patient’s comfort.

13. TENS PARAMETERS EOD to q6h (od or EOD) 15 mins to 1 hour (15 mins)
FREQUENCY OF DOSING
EOD to q6h (od or EOD)
DURATION OF SITTING
15 mins to 1 hour (15 mins)
FREQUENCY
Hz / 2-10 Hz
PULSE WIDTH / DURATION
µs ( µs)

15. TENS PARAMETERS
CURRENT – 60 mA ; treatment based on patients sensation (12 – 30 mA).
CONSTANT CURRENT VS VOLTAGE
constant voltage.
HOLD TIME
10:1 to 1:1 ratio (6 to 9” hold 4 to 3” rest ratio)

16. TENS PARAMETERS Associated nerve roots and dermatomes. Point of pain
PLACEMENT OF ELECTRODES
Associated nerve roots and dermatomes.
Point of pain
Acupuncture point proximal/distal to point of pain.
Trans artheral placements ( knee & foot).
Contra lateral placements in inaccessible areas due to amputations, dressings, open wounds & casts.

19. MODULATION IN TENS frequency modulation Frequency modulation
Pulse width modulation
Current modulation
May vary about 10% periodically.
(e.g 12 to 15 to 12 to 15 mA etc.)
Hold: relax ratio modulation
frequency modulation

20. BASELINE CHARACTERISTICS
Group
Diclofenac +
TENS
Age (years)
47.60 ± 22.40
46.11 ± 23.88
Gender (female/male)
22/8
19/11
Durn of pain(years)
1.86 ± 1.12
1.86 ± 1.21
Tingling 7 8
Burning 3
Deep pain 17 15
Restless legs 5

21. DICLOFENAC mean improvement
Symptom
TENS GROUP
mean improvement
(pain score)
DICLOFENAC mean improvement
burning**
3.28 ± 0.64
1.12 ± 0.33
tingling
2.62 ± 0.35
1.68 ± 0.72
restless legs*
2.16 ± 0.56
0.91 ± 0.12
DEEP PAIN**
3.00 ± 0.00
2.00± 0.15
* P<0.05; **P<0.01

22. DOSE
The dose of TENS used varied from 5.5 to 9.0 Hz on the initial day to 3.5 to 5.5 Hz on the last sitting. The dose varied insignificantly for different symptoms
This difference was maintained after 3 weeks, even though the TENS sittings had stopped

23. Improvement in
Physician communication score :1.43 ± 1.19 to ± 0.86 over one month of therapy in all subjects.
Time spent in stretching/strengthening exercise: ± 0.0 to 15.0 ± 0.0 min/week.
social/role activities limitation : 2.25 ± 0.63 to ± 0.39.
Cognitive symptom management : 1.30 ± 0.63 to ± 0.67.
health distress score:3.20 ± 0.82 to 1.35 ± 0.47
Energy/fatigue score: 2.25 ± 0.51 to 3.30 ± 0.50

24. PCS= Physician communication score ,TSE= Time spent in stretching/strengthening exercise,SAL= social/role activities ,CSM= Cognitive symptom management, HDS=health distress score,EFS= Energy/fatigue score

25. Conclusion
Till date no study has tried to assess effect of TENS in osteoporosis-related pain.
This study demonstrates the increased efficacy of TENS in osteoporosis with pain-related symptoms.
The efficacy and efficiency of TENS as a therapeutic modality in persons with osteoporosis and pain is worthy of more extensive study.

26. INDIAN SOCIETY FOR BONE AND MINERAL RESEARCH
ACKNOWLEDGEMENTS
STAFF AND PATIENTS of
BHARTI HOSPITAL
KARNAL
INDIAN SOCIETY FOR BONE AND MINERAL RESEARCH

27. Thank you