TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION IN OSTEOPOROSIS RELATED PAIN Sanjay Kalra, Bharti Kalra, Bharti Hospital, Karnal INDIA bhartihospital@rediffmail.com

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.

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

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).

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.

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.

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.

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)

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 0 - 10. 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.

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.

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 80-150 Hz / 2-10 Hz PULSE WIDTH / DURATION 50 -400 µs (100-200 µs)

TENS PARAMETERS CURRENT 0 – 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)

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.

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

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

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

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

Improvement in Physician communication score :1.43 ± 1.19 to 3.93 ± 0.86 over one month of therapy in all subjects. Time spent in stretching/strengthening exercise: 0.0 ± 0.0 to 15.0 ± 0.0 min/week. social/role activities limitation : 2.25 ± 0.63 to 1.08 ± 0.39. Cognitive symptom management : 1.30 ± 0.63 to 2.00 ± 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

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

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.

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

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