Thursday 12 April 2012

On the Market


TENS machines are highly accessible, safe and cheap. However, each differs slightly with the amount of functions, simplicity and compatibility of the machine. This is why choosing a specific brand or type is difficult, as each manufacturer markets the benefits of their specific product. Therefore, as trusty health professionals our patients depend on our advice and research when purchasing machines to use whilst at home.


As TENS machines differ in the model of the device rather than the outcome, the decision on which product to purchase depends on the patient. The average price that someone would be looking at would be around the $120 mark. However, cheaper devices could be found that will deliver the same amount of pain relief.

The product choice will also depend on the intellectual and technological capability of the patient. Some devices require input of intensity, time, pulse width, rate and program mode, whereas some are as simple as two buttons: on/off and increase/decrease intensity. Some devices also offer a Private Health Care rebate, which could also be a feasible reason to purchase a specific device.

Some examples of TENS machines on the market include:
NEUROTRAC TENS



Features:
•     Compact in size (approx size of a cigarette packet)
•     2 year warranty
•     Hard plastic case
•     Conventional TENS programs
•     Lightweight, reliable, dual channel TENS unit

Price= $112.90


PAIN EZE:



Features:
·        *  Lightweight at only 17 grams
·        *  Effective and clinically proven electrotherapy system
·       *   Only 2 simple buttons (on/off, intensity up/down)

Price= $135.00



PRO TENS:



 Features:
·        *  More functions, power and versatility than most other TENS
·         * Very affordable price

Price= $116.90


Wednesday 4 April 2012

Contraindications, adverse effects & the literature

Finally, we look at the contraindications of using TENS. The previous blogs have looked at the benefits of TENS for cancer patients, however, not all patients are eligible to be prescribed this treatment.



Despite the amount of controversy surrounding the application of TENS on cancer patients, the amount of proven contraindications are minimal. Firstly, when using TENS, the electrodes are usually placed over the site of pain, however, it is important to note that electrodes must NEVER be placed directly over tumours or sites of pathological lesions. This is highly relevant to cancer patients as they are likely to have these lesions and tumours throughout their body. We have been unable to find any thorough research articles explaining as to why electrodes cannot be placed over tumour sites but it seems that many researches are worried about the electricity promoting cancer cell growth.

As with all electrical stimulation TENS cannot be performed on any patient who has a pacemaker, with electrode placement away from any inflamed, irritated or infected skin. Research also shows that TENS should not be used on any patient who has poor sensation or hypersensitivity. Finally, patients who are unable to understand or respond to the instructions of the therapist would be contraindicated.

Along with the contraindications, there has been limited research based around long-term cancer pain relief and the use of TENS, therefore few adverse effects have been documented. It is noted however, that in the case of temporary aggravation of pain as a result of using high frequency stimulation or excessively strong stimulation, the use of acupuncture points should be avoided. These specific points have a systematic effect on the specific site; therefore, changing the electrode placement sites has been shown to abate this negative effect.

The quality and quantity of the research literature investigating the effects of TENS on cancer patients is poor. Evidence documenting the efficacy of TENS in cancer pain relief is sparse and inconclusive. It is the lack of research that is holding back the spread of the use of TENS for cancer patients, as its beneficial effects have not yet been properly proven and documented. Well-designed and controlled studies are much in need. With the problem of inadequate and very few truly randomized controlled trials. Finally, most of the research that has been conducted has been over a short-term and on a very small scale.

REFERENCES:
http://www.ncbi.nlm.nih.gov/pubmed/11687055


Sunday 1 April 2012

Treating types of cancer



As you can see from our previous blogs, TENS treatment is thought to deal with a variety of cancer pains. To make a well-rounded conclusion on the benefits, we researched a number of studies looking at the patient’s responses to the treatments on different cancers, specifically breast and bone cancer. As well as an interesting topic, it was insightful to look into the pain responses of different people and how they responded to TENS after intense chemo, radiation or surgery.

We viewed this research in a way as to determine whether TENS improved the quality of life in the patients. As the palliative cancer patients and their families know they are unlikely to recover from the disease, therefore their remaining time should be as pain free as possible. If there is a chance of recovery, we believe their energy should be focused on fighting the disease rather than focusing on the pain.

The two most reported causes of cancer pain are pain radiating from the cancer itself and pain following chemotherapy and radiotherapy treatments. Although insufficient evidence has been obtained, research shows that TENS can help reduce side effects and the pain associated with a variety of cancers, improving their quality of life. This is incredibly important to those suffering from cancer, especially the terminally ill.

The use of non-pharamolgical interventions such as TENS, as a multidisciplinary treatment can reduce pain in cancer patients. Although insufficient trials have been studied to provide evidence of the possible side effects and long-term use of TENS on patients, many in palliative care consider pain relief and quality of life the higher priority.

An excellent randomized controlled trial conducted by Karen Robb, has identified the improved quality of life, due to decreased anxiety and pain in women diagnosed with breast cancer. She shows how many women who undergo treatment and are diagnosed with the disease have reported feeling that their pain has not been completely recognized or treated. Not only do these women suffer from the pain of the surgery but also secondary pain due to oedema, sensory disturbances, anxiety and depression, with many refusing pharmalogical medication due to the fear of unwanted side effects.

This is the reason why using TENS is an appealing alternative treatment, with a decrease in the overall pain and side effects in patients undergoing chemotherapy. Its use is said to increase the release of beta-endorphins in the body. These endorphins have an analgesic effect, numbing or dulling pains in the effected areas.  The best results however, are found when combining both pharmacological and non-pharmacological treatments.

In some instances TENS treatment is preferred: similar pain relief is found with limited side effects. One of these side effects of the cancer and its chemotherapy is nausea and vomiting. Research has shown that ALTENS can help significantly reduce these symptoms by inhibiting gastric acid secretion and normalising gastric dysrhythmia. As a cancer patient, reducing these symptoms will dramatically improve their quality of life, a major factor that we believe most, if not all patients would happily welcome.

Another prevalent type of cancer that uses TENS as a treatment option is bone cancer. Bone metastases are common, difficult to treat and the most painful cancer-related pain. These factors are all responsible for reducing a person’s quality of life. Many available treatment options have significant side effects and are currently not considered universally effective. Research has said that by stimulating the fibres, hyperexcitability is reduced as well as dorsal horn changes, decreasing the perception of pain. However, sufficient evidence is still lacking to completely understand the benefits of treating bone cancer and its symptoms with a TENS machine.

The main disadvantage found in trials, and personal outcomes of TENS machine use, was the fact that the benefits were only temporary. It is not designed for total, long lasting pain relief, but considering the immense pain that cancer patients undergo every single day, any relief would be accepted with open arms. Also considering that TENS use is simple, portable and cheap, this disadvantage is not that clinically important because it is so easy to apply multiple treatments to increase the pain relief duration.

Through research, many papers found that the use of TENS machine as treatment was more effective in certain areas of the body. The upper extremity was shown to suppress pain more effectively than the lower extremity, with the truncal region showing the greatest reduction in pain. This is one reason why we would recommend treatment for those displaying symptoms from breast cancer. Some cancers however cannot or are difficult to control through the use of TENS. No evidence has been found to show pain relief or reduction in symptoms with cancers occurring in the pelvic region. Treatment with TENS for cancers in the head and neck are also discouraged and seen as a contraindication as this treatment is considered dangerous, with application putting the coratid sinus at risk. 

Palliative care however is not just restricted to cancer patients. A study by Hall and Sykes, outlines the similar principles for pain reduction on non-malignant diseases. These studies show that cardiac failure and COPD patients, surveyed similar pain intensities to those with cancer and therefore should be considered for TENS treatment.





Saturday 31 March 2012

Types of TENS:


Currently two types of TENS are being researched for pain and symptom relief treatment of cancer patients. Conventional TENS is the more basic and well-known of the two stimulation types whereas acupuncture-like TENS known as ALTENS aims to produce similar effects despite using different parameters and electrode placements.


TENS Parameters:

The aim of conventional TENS is to selectively stimulate large-diameter A-beta nerve fibres without stimulating other A or C nerve fibres and motor efferents. This means that the electrical impulses generated from the TENS machine are stimulating nerve fibres that are specific to touch and sensation. By stimulating these nerve fibre types, it disrupts the sensation of pain arising in the surrounding tissues and reduces the amount of information regarding the pain being projected to the brain. In theory, high frequency and low intensity pulsed currents would be most effective in achieving this type of stimulation. Large diameter nerve fibres, known as A-beta fibres, have short refractory periods and can generate nerve impulses at high frequencies. The usual frequencies used are 80-120Hz. The intensity (measured in milliamps) of this treatment is highly dependent on the patient, what they can tolerate and what feels good for them. The intensity is therefore adjusted to suit the patient. A standard TENS device delivers biphasic pulsed currents in a repetitive manner using pulse durations of 50–150ms and pulse frequencies of 1–200pulses/s. Effects usually do not last as long as those produced by ALTENS and often do not outlast the duration of the treatment.
Figure 1. A schematic showing TENS affecting the mechanoreceptors of the skin, which then inhibit nocioceptors transmitting signals of pain to the brain, thereby reducing pain perception.
Image retrieved from: Jones, I. & M, Johnson. (2009). Transcutaneous electrical nerve stimulation. Continuing Education in Anaesthesia, Critical Care & Plan, 9(4), 130-135.
ALTENS parameters:

ALTENS is similar to conventional TENS however, the electrodes are placed in areas of the body that would normally represent acupuncture sites. As a result this allows for TENS stimulation as well as acupuncture-like treatments. However, unlike TENS, ALTENS stimulates small diameter A-delta fibres which leads to an opioid release resulting in a decrease in C fibre activity, this effectively decreases pain perception. Another difference between the two types of TENS is the frequency and the intensity that ALTENS offers. ALTENS offers low frequency and high intensity electrical stimulation to the areas applied. In general, ALTENS offers a frequency of 1-10Hz and a pulse duration of 150-300ms. Low frequency/high intensity TENS appears to cause a release of endogenous opioids in the spinal cord and higher brain centres in the brain in the same manner as acupuncture, without being invasive. The effects of this stimulation outlast the treatment by hours or even days. Also, unlike TENS which has a fairly short treatment duration, ALTENS may be administered for as long as 30 minutes of a given treatment.



Table 1. TENS techniques

Physiological intention
Clinical technique
Conventional TENS
Selective activation of A-beta nerve fibres eliciting segmental pain relief
Low-intensity/high-frequency 
Apply at site of pain
"Strong but comfortable TENS paraesthesiae"
Use when in pain
Acupuncture-like TENS
Activation of A-delta nerve fibres leading to inhibition of C nerve fibres resulting in extra-segmental pain relief
High-intensity/low-frequency Apply to muscles, acupuncture point or trigger point
"Strong but comfortable muscle contractions"
Long duration; 15-30mins




Types of cancer pains & effectiveness of TENS:

Following on from our last post, you may be curious to know exactly what type of pain is experienced by palliative cancer patients and how effectively TENS reducing this pain. Simon (2008) listed the following as types of pain experienced by those in palliative care: bone pain, abdominal pain, neuropathic pain, rectal pain, muscle pain, bladder pain/spasm and pain of short duration. Of these types of pain, Simon (2008) only states TENS as a treatment option to relieve neuropathic pain. However, it was also noted that physiotherapy might be useful for muscle pain relief. Searle et. al (2009) conducted a case study and concluded from the findings that TENS may also be helpful in the relief of bone pain in cancer patients. The researchers also indicated ALTENS to be used as an alternate option to conventional TENS should it prove ineffective. However, ALTENS delivers a higher intensity dose than conventional TENS and as a result not all patients will be able to tolerate this treatment. In conclusion it is evident from these two research articles that TENS can be useful to cancer patients experiencing the described types of pain. Whilst it is not apparent from the evidence, that TENS relieves pain under all conditions, we are of the opinion that it should always be a viable option for palliative cancer sufferers as any pain relief is better than none.
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Tuesday 13 March 2012

TENS FOR PAIN RELIEF IN CANCER PATIENTS:




Electrical stimulation for symptomatic relief in people with a diagnosis of cancer – treating cancer and the musculoskeletal symptoms with electrical stimulation, the literature and safety concerns in palliative care.

Nothing ventured, nothing gained- Why not give it a go?


Transcutaneous electrical nerve stimulation (TENS) is used throughout the world to manage painful conditions as it is inexpensive, noninvasive, safe and is simple to use. Presently, it is commonly used to treat a number of conditions such as arthritis, lower back pain, post-surgical pain, fibromyalgia and to help spread topical steroids. However, there is much controversy surrounding its use for palliative cancer patients, who, in our opinion are the most in need of its beneficial effects.


The relief of pain is obviously the prime objective in providing palliative care. Therefore, when a patient’s pain is difficult to control, exploration of pharmacologic alternatives may be warranted. TENS is one such alternative to the current basic methods of analgesia. It is intended that TENS will enhance the effects of conventional pharmacologic analgesics, effectively reducing their usage and improving overall quality of life for palliative cancer patients. In addition, research is being undertaken to investigate the proposed relief of nausea, vomiting and fatigue; symptoms of cancer patients.




TENS is a physical modality of pain control that delivers non-painful electrical currents to the skin and tissue beneath to reduce pain sensation. Effectively it works by disrupting the pain cycle, modulating the way we process pain sensation from that area. TENS closes the pain gate, so to speak. In addition, it can also trigger the body to release endorphins, which acts as natural painkillers, and thereby promote a feeling of well-being.