TENS in der Schmerztherapie Grundlagen, Praxis, Indikationen, Evidenz

Transkript

1 TENS in der Schmerztherapie Grundlagen, Praxis, Indikationen, Evidenz

2 Transcutaneous electrical nerve stimulation for relieving acute pain in the prehospital setting: a systematic review and meta-analysis of randomized-controlled trials Simpson P et al. (2014) Eur J Emerg Med 21(1): RCTs - renal colic (n= 100) - acute pelvic pain (n= 100) - acute hip pain (n= 100) - acute low back pain (n= 100) In the pooled analysis consisting of 261 patients, the difference in mean final pain score between sham and real TENS was 33mm (95% CI 21-4; p<0.0001) When administered by medics in the prehospital setting to patients with acute pain, TENS appears to be an effective and safe..

3 Effect of TENS on Postoperative Pain and Pulmonary Function in Patients Undergoing Coronary Artery Bypass Surgery Jahangirifard A et al. (2018) Pain Manag Nurs 19(4): n= 100, coronary artery bypass surgery - TENS (n= 50) - control with routine care (n= 50) VAS every 6 h for 72h, rest and coughing, analgetics Every 24 h pulmonary function (FEV) TENS may reduce postoperative pain in resting and coughing, improve pulmonary function, and reduce narcotic use in patients undergoing coronary artery bypass surgery.

4 Transcutaneous electrical nerve stimulation for postoperative pain control after total knee arthroplasty: A meta-analysis of randomized controlled trials Li et al. (2017) Medicine (Baltimore) 96(37):e RCTs, 472 patients 12, 24 and 48 h post surgery significant reduction in - VAS - opioid consumption TENS could significantly reduce pain and opioid consumption after total knee arthroplasty. In addition, there were fewer adverse effects in the TENS groups.

5 Transcutaneous Electrical Nerve Stimulation (TENS) reduces pain and drug intake in the immediate postoperative period following proximal femoral fractures Silva et al. (2017) BJMMR 19(12):1-12 n= 42 women, femoral fracture, postoperatively randomised for 72 h in - TENS group (n= 14), 120Hz, 100µs, non-stop - placebo TENS (n= 14) - control group (n= 14) Long-term TENS reduced postoperative pain and drug intake significantly (p<0.05) TENS, when used uninterrupedly, was shown to be effective both for pain reduction and drug administration in the immediate postoperative period

6 Transcutaneous Electrical Nerve Stimulation (TENS) in the immediate postoperative period following proximal femoral fractures reduces drug costs Silva et al. (2017) BJMMR 20(5):1-9 Cost of analgesic drugs: TENS group US$ 9.62 Placebo TENS group US$ Control group US$ TENS in the immediate postoperative period of patients with proximal femoral fracture led to a significant reduction in the cost of drug administration

7 Postoperative Schmerzen, S3 Leitlinie 2008 (in Überarbeitung) DIVS Deutsche Interdisziplinäre Vereinigung für Schmerztherapie e.v. Die zusätzliche Anwendung einer TENS-Stimulation wird nach einigen chirurgischen Eingriffen empfohlen. Empfehlungsgrad B: (A= sollte, B= soll, C= kann)

8 Evidenz chronischer Schmerz

9 Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: a meta-analysis of randomized controlled trials Johnson M et al. (2007) Pain 130: RCTs, n= placebo patients TENS patients cross-over patients These results indicate that ENS is an effective treatment modality for chronic musculoskeletal pain...

10 Methological quality in randomised controlled trials of transcutaneous electrical nerve stimulation for pain: Low fidelity may explain negative findings Bennett et al. (2011) Pain 152 n= 2268 in 38 Studien aus 3 aktuellen Cochrane Reviews - nur 65% der Studien richtige Elektrodenplatzierung - nur 60% richtige Intensität - nur 15% geben korrekte Dosierung von min. 30 Min an Suboptimale Dosierung der TENS und eine fehlerhafte Auswertung waren besonders häufige Gründe einer mangelnden Studienqualität.

11 TENS wichtigste Parameter - Frequenz - Intensität - Dosierung - Elektroden Anlage, Größe Polung,Typen

12 TENS Hochfrequente Stimulation ( conventional TENS ) Hz - Intensität 3-fache Sensibilitätsschwelle - Intensität submotorisch - segmentaler spinaler Effekt: gate control - schnelle Wirkung: akuter Schmerz

13 TENS Niederfrequente Stimulation ( acupuncture-like TENS ) 2-10 Hz - motorische Stimulation - supraspinaler Effekt: endogene Opioide - langsam eintretende, anhaltende Wirkung: chron. Schmerz

14 Prof. Han Stimulation using one frequency only is not sufficient to release all pain inhibiting neuropeptides. J.S. Han (2003) Trends in Neuroscienes, 26, 1

15 Han-Stimulation Enk Dyn A Enk + Dyn A A B 2Hz 100Hz 2Hz 100Hz S

16 Frequenz Faustregeln - akuter Schmerz, primäre Hyperalgesie: eher hochfrequent - chronischer Schmerz, sekundäre Hyperalgesie: eher niederfrequent - ideal für fast alle Schmerzindikationen: Frequenzkombination nach Han

18 Intensität 3 Möglichkeiten hochfrequente Stimulation deutlich spürbarer Strom, aber nicht schmerzhaft niederfrequente Stimulation deutlich spürbarer Strom mit Muskelzuckungen intensive Stimulation (Aß + A - Fasern) leicht schmerzhafte Intensität

19 Effects of high-frequency, high-intensity transcutaneous electrical nerve stimulation versus intravenous opioids for pain relief after gynecologic laparoscopic surgery Platon et al. (2018) Korean J Anesthesiol 71(2): n= 93, randomized to TENS or max. 10mg morphine iv ma for 1 min; if necessary 1 repetition - cross over if analgesia insufficient Both groups reported significant pain relief with no differences between the groups: - TENS: VAS 5.4 to 1.0 (p < 0.001) - IV opioid group: VAS 5.2 to 1.1 (p < 0.001) TENS and IV opioids are both effective treatments for pain relief after gynecologic laparoscopic surgery...

20 Intensität Variante intensives, leicht schmerzhaftes TENS Hz - leicht schmerzhaft - motorisch - Behandlungszeit 1-5 Minuten, wiederholbar nach 2-3 Minuten

22 Dosierung nozizeptiver Schmerz PENS, 15/30 Hz bei 65 Rückenschmerzpatienten 3x/ Woche über 2 Wochen Hamza MA et al. (1999) Effect of the duration of electrical stimulation on the analgesic response in patients with low back pain. Anesthesiology 91,6:1622-7

23 Dosierung neuropathischer Schmerz mehrstündige Stimulation (Wynn Parry, 1984) wichtig: Pausen einhalten, um eine Gewöhnung zu vermeiden (Han,1998)

24 Dosierung Faustregel abhängig von Klinik und Reaktion nozizeptiver Schmerz: 30 min/ Behandlung, bis zu mehrmals täglich neuropathischer Schmerz: v.a. initial bis zu mehreren Stunden tägl., 30 min - 60 min / Behandlung

26 Elektrodenanlage Faustregeln Elektrodenanlage lokal segmental im Schmerzgebiet Elektrodenanlage über dem peripheren Nerv Elektrodenanlage segmental paravertebral Elektrodenanlage kontralateral

27 Elektrodenpolung Faustregeln Anode auf den Hauptschmerzpunkt, A K Kathode in die Schmerzausstrahlung Epikondylitis A K

28 Elektrodengrösse Faustregeln - Elektrodengröße richtet sich nach dem Schmerzareal - tiefes Schmerzareal: kleine Elektroden verwenden, Elektrodenabstand vergrössern - Adipositas: grosse Elektroden oder 2-Kanalanlage

29 Klinik der TENS nozizeptive/ gemischte Schmerzen

30 TENS for children's procedural pain Lander J et al. (1993) Pain 52: n= 896 Kinder - TENS Gruppe - Placebo Gruppe - Kontroll Gruppe Die Schmerzintensität..war in der TENS Gruppe am geringsten und in der Kontrollgruppe am höchsten.

31 HI -TENS reduces moderate-to-severe pain associated with most wound care procedures: a pilot study Gardner S et al. (2014) Biol Res Nurs 16,3: n= 80 - hochfrequente TENS using HI-TENS may further reduce pain, particulary in patients experiencing severe wound care procedure pain.

32 Transcutaneous nerve stimulation for pain relief during chest tube removal following cardiac surgery Malik et al. (2018) J Anaesthesiol Clin Pharmacol 34(2): n= 50, chest tube removal after cardiac surgery, randomized in - TENS group (n= 25), 30 min before up to 30 min after - Control Group (n= 25) Mean VAS for chest tube removal - TENS group 4.1 ± 1.2 (P < 0.05) - Control group 6.1 ± 0.8 TENS might not replace the conventional analgesics but has definite adjuvant role in decreasing pain scores and improves sense of well-being during chest tube removal after cardiac surgery.

33 HWS

34 LWS MedicoBack

35 Ischialgie

36 Clinical and Economic Impact of TENS in Patients With Chronic Low Back Pain: Analysis of a Nationwide Database Pivec et al. (2013) Orthopedics 36(12): n= TENS und Non-TENS Gruppe Follow up 1 Jahr TENS Group signifikant geringere Krankenhausaufenthalte weniger Bildgebung weniger physikalische Therapie weniger Rückenchirurgie geringere jährliche Behandlungskosten

37 A Meta-Analysis of Transcutaneous Electrical Nerve Stimulation for Chronic Low Back Pain Jaurequi et al. (2016) Surg Technol Int 28: RCTs (Level 1), 4 RCTs (Level 2 ), n= 267 Ø Behandlung 6 Wochen (2-24 Wochen) Ø Follow up 7 Wochen (2-24 Wochen) Die TENS Behandlung bewirkte eine signifikante Schmerzreduktion. (SMD Schmerz vor / nach Therapie 0.844) Die TENS kann zum geringeren Schmerzmittelkonsum führen und sollte in das Behandlungsrepertoir des unteren Rückenschmerzes integriert werden.

38 Omarthrose

39 Coxarthrose

40 Gonarthrose ggf. 100 Hz

41 Transcutaneous Electrical Nerve Stimulation in Patients with Knee Osteoarthritis: Evidence from Randomized Controlled Trials Chen et al. (2016) Clin J Pain 32(2): Systematisches Review und Metaanalyse - 18 RCTs (Review) - 14 RCTs (Metaanalyse) TENS reduziert im Vergleich zur Kontrollgruppe Schmerzen signifikant (p < )

42 Do the effects of Transcutaneous Electrical Nerve Stimulation on knee osteoarthritis pain and function last? Cherian et al. (2015) J Knee Surg 29(6): n= 70, randomisiert in - TENS - standardisierte konservative Therapie Follow up von mindestens 1 Jahr (Ø 19 Monate) In der TENS Gruppe signifikant - geringere Schmerzscores - grössere Funktions- und Aktivitätsscores - grössere Analgetikareduktion - grosse Anzahl von Patienten setzten TENS nach Studienende fort

43 Klinik der TENS neuropathische Schmerzen

44 Trigeminusneuralgie

45 TENS - an alternative to antiviral drugs for acute herpes zoster treatment and postherpetic neuralgia prevention acute herpetic neuralgia Koltek M (2012) Swiss Med Wkly 141:w13229 retrospektive Studie, n= TENS may be safe adjunct or even alternative to antiviral drugs for treatment of acute Herpes zoster. It looks that TENS may be at least as good as antiviral drugs

46 Pregabalin and TENS for postherpetic neuralgia Barbarisi M et al. (2010) Clin J Pain 15 n= 30, Jahre, Ø 15 Monate Neuralgie - Pregabalin bis VAS < 60mm - Randomisierung in 2 TENS-Gruppen : - 4 Wochen TENS - 4 Wochen TENS Placebo.. Pregabalin erzielt in der Kombination mit TENS bessere Ergebnisse

47 Assessment: Efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders. An evidence-based review Dubinsky R et al. (2010) Neurology 74, American Academy of Neurology - 2 studies class II - 1 study class III Tens should be considered in treatment of painful diabetic neuropathy. (Level B)

48 Analgesic effects of transcutaneous electrical nerve stimulation (TENS) in patients with fibromyalgia: A systematic review García Á et al. (2018) Aten Primaria 8 RCTs, n= 281 Pain, Fatigue, Quality of life, Range of Motion, Depression Treatment with TENS is effective for reducing pain in people with fibromyalgia. In addition, the inclusion of TENS in therapeutic exercise programs seems to have a greater effect than practicing therapeutic exercise in isolation. However, no efficacy has been demonstrated in other variables different to pain.

49 The Use of Transcutaneous Electrical Nerve Stimulation (TENS) in a Major Cancer Center for the Treatment of Severe Cancer-Related Pain and Associated Disability Loh et al. (2015) Pain Med 16(6): Seit 2008 werden Patienten mit chronischen Krebsschmerzen im Rahmen einer multimodalen Schmerztherapie mit TENS behandelt TENS ist bei 69.7% der Patienten im Zeitraum von 2 Monaten effektiv

50 Transcutaneous Electrical Nerve Stimulation Reduces Resting Pain in Head and Neck Cancer Patients (HNC): A Randomized and Placebo-Controlled Double-Blind Pilot Study Lee J et al. (2018) Cancer Nurse n= 42, 3 x TENS, randomised in - TENS (group 1) - Placebo (group 2) - Control (group 3) - TENS decreased resting pain and fatigue significantly - Function and pain with function no difference Transcutaneous electrical nerve stimulation may be a viable tool for radiation-induced HNC pain to complement pharmacologic approaches. This nonpharmacologic intervention could decrease the debilitating effects of radiation and analgesics, and improve quality of life

51 TAES Sonderanlage Niederfrequente, nicht-segmentale Stimulation nach Kaada Kathode - Frequenz: 2 Hz - Intensität: Muskelzuckungen - Indikation: Schmerz, Durchblutungsstörungen Anode

52 TENS Kontraindikationen

53 Vielen Dank!