CHRONIC PAIN TREATMENT [Autosaved] [Autosaved]

Category: Education

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Electrical Stimulation • Electricity was first used over 2000 years ago with torpedo fish treating headaches and painful gout in Roman times but not very effectively.

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External Electricity TENS Unit

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Why Neuromodulation • Improvement in low back pain is less likely if persistent for over 3 months Chronic Low Back Pain • Persistent back pain over 1 year – 62 some pain 20 substantially limited activity 16 initially unable to work – still not working • Social issues and pain – social isolation financial problems loss of independence reduced enjoyment of life “burden to family” • Psychosocial factors – depression from chronic pain avoidance of activities due to fear of pain anxiety pain catastrophizing • Preference to minimize or avoid opioid usage • Failed conservative care desire for improved function and pain control Beland 2014

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Failed Back Surgery • Persistent recurrent or worsening pain after technically successful spinal surgery • Scar tissue • Nerve damage • Weakening of physical structures • Decreased strength and physical ability Beland 2016

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Conservative Treatments • Antidepressants • NSAIDS • Muscle Relaxers • Pain medication – weak and strong opioids • Exercise – PT Yoga Pilates • Manipulation • Acupuncture • Behavioral therapies • Multidisciplinary Pain Management • Epidural facet injections • Spinal fusion Beland 2016

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The Gate Theory First scientific basis for use of electrical stimulation for pain • Gate control theory of pain is an attempt to discuss about how pain sensation is transmitted. Pain is defined as the subjective sensation which accompany the activation of nociceptors and which signals the location and strength of actual or potential tissue damaging stimuli. • Various types of pain may range from mild irritation through burning and prickling sensation to more intense stabbing and throbbing sensation and finally to agonizing and intractable pain which may be intolerable to many subjects. control-theory-of-pain.html

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Objectives for Treatment with Neuromodulation • Replace pain sensation with paresthesia requiring mapping of stimulation to the region of pain • Stimulation with electrodes placed percutaneously or through surgical paddle placement Laminectomy • Typical pulse frequencies averaging 40-60 Hz • Burst SCS • High frequency SCS 10000 HZ pain relief without paresthesia • recent advances improve efficacy and expand applicability • Verrillis Sinclair Barnard 2016

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Clinical Indications for Neuromodulation • Epilepsy • Movement Disorders • Psychiatric Disease • Spasticity and Chronic Pain • Chronic Neuropathic Pain • Chronic Pain after Joint Replacement Granville Berti Jacobson 2017 Yampolsky Hem Bendersky 2012

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PAIN Indications for Neuromodulation Failure of all conservative methods for pain control

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Causes of Persistent Post Operative Pain • Disk herniation • Persistent post op compression of spinal nerves • Foraminal stenosis • Altered joint mobility • Pseudo arthrosis • Joint hypermobility with instability • Arachnoiditis or inflammation of nerve roots in the thecal sac • Spinal muscular pain • Epidural fibrosis • Discogenic pain Yampolsky Hem Bendersky 2012

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Dermatome Chart

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Neuromodulation Process • H P review current MRI • Documentation of failed conservative care and Medical Necessity • Discussion and Education on Neuromodulation • Psychological Evaluation • Stimulator Trial 1-3 weeks • Further Education and Evaluation of Risks vs Benefit • Final Surgical Implantation • Reprogramming for optimal pain benefit

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Statistical Benefit of Neuromodulation • Good results are considered to be 50 or greater decrease in pain with less medication use and increased activity. • In a study of over 300 patients treated with spinal cord stimulator with an eight year follow-up there was a 67 long- term success rate. Granville Berti Jacobson Cureus 2017 • Selecting appropriate patients is vital to maximizing efficacy because the cost of implantation and follow-up is very high. Abd-Elsayed Granhi Sachdeva 2016

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Complications with Other Electrical Medical Devices • Spinal Cord Stimulator SCS is a relative contraindication in patients with other electrical pulse devices such as • Pacemaker/Defibrillator ICD Deep brain stimulator • Bladder stimulator • May cause unexpected changes in electrical current leading to morbidity or mortality • Inappropriate high-voltage shock from ICD and malfunction • Vasodilatory effects • Decreased catecholamine production leading to adverse effects in patients with heart failure. Abd-Elysayed Grandhi Sachdeva 2016

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Possible Complications or Indicators for Treatment Failure with Use of Neuromodulation • Smoking status • Drug use • Age • Lengthy delay between times of original pain and onset of SCS implant • Neuroplasticity of pain transmission pathways • Scar formation • Patient reframing of pain over time • Psychological or Psychiatric affective disorders • Verrills Sinclair Barnard 2016

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REFERENCES Abd-Elsayed A. Grandhi R. Sachdeva H. 2016. Lack of electrical interference between spinal cord stimulators and other implanted electrical pulse devices. Journal of Clinical Anesthesia 35 475-478. doi: 10.1016/j.jclinane.2016.08.010 Beland P. 2016. Limitations associated with managing chronic low back pain. Nursing Standard 2014+ 30/34 41. doi: 10.7748/ns.30.34.41.s46 Granville M. Berti A. Jacobson R. 2017. Use of spinal cord stimulation in elderly patients with multi-factorial chronic lumbar and non-radicular lower extremity pain. Cureus 911 doi: 10.7759/cureus.1855 Patents researchers submit patent application "system that secures an electrode array to the spinal cord for treating back pain" for approval. 2015 Jan 18. Heart Disease Weekly Retrieved from Verrills P Sinclair C Barnard A. 2016. A review of spinal cord stimulation systems for chronic pain. Journal of Pain Research. 9 481-492. doi:10.2147/JPR.S108884. Yampolsky C. Hem S. Bendersky D. 2012. Dorsal column stimulator applications. Surgical Neurology International 4/3 275-289. doi: 10.4103/2152-7806.103019

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