Ain't Too Proud to TENS

"Now tell me again. What's this supposed to do?"

Patients often pose this question in the clinic, right after I've slapped electrodes on a sore spot.

The rationale for electric stimulation can get pretty technical, of course. But to keep it simple, I usually just tell patients that it helps with swelling, muscle spasms, inflammation, and temporarily masks the pain.

"Oh. Okay then."

And it's true.

How a little voltage accomplishes these things is really less mysterious than you would think. Neuromuscular stimulation (NMES) is a strong electrical current that's proven to help with recruitment of weak or injured muscles. We use that in the clinic too, but for now we're only talking about using transcutaneous electrical neuromuscular stimulation (TENS) for pain relief.

The TENS current causes the spinal cord to release a natural endorphin called encephalin, which reduces the reactivity of pain pathways. TENS also provides sensory overload at or around the painful area, effectively bum-rushing the nervous system so you notice relatively less pain. Lastly, the electricity causes constriction and dilation of small arteries by way of a few mechanisms. The increased blood flow leads to decreased swelling and increased metabolism of toxic and inflammatory substances.
So yeah, it's not just a distraction. Well, sorta. But nobody can bill for an empirically proven, much needed, and highly demanded therapeutic nap.

But looking past glorified naps, inflammatory substrates, and decreased sensory perception, TENS is not exactly an evidence-based procedure when you try to put numbers on functional outcomes like lifting at work or jumping on the court. More than that, TENS doesn't give rehab people anything to brag about. It's not technical or highly skilled. There are no costly continuing educations tracts where medical professionals get to show off lots of letters for their E-stim certification.

I've never seen a fellow PT "market" the use of E-stim as a strong point in their treatment programs. I mean, could you imagine...?

"My clinic is unsurpassed when it comes to turning this dial and pushing that button."

You could prop any monkey or reader of People Magazine into a rehab setting, teach them a few contraindications, and they could slap electrodes around painful body parts. Oh, and turn the unit on. Yeah, uh...nobody has ever had to remind me to turn the thing on.

PTs do have other good reasons for the backlash against E-stim and other passive modalities like ultrasound. I've learned that the 80's and 90's sometimes had PTs charging insurance companies for 24-plus visits of "treatment" consisting of E-stim and a hot pack for 30 or 60 minutes. Again, therapeutic nap not withstanding, this practice over that many visits is lazy at best and deceptive at worst.

Working on your feet is...work.

One of my past writings was published as a guest editorial in Advance Magazine for PTs. It was a tongue-in-cheek call for PTs to quit acting like they have all the answers and with that, experience the freedom that comes from embracing the limits of our profession. I wrote a sarcastic "about the author" blurb that said I was certified in Ultrasound and E-stim.

Most PTs (and only PTs) would get the joke; the idea of specializing in something that no therapist takes great pride in. To say the least, I found that the editors at Advance are not PTs.

The bottom line is that I use E-stim in the clinic, always as a component of a comprehensive treatment program. Most people love it. Patients often comment, sometimes with creative expressions, on how it works. I do feel it's good practice for PTs to give full disclosure on the matter. Mine usually sounds something like:

"E-stim is not essential in your treatment if you don't prefer it. It doesn't address the root cause of mechanical pain; the poor strength, flexibility, or movement patters. Problems that are mechanical in nature really do require a mechanical change to fix. Manual mobilization of the joints, flexibility work, and ugh, conditioning exercise, are a lot more effort for the patient and the therapist, but they ultimately treat the problem instead of temporarily helping the symptoms.
...and who can deny the power of the therapeutic nap?"

There. Was that so bad? So now lets zap away if it makes you feel good.

Extreme forward head posture with severe kyphosis. And blue. E-stim will definitely fix this dude.
E-stim won't likely be proven alone to be effective for functional outcomes. I don't care. There is an extensive research base of TENS for pain relief (not necessarily functional outcomes) in both the clinical and laboratory settings. If it helps with pain, albeit temporarily, what's the harm in that? You go ahead and try living in pain 24/7 and see if a few hours of nonfunctional, temporary pain relief is worth it.

There's an exciting area of study regarding the use of a slightly different type of electrical current that, rather than stimulating the muscles and nerves to "fire," acts as a specific electrical signal to all tissues in the body. The signal causes those tissues to inhibit or accelerate what they do, which may be a promising way to circumvent the side effects often see with medications.

Until then, if aches and pains cause you to seek a PT, I would probably try to zap you, and would definitely try to get you to move differently.
It's Mental REPS, not Mental Laying Around on TENS.
- - - - -

[Here's the bio that was actually published in the Advance editorial.]

Robert Gorinski is a physical therapist in private practice in Harrisburg, PA. He specializes in ultrasound and the use of other passive modalities. He is creator and founder of the Common Sense Method of Recuperative Rehabilitation Therapy.
- - - - -

No comments:

Post a Comment