Sports Medicine Research: In the Lab & In the Field: Electrical Stim Treatments Improve Patients with Low Back Pain (Sports Med Res)


Wednesday, February 15, 2017

Electrical Stim Treatments Improve Patients with Low Back Pain

Efficacy of Selected Electrical Therapies on Chronic Low Back Pain: A Comparative Clinical Pilot Study

Rajfur J, Pasternok M, Rajfur K, Walewicz K, Fras B, Bolach B, Dymarek R, Rosinczuk J, Halski T, & Taradaj J. Med Sci Monit. 23: 85-100. doi: 10.12659/MSM.899461

Take Home Message: Various electrical stimulation treatments over the course of 3 weeks resulted in improved low back pain.  Interferential stimulation seemed to have the best outcomes in patients with low back disc degeneration. 

Low back pain can be very debilitating and cause significant pain.  Clinicians often use various transcutaneous electrical nerve stimulation (TENS) techniques to help manage chronic low back pain.  There is little research to support TENS use, therefore these authors compared the effects of various electrical stimulation treatments on pain, range of motion, and function among individuals with low back pain.  Patients with low back pain due to disc degeneration were randomized to treatment groups for approximately 3 weeks: conventional TENS (20 participants), Acupuncture-like TENS (20 participants), high-voltage electrical stimulation (20 participants), interferential (21 participants), diadynamic (22 participants), & control/rehabilitation-only (21 participants).   All participants, regardless of group, performed basic rehabilitation exercises.  Their pain, disability, mobility, and postural stability were measured before and after the 3-week treatment period.  All groups improved in pain, disability, mobility, and postural stability.  Upon closer investigation, the authors reported better results for participants in the interferential treatment group in all areas, and the least amount of improvements for the patients in the diadynamic treatment group.  While there were improvements over the 3 weeks, the largest disparity appeared to be that diadynamic and control groups showed significantly lower improvements than the other 4 electrical stimulation treatments.  

These findings are interesting because it shows that there are significant improvements after 3 weeks of treatment with various electrical stimulation treatments or rehabilitation alone.  Interestingly, the authors appeared to have the best outcomes among participants who received a 20-minute interferential treatment 3 times per week, with the theory that this treatment penetrates deeper into the tissues.  This is somewhat surprising since the interferential treatment parameters were only sensory in nature, and was the shortest treatment time – with other treatments ranging from 50 to 60 minutes.  It would be interesting to see what clinical outcomes might be if a clinician performed an interferential treatment with a lower frequency to try to stimulate the a-delta nerve fibers.  The theory about interferential treatment penetrating deeper into tissues is one that is often referenced, but it would be interesting if a research study could prove this more definitively.  The authors also noted that the diadynamic therapy appeared to have the least effect and failed to provide much of a clinical benefit, especially with other options available.  Diadynamic therapy was one that I was less familiar with, and it appears that it is not a valuable addition into clinical practice.  Overall, electrical stimulation treatments appear to improve symptoms and function over the course of a 3-week time frame, with interferential having the most optimal outcomes.  However, these results should be interpreted with caution given the exploratory nature of this study.      

Questions for Discussion:  What are your thoughts on sensory electrical stimulation?  What modalities do you typically use for chronic low back pain? 

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

Related Posts:

Rajfur, J., Pasternok, M., Rajfur, K., Walewicz, K., Fras, B., Bolach, B., Dymarek, R., Rosinczuk, J., Halski, T., & Taradaj, J. (2017). Efficacy of Selected Electrical Therapies on Chronic Low Back Pain: A Comparative Clinical Pilot Study Medical Science Monitor, 23, 85-100 DOI: 10.12659/MSM.899461


Brooke Daniell said...

This is an interesting article, in that it actually includes a control group. Most literature that I have read regarding e-stim lacks a control group. What is interesting about the results, is that most of the patients improved even with control treatment only, in terms of functionality and decreasing pain. The e-stim (especially IFC) seemed to improve the results greatly. This is useful information, as I feel that most clinicians are sometimes unsure as to what type of e-sitm to use with our chronic pain patients. I think that sensory electrical stimulation is great, but unfortunately, the effects are so short-lived. I think it is best used to allow the patient to feel "good" before treatment, and to feel well enough that they are confident in increasing their rehabilitation difficulty and working towards rehabilitation improvements during their treatment session. Also, I would even argue that some of the e-stim parameters used here are on the borderline of targeting motor (a delta) fibers, and not just sensory (a beta) fibers.

Unknown said...

I believe that electrical stimulation is a valuable asset for Athletic Trainers to use on athletes. Like Brooke said, I thought the article is a valuable one because it includes a control group in the study. I think this shows the benefit of stim more so than previous studies indicate. I thought it was good that IFC was shown to have the most significant changes considering I believe that most clinicians use IFC frequently. I myself use it frequently as well, but it can be frustrating that relief is temporary for the athlete. Though this is the case, it is nice that it is the shortest treatment that was tested but has the most significant results since time is precious for ATC's and our athletes. My go to for chronic low back pain is usually IFC and a cryotherapy option usually as well, but I am also a strong believer that therapeutic exercise needs to be included in treatment as well.

Jeffrey Driban said...

Thanks for the comments. It is nice that the authors included a control group because it shows efficacy of the treatments but it is important that we don't dismiss randomized trials that omit a control group b/c these trials may not be testing efficacy but rather effectiveness. For example, if we wanted to know if a new e-stim protocol is more effective than a standard of care or a standard e-stim protocol then we would not need a control group. Also, as noted above - these e-stim protocols were not tested as a solo therapy but rather as a complement to a basic rehabilitation exercises.

Anonymous said...

Is anyone aware of similar research conducted on patients with more acute back pain? This study excluded those with <6 months of pain.

Kelly Martin said...

I think that this article presents valuable information on the guidance of treatment in individuals with low back pain. Low back pain is sometimes hard to manage, and the use of multiple types of TENS in this article is beneficial and insightful to the effects of the various interventions on clinically important outcomes (pain, ROM, and function). This article used a multitude of subjective measures (i.e. VAS, Oswestry, Roland Morris), which I think helps to decrease any sort of error that may be present if only one questionnaire were administered. Personally, I have had success with IFC as a treatment option, although I am not opposed to trying other TENS or modality interventions. Although much like Nicole, I am a bit unfamiliar with diadynamic theory. However, given the results from this article it appears as though the effectiveness of this intervention is not necessarily clinically meaningful. I think that with LBP, exercise and manual therapy are techniques that are just as important in improving these outcomes, and could be included as an adjunct to TENS therapy in those with LBP. As far as future research is concerned – I would be interested to see the effects of the various types of TENS used at a longer term follow up (> 3 weeks) to see how the outcomes may differ at a later point in time. Additionally, I am curious to see the effects of each of the TENS interventions on LBP if each of the duration of application parameters were the same. Overall, I think that this article finding that IFC being the most effective treatment with only a 20 minute application is beneficial for both the clinician and the patient in terms of time management and improved clinical outcomes.

Nicole Cattano said...

Thanks for your comments Kelly. I agree that I really like the use of the patient reported outcomes in this article.

I agree with Brooke that sensory stim is more of a "feel good" modality, but certainly a tool that we have at our disposal. However, the only treatment that appeared to approach a-delta was the brief acupuncture stim. Are there others that you think might as well?

When I think about the resulting treatment vector when performing IFC - I will often opt to use two bipolar set ups to target surrounding musculature, since stimulation cannot penetrate bone - it may just add resistance.

It makes me wonder what others might do when treating the low back???

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