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 J1, Gulati A2.: 

• Pain Med. 2015 Jun;16(6):1204-10. doi: 10.1111/pme.12038. Epub 2013 Feb 25.

Abstract

BACKGROUND:

Cancer pain is difficult to treat, often requiring a multimodal approach. While medication management remains the mainstay for the treatment of cancer pain, medications are often associated with undesired side effects. Transcutaneous electrical nerve stimulation (TENS) provides a potential adjunctive method for treating cancer pain with minimal side effects.

OBJECTIVE:

Few studies have been performed evaluating the efficacy of TENS on cancer pain. We sought to examine the usefulness of TENS on all cancer patients and to specifically look at the use of TENS as a goal-directed therapy to improve functionality.

DESIGN:

Retrospective cohort study.

METHODS:

Since 2008, patients with chronic cancer pain and on multimodal pain regimens were trialed with TENS. Those patients who showed an improvement in pain symptoms or severity were educated about and provided with a TENS unit for use at home. Pain symptoms and scores were monitored with the visual analog scale (VAS), the numerical rating pain (NRP) scale, and Short-Form McGill Questionnaire at the start of TENS treatment and at 2 months follow-up.

RESULTS:

TENS proved beneficial in 69.7% of patients over the course of 2 months. In TENS responsive patients, VAS scores decreased by 9.8 on a 0-100 mm scale (P < 0.001), and NRP scores decreased by 0.8 on a 1-10 scale (P < 0.001).

LIMITATIONS:

Lack of placebo and lack of blinding of physician and patient.

CONCLUSIONS:

TENS provides a beneficial adjunct for the treatment of cancer pain, especially when utilized as a goal-directed therapy.

Wiley Periodicals, Inc.

KEYWORDS:

Cancer Pain; Goal-Directed Therapy; Outcomes; Pain Management; Retrospective Review; Transcutaneous Electrical Nerve Stimulation

Transcutaneous Electrical Nerve Stimulation (TENS) Performed with the Myo-monitor Induced Relaxation and Relief of Pain

Pantaleo, T.,M.D., Prayer-Galletti, F. M.D., Ph.D., Pini-Prato, g., M.D., and Prayer-Galletti, S.,M.D.: "An electromyographic study in patients with myofacial pain-Dysfunction syndrome". Bull. Group. int. Rech.sc Stomat. et Odont. Vol. 26, pp. 167-179, 1983.

Summary:
An electromypgraphic (EMG) study of ipsilateral masseter and temporalis muscles was undertaken in healthy volunteers and in patients with MPD syndrome, with the aim of getting further insight into the pathophysiology of this disease.  Unlike controls, patients had abnormal MKG features and displayed involuntary sustained EMG activity at rest, chiefly in the temporalis muscles.

Transcutaneous electrical nerve stimulation (TENS) performed with the Myo-monitor induced relaxation and relief of pain: these effects were however reversed by voluntary mouth closures.

The correction of occlusal position by acrylic splints was able to induce  persistent reduction or a suppression of the abnormal EMG activity at rest and a good relief of pain: moreover, after the corretion, higher levels of EMG activity were found during maximal  biting in the intercuspal position.
Mechanisms underlying these effects were discussed and in particular it was suggested that abnormal afferenct activity from periodontium and jaw muscles may contribute to the establishment of sustained contraction leading to muscular pain, which in turn may cause reflex muscle activity in vicious circles. 

Freeway Space Measurement Using Mandibular Kinesiograph & EMG Before and After TENS

Konchak PA, Thomas NR, Lanigan DT, Devon RM: "Freeway Space Measurement Using Mandibular Kinesiograph & EMG Before and After TENS". Angle Orthodontist. October 1988.

Department of Community and Pediatric Dentistry, College of Dentistry, University of Saskatchewan, Saskatoon, Canada.

Abstract

This investigation expands on a previous pilot study of the effects of TENS on the resting position of the mandible. The tendency is for an increase in freeway space, but the variability of results makes individual evaluation essential.

PMID: 3264667 [PubMed - indexed for MEDLINE]

TENS Adjunct in the Management of Myofascial Pain-dysfunction

Wessberg GA, Carroll WL, Dinham R, Wolford LM: "Transcutaneous electrical stimulation as an adjunct in the management of myofascial pain-dysfunction syndrome". J Prosthetc Dent. 1981 Mar;45(3):307-14.

Abstract

Twenty-one patients, 14 women and seven men, presenting with symptoms of the MPD syndrome, were treated with a regimen based on a neuromuscular theory of occlusion involving TES. Evaluation of treatment results shows 95% success immediately after therapy and an 86% success 1 year after therapy. No effort was made to establish a personality profile on the patients nor to incorporate active psychotherapy in treatment.

Electromyography Tension and FrequencySpectrum Analysis Before and After TENS

Bazzotti L:Electromyography tension and frequency spectrum analysis at rest of some masticatory muscles, before and after TENS. Electromyogr Clin Neurophysiol. 997 Sep;37(6):365-78.

University of Liège, D.U. of Stomatology (Nancy).

Abstract:

On a population of 52 subjects surface electromyographic recordings were performed of 13.5 sec. of duration before and after ULF (Ultra Low Frequency)-TENS relaxing procedure, while they were holding their mandible at rest. For each recording the average of tension (IEMG) and the median of frequency was calculated. To compute the median of frequencies a Fast Fourier Transformer (FFT) was applied. In order to compare modifications induced by the 45' ULF-TENS relaxing procedure, so that the influence of ULF-TENS could be well isolated from any influence due simply to the time passing between one recording and another, three recordings were performed at different times: the first at time 0', the second at time 0' + 20', and only the third after TENS, time 0' + 20' + 45'. The results of the study permit us to draw the following conclusions: 1. it is confirmed that ULF-TENS can decrease muscle IEMG; 2. the study of the IEMG and frequency of the electromyographic signal at rest can be carried out starting from a window whose size and position in the 13.5 sec. of recording is arbitrary; 3. there is no connection between IEMG and frequency: in other words, at rest, there is no necessary correspondence between high or low IEMG and a high or low frequency values; 4. on application of the neurodiagnostic test of ULF-TENS, the IEMG of the electromyographic signal decreases, while the frequency of the signal remains unchanged. These last two observations permit us to hypothesize that the IEMG and the frequency of the electromyographic signal reflect some different and independent characteristics of the electrical activity of the muscle at rest.

Short-term and Long-term Effects of TENS

Eble OS, Jonas Ie, Kappert HF: "Transcutaneous electrical nerve stimulation (TENS): its short-term and long-term effects on the masticatory muscles." J Orofac Orthop. 2000;61(2):100-11.

Department of Orthodontics, University of Freiburg/Br., Germany. eble@zmk2.ukl.uni-freiburg.de

Abstract

In an electromyographic study on subjects with no functional disturbances of the masticatory muscles, the duration of the post-therapeutic effects of transcutaneous electrical nerve stimulation (= TENS) on the superficial masseter and anterior temporal muscle was analyzed. The myoelectric signals were registered from 20 healthy volunteers in 3 different mandibular positions. The recordings were performed before a 20-minute TENS application with the J-4 Myomonitor and continued with a sequence of follow-up registrations with increasing interval to the initial stimulation. The EMG signals underwent computer-aided analysis and were evaluated by determining the integrated values as a parameter of muscle activity, and after Fourier transformation by 7 describing parameters of the power spectrum (e.g. mean power frequency = MPF). A detailed analysis of variance of all data was used to investigate significant changes of the parameters during the observation period. Muscular response to TENS includes a decrease in muscular activity (= reduction in integrated EMG signals) and a shift in the power spectrum to higher frequencies (increase in MPF). These changes were statistically highly significant for both analyzed muscles and for all different mandibular exercises. As these reactions to TENS are contrary to muscle fatigue, the results can be interpreted as indicating that this type of therapy stimulates a change in the biochemical and physiological muscular conditions, which leads to muscle relaxation. Electromyographically, the post-therapeutic effect lasted for 2 hours in case of normal masticatory muscle activity but for more than 7 hours in case of low muscular loading. The alterations of the integrated EMG values were more persistent than those of the parameters of the power spectrum.

Effects of TENS on EMG and Kinesiographic Activity

Monaco, A, Sgolastra, F, Ciarrocchi, I, Cattaneo, R.: "Effects of transcutaneous electrical nervous stimulation on electromyographic and kinesiographic activity of patients with temporomandibular disorders: a placebo-controlled study". J Electromyogr Kinesiol. 2012 Jun:22(3):463-8. doi: 10.1016/j.jelekin.2011.12.008. Epub 2012 Jan 14.

University of L'Aquila, Department of Health Sciences, L'Aquila, Italy. 

Abstract

The purpose of this study was to assess the effect of a single 60 min TENS application on sEMG and kinesiographic activity in TMD patients in remission, and to assess the sEMG and kinesiographic effect of TENS in placebo and untreated groups. Sixty female subjects, selected according to the inclusion/exclusion criteria, suffering from unilateral TMD in remission were assigned to one of the following group: Group TENS, that received a single session of 60 min of TENS; Group Placebo that received a single session of 60 min of sham TENS; Group Control, that received no treatment. Pre- and post-treatment differences in sEMG of TA, MM, SCM, and DA and interocclusal distance values within groups were tested using the Wilcoxon test. Differences in sEMG and kinesiographic data, among the three groups, were assessed by Kruskal-Wallis test. Significant differences were only observed in the TENS group, for masticatory muscles of both sides; one-way analysis of variance revealed that sEMG values of masticatory muscles of both sides in the TENS group were significantly reduced, in comparison with placebo and control groups. Kinesiographic results showed that the vertical component of the interocclusal distance was significantly increased after TENS only in the TENS group. TENS could be effective to reduce the sEMG activity of masticatory muscles and to improve the interocclusal distance of TMD patients in remission; the placebo effect seems not present in the TENS application.

Myomonitor Efficacy and Myofacial Pain

Wessberg Geroge A., Dinham, Richard, DMD.  "The Myo-monitor and the myo-facial pain dysfunction syndrome."  Journal of the Hawaii Dental Association.  vol. 10, No. 2, Aug. 1977.

The Myofacial Pain Dysfunction Syndrome (MPD, TMJ Syndrome, Craniocervical Syndrome) has plagued dentistry for many years. Therapy for this type of pain  has been highly imaginative.  A few of the more common modalities mentioned (Ramfjord  1971) are occlusal adjustment, occlusal bite splints, immobilization of the mandible, drug therapy, placebo, diathermy, physical therapy, sclerosing agents, psychotherapy, and surgery.  Recent studies of mandibular  movement (Jankelson 1976) stress the importance of a "muscularly oriented occlusal position" for the treatment of the MPD Syndrome.

....Jankelson (Jankelson 1976) assumes a compromise in these trends of thought actually exists.  He describes a relatively precise PRPM at any given stage of development that fluctuates within a minimal range of normal as determined by states of equilibrium within the mandibular musculature.

The postural rest position of the mandible (PRPM) is by definition (Academy of Denture Prosthetists, Glossary of Prosthetic Terms, 1956) the mandibular position assumed when the head is in an upright position and the involved muscles, particularly the elevator and depressor groups, are in equilibrium in tonic contraction, and the condyles are in a neutral, unstrained position.

Summary:
Thirty patients presented symptoms with the Myo-facial Pain Dysfunction Syndrome.  All of these patients received Myo-monitor oriented therapy and nearly all of them professed some initial relief or total remission of their symptoms during the short time  span of this study,

The data presented is based largely on clinical observations and patient response to comparison of their symptoms before and after treatment.  Symptoms evaluated were generally related to muscle tenderness and mandibular mobility.
Conclusion:
Due to clinical observations and patient response in this investigation, it is concluded that:

1. The centric occlusion position is seldom coincident with the myo-centric position of occlusion in patients who exhibit symptoms associated with Myofacial Pain Dysfunction Syndrome.
2. A Myo-monitor generated occlusal position affords some relief if not complete remission of symptoms in 90% of cases treated.
3. Long-term follow-up studies are necessary to evalutate the success of treatment.

Myomonitor Efficacy - An Electromyographic Study with Myofacial Pain Dysfunction

Pantaleo, T.,M.D., Prayer-Galletti, F. M.D., Ph.D., Pini-Prato, g., M.D., and Prayer-Galletti, S.,M.D. "An electromyographic study in patients with myofacial pain-Dysfunction syndrome." Bull. Group. int. Rech.sc Stomat. et Odont. Vol. 26, pp. 167-179, 1983.

Recently dental research has turned to neuro-muscular system: many dental procedures, in order to be entirely successful, require that the masticatory muscles are relaxed and perfectly balanced.  The use of the transcutaneous electrical nerve stimulation (TENS) has been introduced, obtrained with adquate stimulators, such as the Myo-moniotr (Myo-tronics) (Jankelson 1975, Jankelson 1978, Wessberg, 1981): TENS has been able to relieve pain and eliminate the sustained muscle tension of the masticatory muscles of patients with myofacial pain-dysfunction (MPD) syndrome (laskin 1969), combined with occlusal malrelation, which may be the primary cause of MPD syndrome (Lindblom 1953, Alling 1977).

Summary:
An electromypgraphic (EMG) study of ipsilateral masseter and temporalis muscles was undertaken in healthy volunteers and in patients with MPD syndrome, with the aim of getting further insight into the pathophysiology of this disease.  Unlike controls, patients had abnormal MKG features and displayed involuntary sustained EMG activity at rest, chiefly in the temporalis muscles.

Transcutaneous electrical nerve stimulation (TENS) performed with the Myo-monitor induced relaxatio and relief of pain: these effects were however revesred by voluntary mouth closures.

The correction of occlusal position by acrylic splints was able to induce  persistant reduction or a suppression of the abnormal EMG activity at rest and a good relief of pain: moreover, after the corretion, higher levels of EMG activity were found during maximal  biting in the intercuspal position.

Mechanisms underlying these effects were discussed and in particular it was suggested that abnormal afferenct activity from periodontium and jaw muscles may contribute to the establishment of sustained contraction leading to muscular pain, which in turn may cause reflex muscle activity i vicious circles.

The Myo-monitor: Its use and abuse

Jankelson, Bernard, (1978) The Myo-monitor: Its use and abuse (I). Quintessence International No. 2: Report 1601, pp 47-51.

SUMMARY
The Myo-monitor transcutaneously stimulates the motor branches of the Vth and VIIth cranial nerves, relaxes the associated musculature, and then records an occlusal position that is compatible with a continued state of relaxation. Additional techniques have been developed for taking denture impressions (or relining old dentures) functional occlusal diagnosis, occlusal adjustment, and treatment of TMJ and MPD syndrome.

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