By Prof. Phyllis Berger
A female paediatric patient aged 9 years presented with right long thoracic nerve palsy for the second time. The first injury that occurred in 2011 was due to a fall and although the patient had a paralysis of the serratus anterior muscle and was unable to elevate the arm, with rehabilitation and conventional physiotherapy, she recovered completely according to the nerve conduction test that was conducted six months post recovery.
The second injury to the long thoracic nerve was due to a ballet movement that occurred in 2012. Besides the nerve palsy that reoccurred there was also a complication of severe pain and evidence of a complex regional pain syndrome (CRPS). The second injury was limited by the inability to participate in rehabilitation exercises and physiotherapy due to pain and hyperaesthesia in the distribution of C5 and C6 dermatome both in the trapezius and shoulder region. The third nerve conduction test deteriorated to those recorded after the first nerve conduction test.
A different physiotherapy approach was then applied – initially to reduce pain and decrease hyperaesthesia and then to attempt to increase nerve conduction by the inclusion of an electrical device that simultaneously delivers both a low and a high frequency current. This treatment was combined with various pain resolving tactics including acupuncture, individual sub-liminal, low and high frequency electrical currents. Several interventions were applied to tailor the treatment to the patient to achieve maximal improvement in pain and mobility. It is therefore difficult to attribute improvement to one particular modality or even natural resolution of the condition however previous clinical application and experience of activating nerve conduction with the combination current in other conditions implied that improvement could be expected. This particular electrical current is a combination of a low frequency and a magnetic field.
The condition resolved completely with full movement and no pain after 13 treatments over two months – it was evident that the combination of treatment had an effect on expediting the healing in the nerve. The patient was able to resume all her normal activities including gymnastics and ballet.
Prof. Phyllis Berger & Jaye Jacks
A group of seven patients received neurostimulation (Stimpod) post-tennis or golfer’s elbow surgery as their sole treatment to relieve acute post-operative pain, improve mobility and function. Patients undergoing the above-mentioned surgery have had chronic pain with and without neuropathic symptoms for a prolonged period. There is usually severe injury with active inflammatory processes due to the surgery. It was thought that treating these patients aggressively early post-operatively may expedite pain relief and the healing process.
After their surgery, seven patients were given neurostimulation for three treatments of 20 min each on the brachial plexus during the 10 days before the splint was removed. This was followed by 6 treatments, twice weekly of 20 min each after the splint was removed. At each of these treatments 5-min stimulation were administered to four areas: the nerve supply (1) superior and (2) inferior to the elbow and (3 and 4) on either end of the wound. Patients were evaluated for pain with the visual analogue scale, movements of flexion and extension measured with a goniometer, strength and flexibility with a 12-movement activity scale, status of the wound and satisfaction with treatment, mobility and function. These measures were re-evaluated telephonically at one, three and six months after the last treatment.
Significant pain relief was achieved by all of the seven patients before the splint was removed at the 4th treatment. Pain relief, range of movement and function was greatly improved at the final (9th) treatment by six of the seven patients and this was maintained with nearly full improvement of the above parameters for most of the participants at one month after the last treatment. Two patients had to have re-operation due to requiring more extensive surgery in the one patient and falling and injuring the original surgical site in the other patient. At three and six months after the last treatment full improvement in all the parameters above was maintained in the remaining five patients who also had excellent wound healing and satisfaction with their treatment, mobility and function.
It appears that the neurostimulation (Stimpod) has the capacity to improve acute post-surgical pain and reduce pain, improve mobility, function and stimulate wound healing once the splint was removed. This treatment is relatively cost effective, is non-invasive and of short duration. Positive effects were all maintained at 6 months.
T. Goroszeniuk, S. Kothari
Pain Management Centre, Guy’s & St. Thomas’ Hospitals, London. SE1 7EH. UK
Despite adopting a multidisciplinary approach, the management of neuropathic pain not infrequently presents a challenging clinical conundrum. Primary afferent stimulation for the control of chronic pain has been used widely during the last 40 years 1. Current locations of access for stimulation include skin in Transcutaneous Electrical Nerve Stimulation (TENS) and acupuncture, peripheral nerve trunks, and primary afferent collaterals in the dorsal columns during Spinal Cord Stimulation (SCS). We have successfully investigated short external low-frequency stimulation either targetted at the site of the maximum pain or deeper afferent sensory nerves in patients with intractable pain2. We present the preliminary results of our study aimed at symptomatic relief and restoring function in patients with chronic, intractable pain.
We applied External(transcutaneous) Stimulation to 35 eligible patients complaining of peripheral neuropathic pain. The procedure entailed the application of a 2Hz frequency and amplitude between 1mA and 15mA electrical stimulus (Neurotrace III) transcutaneously to a targeted area or nerve supplying the area of intractable pain. The duration of stimulation was 5 minutes in each case and pain scores (VAS) were recorded at 0 and 5 minutes.
We noticed a dramatic reduction of the pain VAS. In 19 cases the VAS reduced to 0 at the end of 5 minutes demonstrating a 100% improvement in their pain status. The VAS scores decreased by 90% in four, 63% in another four and 50% in four more patients. Remaining three cases had their VAS score reduce by 25%, 20% and 15%respectively. In four patients with CRPS, vascular changes were observed at end of procedure.
External Stimulation is a noninvasive, simple and effective initial indicator, in patients with neuropathic pain, prior to longer, medium term percutaneous stimulating catheter trial and subsequent implantation of permanent devices. The external application component allows the procedure to be performed on an outpatient basis and may be considered for diagnostic and repetitive therapeutic procedures. Further investigation is needed to establish a place for this technique in the management of chronic pain.
1. Alo K M., Holsheimer J., New trends in neuromodulation for the management of neuropathic pain. Neurosurgery, 2002, 4,690-704.
2. Goroszeniuk T., Goroszeniuk D., Short neuromodulation trial in neuropathic pain produces varying duration but reproducible pain relief. Pain in Europe IV. 4th Congress of EFIC, Prague, 2-6.09.2003.