Dr Ghazala Tabasam

Objectives The aim of this questionnaire survey was to gather information about the attitudes, beliefs and self-reported use of TENS for pain by physiotherapists in the Kingdom of Saudi Arabia. Design A cross-sectional paper-based questionnaire survey. Setting Physiotherapy staff and student interns working at five clinics of government hospitals in Riyadh, Kingdom of Saudi Arabia. Respondents 110 physiotherapists received the questionnaire and 58 were completed (response rate = 52.72%). Main outcome measures The questionnaire comprised 45 items on beliefs about TENS and clinical experience of using TENS in practice including TENS techniques. Results All five clinics offered TENS treatment administered by the therapist and only during clinic visits. Fifty-seven of the 58 respondents (98.3%) reported that they treated pain as part of their current clinical workload and believed that TENS was beneficial to relieve pain. Thirty -three respondents (57%) used TENS in clinical practice to relieve pain associated with musculoskeletal/orthopaedic conditions and used TENS to manage pain only in combination with other treatments. Respondents who used TENS in clinical practice also reported that treatment was administered in clinic for 10-29 minutes, on average, to generate a strong TENS sensation at the site of pain with electrodes placed over the site of pain (32 respondents, 97%). Seventeen of the 33 respondents (52%) reported that they, on average administered more than 4 TENS treatments per week per patient and 32 respondents (97%) reported that they did not advise patients to self-administer TENS treatment to manage pain unsupervised at home. Conclusions Physiotherapists in Saudi Arabia use TENS techniques that match good practice guidelines, although there is a need to develop service delivery systems and resources to train patients to self-administer TENS at home rather than having to visit clinics. The study revealed a need for educational programmes aimed at updating knowledge and skills about TENS in Saudi Arabia. Key words Transcutaneous Electric Nerve Stimulation (TENS), Pain, Analgesia, Neuromodulation, Physiotherapy, Saudi Arabia

Objectives: To determine the hypoalgesic effect of pulse frequency of transcutaneous electrical nerve stimulation (TENS) when all other TENS parameters are held constant. Data sources: Systematic review of studies using experimentally induced pain on healthy participants where there was a head-to-head comparison of different pulse frequencies. AMED, CINAHL, EMBASE, Inspec, PEDro, Pre-CINAHL, PsycARTICLES, PubMed, SPORTDiscus were searched in September 2006. Review methods: Inclusion criteria were studies that directly compared two or more pulse frequencies head-to-head and recorded outcome as change in pain threshold or pain intensity. Studies were excluded if pulse intensity, pulse pattern, or pulse duration of TENS were not standardized between groups. Two reviewers judged the trial outcome independently. Primary outcome was a report of a statistically significant difference between pulse frequencies for pain threshold or intensity at any time point through the experiment. Results: Twenty studies were identified, of which 13 experimental studies from 12 published reports were included for review. Ten studies found no statistically significant differences in hypoalgesia between pulse frequencies. Of the three studies judged as positive outcome, one reported that 100 pulses per second (pps) was superior to 10pps; one that 4pps was superior to 100pps; and one that 5pps and 80pps were superior to 2pps. Conclusion: Evidence from experimental pain studies suggests that TENS pulse frequency does not influence hypolagesia when its pulse intensity, pulse pattern, and pulse duration are kept constant. Inadequate sample sizes may have generated false negative findings in some studies.

INTRODUCTION: It is claimed that transcutaneous electrical nerve stimulation (TENS) operates via a segmental mechanism by reducing ongoing transmission and sensitization of nociceptive dorsal horn neurons. Hence, TENS electrodes are usually placed at the site of pain. OBJECTIVE: This study compared TENS administered at the site of experimentally induced ischemic pain (ipsilateral forearm) with TENS administered at a location not related to pain (contralateral lower leg). METHODS: Ten healthy, pain free volunteers took part in a cross-over study during which ischemic pain was induced in the nondominant arm using a modified version of submaximal effort tourniquet technique. Pain intensity was taken at 1-minute interval/s for 5 minutes while receiving TENS either at the ipsilateral arm or contralateral leg. RESULTS: There were no statistically significant differences in pain intensity or McGill Pain Questionnaire ratings between TENS given at the arm compared with the leg. DISCUSSION: Taken at face value, the findings suggest that TENS effects were nonspecific and that electrode location does not affect outcome. However, this study should be seen as a call for further research rather than a definitive conclusion. © 2007 Lippincott Williams & Wilkins, Inc.

Objective: To investigate the analgesic effects of different amplitude-modulated frequencies of interferential current therapy (IFT) on cold-induced pain in healthy subjects. Design: Single-blind parallel group methodology was used. Subjects completed 6 cycles of the cold-induced pain test (2 pretreatment, 2 during treatment, 2 posttreatment). During each cycle, subjects plunged their hand into iced water and the time taken to reach pain threshold was recorded. The hand remained immersed in the iced water for a further 30 seconds, after which the self-reports of pain intensity and pain unpleasantness were recorded. Setting: Laboratory in the United Kingdom. Participants: Sixty unpaid, pain-free volunteers without a known pathology that could cause pain. Interventions: IFT delivered on the nondominant arm at a "strong but comfortable" intensity without visible muscle twitches, using a quadripolar application technique at 1 of 6 possible amplitude modulated "beat" frequencies (20, 60, 100, 140, 180, 220Hz). Main Outcome Measures: The percentage change in pain threshold, pain intensity, and pain unpleasantness from the pretreatment baseline. Results: Two-way repeated-measures analyses of variance found no effects for groups for pain threshold (P=.11) or pain ratings (P>.05). There were no effects for cycle for any of the outcome measures. Effects for group by cycle interaction were noted for pain intensity and unpleasantness ratings (P<.05), although post hoc analysis failed to determine the nature of this interaction. Conclusions: Experimentally induced cold pain was not influenced by IFT frequencies. © 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.

Objective: To compare the analgesic effects of differing swing patterns of interferential current (IFC) on cold-induced pain. Design: Single-blind intervention study in which subjects completed 6 cycles of the cold-induced pain test - 2 pretreatment, 2 during treatment, and 2 posttreatment. Setting: Laboratory. Participants: Forty healthy volunteers. Interventions: Subjects were randomly allocated to receive 1 of 4 IFC treatment interventions: 1 ∫ 1, 6 ∫ 6, 6∧6, or burst. IFC was administered for 20 minutes via 4 electrodes attached to the forearm (quadripolar application) at a strong but comfortable intensity using amplitude-modulated frequencies of 1 to 100Hz. Main Outcome Measures: Change in pain threshold and self-report of pain intensity and unpleasantness from pretreatment baseline. Results: Two-way repeated-measure analysis of variance found significant effects for time and group by time interaction (P<.01), but effects for groups failed to reach statistical significance (P=0.1). This suggests that when all groups are considered together, subjects experience a rise in pain threshold when IFC devices are switched on but not when they are switched off. However, the rise in pain threshold was not dependent on the swing pattern employed. Analysis of pain intensity and unpleasantness ratings found no effects for group or group by time interaction. Conclusions: There were no differences in the hypoalgesic effects of different swing patterns. © 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.

The aim of this single‐blind placebo‐controlled study was to examine the analgesic effects of interferential currents (IFC) on experimentally induced ischaemic pain. Ischaemic pain was induced using the submaximal effort tourniquet technique (SETT) and pain intensity was recorded using a visual analogue scale at 1‐min intervals was used as the primary outcome measure. Following baseline recordings 30 healthy volunteers received either active IFC, sham IFC, or no treatment (10 subjects per group). Data were analysed by calculating the mean change in pain intensity at each 1‐min interval by subtracting data during treatment from the baseline data. IFC was administered throughout the duration of the ischaemic pain test via four electrodes (quadripolar application) on the forearm. Active IFC delivered electrical currents at a `strong but comfortable' intensity. A `dummy' stimulator that delivered no current was used as sham IFC. Subjects in the no treatment control group were informed that the IFC device was not switched on. There were significant effects for Groups (P=0·04) which were attributed to a significant reduction in pain intensity for the IFC group when compared with sham and no‐treatment control (P≤0·05). There were no significant effects for Time (P=0·69) or Group–Time interaction (P=0·45). In conclusion, IFC produced significantly greater analgesia than sham and no‐treatment control groups under the present experimental conditions.

Abstract

Background and Purpose. Interferential currents (IFC) and transcutaneous electrical nerve stimulation (TENS) are used for pain management. This study compared the analgesic effects of IFC and TENS on experimentally induced ischemic pain in otherwise pain-free subjects using a modified version of the submaximal-effort tourniquet technique. Subjects. The subjects were 30 volunteers (18 male, 12 female) without known pathology that could cause pain. Their mean age was 33.5 years (SD=9.9, range=21–54). Method. A single-blind, sham-controlled, parallel-group method was used. The primary outcome measure was the change in the self-report of pain intensity during 1 of 3 possible interventions: (1) IFC, (2) TENS, or (3) sham electrotherapy. The IFC and TENS were administered on the forearm, and the sham electrotherapy group received no current output via a dummy stimulator. Results. A 2-way repeated-measures analysis of variance revealed that there was no change in pain intensity during treatment when all 3 groups were considered together. Further analysis revealed that IFC reduced pain intensity when compared with sham electrotherapy but not when compared only with TENS. Discussion and Conclusion. There were no differences in the magnitude of analgesia between IFC and TENS. Interferential currents reduced pain intensity to a greater extent than sham electrotherapy.

The objective of this survey was to collect information about physiotherapists' self-report of their use of interferential therapy (IFT) to manage pain. Physiotherapists working in four city hospitals in the North of England completed a questionnaire designed by the authors to establish the use of IFT. Fifty two of the 57 respondents reported that they had previously used IFT in clinical practice. Thirty six respondents reported that they used IFT on a regular (weekly) basis and 35 of these used it for pain relief. However, 25 of the 35 respondents who regularly used IFT for pain relief reported that they used it on less than 25% of all of the pain patients that they managed in the clinic. The 35 respondents who regularly used IFT for pain relief reported that they administered one to five IFT treatments (n=26) to each patient with individual IFT treatments usually lasting 11–20 minutes (n=27). The respondents reported that they most commonly used amplitude modulated frequencies of 100Hz, together with 6^6 (delivery of a 6-second decrease between two predetermined amplitude modulated frequencies of IFT) swing patterns. Their knowledge about IFT practice was reported to be gathered from departmental colleagues (n=26).

The survey concludes that there was similarity in the IFT parameters and regimens used for pain relief between respondents. Most respondents used a trial and error approach to establishing IFT parameters using feedback from the patient about the comfort of IFT. In addition, IFT devices are large and expensive and remain in physiotherapy clinics and this may be the reason why respondents tend to administer IFT for less than 30 minutes while the patient attends the clinic. Perhaps physiotherapists should consider recommending cheap portable transcutaneous electrical nerve stimulation (TENS) devices instead of IFT, as patients can self-administer TENS whenever they need

Interferential currents (IFC) are a type of transcutaneous electrical nerve stimulation(TENS) and are predominantly administered for the management of pain, however, there is little objective evidence to support their clinical effectiveness. This paper demonstrates the value of laboratory-based studies in the initial assessment of the analgesic effects of an electrotherapy and discusses the findings of a single blind placebo-controlled study which examined the analgesic effects of IFC on cold-induced pain in 40 healthy individuals. Subjects completed six cycles of the cold-induced pain test during which the time to pain threshold(s) and the self report of pain intensity and pain unpleasantness (0–10 cm Visual Analogue Scale) were recorded. Subjects were randomly allocated to receive either active IFC or sham IFC treatment during the third and fourth experimental cycles. Two-way repeated measures ANOVA were performed on the percentage change in each outcome measure from the pretreatment baseline for each subject. Results showed that IFC elevated pain threshold when compared to sham IFC during treatment but not post treatment. There were no differences between the IFC and sham treatment groups for the percentage change in pain intensity and unpleasantness ratings. It was concluded that IFC produced analgesic effects which were greater than those produced by sham IFC for pain threshold, but not for the pain intensity and unpleasantness ratings under the present experimental conditions. However, these effects only occurred when the stimulator was switched on. The clinical implications of these findings are discussed.

Transcutaneous electrical nerve stimulation (TENS) and interferential currents (IFC) are used by physiotherapists for the management of painful conditions. It is claimed that the analgesic profiles of TENS and IFC differ although no studies have directly compared the analgesic effects of the two modalities. The aim of this double blind placebo controlled study was to compare the analgesic effects of TENS and IFC on cold-induced pain in healthy volunteers. Twenty one subjects completed six cycles of the cold-induced pain test (two pre-treatment, two during treatment, and two post-treatment). During each cycle pain threshold was recorded as the time from immersion of the subject's hand in cold water to the first sensation of pain and pain intensity and unpleasantness ratings were recorded using visual analogue scales. Subjects received one of the following treatments during the two treatment cycles: IFC, TENS, or sham electrotherapy. IFC and TENS were delivered at a 'strong but comfortable' intensity via two electrodes applied over the anterior aspect of the forearm. Sham electrotherapy was administered by a 'dummy' stimulator with no current output. All stimulators were visually identical. Analysis of the results found that IFC and TENS significantly elevated pain threshold when compared to sham electrotherapy (P < .05). There were no significant differences in the magnitude of the increase in pain threshold between IFC and TENS. No significant changes in pain intensity or unpleasantness ratings were found between the three treatment groups. We conclude that there were no differences in the analgesic effects of IFC and TENS under the present experimental conditions.

Chronic pain presents a complex challenge in general practice, often leading to cycles of over investigation, overprescribing, and underutilization of holistic support. This article explores how GPs can be better supported to identify chronic pain early, make clinically appropriate decisions without overmedicalizing, and confidently signpost patients to non-medical pain support at the right time. Drawing on the example of Rethinking Pain in Bradford, England–a cross-sector initiative that invests in GP education and provides demedicalised, culturally informed, person-centered pain support–we argue for a shift in the primary care paradigm. Importantly, this approach recognizes the valuable and needed role of GPs in chronic pain care–one that does not necessarily require more time, but rather a shift in mindset and confidence. By enabling GPs to intervene more effectively and holistically, this model has the potential to reduce repeated consultations and break the cycle of high-frequency GP use among people living with chronic pain. Empowering GPs with the tools, training, and networks to navigate chronic pain holistically can reduce harm, improve outcomes, and align care with national strategies for sustainable pain management.

Gender Role Expectancy of Pain (GREP) is a 12 items questionnaire (1) measuring three dimensions of pain; pain sensitivity, pain endurance and willingness to report pain. Recently, Defrin et al (2) found that men had a higher tolerance to heat pain, which correlated with self perception of pain sensitivity. However, there were no sex differences in heat pain threshold (HPT), and no correlation between GREP items and HPT. Comparison with American studies (1,3) suggested that GREP was affected by culture. Main conclusion: Pain sensitivity and willingness to report pain, as measured by GREP, predicted pain threshold and pain intensity.

Gender role refers to the culturally and socially constructed meanings that describe how women and men should behave in certain situations according to feminine and masculine roles learned throughout life. The aim of this meta-analysis was to evaluate the relationship between gender role and experimental pain responses in healthy human participants. We searched computerized databases for studies published between January 1950 and May 2011 that had measured gender role in healthy human adults and pain response to noxious stimuli. Studies were entered into a meta-analysis if they calculated a correlation coefficient (r) for gender role and experimental pain. Searches yielded 4465 'hits' and 13 studies were eligible for review. Sample sizes were 67-235 participants and the proportion of female participants was 45-67%. Eight types of gender role instrument were used. Meta-analysis of six studies (406 men and 539 women) found a significant positive correlation between masculine and feminine personality traits and pain threshold and tolerance, with a small effect size (r = 0.17, p = 0.01). Meta-analysis of four studies (263 men and 297 women) found a significant negative correlation between gender stereotypes specific to pain and pain threshold and tolerance, with a moderate effect size (r = -0.41, p < 0.001). In conclusion, individuals who considered themselves more masculine and less sensitive to pain than the typical man showed higher pain thresholds and tolerances. Gender stereotypes specific to pain scales showed stronger associations with sex differences in pain sensitivity response than masculine and feminine personality trait scales.

Transcutaneous electrical nerve stimulation (TENS) is a non-invasive, inexpensive analgesic technique used to relieve pain. It has been suggested that caffeine, an adenosine antagonist, may interfere with TENS action. This double-blind controlled pilot study investigated the effect of coffee on response to TENS in healthy human participants experiencing experimentally induced pain. Twelve participants (7 female, age range = 20–41 years) took part in two experiments separated by 24 h. Each experiment lasted 80 min and consisted of 3 × 15 min cycles: pre-TENS, during TENS predrink and during TENS postdrink [coffee (100 mg caffeine) or decaffeinated coffee randomized across experiments]. During each cycle, thresholds for electrical (EPT), mechanical (MPT) and cold pressor (CPT) pain were recorded. The statistical analysis modelled the responses for the coffee and decaffeinated coffee conditions during TENS (i.e. as a standard crossover) and detected no statistically significant effects between coffee and decaffeinated drinks for the natural logarithm (ln) transformed values of electrical pain threshold [ln EPT Coffee−ln EPT Decaffeinated coffee mean (standard error) = 0·0147 (0·2159)], mechanical pain threshold [ln MPT Coffee−ln MPT Decaffeinated coffee mean (standard error) = 0·1296 (0·0816)] and cold pain threshold [ln CPT Coffee−ln CPT Decaffeinated coffee mean (standard error) = 0·0793 (0·1139)]. We conclude that a single cup of coffee (100 mg caffeine) had no detectable effect on TENS outcome. Reasons why coffee did not produce a detectable effect on pain threshold are discussed.

People struggle to tell their story of living with pain and when they do it is articulated in a way that may not be understood, heard or taken seriously. Unmasking Pain is an artist-led project that explored creative approaches to tell stories of life with pain. The project was led by a dance theatre company that specialises in storytelling and emotional experiences for players and audiences. The project involved artists and people living with ongoing pain co-creating activities and environments to curiously explore "oneself", through imagination and creative expression. This article discusses insights and perspectives emerging from the project. The project revealed the power of art to make-sense of oneself with or without pain, and how art facilitates expression of complex inner experience and personal stories. People described Unmasking Pain as "explorative joy despite pain", and "a new set of rules" that contrasts with those experienced during clinical encounters. We discuss how art has the potential to improve clinical encounters and promote health and well-being, and whether artist-led activities are an intervention, therapy, or something else. Pain rehabilitation specialists from the project described Unmasking Pain as "freeing-up thinking", allowing conceptual thought beyond the biopsychosocial model of pain. We conclude that art has the potential to shift people living with pain from "I can't do, I am not willing to do it" to "Perhaps I can, I'll give it a go, I enjoyed".

‘Unmasking Pain’ is an innovative artist-led project to explore creative approaches for telling stories of life with persistent pain. The purpose of this qualitative study was to explore and describe the lived experience of taking part in ‘Unmasking Pain’ from the perspectives of people living with pain (workshop attendees), artists (workshop facilitators) and pain rehabilitation specialists. Informed by descriptive phenomenology, data was collected via semi-structured interviews with three artists (workshop facilitators), five workshop attendees (all living with persistent pain) and one pain rehabilitation specialist. Data was analysed using thematic analysis for descriptive phenomenology. Three themes emerged from the analysis: Theme 1 Space to Breathe, reflects the context of ‘Unmasking Pain’ such as the conditions, environment and setting that people experienced; Theme 2 Flexibility to Participate, reflects the experience of the process of ‘Unmasking Pain’ such as the actions or internal workings/behaviours of the experience; and Theme 3 Possibility for Change, reflects the cognitive or emotional experience of ‘Unmasking Pain’. There were nine sub-themes: 1(a) Dissolved hierarchy, 1(b) Human connection, and 1(c) Personally meaningful; 2(a) Go with the flow, 2(b) Enjoyable experience, and 2(c) Curiosity to step into the unknown; and 3(a) Reforming pain, 3(b) Liberating in the moment (now), and 3(c) Gives you a boost (future). In conclusion, the uniqueness of ‘Unmasking Pain’ was to creatively facilitate curiosity and exploration of pain in a non-clinical, sociocultural, humanised context, to enable the possibility of a different pain experience. The findings from this qualitative study exploring the lived experience of taking part in ‘Unmasking Pain’ demonstrates the power and opportunity of the Arts sector and artist-led activities to support people with chronic pain to have a better pain experience.

Raw list of in vivo codes, patterns, sub-themes and overarching themes demonstrating data analysis process.