Professor Mark Johnson

Interest in barefoot running has grown, driven by suggestions of injury reduction and strength improvements. This PhD project investigated the epidemiology of running-related injuries and neuromuscular adaptations to extended periods of barefoot running on grass. A rapid review of the literature (Chapter 2) revealed limited evidence of strength improvements, though some studies suggested increased cross-sectional area and volume of foot intrinsic and anterior leg muscles with prolonged barefoot running. However, no studies had specifically examined muscular adaptation to grass-based barefoot running. A retrospective injury survey (Chapter 3) captured self-reported data on injury location and prevalence among barefoot and shod runners. Injury prevalence did not significantly differ between groups (p = 0.112), though a near-significant increase in Achilles and shin injuries was found in barefoot runners (p = 0.06). Barefoot running did not significantly alter the odds of injury (OR = 0.886, 95% CI [0.749–1.048]). A pilot study (Chapter 4) evaluated muscle contractile properties using tensiomyography following a six-week treadmill running intervention. No consistent changes were detected across participants, regardless of footwear, indicating that tensiomyography was unsuitable for assessing neuromuscular adaptation. Electromyography was selected for the grass-based study to allow real-time measurement of muscle activity during running. A grass-based study (Chapter 5) examined differences in muscle activity using electromyography between barefoot and shod runners following a six-week grass running intervention and also explored participant experiences via semi-structured interviews. A two-way mixed ANOVA showed no significant interaction effects on rectus femoris (p = 0.125), biceps femoris (p = 0.980), or gastrocnemius medialis (p = 0.619). The relatively low training volume, combined with participants’ ongoing running routines, may have reduced the likelihood of observing meaningful neuromuscular adaptations. However, individual variability in muscle activation, particularly in rectus femoris and biceps femoris, highlights the importance of examining personalised responses to surface-based interventions. Interviews revealed that participants enjoyed the novelty of barefoot running on grass but noted barriers such as environmental conditions, surface safety, and temperature challenges. In conclusion, while the study aimed to explore neuromuscular adaptations to barefoot running on grass, changes in muscle activity were observed in some individuals across both barefoot and shod groups, suggesting that surface compliance may influence adaptation alongside footwear. These highly individual responses may have been shaped by prior experience, biomechanical variations and transition duration. The absence of clear group-level trends may reflect limited training volume or study power, underscoring the need for larger trials. A key takeaway from this research is the importance of recognising and interpreting individual responses, rather than relying solely on group averages.

Background Subtle eye movements offer a valuable yet underexplored window into how individuals encode and retrieve emotional memories, particularly in the context of psychological trauma. Objective To offer a perspective on the interrelationship among eye movements, nonconscious mental representations formed during emotionally intense or traumatic experiences (Emotional Memory Images [EMIs]), and adult health sequelae associated with childhood adversity. Study design A synthesis of clinical and theoretical insights, along with interdisciplinary literature, to advance conceptual understanding. Method A selective and interpretive study of peer-reviewed literature was conducted, drawing on sources from psychology, neuroscience, and trauma studies. The authors employed contextual analysis and integrative synthesis to develop a conceptual framework linking EMIs, eye movements, and stress-related adult health outcomes, stemming from childhood adversity. Results This article identified a theoretical link between EMIs and stress response, mediated by the amygdala and observable subtle ocular cues. These cues may serve as indicators of unresolved trauma and potential targets for therapeutic intervention. The Split-Second Unlearning (SSU) framework is proposed as a novel approach for identifying trauma-related health outcomes in adults with a history of childhood adversity, offering a potential and novel targeted therapeutic means for disrupting the automatic stress responses associated with EMIs. Conclusion This article advances the understanding of EMIs by highlighting the role of eye movements in stress-related neural processes. It proposes that decoding subtle oculomotor cues may enhance trauma-informed interventions, particularly in adults with a history of childhood adversity.

The cause of injury is often multifactorial and rarely the preserve of one independent factor. Inconsistency in the use of injury terminology, data collection procedures, calculation of exposure, and operational measures of performance by researchers exist. Standardising the criteria used to attribute injury and climbing activity, coupled with more accurate methods of calculating exposure, will overcome such limitations. Injury prevention in sport should therefore be governed by logical principles that provide the athlete, healthcare professional and coaching team with direction. In the sport of climbing, athletes need to be physically prepared to fully meet the demands imposed upon them. Athletic development and physical preparation strategies are a cornerstone of climbing performance and injury prevention. The ability of musculoskeletal tissues to adapt its material, morphological and physiological properties provide a performance advantage. Although there is a paucity of empirical research evidence in climbing populations, the use of injury surveillance, work load monitoring protocols, and physical preparation strategies may facilitate better future injury prevention planning.

The aim of sports injury rehabilitation is to restore an individual’s athletic function and performance to preinjury levels and to minimise the risk of reinjury. To effectively manage this process, clinicians require a comprehensive knowledge of the generic and specific injuries that climbers may sustain, an understanding of the principles of rehabilitation and an ability to adapt management plans specifically to the needs of the individual. Rehabilitation and physical preparation necessitate the development of systems thinking utilising evidence from published literature, the clinicians experience and shared decision-making with the patient. The central tenet of rehabilitation is the optimal application of mechanical load to stimulate electrochemical activity at cellular level, termed mechanotransduction.

Electrophysiological evidence provides a sound rationale for the use of transcutaneous electrical nerve stimulation to relieve pain, and its widespread use is supported by hundreds of clinical studies. However, there is recurrent uncertainty about the effectiveness of this technique, as highlighted in a recent assessment by the American Academy of Neurology.

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive technique used to reduce pain. It is claimed that TENS frequency is a key determinant of outcome. This study compared TENS delivered at 3 pulses per second (pps) and 80 pps on blunt pressure pain in human participants when TENS intensity was standardized at a strong nonpainful level. Thirty-two pain-free participants completed an experiment in which they received TENS at 3 pps and 80 pps in a crossover fashion. An algometer was used to measure pain threshold for each frequency before and during 20 minutes of TENS. A statistically significant elevation in pain threshold relative to baseline was found for 80 pps when compared to 3 pps after 10 and 20 minutes of TENS (P = .001 and P < .001, respectively). After 20 minutes of TENS, 30 of 32 participants had exceeded a 10N elevation in threshold relative to baseline during 80 pps compared to 19 participants during 3 pps (odds ratio 10.3 (CI, 2.28, 44.78), P = .002). We suggest that the higher rates of impulse generation by TENS at 80 pps resulted in a stronger afferent input to the central nervous system, resulting in stronger segmental inhibition of nociceptive transmission of second-order neurones, in line with the gate control theory of pain. In conclusion, strong nonpainful TENS at 80 pps was superior to 3 pps at increasing pressure-pain threshold in healthy volunteers. We recommend a follow-up study using pain patients. PERSPECTIVE: This study provides evidence that high frequency TENS at 80 pulses per second increases pain threshold to pressure algometry in healthy participants over and above that seen with low frequency TENS at 3 pulses per second when a strong nonpainful TENS sensation is experienced within the site of experimental pain.

During acupuncture some patients experience distinct sensations which are often referred to as needle sensation. Needle sensation may be related to treatment outcome, although what constitutes adequate acupuncture needle sensation is not known. In this paper, we debate the possibility of using the self-report of the overall intensity of needle sensation as a predictor of analgesic outcome to acupuncture. We describe how our approach to establish criteria to determine adequacy of transcutaneous electrical nerve stimulation interventions in clinical trials has been used to inform our search for markers of adequacy of procedural technique for acupuncture. We describe previous research which has focused on developing tools to capture the nature of the descriptors used by patients when they self-report needle sensation and reveal that little attention has been given to its role in outcome. We demonstrate that needle sensation is a complex phenomenon with subjects using multiple descriptors to report their experience. We argue that the intensity of the overall experience of needle sensation may prove useful as a gross marker of the adequacy of acupuncture. We briefly describe our research which isolates individual components of needling technique, such as depth of needle penetration and bidirectional needle rotation, in order to assess their contribution to overall needle sensation intensity.

Objective: To identify through case study the presentation and possible pathophysiological cause of complex regional pain syndrome and its preferential response to stellate ganglion blockade. Setting: Complex regional pain syndrome can occur in an extremity after minor injury, fracture, surgery, peripheral nerve insult or spontaneously and is characterised by spontaneous pain, changes in skin temperature and colour, oedema, and motor disturbances. Pathophysiology is likely to involve peripheral and central components and neurological and inflammatory elements. There is no consistent approach to treatment with a wide variety of specialists involved. Diagnosis can be difficult, with over-diagnosis resulting from undue emphasis placed upon pain disproportionate to an inciting event despite the absence of other symptoms or under-diagnosed when subtle symptoms are not recognised. The International Association for the Study of Pain supports the use of sympathetic blocks to reduce sympathetic nervous system overactivity and relieve complex regional pain symptoms. Educational reviews promote stellate ganglion blockade as beneficial. Three blocks were given at 8, 10 and 13. months after the initial injury under local anaesthesia and sterile conditions. Physiotherapeutic input was delivered under block conditions to maximise joint and tissue mobility and facilitate restoration of function. Conclusion: This case demonstrates the need for practitioners from all disciplines to be able to identify the clinical characteristics of complex regional pain syndrome to instigate immediate treatment and supports the notion that stellate ganglion blockade is preferable to upper limb intravenous regional anaesthetic block for refractory index finger pain associated with complex regional pain syndrome. © 2011 Elsevier Masson SAS.

Objective: To investigate the effect of therapeutic infrared class 3B laser irradiation on skin temperature in healthy participants of differing skin color, age, and gender. Background: Little is known about the potential thermal effects of Low Level Laser Therapy (LLLT) irradiation on human skin. Methods: Skin temperature was measured in 40 healthy volunteers with a thermographic camera at laser irradiated and control (non-irradiated) areas on the skin. Six irradiation doses (2–12 J) were delivered from a 200 mW, 810 nm laser and a 60 mW, 904 nm laser, respectively. Results: Thermal effects of therapeutic LLLT using doses recommended in the World Association for Laser Therapy (WALT) guidelines were insignificant; below 1.5°C in light, medium, and dark skin. When higher irradiation doses were used, the 60 mW, 904 nm laser produced significantly ( p  < 0.01) higher temperatures in dark skin (5.7, SD ± 1.8°C at 12 J) than in light skin, although no participants requested termination of LLLT. However, irradiation with a 200 mW, 810 nm laser induced three to six times more heat in dark skin than in the other skin color groups. Eight of 13 participants with dark skin asked for LLLT to be stopped because of uncomfortable heating. The maximal increase in skin temperature was 22.3°C. Conclusions: The thermal effects of LLLT at doses recommended by WALT-guidelines for musculoskeletal and inflammatory conditions are negligible (<1.5°C) in light, medium, and dark skin. However, higher LLLT doses delivered with a strong 3B laser (200 mW) are capable of increasing skin temperature significantly and these photothermal effects may exceed the thermal pain threshold for humans with dark skin color.

This randomized, placebo-controlled, blinded study investigated the hypoalgesic effects of high-frequency transcutaneous electrical nerve stimulation (TENS) delivered via a glove electrode compared with standard self-adhesive electrodes. Fifty-six TENS-naïve, healthy individuals (18 to 50 years old; 28 men, 28 women) were randomly allocated to 1 of 4 groups (n = 14 per group): glove electrode; placebo TENS using a glove electrode; standard electrode; and no treatment control. Active TENS (continuous stimulus, 100 Hz, strong but comfortable intensity) was applied to the dominant forearm/hand for 30 minutes. Placebo TENS was applied using a burst stimulus, 100-Hz frequency, 5-second cycle time for 42 seconds, after which the current amplitude was automatically reset to 0 mA. Pressure pain thresholds (PPTs) were recorded from 3 points on the dominant and nondominant upper limbs before and after TENS. Statistical analyses of dominant PPT data using between-within groups ANOVA showed significant differences between groups at all 3 recording points (P = .01). Post hoc Scheffe tests indicated no significant difference between the standard electrode and glove electrode groups. There was a significant hypoalgesic effect in the standard electrode group compared with the control group and between the glove electrode group and both the control and placebo TENS groups. There was no significant interactive effect between time and group at any of the recording points (P > .05). Perspective: This study presents a comparison of the hypoalgesic effects of 2 different types of TENS electrode, a novel glove electrode and standard self-adhesive rectangular electrodes. The glove electrode provides a larger contact area with the skin, thereby stimulating a greater number of nerve fibers. The results show that both electrodes have similar hypoalgesic effects and therefore give the clinician another choice in electrode. © 2009 American Pain Society.

This paper considers and discusses the effectiveness of Cyriax treatment for the management of tendinopathies, particularly lateral epicondylitis (LE), and makes the following recommendations and observations:1.There appears to be no evidence of clinically important benefit of deep transverse friction massage (DTFM) for treating tendinopathies.2.RCTs to study the effectiveness of DTFM and Mill's manipulation on LE are needed.3.A similar manipulation technique following DTFM may be found for the management of other tendinopathies similar to that used in treatment of LE. © 2006 Elsevier Ltd. All rights reserved.

This multicenter study assessed the feasibility of conducting a phase III trial of transcutaneous electrical nerve stimulation (TENS) in patients with cancer bone pain recruited from palliative care services. Eligible patients received active and placebo TENS for 1 hour at site of pain in a randomized crossover design; median interval between applications 3 days. Responses assessed at 30 and 60 minutes included numerical and verbal ratings of pain at rest and on movement, and pain relief. Recruitment, tolerability, adverse events, and effectiveness of blinding were also evaluated. Twenty-four patients were randomised and 19 completed both applications. The intervention was well tolerated. Five patients withdrew: 3 due to deteriorating performance status, and 2 due to increased pain (1 each following active and placebo TENS). Confidence interval estimation around the differences in outcomes between active and placebo TENS suggests that TENS has the potential to decrease pain on movement more than pain on rest. Nine patients did not consider that a placebo was used; the remaining 10 correctly identified placebo TENS. Feasibility studies are important in palliative care prior to undertaking clinical trials. Our findings suggest that further work is required on recruitment strategies and refining the control arm before evaluating TENS in cancer bone pain. Perspective: Cancer bone pain is common and severe, and partly mediated by hyperexcitability. Animal studies suggest that Transcutaneous Electrical Nerve Stimulation can reduce hyperalgesia. This study examined the feasibility of evaluating TENS in patients with cancer bone pain in order to optimize methods before a phase III trial. © 2010 American Pain Society.

This retrospective study of long-term use of transcutaneous electrical nerve stimulation (TENS) at Newcastle Pain Relief Clinic indicates that TENS has been a successful analgesic treatment for 58.6% of 1582 patients attending the climic over a period of 10 years. A wide range of pain conditions were found to respond to TENS and many patients continued to use the treatment for several years Most patients not responding to TENS (during a home trial) returned stimulators at the first follow-up appointment. Thus TENS should be considered as a siitple, safe and reusable first line treatment for many pain conditions.

The present study examines the effects of auricular transcutaneous electrical nerve stimulation (TENS) on electrical pain threshold measured at the ipsilateral wrist and autonomie functions including skin temperature, blood pressure and pulse rate in 24 healthy subjects. TENS was administered as low frequency trains of pulses delivered at a 'strong but comfortable' intensity to 1 of 3 auricular points to be examined: 1. (i) autonomic effects (autonomie point), 2. (ii) pain threshold effects (wrist point), 3. (iii) placebo effects at an unrelated point (face point). A fourth untreated group was designated as a situation control. The main finding of the study was that auricular TENS produced no significant overall effects on experimental pain threshold or autonomic functions recorded under the present conditions. However, pain threshold was found to increase by over 50% of its pretreatment baseline in 4 subjects and by 30% in 6 subjects. This rise was not dependent upon the site of auricular TENS. The possible mechanisms of such changes are discussed. © 1991.

Background: Neck pain is a common and costly condition for which pharmacological management has limited evidence of efficacy and side-effects. Low-level laser therapy (LLLT) is a relatively uncommon, non-invasive treatment for neck pain, in which non-thermal laser irradiation is applied to sites of pain. We did a systematic review and meta-analysis of randomised controlled trials to assess the efficacy of LLLT in neck pain. Methods: We searched computerised databases comparing efficacy of LLLT using any wavelength with placebo or with active control in acute or chronic neck pain. Effect size for the primary outcome, pain intensity, was defined as a pooled estimate of mean difference in change in mm on 100 mm visual analogue scale. Findings: We identified 16 randomised controlled trials including a total of 820 patients. In acute neck pain, results of two trials showed a relative risk (RR) of 1·69 (95% CI 1·22—2·33) for pain improvement of LLLT versus placebo. Five trials of chronic neck pain reporting categorical data showed an RR for pain improvement of 4·05 (2·74—5·98) of LLLT. Patients in 11 trials reporting changes in visual analogue scale had pain intensity reduced by 19·86 mm (10·04—29·68). Seven trials provided follow-up data for 1—22 weeks after completion of treatment, with short-term pain relief persisting in the medium term with a reduction of 22·07 mm (17·42—26·72). Side-effects from LLLT were mild and not different from those of placebo. Interpretation: We show that LLLT reduces pain immediately after treatment in acute neck pain and up to 22 weeks after completion of treatment in patients with chronic neck pain.

Chronic neck pain is a common problem and is treated using a variety of conservative treatments. This single-blind, randomized, sham-controlled trial investigated the value of adding electrical stimulation of acupuncture points on the wrist to a standardized program of neck exercises for chronic neck pain. METHODS: At initial recruitment 60 patients were randomly assigned to receive either active or sham electrical stimulation of acupuncture points on the wrist in addition to standardized neck exercise. Active or sham wrist acustimulation was given for 30 minutes 2 times/wk over a period of 4 weeks. A 30 minutes program of standardized neck exercises was also performed simultaneously. RESULTS: Forty-nine patients completed the study (22 active, 27 sham). Statistically significant improvements were found for acustimulation when compared with sham at immediate posttreatment and 1-month posttreatment for Numerical Rating Scale, Northwick Park Neck Pain Questionnaire and Pain Self-Efficacy Questionnaire. In active and sham electrical stimulation group 38.9% and 8.3% of patients reported a reduction of Numerical Rating Scale > 50% at 1-month posttreatment follow-up, respectively. All patients tolerated acustimulation and no adverse effects were reported. DISCUSSION:Electrical acustimulation of the wrist administered as two, 30 minutes sessions /wk added value to standardized neck exercise for chronic neck pain. A 4-week course of treatment produced effects lasting 1-month posttreatment.

This paper considers the physiological mechanisms which contribute to clinical pain by describing how the pain (nociceptive) system changes its sensitivity depending upon the body's needs. The time-course of physiological events following an injury is described to show that the healthy nociceptive system is not a hard-wired pain pathway but rather a dynamic system which can change its state of activity following an injury from a normal (or control) state to a sensitised (or amplified pain) state. This sensitised state enables the body to protect the injury from further damage and this will aid tissue healing. The peripheral acid central mechanisms contributing to a sensitised nociceptive system are described with reference to the symptoms of clinical pain such as hyperalgesia (an increased response to a stimulus which is normally painful), allodynia (pain due to a stimulus which does not normally provoke pain) and spontaneous 'on-going' pain. The role of the NMDA receptor in the development of central sensitisation is explored. It is suggested that in some chronic pain states the nociceptive system maintains a state of sensitivity despite the absence of on-going tissue damage and under such circumstances the nociceptive system itself may have become dysfunctional. Such situations are often initiated by damage to nervous tissue (neuropathic pain) which results in changes in the activity and organisation of neuronal circuits within the central nervous system. The ability of the nociceptive system to operate in a suppressed state is also discussed with reference to pain modulation.

The benefits of transcutaneous electrical nerve stimulation (TENS) for pain relief have not been reliably established, as most systematic reviews find poor methodological quality in many studies. The paradox within the evidence base for TENS is that despite identified sources of bias that may lead to an overestimation of treatment effects, no benefits for TENS can be clearly demonstrated. Conventional assessments of quality assume a single direction of bias, and little work has been undertaken examining other directions of bias. Our hypothesis was that low fidelity in studies (bias leading to an underestimation of treatment effects) may account for inconclusive findings. We included 38 studies from 3 recently published Cochrane systematic reviews that examined TENS for acute, chronic, and cancer pain. We extracted data relating to treatment allocation, application of TENS and to the assessment of outcomes. We quantified these data and judged this against standardised assessment criteria using a “traffic light” approach based on the number of studies reaching the standard. We identified significant sources of potential bias in both directions in relation to study design and implementation fidelity that have not been quantified previously. Suboptimal dosing of TENS and inappropriate outcome assessment were particularly prevalent weaknesses indicating low fidelity. We propose criteria for judging directions of bias in future studies of TENS that may be adapted to assess other trials in which implementation fidelity is important, such as other nonpharmacological interventions for pain.

Despite the widespread use of interferential currents (IFC) by physiotherapists to manage painful conditions, evidence for analgesic effects is sparse, and information on the optimal stimulating parameters is lacking. The aim of this single-blind placebo controlled preliminary study was to examine the analgesic effects of 6@?6 and 1@?1 swing patterns of IFC on cold-induced pain in healthy subjects. Fifteen healthy university student volunteers were randomly allocated to receive either active IFC 6@?6, active IFC 1@?1 or sham IFC. During the experiment, which lasted a total of 60 minutes, each subject completed six identical ten-minute experimental cycles of the cold-induced pain test. During each cycle the time to pain threshold and pain intensity rating measurements were recorded as outcome measures. Experimental cycles 1 and 2 were pre-treatment, cycles 3 and 4 during treatment (active IFC or sham IFC) and cycles 5 and 6 were post-treatment. The main finding of this study was that there was a larger rise in pain threshold for subjects receiving the 6@?6 swing pattern when compared to 1@?1 IFC or sham IFC. The rise in pain threshold was rapid in onset for the 6@?6 IFC group, occurring within ten minutes of IFC switch on and having returned to baseline within 20 minutes of IFC switch-off. No effects were found for pain intensity ratings during treatment. In conclusion, the differential analgesic effects between 6@?6 and 1@?1 swing patterns of IFC found in the present study may have implications for IFC settings used in the clinic. However, one should be cautious in extrapolating the results of this preliminary study on healthy subjects to patients suffering pain from injury and disease. It is imperative to confirm these findings in patient populations.

Cancer-related pain is complex and multi-dimensional; yet, the mainstay of cancer pain management has been the biomedical approach. There is a need for nonpharmacological and innovative pain management strategies. Transcutaneous electrical nerve stimulation (TENS) may have a role. The aim of this systematic review was to determine the effectiveness of TENS for cancer-related pain in adults. The Cochrane Library, MEDLINE, EMBASE, CINAHL, PsychINFO, AMED, and PEDro databases were searched for randomized controlled trials (RCTs) investigating the use of TENS for the management of cancer-related pain in adults. Once relevant studies were identified, two pairs of reviewers assessed eligibility for inclusion in the review based on a study eligibility form and using the 5-point Oxford Quality Scale. Two RCTs met the study eligibility criteria (these involved 64 patients). These studies were heterogeneous with respect to study population, methodology, and outcome measures. This prevented meta-analysis. In one RCT, there were no significant differences between TENS and placebo in women with chronic pain secondary to breast cancer treatment. In the other RCT, there were no significant differences between acupuncture-like TENS (AL-TENS) and sham in palliative care patients; this study was significantly underpowered. There is insufficient available evidence to determine the effectiveness of TENS in treating cancer-related pain. Further research is needed to help guide clinical practice, and large multi-center RCTs are required to assess the value of TENS in the management of cancer-related pain in adults. © 2009 U.S. Cancer Pain Relief Committee.

With the emphasis placed on placebo-controlled methodology in the testing of novel therapies, it is important that placebo effects are studied in their own right. Placebo effects, which may occur whenever a patient and a physician perceive a treatment as effective, may be susceptible to ethnocultural influences. However, experiments utilizing human subjects rarely take ethnocultural effects into account. This preliminary single-blind study examined the analgesic effects of placebo transcutaneous electrical nerve stimulation (TENS) on cold induced pain in 24 healthy first-generation UK-born Asian and White Anglo-Saxon subjects. Pain threshold and pain intensity rating measurements were taken during six 10-min experimental cycles (two pre-, two during and two post-treatment) of the cold-induced pain test. A portable TENS unit with no current output was used to administer placebo TENS during the two treatment cycles. Two-way RM ANOVA performed on log transformed pain threshold and pain intensity data found significant effects for cycle (P ≤ 0.01) and cycle x group interaction (P I 0.01). Further analysis found that Asian subjects produced a significantly greater increase in pain threshold and a significantly greater decrease in pain intensity rating during placebo TENS than White subjects. These findings suggest that ethnocultural background is an important determinant in placebo-induced analgesia in the laboratory setting. It is hoped that this preliminary study will serve to emphasize that ethnocultural factors should be considered during experiments utilizing human subjects.

Background: Cancer-related pain is complex and multi-dimensional but the mainstay of cancer pain management has predominately used a biomedical approach. There is a need for non-pharmacological and innovative approaches. Transcutaneous Electric Nerve Stimulation (TENS) may have a role for a significant number of patients but the effectiveness of TENS is currently unknown. Objectives: The aim of this systematic review was to determine the effectiveness of TENS for cancer-related pain in adults. Search strategy: We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, PsychINFO, AMED and PEDRO databases (11/04/08). Selection criteria: Only randomised controlled trials (RCTS) investigating the use of TENS for the management of cancer-related pain in adults were included. Data collection and analysis: The search strategy identified 37 possible published studies which were divided between two pairs of review authors that decided on study selection. A study eligibility form was used to screen each abstract and where study eligibility could not be determined from the abstract, the full paper was obtained and assessed by one pair of review authors. A standardised data extraction sheet was used to collect information on the studies and the quality of the studies was assessed independently by two review authors using the validated five-point Oxford Quality Scale. Final scores were discussed and agreed between all four review authors. The small sample sizes and differences in patient study populations of the two included studies prevented meta-analysis. Main results: Only two RCTs met the eligibility criteria (64 participants). These studies were heterogenous with respect to study population, sample size, study design, methodological quality, mode of TENS, treatment duration, method of administration and outcome measures used. In one RCT, there were no significant differences between TENS and placebo in women with chronic pain secondary to breast cancer treatment. In the other RCT, there were no significant differences between acupuncture-type TENS and shamin palliative care patients; this study was underpowered. Authors' conclusions: The results of this systematic review are inconclusive due to a lack of suitable RCTs. Large multi-centre RCTs are required to assess the value of TENS in the management of cancer-related pain in adults. Copyright © 2008 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

Objectives: To determine the effectiveness of therapeutic massage (TM) for the symptomatic relief of musculoskeletal pain, and to analyse TM intervention protocols used in studies. Design: Systematic review of randomised controlled clinical trials and experimental studies on healthy human participants. Participants: Patients with musculoskeletal pain and healthy participants with post-exercise pain and soreness. Main outcome measures: Comparisons of TM with: (i) no treatment; (ii) sham interventions; and (iii) active (standard) treatment. Outcome was dichotomised as effective (TM > comparison group) or not effective (TM ≤ comparison group). Results: Twenty studies (1341 participants) met the criteria for review. TM was superior to no treatment in five out of 10 comparisons, superior to sham (laser) treatment in one out of two comparisons, and superior to active treatment in seven out of 22 comparisons. TM was superior to comparison groups in six out of 11 studies using patients with musculoskeletal pain, and in three out of seven studies using patients with low back pain. TM was superior to comparison groups in four out of nine studies using healthy participants experiencing post-exercise pain and soreness. There were no relationships between study outcome and the TM regimen used. Conclusions: The available evidence is inconclusive. A combination of inadequate sample sizes, low methodological quality and insufficient TM dosing is likely to have contributed to the confused evidence base. © 2006 Chartered Society of Physiotherapy.

Recently, the analgesic effects of acupuncture have been brought into question, mainly because of the methodological inadequacies of previous studies. This single-blind placebo-controlled study examined the effects of manual acupuncture administered at a point related to the site of electrically induced pain at the finger (i.e. Pericardium 6) and a point unrelated to the site of electrically induced pain (i.e. Gallbladder 20) in normal subjects. The effects of acupuncture on the amplitudes of the late waveform components of the somatosensory evoked potentials elicited by painful electrical stimulation of the index finger were also examined. The main findings of this study were that, when compared to sham acupuncture or control groups, acupuncture administered at either Pericardium 6 or Gallbladder 20 did not significantly change: (i) sensory detection threshold, pain threshold or pain tolerance to electrically induced pain administered to the index finger, and (ii) P1N1 or N1P2 amplitudes of late latency waveform components of the somatosensory evoked potentials elicited by a painful electrical stimulus delivered to the index finger. Although acupuncture appears to be successful in relieving the pain of many chronic pain sufferers, these findings substantiate recent meta-analyses which conclude that the analgesic effects of acupuncture under placebo-controlled conditions remain in doubt. Our results should serve as an incentive for further research into the analgesic effects of acupuncture under placebo-controlled conditions.

BACKGROUND: Recent reviews have indicated that low level level laser therapy (LLLT) is ineffective in lateral elbow tendinopathy (LET) without assessing validity of treatment procedures and doses or the influence of prior steroid injections. METHODS: Systematic review with meta-analysis, with primary outcome measures of pain relief and/or global improvement and subgroup analyses of methodological quality, wavelengths and treatment procedures. RESULTS: 18 randomised placebo-controlled trials (RCTs) were identified with 13 RCTs (730 patients) meeting the criteria for meta-analysis. 12 RCTs satisfied half or more of the methodological criteria. Publication bias was detected by Egger's graphical test, which showed a negative direction of bias. Ten of the trials included patients with poor prognosis caused by failed steroid injections or other treatment failures, or long symptom duration or severe baseline pain. The weighted mean difference (WMD) for pain relief was 10.2 mm [95% CI: 3.0 to 17.5] and the RR for global improvement was 1.36 [1.16 to 1.60]. Trials which targeted acupuncture points reported negative results, as did trials with wavelengths 820, 830 and 1064 nm. In a subgroup of five trials with 904 nm lasers and one trial with 632 nm wavelength where the lateral elbow tendon insertions were directly irradiated, WMD for pain relief was 17.2 mm [95% CI: 8.5 to 25.9] and 14.0 mm [95% CI: 7.4 to 20.6] respectively, while RR for global pain improvement was only reported for 904 nm at 1.53 [95% CI: 1.28 to 1.83]. LLLT doses in this subgroup ranged between 0.5 and 7.2 Joules. Secondary outcome measures of painfree grip strength, pain pressure threshold, sick leave and follow-up data from 3 to 8 weeks after the end of treatment, showed consistently significant results in favour of the same LLLT subgroup (p < 0.02). No serious side-effects were reported. CONCLUSION: LLLT administered with optimal doses of 904 nm and possibly 632 nm wavelengths directly to the lateral elbow tendon insertions, seem to offer short-term pain relief and less disability in LET, both alone and in conjunction with an exercise regimen. This finding contradicts the conclusions of previous reviews which failed to assess treatment procedures, wavelengths and optimal doses.

Microcurrent electrical stimulation (MES) is an electrotherapeutic approach proposed by manufacturers for the management of acute and chronic pain. Evidence for analgesic efficacy is anecdotal and few controlled studies have been performed to date. This single-blind, placebo-controlled study examined the analgesic effects of MES on experimentally induced pain threshold and pain intensity rating in 36 healthy non-paid university student volunteers. Pain threshold and pain intensity recordings to cold-induced pain were made before, during and aft er a 20 min treatment session. Subjects received either active MES (DC biphasic pulses, 600 μA, 100 pulses per second) or placebo MES (no current output). The results showed no significant differences between active MES and placebo MES for the change in ice pain threshold or pain intensity rating during treatment. However, a significant increase in pain threshold was found in both active MES and placebo MES during the treatment cycles when compared to pre-treatment baseline. This change in pain threshold during active and placebo MES was similar in magnitude to placebo transcutaneous electrical nerve stimulation (TENS) and lower than active TENS as previously reported by ourselves. We conclude that the analgesic effects of active MES on cold-induced pain in healthy subjects were no greater than placebo. It is important to extend these laboratory findings by investigating the clinical efficacy of MES in patients with pain.

BACKGROUND: Treatment efficacy of physical agents in osteoarthritis of the knee (OAK) pain has been largely unknown, and this systematic review was aimed at assessing their short-term efficacies for pain relief. METHODS: Systematic review with meta-analysis of efficacy within 1-4 weeks and at follow up at 1-12 weeks after the end of treatment. RESULTS: 36 randomised placebo-controlled trials (RCTs) were identified with 2434 patients where 1391 patients received active treatment. 33 trials satisfied three or more out of five methodological criteria (Jadad scale). The patient sample had a mean age of 65.1 years and mean baseline pain of 62.9 mm on a 100 mm visual analogue scale (VAS). Within 4 weeks of the commencement of treatment manual acupuncture, static magnets and ultrasound therapies did not offer statistically significant short-term pain relief over placebo. Pulsed electromagnetic fields offered a small reduction in pain of 6.9 mm [95% CI: 2.2 to 11.6] (n = 487). Transcutaneous electrical nerve stimulation (TENS, including interferential currents), electro-acupuncture (EA) and low level laser therapy (LLLT) offered clinically relevant pain relieving effects of 18.8 mm [95% CI: 9.6 to 28.1] (n = 414), 21.9 mm [95% CI: 17.3 to 26.5] (n = 73) and 17.7 mm [95% CI: 8.1 to 27.3] (n = 343) on VAS respectively versus placebo control. In a subgroup analysis of trials with assumed optimal doses, short-term efficacy increased to 22.2 mm [95% CI: 18.1 to 26.3] for TENS, and 24.2 mm [95% CI: 17.3 to 31.3] for LLLT on VAS. Follow-up data up to 12 weeks were sparse, but positive effects seemed to persist for at least 4 weeks after the course of LLLT, EA and TENS treatment was stopped. CONCLUSION: TENS, EA and LLLT administered with optimal doses in an intensive 2-4 week treatment regimen, seem to offer clinically relevant short-term pain relief for OAK.

Interferential (IF) therapy is an electrotherapeutic modality used by physiotherapists for the management of a variety of painful conditions. However, the analgesic efficacy of IF remains in doubt and its mechanism of analgesic action is far from understood. This preliminary study examined the effect of IF on cold-induced pain threshold and tolerance in healthy student volunteers. Interferential therapy, when applied to the anterior aspect of the forearm of healthy subjects, significantly elevated ice pain threshold when compared with a control (no treatment) group. These preliminary findings provide objective evidence for the analgesic effects of IF currents. © 1995 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted.

In the cancer population, painful bony metastases are common, difficult to treat and significantly reduce quality of life. Common treatments include opioid analgesics, bisphosphonates, and radiotherapy; yet these have significant side effects and are not universally effective. Transcutaneous electrical nerve stimulation (TENS) is inexpensive, relatively free from side effects, and widely available. We present a case study of successful TENS therapy in a patient with cancer bone pain and discuss the rationale for using TENS in this setting. © 2009 U.S. Cancer Pain Relief Committee.

Summary

Transcutaneous electrical nerve stimulation (TENS) is used to relieve acute and chronic pain. TENS electrodes are applied at the site of pain or in segments related to the pain, although there is limited research to support either approach. This study investigated the effects of unilateral TENS on mechanical and thermal thresholds at ipsilateral and contralateral sites in healthy human participants. Sensory perception thresholds were measured on the ipsilateral and contralateral thenar eminence of 16 volunteers for von Frey filaments, sharpness, warm, cold and heat pain. TENS was administered over the right median nerve for 10 min at 100 pulses per second (pps) and an intensity which elicited mild tingling in the hand. During TENS, ipsilateral threshold was greater than contralateral threshold for all sensory modalities, although differences were less marked for thermal stimuli. TENS effects had disappeared 30 min after TENS had been switched off although there was a tendency for thermal thresholds to remain elevated. We conclude that during stimulation, TENS elevates somatosensory thresholds within the distribution of the stimulated nerve. The rapid and short‐lived ipsilateral effect is consistent with findings from animal studies and suggests a central segmental mechanism.

Background: Transcutaneous Electrical Nerve Stimulation (TENS) is a non-pharmacological agent, based on delivering low voltage electrical currents to the skin. TENS is used for the treatment of a variety of pain conditions. Objectives: To assess the analgesic effectiveness of TENS for acute pain in adults to see if it had any clear analgesic effect in its own right. Search strategy: The following databases were searched: Cochrane Pain, Palliative and Supportive Care Group Specialised Register; the Cochrane Central Register of Controlled Trials, CENTRAL (in The Cochrane Library); MEDLINE; EMBASE; CINAHL; AMED; PEDro; OTseeker; OpenSIGLE; and, reference lists of included studies. The most recent search was undertaken in August 2008. Selection criteria: Randomised controlled trials (RCTs) of adults with acute pain (less than 12 weeks) were included if they examined TENS given as a sole treatment and assessed pain with subjective pain scales. Studies were eligible if they compared TENS to placebo TENS, no treatment controls, pharmacological interventions or non-pharmacological interventions. Studies on experimental pain, case reports, clinical observations, letters, abstracts or reviews were excluded. Studies on TENS and labour pain, pain due to dental procedures and primary dysmenorrhoea were excluded. Studies where TENS was given with another treatment as part of the formal study design were also excluded. No restrictions were made regarding language. Data collection and analysis: Two authors independently assessed trial eligibility and extracted data. Data were extracted on the following: types of participants and pain condition, study design and methods, treatment parameters, adverse effects, and outcome measures. Study authors were contacted for additional information if necessary. Main results: Of 1479 studies identified in the search, 132 were identified as relevant. Of these, 116 were excluded; the vast majority of these were excluded due to TENS being given with another treatment. Four studies were categorised as awaiting classification as the information provided in the full text failed to clarify their eligibility. Twelve RCTs involving 919 participants at entry were included. The types of acute pain conditions included procedural pain, e.g. cervical laser treatment, venipuncture, screening flexible sigmoidoscopy and nonprocedural pain, e.g. postpartum uterine contractions, rib fractures. It was not possible to perform a meta-analysis due to insufficient data. Authors' conclusions: Due to insufficient extractable data in the studies included in this review, we are unable to make any definitive conclusions about the effectiveness of TENS as an isolated treatment for acute pain in adults. Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Randomised controlled trials were reviewed to evaluate the evidence of the effectiveness of extracorporeal shock wave therapy in the management of tennis elbow. Seven relevant trials were found, which had satisfactory methodology but conflicting results. Further research with well designed randomised control trials is needed to establish the absolute and relative effectiveness of this intervention for tennis elbow.

Head posture assessment has long been advocated as an important part of the examination for patients with neck pain. However, for a comprehensive understanding of the clinical usefulness of head posture assessment for patients with neck pain there is a need to discuss a set of topics, including: i) head posture definition, ii) the biomechanical and physiological implications of head posture changes, iii) whether there are differences in head posture between patients with neck pain and asymptomatic individuals, iv) what are the appropriate measurement procedures, v) what exercises are effective for head posture correction, and, vi) what are the benefits of head posture correction for patients with neck pain. We discussed these points in light of the most recent research, including our own findings on the subject.

Following the success of the previous three editions, Physical Management for Neurological Conditions 4th edition remains the most up-to-date evidence-based textbook for undergraduate students in health professions and qualified therapists.

© 2017 by Begell House, Inc. Interest within the healthcare profession in transdermal delivery of pharmaceuticals through passive, mechanical (phonophoresis) or electromotive (iontophoresis) forces has increased significantly throughout the past decade. The current review will examine the histology and cellular biology of the integument system as related to regulation of transcutaneous delivery of pharmaceutics, and examine currently accepted mechanism(s) of iontophoretic delivery. Additionally, a survey of current iontophoretic devices and electrodes available within the U.S. market, and the limitations of current technology will be presented. Experimental research supporting the use of iontophoresis for local delivery of pharmaceuticals will also be presented in conjunction with the outcomes of clinical investigations where iontophoresis was utilized for the local delivery of these pharmaceuticals. Topic areas to be covered within this section include iontophoresis of antibiotics into integument wounds, local anesthetics, and steroidal and nonsteroidal anti-inflammatory drugs. Finally, an examination of the benefits of combining various forces to enhance transcutaneous drug delivery and future direction(s) of research within this field will be discussed. The purpose of the present review is to provide both researchers and clinical practitioners with an objective basis for the current use of iontophoresis in rehabilitation medicine.

This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the effects of TENS on neuropathic pain in adults.

Background: Cancer-related pain is complex and multi-dimensional but the mainstay of cancer pain management has predominantly used a biomedical approach. There is a need for non-pharmacological and innovative approaches. Transcutaneous Electric Nerve Stimulation (TENS) may have a role in pain management but the effectiveness of TENS is currently unknown. This is an update of the original review published in Issue 3, 2008. Objectives: The aim of this systematic review was to determine the effectiveness of TENS for cancer-related pain in adults. Search methods: The initial review searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, PsychINFO, AMED and PEDRO databases in April 2008. We performed an updated search of CENTRAL, MEDLINE, EMBASE, CINAHL and PEDRO databases in November 2011. Selection criteria: We included only randomised controlled trials (RCTS) investigating the use of TENS for the management of cancer-related pain in adults. Data collection and analysis: The search strategy identified a further two studies for possible inclusion. One of the review authors screened each abstract using a study eligibility tool. Where eligibility could not be determined, a second author assessed the full paper. One author used a standardised data extraction sheet to collect information on the studies and independently assess the quality of the studies using the validated five-point Oxford Quality Scale. The small sample sizes and differences in patient study populations of the three included studies (two from the original review and a third included in this update) prevented meta-analysis. For the original review the search strategy identified 37 possible published studies; we divided these between two pairs of review authors who decided on study selection; all four review authors discussed and agreed final scores. Main results: Only one additional RCT met the eligibility criteria (24 participants) for this updated review. Although this was a feasibility study, not designed to investigate intervention effect, it suggested that TENS may improve bone pain on movement in a cancer population. The initial review identified two RCTs (64 participants) therefore this review now includes a total of three RCTs (88 participants). These studies were heterogenous with respect to study population, sample size, study design, methodological quality, mode of TENS, treatment duration, method of administration and outcome measures used. In one RCT, there were no significant differences between TENS and placebo in women with chronic pain secondary to breast cancer treatment. In the other RCT, there were no significant differences between acupuncture-type TENS and sham in palliative care patients; this study was underpowered. Authors' conclusions: Despite the one additional RCT, the results of this updated systematic review remain inconclusive due to a lack of suitable RCTs. Large multi-centre RCTs are required to assess the value of TENS in the management of cancer-related pain in adults.

This study records the consistency of transcutaneous electrical nerve stimulation (TENS) pulse frequency and pulse pattern used by 13 chronic patients over a 1 year period. The results show that patients prefer specific pulse frequencies and pulse patterns unique to the individual and that they turn to such frequencies and patterns on subsequent treatment sessions. Pulse frequencies and pulse patterns were not related to the cause and site of pain, a finding consistent with previous study in this laboratory. This observation, coupled with the large variability in pulse frequencies and pulse patterns used between individuals, implies that patients prefer such frequencies and patterns for reasons of comfort which may not be related to mechanisms specific to the pain system. © 1991.

This in-depth study examines the relationships between patient, stimulator and outcome variables in a large number of chronic pain patients utilising TENS on a long-term basis, 179 patients completed a TENS questionnaire designed to record age, sex, cause and site of pain and TENS treatment regime. Of these 179 patients, 107 attended our research unit for assessment of the electrical characteristics of TENS during self-administered treatment. Although a remarkable lack of correlation between patient, stimulator and outcome variables was found to exist, the analysis revealed much information of importance: 47% of patients found TENS reduced their pain by more than half; TENS analgesia was rapid both in onset (less than 0.5 h in 75% patients) and in offset (less than 0.5 h in 51% patients); one-third of patients utilised TENS for over 61 h/week; pulse frequencies between 1 and 70 Hz were utilised by 75% of patients; 44% of patients benefitted from burst mode stimulation. The clinical implications of these findings are discussed. © 1991.

A variety of stimulation techniques are used to alter nervous system activity and may be beneficial for cancer pain or in dying patients. Transcutaneous electrical nerve stimulation (TENS) is a noninvasive, inexpensive, safe, and easy to use technique that has a potential role alongside pharmacological management for pain directly or indirectly related to cancer and its treatment. There is a lack of available evidence to determine the effectiveness of TENS for cancer pain and evidence remains equivocal for other types of pain because of difficulties in trial design. Electrical stimulating devices can be implanted into the spinal cord and brain and may prove useful for intractable pain in carefully selected patients who are not responding to other treatments. Electrical stimulating devices such as spinal cord stimulation (SCS) and deep brain stimulation (DBS) can be utilized in the management of cancer-related pain but they are expensive and there is currently a lack of evidence surrounding their use in this situation.

The analgesic efficacy of various pulse patterns of transcutaneous electrical nerve stimulation (TENS) were assessed in 84 normal healthy subjects using the cold pressor pain technique. Burst, modulation, random and continuous TENS all significantly elevated ice pain threshold. Continuous (80 Hz) TENS produced the greatest mean elevation in threshold but the response to random TENS showed the least inter-subject variation. Ice pain tolerance was increased by all modes of TENS, continuous TENS producing the greatest magnitude of response, although these changes did not reach statistical significance. Increasing the size of electrodes reduced the effect of continuous TENS. The clinical implications of these findings are discussed. © 1991.

The efficacy of transcutaneous electrical nerve stimulation (TENS) in producing analgesia in cold-induced pain was assessed using a range of 5 stimulating frequencies (10 Hz, 20 Hz, 40 Hz, 80 Hz and 160 Hz) in 83 normal healthy subjects. TENS significantly elevated ice pain threshold when compared with sham and control groups. TENS frequencies between 20 and 80 Hz produced greatest analgesia, while frequencies below and above this level (10 Hz and 160 Hz), although significantly elevating ice pain threshold, produced effects of a lesser magnitude. The frequency of pulse delivery was the governing factor as no significant differences in stimulus intensity were observed across the treatment groups. Measurement of ice pain tolerance was found to be unreliable under the present conditions. No significant relationships were observed between personality variables as measured by Eysenck Personality Questionnaires and the degree of TENS response. © 1989.

This chapter contains sections titled: Introduction Transcutaneous electrical nerve stimulation Acupuncture Conclusion References Introduction Transcutaneous electrical nerve stimulation Acupuncture Conclusion References

Transcutaneous electrical nerve stimulation (TENS) is used extensively throughout the world to manage painful conditions, including postoperative pain, labor pain, and chronic pain. However, the results of systematic reviews of randomized controlled trials (RCTs) on TENS have questioned the clinical effectiveness of TENS for these conditions. This article critically evaluates TENS effectiveness in light of these systematic reviews and demonstrates that methodological problems associated with RCTs included in systematic reviews may account in part for the negative findings. TENS effectiveness has been determined by some authors using comparisons with active treatments, such as conventional medication, although this is inappropriate because both TENS and the active treatment may be more effective than a placebo control. A sham TENS control group is necessary to determine absolute clinical effectiveness, although in practice this may be difficult to achieve. The authenticity of claims of double-blind procedures in TENS trials is questioned and the role of triple-blinding in trials of TENS discussed. The wide variety of TENS treatment protocols used in RCTs highlights the difficulty of synthesizing the results of TENS trials. Inappropriate TENS treatment interventions in studies with high methodological quality scores emphasize the danger of taking RCT results at face value. This article concludes that it would be hasty to withdraw support for the use of TENS in the management of acute and chronic pain at present as methodological problems associated with some of the RCTs included in systematic reviews may account for the negative findings.

Frequency-modulated transcutaneous electrical nerve stimulation (TENS) delivers currents that fluctuate between preset boundaries over a fixed period of time. This study compared the effects of constant-frequency TENS and frequency-modulated TENS on blunt pressure pain in healthy human volunteers. Thirty-six participants received constant-frequency TENS (80 pps), frequency-modulated TENS (20 to 100 pps), and placebo (no current) TENS at a strong nonpainful intensity in a randomized cross-over manner. Pain threshold was taken from the forearm using pressure algometry. There were no statistical differences between constant-frequency TENS and frequency-modulated TENS after 20 minutes (OR = 1.54; CI, 0.29, 8.23, P = 1.0). Both constant-frequency TENS and frequency-modulated TENS were superior to placebo TENS (OR = 59.5, P < .001 and OR = 38.5, P < .001, respectively). Frequency-modulated TENS does not influence hypoalgesia to any greater extent than constant-frequency TENS when currents generate a strong nonpainful paraesthesia at the site of pain. The finding that frequency-modulated TENS and constant-frequency TENS were superior to placebo TENS provides further evidence that a strong yet nonpainful TENS intensity is a prerequisite for hypoalgesia. Perspective: This study provides evidence that TENS, delivered at a strong nonpainful intensity, increases pain threshold to pressure algometry in healthy participants over and above that seen with placebo (no current) TENS. Frequency-modulated TENS does not increase hypoalgesia to any appreciable extent to that seen with constant-frequency TENS. © 2009 American Pain Society.

The term 'transcutaneous electrical nerve stimulation' (TENS) is synonymous with a standard TENS device. Increasingly, nonstandard TENS-like devices are being marketed to health care professionals for pain relief. These include: interferential current therapy, microcurrent electrical therapy, high-voltage pulsed (galvanic) currents, TENS-pens, transcranial electrical stimulation and Limoge currents, Codetron, transcutaneous spinal electroanalgesia, action potential simulation, and H-wave therapy. This review evaluates the effectiveness of TENS and TENS-like devices for pain relief, to inform health care professionals about device selection. The results from systematic reviews suggest that TENS is not effective for postoperative pain and labour pain, although volatile evaluation models may partly explain the findings. Evidence is inconclusive for chronic pain. Health care professionals should not dismiss the use of TENS for any condition until the issues in clinical trial design and review methodology have been resolved. There is limited experimental evidence available for most TENS-like devices. Claims by manufacturers about the specificity and extent of effects produced using TENS-like devices are overstated and could probably be achieved by using a standard TENS device or a microcurrent electrical therapy device. When making decisions about device selection, health care professionals should consider the physiological intention of currents and whether this can be achieved by using particular devices. Clinical trials that examine the relative effectiveness of TENS-like devices with a standard TENS device are desperately needed.

Transcutaneous electrical nerve stimulation (TENS) is an electrophysical modality used for pain management. This study investigated the dose response of different TENS intensities on experimentally induced pressure pain. One hundred and thirty TENS naïve healthy individuals (18-64 years old; 65 males, 65 females) were randomly allocated to 5 groups (n = 26 per group): Strong Non Painful TENS; Sensory Threshold TENS; Below Sensory Threshold TENS; No Current Placebo TENS; and Transient Placebo TENS. Active TENS (80 Hz) was applied to the forearm for 30 minutes. Transient Placebo TENS was applied for 42 seconds after which the current amplitude automatically reset to 0 mA. Pressure pain thresholds (PPT) were recorded from 2 points on the hand and forearm before and after TENS to measure hypoalgesia. There were significant differences between groups at both the hand and forearm (ANOVA; P =.005 and.002). At 30 minutes, there was a significant hypoalgesic effect in the Strong Non Painful TENS group compared to: Below Sensory Threshold TENS, No Current Placebo TENS and Transient Placebo TENS groups (P <.0001) at the forearm; Transient Placebo TENS and No Current Placebo TENS groups at the hand (P =.001). There was no significant difference between Strong Non Painful TENS and Sensory Threshold TENS groups. The area under the curve for the changes in PPT significantly correlated with the current amplitude (r

2

Objectives: Non-painful needle sensations elicit different hemodynamic responses compared to painful needle sensations which may indicate positive therapeutic benefits. Yet there is evidence regarding the perception of painful and non-painful sensations during acupuncture. This study measured painful and non-painful sensations during and after the insertion of a single acupuncture needle. Design: This study used a repeated measures, crossover design. Setting: This experiment was conducted in the physiology laboratory at Leeds Metropolitan University, UK. Subjects: Fifteen healthy participants were recruited from university staff and students. Intervention: During each session, a single acupuncture needle was inserted at LI10 for 15 minutes, and needle sensations were recorded at 5-minute intervals for a total of 30 minutes. During the first visit, an acupuncture needle was inserted to a depth of 15-25 mm followed by bidirectional rotation (Experimental condition). During the second visit, an acupuncture needle was inserted to a depth of 5mm with mock bidirectional rotation (Control condition). Main Outcome Measures: Needle sensation intensity was measured using a visual analog scale. Painful and non-painful characteristics of needle sensation were reported on the Massachusetts General Hospital Acupuncture Sensation Scale. Participants were also asked to report if needle sensations were painful or not by indicating yes or no. Results: Bidirectional needle rotation increased the overall needle sensation intensity and the intensity of painful and non-painful sensations. Nine participants reported sensations as painful during bidirectional rotation of the needle and no participants reported painful sensations during mock rotation of the needle. There were no differences in sensation characteristics between the participants reporting painful or non-painful sensations except that of numbness which was lower in participants reporting painful sensations compared with those that did not. Conclusions: Bidirectional rotation of an acupuncture needle inserted at a depth of 15-25mm produced stronger painful and non-painful needle sensations compared to mock bidirectional rotation of a needle inserted 5mm into the skin. © 2012 Mary Ann Liebert, Inc.

Abstract

Nowadays the volume of published research is so overwhelming that practitioners are turning to expert groups to interpret and summarise research for them. This paper critically reviews the processes used to establish one-sentence statements about the effectiveness of acupuncture for pain relief. Some one-sentence statements claim that acupuncture is not clinically effective because systematic reviews of clinical trials find similar amounts of pain relief between sham acupuncture and real acupuncture. However, these one-sentence statements fail to account for shortcomings in clinical trials such as inadequate doses and inappropriate acupuncture technique. Establishing the physiological intention of acupuncture and developing criteria to assess whether this has been achieved in trials will help to overcome some of these problems in future trials. In addition, shortcomings in systematic review methodology such as imprecise inclusion criteria, comparisons of heterogeneous study populations and imprecise definitions of acupuncture have resulted in discrepancies in vote counting of outcomes between review groups. Recognition of these issues has produced a shift in favour of acupuncture in recent systematic reviews and meta-analyses. It is hoped that this will be reflected in a reappraisal of some of the negative one-sentence statements about the effectiveness of acupuncture for pain relief.

Objective: Our aim was to determine the effectiveness of low-lever laser therapy (LLLT) in the management of lateral elbow tendinopathy (LET) and to provide recommendations based on this evidence. Background data: LET is a common clinical condition, and a wide array of physiotherapy treatments is used for treating LET. Methods: Randomized controlled trials (RCTs) identified by a search strategy in six databases were used in combination with reference checking. RCTs that included LLLT, patients with LET, and at least one of the clinically relevant outcome measure were selected. Aqualitative analysis of the selected studies was conducted using the Chalmers' technique. Results: Nine RCTs fulfilled the criteria and were included in the review. Although these studies had satisfactory methodology, shortcomings were not absent; poor results were revealed as to the effectiveness of LLLT for LET management. Conclusions: LLLT need not be ruled out for LET as it is a dose-response modality, and the optimal treatment dose has obviously not yet have been discovered. Further research with well-designed RCTs is needed to establish the absolute and relative effectiveness of this intervention for LET.

Objective: The aim of this study was to review the biological and clinical short-term effects of low-level laser therapy(LLLT) in acute pain from soft-tissue injury. Background Data: It is unclear if and how LLLT can reduce acute pain. Methods: Literature search of (i) controlled laboratory trials investigating potential biological mechanisms for pain relief and (ii) randomized placebo-controlled clinical trials which measure outcomes within the first 7 days after acute soft-tissue injury. Results: There is strong evidence from 19 out of 22 controlled laboratory studies that LLLT can modulate inflammatory pain by reducing levels of biochemical markers (PGE 2 , mRNA Cox 2, IL-1β, TNFα), neutrophil cell influx, oxidative stress, and formation of edema and hemorrhage in a dosedependent manner (median dose 7.5 J/cm 2 , range 0.3–19 J/cm 2 ). Four comparisons with non-steroidal anti-inflammatory drugs (NSAIDs) in animal studies found optimal doses of LLLT and NSAIDs to be equally effective. Seven randomized placebo-controlled trials found no significant results after irradiating only a single point on the skin overlying the site of injury, or after using a total energy dose below 5 Joules. Nine randomized placebo-controlled trials ( n = 609) were of acceptable methodological quality, and irradiated three or more points and/or more than 2.5 cm2 at site of injury or surgical incision, with a total energy of 5.0–19.5 Joules. Results in these nine trials were significantly in favor of LLLT groups over placebo groups in 15 out of 18 outcome comparisons. Poor and heterogeneous data presentation hampered statistical pooling of continuous data. Categorical data of subjective improvement were homogeneous (Q-value = 7.1) and could be calculated from four trials ( n = 379) giving a significant relative risk for improvement of 2.7 (95% confidence interval [CI], 1.8–3.9) in a fixed effects model. Conclusion: LLLT can modulate inflammatory processes in a dose-dependent manner and can be titrated to significantly reduce acute inflammatory pain in clinical settings. Further clinical trials with adequate LLLT doses are needed to precisely estimate the effect size for LLLT in acute pain.

Multiple influences prevent recovery from pain. Our viewpoint is that non-conscious emotional memory images (EMIs) triggers outdated stress responses contributing to the intractability of pain. In this perspectives article we explore the concept that EMIs contribute to the persistence of pain. We contend that psychophysiological "stress" responses, resulting from first-time, novel and unprecedented pernicious or adverse events form EMIs within very short time frames (split-second learning). Subsequently, these EMIs are re-triggered in daily living, "re-playing" stress responses. We postulate that EMIs continually "raise the alarm" to socio-ecological stimuli by re-triggering the HPA-axis and amplifying neural input associated with threat, fear, anxiety, and pain, creating a debilitating state of psychophysiological dis-ease. We position the EMI within a philosophical debate on the nature and locus of memory and explain how the EMI, irrespective of whether it is a "thing" or a metaphor, can create a basis of understanding for the client to grasp. We describe a therapeutic approach (Split-Second Unlearning) to "clear" EMIs and the "stickiness" of pain and help people embark on a healing journey. This involves surveillance of clients for micro-expression(s) signifying an in-the-moment stress response, representative of the presence of an EMI, and encouraging the client to become a curious observer within/of their own experience. This helps the client detach their EMI from its stress response. We contend that this occurs rapidly without the need to get bogged down in a whole-life narrative. We advocate further exploration of our EMI model of dis-ease in the context of intractable pain.

Persistent pain is a significant healthcare issue, often unresponsive to traditional treatments. We argue for incorporating non-biomedical perspectives in understanding pain, promoting more comprehensive solutions. This article explores how language, specifically time-related terms, may affect the persistence (stickiness) of pain. We delve into how language influences one's experience of the world, especially in understanding pain through spatial metaphors. Notably, time perceptions differ across languages and cultures and there is no absolute construct of temporal pain experience. In English, time is viewed linearly as past, present, and future. We introduce a framework called Past Adversity Influencing Now (PAIN) which includes various temporal phases of pain; Past Perfect, Past Imperfect, Present, Future Imperfect, and Future Perfect. We suggest that past negative memories (emotional memory images) can "trap" individuals in a "sticky" pain state. We speculate that the process of diagnosing pain as "chronic" may solidify this "stickiness", drawing from the ancient Greek idea of "logos", where pain communicates a message across time and space needing recognition. Our PAIN framework encourages examining pain through a temporal lens, guiding individuals towards a more positive future.

Metaphorical language is used to convey one thing as representative or symbolic of something else. Metaphor is used in figurative language but is much more than a means of delivering "poetic imagination". A metaphor is a conceptual tool for categorising, organizing, thinking about, and ultimately shaping reality. Thus, metaphor underpins the way humans think. Our viewpoint is that metaphorical thought and communication contribute to "painogenicity", the tendency of socio-ecological environments (settings) to promote the persistence of pain. In this perspectives article, we explore the insidious nature of metaphor used in pain language and conceptual models of pain. We explain how metaphor shapes mental organisation to govern the way humans perceive, navigate and gain insight into the nature of the world, i.e., creating experience. We explain how people use metaphors to "project" their private sensations, feelings, and thoughts onto objects and events in the external world. This helps people to understand their pain and promotes sharing of pain experience with others, including health care professionals. We explore the insidious nature of "warmongering" and damage-based metaphors in daily parlance and demonstrate how this is detrimental to health and wellbeing. We explore how metaphors shape the development and communication of complex, abstract ideas, theories, and models and how scientific understanding of pain is metaphorical in nature. We argue that overly simplistic neuro-mechanistic metaphors of pain contribute to fallacies and misnomers and an unhealthy focus on biomedical research, in the hope of developing medical interventions that "prevent pain transmission [sic]". We advocate reconfiguring pain language towards constructive metaphors that foster a salutogenic view of pain, focusing on health and well-being. We advocate reconfiguring metaphors to align with contemporary pain science, to encourage acceptance of non-medicalised strategies to aid health and well-being. We explore the role of enactive metaphors to facilitate reconfiguration. We conclude that being cognisant of the pervasive nature of metaphors will assist progress toward a more coherent conceptual understanding of pain and the use of healthier pain language. We hope our article catalyses debate and reflection.

In this perspective paper, we argue for incorporating personal narratives in positive psychology interventions for chronic pain. Narratives refer to the telling and retelling of events. Narratives detail accounts of events and provide rich, in-depth information on human interactions, relationships, and perspectives. As such, narratives have been used to understand people's experiences with pain and pain coping mechanisms-as well as to facilitate therapeutic outcomes. Furthermore, narrative research has shown that narration can help restore and promote relief, calm, hope, self-awareness, and self-understanding in chronic pain sufferers. Positive psychology interventions have been successful in improving the lives of people living with chronic pain, but these psychology interventions do not typically incorporate personal narratives. Still, narrative, and positive psychology scholarship foci overlap, as both aim to enhance people's quality of life, happiness, and well-being, and to promote the understanding of psychosocial strengths and resources. In this article, we provide a rationale for incorporating personal narratives as an agentic form of positive psychology intervention. To that aim, we outline areas of convergence between positive psychology and narrative research and show how combining positive psychology exercises and narration can have additive benefits for pain sufferers. We also show how integrating narration in positive psychology intervention research can have advantages for healthcare research and policy.

This article explores how paternalistic control and power reside within the family system and how this may influence pain and its persistence. Drawing upon clinical case studies and existing literature, this exploration emphasises the role of paternal dysfunction in creating emotional memory images and delves into how this may influence the chronification and treatment resistance of pain (i.e., making pain “sticky”). We argue that a dysfunctional paternalistic family system, often characterised by authoritarian dynamics, emotional neglect, and abuse, results in adverse experiences and emotional memory images that create a fertile ground for the entrenchment and propagation of psychosomatic symptoms, including pain. Further, the paper emphasizes the potential intergenerational effects of such a scenario, where inherited “Family Rules” drive maladaptive coping mechanisms, which contribute to the persistence of psychological and physiological distress across generations. Understanding these complexities offers new perspectives on treating psychological disorders and their physiological ramifications. It also highlights the urgency of addressing dysfunctional familial dynamics in psychotherapeutic interventions for both immediate and long-term psychophysiological health outcomes.

Objective To investigate the effect of diadynamic currents administered prior to exercises on pain and disability in patients with osteoarthritis of the knee. Design A randomized-controlled trial. Setting Special Rehabilitation Services in Taboão da Serra. Participants Patients with bilateral knee osteoarthritis. Intervention Participants were randomly allocated to Group I (diadynamic currents and exercises; n = 30, 60 knees) or Group II (exercises alone; n = 30, 60 knees) and were treated three times a week for 8 weeks. Main outcome measures The primary outcome measures were change in knee pain evaluated by visual analog scale and disability Index Score (Lequesne). Secondary outcomes included change in mobility (Timed Up and Go test), range of motion (goniometer), muscle strength (dynamometer), a composite score for pain and disability (Western Ontario and McMaster Universities Osteoarthritis questionnaire), and a drug diary to measure consumption of rescue pain medication (paracetamol). All measurements were collected at baseline, 8 weeks, and 6 months from baseline (follow-up). Results There were 60 participants with a mean (SD) age of 63.40 (8.20) years. Between-group differences in the follow-up (8 weeks and 6 months) were observed for pain at rest, pain during activities of daily living and disability. There was improvement in Group I that was maintained for the three variables 6 months after treatment. Mean difference for pain at rest was −3.08 points (95% confidence interval −4.13; −2.02), p < 0.01 with an effect size of 1.4; mean difference for pain during activities of daily living was −2.40 points (95% confidence interval −3.34; −1.45), p < 0.01 with an effect size of 1.24; and mean difference for disability was −4.08 points (95% confidence interval −5.89; −2.26), p < 0.01 with an effect size of 1.04. Conclusion Patients with symptomatic knee osteoarthritis receiving 8 weeks of treatment with diadynamic currents as an adjunct to a program of exercises had significantly greater improvements in pain and disability than those receiving exercises alone. Beneficial effects were sustained for 6 months.

Introduction Wearable neuromuscular and biomechanical biofeedback technology has the potential to improve patient outcomes by facilitating exercise interventions. We will conduct a systematic review to examine whether the addition of wearable biofeedback to exercise interventions improves pain, disability and quality of life beyond exercise alone for adults with chronic non-specific spinal pain. Specific effects on clinical, physiological, psychological, exercise adherence and safety outcomes will also be examined. Methods and analysis A systematic search will be conducted from inception to February 2024. Full articles in the English language will be included. MEDLINE, PubMed, CINAHL, EMBASE, Web of Science, PsycINFO, AMED, SPORTDiscus, CENTRAL databases, clinical trial registries and ProQuest (PQDT) will be used to search for eligible studies. Grey literature and conference proceedings (2022–2024) will be searched for relevant reports. Randomised controlled trials using wearable neuromuscular or kinematic biofeedback devices as an adjunct to exercise interventions for the treatment of chronic spinal pain will be included in this systematic review. The comparators will be wearable biofeedback with exercise versus exercise alone, or wearable biofeedback with exercise versus placebo and exercise. Risk of bias will be assessed using Cochrane Back Review Group criteria and the quality of evidence using Grading of Recommendations Assessment, Development and Evaluation recommendations. Ethics and dissemination The systematic review will be based on published studies, and therefore, does not require ethical approval. The study results will be submitted for publication in an international, open-access, peer-reviewed journal and shared through conferences and public engagement. PROSPERO registration number CRD42023481393.

The intricate dance of eye movements, often overlooked, provides an invaluable gateway to understanding how we perceive and interact with our environment. The purpose of this article is to offer perspective on the relationship be-tween eye movements and emotional memory images (EMIs), and how EMIs contribute to the sequelae in adult health stemming from childhood adversity. We discuss the role of the amygdala and the relationship between eye movements and the stress response to expand the academic discourse on EMIs and trauma and implications for post-trauma inter-vention for adult health sequelae. We argue that recognising and interpreting subtle ocular cues can inform more tar-geted and effective therapeutic approaches for individuals grappling with psychophysiological dis-ease. Our goal is to elucidate how our concept of Split-Second Unlearning (SSU) provides a deeper insight into persistently poor mental and physical health and its long-term effects on adults with a history of childhood adversity. In this article, we further de-velop the discussion around eye movement and how the Split-Second Unlearning framework opens doors for potential treatments targeting adult health sequelae. The implications range from an enhanced understanding of traumas in connection to adverse childhood experiences (ACEs) to objective assessment for undiagnosed trauma and the applica-tion of early intervention, with new therapeutic approaches for adult health outcomes.

Despite the proliferation of biomedical and psychological treatments, the global burden of chronic intractable (long-term) pain remains high—a treatment-prevalence paradox. The biopsychosocial model, introduced in the 1970s, is central to strategies for managing pain, but has been criticised for being decontextualised and fragmented, compromising the effectiveness of healthcare pain support services and patient care. The aim of this study was to apply a simplified version of Ken Wilber’s All Quadrant All Levels (AQAL) framework to pain in a healthcare context to advance a biopsychosocial understanding. Utilising domain knowledge, the author mapped features of pain and coping to intrasubjective, intraobjective, intersubjective, and interobjective quadrants (perspectives), as well as levels of psychological development. Narratives were crafted to synthesize the findings of mapping with literature from diverse disciplines within the contexts of salutogenesis and a social model of health. The findings showed that AQAL-mapping enhanced contextual biopsychosocial coherence and exposed the conceptual error of reifying pain. Its utility lay in highlighting upstream influences of the painogenic environment, supporting the reconfiguration of pain within a social model of health, as exemplified by the UK’s Rethinking Pain Service. In conclusion, a simple version of the AQAL framework served as a heuristic device to develop an integral vision of pain, opening opportunities for health promotion solutions within a salutogenic context.

Mark Johnson, PhD is Professor of Pain and Analgesia and Director of the Centre for Pain Research at Leeds Beckett University. Having initially trained as a neurophysiologist, Professor Johnson has expanded his research into the science of pain and its management, leading a team of pain scholars at the university. His research covers a wide range of topics including studying the effects of nonpharmacological interventions (transcutaneous electrical nerve stimulation [TENS], acupuncture, low-level laser therapy and Kinesio tape) for pain management, individuality and pain, epidemiology of pain, and more recently health promotion and pain. His expertise spans a range of research methodologies including evidence syntheses such as meta-ethnography and meta-analysis including Cochrane Reviews, as well as conducting clinical trials and laboratory studies. In addition to his research, Professor Johnson is involved in pain education for healthcare professionals, patients, and the general public to provide people with up-to-date knowledge for a better understanding of the science of pain and its management.

INTRODUCTION Prostate cancer is the second leading cause of cancerspecific death in the USA and the UK.1 The increased awareness of this disease, in combination with serum testing for prostate-specific antigen (PSA), has led to an increase in the use of radical prostatectomy as a treatment for clinically organ-confined prostate cancer in the USA and elsewhere in the Western world.2 In England and Wales, the age-specific incidence peaked in 1994, with the subsequent rate decreasing towards the underlying trend in most age groups.3 Public awareness of the disease is clearly on the increase, partly because of media interest and growing general interest in men’s health issues.

BACKGROUND: Kinesiology taping (KT) is used in musculoskeletal practice for preventive and rehabilitative purposes. It is claimed that KT improves blood flow in the microcirculation by creating skin convolutions and that this reduces swelling and facilitates healing of musculoskeletal injuries. There is a paucity of physiological studies evaluating the effect of KT on cutaneous blood microcirculation. OBJECTIVES: The purpose of this parallel-group controlled laboratory repeated measures design study was to evaluate the effects of KT on cutaneous blood microcirculation in healthy human adults using a dual wavelength (infrared and visible-red) laser Doppler Imaging (LDI) system. KT was compared with rigid taping and no taping controls to isolate the effects associated with the elasticity of KT. METHODS: Forty-five healthy male and female human adults were allocated to one of the three interventions using constrained randomisation following the pre-intervention measurement: (i) KT (ii) ST (standard taping) (iii) NT (no taping). Cutaneous blood perfusion was measured using LDI in the ventral surface of forearm at pre-intervention, during-intervention and post-intervention in a normothermic environment at resting conditions. RESULTS: Mixed ANOVA of both infrared and visible-red datasets revealed no statistically significant interaction between Intervention and Time. There was statistically significant main effect for Time but not Intervention. CONCLUSION: KT does not increase cutaneous blood microcirculation in healthy human adults under resting physiological conditions in a normothermic environment. On the contrary, evidence suggests that taping, regardless of the elasticity in the tape, is associated with immediate reductions in cutaneous blood flow.

Pain is managed using a biopsychosocial approach and pharmacological and non-pharmacological treatments. Transcutaneous electrical nerve stimulation (TENS) is a technique whereby pulsed electrical currents are administered through the intact surface of the skin with the intention of alleviating pain, akin to ‘electrically rubbing pain away’. Despite over 50 years of published research, uncertainty about the clinical efficacy of TENS remains. The purpose of this comprehensive review is to critically appraise clinical research on TENS to inform future strategies to resolve the ‘efficacy-impasse’. The principles and practices of TENS are described to provide context for readers unfamiliar with TENS treatment. The findings of systematic reviews evaluating TENS are described from a historical perspective to provide context for a critical evaluation of factors influencing the outcomes of randomized controlled trials (RCTs); including sample populations, outcome measures, TENS techniques, and comparator interventions. Three possibilities are offered to resolve the impasse. Firstly, to conduct large multi-centered RCTs using an enriched enrolment with randomized withdrawal design, that incorporates a ‘run-in phase’ to screen for potential TENS responders and to optimise TENS treatment according to individual need. Secondly, to meta-analyze published RCT data, irrespective of type of pain, to determine whether TENS reduces the intensity of pain during stimulation, and to include a detailed assessment of levels of certainty and precision. Thirdly, to concede that it may be impossible to determine efficacy due to insurmountable methodological, logistical and financial challenges. The consequences to clinicians, policy makers and funders of this third scenario are discussed. I argue that patients will continue to use TENS irrespective of the views of clinicians, policy makers, funders or guideline panel recommendations, because TENS is readily available without prescription; TENS generates a pleasant sensory experience that is similar to easing pain using warming and cooling techniques; and technological developments such as smart wearable TENS devices will improve usability in the future. Thus, research is needed on how best to integrate TENS into existing pain management strategies by analyzing data of TENS usage by expert-patients in real-world settings.

Background: Previously, we proposed a “Split-second Unlearning” model to explain how emotional memories could be preventing clients from adapting to the stressors of daily living, thus forming a barrier to learning, health and well-being. We suggested that these emotional memories were mental images stored inside the mind as ‘emotional memory images’ (EMIs). Objective: To elaborate on the nature of these emotional memory images within the context of split-second learning and unlearning and the broader field of psychoanalysis, to initiate a conversation among scholars concerning the path that future healthcare research, practice, and policy should take. Method: A narrative review of the attributes of EMIs utilizing relevant and contentious research and/or scholarly publications on the topic, facilitated by observations and approaches used in clinical practice. Results: We propose a refined definition of EMIs as Trauma induced, non-conscious, contiguously formed multimodal mental imagery, which triggers an amnesic, anachronistic, stress response within a split-second. The systematic appraisal of each attribute of an EMI supports the idea that the EMI is distinct from similar entities described in literature, enabling further sophistication of our Split-second Unlearning model of psychophysiological dis-ease. Conclusion: Exploration of the concept of EMIs provides further insight on mechanisms associated with psychophysiological dis-ease and opportunities for therapeutic approaches.

Background: This is a second update of a Cochrane Review originally published in Issue 2, 2009. Transcutaneous Electrical Nerve Stimulation (TENS) is a non-pharmacological agent, based on delivering low voltage electrical currents to the skin. TENS is used by people to treat a variety of pain conditions. Objectives: To assess the analgesic effectiveness of TENS, as a sole treatment, for acute pain in adults. Search methods: We searched the following databases up to 3 December 2014: the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; MEDLINE; EMBASE; CINAHL; and AMED. We also checked the reference lists of included trials. Selection criteria: We included randomised controlled trials (RCTs) of adults with acute pain (< 12 weeks) if they examined TENS given as a sole treatment and assessed pain with subjective pain scales. Trials were eligible if they compared TENS to placebo TENS, no treatment controls, pharmacological interventions or non-pharmacological interventions. We excluded trials on experimental pain, case reports, clinical observations, letters, abstracts or reviews. Also we excluded trials investigating the effect of TENS on pain during childbirth (labour), primary dysmenorrhoea or dental procedures. Studies where TENS was given with another treatment as part of the formal trial design were excluded. We did not restrict any articles based on language of publication. Data collection and analysis: Two review authors independently assessed study eligibility and carried out study selection, data extraction, 'Risk of bias' assessment and analyses of data. We extracted data on the following: types of participants and pain condition, trial design and methods, treatment parameters, adverse effects, and outcome measures. We contacted trial authors for additional information if necessary. Main results: We included 12 trials in the original review (2009) and included no further trials in the first update (2011). An additional seven new trials met the inclusion criteria in this second update. In total, we included 19 RCTs involving 1346 participants at entry, with 11 trials awaiting classification either because the full text was unavailable or information in the full text failed to clarify eligibility. We excluded most trials because TENS was given in combination with another treatment as part of the formal study design or TENS was not delivered using appropriate TENS technique. The types of acute pain included in this Cochrane Review were procedural pain, e.g. cervical laser treatment, venepuncture, screening flexible sigmoidoscopy and non-procedural pain, e.g. postpartum uterine contractions and rib fractures. We pooled data for pain intensity for six trials (seven comparisons) comparing TENS with placebo but the I

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Background:Home exercise programmes and exercise programmes carried out in a clinical setting are commonly advocated for the treatment of lateral elbow tendinopathy (LET), a very common lesion of the arm with a well-defined clinical presentation. The aim of this study is to describe the use and effects of strengthening and stretching exercise programmes in the treatment of LET.

Eccentric exercises:Slow progressive eccentric exercises for LET should be performed with the elbow in extension, forearm in pronation, and wrist in extended position (as high as possible). However, it is unclear how the injured tendon, which is loaded eccentrically, returns to the starting position without experiencing concentric loading and how the “slowness” of eccentric exercises should be defined. Nor has the treatment regimen of the eccentric exercises of a supervised exercise programme been defined.

Stretching exercises:Static stretching is defined as passively stretching a given muscle-tendon unit by slowly placing and maintaining it in a maximal position of stretch. We recommend the position should be held for 30–45 s, three times before and three times after eccentric exercises during each treatment session with a 30 s rest interval between each procedure. The treatment region of static stretching exercises when a supervised exercise programme is performed is unknown.

Discussion:A well designed trial is needed to study the effectiveness of a supervised exercise programme for LET consisting of eccentric and static stretching exercises. The issues relating to the supervised exercise programme should be defined so that therapists can replicate the programme.

Abstract

Aim. We investigated the literature of randomised placebo‐controlled trials to find out if transcutaneous electrical nerve stimulation (TENS) or acupuncture‐like transcutaneous electrical nerve stimulation (ALTENS) can reduce analgesic consumption after surgery.

Results. Subgroup analysis for adequate treatment (pulse frequency: 1–8 Hz [ALTENS] or 25–150 Hz [TENS], current intensity: “strong, definite, subnoxious, maximal tolerable” or above 15 mA, and electrode placement in the incision area) were performed. Twenty‐one randomised, placebo‐controlled trials with a total of 1350 patients were identified. For all trials, the mean reduction in analgesic consumption after TENS/ALTENS was 26.5% (range −6 to +51%) better than placebo. Eleven of the trials compromising 964 patients, had reports which stated that a strong, subnoxious electrical stimulation with adequate frequency was administered. They reported a mean weighted reduction in analgesic consumption of 35.5% (range 14–51%) better than placebo. In nine trials without explicit confirmation of sufficient current intensity and adequate frequency, the mean weighted analgesic consumption was 4.1% (range −10 to +29%) in favour of active treatment. The difference in analgesic consumption was significantly (p=0.0002) in favour of adequate stimulation. The median frequencies used in trials with optimal treatment was 85 Hz for TENS and 2 Hz in the only trial that investigated ALTENS.

Conclusion. TENS, administered with a strong, subnoxious intensity at an adequate frequency in the wound area, can significantly reduce analgesic consumption for postoperative pain.

Objectives: Non-invasive interactive neurostimulation (InterX

®

The management of neuropathic pain is challenging, with medication being the first-line treatment. Transcutaneous electrical nerve stimulation (TENS) is an inexpensive, noninvasive, self-administered technique that is used as an adjunct to medication. Clinical experience suggests that TENS is beneficial providing it is administered at a sufficiently strong intensity, close to the site of pain. At present, there are too few randomized controlled trials on TENS for neuropathic pain to judge effectiveness. The findings of systematic reviews of TENS for other pain syndromes are inconclusive because trials have a low fidelity associated with inadequate TENS technique and infrequent treatments of insufficient duration. The use of electrode arrays to spatially target stimulation more precisely may improve the efficacy of TENS in the future. © 2011 Expert Reviews Ltd.

Transcutaneous electrical nerve stimulation (TENS) is a technique that delivers mild electrical currents across the intact surface of the skin to reduce pain. TENS is used by practitioners throughout the world to manage painful conditions and TENS equipment can be purchased by the general public so that they can self-administer treatment. There are thousands of experimental and clinical research studies published on TENS and related techniques yet there is uncertainty about the best way to administer TENS in clinical practice. This is because currents used during TENS can be administered in a variety of ways and the findings of research studies have been inconclusive. This book provides guidance on how best to use TENS based on an evaluation of current research evidence. The book covers what TENS is, how it works, and safe and appropriate clinical techniques for many conditions including chronic low back pain, osteoarthritis and cancer pain. It also offers solutions to the problems faced by researchers when trying to design clinical trials on TENS.

Proprioceptive afferent input from neck muscles plays an important role in postural control. Forward head posture has the potential to impair proprioceptive information from neck muscles and contribute to postural control deficits in patients with neck pain. This study investigated whether induced forward head posture affects postural control in healthy participants when compared to natural head posture. Centre of pressure sway area, distance covered and mean velocity were measured during 30. s of static standing using a force platform with 25 healthy individuals (mean age ± SD = 20.76 ± 2.19 years) in 8 different conditions. Base of support, eyes open or closed and natural or forward head posture varied within these testing conditions. The majority of comparisons between natural and forward head posture were not statistically significant (p > 0.05). This suggests that induced forward head posture in young healthy adults does not challenge them enough to impair postural control. Future studies should evaluate whether forward head posture affects postural control of individuals with chronic neck pain. © 2012 Elsevier B.V.

Proprioceptive afferent input from neck muscles plays an important role in postural control. Forward head posture has the potential to impair proprioceptive information from neck muscles and contribute to postural control deficits in patients with neck pain. This study investigated whether induced forward head posture affects postural control in healthy participants when compared to natural head posture. Centre of pressure sway area, distance covered and mean velocity were measured during 30s of static standing using a force platform with 25 healthy individuals (mean age±SD=20.76±2.19 years) in 8 different conditions. Base of support, eyes open or closed and natural or forward head posture varied within these testing conditions. The majority of comparisons between natural and forward head posture were not statistically significant (p>0.05). This suggests that induced forward head posture in young healthy adults does not challenge them enough to impair postural control. Future studies should evaluate whether forward head posture affects postural control of individuals with chronic neck pain.

INTRODUCTION:: Strong nonpainful transcutaneous electrical nerve stimulation (TENS) is prerequisite to a successful analgesic outcome although the ease with which this sensation is achieved is likely to depend on the magnitude of current amplitude (mA) between sensory detection threshold (SDT) and pain threshold, that is, the current window. To measure the current window and participant's perception of the comfort of the TENS sensation at different body sites. METHODS:: A repeated measure cross-over study was conducted using 30 healthy adult volunteers. Current amplitudes (mA) of TENS [2 pulses per second (pps); 30 pps; 80 pps] at SDT, pain threshold, and strong nonpainful intensities were measured at the tibia (bone), knee joint (connective tissue), lower back [paraspinal (skeletal) muscle], volar surface of forearm (nerve) and waist (fat). The amplitude to achieve a strong nonpainful intensity was represented as a percentage of the current window. Data were analyzed using repeated measures analysis of variance. RESULTS:: Effects were detected for body site and frequency for SDT (P<0.001, P=0.018, respectively), current window (P<0.001, P<0.001, respectively), and strong nonpainful TENS as a percentage of the current window (P=0.002, P<0.001, respectively). The current window was larger for the knee joint compared with tibia (difference [95% confidence interval]=12.76 mA [4.25, 21.28]; P=0.001) and forearm (10.33 mA [2.62, 18.40]; P=0.006), and for the lower back compared with tibia (12.10 mA [1.65, 22.52]; P=0.015) and forearm (9.65 mA [1.06, 18.24]; P=0.019). The current window was larger for 2 pps compared with 30 pps (P<0.001) and 80 pps (P<0.001). Participants rated strong nonpainful TENS as most comfortable at the lower back (P<0.001) and least comfortable at the tibia and forearm (P<0.001). CONCLUSIONS:: TENS is most comfortable and easiest to titrate to a strong nonpainful intensity when applied over areas of muscle and soft tissue. © 2013 by Lippincott Williams and Wilkins.

There is great demand in narrowing the knowledge gap to explore the scientific and evidence-based knowledge of CAM in the anticancer field. With this

INTRODUCTION: There is insufficient evidence of a relationship between acupuncture needle sensations (de qi) and hypoalgesia. The aim of this study was to investigate the effects of bidirectional needle rotation at LI10 on acupuncture needle sensations and heat pain thresholds. METHODS: Twenty-two healthy participants received one acupuncture needle at LI10 with bidirectional rotation of the needle in one experimental session and one acupuncture needle at LI10 with mock rotation in a separate session, in a randomised order. Measurements of heat pain thresholds were taken before needle insertion, during needle retention and 15 min after needle removal. At each measurement time point, participants rated needle sensations using the Massachusetts Acupuncture Sensation Scale (MASS) and a visual analogue scale (VAS) of overall intensity of needle sensation. RESULTS: Bidirectional needle rotation produced significantly higher scores for VAS, MASStotal, MASSpain and MASSsensation compared with mock rotation (all p<0.001). There were significantly higher pain thresholds relative to pre-intervention baseline during (p=0.014) and after (p<0.001) bidirectional needle rotation but not during (p=0.1) or after (p=0.62) mock bidirectional needle rotation. Bidirectional needle rotation increased the pain threshold relative to baseline 15 min after the needles were removed (p=0.009). A significant but low correlation between needle sensation and change in pain threshold after needling was only found when data from mock and rotation interventions were combined. CONCLUSIONS: Needle rotation increases the magnitude of hypoalgesia. There is tentative evidence that needle sensation may be associated with the amount of change in pain threshold.

Background and aims: Threatening a perceptually embodied rubber hand with noxious stimuli has been shown to generate levels of anxiety similar to that experienced when a real hand is threatened. The aim of this study was to investigate skin conductance response, self-reported anxiety and the incidence, type and location of sensations when a perceptually embodied rubber was exposed to threatening and non-threatening stimuli. Methods: A repeated measures cross-over design was used whereby 20 participants (>18 years, 14 females) received a threatening (syringe needle) and non-threatening (soft brush) stimulus to a perceptually embodied rubber hand. Perceptual embodiment was achieved using a soft brush to synchronously stroke the participant’s real hand (out of view) and a rubber hand (in view). Then the investigator approached the rubber hand with a syringe needle (threat) or soft brush (non-threat). Results: Repeated measures ANOVA found that approaching the perceptually embodied rubber hand with either stimulus produced statistically significant reductions in the rated intensity of response to the following questions (p<0.01): ‘How strongly does it feel like the rubber hand is yours?’; ‘How strongly does it feel like the rubber hand is part of your body?’; and ‘How strongly does it feel you can move the rubber hand?’. However, there were no statistically significant differences in scores between needle and brush stimuli. Repeated measures ANOVA on skin conductance response found statistically significant effects for experimental Events (baseline; stroking; perceptual embodiment; stimuli approaching rubber hand; stimuli touching rubber hand; p<0.001) but not for Condition (needle versus brush p=0.964) or experimental Event x Condition interaction (p=0.160). Ten of the 20 participants (50%) reported that they experienced a sensation arising from the rubber hand when the rubber hand was approached and touched by either the needle and/or brush but these sensations lacked precision in location, timing, and nature. Conclusion and Implications: Our preliminary findings suggest that the increase in arousal in response to stimuli entering the peripersonal space may not be selective for threat. There was tentative evidence that more intense sensations were experienced when a perceptually embodied rubber hand was approached by a threatening stimulus. Our findings provide initial insights and should serve as a catalyst for further research.

Background and aims: Mirror visual feedback may be a useful clinical tool for reducing pain. Research suggests that reducing the size of a non-painful reflected hand can alleviate complex regional pain syndrome in the affected hand that is out of view. In contrast, research on healthy humans exposed to experimentally induced pain suggests that reducing the appearance of the size of a reflected body part can increase pain. The aim of this study was to investigate the effect of enlarging and reducing the visual appearance of the size of a hand using mirror visual feedback on pain threshold, intensity and tolerance in healthy human participants exposed to cold-pressor pain. Methods: Participants were a convenience sample of 20 unpaid, healthy pain free volunteers aged 18 years or above. Each participant took part in one experiment where they completed cold-pressor pain tests whilst observing normal, enlarged and reduced size reflections of a hand congruent to a hand immersed in the ice cold water. A 4 × 2 factorial repeated measures analysis of variance (ANOVA) was performed on time to pain threshold and pain tolerance, and pain intensity with Condition (four levels: no reflection, reduced reflection, normal reflection, enlarged reflection) being the within-subject factors and Sex (two levels: female, male) between-subject factors. Results: There were no significant effects for Condition, Sex, or Condition × Sex interaction for pain threshold, intensity or tolerance (p > 0.05). There were no significant differences between the 3 mirror reflection conditions for agreement with the statements: “It felt like I was looking directly at my hand rather than at a mirror image”; “It felt like the hand I was looking at was my hand”; and “Did it seem like the hand you saw was a right hand or a left hand?”. Conclusion: Enlarging or reducing the size of a hand using mirror visual feedback did not alter pain perception in healthy human participants exposed to cold-pressor pain. The different sizes of hands generated by mirror visual feedback created an illusion of looking at their own hand but this was not as strong as looking directly at the hand. Implications: In future, investigators and clinicians using mirror visual feedback may consider including an adaptive phase to ensure the reflection has been perceptually embodied. Reasons for the lack of effects are explored to inspire further research in the field.

The term transcutaneous electrical nerve stimulation (TENS) is commonly used to describe a 'standard TENS device'. However, there are increasing numbers of hybrids of these standard TENS devices appearing on the market. The purpose of this paper was to examine the evidence used to support claims about the analgesic effects of TENS-like devices. Information was gathered from a wide range of sources including MEDLINE, the internet and manufacturers. Available literature suggests that Action Potential Simulation (APS) and H-Wave Therapy (HWT) have output characteristics that are similar to a standard TENS device, whereas Interference Current Therapy (IFC), Microcurrent Electrical Stimulation (MES), high voltage TENS pens and Transcutaneous Spinal Electroanalgesia (TSE) do not. There is insufficient experimental evidence to determine whether the differences in output characteristics influence physiological and clinical outcome when compared to a standard TENS device. However, despite the technologically impressive appearance of many TENS-like devices, preliminary evidence suggests that many may produce effects that can be achieved using a standard TENS device. Ambiguity in nomenclature hinders the analysis of research findings and contributes to confusion about the usefulness of TENS-like devices. Clinical trials that examine the relative effectiveness of TENS-like devices with a standard TENS device are urgently needed to inform therapists about device selection.

Aim: To evaluate the effects of preventive treatment with low-level laser therapy (LLLT) on progression of dystrophy in mdx mice. Methods: Ten animals were randomly divided into 2 experimental groups treated with superpulsed LLLT (904 nm, 15 mW, 700 Hz, 1 J) or placebo-LLLT at one point overlying the tibialis anterior muscle (bilaterally) 5 times per week for 14 weeks (from 6th to 20th week of age). Morphological changes, creatine kinase (CK) activity and mRNA gene expression were assessed in animals at 20th week of age. Results: Animals treated with LLLT showed very few morphological changes in skeletal muscle, with less atrophy and fibrosis than animals treated with placebo-LLLT. CK was significantly lower (p = 0.0203) in animals treated with LLLT (864.70 U.l−1, SEM 226.10) than placebo (1708.00 U.l−1, SEM 184.60). mRNA gene expression of inflammatory markers was significantly decreased by treatment with LLLT (p<0.05): TNF-α (placebo-control = 0.51 µg/µl [SEM 0.12], - LLLT = 0.048 µg/µl [SEM 0.01]), IL-1β (placebo-control = 2.292 µg/µl [SEM 0.74], - LLLT = 0.12 µg/µl [SEM 0.03]), IL-6 (placebo-control = 3.946 µg/µl [SEM 0.98], - LLLT = 0.854 µg/µl [SEM 0.33]), IL-10 (placebo-control = 1.116 µg/µl [SEM 0.22], - LLLT = 0.352 µg/µl [SEM 0.15]), and COX-2 (placebo-control = 4.984 µg/µl [SEM 1.18], LLLT = 1.470 µg/µl [SEM 0.73]). Conclusion: Irradiation of superpulsed LLLT on successive days five times per week for 14 weeks decreased morphological changes, skeletal muscle damage and inflammation in mdx mice. This indicates that LLLT has potential to decrease progression of Duchenne muscular dystrophy.

A novel device was developed that measured local electrical skin resistance and generated pulsed local electrical currents that were delivered across the skin around the knee for patients with osteoarthritis (termed eBrace TENS). Currents were delivered using an electrode array of 16 small circular electrode elements so that stimulation could be spatially targeted. The aim of this study was to investigate the effects of spatially targeted transcutaneous electrical nerve stimulation (TENS) to points of low skin resistance on pain relief and mobility in osteoarthritis of the knee (OAK). A randomised, controlled, 3-arm, parallel-group trial was designed that compared pain and function following a 30 to 45 minute intervention of TENS at specific locations depending on the local electrical skin resistance. Pain intensity by the visual analogue scale (VAS), 6-minute walk test, maximum voluntary contraction (MVC), and range-of-motion (ROM) were the primary outcomes. Lowest-resistance TENS reduced pain intensity during walking relative to resting baseline compared with random TENS (95% confidence interval of the difference: -20.8 mm, -1.26 mm). There were no statistically significant differences between groups in distance during the walk test, maximum voluntary contraction (MVC) or range-of-motion (ROM) measures or WOMAC scores. In conclusion, we provide evidence that use of a matrix electrode that spatially targets strong nonpainful TENS for 30 to 45 minutes at sites of low resistance can reduce pain intensity at rest and during walking. © 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

BACKGROUND: Transcutaneous Electrical Nerve Stimulation (TENS) is a non-pharmacological agent, based on delivering low voltage electrical currents to the skin. TENS is used for the treatment of a variety of pain conditions. OBJECTIVES: To assess the analgesic effectiveness of TENS for acute pain in adults to see if it had any clear analgesic effect in its own right. SEARCH STRATEGY: The following databases were searched: Cochrane Pain, Palliative and Supportive Care Group Specialised Register; the Cochrane Central Register of Controlled Trials, CENTRAL (in The Cochrane Library); MEDLINE; EMBASE; CINAHL; AMED; PEDro; OTseeker; OpenSIGLE; and, reference lists of included studies. The most recent search was undertaken in August 2008. SELECTION CRITERIA: Randomised controlled trials (RCTs) of adults with acute pain (less than 12 weeks) were included if they examined TENS given as a sole treatment and assessed pain with subjective pain scales. Studies were eligible if they compared TENS to placebo TENS, no treatment controls, pharmacological interventions or non-pharmacological interventions. Studies on experimental pain, case reports, clinical observations, letters, abstracts or reviews were excluded. Studies on TENS and labour pain, pain due to dental procedures and primary dysmenorrhoea were excluded. Studies where TENS was given with another treatment as part of the formal study design were also excluded. No restrictions were made regarding language. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial eligibility and extracted data. Data were extracted on the following: types of participants and pain condition, study design and methods, treatment parameters, adverse effects, and outcome measures. Study authors were contacted for additional information if necessary. MAIN RESULTS: Of 1479 studies identified in the search, 132 were identified as relevant. Of these, 116 were excluded; the vast majority of these were excluded due to TENS being given with another treatment. Four studies were categorised as awaiting classification as the information provided in the full text failed to clarify their eligibility. Twelve RCTs involving 919 participants at entry were included. The types of acute pain conditions included procedural pain, e.g. cervical laser treatment, venipuncture, screening flexible sigmoidoscopy and non-procedural pain, e.g. postpartum uterine contractions, rib fractures. It was not possible to perform a meta-analysis due to insufficient data. AUTHORS' CONCLUSIONS: Due to insufficient extractable data in the studies included in this review, we are unable to make any definitive conclusions about the effectiveness of TENS as an isolated treatment for acute pain in adults.

Summary

The aim of this study was to investigate the effects of transcutaneous electrical nerve stimulation (TENS) on blood flow and skin temperature following an elevation of baseline blood flow using infrared preheating. A randomized controlled approach was used whereby 66 healthy human subjects (33 male, 33 female) were allocated to one of three intervention groups (n = 22 per group, equal male and female): Control, Low frequency TENS (4 Hz/200 μs), or High frequency TENS (110 Hz/200 μs). TENS was applied just below motor threshold over the median nerve of the right forearm for 15 min immediately following an infrared preheating. Cutaneous blood flow and skin temperature were recorded at 3‐min intervals from the forearm and fingertips during TENS and for 15 min following TENS. Analysis of data revealed no significant differences between High and Low frequency TENS for cutaneous blood flow or skin temperature at the forearm. A small and short lived increase in cutaneous blood flow at the index finger was observed on TENS groups compared with control when TENS was switched off. TENS reduced skin temperature when compared to control during the first 9 min of the 15‐min stimulation period at the middle finger but not at the index finger. It was concluded that the effects of high and low frequency TENS when applied below motor threshold produced changes in blood flow and skin temperature that were transient and small.

A plethora of terms that have been used to describe lateral epicondylitis including tennis elbow (TE), epicondylalgia, tendonitis, tendinosis and tendinopathy. These terms usually have the prefix extensor or lateral elbow. Lateral elbow tendinopathy seems to be the most appropriate term to use in clinical practice because other terms make reference to inappropriate aetiological, anatomical and pathophysiological terms. The correct diagnostic term is important for the right treatment. © 2006 Elsevier Ltd. All rights reserved.

Objective: Our aim was to assess the efficacy of polarized polychromatic noncoherent light (Bioptron light) in the treatment of idiopathic carpal tunnel syndrome. Background: Carpal tunnel syndrome is the most common compression neuropathy, but no satisfactory conservative treatment is available at present. Method: An uncontrolled experimental study was conducted in patients who visited our clinic from mid-2001 to mid-2002. A total of 25 patients (22 women and three men) with unilateral idiopathic carpal tunnel syndrome, mild to moderate nocturnal pain, and paraesthesia lasting >3 months participated in the study. The average age of the patients was 47.4 years and the average duration of patients' symptoms was 5.2 months. Polarized polychromatic noncoherent light (Bioptron light) was administered perpendicular to the carpal tunnel area. The irradiation time for each session was 6 min at an operating distance of 5–10 cm from the carpal tunnel area, three times weekly for 4 weeks. Outcome measures used were the participants' global assessments of nocturnal pain and paraesthesia, respectively, at 4 weeks and 6 months. Results: At 4 weeks, two patients (8%) had no change in nocturnal pain, six (24%) were in slightly less nocturnal pain, 12 (48%) were much better in regard to nocturnal pain and five (20%) were pain-free. At 6 months, three patients (12%) were slightly better in regard to nocturnal pain, 13 (52%) were much better regarding nocturnal pain, and nine patients (36%) were pain-free. At 4 weeks, four patients (16%) had no change in paraesthesia, five (20%) were slightly better, 13 patients(52%) were much better, and three patients (12%) were without paraesthesia. At 6 months, two patients (8%) had no change in paraesthesia, two (8%) were slightly better, 14 (56%) were much better, and seven (28%) were without paraesthesia. Conclusions: Nocturnal pain and paraesthesia associated with idiopathic carpal tunnel syndrome improved during polarized polychromatic noncoherent light (Bioptron light) treatment. Controlled clinical trials are needed to establish the absolute and relative effectiveness of this intervention.

Tennis elbow or lateral epicondylitis is one of the most common lesions of the arm with a well defined clinical presentation, which significantly impacts on the community. Many treatment approaches have been proposed to manage this condition. One is Cyriax physiotherapy. The effectiveness and reported effects of this intervention are reviewed.

This article discusses computer assisted learning (CAL) and the importance of applying it in nurse education. The articles recognizes the general technological developments as exemplified by the Teaching and Learning Technology Programme (TLTP) from which ideas about application and benefits came. The ideas from TLTP are hereby used in CAL and applied to nursing and health-care undergraduate programmes in one university. In the light of this experience the main intention of this article is to consider the benefits and costs of introducing computer programmes as part of the teaching provision for nurses and other health-care professionals both at beginner and advanced level. The article further argues that CAL can also be used for patient teaching thus providing transferable skills and benefits for teachers as well as learners, be they students or patients. To support such multiple uses of CAL selected examples will be offered and appropriate conclusions will be drawn.

Introduction: Electrophysiological studies show frequency-dependent effects of transcutaneous electrical nerve stimulation (TENS) in animal models of hyperalgesia. Evidence of frequency-dependent effects of TENS in humans is conflicting. Objective: To assess the effects of low-frequency and high-frequency TENS at a strong nonpainful intensity on experimentally induced ischemic pain. Methods: Submaximal effort tourniquet tests were carried out on 48 healthy human participants before (baseline) and during TENS at 3 pulsed currents per second (pps), 80 pps, and no current (placebo). TENS was switched on for 20 minutes and a submaximal effort tourniquet test was carried out during the final 5 minutes of the intervention. There was a 30-minute washout, with TENS switched off, between the interventions. Results: Repeated measure analysis of variance detected significant effects for pain intensity [100 mm Visual Analog Scale (VAS)] for condition (P<0.001), time (P<0.001), and time×condition (P=0.039). When compared with pre-TENS lower VAS scores were detected for placebo TENS (P=0.026) and 80 pps (P<0.001), but not for 3 pps (P=0.19). There were lower VAS scores for 80 pps than placebo (mean difference, 13.29 mm; 95% CI, 9.71, 16.87; P<0.001) and 3 pps (mean difference, 19.88 mm; 95% CI, 17.20-22.55; P<0.001), yet 3 pps scores were higher than placebo (mean difference, 6.58 mm; 95% CI 3.45, 9.72; P<0.001). There were significantly lower scores for sensory dimensions of the short-form McGill Pain Questionnaire for both 3 pps and 80 pps when compared with the placebo (P<0.001; P=0.005, respectively), but no significant differences between TENS at 80 and 3 pps (P=1.0). There were no significant effects detected for condition (P=0.217) or for condition×sequence interaction (P=0.800) for affective dimensions. Conclusions: Strong nonpainful TENS delivered at 80 pps reduced experimentally induced ischemic pain when compared with TENS delivered at 3 pps.

Summary

Electrophysiological studies suggest that there are differential frequency effects during TENS. The aim of this experimental study was to assess the effects of strong non‐painful TENS administered at 3 pulses per second (pps) and 80 pps on cold‐pressor pain in healthy human participants. A repeated measure design was used with participants receiving TENS at 3 pps and 80 pps in the same experiment. There were six cold‐pressor pain tests conducted on the hand with each type of TENS delivered via four electrodes on the ipsilateral forearm for 20 min. Outcomes were differences in pain threshold (s) and intensity (VAS) after 5 and 15 min of TENS. A 2 × 3 factorial repeated measure ANOVA was performed on data. Thirty‐five participants completed the experiment. Statistically significant effects were detected for condition, time and interactions between time × condition for both threshold and intensity. There were statistically higher pain thresholds and lower pain intensities for 3 pps when compared to 80 pps after 5 and 15 min of TENS. The differences after 15 min of TENS were 1·70 s to 3·70 s (95% CI) for threshold and 6·63–15·5 mm (95% CI) for pain intensity. In conclusion, strong non‐painful TENS at 3 pps was superior to 80 pps at reducing experimentally induced cold‐pressor pain. The implications of these findings are discussed.

SamenvattingDit diepgaande onderzoek richtte zich op de relaties tussen patiënt-, stimulator- en uitkomstvariabelen van een groot aantal chronische pijnpatiënten, bij wie tens langdurig was toegepast: 179 patiënten vulden een tens-vragenlijst in, met als onderdelen de leeftijd, geslacht, oorzaak en lokalisatie van de pijn en het tens- behandelregiem. Van deze 179 patiënten bezochten er 107 onze onderzoeks- afdeling voor evaluatie van de elektrische karakteristieken van de tens tijdens de zelf toegepaste behandeling.

Psychophysiological “stress” underpins many conditions including anxiety, depression, phobias, chronic fatigue syndrome and non-specific musculoskeletal pain such as fibromyalgia. In this article we develop an understanding of chronic psychophysiological stress from a psychological educational perspective, by drawing on supporting evidence that significant emotional events in early life (traumatic and benign) can influence health and well-being later in life. We suggest that traumatic events instigate psychophysiological “stress” responses and the formation of emotional memory images (EMIs) within very short time frames, i.e., “split-second learning.” Once formed these emotional memories are triggered in daily living “re-playing” psychophysiological stress responses, resulting in chronic psychophysiological “dis-ease.” We describe a novel therapeutic approach to scan clients for mannerisms signifying a subconscious “freeze-like” stress response that involves the client as a curious observer within their own experience, feeding back the non-verbal cues as they arrive in the moment. By breaking down the observable fragments of their split-second Pavlovian response to the trigger, clients can detach their EMI from the psychophysiology stress response, i.e., “split-second unlearning.” Our split-second unlearning model recognizes the EMI as a barrier to moving forward and needs to be unlearned before the client can become naturally adaptive again. We argue that this approach places the client at the center of the work without the need of getting bogged down in a life-long narrative.

OBJECTIVES: To investigate the effect of prolonged low-level laser therapy application combined with exercise on pain and disability in patients with osteoarthritis of the knee. DESIGN: A randomized controlled trial. SETTING: Special rehabilitation services. SUBJECTS: Forty-three participants with knee osteoarthritis. INTERVENTION: Following initial assessment, participants were randomly allocated to the Laser group (n = 22, 44 knees) and received low-level laser therapy while the Placebo group (n = 21, 42 knees) received placebo therapy three times a week for 3 weeks. Both groups then received low-level laser therapy combined with exercise three times a week for the following 8 weeks. MAIN OUTCOME MEASURES: The primary outcome was change in knee pain and disability (Lequesne). Secondary outcomes included change in mobility (Timed Up and Go test), range of motion (goniometer), muscular strength (dynamometer), activity (Western Ontario and McMaster Universities Osteoarthritis questionnaire), and medication intake and relief. RESULTS: Mean (SD) age of participants was 63.02 (9.9) years. Pain scores at baseline, 3 weeks, 11 weeks, and 6 months follow-up were 9.1 (1.3), 2.6 (2.3), 0.2 (0.9), and 0.2 (0.8) for the Laser group and 9.5 (8.0), 7.7 (5.3), 5.6 (2.4), and 7.4 (5.0) for the Placebo group, respectively. Disability scores at baseline, 3 weeks, 11 weeks, and 6 months follow-up were 14.9 (4.7), 7.6 (4.8), 3.9 (4.2), and 3.5 (4.1) for the Laser group and 17.8 (14.7), 15.2 (11.5), 11.6 (6.4), and 15.8 (11.9) for the Placebo Group, respectively. CONCLUSION: In participants with osteoarthritis of the knee, the isolated application of low-level laser therapy in the initial 3 weeks and combined with exercises in the final 8 weeks reduced pain, disability, and intake of medication over a 6-month period.

In this study, we recruited 50 chronic pain (neuropathic and nociceptive) and 43 pain-free controls to identify specific blood biomarkers of chronic neuropathic pain (CNP). Affymetrix microarray was carried out on a subset of samples selected 10 CNP and 10 pain-free control participants. The most significant genes were cross-validated using the entire dataset by quantitative real-time PCR (qRT-PCR). In comparative analysis of controls and CNP patients, WLS (P = 4.80 × 10–7), CHPT1 (P = 7.74 × 10–7) and CASP5 (P = 2.30 × 10–5) were highly significant, whilst FGFBP2 (P = 0.00162), STAT1 (P = 0.00223), FCRL6 (P = 0.00335), MYC (P = 0.00335), XCL2 (P = 0.0144) and GZMA (P = 0.0168) were significant in all CNP patients. A three-arm comparative analysis was also carried out with control as the reference group and CNP samples differentiated into two groups of high and low S-LANSS score using a cut-off of 12. STAT1, XCL2 and GZMA were not significant but KIR3DL2 (P = 0.00838), SH2D1B (P = 0.00295) and CXCR31 (P = 0.0136) were significant in CNP high S-LANSS group (S-LANSS score > 12), along with WLS (P = 8.40 × 10–5), CHPT1 (P = 7.89 × 10–4), CASP5 (P = 0.00393), FGFBP2 (P = 8.70 × 10–4) and FCRL6 (P = 0.00199), suggesting involvement of immune pathways in CNP mechanisms. None of the genes was significant in CNP samples with low (< 12) S-LANSS score. The area under the receiver operating characteristic (AUROC) analysis showed that combination of MYC, STAT1, TLR4, CASP5 and WLS gene expression could be potentially used as a biomarker signature of CNP (AUROC − 0.852, (0.773, 0.931 95% CI)).

• Transcutaneous electrical nerve stimulation (TENS) is a non-invasive, inexpensive, self-administered technique to relieve pain. • There are few side effects and no potential for overdose so patients can titrate the treatment as required. • TENS techniques include conventional TENS, acupuncture-like TENS and intense TENS. In general, conventional TENS is used in the first instance. • The purpose of conventional TENS is to selectively activate large diameter non-noxious afferents (A-beta) to reduce nociceptor cell activity and sensitization at a segmental level in the central nervous system. • Pain relief with conventional TENS is rapid in onset and offset and is maximal when the patient experiences a strong but non-painful paraesthesia beneath the electrodes. Therefore, patients may need to administer TENS throughout the day. • Clinical experience suggests that TENS may be beneficial as an adjunct to pharmacotherapy for acute pain although systematic reviews are conflicting. Clinical experience and systematic reviews suggest that TENS is beneficial for chronic pain.

The effectiveness of transcutaneous electrical nerve stimulation (TENS) for pain relief has been challenged. This article evaluates systematic review findings and demonstrates that studies using appropriate TENS technique and dosage are more likely to demonstrate clinical efficacy. Therefore, it seems reasonable to continue to use TENS as a pain management intervention.

OBJECTIVES: The efficacy of transcutaneous electrical nerve stimulation (TENS) for pain relief has not been reliably established. Inconclusive findings could be due to inadequate TENS delivery and inappropriate outcome assessment. Electronic monitoring devices were used to determine patient compliance with a TENS intervention and outcome assessment protocol, to record pain scores before, during, and after TENS, and measure electrical output settings. METHODS: Patients with chronic back pain consented to use TENS daily for 2 weeks and to report pain scores before, during, and after 1-hour treatments. A ≥ 30% reduction in pain scores was used to classify participants as TENS responders. Electronic monitoring devices "TLOG" and "TSCORE" recorded time and duration of TENS use, electrical settings, and pain scores. RESULTS: Forty-two patients consented to participate. One of 35 (3%) patients adhered completely to the TENS use and pain score reporting protocol. Fourteen of 33 (42%) were TENS responders according to electronic pain score data. Analgesia onset occurred within 30 to 60 minutes for 13/14 (93%) responders. It was not possible to correlate TENS amplitude, frequency, or pulse width measurements with therapeutic response. DISCUSSION: Findings from TENS research studies depend on the timing of outcome assessment; pain should be recorded during stimulation. TENS device sophistication might be an issue and parameter restriction should be considered. Careful protocol design is required to improve adherence and monitoring is necessary to evaluate the validity of findings. This observational study provides objective evidence to support concerns about poor implementation fidelity in TENS research.

Recently, there has been interest in lysergic acid diethylamide (LSD) and psilocybin for depression, anxiety and fear of death in terminal illness. The aim of this review is to discuss the potential use of LSD and psilocybin for patients with persistent pain. LSD and psilocybin are 5-hydroxytryptamine receptor agonists and may interact with nociceptive and antinociceptive processing. Tentative evidence from a systematic review suggests that LSD (7 studies, 323 participants) and psilocybin (3 studies, 92 participants) may be beneficial for depression and anxiety associated with distress in life-threatening diseases. LSD and psilocybin are generally safe if administered by a healthcare professional, although further investigations are needed to assess their utility for patients with persistent pain, especially associated with terminal illness

© 2014 The Cochrane Collaboration. This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the effects of TENS on neuropathic pain in adults.

Abstract

Background and Purpose. It is not fully understood how transcutaneous electrical nerve stimulation (TENS) intensity affects mechanical pain threshold. Method. Sixty‐six healthy volunteers (13 male, 53 female; 132 hands) without prior experience of TENS participated in the study, which comprised a randomized single‐blind controlled trial. TENS was administered for 20 minutes through electrodes (25 × 25 mm) placed on the hands and forearms with a fixed frequency of 100 Hz and pulse duration of 150 µs. TENS intensity was randomized and allocated in a concealed manner so that one arm received TENS with stimulation intensity set at participants' subjective sensory threshold and the other received TENS with stimulation intensity continuously adjusted by physiotherapists to a strong but comfortable non‐painful stimulation. Observers were blinded to stimulation intensity levels. Results. Mechanical pain threshold increased significantly, by a mean total of 0.79 kg/cm2 (95% confidence interval [95% CI]: 0.54–1.04) (p < 0.001) on the strong but comfortable non‐painful stimulation side. The mean change in mechanical pain threshold on the sensory threshold side was 0.19 kg/cm2 and did not reach statistical significance (95% CI–0.15 to 0.51). The mean stimulation intensity level for sensory threshold was 6.7 mA (95% CI: 5.65 to 7.83) which was significantly lower (p < 0.001) than the mean stimulation intensity for the strong stimulation, which was 20.5 mA (95% CI 16.6 to 24.4), respectively. The strong stimulation levels were, on average, 3.05 times higher than sensory threshold, but individual variations were large (range 1.2–6.1). Conclusions. TENS administered at a strong but comfortable non‐painful stimulation intensity increases mechanical pain threshold ipsi‐laterally in healthy subjects, whereas TENS administered at sensory threshold intensity does not. TENS may be ineffective if electrodes are placed contralaterally or distant to the pain site and if stimulation intensity levels are not titrated to subjective strong levels. Further clinical trials are needed to clarify if these findings may also be generalized to populations of chronic pain sufferers. Copyright © 2007 John Wiley & Sons, Ltd.

OBJECTIVE: The aim of this study was to compare the effectiveness of transcutaneous electrical nerve stimulation and interferential therapy (IFT) both in combination with hot pack, myofascial release, active range of motion exercise, and a home exercise program on myofascial pain syndrome patients with upper trapezius myofascial trigger point. DESIGN: A total of 105 patients with an upper trapezius myofascial trigger point were recruited to this single-blind randomized controlled trial. Following random allocation of patients to three groups, three therapeutic regimens-control-standard care (hot pack, active range of motion exercises, myofascial release, and a home exercise program with postural advice), transcutaneous electrical nerve stimulation-standard care and IFT-standard care-were administered eight times during 4 wks at regular intervals. Pain intensity and cervical range of motions (cervical extension, lateral flexion to the contralateral side, and rotation to the ipsilateral side) were measured at baseline, immediately after the first treatment, before the eighth treatment, and 1 wk after the eighth treatment. RESULTS: Immediate and short-term improvements were marked in the transcutaneous electrical nerve stimulation group (n = 35) compared with the IFT group (n = 35) and the control group (n = 35) with respect to pain intensity and cervical range of motions (P < 0.05). The IFT group showed significant improvement on these outcome measurements than the control group did (P < 0.05). CONCLUSION: Transcutaneous electrical nerve stimulation with standard care facilitates recovery better than IFT does in the same combination.

© 2019 Banerjee et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background Kinesiology taping (KT) is used to manage musculoskeletal-related pain. There is a paucity of physiological studies evaluating the effect of KT on stimulus-evoked experimental pain. Objective To investigate the effect of KT (applied to lumbar region) on cutaneous somatosensation to noxious and innocuous stimuli in humans with a non-sensitised normally functioning nociceptive system using quantitative sensory testing (QST). Methods Fifty-four participants were randomised to one of three interventions: (i) KT (ii) standard ‘rigid’ taping (ST) (iii) sham taping (ShT). QST measurements were taken at lumbar sites pre-intervention (T1), during-intervention (T2) and during-intervention (T3) in the following sequence: warm-detection-threshold (WDT), heat-pain-threshold (HTPh), heat-pain-tolerance (HPTo), mechanical-detection-threshold (MDT), mechanical-pain-threshold (MPT) and pressure-pain-threshold (PPT). Results Mixed ANOVA revealed statistically significant interaction between Intervention and Time on MDT (p < .0005) and MPT (p < .0005) but not on WDT (p = .09), HPTh (p = .09), HPTo (p = .51) and PPT (p = .52) datasets. There was no significant simple main effect of Intervention on MDT at T2 (p = .68) and T3 (p = .24), and MPT at T2 (p = .79) and T3 (p = .54); post-hoc tests found KT and ST groups had higher (but non-significant) MDT and MPT than the ShT group. There was a significant simple main effect of Time on MDT and MPT for KT (p < .0005) and ST (p < .0005) groups; post-hoc tests found significant increases in MDT and MPT at T3 and T2 compared with T1 in both KT and ST groups. There was no significant simple main effect of Time on MDT (p = .13) nor MPT (p = .08) for the ShT group. Conclusion Taping, irrespective of the elasticity, may modulate cutaneous mechanosensation. KT, ST and ShT seemed to have similar influence on cutaneous thermal and deep pressure nociception.

© 2019 Informa UK Limited, trading as Taylor & Francis Group. Kinesiology taping (KT) is used in musculoskeletal practice for preventive and rehabilitative purposes. KT is also used in cancer to manage lymphoedema, however, there is little information available about the extent of its use. The aim of the study was to gather views of healthcare professionals on the attitudes, beliefs, and clinical use of KT for managing symptoms and complications in cancer. This was a cross-sectional online questionnaire survey of healthcare professionals including UK-registered nurses, physiotherapists, occupational-therapists, lymphoedema-therapists, and pain physicians using a non-probability self-select sampling technique. A stakeholder event was organized to discuss the survey findings and gain insights into their relevance in cancer care. Seventy-two percent of respondents (96/134) reported not using KT while only 28% of respondents (38/134) reported using KT, the majority of which were physiotherapists and nurses. Respondents reported that they frequently used KT for managing lymphoedema/oedema and scar tissue, and comparatively less frequently for pain and breathlessness. Respondents reported that the most frequent adverse event was skin irritation and that KT was contraindicated or administered with caution for patients with open wounds or fragile skin, especially following radiotherapy. The main barriers to widespread use of KT in cancer were lack of its awareness and research evidence on efficacy. The views expressed by the stakeholders aligned closely with those found by the survey. Stakeholders suggested that there was a need for training and research on the use of KT for cancer care. In conclusion, healthcare professionals working in cancer care settings may not be aware of KT as a potential therapy for managing symptoms and complications.

Chronic pain is a global health concern. This special issue on matters related to chronic pain aims to draw on research and scholarly discourse from an eclectic mix of areas and perspectives. The purpose of this non-systematic topical review is to précis an assortment of contemporary topics related to chronic pain and its management to nurture debate about research, practice and health care policy. The review discusses the phenomenon of pain, the struggle that patients have trying to legitimize their pain to others, the utility of the acute-chronic dichotomy, and the burden of chronic pain on society. The review describes the introduction of chronic primary pain in the World Health Organization's International Classification of Disease, 11th Revision and discusses the importance of biopsychosocial approaches to manage pain, the consequences of overprescribing and shifts in service delivery in primary care settings. The second half of the review explores pain perception as a multisensory perceptual inference discussing how contexts, predictions and expectations contribute to the malleability of somatosensations including pain, and how this knowledge can inform the development of therapies and strategies to alleviate pain. Finally, the review explores chronic pain through an evolutionary lens by comparing modern urban lifestyles with genetic heritage that encodes physiology adapted to live in the Paleolithic era. I speculate that modern urban lifestyles may be painogenic in nature, worsening chronic pain in individuals and burdening society at the population level.

Background andObjectives: Codeine requires biotransformation by the CYP2D6 enzyme, encoded by the polymorphic CYP2D6 gene, to morphine for therapeutic efficacy. CYP2D6 phenotypes of poor, intermediate, and ultra-rapid metabolisers are at risk of codeine non-response and adverse drug reactions due to altered CYP2D6 function. The aim of this study was to determine whether genotype, inferred phenotype, and urinary and oral fluid codeine O-demethylation metabolites could predict codeine non-response following a short course of codeine. Materials and Methods: There were 131 Caucasians with persistent pain enrolled. Baseline assessments were recorded, prohibited medications ceased, and DNA sampling completed before commencing codeine 30 mg QDS for 5 days. Day 4 urine samples were collected 1-2 h post morning dose for codeine O-demethylation metabolites analysis. Final pain assessments were conducted on day 5. Results: None of the poor, intermediate, ultra-rapid metabolisers and only 24.5% of normal metabolisers responded to codeine. A simple scoring system to predict analgesic response from day 4 urinary metabolites was devised with overall prediction success of 79% (sensitivity 0.8, specificity 0.78) for morphine and 79% (sensitivity 0.76, specificity 0.83) for morphine:creatinine ratio. Conclusions: In conclusion, this study provides tentative evidence that day 4 urinary codeine O-demethylation metabolites could predict non-response following a short course of codeine and could be utilised in the clinical assessment of codeine response at the point of care to improve analgesic efficacy and safety in codeine therapy. We offer a scoring system to predict codeine response from urinary morphine and urinary morphine:creatinine ratio collected on the morning of day 4 of codeine 30 mg QDS, but this requires validation before it could be considered for use to assess codeine response in clinical practice.

This is the protocol for a review and there is no abstract. The objectives are as follows: To establish the effectiveness of TENS in the management of cancer-related pain in adults. Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Introduction: Surgical procedures are ever more complex. Day-case surgical loads are increasing and the length of hospital stays are reducing. Management of pain in perioperative settings remains a challenge. Expert panels recommend a multimodal approach which is often interpreted by medical practitioners as polypharmacy. There is variability in non-pharmacological interventions offered to patients, although transcutaneous electrical nerve stimulation (TENS) has been used since the 1970s. Recommendations from expert panels are inconsistent about the use of TENS in perioperative pain settings. Areas covered: This critical review outlines the challenges of managing pain in perioperative settings and uses a narrative synthesis to evaluate the findings of systematic reviews on the clinical efficacy of TENS for pain in perioperative settings. Expert commentary: Moderate evidence from systematic reviews suggests that TENS is superior to placebo (no current) TENS for reducing analgesic consumption and improving pain, pulmonary function, and nausea and vomiting. Therefore, it seems reasonable to offer TENS as an adjunct to core treatment for surgical pain, especially because it is inexpensive and has a favorable safety profile compared with long-term medication. Practical considerations for the integration of TENS into service delivery are discussed.

Pain is a common presentation and this brand new title in the ABC series focuses on the pain management issues most often encountered in primary care.

Abstract

Physiotherapists frequently use interferential therapy for the control of patients' pain. But there is little consistent information about the different effects of varying dosages. In fact there is scanty proof that it works at all.

Transcutaneous electrical nerve stimulation (TENS) is a simple, non-invasive analgesic technique which is used to manage postoperative pain, labour pain and chronic pain. There is widespread use of TENS within health care and patients report satisfaction with the modality. There is an extensive, but confusing, literature on TENS. The purpose of this paper is to critically examine the evidence to support the widespread use of TENS. Problems associated with the findings of patient-centred clinical research are discussed and the importance of using strong evidence in the form of systematic reviews of randomized controlled clinical trails (RCTs) to judge clinical effectiveness is emphasized. The results of systematic reviews of RCTs on TENS suggest that TENS is no more effective than placebo for postoperative pain and labour pain. There is insufficient evidence to determine whether TENS is effective for chronic pain. However, these negative findings may be due, in part, to methodological problems associated with some of the RCTs included in systematic reviews.

Conventional transcutaneous electrical nerve stimulation (TENS) is a simple, non-invasive analgesic technique which is delivered using high frequency (10–250 Hz) currents to produce a ‘strong but comfortable’ paraesthesia within the site of pain. Acupuncture-like TENS (AL-TENS) is a variant of conventional TENS and is defined in this article as the induction of forceful but non-painful phasic muscle contractions using low frequency (1–10 Hz) electrical currents. The purpose of this paper is to discuss the analgesic effects and clinical effectiveness of AL-TENS. There is insufficient evidence to support or refute claims that there are differences in the analgesic profiles of conventional TENS and AL-TENS. Despite a large literature on TENS, it is not possible to perform an objective review of the clinical effectiveness of AL-TENS due to inconsistency in the method of application and insufficient detail on TENS treatment interventions in written reports. The use of banner terms, such as AL-TENS, to describe electrotherapeutic treatment modalities is seriously questioned.

In the health sciences, a wide range of computer‐based courseware is now available. The aim of the study described in this paper has been to compare the effectiveness of a computer‐based learning (CBL) software package and a traditional lecture (TL) for the delivery, of introductory material on pain. Nineteen undergraduate nursing students were divided into two groups to attend a one‐hour learning session which introduced clinical aspects of pain and which was delivered by either CBL or TL. Students were assessed for prior knowledge by a pre‐session test, and for knowledge gain by an identical post‐session test. In addition, a multiple‐choice question paper was used to examine differences in pain knowledge between the two groups, and a questionnaire was used to examine the students’ views on their experience during the learning session. The results demonstrated that both groups showed significant knowledge gain after their respective learning sessions. No significant differences between the groups in the magnitude of knowledge gain were found for clinical aspects of pain delivered during the learning sessions. The attitude questionnaire revealed that students attending CBL reported similar learning experiences to those attending the lecture.

Three patients with unilateral auditory disturbances (singing voices, rockets and gongs, and whistling kettles) are described. The symptoms occurred during benzodiazepine withdrawal in two patients and the instigation of nefopam treatment in one. All patients had mild hearing loss and abnormal auditory evoked potentials. Two showed marked asymmetry of background EEG rhythms over the temporal lobe. In two of the patients the symptoms responded partially to TENS and/or acupuncture.

We report here on the successful but temporary control of severe intractable phantom pain in the right arm of a 47 year old man by acupuncture. Electroencephalographic (EEG) and biochemical variables were measured during a series of acupuncture sessions. An interesting feature of the present case was the patient's preference for manual acupuncture and the rapid on/off analgesic response triggered at a highly specific point. We propose that segmental rather than extrasegmental mechanisms were involved. No significant effects on EEG or biochemical measures were noted during acupuncture treatment.

The importance of TENS as an analgesic technique especially in the control of chronic pain has been confirmed. Doubts about the clinical efficacy of TENS have been dismissed, as 58.6% of patients given a trial of TENS continue to use the technique to control a wide range of chronic pain conditions. Approximately half of the patients using TENS successfully to control a chronic pain condition obtain over 50% reduction in their pain during treatment. For the majority of patients, the onset and offset of pain relief is rapid and only occurs during stimulation, thus to control the pain problem patients use stimulators over the entire day. In general, patients apply TENS to produce a ‘strong but comfortable’ electrical paraesthesia within the painful area, and have specific preferences on pulse frequencies and pulse patterns, turning to these frequencies and patterns on subsequent treatment sessions. Nevertheless, these pulse frequencies and patterns were not related to the cause and site of pain, implying that patients turn to such frequencies and patterns for reasons of comfort, which may not be related to mechanisms specific to the pain system.

Acupuncture-like Transcutaneous Electrical Nerve Stimulation (TENS) is used for pain relief. This study aimed to review the descriptions of the characteristics of acupuncture-like TENS reported within the published literature up to June 2011. A total of 88 items of published literature were retrieved. 35 authors or groups provided 1 publication (Single Contributions - SC) and 10 authors or groups provided more than 1 publication (Multiple Contributions - MC). In order to gain the acupuncture-like effects of TENS, authors often characterised acupuncture-like TENS using: an intensity that caused muscle contractions (6MC, 17SC), or a sensation to tolerance threshold (3MC, 4SC); a 1-4 pulses per second (pps) pulse rate (5MC, 16SC); a 100-200μs pulse duration (2MC, 8SC); stimulation to acupuncture points (5MC, 4SC), or myotomes (3MC, 3SC), or over the painful area (3MC, ISC). Critically, unlike many authors included in the present review, the International Association for the Study of Pain core curriculum does not mention the triggering of muscle contractions when acupuncture-like TENS is defined. This may be an area that that they should reconsider.

Introduction: Complex regional pain syndrome (CRPS) causes disabling pain. Transcutaneous electrical nerve stimulation (TENS) is a treatment option. The aim of this systematic review is to evaluate the effects of TENS in patients with CRPS. Methods: A systematic search was conducted in PubMed, EMBASE, Cochrane CENTRAL, Web of Science, and PEDro databases up to June 2025. Randomized controlled trials (RCTs) involving patients with CRPS that evaluated the effects of TENS, regardless of parameters used, on pain intensity were considered eligible. Comparator groups could include placebo, usual care, or no intervention. Two independent reviewers extracted data, and a descriptive synthesis was performed. Risk of bias was assessed using the RoB 2 tool. Results: Of the 517 records screened, only two clinical trials met the inclusion criteria, encompassing a total of 38 participants (58% women). One study reported improvements in pain, mobility, and edema with conventional TENS compared to sham TENS. The other was a feasibility study that did not reach its recruitment target and presented only individual-level data without between-group comparisons. The assessment of the risk of bias revealed some concern about clarity of reporting of data analysis in both studies and the absence of protocol registration in one. Conclusion: There was insufficient evidence to judge the efficacy of TENS for analgesic and function improvement in patients with CRPS. Further studies are needed to inform clinical decision-making. Systematic review: registration number CRD42024554290.

Background: Uncertainty about the benefit of transcutaneous electrical nerve stimulation (TENS) to relieve pain is long-standing. We systematically reviewed the efficacy and safety of TENS for acute and chronic pain. Methods: We searched 10 databases from inception for randomised controlled trials (RCTs) that evaluated TENS administered using pulsed currents above sensory detection threshold at or close to the site of pain versus placebo and other treatments in adults. We meta-analysed mean pain intensity during or immediately after TENS and proportions of participants achieving > 30% or > 50% relief of pain (PROSPERO - CRD42019125054). Findings: We included 381 RCTs with 24532 participants. TENS reduced pain intensity compared with placebo [91 RCTs, 92 samples, n = 4841, standardised mean difference (SMD) = -0·96 [95% CI, -1·14, -0·78], I² = 88%], and compared with various treatments used in standard of care [61 RCTs, 61 samples, n = 3155, SMD = -0·72 [95% CI, -0·95, -0·50], I² = 88%]. Methodological and clinical characteristics did not modify the effect. Levels of evidence were downgraded because of a considerable number of small sized trials contributing to imprecision in magnitude estimates. Data was limited for other outcomes. Adverse events were mild and not different to comparators [18 RCTs, n = 805, 63/95 events, risk ratio, irrespective of severity, = 0·73 [95% CI, 0·36, 1·48], I² = 66%).Interpretation: There is moderate-certainty evidence that TENS reduces pain intensity during and immediately after stimulation compared with placebo. There were no serious adverse events.Funding Statement: The review was funded by an Investigator Sponsored Study grant from GlaxoSmithKline. The funder had no role in study design, data collection, data analysis, data interpretation, or writing of the report.Declaration of Interests: Prof. Mark I. Johnson (taken from ICMJE form): Dr. Johnson reports grants from GlaxoSmithKline, during the conduct of the study; other from GlaxoSmithKline, other from TENSCare, other from Actegy Ltd , personal fees from Oxford University Press, other from LifeCare Ltd, other from GlaxoSmithKline, other from Eurocept Pharmaceuticals, outside the submitted work; and I was involved in conducting studies [see manuscript] that were considered for inclusion in the work submitted for publication.We declare no competing interests: Dr Carole Paley, Dr Gareth Jones, Dr Mathew R. Mulvey, and Dr Priscilla Wittkopf.

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Background: The POUT trial (CRUK/11/027; NCT01993979) previously reported (with median follow-up 30.3 months) that adjuvant chemotherapy improves disease free survival (DFS) for patients (pts) with histologically confirmed pT2-T4 N0-3 M0 UTUC. Here we present results of a pre-planned analysis updating the primary endpoint and reporting key secondary endpoints including overall survival. Methods: 261 pts with UTUC were enrolled following nephro-ureterectomy and randomised (1:1) to 4 cycles of gemcitabine-cisplatin (gemcitabine-carboplatin if GFR 30-49ml/min) or surveillance with subsequent chemotherapy if required. Pts had 6 monthly imaging and cystoscopy for 2 years, then annually to 5 years. Toxicity was assessed by CTCAE v4. Primary endpoint was DFS. Secondary endpoints included metastasis free survival (MFS), overall survival (OS), toxicity and patient reported quality of life (QoL). The trial closed to recruitment early on advice of the independent data monitoring committee due to evidence of efficacy. Time-to-event endpoints are analysed (intention-to-treat) by Cox proportional hazard models. Unadjusted and adjusted (by nodal status, planned chemotherapy type, microscopic margin status, pathological stage) hazard ratios (HR, < 1 favouring chemotherapy) are reported. Results: From May 2012 to Nov 2017, 261 pts were recruited (129 surveillance; 132 chemotherapy) at 56 UK centres. One participant withdrew consent for data usage and was excluded from analyses. Pts had median age 69 years (range 37-88), 28% pT2, 66% pT3; 91% pN0. To 09/09/2020, median follow up was 48.1 months (IQR: 36.0-60.1). The unadjusted/adjusted HR for DFS was 0.48 (95% CI: 0.33-0.71; p = 0.0003) / 0.50 (95%CI: 0.34-0.75; p = 0.001), and for MFS was 0.52 (95% CI: 0.35-0.77; p = 0.001) / 0.54 (95% CI: 0.36-0.81; p = 0.002). 93/260 (35.8%) pts have died (52/129 [40.3%] surveillance and 41/131 [31.3%] chemotherapy). Chemotherapy conferred a non-statistically significant 28% reduction in relative risk of death (HR = 0.72, 95% CI: 0.47-1.08; p = 0.11; adjusted HR = 0.79, 95% CI: 0.52-1.19; p = 0.26). 3 year OS was surveillance: 67% (95% CI: 58-74%; chemotherapy: 79% (71%-85%). There was no evidence of long-term toxicity associated with chemotherapy (Wilcoxon rank-sum test p-value for worst grade post-6 months = 0.32). Most common grade 2+ adverse events were hypertension (25/240 [10.4%]), lethargy (25/240 [10.4%]) and hearing loss (13/240 [5.4%]). There was no evidence of statistically or clinically relevant differences in QoL. 12 months after treatment (EORTC Q30 global health status mean difference 4.1 and 4.8 at 12 and 24 months respectively in favour of chemotherapy). Conclusions: With additional follow-up, the previously reported DFS benefit for chemotherapy was maintained with no detrimental long-term toxicity. No statistically significant improvement in OS was observed. Clinical trial information: NCT01993979.

Transcutaneous electrical nerve stimulation (TENS) is an analgesic technique used in clinics worldwide. However, its potential value for pain control in labour is often overlooked. The purpose of this study was to evaluate patients' views after experience with TENS in labour. A questionnaire (12 multiple choice questions) was distributed to 17896 parturients in the UK who had used TENS to manage labour pain. The questionnaire was completed and returned by post within the 2 weeks following delivery by 10 077 women. The survey was analysed using descriptive statistics and It was found that 71% of the 10 077 respondents reported ‘excellent’ or ‘good’ relief of labour pain by TENS and 91% would use TENS again in the future. However, 86% of parturients who completed the questionnaire reported receiving additional analgesics during labour and it is therefore impossible to determine whether analgesic effects were directly due to TENS alone. Of the 14% of respondents who completed labour without additional analgesia 1187 (83%) reported ‘excellent’ or ‘good‘ pain relief. Although one must be cautious in the interpretation of the results of a postal survey, the favourable reports of satisfaction while using TENS supports a possible role for TENS as an adjuvant in the management of labour pain.

Background The POUT trial aims to establish whether platinum-based combination chemotherapy is superior to surveillance following nephro-ureterectomy with curative intent for upper tract transitional cell carcinoma (utTCC). Methods We aim to randomise 345 participants world-wide, over a 5-year period. Previous trials of adjuvant chemotherapy for urothelial cancers suggest that potential challenges to recruitment include randomisation between “no treatment” vs chemotherapy with its potential toxicity, and early identification of eligible patients. To support trial design and the development of patient information, we therefore conducted a survey of participating UK centres' current standard treatment and also held a dedicated consumer focus group. During the trial set up period, additional sites expressed interest in participating and the survey was recirculated; results are presented here. Results 26 of 44 UK centres questioned routinely place utTCC patients on surveillance following surgery; 18 give chemotherapy if the patient is considered fit enough. The 9 respondents who specified chemotherapy regimens give gemcitabine and cisplatin or carboplatin, dependent on renal function. All centres discuss patients pre-operatively in a multi-disciplinary team meeting, but 6 centres do not routinely discuss patients post-operatively. The consumer group welcomed the opportunity for utTCC patients to participate in research. They approved of the proposed randomisation between surveillance and chemotherapy and supported the use of a two stage pre- and post-operative information giving process. Conclusions There is no consensus among UK clinicians regarding optimum post-operative treatment of muscle invasive utTCC. The POUT trial offers the opportunity to standardise post-operative management of utTCC internationally and is supported by urologists, oncologists and consumer representatives from the target patient population. The trial design incorporates an initial two-year recruitment optimisation phase which includes qualitative research to inform recruitment practices. Disclosure All authors have declared no conflicts of interest.

Transcutaneous electrical nerve stimulation (TENS) refers to the delivery of electrical currents through the skin to activate peripheral nerves. The technique is widely used in developed countries to relieve a wide range of acute and chronic pain conditions, including pain resulting from cancer and its treatment. There are many systematic reviews on TENS although evidence is often inconclusive because of shortcomings in randomised control trials methodology. In this overview the basic science behind TENS will be discussed, the evidence of its effectiveness in specific clinical conditions analysed and a case for its use in pain management in developing countries will be made.

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Background: The role of post nephro-ureterectomy (NU) treatment for UTUC is unclear. POUT (CRUK/11/027; NCT01993979) addresses whether adjuvant chemotherapy improves disease free survival (DFS) for pts with histologically confirmed pT2-T4 N0-3 M0 UTUC. Methods: Pts (max n = 345) ≤90 days post NU were randomised (1:1) to 4 cycles of gemcitabine-cisplatin (gemcitabine-carboplatin if GFR 30-49ml/min) or surveillance with subsequent chemotherapy if required. Pts had 6 monthly cross sectional imaging and cystoscopy for the first 2 years, then annually to 5 years. Toxicity was assessed by CTCAE v4. Primary endpoint was DFS. The trial was powered to detect a hazard ratio (HR) of 0.65 (i.e. improvement in 3 year DFS from 40% to 55%; 2-sided alpha = 5%, 80% power) with Peto-Haybittle (p < 0.001) early stopping rules for efficacy & inefficacy. Secondary endpoints included metastasis-free survival (PFS), overall survival (OS), toxicity & quality of life. Results: Between May 2012 & Sept 2017, 248 pts were recruited (123 surveillance; 125 chemotherapy) at 57 UK centres. In Oct 2017, the independent trial oversight committees recommended POUT close to recruitment as data collected thus far (data snapshot 05/09/2017) met the early stopping rule for efficacy. At the time of interim analysis, median follow-up was 17.6 months (IQR 7.5-33.6). Pts had median age 69 years (range 36-88), 30% pT2, 65% pT3; 91% pN0;. Grade ≥3 toxicities were reported in 60% chemotherapy pts & 24% surveillance pts. 47/123 (surveillance) & 29/125 (chemotherapy) DFS events were reported; unadjusted HR = 0.47 (95% CI: 0.29, 0.74) in favour of chemotherapy (log-rank p = 0.0009). Two year DFS was 51% for surveillance (95% CI: 39, 61) and 70% for chemotherapy (95% CI: 58, 79). PFS favoured chemotherapy: HR = 0.49 (95% CI: 0.30, 0.79, p = 0.003). Conclusions: Adjuvant chemotherapy improved PFS in UTUC. POUT is the largest randomised trial in this pt population; the trial was terminated early because of efficacy favouring the chemotherapy arm. Whilst follow up for OS continues, this should be considered a new standard of care in these patients. Clinical trial information: ISRCTN98387754.

Sport Climbing debuts at the 2020 Olympic Games in Tokyo. The average age of elite competition climbers has decreased significantly, and adolescent climbers sustain a unique type of climbing-related injury. To critically review the prevalence, identification and management strategies of physeal fractures of the phalanges in the hands of adolescent climbers. Semi-systematic literature review was conducted, searching the following electronic databases: Discover, Academic Search Complete (EBSCO), PubMed, Embase, SPORTDiscus, and ScienceDirect. Studies that reported injuries of the physis in adolescent climbers. Competitive and/or recreartional adolescent climbers Fifty percent of reported adolescent climbing injuries were fractures of the physis. High, repetitive training load during the peak height velocity growth phase was frequently described. A higher proportion of fractures was reported in male athletes, where the middle finger was the most commonly affected digit. Examination usually revealed pain on the dorsal aspect of the PIP joint of the middle or ring finger and occasionally localised swelling. A Salter-Harris type III fracture was the most common presentation. Confirmation of fracture using plain radiographs and/or magnetic resonance imaging (MRI). Early fracture identification reduces the risk of premature closure of the physis and asymmetrical deformity of the finger. MRI using a wrist coil to confirm diagnosis in cases where plain radiographs are inconclusive is recommended. For non-displaced fractures, initial cessation of climbing activity, a resting splint 3–4 weeks (daily removal/tendon gliding exercises) followed by a gradual return to activity with load modification produced favourable results. Epiphysiodesis may be considered in cases where abnormal differential bone growth exists. A diagnostic and therapeutic algorithm was formulated. Fractures of the physis in adolescent climbers are common. Early diagnosis and non-surgical management demonstrate good results. The routine monitoring of training load is advised.

The risk of developing Dupuytrens disease—a benign chronic fibro-proliferative condition of the palmer fascia—has been associated with chronic heavy manual labour. The fingers and hands of climbers are routinely subjected to high load forces which may predispose individuals to disease development. The prevalence within the general population is unknown throughout the lifespan but has been found to increase with age and is estimated to be 12% at 55 yrs and 29% at 75 yrs. There is a paucity of information in regard of this condition in climbers. To characterise Dupuytren’s disease in a large sample of active climbers. Retrospective cross-sectional online survey utilising operational measures of disease, climbing behaviour and injury. Participants recruited via The Climber’s Club of Great Britain and UKClimbing.com 369 active climbers (307 male, 62 female) aged 14–80 Climbing behaviours and key demographics. Prevalence of Dupuytren’s, injuries requiring medical assistance or withdrawal from participation for ≥1 day. The prevalence of Dupuytren’s was 17.6% (65/369). Of the 65 climbers (mean age 51.28 SD ± 13.77), 59 climbers were male (mean age 51.25 SD ±14.01) and 6 climbers were female (mean age 51.50 SD ± 12.37). Dupuytren’s was present in 40 climbers bilaterally and 25 climbers unilaterally. The fourth and fifth fingers were the most commonly affected digits. The youngest climber diagnosed was 23 yrs and 38 climbers were diagnosed ≤ 55 yrs of age. Twenty-one climbers underwent surgery. Of these 19 had successful outcomes and 2 climbers had a recurrence. No climbers reported percutaneous needle fasciotomy or injection of collagenase as a clinical intervention. There was no increased risk of finger injury in Dupuytren’s participants (RR 0.62 (95% CI, 0.43–0.89); OR 0.44 (95% CI, 0.25–0.77)). Dupuytren’s does not appear to increase the risk of finger injury in climbers. A prospective study to investigate disease onset and progression in climbers is warranted.

CYP2D6 Polymorphisms and Response to Codeine and Tramadol,

Mark I Johnson and Helen Radford

Current evidence-based practice guidelines for the management of nonacute persistent and recurring musculoskeletal-related pain have emphasized the use of holistic multidisciplinary approaches including nonpharmacological therapies. Kinesiology taping is a simple, economical, easy-to-apply, nondrug therapeutic technique that is used by health-care professionals for managing and rehabilitating musculoskeletal injuries. High-quality research on kinesiology taping is limited, although recent evidence suggests that kinesiology taping may have a small effect in mitigating pain and may be associated with mild cutaneous side effects. We present a review of the principles of kinesiology taping and an evaluation of research on its efficacy to catalyze discussion among clinicians about the merits of kinesiology taping as an adjunct for pain management.

Cancer pain is a major challenge in healthcare and many patients report unsatisfactory pain relief. Current pain relieving strategies include the use of opioid-based analgesia, bisphosphonates and radiotherapy. Although patients experience some pain relief, these interventions may produce unacceptable side-effects which inevitably affect the quality of life. Acupuncture represents a potentially valuable adjunct to existing strategies for pain relief and it is known to be relatively free of harmful side-effects. Acupuncture is used in palliative care settings for all types of cancer pain, but the evidence-base is sparse, inconclusive and there is very little evidence to show its effectiveness in relieving cancer-related pain. The aim of this chapter is to review the biological mechanisms underpinning acupuncture as a treatment for cancer pain using a Western medical acupuncture model, discuss the clinical indications for treatment, consider acupuncture techniques and safety issues, as well as review the current evidence for clinical efficacy. Directions for future research will also be discussed.

A 76-year-old woman developed a delayed allergic reaction to adhesive pads following home use of transcutaneous electrical nerve stimulation (TENS) for pain management after a complex elbow dislocation. This case highlights the potential for delayed hypersensitivity reactions to TENS electrode pads. Although formal allergology testing was not performed, the woman’s self-directed observations offered valuable insight. The clinical presentation and timing of symptom onset were more consistent with allergic rather than irritant contact dermatitis. Allergic contact dermatitis from TENS pads is often linked to specific allergens in the adhesive materials. Hypoallergenic alternatives aim to reduce this risk by eliminating or substituting known sensitizers. Interestingly, the reaction on the painful arm–where titanium plates had been surgically implanted–extended beyond the electrode placement, whereas on the unaffected, pain-free leg, it remained localized. This suggests that local tissue conditions may modulate the immune response. This case demonstrates the importance of clinician awareness regarding potential dermatological adverse events associated with TENS therapy and emphasizes the need for patient education, particularly when TENS is administered independently. Further investigation into the interaction between local inflammatory states and immune reactivity may inform safer electrode design and guide clinical recommendations for safe TENS use.

Persistent pain remains a significant global health challenge, with prevailing biomedical and biopsychosocial models often falling short in capturing its full complexity. These models frequently lack conceptual and contextual coherence, overlooking the deeply subjective, cultural, and systemic dimensions of pain. As a result, care can become fragmented and suboptimal. This perspective article introduces an integral vision of pain, grounded in the All Quadrants, All Levels (AQAL) framework, which offers a multidimensional approach that integrates subjective experience, objective mechanisms, cultural meaning, spiritual perspectives, and systemic structures. The article outlines how a simplified AQAL framework can serve as a heuristic tool to synthesise individual and collective dynamics—including psychological development and socio-environmental conditions—thereby informing a more comprehensive understanding of pain and its persistence. This includes recognising the role of painogenic environments and the impact of evolutionary mismatch in shaping pain experiences. This integral perspective reframes persistent pain within a salutogenic social model of health, adopting a whole-person, whole-system approach that supports the co-creation of compassionate, community-driven, and context-sensitive care. Ultimately, it reconceptualises persistent pain not merely as a disease state or clinical symptom, but as a dynamic, relational, and meaning-laden experience embedded within the evolving journey of life. This integral vision challenges reductionist paradigms, advancing a more coherent, salutogenic, and humanistic model for understanding and addressing persistent pain.

Abstract

Background: Breast cancer is the most commonly diagnosed women’s cancer with 2.3 million new global cases diagnosed in 2020. The global rise in survivorship has resulted in a significant health and economic burden on society. Breast cancer survivors report being overwhelmed physically and emotionally with treatment adverse effects. Recommendations include self-management support and personalised follow-up to meet patient needs. Persistent post-surgical pain (PPSP) is the most common negative consequence of breast surgery, often relating to inadequate acute post-surgical pain management. An unintended consequence of day surgery is reduced post-operative pain monitoring. There is a need to ensure appropriate support and pain monitoring alongside preparation, behavioural change and expectation management. Web-based interventions (WBI) could be a potential solution. A mixed-methods approach was used to develop a WBI to capture patient self-reported post-operative symptoms and provide individualised self-management advice. Methods: An audit and service evaluation revealed a 46% PPSP rate and identified opportunities where advice could support improved self-management. Developing the WBI (ePainQ) comprised a scoping review, systematic review, and development study with all results informing the development of ePainQ. ePainQ comprised two parts; a website containing supportive information and a post-operative symptom questionnaire. Intervention questions included pain, swelling, infection, functionality and QoL. Advice was generated for each question with different levels, based on CTCAE grading agreed with clinicians. A feasibility study prospectively tested ePainQ for acceptability, usability and perceived usefulness. Feasibility study aims were assessing uptake, retention, follow up and completion rates and acceptability of ePainQ. Study arms: usual care (cohort) or intervention (ePainQ). Intervention: daily online symptom questionnaire for 2 weeks commencing the day after surgery. Participants received immediate advice based on the severity of the reported symptoms, either self-management advice or in cases of clinical concern, advice to contact the hospital team. Reports were immediately available to HCPs as ePainQ was linked to the electronic patient record. Data collection: baseline, 2 weeks, 3 and 9 months post-operatively. Outcome measures: EORTC C30, and BR23, EQ-5D, HADS and BPI. Patient Activation was measured at baseline and 9 months. Results: 69 patients recruited over 8 months; 60 intervention and 9 cohort. Mean age: 57.7yrs (SD 9.8; range 38-82). Recruitment rate was 63%. IT issues prevented 12/60 using ePainQ but engagement of the 48/60 active participants was 89.6%. 40/48 completed a usability scale in which • 97.5% highlighted ePainQ as easy to use • 95% reported not needing any technical support • 90% felt very confident using ePainQ Outcome measures: 69/69 (100%) completion at baseline and 2 weeks. No active withdrawals with 13/69 passive withdrawals by 9 months. 67 participants (97.1%) consented to an interview invite with 14/67 interviews conducted. Participants were a mix of compliance rates to be reflective of the study and capture both positive and negative feedback. Feasibility study results demonstrated that ePainQ was perceived to be simple, easy to use and not requiring much learning to use effectively. All pre-set criteria for progression to a phase III RCT were met. Conclusion: ePainQ was designed in response to patient identified needs. The feasibility study established that ePainQ was accepted, used, and liked by participants who interacted with it. Even participants with limited use felt they had benefited from the advice. Results demonstrated patient positivity towards ePainQ suggesting recruitment rates could be increased if research capacity was improved and higher retention rates if IT issues were resolved and daily reporting duration was slightly reduced.

Citation Format: Sue M. Hartup, Laura Ashley, Michelle Briggs, Galina Velikova, Mark Johnson. Developing and feasibility testing a web-based intervention (ePainQ) to support post-operative pain and symptom self-management following surgery for breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-57.