Peripheral Nerve Stimulation & Scrambler Therapy for Pain Management

Learning Objectives

As a result of participating in this activity, learners will be able/better able to:

Identify patients who may benefit from treatment with peripheral nerve stimulation
Mitigate potential complications and adverse events

Outline

A review of peripheral nerve stimulation (PNS) for acute and chronic pain, including:

Knowledge Gaps in PNS
Preclinical Studies
Mechanisms of Action
Select Uses/Conditions
- Migraine & cluster headache
- Amputation pain
- CRPS
- Post-stroke shoulder pain
- Inguinal/Genital/Pelvic Pain
- Posterior tibial nerve stimulation
- Thoracic postherpetic neuralgia
Complications and Safety
- Diabetes
- Obesity and lead placement
- Anticoagulation
Emerging Applications
- Peripheral nerve field stimulation
- Craniofacial pain
Scrambler Therapy

Desirable Physician Attributes

Patient Care [ACGME/ABMS & IOM] Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health
Medical Knowledge [ACGME/ABMS] about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
Employ Evidence-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care and participate in learning and research activities to the extent feasible.

Accreditation & Designation

Release date: This activity was released 8/27/2021.

Termination date: The content of this activity remains eligible for CME Credit until 8/26/2024, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity includes discussions of unlabeled or investigational uses of commercial and/or developmental products.

This activity includes discussions and explorations of new and evolving topics. Such inclusion includes adequate justifications of statements based upon current science, evidence and clinical reasoning.

Disclosure of Financial Relationships & Measures to Resolve of Conflicts of Interest

[Presenter] Paul Christo discloses the following financial relationships within the past 24 months: Consulting: Eli Lilly, Y mAbs, GlaxoSmithKline

No other person with control of, or responsibility for, the planning, delivery, or evaluation of accredited continuing education has, or has had within the past 24 months, financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships have been mitigated. Materials were reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. In some cases, content may have been modified as part of the review and mitigation process. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).

Additional Reading

Xu, J., Sun, Z., Wu, J., Rana, M., Garza, J., Zhu, A. C., ... & Cheng, J. (2021). Peripheral Nerve Stimulation in Pain Management: A Systematic Review. Pain Physician, 24(2), E131-E152.
Christo, P. J., Kamson, D. O., & Smith, T. J. (2020). Treatment of Déjerine–Roussy syndrome pain with scrambler therapy. Pain management, 10(3), 141-145.
Chakravarthy, K. V., Boehm, F. J., & Christo, P. J. (2018). Nanotechnology: a promising new paradigm for the control of pain. Pain Medicine, 19(2), 232-243.
Günter, C., Delbeke, J., & Ortiz-Catalan, M. (2019). Safety of long-term electrical peripheral nerve stimulation: review of the state of the art. Journal of Neuroengineering and Rehabilitation, 16(1), 1-16.
Chakravarthy, K., Nava, A., Christo, P. J., & Williams, K. (2016). Review of Recent Advances in Peripheral Nerve Stimulation (PNS). Current Pain and Headache Reports, 20(11).
Downs, M. E., Lee, S. A., Yang, G., Kim, S., Wang, Q., & Konofagou, E. E. (2018). Non-invasive peripheral nerve stimulation via focused ultrasound in vivo. Physics in Medicine & Biology, 63(3), 035011.
Ilfeld, B. M., Ball, S. T., Gabriel, R. A., Sztain, J. F., Monahan, A. M., Abramson, W. B., ... & Boggs, J. W. (2019). A feasibility study of percutaneous peripheral nerve stimulation for the treatment of postoperative pain following total knee arthroplasty. Neuromodulation: Technology at the Neural Interface, 22(5), 653-660.
Slavin, K. V. (2008). Peripheral nerve stimulation for neuropathic pain. Neurotherapeutics, 5(1), 100-106.
Ridding, M. C., Brouwer, B., Miles, T. S., Pitcher, J. B., & Thompson, P. D. (2000). Changes in muscle responses to stimulation of the motor cortex induced by peripheral nerve stimulation in human subjects. Experimental Brain Research, 131(1), 135-143.
Deer, T. R., Eldabe, S., Falowski, S. M., Huntoon, M. A., Staats, P. S., Cassar, I. R., ... & Boggs, J. W. (2021). Peripherally Induced Reconditioning of the Central Nervous System: A Proposed Mechanistic Theory for Sustained Relief of Chronic Pain with Percutaneous Peripheral Nerve Stimulation. Journal of Pain Research, 14, 721.
Weiner, R. L., & Reed, K. L. (1999). Peripheral neurostimulation for control of intractable occipital neuralgia. Neuromudulation: Technology at the Neural Interface, 2(3), 217-221.
Papuć, E., & Rejdak, K. (2013). The role of neurostimulation in the treatment of neuropathic pain. Ann Agric Environ Med, 1, 14-17.
Koopmeiners, A. S., Mueller, S., Kramer, J., & Hogan, Q. H. (2013). Effect of electrical field stimulation on dorsal root ganglion neuronal function. Neuromodulation: Technology at the Neural Interface, 16(4), 304-311.
Gordon, T. (2016). Electrical stimulation to enhance axon regeneration after peripheral nerve injuries in animal models and humans. Neurotherapeutics, 13(2), 295-310.
Prasad, A., & Chakravarthy, K. (2021). Review of complex regional pain syndrome and the role of the neuroimmune axis. Molecular Pain, 17.
Wang, S., Wang, J., Liu, K., Bai, W., Cui, X., Han, S., ... & Zhu, B. (2020). Signaling interaction between facial and meningeal inputs of the trigeminal system mediates peripheral neurostimulation analgesia in a rat model of migraine. Neuroscience, 433, 184-199.
Lin, T., Gargya, A., Singh, H., Sivanesan, E., & Gulati, A. (2020). Mechanism of peripheral nerve stimulation in chronic pain. Pain Medicine, 21(Supplement_1), S6-S12.
Goroszeniuk, T., & Pang, D. (2014). Peripheral neuromodulation: a review. Current Pain and Headache Reports, 18(5), 412.
Dodick DW, Silberstein SD, Reed KL et al. Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine. Cephalgia 2015;35(4):344-358.
Yang, Y., Song, M., Fan, Y., & Ma, K. (2016). Occipital nerve stimulation for migraine: a systematic review. Pain Practice, 16(4), 509-517.
Rajneesh, K. F. (2020). Occipital Nerve Stimulation and Sphenopalatine Ganglion Stimulation for Treatment of Intractable Headache Syndromes. Neurology India, 68(8), 231.
Schoenen, J., Jensen, R. H., Lanteri-Minet, M., Láinez, M. J., Gaul, C., Goodman, A. M., ... & May, A. (2013). Stimulation of the sphenopalatine ganglion (SPG) for cluster headache treatment. Pathway CH-1: a randomized, sham-controlled study. Cephalalgia, 33(10), 816-830.
Reddy, C. G., Flouty, O. E., Holland, M. T., Rettenmaier, L. A., Zanaty, M., & Elahi, F. (2017). Novel technique for trialing peripheral nerve stimulation: ultrasonography-guided StimuCath trial. Neurosurgical focus, 42(3), E5.
Deer, T., Pope, J., Benyamin, R., Vallejo, R., Friedman, A., Caraway, D., ... & Mekhail, N. (2016). Prospective, multicenter, randomized, double‐blinded, partial crossover study to assess the safety and efficacy of the novel neuromodulation system in the treatment of patients with chronic pain of peripheral nerve origin. Neuromodulation: Technology at the Neural Interface, 19(1), 91-100.
Hsu, E., & Cohen, S. P. (2013). Postamputation pain: epidemiology, mechanisms, and treatment. Journal of pain research, 6, 121.
Rauck, R. L., Cohen, S. P., Gilmore, C. A., North, J. M., Kapural, L., Zang, R. H., ... & Boggs, J. W. (2014). Treatment of post‐amputation pain with peripheral nerve stimulation. Neuromodulation: Technology at the Neural Interface, 17(2), 188-197.
Gilmore, C. A., Ilfeld, B. M., Rosenow, J. M., Li, S., Desai, M. J., Hunter, C. W., ... & Boggs, J. W. (2020). Percutaneous 60-day peripheral nerve stimulation implant provides sustained relief of chronic pain following amputation: 12-month follow-up of a randomized, double-blind, placebo-controlled trial. Regional Anesthesia & Pain Medicine, 45(1), 44-51.
Cohen, S. P., Gilmore, C. A., Rauck, R. L., Lester, D. D., Trainer, R. J., Phan, T., ... & Boggs, J. W. (2019). Percutaneous peripheral nerve stimulation for the treatment of chronic pain following amputation. Military medicine, 184(7-8), e267-e274.
Soin, A., Syed Shah, N., & Fang, Z. P. (2015). High‐frequency electrical nerve block for postamputation pain: a pilot study. Neuromodulation: Technology at the Neural Interface, 18(3), 197-206.
Frederico, T. N., & da Silva Freitas, T. (2020). Peripheral Nerve Stimulation of the Brachial Plexus for Chronic Refractory CRPS Pain of the Upper Limb: Description of a New Technique and Case Series. Pain Medicine, 21(Supplement_1), S18-S26.
Frederico, T. N., & da Silva Freitas, T. (2020). Peripheral Nerve Stimulation of the Brachial Plexus for Chronic Refractory CRPS Pain of the Upper Limb: Description of a New Technique and Case Series. Pain Medicine, 21(Supplement_1), S18-S26.
Herschkowitz, D., & Kubias, J. (2018). Wireless peripheral nerve stimulation for complex regional pain syndrome type I of the upper extremity: a case illustration introducing a novel technology. Scandinavian journal of pain, 18(3), 555-560.
Chmiela, M. A., Hendrickson, M., Hale, J., Liang, C., Telefus, P., Sagir, A., & Stanton‐Hicks, M. (2020). Direct Peripheral Nerve Stimulation for the Treatment of Complex Regional Pain Syndrome: A 30‐Year Review. Neuromodulation: Technology at the Neural Interface.
Herschkowitz, D., & Kubias, J. (2019). A case report of wireless peripheral nerve stimulation for complex regional pain syndrome type-I of the upper extremity: 1 year follow up. Scandinavian journal of pain, 19(4), 829-835.
Pribicevic, M. (2012). The epidemiology of shoulder pain: A narrative review of the literature. IntechOpen.
Wilson, R. D., Gunzler, D. D., Bennett, M. E., & Chae, J. (2014). Peripheral nerve stimulation compared to usual care for pain relief of hemiplegic shoulder pain: a randomized controlled trial. American journal of physical medicine & rehabilitation/Association of Academic Physiatrists, 93(1), 17.
Wilson, R. D., Knutson, J. S., Bennett, M. E., & Chae, J. (2017). The effect of peripheral nerve stimulation on shoulder biomechanics: a randomized controlled trial in comparison to physical therapy. American journal of physical medicine & rehabilitation, 96(3), 191.
Wilson, R. D., Bennett, M. E., Nguyen, V. Q., Bock, W. C., O'Dell, M. W., Watanabe, T. K., ... & Chae, J. (2018). Fully Implantable Peripheral Nerve Stimulation for Hemiplegic Shoulder Pain: A Multi‐Site Case Series With Two‐Year Follow‐Up. Neuromodulation: Technology at the Neural Interface, 21(3), 290-295.
Rongqing, G., Yafei, W., Zhimin, W., Feng, L., Yuantao, L., Xinhua, C., ... & Kailun, L. (2019). Treatment outcome of acute sacral nerve stimulation in functional anorectal pain. Pain Practice, 19(4), 390-396.
Roy, H., Offiah, I., & Dua, A. (2018). Neuromodulation for pelvic and urogenital pain. Brain Sciences, 8(10), 180.
Shaw, A., Sharma, M., Zibly, Z., Ikeda, D., & Deogaonkar, M. (2016). Sandwich technique, peripheral nerve stimulation, peripheral field stimulation and hybrid stimulation for inguinal region and genital pain. British Journal of Neurosurgery, 30(6), 631-636.
Elahi, F., Reddy, C., & Ho, D. (2015). Ultrasound guided peripheral nerve stimulation implant for management of intractable pain after inguinal herniorrhaphy. Pain Physician, 18(1), E31-8.
Wang, J., Chen, Y., Chen, J., Zhang, G., & Wu, P. (2017). Sacral neuromodulation for refractory bladder pain syndrome/interstitial cystitis: a global systematic review and meta-analysis. Scientific Reports, 7(1), 1-9.
Bhide, A. A., Tailor, V., Fernando, R., Khullar, V., & Digesu, G. A. (2020). Posterior tibial nerve stimulation for overactive bladder—techniques and efficacy. International Urogynecology Journal, 31(5), 865-870.\
Istek, A., Ugurlucan, F. G., Yasa, C., Gokyildiz, S., & Yalcin, O. (2014). Randomized trial of long-term effects of percutaneous tibial nerve stimulation on chronic pelvic pain. Archives of Gynecology and Obstetrics, 290(2), 291-298.
Rego, R. M. P., Machado, N. C., de Assis Carvalho, M., Graffunder, J. S., Ortolan, E. V. P., & de Arruda Lourenção, P. L. T. (2019). Transcutaneous posterior tibial nerve stimulation in children and adolescents with functional constipation: a protocol for an interventional study. Medicine, 98(45).
Sarveazad, A., Babahajian, A., Amini, N., Shamseddin, J., & Yousefifard, M. (2019). Posterior tibial nerve stimulation in fecal incontinence: a systematic review and meta-analysis. Basic and Clinical Neuroscience, 10(5), 419.

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