Neuropathy And Electro Stimulation Part 3

Today's post from absolutept.com (see link below) is the third of 4 looking at the qualities and effectiveness of EMS or Tens units in helping reduce neuropathic symptoms. Not all experts are fans of TENS systems, or believe that electro-stimulation is beneficial to neuropathy patients but as with so many of these things in the neuropathy world; they work for many people and bring relief, so deserve to be taken seriously. The problem may be that to get treatment in this area, many people have to go to private clinics and pay outside their normal insurance and that immediately raises the spectre of rampant commercialism and leads people to suspect they're going to be ripped off. This blog doesn't normally advertise but when someone provides useful and fact based information, which is of benefit to everyone considering their treatment options, then there is no objection to highlighting a medical facility. That's the case here. Chad Reilly (sports physical therapist) provides such a comprehensive analysis of EMS/TENS that patients may wish to take it further, either with him or their local TENS provider. Definitely worth reading if you want to know more about how it all works. All four sections appear within these four days.

 Electric Stimulation and Neuropathy (Part 3)
 Chad's Physical Therapy Blog - Chad Reilly

Effective treatment of symptomatic diabetic polyneuropathy by high-frequency external muscle stimulation. Diabetologia. 2005 May;48(5):824-8. Reichstein L, Labrenz S, Ziegler D, Martin S.


Abstract
AIMS/HYPOTHESIS:
Diabetic distal symmetrical sensory polyneuropathy (DSP) affects 20-30% of diabetic patients. Transcutaneous electrical nerve stimulation (TENS) and electrical spinal cord stimulation have been proposed as physical therapies. We performed a controlled, randomised pilot trial to compare the effects of high-frequency external muscle stimulation (HF) with those of TENS in patients with symptomatic DSP.


METHODS:
Patients with type 2 diabetes and DSP (n=41) were randomised to receive treatment with TENS or HF using strata for non-painful (n=20) and painful sensory symptoms (n=21). Both lower extremities were treated for 30 min daily for three consecutive days. The patients’ degree of symptoms and pain were graded daily on a scale of one to ten, before, during and 2 days after treatment termination. Responders were defined by the alleviation of one or more symptoms by at least three points.

RESULTS:
The two treatment groups were similar in terms of baseline characteristics, such as age, duration of diabetes, neurological symptoms scores and neurological disability scores. The responder rate was significantly higher (p less than 0.05) in the HF group (80%, 16 out of 20) than in the TENS group (33%, seven out of 21). Subgroup analysis revealed that HF was more effective than TENS in relieving the symptoms of non-painful neuropathy (HF: 100%, seven out of seven; TENS: 44%, four out of nine; p less than 0.05) and painful neuropathy (HF: 69%, nine out of 13; TENS: 25%, three out of 12; p less than 0.05). The responders did not differ in terms of the reduction in mean symptom intensity during the trial.

CONCLUSIONS/INTERPRETATION:
This pilot study shows, for the first time, that HF can ameliorate the discomfort and pain associated with DSP, and suggests that HF is more effective than TENS. External muscle stimulation offers a new therapeutic option for DSP.

My comments:

I would have really liked this study had it shown great results with the high frequency (HF) electric stimulation, and compared it to TENS and found the HF worked considerably better. The next study I am going to cite uses the exact same HF machine and calls it EMS (electric muscle stimulation) rather than HF, and that fits with my observations and other research that EMS works better than TENS to control pain.

What I don’t like about this study, however, is that from the description of the parameters I can’t figure out what they used. Plus, other things besides the current are different, including electrode size and placement.

For the TENS group I get:
Waveform: biphasic exponentially decaying
Duty Cycle: continuous (I think)
Pulse Duration: 400 uS
Intensity: 20-30 mA
Rate: 180 Hz
Treatment Length: 30 min
Training Frequency: daily
Training Length: 3 days
Electrodes: two sticky ~2” electrodes per leg, placed on proximal and distal fibula region

For the HS group:
Waveform: biphasic exponentially decaying
Duty Cycle: 3 sec ramp, 3 sec on (3 sec off I think, because that’s what the next study using the same machine reports)
Pulse Duration: does not say but with the high Hz I expect its pretty short
Intensity: adjusted to a pleasant level without pain or uncomfortable paresthesia
Rate: 4096 Hz – 32768
Treatment Length: 30 min
Training Frequency: daily
Training Length: 3 days
Electrodes: two carbon ~3.5” rubber carbon electrodes per leg, placed on the proximal and distal quadriceps.

So in this study the HS group did a lot better, but it is hard to tell if it is due to the difference in current, or the larger electrodes being used in the HS group, or the HS group putting the electrodes over a muscle rather than a bony region. I would expect the larger electrodes to work better because you can turn the machine up higher with greater patient comfort because of lesser current density (coulumbs delivered per square inch of skin). Also I don’t think it’s at all ideal to place the smaller electrodes over the bony region of the fibula, though I find it interesting that the larger electrodes on the quadriceps worked so well since presumably the diabetic neuropathy sufferers were complaining of the most pain and paresthesias in the feet. Another interesting thing is the good results of the HS group was noticed in just 3 days of treatment, which is in accordance with my observation using EMS. My patients report relief immediately after my 12 minute treatment, and those results continue to improve with future treatments. Also interesting from this study is they treated people with both painful and non painful neuropathy, noting it worked on non-painful neuropathy better. My patients tend to report similar improvements painful or not with my protocol, but that could be due to the different parameters where I’m using 4 electrodes per leg instead of two, placing all the electrodes on muscle (including the bottom of the foot), my electrodes are larger still, and I use as long a pulse width as my machines allow (300-450 uS) for as high an intensity as they can tolerate.

So the take home message for me is that all stimulation parameters are not equal, but in this study it is unclear which part of the different stimulation protocols led to the difference in effects. I suspect that greater intensity of stimulation, and on and off period, larger electrodes, placing the electrodes over muscle all contributed to better outcomes in the latter group.

http://absolutept.com/electric-stimulation-and-neuropathy-part-3/

Spinal Cord Stimulation For Neuropathy Vid

Today's post from spacecoastdaily.com (see link below) looks (with the help of a video) at the growing use of neurostimulation devices to control severe nerve pain. There are several systems on the market and you may have heard of them and be curious as to what's involved. Firstly, you should be aware that these devices may not be the best solution for your particular neuropathic problems and secondly, by watching the video, you will quickly realise that implanted devices in the spine is not your every day procedure and carries some risk with it. It's not just a question of getting some wired up pads attached and switching on to release an electrical current (although that type of device is available and works for some). What is explained in this article is a tricky procedure and probably one of the more extreme versions of electrical stimulation you will encounter. It's all a question of talking to your doctor and your specialist (preferably a neurologist) and discovering if this sort of procedure is applicable to your situation. You'll need to ask all the right questions; not least of which is 'what are the chances of success?' That all said, you've probably heard about these things in the course of your Googling, so it's fascinating to see exactly what's involved, even if it scares the bejeezeus out of you!!

Innovative Approach, Recommendations Dealing With Intractable Neuropathic Pain

By Dr. Richard Gayles With Dr. James Palermo, Editor-In-Chief // June 21, 2012


SPACE COAST MEDICINE Q&A

Although the precise number of Americans afflicted with pain is hard to determine with great accuracy, several key pain statistics from the National Pain Foundation show that the sheer quantity of individuals suffering from pain is staggering. 



NEUROSTIMULATION therapies are used for pain relief or symptom relief from certain types of chronic pain. Spinal cord stimulation (SCS) is actually a subcategory of neurostimulation, which also includes peripheral nerve stimulation.

Among the general population pain stats include:

• About 89% of Americans age over 18 suffer from pain at least once a month. Over a three year period, 76 million Americans reported pain lasting 24 hours or more;

• Approximately 42% of adults age 20+ who reported pain stated the pain lasted 1 year or more;

• Americans spend more than $100 billion annually to relieve pain;

• The trend toward even more people experiencing and living with pain will only grow as America’s baby-boomers age, making effective pain management an integral and very important aspect of healthcare services.

We are delighted to welcome Dr. Richard Gayles, who has touched countless lives through expert patient-centered pain management over the past 15 years here on the Space Coast, to bring us up to date on an innovative approach that he sometimes recommends when dealing with a broad scope of neuropathic pain.

SPACE COAST MEDICINE: What cutting edge treatments for pain do you advocate other than injections and medications?


At Florida Pain we routinely use a technique called Spinal Cord Stimulation (SCS). This is an FDA approved technique that utilizes a small wire, which emits a tiny electrical current blocking pain from damaged or irritated nerves.

DR. GAYLES: At Florida Pain we routinely use a technique called Spinal Cord Stimulation (SCS). This is an FDA approved technique that utilizes a small wire, which emits a tiny electrical current blocking pain from damaged or irritated nerves.

SPACE COAST MEDICINE: Is this the same as a TENS unit?

DR. GAYLES: That is a great question, but SCS and a TENS unit are two totally different treatments. SCS has been called a TENS unit on steroids by some patients. The TENS uses pads, which are placed on the surface of the skin over the painful areas, and an electrical current to stimulate only tissues close to the skin surface. The SCS uses a tiny wire or electrode placed carefully within the spinal canal to directly stimulate the spinal cord or an individual spinal nerve. The electrical stimulation of the SCS blocks pain from damaged nerves and substitutes the painful sensation for a pleasant, artificially produced sensation.

SPACE COAST MEDICINE: Can you walk with this device?

DR. GAYLES: When the SCS is used, a patient can certainly walk, and in fact, walking and exercising may be easier without pain. The purpose of the SCS is to reduce pain while increasing function and activity levels. After placement of the SCS, patients are strongly encouraged to begin a program of stretching and strengthening exercises.

SPACE COAST MEDICINE: How do you decide who gets a SCS?

DR. GAYLES: Most patients will get better with time, exercise, physical therapy, medication and/or injections. For patients who do not respond to the more conservative treatments, SCS may be considered after a thorough physical exam, review of MRIs, X-rays, and nerve testing. After a review of the medical records, to ensure that all conservative measures have been exhausted, and there is no urgent need for surgery, a trial of SCS may be scheduled.

SPACE COAST MEDICINE: What is the process of getting a SCS?


Spinal Cord Stimulation uses a tiny wire or electrode placed carefully within the spinal canal to directly stimulate the spinal cord or an individual spinal nerve. The electrical stimulation of the SCS blocks pain from damaged nerves and substitutes the painful sensation for a pleasant, artificially produced sensation.

DR. GAYLES: After careful patient selection, a temporary percutaneous SCS trial is scheduled. The trial is like a test drive to determine how much pain the SCS will relieve. During the trial, SCS wire electrodes are inserted trough a needle into the spinal canal under x-ray guidance and are placed over the spinal level where signals from the damaged nerves are processed. When the SCS is turned on the patient will feel a pleasant tingling sensation over the painful areas. The SCS wires are then secured in place sterilely on the back. The patient is sent home with a small external battery/programmer and is encouraged to perform activities, which may provoke their usual pain. This trial lasts for 5-7 days, and when completed the SCS wire electrodes are pulled out and a band-aid is placed over the injection site. If the patient has greater than 50% reduction in pain and much improved function then a permanent system is inserted.

SPACE COAST MEDICINE: What does insertion entail?

DR. GAYLES: Wire electrodes are inserted through a needle into the spinal canal in a similar fashion as described for the trial. For the most common type of pain—the back–the SCS generator is usually implanted in the lower abdominal area or in the back in the upper gluteal (butt) region, and should be in a location that patients can access with their dominant hand for adjustment of their settings with the patient-held remote control. The SCS is then connected to wire electrodes. The procedure is done as an outpatient either under local anesthesia with sedation or a general anesthetic.

SPACE COAST MEDICINE: How is the SCS powered?

DR. GAYLES: The SCS is battery powered, and the battery lasts approximately 5 to 7 years. There is now a rechargeable SCS, which can last 10 years and is charged by a special belt.

SPACE COAST MEDICINE: Is the implanted SCS permanent?

DR. GAYLES: No, the SCS can be easily removed if desired. There are no permanent changes to the body after removal of the SCS.

SPACE COAST MEDICINE: Does insurance cover the SCS?

DR. GAYLES: Yes, virtually all insurances cover the SCS, including Medicare.

SPACE COAST MEDICINE: What conditions does the SCS treat?


Wire electrodes are inserted through a needle into the spinal canal in a similar fashion as described for the trial. For the most common type of pain—the back–the SCS generator is usually implanted in the lower abdominal area or in the back in the upper gluteal (butt) region, and should be in a location that patients can access with their dominant hand for adjustment of their settings with the patient-held remote control. The SCS is then connected to wire electrodes. The procedure is done as an outpatient either under local anesthesia with sedation or a general anesthetic.

DR. GAYLES: The SCS treats chronic sciatica (radiculopathy), neuropathy, occipital neuralgia, reflex sympathetic dystrophy, phantom limb, pain from peripheral vascular disease, back pain and many other painful conditions caused by nerve damage. In Europe the SCS is also used quite extensively for chronic refractory angina and peripheral vascular disease.

SPACE COAST MEDICINE: Are there limitations after the SCS is implanted?

DR. GAYLES: You can swim, walk, bicycle, jog, but be smart, and avoid the extremes of physical activity. SCS may be picked-up by the airport security machines, but patients avoid problems and carry a card to alert security to the presence of this device. The Medronic SCS has also been used successfully with patients with pacemakers.

To contact Dr. Gayles call 321-784-8211 or log on to FloridaPain.net
Florida Pain Doctor, Richard Gayles, MD

Dr. Richard Gayles brings a wealth of training and experience to Florida Pain. He received a Bachelor of Science in Psychobiology from the University of Michigan in 1987 and his Doctor of Medicine in 1991 at the University of Michigan’s School of Medicine. After graduation, Richard completed a residency and Pediatric Anesthesia Fellowship in the Department of Anesthesiology and Critical Care Medicine at Johns Hopkins Hospital in Maryland.

Dr. Gayles obtained further clinical experience in anesthesiology at St. Bartholomew’s Hospital in London, England. He completed a Chronic Pain Fellowship at the Cleveland Clinic Foundation in Ohio, where he was awarded the “Fellow of the Year Award” in June of 1997. He currently utilizes his expertise at Florida Pain, Merritt Island Surgical Center and Space Coast Surgery Center (located at our facility).

In addition to his clinical experience, Dr. Gayles has participated in research over the past fourteen years, both here at home and abroad. Dr. Gayles is Board Certified by the American Board of Anesthesiology and a Diplomat of the American Academy of Pain Management. He is also certified by the American Board of Pain Medicine, National Board of Medical Examiners and by the American Heart Association in Basic and Advanced Cardiac Life Support. Dr. Gayles holds the Following Special Affiliations: Member of Coast Guard Auxiliary and FAA (an Aero Medical Examiner) ANGEL Flight.

http://spacecoastdaily.com/2012/06/innovative-approach-recommendations-dealing-with-intractable-neuropathic-pain/

Electro Stimulation to Treat Neuropathic Pain

Following on from the post of February 13th, todays' article from hepatitiscresearchandnewsupdates.blogspot.com (see link below) again talks about electro-stimulation of the spinal cord as a means of reducing neuropathic pain. It looks like there will be more articles of this sort in the coming months - it seems to be potentially a hot topic but it's difficult to know how far away a standard, universal and trustworthy treatment may be. The trials seem to be encouraging but neuropathy patients may prefer the believe it when they see it approach. In the meantime, it's worth researching all you can and talking either to your HIV-specialist or neurologist about the possiblities for you.

Spinal Cord Stimulation Effective for HIV Neuropathy
Kate Johnson Monday, February 6, 2012

February 6, 2012 (Miami Beach, Florida) — Constant spinal cord stimulation delivered through a permanently implanted device can offer pain relief to patients with HIV-related polyneuropathy that is refractory to conservative treatment, according to Kenneth Candido, MD, and colleagues. Results were presented in a poster here at the 6th World Congress of the World Institute of Pain.

"We believe that it is not only a new indication, but it offers relief for individuals who were previously left to the devices of primary care physicians who really only have at their disposal the ability to prescribe narcotic analgesics," Dr. Candido, who is chair and professor in the Department of Anesthesiology at Advocate Illinois Masonic Medical Center in Chicago, told Medscape Medical News in an interview during the meeting.

Spinal cord stimulation is a well-established technique currently indicated for the management of failed back surgery syndrome, complex regional pain syndrome, inoperable peripheral vascular disease, and refractory angina pectoris, Dr. Candido and colleagues report.

To date, the team has used the technique in 6 patients with debilitating pain from HIV-related polyneuropathy. The first case is described in the poster.

The patient, a 50-year-old man with a 20-year history of HIV, was receiving highly active antiretroviral therapy (HAART). He had an 8-year history of "excruciating" pain.

"He had ongoing severe peripheral neuropathic pain and burning allodynia in both feet, primarily the plantar surfaces. He had not responded to conservative management, which had included high doses of opioid analgesics, anti-inflammatory medications, antiepileptic drugs, and other adjuvants such as peripheral nerve block therapies and epidural injections," said Dr. Candido.

The syndrome of HIV-related pain tends to have a distal "stocking" distribution in the lower extremities, similar to diabetic peripheral neuropathic pain, he explained. "It has been almost exclusively related to pain below the knees. It tends to be bilateral, and we suspect that the mechanism is similar to diabetic peripheral neuropathic pain, in that there is microvascular disruption either due to the virus attacking the vasculature or, alternatively, due to the HAART therapy, which may have a predisposition for the small blood vessels."

After the patient underwent a trial of temporary spinal cord stimulation, in which 2 eight-electrode leads were advanced into the dorsal epidural space and fluoroscopically guided to T9–T10, with good results, a permanent implant was placed.

"He has now had almost 2 years of reduction in his pain, from a constant level of about 8 out of 10 down to about 1 or 2 out of 10, and we've been able to wean him off his opiate analgesics," said Dr. Candido.

On the basis of this initial experience, 5 other HIV patients have received permanent implants, with similar success.

"The beauty of neuromodulation is that we can tailor therapy to the patient's individual symptoms. While I would say that we've used a lumbar approach and lower thoracic stimulators in all patients, clearly not every individual is exactly alike, so we choose our criteria very carefully and we select the actual placement of the stimulators based on the concordant response that we identify during the trial process. We've individualized it, but by and large every individual has responded favorably to T8 through T10 placement of these electrodes."

Dr. Candido explained that as HIV patients live longer because of HAART, the medical community must find pain relief options that are superior to opiate analgesics, which have the potential for extensive adverse effects, including nausea, vomiting, pruritis, constipation, urinary retention, and respiratory depression.

His group has also permanently implanted continuous intrathecal drug delivery systems in 4 HIV patients who did not want spinal cord stimulators.

"Dorsal column stimulation and/or intrathecal delivery of opioids and adjuvants proves to be the primary modality that we believe should be used as a first-line therapy once individuals are identified with this peripheral neuropathic pain process," he said.

Despite the immunocompromised state of HIV patients, he said no adverse events have been reported.

"We know that individuals who have compromised immune status are always predisposed to...infectious processes.... Infections are found in 1% to 2% of individuals who have a dorsal column stimulator, but...in almost two-and-a-half years, we have not identified any superficial or deep infections associated with the permanent implantation process."

Before proceeding, his group studied the orthopedic literature looking at infection rates among HIV patients with hip and knee replacements. "We haven't seen an increase in the incidence of infection in those individuals, so we extrapolated the orthopedic data to our own neurological/surgical population and found that it was logical and intuitive that we should also not have a high level of systemic infection or even localized infection if we took all the appropriate precautions."

Dr. Candido has disclosed no relevant financial relationships.

6th World Congress of the World Institute of Pain: Abstract 171. Presented February 5, 2012.

http://hepatitiscresearchandnewsupdates.blogspot.com/2012/02/spinal-cord-stimulation-effective-for.html

Is Spinal Cord Stimulation The Answer To Your Neuropathic Pain

Today's post from consultqd.clevelandclinic.org (see link below) discusses the use of spinal cord stimulation, via an implanted device similar to a pacemaker, to alleviate neuropathic pain. This article suggests that it is best suited to people who have had unsuccessful back surgery, or surgery which involves an attempted release of compressed nerves. However, either this or various other variations of electrical cord stimulation, are being used for other forms of neuropathic problems that result in the symptoms most of us share. You should be aware that this is not as simple a procedure as it sounds and is, after all, surgery, which always carries risks. However, depending on the type and severity of your neuropathic symptoms, this may be an option for you. First you need to do your own research carefully and avoid private clinics that offer exaggerated cure claims, like the plague. After that, an extensive discussion with your home doctor and/or neurologist would be very wise indeed but in the end the procedure remains an option. Insurance coverage may be a problem and you should always bear recovery time and the time needed to get used to the device, in mind. As already said, it's not as simple as it may sound but may be worth considering.
 

Spinal Cord Stimulation Is Effective For Chronic Neuropathic Pain By Andre Machado, MD, PhD; and Sean Nagel, MD

Often used for failed back surgery and complex regional pain syndromes

As shown by an increasing body of research, spinal cord stimulation (SCS) is a safe, efficacious, cost-effective and reversible treatment for select patients with severe chronic neuropathic pain.

SCS employs implanted epidural electrodes that deliver short-duration current or voltage pulses to excite sensory axons in the dorsal column. The precise mechanism of action of SCS remains unclear, and our understanding of chronic pain is incomplete. However, SCS is capable of interfering with the relay of non-nociceptive signals from the pain source, replacing painful sensation with more tolerable paresthesia and providing clinical improvement for some intractable pain syndromes affecting the extremities, with or without back involvement.
 
SCS Uses and System Details

In the United States, SCS is most frequently used in cases of failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS). SCS can alleviate axial and radicular pain, but is especially effective for patients with pain predominantly in the leg or arm. At Cleveland Clinic’s Center for Neurological Restoration, we have found the best candidates for this treatment generally are patients who experience persistent pain with neuropathic characteristics (often described as burning or aching), despite having undergone adequate decompressive surgery or spinal fusion.

The SCS system consists of one or more electrode leads connected to an implanted pulse generator similar to a pacemaker. We prefer to use rechargeable generators because of their longevity. Recharging is done at home — from several times per week to biweekly depending on battery size and individual patient electrical settings — by placing a charging device on the skin over the generator.

The SCS electrical leads, configured with four to 16 electrodes, are either cylindrical or paddle-shaped and are differentiated by their method of placement. Cylindrical (percutaneous) leads are implanted into the epidural space using large Tuohy needles, while paddle leads require a laminectomy or laminotomy. Though percutaneous leads are less invasive, paddle leads often are preferred because they are less prone to migrate and provide more efficient stimulation of the spinal cord.

Placement of the leads depends on the topography of the patient’s chronic pain. They are typically implanted in the mid or lower thoracic spine for patients with leg pain (with or without back pain), and in the middle or upper cervical areas for those with upper extremity pain.

Most patients undergo a psychological evaluation to help assess the probability of a successful outcome. Patients also undergo a test of the stimulation for one week with one or more externalized, percutaneously implanted leads connected to a pulse generator to determine the degree of analgesia and to assess if the patient tolerates stimulation well. A satisfactory response — generally a 50 percent or greater reduction in pain — is usually followed by permanent implantation.


 
Long-term Outcomes at Cleveland Clinic

Our experience in the Center for Neurological Restoration indicates that SCS’ effects seem to be long-lasting, as is patient satisfaction.

In 2011, we reported the results of a study evaluating the long-term outcomes of patients implanted with paddle lead SCS systems for FBSS or CRPS at our center between 1997 and 2008. The study assessed overall satisfaction with the therapy and correlated satisfaction with pain alleviation. We accomplished this by a retrospective chart review and a questionnaire survey to gauge present efficacy. We calculated pain reduction using pre- and postoperative scores on an 11-point visual analog scale (VAS). We also asked patients if they would undergo SCS implantation again if they were to have the same outcome.

Thirty-five patients participated in the study. More than 50 percent of those with CRPS reported greater than 50 percent pain relief at a mean follow-up of 4.4 years. Approximately 30 percent of the FBSS patients reported a 50 percent or greater improvement at a mean follow up of 3.8 years. Seventy-eight percent of patients with CRPS and 71 percent of patients with FBSS indicated they would undergo SCS surgery again for the same outcome. This disproportionately high degree of satisfaction suggests the VAS may not be the best way to measure long-term outcomes in these patients, and that improvements in quality of life may not be captured by this simplistic metric.

Our research found that patients implanted recently with SCS leads reported greater pain relief than those whose surgeries were earlier in the study period. This could represent a true decline in SCS efficacy over time, or alternatively may reflect the improvements in newer SCS equipment, with multichannel paddle leads and more programming features that may produce better outcomes than older systems.

A Multidisciplinary Approach to Pain Neuromodulation

At the Center for Neurological Restoration, we routinely implant SCS systems in patients with FBSS, CRPS and other chronic pain conditions. Our primary goal is to reduce pain-related disability and enable patients to be as active as possible. Our pain neuromodulation program has two specialized neurosurgeons and two full-time physician assistants. We strongly believe in a multidisciplinary approach to these complex disorders, and we routinely team with primary care, pain management, and physical medicine and rehabilitation physicians to provide long-term care. The best outcomes are likely achieved by pairing SCS with long-term physical therapy and rehabilitation.

Performed appropriately and in properly selected patients, SCS can be an effective therapy for managing refractory pain. Like other treatment options, however, it is not curative and should be combined with other modalities, especially physical therapy.

Dr. Machado is Director of Cleveland Clinic’s Center for Neurological Restoration. Dr. Nagel is an associate staff member of the Center for Neurological Restoration.

https://consultqd.clevelandclinic.org/2015/02/spinal-cord-stimulation-is-effective-for-chronic-neuropathic-pain/