US Pharm. 2014:39(3):22-24.
Chronic pain, once thought of as something more
psychological than physiological, is now better understood because
clinicians and pain specialists comprehend more fully how pain and its
sensations work at the level of the nervous system. The feeling of pain
stimulates a myriad of emotions, but has its basis in the peripheral
nervous system and spinal cord and how both interact with the brain to
create the actual sensation of pain. The action of neurotransmitters,
the chemical messengers that pass nerve signals, suggests possible new
modalities to relieve pain, particularly regarding mechanisms to
redirect the chemical messengers to modulate the way the brain interacts
with the signals.
Opioids, antidepressants, and other drugs that work with
specific brain chemicals, such as dopamine, that affect emotions and
influence the perception of pain have been the mainstay of pain
treatment. However, pain specialists can now prescribe treatments that
attack moderate-to-severe chronic pain from different angles using
targeted electromedical modalities, such as spinal cord stimulators,
electroanalgesic delivery systems, and pulsed radiofrequency therapies,
which will be the focus of this article. These technologies have the
added advantage of being nonaddictive and drug-free, eliminating drug
interactions and minimizing the potential for medical errors, side
effects and overdose. New technologies being employed for pain relief
also support patients who are being weaned off narcotics.
The use of electrical signals for various
medical treatments has been documented in historical records as early
as 2750 BC, with reference to the electrical properties and treatment
potential of the Nile catfish Malopterurus electricus.1
In more recent historical periods, even Benjamin Franklin documented
pain relief by using electrical currents for a number of ailments,
including frozen shoulder.1
While prescription medications are still the mainstay of
pain relief and can be prescribed using e-prescribing technology in some
states, innovative technologies are now being considered to synergize
and sometimes replace these therapies.2 Today, the clinical use of electro-medical modalities in both diagnosis and treatment is well
documented, with references demonstrating the positive effects on
patients for a myriad of medical conditions such as chronic sciatica,
pain related to peripheral vascular disease, failed back surgery
syndrome, or complex regional pain syndrome.3
While these modalities differ in their delivery
mechanisms, they essentially do the same thing by using electrical
signals sent to the brain to interrupt and/or block sensations of pain.
Several devices, such as the trans cutaneous electrical nerve
stimulation (TENS) unit, have the support of the FDA, Medicare, and even
the insurance industry, creating a path for coverage and thus
accessibility for patient use.4
Spinal Cord Stimulators
Spinal cord stimulators are innovative
devices implanted in the back; they are very compact—the typical size is
as small as a silver dollar. The device is inserted in fatty tissue in
the lower back and the electrodes are inserted into the spinal canal
(see FIGURE 1
below). When in operation, the system sends signals to the spinal cord that redirect the brain to avoid registering pain.5
The patient can turn the device on and off and can control the
frequency of the actual signals with a remote controller similar to a
garage opener. The technology “tricks” the brain into feeling good
sensations rather than bad. This device is usually reserved for those in
constant and persistent pain, such as might occur with such diagnoses
as severe back injuries, shingles, or other chronic pain syndromes, who
have otherwise exhausted their options. It also relies on surgical
implantation, so a patient does run added risk of complications from the
surgery such as infection, bleeding, and paralysis.5
Electroanalgesic Delivery System
Electroanalgesic delivery system treatments involve the
use of computer-modulated electronic signals that extinguish or block
the function of somatic or sympathetic pain nerve fibers. An
electroanalgesic medical device (EAD) is used to produce and deliver
high-frequency signal energy using a computer algorithm that continually
generates a varying sequential and random pattern interrupting nerve
axon transport of pain signals; the signal is delivered via specialty
electrodes.6 The signal energy incorporated by the EAD has a
much higher electrical frequency than the standard TENS technology,
which relies on amplitude modulation (AM) of a lower frequency
electrical current being
delivered to the body. The
TENS technology is similar to the familiar concept of AM radio waves.
EAD technology, on the other hand, delivers electrical signal current to
the body as amplitude-modulated (AM) current in combination with
frequency-modulated (FM) current. This would be like
an AM and FM radio station, and it results in a much more complex
pattern of current. This complex pattern is so variable that the nervous
system cannot accommodate it, and the pain nerves are essentially shut
down. EADs appear to be very potent in their ability to mitigate,
reduce, or quench acute and/or chronic intractable pain conditions, and
are more effective than the older TENS technology. Effectiveness of
electroanalgesia nerve blocks at sympathetic ganglia may be as high as
75%, with very little risk.7
Pulsed radiofrequency (PRF) is a novel
therapeutic modality with many potential applications in pain
management. PRF is a more sophisticated variation of conventional
continuous radiofrequency (CRF), which has been in use since the
mid-1970s. CRF causes localized heating of tissue and results in very
controlled tissue destruction. PRF offers the advantage of pain control
but without associated tissue destruction or other undesirable and
painful sequelae associated with CRF.8
Although very promising, PRF is still in its developmental
stage. PRF relies more on modulating the electrical or magnetic field
without generating excessively destructive thermal/heating effects. It
appears that PRF is at least a hundredfold less destructive than CRF.
This theoretical benefit of PRF is especially promising in cases of
intrinsic neuron-generated (neuropathic) pain in which CRF is relatively
The mechanism by which PRF controls pain
is unclear, but it may involve a temperature-independent pathway
mediated by rapidly changing electrical and/or magnetic fields that are
thought to modulate the transmission of pain signals.8
Although much anecdotal evidence exists in favor of PRF,
there are few quality studies substantiating its utility or exploring
the efficacy of PRF in treating pain. Additionally, most reports are
retrospective in nature and involve only small patient cohorts. The bulk
of PRF research has been conducted in patients with axial low back
pain; however, in recent years, PRF has been studied in a wider range of
The Role of EHRs
Finally, the use of an electronic health
record (EHR) can be useful for capturing data and seamlessly delivering
it to the clinician who is taking care of a patient living with chronic
pain. Any pain management practice is fraught with complexities,
including care plans involving not only innovative technologies but also
pharmacologicl treatments, interventional procedures, or alternative
therapy. Ensuring that an EHR can support these elements is essential to
achieving efficient and reliable quality of care.
It is, however, very important to chose the correct EHR
for a pain management program. Some features to look for in an EHR for a
pain management practice include the following:
Customized care plans with
easy import of data from various sources to demonstrate patient pain
improvement over time. These are vital to support pain management
programs. Many care plans support these electronic therapeutic
modalities and are already pre-formatted and fully customizable for
various treatment objectives and goals regarding a specific diagnosis.
Flow sheet capabilities. Flow sheets allow
clinicians to review current and past treatments and any laboratory
results. Having the ability to review therapies that worked and those
that were not successful helps determine the most appropriate care
pathway for a patient experiencing pain.
Ability to print controlled substance prescriptions
onto state-regulated printing paper. This is helpful for pain
specialists, who prescribe controlled substances and would e-prescribe
them as well if possible.2
Communication with other care providers,
such as the oncologist or the primary care physician, is also critical
for coordination of care and is an element of Meaningful Use stage 2.
The Meaningful Use program is a Medicare and Medicaid program that
provides incentive dollars to providers for the adoption and meaningful
use of certified EHRs. Electronic communication of care plans between
providers can be accomplished via a health information exchange (HIE), a
network allowing EHRs to seamlessly exchange information. When an HIE
is not available, the care plan can be transmitted via the Nationwide
Health Information Network Direct protocol, which is essentially a form
of encrypted e-mail between providers. From a governmental and
reimbursement perspective, supporting Meaningful Use stage 2 is vital
and requires documentation in each encounter.9
Pain is a universal experience, whether it results from
injury or the effects of a disease state. The experience of chronic
pain, however, is an enduring challenge, causing in most instances
severe debilitation if not effectively treated. Having novel approaches
besides the basic pharmacologic modalities can add a dimension of
therapeutic support to the clinician who seeks to stabilize a patient’s
1. Kellaway P. The part played by electric fish in the early history of bioelectricity and electrotherapy. Bull Hist Med. 1946;20:112-132.
2. Figge H. Technology support for pain management: e-prescribing controlled substances. US Pharm. 2013;8(6):HS6-HS9.
3. Woessner J. Electric nerve blocks. In: Boswell M, Cole B, eds. Weiner’s Pain Management: A Practical Guide for Clinicians. Boca Raton, FL: CRC Press; 2006:1233-1242.
4. Center for Medicare and Medicaid Services.
coverage of durable medical equipment and other devices. December 2008.
Accessed January 14, 2014.
5. Cameron T. Safety and efficacy of spinal cord stimulation for the treatment of chronic pain. A 20-year literature review. J Neurosurg. 2004; 100(3, suppl Spine):254-267.
6. Woessner J. Blocking out the pain: electric nerve block treatments for sciatic neuritis. Pract Pain Manage. 2002;2:19-26.
7. Schwartz RG. Electric sympathetic block: current theoretical concepts and clinical results. J. Back and Musculoskeletal Rehab. 1998;10:31-46.
8. Byrd D, Mackey S. Pulsed radiofrequency for chronic pain. Curr Pain Headache Rep. 2008;12:37-41.
9. CMS.gov. Centers for Medicare and Medicaid Services.
Regulations and guidance. EHR incentive program. Stage 2. Updated
December 6, 2013.
Accessed February 14, 2014.
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