Episode 28 - Electrical Stimulation Devices for Back Pain
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Episode Summary
While COVID-19 has the headlines, for many, 2020 has also become synonymous with back pain. Working from home has cast many people from their ergonomic office chairs to couches, spare bedrooms, and dining room chairs.
On this episode, our Back Talk Doc, Dr. Sanjiv Lakhia, explores the benefits of utilizing electrical stimulation to combat those work-from-home back pains. Electrical stimulation, a form of neuromodulation, is essentially applying different types of electrical or electricity-based products and magnetic-based products to influence the physiology of your nervous system, that is, the brain, spinal cord, or peripheral nervous system. (3:46)
Dr. Lakhia identifies and briefly reviews three of the most common electrical stimulation devices.
1.TENS unit (4:50): TENS stands for transcutaneous electrical nerve stimulation and is available at any local pharmacy. The cost ranges from $50 to a couple of hundred dollars. The TENS unit stimulates the sensory nerves to block pain signals and generate endorphins. It is often used for the treatment of acute post-operative pain and chronic intractable pain.
The downside to TENS is that it provides very short-term relief, sometimes providing relief only while being used, with a maximum relief window of 3-4 hours.
2. Alpha-Stim (8:45): Alpha-Stim waveform electrotherapy is FDA approved for the treatment of chronic pain, anxiety, and depression and is one of the more well-researched neuromodulation devices for pain.
The Alpha-Stim works with small electrodes that clip to your earlobe and send a low microcurrent 0.5-hertz frequency wave through cranial nerve connections from the ear into the deep pain centers of the brain. This can stimulate the brainstem as well as the cortex and affect serotonin, norepinephrine, other neurotransmitter levels.
The Alpha-Stim can also be used with wand-like electrode probes that can be applied to each side of an affected area. The probes send quick electrical pulses to the area. The Alpha-Stim may also provide relief to patients suffering from insomnia and other back pain-related sleep problems.
The Alpha-Stim is available by prescription only.
3. H-Wave (15:42): H-Wave is a multi-functional electrical stimulation device intended to speed recovery, restore function, and manage chronic, acute, or post-operative pain.
The H-Wave delivers a low voltage current that promotes injury recovery and rehabilitation by stimulating muscles and can help prevent disuse atrophy.
The H-Wave can provide significant relief, and, like the Alpha-Stim, it appears that the benefits of H-Wave are cumulative and lasting. So, over time, you get better and better results the more you use it. And it's an alternative to the use of prescription pain medication. The typical session lasts around 30 to 60 minutes.
H-Wave is available both by prescription and offered as an OTC model.
For more information on Dr. Sanjiv Lakhia’s practice, visit BackTalkDoc.com
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
While COVID-19 has the headlines, for many, 2020 has also become synonymous with back pain. Working from home has cast many people from their ergonomic office chairs to couches, spare bedrooms, and dining room chairs.
On this episode, our Back Talk Doc, Dr. Sanjiv Lakhia, explores the benefits of utilizing electrical stimulation to combat those work-from-home back pains. Electrical stimulation, a form of neuromodulation, is essentially applying different types of electrical or electricity-based products and magnetic-based products to influence the physiology of your nervous system, that is, the brain, spinal cord, or peripheral nervous system. (3:46)
Dr. Lakhia identifies and briefly reviews three of the most common electrical stimulation devices.
1.TENS unit (4:50): TENS stands for transcutaneous electrical nerve stimulation and is available at any local pharmacy. The cost ranges from $50 to a couple of hundred dollars. The TENS unit stimulates the sensory nerves to block pain signals and generate endorphins. It is often used for the treatment of acute post-operative pain and chronic intractable pain.
The downside to TENS is that it provides very short-term relief, sometimes providing relief only while being used, with a maximum relief window of 3-4 hours.
2. Alpha-Stim (8:45): Alpha-Stim waveform electrotherapy is FDA approved for the treatment of chronic pain, anxiety, and depression and is one of the more well-researched neuromodulation devices for pain.
The Alpha-Stim works with small electrodes that clip to your earlobe and send a low microcurrent 0.5-hertz frequency wave through cranial nerve connections from the ear into the deep pain centers of the brain. This can stimulate the brainstem as well as the cortex and affect serotonin, norepinephrine, other neurotransmitter levels.
The Alpha-Stim can also be used with wand-like electrode probes that can be applied to each side of an affected area. The probes send quick electrical pulses to the area. The Alpha-Stim may also provide relief to patients suffering from insomnia and other back pain-related sleep problems.
The Alpha-Stim is available by prescription only.
3. H-Wave (15:42): H-Wave is a multi-functional electrical stimulation device intended to speed recovery, restore function, and manage chronic, acute, or post-operative pain.
The H-Wave delivers a low voltage current that promotes injury recovery and rehabilitation by stimulating muscles and can help prevent disuse atrophy.
The H-Wave can provide significant relief, and, like the Alpha-Stim, it appears that the benefits of H-Wave are cumulative and lasting. So, over time, you get better and better results the more you use it. And it's an alternative to the use of prescription pain medication. The typical session lasts around 30 to 60 minutes.
H-Wave is available both by prescription and offered as an OTC model.
For more information on Dr. Sanjiv Lakhia’s practice, visit BackTalkDoc.com
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Sponsor: 00:00
This podcast is sponsored by our partner, QxMD. QxMD builds mobile solutions that drive evidence-based medicine in clinical practice. Check out, Read for easy access to research, personalized for you and Calculate for over 500 easy to use decision support tools. Try them today at qxmd.com/apps. Again, that is qxmd.com/apps. This podcast is sponsored by our partner QxMD. QxMD builds mobile solutions that drive evidence-based medicine in clinical practice. Check out, Read for easy access to research, personalized for you and Calculate for over 500 easy to use decision support tools. Try them today at qxmd.com/apps. Again, that is qxmd.com/apps.
Intro: 01:00
Welcome. You are listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery And Spine Associates, where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here is your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 01:35
Hello, friends. Thank you for tuning into this episode of Back Talk Doc. I hope your 2020 is wrapping up in a great way. I know it's been a challenging time for many, but the holiday season is upon us and time for a little bit of reflection as we transition into the new year. But today, though, I want to touch on a topic that I encounter fairly often, at least a question that I encounter when it comes to a specific treatment modality for your low back pain, and that is the idea and the concept of electrical stimulation.
Sanjiv Lakhia: 02:11
Again, if you caught my last episode, where I went over some gift ideas for the holidays for back pain sufferers, as you know, there's so many gadgets, tools, devices, braces, just so many new emerging technologies that can potentially be helpful for treating back pain. And as we've discussed on previous episodes, chronic back pain is a massive burden to the country economically, and from a work perspective, billions of dollars of lost revenue and time off of work. Though every year you can expect new and new exciting things to come out on the market, and you might want to try them.
Sanjiv Lakhia: 02:51
So part of my job here on this podcast at the Back Talk Doc is I really try to bring together and synthesize different things that are out there, and analyze them from both a scientific mindset and then also a practicality perspective, so both from the doctor side and the patient side, and help y'all try and determine, well, what's the best thing for you?
Sanjiv Lakhia: 03:14
Obviously with back pain, it can be extremely difficult and challenging, and many times it requires surgery or requires injections. But one of the things in the United States that really has been a major problem in the last decade or so has been the use of opioids, of narcotic medicine, or opioids for the treatment of back pain has become a major problem. And there are multiple initiatives on both the federal level and a state level to empower doctors and patients to find alternatives.
Sanjiv Lakhia: 03:46
So that brings me to today's topic, again, which is electrical stimulation devices. And this fits under a broader category of neuromodulation. Neuromodulation is essentially the application of different types of electrical or electricity-based products and magnetic-based products to influence the physiology in your nervous system, that is the brain, spinal cord, or peripheral nervous system.
Sanjiv Lakhia: 04:12
Today I wanted to touch on a few of them that are well-known, they've been out there for quite a while. I've had some experience using them or prescribing them for patients. And I want to just share you some information on them as well as my general thoughts. Now, again, please, if you're listening to this, definitely you need to speak with your physician before you go out and purchase these products. And in fact, most of them you require a physician prescription, because like with any treatment, including even Tylenol, there's always upside and downside. So this is for informational purposes only, but I do want to get this information in your hands as you try and evaluate your treatment options.
Sanjiv Lakhia: 04:50
And the context that we'll use here today is really the application of electrical stimulation to low back pain with or without sciatic pain. In particular, muscular back pain is a very common indication for electrical stimulation devices, but also nerve pain. So number one, here, the most common electrical stimulation device that I've encountered is a TENS unit, and TEN, that's T-E-N-S, and it stands for transcutaneous electrical nerve stimulation.
Sanjiv Lakhia: 05:21
And this is something that's been around for decades. And it used to be covered by most commercial insurance plans. But several years ago, it dropped off Medicare coverage, and then most of the commercial providers followed suit. But you can go to just a local pharmacy and purchase one for yourself. And the cost range is anywhere from 50 bucks up to several hundred bucks. And as with most things in life, you get what you pay for.
Sanjiv Lakhia: 05:46
But a transcutaneous electrical nerve stimulator, it's a little box, almost the size of an oversized deck of cards. And all of these kind of look the same. They have a electrical box from which the wires come out and they connect with adhesives to your skin, little sticky electrode pads, as we call them. And from the TENS unit, electrical impulses are sent. And this is typically a battery powered pulse generator, and it sends the electrical signal through the skin.
Sanjiv Lakhia: 06:18
Scientifically, the TENS unit is characterized by biphasic current. And there are certain parameters, the intensity and the frequency of stimulation. What it really does is it stimulates the sensory nerves to block pain signals and generate endorphins. And it's often used for the treatment of acute postoperative pain and chronic intractable pain. This is the classic gate theory, the way it works. For example, if you were to stub your toe against the door or against your bed, the first thing that all of us intuitively would do would be to reach down and grab the toe and rub it really fast.
Sanjiv Lakhia: 06:58
And all you're doing there is the pressure sensation, it sends your signal to the spinal cord and ultimately the brain. And it's a faster signal than the pain signal. It can essentially block the gate of the electrical conduction and help reduce the pain. And this is how TENS unit works. It works off gate theory. It uses a rather strong electrical impulse, and it basically drowns out the pain signals.
Sanjiv Lakhia: 07:25
The way that you use this as to apply it locally to the site of pain or injury. So for example, you could have two electrodes on your lumbar paraspinal, we'll say around L5, and then two on the gluteal muscle. So it's a four electrode circuit. And you lay there with it on for about 20 to 30 minutes, and it will block the pain. It'll definitely turn off the pain signals. So the benefits of the TENS unit is that it can be an alternative to reaching for, let's say, a pain pill. You can use a TENS unit instead.
Sanjiv Lakhia: 07:56
The downside to the TENS unit is that it's very short-term relief, sometimes as little as the time you had it on, to as much as I've seen, maybe three to four hours. If you get three to four hours, that's pretty good, because then it can take the place of a hydrocodone or a pain medicine. That's somewhat unusual.
Sanjiv Lakhia: 08:14
The TENS units also are quite affordable. As we discussed, you can get these over the counter. Amazon certainly has them. You get what you pay for. I always recommend target somewhere around $100. And that ought to be a reasonably priced unit that is effective. Now you can spend 200, 300, $400 as well. And I don't know if you're going to get more quality for the money. Okay. So that's TENS units. And many of you listening probably have your own right now or have been prescribed it in the past.
Sanjiv Lakhia: 08:45
Beyond that, though, there's two other devices that are somewhat interesting and are worth the discussion. But let's touch on one that's called the Alpha Wave. Now the Alpha Wave has also been around for quite some time. I would say it's one of the more well-researched neuromodulation devices for pain, and the Alpha-Stim has multiple indications. It is FDA approved for the treatment of chronic pain, anxiety, and depression. It works differently than a TENS unit.
Sanjiv Lakhia: 09:19
How is that? Well, it has to do with the actual electrical wave, and that's really the distinguishing feature for most of the devices that you're going to encounter or talk about. The Alpha Wave, unlike a TENS unit... A TENS unit uses macrocurrent, meaning it uses basically a hammer current, lots of current. We block out the pain signals via the gate theory and you get the relief. Well, the Alpha-Stim uses what's called a microcurrent. And they have their patented 0.5 hertz wavelength frequency that they claim, the manufacturer claims, and then through a fairly robust medical literature that supports it, that it can really help reduce pain.
Sanjiv Lakhia: 10:05
And what's unique about this is the Alpha-Stim, it's named Alpha-Stim because it also comes with a component where you can run this microcurrent through the brain. It essentially comes with electrodes that are like earbuds, and they clip to your earlobe, and they send this low microcurrent 0.5 hertz frequency wave through cranial nerve connections from the ear into the deep pain centers of the brain. And this can stimulate the brainstem, it can stimulate the cortex and affect serotonin, norepinephrine, other neurotransmitter levels.
Sanjiv Lakhia: 10:46
So that's what's really unique about it. And that's why the Alpha-Stim has obtained an indication for the treatment of anxiety and depression. And this is something that I did get a practitioner certification in a few years ago and I prescribed it to some of my patients, mostly for the indication of treating pain in the body.
Sanjiv Lakhia: 11:06
Now, the other way you can use it is... There's two ways. It can kind of function like a TENS unit in that you have these adhesive electrodes and you can put them over the areas of pain, and run the unit as long as you need. You can even put it on and wear it during the workday under your clothes, and no one would really know. It's such a low intensity stimulation, it's hard to even feel it.
Sanjiv Lakhia: 11:28
The other way is it comes with these electrode probes, they're almost like sticks, where you can apply them. It's a set of sticks or wands, and you'd put them on each side of, let's say, the knee. You can put it on the medial and lateral aspect, and you send about a ten second pulse to stimulation. And Alpha-Stim gives you protocols on how to treat different things like back pain and sciatica and different joint pains. So that's really nice.
Sanjiv Lakhia: 11:57
And you can use it for a quick treatment versus having to have pads applied for 20 to 30 minutes. It can be very relaxing. It is certainly something worth looking at. The electrical component, though, that applies to the ears, the cranial electrical stimulation, is what's really... I think it's really fascinating. It induces in your brain... They have functional MRI studies that indicate when you do the cranial electrical stimulation component of this, it induces what's called an alpha brainwave state.
Sanjiv Lakhia: 12:32
And the alpha brainwave state, that's the state you're really trying to get into when you do parasympathetic exercises, whether it's deep breathing exercises, whether it's meditation, anything that you're trying to do to relax yourself, you're trying to take your brain from the awake beta state into the relaxed alpha state. So that's why it's called the Alpha-Stim. And through some of their own literature, they demonstrate significant reductions in pain, significant reductions in anxiety, significant reductions in depression.
Sanjiv Lakhia: 13:05
The other area where the Alpha-Stim can be quite helpful is with insomnia. And anyone who has back pain can really struggle with getting deep, restful sleep. So there are trainings where they talk about utilizing the Alpha-Stim maybe three to four hours before bed. And what's really cool about it is you really only have to wear it for about 20 minutes. You certainly can do it longer, but 20 minutes, and it builds on itself over time. The therapeutic benefit gets better and better over time.
Sanjiv Lakhia: 13:35
So that's why I think it's this really nice tool. It has a kind of a dual indication. You can treat the peripheral pain with the local probes, and then you can treat the central pain with the cranial electrical stimulation. And it can serve as a nice alternative to opioids or narcotics. Again, it's available by a physician's prescription only.
Sanjiv Lakhia: 13:56
There are a few things you got to watch out for with any electrical stimulation device. If you have a pacemaker, you probably want to stay away from it. Certainly if you have an active infection, you want to be careful. You don't want to apply these probes or devices over areas where there's active infection in a joint. That really wouldn't be a very good idea. So make sure you're working with a qualified provider when you're looking to purchase these products. You can go to their websites, literally, and fax a prescription, and they can send it to you. And then the cost information is there as well.
Sanjiv Lakhia: 14:26
So that's the Alpha-Stim. It's one that I have some experience with. I've used it personally, prescribed it professionally, side effect-wise, minimal. I think when you use the electrical Stim on the ears, the cranial component, it can give you a little bit of a vertigo-type sensation. So you have to use a very low intensity. And if you do suffer from vertigo, you want to be careful with that as well.
Sanjiv Lakhia: 14:49
If you use it on the body, there's really no side effects or abnormal symptoms that you're going to encounter. And again, this is something that's... I may have misspoke early. It's really been FDA cleared versus approved. So the device itself is very, very safe. And there's robust literature. I'll link in the show notes on the articles that are out there, and the medical literature on this, to give you a sense for how it's been studied.
Sanjiv Lakhia: 15:17
So we've covered the TENS unit. We've gone over the Alpha-Stim. One other thing, last thing on the Alpha-Stim, the other area where I've seen pretty good literature on it is in the military setting. The VA has a strong record of using and prescribing the Alpha-Stim for their vets with PTSD. So you'll encounter that, as well, if you go to their website and you take a look at that.
Sanjiv Lakhia: 15:42
Okay, so that's Alpha-Stim. Again, think macrocurrent, hammer, TENS unit, microcurrent, certainly much less, but potentially more powerful. And then the next one I want to talk about is the H-Wave, that's H as in Harry. And the H-Wave, again, is something that's been claimed to be very, very effective for pain, not just muscular pain, but also neuropathic pain or nerve pain. The H stands for the H-Wave or H-reflex, which is... It's a reflex that can be studied in electromyography. And when we'd study it with electromyography, we use a very low intensity stimulus to activate it. Hence, you can do that as well, potentially on a therapeutic level.
Sanjiv Lakhia: 16:30
So the H-Wave delivers a low voltage current, and it promotes injure recovery and rehabilitation by really inducing non-fatiguing muscular contractions that result in shifts in interstitial fluid. It is, in layman's terms, is a muscle stimulator, and that can really help prevent disuse atrophy. If, for example, say, you've had a total knee replacement surgery or if you've come off a lumbar fusion and you've got some atrophy and weakness in your glutes, in your back, H-Wave has a low frequency wave or current that can help prevent some of the muscle breakdown.
Sanjiv Lakhia: 17:06
So it eliminates accumulated proteins that are at the root of a lot of the pain and irritation, the lactic acidosis, all that can be kind of pushed out of the circulation. And it can stimulate... They have some research that it stimulates what's called angiogenesis or blood vessel growth on a capillary level. The nice thing about the H-Wave is that it, again, like the Alpha-Stim, it appears that the benefits are cumulative and lasting. So over time, you get better and better results the more you use it. And it's an alternative, as well, to the use of prescription pain medication.
Sanjiv Lakhia: 17:39
It does have also a second load, which they call a high frequency mode. And this is the one where you are really breaking the chronic pain cycle. The research shows, or researchers really believe that the H-Wave works by affecting the function of what's called a sodium pump within the nerve, and thereby creates a profound anesthetic and analgesic effect. And the pain relief is really quite significant. And the FDA has cleared the H-Wave for use as dental anesthesia. So unlike the TENS unit, these benefits can last long after the device is taken off. And the typical session's about 30 to 60 minutes.
Sanjiv Lakhia: 18:21
Where the H-Wave gains some popularity is that it was used, or has been used in the past, by Kobe Bryant's former trainer for the Lakers. Kobe used this for some of his injuries. And now it's used by several professional teams in the NBA. And if you go to their website, really, they're all about reducing pain and restoring function and limiting the amount of pain medicine that you need. And they really market towards post-operative care, but also can be used for chronic pain and injury.
Sanjiv Lakhia: 18:52
And the H-Wave, from an insurance basis, I have seen it covered some in the workers' comp world, but it is not covered in the commercial world, and neither is the Alpha-Stim. The research on this, also, they have a fair number of articles that are listed that are peer review studies on the H-Wave, and they're listed in Medline and indexed in PubMed. There's a meta-analysis that we can link to from 2008, where they basically determine the H-Wave device is an effective and safe non-pharmacologic analgesic for chronic pain. And I'll put that one in the show notes as well, that you can take a look at if you get a chance.
Sanjiv Lakhia: 19:28
So the H-Wave, I've had several of my patients use it, and it has... Clinically, I've seen really good things with it. The downside for the H- Wave is that insurance coverage is basically nonexistent and it is several thousand dollars, last time I checked, 4,000 to 6,000, and I think the Alpha- Stim is somewhere over $1,000. So these are not cheap, but if you look at it from a cost benefit analysis, particularly when you're looking and comparing it to chronic opioid use and other interventions, it can be cost-effective over the life of the unit. The challenge is most of you listening out there probably don't have that type of discretionary income to spend on it, but you can use something like your Flex Spending Account to get some coverage with it.
Sanjiv Lakhia: 20:22
Though it's one that I really like, I wish it was more accessible to people. Certainly consider prescribing it more if it was. But I just wanted to get it out there for you. We'll link to it in the show notes. If you're suffering from pain and injury, bring it up and talk with your provider about it and see if it's something that they can help you obtain.
Sanjiv Lakhia: 20:40
So we covered the TENS unit, we've covered the Alpha Stim and the H-Wave. Those two are the more commercial products that I wanted to talk about. There's a few other categories here that are worth mentioning. And folks, there's just a ton of different applications. We could do a two-hour webinar on the field of neuromodulation. The field is just explosive right now, for not just pain, but also for neurologic disorders, central nervous system disorders, dementia, seizures, epilepsy, autism. There's just so many different applications that are emerging in the medical literature.
Sanjiv Lakhia: 21:15
One category that I'm not going to talk about today is PEMF. That's P-E-M-F, that's pulse electromagnetic frequency stimulation. That's something that I might do a separate podcast on. But I pulled up a medical necessity criteria review from a commercial payer. And I just want to go over the different ones that are out there and touch on them just briefly here.
Sanjiv Lakhia: 21:37
So we touched on the TENS unit. There is neuromuscular electrical stimulation, and this is something that you might end up having done to you through physical therapy, particularly the neuromuscular NEMS, as we call it, is used quite a bit in post-operative total joint rehab. And it can really help build your muscles back up, similar to how the H-Wave has a muscle stimulator channel on it.
Sanjiv Lakhia: 22:02
There is also the idea of a auricular stimulation or P-Stem. This is a unique product that's out there on the market where, through the placement of needles into very specific auricular acupuncture points, there is some research showing that it can stimulate endorphin levels and help with pain. And that's how a lot of these work. There's the TENS units, the Alpha-Stim, they all work on some level on endorphins, stimulating endorphins in your body. And endorphins are your natural opioids, your natural painkillers. It's like your internal Walgreens or CVS, that if you can flip the switch, you can flood your bloodstream with the opioids, and certainly much safer than taking prescription medication.
Sanjiv Lakhia: 22:45
There's also the idea of functional neuromuscular stimulation. And this is applicable more in the neurologic rehab world, for example, stroke or spinal cord injury. And it's the idea that you can utilize electrical stimulation, where you attempt to replace damaged nerve pathways through the stimulation of muscle so individuals can walk independently. I've seen this used for foot drop therapy and also for stroke therapy.
Sanjiv Lakhia: 23:15
So there you have it. That is a general overview of the idea of using electrical stimulation to help with pain, and in particular back pain. TENS unit, I think is very low risk. It's a low entry point, and you can definitely pick one up for yourself and utilize it. Just make sure that if you have any implantable devices already, if you have a spinal cord stimulator, if you have a pacemaker, if you have a cardiac monitor, please make sure you check with your physician before you utilize this.
Sanjiv Lakhia: 23:44
The Alpha-Stim, it's a well-researched product on the market, indicated for pain and also some mental health aspects, as well as insomnia. It's one that I've used before, had good results with, the H-Wave, as well. It's a step up, so to speak, in cost and commitment. And it does have a little bit unique application in that they have some research that it can help with sciatic and nerve pain in particular. And then you have just a variety of different stimulating products on the market.
Sanjiv Lakhia: 24:14
The other one, I would say, that's very, very interesting, and it's a little bit, I guess, the Alpha-Stim uses a microcurrent, but there is frequency specific microcurrent. That's a whole nother area we can talk about. And I might do an episode where I have a guest on, and we talk about PEMF and frequency specific microcurrent as really an exciting area, where the research is showing some robust applications. And this was... Frequency specific microcurrent is what was used and made famous by Terrell Owens, and I think maybe even Hines Ward. Some of the football players have used it to have rapid healing responses.
Sanjiv Lakhia: 24:54
The one challenge, I would say, overall, though, with electrical stimulation and neuromodulation in general, is that large randomized controlled trials really aren't out there. There isn't a huge database. A lot of the evidence and literature is more scientific evidence. It's a Level C evidence, more anecdotal or case reports. It's just they're very expensive designed large scale trials.
Sanjiv Lakhia: 25:18
But I think when you take into account the scientific evidence that's there, we do know how it can influence neurotransmitter levels in the body. You look at the case reports, look at the Level C evidence and then the clinical feedback, and you couple that with the low risk and the high potential to reduce demand for pain medications, I think electrical stimulation and neuromodulation, in general, is here to stay. And it's a winner. And it's one that I hope you can explore in conversations with your providers. So thank you for listening today. And I hope everyone has a safe end to 2020 and a happy new year. I have some exciting things on tap for the coming year, and I look forward to speaking with you further.
Outro: 26:00
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
This podcast is sponsored by our partner, QxMD. QxMD builds mobile solutions that drive evidence-based medicine in clinical practice. Check out, Read for easy access to research, personalized for you and Calculate for over 500 easy to use decision support tools. Try them today at qxmd.com/apps. Again, that is qxmd.com/apps. This podcast is sponsored by our partner QxMD. QxMD builds mobile solutions that drive evidence-based medicine in clinical practice. Check out, Read for easy access to research, personalized for you and Calculate for over 500 easy to use decision support tools. Try them today at qxmd.com/apps. Again, that is qxmd.com/apps.
Intro: 01:00
Welcome. You are listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery And Spine Associates, where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here is your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 01:35
Hello, friends. Thank you for tuning into this episode of Back Talk Doc. I hope your 2020 is wrapping up in a great way. I know it's been a challenging time for many, but the holiday season is upon us and time for a little bit of reflection as we transition into the new year. But today, though, I want to touch on a topic that I encounter fairly often, at least a question that I encounter when it comes to a specific treatment modality for your low back pain, and that is the idea and the concept of electrical stimulation.
Sanjiv Lakhia: 02:11
Again, if you caught my last episode, where I went over some gift ideas for the holidays for back pain sufferers, as you know, there's so many gadgets, tools, devices, braces, just so many new emerging technologies that can potentially be helpful for treating back pain. And as we've discussed on previous episodes, chronic back pain is a massive burden to the country economically, and from a work perspective, billions of dollars of lost revenue and time off of work. Though every year you can expect new and new exciting things to come out on the market, and you might want to try them.
Sanjiv Lakhia: 02:51
So part of my job here on this podcast at the Back Talk Doc is I really try to bring together and synthesize different things that are out there, and analyze them from both a scientific mindset and then also a practicality perspective, so both from the doctor side and the patient side, and help y'all try and determine, well, what's the best thing for you?
Sanjiv Lakhia: 03:14
Obviously with back pain, it can be extremely difficult and challenging, and many times it requires surgery or requires injections. But one of the things in the United States that really has been a major problem in the last decade or so has been the use of opioids, of narcotic medicine, or opioids for the treatment of back pain has become a major problem. And there are multiple initiatives on both the federal level and a state level to empower doctors and patients to find alternatives.
Sanjiv Lakhia: 03:46
So that brings me to today's topic, again, which is electrical stimulation devices. And this fits under a broader category of neuromodulation. Neuromodulation is essentially the application of different types of electrical or electricity-based products and magnetic-based products to influence the physiology in your nervous system, that is the brain, spinal cord, or peripheral nervous system.
Sanjiv Lakhia: 04:12
Today I wanted to touch on a few of them that are well-known, they've been out there for quite a while. I've had some experience using them or prescribing them for patients. And I want to just share you some information on them as well as my general thoughts. Now, again, please, if you're listening to this, definitely you need to speak with your physician before you go out and purchase these products. And in fact, most of them you require a physician prescription, because like with any treatment, including even Tylenol, there's always upside and downside. So this is for informational purposes only, but I do want to get this information in your hands as you try and evaluate your treatment options.
Sanjiv Lakhia: 04:50
And the context that we'll use here today is really the application of electrical stimulation to low back pain with or without sciatic pain. In particular, muscular back pain is a very common indication for electrical stimulation devices, but also nerve pain. So number one, here, the most common electrical stimulation device that I've encountered is a TENS unit, and TEN, that's T-E-N-S, and it stands for transcutaneous electrical nerve stimulation.
Sanjiv Lakhia: 05:21
And this is something that's been around for decades. And it used to be covered by most commercial insurance plans. But several years ago, it dropped off Medicare coverage, and then most of the commercial providers followed suit. But you can go to just a local pharmacy and purchase one for yourself. And the cost range is anywhere from 50 bucks up to several hundred bucks. And as with most things in life, you get what you pay for.
Sanjiv Lakhia: 05:46
But a transcutaneous electrical nerve stimulator, it's a little box, almost the size of an oversized deck of cards. And all of these kind of look the same. They have a electrical box from which the wires come out and they connect with adhesives to your skin, little sticky electrode pads, as we call them. And from the TENS unit, electrical impulses are sent. And this is typically a battery powered pulse generator, and it sends the electrical signal through the skin.
Sanjiv Lakhia: 06:18
Scientifically, the TENS unit is characterized by biphasic current. And there are certain parameters, the intensity and the frequency of stimulation. What it really does is it stimulates the sensory nerves to block pain signals and generate endorphins. And it's often used for the treatment of acute postoperative pain and chronic intractable pain. This is the classic gate theory, the way it works. For example, if you were to stub your toe against the door or against your bed, the first thing that all of us intuitively would do would be to reach down and grab the toe and rub it really fast.
Sanjiv Lakhia: 06:58
And all you're doing there is the pressure sensation, it sends your signal to the spinal cord and ultimately the brain. And it's a faster signal than the pain signal. It can essentially block the gate of the electrical conduction and help reduce the pain. And this is how TENS unit works. It works off gate theory. It uses a rather strong electrical impulse, and it basically drowns out the pain signals.
Sanjiv Lakhia: 07:25
The way that you use this as to apply it locally to the site of pain or injury. So for example, you could have two electrodes on your lumbar paraspinal, we'll say around L5, and then two on the gluteal muscle. So it's a four electrode circuit. And you lay there with it on for about 20 to 30 minutes, and it will block the pain. It'll definitely turn off the pain signals. So the benefits of the TENS unit is that it can be an alternative to reaching for, let's say, a pain pill. You can use a TENS unit instead.
Sanjiv Lakhia: 07:56
The downside to the TENS unit is that it's very short-term relief, sometimes as little as the time you had it on, to as much as I've seen, maybe three to four hours. If you get three to four hours, that's pretty good, because then it can take the place of a hydrocodone or a pain medicine. That's somewhat unusual.
Sanjiv Lakhia: 08:14
The TENS units also are quite affordable. As we discussed, you can get these over the counter. Amazon certainly has them. You get what you pay for. I always recommend target somewhere around $100. And that ought to be a reasonably priced unit that is effective. Now you can spend 200, 300, $400 as well. And I don't know if you're going to get more quality for the money. Okay. So that's TENS units. And many of you listening probably have your own right now or have been prescribed it in the past.
Sanjiv Lakhia: 08:45
Beyond that, though, there's two other devices that are somewhat interesting and are worth the discussion. But let's touch on one that's called the Alpha Wave. Now the Alpha Wave has also been around for quite some time. I would say it's one of the more well-researched neuromodulation devices for pain, and the Alpha-Stim has multiple indications. It is FDA approved for the treatment of chronic pain, anxiety, and depression. It works differently than a TENS unit.
Sanjiv Lakhia: 09:19
How is that? Well, it has to do with the actual electrical wave, and that's really the distinguishing feature for most of the devices that you're going to encounter or talk about. The Alpha Wave, unlike a TENS unit... A TENS unit uses macrocurrent, meaning it uses basically a hammer current, lots of current. We block out the pain signals via the gate theory and you get the relief. Well, the Alpha-Stim uses what's called a microcurrent. And they have their patented 0.5 hertz wavelength frequency that they claim, the manufacturer claims, and then through a fairly robust medical literature that supports it, that it can really help reduce pain.
Sanjiv Lakhia: 10:05
And what's unique about this is the Alpha-Stim, it's named Alpha-Stim because it also comes with a component where you can run this microcurrent through the brain. It essentially comes with electrodes that are like earbuds, and they clip to your earlobe, and they send this low microcurrent 0.5 hertz frequency wave through cranial nerve connections from the ear into the deep pain centers of the brain. And this can stimulate the brainstem, it can stimulate the cortex and affect serotonin, norepinephrine, other neurotransmitter levels.
Sanjiv Lakhia: 10:46
So that's what's really unique about it. And that's why the Alpha-Stim has obtained an indication for the treatment of anxiety and depression. And this is something that I did get a practitioner certification in a few years ago and I prescribed it to some of my patients, mostly for the indication of treating pain in the body.
Sanjiv Lakhia: 11:06
Now, the other way you can use it is... There's two ways. It can kind of function like a TENS unit in that you have these adhesive electrodes and you can put them over the areas of pain, and run the unit as long as you need. You can even put it on and wear it during the workday under your clothes, and no one would really know. It's such a low intensity stimulation, it's hard to even feel it.
Sanjiv Lakhia: 11:28
The other way is it comes with these electrode probes, they're almost like sticks, where you can apply them. It's a set of sticks or wands, and you'd put them on each side of, let's say, the knee. You can put it on the medial and lateral aspect, and you send about a ten second pulse to stimulation. And Alpha-Stim gives you protocols on how to treat different things like back pain and sciatica and different joint pains. So that's really nice.
Sanjiv Lakhia: 11:57
And you can use it for a quick treatment versus having to have pads applied for 20 to 30 minutes. It can be very relaxing. It is certainly something worth looking at. The electrical component, though, that applies to the ears, the cranial electrical stimulation, is what's really... I think it's really fascinating. It induces in your brain... They have functional MRI studies that indicate when you do the cranial electrical stimulation component of this, it induces what's called an alpha brainwave state.
Sanjiv Lakhia: 12:32
And the alpha brainwave state, that's the state you're really trying to get into when you do parasympathetic exercises, whether it's deep breathing exercises, whether it's meditation, anything that you're trying to do to relax yourself, you're trying to take your brain from the awake beta state into the relaxed alpha state. So that's why it's called the Alpha-Stim. And through some of their own literature, they demonstrate significant reductions in pain, significant reductions in anxiety, significant reductions in depression.
Sanjiv Lakhia: 13:05
The other area where the Alpha-Stim can be quite helpful is with insomnia. And anyone who has back pain can really struggle with getting deep, restful sleep. So there are trainings where they talk about utilizing the Alpha-Stim maybe three to four hours before bed. And what's really cool about it is you really only have to wear it for about 20 minutes. You certainly can do it longer, but 20 minutes, and it builds on itself over time. The therapeutic benefit gets better and better over time.
Sanjiv Lakhia: 13:35
So that's why I think it's this really nice tool. It has a kind of a dual indication. You can treat the peripheral pain with the local probes, and then you can treat the central pain with the cranial electrical stimulation. And it can serve as a nice alternative to opioids or narcotics. Again, it's available by a physician's prescription only.
Sanjiv Lakhia: 13:56
There are a few things you got to watch out for with any electrical stimulation device. If you have a pacemaker, you probably want to stay away from it. Certainly if you have an active infection, you want to be careful. You don't want to apply these probes or devices over areas where there's active infection in a joint. That really wouldn't be a very good idea. So make sure you're working with a qualified provider when you're looking to purchase these products. You can go to their websites, literally, and fax a prescription, and they can send it to you. And then the cost information is there as well.
Sanjiv Lakhia: 14:26
So that's the Alpha-Stim. It's one that I have some experience with. I've used it personally, prescribed it professionally, side effect-wise, minimal. I think when you use the electrical Stim on the ears, the cranial component, it can give you a little bit of a vertigo-type sensation. So you have to use a very low intensity. And if you do suffer from vertigo, you want to be careful with that as well.
Sanjiv Lakhia: 14:49
If you use it on the body, there's really no side effects or abnormal symptoms that you're going to encounter. And again, this is something that's... I may have misspoke early. It's really been FDA cleared versus approved. So the device itself is very, very safe. And there's robust literature. I'll link in the show notes on the articles that are out there, and the medical literature on this, to give you a sense for how it's been studied.
Sanjiv Lakhia: 15:17
So we've covered the TENS unit. We've gone over the Alpha-Stim. One other thing, last thing on the Alpha-Stim, the other area where I've seen pretty good literature on it is in the military setting. The VA has a strong record of using and prescribing the Alpha-Stim for their vets with PTSD. So you'll encounter that, as well, if you go to their website and you take a look at that.
Sanjiv Lakhia: 15:42
Okay, so that's Alpha-Stim. Again, think macrocurrent, hammer, TENS unit, microcurrent, certainly much less, but potentially more powerful. And then the next one I want to talk about is the H-Wave, that's H as in Harry. And the H-Wave, again, is something that's been claimed to be very, very effective for pain, not just muscular pain, but also neuropathic pain or nerve pain. The H stands for the H-Wave or H-reflex, which is... It's a reflex that can be studied in electromyography. And when we'd study it with electromyography, we use a very low intensity stimulus to activate it. Hence, you can do that as well, potentially on a therapeutic level.
Sanjiv Lakhia: 16:30
So the H-Wave delivers a low voltage current, and it promotes injure recovery and rehabilitation by really inducing non-fatiguing muscular contractions that result in shifts in interstitial fluid. It is, in layman's terms, is a muscle stimulator, and that can really help prevent disuse atrophy. If, for example, say, you've had a total knee replacement surgery or if you've come off a lumbar fusion and you've got some atrophy and weakness in your glutes, in your back, H-Wave has a low frequency wave or current that can help prevent some of the muscle breakdown.
Sanjiv Lakhia: 17:06
So it eliminates accumulated proteins that are at the root of a lot of the pain and irritation, the lactic acidosis, all that can be kind of pushed out of the circulation. And it can stimulate... They have some research that it stimulates what's called angiogenesis or blood vessel growth on a capillary level. The nice thing about the H-Wave is that it, again, like the Alpha-Stim, it appears that the benefits are cumulative and lasting. So over time, you get better and better results the more you use it. And it's an alternative, as well, to the use of prescription pain medication.
Sanjiv Lakhia: 17:39
It does have also a second load, which they call a high frequency mode. And this is the one where you are really breaking the chronic pain cycle. The research shows, or researchers really believe that the H-Wave works by affecting the function of what's called a sodium pump within the nerve, and thereby creates a profound anesthetic and analgesic effect. And the pain relief is really quite significant. And the FDA has cleared the H-Wave for use as dental anesthesia. So unlike the TENS unit, these benefits can last long after the device is taken off. And the typical session's about 30 to 60 minutes.
Sanjiv Lakhia: 18:21
Where the H-Wave gains some popularity is that it was used, or has been used in the past, by Kobe Bryant's former trainer for the Lakers. Kobe used this for some of his injuries. And now it's used by several professional teams in the NBA. And if you go to their website, really, they're all about reducing pain and restoring function and limiting the amount of pain medicine that you need. And they really market towards post-operative care, but also can be used for chronic pain and injury.
Sanjiv Lakhia: 18:52
And the H-Wave, from an insurance basis, I have seen it covered some in the workers' comp world, but it is not covered in the commercial world, and neither is the Alpha-Stim. The research on this, also, they have a fair number of articles that are listed that are peer review studies on the H-Wave, and they're listed in Medline and indexed in PubMed. There's a meta-analysis that we can link to from 2008, where they basically determine the H-Wave device is an effective and safe non-pharmacologic analgesic for chronic pain. And I'll put that one in the show notes as well, that you can take a look at if you get a chance.
Sanjiv Lakhia: 19:28
So the H-Wave, I've had several of my patients use it, and it has... Clinically, I've seen really good things with it. The downside for the H- Wave is that insurance coverage is basically nonexistent and it is several thousand dollars, last time I checked, 4,000 to 6,000, and I think the Alpha- Stim is somewhere over $1,000. So these are not cheap, but if you look at it from a cost benefit analysis, particularly when you're looking and comparing it to chronic opioid use and other interventions, it can be cost-effective over the life of the unit. The challenge is most of you listening out there probably don't have that type of discretionary income to spend on it, but you can use something like your Flex Spending Account to get some coverage with it.
Sanjiv Lakhia: 20:22
Though it's one that I really like, I wish it was more accessible to people. Certainly consider prescribing it more if it was. But I just wanted to get it out there for you. We'll link to it in the show notes. If you're suffering from pain and injury, bring it up and talk with your provider about it and see if it's something that they can help you obtain.
Sanjiv Lakhia: 20:40
So we covered the TENS unit, we've covered the Alpha Stim and the H-Wave. Those two are the more commercial products that I wanted to talk about. There's a few other categories here that are worth mentioning. And folks, there's just a ton of different applications. We could do a two-hour webinar on the field of neuromodulation. The field is just explosive right now, for not just pain, but also for neurologic disorders, central nervous system disorders, dementia, seizures, epilepsy, autism. There's just so many different applications that are emerging in the medical literature.
Sanjiv Lakhia: 21:15
One category that I'm not going to talk about today is PEMF. That's P-E-M-F, that's pulse electromagnetic frequency stimulation. That's something that I might do a separate podcast on. But I pulled up a medical necessity criteria review from a commercial payer. And I just want to go over the different ones that are out there and touch on them just briefly here.
Sanjiv Lakhia: 21:37
So we touched on the TENS unit. There is neuromuscular electrical stimulation, and this is something that you might end up having done to you through physical therapy, particularly the neuromuscular NEMS, as we call it, is used quite a bit in post-operative total joint rehab. And it can really help build your muscles back up, similar to how the H-Wave has a muscle stimulator channel on it.
Sanjiv Lakhia: 22:02
There is also the idea of a auricular stimulation or P-Stem. This is a unique product that's out there on the market where, through the placement of needles into very specific auricular acupuncture points, there is some research showing that it can stimulate endorphin levels and help with pain. And that's how a lot of these work. There's the TENS units, the Alpha-Stim, they all work on some level on endorphins, stimulating endorphins in your body. And endorphins are your natural opioids, your natural painkillers. It's like your internal Walgreens or CVS, that if you can flip the switch, you can flood your bloodstream with the opioids, and certainly much safer than taking prescription medication.
Sanjiv Lakhia: 22:45
There's also the idea of functional neuromuscular stimulation. And this is applicable more in the neurologic rehab world, for example, stroke or spinal cord injury. And it's the idea that you can utilize electrical stimulation, where you attempt to replace damaged nerve pathways through the stimulation of muscle so individuals can walk independently. I've seen this used for foot drop therapy and also for stroke therapy.
Sanjiv Lakhia: 23:15
So there you have it. That is a general overview of the idea of using electrical stimulation to help with pain, and in particular back pain. TENS unit, I think is very low risk. It's a low entry point, and you can definitely pick one up for yourself and utilize it. Just make sure that if you have any implantable devices already, if you have a spinal cord stimulator, if you have a pacemaker, if you have a cardiac monitor, please make sure you check with your physician before you utilize this.
Sanjiv Lakhia: 23:44
The Alpha-Stim, it's a well-researched product on the market, indicated for pain and also some mental health aspects, as well as insomnia. It's one that I've used before, had good results with, the H-Wave, as well. It's a step up, so to speak, in cost and commitment. And it does have a little bit unique application in that they have some research that it can help with sciatic and nerve pain in particular. And then you have just a variety of different stimulating products on the market.
Sanjiv Lakhia: 24:14
The other one, I would say, that's very, very interesting, and it's a little bit, I guess, the Alpha-Stim uses a microcurrent, but there is frequency specific microcurrent. That's a whole nother area we can talk about. And I might do an episode where I have a guest on, and we talk about PEMF and frequency specific microcurrent as really an exciting area, where the research is showing some robust applications. And this was... Frequency specific microcurrent is what was used and made famous by Terrell Owens, and I think maybe even Hines Ward. Some of the football players have used it to have rapid healing responses.
Sanjiv Lakhia: 24:54
The one challenge, I would say, overall, though, with electrical stimulation and neuromodulation in general, is that large randomized controlled trials really aren't out there. There isn't a huge database. A lot of the evidence and literature is more scientific evidence. It's a Level C evidence, more anecdotal or case reports. It's just they're very expensive designed large scale trials.
Sanjiv Lakhia: 25:18
But I think when you take into account the scientific evidence that's there, we do know how it can influence neurotransmitter levels in the body. You look at the case reports, look at the Level C evidence and then the clinical feedback, and you couple that with the low risk and the high potential to reduce demand for pain medications, I think electrical stimulation and neuromodulation, in general, is here to stay. And it's a winner. And it's one that I hope you can explore in conversations with your providers. So thank you for listening today. And I hope everyone has a safe end to 2020 and a happy new year. I have some exciting things on tap for the coming year, and I look forward to speaking with you further.
Outro: 26:00
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.