Effect of tDCS in combination with TENS with exercises on pain in patients with upper limb radiculopathy
Description
Purpose: To find the combined effect of transcranial direct electrical stimulation and transcutaneous electrical nerve stimulation with an exercise intervention on pain in individuals with cervical radiculopathy. Method: 44 subjects (male:female=26:18) of age group 18-50 years were recruited and randomly allocated into two equal groups, experimental group and control group. Experimental group received active anodal tDCS for 20 min with an intensity of 2mA while control group received sham anodal tDCS. TENS over the pain distribution area for 20 min with 5 Hz intensity and 80-150 ms pulse duration followed by neck specific exercises were given in both groups. This protocol was given for 5 days in a week for 2 weeks. Pre and post assessment was obtained through outcome measures i.e. Numeric Pain Rating scale and Neck Disability Index for the measurement of pain, functional disability and quality of life. Result: Paired t test was used for within group analysis and it showed significant effect in both group (p=0.001). Independent t-test was used for between group analysis, showed effect was more profound in experimental group (p value =0.001 for NPRS and NDI). Conclusion: It was concluded that active tDCS along with TENS and exercise intervention was effective on pain, disability and quality of life patient with cervical radiculopathy.
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Experimental group received combination of active tDCS (2mA) and TENS (80-150ms) for 20 min. After that patient underwent exercise intervention under the supervision of therapist. Control group received sham-tDCS with placement of tDCS electrodes as that of experimental group but the current was allowed to flow for 2 minutes and then it was turned off in combination with TENS along with exercise intervention on same parameters as experimental group. Transcranial Direct Current Stimulation (tDCS) Step-1 First measure the distance from Nasion (Nz) to Inion (Iz) with measuring tape. Step-2 Measure from external Acoustic meatus from one side to another side & mark at the point of intersection at 50% of length Cz (centre point of vertex) at the point of intersection (step-1 & step-2) i.e. 50% of measured length is marked as Cz. Step- 3 Move 20% laterally each side from Cz to find C3 (left side) and C4 (right side). Step- 4 Measure head circumference at the level of Nz to Iz. Move 10% up from Nz to find Fpz and from Fpz move 5% each side to find Fp1 (left side) and Fp2 (right side). Step-5 Now we get the target areas C3, C4, Fp1and Fp2. Note: - Placement of electrodes was decided with the involvement of extremity. If Right side extremity was targeted then electrode placement was C3 and Fp2. If left extremity was targeted then electrode placement was C4 and Fp1. 10/20 EEG electrode placement system is reliable and valid method to measure the target area because it is individualized to each patient’s head size and shape.15,16 This method is more reliable as compare to EEG cap because that have fixed point for each electrode placement TENS After the assessment of nerve involvement through ULTT, TENS was applied over the dermatomal pattern of pain. Exercise intervention program: Patient was in supine position keeping neck in neutral by placing folded towel under occiput to maintain the neck in neutral position and therapist sitting at the head side of the patient. Patient was explained about the procedure: Instruction was given to the patient to press the towel by occiput and simultaneously performing chin depression. Patient should apply only 10% pressure of the head and hold the position for 10sec. and after that neck should be relaxed with the expiration. It should be hold for 10 sec. with 10 rep. twice a day. In the same position patient apply resistance over the temporal area bilaterally and perform isometric rotation of neck and repeat this exercise for 10 times on each side with same intensity and frequency as the previous exercise. Active range of motion of neck is performed for each movement flexion, extension, lateral flexion and rotation with 10 repetitions twice a day.