Cranial Electrotherapy Stimulation (CES) has a
growing history of applications in rehabilitation medicine in the
United States dating back to early 1970. As a recognized non-drug
treatment of anxiety, depression and insomnia, CES gained its first
major application in the field of addiction treatment and
rehabilitation. By the mid 1980s research was showing additional
important uses of CES in the treatment of closed head injured
patients, and in paraplegic and quadriplegic patients. The most recent
research is showing CES to be highly effective in the management of
chronic pain patients. It may be elevating the pain threshold due to
its stress reducing effects when anxiety and depression are reduced
below clinical levels. Modern theorists of a pain neuromatrix in the
cerebral cortex may provide an additional basis for understanding CES
mechanisms in the control of pain related disorders.
1. Introduction
Cranial Electrotherapy Stimulation (CES) is the application of a small
amount of current, usually less than one milliampere, through the head
via car clip electrodes. It came to the United States in the late
1960s under the rubric "electrosleep". It had been developed in the
U.S.S.R. in 1954, and quickly spread throughout the former Eastern
Bloc, then into Europe and most of the West. It was already in use in
Japan when it finally arrived in the US in the 1960s. By the late
1960s, it was being researched in both animal and human subjects at
several US university medical schools, including the University of
Texas at San Antonio, the University of Wisconsin, and the University
of Tennessee [1-3]. Major research reviews in 1980 [4], and again in
1999 [5] summarized the progress of CES in American medicine.
2. Research in rehabilitation medicine |
2.1. Rehabilitation of addicted persons
The first research and subsequent use of CES in re-habilitation
medicine began in the early 1970s, when research reports began coming
out of the District of Columbia's 600 bed inpatient Rehabilitation
Center for Alcoholics [61, and Veterans Administration Hospitals
[7,8]. Following the publication of its two double-blind,
placebo-controlled studies [9,10], the CompCare Corporation, then the
largest rehabilitation facility in the US, if not in the world, with
approximately 120 inpatient rehabilitation facilities for addiction
patients, plus those with eating disorders, made the decision to put
CES into their core treatment program throughout the nation.
Unfortunately, there was no manufacturer of CES devices available at
the time that could supply that heavy a demand for product so the
plans had to be abandoned. It continued to be used in addiction
treatment, however, with many facilities in both CompCare and other
major addiction treatment chains making wide use of CES in their
clinical treatment protocols.
2.2. The use of CES in paraplegic and quadriplegic patients
Wharton and his coworkers presented their paper "Effects of CES
therapy on spinal cord injured patients" at the annual meeting of the
American Spinal Injury Association in New York in 1982. They had
completed a double-blind study of the use of CES with paraplegics and
quadriplegics who were in an inpatient rehabilitation program in
Dallas. Patients were given either suhsensation level CES or sham CES
one-hour daily for three weeks, Monday through Friday. They were pre
and post tested on standardized psychological measures of depression,
anxiety, and cognitive function. It was found that patients receiving
actual stimulation had significant improvement in all areas measured,
while no placebo effect was found from sham treatment [11] . The
presenters reported that CES was
subsequently employed in the hospital treatment protocol, with the
physical therapists, especially, commenting that patients had much
better morale during muscle exercise training when they used a CES
device during the mandatory passive exercise sessions. They completed
the sessions with little or no complaining, crying or other emotional
negativity and acting out.
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2.3. The use of CES in closed head injured patients
One of the first reports of the use of CES in closed head injured
(CHI) patients appeared in 1988. It was a clinical case presentation
of two CHI patients, the major focus being on their post-traumatic
amnesia and subsequent cognitive deficits. It was found that following
40 minutes of CES treatment daily for three weeks, the first patient
had a 55% improvement in immediate recall and a 56% increase in
delayed recall. The second patient had improved 28% on immediate
recall and 39% on delayed recall [12].
A subsequent double-blind, placebo-controlled study of CHI patients
was published in 1994 [13]. While the major focus of the study was
anxiety and depression in these patients, a side issue was the seizure
disorders suffered by the patients, all of whom were on anti-seizure
medication. It was not known at the time what effect CES might have on
seizures. While earlier studies of addiction patients in one
rehabilitation center had selectively eliminated patients known to
have had withdrawal seizures, another large rehabilitation center had
deliberately and successfully treated similar patients with CES to
prevent withdrawal seizures [14].
During the study, one patient was observed to have a seizure and was
immediately removed from further participation in the study. Following
the study it was discovered that the seizure patient had been a
sham-treated control and had received no stimulation. The researchers
reported that when that subject's parents saw the results in the CES
treated group they insisted that their son receive CES treatment. This
was done, with no further seizure activity reported in this or any of
the other patients who had undergone CES treatment during the study.
2.4. The use of CES in physical therapy
In an early CES study in the US, 23 patients who had been diagnosed
with hemiplegia, paraplegia and muscle spasm following traumatic
injuries, were given CES treatments of one hour each day for four days
in an open clinical trial. Muscle spasticity was tested with an EMG
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The
Use of Cranial Electrotherapy Stimulation in the Management of Chronic
Pain: A Review