Peripheral Nerve Stimulation

Chronic knee pain affects one in four people aged 55 and older. For many, the symptoms are mild to moderate. However, when it is severe, it can be debilitating.

Ongoing knee pain can also occur after knee replacement or ACL surgery. The triggers and causes of this kind of knee pain are complex and can be related to many different factors.

If you suffer from severe knee pain, it can make the simplest tasks seem almost impossible. Everything from walking to sitting down can be painful. Coping with chronic knee pain without seeking treatment can make the situation even worse.

We’ll look at the major possible causes of severe chronic knee pain along with leading options to treat it.

The Knee Is a Highly Vulnerable Joint

The knee is the joint that connects your thigh to your lower leg. It’s the biggest joint in your body. Like all joints, your knees are part of the bones in your skeletal system. Your knees also contain cartilage, muscles, ligaments, and nerves – all of which are vulnerable to damage.

Trauma

The knee bears a great deal of stress from everyday activities, such as walking, lifting, and kneeling, and from high-impact activities, such as running, jumping sports, and aerobics. Pain and damage from traumatic injuries and overuse are common

Arthritis

Knee pain can also result from different types of arthritis including osteoarthritis, rheumatoid arthritis, gout, pseudogout, and septic arthritis. Osteoarthritis of the knee is very common, with 46% of people developing it at some point in their lifetimes.

Post-Knee Replacement Pain

Although uncommon, a small percentage of knee replacement patients continue to have chronic pain on the outer sides of the knee after surgery. This is where the surviving knee ligaments and tendons are located. Most often these connective tissues are damaged either by the surgery or new stresses placed on them by the implant.

A number of other knee replacement patients have nerve irritations. This nerve irritation can be below or above the knee or within the kneecap. Other people become hypersensitive to pain after surgery, experiencing more pain than they should.

Preventing Knee Pain

Although it’s not always possible to prevent knee pain, there are some things you can do to ward off injuries and slow joint deterioration.

Maintain a Healthy Weight and Keep Extra Pounds Off

It’s one of the best things you can do for your knees. Every extra pound puts additional strain on your joints, increasing the risk of injuries and osteoarthritis.

Regularly Exercise to Be Strong and Flexible

Strong muscles will help stabilize and protect your knee joints and muscle flexibility can help you achieve a full range of motion. Prepare for the jumps and pivots of sports like basketball with good hip control by building glute strength. Work on normal ankle mobility to decrease unnecessary stress on the knee.

Use good cushioning shoes and focus on form when running or jogging to minimize pounding on the knees. And approach repetitive work knee stress in jobs such as construction or farming by preparing with exercises to strengthen impacted muscles.

Seeking Medical Help for Chronic Knee Pain

If knee pain persists and impacts the quality of your life, you should see a qualified medical professional to evaluate your condition. Putting off an appointment to address your chronic knee pain issues when they become critical will often allow things to further deteriorate and get worse.

There are a variety of treatments that may be appropriate for each individual situation. They include:

Physical therapy can help strengthen the muscles around your knee and make it more stable.
Medications can be prescribed to relieve pain and address the symptoms causing it.
Corticosteroids can be injected into your knee joint and may help reduce the symptoms of an arthritis flare and provide pain relief that may last a few weeks to a few months.
Hyaluronic acid is a natural substance found in joints. It is a viscous, gel-like substance. A treatment called viscosupplementation injects it to augment the fluid that naturally lubricates your knee joints. This may reduce friction within the joint, thereby reducing pain and stiffness, and preventing the loss of cartilage and bone.
Platelet-rich plasma (PRP) injections may benefit certain people with osteoarthritis with a PRP concentration of many different growth factors that appear to reduce inflammation and promote healing.

But what if these options aren’t sufficiently effective? Or if you want to avoid prolonged use of pain medications? What additional options are there short of surgery?

Peripheral nerve stimulation may be an answer for some patients. Itpresents a drug-free alternative that has proven to be highly effective to control chronic knee pain in appropriate cases.

Peripheral Nerve Stimulation

Neurostimulation has been used successfully to manage intractable chronic pain for over 40 years.

You may have heard of spinal cord stimulation (SMS) which was the first therapeutic approach that used neurostimulation. This therapy uses gentle electrical impulses to interrupt pain signals before they reach your brain. SMS offers a drug-free approach that does not require drugs or physical therapy to work.

Peripheral Nerve Stimulation (PNS) describes a localized and miniaturized approach to using neurostimulation. Peripheral nerve stimulation is different from spinal cord stimulation because it places the stimulating device directly over the nerve at the targeted pain area, not on the spinal cord where the nerve originates.

There are several medical device manufacturers that offer variations of peripheral nerve stimulation devices. Some of these devices are designed for a course of treatment that is 60 days or less. Others are designed for longer term use. Doctors will select specific devices based on each individual patient’s situation.

These PNS devices are small in size, minimally invasive, discreet, and upgradeable. The diameter of the leads implanted to provide stimulation is smaller than the size of a thin strand of spaghetti. There are both temporary and permanent PNS therapy options. They can be removed by your doctor if you decide to discontinue the therapy.

Peripheral Nerve Stimulation and Knee Pain

Peripheral nerve stimulation devices are increasingly used to help patients control their chronic knee pain. Very small electrodes are implanted next to the nerves involved, which can then be stimulated with the goal of relieving knee pain. Control of applying that stimulation is in the hands of the patient when they need it.

Appropriate candidates for peripheral nerve stimulation should have exhausted more conservative treatments without adequate improvement.

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If you suffer from knee pain, you know firsthand how it can impact the quality of your life. That dull, achy, throbbing, and deep pain that you feel when walking. Or the pain at night when you try to sleep. It can make everyday life miserable.

Although these problems are more common as we get older, they can also be an issue for younger adults.

Knee joint problems along with accompanying pain may be the results of a sports injury or accident. Or it can be attributed to osteoarthritis, also known as “wear and tear” arthritis. Rheumatoid arthritis can also affect the knees by causing the joint to become inflamed and by destroying knee cartilage.

Three comparative knee joint illustrations: normal knee – with inflammation – with degeneration

Non-Surgical Treatments – and When to Consider Surgery

There is a broad range of non-surgical treatments that can help provide knee pain relief and maintain your mobility.

From cortisone injections to viscosupplementation, to regenerative biotherapeutics, physical therapy and a variety of other minimally invasive techniques, there are many options available.

For some patients however, non-surgical options just aren’t enough – and an evaluation for total knee replacement might be appropriate. This procedure is more formally known as a total knee arthroplasty. During a total knee arthroplasty, your surgeon replaces your knee joint with an artificial one.

Post-Knee Replacement Nerve Pain

Which brings us to the situation where you may have had a total knee replacement, and continue to suffer with pain long after the procedure.

Large nerves and nerve branches that serve the ankle, foot, toes, and other parts of the lower leg pass through the knee. Some of these nerves and branches are in the back of the knee, and others are in the front and side. The skin and tissue around the knee is also dense with nerve endings.

Knee replacement surgical technique has evolved considerably over the years. However, when surgical incisions are made, some of the nerves, skin, and tissue around the knee are cut. Although surgeons take care not to inadvertently damage large nerves when possible, studies have shown that this can occassionally occur.

Nerve recovery after knee replacement surgery is a slow process. This may involve feelings of tingling, burning, pins and needles, and other pain symptoms around the knee and in the leg. This is usually a sign that nerves are awakening and healing. However, some patients continue to have chronic, lasting pain months after an extended post-surgery period.

Treatment Options for Chronic Post-Knee Replacement Nerve Pain

Your first step at that point is to make an appointment to see the surgeon who performed your knee replacement. He or she can evaluate your knee and check for possible complications from the surgery, such as an infection or a problem with the artificial joint.

However, there are occasions when surgeons are unable to uncover the cause of ongoing pain after knee replacement surgery. Many clinical studies attribute this chronic pain to swelling (inflammation), damage to one or more peripheral nerves around the knee, or other non-specific issues.

In the past, when this chronic pain occurred, patients were left with few treatment options other than taking pain medication. Over recent years, however, a variety of new options have been developed to treat chronic pain after knee replacement surgery. One of the more promising approaches to alleviate this pain is the utilization of Peripheral Nerve Stimulation.

Peripheral Nerve Stimulation (PNS)

Peripheral nerve stimulation is an FDA-cleared non-opioid pain management system used to treat chronic and acute pain. This approach involves placing an extremely small lead wire near the peripheral nerve that is causing you pain in your knee. Ultrasound imaging is used to guide placement of the lead during an outpatient procedure.

The lead is connected to a very small stimulator. Patients can adjust stimulation and customize its output using a small remote controller. When the stimulator is turned on, patients generally feel a comfortable tingling sensation over the targeted nerve. That stimulation masks or prevents pain signals from reaching your brain.

Peripheral nerve stimulation technology has been advancing at a rapid pace in recent years. Configurations of different systems vary widely. Some are intended for long term use, and others are designed to be used for short periods before removal. In fact, there are some systems that are used for only up to 60 days, and after removal of the device, significant and sustained relief continues.

If you have continuing pain after a knee replacement, you should discuss with your medical provider if peripheral nerve stimulation might be an appropriate therapy for you.

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Almost everyone gets acute back pain from time to time. Maybe you did too much yard work, sat in a long car ride or were a little too enthusiastic in a pickup softball game. The end result – you get a backache or get some back pain.

That acute back pain may linger for a few days or few weeks. The good news is that kind of pain almost always goes away. You generally find things that get you by for that short period of time. It might be over-the-counter pain relievers, home remedies such as heat or ice, or maybe see a physical therapist or chiropractor to help you get through it.

A woman with lower back pain clutches her left back with her hand.

Chronic Back Pain

When you have chronic back pain however, you normally will seek out medical professionals. Chronic back pain is pain that just doesn’t go away. You’ve tried all your home remedies and maybe you’ve seen your family doctor a few times. But the pain continues to linger and persist.

Fortunately, there is an extensive range of treatments available ranging from conservative to more aggressive. Starting at the low end of this spectrum are alternatives such as physical therapy, medications, and injection-based treatments, to name a few. And at the top end of the spectrum is spine surgery.

However, what many back pain sufferers and medical professionals often miss are a growing number of pain relief alternatives that sit in the space between conservative treatments and major surgery. And among those alternatives are three classes of neuromodulation therapies: spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRG), and peripheral nerve stimulation (PNS).

These are options that merit consideration when you want to avoid back surgery, or when back surgery has failed to provide the pain relief you are seeking. They also may be appropriate when you doctors haven’t been able to identify the specific musculoskeletal cause of your pain. We’ll take a brief look at each of them here.

Spinal Cord Stimulation (SCS)

A spinal cord stimulator is a medical device that delivers a set of mild electrical currents to disrupt pain signals traveling between the spinal cord and the brain. It is like a pacemaker for chronic pain.

It involves implanting a neurostimulator under the skin along with thin wires called leads. Together they provide pain relief by modifying pain messages before they reach your brain.

Before any permanent stimulator is implanted, a trial procedure is always used to help determine the likelihood that this therapy will work for a patient. This takes place over a 3 to 10 day period where an external stimulator mimics the treatment that would be delivered by the permanent implant.

The level of pain relief stimulation can be adjusted. Depending on the specific spinal cord stimulator, that adjustment can be done by the patient themselves according to when they need it throughout the day, or automatically with some newer technologies.

Both the trial and permanent implantation procedures are usually done on an outpatient basis. This device has over a 50-year track record of use, and in skilled hands, the serious complication rates are very low.

Dorsal Root Ganglion (DRG) Stimulation

Dorsal root ganglion stimulation is another outpatient neurostimulation therapy, similar to traditional spinal cord stimulation. However, rather than placing the electrodes over the spinal cord as in spinal cord stimulation, leads are implanted on the dorsal root ganglion, a cluster of neurons that represent the sensory gate of the spinal cord.

As sensory feedback moves to your brain, it first must pass through the dorsal root ganglion before entering the spinal cord. Thus, when those dorsal root ganglion neurons are properly stimulated, they can modify pain messages before they move to the spinal cord and other areas of the central nervous system.

Also, like spinal cord stimulation, dorsal root ganglion stimulation involves an initial trial to ensure the therapy is likely to be effective. Then the system is implanted under the skin during an outpatient procedure.

Dorsal root ganglion stimulation has number of advantages in appropriate situations. First, it can be targeted in a much more refined way than spinal cord stimulation and uses only 10 percent of the energy that spinal cord stimulation uses, leading to far longer battery life.

In addition, the leads are less likely to shift in comparison with spinal cord stimulation (although some surgeons are far better than others in how they anchor spinal cord stimulation leads to minimize slippage). And finally, given anatomical realities, patients receive the same pain relief whether laying down, standing, sitting, or walking – where the level of stimulation varies for spinal cord stimulation patients as they shift their position.

Peripheral Nerve Stimulation (PNS)

Peripheral nerve simulators work much like spinal cord simulators, except that we send the mild electrical currents directly to nerves outside of the spinal cord. Peripheral nerves run from your spinal cord to the limbs or organs in your body. Thus, if you have joint pain, a peripheral nerve stimulator would be localized directly at the joint where pain is being experienced.

Recently, a new generation of peripheral nerve stimulation devices has been developed. These new devices allow external pulse generators to transmit impulses wirelessly to the implanted electrode, and their implantation is significantly less invasive. Some devices and therapies are designed so that there is no permanent implantation necessary.

Chronic Back Pain Relief Alternatives at Main Line Spine

Main Line Spine’s team includes some of the nation’s leading experts in spinal cord stimulation, dorsal root ganglion stimulation and peripheral nerve stimulation medical technologies. These treatments, when combined with our multifaceted and compassionate care, deliver a high level of pain relief for our patients.

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Severe pain can affect all aspects of your life across social interactions, work, and leisure activities. When this happens, it’s time to see your doctor and consider what options are available to get back to a more normal way of living.

The origins of your pain may be in the low back, shoulder, or knee. Or it may be post-amputation or chronic or acute post-operative pain. Many patients don’t want to take opioids as a solution, even on a short-term basis. For appropriate cases, the answer may be a temporary Peripheral Nerve Stimulation (PNS) system.

An alternative that fits these criteria is the SPRINT PNS system. It does not require permanent implantation and is designed as a 60-day treatment to provide sustained pain relief.

What Is a Peripheral Nerve?

Your body’s nervous system is made up of your brain, spinal cord, and peripheral nerves. Peripheral nerves are the nerves that extend beyond your brain and spinal cord to your organs and extremities—all the way to your fingertips and toes.

Pain signals travel along these peripheral nerves to your brain.

How Does the SPRINT Peripheral Nerve Stimulation Work?

Neurostimulation works by delivering mild electrical signals that disrupt nerve pain signals before they reach your brain. In this way, you can achieve pain relief without the need for medication.

The SPRINT PNS system uses a small pulse generator that sends gentle pulses through very thin, fishing line-sized micro-leads to stimulate the nerve causing your pain. This pulse generator is located outside your body and is not implanted, as is the case for most other systems.

A simple handheld remote communicates with the pulse generator and allows you to easily control the level of pain-relieving stimulation that you need.

After the treatment period had ended, and the micro-lead (or leads) has been removed, the majority of patients continue to experience sustained relief.

The Procedure

During a minor outpatient procedure, your doctor will implant a thin micro-lead directly over the specific nerve or nerves causing your pain. Depending on the location of the nerve, either fluoroscopic (x-ray) or ultrasound guidance will be used to steer the lead to the correct location.

You can then expect to go about your normal activities when using the SPRINT system. When you take a shower, you’ll disconnect the SPRINT pulse generator – and you’ll avoid bathing and swimming during the treatment period.

The SPRINT system then is left in place for up to 60-days, after which your doctor will remove the micro-lead.

SPRINT PNS after procedure completion — SPRINT PNS system after procedure completion, with lead covered by a waterproof bandage and the pulse generator located externally.

Clinical Results to Date

Clinical studies have shown promising outcomes to date for the SPRINT PNS system. 75% of patients have reported significant and sustained pain relief.

The procedure is a good option for patients with low back pain, shoulder pain, knee pain, arthritic joints or discs, post-amputation pain, and post-operative pain. It is also a good option when a radiofrequency neurotomy isn’t considered a viable therapy – or when it has been tried but hasn’t been effective. It is appropriate when other neurostimulation treatments aren’t.

The SPRINT PNS system is a treatment that doesn’t involve medications, is fully adjustable, and can potentially offer more complete pain relief than other similar therapies. It is a safe procedure with low risks.

While appropriate patient selection is key, SPRINT peripheral nerve stimulation is an option to consider for acute and chronic pain where more conservative therapies have been exhausted.

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Did you know that approximately 20% of patients who have a total knee replacement continue to experience chronic pain long after the surgery? Researchers are increasingly focusing on understanding the causes of this issue, but the specifics of exactly why this happens have been hard to pin down.

Chronic pain after a total hip replacement is another common issue, which affects approximately 10% of patients.

In fact, far beyond joint replacement pain issues, you may be experiencing chronic pain symptoms in any part of your musculoskeletal system. And you may have tried an epidural, other injections, or other treatments without success.

One of the alternatives that Main Line Spine considers to help patients alleviate pain in these situations are very small and localized peripheral nerve, micro-neurostimulation devices.

What Is Neurostimulation?

At this point, we’ll pause for a moment to answer the question, “What is Neurostimulation?”

Neurostimulation works by delivering mild electrical signals that disrupt nerve pain signals before they reach your brain. In that way, you can achieve pain relief without the need for medication.

Main Line Spine has a long history and deep expertise in helping patients deal with chronic pain by using devices called “neurostimulators.” Traditionally these devices include several components:

Neurostimulator: This is a device that generates the electrical impulses and contains a battery. It is usually placed under the skin in your abdomen or upper buttock.
Leads: These are thin, insulated medical wires that deliver electrical impulses and which run from the neurostimulator to the epidural space near the spine.
Personal Programmer: This is a handheld device that a patient can use after they leave the Doctor’s office to customize their stimulation within the settings a doctor has selected.

These traditional neurostimulators have proven themselves to be very effective for many patients. However, when it comes to relieving chronic pain in a joint such as a knee or shoulder, a much smaller neurostimulator is more appropriate.

This localized approach is known as peripheral neurostimulation. The neurostimulator and leads are placed directly at the nerve identified as causing the pain.

External SPRINT PNS Pulse Generator on a leg for knee pain along with components of SPRINT PNS system. — SPRINT® is one provider of Peripheral Nerve Stimulation (PNS) systems. One application of their model is a 60-day therapy that relieves knee pain without requiring a permanent implant.

Peripheral Micro-Neurostimulators

Peripheral Micro-Neurostimulators are designed for very localized chronic pain relief. They take advantage of many technical innovations developed in recent years, including component miniaturization.

The microstimulators that Main Line Spine uses, in appropriate cases, are the smallest, most-compact neurostimulation systems available. They come with an extremely small neurostimulator that is implanted by your Doctor at your impacted joint.

These neurostimulators have small metal electrodes near the tip that create an electrical field of energy when power is applied. This electrical energy aids in blocking the pain signals that come from certain nerves.

All of these microstimulators offer a variety of programming options that enable you to experience pain relief when and how you need it.

Trial Period

If the conservative care options you’ve tried in the past have failed to alleviate your chronic-pain symptoms, this non-opioid, minimally invasive treatment option might be appropriate for you.

If you decide to move ahead, your Doctor will start you with a trial period to confirm that this peripheral neuromodulation approach will work for you.

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