BlueCross BlueShield of Tennessee Medical Policy Manual

Electrical Stimulation of the Autonomic Sympathetic Nervous System (i.e., Sympathetic Therapy) for the Treatment of Pain

DESCRIPTION

Sympathetic therapy describes a type of non-invasive electrical stimulation of the peripheral nerves with the intent to alleviate chronic pain. Unlike TENS (transcutaneous electrical nerve stimulation) or interferential electrical stimulation, sympathetic therapy is not designed to treat local pain, but is purported to treat chronic pain conditions associated with the sympathetic nervous system.

The autonomic nervous system functions to regulate the body's unconscious actions. It has two divisions: the sympathetic nervous system, which accelerates the heart rate, constricts blood vessels, and raises blood pressure, and the parasympathetic nervous system, which slows the heart rate, increases intestinal and gland activity, and relaxes sphincter muscles.

Based on the location of the patient's pain and treatment protocols supplied by the manufacturer, electrodes are placed in various locations on the lower legs and feet or the hands and arms. Treatment may include daily 1-hour sessions in the physician's office, followed by at-home sessions. Examples of sympathetic therapy delivery systems are the Dynatron® STS™ clinical device and the Dynatron® STS RX™ home unit.

POLICY

See also:

IMPORTANT REMINDERS

ADDITIONAL INFORMATION  

Well-designed studies in peer-reviewed journals are lacking regarding this technology. The safety and efficacy of this technology is not known, therefore, electrical stimulation of the autonomic sympathetic nervous system for the treatment of pain remains investigational.

SOURCES

Guido, E. H. (2002). Effects of sympathetic therapy on chronic pain in peripheral neuropathy subjects. American Journal of Pain Management, 12 (1), 31-34. (Level 4 evidence - Industry sponsored)

Hurley, D., Minder, P., McDonough, S., Walsh, D., Moore, A., and Baxter, D. (2001, April) Interferential therapy electrode placement technique in acute low back pain: a preliminary investigation. Archives of Physical Medicine and Rehabilitation, 82 (4), 485-93. Abstract retrieved October 5, 2017 from PubMed database.

U. S. Food and Drug Administration. (2001, May). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K010565 (Dynatron® STS). Retrieved June 2, 2009 from http://www.accessdata.fda.gov.

U. S. Food and Drug Administration. (2001, May). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K010948 (Dynatron® STS – home model). Retrieved January 5, 2016 from http://www.accessdata.fda.gov.

Washington State Department of Labor and Industries. Office of the Medical Director. (2002, April) Technology assessment: Dynatron® STS. Retrieved October 4, 2017 from http://www.quackwatch.org. 

ORIGINAL EFFECTIVE DATE:  6/1/2002

MOST RECENT REVIEW DATE:  11/9/2017

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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