tens for pain relief in labor and post surgery (2) nw 2003 format

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TENS FOR PAIN RELIEF IN

LABOR AND POSTSURGERY

By :- AIZA ZAKIMPT-Ortho 1st Yr

Moderator:-Dr.Sohrab A Khan



TENS-Transcutaneous Electrical

Nerve Stimulation A simple,non-invasive analgesic technique used

extensively in health care settings (Johnson1997,Robertson&Spurritt 1998)

Mainly used for symptomatic management of acute & chronic pain(Walsh 1997,Woolf &Thompson1994)

Also claimed to have antiemetic&tissue healingeffects(Walsh1997,Pearl et al1999)



Mechanism of action

Pain modulation during & after TENS isachieved primarily through two basic

neurophysiological mechanisms aimed atclosing the spinal gate(Wall&Melzack1994,Walsh 1997,Barr 1999)

PAIN GATE MECHANISM

ENDOGENOUS OPIATE SYSTEM(mainlyendorphins,enkephalins,)



Features of TENS devices

Pulse waveform(fixed)-Monophasic/Biphasic

(sym/assym) Pulse amplitude (adjustable)

-1-50mA

Pulse duration (often fixed)-10 -1000 micro sec

Pulse frequency(adjustable)-1-250 p.p.s

Pattern-continuous,burst,

Modulated

Channels-single/dual



TYPES

Three main modes of TENS found -

Conventional, Acupuncture-like, Intense

TENS (Walsh 1997, Woolf &Thompson1994,Vladimir 2008)



Contd..

Conventional-High frequency low intensity

amp-10-30 mA Freq-10-200Hz

AL-TENS-Low frequency high intensityamp-high

Intense TENS-High freq high intensity

amp-highest tolerable Freq-200Hz



Electrodes

Different shapes & sizes available

Single channel offer 2 & dual channel offer 4

electrodes for large vague or multiple areas Electrodes-non sterile carbon silicon,

reusable/self adhesive/sterile, disposible

Contd«



Contd..ELECTRODE PLACEMENT

Over & around painful area

At spinal nerve roots segmentally relatedto involved dermatome or myotome

Peripheral nerve

Related motor points,trigger points or acupuncture points



Dosimetry

Mode, Duration & Frequency-Based onpatient¶s comfort

Scientific literature shows no evidence tosupport the belief that particular modeselection is more efficacious for any givenacute or chronic pathological condition (Leoet al 1986,Johnson et al 1991, Chesterton,Foster et al 2003)

No correlation between patient, site, cause of pain & TENS parameters chosen & outcomes



Contraindications Pacemakers(unless recommended)

Epilepsy(unless recommended)

Pregnancy(unless recommended during--First trimester

-Over the uterus

Not to be applied over carotid sinus,broken or

dyaesthetic skin



TENS IN LABOR



STAGE 2

Stage of expulsion or

stage of delivery

Start with full cervicaldilation & end with birth of

baby.

Duration of contraction-

30sec-1min.

Gap between the

contraction-

5-10min

Stage lasts for 1-2 hrs



STAGE 3

Placental stage

From birth of baby to

expulsion of afterbirths

{placenta, umblical cord &

membranes}

Shortest stage ± 5-30 min



TENS in labor pain

Effectiveness of TENS for relief of pelvic & backpain associated with 1st&2nd stages of labor wasfirst evaluated by Augustinsson & colleagues in1977.

Pain is successfully controlled by applying TENSPara spinally at T10-L1 & S2-S4 levels during

1st&2nd stage of labor respectively.

There are specially designed obstetric TENSdevices which have dual channels & boost

control button/trigger switch for contraction pain



Electrodes position & characteristics of

TENS when used in labor pain

1st stage labor-Electrodes positioned to

target afferents active during distensionof cervix & lower uterine segment

2nd stage-Electrodes positioned totarget afferents active during distensionof pelvis & perineum

Between contractions-low intensity/low

frequency (burst-2 bursts per sec) During contractions-high intensity/high

frequency (continuous-80-100 Hz)



contd..

Researches show that patients acceptence of TENS as an adjunctive treatment for paincontrol is high

No adverse/side effects have been noted

among mothers or babies Researchers have concluded that TENS is an

effective, non pharmacological, non invasive,adjuvant pain relief modality in early stages of

labor Contd«



Advantages

Advantages of TENS over conventionalanalgesic methods used during labor includethe administration of a safe, non invasive,readily reversible analgesia that does not

affect the vital functions of mother & childduring or immediately following delivery.

It has also been reported that TENS

facilitated the mother¶s ability to concentrate onbreathing & relaxation techniques (Grim, LC,Morey 1985)



Disadvantage

Using TENS during foetal monitoring leads tointerference secondary to electrical signalgenerated by TENS device.

This inconvenience can be avoided by temporarilylowering the TENS amplitude or turning off the

device during fetal monitoring or using specialfilter developed to suppress stimulus artifact fromTENS unit,so that fetal monitering notaffected(Bundsen & Ericson)



Cluett E in 1994 in his review concluded that TENS

and ENTONOX (drug) are both equally effective in

females having short labors and needed no other form

of analgesia.(CHIA et al 1990)

Kaplan et al concluded that TENS is a effective non

pharmacological,non invasive adjuvant pain relief

modality for use in labor and delivery and it also

reduces the duration of first stage of labor and amountof analgesic intake with no adverse effects.

Contd«

Evidences:-



Contd«

V.Span et al 2006 concluded that it lowers pain butthere is no change in patients request for epiduralanasthesia.

Dowswell et al 2009 in their review concluded thatthere is only limited evidence that TENS reduces painin labor and it does not seem to have any effect (either positive or negative) on other outcomes for mothersand babies.The use of TENS at home in early labor

have not been evaluated.

Also concluded that TENS is widely available inhospital settings only and women should have choiceof using it in labor pain.



TENS for post surgical painrelief



TENS FOR POST-SURGICAL

PAIN RELIEF Hymes et al(1974) were the first to report

success of conventional TENS for acute painresulting from surgery using sterile electrodes

paraincisionally Potentially,TENS can relieve pain & reduce

consumption of opioid&non opioid medication &associated adverse effects including

drowsiness,ileus,respiratorydepression&gastrointestinal upset &improvesrespiratory function(Ali 1981,Benedetti et el1997,Chiu et al 1999)

Contd«



Investigators have evaluated the analgesic

effects of TENS in patients who underwentcholecystectomies or other abdominal surgery,

thoracotomies, leminectomies & other types of

orthopaedic & gynaecological surgery

(Ali et al,Navarthanam et al, Liu et al, Schuster

et al, Solomon et al, Richardson et al, Pike,

Smith,Issenmman, De Santana et al 2009,

Erdogan et al 2005, Bjordal et al 2003, Navaro2000)



Several investigators examined effect of

postoperative TENS applied for brief periods of time, rather than on continuous 24 hour basis

(Stratton et al, Liu at al 1985))

Warfield,Stein & Frank in their study concluded

that patients receiving TENS had lower pain

level, had shorter stays in ICU & tolerated chest

physical therapy more comfortably.But nosignificant difference in groups taking narcotics



Contd«

Patient receiving TENS also showed early

mobility,fewer incidences of postoperativepulmonary complications (Warfield,Stein &Frank1985)

Benedetti et al (1997) has shown that TENS was

effective for mild to moderate pain associated withthoracic surgical procedures but ineffective for severe pain

It can be used as an adjunct to other medicationswhen pain is moderate &can be the only paintherapy when pain is mild



Contd«

In a study it was also noted TENS is mosteffective for managing pain in drug naïvepatients i.e patients who have not usednarcotic medication for more than 2 wks in 6months prior to surgery.This finding implies

that lack of effectiveness of TENS in patientswith chronic pain may be due to history of significant prescription drugintake(Solomon,Long 1980)

Contd..



Erdogan M et al, 2005 recommended

routine use of TENS after concludingthatTENS reduced opioid intake, improved

respiratory func & had no side effects

(Bjordal et al, 2003) TENS administered

with strong subnoxious intensity over

wound area (1-8 Hz AL-TENS or 25-150

Hz) significantly reduced analgesic intakefor post-op pain



Contd«

For successful use of TENS, patients should

be carefully evaluated preoperatively & any

history of narcotic use should be noted

They should be introduced to the TENS

treatment protocol preoperatively whenever

possible, to determine optimal electrode

placement sites& stimulus parameters& to

allay patient¶s apprehension associated with

electrical stimulation

Contd«



Contd..

Ongoing staff education & training&development of protocols are critical to

the successful implementation of

postoperative pain management programincorporating TENS (Smith, LaFlamme

1980)

Consideration of each patient¶s response

to,& tolerance of, electrical stimulation iscritically important to the successful

application of TENS



Contd«

For post surgical pain,a highfrequency,long pulse duration combinedwith a comfortable intensity, withoutmuscle contraction has been reported toproduce the greatest pain relief (Ho et al1987,Manheimer & Lampe 1984).However

low frequencies have also found to beeffective (De Santana et al 2009,Bjordal etal 2003)



Thank You

tens for pain relief in labor and post surgery (2) nw 2003 format

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