Effective analgesia for extracorporeal shock wave lithotripsy: transcutaneous electrical nerve stimulation

Role of Complementary Medicine (Music, Acupuncture, Acupressure, TENS and Audio-Visual Distraction) in Shockwave Lithotripsy (SWL): A Systematic Review From EAU Sections of Urolithiasis (EULIS) and Uro-Technology (ESUT)

We performed a systematic review to look at the role of alternative or complementary medicine such as music, acupressure, acupuncture, transcutaneous electrical nerve stimulation (TENS) and audiovisual distractions to decrease analgesia requirement and alleviate anxiety during SWL. Twenty-three papers(2439 participants) were included: Music (n = 1056.6%), Acupuncture (n = 517.7%), Acupressure (n = 13.8%), TENS (n = 617.2%), and audiovisual distraction (n = 14.6%). Most of the studies showed that complementary therapy, lowered pain, and anxiety with higher patient satisfaction and willingness to undergo the procedure. With its feasibility and convenience, urological guidelines need to endorse it, and more should be done to promote its use in outpatient urological procedures.

The effect of transcutaneous electrical nerve stimulation for pain relief during extracorporeal shock-wave lithotripsy procedure

The purpose of this study was to investigate the effect of transcutaneous electrical nerve stimulation (TENS) for pain relief during extracorporeal shock-wave lithotripsy (ESWL) procedure. An experimental study with repeated measures design was used in this study. Fifty patients aged 20-65 years receiving ESWL treatment were used for this convenience sample. Two applications were used for each patient: one involving administration of TENS instrument for ESWL treatment and the other without TENS. For effective stimulation, 2 stimulator electrodes were placed paravertebrally at L1 and 2 near the lithotripter shock tube before ESWL. Blood pressure, heart rate, pain intensity, analgesic use, and side effects were measured every 10 minutes during the procedure and after the end of ESWL. Results showed that TENS application decreased patients' intensity of pain and amount of analgesic requests and, related to that, decreased the incidence of side effects and increased patients' satisfaction during ESWL. TENS application is recommended as a pain-relieving technique during ESWL.

Analgesia during extracorporeal shockwave lithotripsy: fentanyl citrate versus parecoxib sodium

BACKGROUND AND PURPOSE

Shockwave-induced pain may become an important issue during extracorporeal shockwave lithotripsy (SWL), although the new generation of lithotriptors generally produces less pain than previous models. The aim of the study was to compare the analgesic effect of a cyclooxygenase-2-specific inhibitor (parecoxib sodium) with that of our standard method of analgesia (fentanyl citrate) in patients who needed pain relief when undergoing SWL.

PATIENTS AND METHODS

Fifty-eight patients who were undergoing SWL for renal calculi were randomized to receive intravenously either fentanyl citrate (group A, n = 30) or parecoxib sodium (group B, n = 28) when they felt that their pain during the session became intolerable. Lithotripsy was recommenced 10 minutes after administration of analgesia. The severity of pain before and after administration of the analgesic regimens was evaluated using a five-level verbal scale. The effectiveness of each drug was evaluated with respect to degree of pain relief and ensuing tolerance of the procedure to completion, as well as the need for supplementary analgesia (half the standard dose of fentanyl citrate).

RESULTS

The patients in the two groups were comparable with regard to age, sex, body mass index, and stone size. There was no statistically significant difference in the maximum energy level achieved as well as in the total number of shock waves given in the two groups. Administration of fentanyl citrate resulted in alleviation of pain and completion of SWL in 27 patients (90%), whereas parecoxib sodium was effective in five patients (17.8%) (P < 0.01). The remaining 23 patients in group B received supplementary analgesia, and 22 completed the lithotripsy session.

CONCLUSIONS

Parecoxib sodium was not as effective as fentanyl citrate in alleviating pain during SWL. Its use, however, may lower the dose of opioid-based analgesia in this group of patients.

Deep Tissue Afferents, but not Cutaneous Afferents, Mediate Transcutaneous Electrical Nerve Stimulation–Induced Antihyperalgesia

In this study we investigated the involvement of cutaneous versus knee joint afferents in the antihyperalgesia produced by transcutaneous electrical nerve stimulation (TENS) by differentially blocking primary afferents with local anesthetics. Hyperalgesia was induced in rats by inflaming one knee joint with 3% kaolin-carrageenan and assessed by measuring paw withdrawal latency to heat before and 4 hours after injection. Skin surrounding the inflamed knee joint was anesthetized using an anesthetic cream (EMLA). Low (4 Hz) or high (100 Hz) frequency TENS was then applied to the anesthetized skin. In another group, 2% lidocaine gel was injected into the inflamed knee joint, and low or high frequency TENS was applied. Control experiments were done using vehicles. In control and EMLA groups, both low and high frequency TENS completely reversed hyperalgesia. However, injection of lidocaine into the knee joint prevented antihyperalgesia produced by both low and high frequency TENS. Recordings of cord dorsum potentials showed that both low and high frequency TENS at sensory intensity activates only large diameter afferent fibers. Increasing intensity to twice the motor threshold recruits Adelta afferent fibers. Furthermore, application of EMLA cream to the skin reduces the amplitude of the cord dorsum potential by 40% to 70% for both high and low frequency TENS, confirming a loss of large diameter primary afferent input after EMLA is applied to the skin. Thus, inactivation of joint afferents, but not cutaneous afferents, prevents the antihyperalgesia effects of TENS. We conclude that large diameter primary afferent fibers from deep tissue are required and that activation of cutaneous afferents is not sufficient for TENS-induced antihyperalgesia.

PERSPECTIVE

Transcutaneous electrical nerve stimulation (TENS) is an accepted clinical modality used for pain relief. It is generally believed that TENS analgesia is caused mainly by cutaneous afferent activation. In this study by differentially blocking cutaneous and deep tissue primary afferents, we show that the activation of large diameter primary afferents from deep somatic tissues, and not cutaneous afferents, are pivotal in causing TENS analgesia.

Subjective Pain Scale and the Need for Analgesia during Shock Wave Lithotripsy

OBJECTIVE

To investigate patients' opinions on the degree of pain during shock wave lithotripsy, and the need for analgesics in patients with urinary stone.

METHODS

A prospective questionnaire study involving subjective pain assessment during and just after shock wave lithotripsy was performed in consecutive patients with uncomplicated renal or ureteral stones. The patients were given unbiased information on the analgesics prior to the procedure. Ten minutes after beginning shock wave lithotripsy, the degree of pain was rated by the patient using a 10-point visual analog scale. After the procedure, the patients were asked to complete a self-administered questionnaire. Based on the response for the questionnaire, the patients were divided as 'tolerable' or 'non-tolerable' group.

RESULTS

The results from 180 patients (males 113, females 67) with a mean age of 50.0 +/- 13.0 were analyzed. The average subjective pain score was 6.6 +/- 2.3 during the procedure, and 70 (38.9%) patients responded that they were able to tolerate the pain without analgesics. A total of 116 (64.4%) patients did not agree that analgesic should be recommended to other patients. Subjective pain score during the procedures was not affected by laterality, size of stone, level of education or socioeconomic status, but was affected by patient age (p = 0.042), sex (p = 0.012) and location of stone (p = 0.014). Right and kidney stones were significantly higher in the 'non-tolerable' group than in the 'tolerable' group (p = 0.003 and p = 0.011, respectively), and the 'non-tolerable' patient group had a significant higher pain score than the 'tolerable' group (p < 0.001).

CONCLUSIONS

Our result shows that subjective pain severity during shock wave lithotripsy is high but may be well tolerated in some patients. Our findings raise the question as to whether routine analgesics are required during newer generation shock wave lithotripsy procedures in all patients with a urinary stone.

Effect of the frequency of transcutaneous electrical nerve stimulation on analgesia during extracorporeal shock wave lithotripsy

In this prospective, randomised, sham controlled study, we set out to determine which transcutaneous electrical nerve stimulation (TENS) therapy modality (conventional vs acupuncture-like) is more effective as a supplementary analgesic regimen during extracorporeal shock wave lithotripsy (ESWL). Patients were prospectively randomised to one of three groups. In Group I (n=22), conventional TENS (impulse pattern: continuous at 80 Hz; intensity: 10-30 mA) was applied. In Group II (n=22) acupuncture-like TENS (impulse pattern: burst at 2 Hz; intensity: 15-50 mA) was applied. In Group III (n=22) (control group), stimulation was started at 1 mA and the intensity increased to no more than 10 mA until it produced a tickling sensation. Alfentanil was administered through a patient controlled analgesic device. Alfentanil consumption, hemodynamics and respiratory parameters, a 10-cm visual analogue pain scale, patient satisfaction, recovery and discharge times were evaluated. The consumption of alfentanil was significantly lower in Group I than in Groups II and III (P<0.0001). Pain scores were lower in Group I than in the other two groups (P<0.05). Patients in Group I were more satisfied with their analgesic medication than those in the other two groups (P<0.05). Both the time to an Aldrete score >8 and a modified post-anaesthetic discharge score >8 were significantly shorter in Group I (2.3+/-1.8, 49.1+/-14.6) than those of Groups II (4.6+/-2.2, 60.2+/-18.1) and III (4.9+/-2.8, 58.4+/-16.5) (P<0.0001 and P<0.05, respectively). We conclude that the use of conventional TENS is effective in decreasing the analgesic requirements and the incidence of alfentanil-related side effects during ESWL.

Electroanalgesia: its role in acute and chronic pain management

Interest in nonpharmacologic alternatives to conventional analgesic drugs for the management of acute and chronic pain has lead to an evaluation of the use of electroanalgesic therapies.