Urolithiasis (2014) 42:189–193 DOI 10.1007/s00240-014-0655-2
Review
Complementary approaches to decreasing discomfort during shockwave lithotripsy (SWL) Goh Ngee‑Ming · Drake Tamsin · B. P. Rai · B. K. Somani
Received: 14 December 2013 / Accepted: 4 March 2014 / Published online: 20 March 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Shock wave lithotripsy (SWL) is an established treatment for renal stones. Although non-invasive, it can cause significant pain and anxiety during the procedure. Our purpose was to review the literature to look at the effect of complimentary therapy in patients undergoing SWL and whether it led to a reduction in the requirement of analgesics and anxiolytics. A systematic review was performed on the use of acupuncture, auricular acupressure, transcutaneous electrical nerve stimulation (TENS) and music during SWL. Only prospective randomized controlled trials were selected. Two reviewers independently extracted the data from each study. Outcomes relating to analgesia requirement, anxiety and stone-free rates (SFR) were compared. Seven papers were identified reporting on 591 patients (acupuncture-3, TENS-1 and music-3). Pain control/analgesia requirement was significantly better in four studies (music2, acupuncture-1, TENS-1). Significantly lower anxiety was noted in one study with music and two using acupuncture. No difference in SFR was noted with the use of complementary therapy. No major or minor side effects were noted. Complementary therapy for SWL can help lower analgesia requirement and the anxiety associated with it. However, it does not have any effect on the SFR. Keywords Complementary therapy · Shock wave lithotripsy · Music · Acupuncture · Acupressure
Introduction Shock wave lithotripsy (SWL) causes renal stone disruption and enables passage of the subsequent debris down the ureters into the bladder. It can, however, cause renal parenchymal injury, sepsis, subcapsular haematoma [1–3], and pain especially if the calculus is near a bone. From the early 1980s SWL has become an accepted method of stone management [4–6]. Since then, the benefits of an outpatient, ambulatory day procedure has proved highly appealing to patients [7]. Given that discomfort can limit the power levels used in SWL, a potential area for SWL advancement thus lies in using alternative and complementary therapies for analgesia. Alternative or complementary medicine has often been portrayed as traditional medicine that deviates from the norm and has little or no scientific evidence for their use. However, given the popularity of their often holistic or spiritual approach, this lack of evidence is being addressed. To this end, we aimed to conduct a systematic review to assess the effect of complimentary therapy in SWL and whether it led to a reduction in analgesic/anxiolytic use. Our secondary aim was to look at whether it led to better stone-free rates (SFR).
Methods G. Ngee‑Ming · D. Tamsin · B. K. Somani (*) Department of Urology, University Hospitals Southampton NHS Trust, Southampton, UK e-mail: [email protected] B. P. Rai Department of Urology, Ninewells Hospital Dundee, Dundee, Scotland, UK
Search strategy The Cochrane Library, Medline and PubMed databases were searched from inception to April 2012. We limited the searches to include only articles written in English using the following terms: “complementary
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190
therapy”, “complementary medicine”, “complementary treatment(s)”, “acupuncture”, “acupressure”, “TENS”, “music”, “SWL”. Boolean operators (NOT, AND, OR) were also used in succession to narrow and broaden the search. Eligibility criteria Studies were eligible for inclusion if they were randomized control trials involving the use of SWL to treat renal and/or ureteric stones with concurrent use of at least one complementary therapy. Studies were excluded if there were not in English, not human-based studies, outcomes of interest were not presented, or if they were not original studies. Study selection The first step in study selection was the exclusion of duplicate reports. (i.e. reports of the same study). The title and abstract of the trials identified by the search were examined and any studies which were obviously irrelevant were excluded at this stage. The full text of each of the remaining studies was then reviewed for eligibility, and all relevant information and data extracted.
Urolithiasis (2014) 42:189–193 Literature search (No. = 242) Potential articles for evaluation of abstract (No. = 45)
Articles excluded after screening abstracts (No. = 22)
Potential articles for evaluation of full manuscript (No. = 23)
Articles excluded after screening full manuscripts (No. = 16)
Articles excluded after screening of the title (No. = 197)
Included articles = 7
Fig. 1 Outcomes of the literature search
Study characteristics The studies included in this systematic review were published between 1988 and 2007. The number of patients studied ranged 35–193, hence averaging 84.4 patients per study. There was no significant difference in the stone location in individual studies. Meta-analyses of the extracted data were not performed because there was significant heterogeneity among the seven studies in terms of outcomes measures examined. Effects of complementary therapy on SWL outcomes
Data extraction and quality assessment Two reviewers (NG and TD) extracted the data using a standardized data collection sheet to increase homogeneity and reduce bias. Disagreement between the two extracting authors was resolved in consensus by the senior author (BKS). The following information/data were extracted from each eligible study: first author, title, year of publication, journal, study design, number of cases and control, population demographics (including gender, age and weight), shock wave treatment protocol used (including number and/or voltage of shocks and duration of therapy in minutes), stone size and location, symptoms of renal colic within the previous 12 h of shock wave treatment, presence of a nephrostomy at the time of shock wave treatment, analgesia used, stone-free rate, pain and/or anxiety scores and side effects and/or adverse effects of treatment.
1. Analgesia Pain control/analgesia requirement was significantly better in four studies (music-2, acupuncture-1, TENS-1). There was a reduction of fentanyl requirement with the use of music in two studies [23, 25] and the use of TENS in one study [26] (Tables 1, 2). 2. Anxiety scores Significantly lower anxiety was noted in one study with music and one with acupuncture [25, 28]. 3. Stone-free rates (SFR) There was no significant difference in SFR with the use of complementary therapy [26, 27]. 4. Complication rates/adverse effects No major or minor side effects were noted with the use of complementary therapy [23–29].
Discussion Results Literature search Searching the 3 databases identified a total of 242 articles. After the initial screening, 45 potential articles were identified of which 7 were included in the final review (Fig. 1).
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As far as we are aware, this is the first systematic review to look at the outcomes of complementary therapy use during SWL. A relatively small number (n = 7) of studies were identified for review. Several consistent findings were apparent with the use of complementary therapy during SWL, including better analgesia and reduced anxiety. Furthermore, there were no major or minor side effects
Control: 53 ± 12. Music: 54 ± 15
Kock et al. [23]
Range 18–55. Group 1: 37.7 ± 11.9, Group 2: 41.4 ± 12.96, Group 3: 39.4 ± 14.1 Range 15–58. Group 1: median 43 (range 18–55), Group 2: median 35 (range 23–58) Group 1: 76.9 ± 5, Group 2: 77.0 ± 0.4
Range 34–56. Group 1: 46 (36–56), Group 2: 44 (34–54)
Karamarz et al. [26]
Wang et al. [29]
Mora et al. [28]
Resim et al. [27]
Range 19–68. Group 1: 39.30 ± 3.20, Group 2: 40.89 ± 3.24
Yilmaz et al. [25]
Soledad Cepeda et al. [24] Range 15–65. Group 1: 40.7 ± 12.1, Group 2: 41.0 ± 11.4
Age
Study
56 (Group 1 [acupuncture] n = 29, Group 2 [control] n = 27)
100 (50 in 2 groups: acupuncture and control)
35 (Group 1: [acupuncture] n = 17, Group 2: [midazolam + tramadol] n = 18)
66 (22 in 3 groups: conventional TENS, acupuncture TENS, and control)
193 (Group 1: [music throughout] n = 97, Group 2: [music at treatment conclusion] n = 96) 98 (Group 1: [midazolam] n = 50, Group 2: [music] n = 48)
43 (control 22, music 21)
Sample size
Table 1 Characteristics of the studies examining the effects of complementary therapy during SWL
2,500 shocks for renal calculi, 3,000 shocks for ureteric calculi
Not standardized
Only included if 1st treatment and only one stone. ESWL duration (min): Group 1: 30.40 ± 0.62, Group 2: 28.58 ± 1.088 [p = 0.004]. Shocks: Group 1: 3,016 ± 64.22, Group 2: 3,043 ± 110.42 [p = 0.662]. Voltage (kV): Group 1: 21.03 ± 0.48, Group 2: 21.96 ± 0.54 [p = 0.542] 9 kV initially increased to 24 kV. Time of ESWL (min): Group 1: 29.4 ± 5.4, Group 2: 27.2 ± 6.3, Group 3: 29.3 ± 6.3 Not standardized
Music
Stimulus load kV min 103. Control: 59 ± 14. Music: 65 ± 13 [not significant] Only included if 1st treatment. Treatment voltage of 17 V always reached. Group 1: 20.0 ± 15.4 min, Group 2: 22.2 ± 19.0 min [p = 0.393]
Auricular acupuncture
Auricular acupuncture
Electro-acupuncture
TENS
Music
Music
Complementary therapy studied
Duration/voltage of SWL, stone size/location
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Auricular acupuncture
Auricular acupuncture
Electro-acupuncture No side effects with electro-acupuncture. Mild orthostatic hypotension and dizziness in some Group 2 patients
Lower anxiety and pain scores with auricular acupressure
Lower opiate (alfentanyl) requirements, lower pain scores and lower anxiety scores with acupuncture Wang et al. [29]
Resim et al. [27]
Mora et al. [28]
Stone-free rate, maximum energy level applied
TENS Lower incidence of nausea and dizziness Karamarz et al. [26]
Lower opiate (fentanyl) requirements with music. Also lower STAI-trait anxiety. Less anxious/more comfortable on 7-point verbal scale Lower opiate (alfentanyl) requirements, lower pain scores and increased patient satisfaction with conventional TENS compared to acupuncture-like TENS or music
Reduction in alfentanyl requirements
Kock et al. [23] Soledad Cepeda et al. [24] Yilmaz et al. [25]
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Stone-free rate
No difference in adverse event rates Similar side-effect incidence Duration of stay Pain Score, alfentanyl use STAI-state anxiety
Other No effect Effect Study
Table 2 Effects of complementary therapy on SWL outcomes
Music Music Music
Urolithiasis (2014) 42:189–193
Complementary therapy studied
192
noted from the use of such complementary therapy. In the study by Yilmaz and colleagues [25], the stone location was evenly matched and a third generation electrohydraulic lithotripter was used with all patients undergoing only one session of SWL. The music group had a significantly shorter SWL session (28.6 min compared to 30.4 min) with significantly better anxiety scores after sedation and before and after SWL treatment. The fentanyl requirement was also 21 μg compared to 36 μg (p = 0.008). Similarly Karamarz [26] reported the use of second generation lithotripter and showed a lesser alfentanil requirement 956 μg in the TENS group compared to 1,916 μg where the former group also had a higher number of stones in the upper pole calyx. Acupuncture was the most popular and widespread complementary therapy. The various forms of acupuncture use pressure, heat or needles, sometimes in combination or augmented with electrical stimulation, to provide health benefits. Until recently the basis for these benefits has been unknown, but Wang et al. have evaluated much of the scientific literature behind acupuncture. They have surmised that data so far suggest the practice stimulates the “release of endogenous opioid-like substances, including enkephalin, β-endorphin, and endomorphine, that modulate pain signals” [8]. Whilst acupuncture science develops, in practice Gejervall et al. [9] found that electro-acupuncture offered significantly less pain control than conventional analgesia in women during in vitro fertilization, though it did offer less fatigue and confusion as side effects. Conversely, Groppetti et al. [10] gathered evidence to support electro-acupuncture as an alternative in post-operative analgesia, albeit in dogs. Transcutaneous electrical nerve stimulation (TENS) covers a variety of methods by which the skin is stimulated with electrical pulses of varying frequency, intensity and duration. Proposed theories for the mechanisms behind TENS’ effects are similar to those for acupuncture. Again endogenous pain control [11] is postulated as a mechanism, though the gate-control theory is also proposed [12]. In practice, TENS is primarily used in chronic pain, though some centres also offer it to alleviate labour pains [13]. Despite its relatively extensive usage, however, the latest Cochrane review [14] has found no good evidence either supporting or disapproving the use of TENS for chronic pain, primarily down to a lack of large and well-designed randomized control trials. There have been some surgically orientated trials, however, with Hamza et al. [15] using TENS post-gynaecological surgery, and Cipriano et al. [16] and Gregorini et al. [17] post-cardiac surgery, all finding benefits to pain control, including reduced opioid requirements and hence reduced side effects. A more clinically pertinent trial by Rawat et al. [18] using TENS with biliary lithotripsy, however, found no reduction in intravenous analgesia requirement or in pain perception.
Urolithiasis (2014) 42:189–193
Since Gardner et al. [19] reported their results with music on pain control in dental procedures in 1960, it has been widely accepted that music has beneficial effects. The Cochrane review in 2010 [20] concluded that music did reduce pain control and opioid requirements though the benefits were only small. Regarding the basis for these benefits, while the gate theory is proposed, and distraction also a factor depending on the environment, emotional valence is now being shown to be vital for music’s effects [21]. A study by Kulkarni et al. [22] showed a significant reduction in sedation requirement with patient-selected music contributing favourably to overall patient experience. Overall, improving SWL analgesia and patient experience could have benefits to lithotripsy application, compliance with further therapy sessions and pharmacological side effects [23–29]. In turn, methods such as acupuncture, TENS and music offer an avenue to these benefits.
Conclusions In conclusion, our review leads us to suggest that complementary therapy for SWL can help lower analgesia requirements and the anxiety associated with it in some cases. However, it does not have any effect on the SFR achieved. Conflict of interest The authors declare that they have no conflict of interest.
References 1. Pemberton J (1987) Extra-corporeal shock wave lithotripsy. Postgrad Med J 63:1025–1031 2. Evan AP, Willis LR, Connors B et al (1991) Shock wave lithotripsy-induced renal injury. Am J Kidney Dis 17(4):445–450 3. Dhar NB, Thornton J, Karafa MT et al (2004) A multivariate analysis of risk factors associated with subcapsular hematoma formation following electromagnetic shock wave lithotripsy. J Urol 172(6;1):2271–2274 4. Chaussy C, Schmiedt E, Jocham D et al (1980) Extracorporeally induced destruction of kidney stones by shock wave. Lancet 2:1265–1268 5. Chaussy C, Schmiedt E, Jocham D et al (1982) First clinical experiences with extracorporeally induced destruction of kidney stones by shock waves. J Urol 127:417–420 6. Varkarakis J, Protogerou V, Albanis S, Sofras F, Deliveliotis C (2003) Comparison of success rates and financial cost of extracorporeal shock-wave lithotripsy in situ and after manipulation for proximal ureteral stones. Urol Res 31(4):286-290 7. Aboumarzouk OM, Kata SG, Keeley FX, McClinton S, Nabi G (2012) Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi. Cochrane Database Syst Rev (5):CD006029. doi:10.1002/14651858.CD006029.pub4 8. Wang SM, Kain ZN, White P et al (2008) Acupuncture analgesia: I. The scientific basis. Anaesth Analg 106:602–610 9. Gejervall AL, Stener-Victorin E, Möller A et al (2005) Electroacupuncture versus conventional analgesia: a comparison of pain
193 levels during oocyte aspiration and patients’ experiences of wellbeing after surgery. Hum Reprod 20(3):728–735 10. Groppetti D, Pecile AM, Sacerdote P et al (2011) Effectiveness of electroacupuncture analgesia compared with opioid administration in a dog model: a pilot study. Br J Anaesth 107(4):612–618 11. Sluka KA, Walsh D (2003) Transcutaneous electrical nerve stimulation: basic science mechanisms and clinical effectiveness. J Pain 4(3):109–121 12. Melzack R, Wall PD (1965) Pain mechanisms: a new theory. Science 150(3699):971–979 13. van der Spank JT, Cambier DC, De Paepe HM et al (2000) Pain relief in labour by transcutaneous electrical nerve stimulations (TENS). Arch Gynaecol Obstet 264(3):131–136 14. Nnoaham KE, Kumbang J (2008) Transcutaneous electrical nerve stimulation (TENS) for chronic pain. Cochrane Database Syst Rev(3):CD003222. doi:10.1002/14651858.CD003222.pub2 15. Hamza MA, White PF, Ahmed HE et al (1999) Effect of the frequency of transcutaneous electrical nerve stimulation on the postoperative opioid analgesic requirement and recovery profile. Anesthesiology 91(5):1232–1238 16. Cipriano G Jr, de Camargo Carvalho AC, Bernardelli GF et al (2008) Short-term transcutaneous electrical nerve stimulation after cardiac surgery: effect on pain, pulmonary function and electrical muscle activity. Interact Cardiovasc Thorac Surg 7:539–543 17. Gregorini C, Cipriano Junior G, Aquino LM et al (2010) Shortduration transcutaneous electrical nerve stimulation in the postoperative period of cardiac surgery. Arq Bras Cardiol 94(3):325– 331 (345–351) 18. Rawat B, Genz A, Fache JS et al (1991) Effectiveness of transcutaneous electrical nerve stimulation (TENS) for analgesia during biliary lithotripsy. Invest Radiol 26:866–869 19. Gardner WJ, Licklider JC, Weisz AZ (1960) Suppression of pain by sound. Science 132(3418):32–33 20. Cepeda MS, Carr DB, Lau J, Alvarez H (2006) Music for pain relief. Cochrane Database Syst Rev (2):CD004843. [Review. Update in: Cochrane Database Syst Rev (2013) 10:CD004843] 21. Roy M, Peretz I, Rainville P (2008) Emotional valence contributes to music-induced analgesia. Pain 134:140–147 22. Kulkarni S, Johnson PC, Kettles S et al (2012) Music dur ing interventional radiological procedures, effect on sedation, pain and anxiety: a randomised controlled trial. Br J Radiol 85(1016):1059–1063 23. Kock ME, Kain ZN, Ayoub C et al (1998) The sedative and analgesic sparing effect of music. Anesthesiology 89:300–306 24. Cepeda MS, Diaz JE, Hernandez V et al (1998) Music does not reduce alfentanil requirement during patient-controlled analgesia (PCA). Use in extracorporeal shock wave lithotripsy for renal stones. J Pain Symptom Manage 16(6):382–387 25. Yilmaz E, Ozcan S, Basar M et al (2003) Music decreases anxiety and provides sedation in extracorporeal shock wave lithotripsy. Urology 61(2):282–286 26. Karamarz A, Kaya S, Karaman H et al (2004) Effect of the frequency of transcutaneous electrical nerve stimulation on analgesia during extracorporeal shock wave lithotripsy. Urol Res 32:411–415 27. Resim S, Gumusalan Y, Ekerbicer HC et al (2005) Effectiveness of electro-acupuncture compared to sedo-analgesics in relieving pain during shockwave lithotripsy. Urol Res 33:285–290 28. Mora B, Iannuzzi M, Lang T et al (2007) Auricular acupressure as a treatment for anxiety before extracorporeal-shock wave lithotripsy in the elderly. J Urol 178:160–164 29. Wang SM, Punjala M, Weiss D et al (2007) Acupuncture as an adjunct for sedation during lithotripsy. J Altern Complement Med 13(2):241–246
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Review
Complementary approaches to decreasing discomfort during shockwave lithotripsy (SWL) Goh Ngee‑Ming · Drake Tamsin · B. P. Rai · B. K. Somani
Received: 14 December 2013 / Accepted: 4 March 2014 / Published online: 20 March 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Shock wave lithotripsy (SWL) is an established treatment for renal stones. Although non-invasive, it can cause significant pain and anxiety during the procedure. Our purpose was to review the literature to look at the effect of complimentary therapy in patients undergoing SWL and whether it led to a reduction in the requirement of analgesics and anxiolytics. A systematic review was performed on the use of acupuncture, auricular acupressure, transcutaneous electrical nerve stimulation (TENS) and music during SWL. Only prospective randomized controlled trials were selected. Two reviewers independently extracted the data from each study. Outcomes relating to analgesia requirement, anxiety and stone-free rates (SFR) were compared. Seven papers were identified reporting on 591 patients (acupuncture-3, TENS-1 and music-3). Pain control/analgesia requirement was significantly better in four studies (music2, acupuncture-1, TENS-1). Significantly lower anxiety was noted in one study with music and two using acupuncture. No difference in SFR was noted with the use of complementary therapy. No major or minor side effects were noted. Complementary therapy for SWL can help lower analgesia requirement and the anxiety associated with it. However, it does not have any effect on the SFR. Keywords Complementary therapy · Shock wave lithotripsy · Music · Acupuncture · Acupressure
Introduction Shock wave lithotripsy (SWL) causes renal stone disruption and enables passage of the subsequent debris down the ureters into the bladder. It can, however, cause renal parenchymal injury, sepsis, subcapsular haematoma [1–3], and pain especially if the calculus is near a bone. From the early 1980s SWL has become an accepted method of stone management [4–6]. Since then, the benefits of an outpatient, ambulatory day procedure has proved highly appealing to patients [7]. Given that discomfort can limit the power levels used in SWL, a potential area for SWL advancement thus lies in using alternative and complementary therapies for analgesia. Alternative or complementary medicine has often been portrayed as traditional medicine that deviates from the norm and has little or no scientific evidence for their use. However, given the popularity of their often holistic or spiritual approach, this lack of evidence is being addressed. To this end, we aimed to conduct a systematic review to assess the effect of complimentary therapy in SWL and whether it led to a reduction in analgesic/anxiolytic use. Our secondary aim was to look at whether it led to better stone-free rates (SFR).
Methods G. Ngee‑Ming · D. Tamsin · B. K. Somani (*) Department of Urology, University Hospitals Southampton NHS Trust, Southampton, UK e-mail: [email protected] B. P. Rai Department of Urology, Ninewells Hospital Dundee, Dundee, Scotland, UK
Search strategy The Cochrane Library, Medline and PubMed databases were searched from inception to April 2012. We limited the searches to include only articles written in English using the following terms: “complementary
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190
therapy”, “complementary medicine”, “complementary treatment(s)”, “acupuncture”, “acupressure”, “TENS”, “music”, “SWL”. Boolean operators (NOT, AND, OR) were also used in succession to narrow and broaden the search. Eligibility criteria Studies were eligible for inclusion if they were randomized control trials involving the use of SWL to treat renal and/or ureteric stones with concurrent use of at least one complementary therapy. Studies were excluded if there were not in English, not human-based studies, outcomes of interest were not presented, or if they were not original studies. Study selection The first step in study selection was the exclusion of duplicate reports. (i.e. reports of the same study). The title and abstract of the trials identified by the search were examined and any studies which were obviously irrelevant were excluded at this stage. The full text of each of the remaining studies was then reviewed for eligibility, and all relevant information and data extracted.
Urolithiasis (2014) 42:189–193 Literature search (No. = 242) Potential articles for evaluation of abstract (No. = 45)
Articles excluded after screening abstracts (No. = 22)
Potential articles for evaluation of full manuscript (No. = 23)
Articles excluded after screening full manuscripts (No. = 16)
Articles excluded after screening of the title (No. = 197)
Included articles = 7
Fig. 1 Outcomes of the literature search
Study characteristics The studies included in this systematic review were published between 1988 and 2007. The number of patients studied ranged 35–193, hence averaging 84.4 patients per study. There was no significant difference in the stone location in individual studies. Meta-analyses of the extracted data were not performed because there was significant heterogeneity among the seven studies in terms of outcomes measures examined. Effects of complementary therapy on SWL outcomes
Data extraction and quality assessment Two reviewers (NG and TD) extracted the data using a standardized data collection sheet to increase homogeneity and reduce bias. Disagreement between the two extracting authors was resolved in consensus by the senior author (BKS). The following information/data were extracted from each eligible study: first author, title, year of publication, journal, study design, number of cases and control, population demographics (including gender, age and weight), shock wave treatment protocol used (including number and/or voltage of shocks and duration of therapy in minutes), stone size and location, symptoms of renal colic within the previous 12 h of shock wave treatment, presence of a nephrostomy at the time of shock wave treatment, analgesia used, stone-free rate, pain and/or anxiety scores and side effects and/or adverse effects of treatment.
1. Analgesia Pain control/analgesia requirement was significantly better in four studies (music-2, acupuncture-1, TENS-1). There was a reduction of fentanyl requirement with the use of music in two studies [23, 25] and the use of TENS in one study [26] (Tables 1, 2). 2. Anxiety scores Significantly lower anxiety was noted in one study with music and one with acupuncture [25, 28]. 3. Stone-free rates (SFR) There was no significant difference in SFR with the use of complementary therapy [26, 27]. 4. Complication rates/adverse effects No major or minor side effects were noted with the use of complementary therapy [23–29].
Discussion Results Literature search Searching the 3 databases identified a total of 242 articles. After the initial screening, 45 potential articles were identified of which 7 were included in the final review (Fig. 1).
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As far as we are aware, this is the first systematic review to look at the outcomes of complementary therapy use during SWL. A relatively small number (n = 7) of studies were identified for review. Several consistent findings were apparent with the use of complementary therapy during SWL, including better analgesia and reduced anxiety. Furthermore, there were no major or minor side effects
Control: 53 ± 12. Music: 54 ± 15
Kock et al. [23]
Range 18–55. Group 1: 37.7 ± 11.9, Group 2: 41.4 ± 12.96, Group 3: 39.4 ± 14.1 Range 15–58. Group 1: median 43 (range 18–55), Group 2: median 35 (range 23–58) Group 1: 76.9 ± 5, Group 2: 77.0 ± 0.4
Range 34–56. Group 1: 46 (36–56), Group 2: 44 (34–54)
Karamarz et al. [26]
Wang et al. [29]
Mora et al. [28]
Resim et al. [27]
Range 19–68. Group 1: 39.30 ± 3.20, Group 2: 40.89 ± 3.24
Yilmaz et al. [25]
Soledad Cepeda et al. [24] Range 15–65. Group 1: 40.7 ± 12.1, Group 2: 41.0 ± 11.4
Age
Study
56 (Group 1 [acupuncture] n = 29, Group 2 [control] n = 27)
100 (50 in 2 groups: acupuncture and control)
35 (Group 1: [acupuncture] n = 17, Group 2: [midazolam + tramadol] n = 18)
66 (22 in 3 groups: conventional TENS, acupuncture TENS, and control)
193 (Group 1: [music throughout] n = 97, Group 2: [music at treatment conclusion] n = 96) 98 (Group 1: [midazolam] n = 50, Group 2: [music] n = 48)
43 (control 22, music 21)
Sample size
Table 1 Characteristics of the studies examining the effects of complementary therapy during SWL
2,500 shocks for renal calculi, 3,000 shocks for ureteric calculi
Not standardized
Only included if 1st treatment and only one stone. ESWL duration (min): Group 1: 30.40 ± 0.62, Group 2: 28.58 ± 1.088 [p = 0.004]. Shocks: Group 1: 3,016 ± 64.22, Group 2: 3,043 ± 110.42 [p = 0.662]. Voltage (kV): Group 1: 21.03 ± 0.48, Group 2: 21.96 ± 0.54 [p = 0.542] 9 kV initially increased to 24 kV. Time of ESWL (min): Group 1: 29.4 ± 5.4, Group 2: 27.2 ± 6.3, Group 3: 29.3 ± 6.3 Not standardized
Music
Stimulus load kV min 103. Control: 59 ± 14. Music: 65 ± 13 [not significant] Only included if 1st treatment. Treatment voltage of 17 V always reached. Group 1: 20.0 ± 15.4 min, Group 2: 22.2 ± 19.0 min [p = 0.393]
Auricular acupuncture
Auricular acupuncture
Electro-acupuncture
TENS
Music
Music
Complementary therapy studied
Duration/voltage of SWL, stone size/location
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Auricular acupuncture
Auricular acupuncture
Electro-acupuncture No side effects with electro-acupuncture. Mild orthostatic hypotension and dizziness in some Group 2 patients
Lower anxiety and pain scores with auricular acupressure
Lower opiate (alfentanyl) requirements, lower pain scores and lower anxiety scores with acupuncture Wang et al. [29]
Resim et al. [27]
Mora et al. [28]
Stone-free rate, maximum energy level applied
TENS Lower incidence of nausea and dizziness Karamarz et al. [26]
Lower opiate (fentanyl) requirements with music. Also lower STAI-trait anxiety. Less anxious/more comfortable on 7-point verbal scale Lower opiate (alfentanyl) requirements, lower pain scores and increased patient satisfaction with conventional TENS compared to acupuncture-like TENS or music
Reduction in alfentanyl requirements
Kock et al. [23] Soledad Cepeda et al. [24] Yilmaz et al. [25]
13
Stone-free rate
No difference in adverse event rates Similar side-effect incidence Duration of stay Pain Score, alfentanyl use STAI-state anxiety
Other No effect Effect Study
Table 2 Effects of complementary therapy on SWL outcomes
Music Music Music
Urolithiasis (2014) 42:189–193
Complementary therapy studied
192
noted from the use of such complementary therapy. In the study by Yilmaz and colleagues [25], the stone location was evenly matched and a third generation electrohydraulic lithotripter was used with all patients undergoing only one session of SWL. The music group had a significantly shorter SWL session (28.6 min compared to 30.4 min) with significantly better anxiety scores after sedation and before and after SWL treatment. The fentanyl requirement was also 21 μg compared to 36 μg (p = 0.008). Similarly Karamarz [26] reported the use of second generation lithotripter and showed a lesser alfentanil requirement 956 μg in the TENS group compared to 1,916 μg where the former group also had a higher number of stones in the upper pole calyx. Acupuncture was the most popular and widespread complementary therapy. The various forms of acupuncture use pressure, heat or needles, sometimes in combination or augmented with electrical stimulation, to provide health benefits. Until recently the basis for these benefits has been unknown, but Wang et al. have evaluated much of the scientific literature behind acupuncture. They have surmised that data so far suggest the practice stimulates the “release of endogenous opioid-like substances, including enkephalin, β-endorphin, and endomorphine, that modulate pain signals” [8]. Whilst acupuncture science develops, in practice Gejervall et al. [9] found that electro-acupuncture offered significantly less pain control than conventional analgesia in women during in vitro fertilization, though it did offer less fatigue and confusion as side effects. Conversely, Groppetti et al. [10] gathered evidence to support electro-acupuncture as an alternative in post-operative analgesia, albeit in dogs. Transcutaneous electrical nerve stimulation (TENS) covers a variety of methods by which the skin is stimulated with electrical pulses of varying frequency, intensity and duration. Proposed theories for the mechanisms behind TENS’ effects are similar to those for acupuncture. Again endogenous pain control [11] is postulated as a mechanism, though the gate-control theory is also proposed [12]. In practice, TENS is primarily used in chronic pain, though some centres also offer it to alleviate labour pains [13]. Despite its relatively extensive usage, however, the latest Cochrane review [14] has found no good evidence either supporting or disapproving the use of TENS for chronic pain, primarily down to a lack of large and well-designed randomized control trials. There have been some surgically orientated trials, however, with Hamza et al. [15] using TENS post-gynaecological surgery, and Cipriano et al. [16] and Gregorini et al. [17] post-cardiac surgery, all finding benefits to pain control, including reduced opioid requirements and hence reduced side effects. A more clinically pertinent trial by Rawat et al. [18] using TENS with biliary lithotripsy, however, found no reduction in intravenous analgesia requirement or in pain perception.
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Since Gardner et al. [19] reported their results with music on pain control in dental procedures in 1960, it has been widely accepted that music has beneficial effects. The Cochrane review in 2010 [20] concluded that music did reduce pain control and opioid requirements though the benefits were only small. Regarding the basis for these benefits, while the gate theory is proposed, and distraction also a factor depending on the environment, emotional valence is now being shown to be vital for music’s effects [21]. A study by Kulkarni et al. [22] showed a significant reduction in sedation requirement with patient-selected music contributing favourably to overall patient experience. Overall, improving SWL analgesia and patient experience could have benefits to lithotripsy application, compliance with further therapy sessions and pharmacological side effects [23–29]. In turn, methods such as acupuncture, TENS and music offer an avenue to these benefits.
Conclusions In conclusion, our review leads us to suggest that complementary therapy for SWL can help lower analgesia requirements and the anxiety associated with it in some cases. However, it does not have any effect on the SFR achieved. Conflict of interest The authors declare that they have no conflict of interest.
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