Original Article The Effect of Transcutaneous Electrical Nerve Stimulation for Pain Relief During Extracorporeal Shock-Wave Lithotripsy Procedure ---
From the Department of Surgical Nursing, Nursing Faculties, Ege University, Izmir, Turkey. Address correspondence to Esma Ozsaker, PhD, RN, Hemsirelik Fakultesi, Ege Universitesi, 35100, Bornova, Izmir, Turkey. E-mail: esma. [email protected]
Received December 24, 2010; Revised June 8, 2012; Accepted June 8, 2012. Presented at the Sixth Surgical and Operating Room Nursing Congress, 2009, Kusadasi, Turkey. 1524-9042/$36.00 Crown Copyright Ó 2014 Published by Elsevier Inc. on behalf of the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2012.06.003
Esma Ozsaker, PhD, RN, and Alev Diramali, PhD
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. Crown Copyright Ó 2014 Published by Elsevier Inc. on behalf of the American Society for Pain Management Nursing
Extracorporeal shock-wave lithotripsy (ESWL) has revolutionized the treatment of urinary stone disease because of its simplicity, efficacy, and minimal morbidity (Bal & Hatipoglu, 2002; Reichelt, Zermann, Wunderlich, Janitzky, & Schubert, 1999). Researchers have revealed that the ESWL procedure causes pain, and many pharmacologic methods are used to relieve the pain (Chin, Tay, Ng, Lim, & Chang, 1997; Ozcan, Yilmaz, Buyukocak, Basar, & Apan, 2002; Reichelt, Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 59-68
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Zermann, Wunderlich, Janitzky, & Schubert, 1999; Unsal, Cimentepe, Bozoklu, & Saglam, 2001). Two different causes may result in pain during the ESWL procedure. The first is the exogenous pain resulted from the trauma caused on pain receptors in skin by the shock waves moving through the skin and muscles toward the kidneys. The second is the visceral pain, which is the acute organ pain caused by distension of renal capsule around the affected area and the multiplied intrarenal pressure. In addition to this, it has been stated that the effect of shock waves on the twelfth costa and the movements of the stone fragments during the ESWL procedure contribute to the pain (Torrecilla-Ortiz, Rodrıguez-Blanco, Dıaz-Vicente, Gonzalez-Satue, Marco-Perez, Trilla-Herrera, . Mila, 2000; Yilmaz, Batislam, Tuglu, Basar, Boratav, & Basar 2002). Moreover, besides the factors related to patients, shock wave generation and focusing, structure of the shock wave and the highest peak pressure, size of the focal zone, and area of shock wave entry at the skin are the physical factors contributing to cause pain (Ayyildiz, Nuhoglu, Huri, Gurdal, & Germiyuanoglu 2004; Chin et al., 1997; Resim, Gumusalan, Ekerbicer, Sahin, & Sahinkanat, 2005). Inadequate pain control in patients can lead to many complications, reduction of participation in treatment and care, patient dissatisfaction, longer hospitalization, and increased costs (Allred, Byers, & Sole, 2010; Valente, 2006). During ESWL, cooperation of the patient to break up the stone easily and eliminating pain in the patient are important in increasing the effectiveness of ESWL. General anesthesia, spinalepidural anesthesia, local anesthesia/analgesic agents, acupuncture, opioid analgesics, analgesic antiinflammatoriess, and sedatives have been used as methods and drugs for pain relief during ESWL (Ayyildiz et al., 2004; Turna, & Nazli, 2005). Intravenous sedative analgesics, such as fentanyl, alfentanyl, ketamine, and midazolam, are widely used in ESWL, which is a day case procedure, because they have especially short-term effects (Kararmaz, Kaya, Karaman, & Turhanoglu 2004; Resim et al., 2005; Unsal et al., 2001). Opioids seem to be a favorable analgesic during ESWL; however, opioid administration may be problematic, especially at high doses, because ESWL is generally carried out in an outpatient setting. Therefore, different techniques have been tried for decreasing the dosage of opioids (Ozcan et al., 2002). Nurses spend more time with patients experiencing pain than any other health care professional and are therefore in an ideal position to consider other pain-relieving strategies to complement the analgesics currently used (Dunn, 2004). Although there is no
standard method that can be applied to all patients’ pain control, pain management should begin with a preventive approach to pain, and both pharmacologic and nonpharmacologic methods should be used together for the most effective pain control (Allred et al., 2010). In pain control, nonpharmacologic pain control methods can be used to increase the effect of analgesics, in case of insufficient effect of analgesics, or when analgesics can not be used. Among nonpharmacologic pain control methods, transcutaneous electrical nerve stimulation (TENS), application of hot and/ or cold compresses, exercises, positioning, and massage are physical techniques commonly used in pain control, and relaxation, distraction, and hypnosis are cognitive/behavioral techniques (Arslan & Celebioglu, 2004). The nonpharmocologic approach to pain management includes a wide variety of techniques that not only address the physical sensations of pain, but also attempt to prevent suffering by enhancing the psychoemotional and spiritual components of care (Yavuz, 2006). TENS is a method for the electrical stimulation of nerves through electrodes applied to the skin (Ainsworth, Budelier, Clinesmith, Fiedler, Landstrom, Leeper, . Sluka, 2006; Sluka & Walsh, 2003; Yavuz, 2006). Pain relief through skin stimulation methods is based on the Gate Control Theory or increase in levels of endorphin, which is the natural morphine of the body. Skin-stimulation techniques have some advantages, such as reducing the intensity of pain or sometimes relieving it, alleviating muscle spasm, increasing physical activity, creating general relaxation, reducing anxiety, and strengthening the patient-nurse relation (Kocaman, 1994). Therefore, use of nonpharmacologic methods in pain management may be more effective and beneficial, and pain could be managed more effectively through combination of pharmacologic and nonpharmacologic methods (Mccaffery, 2002). There are few research studies about the nonpharmacologic methods for controlling the pain during ESWL procedures. The results on effectiveness of these methods are contradictory and controversial. Therefore, further investigations are necessary to detect the effects of TENS for pain relief during shock-wave lithotripsy procedures. The purpose of the present study was to investigate the effect of TENS for pain relief during the ESWL procedure.
METHODS Study Design An experimental repeated-measures design and selfcontrolled design with patients acting as their own
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control were used in this research (Emiroglu, 2004; Polit, Beck, & Hungler, 2001). The study was conducted at Lithotripsy Unit at Ege University Hospital in I_zmir, Turkey. Sample The sample consisted of 50 patients who applied to lithotripsy unit from May 15, 2006, to February 15, 2007, and whose body mass index was 20 mm2 1 ESWL ¼ extracorporeal shock-wave lithotripsy.
% 50.0 50.0 50.0 50.0 68.0 32.0 36.0 24.0 40.0 46.0 54.0 12.0 46.0 42.0 42.0 56.0 2.0
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TABLE 2. Patient Anxiety Score Before Application and ESWL Variables (n ¼ 50) First Application (Without TENS)
Second Application (With TENS)
Anxiety score ESWL duration (min) Voltage (kV) Shocks (n)
32.86 27.66 19.98 1954.0
(7.49) (2.42) (1.33) (80.07)
36.86 28.04 19.96 1977.00
(9.06) (2.28) (.90) (44.27)
t ¼ 5.50** t ¼ 1.373 t ¼ 0.136 t ¼ 2.250*
ESWL ¼ extracorporeal shock-wave lithotripsy; TENS ¼ transcutaneous electrical nerve stimulation. *p < .05. **p < .001.
applications was found to be statistically significant (t ¼ 5.50; p < .001; Table 2). Although there was a significant difference, it was observed that the patients had mild anxiety (scores of 20-39) before the procedures in both application. Pain Distribution of average scores of the perceived pain (VAS) according to the time of measurement in the first and second applications is presented in Table 3 and Fig. 1. VAS score was found to be significantly low in patients to whom TENS was applied (first application) compared with those to whom it was not applied (second application; p < .05). There was a significant difference between VAS scores according to the times (10th min, 20th min, and at the end; p < .05). The VAS score at the 20th minute during the procedure was found to be higher compared with those at the 10th minute and at the end of the procedure. It was observed that there was not a significant difference between the two applications regarding the amount of the effect caused by the time (F ¼ 1.868; p > .05).
No significant difference was found between the VAS average scores in the first and the second applications according to age (first application: F ¼ 0.393; p > .05; second application: F ¼ 0.174; p > .05) and sex (first application: F ¼ 0.235; p > .05; second application: F ¼ 0.094; p > .05). No significant difference was found between the VAS average scores in the first and the second applications regarding location of the stone (first application: F ¼ 0.393; p > .05; second application: F ¼ 0.040; p > .05) and stone diameter (first application: F ¼ 0.004; p > .05; second application: F ¼ 0.055; p > .05). No significant difference was found between the two applications regarding speed of pulse, systolic blood pressure, diastolic blood pressure, or rate of respiration when distribution of physiologic symptoms was analyzed according to the measurement times in the first and second applications (p > .05). A statistically significant difference was found between the two applications regarding number of demanded analgesics (t ¼ 9.966; p < .001) and number of bolus doses delivered by PCA pump as a result of successful demands of the patients (t ¼ 6.348; p < .001).
TABLE 3. Mean Visual Analog Scale (VAS) Pain Score According to Application (n ¼ 50) First Application (Without TENS) VAS
10th min 20th min End of ESWL
4.97 5.30 2.54
Second Application (With TENS) Mean
(1.66) 4.16 (1.06) 4.82 (.84) 1.92 Application: F ¼ 56.674* Time: F ¼ 142.570* Application and time: F ¼ 1.868
ESWL ¼ extracorporeal shock-wave lithotripsy; TENS ¼ transcutaneous electrical nerve stimulation. *p < .001.
(SD) (1.61) (.91) (.81)
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used, and TENS was used in the second session. This type of study is called a repeated-measures design of experimental study in the literature (Polit et al., 2001; Emiroglu, 2004).
VAS score according to time.
Compared with the first application, the number of demanded analgesics was significantly lower in the 2nd application in which TENS was applied (Table 4). It was noted that 36.0% of the patients reported adverse effects in the first application (without TENS) and that this percentage was 20.0% in the second application (with TENS). It was observed that the patients had dizziness or mild nausea that did not require any antiemetic treatment. It was noted that there was a statistically significant difference between the two applications when they were compared regarding presence of adverse effects (p < .05). There was a statistically significant difference between the first application (without TENS) and the second application (with TENS) when the characteristics of patients’ pain were analyzed (c2 ¼ 20.395; p < .01; Table 5). Comparing the level of patients’ satisfaction from the pain treatment, it was noted that the level of satisfaction in the second application (with TENS) was statistically significantly higher than in the first application (without TENS; Z ¼ 5.816; p < .01).
DISCUSSION In this research, ESWL was carried out on the same patient in two sessions. In the first session TENS was not
ESWL Variables The total number of shock waves applied during an ESWL procedure is one of the important parameters, and this number is 2,000-2,500 in clinical practice. According to the literature, it is suggested that the application be in a great number of small doses to decrease the harm to the kidney, because making the application at one time and with high doses expands the periglomerular and intratubular areas (Turna & Nazli, 2005). Approximately 2,000 shockwaves are applied to each patient in the clinics where the present research was carried out. A statistically significant difference was found between the two applications regarding the numbers of the shock waves applied to the patient. A higher number of shock waves in the second application (1,977 44.27) compared with the first application (1,954 80.07) suggests that it is due to the increase in the patient’s tolerance to pain thanks to the TENS application. Anxiety An analysis of the anxiety scores of the patients before the ESWL procedure revealed that the difference between the two applications was found to be statistically significant (t ¼ 5.50; p < .001). Although there was a statistically significant difference, it was observed that the patients had mild anxiety (scores of 20-39) before the procedures in both applications. In Bal and Hatipoglu’s (2002) study, it was determined that the state anxiety was at a moderate level (scores of 40-59) in 62% of the patients to whom ESWL would be applied. In their study, Margalith and Shapiro (1997) stated that education was effective in coping with a disease and a stress-causing situation, that the level of anxiety was lower in those with a higher education level compared with a lower education level, and that this resulted from the fact that the patients with higher
TABLE 4. Mean Analgesic Requests of Patients According to Application (n ¼ 50) First Application (Without TENS)
Second Application (With TENS)
t ¼ 9.966*
TENS ¼ transcutaneous electrical nerve stimulation. *p < .001.
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TABLE 5. Comparison of Patients’ Pain Characteristics According to Application (n ¼ 50) First Application (Without TENS)
Second Application (With TENS)
c2 ¼ 20.395*
TENS ¼ transcutaneous electrical nerve stimulation. *p < .01.
education were more interested in anxiety and coping mechanisms and more open to recent information (Bal & Hatipoglu, 2002). In the present study, the patients’ anxiety was at a mild level before the procedure, and it is thought that this was due to the fact that most of the participants were graduates of high school/college. According to the literature, similarly to this study, higher educational level seems to have a protective effect against anxiety and depression, which accumulates throughout life (Bjelland, Krokstad, Mykletun, Dahl, Tell, & Tambs, 2008). In addition, decreased anxiety could also be due to knowing what to expect on the second round of therapy. Yilmaz et al. (2002) found that level of state anxiety was lower in the group of patients to whom information was given before the ESWL procedure compared with a group of patients who were not informed before the procedure. In our study, however, the level of anxiety was higher when the patients arrived for the second session, although they had information about the procedure beforehand (p < .05). Similarly, in the study conducted by Bal and Hatipo glu (2003), average anxiety scores of the patients to whom ESWL would be applied were compared according to the number of procedures, and it was noted that average anxiety scores were higher in those having second, third, and fourth procedures than in those to whom it would be applied for the first time. Moreover, no significant difference was found between the groups in that study. This is explained in the literature with Haber and Krainovich’s behavioral theory, which states that the cause of the anxiety in the first procedure is fear of the unknown since they have never experienced that procedure before; on the other hand, anxiety increases as a learned behavior owing to the sensitivity to the endogenous and environmental stimulants in the second and following procedures (Bal & Hatipoglu, 2002). Lower level of anxiety during and after the second application is considered to result from the TENS application, although it was higher before the procedure in
the second application compared with the the first application. According to the literature, it is stated that using coping methods together with analgesics reduce anxiety as well as pain (Yavuz & Ozbayir, 2000). Pain Reichelt et al. (1999) stated that TENS has a painreducing or pain-relieving effect at a level of 30%-77% in most patients. In the study by Ayyildiz et al. (2004), pain relief during ESWL was found to be statistically significant in 31 of 56 patients (55.35%) to whom TENS was applied during a shock-wave lithotripsy procedure (p < .001). Similarly, in Kararmaz et al.’s (2004) research, in which the effects of the frequency of TENS on analgesia during ESWL were analyzed, it was noted that VAS pain score was significantly low especially at high energy levels in the group to whom TENS was applied compared with the other groups (p < .001). The results of the study by Reichelt et al. (1999) showed that the pain of 70% of the patients was relieved significantly in a shock-wave lithotripsy procedure with TENS, as well. In Oncel, Sencan, Yildiz, and Kurt’s (2002) study, in which the effectiveness of TENS in pain management in patients with costal fractures was analyzed, TENS was found to be more effective than nonsteroidal antiinflammatory drugs. In the present study as well, the difference between the average VAS scores in the two applications made on the same patient was found to be statistically significant. VAS score was found to be significantly low when TENS was applied (second application; p < .05). It was observed that TENS application is effective in pain relief in patients. The literature reports that factors affecting pain are related not only to the patient but also to various environmental factors which should be taken into consideration, that age and sex have effects on pain intensity, and, as stated in one study, the intensity of pain is higher in young women. Similarly, studies have revealed that the pain sensitivity of the patients decreases with age
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(Yucel, 2000). In the study by Salinas, Lorenzo-Romero, Segura, Calero, Hernandez-Millan, Martinez-Martin, and Virseda (1999) on the factors determining the need for analgesics and sedatives in ESWL procedures, it was noted that use of analgesics was higher in young patients (p < .01) and that the highest sedative use (p < .01) was in young patients (p < .001). In the present study, no significant difference was found between the age groups regarding average pain scores (p > .05) as a result of the statistical analysis, although the average pain scores (VAS) were lower in 42–65-year-old group at the 10th minute and at the end of the procedure in the first and second applications. It is known that another factor affecting pain behavior is sex, the level of tolerance to pain being higher in men, this difference between women and men reflecting cultural attitudes toward pain. A study conducted with postoperative patients revealed that women experience pain with higher intensity than men, although the difference was not statistically significant (Kuguoglu, 2006). In the study by Ayyıldız et al. (2004), it was noted that the pain of two female patients did not decrease (VAS 10) and the average VAS value was higher in female patients (5.0 0.6) than in male patients (4.6 0.4) despite the use of TENS in the shockwave lithotripsy procedure. In the present study, it was noted that average VAS scores were lower in men in the second application and that use of TENS decreased the average pain scores more, whereas the average VAS scores were higher in men than in women in the first application. However, no significant difference was found between male and female patients regarding average pain scores in the first and second applications as a result of the statistical analysis (p > .05). Similarly, the study by Eti Aslan to determine the relation of postoperative pain with personal characteristics revealed that sex is not related to reporting of pain (Kuguoglu, 2006). Berwin, Husseiny, Papatsoris, Hajdinjak, Masood, and Buchholz (2009) found that the location and diameter of the stones affect the experience of pain and that small stones induce more pain than large stones during treatment. The present study also revealed that average pain scores were higher in the upper calyces stones, although there was not a statistically significant difference (p > .05) when the relation between the location of the stone and the perceived pain score average was analyzed. This could be explained with the fact that the pain increases with the pressure the shock waves make on the 12th costa, because the stones in the upper calyces are closer to the 12th costa (Yilmaz et al., 2002). An analysis of the relationship between the diameter of the stone and the perceived
pain score average revealed no significant difference (p > .05). In accordance with these results, it was concluded in the present study that the location and size of the stones do not affect the patient’s pain in ESWL procedures. According to the literature, the need for opioid analgesics decreases in the patients to whom TENS is applied. The study by Kararmaz et al. (2004), in which the effects of the frequency of transcutaneous electrical nerve stimulation on analgesia during ESWL were analyzed, noted that alfentanyl consumption was considerably lower in the group to whom conventional TENS was applied compared with the other groups (p < .001). Bjordal et al. (2003) stated that TENS in postoperative pain management reduces the intensity of pain and the need for analgesics, and Reichelt et al. (1999) stated that with TENS use only 38% of patients needed pain treatment. Aldemir (2000) stated that conventional TENS is a considerably effective method in postoperative pain treatment and in reducing postoperative opioid need; effective postoperative analgesia was obtained in 80% of patients with major abdominal and thoracic operations and 77% needed less opioid. The difference between the two applications in the present study was statistically significant when the distribution of the number of demanded analgesics in the applications was analyzed (p < .05). The number of the demanded analgesics was found to be significantly low when TENS was applied. These results are similar to those in the literature. Dizziness or mild nausea that would not require antiemetic treatment was observed during the procedure. Opioids cause nausea as a result of the stimulation on chemoreceptor trigger area, inhibition of gastrointestinal motility, and stimulation on vestibular nerves (Kocaman, 1994). It was noted that there was a statistically significant difference between the two applications regarding the presence of adverse effects (p < .05); TENS reduced the presence of adverse effects in patients. This is considered to result from the decrease in the patients’ demand for analgesics thanks to TENS applications. Moreover, it is stated that TENS has an antiemetic effect besides its analgesic effect and is effective on postoperative nausea related to opioid treatment (Johnson, 2002). In addition to this, it was stated in earlier studies that TENS reduced postoperative atelectasis and the frequency of nausea and vomiting (Bjordal et al., 2003), that it was more effective when used in combination with opioids in postoperative analgesia, and that it reduced the adverse effects induced by the opioids by decreasing the patients’ need for opioids by more than 50% (Aldemir, 2000). Similarly to this study, the results of the study by Kararmaz et al. (2004), in which the effects of the frequency of TENS on
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analgesia during ESWL were analyzed, revealed that the incidence of nausea and dizziness was lower in patients to whom conventional TENS was applied (p < .05). It was observed that the results of our research were in accordance with those in the literature. A significant difference was found when the characteristics of the patients’ pain in the first and second applications were compared (p < .05). A change in the characteristics of pain was observed in some of the patients with TENS application. Similarly to our study, Bilgehan and Akc¸ali (2002) conducted a study on the effectiveness of TENS on birth pain and determined that TENS did not have a clear superiority compared with placebos, but the characteristics of the pain changed and tolerance to pain increased (Bilgehan & Akcali, 2002). One of the methods used to evaluate quality is to evaluate patients’ satisfaction (Yavuz, 1998). Patients’ satisfaction level was found to be statistically significantly higher in the second application in which TENS was used compared with the first application (without TENS) in the present study (p < .05). This is thought to be related to the fact that the patients’ pain was reduced with TENS application. As a result of the analysis, a negative relationship was also found between the patients’ satisfaction and perceived pain score during the applications. It was observed that satisfaction from the procedure increased as average pain scores decreased.
CONCLUSION Results showed that the TENS application reduced patients’ intensity of pain due to ESWL treatment,
patients demanded fewer analgesics, adverse effects decreased, and patients’ satisfaction was higher. It is recommended that the evidence obtained in this research should be supplemented by repeating the study on similar groups, similar studies with different frequency and current density applied to larger groups of patients, and investigating the effects of TENS application combined with different pharmacologic and nonpharmacologic therapeutic techniques, because of the subjective quality of pain. After an evaluation of the conclusions, TENS application should be recommended for use in nursing care for more effective pain control in patients during ESWL treatment.
CINICAL IMPLICATIONS TENS application, as a nursing intervention, is a noninvasive and safe therapy for health promotion of patients. Nurses who can use TENS application as an intervention for patients who have undergone ESWL treatment promote nursing autonomy. It is advisable that TENS application become a part of nursing care offered to patients experiencing pain, because TENS application is a low-cost therapy that has no side effects. Acknowledgments The authors thank Gulden Ugur, Meryem Yavuz, and Fatma Demir Korkmaz for their helpful comments on this study and Hatice Uluer for statistical analyses.
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