JAMES A. MCCARTHY, BS, and ROBERT W. ZIGENFUS, BS
The literature has frequently contained reports of new and widespread clinical application of transcu taneous electrical nerve stimulation (TENS) as a treatment modality. This report describes a rela tively successful clinical endeavor in the acute care setting. Transcutaneous electrical nerve stimulation was administered to a patient experiencing the symptomatic pain and paresthesia frequently ac companying Guillain-Barre Syndrome. Our patient was a 20-year-old woman in her second month of hospitalization for treatment of Guillain-Barre Syndrome. At the time TENS treat ment was initiated, her condition demanded a res pirator, a tracheotomy, nasal-gastric tubes, a cardiac monitor, frequent suctioning, and meticulous inten sive-care nursing. The physical therapy program since hospitalization included range-of-motion ex ercises, protective hand and dorsiflexion splinting, and close consultation and cooperation with the nursing staff regarding positioning, splint applica tion, and psychosocial support. A major management problem was the patient's experience of excruciating pain. This existed in her low back, and bilaterally in the posterior hip, thigh, and calf with intense burning paresthesia in her feet. She was receiving Diazepam (Valium®)* 10 mg, t.i.d.; and intermuscular Pentazocine (Talwin®)f 50 mg, every three hours, p.r.n. The patient was still in substantial discomfort during all waking hours. Consequently, she requested fre quent repositioning as often as three to four times per hour.
Mr. McCarthy is Staff Physical Therapist, Deaconess Hospital, Evansville, IN 47747. Mr. Zingenfus is Director of Physical Medicine, Deaconess Hospital, Evansville, IN 47747. * Roche, Division of Hoffman-La Roche, Inc, Nutley, NJ 07110. t Winthrop Laboratories, 90 Park Ave, New York, NY 10016.
Volume 58 / Number 1, January 1978
PROCEDURES The attending physician approved our request to initiate TENS on a trial basis. The technique and our goals were explained to the patient prior to application. The most favorable results obtained from TENS were achieved with the following program. A dualchannel stimulator was used. Two 5.08 cm x 10.16 cm electrodes were coated with conduction gel. They were placed paravertebral^ approximately 2.5 cm lateral to the L4-S2 spinous processes. Two 5.08 cm x 5.08 cm electrodes, coated with conduc tion gel, were placed midway between the ischial tuberosity and the greater trochanter of the femur above the sciatic nerve. The electrodes were re moved daily for skin care, cleansing, and reapplication of conduction gel. The pulse width, rate, and intensity were adjusted to patient comfort. The patient and the nursing staff were instructed in the theory, mechanics, and application of TENS. The TENS was administered according to the pa tient's needs for pain management. The patient's motor status did not allow her to operate the stimulator independently; thus, the nursing staff performed this service when the the patient re quested it. They also provided bedside documenta tion of treatment duration, intensity, and general comments they felt appropriate. The general com ments tended to report the areas and extent of pain the patient experienced, with and without the TENS, pain medication as administered in conjunc tion with TENS, and periods the patient fell asleep with the unit in operation. RESULTS The range of duration for the use of TENS as requested by the patient and as documented by the 23
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Transcutaneous Electrical Nerve Stimulation: An Adjunct in the Pain Management of Guillain-Barre Syndrome
mitigate the foot paresthesia, TENS was continued with electrode placement as originally described. This was justified by the improvement and relief the patient consistently reported in her back and lower extremities. On this basis, it was a successful adjunct to pain management and patient care. The team approach was found to be a most beneficial aspect of our procedure for carrying out TENS in an acute care setting. This approach was necessary to decrease demand on the therapist, to provide for use of the unit as needed in the thera pist's absence, and to provide some ongoing docu mentation. Our case report summarizes an isolated clinical experience. Thus, one can only speculate, within the limits of such experience, if TENS had any influence on resolving the patient's pain; or whether the pain gradually diminished and disappeared strictly as part of the normal recovery process. SUMMARY
DISCUSSION We were unable to decrease the intense burning paresthesia the patient experienced in her feet with the described electrode placement. Alternate, but unsuccessful, attempts to influence the foot pares thesia included placement of electrodes in the low back as previously noted, with bilateral trial place ment of: 1) a 5.08 cm x 5.08 cm electrode over the common peroneal nerve as it curves superficially to the neck of the fibula; 2) a 5.08 cm x 15.24 cm electrode around the circumference of the distal leg immediately proximal to the malleoli; and 3) a 5.08 cm x 15.24 cm electrode wrapped around the dorsal and plantar surfaces of the foot. The patient reported an immediate severe in crease in burning paresthesia with trial number three even at low intensity. Despite our inability to
Transcutaneous electrical nerve stimulation was applied in the pain management of a patient with Guillain-Barre Syndrome. As subjectively reported by the patient, her back and lower extremity pain was significantly decreased although her foot pares thesia was not decreased. The program was contin ued for an 11-day period because TENS was consid ered a valuable adjunct for the patient's comfort. Transcutaneous electrical nerve stimulation is a valuable addition to our repertoire of available physical therapy modalities. We hope that as clinical experience with TENS increases, fellow clinicians will volunteer the experiences of their endeavors. Acknowledgment. The authors are indebted to the nursing staff of Deaconess Hospital for their extended cooperation and efforts and to the physical therapy staff for their constructive criticisms.
SUGGESTED READINGS
1. Report on the Findings and Recommendations on Transcuta neous Electrical Nerve Stimulation for Pain Relief by the Panel on Review of Neurological Devices. Food and Drug Administration, DHEW, Rockville, MD, February 1976, 16 PP 2. Thorsteinsson G, Stonnington HH, Still well GK: Transcuta neous electrical stimulation: A double-blind trial of its efficacy for pain. Arch Phys Med Rehabil 58:8-13, 1977 3. Loeser JD, Black RG, Christman A: Relief of pain by transcutaneous stimulation. J Neurosurg 42:308-314, 1975 4. Sternbach RA, Ignelzi RJ, Deems LM et al: Transcutaneous
24
electrical analgesia: A follow-up analysis. Pain 2:35-41, 1976 5. Melzack R: Prolonged relief of pain by brief, intense transcu taneous somatic stimulation. Pain 1:357-373, 1975 6. Agnew DC, Merskey H: Words of chronic pain. Pain 2:7381,1976 7. Loeser JD, Black RG: A taxonomy of pain. Pain 1:81-84, 1975 8. Melzack R, Torgerson NS: On the language of pain. Anaes thesia 34:50-59, 1971 9. Melzack R: The McGill pain questionnaire: Major properties and scoring methods. Pain 1:277-299, 1975
PHYSICAL THERAPY
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nursing staff was from one-half hour to three and one-half hours. The intensity (amplitude) setting ranged from 4.5 to 10.0 for the low back channel and 2.5 to 4.0 for the gluteal channel. The rate and pulse width, as determined by patient comfort, remained constant at 6.0 and 10.0 respectively. The frequency of stimulation varied from one to four times per day. The patient was questioned by her attending physician following initiation of treatment. The phy sician proposed a scale with "0" indicating the pain was unchanged and "10" indicating the pain was completely eliminated, or 100 percent improve ment. On this scale, the patient reported her pain as improved 7 to 8 for her back and lower extremi ties. She consistently reported this degree of pain relief throughout the 11-day duration of the TENS program. Although this rating system might appear vague, it served the physician's clinical need to assess the value of TENS for his patient.
The literature has frequently contained reports of new and widespread clinical application of transcu taneous electrical nerve stimulation (TENS) as a treatment modality. This report describes a rela tively successful clinical endeavor in the acute care setting. Transcutaneous electrical nerve stimulation was administered to a patient experiencing the symptomatic pain and paresthesia frequently ac companying Guillain-Barre Syndrome. Our patient was a 20-year-old woman in her second month of hospitalization for treatment of Guillain-Barre Syndrome. At the time TENS treat ment was initiated, her condition demanded a res pirator, a tracheotomy, nasal-gastric tubes, a cardiac monitor, frequent suctioning, and meticulous inten sive-care nursing. The physical therapy program since hospitalization included range-of-motion ex ercises, protective hand and dorsiflexion splinting, and close consultation and cooperation with the nursing staff regarding positioning, splint applica tion, and psychosocial support. A major management problem was the patient's experience of excruciating pain. This existed in her low back, and bilaterally in the posterior hip, thigh, and calf with intense burning paresthesia in her feet. She was receiving Diazepam (Valium®)* 10 mg, t.i.d.; and intermuscular Pentazocine (Talwin®)f 50 mg, every three hours, p.r.n. The patient was still in substantial discomfort during all waking hours. Consequently, she requested fre quent repositioning as often as three to four times per hour.
Mr. McCarthy is Staff Physical Therapist, Deaconess Hospital, Evansville, IN 47747. Mr. Zingenfus is Director of Physical Medicine, Deaconess Hospital, Evansville, IN 47747. * Roche, Division of Hoffman-La Roche, Inc, Nutley, NJ 07110. t Winthrop Laboratories, 90 Park Ave, New York, NY 10016.
Volume 58 / Number 1, January 1978
PROCEDURES The attending physician approved our request to initiate TENS on a trial basis. The technique and our goals were explained to the patient prior to application. The most favorable results obtained from TENS were achieved with the following program. A dualchannel stimulator was used. Two 5.08 cm x 10.16 cm electrodes were coated with conduction gel. They were placed paravertebral^ approximately 2.5 cm lateral to the L4-S2 spinous processes. Two 5.08 cm x 5.08 cm electrodes, coated with conduc tion gel, were placed midway between the ischial tuberosity and the greater trochanter of the femur above the sciatic nerve. The electrodes were re moved daily for skin care, cleansing, and reapplication of conduction gel. The pulse width, rate, and intensity were adjusted to patient comfort. The patient and the nursing staff were instructed in the theory, mechanics, and application of TENS. The TENS was administered according to the pa tient's needs for pain management. The patient's motor status did not allow her to operate the stimulator independently; thus, the nursing staff performed this service when the the patient re quested it. They also provided bedside documenta tion of treatment duration, intensity, and general comments they felt appropriate. The general com ments tended to report the areas and extent of pain the patient experienced, with and without the TENS, pain medication as administered in conjunc tion with TENS, and periods the patient fell asleep with the unit in operation. RESULTS The range of duration for the use of TENS as requested by the patient and as documented by the 23
Downloaded from https://academic.oup.com/ptj/article-abstract/58/1/23/4559120 by University of Texas at Dallas user on 04 February 2019
Transcutaneous Electrical Nerve Stimulation: An Adjunct in the Pain Management of Guillain-Barre Syndrome
mitigate the foot paresthesia, TENS was continued with electrode placement as originally described. This was justified by the improvement and relief the patient consistently reported in her back and lower extremities. On this basis, it was a successful adjunct to pain management and patient care. The team approach was found to be a most beneficial aspect of our procedure for carrying out TENS in an acute care setting. This approach was necessary to decrease demand on the therapist, to provide for use of the unit as needed in the thera pist's absence, and to provide some ongoing docu mentation. Our case report summarizes an isolated clinical experience. Thus, one can only speculate, within the limits of such experience, if TENS had any influence on resolving the patient's pain; or whether the pain gradually diminished and disappeared strictly as part of the normal recovery process. SUMMARY
DISCUSSION We were unable to decrease the intense burning paresthesia the patient experienced in her feet with the described electrode placement. Alternate, but unsuccessful, attempts to influence the foot pares thesia included placement of electrodes in the low back as previously noted, with bilateral trial place ment of: 1) a 5.08 cm x 5.08 cm electrode over the common peroneal nerve as it curves superficially to the neck of the fibula; 2) a 5.08 cm x 15.24 cm electrode around the circumference of the distal leg immediately proximal to the malleoli; and 3) a 5.08 cm x 15.24 cm electrode wrapped around the dorsal and plantar surfaces of the foot. The patient reported an immediate severe in crease in burning paresthesia with trial number three even at low intensity. Despite our inability to
Transcutaneous electrical nerve stimulation was applied in the pain management of a patient with Guillain-Barre Syndrome. As subjectively reported by the patient, her back and lower extremity pain was significantly decreased although her foot pares thesia was not decreased. The program was contin ued for an 11-day period because TENS was consid ered a valuable adjunct for the patient's comfort. Transcutaneous electrical nerve stimulation is a valuable addition to our repertoire of available physical therapy modalities. We hope that as clinical experience with TENS increases, fellow clinicians will volunteer the experiences of their endeavors. Acknowledgment. The authors are indebted to the nursing staff of Deaconess Hospital for their extended cooperation and efforts and to the physical therapy staff for their constructive criticisms.
SUGGESTED READINGS
1. Report on the Findings and Recommendations on Transcuta neous Electrical Nerve Stimulation for Pain Relief by the Panel on Review of Neurological Devices. Food and Drug Administration, DHEW, Rockville, MD, February 1976, 16 PP 2. Thorsteinsson G, Stonnington HH, Still well GK: Transcuta neous electrical stimulation: A double-blind trial of its efficacy for pain. Arch Phys Med Rehabil 58:8-13, 1977 3. Loeser JD, Black RG, Christman A: Relief of pain by transcutaneous stimulation. J Neurosurg 42:308-314, 1975 4. Sternbach RA, Ignelzi RJ, Deems LM et al: Transcutaneous
24
electrical analgesia: A follow-up analysis. Pain 2:35-41, 1976 5. Melzack R: Prolonged relief of pain by brief, intense transcu taneous somatic stimulation. Pain 1:357-373, 1975 6. Agnew DC, Merskey H: Words of chronic pain. Pain 2:7381,1976 7. Loeser JD, Black RG: A taxonomy of pain. Pain 1:81-84, 1975 8. Melzack R, Torgerson NS: On the language of pain. Anaes thesia 34:50-59, 1971 9. Melzack R: The McGill pain questionnaire: Major properties and scoring methods. Pain 1:277-299, 1975
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/58/1/23/4559120 by University of Texas at Dallas user on 04 February 2019
nursing staff was from one-half hour to three and one-half hours. The intensity (amplitude) setting ranged from 4.5 to 10.0 for the low back channel and 2.5 to 4.0 for the gluteal channel. The rate and pulse width, as determined by patient comfort, remained constant at 6.0 and 10.0 respectively. The frequency of stimulation varied from one to four times per day. The patient was questioned by her attending physician following initiation of treatment. The phy sician proposed a scale with "0" indicating the pain was unchanged and "10" indicating the pain was completely eliminated, or 100 percent improve ment. On this scale, the patient reported her pain as improved 7 to 8 for her back and lower extremi ties. She consistently reported this degree of pain relief throughout the 11-day duration of the TENS program. Although this rating system might appear vague, it served the physician's clinical need to assess the value of TENS for his patient.
