Transcutaneous Electrical Nerve Stimulation In The Symptomatic Management of

Thrombophlebitis H. J.

Roberts, M.D., F.A.C.A.

WEST PALM

BEACH,

FLORIDA

Acute and recurrent active thrombophlebitis in the lower extremities is frequently encountered in medical practice. The enormity of the problem is indicated by recent estimates of 20 million attacks of deep vein thrombosis and

200,000 deaths from pulmonary embolism annually in the United States.’ Many factors are involved, including prolonged standing or sitting, habitual leg crossing, the wearing of tight hose or garments about the lower extremities and waist, and prior attacks of thrombophlebitis. The last factor may be related to a host of precipitating causes-including pregnancy, contraceptive agents, trauma, and a variety of medical and surgical disorders. There are many otherwise well patients with recurring or chronic thrombophlebitis whose limb discomfort is so great that they must curtail their occupations and other activities. This situation has been encountered repeatedly among teachers, nurses, and others who need to stand for prolonged periods, and for whom a variety of treatments provide only marginal relief. Treatment consists of aspirin, other analgesics, supporting hose, proper shoes, rest periods, intermittent heparin, oral anticoagulant therapy, &dquo;anti-inflammatory&dquo; compounds, and even glucocorticoids or corticotropin gel. Transcutaneous electrical nerve stimulation (TENS) has been employed successfully by others in managing diverse painful disorders because of its simple and noninvasive nature.2-8 Confronted with the foregoing clinical challenge of painful thrombophlebitis in the lower extremities, especially in patients whose occupation or family life are threatened by unrelieved discomfort after short periods of weight bearing, we investigated the value of TENS. The relief of pain so achieved in several trial patients was impressive enough to warrant extending its use to others. The improvement was surprisingly sustained in some patients, as evidenced by the prolonged hiatus between treatment and their return for a symptomatic flareup. In others the relief was briefer, but still sufficient to justify continuing such treatment with them as outpatients or at home. From the Mannow Research Beach.

Laboratory,

Palm Beach Institute for Medical

249

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Research,

West Palm

250

Materials and Methods

...

The Stim Tech EPC Dual Output Stimulator (Stimulation Technology, Inc.) was used. Two electrodes were applied by a nurse over the region encompassing the painful venous segment and its nerve supply. In the case of extensive or bilateral disease, two separate venous segments-either on the same extremity or on both limbs-were treated simultaneously. Therapy was administered from 30 to 60 minutes. The initial trial consisted of three or four treatments, separated by intervals of 1 to 3 days. Patients were evaluated before each treatment for subjective decrease of pain and increase of activity. An attempt was made to avoid altering previous supportive therapy during this period of evaluation. The critical technical considerations included proper placement of the electrodes and optimum setting of the three stimulation parameters-pulse amplitude, pulse duration, and pulse repetition rate. Flexible carbon electrodes were applied with an adequate coating of conductive gel. Variations in technique were required for individual patients, including sites of electrode placement, duration of therapy, and the degree of stimulation. For example, it was occasionally necessary to maximize the settings to &dquo;break through&dquo; persistent pain. (This approach has been successfully used in treating other forms of severe fibromuscular and neuritic pain, notably that associated with advanced osteoporosis and vertebral collapse.) After several TENS treatments had achieved modest relief, it was possible to reduce the output and pulse to the conventional range. The efficacy and duration of TENS therapy could be evaluated after this trial period in most instances. When significant relief of pain was sustained, patients were advised to return for treatment only after a painful exacerbation. If the benefit persisted but a few hours or days, they were given the options of discontinuing TENS, returning for additional treatments, or renting a comparable unit from a commercial supplier. When the last option was chosen, patients were instructed on how to select the appropriate settings. Several patients received concomitant TENS treatment to painful areas over a joint or fibromuscular structure in the upper or lower extremities, the back, or the neck (see below). TENS was given to 39 patients with thrombophlebitis; 31 (80%) were women and 8 (20%) were men. This preponderance of women reflects the higher incidence of thrombophlebitis among women in most practices. The age range was from 34 to 82 years, averaging 47 years. The criteria for TENS treatment were persistent pain attributable to active thrombophlebitis in the lower extremities, and failure to respond to conventional medications and supportive measures (see above). Most patients in this series had received either intermittent heparin or a coumarin-type anti-

coagulant.

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251

diagnosis of thrombophlebitis was made in every instance on the basis of exquisite tenderness to gentle palpation over the distribution of the deep veins in the calf or medial thigh, with or without associated edema. The presence of increased deep venous resistance was confirmed in most patients by the noninvasive methods of venous occlusion plethysmography combined with respiratory-compression augmentation maneuvers.9 Thrombophlebitis was diagnosed at the following sites: A clinical

The total number of treatments administered

were as

follows:

Concomitant or subsequent TENS therapy to the calves or thighs of both lower extremities was given to 17 patients. Two or more courses of TENS therapy, separated by at least 3 months, were

given

to 8

patients.

Results The responses to TENS were classified as follows:

therapy, in terms of subjective amelioration of pain,

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252 One patient obtained minimal benefit for a painful leg and thigh during an initial course of only two treatments, but good relief when three treatments were

given during There

a

subsequent

course.

discernible changes in blood chemistries, blood counts, or prothrombin times. No cardiac arrhythmias or other overt clinical complications attributable to TENS were either volunteered or detectable. Improvement was occasionally dramatic. One 62-year-old man presented with marked tenderness over the left posterior calf and thigh, and ipsilateral edema. Thrombophlebitis had occurred in the same extremity 2 years previously following a fracture. Striking relief was experienced after only one treatment. Because of difficulties in transportation that precluded additional treatments, he was not able to return until 9 days later. Many of the patients who received more than four treatments had recurrent severe pain following subsequent excessive activity. Since the symptomatic benefit of TENS was so prompt in some instances, patients had to be cautioned against premature prolonged walking or standing, especially when trauma had been a precipitating factor. For example, the thrombophlebitis was exacerbated in several patients after they resumed customary shopping habits once their pain had abated. The Value of TENS in Certain Clinical Settings. This mode of therapy provided unique advantages for some patients with acute or recurrent thrombophlebitis in whom conventional treatments either were contraindicated or potentially harmful. These treatments included (1) the use of aspirin, baluCpcnrticoids, and phenybutazone (especially in patients with a history of recent peptic ulcer disease), (2) the local application of heat to limbs also affected by occlusive arterial disease, and (3) anticoagulant therapy in patients having anemia or a bleeding diathesis. Case Report. A 64-year-old man with long-standing coronary heart disease presented with painful recurrent thrombophlebitis of the right leg and thigh, notwithstanding the wearing of &dquo;antlembolism&dquo; hose and adequate oral anticoagulant therapy. He had undergone a partial gastrectomy for peptic ulcer. A marginal ulcer subsequently developed after aspirin ingestion. The pedal pulses were reduced. His pain was promptly relieved by four TENS treatments administered over the affected segments in the calf and thigh. were no

The

problem of pelvic vein phlebitis poses a therapeutic as well as a diagnostic challenge. Six patients in this series presented with both persistent hypogastric pain and evidence of bilateral ileofemoral thrombophlebitis. After multiple studies for possible underlying pathology involving the urinary and gastrointestinal tracts, discogenic disease, and retroperitoneal pathology proved normal, it was concluded that pelvic thrombophlebitis was the most likely basis for the pain in each instance. One patient had required the insertion of an inferior vena cava umbrella for recurrent pulmonary embolism several years previously. She

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253

presented with acute edema of the lower extremities superimposed on longstanding lower abdominal discomfort, both of which were attributed to embolization to the umbrella and to a chronic pelvic thrombophlebitis. TENS to the lower abdomen afforded impressive relief in 5 of these patients for whom relief had been impossible earlier. The failure of persistent hypogastric pain to respond to three TENS treatments in the sixth patient raised the possibility of other pelvic pathology. Subsequent diagnostic laparoscopy, however, revealed only distention of the pelvic vessels. Relief of Concomitant Pain Disorders. Many patients in this series also had complex medical disorders, including orthopedic and neurologic problems involving their lower extremities. Fortuitously, the pain of these concomitant conditions could often be relieved by TENS. The types of chronic and acute pain that have been treated successfully with TENS by others include lumbar and cervical problems, causalgia, postherpetic neuralgia, phantom limb pain, thalamic pain, and various peripheral neuropathies. For example, Fox and Melzack8 reported that TENS and acupuncture were equally effective as forms of &dquo;hyperstimulation analgesia&dquo; in managing chronic low back pain. Since the former is noninvasive and can be administered under supervision by paramedical personnel, it was viewed as more practical. Case Report. A 63-year-old man presented with thrombophlebitis involving the left lower extremity. He had experienced an acute cerebral thrombosis 1 year previously, complicated by a probable thalamic syndrome affecting the same limb. Gratifying relief of both types of discomfort was volunteered after he received four TENS treatments.

Discussion

Significant or sustained relief of the pain associated with acute or recurrent thrombophlebitis of the lower extremities was not expected at the outset. There were no comparable clinical reports known to the writer. Even in the case of partial relief provided by such treatment for chronic low back pain, TENS could &dquo;make the difference between unbearable and bearable pain, between a sedentary, sometimes bedridden life and one that, for at least several hours or days a week, allows a normal social, family, or business life ... with more dignity and self assurance.&dquo;8 This report was delayed because of the justified emphasis on the need for long-term observation with any recommended treatment for pain in order to rule out a placebo effect. Indeed, most authorities do not consider such therapy as effective unless the patient continues to experience relief 6 months or longer after its initiation. It is believed, however, that the prompt and repetitious nature of the relief afforded by TENS for active or recurrent thrombophlebitis in this admittedly limited number of patients could not be ascribed solely to a

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254

placebo phenomenon. Confirmatory clinical trials by others

are

obviously

war-

ranted. Patients with several forms of &dquo;visceral&dquo; pain have responded to TENS therapy. The writer reported striking relief of severe or intractable pain associated with acute and recurrent pancreatitis.l° Gordon and associates 11 noted a significant decrease in the frequency and severity of angina pectoris in 5 patients with intractable angina who used TENS for 1 year. However, they could not demonstrate objective improvement in exercise tolerance in these patients. Mechanisms of Actions. There are several possible mechanisms of action for the benefit of TENS in the present clinical context. 1. TENS probably benefits a nonspecific neuropathy involving small nerves on and adjacent to the affected veins. 2. The possibility of augmented healing of local inflammation by the application of electric current and fields has been advanced. The results of preliminary studies (as in experimental bone injury), however, remain inconclusive. Brighton and associates&dquo; reported that bone regrowth can be induced and nonunion fractures healed by delivering a constant flow of low-amperage electricity to the trauma site. Some of the induced effects include a decrease in oxygen tension, the creation of an alkaline environment through the production of hydroxyl radicals, and the activating of cyclic AMP. 3. While there are no known data concerning the effect of TENS upon the endothelial cell lining of arteries, veins, capillaries, and lymphatics, these cells are known to play an important role in physiologic hemostasis and vascular permeability to a variety of pathologic stimuli. Many investigators have attempted to clarify the sites of action and physiologic mechanisms of transcutaneous electrical analgesia. It is likely that several responses are involved: 1. There is evidence that such neurostimulation can partially block noxious input in the periphery. This conclusion was reached by Sternbach and associates13 on the basis of tourniquet pain studies in patients having low back and lower extremity pain, and other disorders. 2. Campbell and Taub14 reported that percutaneous electrical stimulation of digital nerves over the medial nerve distribution in man induces both analgesia and anesthesia in the distal portion of the fingers stimulated. This response was attributed to peripheral blockade of A-delta nociceptors in small myelinated fibers. 3. Weight and Erulkar15 demonstrated that repetitive antidromic stimulation of the postsynaptic axon can reduce the excitatory postsynaptic potential. The accumulation of extracellular potassium ions was believed to reduce transmitter release. 4. Relief of pain from TENS has been predicated upon the &dquo;gate&dquo; theory proposed by Melzack and Wall.16,17 According to this concept, there is inhibi-

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255

pain-carrying fibers in the spinal cord after stimulation of large non-pain-impulse fibers having a lower threshold to stimulation. The transmission of such impulses activates a brain stem mechanism for &dquo;closing the gate&dquo; to information relayed over the small pain fibers, presumably by stimulating inhibitory fibers that block pain signals. The prolonged analgesic effect of TENS (for 30 minutes) and acupuncture (for 3 minutes) have been attributed by Fox and Melzack’ to inhibition of a self-exciting neurone chain at the spinal level or brain stem by the intense brief input. The several interacting systems in the gate-control theory include substantia gelatinosa T cells (acting as transmitters to the dorsal horn), input fibers from the afferent nerves, laminae III I and IV interneurons, and ascending or descending impulses from the dorsal column. 5. Another mechanism for TENS analgesia involves the stimulation of hormone-like transmitter substances called endorphins (for endogenous morphine-like substances) and enkephalins. They occur naturally in the brain (notably the limbic system) and pituitary.ls-21 This group of substances was discovered following the identification of opiate receptors in the brain and other tissues.&dquo; Beta-endorphin is 20 times more potent than morphine in producing analgesia when injected into the brain, and three times more potent when injected intravenously.21 It has been proposed that beta lipotropin, a component of pituitary extracts, may be the pro-hormone for all the endorphins and Met’enkephalin.19 There is additional experimental evidence that acupuncture releases endorphins from the brain, which then circulate to block pain (but not to touch) pathways. Sj6lund and Eriksson22 concluded that acupuncture-like electrical stimulation for the relief of chronic pain is mediated through inhibitory mechanisms involving the release of endorphins. Specifically, the analgesia achieved by TENS usually promptly returned after the injection of naloxone, a specific morphine antagonist; in contrast, the injection of saline had no effect. (The analgesia induced by hypnosis is not affected by naloxone.) It was postulated tion of the smaller

that both TENS and needle acupuncture act on the same central mechanism, possibly the midbrain raphe system. Such long-delayed and prolonged effects are consistent with a hormonal, rather than a simple &dquo;gate&dquo; mechanismespecially for the endorphins (which are more stable than the short-chain

enkephalins). Summary Transcutaneous electrical nerve stimulation (TENS) afforded significant relief of the pain associated with acute and recurrent thrombophlebitis in 90% of 39 patients so treated. The method is simple to administer, noninvasive, and apparently free of side effects. It can be self-administered by the patient after appropriate instruction. TENS can be given in conjunction with analgesics, anticoagulant therapy, and other supportive measures to achieve greater relief

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256 and mobility in patients with thrombophlebitis whose occupations and other activities are severely limited by their pain. Further clinical trials involving larger numbers of patients, and clarification of the analgesic mechanisms involved, are warranted because of the magnitude of this problem. TENS therapy can be uniquely beneficial in certain clinical situations. They include the contraindication of conventional treatments for the pain of thrombophlebitis, pelvic vein phlebitis, and the presence of concomitant painful orthopedic and neurologic disorders.

Roberts, M.D., F.A.C.A. Palm Beach Institute for Medical Research 304 27th Street West Palm Beach, Florida 33407 H. J.

References 1. Moser, K. M.: Pulmonary embolism: Where the problem is not. J.A.M.A., 236: 1500, 1976 2. Adams, J. E.: New Hope in intractable chain. Med. Consult. October 1972, pp. 156-158. 3. Burton, C., Maurer, D. D.: Pain suppression by transcutaneous electronic stimulation. IEEE Trans. Bio-Med. Engin., 21: 81, 1974. 4. Loeser, J. D., Black, R. G., Christman, A.: Relief of pain by transcutaneous stimulation. J. Neurosurg., 42: 308, 1975. 5. Long, D. M.: External electrical stimulation as a treatment of chronic pain. Minn. Med., 57: 195, 1974. 6. Shealy, C. N.: Transcutaneous nerve stimulation for control of pain. Surg. Neurol., 2: 45, 1974. 7. Winter, A., Winter, R. L., Laing, Y. L.: Pain relief—Transcutaneous nerve stimulation. J. Med. Soc. N.J., 71: 365, 1974. 8. Fox, E. J., Melzack, R.: Transcutaneous electrical stimulation and acupuncture: Comparison of treatment for low-back pain. Pain, 2: 141, 1976. 9. Roberts, H. J.: The noninvasive diagnosis of deep venous disorders in the lower extremities : Clinical value of plethysmography combined with augmentation methods and a new scoring system. Angiology, 29: 1978. 10. Roberts, H. J.: Transcutaneous electrical nerve stimulation in the management of pancreatitic pain. South. Med. J., 71: 396, 1978. 11. Gordon, M. J., Marcus, M. L., Kerber, R. E., et al.: Transcutaneous electrical nerve stimulation for the treatment of angina pectoris.

Circulation Abstracts II (October) 1976, No. 0495. 12.

13.

14.

15.

16. 17. 18.

C. T., Friedenberg, Z. B., Mitchell, E. I., et al.: Cited in Medical Tribune, March 9, 1977, p. 1. Sternbach, R. A., Ignelzi, R. J., Deema, L. M., et al.: Transcutaneous electrical analgesia : A followup analysis. Pain, 2: 35, 1976. Campbell, J. N., Taub, A.: Local analgesia from percutaneous electrical stimulation: A peripheral mechanism. Arch. Neurol., 28: 347, 1973. Weight, F. F., Erulkar, S. D.: Modulation of synaptic transmitter release by repetitive postsynaptic action potentials. Science, 193: 1023, 1976. Melzack, R., Wall, P. D.: Pain mechanisms: A new theory. Science, 150: 971, 1965. Melzack, R., Wall, P. D.: Psychophysiology of pain. Int. Anesthesiol. Clin., 8: 3, 1970. Bell, R. M. S., Malick, J. B.: Enkephalins and

Brighton,

endorphins: 19.

20.

21.

22.

A

major discovery? J.A.M.A.,

236: 2887, 1976. Guillemin, R.: Endorphins: Brain peptides that act like opiates. N. Engl. J. Med., 296: 226, 1977. Goldstein, A.: Opioid peptides (endorphins) in pituitary and brain. Science, 193: 1081, 1976. Marx, J. L.: Neurobiology: Researchers high on endogenous opiates. Science, 193: 1227, 1976. Sjölund, B., Eriksson, M.: Electro-acupuncture and endogenous morphines. Lancet, 2: 1085, 1976.

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Transcutaneous electrical nerve stimulation in the symptomatic management of thrombophlebitis.

Transcutaneous Electrical Nerve Stimulation In The Symptomatic Management of Thrombophlebitis H. J. Roberts, M.D., F.A.C.A. WEST PALM BEACH, FLOR...
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