Transcutaneous Electrical Nerve Stimulation

(TENS) in

Raynaud’s Phenomenon Peter Mulder, Ph.D.* Ellen C. Dompeling, M.D.

Janny C.

Slochteren-van der Boor Wietze D. Kuipers and Andries J. Smit, M.D.# van

GRONINGEN, THE NETHERLANDS

Abstract Transcutaneous nerve stimulation (TENS) has been described as resulting in vasodilatation. The effect of 2 Hz TENS of the right hand during forty-five minutes on skin temperature and plethysmography of the third digit of both hands and feet and on transcutaneous oxygen tension (Tcp02) of the right hand was compared with that of a control study using indifferent stimulation of the iliopsoas region in 8 patients with primary Raynaud’s phenomenon. After TENS a slight increase in skin temperature of both hands was found, while plethysmographic amplitude was increased in the contralateral hand only. No changes in TcpO 2 occurred. The authors conclude that the observed small effects of TENS are of no clinical value in primary Raynaud’s phenomenon.

Introduction



TENS, often used because of its analgesic properties, has in several studies been claimed to induce generalized vasodilatation, manifested by an increase in skin temperature or plethysmographic amplitune. However, none of these studies was controlled. A controlled study of the effects of 2 Hz TENS on skin temperature, photoelectric plethysmography, and transcutaneous oxygen tension (Tcp02) was

performed in patients with primary Raynaud’s phenomenon. Patients and Methods Patients

We studied 8

patients with primary Raynaud’s phenomenon with a median age of twenty-four years 5 (range twenty-two to sixty-one); 6 of them were women. All satisfied the criteria of Allen and Brow From the

#Division of Internal Medicine and Cardiology, Department of Medicine,

and

*Division of Physiotherapy, University Hospital

Groningen, Groningen, The Netherlands

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415

positive cooling plethysmography. No evidence of underlying systemic autoimmune disease had been found during follow-up of at least one year before the study. No medication was allowed for at least two weeks before the studies. Patients were asked to abstain from smoking and alcohol on the evening before and on the study days. A light breakfast was allowed on the morning of the study. and had

a

Study Methods All studies were performed by the same investigator (P.M.) in the autumn of 1988 in the morning hours after acclimatization for half an hour in a temperature-stable (22 °C), quiet room. All patients participated in two studies, a TENS and a control study day. They had been informed about the study

purpose but were not aware of the expected differences between the study days. On the TENS study day 2 Hz TENS was administered to the right hand during forty-five minutes. The cathode was placed on the web between ossa MCP I-II, the anode on the ulnar side of the same hand. Both electrodes had a surface of 12 cm2 Stimulation was given with an intensity resulting in visible but not

painful contractions of mm. interossei dorsales, usually 20-40 mA. On the control study day, one week later or earlier, the same procedure was used. However, now the stimulation electrode was placed in the middle of the tractus iliotibialis region on the right side and 2 Hz stimuli were given in an intensity that was easily perceived but not painful to the patient. The TENS equipment was removed after TENS or the control stimulus, ie, after forty-five minutes, on both study days. Before, during, and for four hours after TENS at fifteen-minute intervals, measurement of skin temperature (using a thermocouple) and photoelectric plethysmography were performed in the dig III of both hands and feet while transcutaneous p02 of dig III of the right hand was measured with a radiometer. Analysis of variance was used to compare the results on the TENS day with those of the control study day. Separate analysis was used for periods during and after TENS. Results were considered statistically significant at the 5% level. ’

Results No differences were present between the baseline skin temperature on both study days. On both study days a gradual increase in skin temperature in both fingers and toes occurred during the first hour of the after the

patients had been acclimatized already for half an hour. A slightly higher skin temperature of the right middle finger (33.4 compared with 32.8 °C, p < 0.05) was found for the whole period after, but not during, TENS compared with the control study (Fig. 1). In the left middle finger (LMF) a significantly higher temperature was found in the two-to-four hour period after TENS (Fig. 2). study period, ie,

TENS did not influence temperature of the Base-line

differences

toes.

comparable on both study days. During TENS no increase in plethysmographic amplitude was present in the

plethysmographic amplitudes

were

observed. After TENS

an

were

LMF but not in other digits

(Fig. 3). No differences in Tcp02 of the right middle finger were found between the study days. Discussion

Systemic vasodilatation has been claimed to be induced by TENS in several uncontrolled studies in different patient In 1980 Abram et al, using TENS for analgesia in 33 patients with chronic pain in one extremity, observed an increase in skin temperature both ipsilaterally and contralaterally in those

groups.’-4

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416 2

patients in whom analgesia was indeed obtained but not in those in whom TENS failed to induce analgesia. Most studies have been published by Kaada. He observed a marked increase (7-10 °C) in skin temperature

Fig. I. Skin temperature of the third digit of the right hand before, during, and for four hours after TENS or control stimulation. The 45-minute period of stimulation is indicated with the TENS block. Indicated are means and SDs for the TENS-study day (-) and for the control study ( .....).

Fig. 2. Skin temperature of the third digit of the left hand before, during, and for four hours after TENS or control stimulation. The 45-minute period of stimulation is indicated with the TENS block. Indicated are means and SDs for the TENS-study day (-) and for the control study ( ......).

Fig. 3. Plethysmography of the third digit of the left hand before, during, and for four hours after TENS or control stimulation. The 45-minute period of stimulation is indicated with the TENS block. Indicated are means and SDs for the TENS-study day ( and for the control study ( .......).

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417 in patients with Raynaud’s phenomenon or diabetic polyneuropathy for periods of four to eight hours after and also observed plethysmographic signs of peripheral vasodilatation in other TENS

Buhring3

Dooley4

found patient groups. On the other hand Ebersold6 and these studies diverse methods for stimulation were used.

Ignelzi’

no

change or a fall in skin temperature.

Our initial experiences with this technique in patients with Raynaud’s phenomenon left the that the subjective effect of TENS

was

In

impression

at best marginal. This prompted us to perform the present controlled

study. Although cold provocation studies were considered, we eventually, for reasons of comparability, decided to use the method described by Kaada, which is well standardized between his different studies and had provided the most consistently positive results. With this method, TENS results in a slight increase in skin temperature of the hands for several hours after TENS. However, no temperature change was induced by TENS in the other extremities in the patients with primary Raynaud’s phenomenon. Plethysmography and Tcp02 demonstrated no signs of vasodilatation, except for the contralateral hand. Both on the TENS and the control study day an increase in skin temperature was observed during the first part of the study, even despite a previous period of acclimatization. It seems logical to suppose that the study circumstances with a quiet, warm room were primarily responsible for this sustained increase in skin temperature. An effect of the elctrical stimulation cannot, of course, be excluded, even when the intensity was such that the stimulation was not painful for the patient. Electrical stimulation resulting in

pain is usually accompanied by local vasodilatation. ~ Study circumstances comparable to ours were present in some of the other studies discussed above, implying that the described systemic vasodilatation in these uncontrolled studies was at most partly due to TENS. Conclusion TENS does not

seem

to be

of clinical value in the treatment of

Raynaud’s phenomenon.

Andries J. Smit, M.D.

Department of Medicine University Hospital Groningen Oostersingel 59 9713 EZ Groningen, The Netherlands

Refences 1. Kaada B: Vasodilatation induced by transcutaneous nerve stimulation in peripheral ischemia (Raynaud’s phenomenon and diabetic polyneuropathy). Eur Heart J 3:303-314, 1982. 2. Abram SE, Assiddao CB, Reynolds AC: Increased skin temperature during Transcutaneous Electrical Stimulation. Anesth Analg 59:22-25, 1980. 3. Buhring M: Physikalische Therapie bei Patienten mit peripherer arterieller Verschlusskrankheit und Claudicatio intermittens. Theapiewoche 35:3296-3300, 1985. 4. Dooley D, Sharkey MJ: Electrostimulation of the nervous system for patients with demyelinating and degenerative diseases of the nervous system and vascular diseases of the extremities. Appl Neurophysiol 40:208-

5. Allen EV, Brown GE: Raynaud’s disease: A critical review of minor requisites for diagnosis. Am J Med Sci

183:187-200, 1932. 6. Eversold M, Laws ER, Albers JW: Measurements of autonomic functions before, during and after transcutaneous stimulation in patients with chronic pain and in control subjects. Mayo Clin Proc 52:228-232, 1977. 7. Ignelzi RJ, Steinbach RA, Calaghan M: Somatosensory changes during transcutaneous electrical analgesia. In: Advances in Pain Research and Therapy, ed. by Bonica J J, Albe-Fessard D.New York: Raven Press, 1976, pp 421-425. 8. Westerman RA, Widdop RE, Hogan C, et al: Non-invasive tests of neurovascular function: Reduced responses in diabetes mellitus. Neurosci Lett 81:177-182, 1987.

217,1978.

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Transcutaneous electrical nerve stimulation (TENS) in Raynaud's phenomenon.

Transcutaneous nerve stimulation (TENS) has been described as resulting in vasodilatation. The effect of 2 Hz TENS of the right hand during forty-five...
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