Efficacy of transcutaneous electrical nerve stimulation for pain relief in women undergoing office endometrial biopsy

Use of Transcutaneous Electrical Nerve Stimulation (TENS) for Pain Management During Intrauterine Device Insertion: A Case Series

This case series details the use of transcutaneous electrical nerve stimulation (TENS) for pain management during intrauterine device (IUD) insertion in three different patients. We used a 100 mm horizontal line visual analog scale (VAS) to assess pain associated with the procedure. Case 1 is a 39-year-old primiparous female with a past medical history of depression who presented to the clinic for Mirena IUD insertion. The patient rated overall pain during the procedure as 10 mm, with the most discomfort during IUD placement inside the uterus, which she rated 20 mm. Case 2 is a 16-year-old nulliparous female with no significant past medical history who presented for Mirena IUD insertion. The patient rated overall pain during the procedure as 40 mm, with the most discomfort during IUD placement inside the uterus, which she rated 45 mm. Case 3 is a 37-year-old multiparous female with no significant past medical history who also received a Mirena IUD. She rated overall pain during the procedure as 20 mm. All patients reported lower pain scores when compared to previously reported median pain scores associated with the procedure, highlighting the analgesic effects of TENS.

The effect of informing the patient about the procedure with video imaging before office hysteroscopy on pain

OBJECTIVE

To evaluate the effect of informing patients undergoing diagnostic office hysteroscopy via a video 24 h before the procedure and determine the changes in pain scores, channel transit time, the degree of difficulty of the procedure, and physiological parameters.

DESIGN

Single-blind randomized controlled trial.

SETTING

The study was conducted between September 1, 2021 and April 1, 2022 at the University of Health Sciences Bakirkoy Dr. Sadi Konuk Training and Research Hospital.

PARTICIPANTS

A total of 134 patients aged 18-65 years who needed diagnostic office hysteroscopy.

INTERVENTIONS

Participants were randomized into two groups, the standard information group (Group 1: controls), and the video information + standard information group (Group 2). After office hysteroscopy, a visual analog scale (VAS) and Likert scale were used to assess pain and the degree of difficulty of the procedure, respectively. Physiological parameters were evaluated before and after the procedure.

MAIN OUTCOME MEASURE

To determine the effect of video-based multimedia information administered 24 h before office hysteroscopy on post-procedure pain.

RESULTS

The mean VAS score of the group that watched the training video (3.02 ± 1.88) was significantly lower than the control group (4.72 ± 2.54) who did not watch the training video (p < 0.001). The mean cervical channel transit time in seconds (sec) during the procedure was found to be significantly higher in the control group (21.57 ± 15.10 s) than in the video-watching group (p = 0.011). There was no significant difference between the groups in terms of physiological parameters and the degree of ease of the procedure.

CONCLUSION

Our study has shown that informing patients in a pre-procedure video is an effective approach that shortens the duration of the channel transit time and reduces pain.

Characterising the Features of 381 Clinical Studies Evaluating Transcutaneous Electrical Nerve Stimulation (TENS) for Pain Relief: A Secondary Analysis of the Meta-TENS Study to Improve Future Research

Background and Objectives: Characterising the features of methodologies, clinical attributes and intervention protocols, of studies is valuable to advise directions for research and practice. This article reports the findings of a secondary analysis of the features from studies screened as part of a large systematic review of TENS (the meta-TENS study). Materials and Methods: A descriptive analysis was performed on information associated with methodology, sample populations and intervention protocols from 381 randomised controlled trials (24,532 participants) evaluating TENS delivered at a strong comfortable intensity at the painful site in adults with pain, irrespective of diagnosis. Results: Studies were conducted in 43 countries commonly using parallel group design (n = 334) and one comparator group (n = 231). Mean ± standard deviation (SD) study sample size (64.05 ± 58.29 participants) and TENS group size (27.67 ± 21.90 participants) were small, with only 13 of 381 studies having 100 participants or more in the TENS group. Most TENS interventions were ‘high frequency’ (>10 pps, n = 276) and using 100 Hz (109/353 reports that stated a pulse frequency value). Of 476 comparator groups, 54.2% were active treatments (i.e., analgesic medication(s), exercise, manual therapies and electrophysical agents). Of 202 placebo comparator groups, 155 used a TENS device that did not deliver currents. At least 216 of 383 study groups were able to access other treatments whilst receiving TENS. Only 136 out of 381 reports included a statement about adverse events. Conclusions: Clinical studies on TENS are dominated by small parallel group evaluations of high frequency TENS that are often contaminated by concurrent treatment(s). Study reports tended focus on physiological and clinical implications rather than the veracity of methodology and findings. Previously published criteria for designing and reporting TENS studies were neglected and this should be corrected in future research using insights gleaned from this analysis.

Effects of high-frequency, high-intensity transcutaneous electrical nerve stimulation versus intravenous opioids for pain relief after hysteroscopy: a randomized controlled study

OBJECTIVE

To compare the time spent in the Post-Anesthesia Care Unit (PACU) and the pain-relieving effects of treatment with high-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) or intravenous (IV) opioids after hysteroscopy.

METHODS

All patients who postoperatively reported a visual analogue scale (VAS) pain score of ≥3 were included in the study. TENS treatment was given with a stimulus intensity between 40 and 60 mA for 1 minute and repeated once if there was insufficient pain relief. In the opioid group, a fractionated dose of 5 mg morphine was administered. If the patient reported insufficient pain relief after the assigned treatment, the patient was reassigned to the other treatment group.

RESULTS

Seventy-four women were randomized to TENS (n=38) or IV opioids (n=36) for treatment. Both groups reported significant pain relief after discharge from the PACU, with a decrease of VAS scores from 5.6 to 1.4 in the TENS group (P<0.001) and 5.1 to 1.3 in the opioid group (P<0.001). There were no significant differences between the groups. When only the responders in both groups, i.e., patients with VAS scores of <3 on respectively assigned treatments, were compared, the TENS responders (n=22) were found to have spent a significantly shorter time in the PACU (91 vs. 69 minutes, P=0.013) compared to the opioid responders (n=20).

CONCLUSION

Using TENS as first line of pain relief may reduce the need for postoperative opioids. In addition, TENS appears preferable as the first line of treatment due to its association with a shorter time spent in the PACU if the patient responds to the treatment.

TRIAL REGISTRATION

Västra Götalandsregionen Identifier: 211261.

Pharmacological and non-pharmacological pain relief for office hysteroscopy: an up-to-date review

In-office hysteroscopy is considered the standard technique for visualization of the uterine cavity and the diagnosis of intrauterine pathologies. Moreover, nowadays, it is possible to treat a vast number of intracavitary diseases in the office, without the need for the inpatient setting. However, in some cases, pain might occur, and this is the most common reason for not completing the procedure. Over the last 20 years, many efforts have been carried out to miniaturize the instrumentation and to improve the techniques in order to avoid discomfort. Nonetheless, hysteroscopy still provokes distress for many patients. For this reason, pharmacological and non-pharmacological treatments for intraoperative and postoperative pain relief have been widely used for in-office hysteroscopy, with different results in various groups of women. The purpose of this review was to analyze the current literature on pharmacological aids (non-steroidal anti inflammatory drugs, cyclooxygenase-2 inhibitors, antispasmodics, local anesthetics, prostaglandins, opioids) and non-pharmacological interventions (transcutaneous electrical nerve stimulation, uterine stretching, uterine pressure, warming of distension medium, hypnosis, music, vocal-local) and to evaluate their impact on the relief from pain experienced during in-office hysteroscopy.

Methods of pain control during endometrial biopsy: A systematic review and meta-analysis of randomized controlled trials

AIM

To review effectiveness of methods for reducing pain during endometrial biopsy.

METHODS

PubMed, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov databases were searched for randomized controlled trials that examined effectiveness of pain control methods for endometrial biopsy. Risk of bias was assessed from sequence generation, allocation concealment, blinding, incomplete outcome data and selective outcome reporting. Heterogeneity was examined from forest plot, statistical tests of homogeneity, and I² statistic. For meta-analysis of pain scores, weighted mean difference with 95% confidence interval (CI) were estimated.

RESULTS

Twenty-six studies were included in the review. Marginally significant reduction in the pain score during the procedure in participants with intrauterine lidocaine relative to control was observed (mean difference [MD] -1.31, 95% confidence interval [CI] -2.70 to 0.09, P = 0.07). Subgroup analysis showed that in studies that used low-pressure suction devices, intrauterine lidocaine was associated with statistically significant reduction in pain during the procedure (MD -2.22, 95% CI -3.72 to -0.73, P = 0.004). There was a significantly lower pain score during biopsy in the anesthetic spray group compared to control (MD -0.96, 95% CI -1.53 to -0.39, P = 0.001). Significant heterogeneity on types of intervention and outcome measures among studies that examined paracervical block and nonsteroidal anti-inflammatory drugs (NSAID) was observed. However, paracervical block and NSAID were associated with significant pain reduction compared to placebo in most of the related studies.

CONCLUSION

Intrauterine anesthetics, anesthetic cervical spray, paracervical block and oral NSAID provide effective pain control during endometrial biopsy.

The Effects of Transcutaneous Electrical Nerve Stimulation on Post-Episiotomy Pain Severity in Primiparous Women: A Randomized, Controlled, Placebo Clinical Trial

Background:

Episiotomy or cutting the perineum is the most common operation in obstetrics. Perineal pain is the main complication of episiotomy that affects the quality of life and mental health of the mother. Reducing the pain and side effects of the chemical drugs prescribed for pain relief has attracted the attention of both physicians and scientists. This study was conducted to determine the effects of transcutaneous electrical nerve stimulation (TENS), as an alternative method, on post-episiotomy pain severity.

Materials and Methods:

This randomized clinical trial was performed on 120 primiparous women who had referred to Sanandaj Besat Hospital in 2018. The patients were divided randomly into three groups, including the intervention group (TENS-On), the placebo group (TENS-Off), and the control group. TENS electrodes were placed near the episiotomy site in genitofemoral and pudendal nerves. The pain was measured after episiotomy in lying, sitting, and activity positions. The pain severity was measured using a pain measurement instrument (numeral rating score) at four-time points, i.e., before the intervention as well as 30, 60, and 120 minutes after the TENS intervention. For data analysis, Pearson correlation, student’s t-test, Kruskal-Wallis test, ANOVA test, and Mann-Whitney U tests were used.

Results:

Intragroup evaluation results for placebo and control groups demonstrated no significant difference in the pain score (P>0.05). A significant difference was observed between the mean pain severity of the intervention group and that of the group with walking activities (P=0.04). In terms of the intergroup evaluation, there was a significant difference observed between the mean pain severity of the lying position and that of the control group (P=0.008). Regarding the sitting position, no significant difference was observed between its mean pain severity and that of the other two groups (P=0.04).

Conclusion:

TENS is an effective and safe method for post-episiotomy pain relief and a routine method used in the obstetrics and gynecology ward.

Approaches to acute pain management in older people

Pain is a diverse, individual experience and is associated with distress and suffering. Uncontrolled acute pain has been linked to delayed recovery and prolonged hospital stay. Nurses have a duty of care to their patients and acute pain management is integral to this. However, acute pain in older people can be difficult to manage, often because of under-reporting or difficulties in assessment. Older people have altered physiology often compounded by multiple co-morbidities and polypharmacy, all of which affect the appropriateness of, and available, pharmacological pain management strategies. In addition, older people are at greater risk of adverse drug reactions, drug interactions and side effects from analgesia. Consequently, non-pharmacological strategies should also be integral to pain management.

Does transcutaneous electrical nerve stimulation (TENS) alleviate the pain experienced during bone marrow sampling in addition to standard techniques? A randomised, double-blinded, controlled trial

AIMS

Bone marrow aspiration and trephine (BMAT) biopsies remain important tests in haematology. However, the procedures can be moderately to severely painful despite standard methods of pain relief. To test the efficacy of transcutaneous electrical nerve stimulation (TENS) in alleviating the pain from BMAT in addition to standard analgesia using a numerical pain rating scale (NRS).

METHODS

70 patients requiring BMAT were randomised (1:1) in a double-blind, placebo-controlled trial. -35 patients received TENS impulses at a strong but comfortable amplitude (intervention group) and 35 patients received TENS impulses just above the sensory threshold (control group) (median pulse amplitude 20 and 7 mA, respectively). Patients and operators were blinded to group allocation. Pain assessments were made using a numerical pain scale completed after the procedure.

RESULTS

No significant difference in NRS pain recalled after the procedure was detected (median pain score 5.7 (95% CI 4.8 to 6.6) in control vs 5.6 (95% CI 4.8 to 6.4) in the intervention group). However, 100% of patients who had previous experience of BMAT and >94% of participants overall felt they benefited from using TENS and would recommend it to others for this procedure. There were no side effects from the TENS device, and it was well tolerated.

CONCLUSIONS

TENS is a safe, non-invasive adjunct to analgesia for reducing pain during bone marrow biopsy and provides a subjective benefit to most users; however, no objective difference in pain scores was detected when using TENS in this randomised controlled study.

CLINICAL REGISTRATION NUMBER

NCT02005354.

Vaginal misoprostol versus a rectal nonsteroidal anti-inflammatory drug to reduce pain during Pipelle endometrial biopsies: a prospective, randomized, placebo-controlled trial

BACKGROUND

To evaluate and compare the efficacy of vaginal misoprostol and a rectal nonsteroidal anti-inflammatory drug (NSAID) on pain relief during Pipelle endometrial biopsies in a placebo-controlled randomized study.

METHODS

One hundred and fifty-one women who had an indication for a Pipelle endometrial biopsy were randomized into three groups as follows: group 1, vaginal misoprostol; group 2, rectal NSAID, and group 3, control. After the procedure, the women were asked to record their pain severity on a visual analog scale. The secondary outcome of the study was patient acceptability, and vasovagal symptoms and analgesic requirements after the procedure were also recorded.

RESULTS

There were no statistically significant differences in the demographic characteristics of the patients. The primary study outcome was the comparison of the median visual analog scale pain scores of groups 1 and 2 versus group 3 (controls); no statistically significant differences were found (p = 0.502). In addition, the patient acceptability (Likert scale), vasovagal symptoms and analgesic requirements after the procedure were similar among the groups (p = 0.204, 1 and 0.546, respectively).

CONCLUSION

Our study did not demonstrate a reduction in pain relief during Pipelle endometrial biopsies for patients receiving vaginal misoprostol or a rectal NSAID when compared to patients receiving placebo treatment.