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TNS for Back Pain in Late Pregnancy
CASE STUDY
TNS for Back Pain in Late Pregnancy LESLEY HILL MCSP
SUmIlla~:A case study is presented in which a young woman obtained
ender, and there was no referred pain consistent with nerve oot involvement. The midwives did not feel that the pain could be referred rom contractions. The patient was unable to comply with any suggestion and it was decided to try TNS.
immediate relief from severe back pain in late pregnancy (on the day she gave birth) by using transcutaneous nerve stimulation (TNS).
rreatment
Senior Obstetric Physiotherapist, Nuneaton Maternity Hospital
Key Words: Back pain, pqnanq, labour, analgesia, transcutanemsnem stimulation (TNS).
Introduction I WAS called t o the maternity ward to see a 22-year-old woman three days after she had been admitted complaining of severe back pain. She was 3 8 weeks into her second pregnancy, her first baby having been born vaginally 2% years previously. She had no history of previous back problems, or even significant backache in either pregnancy. History Pain had developed slowly during the morning of October 29, 1989, increasing in intensity until she was admitted by her GP later the same day. On October 30, she was complaining of severe upper back pain and was unable to get on or off the bed without assistance. Panadol was given at 11 am, 3 pm and 10.45 pm without appreciable effect. At 4.15 p m she was also given 5 0 mg of pethidine. A few irregular uterine contractions were noted. A request for treatment to relieve back pain was received by the physiotherapy department on October 31. The patient was now complaining of pain to the right side of the lumbar spine and flank, with tenderness and guarding. She was seen by a colleague who recommended ice as a safe means of relieving pain until I was able to see her on the following day. On cardiotocograph (CTG)monitoring, only small contractions were noted, but the uterus remained irritable. There were no urinary symptoms, and on microscopy of urine nothing was abnormal. Analgesics continued to be given during October 31: 11.40 pm panadol, 12.30 pm distalgesic, 2.30 pm 5 0 mg pethidine, and 10.30 p m distalgesic. At 4 am on November 1 her membranes ruptured and occasional mild contractions continued t o be recorded. The severe back pain continued, and the midwives were unable t o palpate the abdomen or monitor for very long because the patient was in too much pain. Distalgesic was given at 3.30 and 11 am on November 1.
A Spembly obstetric TNS unit was shown to her and pxplained briefly. She agreed to try it. At 11.15 am it was applied and she was shown how t o :ontrol the unit. One pair of electrodes was placed on her back between r10 and L l and the other between S2 and S4. Both circuits were in use on a pulsed mode, boosting to continuous when :ontractions or increased back pain were felt. Using the d s e d mode the patient commented on immediate relief Df her back pain although maximum endorphin level is only reached after 40 minutes (Salar era/, 1981). She felt tired, rolled on to her side and went to sleep. The staff midwife on the ward reported later that between half and one hour later, she had got up out of bed, and was happily walking around. Although she had not been thought to have been in established labour, she was transferred to the labour suite a t 4.15 pm later that afternoon. No further analgesics were requested or offered until 5 pm when Entonox was given. At 7 cm dilated, the patient requested pethidine for the contractions. This was not given because it was too close to full dilatation, which occurred at 6.50 pm. She went on to deliver normally a baby weighing over 9 Ib at 7.48 pm on November 1. After application of the TNS, the only other analgesic used was Entonox. The TNS was kept on until after the delivery. Transcutaneous Nerve Stimulation TNS reduces the pain felt in labour in tw o ways: 1. Endorphin release is stimulated by the low frequency current, which results in a rise in the pain threshold (Salar er a/, 1981).
2. The TNS can be 'boosted' to a high frequency current which stimulates the large myelinated nerve fibres so that the 'gate' is closed to pain (Melzack and Wall, 1965). Conclusion On using the TNS, the patient experienced immediate relief of her severe and disabling back pain, and no further medication was needed.
Examination On examination at 10.45 am on November 1 it was very difficult t o ascertain the true nature of the pain, or to examine her properly. She was in severe discomfort in every position, and needed help to get on or off the bed. She could not stay in any one position for long, and could not take her weight through her right leg. The right sacroiliac joint was not
566
REFERENCES Melzack, R and Wall, P D (1965). 'Pain mechanisms: A new theory', Science, 150, 971- 979. Salar, G, Job, 1, Mingrino, S, Bosio, A and Trabucchi, M (1981). 'Effect of transcutaneous electrotherapy on cerebro-spinal fluid betaendorphin content in patients without pain problems', Pain, 10. 169-172.
P h y s i o ~ ySeptember , 1990, w d 76, no 9
TNS for Back Pain in Late Pregnancy LESLEY HILL MCSP
SUmIlla~:A case study is presented in which a young woman obtained
ender, and there was no referred pain consistent with nerve oot involvement. The midwives did not feel that the pain could be referred rom contractions. The patient was unable to comply with any suggestion and it was decided to try TNS.
immediate relief from severe back pain in late pregnancy (on the day she gave birth) by using transcutaneous nerve stimulation (TNS).
rreatment
Senior Obstetric Physiotherapist, Nuneaton Maternity Hospital
Key Words: Back pain, pqnanq, labour, analgesia, transcutanemsnem stimulation (TNS).
Introduction I WAS called t o the maternity ward to see a 22-year-old woman three days after she had been admitted complaining of severe back pain. She was 3 8 weeks into her second pregnancy, her first baby having been born vaginally 2% years previously. She had no history of previous back problems, or even significant backache in either pregnancy. History Pain had developed slowly during the morning of October 29, 1989, increasing in intensity until she was admitted by her GP later the same day. On October 30, she was complaining of severe upper back pain and was unable to get on or off the bed without assistance. Panadol was given at 11 am, 3 pm and 10.45 pm without appreciable effect. At 4.15 p m she was also given 5 0 mg of pethidine. A few irregular uterine contractions were noted. A request for treatment to relieve back pain was received by the physiotherapy department on October 31. The patient was now complaining of pain to the right side of the lumbar spine and flank, with tenderness and guarding. She was seen by a colleague who recommended ice as a safe means of relieving pain until I was able to see her on the following day. On cardiotocograph (CTG)monitoring, only small contractions were noted, but the uterus remained irritable. There were no urinary symptoms, and on microscopy of urine nothing was abnormal. Analgesics continued to be given during October 31: 11.40 pm panadol, 12.30 pm distalgesic, 2.30 pm 5 0 mg pethidine, and 10.30 p m distalgesic. At 4 am on November 1 her membranes ruptured and occasional mild contractions continued t o be recorded. The severe back pain continued, and the midwives were unable t o palpate the abdomen or monitor for very long because the patient was in too much pain. Distalgesic was given at 3.30 and 11 am on November 1.
A Spembly obstetric TNS unit was shown to her and pxplained briefly. She agreed to try it. At 11.15 am it was applied and she was shown how t o :ontrol the unit. One pair of electrodes was placed on her back between r10 and L l and the other between S2 and S4. Both circuits were in use on a pulsed mode, boosting to continuous when :ontractions or increased back pain were felt. Using the d s e d mode the patient commented on immediate relief Df her back pain although maximum endorphin level is only reached after 40 minutes (Salar era/, 1981). She felt tired, rolled on to her side and went to sleep. The staff midwife on the ward reported later that between half and one hour later, she had got up out of bed, and was happily walking around. Although she had not been thought to have been in established labour, she was transferred to the labour suite a t 4.15 pm later that afternoon. No further analgesics were requested or offered until 5 pm when Entonox was given. At 7 cm dilated, the patient requested pethidine for the contractions. This was not given because it was too close to full dilatation, which occurred at 6.50 pm. She went on to deliver normally a baby weighing over 9 Ib at 7.48 pm on November 1. After application of the TNS, the only other analgesic used was Entonox. The TNS was kept on until after the delivery. Transcutaneous Nerve Stimulation TNS reduces the pain felt in labour in tw o ways: 1. Endorphin release is stimulated by the low frequency current, which results in a rise in the pain threshold (Salar er a/, 1981).
2. The TNS can be 'boosted' to a high frequency current which stimulates the large myelinated nerve fibres so that the 'gate' is closed to pain (Melzack and Wall, 1965). Conclusion On using the TNS, the patient experienced immediate relief of her severe and disabling back pain, and no further medication was needed.
Examination On examination at 10.45 am on November 1 it was very difficult t o ascertain the true nature of the pain, or to examine her properly. She was in severe discomfort in every position, and needed help to get on or off the bed. She could not stay in any one position for long, and could not take her weight through her right leg. The right sacroiliac joint was not
566
REFERENCES Melzack, R and Wall, P D (1965). 'Pain mechanisms: A new theory', Science, 150, 971- 979. Salar, G, Job, 1, Mingrino, S, Bosio, A and Trabucchi, M (1981). 'Effect of transcutaneous electrotherapy on cerebro-spinal fluid betaendorphin content in patients without pain problems', Pain, 10. 169-172.
P h y s i o ~ ySeptember , 1990, w d 76, no 9