J Gordon Gadsby and Michael Flowerdew Mikjos Productions, Leicester 2000 £34.95 or $59.95 plus shipping (UK £1.20, EU €3.50, $10 elsewhere).
(Reviewed by David Mayor, EJOM Vol. 3 No. 5)
‘Needles are not necessary. Modern approaches to electroacupuncture require no metaphysical rituals; it is relatively simple, a useful clinical tool for pain control and other conditions, can be easily taught to practitioners and used alongside conventional medicine.’
This CD-Rom on transcutaneous electrical nerve stimulation (TENS) breaks new ground, both in its format and in the way practical procedures are based firmly on literature review as well as the authors’ considerable experience of electrotherapy over the years.
Of course, a number of technical books are available on TENS, and some simple manuals for patient use, but this practitioner’s guide marries the two in a format that is becoming more and more popular for material that would normally appear between two printed covers.
After a very readable and reasonably detailed history of electrotherapy, complete with amusing illustrations (simply accessed, like the references, by clicking on the relevant highlighted text), the authors cover the possible mechanisms involved in TENS succinctly and clearly. The usual argument that it is ‘only’ placebo is well dealt with, as are the Melzack-Wall Gate theory and the endorphin hypothesis. If there is a shortcoming here, it is maybe in a lack of detail on the neurochemical effects of the different frequencies of TENS.
However, this is amply compensated in a thorough and fascinating account of the bioelectric understanding of the ‘body electric,’ as elaborated by Robert O. Becker and others. A semiconductor model of the acupuncture point is developed, and the DC potentials of the body described. Strangely, despite this emphasis on a DC system and awareness of the historical importance of ‘medical galvanism,’ its consequences for modern methods of treatment using monophasic forms of stimulation are not really explored, except for a warning that positive stimuli might aggravate pain from tissue damage.
The third section is about the TENS machine itself and the parameters used, and is again very thorough and readable. The usual categories of high frequency conventional TENS, low frequency acupuncture-like TENS (ALTENS), pulse burst (intermittent), modulated and brief intense TENS are described - though how often anyone ever uses the latter I always wonder. In addition, there are short sections on ‘neuro-electric acupuncture’ (NEAP, or TENS applied to acupuncture body points), and acupuncture ear point stimulation. The importance of using biphasic, charge balanced square wave stimulation is emphasised throughout. The recommendations at the end of the chapter will be very helpful for anyone considering the merits of the many different TENS units available.
The fourth section is the core of the CD-ROM, setting out the authors’ strategies for dealing with acute and chronic pain in general, followed by sections on more specific problem areas. For acute (and subacute) pain, they recommend ALTENS (2 pulses per second, pps, with pulse width of 200 µsec) at strong intensity for 30 minutes, and for chronic pain 60-80 pps. 80-100 µsec, at a comfortable intensity that produces distinct paraesthesiae in the pain area, for an hour or more maybe several times daily. Their suggestions on what to do if these initial settings do not work, and on the pad locations to use, are clearly and simply set out.
The subsections on specific areas are divided into very useful background reviews, followed by the practicalities of applying the lessons learned from these. Although several of the reviews can only offer cautious conclusions (’there is no clear evidence ...,’ ‘a paucity of robust studies,’ etc), these should be familiar to anyone who reads research papers, particularly in physical therapy, and need not deter us from action. There is plenty of information here to enable practitioners to design useful treatments.
The particular topics covered are labour and delivery, postoperative pain, control of vomiting and nausea, dysmenorrhoea and dentistry. Mick Flowerdew’s interests in dental analgesia and the use of electroacupuncture during pregnancy are very evident here, and the information on EDA, electronic dental analgesia, would be hard to find elsewhere. In a following CD-ROM, the authors promise to cover more areas of application. One study mentioned here, on dysmenorrhoea,1 indicates that TENS of course does not just reduce pain, but may also significantly affect menstrual flow, clot formation, fatigue and the incidence of diarrhoea. Such effects show that TENS-like methods may have far wider applicability than in just those areas mentioned.
The fifth section illustrates electrode placements for different conditions, beginning with musculoskeletal problems and some colourful dermatome illustrations, with more specific locations indicated for various spinal, limb and temporomandibular joint conditions. Problems specific to women (dysmenorrhoea, PMT, labour pain) are followed by protocols for neuralgias, dental uses and then a miscellany of postoperative pain, emesis, skin ulcers and irritable bowel syndrome. At the end is a short subsection on electrode care.
The usual precautions observed are then noted, with comments where these seem to be overstated (the authors finding no evidence, for instance, that TENS should be avoided when operating an ordinary domestic microwave oven).
The final section offers a preview of the follow-up CD-ROM, which will be on NEAP, or needleless acupuncture, for a wider range of conditions than described here. While I cannot agree with the authors’ offhand dismissal of traditional meridian theory and its basis in the manipulation and balancing of qi, in favour of an acupuncture ‘based entirely on scientific principles’ (as if any form of healing could ever be that), given the overall quality of this, their first production, I am certainly looking forward to their next. I am sure it will be sensible, useful and stimulating.
As for the CD-ROM format, while this is clearly a very cheap medium to work with nowadays and admirably suited to reference works, I am not yet convinced that it is the right one for text that requires careful reading. To compound this, here the authors have chosen to provide the text itself as read-only, with only the illustrations available in a separate printable file. I find reading such chunky reviews of clinical studies from a computer screen not altogether relaxing (despite the tasteful lilac text and green click-ons!), although it is fun navigating around the different sections using the various facilities Adobe offers, even if a bit tedious having to key in repeat ‘find’ commands. I was slightly disappointed too that only certain words in the comprehensive index are linked to the relevant passages in the text.
The illustrations do provide pretty much all you might require for practical use, but printing out 41 colour pages to make up your own manual takes quite a lot of ink, especially if you are not totally enamoured of the fuzzy android images that result. It is also a shame that the useful strategy flowcharts are not printable. Being a fairly traditional bookworm, I would prefer to cut and paste my own text version, and to be able to transfer references to my own database without having to type them out laboriously (particularly those with lengthy website addresses). I also don’t want to have to rush to my PC in the middle of a treatment if I’ve forgotten which parameters to use in what condition. A printable sheet of guidelines for patients would have been useful, and maybe some evaluation forms as well. After all, the two files of this publications between them only take up about 7 MB, and it might even have been possible (funds permitting) to flesh out the images with a video of androids sticking electrodes on each other. Now that would grab the attention! Perhaps, with the proceeds from this first CD-ROM, the next will be more adventurous.
The CD-ROM is available from: J Gordon Gadsby, 47 Milton Crescent, Leicester LE4 0PA Tel: +44 (0)116 235 2204
Available in Adobe Acrobat format for both PC and Mac computers (Adobe Acrobat Reader supplied). For details see: http://freespace.virgin.net/joseph.gadsby/page6.htm.
David Mayor David Mayor is a traditionally trained acupuncturist currently compiling a textbook on electroacupuncture for the publishers Churchill Livingstone. With a background in publishing, he has a particular interest in how different media affect the way we take in and undstand information.