Dermatology Online Journal
Vibration anesthesia: A noninvasive method of reducing discomfort prior to dermatologic procedures
- Author(s): Smith, Kevin C, MD
- Comite, Stephen L, MD
- Balasubramanian, Suprina
- Carver, Alan, MD
- Liu, Judy F
- et al.
Vibration anesthesia: A noninvasive method of reducing discomfort prior to dermatologic proceduresDepartment of Neurology, Mount Sinai School of Medicinea. email@example.com
Kevin C Smith MD, Stephen L Comite MD, Suprina Balasubramanian, Alan Carver MDa and Judy F Liu
Dermatology Online Journal 10 (2): 1
In some dermatologic and cosmetic procedures, local anesthesia is not sufficient for relieving pain; often patients are averse to injections. We propose vibration anesthesia, the use of vibration delivered with commercially available inexpensive massagers to reduce discomfort. We find the analgesic effect of vibration helpful in minimizing pain in patients undergoing injections of botulinum toxin type A treatment for hyperhidrosis, injection of filler substances such as Restylane™ and Juvederm™, laser therapy for leg veins, nail-fold injections, Q-switched laser treatment of tattoos, incision and drainage of abscesses, and cautery of facial warts, as well as facilitating anesthetic injections for needle-phobic patients. We expect that additional uses will be found as experience with this modality grows. Although the use of vibration anesthesia generally does not eliminate pain completely, it can serve to make the injection or procedure much more tolerable.
In Plutarch's Life of Caius Marius, Marius says, "I see the cure is not worth the pain." Many patients unfortunately agree, so physicians routinely try to prevent, reduce, and relieve pain for their patients. Dermatologic procedures frequently involve injections or surgery, and can cause discomfort. Topical or injectable anesthetics (and sometimes ice or cold air) are widely used and are safe and effective . Although local anesthesia is sufficient for many dermatologic procedures, administration of local anesthetic may be difficult, and it may cause unacceptable discomfort. It also has certain associated risks (e.g., nerve blocks at the wrist or ankle before treatment of hyperhidrosis with botulinum type A, or in cases where very large surface areas need to be treated, e.g., with laser treatment of leg veins).
Although handholding and talking (so-called talkesthesia) during painful procedures are helpful, they often do not provide sufficient relief . A myriad of techniques exists to supplement local anesthesia and reduce or eliminate the need for narcotic analgesics and benzodiazepines with their associated risks and side effects.
Warming and buffering the local anesthesia can independently and synergistically help to minimize pain [3, 4, 5, 6, 7, 8, 9]. Small-diameter (30-, 31-, or 32-gauge) needles cause less pain than do large-diameter needles. Slowly inserting the needle, inserting the needle through a pore, and slowly injecting can ease the pain of anesthetic administration. Longer needles and longer-acting anesthetics can minimize pain by reducing the required number of needle sticks. Injecting through a previously anesthetized area is helpful [3, 10, 11, 12]. Iontophoresis has been reported to be helpful in the administration of local anesthesia, but this technique requires special instrumentation and training . Hypnosis can reduce the anxiety and pain associated with dermatologic procedures, but its use also requires special training . Tactile stimulation (e.g., stroking the skin adjacent to an injection site) is often somewhat helpful.
Cooling using sprays, cold air, ice, ice packs, and gels can reduce the discomfort of many procedures, including laser surgery [15, 16, 17, 18, 19, 20]. Swinehart has proposed a three-step process: cryogel packs followed by benzyl-alcohol-containing normal saline (an almost painless solution producing moderate local anesthesia), followed by the typical anesthesia .
Many topical anesthetics, including EMLA™, Elamax™, liposome-encapsulated lidocaine cream, amethocaine, cetacaine, and benzocaine products can aid in minimizing the pain of cutaneous procedures including intralesional lidocaine infiltration. However, the use of these anesthetics can be time consuming, and it is occasionally associated with complications. The most common complication of topical anesthesia is contact dermatitis [2, 22, 23, 24, 25, 26]. The use of Elamax™, which does not contain prilocaine, may minimize the possibility of contact dermatitis [27, 28, 29]. EMLA™, in particular, is associated with extensive corneal deepithelialization,  purpura and petechiae [31, 32, 33] and even methemoglobinemia if applied to large areas [34, 35, 36, 37].
Children present a special challenge. Chen and Eichenfield , in their comprehensive article on pediatric anesthesia, state, "The best results in pain control are obtained with a slowly injected, buffered, and prewarmed solution, delivered with a pinch. The latter technique, which is particularly helpful in the use of injectable lidocaine in children, is based on the principle of counter-irritation, whereby the skin surrounding the needle entry point is pinched during the puncture and infiltration of anesthetic to diffuse the pain stimulus."
Vibration has been used for many years and has been shown to minimize concurrent pain. The term anesthesia refers to the elimination of pain and other sensation; the term analgesia refers to the reduction of pain. The application of vibration has long been used for its analgesic effects. According to the gate control theory of pain hypothesized decades ago by Melzack and Wall, A-β nerve fibers, which transmit information from vibration receptors (Pacinian corpuscles and Meissner corpuscles) and touch receptors in the skin, stimulate inhibitory interneurons in the spinal cord that in turn act to reduce the amount of pain signal transmitted by A-δ and C fibers from the skin to second-order neurons that cross the midline of the spinal cord and then ascend to the brain [38, 39]. Thus, counterstimulation, akin to stroking or pinching the skin, can alleviate pain sensation . Vibration may, in some cases, also have a placebo effect that is additive to its neurophysiological effect to reduce pain transmission from the peripheral pain receptors to the brain. Regarding the treatment of pain by vibration, a Lancet editorial concludes that the use of vibration is "simple, safe, and highly effective and has the added advantage of being cheap to establish and maintain" . The editorial also points out that some of the massagers used to deliver vibration have sexual connotations. In order to prevent misunderstandings, it is helpful to carefully explain the professional use and mechanism of action of these devices with patients and staff prior to usage .
We have used vibration produced by commercially available massagers to minimize and alleviate the pain associated with a variety of cosmetic and surgical dermatologic procedures.
Equipment and techniques
|AcuVibe Softouch™ rechargeable personal massager, commonly used by the authors to produce vibration anesthesia (see audiovisual 1).|
Video Clip 1 Video Clip 1. To eliminate the need for regional anesthesia during botulinum toxin treatment of hand hyperhidrosis, two massagers are used.
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For procedures below the face, we generally use one or two of the AcuVibe Softouch™ rechargeable personal massagers (which can be purchased from a variety of sources, including SharperImage.com). Use of this massager for analgesia requires the use of an assistant. We recommend that the assistant firmly apply one or two of the massagers within a few centimeters of the area to be treated. The vibration should be started about 2-3 s before beginning the procedure in order that adequate inhibition of pain transmission is established at the level of the spinal cord. On the low setting, the AcuVibe™ produces 4,500 vibrations per minute (75 Hz); on the high setting, 5,700 vibrations per minute (95 Hz). We recommend using the high setting whenever possible.
For very painful procedures such as multiple botulinum toxin type A injections into the palms or soles for the treatment of hyperhidrosis, two AcuVibe™ massagers should be applied to the hand or foot that is being treated: one on the dorsal surface, and the other on the palmar or plantar surface. The assistant should reposition the massagers in tandem with the physician's injections. To maintain hygiene, we recommend the use of a small disposable glove or a condom to cover the portion of the massager in contact with the patient.
In addition to vibration anesthesia, additional measures to minimize discomfort during the administration of botulinum toxin type A for palmar and plantar hyperhidrosis include the following:
- The administration of the synergistic combination of of acetaminophen (1 g) and ibuprofen (600 mg) 1 hour before the procedure [42, 43, 44, 45, 46].
- The use of very fine (31-gauge) SteriJect™ needles mounted on HSW Dose Saver™ 1-ml syringes (both obtainable from www.air-tite.com). The 31-gauge needles produce a smaller track in the skin than 30-gauge needles, so an added advantage is that there is less backflow of botulinum toxin type A onto the skin after each injection.
- The use of normal saline with benzyl-alcohol preservative as a reconstituting agent for the botulinum toxin type A; in addition to its action as a preservative, benzoyl alcohol is a mild local anesthetic.
|Figure 2||Video Clip 2|
|Fig. 2. Fingertip vibrating massager, useful when working without an assistant, especially for smaller facial lesions.|
|Video Clip 2. Demonstration of the fingertip vibrating massager used to lessen pain thereby reducing the need for topical
or injection anesthesia.|
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Another massager useful for facial procedures, for procedures in tight spaces, or for physicians without assistants, is the Vibrating Fingertip Massager from Brookstone and other suppliers. This device is placed over the physician's finger on the nondominant hand. When the vibration is not needed, the physician can simply move the finger with the massager off the procedure area.
Although the use of this device requires additional dexterity, minimal practice is necessary to become facile with this massager. The Vibrating Fingertip Massager operates at 9,000 vibrations per minute (150 Hz) but produces a less powerful vibratory stimulus than either the Hitachi Magic Wand™ or the AcuVibe Softouch™. We recommend the use of inexpensive and disposable finger cots in medium or large size, available from many medical suppliers such as Henry Schein, to cover the fingertip massager.
Video Clip 3 Video Clip 4 Video Clip 3. Use of the Hitachi Magic Wand™ to aid with anesthesia while injecting triamcinolone acetonide into the proximal nail fold for the treatment of psoriatic nails.
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Windows Media: Dial-up | Broadband Video Clip 4. Use of the Hitachi Magic Wand™ to lessen pain while injecting a filler, Restylane™, into the nasolabial fold.
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Video Clip 5 Video Clip 6 Video Clip 5. The Conair™ double-headed massager being used for reducing the discomfort associated with laser treatment of leg veins.
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Windows Media: Dial-up | Broadband Video Clip 6. Use of the Hitachi Magic Wand™ without attachments to minimize discomfort during an Intense Pulsed Light (IPL) treatment of the face.
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|Fig. 3. Hitachi Magic Wand™ with the Wonder Wand™ attachment, helpful in applying vibration close to a procedure, such as for smaller areas (especially on the face)|
For facial procedures and also to reduce the discomfort associated with Q-switched laser treatment of tattoos, the Hitachi Magic Wand™ with the Wonder Wand™ attachment (from hitachi-magic-wand.com or from drugstore.com) provides a smaller massage head, which allows the operator to apply vibration very close to the point of injection or laser treatment. The Wonder Wand™ attachment is made of a smooth blue plastic that is easily cleaned after use, for example, by using ASEPTI-wipes II™ (www.henryschein.com, www.acuson.com/ transducers/tcare-precleaners.html).
Video Clip 7 Video Clip 7. Use of the Hitachi Magic Wand™ during botulinum toxin treatment of axillary hyperhidrosis.
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The Hitachi Magic Wand™ works at 5,000 or 6,000 vibrations per minute (83 Hz or 100 Hz) but produces a somewhat less powerful vibratory stimulus than the AcuVibe™. Using this massager sometimes requires the help of an assistant to position the tip of the massager as close as possible to the areas being treated and to reposition the tip of the massager as the practitioner treats other areas.
The Conair double-headed massager, which also runs on 120 volts, is very effective for reducing the discomfort associated with laser treatment of leg veins. This massager can be purchased from a variety of sources, including Wal-Mart.
|The Conair™ double-headed massager.|
We have not encountered any side effects using these massagers for vibration anesthesia.
Our results are anecdotal because it is clearly difficult to blind or placebo-control patients to the obvious sensation of vibration. Although vibration anesthesia can be helpful as an adjunct to minimize discomfort during a variety of procedures, we very frequently use vibration to reduce the discomfort of palmar and plantar injections of Botox™ in the treatment of patients with hyperhidrosis. Some of our most grateful patients are those who previously have had a nerve block at the wrist before botulinum type A injection and have found vibration anesthesia to be much more comfortable. A major advantage of vibration anesthesia is that both palms or both soles can be treated in one session. (When nerve blocks are used, usually only one hand or foot is treated at a time to minimize immediate postoperative disability.) In addition, traditional nerve-block anesthesia is much more time consuming than vibration anesthesia.
Botulinum type A treatment of the palms (a sensitive area) usually requires 25-50 injections, so many practitioners espouse the use of regional blocks. Vibration anesthesia may obviate the need for regional nerve blocks with their associated discomfort, risks, and immediate postoperative morbidity [47, 48, 49, 50, 51]. Other practitioners have described the use of intravenous regional blocks (Bier's block) to help with analgesia in the botulinum type A treatment for patients with hand hyperhidrosis [52, 53]. Special training and equipment is needed for the safe performance of intravenous regional blocks.
Since starting the use of vibration anesthesia in April 2003, one author has not found it necessary to use regional blocks for botulinum type A treatment of hyperhidrosis of the palms or soles. Vibration anesthesia has eliminated the need for anesthetic injections, and the associated risks and side effects of regional anesthesia. In one case, prior to botulinum type A injection for palmar hyperhidrosis, the patient had a nerve block administered to one wrist by a plastic surgeon and vibration anesthesia administered to the other hand. Subsequently, the patient expressed a preference for vibration anesthesia. The day after the procedure, the hand that had been treated with vibratory anesthesia appeared normal; whereas, the hand that was treated with the nerve block was livedoid and bruised, possibly the result of nerve-block-associated vasodilation.
Botulinum type A injection for axillary hyperhidrosis is usually well tolerated and performed without anesthesia [54, 55]. One author has had a patient who found botulinum type A treatment of axillary hyperhidrosis without anesthesia very painful. Using a ring block with injection anesthesia was equally as uncomfortable. With the use of vibration anesthesia she found the procedure more tolerable, and she prefers this technique to relieve pain during treatment.
Using the vibrating fingertip massager can be effective in the treatment of patients with facial lesions. One author has found it helpful in treating facial lesions that may require mild cautery, and in which patients find injection anesthesia uncomfortable, such as in the case of recurrent facial warts. We do not recommend vibration anesthesia for procedures requiring high cautery settings.
For those patients who are needle phobic, the distraction and pain reduction created by vibrating massagers can be helpful in reducing the sensation of needle insertion. We speculate that vibration anesthesia may be helpful for venipuncture in sensitive patients.
According to the gate control theory of pain, hypothesized decades ago by Melzack and Wall, A-β nerve fibers (which transmit information from touch and vibration receptors in the skin) stimulate inhibitory interneurons in the spinal cord, which in turn act to reduce the amount of pain signal transmitted from A-δ and C fibers across the midline of the spinal cord and from there to the brain.
Two types of afferent fibers involved in mechanical pain have been described: slower but very fine unmyelinated C fibers (0.4-1.1 µm in diameter), which mainly transmit burning pain, and A fibers, which include thinly myelinated A-δ fibers (1-5 µm in diameter), which chiefly transmit pricking pain . The A-δ fibers release several peptide neurotransmitters, of which substance P is the most important in exciting secondary dorsal horn neurons (see the above diagram). Secondary neurons then ascend to the brain mainly via spinothalamic tracts. Touch, like pain, is transmitted as a superficial sensation by A-β fibers; vibration is a deep sensation . Each major system forms a separate sensory tract in the spinal cord. The lemnical (dorsal column) system carries vibration, whereas the other important system, the ventrolateral system, relays nociceptive stimuli such as pain and crude touch.
The proposed mechanisms by which vibration minimizes pain may include both peripheral and central mechanisms. According to the gate control theory of pain, the strength of synaptic transmission at the dorsal horn and, similarly, at the trigeminal ganglia junctions is decreased, probably by presynapatic inhibition, when large, non-pain-signaling axons within the nerve are stimulated (causing the gate to "close") . These are touch receptors and vibration receptors (Pacinian corpuscles and Meissner's corpuscles). Transcutaneous electrical nerve stimulation (TENS) may, in some ways, work in a manner similar to vibration. According to Longe et al. in a discussion comparing and contrasting vibration and TENSm "The mechanism of action of these procedures is generally explained by the gate-control theory of pain inhibition in which large diameter sensory fibres (A-β), conducting impulses from the selective activation of low threshold mechanoreceptors, reduce the painful input of the small diameter nociceptive afferents (C-fibres) by triggering local inhibitory circuits in the substantia gelosa of the dorsal horn" . In the cat model, vibration inhibits nociceptive receptors in the dorsal horn neuron . Acting in a central location, vibrotactile and pain sensations produced activation in similar regions within the somatosensory cortices of the brain .
The interaction of vibration and pain is complex; under some circumstances chronic exposure to vibration can cause or exacerbate pain. For example, the long-term use of hand-held vibrating tools may cause nerve dysfunction . Prolonged exposure to vibration is a risk factor for lower back pain [62 ].
Whole-body vibration has, however, been tested as a treatment for back pain . As Rittweger et al. point out, "There are differences, of course, between industrial and therapeutic whole-body vibration, namely, the method of application, the subject's posture, the frequency of application, and the temporal duration of exposure and the resulting fatigue."
In addition to reducing acute pain by counterstimulation, vibration has been used to treat and reduce other types of pain. In chronic pain syndromes, vibratory stimulation has been shown to be more effective than placebo . Lundberg, in a study of 366 patients, reported that muscle vibration could reduce chronic muscle pain. "The best pain reducing site was found to be either the area of pain, the affected muscle or tendon, the antagonistic muscle or a trigger point outside the painful area. In most patients the best pain reducing effect was obtained when the vibratory stimulation was applied with moderate pressure. To obtain a maximal duration of relief of chronic pain the stimulation had to be applied for about 25-45 minutes" . In a similar study, vibration produced relief of chronic muscle pain when applied with moderate pressure for 20 minutes . The pain relief lasted at least 3 hours but often 12 hours or more . In another study, 59 percent of 267 patients with chronic neurogenic or musculoskeletal pain had relief of up to 18 months .
Vibration of an unexercised muscle reduces pain perceived from local pressure . Vibratory stimulation reduced the pain associated with both electrically induced and clinical pain overlying the extensor carpi radialis longus muscle. In this study, moderate pain was produced by low frequency (2 Hz) electrical stimulation with cutaneous fascicles of the median nerve . The authors report, "Vibration within the area of projected pain reduced the sensation of pain more efficiently than vibration outside that area. Moderate pain was sometimes completely inhibited but intense pain was only moderately reduced. Pressure and cooling produced some pain relief, whereas mild warming had an ambiguous effect. Since the painful input was derived from stimulation of fibres in the nerve trunk, and not from peripheral nociceptors, the pain suppressing effects of vibration and cooling are not explicable in terms of lowered excitability of the nociceptive nerve endings in the skin. Instead, the results indicate that activity in low threshold mechanoreceptive and cold sensitive units suppress pain at central (probably segmental) levels."
Kakigi and Shibasaki confirm the role of vibration in alleviating pain . In a later study Kakigi and Watanabe show that both the gate control theory and diffuse noxious inhibitory control accounted for the pain relief following CO2 laser stimulation, rather than simple changes in the subjects' attention . The authors believe that the vibratory pain relief effect is not simply at the level of the dorsal horn but also in the brain, "The responsible sites for this phenomenon are considered to be the dorsal horn of the spinal cord, the brainstem and some parts of the brain such as the second sensory cortex and the cingulate cortex."
The pain-relieving effect of vibratory stimulation on orofacial pain is not affected either by probe size or by vibratory frequency, at least within the 10-200 Hz range . In one study vibration applied distally is more effective than vibration applied proximally to the pain threshold . In another study, whether the vibration is to an area of 12.5 cm² or 25 cm² does not affect mean pain threshold . Interestingly, in a study of vibration and thermal pain, vibration applied in the adjacent dermatome as well as the contralateral dermatome in the volar forearm significantly decreases the thermal pain perception .
Sinus pain may be relieved by vibratory stimulation . Vibratory stimulation decreases the intensity of tinnitus in one study . Phantom pain is relieved by vibration in 75 percent as opposed to 44 percent of patients treated with placebo .
TENS, vibratory stimulation, and electroacupuncture are more effective than placebo . TENS and vibratory stimulation are overall more effective than aspirin in relieving pain of myofascial or musculoskeletal origin . TENS plus vibratory stimulation is helpful in the pain relief in a patient with painful legs and moving toes, with vibration alone being more successful than TENS .
Vibration or TENS are not sufficient, however, to relieve the intense orofacial pain associated with pulp surgery, abscess incision, or tooth extraction; all of the patients have to be given conventional local anesthesia .
One study shows that vibration is not helpful in relieving HIV-associated neuropathic pain . The HIV symptoms that are tested, including burning and painful soles of the feet, as well as paresthesia, are associated with sensory findings, so they are likely not applicable to the immediate pain elicited by certain dermatologic surgery or cosmetic procedures.
Pain relief with vibratory stimulation is likely not associated with release of endogenous opioids, as it was not reversed with naloxone . Similarly, naloxone does not influence oral pain after molar removal, followed by TENS or vibratory stimulation . Relief of pain from vibratory stimulation does seem to be correlated with the CSF substance-P-like immunoreactivity levels (SPLI) .
The role of vibration in minimizing pain may not simply be a result of counterstimulation. In a study using functional MRI in 2001, attention altered perception of pain .
Consequently, although the gate control theory of pain explains how vibration, either by stimulating touch receptors and or by stimulating vibration receptors, can minimize or alleviate the sensation of pain at the spinal cord level, other central and peripheral mechanisms may also have influence.
For the many dermatologic and cosmetic procedures for which injection or topical anesthesia is undesirable or simply insufficient for relieving pain, we have described the use of safe, simple, and inexpensive commercially available massagers to produce vibration anesthesia. In some circumstances, optimal use of these massagers requires an assistant; however, the practitioner without assistance can use other types of massagers. Vibration anesthesia can potentially help with a variety of procedures, including injection of botulinum type A for hyperhidrosis, injection of filler substances like Restylane™ and Juvederm™, laser therapy for leg veins, Q-switched laser ablation of tattoos, nailfold injections, injections for needle-phobic patients, incision and drainage of abscesses, and cautery of facial warts. It is important when using vibration anesthesia also to use other techniques to minimize discomfort. These should include so-called talkesthesia and may also include premedication (e.g., with acetaminophen plus an NSAID), the use of very fine needles (e.g., 31-gauge SteriJect needles for Botox™ injections, and 30-gauge MaxFLO™ needles for filler injections), buffering and warming of anesthetic solutions and reconstitution of botulinum type A using normal saline with benzyl alcohol preservative (which acts as a mild local anesthetic). We expect that there will be other indications for vibration anesthesia in dermatology.
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