Value of TENS for relief of chronic low back pain with or without radicular pain

Bioelectric medicine: unveiling the therapeutic potential of micro-current stimulation

Bioelectric medicine (BEM) refers to the use of electrical signals to modulate the electrical activity of cells and tissues in the body for therapeutic purposes. In this review, we particularly focused on the microcurrent stimulation (MCS), because, this can take place at the cellular level with sub-sensory application unlike other stimuli. These extremely low-level currents mimic the body's natural electrical activity and are believed to promote various physiological processes. To date, MCS has limited use in the field of BEM with applications in several therapeutic purposes. However, recent studies provide hopeful signs that MCS is more scalable and widely applicable than what has been used so far. Therefore, this review delves into the landscape of MCS, shedding light on the multifaceted applications and untapped potential of MCS in the realm of healthcare. Particularly, we summarized the hierarchical mediation from cell to whole body responses by MCS including its physiological applications. Our final objective of this review is to contribute to the growing body of literature that unveils the captivating potential of BEM, with MCS poised at the intersection of technological innovation and the intricacies of the human body.

Diagnosis and Treatment of Low Back Pain: Synopsis of the 2021 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline

ABSTRACT

Low back pain is a significant issue in the US Department of Veterans Affairs and Department of Defense populations as well as the general US population at large. This type of pain can be distressing to those who experience its effects, leading patients to seek relief of their symptoms. In 2022, leadership within the US Department of Veterans Affairs and US Department of Defense approved a joint clinical practice guideline for the management of low back pain. The guideline provides evidence-based recommendations for assessing and managing low back pain. Development of the guideline included a systematic evidence review, which was guided by 12 key questions. A multidisciplinary team, which included clinical stakeholders, reviewed the evidence that was retrieved and developed 39 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. The scope of the clinical practice guideline is broad; however, the authors have focused on key recommendations that are important for clinicians in the evaluation and nonoperative treatment of low back pain, including pharmacologic therapies and both noninvasive and invasive nonpharmacologic treatments.

The effect of transcutaneous electrical nerve stimulation on pain and electrical stimulation muscle thickness in patients with non-specific chronic low back pain-based ultrasonographic evaluation

Aim: The existing mechanisms of transcutaneous electrical nerve stimulation (TENS) focuses more on the effect of neural tissue. This study investigated the effect of TENS on the thickness of the erector spinae muscles and reducing pain. Patients & methods: 56 individuals with low back pain participated in this single-blind, pre/post-test study. For 2 weeks, participants underwent ten sessions of TENS. The ultrasound evaluations examined the thickness of the erector spinae muscle, and the visual analog scale measured the severity of low back pain. Results: There was a decrease in pain score and muscle thickness after the interventions (p ≤ 0.004). There was also a strong correlation between reducing pain and decreasing muscle thickness (R = 0.709; p = 0.000). Conclusion: Following TENS in the lumbar, in addition to reducing pain, the thickness of the erector spinae muscles also decreased. Clinical Trial Registration: IRCT20200423047173N1 (ClinicalTrials.gov).

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.

Effect of Modulated TENS on Corticospinal Excitability in Healthy Subjects

Conventional transcutaneous electrical nerve stimulation (TENS) has been reported to effectively alleviate chronic pain, including phantom limb pain (PLP). Recently, literature has focused on modulated TENS patterns, such as pulse width modulation (PWM) and burst modulation (BM), as alternatives to conventional, non-modulated (NM) sensory neurostimulation to increase the efficiency of rehabilitation. However, there is still limited knowledge of how these modulated TENS patterns affect corticospinal (CS) and motor cortex activity. Therefore, our aim was to first investigate the effect of modulated TENS patterns on CS activity and corticomotor map in healthy subjects. Motor evoked potentials (MEP) elicited by transcranial magnetic stimulation (TMS) were recorded from three muscles before and after the application of TENS interventions. Four different TENS patterns (PWM, BM, NM 40 Hz, and NM 100 Hz) were applied. The results revealed significant facilitation of CS excitability following the PWM intervention. We also found an increase in the volume of the motor cortical map following the application of the PWM and NM (40 Hz). Although PLP alleviation has been reported to be associated with an enhancement of corticospinal excitability, the efficiency of the PWM intervention to induce pain alleviation should be validated in a future clinical study in amputees with PLP.

Comparison of the effectiveness of an e-health program versus a home rehabilitation program in patients with chronic low back pain: A double blind randomized controlled trial

OBJETIVE

We conducted a randomized double blind clinical trial, to compare the effectiveness of McKenzie exercises and electroanalgesia via an e-Health program versus a home rehabilitation program on functionality, pain, fear of movement and quality of life in patients with non-specific chronic low back pain.

METHODS

Seventy-four participants with non-specific chronic low back pain were randomized to either the e- Health program group (n = 39) or the home rehabilitation program group (n = 35). The interventions consisted of the e-Health program group performing McKenzie exercises and received transcutaneous electrical nerve stimulation, while the home rehabilitation group attended an information session to explain the exercises, which they then performed at home with printed instructions. Both groups performed 3 weekly sessions for 8 weeks. The following were analyzed main measures: pain, disability, fear of movement, quality of life, trunk muscle endurance and trunk anteflexion motion were assessed at baseline and at 2 months.

RESULTS

Independent samples Student's t-tests showed that although the patients who followed the e-Health program showed significantly greater improvement than those who followed the home disability rehabilitation program in terms of intensity of pain, lumbar flexion mobility (P < 0.001), and the following dimensions of quality of life (P < 0.005), both groups improved significantly in the immediate post-treatment follow up compared with baseline scores.

CONCLUSIONS

Patients with chronic low back pain who followed an unsupervised home intervention supported by an individualized video exercise program showed greater post-treatment improvement than those who followed the same program with printed instructions.

Immediate analgesic effect of two modes of transcutaneous electrical nerve stimulation on patients with chronic low back pain: a randomized controlled trial

Objective

To compare and assess the immediate analgesic effects of conventional and burst transcutaneous electrical nerve stimulation in patients with chronic low back pain.

Methods

We conducted a three-arm single-blinded randomized controlled trial. A total of 105 patients with non-specific chronic low back pain aged between 18 and 85 years were randomly assigned into the following groups: Placebo Group (sham electrical stimulation), Conventional TENS Group (continuous stimulation at 100Hz for 100µs with sensory intensity), and Burst TENS Group (stimulation at 100Hz modulated at 2Hz for 100µs with motor-level intensity). All groups received a single application of transcutaneous electrical nerve stimulation for 30 minutes. The outcomes, namely, pain intensity, quality of pain, and pressure pain threshold were measured by the visual analog scale, McGill pain questionnaire, and algometry, respectively. The patients were evaluated before and immediately after the transcutaneous electrical nerve stimulation application.

Results

Pain intensity (visual analog scale score) and quality of pain (McGill pain questionnaire score) significantly decreased (p<0.05) in Intervention Groups (Conventional TENS Group and Burst TENS Group). A positive effect was observed in the interventions compared to the Placebo Group in all domains of the McGill pain questionnaire (p<0.05), excepting for the pain intensity. Pressure pain threshold significantly increased (p<0.05) immediately after the transcutaneous electrical nerve stimulation application in both Intervention Groups, but not in the Placebo Group. For significant difference was found during assessment when comparing both Intervetion Group.

Conclusion

Both transcutaneous electrical nerve stimulation modes were effective for pain modulation. Moreover, there was an increase in the pressure pain threshold. No significant results were found to indicate the best mode for the treatment of chronic low back pain.

Clinical Trial Registration: RBR-59YGRB.

Effects of transcutaneous electrical nerve stimulation and instrument-assisted soft tissue mobilization combined treatment on chronic low back pain: A randomized controlled trial

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain (CLBP) requires a treatment period of ⩾ 6 weeks to decrease pain and disability and is ineffective as sole treatment. Instrument-assisted soft tissue mobilization (IASTM) has rapid effects in musculoskeletal disorders.

OBJECTIVE

This study aimed to investigate the effects of a 3-week combined TENS and IASTM treatment (TICT) on CLBP.

METHODS

Thirty-two young men with CLBP were randomly divided into the TICT and control groups (n= 16 each). Patients were evaluated with the visual analog (VAS) and face pain-rating scales (FPRS) for pain, the Oswestry Disability Index (ODI) and passive straight leg raise (PSLR) test for flexibility, and the supine bridge test (SBT) for endurance before and after the treatment course. The TICT group received TICT on the lower back, glutes, and hamstrings, six times in 3 weeks.

RESULTS

Group, time, and group × time interaction effects on pain were significant (VAS and FPRS, all p< 0.001). Group × time interaction (ODI, p< 0.001; PSLR, p< 0.05; SBT, p< 0.01) and group (ODI, p< 0.05) and time main effects (ODI, p< 0.001; PSLR, p< 0.01; SBT, p< 0.001) on motor function were significant.

CONCLUSION

Thus, short-term TICT decreased pain level and increased motor function in CLBP patients, yet further investigation is needed on different age and gender groups.

Efficacy of a combination of hypnosis and transcutaneous electrical nerve stimulation for chronic non-cancer pain: A randomized controlled trial

BACKGROUND

Chronic non-cancer pain, which persists for at least three months, seriously affects quality of life. Chronic non-cancer pain patients are usually managed by a multidisciplinary team using pharmacological and non-pharmacological strategies. Nurses perform transcutaneous electrical nerve stimulation (TENS) and hypnosis, which are widely used in France for the treatment of chronic pain in pain departments.

OBJECTIVE

To assess pain relief at three months, comparing a simultaneous combination of hypnosis and TENS (intervention) with TENS alone (control).

DESIGN

Randomized controlled trial.

METHODS

Patients aged 18-80 years, suffering from chronic peripheral neuropathic and/or nociceptive non-cancer pain were included (September 2013 to May 2017) and followed for six months. The primary outcome was the pain intensity difference (by visual analog scale score) between month 3 and baseline. The secondary outcomes, assessed at months 3 and 6, were SF36 score, analgesics consumption and number of TENS sessions performed at home (last seven days).

RESULTS

Seventy-two patients were included, suffering from a combination of chronic non-cancer nociceptive and neuropathic pain, with a mean pain intensity of about sixty out of a hundred. The results show an important pain reduction (forty percent) in both groups at 3 months. No significant difference was observed between the control and intervention groups. Similarly, SF36 score, change in analgesic intake and patient compliance did not differ significantly between groups.

CONCLUSIONS

This is the first randomized controlled study showing a decrease of pain intensity and a high level of compliance with transcutaneous electrical nerve stimulation alone or associated to hypnosis. The combination does not seem to be more efficient than transcutaneous electrical nerve stimulation alone. Chronic non-cancer pain remains a major issue and a substantial proportion of patients do not appear to benefit from interventions.

IMPACT

This study increases our understanding of the combination of two non-pharmacological methods in chronic non-cancer pain patients. The combination of the two non-pharmacological strategies did not appear to be more efficient than one alone. Further research on non-pharmacological treatments targeting to patient's characteristics are needed to find appropriate strategies in patients with complex multidimensional pain conditions. Clinical Trial Number: NCT01944150 (Sept. 17, 2013).

Effect of Pain Education, Cryotherapy, and Transcutaneous Electrical Nerve Stimulation on the Pain, Functional Capacity, and Quality of Life in Patients With Nonspecific Chronic Low Back Pain: A Single-Blind Randomized Controlled Trial

OBJECTIVE

The aim of the study was to analyze the effects of pain education and the combined use of cryotherapy and transcutaneous electrical nerve stimulation on the pain sensation, functional capacity, and quality of life of patients with nonspecific chronic low back pain.

DESIGN

This is a randomized controlled and blind clinical trial including patients with nonspecific chronic low back pain in the following 4 groups: control group, cryotherapy group, burst transcutaneous electrical nerve stimulation group, and cryotherapy combined with burst transcutaneous electrical nerve stimulation group. They were evaluated at baseline and after the protocol was concluded using the following: Roland-Morris questionnaire and sit-to-stand test; quality-of-life questionnaire; and pain. The protocol consisted of 10 sessions with pain education associated the combination of the electrophysical agents.

RESULTS

There were no statistical differences between groups after the intervention protocol. In the within analysis, all groups presented an improvement in visual analog scale scores, Roland-Morris questionnaire, sit-to-stand test, and pain domain of quality-of-life questionnaire.

CONCLUSIONS

This study showed that with pain education, there was no difference between cryotherapy and transcutaneous electrical nerve stimulation alone, combined, or placebo mode in improving pain, functional capacity, and quality of life in patients with nonspecific chronic low back pain.

Effects of the Russian current in the treatment of low back pain in women: A randomized clinical trial

BACKGROUND

Low back pain (LBP) is a high impact condition that affects the working population, generating social and economic repercussions, the most relevant symptoms being pain and functional disability. Conservative treatment is often based on stabilizing spinal muscles with exercises: the Russian current (RC) is reported as an alternative, because it promotes muscle contraction, providing muscle strengthening and hypertrophy.

OBJECTIVE

To assess the effectiveness of the RC in aiding the treatment of low back pain.

METHODS

This randomized study included 23 women aged 18-30 years, divided into two groups: the control group (CG) and the Russian current group (RCG), for four weeks. Pain (visual analogue scale, VAS; pressure algometer, PA), function (Oswestry Low Back Disability Index), resistance (trunk resistance [TR] test) and thickness changes in the muscle (ultrasound image) were evaluated before and after the RC protocol and at one-month follow-up.

RESULTS

There were significant VAS reductions in both groups, but at follow-up these had only been maintained in the RCG, which presented lower values than the CG in the second evaluation. For PA, Oswestry and TR, there were differences only in the RCG. In a comparison of LBP between the groups, the initial difference disappeared in subsequent evaluations; TR presented higher values in evaluation 2 and 3 in the RCG group. In terms of thickness changes, differences between the groups were reduced after treatment.

CONCLUSION

The proposed treatment was effective in the reduction of LBP, with short-term improvement in resistance and thickness changes of the multifidus.

Pharmacological and non-pharmacological treatments for neuropathic pain: Systematic review and French recommendations

Neuropathic pain remains a significant unmet medical need. Several recommendations have recently been proposed concerning pharmacotherapy, neurostimulation techniques and interventional management, but no comprehensive guideline encompassing all these treatments has yet been issued. We performed a systematic review of pharmacotherapy, neurostimulation, surgery, psychotherapies and other types of therapy for peripheral or central neuropathic pain, based on studies published in peer-reviewed journals before January 2018. The main inclusion criteria were chronic neuropathic pain for at least three months, a randomized controlled methodology, at least three weeks of follow-up, at least 10 patients per group, and a double-blind design for drug therapy. Based on the GRADE system, we provide weak-to-strong recommendations for use and proposal as a first-line treatment for SNRIs (duloxetine and venlafaxine), gabapentin and tricyclic antidepressants and, for topical lidocaine and transcutaneous electrical nerve stimulation specifically for peripheral neuropathic pain; a weak recommendation for use and proposal as a second-line treatment for pregabalin, tramadol, combination therapy (antidepressant combined with gabapentinoids), and for high-concentration capsaicin patches and botulinum toxin A specifically for peripheral neuropathic pain; a weak recommendation for use and proposal as a third-line treatment for high-frequency rTMS of the motor cortex, spinal cord stimulation (failed back surgery syndrome and painful diabetic polyneuropathy) and strong opioids (in the absence of an alternative). Psychotherapy (cognitive behavioral therapy and mindfulness) is recommended as a second-line therapy, as an add-on to other therapies. An algorithm encompassing all the recommended treatments is proposed.

The Chinese Association for the Study of Pain (CASP): Consensus on the Assessment and Management of Chronic Nonspecific Low Back Pain

Chronic nonspecific low back pain (CNLBP) is defined as pain or discomfort originating from the waist, which lasts for at least 12 weeks, but no radiculopathy or specific spinal diseases. CNLBP is a complicated medical problem and places a huge burden on healthcare systems. Clinical manifestation of CNLBP includes discogenic LBP, zygapophyseal joint pain, sacroiliac joint pain, and lumbar muscle strain. Further evaluation should be completed to confirm the diagnosis including auxiliary examination, functional assessment, and clinical assessment. The principle of the management is to relieve pain, restore function, and avoid recurrence. Treatment includes conservative treatment, minimally invasive treatment, and rehabilitation. Pharmacologic therapy is the first-line treatment of nonspecific LBP, and it is most widely used in clinical practice. Interventional therapy should be considered only after failure of medication and physical therapy. Multidisciplinary rehabilitation can improve physical function and alleviate short-term and long-term pain. The emphasis should be put on the prevention of NLBP and reducing relevant risk factors.

Vojta Therapy versus transcutaneous electrical nerve stimulation for lumbosciatica syndrome: A quasi-experimental pilot study

BACKGROUND

Lumbosciatica is a common condition that affects patients' quality of life.

OBJECTIVE

To determine the efficacy of Vojta Therapy and transcutaneous electrical nerve stimulation (TENS) in the treatment of lumbosciatica.

METHODS

A "pre-post" quasi-experimental pilot study was carried out on 12 patients between 31 and 74 years of age who had been diagnosed with lumbosciatica and referred to the Physiotherapy Unit of the Quintanar de la Orden Health Center. Subjects were prescribed either TENS or Vojta, assigned alternately (6:6). All patients received one session of 30 min per day for 15 days. Tests to evaluate pain, disability, functionality, and radiculopathy were performed.

RESULTS

The differences between pre-post measures and improvement after both treatments were analyzed with nonparametric tests. Significant improvements were noted after both treatments in indices for pain, disability, and flexibility, with the exception of disability after TENS, according to the Roland-Morris test (p = 0.066). Improvements in radiculopathy (Làsegue sign) were only observed with Vojta (p = 0.031). An overall decrease in scores obtained after Vojta was observed with respect to those obtained after TENS (difference V-T): pain according to the Visual Analog Scale (V-T = 2.84; p = 0.033) or Oswestry back pain (V-T = 2.67; p = 0.030) and leg pain tests (V-T = 3.25; p = 0.063); disability according to Oswestry (V-T = 28.33; p = 0.005) and Roland-Morris (V-T = 5.67; p = 0.044); flexibility according to Schöber (average gain V-T = 0.43; p = 0.292) and the fingertips to floor distance test (V-T = 7.5; p = 0.016).

CONCLUSIONS

Vojta Therapy led to significantly greater improvements in pain, disability, flexibility, and radiculopathy than TENS. Future studies will require larger samples to confirm these findings.

Transcutaneous electrical nerve stimulation (TENS) for chronic pain - an overview of Cochrane Reviews

BACKGROUND

Chronic pain, considered to be pain lasting more than three months, is a common and often difficult to treat condition that can significantly impact upon function and quality of life. Treatment typically includes pharmacological and non-pharmacological approaches. Transcutaneous electrical nerve stimulation (TENS) is an adjunct non-pharmacological treatment commonly recommended by clinicians and often used by people with pain.

OBJECTIVES

To provide an overview of evidence from Cochrane Reviews of the effectiveness of TENS to reduce pain in adults with chronic pain (excluding headache or migraine).To provide an overview of evidence from Cochrane Reviews of the safety of TENS when used to reduce pain in adults with chronic pain (excluding headache or migraine).To identify possible sources of inconsistency in the approaches taken to evaluating the evidence related to TENS for chronic pain (excluding headache or migraine) in the Cochrane Library with a view to recommending strategies to improve consistency in methodology and reporting.To highlight areas of remaining uncertainty regarding the effectiveness of TENS for chronic pain (excluding headache or migraine) with a view to recommending strategies to reduce any uncertainty.

METHODS

Search methodsWe searched the Cochrane Database of Systematic Reviews (CDSR), in the Cochrane Library, across all years up to Issue 11 of 12, 2018.Selection of reviewsTwo authors independently screened the results of the electronic search by title and abstract against inclusion/exclusion criteria. We included all Cochrane Reviews of randomised controlled trials (RCTs) assessing the effectiveness of TENS in people with chronic pain. We included reviews if they investigated the following: TENS versus sham; TENS versus usual care or no treatment/waiting list control; TENS plus active intervention versus active intervention alone; comparisons between different types of TENS; or TENS delivered using different stimulation parameters.Data extraction and analysisTwo authors independently extracted relevant data, assessed review quality using the AMSTAR checklist and applied GRADE judgements where required to individual reviews. Our primary outcomes included pain intensity and nature/incidence of adverse effects; our secondary outcomes included disability, health-related quality of life, analgesic medication use and participant global impression of change.

MAIN RESULTS

We included nine reviews investigating TENS use in people with defined chronic pain or in people with chronic conditions associated with ongoing pain. One review investigating TENS for phantom or stump-associated pain in people following amputation did not have any included studies. We therefore extracted data from eight reviews which represented 51 TENS-related RCTs representing 2895 TENS-comparison participants entered into the studies.The included reviews followed consistent methods and achieved overall high scores on the AMSTAR checklist. The evidence reported within each review was consistently rated as very low quality. Using review authors' assessment of risk of bias, there were significant methodological limitations in included studies; and for all reviews, sample sizes were consistently small (the majority of studies included fewer than 50 participants per group).Six of the eight reviews presented a narrative synthesis of included studies. Two reviews reported a pooled analysis.Primary and secondary outcomes One review reported a beneficial effect of TENS versus sham therapy at reducing pain intensity on a 0 to 10 scale (MD -1.58, 95% CI -2.08 to -1.09, P < 0.001, I² = 29%, P = 0.22, 5 studies, 207 participants). However the quality of the evidence was very low due to significant methodological limitations and imprecision. A second review investigating pain intensity performed a pooled analysis by combining studies that compared TENS to sham with studies that compared TENS to no intervention (SMD -0.85, 95% CI -1.36 to -0.34, P = 0.001, I² = 83%, P < 0.001). This pooled analysis was judged as offering very low quality evidence due to significant methodological limitations, large between-trial heterogeneity and imprecision. We considered the approach of combining sham and no intervention data to be problematic since we would predict these different comparisons may be estimating different true effects. All remaining reviews also reported pain intensity as an outcome measure; however the data were presented in narrative review form only.Due to methodological limitation and lack of useable data, we were unable to offer any meaningful report on the remaining primary outcome regarding nature/incidence of adverse effects, nor for the remaining secondary outcomes: disability, health-related quality of life, analgesic medication use and participant global impression of change for any comparisons.We found the included reviews had a number of inconsistencies when evaluating the evidence from TENS studies. Approaches to assessing risk of bias around the participant, personnel and outcome-assessor blinding were perhaps the most obvious area of difference across included reviews. We also found wide variability in terms of primary and secondary outcome measures, and inclusion/exclusion criteria for studies varied with respect to including studies which assessed immediate effects of single interventions.

AUTHORS' CONCLUSIONS

We found the methodological quality of the reviews was good, but quality of the evidence within them was very low. We were therefore unable to conclude with any confidence that, in people with chronic pain, TENS is harmful, or beneficial for pain control, disability, health-related quality of life, use of pain relieving medicines, or global impression of change. We make recommendations with respect to future TENS study designs which may meaningfully reduce the uncertainty relating to the effectiveness of this treatment in people with chronic pain.

Transcutaneous electrical nerve stimulation (TENS) for chronic pain - an overview of Cochrane Reviews

BACKGROUND

Chronic pain, considered to be pain lasting more than three months, is a common and often difficult to treat condition that can significantly impact upon function and quality of life. Treatment typically includes pharmacological and non-pharmacological approaches. Transcutaneous electrical nerve stimulation (TENS) is an adjunct non-pharmacological treatment commonly recommended by clinicians and often used by people with pain.

OBJECTIVES

To provide an overview of evidence from Cochrane Reviews of the effectiveness of TENS to reduce pain in adults with chronic pain (excluding headache or migraine).To provide an overview of evidence from Cochrane Reviews of the safety of TENS when used to reduce pain in adults with chronic pain (excluding headache or migraine).To identify possible sources of inconsistency in the approaches taken to evaluating the evidence related to TENS for chronic pain (excluding headache or migraine) in the Cochrane Library with a view to recommending strategies to improve consistency in methodology and reporting.To highlight areas of remaining uncertainty regarding the effectiveness of TENS for chronic pain (excluding headache or migraine) with a view to recommending strategies to reduce any uncertainty.

METHODS

Search methodsWe searched the Cochrane Database of Systematic Reviews (CDSR), in the Cochrane Library, across all years up to Issue 11 of 12, 2018.Selection of reviewsTwo authors independently screened the results of the electronic search by title and abstract against inclusion/exclusion criteria. We included all Cochrane Reviews of randomised controlled trials (RCTs) assessing the effectiveness of TENS in people with chronic pain. We included reviews if they investigated the following: TENS versus sham; TENS versus usual care or no treatment/waiting list control; TENS plus active intervention versus active intervention alone; comparisons between different types of TENS; or TENS delivered using different stimulation parameters.Data extraction and analysisTwo authors independently extracted relevant data, assessed review quality using the AMSTAR checklist and applied GRADE judgements where required to individual reviews. Our primary outcomes included pain intensity and nature/incidence of adverse effects; our secondary outcomes included disability, health-related quality of life, analgesic medication use and participant global impression of change.

MAIN RESULTS

We included nine reviews investigating TENS use in people with defined chronic pain or in people with chronic conditions associated with ongoing pain. One review investigating TENS for phantom or stump-associated pain in people following amputation did not have any included studies. We therefore extracted data from eight reviews which represented 51 TENS-related RCTs representing 2895 TENS-comparison participants entered into the studies.The included reviews followed consistent methods and achieved overall high scores on the AMSTAR checklist. The evidence reported within each review was consistently rated as very low quality. Using review authors' assessment of risk of bias, there were significant methodological limitations in included studies; and for all reviews, sample sizes were consistently small (the majority of studies included fewer than 50 participants per group).Six of the eight reviews presented a narrative synthesis of included studies. Two reviews reported a pooled analysis.Primary and secondary outcomes One review reported a beneficial effect of TENS versus sham therapy at reducing pain intensity on a 0 to 10 scale (MD -1.58, 95% CI -2.08 to -1.09, P < 0.001, I² = 29%, P = 0.22, 5 studies, 207 participants). However the quality of the evidence was very low due to significant methodological limitations and imprecision. A second review investigating pain intensity performed a pooled analysis by combining studies that compared TENS to sham with studies that compared TENS to no intervention (SMD -0.85, 95% CI -1.36 to -0.34, P = 0.001, I² = 83%, P < 0.001). This pooled analysis was judged as offering very low quality evidence due to significant methodological limitations, large between-trial heterogeneity and imprecision. We considered the approach of combining sham and no intervention data to be problematic since we would predict these different comparisons may be estimating different true effects. All remaining reviews also reported pain intensity as an outcome measure; however the data were presented in narrative review form only.Due to methodological limitation and lack of useable data, we were unable to offer any meaningful report on the remaining primary outcome regarding nature/incidence of adverse effects, nor for the remaining secondary outcomes: disability, health-related quality of life, analgesic medication use and participant global impression of change for any comparisons.We found the included reviews had a number of inconsistencies when evaluating the evidence from TENS studies. Approaches to assessing risk of bias around the participant, personnel and outcome-assessor blinding were perhaps the most obvious area of difference across included reviews. We also found wide variability in terms of primary and secondary outcome measures, and inclusion/exclusion criteria for studies varied with respect to including studies which assessed immediate effects of single interventions.

AUTHORS' CONCLUSIONS

We found the methodological quality of the reviews was good, but quality of the evidence within them was very low. We were therefore unable to conclude with any confidence that, in people with chronic pain, TENS is harmful, or beneficial for pain control, disability, health-related quality of life, use of pain relieving medicines, or global impression of change. We make recommendations with respect to future TENS study designs which may meaningfully reduce the uncertainty relating to the effectiveness of this treatment in people with chronic pain.

The Effect of Spinal Mobilization With Leg Movement in Patients With Lumbar Radiculopathy-A Double-Blind Randomized Controlled Trial

OBJECTIVES

To evaluate the effect of spinal mobilization with leg movement (SMWLM) on low back and leg pain intensity, disability, pain centralization, and patient satisfaction in participants with lumbar radiculopathy.

DESIGN

A double-blind randomized controlled trial.

SETTING

General hospital.

PARTICIPANTS

Adults (N=60; mean age 44y) with subacute lumbar radiculopathy.

INTERVENTIONS

Participants were randomly allocated to receive SMWLM, exercise and electrotherapy (n=30), or exercise and electrotherapy alone (n=30). All participants received 6 sessions over 2 weeks.

MAIN OUTCOME MEASURES

The primary outcomes were leg pain intensity and Oswestry Disability Index score. Secondary variables were low back pain intensity, global rating of change (GROC), straight leg raise (SLR), and lumbar range of motion (ROM). Variables were evaluated blind at baseline, post-intervention, and at 3 and 6 months of follow-up.

RESULTS

Significant and clinically meaningful improvement occurred in all outcome variables. At 2 weeks the SMWLM group had significantly greater improvement than the control group in leg pain (MD 2.0; 95% confidence interval [95% CI], 1.4-2.6) and disability (MD 3.9; 95% CI, 5.5-2.2). Similarly, at 6 months, the SMWLM group had significantly greater improvement than the control group in leg pain (MD 2.6; 95% CI, 1.9-3.2) and disability (MD 4.7; 95% CI, 6.3-3.1). The SMWLM group also reported greater improvement in the GROC and in SLR ROM.

CONCLUSION

In patients with lumbar radiculopathy, the addition of SMWLM provided significantly improved benefits in leg and back pain, disability, SLR ROM, and patient satisfaction in the short and long term.

Randomized study of the impact of a therapeutic education program on patients suffering from chronic low-back pain who are treated with transcutaneous electrical nerve stimulation

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS) is often used for the treatment of low-back pain (LBP). However, its effectiveness is controversial.

OBJECTIVE

To determine the efficacy of TENS in the treatment LBP when associated to a therapeutic education program (TEP).

DESIGN

Open randomized monocentric study.

SETTING

University hospital between 2010 and 2014.

PATIENTS

A total of 97 patients suffering from LBP.

INTERVENTIONS

Routine care (TENS group) or routine care plus a therapeutic education program (TENS-TEP group) based on consultation support by a pain resource nurse.

MAIN OUTCOME MEASURES

EIFEL and Dallas Pain Questionnaire scores.

RESULTS

Twenty-two patients (44%) were still assessable at the end-of-study visit, whereas 33 (70%) were assessable at the same time point in the TENS-TEP group (P = .013). The EIFEL score and the Dallas score had a similar evolution over time between groups (P = .18 and P = .50 respectively). Similarly, there were no significant differences between the groups with respect to resting pain scores (P = .94 for back pain and P = .16 for leg pain) and movement pain scores (P = .52 for back pain and P = .56 for leg pain). At Month 6, there was no significant difference between the groups (P = .85) with regard to analgesics and social impact. Two patients presented a serious adverse event during the study (one in each group) but non-attributable to the treatment studied.

CONCLUSION

This study does not support the use of TENS in the treatment of patients with chronic LBP even though patients benefited from a therapeutic education program by a pain resource nurse. However, the higher number of premature withdrawals in the TENS group may be due to early withdrawal of patients who did not experience improvement of their symptoms.

Effectiveness of fixed-site high-frequency transcutaneous electrical nerve stimulation in chronic pain: a large-scale, observational study

Objective

The objective of this study was to assess the effectiveness of fixed-site high-frequency transcutaneous electrical nerve stimulation (FS-TENS) in a real-world chronic pain sample.

Background

There is a need for nonpharmacological treatment options for chronic pain. FS-TENS improved multisite chronic pain in a previous interventional study. Large observational studies are needed to further characterize its effectiveness.

Methods

This retrospective observational cohort study examined changes in chronic pain measures following 60 days of FS-TENS use. The study data were obtained from FS-TENS users who uploaded their device utilization and clinical data to an online database. The primary outcome measures were changes in pain intensity and pain interference with sleep, activity, and mood on an 11-point numerical rating scale. Dose-response associations were evaluated by stratifying subjects into low (≤30 days), intermediate (31-56 days), and high (≥57 days) utilization subgroups. FS-TENS effectiveness was quantified by baseline to follow-up group differences and a responder analysis (≥30% improvement in pain intensity or ≥2-point improvement in pain interference domains).

Results

Utilization and clinical data were collected from 11,900 people using FS-TENS for chronic pain, with 713 device users meeting the inclusion and exclusion criteria. Study subjects were generally older, overweight adults. Subjects reported multisite pain with a mean of 4.8 (standard deviation [SD] 2.5) pain sites. A total of 97.2% of subjects identified low back and/or lower extremity pain, and 72.9% of subjects reported upper body pain. All pain measures exhibited statistically significant group differences from baseline to 60-day follow-up. The largest changes were pain interference with activity (-0.99±2.69 points) and mood (-1.02±2.78 points). A total of 48.7% of subjects exhibited a clinically meaningful reduction in pain interference with activity or mood. This proportion increased to 57.1% for the high utilization subgroup.

Conclusion

FS-TENS is a practical option for treating multisite chronic pain. The greatest impact is on pain interference with activity and mood. FS-TENS utilization and effectiveness exhibit a dose-response association, suggesting that daily use maximizes pain relief.

Transcutaneous electrical nerve stimulation and interferential current demonstrate similar effects in relieving acute and chronic pain: a systematic review with meta-analysis

BACKGROUND

Transcutaneous electrical nerve stimulation and interferential current have been widely used in clinical practice. However, a systematic review comparing their effects on pain relief has not yet been performed.

OBJECTIVES

To investigate the effects of transcutaneous electrical nerve stimulation and interferential current on acute and chronic pain.

METHODS

We use Pubmed, Embase, LILACS, PEDro and Cochrane Central Register of Controlled Trials as data sources. Two independent reviewers that selected studies according to inclusion criteria, extracted information of interest and verified the methodological quality of the studies made study selection. The studies were selected if transcutaneous electrical nerve stimulation and interferential current were used as treatment and they had pain as the main outcome, as evaluated by a visual analog scale. Secondary outcomes were the Western Ontario Macmaster and Rolland Morris Disability questionnaires, which were added after data extraction.

RESULTS

Eight studies with a pooled sample of 825 patients were included. The methodological quality of the selected studies was moderate, with an average of six on a 0-10 scale (PEDro). In general, both transcutaneous electrical nerve stimulation and interferential current improved pain and functional outcomes without a statistical difference between them.

CONCLUSION

Transcutaneous electrical nerve stimulation and interferential current have similar effects on pain outcome The low number of studies included in this meta-analysis indicates that new clinical trials are needed.

Comparison of the effectiveness of two physiotherapy programs for female patients with lumbar spine discopathy

Background. Lower back pain is one of the most common problems in the human body relat-ed to the disturbances of the motor organ’s structure and function. It challenges contemporary physiotherapy which aim is to reduce or, when possible, eliminate pain, restore fitness for eve-ryday life and prevent recurrences. The aim of the study was to compare two physiotherapy programmes in terms of lowering pain intensity, improvement of lumbar and thoracolumbar spine mobility, as well as functional ability in females with lumbar spine discopathy. Material and methods. The study included 100 women aged 45-50 with lumbar spine disco-pathy being treated in outpatient conditions. The patients were divided into two 50-subject groups depending on the programme used. The physiotherapy programme for group I patients included classic massage, kinesiotherapy and interferential currents, and in group II: classic massage, kinesiotherapy and ultrasound. The research tool was the Numeric Pain Rating Scale (NRS), the Roland Morris Disability Questionnaire (RMDQ) and measurements of lumbar and thoracolumbar spine mobility. The Wilcoxon and Mann-Whitney U tests were used for the analysis. Results. After completion of the physiotherapy programme, the women in group I experi-enced significantly lower pain (p=0.037) and higher functional efficiency (p=0,001). The range of improvement, assessed by the difference in the results of study II and III, was signif-icantly higher for the II group of women (p=0,002). One month after completion of therapeu-tic treatment, there were no statistically significant differences between the groups (p=0,169, p=0,067). Conclusions. The use of interferential currents in the physiotherapy of individuals with lum-bar spine discopathy compared to ultrasound therapy allows for greater improvement in reduc-ing pain intensity, lumbar and thoracolumbar spine mobility, as well as higher functional effi-ciency. The effectiveness of ultrasound had increased over time since the end of therapy and only after one month in the case of both physiotherapy programmes, similar effects could be observed.

Meta-analysis of transcutaneous electrical nerve stimulation for relief of spinal pain

We conducted a systematic review and meta-analysis analysing the existing data on transcutaneous electrical nerve stimulation (TENS) or interferential current (IFC) for chronic low back pain (CLBP) and/or neck pain (CNP) taking into account intensity and timing of stimulation, examining pain, function and disability. Seven electronic databases were searched for TENS or IFC treatment in non-specific CLBP or CNP. Four reviewers independently selected randomized controlled trials (RCTs) of TENS or IFC intervention in adult individuals with non-specific CLBP or CNP. Primary outcomes were for self-reported pain intensity and back-specific disability. Two reviewers performed quality assessment, and two reviewers extracted data using a standardized form. Nine RCTs were selected (eight CLBP; one CNP), and seven studies with complete data sets were included for meta-analysis (655 participants). For CLBP, meta-analysis shows TENS/IFC intervention, independent of time of assessment, was significantly different from placebo/control (p < 0.02). TENS/IFC intervention was better than placebo/control, during therapy (p = 0.02), but not immediately after therapy (p = 0.08), or 1-3 months after therapy (p = 0.99). Analysis for adequate stimulation parameters was not significantly different, and there was no effect on disability. This systematic review provides inconclusive evidence of TENS benefits in low back pain patients because the quality of the studies was low, and adequate parameters and timing of assessment were not uniformly used or reported. Without additional high-quality clinical trials using sufficient sample sizes and adequate parameters and outcome assessments, the outcomes of this review are likely to remain unchanged.

SIGNIFICANCE

These data highlight the need for additional high-quality RCTs to examine the effects of TENS in CLBP. Trials should consider intensity of stimulation, timing of outcome assessment and assessment of pain, disability and function.

Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults

BACKGROUND

Neuropathic pain, which is due to nerve disease or damage, represents a significant burden on people and society. It can be particularly unpleasant and achieving adequate symptom control can be difficult. Non-pharmacological methods of treatment are often employed by people with neuropathic pain and may include transcutaneous electrical nerve stimulation (TENS). This review supersedes one Cochrane Review 'Transcutaneous electrical nerve stimulation (TENS) for chronic pain' (Nnoaham 2014) and one withdrawn protocol 'Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults' (Claydon 2014). This review replaces the original protocol for neuropathic pain that was withdrawn.

OBJECTIVES

To determine the analgesic effectiveness of TENS versus placebo (sham) TENS, TENS versus usual care, TENS versus no treatment and TENS in addition to usual care versus usual care alone in the management of neuropathic pain in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, AMED, CINAHL, Web of Science, PEDro, LILACS (up to September 2016) and various clinical trials registries. We also searched bibliographies of included studies for further relevant studies.

SELECTION CRITERIA

We included randomised controlled trials where TENS was evaluated in the treatment of central or peripheral neuropathic pain. We included studies if they investigated the following: TENS versus placebo (sham) TENS, TENS versus usual care, TENS versus no treatment and TENS in addition to usual care versus usual care alone in the management of neuropathic pain in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all database search results and identified papers requiring full-text assessment. Subsequently, two review authors independently applied inclusion/exclusion criteria to these studies. The same review authors then independently extracted data, assessed for risk of bias using the Cochrane standard tool and rated the quality of evidence using GRADE.

MAIN RESULTS

We included 15 studies with 724 participants. We found a range of treatment protocols in terms of duration of care, TENS application times and intensity of application. Briefly, duration of care ranged from four days through to three months. Similarly, we found variation of TENS application times; from 15 minutes up to hourly sessions applied four times daily. We typically found intensity of TENS set to comfortable perceptible tingling with very few studies titrating the dose to maintain this perception. Of the comparisons, we had planned to explore, we were only able to undertake a quantitative synthesis for TENS versus sham TENS. Insufficient data and large diversity in the control conditions prevented us from undertaking a quantitative synthesis for the remaining comparisons.For TENS compared to sham TENS, five studies were suitable for pooled analysis. We described the remainder of the studies in narrative form. Overall, we judged 11 studies at high risk of bias, and four at unclear risk. Due to the small number of eligible studies, the high levels of risk of bias across the studies and small sample sizes, we rated the quality of the evidence as very low for the pooled analysis and very low individual GRADE rating of outcomes from single studies. For the individual studies discussed in narrative form, the methodological limitations, quality of reporting and heterogeneous nature of interventions compared did not allow for reliable overall estimates of the effect of TENS.Five studies (across various neuropathic conditions) were suitable for pooled analysis of TENS versus sham TENS investigating change in pain intensity using a visual analogue scale. We found a mean postintervention difference in effect size favouring TENS of -1.58 (95% confidence interval (CI) -2.08 to -1.09, P < 0.00001, n = 207, six comparisons from five studies) (very low quality evidence). There was no significant heterogeneity in this analysis. While this exceeded our prespecified minimally important difference for pain outcomes, we assessed the quality of evidence as very low meaning we have very little confidence in this effect estimate and the true effect is likely to be substantially different from that reported in this review. Only one study of these five investigated health related quality of life as an outcome meaning we were unable to report on this outcome in this comparison. Similarly, we were unable to report on global impression of change or changes in analgesic use in this pooled analysis.Ten small studies compared TENS to some form of usual care. However, there was great diversity in what constituted usual care, precluding pooling of data. Most of these studies found either no difference in pain outcomes between TENS versus other active treatments or favoured the comparator intervention (very low quality evidence). We were unable to report on other primary and secondary outcomes in these single trials (health-related quality of life, global impression of change and changes in analgesic use).Of the 15 included studies, three reported adverse events which were minor and limited to 'skin irritation' at or around the site of electrode placement (very low quality evidence). Three studies reported no adverse events while the remainder did not report any detail with regard adverse events.

AUTHORS' CONCLUSIONS

In this review, we reported on the comparison between TENS and sham TENS. The quality of the evidence was very low meaning we were unable to confidently state whether TENS is effective for pain control in people with neuropathic pain. The very low quality of evidence means we have very limited confidence in the effect estimate reported; the true effect is likely to be substantially different. We make recommendations with respect to future TENS study designs which may meaningfully reduce the uncertainty relating to the effectiveness of this treatment modality.

TENS-like Stimulation Downregulates Inflammatory Cytokines in a PC-12 Cell Line

OBJECTIVES

The purpose of this study was to evaluate the effects of transcutaneous electrical nerve stimulation (TENS)-like stimulation on the expression of the proinflammatory cytokines tumor necrosis factor α (TNF-α), interleukin 1β (IL-1β), and IL-6 in PC-12 cells, which are commonly used as neuronal cell models.

METHODS

Nerve growth factor-differentiated PC-12 cells were exposed to electrical stimulation for 15 minutes at 1 mA, 200 μs, and 100 Hz. Cell lysate from stimulated and control cells was assayed for TNF-α, IL-1β, and IL-6. In 6 trials, cells were preincubated with the L-type ion channel blocker nicardipine. Cultured cells were also incubated with Alexa Fluor 488 and visualized by fluorescence microscopy to determine the nuclear vs cytoplasmic distribution of the p65 sub-unit of NF-κB RESULTS: Compared with control (unstimulated) cells, the stimulated cells had a downregulation of the assayed cytokines. However, preincubation with the L-type ion channel blocker nicardipine blocked this effect of stimulation. Additionally, it was noted that TENS-like stimulation promoted a relative sequestration of the p65 subunit of NF-κB in the cytoplasm vs the nucleus.

CONCLUSIONS

It appears that in this cell line and with these stimulation parameters, TENS-like stimulation attenuated the expression of the assayed proinflammatory cytokines, in part by promoting the relative sequestration of the p65 subunit of NF-κB in the cytoplasm, and that voltage-dependent calcium channels have a role in the cascade of events initiated by the TENS-like stimulation.

Non-pharmacological treatments for pain relief: TENS and acupuncture

Acupuncture and transcutaneous electrical nerve stimulation (TENS) are non-pharmacological methods that have been used for millennia to relieve pain. As with all complementary treatments, efficacy evaluations face two hurdles: the non-feasibility of double-blinding and the difficulty in identifying the optimal control population or treatment. Nevertheless, recent studies of good methodological quality have demonstrated benefits in many types of pain compared to conventional treatment. The mechanisms of action of acupuncture and TENS, which are increasingly well understood, involve endogenous pain control systems, cerebral plasticity, and nonspecific effects (e.g., expectations and placebo effect). No serious adverse effects have been reported. These data support the more widespread use of non-pharmacological pain management, most notably in patients with chronic pain inadequately relieved by medications alone.

Efficacy of Selected Electrical Therapies on Chronic Low Back Pain: A Comparative Clinical Pilot Study

Background

In the currently available research publications on electrical therapy of low back pain, generally no control groups or detailed randomization were used, and such studies were often conducted with relatively small groups of patients, based solely on subjective questionnaires and pain assessment scales (lacking measurement methods to objectify the therapeutic progress). The available literature also lacks a comprehensive and large-scale clinical study. The purpose of this study was to assess the effects of treating low back pain using selected electrotherapy methods. The study assesses the influence of individual electrotherapeutic treatments on reduction of pain, improvement of the range of movement in lower section of the spine, and improvement of motor functions and mobility.

Material/Methods

The 127 patients qualified for the therapy (ultimately, 123 patients completed the study) and assigned to 6 comparison groups: A – conventional TENS, B – acupuncture-like TENS, C – high-voltage electrical stimulation, D – interferential current stimulation, E – diadynamic current, and F – control group.

Results

The research showed that using electrical stimulation with interferential current penetrating deeper into the tissues results in a significant and more efficient elimination of pain, and an improvement of functional ability of patients suffering from low back pain on the basis of an analysis of both subjective and objective parameters. The TENS currents and high voltage were helpful, but not as effective. The use of diadynamic currents appears to be useless.

Conclusions

Selected electrical therapies (interferential current, TENS, and high voltage) appear to be effective in treating chronic low back pain.

Problems, Solutions, and Strategies Reported by Users of Transcutaneous Electrical Nerve Stimulation for Chronic Musculoskeletal Pain: Qualitative Exploration Using Patient Interviews

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS) could offer a non-drug form of pain relief, but there is no consensus regarding its effectiveness for chronic musculoskeletal pain or chronic low back pain. A recent review of previous trial methods identified significant problems with low treatment fidelity. There is little information available to inform the development of a pragmatic implementation design for a TENS evaluation.

OBJECTIVES

The aim of this study was to explore the experiences of patients who were receiving secondary care in a pain clinic and who had expertise in using TENS to manage chronic musculoskeletal pain. These key informants were selected because they had the potential to generate knowledge that could inform research design and clinical practice.

DESIGN

A qualitative method using individual semistructured interviews with open questions was selected for its capacity to generate rich data.

METHODS

Semistructured interviews were conducted with 9 patients (6 women, 3 men). Thematic analysis was used as the primary data analysis method, and this analysis was enhanced by a case-level analysis of the context and processes of TENS use of each individual.

RESULTS

Data analysis indicated that patients learned to address a range of problems in order to optimize TENS use. Patients may need to personalize the positioning of electrodes and the TENS settings and to readjust them over time. Patients learned to use TENS in a strategic manner, and the outcomes of each strategy varied.

CONCLUSIONS

The findings indicated that a pragmatic TENS evaluation may need to incorporate a learning phase to allow patients to optimize this complex pattern of TENS usage, and evaluation may need to be sensitive to the outcomes of strategic use. These findings also have implications for clinical practice.

Direct and Indirect Benefits Reported by Users of Transcutaneous Electrical Nerve Stimulation for Chronic Musculoskeletal Pain: Qualitative Exploration Using Patient Interviews

BACKGROUND

There is no consensus regarding the effectiveness of transcutaneous electrical nerve stimulation (TENS) for management of chronic musculoskeletal pain or chronic low back pain. A recent review of previous trial methodology identified significant problems with low treatment fidelity. There is little information available to guide selection of patient-reported outcome measures appropriate for TENS evaluation.

OBJECTIVES

The purpose of this study was to explore the experiences of patients at a secondary care pain clinic who successfully used TENS to help manage chronic musculoskeletal pain. These key informants were selected because they had the potential to generate knowledge that could inform research design and clinical practice.

DESIGN

A qualitative method using individual semistructured interviews with open questions was selected for its capacity to generate rich data.

METHODS

A mini focus group informed the development of a discussion guide for semistructured interviews with 9 patients (6 women, 3 men). Thematic analysis was used as the primary data analysis method, and this analysis was enhanced by a case-level analysis of the context and processes of TENS use of each individual.

RESULTS

Data analysis indicated that distraction from pain and a reduction in the sensations associated with muscle tension or spasm should be considered as separate outcomes from pain relief. These direct benefits led to a wide range of indirect benefits dependent on patient decision making, including medication reduction, enhanced function, psychological benefits, and enhanced ability to rest.

CONCLUSIONS

The findings indicate that evaluating TENS using a unidimensional pain scale is likely to overlook potential benefits. The complex pattern of TENS usage, as well as multiple direct and indirect outcomes, indicates that TENS could be considered as a complex intervention.

Noninvasive and alternative management of chronic low back pain (efficacy and outcomes)

OBJECTIVES

The goal of this article is to provide a thorough literature review of available noninvasive and alternative treatment options for chronic low back pain. In particular, the efficacy of each therapy is evaluated and pertinent outcomes are described.

MATERIALS AND METHODS

A comprehensive search for available literature was done through PubMed and Cochrane data base for topics discussed in this paper.

RESULTS

Relevant current and past references were reviewed and presented to reflect the efficacy of each therapy and related outcomes.

CONCLUSIONS

There are a wide variety of noninvasive and alternative therapies for the treatment of chronic low back pain. Those with the strongest evidence in the literature for good efficacy and outcomes include exercise therapy with supervised physical therapy, multidisciplinary biopsychosocial rehabilitation, and acupuncture. Therapies with fair evidence or moderately supported by literature include yoga, back schools, thermal modalities, acupressure, and cognitive-behavioral therapy. Those therapies with poor evidence or little to no literature support include manipulation, transcutaneous electrical nerve stimulation, low-level laser therapy, reflexology, biofeedback, progressive relaxation, hypnosis, and aromatherapy. Providers delivering care for patients with chronic low back pain must carefully evaluate these available treatment options related to their efficacy or lack thereof as well as relevant outcomes.

[Evidence-based physiotherapy]

This article on physiotherapy presents some current evidence stating the strengths and weaknesses of the physiotherapeutic procedures. In the area of physiotherapy empirical data obtained during decades were overtaken by evidence from current studies. The author points out the great problem of physiotherapy, namely the heterogeneity of the applied parameters. Knowledge of current evidence may be very important and helpful for the physicians, but the author proposes, from the practical point of view, that physiotherapeutical procedures based on exprience and used for many years should not be entirely neglected. Nowadays physiotherapy plays an important role in the treament of locomotor diseases but its use is increasing in other fields of medicine, as well.

What makes transcutaneous electrical nerve stimulation work? Making sense of the mixed results in the clinical literature

Transcutaneous electrical nerve stimulation (TENS) is a nonpharmacological treatment for control of pain. It has come under much scrutiny lately with the Center for Medicare Services rendering a recent decision stating that "TENS is not reasonable and necessary for the treatment of CLBP [chronic low back pain]." When reading and analyzing the existing literature for which systematic reviews show that TENS is inconclusive or ineffective, it is clear that a number of variables related to TENS application have not been considered. Although many of the trials were designed with the highest of standards, recent evidence suggests that factors related to TENS application need to be considered in an assessment of efficacy. These factors include dosing of TENS, negative interactions with long-term opioid use, the population and outcome assessed, timing of outcome measurement, and comparison groups. The purpose of this perspective is to highlight and interpret recent evidence to help improve the design of clinical trials and the efficacy of TENS in the clinical setting.

Electrical stimulation for chronic non-specific low back pain in a working-age population: a 12-week double blinded randomized controlled trial

Background

Non-invasive electrotherapy is commonly used for treatment of chronic low back pain. Evidence for efficacy of most electrotherapy modalities is weak or lacking. This study aims to execute a high-quality, double-blinded randomized controlled clinical trial comparing 1) H-Wave® Device stimulation plus usual care with 2) transcutaneous electrical nerve stimulation (TENS) plus usual care, and 3) Sham electrotherapy plus usual care to determine comparative efficacy for treatment of chronic non-specific low back pain patients.

Methods/Design

Patients- Chronic non-specific low back pain patients between ages of 18–65 years, with pain of at least 3 months duration and minimal current 5/10 VAS pain. Patients will have no significant signs or symptoms of lumbosacral nerve impingement, malignancy, spinal stenosis, or mood disorders.

Study design- Double blind RCT with 3 arms and 38 subjects per arm. Randomization by permuted blocks of random length, stratified by Workers Compensation claim (yes vs. no), and use of opioids. The null hypothesis of this study is that there are no statistically significant differences in functional improvement between treatment types during and at the end of a 12-week week treatment period.

Data collection- Subjective data will be collected using Filemaker Pro™ database management collection tools. Objective data will be obtained through functional assessments. Data will be collected at enrollment and at 1, 4, 8, and 12 weeks for each participant by a blinded assessor.

Interventions- H-Wave® device stimulation (Intervention A) plus usual care, transcutaneous electrical nerve stimulation (TENS) (Intervention B) plus usual care, and sham electrotherapy plus usual care (control). Each treatment arm will have identical numbers of visits (4) and researcher contact time (approximately 15 hours).

Outcomes- Primary outcome measure: Oswestry Disability Index. Secondary measures include: Rowland Morris Instrument, VAS pain score, functional evaluation including strength when pushing and pulling, pain free range of motion in flexion and extension. Outcome measures assessed at baseline, 1, 4, 8, and 12 weeks. Treatment failure will be defined if patient terminates assigned treatment arm for non-efficacy or undergoes invasive procedure or other excluded cointerventions. Data will be analyzed using intention-to-treat analysis and adjusted for covariates related to LBP (e.g. age) as needed.

Discussion

Study strengths include complex randomization, treatment group allocation concealment, double blinding, controlling for co-interventions, rigorous inclusion criteria, assessment of compliance, plans for limiting dropout, identical assessment methods and timing for each treatment arm, and planned intention-to-treat analyses.