Current concepts in low back pain: a review

WITHDRAWN: Transcutaneous electrical nerve stimulation and acupuncture-like transcutaneous electrical nerve stimulation for chronic low back pain

BACKGROUND

In view of the claims and counter-claims of the effectiveness of transcutaneous electrical nerve stimulation, it would seem appropriate to systematically review the literature.

OBJECTIVES

To determine the effectiveness of transcutaneous electrical nerve stimulation in reducing pain and improving range of movement in patients with chronic low back pain.

SEARCH STRATEGY

Electronic searches of EMBASE, MEDLINE, CISCOM, AMED for all studies of TENS in the English language, identifying those treating chronic low back pain and hand searching their references.

SELECTION CRITERIA

The inclusion criterion for studies included in this review, 6 of 68 identified, was comparisons of TENS/ALTENS versus placebo in patients with chronic low back pain.

DATA COLLECTION AND ANALYSIS

Outcome data on pain reduction, range of movement, functional status and work was extracted by two independent reviewers together with trial design qualities to construct a Quality Index.

MAIN RESULTS

The ratio of odds of improvement in pain for each comparison was calculated: TENS vs. placebo at 1.62 (95% CI 0.90, 2.68); ALTENS vs. placebo at 7.22 (95% CI 2.60, 20.01) and TENS/ALTENS vs. placebo at 2.11 (95% CI 1.32, 3.38) times that of placebo. An improvement in pain reduction was seen in 45.80% (CI 37.00%, 55.00%) of TENS; 86.70% (CI 80.00%, 93.00%) of ALTENS; 54.00% (CI 46.20%, 61.80%) of TENS/ ALTENS and 36.40% (95%CI 28.40%, 44.40%) of placebo subjects. The odds of improvement in range of movement on ALTENS vs. placebo was 6.61 times (95% CI 2.36, 18.55) that of placebo.

AUTHORS' CONCLUSIONS

Transcutaneous electrical nerve stimulation appears to reduce pain and improve the range of movement in chronic low back pain subjects. A definitive randomised controlled study of ALTENS, TENS, placebo/no treatment controls, of sufficient power, is needed to confirm these findings.

Transcutaneous electrical nerve stimulation and acupuncture-like transcutaneous electrical nerve stimulation for chronic low back pain

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS), originally based on the gate-control theory of pain, is widely used for the treatment of chronic low back pain. Despite its wide use and theoretical rationale, there appears at first glance little scientific evidence to support its use. This Cochrane review examines the available evidence on TENS for the treatment of chronic back pain through an exhaustive search of the literature.

OBJECTIVES

Transcutaneous electrical nerve stimulation (TENS) and acupuncture-like transcutaneous electrical nerve stimulation (ALTENS) for chronic low back pain management have experienced a tremendous growth over the past 25 years. The objective of this review was to assess the effects of TENS and ALTENS for reducing pain and improving function in patients with chronic back pain.

SEARCH STRATEGY

We searched MEDLINE up to November 1997, EMBASE from 1985 to September 1995, Amed and Ciscom to January 1995, reference lists of the retrieved articles, proceedings of conferences and contacted investigators in the field.

SELECTION CRITERIA

Randomised trials comparing TENS or ALTENS therapy to placebo in patients with chronic low back pain.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data on pain reduction, range of movement, functional and work status.

MAIN RESULTS

Six trials were included. The trials included 288 participants with an average age range of 45 to 50 years and approximately equal numbers of women and men. The overall odds ratio for improvement in pain for each comparison was: TENS/ALTENS versus placebo 2.11 (95% confidence interval 1.32 to 3. 38), ALTENS versus placebo 7.22 (95% confidence interval 2.60 to 20.01) and TENS versus placebo 1.52 (95% confidence interval 0.90 to 2.58). The odds ration for improvement in range of motion on ALTENS versus placebo was 6.61 (95% confidence interval 2.36 to 18.55).

REVIEWER'S CONCLUSIONS

There is evidence from the limited data available that TENS/ALTENS reduces pain and improves range of motion in chronic back pain patients, at least in the short term. A large trial of ALTENS and TENS is needed to confirm these findings.

A review of research on acupuncture for the treatment of lumbar disk protrusions and associated neurological symptomatology

The association between acupuncture (AP) and pain relief is so strong that it has tended to obscure any other potentially significant clinical results. This review indicates the wealth of data from around the world on various aspects of AP treatment for low back syndromes related to lumbar intervertebral disk prolapse (PID). Although plentiful, the research is variable in quality, especially with respect to design, consistency, and follow-up. Even so, the large number of patients who appear to have been treated successfully (i.e., given a high degree of symptomatic relief) supports a potential role for AP. This is further supported by studies on patients who had previously had unsuccessful treatment with conservative methods. The role envisaged for AP, in cases of lumbar PID and sciatica, is at least of a supplementary therapy capable of reducing the requirement of more invasive forms of treatment. No such role is envisaged in cases of cauda equina compression where surgery must remain the treatment of choice. AP should be explored more fully, using appropriate designs, so that this discipline may achieve its full therapeutic potential in the West.