Abstract
Background and aims
There has been no comprehensive evaluation of the efficacy of transcutaneous electric nerve stimulation (TENS) for acute low back pain (LBP). The aim of this systematic review was to investigate the efficacy and safety of TENS for acute LBP.
Methods
We searched MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL and PsycINFO (inception to May 2018) for randomised placebo controlled trials. The primary outcome measure was pain relief in the immediate term (within 2-weeks of administration) assessed using the 100 mm visual analogue scale. A mean difference of at least 10 points on the 100-point pain scale was considered clinically significant. Methodological quality of the eligible studies was assessed using the PEDro scale and overall quality assessment rating was assessed using GRADE.
Results
Three placebo controlled studies (n = 192) were included. One low quality trial (n = 63) provides low quality evidence that ~30 min treatment with TENS in an emergency-care setting provides clinically worthwhile pain relief for moderate to severe acute LBP in the immediate term compared with sham TENS [Mean Difference (MD) – 28.0 (95% CI – 32.7, −23.3)]. Two other studies which administered a course of TENS over 4–5 weeks, in more usual settings provide inconclusive evidence; MD −2.75 (95% CI −11.63, 6.13). There was limited data on adverse events or long term follow-up.
Conclusions
The current evidence is insufficient to support or dismiss the use of TENS for acute LBP.
Implications
There is insufficient evidence to guide the use of TENS for acute LBP. There is low quality evidence of moderate improvements in pain with a short course of TENS (~30 min) during emergency transport of patients to the hospital. Future research should evaluate whether TENS has an opioid sparing role in the management of acute LBP.
Authors’ statements
Research funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Chris Maher, Chris Lin, Adrian Traeger and Gustavo Machado hold research fellowships funded by Australia’s National Health and Medical Research Council.
Conflict of interest: The authors have no conflicts of interest to disclose.
Informed consent: Not applicable.
Ethical approval: Not applicable.
Authors’ contributions
JB, JW, CAS were involved in study inception and design. JB, JW, SG, CAS were involved in the article search and data extraction. All authors discussed the results and commented on the manuscript.
Appendix
Summary of search strategy.
| 1 | Randomised study OR random allocation OR Radomi*ed controlled trial OR Random$ Control$ trial OR RCT OR REVIEW, ACADEMIC.pt. OR REVIEW, TUTORIAL.pt. OR META–ANALYSIS.pt. OR META–ANALYSIS.sh. OR systematic review$ OR systematic overview$ OR meta-analy$ or metaanaly$ or (meta analy$) |
| 2 | ANIMAL/ not HUMAN/ |
| 3 | 1 NOT 2 |
| 4 | Low back pain OR mechanical back pain OR lumbago OR acute low back pain or Low-back pain |
| 5 | TENS OR Transcutaneous electric Nerve stimulation OR analgesic cutaneous electrostimulation OR cutaneous electrostimulation, analgesic OR electric stimulation, transcutaneous OR electroanalgesia OR electrostimulation, analgesic cutaneous OR electrostimulation, transdermal OR nerve stimulation, transcutaneous OR inferential therapy OR inferential current OR Codetron OR transcutaneous electric* stimulation OR transcutaneous electric* nerve stimulation |
| 6 | 4 AND 5 |
| 7 | 3 AND 6 |
References
[1] Walker BF. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord 2000;13:205–17.10.1097/00002517-200006000-00003Search in Google Scholar PubMed
[2] Walker BF, Muller R, Grant WD. Low back pain in Australian adults: the economic burden. Asia-Pacific J Public Health 2003;15:79–87.10.1177/101053950301500202Search in Google Scholar PubMed
[3] Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, Williams G, Smith E, Vos T, Barendregt J, Murray C, Burstein R, Buchbinder R. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 2014;73:968–74.10.1136/annrheumdis-2013-204428Search in Google Scholar PubMed
[4] Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of physicians. Ann Intern Med 2017;166:514–30.10.7326/M16-2367Search in Google Scholar PubMed
[5] Traeger A, Buchbinder R, Harris I, Maher C. Diagnosis and management of low-back pain in primary care. Can Med Assoc J 2017;189:E1386–95.10.1503/cmaj.170527Search in Google Scholar PubMed PubMed Central
[6] Machado GC, Maher CG, Ferreira PH, Pinheiro MB, Lin C-WC, Day RO, McLachlan AJ, Ferreira ML. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. Br Med J 2015;350:h1225.10.1136/bmj.h1225Search in Google Scholar PubMed PubMed Central
[7] Machado GC, Maher CG, Ferreira PH, Day RO, Pinheiro MB, Ferreira ML. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Ann Rheum Dis 2017;76:1269–78.10.1136/annrheumdis-2016-210597Search in Google Scholar PubMed
[8] Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis. JAMA Intern Med 2016;176:958–68.10.1001/jamainternmed.2016.1251Search in Google Scholar PubMed
[9] Deyo RA, Walsh NE, Martin DC, Schoenfeld LS, Ramamurthy S. A controlled trial of transcutaneous electrical stimulation (TENS) and exercise for chronic low back pain. N Engl J Med 1990;322:1627–34.10.1056/NEJM199006073222303Search in Google Scholar PubMed
[10] American Physical Therapy Association. American Physical Therapy Association Anthology, vol. 2. American Physical Therapy Association, 1993.Search in Google Scholar
[11] Barr JO. Transcutaneous electrical nerve stimulation for pain management. In: Nelson RM, Hayes KW, Currier DP, editors. Clinical Electrotherapy. 3rd ed. Norwalk, CT: Appleton & Lange, 1999:291–354.Search in Google Scholar
[12] Sluka KA, Walsh D. Transcutaneous electrical nerve stimulation basic science mechanisms and clinical effectiveness. J Pain 2003;4:109–21.10.1054/jpai.2003.434Search in Google Scholar PubMed
[13] Bertalanffy A, Kober A, Bertalanffy P, Gustorff B, Gore O, Adel S, Hoerauf K. Transcutaneous electrical nerve stimulation reduces acute low back pain during emergency transport. Acad Emerg Med 2005;12:607–11.10.1197/j.aem.2005.01.013Search in Google Scholar
[14] Jauregui JJ, Cherian JJ, Gwam CU, Chughtai M, Mistry JB, Elmallah RK, Harwin SF, Bhave A, Mont MA. A meta-analysis of transcutaneous electrical nerve stimulation for chronic low back pain. Surg Technol Int 2016;28:296–302.Search in Google Scholar
[15] Resende L, Merriwether E, Rampazo EP, Dailey D, Embree J, Deberg J, Liebano RE, Sluka KA. Meta-analysis of transcutaneous electrical nerve stimulation for relief of spinal pain. Eur J Pain 2018;22:663–78.10.1002/ejp.1168Search in Google Scholar
[16] Wu LC, Weng PW, Chen CH, Huang YY, Tsuang YH, Chiang CJ. Literature review and meta-analysis of transcutaneous electrical nerve stimulation in treating chronic back pain. Reg Anesth Pain Med 2018;43:425–33.10.1097/AAP.0000000000000740Search in Google Scholar
[17] Low Back pain and sciatica in over 16’s: assessment and management: National Institute for Health and Care Excellence (NICE) guidelines. Medycyna Pracy 2011;63:295–302.Available at: https://www.nice.org.uk/guidance/ng59/chapter/Recommendations. Accessed: Jun 2017.10.1016/j.jphys.2017.02.012Search in Google Scholar
[18] Australian Physiotherapy Association. Choosing Wisely Australia. Available at: https://www.physiotherapy.asn.au/APAWCM/Advocacy/Campaigns/Choosing_Wisely.aspx. Accessed: Dec 2017.Search in Google Scholar
[19] Machado LA, Kamper SJ, Herbert RD, Maher CG, McAuley JH. Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials. Rheumatology (Oxford) 2009;48:520–7.10.1093/rheumatology/ken470Search in Google Scholar
[20] Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions, version 5.2.0. Cochrane Collaboration, 2017.Search in Google Scholar
[21] Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH, Fainsinger R, Aass N, Kaasa S. European Palliative Care Research Collaborative (EPCRC). Studies comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage 2011;41:1073–93.10.1016/j.jpainsymman.2010.08.016Search in Google Scholar
[22] Dworkin RH, Turk DC, Wyrwich KW, Beaton D, Cleeland CS, Farrar JT, Haythornthwaite JA, Jensen MP, Kerns RD, Ader DN, Brandenburg N, Burke LB, Cella D, Chandler J, Cowan P, Dimitrova R, Dionne R, Hertz S, Jadad AR, Katz NP, et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain 2008;9:105–21.10.1016/j.jpain.2007.09.005Search in Google Scholar
[23] Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von Korff M, Bouter LM, de Vet HC. Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine (PhilaPa1976) 2008;33:90–4.10.1097/BRS.0b013e31815e3a10Search in Google Scholar
[24] Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 2003;83:713–21.10.1093/ptj/83.8.713Search in Google Scholar
[25] de Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother 2009;55:129–33.10.1016/S0004-9514(09)70043-1Search in Google Scholar
[26] Macedo LG, Elkins MR, Maher CG, Moseley AM, Herbert RD, Sherrington C. There was evidence of convergent and construct validity of Physiotherapy Evidence Database quality scale for physiotherapy trials. J Clin Epidemiol 2010;63:920–5.10.1016/j.jclinepi.2009.10.005Search in Google Scholar PubMed
[27] Pinto RZ, Maher CG, Ferreira ML, Ferreira PH, Hancock M, Oliveira VC, McLachlan AJ, Koes B. Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis. Br Med J 2012;344:e497.10.1136/bmj.e497Search in Google Scholar PubMed PubMed Central
[28] Pinto RZ, Maher CG, Ferreira ML, Hancock M, Oliveira VC, McLachlan AJ, Koes B, Ferreira PH. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med 2012;157:865–77.10.7326/0003-4819-157-12-201212180-00564Search in Google Scholar PubMed
[29] Egger M, Smith GD, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. Br Med J 1997;315:629–34.10.1136/bmj.315.7109.629Search in Google Scholar PubMed PubMed Central
[30] Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.Search in Google Scholar
[31] Herman E, Williams R, Stratford P, Fargas-Babjak A, Trott MA. A randomized controlled trial of transcutaneous electrical nerve stimulation (CODETRON) to determine its benefits in a rehabilitation program for acute occupational low back pain. Spine 1994;19:561–8.10.1097/00007632-199403000-00012Search in Google Scholar PubMed
[32] Lourenzi VDGCM, Jones A, Lourenzi FM, Jennings F, Natour J. THU0638-HPR effectiveness of the transcutaneous electrical nerve stimulation in pain control of patients with acute low back pain: a randomized controlled trial. Ann Rheum Dis 2015;74:1322.10.1136/annrheumdis-2015-eular.4989Search in Google Scholar
[33] Johnson MI, Paley CA, Howe TE, Sluka KA. Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database Syst Rev 2015;CD006142. doi: 10.1002/14651858.CD006142.pub3.Search in Google Scholar PubMed PubMed Central
[34] Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database Syst Rev 2008;4:CD003008.10.1002/14651858.CD003008.pub3Search in Google Scholar PubMed PubMed Central
©2019 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.
