Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromodulation Techniques for Pain Management

A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Neurology".

Deadline for manuscript submissions: closed (31 July 2022) | Viewed by 68433

Special Issue Editors


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Guest Editor
Centre for Pain Research, School of Health, Portland Building, Leeds Beckett University, Leeds, UK
Interests: pain; perception; pain management; analgesia; neuromodulation therapy; transcutaneous electrical nerve stimulation (TENS); individuality in pain; pain education; epidemiology of pain; sports-injuries and pain
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Co-Guest Editor
Center for Neuroplasticity and Pain - CNAP, Aalborg University, Alborg, Denmark; and Centre for Pain Research, Leeds Beckett University, Leeds, UK
Interests: pain; pain perception; pain modulation; pain plasticity; neuroplasticity

Special Issue Information

Dear Colleagues,

There are many therapeutic techniques that modulate activity of neurons to alleviate pain. One of the most popular techniques is transcutaneous electrical nerve stimulation (TENS), an inexpensive, safe, and self-administered treatment that is prescribed by health care professionals and purchased by patients without prescription. There is strong evidence that TENS inhibits central nociceptive transmission, but a long-standing debate as to whether these physiological effects translate into clinically meaningful reductions in pain when compared with placebo (i.e., no currents). Cochrane reviews on TENS for specific conditions are inconclusive, although non-Cochrane reviews with meta-analyses suggest that TENS is superior to placebo (see Johnson (2014) and Johnson (2020) for reviews). Likewise, uncertainty about efficacy and effectiveness has been long-standing for many other neuromodulation techniques, and this contributes to inconsistency in treatments offered to patients.

The purpose of this Special Issue is to disseminate research and catalyse debate on all matters related to the use of neuromodulation techniques to manage pain, with a particular focus on TENS. The scope is broad to include any technique that delivers energy into the body to influence neural activity with the goal of alleviating pain. Treatments include: TENS and non-invasive electrotherapeutic techniques (e.g. interferential therapy, transcutaneous electrical acupoint stimulation, and non-invasive brain stimulation); invasive electrotherapeutic techniques (e.g. percutaneous, spinal cord, and brain stimulation) and electrophysical techniques (e.g. thermal, microthermal, photomodulation and mechanical modalities, including acupuncture). We welcome articles on efficacy, effectiveness, utility, service delivery, mechanisms of action, factors influencing response, technological advances, and viewpoints. We will not consider articles about techniques used to manage non-painful ailments such as nausea and vomiting, constipation, bladder dysfunction, dementia, or for neuromuscular rehabilitation.

Prof. Mark I. Johnson
Dr. Priscilla G. Wittkopf
Guest Editors

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Keywords

  • Transcutaneous electrical nerve stimulation (TENS)
  • Neuromodulation therapy
  • Electrophysical agents
  • Pain
  • Analgesia
  • Pain management

Published Papers (8 papers)

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Research

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13 pages, 1607 KiB  
Article
TENS Improves Cisplatin-Induced Neuropathy in Lung Cancer Patients
by Sanja Tomanovic Vujadinovic, Nela Ilic, Ivan Selakovic, Una Nedeljkovic, Nevena Krstic, Natasa Mujovic, Emilija Dubljanin Raspopovic and Dragana Jovanovic
Medicina 2022, 58(10), 1405; https://doi.org/10.3390/medicina58101405 - 6 Oct 2022
Cited by 2 | Viewed by 2075
Abstract
Background: Cisplatin-induced peripheral neuropathy is a common complication of cisplatin therapy, which develops in most patients with lung cancer. There are no effective preventive measures and once it occurs there is no effective therapy, except symptomatic. In this study, we aimed to assess [...] Read more.
Background: Cisplatin-induced peripheral neuropathy is a common complication of cisplatin therapy, which develops in most patients with lung cancer. There are no effective preventive measures and once it occurs there is no effective therapy, except symptomatic. In this study, we aimed to assess the effect of transcutaneous electrical nerve stimulation (TENS) therapy on the pain intensity and the quality of life of patients with cisplatin-induced neuropathy. Material and Methods: A prospective cohort study was performed from 2013 to 2018, at the Clinical Center of Serbia. After the initial evaluation of 106 newly diagnosed patients with lung cancer, 68 patients did not have peripheral neuropathy. These 68 patients continued in the study and started the cisplatin chemotherapy. Forty of these patients developed cisplatin-induced neuropathy, which was manifested by neuropathic symptoms and proven by ENG examination. All patients with cisplatin-induced neuropathy were treated with TENS therapy. Their neuropathic pain and quality of life were evaluated using the following questionnaires at diagnosis, after cisplatin therapy and after four weeks of TENS use: DN4, VAS scale, EORTC QLQ-C30 and FACT-L. Results: Two thirds (68%) of the patients with cisplatin-induced neuropathy were male and the majority were smokers (70%). Adenocarcinoma was the most common (38%), followed by squamous (33%) and small-cell carcinoma (28%). The application of TENS therapy had a positive effect on reducing the neuropathic pain and increasing the quality of life for patients with painful cisplatin-induced neuropathy. The VAS and DN4 scores significantly decreased after TENS therapy, in comparison to its values after cisplatin therapy (p < 0.001). After TENS therapy, patients had significantly higher values in most of the domains of EORTC QLQ-C30 and FACT- L, in comparison with the values after cisplatin therapy (p < 0.001). Conclusion: The application of TENS therapy has a positive effect on reducing neuropathic pain and increasing the quality of life for patients with lung cancer and cisplatin-induced neuropathy. Full article
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Review

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27 pages, 445 KiB  
Review
Using TENS for Pain Control: Update on the State of the Evidence
by Carol G. T. Vance, Dana L. Dailey, Ruth L. Chimenti, Barbara J. Van Gorp, Leslie J. Crofford and Kathleen A. Sluka
Medicina 2022, 58(10), 1332; https://doi.org/10.3390/medicina58101332 - 22 Sep 2022
Cited by 18 | Viewed by 10295
Abstract
Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological intervention used in the treatment of acute and chronic pain conditions. The first clinical studies on TENS were published over 50 years ago, when effective parameters of stimulation were unclear and clinical trial design was [...] Read more.
Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological intervention used in the treatment of acute and chronic pain conditions. The first clinical studies on TENS were published over 50 years ago, when effective parameters of stimulation were unclear and clinical trial design was in its infancy. Over the last two decades, a better understanding of the mechanisms underlying TENS efficacy has led to the development of an adequate dose and has improved outcome measure utilization. The continued uncertainty about the clinical efficacy of TENS to alleviate pain, despite years of research, is related to the quality of the clinical trials included in systematic reviews. This summary of the evidence includes only trials with pain as the primary outcome. The outcomes will be rated as positive (+), negative (−), undecided (U), or equivalent to other effective interventions (=). In comparison with our 2014 review, there appears to be improvement in adverse events and parameter reporting. Importantly, stimulation intensity has been documented as critical to therapeutic success. Examinations of the outcomes beyond resting pain, analgesic tolerance, and identification of TENS responders remain less studied areas of research. This literature review supports the conclusion that TENS may have efficacy for a variety of acute and chronic pain conditions, although the magnitude of the effect remains uncertain due to the low quality of existing literature. In order to provide information to individuals with pain and to clinicians treating those with pain, we suggest that resources for research should target larger, high-quality clinical trials including an adequate TENS dose and adequate timing of the outcome and should monitor risks of bias. Systematic reviews and meta-analyses should focus only on areas with sufficiently strong clinical trials that will result in adequate sample size. Full article
47 pages, 4247 KiB  
Review
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
by Mark I. Johnson, Carole A. Paley, Priscilla G. Wittkopf, Matthew R. Mulvey and Gareth Jones
Medicina 2022, 58(6), 803; https://doi.org/10.3390/medicina58060803 - 14 Jun 2022
Cited by 9 | Viewed by 6522
Abstract
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 [...] Read more.
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. Full article
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14 pages, 1605 KiB  
Review
Analgesic Effects of Interferential Current Therapy: A Narrative Review
by Érika Patrícia Rampazo and Richard Eloin Liebano
Medicina 2022, 58(1), 141; https://doi.org/10.3390/medicina58010141 - 17 Jan 2022
Cited by 15 | Viewed by 10790
Abstract
Background and Objectives: Transcutaneous electrical stimulation of low- and medium-frequency currents is commonly used in pain management. Interferential current (IFC) therapy, a medium frequency alternating current therapy that reportedly reduces skin impedance, can reach deeper tissues. IFC therapy can provide several different [...] Read more.
Background and Objectives: Transcutaneous electrical stimulation of low- and medium-frequency currents is commonly used in pain management. Interferential current (IFC) therapy, a medium frequency alternating current therapy that reportedly reduces skin impedance, can reach deeper tissues. IFC therapy can provide several different treatment possibilities by adjusting its parameters (carrier frequency, amplitudemodulated frequency, sweep frequency, sweep mode or swing pattern, type of application (bipolar or quadripolar), time of application and intensity). The objective of this review article is to discuss the literature findings on the analgesic efficacy of IFC therapy. Conclusions: According to the literature, IFC therapy shows significant analgesic effects in patients with neck pain, low back pain, knee osteoarthritis and post-operative knee pain. Most of the IFC parameters seem not to influence its analgesic effects. We encourage further studies to investigate the mechanism of action of IFC therapy. Full article
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102 pages, 8767 KiB  
Review
Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses
by Carole A. Paley, Priscilla G. Wittkopf, Gareth Jones and Mark I. Johnson
Medicina 2021, 57(10), 1060; https://doi.org/10.3390/medicina57101060 - 4 Oct 2021
Cited by 22 | Viewed by 10338
Abstract
Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to [...] Read more.
Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors’ conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with ‘sufficient data’ demonstrating benefit. There were no examples of meta-analyses with ‘sufficient data’ demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with ‘insufficient data’ and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward. Full article
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35 pages, 5879 KiB  
Review
Resolving Long-Standing Uncertainty about the Clinical Efficacy of Transcutaneous Electrical Nerve Stimulation (TENS) to Relieve Pain: A Comprehensive Review of Factors Influencing Outcome
by Mark I. Johnson
Medicina 2021, 57(4), 378; https://doi.org/10.3390/medicina57040378 - 14 Apr 2021
Cited by 25 | Viewed by 16681
Abstract
Pain is managed using a biopsychosocial approach and pharmacological and non-pharmacological treatments. Transcutaneous electrical nerve stimulation (TENS) is a technique whereby pulsed electrical currents are administered through the intact surface of the skin with the intention of alleviating pain, akin to ‘electrically rubbing [...] Read more.
Pain is managed using a biopsychosocial approach and pharmacological and non-pharmacological treatments. Transcutaneous electrical nerve stimulation (TENS) is a technique whereby pulsed electrical currents are administered through the intact surface of the skin with the intention of alleviating pain, akin to ‘electrically rubbing pain away’. Despite over 50 years of published research, uncertainty about the clinical efficacy of TENS remains. The purpose of this comprehensive review is to critically appraise clinical research on TENS to inform future strategies to resolve the ‘efficacy-impasse’. The principles and practices of TENS are described to provide context for readers unfamiliar with TENS treatment. The findings of systematic reviews evaluating TENS are described from a historical perspective to provide context for a critical evaluation of factors influencing the outcomes of randomized controlled trials (RCTs); including sample populations, outcome measures, TENS techniques, and comparator interventions. Three possibilities are offered to resolve the impasse. Firstly, to conduct large multi-centered RCTs using an enriched enrolment with randomized withdrawal design, that incorporates a ‘run-in phase’ to screen for potential TENS responders and to optimise TENS treatment according to individual need. Secondly, to meta-analyze published RCT data, irrespective of type of pain, to determine whether TENS reduces the intensity of pain during stimulation, and to include a detailed assessment of levels of certainty and precision. Thirdly, to concede that it may be impossible to determine efficacy due to insurmountable methodological, logistical and financial challenges. The consequences to clinicians, policy makers and funders of this third scenario are discussed. I argue that patients will continue to use TENS irrespective of the views of clinicians, policy makers, funders or guideline panel recommendations, because TENS is readily available without prescription; TENS generates a pleasant sensory experience that is similar to easing pain using warming and cooling techniques; and technological developments such as smart wearable TENS devices will improve usability in the future. Thus, research is needed on how best to integrate TENS into existing pain management strategies by analyzing data of TENS usage by expert-patients in real-world settings. Full article
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Other

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14 pages, 3902 KiB  
Systematic Review
Effects of Transcutaneous Electrical Nerve Stimulation on Pain and Chemotherapy-Induced Peripheral Neuropathy in Cancer Patients: A Systematic Review
by Mirosława Püsküllüoğlu, Krzysztof A. Tomaszewski, Aleksandra Grela-Wojewoda, Renata Pacholczak-Madej and Florian Ebner
Medicina 2022, 58(2), 284; https://doi.org/10.3390/medicina58020284 - 14 Feb 2022
Cited by 8 | Viewed by 7826
Abstract
Transcutaneous electrical nerve stimulation (TENS) is the usage of a mild electrical current through electrodes that stimulate nerves. Patients with malignancies experience pain and chemotherapy-induced peripheral neuropathy. A systematic review was performed to find research evaluating the effect of TENS on these two [...] Read more.
Transcutaneous electrical nerve stimulation (TENS) is the usage of a mild electrical current through electrodes that stimulate nerves. Patients with malignancies experience pain and chemotherapy-induced peripheral neuropathy. A systematic review was performed to find research evaluating the effect of TENS on these two common symptoms decreasing the quality of life in cancer patients. PubMed, the Cochrane Central Register of Controlled Trials and EMBASE were searched. Original studies, namely randomized controlled trials, quasi-randomized controlled trials and controlled clinical trials, published between April 2007 and May 2020, were considered. The quality of the selected studies was assessed. Seven papers were incorporated in a qualitative synthesis, with 260 patients in total. The studies varied in terms of design, populations, endpoints, quality, treatment duration, procedures and follow-up period. Based on the results, no strict recommendations concerning TENS usage in the cancer patient population could be issued. However, the existing evidence allows us to state that TENS is a safe procedure that may be self-administered by the patients with malignancy in an attempt to relieve different types of pain. There is a need for multi-center, randomized clinical trials with a good methodological design and adequate sample size. Full article
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6 pages, 256 KiB  
Perspective
Foundational Research Could Improve Future Transcutaneous Electrical Nerve Stimulation Evaluations
by Peter W. Gladwell, Fiona Cramp and Shea Palmer
Medicina 2022, 58(2), 149; https://doi.org/10.3390/medicina58020149 - 19 Jan 2022
Cited by 3 | Viewed by 2144
Abstract
Background and objectives: There is a lack of good quality evidence regarding the effectiveness of transcutaneous electrical nerve stimulation (TENS) for chronic musculoskeletal pain, including chronic low back pain. High quality randomised controlled trials (RCTs) have been called for to establish effectiveness over [...] Read more.
Background and objectives: There is a lack of good quality evidence regarding the effectiveness of transcutaneous electrical nerve stimulation (TENS) for chronic musculoskeletal pain, including chronic low back pain. High quality randomised controlled trials (RCTs) have been called for to establish effectiveness over and above placebo and some guidance has already been offered regarding the design of such trials. This article expands the discussion regarding the design of future TENS trials. There is qualitative evidence of the complexity of TENS as an intervention which should be considered in future TENS evaluations. This complexity includes multiple benefits reported by patients, depending on their chosen contexts of TENS use. The ideal content and delivery of support for patients to optimise TENS use also lacks consensus. There is no evidence that a TENS education package has been designed to support the complex set of behaviours and choices which experienced users suggest are required to optimise TENS benefits. Finally, clinical and research outcomes have not been contextualised and related to the specific strategies of use. Conclusions: We suggest that research is required to develop consensus about the content and delivery of training in TENS use for patients who live with pain, informed by the experience of patients, clinicians, and researchers. Once a consensus about the content of TENS training has been reached, there is then a need to develop a TENS training course (TTC) based on this content. An effective and acceptable TTC is needed to develop the knowledge and skills required to optimise TENS use, supporting patients to build confidence in using TENS in everyday life situations with the aim of reducing the impact of chronic pain on function and quality of life. Further research is required to extend the evidence base regarding appropriate, contextualised TENS patient-reported outcomes. Full article
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