Gibson W;Wand BM;O`Connell NE Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults. Cochrane Database Syst Rev. 2017 Sep 14;9:CD011976. doi: 10.1002/14651858.CD011976.pub2.
Discipline Area Score
Nurse 5 / 7
Rehab Clinician (OT/PT) 5 / 7
Physician 4 / 7

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one Cochrane Review 'Transcutaneous electrical nerve stimulation (TENS) for chronic pain' (Nnoaham 2014) and one withdrawn protocol 'Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults' (Claydon 2014). This review replaces the original protocol for neuropathic pain that was withdrawn.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.

Comments from MORE raters

Nurse rater

I'm surprised to have such a dearth of research information on a widely used intervention for such a long period of time It would be helpful to standardize "other therapies" in future studies to have better comparison. Definitely more research is needed on the concept of TENS for effective pain management.

Nurse rater

Neuropathic pain is difficult to manage and prevalent in diabetes. Non-medicine options for managing pain can be helpful. The study found TENs studies of low methodological quality and used various different methods. Those that compared sham with 'real' TENs did not show any significant differences. The information will be useful when informing people about pain management options.

Nurse rater

Since there do not seem to be benefits related to TENS units and neuropathy pain, it is relevant that diabetes educators know this information and not recommend the use of these devices to their patients. However the risk seems to be low that there is any danger to their use in those patients who want to try this modality.

Physician rater

The study confirms that the evidence of effectiveness for TENS in treating neuropathic pain is weak at best. This was my earlier impression, but the study does confirm low quality evidence and I agree that there is no compelling reason to recommend TENS for neuropathic pain. This should be disseminated to the public, as there are some therapists who use TENS for this purpose and the message of "buyer beware" seems appropriate.

Physician rater

This is a comprehensive review of the subject.

Physician rater

This review clearly shows that TENS should not be considered as a valid therapeutic option in the treatment on neuropathic pain. Further, better designed, studies are necessary.

Physician rater

This meta-analysis, based on such a weak database of RCTs that it concludes, "unable to confidently state whether TENS is effective for pain control in people with neuropathic pain", is of little assistance to clinicians other than to reaffirm the lack of evidence that TENS is effective. This is pretty disappointing when one considers the very large number of patients with neuropathic pain, many of whom have received or are receiving trials of TENS. The chronic pain specialist community needs to provide far better research regarding the efficacy (or lack of efficacy) of TENS.
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