Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Primary Low Back Pain in Adults

Leslie Verville¹, Cesar A Hincapié^{2

3

4}, Danielle Southerst¹, Hainan Yu¹, André Bussières^{5

6}, Douglas P Gross⁷, Paulo Pereira^{8

9}, Silvano Mior^{1

10}, Andrea C Tricco^{11

12

13}, Christine Cedraschi^{14

15}, Ginny Brunton^{1

16

17}, Margareta Nordin¹⁸, Gaelan Connell¹, Heather M Shearer^{1

10

19}, Jessica J Wong¹, Léonie Hofstetter^{20

21

22}, Andrew Romanelli²³, Brett Guist²⁴, Daphne To²³, Kent Stuber^{10

25}, Sophia da Silva-Oolup^{24

26}, Maja Stupar¹⁰, Danny Myrtos²³, Joyce G B Lee¹⁰, Astrid DeSouza¹, Javier Muñoz Laguna^{20

21

22}, Kent Murnaghan²⁷, Carol Cancelliere²⁸

Affiliations

¹ Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada.
² EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland. cesar.hincapie@uzh.ch.
³ Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland. cesar.hincapie@uzh.ch.
⁴ University Spine Centre Zurich (UWZH), Balgrist University Hospital and University of Zurich, Zurich, Switzerland. cesar.hincapie@uzh.ch.
⁵ Département chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières (Québec), Québec, Canada.
⁶ School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Québec, Canada.
⁷ Department of Physical Therapy, University of Alberta, Edmonton, Canada.
⁸ Department of Neurosurgery, Centro Hospitalar Universitário São João, Porto, Portugal.
⁹ Faculty of Medicine, University of Porto, Porto, Portugal.
¹⁰ Department of Research and Innovation, Canadian Memorial Chiropractic College, Toronto, Canada.
¹¹ Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada.
¹² Epidemiology Division and Institute for Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
¹³ Queen's Collaboration for Health Care Quality Joanna Briggs Institute Centre of Excellence, Queen's University, Kingston, Canada.
¹⁴ Division of General Medical Rehabilitation, Geneva University and University Hospitals, Geneva, Switzerland.
¹⁵ Division of Clinical Pharmacology and Toxicology, Multidisciplinary Pain Centre, Geneva University Hospitals, Geneva, Switzerland.
¹⁶ EPPI-Centre, UCL Institute of Education, University College London, England, United Kingdom.
¹⁷ Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada.
¹⁸ Departments of Orthopedic Surgery and Environmental Medicine, NYU Grossman School of Medicine, New York University, New York, United States.
¹⁹ Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada.
²⁰ EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland.
²¹ Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland.
²² University Spine Centre Zurich (UWZH), Balgrist University Hospital and University of Zurich, Zurich, Switzerland.
²³ Department of Clinical Education, Canadian Memorial Chiropractic College, Toronto, Canada.
²⁴ Department of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, Canada.
²⁵ Parker University Research Center, Dallas, United States.
²⁶ Department of Graduate Education, Canadian Memorial Chiropractic College, Toronto, Canada.
²⁷ Library and Information Services, Canadian Memorial Chiropractic College, Toronto, Canada.
²⁸ Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada. carolina.cancelliere@ontariotechu.ca.

PMID: 37991646
PMCID: PMC10684422
DOI: 10.1007/s10926-023-10121-7

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Primary Low Back Pain in Adults

Leslie Verville et al. J Occup Rehabil. 2023 Dec.

. 2023 Dec;33(4):651-660.

doi: 10.1007/s10926-023-10121-7. Epub 2023 Nov 22.

Authors

Affiliations

¹ Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada.
² EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland. cesar.hincapie@uzh.ch.
³ Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland. cesar.hincapie@uzh.ch.
⁴ University Spine Centre Zurich (UWZH), Balgrist University Hospital and University of Zurich, Zurich, Switzerland. cesar.hincapie@uzh.ch.
⁵ Département chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières (Québec), Québec, Canada.
⁶ School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Québec, Canada.
⁷ Department of Physical Therapy, University of Alberta, Edmonton, Canada.
⁸ Department of Neurosurgery, Centro Hospitalar Universitário São João, Porto, Portugal.
⁹ Faculty of Medicine, University of Porto, Porto, Portugal.
¹⁰ Department of Research and Innovation, Canadian Memorial Chiropractic College, Toronto, Canada.
¹¹ Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada.
¹² Epidemiology Division and Institute for Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
¹³ Queen's Collaboration for Health Care Quality Joanna Briggs Institute Centre of Excellence, Queen's University, Kingston, Canada.
¹⁴ Division of General Medical Rehabilitation, Geneva University and University Hospitals, Geneva, Switzerland.
¹⁵ Division of Clinical Pharmacology and Toxicology, Multidisciplinary Pain Centre, Geneva University Hospitals, Geneva, Switzerland.
¹⁶ EPPI-Centre, UCL Institute of Education, University College London, England, United Kingdom.
¹⁷ Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada.
¹⁸ Departments of Orthopedic Surgery and Environmental Medicine, NYU Grossman School of Medicine, New York University, New York, United States.
¹⁹ Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada.
²⁰ EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland.
²¹ Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland.
²² University Spine Centre Zurich (UWZH), Balgrist University Hospital and University of Zurich, Zurich, Switzerland.
²³ Department of Clinical Education, Canadian Memorial Chiropractic College, Toronto, Canada.
²⁴ Department of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, Canada.
²⁵ Parker University Research Center, Dallas, United States.
²⁶ Department of Graduate Education, Canadian Memorial Chiropractic College, Toronto, Canada.
²⁷ Library and Information Services, Canadian Memorial Chiropractic College, Toronto, Canada.
²⁸ Institute for Disability and Rehabilitation Research and Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada. carolina.cancelliere@ontariotechu.ca.

PMID: 37991646
PMCID: PMC10684422
DOI: 10.1007/s10926-023-10121-7

Abstract

Purpose: To evaluate benefits and harms of transcutaneous electrical nerve stimulation (TENS) for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline.

Methods: We searched for randomized controlled trials (RCTs) from various electronic databases from July 1, 2007 to March 9, 2022. Eligible RCTs targeted TENS compared to placebo/sham, usual care, no intervention, or interventions with isolated TENS effects (i.e., combined TENS with treatment B versus treatment B alone) in adults with CPLBP. We extracted outcomes requested by the WHO Guideline Development Group, appraised the risk of bias, conducted meta-analyses where appropriate, and graded the certainty of evidence using GRADE.

Results: Seventeen RCTs (adults, n = 1027; adults ≥ 60 years, n = 28) out of 2010 records and 89 full text RCTs screened were included. The evidence suggested that TENS resulted in a marginal reduction in pain compared to sham (9 RCTs) in the immediate term (2 weeks) (mean difference (MD) = -0.90, 95% confidence interval -1.54 to -0.26), and a reduction in pain catastrophizing in the short term (3 months) with TENS versus no intervention or interventions with TENS specific effects (1 RCT) (MD = -11.20, 95% CI -17.88 to -3.52). For other outcomes, little or no difference was found between TENS and the comparison interventions. The certainty of the evidence for all outcomes was very low.

Conclusions: Based on very low certainty evidence, TENS resulted in brief and marginal reductions in pain (not deemed clinically important) and a short-term reduction in pain catastrophizing in adults with CPLBP, while little to no differences were found for other outcomes.

Keywords: Low back pain; Meta-analysis; Systematic review; Transcutaneous electrical nerve stimulation.

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Conflict of interest statement

Competing Interests: All team members provided DOI forms to WHO for evaluation at inception. CC (Carol Cancelliere), LV, DS, HY, GC, JJW, HMS report funding from the Canadian Chiropractic Guideline Initiative. ACT is funded by a Tier 2 Canada Research Chair in Knowledge Synthesis. JJW is funded by a Banting Postdoctoral Fellowship from the Canadian Institutes of Health Research (CIHR). CAH reports grants to the University of Zurich from the Foundation for the Education of Chiropractors in Switzerland, the Swiss National Science Foundation (SNSF), and the European Centre for Chiropractic Research Excellence (ECCRE) outside the submitted work. SM reports grants from Canadian Chiropractic Association, Canadian Chiropractic Research Foundation, and Canadian Institute of Health Research outside of submitted work. JJW reports grants from the Canadian Institutes of Health Research (CIHR) and Canadian Chiropractic Research Foundation (paid to university), and travel reimbursement for research meetings from the Chiropractic Academy of Research Leadership outside the submitted work. JML reports a grant from the European Cooperation in Science and Technology (COST) outside the submitted work. AB reports grants from the Canadian Chiropractic Association, Canadian Chiropractic Research Foundation, and Health Canada outside the submitted work.

Figures

**Fig. 1**
Flow diagram of literature search ^a4 RCTs from previous review were also identified from current search; thus, they did not add to the total ^b1 report contained 2 RCTs [2]

**Fig. 2**
TENS versus sham for pain in the immediate term (closest to 2 weeks); scale range is 0 to 10

**Fig. 3**
TENS versus no intervention or interventions where the effects of TENS were isolated for pain in the immediate term (closest to 2 weeks); scale range is 0 to 10

See this image and copyright information in PMC

References

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1. Shimoji K, Takahashi N, Nishio Y, Koyanagi M, Aida S. Pain relief by transcutaneous electric nerve stimulation with bidirectional modulated sine waves in patients with chronic back pain: a randomized, double-blind, sham-controlled study. Neuromodulation. 2007;10(1):42–51. doi: 10.1111/j.1525-1403.2007.00086.x. - DOI - PubMed
1. Verville L, Hincapié CA, Southerst D, Yu H, Bussières A, Gross DP, et al. Systematic review to inform a World Health Organization (WHO) clinical practice guideline: benefits and harms of transcutaneous electrical nerve stimulation (TENS) for chronic primary low back pain in adults. J Occup Rehabil. 2023. 10.1007/s10926-023-10121-7. - PMC - PubMed
1. 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. - PMC - PubMed
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Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Primary Low Back Pain in Adults

Affiliations

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Primary Low Back Pain in Adults

Authors

Affiliations

Abstract

Conflict of interest statement

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References

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