Transcutaneous Electrical Nerve Stimulation (TENS) for Postoperative Pain Relief: Difference between revisions

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'''Original Editor '''- [[User:User Name|Aminat Abolade]]
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== Introduction ==
== Introduction ==
[[File:ElectricalMusclestimulation.jpg|thumb]]
[[File:ElectricalMusclestimulation.jpg|thumb]]
Conventional approaches to the management of post-operative pain remains inadequate. Intermittent ‘on-demand’ administration of opiates results in fluctuating plasma levels and poor pain relief; increasing the frequency of administration and the amount of opiate may improve pain control but results in unwanted side effects. Intravenous opiate infusion may provide better analgesia but with the risk of respiratory depression.<ref>Cuschieri RJ, Morran CG, McArdle CS. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2498262/ Transcutaneous electrical stimulation for postoperative pain]. Annals of the Royal College of Surgeons of England. 1985 Mar;67(2):127.</ref>
Traditional management of postoperative pain with the use of opiates has resulted in unwanted side effects such as respiratory depression, nausea and vomiting, hypotension and bradycardia, pruritus and inhibition of bowel movements.  Investigations on effective management of postoperative pain with minimal side effects has led to the use of [https://www.physio-pedia.com/Transcutaneous_Electrical_Nerve_Stimulation_(TENS) Transcutaneous Electrical Nerve Stimulation (TENS)] due to its success in pain control.  


The success of [[Transcutaneous Electrical Nerve Stimulation (TENS)|Transcutaneous Electrical Stimulation]] in the management of chronic pain along with its absence of side effects, particularly respiratory depression, has led to its recent use in the management of post-operative pain. Transcutaneous Electrical Nerve Stimulation (TENS) is an effective adjunctive therapy for postoperative pain; however, effects of different frequencies of stimulation have not been systematically investigated.<ref name=":0">DeSantana JM, Sluka KA, Lauretti GR. [https://pubmed.ncbi.nlm.nih.gov/19158541/ High and low frequency TENS reduce postoperative pain intensity after laparoscopic tubal ligation: a randomized controlled trial.] The Clinical journal of pain. 2009 Jan 1;25(1):12-9.</ref>
The effects of extensive use of [https://www.physio-pedia.com/Transcutaneous_Electrical_Nerve_Stimulation_(TENS) Transcutaneous Electrical Nerve Stimulation (TENS)] to control postoperative pain has been quite controversial and this can be attributable to the varying intensity of postoperative pain and the type of surgical operation performed.<ref>Cuschieri RJ, Morran CG, McArdle CS. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2498262/ Transcutaneous electrical stimulation for postoperative pain.] Annals of the Royal College of Surgeons of England. 1985 Mar;67(2):127.</ref>


== Description ==
=== '''How Transcutaneous Electrical Nerve Stimulation is applied''' ===
Transcutaneous Electrical Nerve Stimulation (TENS) is a non-pharmacologic strategy that is used to treat postoperative pain during cardiac operations<ref>Bayindir O, Paker T, Akpinar B, Erenturk S, Askin D, Aytac A. [https://www.sciencedirect.com/science/article/pii/105307709190012I Use of transcutaneous electrical nerve stimulation in the control of postoperative chest pain after cardiac surgery.] Journal of cardiothoracic and vascular anesthesia. 1991 Dec 1;5(6):589-91.</ref>,cholecystectomy<ref>Sim DT. [https://www.sciencedirect.com/science/article/pii/S0031940610604476 Effectiveness of transcutaneous electrical nerve stimulation following cholecystectomy. Physiotherapy.] 1991 Oct 10;77(10):715-22.</ref>,cesarean delivery<ref>Smith CM, Guralnick MS, Gelfand MM, Jeans ME. [https://www.sciencedirect.com/science/article/pii/0304395986902095 The effects of transcutaneous electrical nerve stimulation on post-cesarean pain]. Pain. 1986 Nov 1;27(2):181-93.</ref>, and thoracotomy<ref>Warfield CA, Stein JM, Frank HA. [https://www.sciencedirect.com/science/article/pii/S0003497510619571 The effect of transcutaneous electrical nerve stimulation on pain after thoracotomy.] The Annals of thoracic surgery. 1985 May 1;39(5):462-5.</ref>. A systematic review by ' Bjordal and colleagues<ref>Bjordal JM, Johnson MI, Ljunggreen AE. [https://www.sciencedirect.com/science/article/pii/S1090380102000988 Transcutaneous electrical nerve stimulation (TENS) can reduce postoperative analgesic consumption. A meta-analysis with assessment of optimal treatment parameters for postoperative pain]. European Journal of Pain. 2003 Apr 1;7(2):181-8.</ref>' showed decrease in the use of analgesic in patients using TENS post-operatively. The use of TENS in treatment plan reduces the occurrence of postoperative complications, such as paralytic ileum, atelectasis, and improves pulmonary function<ref>Ali J, Yaffe CS, Serrette C. T[https://europepmc.org/article/med/6970995 he effect of transcutaneous electric nerve stimulation on postoperative pain and pulmonary function]. Surgery. 1981 Apr 1;89(4):507-12.</ref>. However, some surgical procedures have been reported to be too painful for TENS to have a significant effect on the pain, such as in severe postoperative pain following posterior thoracotomy.<ref name=":0" />
{{#ev:youtube|https://www.youtube.com/watch?v=EB3d57MXtG8&t=123s}}


Since 1970,TENS has been used as a complementary therapeutic method to control acute and chronic pain of various abdominal and thoracic surgeries. It is based on the [[Https://en.wikipedia.org/wiki/Gate control theory|Gate Control theory of pain]], in which the modulation of pain results from the activation of descending inhibitory pathways.<ref>Dafny, N. (2014). Pain modulation and mechanisms. In: Neuroscience online. Houston, TX: UTHealth. </ref> TENS is a safe and simple method whose daily repeated application produces analgesic tolerance at spinal opioid receptors and increases the toleration threshold of pain. Also, TENS leads to the release of endorphins and serotonin and analgesic hormones and reduction of cytokine levels. Furthermore, electrical stimulation indirectly improves muscle spasm by increasing blood flow to muscle tissue. In the 2015 study by Galli, Chiavegato, and Liebano conducted on 74 kidney donors, patients in TENS group had significantly lower pain during respiratory maneuvers and higher maximal expiratory pressure compared with the control group. In another study, Fiorelli et al. (2012) applied TENS after thoracotomy for 5 consecutive days and found that pulmonary function (forced expiratory volume in 1 second [FEV1] to forced volume capacity [FVC] ratio) was significantly better and blood cytokine levels and narcotic consumption were significantly lower in the TENS group than the placebo group.<ref>Fiorelli A, Morgillo F, Milione R, Pace MC, Passavanti MB, Laperuta P, Aurilio C, Santini M. [https://academic.oup.com/ejcts/article/41/4/861/644124 Control of post-thoracotomy pain by transcutaneous electrical nerve stimulation: effect on serum cytokine levels, visual analogue scale, pulmonary function and medication]. European Journal of Cardio-Thoracic Surgery. 2012 Apr 1;41(4):861-8. </ref> In addition to the pain relief action of TENS, Unterrainer et al. (2010) reported the effectiveness of TENS in improving cognitive functions in patients undergoing spinal surgery.<ref>Jahangirifard A, Razavi M, Ahmadi ZH, Forozeshfard M. [https://academic.oup.com/ejcts/article/41/4/861/644124 Effect of TENS on postoperative pain and pulmonary function in patients undergoing coronary artery bypass surgery. Pain Management Nursing]. 2018 Aug 1;19(4):408-14.</ref>
== Description  ==
Transcutaneous Electrical Nerve Stimulation (TENS) is a non-invasive, non -pharmacologic method of pain relief through electrical stimulation. The use of TENS postoperatively has showed a reduction in the use of analgesics in patients and a reduction in occurrence of postoperative complications such as respiratory depression. Although, reports have showed that some surgical procedures are too painful for TENS to have a significant effect on pain such as in severe postoperative pain after posterior thoracotomy.


Hence, simultaneous use of TENS with pharmacologic therapies for analgesia should produce a greater reduction in postoperative pain and a concomitantly decreasing medicine intake, reducing side effects, and improving treatment for pain.<ref name=":0" />
Application of TENS as an auxiliary therapeutic method in management of acute and chronic pain of various abdominal and thoracic surgeries occurred since 1970. Its use was based on the Gate Control Theory of Pain and daily repeated application produces analgesic tolerance at spinal opioid receptors and increases the toleration threshold of pain. In addition, TENS results in the release of endorphins, serotonin, analgesic hormones and reduction of cytokine levels and increases blood flow to the muscle tissue. Recent studies have showed that use of TENS in patients resulted in significant pain reduction during respiratory manoeuvres and higher maximal expiratory pressure<ref>Galli TT, Chiavegato LD, Liebano RE. [https://onlinelibrary.wiley.com/doi/abs/10.1002/ejp.521 Effects of TENS in living kidney donors submitted to open nephrectomy: A randomized placebo‐controlled trial.] European Journal of Pain. 2015 Jan;19(1):67-76.</ref>, improvement in pulmonary function, low blood cytokine levels and narcotic consumption<ref>Fiorelli A, Morgillo F, Milione R, Pace MC, Passavanti MB, Laperuta P, Aurilio C, Santini M. [https://academic.oup.com/ejcts/article-abstract/41/4/861/644124 Control of post-thoracotomy pain by transcutaneous electrical nerve stimulation: effect on serum cytokine levels, visual analogue scale, pulmonary function and medication.] European Journal of Cardio-Thoracic Surgery. 2012 Apr 1;41(4):861-8.</ref> and improvement in cognitive functions in patients undergoing spinal surgery<ref>Unterrainer AF, Friedrich C, Krenn MH, Piotrowski WP, Golaszewski SM, Hitzl W. [https://journals.lww.com/jnsa/fulltext/2010/01000/postoperative_and_preincisional_electrical_nerve.1.aspx Postoperative and preincisional electrical nerve stimulation TENS reduce postoperative opioid requirement after major spinal surgery.] Journal of Neurosurgical Anesthesiology. 2010 Jan 1;22(1):1-5.</ref>.


=== '''How Transcutaneous Electrical Nerve Stimulation is applied''' ===
{{#ev:youtube|https://www.youtube.com/watch?v=EB3d57MXtG8}}
=== '''Studies in Postoperative Rehabilitation''' ===
=== '''Studies in Postoperative Rehabilitation''' ===
Transcutaneous Electrical Nerve Stimulation (TENS) has been used extensively to control postoperative pain, but its effects are controversial. This is probably due to the different types of operations performed and, therefore, to the varying intensity of postoperative pain. Here we present an extensive study with TENS in 324 patients who underwent different types of thoracic surgical procedures: posterolateral [https://en.wikipedia.org/wiki/Thoracotomy thoracotomy], muscle-sparing [https://en.wikipedia.org/wiki/Thoracotomy thoracotomy], [https://en.wiktionary.org/wiki/costotomy costotomy], [https://www.medicinenet.com/how_is_a_sternotomy_done/article.htm#:~:text=A%20sternotomy%20is%20a%20surgical,to%20access%20the%20thoracic%20cavity. sternotomy], and video-assisted [https://en.wikipedia.org/wiki/Thoracoscopy thoracoscopy]. Each patient cohort was randomly subdivided into three treatment groups: TENS, placebo TENS and control. The effectiveness of TENS was assessed by two factors: the time from the beginning of treatment to the request for further analgesia and the total medication intake during the first 12 hours after operation.Whereas posterolateral [https://en.wikipedia.org/wiki/Thoracotomy thoracotomy] produced severe pain, muscle-sparing [https://en.wikipedia.org/wiki/Thoracotomy thoracotomy], [https://en.wiktionary.org/wiki/costotomy costotomy], and [https://www.medicinenet.com/how_is_a_sternotomy_done/article.htm#:~:text=A%20sternotomy%20is%20a%20surgical,to%20access%20the%20thoracic%20cavity. sternotomy] caused moderate pain, and video-assisted [https://en.wikipedia.org/wiki/Thoracoscopy thoracoscopy] caused only mild pain. The TENS treatment was not effective in the posterolateral [https://en.wikipedia.org/wiki/Thoracotomy thoracotomy] group, but it was useful as an adjunct to other medications in the muscle-sparing [https://en.wikipedia.org/wiki/Thoracotomy thoracotomy], [https://en.wiktionary.org/wiki/costotomy costotomy], and [https://www.medicinenet.com/how_is_a_sternotomy_done/article.htm#:~:text=A%20sternotomy%20is%20a%20surgical,to%20access%20the%20thoracic%20cavity. sternotomy] groups. In contrast, representing the only pain control treatment with no adjunct drugs, it was very effective in patients having video-assisted [https://en.wikipedia.org/wiki/Thoracoscopy thoracoscopy]. Conclusions from these findings show that TENS is useful after thoracic surgical procedures only when postoperative pain is mild to moderate; it is uneffective for severe pain.<ref>Benedetti F, Amanzio M, Casadio C, Cavallo A, Cianci R, Giobbe R, Mancuso M, Ruffini E, Maggi G. C[https://www.sciencedirect.com/science/article/abs/pii/S0003497596012490 ontrol of postoperative pain by transcutaneous electrical nerve stimulation after thoracic operations.] The Annals of thoracic surgery. 1997 Mar 1;63(3):773-6.</ref>
{| class="wikitable"
!RESEARCH STUDY
!TREATMENT PLAN
!RESULT
!CONCLUSION
|-
|Effects of Transcutaneous Electrical Nerve Stimulation (TENS) on postoperative pain in patients who underwent different types of thoracic surgical procedures: posterolateral thoracotomy, muscle-sparing thoracotomy, costotomy, sternotomy, and video-assisted thoracoscopy.<ref>Benedetti F, Amanzio M, Casadio C, Cavallo A, Cianci R, Giobbe R, Mancuso M, Ruffini E, Maggi G. [https://www.sciencedirect.com/science/article/pii/S0003497596012490 Control of postoperative pain by transcutaneous electrical nerve stimulation after thoracic operations.] The Annals of thoracic surgery. 1997 Mar 1;63(3):773-6.</ref>
|
{| class="wikitable"
|Assessment  of the effectiveness of TENS was carried out based on two factors: the time from the beginning of treatment to the request for further analgesia and the total medication intake during the first 12 hours after operation. Three treatment  groups: TENS, Placebo TENS and Control were used and each patient group was randomly  subdivided into them.
|}
|
{| class="wikitable"
|TENS treatment was not effective in the posterolateral thoracotomy group while its use as an adjunct to analgesics was effective in the muscle-sparing thoracotomy, costotomy, and sternotomy groups. When TENS was applied  without analgesics being used, it was very effective in patients having video-assisted thoracoscopy.  
|}
|Conclusions from this study showed that TENS is not effective for severe pain and should be applied only when postoperative pain is mild to moderate after thoracic surgical procedures.
|-
|
{| class="wikitable"
|Effects  of Transcutaneous Electrical Nerve Stimulation (TENS) on acute postoperative  pain intensity and mobility after Hip Fracture<ref>Elboim-Gabyzon M, Najjar SA, Shtarker H. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6825510/ Effects of transcutaneous electrical nerve stimulation (TENS) on acute postoperative pain intensity and mobility after hip fracture: A double-blinded, randomized trial. Clinical interventions in aging]. 2019;14:1841.</ref>
|}
|
{| class="wikitable"
|Twenty-four  hours after surgery, the standard rehabilitation care began which included  five-daily 30 minutes physical therapy treatments. Intensity of pain at rest, at night and during ambulation were evaluated using the Numeric Rating Scale, Functional Ambulation Classification instrument, time to complete five  sit-to-stand tests and two-minute walk test. Wilcoxon score rank tests was used to analyse  the data.
|}
|
{| class="wikitable"
|Remarkable  loss of pain during walking and higher level of mobility in the active TENS  group compared to the sham TENS group but no further effects were noted on  pain intensity at rest and at night and on five times sit-to-stand  performance.
|}
|
{| class="wikitable"
|Inclusion  of TENS to the standard care of elderly patients in the early days following  Gamma nail surgical fixation of extracapsular hip fracture is recommended for  pain management while walking and functional gait recovery. Further investigations  on the effects of TENS on long-term functional outcomes should be done.
|}
|-
|Effects of Transcutaneous Electrical Nerve stimulation (TENS) on persistent postoperative pain in rehabilitation of a patient after a multilevel spinal fusion for spinal stenosis<ref>Pons T, Shipton EA. [https://www.tandfonline.com/doi/abs/10.3109/09593985.2010.483268 Multilevel lumbar fusion and postoperative physiotherapy rehabilitation in a patient with persistent pain. Physiotherapy theory and practice.] 2011 Apr 1;27(3):238-45.</ref>
|TENS was used for up to 8 hours a day in combination with a progressive walking exercise programme from pool to land. Progression was determined from shuttle walk test results.
|
{| class="wikitable"
|Reduction in pain and improved walking  distance.
|}
|Further investigation is needed to confirm the validity of this physiotherapy approach used.
|-
|
{| class="wikitable"
|Effects of Transcutaneous Electrical Nerve stimulation  (TENS) on  postoperative pain relief following inguinal herniorrhaphy<ref>Gilbert JM, Gledhill T, Law N, George C. [https://pubmed.ncbi.nlm.nih.gov/3530368/ Controlled trial of transcutaneous electrical nerve stimulation (TENS) for postoperative pain relief following inguinal herniorrhaphy.] British journal of surgery. 1986 Sep;73(9):749-51.</ref>
|}
|Use of TENS in addition to postoperative analgesia twice daily for 3 days. Data for the active and inactive groups were compared using the Mann-Whitney U test and the Wilcoxon matched pairs signed ranks test.
|
{| class="wikitable"
|An infected wound and  a basal pulmonary collapse occurred in patients with inactive TENS machine. There  was no significant difference between the groups with active or inactive TENS  machines for either pain score, peak flow or pethidine requirement. Pain  diminished significantly with time after operation, Peak expiratory flow  decreased markedly after operation and then rose gradually.
|}
|Use of TENS did not reduce postoperative pain but TENS had considerable patient appeal and many patients believed that it was effective.
|}


Another study carried out on the effects of Transcutaneous Electrical Nerve Stimulation (TENS) on acute postoperative pain intensity and mobility after Hip Fracture showed that addition of TENS to the standard care of elderly patients in the early days following Gamma nail surgical fixation of extracapsular hip fracture is recommended for pain management while walking and functional gait recovery and the effect of TENS on long-term functional outcomes should be explored in future studies. The standard rehabilitation care included five daily 30 minutes physical therapy treatments beginning 24 hours after surgery. Outcome measures were: pain intensity at rest, at night and during ambulation (assessed with the Numeric Rating Scale; Functional Ambulation Classification instrument; time to complete five sit-to-stand tests; and two-minute walk test). Data were analysed with [https://en.wikipedia.org/wiki/Wilcoxon_signed-rank_test#:~:text=The%20Wilcoxon%20signed%2Drank%20test,is%20a%20paired%20difference%20test). Wilcoxon score rank tests]. Significance was set at p≤0.05. Results showed significant greater pain reduction during walking was noted in the active TENS group compared to sham TENS group. Additionally, advantage of active TENS was demonstrated in greater increase in walking distance on the fifth day and higher level of mobility compared to the sham TENS group. No additional effects of active TENS were noted on pain intensity at rest and at night and on five times sit-to-stand performance.<ref>Elboim-Gabyzon M, Najjar SA, Shtarker H. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6825510/ Effects of transcutaneous electrical nerve stimulation (TENS) on acute postoperative pain intensity and mobility after hip fracture: A double-blinded, randomized trial]. Clinical interventions in aging. 2019;14:1841.</ref>
=== '''Implications for use in physiotherapy''' ===
A lot of investigations have been carried out on the clinical efficacy of TENS for acute and chronic pain management including knee [[osteoarthritis]], [[Rheumatoid Arthritis|rheumatoid arthritis]], [[Low Back Pain|low back pain]], [[Neck Pain: Clinical Practice Guidelines|neck pain]], post-amputation pain, post-stroke pain, [[Spinal Cord Injury|spinal cord injury]], diabetic peripheral neuropathy, chronic and recurrent headache, [[Neuropathic Pain|neuropathic pain]], and [[Cancer Pain|cancer pain]]. However, there was an extensive variation in the frequency of use and this could be attributable to a lack of knowledge of the modality, and neurophysiological rationale underpinning it, or perhaps a lack of confidence with results and often reviewers are unable to make definitive judgement about clinical efficacy because of inadequate Randomised Controlled Trial (RCT) design, poor reporting and concerns about trial fidelity and TENS technique.<ref>Dafny, N. (2014). Pain    modulation and mechanisms. In: Neuroscience online. Houston, TX:     UTHealth. </ref> Consequently, the use of TENS as an adjunct to analgesic medication in multi-modal management of acute post-surgical pain should be considered.


A study on the effectiveness of Transcutaneous Electrical Nerve timulation (TENS) for persistent pain post operatively used in rehabilitation of a patient after a multilevel spinal fusion for spinal stenosis showed that  despite the lack of available evidence-based outcomes for the physiotherapy intervention for persistent pain following multilevel fusion, physiotherapy improved walking distance and reduced pain levels. A novel intervention was the use of TENS for up to 8 hours a day in combination with a progressive walking exercise programme from pool to land. Progression was determined from [https://www.sciencedirect.com/topics/medicine-and-dentistry/shuttle-walk-test shuttle walk test] results. These improvements in pain and walking distance were made despite poor medication compliance and a reported high level of postsurgical pain and further research is needed to confirm the validity of this novel physiotherapy approach used in treating persistent pain following multilevel spinal fusion.<ref>Pons T, Shipton EA. [https://www.tandfonline.com/doi/abs/10.3109/09593985.2010.483268 Multilevel lumbar fusion and postoperative physiotherapy rehabilitation in a patient with persistent pain. Physiotherapy theory and practice]. 2011 Apr 1;27(3):238-45.</ref>
=== '''Resources''' ===
*[https://www.sciencedirect.com/science/article/pii/S0003497596012490 Control of postoperative pain by Transcutaneous electrical nerve stimulation after thoracic operations.]
*[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6825510/ Effects of transcutaneous electrical nerve stimulation (TENS) on acute postoperative pain intensity and mobility after hip fracture: A double-blinded, randomized trial]
*[https://pubmed.ncbi.nlm.nih.gov/3530368/ Controlled trial of transcutaneous electrical nerve stimulation (TENS) for postoperative pain relief following inguinal herniorrhaphy]
*[https://www.tandfonline.com/doi/abs/10.3109/09593985.2010.483268 Multilevel lumbar fusion and postoperative physiotherapy rehabilitation in a patient with persistent pain]
*[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5604662/ Transcutaneous electrical nerve stimulation for postoperative pain control after total knee arthroplasty]


=== '''Current use in physiotherapy''' ===
== References  ==
The widespread availability of TENS for use in physiotherapy has been well documented. In a survey carried out of 139 National Health Service hospitals in England with a response rate of 83.5%, TENS was identified as the second most widely owned electrotherapeutic modality, although regularity of use was more limited<ref>Pope GD, Mockett SP & Wright JP. [https://www.sciencedirect.com/science/article/pii/S0031940605670502 A survey of electrotherapeutic modalities: ownership and use in the NHS in England]. Physiotherapy 1995;81: 82-91</ref>. Similar levels of ownership were reported in 1993-4 in Northern Ireland, although use was again lower, except in the treatment of [https://link.springer.com/referenceworkentry/10.1007%2F978-3-540-29805-2_2887#:~:text=Definition,and%20delivery%20of%20her%20baby. obstetric pain].<ref>Walsh DM. TENS Clinical Applications and Related Theory. New York:Churchill Livingstone, 1997</ref> A report on the use of TENS in Canada, where a quarter of all hospitals with 200 or more beds were surveyed, with an 84% response rate, indicated that TENS was available in all the hospitals. The devices were mainly located in the physiotherapy departments, and physiotherapists were the principal users. The most common applications were in the treatment of acute and chronic pain; however, there was a wide variation in the frequency of use.<ref>Reeve J, Menon D & Corabian P. [https://www.cambridge.org/core/journals/international-journal-of-technology-assessment-in-health-care/article/transcutaneous-electrical-nerve-stimulation-tens-a-technology-assessment/F04B5992B61413660F101121B8F6D023 Transcutaneous electrical nerve stimulation (TENS): a technology assessment.] Int J Technol Assess Health Care 1996; 12: 299-324</ref>


It would therefore seem that TENS is widely available within physiotherapy departments, but there is a variation in use. This may be attributable to a lack of knowledge of the modality, and neurophysiological rationale underpinning it, or perhaps a lack of confidence with results.<ref>Ellis B. T[https://www.tandfonline.com/doi/abs/10.1179/ptr.1998.3.1.3 ranscutaneous electrical nerve stimulation for pain relief: recent research findings and implications for clinical use]. Physical therapy reviews. 1998 Mar 1;3(1):3-8.</ref>Basic information on this modality and its proposed effects are included in standard undergraduate physiotherapy text books on electrotherapy. In these texts, suggested clinical situations where TENS may be used include: the relief of acute pain such as Postoperative pain, Acute low back pain (LBP) and Phantom-limb pain, Labour pain and the treatment of chronic pain, for example [https://www.uclahealth.org/neurosurgery/causalgia Causalgia], Chronic low back pain and Arthritic pain of various types.<ref>Low JL, Reed A. Electrotherapy explained: principles and practice. Elsevier Health Sciences; 2000.</ref>
=== '''Recent research findings and Implications for clinical use''' ===
Many systematic reviews have attempted to evaluate the clinical efficacy of TENS for acute and chronic pain including knee [[osteoarthritis]], rheumatoid arthritis, low back pain, neck pain, post-amputation pain, post-stroke pain, spinal cord injury, diabetic peripheral [https://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/symptoms-causes/syc-20352061 neuropathy], chronic and recurrent headache, neuropathic pain, and cancer pain. The largest meta-analysis of TENS to date provided the evidence that TENS alleviated chronic musculoskeletal pain. Often reviewers are unable to make definitive judgement about clinical efficacy because of inadequate Randomised Controlled Trial (RCT) design, poor reporting and concerns about trial fidelity and TENS technique.<ref>Johnson M, Martinson M. E[https://www.sciencedirect.com/science/article/pii/S0304395907000735 fficacy of electrical nerve stimulation for chronic musculoskeletal pain]: a meta-analysis of randomized controlled trials. Pain. 2007 Jul 1;130(1-2):157-65.</ref>
A Cochrane review of 19 RCTs (1346 participants) found that TENS was superior to placebo TENS as stand-alone treatment for Acute Pain in adults.<ref>Johnson MI, Paley CA, Howe TE, Sluka KA. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006142.pub3/abstract Transcutaneous electrical nerve stimulation for acute pain]. Cochrane Database of Systematic Reviews. 2015(6).</ref> There were seven RCTs that investigated procedural pain in perioperative settings and four of these RCTs found that TENS was beneficial. Conditions included pelvic pain during office [https://en.wikipedia.org/wiki/Hysteroscopy hysteroscopy] (142 patients), pain during screening flexible [https://en.wikipedia.org/wiki/Sigmoidoscopy sigmoidoscopy] (90 patients), pain during unsedated [https://en.wikipedia.org/wiki/Colonoscopy colonoscopy] (90 patients), pain during plastic surgery (100 patients). Three RCTS found that TENS did not confer benefit for procedural pain during laser treatment of the cervix (100 patients), intravenous needlestick techniques (71 blood donors), and flexible [https://en.wikipedia.org/wiki/Cystoscopy cystoscopy] (148 patients). Simpson et al. conducted a meta-analysis of four RCTs and found that TENS reduced moderate-to-severe acute lower back pain, acute pelvic pain, renal colic, and pain associated with hip fracture by 28-44 mm (95% CI) on a 100 mm visual analogue scale. They recommended TENS for use by emergency medical services in prehospital settings.<ref>Simpson PM, Fouche PF, Thomas RE, Bendall JC. [https://journals.lww.com/euro-emergencymed/fulltext/2014/02000/Transcutaneous_electrical_nerve_stimulation_for.3.aspx Transcutaneous electrical nerve stimulation for relieving acute pain in the prehospital setting: a systematic review and meta-analysis of randomized-controlled trials.] European Journal of Emergency Medicine. 2014 Feb 1;21(1):10-7.</ref>
In recent years, a series of systematic reviews, some with meta-analysis, provide a growing body of evidence that TENS has clinical utility in post-surgical settings. Freynet et al. A reported that seven of nine RCTs found TENS reduced analgesic consumption and improved the duration of recovery room stay for patients with moderate pain associated with muscle sparing [https://en.wikipedia.org/wiki/Thoracotomy thoracotomy] incision. Their review provided evidence that TENS was beneficial as a standalone treatment for mild post-[https://en.wikipedia.org/wiki/Thoracotomy thoracotomy] pain (i.e. video-assisted [https://en.wikipedia.org/wiki/Thoracoscopy thoracoscopy] incision) but not for severe post-[https://en.wikipedia.org/wiki/Thoracotomy thoracotomy] pain (i.e. posterolateral [https://en.wikipedia.org/wiki/Thoracotomy thoracotomy] incision).<ref>Freynet A, Falcoz PE. [https://academic.oup.com/icvts/article-abstract/10/2/283/645455 Is transcutaneous electrical nerve stimulation effective in relieving postoperative pain after thoracotomy?. Interactive cardiovascular and thoracic surgery]. 2010 Feb 1;10(2):283-8.</ref> In the same year, Sbruzzi et al. [13] provided evidence that TENS alleviated post-[https://en.wikipedia.org/wiki/Thoracotomy thoracotomy] and sternotomy pain when combined with analgesic medication in a systematic review of 11 RCTs (570 patients). <ref>Sbruzzi G, Silveira S, Silva D, Coronel C, Plentz R. [http://www.bjcvs.org/pdf/1961/en_v27n1a12.pdf Transcutaneous electrical nerve stimulation after thoracic surgery: systematic review and meta-analysis of 11 randomized trials.] Brazilian Journal of Cardiovascular Surgery. 2012 Jan 16;27(1):75-87.</ref>Subsequently, Kerai et al. found that TENS reduced the severity of pain and analgesic consumption for a variety of surgical procedures (eight RCTs, 442 patients) although they noted that studies lacked adequate sample size, robust methodology and consistency in TENS parameters<ref>Kerai S, Saxena KN, Taneja B, Sehrawat L. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4155281/ Role of transcutaneous electrical nerve stimulation in post-operative analgesia]. Indian journal of anaesthesia. 2014 Jul;58(4):388.</ref>. Beckwee et al. evaluated TENS for post-surgical knee arthroplasty pain (five RCTs, 347 patients) and reported that two studies found benefits during TENS. The three studies that did not find benefits delivered TENS at sub-optimal stimulation intensities.<ref name=":1">Beckwée D, Bautmans I, Swinnen E, Vermet Y, Lefeber N, Lievens P, Vaes P. [https://journals.sagepub.com/doi/abs/10.1177/2050312114539318 A systematic review investigating the relationship between efficacy and stimulation parameters when using transcutaneous electrical nerve stimulation after knee arthroplasty]. SAGE open medicine. 2014 Jun 16;2:2050312114539318.</ref> Gajjar et al. evaluated various analgesic treatments for [https://www.cancer.net/blog/2019-06/colposcopy-how-prepare-and-what-know#:~:text=A%20colposcopy%20is%20used%20to,or%20noncancerous%20growths%20called%20polyps. colposcopy] pain in women that included one RCT (100 women) which found that TENS did not provide additional benefit when combined with direct infiltration of [https://en.wikipedia.org/wiki/Lidocaine lignocaine].<ref>Gajjar K, Martin‐Hirsch PP, Bryant A, Owens GL. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006120.pub4/abstract Pain relief for women with cervical intraepithelial neoplasia undergoing colposcopy treatment.] Cochrane Database of Systematic Reviews. 2016(7).</ref><ref name=":1" />
=== '''Conclusion''' ===
Evidence from systematic reviews of placebo controlled trials suggests that TENS alleviates pain and reduces analgesic consumption when administered using appropriate technique. Indirect benefits include improvements in pulmonary mechanics and general mobilization reducing the risk of chest infections, hypoxia, pressure sores and deep vein thrombosis. Thus, TENS should be considered as an adjunct to multi-modal management, including analgesic medication, for the management of acute post-surgical pain. Nevertheless, Randomized Controlled Trials (RCTs) on TENS often have small samples sizes which undermine confidence in the findings of systematic reviews. Meta-analyses of studies with small sample sizes have been shown to distort effect estimates of clinical efficacy. To improve confidence in estimates of clinical efficacy of TENS, there needs to be pooling of data from Randomized Controlled Trial(RCTs) with larger samples.<ref>Johnson MI. Post-Surgical Pain: [https://quintet.no/media/postsurgical-pain-the-status-of-evidence-for-the-use-of-transcutaneous-electrical-nerve-stimulation-tens-qo85.pdf The Status of Evidence for the Use of Transcutaneous Electrical Nerve Stimulation (TENS)]. Analg Resusc: Curr Res 6: 1. of. 2017;3:2.</ref>
== Related articles ==
* [[Transcutaneous Electrical Nerve Stimulation (TENS)]]
* [https://pubmed.ncbi.nlm.nih.gov/19158541/ High and Low Frequency TENS Reduce Postoperative Pain Intensity After Laparoscopic Tubal Ligation A Randomized Controlled Trial]
* [https://pdfs.semanticscholar.org/d400/979d55aad226c92905b4ccfa0185ccefaf23.pdf Effectiveness of Transcutaneous Electrical Nerve Stimulation on Postoperative Pain With Movement]
* [https://pubmed.ncbi.nlm.nih.gov/22219414/ Control of post-thoracotomy pain by Transcutaneous Electrical Nerve Stimulation: Effect on serum cytokine levels, visual analogue scale, pulmonary function and medication]
* [https://pubmed.ncbi.nlm.nih.gov/3530368/ Controlled trial of Transcutaneous Electrical Nerve Stimulation (TENS) for postoperative pain relief following inguinal herniorrhaphy]
* [https://pubmed.ncbi.nlm.nih.gov/29396016/#:~:text=Patients%20in%20the%20TENS%20group,undergoing%20coronary%20artery%20bypass%20surgery. Effect of TENS on Postoperative Pain and Pulmonary Function in Patients Undergoing Coronary Artery Bypass Surgery]
* [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5604662/ Transcutaneous Electrical Nerve Stimulation for Postoperative pain relief after total knee arthroplasty]
*[[Transcutaneous Electrical Nerve Stimulation for Dementia]]
== References  ==
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<references />
[[Category:Electrotherapy]]
[[Category:Electrophysical]]
[[Category:Transcutaneous Electrical Nerve Stimulation]]

Latest revision as of 15:23, 26 September 2020

Original Editor - Aminat Abolade

Original Editor - User Name

Top Contributors - Aminat Abolade, Kim Jackson and Leana Louw  

Introduction[edit | edit source]

ElectricalMusclestimulation.jpg

Traditional management of postoperative pain with the use of opiates has resulted in unwanted side effects such as respiratory depression, nausea and vomiting, hypotension and bradycardia, pruritus and inhibition of bowel movements.  Investigations on effective management of postoperative pain with minimal side effects has led to the use of Transcutaneous Electrical Nerve Stimulation (TENS) due to its success in pain control.

The effects of extensive use of Transcutaneous Electrical Nerve Stimulation (TENS) to control postoperative pain has been quite controversial and this can be attributable to the varying intensity of postoperative pain and the type of surgical operation performed.[1]

How Transcutaneous Electrical Nerve Stimulation is applied [edit | edit source]

Description[edit | edit source]

Transcutaneous Electrical Nerve Stimulation (TENS) is a non-invasive, non -pharmacologic method of pain relief through electrical stimulation. The use of TENS postoperatively has showed a reduction in the use of analgesics in patients and a reduction in occurrence of postoperative complications such as respiratory depression. Although, reports have showed that some surgical procedures are too painful for TENS to have a significant effect on pain such as in severe postoperative pain after posterior thoracotomy.

Application of TENS as an auxiliary therapeutic method in management of acute and chronic pain of various abdominal and thoracic surgeries occurred since 1970. Its use was based on the Gate Control Theory of Pain and daily repeated application produces analgesic tolerance at spinal opioid receptors and increases the toleration threshold of pain. In addition, TENS results in the release of endorphins, serotonin, analgesic hormones and reduction of cytokine levels and increases blood flow to the muscle tissue. Recent studies have showed that use of TENS in patients resulted in significant pain reduction during respiratory manoeuvres and higher maximal expiratory pressure[2], improvement in pulmonary function, low blood cytokine levels and narcotic consumption[3] and improvement in cognitive functions in patients undergoing spinal surgery[4].

Studies in Postoperative Rehabilitation[edit | edit source]

RESEARCH STUDY TREATMENT PLAN RESULT CONCLUSION
Effects of Transcutaneous Electrical Nerve Stimulation (TENS) on postoperative pain in patients who underwent different types of thoracic surgical procedures: posterolateral thoracotomy, muscle-sparing thoracotomy, costotomy, sternotomy, and video-assisted thoracoscopy.[5]
Assessment of the effectiveness of TENS was carried out based on two factors: the time from the beginning of treatment to the request for further analgesia and the total medication intake during the first 12 hours after operation. Three treatment groups: TENS, Placebo TENS and Control were used and each patient group was randomly subdivided into them.
TENS treatment was not effective in the posterolateral thoracotomy group while its use as an adjunct to analgesics was effective in the muscle-sparing thoracotomy, costotomy, and sternotomy groups. When TENS was applied without analgesics being used, it was very effective in patients having video-assisted thoracoscopy.
Conclusions from this study showed that TENS is not effective for severe pain and should be applied only when postoperative pain is mild to moderate after thoracic surgical procedures.
Effects of Transcutaneous Electrical Nerve Stimulation (TENS) on acute postoperative pain intensity and mobility after Hip Fracture[6]
Twenty-four hours after surgery, the standard rehabilitation care began which included five-daily 30 minutes physical therapy treatments. Intensity of pain at rest, at night and during ambulation were evaluated using the Numeric Rating Scale, Functional Ambulation Classification instrument, time to complete five sit-to-stand tests and two-minute walk test. Wilcoxon score rank tests was used to analyse the data.
Remarkable loss of pain during walking and higher level of mobility in the active TENS group compared to the sham TENS group but no further effects were noted on pain intensity at rest and at night and on five times sit-to-stand performance.
Inclusion of TENS to the standard care of elderly patients in the early days following Gamma nail surgical fixation of extracapsular hip fracture is recommended for pain management while walking and functional gait recovery. Further investigations on the effects of TENS on long-term functional outcomes should be done.
Effects of Transcutaneous Electrical Nerve stimulation (TENS) on persistent postoperative pain in rehabilitation of a patient after a multilevel spinal fusion for spinal stenosis[7] TENS was used for up to 8 hours a day in combination with a progressive walking exercise programme from pool to land. Progression was determined from shuttle walk test results.
Reduction in pain and improved walking distance.
Further investigation is needed to confirm the validity of this physiotherapy approach used.
Effects of Transcutaneous Electrical Nerve stimulation (TENS) on postoperative pain relief following inguinal herniorrhaphy[8]
Use of TENS in addition to postoperative analgesia twice daily for 3 days. Data for the active and inactive groups were compared using the Mann-Whitney U test and the Wilcoxon matched pairs signed ranks test.
An infected wound and a basal pulmonary collapse occurred in patients with inactive TENS machine. There was no significant difference between the groups with active or inactive TENS machines for either pain score, peak flow or pethidine requirement. Pain diminished significantly with time after operation, Peak expiratory flow decreased markedly after operation and then rose gradually.
Use of TENS did not reduce postoperative pain but TENS had considerable patient appeal and many patients believed that it was effective.

Implications for use in physiotherapy[edit | edit source]

A lot of investigations have been carried out on the clinical efficacy of TENS for acute and chronic pain management including knee osteoarthritis, rheumatoid arthritis, low back pain, neck pain, post-amputation pain, post-stroke pain, spinal cord injury, diabetic peripheral neuropathy, chronic and recurrent headache, neuropathic pain, and cancer pain. However, there was an extensive variation in the frequency of use and this could be attributable to a lack of knowledge of the modality, and neurophysiological rationale underpinning it, or perhaps a lack of confidence with results and often reviewers are unable to make definitive judgement about clinical efficacy because of inadequate Randomised Controlled Trial (RCT) design, poor reporting and concerns about trial fidelity and TENS technique.[9] Consequently, the use of TENS as an adjunct to analgesic medication in multi-modal management of acute post-surgical pain should be considered.

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ Cuschieri RJ, Morran CG, McArdle CS. Transcutaneous electrical stimulation for postoperative pain. Annals of the Royal College of Surgeons of England. 1985 Mar;67(2):127.
  2. ↑ Galli TT, Chiavegato LD, Liebano RE. Effects of TENS in living kidney donors submitted to open nephrectomy: A randomized placebo‐controlled trial. European Journal of Pain. 2015 Jan;19(1):67-76.
  3. ↑ Fiorelli A, Morgillo F, Milione R, Pace MC, Passavanti MB, Laperuta P, Aurilio C, Santini M. Control of post-thoracotomy pain by transcutaneous electrical nerve stimulation: effect on serum cytokine levels, visual analogue scale, pulmonary function and medication. European Journal of Cardio-Thoracic Surgery. 2012 Apr 1;41(4):861-8.
  4. ↑ Unterrainer AF, Friedrich C, Krenn MH, Piotrowski WP, Golaszewski SM, Hitzl W. Postoperative and preincisional electrical nerve stimulation TENS reduce postoperative opioid requirement after major spinal surgery. Journal of Neurosurgical Anesthesiology. 2010 Jan 1;22(1):1-5.
  5. ↑ Benedetti F, Amanzio M, Casadio C, Cavallo A, Cianci R, Giobbe R, Mancuso M, Ruffini E, Maggi G. Control of postoperative pain by transcutaneous electrical nerve stimulation after thoracic operations. The Annals of thoracic surgery. 1997 Mar 1;63(3):773-6.
  6. ↑ Elboim-Gabyzon M, Najjar SA, Shtarker H. Effects of transcutaneous electrical nerve stimulation (TENS) on acute postoperative pain intensity and mobility after hip fracture: A double-blinded, randomized trial. Clinical interventions in aging. 2019;14:1841.
  7. ↑ Pons T, Shipton EA. Multilevel lumbar fusion and postoperative physiotherapy rehabilitation in a patient with persistent pain. Physiotherapy theory and practice. 2011 Apr 1;27(3):238-45.
  8. ↑ Gilbert JM, Gledhill T, Law N, George C. Controlled trial of transcutaneous electrical nerve stimulation (TENS) for postoperative pain relief following inguinal herniorrhaphy. British journal of surgery. 1986 Sep;73(9):749-51.
  9. ↑ Dafny, N. (2014). Pain modulation and mechanisms. In: Neuroscience online. Houston, TX: UTHealth. 
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