Running Head: TENS AND CHRONIC PAIN

A Systematic Review of the Effectiveness of Transcutaneous Electrical Nerve Stimulation in the Treatment of Chronic Pain

Touro University Nevada Tracie Dunton Meg Isagholi Sheena Marquez Corinne Trenholm

TENS AND CHRONIC PAIN Introduction Chronic pain is a serious health problem that contributes greatly to disease, death, and disability (Institute of Health, 2011). Chronic pain, according to the American Chronic Pain Association (ACPA) (2012), is defined as ongoing or recurrent pain, lasting beyond the usual course of illness or injury or more than 3 to 6 months, and which adversely affects the individuals well-being. Although those suffering from chronic pain may not be able to identify the root cause for their pain, chronic pain may persist due to infections, mechanical problems, injuries, or acquired conditions and diseases (Institute of Medicine, 2011). Pain alerts the body of actual or potential injury and is a mechanism that protects individuals. With chronic pain, however, changes occur in the peripheral and central nervous system which cause maladaptive, persistent pain. The nervous system becomes hypersensitive and over-responsive to stimuli that would normally not be painful (Institute of Medicine, 2011). In 2002, the World Health Organization warned that chronic pain was increasing at an alarming rate (Robinson, Kennedy, & Dominic, 2011). In 2006, the ACPA stated that approximately 50 million people in the United States were affected by chronic pain (Fisher, Emerson, Firpo, Ptak, Wonn, & Bartolacci, 2007). In 2011, the Institute of Medicine stated that chronic pain affects over 100 million adults living in U.S, thus doubling the incidence of chronic pain in five years. Furthermore, chronic pain rates will continue to rise due to the aging U.S population, increasing the relevance of obesity, progress in saving lives of people with catastrophic injuries, undermanaged acute postsurgical pain, and new treatment options and health care coverage for clients that were invisible to the system (Institute of Medicine, 2011). All individuals are at risk of developing chronic pain. According to the Institute of Medicine (2011) Americans do not receive adequate pain prevention, assessments, or treatment. A clinicians role should be to guide, coach, and assist clients with day-to day self-management,

TENS AND CHRONIC PAIN however, many of these professionals lack training on how to support clients in their daily roles and there is little reimbursement for their doing so. Professionals also lack understanding of how to individualize treatment using the best combination of treatments (Institute of Medicine, 2011). Chronic pain is a debilitating condition that affects ones physical and psychological state and in turn negatively impacts daily activities, routines, and role performances (Fisher et al., 2007). In the study completed by Fisher et al. (2007), feelings of sadness, depression, frustration, and anger were among some of the emotions that were expressed by the participants with chronic pain. Participants also reported a decline in their relationships due to the presence and challenges of their pain and expressed a lack of support from friends, co-workers, and medical professionals. Physical limitations in everyday activities range from person to person. Pain can impact the simplest tasks such as dressing to more complex tasks such as work and role performance. Not only does pain interfere with tasks that are needed to engage in daily function but also those that are associated with leisure and enjoyment. Stress related to finances, family, and psychological status further adds to a diminished quality of life (Fisher et al., 2007). Occupational therapists are skilled in helping clients with functional impairments. By utilizing a holistic approach, occupational therapists can focus on a clients physical and mental status and incorporate the best combination of appropriate intervention strategies. Of these intervention strategies, transcutaneous electrical nerve stimulation (TENS) may be used to help reduce pain to help clients engage in meaningful occupations and enhance their quality of life. Transcutaneous Electrical Nerve Stimulation Transcutaneous electrical nerve stimulation (TENS), according to Jones and Johnson (2009), is a non-invasive analgesic technique that is used to relieve nociceptive, neuropathic, and musculoskeletal pain (p. 130). TENS devices consists of a portable pulse generator that

TENS AND CHRONIC PAIN connects to electrodes. The adhesive electrode pads are placed on the surface of the skin where pulsed electrical currents are delivered across the skin to activate underlying nerves. TENS devices include adjustable knobs for pulse rate, pulse duration, and amplitude (Jones & Johnson, 2009). The pulse duration (width) is measured in microseconds and ranges from 40 to 300 microseconds. The pulse rate (frequency) is measured in pulses per second and can range from 2 to 200 Hz (Watson, 2012). High-frequency TENS (HF-TENS) is often associated with a frequency of greater than 10 Hz and low-frequency TENS (LF-TENS) is anything less than 10 Hz (Vance, Rakel, Blodgett, DeSantana, Amendola, Zimmerman, Walsh & Sluka, 2012). The amplitude (intensity) starts at zero and can go as high as 100 milliamps. There are different TENS techniques that are used to activate populations of nerves (Jones & Johnson, 2009). Conventional TENS is the most common which uses a low intensity and high frequency setting. Acupuncture-like TENS uses a high intensity and low frequency, whereas, intense TENS uses a high intensity and high frequency setting (Jones & Johnson, 2009). Theory There are several theories on the physiological mechanism of TENS that results in its analgesic effect. Theories include the endogenous opioids theory, the effect of TENS on muscle activation and oxygenation theory and the gate control theory. Endogenous opioids are the naturally occurring substances within the body that help to inhibit the sensation of pain (Konuer, Sreemantula & Rizwan, 2009). Several studies have produced results where healthy subjects treated with either low frequency or high frequency TENs, have increased levels of endogenous opioids in their blood stream and cerebrospinal fluid (Sluka & Walsh, 2003). The endogenous opioids bind with opioid receptors in the central nervous system to inhibit nociceptive neural pathways resulting in pain reduction (Sluka & Walsh, 2003).

TENS AND CHRONIC PAIN The second theory on TENS mechanism of action infers that TENS has a more localized effect; it reduces the resting muscle activation level, reduces oxygen consumption, and increases blood flow to the muscles where TENS is applied. Increased involuntary muscle activation (spasm) is believed to result in increased pain and muscle fatigue. The muscle pain and fatigue is the result of increased muscular oxygen metabolism with a simultaneous decrease in the available oxygen from blood due to the vasoconstriction of blood vessels caused by the muscle spasm (Kavcic, Lehman & McGill, 2005). A study by Kavicic et al. (2005) found that after a single 20 minute high-intensity modulated TENS treatment, resting muscle activation was decreased, intramuscular blood flow was increased, and muscle oxygenation was increased with participants reporting a reduction in muscular pain. The gate-control theory is the oldest and most widely investigated theory on the analgesic mechanism of TENS (Sluka & Walsh, 2003). The gate-control theory is based on the premise that TENS application excites the peripheral nerves that inhibit the perception of pain. According to the gate-control theory, nociceptive input is inhibited at the spinal cord level by the activation of peripheral large diameter primary afferent neurons that produce an inhibitory effect on the small diameter fibers which synapse with neurons in the ascending spinal cord tracts that send pain signals to the brain (Sluka & Walsh, 2003). In our review of the literature, we found that a majority of the studies investigating the efficacy of TENS are based upon the gate-control theory. Purpose As occupational therapy students we are introduced to various physical agent modalities (PAMs). A modality is an intervention that produces a physiological response in soft tissue structure through the use of light, water, temperature, sound or electricity (McPhee, Bracciano &

TENS AND CHRONIC PAIN Rose, 2003). TENS is specifically used for pain control. Although it does not cure the pain, it provides an analgesic effect allowing better occupational performance. The purpose of our study is to conduct a systematic review on the effectiveness of TENS for individuals with chronic pain. The objective of the study is to find peer reviewed articles to see whether TENS reduces chronic pain or has no effect on pain levels. Managing chronic pain for patients is crucial because it affects ones occupational performance. Therefore, being able to find evidence based research that supports the use of TENS for chronic pain will allow therapists to incorporate appropriate modalities in treatment plans. As occupational therapists we will be dealing with clients who are experiencing chronic pain and being knowledgeable in the effective means of pain relief will improve outcomes for our clients. In addition, as occupational therapists we will be seeing many patients who have had a long history of chronic pain and the resulting psychological factors impacting their engagement in occupations. Individuals who have been experiencing chronic pain may become depressed, because their pain may restrict them from engaging in meaningful occupations. The American Occupational Therapy Association (AOTA) states that PAMs should be used as an adjunctive measure in the occupational therapy clinic in preparation or in conjunction with functional activities or occupations (McPhee, Bracciano & Rose, 2003). AOTA believes preparatory methods support and promote the achievement of the performance skills necessary to enable an individual to resume or assume habits, routines and roles for engagement in occupations (McPhee, Bracciano & Rose, 2003). Occupational therapists are skilled in helping clients with functional impairments. By utilizing a holistic approach, occupational therapists can focus on a clients physical and mental status and incorporate the best combination of appropriate intervention strategies. Of these

TENS AND CHRONIC PAIN intervention strategies, TENS may be used to help reduce pain thus allowing clients to engage in meaningful occupations and enhance their quality of life. Hypothesis We hypothesize that the use of TENS provides relief in individuals experiencing chronic pain. According to the gate control theory of pain, stimulation of large diameter afferent nerve fibers inhibits nociceptive fiber evoked responses in the dorsal horn of the spinal cord (Sluka & Walsh, 2003). This theory suggests that altered stimulation of the nervous system through transcutaneous electrodes placed on areas of the body can modify an individuals perception of pain. Therefore TENS should reduce an individuals level of pain. Methods The EBSCO Multi Search database and PubMed database were searched using the following key words: transcutaneous electrical nerve stimulation, pain, chronic pain, pain treatment, and TENS. EBSCO Multi Search limiters included full text, peer reviewed articles. PubMed search limiters included full text articles. Initial database searches returned 188 potential articles. The 188 articles were screened to determine if they met our initial inclusion and exclusion criteria by reading the articles abstracts. Our initial inclusion criteria included original research in the form of qualitative studies, quantitative studies, or meta-analysis investigating the effect of TENS on chronic pain. Articles that examined the effect of TENS on labor pain, articles published earlier than 2005, and systematic reviews or literature reviews were excluded. From the 188 potential articles, fifteen articles were determined to meet the initial search criteria (see Appendix).

TENS AND CHRONIC PAIN Randomized control trails and meta-analysis are considered to be the highest level of evidence for examining the efficacy of clinical treatments (Sluka & Walsh, 2003). When examining the efficacy of TENS it is also important that the researchers blind the participants to whether they have been assigned to the treatment or the placebo group (Sluka & Walsh, 2003). Therefore, we further refined our inclusion and exclusion criteria to limit the articles for inclusion to those of Level I or Level II quality of evidence; meta-analysis and blinded randomized control trials. This resulted in a total of ten articles included in this systematic review. However, after in-depth review and analysis, one of the ten articles was further excluded resulting in the nine articles that have been included in this review (see Appendix). The decision to exclude the tenth randomized control study (Jarzem et. al, 2005) was due to the fact that although pain was initially used as an outcome measure for this study, the pain scale was not included in the final data analysis due to incomplete data, thus it was determined this study did not measure the effect of TENS on reducing chronic pain. Main Findings Musculoskeletal Pain Musculoskeletal pain is defined as pain that affects the muscles, ligaments, and tendons, along with bones (American Chronic Pain Association, 2012). Of the nine articles reviewed, seven looked at the effectiveness of TENS for chronic musculoskeletal pain. These articles yielded similar results indicating that active TENS is effective in decreasing pain intensity for patients experiencing chronic musculoskeletal pain, and a positive correlation was found regarding patient satisfaction in the use of this modality. A study conducted by Oosterhof et al. (2007) examined effects of the origin of pain on predicting results of high frequency TENS in the

TENS AND CHRONIC PAIN treatment of chronic pain. It was found that predicting patients satisfaction with TENS depends on the origin of their pain. Patients diagnosed with peripheral neuropathic pain and osteoarthritis were less satisfied; whereas those diagnosed with chronic pain related to bone or soft tissue injury were significantly more satisfied with the use of high frequency TENS treatment (Oosterhof et al., 2007). Three studies conducted by Buchmuller et al. (2011), Jarzem et al. (2005), and Kofotolis (2009), looked at the effectiveness of TENS in treatment of chronic low back pain. Chronic low back pain is one of the most common as well as costly musculoskeletal pain syndromes. Chronic low back pain affects up to 80% of the population at some point throughout their lifetime (Kofotolis, 2009). The study conducted by Buchmuller et al. (2011) found no statistically significant difference in the improvement of the functional status observed between patients receiving active TENS in the treatment of chronic lower back pain. However, the study found that after 6 weeks, patients weekly evaluation of pain intensity showed a highly significant difference in favor of active TENS over sham TENS in both the lumbar and radicular components of pain (Buchmuller et al. (2011). The study conducted by Jarzem et al. (2005) found active TENS significantly reduced pain and improved performance on a majority of standardized tests of physical capacity. This study suggests that active TENS treatment may be useful for short-term pain relief in patients with chronic low back pain and therefore may increase the patients ability to participate in therapy. The study conducted by Kofotolis (2009) found that combining active TENS with rhythmic stabilization, which consists of alternating (trunk flexion-extension) isometric contractions against resistance for 10 seconds, produced improvements in functional disability and pain intensity. This combination was found to be

TENS AND CHRONIC PAIN more effective than active TENS treatment alone. This study suggests a combination of active TENS along with another treatment should be used in therapy instead of active TENS alone. A study conducted by Escortell-Mayor et al. (2011) compared the effectiveness of manual therapy with active TENS to reduce pain intensity in patients with mechanical neck disorder. This study found that both manual therapy as well as active TENS produces clinically relevant short-term pain reduction in patients experiencing chronic mechanical neck disorder (Escortell-Mayor et al., 2011). Although both types of treatment resulted in short-term pain reduction and high patient satisfaction levels, no evidence was found indicating a difference between the two groups. A study conducted by Miller et al. (2006) examined the effects of active TENS in patients with Multiple Sclerosis as well as the effect of TENS application time on its effectiveness. This study found a non-significant reduction of pain following a two-week 60 minute per day application of active TENS compared to a highly significant reduction of pain following an 8 hour application of active TENS treatment (Miller et al., 2006). This study suggests that the application of active TENS over a longer period of time, leads to increased improvements of pain associated with spasticity and muscle spasms in patents diagnosed with Multiple Sclerosis. A meta-analysis of randomized controlled trials conducted by Johnson and Martinson (2007) examined any modality of electrical nerve stimulation (ENS), ([ENS is synonymous to TENS]) to treat chronic musculoskeletal pain in any anatomical region. A total of 38 studies in 29 papers, which included 335 placebos, 474 TENS, and 418 cross-over studies were reviewed. Results indicated that for all studies combined TENS reduced pain significantly. On average pain relief provided by TENS was about three times the pain relief experienced by a placebo

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TENS AND CHRONIC PAIN (Johnson & Martinson, 2007). This study suggests that TENS is an effective treatment modality for patients diagnosed with chronic musculoskeletal pain. Neuropathic Pain and Osteoarthritis Neuropathic pain is caused by damaged, dysfunctional, or injured nerves. Nerve damage or dysfunction can occur from an injury, disease, or may not have an obvious cause. Pain is a result of the nerves sending incorrect signals to pain centers thus creating symptoms of shooting and, or, burning pain (American Chronic Pain Association, 2012). Osteoarthritis (OA) is commonly referred to as a wear and tear disease that is caused by the breakdown of cartilage in joints. This breakdown of cartilage causes tendons and ligaments to stretch causing pain. Pain is also a result of bones rubbing together and reactive bone formation (Yasuda, 2008). Of the nine articles reviewed, the articles completed by Gossrau et al., Vance et al., and Oosterhof et al. looked at the effectiveness of TENS on neuropathic and OA pain. These three articles yielded similar results revealing that TENS may be effective at treating some pain related disorders but not others. The study completed by Vance et al. (2012) examined the effectiveness of TENS on individuals with knee OA. They found that TENS had minimal effects on OA pain. They further found that the placebo group and TENS group had similar results suggesting a strong placebo effect. The study completed by Gossrau et al. (2011), which looked at the effectiveness of TENS on diabetic neuropathy, had strikingly similar results to the study completed by Vance et al. TENS was found to be ineffective for individuals suffering from diabetic neuropathic pain with a strong placebo effect. The study completed by Oosterhof et al. (2008) examined the effectiveness of TENS on neuropathic pain, OA, and musculoskeletal disorders. TENS was shown to work for individuals with musculoskeletal disorders but proved to be ineffective for those with OA and neuropathy. These findings suggest that TENS does not

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TENS AND CHRONIC PAIN provide pain relief for individuals suffering from OA or neuropathic pain and further supports that TENS is effective at treating pain related to musculoskeletal disorders. Short term vs. long term After systematically reviewing ten research articles measuring the effects of TENS on chronic pain, it was evident that when considering the effectiveness of TENS one must consider the time frame in relation to its effectiveness. Reducing the intensity of chronic pain can have short term or long term effects. Short term effects can be defined as an immediate effect on pain, lasting 0-48 hours after treatment. Long term effects are considered any reduction in pain lasting longer than 48 hours. In our review of the literature, we found no standard timeline delineating short term versus long term pain relief. Therefore, the above criteria for defining short term versus long term pain relief were established by the authors of this systematic review. Of the articles reviewed, Oosterhof et al. (2007), Johnson and Martinson (2007), Buchmuller et al. (2011), and Jarzem et al. (2005), looked at the effectiveness of both short term and long term effectiveness of TENS for individuals with chronic musculoskeletal pain. However, these studies found TENS to only be effective with short term effects. In these studies, the participants who received TENS treatment admitted that the treatment of TENS reduced their perception of pain lasting up to 48 hours. However, the articles by Johnson and Martinson and Buchmuller et al., did not specifically compare the short term versus long term effects of TENS for individuals with chronic pain. Therefore, the findings were inconclusive for examining the short term versus long term effects of TENS treatment for individuals experiencing chronic pain. Discussion

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TENS AND CHRONIC PAIN The results of the systematic review demonstrated that the application of TENS has a short term effect for individuals with musculoskeletal pain. The findings on the long-term effects of TENS were inconclusive. This review also demonstrates that active TENS was found to be effective in decreasing clients perception of pain in those experiencing chronic musculoskeletal pain, whereas TENS did not provide pain relief for individuals suffering from osteopathic or neuropathic pain. No correlation was found between the type of active TENS used and pain relief. Active TENS includes high-frequency (HF; >10 Hz), low frequency (LF; <10 Hz), variable-frequency (VF), and acupuncture-like TENS. Acupuncture-like TENS is very low frequency, high-amplitude stimulation (Johnson & Martinson, 2007). Regardless of the type of TENS used, any form of active TENS was found to be beneficial in those experiencing chronic musculoskeletal pain. These findings support our initial hypothesis that TENS does reduce an individuals level of pain. However, TENS appears to only be affective for the short term relief of musculoskeletal pain. The results create various implications for practicing occupational therapists. First, it teaches occupational therapists to identify the underlying factor that is causing chronic pain prior to using TENS. For those suffering from musculoskeletal pain, TENS can be used as a preparatory method at the beginning of a treatment session to reduce the clients pain for a short period of time, allowing them to participate in therapeutic activities. In addition, TENS can be applied during therapy to help reduce pain and increase performance in functional tasks. Occupational therapists can also educate their clients on how to apply and use TENS in their home and/or work. By purchasing a unit, clients are able to use TENS at their own discretion. Clients can self-administer TENS when they are experiencing pain and/or to prevent pain from occurring, such as before they engage in a specific activity that may aggravate their ailment.

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TENS AND CHRONIC PAIN When clients experience reduced levels of pain, they will be more inclined to participate in activities of daily living, as well as other actives they find meaningful, which will ultimately improve their overall quality of life. Clients who suffer from chronic pain often take pain medications that can have adverse effects on their physical and mental health. Pain medications also interfere with ones ability to engage in occupations such as driving, working with machinery, social engagement, and even basic activities of daily living such as grooming and dressing. Giving clients the ability to prevent and control their pain with TENS can help eliminate or reduce the need for pain medications. Along with the above research findings, there were other striking details found during the research review that can help occupational therapists when working with clients suffering from chronic pain. In one study that was initially reviewed, but eliminated due to the narrowing of the exclusion criteria, the authors found that although there was no significant treatment effect as a group level, there were several participants in the study that did find TENS to be effective and requested a TENS unit for further treatment at the end of the study (Norrbrink, 2009). In the two studies completed by Gossrau et al. (2011) and Grace et al. (2012), the findings show that TENS has a strong placebo effect. Both studies found that participants receiving inactive TENS experienced a comparable benefit to those receiving active TENS. Based on these findings, occupational therapists must consider their clients perspectives. If a client views TENS as an effective treatment that reduces pain and helps them engage in occupations, then TENS should be considered worthwhile and used as a complementary treatment. Implications for Future Research

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TENS AND CHRONIC PAIN Currently, there are no prescribed guidelines for the use of TENS. The application of electrode placement, intensity, and frequency are not delineated to users. The lack of standardization makes it difficult for practitioners to find statistically significant findings. Among the studies reviewed, the placement of electrodes, frequency, intensity, and even an individuals stage of disease varied and these differences can impact the effectiveness of TENS. Future research should focus on having guidelines that all researchers follow in order to have accurate measurements. There also remains a lack of rigorously randomized control trials (RCTs) investigating the efficacy of TENS for treating all types of chronic pain. This is evidenced by our search of the literature only identifying eight RCTs on TENS since 2005. Furthermore, only one of the eight RCTs had group sizes greater than 100 (Buchmuller et. al., 2011). Larger group sizes increase the power of the study. Therefore, more large scale RCTs are needed to investigate the efficacy of TENS for the treatment of chronic pain. Conclusion This systematic review of published peer reviewed literature provides evidence that TENS is an effective modality for providing short-term relief from musculoskeletal pain. Thus, TENS can be a used as a preparatory or adjunct treatment to enhance the occupational performance of individuals suffering from chronic musculoskeletal pain. Findings on the efficacy of TENS for providing long-term pain relief were equivocal. TENS was not found to be effective for providing long-term pain relief or for the relief of osteoarthritis or neuropathic pain. The current lack of standardization for TENS procedures warrants the need for more large scale

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TENS AND CHRONIC PAIN studies using a standardized TENS protocol in order to establish the efficacy of TENS for pain relief.

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TENS AND CHRONIC PAIN References American Chronic Pain Association. (2012). Neuropathic pain. Retrieved from http://www.theacpa.org/conditionDetail.aspx?id=29 Buchmuller, A., Navez, M., Milletre-Bernardin, M., Pouplin, S., Presles, E., Lanteri-Minet, M., Camdessanche, J. P. (2011). Value of TENS for relief of chronic low back pain with or without radicular pain. European Journal of Pain, 16, 656-665. Escortell-Mayor, E., Riesgo-Fuertes, R., Garrido-Elustondo, S., Asunsolo-del Barco, A., DiazPulido, B., Blanco-Diaz, M., & Bejerano-Alvarez, E. (2010). Primary care randomized clinical trial: Manual therapy effectiveness in comparison with TENS in patients with neck pain, Journal of Manual Therapy, 16, 66-73. doi: 10.1016/j.math.2010.07.003 Fisher, G., Emerson, L., Firpo, C., Ptak, J., Wonn, J., & Bartolacci, G. (2007). Chronic pain and occupation: An exploration of the lived experiences. American Journal of Occupational Therapy, 61(3), 290-302. Gossrau, G., Wahner, M., Kuschke, M., Konrad, B., Reichmann, H., Wiedemann, B., & Sabatowski, R. (2011). Microcurrent transcutaneous electric nerve stimulation in painful diabetic neuropathy: A randomized placebo-controlled study. Pain Medicine, 12, 953960. Institute of Medicine (2011). Relieving pain in america: A blueprint for transforming prevention, care, education, and research. Washington, D.C: National Academies Press. Jarzem, P. F., Harvey, E. J., Arcaro, N., & Kaczorowski, J. (2005). Transcutaneious electrical nerve stimulation [TENS] for chronic lower back pain. Journal of Musculoskeletal Pain, 13(2), 3-9. doi: 10.1300/J094v13n02_02

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TENS AND CHRONIC PAIN Johnson, M., & Martinson, M. (2007). Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: A meta-analysis of randomized controlled trials. The Journal of Pain, 130, 157-165. doi: 10.1016/j.pain.2007.02.007 Kofotolis, N. Vlachopoulos, S. Kellis, E. (2008).Sequentially allocated clinical trial of rhythmic stabilization exercise and TENS in women with chronic low back pain. Clinical Rehabilitation, 22(2), 99-111. McPhee S., Bracciano, A., Rose, B. (2003). Physical agent modalities: A position paper. The American Journal of Occupational Therapy, 57(6), 650-651. Miller, L. Mattison, P. Wood, L. (2007). The effects of transcutaneous electric nerve stimulation (TENS) on spasticity in multiple sclerosis. Multiple Sclerosis, 13(4), 527-533. Oosterhof, J., Samwel, H., De Boo, T., Wilder-Smith, O., Oostendorp, R., & Crul, B. (2007). Predicting outcome of TENS in chronic pain: A prospective, randomized placebo controlled trial, The Journal of Pain, 136, 11-20. doi: 10.1016/j.pain.2007.06.009 Robinson, K., Norelee, K., & Harmon, D. (2011). Is occupational therapy adequately meeting the needs of people with chronic pain?. The American Journal of Occupational Therapy, 65(1), 106-113. Sluka, K. A. & Walsh, D. (2003). Transcutaneous electrical nerve stimulation: Basic science mechanisms and clinical effectiveness. The Journal of Pain, 4(3), 109-121. doi: 10.1054/jpai.2003.434 Vance, C., Rakel, B., Blodgett, N., DeSantana, J., Amendola, A., Zimmerman, M., Walsh, D., & Sluka, K. (2012). Effects of transcutaneous electrical nerve stimulation on pain, pain sensitivity, and function in people with knee osteoarthritis: A randomized controlled trial. Physical Therapy,92(7), 898-910.

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TENS AND CHRONIC PAIN Watson, T. (2012). Transcutaneous electrical nerve stimulation. Retrieved from http://www.electrotherapy.org/modalities/tens.htm

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TENS AND CHRONIC PAIN Appendix

Author(s) & Publication Year Kofotolis, N. D., Vlachopoulos, S. P., & Kellis, E. (2007) Saima Amanat, S., Shahbaz, N., Hassan, Y., Abdullah, M., & Herekar, A. (2010) Vance, C. G. T., Rakel, B. A., Blodgett, N. P., DeSantana, J. M., Amendola, A., Zimmerman, M. B., Walsh, D. M., & Sluka, K. A. (2012) Norrbrink, C. Kavcic, N. S., Lehman, G. H., & McGill, S.M. (2005) Shokrzadeh, A., Seddighi, A, Seddighi, A. S. (2010) Oosterhof, J., Samwel, H., De Boo, T., Wilder-Smith, O., Oostendorp, R., Crul, B. (2007) Johnson, M. & Martinson, M. (2007) Miller, L., Mottison, P., Paul, L., & Wood, L. (2007) Buchmuller, A., Navez, M., MilletreBernardin, M., Pouplin, S. Presles, E., Lanteri-Minet, M. Camdessanche, J. P. (2011) Escortell-Mayor, E., Riesgo-Fuertes, R., Garrido-Elustondo, S., Asunsolodel Barco, A., Diaz-Pulido, B., Blanco-Diaz, M., Bejerano-Alvarez (2011) Title of Journal Article Sequentially allocated clinical trial of rhythmic stabilization exercises and TENS in women with chronic low back pain Type of Research Study Randomized control trail with single-blinding & placebo control group. Included in this Yes

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Carpal tunnel syndrome: Pain reduction after microams transcutaenous electrical stimulation

Hospital based quasi experimental of patients with CTS

No

Yes Effects of transcutaneous electrical nerve stimulation on pain, pain sensitivity, and function in people with knee osteoarthritis: A randomized controlled trial Transcutaneous electrical nerve stimulation for the treatment of spinal cord injury neuropathic pain Effect of modulated TENS on muscle activation, oxygenation and pain: Searching for a phsyiological mechanism Therapeutic results of transcutaneous electrical nerve stimulation in post laminectomy syndrome Randomized control trail with double-blinding & placebo control group (sham TENS). Two group study, non- randomized, no control No

Single group, pre and post test measures.

No

Single group, pre and post test measures

No

Predicting outcome of TENS in chronic pain: A prospective, randomized, placebo controlled trial Efficacy of eletrical nerve stimulation for chronic musculoskeletal pain: A metaanalysis of randomized controlled trials The Effects of transcutaneous electrical nerve stimulation(TENS) on spacticity in multiple scelorosis

Randomized control trial with single blinding & placebo control group (sham TENS). Meta-analysis of randomized controlled trials of TENS Randomized control trail with single blinding and repeated cross-over.

Yes

Yes

Yes

Value of TENS for relief of chronic low back pain with or without radicular pain

Randomized control trail with single-blinding & placebo control group (sham TENS).

Yes

Yes Primary care randomized clinical trial: Manual therapy effectiveness in comparison with TENS in patients with neck pain Transcutaneous Electrical Nerve Stimulation [TENS] for short-term treatment of low back pain- Randomized double blind crossover study of Sham vs. Conventional Tens Randomized control trail, treatment comparision, no placebo control

Jarzem, P. F., Harvey, E.J., Arcaro, N., Kaczorowski, J. (2005) Gossru, G., Wahner, M., Kuschuke, M., Konrad, B., Reichmann, H., Wiedermann, B., Sbabtowski, R. (2011).

Randomized control trail with double-blinding & placebo control group (sham TENS).

Yes

Microcurrent transcutaneous electrical nerve stimulation in painful diabetic neuropathy: A randomized placebo-controlled study.

Randomized control trail with single-blinding & placebo control group (sham TENS).

Yes

Persson, A. L., Lloyd-Pugh, M., & Sahlstrom, J.(2010) Jarzem, P. F., Harvey, E.J., Arcaro, N., Kaczorowski, J. (2005)

Trained long-term TENS users with chronic non-malignant pain. A retrospective questionnaire study of TENS usage and patient's experiences. Transcutaneous Electrical Nerve Stimulation [TENS] for chronic low back pain

No Cross-sectional study by questionnaire Randomized control trail with double-blinding & placebo control group (sham TENS). No*

* Article was excluded due to lack of data on pain measurement scale (Visual Analago Scale) resulting in pain not being an outcome measure in the final results.