Is transcutaneous electric nerve stimulation (TENS) effective for cancer pain in adults? Adam Hurlow 2/11/11

EBM:TENS cancer pain Three part question In [patients with cancer pain] is [TENS] effective at [reducing pain]? Clinical Scenario Multiple hospital inpatients/ outpatients with cancer pain partially controlled with a combination of opioids, non-opioid analgesia and adjuvants but increasing side effects/toxicity with escalating dose. TENS either difficult to get hold of or costs the patient. Is it worth pursuing?

EBM: TENS cancer pain Search Strategy Robb KA, Bennett MI, Johnson MI, Simpson KJ, Oxberry SG. Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults. Cochrane Database of Systematic Reviews 2008, Issue 3. Medline , CINAHL , EMBASE , AMED Updated to Last update AMED, MEDLINE (via OVID) EMBASE 26/10/11 & CINAHL 1/11/1, CENTRAL 2008 to June 2011

EBM:TENS cancer pain Search Outcome The original Cochrane review 2008 identified 2 eligible studies neither showed a significant difference in favour of TENS vs placebo. The updated search identified 2 further potential eligible studies 1 of which was rejected as it dealt with percutaneous electroacupuncture

EBM:TENS cancer pain Author, date and countr y Patient group Study type (level of evidence) OutcomesKey resultsStudy Weaknesses Bennett MI, Johnson MI, Brown S, Searle RD, Radford H, Brown JM. Uk, adults with metastatic bone pain referred to SPC services in 2 cities Randomised, placebo- controlled crossover feasibility study NRS pain relief and pain intensity, VRS pain relief and pain intensity at baseline, 30 mins & 60 mins Difference in the proportion experiencing good or v. good pain relief on movement with active vs placebo TENS was statistically significant: (ss) 36.8% (95% CI 7.55 to 66.2%). NRS on movement not ss but +ve. No improvement in pain at rest. 19/24 completed. 5/22 adverse effects due to TENS. 1 withdrawal due to pain during active TENS. 1 during placebo. 3 deteriorating health Participant blinding not maintained (10/19 ID placebo). Not powered to look for ss. Allocation concealment not discussed.

EBM:TENS cancer pain Author, date and country Patient groupStudy type (level of evidence)OutcomesKey resultsStudy Weaknesses Gadsby JG, Franks A, Jarvis P, Dewhurst F UK, hospice inpatients with terminal cancer Double-blind RCT.EORTC QOL- C30 at baseline and on Day 6 - pain, N&V, fatigue, global quality of life and 5 functional scales. No change in mean pain scores with TENS. OR 0.5 times higher than palcebo and 0.16 than control Low numbers. 2 placebo did not complete. Not clear how non- completers handled in analysis. But binding sustained

EBM:TENS cancer pain Author, date and country Patient grou p Study type (level of evidence)OutcomesKey resultsStudy Weaknesses Robb KA, Newham DJ, Williams JE. 2007, UK 41patient s with >6/12 pain following treatment of breast cancer Randomised, placebo- controlled crossover trial design. Brief Pain Inventory (BPI) short form: at baseline then weekly rwhilst receiving treatment.Post- treatment measure ment at 3, 6 and 12/12 No significant difference in pain relief scores between TENS & placebo. 13 women continued TENS 6 placebo. 2 increase pain, 1 skin reaction 8 participants did not complete. The distribution of these participants was not reported. A minority of participants may have identified the placebo but this was not formally analysed and numbers were not provided.

EBM:TENS cancer pain Comment(s) The step 1 evidence is equivocal regarding the used of TENS in cancer pain. Clinical Bottom Line There is poor evidence to support the use of TENS in cancer pain.

EBM:TENS cancer pain Bennett MI, Johnson MI, Brown S, Searle RD, Radford H, Brown JM. Feasibility study of Transcutaneous Electrical Nerve Stimulation (TENS) for cancer bone pain. Journal of Pain 2010;11(4): Gadsby JG, Franks A, Jarvis P, Dewhurst F. Acupuncture-like transcutaneous electrical nerve stimulation within palliative care: a pilot study. Complementary Therapies in Medicine 1997;5:13-8. Robb KA, Newham DJ, Williams JE. Transcutaneous electrical nerve stimulation vs. transcutaneous spinal electroanalgesia for chronic pain associated with breast cancer treatments. Journal of Pain and Symptom Management 2007;33(4): Robb KA, Bennett MI, Johnson MI, Simpson KJ, Oxberry SG. Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults. Cochrane Database of Systematic Reviews 2008, Issue 3.