Efficacy of Transcutaneous Electrical Nerve Stimulation for Postoperative Pain, Pulmonary Function, and Opioid Consumption Following Cardiothoracic Procedures: A Systematic Review

Evidence summary on pain management in thoracoscopic lung cancer surgery

Objective

The study aimed to systematically retrieve, evaluate and summarize evidence on perioperative pain management in adults undergoing thoracoscopic lung cancer surgery, to assist oncology nurses in improving pain assessment and management.

Methods

The research question was established using PIPOST model and a systematic search was conducted in English and Chinese databases, professional society websites and guideline platforms for literature published between January 2017 and December 2024. Included literature types comprised guidelines, systematic reviews, evidence summaries, expert consensus, and standards. After literature searching and screening in January 2025, the remaining guidelines were evaluated by four investigators, while other literature was assessed by two investigators. Evidence was then extracted and graded.

Results

Eighteen articles were included, comprising 5 systematic reviews, 3 guidelines, 2 clinical decisions, 4 evidence summaries, 3 expert consensus, and 1 standard. Twenty-five pieces of evidence across six topics were summarized, covering organizational management, high-risk patient assessment and preoperative education, pain assessment, intraoperative analgesia, multimodal pharmacological strategies, and non-pharmacological interventions.

Conclusions

This evidence summary highlights effective strategies for perioperative pain management in thoracoscopic lung cancer surgery, which could support oncology nurses in implementing comprehensive pain assessment, identifying high-risk patients, and applying diversified analgesic interventions.

Practice Advisory for Postoperative Pain Management of Cardiac Surgical Patients: A Report by Society of Cardiovascular Anesthesiologists

Moderate to severe pain after cardiac surgery is relatively common, which increases the risk of postoperative cardiopulmonary complications and delays hospital discharge. Opioids have been useful agents for postoperative pain control after cardiac surgery, but are associated with serious adverse effects. As a result, multimodal analgesia has been adopted widely to decrease reliance on opioids for treating postoperative pain, reduce opioid-related adverse effects, and promote early recovery. The advent of fascial plane blocks has expanded the use of regional analgesia for pain management after cardiac surgery that was otherwise limited due to the fear of devastating neurological sequelae in the setting of systemic anticoagulation. This practice advisory reviews and evaluates the recent literature related to the use of pharmacological and non-pharmacological therapies to treat pain after cardiac surgery to help providers with the selection of appropriate pain management interventions for their patients.

Effect of Transcutaneous Electrical Nerve Stimulation on Patients with Total Knee Replacement: A Randomized Controlled Trial

PURPOSE

The aim of this study was to determine the effect of transcutaneous electrical nerve stimulation (TENS) on pain, functionality, quality of life, and analgesic consumption in patients undergoing TKR.

DESIGN

A single center, randomized controlled trial.

METHODS

A total of 52 participants were randomly assigned to the intervention (n = 26) and control (n = 26) groups. The intervention group was exposed to conventional TENS. Data were collected with a Patient Identification Form, the Visual Analogue Scale (VAS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Quality of Life Scale (SF-36), and the Analgesic Tracking Form.

RESULTS

VAS and WOMAC scores significantly decreased in the intervention group, over time, while they increased in the control group. SF-36 scores significantly increased in the intervention group over time. It was determined that analgesic consumption was significantly lower in the intervention group than in the control group.

CONCLUSIONS

TENS significantly reduced pain and increased functionality and quality of life. Our findings suggest that TENS may be an effective adjunctive analgesic therapy in patients receiving TKR; however, more testing is needed in larger and more heterogeneous populations.

CLINICAL IMPLICATIONS

Nurses can provide effective postoperative pain control in patients undergoing TKR, increase functionality, accelerate the healing process, and improve their quality of life by using TENS, a non-pharmacological treatment method, in the perioperative period.

Effects of transcutaneous electrical nerve stimulation on pain, respiratory function, and analgesic drug usage after thoracotomy: a prospective randomized study

Objective

Transcutaneous electrical nerve stimulation (TENS) has been applied to alleviate post-thoracotomy pain. In this study, we investigated the effects of TENS on pain scores, additional opioid doses, opioid-related side effects, and potential respiratory and cardiac complications.

Method

In this controlled, randomized study, 40 patients underwent muscle-sparing thoracotomy. The TENS group consisted of 20 patients (Group T), while the control group included 20 patients (Group C). Postoperative pain scores, supplemental analgesia doses, opioid-related side effects, and postoperative cardiac and respiratory complications were measured.

Results

There was no statistically significant difference between the two groups in terms of demographic characteristics. Pain scores in Group T were consistently lower throughout various time intervals. The additional analgesia dose in Group T was significantly lower at 24, 48, and 72 h (respectively, p = 0.007, p = 0.043, p = 0.032). Opioid-related constipation, nausea, and vomiting were lower in Group T (respectively, p = 0.047, p = 0.044). Group T exhibited significantly lower postoperative complications related to secretion retention (p = 0.044).

Conclusion

The application of TENS for post-thoracotomy pain control helps prevent secretion retention and reduces opioid usage, thus mitigating opioid-related side effects.

Knowledge, attitudes, and practices of transcutaneous electrical nerve stimulation in perioperative care: A Swedish web-based survey

OBJECTIVES

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive adjunct to multimodal pain management for acute postoperative care across various surgeries. Despite extensive evidence supporting its efficacy, TENS remains underutilized in clinical practice. This study aimed to assess the knowledge, attitudes, and practices of healthcare professionals regarding TENS in perioperative settings to support its integration into routine clinical practice.

METHODS

A web-based questionnaire was distributed to anesthesiology department heads at all university hospitals (n = 7) in Sweden and three smaller, randomly selected hospitals across three geographical areas. Department heads forwarded the questionnaire to anesthesiologists, nurse anesthetists, critical care nurses, and registered nurses with basic education working in perioperative settings. The questionnaire included four sections: demographic information, general postoperative phase information, TENS use for postoperative pain relief, and open-ended questions.

RESULTS

The survey was sent to 870 respondents, yielding a response rate of 28% (n = 246). Among respondents, 69% reported lacking adequate knowledge to administer TENS, and 79% indicated they did not use TENS in their practice. Furthermore, 45% noted an absence of clinical guidelines supporting the use of TENS in their clinic, while 32% were unsure about the existence of guidelines. However, 60% expressed interest in developing theoretical knowledge and practical skills for TENS application.

CONCLUSIONS

This study highlights that substantial knowledge gaps and the lack of clear clinical guidelines limit the use of TENS for acute postoperative pain management. These deficiencies may lead to inadequate pain control, increased opioid use, and opioid-related adverse effects. We recommend that hospital leadership and professional bodies develop and implement comprehensive educational programs and establish clear, evidence-based clinical guidelines for TENS use in postoperative pain management. Addressing these gaps is essential for improving clinical practice and empowering patients through greater involvement and autonomy in pain management strategies.

Implementing an evidence-based guideline to decrease opioids after cardiac surgery

BACKGROUND

Deaths related to overdoses continue growing in the United States. The overprescription of opioids after surgical procedures may contribute to this problem.

LOCAL PROBLEM

There is inconsistency in the prescription of opioids in cardiovascular surgery patients. Recommendations regarding the reduction of opioids at discharge are not fully implemented.

METHODS

This is a single-center, pre-post quality improvement project in adult patients after elective cardiac surgery through sternotomy.

INTERVENTIONS

Changes in guidelines, modification of order sets, creation of dashboards, and education to the providers to increase the prescription of acetaminophen around the clock on the step-down unit and at discharge, decrease the number of opioid tablets to 25 or less at discharge and decrease the prescription of opioids to 25 or less morphine milligram equivalents (MME) at discharge.

RESULTS

The preintervention group included 67 consecutive patients who underwent cardiac surgery from November to December 2021. The postintervention group had 67 patients during the same period in 2022. Acetaminophen prescription on the step-down unit increased from 9% to 96% ( p < .001). The proportion of patients discharged with 25 or less opioid tablets increased from 18% to 90% ( p < .001) and with 25 or less MME from 30% to 55% ( p < .01). Acetaminophen prescription at discharge increased from 10% to 48% ( p < .001).

CONCLUSIONS

Our intervention increased the use of acetaminophen and decreased the overprescription of opioids in cardiac surgery patients at discharge. Further research is necessary to continue improving pain management to reduce the number of opioids prescribed at discharge.

The Impact of Transcutaneous Electrical Nerve Stimulation (TENS) on Acute Pain and Other Postoperative Outcomes: A Systematic Review with Meta-Analysis

This study aimed to investigate the efficacy and safety of transcutaneous electrical nerve stimulation (TENS) in postoperative acute pain control. PubMed, Scopus, and Cochrane Library were searched on 1-8 December 2022, for randomized controlled trials on the analgesic effects of TENS. The outcomes were pain intensity and opioid use (primary), and postoperative (PO) adverse events, blood pressure, and the duration of hospital stay (secondary); PROSPERO CRD42022333335. A total of 40 articles were included in the meta-analysis. Pain intensity at rest and during coughing for all types of surgeries combined was lower in the TENS group (standardized mean difference (SMD) = -0.51 [-0.61, -0.41], p < 0.00001, 29 studies, and -1.28 [-2.46, -0.09], p-value = 0.03, six studies, respectively). There was a statistically significant decrease in morphine requirements, as well as in the incidence of postoperative nausea and vomiting, dizziness, and pruritus. There was no difference between the groups in postoperative pain intensity during walking, in blood pressure, and only a borderline difference in the length of hospital stay. The subgroup analysis by surgery type did not show significant differences between the groups in pain severity at rest. Thus, TENS has a potential for pain control and postoperative recovery outcomes.

High-frequency, high-intensity transcutaneous electrical nerve stimulation compared with opioids for pain relief after gynecological surgery: a systematic review and meta-analysis

OBJECTIVES

Opioids are important for postoperative analgesia but their use can be associated with numerous side effects. Transcutaneous electrical nerve stimulation (TENS) has been used for acute pain treatment and has dose-dependent analgesic effects, and therefore presents an alternative to intravenous (iv) opioids for postoperative pain relief. The aim of this meta-analysis was to compare high-frequency, high-intensity (HFHI or intense) TENS to iv opioids with regard to postoperative pain intensity, recovery time in the Post Anesthesia Care Unit (PACU) and opioid consumption after elective gynecological surgery.

METHODS

We searched Medline, Embase, Web of Science, Cochrane, Amed and Cinahl for RCTs and quasi-experimental studies (2010-2022), and WHO and ClinicalTrials.gov for ongoing/unpublished studies. Meta-analysis and subsequent Trial Sequential Analysis (TSA) was performed for all stated outcomes. Quality of evidence was assessed according to GRADE.

RESULTS

Only three RCTs met the inclusion criteria (362 participants). The surgical procedures involved surgical abortion, gynecologic laparoscopy and hysteroscopy. The applied TENS frequency was 80 Hz and intensity 40-60 mA. There was no difference in pain intensity according to Visual Analogue Scale (VAS) at discharge from PACU between the TENS and opioid group (MD VAS -0.15, 95 % CI -0.38 to 0.09) (moderate level of evidence). Time in PACU was significantly shorter in the TENS group (MD -15.2, 95 % -22.75 to -7.67), and this finding was manifested by TSA (high-level of evidence). Opioid consumption in PACU was lower in the TENS group (MD Morphine equivalents per patient mg -3.42, 95 % -4.67 to -2.17) (high-level of evidence).

CONCLUSIONS

There was no detectable difference in postoperative pain relief between HFHI TENS and iv opioids after gynecological surgery. Moreover, HFHI TENS decreases recovery time and opioid consumption in PACU. HFHI TENS may be considered an opioid-sparing alternative for postoperative pain relief after gynecological surgery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021231048.

Developments in Postoperative Analgesia in Open and Minimally Invasive Thoracic Surgery Over the Past Decade

Whether through minimally invasive or conventional open techniques, thoracic surgery is often reported to be one of the most painful surgical procedures due to the incision of intercostal and respiratory muscles, rib injury or resection, and placement of surgical drains. Some of the more severe complications related to poor analgesia include prolonged intensive care unit stay, mechanical ventilation, pneumonia, and the development of chronic postoperative pain syndromes. Over the past few decades, much progress has been made in recognizing the importance of multimodal analgesic techniques. These may include a variety of regional anesthetic techniques such as epidural anesthesia, fascial plane blocks, and intrapleural catheters, as well as the utilization of opioid and opioid-sparing oral regimens. This article provides an up-to-date review of pain management following thoracic surgery, emphasizing multimodal techniques and enhanced recovery pathways. In our review, we included articles published between 2010 and 2022. PubMed and Google Scholar were researched using the keywords thoracic, cardiac, pain control, thoracic epidural analgesia, fascial plane blocks, multimodal analgesia, and Enhanced Recovery after Surgery in thoracic surgery. Over 100 articles were then reviewed. We excluded articles not in English and articles that were not pertinent to cardiac or thoracic surgery. Eventually, 53 articles were included in the review, composed of clinical trials, case series, and retrospective cohort studies. A variety of pain control methods employed in thoracic and cardiac surgery range from opioids and opioid-sparing medications, such as acetaminophen and gabapentin, to regional techniques, such as fascial plane blocks to epidural anesthesia. Multimodal anesthesia combining regional and opioid-sparing analgesics and their combination in enhanced recovery protocols were shown to provide adequate pain control, decrease opioid consumption and lead to shorter lengths of stay. Postoperative pain control remains one of the biggest challenges in the care of thoracic surgery patients. Analgesic plans must be individualized for each patient. Multimodal analgesia remains the gold standard; however, more studies are still warranted. Finding the optimal combination of opioid and non-opioid pain medication and local anesthetic delivered via suitable regional technique will improve the outcomes and lead to successful patient recovery.

Multimodal non-invasive non-pharmacological therapies for chronic pain: mechanisms and progress

BACKGROUND

Chronic pain conditions impose significant burdens worldwide. Pharmacological treatments like opioids have limitations. Non-invasive non-pharmacological therapies (NINPT) encompass diverse interventions including physical, psychological, complementary and alternative approaches, and other innovative techniques that provide analgesic options for chronic pain without medications.

MAIN BODY

This review elucidates the mechanisms of major NINPT modalities and synthesizes evidence for their clinical potential across chronic pain populations. NINPT leverages peripheral, spinal, and supraspinal mechanisms to restore normal pain processing and limit central sensitization. However, heterogeneity in treatment protocols and individual responses warrants optimization through precision medicine approaches.

CONCLUSION

Future adoption of NINPT requires addressing limitations in standardization and accessibility as well as synergistic combination with emerging therapies. Overall, this review highlights the promise of NINPT as a valuable complementary option ready for integration into contemporary pain medicine paradigms to improve patient care and outcomes.

Transcutaneous electrical nerve stimulation over acupoint for chronic obstructive pulmonary disease: A systematic review and meta-analysis

Background

Transcutaneous electrical nerve stimulation over an acupoint (acu-TENS), a new technique applied in pulmonary rehabilitation programs, has been gradually used in the management of chronic obstructive pulmonary disease (COPD). However, the effects of acu-TENS have not been fully evaluated. Therefore, this review was conducted to assess the effects of acu-TENS on COPD.

Methods

A total of seven electronic databases were searched from their inception to September 2021 for randomized controlled trials of acu-TENS for COPD. Two investigators independently performed data extraction and methodological quality assessment. Heterogeneity was examined by Cochrane χ2 and I 2 tests. The source of heterogeneity was investigated by subgroup analysis or sensitivity analysis.

Results

In our review, ten studies between 2008 and 2021 were included. The aggregated results indicated that acu-TENS showed positive effects in forced expiratory volume in 1 s (FEV1) [MD = 0.13 L, 95% CI (0.11-0.16), P < 0.00001], FEV1% predicted [MD = 5.92%, 95% CI (3.43-8.41), P < 0.00001], 6-min walk distance (6MWD) [MD = 14.68m, 95% CI (6.92-22.44), P = 0.0002], dyspnea visual analog scale (DVAS) [MD = -7.58, 95%CI (-14.33 to -0.84), P = 0.03], modified Borg scale (MBS) [MD = -0.46, 95% CI (-0.86 to -0.06), P = 0.03], and COPD assessment test (CAT) [MD = -4.25, 95% CI (-5.24 to -3.27), P < 0.00001]. Although six studies reported adverse effects, only one patient had shoulder pain after acu-TENS.

Conclusion

Acu-TENS seems to be effective in improving pulmonary function and health status in patients with COPD, with little effect on exercise capacity and dyspnea. However, this result should be interpreted with caution, and high-quality RCTs were needed for further verification.