What is the value of Transcutaneous Electrical Nerve Stimulation (TENS) in controlling secondary back pain in patients with lymphoma?

TENS for Secondary Back Pain in Lymphoma Patients

TENS can be considered as part of a multimodal pain management approach for lymphoma patients with secondary back pain, but should never be used as standalone therapy and must be combined with appropriate oncologic treatment, physical therapy, and other analgesic interventions. 1

Primary Treatment Considerations

The most critical issue in lymphoma patients with back pain is identifying and treating the underlying cause, not just managing symptoms:

• Back pain in lymphoma patients warrants urgent evaluation for spinal cord compression, which occurs in 5-11% of lymphoma cases and represents a medical emergency requiring immediate radiation therapy or surgical decompression 2, 3, 4
• Characteristically, patients with lymphoma-related spinal cord compression complain of back pain several months before developing neurological symptoms 2
• Only one-third of patients have positive spine radiographs at the time of spinal cord compression, making CT or MRI essential for patients with lymphoma suffering from back pain 2

TENS as Adjunctive Therapy

Guideline-Based Framework

TENS is explicitly recommended in oncology guidelines as one physical modality option for cancer-related pain management, but with important caveats 1:

• The NCCN recommends TENS among non-pharmacologic rehabilitation interventions and modalities for pain management, alongside movement-based therapies 1
• TENS should be part of multimodal pain management for chronic back pain, not used as monotherapy 5, 6
• The American Society of Anesthesiologists supports TENS as part of multimodal approaches for chronic back pain 5, 7

Evidence Quality and Limitations

The evidence base for TENS effectiveness is notably weak:

• Insufficient evidence exists to determine TENS effectiveness for acute or subacute low back pain according to the American College of Physicians 5
• For cancer-related pain specifically, evidence is inadequate with contradictory results from only three small randomized controlled trials involving 88 cancer patients total 7
• TENS must be combined with exercise, physical therapy, and medications rather than used alone 5, 6

Practical Implementation Algorithm

If TENS is used in lymphoma patients with secondary back pain:

1. First, rule out spinal cord compression with MRI or CT imaging, especially if neurological symptoms are present 2, 3
2. Initiate definitive oncologic treatment (radiation, chemotherapy, or surgery as indicated) for the underlying lymphoma-related pathology 2, 3, 8
3. Refer to physical medicine and rehabilitation for comprehensive pain management planning 1
4. Implement TENS only as one component of a multimodal regimen that includes:
   • Appropriate analgesic medications 1
   • Physical therapy and therapeutic exercise 1
   • Other physical modalities (massage, heat/ice, positioning) 1
   • Energy conservation and pacing strategies 1

Important Clinical Caveats

• Approximately one-third of patients experience mild skin irritation at electrode sites with TENS use 5, 6, 7
• TENS provides at best modest short-term pain reduction (mean 1.94 cm on 10-cm pain scale) with low-certainty evidence 6
• The primary focus must remain on treating the underlying lymphoma and preventing or managing spinal cord compression, which has a median survival of 30 months when occurring at relapse but significantly better outcomes when detected at initial presentation 2
• High-dose, short-term radiation (5 Gy × 5-6) is as effective as low-dose, long-term treatment for lymphoma-related spinal cord compression, with approximately 90% response rates 2