Percutaneous Versus Transcutaneous Electrical Nerve Stimulation for the Treatment of Musculoskeletal Pain. A Systematic Review and Meta-Analysis

Background The justification for this review is the need for high-quality evidence to assist in the decision-making process when applying percutaneous electrical nerve stimulation (PENS) or transcutaneous electrical nerve stimulation (TENS) in a clinical setting. The main aim was to determine if the use of PENS is more effective and should be recommended when compared to TENS for the reduction of musculoskeletal pain intensity. Methods A search for randomized controlled trials (RCTs) was performed. Studies published until 31/12/2020, comparing the effectiveness of PENS and TENS, were considered. The main outcome was pain assessed with a visual analog scale or numerical pain rating scale. Results Nine RCTs were included in the qualitative analysis, with seven of them in the quantitative analysis (n = 527). The overall effect of PENS on pain was statistically but not clinically superior to TENS (mean difference [MD]=-1.0 cm; 95% confidence interval [CI]: -1.5 to -0.4) with a high level of heterogeneity (I-2=76%, P > .01). When only studies with a lower risk of bias (n = 3) were analyzed, the heterogeneity decreased to I = 0% (P = .06) and no difference was observed between TENS and PENS (MD=-0.81 cm; 95% CI:-1.6 to 0.02) with a moderate recommendation level according to GRADE. There were no data concerning adverse effects. Conclusions There is low-quality of evidence for more pain intensity reduction with PENS, but the difference was not clinically significant. However, when only studies with low risk of bias are meta-analyzed, there is a moderate quality of evidence that there is no difference when TENS or PENS is applied for pain intensity.