% 1 10 Transcutaneous Electrical Nerve Stimulation (TENS) ara eel aN 3 Y Introduction Y Advantages of TENS ¥ Definition ¥ Disadvantages of TENS y Terminology ¥ Indications yY Principle Y Precautions ¥ Equipment Y Contraindications ¥ ModefTechniques of TENS Y Applications of TENS ¥ Theories of pain control using TENS _¥_ Safety protocols for TENS ¥ Methods of application of TENS v Electrode placement chart Y Electrode placement v References INTRODUCTION TENS is a low frequency modality, which is a non-invasive analgesic technique, which is used to relieve nociceptive, neuropathic and musculoskeletal pain. ! DEFINITION Transcutaneous Electrical Nerve Stimulation (TENS) is the application of electrical stimulation to the skin via surface electrodes to stimulate nerve fibers, primarily used for relief of pain. TENS is often generated by a battery operated small machines. TERMINOLOGY TENS — Transcutaneous Electrical Nerve Stimulation — 4PE setts of etectrotherany ‘TNS - Transcutaneous Nerve Stimulation TES - Transcutaneous Electrical Stimulation ae t (sensory) stimulation for pain management. It is a technique of TENS provides afferent Censor? sensory pathways by modifying the impulse, neuro-modulation that affec EQUIPMENT ahd i i i battery powered pulse gene; Transcutaneous Electrical Nerve Stimulator consists ofa ; ator with two circuits will have four carbon rubber electrodes. Different types of TENS, apparatuses are available. Most commonly used waveform shape is symmetrical, biphasic, (1 rectangular shape. 1. Output intensity 0-80 mA Display unit 3, Pulse duration/Pulse width’S0-250 pS 4. Duration of treatment 20-60 min, 2. Pulse rate/pulse frequency 2-150 Hz 5. Mode: Burst, modulated, continuous Figure 10.1: General parameters on modern TENS device. MODES OF TENS !")4,51 1. Conventional TENS/High TENS. 2. Acupuncture like TENS/Low TENS. 3. Burst TENS. 4. Brief Intense TENS. 5. Modulated TENS. 1, vi ntional TENS/High TENS: This mode of TENS is the most commonly used technique and it is selected as the first line of option for most of the patients. High Frequency: 90-130 Hz. |" Transcutaneous Electrical Nerve Stimulation (TENS) Low intensity stimulation: It produces sensory stimulation (Paraesthesia/prickling and tingling sensation, non-noxious stimulation). (30 mA) short Pulse Duration: 150 ps. Treatment time: 20-60 minutes. uses: Acute pain relief, post-surgical pain relief. Electrode placement: Over dermatome. Mechanism of Pain Relief: High TENS primarily activates large diameter, low threshold, non-noxious afferents AB fibres and pre synoptically suppresses the A6 fibres at the substantia gelatinosa of dorsal gray horn cells of the spinal cord (pain gate mechanism). Thus, there is rapid onset of pain relief but temporary analgesia. High TENS also work by elevating the release of inhibitory neurotransmitters such as gamma amino butyric acid (GABA) and serotonin and reducing the release of excitatory neurotransmitters such as glutamate and aspartate. ike TEN! TENS: It is a form of hyper stimulation and it can ” be used if patients do not respond to the High TENS. Low Frequency: 2-4 Hz. High intensity: It will produce noxious sensation and muscle twitch (approximately >30 mA). Longer Pulse Duration: 200 us. Treatment time: 30 minutes. Electrode placement: Over the muscles, acupuncture points, trigger points. Uses: Chronic musculoskeletal pain relief. Mechanism of pain relief: Primarily stimulates small diameter, high threshold AS fibres, C fibres and small motor fibers, furthermore it activates extra segmental descending pain inhibitory pathways. This mode of TENS is believed to operate primarily through descending pain suppression system/ Endogenous opiate mechanism. Thus there is slow onset of pain relief but relatively longer analgesia, usually lasts longer than conventional TENS. . Burst TENS: Burst mode has high frequency trains of pulses delivered at a low frequency. Burst mode is a combination of conventional TENS and acupuncture like TENS and comprises a base line low frequency current together with high frequency trains. The frequency of train of (series) of pulse is 1-5 Hz with the internal frequency of trains around 100Hz. Intensity: High. Mechanism of pain relief: Burst TENS stimulates both the small diameter (AS fibres) and large diameter (Af fibres) at the same time.Burst mode TENS is comfortable over acupuncture TENS because the pug, produce a comfortable muscle contraction. Both routes pain relief (pain ing mechanism and endogenous opiate mechanism). Bate 4 z 5 a > High TENS . Time 4 2 2 2 + Low TENS & 7 Time 4 2 é 2 Burst TENS = Time 4 AN gH * Modular TENS = Time Figure 10.2: Waveforms of modes of TENS. 4. Brief Intense TENS: The brief duration of application and the stimulus intensity is higher than in the other modes, producing a somewhat brief yet intense stimulation during treatment. High frequency: 100-150 Hz. High tolerable intensity given for a short period of time (< 15 minutes duration) Long pulse duration: 150 ~ 250 ps. Uses: Post operative conditions, Local painful conditions. Mechanism of pain relief: Simulates small diameter, high threshold cutaneous afferents A6 fibres blockade and elicits peripheral nerve activate extra segmental analgesic mechanism. Modulated TENS: Modulation means, there is variation in frequency, amplitude, and pulse duration in a cyclical fashion. Sometimes some units have modulationTrans ic vy. cutaneous Electrical Nerve Stimulation (TENS) LLL Continuous Burst Frequency modulation = - | | ll JUL ULL ULI AUNT ULL). esse wlll ith willl Figure 10.3: Waveform characteristic features of TENS. Amplitude modulation Table 10.1: Shows the features of various modes of TENS. Conventional/ | Acupuncture Brief Intense TENS | Burst Modulation High TENS Like TENS/ TENS Low TENS) High (>80 Hz) | Low (<10Hz) | High (>80 Hz) Low (<10 Hz) variable Comfortable Comfortable/ Comfortable/ Comfortable/variable tolerable tolerable —T Pulse duration | Short Long Long Variable (<150 psec) | (>150 psec) (>150 psec) Duration of | 20-60minutes | 30-40minutes | 15 minutes 20-30 minutes treatment Experience of ‘| Tingling Strong, Uncomfortable, Variable the patient | sensation, comfortable Noxious Paraesthesia. | muscle twitching he1. i wi Long(> 1Hour) | Long(> Few hours) (> Fewhours) Both acute and chronic pain relief Gate control mechanism of pain using TENS: Pain transmission occurs through small diameter, slow conducting and nociceptive nerve fibres (Ad, C fibres). High TENS stimulates mechanoreceptors and activates the large diameter, fast conducting through highly myelinated, proprioceptive sensory nerve fibres (AB fibres) (substantia gelatinosa- T cells), thereby pre synaptically inhibited/ gating the pain transmission of Aé fibers at spinal cord level (segmental analgesia). (6.71 High TENS/Conventional TENS + Stimulation of mechanoreceptors and activates AB fibres Superimposes Aé fibers (fast pain) at substantia gelatinosa Pre-synaptic inhibition of A6 fibres/acute pain relief.Transcutaneous Electrical Nerve Stimulation (TENS) Paraesthesia Mechano stimuli (High TENS) AB fibers @ @ | Dorsal column LsT OF sp.wip 9 © @ SG in spinal cord Noxious stimuli Aé and C fibers > Figure 10.4: High TENS pain modulation at the spinal cord level using pain gate control mechanism. 2. Opiate mediated control system: Low TENS produces muscle twitches to brows stimulate free nerve endings and activates the small diameter, slow conducting, ) Hig pain, sensory nerve fibres (Aé fibres) and small diameter motor afferents causes fe activation of interneuron and release of encephalin and endorphins from substantia msi gelatinosa to elicit presynaptic inhibition of C fibres pain /chronic pain relief. 7:81 ea Low TENS/Acupuncture TENS 2). 1 Stimulation of AS fibres V Activation of interneuron L Release of encephalin and endorphins from substantia gelatinosa L Presynaptic inhibition of C fibres pain/chronic pain reliefmas Essentials of Electrotherapy Mechano stimuli Bry (Low TENS) LF Asfibers Gain ®, Endorphins 6 sr @ ® b OS se.vir > ® Muscle twitch paraesthesia @®|] Dorsal column ® Spinal cord Noxious stimuli AB and C fibers Figure 10.5: Low TENS pain modulation at the spinal cord level using opiate mediated mechanism. a ee mecree menanen. METHODS OF APPLICATION OF TENS 1. Sensory Level Stimulation: High TENS/Acute Pain. 2. Motor Level Stimulation: Low TENS/Chronic Pain. 3. Noxious Level Stimulation: Brief Intense TENS/both Sensory and Motor Stimulation. ELECTRODE PLACEMENT * Over the most intense pain/greatest tender points. * Within the same dermatome, myotome. * Trigger point. * Acupuncture point proximal to the point of pain. * Acupuncture point distal to the point of pain. * Stimulation of peripheral nerves, (superficial areas) for neurogenic pain. * Over the spinal nerve roots close to the vertebral column. Cathode proximal t0 anode (near to spinal cord). * Transarthral placements at the sites of joints. * Contra lateral placements are suggested when the pain site is not accessible due amputation, dressings, open wounds and casts,'d Motor je duel we Transcuta meous Electrical Nerve Stimulation (TENS) the choice of electrode position is often ide: tific i 1 oi of pany ified by trial and error by effective result oxi plectrode fixation: Wet with saline solution and secure ¢] sondage: ‘ Ap lication: Cathode is placed distal to the jaced near pain. lectrodes with velcro straps/ Pain, anode over the site of the pain or diagonally Pl OF TENS + Itisa simple, non-invasive, portable device, «tis an inexpensive and self-administered technique, «TENS is user friendly and safe to be used at home. « The precautions and contraindications associated with TENS are very few and largely based on common sense. - + Very minimal side effects. + TENS is non-addictive. DISADVANTAGES OF TENS Minimal skin irritation happens due to allergic reaction following application’ of the adhesive tape, conducting gel. + Acute pain (9! * Post operative incision pain. !!011 * Labour pain. [12,13] * Primary dysmenorrhoea. !"41 * Myofascial pain dysfunction. I * Chronic pain [1617] * Pain of arthritis. !81 (Osteo Arthritis, 9! Rheumatoid Arthritis 7). Chronic musculoskeletal pain. !!1 (Chronic low back pain, !@21 neck pain 1) * Stump pain and phantom limb pain. I * Diabetic neuropathy. 1 * Radiculopathies. (71 * Complex regional pain syndromes. 5)Essentials of Electrotherapy Trigeminal neuralgia, 1 Fibromyalgia, !! Caner pain (8 Spasticity in stroke patients, !52 33] Relief of pain in palliative care/terminally ill. CONTRAINDICATIONS®!! Do not apply over the demand type of cardiac pacemaker. It can interfere the function of pacemaker. with Electrodes should not be placed directly over the carotid artery (sinus antero lateral region of the neck, There is a potential risk that stimulatio, site might cause acute hypotension through a vasomotor reflex, Altered sensation. Example: In case of nerve lesions or neuropraxia it may cay. burns. * Placement of electrodes on infected skin. Over abdominal, lumbosacral or pelvic regions during pregnancy other than for Labor/delivery. Because it may induce premature labor. ) in the Mat this Someone with venous or arterial thrombosis or thrombophlebitis. Someone with indwelling phrenic nerve or urinary bladder stimulators, Near operating short wave diathermy device. Around the head. On the eyes. Over the active tumour. Over the mucosal surfaces. Do not apply over the damaged skin. Electrodes across the chest of a patient with cardiac disease. PRECAUTIONS Never apply TENS for undiagnosed pain. TENS is designed for external use only. Keep out of the reach of children. Areas of skin irritation, damage or lesions. Athletes should not be permitted to participate in sports while under the influence of TENS analgesia.srserneeeestrreyus ectrical Nerve Stimulation (TENS) . ants with diagnosed mali atientS with diag Ngnancies that have beer | fore vin. ave been diagnosed as terminal psychogenic P roa of Sensory TOSS does not respond well, permatitis in prolonged use. jpssues Vulnerable to hemorrhage or hematoma. sme caution is needed with patients taking narcotic medi ave hyposensitive areas. ication or who are XTIONS OF TENS 1 Obstetrical TEN’ Form of analgesia during delivery of a baby. 1 stage? Large sine electrodes are placed on T8-L1 para vertebral region (immediately after e onset of labour pain) with the frequency of 120Hz and the pulse duration of 150 pisec. Electrodes are positioned to target afferents active during distension of cervix and lower uterine segment. pv stage: Large size electrodes are placed on 2-4; electrodes are positioned to target afferents active during distension of pelvis and perineum. 3 stage: Remove the distal 2 electrodes and relocate to anterior abdomen V shape-pubic triangle. After the delivery: Electrodes are positioned on proximal thoraco-lumbar region. After the caesarean delivery: Frequency is fixed at 80-120Hz, with the comfortable stimulus intensity and the pulse duration of 150 yssec, for Thour/ 4 times daily. pxtre Ast stage of labour 2nd stage of labourPETTY ncn 2. TENS application for Post-operative Pain: sect pan i laced parallel, one j Electrodes placement: Large sized electrodes are placed parallel, one inh, from the incision site and crisscross pattern. fa) (b) HI She Figure 10.7 (a) & (b): Parallel and crisscross electrode placement to the incision site, 3. Effect of TENS on Spasticity: Neurophysiology background: A normal stretch reflex is modulated, inhibiteg or facilitated by the higher centers of the brain; but if this connection is damaged, spasticity is the result. Spasticity is therefore mostly due to an excess of impulses from c-motor neurons due to a spinal cord injury or brain injury. TENS is though; to reduce spasticity by reducing/inhibiting excessive c-motor neuron activity.'« “I This inhibition is accomplished by stimulating the Ia afferent nerve of the muscle that is antagonist to the spastic muscle. For example, stimulate the peroneal nerve to inhibit soleus/ gastrocnemius spasticity. Parameters used for spasticity control are that of conventional TENS. SAFETY PROTOCOLS FOR TENS APPLICATION © Check the contraindications with the patient. ‘* Test skin for normal sensation using blunt/sharp test. © Set electrical characteristics of TENS while the device is switched off. * Connect electrodes to pins on lead wire and position electrodes on the patients | skin. + Ensure TENS device is switched off and connect the electrode wire to the TENS device. * Switch the TENS device ON. © Gradually increase the intensity until the patient experiences the first “tingling sensation from the stimulator.Transcutans eous Electrical Nerve Stimulation (TENS) Gradually increase the intensity furthe: sh " T unti 0 crmnfortable’ tingling sensation, il the patient experiences a‘strong but This intensity should not be painful or caus ause TENS or Acupuncture Like-TENS are being muscle contraction (unless Intense used), yL FOR THE SAFE TERMINATION OF TENS Gradually decrease the intensity until the pati i a patient c ingli i ST TENS Seven experiences no tingling sensation. | pisconnect the electrode wire from the TENS device «Disconnect electrodes from the pins on the lead wire 4 Remove the electrodes from the patient's skin, @UECTRODE PLACEMENT CHART Trigeminal Cervical neuralgia radiculopathy Shoulder pain Stump neuroma and Phantom pain Carpal | tunnel Low back pain syndrome Dismenorrhoea Hip pain Knee pain Peripheral neuropathy Most commonly used TENS electrode placement sites. DOCUMENTATION TIPS FOR TENS Type of Stimulator: Portable Battery operated T Modes of TENS: Conventional TENS/Acupunc! TENS. ENS/Line powered TENS. ture TENS/Brief Intense TENS /Bur:Essentials of Electrotherapy Treatment area: Electrode arrangement: Bipolar method/Quadripolar method. Parameters: Frequency: Hz. Intensity: ma. Pulse duration: is, Type of TENS: Continuous/Burst. Electrode placement: Around the painful area over the painful area/ over the dermatomy over the tender points/ acupuncture points. . Treatment Duration: Minutes. Number of treatments per day: SUMMARY OF TENS TENS stands for transcutaneous electrical nerve stimulation. Definition: Electrical impulses are allowed to pass through the skin in order to excite the nerve. Uses: Acute pain, chronic pain, effective in managing pain associated with trauma, surgery, sprain, strain, rheumatoid arthritis, neuralgia. Mechanism of action: High TENS-Gate control mechanism, Low TENS- Opioid release mechanism and Descending inhibition mechanism. Modes of TENS: High TENS, Low TENS, Burst TENS, Brief Intense TENS and Modulated TENS. Advantages: * Itis anon invasive therapy used to control pain. © Safe. * Minimal side effects. ¢ Non-addictive. * Cost effective. Contraindications: * Cardiac pacemaker * Diabetic pumps. ¢ Seizure disorder. © Over the heart, throat, brain or spinal cord. Side effects: Skin irritation under the electrodes. * Defibrillator. * Pregnant women.