Transcutaneous Electrical Nerve Stimulation (TENS)

Overview
⚫ In 1967, Wall and Sweet reported temporarily abolishing chronic pain by electrically stimulating
peripheral nerves via electrodes on the surface of the skin (<0.5 cm).
⚫ This technique soon became known as transcutaneous electrical nerve stimulation (TENS). (with low
frequency < 1000)
⚫ TENS treats the symptoms of pain much as pain medication does.
⚫ However, it needs to be emphasized the fact that TENS will not cure the underlying problem.
⚫ TENS is a technique-based intervention.
⚫ Users need to select the location of stimulation and choose different electrical characteristics of currents
(pulse amplitude, frequency, pattern and duration) to achieve successful treatment.
Theoretical Mechanisms for Pain Relief With TENS
⚫ Gated control theory
1. Melzack and Wall proposed (1965).
2. Four distinct components:
A. Afferent fibers (Aβ, Aδ, C).
B. Neural interactions within the dorsal horn of the spinal cord.
C. Transmission cells or T cells.
D. Descending controls from higher brain centers.

3. The gate is closed by large fibers activity tends to inhibit T cells via facilitation of the SG.
4. The gate is open with small fibers activity tends to facilitate transmission.
5. TENS stimulates large sensory fibers with frequency stimulation.
⚫ Endogenous inhibition
1. Based on the existence of natural opiates (pain suppressors) in the body.
2. Opiates are produced by the pituitary gland (beta endorphins) and in the spinal cord (enkephalins).
3. Stimulation of sensory nerves with low-frequency TENS stimulates the release of these opiates, thus
affecting the pain.
⚫ Enhancing blood flow in the skin and deeper tissues
1. TENS stimulation induces local vasodilation (sympathetic nervous system stimulation) that may
alter the circulation of trigger point, thus decreasing the pain.
2. Fatigue of muscle spasm produced by sustained muscle contraction may subsequently lead to
improved blood flow.
 3. Response to stimulation producing muscle contraction ay supply required oxygen and rid the area
of stimulating or sensitizing chemical mediators (muscle pumping).
⚫ Others
1. Affect the flow of energy (chi) → electroacupuncture (電針灸).
2. Placebo effect (安慰劑效應)
Types of TENS Techniques
⚫ Pulse waveform: monophasic, symmetrical biphasic (the most common), asymmetrical biphasic, or
spike-like biphasic pulse.

⚫ Conventional mode
1. High frequency: 60 pps – 150 pps (high frequency). → optimal for pain relief: 60 pps.
2. Short pulse width (duration): 50μsec – 100μsec.
3. Patient will experience a comfortable cutaneous stimulation (Aβ nerve) without muscle contraction
(relative low intensities).
4. The first choice in electrotherapeutic intervention for pain control.
5. It affects primarily the large-diameter myelinated afferent neurons (gate control theory).
6. Avoid accommodation → increase amplitude, frequency or pulse width.
7. Duration: 30 – 60 min in the home setting and can be repeated several times a day on the basis of
patient response.
8. Pain relief effects may be of shorter duration than other modes.
⚫ Strong low-rate mode (acupuncture-like mode)
1. Low frequency: below 10 pps, common in 1 pps – 4 pps.
2. Wide pulse width: 100μsec - 250μsec.
3. The pulse amplitude is set at a level to produce visibly strong and rhythmical muscle twitches. (the
intensity should be strong but within the patient’s comfort level)
4. This type of stimulation affects both sensory (Aδ nerves to produce brief sharp pain) and motor
nerves (stimulation of muscle contraction or twitches).
5. Proposed theory: endogenous inhibition.
6. The pain-relieving effects are usually of longer duration.
7. Should not be applied for longer than 45 min at a time → too long can result in delay-onset muscle
soreness (DOMS).
8. Primarily for control of chronic pain.
⚫ Brief-intense mode
1. High frequency: from 60 pps to more than 150 pps.
2. Wide pulse width: 50μsec – 250μsec.
 3. The pulse amplitude is set at a level to produce muscle contraction, with high settings yielding
uncomfortable tetanic muscle contractions and low settings yielding nonrhythmic muscle
fasciculation.
4. The output characteristics are most similar to the pulse-burst mode.
5. This mode is used in preparation for and during potentially painful medical procedures including
wound debridement, friction massage, joint mobilization, passive stretching, and more.

⚫ Pulse-burst mode (burst or pulse train mode)

1. The high carrier frequency is modulated by a low burst frequency.
2. Pulse duration: 50μsec – 200μsec.
3. The pulse amplitude can be set at high stimulation to produce intermittent tetanic muscle
contractions and paresthesia and at low stimulation to produce a sensation of paresthesia.
4. This type of TENS can offer the benefits of both high-rate conventional TENS and low-rate
acupuncture-like TENS.
5. Pain relief via the gating mechanism (high frequency) and the endorphin-mediated response (low
frequency).
6. It can be used to improve patient acceptance of high-amplitude stimulation, which induces muscle
beating associated with the strong low-rate mode.
⚫ Modulated mode
1. Automatically change one or more output (pulse duration, amplitude or frequency) by a given
percentage from an initially set level.
2. To prevent accommodation to stimulation or to improve patient tolerance.
⚫ Hyperstimulation mode (non-invasive electroacupuncture mode)
1. Pulse frequency: 1 – 4 pps.
2. Pulse duration: 500 ms.
3. Use 1 – 3 mm probe-type electrode.
4. It is the only mode that regularly utilizes either direct or monophasic pulse current.
5. This mode relies on high current density to produce very noxious cutaneous stimulation that is sharp
and burning in character, without resultant muscle contraction (Endorphin-mediated response).
 Type Frequency Pulse width 肌肉收縮 mode 止痛機制 作用
Conventional 60 – 150 pps 50 – 100 μs X N 門閥 快速止痛，容
(高頻短波寬) 易適應，第一
次使用
Strong low-rate 1 – 4 pps 100 – 250 μs V N 內生性鴉片 慢性疼痛，治
(針灸式，低頻 療時常<45
長波寬)
Brief-intensity 60 – 150 pps 50 – 250 μs V N 內生性鴉片 止痛、用於醫
療處理前
Pulse-burst 低頻(1 – 4 pps)內 50 – 200 μs V B 門閥 + 內 快速+慢性
帶高頻(5 – 100pps) 生性 止痛
Modulated mode 固定 固定 M 不容易適應，
耐受度高
hyperstimulation 1 – 4 pps 500 ms 放 在 motor X 內生性 唯一直流電，
point 就會收縮 電流高密度

Electrode Placement Options

⚫ Electrode site options for localized pain
1. TENS electrodes must be positioned o healthy innervated skin where sensation is intact, so it is
important to check skin sensation prior to application.
2. Single or dual channel the electrodes should be at least 1 inch apart.
3. Just proximal to the site of pain → useful if pain arises from a distal extremity location.
4. Just outside the proximal and distal margins of the painful region (brackets).
5. One electrode over site of pain, the other over the related spinal nerve root.
6. Distal to the site of pain (more limited effectiveness).
7. Crisscross placement (modified interferential technique) → the most commonly used.
8. Dermatomal distribution of the nerve involved.
9. Segmentally related myotomes.
⚫ Specific stimulation sites
1. Motor point: low-frequency TENS can evoke muscle contraction.
2. Trigger point: one electrode may be placed over the trigger point while the other is located at the
reference zone.
3. Acupuncture point
→ electrodes are placed on a single point or on multiple points simultaneously along the acupuncture
 meridian that passes through the painful area or points on the auricle (electroacupuncture).
4. A specific peripheral nerve that innervates a painful region can be targeted for stimulation, especially
where located superficially.
 Electrodes from one channel may be placed at varying distances apart along the course of a nerve.
 Two electrodes can be used to simultaneously stimulate two peripheral nerves.
5. Contralateral placement to a painful region
 Limited sensation, skin irritation, herpes zoster (帶狀泡疹), post-herpetic neuralgia, causalgia,
phantom pain (幻痛), even or casting.
Principles Underlying Applications of TENS
⚫ Indications
1. Acute / chronic pain, arthritic pain, peripherally neurologic pain, and cancer-related pan,
postoperative pain, menstrual pain, phantom pain, obstetric pain, cardiopulmonary pain.
2. Preceding potentially painful interventions to elevate the patient’s pain threshold (stretching a
contracture, wound debridement).
⚫ Contraindications
1. Demand-type cardiac pacemaker or unstable arrhythmias.
2. Stimulation over the carotid sinus may induce an acute hypotensive response, or fainting: electrodes
should not be placed on the anterior neck.
3. Venous or arterial thrombosis or thrombophlebitis.
4. Pelvis, abdomen, trunk and low back during pregnancy.
⚫ Precautions
1. Undiagnosed pain syndrome, eyes, internal mucosal membrane, over open wounds, impaired
sensation, cardiovascular problems, epilepsy (癲癇) and seizure disorder, stimulation on the head or
upper cervical region, confused or incompetent patient, while operating a motor vehicle or other
hazardous equipment.
2. Cardiac problems: electrodes should not be placed on the anterior chest wall.
⚫ Critical evaluation of TENS use
1. Skin care
 Prevention of adverse skin reactions (allergic, chemical and electrical factors).
 Prior to treatment, electrode sites should be inspected for cuts and abrasions: focal paths of low
impedance that produce high-density electrical currents.
 Regular inspection of the patient’s skin and use of alternate electrode sites may minimize the
occurrence of irritation from most of these factors.
2. Combination of TENS modes with electrode placement options
 The ranking order for most accepted TENS modes: conventional > modulated > pulse-burst >
strong low-rate > brief-intense > hyperstimulation.
 Conventional TENS and low-amplitude formats of pulse-burst and modulated modes can be done
using all of the previous electrode sites.
 Higher-amplitude stimulation (strong low-rate, brief intense, pulse-burst, and modulated TENS)
that involves muscle contraction must stimulate the muscle via a peripheral nerve or motor point
(motor-level stimulation).