Transcutaneous
Electrical Nerve
Stimulation (TENS)
Electrotherapy I PST 313
Introduction
• TENS is a non-invasive, safe, easy-to-use, and low-cost technique to control
pain
• It is a method of electrical stimulation to the skin through surface electrodes
• It primarily aims to provide a degree of symptomatic pain relief by exciting
sensory nerves
Introduction
• It stimulate nerve fibers to produce different physiological effects
• It is achieved through either the pain gate mechanism and/or the opioid
system
Introduction
• The first TENS units were developed and became popular after
publication of the pain gate theory by Melzack and Wall in 1965
• TENS is currently one of the most frequently used electrophysical
agents to relieve acute and chronic pain.
MECHANISM OF ACTION
• The type of stimulation delivered by the TENS unit aims to stimulate the
sensory nerves
• Which activate specific natural pain relief mechanisms
• There are two primary pain relief mechanisms which can be activated:
1. The Pain Gate Mechanism
2. The Endogenous Opioid System
Pain gate theory
• Stimulation of large-diameter afferents inhibits nociceptive fiber-evoked responses
in the dorsal horn
• Pain relief by means of the pain gate mechanism involves activation of the A beta
(Aβ) sensory fibres
• Which reduces the transmission of the noxious stimulus from the C-fibres through
the spinal cord
• And then on to the higher centres
• The Aβ fibres appear to appreciate being stimulated at a relatively high rate (80 -
130 Hz).
The Endogenous Opioid System
• This involves the activation of peripheral and CNS opioid receptors
• This is to stimulate the A-delta (Aδ) fibres which respond preferentially to a
much lower rate of stimulation (2-5 Hz)
• This will activate the opioid mechanisms
• Causing the release of an endogenous opiate (encephalin) in the spinal cord
• Then reduce the activation of the noxious sensory pathways and provide
pain relief
• It is difficult to find support for the concept that there is a single
frequency that works best for every patient, but this range appears to
cover the majority of individuals
Combination
Physical Principles of TENS
• TENS is not a specific type of equipment or electric current
• It is a method of activating nerve fibers by delivering electrical impulses
through the skin using surface electrodes
• TENS units traditionally emit two basic types of electric current:
a. A rectangular biphasic symmetrical pulsed current
b. A biphasic asymmetrical balanced pulsed current.
Physical Principles of TENS
• Both types of electric currents are considered non-polarized
• They have no sustained polarity
• Hence, used for long periods of time without presenting the risk of
chemical burns to the skin
Types of TENS
• There are two major types of TENS
1. High TENS
2. Low TENS
HIGH TENS
• Stimulation at a relatively high frequency (80 - 130Hz)
• A relatively narrow pulses (50–200μs)
• 30 minutes is probably the minimal effective time, but it can be
delivered for as long as needed.
• The main pain relief is achieved during the stimulation
• Limited ‘carry over’ effect – i.e. pain relief after the machine has been
switched off
• TENS in this mode is most effective during the intervention
Low TENS
• Lower frequency stimulation (2-5Hz)
• Wider pulses (200-250µs)
• 30 minutes will need to be delivered as a minimally effective dose.
• It takes some time for the opioid levels to build up
• Hence, the onset of pain relief may be slower than with the high TENS
Low TENS
• Once sufficient opioid has been released however, it will keep on working
after cessation of the stimulation.
• The ‘carry over’ effect may last for several hours, though the duration of this
carry over will vary between patients.
• Many patients find that stimulation at this low frequency at intervals
throughout the day is an effective strategy.
Electrode Placement
• The most common technique is placing the electrodes on either side of
the lesion or pain areas
Electrode Placement
• In order to get the maximal benefit from the modality
• The stimulus is targeted at the appropriate spinal cord level
(appropriate to the pain)
Electrode Placement
• Stimulation of appropriate nerve root(s)
• Stimulate the peripheral nerve (best if proximal to the pain area)
• Stimulate motor point (innervated by the same root level)
• Stimulate trigger point(s) or acupuncture point(s)
• Stimulate the appropriate dermatome, myotome or sclerotome
Electrode Placement
• A two channel application can be applied If the pain source is vague,
diffuse or particularly extensive
• A two channel application can also be effective for the management of a
local and a referred pain combination
• One channel used for each component
• The low frequency TENS can be effectively applied to the contralateral
side of the body
Indications
• Acute pain
• Chronic pain
• Low back pain
• Osteoarthritis pain
• Diabetic peripheral neuropathy
Contraindications
• Undiagnosed pain
• Pacemaker or other active implants
• Pregnancy
• Carotid sinus
Contraindications
• Damaged skin
• Patients with impaired cognition
• Thrombosis or thrombophlebitis
• Hemorrhage
• Malignant tumors
PRECAUTIONS
• Electrodes should not be placed over the eyes
• Epilepsy
• Reproductive organs
• Lack of normal skin sensation: If there is abnormal skin sensation, the
electrodes should preferably be positioned elsewhere to ensure effective
stimulation
• The use of abdominal electrodes during labour may interfere with foetal
monitoring equipment and is therefore best avoided
