TRANSCUTANEOUS

ELECTRICAL NEUROMUSCULAR
STIMULATION
Definition
 Transcutaneous Electrical Nerve Stimulation (TENS) is a
method of electrical stimulation which primarily aims to
provide a degree of pain relief (symptomatic) by
specifically exciting sensory nerves and thereby
stimulating either the pain gate mechanism and/or the
opioid system.

Sreeraj S R
Mechanism of Action
Possible Pain-Relieving Mechanisms;

 Activation of ‘pain-gating’ mechanisms.

 Stimulation of the descending pain suppression system
and endogenous opiate mechanisms.
 The Central Biasing Theory
 Removal of the substances which stimulate pain nerve
endings from within the damaged area

Sreeraj S R
 Primary afferent fibres

Sreeraj S R
4/4/2020
Ascending Pain Pathway

DRG: Dorsal Root Ganglion,
The spinothalamic PAG: Periaqueductal Grey Matter

transmits
tract: signals that are
important for pain localisation.

 The spinoreticular tract:diffuse network

of neuron which extends from medulla
below to thalamus above This pathway
is involved in the emotional aspects of
pain. The major role of these fibers
is thought to be
arousal rather than
discrimination per se

Sreeraj S R
4/4/2020
 Inhibition of pain
 Gate control theory of pain
transmission
 The gate control theory of pain
was proposed by Melzack and
Wall in 1965
 It describe a process of inhibitory
pain modulation at the spinal cord
level.
 By activating Aβ fibres with
tactile, inhibitory inter neurones
in the dorsal horn are
activated leading to inhibition
of pain signals

Sreeraj S R
Inhibition of pain transmission
Descending inhibition
 ThePeriaqueductal Grey (PAG) in
the midbrain and the Rostral
Ventromedial Medulla (RVM) are
involved.
 These centres high
contain
concentrations of opioid receptors
and endogenous opioids.
 Descending pathways project to the
dorsal horn and inhibit pain
transmission.
 These pathways are monoaminergic,
which modulate the serotonin,
dopamine, norepinephrine, and/or
histamine neurotransmitter systems
in the brain.
4/4/2020 Sreeraj S R
Opiate-mediated control
 Endogenous opioids
 Endorphins
 Dynorphins
 Enkephalins
Neurophysiology background:
 The brain can secrete its own analgesic substance such
as endorphins to modulate pain.
 Endorphins are neuropeptides that act on the CNS and
peripheral nervous system to reduce pain.
 They have the similar pharmacological effect as
morphine.

Sreeraj S R
Parameters used for TENS
 Waveforms
 Frequency or Rate
 Pulse width or Duration
 Amplitude or Intensity

Sreeraj S R
 Wave forms
 Square / rectangular Triangular / spike
 Instantaneous rise  Rapidly rising, but
not instantaneous
 Less irritating as
 More skin irritating
skin sine wave therefore requires
approaches frequent movement of
 form
For damage electrodes or shorter
nerve with pain treatment times to avoid
associated skin irritation
 pathology
For hypersensitive  For acute pain or resistant
tissue
and chronic pain patients
 Immediate, short lasting
 Delayed, long- pain relief
lasting analgesia
4/4/2020 Sreeraj S R
 Frequency or Rate
High Frequency (80-120):
 Large myelinated fibers respond effective > 100Hz
 Immediate relief of pain
 Acute pain

Low Frequency (1-20):

 Small unmyelinated fibers respond effectively at <100Hz
 Increase endorphin production, thus analgesia following stimulation
 Chronic pain

Sreeraj S R
Pulse width or Duration
Pulse width Indications

50μs Large myelinated fibers (sensory

touch)
100 - 150μs Normal neuromuscular system

200 μs Small myelinated fibers

200 – 300 μs Patients with neurological damage

Sreeraj S R
Amplitude or Intensity
 TENS units intensity ranges form 1 mA to 100 mA
 TENS is only effective when the patient actually feels
the stimulus
 Patients need to increase the intensity when the body
accommodates to the stimulus (when they don’t feel the
stimulation anymore)
 Dying batteries can cause fading intensities

Sreeraj S R
Types of TENS
 Conventional TENS or High Frequency TENS

 Acupuncture-like TENS (AL-TENS) or Low Frequency TENS

 Brief TENS or Intense TENS

 Burst TENS

 Modulated TENS or Modified TENS

Sreeraj S R
Conventional or High TENS
 Frequency – 50 Hz to 100 Hz
 Pulse Width – 20 μs to 60 μs
 Intensity – (0 mA to 30 mA).
 The intensity until a prickling or tingling sensation is felt.
 Principle –Presynaptic inhibition by pain gate
mechanism by stimulating Aα and Aβ fibres.
 Duration – 30 to 60 minutes once or
twice daily.

Sreeraj S R
 Acupuncture or Low TENS
 Frequency – 1 Hz to 4 Hz
 Pulse Width – 150 μs to 250 μs
 Intensity – 30 mA to 60 mA.
 applied to acupuncture points or motor points of muscle in the
segmentally related myotome.
 Principle –This stimulates the high threshold Aδ and C fibres,
which lead to release of endogenous opioids and provides further
sensory input from muscle spindle afferents (chemical theory).
 Duration – 20 to 30 minutes once a day.

Sreeraj S R
Burst TENS
 Burst TENS is a series of pulses (i.e. a train), repeated 1-
5 times a second, commonly twice.
 Each train or burst consists of a number of individual
pulses at the usual conventional TENS frequencies of 50
Hz to 100 Hz but at higher intensity.
 It combines both the conventional and acupuncture-like
TENS and
 therefore provides pain relief by both routes.

Sreeraj S R
Brief or Intense TENS
 Frequency – More than 100 Hz
 Pulse Width – 150 μs to 250 μs
 Intensity – Highest level tolerated by the patient.
 Principle –Activity in cutaneous Aδ afferents induced by
intense TENS produce peripheral blockade of nociceptive
afferent activity (Central biasing mechanism).
 Duration – 30 to 60 minutes once or twice daily.

Sreeraj S R
Modulated or Modified TENS
 In modulated TENS the pulse length, frequency, and
amplitudes can be constantly and automatically varied.
 This cyclical variation is believed to prevent adaptation of
the nerves to the current (no accommodation)
 is particularly appropriate as a variant of conventional
TENS used over long periods.

Sreeraj S R
Electrode Placement

Sreeraj S R
Electrode Placement

Sreeraj S R
 Electrode Placement

The position of electrodes and electrical characteristics of TENS

when used to manage labour pain

Sreeraj S R
 Electrode Placement

4/4/2020 Sreeraj S R
 Contraindication
 Someone with a pacemaker
 Someone with undiagnosed pain.
 Someone with a heart condition
 On head or neck of someone with epilepsy
 Someone with venous or arterial thrombosis or thrombophlebitis
 Someone with indwelling phrenic nerve or urinary bladder
stimulators
 Near operating diathermy device

Sreeraj S R
 Contraindication
 Around the head
 On the eyes
 Over mucosal surfaces
 Using electrodes on infected skin
 Electrodes across the chest of a patient with cardiac disease
 Electrodes should not be placed near carotid artery in the
anterolateral region of the neck. There is a potential risk that
stimulation at this site might cause heart block by exciting the
vagus nerve.

Sreeraj S R
 Precautions
 Areas of skin irritation, damage or lesions
 Areas with impaired sensation
 Over abdominal, lumbosacral or pelvic regions during pregnancy
other than for labor/delivery
 Tissues vulnerable to hemorrhage or hematoma
 Athletes should not be permitted to participate in sports while
under the influence of TENS analgesia
 Extreme caution is needed with patients taking narcotic
medication or who are known to have hyposensitive areas.

Sreeraj S R
Precautions
 Incompetent patients may not be able to manage the device and it must be kept
out of reach of children.
 For patients with diagnosed malignancies that have been diagnosed as
terminal, TENS can be used for pain control with informed consent of the
patient.
 Otherwise, TENS should not be used when malignancies are present.

Sreeraj S R
References
1.Tim Watson.
http://www.electrotherapy.org/modality/transcutaneous-electrical-ner
ve-
• stimulation-tens
2.http://www.answers.com/topic/pain-1
3.http://www.david.curtis.care4free.net/painrev.htm
4.Transcutaneous Electrical Nerve Stimulation. McGill Lecture Notes –
January 22nd, 2002
5.Mark Johnson. Transcutaneous electrical nerve stimulation (TENS).P
259-286
6.Foster A, Palastanga N. Clayton’s electrotherapy,9 edition, AITBS Publishers, pp
Sreeraj S R
th
THANK YOU

Sreeraj S R