LOW FREQUENCY

CURRENTS
PHYSICAL AGENTS AND ELECTROTHERAPY-I
 TENS
TRANSCUTANEOUS ELECTRICAL
NERVE STIMULATION
Instructor name: Meerub Shakil
DEFINITION
◦ Transcutaneous electrical nerve stimulation (tens) is the application of low-frequency current in the
form of pulsed rectangular currents through surface electrodes on the patient’s skin to reduce pain. A
small battery-operated machine is generally used to generate current, which has a specific stimulatory
effect.
◦ Parameters in TENS apparatus;
i. Pulse shape - usually rectangular
ii. Pulse width – usually fixed at 100 to 200 microseconds, other units variation from 50 to 300
microseconds
iii. Frequency – set as low 2Hz to high 600Hz, commonly 150Hz used
iv. Intensity – can be varied from 0 to 60 milliamperes, set according to the patient experience.
◦ The effect and use of TENS depend upon gate control theory and pain modulation
PAIN MODULATION
◦ Modulation of pain means the process of alterations in the pain signals along the transmission pathway of pain. It is
when your brain interacts with your nerves to adjust the intensity and duration of pain. Modulation involves the release of
chemicals, such as endorphins and serotonin, that reduce the pain signals. It also involves the activation of descending pain-
modulating pathways that project from the midbrain to the dorsal horn. Modulation explains why individuals respond to the
same stimulus differently.
◦ Pain is the uncomfortable feeling that happens when certain sensors in our body, called nociceptors, get activated by things
like heat, cold, or pressure. These sensors are like wires that carry pain signals. When they get triggered, they send messages
to our brain. There are two types of these sensors: A-Delta fibers, which are fast and big, and C-fibers, which are slower and
smaller.
◦ The first type of sensors, A-Delta and C-fibers, transmit the pain signals from the body to the spinal cord. Then, second-order
sensors carry these signals from the spinal cord to the brain. These second-order sensors are nociceptive, meaning they
specifically send pain signals. They have their cell bodies in a place called the dorsal root ganglion.
◦ Fast pain, like when you touch something hot, is sent through the big and fast A-Delta sensors in the skin. Slow pain, which
can come from both the skin and deeper tissues like ligaments and muscles, is carried by the slower C-fibers. Most of these
second-order sensors send their signals to the thalamus, which is a part of the brain.
 PAIN GATE CONTROL THEORY
◦ The pain gate theory was first postulated by Ron Melzack and Pat Wall in 1965. This theory was later modified in 1982. they suggest that
pain perception is not solely determined by incoming pain signals but is also influenced by the activity of non-painful sensory nerves. Here
are the key points of the theory:
◦ Nociceptors and Non-nociceptors: The theory distinguishes between nociceptors (pain receptors) and non-nociceptors (non-pain
receptors). Nociceptors transmit pain signals, while non-nociceptors transmit other sensory information, such as touch or pressure.
◦ The "Gate" in the Spinal Cord: According to the theory, there is a "gate" in the spinal cord that can open or close to control the
transmission of pain signals to the brain. This gate is controlled by the balance of activity between nociceptors and non-nociceptors.
◦ Inhibition of Pain Signals: When non-nociceptive sensory input (e.g., gentle touch) is strong, it can close the gate and inhibit the
transmission of pain signals to the brain. In other words, the brain receives less pain information when non-painful sensory input is active.
◦ Activation of Pain Signals: Conversely, when nociceptive input (e.g., injury or noxious stimuli) is strong, it opens the gate, allowing pain
signals to pass through to the brain. This results in an increased perception of pain.
◦ Psychological and Cognitive Factors: The theory also acknowledges the role of psychological and cognitive factors, such as attention,
emotions, and past experiences, in modulating the perception of pain. These factors can influence the opening or closing of the pain gate.
◦ Clinical Applications: The Pain Gate Control Theory has had significant implications for pain management. Techniques like
Transcutaneous Electrical Nerve Stimulation (TENS) are based on this theory, where electrical stimulation of non-nociceptors can help
reduce the perception of pain
 HIGH TENS LOW TENS

In this high frequency and low-intensity  In this low frequency and high intensity
electrical stimulation is applied. electrical pulses are applied, it gives a sharp
The stimulation will cause an impulse to be stimulus and like a muscle twitch.
carried along with the large diameter afferent  As the nociceptive stimulus is carried toward the
fibers and produces presynaptic inhibition of cerebrum, its passage through the midbrain will
transmission of nociceptive A-delta and C- cause the periaqueductal area of gray matter and
fibers at substantia gelatinosa of the pain gate. raphe nucleus to interact to release the opiate-
Frequency — 100–150 Hz like substances at cord level. The encephalins
and endorphins released have the effect of
Pulse width — 100 and 500 ms blocking forward transmission in the pain
Intensity — 12–30 mA circuit.
 Frequency — 1–5 Hz
 Pulse width — 100 and 500 ms
 Intensity — 30 mA or more
 HIGH LOW BRUST
BURST TENS
100–150 Hz 1–5 Hz >100Hz
FREQUENCY
◦ In this high frequency, short pulse, high-
intensity electrical current is used. 100 to 500 150 to 250 150 to 250
PULSE
(microsec) (microsec) (microsec)
◦ Burst TENS is a series of impulses repeated width
for 1–5 times per second.
12 to 30 mA > 30 mA Strong but
◦ Each train (burst) lasts for about 70 ms. INTENSITY comfortable
◦ The benefits of Burst TENS are that it
High-Frequency TENS is Low-Frequency TENS may Burst TENS is believed to
combines both conventional and acupuncture- PAIN REFIEF thought to work by
stimulating sensory nerves,
stimulate the body's
endorphin release, acting as
activate the body's own
pain-inhibiting mechanisms,
like TENS and thus provides pain relief by which can block or "gate" a natural painkiller possibly through endorphin
MECHANISM the perception of pain release.
both routes. signals as per the Pain Gate
Control Theory

It is often used for acute or It is commonly used for It is used for chronic pain,
APPLICA- chronic pain conditions,
including post-surgery pain,
chronic pain conditions,
such as fibromyalgia,
especially when patients
have built up a tolerance to
musculoskeletal pain, and osteoarthritis, and menstrual continuous TENS, or when
TION neuropathic pain. pain. It's also used in labor
pain management.
a combination of pain relief
mechanisms is desired.
METHODS OF TREATMENT
Electrode placement:
◦ TENS electrode can be placed over —
I. Area of greater intensity of pain.
II. Superficial nerve proximal to the site of pain.
III. To the appropriate dermatome.
IV. To the nerve trunk trigger point.
◦ Some treatment methods may be used depending on the severity of the problem.
1. TENS can be used for a single daily treatment of 40 minutes duration.
2. Portable TENS can be used continuously for 24 hours.
3. TENS can be used in night, e.g. for the treatment of phantom limb pain
INDICATIONS
◦ TENS can be used for the treatment of:
1. Chronic pain syndrome
2. Phantom limb pain
3. Reflex sympathetic dystrophy
4. Postoperative pain
5. Obstetric pain.
DANGERS AND CONTRAINDICATIONS
Continuous application of high TENS may result in some electrolytic reaction below the skin surface.
TENS is contraindicated in patients having cardiac pacemakers may be because of possible interference
with the frequency of pacemakers.
TENS should be avoided in the first three months of pregnancy.
TENS should be avoided in hemorrhagic conditions.
TENS should be avoided over open wounds, carotid sinus, over the mouth, near eyes, etc
ELECTRODE PLACEMENT
THANK YOU

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