Transcutaneous

Electrical Nerve
Stimulation 12
LEARNING OBJECTIVES
On completion of the chapter, the student will be able to:
• Describe transcutaneous electrical nerve stimulation (TENS).
• Explain the mechanism of action of TENS.
• Describe different types of TENS modes.
• Understand the clinical uses of TENS.
• Describe the contraindications and precautions of TENS.
• Explain electrode placement.
• Understand the application procedure.

CHAPTER OUTLINE
• Mechanism of Action • Contraindications and Precautions
• Parameters • Electrode Placement
• TENS Modes • Application Procedure
• Clinical Uses

KEY TERMS
Acupuncture TENS: It is the low frequency and high amplitude TENS.
Brief intense mode TENS: It is the high amplitude and high frequency TENS.
Conventional TENS: It is the high frequency and low amplitude TENS.
Hyperstimulation mode: It is the electroacupuncture TENS. It uses high amplitude that produces noxious cutaneous
stimulation which is sharp and burning in character, without resultant muscle contraction.
Modulated mode: Modulated mode allows one of the parameters of the TENS such as pulse duration, or amplitude, or
frequency to change automatically by a given percentage from an initial set level.
Opioid activation: It is the activation of descending inhibitory pathway through release of endogenous opioids.
Pain gate theory: As the name suggests, there is a gate in the spinal cord through which pain- carrying nociceptor fibers
pass to the brain. The use of TENS results in stimulation of pain inhibitor fibers which also enter at the gate in the spinal
cord. It is believed that these pain inhibitors stop the transmission of the pain carrying fibers at the gate. Therefore, the
mechanism is known as pain gate theory.
Phantom limb pain: Phantom limb pain is the sensation experienced by the individuals after the amputation. There is a
feeling of intact leg, though the part is amputated.
Pulse burst mode: It consists of both the high setting (high amplitude) and low setting (low amplitude).
TENS: Transcutaneous Electrical Nerve Stimulation is the low frequency current used clinically by a variety of health care
professionals for reducing pain.
 Electrotherapy: Principles and Practice

INTRODUCTION
Unit IV ▶ Therapeutic Currents

Transcutaneous Electrical Nerve Stimulation (TENS) is a noninvasive analgesic technique that is used to
relieve nociceptive, neuropathic and musculoskeletal pain.1 TENS is the use of electric current produced by
a device to stimulate the nerves for therapeutic purposes. TENS, by definition, covers the complete range
of transcutaneously applied currents used for nerve excitation, although the term is often used with a more
restrictive intent, namely to describe the kind of pulses produced by portable stimulators used to treat pain.2 In
the clinical context, it is most commonly assumed to refer to the use of electrical stimulation with the specific
intention of providing symptomatic pain relief.
Over 77% of pain specialists use transcutaneous electrical nerve stimulation (TENS) to manage chronic
pain, and over half of chronic pain patients who have been given TENS report that they find it beneficial and
wish to continue using it.3 Transcutaneous electrical nerve stimulation (TENS) is used clinically by a variety
of health care professionals for reducing pain.4 Long before the invention of the TENS unit – thousands of
years earlier, the ancient Egyptians discovered that the shock produced by the electric eels provided relief
from pain. Hieroglyphs dating as far back as 2500 BC show an electric fish, or eel, being used as a form of
treatment. The first recorded use of electricity for pain relief appeared in compositions Medicae, written in
46 AD by Scribonis Largus, a Roman physician. A live torpedo fish (also called the electric ray) was used for
the treatment of gout and headache, its electrical discharge being used to shock the affected body part into
numbness.5

Inventions During 19th Century

By the 19th century, scientists had invented a number of machines
that administered static electricity specifically to relieve pain. Interest
was re-awakened in 1965 by Melzack and Wall, who provided a
physiological rationale for electro-analgesic effects. They proposed
that the transmission of noxious information could be inhibited by
activity in large diameter peripheral afferents or by activity in pain
inhibitory pathways descending from the brain.
These inventions, somewhat larger and far less sophisticated than
the modern TENS machine, proved very popular until the emergence
of medical painkillers, when interest waned. The American
neurosurgeon and pain relief pioneer, Clyde Norman Shealy, had Figure 12.1: Clyde Norman Shealy
designed the first modern TENS unit patented in 1974 (Fig. 12.1).6

MECHANISM OF ACTION
The use of conventional (high-frequency) TENS was originally based on the gate control theory of pain,7
which suggested that counter stimulation of the nervous system could modify the perception of pain. Later
studies suggested that with low-frequency, high- amplitude (“acupuncture-like”) stimulation, TENS could
also raise endorphin levels in the spinal fluid.8

Pain Gate Theory

In 1965, Melzack and Wall proposed the gate theory of pain which they subsequently reviewed in 1978.
They originally postulated that interneurons in the substantia gelatinosa in the dorsal horn of the spinal

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Chapter 12 ▶ Transcutaneous Electrical Nerve Stimulation

Unit IV ▶ Therapeutic Currents

Figure 12.2: Pain gate control

cord acted as a gate to modulate sensory input.10 This theory has been credited with rekindling interest
in electrical control of pain and inspiring research with important scientific and clinical ramifications.11
The essence of this theory is that small diameter myelinated A-delta neurons and small diameter, unmyelinated
C fiber, also known as pain carrying nociceptives, project to the spinal cord where they synapse directly or via
interneurons with the transmission cells (T cells) in the dorsal horn of the gray matter. The T cells relay the
small diameter pain carrying sensation to the higher centers (Fig. 12.2).
Large diameter myelinated A beta and alpha fibers (mechanoceptors), also known as pain inhibiting
fibers, arise from the peripheral part and terminate on T cells through substantia gelatinosa of the spinal cord.
The stimulation of the mechanoceptors large diameter fibers (A beta and alpha) inhibit the nociceptors at the
T cells and prevent transmission to the higher centers. The inhibitory input caused by activation of the large
diameter, mechanosensitive afferent is said to close the gate to nociceptor transmission. This is also known as
“Pain Gate Control Theory”.19

Opioid Activation
Another mechanism proposed is activation of descending inhibitory pathway through release of endogenous
opioids.9 The areas involved in descending inhibition include nucleus raphe magnus in rostral ventral medulla
(RVM) and the periaqueductal gray (PAG). The PAG sends projections to the RVM, which in turn sends
projections to the spinal dorsal horn. The stimulation of PAG or the RVM produces inhibition of dorsal
horn nucleus including spinothalamic tract cells. Specific and different opioid receptors are activated through
release of endogenous opioids by different frequencies of TENS.

Must Know
Application of low frequency TENS causes activation of δ-opioid receptors and high frequency TENS activates μ-opioid
receptors. These opioid receptors in turn activate the PAG-RVM pathway.

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 Electrotherapy: Principles and Practice

PARAMETERS
Unit IV ▶ Therapeutic Currents

Must Know
Clinical trials suggest that adequate output, Judicious selection of various parameters such as waveform,
particularly intensity, is critical to obtaining frequency, pulse width, amplitude and frequency modulation
can play a great role in effective management of pain.
pain relief with TENS.10 Most of TENS
• Waveform: Rectangular monophasic or biphasic
units produce an electric output having one • Pulse duration: Up to 500 microseconds
characteristic waveform, usually of symmetric • Frequency: Between 01 and 200 Hz
or balanced asymmetric biphasic type with • Intensity: Up to 100 mA/as per the tolerance of the patient
zero net current to minimize skin irritation.11

Amplitude
The TENS units have amplitude control switch ranging from 1 mA to 100 mA. Intensity from 1 mA to 100
mA is sufficient because the primary target is the stimulation of sensory nerves, which can easily depolarize
the sensory nerves. The intensity of amplitude depends on the condition and severity of pain. The use of
high-intensity (9– to 12–mA) stimulation was significantly more effective in decreasing the postoperative
analgesic requirements than a low intensity (4–5 mA) of stimulation when used as an adjunct to PCA (patient
controlled analgesia).12 Furthermore, intermittent electrical stimulation for short intervals (30 min) has been
found to be more effective than prolonged or continuous stimulation.13

Frequency
The selection of frequency for TENS is one of the important parameters which may alter the results if selected
wrongly. The frequency may range from 1 Hz to 200 Hz. The frequency is one of the criteria for classification
of the TENS. High-frequency TENS reduces primary hyperalgesia to heat and mechanical stimuli for up to
1 day after treatment. In contrast, low-frequency TENS is ineffective in reducing primary hyperalgesia.14,15
Hansson P et al. reported that the use of high-frequency stimulation produced greater analgesic effects.16 They
reported comparable analgesic effects at both low and high frequencies of stimulation; however, the patients
“preferred” high-frequency stimulation. It has also been reported that low-frequency stimulation requires a
higher intensity to produce pain relief equivalent to high-frequency stimulation.17

Pulse Width
Pulse width is actually the length of time for which the current acts on the nerve. It ranges from 40 microseconds
to 500 microseconds. A microsecond is a millionth of a second and such short duration pulses are used to
achieve analgesic effects as the target is the sensory nerve which tends to have relatively low thresholds. Long
duration impulses are not required in order to force a sensory nerve to depolarize, therefore, stimulation for
less than a millisecond is sufficient. The 200 microsecond pulse duration in clinical practice is commonly
used by the clinicians; however, pulse width can be modified accordingly.

Waveform
Presently, the waveform used in the physiotherapy practice in TENS is biphasic which has positive and
negative phases. The biphasic nature of the pulse means that there is usually no net DC component (often
described by the manufacturers as ‘zero net DC’), thereby minimizing any skin reactions due to the buildup
of electrolytes under the electrodes (Fig. 12.3).

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Chapter 12 ▶ Transcutaneous Electrical Nerve Stimulation

Unit IV ▶ Therapeutic Currents

Figure 12.3: Biphasic wave form, which has negative and positive waves

The waveforms can be modified into square, triangular, rectangular and sine waves.

Modulation
The pulses of different frequency, intensity and pulse duration are modulated in such a way that leads to less
irregular pulses. This modulation helps in minimizing the effects of accommodation which often occur with
electrical stimulation of nerve and muscles.

Duration
Transcutaneous electrical nerve stimulation currents are used for a longer period of time. Many authors
suggest that analgesic effect of the TENS does not remain for a longer period of time.

TENS MODES
Five types of TENS modes have been discussed with regularity in the literature.18 The classification of
transcutaneous electrical stimulation is based on the frequency and amplitude.

Conventional
Conventional TENS is also known as high TENS as it is characterized by high frequency and low amplitude
(Fig. 12.4). Conventional mode has the frequency range from 10 Hz to 100 Hz and the amplitude that
produces comfortable cutaneous stimulation without muscle contraction.19 The studies have shown that the
frequencies approximately 60 Hz are optimal for relieving pain.20 On the other hand, frequencies above 80
to 200 Hz may worsen pain of some patients.21 A short pulse duration ranging from 50 to 100 microseconds
favors preferential stimulation of large diameter myelinated afferent neurons.22

Must Know
The conventional TENS stimulates selectively large diameter A beta fibers, without stimulating the pain nociceptor
A delta and C fibers. The A beta fibers block the pain carrying A delta and C fibers to reach the higher centers at the
spinal cord. This mode of TENS elicits segmental analgesia.

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 Electrotherapy: Principles and Practice
Unit IV ▶ Therapeutic Currents

Figure 12.4: Conventional TENS with high frequency and low amplitude

Practical Tip
To prevent accommodation, the current must be periodically increased in order to maintain adequate perception of
electrical paresthesia. This mode is mostly used by the clinicians.

Acupuncture-Like TENS
Acupuncture mode of TENS is also known as strong low-rate mode TENS. It is a high amplitude and low
frequency TENS. This mode of TENS has a frequency below 10 Hz. However, the most commonly used
is 1 to 4 Hz with pulse duration rangeing from 100 to 300 microseconds. The amplitude is usually higher
(above 30 mA) than the conventional TENS to produce visibly strong and rhythmical muscle contraction.
Acupuncture-like TENS selectively stimulates the A delta and C fibers that releases endogenous opioid-like
substances at cord level. Substances like enkephalins and beta endorphins block the transmission of pain
stimuli and elicit extrasegmental analgesia. This type of TENS is effective in chronic and deep situated pain.

Brief-Intense Mode TENS

It is a high amplitude and high frequency TENS. This mode of TENS has the frequency rangeing from 60 Hz
to 150 Hz, pulse duration 50-250 microseconds and amplitude is adjusted to produce either uncomfortable
tetanic muscle contraction (high setting) or nonrhythmic muscle fasciculation (low setting). The aim of such
type of TENS is to produce significant muscle fatigue with continuous stimulation. The brief intense mode
of TENS activates small diameter afferents to elicit peripheral nerve blockade and extrasegmental analgesia.

Pulse Burst Mode

This type of TENS is also called burst or pulse train.18 It consists of both high setting (high amplitude) and
low setting (low amplitude). The patient experiences either uncomfortable tetanic muscle contraction (high
setting) or nonrhythmic muscle fasciculation (low setting). This type of TENS is characterized by a high carrier
frequency of 50-100 Hz which is modulated by a low burst frequency of 1 to 4 Hz. The 1-4 Hz frequency is a
series of pulses (train) with the pulse duration of 50 to 100 microseconds (Fig. 12.5).

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Chapter 12 ▶ Transcutaneous Electrical Nerve Stimulation

Modulated Mode

Unit IV ▶ Therapeutic Currents

This type of TENS is designed to prevent accommodation to occur and to improve patient tolerance. The
modulated mode allows one of the parameters of the TENS such as pulse duration, or amplitude, or frequency
to change (modulate) automatically by a given percentage from an initial set level (Figs 12.6A to C).

Hyperstimulation Mode
This type of TENS is also known as noninvasive electroacupuncture TENS. It is the only mode that regularly
utilizes either direct or monophasic pulsed currents. Hyperstimulation mode uses high amplitude that
produces very noxious cutaneous stimulation which is sharp and burning in character, without resultant
muscle contraction. This type of TENS is applied through a small probe type electrode, with a tip that may
be only 1 to 3 mm in diameter. The pulse duration required for such type of TENS is very long, i.e., 500 msec
and the frequency can exceed 100 Hz with amplitude not exceeding 50 mA. Table 12.1 shows different modes
of TENS.

Figure 12.5: Pulse burst mode

A B

Figures 12.6A to C: Modulated mode TENS in which the parameters of TENS are modulated. A. Intensity,
B. Pulse duration, C. Frequency

Contd…
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 Electrotherapy: Principles and Practice
Unit IV ▶ Therapeutic Currents

TABLE 12.1: Different Modes of TENS

Mode Amplitude Frequency Pulse Width Mechanism of Action
(in microseconds)
Conventional To produce 10 Hz – 100 Hz 50–100 Selectively stimulates
(High frequency low comfortable large diameter A beta
amplitude) cutaneous sensation fibers
without stimulating
muscles
Acupuncture-like High amplitude Less than 10 Hz 100–300 Selectively stimulates
(High amplitude and low above 30 mA. To the A delta and C
frequency) produce visibly fibers that release
strong and rhythmic endogenous opioid-
muscle contraction like substances at
cord level
Brief-Intense Uncomfortable 60 Hz – 150 Hz 50-250 Small diameter
(High amplitude and high tetanic muscle afferents to elicit
frequency) contraction or peripheral nerve
nonrhythmic muscle blockade and
fasciculation to extrasegmental
produce fatigue. analgesia
Pulse Burst Mode To produce High carrier 50 -100 Stimulate small
uncomfortable frequency 50-100 diameter, high
tetanic muscle Hz, modulated threshold peripheral
contraction or by a low burst afferents (A-delta)
nonrhythmic muscle frequency from 1 in order to activate
fasciculation to 4Hz extrasegmental
descending pain
inhibitory pathways
Hyperstimulation Less than 50 mA, 100 Hz or more 500 Small diameter
produces very afferents
noxious cutaneous
stimulation

CLINICAL USES
The primary use of TENS has been recognized as the symptomatic relief in the management of chronic
intractable pain and as an adjunctive treatment in the management of post-surgical and post-traumatic acute
pain23,11.

Phantom Limb Pain

Phantom pain or sensation is experienced by the individuals after amputation. The patients feel that they have
the intact leg or arm, their finger and toes are still working. These patients often fall in the morning when
they try to stand on the amputated leg. The feeling of presence of normal leg can be eliminated with the help
of TENS. The application of TENS for 60 minutes to generate a strong but comfortable sensation at the site of
stump pain helps in reducing phantom pain and or associated with rest and movement24.

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Chapter 12 ▶ Transcutaneous Electrical Nerve Stimulation

Practical Tip

Unit IV ▶ Therapeutic Currents

The application of conventional transcutaneous electrical nerve stimulation to the painful limb or stump with the
parameters of continuous pulse pattern, pulse duration of 80 microseconds, pulse frequency of 100 Hz, strong
but comfortable intensity may reduce pain both on movement and at rest25. This may prove to be a useful aid for
perceptual embodiment of an artificial limb.25

Postsurgical Pain
TENS undoubtedly has a role in the management of postoperative pain although its effect is not as strong as
that of epidural analgesia with local anesthetics. TENS, however, is easy to administer, has less side effects, and
can be applied by the patients themselves.
High frequency TENS given for 15 min to 20 min can decrease postsurgical pain perception by 50% at rest
and by 11% during movement. High frequency TENS increases muscle contraction ability by 30%, compared
with the initial contraction before treatment26.

Practical Tip
The use of acupuncture-like TENS with adequate treatment, pulse frequency of 1-8 Hz to produce strong, definite,
subnoxious, maximal tolerable contraction can reduce the consumption of analgesics after surgery. The electrodes
can be placed over the incision area27.

Neuropathic Pain
The use of TENS shows significant reduction in pain and hypersensitivity of the hand32. Nearly half of those
suffering from a spinal cord injury (SCI) are at risk of developing neuropathic pain. Providing relief from spinal
cord injury related neuropathic pain is often difficult.33 The conservative management for the patients with
spinal cord injury and pain include non-pharmacological conservative treatment such as physical therapy,
relaxation, and acupuncture; these are preferred over opioids.34 This preference might be associated with the
severity of the side effects experienced, the limited pain relief provided by pharmacological treatment, or
both. Treatment with transcutaneous electrical nerve stimulation (TENS) is rarely associated with negative
side effects and has been reported to be effective in patients with peripheral neuropathic pain,35 e.g., patients
with diabetic neuropathy36 and patients with pain of differing origin27.

Dysmenorrhea
Dysmenorrhea is a very common complaint that refers to painful menstrual cramps in the uterus. Stimulation
of the cutaneous sensory nerves directly over the area through the transcutaneous electrical nerve stimulation
(TENS) relieves pain. It is thought to alter the body’s ability to receive and perceive pain signals rather than by
having a direct effect on the uterine contractions. The studies found that high-frequency TENS may help in
relieving the pain pertaining to dysmenorrhea.38

Labor Pain
The Low-voltage currents emitted by transcutaneous electrical nerve stimulation are being used for pain relief
in labor. TENS application reduces the duration of the first stage of labor and the amount of analgesic drug
administered. Use of TENS in pregnancy does not affect the childbirth process consequences, the maternal
outcomes and the fetal outcomes. There are no adverse effects on mother or newborns. The application of

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 Electrotherapy: Principles and Practice

both high and low frequency TENS has been found effective in reducing labor pain39. These TENS increase
Unit IV ▶ Therapeutic Currents

β-endorphins, methionine-enkephalin concentration, production of inhibitory neurotransmitters such

as GABA (gamma-aminobutyric acid) and serotonin, and reduce neurotransmitters release (aspartate and
glutamate). These natural analgesic substances inhibit the production of catecholamines40.

CONTRAINDICATIONS AND PRECAUTIONS

Serious adverse effects of TENS on skin and underlying structures are not common like with interferential
therapy and other low frequency currents. However, occasional superficial electrical burns have been noted
by the patients and clinicians, which may be because of improper placement of electrodes. Some patients
experience mild autonomic responses and minor skin irritation beneath electrodes.

Pacemakers and Cardiovascular Disorders

TENS has been shown to interfere with pacemaker function. Therefore, it should not be applied directly over
the pacemaker, however; some clinicians advise that TENS could be used on the chest away from the site of
pacemaker. The application of TENS on anterior and posterior areas of the chest should never be advised as
this may compromise pulmonary ventilation due to excessive stimulation of the intercostal muscles.

Hemorrhage
The contraction of muscles during application of high or burst TENS increases the blood circulation in the
local area that may lead to further increase in the size of hematoma. Therefore, electrodes should not be
placed over areas where there has been recent hemorrhage as the currents may cause further hemorrhage.

Thrombosis
The application of TENS is absolutely contraindicated on the calf muscles and other potential area of
thrombosis especially with postsurgical patients because of the potential for embolism.

Pregnancy
There are many studies which state that the use of TENS during labor and delivery29 is beneficial and reduces
the duration of the first stage of labor and the amount of analgesic drug administered. However; TENS
should not be administered over the abdomen or pelvis during pregnancy because the effects of TENS on
fetal development are still unknown and currents could inadvertently cause uterine contractions and induce
premature labor30.

Carotid Sinus
Application of TENS over the carotid sinus may reflexively induce slowing of the heart rate, fall in blood
pressure, or fainting, hence, should be recognized to be hazardous.

Epilepsy
TENS is not absolutely contraindicated for the patients with epilepsy. However, the clinicians should be
cautious while applying TENS to patients with epilepsy and should not apply electrodes on the neck or head.

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Chapter 12 ▶ Transcutaneous Electrical Nerve Stimulation

Undiagnosed Pain

Unit IV ▶ Therapeutic Currents

TENS should be applied with caution to the patients with undiagnosed pain.

ELECTRODE PLACEMENT
Different sizes and shapes of electrodes are available in the market. There are reusable, disposable, nonsterile
and presterilized electrodes, out of which reusable nonsterile electrodes are more often used in the clinics. The
electrodes are usually made up of carbonized and siliconized carbon rubber. These are the reusable nonsterile
electrodes which can be used for a long period of time, however; cuts and irregular surfaces should be checked
prior to application of the electrodes, and use of these electrodes for more than six months is not advisable.
There are four basic options for placement of electrodes as listed below. The first three are when using two
electrodes or one channel. The last option makes use of two channels or four electrodes.
i. The first option is the placement of electrode directly over the painful areas or proximal to the site of
pain.
ii. Second option is the placement of electrodes just outside the proximal and distal margins of the painful
region in a manner that ‘brackets’ this area. For example, if the site of pain is in the vertebral column, the
electrodes should be placed on either side of the column.
iii. The third option of placement of electrodes is basically for the radicular or referred pain. One electrode
is placed over the painful area (proximal part), while other electrode is placed over the distal area related
to the spinal nerve root of the referred pain.
iv. The fourth option of electrode placement is criss-cross or modified in which four electrodes of two
channels are used. For example, painful knee joint. Two electrodes of one channel can be placed directly
over the painful site and other two electrodes can be placed adjacent to the painful area.

Nerve
The electrodes over the course of peripheral nerve, especially where located superficially, can also be placed.
The stimulation of proximal part of the nerve is preferred over the distal, if two electrodes are used.

Trigger Points
Trigger point is a painful area on compression with some referred pain. The electrodes can be placed relative
to a trigger point. One electrode can be placed directly over the trigger point and other electrode is placed
over its relative area of referred pain.

Motor Point
Motor point is the area of a muscle where nerve enters into the muscle, it is usually situated in the proximal
one third of the muscle. Such points would seem well suited to afford input to the central nervous system,
permit efficient stimulation of muscle contractions.18
The electrodes are secured on the body or extremities with the help of surgical tape, or a variety of paper
or foam adhesive patches. The Velcro straps and bandages may also be used to secure the electrodes firmly on
the treatment area.

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 Electrotherapy: Principles and Practice

Placement of Electrodes for Phantom Pain

Unit IV ▶ Therapeutic Currents

Both the high and low frequency transcutaneous electrical nerve stimulator can be used for phantom pain.
High-frequency TENS
Electrodes are placed at the site of pain, over nerve bundles proximal to the site of pain (Fig. 12.7A). Electrodes
can also be placed on each paravertebral region in the same segment as the pain (Fig. 12.7B).
Low-frequency TENS
Both the electrodes are placed on the contralateral limb at the mirror site to the phantom limb pain in the
same myotome as the pain (Fig. 12.7C).

Placement of Electrodes for Low Back Pain

To relieve localized pain in the lower back area, single channel (two electrodes) or two channels (four
electrodes) can be used. In case of single channel, the electrodes are placed on either side of the site of pain on
the paravertebral region. If two channels or four electrodes are used, two electrodes of one channel are placed
on the right paravertebral region and two electrodes of second channel are placed on left paravertebral region
of the painful area (Fig. 12.8).

A B C

Figures 12.7A to C: Placement of electrodes for phantom pain

Figure 12.8: Placement of electrodes for back pain

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Chapter 12 ▶ Transcutaneous Electrical Nerve Stimulation

Placement of Electrodes for Sciatica

Unit IV ▶ Therapeutic Currents

Two channels are used for sciatic pain. Two electrodes of one channel are
placed on either side on the paravertebral region of the nerve roots. The
electrodes are not placed directly over the nerve roots. The electrodes of
other channel are placed on the sciatic notch and distal posterior thigh.
If pain distribution is in the whole course of the sciatic nerve, then one
electrode is placed on the paravertebral region of the same side, second
electrode of the first channel is placed on the sciatic notch. The third
electrode is placed on the mid posterior thigh and the fourth electrode is
placed on the mid posterior calf muscles (Fig. 12.9).

Electrode Placement for Labor Pain

Single channel or two channels can be used for labor pain. To use single
channel, electrodes are placed over the painful area, usually the sacral Figure 12.9: Placement of electrodes
for sciatic nerve pain (Sciatica)
region. To use four electrodes (two channels), the electrodes of first
channel remain in the same position, while the electrodes of second channel are placed on the hips down
toward the groin.
Method II: One pair of electrodes is placed paravertebrally at the level of T10-L1 and another pair of
electrodes at the level of S2 to S4. The intensity of current can be controlled by the therapist with the intensity
knob. Note: Electrodes shall not be placed directly on the uterus.

Electrode Placement for Menstrual Pain or Cramp

Single channel is used. The electrodes are placed
directly over the painful area. High frequency with
high amplitude TENS is preferred for acute ischemic
pain (Fig. 12.10).

Placement of Electrodes for Knee Joint

Single channel or two channel electrodes can be used
depending on the area of pain. The electrodes of single
channel are placed directly over the painful area.
When using four electrodes, electrodes are arranged
in a criss-cross manner on each side of the knee joint
(Fig. 12.11).
Figure 12.10: Placement of electrodes for menstrual pain
Placement of Electrodes for Shoulder or cramp
Joint
Similar to the knee joint, single or two channel electrodes can be used for the shoulder joint. If the area of pain
is small, one electrode is placed directly over the joint line or painful site, and other electrode is placed on the
insertion of the deltoid lateral fibers (Fig. 12.12).

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 Electrotherapy: Principles and Practice
Unit IV ▶ Therapeutic Currents

Figure 12.11: Placement of Electrodes for Knee Joint Figure 12.12: Placement of Electrodes for Left Shoulder

APPLICATION PROCEDURE
• The patient is screened for contraindication to the TENS.
• Skin should be thoroughly checked for cut and abrasions.
• The electrodes should not be used for a long period of time.
• The area of treatment is inspected after the treatment for skin allergy to the electrode or gels.
• The electrodes are placed as mentioned earlier.
• After securing electrodes firmly on the treatment area, the patient is made aware of the sensation of current
he or she is going to experience.
• The intensity of current is increased gradually till a desired muscle contraction or sensation is achieved.

Summary
• Transcutaneous electrical nerve stimulation is a noninvasive analgesic technique of delivery of electrical current
through the skin to cause depolarization of the sensory, motor, and nociceptive nerve for modulating the pain.
• The mechanism of action of TENS is to stimulate the large diameter myelinated A beta and alpha fibers, also
known as pain inhibiting fibers, which arise from the peripheral part and terminate at T cells.
• The stimulation of pain inhibiting fibers blocks the pain carrying nociceptors at the T cells and prevents transmission
to the higher centers.
• TENS uses rectangular monophasic or biphasic waveforms, with pulse duration up to 200 microseconds, and
frequency between 01 to 300 Hz.
• TENS can be delivered using conventional, acupuncture-like, bursts and brief intense modes.
• The electrodes of the TENS are placed directly over the tender areas, trigger points or acupuncture points, and on
the dermatomes of the nerves.
• TENS is used for providing relief from phantom and stump pain, postsurgical pain, neuropathic pain and
dysmenorrhea. However, it should not be applied directly over the pacemaker or the heart in case of any cardiac
disorder, hemorrhagic area and thrombotic area.

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Chapter 12 ▶ Transcutaneous Electrical Nerve Stimulation

References

Unit IV ▶ Therapeutic Currents

1. Johnson M. Watson T. Transcutaneous electrical nerve stimulation, Electrotherapy: Evidence-based Practice.
, 2008 Edinburgh Churchill Livingstone (pg. 253-96)
2. Robertson, Valma J.; Alex Ward; John Low; Ann Reed (2006). Electrotherapy Explained: Principles and
Practice (4th ed.). Butterworth-Heinemann (Elsevier). ISBN 978-0- 7506-8843-7.
3. Berman BM, Bausell RB. The use of non-pharmacological therapies by pain specialists. Pain. 2000;85:313–
315. .
4. Kathleen A. Sluka, Transcutaneous electrical nerve stimulation: Basic science mechanisms and clinical
effectiveness The Journal of Pain Volume 4, Issue 3, April 2003, Pages 109-121
5. Kellaway P. The William Osler medal essay: The part played by electrical fish in the early history of
bioelectricity and electrotherapy. Bull His Med, 20:112-137, 1949. On Roger M. Nelson, Karen W. Hayes,
Dean P. Currier: Clinical Electrotherapy, Appleton & Lange, Stamford, Connecticut, third editionpp292.
6. Top TENS, [Link]
7. Melzack R, Wall PD. Pain mechanisms: a new theory . Science 1965; 150:971–9.
8. Sjolund BH, Eriksson MBE. . Endorphins and analgesia produced by peripheral conditioning stimulation. Adv
Pain Res Ther 1979; 3:587–90.
9. Sluka KA, Walsh D. Transcutaneous electrical nerve stimulation: Basic science mechanisms and clinical
effectiveness. J Pain. 2003;4:109–21 [PubMed]
10. Josimari M. DeSantana Email author, Deirdre M. Walsh, Carol Vance, Barbara A. Rakel, Kathleen A. Sluka:
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Rheumatology Reports, December 2008.
11. Roger M. Nelson, Karen W. Hayes, Dean P. Currier: Clinical Electrotherapy, Appleton & Lange, Stamford,
Connecticut, third editionpp293.
12. Wang B, Tang J, White PF, Naurse R, Sloninsky A, Kariger R, Gold J, Wender RH: Effect of the intensity of
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FA Davis,1984 on Roger M. Nelson, Karen W. Hayes, Dean P. Currier: Clinical Electrotherapy, Appleton &
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22. Howson DC, Peripheral neural excitability: Implication for transcutaneous electrical nerve stimulation. Phys
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Hand Surgery (European Volume), First Published February 1, 2005.
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85 — 94.
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36. Carroll D, Moore RA, McQuay HJ, Fairman F, Tramer M, Leijon G. Transcutaneous electrical nerve stimulation
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Chapter 12 ▶ Transcutaneous Electrical Nerve Stimulation

Unit IV ▶ Therapeutic Currents

ASSESS YOURSELF
Long Answer Questions
1. Describe transcutaneous electrical nerve stimulation (TENS) and explain its mechanism of action.
2. Describe different types of TENS modes
3. Elucidate the clinical uses of TENS
4. Explain the contraindications and precautions of TENS
5. Describe the gate control theory of pain.

Short Answer Questions

1. What is TENS?
2. Who proposed the gate control theory?
3. What is the pain gate theory?
4. Which are the pain carrying fibers?
5. Which are the pain inhibiting fibers?
6. Why short pulse widths are required to achieve analgesic effects?
7. Which type of waveform is used in the TENS?
8. What are the advantages of modulation of frequency, intensity and pulse durations?
9. What are different modes of TENS?
10. Why conventional mode of TENS is called high TENS?
11. How conventional mode helps in relieving pain?
12. What is acupuncture-like TENS?
13. What is the brief intense mode TENS?
14. What is the pulse mode of TENS?
15. What is the modulated mode of TENS?
16. What are the indications of TENS?
17. What are the contraindications of TENS?

Short Notes
a. Gate theory
b. Opioid activation
c. Parameters of TENS
d. Conventional TENS
e. Acupuncture-like TENS
f. Brief Intense mode TENS
g. Pulse Burst mode TENS
h. Modulated mode of TENS
i. Hyperstimulation mode of TENS

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 Electrotherapy: Principles and Practice
Unit IV ▶ Therapeutic Currents

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