Review Article DOI: 10.

4176/090119

Transcutaneous Electrical Nerve Stimulation (TENS)

A Possible Aid for Pain Relief in Developing Countries?

Tashani O, Johnson MI
Centre for Pain Research, Faculty of Health, Leeds Metropolitan University, UK, Leeds Pallium Research Group
Abstract: Transcutaneous electrical nerve stimulation (TENS) refers to the delivery of electrical currents through the skin to
activate peripheral nerves. The technique is widely used in developed countries to relieve a wide range of acute and chronic
pain conditions, including pain resulting from cancer and its treatment. There are many systematic reviews on TENS although
evidence is often inconclusive because of shortcomings in randomised control trials methodology. In this overview the basic
science behind TENS will be discussed, the evidence of its effectiveness in specific clinical conditions analysed and a case for
its use in pain management in developing countries will be made.
Key words: Transcutaneous Electrical Nerve Stimulation (TENS), Pain, Analgesia, Pain relief, Pain management, Developing
countries, Pain gate theory

Introduction illnesses and relieve pain. However, increased use of

Transcutaneous electrical nerve stimulation (TENS) is pharmacological agents to manage pain resulted in the
widely used in western and developed countries to relieve decline of the electrotherapy at the end of the 19th
a wide range of painful conditions, including non- century. In 1965, Ronald Melzack from McGill University
malignant acute and chronic pain and pain resulting from in Montreal Canada and Patrick Wall from University
cancer and its treatment [1-3]. TENS is inexpensive, non- College London UK, published their seminal paper which
invasive and safe with no major side effects. TENS can be proposed a gating mechanism in the central nervous
self administered by patients following simple training and system to regulate the flow of nerve signals from
because there is no potential for toxicity, patients can peripheral nerves en-route to the brain [5]. According to
titrate the dosage on an as-needed basis. During TENS this Gate-Control Theory of Pain, activity in large diameter
pulsed electrical currents are generated by a small battery low threshold mechanoreceptive (touch-related) nerve
operated TENS device that can be kept in the pocket or fibers could inhibit the transmission of action potentials
attached to the user’s belt. Currents from the TENS device from small diameter higher threshold nociceptive (pain-
are delivered through the skin by two self-adhering related) fibers through pre and post synaptic inhibition in
electrode pads (Figure 1). the dorsal horn of spinal cord. Humans utilise this
mechanism whenever they rub their skin to relieve pain.
The purpose of TENS is to selectively activate nerve Because nociceptive fibers (A-delta and C-fibers) have a
fibers. Maximal pain relief is achieved when TENS higher threshold of activation than mechanoreceptive
generates a strong non-painful electrical sensation fibers (A-beta fibers) Melzack and Wall proposed that it
beneath the electrodes. Pain relief is usually rapid in onset would be possible to selectively stimulate
and stops shortly after TENS is turned off. For this reason mechanoreceptive fibers by titrating the amplitude of
patients are encouraged to deliver TENS for as long as electrical currents delivered across the surface of the skin
needed, which may be for hours at a time and throughout (ie TENS). This would prevent signals from nociceptive
the day. The main contraindication is patients with fibers from reaching higher centres of the brain, thus
implanted stimulators such as pacemakers. In the UK, reducing pain (Figures 2). In essence, TENS electrically
TENS devices can be purchased without prescription, rubs pain away.
although this is not the case in some European countries.
TENS devices, including electrode leads, pads and battery, In addition to interrupting nociceptive signals, at spinal
retail for approximately £30GBP although bulk buying can cord dorsal horn, we now know that TENS analgesia also
markedly reduce cost. Interestingly, TENS does not appear involves a descending inhibitory mechanism that could be
to be widely available for patient use in developing partially prevented by spinalization [6]. Activity in nerve
countries. fibers descending from the brain can also block onward
transmission of peripheral nerve signals within the spinal
In this review the basic science behind TENS will be cord. Humans utilise this mechanism whenever they
discussed, the evidence of its effectiveness in specific mentally distract themselves to not feel pain despite the
clinical conditions will be provided and a case for its use in presence of tissue damage (Figure 2)
pain management in developing countries will be made.
Evidence gathered from animal studies suggested that
Physiological principle of TENS induced pain relief low frequency TENS effects may be due to release of
The ancient Egyptians are usually acknowledged as the endogenous opioids [6]. This explains why analgesia may
first people who used electrogenic fish to apply electricity persist for hours after electrical stimulation has stopped
for pain relief. Yet, the first documented use of this kind of because endorphins have long lasting effects in the central
pain relief is of a Roman Physician in 46 AD [4]. In 1786, nervous system. The released opioids may generate their
Luigi Galvani, an Italian doctor, demonstrated that the leg analgesic action at peripheral, spinal and supraspinal sites
of a frog contained electricity. This observation and other [7,8]. However, other neurochemicals have been
advancements in generating electricity lead to a implicated in TENS analgesia including GABA [9],
resurgence in the use of electricity to treat different

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Review Article DOI: 10.4176/090119

acetylcholine [10], 5-HT [11], noradrenaline [12] and pleasant ‘electrical paraesthesiae’. Physiologically,
adenosine [13]. conventional TENS activates large diameter non-noxious
afferents which has been shown to close the pain gate at
spinal segments related to the pain [6]. Another
technique, which is used less often is acupuncture-like
TENS (AL-TENS) using high-intensity and low-frequency
(less than 10pps, usually 2pps) administered over
muscles, acupuncture and trigger points [16]. The purpose
of AL-TENS is to activate small diameter afferents which
has been shown to close the pain gate using extra-
segmental mechanisms [2]. TENS can also be used as a
counter-irritant, termed intense TENS, using high-intensity
and high-frequency currents (Table 2, Figure 3).

Figure 1 A standard TENS device.

TENS and TENS-like devices

In health care the term TENS refers to the delivery of
currents using a ‘standard TENS device’ (Table 1) [3].
However, there are a variety of devices that deliver
electrical currents through the skin but have technical
output characteristics that differ from a standard TENS
device. We have previously described these as “TENS-like
devices” and include Trancutaneous Spinal
Electroanalgesia, Interferential Therapy, Microcurrent
Stimulation and Pain Gone pens (see [3,14,15] for a
review of these devices). The remainder of this review will
Figure 2 Diagrammatic representation of the principle of
focus on standard TENS devices.
conventional TENS. By selectively activating A-beta fibers, TENS
shuts the Pain Gate on A-delta and C fibers preventing pain-
Table 1 Technical output specifications of a standard TENS related signals reaching the brain.
device
50-250g
Weight Clinical effectiveness of TENS
6 x 5 x 2 cm (small device)
Dimensions 12 x 9 x 4 cm (large device) In Western clinical practice TENS has been shown to
Cost Approximately £30 have a role in pain management [2]. There are many
Pulse waveform Monophasic symmetrical biphasic
systematic reviews on TENS although evidence is often
(usually fixed) asymmetrical biphasic inconclusive because of shortcomings in RCT
methodology. Early systematic reviews suggested that
Pulse amplitude
1-50mA into a 1 kΩ load TENS was of limited benefit as a stand alone pain therapy
(usually adjustable)
for acute pain. Carroll et al. judged there to be no benefit
Pulse duration
of TENS for postoperative pain because 15 of 17 RCTs
(sometimes fixed, 10-1000µs
found no differences in pain relief between active and
sometimes adjustable)
placebo TENS [17]. However, Bjordal et al. re-assessed
Pulse frequency
1-250pps the evidence and concluded that TENS reduced post-
(usually adjustable)
operative analgesic consumption if TENS was applied
usually continuous and burst
available (some devices have using adequate TENS technique [18]. Systematic reviews
Pulse pattern modulated amplitude, modulated have also concluded that there was no evidence for TENS
frequency, modulated pulse producing beneficial analgesic effects during childbirth
duration, random frequency) [19,20] and insufficient evidence to determine the
Channels 1 or 2 effectiveness of TENS in reducing pain associated with
Batteries PP3 (9V), rechargeable primary dysmenorrhoea [21]. RCTs suggest that TENS is
Timer, most devices deliver effective for acute orofacial pain, painful dental
Additional features constant current output procedures, fractured ribs and acute lower back pain (for
review see [22].
TENS Techniques
TENS is a technique to stimulate different categories of Previously, systematic reviews suggested that TENS
nerve fibers. The most commonly used TENS technique is may be of benefit for chronic pain but definitive
termed conventional TENS. During conventional TENS, conclusions were hindered by shortcomings in RCT
low-intensity pulsed currents are administered at high- methodology [23,24]. Reviews on rheumatoid arthritis of
frequencies (between 10-200 pulses per second, pps) at the hand [25], whiplash and mechanical neck disorders
the site of pain. The user experiences a “strong, non- [26], chronic low back pain [27], poststroke shoulder pain
painful TENS sensation often described as ‘’tingling’ or [28] and chronic recurrent headache [29] were

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Review Article DOI: 10.4176/090119

Table 2 TENS techniques

Patient Electrode Physiological Analgesic
TENS parameters Regimen
experience location Intention profile
To stimulate
Strong, non- large diameter
Low intensity Usually
painful TENS Dermatomes non-noxious Use TENS
Conventional (amplitude), high rapid
paraesthesia with Site of pain afferents (A- whenever
TENS frequency (10-200 pps) onset and
minimal muscle beta) to produce in pain
offset
activity segmental
analgesia
To stimulate
Myotomes small diameter
High intensity
Site of pain cutaneous and Use TENS May be
(amplitude), low Strong
Muscles motor afferents for 20-30 delayed
AL-TENS frequency (1-5 bursts of comfortable
Motor nerves (A-delta) to minutes at onset and
100 pps) muscle twitching
Acupuncture produce a time offset
points extrasegmental
analgesia
To stimulate
Dermatomes Short Rapid
High amplitude Uncomfortable small diameter
Site of pain periods onset and
Intense (uncomfortable/noxious (painful) cutaneous
Nerves only 5-15 delayed
TENS ), high frequency (50- electrical afferents (A-
proximal to minutes at offset
200pps) paraesthesia delta) to produce
pain a time
counter irritation

inconclusive. In contrast, systematic reviews have than £15GBP if bought in bulk. Once purchased a TENS
demonstrated TENS efficacy for knee osteoarthritis [30] device will not perish or deteriorate and devices in the
and chronic musculoskeletal pain [31]. RCTs have also developed world are used for many decades without the
demonstrated effects for a range of other chronic pain need for further servicing or repair. Often clinics purchase
conditions including localized muscle pain, post-herpetic TENS devices in bulk and loan them to patients for short
neuralgia, trigeminal neuralgia, phantom limb and stump and long term use, on the proviso that the patient returns
pain and diabetic neuropathies (for review see [3]. A the device to the clinic when it is no longer needed.
recent Cochrane review by Robb et al. concluded that Running costs are minimal and include battery and
there is insufficient available evidence to determine the reusable electrode pad replacement. Manufacturers
effectiveness of TENS in treating cancer-related pain recommend that individual pads have longevity of one
[32,33]. month on daily use, although patients often use them for
far greater lengths of time, especially if they take care to
Pain Management in developing countries: Could store them carefully. Electrode costs can be reduced by
TENS help? using carbon rubber electrodes which are smeared with
The International Association for The Study of Pain electrode gel and attached to the skin with micropore
(IASP) speculate that “the prevalence of most types of tape, rather than using self adhering electrodes. In
pain may be much higher in developing countries than in general, battery and electrode use depends on how often
developed countries”, although epidemiological evidence is the patient uses TENS
lacking [34]. It is known that there is a higher incidence of
pain conditions associated with epidemics such as TENS has no known drug interactions and so can be
HIV/aids in the developing world. An IASP Developing used in combination with pharmacotherapy to reduce
Countries Task Force, which included Africa and the medication, medication-related side effects and medication
Middle East reported that pain management in the general costs. TENS has very few side effects with no incidents of
population was inadequate, although there was serious or adverse events reported in the literature. TENS
considerable variations between regions [35]. Limited has a rapid onset of action, unlike medication, and there is
resources, ignorance by health care professionals and a no potential for toxicity or overdose.
lack of pain specialists were contributing factors. This has
impacted significantly on pharmacological therapy with Clearly, there is a case to use TENS for pain
many drugs commonly used in the developed world being management in the developing world. However, research
unavailable to the general public because of the weak is needed to determine the feasibility of TENS use in
economy and limited purchasing power of citizens [36]. In developing countries. Perhaps health promotion
addition, drugs even when available may be fake, authorities should alert the public and heath care
adulterated, passed their expiry date or perished due to practitioners to the role of TENS as an important aid in the
inadequate storage. fight against pain.

TENS is advantageous in this regard. It is inexpensive

when compared to drug therapy. The cost of a TENS
device is £30GBP, although devices are available for less

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Review Article DOI: 10.4176/090119

18. Bjordal, J.M., M.I. Johnson, and A.E. Ljunggreen,

Transcutaneous electrical nerve stimulation (TENS) can reduce
postoperative analgesic consumption. A meta-analysis with
assessment of optimal treatment parameters for postoperative
pain. Eur J Pain, 2003. 7(2): p. 181-88.
19. Carroll, D., et al., Transcutaneous electrical nerve stimulation
does not relieve in labour pain: updated systematic review.
Contemporary Reviews in Obstetrics and Gynecology, 1997.
September 1997: p. 195-205.
20. Carroll, D., et al., Transcutaneous electrical nerve stimulation
in labour pain: a systematic review. Br J Obstet Gynaecol,
1997. 104(2): p. 169-75.
21. Proctor, M.L., et al., Transcutaneous electrical nerve
stimulation and acupuncture for primary dysmenorrhoea.
Figure 3 Output characteristics (settings) of a standard Cochrane Database Syst Rev, 2002(1): p. CD002123.
TENS device. The user can control the amplitude 22. Johnson, M., S. Oxberry, and K. Simpson, Transcutaneous
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