COLLEGE OF PHYSICAL THERAPY

Notes on TENS

mechanisms. The effectiveness of

Transcutaneous TENS varies with the
clinical pain being treated, but
Electrical Nerve research would suggest that when
used ‘well’ it provides significantly
Stimulation greater pain relief than a placebo
intervention. There is an extensive
(TENS) research base for TENS in both the
clinical and laboratory settings and
whilst this summary does not
Introduction provide a full review of the
literature, the key papers are
referenced. It is worth noting that
the term TENS could represent the
use of ANY electrical stimulation
using skin surface electrodes which
has the intention of stimulating
nerves. 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.
If you do a literature search on the
term TENS, do not be surprised if
you come across a whole lot of
‘other’ types of stimulation which
technically fall into this grouping.
TENS is a method of electrical
stimulation which primarily aims The illustrations shows a 2 channel
to provide a degree of TENS unit as it has 4 lead wires
symptomatic pain relief by exciting (Each channel has two lead wires)
sensory nerves and thereby with electrode pads attached.
stimulating either the pain gate
mechanism and/or the opioid
system. The different methods of
applying TENS relate to these
different physiological
 COLLEGE OF PHYSICAL THERAPY
Notes on TENS

Aβ fibres appear to appreciate

being stimulated at a relatively
high frequency HF (in the order of
90 - 130 Hz or pps). 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. Clinically it
is important to enable the patient
to find their optimal treatment
frequency – which will almost
certainly vary between individuals.
Mechanism of Action Setting the machine and telling the
The type of stimulation delivered patient that this is the ‘right’
by the TENS unit aims to excite setting is almost certainly not going
(stimulate) the sensory nerves, and to be the maximally effective
by so doing, activate specific treatment, though of course, some
natural pain relief mechanisms. pain relief may well be achieved.
For convenience, if one considers
that there are two primary pain An alternative approach is to
relief mechanisms which can be stimulate the A delta (Aδ) fibres
activated : the Pain Gate which respond preferentially to a
Mechanism and the Endogenous much low frequency LF (in the
Opioid System, the variation in order of 2 - 5 Hz), which will
stimulation parameters used to activate the opioid mechanisms,
activate these two systems will be and provide pain relief by causing
briefly considered. the release of an endogenous opiate
(encephalin) in the spinal
Pain relief by means of the pain cord which will reduce the
gate mechanism involves activation activation of the noxious sensory
(excitation) of the A beta (Aβ) pathways. In a similar way to the
sensory fibres, and by doing so, pain gate physiology, it is unlikely
reduces the transmission of the that there is a single (magic)
noxious stimulus from the ‘c’ frequency in this range that works
fibres, through the spinal cord and best for everybody – patients
hence on to the higher centres. The
 COLLEGE OF PHYSICAL THERAPY
Notes on TENS

should be encouraged to explore material of the electrodes, the

the options where possible. conductive gel or the tape
employed to hold the electrodes in
A third possibility is to stimulate place. Most TENS applications are
both nerve types at the same time now made using self adhesive, pre
by employing a burst mode gelled electrodes which have
stimulation. In this instance, the several advantages including
higher frequency stimulation reduced cross infection risk, ease of
output (typically at about 100Hz) is application, lower allergy incidence
interrupted (or burst) at the rate of rates and lower overall cost. Digital
about 2 - 3 bursts per second. TENS machines are becoming more
When the machine is ‘on’, it will widely available and extra features
deliver pulses at the 100Hz rate, (like automated frequency sweeps
thereby activating the Aβ fibres and and more complex stimulation
the pain gate mechanism, but by patterns) are emerging, though
virtue of the rate of the burst, each there remains little clinical
burst will produce excitation in the evidence for enhanced efficacy at
Aδ fibres, therefore stimulating the the present time. Some of these
opioid mechanisms. For some devices do offer pre-programmed
patients this is by far the most and/or automated treatment
effective approach to pain relief, settings.
though as a sensation, numerous
patients find it less acceptable than Impedence of Current
some other forms of TENS as there
is more of a ‘grabbing’, ‘clawing’ Flow
type sensation and usually more by The quantity of current that flow in
way of muscle twitching than with the tissues depend on impedance of
the high or low frequency modes. that pathway.The impedance
include oh-mic resistance and
TENS as a treatment technique is inductive resistance. The inductive
non invasive and has few side resistance negligible in the tissues .
effects when compared with drug Generally,watery tissue as
therapy. The most common blood,muscle and nerve has low
complaint is an allergic type skin ohmic resistance :bone and fat has
reaction (about 2-3% of patients) higher and epidermis has the
and this is almost always due to the highest of all.
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Notes on TENS

Conventtional Acupuncture-like Brief Intense TENS

TENS(High) TENS(Low)

Physiological To activate large To produce To activate small

Intervention diameter non- muscle twitch to diameter noxious
notious afferent activate small affrents to elicit
to elicit diameter motor peripheral nerve
segmental affrent to elicit blockade and
analgesia. extra segmental extrasegmental
analgesia. analgesia.

Clinical Low intensity High High intensity

Teqnique \High Frequency intensity\Low \High frequency to
at site of pain to frequency over produce maximum
produce strong muscle or parathesia
but comfrtable Acupuncture
sensation. points to produce
strong but
comfortable
contraction.

Duration of 30 min No more than 20 no more than 5

stimulation min min
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Notes on TENS

Types of TENS Contraindications

Electrode Placement  Patients who do not
comprehend the
Technique physiotherapist’s instructions or
this is determined by the target who are unable to co-operate
muscle or muscle group either  It has been widely cited that
single or in relation to other application of the electrodes
muscles over the trunk, abdomen or
pelvis during pregnancy is
 Unilateral : Unilateral contraindicated BUT a recent
placement causes inflammation review suggests that although
of one limb or half of muscle not an ideal (first line)
pair. treatment option, application of
 Bilateral : It allow the TENS around the trunk during
stimulation of both limbs or pregnancy can be safely applied,
both halves of a muscle Pair and no detrimental effects have
 Uni-polar : Only one of two been reported in the literature
essential leads and the electrode (see www.electrotherapy,org for
connected to it are placed over publication details).TENS
the target area affected by the during labour for pain relief is
stimulation This electrode is both safe and effective.
called treatment electrode.  Patients with a Pacemaker
 Quadripolar : Involve the use should not be routinely treated
of two sets of electrode each with TENS though under
originating from its own carefully controlled conditions
channel. It may be considered it can be safely applied. It is
the concurrent application of suggested that routine
two bipolar circuit. This application of TENS for a
technique could be used with patient with a pacemaker or any
stimulation of agonist and other implanted electronic
antagonist. Also could be used device should be considered a
in crossed pattern or for large contraindication.
flat area as back.  Patients who have an allergic
response to the electrodes, gel
or tape
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Notes on TENS

 Electrode placement over

dermatological lesions e.g.
dermatitis, eczema
 Application over the anterior
aspect of the neck or carotid
sinus

Precautions The Evidence for TENS

 If there is abnormal skin
for Pain Control
sensation, the electrodes should A 2020 review suggests that the use
preferably be positioned of TENS has positive outcomes in
elsewhere to ensure effective treatment of Primary Dysmenorrhea .
stimulation
 Electrodes should not be placed A 2014 study set out to provide a
over the eyes critical review of the latest basic
 Patients who have epilepsy science and clinical evidence for
should be treated at the TENS. Key findings were:
discretion of the therapist in
consultation with the  Application of TENS at
appropriate medical inadequate intensities is one of
practitioner as there have been the primary factors attributed to
anecdotal reports of adverse conflicting reports of TENS
outcomes, most especially (but efficacy. Using the strongest
not exclusively) associated with intensity that remains
treatments to the neck and upper comfortable produces
thoracic areas hypoalgesia in healthy subjects
 Avoid active epiphyseal regions is imperative; lower intensities
in children (though there is no are ineffective. In addition to
direct evidence of adverse activation of greater numbers of
effect) sensory afferents, higher pulse
 The use of abdominal electrodes amplitudes are proposed to
during labour may interfere activate deeper tissue afferents
with foetal monitoring allowing for greater analgesia.
equipment and is therefore best High intensity TENS decreases
avoided. post-operative opioid
 COLLEGE OF PHYSICAL THERAPY
Notes on TENS

requirements and negative modulation, a measure of

opioid-side effects. central inhibition.
 Both High Frequency(HF) and
Low Frequency(LF) TENS been Effectiveness on Chronic
shown to provide analgesia
specifically when applied at a
Pain
strong, non-painful intensity. There are nine reviews
HF TENS may be more effective investigating TENS use in people
for people taking opioids. with defined y chronic pain or in
 Effective analgesia for chronic people with chronic conditions
pain conditions may be limited associated with ongoing pain. One
by the development of tolerance review investigating TENS for
to TENS if repeated application phantom or stump‐associated pain
of either HF or LF TENS at the in people following amputation did
same frequency, intensity and not have anincluded studies. For
pulse duration is used daily. people with chronic pain, This
 Application of TENS electrodes overview offers very low quality
at acupoint sites may increases evidence and cannot confidently
analgesia and targeting the use make any statement regarding the
of TENS during movement or effectiveness of TENS for people
required activity may provide with chronic pain. The very low
the most benefit. quality of all reviewed evidence
means we have very limited
 Systematic reviews suggest that confidence in any suggested
TENS, when applied at estimate of effect for all outcomes
adequate intensities, is effective and the true effect is likely to be
for postoperative different from that summarised
pain, osteoarthritis , here and within individual reviews.
painful diabetic neuropathy and
some acute pain conditions.

 Emerging evidence suggests END.

TENs may be helpful for peoples

with fibromyalgia and spinal cord
injury .
 TENS may be effective in
restoration of central pain