Transcutaneous electrical nerve stimulation (TENS)

Introduction
Transcutaneous electrical nerve stimulation is the application
of low frequency in the form of pulsed rectangular currents through
surface electrodes on the patients skin to reduce pain.
Transcutaneous electrical nerve stimulation (TENS) currently
is one of the most commonly used forms of electroanalgesia.
Use of TENS: for various types of conditions such as low back pain
(LBP), myofascial and arthritic pain, sympathetically mediated pain,
bladder

incontinence,

neurogenic

pain,

visceral

pain,

and

postsurgical pain.
The currently proposed mechanisms by which TENS produces
neuromodulation

include the following:

Presynaptic inhibition in the dorsal horn of the spinal

cord
Endogenous pain control (via endorphins, enkephalins,
and dynorphins)
Direct inhibition of an abnormally excited nerve

Restoration of afferent input.

Recent clinical applications

Treatment for chronic and intractable pain, where the drug
therapy is undesirable or no longer effective.
Peripheral stimulation to control respiratory and urinary
functions.
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 Cerebellar stimulation for control of disorders in motor

function, including epilepsy.

Auditory and visual prosthesis

Therapeutic sleep treatments
In addition, Electrical stimulation was found to significantly
reduce the incidence of post operative complications such as
atelectasis and ileus.
The stimulation patterns are:
Rate 100-150 Hz
Pulse width 250- 400 s
Output level 20- 35 mA
What is pain?
Pain is an unpleasant disturbed sensation, which accompanies
the activation of nociceptors. Nocireceptors are sensory
receptors, which carries pain stimulus.
Any physical, chemical, thermal or mechanical stimulus like
heat, cold or pressure activates these nocireceptors. These are
free nerve endings found in all body tissues.
Once

these

nocireceptors

are

stimulated,

it

releases

neuropeptide, which initiates the electrical impulses along the

afferent fibres towards the spinal cord (dorsal horn), Then, the
afferent fibers carry the pain stimulus to the higher center.

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Electrical stimulation delivered by a TENS unit reduces pain

through nociceptive inhibition at the presynaptic level in the dorsal
horn, thus limiting its central transmission.
The electrical stimuli on the skin preferentially activate lowthreshold myelinated nerve fibers. The afferent input from these
fibers inhibits propagation of nociception carried in the small
unmyelinated C fibers by blocking transmission along these fibers
to the target or T cells located in the substantia gelatinosa (laminae
2 and 3) of the dorsal horn.
Electrical stimulation of neuromuscular tissue produces the
following responses
1. Initiate or block conduction of action potentials along
nerve pathways.
2. Stimulate contraction of specific muscle groups
3. Induce a state of anesthesia.
To accomplish these effects, a sufficient current density must be
established at a specific site for a given length of time.This will
cause a translocation of a specific amount of charge across the
tissue boundary
Charge transfer in regions far from the stimulating electrodes is
determined by four factors: Current magnitude, time of application,
electrode geometry, and tissue impedance.
For effective stimulation, current pulses should have a pulse
width approximately equal to the membranes electrical time
constant.

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The afferent fibers are of two types

1. A Delta fibres
2. C fibres
A Delta fiber:
Fast conducting large diameter myelinated fibres , which
conducts at the velocity of 5- 30 m/s
Fast pain that originates from receptors located in the skin is
transmitted by A Delta fibres
The pain stimulus is carried by peripheral nerves to the spinal
cord through Brain Stem to cerebral cortex where the pain is
appreciated at a conscious level.
C Fibres:
Slow conducting small diameter non-myelinated fibres , which
conducts with a velocity of 2-5 m/s
Slow pain that originates from both superficial skin and
deeper (ligaments and muscle tissue) are transmitted by C
Fibres.
This route involves a number of synapses and the inhibition of
impulses on their route to the cortex is a mechanism whereby
pain can be modulated.
Postulates of pain relief mechanism
The

gate

control

theory

stimulating sensory nerve

suggests

that

by

electrically

receptors, a gate mechanism is

closed in a segment of the spinal cord, preventing pain

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carrying messages from reaching the brain and blocking the

perception of pain.
The

Endorphin

release

theory

suggests

that

electrical

impulses stimulate the production of endorphin in the body.

This morphine like substances block pain messages from
reaching the brain.
The pain is controlled by
The gate of passage of pain stimulus to cerebral cortex usually
is closed, inhibiting constant nociceptive transmission via C
fibers from the periphery to the T cell.
When

painful

peripheral

stimulation

does

occur,

the

information carried by C fibers reaches the T cells and opens

the gate, allowing pain transmission centrally to the thalamus
and cortex, where it is interpreted as pain.
The gate control theory postulated a mechanism by which the
gate is closed again, preventing further central transmission of
the nociceptive information to the cortex. The proposed
mechanism for closing the gate is inhibition of the C-fiber
nociception by impulses in activated myelinated fibers (A Delta
fibres).
This gate control mechanism modulates sensory inputs (neuro
modulation) before they evoke pain perception.
The postulate is that stimulation of fast conducting A-B fibres
inhibits smaller, slower conducting C fiber sensory inputs.
Both afferent fibres conduct at low frequency

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(ie) A Delta fibres -> 40 pulses / sec and

C Fibres -> 15 pulses / sec.

If a higher frequency of stimulation is applied a physiological

block to conduction might occur.
The device that is used to produce this frequency is TENS.
PAIN RELEIF THROUGH ELECTRICAL STIMULATION:
Electrical impulses are used to block the pathways of the
transmission of pain.
The impulses are produced in a battery-powered pulsegenerator to which pair of electrode-tipped wires is attached.
Applied to the skin overlying any painful area of the body.
These electrodes provide continuous, mild electrical
stimulation.
These signals seem to jam the pain signals traveling along the
nerve pathways before they can reach the brain.
Effective placement of the stimulating electrodes produces a
tingling sensation in the painful area.
TENS instrumentation:

TYPES OF WAVEFORMS:
Square wave.

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 Spike wave.
Rectangular wave
Most of the stimulators have adjustable settings to control the
amplitude (Intensity) of stimulation by controlling voltage, current
and the width (duration)of each pulse.
Electrodes are placed at specific sites on the body for treatment
of pain.
The current travels through the electrodes and into the skin,
stimulating

specific

nerve

pathways

to

produce

tingling

or

massaging sensation that reduces the perception of pain

Pulse width, Frequency and Intensity
Pulse width : often fixed at 100s or 200 s
Frequency: can be as low as 2 Hz or as high as 600 Hz.
A frequency of 150Hz is commonly used.
Intensity can be varied from 0 to 60 mA.
The patient or therapist can control the intensity and a
tingling sensation should be felt.
For spike pulse waveform,
500 ms spike pulse
Adjustable intensity

------>0 to 75mA

Adjustable frequency
For Square stimulating waveform,

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------>12 to100 pulses per sec.

 Pulse frequency .> 20-200 Hz

Pulse width

..> 50-100 s

Output voltage .> 0.1 120 V

Output Current > 25 mA
Electrodes

Transcutaneous electrical nerve stimulation (TENS) electrodes

are commonly molded from an elastomer such as silicon
rubber, loaded with carbon particles to provide conductance.

Conformability is achieved by making the electrode thin.

Skin irritation at the site of electrode application is diminished
by the use of carbonized rubber electrodes applied with a
tinture of Benzoin interface.
Usefully carbon loaded silicon rubbers have a minimum
resistivity near 10 ohm cm.

A thin electrode may exhibit impedance which is not negligible

as compared to the impedance of the interface and tissue
under it (Elecrode- tissue interface).

The skin electrode system must be designed to minimize

impedance variations with motion, to conform to the body
surface to provide uniform impedance across the surface of
the electrode and to have an adequate surface area.
The adequate surface area can be determined keeping in view
the peak square- wave current threshold of thermal damage as
a function of the electrode surface area.

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Current threshold of thermal damage Electrode Surface area

The thermal damage threshold varies widely with skin

impedance, which is a function of skin preparation.

Positioning of electrodes (various triggering Zones)

Acupuncture points , motor points or trigger points
The area of greatest intensity of pain
The appropriate spinal segment.
The appropriate peripheral segment.
Whichever position is chosen for electrode placement , its best
if the skin below them has an intact sensory mechanism.
Complications

Electrodes used in TENS should be relatively large (4 cm 2) to

reduce current densities at the skin surfaces. Because the
application times are relatively long, the development of a skin
rash at the stimulation site is the most frequent complication.

Safety Aspects of TENS

TENS electrodes should never be placed:
Over the eyes due to the risk of increasing intraocular
pressure
Trans cerebrally
On the front of the neck due to the risk of an acute
hypotension or even a laryngospasm.

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 Through the chest using an anterior and posterior electrode

positions
Internally, Except for specific applications of dental, vaginal,
and anal stimulation that employ specialized TENS units.
On broken skin areas or wounds, although it can be placed
around wounds.
Over a tumor/ malignancy
Directly over the spinal column
Should never be used across an artificial cardiac pacemaker
(or other indwelling stimulator, including across its leads) due
to risk of interference and failure of the implanted device.
On areas of numb skin/ decreased sensation TENS should be
used with caution because it is likely less effective due to
nerve damage.
It may also cause skin irritation due to inability to feel
currents until they are high.
TENS should also be used with caution in people with epilepsy
or pregnant women
Tens should not be used over area of the uterus as the effects
of electrical stimulation over the developing fetus are not
known.
There is an unknown level of risk when placing electrodes over
an infection (possible spreading due to muscle contractions),
but cross contamination with the electrodes themselves is of
greater concern.

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