TENS

Transcutaneous Electrical Nerve

Stimulation Therapy
 OBJECTIVES:
 Definition
 Characteristics
 Modes
 Pain theories
 Pain modulation
 Technique of application
 Therapeutic uses
 Contraindications and dangers
 Clinical Method of application
 DEFINATION:
 Defined as the application of pulsed current
over the skin surface for the purpose of pain
modulation or pain relief.

 It is an EPA capable of inducing

electroanalgesia by means of pulsed electrical
current delivered over the skin surface.
 CHARACTERISTICS:
 Wave form
 Pulses versus burst of pulses
 Current amplitude
 Wave form:

 It is biphasic either symmetrical or

asymmetrical, and balanced.
 Pulses v/s burst of pulses:
 The TENS units may be programmed as to
deliver: single pulse or burst of pulses
 IPD

PD

IBuD

BuD
PULSE/INTERPULSE DURATION:
 PD varies between 50 and 400us.
 The IPD is the elapsed time between each
pulse. Its value varies according to the set pulse
frequency and pulse duration.
 Pulse frequency is defined as the number of
pulses delivered per sec and is commonly
expressed in Hz, in most TENS PF ranges
between 1 – 200 Hz.
 BURST OF PULSES:
 Among 5 classic modes of TENS therapy, one is
known as Burst TENS, in which electrical pulses are
delivered in bursts of pulses. The number of pulses
per burst varies from one TENS unit to the next.
 BuD, is the time elapsed from the begining to the
termination of one burst, where as the IBuD is the
duration between two bursts.
 Burst Frequency (f), expressed in bursts per second,
it is low in most TENS, ranging between 1 and 10
bups, and the number of pulses per burst often
ranges between 5 and 10 pulses.
 CURRENT AMPLITUDE:
 Current amplitude refers to the magnitude of
current delivered by the TENS unit and is
measured in milliamps.
 In most TENS stimulators, current amplitude
varies between 0 – 120 mA. Such a range of
current amplitude is more than necessary to
depolarize all peripheral nerve fibers within
and through the skin.
 MODES:
 Total 5 modes of TENS on the basis of
stimulation parameters (pulse/burst duration,
pulse burst frequency and current
amplitude)and physiological and therapeutic
requirements:
 CONVENTIONAL
 ACUPUNCTURE – LIKE
 BRIEF INTENSE
 BURST
 MODULATION
 CONVENTIONAL TENS:
 CONVENTIONAL TENS OR HIGH RATE TENS :
The form of application of TENS mode is based on sensory level
stimulation . Sensory level stimulation is above the sensory threshold
but not above the motor threshold. Modulation of pain is achieved
via inhibitor of pain fibers by large diameter fiber activation, that is ,
gate mechanism. Pain relief is usually fast. It uses following
parameters.

1: Frequency : 50 to 100 pps

2: phase /pulse duration : 2 to 50 microsecond
3: Amplitude : Comfortable tingling or pins
4: Electrode placement : around or over the site of pain , are almost
commonly place.
5 : Duration of treatment : 15 to 20 minutes
6: Indications: acute to chronic pain
 ACUPUNCTURE LIKE TENS
 STRONG LOW RATE TENS OR ACUPUNCTURE LIKE TENS:

This form of application is based on motor-level stimulation that produce

visible muscle contraction. It is applied in chronic pain. Analgesic is
produced through stimulated -evoked production of endogenous opiates. It
uses following parameters:

1: Frequency : 1 to 5 pps
2: phase /pulse duration : 150 to 300 microsecond
3: Amplitude : strong, but comfortable twitches
4: Electrode placement : place in an area remote from the pain site over
acupuncture points/related dermatomes/myotomes.
5 : Duration of treatment : 30 to 40 minutes
6: Indications: chronic pain
 BRIEF INTENSE TENS
 BRIEF INTESE TENS
This mode provides quick but short-term pain relief,
and is suitable prior to passive muscle stretching, deep
friction massage, joint mobilization and wound
debridement. Following parameters are used:

1: Frequency : 80 to 150 pps

2: phase /pulse duration : 50 to 250 microsecond
3: Amplitude : To patient tolerance
4: Electrode placement : over motor
points/myotomes/dermatomes
5 : Duration of treatment : 15 to 20 minutes
6: Indications: soft tissue tightening
 BURST TENS
 BURST MODE OR PULSE TRAIN TENS:
This mode combines the characteristics of both high and low
rate versions. Stimulates endogenous opiates but the current
is more tolerable to patients as compared to low rate TENS .
Use the following parameters.

1: Frequency : 50 to 100 pps

2: Phase/pulse duration: 50 to 200 microsecond
3: Amplitude : comfortable /intermittent
4: Electrode placement : over motor points/directly over pain
sites/dermatomes/myotomes
5 : Duration of treatment : 15 to 20 minutes
6: Indications: acute as well as chronic pain.
 MODULATION TENS
 The mode calls upon the random electronic
modulation of pulse duration, pulse frequency
and current amplitude.
 WHICH MODE IS BEST?
 The current body of evidence does not support
view that one mode of TENS delivery is better
than any other for any painful pathological
conditions.
 Evidence obtained from long-term users of TENS
therapy reveals no correlation between patient,
site, and cause of pain versus TENS mode
selection (Johnson et al.).
 This explain why the general recommendation is
to begin therapy with the conventional modes of
TENS.
 Review articles by Bjordal et al. (2003) and
Johnson et al. (2007) suggest that TENS
therapy, regardless of mode delivery, can
provide significant pain relief and as a result,
presents as a viable alternative to drug and
surgical therapy.
 PAIN CONTROL
THEORIES
Where have we been?

Where are we now?

 Where have we been?
 Specificity theory
 4 types of sensory receptors – heat, cold, touch, pain
 A nerve responded to only one type
 Nerve was continuous from the periphery to the brain
 Pattern theory
 A single nerve responded to each type of sensation by
creating a code (i.E. Different telephone rings)
 Gate control theory
 Melzack & wall, 1965 – the basis for theories today
 Non-painful stimulus can block the transmission of a
painful stimulus
 Pain Theory: Historical
Perspectives
 Theories regarding the cause, nature, and
purpose of pain have been debated since the
dawn of humankind.
 Most early theories were based on the
assumptions that pain was related to a form of
punishment.
 The word “pain” is derived from the Latin
word “poena” meaning fine, penalty, or
punishment.
 The Romans, coming closer to contemporary
thought, viewed pain as something that
accompanied inflammation.
 In the 2nd century, Galen offered the Romans his
works on the concepts of the nervous system.
 However, the views of Aristotle weathered the winds
of time.
 In the 4th century, successors of Aristotle
discovered anatomic proof that the brain was
connected to nervous system
 Despite this, Aristotle’s belief prevailed until the 19th
century, when German scientist provided irrefutable
evidence that the brain is involved with sensory and
motor function
 Specificity Theory of Pain
Modulation
 Modern concepts of pain theory continue to
advance from the ideas of Aristotle.
 However, controversy still exists as to which theories
are correct.
 The theories accepted at the turn of the century
were the specificity theory and the pattern
theory, two completely different and seemingly
contradictory views
 The specificity theory suggests that there is a
direct pathway from peripheral pain receptors
to the brain.
 The pain receptors are located in the skin and are
purported to carry pain impulses via a continuous
fiber directly to the brain’s pain center
 The pathway includes the peripheral nerves, the
lateral STT (spinothalamic tract) in the spinal cord
and the hypothalamus (the brain’s pain center)
 This theory was examined and refuted using clinical,
psychological, and physiological evidence by
Melzack and Wall in 1965.
 They discussed clinical evidence describing pain sensations
in severe burn patients, amputee patients, and patients with
degenerative nerve disease.
 These syndromes do not occur in a fixed, direct
linear system
 Rather in the quality and quantity of the
perceived pain are directly related to a
psychological variable and sensory input.
 This theory had been previously addressed by
Pavlov, who inflicted dogs with a painful
stimulus, then immediately gave them food.
 The dogs eventually responded to the stimulus
as a signal for food and showed no responses
to the pain
 The psychological aspect of pain perception was later
addressed by Beecher, who studied 215 soldiers
seriously wounded in the Battle of Anzio, finding that
only 27% requested pain-relieving medication
(Morphine).
 When the soldiers were asked if they were
experiencing pain, almost 60% indicated that they
suffered no pain or only slight pain, and only 24%
rated the pain as bad.
 This was most surprising because 48% of the soldiers
had received penetrating abdominal wounds.
 Beecher also noted that none of the men were suffering
from shock or were insensitive to pain because
incompetent intravenous insertions resulted in
complaints of acute pain.
 The ancient Greek believed that pain was
associated with pleasure because the relief of
pain was both pleasurable and emotional.
 Aristotle reassessed the theory of pain and
declared that the soul was the center of the
sensory processes and that the pain system was
located in the heart
 The conclusion was drawn that the pain experienced
by these men was blocked by emotional factors.
 The physical injuries that these men had received was
an escape from the life-threatening environment of
battle to the safety of a hospital, or even release form
the war.
 This relationship suggests that it is possible for the
central nervous system to intervene between the
stimulus and the sensation in the presence of certain
psychological variables.
 No physiological evidence has been found to suggest
that certain nerve cells are more important for pain
perception and response than others; therefore, the
specificity theory can be discounted.
 Contemporary Pain
Control Theories
 Although both the specificity and pattern
theories of pain transmission were eventually
refuted, they did provide some lasting
principles that are still present in contemporary
pain modulation theories
 The strengths of these 2 theories, plus findings
obtained through additional research, were factored
together to for the basis of the current perspective
regarding pain transmission and pain modulation.
 Still, there is much to be learned and studied
before the exact mechanisms of pain
transmission and perception are understood.
 Pattern Theory of Pain
 States that there are no specialized receptors in
the skin.
 Rather, a single “generic” nerve responds
differently to each type of sensation by creating
a uniquely coded impulse formed by a
spatiotemporal pattern involving the frequency
and pattern of nerve transmission.
 An analysis of the word’s elements
 “Spatio”- the distance between the nerves impluses
 “temporal”- the frequency of the transmission
 An example of this type of coding can be found
with most institutional phone systems.
 A call from inside a university has a different ring
from an outside call.
 Although this theory was closer to being
neurological correct there were still
shortcomings
 Melzack and Wall disproved this theory as well,
based on the physical evidence of physiological
specialization of receptor-fiber units.
 Plus this theory failed to account for the brains role in
pain perception.
 Gate Control Theory
 Implies a non-painful stimulus can block the
transmission of a noxious stimulus.
 Is based on the principle that the gate, located
in the dorsal horn of the spinal cord, modulates
the afferent nerve impulses.
 The SG (substantia gelatinosa) acts as a modulating
gate or a control system between the peripheral nerve
fibers and central cells that permits only one type of
nerve impulse (pain or no pain) to pass through.
 SG monitors the amount of activity occurring on both
incoming tracts.
 Opening and closing the gate to allow the appropriate
information to be passed along to the T cell.
 Impulses traveling on the fast, non-pain fibers ↑
activity in the SG.
 Impulses on the slower pain fibers exert an
inhibitory influence.
 When the SG is active, the gate is in its “closed”
position and a non-painful stimulus is allowed to
pass on to the T cell.
 Example:
 Bumping the head
 The initial trauma activates the A-delta and, eventually,
C fibers
 Rubbing the traumatized area stimulates the A-beta
fibers, which activate the SG to close the spinal gate
 Thus inhibiting transmission of the painful stimulus
 Phantom limb pain
 Melzack (1992) 7 features
1. Phantom limb feels real. Sometimes amputees
try to walk on their phantom limb.
2. Phantom arm hangs down at the side when
resting. Appears to swing in time with other
arm, when walking.
3. Sometimes gets stuck in awkward position. If
behind the patients back, then patient feels
obliged to sleep on stomach.
4. Artificial limb appears to fit like a glove. See
artificial limb as part of their body.
 Phantom limb pain
5 Phantom limbs give impression of pressure
and pain
6 Even if phantom limb is experienced as
spatially detached from the body, it is still felt
to belong to the patient.
7 Paraplegic people experience phantom limbs.
They can even experience continually cycling
legs.
 Phantom limb pain
Not just the cut nerve endings (neuromas) sending
messages to the brain, because cuts made
along the neural pathways only produce a
temporary relief from pain.
 Phantom limb pain
Melzack believes - brain contains a neuromatrix of
the body image - neurosignature - like a hologram.
 Phantom limb pain
Connections to this neuromatrix - sensory systems,
emotional and motivational systems. It is the
emotional and motivational systems that cause
the phantom limb experience.
 Phantom limb pain
 Neuromatrix pre-wired - young amputees
experience phantom limb pain.
 People born without limbs also experience
phantom limb pain.
Gate Control Theory
Proposed by Melzack and Wall in the 1960's
 Gate opened or closed by 3
factors

1. Activity in the pain fibres - opens the gate

2. Activity in other sensory nerves - closes the
gate
3. Messages from the brain - concentrating on the
pain or trying not to think about it
CONDITIONS THAT OPEN OR CLOSE THE GATE
  Conditions that open the Conditions that close the
gate gate

Physical Extent of the injury Medication

conditions

  Inappropriate activity Counterstimulation, eg

level massage
Emotional Anxiety or worry Positive emotions
Conditions

  Tension Relaxation

  Depression Rest

Mental conditions Focusing on the pain Intense concentration or

distraction

  Boredom Involvement and interest

in life activities
 Three variables control this gate
1. A-Delta fibres (sharp pain)
2. C fibres (dull pain)
3. A-Beta fibres that carry messages of light touch
 Pain Gate Theory
 Special neurons located in the grey matter of the
spinal cord make up the gate This gate has the
ability to block the signals from the a-delta and
c-delta fibres preventing them from reaching the
brain.
 Pain Gate Theory
 The special neurons in the spinal cord are
inhibitory ie they keep the gate closed. These
special neurons make a pain blocking agent
called enkephalin. This is an opiate substance
similar to heroin which can block Substance P
the neurotransmitter from the C fibres and the
A-delta fibres and this keeps the gate closed.
 Pain Gate Theory
 C-Fibres and A-Delta fibres obstruct (inhibitory)
the special gate neurons and tend to open the
gate. A-beta fibres are irritable (excitatory) to the
special gate neurons and tend to keep the gate
closed.
 Pain Gate Theory
 If impulses in the C and A-Delta Fibres are
stronger than the A-beta Fibres the gate opens.
A-delta fibres are always stronger.
 Pain Gate Theory
 Specialised nerve impulses arise in the brain
itself and travel down the spinal cord to influence
the gate. This is called the central control trigger
and it can send both obstructive and irritable
messages to the gate sensitising it to either C or
A-beta fibres.
 TENS has rapidly been accepted as a standard modality in the
management of both
acute and chronic pain

ES controls pain noninvasively and without narcotics.

TENS therefore, is a specialized form of ES that is designed to

reduce pain, in contrast to other form of ES.

The compact, portable TENS devices are available today are

ideal for patient use ,offering continuity as well as
continuation of care once the patient is out of the hospital.

TENS is generally an alternating current , characterized by a

variable phase duration and a variable phase interval which
can be used to vary the frequency.

TENS produce their effects by activation of opioid receptors in

the central nervous system
 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 aim, namely to describe the kind of pulses
produced by portable stimulators used to treat pain.

The unit is usually connected to the skin using two or

more electrodes.

A typical battery-operated TENS unit is able to

modulate pulse width, frequency and intensity.
Generally TENS is applied at high frequency (>50 Hz)
with an intensity below motor contraction (sensory
intensity) or low frequency (<10 Hz) with an intensity
that produces motor contraction.
 CLINICAL USES OF
TENS:


1: Pre and post operative surgical pain

2: Non-united fracture pain
3: Healing
4: TM joint Pain
5: podiatric pain
6: Dental pain
7: Obstetrics
8: Acute Arthritis
9: Sports Injuries
10: Alleviate neuropathic pain

It is used extensively and recommended by sports coaches,

physiotherapy, pain clinics, doctors and other medical practitioners.

PAIN RELIEF BY TENS :
1: TENS is said to alter the sensitivity of the peripheral receptors or
free nerve ending which conduct and transmit the nociceptive
stimuli .Increased blood circulation may be caused due to muscle
contraction and relaxation specifically when using a burst or
modulative mode. Thus improved blood supply will bring more
oxygen and help to remove the exudates.

2: Transmission of impulses in A-delta and C- fibers (afferent nerves)

which convey the nociceptive information is blocked by TENS.
Blocking of A-delta and C-fibers, causing analgesia, is achieved at
the 100 bps with a pulse duration of 500/sec given for 20 minutes
continuous stimulation. Burst or rhythmic stimulation , in contrast ,
will not produce analgesia.

3: Autonomic nerves system is also effected by TENS frequency of

about 100 bps bring improved circulation , which helps in relieving
pain by removing the exudates from the area and by bringing more
oxygen for the part.
 ENDORPHINE CONCEPT
 The body produces endorphin, a morphine-like
molecule to serve as an endogenous analgesics
whenever the body senses pain.

Blood levels of this substance increases when the

incoming signals to the brain indicate the presence
of pain.

TENS research indicates that endorphin production

may be enhanced by ES , producing a pain like
reaction effect on the cells producing the endorphin
HOW DOES TENS WORK?
There are two theories that explain why this technology works as
an alternate therapy for acute and chronic pain.:

The first is the Gateway Theory. Its premise is that the electrical
stimulation blocks pain that is transmitted through nerve endings.

The second theory is the Endorphin-release Theory. These

electrical currents trigger the body to produce endorphins which
help the body's nerve system to combat pain. This type of therapy
produces, and provides, thousands of individuals with relief from
back and neck pain, and recovery from surgery and injury,
without the need for prescription drugs.
 "TENS units are an affordable alternative for
those suffering pain," Maroney explained. "No
matter which theory you or your medical
professional believes in, this technology is
becoming more mainstream in the U.S.; it has
developed a reputation as an effective
alternative therapy."
IS CONTINUAL USE OF A TENS
UNIT ADDICTIVE?

No. One of the problems encountered in the medical

field of pain relief is sometimes a patient is told to use
only TENS unit for one hour. That is not correct.

The TENS unit is used when you have pain while

sitting down, trying to get to sleep at night, or
exercising such as golfing, aerobics etc. If you turn the
unit off and your pain returns then turn it back on.
 CAN PAIN RELIEF
GELS/LOTIONS BE USED WITH
TENS FOR PROLONGED
RELIEF ?
Yes. It actually may be beneficial to use them in
conjunction with the TENS unit. The TENS unit can
increase the blood flow to the painful area and the
absorption of the gel may be enhanced by giving
better penetration and pain relief from the gel.

The "carryover" effect of using TENS is enhanced

with the use of topical gels. Carryover is the amount
of relief time (one has after using a TENS unit) before
the pain returns and the patient is uncomfortbable
again
CAN ELECTRICAL STIMULATION
HELP OPEN WOUNDS HEAL
AND BONES THAT WILL NOT
REATTACH?
Yes. Most of the studies were done on wounds
with a form of stimulation called pulsed
galvanic stim. There was one report on the use of
TENS for decubitus ulcers. Electrical stimulation
can be very helpful for diabetic patients who
have open wounds occur on their feet and legs.
For bones, the current is generally a micro
current or the use of the electrical field created
by a circumduction coil.
 Case 1
 
A 50-year-old man had a15-years
history of histamine cluster headaches,
often disabling, without satisfactory
response to various medications. He
had several medical workups including

computerized axial tomography.
 
Treatment consisted of one half to one hour treatment
sessions with active electrodes placed bitemporally and
one referable electrode placed on the right posterior
neck. This patient received immediate complete relief
of his headaches which lasted up to 24 hours.
Treatments were continued every 24 hours with
continued relief.
  
A 48-year-old woman had a six-month history
of a constant nagging pain along the lateral
side of the right leg from below the knee to
the ankle. There were no other symptoms or
signs. Further history indicated that she had
been on
Anti-tuberculosis therapy for longer than nine
months. This patient underwent an extensive
workup including nerve conduction velocities
and electromyography which were reported
  as normal.
The TENS treatment was with circular electrodes, the
active around the right ankle and the referable around
the leg just below the knee. The treatment took
approximately 45minutes. She obtained complete relief
with one treatment without recurrence of pain.
 
  
A 49-year-old man with T4-level paraplegia of three
years duration, secondary to a fall off a ladder,
presented for therapy. He had had severe, constant
pain at the operation site and over the upper back. The
examination was negative for peripheral pain. Tests,
including tomography, were normal for his condition.
Surgical intervention was
not indicated; further, the patient did not desire any
surgical procedure. Potent medications werepartially
effective.
The TENS treatment consisted of a total of six electrodes, two
placed over the operative site, two over the upper trapezius, and
two on the posterior neck. The treatments were for one hour
periods. Relief was experienced for one and half hour initially,
with increasing pain-free periods with subsequent treatments. The
patient has decreased his medications and can now participate
fully in his exercise maintenance program and a more complete
social life utilizing his wheelchair. He owns a home TENS unit.
 
 Case 4
 
A 39-year-old markedly obese woman,
working as a chef, had a four-year history of
unbearable low and mid back pain. She wore a
high back brace, was on potent analgesics,
and could not sing in her church choir.
Because of her weight and other medical
factors, surgical intervention was not
considered practicable. She was treated with
TENS: two active electrodes over the low back
and two referable electrodes para spinal in

the mid-back region.
Treatment consisted of one hour sessions . After three treatments
she decreased her medications, resumed her profession at home
and singing in the church choir. She, also, owns a home unit.
TREATING ACUTE AND
CHRONIC PAIN:
Prior Medications:
If the patient has been on heavy medication prior to starting
TENS , sufficient time should be allowed for the effects of the
drugs to diminish, usually a week or so, before the
effectiveness of the TENS program is evaluated.

Preparing the Patient:

Skin in the area of electrode placements should be clean and
clear of lesions. Standard electrical conduction gels or sprays or
sponge electrodes. Commercial tapes or house hold mending
tapes may be used to secure electrodes in position for short
term use. Longer applications may requires special tapes
and /or electrodes to maintain contact throughout the long
period of stimulation, perhaps for hours or days.
ELECTRODE PLACEMENT:

Probably one of the most controversial topics with TENS is

the question of ideal electrode placement.

Many techniques are suggested, based on nerve roots,

acupuncture points , and trigger points ; all are valuable but
vary with each individual case.

The use of electrical probes is sometimes effective in

locating tender or key points.

An experienced practitioner with TENS will quickly be able

to establish several key anatomic points to cover most
conditions.
 PLACEMENT OF ELECTRODES FOR THE UPPER
EXTREMITY :
Nerve root
Acromion tip
Lateral epicondyl

 PLACEMENT OF ELECTRODES FOR THE LOWER

EXTREMITY :
Nerve root
Gluteal
Popliteal
Posterior lateral malleolar

 PLACEMENT OF ELECTRODES FOR THE LOWER BACK:

Associated nerve roots/dermatomes
Gluteal site
Popliteal site
Crossed pattern
GENERAL CONFIGURATION:

1: Associated Nerve roots/Dermatomes

2: Point of pain
3: Acupuncture point proximal to point of pain
4: Acupuncture point distal to point of pain
5: If the pain can be pin-pointed, consider the cross –pattern
techniques, above with the crossing point at the painful site.
6: Trans-arthral placements are effective at the shoulder,
knee , elbow, wrist, and foot.
7: Bilateral placements are extremely effective when
practical, especially with mid back and low back conditions.
8: Contra-lateral placements are suggested when the pain
site is not accessible due to amputation, dressings, open
wounds, and casts.
9: Rarely more than four electrodes needed.
 OBSTETRICS CASES :
LABOR AND DELIVERY:
The use of TENS as a form of analgesia for delivery is growing
rapidly.
Apparently safe/ noninvasive/nondrug method of providing a
relatively pain-free delivery.

Techniques During Labor:

Prior to labor:
familiarize the mother-to-be in the use of the TENS unit and the
parameters controls.
Instruct her to place (or have placed) two electrodes at the mid thoracic
level on each side at the spine, near the nerve root.

Elongated electrodes(1x6 inches) are preferred so that several nerve

roots may be covered , extending distally from approximately T8 to
L1 . This circuit is activated on the morning of immediate delivery
and left on all through delivery.
 Parameters:
Frequency : Should be high (80 to 120 Hz)
Pulse Width should be medium(150 usec)
Amplitude should be comfortable.

During Labor Contractions:

A second pair of elongated electrodes, may be placed para-vertebrally
along the lowest portion of the spine ( approximately at S1 and
below) .

Activate this circuit with each labor contraction. Parameters are same
as above, except that amplitude may be increased to block the
contraction pain but should not be left on when the pain decrease.

Second Stage of Labor:

Remove the distal two electrodes from the sacral region and relocate,
in a V configuration, diagonal and lateral to pubis triangle; activate
them to coincide with contraction pain. Do not change frequency or
width, but amplitude may be increased to block contraction pain
although not enough to cause muscle contractions.
 Special Circumstances Following Labor:


TENS may be used following delivery for postpartum

pain. With cesareans sectioned patients, the incision and
scar discomfort may also be modified with TENS
applications. The placement of electrodes is different ;
place the proximal pair as described previously, but
place the distal pair at both ends of the incisions/scars.

Parameters:
Frequency: should be high ( 80 to 120 Hz )
Pulse width : should be medium ( 150 usec)
Amplitude : should be minimal
Regimens should be 1 hour , four times daily. If pain
is severe , additional sessions are recommended ; if
treatment is necessary for as prolonged period of time
, modulation may be added to the current to avoid
accomodation.
 MORNING SICKNESS:

TENS has also proved effective in controlling “morning sickness”

and other forms of nausea(e.g following chemotherapy and
medications)
Parameters:
Frequency: 80 to 120 Hz
Pulse Width: should be medium( 150 usec)
Amplitude should be minimal but sensed
Regimen should be 30 minutes every morning

Incisional and Scar Pain:

Incisional and scar pain should be treated as acute pain.

Parameters same as above :

Electrode Placements:
SAFETY & PRECAUTIONS:
1: Do not place electrodes in the area of the carotid
artery(Sinus) in the antero -lateral region of the neck.

2: Do not use TENS on a patiient with a demand-type pace

maker in place.

3: Do not administer TENS for undiagnosed pain. Pain is an

important diagnostic symptoms and should not be masked.

4: Extreme caution is needed with patients under the

influence of narcotic medication or who are known to have
hyposensitive areas.

5: Caution is recommended in using TENS for pain control

for a pregnant patient other than for labor/delivery.


6: 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 a acute

hypotension (through a vaso-vagal reflex) or even a laryngo-
spasm through the chest using an anterior and posterior
electrode positions, or other trans-thoracic applications
understood as "across a thoracic diameter"; this does not
preclude coplanar applications

On broken skin areas or wounds, although it can be placed

around wounds.
Over a tumor/malignancy (based on in vitro experiments
where electricity promotes cell growth)

Directly over the spinal column

 On areas of numb skin/decreased sensation TENS
should be used with caution because it's likely less
effective due to nerve damage. It may also cause
skin irritation due to the inability to feel currents
until they are too high.
There's an unknown level of risk when placing
electrodes over an infection (possible spreading
due to muscle contractions).
TENS should also be used with caution in people
with epilepsy or pregnant women; do not use over
area of the uterus as the effects of electrical
stimulation over the developing fetus are not
known.
THANK
YOU!!!