Saurab Sharma presented on Transcutaneous Electrical Nerve Stimulation (TENS). The objectives were to understand TENS theory, application techniques, uses, electrode placement, and precautions. TENS delivers electricity across the skin to activate nerves and provides pain relief for acute, chronic non-malignant, and palliative malignant pain. Different application techniques include high frequency, low frequency, brief intense, burst mode, and modulated TENS. Common uses are postoperative, labor, musculoskeletal, and neuropathic pain. Electrodes are placed over painful sites and precautions taken with pacemakers, malignancy, and skin conditions.

1. Saurab Sharma, MPT
Lecturer, KUSMS
TENS (Transcutaneous Electrical
Nerve Stimulation)
MSK II
Physiotherapy II
Electrotherapy
Lecture 1

2. Objectives of session
 At the end of the class, students will be
able to:
 Understand the theory of TENS
 Explain the techniques of TENS
application
 Identify the uses of TENS
 Identify Precautions and2

3. Contents
 Introduction
 Features of TENS
 Applications of TENS
 Uses of TENS – common and uncommon
 Electrode Placement
 Precautions and contraindications
3

4. Introduction
 Transcutaneous Electrical Nerve
Stimulation
 Delivers electricity across the intact surface
of the skin to activate underlying nerves
 Simple, non-invasive analgesia causing
modality
 For pain- acute, chronic non-malignant
 For palliative care of malignant conditions4

5. Keys principles
Outcome of treatment is based on the:
 Knowledge of intent of TENS
application
 Location of electrode placement
 Selection of appropriate current types
 Dosage
5

6. Principles of Nerve Fibre
Activation
 Initially- stimulation of non-nociceptive
nerve fibres like A-alpha, A beta fibres
which have low threshold of stimulation
causing tingling
 Followed by activation of A-delta and C-
fibres causing pain
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7. Principles of Nerve Fibre
Activation
 Low intensity current with pulse duration
50-500 micro seconds stimulates larger
diameter fibres (A beta) without
activation of smaller diameter fibres (A
delta and C)
 Pulse duration more than 500 micro
seconds activates small diameter fibres7

8. Typical features of TENS
Pulse wave form • Monophasic
• Symmetric biphasic
• Asymmetric biphasic
Pulse amplitude
(adjustable)
1-50 mA
Pulse duration (often fixed) 50- 500 micro seconds
Frequency 1- 200 Hz
Pulse patterns Continuous
Burst
Channels Single or double channels
8

9. Parameter High-TENS Low TENS Brief -TENS
Intensity Sensory Motor Noxious
Pulse
Frequency
(Hz)
60-100 Hz 2-4 Hz Variable
Pulse (micro
sec)
60- 100 150- 250 300 – 1000
Mode Modulated Modulated
Burst
Modulated
Treatment
duration
As needed 30 minutes 15- 30
minutes
Onset of
relief
<10 minutes 20- 40
minutes
< 15 minutes9

10. Techniques of TENS application:
1. Conventional or High Frequency
TENS
2. Acupuncture or Low Frequency TENS
3. Brief Intense TENS
4. Burst Mode TENS
5. Modulated TENS
10

11. Techniques of TENS application:
1. Conventional or High Frequency
TENS
2. Acupuncture or Low Frequency TENS
3. Brief Intense TENS
4. Burst Mode TENS
5. Modulated TENS
11

12. 1. Conventional /High Frequency
TENS
 Paresthesia is created without motor
response
 A-Beta filers are stimulated to SG
enkephlin interneuron (pure gate theory)
 Applied 30 minutes to 24 hours
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13. 1. Conventional /High Frequency
TENS
 Creates the fastest relief
 Relief is short lived (45 sec 1/2 life)
 May stop the pain-spasms cycle
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14. Application of High TENS
 Pulse rate: high 75-100 Hz (generally
80), constant
 Pulse width: narrow, less than 300 mSec
generally 60 microSec
 Intensity: comfortable to tolerable
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15. Techniques of TENS application:
1. Conventional or High Frequency
TENS
2. Acupuncture or Low Frequency TENS
3. Brief Intense TENS
4. Burst Mode TENS
5. Modulated TENS
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16. 2. Low frequency/ Acupuncture like
TENS
 Activation of descending pain
suppression pathway activating
endorphins
 Longer lasting pain relief but slower to
start
 Application
Frequency usually- 1-5 Hz (below
10 Hz)
Pulse width: 200-300 micro16

17. Techniques of TENS application:
1. Conventional or High Frequency
TENS
2. Acupuncture or Low Frequency TENS
3. Brief Intense TENS
4. Burst Mode TENS
5. Modulated TENS
17

18. 3. Brief, Intense TENS:
hyper-stimulation analgesia
Similar to high frequency TENS
Highest rate (100 Hz)
pulse width: 200 micro sec
Intensity to a very strong but tolerable
level
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19. 3. Brief, Intense TENS:
hyper-stimulation analgesia
Treatment time is only 15 minutes, if
no relief then treat again after 2-3
minutes
Mono or biphasic current give a “bee
sting” sensation
Utilize motor, trigger or acupuncture
points.
19

20. Techniques of TENS application:
1. Conventional or High Frequency
TENS
2. Acupuncture or Low Frequency TENS
3. Brief Intense TENS
4. Burst Mode TENS
5. Modulated TENS
20

21. 4. Burst TENS
 Carrier frequency is at a certain rate with a
built in duty cycle
 Similar to low frequency TENS
 Carrier frequency of 70-100 Hz packaged
in bursts of about 7 bursts per second
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22. 4. Burst TENS
 Pulses within burst can vary
 Burst frequency is 1-5 bursts per second
 Strong contraction at lower frequencies
 Combines efficacy of low TENS with the
comfort of conventional TENS
22

23. 4. Burst TENS- Application
 Pulse width: high 100-200 micro
seconds
 Pulse rate: 70-100 pps modulated to 1-5
burst/sec
 Intensity: strong but comfortable
 treatment length: 20-60 minutes
23

24. Techniques of TENS application:
1. Conventional or High Frequency
TENS
2. Acupuncture or Low Frequency TENS
3. Brief Intense TENS
4. Burst Mode TENS
5. Modulated TENS
25

25. 5. Modulated Stimulation:
 Keeps tissues reactive so no
accommodation occurs
 Simultaneous modulation of amplitude
and pulse width; Frequency can also be
modulated
 As amplitude is decreased, pulse width
is automatically increased to deliver
more consistent energy per pulse26

26. Contents
 Introduction
 Features of TENS
 Applications of TENS
 Uses of TENS – common and
uncommon
 Electrode Placement
 Precautions and contraindications
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27. USES of TENS
28

28. Biophysical Effects
 Primary use is to control pain through
Gate Control Theory
 May produce muscle contractions
 Various methods
High TENS (Activate A-delta fibers)
Low TENS (release of -endorphins)
Brief-Intense TENS (noxious
stimulation to active C fibers)
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29. Common conditions where TENS is
used
Relief of Acute Pain:
 Post operative pain
 Labour pain
 Dysmenorrhoea
 Angina Pectoris
 Orofascial pain, dental procedures
 Physical trauma- fracture ribs, minor
medical procedures
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30. Common conditions where TENS is
used
Relief of Chronic Pain:
 Low back pain
 Arthritic pain: RA, OA
 Myofascial pain
 Neuropathic pain- trigeminal neuralgia,
phantom pain, post-herpes pain
 Cancer pain
 CRPS (Complex Regional Pain
syndrome)
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31. Other conditions where TENS is
used
Non-analgesic effects:
 Reducing symptoms of Alzheimer’s
dementia
 Neuromuscular stimulating effects
 Faecal and urinary incontinence
 Antiemetic effects:
 Morning sickness, motion sickness, post
chemotherapy, nausea due to other drugs
 Improving blood flow
 Wound healing/ Fracture healing
 Raynaud’s disease
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32. Electrode placement
33

33. Electrode Placement:
 Directly over painful sites: trigger points
 Dermatomes, Myotomes
 Accupunture points
 Spinal nerve roots
 May be crossed or uncrossed
 Horizontal or vertical
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34. Electrode Placement:
35

35. Contraindications:
 Pacemakers
 Malignancy
 Over carotid sinus (vasovagal reflex)
 Pregnancy
 Active infections, Skin conditions
 Areas over impaired or absent sensation
 Cardiac conditions- arrhythmia
 Neurological conditions: epilepsy, stroke
 Non-cooperative patients36

36. Precautions/ side effects:
 Dysaethesia
 Contact dermatitis
 Autonomic reactions- nausea, dizziness,
fainting
37

37. Summary
 Uses of TENS
 Application/ Types of TENS
 Precautions/ Contraindications
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38. References
 Tim Watson. Electrotherapy: Evidence Based
Practice. 2008. Churchill Livingstone. 12th
edition.
 Joseph Kahn. Principles and Practice of
Electrotherapy. 2000. Churchill Livingstone.
4th Edition.
 John Low, Ann Reed. Electrotherapy
Explained. Principles and Practice.
Butterworth Heinemann. 3rd Edition.
 Forster and Palastanga. Clayton’s
Electrotherapy Theory and Practice. Aitbs
Publishers. 9th edition
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