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  2. 2.  TENS is a method of electrical stimulation which primarily aims to provide a degree of symptomatic pain relief by exciting sensory nerves and thereby stimulating either the pain gate mechanism and/or the opioid system. The different methods of applying TENS relate to these different physiological mechanisms
  3. 3. Transcutaneous Electrical Neuromuscular Stimulation  Pain control treatment  Can cause muscle contractions, but that is not why it is used  Decreases patient’s pain perception by decreasing the conductivity & transmission of noxious impulses from small pain fibers (effects large diameter fibers)  Moderate caffeine levels (200 mg, approx 2-3 c. coffee) may decrease effectiveness of TENS
  4. 4. What is pain? “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” ISAP (1979)
  5. 5. DEFINITION  Pain is a noxious unwanted perception in which the patient seeks medical intervention.  “Pain is subjective, individual and modified by degrees of attention, emotional state and the conditioning of past experiences.” (Livingstone 1943). The intensity of the pain is not directly proportional to the degree of suffering. Because it is basically a psychological experience and depends on how it is interpreted or experienced
  6. 6. TYPES  Acute pain – shorter duration up to six months  Acute monophonic pain  Recurrent acute non-malignant pain  Chronic pain – longer duration > six months  Chronic malignant pain - progressive  Intractable-benign  Chronic pain associated with non-malignancy disease – identifiable pathology  Chronic non-malignant pain syndrome  Recurrent acute – migraine  Chronic and acute pain may have different causes – behavioral factors may be involved in acute pain
  8. 8. How do we experience pain?  Specificity theory – Desecrates  posits that there are specific sensory receptors for different types of sensations (i.e., pain, touch, pressure)  Pattern theory – Melzack & Wall (1982)  posits that pain results from the type of stimulation received by the nerve ending and the key determination of pain is the intensity of the stimulation  Both theories have limitations  pain can be experienced without tissue damage  tissue damage can occur without pain being felt  Phantom limb pain experience not accounted for by the theories – Fordyce (1988) study of amputees
  9. 9. PHYSIOLOGY OF PAIN Receptors A fibers – Localized and quick type of pain C fibers – Slow acting type of pain(Peripheral Nervous System) Spinal Cord (Substantia Gelatinosa) Spinothalamic Tracts (Lateral / Anterior) Thalamus Cerebral Cortex (Somatosensory Cortex) Influenced by Limbic system & Reticular formation
  10. 10. Gate Control Theory  Gate control theory –  Melzack & Wall (1965)  severity of pain sensation determined by balance between excitatory and inhibitory inputs to T cells in spinal cord  C & A-delta nociceptor afferents give excitatory input to dorsal root ganglion of spinal cord– A-delta (myelinated) about 40 mph and C fibers (unmyelinated) about 3 mph, other sensory information travels at about 180 -240 mph  Substantia gelatinosa, large diameter A-beta non-nociceptor afferents give inhibitory input  Increased firing of non-nociceptor afferents causes presynaptic inhibition of T cells and the spinal gate from excitatory cells to the brain is closed. –  Physical agent modalities and physical activities believed to close the gate by activating the non-nociceptor afferents  The theory does not explain pain modulation descending from brain
  11. 11. Central Control Mechanisms of Pain  Not well understood  Periaqueductral gray seems to be involved in pain – electrical stimulation can block the experience of pain  Spinothalamic tract which carries the impulses up the spinal cord, through the brain stem to the thalamus  Cerebral cortex  sensory area of parietal lobe: localization and interpretation of pain - somatosensory cortex  limbic system: affective and autonomic response  temporal lobe: pain memory
  12. 12. The same part of the brain – the anterior cingulate cortex – responds to physical and emotional pain. Where is pain in the brain?
  13. 13. Chemical processes involved in pain  Substance P Chemical mediator thought to be involved with transmission of pain. Associated with inflammatory pain It excites pain transmitting neurons when released Its mechanism is not fully understood  Glutamate – release affects amount of pain experienced  Prostaglandins, bradykinin – released when tissue damaged
  14. 14. Chemical processes involved in pain Endorphins  Pain perception modulated by these opiate like neurotransmitters  The endorphins bind to certain sites on the nervous system including peripheral nerves  They suppress pain transmission at the spinal cord level by inhibiting the release of the neurotransmitter gamma aminobutyric acid (GABA) in the periaqueductal gray matter (PAGM) and raphe nucleus of the brain  High concentration of opiate receptors in limbic area of brain explains the stress relief and euphoria associated with opiates  Limbic system involved with emotional component of pain
  15. 15. Tens&parameters
  16. 16. Conventional tens
  17. 17. acupunturetens
  18. 18. Brief intense tens  Rapid pain relief  15-30minutes  High frequency& more pulse width
  19. 19. Burstmode of conventional tens
  20. 20.  Stimulation of appropriate nerve root(s)  Stimulate the peripheral nerve (best if proximal to the pain area)  Stimulate motor point (innervated by the same root level)  Stimulate trigger point(s) or acupuncture point(s)  Stimulate the appropriate dermatome, myotome or sclerotome
  21. 21. Introduce yourself to patient Give assurance/confidence
  22. 22. Case sheet reading  Go through the medical reports  Find out diagnosis/general contra- indications/previous physiotherapy treatment
  23. 23. Checking general contraindications  Hyper pyrexia  Epilepsy  Severe renal and cardiac problems  Severe hypo/hypertension  Cardiac pacemakers  Infections  Pregnant women  Metal implants  Mentally retarded/upset patients  Malignancy  Anterior aspect of neck/carotid sinus/eyes
  24. 24. Tray preparations Skin resistance lowering/testing tray  Pillows  Cotton  Soap  Towel  Mackintosh  Petroleum jelly  Test tubes ( hot &cold)  U-pin (sharp &blunt)  Clips  Bowl of water  IR lamp  Hot &cold packs Treatment tray  Pillows  Towel  Bed sheet  Cotton  Adhesive tapes  Straps/goggles  Salt/Powder  Scissor/ Inch tape  Paper  Graph paper  Pencil/scale/eraser  Machine& accessories  Sand bags/crepe bandages
  25. 25. Checking local contraindications  Open wounds  Scars  Local skin infections  Cuts  Abrasions  Eczema  Local hemorrhagic spots  Skin sensitivity (testing)
  26. 26. Apparatus preparation  Check the apparatus& accessories like electrodes, leads, cables, plugs, power sockets, switches, controls, dials and others
  27. 27. Apparatus checking  Demonstration of the treatment  Check the functioning of machine in front of the patient  Explanation of treatment
  28. 28. Positioning the patient  Comfortable  Relaxed  appropriate
  29. 29. Skin resistance lowering  Do skin resistance lowering  Neatly &perfectly  Use items required in an orderly manner
  30. 30. Selection of technique  Use proper technique of application
  31. 31. Placement of electrodes  Appropriate placement according to the condition &patient  Use adhesives &straps  Apply gel evenly on electrode  Maintain good contact with the skin  No leads crossing each other  Confirm connections &above all
  32. 32. Instructions & warnings Instructions  Don’t move  Don’t sleep  Don’t touch leads, apparatus, therapist and any other metal near by you Warnings  Inform more heating/uncomforta ble sensations  Inform burning sensation immediately
  33. 33. Treatment  Proper execution of treatment  Appropriate intensity should be used  Set duration of treatment acc. to condition status  Supervise the treatment through out the session
  34. 34. Termination  Put knobs to zero  Remove electrodes  Switch off the machine &mains  Clean the area &inspect for adverse reactions  Manage if anything &give instruction regarding next coming  Winding up procedure
  35. 35. Recording Accurate record of all parameters of treatment including area treated , technique, dosage and the outcomes
  36. 36. CONTRAINDICATIONS  Patients who do not comprehend the physiotherapist’s instructions or who are unable to co-operate  • It has been widely cited that application of the electrodes over the trunk, abdomen or pelvis during pregnancy is contraindicated BUT a recent review suggests that although not an ideal (first line) treatment option, application of TENS around the trunk during pregnancy can be safely applied, and no detrimental effects have been reported in the literature (see www.electrotherapy,org for publication details)  • TENS during labour for pain relief is both safe and effective  • Patients with a Pacemaker should not be routinely treated with TENS though under carefully controlled conditions it can be safely applied. It is suggested that routine application of TENS for a patient with a pacemaker or any other implanted electronic device should be considered a contraindication.  • Patients who have an allergic response to the electrodes, gel or tape  • Electrode placement over dermatological lesions e.g. dermatitis, eczema  • Application over the anterior aspect of the neck or carotid sinus
  37. 37. PRECAUTIONS  If there is abnormal skin sensation, the electrodes should preferably be positioned elsewhere to ensure effective stimulation  • Electrodes should not be placed over the eyes  • Patients who have epilepsy should be treated at the discretion of the therapist in consultation with the appropriate medical practitioner as there have been anecdotal reports of adverse outcomes, most especially (but not exclusively) associated with treatments to the neck and upper thoracic areas  • Avoid active epiphyseal regions in children (though there is no direct evidence of adverse effect)  • The use of abdominal electrodes during labour may interfere with foetal monitoring equipment and is therefore best avoided