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Transcutaneouselectrical nerve stimulation (TENS): A potential intervention for

pain management in India?

Article · September 2013

DOI: 10.4103/0970-5333.124590

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Review Article

Transcutaneous electrical nerve stimulation

(TENS): A potential intervention for pain
management in India?
Gourav Banerjee, Mark I Johnson
Centre for Pain Research, Faculty of Health and Social Sciences, Leeds Metropolitan University, Civic Quarter, England, United Kingdom

ABSTRACT
Globally, the burden of pain and consequent disability on healthcare and economy is significant. Given the pain prevalence, inconsistent,
and inadequate specialist health care services in India, the burden is likely to be magnified. Analgesic medication is the mainstay treatment
for most types of pain; however, its side effects and financial costs for prolonged periods of time have resulted in the search for safer,
inexpensive treatment options. Transcutaneous Electrical Nerve Stimulation TENS is a non-invasive, self-administered and inexpensive
analgesic technique used worldwide to manage pain. Evidence suggests that TENS is effective in relieving acute and chronic pain and
can be used as a stand-alone treatment for mild to moderate pain or as an adjunct for moderate to severe pain. The purpose of this study
is to overview the principles, techniques, and clinical research evidence when TENS is used to manage pain with reference to health care
and research studies conducted in India. A summary of evidence was formed based on Cochrane reviews, systematic reviews and meta-
analyses on TENS with respect to pain management.

Key words: India, non-pharmacological analgesia, pain management, transcutaneous electrical nerve stimulation

Pain as a Healthcare Problem in India
A recent systematic review[1] estimated that the weighted
mean ± SD prevalence of chronic pain worldwide was
30.3% ± 11.7% (19 studies, 65 surveys, 34 countries, 182,019
respondents) with no correlation between Human
Development Index (HDI) and prevalence with insufficient
reliable data to estimate with any certainty the prevalence of
chronic pain in developing countries. Pain and consequent
disability impose significant burden on a country’s healthcare
and economy.[2-4] Data on the prevalence of pain in India has not
been established; however, a multinational study conducted
by the World Health Organisation (WHO)[3] in 1998 estimated
that prevalence of chronic pain in India was 19% sampled from a
population of 398 members of the general public in Bangalore.
India’s population is above 1.2 billion, so it can be extrapolated
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that 0.32 billion people may be experiencing musculoskeletal
pain at any given period. More recently, Bihari, et al [5] estimated
that the prevalence of musculoskeletal pain in Gurgaon and
Noida was 25.9% using a sample of 2086 people, with pain
being more prevalent in females (31.3%) than males (20.9%).
Thus, a significant proportion of the Indian population
experiences chronic pain which jeopardizes India’s growing
but inadequate healthcare infrastructure[6].
Similar approaches to pain management are taken in different
regions of the world with medication being the mainstay
treatment.[7,8] However, long-term analgesic medication
has its problems including side effects and ongoing costs
of buying drugs. For these reasons inexpensive, safe and
easy to use non-drug alternatives are becoming popular.
Ideally, treatments that can be self-administered by patients
without the need of clinical supervision will reduce health
Address for correspondence:
Gourav Banerjee
C/O Prof. Mark I. Johnson
Faculty of Health and Social Sciences,
Leeds Metropolitan University,
Civic Quarter, Leeds LS1 3HE, United Kingdom.
E-mail: gourav.banerjee@live.co.uk

132 Indian Journal of Pain | September-December 2013 | Vol 27 | Issue 3

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Banerjee and Johnson: TENS for pain management in India
care costs. The purpose of this review study is to overview
the principles, techniques and clinical research evidence
when Transcutaneous Electrical Nerve Stimulation (TENS)
is used to manage pain with reference to health care and
research studies conducted in India.
Introduction to TENS
During TENS pulsed electrical current is delivered across the
intact surface of the skin to stimulate the underlying nerves.
Current is generated by a portable TENS device powered by
batteries (usually 9V) or A.C. mains and delivered to the skin
via electrode leads and self-adhesive electrodes attached
to the skin surface[9] [Figure 1]. If self-adhesive electrodes
are not available, carbon-rubber electrodes smeared with
conducting gel are used and secured to the skin using Velcro
straps or medical adhesive tape.[10] Most TENS devices enable
the user to vary amplitude (which affects subjective intensity
of currents), frequency, pattern, and duration of the pulsed
electrical current. TENS is used for symptomatic relief of
mild to moderate pain of any origin, including nociceptive,
neuropathic, and musculoskeletal.[11] TENS may be used
on its own or as an adjunct to pharmacotherapy, especially
for moderate to severe pain.[10,12] TENS can also be used to
produce non-analgesic physiological effects and has been
found to be beneficial in the management of dementia[13],
post-operative nausea and vomiting,[14] and wound healing.[15]
TENS devices and their accessories are inexpensive, easy to
use, and can be purchased by individuals over the counter
at pharmacies or over the internet. Individuals are able
to self-administer TENS treatment and learn to titrate
dosages accordingly to manage their painful condition.
TENS effects are rapid in onset and there are few adverse
effects or drug-interactions; TENS has no potential for
toxicity or overdose and is economical when compared
with long-term drug therapy. TENS is used throughout
the world, although most commonly in countries with
HDI of > 0.9 (i.e., developed countries). To date, there
appears to have been little information about the use of
TENS in developing countries. It is suspected that there is
an awareness of the potential benefits of TENS for use in
clinical settings in urban regions of developing countries
although whether this translates into TENS being offered
to patients by healthcare professionals is not clearly known.
Historical Perspective of TENS
The use of electricity to heal dates back over 4000 years;
ancient Egyptians (2,500 BC[12]) and Romans (46 AD[16])
used fish to administer ‘shocks’ to treat a variety of
painful ailments. These early practitioners were oblivious
Indian Journal of Pain | September-December 2013 | Vol 27 | Issue 3
to the concept of electricity, but they found that the
‘shock’ administered by the fish caused numbness in
painful body parts. It was not until the discovery of
electricity in the 1700s that it was realized that the fish
were in fact electrogenic. Devices were developed to
generate electricity and this resulted in increased use of
electricity in medicine until the late 19th century when
pharmacological interventions became popular. Interest
in the use of medical electricity was rekindled in 1965 with
the publication of ‘Pain Gate’ theory by Melzack and Wall[17]
which offered a physiological rationale for electroanalgesia.
Pioneering research on the use of electricity to relieve
pain continued in late 1960s when Shealy and colleagues
(1967)[18] and later, Reynolds (1969)[19] worked on invasive
techniques of neuro-modulation of the spinal cord and
brain, respectively. TENS was initially used to determine
the success of dorsal column stimulation implants until
it was realized that TENS could be a beneficial treatment
when used on its own (Long, 1970’s).[20,21]
TENS Techniques and Parameters
A standard TENS device delivers repetitive biphasic
pulsed currents with an amplitude ranging from 0 to 60
mA, pulse durations between 50 and 400 microseconds
and pulse frequencies between 1 and 200 pulses per
second (pps) [Figure 2]. Different TENS techniques
are used to selectively activate different afferent nerve
fibers [Table 1].[9,12,22,23] There are also several kinds of
TENS-like devices which deliver current across the
intact surface of the skin but are considered different
to a standard TENS device because they have different
technical output specifications. TENS-like devices
include: Interferential therapy, microcurrent electrical
therapy, transcutaneous spinal electroanalgesia and
a
b
Figure 1: TENS and accessories applied to the forearm using
(a) carbon-rubber electrodes and (b) self- adhering electrodes
133
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Banerjee and Johnson: TENS for pain management in India

transcranial electrical stimulation. Their clinical
evidence is, however, limited.[9,10]
Physiological Rationale and
Postulated Mechanisms of Action
The mechanism of action of TENS-induced analgesia is
consistent with pain gate theory. Conventional TENS (low
intensity, high frequency) alleviates pain through selective
activation of non noxious, low threshold, large diameter Aβ
fibers which in turn inhibit ongoing central nociceptive cell
activity and reduce central sensitization in the spinal cord
(spinal mechanism resulting in segmental effects).[11,12,24] To
achieve this effect, conventional TENS is administered to
generate sensations of non-painful electrical paraesthesiae.
pulsing and muscle twitching. At intensities above pain
threshold, AL-TENS may also activate diffuse noxious
inhibitory controls producing counter irritant effects.
Intense-TENS (high intensity, high frequency) alleviates pain by
stimulating high threshold small diameter cutaneous afferents
leading to inhibition of central nociceptive transmission via
spinal and supraspinal mechanisms. In addition, intense TENS
causes nerve impulses travelling antidromically in cutaneous
efferents resulting in blockade of orthodromic nociceptive
impulses arising from nociceptor activity travelling in small
diameter Aδ afferents toward the central nervous system.[11,12]
To achieve this effect, intense TENS is administered to generate
sensations of painful electrical paraesthesiae, and can only be
tolerated by the patient for short periods of time.

Acupuncture-like TENS (high intensity, low frequency)
alleviates pain through selective activation of small
diameter, (skin and muscles) high threshold Aδ peripheral
afferents which in turn activates descending pain inhibitory
pathways arising in the midbrain periaqueductal grey and
the rostral ventromedial medulla (supraspinal mechanism
resulting in segmental and extrasegmental effects).[11,12] AL-
TENS is administered to generate sensations of electrical
These TENS techniques cause the release of a variety of
neurotransmitters in the central nervous system including
opioids (endorphins), serotonin (5-HT), acetylcholine (ACh),
norepinephrine, and gamma-amino-butyric-acid (GABA).
In the rostral ventral medulla, high and low frequency TENS
produces hypoalgesia by activation of (delta) and (mu)
opioid receptors, respectively. In addition, low-frequency
TENS is associated with reduction of aspartate and glutamate
levels in the spinal cord.[24-26] Further, it is thought that TENS
induced pain relief may be augmented by dilation of local
blood vessels[27], although evidence is far from conclusive.

Common Sites for TENS Electrodes

Figure 2: Output characteristics of a standard TENS device. Circles
represent dial controls for pulsed current amplitude (A), frequency (F)
and duration (D). Pulsed current patterns are represented by B (burst
mode), C (continuous mode) and M (amplitude modulation mode)
in Pain Management
Choosing an optimal electrode placement site at first may
involve some degree of ‘trial and error’. The order of priority
of optimal electrode placement sites is:
1. Painful area (over, close, or proximal to pain site, Figure 3)
2. Peripheral nerve (eg., over superficial radial nerve for
pain on dorsum hand, 1st 2nd digits)
3. Spinal nerve roots (parallel to vertebral column and
over intervertebral foramen)
4. Other specific sites: Acupuncture, Trigger and Motor
points. Dermatome / Myotome

Table 1: TENS techniques and their parameters

Type Pulse Duration Pulse Frequency and Pattern Technique

Conventional TENS Low (50-200 s) High (50-100 Hz) using continuous At the site of pain; strong but comfortable
(C-TENS) pulses paraesthesiae; administer whenever in pain
Acupuncture-Like TENS High (100-400 s) Low (2-4 Hz) Over muscles, acupuncture or trigger points;
(AL-TENS) using continuous pulses or High (50-100 strong but comfortable muscle contractions;
Hz) using trains (bursts) of pulses 15-30 mins x 3 times per day
Brief Intense TENS High (200-250 s) High (upto 200 pps) using continuous Over nerves on painful site; maximum tolerable
pulses contractions; few mins (5-15) at a time

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Banerjee and Johnson: TENS for pain management in India
Figure 3: Frequently used TENS sites
TENS should not be administered over the site of pain when
there is a local contraindication (see below) or if the skin at
that site is hypersensitive. For devices that use monophasic
waveforms, or asymmetrical biphasic waveforms, it is best
to apply the cathode proximal to the anode (i.e., toward
the spinal cord) because it is the cathode that excites the
axon to generate the action potential.
It is wise to use conventional TENS at the site of pain
when TENS is tried on a patient for the first time as TENS
sensations of ‘tingling’ or ‘buzzing’ are better tolerated
than those of twitching. It is important that the patient
understands that they need to use an intensity of TENS that
is strong but not painful. If intensity is too weak then there
will be insufficient afferent input to generate hypoalgesia.
If intensity is too strong it will be uncomfortable and
the patient would not be able to tolerate TENS for any
appreciable length of time. Generally, conventional TENS
can be administered regularly throughout the day although it
is also advisable to take intermittent breaks from stimulation
to reduce skin irritation. AL-TENS and intense TENS, which
are administered using higher amplitudes of current should
not be used for more than 20-30 minutes as longer duration
may cause muscle fatigue and/or skin irritation. In addition,
AL-TENS should not be used in cases of acute soft tissue
injuries or over areas devoid of muscle tissues.
Skin and electrodes should be cleaned before and after
application to reduce the possibility of surface lipids and dirt
reducing conduction of electrical currents through the skin.[12,22]
Contraindications and Precautions
All patients should have had their pain assessed before being
given a trial of TENS. Comprehensive safety guidelines are
available from the Canadian Physiotherapy Association[28]
Indian Journal of Pain | September-December 2013 | Vol 27 | Issue 3
including a comprehensive list of contraindications. TENS
is contraindicated at any site on the body for
 Patients using pacemakers or with cardiac conditions
 Impaired cognition, comprehension or other mental
illnesses
The main situations where TENS is contraindicated locally
and electrodes should not be applied over the region of
concern are:
 The neck or head for patients with epilepsy and post-
stroke patients
 The pelvis or abdomen including uterus during
pregnancy (TENS is used on the back for labor pain)
 Areas where there has been recent hemorrhage, varicose
veins, bleeding disorders (risk of further hemorrhage)
 Over ischemic tissue and thrombosis (risk of embolism)
 Transorbitally across the eyes (risk of increase in
intraocular pressure)
 The anterior neck or carotid sinus (risk of hypotension,
laryngeal spasm)
 Dysaesthetic skin or tactile allodynia (risk of skin
irritation, burn, increased pain)
 Anterior or posterior areas of chest (risk of compromising
pulmonary ventilation)
 Broken or frail, irritated or inflamed skin (apply over
areas surrounding the wound)
 Areas of active malignancy (though TENS is found to
be of help in cancer bone pain)
 Areas of active epiphyseal regions in children
Also, TENS should not be used:
 Internally (mouth)
 While driving or during operation of other hazardous
machineries
 If the individual has an allergy to electrodes, gel or tape
 In water
Previous TENS-related Studies
Conducted in India
Experimental TENS studies [29-32] conducted in India
have shown that AL-TENS increased experimental pain
threshold in otherwise pain-free Indian participants.
A case-report[33] suggested TENS was beneficial as an
adjunct in the management of type 1 complex regional
pain syndrome. We found 14 clinical studies on TENS
that had been conducted in India on searching medical
and physiotherapy electronic databases using relevant
keywords (MEDLINE, PEDro, IndianJournals.com, up
to September, 2013). The authors of most of the studies
concluded that TENS was beneficial for pain relief in
135
136
Table 2: Summary of pain-related TENS clinical studies in India
First Author Methodology TENS Finding
(Year) Technique
Mittall[34] Non-randomized study: TENS in the treatment of post herpetic neuralgia. n=10, single group, C-TENS 60% patients reported 50% or more reduction in pain
(1998) intervention carried out for 20 minutes daily for 10 days, no follow-up following TENS therapy patients with a shorter duration of
neuralgia responded better to TENS
Padma[35] Non-randomized, controlled study: efficacy and safety of TENS on uterine activity, duration of C-TENS TENS seems an effective, simple to administer method of
(2000) labor, intrapartum foetal heart rate, and APGAR score, in relieving the pain of parturition. n=70, pain relief with no side effects. It is effective in relieving
2 groups (TENS vs sham TENS), intervention carried out during active phase of labor. Assessed 1 low back pain in 50% [of cases], but has no effect on the
hour after delivery lower abdominal pain with present stimulation technique
Thakur[36] Randomized, comparative study: TENS vs tramadol hydrochloride for pain relief in labor. n=300, C-TENS Pain relief in labor with TENS is as good as that with
(2004) 3 groups, intervention carried out during active phase of labor (37 – 42 weeks) tramadol. TENS has hardly any side effects
Naikmasur[37] Randomized comparative study between pharmacotherapy (analgesics and muscle relaxants) and C-TENS Compared to the pharmacotherapy group, significant
(2009) physiotherapy methods (TENS + UST + LASER) in the management of TMJ MFPS. n=20, divided improvements were observed in all outcome measures in
into 2 equal groups. Outcomes measured at baseline, 1, 4, 8, and 16 weeks following intervention physiotherapy group
Rajpurohit[38] Comparative, randomized study: effectiveness of TENS vs MENS in bruxism associated C-TENS MENS could be used as an effective pain relieving adjunct
(2010) masticatory muscle pain relief. n=60, 2 groups, 1 week intervention – 20 minutes treatment to TENS in the treatment of masticatory muscle pain due
session daily, no follow-up to bruxism
Chandra[39] Non-randomized study: effectiveness of TENS as an adjunct to thoracic epidural analgesia for the C-TENS TENS is a valuable strategy to alleviate postoperative pain
(2010) treatment of post-operative posterolateral thoracotomy. n=60, 2 groups (TENS vs placebo – alongside following thoracic surgery with no side effects and with a good
other analgesics), 45 minute intervention. Post-op pain assessment at 2, 4, 6, 8 and 10 hour hemodynamic stability; however, the effects are short lasting
Singla[40] Non-randomized study: efficacy of TENS in the management of trigeminal neuralgia. n=30, 20- Brief I-TENS TENS was found to be safe, easily acceptable, and
(2011) 40 days intervention, follow-up at 1 and 3 months non-invasive outdoor patient department procedure for
management of trigeminal neuralgia
Prabhakar[41] Comparative, experimental RCT: effectiveness of TENS vs cervical spine mobilization in the C-TENS Cervical mobilization when compared to TENS is equally
(2011) management of cervical radiculopathy. n=75, 3 groups, 3 weeks intervention (alternate days) – effective in relieving pain, reducing radicular pain in upper
10 treatment sessions of 30 minutes, follow-up at 6 weeks limb and improving the functional outcome
Devan[42] Comparative, experimental randomized study: effectiveness of TENS vs IFT in the treatment of C-TENS Both TENS and IFT are effecting in treating frozen shoulder.
(2011) adhesive capsulitis. n=50, 2 groups, 4 weeks intervention (2-3 times weekly) – 10 treatment IFT is more effective in reducing pain intensity and restoring
sessions of 20 minutes, follow-up at 6 months shoulder function for people with adhesive capsulitis
Dhinkaran[43] Randomized comparative study: effectiveness of MET + corrective exercises vs TENS + corrective C-TENS MET + corrective exercises is moderately better than TENS
(2011) exercises in LBP due to SI joint dysfunction. n=30, divided into 2 equal groups, 6 treatment + corrective exercises in improving functional ability and
Banerjee and Johnson: TENS for pain management in India

sessions. Outcomes measures following the end of treatment sessions i.e., the 6th day decreasing pain
Thiyagarajan[44] Quasi – Experimental comparative study to assess the efficacies between PIR and PIR + TENS, C-TENS PIR + TENS showed significant reduction of pain
(2012) following purposive sampling method of patients with MFPS of upper trapezius: n=20 divided into 2 compared to PIR alone
equal groups, 1 week duration of treatment sessions, outcomes measured following intervention
Mehta[45] One time observational design using convenient sampling of 7 consecutive patients with rib C-TENS Improvements in all outcomes; TENS is an effective, reliable
(2013) fracture. Before and immediately after TENS therapy, VAS, PEFR, and SpO2 were recorded and and practical method in controlling pain and thereby
responses were compared improving pulmonary functions in patients with rib fractures
Rashid[46] Comparative study to investigate the effect of brief intense TENS and ice on pain relaxed elbow Brief I-TENS Compared to TENS, cryotherapy was effective in reducing
(2013) extension angle. n=45, divided into 3 groups (cryotherapy, brief I-TENS, and sham TENS). Outcomes perceived pain in elbow flexors after eccentric bouts
measured before exercise, before intervention, 48 hours post-exercise and post-intervention.
Yadav[47] Prospective experimental study to evaluate the effectiveness of TENS in reducing neuropathic C-TENS TENS can be given to diabetic neuropathy patients for
(2013) pain in patients with diabetic neuropathy. n=20, outcome measures were recorded before and three weeks to achieve pain reduction
after the treatment session (3 weeks)
C-TENS: Conventional TENS; IFT: Interferential Therapy; LASER: Light Amplification by Stimulated Emission of Radiation; MENS: Microcurrent Electrical Nerve Stimulation; MET: Muscle Energy Technique; MFPS:
Myofascial Pain Syndrome; n: Number of participants; PFER: Peak Expiratory Flow Rate; PIR: Post-isometric Relaxation; RCT: Randomized Controlled Trial; SpO2: blood oxygen saturation; UST: Ultrasound Therapy;
TMJ: TemporoMandibular Joint Dysfunction; VAS: Visual Analog Scale

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Banerjee and Johnson: TENS for pain management in India

various conditions including trigeminal neuralgia, low
back pain in labor, bruxism-associated masticatory pain,
post-operative thoracic pain, cervical radiculopathy,
low back pain specific to sacro-iliac joint dysfunction,
fracture rib, diabetic neuropathy, temporomandibular
joint dysfunction, and pain in frozen shoulder [Table 2].
Clinical Effectiveness
Meta-analyses and systematic reviews on TENS have yielded
inconsistent results because several clinical trials were
underpowered and lacked methodological rigor. This can
be attributed in part to the fact that blinding and placebo
intervention in electrophysical treatments is difficult.
Recently, it has been shown that inadequate control
groups, inappropriate TENS technique, suboptimal dose,
poor adherence, and inappropriate outcome measures have
contributed to negative findings on TENS.[48] A systematic
review of TENS on experimental pain studies by Claydon
et al [49] found that the efficacy of TENS depended on the
selection of different combinations of intensity, frequency,
and stimulation site. Evidence for TENS in acute pain
and chronic pain has been conflicting, but more recently
evidence is tending toward effects over and above that is
seen with placebo (no current) TENS. Some guidelines
recommend TENS for the management of pain in certain
conditions while for others, they do not. For example,
the United Kingdom’s National Institute for Health and
Clinical Excellence (NICE) guidelines recommend the
use of TENS in osteoarthritis[50] but not in persistent
non-specific low back pain.[51] A summary of the reviews
and meta-analyses is provided below to demonstrate the
conflicting evidence for TENS effectiveness as adapted
from Johnson and Bjordal.[52] [Table 3].
There has been an on-going debate about the clinical
effectiveness of TENS across the world, with evidence
for efficacy changing over time leading to uncertainty
about whether TENS should be offered. The use of TENS
is supported by a vast quantity of case series and clinical
studies without control groups. Large meta-analyses have
found that TENS reduces chronic musculoskeletal pain
and post-operative pain, although many systematic review
findings are inconclusive because there is insufficient
good-quality RCTs to make a judgement. Often evidence
from RCTs is compromised because most RCTs are
methodologically weak using inadequate sample sizes,
inappropriate outcome measurement protocols and sub-
optimal TENS technique.[84] Outcome tends to be positive
if clear criteria for adequacy of TENS technique and dosage

Table 3: Summary of reviews and meta-analyses

Not Effective
Labor Pain (SR and MA by Mello et al , 2011)[53]
Chronic Low Back Pain (SR by Dubinsky and
Miyasaki, 2010)[54]
Chronic Low Back Pain (MA by Brosseau et al.,
2002)[55]
Chronic Low Back Pain (CR by Milne et al., 2001)[56]
Labor Pain (SR by Carroll et al., 1997 a,b)[57]
Postoperative Pain (SR by Carroll et al., 1996)[58]
CR: Cochrane Review; MA: Meta-analysis; SR: Systematic Review
Inconclusive / Conflicting
Neck Pain (CR by Kroeling et al.,
2013, 2009)[59,60]
Cancer Pain (CR by Hurlow et al.,
2012)[61]
Chronic Low Back Pain (SR by
Middelkoop 2011)[62]
Acute Pain (CR by Walsh et al.,
2011, 2009)[63]
Chronic Pain (CR by Nnoaham et
al., 2010, 2008)[64]
Amputee Pain (CR by Mulvey
et al., 2010)[65]
Cancer Pain (CR by Robb et al.,
2009)[66]
Knee Osteoarthritis (CR by Rutjes
et al., 2009)[67]
Labor Pain (CR by Dowswell et al.,
2009)[68]
Chronic low back pain (CR by
Khadilkar et al., 2008, 2007,
2005)[69]
Chronic Pain (CR by Carroll et al.,
2008, 2001)[70]
Chronic Headache (CR by
Bronfort et al., 2004)[71]
Post Stroke Shoulder Pain (CR by
Price and Pandyan , 2008, 2000)[72]
Effective
Acute Pain in Prehospital Setting (SR and MA by Simpson
et al., 2013)[73]
Postoperative Thoracic Surgery (SR and MA by Sbruzzi
et al., 2012)[74]
Post Thoracotomy Pain (SR by Freynet and Falcoz,
2010)[75]
Painful Diabetic Neuropathy (SR by Dubinksy and
Miyaskli, 2010)[54]
Painful Diabetic Neuropathy (MA by Jin et al., 2010)[76]
Primary Dysmenorrhoea (CR by Proctor et al., 2010, 2002)[77]
Rheumatoid Arthritis Hand (CR by Brosseau et al., 2009,
2003)[78]
Chronic Musculoskeletal Pain (MA by Johnson and
Martinson, 2007)[79]
Knee Osteoarthritis – short-term relief (MA by Bjordal
and Johnson, 2007)[80]
Knee Osteoarthritis (CR by Osiri et al., 2002)[81]
Postoperative Pain (MA by Bjordal et al., 2003)[82]
Chronic low back pain (CR by Flowerdew and Gadsby,
2000)[83]

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Banerjee and Johnson: TENS for pain management in India
were set a priori. Recommendations about the use of
TENS from professional and government bodies are also
inconsistent. For example, in 2007 the American College of
Physicians and the American Pain Society concluded that
TENS had not been proven as effective for chronic low back
pain[85], yet 1 year later the North American Spine Society
concluded that TENS reduced chronic low back pain in the
immediate short term but not in the long term.[86] Recently,
the USA Centers for Medicare and Medicaid Services
withdrew coverage for TENS for chronic low back pain[87]
because of insufficient evidence to judge effectiveness
rather than evidence of a lack of effectiveness. Overall,
TENS experts are confident that there is sufficient evidence
from clinical research to suggest that TENS should remain
an adjunct to core treatment for pain management and
that negative outcome trials are due to methodological
shortcomings rather than evidence of a lack of effect.[88,89]
Cost, Availability, and Usage of TENS
in India
In India, TENS is available without prescription either over-
the-counter or from the internet. Standard TENS devices
with accessories cost between Rs 1,800 and Rs 2,550 with
more advanced TENS devices between Rs 22,000 and Rs
25,800. We conducted a survey[90] of attitudes and beliefs
about the use of TENS for pain management by Indian
physiotherapists and found that all physiotherapists in our
survey reported that they used TENS on patients to relieve
pain. They predominantly used it for musculoskeletal and
neuropathic pain but did not regularly use it for post-
operative, cancer, dysmenorrhoea pain. Furthermore, 76%
of respondents reported that they did not recommend their
patients to use TENS at home. This approach does not align
with good practice guidelines which suggest that in most
instances TENS should be used whenever pain is present
and self-administered on an as needed basis.
Issues Associated with Using TENS
in India
In India, it is likely that many health care professionals
have not considered TENS as a possible treatment option
for pain. Medical practitioners need to be aware of TENS
as a viable treatment option so that they can encourage and
support the use of TENS by nurses, physiotherapists, and
other healthcare professionals. In the UK, it is often the
physician who either recommends the use of TENS to their
patients or refers them to a physiotherapist or a nurse who
then recommends TENS and educates them on how to use it.
138
Technological developments in electronic gadgetry have
touched lives of most urban dwellers including those
of lower socioeconomic groups. Therefore, acceptance
of TENS as part of a health care package should not
be too difficult, especially where health care services
adopt a modern (Western) model. Thus, in in-patient
settings TENS devices could be loaned to patients for
their duration of stay in hospital. Similar to the model of
patient-controlled analgesia, patients could be trained on
how to self-administer and use TENS for managing pain
postoperatively or during early stages of labor. Costs to the
clinic would be the initial outlay for TENS devices and then
the running costs of replacing batteries and self-adhering
electrodes. The latter may be moderately expensive as a new
set of self-adhering electrodes would be necessary for each
new patient to reduce any potential risk of cross infection.
One way to overcome this problem would be to use carbon-
rubber electrodes that can be sterilized and reused.
For out-patients with acute pain it may be possible to loan
them a TENS device for a short duration. For patients with
chronic pain who require TENS for a more prolonged
period of time, it may be worth loaning them a TENS device
for a month and if it proves beneficial then the patient
can buy a TENS device for themselves, perhaps through a
series of monthly instalments. This approach is used by
some clinics in the UK.
Greater barriers to using TENS are more likely to exist
in rural settings where healthcare services are resource
limited and attitudes and approaches to pain management
may be more traditional. The use of carbon-rubber
electrodes smeared with conductive gel would be more
appropriate not only because it would be less expensive
but also because self-adhering electrodes deteriorate very
rapidly if they are not kept in cool, dust free conditions
which may not always be available. In addition, the cost of
replacement batteries may also be prohibitive.
In rural settings, there may be socio-cultural barriers to
accepting TENS as a viable treatment option including a
lack of knowledge about TENS by the practitioner, and
patients with negative attitudes and beliefs, a fear of
electricity and of technology, inability to understand how
to use TENS and a reluctance to try novel treatments. Not
being able to attach the TENS device to an item of clothing
(e.g., sarees) may also prove a barrier.
Conclusions
TENS is a safe, economical electrotherapeutic treatment
used globally to relieve pain. Evidence to support
Indian Journal of Pain | September-December 2013 | Vol 27 | Issue 3
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Banerjee and Johnson: TENS for pain management in India
effectiveness is generally positive and TENS is recommended
in many good practice guidelines as a standalone treatment
for mild to moderate pain and an adjunct to core treatment
for managing moderate-severe pain. TENS has fewer
adverse effects than analgesic drugs and can be self-
administered for prolonged periods of time.
Suggested Reading
Johnson MI. Transcutaneous electrical nerve stimulation
(TENS). Research to support clinical practice. Oxford
University Press. Release date March 2014.
Johnson MI, Bjordal JM. Transcutaneous Electrical
Nerve Stimulation for the management of painful
conditions: Focus on neuropathic pain. Expert Reviews
in Neurotherapeutics 2011;11:735-53.
Johnson MI. Transcutaneous electrical nerve stimulation.
In: Watson T, editor. Electrotherapy: Evidence-based
Practice. Edinburgh: Churchill Livingstone; 2008. p. 253-96.
Johnson MI. Transcutaneous electrical nerve stimulation:
Mechanisms, Clinical Applications and Evidence. Reviews
in Pain 2007;1:7.
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How to cite this article: Banerjee G, Johnson MI. Transcutaneous
electrical nerve stimulation (TENS): A potential intervention for pain
management in India?. Indian J Pain 2013;27:132-41.
Source of Support: Nil. Conflict of Interest: None declared.
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