Response of Plasma beta-Endorphins to

Transcutaneous Electrical Nerve Stimulation in

Healthy Subjects

GEORGE S. HUGHES, Jr.,

PETER R. LICHSTEIN,
DEBBIE WHITLOCK,
and CHRIS HARKER

A study of 31 healthy volunteers was done to test the hypothesis that analgesia
produced by low frequency/high intensity (LoF/Hil) transcutaneous electrical
nerve stimulation (TENS) is mediated by release of beta-endorphin (β-E). After
randomization, Group 1 (n = 10) received no stimulation (placebo); Group 2 (n =
9) received 30 minutes of high frequency/low intensity (HiF/Lol) TENS; and Group
3 (n = 12) received 30 minutes of low frequency/high intensity (LoF/Hil) TENS.
Blood pressure, pulse, plasma β-E levels, and evoked potential response were
measured before and after treatment. Mean plasma β-E increased with treatment
in Groups 2 and 3 and fell in Group 1, but the difference between the groups was
not statistically significant. Sixty-seven percent of Groups 2 and 3 showed an
increase in plasma β-E levels compared with 30 percent in Group 1 (two-sample
test of proportions, p < .05). Evoked potential response, a measure of pain
threshold, varied directly with plasma β-E level independent of the type of
treatment applied. This study did not demonstrate a difference between the
effects of HiF/Lol versus LoF/Hil TENS on plasma β-E in healthy subjects.
KEY WORDS: Electric stimulation, Physical therapy.

Transcutaneous electrical nerve stimulation (TENS) has
been used successfully in the treatment of acute and chronic
pain syndromes, but the physiologic mechanism by which
TENS produces analgesia has not been fully explained.1,2 In
current practice, TENS is applied to the sensory nerve or the
acupuncture point associated with the painful area. Stimula­
tion is delivered at either high frequency/low intensity (HiF/
Lol) or low frequency/high intensity (LoF/Hil). The mecha­
nism of action may vary with both frequency and intensity.
Stratton proposed that HiF/Lol TENS stimulates A-delta
fibers, which block transmission of nociceptive stimuli by
small unmyelinated C-fibers in the spinal cord2; this proposal
is in keeping with Melzack's gate central theory of pain.
Transmitting nociceptive stimuli to higher levels of the CNS
might be further impaired by TENS-mediated release of en­
kephalins.2 The onset of analgesia in HiF/Lol TENS is less
than 10 minutes and continues for approximately 30 minutes
after stimulation is terminated.3-6 The analgesic action of
HiF/Lol is not blocked by administering the narcotic antag­
onist naloxone hydrochloride. In contrast, stimulation at
LoF/Hil produces analgesia after approximately 15 to 30
minutes but with a longer duration (several hours) of action
Drs. Hughes and Lichstein are both Assistant Professors, East Carolina
University School of Medicine, Section of General Internal Medicine, Green­
ville, NC 27834 (USA).
Ms. Whitlock is a physical therapist at New Hanover Hospital, Wilmington,
NC 28401.
Ms. Harker is a biostatistician with the Center for Health Services Research
and Development, East Carolina University, Greenville, NC 27834.
This article was submitted August 4, 1983; was with the authors for revision
five weeks; and was accepted February 3, 1984.
after termination. The analgesic effect of this stimulation may
be blocked with intravenous naloxone hydrochloride.3"7 These
findings suggest that LoF/Hil TENS produces analgesia
through the release of beta-endorphin (β-E), whereas HiF/
Lol acts by other mechanisms, perhaps the release of enkeph-
alins.4,8-14
Previous studies of TENS analgesia have used patients with
chronic pain to assess levels of cerebrospinal endorphins,9,15-
17
or changes in analgesic effect after administration of the
opiate antagonist naloxone hydrochloride.9,18 Few studies
have addressed possible placebo effects associated with TENS
analgesia,18 although Levine et al19 have proposed that the
release of β-E may mediate placebo-induced analgesia. The
purpose of this study was to compare changes in plasma β-E
and evoked potential response (EPR), a quantifiable painful
stimulus, after applying HiF/Lol and LoF/Hil TENS in
healthy volunteers. A placebo group was also used in which
the TENS electrodes were applied, but no current was deliv­
ered. We proposed that if LoF/Hil TENS acts through the
release of β-E, greater increases would occur in plasma β-E
with LoF/Hil TENS than with either HiF/Lol TENS or
placebo treatment. In addition, if TENS analgesia is mediated
by release of β-E, the pain threshold, as measured by the EPR,
should vary with the level of plasma β-E.
METHOD
Subjects
Thirty-six healthy adult volunteers (18 men and 18 women
with a mean age of 25 years) served as subjects. After obtaining

1062 PHYSICAL THERAPY

 RESEARCH

signed informed consent, subjects were screened for acute or
chronic painful disorders, medical illnesses, and pregnancy.
We asked all subjects to refrain from consumption of drugs,
caffeine, and alcohol for 24 hours before participating in the
study and to avoid strenuous exercise on the day of the study.
Equipment
We used the TENSMATE Series 3000* TENS stimulators.
A Neuroprobe† was used to locate acupuncture points and to
elicit the EPR. With the subjects in a supine position, we
measured blood pressure in the right arm with an anaeroid
sphygmomanometer and determined pulse rate by palpation
of the radial artery.
Procedure
We randomly assigned 12 subjects to each of the three
experimental groups. Each subject listened to a tape recorded
explanation of the TENS procedure that stated "various in­
tensities of electrical stimulation will be employed, including
some that may be below your level of perception." While the
subjects sat on a treatment table in a quiet room, we measured
the EPR on the left side at acupuncture point UB-31 (located
approximately 3 in medial to the inferior angle of the scapula)
with the neuroprobe. We recorded the EPR as the intensity
of Neuroprobe output at which the subject reported an un­
comfortable sensation. The subject assumed a prone position
and the Neuroprobe was used to locate acupuncture point
UB-40 (behind the left knee) and UB-60 (posterior to the
lateral malleolus of the left leg). Conductivity gel was applied
to 8- by 14-cm2 carbon rubber electrodes that were taped to
the skin at these two points. Subjects assumed a comfortable
supine position for the remainder of the experiment. A 21-
gauge heparin lock was inserted into the left antecubital vein.
After a 10-minute period of quiet relaxation, pulse and blood
pressure were measured, and we withdrew an 8-ml sample of
venous blood into a heparinized glass tube that was immedi­
ately placed in ice. The plasma was separated by centrifuga-
tion at 4°C, 2500 rpm for 15 minutes, and the samples stored
in a freezer at - 15°C in heparinized glass tubes.
We determined plasmaβ-Eusing a radioimmunoassay kit.‡
Using this technique, less than 0.1 percent cross reactivity
with beta-lipotropin and 100 percent cross reactivity with
human β-E occurs. No cross reactivity takes place with en­
kephalin. Normal baseline values are reported to range from
4 to 10 ± 1.4pmol/L.20
For Group 1 (placebo group), we did not turn on the TENS
unit. Group 2 received 30 minutes of high frequency (101-
108 Hz) and low intensity (26-44 mA) TENS. The intensity
was set to produce a sensation of cutaneous warmth and
"tingling" over the stimulated area. Group 3 received 30
minutes of low frequency (4-7 Hz) and high intensity (45-65
mA) TENS delivered at two-second intervals. The intensity
for this group was set to produce a mild, nontetanic, nonpain-
ful muscle contraction. The subjects, but not the investigators,
were blind to the experimental groups during TENS. A sepa­
rate investigator who was blind to which group the samples
belonged determined all plasma β-E.
After 30 minutes of treatment, a second 8-ml sample of
venous blood was obtained and handled in an identical man­
ner to the baseline samples. We measured pulse and blood
pressure before the heparin lock was removed and the exper­
iment completed.
Data Analysis
We used a paired student's t test to compare changes
between mean baseline and posttreatment blood pressure,
heart rate, EPR, or plasma β-E levels among the three exper­
imental groups. A chi-square analysis was done to examine
the direction of change between β-E levels and the type of

*
EMPI Inc, 261 S Commerce Circle, Minneapolis, MN 55432.
† ‡
Neuromed, Inc, 1 Armour Ct, Lake Bluff, IL 60044. Immuno Nuclear Co, Stillwater, MN 55082.

TABLE 1
Effect of Transcutaneous Electrical Nerve Stimulation on Selected Hemodynamics, Evoked Potential Response, and Plasma beta-
Endorphin Levels in Healthy Volunteers (Mean ± 1 SE)
Group 1 Group 2 Group 3
Placebo HiF/Lol LoF/Hil
Variables (n = 10) (n = 9) (n = 12)
Pretest Posttest Pretest Posttest Pretest Posttest
Frequency (Hz) 0.0 ± 0.0 0.0 ± 0.0 104 ± 0.6 104 ± 0.6 4.25 ± 0.25 4.25 ± 0.25
Intensity (mA) 0.0 ± 0.0 0.0 ± 0.0 32.0 ± 1.3 32.5 ± 1.6 56.7 ± 1.4 56.7 ± 1.4
Pulse width (msec) 0 0 530 530 530 530
Blood pressure (sys­ 107 ± 4.7 106 ± 4.2 117 ± 2.9 112 ± 3.3 114 ± 2.1 112 ± 2.8
tolic) (mm Hg)
Blood pressure (dia­ 65 ± 2.8 64 ± 1.7 70 ± 2.5 72 ± 2.6 71 ± 2.5 70 ± 2.3
stolic) (mm Hg)
Heart rate (beats/min) 65.1 ± 2.5 65.1 ± 2.3 69.9 ± 1.7 63.3 ± 1.1 64.8 ± 3.42 64.5 ± 3.5
Evoked potential re­ 98 ±16.3 107 ±17.7 95 ±12.0 99 ±13.7 105 ±12.2 120 ±15.8
sponsea (mA)
Plasma beta-endor- 11.3 ± 6.61 7.5 ±8.43 18.9 ± 5.11 22.3 ±10.47 17.3 ± 6.50 23.6 ± 5.63
phins (pmol/L)
a
Median values given rather than mean values.

Volume 64 / Number 7, July 1984 1063

TENS used. We determined if percentages of change in β-E
TABLE 3
levels were statistically different among the groups with a two- Changea in Plasma beta-Endorphin (β-E) in Response to
sample test of proportions. We computed a Pearson's corre­ Transcutaneous Electrical Nerve Stimulation in Healthy
lation coefficient (r) for the change of EPR and the amount Volunteers
of change in β-E levels. A one-way analysis of variance
(ANOVA) was used to examine possible differences between No Change or
Increase in
Decrease in Row
the amount of change in β-E levels depending on the direction Plasma β-E
Group Plasma β-E Total
of change in EPR. Level
Level
(n) (%) (n) (%) (n) (%)
RESULTS
1. Placebo 7 70.0 3 30.0 10 32.3
Two subjects from Group 1 and three subjects from Group 2, 3. HiF/ 7 33.3 14 66.7 21 67.7
2 were dropped because of faulty sample handling or initially Lol and
LoF/Hil
unreported chronic painful complaints. Therefore, the results
TOTAL 14 45.2 17 54.8 31 100.0
are based on data from 31 subjects: Group 1, n = 10; Group
a 2
2, n = 9; and Group 3, n = 12. Mean ages were similar in x = 3.73,d f = 1 , p= <.05.
each of the groups: Group 1, 25 ± 2 yr; Group 2, 26 ± 1 yr;
and Group 3,25 ± 1 yr. Also, an equal sex distribution existed
among the groups. lationship appeared, however, between the time of day and
level of plasma β-E (Tab. 4).
Table 1 shows the frequency, intensity, and pulse width To assess the hypothesis that EPR varies with β-E, we
used. No significant difference appeared in mean baseline computed a Pearson's correlation coefficient (r) for the change
blood pressure, heart rate, EPR, or plasma β-E levels among of EPR and the amount of change in β-E levels in all 31
the three groups (Tab. 1). No significant change occurred subjects. A significant positive relationship existed between
between mean baseline and 30-minute readings for these change in EPR and the amount of change in β-E (r = .49, df
variables. In Group 1, 30 percent (n = 3) of the subjects = 29, p < .001). A one-way ANOVA test showed a statistically
demonstrated a rise in plasma β-E. Sixty-seven percent of significant difference in the amount of change in β-E levels
subjects in both Group 2 (n = 6) and Group 3 (n = 8), depending on the direction of change in EPR (F = 4.631; df
however, showed elevation in β-E. A chi-square statistic failed = 1,29;p =.04).
to show a significant association between the direction of
change of β-E levels and the type of TENS used (Tab. 2). By DISCUSSION
merging the two treatment groups, we compared β-E levels
between TENS treatment and TENS placebo. In this case, a We have shown that 67 pefcent (n = 14) of healthy subjects
chi-square statistic showed a significant relationship (p = .05) exhibited an increased plasma β-E after 30 minutes of either
between the direction of change in β-E levels in placebo and HiF/Lol or LoF/Hil TENS with a technique described by
treatment (Tab. 3). Thirty percent of the placebo group had Anderson et al.7 Our findings are in agreement with other
increased β-E levels; 67 percent of the combined treatment studies showing that plasma β-E levels increase with LoF/Hil
groups had elevated β-E levels. A two-sample test of propor­ TENS.7-16 In Group 1 (placebo), 30 percent showed elevation
tions showed these percentages to be statistically different of β-E. This finding is consistent with those of Thorsteinsson
(z = -1.723, p = 0.05 one-tailed) (Tab. 3). et al18 and other studies in which the response to placebo
analgesia has been evaluated.19 The finding of no significant
The mean and median values for plasma β-E levels were differences between groups with respect to change in vital
not statistically different (paired student's t test and one-way signs is in agreement with other studies of healthy patients.21
ANOVA). We did obtain, however, a wide range of values. Increased systolic blood pressure and skin temperature, how­
An explanation for the wide range of values in nonstressed ever, have been reported in chronic pain patients experiencing
individuals could be based on the diurnal rhythm of adreno- relief of symptoms with TENS.22
corticotrophin (ACTH) and plasma β-E (vide infra). No re-
Our data did not support the hypothesis that HiF/Lol and
LoF/Hil TENS differ in their ability to stimulate release of β-
E. The sample size in this experiment is small, and a larger
cohort might have demonstrated significant difference. The
TABLE 2 following are other possible explanations for our findings: 1)
Changea in Plasma beta-Endorphin (β-E) in Response to
a possible discrepancy may exist between plasma β-E levels
Transcutaneous Electrical Nerve Stimulation in Healthy
Volunteers
and the level of β-E active at particular sites along pathways
of pain perception (peripheral nerves, spinal cord, and CNS);
No Change or 2) the effect of TENS on healthy subjects or subjects of varying
Increase in
Decrease in Row Total age groups may differ from the effects documented in pain
Group β-E levels
β-E levels patients; and 3) our technique, including pulse width, surface
(n) (%) (n) (%) (n) (%)
area of the electrodes, and the points selected for stimulation,
1. Placebo 7 70.0 3 30.0 10 32.3 may not have been optimal to demonstrate differences. The
2. HiF/Lol 3 33.3 6 66.7 9 29.0 30-minute sampling interval should have been adequate to
3. LoF/Hil 4 33.3 8 66.7 12 38.7 evaluate changes in plasma β-E levels,23 given the short halflife
TOTAL 14 45.2 17 54.8 31 100.0
of β-E (10 minutes) and their appearance in other body fluids
a
x 2 = 3.68, df = 2, p = NS. (eg, cerebrospinal fluid) after similar intervals.9,15,16 The bio-

1064 PHYSICAL THERAPY

 RESEARCH

TABLE 4
Baseline Plasma beta-Endorphins (β-E) and Time of Collection in Healthy Volunteers

Groups
1 2 3
Placebo HiF/Lol LoF/Hil
(n = 9) (n = 12)
(n = 10)
Patient Time of β-Ea Patient Time of β-Eb Patient Time of β-Ec
number day number day number day
3 0910 10.2 2 0850 10.6 9 0919 66.9
8 0914 40.3 7 0915 36.5 5 0922 15.6
10 0925 1.0 11 0930 1.0
6 0930 3.3 26 0940 17.9 33 1005 1.0
27 0950 18.8 35 1030 5.4 36 1015 32.4
28 1045 12.4 15 1045 34.1 34 1020 25.2
16 1100 57.0 17 1105 53.4 1 1035 16.7
31 1210 1.0 30 1110 18.9 19 1200 66.9
20 1635 1.0 18 1205 40.3
14 1640 45.4 12 1625 19.8 13 1635 10.7
21 1640 11.3 24 1702 21.2
25 1750 9.2
a
= 19.1 (pmol/L) Median ± SE = 11.3 ± 6.6.
b
= 23.1 (pmol/L) Median ± SE = 18.9 ± 5 . 1 .
c
= 25.6 (pmol/L) Median ± SE = 17.3 ± 6.5.

logic activity of endogenous opiates, however, may remain
for several hours.23-27
Our findings support the hypothesis that TENS may pro­
duce analgesia by increasing β-E levels because we demon­
strated an increase in both treatment groups (Tab. 3). In
addition, we showed a significant correlation between the
increase in β-E, regardless of treatment group, and the increase
in EPR, a measure of pain threshold. This correlation supports
the hypothesis that TENS-induced analgesia is mediated, at
least partially, by increased release of β-E.
We cannot explain why our baseline β-E levels were slightly
higher than previous studies.20 Wide variation of individual
plasma β-E has been described,28 however, and could account
for some of the differences in our groups. A larger sample size
or performance of all studies at the same time of day may
reduce some interindividual variability (vide infra). Also,
circadian rhythm of plasma β-E and ACTH, which are se­
creted from a common hypothalamic-pituitary precursor in a
diurnal fashion, have been described and may have accounted
for some of the variations.23-27,29-31 The pain response is a
complex phenomenon and input to the CNS from higher
cortical centers may affect pain modulation.32,33 It is possible
that other endogenous opiates, for example, dynorphin or
other receptors such as µ, k, λ, or є, may also play a role in
the analgesic response to TENS.
Manipulation of frequency and intensity of TENS along
with variation of pulse width, surface area of the electrodes,
and the points selected for stimulation may be necessary to
optimize TENS analgesia. Other elements of the therapeutic
setting, including time of day in the proposed circadian cycle
of β-E release, may modulate the analgesic response to TENS.
CONCLUSION
This study of 31 healthy volunteers supports the hypothesis
that TENS analgesia is mediated by the release of β-E. In
addition, a relationship was demonstrated between increased
β-E levels and an increase in the pain threshold as measured
by the EPR. This study failed to show a greater increase in β-
E with LoF/Hil than with HiF/Lol TENS. These findings
suggest that efforts to maximize release ofβ-Eby TENS might
increase analgesic effects.
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PHYSICAL THERAPY