Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 19–24 19

DOI 10.3233/BMR-140482
IOS Press

Upper trapezius relaxation induced by TENS

and interferential current in computer users
with chronic nonspecific neck discomfort:

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An electromyographic analysis
Adriano Alexandre Acedoa, Ana Carolina Luduvice Antunesa, André Barros dos Santosa,
Cintia Barbosa de Olveiraa , Claudia Tavares dos Santosa, Gustavo Lacreta Toledo Colonezia,
Felipe Antonio Medeiros Fontanaa and Thiago Yukio Fukudab,∗
a
b
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Physical therapist staff, Centro Universitário São Camilo, São Paulo SP, Brazil
Department of Physical Therapy, Irmandade da Santa Casa de Misericórdia de São Paulo, Centro Universitário
São Camilo, São Paulo SP, Brazil

Abstract.
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BACKGROUND: Recent studies have shown that a transcutaneous electrical nerve stimulation (TENS) and interferential current
(IFC) application reduces pain in subjects with musculoskeletal disorders. However there are no clinical trials evaluating or
comparing the muscle relaxation generated for these devices.
PURPOSE: To compare the muscle relaxation of the upper trapezius induced by the application of TENS and IFC in females
with chronic nonspecific neck discomfort.
METHODS: Sixty-four females between 18 and 40 years of age and a history of nonspecific neck discomfort were randomly
assigned to a TENS or an IFC group. The women in the TENS (N = 32; mean age 22 years) and IFC (N = 32, mean age
23 years) group were submitted to current application during 3 consecutive days and were assessed by electromyography (EMG)
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in different times aiming to quantify the muscular tension of the upper trapezius. A visual analogue scale (VAS) was used as pain
measure at baseline (before TENS or IFC application) and at the end of the study.
RESULTS: At baseline, demographic, pain, and EMG assessment data were similar between groups. Those in the IFC group
had a significant trapezius relaxation after 3 IFC applications when compared to baseline and intermediate evaluations (P <
0.05). In contrast, the same analysis showed no significant difference between all assessments in the TENS group (P > 0.05). In
relation to pain relief, both groups showed an improvement at the end of the study when compared to baseline (both, P < 0.05).
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The between-group analysis showed no difference for the subjects who received such IFC as TENS application (P < 0.05).
CONCLUSION: IFC induced the upper trapezius relaxation after 3 sessions in females with neck discomfort, but the TENS
application did not change the muscular tension. However, these results should be carefully interpreted due to the lack of differ-
ences between groups. A significant pain decrease was found in the subjects of both groups, however, only the IFC application
presented a clinically important improvement.

Keywords: Electrical stimulation, transcutaneous electrical nerve stimulation, muscle relaxation, electromyography, neck pain

1. Introduction

The stress level of the population has increased,

leading to a compensatory muscle tension, and there-
∗ Corresponding author: Thiago Yukio Fukuda, Physical Ther- fore, several musculoskeletal disorders [1]. These dis-
apy Department, Avenida Nazaré, 1501, 04263-200, São Paulo SP, orders may affect specially the postural muscles, be-
Brazil. E-mail: tfukuda10@yahoo.com.br. cause they are the most requested during functional ac-

ISSN 1053-8127/15/$35.00 
c 2015 – IOS Press and the authors. All rights reserved
20 A.A. Acedo et al. / Upper trapezius relaxation induced by TENS and IFC in computer users
tivities [2,3]. The muscles of the neck and shoulder are
the most affected in workers of different occupations,
especially those that involve repetitive movements as
typing in a computer for a long time [4,5]. This pattern
of muscle tension is found mainly in the upper fibers of
the trapezius muscle, and for this reason, it is an area
much investigated in the literature by electromyogra-
phy [1,4,6].
Thus, the vicious cycle involving stress, repetitive
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activities, and tension in the trapezius also leads to
greater difficulty in returning to basal muscle activity
after a workday [5]. It is usual in the clinical prac-
tice finding subjects with muscular discomfort in the
neck area, even without a clear diagnosis of disc her-
niation, radiculopathies, spine injuries or degenerative
processes.
There are several modalities used in physical ther-
apy focusing on pain relief and muscle relaxation such
as physical agents for cooling, heating, electrical stim-
ulation, and others [7]. The transcutaneous electrical
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nerve stimulation (TENS) and the interferential current
(IFC) are noninvasive methods used for analgesia, but
there is a lack of consensus in the literature regarding
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the muscle relaxation effects [8]. TENS has been de-
scribed as a device that generates alternating electrical
current of low-frequency, acting at the sensory level
by closing the spinal cord gates, releasing endorphins,
and helping in tissue repair [9]. On the other hand, the
IFC is the application of alternating medium-frequency
(4.000 Hz) amplitude modulated at low frequency, pre-
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senting a higher tissue penetration and less discomfort
when compared to TENS [8,10].
The analgesic effects of the these currents are al-
ready well established in the literature, however, there
are no studies comparing the muscle relaxation by low-
and medium-frequency currents on a sensory level, i.e.,
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using current intensity (mA) only in the sensory thresh-
old. Therefore, the aim of the present study was to
compare the muscle relaxation of the upper trapez-
ius (primary outcome) and pain relief (secondary out-
come) induced by the application of TENS and IFC in
females with chronic nonspecific neck discomfort.
2. Methods
2.1. Participants
Sixty-four women with chronic nonspecific neck
discomfort participated in the study and were ran-
domly assigned to one of two groups: a TENS group
(n = 32) and an IFC group (n = 32). All volunteers
were informed about the procedures for the study and
signed informed consent written in accordance with
the National Health Council, resolution 196/96. This
study was approved by the Research Ethics Committee
of Centro Universitário São Camilo (CUSC), Brazil.
Females between 18 and 40 years old were included
if they had a history of chronic nonspecific neck dis-
comfort with a visual analog scale (VAS) score over
3/10, if they use computer for at least 14 hours per
week or 2 hours daily, and if they had pain during
trigger point palpation of the neck area. For this eval-
uation, the trigger point was considered active if the
subject presented local pain during a moderate digital
pressure in the middle third of the upper trapezius. The
participants were recruited from the college students of
the university by a single physical therapist with more
than 10 years of clinical experience in spine rehabilita-
tion.
Females were excluded if they had musculoskele-
tal disorders, physical therapy in the last 6 months, re-
ferred or irradiated pain, body mass index over 28, pre-
vious surgery involving the upper extremities, if were
pregnant or using corticosteroids or anti-inflammatory
medication, as well as other traditional TENS or IFC
contra-indications [1,7]. A standard cervical clinical
examination was performed to rule out concomitant
pathology of the upper extremities.
The assignment of subjects in the two groups was
performed randomly using opaque and sealed en-
velopes containing the names of the groups: TENS and
IFC. The envelopes were picked by an individual not
involved in this study. Three therapists were trained in
delivering the device protocols used for the study and
provide all treatment.
2.2. Intervention
The TENS and IFC applications and electromyo-
graphic (EMG) registration were performed on each
subject in a standardized protocol with duration of 5
days. On the first day, subjects remained at rest in
the supine position for 30 minutes before the first as-
sessment. We then analyzed the RMS value of the
EMG signal of both sides of the upper trapezius mus-
cle. This first registration (initial evaluation) was per-
formed with the subject seated on a standardized chair
with the forearms supported.
After the initial evaluation, the subjects of both
groups (TENS and IFC) were submitted to the current
application by self-adhesive silicone electrodes, with
 A.A. Acedo et al. / Upper trapezius relaxation induced by TENS and IFC in computer users
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Fig. 1. Consort flow chart.
the bipolar technique, i.e., 2 electrodes on each side of
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the upper trapezius for 30 minutes. In each side, one
electrode was placed laterally on the C7 spinous pro-
cess, and the other on the supraspinatus fossa. The in-
tensity (mA) was raised according to the subject’s tol-
erance, remaining in the sensorial level. Soon after this
application, another EMG registration was performed
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at the same condition mentioned before (evaluation 1).
On the second day, the patients received only the
TENS or IFC application on the upper trapezius mus-
cle bilaterally for 30 minutes. On the third day, the pa-
tients were initially assessed in relation to the EMG
registration (evaluation 2), followed by TENS or IFC
application. After this application, we performed the
EMG registration again (evaluation 3). There were no
activities or analysis on the fourth day.
On the fifth day, only the EMG registration (final
evaluation) was performed (Fig. 1). The same proce-
dure prior to the analysis was performed in the evalu-
ation 2 and final evaluation, i.e., the subjects remained
at rest in the supine position for 30 minutes to avoid
or minimize possible tensions due to the test situation
21
(“lab effect”). Although it was not the main purpose of
the study, we performed a pain assessment by visual
analogue scale (VAS) at initial and final evaluation.
The 0–10 cm VAS, where 0 represented “no pain” and
10 represented “worst imaginable pain”, was used to
assess cervical pain intensities. The VAS has reported
a minimal clinically important difference (MCID) of
2.0 cm (± 0.3 cm at a 95% confidence interval) [11].
2.3. Instrumentation and EMG
The TENS (Quark R
, TensVif 993) equipment was
used in the Burst mode, with a frequency of 100 Hz and
pulse duration of 150 µs. The IFC (KLD Biosistemas,
Endophasys) equipment had a carrier frequency of
4.000 Hz, an amplitude modulated frequency (AMF)
of 100 Hz, a variation frequency (ΔF) of 60 Hz, and
a slope of 6/6. The intensity (mA) in both devices was
set at the tactile sensation threshold.
The EMG equipment utilized in this study was the
portable CS400/EMG System with eight channels. The
EMG rectified signals of the trapezius muscle were ob-
tained by surface Ag/AgCl (10 × 20 mm) differential-
type electrodes with inter-electrode capture distance of
20 mm and a pre-amplification of 20-fold, and send to
the amplifier (frequency range: 20–500 Hz; noise sig-
nal rate: 3 µV RMS; CMMR: 100 dB), which has a
gain of a factor of 50, achieving a gain of 1.000 fold
for the EMG signal.
The capture electrodes were positioned at the mid-
point between the spinous process of the C7 vertebra
and the acromion bilaterally according to SENIAM –
European Recommendations for Surface Electromyo-
graphy criteria [12]. The reference electrode was posi-
tioned in right lateral malleolus. Before the electrodes
were positioned, we shaved the exposed area, followed
by sterilization with hydrated 70% ethyl alcohol. Af-
terwards, an EMG signal capture was performed in the
predetermined condition for 30 seconds. The first and
last 5 seconds were removed. Thus, the raw EMG sig-
nal was rectified and the RMS values were calculated
during the intermediate 20 seconds.
2.4. Statistical analysis
Data were analyzed with SPSS Version 13.0. (SPSS,
Chicago, IL, USA). Descriptive statistics for demo-
graphic data and all outcome measures were expressed
as averages and standard deviations. Comparison be-
tween the dominant and non-dominant side was per-
formed using dependent T test. The data for the RMS
22 A.A. Acedo et al. / Upper trapezius relaxation induced by TENS and IFC in computer users
Table 1
Demographic data of the TENS and IFC groups
TENS∗ IFC∗
Age (y) 22.0 ± 3.0 23.0 ± 3.0
Body mass (kg) 60.4 ± 3.6 61.3 ± 2.6
Height (m) 1.59 ± 0.3 1.60 ± 0.2
Body mass index 23.6 ± 3.1 24.4 ± 2.9
(kg/m2 )
Duration of symptons 2.1 ± 1.7 2.8 ± 0.9
(months)
Abbreviations: TENS, Transcutaneous Electrical Neural Stimula-
tion; IFC, Interferential Current. ∗ Values are mean ± SD, there were
no differences between groups (P > 0.05).
value of the EMG signal were analyzed using separate
2 × 5 (group by time) mixed model ANOVAs. The
factor group had 2 levels (TENS and IFC) and the re-
peated factor time had 5 levels (initial, 1, 2, 3, and final
evaluations).
3. Results
3.1. Baseline data
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There was no statistically significant difference
(P > 0.05) for age, height, body mass, and duration of
symptoms between the participants in the TENS and
IFC groups (Table 1). There was no statistical differ-
ence between the dominant and non-dominant side in
the intra-group analysis (TENS, P = 0.5 and IFC, P =
0.6). For this reason, both sides were considered to-
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gether for the comparison between groups. There was
also no statistically significant difference (P = 0.4) be-
tween groups for the studied variables (EMG data and
VAS) at baseline (initial evaluation) (Table 2).
3.2. EMG registration and pain
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There was a statistically significant group-by-time-
interaction for the 2-by-5 mixed-model ANOVA for
muscle tension and pain assessment measures (P <
0.01). Planned pairwise comparisons for the RMS
value of the EMG signal indicated that the subjects in
the IFC group had significant muscle relaxation at final
evaluation when compared to baseline (initial evalua-
tion), evaluations 1, 2, and 3 (P < 0.01, P < 0.02, and
P < 0.05, respectively). The same analysis showed no
significant difference between all assessments in the
subjects of the TENS group (P > 0.05). In relation to
pain relief, both groups showed an improvement at fi-
nal evaluation when compared to baseline (both, P <
0.05).
The analysis of differences between groups at eval-
uations 1, 2, and 3, as well as final evaluation showed
P value
no difference for the subjects who received such IFC as
0.770
0.698
TENS application (P < 0.05). There was also no dif-
0.924 ference in the between-group analysis for VAS (P >
0.801 0.05).
It is important to highlight that we controlled the use
0.621
of any anti-inflammatory, muscular relaxant, or anal-
gesic medication; and no subject reported performing
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physical activity during this period.
4. Discussion
This randomized interventional study aimed to com-
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pare the muscular relaxing effects of the upper trapez-
ius induced by TENS and IFC application in females
who used a computer daily and presented chronic un-
specific neck discomfort. The results of EMG evalua-
tion showed that IFC can reduce the trapezius muscle
tension; however, three sessions are needed to achieve
this effect. On the other hand, there was no relaxation
effect using the TENS application. Both groups pre-
sented a decrease of the pain level. It is important to
highlight that there was no difference between groups
for all assessments.
The assessment of muscle activity can be performed
by EMG [13], since the RMS value is a tool of quan-
tifying and processing the EMG signal, showing a lin-
ear relationship with muscle tension at rest and during
functional tasks [14].
Previous studies have linked the TENS and IFC ap-
plication as a tool to provide pain relief and muscle re-
laxation [8,15,16]. There is also hypothesis about ef-
fects of increasing blood flow and excitation of large
diameter afferent fibers (Gate theory) [9,17,18]. How-
ever, there is a lack of clinical studies using quan-
titative assessment for muscle relaxation induced by
TENS and IFC.
The results of the present study demonstrate that a
decrease in muscular activity can be observed at sen-
sorial level stimulation in medium-frequency current,
ie., using current intensity (mA) only in the sensory
threshold. However, this relaxation appears to be more
related to cumulative rather than immediate effect, be-
cause we observed that there was significant relaxation
in the final evaluation when compared to initial as-
sessment for the subjects who received IFC applica-
tion. This information corroborates the data from re-
cent meta-analysis conducted by Fuentes et al. [15]. A
hypothesis for the lack of effect using TENS applica-
 A.A. Acedo et al. / Upper trapezius relaxation induced by TENS and IFC in computer users 23

Table 2
Outcome measures for the TENS (n = 32) and IFC (n = 32) groups
RMS value of the EMG signal (µV) – trapezius muscle VAS (0–10 cm)
Initial Evaluation 1 Evaluation 2 Evaluation 3 Final Initial Final
TENS∗ 10.5 ± 1.7 11.4 ± 3.8 10.8 ± 1.9 10.5 ± 1.9 10.3 ± 1.8 4.2 ± 1.3 2.9 ± 0.5
(9.9, 11.1) (10.0, 12.8) (10.1, 11.5) (9.8, 11.2) (9.6, 10.9) (3.7, 4.7) (2.7, 3.1)
IFC∗ 11.2 ± 2.5 10.5 ± 1.4 10.5 ± 1.7 10.2 ± 1.1 9.7 ± 0.8 4.6 ± 1.9 2.4 ± 0.5
(10.3, 12.1) (10.0, 11.0) (9.7, 10.4) (9.8, 10.6) (9.4, 10.0) (3.9, 5.3) (2.2, 2.6)
Abbreviations: TENS, Transcutaneous Electrical Neural Stimulation; IFC, Interferencial Current; RMS, Root Mean Square; EMG, Electromyo-
graphic; VAS, Visual Analogue Scale. ∗ Values are mean ± SD (95% confidence interval).

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tion is that this device provide a low-frequency cur-
rent, suffering a high tissue resistance, leading to a pe-
ripheral vasodilatation, and consequently, insufficient
to promote the trapezius relaxation [9,10,16,19].
Hou et al. [20] postulated that electrical stimulation
can lead to physiological suppression of sympathetic
fibers of small arterioles in the muscle belly, reducing
sympathetic tonus, and thereby, increasing local blood
flow. This mechanism has been suggested as the main
cause of increased tissue oxygen and, consequently,
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providing a clinical reduction of the pain-spasm-pain
cycle [21–23].
Based on this information, one factor should be
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taken into account when utilizing this equipment aimed
at muscle relaxation. It is necessary to receive IFC
for a long time in each session, since the subjects
of the present study have received applications for
30 minutes. Some authors have shown that electri-
cal stimulation applications for a short time (approxi-
mately 20 minutes) are not sufficient to promote ther-
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ate muscle relaxing. This proceeding was also used in
previous studies [26,27].
The present study contributed to the literature be-
cause this is the first clinical study investigating im-
mediate and cumulative muscle relaxation by surface
EMG in subjects with chronic discomfort in the cer-
vical area. Further research is needed to relate other
IFC and TENS parameters such as modulated or car-
rier frequency, duty cycle, intensity, and time. In addi-
tion, these findings need to be correlated with clinical
evaluations of local microcirculation in subjects with
chronic diseases, neck, and superior limb disorders, as
well as in spastic muscles of neurological patients.
5. Conclusion
IFC induced the upper trapezius relaxation after 3
sessions in females with chronic unspecific neck dis-
comfort, but the TENS application did not change the

apeutic effects [19]. As a secondary outcome, both
groups showed significant pain reduction at the final
evaluation when compared to initial evaluation. How-
ever, Farrar et al. [24] and Forouzanfar et al. [25]
showed that the minimal clinically important differ-
ence (MCID) for VAS is approximately 2 points.
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muscular tension. However, these results should be
carefully interpreted due to the lack of differences be-
tween groups. A significant pain decrease was found
in the subjects of both groups, however, only the IFC
application presented a clinically important improve-

ment.
Therefore, only the IFC group presented a mean im-
provement in pain that superpassed the MCID (2.2 for
IFC and 1.3 for TENS).
Ethics
This study presents a limitation due to the lack of
a sham group. However, this bias was minimized be-
cause the subjects submitted to IFC and TENS therapy The protocol for this study was approved by the
performed complete rest before the initial EMG evalu- Ethics Committee on Research of the Centro Univer-
ation trying to avoid or minimize possible tensions due sitário São Camilo (CUSC).
to the test situation (“lab effect”). Another justification
is the fact that EMG is a quantitative tool for analyzing
the muscular tension, and therefore was not directly in- References
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