The Treatment of Fibromyalgia Pain Using Transcutaneous Electrical Nerve Stimulation

Submitted by:

Guy Beachnau SPT,

Daniel J. Fleming SPT,

Jordan Krygsheld SPT,

Alexandra Shaner SPT

 Fibromyalgia (FMS) is a neuropathic, central sensitivity syndrome with chronic,

widespread pain, coinciding with fatigue, sleep disturbances, and hyperalgesic trigger points.

The current theory regarding the cause of fibromyalgia is overactivity of pronociceptive

pathways, resulting in increased pain perception and sensitivity due to less active antinociceptive

pain-inhibiting pathways.1 FMS-related pain interferes with patients’ daily lives by limiting their

activity and function. Treatment for individuals with FMS is based primarily around pain

management/relief, especially during movement, to increase their function and participation in

activities of daily living.2 Transcutaneous electrical nerve stimulation (TENS) has been found to

be beneficial in the treatment of chronic pain, and may be beneficial for intervention in FMS

patients.3

TENS operates on the gate control theory of pain in which electrical stimulation

interrupts nociceptive signals and prevents them from being transmitted further through the

central nervous system. High frequency stimulation provides a disruption in the pain stimuli and

instead increases the release of endogenous opioids, such as enkephalins, to help decrease pain

sensation.4 TENS is a therapeutic intervention that applies an electrical current between

electrodes and passes through tissue. Sensory level stimulation is at a low enough intensity that

only cutaneous sensory nerves are activated. General parameters for sensory level stimulation

use an alternating current with a low pulse amplitude (mA) and high pulse duration (µsec) to

provide a comfortable treatment without being intense enough to generate a muscle contraction.

A strong but comfortable sensation is desired to provide a noticeable stimulation to the patient. 5

This stimulation is believed to be beneficial for FMS patients by blocking the transmission of

pain sensation through the CNS.

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 In order to determine the effectiveness of TENS on pain management in fibromyalgia, a

thorough investigation was conducted to find quality articles of randomized controlled trials

experimenting on this phenomenon. There is a substantial amount of evidence that supports the

efficacy of TENS in the reduction of pain during treatment application in patients with FMS. The

highest quality article that was found, receiving a 9/10 score by PEDro, involved the application

of TENS protocol near the spinal cord and supports the treatment as effective.2

Two groups were formed through random assignment and given active TENS, placebo

TENS, or no TENS at separate times, and it was established that there was a significant

difference in pressure pain thresholds (PPTs) among groups after active TENS treatment only.

Using a digital pressure algometer, PPTs measured deep tissue hyperalgesia, resulting in an

increase in PPT for individuals during active TENS treatment. This study showed that there was

a reduction in pain with movement, but not at rest, with a single thirty-minute active TENS

treatment in individuals with FMS. The restoration of conditioned pain modulation (CPM), or

the use of applying another pain, would be displayed as improved function. In the study, the

active TENS group showed increased CPM which suggests regeneration of central inhibition.2

As a result, this study suggests an increase in pain inhibition in people with FMS during a single

TENS treatment. Taking into account the quality of this article, and their substantial findings, it

is reasonable to conclude that TENS is an effective modality to use to decrease pain in patients

with FMS.

In search of further credibility, several other articles were found that agree with the

findings of Dailey et al.2 A study conducted by C. Vance et al.5 showed that a greater final

intensity of TENS characterized as “strong but comfortable” resulted from exposure to the full

range of TENS stimulation intensities from sensory threshold to noxious threshold using the

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Setting of Intensity of TENS (SIT) protocol in women with fibromyalgia. The SIT test

introduced the patient to a sensory threshold (ST), then a perceived sensation of “strong but

comfortable” (SC1), increased to “noxious” (N) deemed by subjects, and was followed by a

decrease in intensity which was characterized as “strong but comfortable” (SC2). With the use of

the Wilcoxon signed-rank test, it was confirmed that there was a significant increase from SC1 to

SC2, indicating backing away from a noxious sensation will result in a higher comfortable

intensity.5 These findings support the use of TENS SIT protocol for women with FMS.

Further findings of the same research found that subject characteristics such as age and

anxious symptoms on the response to the SIT test showed significant difference in the slopes of

linear regression analyses. There was a greater slope for the older age group than those under

forty years, and subjects in the high anxiety group had a higher slope compared to the individuals

who scored within the normal range of anxiety on the Patient-Reported Outcomes Measurement

Information System (PROMIS).5 Although the older individuals and those with anxiety had a

higher tolerance to intensity of TENS, the current study did not show a significant correlation

between the level of pain experienced by a more generalized population. Therefore, in order to

aid in the reduction of pain, subjects that were exposed to the full range of TENS intensities

chose a higher final stimulation intensity.5 This article suggests that although TENS treatment is

effective for the general population, specific parameters such as higher intensities, may be more

effective for subpopulations or people with additional characteristics, such as disease severity.

While the effectiveness of TENS treatment has shown to be significant in its ability to

reduce pain during application, there is little data to support it being more effective than other

modalities such as acupuncture or warmth. This may be a key finding for patients that fear

having an electrical current sent through their body or for patients that have contraindications to

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TENS treatment. Individuals with a pacemaker implant, for example, cannot use TENS as the

electrical current could have an adverse effect on their device. For individuals in either of these

two categories, knowing the similar effectiveness of other modalities will be helpful. There is

also little evidence to suggest that long term pain relief can be accomplished through the use of

electrical stimulation. The aim of TENS should be to minimize FMS related pain while in use,

similar to the effects of an analgesic drug.3

Acupuncture is being used in many ways in modern patient care. Primarily, it is used as a

form of pain control. As with TENS, acupuncture activates endogenous opioids within the

patient where the needle is inserted. These natural opioids block pain sent to the brain to reduce

its intensity. When compared to acupuncture, there is a significantly lower PPT in patients

treated with TENS. This could be due to acupuncture’s mechanical agitation property which may

have a greater effect on the pressure that PPT measures compared to TENS that only uses an

electrical current. Looking at fatigue scores, there was no significant difference between patients

treated with TENS compared to those treated with acupuncture. These findings suggest that it

may be more effective in the treatment of patients with FMS to use acupuncture if the primary

goal was to increase the patient’s PPT. Both modalities however have significant effects on

reducing common symptoms of FMS.6 Acupuncture is a viable modality for patients who are

either not comfortable with TENS, or for those are do not qualify for the treatment.

Superficial warmth is another modality, that, when compared to TENS, shows similar

significant results. In Lӧfgren and Norrbink’s7 cross-over study on pain relief in women with

FMS, comparing superficial warmth versus TENS treatment, it was found that there were no

differences in pain duration between the warmth and TENS treatment groups. Furthermore, it

was found that fifty-three percent of patients preferred warmth in contrast to TENS, most likely

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due to comfortability. It was also discovered that forty-one percent of patients reported better

immediate pain relief in the warmth group in comparison to thirty-four percent in the TENS.

Some participants found both treatments equally effective in alleviating pain, and one did not

answer the questionnaire. Upon further analysis, there was only slight preference toward TENS

in long-lasting pain relief versus warmth therapy. Patients completed an FMS impact

questionnaire as well that indicated the duration of days patients felt improvement was best after

superficial warmth but conversely, declined after TENS treatment. Interestingly, patients’

depression ratings also tended to increase after TENS.7 Based upon the results of this study, there

is no strong benefit in using TENS over other therapeutic interventions, such as superficial

heating, in the treatment of FMS pain. However, the application of a second TENS unit could

potentially show further pain relief.

While many studies have examined the effect of a single TENS unit on the treatment of

FMS pain, Lauretti et al.4 conducted an experiment that evaluated the use of two TENS devices

used simultaneously in comparison to a placebo and single TENS unit intervention. Each of the

three groups received treatment on their respective devices for twenty minutes, twice per day

(just after waking and before bed), for seven consecutive days. Patients in each group ranked

their pain using a Visual Analogue Scale (VAS) before and after their designated interventions.

The study found the greatest decrease in pain was found in the dual TENS group, then single

TENS unit, and placebo group respectively. Additionally, fatigue improvement was noted most

after use of two units in relation to the other two treatment groups. No adverse effects were seen

with the use of dual TENS units in comparison to a single unit. While positive, pain-reducing

results were shown during application of a single TENS device, two simultaneously applied

TENS devices were shown to have a greater analgesic effect in comparison.4 The use of two

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devices increases pain threshold which may prove more beneficial to decrease FMS-related pain,

and increase function in activities of daily living more than the use of other modalities. Further

experimentation is required in this area to support or refute dual-TENS as a more effective

treatment of FMS pain than other modalities.

After reviewing several articles, we believe that a therapeutic intervention involving

TENS could be beneficial in the treatment of reducing pain sensation in FMS patients. While

other modalities may have similar outcomes, Lauretti et al.4 showed that the application of two

TENS units further reduced pain than a single unit, providing evidence that TENS may have

increased results when applied with dual units. Acupuncture had better results related to

increasing PPT. Although, a multidisciplinary review of the management of FMS conducted by

Macfarlane et al.8 and seventeen other members declared exercise as the only unanimous “strong

for” therapies for FMS after a review of one hundred seven eligible articles. Since acupuncture

and TENS are both considered as short-term pain relief, lasting upwards of one hour post-

treatment, for a chronic condition such as FMS it is reasonable to believe a portable TENS unit

may be more practical than acupuncture; particularly since it can be used in conjunction with

exercise. Furthermore, Dailey et al.2 suggests that both pain and fatigue are decreased with TENS

during movement. These effects are seen at both the application site and outside of the site

location implying a widespread effect, further supporting the claim of Lauretti et al.4 that two

TENS units may increase effect throughout the whole body.

Further research is needed to determine the effects of TENS with FMS patients. We

recommend looking at the effects of TENS application on the cervical and lumbar region, as

recommended by Lauretti et al.4, to reduce pain perception during exercise. The research of

Vance et al.5 did not make a clear decision that the SIT protocol was related to TENS

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effectiveness. However, it is still a good system for determining intensity for a study, by

increasing the intensity while remaining comfortable, a strong need when pairing with exercise.

We expect that the decrease in pain and fatigue from TENS will improve quality of exercise as a

treatment option for patients with FMS.

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