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154]

ORIGINAL ARTICLE

Effects of conventional and acupuncture-like

transcutaneous electrical nerve stimulation
on osteoarthritis of the knee
O. G. Sokunbi,
M. B. Usman
Department of Medical Rehabilitation,
University of Maiduguri, Maiduguri,
Borno State, Nigeria
Address for correspondence:
Dr. O. G. Sokunbi,
Department of Medical Rehabilitation,
University of Maiduguri, Maiduguri,
Borno State, Nigeria.
E-mail: ganiyusokunbi@gmail.com
Abstract
Background: Transcutaneous electrical nerve stimulation (TENS) is one of the most widely
used physical modalities for the management of osteoarthritis (OA) knee and various
stimulation parameters have been adopted with varying stimulation frequencies. However,
the optimal stimulation frequency of TENS in the management of OA knee pain appeared
not to have been well studied. Aim: The purpose of this study is to find out, which among
conventional TENS (ConTENS) and acupuncture-like TENS (AcuTENS) is more effective
for treating knee OA. Materials and Methods: Twenty-four patients with knee OA were
randomly allocated to three groups. ConTENS AcuTENS and Placebo TENS (PlaTENS).
Participants in the ConTENS and AcuTENS group received TENS treatment with current
intensity and frequency based on their group allocation at selected acupuncture points
(acupoints) for knee pain; the Pla-TENS participants received intervention, which was
identical to the ConTENS treatment group, but the circuit was disconnected. Participants
in the three groups were also treated with soft tissue manipulation around the knee joint.
Each group received treatment 3 times a week for 3 weeks during the study. Outcome
measures were pain intensity measured with numeric pain rating scale (NPRS), goniometric
assessment of knee active range of motion and knee functional mobility measured with
timed up and go test. Data were collected prior to intervention, at weekly basis during
intervention and at 4 weeks follow-up assessment. Results: The ConTENS and AcuTENS
reported lower pain intensity scores and increase in the knee active range of flexion than
the PlaTENS group at the end of 3 weeks of treatment and at follow-up assessments.
However, only the AcuTENS group recorded statistically significant lower pain intensity
and improvement in knee flexion than other groups (P < 0.005). Conclusion: AcuTENS
treatment was more effective than ConTENS in pain relief and increasing active range of
knee flexion for patients with OA of the knee
Key words: Acupuncture, knee joint, osteoarthritis, transcutaneous electrical nerve
stimulation

INTRODUCTION most frequently associated with disability. OA of the knee

causes patients severe discomfort and a reduced ability to
Osteoarthritis (OA) is the most common form of arthritis[1] work.[1,2] Knee OA is responsible for a higher percentage of
affecting 80% of those aged 65 or older.[2] It is the eighth disability than any other medical condition for the following
leading cause of disability globally,[3,4] with the knee joint activities: stair climbing, walking a mile and housekeeping.[5]
Anti-inflammatory drugs used to treat the symptoms of this
Access this article online disorder, usually, have various side-effects.[3] Patients with
Quick Response Code: chronic pain increasingly seek alternative methods for
Website:
pain relief, particularly transcutaneous electrical nerve
www.njecbonline.org stimulation (TENS).

DOI: Transcutaneous electrical nerve stimulation is one of the

10.4103/2348-0149.144835 most widely used physical modalities for the management
of OA knee.[5] TENS has the advantage of being efficacious,

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Sokunbi and Usman: Treatment of knee osteoarthritis
inexpensive, simple and essentially free of side effects. TENS
may even be used at home by patients themselves due to
its portability and simplicity. Acupuncture is a system of
healthcare, which has been practiced for more than 3000
years.[6] Classical acupuncture is based on the theory that vital
energy, called de qi, flows through the body along pathways
called meridians. There are specific points along these
meridians, called acupuncture points, or acupoints, at which
the de qi may be accessed. Inserting needles into these points
permits the practitioner to restore harmony to the system by
rebalancing the flow of de qi.[7] In the Western medical model,
acupuncture is thought to relieve pain through the gate-control
mechanism or through the release of neurochemicals.[8-10] Stux
and Pomeranz[11] describe the possible neural mechanisms
of acupuncture analgesia as follows: Small diameter muscle
afferents are stimulated, sending impulses to the spinal cord,
which then activates three centers (spinal cord, midbrain,
and pituitary) to release neurochemicals (endorphins and
monoamines) that block pain messages. It seems that the
practice of acupuncture has not gained so much popularity and
acceptance when compared with the use of TENS in Nigeria
where this present study was carried out.
Research into TENS for OA knee pain has been carried out
for more than 20 years, and various stimulation parameters
have been adopted with stimulation frequencies ranging from
2 Hz to 100 Hz. Jensen et al.[12] reported the effectiveness
of conventional TENS (ConTENS) (80 Hz, 150 s) in relieving
pain due to OA of the knee. Han et al.[13] found that using
low-frequency (2 Hz pulse trains), high intensity also known
as acupuncture-like TENS (AcuTENS) mode on patients with
chronic pain increased the cerebrospinal fluid levels of
endorphins. Subsequent to their findings, several studies
examined the efficacy of acupuncture and TENS treatment
for chronic pain conditions; however, there results were
inconclusive. [5-8] The present study was carried out to
investigate the effects of ConTENS and AcuTENS on knee
OA among Nigerian adults.
MATERIALS AND METHODS
Design
A randomized placebo-controlled trial.
Ethical approval
Approval for the study was sought and obtained from the
Hospital Research and Ethics Committee of University of
Maiduguri Teaching Hospital (UMTH), Maiduguri, Borno
State, Nigeria before commencement of the study. After
explaining the experimental procedures and the potential
risks involved, a written informed consent was obtained from
all the participants.
Participants
The participants for this study were males and females aged
45 years and above who have been clinically and radiologically
70 Nigerian Journal of Experimental and Clinical Biosciences | July-December 2014 | Vol 2 | Issue 2
diagnosed with OA of the knee Joint according to American
College of Rheumatology. They are patients who are attending
Physiotherapy Clinics of UMTH, Maiduguri, Nigeria. Further
inclusion criteria include knee pain lasting for 3 months or
longer with no other medical and surgical conditions such as
benign or malignant tumors. Patients currently on analgesics
at the time of the study were allowed to participate only if
the medications had made no changes to their symptoms and
there had been no changes in the dosage for at least 1 month
prior to the commencement of this study. Patients with skin
conditions that might impair skin sensation or prevent the
use of TENS on the knee joints were also excluded.
Sample size estimation
Sample size estimation was based on the assumption that
TENS could reduce pain intensity by at least 1.5 on numeric
pain rating scale (NPRS) (this was based on the previous work
by Itoh et al. which explored the effect of acupuncture and
TENS in the treatment of knee OA). To yield a power of 80%
with a significant level of 0.05, a sample size of at least 6
subjects in each group was required (sample size estimation
was determined by power analysis sample size software).
Randomization
Participants were randomized into three groups using a
computer generated table of randomization; ConTENS group,
AcuTENS group and Placebo TENS (PlabTENS) group.
Assessments
Assessments of pain intensity, active range of knee
movements and functional mobility were carried out prior
to intervention, and at 1st week, 2nd week, and 3rd week of
intervention and at 4 weeks post-intervention follow up
assessments. Pain intensity was measured with (NPRS. NPRS
is a verbally administered scale that measures pain intensity
(0 = ‘‘no pain at all’’ to 10 = ‘‘worst possible pain). Reliability
and construct validity of NPRS with visual analog scale was
reported by von Baeyer et al.[14] Knee joint active range of
motion was measured with Universal goniometer according to
the procedure stated by Watkins et al.[15] with the participants
in supine lying position. Universal goniometer was found
to have greater validity when measuring the large angles
of knee flexion (r = 0.73 and 0.77).[15] Functional mobility
was assessed with timed-up-and-go test. With participants
seated in chair with knee and hip joints maintained at 90°,
feet in contact with the floor and with the forearm resting
on the arm rest, the timed-up-and-go test was carried out
as described by Nordin et al.[16] The timed-up-and-go test has
been validated and showed good intrarater and interrater
reliability (r = 0.93 and 0.96, respectively).[16]
Interventions
Dual-channel TENS (Chinese, model 7000) was used to
provide TENS treatment. Treatments were carried out 3 times
a week for 3 consecutive weeks.
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Sokunbi and Usman: Treatment of knee osteoarthritis
Conventional transcutaneous electrical nerve
stimulation
The ConTENS group received treatments for 30 min
on the OA affected knee. Electrodes are positioned at
selected points widely accepted for acupuncture treatment
(acupoints) of knee pain, namely Liangqiu (ST34), Zusanli
(ST36), Yinlingquan (SP9), Xuehai (SP10) and Yanglingquan
(GB34).[17] Acupuncture points are selected because they were
highly reproducible and convenient.[17] ConTENS treatment
was delivered at 100 Hz with a pulse width of 200 us. The
intensity of the current was set at a comfortable level as
determined by each participant and ranges between 25 mA
and 35 mA. The intensity of the current was increased at 5 min
into the stimulation and/or whenever participants reported
accommodation to the stimulation.
Acupuncture-like transcutaneous electrical nerve
stimulation
Participants in the AcuTENS groups received TENS treatment
for a total of 30 min. Electrodes placements are similar to
as described above. The following TENS variables are used:
Lowest rate/frequency possible (2 Hz), the highest intensity
that will be tolerable for the subject for 30 min. Whenever
the subject could tolerate the highest intensity stimulation,
the duration of the pulse will be increased to the point of
tolerance. Tolerance was defined as the level at which the
participants ask the investigator to stop increasing the
stimulation.
Placebo transcutaneous electrical nerve stimulation
Participants in the PlaTENS group intervention was identical
to the ConTENS treatment group, but the circuit was
disconnected such that when the TENS machine was turned
on, an indicator light, light up; however, there was no
electrical output.
Figure 1: Participants flow chart
Nigerian Journal of Experimental and Clinical Biosciences | July-December 2014 | Vol 2 | Issue 2
Soft tissue massage
Massage treatments to the thigh and the knee joint area
was administered to the participants in all the groups in
this study. Techniques of soft tissue massage used were as
described by Clay and Pound.[18] Subjects are positioned
in half sitting or supine lying position with proper pillow
support at the back of the head and the knee. Massage
treatment was carried out for 5 min, 3 times weekly for
3 weeks.
Data analyses
Descriptive statistics of mean and standard deviation were
used to summarize data on pain intensity, range of motion
and functional mobility. Repeated measures analysis of
variance (ANOVA) was used to analyze the changes in the
NRS, knee range of movements and functional mobility scores
among the groups. Level of significance was set at P < 0.05.
After detection of significant changes in the overall time
course with repeated measures ANOVA, a post-hoc analysis
was carried out with Boferroni’s correction.
RESULTS
A total of 27 participants met the inclusion criteria, 10
participants each were randomized into the conTENS and
AcuTENS groups while 7 participants were randomized into
the PlaTENS group. The total dropout rate was the same in
every group with one participant in each group. Participants
did not give any reason for the dropout. Thus, 9 participants
were present in each of the ConTENS and AcuTENS groups
and 6 participants were present in the PlaTENS group at the
end of the 3 weeks of treatment and at 4 weeks follow-up
assessment [Figure 1].
Age and body mass index (BMI) of the participants of the three
groups are presented in Table 1. ANOVA did not show any
significant difference in the age and BMI of the participants
among the three groups (P > 0.05). The pain intensity profile
of the participants is presented in Table 2. Participants in
the ConTENS and AcuTENS groups experienced reduction
in the pain intensity during intervention and at follow up.
However, AcuTENS group recorded greatest pain reduction
during intervention and at follow up stages with pain
Table 1: Demographic characteristics
of the participants
Groups Age (years) BMI (kg/m2)
Conventional 58.11±10.3 30.23±5.5
TENS group (n=9)
Acupuncture-like 56.33±6.02 29.4±4.79
TENS group (n=9)
Placebo TENS 58.67±10.19 28.7±4.14
group (n=6)
F 5.124 0.160
P 0.150 0.854
BMI = Body mass index, TENS = Transcutaneous electrical nerve stimulation
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Sokunbi and Usman: Treatment of knee osteoarthritis

intensity scores of 4.88 ± 1.53 at the end of the 1st week of
treatment, 2.55 ± 1.42 at the end of 2nd week of treatment,
1.44 ± 1.23 at the end of 3rd week of treatment and 1.34 ±
1.53 at 4-week follow up assessment. ANOVA test showed
significant difference during intervention and at follow up
(P < 0.05). Post-hoc analysis of the pain intensity scores
showed statistically significant difference in pain intensity
scores between AcuTENS and ConTENS groups at 2nd week,
3rd week of treatment and at follow up assessment (P <
0.05). In a similar vein, statistically significant difference
in the pain intensity scores between the AcuTENS and
PlaTENS groups were present at all stages of data collection
during intervention and at follow up assessment (P < 0.05).
Conversely the ConTENS and PlaTENS groups did not show
statistical significant difference in the pain intensity scores
at all stages of data collection during intervention and at
follow up (P > 0.05) [Table 3].
Table 4 shows the mean scores for the functional mobility of
the participants in each group. AcuTENS and ConTENS group
showed improvement in functional mobility with functional
mobility test scores progressively reduced from the 1st week
of treatment to follow up assessments in the AcuTENS group
and ConTENS group. However, ANOVA test carried out on
post intervention functional mobility score did not show a
significant difference among the three groups at all stages
of data collection (P > 0.05).
Effects of intervention on active range of knee flexion are
presented in Table 5. Surprisingly, participants in all the
groups demonstrated the full range of active knee extension
at all stages of data collection. The AcuTENS group recorded
the highest increase in the active range of knee flexion at
the end of the 1st week of treatments (126.66 ± 8.29), 2nd
week of treatment (131.11 ± 6.50), 3rd week of treatment
(134.44 ± 1.66) and at follow up assessment (135 ± 8.39).
Statistically significant difference in the active knee range
of flexion was recorded at 3 weeks of treatment between
conTENS and AcuTENS (P = 0.028) and between AcuTENS
and PlaTENS (P = 0.008) [Table 6].

Table 2: Participants pain intensity scores

Groups Pain intensity scores
Pre-intervention 1 week
st
2nd week 3rd week Follow-up
of treatment of treatment of treatment assessment
Conventional TENS 7.88±1.88 6.55±1.94 5.11±2.02 3.22±1.20 3.20±1.40
group (n=9)
Acupuncture – like 7.33±1.58 4.88±1.53 2.55±1.42 1.44±1.23 1.34±1.53
TENS group (n=9)
Placebo group (n=6) 8.33±1.36 7.16±1.16 6.00±0.89 4.66±1.03 6.56±0.03
F 0.698 4.108 9.987 13.967 17.967
P 0.509 0.031* 0.001* 0.00* 0.00*
*Significant. TENS = Transcutaneous electrical nerve stimulation

Table 3: Post-hoc analysis of the pain intensity scores

Groups Preintervention 1st week 2nd week 3rd week Follow-up
of treatment of treatment of treatment assessment
AcuTENS versus ConTENS 1.00 1.26 0.08 0.013* 0.00*
AcuTENS versus PlabTENS 0.778 0.045* 0.002* 0.013* 0.00*
ConTENS versus PlabTENS 1.00 1.00 0.903 0.90 1.00
*Significant. ConTENS = Conventional TENS, AcuTENS = Acupuncture-like TENS, PlabTENS = Placebo TENS, TENS = Transcutaneous electrical nerve
stimulation

Table 4: Participants functional mobility scores

Groups Preintervention Functional mobility Functional mobility Functional mobility Functional mobility
functional mobility test score at first test score at second test score at third test score at
test score week week week follow-up
ConTENS 30.77±26.07 26.55±24.22 22.55±22.80 18.11±19.85 17.8±6.5
group (n=9)
AcuTENS 30.22±22.73 19.11±11.85 12.55±6.08 7.11±2.36 7.09±5.64
group (n=9)
PlabTENS 33.50±18.24 28.33±17.78 25.16±20.15 22.33±17.56 21.25±17.5
group (n=6)
F 0.039 0.547 1.150 2.147 0.672
P 0.962 0.587 0.336 0.142 0.902
ConTENS = Conventional TENS, AcuTENS = Acupuncture-like TENS, PlabTENS = Placebo TENS, TENS = Transcutaneous electrical nerve stimulation

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Sokunbi and Usman: Treatment of knee osteoarthritis

Table 5: Participants active range of knee flexion scores

Groups Preintervention 1st week 2nd week 3rd week Follow-up
of treatment of treatment of treatment assessment
ConTENS group (n=9) 111.66±14.79 117.22±15.02 120.55±13.09 125.44±9.51 125.42±4.29
AcuTENS group (n=9) 114.44±15.50 126.66±8.29 131.11±6.50 134.44±1.66 135±8.39
PlabTENS group (n=6) 112.50±12.54 114.16±10.68 118.33±9.30 122.50±6.12 120±7.22
F 0.085 2.417 3.694 6.902 2.889
P 0.919 0.114 0.142 0.005* 0.00*
*Significant. N.B: Participants in all the groups demonstrated full range of active knee extension (0° at all stages of data collection)

Table 6: Post-hoc analysis of the participants active knee flexion score

Groups Preintervention 1st week 2nd week 3rd week Follow-up
of treatment of treatment of treatment assessment
AcuTENS versus ConTENS 1.00 0.313 0.114 0.028* 0.00*
AcuTENS versus PlabTENS 1.00 0.173 0.077 0.008* 0.00*
ConTENS versus PlabTENS 1.00 1.00 1.00 0.100 1.00
*Significance. ConTENS = Conventional TENS, AcuTENS = Acupuncture-like TENS, PlabTENS = Placebo TENS, TENS = Transcutaneous electrical nerve
stimulation

DISCUSSION according to this theory, large diameter afferents (type 1

The present study assessed the effects of AcuTENS and
ConTENS on knee OA. The AcuTENS and the conTENS
groups showed decreases in pain intensity (NPRS scores)
compared to the PlaTENS during treatment and at follow
up assessments. The AcuTENS treatment groups showed
overall statistically significant greater improvement than
PlaTENS with pain reduction at all stages of data collection.
Conversely, comparison of the pain intensity scores between
ConTENS and PlaTENS did not show statistical significant
difference. Furthermore, the AcuTENS group showed greater
improvement with functional mobility and range of knee
flexion than either of the conTENS or PlaTENS group. These
results suggest AcuTENS treatment was significantly more
effective than ConTENS in the management of knee OA.
muscle afferents and A beta skin afferents) are stimulated
at low intensity and high frequency in the same dermatome
as the site of the pain. This release glutamate and γ-amino-
butyric acid to cause presynaptic inhibition of adjacent
pain fibers (small diameter A delta and C afferent fibers) to
prevent nociceptive stimuli from reaching the spinal cord
transmission neurons. This form of analgesia starts within
100 ms of TENS stimulation and disappear within seconds
of turning off the machine.[11] The transient nature of the
analgesic effects of ConTENS perhaps could be part of the
reasons why the seemingly reduced pain intensity levels of
the participants in the ConTENS group in the present study
did not differ significantly from the pain intensity level of the
participants in the placebo group after intervention and at
follow up assessments.

The results of the present study in terms of the analgesic
effect of TENS treatment corroborate findings from previous
studies[19,20] Ng et al.[19] carried out a randomized control
trial on 24 patients to examine the relative effectiveness of
electro-acupuncture (EA) and TENS in alleviating OA-induced
knee pain. The result of their study showed greater reduction
in pain intensity and functional mobility in the EA and the
TENS groups’ immediately after intervention. However,
improvement in functional mobility was maintained only in
the EA group at 2 week follow up assessment, which was not
seen in the TENS group. Itoh et al.[20] investigated the effects
of using either acupuncture treatment and/or ConTENS
treatment alone or in combination on 32 patients with knee
OA. Findings from their study showed the ConTENS group
recorded a decrease in pain intensity and improvement
in knee function, which showed no statistical significant
difference from the control group.
Conventional TENS was developed in the early 1970 as a
result of the gate theory of pain. For analgesia to occur
Conversely, an essential feature of AcuTENS is the use of
strong stimulation to produce strong sensation otherwise
known as de qi (this is similar to the sensations obtainable
with the use of acupuncture needles). AcuTENS are stimulated
at low frequency and high intensity. In general, de qi occurs
with current or voltage stimulation, which is 5-10 times the
threshold value for muscle contraction. The intensity is kept
below the level at which patient find it intolerable and hence
that a pleasant mild aching sensation is felt.[11] AcuTENS can
be given as little as twice weekly with lasting effects because
of endorphin release, whereas ConTENS must typically be
used throughout the day to obtain sustained analgesia.
Although weaker stimulation by the ConTENS can release
some endorphins, the stronger intensities of AcuTENS recruit
type III fibers, causing greater and longer lasting analgesic
effects. In addition, ConTENS is mainly segmental in nature,
not involving pituitary mechanisms. In contrast AcuTENS
combine segmental and non-segmental effects.[11] It involves
the brain stem, pituitary plus segmental mechanisms through
endorphins and serotonin. AcuTENS usually takes 20-30 min

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Sokunbi and Usman: Treatment of knee osteoarthritis
to reach a maximum effect and the analgesia outlasts the
therapy by several hours or days.[11] This perhaps could be
responsible for the sustained pain reduction at follow up
assessments observed in AcuTENS group, which was not
present in the ConTENS group.
CONCLUSION
The results of the present study have shown that AcuTENS
treatment is more effective than ConTENS for pain relief and
improvement in active knee range of movements in patients
with knee OA. Large scale clinical trials are warranted.
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How to cite this article: Sokunbi OG, Usman MB. Effects of
conventional and acupuncture-like transcutaneous electrical nerve
stimulation on osteoarthritis of the knee. Niger J Exp Clin Biosci
2014;2:69-74.
Source of Support: Nil, Conflict of Interest: None declared.