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MSK II

Physiotherapy II
Electrotherapy
Lecture 1
TENS (Transcutaneous Electrical
Nerve Stimulation)

Saurab Sharma, MPT


Lecturer, KUSMS
Objectives of session
At the end of the class, students will be

able to:

Understand the theory of TENS

Explain the techniques of TENS

application

Identify the uses of TENS

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Identify Precautions and
Contents
Introduction

Features of TENS

Applications of TENS

Uses of TENS common and uncommon

Electrode Placement

Precautions and contraindications


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Introduction
Transcutaneous Electrical Nerve
Stimulation

Delivers electricity across the intact surface


of the skin to activate underlying nerves

Simple, non-invasive analgesia causing


modality

For pain- acute, chronic non-malignant

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For palliative care of malignant conditions
Keys principles
Outcome of treatment is based on the:
Knowledge of intent of TENS

application

Location of electrode placement

Selection of appropriate current types

Dosage
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Principles of Nerve Fibre
Activation
Initially- stimulation of non-nociceptive
nerve fibres like A-alpha, A beta fibres
which have low threshold of stimulation
causing tingling

Followed by activation of A-delta and C-


fibres causing pain
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Principles of Nerve Fibre
Activation
Low intensity current with pulse duration

50-500 micro seconds stimulates larger


diameter fibres (A beta) without
activation of smaller diameter fibres (A
delta and C)

Pulse duration more than 500 micro

7 seconds activates small diameter fibres


Typical features of TENS

Pulse wave form Monophasic


Symmetric biphasic
Asymmetric biphasic
Pulse amplitude 1-50 mA
(adjustable)
Pulse duration (often fixed) 50- 500 micro seconds
Frequency 1- 200 Hz
Pulse patterns Continuous
Burst
Channels Single or double channels
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Parameter High-TENS Low TENS Brief -TENS
Intensity Sensory Motor Noxious
Pulse 60-100 Hz 2-4 Hz Variable
Frequency
(Hz)
Pulse (micro 60- 100 150- 250 300 1000
sec)
Mode Modulated Modulated Modulated
Burst
Treatment As needed 30 minutes 15- 30
duration minutes
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Onset of <10 minutes 20- 40 < 15 minutes
relief minutes
Techniques of TENS application:
1. Conventional or High Frequency

TENS

2. Acupuncture or Low Frequency TENS

3. Brief Intense TENS

4. Burst Mode TENS

5. Modulated TENS
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Techniques of TENS application:
1. Conventional or High Frequency

TENS

2. Acupuncture or Low Frequency TENS

3. Brief Intense TENS

4. Burst Mode TENS

5. Modulated TENS
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1. Conventional /High Frequency
TENS
Paresthesia is created without motor
response

A-Beta filers are stimulated to SG


enkephlin interneuron (pure gate theory)

Applied 30 minutes to 24 hours

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1. Conventional /High Frequency
TENS

Creates the fastest relief

Relief is short lived (45 sec 1/2 life)

May stop the pain-spasms cycle

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Application of High TENS
Pulse rate: high 75-100 Hz (generally
80), constant

Pulse width: narrow, less than 300 mSec


generally 60 microSec

Intensity: comfortable to tolerable

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Techniques of TENS application:
1. Conventional or High Frequency

TENS

2. Acupuncture or Low Frequency TENS

3. Brief Intense TENS

4. Burst Mode TENS

5. Modulated TENS
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2. Low frequency/ Acupuncture like
TENS
Activation of descending pain
suppression pathway activating
endorphins

Longer lasting pain relief but slower to


start
Application
Frequency usually- 1-5 Hz (below
10 Hz)
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Pulse width: 200-300 micro
Techniques of TENS application:
1. Conventional or High Frequency

TENS

2. Acupuncture or Low Frequency TENS

3. Brief Intense TENS

4. Burst Mode TENS

5. Modulated TENS
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3. Brief, Intense TENS:
hyper-stimulation analgesia
Similar to high frequency TENS

Highest rate (100 Hz)

pulse width: 200 micro sec

Intensity to a very strong but tolerable


level

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3. Brief, Intense TENS:
hyper-stimulation analgesia
Treatment time is only 15 minutes, if
no relief then treat again after 2-3
minutes

Mono or biphasic current give a bee


sting sensation

Utilize motor, trigger or acupuncture


points.
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Techniques of TENS application:
1. Conventional or High Frequency

TENS

2. Acupuncture or Low Frequency TENS

3. Brief Intense TENS

4. Burst Mode TENS

5. Modulated TENS
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4. Burst TENS
Carrier frequency is at a certain rate with a
built in duty cycle

Similar to low frequency TENS

Carrier frequency of 70-100 Hz packaged


in bursts of about 7 bursts per second

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4. Burst TENS
Pulses within burst can vary

Burst frequency is 1-5 bursts per second

Strong contraction at lower frequencies

Combines efficacy of low TENS with the


comfort of conventional TENS

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4. Burst TENS- Application
Pulse width: high 100-200 micro
seconds

Pulse rate: 70-100 pps modulated to 1-5


burst/sec

Intensity: strong but comfortable

treatment length: 20-60 minutes


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Techniques of TENS application:
1. Conventional or High Frequency

TENS

2. Acupuncture or Low Frequency TENS

3. Brief Intense TENS

4. Burst Mode TENS

5. Modulated TENS
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5. Modulated Stimulation:
Keeps tissues reactive so no
accommodation occurs

Simultaneous modulation of amplitude


and pulse width; Frequency can also be
modulated

As amplitude is decreased, pulse width


is automatically increased to deliver
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Contents
Introduction

Features of TENS

Applications of TENS

Uses of TENS common and


uncommon

Electrode Placement

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Precautions and contraindications
USES of TENS

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Biophysical Effects
Primary use is to control pain through
Gate Control Theory

May produce muscle contractions

Various methods
High TENS (Activate A-delta fibers)
Low TENS (release of -endorphins)
Brief-Intense TENS (noxious
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stimulation to active C fibers)
Common conditions where TENS is
used
Relief of Acute Pain:
Post operative pain
Labour pain
Dysmenorrhoea
Angina Pectoris
Orofascial pain, dental procedures
Physical trauma- fracture ribs, minor
medical procedures
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Common conditions where TENS is
used
Relief of Chronic Pain:
Low back pain
Arthritic pain: RA, OA
Myofascial pain
Neuropathic pain- trigeminal neuralgia,
phantom pain, post-herpes pain
Cancer pain
CRPS (Complex Regional Pain
syndrome)
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Other conditions where TENS is
used
Non-analgesic effects:
Reducing symptoms of Alzheimers
dementia
Neuromuscular stimulating effects
Faecal and urinary incontinence

Antiemetic effects:
Morning sickness, motion sickness, post
chemotherapy, nausea due to other drugs
Improving blood flow
Wound healing/ Fracture healing
Raynauds disease
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Electrode placement

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Electrode Placement:
Directly over painful sites: trigger points

Dermatomes, Myotomes

Accupunture points

Spinal nerve roots

May be crossed or uncrossed

Horizontal or vertical
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Electrode Placement:

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Contraindications:
Pacemakers
Malignancy
Over carotid sinus (vasovagal reflex)
Pregnancy
Active infections, Skin conditions
Areas over impaired or absent sensation
Cardiac conditions- arrhythmia
Neurological conditions: epilepsy, stroke
Non-cooperative patients
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Precautions/ side effects:
Dysaethesia
Contact dermatitis
Autonomic reactions- nausea, dizziness,
fainting

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Summary
Uses of TENS

Application/ Types of TENS

Precautions/ Contraindications

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References
Tim Watson. Electrotherapy: Evidence Based
Practice. 2008. Churchill Livingstone. 12th
edition.
Joseph Kahn. Principles and Practice of
Electrotherapy. 2000. Churchill Livingstone.
4th Edition.
John Low, Ann Reed. Electrotherapy
Explained. Principles and Practice.
Butterworth Heinemann. 3rd Edition.
Forster and Palastanga. Claytons

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Electrotherapy Theory and Practice. Aitbs
Publishers. 9th edition