TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

TENS (Transcutaneous Electrical Nerve Stimulation)

Sagar Naik, PT
By definition, any stimulating device, which delivers electrical currents across the intact surface of the skin, is TENS. TENS is low-intensity, short impulses applied largely for pain relief. TENS is the application of a pulsed rectangular wave current via surface electrodes on the patients skin. Transcutaneous electrical nerve stimulation (TENS) is a simple, noninvasive analgesic technique that is used extensively in health-care settings by physiotherapists, nurses, and mid-wifes. TENS is mainly used for the symptomatic management of acute and non-malignant chronic pain. However, TENS is also used in palliative care to manage pain caused by metastatic bone disease and neoplasm. It is also claimed that TENS has antiemetic and tissue healing effects although it is used less often for these actions. Small battery operated machines in which circuits modify the batterys output in such a way that it will have a stimulatory effect often generate TENS. Many different types of TENS apparatus are manufactured on the basis of following parameters:  Pulse Shape Usually rectangular.  Pulse Width Measured in microseconds (s) and is often fixed at 100 s or 200 s. Other units can vary the pulse width from 50 s through to 300 s.  Frequency Can be as low as 2 Hz or as high as 600 Hz. A frequency of 150 Hz is commonly used.  Intensity Can be varied from 0 to 60 milliamperes (mA). The wide range of variation in pulse width, frequency, and intensity gives great flexibility in terms of the treatments applied to patients with chronic pain syndromes. To be effective it is necessary for TENS to be able to affect conducting afferent nerves. It is thus appropriate to ensure that there is some cutaneous sensation and that this is sufficient to provide protection against the application of excessive current.

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Advantages of TENS:
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 In medicine, TENS is the most frequently used electrotherapy for producing pain relief.

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TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

Pain Transmission: Origin:

The fibres of lateral spinothalamic tract origin from substantia gelatinosa of Rolando (SGR) situated in the posterior gray column. The first order neurons are in posterior nerve root ganglia.

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Pain Gate Theory:

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Termination: Function:
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Axons from second order neurons mostly cross to the opposite side and reach the lateral column of same segment. Few fibres may ascend one or two segments and then cross to the opposite side and ascend in the lateral column. All the fibres pass through medulla, pons, and midbrain towards thalamus along with the fibres of anterior spinothalamic tract. The fibres of lateral spinothalamic tract from spinal leminiscus along with the fibres of anterior spinothalamic tract at the lower part of medulla. Some of the fibres of lateral spinothalamic tract form collaterals and reach the reticular formation of brain stem. The fibres of lateral spinothalamic tract terminate in the ventral posterolateral nucleus of thalamus. From here, third order neuron fibres relay to the somesthetic area of cerebral cortex. The fibres of this tract carry impulses of pain and thermal sensations. The unilateral lesion or sectioning of the lateral spinothalamic tract causes loss of pain (analgesia) and temperature (thermoanaesthesia) below the level of lesion in the opposite side. The bilateral section of this tract leads to loss of pain and temperature sensations on both the sides below the level of lesion.

 Afferent input is predominantly via the posterior root of the spinal cord and all afferent information must pass through synapses in the substantia gelatinosa and nucleus proprius of the posterior horn.

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Course:

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 It is popular because it is non-invasive, easy to administer and has few side effects or drug interactions.  As there is no potential for toxicity or overdose, patients can administer TENS themselves and titrate the dosage of treatment as required.  TENS effect are rapid in onset for most patients so benefit can be achieved almost immediately.  TENS is cheap when compared with long-term drug therapy.

TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

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 It is at this level that the pain gate first postulated by Melzack and Wall in 1965 operates. They proposed the existence of a gating mechanism at the spinal level that could alter ascending transmissions of nociceptive input.  The mechanism by which the gate influences afferent transmission is based on the quantity of input between A and C fibres to the dorsal horn of the spinal cord.  The substantia gelatinosa consists of a group of cells located in the dorsal horn of the spinal cord.  The A and C fibres project to, and synapse on, both the substantia gelatinosa and the first central transmission (T) cells in the dorsal horn.  It was thought that the T cells, when sufficiently stimulated, activated an action system that is responsible for response and perception.  The T cells are, in turn, excited by the A and C fibres.  Melzack and Wall felt that the substantia gelatinosa modulated the transmission from peripheral (A & C) fibres to central (T) cells by presynaptically inhibiting the fibres from stimulating the T cells.  The gate is closed by high levels of activity in the A fibres.  Using the negative feedback system, the A fibres exert presynaptic on the T cells via facilitation of the substantia gelatinosa.  The gate is opened with high levels of activity from the C fibres, preventing the substantia gelatinosa from exerting its inhibition on the T cells.  This results in T cell excitation by either spatial or temporal summation. The net result is the perception of pain.  If nociceptive information is allowed through the gate then this traffic will continue up the lateral spinothalamic tract of the spinal cord to the thalamus, and from here to the cerebral cortex.  As this stimulus passes through the brainstem it may cause an interaction between the periaqueductal area of grey matter (PAG) and the raphe nucleus in the midbrain.  These nuclei form part of the descending pain suppression system and their descending neurons can release an endogenous opiate substance into the substantia gelatinosa at the spinal cord level.  The chemical nature of this endogenous opiate, which may be endorphin or enkephalin, is such as to cause inhibition of transmission in the nociceptive circuit synapses.  This is achieved y blocking the release of the chemical transmitter (substance P) in the pain circuit.

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TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

 Serotonin is a neurotransmitter that has been found to be important in many behavioral states. It may play an important role in nociception, because decreased cerebrospinal fluid (CSF) levels of serotonin cause an increase in sensitivity to painful stimulation.

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D Conventional TENS or High Frequency TENS:  Frequency 50 Hz to 100 Hz  Pulse Width 20 s to 60 s  Intensity Till patient receives strong paraesthesia without muscle contraction (0 mA to 30 mA). The intensity is turned up gradually until a prickling or tingling sensation is felt. It should be neither painful nor should it cause a muscle contraction.  Principle The aim of conventional TENS is to activate selectively large diameter A fibres without concurrently activating small diameter A and C (pain related) fibres or muscle efferents. [Presynaptic inhibition by pain gate mechanism by stimulating A and A fibres.]  Duration 30 to 60 minutes once or twice daily.  Notes 1) Very comfortable for the patient. 2) Produces shorter level of pain relief. 3) More accommodation.  Uses High frequency TENS is mainly used for acute pain. D Acupuncture-like TENS (AL-TENS) or Low Frequency TENS:  Frequency 1 Hz to 4 Hz  Pulse Width 150 s to 250 s  Intensity Till patient receives muscle contraction of related myotome (30 mA to 60 mA). This kind of stimulation is often applied to acupuncture points but is sometimes applied to the motor points of muscle in the segmentally related myotome.  Principle The purpose of AL-TENS is to selectively activate small diameter fibres (A or group III) arising from muscles (ergoreceptors) by the induction of phasic muscle twitches. [This stimulates the high threshold A and C fibres, which lead to release of endogenous opioids and provides further sensory input from muscle spindle afferents (chemical theory).]

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Types of TENS:

TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

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D Brief TENS or Intense TENS:  Frequency More than 100 Hz  Pulse Width 150 s to 250 s  Intensity Highest level tolerated by the patient.  Principle The aim of intense TENS is to activate small diameter A cutaneous afferents by delivering TENS over peripheral nerves arising from the site of pain. [Activity in cutaneous A afferents induced by intense TENS has been shown to produce peripheral blockade of nociceptive afferent activity and segmental and extrasegmental analgesia (Central biasing mechanism).]  Duration 30 to 60 minutes once or twice daily.  Notes 1) Comfortable for the patient. 2) Short level of pain relief. 3) Less accommodation.  Uses Intense TENS is mainly used for acute pain.

D Burst TENS:  Burst TENS is a series of pulses (i.e. a train), repeated 1-5 times a second, commonly twice.  Each train or burst consists of a number of individual pulses at the usual conventional TENS frequencies of 50 Hz to 100 Hz but at higher intensity.  The benefit claimed for this is that it combines both the conventional and acupuncture-like TENS and therefore provides pain relief by both routes.  The burst TENS is believed to be advantageous, because it allows stimulation of pain-carrying fibres while the patient perceives a relatively comfortable sensation because of the high internal frequency. D Modulated TENS or Modified TENS:  In modulated TENS the pulse length, frequency, and amplitudes can be constantly and automatically varied.

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 Duration 20 to 30 minutes once a day.  Notes 1) Increase in the endorphins level in the CSF. 2) Long lasting pain relief. 3) Longer time is taken for pain relief. [When pain relief is produced the administration of Naloxone (an antimorphine agent) will cause return of pain.]  Uses Low frequency TENS is mainly used for chronic pain.

TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

 This cyclical variation is believed to prevent adaptation of the nerves to the current (no accommodation) and is particularly appropriate as a variant of conventional TENS used over long periods.

Biological Effects of TENS:

TENS effects can be subdivided into analgesic and non-analgesic effects.  Analgesic Effects: x Relief of acute pain x Relief of chronic pain  Non-Analgesic Effects: x Antiemetic effects x Improving blood flow In clinical practice, TENS is predominantly used for its symptomatic relief of pain although there is increasing use of TENS as an antiemetic and for restoration of blood flow to ischaemic tissue and wounds. [Antiemetic: Preventing or relieving nausea and vomiting.]

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D Mechanism of Action: Stimulation-induced analgesia can be categorized according to the anatomical site of action into peripheral, segmental, and extrasegmental. y The main action of conventional TENS is segmental analgesia mediated by A fiber activity. y The main action of acupuncture-like TENS is extrasegmental analgesia mediated by ergoreceptors activity. y The main action of intense TENS is extrasegmental analgesia via activity in small diameter cutaneous afferents. 1) Peripheral Mechanism:  The delivery of electrical currents over a nerve fiber will elicit nerve impulses that travel in both directions along the nerve axon, termed antidromic activation.  TENS-induced nerve impulses traveling away from the central nervous system will collide with and extinguish afferent impulses arising from tissue damage.  For conventional TENS, antidromic activation is likely to occur in large diameter fibres and as tissue damage may produce some activity in large diameter fibres conventional TENS may mediate some of its analgesia by peripheral blockade in large diameter fibres.  TENS-induced blockade of peripheral nerve transmission is due to increase in the negative peak latency of the compound action potential.

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TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

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2) Segmental Mechanism:  Conventional TENS produces analgesia predominantly by a segmental mechanism whereby activity generated in A fibres inhibits ongoing activity in second-order nociceptive (pain related) neurons in the dorsal horn of the spinal cord.  TENS could significantly reduce ongoing nociceptor cell activity in the dorsal horn cell when it was applied to somatic receptive fields.  The neuronal circuitry for conventional TENS analgesia is located in the spinal cord and it is likely that a combination of pre-synaptic and postsynaptic inhibition takes place.  Opioid receptor antagonist naloxone has failed to reverse analgesia from high-frequency TENS, suggesting that non-opioid transmitters may by involved in this synaptic inhibition.  This non-opioid inhibitory neurotransmitter is gamma aminobutyric acid (GABA).  The clinical observation that conventional TENS produces analgesia that is short lasting and rapid in onset is consistent with synaptic inhibition at a segmental level. 3) Extrasegmental Mechanism:  TENS-induced activity in small diameter afferents has also been shown to produce extrasegmental analgesia through the activation of structures, which form the descending pain-inhibitory pathways, such as periaqueductal grey (PAG), nucleus raphe magnus, and nucleus raphe gigantocellularis.  Phasic muscle contractions produced during acupuncture-like TENS generates activity in small diameter muscle afferents (ergoreceptors) leading to activation of the descending pain-inhibitory pathways.  Acupuncture-like TENS is mediated by endorphins. Acupuncture-like TENS increases cerebrospinal (CSF) endorphin levels.

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 The contribution of peripheral blockade on analgesia is likely to be greater during intense TENS.  Impulses traveling in A fibres induced by intense TENS will collide with nociceptive impulses, also traveling in A fibres.  Most of the people cannot tolerate direct activation of A afferents by TENS and therefore intense TENS is administered for only brief periods of time in clinical practice.

TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

Types of Electrodes Used in TENS:

 The most popular type of electrode is the carbonized silicon variety. x It requires a conductive gel to decrease impedance between the electrode skin interface and has an adhesive patch for skin fixation. x Its advantages include being durable, reusable, and less costly than other types of electrodes. x It has disadvantage of increasing the incidence of skin irritation secondary to the conductive gel or adhesive used. Occasionally, electrode paste will dry out under the electrode, increasing resistance and decreasing the electrical flow. On carbonized silicon electrode, hot spots may occur as result of electrodes drying out and producing uneven patches of skin resistance. Some patients using TENS for longer periods of time find the use of electrode gel and patches bothersome, especially when pain stems from a difficult to reach area, such as the lower back and cervical regions.  An alternative choice is the Karaya electrode. x The Karaya electrode has flexible conductive sheets made of a hydrophilic polysaccharide that becomes self-adherent when moistened. x Although Karaya electrodes are more expensive than are carbonized silicon electrodes, the homogeneous current density on the surface of the Karaya electrode reduces the possibility of the development of hot spots.  A variety of other disposable electrodes is available, all of which have advantage of being pregelled and self-adhesive.  Choosing an electrode involves several criteria: y Area to be stimulated; for example, a large-surface-area electrode for postoperative incisional pain, as opposed to a small-surface-area electrode for acupuncture-point stimulation. y Patient preference; for example, cost, ease of application, ability to reuse. y Patients skin type; for example, the patients sensitivity to adhesive-patch material.  Numerous electrodes are available for postoperative use. These electrodes are sterile, are self-adhesive, and have conductive paste. Some desirable characteristics in postoperative electrodes include: y Total surface area is conductive, adhesive, and sterile. y Easily conforms to body contours. y Durable, in that the conductivity and adhesion last for the duration of the 3 to 5 day postoperative period. y Easy application and removal.

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TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

 Some electrodes are easily aligned with curved incisions because they are segmentalized or can be notched. Others can be cut to fit a small incision. The use of small electrodes over acupuncture points has been recommended for a variety of operative procedures.

 The most usual is to site electrodes close to where the pain is perceived to be; often one electrode is sited over the place where the most intense pain is felt or the greatest tenderness elicited.  The electrodes may be placed within the same dermatome, myotome, or sclerotome. They may be placed to pass current through the long axis of the dermatome. In many, but not all, circumstances the dermatome, myotome, and sclerotome overlap. Dermatomal technique may be utilized in three ways: y Placement within the involved dermatome y Placement on a specific site in the dermatome (for example, a trigger, motor, or acupuncture point) y Placement on both anterior and posterior aspects of a particular dermatome (for example, the thoracic region)  Trigger or acupuncture points may be the preferred sites of current application. It is considered that their lower resistance compared with the surrounding skin due to active sweat glands and local vasodilatation can locate acupuncture points; they can be found by using an electronic probe.  Stimulation of peripheral nerves is used. Electrodes are placed in the line of the nerve and where it is particularly superficial. This method is used principally for the treatment of neurogenic pain such as postherpetic neuralgia. Some advantages of this technique are as follows: y Peripheral receptors are bypassed. First, the cutaneous peripheral receptors have been shown to adapt rapidly to stimuli. Secondly, selective blocking of superficial receptors has been shown to be ineffective in completely blocking the effects of TENS transmitted to the nerves. y Remote stimulation of deeper nerves is possible before the nerve branches to innervate deeper fields. y It may be used in sensitive dermatologic conditions. y It requires less amplitude of output to stimulate directly over a nerve trunk. y It may be an effective means of locating acupuncture points.  Another area of electrode placement location is paravertebral. Relating electrical stimulation to a specific spinal cord segment and nerve root may be an effective TENS technique. To control radicular pain, one electrode is placed

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Electrode Placement in TENS:

TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

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Bracket Method
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 Cathode is the active electrode, in stimulation of a nerve fiber it should be applied nearest to the desired destination of the action potential. Thus for stimulation of sensory nerves it is proximal to the anode, i.e., nearer the spinal cord. [Dermatome: The area of the skin, supplied by one dorsal root is called a dermatome. Myotome: From anterior horn motor nerve emerges and supplies the skeletal muscle, which is known as myotome. Sclerotome: A group of mesenchymal cells migrating from mesodermal somite towards notochord are called sclerotome. Trigger Point: Local regions of increased tenderness are known as trigger points.

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Painful Area Painful Area Criss-Cross Method

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paraspinally and second is placed on the corresponding dermatome or on the superficial peripheral nerve. An alternative approach is contralateral electrode placement, which may be used in cases where the painful area or the desired ipsilateral stimulation points are hyperesthetic or irritable. Some examples are postherpetic neuralgia, causalgia, and reflex-sympathetic dystrophy.  Transcranial placement is effective for a variety of syndromes, including migraine headaches.  Dual-channel devices using four electrodes or large-sized electrodes should be used for pains covering large areas. Dual-channel stimulators are useful for patients with multiple pains such as low back pain and sciatica or for pains, which change in their location and quality as during childbirth.  The area of pain may be surrounded by a bracket or criss-cross method.

TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

Clinical Indications of TENS:

 Acute Pain Acute pain can often be effectively treated by conventional (high frequency) TENS. TENS is effective in treating acute pain is by early intervention to prevent the initial establishment of the pain in the overall pain spasm pain cycle. y Minor Sports Injuries x Shoulder contusions x Rib contusions x Hip pointers x Ankle sprains [Contusion: A bruise; an injury without a break in the skin is called contusion. Sprain: Partial tear of joint ligament is known as sprain.] y Acute Spinal Pain x Acute torticollis x Various spinal sprains and strains [Torticollis: Wryneck, a contracted state of the cervical muscles causing twisting of the neck and inclination of the head to one side is called torticollis.] y Rib Fractures y Temporomandibular Joint Myofascial Pain Dysfunction y Acute Tendinitis
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Motor Point: It is a point which when stimulated leads to maximum contraction with minimal current. So, it is a point where 1) main nerve enters the muscle 2) muscle becomes superficial 3) junction of upper and lower of muscle Acupuncture Point: Acupuncture points seem to be where bundles of A nerves pierce the deep fascia. They apparently have lower electrical impedance than the surrounding area. Causalgia: Severe burning pain and trophic skin changes from injury to nerve fires is known as causalgia. Migraine: Paroxysmal headache, vomiting and focal usually visual, neurological events. The attack begins with malaise and irritability followed by a severe throbbing hemicranial headache, photophobia and vomiting.]

TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

[Tendinitis: Painful inflammation of a tendon caused by injury, overuse or prolonged pressure is called tendinitis.] y Dental Pain y Patellofemoral Pain  Chronic Pain TENS reduces drug dependence; sleep disturbance, pain tolerance, and also helps in psychological factors. y Low Back Pain

y Degenerative Joint Disease

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y Peripheral Nerve Injury
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y Causalgia Severe burning pain and trophic skin changes from injury to nerve fires is known as causalgia. y Peripheral Neuropathy Non-acute traumatic degeneration of the nerves of the limbs is called peripheral neuropathy. It includes rapid onset post-infective polyneuritis, slow onset hereditary sensorimotor neuropathy, and mononeuropathies. y Stump and Phantom Limb Distal end of a limb left after amputation is called stump. The perception that a limb is present after it has been amputated is called phantom limb. y Migraine Headaches Paroxysmal headache, vomiting and focal usually visual, neurological events. The attack begins with malaise and irritability followed by a severe throbbing hemicranial headache, photophobia and vomiting.

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y Rheumatoid Arthritis An autoimmune inflammatory arthropathy presenting with morning stiffness in and around joints lasting at least one hour before maximum improvement, soft tissue swelling of three or more joints, swelling of the proximal interphalangeal, metacarpophalangeal or wrist joints, symmetric arthritis, rheumatoid nodules, presence of rheumatoid factor and roentgenographic erosions and/or periarticular osteopenia.

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TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

y Postherpetic Neuralgia Severe burning pain may occur following herpes zoster and persist for a long time is known as postherpetic neuralgia. y Trigeminal Neuralgia Recurrent paroxysmal, brief episodes of intense pain over one side of the face confined to one of the three divisions of trigeminal nerve is called trigeminal neuralgia. y Angina Pectoris Discomfort due to transient myocardial ischaemia and occurs when there is an imbalance between myocardial oxygen supply and demand. y Facial Pain y Metastatic Bone Pain

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 Postoperative Pain Another common clinical use of TENS is in the management of postoperative pain. There are numerous types of surgeries for which TENS can be utilized, including abdominal, thoracic, and orthopedic procedures. TENS has several advantages over traditional postoperative pain analgesics, including decreased risk of addiction and physiologic depression, as well as increased patient participation. It reduces narcotic usage, increases ability to cough and breathe deeply, decreases incidence of atelectasis, pneumonia, and ileus; and decreases hospital stay. [Atelectasis: Collapse or incomplete expansion of the lungs is known as atelectasis. Pneumonia: Consolidation of a part or the whole of the lung from an acute inflammatory exudate into the alveolar spaces is called pneumonia. Ileus: Impairment of the forward flow of the intestinal contents which is either paralytic secondary to electrolyte abnormalities, surgery, peritoneal irritation or mesenteric artery accidents or obstructive due to adhesive bands, foreign bodies, intussusception or tumours.]

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TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

 Other Clinical Conditions y Raynauds Disease A disorder wherein exposure to cold causes sudden contraction of small arteries supplying the fingers and toes. y Diabetic Polyneuropathy y Ulcer Healing

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y Morning sickness y Motion / Travel sickness

y Labor and Delivery Advantages of using TENS in labor and delivery are as follows: 1) It is safe to both mother and child. 2) It is noninvasive. 3) It is easily administered. 4) It is readily reversible. Electrodes are commonly placed at T10 L1 and S2 S4 spinal levels because uterine contractions and dilation of the cervix core mediated in afferent nerve pathways rather than entering the sympathetic nerve distribution of T10 L1. Pain impulses from distension and stretching of the delivery canal, pelvic floor, vulva, and perineum reach the spinal cord via pudendal nerves and the dorsal roots of S2 S4. y Dysmenorrhoea Pain or discomfort experienced just before or during menstrual periods is known as dysmenorrhoea. y Postoperative nausea associated with opioid medication y Nausea associated with chemotherapy

y Reduction in ischaemia due to reconstructive surgery

Contraindications of TENS:
 Undiagnosed pain (unless recommended by a medical practitioner)  Pacemakers (unless recommended by a cardiologist) This is because the electrical field generated by TENS could interfere with implanted synchronous type of cardiac pacemaker. TENS may be safely administered to patients with the asynchronous (fixed-rate) type of cardiac pacemaker.
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TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

 Heart disease (unless recommended by a cardiologist)  Epilepsy (unless recommended by a medical practitioner) A disorder of the brain caused by abnormal electrical activity, characterized by seizures, and is a symptom rather than a disease itself.  Pregnancy x First trimester (unless recommended by a medical practitioner) x Over the uterus To reduce the risk of including labor, TENS should not be administered over pregnant uterus although TENS is routinely administered on the back to relieve pain during labor.  Do not apply TENS: x Over the carotid sinus Placement of TENS electrodes over the carotid sinus is contraindicated, as it has been found to produce arrhythmia and bradycardia. TENS should not be delivered over the anterior part of the neck as currents may stimulate the carotid sinus leading to an acute hypotensive response via a vagovagal reflex. TENS currents may also stimulate laryngeal nerves, leading to a laryngeal spasm. [Arrhythmia: Loss or an irregularity of rhythm is known as arrhythmia. Bradycardia: Slow heart beat exhibiting slow pulse rate, less than 60 per minute is known as bradycardia.] x On broken skin x On dysaesthetic skin Therapists should ensure that a patient has normal skin sensation prior to using TENS as if TENS is applied to skin with diminished sensation the patient may be unaware that they are administering high-frequency currents and this may result in a minor electrical skin burn. x Internally (mouth) TENS should not be applied internally (mouth), or over areas of broken or damaged skin. x Over the pharynx Electrode placement along the pharyngeal area may hamper breathing.  Patients who do not comprehend the physiotherapists instructions or who are unable to co-operate  Patients who have allergic response to the electrodes, gel, or tape  Dermatological conditions e.g., dermatitis, eczema
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TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

Hazards of TENS:

Safety Protocols for TENS:

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D Protocol for the safe application of TENS:  Check contraindications with patient.  Test skin for normal sensation using blunt/sharp test.  TENS device should be switched off and electrode leads disconnected.  Set electrical characteristics of TENS while device is switched off.  Connect electrodes to pins on lead wire and position electrodes on patients skin.  Ensure TENS device is still switched off and connect the electrode wire to the TENS device.  Switch the TENS device on.  Gradually (slowly) increase the intensity until the patient experiences the first tingling sensation from the stimulator.  Gradually (slowly) increase the intensity further until the patient experiences a strong but comfortable tingling sensation.  This intensity should not be painful or cause muscle contraction (unless intense TENS or acupuncture-like TENS are being used). D Protocol for the safe termination of TENS:  Gradually (slowly) decrease the intensity until the patient experiences no tingling sensation.
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 Patient may experience skin irritation with TENS such as reddening beneath or around the electrodes. This is commonly due to dermatitis at the site of contact with the electrodes resulting from the constituents of electrodes, electrode gel, or adhesive tape.  It is crucial that patient is educated on the appropriate administration of TENS. Patient should be encouraged to follow set safety procedures when applying and removing TENS to reduce the chance of an electric shock.

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 Patient with current or recent bleeding / hemorrhage or with compromised circulation e.g., ischaemic tissue, thrombosis and associated conditions [Dermatitis: Inflammation of the skin characterized by itching, redness and various skin lesions is known as dermatitis. Eczema: A superficial inflammation affecting the epidermis, which manifests in redness, itching, weeping, oozing, and crusting is known as eczema. Thrombosis: The formation of a fibrinous clot in any part of the circulatory system is known as thrombosis.]

TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION)

Sagar Naik, PT

 Switch the TENS device off.  Disconnect the electrode wire from the TENS device.  Disconnect electrodes from the pins on lead wire.  Remove the electrodes from the patients skin.

 Psychogenic Pain  Pain of central nervous system (CNS) origin  Diabetic and alcoholic neuropathy

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Poor Response of TENS: