TRANSCUTANEOUS ELECTRICAL NERVE

STIMULATION (TENS)
A Comprehensive Overview for Undergraduate
Physiotherapy Students
1. Definition
Transcutaneous Electrical Nerve Stimulation (TENS) is a non-
invasive, drug-free method of pain control that uses low-voltage
electrical current delivered through electrodes placed on the skin
to stimulate nerve fibers. TENS is primarily used for pain relief,
though its applications extend to various physiological and
therapeutic domains within physiotherapy practice.
2. Mechanism of Action
TENS operates through several physiological mechanisms:
2.1 Gate Control Theory
 Proposed by Melzack and Wall (1965)
 Stimulation of large diameter, myelinated A-beta sensory
nerve fibers
 "Closes the gate" to pain transmission by inhibiting small
diameter C fibers
 This occurs at the substantia gelatinosa in the dorsal horn of
the spinal cord
 Results in reduced pain perception in the brain
2.2 Endogenous Opioid Release
 Low-frequency TENS (2-10 Hz) stimulates the release of
endorphins, enkephalins, and dynorphins
  These endogenous opioids bind to opioid receptors (μ, δ,
and κ)
 Creates analgesic effects similar to morphine
 Effects may be reversed by naloxone (an opioid antagonist)
2.3 Increased Blood Flow
 TENS causes local vasodilation
 Improves circulation and tissue oxygenation
 Aids in removal of pain-inducing substances
 Promotes healing by increasing delivery of nutrients
2.4 Muscle Re-education
 Can facilitate muscle contraction in weakened muscles
 Helps reduce muscle spasm
 Assists in preventing muscle atrophy
3. Types of TENS Applications
3.1 Conventional TENS (High-Frequency)
 Frequency: 80-120 Hz
 Pulse width: 50-100 μs
 Intensity: Low (sensory level, comfortable tingling)
 Duration: 30-60 minutes, multiple times daily
 Mechanism: Primary action via gate control theory
 Onset: Rapid pain relief but shorter duration
3.2 Acupuncture-Like TENS (Low-Frequency)
 Frequency: 2-10 Hz
 Pulse width: 200-300 μs
 Intensity: High (motor level, visible muscle contractions)
  Duration: 20-30 minutes, fewer sessions needed
 Mechanism: Endogenous opioid release
 Onset: Slower onset but longer-lasting effects
3.3 Brief Intense TENS
 Frequency: 100-150 Hz
 Pulse width: >200 μs
 Intensity: Maximum tolerable (noxious level)
 Duration: 15-30 minutes
 Application: Restricted to very localized pain
 Note: May be uncomfortable but highly effective for acute
pain
3.4 Burst Mode TENS
 Combines aspects of both conventional and acupuncture-
like TENS
 Delivers high-frequency bursts (80-100 Hz) at a low
frequency (2-4 Hz)
 Provides both immediate and longer-lasting relief
3.5 Modulated TENS
 Parameters (frequency, pulse width, or amplitude) vary
during treatment
 Helps prevent accommodation to electrical stimulation
 Useful for longer treatment sessions
4. Current Parameters and Technical Aspects
4.1 Waveforms
  Monophasic: Current flows in one direction only (rarely
used due to polarization)
 Biphasic symmetric: Equal positive and negative phases
(balanced charge)
 Biphasic asymmetric: Unequal positive and negative
phases
 Polyphasic: Multiple phase changes within each pulse
4.2 Pulse Width (Duration)
 Ranges from 50-300 microseconds
 Shorter pulse widths (50-100 μs) primarily activate sensory
nerves
 Longer pulse widths (150-300 μs) can activate motor
nerves
 Wider pulses generally produce stronger sensations
4.3 Frequency (Pulse Rate)
 Low frequency: 2-10 Hz (endorphin release, longer-lasting
effects)
 High frequency: 80-120 Hz (gate control, immediate relief)
 Choice depends on treatment goals and patient response
4.4 Amplitude (Intensity)
 Measured in milliamperes (mA)
 Sensory level: Comfortable tingling without muscle
contraction
 Motor level: Visible muscle twitching
 Noxious level: Strong but tolerable sensation
4.5 Electrode Types and Placement
  Self-adhesive electrodes: Most common, convenient,
reusable
 Carbon rubber electrodes: Require conductive gel and
securing straps
 Placement strategies:
o Over the painful area

o Along dermatomes

o Along nerve pathways

o At trigger points

o Around joint lines

o Over acupuncture points

o Segmental placement (at related spinal levels)

5. Indications
5.1 Pain Management
 Acute pain conditions
o Post-operative pain

o Traumatic injury

o Procedural pain

 Chronic pain conditions

o Osteoarthritis

o Rheumatoid arthritis

o Low back pain

o Neck pain

o Neuropathic pain

o Phantom limb pain

o Complex regional pain syndrome

5.2 Musculoskeletal Applications

  Muscle spasm reduction
 Joint stiffness
 Tendinopathies
 Myofascial pain
 Sports injuries
5.3 Neurological Applications
 Peripheral nerve regeneration
 Spasticity management
 Post-stroke rehabilitation
 Multiple sclerosis
 Spinal cord injury
5.4 Other Applications
 Wound healing
 Edema reduction
 Labor pain
 Dysmenorrhea
 Bladder dysfunction
6. Contraindications
6.1 Absolute Contraindications
 Cardiac pacemakers or implanted defibrillators
 First trimester of pregnancy (abdominal/lumbar regions)
 Undiagnosed pain (requires medical diagnosis first)
 Epilepsy (electrode placement near head/neck)
 Malignancy (direct application over tumor sites)
6.2 Relative Contraindications
  Impaired sensation
 Cognitive impairment (unable to provide feedback)
 Skin conditions or irritation at electrode sites
 Metal implants in the stimulation area
 Pregnancy (beyond first trimester)
 Heart disease
 Children (caution with parameter selection)
 Concurrent use with high-frequency surgical equipment
7. Precautions
7.1 Electrode Placement Precautions
 Avoid placement over:
o Carotid sinus (risk of hypotension)

o Laryngeal/pharyngeal muscles (swallowing

difficulties)
o Eyes

o Anterior neck (may trigger vagal response)

o Mucous membranes

o Areas of skin breakdown or infection

o Areas with diminished sensation

7.2 Patient Safety Precautions

 Start with low intensity and gradually increase
 Provide clear instructions on home use
 Regular skin checks under electrodes
 Remove electrodes after maximum recommended usage
time
 Avoid driving or operating machinery during stimulation
 Do not use in wet environments or while bathing
  Periodic reassessment of treatment effectiveness
 Store equipment safely away from children
7.3 Equipment Precautions
 Regular battery checks
 Electrode maintenance (replacement when adhesiveness
diminishes)
 Periodic calibration of device
 Follow manufacturer's maintenance guidelines
8. Clinical Treatment Protocols
8.1 Acute Pain Management Protocol
 Frequency: 80-120 Hz
 Pulse width: 50-100 μs
 Intensity: Comfortable sensory level
 Duration: 30-60 minutes, multiple sessions daily
 Electrode placement: Around the painful area
 Course: As needed for pain control
8.2 Chronic Pain Protocol
 Frequency: Alternating between high (80-120 Hz) and low
(2-10 Hz)
 Pulse width: 200-300 μs
 Intensity: Strong but comfortable
 Duration: 30-60 minutes, 2-3 times daily
 Electrode placement: Over painful area and related
dermatomes
 Course: Regular use with periodic reassessment
8.3 Neuropathic Pain Protocol
 Frequency: Low (2-10 Hz)
 Pulse width: 200-300 μs
 Intensity: Strong sensory or mild motor response
 Duration: 30-40 minutes, 1-2 times daily
 Electrode placement: Along affected nerve distribution
 Course: Daily for 4-6 weeks, then reassess
8.4 Post-Operative Pain Protocol
 Frequency: 100-120 Hz
 Pulse width: 100-150 μs
 Intensity: Comfortable sensory level
 Duration: Continuous or 1 hour on/1 hour off
 Electrode placement: Around surgical site (not directly on
wound)
 Course: First 72 hours post-surgery or until pain controlled
8.5 Sports Injury Protocol
 Frequency: 80-100 Hz initially, then 2-10 Hz
 Pulse width: 150-200 μs
 Intensity: Comfortable to strong sensory level
 Duration: 20-30 minutes, 3-4 times daily
 Electrode placement: Around injury site and related trigger
points
 Course: Acute phase (3-5 days) then reassess
9. Clinical Assessment and Outcome Measures
9.1 Pre-treatment Assessment
  Pain assessment (VAS, NRS, McGill Pain Questionnaire)
 Functional assessment
 Sensory testing (if neuropathic component)
 Documentation of medication use
9.2 Monitoring During Treatment
 Patient comfort and tolerance
 Immediate pain response
 Adverse reactions
 Parameter adjustments
9.3 Outcome Measures
 Pain reduction (short and long-term)
 Functional improvement
 Medication use reduction
 Quality of life measures
 Patient satisfaction
10. Future Directions and Research
10.1 Current Research Areas
 Integration with other modalities
 Optimization of parameters for specific conditions
 Long-term effectiveness
 Neurophysiological mechanisms
 Cost-effectiveness studies
10.2 Technological Advances
 Wireless TENS units
 Smartphone-controlled devices
  Wearable TENS technology
 Integration with telerehabilitation
 AI-guided parameter optimization
11. Practical Application Guidelines for Students
11.1 Patient Education Points
 Mechanism of action in simple terms
 Realistic expectations
 Safety instructions
 Self-management strategies
 Troubleshooting common issues
11.2 Documentation Requirements
 Parameters used
 Electrode placement
 Treatment duration
 Patient response
 Adverse effects if any
 Plan for progression
11.3 Common Clinical Errors
 Insufficient intensity
 Poor electrode contact
 Incorrect electrode placement
 Inadequate treatment duration
 Failure to progress parameters
References and Further Reading
 Melzack R, Wall PD. Pain mechanisms: a new theory.
Science. 1965;150(3699):971-979.
 Johnson MI. Transcutaneous Electrical Nerve Stimulation
(TENS): Research to support clinical practice. Oxford
University Press; 2014.
 Watson T. Electrotherapy: evidence-based practice. 12th
ed. Elsevier; 2008.
 Sluka KA, Walsh D. Transcutaneous electrical nerve
stimulation: basic science mechanisms and clinical
effectiveness. J Pain. 2003;4(3):109-121.
 Vance CG, Dailey DL, Rakel BA, Sluka KA. Using TENS
for pain control: the state of the evidence. Pain Manag.
2014;4(3):197-209.