Transcutaneous Electrical Nerve Stimulation (TENS)

Abstract

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive, self‐administered technique to relieve pain. During TENS, pulsed electrical currents are administered across the intact surface of the skin to generate strong nonpainful TENS sensations or mild muscle twitching at the site of pain. TENS inhibits onward transmission of nociceptive (pain‐related) information in the central nervous system and appears to be beneficial for acute and chronic pain. Large meta‐analyses suggest positive outcomes for the relief of musculoskeletal and post‐operative pain, although many systematic reviews are inconclusive. Evidence suggests that some investigators have used small study sample sizes and TENS techniques that are unlikely to be effective based on the findings of studies that have evaluated optimal TENS settings using healthy volunteers. The national institute of health and clinical excellence (UK) recommend TENS for rheumatoid arthritis, osteoarthritis and musculoskeletal pain associated with multiple sclerosis but not for nonspecific low back pain and labour pain. TENS is inexpensive, safe and popular with patients and for this reason practitioners continue to offer patients TENS until better quality evidence emerges.

Key Concepts:

  • Pain is a major healthcare problem with the prevalence of chronic pain estimated to be greater than 20% in many European countries.

  • TENS is an inexpensive, noninvasive, self‐administered technique that delivers pulsed electrical currents across the intact surface of the skin to relieve pain.

  • Conventional TENS is administered using low intensity, high frequency currents to generate a strong nonpainful TENS paraesthesia within the site of pain, and acupuncture‐like TENS is administered using high intensity, low frequency currents to generate a strong nonpainful pulsating TENS sensation often accompanied by muscle twitching.

  • Conventional TENS is used in the first instance, and acupuncture‐like TENS, which is a form of hyperstimulation, is used for patients who do not respond to conventional TENS.

  • There is strong neurophysiological evidence that TENS synaptically inhibits onward transmission of nociceptive (pain‐related) impulses in the central nervous system.

  • Clinical experience suggests that TENS is beneficial for acute and chronic pains that are nociceptive, neuropathic or musculoskeletal in origin.

  • There are many randomised controlled clinical trials on TENS, but most are methodologically weak with small sample sizes and underdosing of TENS.

  • The majority of systematic reviews on TENS are inconclusive with the National Institute of Health and Clinical Excellence in the UK recommending that TENS is not cost effective for the management of nonspecific low back pain and established labour pain.

  • There are some good quality systematic reviews on TENS that suggest that TENS is effective for musculoskeletal pain and post‐operative pain with the National Institute of Health and Clinical Excellence in the UK recommending that TENS is cost effective for the management of rheumatoid arthritis, osteoarthritis and musculoskeletal pain associated with multiple sclerosis.

Keywords: transcutaneous electric nerve stimulation (TENS); electric stimulation therapy; acupuncture; gate control theory of pain; chronic pain; randomised controlled clinical trial; meta‐analysis

Figure 1.

Transcutaneous electrical nerve stimulation.

Figure 2.

The electrical characteristics of a standard TENS device.

Figure 3.

Electrode positions during TENS for painful conditions.

Figure 4.

Mechanism of action of conventional TENS (white arrows indicate direction of nerve impulses).

Figure 5.

Mechanism of action of acupuncture like TENS (white arrows indicate direction of nerve impulses).

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References

Aarskog R, Johnson MI, Demmink JH et al. (2007) Is mechanical pain threshold after transcutaneous electrical nerve stimulation (TENS) increased locally and unilaterally? A randomized placebo‐controlled trial in healthy subjects. Physiotherapy Research International 12: 251–263.

Bedwell C, Dowswell T, Neilson JP and Lavender T (2011) The use of transcutaneous electrical nerve stimulation (TENS) for pain relief in labour: a review of the evidence. Midwifery 27: e141–e148.

Bennett MI, Hughes N and Johnson MI (2011) Methodological quality in randomised controlled trials of transcutaneous electric nerve stimulation for pain: low fidelity may explain negative findings. Pain 152: 1226–1232.

Bjordal JM, Johnson MI and Ljunggreen AE (2003) Transcutaneous electrical nerve stimulation (TENS) can reduce postoperative analgesic consumption. A meta‐analysis with assessment of optimal treatment parameters for postoperative pain. European Journal of Pain 7: 181–188.

Bjordal JM, Johnson MI, Lopes‐Martins RA et al. (2007) Short‐term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta‐analysis of randomised placebo‐controlled trials. BMC Musculoskeletal Disorders 8: 51.

Breivik H, Collett B, Ventafridda V, Cohen R and Gallacher D (2006) Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. European Journal of Pain 10: 287–333.

Bronfort G, Nilsson N, Haas M et al. (2004) Non‐invasive physical treatments for chronic/recurrent headache. Cochrane Database of Systematic Reviews CD001878. http://www.ncbi.nlm.nih.gov/pubmed?term=bronfort%20tens

Brosseau L, Judd MG, Marchand S et al. (2003) Transcutaneous electrical nerve stimulation (TENS) for the treatment of rheumatoid arthritis in the hand. Cochrane Database of Systematic Reviews 3: CD004377. http://www.ncbi.nlm.nih.gov/pubmed/12918009

Brown L, Holmes M and Jones A (2009) The application of transcutaneous electrical nerve stimulation to acupuncture points (Acu‐TENS) for pain relief: a discussion of efficacy and potential mechanisms. Physical Therapy Reviews 14: 93–103.

Burri H and Piguet V (2009) UninTENSional pacemaker interactions with transcutaneous electrical nerve stimulation. Europace 11: 283–284.

Carroll D, Moore RA, McQuay HJ et al. (2001) Transcutaneous electrical nerve stimulation (TENS) for chronic pain. Cochrane Database of Systematic Reviews 3: CD003222. http://www.ncbi.nlm.nih.gov/pubmed/11687055

Carroll D, Tramer M, Mcquay H, Nye B and Moore A (1996) Randomization is important in studies with pain outcomes: systematic review of transcutaneous electrical nerve stimulation in acute postoperative pain. British Journal of Anaesthesia 77: 798–803.

Carroll D, Tramer M, Mcquay H, Nye B and Moore A (1997) Transcutaneous electrical nerve stimulation in labour pain: a systematic review. British Journal of Obstetrics and Gynaecology 104: 169–175.

Chartered Society Of Physiotherapy, C (2006) Guidance for the Clinical use of Electrophysical Agents. London: Chartered Society of Physiotherapy.

Chen C, Tabasam G and Johnson M (2008) Does the pulse frequency of transcutaneous electrical nerve stimulation (TENS) influence hypoalgesia? A systematic review of studies using experimental pain and healthy human participants. Physiotherapy 94: 11–20.

Chen CC and Johnson MI (2009) An investigation into the effects of frequency‐modulated transcutaneous electrical nerve stimulation (TENS) on experimentally induced pressure pain in healthy human participants. Journal of Pain 10: 1029–1037.

Chen CC and Johnson MI (2010a) A comparison of transcutaneous electrical nerve stimulation (TENS) at 3 and 80 pulses per second on cold‐pressor pain in healthy human participants. Clinical Physiology and Functional Imaging 30: 260–268.

Chen CC and Johnson MI (2010b) An investigation into the hypoalgesic effects of high‐ and low‐frequency transcutaneous electrical nerve stimulation (TENS) on experimentally induced blunt pressure pain in healthy human participants. Journal of Pain 11: 53–61.

Chen CC and Johnson MI (2011) Differential frequency effects of strong nonpainful transcutaneous electrical nerve stimulation on experimentally induced ischemic pain in healthy human participants. Clinical Journal of Pain 27: 434–441.

Claydon L and Chesterton L (2008) Does transcutaneous electrical nerve stimulation (TENS) produce ‘dose‐responses’? A review of systematic reviews on chronic pain. Physical Therapy Reviews 13: 450–463.

Coldron Y, Crothers E, Haslam J et al. (2007) ACPWH guidance on the safe use of Transcutaneous Electrical Nerve Stimulation (TENS) for musculosketal pain during pregnancy. http://www.electrotherapy.org/downloads/Modalities/TENS in pregnancy guidelines.pdf.

Cowan S, Mckenna J, Mccrum‐Gardner E et al. (2009) An investigation of the hypoalgesic effects of TENS delivered by a glove electrode. Journal of Pain 10: 694–701.

Cruccu G, Aziz TZ, Garcia‐Larrea L et al. (2007) EFNS guidelines on neurostimulation therapy for neuropathic pain. European Journal of Neurology 14: 952–970.

Desantana JM, Da Silva LF and Sluka KA (2010) Cholecystokinin receptors mediate tolerance to the analgesic effect of TENS in arthritic rats. Pain 148: 84–93.

Desantana JM, Santana‐Filho VJ, Guerra DR et al. (2008a) Hypoalgesic effect of the transcutaneous electrical nerve stimulation following inguinal herniorrhaphy: a randomized, controlled trial. Journal of Pain 9: 623–629.

Desantana JM, Walsh DM, Vance C, Rakel BA and Sluka KA (2008b) Effectiveness of transcutaneous electrical nerve stimulation for treatment of hyperalgesia and pain. Current Rheumatology Reports 10: 492–499.

Dowswell T, Bedwell C, Lavender T and Neilson JP (2009) Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Cochrane Database of Systematic Reviews 2: CD007214. http://www.ncbi.nlm.nih.gov/pubmed/19370680

Dubinsky RM and Miyasaki J (2010) Assessment: efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence‐based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 74: 173–176.

Francis RP and Johnson MI (2011) The characteristics of acupuncture‐like transcutaneous electrical nerve stimulation (acupuncture‐like TENS): a literature review. Acupuncture and Electro‐therapeutics Research 36(3–4): 231–258.

Freynet A and Falcoz PE (2010) Is transcutaneous electrical nerve stimulation effective in relieving postoperative pain after thoracotomy? Interactive CardioVascular and Thoracic Surgery 10: 283–288.

Hingne PM and Sluka KA (2008) Blockade of NMDA receptors prevents analgesic tolerance to repeated transcutaneous electrical nerve stimulation (TENS) in rats. Journal of Pain 9: 217–225.

Hurlow A, Bennett MI, Robb KA et al. (2012) Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults. Cochrane Database of Systematic Reviews 3: CD006276. http://www.ncbi.nlm.nih.gov/pubmed/22419313

Jena S, Witt CM, Brinkhaus B, Wegscheider K and Willich SN (2008) Acupuncture in patients with headache. Cephalalgia 28: 969–979.

Jin DM, Xu Y, Geng DF and Yan TB (2010) Effect of transcutaneous electrical nerve stimulation on symptomatic diabetic peripheral neuropathy: a meta‐analysis of randomized controlled trials. Diabetes Research and Clinical Practice 89: 10–15.

Johnson M (1998) Acupuncture‐like transcutaneous electrical nerve stimulation (AL‐TENS) in the management of pain. Physical Therapy Reviews. 3: 73–93.

Johnson M (2001) Transcutaneous electrical nerve stimulation (TENS) and TENS‐like devices. Do they provide pain relief? Pain Reviews 8: 121–128.

Johnson M and Martinson M (2007) Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: a meta‐analysis of randomized controlled trials. Pain 130: 157–165.

Johnson MI, Ashton CH and Thompson JW (1991) An in‐depth study of long‐term users of transcutaneous electrical nerve stimulation (TENS). Implications for clinical use of TENS. Pain 44: 221–229.

Khadilkar A, Odebiyi DO, Brosseau L and Wells GA (2008) Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low‐back pain. Cochrane Database of Systematic Reviews 4: CD003008. http://www.ncbi.nlm.nih.gov/pubmed/18843638

Koke AJ, Schouten JS, Lamerichs‐Geelen MJ et al. (2004) Pain reducing effect of three types of transcutaneous electrical nerve stimulation in patients with chronic pain: a randomized crossover trial. Pain 108: 36–42.

Kolen AF, De Nijs RN, Wagemakers FM, Meier AJ and Johnson MI (2012) Effects of spatially targeted transcutaneous electrical nerve stimulation using an electrode array that measures skin resistance on pain and mobility in patients with osteoarthritis in the knee: a randomized controlled trial. Pain 153: 373–381.

Kroeling P, Gross A, Goldsmith CH et al. (2009) Electrotherapy for neck pain. Cochrane Database of Systematic Reviews 4: CD004251. http://www.ncbi.nlm.nih.gov/pubmed/19821322

Liebano RE, Rakel B, Vance CG, Walsh DM and Sluka KA (2011) An investigation of the development of analgesic tolerance to TENS in humans. Pain 152: 335–342.

Ma YT and Sluka KA (2001) Reduction in inflammation‐induced sensitization of dorsal horn neurons by transcutaneous electrical nerve stimulation in anesthetized rats. Experimental Brain Research 137: 94–102.

Machado LA, Kamper SJ, Herbert RD, Maher CG and McAuley JH (2009) Analgesic effects of treatments for non‐specific low back pain: a meta‐analysis of placebo‐controlled randomized trials. Rheumatology (Oxford) 48: 520–527.

Maeda Y, Lisi TL, Vance CG and Sluka KA (2007) Release of GABA and activation of GABA(A) in the spinal cord mediates the effects of TENS in rats. Brain Research 1136: 43–50.

Mello LF, Nobrega LF and Lemos A (2011) Transcutaneous electrical stimulation for pain relief during labor: a systematic review and meta‐analysis. Revista Brasileira de Fisioterapia 15: 175–184.

Moran F, Leonard T, Hawthorne S et al. (2011) Hypoalgesia in response to transcutaneous electrical nerve stimulation (TENS) depends on stimulation intensity. Journal of Pain 12(8): 929–935.

Mulvey MR, Bagnall AM, Johnson MI and Marchant PR (2010) Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Cochrane Database of Systematic Reviews 5: CD007264. http://www.ncbi.nlm.nih.gov/pubmed/20464749

National Institute For Health and Clinical Excellence (2009) NICE clinical guideline 88 Early management of persistent non‐specific low back pain London. http://www.nice.org.uk/nicemedia/live/11887/44334/44334.pdf

Nnoaham KE and Kumbang J (2008) Transcutaneous electrical nerve stimulation (TENS) for chronic pain. Cochrane Database of Systematic Reviews 3: CD003222. http://www.ncbi.nlm.nih.gov/pubmed?term=nnoaham%20tens

Oosterhof J, Samwel HJ, De Boo TM et al. (2008) Predicting outcome of TENS in chronic pain: a prospective, randomized, placebo controlled trial. Pain 136: 11–20.

Oosterhof J, Wilder‐Smith OH, de Boo T, Oostendorp RA and Crul BJ (2012) The long‐term outcome of transcutaneous electrical nerve stimulation in the treatment for patients with chronic pain: a randomized, placebo‐controlled trial. Pain Practice. Doi: 10.1111/j.1533‐2500.2012.00533.x [Epub ahead of print].

Pantaleao MA, Laurino MF, Gallego NL et al. (2011) Adjusting pulse amplitude during transcutaneous electrical nerve stimulation (TENS) application produces greater hypoalgesia. Journal of Pain, 12: 581–590.

Poitras S and Brosseau L (2008) Evidence‐informed management of chronic low back pain with transcutaneous electrical nerve stimulation, interferential current, electrical muscle stimulation, ultrasound, and thermotherapy. Spine Journal 8: 226–233.

Price CI and Pandyan AD (2001) Electrical stimulation for preventing and treating post‐stroke shoulder pain: a systematic Cochrane review. Clinical Rehabilitation 15: 5–19.

Proctor ML, Smith CA, Farquhar CM and Stones RW (2002) Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea. Cochrane Database of Systematic Reviews 1: CD002123. http://www.ncbi.nlm.nih.gov/pubmed/11869624

Radhakrishnan R and Sluka KA (2005) Deep tissue afferents, but not cutaneous afferents, mediate transcutaneous electrical nerve stimulation‐Induced antihyperalgesia. Journal of Pain 6: 673–680.

Rakel B, Cooper N, Adams HJ et al. (2010) A new transient sham TENS device allows for investigator blinding while delivering a true placebo treatment. Journal of Pain, 11, 230–238

Robb K, Oxberry SG, Bennett MI et al. (2009) A cochrane systematic review of transcutaneous electrical nerve stimulation for cancer pain. Journal of Pain and Symptom Management 37: 746–753.

Rutjes AW, Nüesch E, Sterchi R et al. (2009) Transcutaneous electrostimulation for osteoarthritis of the knee. Cochrane Database of Systematic Reviews 4: CD002823. http://www.ncbi.nlm.nih.gov/pubmed/19821296

Sandkühler J (2000) Long‐lasting analgesia following TENS and acupuncture: spinal mechanisms beyond gate control. In: Devor M, Rowbotham MC and Wiesenfeld‐Hallin Z (eds) 9th World Congress on Pain: Progress in Pain Research and Management, pp. 359–369. Seattle: IASP Press.

Walsh DM, Howe TE, Johnson MI and Sluka KA (2009) Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database of Systematic Reviews 2: CD006142. http://www.ncbi.nlm.nih.gov/pubmed/19370629

Further Reading

Johnson M (2008) Transcutaneous electrical nerve stimulation. In: Watson T (ed.) Electrotherapy: Evidence Based Practice, pp. 253–296. Edinburgh: Churchill Livingstone.

Johnson MI, Oxberry SG and Robb K (2008) Stimulation‐induced analgesia. In: Sykes N, Bennett M and Yuan C‐S (eds) Cancer Pain, pp. 235–250. London: Hodder Arnold.

Johnson MI and Walsh DM (2010) Pain: continued uncertainty of TENS' effectiveness for pain relief. Nature Reviews Rheumatology 6(6): 314–316.

Walsh D (1997) TENS: Clinical Applications and Related Theory. New York: Churchill Livingstone.

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Johnson, Mark I(Oct 2012) Transcutaneous Electrical Nerve Stimulation (TENS). In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0024044]