T.E.N.S.

Trancutaneous Electrical Nerve Stimulation

General Concepts:
An Approach to pain control
Trancutaneous Electrical Nerve Stimulation: Any stimulation in which a current is applied across the skin to stimulate nerves 1965 Gate Control Theory created a great popularity of TENS TENS has 50-80% efficacy rate TENS stimulates afferent sensory fibers to elicit production of neurohumneral substances such as endorphins, enkephalins and serotonin (i.e. gate theory)

TENS
Indications
Control Chronic Pain Management postsurgical pain Reduction of posttraumatic & acute pain

Precautions
Can mask underlying pain Burns or skin irritation prolonged use may result in muscle spasm/soreness caffeine intake may reduce effectiveness Narcotics decrease effectiveness

TENS may be:

high voltage interferential acuscope low voltage AC stimulator classical portable TENS unit

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 from pituitary) Brief-Intense TENS (noxious stimulation to active C fibers)

Techniques of TENS application:

Conventional or High Frequency Acupuncture or Low Frequency Brief Intense Burst Mode Modulated

Protocol for Various Methods of TENS

Parameter Intensity Pulse Fq Pulse Duration Mode Tx Duration Onset of Relief High TENS Sensory 60-100 pps Low TENS Motor 2-4 pps Brief-Intense TENS Noxious Variable 300-1000sec Modluated 15-30 min <15 min

60-100 sec 150-250 sec Modulated As needed < 10 min Modulated Burst 30 min 20-40 min

Conventional Tens/High Frequency TENS

Paresthesia is created without motor response A Beta filers are stimulated to SG enkephlin interneuron (pure gate theory) Creates the fastest relief of all techniques Applied 30 minutes to 24 hours relief is short lives (45 sec 1/2 life) May stop the pain-spasms cycle

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 tolerance

Set up:
2 to 4 electrodes, often will be placed on post-op. Readjust parameters after response has been established. Turn on the intensity to a strong stimulation. Increase the pulse width and ask if the stimulation is getting wider (if deeper=good, if stronger...use shorter width)

Low Frequency/Acupuncture-like TENS:

Level III pain relief, A delta fibers get Beta endorphins Longer lasting pain relief but slower to start Application
pulse rate low 1-5ppx (below 10) Pulse width: 200-300 microSec Intensity: strong you want rhythmical contractions within the patients tolerance

Burst Mode 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 Pulses within burst can vary Burst frequency is 1-5 bursts per second Strong contraction at lower frequencies Combines efficacy of low rate TENS with the comfort of conventional TENS

Burst Mode TENS - Application

Pulse width: high 100-200 microSec Pulse rate: 70-100 pps modulated to 1-5 burst/sec Intensity: strong but comfortable treatment length: 20-60 minutes

Brief, Intense TENS: hyperstimulation analgesia

Stimulates C fibers for level II pain control (PAG etc.) Similar to high frequency TENS Highest rate (100 Hz), 200 mSec pulse width intensity to a very strong but tolerable level 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.

Brief Intense TENS - Application

Pulse width: as high as possible Pulse rate: depends on the type of stimulator Intensity: as high as tolerated Duration: 15 minutes with conventional TENS unit. Locus stimulator is advocated for this treatment type, treatment time is 30 seconds per point.

Locus point stimulator

Locus (point) stimulators treatment occurs once per day generally 8 points per session
Auricular points are often utilized

Treat distal to proximal Allow three treatment trails before efficacy is determined Use first then try other modalities

Modulated Stimulation:
Keeps tissues reactive so no accommodation occurs Simultaneous modulation of amplitude and pulse width As amplitude is decreased, pulse width is automatically increased to deliver more consistent energy per pulse Rate can also be modulated

Electrode Placement:
May be over the painful sites, dermatomes, myotomes, trigger points, acupuncture points or spinal nerve roots. May be crossed or uncrossed (horizontal or vertical

Contraindications:
Demand pacemakers over carotid sinuses Pregnancy Cerebral vascular disorders (stroke patients) Over the chest if patient has any cardiac condition