Transcutaneous Electrical Nerve Stimulation for Pain Relief

Transcutaneous Electrical Nerve Stimulation for Pain Relief

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Description: TENS physiological effects, Antidromic Effect, Gate control theory, Neurotransmitter release in the CNS, Pain memory: long-term potentiation (LTP), TENS Indications, Postoperative TENS after surgery of the shoulder, transcutaneous electrical nerve stimulation effective, relieving postoperative pain after thoracotomy, Efficacy of electrical nerve stimulation for chronic musculoskeletal pain, meta-analysis of randomized controlled trials, Transcutaneous electrical nerve stimulation.

 
Author: PainCourse (Fellow) | Visits: 2100 | Page Views: 2109
Domain:  Medicine Category: Therapy Subcategory: Pain 
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Contents:
Transcutaneous Electrical Nerve Stimulation
TENS / ENS/ TNS/ EA

TENS - physiological effects 1
Antidromic Effect

immediate effect

Mark Johnson, 2000

TENS - physiological effect 2
Gate control theory
immediate effect, lasting for minutes

Pain
via A- and C- Fasern

Block

TENS-Impulses
via A - and A - Fasern

TENS - physiological effect 3
Neurotransmitter release in the CNS
slow effect, lasting for hours

-

Enkephalin

- Endorphin - Endomorphin - Monoamines: Noradrenalin, Serotonin

TENS - physiological effect 4
Pain memory: long-term potentiation (LTP)

,,...none of the analgetics of today extinguishes the existing pain memory. Reversing of the sensitizing might be achieved by the methods of counterirritation like TENS." Sandk�hler, Dt. �rzteblatt 42, 2001

TENS
Indications
,,Clinicans cannot assume that any particular pain will not respond to TENS....."

Johnson et al. (1991) An in-depth study of long-term users of transcutaneous electrical nerve stimulation (TENS) Pain, 44, 1991

TENS - Indications

TENS - Indications

acute postoperative pain

Postoperative TENS after surgery of the shoulder
Likar R et al. (2001) Der Schmerz 15, 3

n= 30 Intensity: 6 mA, 80 Hz, paravertebral C 4/5

"...shows that TENS post operative in surgery of the shoulder markly reduces pain and need of analgetics in the first 72 hours."

acute postoperative pain

Is transcutaneous electrical nerve stimulation effective in relieving postoperative pain after thoracotomy?
Freynet A et al. (2009) European Association for Cardio-Thoracic Surgery

9 RCT`s 7 of 9 RCT`s were in favour of TENS

"...TENS in combination with postoperative medication is a safe and effective method to reduce postoperative pain and supports recovery of the patient."

chronic musculoskeletal pain

Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: A meta-analysis of randomized controlled trials
M. Johnson et al. (2007) Pain 130:157-165
Prof. M. Johnson

A total of 38 studies in 29 papers, which included 335 placebo, 474 ENS, and 418 cross-overpatients, met the selection criteria.

,,These results indicate that ENS is an effective treatment modality for chronic musculoskeletal pain and that previous, equivocal results may have been due to underpowered studies."

chronic neuropathic pain

Transcutaneous electrical nerve stimulation for treatment of spinal cord injury neuropathic pain
Norrbrink C (2009) J Rehabil Res Dev 46,1: 85-93 (Karolinska Institut)

- n=24, - 80 Hz or 2 Hz burst, -3x daily for 2 weeks, cross over Design

,,In conclusion TENS should be considered as complementary therapy for patients with lesion of the spinal cord and neuropathic pain."

chronic neuropathic pain

Assessment: Efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review)
Dubinsky R et al. (2010) Neurology 74, American Academy of Neurology

- 2 studies class II - 1 study class III

,,Tens should be considered in treatment of painful diabetic neuropathy ." (Level B)

cancer pain

Feasibility study of transcutaneous electical nerve stimulation (TENS) for cancer bone pain.
Bennett MI, Johnson Mi, Brown SR et al. (2010) J Pain 11,4:351-359

- Randomised, placebo controlled cross over study - n=24

"By TENS pain during movement is reduced, in a higher degree than resting pain.."

Stump- / Phantom pain

ipsilateral

kontalateral

Guideline US Department of Veteran Affairs and Department of Defense 2008 TENS as first line therapy (Strength of Recomendation A)

TENS
Parameter

Frequency Intensity Dosage

Setting of electrodes Poles of electrodes

TENS

Frequency
1 - 120 Hz

TENS
high frequency

50 - 100 Hz

(conventional TENS)

sensory level intensity

segm. spinal effect: gate control

TENS
low frequency

2 � 10 Hz (acupuncture-like TENS) motor-level intensity supraspinal effect: endogenous opioids

Frequency of TENS

2

15

100

Hz

Neuropeptides

EM / ENK /EP

DYN

Opioid receptors



d
Synergism



Peptide interaction

Physiological effects
( Han, 2001)

ANALGESIA

Han - Stimulation
Enk Dyn Enk + Dyn

A

2Hz

100Hz

2Hz

B

100Hz

0
( Han, 2001)

3

6

9

12

15 S

Frequencies and Indications
Recommendations
- acute pain, primary hyperalgesia: high frequency - chronic pain, secondary hyperalgesia: low frequency - ideal for most pain conditions: Han - Stimulation

Practice

Program 1, 100 Hz Program 3, 2 Hz Program 6, Han-Stimulation

TENS

Intensity
0 - 70 mA

Intensity

pain (A , c-fibres) motoric sensoric (A�- fibres)

Intensity
Recommendations

� high frequency: sensible, but not painful A�- fibres � low frequency: causing muscle contractions

High Intensity TENS
Hyper-stimulation analgesia

- Similar to high frequency TENS, but stimulates A or C fibers for supraspinal pain control (PAG etc.) - 100 Hz - Intensity to a very strong, just tolerable level (Motor-level intensity) - Short treatment time of 1 - 15 minutes, repeatable after 1-3 minutes

High frequency, high intensity transcutaneous electric nerve stimulation for pain relief after surgical abortion
B. Platon et al. (2008) Abstract12th World Congress on Pain, IASP

n = 200, randomized to Tens or max. 50�g Fentanyl iv 20 � 60 mA for 1 Minute; if necessary 1 repetition

Conclusion: Treatment with TENS after surgical abortion induced a prompt onset, similar pain relief and a shorter visit in the recovery ward, compared with opiods

Intensity
Recommendations

� high frequency: sensible, but not painful A�- fibres � low frequency: causing muscle contractions � high-intensity: just tolerable, slightly painful A�-, A - fibres

Practice

Intensity just tolerable level

TENS

Dosage

Dosage
nociceptive pain

back pain n= 65 15/30 Hz PENS , 3x/ week for 2 weeks
Ghoname et al., 1998

Dosage
neuropathic pain

up to several hours daily (Wynn Parry, 1984)

interruptions to avoid tolerance (J. Han,1998)

Dosage
Recommendations

� Nociceptive pain:
acute: 30 min/ treatment, 1 - 4 x/ die chron.: 30 min/ treatment, 1 - 2 x/ die or for several days � Neuropathic pain: up to several hours daily in the beginning

TENS
In combination with opioids

To avoid opiod tolerance � prefer high freqency TENS � reduce amount of treatments
(Chandran, 2003)

Electrode
Materials

Self adhesive electrodes

Silicon rubber

Aluminium

Electrode
Materials

Gloves

Socks

TENS

Setting of electrodes

Setting of electrodes
Recommendations

Electrodes segmentaly in pain area Electrodes at the peripheral, innervating nerve Electrodes segmentaly paravertebral Electrodes contralateral

- Use trigger- and acupuncture points - Cave: electrodes must not touch each other!

TENS

Poles of electrodes

Poles of electrodes
Anode = positive pole= more analgetic

Cathode = negative pole= less analgetic

Epicondylitis radialis

Practice

� 2 Hz, Prog. 3 � Han-Stimulation, Prog. 6

Poles of electrodes
Recommendations
� locally Anode on the locus dolendi, Cathode on pain radiation � paravertebrally Anode on the pain area, Cathode paravertebral

I

t

Pitfalls
Common reasons for unsatisfying results
� Dosage sufficient ?

� Muscle twitches with low frequency ? � Frequency: non responder ? � Electrode placement: locus dolendi; segmentally, paravertebrally ? � Size of electrodes sufficient ? � Intenstiy: A- Stimulation ? � Other therapies combined ? � Compliance sufficient ?

TENS
Precautions and Contraindications

Patients with pacemaker and other electronic implants Severe Arrhytmia Skin lesions Pregnancy Epilepsy Implants of metall are no contraindication using biphasic impulses with AKS

TENS
Side effects are rare

Overstimulation Skin irritation Arrhytmia Danger by simultaneous usage of a high frequency device

Thank you very much !

bertramdisselhoff@web.de

Kaada - Stimulation
Low frequency (2 Hz), non-segmental stimulation
Birger Kaada

Cathode

-

analgetic Anode

- improves blood flow

Practice

� 2 Hz, Prog. 3

TAES: Acupuncture point stimulation
Labor pain
Sp 6

TENS on four acupuncture points (Hegu [Li 4] and Sanyinjiao [Sp 6]) (n=52) or the TENS placebo (n=53) ,,The application of TENS on specfic acupuncture points could be a non-invasive adjunct for pain relief in the first stage of labor."
Chao An-Shine et al. (2007) Pain relief by applying transcutaneous electrical nerve stimulation (TENS) on acupuncture points during the first stage of labor: A randomized double-blind placebo-controlled trial. Pain 127,214-220

Practice muscle stimulation Extensor carpi

Kathode
proximal

Anode
distal

TENS

Size of electrodes

Size of electrode and current density

Current density is highest at the surface and diminishes in deeper tissue

The smaller the electrode the higher the current density and the deeper the penetration

Size of electrodes
Recommendations

Size of electrodes depends on size of pain area - Small area: Use small electrodes - Large area: Use large electrodes Use small electrodes for deeper processes and increase spacing of electrodes Use small electrodes for low frequency stimulation in order to achieve a sufficient density of current for the motoric stimulation

Cervical - Syndrome

Practice

� 2 Hz, Prog. 3 � Han-Stimulation, Prog. 6

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