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TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (T.E.N.S)

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (T.E.N.S). BY ABDULLAH RADWAN. DEFINITION. TENS is a non invasive modality for relief of pain. It is the procedure of applying controlled low voltage electrical impulses to the central nervous system through electrodes placed on the skin.

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TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (T.E.N.S)

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  1. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (T.E.N.S) BY ABDULLAH RADWAN

  2. DEFINITION • TENS is a non invasive modality for relief of pain. • It is the procedure of applying controlled low voltage electrical impulses to the central nervous system through electrodes placed on the skin. • The current used is either monophasic or biphasic, its wave form is either square or spike in shape.

  3. Monophasic vs biphasic waves

  4. Square vs spike shaped waves

  5. Physiologic basis for the use of TENS: • It is the modulation of noxious impulse by an innocuous one to decrease painful sensation by 3 possible neurophysiologic mechanisms operating single or in combination. • 1. Modulation of pain in the dorsal horn of the spinal cord at the segmental level. • 2. Activation of a supraspinal inhibitory system on the nociceptive spinal neurons. • 3. A direct effect of the electrical current on the afferent stimulus in the peripheral nerve.

  6. 1. Modulation of pain in the dorsal horn of the spinal cord at the segmental level: (The gate control theory) Through stimulation of the large myelinated nerve fibers (α & β) and subsequent inhibition of pain impulses transmission through small non-myelinated nerve fibers ( C).

  7. 2. Activation of a supraspinal inhibitory system on the nociceptive spinal neurons. • The reticular cells in the brain stem are activated by somatosensory stimuli. • These stimuli may be innocuous (non-painful) in case of high frequency low-intensity TENS (traditional TENS) or nociceptive (painful) in case of low-frequency high-intensity TENS (acupuncture like stimulation).

  8. 3. A direct effect of the electrical current on the afferent stimulus in the peripheral nerve. • Through the block of nerve conduction or the change in pain threshold (increase). • However, the peripheral effect of TENS is not important in pain modulation.

  9. INDICATIONS OF TENS • 1. ACUTE PAIN, • 2. CHRONIC PAIN, • 3. POST-OPERATIVE PAIN, • 4. PAIN OF CARDIOPULMONARY DISORDERS.

  10. 1. ACUTE PAIN, a. Acute athletic and traumatic injuries: • Mild hip strain • Shoulder contusions • Ligamentous strains b. Acute pain of arthritic origin c. Post-herpetic neuralgia d. Labour pain e. Tooth extraction

  11. 2. CHRONIC PAIN, • Rheumatoid arthritis • Osteoarthritis • Chronic myofascial pain syndromes • Chronic cervical pain as in c.s • Chronic low back pain

  12. 3. POST-OPERATIVE PAIN, • Artificial joint replacement especially hip and knee • Abdominal and thoracic surgeries • Post-operative pediatric pain • Post-operative complications as paralytic ileus.

  13. 4. PAIN OF CARDIOPULMONARY DISORDERS. • Thrombophlebitis • After thoracotomy to ↑ pulmonary function tests particularly the forced vital capacity.

  14. CONTRAINDICATIONS OF TENS • Cardiac pacemaker • Application over carotid sinuses→ Vasovagal reflex →cardiac arrest. • Unknown progressive pathology (undiagnosed) • Malignancy • 1st 3 months of pregnancy.

  15. PRECAUTIONS • CARE SHOULD BE TAKEN IN THE FOLLOWING APPLICATIONS: • Pregnancy (unknown effect) • Over the eyes • Internal use over mucosal linings of internal structures. • Anterior chest wall in cardiacs • Cerebrovascular accident, transient ischemic attacks, and or epilepsy. • The unreliable patient. • TENS should be kept out of the reach of children. • TENS should not be used while operating vehicles. • Application and removal of electrodes should be taken when the appliance is switched off. • Electrodes should not be placed over broken skin sites.

  16. SIDE EFFECTS • Allergy or prickling sensation may occur during stimulation which can be avoided through: • Use of solid electrodes • Interrupt the period of stimulation • Use of corticosteroid cream 2. Unpleasant sensation 3. Laryngeal and pharyngeal ms. spasm on application to the neck. 4. Addiction to stimulation.

  17. STIMULATION CHARACTERISTICS OF TENS • AMPLITUDE → 0 – 80 milli-ampere, • Pulse rate → 1 – 150 Hz, • Pulse duration → 30 – 250 ms, • Wave form → square or spike, monophasic or biphasic. • Stimulation with high pulse rate (50-100 Hz), narrow pulse width (30- 75 ms) and low amplitude (10- 30 MA) will produce comfortable tingling sensation but not ms. Contraction.

  18. METHODS OF TENS APPLICATION • TRANSCUTANEOUS: • By a trans-cutaneous nerve stimulator to the skin surface at the site of pain or any site related to it. • Used by the patient and monitored by the physical therapist.

  19. Trans-cutaneous

  20. 2. PERCUTANEOUS: • Used to evaluate the possible value of an implantable nervous system stimulator. • Carried out by needle electrodes inserted through the skin near the peripheral nerve or epidural or sub-arachnoid's space for spinal cord stimulation. If pain is controlled by percutaneous application, implantation of electrodes is performed. • Performed only in physician office, clinic or hospital outpatient department.

  21. 3. IMPLANTATION Discussed

  22. ELECTRODES 1. Mostly, Carbon filled silicone electrodes: • Electrodes require application of conductive gel and are fixed to the skin by adhesive tape. 2. Solid electrodes (Karya electrodes): • large molecular weight polysaccharide mixed with hydric alcohol. • Hydrophilic and adhere to the skin when wet. • Less incidence of skin irritation.

  23. Solid vs carbon electrodes

  24. TECHNIQUE OF STIMULATION • The patient should recognize the device and the electrodes, then place it over his hand and forearm to recognize the sensation of electrical stimulation. • Then, the patient should put the electrodes over the painful area with the pulse width and frequency should be at the lowest level. • Then, gradual increase of pulse width and frequency to the maximum tolerated non painful level. • If pain is not relieved, the process should be repeated on another day or after 30 min. • If pain failed to be relieved after 3 consecutive trials, the patient should be treated by another different type of therapy. • If pain is relieved, patient is instructed how to use the apparatus for prolonged times at home.

  25. ELECTRODES PLACEMENT • Mostly, pair of electrodes is placed over the painful area. • Nerve root irritation → electrodes placed paravertebrally over the affected spinal cord segments. • Muscular or bony pain → electrodes placed over myotomal or sclerotomal distribution. • Peripheral nerve injury or peripheral neuropathy → electrodes placed over the peripheral nerve proximal to site of pain. • Post-herpetic neuralgia → electrodes placed over the contralateral region corresponding to the painful region. • Bilateral stimulation of painful regions or spinal cord segments is indicated in LBP syndromes.

  26. DURATION AND FREQUENCY OF TREATMENT • 30 – 60 min, twice daily or 3 to 5 per week. • In chronic conditions → patient should be instructed how to use the apparatus at home.

  27. TENS devices • Very safe • Compact • Portable • Easy to operate • Non invasive • Non addictive • Does not produce any adverse irreversible change in the body.

  28. Thank you

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