Tens

Athletes Care and Rehabilitation

2. Transcutaneous Electrical Nerve
Stimulation(TENS)
TENSisastimulatingdevicewhichdeliverselectrical
currentacrosstheintactsurfaceoftheskinviasurface
electrodes.
Itisasimple,non-invasive,analgesic(actingtorelieve
pain)technique.Thiscurrentisusuallygeneratedby
asmallbattery-operatedmachines.
Inbattery,circuitsmodifytheoutputinsuchaway
thatitwillhaveastimulatoryeffect.TENSisatherapy
thatuseslow-voltageelectricalcurrentforpainrelief.

3. Parameters of TENS:
1)Waveform:
Biphasicwaveform (having both the negative and positive phases)
These waveforms can besquare, rectangular, sine wave, and triangular spikes.
For hypersensitive patients and the pain associated with nerve injury, used rectangular waves.
The triangular (spike-shaped waves) are recommended for intense or hyper-irritating
stimulation, as done in acute pain or for the resistant tissue.
2)Frequency:
The frequency of TENS can behigh (80-120Hz),which is selectedfor the acute
conditionscausing immediate pain relief.
Thefrequency can be low (1-20Hz),which is used forchronic pain.
3)Pulsed width:
It is the length of time, the current is acting on the patient in each pulse.
Thepulse widthvaries from50-400 μs.
For normal neuromuscular system, the pulse width selected is from 50-400 μs
Patients withneurologic damage, higher widths of 200-300 μsare suggested.
4)Amplitude:
Most TENS units have an amplitude control ranging from1mAto100mA
For the immediate relief of pain, referred to the high amplitude and narrow width
combination.

4. Types of TENS(Modes):
1)Conventional (high TENS)
This mode is used toactivate selectively large-diameterAβ
fiberswithout concurrently activating small diameter Aδand C
(pain-related) fibers. Conventional (high-frequency low
intensity) TENS is themost commonly used mode of TENS.
It is effective in modulating acute pain via inhibition of pain fibers
by large diameter fiber activation(gate mechanism). the
stimulation parameters are as follows-
Alow intensity: 12-30 mAproducing comfortable tingling
sensation and paresthesia, but no muscle contraction.
Ahigh frequencytypically above100 Hz (80-120Hz)
Apulse durationwhich is usuallyshort (50-80μs)
Durationof treatment:20-60 minute
As the Aβ fibers are stimulated, this TENS mode achieves analgesia
primarily by spinal segmental mechanisms,i.e. gating effect.

5. Acupuncture like (low TENS):
It is a common misconception that this mode derives its name from
application over acupuncture points. Acupuncture like(low-frequency
high intensity)TENS primarilystimulates the Aδand C nociceptive
fibers. the stimulation parameters are:
low frequencyusually2-5Hz
Ahigh intensity: 30mA or more,(enough to produce visible muscle
contraction)
Long pulse duration (150-300μs)
Duration of treatment: 30-40 minutes
The electrode should be positioned to produce visible muscle
contractions. examples-over a myotomerelated to the painful area, the
intensity should be increased until the patient experience the same
desired muscle contractions.
This mode of TENS is operating primarily through thedescending pain
suppression system. Thus there is a relatively longer onset to analgesia,
which lasts more than the conventional TENS.

6. 3) Brief intense TENS:
Thismodeisusedtoproviderapidonset,butshorttermpainrelief.Itusedduring
painfulproceduresdonebytheclinicians,suchaswounddebridement,joint
mobilization,etc.theparametersinclude:
Amplitude:topatient’stolerance
Pulserate:125-250Hz
Pulseduration:200-250μs
Durationoftreatment:15minutes
Durationofpainrelief:temporary
4)Burstmode(pulsetrains)TENS:
ThismodeofTENSwasdevelopedbyErikssonandSjölundin1976.Theburst
modeprovidesapackagingofseveralstimuliinagrouprangingfrom1-10.Itis
presentedinaburstofenergy.Thepatientsenseditasasinglestimulus.Pain
reliefisthroughthestimulationofendogenousopiates.somepatientsprefer
thismodebecausethepulsetrainsproduceamorecomfortablemuscle
contraction.Theparametersinclude:
Amplitude:comfortableintermittentparesthesia
Frequency:50-100Hz,deliveredinpacketsorburstsof1-4Hz
Pulseduration:50-200Hz
Durationoftreatment:20-30minutes
Durationofpainrelief:long-lasting

7. Indications:
ReliefofAcutePain
Postoperativepain
Labourpain
Musculoskeletalpain
Bonefracture
Dentalprocedures
ReliefofChronicPain
Lowback
Arthritis
Peripheralnerveinjuries
Anginapectoris
Facialpain
Metastaticbonepain

8. Contraindications:
Undiagnosed pain (unless recommended by a medical
practitioner)
Pacemakers (unless recommended by a cardiologist)
Heart disease (unless recommended by a cardiologist)
Epilepsy (unless recommended by a medical practitioner)
Pregnancy: first trimester , over the uterus
Do not apply TENS: over the carotid sinus, on broken skin,
on dysaesthetic skin, internally (mouth)

9. TENS and Electrodes:
A variety of TENS models are currently available ranging from single or dual-
channel to multi-channel units.
There is a broad range of types and sizes of electrodes used with TENS. Electrode
can be a carbon rubber electrode. which is made to be covered with a
conductive gel. Probably the most popular choice of electrode is a self-adhesive
type, which comes in a variety of shapes and sizes and can be mold over
irregularly shaped areas of the body.
Electrode Placement for TENS:
One of the primary factors responsible for a poor response to TENS treatment is
that of ineffective electrode placement. Essentially, there are four broad
categories of anatomical sites to which the TENS electrodes can be applied-
Painful area
Peripheral nerve
Spinal nerve root
Other specific points (acupuncture, trigger, motor points)

10. Interferential Therapy(IFT)

11. What is Interferential therapy?
Interferentialtherapy(IFT)iswidelyusedin
physiotherapy.ItisdevelopedbyDr.HansNemecof
Vienna,Austriaintheearly1950s.Itisveryhelpfulin
relievingpainduetomusclespasmandvariousotherkinds
ofpain.
Interferentialtherapyisaformofelectricaltreatmentin
whichweusedinterferentialcurrent.
Asthenamesuggests,therehastobetwocurrentthat
interfereswitheachotherresultingintheproductionof
interferentialcurrent.
Whentwomediumfrequencycurrentinterferes,they
produceabeatfrequency.Thisbeatfrequencyistermedas
Interferentialcurrent.Thetreatmentprocessthroughthis
currentiscalledasInterferentialTherapy.

12. Thebasicprincipleofinterferentialtherapy(IFT)istousethe
importantphysiologicaleffectsoflow-frequencyelectrical
stimulationofnervewithouttheassociatedpainfulandsome
whatunpleasantsideeffects.
Toproducelow-frequencyeffectsatsufficientintensityand
sufficientdepth,thepatientcanexperiencemuchdiscomfortin
thesuperficialtissue(i.e.intheskin).
Thisisduetotheimpedanceoftheskin.
Interferentialtherapyutilizestwoofthesemediumfrequency
currents,passedthroughthetissuessimultaneously,wherethey
interferewitheachother.
Thisinteractiongivesrisetoaninterferencecurrent(orbeat
frequency).
Beatfrequencycontrolledthroughinputfrequency.
forexample-onecurrentwasat4100Hzandit’sassociatecurrent
at4000Hz,theresultantbeatfrequency,wouldbeat100Hz.
Principleof IFT:

13. Electrode:
Mainly two types of electrode used in IFT –
Suction electrode
Flat carbon rubber electrode
The suction electrode has the advantage of allowing the
application to large flat areas or patients who are relatively
immobile.
Flat carbon rubber electrodes may be easier to apply to the
peripheral limbs, when they may be held in position by bandages
or velcrostraps.
Current intensity:
Always turn the intensity dial to zero before beginning the
treatment.
The intensity should be slowly turned up until the patient
signals that the required sensation has been reached.
To neutralize adaptation, adjust intensity periodically.
Treatment duration:
Treatment time has been reported by most clinicians to be
between 10-15 minutes.

14. Physiological Effects of IFT:
This depend upon:
Magnitude of current.
Type of mode used i.e.rhythmic or constant.
The frequency range used.
Accuracy of electrode positioning.
Main physiological effect are-
Pain relief
Muscle stimulation
Increased local blood flow
Reduction of edema
Effect of autonomic nervous system

15. Indication:
Pain-both cases of pain and referred pain.
Muscle spasm
Edema
Hematoma
Chronic ligament lesion
Trigger point
Contraindication:
Arterial disease
Hemorrhage
Skin infection
Pregnant uterus
Malignancy
Pacemakers
Deep vein thrombosis
Large open wounds
Advanced cardiac disease
Hypertension
Infection

16. Paraffin wax bath

17. Paraffin waxhas been used for many years, it is an
effective medium for heat transfer to the skin and
joint. It is a form ofdeep heat therapy.
A paraffin treatment uses warmoil-based (mineral
oil) waxto provide pain relief to hand, feet, and sore
joints and muscles. Liquefied paraffin wax is very
efficient at absorbing and retaining heat.
The warm paraffin wax applied to the skin makes the
blood vessels expand and therefore helps the
circulation, bringing healing nutrients to the surface
and flushing toxins out of the skin.

18. Paraffin Wax Bath Unit:
Paraffinwaxbaththerapyisanapplicationofthemolten
paraffinwaxonthebodypart.Thetemperatureofthe
paraffinwaxismaintainingat42-52°c,whereasitsmelting
pointis51-55°c.
Ifthemoltenwaxat51-55°cispouredonthebodypart,it’s
maycauseburnoverthebodytissue,whichiswhysome
impurityisaddedtolowerdownitsmeltingpointsuchas
liquidparaffin,mineraloilorpetroleumjelly.
Thecombinationoftheparaffinandthemineraloilhas
lowspecificheatwhichenhancesthepatient’sabilityto
tolerateheatfromtheparaffinbetterthanfromthewater
ofthesametemperature.
Thecompositionofthesolidwax:liquidparaffin:
petroleumjellyis2:1:1orParaffinwax:ormineraloilis7:1
or6:1ratio.
Themodeofthetransmissionofheatfromparaffintothe
patientskinisthroughconduction.

19. Preparation of Patient or Method:
Thenatureofwaxtreatmentisexplained.
Theareatobetreatedisinspectedforcontraindication.
Lookforanywound,skininfection,rashes,etc.onthepart
tobetreated.
Cleanedtheskinusingtissuepaperorcotton.
Thejewelryfromthepartshouldberemoved.
Tellthepatientinbriefaboutthetemperatureofthewax
and
Dripdownafewdropsofmoltenwaxonthedorsalsurface
ofyourhandtocheckthetemperature.
Psychologicallypreparepatientandminimizedfearofheat
Aftertheabovestepthepatientisalwaysfoundto
cooperateandfearofmoltenwaxandheatisremoving
fromthemind.

20. Methods
Theparttobetreatedmustbecleanedbysoapand
moisturetobesoakedbyatowel.
Thepositionofthepatientshouldbesuchthatthe
parttobetreatedcomesclosertothewaxbath
container.
Beforeapplicationonemustensurethatthereshould
benomoistureonthebodytissuesotherwiseburn
couldoccur.
Thewarmwaxisplacedonthebodytissuesbyvarious
techniquesandthetreatmentisgivenforabout10-20
min

21. Techniques of Application:
Various techniques used for the application ofparaffin
wax are as follows:
1)Direct pouring method:
The molten Wax is directly poured by a mug or utensil
on the part to be treated and then wrapped around by
a towel.
The wax is allowed to solidify for about 10-20 minutes.
Several (4-6) layers can be made over the body tissues.
This method applies to areas like the knee, elbow.

22. 2)Brushing method:
It is a less commonly used method of paraffin wax
application. In this method, 8-10 coats of wax are applied to
the area with a paintbrush using even and rapid strokes.
This method is commonly used for areas like the hip, knee,
elbow, shoulder, etc
The area is then wrapped with a towel for 10-20 minutes
and after this time, paraffin wax is removed

23. 3)Immersion method:
This method of application provides somewhat vigorous
The body part to be treated dipped 3-4 time to form a
thin coat and then left immersed in paraffin wax for 20-
30minutes
A thin glove of solid paraffin wax formed slows the heat
The patient is in a comfortable position during the
treatment.
With the immersion method, the temperature elevation
of body tissue is 2°c higher than the dipping method.

24. 4)Dipping method:
It provides mild heating. The patient should wash and dry
the part to be treated. Dipping is repeated until a thick coat
is formed. In other words, at least 8-12 times until thick
glow on a part.
Once thick glow of wax is formed the treated area should
be wrapped 1st in a plastic and then wrapped with a towel.
If edema is concerned then the area may be elevated.
The effective duration of this treatment is 10-15 minutes.
5)Toweling or bandaging method
A towel or a roll of bandage is immersed in molten paraffin
wax and then wrapped around the body part.
Several layers can be made over the body part.
This method is preferably used for treating proximal parts
of the body.

25. Physiological Response:
1)Heat production:
There is a marked increase in skin temperature in the 1
st
two minutes, up
to 12-13°c.
This drop, while in the wax wrapping to an increase ofabout 8°c at the
end of 30 minutes.
In the subcutaneous fascia, there is an increase of 5°c at the end of the
treatment.
In the superficial muscles, then in only about 2-3°c rise in temperature at
the end of the treatment
2)Circulating effect:
Stimulation of superficial capillaries and arterioles causes local
hyperemia and reflex vasodilatation.
Hyperemia is due to the response of the skin to its function of heat
regulation.
Skin and subcutaneous tissue temperature drop after15-20 minute,
reducing the vasodilatation
Exercise after the wax is essential to increase the muscle circulation and
sedative effect of heat to obtain more range of movement and muscle
strength.

26. 3)Analgesic effect:
The most important effect of wax its marked sedative
effect on the tissue.
It is this effect that is used before the exercise, in the
treatment of superficially placed joints.
4)Stretching effect:
Wax leaves the skin moist, soft, and pliable.
This is useful for stretching scar and adhesion before
applying mobilization techniques.

27. Indicationsand Uses of Paraffin Wax Bath:
Arthritic condition (like rheumatoid arthritis and
other poly or oligo arthritic conditions.)
Pain (sprain, strain affecting the small distal joint)
Stiff joints (following trauma or disease)
Chronic inflammation
Contraindication:
Open wound
Skin infection
Defective skin sensation
Ischemic conditions
Skin allergy