TENS as a Modality for Chronic Pain Management in Occupational Therapy

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Contents Hide
1 What is TENS?
2 Pros
3 Cons
4 Pros vs Cons
5 Uses
6 Conclusion
7 Product Recommendations

What is TENS?

One modality that I do not see enough in practice is TENS for pain control, especially for chronic pain. The go-to always seems to be medications. And that’s about it. I’ve been guilty just as many as other therapists — waiting for analgetics to kick and timing it with therapy. But in hindsight, this does not teach patients the proper way to manage their pain. And this is likely a systemic, cultural, and personal issue, but likely rooted in the medical model, particularly the focus on the biomedical for pain management. As many pain neuroscientists and clinicians now know, pain is much more complex than simply tissue injury and the body.

One very useful tool that occupational therapists have that they can use is TENS. Transcutaneous electrical nerve stimulation is a nonpharmacological (yay! we don’t have to wait for the therapeutic effect of Norco) intervention that helps to reduce pain. In terms of the mechanism of action, TENS works by activating the inhibitory systems in our central nervous system to reduce pain.1 

Pros

I like TENS for pain management for many reasons:

  • I’ve used it personally for lower back pain and it has allowed me to do incredible things without taking any medications.
  • It is inexpensive. The TENS unit I purchased cost $26 and has 2 channels with 2 pads each, for a total of 4 pads. There’s a cost of recharging it or finding replacement batteries, but in a country such as the US where healthcare is ridiculously expensive, TENS is much cheaper over the long-term compared to medications like opioids.
  • You don’t need a prescription. Major advantage here.
  • It works immediately. This is one major advantage over Rx in my opinion. You turn on the TENS unit and it can begin to work immediately and ‘distract’ patients from pain instead of waiting 30 minutes for patients to find relief.
  • There are no major adverse effects, and especially no side-effects.
  • You can adjust the intensity for therapeutic effect. For example, my TENS unit has 20 step intensities from 0-50V. I’ve never gone higher than around 6/20 and this is enough for me. For those with more intense pain, they have the ability to go much higher.

Cons

However, there are some downsides and this is what I think is the major barrier to the use of TENS in practice.

  • Certifications. Politics. Some states, probably most states have specific requirements for PAMs certifications to use things like TENS. I don’t want to get into the politics of this, but this is primarily why occupational therapists (compared to physical therapists) don’t and aren’t using TENS in practice.
  • Contraindications such as cardiac issues, epilepsy, etc. However, most patients that I see would actually be able to use TENS and are not limited by these contraindications. But you should be aware of them, of course before you turn on one.
  • Electrode pads. It may be expensive to replace pads for every patient if where an occupational therapist works has limited resources for these supplies. But seriously, they are not that expensive.
  • Low tolerance to TENS. Some patients may have extreme sensitivities to repeated applications of specific frequencies of TENS. However, this can be addressed by using different frequencies and intensities. Furthermore, in conjunction with Rx, TENS tolerance can even be delayed to modulate and promote the use of TENS2 
  • Small learning curve for patients – but if patients can learn to take a list of complicated medications, they can likely handle using a TENS unit themselves. Some units are very user-friendly and have presets. Others can be pre-programmed by practitioners and locked-out.
  • Some facilities may require a doctor’s order before use. But come on, we ask for medication orders all the time!

Pros vs Cons

Looking at this list of pros vs. cons, the pros (other than the certification part) far outweigh the cons. Compared to medications, if after a trial TENS doesn’t work for a patient, then it doesn’t work. With medications, they could experience side-effects that can even get in the way and pose a barrier to recovery and function. Take constipation for example. I’ve experienced this while on Cymbalta and it made me so miserable (despite trying multiple things to manage constipation with lot’s of research behind it) that I ultimately decided to get off of it and that’s how I discovered TENS.

Uses

Research has shown TENS to be beneficial for many conditions and populations:

  • Neck pain for some participants 3 
  • Thoracic surgery pain4 
  • Cancer pain5 
  • Diabetic peripheral neuropathy6 
  • Chronic pain7 
  • Nonspecific lower back pain8 
  • Anecdotally: low-back pain for me from 2 herniated discs at L4-L5.
  • Hand rheumatoid arthritis9 
  • Knee osteoarthritis10 
  • Chronic musculoskeletal pain11 

TENS has not been shown to be as useful for:

  • Labor pain12 
  • Phantom limb pain13 
  • Neurological disorders

…at least based on these studies. But your mileage may vary with your patients.

Conclusion

Systematic reviews and research shows that TENS works for many conditions. The cost and risks (while there) are low. In my opinion, TENS can be a very useful adjunctive if not replacement modality for pain management for occupational therapists. Patients can use it as a preparatory method, while in therapy, or they can borrow it and use it themselves. This helps to empower patients in settings such as the hospital by allowing them to use it themselves in a culture (understandably) where nurses primarily help manage pain medications. I am honestly surprised that TENS is not used more. Maybe it’s because most of the occupational therapists aren’t certified to use it. Maybe they are hesitant because they only used it one time in a lab in OT school and aren’t comfortable. If this is you, go buy yourself a TENS unit and play around with it at home. Then get your hours to become certified (as much of a pain that it may be in certain states). It’s worth it as it helps advance your career and benefits the patients from your ability to use other modalities too such as ice. Some institutions still require a doctor’s orders too though. Who knows, you may even be in pain yourself. Overall, the benefits far outweigh the downsides and these should not be excuses to be over-reliant on medications for the sole magic pill for pain management.

Product Recommendations

Personally, I’ve used the Auvon TENS/EMS (PMS) unit that is available from Amazon. I’ve purchased it and regularly use it myself and I have also purchased it for a family member. It is extremely inexpensive (and may even qualify for FSA/HSA), easy to use via it’s presets, and is rechargeable via USB. One charge lasts a really really long time. I brought it for a trip down to southern California and did not need to charge it a single time. For $26, that’s literally the cost of a meal these days due to inflation so there’s no excuse for patients not to be able to afford one. At the very least, you can lend it to patients and see how they like it and if they don’t return it, you’re literally only out $26.

I think the benefit to cost ratio is well justified. Lower pain equals better functional outcomes, faster discharges, lower readmissions, less penalties from said re-admissions, and a better overall bottom-line from an economics perspective. Compare this to the cost of pain medications to the patient over their time of use, likely years, if not forever which equates to thousands of dollars and rising.

This Auvon one is a great unit for patients, but for therapists themselves, you may want to get a unit that allows you to customize the parameters such as the frequency and on/off times for more precise use in the field. I just purchased an iSTIM TENS/EMS device which allow you to customize each specific parameter and will be playing around with it before I write a review on it.

 

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  2. Liebano R, Rakel B, Vance C, et al. An investigation of the development of analgesic tolerance to transcutaneous electrical nerve stimulation (TENS) in humans. Pain. 2011;152:335–342[↩]
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  6. Jin DM, Xu Y, Geng DF, Yan TB. Effect of transcutaneous electrical nerve stimulation on symptomatic diabetic peripheral neuropathy: a meta-analysis of randomized controlled trials. Diabetes Res. Clin. Pract. 2010;89(1):10–15.[↩]
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  8. Machado LA, Kamper SJ, Herbert RD, Maher CG, McAuley JH. Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials. Rheumatology (Oxford) 2009;48:520–527.[↩]
  9. Brosseau L, Judd MG, Marchand S, et al. Transcutaneous electrical nerve stimulation (TENS) for the treatment of rheumatoid arthritis in the hand. Cochrane Database Syst. Rev. 2003;3:CD004377.[↩]
  10. Bjordal JM, Johnson MI, Lopes-Martins RA, Bogen B, Chow R, Ljunggren AE. Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled [↩]
  11.  Johnson M, Martinson M. Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: a meta-analysis of randomized controlled trials. Pain. 2007;130:157–165.[↩]
  12. Bedwell C, Dowswell T, Neilson JP, Lavender T. The use of transcutaneous electrical nerve s timulation (TENS) for pain relief in labour: a review of the evidence. Midwifery. 2011;27:e141–e148.[↩]
  13. Mulvey MR, Bagnall AM, Johnson MI, Marchant PR. Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Cochrane Database Syst. Rev. 2010;5:CD007264.[↩]