TENS (Transcutaneous Electrical Nerve Stimulation)

Learn about TENS (Transcutaneous Electrical Nerve Stimulation) as treatment for chronic pain, Alzheimer's disease and ADHD.

Before engaging in any complementary medical technique, you should be aware that many of these techniques have not been evaluated in scientific studies. Often, only limited information is available about their safety and effectiveness. Each state and each discipline has its own rules about whether practitioners are required to be professionally licensed. If you plan to visit a practitioner, it is recommended that you choose one who is licensed by a recognized national organization and who abides by the organization's standards. It is always best to speak with your primary health care provider before starting any new therapeutic technique.

• Background
• Theory
• Evidence
• Unproven Uses
• Potential Dangers
• Summary
• Resources

Background

Transcutaneous electrical nerve stimulation (TENS) involves the passage of low-voltage electrical current to electrodes pasted on the skin. The current is delivered through wires from a small battery-powered power unit. The frequency and intensity of this treatment depend on the specific condition and treatment goals. Accordingly, the electrode pads are placed in various sites on the body. Frequency, intensity, and site of application are believed to be pivotal to achieving optimal effects during and after stimulation.

TENS is most commonly used for pain management. There are different types of TENS:

• Conventional TENS — High- or low-frequency electrical current is applied, often near affected areas.
• Acupuncture-like TENS — Lower-frequency current is used at specific trigger points.
• Auricular TENS — Electrical current is applied to the ear

Theory

Electricity has been used medicinally for thousands of years. Stone carvings from ancient Egypt depict electric fish being used to treat pain. In ancient Greece, electrogenic torpedo fish were used to treat arthritis and headache.

There are several proposed explanations for how TENS may work:

• It may affect the nerves that perceive pain or light touch.
• It may interfere with nerve pathways.
• It may alter the natural chemicals (such as encephalins, endorphins, opioids or substance P) that affect the way pain is perceived and transmitted.

None of these mechanisms has been clearly demonstrated in scientific research, and the basis of potential activity of TENS is controversial.

Theories traditionally used to explain acupuncture, such as effects on flow of vital energy, have also been offered to explain TENS. It is sometimes suggested that TENS may affect the cardiovascular system, increasing heart rate and reducing blood pressure.

Evidence

Scientists have studied TENS for the following health problems:

Dental procedure pain: Several small studies report that various TENS techniques reduce pain and the need for pain medications during dental procedures. TENS may also be useful in relieving pain associated with mandibular fractures. Because of problems with the quality of these trials, this evidence can be considered only preliminary. Better research is necessary to make a strong recommendation.

Knee osteoarthritis" Multiple trials report improvements in knee stiffness, physical performance, range of motion, and pain in patients with knee osteoarthritis treated with TENS. It is not clear that TENS improves walking distance or swelling. Some of these studies are small and are not of high-quality. Better research is needed to make a strong recommendation.

Anesthesia (pain relief during surgery): Auricular TENS is sometimes used in Europe to reduce the need for anesthesia during surgical procedures. There is not enough reliable evidence to make a recommendation.

Alzheimer's disease: A small amount of early research reports that TENS may improve some symptoms of Alzheimer's disease, such as mood, memory and cycles of daily rest and activity. Better studies are necessary to make a conclusion.

Angina (chest pain from heart disease): Several small, brief studies (mostly from the 1980s and 1990s) report benefits of TENS on angina pectoris, but most were not well designed or reported. It has been suggested that TENS may improve exercise tolerance and measures of ischemia but not improve symptoms. People with heart disease or chest pain are advised to seek immediate medical attention from a licensed physician. Many well-studied drugs for heart disease are available. Further study is needed before conclusions can be drawn regarding the effectiveness of TENS in this area.

Ankylosing spondylitis: Early research does not provide enough scientific evidence to draw a firm conclusion about effectiveness.

Back pain: The use of conventional TENS or acupuncture-like TENS in people with low back pain is controversial. Studies have used a variety of TENS techniques and defined back pain in different ways. Multiple trials have been published, but most research is not well designed or reported. Overall, it remains unclear if TENS is beneficial. Better-designed research is needed to make a firm conclusion.

Burn pain: Early research does not provide enough scientific evidence to draw a firm conclusion about effectiveness of TENS for burn pain.

Cancer pain: Early research does not provide enough scientific evidence to draw a firm conclusion about effectiveness of TENS for cancer pain.

Chronic pain: The effect of TENS on chronic pain of various causes and locations is controversial. Multiple studies have been published, and even though they have reported benefits, studies have overall been of poor quality. Better-designed research is needed to make a firm conclusion.

Dysmenorrhea (painful menstruation): Several small studies report that TENS may reduce short-term discomfort and the need for pain medications. However, this research has not been high-quality overall. Better-designed trials are needed to make a firm conclusion.

Headache: Preliminary studies report that TENS may have some benefits in patients with migraine or chronic headache. However, this research has not been high-quality overall. Better-designed trials are needed to make a firm conclusion.

Hemiplegia, hemiparesis (paralysis on one side of the body): Early research does not provide enough scientific evidence to draw a firm conclusion about effectiveness.

Labor pain: The use of TENS for labor pain is controversial. Multiple studies have been published, but even though they reported a reduced need for pain medications, studies have been small, poorly designed and without clear descriptions of results overall. Better-designed trials are needed to make a firm conclusion. It is not clear if passage of electricity using TENS has harmful effects on the fetus.

Local anesthesia during gallstone lithotripsy: Lithotripsy involves the use of sound waves to break up gallstones. Early research does not provide enough scientific evidence to draw a firm conclusion about effectiveness.

Facial pain, trigeminal neuralgia, bruxism (tooth grinding) pain: Several small studies report benefits when TENS is used to treat chronic facial pain of various causes. However, these trials are not well designed or reported, and additional research is needed to make a firm conclusion.

Myofascial pain: Early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness of TENS for myofascial pain.

Pregnancy-related nausea or vomiting: Early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness of TENS for pregnancy-related nausea or vomiting.

Neck and shoulder pain: Early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness of TENS for neck and shoulder pain.

Pain from broken bones, rib fracture or acute trauma: A randomized controlled trial in 100 patients with minor rib fracture showed TENS therapy to be more effective for relieving pain than were nonsteroidal anti-inflammatory drugs or placebo therapy.

Diabetic peripheral neuropathy: Early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness of TENS for peripheral neuropathy.

Phantom limb pain: Early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness of TENS in phantom limb pain.

Post-herpetic neuralgia (pain after shingles): Early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness of TENS in post-herpetic neuralgia.

Postoperative ileus (bowel obstruction): Early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness.

Postoperative nausea or vomiting: Early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness.

Postoperative pain: There are multiple studies of TENS being used to treat pain after different types of surgery, including abdominal surgery, heart surgery, lung surgery, gynecologic surgery and orthopedic surgery. Some studies report benefits (less pain, less pain with movement, or less need for pain medications), and others find no improvements. Better-quality research is needed to make a firm conclusion.

Post-stroke rehabilitation: One study on spastic dropped foot in subacute stroke reported that TENS had a beneficial effect. Further research is needed to draw a firm conclusion about effectiveness.

Rheumatoid arthritis: A small number of studies report improved joint function and pain in rheumatoid arthritis patients treated with TENS. However, this research is not well designed or reported, and better studies are needed to make a clear conclusion.

Skin ulcers: Early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness.

Spinal cord injury: Early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness.

Temporomandibular joint pain: Early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness.

Urinary incontinence, overactive bladder, detrusor instability: Several small, poorly designed studies exist. Early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness.

Spinal muscular atrophy (in children): One early study in eight children with spinal muscular atrophy reflected unfavorably on TENS therapy. Early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness.

Pain during hysteroscopy: A randomized controlled trial in 142 women undergoing hysteroscopy showed that the group who received TENS therapy experienced a significantly lower level of pain. Further high-quality scientific evidence is needed to draw a firm conclusion about effectiveness.

Gastroparesis: One small study of 38 gastroparesis patients receiving percutaneous electrical nerve stimulation (similar to TENS) reported a reduction in nausea and vomiting and a favorable weight gain after 12 months of therapy on the stomach. It is uncertain if these results would be seen with TENS therapy. This early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness.

Chronic obstructive pulmonary disease rehabilitation: One small randomized controlled trial involving 18 people undergoing rehabilitation for chronic obstructive pulmonary disease (COPD) showed improved muscle strength in the lower extremities as a result of TENS therapy. This suggests that TENS could be useful in adjunct to other components in a rehabilitation program for COPD. This early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness.

Carpal tunnel syndrome: A small, well-designed trial in 11 patients with carpal tunnel syndrome reported that TENS therapy was an effective treatment for pain. This early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness.

Soft tissue injury: A randomized controlled trial examined 60 patients with shoulder tendonitis and the effect of TENS and shock-wave therapy on pain. This study showed shock-wave therapy to be more effective than TENS for this condition. Another randomized trial evaluated burst TENS in Achilles tendon injuries. TENS appeared to be beneficial after suture of the Achilles tendon. Further research is needed to confirm these results.

Multiple sclerosis: In a small randomized controlled trial, patients with multiple sclerosis treated with TENS showed a trend toward improvement. Larger, well-designed studies are needed before conclusions can be drawn.

Intermittent claudication: A small randomized controlled trial suggests chronic electrical muscle stimulation may be beneficial for the relief of intermittent claudication symptoms. Further evidence is needed before drawing a firm conclusion.

Attention-deficit hyperactivity disorder (ADHD): A small randomized controlled trial found a moderate benefit in children with ADHD, but further research is warranted before a firm conclusion can be drawn.

Cognitive impairment: Preliminary evidence reports improvements in mood and mild cognitive impairment in elderly patients who do not suffer from Alzheimer's disease or early dementia. However, this early research does not provide enough high-quality scientific evidence to draw a firm conclusion about effectiveness.

Knee replacement pain: Preliminary evidence has found TENS not to relieve postoperative pain after knee replacement. Further research is needed to confirm these results.

Unproven Uses

TENS has been suggested for many uses, based on tradition or on scientific theories. However, these uses have not been thoroughly studied in humans, and there is limited scientific evidence about safety or effectiveness. Some of these suggested uses are for conditions that are potentially life-threatening. Consult with a health care provider before using TENS for any use.

Potential Dangers

In general, TENS is reported as being well tolerated, although research on safety is limited. Skin irritation and redness are the most common side effects, occurring in up to one-third of people. Electrode paste may cause hives, welts or allergic skin reactions (contact dermatitis). Electrical burns may occur with excessive use or improper technique.

Because there is a risk of burns, TENS should be used with caution in people with decreased sensation, such as people with neuropathy. TENS should not be used in people with implanted medical devices such as cardiac defibrillators, pacemakers, intravenous infusion pumps or hepatic artery infusion pumps. Electrical shock or device malfunction may occur.

There are isolated reports of several other side effects, including fluid buildup in the lung, partial collapse of the lung, loss of sensation, pain or unpleasant sensations (near or away from the site of TENS), increased hair growth, headache, muscle aches, nausea, agitation and dizziness. It is not clear if TENS caused these problems. Seizures have been reported, and TENS should be used cautiously in people with seizure disorders. It is sometimes suggested that TENS may affect the cardiovascular system, increasing heart rate and reducing blood pressure.

Although multiple studies have used TENS for pain relief during childbirth, evidence about its safety is limited, and a theoretical risk of harm to the fetus exists. Elevations in fetal heart rate and interference with fetal heart monitoring equipment have been reported. This technique should not be used unless under the strict supervision of an experienced licensed health care practitioner. Safety of TENS is not established in children.

Summary

TENS is most commonly used to manage pain, although it has been recommended or studied for many other medical conditions. Preliminary evidence suggests that TENS may be beneficial in the control of dental procedure pain and knee osteoarthritis symptoms. Other uses of TENS have not been sufficiently studied to draw firm conclusions. Skin reactions may occur. People with implanted medical devices should avoid TENS. TENS should be used cautiously and only under medical supervision in pregnant women, children and people with seizure disorders.

The information in this monograph was prepared by the professional staff at Natural Standard, based on thorough systematic review of scientific evidence. The material was reviewed by the Faculty of the Harvard Medical School with final editing approved by Natural Standard.

Resources

1. Natural Standard: An organization that produces scientifically based reviews of complementary and alternative medicine (CAM) topics
2. National Center for Complementary and Alternative Medicine (NCCAM): A division of the U.S. Department of Health & Human Services dedicated to research

Selected Scientific Studies: Transcutaneous Electrical Nerve Stimulation

Natural Standard reviewed more than 1,460 articles to prepare the professional monograph from which this version was created.

Some of the more recent studies are listed below:

1. Abell TL, Van Cutsem E, Abrahamsson H, et al. Gastric electrical stimulation in intractable symptomatic gastroparesis. Digestion 2002;66(4):204-212.
2. Allais G, De Lorenzo C, Quirico PE, et al. Non-pharmacological approaches to chronic headaches: transcutaneous electrical nerve stimulation, lasertherapy and acupuncture in transformed migraine treatment. Neurol Sci 2003;May, 24(Suppl 2):138-142.
3. Al-Smadi J, Warke K, Wilson, et al. A pilot investigation of the hypoalgesic effects of transcutaneous electrical nerve stimulation upon low back pain in people with multiple sclerosis. Clin Rehabil 2003;17(7):742-749.
4. Alvarez-Arenal A, Junquera LM, Fernandez JP, et al. Effect of occlusal splint and transcutaneous electric nerve stimulation on the signs and symptoms of temporomandibular disorders in patients with bruxism. J Oral Rehabil 2002;Sep, 29(9):858-863.

1. Amarenco G, Ismael SS, Even-Schneider A, et al. Urodynamic effect of acute transcutaneous posterior tibial nerve stimulation in overactive bladder. J Urol 2003;Jun, 169(6):2210-2215.
2. Anderson SI, Whatling P, Hudlicka O, et al. Chronic transcutaneous electrical stimulation of calf muscles improves functional capacity without inducing systemic inflammation in claudicants. Eur J Vasc Endovasc Surg 2004;27(2):201-209.
3. Benedetti F, Amanzio M, Casadio C, et al. Control of postoperative pain by transcutaneous electrical nerve stimulation after thoracic operations. Ann Thorac Surg 1997;63(3):773-776.
4. Bloodworth DM, Nguyen BN, Garver W, et al. Comparison of stochastic vs. conventional transcutaneous electrical stimulation for pain modulation in patients with electromyographically documented radiculopathy. Am J Phys Med Rehabil 2004;83(8):584-5591.
5. Bodofsky E. Treating carpal tunnel syndrome with lasers and TENS. Arch Phys Med Rehabil 2003;83(12):1806-1807.
6. Bourjeily-Habr G, Rochester CL, Alermo F, et al. Randomised controlled trial of transcutaneous electrical muscle stimulation of the lower extremities in patients with chronic obstructive pulmonary disease. Thorax 2002;Dec, 57(12):1045-1049.
7. Breit R, Van der Wall H. Transcutaneous electrical nerve stimulation for postoperative pain relief after total knee arthroplasty. J Arthroplasty 2004;19(1):45-48.
8. Brosseau L, Milne S, Robinson V, et al. Efficacy of the transcutaneous electrical nerve stimulation for the treatment of chronic low back pain: a meta-analysis. Spine 2003;27(6):596-603.
9. Burssens P, Forsyth R, Steyaert A, et al. Influence of burst TENS stimulation on the healing of Achilles tendon suture in man. Acta Ortho Belg 2003;69(6):528-532.
10. Campbell TS, Ditto B. Exaggeration of blood pressure-related hypoalgesia and reduction of blood pressure with low frequency transcutaneous electrical nerve stimulation. Psychophysiology 2002;Jul, 39(4):473-481.
11. Carroll D, Moore RA, McQuay HJ, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic pain (Cochrane Review). Cochrane Database of Systemic Reviews 2001;4.
12. Carroll D, Tramer M, McQuay H, et al. Transcutaneous electrical nerve stimulation in labour pain: a systematic review. Br J Obstet Gynaecol 1997;104(2):169-175.
13. Cheing GL, Hui-Chan CW, Chan KM. Does four weeks of TENS and/or isometric exercise produce cumulative reduction of osteoarthritic knee pain? Clin Rehabil 2003;16(7):749-760.
14. Cheing GL, Hui-Chan CW. Would the addition of TENS to exercise training produce better physical performance outcomes in people with knee osteoarthritis than either interventioin alone. Clin Rehabil 2004;18(5):487-497.
15. Cheing GL, Tsui AY, Lo SK, et al. Optimal stimulation duration of tens in the management of osteoarthritic knee pain. J Rehabil Med 2003;Mar, 35(2):62-68.
16. Chesterton LS, Barlas P, Foster NE, et al. Sensory stimulation (TENS): effects of parameter manipulation on mechanical pain thresholds in healthy human subjects. Pain 2002;Sep, 99(1-2):253-262.
17. Chesterton LS, Foster NE, Wright CC, et al. Effects of TENS frequency, intensity and stimulation site parameter manipulation on pressure pain thresholds in healthy human subjects. Pain 2003;106(1-2):73-80.
18. Chiu JH, Chen WS, Chen CH, et al. Effect of transcutaneous electrical nerve stimulation for pain relief on patients undergoing hemorrhoidectomy: prospective, randomized, controlled trial. Dis Colon Rectum 1999;42(2):180-185.
19. Coloma M, White PF, Ogunnaike BO, et al. Comparison of acustimulation and ondansetron for the treatment of established postoperative nausea and vomiting. Anesthesiology 2002;Dec, 97(6):1387-1392.
20. Cramp FL, McCullough GR, Lowe AS, et al. Transcutaneous electric nerve stimulation: the effect of intensity on local and distal cutaneous blood flow and skin temperature in healthy subjects. Arch Phys Med Rehabil 2002;Jan, 83(1):5-9.
21. Crevenna R, Posch M, Sochor A, et al. Optimizing electrotherapy: a comparative study of 3 different currents [Article in German]. Wien Klin Wochenschr 2002;Jun 14, 114(10-11):400-404.
22. De Angelis C, Perrone G, Santoro G, et al. Suppression of pelvic pain during hysteroscopy with a transcutaneous electrical nerve stimulation device. Fertil Steril 2003;Jun, 79(6):1422-1427.
23. de Tommaso M, Fiore P, Camporeale A, et al. High and low frequency transcutaneous electrical nerve stimulation inhibits nociceptive responses induced by CO2 laser stimulation in humans. Neurosci Lett 2003;May 15, 342(1-2):17-20.
24. Deyo RA, Walsh NE, Martin DC, et al. A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. N Engl J Med 1990;322(23):1627-1634.
25. Domaille M, Reeves B. TENS and pain control after coronary artery bypass surgery. Physiotherapy 1997;83(10):510-516.
26. Fagade OO, Obilade TO. Therapeutic effect of TENS on post-IMF trismus and pain. Afr J Med Med Sci 2003;32(4):391-394.
27. Fehlings DL, Kirsch S, McComas A, et al. Evaluation of therapeutic electrical stimulation to improve muscle strength and function in children with types II/III spinal muscular atrophy. Dev Med Child Neurol 2002;Nov, 44(11):741-744.
28. Forst T, Nguyen M, Forst S. Impact of low frequency transcutaneous electrical nerve stimulation on symptomatic diabetic neuropathy using a new Salutaris device. Diabetes Nutr Metab 2004;17(3):163-168.
29. Grant DJ, Bishop-Miller J, Winchester DM, et al. A randomized comparative trial of acupuncture versus transcutaneous electrical nerve stimulation for chronic back pain in the elderly. Pain 1999;82(1):9-13.
30. Guo Y, Shi X, Uchiyama H, et al. A study on the rehabilitation of cognitive function and short-term memory in patients with Alzheimer's disease using transcutaneous electrical nerve stimulation. Front Med Biol Eng 2002;11(4):237-247.
31. Hamza MA, White PF, Ahmed HE, et al. Effect of the frequency of transcutaneous electrical nerve stimulation on the post-operative opioid analgesic requirement and recovery profile. Anesth Analg 1999;88:212.
32. Hardy SG, Spaulding TB, Liu H, et al. The effect of transcutaneous electrical stimulation on spinal motor neuron excitability in people without known neuromuscular diseases: the roles of stimulus intensity and location. Phys Ther 2002;Apr, 82(4):354-363. Erratum in: Phys Ther 2002;May, 82(5):527.
33. Herman E, Williams R, Stratford P, et al. A randomized controlled trial of transcutaneous electrical nerve stimulation (CODETRON) to determine its benefits in a rehabilitation program for acute occupational low back pain. Spine 1994;19(5):561-568.
34. Hettrick HH, O'Brien K, Laznick H, et al. Effect of transcutaneous electrical nerve stimulation for the management of burn pruritus: a pilot study. J Burn Care Rehabil 2004;25(3):236-240.
35. Hou CR, Tsai LC, Cheng KF, et al. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil 2002;Oct, 83(10):1406-1414.
36. Hsieh RL, Lee WC. One-shot percutaneous electrical nerve stimulation vs. transcutaneous electrical nerve stimulation for low back pain: comparison of therapeutic effects. Am J Phys Med Rehabil 2003;81(11):838-843.
37. Johansson BB, Haker E, von Arbin M, et al. Acupuncture and transcutaneous nerve stimulation in stroke rehabilitation: a randomized, controlled trial. Stroke 2001;32(3):707-713.
38. Johnson CA, Wood DE, Swain ID, et al. A pilot study to investigate the combined use of botulinum neurotoxin type a and functional electrical stimulation, with physiotherapy, in the treatment of spastic dropped foot in subacute stroke. Artif Organs 2002;Mar, 26(3):263-266.
39. Jonsdottir S, Bouma A, Sergeant JA, et al. Effects of transcutaneous electrical stimulation (TENS) on cognition, behavior, and the rest-activity rhythm in children with attention deficit hyperactivity disorder, combined type. Neurorehabil Neural Repair 2004;18(4):212-221.
40. Koke AJ, Schouten JS, Lamerichs-Geelen MJ, et al. Pain reducing effect of three types of transcutaneous electrical nerve stimulation in patients with chronic pain: a randomized crossover trial. Pain 2004;108(1-2):36-42.
41. Law PP, Cheing GL. Optimal stimulation frequency of transcutaneous electrical nerve stimulation on people with knee osteoarthritis. J Rehabil Med 2004;36 (5):220-225.
42. Luijpen MW, Swaab DF, Sergeant JA, et al. Effects of transcutaneous electrical nerve stimulation (TENS) on self-efficacy and mood in elderly with mild cognitive impairment. Neurorehabil Neural Repair 2004;18(3):166-175.
43. Meechan JG, Gowans AJ, Welbury RR. The use of patient-controlled transcutaneous electronic nerve stimulation (TENS) to decrease the discomfort of regional anaesthesia in dentistry: a randomised controlled clinical trial. J Dent 1998;26(5-6):417-420.
44. Milne S, Welch V, Brosseau L, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain (Cochrane Review). Cochrane Database Syst Rev 2001;2:CD003008.
45. Munhoz RP, Hanajima R, Ashby P, et al. Acute effect of transcutaneous electrical nerve stimulation on tremor. Mov Disord 2003;18(2):191-194.
46. Murray S, Collins PD, James MA. An investigation ingo the 'carry over' effect of neurostimulation in the treatment of angina pectoris. Int J Clin Pract 2004;58(7):669-674.
47. Naeser MA, Hahn KA, Lieberman BE, Branco KF. Carpal tunnel syndrome pain treated with low-level laser and microamperes transcutaneous electric nerve stimulation: a controlled study. Arch Phys Med Rehabil 2002;Jul, 83(7):978-988. Comment in: Arch Phys Med Rehabil 2002;Dec, 83(12):1806. Author reply, 1806-1807.
48. Ng MM Leung MC, Poon DM. The effects of electro-acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic knees: a randomized controlled trial with follow-up evaluation. J Altern Complement Med 2003;9(5):641-649.
49. Okada N, Igawa Y, Ogawa A, et al. Transcutaneous electrical stimulation of thigh muscles in the treatment of detrusor overactivity. Br J Urol 1998;81(4):560-564.
50. Olyaei GR, Talebian S, Hadian MR, et al. The effect of transcutaneous electrical nerve stimulation on sympathetic skin response. Electromyogr Clin Neurophysiol 2004;44(1):23-28.
51. Oncel M, Sencan S, Yildiz H, et al. Transcutaneous electrical nerve stimulation for pain management in patients with uncomplicated minor rib fractures. Eur J Cardiothorac Surg 2003;22(1):13-17.
52. Osiri M, Welch V, V, Brosseau L, et al. Transcutaneous electrical nerve stimulation for knee osteoarthritis (Cochrane Review). Cochrane Database Syst Rev 2000;4:CD002823.
53. Pan PJ, Chou CL, Chiou HJ, et al. Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulders: a functional and sonographic study. Arch Phys Med Rehabil 2003;Jul, 84(7):988-993.
54. Peters EJ, Lavery LA, Armstrong DG, et al. Electric stimulation as an adjunct to heal diabetic foot ulcers: a randomized clinical trial. Arch Phys Med Rehabil 2001;82(6):721-725.
55. Poletto CJ, Van Doren CL. Elevating pain thresholds in humans using depolarizing prepulses. IEEE Trans Biomed Eng 2002;Oct, 49(10):1221-1224.
56. Pope MH, Phillips RB, Haugh LD, et al. A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain. Spine 1994;19(22):2571-2577.
57. Price CIM, Pandyan AD. Electrical stimulation for preventing and treating post-stroke shoulder pain (Cochrane Review). Cochrane Database of Systemic Reviews 2001;4:CD001698.
58. Proctor ML, Smith CA, Farquhar CM, et al. Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea. Cochrane Database Syst Rev 2003;4:CD002123. Last updated 2003-02-28.
59. Rakel B, Frantz R. Effectiveness of trancutaneous electrical nerve stimulation on postoperative pain with movement. J Pain 2003;4(8):455-464.
60. Reichelt O, Zermann DH, Wunderlich H, et al. Effective analgesia for extracorporeal shock wave lithotripsy: transcutaneous electrical nerve stimulation. Urology 1999;54(3):433-436.
61. Smart R. A prospective randomized controlled study of VAX-D and TENS for the treatment of chronic low back pain. Neurol Res 2001;23(7):780-784.
62. Sonde L, Gip C, Fernaeus SE, et al. Stimulation with low frequency (1.7 Hz) transcutaneous electric nerve stimulation (low-TENS) increases motor function of the post-stroke paretic arm. Scand J Rehabil Med 1998;30(2):95-99.
63. Sonde L, Kalimo H, Fernaeus SE, et al. Low TENS treatment on post-stroke paretic arm: a three-year follow-up. Clin Rehabil 2000;14(1):14-19.
64. Soomro NA, Khadra MH, Robson W, et al. A crossover randomized trial of transcutaneous electrical nerve stimulation and oxybutynin in patients with detrusorinstability. J Urol 2001;166(1):146-149.
65. Svihra J, Kurca E, Luptak J, et al. Neuromodulative treatment of overactive bladder: noninvasive tibial nerve stimulation. Bratisl Lek Listy 2002;103(12):480-483.
66. Takimova ME, Latfullin IA, Azin AL, et al. [Possibilities to improve the cerebral venous tonus in patients suffering of accelerated aging in blood circulation system by the nonmedicamentousal sympathocorrection method]. Adv Gerontol 2004;14:101-104.
67. Tsukayama H, Yamashita H, Amagai H, et al. Randomised controlled trial comparing the effectiveness of electroacupuncture and TENS for low back pain: a preliminary study for a pragmatic trial. Acupunct Med 2002;Dec, 20(4):175-180.
68. Tunc M, Gunal H, Bilgili T, et al. The effect of TENS on epidural patient controlled analgesia with tramadol for postthoracotomy pain relief. Turk Anesteziyoloji Ve Reanimasyon 2003;30(7):315-321.
69. van Balken MR, Vandoninck V, Messelink BJ, et al. Percutaneous tibial nerve stimulation as neuromodulative treatment of chronic pelvic pain. Eur Urol 2003;Feb, 43(2):158-163. Discussion, 163.
70. van der Ploeg JM, Vervest HA, Liem AL, et al. Transcutaneous nerve stimulation (TENS) during the first stage of labour: a randomized clinical trial. Pain 1996;68(1):75-78.
71. van der Spank JT, Cambier DC, De Paepe HM, et al. Pain relief in labour by transcutaneous electrical nerve stimulation (TENS). Arch Gynecol Obstet 2000;264(3):131-136.
72. van Dijk KR, Scherder EJ, Scheltens P, et al. Effects of transcutaneous electrical nerve stimulation (TENS) on non-pain related cognitive and behavioural functioning. Rev Neurosci 2003;13(3):257-270.
73. Vandoninck V, Van Balken MR, Finazzi Agro E, et al. Posterior tibial nerve stimulation in the treatment of urge incontinence. Neurourol Urodyn 2003;22(1):17-23.
74. Wang B, Tang J, White PF, et al. Effect of the intensity of transcutaneous acupoint electrical stimulation on the postoperative analgesic requirement. Anesth Analg 1997;85(2):406-413.
75. Wong RK, Jones GW, Sagar SM, et al. A Phase I-II study in the use of acupuncture-like transcutaneous nerve stimulation in the treatment of radiation-induced xerostomia in head-and-neck cancer patients treated with radical radiotherapy. Int J Radiat Oncol Biol Phys 2003;57(2):472-480.
76. Xiao WB, Liu YL. Rectal hypersensitivity reduced by acupoint TENS in patients with diarrhea-predominant irritable bowel syndrome: a pilot study. Dig Dis Sci 2004;49(2):312-319.
77. Yokoyama M, Sun X, Oku S, et al. Comparison of percutaneous electrical nerve stimulation with transcutaneous electrical nerve stimulation for long-term pain relief in patients with chronic low back pain. Anesth Analg 2004;98(6):1552-1556.
78. Yuan CS, Attele AS, Dey L, et al. Transcutaneous electrical acupoint stimulation potentiates analgesic effect of morphine. J Clin Pharmacol 2002;Aug, 42(8):899-903.
79. Wang B, Tang J, White PF, et al. Effect of the intensity of transcutaneous acupoint electrical stimulation on the postoperative analgesic requirement. Anesth Analg 1997;85(2):406-413.

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